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Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Online ISSN Number 2455-538X
Where Do We Need More than One Approach for Acetabular Fractures and Which One First?
/in Volume 3 | Issue 1 | Jan-April 2017Vol 3 | Issue 1 | Jan – Apr 2017 | page:10-13 | Raju Vaishya, Vipul Vijay, Amit K Agarwal, Abhishek Vaish
Author: Raju Vaishya [1], Vipul Vijay [1], Amit K Agarwal [1], Abhishek Vaish [2]
[1] Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India,
[2] Department of Orthopaedics, Canterbury Christ Church University, Kent, UK.
Address of Correspondence
Dr. Raju Vaishya,
Indraprastha Apollo Hospitals, New Delhi, India.
E-mail: raju.vaishya@gmail.com
Abstract
Acetabular fractures are often difficult to manage. The majority of fractures require anatomical reduction to prevent secondary
osteoarthritis and instability. Often a single approach is sufficient to fix these fractures. The choice of approach depends on the
major anatomical involvement of the acetabulum. However, some fracture patterns require more than a single approach to fixing the
fractured fragments adequately. This article addresses this particular issue.
Keywords: Acetabulum, fractures, pelvic, surgical approaches.
What to Learn from this Article?
The fixation of all the acetabular fractures cannot be achieved with a single approach, at all the times. Hence, it is necessary to do a good pre-operative planning and identify the fractures which may require a dual approach to achieve satisfactory fixation.
Introduction
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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
The basic fracture fixation principles in the lower extremity are anatomical reduction and the possibility of early rehabilitation. A combination of these two factors can help one achieve good prognosis and outcomes. The acetabular fractures are no different. They should be managed aggressively, and an attempt should be made to achieve anatomical reduction so as to prevent the most common complication of osteoarthritis (1). There are some restrictions on the surgical management of acetabulum fractures which may influence the decision of the treating surgeon towards an operative or conservative treatment. Factors like the proximity to important anatomical structures, the difficulty in achieving surgical exposure and the lack of experience in managing these fractures, all influence the decision-making (1).
With advances in imaging technology, a better understanding of anatomy and improved approaches for the management of the acetabulum fractures; focus is shifting towards an effort to achieve anatomical reduction (2). The first step in achieving anatomical reduction for any fracture is good surgical exposure. The most commonly used approaches are the Kocher Langenback and ilioinguinal approach, which have been the workhorse for acetabular surgeons. Recently, further modifications and some extensile approaches like iliofemoral, Stoppa’s, trochanteric osteotomy, etc have also been introduced (3-8). The type and combination of the surgical approach to be used is of paramount importance in achieving a good outcome.
Limitations of a Single Approach
The first step is to understand the anatomy, displacement and the direction of displacement of the fracture. The second step is to plan an approach which would allow proper visualization and accurate reduction of the fracture fragments (2). The ilioinguinal approach is useful for fixation of the anterior column and wall fractures, but they are unable to help in achieving an accurate reduction in cases of displaced posterior column fractures (1) (Figure 1). Similarly, the Kocher-Langenback approach can be used for good visualization of the posterior column and wall fractures, but they provide inadequate exposure to the anterior column and wall (1) (Figure 2).
Matta emphasized the need for anatomical reduction of the fracture fragments in acetabulum for optimal results (9). The key to anatomical reduction is good exposure and visualization of the fracture fragments. A single approach can adequately manage fractures involving a single column or wall. Also, certain bicolumnar fractures which have minimal displacement in one of the columns can also be managed by approaching the more displaced column directly.
However, in certain fractures like T-type fractures with significant displacement in both columns cannot be managed with a single approach. They require either the use of the described extensile approaches like iliofemoral, tri-radiate, etc. or the use of sequential approaches. These approaches are not without their sets of complications like increased rates of infection, delayed rehabilitation, higher rates of ectopic ossification and prolonged abductor weakness (2). Hence, whenever an extensile or a sequential approach is planned, the decision should be based on sound scientific judgement.
Fractures which can not be accessed through K-L approach alone
1. Both columns fractures
2. Anterior column fractures
3. Anterior column and posterior Hemi transverse fracture
Fractures which can not be accessed through ilioinguinal approach alone
1. T-type fractures
2. Isolated posterior column fractures
Fractures needing more than one approach
The fractures which may require more than one approach for an optimal result include –
1. T-type fractures
2. Selected both column fractures with significant displacement (>10mm) in both the columns.
3. Transtectal transverse fractures
4. Transverse fractures with posterior wall fracture with wide displacement
T-type and complete both column fractures
The T-type fractures and complete both column fractures need special mention. In these types of fractures, the femoral head is displaced medially, and both the columns rotate around the femoral head in opposite directions. This mechanism of rotation of the two columns can be understood as one similar to the two doors of a gate opening up in opposite direction around a central hinge. Any attempt at indirect reduction of the columns in these types of fractures will only lead to maintenance of the malrotation and the persistence of inaccurate reduction (1). These fractures are an absolute indication for open reduction, direct visualization, and internal fixation. Hence, these fractures may sometimes require the use of extensile approach or two sequential approaches for optimal fixation (2).
