COMPLICATED ANKLE INJURY

30th november morning 8 am i recieved this 35 year old 38 weeks pregnant lady in my hospital with history injury when stairs collapsed at her house.. i am putting her xrays here. <>

Materials used for AO implants - An overview and outlook

Introduction
AO implants are manufactured from a wide range of different materials. This article will provide you with an overview of the most commonly used materials and explain their clinical advantages.
The majority of metallic AO trauma implants are manufactured from Cr-Ni-Mo stainless steel, CP titanium, or Ti-6Al-7Nb alloy. A few cobalt-base alloys with commercial names such as L-605 and Elgiloy are also used for specialty implants. Nonmetallic implant materials include PEEK (polyetheretherketone) and resorbable polylactide polymers. Influences on specific material selection during the implant design phase include anatomical location, perceived stress limits, diagnostic imaging considerations, competitive factors, and most importantly, the capability to solve a clinical problem. Calcium sulfate, calcium phosphate, and other bioceramics used for bone grafting or as bone void fillers will not be covered in this review article.

Stainless steel
Implant quality 316L stainless steel meeting International Organization for Standardization (ISO), American Society for Testing and Materials (ASTM) and AO ASIF compositional, metallurgical, and mechanical requirements is used for a large number of fracture fixation devices. The wide combination of mechanical properties is ideal for a variety of implants. Some of the product features include:
Cerclage wire—ability to twist and deform without breaking.
Reconstruction plates—3-D contourability.
DHS—good fatigue strength.
Bone screws—excellent torsional strength and ductility.
Bone plates—high strength with good ductility.

The positive attributes of implant quality 316L (ISO 5832-1) are offset by a few deficiencies including the possibility of nickel allergy due to the 15% nickel content and considerable signal artifact during MRI that may interfere with diagnostic imaging. The use of Fast Spin Echo pulse sequence during MRI can reduce the amount of artifact obtained with stainless steel. Low-nickel implant stainless compositions that contain a maximum 0.05% nickel are emerging to address the nickel sensitivity problem. AOCID recently coordinated a literature survey at the Technical University Munich on low nickel sensitization in animals and humans and an AO Research Grant is funding a paravertebral patch test study of Ni-sensitized patients in Germany. Fortunately, the low-nickel implant alloys exhibit improved mechanical properties and corrosion resistance.



Titanium
Pure titanium is considered the benchmark by which all other biomaterials are judged due to its outstanding combination of long term corrosion resistance and biocompatibility. The low amount of MR artifact and ability to be anodized for color-coded implant systems are unique properties of titanium. Pure titanium can be cold worked for added strength but the majority of trauma applications include relatively low-stressed maxillofacial, cranial, and hand implants. Its overall mechanical properties are somewhat inferior to stainless steel.



Titanium alloys
α+ß titanium alloys such as Ti-6Al-7Nb offer increased strength for highly stressed AO implants such as cannulated and solid IM nails, universal spine clamps, LISS plates, thoracolumbar rods, and cannulated screws. They offer improved strength but less tensile and bending ductility when compared to pure titanium. Ti-15Mo is a relatively new ß titanium alloy with moderate strength, high ductility, and excellent notch sensitivity.



PEEK
PEEK is an advanced thermoplastic polymer that is available as an implantable material. Special synthesis methods and processing precautions control the composition, uniformity, and internal cleanliness. Current applications include vertebral spacers, spiked washers, and other implants are under development. PEEK offers good mechanical properties (100 MPa YS; 20% elongation; 170 MPa flexural strength) and radiolucency.

Fig. PEEK vertebral spacers

PEEK spiked washers are formulated with 6% barium sulfate for radiopacity as a replacement for the polyoxymethylene (POM) C spiked washer with stainless steel reinforcement ring. Unconventional machining and cleaning procedures are required to provide noncontaminated surfaces during fabrication operations. PEEK mechanical properties will not be degraded during steam autoclaving, ETO, or gamma sterilization.



Resorbable polylactide
The generalized chemical formula for polylactide polymer is (C3H4O2)n. Various isomers known as L-lactide, D-lactide, and DL-lactide refer to the structural orientation of the polymer. Isomers can be differentiated on the basis of their specific optical rotation. Amorphous (noncrystalline) 70:30 L/DLpolylactide is the primary stereoisomer used for mid-face and cranial resorbable plates, screws, and burr hole covers. The in vivo degradation mechanism is well-documented in the literature.
PLA -> lactic acid -> water + CO2
Handling operations are critical since polylactide granules are supplied in inert gas purged foil packs, stored at a low temperature, vacuum dried at a high temperature, and transferred under inert gas cover to injection molding or compression molding equipment.
Resorbable polymers are ideal for craniofacial implants because of their small mass and the low applied stress. Their excellent vascularity and 4–6 week fracture healing timeframe are favorable clinical factors. Material improvements such as higher strength and faster resorption rate plus improved implant designs will offer expanded opportunities in the future for resorbable polymers.

