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   Table of Contents - Current issue
January-March 2018
Volume 53 | Issue 1
Page Nos. 1-87

Online since Wednesday, January 2, 2019

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Ilizarov hip reconstruction for late sequelae of childhood septic arthritis p. 1
Mahmoud A El-Rosasy, Mostafa A Ayoub
Background The management of hip instability because of septic arthritis in childhood is difficult. Ilizarov hip reconstruction (IHR) is a double-level femoral osteotomy with the objective of eliminating hip instability, through a proximal valgus extension–derotation osteotomy, and a distal varization-lengthening osteotomy for mechanical axis correction and equalization limb length. Patients and methods IHR was performed for 16 adult patients with complaints of hip pain, leg-length discrepancy, limping, reduced activity, and limited abduction of the hip as a result of childhood septic arthritis. Their ages ranged from 19 to 32 years (mean 23.2±4.2 years). Results Ilizarov external fixator was used in all cases. At the time of last follow-up, which ranged from 60 to 132 months (mean 85.6±23.5 months), the Harris hip score showed excellent functional outcome in two (12.50%) cases, good in 13 (81.25%) cases, and fair in one (6.25%) case. There was no poor functional outcome in any case. Preoperatively, the mean Harris hip score was 56.18 points, and at the time of last follow-up, it improved to a mean of 84.62 points. Pain subsided in all patients, the Trendelenburg sign became negative in all but three (19%) patients, no patient had limb-length discrepancy, and the alignment of the extremity was reestablished in all cases. No additional operations were required. Conclusion IHR is a valuable and durable solution for the late sequelae of childhood septic arthritis of the hip presenting in adult patients.
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Fixation of proximal and distal tibial fractures by intramedullary nail and blocking screws p. 8
Ihab I El-Desoukey, Ahmed E Kandil, Abdel G El Said
Introduction Intramedullary fixation of the metaphyseal fractures of the tibia with a short proximal or distal fragment is associated with an increased rate of malalignment. The use of blocking screws (Poller screws) bedside the intramedullary nail narrows the medullary cavity and decreases the degree of nail translation and malalignment. Patients and methods Between January 2012 and May 2013, 20 cases of metaphyseal tibial fractures were included in the study. There were 12 males and eight females, with the mean age of these patients was 36 years (range: 19–60 years). Fracture site was the proximal segment in seven cases and the distal segment in 13 cases. Intramedullary fixation supplemented by blocking screws was done in all cases. Results The average duration of the follow-up was 33 weeks (range: 19–54 weeks). A total of 16 patients achieved union with maintenance of the alignment of their fractures. One patient progressed to 5° of valgus and healed at this position, and three patients had persistent 2° of varus deformity. One of these patients experienced fissure fracture at the site of blocking screw. Delayed weight bearing and casting was done for 6 weeks, and the fracture was healed with 3° of varus of the proximal segment. Conclusion This technique is recommended to treat proximal and distal tibial fractures that minimizes the malalignment rate and allow early return to activities.
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Medial displacement calcaneal osteotomy in treatment of stage II posterior tibial tendon deficiency p. 14
Nady S El-Sayed, Mohamed M Fadel, Ahmed O Yosef, Amr M.M Soliman
Background Medial displacement calcaneal osteotomy is indicated in individuals with stage 2 posterior tibial tendon deficiency (PTTD) with a supple hindfoot and the absence of clinical or radiographic arthritis. Patients and methods This prospective study evaluated the effects of medial displacement calcaneal osteotomy and flexor digitorum longus transfer to navicular bone on pedal realignment and function in 14 patients (15 feet) with a stage 2 PTTD. Results American College of Foot and Ankle Surgeons scoring scale module number 3 was measured before the reconstruction and at latest follow-up, and also patients’ satisfaction were reported, demonstrating a good realignment in short-term follow-up (15–18 months). The American College of Foot and Ankle Surgeons score improved postoperatively from average of 53.5 to 87.4 without progression of arthritis at adjacent joints. Conclusion This simple surgical procedure has an excellent effect on realignment and function of PTTD stage 2 without marked forefoot abduction.
