A modified angled plate for fixation of proximal femoral varus osteotomy in neuromuscular hip dislocation: Mechanical and clinical study

INTRODUCTION

Proximal femoral osteotomy is an important step in the management of paralytic hip dislocation. Fixation by the angled plate is demanding and carries the risk of many complications. In this study, we made certain modifications for the angled plate. Does this plate provide a stable fixation for proximal femoral varus osteotomy? The main objective of this study was to assess the results of the modified plate in fixation of proximal femoral varus osteotomy in patients with neuromuscular hip dislocation.

HYPOTHESIS

This new system would offer significant advantages over the existing systems in terms of easy application and stable fixation.

MATERIAL AND METHODS

Twenty patients with paralytic hip dislocation were included in this study. The ages ranged from 5 to 15 years with a mean of 8.88±2.92 years. There were 12 boys and 8 girls. Seventeen patients had cerebral palsy and 3 had meningocele disease. Preoperative radiographs were done, and the migration percentage (MP), acetabular index (AI), and neck-shaft angle (NSA) were measured. All patients were treated with open reduction, pelvic osteotomy, and proximal femoral varus osteotomy. The femoral osteotomy was fixed by the modified angled plate in all cases.

RESULTS

The osteotomy sites united in all patients and the mean time of union was 2.9±0.65 months. The acetabular index, migration percentage, and neck-shaft angle were reduced postoperatively. This reduction was statistically significant. The hips remained stable throughout the period of follow-up in all patients. No cases were complicated by non-union or implant failure.

CONCLUSION

The modified angled plate (canulated interlocking blade Plate 90°) is a good method for the fixation of proximal femoral varus osteotomy in the management of neuromuscular hip dislocation. It provides a stable fixation.

LEVEL OF EVIDENCE

IV; case series.

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

The use of free nonvascularized fibular graft in the induced membrane technique to manage post-traumatic bone defects

PURPOSE

The aim of the present study is to assess the results of free nonvascularized fibular graft in the induced membrane technique to manage bone defects.

MATERIALS AND METHODS

Fifteen patients with segmental skeletal defects were treated by the induced membrane technique using free nonvascularized fibular graft. The ages ranged from 20 to 48 years with an average of 32 years. The cause of the defects was post-traumatic bone loss in all cases. The defects were located in the distal femur in nine cases, proximal tibia in two cases and middle third of the tibia in four cases. The defects ranged from 5 to 14 cm with an average of 8 cm. All cases were treated by the induced membrane technique in two stages. Autogenous cancellous bone graft and free nonvascularized fibular graft were used to fill the defect in the second stage of surgery.

RESULTS

All cases healed without additional procedures after the second stage except in two cases. The time-to-bone union ranged from 4 to 13 months with an average of 7 months. After physiotherapy, all cases regained good range of ankle and knee movements except two cases. The complications included nonunion of the graft in two cases, deep wound infection in one case, and chronic pain along the iliac crest in one case. No cases were complicated by implant failure or refracture.

CONCLUSION

The use of free nonvascularised fibular graft in the induced membrane technique reduces the time of healing and improves the final outcome.

Comminuted long bone fractures in children. Could combined fixation improve the results?

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Bicondylar tibial plateau fractures involving the posteromedial fragment : morphology based fixation

The aim of this study is to describe the morphology of the posteromedial fragment in the setting of bicondylar tibial plateau fractures and to use it as a base for selection of the method of fixation. Twenty two -patients with bicondylar tibial plateau fractures -involving the posteromedial fragment were included in this study. Plain X- ray and computed tomogram (CT) were performed in all patients. Thirteen patients were treated by dual plating while nine were treated by single lateral plate. The mean posteromedial fragment height was 39 mm. The cephalad surface area percentage of the posteromedial fragment relative to the entire tibial plateau ranged from 10% to 43%. with an average of 28%. The average knee motion at the final follow up was 110°. Two cases were complicated by implant failure. Morphological study of the posteromedial fragment could help in selection of the proper method of fixation.

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

Is there a safe zone to avoid superficial radial nerve injury with Kirschner wire fixation in the treatment of distal radius? A cadaveric study

AIM OF THE STUDY

To determine the relation of the superficial radial nerve to bony land-marks and to identify a safe zone for K-wire pinning in the distal radius.

METHOD

The superficial radial nerve was dissected in sixteen upper extremities of preserved cadavers.

RESULTS

We found that the superficial radial nerve emerged from under brachioradialis at a mean distance of 8.45 (±1.22) cm proximal to the radial styloid. The mean distance from the first major branching point of the superficial radial nerve to the radial styloid were 4.8 ± 0.4 cm. All branches of the superficial radial nerve were found to lie in the radial half of an isosceles triangle formed by the radial styloid, Lister's tubercle and the exit point of the superficial radial nerve. There is an elliptical area just proximal to the Lister's tubercle. This area is not crossed by any tendons or nerve. It is bounded by the extensor carpiradialis brevis, extensor pollicis longus.

CONCLUSION

Pinning through the radial styloid is unsafe as the branches of the superficial radial nerve passé close to it. The ulnar half of the isosceles triangle is safe regarding the nerve. The elliptical zone just proximal to the Lister's tubercle is safe regarding the tendons and nerve.

