Shoulder arthroscopy: part I Is it justifiable after acute first-time anterior shoulder dislocation?

We reported on 34 young labor men, mean age 31.4 years with high physical demands who sustained first-time anterior dislocation of the shoulder. All were treated initially with closed reduction and immobilization, followed by shoulder therapy programs. Despite this, patients still suffered episodes of pain, discomfort and/or insecurity and feelings of joint being out on performing a particular activity. MRI was done for all cases, then, arrangement was made for arthroscopic evaluation some weeks to few months after primary treatment. The pathologic findings at arthroscopy divided the cases into 5 groups: capsular tears only in 5 patients; 4 [11.8%] of them [G1] the tear was defined at the glenoid attachment - in the rest one [2.9%] it was at the humeral insertion [G2]. Capsular tears associated with partial labral detachment [G3] in 9 [26.5%], capsular tears and complete labral detachment [G4] in 17 [50.0%], and complex injury [G5] in the remaining [8.8%] shoulders that demonstrated full labral detachment from the glenoid, frank tearing and fraying of the capsular structure which was seen as well avulsed from the labrum. No bony Bankart lesions, or mid-capsular tears were defined. The decision, based on the literature review [1-4-5-8-12-13-14-15-17-18-32] was to continue conservative treatment and observation for the 5 patients suffered capsular tears, but, an arthroscopic repair was an option in our mind for the 4 shoulders with glenoid capsular detachment, and an open surgery for the humeral avulsion of the glenohumeral ligament. While the option for the fifth group of cases was open shoulder stabilization procedures. The third, and fourth groups of cases including 26 shoulders were considered as an ideal candidates for arthroscopic treatment. This study emphasizes that a systemic arthroscopic examination of the glenohumeral joint is not only more confirmatory, defining the exact pathologic anatomy associated with first-time anterior shoulder dislocation, but as well how best in patient selection, and decision making

Shoulder arthroscopy: part II arthroscopic Bankart repair for anterior shoulder instability using suture anchor reconstruction technique

Suture anchor reconstruction technique was used in 19 shoulders over the last 2.7 years in 19 patients in an attempt to restore anterior stability. All the patients had traumatic anterior instability diagnosed on physical examination and at arthroscopy. Discrete Bankart lesion and well formed glenohumeral ligaments, with or without capsular laxity was the evidence consistent with instability in all patients, and each underwent a standardized procedure, however, the number of anchors were different for every patient, range 1-to-3 according to the size of the lesion. Additional capsulorraphy procedures were done to reduce excess capsular volume including; plication sutures in 8 shoulders, and thermal shrinkage in 7. All patients were young active men with high physical demands, the average age at the time of operation was 25.2 years. All were right handed, the dominant side was affected in 11 patients. None of the patients had prior instability operations. The follow-up averaging 18 months, range 9-to-3 1 months. None of the patients developed redislocation, subluxation, or positive apprehension during the follow-up period. No major intra-operative, or pen-operative complications were reported during this study. 75%-to-full range of motion of the shoulder joint as compared with the opposite asymptomatic side was preserved 21 in most patients. Using the shoulder evaluation scale advocated by Rowe; and Zarins, 1981 1421, the patients had excellent-to-good results with an overall average score of 85.82 points; but 5 patients had episodes of moderate pain with activity, and 7 had moderate limitation in overhead work. It would appear that arthroscopic repair of pathologic Bankart lesion in a carefully selected patients using suture anchor technique is a favorable answer restoring stability to the shoulder better than non-operative treatment of first-time dislocation and to surgical treatment of recurrent shoulder dislocation

Shoulder arthroscopy: part III arthroscopic versus open anterior shoulder stabilization

