Wael Koptan

Four-part fracture dislocations of the proximal humerus in young adults: results of fixation.

INTRODUCTION Four-part fracture dislocations of the proximal humerus occurring in young age are extremely difficult fractures with a high incidence of complications. The risk of avascular necrosis is high; hence, prosthetic replacement is the treatment of choice in older patients with these complex fractures; on the other hand, the longevity of the prosthesis is the main concern in young age. Thus, every effort should be made to fix these fractures in the young. The purpose of this study is to evaluate the results of fixation in a series of young patients with four-part fracture dislocations; to support the trend to fix these fractures; and reserve prosthetic replacement to older patients. METHODS In a prospective study, 39 patients younger than 40 years of age with four-part fracture dislocations were treated with open reduction and fixation either with K-wires or with a proximal humerus plate. Ethibond sutures were used in all patients to supplement fixation of tuberosities. In 18 patients, the dislocation was anterior and in 21 patients it was posterior. Twelve patients had an anatomic neck fracture and 27 had a surgical neck fracture. Surgery was performed within 1 week after the injury. Physiotherapy was initiated according to the general condition of the patient and the stability of fixation; the average time was 5 days after surgery. RESULTS Patients were followed up for an average of 26 months. Union was achieved in 36 patients and three patients had nonunion, all in anatomic neck fractures. Avascular necrosis developed in eight patients, seven of which were fractures of the anatomic neck and one was in the surgical neck. The average Constant score was 77; 26 patients were pain free, nine had mild pain and four had moderate pain. The mean active anterior elevation was 145°. Patients were divided into two groups based on the anatomic configuration of the fracture; in 12 patients (group 1), the head was fractured at the anatomical neck and in 27 patients (group 2), the head was fractured at the surgical neck. In group 2, the active anterior elevation was significantly better and the Constant score was higher. CONCLUSIONS Anatomical reduction and rigid fixation with meticulous surgical technique can lead to satisfactory results. The results in surgical neck fractures are superior to anatomic neck fractures with significantly less complications.

All pedicle screw instrumentation for Scheuermann's kyphosis correction: is it worth it?

BACKGROUND CONTEXT Scheuermanns kyphosis has long been treated by a two-staged fusion and instrumentation with a hybrid construct using hooks, pedicle screws, and sublaminar wires. Recent interest in all pedicle screw constructs led to its use in the treatment of Scheuermanns kyphosis. Evaluation of this newly described application is needed. PURPOSE To compare the results of segmental all pedicle screw constructs versus two-staged hybrid instrumentation in patients with Scheuermanns kyphosis analyzing the amount of correction and incidence of complications. STUDY DESIGN Retrospective case series reporting on two groups of patients with Scheuermanns kyphosis treated with single-staged all pedicle screws technique versus two-staged anterior release and posterior hybrid instrumentation followed-up for a minimum of 2 years. PATIENT SAMPLE The study included 33 patients divided into two groups. The average age was 15 years+9 months and 16 years+8 months, respectively. The average preoperative dorsal kyphosis was 85.5 degrees (Group 1) and 79.8 degrees (Group 2). OUTCOME MEASURES The deformity was measured by Cobbs method preoperatively, postoperatively, and at final follow-up. Operative time and blood loss were also measured and recorded. The results of the Scoliosis Research Society (SRS)-30 questionnaire were also reviewed. METHODS The study included 16 patients who underwent a single-staged correction by segmental all pedicle screw constructs and multiple-level posterior osteotomies (Group 1) and 17 who underwent a two-staged fusion and instrumentation with a hybrid construct (Group 2). RESULTS Both groups were followed for a minimum of 2 years. The deformity correction of Group 1 had an average of 52.2% postoperatively with 2.4% loss at final follow-up in comparison to Group 2 where the correction was 48.7% postoperatively with 3.1% loss at final follow-up. The operative time was considerably less in Group 1 with an average of 215 minutes than Group 2 with an average of 315 minutes. The average blood loss was 620cc in Group 1 and 910cc in Group 2. The SRS-30 questionnaire in Group 1 averaged 134 and in Group 2 averaged 120. CONCLUSIONS The use of multiple-level all pedicle screws technique allowed a rigid anchor for posterior correction of the deformity with less operative time, blood loss, and hospital stay without the need for anterior release. A better correction was achieved and preserved with the use of all pedicle screw constructs. This technique is a useful modality in the treatment of Scheuermanns kyphosis.

Proximal humeral fractures treated with hemiarthroplasty: Does tenodesis of the long head of the biceps improve results?

