Modification of ordinary jig (angle guide) used for DCS fixation so as to make it more suitable for biological DCS. We have modified the jig used for ordinary DCS fixation so as to make it more suitable for biological DCS. In ordinary DCS jig, the hole for guide wire lies towards one end and the handle is attached at the other end. We have removed the handle and attached it adjacent to hole for guide pin so that the other end is free and can be slided in submuscular plane without actually exposing the whole length of femur. Subsequently, we beveled the free end and removed the sharp points and this helps in making sub muscular plane easily and with minimum soft tissue trauma. The modified jig was applied in a patient with fracture subtrochanteric femur in submuscular plane through 2 cm long incision and its position confirmed by c-arm. Position was found to be similar to that observed with ordinary DCS jig. The idea of making this presentation is that we can modify classical instrumentation used for internal fixation to make them suitable for biological fixation. This is a small innovation in that direction.
Anatomically contoured periarticular plates for treatment of proximal tibia fractures is fast becoming the standard for care. The aim of our study was to assess the accuracy of the anatomic contour of proximal lateral tibial plates of AO Stryker and Zimmer in Indian patients. We assessed the accuracy of the anatomic contour of proximal lateral tibial plates of AO Stryker and Zimmer in 50 Indian dry tibiae. All the plates were placed on the 50 tibia by two independent surgeons according to what they felt was the best fit. The tibiae and the plate fits were mapped, quantified, and analysed using digital image capturing and adobe photoshop software. By corresponding the clinical appearance of good fit with our digital findings, we created numerical criteria for plate fit in three planes: coronal (volume of free space between the plate and bone), sagittal (alignment with the tibial plateau and shaft), and axial (match in curvature between the proximal horizontal part of the plate and the tibial plateau). An anatomic fit should mirror the shape of the tibia in all three planes and only ten plates of different companies qualified this Recognising and understanding the substantial variations in fit that exist between anatomically contoured plates, it might be worthwhile developing proximal tibia plates specific for the Indian population or validating this study by having a larger multicentric study group. This paper would suggest caution when these plates are used as a tool for indirect reduction of the fractures.
Displaced intra-capsular fractures of femoral neck are treated by osteosynthesis in young adults. Using a standard protocol, we have compared the results of internal fixation after closed (CRIF) and open reduction (ORIF) in these patients. We have also studied the risk factors that influence non-union and avascular necrosis (AVN). Patients in the age group of 15–50 years, who were scheduled for internal fixation within 1 week of injury, were randomized into two groups, one for closed reduction and the other for open reduction. The two groups were compared for factors such as age, gender, time of surgery and posterior comminution as well as union and complications. Using univariate and multivariate methods the factors influencing non-union and AVN were analyzed. The average duration of surgery in patients undergoing CRIF was less than half of that in the ORIF group. The rates of union (p=0.93) and avascular necrosis at 2 years (p=0.85) were comparable. Rates of complications like deep vein thrombosis and infection were also found to be comparable. Guide wire breakage was found in 2 patients undergoing CRIF. Posterior comminution, poor reduction and improper screw placement were the major factors influencing non-union. An accurate reduction in both the planes and placement of screws parallel or slightly divergent to each other had a positive influence on union. An overall AVN rate of 16.3% (15/92) was encountered and it was not influenced by any of the factors. A delay of more than 48 hrs in surgery did not influence the rates of union or AVN.
Twenty one cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, managed by reconstruction nail were reviewed. All patients underwent simultaneous surgery for both fractures and operative treatment was executed as early as general condition of the patient permitted. Delay in treatment was generally because of associated injuries [head, chest or abdominal]. There were 20 males and 1female patients with an average age of 34.5 years. There was delayed diagnosis of neck fracture in 2 cases and these cases were not included in the study. Our average follow-up is 30.9 months. There was one case of nonunion of a femoral neck fracture, one case of avascular necrosis and one neck fracture that united in varus. There were 4 nonunions and 6 cases of delayed union of femoral shaft fractures. Mean time for union of femoral neck fracture was 15 weeks and for shaft fracture was 22 weeks. In our results, shaft fracture determined the total union period. Though complications involving the femoral shaft fracture were greater than the femoral neck fractures, the shaft complications were more manageable compared to neck complications. This stresses the need to realize the significance and seriousness of both components of this complex injury, in evaluation, management and postoperative care.
We have compared the results and complications after closed and open reduction with internal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury.
Thirty patients of infected nonunion of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Nonunion, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12cm (median bone gap of 7 cm), 10 cases of stiff non-union (6 of which had an associated deformity) and 5 cases of mobile non-union. The median time in Ilizarov frame was 150 days. Median follow up after frame removal was 33.5 months. Bone grafting at docking site was required in only 3 cases(10%). There were 3 cases of refracture(10%) and 3 cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in 3(10%), fair in none (0%) and poor in 6 (20%). The functional results were excellent in 8 patients (26.7%), good in 12 (40%), fair in3 (10%) and poor in 7 (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to appreciate the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.
