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   Table of Contents - Current issue
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April-June 2017
Volume 52 | Issue 2
Page Nos. 79-167

Online since Thursday, November 23, 2017

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ORIGINAL ARTICLES  

Diagnosis and á la carte treatment of intra-articular painful shoulder lesions after single nondislocating traumatic event to the shoulder Highly accessed article p. 79
Roshdy M El Sllab, Naser M Selim
DOI:10.4103/eoj.eoj_22_17  
Background There is an intra-articular forgotten and sometimes hidden pathology that leads to post-traumatic chronic shoulder pain. Aim The aim of this study was to define the intra-articular pathology associated with chronic shoulder pain after nondislocating traumatic event and to evaluate the results of á la carte treatment of these conditions. Patients and methods Between April 2009 and November 2010, 100 patients were presented to us at the outpatient clinic in Mansoura University Hospital with shoulder pain after traumatic event. Sixty-eight patients were male and 32 patients were female. Their average age was 40.8 years (range: 27–55). Clinical examination and plain radiograph were performed for all patients. Conservative treatment was started; 80 patients had improved and 20 male patients did not improve, to whom MRI and shoulder arthroscopy and á la carte management according to the confronted intra-articular lesion(s) were performed. Results The results were assessed according to the University of California at Los Angeles shoulder score. All patients were satisfied with the results of treatment; 16 patients had excellent results, four patients had good results (>27 points), and no one had fair or poor results (<27 points) according to UCLA shoulder score. Conclusion Chondrolabral lesions, subscapularis tears, and long head of the biceps tendon tears and/or instability are important causes of shoulder pain after nondislocating shoulder trauma. Shoulder arthroscopy is both diagnostic and therapeutic for these lesions. Á la carte management including debridement, repair (arthroscopic or open), tenotomy, and capsular plication according to the confronted intra-articular lesion(s) gives excellent results in 80% of patients according to ULCA sore.
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Results of treatment of terrible triad injury of the elbow Highly accessed article p. 85
Aly Mohamedean
DOI:10.4103/eoj.eoj_23_17  
Background/aim A complex elbow dislocation with associated radial head and coronoid process fractures was named the terrible triad by Hotchkiss because of historically poor outcomes. This study aimed at assessing the results and functional outcome of treatment of terrible triad injuries of the elbow. Patients and methods Between 2010 and early 2013, 11 patients suffering from terrible triad injuries of the elbow were treated at Assiut University Hospitals; eight were male individuals and three were female individuals with the mean age of 43 years (range: 26–70 years). The right elbow was injured in five, and the left was injured in six patients. The radial head was replaced by a prosthesis in five and treated by internal fixation in five patients, whereas conservative treatment was decided only in one patient; the coronoid process was fixed by screws in four, whereas four were treated by suturing of the anterior capsule and were treated conservatively. Results The mean follow-up was 13.3 months (range: 6–30 months) According to the Mayo Elbow Performance Score, three patients had excellent outcome, seven had good outcome, whereas only one had fair outcome. Conclusion Prompt surgical attention with a systematic approach to restore anatomy and provide sufficient stability to allow early motion are the key factors for a successful outcome.
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Compression distraction for the management of complex femoral nonunion Highly accessed article p. 91
Mootaz F Thakeb
DOI:10.4103/eoj.eoj_24_17  
Background Complex nonunion is defined as established nonunion of at least 6 months’ duration with one of the following criteria: infection, bone defect or shortening of more than 4 cm, deformity, and an attempt to achieve union that failed to heal after at least one supplementary surgical intervention such as bone graft. Internal fixation methods are limited in their ability to deal with infection, bone defect, or shortening, and they involve extensive dissection around the fracture site for realignment of severe deformity. The Ilizarov method of compression distraction is particularly valuable in these complex cases. Patients and methods Between January 2004 and December 2010, 52 patients were treated for complex femoral nonunion using Ilizarov circular fixator. A monofocal treatment confined to the nonunion site (simple stabilization of the nonunion with compression and then stimulation of healing by distraction) was used in 23 patients; four of them had infected nonunion. Bifocal compression distraction technique with corticotomy (compression of the nonunion with distraction at the corticotomy) was used in 29 patients; 10 of them were infected. Results Bone healing was identified radiologically as callus bridging three cortices in 48 patients after a mean of 6.3 (4–12) months. Twenty patients of 23 treated using the monofocal technique had a mean healing time of 5.6 (4–9) months. Totally, 28 patients of 29 treated with bifocal compression distraction had healing after a mean of 6.8 (4–12) months. Using the criteria proposed by Paley and Maar, 30 patients had excellent functional results, 15 patients had good results, two had fair results, and five had poor results. The bony results were excellent in 35 patients, good in eight, fair in four, and poor in five. Conclusion Both monofocal and bifocal compression distraction techniques are effective in the treatment of complex femoral nonunion. Less treatment time is achieved for monofocal cases (mean: 5.6 months). In bifocal cases, acute shortening and lengthening has a much lower treatment time (mean: 5.5 months) compared with bone transport (mean: 9.3 months) and should be used when possible.
