Training by Publishing

Vol 5 | Issue 1 | Jan – April 2019 | page:1-2 |  Dr. Ashok Shyam.


Author:  Dr. Ashok Shyam [1,2].

[1] Indian Orthopaedic Research Group, Thane, India
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India

Address of Correspondence
Dr. Ashok Shyam
IORG House, A-203, Manthan Apts, Shreesh, CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@yahoo.co.uk


Editorial: Training by Publishing

This is a digital world we live in. In last 20 years technology has changed the face of this world especially the way in which the data is shared and interaction is improved. This has accelerated things especially scientific inquiry and distribution of scientific concepts. In field of orthopaedics this has led to better implants and more literature. Increased numbers of journals and articles have led to increased awareness about the results of particular surgery and implant. Also it has improved the propagation of awareness about a new technique / implant and its results. In last century, a new technique would simply remain with a single surgeon or country for a long time [Ilizarov ring fixator for example], but now with advent of the online tools and websites, distribution of knowledge is simply amazing.
One of the areas where technology can be successfully used is area of Training in surgical skills. We are currently having video websites like Vu-medi and many more videos on you tube etc, however I believe journals can play a very active part in this area. Surgical training of highest quality can reach each and every corner of the world simply by combining a format which will include text, pictures as well as videos. We all have basic surgical skill sets and to step up our training we would simply need to conceptualise and visualise different methods. This can easily be gained from the above format. Of course the learning curve for such training would be much longer and at times there will be unforeseen complications and difficulties. For this reason such articles should have a continued thread of comment and discussions which can be compiled over a period of time and better a list of frequently asked questions. This can provide answers to queries for a new trainee or even for an experienced surgeon. I believe the techniques should be open peer reviewed and not undergo a blinded peer review. The reviewers should be openly allowed to ask the surgeons questions and doubts that the reader will have. A post publication review of the technique is one of the most important part of this initiative where readers and peers can comment on the published technique. The goal of this entire exercise should be improvement of technique and to impart correct surgical principles to the trainees.
Trauma International wants to pioneer in this area of surgical training by publishing and will be inviting several surgeons on our special editorial board where techniques can be invited and published. I believe this will help surgeons from all across the world to learn new techniques and also improve older techniques. Innovations and tricks and tops in older techniques can easily be demonstrated by using the online tools. Open access will allow much better outreach and more audience for the author too. I sincerely hope that this idea will take firm root and will grow over a period of time. Although this will not be without challenges but with help of our editorial board and our authors we will definitely be able to achieve this goal
If you have any further opinions about this idea, please write to me. With this I leave you to enjoy this issue with symposium on distal femur fracture
Dr Ashok Shyam
Editor – Trauma International


How to Cite the article: Shyam AK. Training by Publishing. Trauma International Jan-April 2019;2(1):1-2

Dr Ashok Shyam

Dr Ashok Shyam


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The New Age of Trauma Resuscitation – Introducing Tranexamic Acid in an Accident & Emergency Department in Karachi Pakistan

Vol 5 | Issue 1 | Jan-April 2019 | page: 10-13  |Muhammad Muzzammil, Muhammad Saeed Minhas, Jahanzeb Effendi, Syed Jahanzeb, Muhammad Ovais, Azeem Jamil, Ayesha Mughal, Abdul Qadir


Author: Muhammad Muzzammil[1], Muhammad Saeed Minhas[2], Jahanzeb Effendi[3],   Syed Jahanzeb[2], Muhammad Ovais[1], Azeem Jamil[2], Ayesha Mughal[2], Abdul Qadir[2]

1Department of Orthopedics, Dr. Ruth K M Pfau Civil Hospital , Karachi.
2Department of Orthopedics, Jinnah Post Graduate Medical Centre, Rafiqui Shaheed Road, Karachi.
3Department of surgery, MC 7742, San Antonio.

Address of Correspondence
Dr. Muhammad Muzamil,
Department of Orthopedics, Dr. Ruth K M Pfau Civil Hospital , Karachi.
Email: muzzammil_sangani@hotmail.com


Abstract

Background: In traumatic patients there is increase loss of blood and requires excessive blood transfusion as compared to other diseases. Clinical efficacy and clinical safety of tranexamic acid in decreasing blood loss assess during this study in post traumatic patients.
Method: Prospectively conducted randomized doubleblind placebo controlled study carried out. Patients were blindly randomized into two groups to receive either intravenous 1gm tranexamic acid 20 min or similar volume of 0.9% saline as placebo (P). Inclusion criteria was based on pulse rate >110 per min or systolic pressure level <90mmHg, hemorrhage or in danger of serious hemorrhage.Patients’ total blood loss was measured, needs of transfusion and hospital stay recorded. The post traumatic hemoglobin, hematocrit values, serum creatinine, activated thromboplastin time, prothombin time, platelets count and pulmonary embolism symptoms were comparatively evaluated.
Results: The total measured blood loss in tranexamic acid group (276 ± 53 mL) when comparing to control group (523 ± 74 mL) was less significantly. The requirement of blood transfusion in comparison was high in the control group and post traumatic hematocrit values were higher with in the tranexamic acid group. After administration of tranexamic acid in traumatic patients there have been no clinically relevant differences within the vital signs and no thromboembolic complications were detected in either group.
Conclusion: In traumatic patients, the prophylactic usage of tranexamic acid has effectively decreased blood loss, transfusion needs and hospital stay without any complication or adverse effects of thrombosis. Thus, TXA can be used safely and effectively in trauma subjects.
Keywords: trauma, tranexamic acid, blood loss, transfusion, hospital stay.


