Background The incidence of periprosthetic femoral fractures above a total knee arthroplasty (TKA) is continuously increasing because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. Locked compression plate (LCP) devices designed for the distal femur offer advantages for the treatment of such fractures. LCPs can be inserted with relative ease, provide a fixed-angle construct and improve the fixation in osteoporotic bones. Patients and methods During the period between January 2008 and March 2011, 12 displaced distal femoral periprosthetic fractures above a well-fixed nonstemmed TKA in 12 patients were treated by a lateral LCP. The mean age of the patients at the time of surgery was 62 years (range 58-68 years), comprising 10 women and two men. One patient did not complete the follow-up and was excluded from the analysis. Hence, 11 fractures were available for a minimum follow-up of 6 months or until fracture healing. Results Radiographical union was obtained in 10 (91%) out of 11 patients. Nonunion occurred in one (9%) case. The mean consolidation time was 14 weeks (range 12-16 weeks). No axial deviation over 10° was noted. There were no mechanical complications due to failure of the implant. No general, decubitus, or infectious complications were noted. Functional recovery was satisfactory. Conclusion Osteosynthesis with LCP is effective in the treatment of periprosthetic, distal femoral fractures above a TKA without component loosening. It is beneficial for the management of these challenging fractures with a high rate of fracture healing.

Background Combining the advantages of intramedullary fixation with those of a sliding screw theoretically overcomes the usual complications of dynamic hip-screw fixation. A comparative study was conducted to evaluate the credibility of the use of intramedullary screw over the conventional dynamic hip-screw. Patients and methods A total of 100 elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (50 patients) or intramedullary hip-screw (50 patients). All patients were followed up prospectively for 1 year. A detailed assessment of the functional status and the plain radiographs of the hip was performed at 1, 3, 6, and 12 months postoperatively. The two treatment groups were strictly comparable. Results The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate, but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a wound hematoma after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one nonunion, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at 12 months postoperatively. Six of these patients also had pain in the mid-portion of the thigh; three of the six patients had the hardware removed because of the pain, and the symptoms resolved. Conclusion Routine use of intramedullary hip-screws cannot be recommended for the treatment of intertrochanteric femoral fractures because of the reported complications. However, the intramedullary device is a promising alternative, especially for a comminuted fracture with subtrochanteric extension or a reverse oblique pattern.

Objective Minimally invasive methods for lumbar discectomy are gaining popularity among surgeons' practice and patients' demands, and outcomes after such procedures have shown results comparable to conventional open discectomies. In this study, a group of patients were studied for outcomes after microscopic lumbar discectomy (MLD) with ligamentum flavum preservation. Patients and methods Thirty-four patients diagnosed with lumbar disc herniation resistant to conservative treatment underwent MLD for excision of herniated disc fragments, in addition to nerve root and dural exploration and decompression. Results The majority of patients experienced early relief of radicular leg pain and heaviness within 48 h of surgery. Parasthesias resolved 5-8 weeks after surgery. Early follow-up visits showed partial recovery of neural deficits and minor back-pain complaints. Recurrent and residual back-pain and leg pain occurred in six patients. Conclusion MLD is an effective and safe procedure that offers a minimally invasive solution for herniated lumbar discs resistant to medical treatment, with better surgical outcomes and faster return to normal activity.

Background There are several techniques to achieve four corner fusion to provide pain relief in cases of scaphoid nonunion advanced collapse (SNAC) wrist while preserving a function, but can be complicated with malunion, nonunion, hardware impingement or incomplete correction of the lunate extension. We evaluate a new time preserving and simple technique to achieve four corner fusion for the management of nonunion scaphoid with painful arthritis of the wrist. Patients and methods A prospective study was conducted on 16 patients with SNAC of the wrist. Their mean age was 31 years, and the average duration of symptoms was 21 months (range 5-60 months). Through a dorsal approach using a tubular osteotome, the junction between the capitate, lunate, hamate and triquetrium was excised down to the volar capsule and replaced with a core of cancellous iliac bone graft extracted using the same tool. Results The preoperative mean range of wrist flexion was 53° (30°-80°), the mean range of wrist extension was 56° (30°-80°), the mean visual analogue score was 3.2 and the Mayo score was poor in five, fair in three and good in six patients. The postoperative mean range of wrist flexion was 44° (10°-60°), the mean range of wrist extension was 49° (20°-70°), the visual analogue score was 0.7 and the Mayo score was excellent in eight patients, good in seven and poor in one patient. Only one patient proceeded to nonunion. Conclusion This new simple technique can be performed to achieve four corner fusion in the management of SNAC.