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Salvage of dislocated hip and knee during limb lengthening for congenital femoral deficiency p. 100
Mahmoud A El-Rosasy, Mostafa A Ayoub
DOI:10.4103/eoj.eoj_25_17  
Background The articular and soft tissue deficiencies associated with congenital femoral deficiency are reported to predispose to joint dislocation during limb lengthening, which would negate the value of limb lengthening. Patients and methods The cases of 17 children who suffered hip and/or knee dislocation as a result of femoral lengthening for congenital femoral deficiency of Paley’s classification type 1 and 2a were included. Their ages ranged from 4.5 to 13 years (average: 6.8 years). The average lengthening achieved at the time of diagnosis of the dislocation was 5.7±1.048 cm (range: 4.5–8 cm). Hip dislocation only was present in seven (41%) cases, knee dislocation only in six (35%) cases, and combined dislocation in four (24%) cases. Results A center-edge angle of Wiberg less than 22° had a highly significant effect on hip dislocation (P=0.001), and all knee dislocations were associated with a hypoplastic lateral femoral condyle. Both joint dislocations were common when the child had a center-edge angle of 15–20° together with a hypoplastic lateral femoral condyle. Discussion and conclusion Hip dislocations were managed with soft tissue release and pericapsular acetabuloplasty with satisfactory Mckay’s hip scores in all cases. Knee dislocations were reduced and stabilized by means of extra-articular ligament reconstruction with satisfactory Judet’s knee criteria in 82% of cases.
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Evaluation of combined high tibial osteotomy and ‎ilizarov external fixator in the treatment of late-onset tibia ‎var p. 109
Mohammed A Meselhy
DOI:10.4103/eoj.eoj_26_17  
Purpose The purpose of this study was to evaluate the results of combined high tibial osteotomy in combination with gradual translation by ilizarov external fixator in the treatment of late-onset tibia vara. Patients and methods A total of 23 patients with a diagnosis of late-onset tibia vara, 16 (69.6%) male and seven (30.4%) female, were included in this study; in 14 (60.9%) patients the deformity was on the right side, whereas in nine (39.1%) patients the deformity was on the left side. The etiology was Blount’s disease in all patients. The mean age of the patients was 23 years, ranging from 13 to 35 years, and the mean preoperative mechanical axis deviation was 84.39 mm. The mean preoperative medial posterior tibial angle was 61.17°, whereas the mean preoperative proximal posterior tibial angle was 63.09°. Results The mean duration of external fixator application was 124.6 days, ranging from 90 to 170 days; the mean postoperative medial proximal tibial angle was 86.22°, with a P value of 0.001; the mean postoperative proximal posterior tibial angle was 79.74°, with a P value of 0.001; and the mean postoperative mechanical axis deviation was 10.7 mm, with a P value of 0.001. Residual deformity was present in three (13%) cases, ranging from 5 to 18°; no neurovascular complication was seen in both early and late postoperative periods; and limb length discrepancy was present in five (21.7%) cases, which was between 1.5 and 2.7 cm. Conclusion High tibial osteotomy in combination with gradual correction by ilizarov is safe and effective in the management of late-onset tibia vara.
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Evaluation of ilizarov role in correction of relapsed clubfoot p. 115
Khaled S Salama, Moawed F El-Adawy, Sam S Samaan, Ibrahim I Rakha
DOI:10.4103/eoj.eoj_27_17  
Background About 20% of operated clubfeet develop recurrence or show a marked residual deformity. The failure of concentric reduction at the time of initial surgery has to be considered as a main factor. Residual forefoot adduction and supination are the most common persistent deformities. Methods of classification, assessment, and treatment of this problem were advanced over many years. Conventional management techniques tend to have many disadvantages including neurovascular injury, soft tissue problems, and a shortened foot. Patients and methods We present our experience in correction of 20 relapsed clubfeet deformities managed by gradual correction using Ilizarov frame without soft tissue release or bony procedures. The age at the time of operation ranged from 3 to 7 years with a mean of 4.4±1.31 years. The duration of use of fixators for correction ranged from 6 to 8 weeks with a mean of 7.09±0.37 weeks. This was followed by 6 weeks of leg cast. The patient was followed up with the use of custom-made shoes. The follow-up period ranged from 24 to 31 months, with a mean of 27.68±1.91 months. Results In all, 8 ft (40%) achieved excellent results, 6 ft (30%) achieved good results, 4 ft (20%) achieved fair results, and 2 ft (10%) achieved poor results. Complications were reported as pin tract infection in 6 ft, residual forefoot adduction in 4 ft, joint stiffness in 4 ft, toe flexion deformity in 2 ft, and radiological osteopenia in 2 ft. Conclusion The Ilizarov technique in relapsed complex foot deformity correction enables correction of individual components of the deformity at rates that may be tailored to achieve accurate three-dimensional control using an easy-to-handle, light, cheap, and simple frame.
