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   Table of Contents - Current issue
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October-December 2016
Volume 51 | Issue 4
Page Nos. 291-376

Online since Tuesday, June 27, 2017

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ORIGINAL ARTICLES  

Image intensifier-guided percutaneous drilling for osteoid osteoma of the proximal femur Highly accessed article p. 291
El-Negery A Abed
DOI:10.4103/1110-1148.208996  
Purpose The aim of this study was to evaluate the efficacy of image intensifier-guided percutaneous drilling destruction of the nidus as a minimally invasive surgery for osteoid osteoma (OO) of the proximal femur. Background OO is a painful, benign, small osteogenic bone tumor. For a long time, surgery was the only treatment for these lesions. Different minimally invasive therapeutic techniques have been proposed. Patients and methods Between 2009 and 2011, 14 patients (nine male and five female) with OO were treated at Mansoura University Hospitals by percutaneous drilling destruction of the nidus under image intensifier. Results All procedures were technically successful. Clinical success was achieved in 94.5% of patients. Only one patient had incomplete removal of the nidus. There were no other complications. Conclusion Image intensifier-guided percutaneous drilling destruction of the nidus is a safe, simple, and effective minimally invasive technique for the treatment of OO of the proximal femur.
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Plate augmentation leaving the nail in situ and bone grafting for the treatment of nonunited diaphyseal fractures p. 297
Hosam M Khairy
DOI:10.4103/1110-1148.208997  
Background Intramedullary nailing (IMN) is now the standard treatment for diaphyseal fractures. Despite recent advances in nailing techniques and designs, some cases of nonunion are still encountered. There are different lines of treatment for nonunion over IMN such as nail conversion to plate, exchange nailing, augmentation plating with bone grafting, and external fixation with nail retention. The aim of our study is to evaluate augmentation plating and bone grafting as a method of treatment for nonunited diaphyseal fractures over IMN. Patients and methods Eleven patients were included in this study. They were nine men and two women; their ages averaged 41 (18–54) years. The femur was affected in three cases, the tibia in six cases, and the humerus in two cases; all of them were treated by augmentation plating and bone graft. Results The follow-up duration averaged 14 (range: 9–24) months; union was achieved in all cases without complications of infection, implant failure, nonunion, or joint stiffness. Conclusion Augmentation plating and bone graft represents a good solution for the treatment of nonunited diaphyseal fractures over IMN
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Medial opening wedge high tibial osteotomy: A technique to avoid patella infera p. 303
Adham Elgeidi, Ahmed El-Hawary, Farouk Youssef
DOI:10.4103/1110-1148.209009  
Background High tibial osteotomy (HTO) is an established treatment for medial compartment osteoarthritis of the knee with varus malalignment. Medial opening wedge osteotomy eliminates most of the disadvantages of the lateral closing wedge osteotomy. Nevertheless, the changes in tibial slope and patellar height after opening wedge HTO with frequent occurrence of patella baja make subsequent knee arthroplasty more difficult. Purpose The purpose of this study was to evaluate the results of a simple technique for medial opening wedge HTO with internal fixation and early mobilization in patients with combined medial compartment osteoarthritis and varus alignment of the knee. Patients and methods Opening-wedge HTO and internal fixation with a standard AO large-fragment T plate with posterior tricortical iliac bone autograft was assessed. Forty-five patients with 61 knees with combined medial femorotibial osteoarthritis and varus deformity of the knee were treated with opening wedge HTO. There were 21 women with 29 knees, with a mean age 45.5 years (30–58 years), and 24 men with 32 knees, with a mean age 41.63 years (30–55 years). Mean follow-up was 35.9 months (13–62 months). Radiographic measurements [femorotibial angle, tibial slope, Insall–Salvati, and Blackburne–Peel (BP) ratios] were taken preoperatively and postoperatively and on follow-up. Preoperative and postoperative (last follow up) values of these parameters were compared. Results Fifty of the 61 (82%) knees had an excellent or good result, whereas in 11 knees there was recurrent pain. There were no implant failures, loss or correction, delayed union, or nonunion. Femorotibial angle was changed from a mean of −7.2° of varus into a mean of 8.3° of valgus (P=0.000). Tibial slope was significantly decreased from a mean of 11.4° to a mean of 9.2° (P=0.002). Insall–Salvati ratio was significantly increased from a mean of 1.1 to a mean of 1.2 (P=0.000). There was a significant decrease in the BP ratio from a mean of 0.9 to a mean of 0.7 (P=0.005). Twenty-five percent of postoperative BP values satisfied the criteria for patella infera (BP<0.54). Conclusion Opening wedge HTO using a simple technique with rigid fixation and early mobilization decreased the posterior inclination of the tibial slope, straightened the patellar tendon, and elevated the tibiofemoral joint line. The decrease in the inclination of the posterior slope of the tibia and the stretching of the patellar ligament compensate for the elevation of the joint line. This together with the early mobilization protocol resulted in the low incidence of patella infera.
