Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients.

Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type IIB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50° ° (range 20°-70°), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficial, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients / Fixação de fraturas em martelo com técnica de placa de gancho modificada: Uma série de casos prospectivos de 17 pacientes

Abstract Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type MB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50º º (range 20º-70º), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficiai, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Resumo Objetivo Diversas modalidades têm sido sugeridas para o tratamento de fraturas em martelo; no entanto, o tratamento inadequado pode causar retardo de extensão, deformidade em pescoço de cisne ou artrite da articulação interfalangiana distal (AIFD). Este estudo teve como objetivo avaliar os desfechos (funcionais, radiológicos e complicações) da redução aberta e fixação interna (RAFI) das fraturas em martelo com placas de gancho de baixo custo fabricadas com mini placas de titânio de baixo perfil. Métodos Série de casos prospectivos de 17 pacientes consecutivos (idade média de 32,3 anos) com fraturas em martelo (seis do tipo IB e 11 do tipo IIB de Wehbe). Onze (64,7%) pacientes eram do sexo masculino. A mão acometida era a dominante em todos os pacientes, com acometimento do dedo indicador em seis (35,3%), anelar em cinco (29,4%), mínimo em três (17,65%) e médio em três (17,65%) pacientes. O mesmo cirurgião de mão experiente realizou todas as cirurgias. Resultados O tempo operatório médio foi de 37,65 minutos. Após um acompanhamento médio de 10,94 meses (intervalo de 6 a 27), observou-se movimento médio da AIFD de 50º (intervalo de 20º a 70º), retardo de extensão em quatro (23,5%) pacientes e complicações em seis (35,29%) pacientes. De acordo com os critérios de Crawford, os desfechos foram excelentes em seis (35,3%), bons em sete (41,2%) e regulares em quatro (23,5%) pacientes. Conclusão A técnica da placa de gancho modificada para fixação de fraturas em martelo é benéfica e econômica, mas exigente; permite fixação estável e adequada para permitir a movimentação precoce da AIFD com desfechos funcionais aceitáveis.

Femoral malalignment after gamma nail insertion in the lateral decubitus position.

INTRODUCTION: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position. METHODS: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides. RESULTS: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019). DISCUSSION: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus -valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Accuracy of plain antero-posterior radiographic-based methods for measurement of acetabular cup version.

INTRODUCTION: Acetabular cup version is crucial for successful total hip arthroplasty (THA). Many methods have been described for measurement of cup version angle. The aim of this study is to assess the accuracy of five commonly used methods for measurement of acetabular cup version in plain antero-posterior views of the pelvis and hip. MATERIAL AND METHODS: Sixty primary THA cases were subjected postoperatively to plain A-P of the pelvis (AP-P), A-P view of the hip (AP-H), and computed tomography (CT) imaging. The acetabular cup version was measured in AP-P and AP-H by five methods (Lewinnek, Widmer, Hassan et al., Ackland et al., and Liaw et al.). These measurements were compared to the CT measurement. RESULTS: All plain X-ray methods showed no significant differences from the CT, except those of Hassan et al. in AP-H, and Widmer and Ackland et al. in AP-P. CONCLUSIONS AND RECOMMENDATIONS: For measurement of acetabular cup version angle, we recommend the use of Lewinnek and Liaw et al. methods both in AP-P and in AP-H, while Hassan et al.'s method is recommended in AP-P only, and Widmer and Ackland et al.'s methods in AP-H only.

Kyphoplasty for osteoporotic vertebral fractures with posterior wall injury.

BACKGROUND CONTEXT: Cement augmentation techniques are standard treatments for osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with lower rates of cement leak and better deformity correction; however, posterior wall fractures are relative, but not absolute; contraindications for both techniques and hence treatment practices vary among spine centers. PURPOSE: The primary aim of this study was to assess our center's incidence of posterior cement leakage in osteoporotic vertebral fractures with posterior wall injury treated by balloon kyphoplasty (BKP). Secondarily, physiological results, pain relief, complication rates, and non-posterior cement leakage were also evaluated. STUDY DESIGN: This is a prospective cohort study done in a high-volume spine center in Germany. PATIENT SAMPLE: Eighty-two patients with 98 osteoporotic vertebral fractures with posterior wall cortical injury were studied from 2012 to 2016. OUTCOME MEASURES: The following were the outcome measures: (1) physiological measures: standing plain x-rays (anteroposterior and lateral views), with the following parameters evaluated: cement leak behind the posterior vertebral body border, Cobb angle for local sagittal deformity, vertebral wedge angle, and anterior vertebral height; (2) cement volume injected in each vertebra; and (3) self-report measures: visual analog scale (VAS). METHODS: All patients underwent BKP using a bipedicular approach. Preoperative clinical and neurologic evaluations were done. Radiological evaluations included plain X-ray images, computed tomography scans and magnetic resonance imaging. The average follow-up period was 18 months. RESULTS: No cement leakage into the spinal canal occurred in any of the patients. Asymptomatic leakage into other sites was seen in 22 vertebrae (22.45%). There was significant improvement in the Cobb angle, the vertebral wedge angle, and the anterior vertebral height in all cases. The mean preoperative VAS was 8.1, and this improved to 2.3 on the third postoperative day. CONCLUSION: Balloon kyphoplasty is a viable option for the treatment of osteoporotic vertebral fractures even with posterior wall involvement.

Posterior-only surgical correction of adolescent idiopathic scoliosis: an Egyptian experience.

