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BACKGROUND Hepatitis C virus (HCV)-related decompensated cirrhosis is a severe life-threatening illness. The safety of direct-acting antivirals (DAAs) has opened a gate of hope for that subgroup of patients who were previously contraindicated for interferon therapy. OBJECTIVE We aimed at the investigation of the safety and efficacy of different DAAs regimens in the treatment of HCV-related decompensated cirrhosis patients, to determine sustained virological response (SVR)12 rates and to analyze the factors associated with response. METHODS A retrospective, single-center study including HCV-related decompensated cirrhosis patients who received DAAs. Demographic, laboratory and clinical data were analyzed. The SVR12 rate was the primary outcome measure. Secondary outcomes included the predictors of response, changes in the baseline model for end-stage liver disease and child-turcotte-pugh (CTP) scores, and fibroindices (APRI and fibrosis-4 index) at 12 weeks after treatment. RESULTS In total, 145 eligible patients (141 with CTP class B and 4 with class C) were enrolled in this study. SVR12 was achieved by 88.06% (118/134) of efficacy population on different DAAs regimens, Treatment was discontinued in 11 patients because of severe side effects without any deaths. Younger age showed a significant positive association with SVR12. CONCLUSIONS DAAs can be used for the treatment of HCV-related decompensated liver disease, with acceptable SVR12 rates and safety profiles.

Background: The ulnar nerve injury induce sever hand malfunction due to intrinsic muscle paralysis. The ulnar nerve repair in proximal area (high ulnar nerve injury) seldom leads to intrinsic muscle function because of long distance of nerve return. Therefore, the best techniques to restore intrinsic hand function in patient with high ulnar nerve injury is distal nerve transfer to minimize the regeneration time and distance. Objective: The aim of this study is to describe the surgical results obtained with the transfer of the motor branch of the anterior interosseous nerve destined to the pronator quadrates muscle to the motor division of the ulnar nerve (the deep branch of ulnar nerve). Methods: It is a retrospective study of thirty elderly patients with high ulnar nerve injury underwent a transfer of distal branch of anterior interosseous nerve to deep branch of ulnar nerve, and end to end suture of the ulnar nerve at the site of injury in Sohag microsurgery unit. Results: The mean postoperative follow-up period was 22 months (range from 12 to 38 months). At the final follow-up, twenty-seven (90%) patients showed good results according to the Highet-Zachary scheme (M3 or M4, S3+, and negative Froment’s sign). The other three patient (10%) showed a poor result (M1, S2, positive Froment’s sign). Conclusion: This technique of transfer of distal branch of anterior interosseous nerve to deep motor branch of ulnar nerve and primary repair of ulnar nerve at site of injury is effective for motor and sensory recovery of distal ulnar innervated side of the hand.

The purpose of this study is to compare results of usage of reamed interlocking nail versus plating in management of aseptic non- union fracture shaft tibia. 20 patients with aseptic non union tibia were managed in our department between June 2015 and June 2016. Patients were divided randomly in this retrospective study into two groups: plating group (10 patients) and nailing group (10 patients). Mean age of patients (plating group) was 40.3 years old, while in (nailing group) was 30.3 years old. Iliac bone graft was used in 4 patients (plating group) and 3 patients (nailing group). Initial fracture was simple in 8 cases (4 in plating group and 4 in nailing group) and compound in 12 cases (6 in plating group and 6 in nailing groups). All patients were followed up in our patient clinic; with a mean period of follow up was 36.9 weeks. 19 cases healed and one case lost from (plating group). Mean period of healing was 6.7 months (plating group) while 4.7 months in (nailing group). According to Olerud and Molander score, 2 patients excellent, 2 good and 5 fair (plating group), while 1 patients excellent, 7 good and 2 fair (nailing group). No significant complications rate difference was found between the two groups. Reamed interlocking nail can obtain higher union rate, shorter time to union incidence and less compl-ications rate than plating in the treatment of aseptic non union fracture shaft tibia.

