Introduction There is considerable debate as to the ideal procedure for the treatment of symptomatic flexible flatfoot (FFF) that is not followed by recurrence and that minimizes complications. The purpose of the present study was to evaluate the results of calcaneal lengthening using Mosca's technique in adolescents with FFF in whom conservative treatment had been applied for more than 1 year but had failed. Patients and methods Calcaneal lengthening osteotomy was performed using Mosca's technique in 14 patients including ten males and four females. Five cases were bilateral making the total of 19 feet. The mean age at surgery was 13.53 (range 11.5–16) years. All FFF patients were evaluated as idiopathic. Bilateral cases were operated on at two sessions with an average interval of 15.6 (range 12–21) months. The American Orthopaedic Foot and Ankle Society ankle-hind foot scale was used for clinical assessment, and radiographic assessment was based on six parameters on standard anteroposterior and lateral radiographs. Results The mean follow-up period was 27.89 (range 18–44) months. The mean American Orthopaedic Foot and Ankle Society score increased from 57.53 preoperatively to 96.32 postoperatively. All radiographic parameters significantly improved. Four patients had mild occasional pain. There was no nonunion nor secondary subsidence of the arch. All patients stated that they were satisfied with the procedure. Conclusion Correction of FFF deformity with Mosca's lateral calcaneal lengthening was an effective and reproducible method to restore normal foot alignment and good function.

Study design This is a prospective nonrandomized single-surgeon experience of posterior lumbar interbody fusion (PLIF) using a single polyetheretherketone (PEEK) transforaminal lumbar interbody fusion (TLIF) cage in degenerative lumbar disorders. Summary of background data The PLIF procedure has gained popularity, with different indications. TLIF PEEK cages can be used either singly or doubly. There are several practical problems encountered in the TLIF procedure with implantation of two cages. Objectives The aim of this work is to evaluate single-surgeon experience of early results of PLIF using a single PEEK TLIF cage in degenerative lumbar disorders. Patients and methods The study included 19 consecutive cases with degenerative lumbar disorders. There were 12 female and seven male patients. Their age ranged between 22 and 68 years. The follow-up period ranged between 6 and 16 months. All patients were diagnosed using MRI. Postoperative and follow-up radiography and multislice computed tomography were used to verify the screws and position of the cage, to exclude cage subsidence or migration, and to show the fusion status. The Visual Analog Scale (VAS) for back and leg pain was used. Results All the patients had good cage positioning and none had instrumentation failure or screw loosening. Postoperative intervertebral height in all the patients was better than the preoperative ones. Moreover, cage migration, retropulsion, subsidence, or pseudoarthrosis was not observed at the end of follow-up. VAS for leg pain showed a statistically significant improvement from 7.9 preoperatively to 2.8 at the end of follow-up. VAS for back pain also showed a statistically significant improvement from 6.8 preoperatively to 3.7 at the end of follow-up. Conclusion Early results of PLIF using a single PEEK TLIF cage in degenerative lumbar disorders are encouraging. However, longer follow-up is still necessary.

Background Traditional diaphragmatic incision to expose the thoracolumbar junction is associated with significant morbidity. In an effort to eliminate the drawbacks during and after thoracolumbar exposure, the technique of diaphragmatic mobilization has been developed to expose T12, L1 and upper L2 vertebral bodies. Objective The objective of this study was to demonstrate the feasibility and clinical experience of diaphragmatic mobilization technique to the thoracolumbar junction. Materials and methods Seventeen patients with spinal pathology at the thoracolumbar junction (T12, L1 and L2) underwent surgery using left-sided thoracotomy with diaphragmatic mobilization. In each case, the lateral aspect of the involved vertebra with the disc space proximal and distal was exposed with the mid-vertebra proximal and distal. Preoperative and intraoperative fluoroscopy was used to assure correct level together with daily postoperative chest radiography until chest drain removal. Operative results, complications and early outcomes were assessed. Conclusion Diaphragmatic mobilization allowed adequate thoracolumbar exposure to perform corpectomy, decompression and strut grafting plus or minus fixation without the need for circumferential release, thus avoiding its possible complications. In addition, it can be considered as an alternative for surgeons lacking experience, or facilities with video-assisted thoracoscopic surgery.