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Subcapital reorientation for moderate and severe slipped capital femoral epiphysis: early results of Ain Shams University Hospitals p. 122
Mahmoud A Mahran, Mohamed A.M Eid
DOI:10.4103/eoj.eoj_28_17  
Background Subcapital reorientation for severe slipped capital femoral epiphysis offers the double benefit of immediate restoration of range of motion (ROM), limb length discrepancy (LLD), and long-term hip preservation from premature osteoarthrosis. Patients and methods Modified Dunn’s technique through safe surgical hip dislocation was performed in 12 adolescents who presented with moderate-to-severe slipped capital femoral epiphysis. There were 10 males and only two females, with a mean age of 15 years. The mean Southwick’s slip angle was 47°. Only two slips were clinically unstable. Results After a mean follow-up of 23 months, the mean α angle measured 37°, and the mean slip angle decreased to 4.7°. The mean hip flexion range was 104°; the mean internal rotation in flexion was 33°; and the mean external rotation in flexion was 34°. The mean Harris hip score at the latest follow-up was 99.6. None of the cases developed chondrolysis or osteonecrosis. Conclusion It has been a long-standing orthopedic myth, believed by many surgeons, that the capital epiphysis cannot be realigned for fear of avascular necrosis. On the basis of the present study, we believe that subcapital reorientation through safe surgical hip dislocation approach restores close to normal the proximal femoral anatomy, and thus, presumably, would offer good long-term outcomes for a condition that can have serious lifelong consequences on young adults.
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Anterior stabilization of sacroiliac disruption through transiliac osteotomy p. 129
Yasser S Hannout, Mohamed E Habib, El Sayed Morsi
DOI:10.4103/eoj.eoj_29_17  
Background Sacroiliac joint diastases from high-energy trauma are always complicated by pain and disability. Open reduction and anterior stabilization with a plate are biomechanically advanced because of direct reduction and stabilization. We report our experience of managing 15 patients with sacroiliac disruption by anterior double plates. The purpose of this study was to evaluate the effectiveness of anterior pelvic plating for these complicated fractures. Patients and methods This study included 15 patients who sustained sacroiliac disruption from January 2008 to March 2012 at Menoufia University Hospital. All patients were treated by anterior double plates through an anterolateral approach with transiliac osteotomy. All patients were males. Results The average age was 34 years with a range of 20–49 years. The mean follow-up period was 20 months with a range of 12–36 months. The average healing period was 16 weeks. The clinical results according to the Coles pelvic score revealed 12 cases of satisfactory (five of excellent and seven of good) and three cases of unsatisfactory results (two fair and one poor). Conclusion Posterior injuries, especially sacroiliac disruptions, affect the long-term outcome significantly; therefore, an anterior approach would allow adequate exploration and the reduction can be confirmed. Double plates allow rigid fixation. Bone-to-bone healing of osteotomy revealed decreased risk of wound complications.
