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   2017| January-March  | Volume 52 | Issue 1  
    Online since November 6, 2017

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Minimally invasive approach for stabilization of type III acute acromioclavicular dislocation by using suture anchors
Naser M Selim
January-March 2017, 52(1):1-5
Background Acute complete acromioclavicular (AC) joint dislocation can be treated by surgical stabilization with or without reconstruction of the coracoclavicular ligaments. Aim The aim of the study was to evaluate the results of using mini-open approach for the stabilization of acute complete AC dislocation, by using suture anchors. Patients and methods This study evaluated the results of treatment of 30 patients with acute complete AC dislocation operated in Mansoura Emergency Hospital. The study described fixation of AC joint dislocation performed through mini-open approach, using suture anchors. Results Overall, 80% of patients were satisfied with the results of their surgery. According to Constant–Murley score, 18 (60%) patients had excellent results, six (20%) patients had good results, and six (20%) patients had poor results. There were no incidences of infection, soft tissue ossification, bone erosion, or painful scar. Four (20%) patients had recurrent deformity. Conclusion Acute complete AC joint dislocation can be treated by suture anchor fixation through mini-open approach. It is a simple and reliable method of fixation with lower incidence of complications and can be carried out through cosmetic approach, but it carries the risk for recurrent deformity.
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Floating knee injuries: treatment with a single approach
Aly Mohamadean, Hossam A Beeh
January-March 2017, 52(1):6-12
Introduction The ‘floating knee’, a term first used by Blake and McBride in 1974, describes concomitant fractures of the ipsilateral femur and tibia. ‘Floating knee’ injuries may include combinations of diaphyseal, metaphyseal and intra-articular fractures. Patients and methods We report a series of 21 patients who had Fraser type I floating knee injury treated with the retrograde femoral and antegrade tibial intramedullary nail using a single knee incision during a period between 2005 and 2009. The mean age of the patients at the time of injury was 30.6 years (range: 19–50 years); 17 of them were male and four were female. All patients had sustained their injuries in motor vehicle accidents. Results The average time for union of femoral shaft fractures was 15.8 (range: 8–56) weeks. The average time for union of tibial fractures was 22.9 (range: 18–30) weeks. There was no malunion exceeding 10° of angulation or rotation in either fracture. There was no patient leg length discrepancy. There was no deep infection. The final functional outcomes after bony union using the criteria of Karlström and Olerud were as follows: 11 excellent results (52.3%), six good (28.5%), three fair (14.3%) and one poor result (4.7%). The overall satisfactory outcome rate was 81% (17/21).
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Dega osteotomy for the treatment of developmental dysplasia of the hip
Elsayed E Saoudy, Yousuf M Khira
January-March 2017, 52(1):38-44
Background The neglected developmental dysplasia of the hip with adaptive changes in bone and soft tissue is difficult to treat. Dega osteotomy is added to open reduction to confer concentric stable reduction with good coverage of the head of the femur. Patients and methods Forty hips in 32 patients were treated using open reduction and Dega osteotomy. There were 30 dislocated and 10 subluxated hips according to Tonnis grading. Radiographic parameters used in this study included the acetabular index, the acetabular angle of sharp, the caput-collum-diaphyseal angle, and the center-edge angle of Wiberg; the final radiographic outcome was evaluated according to the Severin classification. Clinical results were evaluated according to the modified McKay criteria. Results The mean follow-up period was 96 months. The final results according to Barrett’s modification of McKay’s criteria were as follows: 34 (85%) with favorable results and 6 (15%) hips with unfavorable results. According to the Severin criteria for the evaluation of radiographic results, 74% were types I and II whereas 26% showed types III and IV; no hips were rated as Severin’s groups V or VI. Eight (33.4%) hips in children with unilateral involvement had developed coxa magna, but in no case did this interfere with hip concentricity. Three hips showed avascular necrosis on the latest radiographs. Conclusion The Dega osteotomy added to the open reduction, capsulorrhaphy, and femoral shortening is a safe, simple, and adequate procedure for the management of neglected developmental dysplasia of the hip patients after 2 years of age, with lower complication rates. Restoring the acetabulum to normal or nearly normal can result in good long-term results.
