The most common management of open injuries of the extensor tendons in Zones III to V (PIP to MP joint) is tendon suturation and digit immobilisation in extension for 4 to 6 weeks. Dynamic splinting and early mobilisation has been already successfully tested in the treatment of extensor tendons injuries in Zones VI to VII. In the current study we performed a protocol, including strong suture technique of the lacerated extensor tendon in Zone III to IV in addition with early mobilisation.

From 1999 until 2002, 23 lacerated extensor tendons (Zones III – V) in 22 patients were managed at the Orthopaedic Department of the Univercity of Ioannina. The mean age of the patients was 36 years old (14 – 70 years). The principle treatment has taken place at the emergency room and included suture of the lacerated central slip, using the Kessler-Tajima technique, plus continuous suture of the epitenon. Injuries of other structures (lateral bands, sagittal band, joint captule) were also managed by suturing. After a period of 5 days (Zone V) to 3 weeks (Zone III) of immobilisation in a static splint, injured digit mobilisation started using a dynamic extensor splint until the 5th week after injury.

The mean follow up was 7 months (3–24 months). There have been no ruptures of the extensor mechanism nore permanent digit deformities. Minimal (until 30o) loss of MP flexion or DIP extension has been regarded in 5 patients. The grip strength has been affected in 4 patients, and the grip strength between the 1st and 2nd digit (“the key pinch strength”) has been affected in 12 patients, compared with the contralateral hand. No further operation for tenolysis has been necessary.

Satisfactory results have been obtained, by early mobilisation using dynamic splinting, in the treatment of open injuries of extensor tendons in Zones III – IV under the following conditions: using strong suture technique, a co-operative patient and weekly examination of the patient. Using a dynamic splint only for the injured digit is better accepted by the patient.

Purpose: We perform the results of the operative treatment of cubital tunnel syndrome, and a retrospective review of the surgical options of in situ decompression of the ulnar nerve, release and anterior transposition of the ulnar nerve and ulnar nerve release and partial medial epicondylectomy.

Material and Methods: Seventy four patients, 52 male and 22 female, (78 elbows), were treated surgically from October 1991 to November 2002.The mean age was 51 years (range, 13 to 72 years). Sixty four patients were assessed postoperatively with mean follow-up 80 months (range 6–139 months). Twenty patients underwent in situ decompression of the ulnar nerve, 34 patients release and anterior transposition and 14 ulnar nerve release and partial medial epicondylectomy. According to the McGowing evaluation system were classified in Grade I, none, Grade II, 38 patients and Grade III 26 patients. The 64 patients were evaluated clinically and 16 of them by EMG studies postoperatively.

Results: Sixty one patients had had subjective improvment of their symptoms. Thirty seven patients (57.8%) excellent, 21 patients (32.8%) good, 3 patients (4.6%) fair and 3 patients (4.6%) poor results. (Wilson & Krout). The comperative results among the surgical options of our study showed improvement in the subjective outcome of 32 out of 34 patients who had release and anterior transposition of the ulnar nerve. From the 20 patient who had in situ decompression of the ulnar nerve, 19 had improvement and from the rest 14 patients who had had ulnar nerve release and partial medial epicondylectomy, they all had improvement.

Conclusions: The results for the patients in this study who had ulnar nerve release and partial medial epicondylectomy, are comparable in good results with other operative treatment options for the cubital tunnel syndrome.

Complex hand injuries are those which involve more than one functionally significant anatomic structure of the hand (i.e vessels, nerves, tendons, bones). The epidemiologic and management characteristics of these injuries, encountered in a specialized center covering an urban and agricultural population, were recorded and studied.

Between 1997 and 2002 the Orthopaedic Department of the University of Ioannina surgically treated 211 complex hand injuries in 190 patients with a mean age of 35 year (range 2.5–73). The majority of patients were male (89%). The incidence of these injuries was low at the extremes of the age distribution (children and adults over 60 years old). The greatest incidence was in the 15–30 year old age group. The mechanism of the injury was found to be clean cut trauma in 31% and avulsion or crushing in 69%; with the later being frequent agricultural injuries. Fifty-nine per cent of the injuries were viable, while 41% where non-viable (complete amputation in 63% and incomplete in 37%). Of the non viable injuries 66% eventually underwent stump configuration. Primary repair of only one anatomical structure was performed in 58%, most commonly osteosynthesis and tendon suturing. In 42% primary repair of more than one structure was performed, most commonly osteosynthesis and tendonorrhaphy in avulsion injuries and neuroraphy combined with tendonorrhaphy in clean cut injuries.

