Cement beads and cement spacers: indications, techniques, and clinical results

Objectives

To report our experience on the use of antibiotic coated nails (ACN) and cement beads for the management of bone infections.

Materials and methods

Infected nonunion (INU) cases were classified as: Type I (mild infection with no gap), Type II (moderate with good alignment, severe infection, gap <3 cm, no deformity), Type III (severe infection with gap ≥3 cm, deformity and limb shortening). Treatment involved either the insertion of ACN and cast (Type I), insertion of ACN, beads and external fixator (Type II), or Ilizarov methodology (Type III). A subset of 28 open fractures were admitted with severe contamination or delayed presentation with established infection and treated with debridement, ACN insertion, and antibiotic beads placed in soft tissue dead space areas.

Results

Results of 133 cases were classified excellent, good, and poor. Type I INU reported 40 excellent and 22 good results. Type II INU reported 28 (39%) excellent, 30 (43%) good, and 13 (18%) poor results. Poor results were due to uncontrolled infection and knee stiffness. Three patients required knee fusion and 1 required amputation. Fracture union was reported in 68 cases. Four of the 28 Gustilo grade III open fractures treated with ACN developed infected nonunion and had poor function caused by stiff knees.

Conclusions

An antibiotic impregnated cement nail (ACN) fills the dead space and elutes high concentrations of antibiotics providing some mechanical stability. We recommend the adjunct use of an ACN for the management of INU cases and for use in select cases of Gustilo grade III open fractures.

Indian orthopaedics: the past, present, and future

The editorial summarizes the Indian orthopaedic history in brief and provides an overview of the articles to be published in the Indian traumatology edition.

Trauma care systems in India and China: A grim past and an evolving future

Neither India nor China has a formalized trauma system in place. There are many similarities between the 2 countries in terms of size, rapid economic growth, increasing number of motor vehicles, and high rates of road traffic accident (RTA) fatalities. This paper describes the current development of elements of the trauma system in China and the strategies and efforts made to improve the trauma system in India. In China, though not organized and formalized, different phases of the trauma system are present at varying levels of maturity. In India, efforts are made to implement a trauma system by mainly focusing on preventive measures and the creation of trauma designated facilities. Although progress has been made, the concept of "adequate trauma care for all" continues to remain an aspiration in many Asian countries, including India and China. Continued and concerted effort across many levels will be required to achieve this goal.

Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: management by excision of non-union, bone grafting and stabilization by LCP in different modes

Non-union of the humeral shaft is infrequently noticed after surgical fixation. Sixty eight patients whose osteosynthesis of humeral shaft had failed leading to non-union were identified over a duration of 10 years from (January 2006 to December 2015). Clinical and radiographical follow-up was available for 64 patients (4 patients were lost for follow-up), with a mean age of 58 years (range 25-78 years). All patients had aseptic atrophic non-union of either: proximal shaft (n=12), mid shaft (n=38), and lower shaft (n=14). All these patients had failure of primary fixation, with a minimum duration from 36 to 110 weeks. Non-unions were operated by excision of non-union, autogenous bone grafting and osteosynthesis by locking compression plating. Adequate fixation of non-union with bone grafting was achieved in all patients. All non-unions healed well at an average of 16 weeks (range 6-36 weeks). The mean length of follow-up was 120 weeks (range 60-250 weeks). The mean range of movements following healing of non-union was forward flexion of 140°, external rotation and internal rotation of 30° at shoulder and average fixed flexion deformity of 10° and flexion of 130° at elbow. Two patients had postoperative radial nerve palsy because of neuropraxia, which recovered in eight weeks. Three patient developed superficial infections at the iliac crest, which settled with antibiotics, dressings in 3 weeks time and two patients had some discomfort over the fibular graft harvest site. In all patients complete clinical and radiological union was achieved with satisfactory outcome in terms of relief of symptoms and functional improvement in the range of movements. The main points in surgical treatment were complete excision of non-union, correction of deformity, use of plenty of corticocancellous graft, furthermore the use of intramedullary fibula and osteosynthesis by long locking compression plating in different modes of fixation provided good to excellent results and clinical outcome.

Accuracy of valgus osteotomy using dynamic hip screw

BACKGROUND

Non-union of neck femur is a common but difficult situation to manage especially in young adults. There are two main options of arthroplasty or osteotomy. The aim of this study was to assess the results of intertrochanteric valgus osteotomy in non-union femoral neck fractures.

