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   Table of Contents - Current issue
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July-September 2017
Volume 52 | Issue 3
Page Nos. 169-249

Online since Wednesday, February 14, 2018

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ORIGINAL ARTICLES  

Locked knee in children owing to torn discoid lateral meniscus: the role of arthroscopic management Highly accessed article p. 169
Bahaa A Motawea, Mohamed M Abouheif
DOI:10.4103/eoj.eoj_48_17  
Background Discoid meniscusis a relatively rare congenital anatomical abnormality in which the meniscus is discoid rather than semilunar in shape. A torn discoid lateral meniscus (DLM) can be a potential cause of mechanical symptoms in children; moreover, it is considered the commonest reason for arthroscopic interventions performed on children. Hypothesis Arthroscopic reshaping of the meniscus (meniscoplasty) by partial excision of the central part achieves good results in these patients. Patients and methods Twenty patients (20 knees) presenting with symptomatic torn DLM were included in the study. The age ranged from 3 to 11 years, with a mean of 7.2 years. Five of them were males and 15 were females. Seventeen of them had locked knee owing to displaced bucket handle tear of DLM. Two patients had complex tear of DLM, whereas only one patient had a longitudinal cleavage tear. All the cases experienced knee pain and swelling. Clinical evaluation of the patients was done according to the subjective and objective International Knee Documentation Committee (IKDC) 2000 forms, and Lysholm knee score. Moreover, radiological evaluation was performed using plain radiographs and MRI. All patients were managed by reshaping of the meniscus by arthroscopic central partial meniscectomy regardless of the tear type. The duration of follow-up ranged from 22 to 36 months, with a mean of 26.4 months. Results All the patients showed dramatic improvement postoperatively. The average postoperative subjective IKDC score was 76% as compared with 29.25% preoperatively. Postoperative IKDC objective grade was A in six (30%) cases and B in 13 (65%) cases at the end of follow-up, as compared with the preoperative grade assessment, which was D in six (30%) cases and C in 14 (70%) cases, with statistically highly significant results (P<0.001). Conclusion Torn DLM can be a potential cause of symptomatic knee pain and effusion in children and should not be overlooked. Arthroscopic central partial meniscectomy (meniscoplasty) can give good results in these cases.
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Short-term (2 years) results of primary total hip replacement in 40 mobile elderly patients with fractured neck of femur Highly accessed article p. 175
Mohamed S Abd El-Maksoud Mohamed Ismail, Sherif A Khaled, Ashraf El-Nahal, Ibrahim El-Geady
DOI:10.4103/eoj.eoj_49_17  
Background The option of primary total hip replacement in patients with fractured neck of femur gives satisfactory functional results, which evokes the idea of this research to study the outcome of total hip replacement (THR) in patients older than 60 years having fractured neck of femur. Patients and methods A total of 40 active patients older than 60 years were included in our series. Patients were operated after a mean of 5 weeks after fracture. All patients were operated on by THR, under regional anesthesia, using modified Hardinge approach in lateral position. Postoperatively, all patients were allowed to bear weight as tolerated on the second day after operation. All patients were followed up at 6 weeks, 3 months, 6 months, and every 6 months thereafter. Results The results were good in all patients at 3 months, excellent in 23 patients at 6 months, and excellent among all at 2-year follow-up, with mean harris hip score (HHS) of 94. Conclusion Primary THR is a good line of treatment in active patients older than 60 years with fractured neck of femur.
