A case report of the Hoffa fracture and a review of literature

The Hoffa fracture is an uncommon fracture. There is a lot of confusion about its diagnosis and management with several conflicting reports in literature. We reported a 25-year-old patient with non-union of Hoffa fracture, and meanwhile tried to develop an algorithm-based treatment for Hoffa fractures. A systematic review of the available literature was performed. Medline, Embase, the Cochrane Library and PubMed were searched for relevant articles. Fifty-five articles were reviewed, and the clinical knowledge base was summarized. The understanding of the mechanism of trauma has become more nuanced. The literature has also evolved to classify the fracture with the purpose of surgical management in mind. This can be used to plan approach and fixation with preservation of blood supply. Classification can also prognosticate the outcomes in Hoffa fracture.

Proximal Fibular Osteotomy: Biomechanics, Indications, Technique, and Results

The evidence base is growing regarding proximal fibular osteotomy. Most studies show that the pain relief and improvement in terms of radiology is statistically significant. More understandable biomechanical theories explaining this improvement are appearing. Because it has a low complication rate and is relatively easy to execute, proximal fibular osteotomy should definitely be considered in any algorithm for the treatment of medial compartment osteoarthritis of the knee. [Orthopedics. 2020;43(6):e627-e631.].

COVID-19 in the operating room: a review of evolving safety protocols

BACKGROUND

The COVID-19 pandemic has already infected more than 3 million people across the world. As the healthworkers man the frontlines, the best practices model is continuously evolving as literature concerning the Coronavirus develops.

METHODS

A systematic review of the available literature was performed using the keyword terms "COVID-19", "Coronavirus", "surgeon", "health-care workers", "protection" and "Orthopaedic Surgery". All peer-reviewed articles we could find were considered. Randomized controlled trials (RCTs), prospective trials and retrospective studies, as well as reviews and case reports, were included in this systematic review.

RESULTS

Even though surgical specialties including orthopedics are on the relative sidelines of the management of this pandemic but best practices models are inevitably developed for surgical specialties. The algorithm of postpone, delay, and operate only when life-threatening conditions exist is going to be useful up to a point.

CONCLUSION

The surgical staff needs to keep abreast of the latest literature concerning safety measures to be taken during surgical procedures. Review articles can go some distance in helping in this educational process. This knowledge must evolve as new information comes to light.

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir

PURPOSE

Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature.

METHODS

From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered.

RESULTS

All patients weremales with an age range of 11e32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot.

CONCLUSION

Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population

OBJECTIVES

Diabetes mellitus (DM), is affecting an ever increasing number of people worldwide. Diabetes is associated with several musculoskeletal manifestations. These may involve, the upper as well as the lower limb. We conducted this study to find out the prevalence of musculoskeletal problems in type 2 diabetics in the Kashmiri population.

METHODOLOGY

The study was conducted on 403 patients with diabetes and 300 controls. All patients underwent screening for any musculoskeletal abnormalities. The patients with musculoskeletal abnormalities were further assessed to find the exact diagnosis according to predefined criteria.

RESULTS

The hand was involved in 80 patients [19.8%] in the diabetic group and 15 (5%) patients of the control group. The elbow was affected in 56 patients [14%] in the diabetic group and 24 patients [5.9%] in the non-diabetic group. The shoulder involvement was diagnosed in 61 patients [15%] on the diabetic cohort and 15 patients in the non-diabetic cohort. All the upper limb figures showed a statistically significant difference i.e. P value <0.05.

CONCLUSION

The prevalence of musculoskeletal complications in type 2 diabetics in Kashmir is quite high.

The Gibson and Piggott osteotomy for adult hallux valgus

BACKGROUND

The Gibson and Piggott procedure for hallux valgus is based on sound surgical principles addressing the basic pathologies of this disorder. However, this procedure has not been studied extensively in the literature in comparison to the Mitchell and Chevron osteotomies.

