Long-standing Nonunited Fracture Lateral Humeral Condyle in Children. Evaluating a Two-stage Surgical Treatment Strategy With Critical Review.

OBJECTIVE: This work aimed to evaluate the results of using a 2-stage surgical treatment strategy without doing anterior transposition of the ulnar nerve (ATUN) for cases with long-standing nonunited fracture lateral humeral condyle (LHC) in children, accompanied by a critical review. METHODS: A consecutive 12 children with a long-standing ">2 years" nonunited LHC with evident radiologic gross anatomic distortion of the elbow were included in this study. A 2-stage surgical treatment strategy was applied, wherein the first stage, open functional reduction, osteosynthesis, and iliac bone graft were done. Then after 6 months, the second stage surgery was carried out in the form of supracondylar humeral corrective osteotomy if the cubitus valgus angle was ≥20 degrees. ATUN was not done for any of the cases even with those having ulnar nerve dysfunction. RESULTS: Union took place in 11 out of the 12 cases after a mean follow-up period of 11 weeks (range: 8 to 14 wk; SD: 1.6). All the 7 cases showed preoperative ulnar nerve dysfunction and reported clinical recovery at the end of their follow-up. CONCLUSIONS: Two-stage surgical treatment strategy without ATUN is a convenient, reproducible, and successful line of treatment for children presented with longstanding nonunited LHC with anatomically distorted elbow. LEVEL OF EVIDENCE: Level IV-case series.

Blount's disease - an up-to-date insight with contemporary treatment guidelines deduced from critical analysis of a large 146 surgical case series.

To elucidate an up-to-date insight and derive clear treatment guidelines for Blount's disease deduced from critical analysis of 146 surgical case series. Cases were presented and analyzed separately under its two basic clinical groups and the author further derived four subcategories under each of these two groups; the first basic group was the early onset clinical variant; infantile tibia vara (ITV) included 56 cases. The second group was the late onset clinical variant; late onset tibia vara (LOTV) included 90 cases. Different operative procedures used for treatment of these cases were proximal tibial osteotomy (PTO), temporary eight-plate proximal lateral tibial hemiepiphyseodesis (PLTH), or medial plateau elevation either on a monomodal or multimodal line of treatment. After a mean follow-up period of ~5 (2-12) years, the results were critically analyzed using case series descriptive analysis. In ITV variant, both PTO and temporary eight-plate PLTH monomodal line of treatment gave satisfactory results for de-novo (stages I, II, and III) subcategory while multimodal line of treatment was needed for achieving satisfactory results for neglected (stages IV, V, and VI) and relapsed subcategories. For LOTV variant, PTO monomodal line of treatment gave satisfactory results when applied for treatment of its de-novo subcategory. The derived treatment guidelines for Blount's disease can be of value for recruiting the most suitable treatment modality for each case entity of the disease, leading to satisfactory outcome with prevention of recurrence.

Vascular Complications during Ilizarov Fixator Surgery to the Femur: Two Case Reports with the Introduction of a Method for Determining the Safe Vascular Corridor around the Femur.

AIM: To perform an in-depth review of the safe vascular corridor around the femur in order to decrease possible vascular injury. BACKGROUND: Despite regular use of half pins in the femur, there is no region entirely safe for percutaneous pin placement. Damage to a major nerve or vessel must be avoided at all costs. Vascular complications during Ilizarov fixator surgery to the femur are rare but serious. CASE DESCRIPTION: Of 306 cases of Ilizarov fixation to the femur in the period from 2002 to 2016, two cases had vascular complications. The first case developed a delayed superficial femoral artery (SFA) pseudoaneurysm and the second case sustained an early deep femoral artery (SFA) injury. CONCLUSION: The in-depth review of the vascular anatomy around the femur with relevance to the placement of half pins indicates that the femoral shaft segment greatest at risk to lead to a vascular injury lies between the two points: 8 and 24 cm proximal to the adductor tubercle. HOW TO CITE THIS ARTICLE: Khanfour AA, Khanfour AA. Vascular Complications during Ilizarov Fixator Surgery to the Femur: Two Case Reports with the Introduction of a Method for Determining the Safe Vascular Corridor around the Femur. Strategies Trauma Limb Reconstr 2019;14(2):106-110.

A modified Puddu technique for the treatment of adolescent mild to moderate tibia vara.