Bone elongation through callotasis is a relatively simple procedure from a surgical point of view. Bone elongation results are amazing and highly beneficial to the patients‘life quality. A good use of the external fixation leads us to meet various orthopaedic and surgical techniques which were unthinkable years ago and which nowadays are a standard practice in pediatric and adult orthopaedics units worldwide. External fixation entails the use of percutaneously placed transosseus pins and/or wires secured to external scaffolding to provide support to a limb. The benefits of external fixation are numerous. When compared with internal plates and intramedullary nails, external fixators cause less disruption of the soft tissues, osseous blood supply, and periosteumin. Our task is to restore the anatomy of the locomotor system mechanically and, which is even more important, biologically, since the whole future life of these bones and joints will depend on it using new mini external fixator device manufactured and developed by Kuwait institute of science and research (KISR). Our study is a short term prospective study of patients received in emergency unit and orthopedic department at Sohag university hospital. After taking of written consent from the patients and approval of the ethical committee, 22 patients with posttraumatic or congenital wrist or hand deformities were treated by the new mini ex.fix. All patients were admitted to orthopedic trauma unit with hand and wrist deformities either traumatic or congenital and placed on radiolucent operating table. General anesthesia had been given to all patients. The new mini external fix technique should be considered for bone lengthening for the surgical treatment of Madelung‘s and other hand and wrist deformities in patients suffering from persistent pain , deformity when gradual correction and lengthening is indicated as its easy for the patient and the operating surgeon with promising results.

The purpose of this study was to evaluate the outcomes of coverage of soft tissue defects of leg and foot by sural flap with preserving a lane of skin over the pedicle (cutaneous pedicle) with open passage between donor and recipient sites. A proscriptive study including thirty-six patients with distal lower limb soft tissue defects was carried out in the period between June 2018 and June 2019 at Sohag University Hospital. All these 36 patients underwent modified sural flap with preserved lane of skin over the pedicle with open passage for the pedicle between donor and recipient sites. Evaluation of viability of the flap, resistance against infection, healing of the flap, donor site healing and weight bearing, postoperative follow up to nine months. Group of patients including thirty-six patients with distal lower limb soft tissue defects underwent modified sural flap, the indication for flap cover was Motor car accident in 26 cases (72.2%) and exposed plate was in 6 cases (16.7%) crushing trauma was in 4 cases (11.1%). Infection were the common complications encountered Six cases (16.7%) three cases (8.35%) complicated by distal ischemia and One case (2.8%) was totally lost with increase in the flap viability with modified sural flap. Modified sural flap by preserving alane of skin over the pedicle and open passage between donor and recipient site increase venous return of the flap and increase flap viability.

There are different causes for finger amputation. Causes are starting from clean cut amputation up to avulsion. There are many factors affecting the results of finger replantation, as cause of injury, age of the patient, level of amputation, time passed after injury, methods for preservation of the amputated part, trained surgeons, and surgical equipments. Other factors affect the results of finger replantation are number of digital amputation, surgeon comfortability, and patient cooperation. This study included 38 patients presented by amputation of 57 fingers. The average age was 23 years old. The main cause was machine injury. The dominant hand was the right hand. The dominant finger was the thumb. The level of injury was proximal to the proximal interphalangeal joint in most of cases. The average time passed between injury and replantation was 2 hours. The average time of surgery for one digit replantation was 4 hours. The principles of treatment was exploration of the neurovascular and tendons in the amputated digit initially then that of the stump. The order of treatment was bone fixation by 2 kirschner wire, digital artery, digital vein, flexor tendon, digital nerve, extensor tendon. Skin closure should be loose. The average follow up was 58 months. All fingers have been survived except five. The average time for bone union was 8 weeks. According to Chen's criteria, the overall results were classified as grade I (excellent) in 20 cases, grade II (good) in 16 cases and grade III (fair) in 2 cases. The tendon function was excellent in 20 fingers, good in 26 fingers fair in 3 fingers, poor in 2 fingers and failure in 6 fingers. The 2 point discrimination was 6 mm in 9 fingers, 7-10 mm in 29 fingers, and 12-15 mm in 13 fingers. The mean grip and pinch strengths were 80 % and 85% respectively compared to contralateral hand. All of patient had returned to their normal daily activities. Finally, finger replantation is not an easy job and it is considered as challenging procedure even for the specialist. I think that many factors affecting the results of finger replantation have not been discovered yet.

