Intramedullary Nailing with Blocking Screws in the Treatment of Fractures of Proximal and Distal Ends of Tibia - A Prospective Observational Study in a Tertiary Care Hospital of Kannur, Kerala

BACKGROUND Fractures of both proximal and distal metaphyses with small distal fragment of tibia are not uncommon. Internal fixation using intramedullary nails alone could lead to misalignment. Using blocking screws (Poller screws) in addition to intramedullary nails would help in narrowing the medullary cavity and decreases the degree of misalignment and chances of displacement. The present study was conducted to evaluate functional and radiological outcome of blocking screws with intramedullary nail in the treatment of proximal and distal metaphyses fractures of tibia with short distal fragment. METHODS A prospective observational study of 34 patients with proximal and distal tibial metaphyses fractures was treated with statically locked intramedullary nailing with supplementary blocking screws. The study was conducted from January 2018 to December 2020 with a maximum follow up of 18 months. Medullary canal diameter was measured at the levels of fracture and isthmus. RESULTS Among the 34 patients, 29 (85.29 %) were males and 05 (14.70 %) were females with a male to female ratio of 5.8 : 1. The mean age was 34.97 ± 3.10 years. The mean healing period was 20 ± 1.45 weeks. 25/34 (73.52 %) of the patients showed Karlstrom and Olerud functional grading score of excellent. The fracture varus/valgus alignment was 1.9 ± 0.3 degrees. The mean antecurvatum/recurvatum alignment was 0.3 degrees. CONCLUSIONS Blocking screws act as reduction tools, help in reducing the medullary lumen of distal metaphyses and prevent failures in initial reduction. They extend the indication of intramedullary nailing to the distal segment of tibia and minimize the misalignment in terms of varus /valgus and/or antecurvatum/recurvatum. KEYWORDS Tibia, Intramedullary, Blocking Screws, Internal Fixation and Misalignment

Intra Focal K-Wiring for Distal End Radius (Kapandji Technique): Surgical Technique

Many years distal end radius fractures (DRF) are the most encountered type of fracture. In standard form, extra-articular distal end radius fractures were fixed after manual reduction and then pinned extra-articular by drilling distal cortex and passing fracture site to fix proximal fragment (Figure 1). But after 2 to 3 weeks depending upon osteoporosis fracture collapse(cancellous bone heal by collapse) and flexibility of the K wire distal fragment moves back until the K wire abut the inferior edge of the proximal fragment and does not avoid secondary displacement (Figure 2) [1].

Subcapital phalangeal fractures in children: A retrospective review

Introduction: Phalangeal neck fractures represent a subset of pediatric hand injuries which pose challenges to the treating physician. The aim of this study was to understand which radiographic or clinical variables were associated with the need for closed reduction and percutaneous pinning or were associated with the need for open reduction internal fixation. Methods: A retrospective review was performed on pediatric patients treated for subcapital phalangeal neck fracture of the middle or proximal phalanx between 2009 and 2014. Non-operative and operative groups (open reduction internal fixation, closed reduction percutaneous pinning) compared displacement and angulation of the distal fragment at the time of initial injury, displacement, and angulation of the distal fragment at the time of final follow-up, mechanism of injury, delays in treatment, time to union, and rate of complications. Results: One hundred seventy seven patients met eligibility criteria for the review. Average age was 9.1 years for the surgical group and 8.5 years for the non-surgical group. Time to union was significantly higher for the surgery group (53 vs 30 days, p < 0.001). The degree of sagittal plane translation and sagittal angulation were predictive factors for surgical treatment. Sagittal plane angulation was higher in the surgical group (26.5° vs 9°, p < 0.001). A delay in treatment with subsequent surgery was not predictive of a need for open reduction internal fixation over closed reduction percutaneous pinning ( p = 0.19). Final sagittal angulation was corrected to a median of zero, an eight degree difference from the non-surgical group ( p = 0.002). Conclusions: This study demonstrates that a strong correlation between initial sagittal plane angulation and a need for surgery. A longer time to union and decreased range of motion may be expected in patient's requiring operative intervention. Delay in treatment was not associated with open reduction over closed reduction percutaneous pinning within the surgical group.

