Effect of double plate technique combined with autogenous iliac bone graft in the treatment of femoral nonunion after intramedullary nailing / 中国骨伤

OBJECTIVE@#To investigate the clinical effect of double plate combined with iliac bone graft in the treatment of femoral nonunion after intramedullary nailing.@*METHODS@#From December 2008 to December 2017, double plate combined with autogenous iliac bone graft was used to treat femoral nonunion after intramedullary nailing. There were 11 cases, including 10 males and 1 female, aged 35 to 62 years, and the time from fracture to nonunion was 12 to 20 months. According to Judet classification, there were 8 cases of atrophic nonunion and 3 cases of proliferative nonunion. Regular follow-up was conducted after operation to record the fracture healing time, load-bearing activity time and complications, and to observe the repair effect of double plate fixation combined with iliac bone graft on nonunion after femoral shaft fracture operation.@*RESULTS@#All patients were followed up for 12 to 22 months. The operation time was 70 to 130 min and the blood loss was 180 to 350 ml. After operation, 2 cases had knee stiffness, which recovered after passive exercise with CPM machine for 2 weeks;1 case had pain in iliac bone donor area, which was relieved after 3 months. The time of fracture healing was 24 to 40 weeks, and the time of complete weight-bearing activity was 14 to 32 weeks. SF-36 quality of life score at the final follow-up:body pain 70 to 82, activty 70 to 82, social function 72 to 83, the overall health 72 to 82. At the end of the follow-up, there were no complications such as limb shortening, infection, poor wound healing, internal fixation failure (fracture, loosening).@*CONCLUSION@#It is an effective method to treat nonunion of femur after intramedullary nailing by using double plate combined with autogenous iliac bone graft.

Ultrasound-guided multiple peripheral nerve blocks, a way out for anesthesia in morbidly obese patients for bone marrow aspiration / Múltiplos bloqueios de nervos periféricos guiados por ultrassom, uma saída para anestesia em pacientes com obesidade mórbida para aspiração de medula óssea

Abstract Morbid obesity is associated with various pathophysiological changes which affect the outcome of anaesthesia and surgery. So it's challenging to give anaesthesia to such patients. We present a 59-year-old adult morbidly obese, hypertensive, diabetic female with hypothyroidism operated for proximal humerus fracture and now presented with non-union of fracture, requiring percutaneous injection of bone marrow aspirate from the iliac crest to the site of non-union. The patient was extremely anxious and refused to undergo the procedure under local anaesthesia or sedation and demanded anaesthesia. Given her comorbidities general anaesthesia (GA) was avoided and the procedure was accomplished using Ultrasound (USG) guided Transversus abdominis plane (TAP) block and Lateral Femoral Cutaneous Nerve (LFCN) block for the bone marrow aspirate from the iliac crest and Intercostobrachial nerve block (T2) was given to prevent pain while injecting the aspirate into the non-union site. Dexmedetomidine and ketamine were given for deep level sedation and analgesia. TAP block and LFCN block is generally used for post-op analgesia but can be also used for surgical anaesthesia instead of General anaesthesia in specific scenarios. Its perioperative application and its potential use instead of GA have been discussed.

Resumo A obesidade mórbida se associa a várias alterações fisiopatológicas que afetam o desfecho da anestesia e cirurgia. É, portanto, um desafio anestesiar tais pacientes. Apresentamos uma mulher adulta de 59 anos, obesa mórbida, hipertensa, diabética, com hipotiroidismo, submetida a cirurgia devido a fratura proximal do úmero e que compareceu ao serviço com fratura não consolidada, e com indicação de injeção percutânea de aspirado de medula óssea da crista ilíaca na fratura não consolidada. A paciente estava extremamente ansiosa e recusou o procedimento sob anestesia local ou sedação e exigiu anestesia. Em função de suas comorbidades, Anestesia Geral (AG) foi evitada e o procedimento foi realizado usando bloqueio do Plano Transverso Abdominal (PTA) guiado por Ultrassonografia (USG) e bloqueio do Nervo Cutâneo Femoral Lateral (NCFL) para aspiração de medula óssea da crista ilíaca. O bloqueio do nervo Intercostobraqueal (T2) foi realizado para evitar dor durante a injeção do aspirado. Dexmedetomidina e ketamina foram dadas para sedação profunda e analgesia. O Bloqueio PTA e bloqueio NCFL geralmente são usados para analgesia pós-operatória, mas também podem ser usados para anestesia cirúrgica substituindo a anestesia geral em condições clínicas específicas. O emprego desses bloqueios no perioperatório e seu uso potencial no lugar de AG têm sido discutidos.

