Khaled Salem

Treatment of Tossy III acromioclavicular joint injuries using hook plates and ligament suture.

Objectives: The management of acromioclavicular (AC) injuries has long been debated. We analyzed our results in treating such cases using hook plates and ligament suture. Design: Retrospective nonrandomized study. Setting: Level I Trauma Center (University Hospital). Patients: Twenty-five patients (mean age 41 years) with complete Tossy III AC joint disruptions. Using the Rockwood classification, 15 dislocations were classified as type V injuries, 9 as type III injuries, and 1 as a type IV injury. Intervention: All patients were operatively treated using AC hook plates with ligament suturing after a median delay of 7 days. Main Outcome Measures: Clinical and radiographic evaluation using Constant-Murley functional score and Taft et al criteria. Results: A retrospective clinical and radiographic evaluation of 23 patients was performed after an average follow-up period of 30 months. The mean Constant score was 97 (range, 90-100) points, and the mean Taft score was 10.6 points. All but 1 patient were satisfied with their treatment outcome. Eight cases showed some loss of reduction after plate removal. A poor correlation existed, however, between clinical and radiographic results. Conclusions: The hook plate is a reliable fixation tool for complete AC joint dislocations, ensuring immediate stability and allowing early mobilization with good functional and cosmetic results. Routine plate removal should however be reevaluated.

Ankle Arthrodesis Using Ilizarov Ring Fixators: A Review of 22 Cases:

Background: Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. Methods: Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. Results: Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. Conclusions: The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.

Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation

We treated 30 tibial plateau fractures (Schatzker Type VI) in 29 patients, with a mean age of 41.4 (20–76) years, with the Ilizarov fixator. In 18 fractures, we combined the treatment with minimal internal fixation. All fractures were the result of high-energy trauma, and 20 patients had associated injuries. Twenty-eight fractures were available for follow-up after 27 (16–36) months. Using The Knee Society clinical rating system, 18 knees were rated as excellent, seven as good, one as fair, and two as poor. There was a direct correlation between the presence of associated injuries and the final outcome. The most significant concomitant injuries were distal femoral fractures and extensive soft-tissue injury. This study emphasizes the clinical success and low morbidity associated with the use of external fixation and minimal internal fixation.RésuméNous avons traité chirurgicalement 30 fractures du plateau tibial (Type Schatzker VI) chez 29 malades—âge moyen de 41,4 ans (20–76)—avec un fixateur d’Ilizarov. Pour 18 fractures nous avons combiné le traitement avec une fixation interne légère. Toutes les fractures étaient le résultat d’un traumatisme à haute énergie et 20 patients avaient des lésions associées. Après un suivi de 27 mois (16–36) 28 fractures étaient étudiables. Avec le score de la Knee Society, 18 genoux ont été estimés comme excellents, sept comme bons, un comme moyen, et deux comme mauvais. Il y avait une corrélation directe entre la présence de blessures associées et le dernier résultat, le plus significatif étant l’existence d’une fracture fémorale distale et l’importance des lésions des parties molles. L’étude met en relief le succès clinique et la basse morbidité associés à l’usage du fixateur externe et de la fixation interne légère.

The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children.

The indications for physiotherapy after supracondylar humeral fractures in children are not clear in the literature, even in the presence of an active or passive limitation of elbow joint motion. The authors therefore performed a prospective randomized study to assess the effectiveness of physiotherapy in improving the elbow range of motion after such fractures. The authors studied two groups of 21 and 22 children with supracondylar humeral fractures Felsenreich types II and III, all without associated neurovascular deficits. All children were treated by open reduction and internal fixation with Kirschner wires inserted from the radial side of the humerus. Postoperative follow-up at 12 and 18 weeks showed a significantly better elbow range of motion in the group with weekly physiotherapy, but there was no difference in elbow motion after 1 year. In each group, one child had an extension deficit of 15 or 20 degrees. The authors conclude that postoperative physiotherapy is unnecessary in children with supracondylar humeral fractures without associated neurovascular injuries.

Nonsteroidal anti-inflammatory drugs (NSAIDs) in the perioperative phase in traumatology and orthopedics effects on bone healing.