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Mini approach and percutaneous fixation of intra-articular calcaneous fractures p. 134
Taher A Eid, Ahmed Shams, Mohamed El-Sawy
DOI:10.4103/eoj.eoj_30_17  
Introduction Intra-articular calcaneous fracture is one of the most aggravating fractures if not properly managed. Open reduction and internal fixation are associated with high incidence of postoperative soft-tissue complication. Closed reduction and percutaneous fixation had a high incidence of postoperative subtalar osteoarthritis due to an improper reduction of the articular surface, and therefore the mini approach was used for restoring the articular surface and for fixing the fracture by K-wires. Patients and methods A total of 22 patients with 27 intra-articular calcaneous fractures from March 2009 to July 2012 were treated at Menoufia University Hospital. All patients were treated with the miniapproach and percutaneous K-wire fixation for intra-articular calcaneous fractures. The patient sample included 15 males and seven females. In 14 patients, the fractures were caused by falling from heights, whereas in eight patients the cause was road traffic accidents. Five patients had bilateral fractures. According to Sander’s Classification, 13 fractures were of type II, 10 were type III, and four were type VI. Results The average age was 29 years with a range of 21–55 years. The mean follow-up period was 16 months with a range of 12–36 months. The average union period of fractures was 12 weeks, ranging from 10 to 16 weeks. Seven patients had wedge fracture of the dorsolumbar spine but without neurological manifestation. The average operative time was 53 min with a range of 37–109 min. The clinical results according to the Maryland foot score revealed 21 (78%) cases with satisfactory scores (eight excellent and 13 good) and six cases (22%) with unsatisfactory results (four moderate and two poor). Conclusion Percutaneous treatment of fracture calcaneous minimizes soft-tissue complications and postoperative scar formation, which improves functional outcome. The miniapproach for elevation of depressed posterior facet restores joint congruity and decreases late subtalar arthritis.
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Posterior pelvic plating in the treatment of tile type C unstable pelvic injuries: a prospective study p. 139
Ahmed El-Bakoury, Abdullah Hammad
DOI:10.4103/eoj.eoj_31_17  
Introduction Unstable pelvic ring disruptions result from high-energy trauma and are often associated with multiple concomitant injuries. Internal fixation has become the preferred treatment for unstable posterior pelvic ring injuries. Several methods of fixation of posterior pelvic injuries have been described, including anterior pelvic plating, posterior sacroiliac plating, lumbopelvic fixation, and percutaneous fixation with iliosacral screws. Aim The aim of this study was to report on the clinical and radiological results of plate osteosynthesis for fixing posterior pelvic injuries in Tile’s C completely unstable pelvic ring injuries. Patients and methods This study involved 21 patients with Tile type C pelvic injuries who had their posterior injuries fixed by plate osteosynthesis. The mean duration of postoperative follow-up was 25.29±9.93 (13–48) months. The clinical outcome was assessed with postoperative Majeed’s score and the rate of postoperative complications. The radiological outcome was assessed through the measurement of posterior displacement as per the method of Matta and Tornetta. Results The mean±SD postoperative Majeed score was 76.57±11.21. There was a statistically significant improvement in the postoperative vertical displacement of the posterior injury (P<0.001). The incidence of postoperative complications was 38.1%. Conclusion Pelvic plating is an effective procedure in the management of completely unstable posterior pelvic ring injuries. The treatment of these complex injuries is associated with a relatively high incidence of postoperative complications.
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Vertebroplasty versus kyphoplasty: a comparative study of safety and cost-effectiveness and tips to improve outcomes of vertebroplasty p. 144
Ahmed M Morsi, Amr A Abdelrahman, Mohamed F Khattab
DOI:10.4103/eoj.eoj_32_17  
Background Vertebroplasty (VP) has been found to be effective in treating persistent pain resulting from osteoporotic vertebral fractures. It brings rapid and significant pain relief but shows high rates of cement leakage (CL) and does not restore lost vertebral height. Kyphoplasty (KP) can partially restore vertebral height with minimal risk for CL but is very expensive, time consuming, and exposes surgeons to higher radiation risk. Patients and methods Thirty-one patients who underwent either VP or KP were included in the study. VP technique was refined to minimize complications and maximize outcome. VP was performed unipedicularly, whereas KP was performed usually bipedicularly (except for two patients). Pain relief and functional outcome were evaluated using the Visual Analogue Scale and the Oswestry Disability Index. Radiographs were used to evaluate CL, vertebral height restoration, and cemented vertebral body fraction. Results Twenty patients underwent VP and 11 patients underwent KP. The mean duration was 45.5 and 70.9 min for VP and KP, respectively. The mean number of C-arm images was 46 and 163 images for VP and KP, respectively. The mean reduction in Visual Analogue Scale was 7.2 and 7.6 points for VP and KP, respectively. The mean reduction in the Oswestry Disability Index was 66.3 and 72.1 points for VP and KP, respectively. The mean regain in vertebral height was 19.7 and 42.5% after VP and KP, respectively. Symptomatic adjacent level fractures occurred in two VP patients and one KP patient. Conclusion KP is more effective compared with VP in terms of vertebral height restoration, but is very expensive, time consuming, and entails more radiation exposure to surgeons compared with VP. Both techniques are equally effective as regards pain relief. CL can be minimized by refining VP technique.