Transtectal fractures which have an anterior displacement also may require sequential approaches for fixation of these fractures. Some of the transtectal fractures may be fixed using a single anterior or posterior approach, especially if they have isolated posterior displacement. Some fractures with high anterior obliquity, on Judet views, with minimal displacement may also be fixed with an isolated posterior approach. Fractures with large displacement (>10 mm) in the anterior direction, usually need sequential surgical approaches (10).
In the transtectal fractures, the vertical nature of the fracture line makes it difficult to palpate the reduction through the greater sciatic notch (11). Moreover, since the fracture line passes through the supra-acetabular dome, imperfect reductions are very poorly tolerated (11). An adequate fixation may require in some of these fractures to utilize two approaches.
Transverse plus posterior wall fractures may make it difficult to be fixed through the isolated anterior approach. If approached through the K-L approach alone, the reduction of the transverse fractures may be difficult to assess through the posterior wall window, even after femoral head distraction. This may make it useful that the surgeon fixes the posterior wall using the K-L approach and then use the ilioinguinal approach for fixation and assessment of the transverse fracture reduction and fixation (1).
Decision making
The decision making for the choice of effective approach depends on the pre-operative CT scan (10). The first choice of fixation of the fractures mentioned is the Kocher-Langenback approach in preferably prone or lateral decubitus position. The pre-operative CT scan should be assessed and if there is a vertical fracture pattern or greater anterior displacement, then it would not be amenable to fixation through the isolated posterior approach but would require an additional anterior approach for optimal fixation (1,10).
Which approach first?
The decision of the first approach to be used depends on various factors. The amount of communication in one of the columns is one of the major determinants. The column which has a greater amount of communition should be fixed first. In the presence of a dislocation, the approach which gives direct access to the side of dislocation should be approached first. In case both the columns have equal comminution or are equally displaced, most of the surgeons prefer making the posterior approach first in the prone or the floppy lateral position (2). The anterior approach is made after making the patient supine.
The T-type fractures are a special case in the combined approach. It is often impossible to fix the posterior column through the K-L approach, without the screws passing through the anterior column fractures (11). Thus, the fractures of the anterior column must be reduced first, which makes the subsequent reduction of the posterior column and wall more amenable.
There have been some studies in the recent English literature, which have used the simultaneous anterior and the posterior approaches by two surgical teams (2). The advantages of simultaneous anterior and posterior approaches are decreased surgical time and simultaneous assessment of the reduction from anterior as well as the posterior directions. The disadvantages of this simultaneous approach are the requirement of two surgical teams which are equally adept and versed with acetabular fractures (2). Also, the anterior exposure is a bit difficult in the floppy lateral position, and the exposure is tough in obese patients (2).
Disadvantages
The disadvantages with the use of simultaneous or sequential approaches for acetabular fixation are –
1. Increased blood loss
2. Increased morbidity
3. Increased incidence of heterotopic ossification – due to increased soft tissue manipulation
4. Increased surgical time
Literature review
Combined exposures of the acetabulum have been used in the literature. Matta reported a very low incidence of 2% out of a total of 262 fractures operated (12). Letournel used a sequentially combined approach in only 3% of the cases, out of a total of 849 cases (3). Similarly, Mayo reported an incidence of 4% for combined approaches in their series of the acetabulum fractures (13).
The most important aim in acetabular fractures is anatomical reduction and adequate fixation. Even though all these studies emphasize that the number of fractures requiring more than one approach be limited, surgeon awareness is important so that an inaccurate reduction is not accepted. Adequate pre-operative planning using all the possible radiographic views and the CT scans available should be done, so that the surgeon is aware of the possibility of using two approaches based on the type of fracture and the displacement. This information can help the surgeon as well his team, including anaesthetists and assistants, be aware and prepared for the same.
The decision regarding whether the approach is made simultaneous or sequential and under the same or different anaesthesia, should be taken by surgeon expertise and OT backup. In most scenarios, the column with more comminution should be approached first and in the setting of equal comminution, the posterior column should be approached first.
References
1. Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Techniques Orthopaed 1986;1(1):13-22.
2. Harris AM, Althausen P, Kellam JF, Bosse MJ. Simultaneous anterior and posterior approaches for complex acetabular fractures. J Orthop Trauma. 2008 Aug;22(7):494-7.
3. Letournel E, Judet R, eds. Fractures of the Acetabulum. 2nd ed. Berlin, Germany: Springer-Verlag; 1993.
4. Mears DC, Rubash HE. Extensile exposures of the pelvis. Contemp Orthop. 1983;6:21–32.
5. Reinert CM, Bosse MJ, Poka A, et al. A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg. 1988;70A:329–337.
6. Routt ML Jr, Swiontkowski MF. Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am. 1990;72:897–904.
7. Griffin DB, BeaulA ˜ PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the
acetabulum. J Bone Joint Surg Br. 2005;87:1391–1396.
8. Wey J, DiPasquale D, Levitt L, et al. Operative treatment of acetabular fractures through the extensile Henry approach. J Trauma. 1999;46: 255–260.
9. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients operatively treated within three weeks after injury. J Bone Joint Surg. 1996;78A:1632–1644.
