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   Table of Contents - Current issue
July-September 2016
Volume 51 | Issue 3
Page Nos. 187-289

Online since Friday, June 23, 2017

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Infected orthopedic implants Highly accessed article p. 187
Abulfotooh M Eid
Infected orthopedic implants present a heavy burden to patients, surgeons and the community in terms of morbidity, mortality and cost. In this mini review sources of infection are traced and so are the risk factors and incidence. The pathomechanisms are explored and the clinical presentations as well as diagnostic tools are discussed. In addition, the various treatment methods are explained.
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Minimally invasive plate osteosynthesis in the treatment of proximal humeral shaft fractures p. 199
Abed A El-Negery, Yaser Y Abed
Introduction The treatment for proximal humeral shaft fracture is still controversial, attributed to the multiplicity of treatment options. The aim of this study was to evaluate the results of minimally invasive plate osteosynthesis (MIPO) in the treatment of proximal humeral shaft fractures. Patients and methods Between February 2007 and November 2011, 20 patients with displaced fracture of the proximal one-third shaft of the humerus were treated using the MIPO technique. The average age of the patients was 45.3 years, and there were 13 male and seven female patients. Eleven (55%) patients had AO (AO Foundation is a medically guided, not-for-profit organization led by an international group of surgeons specialized in the treatment of trauma and disorders of the musculoskeletal system) type 12C fractures. The right humerus was fractured in 11 (55%) patients. Falls were the most common cause of fracture in eight (40%) patients. Follow-up was carried out regularly with radiography and measurement of range of movement of the elbow. Results All fractures healed in an average time of 10.35 weeks within an average follow-up of 23.46 months. Surgery was performed on average 1.75 days after injury. Fractures were fixed using dynamic compression plating in 12 cases and locked plating in eight cases. The average range of elbow range of motion was 123 degrees; 12 (60%) patients were able to achieve full elbow extension at last follow-up. The average extension lag was 5.25°. The average range of elbow flexion was 128.25°. Six complications occurred in our cases. There were two cases of shoulder impingement. One patient developed deep infection. Three (15%) patients had postoperative radial nerve injuries. All of them recovered spontaneously. Conclusion Although MIPO is technically demanding, it is a safe and efficient procedure for the treatment of humeral shaft fracture. Adequate healing and low complication rate can be obtained if the appropriate surgical technique is used. Elbow flexion contracture can be regarded as a possible complication that can be avoided by the use of early adequate elbow rehabilitation protocol.
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Isolated subtalar arthrodesis after fractures of the calcaneus p. 205
Adel M Salama, Elsayed E Saoudy
Background Involvement of the subtalar joint in fracture calcaneus may give rise to chronic pain and permanent functional impairment. This can be produced by subtalar incongruity with calcaneofibular abutment and/or impingement of the tendon, nerve, or other soft tissue. Patients and methods Twenty patients (16 males and four females) underwent subtalar arthrodesis for the treatment of subtalar arthrosis after calcaneal fracture. All patients were initially treated conservatively; the mean time for fusion operation was 20 months (range: 12–36 months). The indications for operation were severe pain and disability in an incongruent subtalar joint with lateral impingement after failed conservative treatment. The fusion was fixed by using cannulated screws in all cases. Results All patients studied at the time of follow-up had a solidly fused subtalar arthrodesis. Two cases had a superficial wound infection and were treated with antibiotics. The mean postoperative period of recovery after which the patient could return to work or daily activities was 9 months (range: 6–12 months). In 16 (80%) patients, there was some residual pain; only four (20%) had no complaints. The result assessments with respect to the American Orthopedic Foot and Ankle Society score showed four (20%) patients with excellent score, good in 10 (50%), fair in four (20%), and poor in two (10%). There was no correlation between the type of accident, the weight of the patient, the recovery period, and the outcome of the American Orthopedic Foot and Ankle Society. Conclusion Isolated subtalar arthrodesis with screw fixation is an effective surgical intervention with significant clinical improvements in some patients with post-traumatic arthrosis of the subtalar joint.
