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Vol 3 | Issue 1 | May – June 2017 | page:41-42 | Neeraj Bijlani, Ashok Shyam

Author: Neeraj Bijlani [1], Ashok Shyam [2]

[1] OrthoTech Clinic and Sai Baba Hospital, Mumbai, India
[2] Indian Orthopaedic Research Group, Thane & Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.

Address of Correspondence
Dr.Neeraj Bijlani
OrthoTech Clinic, 405, Shubham Atlanta, RC Marg, Chembur East, Mumbai 400071.
Email: drbijlani@gmail.com

Abstract

Mobile apps have been an integral part of our lives since the App Store was launched in 2009. Now after the Mobile Apps Revolution, Medical Apps have also been an integral part of our Lives. To begin with this series we present to you an app which makes Review of Literature, Reading Articles and Abstracts on the go and Following topics, Journals and Specialities very easy at the tap of a finger.

Introduction:
The iPhone App Store was launched in July 2008 and was followed by the Google Play store in 2012. The above ones are the most popular mobile operating sys-tem in the world till date. The mobile apps have changed our lives and the way we com-municate with each other and go about doing things. So is the world of Medical and Orthopaedic Apps which have been on the forefront since last few years.
Here we present you a series of review of few Medical Apps which we regularly use and make a difference in our lives and the way we practice Orthopaedics and increase productivity.

Review:
Read by QxMD is a free app available to download from the iPhone App Store and Google Play Store and can also be used as a Web App from the Windows Platform and Computer.
It is like Twitter for Medical Literature. As soon you install the app on your mobile device, you get a screen (Fig. 1) to Sign Up or Login (if you already have an account). After you tap Sign up You are taken to a Personalisation Page (Fig. 2) which is self-explanatory. After you have completed the sign up process fill up very few fields. So in profession I filled up Physician and Speciality – Orthopaedics and Location – India that is where we are from (Fig. 3).
After that there are some other specialities which you can follow so I follow Sports Medicine. Then the next screen takes you to Keywords (which can be words like Rotator Cuff Tears, Distal Radius Fracture, and VTE prophylaxis. Then there are collections which you can follow which could be accumulated articles which someone has made for example I follow Trauma and Elbow. (You can also create your own collection which someone may follow (something like a trending topic on twitter or Facebook). The last important point is Journals to follow- Here multiple journals can be added ; For Example I have added Journal of Bone and Joint Surgery – American Volume, Bone and Joint Journal British , Journal of Shoulder and Elbow Surgery, Arthroscopy and Journal of Paediatric Orthopaedics ( Fig. 4,5). After Clicking on next, we have an option of either filling up a small form with name, email and then we are taken to something called as featured papers which is like the twitter feed or Facebook timeline. (Fig. 6)
It also gives you push notifications about reading for papers and also you can get CME Credits (which we are yet to use) but a feature more useful in USA.

 


After the registration process you get the following screen options below as shown here (Fig. 7):-Featured papers; My Followed Journals; My Followed Collections; My Followed Keywords; Recently Viewed Papers; Search
My Followed Journals show all the latest articles journal wise and date wise with abstracts. My Followed Collections show the collection of articles (abstracts) which you can read. Here you also have an option of gaining library access in the app (Fig. 8) if you have off campus library access you can enter your library username and password and the app will automatically download the pdf for you if available from your library during you reading from the app. My Followed Keywords will show you relevant articles from the topics which you have been following. Recently Viewed Papers will show you your downloaded papers. Search is also very good where you can either search for papers or topics. Example: Osteoid Osteoma Search gave me very good results.

Salient Features
Things to mention here

  • PDFS are available easily inside app is you have subscription or Library Access.
  • Papers are Searchable
  • Favourite Journals and Topics are easy to follow.
  • You can always change settings and follow new journals or new topics and un-follow topics and journals which you followed earlier.

Conclusion:
Read by QxMD is one of my essential go to apps for daily reading on my interested Orthopaedic topics as well as helps me in review of literature. It helps me keeping abreast of Latest knowledge by sending me push notifications of trending articles and articles of my favourite journals and keywords. I surely recommend it to start using it now. The best part it is totally free to use and is AD- Free.

How to Cite this article: Bijlani N, Shyam AK. Most Essential Mobile App for Trauma Surgeon – Episode 1 – Review of Mobile app – Read by QxMD. Trauma International Jan – April 2017;3(1):41-42.

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Digastric Trochantric Flip OsteDigastric Trochantric Flip Osteotomy When and How to do it in Acetabular Fractures-?otomy When and How to do it in Acetabular Fractures-?

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Vol 2 | Issue 2 | May – Aug 2016 | page:9-16 | U K Sadhoo

Author: U K Sadhoo [1]

[1] Nayati Hospital, Mathura, U.P. 281003

Address of Correspondence
Dr. U K Sadhoo
Nayati Hospital, Mathura, U.P. 281003
Email: uksadhoo@yahoo.com

Abstract

Acetabulum is one of the most anatomically complex regions of the body. Fractures in this area are difficult to visualise due to complex anatomy and overlaping of radiological shadows. Plain radiology od acetabular and pelvis fractures require detailied understanding of the imaging techniques and anatomy. Newer advances like 3-D CT etc have added new dimensions to the radiological assessment of acetabular fractures. Current review focusses on basic radiological principles to help the readers understand and categorised acetabulam fractures an also plan the surgical intervention.
Keywords: Acetabular fractures, radiological asessement, CT Scan.

Introduction

Acetabulum is a major weight-bearing joint, connecting Axial skeleton to lower limbs. Therefore a fracture of Acetabulum has implications for the mobility and disability for rest of life. Until the pioneering work of Judet and Letournal (1), these injuries were poorly understood and inadequately treated. Now this sub-specialty has come of age. The difficulty in understanding the nature of these injuries is the complex shape of Pelvis anatomy. Radiology not only provides an accurate assessment, it also gives a pointer to the approach and definitive treatment. Judet and Letournal classification is based on the lines produced by xray beams on the cortical surfaces in AP and two 45 degree oblique projections. Though advent of CT has enhanced our understanding, this classification remains the de facto standard. The other classifications are AO/OTA classification and the CT based Harris et al classification (3,4)

Anatomy

Acetabulum is formed by confluence of Ilium, Ischium and Pubis into an inverted horse-shoe shaped structure that is deficient inferiorly, bridged by Transverse Acetabular Ligament. The central non-articular part is known as cotyloid fossa which houses fat (Pulvinar) and Ligamentum Teres (Fig 1). Bony Acetabulum has inclination of 55-60 degrees to horizontal. This is deepened by Labrum, a soft fibro-cartilagenous structure not unlike meniscus. This increases the load-sharing area and provides additional check against dislocation.