Complex acetabular fractures are due to high-energy trauma in most cases. The operative management of these types of fractures is often difficult and technically challenging. Almost all of these types of fractures are treated through extensile approaches, and a variety of them have been described. Some of these approaches are associated with complications such as infection, heterotopic ossification, and increased blood loss in addition to increased operative time. This retrospective study was performed at an academic Level I trauma center. From January 2013 to March 2019, 21 patients with complex acetabular fractures were treated with open reduction and internal fixation through a single anterior modified Stoppa approach. The average operative time was 98.80 minutes (range, 60–180 minutes), the average follow-up time was 40 months (range, 24–72 months), and the average Harris Hip Score (HHS) was 87.85 (range, 75–100). At the latest follow-up, 12 (57.1%) patients had an excellent HHS, 8 (38.1%) patients had a good HHS, and 1 (4.8%) patient had a fair HHS. Complex acetabular fractures can be effectively managed by a modified Stoppa approach without the need for extensile or combined approaches. [ Orthopedics . 2021;44(3):e353–e358.]

Objective Management of infected distal radius nonunion with a bone defect and radiocarpal and distal radio-ulnar joint arthritis is considered an orthopaedic challenge. Although several methods have been described but none provide a satisfactory solution. Free vascularised fibula bone graft constitutes a good option to eradicate the infection, correct the deformity, compensate for the shortening and maintain motion. Material and methods This study included 15 cases with infected distal radius nonunion associated with bone defects. Nine cases were males and six were females. The average age of the patient was 20 years (range 8 - 60 years). The right wrist was involved in 10 patients and left was affected in 5 patients. Nine cases resulted from a motor vehicle accident, four cases after a firearm injury and two cases due to falling from a height. The average number of previous surgical procedures was three (range 2 -6). The principle of treatment was debridement, excision of distal radius and trimming of the proximal part of radius back to healthy bleeding bone, inserting the free vascularised proximal fibular bone graft to compensate the defect and fixation of the graft. Results The procedure was successful in 13 of 15 cases. Bone union was achieved at an average of 4 months. No clinical evidence of osteomyelitis or or infection at final follow-up. Pain was completely relieved in all cases. Wrist joint range of motion averaged flexion 50˚, extension 45˚ and handgrip was the same as the normal site. Twelve cases out of 15 returned to their daily activities. Conclusion Free vascularised proximal fibula bone graft is a new indication for the treatment of an infected distal radius nonunion with a bone defect.

Background The main goal of anti-HCV therapy in patients with decompensated (Child-Pugh B) cirrhosis not on a transplant waiting list is to achieve improvement in liver function and survival. Several studies have demonstrated acceptably high SVR rates, equivalent in Child-Pugh B patients, in individuals with decompensated cirrhosis, together with an effect of therapeutic viral clearance on liver function, with significant improvements in bilirubin, albumin and international normalized ratio values and, as a result, in MELD and Child-Pugh scores in one-third to half of patients. Similar results were reported in real-world studies. Patients with Child-Pugh B cirrhosis benefited more from viral clearance in terms of adverse event-free survival at 15 months than those with Child-Pugh C cirrhosis. Aim of the Work Assessment of the safety & efficacy of sofosbuvir/ ledipasvir in infected naïve and experienced HCV Egyptian patients with decompensated liver disease. Patients and Method This study was conducted on 100 patients with HCV related decompensated liver disease who presented to the hepatology outpatient clinic in El Agouza Police hospital and were evaluated according to the inclusion and exclusion criteria. Conclusion Ledipasvir/sofosbuvir is effective and safe in the treatment of HCV decompensated patients Child Pugh B. MELD and Child scores significantly improved with HCV treatment in decompensated patients Recommendations Longer follow up with assessment of the need for liver transplantation or HCC development is important. Larger number of patients is required.

Background: chronic hepatitis C virus (HCV) is a major cause of liver-related morbidity and mortality. Successful antiviral therapy with sustained viral clearance is associated with improved quality of life, and reduced risk of liver complications such as cirrhosis and hepatocellular carcinoma. Aim of the Work: to evaluate the impact of HCV eradication using direct acting antiviral drugs (DAADs) on cognitive function among hepatitis c virus infected patients. Patients and Methods: this study was conducted at Viral Hepatitis Unit of Dar El Shefaa Hospital (one of the centers of national committee for control of viral hepatitis) and MASRI (Faculty of Medicine Ain-Shams Research institute) unit at El-Demerdash Hospital. Data were prospectively collected using MoCA, PHQ-9 and PSQI scales to assess the cognitive function of the treated patients with the newly used DAADs before the start of treatment, during treatment and at 12 weeks after the end of treatment, and the laboratory data were collected from the files of the patients in the previously mentioned centers. Results: results of the current study as regarding the analytical part of the study showed that: Pre treatment: slightly cognitive impairment was found with mild level of depression and sleep disturbance with MoCA test Mean ± SD 23.02 ± 4.96. At the end of treatment: there was no direct effect of the newly used drugs on the cognitive function. After 3 months of treatment (SVR): there was significant improvement of the cognitive function. Conclusion: HCV eradication had beneficial effect on cognitive function. Sofosbuvir based treatment had no effect on cognitive function.