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Bone marrow injection for the treatment of aneurysmal bone cyst p. 209
Mahmoud I Abdel-Ghany
Study design Patients with aneurysmal bone cyst (ABC) lesion were treated by an injection of autologous bone marrow aspirates (ABM) and follow-up was performed to obtain the final results. Patients and methods Sixteen patients had an ABC that was treated by ABM injections. This study included 16 patients, 11 (68.75%) females and five (31.25%) males. Their age ranged from 3 to 14 years, with an average age of 7.5 years. The number of injections for every patient ranged from 2 to 6, with an average of 4.4. This study included five (31.25%) patients with a proximal femoral cyst, nine (56.25%) patients with a tibial cyst (two distal and seven proximal tibiae), and two (12.5%) patients with a proximal humeral cyst. All patients were treated by an injection of ABM obtained from the iliac crest. The bone marrow (BM) aspirates were obtained percutaneously using a BM aspiration needle. On the basis of radiographic follow-up during injections, we decided to continue with the administration of injections. The average size of the defect was 2.3 cm and the average amount BM/injection was 10.2 cm3. Results The pain score according to Visual Analogue Score ranged from 3 to 9, with an average of 5.7, which improved to an average of 1.5 at the final follow-up. Duration of healing time ranged from 21 to 90 days, with an average of 42.2 days. Motion of the arm, as patients could move their arm without pain, was allowed. Weight bearing for the lower limbs was also allowed as patients reported that pain subsided even when no complete healing was achieved according to radiological investigations. Conclusion The presence of an ABC leads to the risk of fractures and recurrences after various modalities of treatment. The BM has the advantage of percutaneous treatment (minimal invasive) and no recurrence was reported in the current study.
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Registry on the management of postmenopausal and corticosteroid-induced osteoporosis in Egypt p. 215
Timour El-Husseini, Adel H Adawy, Hassan M Bassiouni, Elhusseini E Elsaka
Objectives Osteoporosis is a systemic disease which is characterized by low bone mineral density and abnormal bone architecture, which subsequently leads to bone fractions. The most common types of osteoporosis are postmenopausal osteoporosis and corticosteroid-induced osteoporosis. Long-term treatment and high compliance are required in treatment of osteoporosis to successfully achieve the beneficial goal of reducing future fractures and enhancing quality of life. Hence, the primary objective of this disease registry study was to describe the therapeutic management trends for postmenopausal and corticosteroids-induced osteoporosis and to improve our understanding of the choice of medication prescribed by the physicians, whereas the secondary objectives were to characterize the factors influencing patient compliance and to collect inefficacy data and fracture data in compliant and noncompliant patients over long term (over 6 months of treatment). Patients and methods This study was a local, multicenter, observational disease registry. The study comprised a single baseline visit and four follow-up phone calls over 6 months of duration. A total of 571 patients were enrolled who fulfilled the inclusion and the exclusion criteria of the study. Results The most commonly prescribed osteoporosis treatment class was bisphosphonates in 523 (91.6%) patients, followed by calcium in 458 (80.18%) patients, vitamin D3 or vitamin D in 288 (50.4%) patients, and calcitonin in 35 (6.1%) patients. The assessment of patient compliance showed that 409 (71.6%) patients were fully compliant throughout the 6-month follow-up period, whereas 162 (28.4%) patients were noncompliant. The most frequent causes of noncompliance were gastritis, missing doses, poor improvement, and patient on several medications. Patients who were compliant to their medications showed lower fracture rates than those who were noncompliant. Conclusion Bisphosphonates and calcium were the most frequently prescribed medications. Lower numbers of fractures were noticed in compliant patients than in noncompliant patients.