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Bipolar hemiarthroplasty for the treatment of unstable trochanteric fracture femur in the elderly p. 313
Elsayed E Saoudy, Adel M Salama
DOI:10.4103/1110-1148.208998  
Background Hemiarthroplasty using bipolar prostheses for unstable intertrochanteric fractures of the femur in the elderly yields good clinical results in terms of early postoperative ambulation. This will have a direct effect on the general condition and postoperative rehabilitation. Patients and methods Thirty patients with unstable proximal extracapsular femoral fractures were treated with bipolar hemiarthroplasty. There were 22 men and eight women, with mean age of 60 years (range: 55–70 years). Primary cemented bipolar hemiarthroplasty was performed using the Hardinge lateral approach in a lateral decubitus position. Harris hip score was used for the clinical evaluation of the patients. Results Clinically, the Harris hip score at the last follow-up ranged from 93 to 54, with a mean value of 79.5. Postoperative radiographs showed a good position in all patients. According to the Gruen scoring for cementation, 15 (50%) cases scored A, eight (26.66%) cases scored B, three (10%) cases scored C1, two (6.66%) cases scored C2, and two (6.66%) cases scored D. Four cases developed complications in this study: infection (two patients), loosening (one patient), and acetabular wear (one patient). Revision was performed in one patient because of loosening. Conclusion Primary cemented bipolar hemiarthroplasty is a good choice in elderly patients with unstable intertrochanteric fractures of the femur, and it saves time as well as cost, with little significant complications.
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Operative versus nonoperative treatment of type 1 fifth metatarsal fracture in nonprofessional athletes p. 319
Sherif M Sokkar, Ashraf Abdelkafy
DOI:10.4103/1110-1148.208999  
Introduction Treatment approach to fifth metatarsal fractures (FMFs) in athletes has been largely influenced by the eagerness to reduce the time away from sport and ensure healing, which provided the drive for primary fixation as the accepted standard of treatment for the athlete. Patients and methods The current study was conducted as a prospective cohort study. A total of 24 patients who had FMF type 1 (avulsion of the tuberosity) were divided into two groups. Group 1 included 12 patients who underwent open reduction and internal fixation using a single screw, whereas group 2 included 12 patients who underwent nonoperative treatment in the form of below-knee cast. Results The average American Orthopaedic Foot and Ankle Society score for group 1 was 98.3, whereas for group 2 was 93.9 (P=0.03). The average visual analog scale for pain in group 1 was 0.5, whereas in group 2 was 1.1 (P=0.13). The average fracture union time in group 1 was 3.8 weeks, whereas in group 2 was 7.5 weeks (P=0.00001). The average time for return to sports in group 1 was 7.1 weeks, whereas in group 2 was 8.7 weeks (P=0.00023). Conclusion Operative treatment of FMF type 1 showed significantly superior American Orthopaedic Foot and Ankle Society scores, less fracture healing time, and less time required to return to recreational sports over those who were treated conservatively; however, there was no difference in pain scores.
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Anterior cruciate ligament graft fixation: clinical and radiological effects on anterior cruciate ligament reconstruction with hamstring tendon graft p. 323
Roshdy M El Sllab, Naser M Selim
DOI:10.4103/1110-1148.209000  
Aim of the study The aim of this study was to compare the results both clinically and radiologically in patients undergoing anterior cruciate ligament (ACL) reconstruction using two different methods of graft fixation. Patients and methods In a retrospective way, at Mansoura knee surgery unit, 120 patients underwent ACL reconstruction with hamstring graft with the use of an interference screw fixation in both the femoral and the tibial tunnel in 60 patients (group A) and rigid fix fixation in the femoral tunnel and screw and washer fixation distal to the tibial tunnel in another 60 patients (group B). The evaluation included International Knee Documentation Committee ratings, Lysholm score, and standardized radiographs, MRI. The diameter of the tunnel on MRI was compared with the tunnel diameter obtained from the operative sheet. Results No significant difference in clinical results was found with using Lysholm score and International Knee Documentation Committee between the two groups. Radiologically, in group A, eight patients had developed femoral tunnel widening and four had developed tibial tunnel widening. In group B, 12 patients had tunnel widening in the femur and 20 in the tibia. There was a significant reduction of tunnel widening in the tibia using interference screw fixation compared with the fixation by screw and washer distal to the tibial tunnel. Conclusion The position of the fixation sites and type of fixation device are major factors in the development of tunnel widening after ACL surgery, but they do not significantly affect the clinical results.
