Arthroscopic reduction and internal fixation of capitellar and trochlear fractures: A case series

Background In a simple isolated capitellar/trochlear fracture without extensive posterior comminution, arthroscopic reduction and internal fixation (ARIF) can provide an alternative option to open reduction internal fixation. The purpose of this retrospective case series was to report on the technique and outcomes of arthroscopic reduction and internal fixation of capitellar/trochlear fractures. Methods All patients that underwent ARIF at a single upper extremity referral centre in the last twenty years were reviewed. Patient demographics, preoperative, intraoperative, and postoperative records were obtained through chart review and telephone followup. Results Ten cases of ARIF were identified over a twenty year period performed by two surgeons. The average age of patients was 37 years (17–63 years), with nine females and one male. With an average followup of eight years, nine of ten patients had a mean range of motion from 0 to 142 degrees. Their average MEPI and PREE score were 93 ± 7 and 8 ± 14, respectively. Four patients had focal cartilage collapse with three that required a reoperation. There were no infections, nonunions, or arthroscopy related complications. Conclusion ARIF offers an alternative to ORIF for capitellar/trochlear fractures producing good results while providing better visualization of the fracture reduction and minimizing soft tissue dissection.

Knotless Reconstruction of Chronic Achilles Tendon Ruptures With <3-cm Defects: Technique Tip

Chronic Achilles tendon ruptures can result in tendon lengthening and significant functional deficits including gait abnormalities and diminished push-off strength. Surgical intervention is typically required to restore Achilles tension and improve ankle plantarflexion strength. A variety of surgical reconstruction techniques exist depending on the size of the defect and amount of associated tendinosis. For smaller tendon defects 2 to 3 cm in size, primary end-to-end repair using an open incision and multiple locking sutures is an established technique. However, a longer skin incision and increased soft tissue dissection is required, and failure at the suture-tendon interface has been reported that can result in postoperative tendon elongation and persistent weakness. In this report, we describe a novel technique to reconstruct chronic midsubstance Achilles tendon ruptures using a small incision with knotless repair of the tendon secured directly to the calcaneus. This technique minimizes wound healing complications, increases construct fixation strength, and allows for early range of motion and rehabilitation. Level of Evidence: Level V, Expert Opinion.

RETROGRADE INTRAMEDULLARY INTERLOCKING NAILING: A PROSPECTIVE STUDY IN SUPRACONDYLAR FRACTURE OF FEMUR

Introduction: In addition, a retrograde intramedullary supracondylar nail has got distinct advantages of preservation of fracture hematoma, decreased blood loss, minimal soft tissue dissection, less operative time, and reduced rate of infection. The purpose of this study is to evaluate the results of supracondylar and intercondylar fracture of the femur, treated by close or open reduction and internal xation using a retrograde intramedullary supracondylar nail. Methods: A total number of 32 patients were enrolled in this study who presented with supracondylar femur fracture and had undergone a closed reduction and internal xation by Retrograde Femoral nail. Neer's and Sander's evaluation scoring system was used for evaluation. Results: Neer's rating was used to assess the result, according to which there were good to excellent results in 74.20% of cases. Conclusion: Supracondylar femur nail is an optimum tool for many supracondylar fractures of the femur, but it needs attention to technique to prevent the difculty

Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures

Purpose We describe a novel technique that uses an aiming drill guide and ankle arthroscopy for direct visualization and reduction of the depressed articular surface located between the posterior tibia and the fractured posterior malleolus. This technique requires less soft tissue dissection to visualize and reduce the depressed articular surface. Methods Between June 2014 and May 2019, 126 patients were surgically treated for trimalleolar fractures. Among them, 11 had depressed articular fragment between the posterior tibia and the fractured posterior malleolus reduced using our novel technique. The study included six men and five women, with a mean age of 46.5 (range: 23–62) years. Results In eight (73%) cases, the articular surface was reduced, with the articular surface step-off being less than 2 mm, as noted on postoperative computed tomography (CT). Syndesmosis congruity within an anterior-to-posterior difference of less than 2 mm was confirmed in nine (82%) cases via postoperative CT. The mean 100-mm visual analog scale (VAS) and the mean Olerud-Molander ankle score at the final follow-up were 16.6 ± 14.5 and 87.7 ± 7.5, respectively. Conclusions The depressed articular fragment located between the posterior tibia and the fractured posterior malleolus can be treated using an aiming drill guide and ankle arthroscopy. Ankle arthroscopy is used for direct visualization of the depressed articular surface, and the aiming drill guide can guide the bone plunger precisely to the depressed articular surface for reduction. This technique requires less soft tissue dissection than conventional techniques to visualize and reduce the depressed articular surface.

A COMPARATIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL OUTCOME OF HIGH ENERGY PROXIMAL TIBIA FRACTURE USING ILLIZAROV EXTERNAL FIXATOR VS HYBRID EXTERNAL FIXATOR

Background: In High energy proximal tibia fracture aim is to achieve adequate reduction and stability without signicantly compromising the soft tissue integrity and vascularity . External xator minimizes soft tissue dissection and minimize other complications. Method: 60 patients' high energy proximal tibia fracture with cases were considered in the study. 30 patients were treated with Ilizarov external xator and 30 patients were treated with hybrid external xator. Results were analyzed both clinically and radiologically using Johner and Wruh's criteria. Results: Mean time of union was 22 week in ilizarov xator group and 34 week in hybrid xator group. Pin tract infection occured in 6 patient (20%) in ilizarov xator group and 4 patient in hybrid xator group. Joint stiffness occured in 3 Patient (10 %) in ilizarov group and 10 patient in hybrid xator group.Shortning occured in 2 patient (6.6 %) in ilizarov xator group and 2 patient in hybrid xator group. Overal results in ilizarov group were excellent in 23 patient (76.7%), good in 5 patient (16.67%) , fair in 2 patient (6.67%) while in hybrid group excellent in 16 patient( 53.33%),good in 10 patient(33.33%),fair in 4(13.33%)patient. Conclusion: External xators are excellent modalities in treatment of high energy proximal tibia fracture with ilizarov method has advantage of early mobilization and early union but require long operative time and bulky framework on other hand hybrid xator has simpler construct ,lesser operative time but has lesser stability , longer union time and longer immobilization time.

Arthroscopically Assisted Eaton–Littler Trapeziometacarpal Ligamentoplasty

Background Eaton–Littler ligamentoplasty has proven its efficacy in the treatment of trapeziometacarpal (TMC) instability. Description of Technique In this article, we describe the arthroscopically assisted Eaton–Littler ligamentoplasty through two clinical cases. Patients and Methods Arthroscopy is used to accurately place the metacarpal bone tunnel and pass the slip of flexor carpi radialis tendon in the latter. This procedure avoids soft-tissue dissection and could improve the outcome of this well-known surgery. Results The two clinical cases showed good short-term outcome with a decrease of pain and good function. Conclusions Arthroscopy to assist Eaton–Littler TMC ligamentoplasty is technically feasible, allowing a less invasive surgery. A larger prospective controlled study with a longer term outcome is mandatory to assess the real advantages of this modified procedure.

Functional outcome of proximal 1/3rd, distal 1/3rd and diaphysial tibial fractures in adults operated with expert tibial nailing

<p class="abstract"><strong>Background:</strong> Fractures of the tibial shaft are increasing due to high velocity trauma and industrialisation. Not only they are common but also difficult to treat. Until recently surgeons had to rely on non-operative treatment, V nailing, plates and screws and external fixator but they had their drawbacks like prolonged immobilisation infection, delayed union and non-union. Numerous modifications in nail and screw design have led to development of the expert tibial nail. Multidirectional interlocking screws ensure that alignment can be well maintained and stability preserved in short proximal or distal tibial segments.</p><p class="abstract"><strong>Methods:</strong> 30 patients were admitted and operated during September 2014 to September 2016 in Mamata general hospital Khammam. All patients were evaluated with Klemm Borner’s criteria and complications following surgery.<strong></strong></p><p class="abstract"><strong>Results:</strong> 87% of patients achieved good or excellent results, fair results were obtained in 3 (10%) patient and poor result in one (3%) patient. 2 (6%) patients had malunion, 2 (6%) patients had delayed union, 1 (3%) patient had deep infection led to implant failure.</p><p class="abstract"><strong>Conclusions:</strong> Intramedullary nailing is a safe and effective technique for the treatment of tibial metaphyseal fractures. It avoids the additional soft-tissue dissection associated with traditional open procedures as well as the complications associated with external fixators. Expert tibial nail can give excellent functional and clinical results. Complications such as failure of the bone-implant construct or post-operative malallignment are avoidable if careful pre-operative planning is allied with meticulous surgical technique.</p>