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The use of locked plate as a definitive fixation for open supracondylar fracture of the femur with partial bone loss in polytraumatized patients
Mootaz F Thakeb, Wael Samir
January-March 2017, 52(1):13-17
Background Open supracondylar fractures of the femur are complex injuries usually presenting in a polytraumatized patient. Partial circumferential bone loss may result at the time of injury or during debridement. The way in which the fracture is treated has a substantial influence on the local mechanical and biological environment, which in turn will influence the quantity and quality of the osteogenic response. Although early skeletal stabilization can stop the cycle of injury, remove nidus for infection, and halt ongoing hemorrhage, it may be prudent to delay definitive surgery until the patient’s general condition is optimized. Meanwhile, debridement and a preliminary spanning external fixator is used to stabilize the fracture. The use of a locked plate for the fixation of supracondylar fracture of the femur with partial bone loss creates a rigid biomechanical environment needed for healing and maintenance of alignment until fracture healing. Patients and methods Eighteen patients with open supracondylar fracture of the femur were treated between January 2009 and June 2011. All patients were treated surgically within the first 24 h. Radical soft tissue and bone debridement was performed. Thirteen patients underwent definitive fracture fixation using a laterally placed locked distal femur plate. Five patients had their fractures primarily stabilized by an external fixator until improvement of their general condition. Results Bone healing was obvious on follow-up radiographs in 10 patients without the need for supplementary surgical procedures at a mean of 16 (12–20) weeks. Seven patients with no progressive radiologic healing by 20 weeks’ follow-up underwent an iliac crest cancellous bone graft; healing was then realized radiologically after a mean of 12 (8–18) weeks. Using the IOWA knee functional score for final patient assessment, we found excellent results in 14 patients, good results in three patients, and fair results in one patient. Conclusion Generally stable polytraumatized patients should be treated with thorough initial debridement, local antibiotics, and early definitive fracture fixation using a locked distal femur plate. Critically unstable patients with hemorrhagic shock are to be treated with damage control until improvement in their general condition. Bone graft is to be delayed for 20 weeks as many fractures would successfully heal by that time, even with partial bone loss.
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Reconstruction of posterolateral bundle in partially torn anterior cruciate ligament using hamstring tendons
Ehab I El-Desoky, Ahmed Rizk, Samir M Abdullah, Ahmed Abdel-Aziz
January-March 2017, 52(1):26-31
Purpose Partial tear of the anterior cruciate ligament (ACL) is a frequent injury. Controversy as regards reconstruction of partially torn ACL is still present. We prospectively evaluated clinical outcome of patients after reconstruction of partially torn ACL that involves posterolateral (PL) bundle with hamstring tendons. Methods and results Between August 2008 and August 2011, 20 (PL) bundle tears of ACL-deficient knees of 20 active athletic patients were evaluated and reconstructed with hamstring tendons. There were 17 male and three female patients; the mean age of the patients was 29 years (range: 21–37 years). Assessment was carried out using Lysholm score, International Knee Documentation Committee (IKDC), and KT-1000. Cases were subjected to scoring at 6 months postoperatively with improved outcome using Lysholm score from 65.5 (range: 30–89) to 91 (range: 81–100). A clear difference in IKDC scoring was found as regards knee stability testing. Side-to-side laxity using KT-1000 measurement improved from 3 mm preoperatively to 1 mm postoperatively. Conclusion Reconstruction of PL bundle of partially torn ACL provides a logical way to augment knee stability.
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Outcome of elastic stable intramedullary nailing of displaced midshaft clavicular fracture: does the presence of fracture comminution differ?