To evaluate the efficacy of a particular line of treatment, criteria based on functional basis and complication rate must be considered. This work was carried out because of the authors' conviction that any new operative procedure must be critically assessed, on this basis, comparison with other procedures must be included. Forty one shoulders were allocated to an arthroscopic repair group [19 shoulders], and an open repair group [22 shoulders]. The two groups were generally comparable in terms of age [a mean of 25.2 years in the arthroscopic group and 27.3 years in the open group], gender [all patients in either group were males], mechanism of injury and etiology of instability [all patients related a history of a traumatic event], dominant extremity [the right and the dominant side was the most vulnerable], duration of symptoms [a mean of 13 months and 19 months for the arthroscopic and open groups respectively], level of daily activities and effort demand [all were young active with high physical demand]. Three variations were existed: [1] pre-selection and pre-conditioning was the strategy in the arthroscopic repair group, so that, procedural option was determined on the basis of the pathological findings, only at the time of surgery, modification of treatment was possible. [2] the arthroscopic procedure involved an anatomic repair of the avulsed anterior capsule and labrum to the glenoid lip using standardized suture anchor technique and an incorporation of capsulorraphy in most shoulders. While in the open repair group, different operative modalities were employed using familiar techniques including: 2 soft tissue reconstructions; Magnuson - Stack [4 shoulders] and Putti-Platt [6 shoulders]. In addition, coracoid tip with its attached muscles transfer [Bristow operation in 9 shoulders] and rerouting [Boytchev operation in 3 shoulders]. [3] the duration of the follow-up, which considered short-to-mid term [averaging 18 months] and long-term [averaging 71 months] in the arthroscopic and open groups respectively. The treatment outcomes for each group were determined according to the recurrence rate, the presence or absence of -pain, the range of motion, the strength and the return to pre-injury activity. Analysis of the measured parameters for both approaches; open and arthroscopic showed no significant differences, both yielded comparable results

Shoulder arthroscopy: part IV idiopathic frozen shoulder: arthroscopic distension, release, and debridment

Twenty three carefully selected patients with frozen shoulder with variable degrees of complaint and severity constituted the material of the present study. All failed to response to the conventional lines of conservative treatment as an initial measures, and then, arthroscopic management was undertaken followed by a well designated physical therapy program and stretching mobilization. The indication for surgery was persistent pain, stiffness, and limited function. There were 15 [65.2%] males, and 8 [34.8%] females with an average age of 49.6 years. All were right handed, and all but 2 were unilateral dominant-side presentation - for bilateral affection, arthroscopy was done in one shoulder, the one with the severe symptoms. Before operation, all the patients had shoulder pain and motion restriction for at least 6 months despite conservative treatment. At operation, synovectomy, rotator interval capsulotomy, and glenohumeral joint and subacromial space debridment and clean-up were done for all cases, additionally, selective release procedures were performed in a controlled manner according to the findings, varied from limited freeing-up to a more aggressive or a complete release of the contracted anterior capsulo-ligamentotendinous structures. The range of external rotation at the side and in abduction was examined intermittently to check improved laxity and motion arc. The functional mobility, the range of motion in the different planes, the power, and pain were assessed and recorded before and after surgery according to the Constant scoring system [9]. Functional assessment was carried out at 3 post-operative intervals during the course of follow-up; immediate postoperative, at 10 th week, and finally at 20 th week. Final re-assessment at the end of the treatment showed appreciable improvement with no significant recorded complications. On conclusion, the combination strategy; arthroscopic management with shoulder exercises can offer effective treatment for frozen shoulder

Shoulder arthroscopy: part V post-arthroscopic immediate pain control, and then, early mobilization

Any evolution in surgical procedure must seek to improve established results, minimize previous complications, and maximize applicability to the general patient population. Arthroscopic examination and treatment of selected shoulder disorders have undoubtedly earned a permanent role in the practice of orthopaedic surgery, with an exciting and expanding future. The current study was designed to evaluate the clinical value of a post-arthroscopic local analgesic method using a single intra-articular injected dose of a mixture of 20mg [4 ml] tenoxicam, 20mg [0.5 ml] triamcinolone acetonide, 0.2% [10 ml] ropivacaine, and 0.5 ml of a 1: 1000 epinephrine solution, in an attempt to achieve a pain-free post-operative period to allow for early rehabilitation. The study was conducted in 76 patients, mostly were young active men, all underwent shoulder arthroscopic surgery for diagnostic and therapeutic purposes. Visual analogue scale [VAS] scores as regards pain intensity and relief were taken before surgery and then, at recovery, 1, 2, 4, 8, 24 hours postoperatively. In addition, patients were assessed for quality of sleep and for daily living. The physiotherapist's opinions about the analgesia provided were also recorded as indicated by the patient's ability to participate in the immediate post-operative mobilization programs. The results revealed a significant benefit as it offered an immediate post-operative pain relief, high therapist compliance, and good patient satisfaction. In addition, the incidence of adverse actions was negligible

