Hani El-Mowafi

The effect of low-intensity pulsed ultrasound on callus maturation in tibial distraction osteogenesis

Callus distraction is currently the most popular method of bone lengthening. Prolonged treatment time is one of its major problems. In this study, we investigated the effect of low-intensity pulsed ultrasound on tibial distraction osteogenesis. We managed 20 patients with tibial defects ranging from 5 cm to 8 cm with distraction osteogenesis using the Ilizarov external fixator. After the completion of distraction, ten patients received daily 20 min of low-intensity pulsed ultrasound stimulation (30 mW/cm2) onto the bone lengthening site (group A) while rigid fixation was maintained in the remaining patients (group B). All patients were followed with weekly radiographs to determine the formation of an external cortex and an intramedullary canal, at which time the fixator was removed. The mean healing index in group A was 30 (27–36) days/cm while it was 48 (42–75) days/cm in group B. In group B, one patient failed to consolidate the regenerated bone. Low-intensity pulsed ultrasound stimulation is highly effective in achieving maturation of bone and reducing time of distraction osteogenesis.RésuméLa distraction du cal est la méthode d’allongement de l’os la plus populaire actuellement. La longueur du traitement est un de ses problèmes majeurs. Nous avons étudié l’effet des ultrasons pulsés de basse intensité sur l’ostéogenèse dans la distraction tibiale.Nous avons traité 20 malades présentant un défaut tibial de 5 à 8 centimètres avec ostéogenèse de distraction utilisant un fixateur externe d’Ilizarov. Après l’achèvement de la distraction 10 malades ont reçu quotidiennement une stimulation par ultrasons (30 mW/cm2) sur l’emplacement de l’allongement osseux pendant 20 minutes (groupe A), pendant que la fixation rigide était maintenue pour le restant des malades (groupe B). Tous les malades ont été suivis avec des radiographies hebdomadaires pour déterminer la formation d’un cortex périphérique et d’un canal intramédullaire au moment ou le fixateur a été enlevé. L’index de consolidation moyen dans le groupe A était 30 (27–36) jours/cm pendant qu’il était 48 (42–75) jours/cm dans le groupe B. Dans le groupe B un malade n’a pas consolidé l’os régénéré. La stimulation par ultrasons pulsés de basse intensité est très efficace pour favoriser la maturation osseuse et réduire le temps d’ostéogenèse dans la distraction.

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.

The management of tibial pilon fractures with the Ilizarov fixator: The role of ankle arthroscopy.

BACKGROUND Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. PURPOSE This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. METHODS From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgőwer classification. Follow up ranged from 10 to 37 months with a mean of 18 months. RESULTS All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. CONCLUSION We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. LEVEL OF EVIDENCE level 2.

Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy

Background: Ankle fusion is difficult to achieve in the diabetic Charcot ankle Brodsky type 3a because of the poor quality of the bone and the inability to achieve a stable biomechanical construct. The aim of this study was to report the outcome of ankle fusion using a combination of an intramedullary nail and a circular external fixator in patients with diabetic Charcot arthropathy. Methods: We prospectively studied 24 patients with diabetic Charcot arthropathy of the ankle who were treated by fusion of the tibiotalar joint using a combined retrograde intramedullary nail and Ilizarov external fixator. Their mean age was 50.7 ± 6.9 (range, 43-62) years. The mean follow-up after surgery was 36.4 ± 5.8 (range, 24-98) months. Results: Twenty-two patients (92%) achieved clinical and radiographic solid bony fusion. No patients in this series needed amputation. All the patients were pain free, and the mean American Orthopaedic Foot & Ankle Society Score (AOFAS) improved significantly from 34.6 ± 6.8 to 66.4 ± 4.5 at the last follow-up. Two patients developed an ulcer over the heel due to a prominent nail. The ulcer healed after nail removal. Eight patients developed pin tract infection. Conclusion: We report a successful outcomes of ankle fusions using combined intramedullary nail locked only proximally and ring external fixator (hybrid fixation) in patients with diabetic Charcot arthropathy. Level of Evidence: Level IV, case series.

Randomized, double-blind, placebo-controlled, interventional phase IV investigation to assess the efficacy and safety of r-hirudin gel (1120I.U) in patients with hematomas

Essentials Efficacy and safety data on recombinant hirudin gels for the treatment of hematomas is limited. We assessed the clinical efficacy of a topical r‐hirudin gel in 199 patients with hematomas. Treated patients exhibited significant reductions in hematoma size and flare within 16 days. r‐hirudin gel treatment induces a complete resolution of hematomas and associated edema in 98%, and 99% of patients, respectively.

Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet

BACKGROUND Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex. METHODS We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months. RESULTS The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation. CONCLUSION Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.