مجله جراحی استخوان و مفاصل ایران
سال دهم شماره 3 (پیاپی 40، تابستان 1391)

Treatment of Legg–Calvé-Perthes disease in older children with greater involvement of the femoral head remains uncertain. Innominate، femoral or combined osteotomies are generally provide more coverage of the femoral head by the acetabulum with the objective of achieving a more spherical head and congruent joint. The purpose of the study was to evaluate the radiographic outcomes of simultaneous femoral and pelvic osteotomies. We reviewed the radiographic changes of 20 patients with Legg–Calvé–Perthes disease with a disease onset of over eight years of age who had undergone combined femoral and Salter innominate osteotomies. The hips in these 20 patients comprised 11 lateral pillar (LP) groups B، 7 B/C، and 2 C. The patients were evaluated with a mean follow-up of five years and five months using the Stulberg radiographic assessment. Among those 20 hips، six became Stulberg II (SII)، nine SIII، and five SIV. From the 11 LPB hips، five became SII، four SIII، and two SIV. The seven LPB/C turned out to be SII in one case، SIII in four، and SIV in two. One of the two LPC hips became SIII and one SIV. The three female patients had one LPB، one LPB/ C، and one LPC hip، and surgery resulted in SIII hips in all. Combined osteotomies in older children with a higher LP grouping can marginally improve the radiographic outcome in comparison with the natural history in LPB/C and LPC cases by converting a number of poor to fair results.

Backgroud: Most pediatric open long bone fractures are the results of high energy trauma، and can lead to complications. The aim of this study is to compare the results of two commonly used operative techniques for tibial or femoral fractures; namely external fixator and flexible intrameduly rods.

In this clinical series، 42 children with 45 femoral or tibail open fractures from 2009 to 2011 who were treated by either external fixator (EF) (24 cases) or TEN (21 cases) were compared. In few cases combination of TEN and pin were used for more stability. The patients were evaluated and compared for infection، nonunion، malunion and refracture.

Bony union in the EF group was achieved in 3. 8 months and in TEN group in 3. 6 months (p≥. 05). In each group، 2 fracture-site infections without any evidence of osteomyelitis was obsereved. Five pin site infection in EF group needed changing the pin site. In TEN group early nail removal was necessary because of painful bursitis in one case at nail insertion site. There were 4 femoral refractures in EF group after frame removal. In 10 patients with TEN and extra pin no symptom or problem was seen.

In our study EF was effective as a definitive treatment. Flexible intramedullary nails were also effective and their results were similar to those of EF. Combination of TEN and pin caused more stability without any symptoms.

The knee anterior cruciate ligament (ACL) rupture is one of the common damages among athletes. To compensate for ACL deficiency، ligament reconstruction is done to recreate the function of ACL. The aim of this study was to investigate the effect of single bundle and double bundle ACL reconstruction on the compression stresses of menisci. We simulated 4 cases with geometrical modeling: intact knee sectioned ACL، single and double bundle ACL reconstruction. We then built a three dimensional finite element geometrical model of knee from MRI images of normal knee. First، the bone and soft tissue points cloud models and then the geometrical models were built. The bones were modeled as rigid bodies، articular cartilage، menisci as linear elastic and ligaments as nonlinear springs. The loading condition was application of a 50 N anterior load to tibia. The maximum compression stress was similar to intact knee and was lower than two reconstruction cases. Distribution of compression stress wasn’t similar to intact knee but in reconstruction cases، it was similar. The contact areas in intact knee were higher in lateral section، while in reconstructed knees were higher in medial section of the knee. ACL removal changes the distribution of compression stress of menisci in comparison with intact knee، single bundle and double bundle reconstruction. Furthermore evaluating contact areas in these four cases showed that removing the ACL may lead to decrease in the contact area but reconstruction may compensate for this.

