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   Table of Contents - Current issue
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January-March 2019
Volume 54 | Issue 1
Page Nos. 1-96

Online since Tuesday, September 24, 2019

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ORIGINAL ARTICLES  

Supramalleolar osteotomy for treatment of post-traumatic angular tibial deformities affecting the ankle joint Highly accessed article p. 1
Ahmed Shawkat Rizk, Mahmoud Ibrahim Kandil
DOI:10.4103/eoj.eoj_3_19  
Background Angular deformities of the leg resulting from malunion of distal tibial fractures or physeal arrest in skeletally immature patients are usually associated with ankle and foot pain secondary to disturbed mechanics and joint overload and could inevitably lead − if uncorrected − to degenerative arthritis. This prospective, case series study aims to evaluate the functional and radiological outcomes of supramalleolar corrective osteotomies for treating symptomatic angular deformities of the tibia and to assess its role in preventing or postponing degenerative arthritis of the ankle joint. Patients and methods This study included 18 patients presented with symptomatic angular tibial deformities secondary to malunion of previous distal tibial fractures or post-traumatic physeal arrest. Twelve patients had varus deformities of the ankle, while six patients had valgus deformities. Partial fibulectomy proximal to the level of the planned osteotomy was initially done in all patients; varus deformities were corrected with medial opening-wedge osteotomy and bone grafting with or without tibial fixation, while valgus deformities were corrected with medial closing-wedge osteotomy fixed by plates and screws. The ankle–hindfoot scale of the American Orthopaedic Foot and Ankle Society was used for evaluating the functional results preoperatively and postoperatively. Results The mean age of the patients at presentation was 17.6±5.9 years (ranged from 10 to 44 years). All the osteotomies united in an average duration of 10±4.8 weeks (ranged from 7 to 15 weeks) with no reported surgery-related complications apart from delayed wound healing in two cases. The deformity was clinically improved in all the 18 patients, while the radiological parameters were satisfactory in 16 patients with statistically significant improvement (P<0.001) in mean postoperative tibial articular surface, talar tilt, tibiocrural, and the malalignment angles in the last follow-up compared with the mean preoperative values while two cases showed incomplete correction with residual deformity in the last follow-up. The mean (American Orthopaedic Foot and Ankle Society) ankle–hindfoot score was markedly improved from 43.8±7.5 preoperatively to 75.6±9.4 in the last follow-up indicating a statistically significant improvement (P<0.001). No progressive joint narrowing was detected in any of the studied cases throughout the follow-up period that extended for with a mean duration of 5.5±2.8 years. Conclusion Supramalleolar osteotomy is an effective procedure for treating symptomatic angular deformities of the tibia. Supramalleolar osteotomies − not only − correct the deformity and improve the functional outcome, but also represent a joint-preserving surgery protecting the articular cartilage through correcting the mechanics and equally redistributing the joint loads thus preventing progressive degenerative arthritis.
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Scarf osteotomy in severe hallux valgus deformity p. 15
Ahmed H Waly, Mohamed G Morsy
DOI:10.4103/eoj.eoj_6_19  
Context Hallux valgus is one of the most common forefoot deformities. Multiple operative techniques are described for the correction of this deformity. Diaphyseal osteotomies like scarf osteotomy proved to improve from moderate to severe degrees. Aims The aim of this study was to evaluate the results of scarf osteotomy over a minimum 1-year follow-up for patients with severe hallux valgus. Settings and design A case series study held at Alexandria University, El-Hadra University Hospital. Patients and methods Forty-one osteotomies in 37 patients were done from February 2012 to October 2014. The mean follow-up was 14 months (12–18 months). The mean intermetatarsal angle was 20.4°. The mean hallux valgus angle was 43.5°. The patients were evaluated using the American Orthopaedic Foot and Ankle Society score. Results The average follow-up was 1 year. All cases achieved radiological union at an average of 2.5 months. The mean AOFAS score improved from 58 to 95 points. The mean intermetatarsal angle improved from 20.4° to 12.1°. Two patients reported postoperative stiffness of the metatarsophalangeal joint. There were no cases of pseudarthrosis or osteonecrosis of the metatarsal head. Conclusion Scarf osteotomy for moderate to severe degrees of hallux valgus had very good results over 1 year follow-up with a low complication rate.
