Hatem G. Said

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.

Vascular Obstruction at the Level of the Ankle Joint as a Complication of Hip Arthroscopy

We report a case of foot vascular obstruction as a complication of hip arthroscopy. A 23-year-old female patient underwent hip arthroscopy for femoroacetabular impingement. The duration of the procedure was 80 minutes, including 20 minutes with traction for arthroscopy of the central compartment and 60 minutes without traction for cam treatment in the peripheral compartment. Three days postoperatively, the patient complained of a cold foot and pain and paresthesia during leg and foot elevation with continuous passive motion therapy. With persisting symptoms, she was seen by the referring physician 4 days postoperatively. Pulselessness at the level of the ankle and reduced capillary perfusion were observed. Doppler sonography and magnetic resonance angiography showed an occlusion of the peroneal, posterior tibial, and anterior tibial arteries at the level of the right ankle. The patient was readmitted to the hospital and underwent intravenous prostaglandin E1 therapy for 9 days, followed by oral clopidogrel treatment for 6 weeks. After 8 weeks, follow-up Doppler sonographic findings were normal. Subjective paresthesia and sensation of coldness resolved completely after 6 months. Possible theories for this complication and strategies on how to avoid it are discussed.

Intra-Articular Hip Injection Using Anatomic Surface Landmarks

Intra-articular hip injection is a frequently used technique for diagnostic and therapeutic purposes and is gaining more importance for the early diagnosis of hip disease. It is commonly performed with imaging guidance such as ultrasonographic or fluoroscopic control. We describe our technique of injection of the hip using relative distances from anatomic surface landmarks, with the needle insertion point at the site of the proximal anterolateral portal for hip arthroscopy, with a posterior direction of 30° and targeted toward a junctional point between 2 perpendicular lines, 1 distal from the anterior superior iliac spine and the second anterior from the tip of the greater trochanter. This technique can be used without imaging guidance in the outpatient clinic. Moreover, it minimizes the need for radiographic exposure for more critical injections, such as the injection of contrast material before conducting magnetic resonance arthrogaphy of the hip.

Hip Arthroscopy for Excision of Osteoid Osteoma of Femoral Neck

Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management. The patients improved dramatically postoperatively. OO of the femoral neck should be included in the differential diagnosis of hip pain in young patients. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.

Multidetector CT for thorn (wooden) foreign bodies of the knee

PurposeThorn (wooden) foreign bodies of the knee present a challenge in their diagnosis. Partly because of inaccurate history and sometimes a long duration of symptoms, radiographs are negative and MRI may show synovitis without a specific pathology.MethodsWe report a case of a 16-year-old male patient with a date palm thorn foreign body, which caused septic arthritis. He underwent two open surgeries. Both failed to detect the loose body. An MRI of the knee showed a high signal in the posterolateral compartment; however, the pathology could not be confirmed except by 64 Multidetector CT (MDCT) that clearly identified the thorn and its location.ResultsArthroscopic removal and synovectomy were done by a 4-portal technique. The patient went on to complete recovery.ConclusionMultidetector CT has proven very useful in identifying wooden foreign bodies, their size and location.

Therapeutic effects of peripheral magnetic stimulation on traumatic brachial plexopathy: clinical and neurophysiological study.

OBJECTIVE To evaluate the therapeutic effects of peripheral repetitive magnetic stimulation (rMS) on recovery of traumatic brachial plexopathy. PATIENTS AND METHODS Thirty-four patients with traumatic brachial plexopathy were studied. Strength of different muscles of upper limbs was evaluated neurologically. Nerve conduction studies (NCS), upper limb F-waves and visual analogue scales (VAS) for shoulder pain were obtained for all patients. These were randomly assigned into two groups with a ratio of 2:1; each patient received conventional physical therapy modalities and active exercises as well as real or sham rMS applied over the superior trapezius muscle of the affected limb daily for 10 sessions. Patients were reassessed with the same parameters after the 5th and the 10th session, and 1 month after rMS treatment. RESULTS No significant between-group differences were recorded at baseline assessment. Significant improvement was observed (time X groups) after real rMS in comparison to the sham group (P=0.0001 for muscle strength and 0.01 for VAS of shoulder pain). These improvements were still present at 1 month after the end of treatment. In accordance with the clinical improvement, a significant improvement was recorded in the neurophysiological parameters in the real vs the sham group. CONCLUSIONS We demonstrate that peripheral rMS for 10 sessions may have positive therapeutic effects on motor recovery and pain relief in patients with traumatic brachial plexopathy. Therefore, it is a useful adjuvant in the therapy of these patients.

