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Fulltext The tale of two vessels, vascular complications following a breach of the pelvic inner table due to acetabular screws: a report of two cases

Ayob KA, Merican AM, Sulaiman SH, Hariz Ramli AR

Jt Dis Relat Surg, 2021;32(1):239-244.
PMID: 33463444 DOI: 10.5606/ehc.2021.77862

Injuries to the pelvic vasculature during total hip arthroplasties are rare but have serious consequence. They demand urgent and early identification so that appropriate treatment can be instituted. If the bleeding is severe, cardiovascular compromise occurs intraoperatively and this will alert the surgeon of this possibility during acetabular screw placement. Alternatively, a delay in diagnosis can occur because the bleeding and the injured vessel are in the pelvic cavity and not visualized during the surgery. In this article, we report two cases from our center occurring within a six-month interval that sustained a vascular injury during acetabular drilling for screw placement for cementless cup fixation. Each case had a different vessel injury and different lessons can be learned from these rare injuries. The first case had an injury of the inferior gluteal artery following a breach of the sciatic notch. The vessel was treated with percutaneous embolization. The second case demonstrated a venous injury, following a medial protrusio technique for congenital hip dysplasia and a short anterosuperior screw, transecting the external iliac vein. This was subsequently repaired using an endovascular technique. We conclude the reasons for these vessel injuries after analyzing advanced imaging, discuss measures to avoid vessel injury and detail the minimally invasive method for their treatment.
Single-stage reconstruction of a traumatic tendocutaneous defect of the Achilles using free composite anterolateral thigh flap with vascularized fascia lata

Liang Yii RS, Chai SC, Zainal HM, Basiron N

Jt Dis Relat Surg, 2022;33(3):673-679.
PMID: 36345197 DOI: 10.52312/jdrs.2022.843

Combined tendocutaneous defect of Achilles tendon remains a complex reconstructive challenge whereby both the soft tissue coverage and tendon reconstruction have to be considered to achieve a good functional and aesthetic outcome. A 14-year-old boy who sustained an open right calcaneum fracture (Gustilo-Anderson IIIB) with a transected Achilles tendon and huge skin defect from motorcycle wheel spoke injury was admitted. The Achilles tendon repair site broke down following initial surgical debridement and primary repair, resulting in a sizeable combined tendocutaneous defect. Simultaneous soft tissue coverage and tendon defect reconstruction using composite sensate free anterior lateral thigh (ALT) fasciocutaneous flap with vascularized fascia lata was performed subsequently. The vascularized fascia lata was tubularized to wrap the native proximal stump of Achilles tendon and secured using the modified Krakow suturing technique. The distal end of tubularized fascia lata was, then, secured by drilling across right calcaneum bone, passing the suture transosseously and screwed. He led an uneventful postoperative recovery with satisfactory functional and aesthetic outcomes at one year of follow-up. In conclusion, the present case demonstrates the reliability of this technique and its advantages over other flap choices in reconstruction of a huge combined tendocutaneous defect.
Does obesity affect diaphyseal femoral fracture healing treated with intramedullary locking nail?

Issace SJJ, Singh RSJS, Sisubalasingam N, Tokgöz MA, Jaiman A, Rampal S

Jt Dis Relat Surg, 2023;34(1):9-15.
PMID: 36700258 DOI: 10.52312/jdrs.2023.649

OBJECTIVES: This study aims to evaluate the effect of obesity on radiological fracture union in diaphyseal femoral fractures (DFFs) treated with intramedullary nailing (IMN).
PATIENTS AND METHODS: Between January 2017 and December 2018, a total of 120 patients (101 males, 19 females; mean age: 35.1±3.0 years; range, 18 to 72 years) treated with IMN for closed DFFs were retrospectively analyzed. Data including age, sex, location, weight, height, comorbidities such as diabetes mellitus, hypertension or kidney injury, date of injury, mechanism of injury, type of femoral fractures (AO classification), date of surgery, duration of surgery, IMN length and diameter used, date of radiological fracture union and complications of surgery such as nonunion, delayed union, and infections were recorded.
RESULTS: Of the patients, 63 had obesity and 57 did not have obesity. There was a statistically significant difference in fracture configuration among patients with obesity; they sustained type B (p=0.001) and type C (p=0.024), the most severe fracture configuration. The nonunion rate was 45%. Obesity had a significant relationship with fracture nonunion with patients with obesity having the highest number of nonunion rates (n=40, 74.1%) compared to those without obesity (n=14, 25.9%) (p=0.001). Fracture union was observed within the first 180 days in 78.9% of patients without obesity, while it developed in the same time interval in only 38.1% of patients with obesity (p=0.001).
CONCLUSION: Fracture union time for the patients with obesity was longer, regardless of the fracture configuration. Obesity strongly affects fracture union time in DFFs treated with an IMN. Obesity should be considered a relative risk in decision-making in the choice of fixation while treating midshaft femoral fractures.

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