References

1. Astedt B. Clinical pharmacology of tranexamic acid. Scandinavian Journal of Gastroenterology. 1987; 22: 22–5.
2. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, McClelland B, et al. Antifibrinolytic use for minimizing perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2007;4:CD001886.
3. “Lysteda (tranexamic acid) Package Insert” (PDF). (online)(Cited 2 June 2016). Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022430s004lbl.pdf.
4. Roberts I. Tranexamic acid: a recipe for saving lives in traumatic bleeding. J Tehran Heart Cent 2011; 6:178.
5. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs 1999; 57:1005-32.
6. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 2010; 376: 23–32.
7. TXA implementation pages—how to do it. (online) (Cited 2 June 2016). Available from: http://www2.le.ac.uk/departments/cardiovascular-sciences/research/population-research-and-clinical-trials/emergency-medicine-group/research/injury/txa-implementation-pages-how-to-do-it.
8. Committee on Tactical Combat Casualty Care. Tranexamic acid (TXA) in tactical combat casualty care. Guideline revision recommendation. 2011. (Online) (cited 2 June 2016). Available from: http://www.medicalsci.com/files/tranexamic_acid__txa__in_tactical_combat_casualty_care.pdf.
9. Luz L, Sankarankutty A, Passos E, Rizoli S, Fraga G, Nascimento Jr B. Tranexamic acid for traumatic hemorrhage. Rev Col Bras Cir.2012;39:77-80
10. CRASH-2 collaborators; Guerriero C, Cairns J, Perel P, Shakur H, Roberts I. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One 2011; 6:e18987.
11. Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss. British Journal of Surgery 2013; 100: 1271–9.
12. Horrow JC, Van Riper DF, Strong MD, Grunewald KE, Parmet JL. The dose-response relationship of tranexamic acid. Anesthesiology 1995; 82: 383–92.
13. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38(2):185-93.
14. Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma. 2008;65(4):748-54.
15. Mahdy AM, Webster NR. Perioperative systemic haemostatic agents. Br J Anaesth 2004;93:842-58
16. Godier A, Roberts I, Hunt B. Tranexamic acid: less bleeding and less thrombosis. Crit Care2012;16:135.
17. Jiménez J, Iribarren J, Lorente L, Rodríguez J, Hernandez D, Nassar I, et al. Tranexamic acid attenuates inflammatory response in cardiopulmonary bypass surgery through blockade of fibrinolysis: a case control study followed by a randomized double-blind controlled trial. Crit Care2007;11:R117.
18. “The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial.” The Lancet 377(9771): 1101.e1101-1101.e1102.
19. Weber, C. F., et al. “Tranexamic acid partially improves platelet function in patients treated with dual antiplatelet therapy.” European Journal of Anaesthesiology (EJA) 2011;28(1): 57-62
20. Bekassy Z, Astedt B. Treatment with the fibrinolytic inhibitor tranexamic acid-risk for thrombosis? ActaObstetGynecolScand1990;69:353-4.
21. World Health Organization. Injuries and violence: the facts 2014. (Online). Available from URL: http://apps.who.int/iris/bitstream/10665/149798/1/9789241508018_eng.pdf?ua=1&ua=1&ua=1
22. Murray C, Lopez A: The Global Burden of Disease. Volume 1. Cambridge, MA: Harvard University Press; 1996
23. Minhas MS, Khan KM, Effendi J, et al. Improvised explosive devise bombing police bus: Pattern of injuries, patho-physiology and early management [J]. J Pak Med Assoc, 2014, 64 ( 12 Suppl 2 ): S49-S53
24. Minhas M S, Mahmood K, Effendi J, Kumar R, Bhatti A . Terrorist Bomb Blasts: Emergency department management of multiple incidents. Trauma International July-Sep 2015;1(1): 36-40.)
25. Khan, A., et al. “Transfer delay and in-hospital mortality of trauma patients in Pakistan.” International Journal of Surgery 8(2): 155-158.


How to Cite this article:  Muzzammil M, Minhas M S, Effendi J, Jahanzeb S, Ovais M, Jamil A, Mughal A, Qadir A. The New Age of Trauma Resuscitation – Introducing Tranexamic Acid in an Accident & Emergency Department in Karachi Pakistan. Trauma International Jan-April 2019;5(1):10-13.