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Ilizarov treatment of severe type I fixed flexion deformities of the knee joint p. 21
Badawi Ihab
Background Two types of flexion contracture of the knee can be distinguished: the one associated with joint destruction and ankylosis, and the other in which joint anatomy and mobility are preserved. In the first type, the aim of treatment is to obtain an ankylosed knee in a functional position, and in the second is the correction of deformity and preservation of movements. Treatment of severe deformities is associated with serious complications such as insufficient correction, skin necrosis, neurovascular problems, leg-length discrepancy, posterior subluxation of the tibia, fractures of the femur and the tibia, and recurrence of the deformity. The Ilizarov method offers a minimally invasive procedure that allows gradual correction of the deformity with relatively few complications. Aim This study was carried out to assess the results of gradual correction of severe type I fixed flexion deformities of the knee joint using Ilizarov external fixator. Patients and methods This study included eight patients having severe type I fixed flexion deformity of the knee joint. The preoperative fixed flexion deformity ranged from 50 to 80° (mean: 67.5±8.3°). All knees were stiff preoperatively. The cause of the deformity was juvenile rheumatoid arthritis in four (50%) patients, infection following open reduction and internal fixation of a tibial plateau fracture in three (37.5%) patients, and repeated hemarthrosis of the knee in one (12.5%) patient. Results Full correction was achieved in all patients following removal of the fixator. The follow-up period ranged from 12 to 36 months (mean: 24±4.3 months) following removal of the brace. Two (25%) patients had no recurrence of the deformity, whereas the remaining six (75%) cases had partial recurrence of the deformity that ranged from 5 to 25° (mean: 11.25±9.5°) during the follow-up period. Conclusion Ilizarov gradual distraction is an option to improve the quality of life of patients having severe type I fixed flexion deformities of the knee joint despite the high rate of partial recurrence.
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Arthroscopic treatment of anterolateral ankle soft-tissue impingement in athletes p. 26
Mohamed Yahia
Background Ankle sprains are the most common musculoskeletal injuries that occur in athletes. Although often considered minor, they can lead to development of chronic anterolateral soft-tissue ankle impingement. This ankle sprain if left untreated, owing to repetitive actions, can lead to development of thickenings ‘pathological synovial or capsular tissue’ within the ankle joint, which causes persistent painful limitation of ankle movement as a result of entrapment of this pathological tissues in the anterolateral aspect of the joint. As impingement progresses, movements essential to athletes may become impossible; therefore, successful arthroscopic ankle debridement and impinged-soft tissue excision is the procedure of choice, allowing athletes to return fast to their previous preinjury sports activities level. Patients and methods A total of 25 elite athletes complaining of persistent anterolateral ankle pain during sports participation, who were diagnosed by history, physical examination, and magnetic resonance imaging to have anterolateral ankle impingement with unsuccessful conservative management for at least 6 months, underwent arthroscopic debridement and excision of the anterolateral impinged hypertrophic, inflamed, and scarred soft tissue. Any athlete diagnosed to have associated ankle instability or tibial or talar chondral lesion was excluded from this study. Results There were 13 right ankles and 12 left ankles. There were 14 male and 11 female patients. No bilateral cases existed. The mean duration of symptoms till operation was 8.9 months. The mean postoperative follow-up was 15 months. At the final postoperative evaluation, 23 athletes were satisfied and reparticipated in the same preinjury sports activities level without complaints, whereas two (8%) athletes were unsatisfied and retired from high-level sports activities. The mean time to return to full sports activities with high performance was 8 weeks. According to American Orthopaedic Foot and Ankle Society (AOFAS) at the final postoperative follow-up evaluation, nine patients had excellent results, 14 patients had good results, and two patients had fair results. A significant improvement of the AOFAS (P<0.05) was seen at the final postoperative evaluation. Four athletes had reinversion injuries within 4 months postoperatively. Two of them had fair AOFAS results at the final postoperative evaluation. There were no postoperative complications. Conclusion Ankle arthroscopy is a useful and safe method in diagnosis and treatment of anterolateral soft tissue ankle impingement in elite athletes, with early return to full sports activities. Final outcome may be affected negatively with new inversion injuries during the early postoperative period.
