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ORIGINAL ARTICLES
Clinical outcome of using a third-generation short gamma nail in the treatment of extracapsular proximal femoral fractures
Ihab I El-Dessokey, Molham M Mohammed
October-December 2013, 48(4):354-362
DOI:10.4103/1110-1148.130489  
Introduction A sliding hip screw is still considered the gold-standard method for fixation of extracapsular hip fractures; however, failures are still encountered with some subtypes. A short gamma nail is considered to allow better fixation for unstable subtypes, with the additional advantages of intramedullary fixation. Aim The aim of the study was to prospectively evaluate the clinical outcome of traumatic proximal femoral fractures fixed with a short gamma nail (third-generation design), with a particular focus on our experience of surgical techniques. Patients and methods We prospectively reviewed the results of 20 patients who had undergone intramedullary fixation with a short gamma nail for traumatic extracapsular proximal femoral fractures in Kasr Al-Ainy hospitals during an 18-month period from September 2009 to March 2011. The average age of the patients was 55 years (range 31-69 years), with seven male patients and 13 female patients. The average operative time was 75 min (range 50-110 min). Clinical and radiographic assessments were performed during follow-up visits at 6 weeks, 12 weeks, 6 months, 1 year, and 1΍ years using the Kyle scoring system. Results Nineteen of the 20 traumatic fractures healed uneventfully. One patient required reoperation after a period of 6 months for screw cutout, although this patient was healed completely. Walking and squatting ability was restored in all patients by 6 months postoperatively. Conclusion This study suggests that a short gamma nail is a reliable implant for proximal femoral fractures, leading to a high rate of bone union and minimal soft tissue damage. Intramedullary fixation has biological and biomechanical advantages, but the operation is technically demanding, with some restrictions.
  5,737 293 -
Subscapularis release and tendon transfer in treatment of posterior shoulder dislocation in obstetric brachial plexus palsy
Yousuf M Khira, Elsayed El-Etewy Soudy
July-September 2013, 48(3):220-228
DOI:10.4103/1110-1148.125828  
Background Muscle imbalance of the shoulder results in weak external rotation and abduction. Active internal rotation and adduction can cause glenohumeral joint deformity with late posterior dislocation. Patients and methods This prospective study conducted from 2004 to 2009 included 34 patients, 18 girls and 16 boys, with a mean age of 4 years (1-7 years). The right side was affected in 19 patients, whereas the left side was affected in 15 patients. All patients suffered from obstetric brachial plexus palsy with internal rotation contracture and defective shoulder abduction plus posterior dislocation or subluxation of the humeral head. These patients were treated by soft tissue release (subscapularis slide and anterior soft tissues release) with or without tendon transfer (latissimus dorsi and teres major to infraspinatus). Conclusion Subscapularis release provided an objective functional benefit; however, it degraded over time. Teres major and latissimus dorsi to infraspinatus transfer is a useful procedure for correction of defective shoulder abduction and external rotation in obstetric brachial plexus palsy as it increases the stabilizing action of the rotator cuff, thus allowing the deltoid to act with maximal force.
  3,625 255 -
EDITORIAL
The myths of trabecular metal: 'the next best thing to bone'
Yousry Eid
October-December 2013, 48(4):327-329
DOI:10.4103/1110-1148.130387  
  2,199 1,264 -
INTERNATIONAL CHAPTER
Tumors for the general orthopedist: how to save your patients and practice
Kristy L Weber, Terrance Peabody, Frank J Frassica, Michael P Mott, Theodore W ParsonsIII
July-September 2013, 48(3):307-317
DOI:10.4103/1110-1148.125842  
It is likely that most orthopedic surgeons will see a patient with a benign or a malignant musculoskeletal tumor sometime during their career. However, because of the rarity of these entities, many surgeons may benefit from a review of how to evaluate a patient with a bone lesion or a soft-tissue mass. A logical approach is necessary for the evaluation of imaging studies as well as in the workup of children and adults with a possible tumor. It is important to have a good working relationship with a musculoskeletal radiologist to assist in interpreting the images. If the treatment algorithms lead to a conclusive diagnosis of a benign bone tumor, benign soft-tissue mass, or metastatic bone disease, the orthopedic surgeon may choose to definitively treat the patient. If the workup indicates an indeterminate lesion, it may be prudent to discuss the situation with an orthopedic oncologist or transfer the care of the patient to a physician with more specialized knowledge. A careful, logical workup is needed before surgery to limit risks to the patient and optimize the chances for a favorable outcome.
  3,079 173 -
ORIGINAL ARTICLES
Fixation of tibial bony avulsion of the posterior cruciate ligament using the posteromedial approach
Mohamed E Attia, Amr I Zanfaly
April-June 2014, 49(2):81-85
