Forearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location and complexity, patient characteristics and surgical technique. Treatment of diaphyseal forearm nonunions differs from that of other type of diaphyseal nonunions because of the intimate relationship between the radius and ulna and their reciprocal movement. There is a wide variation of surgical techniques, and the optimal choice of management remains subject to debate. In this review, we aim to summarize the available evidence in the literature on forearm nonunions and combine it with practical recommendations based on our clinical experience to help guide the management of this complex problem.
Several proximal tibial osteotomy techniques for the medial compartment arthrosis of the knee are described and traced in their development. These techniques are of the closed wedge, dome and open wedge types. We detail the differences in planning and surgery as well the need for different fixation devices. This historical and technical description will benefit those surgeons wishing to undertake the procedure as an alternative to joint replacement strategies.
Hazem Mossad El-Tayeby,
Amin Abdel Razek Youssef Ahmed
Ankle reconstruction prior to limb lengthening for was performed in 13 patients with fibular hemimelia with complete radiological absence of the fibula (type II). There were different degrees of absence of metatarsal rays. The hindfoot deformity was a heel valgus in 12 patients and equinovarus in 1 patient. The patients’ ages ranged from 9 to 26 months. Excision of the fibular anlage was performed with lateral subtalar and ankle soft tissue releases to restore the ankle and subtalar joint relationships. In all cases, the fibular anlage ended distally in a cartilaginous lateral malleolar remnant that was fused to the talus in two patients. This fibular remnant was advanced distally and fixed to the tibia with 2 Kirschner wires to recreate an ankle mortise. The period of follow-up ranged from 12 to 38 months. All patients had a stable ankle without tendency to valgus deformity or subluxation. The ankle range of movement was a mean of 27.3° plantarflexion (25–30) and 18° dorsiflexion (15–20). Reconstruction of the ankle in type II fibular hemimelia using advancement of the cartilaginous lateral malleolar remnant has produced encouraging results in the short-term but longer follow-up is needed.
D. K. Agarwal,
D. K. Patro,
The fibular head is often used as donor graft material for reconstruction of defects of the distal radius. However little is known on the safety of such a procedure. This report describes the long-term donor-site morbidity following the procedure. Fourteen patients who underwent simple or marginal resections of the proximal fibula between 1990 and 2007 were reviewed. Subjective donor-site morbidity, knee and ankle range of motion and instability, presence of sensory or motor function loss, gait and fibular regeneration were assessed. The mean age at surgery was 25 years; six were male, eight were female and the mean follow-up was 11 years. Abnormal clinical findings were present in 10 patients (71.4 %): nine patients (64.3 %) had Grade 2 varus laxity at the knee confirmed by stress radiographs; one had sensory loss in the distribution of the superficial peroneal nerve. Patients with varus laxity had significantly higher mean age at surgery than those without varus laxity (p = 0.001). None had deformity at the knee or ankle. The range of joint movements was normal. All had a normal tibiotalar angle and none had proximal migration of the fibula. One patient demonstrated near-complete regeneration of the fibula. Donor-site morbidity following simple and marginal resection of the proximal fibula is acceptable. Older patients had a higher risk of demonstrable varus laxity at the knee but proximal fibula resection in children appears to be safe.
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Singh J, Rambani R, Hashim Z, Raman R, Sharma HK. The relationship between time to surgical debridement and incidence of infection in grade III open fractures. 2012; 7 (1):33-37.
Objective The purpose of this study was to determine the association between time to initial debridement and infection rate in high-energy (grade III) open fractures of tibia.
Methods All patients presenting with open fractures were included in the study. The inclusion criteria were Gustilo III A, B and C open fractures of tibia. Time of injury, time of arrival to the hospital, time of initial debridement and subsequent soft tissue procedures were recorded. The primary outcome measure was a diagnosis of infection or osteomyelitis at 1 year. Secondary outcome measure was fracture union at 1 year.