10. Bogdan Y, Dwivedi S, Tornetta P 3rd. A surgical approach algorithm for transverse posterior wall fractures aids in reduction quality. Clin Orthop Relat Res. 2014 Nov;472(11):3338-44.
11. Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood Green’s Fractures in adults. 6th edn. New York, USA: Lipincott William & Wilkin’s;2006.
12. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients operatively treated within three weeks after injury. J Bone Joint Surg. 1996;78A:1632–1644.
13. Mayo KA. Open reduction and internal fixation of fractures of the acetabulum: results in 163 fractures. Clin Orthop. 1994;305:31–37.
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New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts
/in Volume 3 | Issue 1 | Jan-April 2017Vol 3 | Issue 1 | Jan – Apr 2017 | page:3-4 | Dilip D Tanna, Govind S Kulkarni, Sudhir Babhulkar, S. C. Goel, Sushrut Babhulkar, Sunil Kulkarni, Amit Ajgaonkar, Ashok Shyam
Author: Dilip D Tanna [1], Govind S Kulkarni [2], Sudhir Babhulkar [3], S. C. Goel [4], Sushrut Babhulkar [3], Sunil Kulkarni [2], Amit Ajgaonkar [5], Ashok Shyam [6,7]
[1] Saifee Hospital Medical research center, Mumbai , India.
[2] Sushrut Institute of Medical Sciences,Research Centre & Post-Graduate Instt of Orthopedics,Central Bazar Road,Ramdaspeth,Nagpur,INDIA 400 010
[3] Post Graduate institute of Swasthiyog Pratisthan Miraj, India
[4] Professor of Orthopaedics, Institute of Medical Sciences, BHU, Varanasi, India
[5] Zenith Hospital, Malad, Mumbai, India
[6] Indian Orthopaedic Research Group, Thane, India.
[7] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India.
Address of Correspondence
Dr. Ashok K. Shyam.
IORG House, A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@gmail.com
New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts
Trauma as a faculty is developing rapidly along with understanding of fracture patterns, change in trauma scenario and also development in new implants. However outreach of these new developments and percolation and applicability of these new developments is still a big question. We see cases that are complicated by wrong choice of surgery, wrong choice of implant and improper use of principles. Trauma International tried to interview the core team of Trauma Society of India on these two question of new implants and education and research in field of Trauma. We have compiled the responses in this editorial
Dr DD Tanna: New implants like the precontoured anatomical plates are really good. They are definitely expensive but are good. Some Indian companies are also producing excellent variants of the anatomical plates and I believe these will definitely help in better management of complex articular fractures. However I also believe that not every new implant is a real improvement over the previous one. We have to wait for the clinical results and we have to be smart in selecting our cases to use these implants
Trauma education is an ongoing process and we are all students at the same time. We have to continue to learn how to learn, only then we can learn about the new methods and technologies and also learn them well. It is essential for our growth as a surgeon and helps us deliver best treatment to our patients
Dr Sudhir Babhulkar: New implants like fragment specific fixation and anatomic contoured plates are an excellent addition to armamentarium of a trauma surgeon. However we should learn to use them wisely and carefully
Teaching the young generation is the key to spreading trauma education. Traumacon has created that interest in young surgeons about trauma. We need to focus on them and help them develop proper understanding of principles and correct execution of surgical techniques. Conferences, courses workshops all are needed to achieve this aim. Also teaching about correct principles and techniques should reach periphery. My practice has been 50 to 60% complicated reffered cases. Most of the cases were complicated because of wrong application of surgical principles. I think teaching that will address these issues the correct solution for trauma education in India.
Dr GS Kulkarni: About new implants, some of them are really useful in certain situations like fragment specific fixation and contoured plates, but some new implants are not as useful as they are made to appear. New implants should be focussed on solving a surgical problem and should not be innovation for the sake of innovations. We have our innovation which is slotted plate for lengthening over a plate and it is aimed to solve a particular problem. I think that is how innovation should be aimed at.
The focus of trauma education should be basics of trauma surgery. That is where many complications arise. Especially as cases of road traffic accidents are rising, basics of management of open fracture should be emphasised more. Principles of debridements, wound closure, when to close the compound wound, methods of closing the wound, external fixation and stabilisation of compound fracture should all be reviewed and highlighted again and again. Another area is use of antibiotics in fracture surgery specifically local and systemic therapies. Current evidence and experience suggest that with proper surgical management, a single day antibiotic therapy is enough. However most surgeons will give either three day or five day antibiotic therapy which is not good for the patient as well as the fracture. If there is a need for prolonged infection control use of local antibiotics systems like cement beads or cement rods should be utilised to reduce the systemic load of antibiotics. Even in cases of closed fracture proper surgical principles should be followed. For example if a surgeon is using locking plates without understanding the principles of locked plates, it becomes a dangerous implant in his hands and is one of the main cause of complications.