Complex hand injuries are frequently seen in young male adults and the most common mechanism of injury is avulsion-crushing. Most of them are work-related accidents, so prevention should focus on adherence to safety guidelines. Management of such injuries requires special surgical techniques and expertise, necessary for staged reconstruction.

Purpose: Vascular injuries occur in approximately 3% of all patients with major civilian trauma and peripheral vascular injuries account for 80% of all cases of vascular trauma. Upper extremity arterial injuries represents about 30% of all cases arterial trauma. The present study was designed to document and analyze the respective role of arterial damage and associated injuries on functional outcomes after upper extremity arterial trauma.

Material and Methods: Excluding the arterial injuries resulting in immediate amputation there were 57 patients who sustained arterial trauma of the upper extremity. Their mean age was 33 years (range 4–68 years), and 40 were males and 19 were females. The most frequently injured vessel was the ulnar artery (42%) followed by the brachial artery (29.8%), radial artery (26.3%) and axillary artery (1.7%). Concomitant fractures or nerve injuries were present in 54% and 45% respectively.

Results: An average of 5.6 hours elapsed between the time of injury and the time of vessel reconstruction. The most common method of surgical management was end to end anastomosis. Twenty one autogenous vein grafts were employed. Primary nerve repair was carried out in 29 patients and in another 18 secondary repair was performed. None of patients had any residual compromise from the arterial injury.

Discussion: Vascular injuries are potentially limb threatening. Improvements in the technical ability to revascularize injured extremities and advances in microsurgery, resulting in the low present day limb loss rate associated with attempted vascular repairs. Associated injuries, rather than vascular injuries, cause long-term disability in the trauma of the upper extremity. Persistent nerve deficits, joint contractures and pain are principal reasons for functional impairment

Purpose: Although transient osteoporosis of the hip was initially described in pregnant women, now most frequently identified in middle-age and older men. Has also been reported to occur in either hip and in both successively. This condition is referred as migratory transient osteoporosis of the hip. In this study the authors describe five cases of migratory hip osteoporosis and the differential diagnosis with osteonecrosis is also discussed.

Material and Methods: Thirty-four patients with transient osteoporosis were presented. Of the 34 patients five had a similar episode of severe pain in the contralateral hip 14 months mean time later. Early bone scans and MRI of the hips had been carried out in all of the patients. After the evaluation of these findings and thorough exclusion of other conditions diagnosis of migratory transient osteoporosis was demonstrated, and confirmed by the natural course of the disease.

Results: All cases were treated with nonsteroidal anti-inflammatory medications and protected weight-bearing. The course of the disease has not been appreciably altered by medical treatment, and the mean time interval from the onset of symptoms to clinical recovery was 4.6 months (range 3 to 6 months). Imaging findings on MR confirmed the diagnosis during both episodes and paralleled the reduction of pain.

Conclusions: Migratory transient osteoporosis of the hip is a rare self-limited condition of uncertain etiology and pathogenesis, which “migrate” from one hip to the other. Magnetic resonance imaging is highly sensitive in the early detection of this condition and moreover is helpful in the exclusion of other entities. Although the diagnosis is one of exclusion, it must be considered and contrasted with hip osteonecrosis.

Purpose: The first 50 free flap operations performed at our clinic by the same surgical team were reviewed and assessed as to the cause and location of the defects, donor sites, complications and results. An attempt was then made to determine what could be learned from this experience.

Material and Methods: There were 46 males and 4 females who underwent free flap operations (mean age, 28.5 years; range 6 to 56 years). The lower extremity was the most frequent site of defect (72.5%). The next most frequent sites were the arm and the hand (27.5%). Trauma was by far the most common cause. Latissimus dorsi and forearm flap were the most useful flaps. Fractures in the wound were present in 26 patients.

Results: The fate of the flaps has been analysed. In two latissimus dorsi flap emergency re-exploration was performed and were successfully managed. Two flaps, underwent necrosis, due to thrombosis at the site of arterial anastomosis. Two flaps were lost due to inappropriate blood flow of the recipient vessels. Other complications included pressure ulcer, infection, and hematoma. The overall survival rate of the 50 cases was 92%.