DOI:10.4103/1110-1148.145299  
Background Tibial avulsion fractures of the posterior cruciate ligament are not infrequent. Controversies exist between fixation of the fragments and their reconstruction in patients with small bony fragments. This prospective study was undertaken to study the results after fixation of the fragments using a lag screw. Objective This study was designed to evaluate the efficacy of the treatment of posterior cruciate ligament avulsion fractures using the posteromedial approach and fixation with navicular screws. Study design This was a prospective study conducted in 12 patients treated by fixation with navicular screws through the posteromedial approach. Patients and methods From June 2008 to March 2010, 12 patients with acute posterior cruciate ligament avulsion fracture of the tibial attachment were treated surgically at Zagazig University Hospital and Health Insurance Hospital. Nine patients were male and three were female. Navicular screw fixation was used in all 12 patients in avulsed bony fragments, with washers in eight patients and no washers in four patients. Results All the avulsion fractures achieved union at an average of 10-14 weeks. All patients had severe posterior instability (>10 mm) preoperatively. After union of the fracture, no case suffered severe instability. Patients were followed up for an average of 7.58 months (range 6-12 months). Of the 12 patients included in this study, four (33.3%) showed excellent results, seven (58.3%) showed good results, and one (8.3%) showed a fair result. Conclusion The treatment of avulsion fracture of the posterior cruciate ligament by open reduction through the posteromedial approach and internal fixation using partially threaded screws gives very good functional and radiological results. The dissection involved is minimal and risk to the neurovascular structures is negligible.
  2,884 319 3
Partial fibulectomy for treatment of tibial nonunion
Ahmed Shawkat Rizk
March 2014, 49(1):18-23
DOI:10.4103/1110-1148.140533  
Background Despite the improved rate of union reported in tibial shaft fractures, there continues to be a small number of patients with delayed union and nonunion who present a dilemma to the surgeons. Because the spectrum of injuries to the tibia is so great, many methods of treatment are available to treat tibial nonunions. Aim The aim of the study was to evaluate partial fibulectomy as an easy, simple, and effective treatment option in the treatment of certain types of tibial nonunions. Patients and methods This prospective study included 20 patients with established tibial nonunion. All patients were evaluated clinically in laboratory and radiologically before surgery and followed up until after complete union of the tibial fractures. Results All fractures were united at an average duration of 15 weeks (range 10-19 weeks) after partial fibulectomy, with acceptable alignment in the coronal and sagittal planes. There were no neurovascular complications, no limitation of joint motion, and no problems at the fibulectomy site. Conclusion The results were very satisfactory and were significantly in favor of using this easy, simple procedure in the treatment of certain patients of tibial nonunions.
  2,695 163 1
Repair of ulnar collateral ligament injuries of thumb metacarpophalangeal joint with microanchors
Ashraf N Moharram
March 2014, 49(1):34-37
DOI:10.4103/1110-1148.140536  
Background Ulnar collateral ligament (UCL) injuries of the metacarpophalangeal (MCP) joint of the thumb are common. Complete rupture can be a debilitating injury resulting in decreased grip and pinch strength. Purpose The present study evaluated prospectively the functional results of 27 patients who had open repair of UCL of the thumb using microanchors either acutely or delayed (up to 9 weeks postinjury). Patients and methods Through a standard S-shaped incision over the dorsoulnar aspect of the thumb, one or two 1.5- or 1.3-mm microanchors are fixed to the base of the proximal phalanx in the footprint of the avulsed ligament and are used to suture the proximally based flap after temporary pinning of the MCP joint. Results The stability, range of motion, pinch grip, and radiographs were evaluated at least 16 months after surgery. The mean time off work was 10 weeks. All patients had equal stability and normal pinch grip when compared with the untreated thumb, allowing all patients to return to preinjury activities, including sports, except one (96% of patients). During final follow-up, radiographs showed no implant complications and no osteoarthritic changes in the MCP joints, and stress testing showed that all patients had normal stability in the treated thumb when compared with the untreated thumb. Only two patients complained a lumpy swelling at the ulnar aspect of the MCP joint, one of which was tender. Conclusion Repair of UCL of the MCP joint of the thumb with this technique is an effective, durable, and safe method to allow restoration and maintenance of a stable, pain-free thumb.
  2,611 118 -
Cemented calcar replacement hemiarthroplasty for unstable intertrochanteric fracture femur in elderly patients
Ayman A Bassiony, Mohamed K Asal, Haytham A Mohamed
June 2013, 48(2):190-193
DOI:10.7123/01.EOJ.0000428840.48748.89   
Background