Surface modification
Implant surface interactions are primarily responsible for biological response and have a pronounced effect on the clinical performance of trauma products. Ongoing research by the AO Research Institute has identified the importance of metallic implant surface microtopography on the cellular reactions that are obtained. Movement between implant surface and soft tissue may cause fibrous capsule formation around a liquid filled void on stainless steel. The liquid phase allows buildup of cellular detritus, fretting debris, and possible infection. Capsule formation is not observed on titanium implants. Recent findings in Davos indicate that there is a strong correlation between lack of fine microroughness and the presence of a liquid filled void. Results have supported the hypothesis that stainless steel void formation is due to lack of microtopography and the inability of cells to adhere to surface discontinuities. Other surface modifications for implants include low friction anodizing to improve the fretting and galling resistance of titanium. Bulk coatings include HA to encourage biological fixation and antiseptic or antibiotic antibacterial films. Osteoinductive additives such as BMP-2, IGF-1, and TGF-ß1 will be applied to implant surfaces in the future to control specific biological functions.



Future developments
Substantial efforts have been made by many research groups to develop metallic foams that provide low stiffness, stable bony ingrowth, structural support, and delivery of bone forming compounds. Long-range developments are also under investigation to explore advanced material technologies such as:
Nonmagnetic amorphous metals with high strength and good wear properties.
Titanium shape memory alloys that do not contain nickel.
Nanotechnology processing to produce CP titanium with strength levels that exceed Ti-6Al-7Nb.
Novel titanium alloys that demonstrate an ultralow elastic modulus, extremely high strength, and super plasticity due to a dislocation-free plastic deformation mechanism.

Potential clinical applications for these new materials include implants with low apparent density for osteoporotic bone, improved MR or CT imaging, in vivo shape memory activation, and better resistance to fatigue fracture.



Conclusion
Successful integration of implant materials for AO implant applications is the result of close cooperation between clinicians, research scientists, material specialists, product development designers, and manufacturing engineers. Clinical feedback especially through the medical AO Expert Groups is crucial to understand the advantages, disadvantages, and limitations of conventional and advanced biomaterials. Active participation within the ISO and ASTM implant committees ensures that high quality AO material standards will be maintained on a worldwide basis. Full manufacturing support by the producers is needed to determine processing response and cost-effective manufacturing strategies for new implant materials. This team effort within the AO is responsible for providing surgical implants with improved properties and superior clinical performance

PLACEBO EFFECT

More than half of doctors offer fake prescriptions to make patients feel better -- and that's OK, most doctors say.
The findings come from a survey of 679 internists and rheumatologists. Doctors in these specialties often see patients with chronic illnesses or chronic pains that are difficult, if not impossible, to cure. Sometimes fake medicine -- placebos -- make such patients feel better.
Fake drugs can have very real benefits. It's called the placebo effect. In clinical trials, many patients who receive placebos do better than real-world patients who get no treatment at all, notes study researcher Jon C. Tilburt, MD.
"Twenty to thirty percent of the benefit seen in rheumatism drug studies are due to the placebo effect. Real changes in health go along with the belief that patients will get better," Tilburt tells WebMD.
Tilburt and colleagues asked the doctors a series of questions, each a bit more blunt than the last:
If a clinical trial showed a sugar pill was better than no treatment for fibromyalgia, would you recommend sugar pills to fibromyalgia patients? Yes, 58% of the doctors said.
Do you ever actually recommend treatments primarily to enhance a patient's expectations? Yes, 80% of the doctors said.
In the last year, did you recommend a placebo treatment to a patient? Yes, 55% of the doctors said.
What did the doctors actually tell their patients? Over two-thirds of those who prescribed placebos told patients they were getting "medicine not typically used for your condition but which might benefit you."
Is it "appropriate" to fool patients this way? Yes, 62% of the doctors said.
"I don't think doctors have anything but the patients' best interest in mind when they give a placebo prescription," says Tilburt. "They are thinking about both the physical and psychological well-being of the patient."
The hard-to-accept truth is that doctors don't have proven treatments for many of the ills that plague their patients.
"With untreatable conditions or chronic conditions when we have run out of treatments, doctors are willing to try virtually anything -- if they are convinced it is safe -- to make the patient feel better, even if the mechanism is a psychological mechanism," Tilburt says.
Placebo Prescriptions: Right or Wrong?
Is it right for doctors to prescribe treatments they believe are not biochemically effective?
Here's the official policy of the American Medical Association:
Use of a placebo without the patient's knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient.
A placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient's welfare.
Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use.
Placebo Prescriptions: Right or Wrong?
That last point seems tricky. How can a fake drug work if a patient knows it is fake?
The AMA policy says doctors should explain to patients that they can better understand their condition if they try different medicines, including a placebo. If the patient agrees to this, the doctor does not have to identify which medicine is fake, nor does the doctor have to get the patient's specific consent before giving the patient the fake treatment.
There's nothing wrong with this approach, says medical ethicist Arthur Caplan, PhD, professor of bioethics at the University of Pennsylvania, Philadelphia.
"It is ethical to use treatments that are low risk and have few side effects if you can relieve people's symptoms," Caplan tells WebMD. "Placebos are especially useful in the treatment of the psychological aspects of disease. Most doctors will tell you they have used placebos."
But doctors do often prescribe placebos the wrong way. In today's world, a doctor can't write a prescription for a sugar pill. The doctor has to prescribe something -- and every active medicine carries some risk of side effects.
"What you can use as a placebo is complicated. I have seen people dispensing antibiotics as placebo for mothers who want something for their kids' flu," Caplan says. "Not only does this not help, but it does build up drug resistance and may have some serious side effects for the child."
Most doctors use relatively harmless drugs, such as baby aspirin, as placebos. Clearly, great care must be taken to ensure that the placebo drug's risk is less than the benefit of the hoped-for placebo effect.
"We know it is wrong when doctors give potentially harmful medicines in a manner that may not be warranted," Tilburt says. "If I think it will actually have only a placebo effect, I should not give a patient a sedative. The compulsion by doctors to benevolently promote patient expectations can play out in a way harmful to patients."
In the end, Tilburt suggests, the effectiveness of a placebo treatment may well hinge on the trust patients have in their doctors.
"Maybe it isn't about taking a pill at all," he says. "Maybe it is the relationship between the doctor and the patient that makes the real difference."
Tilburt, formerly with the bioethics department of the National Institutes of Health, is now assistant professor of medicine at the Mayo Clinic, Rochester, Minn. The study appears in the Oct. 24 online first edition of the journal BMJ.

