The Egyptian Orthopaedic Journal

Mini-open repair for acute Achilles tendon rupture using the ring forceps technique Hatem S.A Elgohary, Mhmod A Elghafar The Egyptian Orthopaedic Journal 2018 53(4):285-291 Background Treatment of acute closed rupture of the tendo-Achilles is a challenge for the orthopedic surgeons. The aim of this study was to assess the results of repairing the tendo-Achilles using the ring forceps technique through a mini-open approach. Patients and methods A total of 21 adult patients with a closed rupture of the Achilles tendon were managed in Mansoura Emergency Hospital in the period between February 2009 and January 2013 with a mini-open technique using the ring forceps. Seventeen patients were males and only four females, and the mean age was 31 years, with a range 20–48 years. Rupture was diagnosed on the basis of a clinical examination, palpation of the defect, and a positive Thompson test result. Patient assessment at follow-ups was done using the American Orthopedic Foot and Ankle Society scoring system. Results Patients were followed up for a mean duration of 1.8 years (range, 1–3 years). All patients returned to their full preinjury level of activity. The mean American Orthopedic Foot and Ankle Society score was 100 (range, 100–100). No patient developed reruptures, sural nerve injury, wound infection, or deep venous thrombosis. Conclusion The management of acute closed rupture of the Achilles tendon with a mini-open technique using the ring forceps is an excellent way of management without skin complications or hazard on the sural nerve and with excellent functional results.

Subcutaneous versus submuscular ulnar nerve transposition in cubital tunnel syndrome Mohamed E Attia The Egyptian Orthopaedic Journal 2018 53(4):292-297 Introduction There are different surgical procedures for treatment of cubital tunnel syndrome (CubTS), which can be divided into two types, decompression and transposition procedures. Decompressive procedures include simple decompression with or without medial epicondylectomy without mobilizing the nerve. The transposition procedures mobilize the nerve anteriorly for more protection by subcutaneous, intramuscular, and submuscular methods, depending on the position in which the ulnar nerve is placed. Patients and methods A total of 24 patients with moderate CubTS (according to Dellon’s grading system) between March 2011 and April 2013 were classified according to age and sex into anterior subcutaneous transposition and anterior submuscular transposition groups. The two groups were prospectively followed up for 2 weeks, 6 months, and 12 months postoperatively, and outcome was assessed using the Bishop rating system. Results A total of 24 patients with moderate CubTS were used in this study to compare the operative technique (incision length and operative time), postoperative care (postoperative pain and complications), and the outcome between subcutaneous transposition and submuscular transposition of the ulnar nerve as two surgical modalities in treating moderate CubTS. Final results present that the subcutaneous transposition of the ulnar nerve was associated with shorter incision, shorter operative time, less postoperative pain, less postoperative complication, and better outcome compared with the submuscular transposition. Conclusion Subcutaneous ulnar nerve transposition in the treatment of CubTS, as compared with the submuscular approach, is an easier surgical technique with less operative time and postoperative pain, earlier postoperative mobilization, and better postoperative outcome.

Arthroscopic assessment of glenoid bone defect in patients with anterior shoulder instability Emad Zayed, Hussein Abo-ElGhit, Abd-El-Rahman Mahmoud The Egyptian Orthopaedic Journal 2018 53(4):298-302 Purpose The purpose of this study was to assess the reliability of arthroscopic estimation of anterior glenoid bone defect in patients with anterior shoulder instability, by comparing it with anteroposterior diameter equation method in computed tomography (CT) glenoid en-face view with head subtraction. Patients and methods Thirty patients with anterior shoulder instability underwent shoulder CT glenoid en-face view scans and were found to have anterior glenoid bone defect. The anterior glenoid bone loss of each patient was studied using the anteroposterior distance from the center of a best-fit circle drawn on the inferior portion of the glenoid. Arthroscopic estimation of the anterior glenoid bone defect was done in all those patients as a part of the planned final procedure. The mean percent bone loss studied in CT was compared with arthroscopy to determine the reliability of arthroscopy in the measurement of anterior glenoid bone defect. Results The mean percentage of anterior glenoid bone defect calculated with CT diameter equation method was 17.3±9.7, whereas the mean percentage of arthroscopic estimation of anterior glenoid bone defect was 22.55±9.9, which shows statistically significant difference (P<0.04) between diameter equation percent and arthroscopic percent in the studied patients. The study showed that the arthroscopic estimation significantly overestimates anterior glenoid bone defect. Conclusion Our finding suggests that arthroscopy significantly overestimates anterior glenoid bone defect compared with CT glenoid en-face view anteroposterior distance method, and the surgeons should not relay on arthroscopic measurement of the defect to plan for surgery.

