Orthopaedics

Percutaneous transdeltoid osteosynthesis for proximal humeral fractures with the proximal humeral internal locking system plate Khaled M Balam The Egyptian Orthopaedic Journal 2018 53(3):191-195 Purpose This study was designed to evaluate clinical outcomes and complications following minimally invasive plate osteosynthesis (MIPO) with the proximal humeral internal locking system (PHILOS) for treating proximal humeral shaft fracture. Patients and methods Between March 2012 and March 2013, 37 patients with unilateral proximal humeral shaft fractures were treated using the MIPO technique with the PHILOS through the transdeltoid approach. All fractures were closed with no associated injuries and classified as two part (n=13), three part (n=19), and four part (n=5), according to the Neer’s classification. Patients were followed-up for 16.9 months (range, 12–24 months), radiologically and functionally. Postoperative complications and functional constant shoulder score was used. Results No intraoperative complications occurred. Postoperative complications included subacromial impingement in three patients. There was no deep infection, neurovascular damage, breakage, or implant loosening. All fractures united in an average time of 10 weeks (8–12 weeks). In terms of function, the Constant–Murley score was 89 points on average (range, 75–100 points). The range of motion of the involved shoulder was satisfactory, and pain-free in 84% of patients. Conclusion Using the MIPO technique with the PHILOS plate through the transdeltoid approach is a valid and safe method of treating proximal humeral shaft fractures.

Segmental ploymethylmethacrylate-augmented fenestrated pedicle screw fixation in patients with osteoporotic unstable thoracolumbar fractures: a clinical evaluation Mohamed Abdelaziz, Sallam Fawzy The Egyptian Orthopaedic Journal 2018 53(3):196-201 Objective Osteoporosis has been implicated as a cause of hardware failure and, more specifically, pedicle screw loosening and pull-out. A clinical evaluation of results of augmented fenestrated pedicle screws was performed to determine the safety, performance, and effectiveness of this technique in the osteoporotic spine with an unstable thoracolumbar fracture. Patients and methods Over the past 2.5 years, the clinical and radiographic results of 11 consecutive patients with poor bone stock with osteoporotic spinal fractures were reviewed. These patients underwent instrumented spinal fixation using fenestrated pedicular screws with cement augmentation. Implant stability was evaluated by initial postoperative plain radiography and three months, thereafter. After the first 12 months, radiographic controls were taken every 6 months. Complications were evaluated in all cases. Results All patient were followed clinically and radiologically for a mean of 11.3 ms (range: 6–30 ms). None of the patients experienced serious intraoperative complications (hypotension, cement embolization, myocardial infarction, or cement leakage) nor postoperative complications (late postoperative implant failure, or kyphosis), with early safe postoperative mobilization. Conclusion Pedicular fixation using fenestrated pedicular screws with cement augmentation for treatment of osteoporotic spinal fractures reduces the likelihood of pedicular screw loosening with subsequent reduction of late postoperative sagittal instability with early safe mobilization.

Management of infected total knee arthroplasty by Ilizarov fixator Abdel-Salam Abdelaleem Ahmed, Hosam A El Bigawi‎ The Egyptian Orthopaedic Journal 2018 53(3):202-209 Introduction Persistent infection after total knee arthroplasty (TKA) is a very serious complication. Arthrodesis is considered if the prosthesis cannot be retained or revision surgery is obviated. The purpose of this study was to evaluate the radiological and functional results of knee arthrodesis with Ilizarov external fixator to treat infected TKA. Patients and methods This was a retrospective study of 13 patients with infected TKA treated by implant removal, debridement, and fusion by Ilizarov fixator operated from October 2010 to March 2015. The study included nine females and four males with a mean age of patients of 64.08 years. Seven patients were diabetics and two had a past history of deep venous thrombosis. Time, from the primary TKA till knee fusion, ranged from 18 to 37 months. All patients had previous surgical interventions with a mean of 4.62 procedures. Eleven patients had draining sinuses. In addition to clinical and radiographic evaluation, the functional assessment was done by Western Ontario and McMaster Universities Osteoarthritis index questionnaire. Results Patients were followed up for a mean of 28.62 months. The mean external fixator period was 7.77 months. Postoperative hematoma occurred in one patient. Pin track infection occurred in 10 cases. All cases had successful fusion except two patients and infection was controlled in all cases. The mean leg length discrepancy was 3.96 cm. The mean postoperative Western Ontario and McMaster Universities Osteoarthritis index score was 30.08. Conclusion Knee arthrodesis by Ilizarov external fixator for treating persistently infected TKA achieved high fusion and infection control rates and provided a stable limb with pain relief and functional improvement.