Radiology

X-rays (Fig. 3):
Look for 6 landmarks :
1. Post. Wall : Lateral-most projection on AP and Obturator view x-ray. Seen clearly because of anteverted Acetabulum.
2. Ant. Wall : Superimposed on post. Wall, still visible as undulation line on good quality x-ray.
3. Dome : weight-bearing area of acetabulum.
3 variants :
TransTectal : through weight-bearing area
Juxta Tectal : at roof of cotyloid fossa where it joins articular area
Infra Tectal : Through floor Cotyloid fossa. Juxta and infra-Tectal don’t involve weight bearing surfaces so rarely need operative measures.
4. Tear Drop : Not an anatomical structure. Seen on AP projection. Lateral wall represents inferior-most Acetabulum articular surface, medial boundary by Quadrilateral plate.
5. Ilio-Ischial line : representing Posterior column
6. Ilio-Pectineal line : representing Anterior column

AP View 1-minute assessment (Fig. 4) : Basic, quick, cheap investigation. Look at 4 lines, 1 curve, 1 circle; it gives lot of information, enough to make a considered decision about the severity of injury and urgency of treatment. It may not pick up subtle fractures, small intra-articular fragments, marginal impaction. There is virtually nil to be deduced from x-ray about the soft tissue component of injury.


Judet Views (Fig. 5,6,7) : Patient is tilted 45 degree to horizontal, once with injured side up, then normal side up, at right angle to each other. The x ray beam is perpendicular to Horizontal, focused on affected hip in both views.


Obturator : shows Iliac wing seen end-on, Obturator foramen in full profile. (highlights Anterior column, Posterior Wall)
Iliac : shows Iliac blade, Posterior column, Ant. wall (most lateral projection), Sciatic notch, Quadrilateral plate.
Sometimes, it is not possible to do Judet views because of patient discomfort. In such cases, angiographic C-arm can be tilted, instead of the patient, to gain necessary information (7).


Planar CT scan (Fig 8,9,10) : Thin-slice scans, axial, coronal and sagittal, are invaluable tool for complete evaluation of Acetabulum fractures. It can show marginal impaction, intra-articular fragments, subtle fracture lines, and posterior Sacro-Iliac injury. It thus complements the information gained on x-rays. In addition, soft tissue injury like Morell-Lavalle lesion can be picked up on CT (or MRI).


3D CT (Fig.11): It is a reformatted image from thin sections into 3D surface-rendered images. These images are easy to understand, easy to manipulate in any direction, with or without femoral head in acetabulum. No doubt finer details like intra-articular bone pieces, impaction, and fine fracture lines are lost but it remains a powerful tool to have a bird’s eye-view of a very complex anatomy and injury. One major advantage is the ability to process data into reformatted images (Fig.12) to appear as planar AP or Judet views without the need to move or tilt the patient (5).


CT can show fracture in coronal or sagittal planes; it can also be used with artefact-suppression software for post–op evaluation of adequacy of reduction, intra-articular metal or loose bone pieces (Fig 13). The fracture lines through the Dome need understanding to interpret the diagnosis correctly (Fig 14).
Proximal 10mm of Axial CT also corresponds to the weight-bearing Dome (6). Therefore, if a fracture does not involve the proximal 10mm of Acetabulum, conservative treatment is indicated.

Judet and Letournal Classification:

Before discussing Classification, it is important to keep the following points in mind:
-Fractures are described with respect to a lateral-facing Acetabulum (Fig 1). This is quite different from real-life situation in which Acetabulum is tilted anteriorly and inferiorly. Therefore, a Transverse fracture orients in oblique-sagittal plane in a Pelvis-AP x-ray than a horizontal line.
-Walls are part of the column (Fig 2). Therefore, it is possible to break either wall or column or both simultaneously. For a column to break, exit line is through Obturator oval in most, but not all, cases. Add to this, part or complete Transverse # element and many possibilities emerge.


10 fracture patterns are recognized (fig. 15, 16); 5 elementary and 5 associated which are combination of one or more of elementary pattern. All of them are based on the walls getting separated from columns and columns getting broken at Sciatic buttress, with transversely oriented fracture through Acetabulum completing the picture.


5 elementary types are Anterior Wall, Anterior Column, Posterior Wall, Posterior Column and Transverse fracture (Fig. 15).
5 Associated patterns (Fig. 16), as name suggests, are combination of two or more Elementary patterns. These are: Posterior wall and Column fracture, Transverse with Post Wall, T Shaped, Ant Wall/Column with Posterior Hemi-transverse and associated both column. Not every fracture can be pigeon-holed in these 10 patterns, but it is as good a working classification as any.


5 patterns of these 10 constitute 80% of all Acetabulum fractures: Post Wall, Transverse, Transverse with Post wall, T shaped and Both Columns (Fig. 30).(5,6)
Post. Wall ( Fig.17,18) : A part of the rim with articular surface is broken. Often, it is displaced with subluxed/dislocated head Femur and best seen on Judet Obturator view (Fig 5,6). Comminution is not uncommon. Sciatic involvement is not infrequent and subtle injury even more common. On CT, marginal impaction can be picked up easily (Fig. 8).
Ant. Column (Fig 19) : Uncommon. Pure Ant. Wall fracture is even less common. It generally is a hallmark of elderly, osteoporotic individuals.


Transverse # (Fig. 20) : The fracture runs obliquely and can exit through weight-bearing Dome, at junction with Cotyloid fossa or through fossa itself. The distal fragment displaces medially and rotates. Both these factors need to be taken into account at ORIF. Though the fracture line traverses both Ilio-Pectineal and Ilio-Sciatic line, thus involving Anterior AND Post Columns, it still is not a “Both Column” Fracture, a term reserved for


Post Wall and Column # (Fig 22, 23) : Post. Column break can occur in isolation or may be accompanied by Wall fracture. Column component exits proximally, Sciatic notch and distally, Obturator foramen. This is an unstable situation and at ORIF, Sciatic Nerve and Superior Gluteal neurovascular bundle are at risk.


Ant. Column with Post. Hemitransverse # (Fig. 24) : Not to be confused with Transverse or T #. The fracture line of Ant. Component exits obliquely compared to the straight line in Transverse #.


T-shaped # (fig. 25, 26) : The transverse component has additional break in Obturator fossa. This essentially separates Anterior and Posterior components. Therefore choosing appropriate approach is of paramount importance. Generally, the more displaced fragment decides approach. The other component is then reduced and held indirectly. Sometimes, two approaches may necessary.


Transverse with Post. Wall # (Fig. 27, 28) ; As name indicates, the post wall component makes the head displace posteriorly, often with communition.