MATERIAL AND METHODS

We report a prospective study conducted on 50 adult feet with hallux valgus. The Gibson and Piggot osteotomy was done on all the feet.

RESULTS

We obtained 76% excellent and 18% good results with this procedure.

CONCLUSION

The results bear out the fact that this procedure is a useful procedure for the management of this disorder.

Toilet seat injury of the Achilles tendon a series of twelve cases

Lacerations of the Achilles tendon are caused by a number of mechanisms. The toilet seat as a cause of Achilles tendon injury is rare. We report on this rare mechanism of laceration of the tendo Achilles. The injury can be avoided with the use of western toilets and the additional devascularisation caused by extending the wound should be avoided while repairing the tendon in such situations.

Contracture of the third toe as a delayed presentation of a foreign body in the foot

Foreign body retention in the foot after a penetrating injury is an unusual occurrence with varied presentation. A degree of suspicion needs to be present in situations where there is an inexplicable swelling, sinus, abscess, or tenderness. The authors present a case with a contracture of the third toe that had been caused by plantar fascial fibrosis secondary to retention of a rubber foreign body in the foot. This case report highlights the fact that an ultrasound to rule out retention of the foreign body might be a judicious investigation if common causes of toe contracture are excluded. It may also have therapeutic implications.

The reciprocal ledge closing wedge osteotomy for post traumatic coxa vara

To report a proximal femoral osteotomy with retention of bone ledges in a reciprocal position to increase bone contact and stability. The method was applied to 5 patients over a 3-year period. All patients had coxa vara. The average length gained was 1.5 cm, and the average neck shaft angle improvement was 30°. The Harris hip score improved from an average of 63 to 82. The reciprocal ledge osteotomy is technically less demanding and also allows conversion of normal shear forces around the upper femur to stabilizing forces. This method allows easier use of the DHS implant as potential rotation about the axis of the screw is negated by the ledges and the dynamic forces.

Transmalleolar approach to a tubercular lytic lesion of the talar body: a case report

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

A reciprocating ledge technique in closing wedge osteotomy for genu valgum in adolescents

PURPOSE

To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy.

METHODS

Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee.

RESULTS

All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12-15) weeks. The mean correction of the tibiofemoral angle was 13 degrees. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity.

CONCLUSION

Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.

Treatment of ipsilateral high energy tibial plateau and calcaneal fractures by a circular wire fixator: a case report

Introduction

High energy tibial plateau fractures along with calcaneal fractures individually produce several challenges for the orthopaedic surgeon. The principles of bony reconstruction include anatomic reduction and rigid internal fixation of intra-articular fractures and accurate restoration of the coronal, sagittal and transverse mechanical axes. Due to the tenuous nature of the soft tissue and devitalisation of the comminuted fragments with open reduction, external fixation of type 6 tibial plateau fractures is recommended. We report a case with ipsilateral high energy tibial plateau and calcaneal fractures both of which were managed with an ilizarov ring fixator.

Case presentation

A 55-year-old Kashmiri female presented to our department with an ipsilateral fracture of the tibial plateau and the calcaneum. Both were closed reduced and stabilized with an ilizarov ring fixator.

Conclusion

The circular wire fixator provides a viable method to manage such fractures especially if they are co existent. This is especially true in situations where the soft tissue is compromised.

Draining infected non union of the distal third of the tibia. The use of invaginating docking over short distances in older patients

BACKGROUND

The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group.

MATERIAL AND METHODS

12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years.

RESULTS

The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result.

CONCLUSION

The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

Differentiating mass disasters. The barzullah classification

BACKGROUND

To assess the pattern of mass casualty incidents managed at our hospital over the last eight years, and evolve a differentiating classification based on this pattern. A combination of retrospective and prospective assessment was made.

MATERIAL AND METHODS

All patients receiving injuries in mass casualty incidents and managed at our hospital. Patients with an injury severity score above 9. Management of injuries as per the trauma management protocol. Classification based on the data collected during the study and application of this classification to the subsequent mass casualty incidents to allow comparison between similar incidents in different settings.

