Background:Neglected femoral neck fracture in adults still poses a formidable challenge. Existing treatment options varies from osteotomy (with or without graft) to osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularized, and nonvascularized fibula). The aim of this study was to assess outcome of nonvascularized fibular strut graft and cancellous screw fixation in neglected femoral neck fractures in the younger age group.Materials and Methods:Medical records of 32 patients of neglected femoral neck fracture, in the age group of 22-45 years (mean 37.8 years), operated between May 1994 to December 2001, were retrospectively reviewed. After the application of inclusion and exclusion criteria, 28 patients having three years minimum follow-up (mean 4.6 years) were included. Delay between injury and operation varied from four weeks to 42 weeks (mean 16.4 weeks). Closed reduction was achieved in 17 patients; open reduction through Watson-Jones anterolateral approach was performed in the remaining 15 patients in whom closed reduction failed. The fracture was transfixed with three parallel guide wires. Appropriate sized cannulated lag screw (7 mm) was then inserted in two of the wires. Selection of the third guide wire for fibula depended on the space available in both anteroposterior and lateral view.Results:Satisfactory bony union was obtained in 25 patients, of whom in four cases, the union occurred in 10-20° (mean 15°) of varus. Nonunion occurred in three patients (9.37%), and aseptic necrosis occurred in another six patients (18.75%). Of the 25 patients where union was achieved, five patients showed excellent results; 14 good and six had poor functional result, as evaluated using modified Anglen criteria.Conclusion:Nonvascularized fibular strut graft along with cancellous screws provides a dependable and technically less-demanding alternative procedure for neglected femoral neck fractures in young adults. Fibula being cortical provides mechanical strength besides stimulating the union and getting incorporated as biological graft.
Background:Gap nonunion of long bones is a challenging problem, due to the limitation of conventional reconstructive techniques more so if associated with infection and soft tissue defect. Treatment options such as autograft with non-vascularized fibula and cancellous bone graft, vascularized bone graft, and bone transportation are highly demanding on the part of surgeons and hospital setups and have many drawbacks. This study aims to analyze the outcome of patients with wide diaphyseal bone gap treated with induced-membrane technique (Masquelet technique).Materials and Methods:This study included 9 patients (7 males and 2 females), all with tibial bone-gap. Eight of the 9 patients were infected and in 3 patients there was associated large soft tissue defect requiring flap cover. This technique is two-stage procedure. Stage I surgery included debridement, fracture stabilization, application of spacer between bone ends, and soft tissue reconstruction. Stage II surgery included removal of spacer with preservation of induced membrane formed at spacer surface and filling the bone-gap with morselized iliac crest bone-graft within the membrane sleeve. Average bone-gap of 5.2 cm was treated. The spacer was always found to be encapsulated by a thick glistening membrane which did not collapse after its removal. All patients were followed up for an average period of 21.5 months.Results:Serial Radiographs showed regular uptake of autograft and thus consolidation within themselves in the region of bone gap and also with host bone. Bone-union was documented in all patients and all patients are walking full weight-bearing without support.Conclusions:The study highlights that the technique provide effective and practical management for difficult gap nonunion. It does not require specialized equipment, investigations, and surgery. Thus, it provides a reasonable alternative to the developing infrastructures and is a reliable and reproducible technique.
The current study tries to highlight the causes and quantity of neglect of malignant bone and soft tissue tumors prevalent in our country, which poses a therapeutic challenge for management and consequent mutilating surgeries with poor outcome resulting in loss of extremity and existence.
Background: Several fixation devices have been developed to overcome the difficulties encountered in the management of the unstable trochanteric fractures. PFN in unstable fracture patterns is progressively becoming standard method of fixation in view of its superior biomechanics and prevention of varus collapse in comparison to extramedullary devices. However, evolution of PFN is also not free from complications and may comprise complications associated with the migration of the interlocking head screws (Z-effect and reverse Z-effect), varus collapse, screw cutout, peri-implant fracture, non-union, delayed union, shortening and infection. Aims & Objectives: The objective of the paper is to describe the technical hitches, errors and modes of failure of PFN in unstable trochanteric fractures with their literature-based explanations and the recommendations to avoid such complications. Materials and methods: The current study is a critical appraisal of the technical hitches, errors and modes of failure of PFN in the course of its evolution in treatment of unstable trochanteric fractures. All patients with unstable trochanteric fractures from July 2013 to June 2015, treated with PFN were included in the study. The technical complications involved with surgical procedure and techniques adapted to overcome such complications were noted. All patients were followed up for a period of 2 years and final outcome assessment comprised the post-operative complications, mobility status, shortening and Harris hip score. Results: Forty five patients with unstable trochanteric fractures were treated with PFN during the study period. Forty two patients were available for final follow up at 2 years. Technical difficulties with the implantation of the PFN were documented in a total of 16 patients (35.55%) which included failed closed reduction in 8, entry point issues in 7, guide wire breakage in 3, fracture at nail tip in 1, difficulty in proximal locking due to Jig mismatch in 4. Post-operative complications included varus mal-reduction in 4, lag screw cutout leading to non-union in 2, differential migration of screws in 3, locking bolt missing the nail hole in 1 and peri-implant fracture in 1. All fractures went into union, except two with mean shortening of 0.5 cms. Mean neck shaft angle achieved post reduction was 130.5 degrees (range from 125-137) and at final follow up was 129.8 degrees. Conclusion: Even though intramedullary fixation is an established method of treatment of unstable trochanteric fractures, the evolution of the procedure is not free from complications. Surgery is technically demanding. However with proper execution, good outcome can be achieved with acceptable rates of complications even in unstable trochanteric fractures. Concerning the techniques making proper entry point, adequate reaming of proximal femur, passing the nail to avoid varus & distraction at fracture site and placing the lag screw in the inferior part of neck in anterior posterior projection and central in lateral projection reduces risk of fi...
Iatrogenic vascular injuries during total hip arthroplasty (THA) are rare but have serious consequences. The early diagnosis of vascular injuries is often difficult as the signs and symptoms are not specific. The average frequency is between 0.16% and 0.25%. Various mechanisms described in literature for causing iatrogenic vascular insult are injuries by retractors, mechanical stress, laceration, thrombotic occlusion and formation of false aneurysm. Such complications better be prevented or efficiently treated by thorough preoperative evaluation and vigilant post-operative examination. A case of common femoral artery thrombosis following THA is presented with emphasis on difficult aspect of diagnosis and management.
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