Both Column # (fig. 29) : No part of the weight-bearing Dome is connected to the Sciatic buttress. On Obturator view, “Spur” sign is characteristic of this pattern.


Fragility Fractures : (Fig. 31, 32) : With increasing longevity, the fracture patterns are also changing due to osteoporosis. Anterior wall, column injuries are common and many injuries are because of trivial fall on Greater Trochanter.

“Gull wing” sign, which shows a depressed/punched-in part of weight bearing area, is a bad prognostic indicator.

Some of these fractures can be picked only on MRI and if, despite negative X-ray, a strong suspicion prevails, MRI is indicated.

Conclusion

Acetabulum fractures need evaluation comprehensively by X-rays and CT Scans. Only then can this complex injury to a complex region be understood. Radiology not only provides assessment of injury, it helps choose best possible approach for stabilization, if indicated..

References

1. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980;(151):81–106.
2. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium: 2007—Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 suppl):S1–S133.
3. Harris JH Jr, Lee JS, Coupe KJ, Trotscher T. Acetabular fractures revisited: part 1—redefinition of the Letournel anterior column. AJR Am J Roentgenol 2004;182(6):1363–1366.
4. Harris JH Jr, Coupe KJ, Lee JS, Trotscher T. Acetabular fractures revisited: part 2—a new CT-based classification. AJR Am J Roentgenol 2004;182(6):1367–1375
5.Leschka S, Alkadhi H, Boehm T, Marincek B, Wildermuth S. Coronal ultra-thick multiplanar CT reconstructions (MPR) of the pelvis in the multiple trauma patient: an alternative for the initial conventional radiograph. Rofo 2005;177(10):1405–1411.
6. Olson SA, Matta JM. The computerized tomography subchondral arc: a new method of assessing acetabular articular continuity after fracture (a preliminary report). J Orthop Trauma 1993;7(5):402–413
7. Geijer M, El-Khoury GY. Imaging of the acetabulum in the era of multidetector computed tomography. Emerg Radiol 2007;14(5):271–287
8. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br 2005;87(1):2–9
9. Patel NH, Hunter J, Weber TG, Routt ML Jr. Rotational imaging of complex acetabular fractures. J Orthop Trauma 1998;12(1):59–63.

How to Cite this article: Makker H. Digastric Trochantric Flip Osteotomy –When and How to do it in
Acetabular Fractures-? Trauma International Jan – April 2017;3(1):24-26.

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Decision Making in Acetabulum Fractures – When to Operate and When Not to?

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Vol 3 | Issue 1 | Jan – Apr 2017 | page:6-9 | Raja Bhaskara Kanakeshwar, Ramesh Perumal, C Arun Kamal, J Dheenadhayalan.

Author: Raja Bhaskara Kanakeshwar [1], Ramesh Perumal [1], C Arun Kamal [1], J Dheenadhayalan [1]

[1] Department of Trauma and Orthopaedics, Ganga Hospital, Mettupalayam, Coimbatore, Tamil Nadu, India

Address of Correspondence
Dr. Raja Bhaskara Kanakeshwar,
Ganga Hospital, Mettupalayam Road, Coimbatore, Tamil Nadu, India.
E-mail: rajalibra299@gmail.com

Abstract

The complexity of acetabulum fractures has always been challenging to the operating surgeon. In the past 50 years, following pioneering work by LeTournel and Judet, there is better clarity to the treating surgeon regarding the management of these fractures. 3D computerized tomography imaging has helped surgeons understand the fracture better andit remains the investigation of choice. Roof-arc angle measurements and the percentage of the fracture involving the superior dome are important determinants in deciding whether to operate or treat conservatively. Nonoperative management is mainly for undisplaced fractures and patients
not fit for surgery. Fluoroscopy under anesthesia to check for hip joint stability and percutaneous screw fixation are new upcoming management modalities. The approaches described by LeTournel and Judet – Kocher-Langenbeck, Ilioinguinal, Iliofemoral, and extended Iliofemoral – remain the “gold standard” for appropriate fractures, but the availability of newer alternative approaches have expanded over time thereby facilitating surgeons to operate better.
Keywords: Acetabulum fracture, 3D computerized tomography, roof-arc angle, Kocher-Langenbeck approach.

What to Learn from this Article?

This article gives an insight to the reader regarding the basic principles regarding the decision making
to treat acetabulum fractures operatively or non-operatively. The importance of 3 dimensional CT images and usefulness of the roof arc
angles in making decisions to manage acetabulum fractures has been explained. Appropriate approaches for appropriate fractures have
been tabulated to guide the treating surgeon.

Introduction

‘ Good surgeons know how to operate, better ones when to operate, and the best when not to operate’.
This famous saying applies right for all fractures including complex ones involving the acetabulum . High velocity road traffic accidents have frequently resulted in acetabulum fractures mostly involved with multiple fractures. In the 1950s and 1960s , both operative and non operative treatment regimens were purported to be the best and there was much confusion due to the unavailability of a comprehensive classification (1,2,3) . Landmark and meticulous work by Judet et al. provided clarity and gave recommendations for operative treatment based on their 10 year study following poor results from non-operative treatment (4). Contributions from LeTournel and Matta also threw light on the various indications when surgery was needed and how to manage these fractures (4,5) . The advent of 3- dimensional Computerised tomography ( CT ) allowed surgeons to understand the fracture pattern better and also plan the management better (5,6) . With the advances in imaging and surgical expertise , the increase in threshold for surgeons to operate and the advances in minimally invasive fixation techniques , non-operative treatment still forms the best treatment for particular fracture patterns and patient factors.

Diagnosis and Imaging

No matter what method of treatment has been selected, obtaining an excellent long-term result in the treatment of acetabulum fractures depends on restoring a congruent and stable hip joint with an anatomically reduced articular surface of the femoral head . Understanding the anatomy of the innominate bone, defining the injury through radiographic assessment, and then determining a suitable treatment plan remains of utmost importance (4,7,8) .In the 1960s Judet after detailed studying of the acetabulum through dry models, advocated the need of two 45-dgree oblique views in addition to the standard AP view of the pelvis to study the anatomy of the fracture better . Since then these views are commonly used worldwide to assess any acetabulum fracture radiographically (4,7,8,9) . Advances in CT technology have not only improved the information provided by the two-dimensional images but also now offer useful three-dimensional images as well as computer-generated  images which allow better understanding of the fractures(10-13) . C-arm image intensifier fluoroscopy has evolved nowadays and remains a method of intra-operative assessment regarding the stability of acetabular fractures (14).  As of today, the ‘gold standard’ of imaging for the evaluation and assessment of acetabulum fractures includes plain x-rays involving a standard AP view of the pelvis , 45-degree oblique views (Judet views) and a plain CT scan with 3-dimensional  images (4,13,14) .