INTRODUCTION Pathology of the long head of the biceps (LHB) may be the cause of anterior shoulder pain after hemiarthroplasty for treatment of fractures of the proximal humerus. The currently available literature lacks adequate randomised trials examining whether tenodesis of the LHB improves results. The purpose of this study was to evaluate the effects of tenodesis of the LHB on the clinical outcome following hemiarthroplasty for fractures of the proximal humerus. METHODS This prospective randomised study included 37 patients treated with hemiarthroplasty for four-part fractures, fracture dislocations and head-splitting fractures. The LHB was left intact in 18 patients (group 1) and tenodesis was performed in 19 patients (group 2). The mean age was 51.0 ± 3.7 years and 53.1 ± 4.6 years in group 1 and group 2, respectively. All patients were operated on by the same surgeon in the first 5 days after injury and one type of prosthesis was used. The shoulder was immobilised for 4 weeks before performing the same physiotherapy protocol. Pain and range of motion were assessed by a blinded observer. RESULTS Patients were followed up for a mean of 25.1 ± 3.9 months in group 1 and 22.6 ± 3.6 months in group 2. They were evaluated using the Constant score; it had a mean of 69.8 ± 6.6 for group 1 and a mean of 74.4 ± 6.5 points for group 2 (p = 0.04). Shoulder pain affected six patients in group 1 (33.3%) and only affected three patients in group 2 (15.8%) (p = 0.03). There was no significant difference in active anterior elevation of the shoulder between both groups. CONCLUSIONS The data obtained support the hypothesis to routinely perform a tenodesis of the LHB during hemiarthroplasty for treatment of fractures of the proximal humerus to improve pain and have better results. LEVEL OF EVIDENCE Level I therapeutic.

Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved. We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap.

Under-coracoid-around-clavicle (UCAC) loop in type II distal clavicle fractures

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Direct repair of spondylolysis presenting after correction of adolescent idiopathic scoliosis.

BACKGROUND CONTEXT Although spondylolysis is found in 6% of idiopathic scoliosis patients, very little was reported on management of pars defects in this group. These patients with painful spondylolysis are most eligible for direct repair of the defect rather than lumbosacral fusion in an attempt to save motion segments. PURPOSE The aim of this work was to analyze the clinical and radiologic outcome of pars repair in a group of adolescents who presented after surgical correction of their idiopathic scoliosis. STUDY DESIGN A prospective nonrandomized study. PATIENT SAMPLE Ten consecutive patients with spondylolysis presenting after an average of 3 months (range, 2-7 months) from correction of their idiopathic scoliosis with low back pain not responding to conservative therapy and interfering with everyday activities. The mean age at operation was 16 years (range, 14-19 years). OUTCOME MEASURES Total blood loss, operative time, and hospital stay were recorded. Clinical outcome was assessed by the Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 questionnaire. Fusion of the pars interarticularis was assessed using plain, lateral, and oblique radiographs and a computed tomography (CT) scan. METHODS The surgical technique consisted of thorough debridement of the defect, impacting the gap created with a tricortical iliac crest graft, and rigid fixation by either pedicle screws and a V-shaped rod (five patients) or a cable-screw construct (five patients). RESULTS Patients were followed up for an average of 4.5 years (range, 2-7 years). Nine patients had a good-to-excellent result, returned to normal everyday life, and participated in sports when desired. The mean ODI, VAS, and SRS total scores were 11 (range, 0-34), 1.1 (range, 0-2), and 92 (range, 61-108), respectively. Follow-up radiographs and CT scans revealed healing of all defects in nine cases, no signs of disc degeneration in any, and no implant-related complications. CONCLUSIONS The results of direct repair of spondylolysis in idiopathic scoliosis patients were very satisfactory both clinically and radiologically. Direct repair appears to be a logical alternative to spinal fusion; lumbar spine mobility was preserved, and precocious motion segments were saved with a relatively simple operation.

Lumbar fusion for lytic spondylolisthesis: Is an interbody cage necessary?

Study Design: This study was a retrospective observational study. Purpose: The purpose of the study was to determine the radiological and clinical outcome of using locally sourced autologous bone graft in the surgical management of single-level lumbar lytic spondylolisthesis. Background: Many spinal surgeons supplement pedicle screw fixation of lumbar spondylolisthesis with cages. In developing countries, the high cost of interbody cages has precluded their use, with surgeons resorting to filling the interbody space with different types of bone graft instead. This study reports on the clinical and radiological outcome of posterior lumbar interbody fusions for low-grade lytic spondylolisthesis using locally sourced autologous bone graft. Material and Methods: Posterior interbody fusion was performed in 22 consecutive patients over 18-month period, using (BRAND) pedicle screw system and locally sourced bone graft, i.e., bone removed during neural decompression. There were no postoperative restrictions, and all patients underwent clinical outcome measurements using Oswestry Disability Index (ODI), visual analogue pain score (VAS) at a minimum follow-up of 12 months, and computed tomography (CT) assessment of fusion with intraobserver validation by radiology consultant blinded, at 6 and12 months. Nearly 50% of the population were smokers. Results: There was significant clinical improvement in ODI, VAS back pain, and VAS leg pain (P < 0.001). By contrast, the radiologic fusion rate measured by CT at 12 months was less satisfactory at 64%. There was no difference in clinical outcome between the fused group and nonfused population. Conclusions: These results indicate that the use of locally sourced bone graft in single-level lumbar lytic low-grade spondylolisthesis. Interbody fusion provides good clinical outcomes. The use of an interbody cage may not be clinically necessary. Our radiologic outcome, however, shows inferior fusion rates compared with published data. Future research will focus on long-term outcomes