Musculoskeletal congenital malformations: do paternal occupational exposures play a role?

BACKGROUND

Paternal occupational exposures to potential health hazards are likely to affect congenital malformations through the spermatogenesis cycle.

PURPOSE

The aim of this case-control study was to assess the relationship between the risk of musculoskeletal congenital malformations in offspring and paternal workplace exposure to potential health hazards during the preconception period.

METHOD

The study comprised 105 patients (cases) with a musculoskeletal congenital malformation(s) and 135 controls matched for age and demographic characteristics. Both parents of each case and control were interviewed in the hospital by a trained physician. They also completed a questionnaire focusing on the preconception period and on the 3-month period immediately before and after the pregnancy conception date, respectively, of the child under study.

RESULTS

The odds of having a child with a congenital malformation was higher (P < 0.05) if the father was occupationally exposed to pesticides, solvents, or welding fumes during the preconception period.

CONCLUSION

Control of workplace exposures and adherence to threshold limit values of these potential health hazards should be adopted to minimize the risk of fathers having offspring with a congenital malformation.

Indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures

The aim of the present study is to assess the results of indirect reduction and hybrid external fixation in management of comminuted tibial plateau fractures. The study included 28 patients with high-energy tibial plateau fractures (Schatzker type V and VI). The ages ranged from 22 to 58 years with an average of 35 years. The trauma was a road traffic accident in 16 cases and a fall from a height in 12 cases. Concomitant soft tissue injuries were present in 18 cases such as skin wounds in 6 cases, excessive swelling with skin blisters in 9 cases, and compartment syndrome in 3 cases. After clinical and radiological evaluation all the patients were treated by indirect reduction using a traction table and a hybrid external fixator. The average time to healing was 3.2 months. At the final follow-up the range of knee movement ranged from 0 degrees-140 degrees with an average of 110 degrees. The results were satisfactory in 23 cases and unsatisfactory in 5 cases according to the Rasmussen knee functional score. Complications included pin tract infection in 12 cases, an extension lag in 2 cases, varus deformity of about 15 degrees in one case, deep infection in one case and early osteoarthritic changes in 2 cases. Hybrid external fixation is a good method for treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Arthrodesis of the ankle joint by Ilizarov external fixator in patients with infection or poor bone stock

BACKGROUND

Ankle arthrodesis is the most common surgical treatment for end stage ankle arthritis. Many surgical techniques have been described to achieve this purpose. The aim of the present study is to assess the results of the Ilizarov external fixator in performing ankle fusion in patients who have infection or poor bone stock at the region of the ankle joint.

PATIENTS AND METHODS

Twelve patients with secondary ankle arthritis were treated by ankle arthrodesis using the Ilizarov external fixator. Eight were males and four were females. The age ranged from 23 to 56 with an average of 42.8 years. Active infection was present in 7 cases and the bone stock was deficient in 5 cases. Bone lengthening was done in 4 cases to equalize the limb length.

RESULTS

Sound fusion was achieved in all the cases except one. Infection was controlled in all the infected cases. Ten cases could walk without support, one could walk with a cane and one case required an ankle foot orthosis. All patients were satisfied with their results except one. The complications had included pin tract infection in 9 cases, varus deformity of about 15 degrees in 1 case and fibrous ankylosis in 1 case.

CONCLUSION

The Ilizarov technique is a good method for ankle fusion especially in presence of infection, bone defects or shortening.

Bifocal and trifocal bone transport for failed limb reconstruction after tumour resection

The aim of the present study is to assess the results of bifocal and trifocal bone transport for elimination of bone defects due to failed limb reconstruction after tumour resection. Thirteen patients, nine with giant-cell tumour and four with osteosarcoma, with bone defects resulting from wide tumour resection were managed by bone transport with an Ilizarov frame. The ages ranged from 12 to 46 years. Bone transport was used as a second line of management after failure of other modalities for reconstruction. According to the Enneking system for the functional evaluation after surgical treatment of musculoskeletal tumours, the percentage rating of function was 47% in one case, 70% in 2 cases and more than 85% in 10 cases. Most of the complications were treated successfully during the course of treatment. Bone transport with two or three osteotomies is a reliable method for eliminating bone defects as a limb salvage procedure after failure of other modalities for reconstruction.

Distraction osteogenesis in management of composite bone and soft tissue defects

A soft tissue defect is one of the most difficult problems that may accompany bone defects. Plastic surgery is often required. During distraction osteogenesis, not only the bone but also the soft tissues are lengthened, which may help in spontaneous closure of the soft tissue defects. This study examines 11 cases of composite bone and soft tissue defects which were managed by distraction osteogenesis. After debridement of the necrotic tissues, the soft tissue defects ranged from three by four centimetres to five by 14 centimetres and the bone defects ranged from four to 12 centimetres. All the soft tissue defects healed during the process of bone transport without the need for plastic surgery, except in one case. The complications were successfully managed during the course of treatment. Distraction osteogenesis is a good method for simultaneous treatment of composite bone and soft tissue defects.