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Opening wedge high tibial osteotomy as treatment for chronic multiple ligament injuries in the varus knee: the rationale of treatment and early results p. 223
Adham Elgeidi, Abd Elrahman Elganainy, Farouk Youssef
Background In patients with chronic multiple ligament-injured knee, failure to correct the varus malalignment of the knee and posterolateral instability will often result in failure of ligament reconstruction. Opening wedge high tibial osteotomy (HTO) can address both the varus and anteroposterior instability. Purpose To assess the functional outcomes of opening wedge HTO in treating anteroposterior instability and varus malalignment of the knee in patients with chronic multiple ligament-injured knee. Patients and methods Overall, 12 patients with 12 knees with combined grade 3 posterolateral, anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL) instability and varus alignment of the knee were treated with opening wedge HTO. All 12 varus knees had grade 3 posterolateral instability. Moreover, six patients had ACL deficiency, four patients had PCL deficiency, and two patients had combined ACL and PCL deficiency. Posteromedial opening wedge HTO was done for the ACL-deficient knees to decrease the tibial slope. Anteromedial opening wedge HTO was done for the PCL-deficient knees to increase the tibial slope. Knees with combined ACL and PCL deficiency were treated by posteromedial opening wedge HTO to address the ACL deficiency. Second-stage ligament reconstruction was performed in patients with continued instability after the osteotomies had healed and after at least 6 months of rehabilitation. Results Of 12 knees, eight had sufficient improvement in knee function that a subsequent ligament reconstruction was not necessary. There was a significant difference between the preoperative and postoperative coronal (femorotibial angle) alignments. There was a significant difference between the preoperative and postoperative posterior tibial slopes in the ACL patient group but not for the PCL patient group. Of six patients with ACL injuries, two required posterolateral complex (PLC) reconstruction, one of them needed in addition ACL reconstruction. Of four patients with PCL injury, one required PLC and PCL reconstruction. Of two patients with combined ACL and PCL injury, one required PLC and PCL reconstruction. Of six patients with high-velocity knee injuries, four needed further ligament reconstruction. Conclusion Opening wedge HTO can be an effective method of treatment for patients with combined chronic multiple ligament injuries and varus knee. Patients with an appropriate opening wedge and manipulation of the slope to enhance stability may not require the second soft tissue procedure. Patients with low-velocity knee injuries may not require a second-stage ligament reconstruction after healing the osteotomy and rehabilitation.
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Management of crescent fracture–dislocation of the sacroiliac joint: iliosacral screws versus plate fixation p. 231
Sherif A Khaled, Mahmoud M Abdel Karim, Ahmed H Abdel-Azeem
Background Crescent fracture–dislocations are a well-recognized subset of pelvic ring injuries, which result from a lateral compression (LC) force. They are characterized by the disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. They are classically fixed using open reduction and internal fixation using plates and screws. We hypothesized that iliosacral screws (IS) can provide stable fixation in Day type II and Day type III. Patients and methods This clinical study was conducted with the aim of assessing the clinical results and functional scores of 43 patients (34 male and nine female patients). Their ages ranged from 16 to 64 years. The study included 43 patients who had sustained LC pelvic fractures (44 fractures) and had been operated upon between April 2000 and June 2010 (one patient had sustained bilateral fractures). Radiography and computed tomography of the pelvis were obtained for all patients. The classification by Day and colleague was used with three distinct types of crescents. Percutaneous IS alone were used in 20 fractures; a plate was used in 22 fractures, and two fractures were fixed with both plates and IS. LC II (LC screws) were added in two cases. The average follow-up period was 53 months (range: 4–126 months). Two patients died and one patient was lost to follow-up. The principal goal of surgical intervention was the accurate and stable reduction of the sacroiliac joint. Results Intraoperatively, there was no significant blood loss in cases treated with IS; the average blood loss in cases treated with open reduction and internal fixation using the plate was 600 ml (range: 200–1000 ml). The operative time was shorter for cases treated with IS (40 min; range: 30–60 min) than that for cases treated with plates (100 min; range: 60–150 min). The difference was statistically significant with a P-value of less than 0.001. The clinical results were good in all cases; there were no wound complications, neurological complications, or residual rotational deformity of the limb. The healing rate was 100%. The Majeed score was used for functional evaluation, and the mean score for the 40 patients was 86.2 points (range: 53–100 points); 26 (65%) patients scored greater than 85 points (excellent), 12 (30%) patients scored 66–84 points (good), and two (5%) patients scored 53 and 64 points (poor). The average Majeed score for the group fixed with plates was 84.56 points (range: 66–100 points), and it was lower than the Majeed score for IS, which was 87.2 points (range: 53–97 points). However, the difference was not statistically significant, with a P-value of 0.404. The average Majeed score for cases fixed with plates and IS was 91.5 points (range: 90–93 points). Discussion and conclusion Percutaneous IS fixation is a good option for types II and III crescent fractures, with lesser blood loss and shorter operative time compared with plate fixation. The functional outcome of the cases fixed with IS was better; however, the difference was not statistically significant. Level of evidence The level of evidence was IV (case series).