Outcomes and prognostic factors of surgical management of floating knee injuries Hatem S.A. ELgohary, Mhmod A Elghafar, Nabil A Elmoghazi The Egyptian Orthopaedic Journal 2018 53(3):210-218 Background Floating knee injuries are complex injuries that are generally caused by a high-energy trauma such as a motorcycle or a car accident. Local trauma to the musculoskeletal and the soft tissues is often extensive and life-threatening; associated injuries may also be present, producing a challenging problem to manage. In this study, the authors presented the outcome of these injuries after surgical management. Patients and methods In this prospective study, 32 patients with 34 floating knee injuries were managed over a 3-year period; both fractures of the floating knee injury were fixed surgically by different modalities. The associated injuries were managed appropriately. Fractures were classified according to Fraser classification, and the outcome was evaluated by the Karlstrom criteria. Results The main mode of injury was motorcycle accident (62.2%). Twenty-nine (90.3%) patients had associated visceral or skeletal injuries. The complications presented in 17 (50%) patients. According to the Karlstrom criteria, the end results were as follows: excellent − 15 (44%), good − seven (20.6%), acceptable − eight (23.6%), and poor − four (11.8%). Conclusion The optimal final outcome of floating knee injuries was achieved with appropriate management of the associated injuries, intramedullary nailing of both the fractures and early aggressive postoperative rehabilitation. The associated injuries and the type of fracture (open, intra-articular, comminution, knee ligament injuries) are the prognostic indicators in the floating knee.

Outcome of curettage of peritrochanteric benign lesions in skeletally immature patients without internal fixation Bahaa Z Hasan, Khaled S. Abd El Saleh The Egyptian Orthopaedic Journal 2018 53(3):219-229 Background Peritrochanteric benign lesions are common in skeletally immature patients, which might cause limping and bone destruction up to pathological fracture. Many techniques have been described for the treatment of such lesions; curettage is one of them, which may be combined with bone graft and internal fixation. Curettage without internal fixation is the principal technique used in this study. Patients and methods This study included 20 patients, with 12 males and eight females, and their mean age was 10.6 years (range, 4–15 years). The diagnosis was 12 cases of simple bone, three cases of aneurysmal bone cyst, two cases of fibrous dysplasia, two cases of nonossifying fibroma, and one case of osteoid osteoma. Treatment included curettage, either simple or extended by high-speed burr and phenol adjuvant, and only cast as external immobilization. Patients were placed in hip spica or antirotational cast for 6–8 weeks. The visual analog scale (VAS) and Harris hip score (HHS) were used for preoperative and postoperative clinical and functional assessments. Results The mean follow-up period was 30.5 months. Clinically, 17 patients had full recovery 3–6 months postoperatively with excellent results according to HHS for hip function and VAS for pain assessment. The VAS score decreased highly significantly, which denoted pain improvement after treatment. HHS increased highly significantly, which denoted improvement of functional activity after treatment. Three patients developed complications. Conclusion Curettage without internal fixation and its replacement by external immobilization by cast is effective, less morbid, and technically simple procedure for the treatment of peritrochanteric benign lesions in skeletally immature patients. Good satisfactory results in local tumor control and excellent long-term functional and radiological results with less emotional negative effects on the patient or his family have been recorded.