Background Superficial and deep medial collateral ligament (MCL) together with the posterior oblique ligament (POL) works in harmony to control anteromedial rotatory instability (AMRI) throughout the knee range of motion (ROM). Associated anterior cruciate ligament (ACL) injury, the most common type of combined ligamentous knee injury, will worsen the instability in all directions, greatly compounding the challenge to the management plan. Hypothesis Near-anatomical reconstruction of both the ACL and the MCL will restore knee AMRI to normal with minimal ROM deficit. Patients and methods Twenty-five patients with chronic combined ACL and MCL injury (>3 months since injury) were included in this study. Anatomical ACL with percutaneous MCL-POL was performed and the patients were assessed at 2 years for knee stability, ROM, and complications. Results The mean subjective International Knee Documentation Committee score among the patients was 43.32 ± 7.58 (range 28–60) at the end of follow-up. The mean was 94.76 ± 3.7 (range 89–100) (P < 0.0001). Knee stability was restored to normal in 84% and to nearly normal in 16%. Conclusion Anatomical ACL with percutaneous MCL-POL reconstruction gives very good results in cases of chronic AMRI. This technique is associated with little morbidity and can be achieved through minimally invasive incisions.

Background In patients with infected nonunion the primary goal is eradication of infection, before achieving union. Release of antibiotics from bone cement at a higher concentration prevents bacterial growth and formation of biofilm by bacteria. Penetration of antibiotics to the surrounding tissue, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. Patients and methods This was a prospective study of 12 patients with infected nonunions managed with antibiotic-impregnated bone cement who were followed up for an average period of 1.2 years, with encouraging results. The infected fracture site was exposed and thorough debridement done. The implant was replaced with vancomycin and clindamycin-impregnated cement following adequate debridement. Culture and sensitivity was done for the debrided tissues to identify the pathogen and sensitive antimicrobial agent. Follow-up was performed clinically, radiologically, and using laboratory investigations (by complete blood cell count, erythrocyte sedimentation rate, C-reactive protein). Results Infection was eradicated in all patients except one after an average period of 9 weeks (range: 6–14 weeks). Culture revealed no growth and discharge disappeared at the end of this period. Cement was removed after an interval of 6–12 weeks after control of infection and was replaced with definitive fixation with or without bone grafting. Conclusion Management of infected nonunions using antibiotic-impregnated cement is a simple and very effective method that allows infection control and promotes bone union. This simple procedure is encouraging, cost effective, and less cumbersome.

Background It is important to ensure a hip replacement that has no complications and lasts for a reasonable length of time especially in young active patients. The ideal articulation should have good lubrication with minimal wear, should be hard enough to resist fractures, and should be highly biocompatible and available in different head sizes. The use of ceramics as bearing surfaces has had a long and successful history. Ceramic-on-ceramic (C.o.C) is a very wear-resistant, versatile articulation with different neck lengths and head diameters (28–32 mm, with large ceramic heads with a diameter of 36–40 mm now available). Aim The aim of the study was to investigate a possible effect of different ceramic head sizes on early clinical results in patients treated with C.o.C total hip replacement (THR), with special concern on postoperative hip range of motion (ROM) and stability. Patients and methods This study included 40 cases in 35 patients with end-stage arthritis. All cases were treated with C.o.C THR. Cases were divided into three groups according to the size of the ceramic head. Group I included 13 cases with 28-mm heads. Group II included 12 cases with 32-mm heads. Group III included 15 cases with 36-mm heads. Results were assessed according to the Harris Hip Score (HHS). Results There was significant improvement in the HHS at 6 weeks postoperatively in all the three groups compared with the preoperative HHS; this improvement became much more significant at 6 months postoperatively. At 6 weeks postoperatively, there was a statistically nonsignificant difference in the mean postoperative hip ROM scores between group I and group II cases and also between group II and group III cases, whereas there was a statistically significant difference in the mean postoperative hip ROM scores only between group I and group III cases. At 6 months postoperatively, the difference in mean postoperative hip ROM scores between all the three groups of cases became statistically nonsignificant. Although dislocation occurred in only one case (representing 2.5% of all the studied cases) with a 28-mm head, no sharp correlation between the head size and dislocation was detected. Conclusion Increasing the head size can safely improve the ROM especially in the early postoperative period but the term ‘large head’ could be a relative or a nonspecific term when considering the clinical (true) but not the technical (theoretically possible) ROM or if the relation between the head diameter to the size of the ceramic liner/cup construct and the head/neck ratio are not considered. The head size is critical for stability in THR but dislocation is multifactorial. Although C.o.C articulation is a marvelous bearing surface for young active patients, especially women in the child-bearing period, the 36-mm heads could not be used in most female cases (being restricted by the size of the native bony acetabulum), and therefore male patients have a better scope of being treated with 36-mm heads.