A comparative study between endoscopic plantar fasciotomy and platelet-rich plasma for treatment of resistant plantar fasciitis Ehab M.S Ragab The Egyptian Orthopaedic Journal 2018 53(4):303-309 Background Plantar fasciitis (PF) is the most common cause of heel pain. Some patients with PF are resistant to conservative lines of management, which can lead to physical disability. The aim of this study is to compare the effectiveness and outcome of endoscopic plantar fasciotomy (EPF) and local injection of platelet-rich plasma (PRP) for treatment of resistant cases of PF. Patients and methods A total of 51 patients with resistant PF were enrolled in this study between August 2011 and May 2014. Patients were either enrolled in the surgical (EPF) group (25 patients) or to the PRP group (26 patients) after a minimum period of conservative treatment of 6 months. Before and after visual analog scores (VAS) and American orthopaedic foot and ankle society (AFOAS) were recorded and compared between the two groups. Results Both groups achieved improvement at 6 weeks, 6 months, and 12 months. At the end of follow-up, in the first group (EPF), the average VAS was improved from 8.31 to 2.34, and the average AFOAS was improved from 43.75 to 87.25. A total of 20 (80%) patients were satisfied, four (16%) patients were satisfied with reservation, and one (4%) patient was not satisfied. In the second group (PRP), the average VAS was improved from 8.28 to 2.55, and the average AFOAS was improved from 42.95 to 86.75. A total of 19 (73.08%) patients were satisfied, five (19.23%) patients were satisfied with reservation, and two (7.69%) patients were not satisfied. Conclusion Both EPF and PRP are effective in treating resistant PF, and the end results of EPF are better than those of PRP injection regarding pain relief, AFOAS, and patient satisfaction. So PRP injection should be tried before invasive surgical interference.

Pedicle subtraction osteotomy for the treatment of posttraumatic thoracolumbar kyphosis Mohamed El-Soufy, Amr El-Adawy, Tarek Elhewalla The Egyptian Orthopaedic Journal 2018 53(4):310-315 Background Posttraumatic thoracolumbar deformity is a common complication of spinal trauma after conservative treatment or after inadequate surgical management. The goals of surgery are to decompress the neural elements and restore sagittal and coronal balance and to optimize the chances for successful fusion. These goals can be achieved through an all-anterior, all-posterior, or a combined anterior and posterior approach. Patients and methods A total of 13 patients with symptomatic posttraumatic thoracolumbar kyphosis were treated with pedicle subtraction osteotomy. The mean age of the patients was 35.3 years. The injury level was L1 in eight cases, L2 in three cases, and T12 in two cases. Of the 13 patients, eight had been managed conservatively and five had initial posterior pedicle screw fixation. Most patients (69.2%) complained of chronic and worsening pain in the thoracolumbar junction region, 38.4% were found to have progressive kyphosis, and none had conus or cauda neurologic impingement. Results The mean surgical time was 206 min, with a mean intraoperative blood loss of 700.7 ml. All patients completed follow-up for at least 2 years. Complications were encountered in six cases. The average Cobb angle decreased from 38.4° preoperatively to 2.3° after surgery. The mean visual analog scale for back pain decreased from 54.4 preoperatively to 18.5 at the last follow-up, and the Oswestry disability index score changed from a mean value of 53.07 preoperatively to 24.5 at the last follow-up. All patients achieved bony fusion based on the presence of trabecular bone bridging at the osteotomy site. Conclusion The pedicle subtraction osteotomy achieves satisfactory kyphosis correction and good fusion with less blood loss and complications than other approaches.

Treatment of acromioclavicular joint dislocation by hook plate and direct coracoclavicular ligament reattachment to the clavicle Haytham A Mohamed, Fady M Fahmy The Egyptian Orthopaedic Journal 2018 53(4):316-321 Objective The aim of this study is to evaluate the clinical outcome of treatment of acute acromioclavicular (AC) joint dislocation by clavicular hook plate and coracoclavicular ligament reattachment to the clavicle. Patients and methods A prospective study including 20 patients with AC joint dislocation either type III or V was conducted from October 2012 to June 2014 in Ain Shams University Hospitals. Patients were treated by open reduction of the dislocated AC joint and internal fixation by clavicular hook plate together with reattachment of the coracoclavicular ligament by transosseous sutures to the clavicle. The plate was removed after 3 months of the operation. The patients were evaluated by plain radiography for AC joint stability and functionally by Constant–Murley score. Results The mean follow-up period of the 20 patients was 18.05 months. The mean age was 33.35 years. The operative time of our procedure was of a mean of 43.65 min. All the patients had the plate removed at the third month postoperatively (mean, 97.3 days). Follow-up radiograph after plate removal showed maintained reduction of AC joint in 18 patients. Slight loss of reduction of 1–2 mm was noticed in the other two patients. The mean Constant–Murley score in the last follow-up was 92.9. Conclusion Based on this study, the treatment of acute AC joint dislocation using the clavicular hook plate combined with coracoclavicular ligament reattachment to the clavicle yields good short-term clinical results with a good functional outcome and low complication rate compared with other operative procedures.