Discussion: Limb reconstructive surgery has significantly improved and expanded with the use of microsurgical techniques. Evaluation of the recipient vessels is always the first priority. The choice of the flap, specially regarding the length and size of the pedicle is also very crucial in order to achieve good results. In addition important factors seemed to be: improvement in techique of micro-vascular anastomosis, diseased vessels, vascular spasm, hypotension, postoperative edema, and hematoma. We believe that an “orthoplastic” approach in covering soft tissue defects is beneficial.

Natural history studies of scaphoid non-unions focus on symptomatic non-unions. As a consequence, neither the real incidence nor the long-term sequels of asymptomatic scaphoid pseudarthrosis have been sufficiently studied.

Three adult patients (38, 40 and 79 years of age) with long-standing asymptomatic scaphoid non-union are presented. The lesions were identified in radiographs taken in the accident and emergency department after new injuries. All patients could recall the initial fracture, which occurred 17.5, 20 and 40 years respectively before the index examination.

Although all the patients were heavy manual workers and in two the non-union occurred in their dominant upper extremity, none could recall pain during activities. Radiographic evidence of carpal malalignment and/or arthritis was noted in all patients. At the 3-month follow-up after the new injury all patients remained asymptomatic with only mild limitations in the range of motion.

With evolving trends of ORIF in unstable scaphoid fractures, there is need for larger-scale natural history studies that include asymptomatic scaphoid non-unions. Such lesions are currently poorly understood and their treatment (if one is needed) remains unclear.

Introduction: Osteochondral lesions of the talus may cause persistent joint pain requiring surgical treatment, which today can be performed arthroscopically. The purpose of this study is to evaluate the effectiveness of arthroscopic treatment of these lesions.

Material and Method: Seventeen patients (7 males and 10 females) underwent ankle arthroscopy from 1998 through June 2002 for treatment of osteochondral lesions of the talus. Their age ranged from 11 – 68 years. The right talus was affected in 12 and the left in 5 patients. All but one had a history of previous trauma, for which they had been treated conservatively for at least 6 months.

Bone scanning, CT and MRI were performed for lesion staging according to Brent and Harty. One patient was stage I, 2 were stage II, 7 were stage III, and 7 were stage IV.

The patients underwent ankle arthroscopy without use of a distractor. Inspection of the joint was followed by shaving and debridement of the lesion with or without drilling.

Results: Follow-up had a mean duration of 15 months (range 8 – 24 months). Outcome was evaluated with the Ogilvie-Harris score for pain, swelling, stiffness, limp and patient activity level. All patients had excellent or good results. In all cases there was a reduction in lesion size.

Conclusions: Arthroscopy is effective for treatment of osteochondral lesions of the talus. It causes less morbidity than open surgery and patients are able to follow an early mobilization and rehabilitation protocol. However, specialized surgical tools, as well as an in-depth knowledge of joint anatomy are required to avoid iatrogenic damage.

Although primary flexor tendon repair in children yields satisfactory results, some children end up with poor function because of delay in diagnosis, technical difficulties and the inability to follow a structured rehabilitation program. The aim of this study is to evaluate the functional outcome after two stage reconstruction with the modified Paneva technique (which includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superficialis in the first stage and reflecting the latter as a “pedicled” graft through the pseudosheath created around the silicone rod, in the second stage) in children.

Nine patients (nine digits) with a mean age of 8.2 year (range 3–15) were treated for zone II lesions. Their pre- operative status in the Boyes and Hunter scale was grade 2 in three, grade 3 in three, grade 4 in one and grade 5 in two patients.

After a mean of 42 months of follow-up (minimum 12 months), according to the Buck-Gramco scale there were four excellent, four good and one poor result and according to the revised Strickland scale three excellent, five good and one poor. Children over the age of 10 had slightly improved Total Active Motion (mean +35°) compared to younger patients. No significant length discrepancies were noted. Two postoperative infections were treated and one graft-related re-operation was necessary.

Staged flexor tendon reconstruction in children is technically feasible and efficient. Delaying such a reconstruction in younger children does not seem justified.