Unstable intertrochanteric fractures in elderly patients are associated with a high rate of complications and poses difficulty in fixation. Cemented calcar replacement hemiarthroplasty may be a suitable treatment in these patients. The aim of this study is to assess the clinical and functional results of the use of such a prosthesis in old patients with an unstable intertrochanteric fracture of the femur.

Patients and methods

Thirty patients were included in this prospective study, mean age 66 years. All the patients had unstable intertrochanteric fractures. Only patients with type III, IV, or type V fractures according to the Evans’ classification were included in the study. Functional and radiological results were assessed after a mean follow-up period of 22 months.

Results

At the end of the study, only 24 patients were available for evaluation. The mean follow-up period was 22 months (range, 18–36 months). At the last follow-up, the mean Harris hip score was 85 points. Radiologically, all stems were stable, without significant changes in alignment or progressive subsidence. No infection or thromboembolic complications were encountered.

Conclusion

Cemented bipolar hemiarthroplasty with calcar replacement is a good option for unstable intertrochanteric fractures in the elderly. It allows early weight bearing and rapid return to prefracture activity and does not have the difficulty and complications of internal fixation of this complex fracture.

  2,449 263 -
INTERNATIONAL CHAPTER
Acute trauma to the upper extremity ( what to do and when to do it)
Jennifer M Wolf, George S Athwal, Alexander Y Shin, David G Dennison
March 2013, 48(1):95-105
DOI:10.7123/01.EOJ.0000427643.72708.e3   

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.

  2,535 149 -
ORIGINAL ARTICLES
Technical tips for fixation of proximal humeral fractures in elderly patients
Michael E Torchia
June 2013, 48(2):200-208
DOI:10.7123/01.EOJ.0000431737.30654.0f   

Despite the application of modern locking plate technology, complications remain common after fixation of proximal humeral fractures in elderly patients. Varus deformity and intra-articular hardware are most often responsible; fortunately, both of these complications can be avoided. Recent advances in imaging, reduction techniques, fixation methods, and postoperative care have made surgical outcomes more reliable. Particular attention should be paid to obtaining high-quality fluoroscopic images, avoiding varus reductions, supporting the osteoporotic humeral head, using appropriate screw length, using tension band sutures liberally, and protecting the construct postoperatively. Using these methods, many proximal humeral fractures in patients older than 75 years can be fixed reliably.

  2,333 285 -
Salter versus Dega osteotomy after open reduction of developmental dysplasia of the hip in young children
Ahmed Essam Kandil, Abo Saeed, Hassan El-Barbary, Mohamed Hegazi, Mohamed El-Sobky
March 2013, 48(1):80-87
DOI:10.7123/01.EOJ.0000426261.81593.d6   
Background

Numerous pelvic osteotomies for the treatment of developmental dysplasia of the hip have been described.