 



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A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture

Vol 5 | Issue 1 | Jan-April 2019 | page: 23-27 | Niraj Ranjan, Arvind Agarwal, Atul Garg


Author: Niraj Ranjan [1], Arvind Agarwal [1], Atul Garg [1]

[1] Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi

Address of Correspondence
Dr. Niraj Ranjan,
Department of Orthopaedics , Maharaja Agrasen Hospital, New Delhi
E-mail: niraj.ranjan333@gmail.com


Abstract

Introduction: The overall incidence of distal femur fractures is approximately 37 per 100,000 person-years.1 These fractures are either caused by high energy trauma in younger group or low energy falls in elderly population typically older women. As these fractures can lead to long term disability managing them is challenging task. Operative treatment for fracture fixation is recommended for optimal outcome. Although different modes of fracture fixation have evolved in and no single method is uniformly successful. In our study we have compared fixation of distal femur fracture using locking plate and intramedullary nail.
Materials and Methods: Retrospectively collected data of operated distal femur fracture of 60 patients was included. Out of these 30 patients were operated with retrograde distal femoral nail and 30 were operated with locking distal femur plate. Patients were assessed with plain radiographs and CT scan was done for complex and intra articular fractures. AO ( Muller) classification was used to classify the fracture type. Postoperative functional results were evaluated using Schatzker and Lambert critera at 1 year follow up.
Results: Mean age of the patients in the study was 45 yrs. with 73.33 % male and 26.67 % female patients. There were 41 extra articular fractures (type A) while 19 were intrarticular fractures (type C). 22 type A and 8 type C fractures were treated with retrograde nailing while 19 type A fractures and 11 type C fractures were treated with locking plate. In LCP group 28.57% cases had excellent result while 42.86% cases had good result while in retrograde supracondylar nail 13.33% had excellent result and 23.33 % had good result. There were 2 cases of infection, one in each group and 3 cases of malunion, which were managed with nail. Delayed union was encountered in 3 patients, two of them were managed with LCP.
Conclusion: Open reduction and internal fixation of distal femur has achieved excellent to good functional results with locking plate construct in all types of fractures while retrograde supracondylar nail can achieve comparable results when used in simple extraarticular fractures.For other fractures it is difficult to maintain length, alignment and rotation with retrograde nail.
Keywords: distal femur fracture, Retrograde intramedullary nail, locking distal femur plate, minimally invasive plating technique, Schatzker and Lambert criteria.


References

1. Neer C. Fractures of the clavicle. In: Rockwood CA Jr., Green DP, editors. Fractures in Adults. 2nd ed. Philadelphia, PA: Lippincott; 1984. p. 707-13.
2. Lenza M, Faloppa F. Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle. Cochrane Database Syst Rev 2015;5:CD007428.
3. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4:107-12.
4. Crenshaw AH. Fractures of the shoulder girdle, arm and forearm. In: Crenshaw AH, editor. Campbell’s Operative Orthopedics. 8th ed. St Louis: Mosby; 1992. p. 989-1053.
5. NEER CS 2nd. Nonunion of the clavicle. J Am Med Assoc 1960;172:1006-11.
6. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968;58:29-42.
7. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD, Evidence-Based Orthopaedic Trauma Working Group. et al. Treatment of acute midshaft clavicle fractures: Systematic review of 2144 fractures: On behalf of the evidence-based orthopaedic trauma working group. J Orthop Trauma 2005;19:504-7.
8. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-9.
9. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: A prospective study of 222 patients. Acta Orthop 2005;76:496-502.
10. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-65.
11. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am 2003;85-A:790-7.
12. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am 2006;88:35-40.
13. Lenza M, Belloti JC, Andriolo RB, Gomes Dos Santos JB, Faloppa F. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev 2009;2:CD007121.
14. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am 2007;89:1-0.
15. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow-up. J Shoulder Elbow Surg 2004;13:479-86.
16. Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, et al. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: A multicenter, randomized, controlled trial. J Bone Joint Surg Am 2013;95:1576-84.
17. Judd DB, Pallis MP, Smith E, Bottoni CR. Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead NJ) 2009;38:341-5.
18. Smekal V, Irenberger A, Attal RE, Oberladstaetter J, Krappinger D, Kralinger F, et al. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients. Injury 2011;42:324-9.
19. Böhme J, Bonk A, Bacher GO, Wilharm A, Hoffmann R, Josten C, et al. Current treatment concepts for mid-shaft fractures of the clavicle results of a prospective multicentre study. Z Orthop Unfall 2011;149:68-76.
20. Kulshrestha V, Roy T, Audige L. Operative versus nonoperative management of displaced midshaft clavicle fractures: A prospective cohort study. J Orthop Trauma 2011;25:31-8.


How to Cite this article: Ranjan N, Agarwal A, Garg A. A Comparative Study of Conservative and Surgical Management of Displaced Midshaft Clavicle Fracture. Trauma International Jan – Apr 2019;5(1):23-27

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Cannulated Cancellous Screw and Ender’s Nail Fixation in Stable Intertrochanteric Femur Fracture in Elderly Patient With Co-Morbid Condition

Vol 5 | Issue 1 | Jan-April 2019 | page: 17-22  |Rohan R Memon, Drashtant Patel


Author: Rohan R Memon[1], Drashtant Pate[l1]

1 Department of orthopaedics, VS General hospital,NHL Medical college. Ahmedabad

Address of Correspondence
Dr. Rohan Rafik Memon,
Department of orthopaedics, VS General hospital,NHL Medical college. Ahmedabad
Email: rhnmemon222@gmail.com


