Bridge plating with decortication, autologous bone graft, and tight closure: a "stepwise surgical diamond concept" for treatment of nonunion in a series of fifty five patients.

PURPOSE: This study was conducted to assess a stepwise surgical procedure applied to treat a continuous series of patients with aseptic atrophic nonunion of long bones. METHODS: A retrospective review was performed of the medical files of patients treated by the senior author between January 2014 and January 2021 for aseptic atrophic nonunion of long bones using a standard stepwise surgical procedure consisting of four successive surgical steps: bridge locked plating, aggressive osteoperiosteal decortication, copious autologous iliac bone grafting, and tight closure without drainage. Patients were clinically and radiographically evaluated until bone healing, then at final follow-up for the purpose of the study. The primary objective of the study was to assess completion of bone healing; secondary objectives were the time required reaching bone union, the occurrence of complications at the iliac bone graft donor site, and the achievement of bone consolidation after a second attempt of treatment when indicated following failure of the index procedure. RESULTS: There were a total of 55 patients. One patient died from myocardial infarction before reaching bone healing and another one lost from early follow-up. There were remaining 53 patients with 37 years of mean age. The affected bone was the clavicle in five patients, humerus in 14, ulna in four, radius in one, femur in 13, and tibia in 16. The mean follow-up period was 3.4 years. A total of 52 patients (98.1%) achieved bone healing at a mean of 14.8 weeks from the index procedure. The only patient who did not reach bone healing after the index procedure was successfully revised using decortication-bone graft and new fixation with intra-medullary femoral nailing. Four patients (7.5%) developed local complications at the site of iliac bone harvesting. CONCLUSION: Our stepwise surgical procedure was very effective treating aseptic atrophic nonunion of long bones. However, as this study is a retrospective review of a limited series of one surgeon's experience, prospective comparative studies with large number of patients are suitable to define the advantages and indications of the procedure herein described.

The adjunct use of lateral hinged external fixator in the treatment of traumatic destabilizing elbow injuries.

PURPOSE: The purpose of this study is to evaluate the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries. METHODS: A retrospective review was performed on the medical records of patients in whom a lateral monolateral elbow hinged external fixator was applied by the senior author. The indication to apply the fixator corresponded to a variety of acute injury patterns ranging from simple elbow trauma or dislocation to complex fracture-dislocation, and the decision was based on either the presence of recurrent or persistent instability in any direction and/or to secure a vulnerable or weak bony fixation or soft tissue repair as intra-operatively judged by the surgeon. The fixator was inserted in the same setting after the repair of the associated ligamentous and/or bony structures. Patients operated after one month of the trauma and those presented with open elbow injury or associated humeral or ulnar shaft fracture were excluded. Rehabilitation was immediately started and the fixator removed at six to eight weeks with elbow testing and gentle manipulation under general anaesthesia, and resuming of rehabilitation after removal. Clinical assessment was performed for all patients according to the Mayo Elbow Performance Score (MEPS) with evaluation of range of motion at regular intervals till the end of the post-operative first year, then at final follow-up for the purpose of the study with radiographic assessment for evaluation of elbow reduction and concentricity. RESULTS: There were 13 patients with a mean age of 42 years. Two patients had instability secondary to LCL rupture; one patient had redislocation because of associated coronoid process fracture; one patient had radial head fracture with rupture of both collateral ligaments; five patients had terrible triad injury with variable association of collateral ligaments lesions; and four patients had posterior Monteggia fracture-dislocation. The mean MEPS was 90 at a mean follow-up of seven years with six excellent, six good, and one fair result. All patients had a concentrically reduced and stable elbow as assessed clinically and radiologically with a mean functional arc of motion of 132° for extension-flexion and 178° for pronation-supination. CONCLUSION: The hinged elbow external fixator represents a valuable adjunct in the therapeutic arsenal for the treatment of unstable elbows after bony and soft tissue repair. It provides satisfactory results in terms of stability and function and should be available in the operating room when a surgeon treats a complex elbow dislocation or fracture-dislocation.

Minimally invasive percutaneous plate osteosynthesis for treatment of proximal humeral shaft fractures.

PURPOSE: The objective of this study was to evaluate the feasibility and safety of a minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure for proximal humeral shaft fractures using lateral minimal proximal and distal approaches and lateral bridge plating with primary radial nerve control, and to assess its clinical and radiographic outcomes. METHODS: A retrospective review was done for the medical records of adult patients admitted for fracture of the proximal humeral shaft without associated injury to the ipsilateral upper limb and who consented to undergo a novel MIPPO technique herein reported. Patients were reviewed at regular follow-up periods and assessed at a final follow-up for evaluation of Constant, normalized Constant, and QuickDASH scores. RESULTS: There were 21 adult patients with mean age of 56 years. Three patients were lost from early follow-up; one of them had post-operative radial nerve paralysis. Eighteen patients were reviewed for the purpose of this study at a mean of 20 months of final follow-up; among them, one patient developed post-operative radial nerve paralysis with complete recovery after three months. Bone healing was achieved without any malalignment in 17 patients at a mean of 15 weeks, and one patient developed nonunion. At final assessment (mean, 20 months), the mean values of Constant, normalized Constant, and QuickDASH scores were 84 (range, 59 to 100), 95 (range, 73 to 100), and 5 (range, 0 to 18.2) respectively. CONCLUSION: Compared to pre-reported methods of MIPPO, this technique of lateral proximal and distal mini-approaches with lateral bridge plating after primary control of the radial nerve seems safe and feasible for proximal humeral shaft fractures. It gives good clinical and radiographic results with excellent restoration of upper limb function, very low incidence of post-operative radial nerve injury, and high rate of bone union in good alignment.

Hip avascular necrosis in a healthy pregnant woman: A case report and review of literature.

BACKGROUND: Hip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity. CASE REPORT: We report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age. DISCUSSION: With less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called "Pelvic pain syndrome" and transient osteoporosis of the hip. CONCLUSION: Having a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.