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Ilizarov hip reconstruction osteotomy for neglected dislocation of the hip in young adults p. 238
Osman A.E. Mohamed
Background Neglected dislocation of the hip joint in young adults is a difficult problem. Patients with an unstable hip secondary to any aetiology usually have loss of bone from the proximal femur or shortening of the limb or both. Objective In the present study we report our results in the treatment of the neglected dislocation of the hip joint in young adults by pelvic support osteotomy using the Ilizarov method. Patients and methods From 2007 to 2014, 30 patients (20 women and 10 men) with neglected dislocation of the hip joint were treated in the Orthopaedic Department of Al-Azhar University Hospital, Damietta, Egypt. Their mean age was 22.5 years (range: 19–35 years). The main complaints were pain, leg length discrepancy, limping and limited abduction of the hip. All patients underwent valgus extension osteotomy in the proximal femur and distal femoral osteotomy for lengthening. The average follow-up ranged from 2 to 7 years. Results All hips were pain free at follow-up. The Trendelenburg sign became negative in 25 patients. There was no limb length discrepancy and alignments of the extremity were re-established. Five patients had a lurch gait. Valgus extension osteotomy provided stability of the hip joint and maintained some motion of the hip joint. By using the Ilizarov technique we could prevent the valgus effects created by the valgus extension osteotomy while achieving lengthening of the femur through distal osteotomy in the femur. Conclusion Pelvic support osteotomy with Ilizarov modification can provide an alternative to other techniques in managing patients having excision arthroplasty who are severely disabled as a result of abductor weakness, instability and limb length discrepancy.
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Conversion arthroplasty after failed dynamic hip screw fixation of intertrochanteric fractures p. 243
Emad G.K. Mohamed El Banna
Background Failed treatment of intertrochanteric fractures typically leads to profound functional disability and pain. Factors that guide the choice of salvage treatment include the anatomic site of nonunion, the quality of the remaining bone and articular surface, and patient factors (such as age and activity level). Patients and methods Between 2010 and 2013, 30 patients (seven women and 23 men) with a mean age of 60 years (range: 50–70 years) were treated at the Orthopedic Department of Beni Suef University, following failure of internal fixation with dynamic hip screw of intertrochanteric fracture, using prosthetic replacement (12 bipolar hemiarthoplasty and 18 total hip replacement). The average follow-up was 14 months (range: 3–26 months). Results At the end of follow-up, nine hips had excellent results, 11 had good result, five had fair results, and five had poor results according to Harris hip score. Conclusion Hip arthroplasty is an effective salvage procedure after the failed treatment of an intertrochanteric fracture in older patients.
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Posterior bone block: a reliable method to treat recurrent nonlocked posterior shoulder dislocation with engaging reverse Hill–Sachs lesion p. 252
Mohamad H Fahmy
Background Posterior shoulder dislocation was first reported in 1839 by Sir Astley Cooper. Hill and Sachs, in 1940, stated that with any dislocation event the soft bone of the humeral head impacts against the harder, sharper edge of the glenoid, leading to an impression fracture of the posterosuperior head in recurrent anterior dislocation. A reverse Hill–Sachs lesion is an impression fracture in the anterosuperior head in recurrent posterior dislocation. In 1952, McLaughlin described his surgical technique to treat an anterior impression fracture of the humerus after recurrent posterior shoulder dislocation. Hypothesis Our hypothesis is to prove that posterior bone block augmentation of the posterior glenoid is a safe and reliable line of treatment in cases of recurrent posterior instability with engaging reverse Hill–Sachs lesion. Patients and methods Between March 2009 and March 2011 five cases were referred to us with chronic recurrent posterior shoulder dislocation with engaging reverse Hill–Sachs lesion. The mean age of the patients was 28 years (range: 20–36 years). There were two left and three right shoulders. All patients were male. All patients were manual workers. All sustained traumatic dislocations through nonathletic accidents. None of the patients had epileptic fits before. Preoperatively, the mean active forward elevation was 140° (range: 130°–150°) and external rotation with the arm at the side was 35° (range: 20°–50°). Preoperative constant score average was 40 points (range: 30–50 points). The mean time interval between injury and surgery was 12 months (range: 8–16 months). All cases had engaging reverse Hill–Sachs lesion. None of the cases had significant posterior glenoid bone loss. All patients were treated with open posterior bone block augmentation of the posterior glenoid harvested from the anterior iliac crest. Results Patients were evaluated at 3, 6, 12, and 24 months. Range of motion was recorded and follow-up radiographs were taken to evaluate graft incorporation. The mean follow-up time for the five patients was 30 months (range: 24–36 months). At 6 months postoperatively, the mean forward elevation was 165° (range: 160°–170°) and external rotation with the arm at the side was 55° (range: 40°–70°). Patients were evaluated postoperatively according to the constant score system (maximum: 100 points). We found a mean postoperative constant score of 87.5 points (range: 80–95 points), a fairly good result considering the nature of bone loss. Conclusion The posterior bone block can successfully restore the stability and function of the shoulder in patients with recurrent posterior dislocations with significant engaging reverse Hill–Sachs lesion in which arthroscopic soft-tissue reconstruction is not a reasonable option. This technique can be used for combined soft tissue and bony defects as well as for revisions after previous soft-tissue reconstructions.