Objective Management of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. Patients and methods Thirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6–33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. Results All the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. Conclusion Skin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

Introduction The currently accepted treatment for displaced supracondylar humeral fractures in children is closed reduction and fixation with percutaneous Kirschner wires. The aim of this study was to study the results of a cross-wiring technique, achieved solely from the lateral side, in an effort to reduce the risk of ulnar nerve injury. Conclusion there was no significant difference between lateral cross-wiring technique and traditional lateral pinning as regard postoperative clinical results and radiological results. Introduction Supracondylar fractures of the humerus in children accounts for 60% of all fractures around the elbow. (1) It represents 4 - 6.5% of all paediatric fractures. In treatment of non-displaced Type I fractures simple immobilization with a posterior splint applied at 60-90o of elbow flexion is preferred. (2) Currently, the treatment of choice for type II fractures is operative reduction and pinning rather than cast. (3) Most cases of type III fractures require operative reduction and pinning. The results of type III fractures treated with closed reduction and cast immobilization are not as good as the results of pinning. (4) There are various options for the pattern of K-wire fixation of displaced supracondylar fractures. Studies found the greatest resistance to rotation occurred with medial-lateral cross pinning. (5) The second most stable pattern was fixation utilizing three lateral diverging pins. The least stable was fixation with two lateral pins, which cross at the fracture site. While medial-lateral cross pinning has the greatest resistance; the disadvantage is the risk of ulnar nerve injury. (6) Lateral pinning is recommended (7) to avoid iatrogenic ulnar nerve injury that can occur with medial lateral cross pinning. Although iatrogenic ulnar nerve injuries usually resolve, several permanent iatrogenic ulnar nerve injuries have been described. (8) Closed reduction and lateral cross-wiring technique with ascending and descending K-wires is an effective method to treat type II and III supracondylar fractures in children. Regardless of stability, this method can be used to avoid iatrogenic ulnar nerve injuries. (9) Aim of the work The aim of this work is to assess clinical results of fixation of supracondylar humeral fractures by lateral cross-pinning versus traditional lateral pinning in children.

Background : 'The purpose of this study is to compare results of usage of reamed interlocking nail versus plating in management of aseptic non- union fracture shaft tibia .Methods :20 patients with aseptic non union tibia were managed in our department between June 2015 and June 2016.Patients were divided randomlyin this retrospective study into two groups : plating group ( 10 patients ) and nailing group (10 patients ). Mean age of patients ( plating group ) was 40.3 years old, while in ( nailing group) was 30.3 years old. Illac bone graft was used in 4 patients (plating group ) and 3 patients (nailing group).Initial fracture was simple in 8 cases ( 4 in plating group and 4 in nailing group )and compound in 12 cases ( 6 in plating group and 6 in nailing group).Results :All patients were followed up in our patient clinic, with a mean period of follow up was 36.9 weeks. 19 cases healed and one case lost from( plating group). Mean period of healing was 6.7 months (plating group) while 4.7 months in (nailing group).According to Olerud and Molander score ,2 patients excellent , 2 good and 5 fair (plating group) ,while 1 patients excellent , 7 good and 2 fair (nailing group).No significant complications rate difference was found between the two groups . Conclusion:Reamed interlocking nail can obtain higher union rate , shorter time to union incidence and less complications rate than plating in the treatment of aseptic non union fracture shaft tibia.