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Total knee replacement in severe varus and flexion knee deformities using economical solutions p. 329
Hatem M.A Bakr
DOI:10.4103/1110-1148.209001  
Background Total knee replacement in severe deformities is a challenging procedure. Varus and flexion are the commonest deformities seen. Thorough soft tissue release and balancing is the key to a successful outcome. We tried to correct these cases without the need for expensive augments and specialized prosthesis. Aim of the work The purpose of this study is to offer economical solution for severe varus and flexion knee deformity and perform a follow-up. This was achieved by using bone grafts from the cuts, proper tissue release, and good preoperative and intraoperative assessment. Patients and methods Our study included 30 knees in 23 patients with severe flexion and varus deformities. The average preoperative varus deformity was 20° (range: 14°–38°), and the average flexion deformity was 15.6° (range: 5°–30°). Bone graft was used in eight (26%) cases and tibial stems in two (6%) cases. No constrained prosthesis was used. Results The average follow-up was 31 months (range: 8–65 months). The average postoperative range of flexion was 115° (range: 90°–147°), range of extension was between 0° and 6°, and the average varus correction was 26° (range: 12°–42°). At the final follow-up, we had 15 excellent, 12 good, two fair, and one poor functional result, giving a 90% success rate. Conclusion Total knee arthroplasty is a challenging procedure in severe grade of knee deformity. Different surgical facilities and solutions must be available to achieve optimum results. Although a wide scale of prosthesis types and bone defect replacement has been used in treating these cases, we were able to treat them with minimal cost and good results.
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Treatment of open tibial fractures using unreamed interlocking nails p. 333
Saied K Abdelhamid, Abdelhamid A Attalla, Mohamed A Abdel-Aal
DOI:10.4103/1110-1148.209002  
Background Internal splintage of open tibial fractures have gained acceptance as a preferred method of early stabilization of such injuries. Patients and methods Fifty-five patients were operated upon. They were followed from July 2008 to March 2012 (44 months), with an average follow-up time of 23 months. The final results were evaluated through a scheme including seven parameters: pain, union, malunion, infection, range motions of nearby joints, implant and technical failure, and activity and return to the same work. Results According to previous parameters, union was achieved in 52 (94.5%) cases at an average time of 20 weeks (16–52 weeks), with 5.5% incidence of nonunion. Excellent and good range of knee and ankle motions were achieved at the final follow-up visit in 49 (89.09%) cases. The incidence of complication was acceptable; mainly, malunion was found in 7.3%, deep infection in 12.7%, implant and technical failure in 9.1%, and full activity and return to the same work in 89.1% cases. The overall results of our series are as follows: excellent in 19 (34.5%) cases, good in 27 (49.1%) cases, fair in six (10.9%) cases, and poor in three (5.5%) cases. Conclusion Utilizing unreamed interlocking nail for open tibial fractures is a good method of treatment, particularly those of grades II and IIIA. The high proportions of excellent and good results confirm that this technique is superior to all other known methods of fracture fixation.
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Sling reconstruction of acromioclavicular joint dislocation: is screw fixation necessary? p. 339
Mohamed M.F Sharaby, Mohamed F Mostafa
DOI:10.4103/eoj.eoj_88_16  
Background Acromioclavicular joint injuries have been in much controversy with regard to the ideal method of treatment. The loop technique has been successfully used to stabilize this joint with variable success. Adding a Bosworth screw to the loop fixation may improve its efficacy and decrease the incidence of postoperative subluxation. This comparative study evaluates the efficacy of loop fixation for both acromioclavicular and coracoclavicular ligament reconstruction versus a loop combined with Bosworth screw with regard to function, radiology, and fixation-related complications. Patient and methods Over a 5-year period, we treated 50 patients with acute acromioclavicular joint dislocations with two methods of fixation. Only 47 patients continued follow-up. Group I (N=24) was managed with reconstruction of the coracoclavicular and acromioclavicular ligaments by means of loop fixation. In group II (N=23), a Bosworth screw was added to the loop fixation. Results The mean follow-up period was 24.2±5.9 months (range: 15–34 months) for the first group and 23.3±6.5 months (range: 13–36 months) for the second group. The mean postoperative pain score (visual analog scale) was 1.38±1.7 for group I and 1.35±1.27 for group II. The mean Constant score was 90.2±8.1 for group I and 92.2±5.5 for group II. The mean Taft score was 10.6±1.4 and 10.9±1.3 in the first and second groups, respectively. Recurrence was detected in four patients, two in each group. There was no statistically significant difference in results between the two groups. Conclusion Sling technique was found efficient enough to maintain stability of the acutely dislocated acromioclavicular joint without the need to augment this reconstruction with a screw.
