Simplified Kirschner­wire-based dynamic external fixator for unstable proximal interphalangeal joint fractures.

PURPOSE: Ligamentotaxis is a well-established treatment modality for treating challenging articular fractures. Many devices have been evolved to apply this principle to complex proximal interphalangeal joint (PIPJ) fractures. Although they gave satisfactory results, these devices were sometimes costly, complex and cumbersome. The aim of this study was to evaluate the short-term functional and radiological outcomes of treating complex intra-articular PIPJ fractures using a simplified, preloaded Kirschner­wire (K­wire)-based dynamic external fixator. METHODS: Twenty consecutive patients with intraarticular PIPJ fractures, who fulfilled the study selection criteria, have been treated during 2018 and included in this prospective study after the approval of the responsible institutional ethics committee. Plain radiographs were used for assessing fracture reduction, congruity and healing. The visual analogue sore (VAS) and the Michigan Hand Outcome Questionnaire (MHQ) were used for functional evaluation. PIPJ range of motion (ROM) and hand grip-strength were also assessed. RESULTS: At the final follow-up, all patients had no residual pain. The average PIPJ-ROM was 76.4 ± 23.51°, and the average grip-strength was 85 ± 13.95% as compared to the healthy side. The mean normalized MHQ score was 83 ± 12.63 points, with 4, 13, and 3 patients had excellent, good, and fair results retrospectively. Complications included pin tract infection (one case), stress fracture related to the applied wires (one case), and flexion contractures (four cases; three of them were symptomatic). CONCLUSIONS: The used fixator technique is simple, reliable, available, reproducible, time-saving and cost-effective for managing complex PIPJ fractures while allowing early joint mobilization, which proven effective in achieving high satisfactory functional results.

Trans-calcaneal retrograde nailing for secondary-displaced traumatic ankle fractures in diabetics with insensate feet: a less-invasive salvage-arthrodesis technique.

PURPOSE: Secondary displacement of traumatic ankle fractures with subsequent soft-tissue breakdown is a troublesome issue after inappropriate conservative treatment among non-compliant diabetic patients with severe peripheral neuropathy. This study was conducted to evaluate the results of a less-invasive arthrodesis procedure as an alternative to osteosynthesis in these complex scenarios. METHODS: A total of 46 diabetics, who underwent fluoroscopy-assisted trans-calcaneal retrograde nailing-based ankle arthrodesis between 2012 and 2018 for salvaging secondary-displaced diabetic ankle fractures in their insensate feet, were evaluated in this retrospective study. All fractures were associated with uninfected mechanical ulcers overlying malleoli, without Charcot changes, after failed conservative cast immobilization. The patients (mean age: 52.52 ± 3.70 years; 18 males; 46 feet) were evaluated radiologically for union and clinically for limb salvage, modified American Orthopedic Ankle and Foot Scale (AOAFS), and the overall subjective patients' satisfaction. RESULTS: The mean follow-up was 29.5 ± 3.1 months. All ulcers have healed with local care only with 100% limb salvage. Four patients experienced minor wound healing problems at posterior heel, and another one developed acute Charcot changes that was successfully managed by offloading and repeat surgery. Forty patients (86.96%) had fully consolidated fusions with a mean time to fusion 15.78 ± 2.58 weeks, while the other six cases had stable fibrous-union. At the final follow-up, the mean modified-AOFAS was 76.85 ± 6.0 from 86 total points. All, but four patients (91.30%) were completely satisfied while the other four patients were partially satisfied. CONCLUSIONS: The presented less-invasive arthrodesis technique is reproducible and effective alternative for salvaging unstable diabetic ankle fractures in the insensate feet when standard surgical procedures would be more risky. LEVEL OF EVIDENCE: IV, retrospective case series.

Dual Mobility Cup: Does It Improve Patient's Satisfaction After Total Hip Arthroplasty? A Prospective Comparative Randomized Study.

