PURPOSE

To evaluate the late radiographic and functional complications occurring after treatment of reverse oblique trochanteric fractures with the proximal femoral nail.

Our objective was to investigate the adequacy of the antegrade intramedullary nailing for the treatment of proximal and distal humeral fractures.

From January 2004 to April 2008, 28 proximal humerus fractures and 9 distal humerus fractures were treated with intramedullary nailing. Mean age of the patients was 69-year-old (39–82). 26 patients were males. All fractures of the first group were treated with closed static intramedullary nailing whereas in the second group closed static intramedullary nailing was achieved in 7 fractures. The clinical and radiological outcomes were evaluated.

All the proximal humerus fracture – but one – obtained bone-union at an average of 3 months (from 2 to 4 months). The mean follow up was 22 months (6–40). Functional outcome measured by Constant score showed 22 patients with an excellent and good result and 6 with a poor result. One case with osteonecrosis of the humeral head was recorded. Malunion of the greater tuberosity was recorded in 7 fractures. Only 5 distal humerus fractures united at an average of 5 months (from 4 to 7 months). Functional outcome measured by Burri – Lob score showed 3 patients with an excellent and good result and 6 with a poor result. Failure of the distal locking was noticed in 5 patients and 3 fractures united in valgus position

The antegrade closed intramedullary nailing is an effective treatment method for the proximal humerus fractures. However the role of the nailing for the distal humerus fractures is humeral nail is effective for the treatment of proximal humeral fractures remains

Introduction: High energy tibial pilon fractures are usually associated with a significant bone loss in the metaphyseal area of the tibia. This study evaluates three different treatment options for the management of the metaphyseal bone loss.

Materials and Methods: Betwwen 1996 and 2007, 85 high energy pilon fractures- Ovadia Beals type IV: 39 and V: 46- were treated and reviewed in our institution. Twenty four fractures were open, and fifty one closed fractures had soft tissue lesion grade1 or 2 according to Tscherne classification. To restore the bone continuity in tibia metaphyseal area bone graft substitutes were used in 53 fractures, acute shortening and proximal lengthening in 18 fractures and bone transport in 14 fractures. Evaluation was carried out according to the Ovadia-Beals evaluation system.

Results: The mean average follow up was 6 years. Thirty seven fractures (70%) treated with bone graft substitutes achieved an excellent or good result. Eleven fractures (61%) treated with proximal tibia lengthening achieved an excellent or good result, whereas only eight fractures (57%) treated with bone transport achieved an excellent or good. Bone infection was recorded in 6 fractures, all in the group of the patients treated with bone graft substitutes.

Conclusion: The management of the metaphyseal bone loss in the high energy tibial pilon fractures is a basic priority to achieve a satisfactory result. Hybrid external fixation with the use of bone graft substitutes seems to be a more suitable technique to these devastating injuries. However bone infection remains a major concern for these devastating injuries.

Purpose. To assess the efficacy of the treatment of the aseptic hypertrophic nonunion of the tibia and the secondary deformities by distraction-osteogenesis.

Material Methods: Between 1998 and 2006, 28 patients with a hyperthrophic tibia nonunion were treated by distraction or compression-distraction depending on the mobility of the nonunion. The mean age of the patients was 37.5 years (range 24 to 68) and the average number of previous surgeries on the affected limb was 2 (from 1 to 4). No active bone infection or history of infection was recorded in this series. Closed distraction was applied in 11 patients, closed distraction – compression in 8 and osteoclasis following by distraction in 9 patients. In all cases an external fixation device (19 circular, 11 monolateral external frames) modified to meet the nonunion requirements was used.

Results: Distraction or distraction-compression resulted in solid union in all patients (mean time to union 8.4 months, mean follow up 5 years). The external fixator remained in place for an average of 8.2 months (range 7 to 11.5 months). Mean leg length discrepancy 2.5 cm and mean angular deformity 12° were also corrected on the same procedure

Conclusions: Treatment of the tibia nonunion by callus distraction or distraction – compression leads to successfully results. The procedure and the frame have to be individualized according to the nonunion pathology and the secondary tibia deformities.

Purpose: To evaluate the efficacy of intramedullary nailing for the treatment of the fractures of the proximal quarter of the tibia with special respect on the reduction accuracy.

