Tratamento cirúrgico de displasia de desenvolvimento do quadril de apresentação tardia depois da idade da marcha / Surgical treatment of the late - presenting developmental dislocation of the hip after walking age

OBJETIVO: Os casos de displasia de desenvolvimento do quadril (DDQ) ainda ocorrem depois da idade da marcha devido ao diagnóstico tardio ou ausente e à falha do tratamento conservador. A escolha do tratamento da DDQ depois da idade da marcha continua controversa e uma das opções é a redução a céu aberto combinada com osteotomia do inominado.MÉTODOS: Vinte pacientes com 26 quadris com DDQ tratados cirurgicamente foram avaliados de 2005 a 2008, usando-se a osteotomia do inominado pela técnica de Salter depois de redução e capsulorrafia a céu aberto. A idade dos pacientes no momento da cirurgia variou de 12 a 18 meses (média de idade 14,7 meses). De 15 pacientes do sexo feminino e cinco do masculino, seis tiveram luxação bilateral e dos restantes, nove tiveram luxação do quadril esquerdo e cinco, do direito.RESULTADOS: Os resultados foram avaliados de acordo com os critérios modificados de McKay e dos critérios radiológico de Severin, depois de acompanhamento médio de 46,7 meses. Oitenta e nove por cento dos quadris foram classificados como excelentes ou bons pelos critérios de McKay. Não houve resultados ruins. De acordo com os critérios de Severin, 77% eram do tipo I e II, enquanto 23% eram do tipo III e IV; nenhum quadril foi classificado nos tipos V ou VI. Houve um caso (3,8%) de reluxação, mas a cirurgia de revisão resultou em redução estável, concêntrica e permanente. Não há relato de casos de infecções, fratura do enxerto e lesão vacular ou nervosa.CONCLUSÃO: A redução a céu aberto combinada com a osteotomia de Salter não afeta o quadril com relação à remodelação em crianças entre 12 e 18 meses de idade. Nível de Evidência IV, Série de Casos.

OBJECTIVE: Cases of developmental dislocation of the hip (DDH) still occur after walking age because of late or missed diagnosis and failed conservative treatment. The choice of treatment for DDH after walking age continues to be controversial, and one of the options is open reduction combined with innominate osteotomy.METHODS: Twenty patients with 26 surgically treated hips with DDH, were evaluated from 2005 to 2008, using innominate osteotomy by Salter's technique after open reduction and capsulorraphy. The age of patients, fifteen females and five males, at time of surgery ranged from 12 to 18 months (mean age 14.7 months). Six patients had bilateral dislocation and in the remaining, nine had their left hip dislocated and five had their right hip dislocated.RESULTS: The results were evaluated according to modified McKay criteria and to Severin radiological criteria, after a mean follow-up of 46.7 months. Eighty – nine percent of hips were rated as excellent or good by McKay criteria. There were no poor results. According to Severin criteria, 77% were type I and II while 23% showed type III and IV, no hips were rated as Severin's group V or VI. There was one case (3.8%) of re-dislocation, but revision surgery resulted in stable, concentric, and permanent reduction. No cases of infection, graft fracture and vascular or nervous injury were reported.CONCLUSION: Open reduction combined with Salter osteotomy does not hurt the hip with regard to acetabular remodeling for children between 12 and 18 months of age. Level of Evidence IV, Case Series.

Radiological evaluation of total knee arthroplasty

X-Ray analysis of a subset of TKA performed using a standard posterior cruciate ligament [PCL] retaining cemented technique to study the component malposition, overall post-operative alignment and mechanical loosening with respect to components positioning during follow-up period. This is a prospective study where we radiographically evaluated twenty-six primary TKAs [15 right and 11 left] in 20 patients [six patients received two stage bilateral total knee replacement] performed between July 2004 and December 2005. There were a total of 13 women and 7 men. The mean age at the time of the operation was 68 years and the follow-up period ranged from 18-32 months. The indication for knee replacement in all cases was advanced osteoarthritis. Radiographs were done immediately postoperative, at 6 weeks, at 3 months, at 6 months and then every year after surgery, and each time were compared to the postoperative controls. The overall alignment was acceptable in 19 knees, 3 had excessive valgus and 4 had varus alignment. At the last follow-up which was up to 32 months in some cases, none of the cases developed loosening as evidenced by non appearance of radiolucent zones or shifts in the position of the components. Moreover, the seven cases with joint malalignment didn't show signs of aseptic loosening within the available follow-up period. For the patellar angle, the mean tilt angle was 12° +/- 6°. In 17 knees the patellar prosthesis was displaced superiorly, and in seven cases there was medial displacement of the patellar prosthesis. Evaluation of total joint arthroplasty must be clinical, radiological and with annual intervals, in order to discover early failure signs. Proper alignments are critical for achieving good results thus keeping loosening to a minimum. Concerning the present study, aseptic loosening was not a complication of the toted knee arthroplasty evaluated at a follow-up period of up to almost three years in some cases, including those cases with documented postoperative joint malalignment