Introduction and aim. It is well known that development of acute kidney injury (AKI) increases mortality in hospitalized cirrhotic patients; therefore many novel markers have been studied for early detection, differential diagnosis and prognosis in cirrhotic patients with AKI. The aim of the current work is to evaluate urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) as a diagnostic biomarker for different causes of acute kidney injury in liver cirrhosis and to assess it as a prognostic marker. Material and meth-ods. Out of 83 cirrhotic patients with AKI admitted between October 2015 and June 2016; 70 patients were included in this prospective study. Routine laboratory tests, uNGAL and fractional excretion of Na were obtained on admission. End points were death or improvement of kidney function and discharge. Results. The patients included in our study were 41 males and 29 females with mean age 54.27 ± 6.08 years. HCV was the etiology of cirrhosis in 69 cases while one had combined HBV and HCV infection. More than 50% of patients were classified as Child C. Causes of kidney injury were prerenal, hepatorenal syndrome (HRS) and intrinsic tubular injury (iAKI) in 39 patients (55.7%), 17 patients (24.3%) and 14 patients (20%) respectively. mean value of uNGAL in prerenal, HRS and iAKI was 21.70 ± 7.31, 115.53 ± 68.19 and 240.83 ± 116.94 ng/mg creatinine respectively. MELD above 20 and uNGL above 32 were predictors of mortality. Conclusion. A single baseline measurement of uNGAL level has the ability to determine type of kidney dysfunction in cirrhotic patients, perhaps accelerating management decisions and improving outcomes.

GOALS In this pilot study, we compared midodrine and albumin in the prevention of paracentesis-induced circulatory dysfunction (PICD). BACKGROUND PICD with pronounced arterial vasodilatation in cirrhotics with tense ascites can be prevented by the infusion of albumin, which is an expensive treatment modality. Various vasoconstrictors have also been used to prevent PICD, but there are few studies about the usage of midodrine. STUDY Fifty patients with cirrhosis and tense refractory ascites were randomly assigned to be treated with either midodrine (n=25) (12.5 mg 3 times/d; over 3 d) or albumin (n=25) (8 g/L of removed ascites) after a large-volume paracentesis. Effective arterial blood volume was assessed indirectly by measuring serum creatinine, serum sodium, plasma renin activity, and aldosterone concentration before and 6 days after paracentesis. RESULTS Midodrine therapy was cheaper compared with albumin therapy, but serum creatinine, serum sodium, plasma renin activity, and plasma aldosterone concentration values after treatment [0.99±0.19 to 3.02±2.58 mg/dL (P=0.001), 132.36±3.2 to 130.2±4.1 mEq/L (P

Among patients with chronic liver disease, impairment in HRQOL has been reported. Hepatocellular carcinoma (HCC) is one of the major squeal of chronic liver diseases. So, relationship between subjective HRQOL and HCC must be analysed. This study assessed the effect of HCC on HRQOL, and its loco-regional treatment on HRQOL. Forty patients with HCV related chronic liver disease as a control group was enrolled in the study. Eighty HCC patients on top of chronic HCV liver disease categorized according to the modality of loco-regional treatment (BCLC staging system) into GI; 40 HCC patients treated with radiofrequency ablation (RFA) and GII; 40 HCC patients treated with trans-arterial chemoembolization (TACE). The SF-36 questionnaire was performed before and one month after the intervention. Comparing the parameters of HRQOL in GI before and after RFA, and in GII before and after TACE; there was a statistically significant improvement in group I. However, the improvement in group II (TACE) was non-significant (P>0.05).

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

Liver fibrosis is a common pathway leading to cirrhosis, which is the final result of injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Liver biopsy has been considered to be the “gold standard” to assess fibrosis. However, liver biopsy being invasive and, in many instances, not favored by patients or physicians, alternative approaches to assess liver fibrosis have assumed great importance. Moreover, therapies aimed at reversing the liver fibrosis have also been tried lately with variable results. Till now, there has been no consensus on various clinical, pathological, and radiological aspects of liver fibrosis. The Asian Pacific Association for the Study of the Liver set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The process for the development of these consensus guidelines involved the following: review of all available published literature by a core group of experts; proposal of consensus statements by the experts; discussion of the contentious issues; and unanimous approval of the consensus statements after discussion. The Oxford System of evidence-based approach was adopted for developing the consensus statements using the level of evidence from 1 (highest) to 5 (lowest) and grade of recommendation from A (strongest) to D (weakest). The consensus statements are presented in this review.

The series included 36 patients, predominantly male, mean age 30.3 years. The most common cause of injury was motor car accident in 20 patients. Postreduction radial nerve injury occurred in nine cases. Open fracture humerus with radial nerve injury in seven cases. The fractures were situated in the middle or distal third of the humeral shaft. Most were transverse fractures. Twelve patients had surgery on the day of injury and the other 24 at a mean of 8 days later (3-14). Narrow dynamic compression plate was generally used for fixation. Exploration of the radial nerve demonstrated compression at the lateral intermuscular septum in 19 cases, entrapment in the fracture site in nine cases, and loss of its continuity in eight cases. Neurolysis was required in 20 cases, epineurorrhaphy in nine cases, interfascicular nerve grafts in five, and first-intention tendon transfer in two. Results of nerve surgery were assessed with the MRC (Medical Research Council) at a mean follow-up of 8.2 years. Outcome was rated good to excellent in 28 patients, fair in 1, and poor (failure) in 3. First-intention tendon transfers were performed in 2 patients and 2 patients were lost to follow-up. Mean delay to recovery was 7 months after neurolysis and nerve repair and 15 months after nerve grafts. The fracture was united in all cases. The mean time of union was 5 months.

