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CASE REPORT

Clinical outcome of treatment of ABC proximal femur with non vascularized autologous fibular strut graft and supplementary fixation with a cannulated cancellous screw

Author : Dr Rajat Tak (SR), Dr Vikas (SR) , Prof. Rajesh Goel , Prof . R.P Meena

Dept. Of Orthopaedics , NMCH Kota .

 

Abstract :

The aim of the study was to evaluate result of Aneurysmal Bone Cyst of Proximal Femur treated by Non Vascularized Autologous Fibular strut graft and supplementary fixation using cannulated cancellous screw. Non vascularized autologous fibular strut graft acts as mechanical as well as biological graft . The hypothesis behind this study is to add fixation to fibular strut graft which helps in immediate structural support,  early consolidation of defect  and remodeling .

INTRODUCTION :

Aneurysmal bone cysts (ABC) are benign active or aggressive bone lesions in children and adults that commonly arise in the long bones, especially the proximal femur, tibia, and humerus and in the posterior elements of the spine (1, 2). They are extremely rare, occurring in 1.5 per one million people. They most commonly occur in the metaphysis of long bones during the first two decades of life and usually present with pain, swelling or fracture. The aetiology of ABC is unknown, but numerous authors have proposed that they form in response to vascular disruption in the bone due to a pre-existing primary tumour or a traumatic insult (3).

Case Report :

This was 17-years-old, male, with no significant medical history, who presented in outdoor of orthopaedics new medical college hospital, Kota for pain in the right thigh and limp in the right lower limb. He had symptoms for 2 weeks prior to the time of presentation. He had a history of sustaining a fall while playing which caused pain and swelling in the inner side of the right groin and thigh .There was no history of fever, chronic illness or swelling in other body regions. The blood analysis, including a complete blood count, erythrocyte sedimentation rate, liver and renal function tests, fasting blood sugar levels and coagulation profile were within normal limits.

Radiograph showed a cystic lesion in proximal femur invading almost the entire femoral neck. Trochanter was not affected by this lesion and it did not cross the growth plate. MRI was suggestive of  multilocular  lesion with cavities that were separated by septa and thin cortical bone. Patient was admitted and posted for surgery. The material from lesion sent for histopathology which confirmed the diagnosis of an aneurysmal bone cyst .

Operative procedure :

Under spinal anaesthesia patient was put on a radiolucent traction table. The affected limb and pelvic region was painted with 10% povidone iodine solution followed by sterile drapping. First fibular strut graft was harvested from the same side 2-3 cm more than the approximate length of graft required. This prevents cross contamination of tumor into graft site . Fibular graft was taken subperiosteally through lateral skin incision over middle of shaft. Periosteum was left behind which helps in fibular reconstitution. The wound was sutured into layers and dressed.

Lateral incision was placed over mid of greater trochanter and extended distally. Soft tissue was dissected, vastus lateralis was elevated to expose lateral cortex of femur. A DHS guide wire was placed in centre of the neck in both AP and Lateral views under fluoroscopy. Cortical window was created with the help of drilling the cortex with 8 mm reamer over guidewire  to open the lesion and decompresses the cavity. Window created was large enough to allowed complete curettage of the lesion. The material obtained from lesion was examined grossly and sent for histopathology.  Curettage of the lesion was done with a curettage spoon. The harvested fibula was then sized accordingly and fit into the defect snuggly. Fibular graft was gently hammered into the defect over the centrally placed guidewire through the cortical window and was supplemented by two 6.5 mm cannulated cancellous screws without crossing capital physis.

 

Postoperative AP, Lateral radiographs were taken. Intravenous antibiotic cover was given for 3-4 days. Patients was discharged after 5 days. Sutures were removed after 2 weeks .Weight bearing was not allowed postoperatively. Patient was followed 6 weekly upto 3 months and 3 monthly thereafter with monitoring of clinical as well as radiological recovery. Serial x rays were taken in every follow up visit and records were maintained. Toe touch weight bearing with help of walker or crutches was allowed after 6 weeks this was followed by weight bearing as tolerated which was allowed at 3 months post op.

Radiograph of a case of aneurysmal  bone cyst (17/M) of right proximal femur treated with curettage and non vascularized autologous fibular strut graft and supplementary fixation with cannulated cancellous screws .

