Triple management of cubitus valgus deformity complicating neglected nonunion of fractures of lateral humeral condyle in children: a case series.

BACKGROUND: Long standing nonunion of the lateral humeral condyle (LHC) usually results in elbow pain and instability with progressive cubitus valgus and tardy ulnar neuritis. Surgical treatment of long standing nonunion is still a controversial issue due to the reported complications, such as stiffness, loss of elbow motion, and avascular necrosis of the LHC fragment. In this study, we reported the outcomes of treatment of cubitus valgus deformity in long standing nonunion of the LHC in children treated with combined triple management (fixation of the nonunion site, dome corrective osteotomy, and anterior transposition of ulnar nerve) through a modified para-triceptal approach. METHODS: We evaluated ten patients with cubitus valgus deformity more than 20 degrees after neglected nonunion of the lateral humeral condyle more than 24 months. Only childern with post-operative follow up more than 24 months were included in this study. All patients were evaluated clinically, radio logically, and by pre- and post-operative functional evaluation using Mayo elbow performance score. For evaluation of ulnar nerve affection, the Akahori's system was used. RESULTS: There were six females and four males with the average age of 7.7 years at operation. The left elbow was affected in six patients and the right elbow was affected in four patients. The average time between fracture of the LHC and operation was 40.3 months with average post-operative follow up of 44.3 months. The average carrying angle of the healthy side was 5.5 degrees and pre-operative carrying angle of the affected side was 33.5 degrees. The average post-operative carrying angle of the affected side was 6.1 degrees. The improvement of the carrying angle at the last follow up was found statistically significant (p < 0.05). All six patients that had pre-operative various degrees of ulnar nerve affection had completely improved at last follow up. The osteotomy site united in an average time of 43 days, whereas the LHC nonunion site united in an average time of 77.2 days. The osteotomy site united in significantly less time than the LHC non-union site (p < 0.05). The correlation between time since injury and time of union of LHC non-union site was significant (p < 0.05). Post-operative elbow range of motion was not changed in five patients, slightly decreased in four patients, and increased in one patient. Three patients had an average 6.7 degrees (range; 5-10) loss of the last degrees of flexion. One patient developed extension lag of 10 degrees. The mean elbow range of motion (ROM) pre-operatively was 139 ± 4.6 degrees while the mean post-operative ROM was 138 ± 5.3 degrees. The difference was found to be statistically insignificant (p > 0.05). The mean pre-operative Mayo elbow performance score was poor 55 ± 9.7, four patients had fair score, and six had poor score. The mean post-operative Mayo elbow performance score was excellent 92.5 ± 10, six patients had excellent score, and four had good score. The improvement of the Mayo score at the last follow up was found to be statistically significant (p < 0.05). No intra-operative complications were recorded during any of the procedures and no patient developed a wound or pin track infection post-operatively. At the last follow up, none of the patients had developed avascular necrosis of the LHC. CONCLUSION: Preservation of the blood supply of the nonunited fragment is the key to successful management. This combined technique successfully addresses different aspects of the problem simultaneously and provides a durable solution without deterioration of the results over time. The para-triceptal approach provided excellent exposure of both sides of the elbow with minimal disruption of the triceps muscle.

Dynamic hip screw and fibular strut graft for fixation of fresh femoral neck fracture with posterior comminution.

INTRODUCTION: Posterior comminution of the femoral neck fracture is a major cause of delayed and non-union owing to the loss of the buttressing effect against the posterior rotation. When a femoral neck fracture with posterior comminution is anatomically reduced, only the anterior portions of the femoral neck fracture surfaces are brought into contact leaving a posterior defect. The purpose of this study was to evaluate the use of fibular strut grafting and dynamic hip screw (DHS) for fresh femoral neck fractures with posterior comminution in young patient less than 50 years. MATERIALS AND METHODS: Between October 2012 and March 2016, 35 patients aged 20-50 years, 30 men and 5 women underwent fixation using DHS and fibular strut grafts for Garden grades III (25 patients) and IV (10 patients) femoral neck fractures with posterior comminution. All fractures were reduced by closed methods, and no hip was aspirated. Clinical and radiological outcomes were evaluated. RESULTS: All patients were in the age group of 20-50 years (mean 37 years). The mean delay in presentation after injury was 1 day. The mean final follow-up for these 35 patients was 27.2 months. Healing of the femoral neck was attained in 34 cases, with an average time to union of 4.8 months (range 4-8 months). One patient underwent arthroplasty due to failure of fixation. According to the Harris hip score, outcome was good to excellent in 30 patients, fair in 4, and poor in 1. CONCLUSIONS: In our study, only one patient developed non-union and no patients had avascular necrosis of the femoral head. Closed reduction, fibular strut grafts, and DHS fixation is a reliable procedure for femoral neck fractures with posterior comminution in young adults.

Vascularized fibular medialization for reconstruction of the tibial defects following tumour excision.

PURPOSE: The purpose of this study was to evaluate the functional and oncologic results of fibular medialization when used alone as a single-stage reconstructive technique after wide excision of malignant tumours of the proximal, middle, or distal tibia. METHODS: Between December 2010 and May 2015, 14 patients (six males and eight females) with primary malignant tumours of the tibia (eight proximal, four diaphyseal, two distal) were treated by wide excision. The mean age of the patients at the time of surgery was 23.2 years (11-38). The fibula was mobilized medially with its vascular pedicle to fill the defect and was fixed by a long plate and screws bypassing the graft. The average size of the defects reconstructed was 19.5 cm (18-22). Patients were evaluated functionally using the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS: The mean follow-up period was 31.3 months (range, 17-54). The average time for complete union was 7.6 months (range, 6-9). At final follow-up all patients had fully united grafts; 11 walked without aids. Chest metastases developed in one patient, superficial wound infection in two patients and leg length discrepancy in four patients; one case had LLD of more than 3 cm. The mean MSTS score was 23/30 points (76.5%). The minimum score was 40% (12/30) and the maximum was 90% (27/30). CONCLUSIONS: Ipsilateral pedicled vascularized fibular centralisation or medialization is a durable reconstruction for tibial defects after wide excision of bone tumours with an acceptable functional outcome. Stable osteosynthesis is the key to union.