Tratamiento de defectos masivos de tibia: técnica de transporte óseo con fijador AO [Arbeitsgemeinschaft für Osteosynthesefragen] / Treatment of massive defects tibia: bone transport technique with fixator AO / Tratamento de defeitos maciços da tíbia: técnica de transporte ósseo com fixador AO

Introducción: La transportación ósea se refiere al traslado de un fragmento de hueso a través de un defecto óseo, por distracción osteogénica. Objetivo: Describir la técnica quirúrgica con fijador externo AO, y evaluar los resultados de este tratamiento en defectos óseos diafisarios de tibia mayores de 4 cm, secundarios a fracturas expuestas graves o pseudoartrosis infectadas. Material y método: Se realizó un estudio descriptivo de tipo serie de casos, retrospectivo, de los 14 pacientes tratados entre abril del 2011 y abril del 2015, con las lesiones o secuelas mencionadas en diferentes centro de Montevideo. Resultados: Todos los pacientes tenían secuelas a fracturas expuestas graves con defecto segmentario de tibia mayor a 4 cm. El seguimiento promedio fue de 13 meses (entre 6 y 27). La media de edad fue de 32 años (entre 15 y 53), la perdida ósea promedio 6,7 cm (entre 4 y 11), la velocidad de distracción de 0,58 mm/día, el período de distracción promedio fue de 92 días (entre 35 y 172), y el tiempo medio de fijadores externos desde el inicio fue de 194 días. Todos los pacientes requirieron algún procedimiento quirúrgico en el sitio de acoplamiento. Se logró la consolidación en 9 pacientes, hubo 2 pseudoartrosis, 2 pacientes abandonaron el tratamiento y uno decidió la amputación. No hubo ninguna recidiva de infección. Conclusión: La técnica de transportación ósea mediante el uso de fijadores externos AO, es una alternativa válida para el tratamiento de las perdidas óseas diafisarias de tibia con o sin infección.

Introduction: Bone transport is the slow transportation of the bone fragment along a bone defect, providing distraction osteogenesis. Objective: To describe the surgical technique of bone transport using the AO external fixator and to present the result of this procedure in tibial diafisis defects of more than 4 cm long, which were the result of severe open fractures or infected no unions. Material and Methods: This is a retrospective, descriptive study of 14 patients treated in several centers in Montevideo from April 2011 to April 2015. Results: The average age of the patients was 32 years (15-32), the average bone loss 6,7 cm (4-11), the distraction speed 0,58 mm/day, the mean distraction period 92 days (35-172) and the mean time external fixation was 194 days. The mean follow up was 13 months (6-27). All patients needed an additional surgical procedure in the docking site. Bone healing was accomplished in 9 patients and there were 2 no unions. There were 2 further patients who abandoned the treatment and another patient who requested amputation. At the latest follow up there was no recurrence of infection. Conclusion: Bone transport using AO external fixator, is a valid alternative for the treatment of segmental bone loss of the diafisis of the tibia with or without infection.

Introdução: O transporte ósseo é o transporte lento do fragmento ósseo ao longo de um defeito ósseo, que proporciona distração osteogênica. Objetivo: Descrever a técnica cirúrgica de transporte de osso, utilizando o fixador externo AO e apresentar o resultado deste procedimento nos defeitos da diáfise da tíbia de mais de 4 cm de comprimento, que foram um resultado de fracturas expostas graves ou ausência de juntas infectados. Material e métodos: Trata-se de um estudo descritivo e retrospectivo de 14 pacientes atendidos em diversos centros de Montevidéu no período de abril de 2011 a abril de 2015. Resultados: A idade média dos pacientes era de 32 anos (15-32), a 6,7 cm perda óssea média (4-11), a taxa de distracção 0,58 milímetros/dia, período médio de 92 dias distracção (35-172) e o tempo médio de fixação externa foi de 194 dias. O seguimento médio foi de 13 meses (6-27). Todos os pacientes precisaram de um procedimento cirúrgico adicional no local de encaixe. A cicatrização óssea foi realizada em 9 pacientes e não houve 2 articulações. Houve mais 2 pacientes que abandonaram o tratamento e outro paciente que solicitou a amputação. No último seguimento, não houve recidiva da infecção. Conclusão: O transporte ósseo utilizando o fixador externo AO é uma alternativa válida para o tratamento da perda óssea segmentar da diáfise da tíbia com ou sem infecção.

