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   Table of Contents - Current issue
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July-December 2019
Volume 5 | Issue 2
Page Nos. 51-114

Online since Tuesday, December 31, 2019

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EDITORIAL  

Diamonds are expensive, rings are not: Mastering The Paradoxical Evolution Of Nonunion Treatment p. 51
Milind M Chaudhary
DOI:10.4103/jllr.jllr_24_19  
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REVIEW ARTICLES Top

Monofocal distraction of stiff hypertrophic nonunions. How and why does it work? A systematic review and mechanobiological explanation p. 54
Yashwant Singh Tanwar, Nando Ferreira
DOI:10.4103/jllr.jllr_19_19  
Stiff nonunions represent a unique subgroup of nonunions which pose distinct management challenges. Distraction of stiff nonunion, although seemingly counterintuitive, has for long been shown to provide predictable results. Potential advantages of such a management protocol include gradual correction of deformity and limb length; noninvasive nature with minimal insult to the local biology, and in some cases, resolution of infection. In the present article, we systematically review publications describing the results of monofocal distraction of stiff nonunions. An overall union rate of >95% without bone grafting was seen in 178 patients across 12 included publications. The theoretical mechanobiological explanation for the success of this management strategy is also explored.
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Blocking screws for intramedullary nail guidance p. 62
Keir A Ross, Michael E Steinhaus, S Robert Rozbruch, Austin T Fragomen
DOI:10.4103/jllr.jllr_16_19  
Intramedullary nails (IMNs) are commonly used for fracture fixation of the femur and tibia, and internal lengthening nails (ILNs) can be used for deformity correction and limb lengthening. While this form of fixation has demonstrated substantial success, one major limitation is imperfect reduction and malalignment, particularly when used for fractures or osteotomies in the metaphysis. One means of overcoming this challenge is through the use of blocking screws, given their ability to guide the path of the nail, decrease the width of the medullary canal, and maintain reduction. In this literature review, indications, techniques, outcomes, and complications are reported. Searches of PubMed and The Cochrane Collaboration were performed. Technique articles and single case reports were not reviewed. All other English studies reporting outcomes of IMN or ILN fixation of the femur or tibia with concomitant use of blocking screws were reviewed. Blocking screws have been used successfully in the lower extremity for both trauma and in deformity surgery. Key techniques are placing the screws in the concavity and perpendicular to the plane of deformity, with adequate distance from the planned path of the nail and from the fracture or osteotomy site. Current data suggest high rates of union with adequate alignment and a low complication rate, although most studies are small, retrospective case series. Blocking screws appear to be a reasonable strategy for achieving fixation in difficulty, metaphyseal segments. Further, well-designed prospective studies should be carried out to make more definitive conclusions.
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ORIGINAL ARTICLES Top