Patients: This is a retrospective study which was conducted in our institution between October 2004 and March 2007. 30 extrarticular proximal tibia fractures were treated with intramedullary nailing. The mean age of the patients was 27 years (19 to 47). Seven fractures (23%) were open – Gustillo grade I-, twelve fractures (12%) had segmental comminution and six (6%) were bifocal fractures. Static intramedullary nailing was chosen in all cases. Distal dynamization was performed routinely in all fractures at an average of 7 weeks (6 to 12 weeks) after the primary operation. Union of the fracture and the accuracy of the reduction were assessed clinically and radiologically.

Results: The average follow up was 16 months (9 to 22). All fractures united without additional procedures. Acceptable alignment was obtained in 28 of 30 fractures (93%). Postoperative angulation was satisfactory (average frontal and sagittal plane deformity of less than 2 degrees) in 26 fractures (87%). Two patients had frontal plane deformities (one 4° varus and one valgus 7°) and two patients had a saaggital plane deformities (7° procuvartum). No significant complication was recorded.

Conclusions: The proximity of the upper tibia fracture to the knee makes the treatment of these fractures more challenging. Closed intramedullary nailing combined with special reduction technique is a safe and effective method of managing of the proximal tibia fractures.

Purpose: To evaluate the results of the treatment of tibia fractures with external fixation and subsequently exchanging it to intramedullary osteosynthesis

Material and Methods: This is a retrospective study of 25 tibia fractures which were treated in our institution between January 2002 and December 2005. There were 17 men and 8 women with an average age of 32 years (range, 19 to 70). According to AO-OTA there were 7 type B2, 12 type C1, 3 type C2 and 3 type C3. All fractures were open (Gustilo Anderson type I (2), type II (8), type III (15). The planned treatment protocol included provisional management with external fixation and sequential converse to a static intramedullary nailing. The mean duration of external fixation was 9 3 weeks (range, 2 to 7). In all cases nailing was preceded by a period in plaster lasting an average of 4 weeks.

Results: All patients were reviewed after an average time of 12 months (range 9–21). Bone union was noted in all fractures at an average of 19 weeks (range, 8 to 32) after the intramedullary nailing. There was one case with deep infection, without compromising the consolidation of the fracture. A leg shortening from 1.5 cm to 3 cm was recorded in 6 cases. Angular malalignment from 2° to 5° of tibia was recorded in 2 cases. 3 additional surgeries for leg lengthening were recorded but no further surgery due to the tibia malalignment was needed.

Conclusions: The management of open tibia fracture remain a challenging problem. Exchange of the external fixation to intramedullary nailin is a safe and effective treatment modality of managing of these difficult tibia fractures.

Purpose: To assess the function of the knee joint and the development of knee arthrosis, at seven years postoperatively, in patients in whom a high energy tibial plateau fracture had been treated with minimal internal fixation augmented by small wire external fixation frames.

Material and Methods: Between October 1989 and November 1999, one hundred twenty nine high energy tibial plateau fractures were treated with hybrid fixation including small wire circular or hybrid frames, minimum internal fixation and occasionally provisional extension of the external fixation to the distal femur. The average patient age was 39 years. There were 69 (53%) C1 fractures, 19 (15%) C2 and 41 (32%) C3 fractures and 49 (38%) fractures were open. Complex injury according to Tscherne-Lobenhoffer classification was recorded in 87 (67%) patients. Clinical, subjective, objective and radiographic results were evaluated after an average follow up of 84 months.

Results: Results were assessed according to the criteria of Honkonen–Jarvinen. Excellent or good functional result was recorded in 98 (76%) patients. However, only 74 (57.5%) patients retained an excellent or good radiographic result at the final follow up. Compared with the radiographic appearance of the post-traumatic arthritis after an average of 48 months, there was found no statistically significant deterioration of the knee arthrosis (p< 0,05). No reconstruction operations were performed after the completion of the index procedure.

Conclusion: A high percentage of radiographic post-traumatic arthritis should be expected, after high energy tibial plateau fractures had been treated with minimal internal fixation augmented by small wire external fixation frames. However, because all the objectives of the fracture treatment can be obtained, the functional results remain satisfactory over time.

Purpose: To assess the function of the knee joint and the development of post-traumatic arthritis at a minimum of five years after injury in patients in whom an intra-articular distal femoral fracture had been treated with a reamed retrograde intramedullary nail.