Dr SC Goel: There are new implants launched every year and such developments should be taken with pinch of salt. Lot of these may be industry driven and we need good multicentric trails to validate the results before using them
About education and research, I feel we should have focus on basic sciences too. Unfortunately there are not many basic science labs in India. There are many surgeons who have innovative ideas and techniques but do not get a chance to promote their ideas. I think either TSI or IOA should take these projects ahead and give a chance to all innovators to come forward
Dr Sushrut Babhulkar: The science of orthopaedic trauma is evolving and our understanding of it is changing and that is reflected in development of new implants. New implants in trauma are very different from new implants in Arthroplasty where it is more industry driven rather than real evolution. As our understanding of fracture pattern and soft tissue injury improves and as we encounter more varied bone quality, the need for new implants will increase. These improvement in basic understanding is what fuels development of new implants in trauma and I think we are moving forward in sensible direction as far as trauma implants are concerned
Education should focus on accurate understanding of principles of trauma surgery and principles of various implants. Both should be used in perfect harmony to achieve excellent result. If either of these principles are not followed, it would lead to complications. This is the main teaching of Traumacon every year. Again research should be promoted but not enforced, if it is enforced, we will get more poor quality research and publications.
Sunil Kulkarni: We are facing new challenging in trauma surgery and number of complex and articular trauma has increased due to high energy accidents. I think new implants have helped us a lot in dealing with these complex injuries. Although simple trauma is still managed well with conventional implants, so proper patient selection is essential.
Trauma education should be about practical knowledge. Textbook knowledge is not of much use in clinical practice. Especially trauma is a branch where even after decades of practice, on can see a completely new case of face new surgical challenge. Education should be focussed on preparing trauma surgeons to face these challenges and difficult practical problems.
Dr Amit Ajgaonkar: New implants have definitely added more tools for trauma surgeons. Implants like Halifax nails, fragment specific fixation, far-cortex locking plates are based on sound principles and have definite advantages in properly selected cases
Trauma Education should focus on peripheral surgeons. In recent months I have travelled a lot across the country and especially in the interiors. I realised that maximum trauma work is done by the peripheral surgeon in rural settings. There is an urgent requirement to provide both training as well as infrastructure to these places. I think TSI, IOA and Traumacon can contribute a lot in terms of improving the training but government should also focus on improving the infrastructure.
If we carefully note the views of all the experts above we can deduce a chain of thought which can be summarised easily. New implants are good but understanding of the principles behind the implant and proper patient selection is must. As far as trauma education is concerned, all the experts believe basic principles are the building blocks and practical knowledge is of utmost importance. I too believe that trauma Education and research are not different entities, both are actually part of one spectrum. Academics originates from new research and initiation of research is from academics. Thus they both fulfil each other and through the churning of both these, innovative ideas and new implants are born.
We thanks our panel for sharing their thoughts with us and we leave the readers now to enjoy the current issue of TI
Dr Ashok Shyam
Editor – Trauma International.
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Editorial – 10 years of Traumacon!!
/in Volume 3 | Issue 1 | Jan-April 2017Vol 3 | Issue 1 | Jan – Apr 2017 | page:1-2 | Dr. Sushrut Babhulkar and Dr. Ashok K Shyam
Author: Sushrut Babhulkar [1], Ashok K Shyam [2,3]
[1] Sushrut Institute of Medical Sciences,Research Centre & Post-Graduate Instt of Orthopedics,Central Bazar Road,Ramdaspeth,Nagpur,INDIA 400 010.
[2] Indian Orthopaedic Research Group, Thane, India.
[3] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India.
Address of Correspondence
Dr. Suhrut Babhulkar
Sushrut Institute of Medical Sciences,Research Centre & Post-Graduate Instt of Orthopedics,Central Bazar Road,Ramdaspeth,Nagpur,INDIA 400 010
Email: sushrutdsurgeon@gmail.com
Editorial: 10 years of Traumacon!!
Traumacon is arguably the biggest trauma conference in India. It was started in 2007 and has completed 10 years in 2017. It is a proud moment for the entire Traumacon organisers and Trauma Society of India (TSI). TSI was started 15 years back with Dr DD Tanna as president and Dr Sudhir Babhulkar as Secretary and ably supported by Dr GS Kulkarni and Dr SC Goel. In those days, arthroplasty, arthroscopy and spine were considered as major specialities of Orthopaedics, while trauma was considered as one of basic units of orthopaedics. Following the trend, there were speciality conferences only in arthroscopy, arthroplasty, spine and also in paediatric orthopaedics but no dedicated conference for trauma existed. TSI took on itself to develop the faculty of trauma in India and with that premise in focus a dedicated trauma conference ‘Traumacon’ was conceived. A proper pattern of the conference was established and the first conference was planned in Mumbai. This was a runaway success and support from the entire orthopaedic faculty was tremendous. Dr Sushrut Babhulkar, Dr Sunil Kulkarni and Dr Amit Ajgaonkar took responsibility of making Traumacon the event of the year in Trauma Calendar of all orthopaedic surgeons.
Traumacon differs a lot from other orthopaedic conferences. At times there is criticism that TSI is a much closed door society and this is in fact true and deliberate. This is done to maintain proper ethics and code of conduct. The core group is involved passionately in all aspects of Traumacon and take decision in terms of scientific program and faculty. At the end of every Traumacon, the preparation for next meeting starts with review of all faculty and comments from delegates are reviewed. The plan for the next year is chalked immediately at the end of one meet after deep scientific and academic deliberations among the core group of TSI. This helps in maintaining the continuity and also improve quality year after year.