ACL RECONSTRUCTION

http://http://www.hipsknees.info/flash5/HTML/demo.html

this is the link to understand the surgical procedure of reconstruction of ACL using bone tendon bone method... this is for patients information.. u need to instal java to run this movie..

Computer-Assisted Knee Surgery

Computer-assisted surgery helps surgeons align the patient's bones and knee replacement implants with a degree of accuracy not possible with the naked eye. For the first time, doctors have detailed information allowing them to balance the ligaments and it is given to them before they make the necessary cuts.
Computers also help doctors who use smaller incisions instead of the traditional larger openings. Small-incision surgery, most often referred to as minimally invasive surgery, offers the potential for faster recovery, less bleeding and less pain for patients.
Think of it this way. Perhaps you've seen the on-board computers in newer cars that provide driving directions using satellite navigation systems. On-board computers collect data points from satellites and use precise coordinates to give drivers directions from point A to point B. It provides a degree of precision, speed and accuracy not attainable with a map and compass.
Similarly, computers used during orthopaedic surgeries offer visual mapping to help doctors make crucial decisions before and throughout the knee replacement operation. The objective is to combine the precision and accuracy of computer technology with the surgeon's skill to perform surgery.
An advantage is that the doctor has greater "vision" when it counts — during surgery. This supports decision-making and enhances the surgeon's flexibility.
Here's how it works. Computer-assisted surgery uses:
the computer system
cameras
software
specialized surgical instruments
physician training The software and instrumentation of the Ci™ System are designed to work together. (Some systems use traditional surgical tools that must be adapted for use with computers). Imaging technology allows the surgeon to see a computer generated picture representation of a patient's knee joint allowing them the potential to operate with smaller openings and with more precision.


Visual Mapping of Knee Joint

The Ci™ System's lightweight, wireless computer system is used with a small camera array. A digital model is produced that serves as a map for each operation. The cameras take data via infrared signals from reflectors placed on the patient's body and on specially designed surgical instruments. The computer uses the data to track the exact position of the patient and the instruments on a monitor. The combination of computer visualization and special surgical instruments allows doctors to align the knee replacement implant with greater precision than when doing the procedure with the naked eye.
Advocates of the technology say they expect the use of computer-aided surgery to spread rapidly in the next decade because of the following potential benefits:
support for the doctor in pre-operative planning
intra-operative flexibility to adapt the plan based on the data shown during the surgery
improved surgical accuracy and consistency
The future of computer-assisted surgery is exciting and promising. Total joint replacement is a proven procedure that has been successful for decades in helping people live with less pain and greater mobility. Some surgeons will adapt the technology right away; others will await further results while adhering to the traditional hands-on approach they've used for years.

The way a knee replacement will perform depends on your age, weight, activity level and other factors. There are potential risks and recovery takes time. If you have conditions that limit rehabilitation, you should not have this surgery. Only your orthopaedic surgeon can decide whether partial or total knee replacement is right for you.

Refobacin Plus - A New Antibiotic Bone Cement

Antibiotic bone cements have increased in popularity as a complementary treatment to systemically administered antibiotics for
periprosthetic infection. One successful application of antibiotic bone cement is in the 2-stage revision of infected arthroplasties
using antibiotic-loaded spacers, with the advantage of direct antibiotic delivery to the site of infection.
The mechanisms by which the antibiotic is released from the bone cement (PMMA) is still largely undefined. It is believed the
antibiotic is first released directly from the surface and subsequently flows from interconnecting voids and cracks through the
cement rather than by a diffusion process.
Refobacin Plus (Biomet) contains gentamicin and is essentially a high viscosity bone cement, but has an initial low viscosity to
allow for vacuum mixing and adequate delivery

HUCKSTEP LOCKING COMPRESSION NAIL

OPERATION TECHNIQUE

EQUIPMENT

The equipment required for insertion of the locking nail and screws is illustrated.
NAILS