True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware

Category: Trauma; Ankle Introduction/Purpose: Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal. Methods: Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique. Results: There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups. Conclusion: Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.

PO 18074 - Rotational biplanar Chevron osteotomy

Introduction: The Chevron osteotomy is a reliable and popular osteotomy for treating hallux valgus worldwide. Many modifications have been described, but none of them address the rotational deformity of the first metatarsal. The objective of this study is to describe a variation of biplanar Chevron osteotomy that can address first metatarsal rotation when necessary. Methods: The indications for the Rotational Biplanar Chevron Osteotomy (RBCO) are mild to moderate hallux valgus deformity associated with hallux pronation related to internal rotation of the first metatarsal bone. We describe a technique that uses a medial-based wedge parallel to the plantar limb of the osteotomy to free the distal fragment for correct rotation. Results: The more recent concern about hallux valgus surgery represents a very interesting concept that this deformity truly occurs in three different planes, and we may have mistreated the rotation component using current techniques. Many authors have revisited numerous common techniques to adapt them to correct metatarsal pronation. To the best of our knowledge, this is the first paper to describe a modification of the Chevron osteotomy to address rotation of the first metatarsal. Conclusion: We can conclude that rotational biplanar Chevron osteotomy is an useful tool in the treatment of mild hallux valgus associated with metatarsal pronation.

Can isolated tibia intramedullary interlocking nailing in fracture distal 1/3rd both bone leg prevent fracture malalignment: will concurrent fibula fixation help?

<p class="abstract"><strong>Background:</strong> Different stand point prevails till date concerning fibular osteosynthesis in distal third both bone fracture fixation. This study was done to assess the post op alignment of distal third both bones fracture without fixing Fibula.</p><p class="abstract"><strong>Methods:</strong> A total of 30 patients who had distal 1/3rd extra articular tibia and fibula fractures were included in the study from July 2016 to April 2019. Tibial nailing was done in all cases with care is taken particularly to prevent malalingment of distal fragment. Radiological malalignment were assessed post operatively.<strong></strong></p><p class="abstract"><strong>Results:</strong> Of 30 patients, 5 patients had excellent results and 21 patients had good results, only 4 patients had fair results with valgus and varus malalignment, however these patients did not have any clinical problems associated with these malalignment at one year follow up. No patients had poor results. Valgus tibial malalignment is observed more frequently when fibular fracture is at proximal level.</p><p class="abstract"><strong>Conclusions:</strong> The level of Fibular fracture is important to determine when the fixation of this bone is indicated. Fixing ipsilateral tibial fracture with intramedullary interlocking (IMIL) nailing without fibular synthesis produce no gross change in alignment provided adequate care is taken for intra operative centering of the nail in both AP and lateral views.</p>

How many species of the aquatic sloth Thalassocnus (Xenarthra: Megatheriidae) were in Chile?: new evidences from the Bahía Inglesa Formation, with a reappraisal of their biochronological affinities

The aquatic sloth, Thalassocnus, is one of the most intriguing lineage of mammal known from the southern pacific coast of South America during the late Neogene. It was initially recognized in Perú, but recent paleontological surveys also recorded its presence in Chile. However, the determination of how many species of Thalassocnus were actually present in Chile remains as an open question. Here, we provide a detailed morphological description of an isolated distal fragment of humerus recovered at the Mina Fosforita member (ca. 7 Ma), Bahía Inglesa Formation (Atacama Region, northern Chile), which is referred to Thalassocnus. Morphological comparisons with others forms from Chile and Perú allow us to attribute the CPUC/C/557 specimen to Thalassocnus cf. T. natans, though some degree of intraspecific variation is acknowledged. The assessment of the stratigraphic provenance of the materials with previously assigned to Thalassocnus from the Bahía Inglesa, Horcón and Coquimbo formations, permits us to propose that the taxonomic diversity of Thalassocnus in Chile is unequivocal conformed by T. carolomartini, and T. natans. We also admitted the likely presence of T. antiquus and probably T. yaucensis. Futures discoveries of more complete specimens, and/or the detailed analysis of undescribed specimens from Chile will undoubtedly contribute to illustrate the evolutionary history of the Thalassocnus radiation in Chile.