Arthroscopic treatment of acromioclavicualr joint arthritis, a modified approach in the distal clavicle excision with preservation of the superior A.C.J ligament

The acromioclavicular [AC] joint arthritis is a common and sometimes under-looked source of shoulder problems. The procedure of subacromial decompression with distal clavicular end resection [either open or arthroscopic] was the usual treatment proposed. With the increasing popular usage of this technique, some failure rates were reported after either open or arthroscopic techniques. This was attributed to Inadequate resection, or partial ACJ instability due to injury or resection of the superior ligament during the ACJ resection, and underlying muscle injury due to lack of experience or difficult portals handling. Our Aim was to assess the results of arthoscopic management of A.C.J arthritis, by distal clavicle resection using a modified arthroscopic portals and technique. Thirty two patients were managed arthroscopicaly, after proper diagnosis of A.C arthritis. A modified arthroscopic approach through anterior working portal -instead of the classical anterosuperior portal-and posterior viewing portal were used with the resection of acromial side [osteophytes] preceding the clavicular side instead of resection the clavicular side directly. This approach brings better handling of the joint and easier in preserving the superior AC ligament as widening of the ACJ is less than 1.5cm from both acromial and clavicular ends. All patients were followed up for six months using the UCLA shoulder scale in analysis of the results. This modified approach proved successful results, and comparable with the classical anterosuperior, and posterosuperior approach, showed earlier recovery. In this series 90.6% of patients showed excellent results after an average of 3.7 months, while 6.4% of patients showed good results, and only 3% showed poor results. The Meticulous preoperative evaluation, and this modified approach using the anterior portal instead of the classical anterosuperior one, with the resection of less than 1.5cm of the clavicle, preserve the superior A.C ligament, and consequent the horizontal stability of the joint. Moreover the adequate subacromial decompression that may accomplish the procedure could be easier and better. Both- viewing and working at the joint using the modified portals decreased the long learning curve, and achieved better final results

Total hip arthroplasty after failed fixation of acetabular fracture

This study included eighteen patients, previously treated by open reduction and internal fixation of fracture acetabulum, who suffered from posttraumatic osteoarthrosis and /or avascular necrosis of the femoral head. They were treated by total hip arthroplasty through a posterior Kocher Langebeck approach. The mean age at the time of the acetabular fractures was 41.3 years and the mean age at the time of the total hip arthroplasty was 51.6 years. The average time from internal fixation of the acetabular fracture to the arthroplasty was 3.6 years .The exposure was difficult in eight patients due to extensive scarring and heterotopic bone ossification. Cup revisions were performed in two patients due to aseptic loosening. Two patients died postoperatively before dependable functional assessment. The mean Harris hip score improved from 46 to 92 in 16 out of 18 patients [P<0.001]. In general, total hip arthroplasty should be reserved for the salvage of hips in which symptomatic posttraumatic ostoearthrosis has developed after operative treatment of acetabular fractures

Locked compression plating of periprosthetic fracture of the femur after hip arthroplasty

Ten patients who sustained periprosthetic fracture of the femur after hip arthroplasty [two with total and eight with hemiarthroplasty] were treated by a locked Compression plate. Fractures were classified using the Vancouver classification system, as type B1 in seven patients and type C in three. Minimally invasive percutaneous osteosynthesis [MIPO] technique was used in six patients while formal open reduction was used in four patients. Nine patients out of ten achieved healing in a good alignment. In only one patient the fracture healed in 12 degrees varus. Inspite of these small number of cases, it can be concluded that the locked compression plating of certain types of periprosthetic femoral fractures is associated with a satisfactory clinical outcome and restoration of function

combination of dual bicortical onlay bone grafting and compression plating for atrophic humeral nonunion

This study was performed to evaluate the functional and radiological results of treatment of the established atrophic nonunited diaphyseal humerus fractures by the combination of compression plating and autogenous dual bicortical bone grafting, to determine whether a standardized treatment of aseptic humeral shaft nonunions results in union after one operation without substantial complications. Eleven adult patients [nine females and two males] who had been diagnosed as atrophic nonunion of humeral diaphyseal fractures were included in this study. All patients were treated by the same technique using compression plating and autogenous fixed dual bicortical bone grafting. The follow up period ranged from 12 to 18 months [average 15 months]. The functional outcome of the operative intervention was evaluated using the Stewart and Hundley [27] rating scale. Union of the fracture occurred in every case. The mean healing time was 18.6 [16-22] weeds. The range of motion of the shoulder and elbow was excellent in 8 patients, that of the shoulder moderate in 3, and, that of the elbow moderate in 2 and poor in 1. the overall functional results were excellent in 7 patients, good in 3 and fair in one case. When attempting to heal persistent nonunited fractures, multiple methods used simultaneously should be considered to increase the chance of success. Given the good functional results in this series, the combination of compression plating and dual onlay bicortical bone grafting appeared to be a good method for treating humeral shaft atrophic nonunions