An early experience of lumbopelvic fixation techniques at Alexandria University

Background The aim of lumbopelvic fixation is to obtain a solid fusion across the lumbosacral junction. There are many indications for lumbopelvic fixation, namely, spinal deformity in cases requiring long segment fusion, pelvic obliquity, pseudarthrosis at the lumbosacral junction, infection or osteolytic tumors, and pathologic fractures. The classical iliac screws should be contained within the iliac bone but have some disadvantages: excessive soft tissue dissection needed for accurate insertion, screw prominence with patient discomfort, and usually, a side connector is needed to connect the iliac screws to the rest of the construct. Lumbopelvic fixation by insertion of S2 alar-iliac (S2AI) screws was recently described to overcome these disadvantages. In this study, the authors present the initial results for the evaluation of lumbopelvic fixation through the insertion of S2AI screws in 19 consecutive patients operated in the neurosurgery department at Alexandria University. Objective The aim of the study was to evaluate the efficacy and complications of lumbopelvic fixation through the use of S2 alar-iliac screws. Methods The authors conducted a retrospective cohort study of data collected from the database of patients who underwent lumbopelvic fixation through the insertion of S2AI screws from 2016 to 2019 at a single institution. Results There were 19 patients indicated for lumbopelvic fixation, operated by modern instrumentation systems using lumbar pedicle screws and S2 alar-iliac screws. There were 14 females and 5 males. The mean age at the time of the operation was 38.6 ± 19.4 years with a range from 11 to 65 years. There was a total of 37 S2AI screws, screw diameter was 7mm in all cases regardless of age, and the length of the screws ranged from 50 mm in a young female patient (11 years) to 90 mm in an old male patient (60 years). Two screws were inserted per patient except in one case with congenital scoliosis due to the bad bone quality and the multiple iatrogenic wrong paths. Postoperative VAS score for back pain was greatly improved in all patients after the first 6 months of follow-up from 8 ± 1.5 to 3.5 ± 1.2 (paired t-test = 11.182, P<0.001). All patients had a good spinal range of motion to maintain normal daily activities without any significant restrictions after the first 3 months of follow-up. Immediate postoperative radiological follow-up had revealed 2 cases of posterior pelvic breaches and one case with anterior pelvic breach but without clinical manifestations with no need for revision. Two cases of unilateral screw breakout were observed after the first 6 months of follow-up. Removal of screws after the first 6 months was done in one patient with spondylodiscitis due to the unresolved infection and screw pullout. Conclusion The insertion of S2AI screws is an effective technique for lumbopelvic fixation with a relatively low rate of complications. Pelvic breaches are the commonest complications encountered during the insertion of S2AI screws, although no significant clinical morbidities were reported.

Direct reduction of high-grade lumbosacral spondylolisthesis with anterior cantilever technique - surgical technique note and preliminary results

Backgrounds Surgical reduction for high-grade spondylolisthesis is beneficial for restoring sagittal balance and improving the biomechanical environment for arthrodesis. Compared to posterior total laminectomy and long instrumentation, anterior lumbar inter-body fusion (ALIF) is less invasive and has the biomechanical advantage of restoring the original disk height and increasing lumbar lordosis, thus improving sagittal balance. However, the application of ALIF is still limited in treating low-grade spondylolisthesis. In this study, we developed a new technique termed anterior cantilever procedure to directly reduce the slippage of high-grade lumbosacral spondylolisthesis. The purpose of our study was to investigate the surgical outcomes of the anterior cantilever procedure followed by ALIF and posterior mono-segment instrumented fixation in high-grade spondylolisthesis. Methods All patients with high-grade spondylolisthesis who underwent anterior cantilever procedure followed by anterior lumbar inter-body fusion (ALIF) and posterior mono-segment instrumented fixation between November 2006 and July 2017 were enrolled in our study. The slip percentage, Dubousset’s lumbosacral angle, pelvic tilt, sacral slope, pelvic incidence, and sagittal alignment were measured pre-operatively and postoperatively at the last follow-up. Surgery time, blood loss, complications, and hospital stay were also collected and analysed. Results A total of 11 consecutive patients with high-grade spondylolisthesis patients were included and analysed. All of the high-grade spondylolisthesis in our series occurred at the L5-S1 level. The median age was 37 years, and the median follow-up duration was 36 months. The average slip reduction was 30% (60 to 30%, P < 0.01), and the average correction of Dubousset’s lumbosacral angle was 13.8° (84.1° to 97.9°, P < 0.01). The median intra-operative blood loss was 300 mL. All patients attained improved sagittal balance after the operation and achieved solid fusion within 9 months after surgery. No incidences of implant failure, permanent neurological deficit, or pseudarthrosis were recorded at the last follow-up. Conclusions Anterior cantilever procedure followed by ALIF and posterior mono-segment instrumented fixation is a valid procedure for treating high-grade spondylolisthesis. It achieved a high fusion rate, partially reduced slippage, and significantly improved lumbosacral angle, while minimizing common complications, such as pseudarthrosis, nerve traction injury, excessive soft tissue dissection, and blood loss in posterior reduction procedures. However, posterior instrumentation is still required to the structural stability in the ALIF procedure. Level of evidence IV