Augmentation of fenestrated pedicle screws with cement in patients with osteoporotic spine

Background: Backing out and failure of pedicle screws in patients with osteoporosis is becoming a big problem due to wide use of these screws nowadays. Purpose: The aim of this study is to evaluate the purchase of fenestrated pedicle screws augmented with cement in patients with osteoporosis. Study Design: This was retrospective observational study. Patients and Methods: From May 2015 to January 2016, 25 patients with a poor bone stock condition underwent posterior fixation by fenestrated pedicle screws and cement augmentation. Assessment of pain improvement was done by visual analogue score (VAS) score while the long-term clinical outcome was assessed using Oswestry low back disability questionnaire (Oswestry disability index [ODI]). Implant stability was evaluated by plain radiography. Complications were evaluated in all cases. Results: All patients were followed up clinically and radiographically for a mean age of 24.84 months. There was a significant reduction in pain and improvement of the quality of life as detected using VAS scores and ODI questionnaire consecutively (P < 0.001). No radiological loosening or backing out of screws was observed. Cement leakage occurred in five cases. Conclusion: Augmentation of fenestrated screws with cement provided effective and lasting purchase in patients with osteoporosis. The only clinical complication strictly related to this technique was cement leakage.

Role of Cerebrolysin in cervical spondylotic myelopathy patients: a prospective randomized study

BACKGROUND CONTEXT Cerebrolysin is a mixture containing 85% free amino acids and 15% biologically active low-molecular weight peptides that is believed to mimic the effects of endogenous neurotrophic factors to interact with the pathologic process cascade of neurodegenerative diseases. No study has examined the effect of Cerebrolysin on cervical myelopathic patients. PURPOSE The objective of this study was to evaluate the effect of Cerebrolysin as a conservative modality on cervical spondylotic myelopathic patients. STUDY DESIGN This is a prospective randomized study. PATIENT SAMPLE A total of 192 patients with cervical spondylotic myelopathy (CSM) were subdivided blindly into two equal groups. OUTCOME MEASURES Followed-up was performed at 1, 3, and 6 months comparing the recovery rate Japanese Orthopaedic Association (JOA) score for cervical myelopathy between the two groups. METHODS Group I received Cerebrolysin and Group II received placebo for 4 weeks; both groups received celecoxib 200 mg for 4 weeks. RESULTS Myelopathy improved in 92% and 52% of patients at 1 month in Groups I and II, respectively; these changed at 6 months to 87% and 33%; the remaining 13% in Group I neither improved nor deteriorated, whereas 60% in Group II neither improved nor deteriorated and 7% deteriorated with statistically significant differences when comparing the mean JOA recovery rate between the 2 groups at 1, 3, and 6 months. CONCLUSIONS Cerebrolysin over 4 weeks is safe and effective for the improvement of CSM as compared with placebo, with no reported cases of neurologic deterioration over 6 months of follow-up.

Time to union and functional outcome following minimally invasive plating of extra-articular fractures of the distal tibia

Background Treatment of distal tibial fractures is often challenging and fraught with complications. Minimally invasive plating is thought to overcome complications associated with open plating and intramedullary fixation in the distal third of the tibia. The aim of this study was to evaluate the use of minimally invasive plating in extra-articular fractures of the distal tibia regarding time to union, functional outcome, and complications. Patients and methods Thirty consecutive patients with extra-articular fractures involving the distal third of the tibia were classified according to the Muller-Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and treated with minimally invasive plating using the anatomical distal plate. In nine cases, the locked anatomical distal plate was used, whereas in 21 cases the conventional nonlocked anatomical distal plate was used. Patients were followed up at 2 and 6 weeks postoperatively and then every 6 weeks with a mean follow-up time of 30 weeks (range: 18–94 weeks), in which time to union and complications were documented. Functional outcome was assessed using the American Orthopedic Foot and Ankle Society ankle scoring system at a minimum of 12 weeks from the start of weight-bearing. Results All cases showed union at a maximum of 16 weeks, except four cases: two had delayed union, one had plate failure that ended in deep infection, and there was a case of nonunion. Overall, the mean time to union was 17 weeks (range: 6–60 weeks). The American Orthopedic Foot and Ankle Society ankle scoring system scored an average of 92.4 points (range: 72–100 points). Conclusion This technique minimizes the soft-tissue complications and provides a good functional outcome for patients with extra-articular distal tibial fractures within a reasonable period of time. Level of evidence The present study was a level IV case series.