Open versus arthroscopic technique for anterior cruciate ligament reconstruction with patellar tendon graft. An early results on post-operative pain, rehabilitation and stability

Anterior cruciate ligament [ACL] reconstruction is a common procedure performed by many surgeons, different grafts have been used but the bone- patellar tendon graft has considered the gold standard for many years. The graft can be inserted either arthroscopically assisted with femoral half tunnel created from the joint, thus avoiding the lateral incision or making two tunnels through a mini-arthrotomy and a lateral femoral incision. A great controversy have been claimed for the advantage and the disadvantage of the two procedure as regards early rehabilitation period and stability. A fourty male patients with ACL deficiency were included in a prospective randomized trial comparing the two procedure with a follow up period of one year. The data obtained preoperatively did not show any significant differences between the two groups. At early follow up there was a differences observed with respect to complications and the progress of rehabilitaion. Evaluation at 12 months postoperatively using Lysholm scoring system revealed good to excellent results in 80% of patients in the first group and 70% in the second one. ACL reconstruction reduced anterior tibial translation of the knee significantly at 6 months follow up with a slight increase of degrees of instability at 12 months in both groups. The arthoroscopic single incision technique did show better results as regards early postoperative pain, swelling, range-of motion or any rehabilitational parameters. We conclude that an arthroscopic single incision technique for ACL reconstruction has an advantage over open mini-arthrotomy two incision technique as regards subjective more than objective parameters

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

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

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

Study of the influence of type of ENT surgical procedure on the frequency of postoperative nausea and vomiting and the role of prophylactic antiemetics

This study was designed to determine the frequency of Postoperative Nausea and Vomiting [PONV] after variant ENT surgeries and to evaluate the efficacy of prophylactic tropisetron for prevention. The study comprised 100 patients [50 males and 50 females]. Their ages ranged between 10-20 years and were randomly allocated into two equal groups: Placebo group received preoperative normal saline and Tropisetron group received tropisetron [5mg]. A dose of IV metoclopramide was given postoperatively as rescue antiemetic. Forty patients underwent tonsillectomy, 20 patients had nasal surgery and 40 patients had ear surgery. PONV was reported in 51 patients: 32 in the placebo group and 19 in the tropisetron group. The frequency of PONV was 67.5% after ear surgery, 47.5% after tonsillectomy and 25% after nasal surgery. Patients who were operated for mastoidectorny had a higher frequency [75%] than those who underwent myringotomy [60%]. Moreover, older patients who underwent tonsillectomy had a higher frequency [55%] than younger ones [40%]. There was a positive non-significant correlation between age and frequency of PONV in the placebo group, despite the positive significant correlation in those who underwent tonsillectomy, [r=0.498, p=0.026]. As regards sex predilection, 33 females and 28 males had PONV. There was a significant [P<0.0l] reduction in frequency of PONV in patients who received tropisetron [3 8%] compared to placebo [64%]. Nausea was detected in 12 patients, retching in 8 patients and vomiting in 12 patients in the placebo group, while in the tropisetron group nausea was detected in 9 patients, retching in 6 patients and vomiting in only 4 patients, with a significant decrease in severity in tropisetron group. Also, there was a significant increase in severity of PONV in favor of ear surgery. Rescue antiemetic was required by 19 [3 8%] patients in placebo and 8 patients [16%] in tropisetron group. We can conclude that surgical manipulations at ear and tonsil regions are associated with more frequency of PONV that could be reduced by the prophylactic use of tropisetron