PyProtif: a PyMol plugin to retrieve and visualize protein motifs for structural studies.

Proteins often possess several motifs and the ones with similar motifs were found to have similar biochemical properties and thus related biological functions. Thereby, multiple databases were developed to store information on such motifs in proteins. For instance, PDBsum stores the results of Promotif's generated structural motifs and Pfam stores pre-computed patterns of functional domains. In addition to the fact that all this stored information is extremely useful, we can further augment its importance if we ought to integrate these motifs into visualization software. In this work, we have developed PyProtif, a plugin for the PyMOL molecular visualization program, which automatically retrieves protein structural and functional motifs from different databases and integrates them in PyMOL for visualization and analyses. Through an expendable menu and a user-friendly interface, the plugin grants the users the ability to study simultaneously multiple proteins and to select and manipulate each motif separately. Thus, this plugin will be of great interest for structural, evolutionary and classification studies of proteins.

Treatment of tibial shaft nonunion with a retained nail in morbidly obese patients.

PURPOSE: Morbid obesity is a rising worldwide health problem. Tibial shaft nonunion with retained intramedullary nail (IMN) in the morbidly obese is a challenging orthopaedic problem. Prolonged immobilization carries a significant risk of complications. This study aimed to investigate whether decortication and cancellous bone grafting with the application of a circular external fixator (CEF) over the preexisting IMN can achieve fracture union and avoid serious complications. METHODS: We retrospectively reviewed 27 consecutive morbidly obese patients treated for tibial diaphysis aseptic nonunion after failed IMN. All cases were treated with osteoperiosteal decortication, cancellous bone grafting, and fixation with CEF over the IMN. Peri-operative multidisciplinary patient evaluation included internal medicine, cardiology, chest, vascular surgery, and anesthesia consultations. The union rate, bone results, functional results, and complications were recorded. RESULTS: The mean age of the patients was 37.9 years. The mean BMI was 45.8. Sixteen cases (59.3%) were treated for hypertrophic nonunion, while 11 cases (40.7%) were treated for atrophic nonunion. Seven cases (25.9%) had open initial injury, 14 cases (51.9%) had associated comorbidities, and seven cases (25.9%) were smokers. Twenty-six cases united. The mean time to union was 5.2 months. Bone results and functional results were good to excellent in 96.3% of the cases. We recorded 25 complications in 21 patients. However, most of the complications were minor. CONCLUSION: Decortication and cancellous bone grafting with the application of CEF over the preexisting nail is a safe and reliable treatment method for aseptic tibial shaft nonunion with retained IMN in morbidly obese patients.

Tibial Tray with a Stem: Does It Have Any Role in Primary Cemented Total Knee Replacement?

Over many decades, total knee replacement (TKR) has become the ideal treatment option for advanced arthritis. Many designs were introduced to increase the stability of the tibial tray, hence the longevity of the prosthesis. This retrospective study was performed on 168 patients who received NexGen cemented primary total knee either with standard tibial tray (group A) or tibial tray with an intramedullary stem (group B) between May 2008 and May 2017. We reviewed all preoperative and postoperative clinical and radiological data retrospectively. In addition, a prospective clinical and radiological reassessment was done. Our aim was to answer the following questions: (1) Is there any difference between both groups in regard to clinical and radiological results? (2) Is there any difference in the revision rate? (3) Is there a role of using stemmed tibial tray in primary TKR? Better results were recorded in obese and severely obese patients having stemmed cemented tibial tray and so for patients with marked and severe preoperative varus angle. Our recommendations are to use cemented tibial tray with a stem in complicated primary surgery without fear of adverse effects on short and intermediate terms of follow-up.

Tibial shaft fractures in the adolescents: treatment outcomes and the risk factors for complications.

BACKGROUND: Tibial shaft fractures are common injuries in the adolescent age group. The optimal method of treatment in this age group is still controversial. It relies on several factors including patient's age, fracture pattern, fracture location, and the condition of the soft tissue envelope. The purpose of this study was to report the clinical and radiographic outcomes of adolescent tibial shaft fractures treatment at a level-I trauma center. METHODS: This retrospective study reviewed consecutive patients between 10 and 18 years of age who suffered from tibial shaft fractures between 2009 and 2018 at a level-I trauma center. Outcomes of interest were the successful fracture union (primary outcome) as evaluated by the Radiographic Union Scale in Tibial fractures (RUST) and the complications (secondary outcomes). RESULTS: Fifty-two consecutive adolescent patients treated for tibial shaft fractures using elastic stable intramedullary nails (ESIN), interlocking nails, plates and screws, external fixators, and casts were included in the study. The mean follow-up period was 27.4 months. There was no statistically significant difference in the union rate and time to fracture union between the different treatment methods. Subject weight, fracture type, and method of treatment were significant predictors for the RUST scores at 12 weeks post-operative. Adolescents with heavier bodyweight correlated with lower RUST scores (p<0.001). Open fractures were associated with significantly longer time to union (p<0.001) and lower RUST scores (p<0.001) compared to closed fractures. The patients treated with interlocking nailing showed higher RUST scores than the casting treatment group (p = 0.01). There were no statistically significant differences in complication rates between the fixation methods. Union time was significantly longer with complications than without complications (p = 0.01). Open fractures had higher complication rates compared to closed fractures. In the multivariate logistic model, patients with open fracture were 5.5 times more likely to have complications (OR=5.46; p = 0.04). CONCLUSION: Tibial shaft fractures in adolescents can be treated with several methods including ESIN, interlocking nail, plate and screws, external fixation, and casting. All are valid treatments for adolescent tibial shaft fractures and can achieve favorable outcomes. No single treatment method applies to all patients. Each method has advantages, disadvantages, and specific indications.