 

 

MORSCHER’S OSTEOTOMY IN POSTTRAUMATIC SEQUALE OF HIP IN ADOLESCENT USING DYNAMIC HIP SCREW

ABSTRACT

Premature closure of proximal femoral epiphyseal plate can be a complication of hip dysplasia, Perthe’s disease, trauma or septic arthritis of hip. It may eventually result in Coxavara and shortening of femoral neck and upward migration of greater trochanter. Morscher’s osteotomy is an intertrochanteric osteotomy that can create valgusization with lengthening of femoral neck, correction of high riding greater trochanter and compensates for short limb length as a single stage procedure. The purpose of this case report is to evaluate early results of Morscher’s osteotomy fixed using paediatric dynamic hip screw in adolescence.

INTRODUCTION

Optimal femoral length and adequate neck shaft angle is essential to lever the femoral head around the pelvis effectively, contributing to normal gait pattern [1]. Premature closure of proximal femoral epiphyseal plate can be a complication of hip dysplasia, Perthe’s disease, trauma or septic arthritis of hip. It may eventually result in Coxavara and shortening of femoral neck and upward migration of greater trochanter. This typical deformity reduces tension in pelvic-trochanteric muscles and shortens the abductor lever arm, leading to positive Trendelenburg’s sign and leg length discrepancy[2]. The associated upward migration of greater trochanter results in trochanteric impingement and restricted hip abduction. Pain in hip and limping are often the associated features.
Proximal femoral osteotomies play an important role in the treatment of numerous hip disorders in children[3]. Modern imaging has confirmed the arthrogenic role of morphological femoral head or head/neck disturbances, and thus better understanding of these pathological entities has renewed interest in salvage procedures to preserve the hip. The femoral neck lengthening osteotomy aimed at restoring the normal hip biomechanics by restitution of length of the femoral neck and limb length inequality, and improving the lever arm of the abductor mechanism. The conventional valgus intertrochanteric osteotomy for coxavara cannot address the associated problems of high riding greater trochanter and short femoral neck. Author’s performed Morscher’s osteotomy, which can address all the problems associated with coxavara. It is an intertrochanteric osteotomy that can createvalgusization with lengthening of femoral neck, correction of high riding greater trochanter and compensates for short limb length. The purpose of this case report is to evaluate early results of Morscher’s osteotomy in adolescence.

CASE REPORT

A 16 years old male referred to us with chief complaints of pain in right hip and limping. Patient had a history of fall from height (around 10 feet), 10 years back injuring his right hip. He was able to stand and walk on its own following the episode, but had moderate pain in the hip. He was treated conservatively by pain medication and massage at that time. No radiographs were taken following the injury. Pain gradually improved over a period of time and patient was asymptomatic 1.5 months following injury. After 2 years, during a routine health checkup in school, parents were told about slight limp in child and were asked to consult at higher center for evaluation. But due to poor financial condition of the family, child got neglected for almost 8 years. Limp gradually progresses over a period of time and now since last 5 months, patient started complaining of pain in right hip which forced him for treatment. Pain was mild in intensity to start with, which gradually progresses to moderate intensity limiting his activities of daily living. Pain was relieved with rest and medication. He was not able to squat and sit cross legged. There was no history of any long standing illness in the past, eliminating the possibility of infective pathology.
Patient had a typical short limb gait with shortening of around 3.5 cms in right lower limb. Abduction of right hip was markedly restricted to 20 degrees compared to normal side of 45 degrees due to mechanical block and pain. Also flexion was terminally restricted in affected hip. Hip abductor and flexion strength was 3/5 (MRC Scale). Antero-posterior radiographs of pelvis with both hips and lateral of the affected hip was taken which shows coxavara (Neck shaft angle 110 degrees), trochanteric overgrowth and markedly shortened femoral neck (Fig. 1). Greater trochanter was almost abutting the superior wall of the acetabulum. CT scan shows deficient anterior coverage of the femoral head but the orientation of femoral head in the acetabulum was good (Fig. 2). Morscher’s osteotomy was performed to cater problems of short neck, greater trochanter up riding and limb length discrepancy in single stage. Written consent was taken for treatment and submission of data for research purpose.
Surgery was executed in supine position on fracture table under fluoroscopy control. Pre-operative planning of osteotomy was done on plain paper to avoid surprises during the surgery. For fixation of osteotomy authors have used 135ºpaediatric dynamic hip screw (DHS).A 10-cm longitudinal skin incision is made downwards starting from the tip of greater trochanter along the femoral shaft. The gluteal fascia and fascia lata are divided to expose gluteal muscles, greater trochanter and the vastuslateralis muscle. The latter is then detached from the greater trochanter by an L-shaped incision. Three K-wires guides were inserted: the first K-wire marking the line of osteotomy at the level just above the lesser trochanter and parallel to femoral neck making an angle of 135º using angle guide, second K-wire was inserted along the upper border of femoral parallel to first wire, third wire was above the second wire for partial resection of hypertrophied greater trochanter (Fig. 3). Proximal two osteotomies were done along the guided wires. Partial resected fragment of greater trochanter was placed lateral to femoral neck fragment. Greater trochanter was lowered and placed lateral to femoral neck, which was facilitated by abduction of limb and fixed with two 4.5mm cannulatedcancellous screws. Lag screw was inserted between the first and second wire at an angle of 135º. Distal oblique osteotomy was then performed and 4-hole DHS plate was placed which pulls the femoral shaft distally and laterally. Wound was closed in layers over suction drain.
Post-operatively patient was allowed sitting in bed as tolerated after 2 days. Active ankle pumps and isometric quadriceps exercises were started. Post-operative shortening was 1.5 cms compared to pre-operative limb length discrepancy of 3.5 cms. Post-operative X-ray shows reasonable regaining of neck length, distal transfer of greater trochanter and normalization of neck shaft angle (Fig. 4). After period of immobilization patient was allowed up on crutches after 6 weeks progressing to full weight bearing, when X-rays demonstrate consolidation at osteotomy sites. Abduction strengthening exercises were started after 4 months when greater trochanter shows union. At 6 months follow up, patient was satisfied with the surgery, walking normally with slight limp. He uses shoe raise for compensation of 1.5 cms shortening. He is able to squat and sit cross legged. Active hip abduction improved to 40º, with flexion still terminally restricted. Trendelenburg sign was still positive. X-ray at 6 months follow up shows good union at the osteotomy sites with implants well in place and no evidence of avascular necrosis of femoral head (Fig. 5).