ZusammenfassungZielErreichen eines analgetischen, antiphlogistischen und antipyretischen Effekts in der Traumatologie und Orthopädie ohne oder mit möglichst wenig Nebenwirkungen, unter spezieller Berücksichtigung der Knochenheilung.IndikationenAkute und chronische Entzündungen, z. B. Rheuma, Spondylitis ankylosans.Degenerative Gelenkerkrankungen.Posttraumatische und postoperative Schmerzen, Ödem oder Fieber.Prophylaxe gegen heterotope Ossifikationen.KontraindikationenÜberempfindlichkeit.Gastrointestinale Ulzeration oder Blutung.Schwere Leber- oder Nierenfunktionsstörung.ErgebnisseNichtsteroidale Antirheumatika (NSAR) sind wertvolle Medikamente in der Behandlung verschiedener muskuloskelettaler Erkrankungen. Neben der sehr guten analgetischen Potenz sind ihre antiphlogistischen Effekte vorteilhaft in der Behandlung des traumatischen und postoperativen Ödems. Darüber hinaus haben NSAR einen hemmenden Effekt auf die Ausbildung heterotoper Ossifikationen in der Hüftendoprothetik. Im Rahmen tierexperimenteller Studien konnte aber eine Verzögerung der Knochenbruchheilung nachgewiesen werden. Auch wenn der eindeutige Nachweis dieser Wirkung am Menschen in klinischen Studien nicht vorliegt, empfehlen die Autoren, bei weiteren Risikofaktoren, die möglicherweise die Frakturheilung beeinträchtigen können, wie Rauchen, Diabetes mellitus oder eine periphere arterielle Verschlusskrankheit, die Indikation zur Gabe von NSAR als reine Schmerzmedikation unbedingt streng zu stellen. Bei diesen Patienten sollten therapeutische Alternativen wie zentral wirksame Medikamente (z. B. schwache Opioide) erwogen werden.AbstractObjectiveTo achieve analgesic, anti-inflammatory and antipyretic effects in traumatology and orthopedic surgery without side effects or with the least possible side effects, with special emphasis on bone healing.IndicationsAcute and chronic inflammatory conditions, e. g., rheumatoid arthritis, ankylosing spondylitis.Degenerative joint disease.Posttraumatic and postoperative pain, edema, or fever.Prevention of heterotopic bone formation.ContraindicationsHypersensitivity.Gastrointestinal ulceration or bleeding.Severe hepatic or renal impairment.ResultsNonsteroidal anti-inflammatory drugs (NSAIDs) are invaluable in treating a variety of musculoskeletal conditions. As well as their excellent analgesic potency their anti-inflammatory effects are beneficial in treating posttraumatic and postoperative edema. In addition, NSAIDs inhibit heterotopic bone formation after hip arthroplasty. Animal studies, however, have demonstrated that they cause delayed fracture healing. Although clinical studies have not yet supplied unequivocal evidence of this effect in human subjects, the authors recommend that in the presence of other risk factors which may adversely affect fracture healing, such as smoking, diabetes mellitus or peripheral arterial occlusive disease, the indication of NSAID use for analgesia should be strictly limited. Therapeutic alternatives such as centrally acting agents (e. g., weak opioids) should be considered in these patients.

Nichtsteroidale Antirheumatika (NSAR) in der perioperativen Phase in Traumatologie und Orthopädie

ZusammenfassungZielErreichen eines analgetischen, antiphlogistischen und antipyretischen Effekts in der Traumatologie und Orthopädie ohne oder mit möglichst wenig Nebenwirkungen, unter spezieller Berücksichtigung der Knochenheilung.IndikationenAkute und chronische Entzündungen, z. B. Rheuma, Spondylitis ankylosans.Degenerative Gelenkerkrankungen.Posttraumatische und postoperative Schmerzen, Ödem oder Fieber.Prophylaxe gegen heterotope Ossifikationen.KontraindikationenÜberempfindlichkeit.Gastrointestinale Ulzeration oder Blutung.Schwere Leber- oder Nierenfunktionsstörung.ErgebnisseNichtsteroidale Antirheumatika (NSAR) sind wertvolle Medikamente in der Behandlung verschiedener muskuloskelettaler Erkrankungen. Neben der sehr guten analgetischen Potenz sind ihre antiphlogistischen Effekte vorteilhaft in der Behandlung des traumatischen und postoperativen Ödems. Darüber hinaus haben NSAR einen hemmenden Effekt auf die Ausbildung heterotoper Ossifikationen in der Hüftendoprothetik. Im Rahmen tierexperimenteller Studien konnte aber eine Verzögerung der Knochenbruchheilung nachgewiesen werden. Auch wenn der eindeutige Nachweis dieser Wirkung am Menschen in klinischen Studien nicht vorliegt, empfehlen die Autoren, bei weiteren Risikofaktoren, die möglicherweise die Frakturheilung beeinträchtigen können, wie Rauchen, Diabetes mellitus oder eine periphere arterielle Verschlusskrankheit, die Indikation zur Gabe von NSAR als reine Schmerzmedikation unbedingt streng zu stellen. Bei diesen Patienten sollten therapeutische Alternativen wie zentral wirksame Medikamente (z. B. schwache Opioide) erwogen werden.AbstractObjectiveTo achieve analgesic, anti-inflammatory and antipyretic effects in traumatology and orthopedic surgery without side effects or with the least possible side effects, with special emphasis on bone healing.IndicationsAcute and chronic inflammatory conditions, e. g., rheumatoid arthritis, ankylosing spondylitis.Degenerative joint disease.Posttraumatic and postoperative pain, edema, or fever.Prevention of heterotopic bone formation.ContraindicationsHypersensitivity.Gastrointestinal ulceration or bleeding.Severe hepatic or renal impairment.ResultsNonsteroidal anti-inflammatory drugs (NSAIDs) are invaluable in treating a variety of musculoskeletal conditions. As well as their excellent analgesic potency their anti-inflammatory effects are beneficial in treating posttraumatic and postoperative edema. In addition, NSAIDs inhibit heterotopic bone formation after hip arthroplasty. Animal studies, however, have demonstrated that they cause delayed fracture healing. Although clinical studies have not yet supplied unequivocal evidence of this effect in human subjects, the authors recommend that in the presence of other risk factors which may adversely affect fracture healing, such as smoking, diabetes mellitus or peripheral arterial occlusive disease, the indication of NSAID use for analgesia should be strictly limited. Therapeutic alternatives such as centrally acting agents (e. g., weak opioids) should be considered in these patients.