This study presents the distribution of ulnar variance among Iranian patients with Kienbock’s disease and a control group of normal adults of Iranian population. We evaluated the relationship between ulnar negative variance and Kienbock’s disease in our patients. This study included two groups. In the first group، we، retrospectively، reviewed our orthopaedic department clinic charts in two hospitals in Urmia-Iran، and collected the distribution of ulnar variances in 60 patients with Kienbock’s disease. The second group comprised the distribution of ulnar variances in 400 standard wrist radiographies of normal adult population. Comparisons were made between the findings of the two groups. The mean ulnar variance of the Kienbock’s group was negative 1. 1±1. 7 and the mean ulnar variance of the general population was positive 0. 7±1. 5. The difference of the ulnar variance means was statistically significant (p<. 001). There were 38 (63%) ulnar negative، 16 (27%) neutral and 6 (10%) ulnar positive variance in the Kienbock’s group and preponderance of ulnar negative variance was statistically significant (p=. 027). There were 56 (14%) ulnar negative، 160 (40%) neutral and 184 (46%) ulnar positive variance in the control group and there was no correlation with age or sex. There was an association between ulnar negative variance and development of Kienbock’s disease in this study (p<. 001). The findings of this study support the hypothesis that there is an association between the ulnar negative variance and development of Kienbock’s disease.

There are many cases with lumbar disk herniation in which asymptomatic lumbar canal stenosis will be diagnosed radiologically. In current study، we compared the outcomes of treating these patients with either laminectomy or laminotomy.

In this randomized clinical trial، there were 40 patients with lumbar disk herniation and asymptomatic lumbar canal stenosis assigned to 2 groups: laminectomy and fenestration. The severity of pain and disability were determined utilizing visual analogue scale (VAS) and Oswestry disability index (ODI) both before and after the surgery and the scores were compared in each group and between the two groups. The outcome of surgery was also compared using Japanese Orthopaedic Association (JOA) scoring system in a one year follow-up. The surgical time، blood loss and duration of hospital stay were also compared.

Significant postoperative decrease in severity of pain and ODI were found in both groups (p<. 001). However، the severity of pain، ODI score and outcomes based on JOA were the same between groups. The mean of surgical time and blood loss were significantly lower in laminotomy group (p<. 001)، but the mean of hospital stay was the same.

The short-term outcome of the two treatment methods is the same and favorable. However، because of the more invasive nature of laminectomy، which is associated with increased risk of instability، the authors suggest that in patients with lumbar intervertebral disk herniation and radiological lumbar canal stenosis، Laminotomy would be a preferred technique.

Spinal deformity in neurofibromatosis، when associated with dystrophic change، is a major treatment challenge. Resection of the vertebral body as an additional step in correction and fusion has not been previously investigated. The purpose of this study is to report an experience with corpectomy and circumferential fusion in dystrophic spines of neurofibromatosis. In a retrospective study، among 16 patients with dystrophic spinal curves، nine cases who had undergone anterior and posterior fusion with 6. 7 years (range 2-11. 9) average follow-up were evaluated. Nine cases with a mean age of 11. 8 years (range 7. 8-17) at surgery consisted of seven kyphoscoliotic patients، who had received one or two levels of cord decompression and corpectomy. Surgery improved the mean preoperative scoliosis of 87 (range 60-110) and local kyphosis of 69. 3° (range 50-100) to 49 (range 15-85) and 49° (range 35-70)، respectively. Loss of correction of 5° in the scoliosis and 13° in the kyphosis angles was observed in the final follow-up. Fusion was achieved in all cases. The average SRS-22 score of 4. 1 (range 3-4. 6) was obtained. Simultaneous anterior and posterior fusion with corpectomy for dystrophic neurofibromatosis spinal deformities is associated with a high fusion rate، good correction، and also good functional outcome.

Osteosarcoma is the most common malignant tumor of bone in young people. We report a case of recurrent post-radiation osteogenic sarcoma in the clavicle of a 28-year-old man with a history of Hodgkin’s lymphoma.

Both patients and providers hope for better management strategies for nonspecific activity-related upper limb pain. The next innovation may arise from the strong evidence that psychological factors responsive to cognitive behavioral therapy (mood، catastrophic thinking، and heightened illness concern) best account for variation in symptom intensity and magnitude of disability. This innovation represents a change in culture for patients and providers، both of whom are accustomed to the biomedical framework that anticipates a direct correspondence between illness (the state of being unwell) and disease (pathophysiology). As a first step health providers can prioritize empathy; remain mindful that words، illness concepts، and treatments can reinforce ineffective coping strategies; and encourage curiosity about the human illness experience.