          

Figure 1: Antero-posterior radiographs of pelvis

with both hips showing coxavara, greater trochanteric

overgrowth and markedly shortened femoral neck.

                                                                              

   Figure 3: Intra-operative image showing placement              Figure 4: Post- operative radiograph showing

   of all three guide wires for osteotomy.                                          lengthening of femoral neck, correction of neck shaft

                                                                                                                  angle, normalization of greater trochanter and fixation

                                                                                                                  with paediatric DHS.

    

                                       Figure 5: Radiograph at 6 months showing consolidation of osteotomy sites.

DISCUSSION

Complex proximal femoral osteotomies play an important role in the treatment of numerous conditions associated with adolescent hip[3]. Indications for these procedures have extended beyond dislocations or subluxations in children with neurological hip diseases.Even in asymptomatic patients there may be an indication for surgery, because development of arthrosis and hip subluxation are not well acceptable[4]. Progression and severity of hip deformities are linked to remaining growth potential. Abnormal biomechanical forces will gradually cause joint incongruence, which eventually leads to osteoarthritis of the hip in young adults[5]. These femoral osteotomies help normalizing the biomechanics, which may halt the progression to advance disease. The presence of advanced arthritis and stiffness may be a contraindication to joint preservation surgery.
Morscher’s osteotomy could simultaneously address problems associated with extra-articular proximal femoral deformities that involve coxavara, overgrowth of greater trochanter, lesser trochanter too medial, shortened femoral neck and limb length discrepancy. Orientation of trochanters in proximal femur is important biomechanically as they serve as the insertion points for critical muscle groups. If the distance of these muscle insertions to the center of femoral head is altered, lever arm dysfunction ensues manifested as muscle weakness and fatigue[6]. Case presented here had proximal and medial migration of greater trochanter, causing reduced muscle tension and lever arm, manifesting as limp and muscle fatigue during walking. So, it is mandatory to test hip abductor and flexion strength before embarking on surgery. Other approaches for correction of proximal femoral anatomy and trochanteric overgrowth have been described. Wagner has given valgus intertrochanteric/ subtrochanteric osteotomy combined with lateral-distal transfer of greater trochanteric osteotomy, but it is reserved for cases where joint congruity is disturbed and femoral head is not spherical[7]. Ganz relative neck lengthening osteotomy, best addresses the extra-articular impingement from greater trochanter and has less chance of hampering the vascularity of femoral head but it does not lengthen the limb[8]. So, it’s important to choose the correct procedure, which deals with all the problems in single stage.
Morscher’s osteotomy is reserved for children above 8 years of age with Trendelenburg sign and limited abduction however, it does not change the orientation of the femoral head in the acetabulum and therefore the congruity of the hip joint stays the same[6,9].

