In the Hoffer technique, the tendons of the latissimus dorsi (LD) and teres major (TM) muscles are transferred to the rotator cuff posterior to the long head of the triceps muscle, which significantly improves external rotation and abduction range of motion in the shoulders of children with obstetric brachial plexus palsy (OBPP) with internal rotation contracture.
Ten children with OBPP C5/C6 pattern were included in the study and underwent simultaneous subscapularis recession and transfer of the LD and TM tendons to the rotator cuff through a single posterior incision. The age at the time of surgery ranged from 3 years and 3 months to 14 years and 1 month, with an average age of 7 years. The age at initial evaluation ranged from 1 year and 6 months to 9 years and 8 months, with an average of 5 years and 11 months.
There was significant improvement in the degree of active shoulder abduction, from a mean 72° (range 40–90°) preoperatively to 136° (range 90–180°) postoperatively. The preoperative passive shoulder external rotation averaged from 78° (range 0–100°) to 64°. The postoperative active external rotation ranged from 0 to 90°.
Transfer of LD and TM tendons through a single incision to the rotator cuff significantly increases the degree of abduction and external rotation in children with OBPP having internal rotation contracture.
Numerous pelvic osteotomies for the treatment of developmental dysplasia of the hip have been described.
To compare the outcome of two types of pelvic osteotomy, Salter and Dega, for the treatment of late-diagnosed developmental dysplasia of the hip.
This prospective study included 32 patients (36 hips), 18 girls and 14 boys, mean age 2.3±0.5 years. Patients were randomized for management with Salter or Dega pelvic osteotomy after open reduction and capsulorrhaphy with or without femoral shortening osteotomy. The Salter osteotomy group included 19 hips and the Dega osteotomy group included 17 hips. The median follow-up period was 12 months (range 9–20 months).
We achieved an overall success rate of 88.9% in the 36 hips, with no significant difference between the two techniques (89.5% in the Salter group and 88.2% in the Dega group, P=1.000). Both techniques achieved comparable reduction of the acetabular index (20.3±9.0π in Salter vs. 22.0±8.9° in Dega group, P=0.565). There was no significant difference in the center-edge angle between the two groups (34.8±13.0° in the Salter group and 37.4±12.1° in the Dega group, P=0.554).
We achieved comparable results with Salter and Dega osteotomy. The latter has a further advantage of avoiding a second surgery required in the Salter technique to remove hardware.
The management of acute trauma to the upper extremity includes the urgent treatment of injuries and the timing and choice of surgical stabilization and reconstruction. To evaluate and treat severe upper extremity trauma, the orthopedic surgeon should understand the principles of the emergency department and operating theater management of commonly seen traumatic injuries to the distal humerus, elbow, forearm, wrist, and hand. A review of the principles for treating these complex injuries, including principles of soft tissue coverage, will aid surgeons in achieving the goal of providing optimal treatment for their patients.
The incidence of posterior subluxation/dislocation of the shoulder secondary to obstetric brachial plexus palsy is found to be relatively high with increasing awareness of the condition and advances in radiological imaging. Left untreated, glenohumeral deformation and functional impairment are progressive with increasing age.
Twelve patients with posterior subluxation (five patients)/dislocation (seven patients) of the shoulder secondary to obstetric brachial plexus palsy were treated by operative reduction with concomitant anterior soft-tissue release and latissimus dorsi and teres major tendon transfers to the rotator cuff. The mean age at surgery was 3 years.
After a mean follow-up of 3 years, the mean aggregate Mallet score improved from 9.5 points preoperatively to 14.4 points postoperatively (increased by 51.6%). Abduction and external rotation improved significantly. Radiologically, the mean percentage of humeral head anterior to the midscapular line improved from 9% preoperatively to 42% postoperatively. All patients except one showed restoration of the dislocation, which was maintained until final follow-up. The mean glenoid version improved from −45.8° preoperatively to −8° at the latest follow-up.
The procedure used results in improved shoulder function and glenohumeral joint remodeling. Postoperative care and rehabilitation programs are mandatory for satisfactory outcome.
Harris and Allen had modified and described a calcar replacement femoral component, which is necessary for the conventional femoral components, as a part of total hip replacement to address many problems related to proximal femoral deficiency. The aim of this study was to compare the clinical and radiological outcomes of a primary salvage calcar replacement hip arthroplasty with secondary salvage calcar replacement hip arthroplasty for treatment of new (group 1, prospective) or failed osteosynthesis or end prosthesis treatment (group 2, retrospective) of unstable trochanteric fractures.
