Humerus non-unions are difficult to treat, especially those with infected non-unions, bone loss, deformity, previous multiple surgeries and/or broken hardware. This paper presents our experience with the use of the Ilizarov frame with humerus non- unions. Eight consecutive humerus non-unions were treated using the Ilizarov frame. Only loose or infected hardware was removed. The Ilizarov frame was applied using safe zones principles of Ilizarov, Catagni and Paley. Aspetic non-unions were treated with deformity correction, sequential compression and distraction, bone grafting and intramedullary stabilisation for diaphyseal nonunions. Infected diaphyseal non-unions were treated intra-medullary reaming with or without excision of infected necrotic bone segment, followed by insertion of antibiotic cement rod and compression. Elbow spanning frames were avoided for supracondylar non-unions. Fine wire fixation of the distal fragment was preferred instead. Free elbow movement was allowed. There were two infected (diaphyseal) and six aseptic non-unions (four diaphyseal and two supracondylar) treated with this technique. Broken hardware was left in-situ in five cases. The average time from the index injury was 14 months, with each case having had an average of 3.2 procedures, prior to the application of the Ilizarov frame. Union was obtained in all cases. The average humerus shortening was 1.5 cm. There was no residual angular or rotational deformity. Infection was eliminated in both the infected non-unions. Primary bone grafting was used in all aseptic nonunions. Additional bone grafting was needed as a secondary procedure in four cases prior to frame removal. T he average time spent in the frame was 4.5 months. The Ilizarov method is a useful option for the management of complex humerus non-unions. Patients learn to tolerate the fixator and can achieve functional shoulder and elbow range with the fixator.
To identify ideal screw placement for internal fixation of intra capsular fracture neck of femur to avoid fixation failures, 20 cadaveric bone measurements of the neck of femur in basal, midcervical and at sub capital regions were carried out using Vernial caliper and CT scan. Midcervical region of neck of femur measurements were further divided into upper half (Superior half) and Inferior half (Inferior Half). AP and Lateral view X-rays were obtained following three parallel screws placements in Femur neck: Configuration 1: Triangular configuration where two screws are inferior and one superior. Configuration 2: Triangular configuration where two screws are placed superiorly and one screw inferiorly.
Neck has wider diameter in the upper half of neck of femur than in the lower half in the mid cervical region. Placing two 7.0 mm cancellous screws (total 14 mm) in the lower half of the neck of femur, as widely practised, has more likely chances of not having purchase in the mid cervical region of the femur neck by at least one screw. Cannulated screws fixation carried out in Reverse triangular configuration of fixation is also likely to support the weaker superior half of the neck which lacks stronger cortex and calcar part as in the inferior part of the neck We also recommend placing a larger screw in the superior half of femur neck and a smaller screw in the inferior half in recon-–IM nail fixation, based upon our experiment result.
MRI scan for the knee joint has often been regarded to be the non invasive alternative to a diagnostic arthroscopy. MRI scan is routinely used to support the diagnosis for meniscal or ACL injuries prior to recommending arthroscopic examination and surgery. Identification of meniscal tears can be difficult to interpret and can be observer dependent as well as dependent upon the sensitivity of the scanner. Similar difficulties may exists in clinical examination as well. Our aim was to compare and correlate clinical, MRI and arthroscopic findings in the diagnosis of meniscal and Anterior Cruciate Ligament (ACL) Injuries. This was an observational study of 131 patients over 36 months who had both MRI and arthroscopic surgery. Our study showed clinical examination had better sensitivity (0.86 vs 0.76)and specificity(0.73 v/s 0.52) in comparing to MRI in diagnosis of medial menisceal injuries. similarly +predictive value and −predictive value were higher for clinical examination. whereas for lateral menisceal and ACL injuries there were marginal differences in sensitivity, specificity and predictive values We conclude that carefully performed clinically examination can give equally or better diagnosis of meniscal and ACL injuries in comparison to MRI scan. MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has much better negative predictive value than positive predictive value in both meniscal and ACL injuries diagnosis. When clinical signs and symptoms are inconclusive, performing MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery. When clinical diagnosis is in favour of either meniscal or ACL injuries, performing MRI scan prior to Arthroscopic examination is unlikely to be of significance. MRI scan should not be used as a primary diagnostic tool in meniscal and ACL injuries
20/21 cases had no superficial or deep infection. 62 years old patient with Schatzker IV tibial plateau fracture had deep infection requiring wound debridement and removal of implant which revealed unabsorbed allograft at one year post op which also cleared the infection.
We recommend using allograft bone in elderly patients to reduce morbidity by avoiding one more surgery of obtaining bone graft. Allograft bone in elderly used with internal fixation also provides a reasonable structural support along with it osteoinductive properties.
Cemented titanium stems in hip arthroplasty are associated with proximal cement-stem debonding and early failure. This was well publicised with the 3M Capital hip. However, corrosion in this setting has been reported with only one stem design and is less widely accepted. We present a series of 12 cemented titanium Furlong Straight Stems which required revision at a mean of 78 months for thigh pain. At revision the stems were severely corroded in a pattern which was typical of crevice corrosion. Symptoms were eliminated after revision to an all-stainless steel femoral prosthesis of the same design. We discuss the likely causes for the corrosion. The combination of a titanium stem and cement appears to facilitate crevice corrosion.
12 patients requiring revision of a cemented Furlong total hip replacement had advanced corrosion of their titanium femoral stems. Thigh pain unlike that of loosening was a characteristic feature of presentation an average 38 months after implantation (range 20–58 months). Radiographs demonstrated fusiform periosteal thickening of the middle and distal thirds of the femur around the prosthetic stem with variable amounts of osteolysis around the tip. None of the femoral stems showed evidence of loosening and in 9 cases revision was solely for recurrent atypical pain. The titanium stems were retrieved at an average 80 months (range 60–113). All were well-fixed but showed signs of advanced corrosion distally with blackened stems, loss of surface metal and thick white deposits. Two stems were examined with scanning electron microscopy and energy dispersive X-ray analysis. Micromotion abrasions were identified proximally with loss of all alloy constituents. Distally, there was selective loss of titanium in a pattern suggestive of crevice corrosion. This may be accelerated by a galvanic effect if a cobalt chromium head is mixed with a titanium stem. After revision to an all stainless steel femoral stem and head, early follow-up demonstrates resolution of both symptoms and radiological abnormalities at an average 13 months (range 3–33) from revision.