The present technique of osteotomy was described by Morscher, as a double osteotomy which consists of two parallel oblique osteotomies, along the upper and lower border of femoral neck, making an angle to the femoral shaft corresponding to the desired neck-shaft angle[10]. Later, Hasler and Morscher showed good results in 32 out of 37 patients treated by this technique with a mean follow-up of eight years[11]. Lengsfeldet al showed satisfactorily results in their long term follow-up study on valgus and neck lengthening osteotomy[12]. Authors believe that haematoma formed at osteotomy site serves as source of signaling molecules and the medial compression force due to pull of iliopsoas facilitates union. Proximal femoral osteotomy could be stabilized with internal or external fixation. Blade plate fixation is one of the described methods, but we used dynamic hip screw which gives excellent control and correction in sagittal and coronal plane. Also, the distal most osteotomy is done parallel to DHS lag screw which helps achieving the desired neck-shaft angle and guides for adequate distalization of the shaft. Only possible disadvantage with this osteotomy is difficulty in future total hip replacement although some reports disagrees with it[13]. This case report helps us to conclude that Morscher’s osteotomy and fixation with easily available dynamic hip screw is a simple and reasonable option for treatment of conditions of hip associated with coxavara, short femoral neck, upward migration of greater trochanter and limb length discrepancy.
Conflict of interest Authors report no conflict of interest, financial or otherwise, concerning the material or methods used in this study or the findings specified in this paper.
Funding There was no sources of financial or material support for this report.
Ethical standard This study was approved by ethical committee and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

  Gaurav Garg
Asstt. Prof. of Orthopaedics,
Department of Orthopaedics,
S.M.S Medical College and Attached Hospitals, Jaipur (Raj.)

Case Report

RECONSTRUCTION OF THE 1ST METATARSAL WITH NONVASCULARISED FIBULAR GRAFT FOLLOWING EN-BLOC RESECTION FOR GIANT CELL TUMOUR

ABSTRACT

Giant cell tumour (GCT) of the small bones is relatively uncommon tumour. It occurs most commonly in the distal portions of femur and radius and proximal end of tibia. GCT of small bones presents at advanced stages with major bony destruction. These tumours represent more aggressive course; associated within creased local recurrence rates (40%) and metastasis. Various treatment modalities like en-bloc resection, cryosurgery, intralesional curettage with burring/phenolization or bone cement are available. In our caseen-bloc resection with reconstruction using nonvascular autogenous fibular strut graft was used in patient of 1ST metatarsal GCT and a favourable functional outcome was observed.

INTRODUCTION

Giant cell tumour (GCT) remains an enigmatic bone tumourdespite being extensively studied. The World Health Organization has classified GCT as “an aggressive, potentially malignant lesion”. The histology does not predict the clinical outcome, and different anatomical sites present with different management problems and difficulties (1). Histological grading by Jaffe et. al (2) and radiological grading by Campanacci (3) have been shown to be unreliable in predicting the risk of local recurrence and prognosis.

CASE REPORT

A 40 years old female presented with pain and swelling over dorsum of left foot. first noticed 4 months earlier and was increasing in size. She also had pain on walking. Examination showed a well defined swelling over the 1ST metatarsal with smooth surface, firm to hard consistency with no tethering of the overlying skin and not mobile.

                                          

                                   Figure : 1                                                                           Figure : 2

Radiograph of the right foot (Figure 2) revealed an expansile, osteolytic lesion of the 1ST metatarsal with soap bubble appearance. The tumour margin was ill defined and the cortices were very thinned out.

                                                         

                                         Figure : 3                                                                           Figure : 4

Magnetic resonance imaging was suggestive of giant cell tumour of the 1st metatarsal with surrounding oedema. The tumour was excised en-bloc along with local site chemoablation with hydrogen peroxide to prevent seeding of tumor cells in surrounding tissue during tumor handling and – a marginal surgical excision as defined by Enneking was achieved. The 1st metatarsal was reconstructed with a non-vascularised fibular graft and fixed with an axial K –wire to achieve 1st tarsometatarsal and metatarso phalangeal arthrodesis. The resected length was measured .The fibular strut graft was chosen because its size and shape matches the metatarsal, and the strength of cortical graft made it possible to ensure appropriate weight transfer.