Radwan A Yasser, Mansour R Ali, Badawy S Walid, Nasef M Nasef
January-March 2017, 52(1):18-25
Background The mainstay of the treatment of the fractures of the clavicle has been nonoperative, even with substantial displacement. Elastic stable intramedullary nailing of displaced midshaft clavicular fracture is a relatively new method for stabilization of these fractures, having a significantly lower rate of complications and earlier return of function. However, there is no general consensus about its indications, especially in comminuted fractures. Materials and methods A prospective study of 46 patients with displaced midshaft clavicular fractures was conducted to evaluate the efficacy and safety of fixation of such fractures using titanium elastic intramedullary nail and to assess the effect of the presence of fracture comminution on the final outcome. Patients were divided into two groups. Group I comprised 21 patients with noncomminuted fractures, whereas group II comprised 25 patients with comminuted fractures. The primary outcome measure was the Constant shoulder score, and the secondary outcome measures included the following: the disability of the arm, shoulder and hand (DASH) score, the union rate, the duration of union, the patients’ satisfaction as regards the cosmetic results, and the prevalence of complications related to surgery. Results All patients were available for follow-up after a minimum of 1 year postoperatively. Osseous union was achieved in all patients in both groups, except in one patient in group II. The median Constant and DASH scores showed progressive postoperative improvement in both groups throughout the follow-up period. At 6 weeks postoperatively, the median Constant and the DASH scores in the noncomminuted group (group I) were significantly better than that in group II (P<0.001 and 0.005, respectively). However, there were no significant differences thereafter. At 1 year postoperatively, 18/21 (86%) patients in group I and 20/25 (80%) patients in group II were satisfied as regards the cosmetic result of the procedure (P=0.71). Conclusion This study has shown that elastic stable intramedullary nailing of displaced midshaft clavicular fractures gives good cosmetic and functional results with minimal morbidity and complications. Medial prominence of the elastic nail was the most common complication. The presence of fracture comminution was associated with a delayed functional recovery; however, it did not affect the final functional outcome or the cosmetic result.
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Functional outcome of pelvic fractures in children: does age affect outcome?
Mohamed Gobba, Sherif A Khaled, Ahmed Galal, Hazem A Azeem
January-March 2017, 52(1):72-77
Objective The objective of this study was to assess the early radiological and functional outcome of either conservatively or surgically treated pediatric pelvic fractures. Patients and methods This was a prospective study of pediatric patients with pelvic fractures resulting from high-energy trauma. Management was either conservative or surgical. Score-based functional outcome assessment was done. Results A total of 30 patients were enrolled in the study. Of them, 20 patients were managed conservatively and 10 patients were surgically treated. We had three mortality cases. The mean follow-up period was 9 months. Functional outcome score was 74 for conservative and 70 after operative treatment according to Majeed score. Limb-length discrepancy, back pain, skin macerations, infection, and nerve injury were the encountered complications. Conclusion Pediatric pelvic fractures classified as Tile A or B can be successfully managed conservatively. All vertically unstable fractures should be reduced and fixed as the pediatric pelvis has a very limited remodeling power for this type of fracture.