Another factor that makes Traumacon different is that the focus of the entire conference in on the delegates. We want our delegates to be exposed to every aspect of orthopaedic trauma, right from the very basic to the latest advancements. Practical sessions and case discussions are aimed to improve the practical knowledge of the delegates and to make difference in their clinical practice. Many delegates have reported that they have significantly changed their operative practices after attending Traumacon and that is the real reward of organising the conference
Principles of trauma surgery are undergoing rapid development along with development of new implants. Rural India is still lacking in good trauma education and surgeons are in need of updating their surgical techniques as well as surgical principles. Needs of these surgeons are specifically addressed in Traumacon and all faculty are passionate to provide practical answers any questions raised by the delegates. This will help in improving the trauma care that the patient receive even in the remotest part of the country. TSI is also conducting the current concepts in trauma symposiums across the country to meet this very aim.
TSI has also worked in the area of academics by affiliating with Thieme and writing guidelines on various areas of orthopaedic trauma. These books are given complimentary to all Traumacon delegates and they can refer these books as an when they need. TSI has also affiliated with the best journal of trauma in the world ‘Injury’ and an Indian supplement is released during Traumacon 2017. Trauma International is also affiliated to TSI and a special issue of the Journal is released every year at Traumacon.
All these activities of TSI and Traumacon have reinvigorated the interest of young orthopaedic surgeons in Trauma and they now look at trauma surgery with more respect. In short TSI has succeeded in promoting trauma as a speciality of Orthopaedics and now many surgeons feel proud in calling themselves trauma surgeons. In future too, TSI and Traumacon will continue its focus on faculty of orthopaedic trauma, academics and newer developments in the area and continue to provide an international platform to all Trauma Surgeons across the country.
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Clinical and radiological outcome of Thoracolumbar fractures treated by Transpedicular Fixation
/in Volume 3 | Issue 1 | Jan-April 2017Vol 3 | Issue 1 | Jan – Apr 2017 | page: 38-45 | Suresh Babu Surapaneni, Venkata Suresh Babu Tummala, Ravikanth Makkena
Author: Suresh Babu Surapaneni [1], Venkata Suresh Babu Tummala [1], Ravikanth Makkena [2]
[1] Department of Orthopaedics, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, Andhra Pradesh, India.
[2] Department of Orthopaedics, ASM Medical College, Eluru, West Godavari, Andhra Pradesh, India.
Address of Correspondence:
Dr. Suresh Babu Surapaneneni,
Suresh Ortho & Multispeciality Clinic, 56-2-18, Koneru Satyanarayana Street,
Canara Bank Road, Patamata, Vijayawada – 520 010, Andhra Pradesh, India.
Phone: +91-9440219597. Tel.: +0866-2474797.
E-mail: drssureshbabu@yahoo.com
Abstract
Background: The injuries involving the spinal cord are generally challenging to manage. The aim of this study was to analyze and compare the clinical including neurological and radiological outcome of thoracolumbar burst fractures treated by short segment and long segment transpedicular instrumentation and posterolateral fusion.
Methods: 34 patients with or without neurological deficit were studied. Gaines scoring, American Spinal Cord Injury Association impairment scale was used for study.
Results: The mean intra-operative correction of K-angle in the short segment group was 14.68° and the loss of correction observed at the last follow-up evaluation was 6.62° with a final gain of 8.06°. The mean intra-operative correction in the long segment group was 19.76° and the loss of correction observed at the last follow-up evaluation was 6.61°. Final gain was 13.15°. On radiological evaluation of wedge angle, mean correction loss of 3.87 degrees and 3.4% implant failure was noted in the short segment group while the long segment group had 1.53 degrees of mean correction loss and no implant failure. There was no positive correlation found between Gaines score with progression of deformity. Neurological Outcome in the short segment group four grades of improvement was found in 1 patient, three grades in 1 patient, two grades in 2 patients and one grade in 6 patients. In the long segment group, three grades of improvement were found in 3 patients, two grades in 2 patients and one grade in 2 patients. 1 of the grade D patient showed improvement within the grade and 3 patients did not show any improvement. Average ASIA motor score improved with treatment from 28.31 to 39.56 points (11.25 points) in short segment group and from 19.91 to 28.46 points (8.55 points) in long segment group.
Conclusion: Transpedicular fixation is a stable, reliable and less surgically extensive construct for addressing thoracolumbar burst fractures. About 6-8° loss of correction was observed with both short and long segment stabilizations in our study. Long segment has better results in terms of maintenance of reduction and final gain. The length of instrumentation does not seem to have any effect on the neurological outcome.
Key Words: Thoracolumbar fractures, Clinical, Radiological outcome.
References
1. Instructional Course Lecture AAOS: Diagnosis and management of thoracolumbar spine fractures. JBJS Vol. 85A: Number 12: Dec. 2003.
2. Harrington PR, Tullos HS. Reduction of severe spondylolisthesis in children. South Med J 1969; 62-1-7.
3. Steffee AD, Biscup RS, Sitowski DJ. Segmental spine plates with pedicle screw fixation- a new internal fixation device for disorders of the lumbar and thoracolumbar spine. Clin orthop 1986; 203: 45-53.