Currently, pegylated interferon is the most effective therapy for hepatitis C but its cost is out of reach of most patients in the developing countries. The aim of this study was to assess the response rate of genotype-4 patients to 24 wks of peg-interferon-alpha2b (Peg-IFN-alpha2b) and ribavirin (RBV) or interferon-alpha2b (IFN-alpha2b) with RBV and amantadine (AMD) as an alternative option.In a controlled study, 180 biopsy-proven naïve chronic hepatitis C patients were allocated into three groups based on their financial affordability to any of the study regimens. Group I (control) comprised 40 patients who received Peg-IFN-alpha2b in a flat dose of 100 mug/wk (the dose available in Egypt) plus RBV 1,000-1,200 mg per day based on body weight for 48 wks. Group II comprised 70 patients who received the same regimen for 24 wks. Group III comprised 70 patients who received induction-dose triple therapy (IDTT) in the form of IFN-alpha2b 3 MU once daily for the first 4 wks then reduced to TIW for 20 wks plus RBV 1,000-1,200 mg per day based on body weight and AMD 100 mg twice daily for 24 wks. Six patients from group I, eight patients from group II, and four from group III discontinued the study either due to financial limitations and/or intolerable adverse effects of the drugs.Intention-to-treat analysis revealed that sustained virological response (SVR) achieved in 22 (55.0%), 34 (48.6%), and 20 (28.6%) in groups I, II, and III, respectively. Adherence-to-treatment analysis (80/80/80) revealed that SVR achieved in 22 (64.7%), 34 (54.8%), and 20 (30.3%) in groups I, II, and III, respectively. In absence of eradication of hepatitis-C-virus-RNA at week 12, there was virtually no chance of achieving SVR. These data collectively may indicate that genotype 4 is "not difficult to treat" as previously reported.Response of genotype-4 patients to 24 wks of Peg-IFN-alpha2b/RBV did not significantly differ from 48 wks, but was significantly higher than IDTT. Although SVR achieved by IDTT is less than Peg-IFN-alpha, yet it might provide a second option when the latter is not affordable. Early virological response should be used as a predictor to SVR to avoid unnecessary expenses in nonresponders patients.

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle

Objective: The treatment of infected non-union both bone forearm is considered as challenge orthopaedic procedure. Infection should be eradicated, non-union should be treated meticulously with debridement, removal of necrotic bridging tissue. Vascularized fibula bone graft is considered as the best solution to bridge the defect and eradicate the infection. Methods: Twenty-four patients (16 men and 8 women), who formed the basis of the study, underwent surgery in the Hand and Microsurgery Unit, Sohag University, from January 2008 to January 2015. The right side was involved in 11 cases and the left side in 13 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 10 cases, infected nonunion of the middle part of radius in 7 cases, post-traumatic bone loss of distal radius in 4 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients). The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin. The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 10 cases and the left fibula in 14 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. Results: The average follow-up was 84 months. Bone union was ultimately obtained in 22 patients except 2 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor. Conclusion: We recommend free vascularized fibula bone graft for treatment of difficult cases of infected non-union both bone forearm not only to restore the anatomy but also to obtain nearly normal hand function.

Objective: Describe a new procedure that combines Oberlin procedure with concomitant shoulder realise in Upper Obstetric Brachial Plexus Palsy. Methods: We present 18 children with upper obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve in concomitant with anterior shoulder release. Eight were males, and 10 were females. The left-side brachial plexus was affected in 11 patients and the right side in 7 patients. Sixteen children had vaginal delivery and 2 children were delivered by cesarean section. The average birth weight was 3800 g (range, 3430-6000 g). Average age at the time of operation was 18 months (range, 12-26 months). The indication for the operation was absent active elbow flexion and no shoulder abduction with internal rotation contracture deformity. Oberlin’s ulnar nerve transfer was done in all cases in concomitant with anterior shoulder release without brachial plexus exploration. Results: The average follow-up was 18 months (range, 12-58 months). Nine children had biceps muscle M5, 6 of them had biceps muscle M4, and 3 children had