The aim of this work was to evaluate the results of a modified 'subphyseal' Puddu technique for the treatment of selected cases of the adolescent tibia vara. Twenty-five legs in 18 patients with adolescent tibia vara between January 2008 and February 2012 were included. The mean value of angular correction was 22.24° (range, 18°-25°, SD 2.0°). All of the osteotomies in this series healed by 8 weeks. There were no postoperative neurologic or vascular complications. At the end of follow-up, no iatrogenic disturbance to the proximal tibial physis was observed, but recurrence was reported in three cases (12%). The modified 'subphyseal' Puddu technique is a reproducible, easy, and convenient technique for the treatment of adolescent tibia vara, provided there is proper case selection.

Late onset tibia vara. Acute correction strategy: proper case selection and a simple external fixation technique.

Following proximal tibial osteotomy for cases of late onset tibia vara, both acute and gradual correction strategies were described, where each has its pros and cons. The aim of this study was to verify the proper selection criteria of cases with late onset tibia vara amenable to successful acute correction strategy using a homogenous patient group with clear inclusion criteria; all the cases were fixed by a low profile semicircular fixator module. Thirty legs in 20 patients (11 boys, nine girls) with late onset tibia vara, treated in our department between January 2005 and February 2008, that complied well with the assigned inclusion criteria constituted the material of this prospective study. Their mean age was 10.4 years (range, 6-14 years). They were all managed using the same modality that was acute correction based on the osteotomy rule II concept and fixed by a low profile miniature Ilizarov fixator module. After a mean follow up period of 5.9 years (range, 5-7) only (13%) of the cases showed recurrence. Proper selection of cases with late onset tibia vara undergoing acute correction strategy is of utmost importance for the sake of a successful outcome. On the other hand, the low profile simplified fixator module used is a handy and a compliant osteotomy fixation tool.

Efficacy of a compliant semicircular Ilizarov pin fixator module for treating infected nonunion of the femoral diaphysis.

Percutaneous transosseous Ilizarov wiring, whilst preferred in the tibia because of its unique properties, carries a high risk of complications in the femur. The aim of this work was to evaluate the efficacy of a more patient-friendly semicircular pin external fixator module built up from parts of the Ilizarov fixator components and its use in managing diaphyseal femoral nonunions. A group of 20 patients with infected diaphyseal nonunions of the femur after internal osteosynthesis were included in this study. The mean age of the patients at the time of surgery was 46 years (range 16-60, SD 15.6). The mean morbidity time since the original trauma was 10.2 months (range 6-15, SD 2.5). All the cases were fixed by the described external fixator module. Bony union with resolution of infection occurred in 18 (94.7 %) out of 19 cases after a mean period in the fixator of 11.2 months (range 8-18 SD 2.9). After a mean follow-up period of 3.5 years (range 2-9, SD 2.6), there were 14 excellent, 3 good, 1 fair and 1 poor results from radiological evaluation and 10 excellent, 7 good, 1 fair and 1 poor results from functional assessment. In conclusion, the described semi-circular pin fixator module is patient-friendly and effective in managing infected nonunions of the femoral diaphysis.

Ilizarov techniques with limited adjunctive surgical procedures for the treatment of preadolescent recurrent or neglected clubfeet.

When choosing the Ilizarov technique for the treatment of recurrent or neglected clubfeet deformity, there was a consensus on the treatment of 3-8-year-old children by the soft-tissue distraction 'bloodless method' either alone or with an adjunctive-limited soft tissue release; whereas, in older children, adjunctive osteotomies were required. Major foot osteotomies such as V, U, Y, or supramalleolar types were established for patients after puberty when the foot bones become fully ossified. So, children falling in the age group between 8 and 13 years (preadolescents) represents a transitional growing stage that has its identity that makes carrying out major foot osteotomies unsuitable. Twenty-five feet in 21 patients with a mean age at the time of operation of 10.9 years (range, 9-13 years) with recurrent or neglected clubfeet deformity who presented to the orthopedic department at Alexandria (Egypt) between February 2004 and December 2008 were treated with the Ilizarov technique combined with adjunctive limited bony and/or soft-tissue procedures as will be discussed. After a mean follow-up period of 3.6 years (range, 2-7 years), 21 children showed good results, four children showed fair results, and no poor results were recorded. No major complications were reported. The Ilizarov technique with limited bony and/or soft-tissue procedures can be considered as a suitable, convenient, efficient, and successful salvage procedure for preadolescent recurrent or neglected clubfeet.

Versatility of Ilizarov technique in difficult cases of ankle arthrodesis and review of literature.

