Strategies in Trauma and Limb Reconstruction

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2013 | November | Volume 8 | Issue 3

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Original Article

Gijs I. T. Iordens, Esther M. M. van Lieshout, Bernd C. Van Es, Niels W. L. Schep, Roelf S. Breederveld, Peter Patka, Dennis Den Hartog

Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:7] [Pages No:141 - 147]

Keywords: Shoulder, Instability, Bankert, Putti-Platt, Procedure

   DOI: 10.1007/s11751-013-0171-x  |  Open Access |  How to cite  | 


Most recent studies on procedures for stabilizing the glenohumeral joint focus on arthroscopic techniques. A relatively simple open procedure is the modified Putti-Platt procedure. The aim of these retrospective case series was to evaluate the functional outcome, patient satisfaction, and quality of life of patients who underwent this procedure. After a median follow-up time of 4.7 (P25–P75 1.7–6.8) years, fifty-one patients could be enrolled with a mean age of 25 (21–39) years. Five patients (10 %) reported re-dislocations. The median Constant score for the affected side was 84 (P25–P75 75–91). Median loss of motion in abduction, elevation, external rotation, and external rotation in 90° of abduction did not exceed 10° when compared to the healthy shoulder. A median Rowe score of 92 (P25–P75 75–95) was measured. The WOSI score and SF-36 showed excellent quality of life. The VAS proved high patient satisfaction with the outcome; 7.9 (6.8–9.5). We concluded that the modified Putti-Platt procedure leads to excellent outcome scores and only marginal restriction in range of motion combined with a high patient satisfaction. Our data prove that excellent results can be obtained with a relatively simple open procedure.


Original Article

Zile Singh Kundu, Paritosh Gogna, Vinay Gupta, Pradeep Kamboj, Rohit Singla, Sukhbir Singh Sangwan

Proximal humeral reconstruction using nail cement spacer in primary and metastatic tumours of proximal humerus

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:6] [Pages No:149 - 154]

Keywords: Proximal humerus, Tumours, Limb salvage, Nail cement spacer

   DOI: 10.1007/s11751-013-0172-9  |  Open Access |  How to cite  | 


Limb salvage surgery for malignant tumours of proximal humerus is an operative challenge, where the surgeon has to preserve elbow and hand functions and retain shoulder stability with as much function as possible. We treated 14 consecutive patients with primary malignant or isolated metastasis of proximal humerus with surgical resection and reconstruction by nail cement spacer. There were 8 females and 6 males, with a mean age of 28.92 years (range 16–51 years) and a mean follow-up of 30.14 months (range 12–52 months). The diagnosis was osteosarcoma in 8 patients, chondrosarcoma in 4 patients and metastasis from thyroid and breast carcinoma in 1 patient each. One of our patients had radial nerve neuropraxia, 1 developed inferior subluxation and 3 developed distant metastasis. Two patients died of disease and one developed local recurrence leading to forequarter amputation, leaving a total of 11 patients with functional extremities for assessment at the time of final follow-up which was done using the Musculoskeletal Tumour Society (MSTS) score. Though we were able to preserve the elbow, wrist and hand functions in all patients, the abductor mechanism, deltoid muscle and axillary nerve were not salvageable in any of cases. The mean MSTS score at the time of final follow-up was 19.09. Thus, proximal humeral reconstruction using nail cement spacer is a technical simple, cost-effective and reproducible procedure which makes it a reliable option in subset of patients where the functions around the shoulder cannot be preserved despite costlier prosthesis.


Original Article

E. Skouras, Y. Hosseini, V. Berger, K. Wegmann, T. C. Koslowsky

Operative treatment and outcome of unstable distal radial fractures using a palmar T-miniplate at a non-specialized institution

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:6] [Pages No:155 - 160]

Keywords: Distal radial fractures, T-miniplate osteosynthesis

   DOI: 10.1007/s11751-013-0170-y  |  Open Access |  How to cite  | 


Treatment options for displaced distal radial fractures are still a controversial topic of discussion. Although good results for the palmar plating of high-volume centers have been published, evidence of its successful use in smaller institutions is still lacking. We report the clinical and radiological results of the treatment for 84 distal radial fractures with a single 2.4-mm T-miniplate in an institution performing <30 procedures per year. According to the AO classification system, there were 30 A, 5 B, and 49 C fractures with a patients mean age of 64 years. After a minimum of 12-month follow-up, we found very good and good results according to the Gardland and Sarmiento scores and a DASH of 5.6. Only five patients were classified as having a moderate outcome. A remaining intra-articular step-off of more than 1 mm was seen in 15 patients. In a comparison of grip strength between the injured and uninjured hands, we saw a difference of 6.8 % less on the injured side. We saw two instances of tendon rupture and one of tendon irritation due to prominent dorsal screws and necessitating revision surgery. Flexor tendon irritation was noted in one patient, requiring a second operation. Modern treatment for distal radial fractures can be performed successfully and with good clinical outcome in smaller institutions. Based on the high and increasing incidence of distal radial fractures, there is no need to transfer these patients into high-volume centers. Level of evidence Case study, Level IV.


