Management of pilon fractures

To clarify which factors influence the final result of surgical management of plafond or pilon fractures, thirty two pilon fractures in 32 patients were treated by open reduction and internal fixation using low profile plates. C.T was obtained before definitive surgery. Management was based on the degree of soft tissue compromise and the type of pilon fracture. Nine patients with Tscherne Grades 0 and l closed injuries underwent immediate open reduction and internal fixation. Seventeen patients with Tscherne Grades II and III underwent temporary stabilization either by splint or calcanean traction for an average duration 13 days before surgery. Four patients presented with open injuries and two patients presented with compartment syndrome, they underwent irrigation, deperidment and fasciotomy then a two pin external fixator was applied for an average 20 days before surgery. Clinical and radiographic evaluations were performed at an average twenty six months after surgery. The radiological score of quality of reduction was anatomic in twenty two cases [68.75%], good in five cases [15.62%], fair in four cases [12.5%] and poor in one case [3.12%]. The clinical outcome was excellent in eighteen cases [56.25%], good in seven cases [21.87%], fair in 5 cases [15.62%] and poor in two cases [6.25%]. There was no iatrogenic injury to the neurovascular bundle. Superficial wound edge necrosis was noted in three cases which healed later without further procedure. Two cases developed deep venous thrombosis. two cases showed delayed union one case of nonunion. No deep infection, or systemic sepsis was ported. Open reduction and stable internal fixation through postero-medial-anterior approach for pilon fractures can ensure anatomic restoration of the articular surface of the distal tibia and early motion of the ankle joint

External fixation for pelvic ring disruptions anatomical and functional outcomes

Unstable pelvic ring disruptions are often associated with significant morbidity and mortality specially in patients with multiple injuries . stabilization of the pelvic ring by external fixator helps to control haemorrhage and allows comfortable mobility of the patient. Thirty five patients were treated by pelvic external fixator for their unstable pelvic injuries, but the analysis of the results included only 26 cases .Open technique for pin placement was used in seventeen cases, while the closed technique was used in nine cases. The fixator pins were inserted into the iliac crest between the iliac cortical tables to a depth of 5 cm . All patients had closed manipulative reduction of the pelvic ring under image control. The average hospitalization period was 16 days for the patients with isolated pelvic injuries. The average hospitalization for all patients was 37 days .Evalualution of the anatomical results depended on the diastasis of the symphysis pubis and proximal migration of the hemipelvis. The satisfactory anatomical results were 57.4% .The functional results were assessed by a numerical scoring system [Majeed 1989] . The satisfactory functional results were 65.38%. The complications were mainly related to the pins of the fixator . These complications were lower for the pins inserted by closed technique . There were two cases of delayed union due to imperfect reduction. External fixation for pelvic ring disruption is a safe simple method .It is suitable for all cases of pelvic ring injuries those are rotationally unstable but vertically stable

Lumbar interlaminar microdiscectomy

The primary rationale lor surgery for disc prolapse is to relieve nerve root irritation or compression due to herniaied disc material. From 1997 to 1999; a total of 47 patients had microdiscectomy through an interlaminar approach for lumbar disc herniation, 27 men and 20 women, had a mean age of 42 years. The procedure was performed under surgical microscope. Clinical outcome and patient satisfaction were assessed at an average follow-up of 12.5 months. The results showed 83% excellent, 13% good, 2% fair, and 2% poor outcome. Microsurgical discectomy has significant shorter operative time [p =0.001] and significant reduction in back and leg pain [p =0.0001]. There were also a significant improvement of function, spinal range of motion, tension signs and sensation [p=0,0001], Although the rate of satisfactory outcomes was approximately the same in both microscopic discectomy and the standard procedure mentioned in previous literatures, microdiscectomy had a shorter duration of postoperative disability and used medications. The use of the microscope can facilitate the operation and give a better visual comfort. Moreover, the surgeon must be familiar with this technique and must have received training in its use

Posterior lumbar interbody fusion with peek cage in spondylolysis and spondylolisthesis

Posterior lumbar interbody fusion [PLIF] is now considered to be the golden standard for lumbar instability caused by spondylolysis or spondylolisthesis. PLIF has many limitations because of the technical difficulties, complications and the gained postoperative increase of the disc height tends to return to preoperative level. The use of poly-ether-ether ketone cage for posterior lumbar interbody fusion is technically less difficult with minimal complications. Twelve patients; ten were female and two male; with spondylolysis and spondylolisthesis of different causes were treated by PEEK interbody cage and interpedicular fixation with or without posterolateral fusion. Age of the patients ranged from 38 to 62 years [mean 50 years]. The patients were followed for a mean 1 year duration and were evaluated both clinically and radiologically. All twelve patients were improved clinically except two patients had partial improvement with occasional and temporary back pain due to causes other than cage complications

reappraisal of the role of the cross-leg flap

This study includes twenty patients treated by [cross-leg] flaps. The indication for operation was chronic traumatic ulcer in 15 cases, scarring and deformity in two cases; irradiation dermatitis with ulceration, post-burn ulcer and vulnerable scar in one case each. There were 17 excellent results [85%] where the flap had completely taken with no loss whatsoever nor ulceration. Postoperative oedema of the flap occurred in 3 of these patients, who had not followed instruction, but was cured in all. Two of the cases required defattening before the outcome could be labeled [excellent]. A [very good] result occurred in 3 cases [15%]. In these 3 patients an excellent result could have been achieved with greater attention to detail. Four cases are reported and 3 of these are taken to illustrate the fact that there may be no other alternative to the [cross-leg] flap. The [cross-leg] flap should therefore retain its place in the surgeon's armamentarium