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Tibial fixation without hardware for anterior cruciate ligament reconstruction: a new technique Highly accessed article p. 180
Taher A El-Satar Eid, El-Sayed Morsy
DOI:10.4103/eoj.eoj_50_17  
Introduction Tibial fixation is the weakest link in anterior cruciate ligament (ACL) reconstruction. Optimal or maximal ACL graft fixation in the tibia remains a challenging goal. Also, tibial fixation with implants for ACL reconstruction can be associated with a wide variety of problems such as graft-tunnel mismatch, graft damage, and poor graft fixation using metal or absorbable implants. Patients and methods A total of 15 male patients, average age 22.2 years (range: 18–36 years), were studied from December 2005 to December 2009. Eleven of our patients had associated medial meniscus injury. The causes of ACL injury were sport accidents in 12 patients and road traffic accidents in three patients. The right limb was affected in nine patients and the left limb was affected in six patients. Results Of the 15 patients, two patients were unwilling to or unable to return for assessment. These two patients were stable and had no complications or complaints at the sixth month for the first patient and at the ninth month for the second one. The results of these two patients were reported. but they were excluded from the evaluation, leaving 13 patients for the final assessment. The follow-up duration was 24 months. Subjectively, no patient complained of residual pain or instability and all patients were able to return to full activities as before injury before 12 months. The preoperative Lysholm Knee Score was poor, with a median of 61 (range: 7–95) as would be expected after injury. The median Lysholm Score at 24 months was 95 (range: 70–95). Objectively, all patients regained full extension and the flexion ranged from 120° to 140°. All patients had a solid end point on the Lachman test, with no positive pivot shift test. Conclusion This report describes a new technique for transosseous tibial fixation for ACL grafts of all varieties. This method secures the ACL graft to the tibial metaphyseal bone, followed by knot tying over a bone bridge and augmented with bone block impacted in the tibial tunnel. This technique is a simple, safe, inexpensive, and reproducible alternative for all types of grafts fixation in the tibial tunnel without hardware in ACL reconstruction.
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Arthroscopic subtalar arthrodesis in malunited fracture calcaneus p. 184
Wael Aldahshan, Faisal El-Sherief, Ashraf M Abdelaziz
DOI:10.4103/eoj.eoj_51_17  
Background Post-traumatic subtalar arthritis is one of the most common complications of calcaneal fracture. Subtalar arthritis with its sequel may not meet the patient’s needs or lifestyle and has a huge impact on the work force and society. The aim of this study was to evaluate the results of arthroscopic subtalar arthrodesis using two posterior portals in patients with subtalar arthritis type 1 Zwipp classification after calcaneal fracture. Patients and methods A prospective study was carried out on 15 heels in 15 consecutive patients with subtalar arthritis type 1 Zwipp classification after a calcaneal fracture for which nonoperative treatment had failed; arthroscopic subtalar arthrodesis was performed using cannulated screws. The mean patient age at the time of surgery was 38 (range: 28–48) years. The average preoperative American Orthopaedic Foot and Ankle Society hind foot score was 43.4 (range 38–57) and the average preoperative visual analogue scale was 8.6 (range: 8–9). The average follow-up period was 36 (range: 30–38) months. One patient was lost to follow-up at the 20th month. Results The average postoperative American Orthopaedic Foot and Ankle Society hind foot score was 89.2 (range: 81–95; P<0.01), which is significantly high. The average postoperative visual analogue scale score was 2.4 (range: 1–4). The union rate was 100%. Conclusion Isolated subtalar arthrodesis using two posterior portals yields good functional results, high safety, and efficacy and a low complication rate with significant clinical improvements as a salvage procedure of G1 post-traumatic subtalar arthritis. Level of Evidence: IV.
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Endoscopic versus open treatment of Haglund’s syndrome p. 190
Mohammed M Mansour
DOI:10.4103/eoj.eoj_52_17  
Purpose The purpose in this study was to compare endoscopic calcaneoplasty with a standard open technique in Haglund’s syndrome management. Patients and methods Two or three portal endoscopic calcaneoplasty was done in 14 patients (17 heels; nine females and five males), with a mean age of 29.7 years, and open calcaneoplasty using a lateral approach was done in 12 patients (17 heels; eight females and four males), with a mean age of 32.6 years. All patients had Haglund’s deformity on radiography and were resistant to conservative therapy for more than 6 months. All patients were evaluated preoperatively and postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) score (Ankle–Hindfoot Scale). Results In the endoscopic group, the AOFAS scores averaged 63.4 points preoperatively and 88.5 points postoperatively (P<0.001) at an average of 16 months (range: 12–23 months) of follow-up. In the open technique group, the AOFAS scores averaged 61.1 points preoperatively and 80.6 points postoperatively (P<0.001), at an average of 20 months (range: 16–28 months) of follow-up. The scores after the endoscopic procedures were better than those after the open procedures. The time to recovery was similar in the two groups, but the endoscopic procedures were performed more quickly than the open procedures (50 min compared with 68 min) and were associated with fewer complications (0% compared with 1% regarding rate of infection, 5.8% compared with 23% regarding rate of altered sensation, and 5.8% compared with 17.6% regarding rate of scar tenderness). Conclusion Endoscopic technique for treatment of Haglund’s syndrome seemed to be a safe and efficient as the open technique and has the advantage of small incisions with better cosmetic appearance, less risk to weaken the Achilles tendon insertion that can cause tendon rupture, and also fewer wound complications such as dehiscence, painful or ugly scars, nerve entrapment within the scar, and hypoesthesia.