Abstract

Background: Intertrochanteric Femur fracture is common in elderly patient with co-morbidity.Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis.
Aims and objectives;  we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures.
Study Design: This is a prospective observational type of study
Place and duration of studyDepartment of orthopaedics, NHL medical college between January 2015 to June 2018
Methodology: 52 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2015 to june 2018. We included those patients having age ≥50 years, with multiple co- morbid conditions like diabetes, hypertension, COPD, Asthma, bleeding disorders and multiple fractures, and duration of the Intertrochanteric fracture ≤ two week. We exclude young active patients < 50 yrs age, fracture > 2 weeks duration, fracture with lateral wall comminution and open fractures. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head.
Results; All the fractures were united within an average period of 13 weeks with a range of 10 – 13 weeks. The functional assessment was done with modified Harris hip score(Table no 1,2) and the mean was 86.3 with a range from 73 to 95 , and 26 patients were excellent, 20 patients were good , 4 patients were fair and two patients were poor with respect to total score. The analysis of this study fulfils the objectives of good functional outcome
Conclusions: The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.
Keywords: Compression screw, Ender nails, osteoporosis, inter-trochanteric fracture


References

[1]. Rockwood and Green;s Fracture in adults, 8th edition: vol.2:2075-2130.

[2]. Hagino H, Furukawa K, Fujiwara S, et al. Recent trend in the incidence and lifetime risk of hip fractures in Tottori, Japan.Osteoporos Int. 2009;20(4):543-548.

[3]. Lawton JO, Baker MR, Dickson RA. Femoral neck fracture: two populations. Lancer 1983;2:70-72.

[4]. Atkin JM. Relavance of osteoporosis in women with fractures of the femoral neck. Br Med J 1984;288’:597-601.Pogrund H, Makin M, Robin G, et al. Osteoporosis in patients with fractured femoral neck in Jerusalem. Clin Orthop 1977;124:165-172.

[5]. Ender J, Simon-Weidner R. Die Fixierung der trochantener bruche mit runden elastischen Kondylennageln. Acta Chir Austria1970;1:40.

[6]. Bonnaire F, Weber A, Bosl O, Eckhardt C, Schweiger, Linke B. “Cutting out” in pertrochanteric fractures – problem of osteoporosis. Unfallchirurg. 2007;110:425–32.

[7]. Beidle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures femur – randomized prospective comparison of gamma nail and dynamic hip screw. JBJS Br. 1991;73:330–4.

[8]. Nordin S, Zulkifil O, Faisham WI. Mechanical failure of DHS fixation in intertochanteric fracture femur. Med J Malaysia. 2001;56:12–7.

[9]. Fogognolo F, Kfuri M, Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with PFN. Arch Orthop Trauma surgery. 2004;124:31–7.

[10]. Wojcik B, Tokarowski A, Swieboda A, Kaleta M, Nowak R. Endernails in the stabilization of trochanteric fracture in elderly. Chir Narzadow Ruchu Ortop Pol. 1999;64:279–83.

[11]. Raughstad TS, Moister A, Haukeland W, Hestenes O, Olerud S. Treatment of petrochanteric and subtrochanteric fractures of the femur by the Ender metod. Clin Orthop. 1970;138:321.

[12]. Pankovich AM, Tarabiski IE. Ender nailing of intertrochanteric fractures of femur. J Bone Joint Surg. 1980;62A:635.

[13].Cobelli NJ, Sadler AH. Ender rod versus compressive screw: fixation of hip fracture. Clin Orthop. 1970;138:321

[14]. Moon MS, Woo YK, Kim ST. A clinical study of trochanteric fractures of the femur: Outcome of the treatment in regard to osteoporosis and type of the treatment. I Korean Orthop Assoc. 1991;26:1693–702.

[15]. Russian LA, Sonni A. Treatment of intertrochanteric and subtrochanteric fractures with Ender intramedullary rods. Clin Orthop. 1980;148:203–12.

[16]. Kuderna H, Bohler N, Colby AJ. Treatment of intertrochanteric and subtrochanteric fracture of the hip by the Ender method. J Bone Joint Surg. 1976;58:604–11.

[17]. Hall LG. Comparison of nail-plate fixation Ender’s nailing for intertrochanteric fractures. J Bone Joint Surg. 1981;63-B:24–8.

[18]. Parker MJ, Handoll HH, Bhonsle S, Gillespie WJ. Condylocephalic nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev. 2000;2:CD000338.


How to Cite this article:  Memon R R, Patel D. Cannulated Cancellous Screw and Ender’s Nail Fixation in Stable Intertrochanteric Femur Fracture in Elderly Patient With Co-Morbid Condition. Journal of Bone and Joint Diseases Jan – Apr 2019;5(1):17-22.