Ilizarov techniques for upper tibial nonunions: How difficult is it to achieve excellent results? p. 71
Milind Madhav Chaudhary, Monish Malhotra, Umamahesh Neeli, Kelvin Vaishnani, Suman Banik, Naeem Jagani
DOI:10.4103/jllr.jllr_23_19  
Introduction: Upper tibial nonunions (UTNUs) pose challenging difficulties such as soft-tissue scarring, infection, deformity, shortening, and small fragments with intra-articular extension. We present a retrospective analysis of probably the largest series of UTNUs using the Ilizarov techniques. Factors determining the outcome based on difficulty scores and NU scores were also assessed. Patients and Methods: Forty-one patients with UTNU (within 10 cm of joint line) were evaluated retrospectively. Fourteen were aseptic and 27 were septic. The mean NU distance was 5.6 cm from the knee joint. The Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores were evaluated and compared with NU severity score (NUSS), NU level of difficulty score (NULODS), and infection severity score (ISS). External fixation duration (EFD) was compared to NUSS and NULODS to determine which is better in predicting the outcome. We also compared our results with the literature. Results: We achieved union in all except one. The mean EFD was 333 days. The mean regenerate lengthening was 8.6 cm. The ASAMI bone score was: excellent – 16, good – 22, fair – 2, poor – 1. The ASAMI functional score was: excellent – 16, good – 14, fair – 9, poor – 2, and failure – 0. We found a positive correlation between NUSS, NULODS, and ISS. EFD correlated better with overall NULODS and subset of NULODS gap score compared to NUSS and NUSS gap score, respectively. Conclusions: Ilizarov is an effective method to treat UTNU. It corrects the deformity, provides stable fixation, achieves union, and corrects limb length discrepancy.
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Ilizarov strategies in the management of nonunions and difficult fractures of the femur p. 79
Ranjit Kumar Baruah, Siddharth Kumar
DOI:10.4103/jllr.jllr_12_19  
Introduction: Infected nonunion, neglected open fractures, aseptic nonunion, and neglected displaced comminuted fractures are difficult fractures of femur requiring tailored management. We used Ilizarov principles and strategies in such difficult presentations and the aim to evaluate results. Materials and Methods: Thirty-eight patients (37 males and 1 female), 3–48 years old, with infected nonunion (11 cases), neglected open fractures (12 cases), aseptic nonunions (9 cases), and neglected displaced comminuted fractures (6 cases) treated during 2000–2015 were evaluated. Cases of infected nonunion were subclassified using Rosens's classification to guide debridement and underwent single-stage monofocal or bifocal treatment. Neglected open fractures were Type 3 open fractures (Gustillo Anderson) after ≥12 h of injury-underwent debridement and single-stage monofocal or bifocal treatments. Aseptic nonunion cases underwent implant removal and monofocal or bifocal treatment. Neglected displaced comminuted fractures were fixed in situ, monofocal treatment, length, and rotation correction was done. Accordion maneuver was used extensively. No bone grafting was done. Results: Thirty-six cases (95%) achieved successful union and 97% cases had infection eradication. Excellent-to-good bony and functional results were seen in 86% and 68% cases, respectively (ASAMI criteria). Complications such as soft-tissue interposition (5%), Grade III pin-tract infection (13%), and hyporegenerate (11%) were seen. Discussion and Conclusion: With Ilizarov strategies tailored for specific situation, satisfactory and predictable results can be obtained offering one-stage solution to the global problems associated with such difficult fractures. The technique obviates need for bone graft or major soft tissue reconstruction.
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Infected subtrochanteric nonunions of femur - Managed by Ilizarov method p. 88
Srinivas Nookala Reddy, Abhilash Rao Vavilala, Karthik Reddy Ratna, Shravan Kumar Yadala
DOI:10.4103/jllr.jllr_21_19  
Background: The management of infected subtrochanteric femoral nonunions is a difficult clinical challenge to the reconstructive surgeon. We analyzed the results of infected subtrochanteric nonunions managed by the Ilizarov method. Materials and Methods: We present a 11-year prospective study of 14 consecutive infected subtrochanteric nonunions treated by the Ilizarov method between 2008 and 2018. The mean age of patients was 45.5 years (range 20–64). All were postoperative infections. The mean shortening of the femur in ten patients was 2.9 cm (range 2–7 cm). Implant removal was done in 12 cases. Wound debridement followed by Ilizarov fixation was done in the same sitting in all the patients except two, where a two-stage procedure was performed. A temporary external fixator was used for two-stage procedure. Long Schanz pins (cephalic pins) were effectively used for improved stability of the proximal fragment. Results: Thirteen of the 14 patients united. Infection was eradicated in thirteen of the fourteen patients. Mean fixator duration was 12.4 months (range 9.5–18) mean range of preserved knee motion was 95°, including two patients who had total knee stiffness. Conclusion: Ilizarov fixation is a reliable method to achieve union in infected subtrochanteric nonunion of femur.
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Regenerative techniques in the management of post-traumatic segmental bone defects at a level one trauma center p. 94
Simon C Lau, Peter Taylor, Daniel De Villiers, Jack Lahy, Simon Chambers, Andrew Oppy
DOI:10.4103/jllr.jllr_10_19  