Figure : 5

Dr. Kuldeep Singh Nathawat

Consultant Orthopaedic Surgeon

Mewar Hospital , Bhilwara

A 38yr old Male came with a history of RTA and sustained closed isolated injury to the right shoulder.

On examination shoulder ROM was restricted with tenderness at scapula and minimal swelling as he presented 10days after injury. His chest, neck and neurological examination was with in normal limits.

He underwent serial X-Rays AND CT Scan of right shoulder, which showed displaced and rotated fracture glenoid with body of scapula extending along lateral boarder upto medial boarder. (Ideberg type VA ).

He was posted for surgery, open reduction and internal fixation of glenoid and lateral border including body done by posterior Judet approach. Post op he has been kept in universal shoulder immobilizer for 3 week.

At 3 week pendulum ROM exercise started and immobilization continued in shoulder arm pouch for another 2 week. After 5 week post op active ROM started in abduction, forward flexion and rotations.

Preop X ray Shoulder AP

Preop X ray Shoulder AP

Pre op CT Anterior view

Pre op CT Anterior view

Preop CT Posterior view

Preop CT Posterior view

Pre op CT Lateral view

Pre op CT Lateral view

Post op AP view Shoulder

Post op AP view Shoulder

Brief Literature about fracture Scapula

Most scapula fractures can be managed effectively with closed treatment. Some injuries with significant displacement have poor long-term outcomes for the shoulder and the upper extremity as a whole if treated with closed techniques.

Because scapula fractures often are associated with other, sometimes life-threatening injuries, delay surgery until the patient is medically stabilized. Absolute contraindications for surgery are few. In the case of a major vascular injury, such as an axillary or brachial artery tear, repair the vessel first, then follow with fracture fixation. Recognising the exact indication for operative treatment of scapula fractures has been suggested by authors. [1,2]

Indications for Surgical Management

Whereas most scapula fractures can be managed with closed treatment, surgical management should be considered for significantly displaced fractures.[1,2] The following injuries occur with enough frequency to merit discussion of operative treatment:

  • Significantly displaced fractures of the glenoid cavity (glenoid rim and fossa).
  • Significantly displaced fractures of the glenoid rack.
  • Double disruptions of the superior shoulder suspensory complex (SSSC) in which one or more elements of the scapula are significantly displaced.

 

Significantly displaced fractures of glenoid cavity (rim and fossa)

Fewer than 10% of glenoid cavity fractures are significantly displaced. Ideberg reviewed over 300 such injuries and proposed the first detailed classification scheme.[3] This classification subsequently was expanded by Goss (see the image below).[4] Type I injuries involve the glenoid rim (IA=anterior rim, IB=posterior rim). Types II-V include fractures of the glenoid fossa. Type VI fractures include all comminuted injuries (ie, more than two glenoid cavity fragments).

rim and fossa

Classification of glenoid cavity fractures:

  • IA- Anterior rim fracture
  • IB- Posterior rim fracture
  • II-  Fracture line through the glenoid fossa exiting at the lateral border of the scapula.
  • III- Fracture line through the glenoid fossa exiting at the superior border of the scapula.
  • IV-  Fracture line through the glenoid fossa exiting at the medical border of the scapula.
  • VA- Combination of types II and IV;
  • VB- Combination of types III and IV;
  • VC- Combination of types II,III and IV;
  • VI- Communited fracture

Other indications for surgical management of these fractures include the following:

  • Glenoid fossa fractures that result in significant displacement of the humeral head such that it fails to lie in the center of the glenoid cavity, thereby resulting in glenoid humeral instability.
  • Fractures of the glenoid fossa with such severe separation of the fracture fragments that non union is likely to occur.

Significantly displaced fractures of glenoid neck

Glenoid neck fractures (see the image below) that cause significant translational or angulatory displacement of the glenoid fragment can interfere with normal shoulder mechanics and/or cause glenohumeral instability. Nordqvist and Petersson evaluated 37 glenoid neck fractures treated nonoperatively and found the functional results at 10- to 20-year follow-up to be fair or poor in 32% of cases. [5]Hardegger et al noted that displaced glenoid neck fractures result in a functional imbalance because the relationship of the glenohumeral joint with the acromion and nearby muscle origins is altered.[6]

glenoid neck

Classification of glenoid neck fractures. Type I includes all minimally displaced fractures. Type II includes all significantly displaced fractures (translational displacement greater than or equal to 1 cm; angulatory displacement greater than or equal to 40°).