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Wrist arthroscopy and MRI for the evaluation of scapholunate and lunotriquetral ligaments tear in Kienbock’s disease p. 21
Haytham Abdel-Moneim
DOI:10.4103/eoj.eoj_7_19  
Purpose The principal intrinsic wrist interosseous ligaments of the wrist are the scapholunate ligament (SLL) and the lunotriquetral ligament (LTL). Injuries to the wrist ligaments are common and can lead to chronic wrist pain. To our knowledge, the incidence of associated intrinsic wrist ligament pathology in Kienbock’s disease has not been previously described. Herein, we used wrist arthroscopy and MRI for the evaluation of SLL and LTL injury in 40 patients with Kienbock’s disease. Patient and methods The study was based on 40 patients with Kienbock’s disease (stages II, IIIa, and IIIb), 17 women and 23 men. Their age ranged from 13 to 46 years (mean, 31 years and 6 months). All patients underwent MRI followed by wrist arthroscopy for the diagnosis of SLL and/or LTL tear. Results The incidence of isolated SLL tear and combined SLL and LTL tear of the 40 patients with Kienbock’s disease included in this study was 27.5 and 7.5% as evaluated with MRI, respectively, and 35 and 15% as evaluated with wrist arthroscopy, respectively. According to Geissler arthroscopic classification, 75% of SLL injury were of grade I, while 25% were of grade III. Moreover, 50% of the patients with ligamentous injury reported a history of trauma with a mean of 4.4 months interval between the trauma and first presentation. Conclusion This study had proved that Kienbock’s disease is associated with tear of SLL and/or LTL in a significant number of patients among the study group. However, it was difficult to distinguish between the degenerative and traumatic ligament tears.
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Monofocal and bifocal management of infected femoral nonunion by an Ilizarov fixator: midterm results p. 26
Abdel-Salam Abdelaleem Ahmed
DOI:10.4103/eoj.eoj_9_19  
Introduction Infected nonunion of the femur with associated bone loss represents one of the most difficult problems in orthopedic practice. The purpose of this study was to evaluate the midterm treatment outcome of the Ilizarov technique in infected nonunion of the femur. Patients and methods This is a retrospective study of 24 patients with infected nonunion of the femur treated by an Ilizarov external fixator. The mean age of the patients was 37.71 years. The study included 19 men and five women. Eighteen (75%) patients had draining sinuses while six (25%) were quiescent. Four cases had associated deformity, and 18 patients had preoperative shortening with a range of 1–6 cm. Failed previous surgeries ranged from two to seven times and the mean duration of nonunion was 28.75 months. Results Monofocal technique was used in eight patients, and bifocal technique was used in 16 patients. All fracture nonunions were fully united with a mean fixator period of 12.75 months. The average follow-up duration was 50.88 months. Persistent infection occurred in two cases after frame removal and managed by further debridement. Two cases had residual valgus deformity and two other patients had 2.5 cm shortening. According to the Association for the Study and Application of the Method of Ilizarov criteria, the bone results were evaluated as excellent in 19 patients, good in four patients, and fair in one patient. The functional results were excellent in 18 patients and good in six patients. Conclusion In spite of the several problems, obstacles, and complications that may occur with the long treatment course, the Ilizarov fixator was effective in treating the difficult disabling problem of infected nonunion of the femur.
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Resection arthroplasty for treatment of nonunion and avascular necrosis of the distal scaphoid p. 34
Ahmed O Youssef, Ahmed S Abdel-Fattah
DOI:10.4103/eoj.eoj_10_19  
Background Posttraumatic osteonecrosis of distal pole of scaphoid is extremely rare, with only few reported cases so far. The purpose of this study was to evaluate the clinical and radiographic results of treatment of distal scaphoid nonunion and avascular necrosis with resection arthroplasty in adult patients. Patients and methods From 2008 to 2013, seven patients presented to the authors for treatment of nonunion and avascular necrosis of the distal part of the scaphoid following distal pole fracture. Pain was evaluated by means of the visual analog scale. The time to return to previous activities and work status were documented. Wrist function was measured according to the Mayo Modified Wrist Score. Carpal height index (Nattrass modification) and radiolunate angle were recorded. Results Follow-up period ranged from 24 to 60 months. Three patients had an excellent result (43%), and four had a good result (57%). There is significant postoperative improvement of pain, range of wrist motion, and Mayo Modified Wrist Score. All patients returned to their previous occupations within 2 months. There were statistically significant increases in the radiolunate angle and no significant decrease in Nattrass carpal height. Conclusion Resection of the distal scaphoid appears to be a valid technique and to constitute an alternative to vascularized bone graft or limited intercarpal arthrodesis for the treatment of scaphoid nonunion with avascular necrosis of distal pole. Level of evidence: level IV, case series.