4. Mirjanli et al: Comparison of Transpedicular fixation configurations in Burst fractures of thoracolumbar vertebra. Turkish Spine Journal. Vol. 6, No. 3 Year 1995.
5. Louis et al: Posterior approach with Louis plates for fractures of the thoracolumbar and lumbar spine with and without Neurological deficits. Spine 1998;23(18):2030-2039. .
6. Parker et al: Successful short segment instrumentation and fusion for thoracolumbar spine fractures. A consecutive 4 1/2 year series. Spine volume 25, Number 9, Pg 1157-1169.
7. Gertzbein SD, Brown CMC et al: The neurological outcome following surgery for spinal fractures. Spine 13: 641-644, 1988.
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The Screw Intra-medullary Elastic Nail Fixation in fresh Displaced Mid Shaft Clavicle Fractures – Technical note
/in Volume 2 | Issue 2 | May-Aug 2016Vol 2 | Issue 2 | May – Aug 2016 | page:53-55 | Wasudeo Gadegone, Vijayanad Lokhande, Yogesh Salphale
Author: Wasudeo Gadegone [1], Vijayanad Lokhande [1], Yogesh Salphale [1]
[1] GMC Chandrapur, Maharashtra, India.
[2] Shushrusha Multispecialty hospital, Chandrapur, India.
[3] Smt. Kashibai Navale Medical College and General Hospital, Pune
Address of Correspondence
Dr. W.M. Gadegone.
VivekNagar Mul-Road Chandrapur 442402, Maharashtra, India.
Email: gadegone123@yahoo.co.in
Abstract
Conservative treatment remains the gold standard in treatment of simple undisplaced midshaft clavicle fractures, but for displaced and comminuted fractures surgical intervention is appropriate especially in young active adults. Surgical stabilisation can be achieved using either a plate or an intramedullary device. One of dreaded complication of intramedullary device in migration of the implant. We have used a screw intramedullary device with screw mechanism at one end which can get hold in the medial cancellous bone, thus preventing chances of migration. This report describes the technique of using the screw intramedullary nail for displace clavicle fracture.
Keywords: clavicle fracture, intramedullary nailing.
Introduction
Although conservative treatment is the gold standard for clavicle fractures, there may be some issues like shoulder impairement, a bump at the fracture site that is cosmetically unacceptable or nonunions which happen when grossly displaced fractures are treated conservatively. Surgical stabilisation may be additionally indicated in cases with completely displaced fractures (gap of > 20mm), potential skin perforation, shortening of clavicle by more than 20 mm, neurovascular injury, and floating shoulder injury. Plating is an option which is used commonly, but leads to scarring and may need repeat surgery of implant removal. Intrameduallry nailing has been successfully used by few authors but has a complications like nail migration. We are using a screw intrameduallry device (Fig. 1) which anchors to the metaphyseal bone by the wide screw head at the end of the nail. This technicaal note simply describes the technique.
Implant
Screw elastic intramedullary nail is available in diameter of 2, 2.5, and 3 mm. The nails are 5-6 cm in length , with screw portion of 10mm length and 4.5mm in diameter. The screw head is of 3.5 mm size where the appropriate screw driver fits (Fig. 1). The nail is made of either steel of titanium and is sufficiently elastic to bend as it traversed the canal from the point of insertion and resilient enough to spring back in the curvature when finally seated. However it is still rigid enough to withstand the torsional, rotational, and angulatory forces.]Nail has a bevelled tip at one end and a threaded head positioned at other. This design allows the self-cutting thread to be advanced and screwed in with a 3.5 mm screw driver. The distal beveled end of the nail aids in fracture reduction and helps in engaging in the subchondral area of the bone, thereby imparting stability. The inserter should firmly grasp the nail in order to control rotation, insertion and nail withdrawal. It is best to mount the nail on a T handle while inserting but other devices can also be used (Fig. 2)
Surgical Technique:
Operative procedure is carried out under interscalanae block or general anaesthesia. Affected shoulder is elevated by a bolster so that clavicle becomes more prominent. This position also helps to restore length and increase exposure of the clavicle (Fig. 3). The procedure is performed under fluoroscopic guidance. A one centimeter skin incision is made over medial end of clavicle and a hole is drilled in the anterior cortex with a 3.2 mm drill bit and guide. The insertion point is made approximately 1 cm lateral to the sternoclavicular joint. The entry portal is then enlarged with an awl (Fig.3).
The reaming of canal is done with sequential reamer and then an elastic nail of appropriate diameter and length is inserted in the medullary canal of clavicle with a universal chuck and T-handle (Fig. 4).
With oscillating movements the nail is advanced until it reaches the fracture site. With the help of percutaneously placed towel clips fracture fragments are approximated (Fig. 5). The reduction is checked in image-intensifier and then the nail is advanced through the fracture site till it reaches distal end of clavicle. Generally nail can be negotiated one cm short of acromioclavicular joint. If closed reduction is unsuccessful, an additional skin incision is made at fracture site for open reduction of the fragments (Fig. 5).