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Closed reduction and Nancy nail fixation for forearm fractures in children p. 347
Ahmed El Naggar, Molham M Mohammad
DOI:10.4103/1110-1148.209004  
Background Forearm fractures in children are common. Children forearm fractures are managed differently than are similar injuries in adults. Treatment alternatives of irreducible unstable pediatric forearm fractures are closed remanipulation under general anesthesia and casting, Kirschner wire and casting, closed or miniopen reduction and intramedullary fixation, and open reduction and internal fixation with plates. The intramedullary nail fixation is preferable in many circumstances to open reduction and plating of the forearm bones as it prevents stripping of the soft tissues; in addition, there is little in the way of surgical scar tissue and is therefore cosmetically acceptable. Patients and methods Thirty-six [32 (88.8%) boys and four (11.2%) girls] patients with fractures of both bones of the forearm were treated with elastic stable intramedullary nails. The surgery was performed within 20 h (range: 12 h–2 days). The fractures were classified according to the Orthopedic Trauma Association classification. All operations were carried out under general anesthesia and under an image intensifier control. Closed manipulation of fractures was performed to correct the length, rotation, and angulation. Blunt-ended 1.5–2.5-mm diameter titanium nails were used. An above elbow splint was applied. Results Functional results were evaluated according to the criteria of Price and colleagues. An excellent result was achieved in 30 (83.3%) patients and a good result in six (16.7%) patients. Three (8.3%) patients had olecranon bursitis due to irritation of the nail, which was resolved after nail removal. Two (5.6%) patients had superficial wound infection (redness and hotness) at the entry site of radial nail and were treated with repeated dressings and empirical antibiotics for 10 days. Conclusion The advantages of an elastic intramedullary nail fixation for the radius and ulna fractures are that it is technically straightforward, allows a high rate of osseous consolidation, is minimally invasive, and allows early mobilization.
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Clinical outcome of hamstring lengthening to correct flexed knee gait in patients with spastic diplegia p. 352
Amin AbdelRazk Y Ahmed, Awad AbdelMoniem A Rafalla
DOI:10.4103/1110-1148.209005  
Background Increased knee flexion during the stance phase of gait (flexed knee gait) is one of the most common gait abnormalities in spastic diplegia. Hamstring lengthening in ambulatory patients is widely considered to be the standard surgical procedure for the correction of increased knee flexion. Aim The aim of this work is to evaluate the results of fractional distal hamstring lengthening in correction of flexion knee gait in ambulatory children with spastic diplegic cerebral palsy. Patients and methods Between 2007 and 2011, twenty six patients with spastic diplegia with flexion knee gait were treated by fractional hamstring lengthening as a part of multi-level management. There were 17 (65.4%) boys and 9 (34.6%) girls in the series, all treated patients were diplegic with both lower limb affection. The mean age of the patients at the time of operation was 8.15 ± 1.826 (range 5 to 12) years, other procedures were needed in 11 patients to treat hip adduction and equinus deformities. Results At the end of a follow up period of 22.9 (12–36) months, a significant reduction in the mean popliteal angle was noted postoperatively as it was improved from a mean of 54.4 ± 4.87 (48–63) preoperatively to 27.2 ± 2.41 (22–30) after surgery. This relation was proved to be statistically significant P ≤ 0.001. Much improvement in the knee flexion on standing was recorded after surgery, as the knee flexion on standing improved from 28.5 ± 4.85 (20–35) preoperatively to 3.7 ± 3.01 (0–10) postoperatively, also this was proved to be statistically significant, P ≤ 0.001. Twelve patients showed improvement by one level in Gross Motor Function Classification System levels (GMFCS) at end of follow up. Three patients showed a complication of hyperextension in one knee during walking; the three patients were treated by combined medial and lateral hamstring lengthening. Conclusion Distal hamstring lengthening is an effective procedure in treatment of cerebral palsy patients with flexion knee gait in a short period of follow up but longer follow up is needed to assess the maintenance of the results.