Injerto óseo vascularizado pediculado del radio distal para tratar la seudoartrosis recalcitrante del cúbito / Vascularized bone graft of the distal radius for recalcitrant ulnar pseudoarthrosis

Introducción: El objetivo de este trabajo es presentar los resultados clínicos y radiológicos de una serie de pacientes tratados con injerto óseo vascularizado pediculado del radio distal para seudoartrosis recalcitrantes de cúbito diafisario o proximal. Materiales y Métodos: Se realizó un estudio retrospectivo que incluyó a pacientes con seudoartrosis del cúbito diafisario o proximal con defectos <6 cm y, al menos, tres cirugías previas y un seguimiento mínimo de dos años tratados con injerto óseo vascularizado pediculado del radio distal. Se registró la cantidad de cirugías previas. Se evaluaron el rango de movilidad del codo y la muñeca, la fuerza de puño comparativa, el dolor mediante la escala analógica visual, el cuestionario QuickDASH y el puntaje de la Clínica Mayo para codo. Resultados: Se incluyó a siete pacientes. La edad media fue de 42 años (rango 26-64). El número promedio de cirugías previas fue 4 (rango 3-7). El seguimiento medio fue de 31 meses (rango 24-43). Todas las seudoartrosis consolidaron. El puntaje de la Clínica Mayo fue bueno en 4 pacientes, excelente en 2 pacientes y moderado en uno. El puntaje QuickDASH posoperatorio promedio fue de 13 (rango 0-29). El arco de flexo-extensión de la muñeca fue del 81% del contralateral. El rango de movilidad del codo fue >100° en 5 pacientes y de 50°-100° en 2 pacientes. Conclusión: El injerto óseo vascularizado pediculado del radio distal es una alternativa eficaz para el tratamiento de la seudoartrosis del cúbito. Nivel de Evidencia: IV

Introduction: The purpose of this study was to analyze the clinical and radiological outcomes of a series of patients treated with pedicled distal radius vascularized bone graft for recalcitrant ulnar nonunions. Methods: A retrospective study was performed. The inclusion criteria were patients with diaphyseal or proximal ulnar nonunions with bone defects <6 cm, at least three previous surgeries and a minimum follow-up of 2 years, treated with pedicled vascularized bone graft of distal radius. The number of previous surgeries was recorded. Elbow and wrist range of motion, comparative grip strength, and pain using the Visual Analogue Scale, QuickDASH questionnaire and Mayo Clinic score for elbow were evaluated. Results: Seven patients were included. The mean age was 42 years (range 26-64). The average number of previous surgeries was 4 (range 3-7). The mean follow-up was 31 months (range 24-43). All pseudoarthrosis consolidated. The Mayo Clinic score was good in 4 patients, excellent in 2 patients and moderate in one patient. The mean postoperative Quick- DASH score was 13 (range 0-29). Flexion-extension arch of the wrist was 81% of the contralateral. The elbow range of motion was >100° in 5 patients and 50°- 100° in 2 patients. Conclusion: The pedicled vascularized bone graft of the distal radius is an effective alternative for the treatment of recalcitrant ulnar nonunions. Level of Evidence: IV

Resultados de la utilización de aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos / Outcomes of cryopreserved allograft in long bones fractures and nonunions

