Galal Z. Said

Resection-shortening-distraction for malignant bone tumours. A report of two cases

We report two patients with malignant bone tumours treated by wide marginal resection in whom the residual bone defect was replaced by progressive distraction after allowing union to commence in the shortened position.

A MODIFIED TENDON TRANSFERENCE FOR RADIAL NERVE PARALYSIS

1. A modified technique of tendon transference for irreparable damage of the radial nerve is described. The tendon of the pronator teres is transferred to the two radial extensors of the wrist and to the tendon of extensor carpi ulnaris. 2. The method succeeds in preventing radial deviation on attempted dorsiflexion of wrist and helps to provide a powerful grip.

Posterior-only surgical correction of adolescent idiopathic scoliosis: an Egyptian experience

Introduction: The aim of this prospective case series study is to document safety and effectiveness of high density pedicle screws through posterior only approach with intraoperative wake-up test in correction of adolescent idiopathic scoliosis (AIS). Methods: Between 2011 and 2015, all surgically treated patients for AIS were followed up for a minimum of 2 years. Clinical outcomes were evaluated using scoliosis research society-22 (SRS) questionnaire. All patients were classified according to Lenke classification. Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. All patients underwent an intra-operative wake-up test after deformity correction and a minimum of 80% metal density of implants was used. Results: This study included 50 patients. The mean age at time of surgery was 16.8 years. The mean follow-up period was 38.1 months. The mean correction rate for the coronal Cobb angle of the major curve was 79.12%, while that of the minor curve was 68.9%. The mean thoracic kyphosis angle was 38.4° preoperatively, 29.76° postoperatively and 30.36° at the last follow-up. The mean SRS-22 questionnaire scores improved significantly at the last follow-up (P > 0.001). There were no neurological deficits at the wake-up test. No cases of pseudarthrosis or metal failure were encountered. Conclusion: This is a prospective study of at least 80% metal density pedicle screws technique and intra-operative wake-up test in Egyptian patients with AIS. It proved to be an effective and safe technique in correction of radiological parameters, with no neurological or implant related complications. It allowed excellent scoliotic and kyphotic curves correction with minimal loss of correction. On the whole it led to better quality of life.

Hypovitaminosis D Among Patients Admitted With Hip Fracture to a Level-1 Trauma Center in the Sunny Upper Egypt Prevalence and Associated Correlates

Introduction: Despite abundant sunshine, hypovitaminosis D is common in the Middle East. The aim of this study was to determine the prevalence of hypovitaminosis D and related correlates among patients with hip fracture in Assiut University Hospitals in Upper Egypt. Materials and Methods: A cross-sectional study was carried out in 133 patients with hip fracture, aged 50 years and older, admitted to Trauma Unit of Assiut University Hospitals, from January through December 2014. Patients were selected by systematic random sampling. Serum 25-hydroxy vitamin D level was measured by enzyme-linked immunosorbent assay; bone mineral density (BMD) by dual-energy X-ray absorptiometry. Weight and height measurements were used for body mass index (BMI) calculation. Results: Patients’ median age was 70 years (range: 50-99); 51.9% were females. Osteoporosis (femoral neck T score: <−2.5 standard deviation) prevalence was 72.2%. Of all patients, 60.9% had vitamin D deficiency (<20 ng/mL); 15.8% reported vitamin D inadequacy (from 20 to 29 ng/mL) and vitamin D levels were normal in 23.3% (>30 ng/mL). According to univariate analysis, vitamin D deficiency was significantly associated with obesity (P = .012) and low T scores of the femoral neck (P = .001), L2 (P = .021), L3 (P = .031), L4 (P = .012), and the greater trochanter (P < .001). In a multivariable logistic regression model, high BMI and low BMD of the femoral neck and greater trochanter were associated with hypovitaminosis D. Conclusion: Prevalence of hypovitaminosis D is high among patients with hip fracture and associated with low BMD and high BMI. Increasing awareness about prevention as well as detection and treatment of vitamin D deficiency is recommended.

Femoral malalignment after gamma nail insertion in the lateral decubitus position

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position. Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides. Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019). Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Accuracy of plain antero-posterior radiographic-based methods for measurement of acetabular cup version

IntroductionAcetabular cup version is crucial for successful total hip arthroplasty (THA). Many methods have been described for measurement of cup version angle. The aim of this study is to assess the accuracy of five commonly used methods for measurement of acetabular cup version in plain antero-posterior views of the pelvis and hip.Material and methodsSixty primary THA cases were subjected postoperatively to plain A-P of the pelvis (AP-P), A-P view of the hip (AP-H), and computed tomography (CT) imaging. The acetabular cup version was measured in AP-P and AP-H by five methods (Lewinnek, Widmer, Hassan et al., Ackland et al., and Liaw et al.). These measurements were compared to the CT measurement.Result sAll plain X-ray methods showed no significant differences from the CT, except those of Hassan et al. in AP-H, and Widmer and Ackland et al. in AP-P.Conclusions and recommendationsFor measurement of acetabular cup version angle, we recommend the use of Lewinnek and Liaw et al. methods both in AP-P and in AP-H, while Hassan et al.’s method is recommended in AP-P only, and Widmer and Ackland et al.’s methods in AP-H only.