Fifteen patients were included in each group, with a mean age of 67.3 years for group 1 patients and 65.8 years for group 2 patients. The female-to-male ratio was 8 : 7 in group 1 and 10 : 5 in group 2. Incidence of preoperative comorbidities was 2.2 per patient in group 1 and 2.0 per patient in group 2. The mean time from the initial unstable trochanteric fracture to the time of calcar replacement hip arthroplasty was 4.2 days and 12.4 months in group 1 and group 2, respectively. The posterolateral approach using the posteriorKocher–Langenbeck proximally and the posterolateral approach distally for the proximal femur without trochanteric osteotomy. All patients were followed up clinically and radiologically, and at the end of the follow-up period (1–3 years) the Merle d’Aubigne and Postel score was used for functional evaluation.
The mean operative time was 105 and 155 min, the mean amount of blood loss was 550 and 850 ml, and the mean period of hospital stay was 11 and 21 days for group 1 and group 2 patients, respectively. Two patients in group 2 had required postoperative ICU admission. Postoperative complication(s) were reported in one patient (6.6%) in group 1 and in five patients in group 2. Postoperative psychological problems and mortality during the first year were reported in three patients (20%). The Merle d’Aubigne and Postel functional outcome score by the end of the first year was found to be satisfactory (above 14 points) in 100 and 93.3% of patients in group 1 and group 2, respectively. After 3 years of follow-up it was satisfactory in 83.3 and 66.7% of patients in group 1 and group 2, respectively.
Primary cemented calcar replacement hip arthroplasty for treatment of unstable trochanteric fractures is associated with lesser pain, better walking ability without mortality or psychological problems, and with measurable better overall functional outcomes compared with salvage calcar replacement hip arthroplasty.
Traumatic bone defects may be primary, following open fractures, or secondary to an aseptic or septic nonunion. The traditional procedures to bridge segmental bone defects include autogenous bone grafting, the open bone grafting (Papineau) technique, posterolateral bone grafting of the tibia, transplantation of allograft bone, and fibula protibia procedures. However, these procedures usually require multiple surgical procedures, no weight bearing during treatment, and have limited extent of bone defect reconstruction. Vascularized bone grafts and bone transport according to the Ilizarov technique show much better results. However, each has its advantages and disadvantages.
Between April 2001 and September 2008, we treated 32 patients with post-traumatic tibial bone defects at the El-Hadra University Hospital. The patents were divided into two groups: group 1 consisted of 17 patients who were treated using the Ilizarov bone transport technique; group 2 consisted of 15 patients who were treated by vascularized fibular grafting. The average age of the patients at the time of the surgery was 39.9 years in group 1 and 29.7 years in group 2. The mean length of the bone defect was 4.1 cm in group 1 and 7.6 cm in group 2. The site of the bone defect was proximal in six and two patients and middle in eight and 13 patients of group 1 and group 2, respectively. The distal tibia was affected in six patients of group 1. All patients had undergone surgeries previously (one to four operations). The results were divided into bone and functional results. The bone results were based on five criteria: union, infection, deformity, lower limb deformities, and the cross-sectional area of union of the regenerated bone and docking site. The functional results were based on five criteria: pain, need for walking aids or braces, ankle or knee deformity or contracture, loss of range of ankle and knee motion compared with the preoperative range, and ability to return to normal activities of daily living and/or work.
The mean amount of the filled defect was 4.1 cm with Ilizarov bone transport and 7.6 cm with vascularized fibular grafting. The external fixator time in group 1 was 6.9±1.39 months. The average time to achieve union in group 2 was shorter than that in group 1 (4.8 months, range 3–9 months), whereas the average time to full weight bearing is 8.7 months (range 5–15 months). The average follow-up period was 10.9 months (range 6–24 months) in the bone transport group and 17.6 months (8–24 months) in the vascularized fibular graft group. The bone results and functional results of Ilizarov bone transport were excellent in 64.7 and 29.4%, good in 17.6 and 41.2%, fair in 5.9 and 17.6%, and poor in 11.8 and 11.8% of the patients in groups 1 and 2, respectively, whereas those of vascularized fibular grafting were excellent in 73.3 and 6.7%, good in 13.3 and 73.3%, fair in 6.7 and 13.3%, and poor in 6.7 and 6.7%, respectively. The main problems in Ilizarov bone transport were patient compliance, pin tract infection (all patients), residual deformity in seven patients, and skin sloughing in one patient who was treated using a skin flap. Stress fracture of the transported fibula (eight patients) and need for secondary procedures (10 procedures) were the main problems in the vascularized fibular graft group.
