Journal of Orthopaedic Surgery and Research - Latest Comments

Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia

mahmoud el-rosasy — 2008-11-02T00:00:00Z

Dear Sir:

I read with interest this article, however, I have some comments for the authors and readers:

(1) The authors described a well known technique of fibular transposition to bridge the tibial defect [1]. This technique would burn the bridges in case it failed where the limb would loose the fibular support and renders following reconstructive procedures difficult and may even urge the surgeon to recommend amputation rather than reconstruction. The current literature does not support the primary use of this technique except in certain cases of extensive bone loss and soft tissue fibrosis.

(2) From the analysis of the results in this study; the leg length discrepancy (LLD) was more than 5 cm. in four cases, the valgus ankle deformity more than 20 degrees in four cases and ankle pain in three cases. This unacceptably high complications rate in only eight cases does not justify the conclusion to recommend using this procedure primarily in cases of CPT. On the other hand the authors did not clarify how a patient with 15.7 cm. could function with such a limb.

(3) The main aim of limb reconstruction is to provide the patient with a limb to carry him rather than carrying it. In which cases the recommendation of amputation and prosthetic fitting would be much better from a functional standpoint.

(4) the authors described the fibular transposition without any trial to stabilize the ankle joint which in my opinion is the main reason for valgus deformity and instability of the ankle and late arthritis and pain.

(5) I strongly caution the readers against using the described technique in preference to the well documented techniques with predictably good bony and functional outcomes e.g. Ilizarov technique combined with intramedullary rod and bone grafting [2, 3].

REFERENCES:

(1) Huntington TW. VI. Case of Bone Transference: Use of a Segment of Fibula to Supply a Defect in the Tibia. Ann Surg. 1905;41(2):249-51.

(2) El-Rosasy MA, Paley D, Herzenburg JE (2007) Congenital Pseudarthrosis of the Tibia. In: Rozbruch RS, Ilizarov S (eds) Limb lengthening and reconstruction surgery. Informa Healthcare USA, New York, pp 485–493

(3) Paley D, Catagni M, Argnani F, Prevot J, Bell D, Armstrong P. Treatment of congenital pseudoarthrosis of the tibia using the Ilizarov technique. Clin Orthop. 1992;280:81–93

Congratulations for a wonderful study and reasoning.

SUHAIL AFZAL — 2008-11-02T00:00:00Z

I really enjoyed reading this article,Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique. The authors have discussed a very important aspect of the anterior cruciate ligament reconstruction. I full agreee with them regarding the concept of the anatomic placement of the tunnel and the dirction of action of the graft through single incision. I feel that there two incision technique should be followed to address the lacunae of the single incision technique.

I sincerely applaud the authors for this study.

Some comments on hypertext journals

Myles Clough — 2006-10-25T00:00:00Z

The foundation of another open source journal in orthopaedics is very welcome.

It is to be hoped that the editorial group will consider and encourage the adoption of some of the advantages of hypertext over text. The most important of these is that the work can be presented in layers rather than as a continuity - which is only needed when one reads from beginning to end of a piece of paper. Most of us read only specific parts of an article; constructing it in layers allows the reader to choose the level of detail he/she wishes to read. For example, the 'top' layer would be the abstract with links to more detailed layers. Some of these layers might correspond to the traditional introduction/methods/results/discussion sections but there might be yet deeper layers describing, for example, the exact operative method with a further link to the manufacturer's manual or perhaps a video. Similarly, in the results section there should be nothing to stop authors from posting (elsewhere) a database of their results and Xrays and encouraging the readers to visit it via a link.

The traditional structure of an article evolved to suit the needs of paper journals. The rising generation of orthopaedic surgeons is familiar with the use of hypertext so there is every reason to believe that e-journals will prompt a new evolution and I hope your journal will promote it.

J.F.M.Clough MD FRCSC

Clinical Instructor, Department of Orthopaedics, University of British Columbia

Past President, Internet Society of Orthopaedic Surgery and Trauma