Overall, there is literature to suggest that surgery should be considered for fractures with translational displacement greater than or equal to 1 cm and/or angulatory displacement greater than or equal to 40° in either the transverse or coronal plane.

Double disruptions of superior shoulder suspensory complex

The SSSC is a bone/soft-tissue ring at the end of a superior and inferior bony strut (see the image below). The ring consists of the glenoid process, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular (AC) joint, and the acromial process. The superior strut is the middle third of the clavicle. The inferior strut is the lateral scapular body and spine.

double disruption

Superior shoulder suspensory complex. (A) anteroposterior view of the bony/soft tissue ring and the superior and inferior bony struts; and (B) lateral view of the bony/soft tissue ring.

Traumatic disruptions of one of the components of the SSSC are common. If the force is sufficient, the ring may fail in two or more places (double disruption), a situation in which significant displacement at one or both of the individual sites and of the SSSC as a whole frequently occurs. Similarly, a disruption of one portion of the ring, combined with a fracture of one of the struts or fractures of both struts, also creates a potentially unstable anatomic situation.

Adverse consequences include delayed union, malunion, and nonunion. Subacromial impingement, decreased strength and muscle fatigue, discomfort due to altered shoulder mechanics, neurovascular compromise due to a drooping shoulder, and glenohumeral degenerative joint disease also can occur.
If unacceptable displacement is present, surgical reduction and stabilization at the injury sites is necessary. Frequently, operative management of one of the injury sites satisfactorily reduces and stabilizes the second disruption indirectly. [7]

Combined fractures of the distal clavicle and the superior aspect of the glenoid cavity is another potentially unstable situation. Each disruption may lead to displacement at the other fracture site. If displacement of the clavicular fracture site is unacceptable, surgical reduction and stabilization is indicated, usually with a Kirschner-wire (K-wire) tension-band fixation construct. Because the proximal clavicular segment is attached to the superior glenoid-coracoid process fragment by means of the coracoclavicular ligaments, this may indirectly reduce and stabilize the glenoid cavity fracture satisfactorily. If not, the glenoid fracture may also require surgical management using the surgical techniques described.

Fracture of the coracoid or the acromion process with a second disruption of the SSSC is another potentially unstable situation. If displacement at either or both sites is unacceptable, surgical management is indicated. For double disruptions consisting of both an acromion and a coracoid fracture, ORIF of the acromion may be all that is required (see the image below).

References

  1. Goss TP. Scapular  Fractures and Dislocations: Diagnosis and Treatment. Jam Acad Ortho Surg. 1995 Jan. 3(1):22-33.
  2. Morioka T, Honna T, Ogawa K. Incomplete Avulsion Fractures of the Scapular Spine caused by violent muscle contraction. Keio J Med. 2013 Dec 10.
  3. Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg.[Am]. 1992 Feb. 74(2):299- 305.
  4. Jaeger M, Lambert S, Sudkamp NP, Kellam JF, Madsen JE, Babst R, et al. The AO Foundation and Orthopaedic Trauma Association (AO/OTA) scapula fracture classification system: focus on glenoid fossa involvement. J Shoulder Elbow Surg. 2013 Apr. 22(4):512-20.
  5. Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma. 1993. 7(2):99-106.
  6. Hardegger FH, Simpson LA, Weber BG. The operative treatment of scapular fractures. J Bone Joint Surg [Br]. 1984 Nov. 66(5):725-31.
  7. Herscovici D Jr, Fiennes AG, Allgower M. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg [Br]. 1992 May. 74(3):362-4.

Case Report

Case Report-1

 

 

Challenges in Thumb Replantation

We thought to put case of Thumb Amputation and discuss important  issues and our experience of management of Thumb  Replantation. I would like to Title  this special case of Thumb Replantation as “ Taking the right call at 7:00 A.M”.