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Arthroscopic management of large-size cam-type femoroacetabular impingement
Amr A Abdelrahman, Tarek M Ghandour
January-March 2017, 52(1):32-37
Background Ganz and colleagues have popularized that femoroacetabular impingement (FAI) is a cause of hip pain in adolescents and young adults, and it can eventually lead to osteoarthritis of the hip. FAI is the result of abnormal contact between the proximal femur and the acetabulum. A size and shape mismatch within the hip joint causes collision events that lead to labral and cartilage degeneration. The principle of treatment is based on providing an adequate clearance during terminal range of movement of the hip, thereby avoiding abutment of the proximal femur on the acetabular rim. Objective The aim of our study was to report the results of arthroscopic femoroplasty in cases with large-size cam-type FAI. Patients and methods Twenty patients (11 male and nine female) with a mean age of 33 years (range: 22–48 years), with a large cam-type FAI underwent arthroscopic femoroplasty. The duration of symptoms before surgical intervention averaged 14 months. The patients were assessed preoperatively and 3 months and 1 year postoperatively using the modified Harris hip score (MHHS). The patients were excluded if the disease state was too advanced to reasonably benefit from arthroscopic intervention, with bone-on-bone contact an absolute contraindication. Results The mean MHHS increased more than 20 points from 52 preoperatively to 72 postoperatively after 3 months and to 75 after 1 year. The mean abduction improved from 22° preoperatively to 28° at 12 months postoperatively. The mean internal rotation improved from 16° preoperatively to 23° at 12 months postoperatively. The mean pain score in MHHS increased from 25.8 preoperatively to 41 at 12 months postoperatively. The mean duration of arthroscopic femoroplasty was 120 min (range: 90–180 min). Conclusion With the advancement in hip arthroscopy techniques, it is now possible to address large cam-type FAI arthroscopically with results comparable to open surgical dislocation and femoroplasty with the advantage of low morbidity and early rehabilitation.
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L-shaped arthroscopic posterior capsular release in frozen shoulder
Mohamed G Morsy
January-March 2017, 52(1):45-49
Background Arthroscopic capsular release in refractory cases of primary frozen shoulder is a well-established and acknowledged procedure with successful outcome. Nonetheless, postoperative limitation of internal rotation is a common complaint that diminishes the postoperative success. Purpose The purpose of this prospective study was to assess the results of a new L-shaped arthroscopic posterior capsular release and compare it with the standard longitudinal technique. Patients and methods Forty-three consecutive patients with primary frozen shoulder in whom conservative medical, physiotherapy, and/or local steroid injection failed to relieve the symptoms were included in the study. Arthroscopic capsular release was performed in all cases. Group 1 underwent the standard longitudinal anterior and posterior release only; group 2 underwent an additional L-shaped posterior capsular release. Constant–Murley functional score was used to assess the overall outcome and patient satisfaction. Results The mean age of the patients was 49 years (range: 27–67 years), with no statistical difference between the two groups. There were 22 patients in group 1 and 21 patients in group 2. The mean follow-up period was 34 months (range: 24–42 months). At the final follow-up, there was a highly significant improvement in Constant score (P<0.001) postoperatively in both groups. A similar finding was noted in the overall range of motions (P<0.001). However, group 2 showed a significant difference in the improvement of the internal rotation range of motion postoperatively. Conclusion The L-shaped arthroscopic posterior capsular release in patients with primary frozen shoulder is a new technique that significantly improves the postoperative internal rotation range of motion.
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Complex femoral fractures: management by interlocking nails and percutaneous cancellous screws
Mostafa A Elkhalek Elsayed, Hatem S.A Elgohary
January-March 2017, 52(1):66-71
Background Complex femoral fractures are fractures involving more than one anatomical region of the femur. Each of these fractures may be fixed with implants selected for each fracture, requiring large incisions. In this study, these fractures were fixed with antegrade interlocking nails and percutaneous cancellous screws. Patients and methods A prospective study was conducted at Mansoura University Emergency Hospital. Twenty-nine skeletally mature patients with complex femoral fractures included in this study were managed with antegrade interlocking nails and percutaneous cancellous screws. The orthopedic trauma association (OTA) classification was used for classifying fractures, and the Gustillo and Anderson classification was used for open fractures. Results All fractures in this study healed without complications. No statistically significant correlations were found between fracture type, fracture level, and healing time. Cases with open fractures of the femoral shaft had longer healing times, which were significant (P=0.03). There were no cases with malunion, femoral neck nonunion, or avascular necrosis of the femoral head. Conclusion Antegrade interlocking nail combined with percutaneous cancellous screws is a potent and effective method for fixing complex femoral fractures.