Introduction: Segmental loss of bone after traumatic injury can be managed with primary amputation or attempted limb salvage with bony regeneration. We aimed to describe our experience of treating traumatic bone loss at a tertiary level one trauma center and propose an approach to help in the treatment of these patients. Methods: Ten patients were identified via a search of the hospital's medical records covering a 5-year period. Each patient was then retrospectively reviewed with injury factors, treatment options, and final outcomes. Each patient was treated based on an anatomic approach developed by the unit to manage segmental bone loss. Results: Of the patients who underwent bony regeneration, we had four distal tibial fractures: three in the upper limb and one distal femoral fracture. Both primary amputation patients had tibial fractures. The mean bone loss was 88.5 mm. We employed bone transport in four cases, Masquelet in two, a free vascularized fibular graft and soft-tissue flap in one instance, and a combination of free vascularized fibula graft and Masquelet in another case. All patients achieved union, although the mean time to union in smokers was 1403 days, compared to 499 days in nonsmokers. Complications included three returns to theater for bone grafting and three recurrent soft-tissue infections. Post regeneration, the patients had a mean Short Form-36 score of 54.2, and most of the patients were “very satisfied” with the outcome of their surgeries. Conclusion: The regeneration of bone after traumatic loss is onerous on patients, is demanding for clinicians, and requires significant health resources. It should only be considered with appropriate patient buy-in and in the absence of contraindications.
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Use of cable bone transport as a method of soft tissue preservation p. 100
Fadi Foad Aboud, Pavel Alexander Nudelman, Haim Shtarker
DOI:10.4103/jllr.jllr_15_19  
Context: Ilizarov method of bone transport is a well-recognized method in treating bone loss; however, soft tissue complications and potential flap compromise associated with the transport process are a major drawback. Aim: We propose the use of a central transport system of cables and pulleys, as introduced by Weber in 1998 to help preserve soft tissue cover, retain flap integrity, and decrease patient discomfort. Design: This was a retrospective study. Patients and Methods: Consecutive series of patients treated for severe bone loss and fragile soft tissue cover, between 2013 and 2018, according to the Weber method of bone transport, were included in the study. In total, six cases were identified. Inclusion criteria were any patient who underwent bone transport using the Weber method due to bone loss caused by trauma or infection. Exclusion criteria were any patient who did not complete the bone distraction process or had a follow-up of <1 month after bone transport apparatus installation. Results: Five out of six patients completed the bone transport process; one case was excluded from the results since the patient was lost to follow-up before bone distraction was begun. The average follow-up was 13.2 months; no patient had soft tissue complications, the transport process was painless, and the flap integrity was maintained. Bone regenerate was good in all except one case since the patient was lost to follow-up a month after transport was initiated. Conclusion: The Weber method is a reliable technique generating good-quality bone, while maintaining the integrity of the soft tissue envelope, minimizing soft tissue complications associated with the classical method of bone transport. The Weber technique is especially valuable when bone transport is performed in a flap covered area, where the excursion of half pins and K-wires can compromise flap survival.
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Bone Ninja app as a body image simulation tool for shared decision-making p. 105
Vache Hambardzumyan, John E Herzenberg
DOI:10.4103/jllr.jllr_17_19  
Background: Reconstruction of preoperative digital photographs to simulate surgery outcomes is a common practice in esthetic surgery and is proven to enhance shared decision-making. Methods: We used the Bone Ninja app to visualize postoperative results of limb deformity correction. To our knowledge, this is the first attempt to use a body image simulation to predict orthopedic surgery. Results: Two patients decided to undergo surgery only after seeing the postoperative simulation. Two patients reported that the actual postoperative results were identical to the simulation, and one patient said that it was very similar. Conclusion: In the authors' opinion, it is a useful educational tool resulting in lesser decisional conflict and unrealistic expectations, better understanding, and improved satisfaction with results. It also helps surgeons with accurate planning and better judgment regarding esthetics.
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Relationship between distal tibial transosseous wires and ankle joint synovium: A cadaveric analysis p. 111
Ranjit Kumar Baruah, Jishnu Prakash Baruah, S Shyam Sunder
DOI:10.4103/jllr.jllr_7_19  
Background: Distal tibial fractures are managed with external fixation techniques such as Ilizarov to prevent soft-tissue-related complications. In spite of adequate care in wire placement techniques, some cases experience synovitis of ankle joint, stiffness of joint due to pin-tract infections, and deep-seated infection. The accurate description of the ankle joint capsular and synovial recess anatomy is still not clear. The purpose of our study was to study the accuracy of the available guidelines for wire insertion by identifying the relationship between the ankle capsular attachments and the wires in an Indian population. Materials and Methods: 1.8-mm Ilizarov transosseous wires were inserted percutaneously through the distal fibula to tibia from posterolateral to anteromedial direction 2 cm above the joint line in 20 embalmed cadaveric limbs. Dissection of the ankle joint was performed after a dye was introduced into the joint capsule to look for the extent of synovium from the joint line, medial malleolus, and lateral malleolus by the visible bulging and color change of the membrane. Distance from the wire to the synovial extensions distally was measured with a vernier caliper. Results: The mean distance of synovial extension from the joint line, medial malleolus, and lateral malleolus were 20.2 mm, 30.8 mm, and 41.4 mm, respectively. Distal wire-to-synovial extension distance anteriorly was ± 0.2 mm. Wire-to-joint line distance after dissection was 20 mm. The proximal synovial extension was found to be in the 101% from the joint line to the wire. Conclusion: The synovial extensions were found to be close to the distal tibial transosseous wires. A minimum distance of 2.5–3 cm from the joint line proximally should be the safe extent for passing the wires to prevent the risk of synovitis.
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