Unstable stenotic degenerative lumbar spondylolisthesis

Unstable stenotic degenerative lumbar spondylolisthesis is a special clinical entity that merits special diagnostic efforts to identify pre-stenotic levels as well as the pathological changes responsible for stenotic symptoms. Following a meticulous diagnostic, extensive decompression, bilateral posterior pedicular instrumentation and unilateral, intertransverse fusion resulted in 78.3% favorable clinical outcome and 95.4% solied fusion rate after a 31 months period of follow up in 22 patients. Individual clinical symptoms showed variable improvement rates. Low back pain improved in 84.2%, claudication distance below 500 meters improved in 76.4%, sciatic pain improved in 86.6% and there was 66.6% neurological recovery. Fusion rate was 95.4% [21 patients]. The results of this study have confirmed that the extent of decompression is the most single parameter associated with early favorable clinical outcome. Also, instrumentation is usually associated with a higher rate of fusion and a lower rate of recurrence, but not related to early clinical outcome

Outcome of transpedicular screw fixation in surgical treatment of isthmic spondylolisthesis in adults

Isthmic lumbar spondylolisthesis is a complex orthopedic and neurosurgical problem. Between 1995 and 2000, twenty three adult patients with symptomatic isthmic lumbar spondylolisthesis who failed to respond to conservative treatment were operated upon by posterolateral fusion and transpedicular screw fixation combined with a variety of decompressive procedures; namely, decompressive laminectomy, excision of fibrocartilaginous pseudoarthrotic mass and/or foraminotomy when indicated by preoperative imaging studies and operative findings. The surgical results were evaluated at an average follow up of 21 months. Nineteen patients had favorable clinical outcome. Solid fusion was evident in 20 patients. Individual clinical symptoms showed variable degrees of improvement. Low back pain improved at variable degrees in 91.3%, sciatica improved in 89%, intermittent claudications improved in 75% and neurological deficits improved in 87.5%. Loosening of screws was the commonest complication encountered occurring in 2 patients. In this study, posterolateral fusion combined with an appropriate decompressive procedure and instrumentation by transpedicular screws without reduction for isthmic spondylolisthesis in adults resulted in a high fusion rate and favorable clinical outcome

Internal fixation of fracture femur associated with hip arthroplasty

During the period between 1996 to 2000 we treated 11 patients with femoral fractures associated with a hip arthroplasty by open reduction and internal fixation. The study included eight females and three males with a mean age of 62.6 years and an average follow up period of 28 months. Of the 11 patients eight had previous total hip replacements while three had hemiarthroplasties. Various methods of fixation were used. In eight patients a broad dynamic compression plate was used, while in one patient a Mennen plate was used, two interfragmentary lag screws were used in another and a condylar compression screw and plate in the last. All but one fracture united. According to the d'Aubigne and Postel 6-point pain and 6 point walking scale, eight patients didn't have any impairment of function [double dagger-points], two patient had a partially impaired function [7-9 points] and one patient had an impaired function [pound pilcrow points]. In our understanding open reduction and internal fixation of fracture femur associated with hip arthroplasty is a satisfactory method with a favourable outcome in most cases, provided there was no loosening problem of the hip arthroplasty before the occurrence of the femoral fracture

Anterior surgical procedures for management of cervical disc disease

The syndrome of radiculopathy and myelopathy secondary to cervical disc disease, continues to receive considerable attention in the literature. Recent advances in diagnostic and surgical techniques have an impact on the management of cervical disc disease. This work is done to present our experience with forty-four patients with cervical disc disease. These patients were operated upon using anterior cervical discectomy with and without bone graft. The herniated disc was the main offending compressing factor as proved by MRI. All patients had significant central or paracentral disc herniation at one or double levels. Thirty patients [68%] had single disc level affection. Anterior cervical discectomy without bone graft was performed in these 30 patients, while in the remaining 14 patients [32%] who had double disc levels affection, anterior cervical discectomy with bone graft was performed. Excision of the posterior longitudinal ligament was done in 9 patients [20%] with the help of operating microscope to remove the subligamentous disc herniation. Excellent to good outcome was achieved in 34 patients [77.3%] and none of our patients showed cervical instability during the postoperative follow-up period. Radiculopathy had responded well to surgery, while in myelopathic patients improvement was achieved in motor power to variable extent, but poor out come was obtained in elderly patients who had severe cord compression with cord malacia and poor preoperative clinical status. Transient dysphagia and hoarseness of voice were the commonest postoperative complications, they occurred in 16%, 11% of patients respectively. No mortality or irreversible morbidity related to surgery were reported in this study