 



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Cannulated Cancellous Screw and Ender’s Nail Fixation in
Stable Intertrochanteric Femur Fracture in Elderly Patient
With Co-Morbid Condition

Comparative study of operative treatment of distal femur fractures using retrograde intramedullary nail versus locking plate Retrospective study

Vol 5 | Issue 1 | Jan-April 2019 | page:3-6 – Raviraj Shinde, Tanvi Shinde, Ajit Shinde


Author: Raviraj Shinde[1], Tanvi Shinde[1], Ajit Shinde[2]

1Department of Orthopaedics, Grant Medical College and Sir.J.J. Group of Hospitals, Mumbai.
2Shree AnnasahebShindeMhaishalkar Charitable Trust, Post Graduate Institute, Ambedkar road, civil hospital chowk, sangli

Address of Correspondence
Dr Raviraj Ajit shinde
Department of Orthopaedics, Grant Medical College and Sir.J.J. Group of Hospitals, Mumbai
Email Id : drravirajshinde@gmail.com


Abstract

Introduction: The overall incidence of distal femur fractures is approximately 37 per 100,000 person-years.1 These fractures are either caused by high energy trauma in younger group or low energy falls in elderly population typically older women. As these fractures can lead to long term disability managing them is challenging task. Operative treatment for fracture fixation is recommended for optimal outcome. Although different modes of fracture fixation has evolved and no single method is uniformly successful. In our study we have compared fixation of distal femur fracture using locking plate and intramedullary nail.
Materials and Methods: Retrospectively collected data of operated distal femur fracture of 60 patients was included. Out of these 30 patients were operated with retrograde distal femoral nail and 30 were operated with locking distal femur plate. Patients were assessed with plain radiographs and CT scan was done for complex and intra articular fractures.  AO ( Muller) classification was used to classify the fracture type. Postoperative functional results were evaluated using Schatzker and Lambert critera at 1 year follow up.
Results: Mean age of the patients in the study was 45 yrs. with 73.33 % male and 26.67 % female patients. There were 41 extra articular fractures (type A) while 19 were intrarticular fractures (type C). 22 type A and 8 type C fractures were treated with retrograde nailing while 19 type A fractures and 11 type C fractures were treated with locking plate. In LCP group 28.57% cases had excellent result while 42.86% cases had good result while in retrograde supracondylar nail 13.33% had excellent result and 23.33 % had good result. There were 2 cases of infection, one in each group and 3 cases of malunion, which were managed with nail. Delayed union was encountered in 3 patients, two of them were managed with LCP.
Conclusion: Open reduction and internal fixation of distal femur has achieved excellent to good functional results with locking plate construct in all types of fractures while retrograde supracondylar nail can achieve comparable results when used in simple extraarticular fractures.For other fractures it is difficult to maintain length, alignment and rotation with retrograde nail.
Keywords: distal femur fracture, Retrograde intramedullary nail, locking distal femur plate, minimally invasive plating technique, Schatzker and Lambert criteria


References

1. J Arneson, T & Melton, Joel & G Lewallen, D & M O’Fallon, W. (1988). Epidemiology of diaphyseal and distal femoral fractures in
Rochester, Minnesota, 1965-1984. Clinical orthopaedics and related research. 234. 188-94.
2. Kolmert L, Wulff K. Epidemiology and treatment of distal femoral fractures in adults.ActaOrthop Scand. 1982 Dec;53(6):957-62.
3. Elsoe R, Ceccotti AA, Larsen P. Population-based epidemiology and incidence of distal femur fractures.IntOrthop. 2018 Jan; 42(1):191- 196. doi: 10.1007/s00264-017-3665-1. Epub 2017 Nov 7.
4. Cambell’s operative orthopedics,11th edition, Vol.3,pg-2805.
5. Schatzker J. Lambert DC: Supradondylar fracture of the femur; Clin. Orthop 138: 77, 1979.
6. Krishna C et al : Current concept of management of supracondylar femur fracture: retrograde femoral nail or distal femoral locking plate IntSurg J. 2016 Aug;3(3):1356-1359
7. El Moumni M, Schraven P, ten Duis HJ, Wendt K: Persistent knee complaints after retrograde unreamed nailing of femoral shaft fractures. ActaOrthopBelg 2010;76:219–225.
8. Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma 2006 ; 20 : 190-196.
9. Krishna C et al : Current concept of management of supracondylar femur fracture: retrograde femoral nail or distal femoral locking plate IntSurg J. 2016 Aug;3(3):1356-1359
10. Gupta SKV, Govindappa CVS, Yalamanchili RK. Outcome of retrograde intramedullary nailing and locking compression plating of distal femoral fractures in adults. OA Orthopaedics 2013 Nov 01;1(3):23.
11. Hierholzer C, von Ruden C, Potzel T, Woltmann A, BuhrenV:Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fracture: a retrospective analysis. Indian J Orthop. 2011;45:243-50.


How to Cite this article:  Shinde R, Shinde T, Shinde A. Comparative study of operative treatment of distal femur fractures using retrograde intramedullary nail versus locking plate; Retrospective study. Trauma International Jan-Apr 2019;5(1):3-6

 


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A Study about the Relationship between Vitamin D Level and Hip Fractures

Vol 5 | Issue 1 | Jan-April 2019 | page: 7-9  |Albert Naveen Anthony, Joe Joseph Cherian, M J Saji.


Author: Albert Naveen Anthony [1], Joe Joseph Cherian [1], M. J Saji [2].