Objective

To compare the outcome of two types of pelvic osteotomy, Salter and Dega, for the treatment of late-diagnosed developmental dysplasia of the hip.

Patients and methods

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).

Results

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).

Conclusion

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.

  2,076 228 -
Functional outcome after surgical plating for humeral shaft nonunion
Mohammed J Al-Sayyad
October-December 2014, 49(4):267-272
DOI:10.4103/1110-1148.154060  
Background Although the great majority of fractures of the mid-third of the humeral shaft heal uneventually when treated nonoperatively, nonunion is not a rare condition. The prevalence of nonunion as a complication of both nonoperative and operative treatment has been reported to be as high as 13%. Open reduction and plate fixation combined with autologous bone grafting can result in reliable healing of these humeral nonunions with excellent functional outcome. Patients and methods Between 2002 and 2007, 30 consecutive nonunion cases of the midpart of the humeral shaft were treated with open reduction and internal fixation by a single surgeon. The series included 14 female patients and 16 male patients with an average age of 42 years (range 19-57 years). The patients were followed up for an average of 28 months (range 24-56 months). The time from diagnosis of nonunion to our treatment of the nonunion averaged 9 months (range 6-24 months). Result According to the Stewart and Hundley Criteria, the functional postoperative result was excellent or good in 24 (73%) cases and fair in six (27%) cases. One year after surgery, all patients had an essentially normal range of motion of the ipsilateral elbow and shoulder. According to the scoring system of Constant and Murley the postoperative average score was 90 (range 88-96). Conclusion Surgical compression plating and autologous bone grafting of humeral diaphyseal nonunions resulted in 100% union rate and mostly excellent or good functional results without significant morbidity.
  1,037 1,162 -
Modified Hoffer technique for treatment of internal rotation deformity in obstetric brachial plexus palsy
Mohamed E Attia, Emad E Abdelhadi
March 2013, 48(1):45-50
DOI:10.7123/01.EOJ.0000426255.51180.a8   
Introduction

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.

Patients and methods

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.

Results

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°.

Conclusion

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.

  1,884 247 -
Effectiveness of Achilles tendon stretching for the treatment of chronic plantar fasciitis
Hesham A Mohamed
October-December 2015, 50(4):215-222
DOI:10.4103/1110-1148.182305  
Background Plantar fasciitis is a common cause of heel pain. Its characteristic features are pain and tenderness on the medial aspect of the heel. The purpose of this study was to evaluate the outcome of the Achilles tendon-stretching protocol for patients with chronic plantar fasciitis. Patients and methods A total of 24 patients who had chronic proximal fasciitis for a duration of at least 6 months participated in this study. The patients received instructions for an Achilles tendon-stretching program. Pain and functional limitations were evaluated with the Foot Functional Index pain subscale and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. The patients were re-evaluated after 6 months. Results The mean Foot Functional Index baseline scoring was 7.69, whereas its mean scoring at follow-up was 1.44. The American Orthopedic Foot and Ankle Society Scale outcome measures also revealed significant improvement for 22 (91%) patients who practiced the Achilles tendon-stretching exercises regularly. Only two (9%) patients reported little improvement, as they were not compliant with the daily stretching routine. Conclusion This study provides an effective, inexpensive, and straightforward treatment protocol for the chronic plantar fasciitis. In addition, compliance may have affected the results if the patients did not perform their exercises regularly.
  870 1,182 -
Laminoplasty versus multiple anterior cervical discectomy for cervical spondylotic myelopathy in patients with a lordotic cervical spine
Khaled M Hassen, Ali Mohammadein
October-December 2013, 48(4):369-375
DOI:10.4103/1110-1148.130497  
Background Using anterior or posterior surgery for multilevel cervical spondylotic myelopathy continues to be a subject of considerable debate. Studies comparing the two approaches are limited and few studies focus on anterior cervical discectomy and fusion (ACDF) as against open-door laminoplasty (ODL). Study design This investigation was designed as a prospective study. Objective The aim of the study was to compare the clinical outcomes, radiographic changes, and complications of patients with multilevel cervical spondylotic myelopathy who underwent ACDF and ODL in the lordotic cervical spine. Patients and methods We evaluated 40 patients (20 patients in the ACDF group and 20 patients in the ODL group) at our institution from September 2005 to December 2008. They were followed up for a minimum of 2 years. The clinical outcomes [Nurick grade and Japanese Orthopaedic Association (JOA) score], radiographic changes (radiograph and MRI), and complications were compared between the two groups. Results ODL showed significantly longer operative time (155 vs. 95 min) and more blood loss (438 vs. 215 ml) compared with ACDF. Both the ACDF and ODL groups showed significant improvement in Nurick grade from 3.5 and 3.4 preoperatively to 1.85 and 1.95, respectively, at last follow-up (P<0.05). Both groups showed significant improvement in the JOA score (P<0.05), and recovery rate was similar (63.2% in the ACDF group and 64.4% in the ODL group) (P>0.05). Cervical motion (on dynamic lateral radiograph) decreased significantly postoperatively in both groups (P<0.05) but was seen to have significantly improved in the ODL group at last follow-up. Minimal complications were reported in both groups. Conclusion Both ACDF and ODL are effective treatment modalities for multilevel cervical spondylotic myelopathy with no significant difference between the two groups in Nurick grade, JOA score, recovery rate, and MRI sagittal canal diameter widening. However, the ODL group showed significantly better cervical motion at last follow-up but, unfortunately, longer operative time and greater blood loss.
  1,828 88 -
QUESTIONS
AAOS-MCQ