Ilizarov bone transport is a good method for management of post-traumatic tibial defects, especially short bone defects; in addition, bone grafting of the docking site is necessary in all cases to achieve union and to shorten the time of external fixator application. Although the vascularized fibular graft yielded better results in longer bone defects with shorter time for union, non-weight-bearing is mandatory until graft hypertrophy to avoid stress fractures, which were the main problem in our series.
The incidence of osteoporotic vertebral compression fractures increases with advancing age and is associated with significant healthcare expenditure. Patients who have sustained fractures from osteoporosis are at increased risk of additional fractures because of loss of bone strength caused by osteoporosis. Vertebroplasty is a minimally invasive vertebral augmentation procedure to relieve pain; it stabilizes the vertebral body. Kyphoplasty is a minimally invasive method for correction and augmentation of osteoporotic vertebral fractures.
This study included two groups of patients suffering from painful osteoporotic vertebral compression fractures: the first group comprised 26 patients with 33 vertebral compression fractures treated by percutaneous vertebroplasty between April 2007 and October 2008. The results of this group were compared with those of another group of 18 patients (24 vertebrae) who were treated by kyphoplasty between November 2008 and July 2011. The visual analog scale (VAS) and the Oswestry Disability Index (ODI) were applied for the assessment of patients preoperatively and postoperatively.
In the vertebroplasty group, the mean VAS score improved from 7.8 to 2.4 according to VAS and from 69 to 15 according to ODI. Cement leakage was noted in four patients (15.4%), without clinical consequence. Ten vertebrae (30.3%) revealed a mean improvement in vertebral height of 11% (8–14%). No patient showed progression of vertebral angles of the augmented vertebrae during the follow-up period. In the kyphoplasty group, the mean pain score improved from 8 to 2.1 according to VAS and from 71 to 17 according to ODI. Cement leakage was noted in two patients (11.11%), without clinical consequence. No thoracolumbar back pain was reported after kyphoplasty. Nineteen vertebrae (79.16%) revealed a mean improvement in vertebral height of 22% (range, 18–38%). No patient showed progression of vertebral angles of the augmented vertebrae during the follow-up period.
Both vertebroplasty and kyphoplasty resulted in significant improvement in VAS pain scores. Vertebroplasty, although less expensive than kyphoplasty, had a statistically greater risk for cement leakage and adjacent vertebral fracture.
Madelung’s deformity is caused by arrest of growth on the ulnar side of the distal epiphysis of the radius. It results in palmar and ulnar tilt of the articular surface, volar translation of the hand and wrist, shortening of the radius, and dorsal subluxation of the ulnar head with incongruity of the distal radioulnar joint.
Six patients with Madelung’s deformity were treated with the Ilizarov method at the Orthopedic Department of health insurance hospitals. Correction was undertaken for pain in the case of two patients, because of impaired function in two, and because of bad cosmoses in another two patients. The cause of the deformity was congenital in four cases and acquired in two after fractures. The patients included five girls and one boy. The ages of the patients varied from 11 to 17 years, with an average age of 14.6 years.
All patients were free from pain at follow-up. Supination improved by a mean of 30π and pronation by a mean of 10π. The mean improvement in flexion was 20π. Extension did not change. Radial and ulnar deviations were increased by a mean of 5 and 10π, respectively, and lengthening of the radius by a mean of 12 mm (6–25). Radiological measurement showed that the mean volar angulation had been reduced from 20 to 10π and ulnar inclination from 40 to 25π. The most common problem was minor pin-tract infection in all cases, which was treated with antibiotics. No loosening of pins or bone fracture occurred. There were no deep pin-tract infections or neurovascular injury.
The Ilizarov technique should be considered for the surgical treatment of Madelung’s deformity in patients suffering from persistent pain when gradual correction and lengthening is indicated. The Ilizarov method is useful for obtaining correction of forearm deformity.
Malunion and nonunion of the juxta-articular distal tibial fractures have been widely treated by internal fixation for many years. Over the last few decades gradual correction of the deformity and/or distraction osteogenesis with an external ring fixator have become more popular among orthopedic surgeons. Ilizarov external fixators not only correct greater degrees of deformity with lesser incidence of complications but also correct more complex deformities compared with other methods of internal fixation such as plate and screws.