[1] Department of Orthopaedics, St. John’s Medical College Hospital, Sarjapur Road Koramangala, Bangalore. India.
[2] Department of Orthopaedics, Narayana Hridalaya Hospital, H.S.R. Layout, Bangalore.

Address of Correspondence
Dr. Joe Joseph Cherian,
Dept. of Orthopaedics, St. John’s Medical College Hospital, Sarjapur Road, Koramangala,
Bangalore – 560034 Karnataka State. India.
E-mail- cherianjoe71@gmail.com


Abstract

Introduction: Hip fractures are devastating injuries that most often affect the elderly and have a tremendous impact on both the healthcare system and society in general. The role of calcium and Vitamin D deficiency in bone metabolism is known and hence the necessity for further evaluation and studies to check its influence in hip fractures.
Method: A descriptive type of study was conducted between October 2012 and July 2014 in St. John’s Medical College and Hospital. Patients who fulfilled the inclusion criteria were included in the study. Once the diagnosis of hip fractures was made then following tests were done on day 1 of admission – Vitamin D (CLIA method), calcium, phosphate, and alkaline phosphatase.
Results: The study also showed that the incidence of the neck of femur fracture was comparable with intertrochanteric fractures. While neck of femur fractures was more common in female patients, while intertrochanteric fracture was common in male patients. These fractures were mainly seen in the age group between 61 and 70 years of age. The overall Vitamin D deficiency was 76% among all patients, with more predominance (84.6%) in female patients. Increased grades of fracture injury were seen in both fracture neck of femur and intertrochanteric fractures, when Vitamin D level was below 20 ng/ml
Conclusion: The prevalence of Vitamin D deficiency among hip fractures necessitates correction of its serum value in the body. The treatment of Vitamin D deficiency may decrease the incidence of hip fractures and result in milder grades of fractures. This may help in better management of hip fractures and reduce the financial burden of healthcare costs.
Keywords: Vitamin D, Vitamin D deficiency, Hip fractures


References

1. Hektoen LF, Saltvedt I, Sletvold O, Helbostad JL, Lurås H, Halsteinli V, et al. One-year health and care costs after hip fracture for homedwelling elderly patients in Norway: Results from the trondheim hip fracture trial. Scand J Public Health 2016;44:791-8.

2. Laird E, Ward M, McSorley E, Strain JJ, Wallace J. Vitamin D and bone health: Potential mechanisms. Nutrients 2010;2:693-724.

3. Bikle DD. Vitamin D and bone. Curr Osteoporos Rep 2012;10:151-9.

4. Jackson RD, LaCroix AZ, Gass M, Wallace RB, Robbins J, Lewis CE, et al. Calcium plus Vitamin D supplementation and the risk of fractures. N Engl J Med 2006;354:669-83.

5. Shinkov A, Borissova AM, Dakovska L, Vlahov J, Kassabova L, Svinarov D, et al. Differences in the prevalence of Vitamin D deficiency and hip fractures in nursing home residents and independently living elderly. Arch Endocrinol Metab 2016;60:217-22.

6. Gorter EA, Hamdy NA, Appelman-Dijkstra NM, Schipper IB. The role of Vitamin D in human fracture healing: A systematic review of the literature. Bone 2014;64:288-97.

7. Lv QB, Gao X, Liu X, Shao ZX, Xu QH, Tang L, et al. The serum 25hydroxyvitamin D levels and hip fracture risk: A meta-analysis of prospective cohort studies. Oncotarget 2017;8:39849-58.

8. Ramason R, Selvaganapathi N, Ismail NH, Wong WC, Rajamoney GN, Chong MS, et al. Prevalence of Vitamin D deficiency in patients with hip fracture seen in an orthogeriatric service in sunny Singapore. Geriatr Orthop Surg Rehabil 2014;5:82-6.

9. de Jong A, Woods K, Suresh M, Porteous M. Vitamin D levels in hip fractures: Rationale and guidelines for rapid substitution therapy. ??? 2012;43:1624.


How to Cite this article:  Anthony A B, Cherian J J, Saji M J. A Study about the Relationship between Vitamin D Level and Hip Fractures. Trauma International JanAprl 2018;5(1):7-9

 


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Complicated Tibial Plateau Fractures in Young Patients: Functional Outcome with Dual Plating through two Incision Technique

Vol 5 | Issue 1 | Jan-April 2019 | page: 28-31 |Abdul Qadir, Muhammad Muzzammil, Muhammad Tahir Lakho, Maratib Ali.


Author: Abdul Qadir [1],Muhammad Muzzammil [1], Muhammad Tahir Lakho [1], Maratib Ali [2]

1 Dept. Of orthopaedic surgery, Dr. Ruth  K.M Pfau Civil Hospital Karachi – Pakistan.

2 Dept. Of orthopaedic surgery, Jinnah Postgraduate Medical Center, Karachi Pakistan.

Address of Correspondence

Dr. Abdul Qadir
Orthopedic surgeon
Dr. Ruth K.M Pfau civil hospital
Dow university of health sciences
Karachi pakistan

Abstract

Objective: Motorbike accidents contribute one of the most important factors of tibial plateau fracture among young populations in Karachi Pakistan. Most surgeons feel challenging to treatment complicated bicondylar fractures of the tibial plateau.This prospective study was designed to evaluate the functional outcomes of dual plating through a two-incisions technique for the fixation of complicated bicondylar tibial plateau fractures in young patients in Karachi Pakistan.

