Amr El-Sayed

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study.

Abstract: One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.

The use of a locked plate in the treatment of ununited femoral shaft fractures

BACKGROUND Sixteen patients with ununited fractures of the femur were treated by locked plate. There were 14 men and 2 women. The youngest patient was 18 years old and the oldest was 48 years (average, 32.9 years). Two fractures were infected and 14 were noninfected. METHODS Time between injury and operation varied from 4 to 26 months (average, 8.2 months). A standard broad dynamic compression plate and AO washers and nuts were used to construct a locked plate. Follow-up ranged from 6 to 24 months. RESULTS All fractures have healed after this operation; bone graft was not used in any of them. Time until healing ranged from 4 to 6 months (average, 4.9 months). Shortening after surgery ranged from 0 to 5 cm (average, 1.8 cm). There was no metal failure or recurrence of infection. Two patients were readmitted 1 year after operation for metal removal, knee arthrolysis, and quadricepsplasty to improve the range of motion of the knee. CONCLUSION Locked plate fixation is rigid enough for bone healing and to allow early postoperative mobilization, with good functional outcome.

Telescoping vascularized fibular graft: a new method for treatment of congenital tibial pseudarthrosis with severe shortening.

Vascularized fibular grafts have proved reliable in the treatment of congenital pseudarthrosis of the tibia with a high success rate. However, severe shortening cannot be primarily corrected by this technique and requires a second-stage lengthening procedure. Ilizarovs method allows correction of shortening and axial malalignment together with the non-union. However, in the dysplastic type with severe shortening, corticotomy of the affected bone may result in delayed consolidation or recurrence of disease. In addition, the large distraction distance (equal to the amount of shortening plus the resulting defect after excision of the pseudorthrosis site) requires prolonged frame application, which may not be tolerated by the patient. We present a new technique combining vascularized fibular graft and Ilizarov distraction that allows simultaneous correction of shortening while treating the non-union in a single-stage operation. This method avoids corticotomy in the congenitally affected bone and markedly shortens the time of frame application.

Delayed selective neurotization for restoration of elbow and hand functions in late presenting obstetrical brachial plexus palsy.

The published experience of obstetrical brachial plexus palsy (OBPP) cases with poor recovery and late neurosurgical intervention are sparse. This study included 19 cases who presented after the age of 1 year with poor recovery of elbow and/or hand function and electrophysiological evidence of reinnervation. Age at surgery averaged 41 months, and the follow-up averaged 50 months. Distal neurotization was performed for restoration of elbow flexion in 11 cases, elbow extension in 3 cases, and finger flexion and/or sensibility in 5 cases. Active elbow flexion increased from an average of 2.7 to 91.8 degrees with an average gain of 89 degrees. Active elbow extension increased from an average of 10 to 56.7 degrees with an average gain of 46.7 degrees. Although, three out of five cases (60%) showed satisfactory recovery of finger flexion, all cases scored<2 using Raimondi score. Four cases gained protective sensation and one case gained discriminative sensation. The results of neurotization in late OBPP are variable. The best and most consistent results are obtained by necrotizing the biceps by the intercostal nerves or, in selected cases, by the flexor carpi ulnaris fascicle of the ulnar nerve. Delayed neurotization is the only way to recover sensory function in the hand.

Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy

Background: In late obstetric brachial plexus palsy (OBPP), restoration of elbow and hand functions is a difficult challenge. The use of free functioning muscle transplantation in late OBPP was very scarcely reported. In this study, we present our experience on the use of free functioning gracilis transfer for restoration of elbow and hand functions in late cases of OBPP. Patients and Methods: Eighteen patients with late OBPP underwent free gracilis transfer for reconstruction of elbow and/or hand functions. The procedure was indicated when there was no evidence of reinnervation on EMG and in the absence of local donors. Average age at surgery was 102.5 months. Patients were evaluated using the British Medical Research Council (MRC) grading system and the Toronto Active Movement Scale. Hand function was evaluated by the Raimondi scoring system. Results: The average follow‐up was 65.8 ± 41.7 months. Contraction of the transferred gracilis started at an average of 4.5 ± 1.03 months. Average range of elbow flexion significantly improved from 30 ± 55.7 to 104 ± 31.6 degrees (P <0.001). Elbow flexion power significantly increased with an average of 3.8 grades (P = 0.000147). Passive elbow range of motion significantly decreased from an average of 147 to 117 degrees (P = 0.003). Active finger flexion significantly improved from 5 ± 8.3 to 63 ± 39.9 degrees (P < 0.001). Finger flexion power significantly increased with an average 2.7 grades (P < 0.001). Only 17% achieved useful hand (grade 3) on Raimondi hand score. Triceps reconstruction resulted in an average of M4 power and 45 degrees elbow extension. Conclusion: Free gracilis transfer may be a useful option for reconstruction of elbow and/or hand functions in late OBPP.

Arthroscopic grading of common wrist disorders and its role in management.

Palmer devised a classification system to guide treatment of triangular fibrocartilage complex tears in 1989. The main division is between traumatic Type I and atraumatic Type II tears. The wrist arthroscopy makes diagnosis and treatment of ulnar impaction syndrome possible in a less invasive way. Arthroscopy is the most valuable tool for diagnosis and treatment of acute scapholunate and lunotriquetral dissociation. Arthroscopic grading of Kienböcks disease better describes articular damage compared with plain radiographs and can help surgical treatment. The wrist arthroscopy generally makes it possible to make the diagnosis of the chondral lesion before they are visible by the usual imaging.

Arthroscopic Treatment of Type 1B Triangular Fibrocartilage Complex Tear by “Outside-In” Repair Technique Using Transcapsular Transverse Mattress Suture

Triangular fibrocartilage complex (TFCC) injuries are increasingly recognized as a cause of ulnar-sided wrist pain. Palmer grouped these tears into either traumatic or degenerative, with various subclassifications. Magnetic resonance imaging (MRI), arthrogram, and arthroscopy are the methods used to establish the diagnosis. Several arthroscopic methods of TFCC repair including outside-in, inside-out, and all-inside techniques have been described. The outside-in repair, which involves piercing the TFCC via the ulnar side of the wrist, has been described by several authors, but the technique varies among authors with respect to instrumentation and subtle surgical modifications. The purpose of this article was to present the technique of arthroscopic outside-in repair using transverse mattress suture for type 1B TFCC tear by modifying classic vertical mattress sutures into sutures that pass completely through the disc.