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Intertrochanteric (IT) femur fractures in the elderly population comprise a major part of geriatric trauma and fractures. There are various modalities of surgical management, ranging from intramedullary fixation and extramedullary fixation to even replacing the hip joint. Apart from the surgeon's choice, other factors, such as geriatric age, bone quality and osteoporosis, medical comorbidities, life expectancy, pre-operative ambulatory status, muscle strength, type and pattern of fracture, and mental health of the patient, play vital roles in determining the ideal modality of management and the long-term outcome. The present case is a 75-year-old lady who had an IT fracture due to a domestic fall, managed surgically with a proximal femoral nail anti-rotation Asia (PFNA2) for an unstable fracture. She presented with blade back-out on the 11th day postoperatively. The patient was investigated thoroughly, and infection was ruled out. She was managed by the removal of the nail, followed by a cemented calcar-replacing bipolar hemiarthroplasty for an unstable comminuted IT fracture. The patient was ambulatory with a walker by the seventh postoperative day and without a walker by the sixth week, and she was self-sufficient in her activities of daily living. Every geriatric IT fracture must be evaluated thoroughly for contributing factors, such as osteoporosis and fracture pattern, to predict outcomes, and a tailor-made strategy of surgical management and stepwise physiotherapy must be provided to the patient for the best results.
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Olecranon fractures are common in orthopedic wards and can be traumatic or pathological in origin. There are very few cases of bilateral olecranon fractures without any associated injuries to the long bones in the literature. We present a unique case of a young 21-year-old male who has an isolated bilateral olecranon fracture following a road traffic accident. The patient had a closed fracture of the ulna on both sides without any associated injuries or neurovascular compromise. Since the patient was young and had good muscle strength preoperatively, we planned fixation of both sides. The patient underwent open reduction and internal fixation with tension band wiring on the right side, which was his dominant side. The left side was operated on by open reduction and internal fixation with an anatomical plate. The patient was started on elbow range of motion on the right side from the second postoperative day and started basic activities such as having food independently by the 10th day postoperatively. The physiotherapy was continued in a stepwise manner, and by the sixth week, the patient had a full range of motion on both sides. The patient had resumed his activities of daily living independently by the sixth week following the surgery. Such cases are rare, and a case-based management plan must be devised for each patient, considering contributing factors such as age, bone quality, osteoporosis, underlying medical comorbidities, functional demands, and muscle strength. We demonstrated a good clinical and radiological outcome by using tension band wiring on the dominant side with a stable olecranon fracture and plating done on the non-dominant side, which had an unstable displaced olecranon fracture.
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Distal humeral intra-articular fractures often result in functional impairment if treated conservatively. These fractures are particularly challenging due to osteoporosis and severe comminution. A 32-year-old female with a grade three open distal humerus intra-articular fracture presented with a 5 cm x 5 cm open wound on her right elbow. The patient underwent open reduction and internal fixation (ORIF) using the BB Joshi external fixator and a local flap for skin coverage, achieving stable fixation and early mobilization. The patient regained a near-normal range of movements and adequate skin coverage of the wound at follow-up. Compared to traditional ORIF, it showed lower infection rates and comparable union rates, leading to better functional outcomes when compared with the studies reported earlier. The BB Joshi external fixator effectively treats grade three open distal humerus intra-articular fractures, minimizing complications and promoting functional recovery.
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The goal for surgical treatment of femoral neck fractures is achieving union through an anatomic reduction and stable fixation while avoiding osteonecrosis. This report describes the case of a 50-year-old male who presented with pain and swelling in his right hip and inability to bear weight over his right lower limb following a road traffic accident. The X-ray revealed a right-sided femoral neck fracture (Garden Type IV and Pauwels Type III). The patient was surgically treated with the GS Kulkarni (GSK) controlled dynamic hip screw. On follow-up, the bone healing time was 14 weeks and the patient achieved a Harris hip score of 93.65 with significant improvement.
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Metastatic lesions in the proximal femur are well-known in the literature and are important since they can progress to pathological fractures and impair the patient's mobility. We present the case of a middle-aged female with a history of breast carcinoma 20 years ago, who experienced diffuse chronic hip pain for the past two months. Radiographs, MRI, and PET scans revealed a metastatic lesion in her proximal femur. After consulting with an oncologist, it was determined that adjuvant chemoradiotherapy was unnecessary. The treatment strategy was dependent on the preoperative general health condition, the life expectancy, amount of metastasis, bone quality, pathological fractures and factors affecting the union and capacity to ambulate the patient postoperatively. The patient underwent a cemented bipolar hemiarthroplasty to excise all metastatic tissue and provide a painless, functional, and mobile joint. Bipolar hemiarthroplasties articulate at two levels, and this dual-bearing design is believed to reduce acetabular wear. The bipolar hemiarthroplasty also eliminated the risk of complications associated with the acetabular component, which would necessitate early revision surgery. Modular bipolar hemiarthroplasty is a good modality of replacement associated with fewer complications and improves quality of life.
RESUMEN
Hip bipolar hemiarthroplasty, a widely employed surgical intervention for managing hip fractures and degenerative hip diseases, can pose significant challenges when revisions become necessary due to complications such as implant loosening, instability, or breakage. This case report presents the intricate management of a 58-year-old male who presented with worsening left hip pain a decade after undergoing hip replacement surgery. Despite a thorough preoperative assessment ruling out infection, intraoperative complexities included the necessity for extended trochanteric osteotomy (ETO) to address a broken stem and associated metallosis. Successful revision surgery was meticulously executed, incorporating techniques for implant removal, femoral shaft augmentation, and postoperative rehabilitation. The ensuing discussion explores the multifaceted aspects of failed hemiarthroplasty, emphasizing the critical roles of surgical precision, judicious patient selection, and ongoing research endeavors aimed at refining surgical strategies to optimize patient outcomes. This case underscores the imperative of a multidisciplinary approach and the continued imperative for advancements in surgical methodologies for effectively managing revision hip arthroplasty cases, thus enhancing the quality of patient care in this intricate clinical domain.