INTRODUCTION: Despite the great success of total hip arthroplasty (THA), many patients were fairly dissatisfied after surgery. Therefore, patient-reported outcome measures have become of an utmost importance in assessing the results after joint replacement. This study was conducted to compare the postoperative patient-reported satisfactions after implantation of two commonly used THA designs. METHODS: Of 180 patients, who initially fulfilled the study selection criteria and received cementless THA, 165 patients were finally eligible and enrolled in this prospective comparative randomized study. All surgeries were carried out between 2010 and 2018. Two groups of homogenous demographic and clinical data were present. Group A patients (n = 80) were treated by large head THA, whereas group B (n = 85) received dual mobility cup designs. The Western Ontario McMaster Universities Osteoarthritis Index and visual analog scale were used for clinical evaluation. The degree of improvement that the patient expected and hoped before undergoing their surgeries was estimated using the score of the new knee society. The self-administered patient satisfaction scale was used to record the levels of patient satisfaction after surgery, and their values were statistically analyzed in relation to preoperative expectation scores (ie, score of the new knee society) and different clinical and sociodemographic variables. RESULTS: After a mean follow-up of 79 ± 4.13 months (range 24 to 96 months), both groups recorded a significant improvement (P < 0.05) in Western Ontario McMaster Universities Osteoarthritis Index and visual analogue scale scores. Patients of group B were significantly more satisfied (P < 0.05) than those of group A up to the first postoperative year. Certain studied variables were linked to superior satisfaction results among group B at the last follow-up. CONCLUSIONS: Dual mobility THA provides better patient satisfaction than their standard large head alternatives specifically among elderly patients, socially unsupported individuals, farmers, heavy manual workers, and those with high levels of expectations. CLINICAL TRIAL REGISTRATION: Clinical Trials.gov identifier: NCT04333316.

Salvage arthrodesis for infected ankle fractures with segmental bone-loss using Ilizarov concepts: a prospective study.

PURPOSE: Complex ankle fractures accompanied with infection and segmental bone loss are a worrying issue. This prospective study was conducted to explore the effectiveness of using Ilizarov concepts in achieving salvage arthrodesis and reconstructing post-debridement defects in such complicated scenarios. METHODS: A total of 44 consecutive patients (mean age 35.61 ± 8.57 years, 30 males, 44 feet) of post-traumatic infected ankle fractures, who met our selection criteria, were enrolled and subjected to radical debridement and salvage arthrodesis using the bifocal bone transport concepts of Ilizarov. All patients were treated between 2012 and 2017 either by acute shortening compression of the arthrodesis site with re-lengthening (ASRL) through the created proximal metaphyseal osteotomy (group I, n = 20) or by gradual bone transport (BT) through the proximal osteotomy with gradual closure of the distal ankle defect (group II, n = 24). Plain-radiographs were used for radiological assessment. Clinically, the outcomes were objectively graded according to the Hawkins criteria, while subjectively the patients reported their satisfaction on a 1-5 points acceptance scale. RESULTS: The mean follow-up was 37.16 ± 5.31 (30-48 months). Successful fusion was achieved in 43/44 patients, with a significantly (P < 0.05) lesser needs for bone-grafting in favour of group II. The results were good in 32 cases, fair in 11, and poor in a single case with no significant difference between the two groups. The acceptance scores were significantly (P < 0.05) superior in group II (3.08 ± 1.1 points) than that group I (2.25 ± 1.4 points). CONCLUSIONS: Bifocal bone transport is effective in salvaging troublesome infected ankle fractures with bone loss. BT is more comprehensive and acceptable than ASRL with lesser needs for bone grafting.

Talectomy for the Management of Resistant Talipes Equinovarus Deformity; Does Adding Ilizarov External Fixator Provide Extra Advantages?

BACKGROUND: The management of resistant talipes equinovarus (TEV) is challenging. Residual deformity and recurrence are among the most feared complications. This study was conducted to evaluate the effectiveness of talectomy in the management of arthrogrypotic TEV and to investigate the value of adding a simplified Ilizarov fixator (SIF). PATIENTS AND METHODS: A total of 42 resistant TEV feet among 23 arthrogrypotic children were operated between January 2012 and 2016. The average age was 6.7 ± 1.67 years. The feet were divided into 2 groups; group A (Casting group) included 20 feet (11 children) that were managed by talectomy and casting, while group B (Fixator group) included 22 feet (12 children) that were treated using a SIF concomitant with talectomy. The results were evaluated morphologically by Dimeglio grading system and functionally by Legaspi system. RESULTS: The average follow-up was 36.62 ± 3.88 months. With the numbers available in this study, there was significant improvement (p ≤ .05) in the Dimeglio scores in both groups, which was significantly more evident (p ≤ .05) among the fixator group. The majority of the good functional results were reported among the fixator group, while the poor feet were observed mainly in the casting group (p ≤ .05). The functional end results were significantly affected (p≤ .05) by the final Dimeglio scores. The age had also statistically significant effect (p≤ .05) on the functional end results in group A only. CONCLUSION: Talectomy is an effective procedure for salvaging arthrogrypotic TEV. Supplementation of the procedure by SIF was associated with more satisfactory morphological and functional results particularly in older children.

Stem length in primary cementless total hip arthroplasty: Does it make a difference in bone remodeling?