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Analysis of different causes and risk factors of anterior cruciate ligament reconstruction failure p. 263
Roshdy M El Sllab, Abd El Rhman A El Ganayny, Naser M Selim
Background Anterior cruciate ligament (ACL) reconstruction failure is characterized by recurrent knee instability, stiffness, or pain that prevents a patient from participating in his or her chosen activities. The etiology of ACL reconstruction failure is multifactorial; surgical errors, infection, trauma, and/or associated pathology are blamed. Aim The purpose of this retrospective study was to define and analyze the causes of failure of ACL reconstruction. Patients and methods This study reviewed 300 patients who underwent ACL reconstructions, which were performed at Mansoura knee Surgery and Arthroscopy Unit over a 5-year period from 2005 to 2010. Untreated laxity, angular deformity, femoral and tibial tunnel malposition, method of fixation, and meniscus surgery were assessed; new trauma and infection were recorded. Assessment included knee stability tests, range of motion, and International Knee Documenting Committee scoring system evaluation. Results In our study, the rate of ACL reconstruction failure was 7%. The main causes of failure were malpositioned tunnels (66.5%) and new trauma (24%). However, 15% of malpositioned tunnels caused failure and 50% of trauma caused failure. Moreover, 33% of infection, 5% of extracortical fixation, 2.2% of partial menisectomy, and 6% of preoperative varus knee were associated with failure. Conclusion Malpositioned tunnels and new trauma are the dominant causes of ACL reconstruction failure. Infection, extracortical fixation, partial menisectomy, and varus knee are risk factors for ACL reconstruction failure; thus, the failure is multifactorial.
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Bone marrow injection for the treatment of bone cysts before skeletal maturity p. 270
Ahmed Sh Rizk, Mohamed O Hegazy, Osama A Wahab Elmansy
Background Bone cysts are benign, osteolytic, fluid-filled bone lesions mostly seen before skeletal maturity. Various treatment modalities with variable outcomes have been described in the literature, but there is no consensus as regards the best procedure. Traditional bone grafting techniques have given way to newer cellular therapies that are potentially less invasive and have a lower complication rate and faster recovery time. The percutaneous method can be used with different materials such as bone marrow (BM) or bone substitutes to optimize results. BM contains the osteoprogenitor cells, various bone morphogenetic proteins, growth factors, and other signaling molecules that provide the appropriate environment for bone formation and remodeling. Aim The aim of this study was to evaluate the role of autologous BM injection in the treatment of different types of bone cysts in children below the age of skeletal maturity as regards the healing time, the occurrence of pathological fractures, and recurrence after healing. Patients and methods Totally, 20 patients with accidentally discovered, uncomplicated bone cysts of different types were included in this prospective case series study. All patients were below the age of skeletal maturity. Patients were evaluated clinically and radiologically before surgery. All cases were treated with three repeated injections (at 3 weeks’ intervals) of BM aspirated from their iliac crests and injected in the cystic lesions under image intensifier. Patients were followed up for a mean time of 26 months postoperatively. Results The results were successful in 18 patients (90% of the studied patients), with a mean healing time of 15.4 weeks. Totally, 15 cases (75% of the studied patients) had completely healed and were graded as Neer I, whereas three cases (15% of the studied patients) healed with small defects and were graded as Neer II, with good functional and radiological results. Only two cases (10% of the studied patients) had recurrence and were considered as failure (Neer IV). Conclusion The satisfactory clinical and radiographic results of this study support the use of percutaneous autologous BM injection as one of the treatment options in the management of cases with bone cysts of different types in patients below the age of skeletal maturity as an easy, safe, simple, and effective treatment method. Repeated injections improve healing rate and shorten the healing time.