Outcomes and Complications With Treatment of Open Tibial Plafond Fractures With Circular External Fixator.

BACKGROUND: Open tibial plafond fractures (Orthopaedic Trauma Association and AO Foundation [OTA/AO] 43) are associated with severe complications, including deep infection (closed fractures, 20%; open fractures, 30%), amputation (3%-14%), and nonunion (up to 25%). Circular external fixators (CEFs) can minimize soft tissue injury. This study aimed to report the rate of union and occurrence of severe complications in patients with open tibial plafond fractures treated with CEFs. METHODS: A retrospective review of case series was conducted at 3 level I trauma centers. The study included patients older than 18 years with open tibial plafond fractures treated with CEFs. The reported outcomes included union rate, deep infection, operative complications, and limb alignment. The radiographic measurements of anatomic alignment were obtained. Fifty-two patients were included in the study. RESULTS: The primary union rate was 79%. No deep infection occurred in the majority (92%) of patients. No patient required amputation of the affected limb or free flap coverage. CONCLUSION: Definitive fixation of open tibial plafond fractures with CEFs avoided severe soft tissue complications but resulted in variation in final radiographic alignment. LEVEL OF EVIDENCE: Level IV, case series.

Early correction of malunited supracondylar humerus fractures in young children.

INTRODUCTION: Supracondylar fracture malunion usually results in cubitus varus deformity. The long-standing unsightly deformity causes psychological stress to the child and his/her parents in addition to biomechanical disturbances and functional disorders in the affected elbow. The optimal timing of corrective osteotomy is not well-established in the literature. The present study aimed to report the results of early correction of cubitus varus deformity using a simple technique and to focus on the timing of early correction after supracondylar fracture malunion. PATIENTS AND METHODS: Thirty consecutive patients treated for recent cubitus varus deformity after malunited supracondylar fractures, in the period between January 2012 and August 2017, were retrospectively reviewed. All patients had early surgical correction of the deformity within one year after the initial injury. In patients who presented with maluniting supracondylar fracture, the fracture was splinted until union was achieved, then active exercises were encouraged until elbow ROM was regained. The deformity was then corrected with a lateral closing wedge (LCW) osteotomy and fixed with two lateral and one medial wire. RESULTS: All the osteotomies united. All the deformities were corrected. The humerus-elbow-wrist (HEW) angle significantly improved compared to the pre-operative values (p<0.001). All patients achieved satisfactory results at the final evaluation. Twenty-six patients (86.7%) achieved excellent results while four patients (13.3%) achieved good results. CONCLUSION: Early correction of cubitus varus deformity avoids the psychological stress of the long-standing unsightly deformity to the young child and his/her family. It also avoids the delayed biomechanical and functional disturbances to the affected elbow. The LCW osteotomy and the three-wires fixation technique are simple and effective to correct the deformity and maintain the correction.

Modified technique for reconstructing reverse Hill-Sachs lesion in locked chronic posterior shoulder dislocation.

BACKGROUND: Among the uncommon and frequently missed orthopedics injuries is the posterior shoulder dislocation, accounting for about 2-4 % of all shoulder dislocations. Commonly, it is associated with the well-known reverse Hill-Sachs lesion. Several surgical treatment modalities such as transfer of subscapularis tendon or lesser tuberosity, humeral rotational osteotomy, osteochondral grafts were used to repair this defect. Hemiarthroplasty or total shoulder arthroplasty was used as salvage procedure in non-constructable defect or neglected old dislocation. PATIENTS AND METHODS: This study included 11 patients with locked chronic posterior shoulder dislocation and reverse Hill-Sachs defects falling in the target range (25-50 % of the head size). The mean age of the patients was 39 (range 31-49) years. Mean time from injury to surgery was 9 (range 3-18) weeks. Open reduction in the dislocated head with the transfer of subscapularis tendon and the attached lesser tuberosity was done to reconstruct the reverse Hill-Sachs defect. The transferred tuberosity was fixed with size 5 Ethibond sutures. RESULTS: The mean follow-up period was 29 (range 24-39) months. The median of the scores was much improved, reaching 30 (range 20-34) (satisfactory) compared with preoperative median of 24 (range 20-25) (unsatisfactory). This was statistically highly significant (P = 0.002). Postoperatively, 9 patients had no pain or restricted daily living activities. No patient had symptoms of shoulder instability. According to the modified UCLA shoulder rating scale, there were 4 patients rated excellent, 5 patients rated good, one patient rated fair and one patient rated poor. CONCLUSION: Reconstructing the reverse Hill-Sachs defect provides adequate stability, pain relief and function in patients with locked chronic posterior shoulder dislocation and a defect involving 25-50 % of the humeral head. The used technique is simple and cost effective with no need for subsequent hardware removal. LEVEL OF EVIDENCE: II.

