Barakat El-Alfy

Functional outcome of salvage of residual and recurrent deformities of clubfoot with Ilizarov technique.

Relapse may occur in severe clubfeet deformities whether treated surgically or nonsurgically. In this study, we evaluate the results of correction of residual and recurrent congenital clubfoot using soft tissue distraction or osteotomy using the Ilizarov external fixation system. This study included 35 feet in 28 patients who were treated between 1999 and 2007. Of these 16 feet in 13 patients with an average age of 13.7 years (range from 11 to 29 years) were treated by percutaneous calcaneal V-osteotomy and gradual correction by the Ilizarov method. Nineteen feet in 15 patients with an average age 10.5 years (range from 4 to 22 years) were treated by soft tissue distraction by the Ilizarov technique. The mean average follow up period was 5.6 years (range from 1 to 8 years). At the time of fixator removal, a plantigrade foot was achieved in 30 feet. Mild residual varus and equinus deformities were present in five feet. At the final follow foot pressure measurement showed recurrent or residual deformity in 10 feet (7 treated by osteotomy and 3 treated by soft tissue distraction). Recurrence may occur with both techniques, depending on many factors such as bone morphology, the number of the pervious operations and the degree of stiffness of the foot prior to the operation.

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.

Management of segmental skeletal defects by the induced membrane technique

Background: Surgical reconstruction of segmental skeletal defects represents a true challenge for the orthopedic surgeons. Recently, Masquelet et al. described a two-stage technique for reconstruction of bone defects, known as the induced membrane technique. The aim of this study is to assess the results of the induced membrane technique in the management of segmental skeletal defects resulting from debridement of bone infection. Materials and Methods: Seventeen patients with segmental skeletal defects were treated in our institution by the induced membrane technique. The average age of the patients was 43 years (range 26- 58 years). The causes of the defects were infected gap nonunion in 12 cases and debridement of osteomyelitis in 5 cases. The defects were located in the tibia (n = 13) and the femur (n = 4). The mean defect was 7 cm (range 4 cm - 11 cm). All cases were treated by the induced membrane technique in two-stages. Results: Bone union happened in 14 patients. The limb length discrepancy did not exceed 2.5 cm in the healed cases. The mean time of healing was 10 months (range 6-19 months). The complications included nonunion of the graft in five cases, failure of graft maturation in two cases, reactivation of infection in two cases and refracture after removal of the frame in one case. These complications were managed during the course of treatment and they did not affect the final outcome in all patients except three. Conclusion: The induced membrane technique is a valid option for the management of segmental skeletal defects. It is a simple and straight forward procedure, but the time required for growth and maturation of the graft is relatively long.

Ilizarov bone transport versus fibular graft for reconstruction of tibial bone defects in children.

The aim of this study was to compare the results of treatment of segmental tibial defects in the pediatric age group using an Ilizarov external fixator versus a nonvascularized fibular bone graft. This study included 24 patients (age range from 5.5 to 15 years) with tibial bone defects: 13 patients were treated with bone transport (BT) and 11 patients were treated with a nonvascularized fibular graft (FG). The outcome parameters were bone results (union, deformity, infection, leg-length discrepancy) and functional results: external fixation index and external fixation time. In group A (BT), one patient developed refracture at the regenerate site, whereas, in group B (FG), after removal of the external fixator, one of the FGs developed a stress fracture. The external fixator time in group A was 10.7 months (range 8–14.5) versus 7.8 months (range 4–11.5 months) in group B (FG). In group A (BT), one patient had a limb-length discrepancy (LLD), whereas, in group B (FG), three patients had LLD. The functional and bone results of the Ilizarov BT technique were excellent in 23.1 and 30.8%, good in 38.5 and 46.2, fair in 30.8 and 15.4, and poor in 7.6 and 7.6%, respectively. The poor functional result was related to the poor bone result because of prolonged external fixator time resulting in significant pain, limited ankle motion, whereas the functional and bone results of fibular grafting were excellent in 9.1 and 18.2%, good in 63.6 and 45.5%, fair in 18.2 and 27.2%, and poor in 9.1 and 9.1%, respectively. Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results, with early removal of the external fixator. However, it had a limitation in patients with severe infection and those with LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. The Ilizarov method has the advantages of early weight bearing, treatment of postinfection bone defect in a one-stage surgery, and the possibility to treat the associated LLD. However, it has a long external fixation time.

Ilizarov External Fixator Versus Retrograde Intramedullary Nailing for Ankle Joint Arthrodesis in Diabetic Charcot Neuroarthropathy

Abstract Charcot neuroarthropathy of the ankle joint is a destructive process that leads to instability and significant morbidity that can end with amputation. Surgical arthrodesis in Charcot neuroarthropathy has a high failure rate. The aim of the present prospective study was to compare the outcomes of an Ilizarov external fixator and retrograde intramedullary nailing (IMN) for tibiotalar arthrodesis in Charcot neuroarthropathy. From February 2010 to October 2013, 27 patients (16 males and 11 females) with Charcot neuropathy of the ankle joint were treated in our department. Their ages ranged from 32 to 75 (average 54) years. Of the 27 patients, 14 received an Ilizarov external fixator and 13 underwent IMN. A preoperative clinical and radiologic assessment of all patients was performed. The outcomes were measured for bone union, development of complications, and clinical follow‐up. The mean score of modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale was 80 ± 2.7 points in the Ilizarov group and 75 ± 1.9 points in the IMN group. In the Ilizarov group, 12 of 14 patients achieved union, and in the IMN group, 10 of 13 patients achieved union. The complication rate was significantly greater in the external fixator group than in the IMN group. The complications in the Ilizarov group included nonunion in 2 patients (14%), pin tract infection in 8 (57%), pin tract loosening in 3 (21%), surgical wound infection in 3 (21%), and wound breakdown in 1 patient (7%). In the IMN group, nonunion occurred in 3 patients (23.1%), back‐out of a distal locking bolt in 2 (15.4 %), and a superficial wound infection that resolved with antibiotics in 1 patient (7.7%). In conclusion, retrograde IMN and the Ilizarov external fixator both yielded better union for tibiotalar arthrodesis in Charcot neuroarthropathy. The Ilizarov external fixator resulted in a greater union rate than IMN but the complications with external fixation were significantly greater than those with IMN. &NA; Level of Clinical Evidence: 4

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.