Outcomes of surgical treatment of posterior cruciate ligament tibial avulsion fractures through an open posterior approach Amr Eladawy, Mohammed Abdeen The Egyptian Orthopaedic Journal 2018 53(3):230-236 Background Avulsion of the tibial insertion of the posterior cruciate ligament (PCL) is believed to be an uncommon injury. A nondisplaced bony avulsion can be treated conservatively with a plaster cast, holding the knee flexed and the tibia pulled forward to diminish tension on the PCL. There is general consensus that a displaced bony PCL avulsion should be surgically reduced and fixed immediately to stabilize the knee joint and prevent nonunion. Hypothesis Our hypothesis was that surgically reduced and fixed displaced bony PCL avulsions stabilize the knee joint and prevent nonunion. Patients and methods This prospective study was performed between January 2010 and August 2013. A total of 11 patients (three females and eight males) with PCL avulsion fracture of the tibial attachment (six isolated and five associated with other ligamentous injuries, meniscal injuries or bony fractures) were treated surgically through a posterior approach at the trauma unit of our university hospital. The mean age of patients was 24.72 years (range, 18–33years). Fixation with a single screw and washer was used in nine cases with a large bony fragment and multiple screws in two cases with comminuted fragments. The operating time was 60 min (range, 45–70 min). All patients were followed for an average of 22 months (range, 19–26 months), and at the end of the follow-up period, patients were evaluated using and Lysholm scoring system. Results All 1-year postoperative radiographs demonstrated union at the fracture site. At the end of the follow-up period, the mean Lysholm score was 88.7 points (range, 70–100 points) with a good overall outcome. Conclusion Treatment of displaced large PCL avulsion injuries with a single lag screw and washer or multiple screws through the open posterior approach results in good clinical and radiographic outcomes.

Management of proximal humeral fractures by proximal humeral internal locking system plate: a prospective case series Mahmoud Abdel Karim, Khaled Farouk The Egyptian Orthopaedic Journal 2018 53(3):237-243 Introduction The objective of this study was to evaluate the functional and radiological outcome after open reduction and internal fixation of proximal humeral fractures with the proximal humeral internal locking system (PHILOS) plate. Patients and methods This prospective case series included 30 patients. All cases were managed by open reduction of the fractures and internal fixation by the PHILOS plate. The inclusion criteria included patients with displaced two, three, and four-part fractures. Six (20%) patients had two-part fractures, 12 (40%) had three-part fractures, 12 (40%) had four-part fractures. There were 18 male patients and 12 female patients. The mean patient age was 49 years (22–74 years). The average follow-up period was 9 months (6–12 months). The functional outcome was assessed using the constant score at 6 months. Radiological evaluation was carried out immediately postoperatively, at 6 weeks, 3 months, 6 months, and 1 year. Results Most of the series patients had a satisfactory outcome. The mean constant score was 72.4 points (range, 46–94 points) at 6 months’ follow up. Healing of the fracture occurred uneventfully in 83.4%. However, some complications were found in this patient series. In two (6.6%) patients, the humeral head collapsed due to avascular necrosis after fracture healing. In one (3.3%) patient, fracture healing occurred with varus displacement, but the patient was satisfied with the outcome. No implant failure and no delayed union or nonunion was noted. Discussion and conclusion Management of proximal humeral fractures with PHILOS plates achieves a good reduction and satisfactory clinical and radiological outcomes; however, some complications might be expected in some patients.

Transforaminal lumbar interbody fusion in recurrent disc herniation Mohamed El-Soufy, Amr M El-Adawy, Mohamed Abdeen The Egyptian Orthopaedic Journal 2018 53(3):244-250 Background Recurrent back and/or leg pain after primary lumbar discectomy is not uncommon. Some spine surgeons believe that fusion is necessary for treating disc reherniation. As repeated discectomy requires the removal of more disc material and posterior elements, such as lamina or facet joint, further invasion at the same surgical level can increase the risk of segmental instability. Patients and methods A total of 20 patients (12 men, eight women) with recurrent lumbar disc herniation were treated via transforaminal lumber interbody fusion. The mean age at the time of operation was 46.6 years (30–62 years). The primary procedures included discectomy with unilateral hemilaminectomy in nine and discectomy with bilateral laminectomy in 11 patients. The time from the primary surgery to that of recurrence averaged 10.6 months (range, 6–18 months). The levels of recurrent disc herniation were nine cases at L4–L5 (six ipsilateral and three contralateral) and 11 at L5–S1 (seven ipsilateral and four contralateral). Results The mean follow-up period was 22.8 months (18–30 months). The mean duration of the operation was 161.75 min (130–190–min), mean intraoperative blood loss was 325 ml (250–500), and mean duration of hospital stay was 4.15 days (3–7 days). At a minimum of 12 months of follow-up, all cases appeared to have solid fusions. Conclusion Transforaminal lumbar interbody fusion technique is an effective procedure with satisfactory clinical results for the treatment of recurrent lumbar disc herniation. The approach achieves a biomechanically stable spine, as it restores the segmental lordosis and has low complication rates.