Original Article

Hany Hefny, Elhussein Mohamed Elmoatasem, Wael Nassar

Valgus osteotomy by external fixation for treatment for developmental coxa vara

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:7] [Pages No:161 - 167]

Keywords: Coxa vara, Osteotomy, External fixator, Ilizarov

   DOI: 10.1007/s11751-013-0178-3  |  Open Access |  How to cite  | 


Valgus subtrochanteric osteotomy is the standard surgical treatment for coxa vara. Nevertheless, there is no consensus on the method of fixation and osteotomy technique. There are some reports on employing rigid internal fixation methods that preclude the need of postoperative immobilization. This is a technical description of a valgus osteotomy performed using external fixation with preoperative and postoperative data on a cohort of 9 patients. In this study, 9 hips in 9 patients with the diagnosis of developmental coxa vara underwent a subtrochanteric osteotomy with stabilization by an external fixator. The planned correction angle was obtained for all 9 patients with the osteotomies healing primarily. Radiographic analysis showed an improvement in Hilgenreiner's epiphyseal angle and the neck-shaft angle. There were no major complications associated with use of this method of stabilization. Minimal access surgery using external fixation for a valgus osteotomy of the proximal femur is safe and effective for the treatment for coxa vara and limb length discrepancy. It has potential advantages over commonly used open techniques and provides available alternative to currently applied methods used for fixation of proximal femoral osteotomies.


Original Article

E. Barron, R. Rambani, H. Bailey, H. K. Sharma

Cost implications of the physiotherapy management of complex tibial fractures treated with circular frames

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:3] [Pages No:169 - 171]

Keywords: Cost analysis, Physiotherapy cost, Complex tibial fractures

   DOI: 10.1007/s11751-013-0173-8  |  Open Access |  How to cite  | 


Seventy-three consecutive patients with complex tibial fractures treated with an Ilizarov frame or Taylor Spatial Frame received physiotherapy between April 2008 and April 2010. Data were collected prospectively, and physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient. The data were categorized for proximal, middle and distal third tibial fractures for analysis. The average cost of physiotherapy for an inpatient with an Ilizarov frame is £121.82 per case, whereas that for an outpatient receiving treatment for trauma was calculated as £404.60. The combined average cost of physiotherapy to support treatment of a complex tibial fracture with a fine wire fixator is £546.27. Treatment involving circular frames is complex and expensive, and the high physiotherapy cost is not reflected in Healthcare Resource Group codes. This cost calculation will help service units, and NHS Trusts develop realistic costing plans to support treatment. Cost implications of the physiotherapy management of complex tibial fractures using the Ilizarov technique.


Original Article

Fergal P. Monsell, James Ralph Barnes, M. C. Bellemore, L. Biston, Allen Goodship

Cytotoxic agents are detrimental to bone formed by distraction osteogenesis

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:8] [Pages No:173 - 180]

Keywords: Osteogenesis, External fixator, Cytotoxic, Chemotherapy, Rabbit, Tibia, Bone tumor

   DOI: 10.1007/s11751-013-0179-2  |  Open Access |  How to cite  | 


Distraction osteogenesis can be used to replace segmental bone loss when treating malignant bone tumors in children and adolescents. These patients often receive cytotoxic chemotherapy as part of their treatment regimen. The effect of cytotoxic drugs on the cellular processes during distraction osteogenesis and the structural and mechanical properties of regenerate bone is unknown. We therefore used a rabbit model of distraction osteogenesis to determine that cytotoxic agents had a detrimental effect on regenerate bone formed by this technique. We administered adriamycin and cisplatinum to 20 rabbits using two different simulated chemotherapy regimens. All rabbits underwent an osteotomy at 12 weeks of age. Distraction osteogenesis began 24 h later at a rate of 0.75 mm a day for 10 days, followed by 18 days without correction to allow for consolidation. Regenerate bone was assessed using plain radiographs, bone densitometry, and mechanical testing. Peri-operative chemotherapy decreased the mechanical properties of the regenerate with regard to yield strain (3.7 × 10−2 vs. 5.2 × 10−2) and energy at yield (2.73 × 107 vs. 3.92 × 107). Preoperative chemotherapy in isolation reduced bone mineral density (0.38 vs. 0.5 g/cm2), bone mineral content (0.24 vs. 0.36 g), and volumetric bone mineral density (0.57 vs. 0.65 g/cm2) with no alterations in the mechanical properties. Conclusions: Preoperative chemotherapy appears to decrease the volume of regenerate bone, without affecting structural integrity, suggesting that the callus formed is of good quality. The converse appears true for peri-operative chemotherapy.