PATIENTS AND METHODS

We present a study of 44 cases of neck femur non-union including untreated fractures, late presentations (more than 3 weeks), treated with compression screw, DHS. From 2006-2016, 44 patients presented to our institute and we analyzed them prospectively on the following criteria: Pauwel's angle, Garden classification, union at fracture site, union at osteotomy site, osteoporosis and AVN changes. Inclusion criteria were age<65, neck not reabsorbed, no AVN. Powel's angle was calculated using the anatomic axis of femur. Wedge angle is equal to Powel's angle minus 30 degree. Entry point of DHS was at the base of greater trochanter and tip of the screw was in the inferior quadrant. Y osteotomy was done in the distal half of the lesser trochanter with a proximal straight cut.

RESULTS

Complete union was noted in 93% of the cases. One patient with uncontrolled diabetes developed severe infection and was treated with excision arthoplasty. AVN occurred in 3 cases. The Powell's angle was reduced to mean 30 (22-39). The neck shaft angle was increased to mean 140 (130-150). Limp was noted in almost all patients but they were able to walk full weight bearing with or without the support of a stick.

CONCLUSION

Valgus intertrochanteric osteotomy achieved good union rates and good functional outcome with minimal complications.

Unstable trochanteric fractures: Issues and avoiding pitfalls

The incidence of trochanteric fractures is rising because of increasing number of senior citizens with osteoporosis. There are various modalities for reduction and internal fixation. However, the incidence of complications remains high. In the herein article we discuss issues that influence the fixation and outcomes of unstable trochanteric fractures. Moreover, the results of a prospective, randomised, cohort, time bound, hospital based, comparative study is presented.

A randomized placebo-controlled trial of the efficacy of denosumab in Indian postmenopausal women with osteoporosis

INTRODUCTION

Osteoporosis is a serious condition affecting up to 50% of Indian postmenopausal women. Denosumab reduces bone resorption by targeting the receptor activator of nuclear factor-κB ligand. This study assessed the efficacy and safety of denosumab in Indian postmenopausal women with osteoporosis.

MATERIALS AND METHODS

In this double-blind, multicenter, phase 3 study, 250 Indian postmenopausal women aged 55 to 75 years (T-score <-2.5 and >-4.0 at the lumbar spine or total hip; serum 25(OH) D levels ≥20 ng/mL) were randomized to receive one subcutaneous dose of denosumab 60 mg or placebo. All subjects received oral calcium ≥1000 mg and vitamin D3 ≥ 400 IU daily. The primary end point was mean percent change in bone mineral density (BMD) at the lumbar spine from baseline to Month 6. Secondary end points included mean percent change from baseline in BMD at total hip, femoral neck, and trochanter at Month 6 and median percent change from baseline in bone turnover markers at Months 1, 3, and 6.

RESULTS

Total 225 subjects (denosumab = 111, placebo = 114) completed the six-month study. Baseline demographics were similar between groups. A 3.1% (95% confidence interval, 1.9%, 4.2%) increase favoring denosumab versus placebo was seen for the primary end point (P < 0.0001). Denosumab demonstrated a significant treatment benefit over placebo for the secondary end points. There were no fractures or withdrawals due to adverse events.

CONCLUSIONS

Consistent with results from studies conducted in other parts of the world, denosumab was well tolerated and effective in increasing BMD and decreasing bone turnover markers over a six-month period in Indian postmenopausal women.

Low bone mineral density in Indian patients with fragility fractures

OBJECTIVE

Low bone mineral density (BMD) is a major risk factor for fragility fractures in osteoporosis. In recent studies, its use with clinical risk factors has been shown to enhance prediction of fragility fractures. The present study was done to assess BMD in Indian patients with fragility fractures using digital X-ray radiogrammetry (DXR-BMD).

METHODS

A total of 228 patients (64 male and 164 female) admitted to an Orthopedic Hospital for management of fragility fracture were recruited. For each patient, DXR-BMD was obtained from an anteroposterior radiograph of the non-dominant hand.

RESULTS

The number of subjects with hip fracture was 104 (40 male, 64 female). Vertebral fractures were seen in 67 patients (11 male, 56 female) and distal radial fracture in 57 patients (13 male, 44 female). The DXR-BMD (g/cm(2)) was significantly lower in subjects with any fragility fracture (0.51 vs. 0.58 in men and 0.41 vs. 0.54 in women). When compared to the age-matched normative reference data by decade, all subjects with fragility fracture had significantly lower DXR-BMD except male subjects in the age decade of 40-49 years.

CONCLUSION

This study confirms lower DXR-BMD in Indian subjects with fragility fractures. This may have a potential role in fracture prediction when used with clinical risk factors in the Indian population.

Controversies in the management of intra-articular fractures of distal humerus in adults

BACKGROUND

The surgical approach, type of olecranon osteotomy, method of stabilization of osteotomy, type of fracture stabilization, orthogonal vs parallel plate fixation, need for transposition of ulnar nerve, place for primary total elbow replacement, and type of rehabilitation schedule after surgical fracture treatment are the controversial issues in the treatment of complex intra-articular distal humerus fractures (C2 and C3) in adults. Severe comminution, bone loss, and osteoporosis at the site of distal articular fractures of humerus often lead to unsatisfactory results due to inadequate fixation. We hereby report the outcome of a series of intracondylar fractures of the humerus treated by open reduction and internal fixation and discuss the controversies in light of published literature.