September 2012, 47(3):329-334
DOI:10.7123/01.EOJ.0000418010.08456.cb   
Full text not available  [PDF]
  78 1,833 -
ORIGINAL ARTICLES
Arthroscopic management of anterior femoroacetabular impingement
Ehab Mohamed Selem Ragab
October-December 2013, 48(4):390-395
DOI:10.4103/1110-1148.130520  
Background Femoroacetabular impingement (FAI) is a recognized cause of intra-articular pathology and secondary osteoarthritis in young adults. Arthroscopy is reportedly useful in the treatment of selected hip abnormalities and has been proposed as a method for correcting underlying impingement. The aim of this study was to evaluate the early outcomes of arthroscopic management of FAI. Patients and methods Thirty-four consecutive patients with clinically and radiographically documented FAI were treated with hip arthroscopy, proximal femoral osteoplasty, labral debridement or repair/refixation, or acetabuloplasty or some combination. Outcomes were measured using the impingement test, Harris Hip Score, pain score on a visual analogue scale, and radiologically preoperatively and postoperatively at 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years. Results There were 25 male patients and nine female patients with up to 3 years of follow-up (mean 20.6 months). The mean age of the patients was 34.2 years. Isolated cam impingement was identified in 16 hips, pincer impingement was found in six, and both types were noted in 12. Three hips were subjected to labral repair and fixation. A comparison of preoperative scores with those obtained at the most recent follow-up indicated a significant improvement (P < 0.05) for all outcomes measured: Harris Hip Score (59.7 vs. 82.9), visual analogue scale score for pain (6.81 vs. 1.81), and positive impingement test (100 vs. 11.76%). The α angle was also significantly improved after resection femoroplasty. Complications included heterotopic bone formation (one hip), four patients with nerve neuropraxia, and two hips have subsequently been subjected to total hip arthroplasty. Conclusion Arthroscopic management of patients with FAI results in a significant improvement in outcomes measures and is comparable with open techniques, with advantages of minimally invasive procedures. Level of evidence Level IV. Therapeutic study.
  1,717 176 -
Treatment of complicated distal tibial fractures in diabetic patients
Mootaz F Thakeb
June 2013, 48(2):145-150
DOI:10.7123/01.EOJ.0000428834.38905.2c   
Background

The treatment of fractures of the distal tibia is associated with high complication rates. Diabetes mellitus places patients at an increased risk for complications following distal tibia fractures whether treated conservatively or surgically. However, this risk is specific to patients with comorbidities of diabetes. There has been debate on the ideal method for the treatment of these patients because much of the literature has highlighted the extremes of potentially poor outcomes. Less invasive techniques for realignment of distal tibial fractures and reduction of the articular fragments using an Ilizarov fixator with or without minimal internal fixation have been recommended as reliable and safe methods for the treatment of these patients.