Objective The purpose of this study was to describe the use of dermal fillers in the treatment of large, soft-tissue defects in diabetic foot with and without the use of external fixation of the foot. Patients and methods Thirteen patients with chronic nonhealing diabetic foot ulcer for several weeks to months were included in the study. There were 11 male and two female patients. Seven patients (three female and four male) were randomly assigned to the Botox injection group, and six patients (four female and two male) were randomly assigned to the external fixator group. The mean ± SD age of patients was 55 ± 10 years. Results At 12 weeks, the proportion of healing was significantly higher in the Botox with an external frame group than in the Botox alone group (89.5 vs. 61.4%, P = 0.026). At final follow-up, 12 (92.3%) patients were ambulatory with a regular or custom shoe and had a good result based on our defined criteria. There were no complications from the injections. Conclusion The use of Botox together with an external fixator is an attractive choice to off-load diabetic foot ulcer.

Purpose The aim of this study was to review the outcome of the Evans technique in patients with chronic lateral ankle–ligament instability. Patients and methods Between August 2009 and June 2012 a prospective study was conducted on 14 patients between 15 and 50 years of age (mean: 26.6 years) with chronic lateral instability who underwent the Evans technique and followed up for 2 years. Patients were assessed postoperatively using the Kaikkonen ankle scoring scale. Stress radiographs were also obtained to evaluate talar tilt and anterior drawer. Results The results were good to excellent in 79% of the 14 patients, fair in 14%, and poor in 7% of patients. Clinical examination showed an anterior drawer test results were equal to or less than that on the unaffected side in 75% of patients. Stress radiographs showed a mean anterior drawer of 7.0±1.8 mm and a mean talar tilt of 4.8 ± 3.8°. Conclusion The Evans reconstruction procedure is a valuable option in treating recurrent and complex chronic lateral ankle instability and provides good ankle instability, particularly when the original, frayed ligaments cannot be easily identified.

Background The tibial plateau is a critical weight-bearing area located on the upper end of the tibia. The lesion may be restricted to the tibia or associated with significant soft-tissue injury. The aim of the present study is to assess the results of closed reduction and Ilizarov external fixation in management of comminuted tibial plateau fractures. Patients and methods The study included 20 patients with high-energy tibial plateau fractures (Schatzker types V and VI). The ages ranged from 23 to 56 years, with an average of 30 years. The trauma was a road traffic accident in 11 cases and a fall from a height in nine cases. The fractures were closed in 16 cases and open in four cases. The open fractures were Gustilo–Anderson type I in one case and type II in three cases. Soft-tissue injuries associated with closed fractures were classified according to Tscherne system. The follow-up period averaged 31 months. The mean duration of surgery was 70 min (range: 40–120 min). The mean time to union was 10.4 weeks. At the final follow-up, the average total range of knee flexion was 112.5° (range: 0–170°). Results Results were satisfactory in 18 cases and unsatisfactory in two cases according to the Rasmussen knee functional score. Complications included pin-tract infection in 12 cases, an extension lag in two cases and varus deformity of about 15° in one case. Conclusion Hybrid external fixation is a good method for the treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Background Anterior cervical discectomy and fusion is the gold standard for the management of cervical radiculopathy. Different materials (cages and plates) were used. Aim This study is designed to compare the results between cages and plates for anterior interbody fusion for cervical radiculopathy. Patients and methods Twenty-four consecutive patients with single-level or double-level cervical radiculopathy that was refractory to conservative treatment were treated surgically. Twelve patients were treated with the stand-alone cage procedure (cage group), and an additional 12 patients were treated with the anterior plating method (plate group). They were selected from Al-Azhar University Hospitals during the period from August 2013 to February 2015. Results There was a significant increase of overall complications in the plate group when compared with the cage group. In addition, the overall outcome was significantly better in the cage group when compared with the plate group (outcome was excellent, good, and fair in 58.3, 33.3, and 8.3%, respectively, in the cage group, compared with 8.3, 50.0, and 41.7% in the plate group with the same order). This outcome was confirmed by the Prolo score, which was significantly higher in the cage group when compared with the plate group (8.41 ± 1.08 vs. 7.41 ± 0.99, respectively). Finally, comparing single or double levels in both groups revealed that outcome was significantly better in the cage group when compared with the plate group. Conclusion Both cage and plating are good methods for interbody fusion in the treatment of cervical radiculopathy. However, cage is better in the overall outcome, and it reduced overall complications in either single-level or double-level cervical radiculopathy.