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Treatment of knee osteoarthritis with platelet-rich plasma in comparison with platelet-rich plasma plus hyaluronic acid: a short-term double-blind randomized clinical study p. 31
El-Tayeb Nasser
Background Platelet-rich plasma (PRP) and hyaluronic acid (HA) intra-articular knee injections are widely accepted as modalities to treat pain and functional limitation associated with knee osteoarthritis. So it can be assumed that a combination of both HA and PRP in one injection could supply many advantages for cartilage repair. It adds the benefit of HA viscosupplementation with PRP regenerative properties. This study aims at finding out whether blending HA with PRP gives better clinical and functional results when compared with PRP intra-articular injection alone. Patients and methods A prospective, double-blind, randomized, multicenter clinical trial was conducted. It included 58 patients with average age of 35 years (range: 29–49 years), started on January 2016 and ended on June 2017. Each patient had initial assessment, and then were followed up after 6 months and then at 12 months. They were randomized into two groups: group 1 (PRP) (24 cases) was injected with PRP only and group 2 (PRP+HA) (34 cases) was injected with PRP plus highly cross-linked sodium hyaluronate. Results Initially, both groups were matched in age and BMI, with P value more than 0.05. Both groups were also matched on their initial assessment by the three clinical assessment methods, namely, knee society score, global impression of changes, and the Western Ontario and McMaster Universities Arthritis Index, with P value more than 0.05. Comparing groups 1 and 2 regarding the follow-up results showed, globally, no significant superiority of group 2 (PRP+HA) over group 1 (PRP). It was quite apparent in global impression of changes at 6 and 12 months, and in Western Ontario and McMaster Universities Arthritis Index at 6 and 12 months, with P value more than 0.05. Knee society score gives results with group 1 (PRP group) at 6 month and after 1 year follow-up, which were better than the results of group 2 (PRP+HA), with P value less than 0.05. Follow-up of each group of patient separately at 6 months and 1 year showed that each of them has highly significant improvement regarding pain and functional outcome, with P value less than 0.001. Conclusion PRP intra-articular injection appears to improve pain and function in middle-aged women with mild to moderate knee osteoarthritis, with no added benefit of blending HA with PRP during injection.
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Opening wedge high tibial osteotomy in varus osteoarthritis of the knee without bone graft p. 38
Mohamed E Attia
Background The aim of this study was to evaluate the efficacy and short-term results of medial opening wedge high tibial osteotomy with the use of a wedge toothed plate in patients with medial compartment osteoarthrosis. Patients and methods This study was conducted from April 2010 and September 2012 and included 16 knees of seven female patients and nine male patients. Their average age was 40 years (range: 28–52 years), and they were treated with medial opening wedge high tibial osteotomy for varus knees with early medial compartment osteoarthrosis. The osteotomy sites were fixed with a wedge toothed plate without bone graft. The mean follow-up period was 11.4 months (range: 6–15 months). Results The average union time was 15 weeks (range: 8–24 weeks). The mean preoperative and postoperative Lysholm scores were 54.1 (range: 30–60) and 82 (range: 67–95), respectively. The mean preoperative femorotibial angle was 3.5° in varus malalignment (range: 3° valgus to 9° varus). It was 7.3° valgus postoperatively. The mean correction of the mechanical axis was 10.7°. There was loss of correction in one patient and needed revision. Four (25%) cases had delayed union. Conclusion Medial opening wedge osteotomy with the use of a wedge toothed plate had advantages of easy application and maintenance of correction in the early follow-up period without bone graft application. Consolidation is obtained without interfering with the rehabilitation period.
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Treatment of distal radius fractures with percutaneous pinning p. 44
Moawed F El-Adawy, Ayman T Henawy, Mohamed S El Haroon
Background Distal radius fracture is one of the common injuries seen in casualty and can be managed by closed reduction and percutaneous pinning. The purpose of this prospective study was to determine the functional results following management of distal radius fractures by percutaneous wire fixation. Materials and methods This study was conducted between June 2014 and June 2017 and included seventy closed distal end radius fractures in 70 patients, comprising 40 (57.14%) males and 30 (42.86%) females. All were managed with closed reduction and percutaneous Kirschner wires fixation. Results The average follow-up was 18 months (range:  12–24 months). All the fractures healed within 10–14 weeks. A total of 36 (51.4%) cases got excellent score, 18 (25.7%) cases were good, 12 (17.1%) cases were fair, and four (5.7%) cases were poor. Most of the patients returned to their preinjury activity level with a 90.7% satisfaction rate. There were 10 cases that experienced pin tract infection and were treated by antibiotic. Conclusion Percutaneous pinning is a simple, minimally invasive technique and is aimed at preventing redisplacement of the distal radius fracture fragments to provide sound bone healing and achieve good radiological and functional results.
