Amr Abdelgawad

Posterolateral Approach for Treatment of Posterior Malleolus Fracture of the Ankle

Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. In the present study, we describe the technique and results of treatment of the posterior malleolus by direct reduction through the posterolateral approach to the ankle. The decision to fix the posterior malleolus was determined by its size and displacement. A total of 12 consecutive patients underwent the posterolateral approach to reduce the posterior malleolus, and these were fixed by posterior plate. Two patients were lost to follow-up in the early postoperative period (both after 2 months). No deep infection or wound dehiscence occurred. Ten patients had adequate (<2-mm displacement of the articular surface) radiologic reduction at the final follow-up visit. There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.

Application of wearable sensors for human gait analysis using fuzzy computational algorithm

Abstract The authors have developed and tested a wearable inertial sensor system for the acquisition of gait features. The sensors were placed on anatomical segments of the lower limb: foot, shank, thigh, and hip, and the motion data were then captured in conjunction with 3D ground reaction forces (GRFs). The method of relational matrix was applied to develop a rule-based system, an intelligent fuzzy computational algorithm. The rule-based system provides a feature matrix model representing the strength of association or interaction amongst the elements of the gait functions (limb-segments accelerations and GRFs) throughout the gait cycle. A comparison between the reference rule-based data and an input test data was evaluated using a fuzzy similarity algorithm. This system was tested and evaluated using two subject groups: 10 healthy subjects were recruited to establish the reference fuzzy rule-base, and 4 relapsing remitting multiple sclerosis subjects were used as an input test data; and the grade of similarity between them was evaluated. This similarity provides a quantitative assessment of mobility state of the impaired subject. This algorithmic tool may be helpful to the clinician in the identification of pathological gait impairments, prescribe treatment, and assess the improvements in response to therapeutic intervention.

Relationship between limb length discrepancy and load distribution across the sacroiliac joint--a finite element study.

We assessed the relationship between leg length discrepancy (LLD) and the load distribution across the sacro‐iliac joint (SIJ). A finite element model of the spine–pelvis was developed with different amounts of LLD by increasing the length of the right femur in the model. Peak stresses and contact loads across the SIJ were computed for different amounts of LLD (1, 2, and 3 cm). The load and the peak stresses across the SIJ articular surfaces progressively increased with the increase in the LLD. Trying to offset the LLD surgically by lengthening of the short side, shortening or stunting the growth (epiphysiodesis) of the long side, or by shoe lifts should decrease the load across the SIJ and should theoretically decrease SIJ pain.

Automatic classification of pathological gait patterns using ground reaction forces and machine learning algorithms

An automated gait classification method is developed in this study, which can be applied to analysis and to classify pathological gait patterns using 3D ground reaction force (GRFs) data. The study involved the discrimination of gait patterns of healthy, cerebral palsy (CP) and multiple sclerosis subjects. The acquired 3D GRFs data were categorized into three groups. Two different algorithms were used to extract the gait features; the GRFs parameters and the discrete wavelet transform (DWT), respectively. Nearest neighbor classifier (NNC) and artificial neural networks (ANN) were also investigated for the classification of gait features in this study. Furthermore, different feature sets were formed using a combination of the 3D GRFs components (mediolateral, anterioposterior, and vertical) and their various impacts on the acquired results were evaluated. The best leave-one-out (LOO) classification accuracy 85% was achieved. The results showed some improvement through the application of a features selection algorithm based on M-shaped value of vertical force and the statistical test ANOVA of mediolateral and anterioposterior forces. The optimal feature set of six features enhanced the accuracy to 95%. This work can provide an automated gait classification tool that may be useful to the clinician in the diagnosis and identification of pathological gait impairments.

Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature.

Deep vein thrombosis and pulmonary embolism are major complications that can occur after ankle injuries. We present the case of a patient with an ankle fracture who developed deep vein thrombosis and massive pulmonary embolism after surgical treatment of the ankle fracture. A review of the published data on this topic is presented. The treating physician should assess patients with ankle fracture for their risk of developing a venous thromboembolic event on an individual basis and provide thromboprophylaxis for those with an increased risk of developing such complications.

Dog bites to the upper extremity in children

Dog bites are common injuries in children. A large percentage of these dog bites affect the upper extremity. There is little information describing the results of treatment of upper extremity injuries in children.

Computer navigation in orthopedic trauma: safer surgeries with less irradiation and more precision.

Exposure of patients and practitioners to ionizing radiation for diagnostic and therapeutic purposes has become the norm rather than the exception. This article discusses the findings from a literature review of intraoperative risks from ionizing radiation to patients and surgeons and the validity of substituting the conventional intraoperative fluoroscopy with computer-assisted orthopedic surgery (CAOS) in orthopedic trauma surgery. Diversity of study designs and measurements exists in reporting intraoperative ionizing radiation, making direct study comparisons difficult. CAOS can effectively reduce the amount of radiation exposure. There are definite advantages and disadvantages for using CAOS in the field of orthopedic trauma. Implementation of CAOS may hold the answer to better patient and surgeon intraoperative radiation safety with decreased operative time and increased procedure precision. The increased safety for patients and surgeons is a critical consideration in recommending CAOS in trauma surgery.

