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To evaluate preoperative neck resorption and postoperative valgus orientation as predictors of union and functional outcome after valgus intertrochanteric osteotomy for treatment of neglected femoral neck fractures and nonunions.Retrospective cohort study.Tertiary care center.Forty consecutive patients with neglected femoral neck fracture and nonunions were treated with valgus intertrochanteric osteotomy, and follow-up was available in 32 patients (average age, 43 years; range, 14-60 years; average nonunion duration, 6 ± 7 months; range, 1-36 months).Valgus intertrochanteric osteotomy.Clinical outcome was assessed with Harris hip score. Plain radiographs were evaluated for union, avascular necrosis, preoperative bone deficiency (neck resorption ratio), and postoperative femoral head fragment alignment (head-shaft angle).Follow-up at 5 ± 3 years (range, 2-12 years) after surgery showed union in 29 patients (91%), and Harris hip score was 82 ± 13 points (range, 63-100 points). The 3 patients with persistent nonunion at the neck of femur had neck resorption ratio0.52. Increased postoperative head-shaft angle was associated with lower follow-up Harris hip score; postoperative valgus alignment15 degrees compared with the contralateral side was associated with poor functional outcome. The presence of avascular necrosis did not affect the outcome.Valgus intertrochanteric osteotomy resulted in union and satisfactory functional outcome in most patients who had neglected femoral neck fractures and nonunions. Preoperative neck resorption ratio0.5 was a risk factor for nonunion, and excessive valgus alignment was a risk factor for poor functional outcome after osteotomy.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different?We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years).According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present.In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

Background Open achilles tendon injuries, present a complex problem to the treating surgeon especially if associated with tendon and soft tissue loss. We present eight such patients treated with tendon repair/reconstruction and reverse flow sural artery flap for soft tissue cover. Patients Eight patients (age, 12-64 years) with a spectrum of open tendo-achilles injuries of acute and chronic (infected), including loss of tendon of up to 10 cm, tendon defects with no distal attachment and one with partial loss of the calcaneum were treated between November 2005 and July 2006. Two of them had significant medical comorbid factors. The skin defect measured after debridement ranged from 6 x 5 cm to 15 x 10 cm. The tendon injuries were sutured directly when possible or sutured to bone if avulsed from the calcaneum. They were otherwise reconstructed using the central part of the proximal segment. A reverse sural artery was used to provide soft tissue cover. Results All flaps survived. All patients had a normal gait, were able to stand on tip toes, had active plantar flexion and had returned to their original occupation 4 months after reconstruction. They had full range of movement at the ankle. One diabetic patient had terminal necrosis of the flap that required a split skin graft. He developed a late infection which did not compromise the functional result. Conclusion In the management of complex tendo-achilles injuries with tendon and soft tissue loss, radical debridement, single stage tendon reconstruction, and reverse flow sural artery flap gives good functional outcome. This gives consistent results across a spectrum of open tendo-achilles injury.

We present a patient with an open, infected Achilles tendon injury with a soft tissue defect of 12 cm x 5 cm and a tendon defect of 10 cm. He underwent a two-stage procedure. A first stage debridement of tendon and soft tissue was followed by a second stage tendo Achilles reconstruction using fascia lata graft and soft tissue cover with a reverse flow sural flap. He had a good functional outcome with minimal donor site morbidity.

A combined Galeazzi and Monteggia fracture dislocation is very rare and there are few reported cases in the English literature worldwide. However, the described injuries are not classical of either fracture dislocation. Both in children and in adults the reported literature does not show classical fracture types of either Galeazzi or Monteggia lesion in the same forearm. Our patient had the classical combination of both Galeazzi and Monteggia fracture in the same forearm. We have described the rare mechanism of injury and management for this injury based on a review of the literature.

Purpose. To evaluate the time required for effective action of phenol against the giant cell tumour (GCT) cells. Methods. Fresh GCT cells were harvested from 9 patients with primary GCT of the distal femur (n=4), proximal tibia (n=4), and proximal humerus (n=1), with the Campanacci tumour grades 3 (n=6), 2 (n=2), and 1 (n=1). Specimens were immersed in 80 % phenol for one, 3, 6, and 10 minutes, and were assessed by a single pathologist for irreversible cell death and the depth of phenol penetration. Results. Phenol caused consistent GCT cell death in 6 of the 9 specimens after 3 minutes and in all 9 specimens after 6 minutes, compared to none in controls (pConclusion. GCT cells immersed in 80% phenol for 6 minutes resulted in consistent cell death.

Background : Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons. Materials and Methods : We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included. Results : There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 Χ 2 to 30 Χ 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery. Conclusion : Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

We assessed the outcome after reconstruction of traumatic, complete, infected, extensor mechanism loss attributable to high-velocity open knee injuries in eight consecutive patients (all males) who presented to us between February 2005 and September 2007 at an average followup of 24 months. All were treated with gastrocnemius flaps. The loss in extensor mechanism was the patellar tendon in five patients, patella and patellar tendon in two patients, and combined patella, quadriceps, and patellar tendon in one patient. The size of the defect ranged from 8 × 5 cm to 15 × 15 cm. The patients were evaluated for functional outcome of the knee, resolution of infection, range of flexion of the knee, and return to work. Four patients had an excellent outcome whereas the others had a good outcome using the Hospital for Special Surgery knee rating scale. All flaps healed primarily with resolution of infection. The average knee flexion was 110°. All patients except two returned to their original occupation. Three patients had an extensor lag of 5°. The gastrocnemius flap is a good option for open knee injuries with extensor mechanism loss, giving consistent results across a wide spectrum of presentation. Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Study Design Efficacy of the percutaneous biopsy of the spine under computed tomographic guidence was investigated, Seventy-five patients, ranging in age from 7 to 72 years, underwent this procedure. Objectives To determine the usefulness of computed tomographically guided biopsies in the treatment of patients with spinal disorders. Summary of Background Data The results of 68 biopsies (90.6%) were judged to be accurate insofar as the samples of tissue obtained could be diagnosed as specific types of enoplasm, infective lesions, reactive lesions of nonspecific type, or noramal bone. Methods Biopsies that yielded a specific abnormality were categorized as true positives. The “normal” biopsies were followed for 6–8 months and were than deemed true negatives. Nondiagnostic ones were considered false negatives. Results The results are acceptable with an accuracy rate of 90.6%. It is a safe and simple procedure with a short learning curve. Conclusions Computed tomographically guided biopsy of the spine is recommended as a procedure of choice, especially in cervical and thoracic lesions. Computed tomography is superior to fluiorascopy when dealing with small, deep-seated lesions especially in the cervical and thoracic regions and with lesions picked up on bone scan only, radiographs being negative. Needle biopsy under computed tomographic guidance is safe and precise.