The standard nails are of titanium alloy and are 10.5, 11.5 and 12.5 mm in diameter, and are used with 4,5 mm fine threaded screws. The 11.5 and 12.5 mm nails are available in lengths of 34, 37, 40 and 43 cm. They have a bullet end, and they either have all transverse screw holes situated at 15 mm apart, or with 4 oblique holes at the top end. This is for screws up the neck and into the head of the femur.
The 12.5 mm nail is also available in 60, 70 and 80 mm lengths for arthrodesis of the knee. A shorter nail inserted retrogradely is however usually recommended for knee arthrodesis.
The 10.5 mm nail is only available with transverse screws, and in lengths of 10 to 40 cm. It is designed for fractures of the humerus and tibia, and for pantalar and elbow arthrodesis. It should never be used for fractures of the shaft of the femur.
The bulbous ended 12.5 mm nail has an enlarged upper quarter of 14.5 mm diameter with four oblique 14.6 mm holes to accomodate 6.5 mm cannulated compression screws for added stability of upper femoral fractures.
The 9.5, 8.5 and 7.5 nails with 3.5 mm screws, and the 5.5 and 6.5 mm nails with 2.7 mm screws only have transverse holes. They are designed for the radius and ulna, and for the smaller humerus.
SCREWS

The 4.5 mm standard diameter titanium alloy screws are used with the 10.5, 11.5 and 12.5 mm nails. They have a fine thread with a 4 mm diameter core, and a 4.5 mm outside diameter. This configuration gives extra strength. thes are unlike coarse threaded screws that are designed to hold plates on to the bone. The only force acting on the screws is the nail acting at right angles. There is therefore no vertical force pulling the screw out of the bone.
The 3.5 screws are used with the 9.5, 8.5 and 7.5 mm nails. The 2.7 mm screws are used with the 5.5 and 6.5 mm nails.
REAMERS AND DRILL BITS

The medullary reamers for the older standard set are solid, straight and of 9, 11 and 13 mm in diameter, and with 400 mm effective reaming length (440 mm overall). They are 0.5 mm larger than the standard nails. This is in order that these nails can be inserted into the medulla of the femur without difficulty, and without the use of a mallet.
The newer sets have cannulated reamers of 8, 9, 10, 11, 12, 13, 14 and 15 mm diameter. These reamers are standard on the Huckstep locking hip set.
The smaller nails also use long drill bits from 4 to 10 mm in diameter, to ream out the medullary cavity.
The drill bits for the standard 4.5 mm diameter screws are 4 mm in diameter, and are 150 and 180 mm in length. There are three drill bits of each size. The 180 mm drill bits are designed for drilling, while the three 150 mm long drill bits are designed to stabilise the jigs on the bone and nail. There are also longer drill bits up to 300 mm if required.
The drill bits for the smaller screws vary from 2.7 mm for the 3.5 mm screws, to 2 mm for the 2.7 mm screws.
The drill for the 6.5 mm cannulated compression screws has a 6 mm diameter and is also cannulated.
INSERTER AND JIGS FOR 10.5 TO 12.5 MM NAILS

The inserter has 3 holes for the jigs depending on the the size of the thigh. At the top of the inserter, where it screws on to the end of the nail, there is a plastic compressor. This is screwed down on the trochanter if compression of the fracture site is required.
The older design of jigs have no sleeves. They are long and short transverse holed, and a short oblique holed. In addition there is a small ‘floating’ jig.
The newer design of jigs have sleeves for all except the floating jig. This is to enable drilling, tapping and insertion of screws to be carried out without removing the jig.
INSERTER AND JIG FOR THE 9.5 TO 5.5 MM NAILS

The inserter is a single straight rod which screws into the end of the nail. The nail end of the inserter has a thread for a small nut which can be used as a compressor if required.
The two floating jigs, one for the 9.5 to 7.5 mm nails, and the other for the 6.5 and 5.5 mm nails are identical but smaller versions of the floating jigs used for the larger nails.
OTHER INSTRUMENTATION
SCREWDRIVERS

These are hexagonal headed for the 4.5 mm standard screws, and are supplied with both a handle, and without a handle for a power screw driver which is usually recommended.
The screwdriver for the smaller 3.5 and 2.7 mm screws have both Phillips and transverse ends.
The 6.5 mm compression screws have a cannulated hexagonal spanner.
TAPS

These are fine threaded for the 4.5 mm screws, and it is usually recommended that they be used with a power screwdriver. The 3.5 and 2.7 mm taps should only be used by hand because of the danger of breakage.
The 6.5 mm tap is cannulated and coarse threaded for the compression screw.
OTHER INSTRUMENTS

a. Punch — A 4 mm punch is supplied for advancing the nail, and also for punching out, if necessary a broken screw.
b. Awl — This is to make the initial hole in the piriform fossa before reaming is commenced.
c. Extractor Attachment — This is designed to screw into the end of the nail at one end, and into a standard hip extractor at the other end. Most screws however do not require to be removed as they are made of inert titanium alloy with a low modulus of elasticity.
d. Spanner for Compressor — This is used to tighten the plastic compressor on the inserter. It is also used to tighten the nuts holding the nail and the jigs to the inserter.
e. Nuts for the Nail and Jigs — These are either knurled or hexagonal, and are used to hold the nail and the jig to the inserter.