Patients and methods

Between June 2008 and January 2012, 25 patients with type II diabetes mellitus receiving oral and/or insulin for blood sugar control, with complicated distal tibia fractures, were treated using an Ilizarov fixator. All patients presented within 6 months from their primary treatment in other centers. Fifteen patients were treated conservatively in a cast or braces. Ten patients were treated surgically. All patients presented with nonunited fractures and 22 patients had varus malalignment. Ten of the 15 patients who were treated conservatively had deep pressure sores. Assessment of the ankle brachial index and vascular Doppler study were used as noninvasive techniques to verify the vascularity in the affected limb.

Results

In all patients, the fractures healed, with no need for any procedure to enhance healing. All patients were followed up for 12 months after fixator removal. The average time in an external fixator was 18.1 weeks (average12–22 weeks). On the final follow-up, none of the patients had a long-term sequel of infection. Malunion with less than 5π varus occurred in five patients. None of the patients developed Charcot neuroarthropathy or required amputation during the treatment or at the final follow-up. Long-term bracing for up to 6 months after frame removal was required in five patients with varus malalignment and in the patient who had a proximal fracture.

Conclusion

Diabetic patients with recent or complicated distal tibia fractures having one or more diabetic comorbidities, but with good peripheral vascularity and continuous control of blood sugar level, they can be treated using an Ilizarov external fixator with a lower complication rate than open reduction and internal fixation procedures and with results comparable to those of nondiabetic patients.