Limb geometry after elastic stable nailing for pediatric femoral fractures.

BACKGROUND Elastic stable intramedullary nailing has become a popular treatment for pediatric long-bone fractures. However, early limb malalignment and length differences may occur in children with femoral fractures who are managed with this procedure. METHODS We prospectively followed sixty-eight children (mean age, 5.6 years) who were managed with elastic stable intramedullary nailing for the treatment of a unilateral femoral shaft fracture in order to evaluate early angular or rotational malalignment or limb-length discrepancy. The average body weight was 21 kg (range, 10 to 45 kg). There were fifty-seven AO/ASIF Type-A fractures and eleven Type-B fractures. Malalignment was assessed with use of radiographs, computed tomography, or navigated ultrasound examination after four to seven months to evaluate the short-term result of fixation and to eliminate changes caused by later bone remodeling. RESULTS The mean femoral length difference was 0.5 mm of femoral lengthening. Only eleven patients (16%) had a limb-length discrepancy of >10 mm. Mechanical axial deviation of >5 degrees occurred in one patient. However, the mean femoral rotational angle difference was 14.5 degrees . Thirty-two children (47%) had > or =15 degrees of torsional malalignment. CONCLUSIONS Elastic stable intramedullary nailing can provide satisfactory results in terms of limb length and axial alignment, but a high rate of early torsional malalignment may be seen.

Hybrid external fixation for arthrodesis in knee sepsis.

Several techniques for knee fusion have been described with success rates ranging from 29% to 100%, with worse results occurring in patients with joint sepsis. We treated 21 patients with persistent infections using knee arthrodesis with a hybrid Ilizarov frame at our institution. There were 13 men and eight women ranging from 21 to 75 years (mean, 49.7 years). Sixteen patients had chronic osteomyelitis and five had previous fusion trials. Two patients required bone transport using the same arthrodesis frame. We corrected associated malalignment in three patients. Solid knee fusion was achieved in all but one patient after a mean external fixation time of 22.7 weeks (range, 11-47 weeks). Limb shortening averaged 2.8 cm (range, 1.5-5 cm). No patients required secondary bone grafting to achieve fusion. Nine patients had complications develop, three of whom required reresection and frame application to treat persistent infection or delayed union. Our results emphasize the clinical success of using the Ilizarov fixator for knee arthrodesis after persistent sepsis.Level of Evidence: Level IV Therapeutic Study. See the Guidelines for Authors for a complete description of levels of evidence.

On the role of hypercubes in the resonance graphs of benzenoid graphs

The resonance graph R(B) of a benzenoid graph B has the perfect matchings of B as vertices, two perfect matchings being adjacent if their symmetric difference forms the edge set of a hexagon of B. A family P of pair-wise disjoint hexagons of a benzenoid graph B is resonant in B if B-P contains at least one perfect matching, or if B-P is empty. It is proven that there exists a surjective map f from the set of hypercubes of R(B) onto the resonant sets of B such that a k-dimensional hypercube is mapped into a resonant set of cardinality k.

Maximum cardinality resonant sets and maximal alternating sets of hexagonal systems

It is shown that the Clar number can be arbitrarily larger than the cardinality of a maximal alternating set. In particular, a maximal alternating set of a hexagonal system need not contain a maximum cardinality resonant set, thus disproving a previously stated conjecture. It is known that maximum cardinality resonant sets and maximal alternating sets are canonical, but the proofs of these two theorems are analogous and lengthy. A new conjecture is proposed and it is shown that the validity of the conjecture allows short proofs of the aforementioned two results. The conjecture holds for catacondensed hexagonal systems and for all normal hexagonal systems up to ten hexagons. Also, it is shown that the Fries number can be arbitrarily larger than the Clar number.