POSITION OF PATIENT

In open nailing the patient should be in the half or full lateral position as shown.
A lateral incision should be used for fractures of the upper third of the femur.
An antero-lateral muscle splitting approach between vastus lateralis and rectus should be used for mid and lower third fractures, plus a separate small lateral incision over the trochanter.
For ‘closed’ nailing the patient should be in the standard lateral position on a traction table. The small lateral incision over the trochanter is used.

FEMORAL REAMING

The femur is reamed either from the piriform fossa just medial to the greater trochanter, or retrogradely from the fracture site when the fracture site is exposed. The effective reaming length of the reamers is 400 mm, (total length 440 mm).
Successive reamers from 8 to 13 mm in diameter are used for the 12.5 mm nail. These are the standard diameter to be used for most femoral fractures. If cannulated reamers are used, these can be used over a guide wire.

ATTACHMENT OF THE NAIL TO THE INSERTER

The nail of correct length is attached to the inserter. The inserter should have the plastic compressor screwed as proximally as possible before the nail is attaced.
The nail is then inserted into the femur by hand with a screwing motion. The inserter must never be hit with a mallet. If the nail cannot be inserted easily by hand, the femur is re-reamed with either the 13 mm or the 14 mm reamer.
A long jig arm is then screwed onto the inserter in the hole furthest from the nail. A drill bit is then inserted from the most distal appropriate hole in the inserter into the most distal hole in the nail. This is to ensure that the alignment of the jig and nail are correct. If necessary the nail is slightly rotated on the inserter using a short 150 mm drill bit before the retaining nut is tightened fully. The jig is then removed. At this stage it is also essential to note which holes in the jig mate with the relevant holes in the nail.
INSERTION OF THE NAIL

The nail is then inserted fully so that the compressor is absolutely flush with the top of the greater trochanter. The plastic compressor ensures that the nail is then 10 mm distal to the top of the trochanter.
REATTACHMENT OF THE JIG

The appropriate length of jig is than attached to the hole in the inserter as near as possible to the thigh. The nearest hole to the nail in the inserter, however. is the only one that can be used with the original oblique hole jig without drilling sleeves.
Any bone which results from the reaming should be squeezed through gauze (using a sterile press if available), and used as bone graft at the fracture site.



COMPRESSION OF FRACTURE NOT REQUIRED
The following method should be used when compression of the fracture is not required, and when only transverse screws are being inserted.
First ensure that the plastic compressor is flush with the top of the trochanter, and also screwed up as tightly as possible.
Only one of the long 180 mm drill bits should be attached to the drill and used for drilling the holes for the screws. The three short 150 mm drill bits supplied on the nail set should usually only be used only for locating the jigs onto the nail.
Drill hole (1), the most proximal of the holes in the nail is then drilled with the long 180 mm drill bit, and filled with a short 150 mm locating drill bit.
The fracture is then impacted by hand, with the correct rotation of the lower femur.
Drill hole 2, the drill hole below and closest to the fracture site itself, is then drilled out. It should not be at the fracture site itself. A short 150 mm locating drill bit is then inserted, and this will lock the fracture in place both to the nail and to the jig. Locating drill bits (1) and 2 are left in place until all the other holes have been drilled and filled with screws.
Drill holes 3, 4 and 5 below the fracture site, and drill holes 6, 7 and 8 above the fracture site are then drilled out with the long 180 mm drill bit.
In the case of the new jigs with sleeves, the holes are measured, tapped and filled with screws without removing the jig arm. Locating drill bits (1) and 2 are then removed, measured, tapped and filled with screws.
In the case of the older type jigs without sleeves, after all the holes 1 to 8 have been drilled, locating drill bits 1 and 2 plus the jig are carefully removed. This should be done without rotating or disimpacting the femur. Drill bits (1) and 2 are then reinserted to lock the femur to the nail again.


Drill holes 3 to 8 are then measured, tapped and filled with screws. Finally drill holes (1) and 2 are filled.If any hole in the nail is not immediately located, and the drill bit hits the side of the nail, the jig should be carefully removed, and the hole in the nail located with the screw depth measure. It will usually be slightly anterior or posterior to the hole in the outer femoral cortex. This hole is then drilled out and through the hole in the nail, and the medial femoral cortex.without the jig in place. The jig is then replaced, and the locating 150 mm drill bit inserted through jig, femur and nail. All further holes should be able to be drilled without trouble.

COMPRESSION OF FRACTURE REQUIRED
If compression of the fracture is required, when open reduction is being carried out, locating 150 mm short drill bit (1) should be inserted through the jig, and into a hole seen in the nail at the fracture site when the nail has been fully inserted.
The fracture is then reduced, and drill hole 2 drilled out, and filled with a short 150 mm locating drill bit
Drill holes 3, 4 and 5 are then drilled out, and short locating drill bit 4 used to lock the nail to the lower femoral fracture.
If the jigs with the drilling sleeves are used, drill holes 3 and 5 are then measured, tapped and filled with 4.5 mm fine threaded screws. Locating drill bits 2 and 4 are left in place until the end of the operation.
If one of the jigs without the drilling sleeve is used, drill bits 2 and 4 plus the jig are carefully removed, and locating drill bits 2 and 4 replaced without the jig in place. Drill holes 3 and 5 are then measured, tapped and filled with screws.
d drill holes 6, 7 and 8 above the fracture site are then drilled out with the long 180 mm drill bit.
In the case of the new jigs with sleeves, the holes are measured, tapped and filled with screws without removing the jig arm. Locating drill bits (1) and 2 are then removed, measured, tapped and filled with screws.
In the case of the older type jigs without sleeves, after all the holes 1 to 8 have been drilled, locating drill bits 1 and 2 plus the jig are carefully removed. This should be done without rotating or disimpacting the femur. Drill bits (1) and 2 are then reinserted to lock the femur to the nail again.