Assessment of the range of motion after total knee arthroplasty for osteoarthritic knees

A prospective study was performed to evaluate the range of motion after total knee replacement for osteoarthritis, one year postoperatively, by comparing it to baseline value. Forty-two knees [23 right and 19 left] primary TKAs in 36 patients [six patients received two stage bilateral total knee replacements] were performed between July 2004 to September 2006. There were a total of 22 women and 14 men. The mean age at the time of the operation was 68 years [range 53 - 82 years]. The average duration of follow-up was 18 months [range 14-22 months]. All prostheses were cemented preserving the posterior cruciate ligament Three different models were used namely: P.F.C. SIG-MA[R] Total Knee System from DePuy, AGC[R] Total Knee System from Biomet, and Columbus[R] Total Knee System from Aesculap. The diagnosis of osteoarthritis was established in all cases. The parameters evaluated were age, sex, preoperatlve knee flexion and extension range, preoperative flexion arc, tibiofemoral angle, and implant design. Advanced age, female gender, and good preoperative flexion and flexion arc were related to better postoperative flexion. Preoperative tibiofemoral malalignment had no significant effect on postoperative flexion. Advanced age, female gender, and good preoperative flexion and flexion arc are related to better postoperative range of motion particularly the degree of flexion

Tibial spine fractures: arthroscopic assisted reduction and percutaneous Kirschner wire fixation

The aim of this prospective study is to evaluate our results in the management of avulsion fractures of the anterior tibial spine with the aid of arthroscopy. Twelve patients with displaced tibial spine fractures with an average age of 13.3 years were the material of this study. After through clinical and radiological evaluation an operative arthroscopy for both diagnosis and treatment was done to assess and to guide both reduction and fixation with percutaneous kirschner wires. Eight added surgical techniques had required to treat the associated local knee injuries. The Lysholm scoring system was used for evaluation of the final results. Nine patients were graded as excellent, two patients as good, and one patient was graded as fair outcome. There was statistically significant correlative between the following; fracture type and positivity of anterior drawer test, age of the patients and final Lysholm scoring system, residual postoperative displacement and the final Lysholm knee scoring system, residual postoperative displacement and positive anterior drawer test was found to be statistically significant. There was no statistically significant correlative between the following; positivity of the valgus stress test and the type of the fracture, fracture type and the final Lysholm knee scoring system. Type IV fracture is the worst type regarding the incidence of associated soft tissue and bony injuries and the high rate of post-operative complications. Objective knee laxity does not always mean subjective knee laxity. The number of patients included in this study is very limited to yield a statistically significant relationship. A new comprehensive classification system is urged by this study

Complications associated with the technique of pedicle screw fixation in thoracic and lumbar spine in 100 consecutive cases

This was a prospective study done in the emergency centre of Mansoura university hospital. Ben ha university hospital and Zagazig university hospital where we reviewed the complications associated with the technique of pedicle screw fixation in 100 patients with spinal instabilities for different reasons where 520 pedicle screws were inserted by five different surgeons but with the same technique. The most common intraoperative problem was unrecognized screw misplacement [8.5% of the total screws inserted]. Fracturing of the pedicle and iatrogenic cerebrospinal fluid leak occurred in 3 patients [3%]. Neurological deficits occurred in 7% of the patients and in 4% reoperations were required. Infection occurred in 8 patients [8%] and required reoperations in 5%. Screw breakage occurred in 1.3% of the total screws inserted with no significant disabilities recorded. A careful analysis of our 100 patients shows that pedicle screw placement may be associated with significant intraoperative and postoperative complications. The intraoperative complications and inadequacies can be kept to a minimum, if attention is paid to careful planning, knowledge of anatomy and careful attention to the technique and details. Also familiarity with the technique and experience results in further diminution of morbidity as shown in our study of the first and second 50 consecutive patients

Carpal tunnel syndrome: a study to assess the improvement of grip strength following open carpal tunnel release without neurolysis

Grip strength following open carpal tunnel release was studied prospectively over three years in Mansoura university hospital. We examined 40 hands from 30 patients [4 males and 26 females] clinically diagnosed as carpal tunnel syndrome. All patients underwent thorough medical history tacking and clinical examination. All the hands were subjected to routine determination of the distal motor latency [DML] and nerve conduction velocity [NCV] along the elbow-wrist segment of both median and ulnar nerves and Median 2L-versus-ulnar INT distal motor latencies. Jamar dynamometer was used to measure grip strength to all patients before and following carpal tunnel release using the standardized positioning and instructions. Grip strength was found to be 16% of the pre-operative level at two weeks. 32% by four weeks, and 70% by six weeks and returned to 96% of the pre-operative level by three months. At six months grip strength had increased to 110% of the pre-operative level and 118% at one year. Our study also showed the efficiency of the use median 2L-versus ulnar in the confirmation of clinical diagnosis of carpal tunnel syndrome. Simple open carpal tunnel without neurolysis is quite enough even in cases with severe muscle atrophy