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Single oblique cage posterior lumbar interbody fusion with local bone graft as an alternative to double straight-ahead cages posterior lumbar interbody fusion with iliac crest graft p. 52
Ahmad M Morsi
Background Posterior lumbar interbody fusion (PLIF) is a fusion technique with reliable and rapid fusion results. The traditional technique describes the use of two cages filled with bone graft and inserted in a straight-ahead direction within the prepared disc space. Bone graft used is usually harvested from the posterior iliac crest. This study evaluates the use of a single cage inserted diagonally through unilateral discectomy and filled with bone fragments obtained from the local decompression procedure. Patients and methods Fourteen patients underwent pedicle screw-rod supplemented PLIF and spinal canal decompression for symptomatic spinal canal stenosis, instability, or spondylolisthesis refractive to conservative treatment. PLIF was performed using a single PEEK cage filled with impacted graft from the locally excised bone. The PEEK cage was inserted into the prepared intervertebral disc space in an oblique (diagonal) manner to obtain near-symmetrical end-plate loading across the midline. Results The mean follow-up period was 15 months. The mean duration of surgery was 170 and 225 min for single-level and double-level fusions, respectively. The mean volume of blood loss was 850 and 1050 ml for single-level and double-level fusions, respectively. The mean duration for hospital stay was 5 days. Postoperative radiographs showed a mean increase in the disc height by 24.4% and a mean increase in lordosis angle by 4.3°. Pain and functional scores showed marked improvement. The mean Visual Analog Scale decreased from 7.8 to 2.2. The mean Oswestry Disability Index decreased from 82 to 28. The mean Economic Prolo Scale was 3.2 whereas the Functional Prolo Scale was 3.8. Interbody fusion was assessed using lateral radiographs. Loss of demarcation of the bony end-plates with consolidation of graft through the cage was the indication of successful fusion. At final follow-up, 10 patients showed solid fusion, three patients showed delayed fusion, and one patient showed loss of reduction of spondylolisthesis after a traumatic incident and required a revision surgery. Yet, patients with delayed union did show similar improvement to those with early union on the Visual Analog Scale and Oswestry Disability Index. Conclusion The use of single unilateral and obliquely inserted PEEK cage is an effective safe procedure for interbody fusion that gives comparable results to the traditional double-cage technique while shortens the operative time, lowers the blood volume loss, and also lowers the cost for implants used without endangering reliability of the technique.
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Is it necessary to plate all posterior wall fractures of the acetabulum? p. 59
Ahmed Shawkat Rizk, Hosam Elsayed Farag
Background Posterior wall injuries represent the commonest type of acetabular fractures. It could be isolated fractures or − more commonly − associated with hip dislocation with varying degrees of displacement and comminution. Being intra-articular injuries affecting the congruency and stability of the hip joint, 30% of patients with such injuries have poor outcomes. Accurate fracture reduction with stable fixation is the standard way for achieving satisfactory results. This study aims to evaluate the suitability and efficacy − in light of the clinical and radiological results − of using only screws for fixation of certain posterior wall fractures through a limited exposure using the Kocher-Langenbeck approach. Patients and methods This study included 16 cases of displaced posterior wall fractures with single, sizable fragment or multiple, noncomminuted fragments treated with open reduction and internal fixation using only screws through a limited exposure using the Kocher-Langenbeck approach. In 14 cases, fractures were associated with hip dislocation whereas the last 2 cases had isolated posterior wall injuries. Radiological assessment according to Matta and Heeg criteria and clinical evaluation according to Postel score were done postoperatively and throughout the follow-up period that extended for a mean duration of 18.9±6.7 months. Results Clinically satisfactory results (excellent and good) were reported in 14 cases, representing 87.5% of the studied cases. One case was rated fair and one case was rated poor, so unsatisfactory results (fair and poor) were reported in two cases, representing 12.5% of the studied cases. According to the modified criteria of Matta, 12 cases had excellent reduction and four cases had good reduction, and according to the radiographic grading criteria by Heeg, 14 cases were excellent with a normal-appearing hip joint compared with the healthy side; one case was fair with joint narrowing less than 50% compared with the other healthy side with no osteophytes and viable head; and one case was rated as poor with advanced degenerative changes, head subluxation, and severe avascular necrosis. No cases developed heterotopic ossification or implant failure. Conclusion Fixation by only screws through a limited exposure could be a simple and reliable fixation method for certain posterior wall fractures with less soft tissue dissection and intraoperative and postoperative complications, with comparable clinical and radiological results to the more complex fixation methods using conventional reconstruction plates or locked plates.