Methods: This is a retrospective study of thirty patients with thirty intercondylar-supracondylar femoral fractures treated with a reamed retrograde nailing. According to the AO-ASIF classification, there were 19 (63%) type C1 fractures, and 11 (37%) type C2. Operative technique included reduction of the fracture (closed in 16 cases), minimal internal fixation in all fractures and the insertion of a retrograde interlocked IM nail. Follow up ranged from 61 to 84 months with an average of 66 months. Functional results were assessed using the HSS score and the radiographic appearance of post-traumatic arthritis using the Ahlback score.

Results: Twelve patients (40%) achieved an excellent HSS score and only four (13%) a poor HSS score. Mean flexion of the knee was 113° (from 90° to 130°), and 21(70%) knees had no extension deficit. No correlation was found between the type of fracture and the final score. No radiographic signs of secondary arthritis were recorded only in 5 (17%) fractures.

Conclusions: A high percentage of radiographic post-traumatic arthritis should be expected, after intra-articular femoral fractures were treated with the insertion of a retrograde IM nail. However, because all the objectives of the fracture treatment can be obtained, the functional results remain satisfactory over time.

Aims: Fibular plating comprises a major component in the treatment of Pilon fractures with ORIF. However its necessity in fractures treated by EX.FIX has been questioned. In order to clarify this technical detail we carried out a retrospective study with Pilon fractures treated by circular þxators. Methods: Between 1992–2001, 65 pilon fractures were treated with circular þxators. Fractures were classiþed according to the systems of Ruedi Ð All-gower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Tension wire þxation at the fracture site was augmented by screws in 39 fractures. The lateral malleolus was internally þxed in 39(60%) patients. In 48(74%) patients the þxation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in þve fractures. Clinical and radiological results were evaluated. Results: Mean follow up was 3 years (1 to 10 years). On the basis of Ruedi-All-gower system, there was found negative correlation of the end result and þbular þxation in all the fractures types. However if Ovadia Beals system was used, þbular þxation was associated with better results in types II and III, but with inferior results in types IV and V. Conclusions: Ovadia Ð Beals classiþcation considers the metaphyseal defect and fracture comminution and should be chosen for the selection of the technique. In fractures with metaphyseal defect, þbular þxation does not allow acute shortening and makes bone transport more difþcult leading to poor results. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

Aims: Circular þxation has become increasingly popular for high-energy tibial plateau fractures (HETPF). These injuries are associated with comminution and soft tissue compromise and may require additional þxation to the femur. This study investigates the indications for bridging the knee joint and the appropriate type of the tibiofemoral construct. Methods: Between 1988 and 1999, 112 patients (mean age: 37; range: 18 to 67) underwent circular þxation for HETPF. There were 8 Schatzker type IV fractures, 11 type V, and 93 Schatzker type VI fractures. 40 fractures were open whereas 55 fractures had Tscherne type 1 or 2 damage of the soft tissues. 30 fractures underwent simple tibial þxation and 80 fractures required extension of the þxation to the femur for 6 weeks, using either þxed or mobile hinges. Mean follow up was 5 years (range, 28 months to 13 years). Results were evaluated according to the system of Honkonen and Jarvinen. Results: 93 (82%) injuries had at least one, and 65 (57%) more than one indication for tibiofemoral þxation. The most common indications were: extensive comminution (73 knees), soft tissue compromise (60 knees), and ligamentous injuries (58 knees). Patients with tibiofemoral þxation achieved better þnal axial alignment and knee stability than patients with tibial þxation. Fixed joint bridging resulted in the same knee ßexion but signiþcantly lower extension lag than mobile bridging. Conclusions: 80% of HETPF are associated with injuries that require knee bridging. Fixed tibiofemoral þxation offers better subjective, clinical, functional and radiological results.

Purpose: The retrospective evaluation of the results of the application of the ring and hybrid systems of external fixation for the management of the high energy injuries of the talus.

Material and Methods: Between 1990–2001, seventeen patients with complex injuries of the talus were treated with the application of ring or hybrid fixators. Eleven patients were males and six females. Isolated fracture of the talus was recorded in five patients, fracture- dislocation in four and pantalar dislocation in eight. The injury was open in twelve patients. Six patients had multiple injuries. To classify the talar injury we used the systems of Hawkins and Marti/Weber. Tension wire fixation with the use of either Ilizarov or hybrid frames was applied in all fractures. Additional internal fixation was performed in eleven fractures. The fixation was extended at the forefoot in all fractures. Results were assessed using Kiel’s evaluation system.