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Treatment of femoral and tibial fractures aseptic nonunion after intramedullary nailing by plate augmentation and bone graft p. 40
Ahmed H Yousry
DOI:10.4103/eoj.eoj_12_19  
Objective Intramedullary nailing is widely used in the treatment of femoral and tibial fractures. But some patients suffer from nonunion after treatment by intramedullary nails. This paper investigates the methods and effects of augmentative compression plate and bone graft in the treatment of femoral and tibial nonunion after intramedullary nailing. Patients and methods Twenty patients treated between July 2009 and December 2014 were included in this retrospective study. The nonunions included 12 femora and 8 tibiae. The duration of nonunion ranged from 6 to 28 months. There were 7 women and 13 men with a mean age of 40 years (range, 21–64 years). Broad and narrow dynamic compression plating combined with bone grafting was the procedure chosen to treat every cases of femoral and tibial nonunion, respectively, in this series. Results The mean follow-up duration was 31.5 months (range, 10–52 months). All the femoral and tibial fractures achieved radiological union. The mean time to union was 20.8 months (range, 12–36 months). One patient had refracture of femoral shaft fracture after removal of interlocking nail and broad dynamic compression plate with refixation by interlocking nail and broad dynamic compression plate again with full union after 18 weeks. Apart from that case of refracture after hardware removal there were no serious complications such as infection, breaking or loosening of the plate and screws during the follow-up period. Conclusion Augmentation plating with bone grafting is a highly effective treatment for aseptic nonunion of the femur and tibia after intramedullary nailing.
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Outcomes of two minimally invasive decompressive techniques for degenerative lumbar spinal stenosis p. 45
Mohamed Hussein, Amr Eladawy, Tarek A El-Hewala
DOI:10.4103/eoj.eoj_13_19  
Background Minimally invasive decompressive procedures have evolved into the modern standard surgical solution for degenerative lumbar spinal stenosis (DLSS) patients, such as the bilateral laminotomy and the unilateral laminotomy for bilateral decompression (ULBD) that is characterized by ipsilateral and contralateral microdecompression under the midline posterior structures and has been successfully used with proven efficacy. Objective To compare the effect of the size of the skin incision and the method of handling the multifidus muscle on the clinical outcomes of the endoscopic laminotomy versus the standard microscopic laminotomy for DLSS. Patients and methods Primary outcome data included the numerical rating scale for back and leg symptoms and Oswestry Disability Index to quantify pain and disability, respectively. Secondary outcome data included operative time, blood loss, and modified Mcnab criteria. Results At the end of the follow-up period, the rate of successful outcome of the endoscopic group was 87.2 and 77.8% for the control group after initial improvement by 87% at 3-month follow-up. The incidence of complications was 13% in both groups. Conclusion For DLSS, the endoscopic ULBD in experienced hands would have a better outcome than the microscopic ULBD regarding the postoperative clinical outcome and patient satisfaction.
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Percutaneous cross-pinning versus two lateral entry pinning in Gartland type III pediatric supracondylar humerus fractures p. 52
Hossam M.A Abubeih, Wael El-Adly, Kamal El-Gaafary, Hatem Bakr
DOI:10.4103/eoj.eoj_15_19  
Background Supracondylar humerus fracture is the most common elbow fracture in children aged 5–7 years, affecting boys more than girls and the majority of fractures are of the extension type. These fractures are usually associated with a number of complications including neurovascular injuries, malunion, and elbow stiffness. Gartland type III fractures are usually treated by closed reduction and percutaneous pinning. Patients and methods A prospective study was carried out on children with Gartland type III extension-type supracondylar humerus fractures. The patients were randomized to undergo fixation either with crossed pinning (group A) or two lateral pinning (group B). We compared both groups with regard to their passive elbow range of motion, Flynn’s criteria, Baumann’s angle, change in Baumann’s angle, and Skaggs method of grading of loss of reduction and complications. Results Group A included 33 patients with a mean age of 5.4 years and group B included 34 patients with a mean age of 4.9 years. Group B had a statistically significant shorter operative time and radiation time. At final follow-up, there were no statistically significant differences between group A and group B with respect to the average Baumann’s angle, change in the Baumann angle, range of elbow motion, Flynn’s grade, or Skaggs criteria. There were no cases of iatrogenic ulnar nerve injury in both groups. Conclusion If a standardized operative technique is followed in each method, then the result of both methods will be same in terms of safety and efficacy. Orthopedic surgeons treating unstable pediatric supracondylar humerus fractures should be familiar with both pinning techniqus.