Surgical management of trapezio-metacarpal joint arthritis. Comparison of two techniques

Osteoarthritis at the base of the thumb affecting the trapeziometacarpal [TMC] joint is a common, painful and disabling condition that severely compromises function of the entire hand. Successful treatment is based on an understanding of the specific anatomy and the unique functional attributes of the human hand and thumb. Surgical procedures for this problem include extra articular ligamentous reconstruction, partial or complete resection of the trapezium with or without tendon interposition arthroplasty, arthrodesis of the trapeziometacarpal joint, osteotomy of the thumb metacarpal, silicone interposition arthroplasty and total joint arthroplasty. The results of this prospective study were represented in which qualitative and quantitative outcomes were assessed clinically and radiographically in 47 thumbs in 40 patients with thumb basal joint arthritis affecting the trapeziometacarpal joint treated with beak ligament reconstruction with tendon interposition arthroplasty [LRTI] [group I including 25 thumbs] or with arthrodesis of the TMC joint [group II including thumbs]

Retrograde closed unreamed interlocking nailing for multiple-level femoral fractures

In a prospective study for the treatment of multiple-level femoral fractures, the results of retrograde, closed unreamed, interlocking technique through the inter-condylar notch of the femur were evaluated. Russell-Taylor tibia1 nail was used in all cases. There were twelve fractures [five were open] in twelve patients; ten were males and two were females. Nine patients had other skeletal trauma and one had rupture of the spleen. The average operative time was 65 minutes [range 45 to 100 minutes]. Blood loss was minimal [average 150 ml]. The average follow up was 19 months [range 11-32 months]. Union occurred without additional surgery within 17 weeks in all, but one patient needed autogenous bone grafting about the most proximal fracture site at the twentieth week. All patients regained full knee motion within four weeks. No cases of infections, screw or nail failures, patellofemoral [PF] problems or problems about the hip were recorded. In most of cases [8 out of 10], simultaneous management of other skeletal or non skeletal trauma was possible. At the terminal follow up, it was evident that retrograde closed unreamed interlocking nailing is a competent method in the treatment of multiple-level femoral fractures, especially in those with multi system and/or multiple skeletal trauma

distal fascicle of the anterior inferior tibio-fibular ligament in correlation with talar impingement

Up till now, the anterior inferior tibiofibular ligament [AITFL] is described in the anatomic tradition as one entity. The present investigation confirmed the presence of what was recently termed [a distal fascicle] of the ligament, which appeared as a separate band found in all [thirteen] the examined cadavers. It took the shape of a parallelogram that lied below and parallel to the rest of the AITFL. A pad of fat separated this fascicle from the rest of the ligament that masked its easy differentiation for a long time. In extreme dorsiflexion of the ankle, the lower border of the fascicle became tight and touched the dome of talus. Also, the clinical study showed audible popping and friction between the thickened fascicle and the opposite hyaline cartilage on talus. This indicated a ligamentous talar impingement with chronic pain on the anterolateral aspect of the ankle in 5 out of 9 patients with soft tissue talar impingement syndrome related to the anterolateral compartment of the ankle. Arthroscopic resection of the distal fascicle gave excellent results with complete relief of pain in all 5 patients suffering of this lesion. Arthroscopic removal of this fascicle along with treatment of other offending pathological lesions gave excellent results in 8 out of 9 patients after an average follow up of 13 months. It was concluded that the anatomy of this distal fascicle has to be included in literature. Furthermore, its pathologic role in talar impingement should be appreciated, yet not overemphasized by clinicians and those dealing with sport injuries, especially when exostoses are absent in radiographs

Intra-articular fractures of the distal humerus in adults. plan for management and evaluation

Over a period of 5 years we collected the results of 19 patients having intrarticular fractures of the distal end of the humerus. We used Muller et al. [1979] classification. the group consisted of Fourteen males and five females; their mean age was 49 years. They were treated by open reduction and internal fixation according to AO technique. The mean follow up was 28 months [range:19 to 52 months]. We evaluated our results using two functional scoring systems. Although there was a little difference ion subgroups, the overall ratings were matching The overall favorable results were 73.8% for both evaluation methods. the results were directly related to the complexity of fracture as four of the five patients with unfavorable results were of type C3 fractures. four patients had re-operation; two for readjustment of loose fixation;one infected fracture for sequestrectomy and one for ulnar nerve transposition. The study clearly disclosed the value of AO classification of fractures; the importance of early rigid internal fixation; early active mobilization and the applicability Broberg and Morrey Functional Rating System