Background Ipsilateral fibular transport is a novel option in limb salvage surgery for patients with large tibial defects. A less common application of the Ilizarov technique is transverse bone transport. The frame allows for gradual transport of the fibula into the adjacent tibial defect site, with precise proximal and distal alignment of the fibula, and compression at tibial contact sites. Here, we outline a method of limb salvage for large tibial bone loss using ipsilateral medial fibular transport using the Ilizarov apparatus in a group of children and adolescents. Patients and methods We retrospectively reviewed six consecutive patients, average age 8 years (range 3-18 years), with infection or trauma-related large tibial bone loss. All patients were treated using gradual medial transport of the ipsilateral fibula using the Ilizarov technique. The follow-up of the patients averaged 4 years, with a range of 4-7 years after removal of the circular external fixator. We reviewed patients' medical records and radiographs. We recorded the fracture type in trauma cases, length of the tibial segment replaced, time to union, additional procedures, knee and ankle range of motion, limb length, satisfaction with the reconstructive surgery compared with amputation, and possible complications. Result The Ilizarov ring fixation time to achieve fibular transport and bone union averaged 11 months (range from 7-17 months). The amount of tibial bone loss replaced using the Ilizarov frame with fibular transport averaged 9.8 cm, with a range of 8-11 cm. Hypertrophy of the transported fibula accompanied full weight bearing and satisfactory lower extremity joints motion occurred in all patients. Four of the six patients had a superficial pin-site infection. All patients and or parents were satisfied with the results, and none of them reported that amputation would have been a better option. Conclusion The Ilizarov technique of ipsilateral medial fibular transport to address massive tibial bone loss led to limb salvage for our six patients, with satisfactory functional results. Adolescent patients may require iliac crest bone grafting at the docking sites if the healing response is poor. Our work shows that ipsilateral fibular gradual transport in children and adolescents provides a reasonable alternative for surgeons addressing limb salvage in patients with large tibial bone loss. Patients should be treated by surgeons familiar and experienced with the Ilizarov method.

Background Nonunion following fracture of the proximal humerus is not uncommon, particularly in the elderly. Stable internal fixation is essential to obtain healing of a nonunited fracture of the proximal humerus. Aim This study aimed at evaluation of the results of open reduction and internal fixation of nonunited fractures of the proximal humerus using the locked plate, synthetic and autogenous bone graft. Patients and methods Twelve patients diagnosed with nonunited fracture of the proximal third of the humerus were included in this study conducted between 2009 and 2011 in Suez Canal University. Eight patients were female and four were male. The mean age of the patients was 72.3 years (range, 65-80 years). The time between injury and surgery ranged from 6 to 12 months (mean 8.7 months). Three patients had undergone previous operations for persistent nonunion. The follow-up period lasted for 7-12 months, with a mean of 9.3 months. Radiographic evaluation was carried out with biplane radiographs taken at the time of the most recent follow-up evaluation, to determine the presence of bridging osseous trabeculae, which is suggestive of healing, as well as any loosening or failure of the fixation. The objective results were assessed on the basis of the modified scoring system of Constant and Murley. The subjective results were assessed on the basis of the score derived from the Disabilities of the Arm, Shoulder, and Hand Questionnaire. Results Radiological bone healing was documented in 11 of 12 patients. Objective and subjective assessments documented marked functional improvement in patients with healing fractures. The results were classified as good in 11 of 12 patients, and few complications were encountered. Conclusion Locked plate used in conjunction with synthetic and autogenous bone grafting is an excellent device for the treatment of proximal humerus nonunions with minimal complications.