Kyphoplasty for osteoporotic vertebral fractures with posterior wall injury

BACKGROUND CONTEXT Cement augmentation techniques are standard treatments for osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with lower rates of cement leak and better deformity correction; however, posterior wall fractures are relative, but not absolute; contraindications for both techniques and hence treatment practices vary among spine centers. PURPOSE The primary aim of this study was to assess our centers incidence of posterior cement leakage in osteoporotic vertebral fractures with posterior wall injury treated by balloon kyphoplasty (BKP). Secondarily, physiological results, pain relief, complication rates, and non-posterior cement leakage were also evaluated. STUDY DESIGN This is a prospective cohort study done in a high-volume spine center in Germany. PATIENT SAMPLE Eighty-two patients with 98 osteoporotic vertebral fractures with posterior wall cortical injury were studied from 2012 to 2016. OUTCOME MEASURES The following were the outcome measures: (1) physiological measures: standing plain x-rays (anteroposterior and lateral views), with the following parameters evaluated: cement leak behind the posterior vertebral body border, Cobb angle for local sagittal deformity, vertebral wedge angle, and anterior vertebral height; (2) cement volume injected in each vertebra; and (3) self-report measures: visual analog scale (VAS). METHODS All patients underwent BKP using a bipedicular approach. Preoperative clinical and neurologic evaluations were done. Radiological evaluations included plain X-ray images, computed tomography scans and magnetic resonance imaging. The average follow-up period was 18 months. RESULTS No cement leakage into the spinal canal occurred in any of the patients. Asymptomatic leakage into other sites was seen in 22 vertebrae (22.45%). There was significant improvement in the Cobb angle, the vertebral wedge angle, and the anterior vertebral height in all cases. The mean preoperative VAS was 8.1, and this improved to 2.3 on the third postoperative day. CONCLUSION Balloon kyphoplasty is a viable option for the treatment of osteoporotic vertebral fractures even with posterior wall involvement.

Instrumented Circumferential Fusion for Tuberculosis of the Dorso-Lumbar Spine. A Single- or Double-Stage Procedure?

Introduction The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization. Material and Methods Between 2003 and 2012, 43 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared with a similar group of 25 patients treated with anterior debridement and fusion, followed 10–14 days later by posterior stabilization and postero-lateral fusion. Results The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 38 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 68 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 53 (78%) patients returned to their pre-disease activity level or work. Conclusion Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Two-Stage Surgical Treatment for Non-Union of a Shortened Osteoporotic Femur

Introduction We report a case of non-union with severe shortening of the femur following diaphysectomy for chronic osteomyelitis. Case Presentation A boy, aged 16 years presented with a dangling and excessively short left lower limb. He was using an elbow crutch in his right hand to help him walk. He had a history of diaphysectomy for chronic osteomyelitis at the age of 9. Examination revealed a freely mobile non-union of the left femur. The femur was the seat of an 18 cm shortening and a 4 cm defect at the non-union site; the knee joint was ankylosed in extension. The tibia and fibula were 10 cm short. Considering the extensive shortening in the femur and tibia in addition to osteoporosis, he was treated in two stages. In stage I, the femoral non-union was treated by open reduction, internal fixation and iliac bone grafting. The patient was then allowed to walk with full weight bearing in an extension brace for 7 months. In Stage II, equalization of leg length discrepancy (LLD) was achieved by simultaneous distraction of the femur and tibia by unilateral frames. At the 6 month follow- up, he was fully weight bearing without any walking aid, with a heel lift to compensate the 1.5 cm shortening. Three years later he reported that he was satisfied with the result of treatment and was leading a normal life as a university student. Conclusions Two-stage treatment succeeded to restore about 20 cm of the femoral shortening in a severely osteoporotic bone. It has also succeeded in reducing the treatment time of the external fixator.

Non-Anatomical Surgical Solutions for Difficult Non-Unions: Case Series

Abstract Non-union occurs when bone healing ceases and does not continue without some type of intervention. Classification of non-union is traditionally based on the amount of callus or bone healing at the fracture site. Successful treatment of non-union often depends on appropriate reduction and realignment of the fracture, bone grafting if necessary, and stabilization. This may not be possible in some neglected and complicated non-unions. Under these circumstances, modification of the standard techniques or a limited surgical interference, that might not be anatomical, may succeed in improving function. We present four cases of non-anatomical salvage solutions for difficult long bone non-unions with satisfactory functional outcome.