The Taylor spatial frame for correction of proximal tibial varus deformity Tarek Abdel A Mahmoud The Egyptian Orthopaedic Journal 2018 53(4):322-330 Background Genu varus deformity secondary to tibia vara is one of the common deformities of the knee joint, and correction by using the Taylor spatial frame (TSF) is an effective method of treatment. Aim of the study This study evaluated the clinical, functional, and radiological outcomes after using the TSF for the correction of proximal tibial varus deformity. Patients and methods This prospective study was done on 14 patients, with eight males and six females, attending Saudi German Hospital in Saudi Arabia between October 2011 and January 2014, and the mean age was 18 years (range, 12–28 years) at the time of surgery. Patients included in the study have nontraumatic genu varus deformity secondary to tibia vara without degenerative changes in the knee. Follow-up evaluation of the results after 1 year of surgery was done using SF-36 scores, the American Academy of Orthopedic Surgeons Lower Limb Module scores, and an objective grading system modified by Tucker and colleagues. Results Patients had a preoperative mechanical axis deviation of 42 mm (range, 25–62 mm) medial to the midline, which was improved postoperative to an average of 4 mm (range, 2–8 mm) medial to the midline. The correction of medial proximal tibial angle was accurate, and the medial proximal tibial angle was improved from preoperative of 65° (range, 45–74°) to postoperative 88° (range, 86–92°). The posterior proximal tibial angle was corrected from preoperative of 72° (range, 66–74°) to postoperative 82° (range, 79–84°). Preoperative limb-length inequality was corrected in all patients, and the average was 0.5 cm (0–2 cm). There were no significant differences between preoperative and postoperative range of movements of both ankle and knee joints. The average postoperative range of motion of the knee joint was 0–130° and for the ankle joint was a 0–40°. Pin-tract infection was found in 42% of patients and treated by frequent dressing and oral antibiotics, and no patients had deep infection. Frame loosening was found in one (7%) patient and was treated by addition of wires. Follow-up evaluation after 1 year postoperatively was done by using SF-36 Health Survey scores, and it was improved in all categories, and according to the American Academy of Orthopedic Surgeons Lower Limb Module Patient Health Outcome score, it was increased from 64 to 92. In addition, according to the objective grading system of Tucker and colleagues, excellent results were achieved in 12 (86%) patients and good result in two (14%) patients. Conclusion Correction of genu varus deformity secondary to tibia vara through using TSF by proximal tibial osteotomy is an effective method to correct the deformity and restoring knee stability with early weight-bearing and high satisfactory results.

Anatomic single-bundle versus anatomic double-bundle anterior cruciate ligament reconstruction: a comparative study based on midterm results Mohamed S Kassem, Bahaa A Motawea, Awad A Rafalla The Egyptian Orthopaedic Journal 2018 53(4):331-340 Introduction Reconstruction of the torn anterior cruciate ligament (ACL) is a common surgical procedure for orthopedic surgeons, especially who are interested in sports medicine. The nonanatomical conventional single-bundle reconstructive procedures fail to recreate the native anatomy of the knee. As a result of suboptimal outcomes following traditional single-bundle ACL reconstruction, there has been a growing interest in anatomic ACL reconstruction. Aim of the study The aim of the study was to compare the midterm clinical results of arthroscopic single-bundle versus double-bundle anatomical anterior cruciate reconstruction using hamstring tendons. Patients and methods From October 2006 to May 2010, arthroscopic anatomic ACL reconstruction was carried out on 152 patients with ACL, who were divided into two equal groups: group A included 76 patients who underwent arthroscopic anatomic single-bundle ACL reconstruction, and group B included 76 patients who underwent arthroscopic anatomic double-bundle ACL reconstruction. Results All patients were analyzed using the International Knee Documentation Committee evaluation form. At the end of follow-up period, which ranged from 5 to 7 years, with an average of 5.2 years (midterm follow up), the results of group A were rated as normal and nearly normal on the total subjective and objective levels in 65 (85%) patients, except in 11 (15%) patients, who were rated abnormal and severely abnormal, whereas the results of group B were rated as normal and nearly normal on the total subjective and objective levels in 69 (91%) patients, except in seven (9%) patients, who were rated abnormal and severely abnormal. The difference in the results between the two groups was statistically not significant. Regarding the complications, there have been four cases of superficial infection related to the medial wound of tendon harvest, one in group A and three in group B, which were treated with oral antibiotics with clearance of infection. Conclusion Our results have showed that the anatomical double-bundle ACL reconstruction technique can achieve better anteroposterior and rotational stability compared with the anatomical single-bundle ACL reconstruction, which is not statistically significant. Considering that the double-bundle technique is more complex, expensive, and lengthy, we recommend the single-bundle anatomical technique as the standard technique, and the double-bundle technique to be used in case of high-demand patients like elite athletes.