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Mismanaged, misdiagnosed lisfranc injuries: long-term follow-up p. 195
Khaled Salama, Sameh Mahmoud Abou El-Fadl
DOI:10.4103/eoj.eoj_54_17  
Introduction Dislocations and fracture-dislocations of the tarsometatarsal joints are disabling injuries that present difficult therapeutic problems. Early recognition is imperative. Most studies cite that up to 20% of injuries are missed or misdiagnosed at first presentation; this number could be as high as 40%. Patients and methods This study included all patients who presented with misdiagnosed or mismanaged Lisferanc injuries to Suez Canal University Hospital during the period from May 2002 to March 2006. Patients’ outcomes were assessed using the American Orthopedic Foot and Ankle Society midfoot score. A total of 19 patients were available at the end of the study. Results The mean age of the patients was 34.05±11.76 years including 17 (89.5%) men and two (10.5%) women. There were 17 patients with combined injury (ligament and bone) and two patients with pure ligamentous injury. The patients were distributed according to the modified Hardcastle classification. There were nine (47.4%) patients with type B lateral fractures; two of these showed fleck sign, six (31.6%) patients with type A lateral fracture, three (15.8%) patients with type C total fracture dislocation, and one (5.3%) patient with type C partial fracture. Four (21.1%) patients were managed after the first week of injury, nine (47.4%) patients were managed between the second week of injury and the seventh week, and six (31.6%) patients were managed after the seventh week of the injury. Four (21.1%) patients developed osteoarthrosis at the end of follow-up. Conclusion Lisferanc injuries are reported to be the most commonly missed injury. Once diagnosed, anatomical reduction and stable fixation is the standard principle governing the treatment of these injuries.
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Osteosynthesis of unstable distal clavicular fractures with and without coracoclavicular ligament reconstruction p. 202
Mohamed G Morsy, Abdullah S Hammad
DOI:10.4103/eoj.eoj_83_17  
Objective and design The aim was to compare the clinical and radiological results of internal fixation of displaced distal clavicular fractures using 3.5 mm locking T-plate alone and the same plate augmented by coracoclavicular (CC) loop using coracoid-based anchor loaded by two high-strength suture threads. This is a prospective clinical study. Patients and methods A total of 41 patients (33 males and eight females) with a displaced distal clavicular fracture were divided randomly into two groups. The mean age of the patients was 30.2 years (range: 21–41 years). All patients underwent internal fixation using 3.5-mm locking T-plate: in group 1 (21 patients), the fracture was fixed with locked plate only (single attack), and in group 2 (20 patients), fracture was fixation with locked plate augmented with CC reconstruction using suture anchor fixed at base of coracoid (double attack). Constant functional score was used to assess the overall clinical outcome and patients’ satisfaction. A standard anteroposterior radiograph was used to assess the union and measure the acromioclavicular overlap. Results The mean follow-up period was 20 months (range: 18–28 months). At the final follow-up, there was a highly significant improvement in Constant score (P<0.001) in both groups. However, patients treated by locked plate augmented by anchor reconstruction of CC ligaments (double attack approach) had better early clinical and range-of-motion outcomes. Conclusion Osteosynthesis with CC ligament reconstruction is an effective technique for fixation of displaced distal clavicular fractures. It does not only provide rigid fixation but also offers promising early clinical results especially regarding the range of motions. Level of evidence The level of evidence is that of a therapeutic case series level IV.