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Incidence of ligamentum flavum hypertrophy in patients with spinal stenosis p. 150
Munir Saadeddin
DOI:10.4103/eoj.eoj_35_17  
Background Spinal stenosis is most common in the cervical and lumbar regions. It is often a consequence of multifactorial acquired degenerative changes. Ligamentum flavum hypertrophy (LFH) is an important known cause, although its actual incidence is less well established. This study was therefore undertaken to evaluate its incidence at a tertiary referral center. Patients and methods A retrospective review of 98 patients with a radiological diagnosis of spinal stenosis was performed. Demographic data were also collected. Results Totally, 24 (24.5%) cases of LFH were identified. The majority of these (17 cases; 70.8%) were at the level of L4/L5 and six (25%) cases involved multiple levels. The incidence of LFH was greater in those patients with spinal stenosis who were aged 60 or older. LFH was also found in patients with other spinal pathologies, such as disc herniation, degenerative changes, and spondylolisthesis. Conclusion LFH was diagnosed in 24.5% of patients with spinal stenosis in this series. It predominantly occurs at the L4/L5 level and is more common in those aged 60 and above. These findings should be considered when selecting the type of management of spinal stenosis.
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Displaced supracondylar fractures of the humerus in children p. 153
Khaled M Mostafa
DOI:10.4103/eoj.eoj_37_17  
Objective and design Supracondylar fractures of the humerus in children are the most commonly diagnosed fractures in childhood. The aim of this study was to evaluate the results of surgical treatment for displaced supracondylar fractures of the humerus. Patients and methods Between 2006 and 2009, 318 patients who met inclusion and exclusion criteria of the study were included. All of them were treated with closed versus open reduction and percutaneous K-wire pinning. Results Patients were followed-up for a period from 24 to 48 months with an average of 36 months. Time elapsed from trauma to surgery was less than 6 h in 213 children with good-to-excellent results in all of them. In 66 children, it was 6–12 h with good-to-excellent results in 58 and fair results in eight children. Among the remaining 39 children who were operated up on more than 12 h after trauma, 24 children showed good-to-excellent results, 11 showed fair results, and four children showed poor results. Conclusion Percutaneous pinning is a successful method for treating displaced supracondylar fractures of the humerus in children. The time elapsed from trauma to surgery is the most important determining factor regarding indications for open reduction and complications.
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Evaluation of the efficacy of autologous platelet-rich plasma injection versus local corticosteroid injection for the treatment of lateral epicondylitis p. 158
Osama Gamal
DOI:10.4103/eoj.eoj_42_17  
Background Local corticosteroid injection is a common treatment procedure for lateral epicondylitis. No statistically important or clinically better results favoring steroid injections were found in recent studies. Platelet-rich plasma (PRP) has shown a broad stimulating effect for repair and is used widely in different sports injuries. This study was performed to evaluate the effectiveness of local injection of autologous PRP versus corticosteroid to treat lateral epicondylitis. Patients and methods This prospective, randomized study included 40 patients with lateral epicondylitis: 20 in group A received 2 ml PRP and 20 in group B received 2 ml local corticosteroid. The final results were measured using the visual analog scale (VAS) for pain and Nirschl staging. The follow-up was continued for 6 months, with assessment at the 1st, 4th, 12th weeks and 6th months. Results The group B showed a significant pain improvement compared with group A in both VAS and Nirschl stage at the first and fourth weeks follow-up visits. At the 12th week visit, the VAS and Nirschl scores were significantly better in group A. At the sixth month follow-up, group A showed a statistically significant decrease in pain in comparison to group B (VAS P=0.001 and Nirschl P=0.002). At the 6-month final follow-up, nine (45%) patients in group B and 18 (90%) patients in group A were completely relieved of pain (P=0.007). Conclusion Autologous PRP is an effective treatment modality compared with corticosteroid injection, with less side effects and recurrence rate.
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CASE REPORT Top

Ossified medial collateral ligament of the knee: two case reports p. 165
Ahmed Rizk Mohamed, Ahmed Samir El Kalyoby, Ahmed Abdel Aziz Ahmed
DOI:10.4103/eoj.eoj_34_17  
Calcification of the femoral origin of the medial collateral ligament (MCL) of the knee is named as Pellegrini–Stieda lesion. Post-traumatic ossification of the whole MCL rarely occurs and results in limitation of range of motion of the knee. We present two case reports with post-traumatic ossified whole MCL with limited range of motion. Surgical excision of the bony mass was carried out after which the knee was medially unstable. MCL reconstruction was carried out using a distally based semitendinosus ligament, which was looped to reconstruct the superficial MCL and the posterior oblique ligament. It is important to reconstruct the MCL of the knee to restore the medial instability that results after excision of an ossified whole MCL.
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