Results Sixty-seven (67) patients with grade III open fractures were included; the mean age was 32.4 years (54 males and 13 females). Eight patients (12 %) in this study went on to develop a deep infection, and there were 6 (8.4 %) non-unions. The infection rate for patients in the group who underwent debridement in less than 6 h and those greater than 6 h was 13.1 and 10.8 %, respectively. No statistically significant difference could be demonstrated between the two groups (p = 0.56). While there was no significant relationship between grade of fracture and infection rate (p = 0.07), the relationship between grade of fracture and non-union was significant (p = 0.02).
Conclusion Our study shows that the risk of developing an infection was not increased if the primary surgical management was delayed more than 6 h after injury. Therefore, reasonable delays in surgical treatment for patients with open fractures may be justified in order to provide an optimal operating environment.
Congenital dislocation of the radial head is rare, although it is the most common congenital anomaly of the elbow. A concomitant progressive cubitus valgus of the elbow has not previously been described in literature. We describe a case of an 8-year-old girl with an unilateral congenital radial head dislocation with a progressive cubitus valgus of 35°, caused by a prematurely closing physis of the lateral humeral condyle. This might be caused by an increased pressure on the lateral physis by the anteriorly dislocated radial head. As no complaints or limitations were present, treatment was non-operative with clinical observation, with satisfactory results after a follow-up of 18 months. A concomitant progressive cubitus valgus can be present in patients with a congenital radial head dislocation. Non-operative treatment can provide satisfactory results.
We report a case of a 30-year old male, who presented with a right distal radius intra-articular fracture complicated by compartment syndrome. He was treated with fasciotomies and fracture fixation with a 3.5 mm LCP (Synthes™), followed 7 days later by skin graft. Repeat radiographs 8 weeks later showed a break across the plate at the level of an unfilled screw hole over the fracture. He underwent exchange plating with a 2.4 mm LCP Distal Radius Plate (Synthes™). This revision was complicated by an infected wound dehiscence 2 weeks later requiring multiple procedures. Radiographs at 20 weeks showed broken distal screws. A second revision was performed. At 12 months, the fracture had healed clinically and radiologically, but the three distal screws had broken. We discuss the multifactorial failures of the these three attempts at osteosynthesis, and which factors helped achieve osseous union. We also discuss the literature on volar locking plate breakage and conclude with the recommendations to avoid this rare complication.
Ibrahim Cumhur Başsorgun,
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Güven M, Demirel M, Özler T, Başsorgun IC, Ipek S, Kara S. An aggressive aneurysmal bone cyst of the proximal humerus and related complications in a pediatric patient. 2012; 7 (1):51-56.
Clinical behavior of aneurysmal bone cyst (ABC) in younger patients can be more aggressive than that in older children and adults. Angular deformity and shortening can occur due to growth plate destruction or tumor resection. A 11-year-old boy who had been operated twice in another center for an ABC located in the left proximal humerus presented to the author\'s institution with complaints of pain, deformity and shortening of the left arm. Plain radiographs revealed left proximal humerus nonunion with a large defect. Reconstruction with nonvascularized fibular autograft was applied and left upper extremity was immobilized in a velpou bandage. At the third-month follow-up, graft incorporation was observed in the distal part; however, proximal part did not show adequate healing on radiographs. Additional immobilization in a sling for 3 months was advised to the patient and his family. However, they were lost to follow-up and readmitted to the author\'s institution at the 12th month postoperatively. Radiographs showed failure of the fibular graft fixation and nonunion of the humerus. Autogenic bone grafts, either vascularized or nonvascularized are the best treatment method for the large defects after tumor curettage or resection. Nonvascularized grafts are technically much easier to use than vascularized grafts and provide excellent structural bone support at the recipient side. However, they may take several months to be fully incorporated. In addition, good therapeutic outcomes require patience and collaboration with the patient and parents. Most importantly, the patient should be monitored closely.