Between January 2006 and December 2008, 13 patients presented at the Minia University Hospital with malunion or nonunion of distal tibial fractures after failure of initial internal fixation with plates and screws. Removal of the implant, application of an Ilizarov external fixator, and adjustment of the hinges based on either the need for correction of the deformity alone or correction of the deformity and lengthening were performed. All patients were men, with an average age of 34.5 years (range, 16–52 years). The mean follow-up period was more than 24 months (range, 14–29 months). Eight patients presented with malunion and five with nonunion of the distal tibia. Three of the five patients who had nonunion presented to the department with radiological and clinical signs of osteomyelitis. One of them was treated by drainage and removal of the plate at another hospital.
Osseous union was achieved in all cases. Only one patient had a residual angular deformity of less than 10π, and two patients had leg-length discrepancy of lesser than 1 cm. The mean amount of tibial lengthening measured at removal of the frame was 1.5 cm. All patients showed marked improvement in both severity and duration of pain. The mean period for which the Ilizarov external fixator was applied was 146 days (range, 87–256 days). There was no recurrence of infection in the three patients who originally presented with osteomyelitis. The functional results were categorized as excellent in four, good in seven, and fair in two patients according to the classification of the Association for the Study and Application of the Method of Ilizarov.
Despite the lengthy duration required for the application of the device to achieve reasonable results, gradual correction of the deformity and distraction osteogenesis can be superior alternatives for the treatment of malunion, nonunion, and/or shortening due to failure of internal fixation of distal tibial fractures.
Anterior impingement is a common cause of pain in the ankle, especially in sportsmen. The primary symptom is anterior pain on dorsiflexion. The condition, first described by Morris and termed ‘footballers’ ankle’ by McMurray, is common in sports involving forced dorsiflexion of the ankle. Although the aetiology of the impingement lesion has not been elucidated clearly, the suspected mechanism is recurrent microtrauma from forced dorsiflexion leading to haemorrhage, scarring and the formation of new bone in the form of spurs at the anterior aspect of the ankle. Once formed, forced dorsiflexion of the ankle causes impingement between the spur and the neck of the talus. Successful open treatment of anterior impingement lesions has been reported previously.
Open debridement was carried out for anterior impingement of the ankle in nine patients. Preoperative radiographs were used to group patients according to both the McDermott and the van Dijk scoring systems. The Ogilvie-Harris scoring system, a visual analogue scale of patient satisfaction, the time to return to full activity, and the ability to return to sports determined the clinical outcome. According to the van Dijk classification, no patients had grade 0 changes, eight had grade 1 changes and one had grade 2 changes. The patient with grade 2 changes corresponded to the patient in McDermott grade 4. This patient had established osteoarthritis of the ankle.
At a mean follow-up of 2 years, according to Ogilvie-Harris, one had good and eight had unsatisfactory results preoperatively, whereas four had excellent, four had good, and one had unsatisfactory results postoperatively. The mean time to return to full activity was 14 weeks; five out of nine were able to play sports at the same level, and six out of nine were satisfied with the results. Most patients did not feel that the range of dorsiflexion returned to normal, but symptomatic relief allowed most to return to high-level sports.
It is concluded that open debridement for anterior ankle impingement is a safe and successful procedure.
The most common articulation used in total hip arthroplasty is metal on polyethylene. However, nowadays, with young and more active patients undergoing the procedure, other bearing surfaces such as metal on metal and ceramic on ceramic have been proposed as an alternative to metal on polyethylene as a solution to the need for reducing wears debris production with subsequent osteolysis and loosening.
The aim of this study is to evaluate the early outcome of total hip replacement using the ceramic-on-ceramic articulations.
This prospective study included 13 patients (15 hips) who had end-stage arthritic hips. All patients were subjected to clinical, laboratory, and radiological evaluation before surgery and up to 3 years postoperatively.
There was a marked improvement in the Harris Hip Score (satisfactory results in 93.3% of the studied group at the last follow-up) especially in the range of motion of the hip joint and postoperative pain relief.
The results were very satisfactory and significantly in favor of using this bearing combination, taking advantage of both the hard, wear-resistant ceramic material and the cementless acetabular fixation. This choice also broadens the spectrum of candidates for total hip replacement including young active women of child-bearing age and men with renal impairment or any patient with less accepted bone quality.
The proximal humerus is one of the primary sites of tumors. Amputation of the upper limb is highly mutilating and artificial limbs provide limited function and poor cosmesis. For these reasons, limb-preserving techniques were established. The most important aspect of limb-salvage surgery is to preserve elbow and hand function after excision of tumors of the proximal humerus, although the shoulder may remain flail, with a limited active range of movement. Endoprosthetic replacement of the proximal humerus is a well-established procedure in salvage of the upper limb that provides a reasonable shoulder function with maintained excellent elbow and hand function.