MATERIALS AND METHODS

One hundred and eighty-four patients of intra-articular fractures of distal humerus (C2 and C3) were operated by posterior transolecranon approach between January 1980 and December 2008. Initially, in the first part Chevron intra-articular osteotomy (n=108) was performed out of which 94 have been published in another publication. In later second part (1993 onward), extra-articular olecranon osteotomy (n=76) was routinely performed. Both columns were stably fixed by orthogonal methods; (n=174) however, during the last 2 years, in 10 patients with severe comminution with bone loss, stabilization was achieved by parallel plating. The osteotomy was routinely stabilized by tension band wiring with two parallel K-wires introduced up to the anterior ulnar cortex. The results were evaluated by the staging system of Caja et al. at a minimum follow-up of 2 years.

RESULTS

In the first part of the study (n=94), there was delayed union in 4% (n=4), with the fracture taking more than 20 weeks for union. There was delayed union of ulnar osteotomy (n=3) and failure of one tension band wiring, requiring revision. Some loss of motion was seen in 20% of cases and these patients did not achieve full flexion and extension. However, all these patients had useful range of function, with 20°-110° of flexion and full pronation-supination. As per the staging system of Caja et al., the results were in the range of excellent to good in 72% cases (n=67), fair in 19% (n=18), and poor in 9% patients (n=9). In the second part of study (n=90) dual plate fixation of both columns by orthogonal methods (n=80) and parallel plate fixation in 10 patients was performed. The results were excellent to good in 78 patients (86%).

CONCLUSIONS

The high rate of union can be achieved in complex intra-articular fractures of distal humerus if the proper principles of stable fracture fixation are followed, i.e., a posterior transolecranon approach and dual fixation of both columns and restoration of the continuity of articular surface. The stability achieved by this technique permits institution of early intensive physiotherapy to restore elbow function.

Role of gamma nail in management of pertrochanteric fractures of femur

BACKGROUND

Pertrochanteric fractures which involve trochanteric fractures with varying fracture geometry pose a significant challenge to the treating orthopedic surgeon. The aim of this study is to evaluate the management of pertrochanteric fractures of the femur using gamma nail [Asia pacific (AP)].

MATERIALS AND METHODS

Sixty patients of pertrochanteric fractures were treated by closed reduction internal fixation by gamma nail from 1 January 1993 to 31 December 2000. Four patients were lost to follow-up. The remaining 56 patients were followed for a mean period of 3.2 years (range 2-4 years).The results were evaluated by assessing the patients regarding their clinical and functional outcome at follow-up as per Kyle's criteria.

RESULTS

Peroperative jamming of nail (n = 1), failed distal locking (n = 1), superior cut out of lag screw (n = 1) and postoperative varus malreduction (n = 1) were the complications observed. End results were excellent in 46.34%, good in 36.58%, fair in 14.64%, poor in 2.43%.

CONCLUSION

Gamma nail in expert hands is a suitable implant for management of pertrochanteric fractures of the femur.

Total knee arthroplasty for severe valgus deformity

BACKGROUND

In 1985, the senior author (C.S.R.) developed a new soft-tissue release technique to balance valgus knees to avoid unacceptably high rates of late-onset instability and the need for primary constrained implants. This report describes the soft-tissue release technique and its long-term results when performed in primary total knee arthroplasty in patients with a severe valgus knee deformity.

METHODS

Four hundred and ninety consecutive total knee arthroplasties were performed by one surgeon between January 1988 and December 1992. In this group, seventy-one patients (eighty-five knees) had a valgus deformity of 10 degrees . Thirty-two patients (thirty-six knees) died, and four patients (seven knees) were lost to follow-up, leaving thirty-five patients (forty-two knees) followed for a minimum of five years. These twenty-seven women and eight men had a mean age of sixty-seven years at the time of the index operation. The technique included an inside-out soft-tissue release of the posterolateral aspect of the capsule with pie-crusting of the iliotibial band and resection of the proximal part of the tibia and distal part of the femur to provide a balanced, rectangular space. Cemented, posterior stabilized implants were used in all knees. Clinical and radiographic evaluations were performed at one, five, and ten years postoperatively.

RESULTS

The mean modified Knee Society clinical score improved from 30 points preoperatively to 93 points postoperatively, and the mean functional score improved from 34 to 81 points. The mean range of motion was 110 degrees both preoperatively and postoperatively. The mean coronal alignment was corrected from 15 degrees of valgus preoperatively to 5 degrees of valgus postoperatively. Three patients underwent revision surgery because of delayed infection, premature polyethylene wear, and patellar loosening in one patient each. There were no cases of delayed instability.