Methods: This prospective study includes 94 cases of Type V and VI tibial plateau fractures of young patient’s age range from 15 to 45 years, operated between January 2014 and December 2016 conducted in two public sector hospital of Karachi Pakistan (Jinnah Post Graduate Medical Center, Civil Hospital Karachi). Exclusion criteria include patients with multiple fractures on the same side or same bone, age >45 years, open contaminated fracture, open fracture,and patients with head injuries. All cases were operated either by lateral locking plate fixation by anterolateral approach or dual plating through double incisions. These all cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 20.0 to analyze the data.

Results: A total of 94 patients (45 Single Plating and 49 Dual Plating)were operated during the study period of 2 years. However, four patients (4 single plating and 0 dual plating) were lost during follow-up who could not be tracked. Both groups were somewhat similar in relation to the age, mechanism of injury, fracture pattern, and soft tissue injury. Preoperatively, there was a significant increase in surgical time with the dual plating group; however, the mean time of reduction between the two groups was not significant. The decision to put bone graft was at the choice of the operating surgeon and was an intra operative decision with 74 (78.7%) patients receiving the bone graft. Post-operatively, there was no immediate difference in between the groups considering thermal alignment and reduction. It took approximately 4–5 months for the fractures to get united. There was normal union,non union or implant failure seen among those patients. There were 10 cases with superficial infection in wounds of dual plating group which were treated with culture sensitive antibiotics for average 2 weeks, healed subsequently. There were three patients found having an incidence of deep infection in a double plating group, wherein 2 patients were positive with Staphylococcus aureus and 1 patient with Escherichia coli was isolated. Extensive wound irrigation and lavage with antibiotic cement beads were given. Repeated irrigation and lavage were done again after 2 weeks with the removal of beads followed by prolonged course of antibiotic therapy for 6 weeks after which the infection resolved.A total of 38 (77%) patients in a double plating group regained full flexion (135°) and full extension (0°) with a good alignment and no pain and instability as compared to single plating group, seen in 30 (66%) patients at follow-up.

Conclusion: Dual plating by two-incision method resulted in better functional outcome regarding limb alignment and range of movements at knee joint with an acceptable soft tissue complication rate in young patients.

Keywords: Complicated tibial plateau fracture, Young patients, Double incision, Dual plating.


References

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2. Yang BM, Kim J. Road traffic accidents and policy interventions in Korea. Inj Control SafPromot 2003;10:89-94.

3. Ghaffar A, Hyder AA, Masud TI. The burden of road traffic injuries in developing countries: The 1st national injury survey of Pakistan. Public Health 2004;118:211-7.

4. Chalya PL, Mabula JB, Ngayomela IH, Kanumba ES, Chandika AB, Giiti G, et al. Motorcycle injuries as an emerging public health problem in Mwanza city, North-Western Tanzania. Tanzan J Health Res 2010;12:214-21.

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6. Schulak DJ, Gunn DR. Fractures of tibial plateaus. A review of the literature. Clin OrthopRelat Res 1975;109:166-77.

7. Cotton FB. Fender fracture of the tibia at the knee. N Engl J Med 1929;201:989.

8. Koval KJ, Helfet DL. Tibial plateau fractures: Evaluation and treatment. J Am AcadOrthopSurg 1995;3:86-94.

9. Phisitkul P, McKinley TO, Nepola JV, Marsh JL. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma 2007;21:83-91.

10. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of highenergy tibial plateau fractures by the ilizarov circular fixator. J Bone Joint Surg Br 1996;78:710-7.

11. Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev 1994;23:149-54.

12. Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: How does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma 2007;21:301-6.

13. Horwitz DS, Bachus KN, Craig MA, Peters CL. A biomechanical analysis of internal fixation of complex tibial plateau fractures. J Orthop Trauma 1999;13:545-9.

14. Jiang R, Luo CF, Wang MC, Yang TY, Zeng BF. A comparative study of less invasive stabilization system (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures. Knee 2008;15:139-43.

15. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004;18:649-57.

16. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN, et al. Complications after tibia plateau fracture surgery. Injury 2006;37:475-84.

17. Yoo BJ, Beingessner DM, Barei DP. Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: A mechanical comparison of locking and nonlocking single and dual plating methods. J Trauma 2010;69:148-55.

18. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: Definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma 1987;1:97-119.

19. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma 2001;15:312-20.

20. Zhang Y, Fan DG, Ma BA, Sun SG. Treatment of complicated tibial plateau fractures with dual plating via a 2-incision technique. Orthopedics 2012;35:e359-64.

21. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C, et al. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin OrthopRelat Res 2005;439:207-14.


How to Cite this article:  Qadir A, Muzzammil M, Lakho M T, Ali M. Complicated Tibial Plateau Fractures in Young Patients: Functional Outcome with Dual Plating through two Incision Technique. Trauma International Jan-Aprl 2019;5(1):28-31.

