Mostafa A. Ayoub

Vertically unstable sacral fractures with neurological insult: outcomes of surgical decompression and reconstruction plate internal fixation

During a 4-year period, 32 patients with type C unstable sacral fractures were treated in our university hospital. All patients had neurological deficits as a result of their sacral fracture. The average age was 31.2 (range 22-54) years and the average Hannover Polytrauma Score (PTS) was 24 (range 19-40) points. Twelve patients had zone I fracture, ten had zone II fracture and ten patients had comminuted fractures involving both zones. All patients underwent surgical decompression and reconstruction plate internal fixation. The average follow up period was 24.4 (range 19-47) months. Twenty-one patients (65.6%) had complete neurological recovery, eight patients (25%) had partial recovery and three patients (9.4%) had no recovery. The relationship between radiological and functional scores was evident but insignificant (P = 0.434). Significantly, the neurological recovery was less favourable in older age groups, pedestrian trauma, vertical shear injuries, comminuted fractures, fifth lumbar root involvement, very low motor power grades and in patients presenting late. Concerning complications, four patients (12.5%) had early infection and five patients (15.6%) had late urological problems and heterotopic ossification. Consequently, we conclude that patients undergoing very early surgical decompression and only reconstruction plate internal fixation can achieve safe early ambulation and better neurological, functional and radiological results.

Salvage of dislocated hip and knee during limb lengthening for congenital femoral deficiency

Background The articular and soft tissue deficiencies associated with congenital femoral deficiency are reported to predispose to joint dislocation during limb lengthening, which would negate the value of limb lengthening. Patients and methods The cases of 17 children who suffered hip and/or knee dislocation as a result of femoral lengthening for congenital femoral deficiency of Paley’s classification type 1 and 2a were included. Their ages ranged from 4.5 to 13 years (average: 6.8 years). The average lengthening achieved at the time of diagnosis of the dislocation was 5.7±1.048 cm (range: 4.5–8 cm). Hip dislocation only was present in seven (41%) cases, knee dislocation only in six (35%) cases, and combined dislocation in four (24%) cases. Results A center-edge angle of Wiberg less than 22° had a highly significant effect on hip dislocation (P=0.001), and all knee dislocations were associated with a hypoplastic lateral femoral condyle. Both joint dislocations were common when the child had a center-edge angle of 15–20° together with a hypoplastic lateral femoral condyle. Discussion and conclusion Hip dislocations were managed with soft tissue release and pericapsular acetabuloplasty with satisfactory Mckay’s hip scores in all cases. Knee dislocations were reduced and stabilized by means of extra-articular ligament reconstruction with satisfactory Judet’s knee criteria in 82% of cases.

Geriatric complex proximal humeral fracture: intraoperative locking plate problems and proposed solutions

Background: Surgical treatment of complex proximal humeral fractures in the elderly is controversial. There are no clear criteria on whether to preserve the humeral head or replace it. The aim of this study was to evaluate the results of locking-plate internal fixation and to clarify the encountered intraoperative problems with their suggested solutions. Methods: The study included 34 patients older than 60 yr of age. Eighteen had three-part fractures and 16 had four-part fractures according to Neer’s classification. All patients had internal fixation with locking plates and according to the encountered problems additional procedures were added to obtain stable reduction and rigid fixation. The clinical evaluation depended on the objective Constant-Murley score (CMS) and the subjective Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: The mean follow up was 27.7±5.6 mo, and the mean age was 69.9±4.4 yr. The mean CMS was 70.9±14.8 points, and the mean DASH score was 28.2±17.8 points. Humeral head avascular necrosis occurred in three (8.8%) with significant reduction in CMS (P=0.001). Partial loss of initial reduction occurred in four patients (11.8%) with significant reduction in CMS (P=0.007). Secondary surgery was mandatory for six patients (17.6%). Conclusions: We believe that locking plate osteosynthesis with preservation of the humeral head is worth considering in elderly patients with complex injuries provided the surgeon and facility are prepared for any problems that may arise.