CONCLUSIONS

The inside-out release technique to correct a fixed valgus deformity in patients undergoing primary total knee arthroplasty is reproducible and provides excellent long-term results.

Nonunion of the diaphysis of long bones

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.

Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up

BACKGROUND

In 1985, the senior author (C.S.R.) developed a new soft-tissue release technique to balance valgus knees to avoid unacceptably high rates of late-onset instability and the need for primary constrained implants. This report describes the soft-tissue release technique and its long-term results when performed in primary total knee arthroplasty in patients with a severe valgus knee deformity.

METHODS

Four hundred and ninety consecutive total knee arthroplasties were performed by one surgeon between January 1988 and December 1992. In this group, seventy-one patients (eighty-five knees) had a valgus deformity of > or =10 degrees . Thirty-two patients (thirty-six knees) died, and four patients (seven knees) were lost to follow-up, leaving thirty-five patients (forty-two knees) followed for a minimum of five years. These twenty-seven women and eight men had a mean age of sixty-seven years at the time of the index operation. The technique included an inside-out soft-tissue release of the posterolateral aspect of the capsule with pie-crusting of the iliotibial band and resection of the proximal part of the tibia and distal part of the femur to provide a balanced, rectangular space. Cemented, posterior stabilized implants were used in all knees. Clinical and radiographic evaluations were performed at one, five, and ten years postoperatively.

RESULTS

The mean modified Knee Society clinical score improved from 30 points preoperatively to 93 points postoperatively, and the mean functional score improved from 34 to 81 points. The mean range of motion was 110 degrees both preoperatively and postoperatively. The mean coronal alignment was corrected from 15 degrees of valgus preoperatively to 5 degrees of valgus postoperatively. Three patients underwent revision surgery because of delayed infection, premature polyethylene wear, and patellar loosening in one patient each. There were no cases of delayed instability.

CONCLUSIONS

The inside-out release technique to correct a fixed valgus deformity in patients undergoing primary total knee arthroplasty is reproducible and provides excellent long-term results.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Tuberculosis of the hip

Tuberculosis of the hip constitutes approximately 15% of all cases of osteoarticular tuberculosis. The common age of presentation is in the second and third decades. In Stages II and III of the disease, the radiologic features are very obvious and diagnostic, and almost always predict the final clinical outcome. A progressive pattern of destruction of the hip occurs in patients who are not treated. Treatment must be instituted early with an aim of salvaging the hip. Treatment comprised of drug therapy, traction, and supervised mobilization produces good results in patients with early stages of the disease. Patients who do not have a favorable clinical response to conservative treatment should have surgery before the hip is destroyed. In the eastern hemisphere, patients prefer a painless but mobile joint, for satisfying the customary needs of squatting, sitting cross-legged, and kneeling. Therefore, excision arthroplasty produces satisfactory results as compared with hip arthrodesis. Total hip arthroplasty should be considered only after a safe period of absolute disease quiescence.

Unusual compressive neuropathies of the upper limb

Compression neuropathies are one of the most common causes of upper extremity pain. This article has addressed the diagnosis and treatment of some of the more unusual neuropathies. As always, a thorough knowledge of anatomy and its valuation, and a careful and impulsive physical examination will guide the clinician to the appropriate diagnosis. Electrical studies, done carefully and with the clinical diagnosis as a label, will often be confirmatory. In cases not responsive to nonoperative measures, surgery to decompress the nerve and to restore missing function will usually proved a modicum of patient improvement.

The hand-foot syndrome in sickle-cell haemoglobinopathy

The hand-foot syndrome is a benign self-limiting condition seen in young children with sickle-cell haemoglobinopathy, usually at the time of a crisis. The authors have observed 36 cases among 4920 patients. The features and management of the condition are discussed and the published literature is reviewed.

The hand-foot syndrome in sickle-cell haemoglobinopathy

The hand-foot syndrome is a benign self-limiting condition seen in young children with sickle-cell haemoglobinopathy, usually at the time of a crisis. The authors have observed 36 cases among 4920 patients. The features and management of the condition are discussed and the published literature is reviewed.

Ankle instability after fibular resection

We have reviewed 104 patients who had partial resection of the fibula for use as a graft. Only 44 were completely free from symptoms, and six had developed significant ankle instability which had required reconstruction by a sliding graft. This procedure successfully restored ankle stability in all six cases.

Ankle instability after fibular resection

We have reviewed 104 patients who had partial resection of the fibula for use as a graft. Only 44 were completely free from symptoms, and six had developed significant ankle instability which had required reconstruction by a sliding graft. This procedure successfully restored ankle stability in all six cases.