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Post-ponseti bracing compliance in Egyptian population during treatment of idiopathic talipes equinovarus p. 62
Elsayed A.E Abdullah, Amin A.Y Ahmed
DOI:10.4103/eoj.eoj_20_19  
Background Several factors may play a role in influencing family acceptance of brace protocol after successful initial correction of talipes equinovarus by Ponseti method. Patients and methods A total of 40 children presented with relapsed sixty idiopathic talipes equinovarus were included. Their age ranged from 8 to 24 months, with a mean of 16 months. Twenty patients (40 clubfeet) (66.6%) were bilaterally affected, and 20 patients (20 club feet) (33.3%) were unilaterally affected. The patients comprised 25 (60%) boys and 15 (40%) girls. Pirani score was used to assess the relapse and severity. Several factors affecting bracing compliance in Egyptian population were studied and analyzed. Results The number of children per family, the ability of one parent alone to apply the brace, residence of parents, the baby’s compliance, bracing hour compliance, and parents get fed up early from using the brace had statistically significant relation with brace noncompliance. Conclusion Proper instructions, education, and encouragement to the parents in the proper use of the postcorrective brace are crucial factors for success of clubfoot treatment by Ponseti method.
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Staged bone grafting using the induced membrane technique in the management of infected nonunion of long bones p. 67
Mohamed Nabil
DOI:10.4103/eoj.eoj_4_19  
Introduction The treatment of bone defect is a demanding matter especially in the presence of infected nonunion. The technique of bone grafting within induced membranes offers a feasible option with nominal complications. Patients and methods In the time period from September 2010 until October 2012, patients who came to the orthopedic emergency in Suez Canal University Hospitals with posttraumatic bone defects and infected nonunion were involved in the study. We used the induced membrane technique and Ilizarov external fixation in all included patients. Results A total of 11 consecutive patients were identified within the time period. The length of bone defect ranged from 2 to 7 cm. All patients demonstrated radiographic evidence of union over the defect after treatment with a mean duration of 88.4 days (84–96 days) from the bone grafting surgery till the appearance of radiographic consolidation. No complication was encountered in this series. Conclusion Masquelet technique is effective in the treatment of cases of infected nonunion of long bones.
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Management of open complex tibial plateau fractures by Ilizarov fixator: average follow-up of 8.5 years p. 72
Abdel-Salam A Ahmed
DOI:10.4103/eoj.eoj_5_19  
Introduction Open tibial plateau fractures are associated with significant soft tissue injuries which increase the risks of complications and their management is highly challenging. Ilizarov external circular fixation is an ideal method of treatment when extensive soft tissue dissection and internal fixation are contraindicated. This retrospective study aimed to evaluate the mid-term results of managing open complex tibial plateau fractures with Ilizarov fixator. Patients and methods The study included 27 patients with open tibial plateau fractures (Schatzker types V and VI) with a mean age of 40.56 years. They included 17 men and 10 women. Sixteen fractures were of open type III-A and 11 were type III-B according to the Gustilo classification. Seven cases had associated injuries. Five patients had previous temporary spanning external fixation. Three patients were diabetics. Above knee frame extension was done in 14 cases. Assisted wound closure by the frame was done in three cases. Results All fractures were fully united with a mean fixator period of 18.37 weeks. The average follow-up duration was 8.52 years. No patient developed a deep infection. According to the ASAMI score, the results were evaluated as excellent in nine patients, good in 14 patients, and fair in four patients. The overall result was judged as satisfactory by all patients. Conclusion The treatment of complex tibial plateau fractures with the Ilizarov fixator is a safe, versatile, and an effective treatment option, and produces good functional results. It also allows early full weight-bearing and good rehabilitation.
