Shepherd's crook deformity: How to set it straight. A five-step surgical guide.

PURPOSE: Fibrous dysplasia (FD) of the proximal femur can result in severe deformity and disability. The results of surgical management in such situations have been reported to be poor. We present a novel, five-step surgical treatment to correct proximal femoral deformity in FD. MATERIAL AND METHODS: This study is a review of prospectively collected data of cases of proximal femur polyostotic FD managed at our institute from 2012 onward. We managed three patients with FD involving four femora (one patient had bilateral disease). Mean age at presentation was 16 years with an average follow-up of 46 months. All underwent five steps, that is, (1) curettage/excision of the lesion, (2) allograft in intramedullary region, (3) lateral closing wedge valgus osteotomy, (4) fixation with extramedullary implant, and (5) augmentation of osteotomy site with autograft. Functional outcome was assessed using Harris Hip Score preoperatively and at the final follow-up. RESULTS: The neck shaft angle was corrected from an average of 91.7° to 152.1°, while the Harris Hip Score improved from an average of 59 to 95. There was no clinical or radiological evidence of recurrence of disease or deformity in any patient till the last follow-up. CONCLUSION: This five-step technique ensures good functional and radiological outcomes in the management of proximal femur FD.

Is Anterior Bridge Plating for Mid-Shaft Humeral Fractures a Suitable Option for Patients Predominantly Involved in Overhead Activities? A Functional Outcome Study in Athletes and Manual Laborers.

BACKGROUND: To assess the functional and radiological outcomes of minimally invasive anterior bridge plating (ABP) for mid-shaft humerus fractures in patients predominantly involved in overhead activities (athletes and manual laborers). METHODS: Forty-eight patients fulfilling inclusion criteria were treated with ABP at a level-I trauma center using a 4.5-mm dynamic/locking compression plate and followed for a period of 1 year. Functional outcome was assessed using the Constant, Mayo elbow, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Range of motion (ROM), subjective strength, and radiographic union were assessed. A general satisfaction questionnaire was also administered. RESULTS: Most patients achieved excellent functional and radiological outcomes. ROM and strength of the shoulder girdle exhibited clinically nonsignificant loss as compared to the opposite side. The mean time for return to the original activities was 64 days (range, 36 to 182 days) and the mean time for confirmed radiographic union was 45 days (range, 34 to 180 days). The mean Constant, Mayo elbow, DASH scores were 95.73 ± 5.76 (range, 79 to 100), 95.94 ± 6.74 (range, 85 to 100), and 1.56 ± 3.15 (range, 0.0 to 14.0), respectively. The majority of patients (43 patients, 89.6%) who fell in the excellent or very good category according to our questionnaire were extremely satisfied. There were 2 cases (4.17%) of nonunion and 3 patients (6.25%) had to change/modify their original occupation. CONCLUSIONS: ABP is fundamentally different from traditional open posterior plating or conventional intramedullary nailing. It gives relative stability with union taking place by callus formation, and a longer plate on the tensile surface ensures that the humerus can withstand greater amount of rotational and bending stresses. The minimally invasive nature causes minimal soft tissue damage and, if done correctly, causes no damage to the vital structures in proximity. ABP for mid-shaft humerus fractures in patients predominantly engaged in overhead activities is a safe and effective treatment modality yielding high rates of union, excellent functional recovery, minimal biological disruption, better cosmesis, and superior satisfaction rates.