Results: The mean follow up was 42 months (range, 25 to 96). We had no cases with deep infection, wound break down, osteomyelitis, or septic arthritis. We had five excellent, eight good, three fair and one poor result. The final radiographic appearance was not satisfactory in six fractures. Avascular necrosis of the talus was diagnosed in four fractures (23.5%).

Conclusions: Using the ring and hybrid external fixation systems a satisfactory reduction of the high energy fractures and dislocations of the talus with the maximum respect of the anatomical architecture of the adjacent tissues can be achieved. The method offers an excellent stability of the fracture, diminishes the rate of the postoperative infection, and reduces significantly the risk of talus avascular necrosis.

Purpose: To evaluate the effectiveness of external fixation in maintaining the reduction of the unstable distal radius fractures and to identify possible factors that might affect the loss of the reduction.

Material and Methods: Sixty-five unstable distal radius fractures were treated with the application of external fixation. Closed reduction was achieved in 45 (69%) fractures. Additional internal fixation (K- wires) was performed in 21(31%) fractures. The external fixator was removed at an average of 35 days. The dorsal, volar and radial displacement of the distal radius, and the radial height were recorded in anterior -posterior and lateral radiographs, immediately after the surgery and six months postoperatively.

Results: Loss of the reduction in, at least, one of the radiographic parameters was noted in 43(66%) fractures. The mean value of the dorsal displacement of the distal radius progressed from 2° immediately after the surgery to 5° at 6-month radiographs. Loss of the reduced volar tilt greater than 4° was measured in 32(49%) fractures. Radial height loss greater than 3 mm was recorded in 22(34%) fractures. Significant difference (p< 0.001) of the reduction loss was found when internal fixation accomplished by K- wires was added. However none corrective osteotomy for malunion of the fracture was needed to be performed. Age and the severity of the injury were not correlated with the final result.

Conclusions: External fixation in unstable distal radius fractures was found inadequate in maintaining the intra-operative reduction and should be augmented with internal fixation or with the use of bone grafts.

Fibular plating comprises a major component in the treatment of Pilon fractures with open reduction and internal fixation. However, its necessity when Pilon fractures are treated by hybrid fixation has been questioned. A retrospective clinical study with 65 high energy pilon fractures treated by circular fixators between 1996 and 2001 was undertaken, in order to clarify this technical detail. The mean age was 35 years (range 21 to 69 years). The fractures were classified according to the systems of Ruedi -Allgower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Hybrid fixation (tension wire fixation at the fracture site augmented by screws) was performed in 39 fractures. The lateral malleolus was internally fixed in 39(60%) patients. In 48(74%) patients the fixation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in five fractures. Clinical and radiological results were evaluated.

Mean follow up was 3 years (range 1 to 10 years). On the basis of Ruedi-Allgower system, there was a negative correlation between the end result and fibular fixation in all the fractures types (p< 0.001). However, if Ovadia Beals system was used, fibular fixation was associated with better results in type II and III, but with inferior results in type IV and V.

We conclude that in fractures with metaphyseal defect, fibular fixation does not allow acute shortening and makes bone transport more difficult leading to poor results. Ovadia – Beals classification considers the metaphyseal defect and the fracture comminution and should be chosen for the selection of the technique. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

We treated 24 patients with high-energy fractures of the tibial plateau by the Ilizarov fixator and transfixion wires. Eleven fractures were open, and 20 patients had complex injuries. Twelve were treated by ligamentotaxis and percutaneous fixation, seven by limited open reduction and five by extensive open reduction. All were followed for at least 24 months.

All the fractures united, with an average time to healing of 14.4 weeks. Thirteen patients achieved full extension and 13 more than 110° of flexion. Twenty-two knees were stable. Fifteen patients walked normally and the rest with only a slight limp. All but two knees had an articular step-off of less than 4 mm and all had normal axial alignment except two. There were no cases of postoperative skin infection, osteomyelitis or septic arthritis.

Ilizarov circular fixation is an ideal method of treatment for these fractures when extensive dissection and internal fixation are contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution.