The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. Acetabular reconstruction in revision total hip arthroplasty can successfully be achieved with hemispherical components featuring a porous or roughened ingrowth surface and options for placement of multiple screws for minor acetabular defect. Acetabular component selection is mostly based on the amount of bone loss present. In the presence of combined cavitary and segmental defects without superior acetabular coverage, reconstructions with a structural acetabular allograft protected by a cage or a custom-made triflange cage have been one of preferred surgical options. The use of a cage or ring over structural allograft bone for massive uncontained defects in acetabular revision can restore host bone stock and facilitate subsequent rerevision surgery to a certain extent. But high complication rates have been reported including aseptic loosening, infection, dislocation and metal failure. On the other hand, recent literature is reporting satisfactory outcomes with the use of modular augments combined with a hemispherical shell for major acetabular defect. Highly porous metals have been introduced for clinical use in arthroplasty surgery over the last decade. Their higher porosity and surface friction are ideal for acetabular revision, optimizing biological fixation. The use of trabecular metal cups in acetabular revision has yielded excellent clinical results. This article summarizes author's experience regarding revision acetabular reconstruction options following failed hip surgery including arthroplasty.

Background:Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India.Materials and Methods:All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study.Results:Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20–39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than 24 h after injury.Conclusion:MVAs are the leading cause of vascular injuries in India. Road safety measures and prevention programs are the need of the hour to prevent these kinds of injuries in the future.

SUMMARY Skeletal myxomas are rare benign tumours. Their occurrence in long bones of the extremities is rarely reported. A 45-year-old man presented with pain in his left proximal thigh for a duration of 4 months. Movements of the hip were painful. Radiography revealed an expansile osteolytic lesion in the left proximal femur near the lesser trochanteric region. On MRI, the lesion showed a homogenous signal enhancement with no cortical disruption. Extended curettage and bone grafting was performed. On gross examination, the curetted specimen was a yellowishwhite mucoid material. Histopathology showed a tumour consisting of spindle-shaped and stellate-shaped cells with widely separated myxoid mucoidy stroma, suggestive of intraosseous myxoma. At 2 years followup, there were no signs of recurrence and the patient was doing well with excellent hip and knee function. BACKGROUND

Introduction: Open long bone fractures of lower limb are cumbersome to treat. Because of the increased chances of infection, wound debridement and external fixation is the primary procedure followed by a secondary intramedullary nailing when the wound improves. Pin tract infection, loss of fixation, non union is the most frequently encountered complications of external fixation. These complications have discouraged surgeons all over the world in accepting external fixation as a definitive method of fracture treatment. Secondary intramedullary interlocking nailing provides intramedullary input of cancellous tissue at the fracture site due to reaming and nailing. Aim: To evaluate the factors determining the outcome after secondary nailing in open fractures of lower extremity. Materials and Methods: The prospective cohort study was conducted from October 2017 to April 2020 at Pondicherry Institute of Medical Sciences, Pondicherry, India, 33 patients who had open long bone fractures of lower limb and underwent secondary nailing following external fixation, were evaluated. The patients were followed up for a period of six months. Factors such as age, bone involved, grade of injury, timing of debridement, time interval between external fixation and secondary nailing were analysed to see whether they affect the outcome of secondary nailing of open fractures of long bones. All patients underwent an initial thorough wound debridement and external fixation application. A secondary nailing was done once wound had settled down. Age, gender, bone involved, grade of injury, timing of debridement and timing of secondary nailing were noted for all the patients and patients were followed up at six weeks, three months and six months. Final functional outcome (end of six months) was calculated using Lower Extremity Functional Scale (LEFS) and radiological union (end of six months) was calculated using Radiological Union Scale in Tibial fractures score (RUST). Results: There were no statistically significant differences in RUST/LEFS score at the end of six months, with respect to age (p-value=0.825/0.847), gender (p-value=0.235/0.348), bone involvement (p-value=0.726/0.757), grade of injury (p-value=0.107/0.546) and timing of debridement (p-value=0.117/0.374). The mean RUST scores at six weeks, three months and six months were 4.39, 6.57 and 9.28, respectively. The mean LEFS scores at six weeks, three months and six months were 20.96, 34.92, 49.5, respectively. The radiological union rate in this study was 60.61% at the final follow-up. But patients who underwent secondary nailing with 10 days of primary debridement and external fixation had a statistically significant (p-value) better outcome in terms of RUST (p-value at 3 months=0.045)/LEFS (p-value at 6 months=0.030). Conclusion: The interval between external fixation and secondary nailing was found to be a significant determinant of radiological outcome at three months (p-value at 3 months=0.045) and better functional outcome at six months (p-value at 6 months=0.030) with patients undergoing secondary nailing within 10 days of external fixation having a good final outcome. However, the radiological outcome between the two groups was comparable at six months follow-up.

Clavicle fractures are very common accounting for 5-10% of all fractures and 44% of all shoulder injuries. Biomechanical studies reveal that the middle third is the weakest and accounts for 80% of all clavicle fractures and more than 50 percent of these fractures are displaced. Traditionally displaced middle third clavicle fractures were treated conservatively with figure of '8' harness with its own complications such as malunion, shortening of the clavicle and non-union in cases of increased displacement. Modern day trend in treating them with internal fixation provide rigid immobilization and pain relief avoiding non-union, shortening and deformity. Earlier studies reported non-union rate of less than 1% with conservative management. But those studies were not standardized. They had variable proportions of patients in various ages, with variable sites of fracture and of variable fracture configuration. Recent studies have shown that displaced mid-shaft clavicular fractures do not have assured favourable outcomes with non-operative management and non-union rates could be as high as 20%. In this study we evaluated 30 patients with middle third displaced comminuted clavicular fractures treated by open reduction and internal fixation with anatomical S plate and primary bone grafting. These patients were followed up at 6 weeks, 12 weeks and 6 months with radiological (X-rays) and functional assessment with DASH score and Constant shoulder score questionnaire. At the end of 6 months all these patients went on to union with a statistically significant functional outcome at various study intervals (DASH score with p value <0.05 and Constant scoring with p value <0.05). Hence we conclude as mid third comminuted clavicle fractures treated with open reduction and internal fixation with anatomical S plate and primary bone grafting, unite early with excellent functional outcome, assessed by DASH and Constant shoulder score.