The symptomatic non-union of the scaphoid, if left untreated, will eventually lead to established arthritis and by that time important alterations in carpal geometry will have occurred. The aim of this paper is to study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes.

The pre-operative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were included (32 posteroanterior and 31 lateral views). Patients’ mean age was 31.3 years and mean time from fracture 50.4 months. The x-rays were digitized and measured using CAD methodology. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The non-unions were classified according to the Herbert and Fisher classification and were further categorized in two subgroups concerning the absence (14) or presence (21) of early arthritic changes in the radio-carpal or in one of the mid-carpal articulations (patients with established or generalized arthritis were excluded).

In total (and varying according to the method of measurement) up to 28% of the patients were presented with an affected carpal height, up to 17% with ulnar translocation of the wrist and up to 48% with a DISI pattern of instability. 62.5% of the patients (including patients without radiologicaly obvious arthritis) had increased radial height and radial inclination. After statistical analysis (ANOVA and regression analysis) no significant differences have been found between the morphological groups or between the two subgroups concerning early arthritis. A tendency of the lunate to translocate both in the coronal and the sagital plain simultaneously was found and the measurement methods were correlated.

In conclusion the carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and from this point of view treating non-union with early arthritis with bone grafting and osteosynthesis or even with additional radial osteotomy seems justified.

Aim: Adequate length is an important prerequisite for a functional digit. Over the last 20 years small external fixators have been developed allowing the principles of distraction osteogenesis to be applied to the small bones of the hand. We present our experience in digital lengthening with the contemporary designs of external fixators.

Methods: From 1998 to 2001, 14 patients (15 rays) were treated with metacarpal or phalangeal lengthening through distraction osteogenesis using a monolateral frame with two half-pins on each site of the osteotomy. The mean age of the patients was 21 years (7–48) and the indications were traumatic amputation in 8 and congenital amputation (transverse deficiency, brachydactyly, constriction band syndrome) in 6. The mean distraction period was 3 weeks and the mean consolidation period 7 weeks. No protective splinting or additional bone grafting was necessary.

Results: The distraction callus consolidated in all patients. The mean total length gained was 17, 5 mm (68% of the original length). The mean treatment time was 2, 8 days for every mm of length gained. One patient suffered angulation at the distraction site due to hardware failure and the fixator had to be revised and in another bony prominence was noted necessitating trimming. No infection, fracture or half pin loosening were observed.

Conclusions: Callotasis using contemporary monolateral external fixators is a reliable technique for digital ray lengthening. Meticulous preoperative planning and surgical technique and close observation of the patient during the distraction phase are necessary in order to avoid complications. Over 2 cm of lengthening can be achieved without bone grafting.

In late cases of brachial plexus palsy or when nerve reconstruction was not that beneficial, pedicled or free neurotized muscles i.e. latissimus dorsi are used to restore or enhance important functions i.e. elbow flexion or extention.

During the last three years, 43 patients with brachial plexus injuries were operated in our Clinic to reconstract the paralysed extremity. In nine of them, the ipsilateral latissimus dorsi was transferred as pedicled neurotized muscle to restore elbow flexion (seven patients) and elbow extension (two patients). Two patients had free latissimus dorsi transfer, which was neurotized directly via three intercostals. The neurovascular pedicle was dissected proximally up to the subclavian vessels and posterior cord, and the muscle was raised from its origin to its insertion and tailored to simulate the shape of biceps or triceps. Then it was passed via a subcutaneous tunnel on the anterior or posterior arm. The reattachment was done with Mitek anchors on the clavicle and the radial tuberosity (elbow flexion) or on the posterior edge of the acromion and the olecranon (elbow extension). The arm was immobilized in a prefabricated splint, which was removed after six to eight weeks.

After the first three months all patients had a powerful elbow flexion or extension. One of the free muscle transfers started to have elbow flexion after eight months and he is still progressing. In one patient skin necrosis and infection occurred near the elbow. The patient after IV antibiotics needed another operation to restore the distal insertion, using fascia lata.

Ipsilateral latissimus dorsi, if strong enough (at least M4), is an excellent transfer for elbow flexion or extension restoration or enhancement, in late cases of brachial plexus paralysis. Contralateral latissimus is an option when the ipsilateral is weak but it takes more time to function since there is a waiting period for reinnervation.