Although clavicle is S shaped, tip of the nail is curved which helps the surgeon to pass the elastic nail into distal fragment. After adequate engagement of the distal fragment, the medial end of screw nail is screwed in the metaphyseal region of the medial end of clavicle and skin closed over it (Fig. 6).
Postoperatively arm pouch sling is given for three weeks. Gentle pendulum exercises of the shoulder are allowed as per pain tolerance immediately after surgery. We tend to limit extreme overhead activities for 3-6 weeks. At four to six weeks, active assisted range of motion in all planes was allowed. When fracture union (defined as radiographic union with no pain or motion with manual stressing of the fracture) was evident, muscle strengthening exercises were also allowed. At eight to twelve weeks, Isometric and isotonic exercises were prescribed for shoulder girdle muscles with return to full activities (including sports) at three months (Fig. 7).
Conclusions
Percutaneous elastic screw intramedullary nailing of the clavicle is a safe, reliable method for fixation of displaced midshaft clavicle fractures. It is less invasive and allows rapid healing by callus formation. Complication rates are low, with better functional and cosmetic results.
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Road Traffic Accidents :Age and Gender distribution and impact of Religious Month and Holidays (Ramadan and Eid) on frequency of RTAs in Karachi Pakistan
/in Volume 2 | Issue 2 | May-Aug 2016Vol 2 | Issue 2 | May – Aug 2016 | page:40-43 | Ranjeet Kumar, Muhammad Muzzammil, Muhammed Saeed Minhas, Anisuddin Bhatti, Vinod Kumar, Syed Jahanzeb.
Author: Ranjeet Kumar [1], Muhammad Muzzammil [1], Muhammed Saeed Minhas [1], Anisuddin Bhatti [1], Vinod Kumar [1], Syed Jahanzeb [1].
[1] Jinnah Postgraduate Medical centre Karachi, Pakistan.
Address of Correspondence
Dr Nadeem A Faruqui
14/116d, Civil Lines,
Kanpur 208001 India
Email: nafaruqui@hotmail.com
Abstract
Background: Road safety is an important public health issue in Pakistan. The aim of this study was to investigate trends in road traffic accidents (RTCs) managed by accident and emergency department in Karachi, Pakistan’s largest city, their age and gender distribution and impact of religious month, Ramadan and Eid on frequency of Road traffic accidents in Karachi
Design: cross-sectional study.
Place and duration of study: Accident & emergency department of Jinnah Post Graduate Medical Center, Civil hospital, Abbasi Shaheed Hospital, Aga Khan hospital and Liaqat Hospital Karachi. Pakistan from Jan 2014 to December 2014.
Patients and Methods: A descriptive cross-sectional study was carried out by ROAD TRAFFIC INJURY RESEARCH AND PREVENTION CENTRE “RTIR&PC” in the five tertiary care hospitals (Civil Hospital ,Jinnah Postgraduate Medical Center, Abbasi Shaheed Hospital and Aga Khan Hospital) of Karachi, Pakistan. All road traffic accident victims presented to the emergency department of the selected hospital, were included in the study. A pretested trauma registry form was completed for all patients.
Results: Total numbers of accidents were 24360 and total number of injured were 30274. Minor injury 23825 approximately 78.6%, around 65 per day, serious were 5382 approximately 17%,around 15 per day and fatal were 1067 approximately 3.5%, 3 per day. Male injured were 25263 around 83% and female were 5011 around 17%. According to casualities with respect to age were from 16-20 years male were 5136 around 20% and female were 553 around 11% total of 5689 , from 21-25 years male were 4785 around 19% and female were 674 around 13% total of 5459 , from 26-30 years male were 3546 around 14% and female were 613 around 12% total of 4159 and under 15 years male were 3165 around 13% and female were 840 around 19% total of 4105 , other age and gender distribution given in table 1. On month wise casualities, highest casualities recorded in month of June and July of 2014. Ramadan was from June to July in 2014 and Eid was in July in 2014. In June 2014 injured were 3080 around 11% and fatal were 72 around 7% and in July 2014 injured were 3506 around 12% and fatal were 112 around 10 %. Record of other months casualities given in table 2. Injuries related to body part were , head and neck 23% ,fatal were 53%, face 17% ,fatal were 16%, chest 1% fatal 1%, abdomen, pelvic contents 1% fatal 1%, extremity, pelvic girdle 29% fatal 17% external injuries 28% fatal 12%.
Conclusion: The study has described trends of RTAs managed by emergency department of hospitals in karachi. Hospital of Karachi experienced a higher burden of RTAs emergencies in the month of Ramadan 2014 as compared with the preceding months of the year. This increase was mostly concentrated among younger ages range from 16-25 years of age. Injuries in city of Karachi are an important public health problem and contribute to major bulk of Emergency facilities. These accidents and the resultant injuries have considerable physical and socioeconomic impacts; therefore, this issue needs to be addressed. By putting into effect laws that enforce road safety measures and helmet usage can prevent these injuries.
Keywords: RTAs (Road traffic accident).