Introducción: El objetivo de este trabajo es evaluar las indicaciones y la incorporación del aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos. Materiales y Métodos: Estudio retrospectivo, 20 pacientes tratados entre 2005 y 2011, 7 fracturas y 14 consolidaciones fallidas de huesos largos en los que se utilizó aloinjerto óseo criopreservado (un paciente con compromiso bilateral de fémur), 11 asociados a autoinjerto. Edad promedio: 45.2 años (rango 19-74). Diez mujeres y 10 hombres. Defectos óseos clasificados en circunferenciales y no circunferenciales. Resultados: La consolidación luego del uso de aloinjerto molido de Banco se logró en 14 casos tras un promedio de 8 meses (rango 4-18); de los 7 restantes, se logró la consolidación luego de cirugías de revisión en 5 casos, uno permaneció sin consolidación y, en otro, se amputó el miembro. Conclusiones: El autoinjerto sigue siendo el patrón de referencia en la reconstrucción de defectos óseos. Los nuevos sistemas de extracción de autoinjertos, como el fresado con irrigación/aspiración (RIA, Synthes) han llevado a que el uso de aloinjerto en fracturas sea poco frecuente. Pero, en los pacientes de nuestra serie, con múltiples cirugías, defectos óseos o trastornos psiquiátricos graves, el aloinjerto óseo crioconservado aislado o asociado a autoinjerto permitió obtener buenos resultados (18 casos consolidaron), aunque 5 casos requirieron cirugías de revisión.

Background: The aim of this study was to evaluate the indications and incorporation of cryopreserved allograft in long bone fractures and nonunions. Methods: Retrospective study of 20 patients treated between 2005 and 2011, with 7 fractures and 14 long bones nonunions in which cryopreserved allograft bone was used (one patient had bilateral femoral involvement), associated with autograft in 11 cases. Average age 45.2 years (range 19 to 74). Ten women and ten men. Bone defects were classified according to whether they were circumferential or not. Results: Bony union after using morcellized allograft was achieved in 14 cases, after an average of 8 months (range 4 to 18), among the remaining 7 cases union was achieved after revision surgery in 5 cases, another case did not achieve consolidation, and an amputation was performed in another patient. Conclusions: Bone autograft remains the gold standard in bone defect reconstructions. Using new extraction systems for autografts, such as reamed irrigation/aspiration (RIA, Synthes) has made the use of allograft in fractures infrequent. In our patients with multiple surgeries, bone defects or severe psychiatric disorders, the use of isolated cryopreserved allograft or associated with bone autograft obtained good results (18 cases with consolidation), although 5 patients required revision surgeries.

Management of Infected Non-Union by Implant Retainment and Papineau Open Bone Grafting – Report of Two Cases.

Introduction : Infection following implant surgery in orthopaedics is a disaster both for surgeon and patient. Management of infected non-union is a most challenging task an orthopaedic surgeon can ever face. Infection following implant surgery not only leads to repeated surgeries, long term antibiotic use, stiffness of neighbouring joints and long term hospital stay but also effects patients economic, social, psychological status. Cases : Here we present report of 2 cases infected non-union ulna which was managed by stabilisation of non-union site by altering position of existing plate followed by period of open dressing till healthy granulation tissue appears. Later open bone grafting procedure done. Both patients were followed up for 15 months. Results : At the end of 4 months both patients achieved bony union without recurrence of infection. So, we conclude management of infected nonunions by altering plate position and by following papineau method of open bone grafting leads to satisfactory results. Conclusion : This technique is simple, effective and done with minimal expenditure and could be best procedure of choice in patients where cost benefit analysis appears critical.

Rescate de clavos endomedulares mediante estabilización con placas / Intramedullary nail rescue with plate stabilization

Introducción: La seudoartrosis de fémur es una complicación poco frecuente luego del enclavado endomedular. Existe controversia sobre el tratamiento que genera mejores resultados luego de esta complicación. En casos específicos, las no uniones femorales pueden ser correctamente tratadas mediante estabilización con placas sobre el clavo endomedular previo. Materiales y Métodos: Estudio retrospectivo de 16 seudoartrosis diafisarias (12 atróficas, 4 hipertróficas), asépticas de fémur tratadas inicialmente con clavo endomedular. Abordaje lateral de fémur para la osteosíntesis con placa. En todos los casos, se conservó el clavo endomedular colocado antes. En 12 pacientes, se realizó descorticación en el foco de no unión con colocación de injerto óseo autólogo; en 3 de ellos, se colocaron también factores de crecimiento. En 4 pacientes, se colocó la placa sin el agregado de injerto. Resultados: Todas consolidaron en 5,3 meses promedio desde la osteosíntesis con placa, sin cirugías adicionales. Un paciente sufrió una infección posquirúrgica que se curó con tratamiento antibiótico oral. Conclusiones: El cambio de clavo endomedular es el método de elección para la mayoría de las seudoartrosis diafisarias, asépticas de fémur, pero es más complejo de realizar en seudoartrosis metafisarias, en seudoartrosis atróficas con importante defecto óseo y cuando el clavo colocado previamente es el de mayor diámetro posible. La placa proporciona compresión y estabilidad del foco de fractura, y resulta una buena alternativa para tratar esta complicación. Recomendamos mínimo desbridamiento de partes blandas y descorticación que se limite sólo al foco de la no unión...

