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   Table of Contents - Current issue
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October-December 2017
Volume 52 | Issue 4
Page Nos. 251-335

Online since Thursday, April 19, 2018

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ORIGINAL ARTICLES  

Combined intramedullary and extramedullary fixation with autogenous bone grafting for the treatment of forearm nonunions with severe bone loss p. 251
Ihab Badawi
DOI:10.4103/eoj.eoj_69_17  
Introduction Nonunions of diaphyseal forearm fractures are uncommon. They are usually associated with either a complex injury or a complication such as infection. As a result, the majorities of nonunions are atrophic and result in a defined bone defect. Bridge plates and bone grafts were used for the treatment of such cases; however, the presence of poor bone quality especially with disuse can decrease the screw purchase and stability of fixation. Combined intramedullary and extramedullary fixation may add to the stability of fixation and improve the rates of success. Aim The aim of this work was to assess the results of treatment of forearm nonunions with severe bone loss using combined intramedullary and extramedullary fixation with autologous iliac crest bone grafting. Patients and methods This study included six patients with forearm nonunions with severe bone loss treated by combined intramedullary and extramedullary fixation with autologous iliac crest bone grafting. The study included three males and three females. Their age ranged from 14 to 47 years (mean: 36.1±12.4 years). The duration of nonunion ranged from 6 to 180 ms (mean: 78±71.5 ms). A total of four (66.7%) cases had been infected previously. The number of previous surgical procedures ranged from 1 to 8 (mean: 3.5±2.5). The forearm was transformed into a single bone in three (50%) cases. Results All nonunions healed satisfactorily. The final pain scale ranged from 0 to 2 points (mean: 1.3±0.8 points). There was a slight limitation in activities of daily living in all points. The hand grip was normal in one patient, slightly weak in four patients, and moderately weak in one patient. Conclusion Combined intramedullary and extramedullary fixation with autogenous bone grafting is a reliable method of treatment of difficult forearm nonunions with significant bone loss.
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Solid aneurysmal bone cyst: follow-up of nine cases p. 257
Awad Abdel-Moniem Rafalla, Mohamed Samir Kasem
DOI:10.4103/eoj.eoj_70_17  
Background Solid aneurysmal bone cyst or reparative granuloma of bone is a rare tumorlike condition that primarily affects the bone. It was first described by Jafe et al. as a non-neoplastic giant cell reparative granuloma of bone. Patients and methods This study included nine patients, with five males. Age ranged from 6 to 34 years at presentation, with mean age of 15.5 years. Femur was affected in three patients, where two of them was in the trochanteric region, and the third ones showed a recurrent distal femoral lesion; followed by distal tibia in two cases, where one of them also was a recurrent lesion; and a single case each in proximal tibia, distal ulna, clavicle, and pelvis. All cases were histologically diagnosed by either incisional biopsy (five cases) or after final treatment. Some cases had radiological and pathological differential diagnoses such as giant cell tumor, hyperparathyroidism, and osteosarcoma. Seven cases were treated by thorough curettage and hydrogen peroxide lavage, with an autologous nonvascularized fibula in two cases. Two cases were managed by en block excision. Follow-up period ranged from 18 to 50 months, with mean follow-up of 33.6 months. Results All curetted cases healed completely without local recurrence. All cases had excellent functional outcome. Conclusion Solid aneurysmal bone cyst is slightly different from ordinary type as it has wider age incidence, and it might have serious differential diagnosis as osteosarcoma, but it is treated almost the same way.