Narender Kumar Magu, Rohit Singla, Paritosh Gogna, Amanpreet , Nishant Jain, Shalini Aggarwal

Lumbar plexus injury in an anterior fracture dislocation of sacroiliac joint: a case report and review of literature

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:5] [Pages No:181 - 185]

Keywords: Lumbar plexus, MRI, Anterior, Dislocation, Sacroiliac, Exploration

   DOI: 10.1007/s11751-013-0177-4  |  Open Access |  How to cite  | 


Displaced unstable pelvic fractures are commonly associated with disruption of the osteoarticular junction of the sacroiliac joint. Posterior sacroiliac dislocation are commonly reported but there are only few reports the anterior type of sacroiliac dislocation where the iliac bone fractures and displaces anterior to sacrum, often in combination with fractures of pubic rami and symphyseal injuries. We present a case of an anterior type of sacroiliac fracture dislocation which was associated with a lumbar plexus injury involving both motor and sensory components. Preoperative neurological assessment was done by MRI scan. The tented nerve roots were explored and decompressed surgically, and sacroiliac fixation was done after reduction in the fracture and joint.



Louay Al-Mouazzen, Karthig Rajakulendran, Nurul Ahad

Fibrous dysplasia, shepherd's crook deformity and an intra-capsular femoral neck fracture

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:5] [Pages No:187 - 191]

Keywords: Fibrous dysplasia, Shepherd's crook, Femoral neck fracture

   DOI: 10.1007/s11751-013-0174-7  |  Open Access |  How to cite  | 


Fibrous dysplasia (FD) is a rare bone disorder in which normal medullary bone is replaced by fibro-osseous tissue. It typically presents in childhood with pain, skeletal deformities, gait abnormalities and occasionally, fatigue fractures. The management of FD remains a challenge. Surgical procedures have been developed to provide symptom relief, correct skeletal deformity and offer mechanical support in cases at risk of fracture. However, there is a paucity of data on the management of acute femoral neck fractures in the adult population with FD. We report the case of a 23-year-old man with a shepherd's crook deformity secondary to FD, who sustained an intra-capsular femoral neck fracture whilst playing football. The patient initially underwent closed reduction and internal fixation with cannulated screws. However, during the procedure, a guide wire broke whilst inside the femoral head. The patient was referred to the senior author, who undertook a second operation to remove the metalwork and correct the varus deformity using a closing-wedge femoral osteotomy, whilst achieving osteosynthesis at the fracture site. At 1-year follow-up, the patient is pain-free and demonstrates a full range of movement. These cases can be technically demanding and carry a greater risk of complication. It is important that preoperative planning is undertaken and surgery performed by individuals with experience in managing FD and complex femoral neck fractures. Correction of the skeletal deformity whilst fixing the fracture will help restore the mechanical axis and reduce the risk of a recurrent fracture.



Ronny Langenhan, Matthias Baumann, Bernd Hohendorff, Axel Probst, Per Trobisch

Arthroscopically assisted reduction and internal fixation of a femoral anterior cruciate ligament osteochondral avulsion fracture in a 14-year-old girl via transphyseal inside-out technique

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:5] [Pages No:193 - 197]

Keywords: Anterior cruciate ligament, Skeletally immature, Femoral avulsion fracture, Arthroscopic reduction and internal fixation

   DOI: 10.1007/s11751-013-0175-6  |  Open Access |  How to cite  | 


Femoral avulsion fracture of the anterior cruciate ligament (ACL) in children and adolescents is rare, and its arthroscopic treatment is even more so. A femoral avulsion fracture of the ACL of a 14-year-old girl was arthroscopically reduced and fixed by a Kirschner wire (K-wire) via an inside-out technique. A 1.4-mm K-wire was drilled inside-out into the osseous defect of the lateral femoral condyle under arthroscopic visualization. The avulsed fragment was reduced and then drilled retrograde by the wire. After bending the intra-articular visible end of the K-wire by a knot pusher, the fragment was gently fixed by pulling the wire from outside. At 24 months, both knee stability and range of motion were the same in the operated and the healthy opposite leg. Magnetic resonance imaging evaluation and conventional radiographs showed an intact ACL without detectable disturbance in the growth plate. Only seven cases of a proximal avulsion of the ACL in children and adolescents have been published. Six were treated by open reduction and internal fixation, one by arthroscopic reduction without fixation.



Sleiman Haddad, Pablo S. Corona, Maria M. Reverté, Carles Amat, Xavier Flores

Antibiotic-impregnated cement spacer as a definitive treatment for post-arthroscopy shoulder destructive osteomyelitis: case report and review of literature

[Year:2013] [Month:November] [Volume:8] [Number:3] [Pages:7] [Pages No:199 - 205]

Keywords: Shoulder, Arthroscopy, Destructive, Infection, Cement, Spacer

   DOI: 10.1007/s11751-013-0176-5  |  Open Access |  How to cite  | 


Arthroscopic revision of rotator cuff lesions is an increasingly popular procedure with a relatively safe profile. However, associated deep articular infection has been described, with potentially destructive joint sequelae. When occurring, it poses the double challenge of eradicating the infectious agent while preserving the articulation and its function. Experience remains scarce and is mostly based on case reports and small series. These also rely on the evidence from the better-described lower extremity joint infections. Through a complex case, the following report addresses this exceptional situation and offers an unusual solution, taking into consideration the peculiarities of the shoulder joint. With the consent of the patient, a single-stage resection arthroplasty with the implantation of an antibiotic-impregnated cement spacer was performed as a long-lasting—if not definite—treatment. After 4 years, the patient maintains excellent function with no radiological signs of wear or loosening.


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