  1,736 109 -
Simultaneous management of ipsilateral gonarthritis and extra-articular deformity
Mohamed A.M. Eid
July-September 2013, 48(3):269-276
DOI:10.4103/1110-1148.125835  
Background Total knee arthroplasty (TKA) with extra-articular deformity represents a technical challenge to the reconstructive surgeon. Restoration of proper lower limb alignment is crucial to maximize the functional outcome and long-term implant survival. The current study postulates that simultaneous TKA and deformity correction, whether by intra-articular means or by extra-articular osteotomy, can yield favorable outcomes if the correct surgical strategy is used according to the magnitude and location of the pre-existing extra-articular deformity. Patients and methods The study was carried out on 14 consecutive primary total knee replacements in patients with osteoarthritis secondary to extra-articular malunions. The mean preoperative coronal plane deformity was 14.3 ± 5.2° of varus. The mean preoperative mechanical axis deviation was 8.2 ± 2.1 mm medial to the center of the knee and the mean limb-length discrepancy was 1.8 ± 0.7 cm of shortening. The mean time between malunion and TKA was 29 ± 6.1 years. The results were analyzed using the Knee Society clinical and functional scores and the Knee Society radiographic evaluation system. Results At a mean follow-up of 30.4 months, the mean preoperative Knee Society knee score of 49.7 points improved to a mean of 90.4 points at the time of the latest follow-up (P < 0.01). The mean preoperative functional score of 46.3 points improved to a mean of 86.9 points (P < 0.01). At the latest follow-up, all extra-articular osteotomy sites showed union on radiographs and no patients showed evidence of loosening. Postoperative radiographs showed restoration of the mechanical axis and appropriate alignment of the components (P < 0.001). The postoperative limb alignment was restored to within 2° of normal in each patient. The only significant difference (P < 0.05) between the two techniques was the mean gain in functional scores, being higher for the isolated arthroplasty (42 ± 12) procedures than for the TKA with osteotomies (37 ± 9). Conclusion Although isolated TKA with intra-articular deformity compensation and ligamentous balancing may be favored in mild to moderate deformities, there may be faster rehabilitation and functional score gain in the short term after surgery. Yet, simultaneous TKA and extra-articular corrective osteotomy has also yielded favorable outcomes and would still remain the technique of choice in severe deformities (>25°), especially with distant deformities from the knee joint line (diaphyseal, metaphyseodiaphyseal). The closer the deformity to the knee joint line, the more it is amenable to intra-articular correction. Careful preoperative planning is necessary to determine which technique would be better in each particular case.
  1,571 156 1
Percutaneous lateral cross-pinning of paediatric supracondylar humeral fractures
Mohamad Osman, Emad Abd Al-Hadi
July-September 2014, 49(3):188-192
DOI:10.4103/1110-1148.148184  
Introduction The currently accepted treatment for displaced supracondylar humeral fractures in children is closed reduction and fixation with percutaneous Kirschner wires. The aim of this study was to study the results of a cross-wiring technique, achieved solely from the lateral side, in an effort to reduce the risk of ulnar nerve injury. Patients and methods Thirty-two cases of displaced supracondylar humeral fractures were treated by the closed reduction and lateral cross-pinning technique. The mean age of the patients was 6 years (range; 4-12). All fractures were of the extension type (Gartland's types II and III). Results The mean follow-up period was 12 months (range; 9-20 months). Using the cosmetic and functional criteria of Flynn and colleagues, cosmetically, 93.8% of the cases achieved a satisfactory outcome and 6.2% achieved fair results with mild cubitus varus. Functionally, 87.5% of the cases achieved satisfactory results and 12.5% achieved unsatisfactory results. Radiologically, all fractures united. The humeral shaft-condylar angle was normal in 90.7% and Baumann's angle was normal in all except two cases. There was no case of secondary displacement. Most complications were mild pin-site problems. There were no iatrogenic nerve injuries. Conclusion The lateral cross-pinning technique offers fracture stability and ulnar nerve safety. It could be considered as a viable option for treating displaced supracondylar fractures in children.
  1,484 195 1
Posterior lumbar interbody fusion with pedicular fixation for surgical treatment of failed back surgery syndrome
Khaled M. Hassen Ali
July-September 2013, 48(3):241-248
DOI:10.4103/1110-1148.125831  
Background Spine surgery can basically yield only two things: decompression of a nerve root and/or stabilization of painful joints. Failure to achieve both of them leads to continuation of back and/or leg pain because of persistence or recurrence of disc herniation and/or stenosis, infection, and fusion failure. Posterior lumbar interbody fusion (PLIF) has been considered the optimal solution for the above-mentioned problems. Aim of the work The aim of the work was to show the effectiveness and safety of PLIF surgery with pedicular fixation in the surgical treatment of failed back surgery syndrome (FBSS). Study design Prospective study. Patients and methods This study included 24 patients with FBSS treated with PLIF with pedicular fixation and an autogenous tricortical iliac bone graft. There were 14 men and 10 women, aged 30-62 years (average 46 years). Among the 24 patients, 10 had recurrent herniated disc with preoperative or intraoperative noticed spinal instability, eight had failed posterolateral fusion, and six had postoperative spondylodiscitis. Results The average Visual Analogue Scale of back pain improved significantly from 7.4 (range 6-9) preoperatively to 2.5 (range 1-5) at the last follow-up. The average Visual Analogue Scale of leg pain improved significantly from 6.1 (range 2-9) preoperatively to 2.8 (range 2-5) at the last follow-up. Finally, the average Oswestry Disability Index improved significantly from 78% (range 60-90%) preoperatively to 36.6% (range 32-48%) at the last follow-up. According to Brantigan evaluation, fusion was considered certain in 23 patients (95.8%) at the last follow-up. Conclusion The outcomes of PLIF with pedicular fixation in the surgical management of FBSS were encouraging in terms of significant improvement in back pain and leg pain, with good fusion rate and good quality of life.
  1,559 109 -
Scaphoid nonunion volar pedicle vascularized graft versus volar peg graft
Salah A Zakzouk, Ashraf A Khanfour
March 2014, 49(1):53-60
DOI:10.4103/1110-1148.140547  
Background Scaphoid fracture nonunion often presents a therapeutic challenge. This is because the vascular supply of the scaphoid renders the proximal pole in many of these fractures avascular. Russe reported the use of an anterior inlay graft and, since then, other techniques of bone grafting have been devised. More recently, vascularized bone grafts for scaphoid nonunion have gained increasing popularity and many methods have been described on the basis of different pedicles. Aim of the study This study performs a comparison of the results of the treatment of scaphoid nonunion fractures using a volar radial vascularized pedicle bone graft and a volar peg graft. Patients and methods In a prospective study, 45 patients with nonunions scaphoid fractures were divided randomly into two equal groups: a group treated using a volar radial vascularized pedicle bone graft and a group treated using a volar bone peg graft technique. Results The final end result was assessed according to the Cooney score scale; in group A (volar peg graft), bone union was achieved in 15 patients (68.20%). There were five excellent, seven good, three fair, and seven poor results. In group B (volar vascularized graft), bone union was achieved in all patients (100%). There were 10 excellent, 10 good, and three fair results. Conclusion A volar vascularized pedicle bone graft is a viable option for the treatment of scaphoid nonunion that leads to rapid union and consolidation of proximal pole scaphoid nonunion, with better both clinical and radiological results.
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Operative reduction and tendon transfer for treatment of posterior dislocation of the glenohumeral joint secondary to obstetric brachial plexus palsy in young children
Mohamad Osman Mohamad
March 2013, 48(1):56-60
DOI:10.7123/01.EOJ.0000426257.11905.6e   
Background