RESULTS

A classification system that mainly differentiates mass casualty incidents on the hospital basis, the criteria being: the time interval between the first information to first reception, and the percentage of admission above the maximum normal intake.

CONCLUSIONS

The Barzullah classification system is the first attempt at developing a hospital based differentiation in mass casualty incidents. It provides a valid and easy method of comparing such incidents between hospitals and perhaps a basis for developing protocol for mass disaster management.

Acute invaginating docking for infected non-unions of the humerus

PURPOSE

To assess the efficacy of acute invaginating docking for infected non-unions of the humerus.

METHODS

Eight men and 3 women aged 17 to 59 years with infected non-unions of the humerus underwent acute invaginating docking with shortening and Ilizarov fixation.

RESULTS

The mean shortening was 2.9 cm owing to additional debridement. The mean time to external fixator removal was 14.9 (range, 8-28) weeks. The final bone result was excellent in 1, good in 8, and fair in 2. The functional result was excellent in 7 and good in 4.

CONCLUSION

This modality enables simultaneous treatment of infected non-unions, axial alignment, vascularity, stability, and function.

Unforeseen difficulties faced by a hospital in dealing with mass disaster victims

Every major mass disaster challenges the health care services, especially in the third world. These challenges include the expected situations mainly pertaining to the overload of patients and the stretching of hospital facilities. We report our experiences about several unforseen challenges faced by our hospital in the 2005 earthquake that struck the Kashmir region.

Operative management of a subtrochanteric fracture in severe osteoporosis. a case report

BACKGROUND

Fractures of the subtrochanteric region of the femur provide several challenges to the operating surgeon due to anatomic and biomechanical peculiarities inherent to this region. These challenges are compounded several times in a severely porotic bone.

CASE PRESENTATION

We report a case with severe osteoporosis who sustained a subtrochanteric fracture and was managed with a Dynamic condylar screw DCS. Three years after the surgery the patient is pain free and has a full range of motion.

CONCLUSION

This highlights the fact that the DCS provides a viable alternative in the management of fractures of the subtrochanteric region in severe osteoporosis. This advantage is particularly manifest in settings where the image intensifier is not easily available.

The unreported morbidity of suicidal poisonings during an insurgency: a 16-year Kashmir experience

Around a million people commit suicide, and at least 10 times this number attempt suicide, worldwide every year. No nationwide epidemiological studies have been undertaken in India but a significant rise in suicides has been observed in Kashmir in recent years. This study was carried out on patients reporting to the Government SMHS Hospital in Srinagar with a history of suicidal poisoning.

Management of lower limb fractures in polytrauma patients with delayed referral in a mass disaster. The role of the Ilizarov method in conversion osteosynthesis

Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases.

Osteosynthesis for a T-shaped fracture of the femoral neck and trochanter: a case report

Ipsilateral fractures of the femoral neck and trochanter are uncommon. We report a 30-year-old man with a T-shaped fracture separating the trochanter and neck from the head. He underwent osteosynthesis using a dynamic compression plate, screws, and pins. Bone union occurred 4 months postoperatively. At the one-year follow-up, the patient was free of pain and had no evidence of avascular necrosis. It is important to preserve the femoral head in young patients by preventing further compromise of the tenuous blood supply.

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.

Delayed union of an operated fracture of the femoral neck

Fracture of the femoral neck continues to be a vexing clinical and therapeutic challenge for the orthopedic surgeon. The fracture has a propensity for non-union and avascular necrosis. It is a challenge for the orthopedic surgeon to decide when to intervene in a case with non-union where the implant continues to be in place. We present a case with persistent clinical and radiological non-union signs where the fracture eventually united after 32 months. The case bolsters the view that a continued conservative regime might entail good results in such situations.