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Factors affecting the management of failed internal fixation of trochanteric hip fractures with conversion to hip arthroplasty p. 359
Ahmed H Abdelazeem, Sherif A Khaled, Mahmoud Abdel Karim, Hazem Abdelazeem
DOI:10.4103/1110-1148.209006  
Purpose Failed internal fixation of intertrochanteric fractures typically leads to profound functional disability and pain. Conversion hip arthroplasty in this situation is technically demanding. The purpose of this study was to evaluate the results, technical problems and complications, as well as the impact, of different factors on such procedure. Patients and methods From May 2009 to October 2011, 30 patients (23 female and seven male) with a mean age of 66 years (range: 50–90 years old) were included in the study. Total hip replacement was used in all cases. Cemented stems were most commonly used because of poor bone quality (standard length in 10, long stems in 14 and calcar replacing in two). Cementless standard length stems were used in four patients. The mean follow-up was 25 months (range: 12–33 months). Results A statistically significant improvement was found comparing preoperative and postoperative conditions (P<0.05). When comparing different factors, the age was the only statistically significant factor affecting the functional outcome, denoting better results with patients younger than 65 years of age (P=0.002). We had four intraoperative fractures, one postoperative fracture, three dislocations, a single case of infection and two cases of implant loosening. Conclusion Although conversion hip arthroplasty is technically demanding, it is associated with a high success rate with good functional outcome and pain relief especially in younger age groups.
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Outcome of arthrodiastasis in treatment of Perthes’ disease p. 366
Osman Abd Ellah Mohamed, Fathy H Salama, Samir A Alshoura, Ibrahim E Abd Elatif Abu Omira, Mohamed A Hassan
DOI:10.4103/1110-1148.209007  
Background Hip distraction in Legg–Calvé–Perthes disease unloads the joint, which negates the harmful effect of the stresses on the articular surface, which may promote the sound healing of the areas of necrosis. Patients and methods Nonarticulated arthrodiastasis without soft tissue release using an Ilizarov external fixator was applied to 45 patients (50 hips) with Legg–Calvé–Perthes disease (>8 years at onset and lateral pillar type C or B). Results Follow-up period ranged from 1 to 8 years, with an average of 3 years. Forty-five (90%) hips had improvement of the range of motion postoperatively. Preoperatively, all patients had constant pain, whereas at last follow-up 40 (80%) patients had no pain and had an improvement. Stulberg classification was applied to 20 cases who reached skeletal maturity at the last follow-up: eight cases were type II, five cases were type III, five cases were type IV, and two cases were type V. Conclusion Nonarticulated hip distraction without soft tissue release seems to be a valid treatment option in cases with Legg–Calvé–Perthes disease where poor results are expected from conventional treatment.
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Arthroscopic remplissage: is it still an option? A report of 51 cases p. 372
Mohamed G Morsy
DOI:10.4103/1110-1148.209008  
Introduction The posterolateral humeral head defects can be large and engaging on the anterior glenoid and usually contribute to anterior shoulder instability in 40–90% of cases. The purpose of this study is to evaluate the results of the largest series of patients who underwent arthroscopic remplissage with Bankart repair for recurrent anterior shoulder instability due to associated Bankart lesion with large and engaging (>25% involvement) humeral Hill–Sachs defects (HSDs). Patients and methods In all, 51 patients underwent arthroscopic Bankart repair with remplissage technique for the treatment of recurrent anterior glenohumeral instability with large and medial HSDs. Preoperative imaging in all patients identified Bankart lesion with an associated HSD that involved greater than 25% of the humeral head. Rowe score was used to clinically assess the patients. Results Forty-six patients were male. The mean age of the patients was 28.7 years. The mean follow-up period was 31 months (range: 20–39 months). At the final follow-up, three patients reported recurrence of instability (two dislocations and one sublaxation). The mean Rowe score improved to 95.4 points (function, 45.5 of 50; stability, 26.4 of 30; motion, 8 of 10; pain, 8 of 10). Conclusion Bankart repair with remplissage technique offered satisfactory results and is still considered to be an effective, safe, and reliable procedure for the treatment of glenohumeral instability in cases with large and medial HSDs.
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