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Dual fixation of midshaft clavicle fractures in adults: intramedullary Kirschner wire with augmentative plate fixation p. 208
Yasser K Aref, Bahaa A Motawea
DOI:10.4103/eoj.eoj_58_17  
Background The clavicle is one of the most commonly fractured bones in the body. In adults, clavicle fractures represent 2.6–5% of all fractures and 44% of all shoulder girdle injuries. Although fracture union usually occurs regardless of the treatment selected, controversy exists regarding optimal management. Although most clavicle fractures can be managed nonoperatively, still there has been debate on how to best treat displaced midshaft clavicular fractures. Without fixation, nonunion rates as high as 15–21% have been reported. Operative fixation for displaced midshaft fractures improve the functional outcomes and decrease nonunion rates. Operative management including open or closed reduction with plate fixation or intramedullary (IM) fixation results in improved outcomes and lower rates of nonunion compared with nonoperative management and is recommended for patients with multiple risk factors for nonunion, especially significant displacement or clavicle shortening. This study was conducted to assess the results and reliability of combined IM and plate fixation of displaced mid-clavicular fractures in adults. Patients and methods Thirty-three adult patients with comparable demographics having displaced mid-clavicular fracture were submitted to surgical fixation by both IM Kirschner wire and short small reconstruction plate. Results were assessed at the end of this period according to Constant and Murley Score (CMS). The CMS is a 100-point functional shoulder-assessment tool in which higher scores reflect increased function. Results At the end of the follow-up period, the mean score was 95.33±9.0. Thirty-two (97%) patients had excellent results, and only one (3%) patient had poor result. The mean final CMS for pain was 14.70±1.74. The mean final CMS for activity of daily living was 19.67±1.91. The mean final CMS for active forward flexion was 9.82±1.04 (145°–174°). The mean final CMS for active abduction was 9.82±1.04 (145°–174°). The mean final CMS for active external rotation was 9.88±0.70. The mean final CMS for active internal rotation was 9.88±0.70. The mean final CMS for strength was 23.88±2.36. Time of union in the studied patients ranged from 8 to 12 weeks, with a mean of 8.25±0.84 weeks. Conclusion Our research data suggest that a relatively new technique using IM Kirschner wire with augmentative anteroinferior short small fragment contoured reconstruction plate fixation is a suitable, reproducible, and effective alternative for surgical fixation of displaced midshaft clavicle fractures in adults and provides reliable functional results.
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A safe percutaneous repair of Achilles tendon rupture p. 215
Emad Zayed, Ahmed Akar, Tarek Abd-El-Ghafar
DOI:10.4103/eoj.eoj_61_17  
Background Although percutaneous repair of Achilles tendon rupture avoids possible complications of open repair as well as conservative treatment, sural nerve injury and re-rupture are the potential complications of percutaneous technique. Here, we describe a surgical technique to minimize the risk of sural nerve injury. Patients and methods This study included 22 patients with complete Achilles tendon rupture treated using the presented percutaneous technique within a mean of 8.5 days (2–28 days) of injury. There were 18 men and four women, with a mean age of 34.7 years (25–48 years). Clinical examination, ankle plain radiograph, and Achilles tendon MRI were done for all patients. All patients were followed up for a mean of 26 months (18–40 months). Results For 22 patients over the period of follow-up, the mean American Orthopedic Foot and Ankle Society Score was 92.81 (82–100). MRI showed satisfactory healing of the Achilles tendon in all patients at 3 months. All patients had a nearly full range of ankle movement recovery at the latest follow-up. The mean time interval from repair to return to work was 7.54 weeks. There was neither sural nerve injury nor re-rupture observed during the follow-up period. Conclusion The presented percutaneous technique is easy and safe, with a low rate of complications. This technique avoids the possible complications of conservative management and open surgery with neither re-rupture nor sural nerve injury, as the percutaneous sutures are not placed in the lateral half of the Achilles tendon proximal to rupture site.