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Modular megaprosthesis for proximal femoral tumors p. 70
Adel R Ahmed
Objectives Limb salvage surgery is the preferred treatment for proximal femoral tumors. The use of modular prosthesis following resection of the tumor is the preferred method, a procedure that is technically demanding. The resection of tumor at the level of proximal femur results in loss of abductors and other musculature necessary for hip stability. This often leads to a higher instability rate. Hip dislocation is a recognized problem after the use of megaprosthesis, with rates of dislocation varying from 1.7% to ∼28%. Patients and methods Between March 2003 and March 2008, 15 patients in our series had resection of the proximal femoral primary malignant tumors and implantation of a modular megaprostheses, using a bipolar acetabular cup. There were seven women and eight men, with a mean age of 37 years (18–68 years). The diagnoses were osteosarcoma (two), chondrosarcoma (eight), malignant fibrous histiocytoma (two), and giant cell tumor (three). All patients had a complete tumor workup before surgery that included routine blood work, bone scan, computed tomography of the chest, and MRI of the femur. All patients had an open biopsy. They were given preoperative radiotherapy and chemotherapy as required. Results The mean follow-up was 5 years (range, 5 months–10 years). Two patients died of causes not related to the prosthesis. The postoperative Musculoskeletal Tumor Society score was 26 (range, 23–30) for the remaining 13 patients. There were one subluxation treated conservatively, and one erosion of the acetabulum that needed conversion into total hip replacement. No infections and local recurrence were encountered. Conclusion Proximal femoral modular megaprosthesis is a good option for reconstruction after resection of proximal femoral tumors.
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Arthroscopically assisted repair of massive full-thickness rotator cuff tears: an analysis of 2-year postoperative follow-up p. 77
Taher A Eid, Yasser S Hannout, Amro S El-Sayed, El-Sayed Morsi
Objectives The aim of this work was to evaluate the clinical results of arthroscopically assisted massive full-thickness rotator cuff repair. Background The treatment modalities of massive rotator cuff tears (as formal open, mini-open ‘arthroscopically assisted,’ and all-arthroscopic repair) show wide variability in terms of the technical prerequisites, the clinical results, and the reported complications. However, arthroscopically assisted repair offers the advantages and avoids the disadvantages of both formal open and all-arthroscopic repair. Patients and methods The clinical results of 12 patients (12 shoulders) with massive full-thickness rotator cuff tears managed by arthroscopically assisted repair were evaluated by the University of California, Los Angles (UCLA) scoring system and with the active range of motion of the affected shoulder. Study type Interventional, prospective. Study design Clinical case series. Primary purpose: treatment. Results Using the UCLA scoring system, the final assessment (at a mean of 27.4 months postoperatively) revealed satisfactory (good and excellent) results in 11 (91.7%) patients and unsatisfactory (poor) results in one (8.3%) patient. Also, the mean value of overall UCLA score significantly improved from (8.8±1.2) preoperatively to (32.4±2.4) postoperatively (P<0.05). In addition, there was a significant improvement in the active range of motion of the operated shoulders (P<0.05). Conclusion Favorable clinical outcomes can be anticipated in the majority of patients with massive full-thickness rotator cuff tears after arthroscopically assisted repair. Overall, ∼92% of patients will be able to successfully return to the previous level of daily living activity and occupational tasks. In addition, the procedure is relatively simple and takes less time, and does not need high technical skills. Recovery is faster with minimal postoperative complications and accelerated rehabilitation (no deltoid detachment).
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Treatment of the femoral shaft fractures in children by a single elastic stable intramedullary nail p. 83
Amro S El-Sayed
Introduction A femoral fracture is the most common major pediatric injury treated by orthopedic surgeons. Although the majority heal without long-term sequelae; the most frequent and expensive complications in the field of orthopedics result from the closed treatment of pediatric femoral fractures. Thus, the occasional unsatisfactory outcome maintains the focus on evolving treatment recommendations. It is a closed surgical procedure that allows early weight bearing and walking. Implantation of flexible nails is performed through very small incisions and does not endanger the physes or the blood supply to the femoral head. It aims at rapid restoration of bone continuity and no joint stiffness, and early rehabilitation. Patients and methods This work is a prospective study of 30 children with femoral shaft fracture who had been admitted to El-Menoufiya University Hospital. All cases that fulfilled the inclusion criteria had been treated by a single elastic stable intramedullary nail (ESIN). Results In a total of 30 patients, there were 20 male and 10 female with mean age 8.4 years (range: 5–14 years). Twenty (66.7%) fractures were on the right side and 10 (33.3%) were on the left side. Seventeen fractures were caused by road traffic accident (RTAs), 12 fractures caused by falling from height, and one case due to falling of heavy object over the femur. Callus was first noted on follow-up radiographs at an average of 4 weeks. Radiological union was achieved in all cases in a mean time of 8.6 weeks (range: 6–12 weeks). According to the scoring criteria for ESINs by Flynn and colleagues, the results were excellent in 26 (87%) patients, successful in three (10%) patients, and poor in one (3%) patient. Conclusion The single elastic stable nailing is an effective treatment option in treating femoral shaft fractures in the 5–15 years age group. Although midshaft transverse fractures are the most amenable for treatment with ESINs, they can be used in any type of fractures.
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