Introduction
Road traffic crashes (RTAs) are one of the most pressing international health and development concerns in the world. Every year, nearly 1.3 million people die as a result of a road traffic collision – more than 3000 deaths each day – and more than half of these people are not travelling in a car. . It was the 2nd leading cause of deaths among 15 – 44 years of age and 80% of these deaths occurred in developing countries . According to the World Health Organization (WHO) 2011 fact sheet, “over 90% of the world’s fatalities on the roads occur in low-income and middle-income countries, even though these countries have less than half of the world’s vehicles [1,2]. In Pakistan, half of all major incidents and two thirds of all deaths in major incidents are due to RTAs In Pakistan [3]. In Pakistan the incidence of road traffic injuries to be around 15–17 per 1000 persons per year estimated by two independent population-based surveys [4–6]. It is estimated that approximately 40 000 people die on the roads every year in Pakistan and many more sustain serious injuries [6]. In addition to the suffering, these injuries contribute significantly to the workload in hospitals, leading to direct costs to the Pakistani economy of over US$ 1 billion [4,7,8]. Various studies in many countries have raised the issue of the increased number of RTCs during holidays and festive periods such as Christmas and New Year [9–11]. An increasing trend of RTAs has also been documented, In countries that celebrate Ramadan, Eid al-Fitr and Eid al-Adha, [12-15]. Ramadan is the ninth month of the Islamic calendar and lasts 29 or 30 days. It is the Islamic month of fasting, in which participating Muslims refrain from eating, drinking, smoking and sex during daylight hours
Methods
It is cross sectional study conducted by Road Traffic Injury Research And Prevention Centre “RTIR&PC” in emergency department of all five major hospitals in Karachi including Jinnah Postgraduate Medical Center, Civil hospital, Abbasi Shaheed Hospital, Aga Khan Hospital and Liaqat Hospital Karachi. . All road traffic accident victims presented to the emergency department of the selected hospital, were included in the study. Inclusion criteria were injured patients of any age or sex presenting to the Accident, Emergency . A pretested trauma registry form was completed for all patients. If the patient was brought unconscious, an attempt was made to collect the information from the patient’s attendant. Basic demographic characteristics, time and date, nature and cause of injury, vital signs and outcome data were recorded. Type of vehicle and mode of collision was recorded in cases of road traffic accident.
Results
Total numbers of accidents were 24360 and total number of injured were 30274. Minor injury 23825 (78.6%), around 65 per day, serious were 5382(17%), around 15 per day and fatal were 1067 (3.5%), 3 per day(table-1, Fig-1).
Male injured were 25263 around 83% and female were 5011 around 17%. According to casualities with respect to age were from 16-20 years male were 5136 around 20% and female were 553 around 11% total of 5689 , from 21-25 years male were 4785 around 19% and female were 674 around 13% total of 5459 , from 26-30 years male were 3546 around 14% and female were 613 around 12% total of 4159 and under 15 years male were 3165 around 13% and female were 840 around 19% total of 4105 (table-2, Fig-2).
On month wise casualities highest casualities recorded in month of June and July of 2014 . Ramadan was from June to July in 2014 and Eid was in July in 2014. In June 2014 injured were 3080 around 11% and fatal were 72 around 7% and in July 2014 injured were 3506 around 12% and fatal were 112 around 10 % (table-3, Fig-3).
Injuries related to body part were , head and neck 23% ,fatal were 53%, face 17% ,fatal were 16%, chest 1% fatal 1%, abdomen, pelvic contents 1% fatal 1%, extremity, pelvic girdle 29% fatal 17% external injuries 28% fatal 12%(fig-4).
Discussion
Trauma is increasingly recognized as a global public health epidemic. WHO has predicted that trauma will rise from 9th leading burden of disease in 1990 to third leading cause in 2020 worldwide . The results of this study revealed a growing rate of RTAs in June and July 2014 (the Islamic month of Ramadan and Eid). In this month, the number of RTAs was higher than the RTAs per month. In present study we found that annual incidence of trauma in road traffic accidents are commonly affecting younger group from 16 -25 years age which also have the highest fatality percentage among all road traffic accidents. In the present study, young age group were predominately involved in the reported RTAs. Fractures of extremities ,external and head injuries were the major injuries sustained by these young people. We also found out that head and neck injuries are the commonest cause of fatality in these incidences. Similar findings have also been reported in research studies from Pakistan [4–8,16-18], India [19-22] and other countries [23-29]. In Ramadan as people wish to be at their homes before iftar (the evening meal when Muslims break their fast). Thus, to return home early, drivers may become impatient and violate traffic rules (e.g. signal violations, speeding, overtaking), often resulting in different forms of RTAs. Similar trend was also observed in other countries celebrating Ramadan [12-15]. The socioeconomic consequences of road traffic injuries include costs of prolonged medical care, loss of the family breadwinner and loss of income due to disability; together these factors often push families into poverty [30].
Conclusion
The study has described trends of RTAs managed by emergency department of hospitals in Karachi. Hospital of Karachi experienced a higher burden of RTAs emergencies in the month of Ramadan 2014 as compared with the preceding months of the year. This increase was mostly concentrated among younger ages range from 16-25 years of age. Injuries in city of Karachi are an important public health problem and contribute to major bulk of Emergency facilities. These accidents and the resultant injuries have considerable physical and socioeconomic impacts; therefore, this issue needs to be addressed. By putting into effect laws that enforce road safety measures and helmet usage can prevent these injuries.
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