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Reliability of specific clinical tests and MRI in the diagnosis of rotator cuff tears in comparison with arthroscopy p. 79
Haytham Abdel-Moneim
DOI:10.4103/eoj.eoj_8_19  
Purpose Imaging for rotator cuff injury may provide false-positive and false-negative results. Moreover, many studies have questioned both the accuracy and reliability of orthopedic special tests of the shoulder. Herein, this study evaluates the sensitivity, specificity, and accuracy of specific clinical tests and MRI of rotator cuff tears in relation to arthroscopic findings. Patients and methods This study was conducted on 45 patients (27 males and 18 females), who were diagnosed clinically to have rotator cuff tears and/or biceps tendon pathology. Mean patients’ age was 26.18 years old. The special clinical tests for rotator cuff tears included in this study were Jobe’s test for supraspinatus tear, drop arm test for infraspinatus tear, lift-off test for subscapularis tear, and speed test for biceps tendinitis. Thereafter, all patients underwent radiographs, MRI, and shoulder arthroscopy. Results Jobe’s test showed sensitivity, specificity, and accuracy of 85.7, 75, and 80.4%, respectively, whereas those of MRI were 85.7, 87.5, and 86.6%, respectively. Drop arm test showed sensitivity, specificity, and accuracy of 100, 69.2, and 84.6%, respectively, whereas those of MRI were 100% for each. Lift-off test showed sensitivity, specificity, and accuracy of 50, 76.9, and 63.5%, respectively, whereas those of MRI were 100, 92.3, and 96.2%, respectively. Speed test showed 80% for each of sensitivity, specificity, and accuracy, whereas those of MRI were 80, 100, and 90%, respectively. Conclusion We could conclude that Jobe’s test and MRI had good correlation with arthroscopy in the diagnosis of supraspinatus tear. Drop arm test had weak correlation whereas MRI had good correlation with arthroscopy in the diagnosis of infraspinatus tear. Lift-off test slightly overestimated the diagnosis of subscapularis tear, whereas MRI findings were close to those of arthroscopy. Speed test and MRI correlated fairly well with arthroscopy in the diagnosis of biceps tendon pathology.
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Surgical correction of congenital radioulnar synostosis: a protocol of treatment p. 87
Tarek H Abdelaziz, Shady S Elbeshry
DOI:10.4103/eoj.eoj_18_19  
Purpose The aim of this study is to establish a protocol of treatment with clear indications of surgical intervention in congenital radioulnar synostosis (CRUS) and to assess the results of this protocol by performing the osteotomy through the synostosis mass. Patients and methods A total of 20 forearms with CRUS in 15 patients underwent surgical correction through an osteotomy of the synostosis mass according to our protocol. The mean age of the patients at surgery was 6.5 years. The synostosis mass was divided, and the osteotomy was fixed using an intramedullary wire. The average duration of follow-up was 4.2 years (3–6 years). Results The desired correction was achieved intraoperatively in all patients. The mean preoperative fixed pronation was 80.7° in the dominant limb, with a mean improvement of 40.7°, and 29.1° in the nondominant limb, with a mean improvement of 49.1°. All patients were extremely satisfied with the result of surgery regarding the cosmetic improvement as well as performing activities of daily living comfortably. Conclusion Correction of CRUS by osteotomy through the synostosis mass is a safe, easy, and efficient technique that markedly improves the child’s function. The clear guidelines set in this study on when to intervene, which forearm to correct, and how much derotation to perform help clarify confusion in literature. Because of loss of correction observed in all forearms, we recommend overcorrection by 10° than initially planned according to the protocol.
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Early results of surgically treated patellar osteochondral fracture following patellar dislocation in adolescents: a case series of ten patients p. 90
Osama Gamal, Ahmed Shams
DOI:10.4103/eoj.eoj_29_19  
Background Adolescents having knee ligaments laxity are more predisposed to patellar dislocation. Associated patellar osteochondral fractures (OCFs) denote a main complication. Many surgical options have been described to treat such injury. This study aimed to assess the early results of operated patellar OCFs following traumatic patellar dislocation in adolescents. Patients and methods Ten adolescent patients diagnosed to have patellar OCFs following traumatic patellar dislocation were surgically treated. After employing an initial arthroscopic examination, if the fragment was big enough, it was fixed by headless titanium compression screws, or else, the loose body was removed and the base was managed with microfracture. Preoperatively and postoperatively, patients evaluation was carried out using the visual analogue scale for pain and postoperatively via the International Knee Documentation Committee score. Results The mean follow-up was 24 months. Five of 10 patients underwent fixation, whereas the other five underwent loose fragments removal with microfracture. The median of visual analogue scale for pain scores demonstrated highly significant improvement (from 8.8 preoperative to 1.55 postoperative, P=0.002). The median International Knee Documentation Committee scores of the nonfixation and fixation group were 85.1 and 74.7, respectively (P=0.144). Conclusion According to this study, the surgical treatment for patellar OCFs following traumatic patellar dislocation in adolescents using headless titanium compression screws or excision and microfracture gave significant improvement. Studies with more patients’ numbers and longer follow ups are still necessary to properly assess the benefits of such management protocol. Level of Evidence: IV.
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