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Shaped graft for aneurysmal bone cyst of upper-limb bones
Mohamed F Mostafa, Yasser Y Abed, Sallam I Fawzy
January-March 2017, 52(1):50-56
Background and purpose The optimal treatment of aneurysmal bone cyst (ABC) remains challenging. The aim of this study was to evaluate the results of using bone grafts shaped to the defects caused by ABCs of upper-limb bones. Patients and methods Totally, 15 patients (12 male and three female) with an average age of 12 years (range: 6–16 years) were treated for ABCs of upper-limb bones by intralesional resection, argon beam coagulation, and shaped bone graft. The grafts were harvested from 14 patients (11 fibulas and three iliac bones) and from the mother of one patient (proximal fibula). Osteosynthesis was required to stabilize the graft in four cases. The modified Enneking’s scoring system was used for functional evaluation. Results One patient developed partial recurrence at 6 months and required reoperation. Superficial wound infection was encountered in one patient. Shortening of the humeral segment was seen in two patients (1 and 1.5 cm) but without angular deformity. After a mean follow-up of 45 months (range: 24–68 months), the mean functional score was 97.3%. Conclusion This technique is reliable to obtain a well-reconstructed and growing bone with no or minimal deformity and good function.
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Safe zones of pin insertion in thoracic spine: a ‘cadaveric study’
Mohammed A Meselhy, Osama F Ahmed
January-March 2017, 52(1):57-61
Purpose This experimental study was conducted to identify the safe zones and angles of half pin insertion in thoracic vertebrae. Materials and methods Simple tools were used, power drill, 4, 5, and 6 mm half pins, goniometer, and portable radiographic apparatus. There were two bony specimens comprising complete lumbar thoracic and cervical spine with ribs and sternum attached, and three cadaveric specimens preserved in formalin, comprising the thorax and abdomen with the back muscle dissected to show the thoracic pedicle. The methodology comprised insertion of the Schanz screw in the thoracic pedicle from T1 to T12 using the free-hand technique in bony skeleton, and then this was repeated on the cadaveric specimens to evaluate the correct angle of insertion, checking the site of half pin insertion using radiography for the cadaveric specimen. Results The suggested safe angulation of half pins was 20°–30° at T1, 15°–25° at T2, 10°–15° at T3, 10°–15° at T4, and from T5 to T9 the safe angle was from 5° to 15°. In T11 and T12, the safe angle was between 0° and 5°. The safe angle of half pin insertion in the pedicle of the thoracic spine in the sagittal plane in all vertebrae from T1 to T12 was between 10° and 15°. Conclusion It was concluded that the application of the external fixator in the thoracic spine is safe, provided there is a better understanding of the anatomical properties of the thoracic spine.
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Treatment of benign cystic lesions of bone with a composite of bone substitute and bone marrow
Elsayed E Saoudy
January-March 2017, 52(1):62-65
Background There are many methods for the treatment of unicameral bone cysts, which are benign cystic lesions seen in the metaphseal–diaphyseal region of long bones in growing children. Patients and methods Totally 20 patients, eight boys and four girls with a mean age of 10 years (range: 8–14 years), who had unicameral bone cysts were treated by curettage and a CaSO4–CaPO4 bone substitute mixed with bone marrow aspiration. The lesion size ranged from 2×4 to 3×7 cm. Results New bone formation was noted in all cases with residual defects in five cases ranging from 15 to 25%. No pathological fracture occurred in this study. Recurrence of the lesion occurred in one case and was treated by reoperation with another dose of CaSO4–CaPO4. Complications within this series included superficial infection with serous drainage 3 weeks postoperatively in two cases treated conservatively. Conclusion Early results of this study using the CaSO4–CaPO4 incorporated with bone marrow aspirate are promising in treating benign bone cysts with bone formation, which can stand for normal bone strength and low rate of complications.
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