Background: Femoral nonunion is a rare complication after intramedullary nailing. There is controversy about the best treatment option. In specific cases, femoral nonunions can be successfully treated by stabilization with plates over an intramedullary nail. Methods: Retrospective review of 16 femur nonunions previously treated with intramedullary nails (12 atrophic, 4 hypertrophic). Lateral approach was used for plate fixation. Previous intramedullary nail was maintained in all cases. Twelve patients underwent osteoperiosteal decortication and autologous bone graft; in 3 of them platelet growth factors were added. In 4 hypertrophic nonunions, no bone graft was added to plate osteosynthesis. Results: Average healing time was 5.3 months after plate fixation. No additional surgeries were needed. One patient suffered a superficial wound infection successfully treated with oral antibiotics. Conclusions: Exchange of intramedullary nail is the method of choice for most aseptic nonunions of femoral diaphysis, but this technique is more demanding in metaphyseal nonunions, in atrophic nonunions with bone defects, and when the biggest intramedullary nail is already in place. Plate provides compression and stability to the fractures, being a good alternative to treat this complication. Minimal debridement of soft tissue and decortication limited to the nonunion is recommended...

Role of percutaneous autologous bone marrow grafting in non-union tibia

To evaluate the efficacy of percutaneous autologous bone marrow grafting in patients with tibial diaphyseal non-union. Descriptive case series. Orthopaedic Surgery Unit, Mardan Medical Complex Teaching Hospital, Bache Khan Medical College Mardan, from March 2011 to October 2012. Fifteen patients [mean age 41.6 year] with tibial non-union were treated with a single percutaneous autologous bone marrow injection. The bone marrow was aspirated from the anterior iliac crest and injected at fracture site. The procedure was carried out under general or spinal anesthesia. The patients were followed up after every four weeks and the rate of healing was assessed clinically as well as radiologically. Union Scale Score was used to assess the progress of union. A score of six or more was considered as sound union. Majority [73.3%, n=11] of the patients achieved a solid union after an average period of 14 weeks [range 12-20 weeks]. Four [26.6%] patients however could not achieve union. The average time duration between the procedure and injury was 37 weeks [range 36-40 weeks]. The average pre injection Union Scale Score was 2 [0-3]. The mean Union Scale Score at the end of study was 5.8 [0-7] and in united cases it was 6.4 [6-7]. Percutaneous autologous bone marrow injection provided an effective safe and easy bone grafting in non-union tibia

Plate augmentation for femoral non-union after intramedullary nailing

This study was conducted to evaluate the clinical results of femoral non-union after intramedullary nailing treated by plate augmentation with or without autogenous bone grafting. a prospective descriptive study from 2004 to 2007, conducted in Orthopaedic unit I, Bolan Medical Complex Hospital, Quetta. We have prospectively analyzed the results of augmentation plate fixation in the treatment of femoral non-union after Intramedullary nailing in 36 patients. The mean age of the patient was3 1.4 years, 34 patients were males' and 2 were females. Age range of the patients was 22 years to 58 years. In 7 patients showing atrophic non-unions, autogenous bone grafting was done. The mean follow up of our patients was 1 year [4-18 months] post-operatively. Solid union was achieved in 34 femoral non-unions, [94.4% union rate]. Two cases showed non-union, requiring further surgery. Plate augmentation is a useful treatment option in the management of non-union of femoral shaft fractures after intramedullary nailing

Seudoartrosis del extremo distal del humero: tratamiento quirurgico y resultados funcionales / Distal humerus nonunion. Surgical treatment and functional results