INTRODUCTION: The aim of this prospective case series study is to document safety and effectiveness of high density pedicle screws through posterior only approach with intraoperative wake-up test in correction of adolescent idiopathic scoliosis (AIS). METHODS: Between 2011 and 2015, all surgically treated patients for AIS were followed up for a minimum of 2 years. Clinical outcomes were evaluated using scoliosis research society-22 (SRS) questionnaire. All patients were classified according to Lenke classification. Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. All patients underwent an intra-operative wake-up test after deformity correction and a minimum of 80% metal density of implants was used. RESULTS: This study included 50 patients. The mean age at time of surgery was 16.8 years. The mean follow-up period was 38.1 months. The mean correction rate for the coronal Cobb angle of the major curve was 79.12%, while that of the minor curve was 68.9%. The mean thoracic kyphosis angle was 38.4° preoperatively, 29.76° postoperatively and 30.36° at the last follow-up. The mean SRS-22 questionnaire scores improved significantly at the last follow-up (P > 0.001). There were no neurological deficits at the wake-up test. No cases of pseudarthrosis or metal failure were encountered. CONCLUSION: This is a prospective study of at least 80% metal density pedicle screws technique and intra-operative wake-up test in Egyptian patients with AIS. It proved to be an effective and safe technique in correction of radiological parameters, with no neurological or implant related complications. It allowed excellent scoliotic and kyphotic curves correction with minimal loss of correction. On the whole it led to better quality of life.

Posterior only approach for fifth lumbar corpectomy: indications and technical notes.

PURPOSE: To evaluate the efficacy and safety of a posterior-only approach for L5 corpectomy, with lumbopelvic fixation for treatment of secondaries, infections, or burst fractures. METHODS: Between 2010 and 2013, 17 patients with L5 pathology had corpectomy through a posterior-only approach, with reconstruction of the anterior column using titanium cages filled with bone graft. The indication for surgery was presence of secondaries in nine patients, spondylitis and spondylodiscitis in five patients and burst fractures due to high energy trauma in three patients. All patients underwent detailed neurological examination as well as plain radiography, computed tomography, and magnetic resonance imaging studies. RESULTS: This study included 17 patients (8 males and 9 females) with a mean age of 48.3 years. The mean operative time was 186.1 minutes with mean blood loss of 744 ml. No intra-operative or immediate post-operative complications were encountered. Three patients died during follow-up due to advanced malignancy. The remaining 14 patients were followed-up for a mean of 24.9 months. One patient had cut through of L3 screws two years after surgery requiring metal removal. One patient had asymptomatic broken screw, with no need for further intervention. CONCLUSIONS: L5 corpectomy is a challenging procedure indicated for treatment of various cases of metastasis, infections, or comminuted fractures. The posterior approach is safe, efficient, and allows both rigid posterior stabilization and anterior reconstruction after L5 corpectomy without the need for an anterior approach and its possible related morbidity.

Two-stage surgical treatment for non-union of a shortened osteoporotic femur.

INTRODUCTION: We report a case of non-union with severe shortening of the femur following diaphysectomy for chronic osteomyelitis. CASE PRESENTATION: A boy, aged 16 years presented with a dangling and excessively short left lower limb. He was using an elbow crutch in his right hand to help him walk. He had a history of diaphysectomy for chronic osteomyelitis at the age of 9. Examination revealed a freely mobile non-union of the left femur. The femur was the seat of an 18 cm shortening and a 4 cm defect at the non-union site; the knee joint was ankylosed in extension. The tibia and fibula were 10 cm short. Considering the extensive shortening in the femur and tibia in addition to osteoporosis, he was treated in two stages. In stage I, the femoral non-union was treated by open reduction, internal fixation and iliac bone grafting. The patient was then allowed to walk with full weight bearing in an extension brace for 7 months. In Stage II, equalization of leg length discrepancy (LLD) was achieved by simultaneous distraction of the femur and tibia by unilateral frames. At the 6 month follow- up, he was fully weight bearing without any walking aid, with a heel lift to compensate the 1.5 cm shortening. Three years later he reported that he was satisfied with the result of treatment and was leading a normal life as a university student. CONCLUSIONS: Two-stage treatment succeeded to restore about 20 cm of the femoral shortening in a severely osteoporotic bone. It has also succeeded in reducing the treatment time of the external fixator.

Instrumented circumferential fusion for tuberculosis of the dorso-lumbar spine. A single or double stage procedure?

PURPOSE: The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization. METHODS: Between 2003 and 2008, 32 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared to a similar group of 25 patients treated with anterior debridement and fusion, followed 10-14 days later by posterior stabilization and postero-lateral fusion. RESULTS: The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 34 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 57 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 43 (75.4%) patients returned to their pre-disease activity level or work. CONCLUSION: Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Failed intramedullary nailing of femur: open reduction and plate augmentation with the nail in situ.

METHODS: Fourteen patients with aseptic fractures that failed to unite after intramedullary nailing (IMN) of the femur were treated by augmentation of fixation by dynamic compression plate (DCP) with the nail in situ. In six of them that had axial or rotational malalignment, direct reduction of the bone fragments and plating were done. Iliac bone grafting was performed in nine cases, when there were gaps between the fragments and in atrophic non-unions. Patients were followed-up for an average of 26 months. RESULTS: All patients had radiological union in an average of 4.3 months with an improvement in alignment, range of motion and shortening. CONCLUSIONS: For failed IMN of the femur, augmentation of fixation by compression plate, with the nail in situ, is a good line of treatment. In cases with malalignment, correction was possible followed by plate augmentation.