Intramedullary versus extramedullary tibial resection in total knee replacement

This study was performed to compare the accuracy of intramedullary versus extramedullary tibial resection in 54 total knee arthroplasties. An intramedullary guide was used in 27 patients[group 1] and an extramedullary guide was used in another 27 patients [group 2]. Femorotibial angles were measured postoperatively with group 1 averaging 7.52-degree valgus in 25 out of 27 patients and 1.5-degree varus in 2 out of 27 patients. In group 2, the average femorotibial angles were 6.92-degree valgus in 26 out of 27 patients and 1.0-degree varus in one patient. The tibial component alignment angles averaged 89.78-degree varus in group I versus 90.85- valgus in group 2. However, 77.8% of the patients were aligned within the range of 7 +/- 2-degree valgus femorotibial angle in group 1 versus 62.96% in group 2

Antegrade intramedullary interlocking nailing versus plating for the treatment of humeral shaft fractures

This prospective r and omized study included 46 humeral shaft fractures managed by antegrade intramedullary interlocking nail [Group I] and compression plate [Group II] with 23 patients in each group. The mean age was 35.6 years in group I and 33.8 years in group II [p>0.05]. The mean blood loss was 145 ml in group I while it was 437 ml in group II [p<0.05]. The mean operative time was 66.7 minutes for group I and 88.2 minutes for group II [p<0.05]. the average time of union was 14.9 weeks for group I and 15.2 weeks for group II [p>0.05]. The UCLA shoulder rating scale was used for assessment of the shoulder function. In group I four patients had excellent results, 13 patients had good results and six patients had fair results, while in group II, 18 patients had excellent results and five patients had good results. The modified rating system of Morrey et al. was used for assessment of the elbow function. All patients in group I had excellent results while in group II 17 patients had excellent results and seven patients had good results

External Rotation Osteostomy of the proximal humerus for the management of residual brachial plexus birth injury [Erb's type] [Improvement of the shape improves the function]

This work performed a total of eleven proximal humeral astronomy in eleven patients with residual obstetric paralysis [Erb's type]. This study aimed at correction of their internal rotation deformity and restoration of some degree of lateral rotation with improving of both the limb function and cosmosis. The age of the patients ranged between 6 and 14 years, as the correction was not done in any patients below the school age. The right side was involved in eight patients. Nine patients did have physiotherapy either early after birth- for at least one year-or at a later stage, but intermittently. Four patients had previous surgery in the from of tendons release and transfer. Every patient should have been able to abduct his shoulder near to the 45 degrees and use his hand reasonably well. Yet, there was some sort of disability such as difficulties in feeding, washing due to fixed internal rotation deformity and limited abduction of the shoulder. Also, there should be no radiological signs of severe bony deformities either in the glenoid or the humerus, but some posterior subluxation in glenohumeral joint could be accepted. The amount of correction needed was determined before surgery on clinical examination in comparison to the other limb. The osteotomy distal was done to the surgical neck of the humerus and plate and screws were used to bold the osteotomy sites. The study reported full correction of the deformities aiming at excellent cosmetic results which satisfied every patients. The functional ability did improved a great deal in all of them as well with an increase in the arc of rotation by an average of 26.9 degrees [range 10 to 66 degrees] and with improved active abduction by an average of 20 degrees [range 8 to 48 degrees]

new four in one stabilizing operation for anterior recurrent dislocation of the shoulder joint

A preliminary study of a new surgical technique included eight male patients with recurrent anterior dislocation of the shoulder, all managed operatively after failure of the rehabilitation program. The new surgical technique included four main steps done in one operation, namely imbrication of the redundant capsule, anterior bone block by using the coracoid process, muscular dynamic buttress for anterior and inferior capsule and finally imbrication of the upper half and lower half of the subscapularis muscle. Our average age 27.88 years ranged from 22 - 40 years. All achieved satisfactory results [excellent to good]. Bony union of the transferred coracoid process has occurred in all patients. No recurrence of dislocation has happened after an average follow up period of 3.15years ranged from 8 months to 6 years