BACKGROUND: Ankle arthrodesis is a well-established procedure that has been successfully used for treatment of end stage arthritis of the ankle for well over a century. Internal fixation for ankle arthrodesis is adequate in most of the cases. However, surgeons and patients are occasionally confronted with cases in need for ankle arthrodesis but do not lend itself well to the ideal position and/or internal fixation. These cases may even contraindicate internal fixation. The aim of this study is to assess the results of ankle arthrodesis using different modalities of Ilizarov techniques and demonstrating its high versatility in treating such difficult cases. PATIENTS AND METHODS: This is a prospective study. Thirty cases of ankle fusion for end stage arthritis or instability were performed in the period between January 2002 and December 2007 at the Health Insurance Reference Hospitals, Alexandria, Egypt. Tibiotalar fusion was done in 22 cases and tibiocalcaneal fusion in 8 cases using different modalities of Ilizarov technique. The mean follow up period was 5.5 years (range 4-8, SD 1.9). RESULTS: Sound and painless fusion was achieved in all the cases except one (97%). The difference between the mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) was found to be statistically highly significant (t=10.1, p=0.001). Many minor complications were encountered during the course of treatment in the form of: pin tract infections, wound dehiscence, cellulitis that was managed effectively with local wound care, oral antibiotics. CONCLUSION: The versatility of the combinations of assemblies afforded by Ilizarov fixator was found to be endless. This makes the Ilizarov fixator to be an effective and versatile mean of treating difficult cases of ankle arthrodesis.

Distal femur non-union after interlocked intramedullary nailing. Successful augmentation with wave plate and strut graft.

Eleven patients with aseptic non-union of a distal metaphyseo-diaphyseal femoral fracture after intramedullary interlocked nailing were treated by wave plate fixation and an interposed tricortical iliac strut graft with the nail in situ. Complete clinical and radiological union occurred in all cases in a mean period of 7.5 months (range: 7-10). Augmentative wave plate fixation with a tricortical iliac strut graft is a biological and simple solution for non-union of the distal diaphyseo-metaphyseal femoral shaft fracture following an intramedullary locked nail fixation. No special instrumentation is required. In spite of early weight bearing, it led to bony union in a reasonable delay in all the patients reported.

Arthrodiastasis for late onset Perthes' disease using a simple frame and limited soft tissue release: early results.

Perthes' disease (Legg-Calvé-Perthes' disease) is relatively common in childhood, affecting 0.8/100.000 children. Late onset Perthes' disease, older than 8 years of age, constitutes about 20% of cases and is known for its aggressive course and poor outcome with chronic hip pain and stiffness. Although containment of the head in the acetabulum is the usual treatment for early cases, its results in treating late-onset cases are universally poor, so that many authors conclude that there is an upper age limit for effectiveness of containment treatment. The emerging philosophy of hip distraction (arthrodiastasis) with release of contractured muscle groups around the hip may be a new concept for treatment of late onset Perthes' disease. Thirty children with late-onset Perthes' disease (age > 8 years) presenting to the orthopaedic department at Sporting Health Insurance Student Reference Hospital - Alexandria, Egypt, between December 2004 till November 2008 were treated by hip arthrodiastasis using minimal soft tissue release and a simple Ilizarov construct. At the end of an average follow-up period of 3.6 years (range: 2-7 years, SD 13) there was an improvement in the range of movement, pain, and superior and lateral subluxation of the head, with a statistically significant difference between pre and post-operative values. Minimal soft tissue release and hip distraction can be regarded as a salvage procedure for late onset Perthes' disease with hip pain, at the stage of necrosis or fragmentation. Furthermore, this method did not result in any alteration in the joint anatomy, thus allowing the possibility for future surgery, if needed.

Evaluation of treatment of late-onset tibia vara using gradual angulation translation high tibial osteotomy.

Late-onset tibia vara or Blount's disease is the most common cause of pathologic genu varum in children and adolescents. Treatment remains controversial. Many studies in the past have shown that an osteotomy with acute correction is the most appropriate treatment. More recently however, there has been a growing interest, especially in severe cases, in using gradual correction with the Ilizarov technique after a single high tibial osteotomy. A retrospective study in 20 children with late-onset tibia vara, who were treated by gradual angulation translation high tibial osteotomy using the Ilizarov technique, was performed. The mean follow-up period was 2.9 years (range: 2-4 years; SD 0.75). Recurrence of varus deformity to various degrees was noted in 10 of 22 cases (45.5%). Recurrence of deformity was found to be significantly related to both the degree of pre-operative deviation and the duration of follow-up. No statistically significant relationship was found between recurrence and the age of the patients at the time of the operation. Angulation translation high tibial osteotomy using the Ilizarov technique is a unique method for realignment of the mechanical axis in late onset tibia vara. It also allows for correction of associated deformities. The rate of recurrence of varus deformity is however relatively high.