Introduccion: Se evaluaron retrospectivamente los resultados funcionales obtenidos luego del tratamiento quirurgico en 17 seudoartrosis del extremo distal del humero tratadas en un lapso de diez años. Materiales y metodos: La edad promedio fue de 41 años (rango, 19 a 73). El tiempo entre la lesion inicial y la cirugiade revision promedio 11 meses (rango, 3 a 21). Cuatro seudoartrosis presentaban infeccion activa. Los 17 pacientes tenían antecedentes de cirugias (rango, 1 a3). Las seudoartrosis fueron extraarticulares (8 casos),extraarticulares intracapsulares (4 casos) e intraarticulares (5 casos); ocho fueron atroficas, seis oligotroficas y tres hipertroficas. Se asocio artrolisis en seis casos. Los metodos de estabilización variaron de acuerdo con el tipo y la ubicación de la seudoartrosis. Se asocio autoinjerto oseo en 11 pacientes. Resultados: El seguimiento promedio fue de 22 meses (rango, 9 a 65). La amplitud de movimiento del codo promedio 98º (rango, 65º a 125º). Cinco pacientes no referian dolor en el ultimo control, en 11 casos el dolor era leve y en uno, moderado. El nervio cubital debio ser transpuestoen forma secundaria en tres pacientes. Conclusiones: Si bien es un procedimiento demandante que en un elevado porcentaje de casos requiere cirugias secundarias (6 casos en esta serie), el tratamiento de estas lesiones mediante la planificacion preoperatoria detallada,el abordaje adecuado, la reducción a cielo abierto yla fijacion interna rigida, con la selección y colocacióne injerto oseo cuando es necesario, y la movilización posoperatoria precoz permiten obtener un elevado índice de consolidación y buenos resultados funcionales en pacientes activos.

Current perspectives in the management of scaphoid nonunions

When left untreated, scaphoid fractures follow a downward spiral resulting in carpal collapse and arthritis. The purpose of intervention is to allow a cartilage-wrapped bone to heal and maintain a smooth articular surface. Proposed treatment options for scaphoid nonunions have varied success rates. Using the Mack Lichtman classification for nonunions, a plan can be formulated for individual patients based on motion loss, degenerative changes, carpal collapse, and fracture instability manifested by bone loss. Stable nonunions may benefit from bone grafting and internal fixation. Unstable nonunions require grafting and fixation. With the development of arthritis, grafting and fixation must be weighed against suitability of a proximal row carpectomy or a four-corner fusion with scaphoid excision. Advanced carpal collapse and arthritis mandates fusion, either limited or complete. CT allows preoperative planning to assess grafting requirements. MRI defines vascular supply if a vascular graft is considered. Vascularized graft options have multiplied as attention has been focused on the impact of improved blood supply on the avascular scaphoid. Patient- and fracturespecific factors are important considerations when determining surgical options; underestimating their importance can compromise surgical results even with a high level of technical skill. Successful treatment of scaphoid nonunions remains a difficult challenge despite improvement in fixation devices and surgical options. By regarding injury status, together with patient factors, surgical options can be narrowed and patient expectations managed more realistically

Volar vascularized graft from the distal radius in management of ununited scaphoid fractures

Scaphoid fracture nonunions often present a therapeutic challenge. This is because the vascular supply of the scaphoid renders the proximal pole in many of these fractures avascular. Recently, vascularized bone grafts for the scaphoid have gained increasing popularity and many methods have been described based on different pedicles aiming to achieve union in these difficult nonunions associated with proximal pole diminished vascularity. In this study, a vascularizsed bone graft from the volar aspect of the distal radius based on the radial portion of the palmar carpal arterial arch was used to treat scaphoid nonunion. Between 1999 and 2004, 31 cases of ununited fractures of the scaphoid were managed by using a vascularized bone graft from the volar aspect of the distal radius and internal fixation using Herbert screws with or without an additional K-wire to hold the graft. There were 29 males and 7 females with a mean age of 31 years [18-46]. Nineteen fractures were associated with DISI. The mean follow up duration was 19 months [11-31]. Bone union was achieved in all patients in an average of 13 weeks [9-20]. There were 13 excellent, 9 good, 8 fair and 1 poor result had it corrected in the postoperative X-ray. Vasculariszed graft from the volar aspect of the distal Radius was found to be a reliable source of bone grafting with the advantage of being simple to harvest with little or no donor site morbidity and associated with a high union rate as well as other advantages as allowing simultaneous correction of humpback deformity and DISI

Treatment of ununited fracture scaphoid using pronator quadrataus musclue pedicle bone graft