 


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Chronic osteomyelitis in Sarajevo, Bosnia-Herzegovina: Long-term health consequences of warfare

Vol 5 | Issue 1 | Jan-April 2019 | page:14 -16  |Katherine O. Ryken, Semin Becirbegovic, Ismet Gavrankopetanovic, J Lawrence Marsh, Marin Schweizer.


Author: Katherine O. Ryken [1], Semin Becirbegovic [2], Ismet Gavrankopetanovic [2], J Lawrence Marsh [1], Marin Schweizer [1]

1 Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
2 Department of Orthopedics&Traumatology, University of Sarajevo ClinicalCenter, Sarajevo, Bosnia-Herzegovina
Address of Correspondence
Dr. Katherine O. Ryken,
University of Iowa Carver College of Medicine, Iowa City, IA
E-mail: kryken@montefiore.org


Abstract

Introduction: Chronic osteomyelitis (COM) is a severely debilitating disease, causing both physical and psychological repercussions for patients. It is particularly common in austere environments and areas of armed conflict. 1,2,3 The most common cause across all age groups is neglected penetrating wounds.4 Often overlooked, COM is one of the many lasting health effects of warfare. Deep infections of the bone following penetrating and blast injuries are common in regions plagued by conflict and cause major physical and social disability.
Materials & Methods: Patient records at the University of Sarajevo Clinical Center Department of Orthopedics & Traumatology were analyzed retrospectively between 2003 and 2013 of patients hospitalized with diagnosed COM.
Results: 155 patients were hospitalized at UCCS for the treatment of chronic osteomyelitis between 2003-2013. Mean age of patients at the time of hospitalization was 56 years. The most common medical comorbidity of patients was diabetes mellitus type 2. Unemployment among patients was 46.1%. The most common cause of COM in this cohort was intentional injury associated with the war between the years of 1992-1995 (46.2%). These were caused by sniper or gunshot wounds (25.4%), landmines or unexploded ordnance (37.7%), and mortar shell explosions (28.8%). The mean hospital stay among patients with COM at UCCS was 31.10 days, although this varied widely depending upon the severity of symptoms and the type of treatment required.
Conclusion: The health burden of chronic osteomyelitis persists for many years beyond the original. Chronic pain and disability contribute to a lifetime of repeated treatments, hospital stays, and high rates of unemployment. This study describes the current burden of COM upon the population of Sarajevo, as well as serving as a foreboding prediction of what can be expected in war zones for many years in the future.
Keywords: Bosnia-Herzegovina, Sarajevo, chronic osteomyelitis, war injuries, orthopedics, infectious disease, social medicine.


References

1. Ibingira, C. B. R. Chronic osteomyelitis in a Ugandan rural setting. East Afr. Med. J.80, 242–246 (2003).
2. Beckles, V. L. L., Jones, H. W. & Harrison, W. J. Chronic hematogenous osteomyelitis in children: a retrospective review of 167 patients in Malawi. J. Bone Joint Surg. Br.92, 1138–1143 (2010).
3. Yun, H. C., Branstetter, J. G. & Murray, C. K. Osteomyelitis in military personnel wounded in Iraq and Afghanistan. J. Trauma64, S163–168; discussion S168 (2008).
4. Baldan, M., Gosselin, R. A., Osman, Z. &Barrand, K. G. Chronic osteomyelitis management in austere environments: the International Committee of the Red Cross experience. Trop. Med. Int. Health TM IH19, 832–837 (2014)
5. Tice, A. D., Hoaglund, P. A. &Shoultz, D. A. Outcomes of osteomyelitis among patients treated with outpatient parenteral antimicrobial therapy. Am. J. Med.114, 723–728 (2003).
6. Casey, K., Demers, P., Deben, S., Nelles, M. E. & Weiss, J. S. Outcomes after long-term follow-up of combat-related extremity injuries in a multidisciplinary limb salvage clinic. Ann. Vasc. Surg.29, 496–501 (2015).
7. Beavis, J.P., Ryan, J.M. High Energy Transfer Missile Wounds in the Siege of Sarajevo and Their Relation to Mine Injuries. J. Conv. Weapons Destr.6, (2002).
8. Geiger, S., McCormick, F., Chou, R. &Wandel, A. G. War wounds: lessons learned from Operation Iraqi Freedom. Plast. Reconstr. Surg.122, 146–153 (2008).
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10. Spellberg, B. & Lipsky, B. A. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am.54, 393–407 (2012)
11. Conterno, L. O. & da Silva Filho, C. R. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst. Rev. CD004439 (2009). doi:10.1002/14651858.CD004439.pub2
12. Murphy, R. A. et al. Multidrug-resistant chronic osteomyelitis complicating war injury in Iraqi civilians. J. Trauma71, 252–254 (2011)..

How to Cite this article:  Ryken K O, Becirbegovic S, Gavrankopetanovic I, Marsh J L, Schweizer M. Chronic osteomyelitis in Sarajevo, Bosnia-Herzegovina: Long-term health consequences of warfare. Trauma International May – Aug 2019;5(1):14-16.

 


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