Non-operative management of acetabulum fractures

To attain the best results,  stability and hip joint congruity must be accompanied by an anatomic (defined as less than 2 mm of displacement) reduction of the displaced articular surface. Therefore, accurate reduction of the intra-articular fracture fragments is critical for a successful outcome.  After proper analysis of the fracture pattern and analysis by imaging, the decision to operate or conserve depends on multiple factors(15) . As a general rule, all stable concentrically reduced acetabular fractures which do not  involve the superior acetabular dome can be considered for nonoperative treatment. Nonoperative management may also be chosen for patients with severe underlying medical problems that preclude surgery which mainly includes a small group of elderly patients. Patient-related factors such as age, preinjury activity level, functional demands, and medical comorbidities must be considered when determining whether a patient is best served by operative or nonoperative management(15,16). The indications for non-operative treatment have been discussed in Table 1 .


Significance of the superior dome of the acetabulum :Rowe et al(11) first recognized the condition of the superior dome of the acetabulum to be one of the most significant prognostic indicators of a good clinical outcome. The superior dome of the acetabulum ( acetabular roof ) is defined as the superior third of the weight bearing area of the acetabulum. Study of axial CT sections by Olson and Matta(10) of the superior 10 mm of the acetabular articular surface are equivalent to the weight-bearing dome region of the acetabulum . These can be useful in determining if acetabular fracture lines involve this region. Controversy still exists regarding the exact amount of displacement that is considered acceptable when the superior dome is involved, but  most authors recommend surgical intervention if displacement exceeds 2 mm(4,10,11) .

Roof arc angle measurements

Of the pioneering works done by Matta, one of the important studies involves proposing the roof arc angle measurements in acetabulum fractures . This measurement is of utmost significance as it helps to determine if the remaining intact acetabulum is sufficient to maintain a stable and congruous relationship with the head of the femur. Using this method, operative versus nonoperative treatment can be decided. The roof arc angle is measured on all three radiograph views without traction. The medial roof arc is measured on the AP view, the anterior roof arc is measured on the obturator oblique view, and the posterior roof arc is measured on the iliac oblique view. To calculate this measurement, the first line is a vertical line through the center of the femoral head and the second line is drawn from the center of the femoral head to the fracture location at the articular surface on the particular view. Roof arc measurements are not applicable to both-column fractures or those with a fracture of the posterior wall. The recommendations of the angles for non-operative treatment have been changing based on various biomechanical studies and have evolved with time . However current recommendations are fractures with a medial roof arc angle of greater than 45 degrees, an anterior roof arc angle of greater than 25 degrees, and a posterior roof arc angle of greater than 70 degrees have sufficient intact acetabulum for nonoperative management (4,11,13,15,16,17).However, the roof arc angle is not without limitations. It is not applicable to both column fractures and fractures of the posterior wall (16). Displaced both column fractures in the presence of secondary congruence especially in a young patient are amenable to non operative treatment . But it must always be remembered that fractures with secondary congruence do not have as good a prognosis as those managed with anatomic reduction. In cases of doubtful stability of the fractures ,dynamic fluoroscopic stress examination with the patient under anesthesia, is one proposed method of identifying fractures at risk(14). However, the exact technique for performing this examination has not been properly defined . When in doubt, it is always safe to assume that all these fractures are unstable until proved otherwise.

Technique for Non-operative treatment

For those patients who meet the criteria of non operative management treatment mainly consists of bed rest with joint mobilization with gradual progression to full weight bearing walking . Progressive weight bearing ambulation is started at about 6 weeks to 12 weeks  when adequate fracture healing is seen on radiographs taken periodically(15) .Traction to the affected limb as a part of non operative treatment is controversial. Traction is only advised to patients with operative indications related to fracture displacement but not amenable to surgery due to their associated conditions(15,16) .
Operative Treatment : Timing of Surgery :Classification of the fracture and subsequent preoperative planning are important and necessary aspects of the operative treatment process . After classifying the fracture based on the radiographs and the CT scan images , the plan for fixation includes the timing of surgery and the approach to be used . In general, the surgical treatment of an acetabular fracture is not an emergency. A 3 to 5 day delay  is commonly used to allow for evaluation of any underlying medical issues or associated injuries and for meticulous preoperative planning( 18,19,20) . The time to surgery has been shown to be a significant predictor of radiologic and clinical outcome and, if possible, should not be delayed beyond 10 days for associated types  and 15 days for elementary fractures(21). Recurrent hip dislocation following reduction, irreducible hip dislocation, progressive sciatic nerve deficit, associated vascular injury, open fractures and ipsilateral femoral neck fracture are indications for emergency acetabular fracture fixation(22) .

Surgical approach 

Selection of the appropriate approach is one of the most important aspects of the preoperative planning for acetabulum fracture fixation . Fracture type, the elapsed time from injury to operative intervention, and the magnitude and location of maximal fracture displacement are the main determinants in the decision making(4,17,18) . The mainstay surgical approaches to the acetabulum are those described by Letournel and Judet: The Kocher–Langenbeck, the ilioinguinal, the iliofemoral, and the extended iliofemoral(4,18) . The first three approaches provide direct access to only one column of the acetabulum (posterior for Kocher–Langenbeck; anterior for ilioinguinal and iliofemoral) and require indirect manipulation for reduction of the fracture lines that traverse the opposite column. A sequential  approach is then added if the single approach proves insufficient to accomplish reduction of the opposite column. The extended iliofemoral approach affords the opportunity for almost complete direct access to all aspects of the acetabulum and is mostly used for delayed treatment of an associated fracture type(20-22) . However, alternative approaches have been proposed  and these include the modified Gibson approach, themodified Stoppa approach, the trochanteric flip osteotomy and a simultaneous combination of the standard anterior and posterior approaches(22) . Appropriate approaches for the particular fracture types have been described below in the Table 2 .

Discussion and Summary

Although significant strides have been made in fracture fixation nowadays, acetabular fracture fixation surgery still remains an extensive surgery with a significant potential complication rate(1-5,17,22) . The results published by LeTournel and Judet in 1993 remain the ‘gold standard’ in the management of acetabulum fractures(4) . As per the current guidelines in the management of acetabulum fractures in order to make a decision the following are recommended by the authors :1) AP view of the pelvis and 45-degree oblique radiographs in association with 3D reconstruction CT images are the investigations of choice for evaluating an acetabulum fracture2) The involvement of the fracture dome and the roof arc angle measurements are important indicators to decide to operate and in achieving a good outcome3) Non displaced fractures and stable non displaced fractures can be treated non operatively . Those patients who are not amenable to surgery due to poor medical conditions can also be treated non operatively 4) Displaced fractures are best managed by open reduction and internal fixation by their appropriate approach and the anatomic congruency of the reduction determines the long term functional outcomeGood sound knowledge about the anatomy of the innominate bone , sharp and meticulous surgical skills, proper pre operative planning and performing surgery on patients with the right indications are factors which have stood the test of time and when practiced give good results to the patient and the operating surgeon .