Pattern of orthopaedic injuries in bear attacks: report from a tertiary care centre in Kashmir

Interaction between humans and wild animals has increased in recent times, because of overlap of habitats. A proportion of this interaction is violent. Most of the literature describing the injuries sustained by humans in such contact pertains to the involvement of soft tissues. Trauma to bones and joints is only witnessed when larger animals attack humans. We studied the pattern of orthopaedic injuries over a period of 2 years in a series of 32 cases presenting to our hospital with a history of being attacked by the Asian black bear (Ursus thibetanus). This paper also documents the complications and challenges involved in managing these injuries. We suggest that orthopaedic traumatologists need to be prepared to deal with such cases in areas where interaction between humans and large wild animals is manifest.

'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist

BACKGROUND

Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma.

RESULTS

At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality.

CONCLUSION

In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.

Femoral ledge sparing closing wedge osteotomy

Collapse

The dynamic condylar screw in the management of subtrochanteric fractures: does judicious use of biological fixation enhance overall results?

Subtrochanteric fractures are fraught with certain anatomic, biologic and biomechanical challenges. Evolution of implants like the Gamma nail, fixed-angle nail plates, compression hip screws and dynamic hip screws with trochanteric stabilization plates underlines a persistent quest for a better implant. We studied the dynamic condylar screw DCS as an implant on a series of 30 consecutive patients with subtrochanteric fractures. Our purpose was to assess this implant as a panacea for subtrochanteric fractures. All cases of AO type A and B were anatomically fixed, whereas type C was biologically plated. The idea was to assess the applicability and adaptability of the DCS. Fractures in 29 cases united, with one patient suffering from an implant failure. There were 17 excellent, 5 good, 5 fair and 3 poor results. The DCS is a definite advance over previous methods of treatment; when combined with the utilization of biological fixation techniques for comminuted fractures, can be relied upon to treat all types of subtrochanteric fractures.

Distraction osteogenesis for ulnar lengthening in Kienbock's disease

Ulnar lengthening is an accepted modality of treatment to achieve joint levelling in Kienbock's disease. The conventional method of ulnar lengthening with a plate and bone graft is fraught with complications including graft site morbidity, non-union, hardware removal and difficulty in the achievement of a proper length. We used a Umex distractor to achieve distraction osteogenesis in a group of 12 patients and assessed them over an average follow-up period of 29.5 months. We had one excellent, ten good and one fair result. We conclude that distraction osteogenesis addresses all the complications of coventional lengthening in addition to providing an increase in the local blood supply, which might be beneficial in a disease that is primarily an avascular necrosis. This procedure addresses both the biomechanical and the biological aspects of this disease.

In situ instrumented posterolateral fusion without decompression in symptomatic low-grade isthmic spondylolisthesis in adults

Forty patients with an average age of 26.5 years were treated for symptomatic low-grade isthmic spondylolisthesis with in situ instrumented posterolateral fusion. All patients had failed previous conservative treatment. Average follow-up was 42.2 months (range: 30-62 months). Low-back pain resolved in 70% of the patients, whereas 65% of those with radicular pain reported complete resolution of the symptoms. At the final follow-up 82.5% of the patients had improvement in their function. Solid fusion was achieved in 70% of the patients. It was uncertain in 10% and a fusion failure was seen in 20%. The anterior slippage as measured by the Taillard method was 31.55% and an average 35% correction was seen after surgery. However, an average 10% loss of correction was seen at the final evaluation. The clinical results were evaluated by Kim and Kim criteria. Satisfactory results were obtained in 65% of patients and this was closely associated with the rate of successful fusion. The results suggest that clinical outcome is closely related to the attainment of solid fusion and decompression or removal of the loose laminar fragment seems unnecessary in patients without major neurological symptoms.

Acute peg in hole docking in the management of infected non-union of long bones

The Ilizarov method has been studied extensively in the management of non-union of long bones. In most cases this involves filling of defects present primarily or after débridement by bone transport. Acute docking over gaps longer than 2 cm has not been adequately studied, however. The purpose of this paper is to report the efficacy of acute peg in hole docking as a bone graft-sparing modality in the management of infected non-union of long bones.