An association exists between hepatitis C virus (HCV) infection and non-Hodgkin’s lymphoma (NHL), but a causal relationship is not fully established. HCV is a lymphotropic virus that represents a major etiologic agent of mixed cryoglobulinemia (MC) type II which is characterized by a low-grade B cell clonal lymphoproliferative disorder that usually progresses to a more aggressive malignant lymphoma. This study assessed the role of cryoglobulin and B lymphocyte stimulator (BLys) in the pathogenesis of NHL in chronic HCV patients. Sixty HCV patients, 30 free of B cell NHL (group I) and 30 with B cell NHL (group II), and 30 healthy controls (group III) were studied. Qualitative cryoglobulin assessment and a quantitative assay for BLys were done. In group II, BLyS positivity rate was 1.5-fold higher than of group I (p ≤ 0.01). A positive association was found between positivity rate of MC and the level of BLyS (p ≤ 0.01). High BLyS levels were associated with HCV-associated lymphoproliferative disorder coupled with positive MC.

PURPOSE Children who had internal rotation contracture deformities of the shoulder secondary to obstetric brachial plexus palsy were studied. The outcomes of anterior shoulder release and tendon transfer in 1-stage procedure were analyzed. METHODS Anterior shoulder release and tendon transfer in 2 separate incisions as 1 procedure were performed in 76 patients for improvement of shoulder function. Anterior shoulder release was performed through the deltopectoral incision, starting with the coracoid process that extended 5 cm caudally. Osteotomy of the coracoid process subperiosteally with retaining the pectoralis minor attached to the periosteum. Z-plasty of the subscapularis and resuturing of the pectoralis minor short head of biceps and coracobrachialis to their original position were performed in all cases. A separate second incision in the posterior axillary fold was carried out to perform rerouting of the latissimus dorsi and teres major tendons with a mean follow-up of 5.6 years (range, 1-7 years). RESULTS The average active external rotation with the arm at the side increased from -26 + 15 degrees preoperatively to 67 + 17 degrees postoperatively (average gain, 85 degrees). The average shoulder abduction increased from 46 + 22 degrees preoperatively to 130 + 32 degrees postoperatively (average gain, 75 degrees). Mallet score improved from 12.3 to 22.6. CONCLUSIONS Anterior shoulder release combined with latissimus dorsi and teres major rerouting significantly improved global shoulder function.

Background: The colle's fracture is the most common fracture site in the upper extremity; it causes functional problems and disabling complications. Treatment of these common fractures and their dysfunctional sequalae continues to challenge surgeons and therapists. Objective: The purpose of this study was to investigate effect of Maitland's mobilization versus closed kinetic chain exercises after stable colle's fracture. Method: Thirty patients had participated in this study. They were assigned randomly into two groups (Group A and Group B) with age ranged from eighteen to fourty five years old. Group A consisted of 15 patients (15 females) received mitland's mobilization with therapeutic ultrasound, group B consisted of 15 patients (15 females) received closed kinetic chain exercises with therapeutic ultrasound for 3 times per week (12) sessions for 4 weeks. Patients were evaluated pre and post treatment for their pain severity, function of the wrist joint, grip strength, wrist joint's ROM and proprioception at 20 wrist flexion, extension, radial and ulnar deviation. Result: The result revealed that there were significant differences between both groups regarding the improvement in function, grip strength, range of motion of flexion, extension, radial and ulnar deviation and there were no significant difference between both groups regarding the improvement in function, grip strength, and joint position sense. Conclusion: Maitland's mobilization versus closed kinetic chain exercises after stable colle's fractures no significant difference in improvement in function, grip strength, and joint position sense, and Maitland's mobilization significantly improve wrist range of motion. Key Word: Colle's fracture, Maitland's mobilization, closed kinetic chain exercises, Proprioception.

Peripheral nerves were first distinguished from tendons by Herophilus in 300 BC. By meticulous dissection he traced nerves to the spinal cord, demonstrating the continuity of the nervous system(1). In 900 AD, Rhazes made the first clear reference to nerve repair. However, not until 1795 did Cruikshank demonstrate nerve healing and recovery of distal extremity function after repair. In the early 1900s, Cajal pioneered the concept that axons regenerate from neurons and are guided by chemotrophic substances. In 1945, Sunderland promoted microsurgical techniques to improve nerve repair outcomes (1). Since that time, there have been a number of advances and new concepts in peripheral nerve reconstruction.