References

1. Laird A, Keating JF. Acetabular fractures: A 16-year prospective epidemiological study. J Bone Joint Surg Br 2005;87:969-973.
2. Ferguson TA, Patel R, Bhandari M, Matta JM. Fractures of the acetabulum in patients aged 60 years and older: An epidemiological and radiological study. J Bone Joint Surg Br 2010;92:250-257.
3. al-Qahtani S, O’Connor G. Acetabular fractures before and after the introduction of seatbelt legislation. Can J Surg 1996;39(4):317-320.
4. Judet R, Judet J, Letournel E. Fractures of the acetabulum: Classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am 1964;46:1615-1646.
5. Stewart MJ. Discussion of prognosis of fractures of the acetabulum. J Bone Joint Surg Am 1961;43A:59.
6. O’Toole RV, Cox G, Shanmuganathan K, Castillo RC, Turen CH, Sciadini MF, et al. Evaluation of computed tomography for determining the diagnosis of acetabular fractures. J Orthop Trauma 2010;24(5):284-290.
7. Borrelli J Jr, Peelle M, McFarland E, Evanoff B, Ricci WM. Computer-reconstructed radiographs are as good as plain radiographs for assessment of acetabular fractures. Am J Orthop (Belle Mead NJ) 2008;37(9):455-459.
8. Heeg M, Otter N, Klasen HJ. Anterior column fractures of the acetabulum. J Bone Joint Surg Br 1992;74(4):554-557.
9. Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum. A retrospective analysis. Clin Orthop Relat Res 1986;205:230-240.
10. Olson SA, Matta JM. The computerized tomography subchondral arc: A new method of assessing acetabular articular continuity after fracture (a preliminary report). J Orthop Trauma 1993;7(5):402-413.
11. Rowe CR, Lowell JD. Prognosis of fractures of the acetabulum. J Bone Joint Surg Am 1961;43A:30-59.
12. Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.
13. Moed BR, Ajibade DA, Israel H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma 2009;23(1):7-15.
14. Parker PJ, Copeland C. Percutaneous fluoroscopic screw fixation of acetabular fractures. Injury 1997;28(9-10):597-600.
15. Tornetta P 3rd. Non-operative management of acetabular fractures. The use of dynamic stress views. J Bone Joint Surg Br 1999;81(1):67-70.
16. Helfet DL, Borrelli J Jr, DiPasquale T, Sanders R. Stabilization of acetabular fractures in elderly patients. J Bone Joint Surg Am 1992;74(5):753-765.
17. Spencer RF. Acetabular fractures in older patients. J Bone Joint Surg Br 1989;71B:774-776.
18. Moed BR. Acetabular fractures: Kocher-langenbeck approach. In: Wiss DA editor. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. p. 817-868.
19. Starr AJ, Watson JT, Reinert CM, Jones AL, Whitlock S, Griffin DR, et al. Complications following the ‘T extensile’ approach: A modified extensile approach for acetabular fracture surgery-report of forty-three patients. J OrthopTrauma 2002;16(8):535-542.
20. Vailas JC, Hurwitz S, Wiesel SW. Posterior acetabular fracture-dislocations: Fragment size, joint capsule, and stability. J Trauma 1989;29(11):1494-1496.
21. Wright R, Barrett K, Christie MJ, Johnson KD. Acetabular fractures: Long-term follow-up of open reduction and internal fixation. J Orthop Trauma 1994;8(5):397-403.
22. Moed BR, Reilly MC. Acetabulum fractures. Rockwood and Green’s: Fractures in Adults. 8th ed. Wolters Kluwer; Netherlands: 1891-1982

How to Cite this article: Kanakeshwar RB, Perumal R, Kamal AC, Dheenadhayalan J. Decision Making in Acetabulum Fractures – When to Operate and When Not to? Trauma International Jan-Apr 2017;3(1):6-9.

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Most Essential Mobile App for Trauma Surgeon – Episode -1 Review of Mobile app – Read by QxMD Neeraj Bijlani1, Ashok Shyam2

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Vol 3 | Issue 1 | Jan – Apr 2017 | page:49-50 | Neeraj Bijlani, Ashok Shyam

Author: Neeraj Bijlani [1], Ashok Shyam [2]

[1] OrthoTech Clinic and Sai Baba Hospital, Mumbai, India
[2] Indian Orthopaedic Research Group, Thane & Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.

Address of Correspondence
Dr.Neeraj Bijlani
OrthoTech Clinic, 405, Shubham Atlanta, RC Marg, Chembur East, Mumbai 400071.
Email: drbijlani@gmail.com

Abstract

Mobile apps have been an integral part of our lives since the App Store was launched in 2009. Now after the Mobile Apps Revolution, Medical Apps have also been an integral part of our Lives. To begin with this series we present to you an app which makes Review of Literature, Reading Articles and Abstracts on the go and Following topics, Journals and Specialities very easy at the tap of a finger.

Introduction

The iPhone App Store was launched in July 2008 and was followed by the Google Play store in 2012. The above ones are the most popular mobile operating sys-tem in the world till date. The mobile apps have changed our lives and the way we com-municate with each other and go about doing things. So is the world of Medical and Orthopaedic Apps which have been on the forefront since last few years.
Here we present you a series of review of few Medical Apps which we regularly use and make a difference in our lives and the way we practice Orthopaedics and increase productivity.

Review

Read by QxMD is a free app available to download from the iPhone App Store and Google Play Store and can also be used as a Web App from the Windows Platform and Computer.
It is like Twitter for Medical Literature. As soon you install the app on your mobile device, you get a screen (Fig. 1) to Sign Up or Login (if you already have an account). After you tap Sign up You are taken to a Personalisation Page (Fig. 2) which is self-explanatory. After you have completed the sign up process fill up very few fields. So in profession I filled up Physician and Speciality – Orthopaedics and Location – India that is where we are from (Fig. 3).