The current situation in hip arthroscopy

Hip arthroscopy is an evolving surgical technique that has recently increased in popularity. Although femoroacetabular impingement was an important launch pad for this technique, extra-articular pathology has been described through hip endoscopy. Good clinical results in the medium term will allow improvements in this technique and increase its indications. Cite this article: EFORT Open Rev 2017;2:58-65. DOI: 10.1302/2058-5241.2.150041

Latarjet Procedure for Anterior Shoulder Instability Due to Tramadol-Induced Seizures: A Multicenter Study.

Background: Seizures, commonly due to epilepsy, are known to cause shoulder instability. Tramadol addiction has recently been found to induce seizures in patients who exceed the recommended dose. Because of the easy accessibility and low cost of tramadol, an increasingly alarming phenomenon of tramadol abuse has been demonstrated in recent years. Purpose/Hypothesis: The purpose of this multicenter study was to investigate shoulder instability resulting from tramadol-induced seizure (TIS) as well as to recommended management for such shoulder instability. The hypothesis was that TIS leads to anterior shoulder dislocations with major bony defects, which favors bony reconstructive procedures as a suitable method of treatment. Study Design: Case series; Level of evidence, 4. Methods: This prospective case series study was conducted on 73 patients (78 shoulders) who presented with anterior shoulder dislocations and a clear history of tramadol abuse. The mean age of the patients was 26.8 years, and the mean number of dislocations was 14. The mean duration of addiction was 17 months, with a mean dose of 752 mg of tramadol hydrochloride per day. Glenoid and humeral bone loss ranged from 15% to 35% and from 15% to 40%, respectively. The mean follow-up period was 28 months. All patients underwent an open Latarjet procedure. Results: Postoperative mean Rowe score and American Shoulder and Elbow Surgeons score at final follow-up (24 months) improved significantly from 20 to 84 and from 44 to 91, respectively (P < .05). The patient satisfaction rate reached 95%, and the mean period of return to work was 12.8 weeks. Five patients (9%) had postoperative seizures due to relapse of the tramadol abuse, but only 3 patients (5%) had redislocations with nonunion or breakage of the graft or hardware. Conclusion: Tramadol addiction has evolved as an important cause of seizures that can result in shoulder dislocation. Anterior shoulder instability with TIS occurs mainly with higher levels of addiction and results in significant humeral and/or glenoid bone defects. The Latarjet procedure is recommended for these patients, after control of addiction, and provides 95% satisfaction at midterm follow-up.

Basics in hip chondrolabral lesions and state of the art

Chondrolabral complex is a weak point along an histological transition zone. Most cartilage and labral lesions in the femoroacetabular impingement syndrome are located in this area. Different classifications are used to evaluate the severity and predict the prognosis of chondrolabral complex injuries. Acetabular Labrum Articular Disruption (ALAD) and Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) classifications are commonly used with a prognosis and treatment implication. Treatment of chondrolabral lesions detected on magnetic resonance imaging (MRI), should only be considered when clinical symptoms are presented. A wide range of treatment options include debridement with or without microfracture, repair or regenerate therapies. The future of hip joint preservation should be directed towards to the development of the treatment of chondrolabral injuries.

Treatment of Irreducible Traumatic Anterior Shoulder Dislocation Caused by Subscapularis Tendon Interposition

Irreducible shoulder dislocation is an uncommon event. When it does occur, blocks to reduction can include bone, labrum, rotator cuff musculature, or tendon. Concomitant rotator cuff tear at the time of initial dislocation is not an exclusive complication of anterior shoulder dislocation in the older population. Indeed, rotator cuff tear should not be excluded based solely on the patients age. Rotator cuff interposition is not an uncommon complication after anterior dislocation of the shoulder. It should be suspected when there is incongruency of the joint and persistent subluxation on postreduction radiographs. If such incongruence or subluxation is seen, a computed tomographic (CT) or magnetic resonance imaging (MRI) scan must then be obtained to determine the nature of the interposed soft tissues. The key to treatment is early diagnosis and adequate imaging. Open reduction and repair of the rotator cuff should be performed. We present a technique for treating irreducible anterior shoulder dislocation caused by interposition of the subscapularis tendon. Both CT and MRI observations, along with intraoperative findings and surgical technique, are discussed.