Drill bit (1) at the fracture site is then removed and the plastic compressor over the trochanter tightened with the spanner until the fracture site is firmly impacted. Care must be taken not to crush the trochanter, and also to make sure that the rotation of the fracture is correct.



The short floating jig is then slid over locating drill bits 2 and 4. Drill hole 6 above, and nearest to the fracture site, is then drilled out and filled with a locating short drill bit until the end of the operation.Drill holes 7, 8 and 9 are then drilled out through the floating jig. The floating jig is then slid off the 3 locating drill bits, and holes 7, 8 and 9 are filled with screws. Finally holes 2, 4 and 6 are measured, tapped and filled. A screw should never be inserted at the fracture site itself as it may cause a stress raiser.Bone graft from all the reamings, plus additional cancellous graft if necessary from the patient’s iliac crest, should be also be used in all established non unions.


In the case of closed percutaneous nailing with the use of sleeved jigs, the first drill hole (1) should be in the most proximal hole in the nail, above the fracture site. This will lock the jig accurately to the nail, and allow holes 2, 3, 4 and 5 below the fracture to be drilled. Short locating 2 and 4 drill bits are then inserted, and left until the end of the operation. Drill holes 3 and 5 are then measured, tapped and filled.Drill bit (1) is then removed, and the compressor over the trochanter tightened to compress the fracture with the correct rotation. Drill holes 6, 7, 8 and 9 above the fracture are then drilled, measured, tapped and filled. Finally locating drill bits 2 and 4 are filled with screws


ELONGATION OF THE FEMUR
In cases where the femur requires elongation, this is best done by open operation. Drill holes 1, 2, 3 and 4 are first drilled above the fracture site. Locating drill bits 2 and 4 are left in place until the end of the operation, while holes 1 and 3 are filled with screws.
The fracture site should be lengthened using skeletal traction or a spreader. Stripping of the periosteum above and below the fracture may be required to achieve the required length. This should not usually aim to be greater than 50 mm at a single operation. This is because of the risk of stretching the neurovascular structures. The action potentials in the common peroneal nerve must be recorded in all cases where these might be at risk. The knee should also be kept flexed during elongation to diminish the risk of neurovascular damage.
Drill bit 5, as illustrated, can be used to maintain length. Drill holes 6, 7, 8 and 9 are then drilled out. A short stabilising drill bit 8 is left in place, while holes 6, 7 and 9 are filled with screws. Finally locating drill bits 2, 4 and 8 are removed and filled with screws. The defect is then filled with cancellous bone graft.
The defect can also be filled with porous coated titanium alloy spacers. These are 10 mm in depth, and 30 mm in diameter, and are threaded over the nail. They require to be inserted at the fracture site after elongation of the femur, and before any holes for locking screws are drilled.



The nail is then carefully partially extracted to just above the fracture site. The spacers placed at the fracture are then threaded, one at a time over the nail, as it is advanced through the spacers and into the distal femur. The remainder of the operation is identical to that described above except that drill bit 5, which is used to maintain length, is not usually required.


It is essential to also use cancellous bone graft on the medial side of the spacers. This may be obtained from either the medullary cavity, or from the patient’s iliac crest. Only a small amount is usually required, and it should extend for the whole length of the spacers, and to the femur above and below the spacers. This graft not only adds strength to to elongation, but also by ingrowth into the porous coating prevents movement of the spacers. The spacers also obviate the necessity for homogenous bone graft with its dangers of HIV infection.

IDEALISM IN SURGERY

A career is shaped like a big S

When you start out, you are at the top of the gentle S curve, full of idealism; you want to S ave the world.
Mid – way, starting to slide down, you largely just want to s ave your ass( stay out of trouble and the courts.
Near the end you have returned to idealism and want to S ave the world again.

HUCKSTEP LOCKING COMPRESSION NAIL

A four-sided solid titanium 6% aluminium 4% vanadium alloy nail, diameter of 12.5mm and with 4.6mm holes spaced at 1 5mm intervals, has been designed and extensively tested since 1967. Titanium screws, inserted with the aid of a special jig, fix both cortices of the femur as well as the nail, and hold the femur rigidly to the nail. Three or four 4.5mm titanium screws re used below, and the same number above, the fracture site.

One end of the nail has four oblique holes at 1300 for use with 4.5mm lag screws up the femoral neck and into the head, for combined fractures of the hip and femoral shaft. Nails with all transverse holes are also available, with all types of nail being bullet tipped.