The value of electrophysiological tests: conventional electroencephalography (EEG), topographic EEG analysis as well as computerized tomography (CT) in the diagnosis and evaluation of 25 patients with manifestations of transient ischemic attacks (TIA) in the domain of the carotid system was assessed. Normal CT was the rule in TIA patients except in 8% of the cases, where nonspecific changes of brain atrophy were described. Conventional EEG, topographic EEG and spectral analysis could detect abnormalities in 48%, 80% and 64% of TIA cases respectively. None of the abnormal EEG records could be missed by topographic EEG analysis. 32% of the records were diagnosed as abnormal by topographic EEG, while conventional EEG failed to detect abnormalities. Spectral analysis of the EEG results revealed a significant decrease regarding mean high limit alpha percent power, and a significant increase regarding mean low and high limit theta percent power, as well as a significant increase of the mean high limit of the slow activities (delta + theta)/fast activities (alpha + beta) percent power ratio in the TIA group as compared to the normal control group.

Between 1998 and 2007, a pronator quadratus pedicled bone graft was performed for 45 patients of ununited scaphoid fracture. One of them had bilateral ununited scaphoid fracture. There were 29 men and 16 women with a median age at operation of 24 (16-32) years. The affected side was the right side (dominant hand) in 32 patients whereas 13 patients had fracture of the nondominant left side. There had been 32 proximal pseudoarthrosis (through or proximal to the junction of the proximal and middle thirds of the bone) and 14 of the middle third of the scaphoid. The original fractures were caused by motor cycle accidents in 23 patients, falling on outstretched hand in 15 patients, and sport injuries in the remaining 7 patients. Surgery was indicated from 5 months to 6 years after injury (average 43 months) because of complaints of pain on heavy work. The fracture has been missed at the initial examination in 23 patients whereas cast immobilization was done for 6 weeks and 3 months in 15 and 7 cases, respectively, that had failed to result in union. There were no preoperative osteoarthritic changes, but in 25 cases, there were avascular necrosis of the proximal fragment of the scaphoid. Forty-three patients showed radiographic union after an average of 14 weeks (12-16 weeks). One patient had dislodgement of the graft and refused to do it again. The average range of movement of wrist improved after operation. Taken as a percentage of the normal range, dorsiflexion increased from 69% to 80%, palmar flexion from 66% to 76%, radial deviation from 45% to 70%, and ulnar deviation from 67% to 84%. Grip strength improved from 82% to 92% of normal. All the patients have been able to return to their former activities with no pain.

We present the case of a 9-year-old male patient who suffered a gunshot injury to the right arm. The patient arrived in shock, his right arm severely traumatized, with soft-tissue loss involving the anterior surface and both sides of the right arm. The humerus was exposed. There was brachial artery defect and damage to the lateral fibers of the median nerve. The mangled extremity severity score (MESS) was 8 points. The patient was treated with general resuscitation, blood transfusion, and debridement. A venous graft, 12 cm in length, to bridge the brachial artery defect, and tendon transfer, triceps to the biceps, was performed in one step. Postoperatively, there was a normal radial pulse, normal skin color, normal temperature, and normal movement of the fingers without pain. Unfortunately, the patient then sustained a second trauma to the right arm 3 weeks later, rupturing the graft. This time he lost 1,500 cc of blood. After another blood transfusion, we performed a second reverse saphenous vein graft. The patient stayed at the hospital for 3 weeks. At follow-up 12 months later, the limb has good function and, except for the presence of a scar and skin graft, is equal in appearance to the left side.

Hepatitis C infection is considered the leading cause of chronic liver disease in Egypt. Hepatitis C virus (HCV) genotype 4 is the predominant genotype in the Middle East including Egypt.1 A striking feature of HCV infection is its association with fat accumulation within hepatocytes,2 which is defined by the presence of hepatic steatosis with or without steatohepatitis.3 Hepatic steatosis has been reported in 30–70% of patients with HCV infection, even when the most common causes of steatosis are excluded.4 A causal relationship between infection with HCV genotype 3 and the incidence of hepatic steatosis has been elicited.5 In Egypt the true prevalence of non-alcoholic fatty liver disease is unknown among patients with HCV who are commonly infected with genotype 4. Our aim was to …

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.