Alignment and soft tissue balance of severe varus knee in total knee replacement

Twenty-nine cases of severe arthritic knee with various degrees of varus deformity [15°-20°] were treated by total knee replacement. Twenty-one [72.4%] of cases were due to osteo-arthritis of knee while the rest [27.6%] were due to rheumatoid arthritis; bilateral affection was reported in 2 patients. There were 20 males and 7 females whose age ranged from 60 to 74 years. The deformity was partially correctable in nine [31%] cases and fixed in twenty [69%] cases. The aim of surgery was to achieve normal alignment of the limb and joint line and to balance the soft tissue structures on both sides of the joint. This required augmentation of medial compartment in 3 [10.3%] cases by bone graft and fixation by cancellous screws. Normal limb alignment was achieved in twenty-five [86.2%] cases. Four [13.8%] cases had residual varus deformity that ranged from [3°- 5° varus]. In three [10.3%] cases lateral laxity was sill present despite the soft tissue surgery

Minimally invasive fixation of diaphyseal fractures of the long weight bearing bones using ender nailing

The effect and result of 115 semirigid Ender nails in 98 patients suffered either closed or open diaphyseal fractures of the long weight-bearing bones, and followed for a minimum of 2 years were reviewed and analyzed. The patients included 67 males and 31 females, ranging in age from 08-to-68 years, with a mean of 37 years. All patients sustained their fractures as a result of a significant high-velocity injury, 76 in a motor vehicle accident, 14 during sport activities - but in 8, the fractures were due to direct blow and heavy object impact at work. Of the 115 fractures, 21 were open injuries and 25 out of the 98 patients had additional injuries and fractures of other bones. The geometry of most fractures were met the criteria that ensured good mechanical effect after Ender nailing, mainly, the maintenance of axial stability. We did not include cases with established instability, except for the 4 cases with segmental tibial shaft fractures. 61[53%] fractures including open injuries and segmental fractures were treated within 8 hours after injury. On the basis of the results of the current study, open fractures did not considered to be a contraindication for primary nailing. Delayed nailing was performed within 7 days of the onset of trauma for the rest of cases. All cases followed a similar therapeutic regimen, in addition to the initial debridement for open fractures. Most patients experienced pain relief in the early post-operative period and many could resume their activities of the daily living. Rapid restoration of bone continuity with no significant mal-alignment was the early positive finding in the majority of cases in the series. In the course of follow-up, we collected sufficient data to rate patients according to Thoreson, et al., scoring system [18]. At final up, an excellent result was obtained in 91.3% of cases and good in the remaining 8.7%. On conclusion, this method proved to be safe and effective with minimal complications - this is particularly true when the procedure is carried out under the right circumstances with careful attention to its indication and its technical aspects, and then, the chances for the success of the fixation can be greatly improved

Vastus medialis obliquus advancement in association with patellectomy in cases of highly comminuted patellar fractures

The results of 13 total patellectomy, combined with vastus medialis obliquus [VMO] advancement in 13 patients followed-up for 9-to-40 months were analyzed. The patients included 9 [69.2%] males, and the other 4 [30.8%] were females. Their ages ranged from 20-to-40 years old. The indication for patellectomy was severely comminuted fracture of the patella. A direct blow to the patella was the causative trauma for all cases; 9 [69.2%] fractures were closed, and 4 [30.8%] were opened. Associated injuries were reported in 3 [23.1%] patients: Colles' fracture, forearm bones fracture, and open intercondylar-supracondylar fracture femur. Functional assessment of the patients was carried out using the scoring scales described by Marshall, et al., 1977; and Levack, et al., 1985 [18-21]. The overall results according to Marshall, et al., were scored 7.5/8 points which considered excellent - and scored 8.2/9 points according to Levack, et al., which considered good. This technique appears to give better functional results as regards pain, discomfort, range of knee movements, quadriceps function and functional activities including: walking, running jumping, and squatting

Primary non-reamed locked nailing in acute open: segmental tibial shaft fractures [high-risk tibial shaft fractures]