The nail has an advantage in being designed for difficult fractures of the entire shaft of the femur, including comminuted fractures and combined fractures of the hip and shaft. The femur may also be lengthened over the nail using bone graft.

A 10.5mm diameter nail is available for the tibia or humerus, and an 11.5mm nail for the smaller femur. Various lengths of nail are also available to accommodate most indications however alternative lengths are available to special order. No X-ray control or special operating table is required, except in closed nailing or where there is an associated fracture of the hip where screws need to be inserted up the femoral neck.

ADVANTAGES

Ability to compress fractures and hold rotation with screws, transfixing both cortices of the bone and nail.

Oblique 4.6mm holes in one end in the standard nail, allow for 4.5mm compression screws up the neck of the femur.

Nail does not usually require removal.

Top of nail recessed in trochanter.

Minimal reaming to 13mm for 12.5mm nail.

Square cross section allows for medullary blood supply to regenerate.

Completely biocompatible.

Modulus of elasticity half that of stainless steel and chrome cobalt.

Stronger than most other implants with symmetrical cortical compression obtained with the nail and screws.

Three diameters of nail available.

Unique jig makes X-ray control or special operating table for shaft fractures unnecessary.

Nail (12.5mm) is 1.1 to 1.8 times stronger than the average femoral shaft with three screws equal to strength of nail.

Ability to be full weight-bearing immediately postoperatively in most cases.

Union usually in 2-6 months, even in previously established non-union.

{{{ OPERATING TECHNIQUE WILL BE SENT IN NEXT BLOG}}}

TomoFix Medial Distal Femur (MDF)

The goal of distal femur varus osteotomy is to shift the mechanical leg axis from the lateral to the medial compartment. There are various possibilities for surgical correction of valgus malalignment. The AO Knee Expert Group (KNEG) favors closing wedge osteotomy of the distal femur for valgus correction, because open wedge osteotomy on the lateral side causes significant morbidity due to tensioning of the iliotibial tract, and friction over the implant. The KNEG also found that distal femur opening wedge osteotomy did not show the same healing capacity as on the tibia and that bone grafting was necessary to avoid pseudarthrosis. Biomechanical testing confirmed superior stability of medial closing wedge techniques as compared to lateral open wedge techniques and favorable axial and torsional loading characteristics of an angular stable internal fixator, the TomoFix medial distal femur (MDF).
The TomoFix MDF features anatomically preshaped plates with a bending angle of 20°. If needed during the operation, this angle can be further bent by using the bending press. The plate profile is 4 mm. The TomoFix MDF is available in a left and right version. The head of the plate offers four isolated LCP holes for 5.0 mm locking head screws. The screw axes of these four LCP holes are converged by 2°. Through this alignment a cut-out of the screws can be prevented and the distance to the cruciate ligament is improved. The bolt angulation of 15° in the frontal plane enables use of longer screws and thus a more stable fixation. Bolt placement is easy and safe due to the anatomically adapted shape. The plate shaft features four standard 4.5/5.0 LCP combination holes which are shifted throughout the longitudinal axis. The end of the plate has a bullet nose for use of a MIO technique. Specific guiding blocks for the left and right plates help to insert the drill socket in the correct axis onto the plate.
The plate is inserted distally under the vastus medial muscle after screwing the threaded LCP drill guides into the four distal plate holes using the guiding block. The distal drill holes are oriented in a 20° angle inclination on the frontal plane to avoid a posterior perforation of locking head screws in the distal femur.
Biomechanical studies demonstrate that interfragmentary compression has a positive effect on bone healing. For this reason a lag screw is positioned in the dynamic compression unit directly above the osteotomy for compression of the osteotomy site.
The Patient can be mobilised as early as day one after surgery. Partial weight bearing is recommended for 6 weeks, active movement of the knee is encouraged. X-ray control after 6 weeks should demonstrate bony healing. Full weight bearing can be allowed in many cases after this time period, if the osteotomy site is still painful and bone healing is incomplete, weight bearing should be delayed for further 3–4 weeks.