PURPOSE: Stem design is usually accused for proximal femoral remodeling following total hip arthroplasty (THA). The aim of this prospective study was to compare the in vivo changes in bone mineral density (BMD) of the proximal femur after implantation of cementless THA with two length alternative stems. METHODS: Between May 2011 and March 2014, 50 patients, who met our selection criteria and received cementless THA, randomized into two groups. Group A received cementless standard femoral stems, while group B received short stems. Harris Hip Score (HHS) and visual analog scale (VAS) were used for clinical assessment. Stem and cup positions and stability were radiologically evaluated. Dual-energy X-ray absorptiometry was used to follow and compare changes in BMD in different zones of proximal femur between both groups. RESULTS: After a mean follow-up of 21.4 ± 3.53 months, there was a significant (p < 0.05) improvement in mean HHS and VAS with no significant differences (p > 0.05) between groups. There was no significant difference (p > 0.05) between groups regarding radiological results and rates of complications. The mean overall BMD was decreased by 11.26% for group A and 8.68% for group B at the final follow-up (p > 0.05). The greatest loss was found in greater trochanter region for group A and so for group B, but to a lesser extent (p < 0.05). CONCLUSIONS: Cementless short stem was not able to hold back proximal femoral bone loss, but only can modify or decrease its incidence within limits.

Prevalence of associated injuries after anterior shoulder dislocation: a prospective study.

PURPOSE: Anterior shoulder dislocation can be associated with many lesions such as Bankart lesions, rotator cuff tears (RCT), Hill-Sachs lesions or greater tuberosity fractures. It has been documented that early management of the associated injury affords better recovery of shoulder function. The aim of this study was to highlight the incidence of associated injuries after anterior shoulder dislocation. METHODS: A total of 240 patients with traumatic anterior glenohumeral dislocations were subjected to complete history taking, neurovascular assessment and pre-reduction plain X-ray. An X-ray was taken immediately after reduction. Ultrasonography (US) and magnetic resonance imaging (MRI) were done within one week after reduction in all patients. Nerve conduction studies were ordered for any patient with suspected nerve injury. RESULTS: Associated lesions were reported in 144 (60%) patients. RCT was the most common injury (67 cases). It was isolated in 34 patients (14.15%), while it was combined with other lesions in 33 cases (13.75%). Axillary nerve injury was encountered in 38 patients, of them 8 (3.33%) were isolated and 30 (12.5%) were combined. Greater tuberosity fracture was found in 37 patients, of them 15 (6.25%) were combined with axillary nerve injury, and in the other 22 patients (9.17%) the fracture was isolated. All cases with Hill-Sachs and Bankart lesion were combined lesions with no isolated cases. There was a significant relation between the incidence of associated injuries and age, mechanism of injury and the affected side. CONCLUSIONS: Lesions associated with traumatic anterior glenohumeral dislocations are more frequent than expected. Thorough clinical examination and detailed imaging including US and MRI are mandatory to avoid a missed diagnosis.

Open unstable metaphyseo-diaphyseal fractures of the tibia in adolescents: treatment by flexible intramedullary nails augmented by external fixator.

INTRODUCTION: The treatment of open and unstable metaphyseo-diaphyseal fractures of the tibia in adolescents is challenging. It is important to choose a fixation method that can maintain alignment, allow wound care and not violate the growth plate. The aim of this work was to evaluate the efficacy of using flexible intramedullary nails (FIN) augmented by external fixator (EF) in the management of such fractures. PATIENTS AND METHODS: A total of 26 males, with a mean age of 14.08 years and average body weight of 49.8 kg, presented with open metaphyseo-diaphyseal tibial fractures. All cases were treated using FIN augmented by mono-lateral EF. The fractures were located at the upper third in 17 cases and at the lower third in nine cases. The fracture pattern was spiral in eight cases, oblique in seven and multi-fragmentary in 11. The results were evaluated according to the scoring system for femoral TENs. RESULTS: All fractures united primarily after an average eight to 12 weeks with no evident angular deformity or limb-length discrepancy. None of the cases required cast immobilization or revision procedure. Twenty patients had excellent results, six patients showed good results and none had poor results. Fracture characteristics as well as patients' characteristics had no statistically significant effect (p > 0.005) on the final end results. CONCLUSIONS: The use of FIN augmented by EF is a good alternative in the management of open metaphyseo-diaphyseal tibial fractures in adolescents. This fixation provides more stability, allows easy access to the wound and early patients' ambulation.

Is it possible to eliminate the plate-related problems and still achieve satisfactory outcome after multilevel anterior cervical discectomy?