Background Acetabular bone stock loss is a major problem in both primary and revision total hip arthroplasty (THA). The loosening of primary cemented and cementless components of THAs is also accompanied by a loss of bone stock. There are several options for reconstruction of the acetabular defects. In 1979, a biologic method was introduced with tightly impacted cancellous allografts in combination with a cemented polyethylene cup for acetabular reconstruction, to restore acetabular bone stock, to restore normal hip biomechanics, and to allow for further revision if needed. Aim of the work In this study, the results of using morcellized impacted bone graft to reconstruct the deficient acetabulum in 54 hips (49 patients) using either cemented or cementless cups are discussed, with a mean follow-up of 36 (6–96) months. Patients and methods Between May 2002 and April 2010, 54 hips (in 49 patients) with deficient bone stock on the acetabular side had undergone total replacement with acetabular reconstruction using morcellized bone impaction grafting; out of the 54 hips, 34 (63%) were primary THA (17 after fracture of the acetabulum, 12 for protrusio acetabuli, three for rheumatoid arthritis, one for dysplastic hip, and one after tuberculosis arthritis) and 20 hips (37%) were revision THA. There were 21 (43%) women (bilateral in three of them) and 28 (57%) men (bilateral in two of them). Average age was 53 years (range 26–98 years). Out of the 54 hips, 14 (26%) were cementless and 40 (74%) were cemented. Mesh was used in 27 (50%) hips to convert a noncontained defect into a contained defect. Octopus ring was used in one hip, and Muller ring was used in another hip to overcome pelvic discontinuity. Results Fifty-four hips in 49 patients were followed up clinically and radiologically, with a mean follow-up of 36 months. In 46 hips (95.8%), the graft showed radiological signs of union to the host bone and no cup loosening. Cup was loose and revised in two patients (4.2%). One patient had octopus ring and morcellized graft in the first operation, and it was revised using a mesh and morcellized graft 8 years later. The other patient had morcellized graft and Muller ring; this failed after 4 years with cup loosening. It was revised using mesh and morcellized graft. Conclusion Acetabular reconstruction is a demanding procedure and needs preoperative planning and armamentarium. Successful results were obtained using the impaction technique for reconstruction. The aim of bone graft is to restore the normal hip mechanics. The union rate of the impacted graft is relatively satisfactory compared with other grafting methods. Augmentation of the grafting technique by mesh or rings added more stability to the cup component. The use of impaction graft in revisions for infected hip did not increase the risk of reinfection.

Background The treatment of distal tibia fractures remains controversial. Despite the well-known advantages of nailing, its use in distal tibia fractures has been reported to be associated with technical difficulties and high malalignment rates. Many surgeons are still hesitant to use nailing for distal tibia fractures. Objectives The aims of this prospective study were to evaluate the results of using static-reamed intramedullary nailing in the treatment of distal tibia fractures, and to define the situations in which nailing may be preferred. Patients and methods Between January 2008 and December 2011, 30 patients – 21 men and nine women – were treated in King Fahad Hospital at Al-Baha, KSA. Their mean age was 28.6 years. According to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, 20 cases had type A, eight had type B, and two had type C fractures. Ten fractures were open: four type I, five type II, and one type III-A. The American Orthopedic Foot and Ankle Society ankle–hindfoot scale was used for assessment in this study. Results The mean follow-up time was 26.3 months. Three patients with open fractures got superficial infections. All the fractures united with acceptable alignment in a mean time of 15.74 months with two delayed unions. No difference in alignment was encountered between the immediate postoperative and final radiographs. Limb length discrepancy of 5 mm or less was encountered in one patient. Two (6.66%) patients had less than or equal to 10° reduced range of ankle motion. One (3.33%) patient lost his job, four (13.33%) patients did not return to their preinjury daily activity, and eight (26.66) patients stopped sports-related activities. Implant removal was carried out for three patients with knee pain. The mean American Orthopedic Foot and Ankle Society score was 93 at the end of follow-up. Conclusion Static-reamed nailing is a safe and effective biological stable fixation option in treating distal tibia fractures. Nailing may be preferred in uncontrollable patients, open fractures, osteoporotic bone, pathological fractures, obese patients, and when early weight-bearing is unavoidable. We did not recommend nailing for articular comminution, failure of closed reduction, and types III-B and III-C open fractures.