Ilizarov distraction osteogenesis over the preexisting nail for treatment of nonunited femurs with significant shortening.

PURPOSE: Nonunion of the femur with significant shortening with retained intramedullary nail (IMN) is a challenging orthopedic problem. We investigated whether the application of Ilizarov distraction osteogenesis over the preexisting nail can simultaneously achieve union and correct shortening. METHODS: Thirteen patients with femoral diaphyseal nonunion associated with significant shortening with retained IMN were retrospectively reviewed. All patients were treated by distraction osteogenesis using a circular external fixator over the preexisting nail. The fixator was used to compress or distract the nonunion site and to gradually distract a separate osteotomy to restore limb length. The osteotomy was done percutaneously using the Gigli saw with the nail in situ. The applied surgical technique was bifocal compression distraction in 11 cases, bifocal distraction in one case, and monofocal distraction in one case. RESULTS: Bone healing was achieved in 11 cases (84.6 %) at both the nonunion and the lengthening sites. The mean length gained was 4 cm (range, 3-6 cm). The mean time to fracture union was 4.9 months (range, 4-6 months). The mean knee flexion improved from 86.5° (range, 40°-135°) preoperatively to 109.6° (range, 60°-125°) at final follow-up (p < 0.05). The mean limb-length discrepancy improved from 4.7 cm (range, 3-7.5) preoperatively to 0.7 cm (range, 0-3) at final follow-up (p < 0.001). Ten out of 13 patients had a total of 14 complications, with a mean of 1.1 complications per patient. CONCLUSIONS: Distraction osteogenesis over the preexisting nail can be a good alternative to treat difficult femoral diaphyseal nonunions associated with significant shortening.

Our experience in the management of segmental bone defects caused by gunshots.

PURPOSE: Bone and soft-tissue defects in the leg can be caused by high-energy trauma. One of the causes of extensive bone defects are gunshot injuries. The incidence of these has been noticeably increasing in recent years in countries with political instabilities due to the random availability of weapons. The aim of this study is to focus on the essentials of treatment of post-gunshot tibial bone loss using the Ilizarov concept. METHODS: In the period between June 2011 and July 2013, 30 patients with open tibial fractures after gunshots comprised the present study with an average follow-up of 18 months. The bone defect was associated with soft-tissue loss in 18 cases. All cases were subjected to extensive debridement of all devitalized tissues back to the healthy bone with viable soft tissue coverage. All cases were treated by the Ilizarov external fixator using the bifocal bone transport technique. RESULTS: The overall bone results were satisfactory in 28 cases (93.3 %). The overall functional results were satisfactory in 22 cases (73.3 %). The bone end results were significantly affected by age and smoking, while the functional end results were significantly affected by smoking, the presence of infection at the time of presentation, and complications during the procedure. CONCLUSIONS: Bone transport is a reliable method in the treatment of gunshot bone defects of the tibia after extensive debridement of all the devitalized tissues. The Ilizarov external fixator allows the functional use of the limb throughout the course of treatment, preventing disuse osteoporosis and increasing patient satisfaction.

Flexor hallucis longus tendon transfer in the reconstruction of extensive insertional Achilles tendinopathy in elderly: an improved technique.

BACKGROUND: Insertional Achilles tendinopathy is a degenerative disease associated with disabling posterior heel pain, gait dysfunction and significant morbidity. The aim of this prospective study was to evaluate the outcomes of complete excision of the pathological tendo-achilles segment in elderly patients with extensive involvement, and reconstructing the defect using a modified technique which was proposed to allow early weight-bearing and rehabilitation. PATIENTS AND METHODS: Thirteen patients (mean age 58.2 years) with extensive insertional Achilles tendinopathy (seven with spontaneous rupture and six without rupture) were operated between January 2008 and July 2012. The average tendon gap after debridement was 6.8 cm. All patients were reconstructed with flexor hallucis longus tendon transfer augmented with a modified turn-down flap. Patient's satisfaction was evaluated using the American orthopedic foot and ankle society (AOFAS)-ankle-hindfoot scale. RESULTS: The mean follow-up period was 24.5 months. The AOFAS scores improved from 57.5±8.44 preoperatively to 98.3±1.01 at final follow-up (p<0.001). Complete pain relieve was achieved in ten patients, while the other three had mild occasional pain. Eleven patients had excellent results, and two had good results. There was no single case of re-rupture, and two patients acquired superficial wound infection which was resolved conservatively. CONCLUSIONS: The modified technique provides a transfer with sufficient length and strength that can restore large tendo-achilles defects in elderly, and is stable enough to allow early protected weight-bearing and rehabilitation with favorable clinical result and minimal morbidity. Resection of all degenerated tendon tissue alleviates pain and improves function.