BACKGROUND: Stand-alone cage-assisted anterior cervical discectomy and fusion (ACDF) has proved to be safe and effective procedure for treatment of mono-segmental cervical degenerative stenosis (CDS). However, the success rate has reported to decline as the number of levels increases. The aim of this prospective study was to evaluate the short-term results of multilevel ACDF using stand-alone polyetheretherketone (PEEK) cages. PATIENTS AND METHODS: Twenty-eight patients (16 males and 12 females; mean age 40.5 years) of symptomatic multilevel CDS were enroled in this study and completed a 2-year post-operative follow-up. All patients underwent contiguous multilevel ACDF, using indirect decompression and stand-alone PEEK cages, between 2009 and 2012. Ten patients underwent two-level fusions (group I), ten underwent three-level fusions (group II), and eight underwent four-level fusions (group III). The visual analogue scales of neck and arm pain and Odom's criteria were used to evaluate clinical outcomes. Radiological evaluation was done to evaluate: fusion, cervical sagittal angle (CSA) and cage subsidence. RESULTS: There was a statistical significant improvement in clinical parameters and radiological CSA values in all groups post-operatively. This improvement was well maintained till final follow-up. Subsidence and non-union were encountered in seven and two fusion levels, respectively, with no significant differences between groups. All patients were satisfied and none of them had major complications or required revision surgery. CONCLUSION: With proper patient selection, meticulous surgical technique and strict post-operative cervical bracing, the less-invasive indirect anterior cervical decompression technique augmented with stand-alone PEEK cage-assisted ACDF is an efficient and safe method for the treatment of multilevel CDS.

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.

Comminuted distal femur closed fractures: a new application of the Ilizarov concept of compression-distraction.

INTRODUCTION: The treatment of intra-articular distal femur fractures with severe metaphyseal comminution is challenging. It is important to choose a technique that provides secure fixation, minimum tissue handling, and early ambulation. The aim of this work was to evaluate the outcomes of application of Ilizarov concept as an early definitive treatment of comminuted distal femur closed fractures. PATIENTS AND METHODS: A total of 17 male patients (mean age 28.53±6.33 years) presented with comminuted distal femur fractures (with 10 type C2 and 7 type C3-2 fractures according to AO/ASIF system) were included in this prospective study. Initial fixation of the articular fragments was done by inter-fragmentary screws, percutaneously through a limited open approach, and stabilization was completed by Ilizarov fixator. The procedure included acute shortening, through the comminution, followed by gradual re-distraction to compensate the created shortening. Radiological and functional results were assessed according to ASAMI evaluation system. RESULTS: The mean amount of intra-operative shortening was 3.68±0.53 cm. The mean external fixation index was 37.24±2.53 days/cm. The mean follow-up period was 18.18±1.91 months. All fractures united primarily in an average 137.65±4.12 days, with no evident angular deformity or limb-length discrepancy. None of the cases required a second major procedure or bone graft. The functional results were excellent in three cases, good in 12, and fair in two patients. CONCLUSIONS: The Ilizarov concept of acute compression-distraction is a valuable alternative for the treatment of distal femur fractures with severe metaphyseal comminution.

Management of open infected comminuted tibial fractures using Ilizarov concept.

BACKGROUND: Bone loss is very common in high energy trauma. It could be treated either by amputation and prosthesis or by reconstruction of both bony and soft tissue structures. The choice of treatment in a given case must be based on the assessment of the local and general condition of the patient such as regional neurovascular supply, and the residual articular and muscular function. Reconstruction may require bone grafts, tibiofibular synostosis, free microvascular soft tissue or bone transplants. The use of Ilizarov concept gives another option for treatment of bone defects. In this study, infected tibial fractures were treated using Ilizarov concept. PATIENTS AND METHODS: Twenty-eight patients (20 males and 8 females) with open comminuted infected fracture of the tibia were included. After debridement, all cases had variable amount of bone defects and were treated using Ilizarov technique. Follow-up was for at least 1 year. Filling of the bone defect was achieved either by compression-distraction method in 13 cases (group I) or by means of bone transport in the other 15 cases (group II). RESULTS: The results were judged as excellent in 16 patients, good in 9 and fair in 2, while one patient was of poor result. Type of fracture, age of the patient and sex had no statistically significant relation with the final end results. Furthermore, there was no significant difference between the two groups. The average external fixator index was 45 days/cm (range from 35 to 70 days/cm). The mean external fixator index was less in group I. CONCLUSION: In the management of infected comminuted tibial shaft fractures, bone transport is indicated for the treatment of major bone loss, whereas compression-distraction is suitable only for treating less extensive bone gaps.