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Ludloff’s diaphyseal osteotomy in the treatment of hallux valgus p. 221
Mostafa Azab, Ahmed El Naggar
DOI:10.4103/eoj.eoj_62_17  
Background Proximal first metatarsal osteotomy combined with distal soft tissue procedure is recommended for the surgical treatment of moderate to severe hallux valgus (HV) deformity with increased intermetatarsal (IM) angle. Materials and methods This is a retrospective study evaluating the results of the Ludloff’s osteotomy, stabilized with two lag screws, for the management of HV cases with HV angle greater than 40° and IM angle greater than 13°. The procedures were undertaken from January 2011 and August 2015 and were done by the authors. The study included 16 female patients. All patients were assessed using the American Orthopedic Foot and Ankle Society Score preoperatively and postoperatively. Results There was a mean correction of HV angle of 30.6° and of IM angle of 7.9°. The average American Orthopedic Foot and Ankle Society Score improved from 48 preoperatively to 92 postoperatively. The average first metatarsal shortening noted was 1.4 mm. One case experienced transfer metatarsalgia. One case had nonunion, which was managed with revision fixation and bone graft. Conclusion Ludloff’s osteotomy is a valuable operative management technique for moderate and severe HV, with low rate of complications.
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A modified technique of reconstruction following excision of the distal ulna for giant cell tumor p. 226
Samir Shaheen, Hashim A Ahmed, Salwa O Makki
DOI:10.4103/eoj.eoj_63_17  
Introduction Giant cell tumors (GCTs), though usually benign, can be aggressive and behave as a high-grade malignant neoplasm. They constitute 4–5% of primary bone tumor. Ulna is an uncommon site for affection. Treatment options range from curettage to radical excision. An effective treatment of GCT of the distal ulna is en-bloc resection, with significant risk of unstable wrist and ulnar stump. Patients and methods We present three patients with distal ulnar GCT, two males and one female. Their ages were 48, 26, and 20 years. After workup diagnosis, the tumor was resected en-bloc with safety margin, and the free ulnar stump was stabilized with one half of the tendon of extensor carpi ulnaris split longitudinally, one half left intact, and the other half detached from its insertion reflected back, threaded through a drill hole in the free ulnar stump redirected back and resutured to the intact half. In all three cases, the same technique was used. The technique was a modification from that described by Goldner and Hayes. Results All the three patients returned to normal activities at 6 weeks, and after a minimum follow-up of 9 months, they remain symptom free with full movements and function in the stable wrist. Conclusion The modification of the old technique has improved the biomechanics and function of the wrist and has stabilized the free ulna stump.
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Total hip arthroplasty for fused hips: clinical and radiological outcome p. 230
Fouad Sadek, Mohamed Abo-Elsoud
DOI:10.4103/eoj.eoj_64_17  
Background Hip fusion restricts most of daily-living activities, and patients request takedown of their fusion hoping to improve gait and function and relieve pain from adjacent joints. Patients and methods We retrospectively reviewed 27 fused hips (22 patients) converted to total hip arthroplasty between 2001 and 2013. A total of 19 male and three female patients had hip fusion for an average of 17 years (range: 6–32), with mean age at conversion of 34 years (range: 22–55). The etiology of fusion was surgical arthrodesis in seven, ankylosing spondylitis in 12, post-traumatic in four, dysplasia in two, and idiopathic in two hips. Posterolateral approach was used in all patients with intraoperative imaging to guide in-situ neck osteotomy and ensure correct positioning of the cup. A total of 18 hips were uncemented, with ceramic-on-ceramic bearing used in 11. Results Patients were followed for a mean of 96 months (range: 36–168). Center of rotation was restored to within 0.5 cm in 24 hips. Limb-length discrepancy averaging 1 cm (range: 0.5–2 cm) was noted in six patients. Harris hip score improved significantly from 46 (range: 20–56) to 78 (range: 42–97) at the last follow-up with a mean flexion range of 85° (65–120°). Abductor lurch with positive Trendelenburg sign was present in eight hips. All but two patients were satisfied with the result. One cup was aseptically loose, making for 96% implant survival. Complications also included two cases of heterotypic ossification, one partial sciatic nerve palsy that later recovered, and one hematoma formation. No dislocations or wound infections were reported. Conclusion Successful takedown of hip fusion is possible with improved function and gait and low complication rate.