From November, 1999, to April 2004, 23 open segmental tibial shaft fractures were treated by primary non-reamed intramedullary locked nailing after appropriate wound debridement. Most patients were active labor men, the youngest was 27 years old and the oldest was 68 years, with an average of 46 years. The mechanism of injury was high energy trauma; road traffic accidents were responsible for the majority of fractures 15[65.2%]; 9[39.1%] patients had been struck by a motor vehicle as a pedestrian, 4[17.4%] were occupants of a motor vehicle that was involved in an accident; one [4.3%] as a driver, and the other 3[13.1%] as passengers - 2[8.7%] were motorbike accidents Industrial accidents due to blunt trauma represented the remaining 8[34.8%] fractures; 6[26.1%] had a fall from a considerable height, and in two patients [8.7%] the tibiae were crushed by a heavy object. Concomitant fractures of other bones had occurred in approximately half of the cases 11[47.8%], three [13%] had in addition, head injury. For all cases, prophylactic antibiotics were started on admission. Surgery was done immediately post-injury, the average time from injury-to-surgery was 4 hours. Delayed nailing after primary debridement was performed between 3-and-8 days in 5 [21.7%] fractures. No post-operative plaster was needed. Additional bone grafting operation was done in 3 [13%] cases, and pedicle muscle flap to cover the exposed bone in another 3 [13%]. Secondary procedures; plastic reconstructive surgery including delayed wound coverage, bone-marrow injection, fibular osteotomy, Illizaroy application, and nail exchange using 1-2 mm larger diameter nail were done in 9[39.1%] patients. Dynamization of the static locked nailing was needed after 3-to-6 months in 11[47.8%] cases to enhance consolidation and corticalization of the formed callus. After dynamization shortening up to 2 cm was observed in 7[30.4%] patients, 4 of the 7, in addition, developed varus and external rotation malalignment. These deformities did not show further change or progression in the course of follow-up. The patients were allowed partial weight-bearing with crutches as tolerated as soon as they were comfortable and as the other injuries had allowed Patients were evaluated clinically - and radiologically until healing of the fractures. Most of the patients 19[82.6%] achieved clinical union in 9-to- 11 weeks after nailing, however, osseous union had occurred in less than 4 months in 5[21.7%] fractures, and between 4-to-8 months in 14[60.9%]. Only 4[17.4%] fractures were not united after 8 months, that needed further surgical intervention to achieve union

Mini-screw fixation for certain fractures of the phalanges and the metacarpals

68 patients with phalangeal or metacarpal fractures were treated in the emergency department at Bab-Elshareia university hospital and health insurance hospital by open reduction and internal fixation using inter-fragmentary lag screw stabilization technique. Operative stabilization was considered because we failed to restore fracture alignment at closed attempts, or fractures failed to maintain closed reduction in plaster immobilization after conservative trials, Phalangeal fractures were accounted for 45 [66.2%] of the total, the remaining 23[33.8%] were metacarpals. There were 59 [86.8%] males and 9[13.2%] females. The youngest patient was 18 years old and the oldest was 55; the mean age was 27 years. All fractures were unstable. The fracture pattern was displaced spiral in 49 [72.1%] cases and displaced oblique in the remaining 19[27.9%]. There were 39[57.4%] injuries to the left hand, 29[42.6%] to the right, and in no instance was there an injury to both hands. Considering all 68 fractures, direct blow was accounted for 80.9% of the total, whereas indirect forces was instrumental in only 19.1% of the fractures. Most of the injuries 39[57.4%] had occurred in young labor men. Athletic injuries, 20[29.4%] fractures had occurred in young adult students. Indoor injuries, 9 [13.2%] fractures had occurred only in females, most of them were in the 5th decade of life. All injuries were closed single-bone fracture. None of the fractures was pathological none was intra-articular and none of the patients had other additional injuries elsewhere, but one, suffered in addition, ipsilateral fracture distal radius. The overall results at final follow-up were excellent in 61[89.7%] patients, and good in 7[10.3%]

Remote fixation of humeral shaft fractures using ender nailing technique

A fracture of the humeral shaft is defined as one occurring below the surgical neck and above the supracondylar ridge of the humerus [1-24], Remote fixation means that, the fracture site is not interfered with and remains untouched during the operative procedure. Nail insertion is carried out through an isolated and restricted proximal or distal incisions [1-3]. Among many humeral shaft fractures that were seen during the period of the study [2001-2004], 46 fractures in 42 patients were nailed using closed Ender technique. Our opinion, all these fractures were not suitable for conservative treatment There were 29 [69.0%] men and 13[31.0%] women, with an average age of 31.5 years. Direct blow to the arm was the causative trauma in all fractures, of the 42 patients, 18[42.9%] were victims of road traffic accident, the next high incidence, 9[21.4%] patients had injured at work. All fractures were closed, except 6[14.3%] open injuries, the skin wound was about 1 cm long in 2 cases and the other 4 were graded Gustilo type-Il [9]. Associated injuries were reported in 13 [31.0%] patients. The level of the fracture was the middle third in 50% of cases, the upper third in 32.6% and the lower third in 17.4%. Retrograde nailing was done for 38[82.6%] fractures and antegrade for the remaining 8[17.4%]. No external splints were used post-operatively, except in open injuries, just for some days for comfort. Active use of the operated arm was encouraged immediately after the operation. After hospital discharge, patients were reviewed for assessment of functional use of the extremity, range of motion of the shoulder and elbow and for progress of healing. The results obtained confirmed the effectiveness of the procedure with regard to union and function with remarkably low incidence of complications. The average time to return to function was 12 days. The safeness, easiness and simplicity of the technique, in addition, the time saving and the low costly far outweigh other surgical alternatives for all these reasons we recommended this treatment modality when indicated