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.

Patients and methods

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.

Results

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.

Conclusion

The procedure used results in improved shoulder function and glenohumeral joint remodeling. Postoperative care and rehabilitation programs are mandatory for satisfactory outcome.

  1,517 71 -
Primary cemented hemiarthroplasty for unstable intertrochanteric fractures in elderly: an intermediate follow-up
Ahmad S Allam
April-June 2014, 49(2):96-100
DOI:10.4103/1110-1148.145303  
Background Standard methods of internal fixation for comminuted or osteoporotic unstable intertrochanteric fractures in the elderly have a relatively high complication rate. This is because of the poor bone quality and prolonged immobilization periods needed to protect the construct until sound union occurs. Aim The aim of the work was to evaluate the results of primary cemented hemiarthroplasty in elderly patients with unstable osteoporotic intertrochanteric fractures. Patients and methods A total of 27 patients (all were above the age of 70 years) with unstable intertrochanteric fractures who were prospectively managed with primary cemented hip hemiarthroplasty were followed for an average of 4 years (range: 3.5-5.5). Harris hip score and patients' satisfaction were the evaluation criteria. Results According to the Harris hip score, 10 patients (37%) were graded as excellent, 12 patients (44.5%) as good, five patients as fair (18.5%), and no patients were graded as having poor end results. Total complications were 11 in number (0.4 complication/patient) with no major complications or operative mortality. Conclusion Primary cemented hemiarthroplasty in elderly's unstable intertrochanteric fractures is a successful procedure regarding early mobilization, functional results, and complication rate.
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Closed reduction with pinning of metaphyseal fractures of the distal radius in children
Ehab I El-Desokey, Ahmed E Kandil
June 2013, 48(2):194-199
DOI:10.7123/01.EOJ.0000428877.41500.5d   
Background

Recent studies have shown favorable outcome with closed reduction and pinning for displaced complete fractures of the distal radius in children compared with closed reduction and casting alone, which showed a high rate of redisplacement in addition to complications that develop from extreme positions for maintaining reduction and anxiety developed from remanipulation of fractures.

Methods

During the period between July 2008 and July 2010, 30 cases of metaphyseal fractures of the distal radius were managed by closed reduction and primary pinning with the application of a forearm cast.

Results

No case of redisplacement was reported until complete healing, and no major complications were observed.

Conclusion

It appears that primary pinning for distal radius fractures is a simple and safe method that can be used as an alternative to closed reduction and casting alone in the treatment of displaced metaphyseal fractures of the distal radius in children (from 5 to 12 years), and this study supports previous studies on this method of treatment.

  1,457 105 -
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