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Clinicopathological study of soft tissue tumors and tumorlike conditions around the wrist and the hand p. 236
Adel R Ahmed, Mohamed A El Gawad, Mohamed Amir
DOI:10.4103/eoj.eoj_65_17  
Backgrond Over the past few years, there has been much interest in the study of tumors and tumorlike conditions around the hand and the wrist. Most of the tumorous conditions result from repetitive strain injuries, but other true tumors do exist. Objective The aim of the work was to clarify the nature, incidence, and distribution of soft tissue tumors and tumorous conditions around the wrist and the hand. This study should clarify the correlation between false and true tumors of the hand and also between benign and malignant tumors. Patients and methods This study includes 178 patients with hand and wrist soft tissue swellings of 107 005 patients who received medical care at Orthopaedic Department at El-Hadara University Hospital during 1 year (from November 2006 to the end of October 2007). Thus, patients of this study represent 0.30% of the patients admitted from the outpatient clinic. Results The present study included 178 patients with soft tissue tumors or tumorlike conditions of the hand and wrist. The most common type was tenosynovitis (48%), and the second common type was simple ganglion (41%). The remaining types were Dupuytren’s contracture (4%), giant cell tumor of tendon sheath (4%), chronic synovitis (0.6%), fibroma (0.6%), neuroma (0.6%), dermoid cyst (0.6%), and synovial sarcoma (0.6%). Malignancy constitutes only 0.6% of the present study. The most commonly affected patients were those in the age between 30 and 49 years; however, the age ranged between 10 and 67 years. Overall, 108 (60.6%) patients were females, whereas the remaining 70 (39.4%) were males. Regarding the occupation, housewives (62 patients; 34.8%) were more commonly affected than those in other occupation. The main presentations were interference with function (75 patients; 42%) and unsightly swelling (62 patients; 36%). Conclusion Malignancy constitutes only 0.6% of the present study. History of diabetes was evident in 56 (31.5%) patients. The incidence of recurrence was very high in cases of trigger finger managed by injection of corticosteroid, ganglia in which injection was done as outpatient procedure, or also where transfixation was done or even after excision. Synovial sarcoma did not show recurrence or metastasis. Regarding the site of the lesion, the palmar aspect of the right hand was affected more than the left side. The smallest size of the swellings measured 0.5 cm3 (ganglion on the dorsum of proximal interphalangeal joint), whereas the largest one measured 4 by 7 cm (chronic synovitis).
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Modified Metaizeau technique for displaced radial neck fracture in adults p. 242
Mohamed F Mostafa, Hatem S.A Elgohary
DOI:10.4103/eoj.eoj_66_17  
Background and purpose Few studies have been reported about closed treatment of the radial neck fractures in adults, which most often are found in children. A prospective study was conducted to evaluate the results of modified Metaizeau technique in the management of displaced radial neck fracture in adults. Patients and methods A total of 12 adults with displaced radial neck fractures were selected after excluding patients with combined neck and head fractures and patients younger than 16 years. After closed reduction, two or more K-wires were inserted from the midshaft of radius in a retrograde direction to stabilize the reduced head. The Mayo elbow performance score was used for final clinical assessment. A proposed scale by authors was used for radiological evaluation. Results Using the modified Masson classification, there were nine type IIb and three type IIIb fractures. After a mean follow-up of 38 months (range: 22–60 months), 10 patients were clinically rated excellent and two were good. Two patients had skin irritation and painful bursitis at the buried ends of K-wires; otherwise, no cases of superficial or deep infection, K-wire breakage or migration, and tendon or nerve injury were indicated. Asymptomatic nonunion was detected in two patients. According to the proposed radiological scale, six patients were excellent, four good, and two poor. Conclusion Closed manipulation and retrograde intramedullary pinning is a minimally invasive technique allowing stable fixation of displaced radial neck fractures in adults, with excellent to good outcomes and low complication rate.
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