Treatment of infected nonunion of forearm bones by ring external fixator Ayman M Ebied, Adel I Elseedy The Egyptian Orthopaedic Journal 2018 53(4):341-347 Background An infected nonunion in the diaphysis of the radius and ulna is a difficult problem to solve. Several methods and techniques have been suggested including repeated debridement followed by internal fixation and bone graft or through vascularized free tissue transfer. The results of treating infected nonunions of the forearm bones by a two-stage treatment strategy using the Ilizarov ring external fixators are reported. All cases were treated at the Menoufia University Hospital. Patients and methods Nine patients with an average age of 49 years (range, 45–52 years) with infected nonunions of one or both bones of the forearm were treated at this unit between August 2005 and September 2007. A staged protocol of treatment was adopted in case of active infection. The first stage included radical debridement of the site of nonunion followed by an interval of antibiotic treatment. The final stage included application of a ring external fixator. Three patients had nonunions of both the radius and ulna, another two had nonunion of the ulna, and four patients had nonunion of the radius. Autogenous cancellous bone graft was used in all patients to treat the defect caused by the nonunion and surgical resection. Patients were evaluated by The Disabilities of the Arm, Shoulder and Hand score. Results The mean period in the external fixator was 22.6±3 weeks (mean±SD). All fractures achieved full bony union with no evidence of deep infection at last review (mean follow-up period 34 months; range, 24–47), as well as vascular or neural compromise. The mean The Disabilities of the Arm, Shoulder and Hand score improved from 90.5 preoperatively to 41.4 postoperatively (P<0.05). One patient was not able to complete his treatment in the external fixator. Conclusion Staged treatment first involves radical debridement of infected bone and soft tissue, which allows eradication of infection. Bone defects can be dealt with through distraction osteogenesis, segment transport, or bone grafts in conjunction with using ring external fixators. The Ilizarov external fixator can be used to overcome bone defects and soft tissue contractures in the forearm, but special expertise in the technique and knowledge of the cross-sectional anatomy of the forearm are essential.

Conventional versus lateral cross-pinning (Dorgan’s technique) for fixation of displaced pediatric supracondylar humeral fractures: a randomized comparative study Ahmed Shawkat Rizk, Mahmoud Ibrahim Kandil The Egyptian Orthopaedic Journal 2018 53(4):348-358 Background Although closed reduction and percutaneous pinning is the standard treatment for the displaced pediatric supracondylar humeral fractures, controversy still exists regarding the optimal pin configuration. The aim of this study was to compare the outcomes of the conventional versus lateral cross-pinning (Dorgan’s technique) in treatment of displaced pediatric supracondylar humeral fractures. Patients and methods A total of 50 children were randomly divided into two equal groups: group I (treated via conventional technique) comprised 15 males and 10 female patients, with a mean age of 5.2±2.7 years, and group II (treated via Dorgan’s technique) comprised 17 males and eight female patients, with a mean age of 7.8±3.1 years. Preoperative and postoperative neurologic and radiological evaluations were performed. Functional and cosmetic outcomes were evaluated according to Flynn’s criteria. The mean follow-up periods were 25.24±7.2 and 27.56±6.3 months in groups I and II, respectively. Results There was no statistical significant difference between both groups regarding patients’ and fracture characteristics, postoperative protocol, union time, and complication rate (pin-tract infections and extensive granulation tissue formation around Kirschner wires). The radiological, functional, and cosmetic outcomes were satisfactory in all patients, with no statistically significant difference between both groups. Dorgan’s technique was more time consuming than conventional cross-pinning, with no cases developing any iatrogenic neurological insult in such group; however, iatrogenic transient ulnar nerve injury occurred in one case in group I. Conclusion Both cross-pinning techniques provide a biomechanically stable fixation, allowing early and safe active elbow movements with satisfactory functional, cosmetic, and radiological outcomes, but Dorgan’s method was more time consuming compared with the conventional method. A properly performed Dorgan’s technique completely avoids the risk of iatrogenic ulnar nerve injury without endangering the radial nerve. Level of evidence: level II, randomized comparative study.