After that there are some other specialities which you can follow so I follow Sports Medicine. Then the next screen takes you to Keywords (which can be words like Rotator Cuff Tears, Distal Radius Fracture, and VTE prophylaxis. Then there are collections which you can follow which could be accumulated articles which someone has made for example I follow Trauma and Elbow. (You can also create your own collection which someone may follow (something like a trending topic on twitter or Facebook). The last important point is Journals to follow- Here multiple journals can be added ; For Example I have added Journal of Bone and Joint Surgery – American Volume, Bone and Joint Journal British , Journal of Shoulder and Elbow Surgery, Arthroscopy and Journal of Paediatric Orthopaedics ( Fig. 4,5). After Clicking on next, we have an option of either filling up a small form with name, email and then we are taken to something called as featured papers which is like the twitter feed or Facebook timeline. (Fig. 6)
It also gives you push notifications about reading for papers and also you can get CME Credits (which we are yet to use) but a feature more useful in USA.


After the registration process you get the following screen options below as shown here (Fig. 7):-Featured papers; My Followed Journals; My Followed Collections; My Followed Keywords; Recently Viewed Papers; Search
My Followed Journals show all the latest articles journal wise and date wise with abstracts. My Followed Collections show the collection of articles (abstracts) which you can read. Here you also have an option of gaining library access in the app (Fig. 8) if you have off campus library access you can enter your library username and password and the app will automatically download the pdf for you if available from your library during you reading from the app. My Followed Keywords will show you relevant articles from the topics which you have been following. Recently Viewed Papers will show you your downloaded papers. Search is also very good where you can either search for papers or topics. Example: Osteoid Osteoma Search gave me very good results.

Salient Features

Things to mention here
PDFS are available easily inside app is you have subscription or Library Access.
Papers are Searchable
Favourite Journals and Topics are easy to follow.
You can always change settings and follow new journals or new topics and un-follow topics and journals which you followed earlier.

Conclusion

Read by QxMD is one of my essential go to apps for daily reading on my interested Orthopaedic topics as well as helps me in review of literature. It helps me keeping abreast of Latest knowledge by sending me push notifications of trending articles and articles of my favourite journals and keywords. I surely recommend it to start using it now. The best part it is totally free to use and is AD- Free.

How to Cite this article: Bijlani N, Shyam AK. Most Essential Mobile App for Trauma Surgeon – Episode 1 – Review of Mobile app – Read by QxMD. Trauma International Jan – April 2017;3(1):49-50.

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Symposium on Pelviacetabular Fractures Part II

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Vol 3 | Issue 1 | Jan – Apr 2017 | page:5 |  Harish Makker

Author: Harish Makker [1]

[1] Consultant Orthopaedic Surgeon, Lucknow, India

Address of Correspondence
Dr.Harish Makker.
282, Rajendra Nagar,opp.water Tank, Lucknow, India 226004 India.
Email: drharishmakkar@gmail.com

Symposium on Pelviacetabular Fractures Part II

Dear Friends,
Orthopaedics was a nascent branch some 60 years back, when it was born out of Surgery. There were few dynamic personalities working as orthopaedician under General Surgeons and they had to fight for their existence. We have come a long way from there and now, there may be more than 17 sub branches [specialties] in orthopaedics itself.
Currently, it is not possible for an orthopaedician to be a master of all the sub branches, hence the need for separate symposium issue in the Journal, for Pelvis and Acetabulum Injuries. [Till the time, may be, when we may have a separate journal for Pelvis and Acetabulum in India].
This is the second part of the Symposium Issue on Pelvis and Acetabulum, and we have covered five chapters written by different masters of the field from AIIMS Delhi, PGI- Chandigarh, Apollo Delhi etc
Each article has some important take home messages which I would like to draw the attention of the reader, As in the chapter on –Dual Approach, the author has very well explained why dual approach-? and which approach first for certain T fractures and T type fractures.
In the article on Ilio Femoral Approach-author has emphasized need for fractures lateral to iliopectineal line.
In the chapter on Pelvic fractures, the author has explained importance of posterior ligaments complex, in lateral compression and vertical shear fractures and variants of lateral compression type fractures.
In the article on Digastric Flip Osteotomy- There comes a time in acetabular fractures-posterior wall and or posterior column fractures when simple Kocher-Langenbeck Approach seems handicapped and you need to have some extension, as in cases of cranial extension of posterior wall fractures and /or need to retrieve loose segments from acetabular joint when with all efforts made by traction, space seems wanting.
Hope you will find it helpful in your day to day practice as the authors have put their combined experience in preparing these manuscript.
I also take this opportunity to invite you to 4th Cadaveric Pelvi-Acetabular fracture fixation workshop on 11th November in Lucknow
We will soon have the third issue of the symposium in hand

Dr Harish Makker
Symposium Editor – Trauma International.

How to Cite the article: Makker H. Symposium on Pelviacetabular Fractures – Part II. Trauma
International Jan – April 2017;3(1):5. 

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Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected and Multiple times Operated Non Union of Long Bones

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Vol 3 | Issue 1 | Jan – Apr 2017 | page:27-31 | Dilip D Tanna, Sangeet Gawhale, Kaustubh Shinde, Viral Gondalia, Hayoung Park, Ashok Shyam

Author: Dilip D Tanna [1], Sangeet Gawhale [1], Kaustubh Shinde [2], Viral Gondalia [1], Hayoung Park [3], Ashok Shyam [4] 

[1] Saifee Hospital Medical research center, Mumbai , India.
[2] BY L Nair medical college & hospital, Mumbai
[3] Researcher Department of Orthopaedics Joint Arthritis & research Laboratory Himchan Hospital Seoul,South Korea
[4] Indian Orthopaedic Research Group, Thane & Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.

Address of Correspondence
Dr D D Tanna
3A new queens road back bay view , mama parmanand marg. Mumbai 400004
Email: ddtanna@me.com

Abstract

Background: Plates with Intramedullary Fibula as Strut graft(IFSG) in Non- union of long bone fractures provides most stable construct overall as fibula acts as second implant, screws have better anchorage and very high pull out strength due to penetration of four cortices and osteogenic property of the fibula is most helpful. The aim of this paper is to re-focus the importance of non-vascularised intramedullary fibula as a second internal biologic stable splint along with rigid osteosynthesis for the treatment of difficult and neglected non -union of long bones.
Methods and Material: 15 cases (13 :2,males: females) of revision surgery for the neglected and multiply operated non-union of the long bones were treated with the debridement, decortication and shingling of the fracture site with addition of the trimmed fibula (as intramedullary strut). Liberal cancellous bone graft was added subperiosteally with stable and rigid internal osteosynthesis by using LCP. DASH Score was used for upper limb and VAS for lower limb for assessment.
Results: Union was achieved in all patients in 12 months (range 9-12 months). Preoperative DASH score averaged 40.86(range 42.6-52.6). DASH score at the last follow-up averaged 20.38 points (range 16.4-24.2).difference was significant. (p=0.0001)
Conclusions: Intra medullary fibula almost works mimicking double plate and adds in the stability as it works as second plate. Its osteogenic property helps in the healing, not only at the fracture site but proximal and distal to it. This prevents slow union at the ends of bone which are usually avascular because of the lysis. Screws have a better hold around osteoporotic bones due to four cortices hold in presence of fibula. Strong bony union can be successfully achieved in almost all cases with rigid compression at the fracture site & additional extensive cancellous bone grafting.
Keywords: Intra- medullary Fibula ,revision non union, rigid osteosynthesis.