Closed posterior dislocation of the ankle without fracture

Closed posterior dislocation of the ankle without fracture.
Full Text
Introduction.....Dislocation of the ankle without associated fracture or wound is an extremely rare injury. [1] Fahey and Murphy [2] classified tibio-talar dislocations into anterior, posterior, medial, lateral, superior or combinations of these basic displacements. Most of these are either open and/or with an associated fracture of the tibia, fibula or the talus itself. Of these the posterior-medial dislocation has been described most often in the literature. [1],[2],[3],[4],[5] Most authors have described this injury in young adult males. Falls, road traffic accidents and sports have been described as the most frequent causes of these injuries. Forced inversion or eversion with axial loading in a maximally planter-flexed foot is thought to be the cause of this injury. The patho-anatomy of this injury has been dependent on findings during surgical repairs and has not been described accurately. We are reporting a case of closed posterior dislocation of the ankle without fracture in an 18-year-old male patient following road traffic accident. The most probable mechanism is forced forward displacement of the tibia leaving the talus behind. The patho-anatomy as evident from the magnetic resonance finding is also being described. The injury is being described not only for its rarity but also to discuss its unique patho-mechanics, mechanism of trauma and its prevention.
Case History....An 18-year-old, 6 feet 4 inch tall male weighing 90 kg presented with pain, swelling and deformity one hour after a road traffic accident. The patient was on a bike when he was hit from behind over the right leg just above the ankle by another fast-moving vehicle where the large heel-breast of his shoes got stuck in the footrest and the leg was pushed anteriorly with great force resulting in a closed posterior dislocation of the talus from the ankle mortise. Physical examination revealed a deformed ankle with foot posteriorly displaced. There was no open injury. Swelling was present. The dorsalis-pedis and posterior tibial pulsations were normal. There was no hypoaesthesia, hyperlaxity or associated injuries.Plain anterior-posterior and lateral radiograph of the right ankle demonstrated a posterior dislocation of the ankle without any fracture or widening of the tibio-fibular syndesmosis [Figure 1]. Patient was treated by leg elevation, above knee slab application and analgesics followed by closed reduction under general anesthesia and application of an above knee cast. Post reduction magnetic resonance imaging [Figure 3] demonstrated a torn anterior talo-fibular ligament and medial collateral ligament. A fibrous talo-calcaneal coalition was also found. He was advised surgical repair of the ligaments which he refused following which he was advised not to bear weight for six weeks. On follow-up at two years although he had painless normal range of ankle motion with full weight bearing and squatting, the x-ray of the ankle revealed osteophytes, calcification of the collateral ligaments beneath the malleoli with mild subluxation of the ankle joint [Figure 2].
Discussion....Dislocation of the ankle requires considerable force because of the mechanical efficiency of the mortise and the strength of the associated ligaments. [3] Since ligaments are stronger than the malleoli, most ankle dislocations are associated with fractures. Wilson et al. , reviewed the literature prior to 1939 and found 16 cases of ankle dislocation without fracture. [1] More recently Soyer et al. , (1994) found 73 cases in the relevant literature. [4] About 50% of ankle dislocations are usually open. However, in our case there was no open injury. An increased participation in outdoor activities is probably the cause of the higher incidence of this injury in young males. Our patient was also an 18-year-old, strong, adult male. Unlike ankle sprains, which predominantly occur in sportsmen, ankle dislocation is caused mainly by road traffic accidents, particularly motorcycle accidents. Sports trauma is the second most common cause.The exact patho-mechanics of this injury has not been described accurately. Most authors suggest the cause as a combination of inversion along with axial loading while the foot is maximally plantar-flexed. This hypothesis is supported by experimental work done by Fernandez [5] on cadavers. The ligaments, which he found to be injured in this type of injury, were the anterior talofibular and calcaneofibular ligament. He also postulated that once the ankle is dislocated without fracture, the tendon of calcaneus pulls it posteriorly. Most authors have supported this postulate. However, Wroble et al. , were of the opinion that dislocations of the talus occur because of extrusion of the talus anteriorly or posteriorly when force is applied in a plantar-flexed foot. [6] In our case, the patient was wearing large shoes resting on the footrest well supported on it by the high heel-breast of the shoe. Being hit from behind above the ankle the patient's foot being plantar-flexed at this time got stuck at the footrest due to the high heel-breast, resulting in the tibia being forcefully pushed anteriorly, leaving behind the talus and the foot [Figure 4]. The associated talocalcaneal bar prevented an associated subtalar dislocation.Since the injury occurs due to inversion, the structures that are primarily torn are the anterior talofibular, the calcaneofibular and posterior talofibular respectively. The deltoid ligament is usually spared. However, in our case since the mechanism of injury was not inversion with axial loading but a forward extrusion of the tibia leaving the talocalcaneal complex with the foot behind, we expected both medial and lateral collateral ligament injuries. Our clinical suspicion was confirmed by MRI report, which documents complete tear of the anterior talofibular and medial collateral ligament. Interestingly, our patient had a talocalcaneal coalition. This may have predisposed the patient to have an ankle dislocation rather than a subtalar dislocation when he was hit from behind. Tarsal coalition as a predisposing cause of ankle dislocation without fracture has not been previously described in the literature.We are reporting this case for its unique mechanism of injury, MRI findings and outcome. We recommend that for racing bikes the footwear should not have a heel with a high breast-line; preferably, they should have a flat sole which will not permit the heel getting stuck in an accident, bringing about this type of grave injury.
References
1
Wilson MJ, Michele AA, Jacobson EW. Ankle dislocations without fracture. J Bone Joint Surg 1939;21:198-204.
2
Fahey JJ, Murphy JL. Dislocations and fractures of the talus. Surg Clin North Am 1965;45:79-102.
3
Uyar M, Tan A, Is¸ler M, Cetinus E. Closed posterior dislocation of the tibiotalar joint without fracturein a basketball player. Br J Sports Med 2004;38:342-3.
4
Soyer DA, Nestor BJ, Friedman SJ. Closed posteromedial dislocation of the tibiotalar joint without fracture or diastasis: A case report. Foot Ankle Int 1994;15:622-4.
5
Fernandes TJ. The mechanism of talo-tibial dislocation without fracture. J Bone Joint Surg Br 1976;58:364-5.
6
Wroble R, Napola J, Malvitz T. Ankle dislocation without fracture. Foot Ankle 1988;9:64-74.