Introduction: Osteomyelitis and septic arthritis (SA) below the elbow are severe conditions affecting the function and viability of the hand. Factors predisposing to these conditions and parameters affecting prognosis are emphasized.

Material and Methods: In a 4 years period, 16 patients with SA (4) or osteomyelitis (12) were treated in a University Orthopaedic Department providing care to a rural population of 1.000.000, Nine had history of trauma in unhygienic environment, 3 had immunodeficiency and in 4 osteomyelitis was iatrogenic [previous fixation of fractures (3) and vein catheterization (1)]. SA was located in the wrist (2) and thumb joints (2) and osteomyelitis involved the radius (3), ulna (1), metacarpals (3) and phalanges (5). Ten patients received oral antibiotics in other centers. The mean delay from onset of symptoms to referral to our center was 22 days. Apart of antibiotics administration, surgical treatment included debridement and irrigation for SA and excision of necrotic bone, stabilization (external fixators), use of antibiotic beads and secondary bridging with bone graft for osteomyelitis. Additional procedures (amputations, arthrodesis) were also required in some cases.

Results: Cultures were positive in 9 of 16 cases [Staph. aureus (5) and enterobacter cloacae (3)]. Patients underwent multiple procedures (mean: 3.8) and 4 underwent amputation of a digit (2) and hand (2) due to the rapid extension of infection threatening and finally taking the lives of 2 elderly and immunosuppressed patients. Mean follow-up period of the 12 surviving and non-amputated patients was 18 months. Union was accomplished in all cases. Functional results were excellent or very good in 10 of 12 patients and good in 2 patients. All patients were satisfied and returned to their previous occupations.

Conclusions: Osteomyelitis and SA below the elbow was frequent in population living in unhygienic environment or working with soil. All cases received medical treatment with delay. Immunosuppressing conditions favored the extension of infection and threatened patients lives. Delay in treatment in combination to immunosuppression resulted to significant morbidity. Early treatment including surgical drainage, thorough debridement and antibiotic administration is necessary for elimination of skeletal infection and salvage of the hand and patients life.

Introduction: Suppurative conditions in closed cavities/tunnels require surgical drainage and irrigation for elimination of infection. The purpose of this study is to evaluate the pattern of extension of infections in hand compartments and the necessity for intraoperative and continuous postoperative catheter irrigation.

Material and Methods: Compartmental infections of the hand and wrist (CIHW) were diagnosed in 42 consecutive patients involving the flexor tendon sheaths (pyogenic flexor tenosynovitis) (28); the tip (3); the carpal tunnel (2); or extended to multiple compartments including the above mentioned and the thenar, midpalmar, web and Parona’s (9). Three patients had diabetes mellitus, 2 suffered from bites, 15 had penetrating injuries and 7 were working with animals or meat products. Fifteen were previously treated in other centers. After meticulous clinical evaluation to define all the involved compartments, all patients were treated with drainage of the respective compartments, sheath irrigation and appropriate antibiotics, whereas continuous postoperative catheter irrigation was used in 24. Hand therapy started the third postoperative day.

Results: Mean follow-up time was 20 months. The most common pathogen was S. aureus (14 patients) whereas cultures were negative in 15. Three patients received additional fungal treatment. Results were excellent or very good in 25 hands and good in 12 regaining full or near full ROM. Recurrence of infection in 4 (that were initially treated inadequately in other centers or had intraoperative sheath irrigation without postoperative continuous irrigation) necessitated a revision of the procedure with extensive debridement and continuous postoperative irrigation. Finally, 1 patient developed complex regional pain syndrome.

Conclusions: A high index of suspicion and profound knowledge of the anatomy is essential for early diagnosis and prompt surgical treatment of CIHW. Initially «benign» infections often extend in multiple compartments of the hand as a result of inadequate initial treatment. Intraoperative irrigation is not always adequate for the resolution of infection, especially in neglected cases or cases with underlying conditions. Early surgical debridement of all the involved compartments in combination to continuous postoperative irrigation, administration of appropriate antibiotics and precocious onset of hand therapy is the treatment of choice for these potentially debilitating, infectious conditions of the hand.

Purpose: To assess þbular graft viability and the evolution of the subsequent bone healing into the hosting tunnel. Methods and Materials: Eight patients (10 grafts) with femoral head AVN were examined with 4 consecutive MRI examinations at 2w, 6w, 3m, and 6m postoperatively using a 1T scanner. A dynamic 3D-T1-w TFE sequence (9 sections every 8s) was applied for estimating the perfusion in the graft (SI curve). Multiplanar imaging in the axis of the graft was used for a delayed fat-suppressed T1-w Spin Echo sequence (acquisition matrix 512, slice thickness 3mm). The following parameters were evaluated: a) more or less than 50% increased SI in the graft, b) maximum SI close to the graft, c) maximum width of the medullary enhancement close to the graft, d) width of osteonecrotic area. The þnal MRI examination together with plain x-ray þlms and clinical examination were used to assess outcome. Results: The decrease of% enhancement area in the graft medulla, the gradual decrease of the enhancement in and around the graft, correlated well with the clinical þndings. The dynamic study and the parameter c, showed no correlation with the clinical status. In 2 cases, enhancement close to the upper end of the graft and in the necrotic zone, suggested expanding inversion of the process. Conclusion: High resolution enhanced MRI, may offer an additional means for assessment of the healing process of vascularized peroneal grafts in patients with femoral head necrosis.