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Percutaneous fixation of pediatric humeral lateral condyle fractures p. 263
Ahmed S Rizk, Osama M Essawy
DOI:10.4103/eoj.eoj_71_17  
Background Traditionally, the initially nondisplaced pediatric humeral lateral condyle fractures were treated conservatively, whereas displaced or rotated fractures were treated by open reduction and internal fixation (ORIF). Late displacement and nonunion were reported in some conservatively treated cases, whereas epiphyseal necrosis with or without nonunion and elbow deformity were reported in some cases treated by ORIF. Few studies have highlighted closed reduction and percutaneous fixation (CRPF) of displaced and/or rotated fractures. The aim of this study is to assess the outcome of CRPF for the treatment of pediatric humeral lateral condyle fractures. Patients and methods A prospective study included 45 cases of PHLCFs that were preoperatively classified according to classification by Song and colleagues; all cases were planned to have percutaneous fixation through either in-situ pinning if initially nondisplaced or closed reduction if displaced or rotated. If closed reduction failed, ORIF was done. The functional results were evaluated according to the modified criteria of Aggarwal and colleagues. Results CRPF was successful in 80.48% of cases with displaced and/or rotated fractures, with satisfactory clinical and radiological results and no reported surgery-related complications in any case till the last follow-up, with a mean follow-up duration of 18.6±3.04 months. ORIF was done in only eight cases (representing 19.52% of the studied cases) after failed closed reduction. There was a statistically significant difference (P<0.001) in the mean radiological union time and the mean time needed for restoration of the full functional capacity of the operated elbow between cases treated by CRPF and cases treated by ORIF. Conclusion CRPF could be the treatment of choice for potentially unstable lateral humeral condyle fractures avoiding the complications of late displacement and elbow stiffness reported in some conservatively treated case. CRPF is an efficient and minimally invasive treatment option for some displaced and/or rotated fractures with very satisfactory clinical and radiological results. ORIF could be restricted only for certain complex cases or after the failure of CRPF. Level of evidence: Level IV.
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The incidence of deep vein thrombosis after knee arthroscopy p. 273
Abo-Bakr Zein Said, Haytham Abdel-Moneim
DOI:10.4103/eoj.eoj_72_17  
Purpose Deep vein thrombosis (DVT) is generally thought to occur rarely in patients who undergo knee arthroscopy, and current practice is not to administer perioperative thromboprophylaxis. In support of this practice, postoperative screening for DVT after 2 weeks from knee arthroscopy was done in this study using ultrasonography technique to detect the DVT incidence after such procedure. Patients and methods This study population consisted of 50 patients, 44 males and six females, who underwent knee arthroscopy and fulfilled the following inclusion criteria: patients aged from 18 to 60 years, those with isolated meniscal injury, and those not known to be at high risk for DVT. Radiographs and MRI were done for all patients preoperatively to diagnose knee injury. The medial meniscus was injured in 39 patients and the lateral meniscus in 11 patients; all were managed arthroscopically. Full DVT screening with lower limbs venous ultrasonography was done for all patients within 2 weeks postoperatively. Results The mean patients’ age at the time of the operation was 27.8 years (range: 18–43 years). The right knee was affected in 22 patients and the left in 28 patients. The tourniquet was used in 43 patients. The mean time for hospital stay was 1.24 days (range: 1–3 days). Only one patient of the 50 developed asymptomatic silent DVT within the first 2 postoperative weeks. Conclusion The incidence of DVT after arthroscopic knee surgery of 50 patients in this study was 2%, which is not a strong prerequisite for perioperative thromboprophylaxis in patients not known to be at high risk.
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Sinus tarsi: a proprioceptive organ? p. 278
Mohamed G Morsy, Timm J Filler
DOI:10.4103/eoj.eoj_73_17  
Background Flexible flatfoot in children is one of the most common disorders in orthopedics. The mechanism of action of the subtalar implants used for correction of the deformity is still unclear. Purpose The aim of this study was to identify the neurohistological nature of the subtalar tissues in an attempt to clarify the mechanism of action of sinus tarsi implants used for correction of flexible flatfeet. Patients and methods From 46 patients (mean age 39 year, 26 male and 20 female), soft tissue material was excised from the sinus tarsi during operative intervention in the foot for different indications. The excised tissues were studied histologically with different staining methods. Results The histological examination revealed the presence of large amount of neural elements (mechanoreceptors) together with abundant elastic fibers in all of the excised subtalar tissues. Conclusion Our findings suggest that the sinus tarsi is a neurosensitive elastic organ and has a proprioceptive information mechanism. This may be of great value in the treatment of patients with flexible flatfeet using subtalar implants.