Background The most notable change in the treatment of fractures has been the shift from the mechanical aspects of internal fixation with absolute stability and primary bone union as the goal to the biological aspects of internal fixation with relative stability and healing with callus as the preferred method, with a huge focus on preservation of the blood supply of bone and soft tissue to ensure the continued vitality of the individual fragments to improve fracture healing. Percutaneous plate fixation minimizes soft tissue compromise with decreased incidence of wound breakdown and deep infection. It also preserves the vascularity of the bone fragments, and thus reduces the time for union, decreases the need for bone grafting even in comminuted fractures, and also decreases the incidence of nonunion, which requires a second major open intervention. Aim The aim of this study was to evaluate the outcome of minimally invasive plate osteosynthesis for the treatment of high-energy tibial shaft (upper and middle thirds) fractures in adults using conventional nonlocked plates through the medial approach. Patients and methods This prospective study included 16 adult male patients who had high-energy closed tibial shaft fractures (upper and middle thirds) with varying degrees of displacement and comminution. All patients were evaluated clinically and radiologically before and after surgery, followed up for a mean time of 14 months postoperatively, and evaluated radiologically and functionally according to the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system. All patients were treated using conventional nonlocked plates inserted percutaneously on the medial surface of the tibia. Results All the fractures united with a mean union time of 16.2 weeks, ranging from 13 to 36 weeks. Clinical and radiological outcomes according to the ASAMI scoring system in this study showed excellent results in 14 patients, representing 87.5% of the studied group, and good results in two patients, representing 12.5% of the studied group. No neurovascular complications, no persistent limitation of the knee or ankle motions, no deep wound infection, and no implant failure occurred in any of the patients until the last follow-up, and none of the patients required a second major open intervention. Conclusion The minimally invasive percutaneous plate fixation technique is an effective method of stabilization for closed tibial shaft fractures, yielding good bone alignment and protecting soft tissues, leading to higher union rates with good functional outcome. The use of conventional nonlocked plates applied through the medial approach decreases the surgical time and the risk of postoperative compartmental syndrome.

Background Patients with pelvic ring injuries present with fractures ranging from single pelvic fractures to those accompanied by many life-threatening injuries. Sacroiliac joint disruption from high-energy trauma is always complicated with chronic pain and long-term morbidity. Open reduction and anterior stabilization with anterior plating have biomechanical advantages. Patients and method Ten patients were studied at Al-Azhar University Hospital (Damietta) during the period from March 2009 to February 2011. There were eight (80%) men and two (20%) women. Their ages ranged from 20 to 50 years. All patients presented with acute pelvic pain, with a history of a road traffic accident in nine (90%) patients and falling from height in one (10%) patient. Plain radiography was the first step in the diagnosis and development of a treatment plan for patients with pelvic trauma. Computed tomography has been proven to be an effective diagnostic tool for the evaluation of pelvic fractures. Results The results were excellent in three (30%) patients, good in six (60%) patients, and poor in one (10%) patient. Complications included posterior pelvic pain in one (10%) patient, superficial infection in one (10%) patient, foot drop in one (10%) patient, and pelvic tilt in one (10%) patient. Conclusion Surgical anterior stabilization was required for type C injuries with two plates lead to excellent outcome and associated with minor complications.