Introduction: Amputation of the fingertip with loss of the finger pulp, exposed bone and nail bed injury is a common problem, not infrequently neglected. Fingertip reconstruction requires new pulp glabrous skin coverage with sensitivity, buttressed by the nail. The aim of this study is the analysis of our experience from the use of a homodigital, island flap for the reconstruction of amputated fingertips Materials and Methods: The homodigital island flap was applied in 46 patients (57 fingers), at every level of finger amputation with special indication on fingertip coverage. For the index and the middle fingers, use of the ulnar bundle is preferred. For the thumb, ring and little finger use of the radial neurovascular bundle is preferable. The neurovascular bundle is well dissected from the flap to the base of the finger. After suturing of the flap the donor area is covered with split thickness skin graft from the hypothenar. The finger is mobilized one week after the procedure. Results: Postoperatively, ROM was normal in 45 fingers, 6 fingers had 100 loss of extension at the DIP and 6 fingers had loss of motion between 100–200 . TPD was 4mm (3–10mm). Three patients had cold intolerance for 8 months. There was no neuroma or sensitive scar formation and no need for a second operation. According to patients cosmesis was acceptable in all fingers. Conclusions: The use of homodigital island flap provides excellent functional reconstruction of the fingertips after a complex tissue loss in Allen III and IV amputations It is a straightforward operation carried out under wrist block with excellent cosmetic results.

Purpose: To review the MRI findings in transient osteoporosis of the hip (TOH) and to investigate the pattern of perfusion in dynamic studies.

Material and Methods: Twenty-seven patients (29 hips), 23–66 years old, were referred for hip pain without history of trauma. In all patients the diagnosis of TOH based on x-rays (decrease bone density of the femoral head) and MRI (bone marrow edema-BME) was confirmed after complete resolution of symptoms and MRI findings after 6–18 months. MRI studies included T1-w SE, T2-w-SPIR-TSE and contrast enhanced T1-w TFE in dynamic mode and delayed SE. Imaging assessment included joint effusion, location and extent of BME (types A–D), sparing of the femoral head, subchondral linear lesions, and collapse.

Results: Joint effusion was observed in 28 of 29 hips. The extent of BME in the femoral head was type A in 5/29 hips, B in 2/29, C in 16/29, D in 6/29. Associated BME of the acetabulum was depicted in 6/29 hips. In 12/29 hips the bone marrow edema was sparing the subchondral area. Subchondral line was only found in 2/29 hips. On dynamic T1–w images all hips presented with a delayed pattern of perfusion up to 40 sec.

Conclusion: MRI findings are useful in diagnosing TOH and differentiating this entity from early AVN.

Aim: The biceps brachii is an important elbow flexor and is the main supinator of the forearm. Avulsion of its distal tendon insertion is an uncommon injury and even more uncommon is the partial tear of this tendon. The rupture typically occurs at its attachment to the radial tuberosity. Nonoperative treatment of these injuries has been described, but significant weakness in flexion and supination or persistent pain may occur. Most authors recommend acute anatomic repair to improve function or relieve pain.

Material and Method: Twenty-five ruptures of the distal biceps tendon were operated at our institution from 1992 to 1997. Twenty-three of the patients were male and 2 female. The dominant extremity was involved in 21 patients. Their average age was 48 years (range, 30–59). Eighteen ruptures were complete, 8 of them were acute, while 10 were chronic, as were the 7 partial ruptures. Three patients with complete rupture and all the patients with partial rupture had a MRI. In 2 chronic patients an anatomic repair was impossible and they were treated with a biceps-to-brachialis transfer. These patients were not included in the final follow-up. All other tendons were repaired anatomically through use of a single anterior incision and bone suture anchors. Follow-up averaged 36 months (range, 12–53 months). At final follow-up subjective and objective data were collected. Patients were questioned about their activity level, job status, and satisfaction at outcome. Elbow range of motion, strength and power were compared with those for the uninjured side while each value was adjusted for dominance and expressed as a percentage of the uninjured side.

Results: All patients returned to their preinjury level of activity and employment by 6 months after surgery. All patients reported that they were satisfied with the result and would undergo the surgery again. The entire group of patients averaged 9.8% more flexion strength and 2.4% less supination strength for the repaired elbow that for the uninvolved elbow. Range of motion was normal in 20 patients. Three patients lacked 10° of extension and one of them lacked 10° of pronation. No patient experienced transient or permanent nerve deficit. None of the patients complained of pain or tenderness. There was no evidence of heterotopic ossification or change in the position of the suture anchors.

Conclusion: The one incision technique with bone suture anchors is a safe and reliable technique for the treatment of complete or partial distal biceps tendon ruptures with very good results referring to restoration of flexion and supination strength and minimal complication rate.