Introduction

Non -union, of multiple times operated long bone fractures, poses the extreme challenge to the orthopaedic surgeons. Surgical treatment of proximal humeral non unions and malunions are technically challenging. Osteosynthesis with bone grafting for the treatment of nonunions is indicated in young, active patients with adequate bone stock in the proximal fragment and preservation of the glenohumeral articular surfaces[2]
Vascularised bone grafting requires surgical experience and equipment not readily available in every hospital. The technique is demanding of time and resources, and vascular thrombosis may compromise the result [5]
Iliac crest cancellous bone graft has no mechanical strength to withstand stresses prior to solid union of the fracture site and also is associated with quite significant graft harvest site morbidity. The fibula transmits one eighth of body weight and can be as useful as vascularised or non-vascularised graft in reconstruction of bony defects.
Compression plating with autogenous grafting is accepted as the gold standard method so has yielded satisfac¬tory results, with 92 to 100% healing rates
Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves function and the degree of independence[6]
Subjects and Methods: 15 patients of multiply operated non union of long bones (13 humerus, 1 femur and one distal tibia non union) were included in a study. All were treated by open reduction of the fracture, debridement and excision of the fibrosis, shingling of the bone both proximally and distal to fracture site and osteosynthesis with strut non vascularised fibular graft and Locking Compression Plate with few locking screws and rest of all are cortical screws to make it rigid and stable construct with extensive cancelleous bone grafting 3600 surrounding the fracture site.
All patients were assessed at final follow up using D.A.S.H score for upper limb and Visual analogue score for lower limb.
All patients were followed up for 4 to 36 (average mean months is 20 months) except two patient, who are under study with last two-two and half months.
Out of 15 patients,13 were male and 2 were female. Out of 15, 13 patients had humerus non union,two had femoral mid shaft non union and remaining one had lower third distal tibia non union.
Out of the 13 humerus cases 4 had proximal humerus, 7 had mid shaft to lower third humerus(M3-L3RD) non union & two patient has non union of segmental shaft humerus fracture.
All were closed fractures except one open fracture and all had eventual atrophic non-union upon presentation. The patients had mild pain, tenderness and abnormal mobility at the non-union site (except distal tibia and middle femur), and limitation of activities of daily living. All patients had stiff¬ness of shoulder and elbow to varying degrees.
The patients with femoral non unions have constant pain at the fracture site and difficulty while bearing weight.
distal tibia non union patient had not started bearing weight as he was on fixator for three months following the Gun shot injury operated in other country.

Surgical technique:

52 years old male, who was operated 4 times within last 10 years, presented to us with this latest x rays showing atrophic gap non union of the proximal humerus (Fig 1 A,1B)


Fracture site was exposed using previous scar in all cases as to avoid cosmetic ugly scar. The fibrous non-union and any devitalised bone were thoroughly excised and the medullary canal opened via sharp thinner humerus awl and 3.5-4.5 mm drill bits.
• Preparation of the medullary canal: The humeral medullary canal was prepared to accept the bone graft. Fibrous and pseu¬doarthrosis tissue were removed completely and the medullary cavity reconstituted both proximally and distally by curettage, drill or the use of serial hand reamers (6mm-9mm). Dilate humerus medullary cavity mainly to measure the cavity
•Uniformly expanded medullary cavity by the reamers was prepared to put in the graft.(Fig 2a,2b)
•Preparation of fibular graft: The mid-shaft of the fibula was then harvested under tourniquet control with care taken to identify and protect the superficial peroneal nerve. The fibular shaft of excess length was harvested so that it could be trimmed as neces¬sary. The fibula graft was trimmed so as to enable it to telescope snugly into the fragments across the fracture site. Size of fibula graft will be one smaller than Last reamer used.
If the thickness did not permit its use, it was conversely bevelled at one of the ends leaving behind proximal wider part in hollow cavity of proximal humerus and remaining part in the distal shaft. Generally in humerus ,it necessary to split fibula in the center, with oscillating saw or reciprocating saw or large bone cutter instruments to reduce the size (Fig 3)


5. Insertion of the fibular graft: The fibular autograft was pushed into one of the fracture fragments and the exact length of graft that needed trimming was assessed. Once the final shaping of the graft was done, the fracture was reduced with the intramedullary fibular graft spanning the fracture site. Confirm it is movable in the humerus medullary cavity on both sides of fracture easily.
• Plate fixation: Reconfirm graft moving in canal push it up all the way proximally(Fig 4 – a,b)
•Reduce fracture , distract slightly hold fibula end and slowly push it distally(Fig 4c
•Compress fracture maximally and add cancellous graft after shingling (Fig 4 c & 4 d)

How to achieve compression at the fracture with intramedullary graft:
It is safer to do compression by Muller’s device as it is applied at the end of the bone and maximum compression can be achieved by this device. If one chooses to compress by D C P holes. Fix screw on one side of fracture , and for opposite side D C P hole should be used which is not going thru the fibula , as if fibula is fixed it will not allow compression. So under C arm see the end of fibula and go beyond it to put other D C P screw and compress . Generally one hole compression is not enough in this non union set up, so it will have to be repeated also on 2nd hole . so it is suggested to use Muller’s device or a webers device to do compression of the fracture.
A LCP was used with quadricortical screw fixation till fibula is extending. Each screw hole was drilled and tapped through four cortices, two in the fractured bone and two in the intact fib¬ula and 4. 5 mm cortical screws were inserted. End of the bone screws were from parent bone and few locking screws were used for osteoporosis.


Shoulder and elbow exercises were started a day after the opera¬tion. Lifting of weights using the operated limb was deferred for a period of three to four months or until osteo-integration of the fibular ends or fracture healing. After hospital discharge, patients were observed on a monthly basis until healing of the fracture. All pa¬tients were examined both clinically and radiologically. Fracture union was considered radiographically if callus formation was seen in three of four cortices on AP and lateral views. Clinical union was considered when the fracture site was painless.
Data collected retrospectively included grip strength, range of motion, radiographic parameters, and functional outcomes as measured by the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire.