Management of displaced posterior cruciate ligament avulsion fractures using arthroscopic suture fixation technique versus Burks and Schaffer approach Mohamed H Khalil The Egyptian Orthopaedic Journal 2018 53(3):251-257 Purpose The purpose of this study was to analyze and compare the results of management of displaced posterior cruciate ligament (PCL) avulsion fractures using cannulated screws through the Burks and Schaffer open approach versus the arthroscopic suture technique. Patients and methods Forty patients with PCL avulsion fractures were included in this randomized prospective study. Twenty patients in group A were treated using the arthroscopic suture technique, whereas 20 patients in group B underwent open reduction and internal fixation of the avulsed PCL fragment by a 4-mm cannulated screw using the Burks and Schaffer approach. The mean follow-up period was 26.75 and 28.55 months for group A and B, respectively. Functional assessment was done using the Lysholm and International Knee Documentation Committee scores. Radiographic evaluation was done by plain radiographs and computerized tomography to assess the rate and time for bone union. Clinical examination compared the regained flexion range of motion and degree of posterior laxity. Results All patients were available at the final follow-up. All patients in both groups achieved bone union at 7–10 weeks postoperative. The Lysholm and International Knee Documentation Committee scores in both groups increased significantly at the final follow-up. There was no statistically significant difference between both groups apart from the operative time for the arthroscopic group being longer than the open group and the regained flexion range in the arthroscopic group was higher than the open group. Eight (40%) patients in the arthroscopic had associated meniscal pathologies, which were treated during the arthroscopic procedure. No neurovascular, nonunion or wound complications were reported in either group. Conclusion Displaced tibial PCL avulsion fractures can be successfully managed using both the open and arthroscopic techniques. Arthroscopic management required a longer operative time than the open approach; however, the regained flexion range was better than the open technique and concomitant pathologies were managed during the arthroscopic procedure. Level of evidence: Level III; prospective comparative study.

Arthroscopic versus mini-open repair of rotator cuff tears Emad Zayed, Ali Al-Gioushy, Tarek Hassan The Egyptian Orthopaedic Journal 2018 53(3):258-265 Background Rotator cuff tears are very common in the general population. Different modalities of repair are well established. We describe two surgical techniques for repair, arthroscopic versus mini-open techniques. Patients and methods This prospective study included 20 patients with complete rotator cuff tear (small to large size) with grade A or B retraction with no or little fatty infiltration of cuff muscles. Patients were divided into two groups, each group included 10 patients: one group was treated by arthroscopic repair by anchors and the other group was treated by mini-open repair by anchors. Results For group A treated by arthroscopic repair over the period of follow-up, the mean Constant and Murley score was 82.1 ± 4.8 (76–90), and all the patients were satisfied. For group B treated by mini-open repair over the period of follow-up, the mean Constant and Murley score was 79.8 ± 7.2 (66–90), and eight patients out of 10 were satisfied. There was no statistically significant difference between both groups (p value 0.4). MRI showed satisfactory tendon healing 6 months postoperatively. Postoperative stiffness occurred in one patient undergoing mini-open repair mainly owing to poor compliance with the rehabilitation program. Conclusion Arthroscopic technique and mini-open technique are viable options for repair of rotator cuff tears in our study, with no significant variations noticed between them, although better results in arthroscopic group.