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A new technique for hamstring tendon graft harvesting p. 282
Taher A Eid
DOI:10.4103/eoj.eoj_74_17  
Introduction Harvesting of hamstring tendon is a very important step in anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction. Although there are many advantages for using the hamstring tendon for cruciate ligaments reconstruction, there are many disadvantages of the traditional technique for hamstring tendon harvesting. Therefore, we have used a new technique to avoid all the disadvantages and allow for fast, easy, and perfect hamstring tendon graft harvesting. The aim of our new technique for hamstring tendon harvesting is to avoid all complications and difficulties related to graft harvesting and keeping sartorial fascia in a good and repairable condition. Patients and methods We carried out arthroscopic ACL reconstruction using hamstring tendons autograft. We used a new technique for hamstring tendons harvesting. This work was done on 12 patients with an average age of 24 years (20–38) between March 2010 and December 2010. Results Subjective assessment was done according to International knee Documentation Committee rating system. This was defined as four grades as follows: normal (a), nearly normal (b), abnormal (c), and severely abnormal (d). Before ACL injury, 12 (100%) patients considered their knees to have been grade A. Twenty-four months after reconstruction, 11 patients rated their knees as normal or nearly normal. One patient rated his knee as abnormal at 2 years of follow-up. This patient had severe osteoarthritic changes. Conclusion It would be advisable to follow this technique of graft harvesting for all individuals undergoing arthroscopic ACL reconstruction using hamstring tendons to avoid the problems encountered with the standard technique and also to achieve an excellent outcome.
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Is bone graft fundamental in opening wedge high tibial osteotomy? Evaluation of the short-term results of opening wedge high tibial osteotomy without using bone graft p. 288
Ahmed Samy, Wael Azzam
DOI:10.4103/eoj.eoj_75_17  
Introduction High tibial osteotomy has been described as an effective procedure for treatment of medial compartmental osteoarthritis of knee. Many techniques have been developed (closing wedge, opening wedge, etc.), but opening (medial) and closing (lateral) wedge osteotomies are the most commonly used. The use of autograft was the gold standard in opening wedge osteotomy for a long time. Patients and methods This is a prospective study carried on 32 knees in 19 patients in a period between January 2011 and January 2013, with a mean follow-up of 17.4±2.87 months. There were 12 males and seven females, with a mean age of 42.5±10.68 years. There were 13 cases with 26 knees with primary osteoarthritis and six were post-traumatic. The preoperative varus angle was measured by the hip–knee–ankle angle on standing scanogram. A single surgical technique was used for knees: medial opening high tibial osteotomy with locked plate fixation but without filling the defect. The preoperative genu varum could not exceed 15°. The following were evaluated: International knee Documentaion committee Scoring (IKDC) functional score and long-leg standing film were performed preoperatively, postoperatively, and at follow-up to evaluate limb alignment and validate the precision of the correction and its stability over time. Results Bone union occurred at 4.3 months on average; two knees required revisions (6.25%). The first was because of delayed union and was revised with an autograft at the seventh month, and another case of nonunion with implant failure was revised at the fourth month by total knee replacement. Before the surgery, the average varus was174±2.18° (165°–176°); after the surgery, the hip–knee–ankle angle was183°±1.88° (179°–184°) (P=0.0001). This correction was maintained at follow-up. Average Knee Score was improved from 68.0±20 preoperatively to 91.0±19 postoperatively. The Visual Analog Scale score was 76±23 and 38±19 at preoperative and postoperative, respectively, with an average reduction of 38 points. Full weight-bearing without assistance was possible after 3 months on an average. Conclusion Union of the arthritic knees was possible without using bone graft (BG). The time to union was comparable to that after using (BG). Meanwhile, It avoids the risks and complications that might be associated with the use BG or Bone substitutes.
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Genu varum with medial compartment osteoarthritis treated with puddu plate p. 296
Ahmed M Elsersawy, Hatem H Ali, Mohamed M Sherif
DOI:10.4103/eoj.eoj_76_17  
Background Gonarthrosis in the relatively young and active population causes major daily discomfort and disability. If the arthritic process is mainly limited to the medial compartment, the axis of a varus knee can be realigned laterally with high tibial osteotomy (HTO) to unload the medial compartment and allow some cartilage regeneration and pain relief. Many techniques have been developed (i.e. closing wedge, opening wedge, dome, and ‘en chevron’ osteotomies), but opening (medial) and closing (lateral) wedge osteotomies are the most commonly used. With opening wedge HTO, good long-term results are obtained with a correct patient selection (a young patient<60 years of age, isolated medial osteoarthritis, and with good range of motion and without ligamentous instability) and a precise surgical technique. This study describes the outcomes of patients who underwent opening wedge HTO using Puddu plate. Aim The aim of this study was to confirm that medial opening wedge HTO with Puddu plate fixation can be a reliable procedure for the treatment of medial compartment osteoarthritis of the knee associated with varus deformity. Patient and methods With meticulous patient selection, an open-wedge HTO using the Puddu plate was performed in 15 knees of 15 patients at El-Sahil Teaching Hospital between May 2010 and March 2013 for a young patient population (<60 years of age) with isolated medial osteoarthritis, with good range of motion, and without ligamentous instability. There were four women and 11 men. Overall, nine patients were affected in the left knee and six in the right. Their mean age was 25.4 years. The average varus angle to be corrected was 8.13. Results All of the patients were followed up for an average of 12 months (8–16 months). There was no nonunion or delayed union in this group, and all patients were encouraged to start full weight-bearing after 6 or 8 weeks. The overall fineness rate was 80% (12/15) at the end of the follow-up with improved symptoms. Two cases of wound infection were treated with antibiotic and daily dressing. One case of deep vein thrombosis was treated satisfactorily with medical therapy. Two had patients had undercorrection, two patients need cancellous bone graft, and three patients needed postoperative casting. Conclusion With meticulous patient selection, medial opening HTO using the Puddu plate has a very high success rate. The benefits of this technique is the short time of operation in comparison with other techniques, no graft used, and no casting postoperatively because the Puddu plate gives rigid fixation, which leads to early range of motion in the knee.