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A 41-year-old female patient sought medical attention due to a malunited distal radius fracture with a positive ulnar variance, experiencing wrist pain and limited range of motion. The patient was successfully treated with an isolated ulnar osteotomy and bone grafting, resulting in significant alleviation of symptoms and improved wrist mobility. Various surgical methods have been proposed to address malunited radius fractures, and ulnar osteotomy has shown promise as an effective technique for such cases.
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Background A midshaft clavicle fracture is a prevalent form of injury of the upper extremity that affects one's quality of life. Several treatment modalities facilitate fixation of the displaced midshaft clavicle to decrease nonunion and malunion of the clavicle fracture. Still, numerous factors influence choosing an optimal surgical intervention. Thus, this study investigates the functional outcome of two standard fixation techniques, titanium elastic nails (TENs) and locking plates, as a prospective comparative study for surgical management of displaced midshaft clavicle fractures. Methods We performed closed/open reduction and internal fixation in 62 patients (40 male and 22 female) with TENs and locking plates, respectively, which were followed up at regular intervals following the surgery (at two, six, 12, 24, and 48 weeks). The surgical outcome was assessed both from functional and radiological standpoints. The influence of surgical fixation on functional outcome was evaluated based on the Constant-Murley score and the fracture recuperation based on union times. Results When compared to plate fixation, TENs had lesser union times. Still, there was no statistical difference in union time between the two groups. The functional assessment graded by Constant-Murley score had a similar distribution of scores between the two groups.With a follow-up of twelve months, the Constant-Murley scores between the groups were not statistically different. While the average score for plate fixation was slightly higher than that of TENs, the nonunion rate was found to be similar in both groups. Conclusion Surgical interventions using both TENs and plate fixation are suitable for managing clavicle midshaft fractures as they have a similar functional outcome. However, considering early recovery with minimal surgical complications, TENs can be a preferred treatment choice for managing displaced midshaft clavicle fractures.
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Introduction Fractures in children are extremely common scenarios encountered by orthopedicians. Conservative treatment has been the most preferred choice for the management of diaphyseal forearm fractures. Traditionally, pediatric forearm fractures are treated by above elbow plaster cast with the elbow flexed to 90 degrees. The purpose of this study was to evaluate the functional and radiological outcomes of children treated with closed reduction and extension casting for forearm fractures. Patient and methods This is a prospective study evaluating the functional and radiological outcomes of 30 children of less than the age of 14 years and without pathological fractures, treated with closed reduction and extension casting for forearm fractures, either both radius and ulna or radius or ulna at middle third level, who reported to the Department of Orthopedics, Dr. D.Y. Patil Medical College, Hospital, and Research Center, Pune, India, between September 2019 and March 2022. Results The mean pre-operative angulation in radius (antero-posterior {AP}) was 22.7, radius (lateral {LAT}) was 24.2, ulna (AP) was 31.2, and ulna (LAT) was 29.2. The immediate post-operative angulation of radius (AP) was 0.7, radius (LAT) was 3.2, ulna (AP) was 0.6, and ulna (LAT) was 4.9. Cast status at two weeks, 83.3% had intact cast and 16.7% had loosened casts. Post removal, most patients had a good rotation of motion (ROM) at three and six weeks. Conclusion Casting with extended elbow is much better as compared to flexion casting in the hands of a trainee doctor. Furthermore, chances of loss of reduction are negligible in extension casting as compared to flexion casting.
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BACKGROUND: With an incidence of 50% of humerus fractures, proximal humerus fractures (PHFs) can significantly impact one's quality of life. Moreover, management of highly comminuted or displaced PHFs poses a significant challenge amongst elderly population due to poor bone quality. Prosthetic replacement of humeral head or its stabilization using external plates is a commonly employed intervention for treating three- and four-part PHFs. Thus, these two methods were compared in this study to identify a preferable intervention. METHODS: Patients were randomly divided into two groups to receive proximal humerus internal locking system (PHILOS®, Synthes, Switzerland) plating and Neer's hemiarthroplasty. The deltopectoral approach was deployed as the surgical method. Their surgical outcome was assessed from functional range of motion (ROM) and Constant-Murley scores at regular intervals of three, six, twelve, and twenty-four weeks. RESULTS: Twenty patients were divided into two groups who received PHILOS® plating and Neer's hemiarthroplasty, averaged 67.2 years and 72.8 years. The ROM pertaining to flexion, extension, abduction, internal rotation, and external rotation for individuals with PHILOS® plating was 20%, 12.5%, 14.7%, 11.5%, and 18.5% higher than those who received Neer's hemiarthroplasty. Moreover, the Murley score was also 8.7 units higher for individuals with PHILOS® plating. CONCLUSIONS: Prognosis following PHILOS® plate osteosynthesis had a better overall outcome than hemiarthroplasty with Neer's prosthesis. Although hemiarthroplasty yielded a consistent functional outcome, PHILOS® plate osteosynthesis tends to restore a greater ROM. Thus, PHILOS® plating is recommended as the suitable method to manage three- and four-part PHF for people above fifty-five years of age.