PurposeFractures of the humeral shaft are common and account for 3%–5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors.MethodsThe study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures.ResultsOf 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p = 0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p = 0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p = 0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months.ConclusionContrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.

IntroductionOpen fractures of the proximal tibia often pose serious challenges to the treating orthopedic surgeon. Management of these complex injuries becomes difficult if they are associated with damage to the extensor mechanism and an exposed knee joint. The scenario becomes more difficult to manage when the soft tissue defect extends to the middle third of the leg. We report a case where we used an extended medial gastrocnemius flap in combination with a saphenous artery fasciocutaneous flap and a medial hemisoleus flap for treatment of an infected proximal tibia fracture with loss of the extensor mechanism and soft tissue defect. To the best of our knowledge, combined use of these three flaps for the management of such injuries has not been reported elsewhere to date.Case presentationA 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He had sustained an open fracture of his left proximal tibia in a road traffic accident five weeks ago and had been operated on elsewhere. He had a stiff, painful knee with an infected wound of 4×4cm over the proximal third of his leg exposing infected, necrotic patellar tendon. He was successfully managed with debridement and simultaneously elevated flaps as described.ConclusionsThis procedure avoids the donor site morbidity associated with free flaps harvested from sites distant from the site of injury, and also does not need the expertise of microvascular reconstruction. To the best of our knowledge, this is also the first report of the combined use of three local flaps for knee extensor reconstruction and soft tissue coverage around the knee.

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Several methods for obtaining knee arthrodesis have been described in the literature and world; over, the commonest cause for arthrodesis is a failed arthroplasty. Less commonly, as in this series, post-infective or traumatic causes may also require a knee fusion wherein arthroplasty may not be indicated. We present salient advantages along with the radiological and functional outcome of twenty four patients treated with a single monorail external fixator. All patients went on develop fusion at an average of 5.4 months with an average limb length discrepancy of 3 cm (1.5–6 cm). Improvements in functional outcome as assessed by the lower extremity functional score (LEFS), and the SF-36 was significant (p = 0.000). Knee arthrodesis with a single monorail external fixator is a reasonable single-staged salvage option in patients wherein arthroplasty may not be the ideal choice. The outcome, though far from ideal, is definitely positive and predictable.Electronic supplementary materialThe online version of this article (doi:10.1007/s11751-016-0247-5) contains supplementary material, which is available to authorized users.

<p class="abstract"><strong>Background:</strong> Treatment of infected distal femur non-union with a stiff knee and severely scarred soft tissues is a challenging problem. We describe a method of addressing the non-union using quadriceps splitting approach to the distal femur.</p><p class="abstract"><strong>Methods:</strong> We retrospectively reviewed 5 patients with distal femur infected nonunion and knee stiffness, who, after infection control, required distal femur bone grafting. All patients had autogenous iliac crest bone grafting of the distal femur using the quadriceps splitting approach. The parameters assessed were the time to surgical wound healing, wound infection, time to bony union, and if any additional procedures were needed.<strong></strong></p><p class="abstract"><strong>Results:</strong> 5 patients were referred with distal femur infected non-union in addition to knee stiffness, with or without an implant <em>in situ</em>. All patients underwent debridement, implant exit, and external fixation of the femur spanning the knee as the primary surgery here, followed later on by iliac crest bone grafting of the distal femur using the above approach. All patients united well within 12 to 16 weeks, without the need for additional procedures.</p><p class="abstract"><strong>Conclusions:</strong> In the presence of pre-existing knee stiffness with severely scarred and contracted soft tissues the quadriceps-splitting approach is a useful method to address bony problems in the distal femur, without the need for a separate procedure for soft tissue or flap cover.</p>