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Latarjet procedure combined with inferior capsular shift for recurrent anterior shoulder instability in patients with hyperlaxity p. 306
Bahaa A Motawea, Mohamed M Abouheif
DOI:10.4103/eoj.eoj_77_17  
Background Recurrent unidirectional anterior shoulder instability is a common disease especially among professional athletes. Open latarjet operation is a common surgical procedure used for the treatment of this condition, especially in cases associated with a high instability severity index score (ISIS) including cases with humeral bone loss (Hill–Sachs lesion) or anteroinferior glenoid bone loss. Persistent apprehension or recurrence of instability after the latarjet procedure might be attributed to associated anterior capsular laxity that was not addressed in the primary surgery. Hypothesis Combining coracoid bone transfer with capsulorraphy and capsular shift, and maintaining the sling effect of the conjoint tendon might be beneficial in patients with recurrent anterior shoulder instability associated with anterior capsular redundancy (ACR). Patients and methods A total of 30 patients with recurrent unilateral symptomatic involuntary unidirectional anterior shoulder instability were studied. All patients had an evidence of joint hyperlaxity with a Beighton score ranging from 6 to 9, mean 7.63±1.07. Evidence of ACR (Sulcus sign) was present. ISIS was superior than or equal to 4. In this study, the ISIS ranged from 6 to 10, with a mean of 8.38 and SD of 0.89. All of the patients underwent an open Latarjet procedure with superior capsular shift and capsulorraphy using Ethibond N:5 sutures wrapped around the serrations of the screw. All the patients were interrogated, examined clinically, and scored according to the Constant–Murley scoring system. Results The most important finding of this study is the marked improvement in the symptoms of instability as well as the level of function after surgery. There was a highly statistically significant difference between the preoperative and the postoperative Constant–Murley score. Conclusion In anterior shoulder instability with ACR, the Latarjet procedure associated with an anteroinferior capsulorrhaphy is an effective alternative to arthroscopic or open capsular shift and should help in reducing postoperative apprehension. The sooner the reconstructive surgery is performed, the better the functional outcome.
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Clinical and radiological outcome of surgical fixation of femoral head fractures p. 314
Mohamed Y Ali, Mohamed A Elsoud
DOI:10.4103/eoj.eoj_78_17  
Background Up to 16% of hip dislocations have associated femoral head fractures, but if incongruency and instability of hip occurred this is an indication for surgery; intervention could range from excision of the fractured part, fixation, or even total hip replacement. Approaches may be anterior or posterior or transtrochanteric. Except for the surgical dislocation of the hip these approaches give limited exposure; surgical dislocation gives access to 360° of the head femur. Patient and methods A retrospective study for prospectively collected data, started by 23 cases and after exclusion of those cases treated conservatively or by excision, or any intervention other than fixation, there were 12 cases left on which the study was conducted. The study was held in Cairo University Hospital on 12 patients with traumatic femoral head fracture treated surgically by reduction and fixation, between November 2012 and June 2016. Results According to Matta reduction criteria, 11 cases had anatomical reduction, one case with imperfect reduction, according to Matta radiographic criteria at follow-up, four cases with excellent score, five cases with good score, three cases with poor score, according to Merle d’ Aubigne and Postel criteria, four cases with excellent score, five cases with good score, one case with fair score, and two cases with poor score. Conclusion Surgical hip dislocation allows inspection of the entire femoral head and the full circumference of the acetabulum for rigid fixation and debridement, with low incidence of avascular necrosis, while anterior Heuter approach to the hip joint is a simple, adequate, muscle-preserving, and viable option for open reduction and internal fixation of femoral head fractures with early rehabilitation.