Ten patients were included in this case-series study. According to the staging system of Enneking and colleagues, they were classified as having eight primary bone tumors; accordingly, there were six cases graded as stage IIB, two cases graded as IB, and two cases graded as solitary metastasis at the proximal humerus. Wide resection was carried out, followed by reconstruction by a modular replacement endoprosthetic system. The mean age of the patients was 36 years (ranging from 17 to 54 years). The follow-p period of the study ranged from 42 to 96 months, with a mean of 61 months.
Excellent functional outcomes were achieved in seven patients at final evaluation, with a mean of 85.5%. Three patients died because of disease progression and were excluded from the functional evaluation. There were no local recurrences, prosthetic instability, dislocation, or infection. Two patients developed radial nerve palsy, one showed spontaneous improvement, and the second showed improvement after the release of adhesions. None of the patients required any revision surgery.
The use of endoprosthetic replacement as a method of reconstruction after major skeletal defects created after wide resection of a tumor at the proximal humerus represents a major progress that provides a stable functional spacer after surgery. It has also obviated the need for prolonged immobilization as in cases of biological reconstruction. It results in a low complication rate and immediate stability, which facilitates normal functioning of the elbow and hand.
There are numerous reports on the outcome of rotator cuff repair, but few have considered age as a factor affecting functional outcome.
Age does not affect the anatomical and functional outcomes of rotator cuff repair.
Twenty-eight patients with arthroscopic rotator cuff repair belonging to three different age groups were prospectively enrolled in the study and were followed up for at least 18 months after surgery. Various clinical features according to age were evaluated. The correlation was assessed between age and outcome, with adjustment for the preoperative score.
The patient mean age was 61.6 years. There was marked improvement in postoperative pain (from 8.2 to 2.3) (P<0.0001). The mean Oxford Score showed significant improvement from 22.8±4 preoperatively to 38.3±4 postoperatively (P<0.001). The Constant Score also showed a significant improvement from 43.9±10 to 81±4 (P<0.001).
There was marked improvement after arthroscopic rotator cuff repair in all age groups. Multivariate regression revealed that age was not correlated with postoperative pain, satisfaction, or functional outcome.
In unstable burst fractures of the thoracic and lumbar spine, short segmental posterior fixation has been associated with a high rate of hardware failure, with recurrence of deformity. Anterior surgical treatment allows direct decompression of the neural elements and reconstruction of the weight-bearing column with fusion of only two levels.
The aim of this study was to evaluate the effectiveness of anterior-only surgery and locked plate fixation in the treatment of unstable burst fractures of the thoracic and lumbar spine.
We included 22 patients (13 men and nine women) with acute thoracolumbar burst fractures treated with anterior surgery, strut iliac graft, and fixation with a locked thoracolumbar plate. The mean age of the patients at the time of surgery was 33.2 years (range 19–55 years). Neurologically, five patients were Frankel B, 13 were Frankel C, and four were Frankel E. All patients had preoperative and postoperative radiographs and computed tomography scan.
The 18 patients with neurological deficit showed at least one Frankel grade improvement on final observation, with 16 (88.9%) patients showing complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 19.9–6.7π at the final observation.
Through the anterior surgery of the spine and locked plate fixation, we can achieve good canal decompression, spinal column alignment, and short segment arthrodesis.
Although many techniques are available to fuse the ankle, current recommendations favor the use of internal fixation with screws and/or plates. Despite the progress, the complication rate remains a major concern. This study is a prospective case series study that was carried out to assess the functional outcome of open ankle fusion using two different techniques: modified compression and sliding graft, and an anterior AO T plate.
Between June 2004 and November 2007, 22 tibiotalar arthrodesis by the modified compression fixation and sliding graft technique were performed (group A), and an anterior T plate (group B); each group included 11 patients. The average age of the patients in group A was 32.9 years (26–53), whereas in group B, it was 32 years (25–54). There were 18 men and four women. Among these, 18 patients had post-traumatic arthritis, three had primary osteoarthrosis, and one had sciatic nerve injury.
A rate of fusion achieved was 100 and 91% (groups A and B, respectively). Patients with a minimum follow-up period of 32 months after the arthrodesis were analyzed. The average follow-up period was 42 months (range, 32–58 months). Tibiotalar fusion was achieved in all the ankles at an average of 13 weeks (range, 10–19 weeks), 14.6 weeks (range, 13–21 weeks) (groups A and B, respectively).
Although arthrodesis of the ankle that uses lag screws for internal fixation is a safe and biomechanically stable method to obtain a solid ankle fusion and yields excellent results in most patients, there were no significant differences between both techniques of ankle fusion.