The aim of this work is to asses the use of Pedicle bone graft using a segment of the pronator quadratus in treatment of 14 cases of ununited fracture of scaphoid. Fourteen cases of ununited fracture of scaphoid with a mean delay of 13 months from the initial injury were treated by a pedicle bone graft using a segment of the pronator quadratus. The non-union was located at the waist in 7 cases, at the junction between the middle and proximal third in 6 cases and at the junction between the middle and distal thirds in 1 case. The mean follow up was 8 [range 5-13] months. The intrinsic blood supply of the graft used and the regeneration power of the osteogenic cells in the periosteum of pedicle probably contribute to this high success rate of union. The single surgical approach, its suitability for regional anesthesia, the ease of dissection of the graft, the lack of donor site morbidity are advantages of the technique employed in this series

Results of using inverted tibial nail in management of distal third femoral fractures

To evaluate the use of tibial nail in fixation of distal third fractures of femur in cases of fresh fractures, cases of non united fractures and cases of peri-prosthetic fracture of total knee replacement and to assess the union rate and the return to functional activity . Thirty patients were included in this study:-Eighteen cases [60%] fresh supracondylar fractures without intercondylar extension of these there were 2 cases segmental fracture of femur.-Eleven cases [36.7%] nonunited fracture distal femur of them 4 cases after fixation with dynamic condylar screw, 4 cases after fixation with femoral condylar buttress plate, one case after external fixator for open fracture distal femur and 2 cases non union after conservative management with cast only.- One case[3.3%] after periprosthetic fracture around total knee replacement . The age of patients ranged from 32 to 76 years, male to female 19 : 11 .The study was carried out at Saudi German Hospital A seer in the period between March 2003 and June 2005 with follow up ranged from 6 months to two years . The tibial nail was used in an inverted position as a tool of fixation of these fractures via transpatellar approach in 19 cases [63.3%], medial parapatellar approach in 3 cases [10%] and lateral approach 8 cases [26.7%] The patients were assessed according to union rate, return to functional activity and knee range of motion . In this study Schatzker and Lambert [1979] scoring system was used .The result was excellent in 25 cases [83.4%] with full range of motion, union of fracture between 10 to 16 weeks and return to sedentary functional activity within 5weeks postoperative . Three cases [10%] the ROM was limited ; one of them following periprosthetic fracture where the ROM was only 90 degrees pre-fracture but fully united within 12 months and the other 2 cases due to lack of cooperation with physiotherapist . One case [3.3%] of infection and one case [3.3%] of delayed union which necessitated re-exposure and bone grafting . The use of inverted tibial nail in fixation of distal femoral fractures is an excellent choice which can be used instead of supracondylar femoral nailing in low economic countries and when it is not available, and can be used with a relatively excellent results instead of condylar and dynamic condylar buttress plate with early return to weight bearing and func-tional activities . The only disadvantages is the arthrotomy of knee joint with subsequent arthroflbrosis which can be overcomed with trans patellar approach and early ROM ex-ercises from first day postoperative

IIizarov distraction compression technique for treatment of infected non union of the tibia

the aim of this work is to assess the results of treatment of infected non united tibia with a segmental defect using the Ilizarov distraction compression technique. Ilizarov method was performed on thirteen patients with infected non-united tibia with segmental bone defect. The average follow-up period was 2.7 years with a minimum of two years. All the tibial defects were the results of severe open fractures [Gustilo grade II or III]. The bone defects ranged in length from 3-8 cm [average = 4.7]. The patients had an average of 3.2 procedures and an average delay of 33 months before this treatment. All the patients had one level tibial transport. At the docking site, all cases underwent cancellous bone auto-grafting. The operation was successful in achieving fracture union in 12 cases, with an average time to union of 8.5 months. Residual ankle stiffness was found in 5 patients, but all 12 patients were ambulatory without aid at the end of follow-up. this procedure is successful in treating these difficult cases and bone grafting is recommended at the docking site to shorten the duration of treatment and to enhance union