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Treatment of aneurysmal bone cyst by curettage and hydrogen peroxide as an adjuvant without refilling of the resultant cavity p. 277
Awad A Rafalla, Amin A Youssef
Background Aneurysmal bone cyst (ABC) is a rare tumor-like lesion with wide controversy as regards the perfect means of treatment and the way to manage the resulting bony cyst after curettage. Patients and methods The study included 24 patients: 13 were male and the mean age was 12.6 years (range: 6–26 years). Six cases were diagnosed as solid ABC, nine (37.5%) cases were in the proximal femur. All cases were treated by thorough curettage followed by washing the cyst with hydrogen peroxide for 5 min. No bone graft or substitute was used as a filler of the cysts, except strut fibular graft, which was used to stabilize weak cysts in nine cases. Plaster cast was used in 11 cases for external fixation. Follow-up ranged from 12 to 46 months (mean: 25 months). Results All cysts healed without pathological fracture. There was no local recurrence until the end of follow-up. All patients returned back to normal life. Conclusion Thorough curettage with lavage of the cyst with hydrogen peroxide could be an acceptable method of treatment of ABC without the need of refilling of the resulting cavity.
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Scaphoid excision and four-corner fusion in the treatment of scaphoid nonunion advanced collapse p. 282
Fathy H Salama, Mohamed A Hassan, Moataz M Mostafa
Background Four-corner arthrodesis with scaphoidectomy is a time-tested, motion-sparing wrist procedure and biomechanically sound intercarpal fusion that results in near-normal load transmission through the radiolunate articulation that has evolved over the past 20 years. Aim The aim of the present study was to evaluate the results of scaphoid excision and four-corner fusion with fixation by K wires in the treatment of stage II and III scaphoid nonunion advanced collapse. Patients and methods A prospective study was conducted from March 2013 to November 2014 at the Al-Azhar University Hospital in Damietta. The study included 20 patients with established scaphoid nonunion advanced collapse grade II and III. All patients were males, and all cases involved the dominant hand (right hand). Their average age was 35 (25–48) years. Their occupations in terms of wrist loading were as follows: 10 patients were heavy manual workers and 10 patients were light manual workers. The mechanism of injury was ‘fall on an outstretched hand’ in 16 cases and ‘hit by heavy object’ in four cases. Results A total of 20 cases were included in this study − 14 of them had good results, four patients had fair results, and two patients had poor results. On reviewing all patients, the following points were checked with each patient: pain and tenderness, range of motion, grip strength, and patient satisfaction. In all patients, we found that there was soft tissue (synovium) interposition, instability, and deformity. Ten patients had 40–100% satisfaction, four patients had 0–100% satisfaction, four patients had 0–80% satisfaction, and the last two patients had 0–40% satisfaction. All patients showed radiological solid fusion by the end of the follow-up period. The mean time to achieve fusion was 10 (9–12) weeks. There were no intraoperative complications. Postoperatively, two patients presented with superficial wound infection that resolved completely with local measures and IV antibiotics (third generation cephalosporin). Two patients showed dorsal impingement of the capitate and the radius. Four patients developed reflex sympathetic dystrophy that also resolved within 6 months after cast removal with physiotherapy and active hand exercise. None of the patients showed deep infection, nonunion, or de Quervain tenosynovitis. Conclusion Patient satisfaction was high, and the procedure offered good-to-excellent pain relief. Advances in surgical exposures, fixation techniques, and implants have allowed for rigid fixation that enables rapid union and commencement of early range of motion. Failure rates and complication rates are relatively low, and the long-term outcomes are promising.
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