Short term results of atraumatic surgical approach for management of tibial plafond pilon fractures using limited exposure, indirect reduction technique, minimal internal fixation, and Ilizarov fixator

Between November 1998 and October 2001, 19 cases of tibial pilon fractures were operated upon by indirect reduction technique combined with minimal internal fixation, bone grafting as necessary and Ilizarov fixator. All were high-energy injuries with Ruedi-Allgower type II in 10 [52.63%] and type III in the remaining 9 [47.36%]. Three [15.78%] fractures were open and four patients [21.05%] had associated injuries. Seventeen [89.47%] patients were males and 2 [10.52%] patients were females. Their age ranged from 25 to 75 years with the mean age 44 years. Approximately half of the injuries were seen in young labor men. All open fractures were sustained by men, except one female that had open fracture with vascular injury. The mean time from admission to surgery was 7 hours for approximately 50% of cases and 7 days for the remaining cases. All 19 ankles were evaluated for an average 20 months postoperative [minimum 10 months and maximum 35 months]. All fractures in this study united with an average time of healing 5.6 months [165 days]. The results were evaluated according to the functional grading method described by Helfet, et al., 1994. The overall results at final follow up was excellent in 10 [52.63%] cases, adequate in 6 [31.57%] and poor in 3 [15.78%]. Complications occurred in 3 [15.87%] cases and included one [5.26%] deep infection, 2 [10.52%] post-traumatic arthritis which were correlated to initial injury and the reduction of the fracture

Experience with 60 total knee arthroplasty

The results of 60 Total knee Arthroplasty [TiCA] in 53 patients followed up for six to twenty four months are analysed. The patients included 40 females [75.5%] and 13 males [24.5%] with 7 of them [13.2%] have bilateral replacement. The indication wasosteoarthritis [OA] in 47 knees [78.3%], Rheumatoid [RA] in 8 knees [13.3%j and posttraumatic arthritis [PTA] in 5 knees [8.3%]. Average Hospital for Special Surgery [H.S.S] score improved from 53.6 points [33-79] preoperatively, to 81.6 points [51-96] after replacement, with 34 knees [56.6%] have excellent scores, 21 [35%] good scores, 4 [6.6%] fair, and 1 knee] 1.6%] have poor score, TKA resulted in marked improvement in pain state, range of knee movement, knee stability and the functional performance of the patients

Digital function following delayed flexor tendon repair in no - man's land

Between February 1999 and December 2000, 112 fingers in 97 patients with neglected cut both flexor tendons in zone-II of the hand were treated by delayed primary repair. There were 79 males and 33 females with ages ranged from 4 to 68 years with an average age of 21 years. Most of the injuries [65] occurred at work and home accidents due to the careless use of cutting tools in 38 fingers and due to personal behavior factors in the remaining 9 digits. Radiologically, all digits were free from any bone or joint abnormalities and clinically, 19 digits were presented with mild to moderate limitation of passive motion of IP joints. The mean period of lapsing between injury and repair was 10 days with a range of 14-35 days

Long term follow-up of surgically reconstructed flexor tendon system of the hand in complicated cases associated with scarred tendon bed using tendon proshesis

This study aimed to evaluate the long-term functional results in surgically reconstructed flexor tendon system of the hand following complicated injuries associated with scarred tendon bed and loss of integrity of its sheath. The study presented the long-term functional results in 32 patients. Most of the injuries [24] had occurred at work. Cutting tools were the causative trauma in the majority of cases. Radiologically, all the operated digits were free from any bone or joint abnormalities. The cases were selected and the neurovascular bundle was, at least, intact at one side of the involved digit; in addition, many were associated with joint contracture of one or more of the digital joints and limited passive motions