Results

Patients were followed-up for an average of 1.5-2 years (range 1-2 years). Union was achieved in all patients in 12 months (range9-12 months ) and patients were very satisfied with the treatment Figure 5 shows long term follow up of case 1 and figure 6 shows the results in case 2. There were no perioperative complications such as wound infection, radial nerve palsy, hematoma formation. Post op two patient had discomfort over the fibular graft harvest site, and one has ASIS graft site morbidity in the form of pain mainly. One patient has persistent fracture line visible on fresh x ray at the shaft of humerus at one year follow up, but still fracture seems to be “ clinically united “ as patient has painless arm movement.


Preoperative DASH score averaged 40.86(range 42.6-52.6). DASH score at the last follow-up averaged 20.38 points (range 16.4-24.2).(p=0.0001)[Table 1] V.A.S (visual analogue scale) in one patient was improved from 6-7 to 2 at the last follow up.[table 1] There was an average loss of 10-20˚ abduction and 15-20˚ flexion of the shoulder. . Range of motion of adjacent joint (knee in lower limb and elbow in upper limb) was restricted in all patients because of history of multiple surgeries and immobilization periods, but was within the functional limit in all except two patients. There was no change in shoulder rotations following surgery on the contrary three patient had pain free rotation of shoulder who had atrophic proximal humerus non union. One patient with preoperative fixed flexion deformity of elbow to varying degrees had persistence of a similar deformity at the last follow-up.

Discussion

Non -union of the long bone, after repeated surgery with multiple failed attempts poses challenging reoperation.
Healing is challenge & unpredicted with any kind of surgery and may have sub-optimal result . We have done 15 cases of previously operated multiple times with failed union
As we have used massive mixed cortico-cancelleous auto graft in almost all cases circumferentially at the non-union site –the reason why it unites in each cases is not definite what worked out of these procedure is not predictable, like shingling & solid compression at the fracture site+cancelleous autograft Vs IMSF autograft.
Before we conclude, that fracture is united, we need evidence of circumferential callus formation , and osteo-integration, which takes long time , to be observed . Though patient is using arm almost normally, probably due to good long bony rigid fixation, and hence clinical signs of union are not convincing. This is observed most often in such multiple times operated cases only after 12 months and so we feel, 12 months minimum time should be considered for union.
The main weakness of our study is
1. Very few number of cases(only 15 cases)-so difficult to judge trend of results
2. What exactly helped union , out of everything we did is unclear
The main strength of our study:
Our procedure can not only salvage the “function less –atrophic non united bone “—-it can even have profound effect on the overall compliance of the patient, reduce repeated morbidity from the lengthy and costly treatment like ilizarov, which has frustrated outcome and at the same time gives pain free extremity function up to its fully maximum ability.
We did not seen any complication like post op infection, radial nerve palsy, implant cut through, not even
fracture of the fibula graft in any case. Two patient had fibula graft site pain, which subsided within 6 months and another female patient had ASIS graft site pain mainly which also settled within a year.
The reason for low complications in all cases may be we were lucky .
Osteoporosis, either as a result of disuse or due to
generalised metabolic causes, compounds the choice of surgical treatment in these patients. It significantly reduces the pull out strength of the screws thus increasing the chance of implant failure. Humeral nonunion in osteoporotic bone presents a reconstructive challenge for the treating orthopaedic
surgeon [3,4].
In case of non-union, mechanical stability at the fracture site and biologic re¬vitalization are keys for the management.
A non-union of a diaphyseal fracture of the humerus can present a major functional problem even in the elderly population. Advances in operative exposures combined with newer techniques of achieving stable internal fixation even in the presence of pathologic bone have enabled the surgeon to successfully treat even the most complex non unions [7]
Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing [8,9]
DCP with cancellous bone graft is a reliable and an effective treatment for revision of aseptic nonunion of humeral shaft fracture after surgical treatment [10,11]
We have used LCP in all 15 cases.
There are four main indications reported in the literature for use of LCP in fractures:1)osteoporotic bone,
2) comminution, 3) intra-articular fracture, and4) short segment periarticular fracture [12,13]
Locked plates and conventional plates rely on completely different mechanical principles to provide fracture fixation and in so doing they provide different biological environments for healing. Locked plates may increasingly be indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates may continue to be the fixation method of choice for periarticular fractures which demand perfect anatomical reduction and to certain types of nonunions which require increased stability for union.[14]

Conclusion 

Non-vascularised intramedullary fibula(along with debridement, decortication & shingling ) as a second internal biologic stable splint along with rigid osteosynthesis can achieve excellent Union for treatment of revision of difficult & neglected non -union of long bones.

References

1. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop Relat Res. 2004 Feb;(419):46-50.
2. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct;39(4):475-82.
3. Ansell RH, Scales JT. A study of some factors which affect the strength of screws and their insertions and holding power in bone. J Biomechanics 1968;1:279–302
4. Schatzker J, Sanderson R, Murnaghan JP. The holding power of orthopaedic screws in vivo. Clin Orthop 1975;108:115–26
5. Jupiter JB. Complex non-union of the humeral diaphysis: treatment with a medial approach, an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am. 1990 Jun;72(5):701-7.
6. Ring D, Perey BH, Jupiter JB. The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients. J Bone Joint Surg Am 1999; 81: 177-90.
7. Jupiter JB, Von Deck M. Ununited humeral diaphyses. J Shoulder Elbow Surg 1998; 7: 644-53.
8. Pugh DMW, McKee MD. Advances in the management of humeral non-union. J Am Acad Orthop Surg 2003; 1: 48-59.
9. Weber BG. Minimax fracture fixation. AO Masters Series. Stuttgart: Thieme Medical Publishers, 2004
10. Lin CL, Fang CK, Chiu FY, Chen CM, Chen TH. Revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture. J Trauma. 2009 Dec;67(6):1393-6.
11. Hierholzer C, Sama D, Toro JB, Peterson M, Helfet DL. Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing. J Bone Joint Surg. 2006; 88A: 1442-drv7
12. SmithWR, Ziran BH,Anglen JO, et al. Locking plates: tips and tricks. J Bone Joint SurgAm 2007;89(10):2298-307. PMID:17966158.
13. Wagner M. General principles for the clinical use of the LCP. Injury 2003;34 Suppl 2:B31-42.
14. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma. 2004 Sep;18(8):488-93.

How to Cite this article: Tanna DD, Gawhale S, Shinde K, Gondalia V, Park H, Shyam AK. Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected and multiple times Operated Non Union of Long Bones. Trauma International Jan – June 2017;3(1):27-31.

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