Introduction Patellar instability is a common cause of knee pain and disability. It can be managed with conservative treatment. Patients in whom conservative treatment fails, usually some form of surgical realignment procedure is performed. Treatment of recurrent patellar instability is a source of much controversy. The operative procedures commonly used include lateral retinaculum release, proximal realignment, distal realignment, or combined procedures. The aim of this study was to evaluate the results of all-inside arthroscopic proximal realignment for recurrent patellar instability. Patients and methods Twenty-six patients (16 female and 10 male patients) undergoing proximal realignment procedure were treated with all-arthroscopic lateral release and medial plication. The patients were operated on under general anesthesia and tourniquet control. Postoperatively, a brace was locked in full extension for 1 week, followed by physical therapy for 2 months. All patients were assessed 6 months postoperatively on the basis of the Lysholm knee scoring scale. Results The mean follow-up period was 37 months (range, 29-48 months). The mean Lysholm knee scoring scale improved significantly from a mean of 55.4 points preoperatively to a mean of 91.2 points postoperatively. There was good improvement as regards pain, stability, ability to climb stairs, and confidence in the operated knees. Conclusion Arthroscopic proximal realignment for recurrent patellar instability is a minimally invasive procedure with minimal complications. It is associated with less morbidity. The period of rehabilitation is relatively shorter, and the results are comparable to those of the established open surgical techniques for this condition.

Background Compound subtrochanteric fractures of the proximal femur caused by bullet injuries are a severe form of injury that are not common, and yet their management represents a major challenge. A specially designed external fixator can be used to treat these fractures, with avoidance of possible complications such as infection or nonunion. The author reviewed his experience with an external fixator in the management of this pattern of fractures. Aim A prospective evaluation was carried out of the result of treatment of bullet-caused subtrochanteric fractures by an external fixator. Patients and methods During the period between February 2011 and January 2012, eight male patients presented to the Kasr Al-Ainy School of Medicine and New Kasr Al-Ainy Teaching Hospital with compound subtrochanteric fractures of the femur caused by bullets. The patients were between 19 and 48 years of age (mean 33.5 years). All cases were primary fractures. They were followed prospectively after fixation of the fractures using a specially designed external fixator. Results The mean duration of healing was 20 weeks (range 18-26 weeks) according to the degree of comminution and soft tissue injury. Three patients developed pin-tract infection that resolved after removal of the frame. One patient developed shortening of about 2 cm. No deformity developed in any patient. No extra measures were needed. At the last follow-up, the results of all cases were scored as good (five cases) to excellent (three cases), with no fair or poor results. Conclusion An external fixator can be a reliable method to treat comminuted subtrochanteric fractures caused by bullet injuries.

Background Fractures of the navicular are not common. To repair navicular fractures, it is important to have an understanding of the surrounding anatomy. The navicular is a boat-shaped bone located in the medial midfoot that has multiple articulations. Objectives This article reviews the diagnosis, classification, and surgical technique for fixation of displaced navicular body fractures. Materials and methods Ten patients with consecutive 10 displaced navicular body fractures were treated surgically between March 2010 and March 2013. Results The mean postoperative score according to the American Orthopedic Foot and Ankle Society score system was 90.2 (85-100). Level of evidence Case series: type IV.

Background Valgus subtrochanteric osteotomy is the gold standard in the surgical treatment of coxa vara. Nevertheless, there has been no consensus on the method of fixation and osteotomy details. In the literature, there are few reports on using rigid internal fixation methods that preclude the need for postoperative immobilization. Patients and methods In this study, 15 hips of 13 patients with the diagnosis of developmental coxa vara underwent subtrochanteric osteotomy with stabilization using an external fixator. Results All osteotomies achieved the planned correction angle, and all osteotomies healed primarily except in one case. Radiographic analysis revealed an improvement in Hilgenreiner's epiphyseal angle and neck-shaft angle. Conclusion This technique proved to be safe and effective in the treatment of proximal femoral deformity associated with coxa vara and limb length discrepancy. It has potential advantages over commonly used open techniques and provides an available alternative to currently applied methods used for fixation of proximal femoral osteotomies.

Spinal tuberculosis accounts for more than 50% of musculoskeletal tuberculosis and mainly involves the dorsal and dorsolumbar regions. Involvement of the lumbosacral region in spinal tuberculosis is rare, with only few reported cases in the literature. The patient may present with pain and minimal neurological deficits. Conservative management is the primary treatment modality with good outcome; surgical intervention is reserved for selected group of patients. In the present article we report an uncommon case of lumbosacral tuberculosis that was treated successfully and review the relevant literature.