Surgical management of non-union of humeral diaphyseal fracture

To evaluate results of operative management of established non-union of humeral diaphysis with Dynamic compression plating [DCP] and Rush pinning with cancellous bone graft. Hospital based prospective study. Conducted at Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi. A total of 21 patients of established un-united humeral diaphyseal fracture, between 15 to 65 years were included in this study. Patients underwent DCP and Rush pinning with bone grafting. Union of fractures clinico-radiographically and functional outcomes with Modified Constant and Murley Scale for shoulder and range of motion for elbow were considered. Among 18 available patients, 14/18 nonunion [77.8%] united within 5.1 +/- 1.8 months. For DCP group 11/13 [84.6%] united in 4.45 +/- 0.96 months. For Rush pin group 3/5 [60%] united in 7.7 +/- 2.1 month [P< 0.001]. Modified Constant and Murley Scale for shoulder assessment, for DCP group, excellent 05, good 03, fair for 03, poor 02 and for Rush pin group excellent 00, good 00, fair 02 and poor 03. Average range of motion of elbow joint 71.7 +/- 15.3% to 82.7 +/- 16.0%. Persistent non-union in four, radial nerve palsy in one, implant failure in two and shoulder impingement in one case noticed. No severe deep infection occurred. Dynamic compression platting with bone graft has shown significantly higher union rate for non-union of humeral diaphysis, while the functional outcome regarding shoulder [P<0.03] and elbow movements [P<0.05] are also proved to be significantly better in DPT as compared to Rush pin

Treatment of non-union and pseudo - arthrosis with iLizarov external fixator

In this work, the results of the treatment of 15 cases with different nonunion and pseudoarthrosis treated with the Ilizarov ring fixator in the period between 1997 and 2001 were reviewed. The pseudoarthrosis was congenital in five patients, infected nonunion in four patients and clean in six patients. All nonunion cases were united,except for two cases and the overall results were good in 80% of the cases

Interlocking nailing and reaming for nonunion of the femoral shaft

Twenty-four consecutive patients with a diagnosis of nonunion of the femoral shaft from 1998 to 2004 were managed by intramedullary reaming and interlocking nailing Adequate follow-up study was obtained in all patients; all but three showed radiologic union at an average of 24 weeks following the procedure, with an overall union rate of 87.5%. The three patients whose fractures failed to consolidate with this treatment had reoperation with simultaneous dynamization and bone grafting. This resulted in healing in 2 of the 3 cases. We concluded that intramedullary nailing with reaming is the optimal treatment for the patient with aseptic nonunion of the femoral shaft If faced with failure to consolidate with this treatment, bone grafting in situ or closed reamed exchange nailing would be prefered instead of dynamization which might result in unacceptable shortening or hardware failure

New implant and technique for valgus osteotomy with dynamic osteotomy plate

With the increased rate of orthopedic trauma especially proximal femur, neck femur fractures, non-union, malunion and hip osteoarthritis; and the increased production of instrumentation, we designed a new implant for valgus osteotomy with dynamic osteotomy plate. This implant overcomes a lot disadvantages occurred with the other implants. The aim of this work is to present this implant and its results in treating union problems [nonunion and malunion] in proximal femur and neck femur fractures. 30 patients with different hip problems were included in this study. From April 2000 to May 2005. 12 females and 18 males. Their age ranged from 21 to 68 years old. All patients submitted to a period of follow up [x-rays and clinical evaluation]. This study reported a significant results in early union, correction of the deformity and good hip range of movement with the use of the valgus osteotomy dynamic plate. In conclusion there is a marvelous results and better outcomes with use of this implant. This paper had been presented in: The 1st SGH group international orthopedic conference Riyadh, KSA in sept. 2002. The annual international congress of the EOA in nov. 2001 Heliopolis Sheraton Cairo Egypt. And the author was awarded

Biological fixation of complex fractures of tibia and femur with the use of standard plates and specially designed plates

Tibial and femoral fractures of high velocity injuries are managed in our department following principles of internal fixator with high rate of union, good surgical outcome regarding alignment, reduction and function with specially constructed plate making the reconstructive interlocking system of little interest. The radiological follow up shows earlier union with callus formation. The technique is simple and percutaneous under x-ray control. In late follow up there is preservation of the anatomy and respect of subtrochantric region. The number of cases is increasing now almost over a period of time of 5 years including different types of femoral and tibial fractures fresh and old and as we gained more experience we had extended the indications of biological fixation to include cases with mal and non-union. This paper had been presented,discussed and accepted in: The annual international congress of the EOA in december 2003 Mena House, Cairo, Egypt. And the author was awarded