‘Whom to blame , it happend in fraction of second’

thumb1          thumb2           thumb3            thumb4

thumb5       thumb6

Repaired one  Digital artery, two Dorsal veins , radial side Digital nerve with 10-0 ethilon. Flexor tendon with 3-0 prolene and extensor tendon with 4-0 prolene.

thumb7       thumb8

2 months Follow up –wound healed well, good nail, skin colour matching to normal skin , length of thumb maintained,good cosmetic appearance ,good rotation of thumb .

Challenges in Thumb Replantation

Issue no 1.-  Details of patient and Injury

Age of patient , Occupation , Comorbid condition , Associated injuries, Distance , level of amputation with critical time , time of injury – night , afternoon, morning

My Case experience -Patient  is 45 year old male , Accountant from Alwar [5 hour distance from jaipur ]with no comorbid and associated injury lost his left Thumb at proximal phalanx shaft level [ long critical time ] at 7:00A:M [early morning ]

Discussion– Thumb is most important in hand due to its position and opposition movement.  Age is not a bar for trial of replantation but technically difficult to identify and repair thin sized 1mm Vessels & Nerves. High demanding occupation require fine function that cannot be matched with replanted hand, but we have no option of perfect artificial Hand either . Associated injuries need to  be managed at same time by specialist  .Critical Time for finger amputation is 12-24 hr, Distal forearm amputation 8-12h, Elbow amputation – 6-8h. Higher the level of amputation lesser the critical time, delayed recovery time ,require multiple surgery in stages. Time of injury is important as availability of skilled surgeon, operation theatre and staff may be an issue sometimes .

Issue no-2 . – Awareness problem

Immediate care of amputated part , Amputation stump , Bandage application , NPO advise ,Awareness of specialized skilled  doctor with its contact number to inform them .

My case experience -He was fortunate to have good primary care of stump at local hospital and amputated part well preserved.  He was advised not to eat and drink till surgery . He was given detail of skilled Hand surgeon with its contact number . He informed doctor about his injury status.

Discussion – Amputated part need to be washed with sterile water for clearing of contamination,  wrapped in dry guaze piece and then kept in clean polybag. Then poly bag is kept in ice box. Amputation stump need to be dressed in a sterile dressing to stop bleeding. Catching artery with forcep will damage the healthy  neurovascular  ends. Detailed  Information of  reffered  doctor is essential to decrease time of counseling and  preop delay .

 

thumb20                    thumb10                                thumb11                                      thumb12

Issue no 3 .- Doctor problem

Availability of operation theatre in  hospital, Problem to opd patients as doctor need to miss  OPD due to emergency

My case experience – Patient is made intelligent by detailed information of surgeon. Patient called up Doctor , who started preparationat Hospital about emergency surgery .

 

Issue no 4.- Hospital problem

Emergency  department –Delay in attending patient – busy due to overload, Delay in sending investigation- viral marker, Hemoglobin , Blood group , X-ray . Ward boy – to shift patient

My case experience -Due to prior information- Emergency was ready to do necessary things.

SDMH hospital took pride to take care of patient at emergency basis

 

Issue no 5.- Patient Apprehension

Reason for delay  in Surgery  , understanding of Risk of loss of patient money and Doctor efforts if surgery fails , Faith in Doctor & Hospital in terms of efforts , Ready to accept failure .

My case experience- Patient and attendents were already primed up for risk , cost involved by the referral doctor.

 

Issue no 6. – Operation theatre problem

Attitude of O.T staff  , Availability of resources – Equipped instrument, Microscope

My case experience- Good team makes it possible .As already informed theatre was available with all facilities for microsurgery.

 

Issue 7.- Post surgery monitoring problem

ICU staff-  for hourly monitoring and maintaining blood pressure , Medication ,Infection , Repeat surgery

My case experience – ICU staff were trained for immediate response if any doubt.

 

Issue 8.-Short  Follow Up Problem

Wound dehiscence  , pin tract infection  bone union ,  absent sensation ,

My case experience -Patient has understood that surgery can bring lost part but motivation, regular exercise is important for early recovery. wound healed well primarily.

 

Issue no. 9 – long term follow up problem .

Cosmetic appearance , Functional , Back to his job or not   .

My case experience -Beauty of Replantation is its cosmetic acceptability .

Constant effort will shift him – Good- Better – Best .

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Dr. Amit Mittal

Consultant Orthopedics Surgeon

 Hand & Reconstructive Microvascular surgery ,Wrist & Elbow Arthroscopy.

Santokba Durlabhji Memorial Hospital, Jaipur