Study on Outcome of Complex Lower Limb Problems treated by Ring External Fixator and Evolvement of Practices toward its Acceptability

ABSTRACT Introduction In the developing world, there is still lack of accessibility and availability of adequate health care. In rural population this further gets limited, due to meager immediate resource at disposition and lack of availability of transports to adequate set ups. This cross-sectional study is undertaken among our rural patients who had undergone this treatment to understand what difficulties they had faced during such treatments and their acceptability toward such treatment. This study was undertaken with the aim to find out the acceptability and adaptability among the rural population for Ilizarov ring fixators. Materials and methods The study consisted of 88 consecutive cases (91 lower limbs) of all age groups, who completed the treatment by Ilizarov methodology between July 2005 and July 2012. A retrospective analysis of the procedure was done through the medical records in terms of preoperative, intra­operative, and after the complete treatment. These were analyzed for limb lengthening in centimeters, correction of deformities, total wearing duration, and final outcome. Subsequently, these patients/parents were interviewed with a questionnaire to assess the self-accessibility (ease) toward self-care; self-distraction; self-adaptability–comfort during wearing time and the difficulties faced. Results Overall the functional outcome was excellent in 18, good in 50, fair in 8, and poor in 4. Out of 91 patients, 67 (73.6%) followed up and could be evaluated for adaptability toward Ilizarov fixator. Overall, 91.04% were satisfied with the treatment by Ilizarov fixator. In the remaining the main reason for not accepting the Ilizarov method was difficulty in commuting in the public transport, ugly and threatening looks of fixator with so many wires crossing the leg. Conclusion Ilizarov method is a very effective tool for manag­ing the complex lower limb problems, especially among the population with low resources. It will ensure delivery of a very low-cost solution offered to the needy patients, wherein otherwise due to multiplicity of problems, integral solution is difficult to achieve within their resources. How to cite this article Shrivastava S, Khan SM, Rathi R, Mundada G, Singh PK, Taywade S. Study on Outcome of Complex Lower Limb Problems treated by Ring External Fixator and Evolvement of Practices toward its Acceptability. J Med Sci 2017;3(2):35-40.

Computed Tomographic Assessment of Reduction of the Distal Radioulnar Joint by Gradual Lengthening of the Radius

Congruency of the distal radioulnar joint was assessed by computed tomography after gradual lengthening of the radius in patients with considerable ulnar positive variance of mean 12 (range 10–17) mm and chronic dislocation of the distal radioulnar joint. Six patients of mean age 25 years were treated by radial osteotomy and subsequent gradual lengthening using either a single-rod or a half-ring external fixator, which was applied for a mean of 81 days. The causes of deformity were distal radial epiphyseal injury in four, malunion of a radius shaft fracture in one and Madelung deformity in one. Computed tomography scans taken at 1 year postoperatively demonstrated that all patients had a congruent distal radioulnar joint. All patients achieved symptom and radiographic parameter improvements at a mean follow-up of 40 months. A disadvantage was unattractive scars on a cosmetically important surface of the forearm. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction of the distal radioulnar joint can be obtained by gradual lengthening of the radius.

Neutral Ring Fixation for High-Risk Nonplantigrade Charcot Midfoot Deformity

Background: Charcot foot arthropathy negatively impacts the health-related quality of life (HRQL) of affected individuals. The disease process often is responsible for the development of significant deformity and disability, often progressing to lower extremity amputation. Many patients are morbidly obese, immunocompromised, and have complex wounds with underlying bony infection or poor bone quality, making operative correction and internal fixation problematic. Methods: Using a prospective clinical algorithm, 26 consecutive diabetic adults with multiple diabetic co-morbidities, including morbid obesity, had operative correction of nonplantigrade Charcot midfoot deformity at the midfoot level. Correction was maintained with a neutrally applied three-level ring external fixator. Average body mass index was 38.31 ± 12.51. Nineteen patients used insulin. Fourteen had open wounds with underlying osteomyelitis. The altered relationship between the forefoot and hindfoot was measured as 14.04 ± 31.09 degrees in the anteroposterior axis, and 16.70 ± 17.47 degrees in the lateral axis before surgery. Surgery included Achilles tendon lengthening, excision of infected bone, correction of the multiplanar deformity, and culture-specific parenteral antibiotic therapy. Results: At a minimum 1-year followup, 24 of 26 patients were ulcer and infection free and able to ambulate with commercially-available depth-inlay shoes and custom accommodative foot orthoses. One patient died of unrelated causes, and one had transtibial amputation for persistent infection. Four developed recurrent plantar ulcers, which resolved with excision of underlying bony prominences. There were two stress fractures through olive wire pin sites, one requiring intramedullary nailing. The radiographic anteroposterior axis was corrected to 3.12 ± 9.42 degrees, and lateral to 10.42 ± 11.86 degrees after surgery. Conclusions: Morbidly obese diabetic individuals with multiple co-morbidities complicating severe Charcot foot deformity can achieve correction of midfoot deformity after operative correction of the deformity and maintenance of that correction with a neutrally applied ring external fixator.