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Extended curettage, bone grafting, and spanning external fixation for the treatment of juxta-articular giant cell tumor of the bone around the knee p. 321
Adel R Ahmed
DOI:10.4103/eoj.eoj_79_17  
Background Treatment of juxta-articular giant cell tumor (GCT) of the bone around the knee remains a dilemma. Many authors recommend cementing, others grafting after extended curettage and others resect and replace by a modular prosthesis. Biological reconstruction remains the cornerstone of our belief in the treatment of GCT. Materials and methods A retrospective review was conducted of GCT around the knee treated between 2000 and 2012 using the technique of extended curettage through a large bone window in situ pasteurization (ISP), followed by bone grafting and spanning external fixation. Thirty patients (10 men, 20 women), aged from 15 to 67 years (average 38 years) with a mean duration of follow-up of 46 months (range: 24–188 months) were identified. The GCTs were staged according to the system of Campanacci and colleagues. Six lesions were classified as stage I, 18 as stage II, and six as stage III. Four patients had an intra-articular fracture of the distal femur at the time of diagnosis. Results All 30 patients are continuously free of disease and there is no local recurrence. Functional evaluation was performed by the International Society of Limb Salvage score criteria. The average functional score was 95% (77–100%). None of the patients complained of pain and none of the patients demonstrated serious instability of the knee joint. All the patients showed union starting from 2 months after surgery with full consolidation 6 months after surgery. The fixator was removed at 4–12 months after surgery. Radiologically, 29 (97%) patients had complete incorporation of the graft (>75% of the International Society of Limb Salvage score) and one (3%) patient had partial incorporation (<75% of the International Society of Limb Salvage score). The overall average radiographic evaluation rating was 97%. Osteoarthritis of the knee joint was not seen in any of our patients. Four patients had intra-articular fracture of the distal femur at presentation; all healed eventually and did not affect the final results. Conclusion Extended curettage, ISP bone grafting, and spanning external fixation is a safe and effective procedure for the treatment of juxta-articular GCT of the bone around the knee.
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Safe zones of half-pin insertion in lumbar vertebrae cadaveric study p. 328
Mohammed A Moselhy, Ali M Ali
DOI:10.4103/eoj.eoj_81_17  
Purpose This experimental study is to know what the safe zones and angles of half-pin insertion in lumbar vertebrae are, and if there are other new sites for half-pin insertion. Materials and methods A cadaver study using two bony and four cadaveric specimens was undertaken to examine the safe sites for half-pin insertion in the lumbar vertebrae. Half pins were inserted into specific demarcated sites. Results From our study we suggest that the pedicle of the lumbar vertebrae is a safe and strong region for the insertion of the half pins with 10°–40° divergence from the midline, where the new site of half-pin insertion in the vertebral body anteriorly and at the level of transverse process is safe at an angle that lies between 50° and 60° from the sagittal plane in L4 and L5. Conclusion We concluded that the application of external fixators in the lumbar spine is valuable with good safety margins of half-pin introduction in both the pedicle and the vertebral body.
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CASE REPORT Top

Primary intermuscular hydatid cyst of the posterior thigh: a rare presentation p. 333
Lutf A Abumunaser
DOI:10.4103/eoj.eoj_80_17  
In this article, we report a rare case of hydatid cyst in the posterior aspect of the thigh of a 70-year-old lady from the endemic region (Yemen). She presented to the orthopedic clinic in King Abdulaziz University Hospital, Jeddah, KSA, complaining of a painless, gradually progressive swelling of the left posterior thigh. Diagnosis was reached by computed tomography scan and MRI of the left thigh, and confirmed with an ultrasound-guided fine needle aspiration. The cyst was treated with a wide excision and 3 months of albendazole. The primary intermuscular hydatid disease is a rare condition. Clinically, it presents as a painless slowly growing mass. Preoperative diagnosis is essential because cyst rupture and dissemination may lead to recurrence. The diagnosis can be obtained by computed tomography scan, MRI, and ultrasound. A fine needle aspiration may done to confirm the preoperative diagnosis. Combination of wide excision and chemotherapy in such cases is the recommended and curative treatment.
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