Minimally Invasive (Sinus Tarsi) Approach for Open Reduction and Internal Fixation of Intra-Articular Calcaneus Fractures in Children: Surgical Technique and Case Report of Two Patients

Calcaneus fractures in children differ from those in adults. Most calcaneus fractures in children can be managed nonoperatively, with good long-term results expected. The width and height of the calcaneus can remodel with time in children. Recently, there has been a trend toward operative treatment of displaced intra-articular fractures of the calcaneus in children to correct the articular deformity. Studies of calcaneal fracture fixation in children used an extended lateral approach, with its possible complications. In the present report, we describe the operative treatment of 2 children (12 and 13 years old), who had a displaced intra-articular fracture of the calcaneus, using a minimally invasive sinus tarsi approach. Adequate reduction was obtained in both cases with no soft tissue complications or implant discomfort. Fixation was obtained using 3.5-mm cortical screws. Anatomic joint alignment was restored. The children were followed up until they had both resumed their full activities with no complications. We recommend this approach for operative treatment of displaced intra-articular fractures of the calcaneus, because it addresses the intra-articular displacement, which is the most important element of the deformity in children.

Congenital tibial dysplasia (congenital pseudoarthrosis of the tibia): an atypical variation.

Purpose: The purpose of the study was to identify those characteristics of congenital tibial dysplasia (CTD) that portend the worst prognosis, including the probable failure of all surgical attempts to achieve union. Clear identification/ classification of this select population of cases could add earlier consideration of relevant treatment options. Method: While several classification systems for CTD exist, the Crawford classification was used to review the literature and our hospital cases (6) to examine the relationship between case characteristics, treatment, and outcome. Results: An atypical variation of Crawford’s type IIC was identified, herein referred to as type IID, that was characterized by early onset, frank pseudoarthrosis, and deformity of the distal-one third of the tibia and fibula. As well, these patients underwent failed multiple surgeries and numerous type treatments over time without good functional outcome and with prolonged physical difficulties. Conclusion: The cases that fall into this newly defined category (IID) of the Crawford classification for CTD are best treated with early amputation rather than repeated attempts to gain union. Significance: Amputation for patients with congenital tibial dysplasia (congenital pseudoarthrosis of the tibia) that are identified as type IID cases and carry the characteristics for a bad prognosis, provides better functional results than repeated surgeries, even when union is achieved. The family should be warned from the beginning that a stable union is unlikely in these cases. Amputation should be offered as a primary or an early option to the family with full disclosure of the long-term advantages and disadvantages of all therapeutic paths.

Prophylactic Intramedullary Rodding Following Femoral Lengthening in Congenital Deficiency of the Femur.

Introduction: Femoral fracture after lengthening of congenital femoral deficiency (CFD) is a common complication with a high incidence, up to 50%. The purpose of this study is to determine whether prophylactic intramedullary Rush rodding after lengthening for CFD is an effective method to prevent femoral fracture and to assess any complications that may result. Methods: Forty-five femoral lengthenings (43 CFD patients) were performed using external fixation. At the time of frame removal (except for 3 cases, 8 d later), prophylactic intramedullary Rush rods were inserted. Special reaming techniques were developed to pass a Rush rod through the solid regenerate bone and past sclerotic pin sites. Mean age at time of rodding was 6.9 years (range, 2.9 to 14.2 y). Mean duration of treatment with external fixation was 184 days (range, 146 to 461 d). Mean follow-up was 4.2 years (range, 1.3 to 8.2 y). This group of cases was compared with a historical cohort of 95 femoral lengthening procedures for CFD without prophylactic intramedullary rodding after frame removal previously performed at the same institute by the same surgeons. Results: Eight cases (18%) developed fracture despite intramedullary rodding (1 case with relatively high-energy trauma, 3 cases during physical therapy, and 4 cases spontaneously). Only 4 of these fractures required intervention. Fractures were more common when a 3.18 mm Rush rod was used (28%) compared with 4.76 mm (8.3%). Patients with prophylactic rodding had a significantly lower incidence of femur fracture rodding than those who did not (18% vs. 34%, respectively; P=0.04). Three out of 45 Rush rods (7%) developed infection that were treated by debridement and removal of the rod, and all healed uneventfully without residual or recurrent infection. There were no cases of avascular necrosis. Conclusions: Prophylactic intramedullary rodding is a safe and effective method to prevent femoral fractures after CFD lengthening. Use of 4.76 mm rod is preferred. The risk of infection is acceptable, when compared with the risk of fracture, loss of length, and angulation. Level of Evidence: Level III—a retrospective comparative study.