Background Treatment of distal tibial fractures is often challenging and fraught with complications. Minimally invasive plating is thought to overcome complications associated with open plating and intramedullary fixation in the distal third of the tibia. The aim of this study was to evaluate the use of minimally invasive plating in extra-articular fractures of the distal tibia regarding time to union, functional outcome, and complications. Patients and methods Thirty consecutive patients with extra-articular fractures involving the distal third of the tibia were classified according to the Muller-Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and treated with minimally invasive plating using the anatomical distal plate. In nine cases, the locked anatomical distal plate was used, whereas in 21 cases the conventional nonlocked anatomical distal plate was used. Patients were followed up at 2 and 6 weeks postoperatively and then every 6 weeks with a mean follow-up time of 30 weeks (range: 18–94 weeks), in which time to union and complications were documented. Functional outcome was assessed using the American Orthopedic Foot and Ankle Society ankle scoring system at a minimum of 12 weeks from the start of weight-bearing. Results All cases showed union at a maximum of 16 weeks, except four cases: two had delayed union, one had plate failure that ended in deep infection, and there was a case of nonunion. Overall, the mean time to union was 17 weeks (range: 6–60 weeks). The American Orthopedic Foot and Ankle Society ankle scoring system scored an average of 92.4 points (range: 72–100 points). Conclusion This technique minimizes the soft-tissue complications and provides a good functional outcome for patients with extra-articular distal tibial fractures within a reasonable period of time. Level of evidence The present study was a level IV case series.

Purpose Patients who undergo an open carpal tunnel surgery frequently complain of a postoperative tender scar as a result of the long incision and of excessive scar formation. Instead, in this study, a double mini skin incision, each 1-cm long, was used in the surgical treatment of the carpal tunnel syndrome (CTS) by using classic instruments with no need for an endoscope. The transverse carpal ligament was easily sectioned. Patients and methods The study population consisted of 40 patients treated in El-Kasr El-Eini Hospital, with CTS and a mean age of 47 years (range: 28–65 years). The average follow-up duration was 12 months (range: 10–15 months). Inclusion criteria included patients with classic CTS without underlying autoimmune disease or traumatic injury. Recurrent cases were excluded in this study. Results Surgical results were evaluated using the Boston Carpal Tunnel questionnaire. Postoperatively, only one patient complained of residual mild pain and one patient complained of residual weak handgrip. Conclusion Double mini incision in the treatment of CTS showed satisfactory pain relief, nontender scar with good functional outcome, and satisfactory healing of wounds.

Purpose The purpose of this study was to present the surgical technique together with the mid-term results for patients with calcifying tendinitis of the distal insertional part of the Achilles tendon. Materials and methods A total of 43 patients (23 female and 20 male), with a mean age of 54.8 (range: 21–71) years at the time of surgery, were operated between 1999 and 2012. Four patients underwent bilateral surgery, with a total of 47 feet undergoing the resection of the calcifying enthesiopathy of the Achilles tendon. A total of five patients were lost to follow-up including two patients who withdrew from the study. Subsequently, 39 patients were followed up with an average of 57.4 (6–144) months after surgery. Clinical and radiological evaluations were carried out and the hindfoot American Orthopedic Foot and Ankle Society score was used before and after the surgery. Results The postoperative American Orthopedic Foot and Ankle Society score at the time of the final follow-up was 88.9 (69–100) points. No ruptures of the Achilles tendon were documented in this study. There were two wound infections in need of revision surgery, and two cases of distal deep vein thrombosis. Overall, 70% of the patients worked at the time of the final follow-up. The average time off work reported in this cohort of patients was 10.5 (6–24) weeks. Conclusion The longitudinal incision of the Achilles tendon with distal release of the tendon and reinsertion with a suture anchor is a reliable procedure for the treatment of calcifying tendinitis of the Achilles tendon with good to excellent results for the majority of patients.