Introduction. The distal part of the interosseous membrane (IM) may contribute to ankle joint stability and therefore partly explain the results of a study that reported no difference in outcome in patients with low Weber C fractures treated with or without a syndesmotic screw. The aim of the current study was to compare the strength of the IM to the interosseous ligament (IL). Method. Six paired cadaveric lower extremities were stripped, leaving only the IM and the IL intact. The tibia was fixed and a load was applied via a steel plate to the lateral surface of the fibula to displace it with respect to the tibia along the line of the fibers of the IM and IL. In group one the interosseous ligament was sectioned and the interosseous membrane was mechanically tested until failure. In group two, the interosseous membrane was sectioned and the interosseous ligament was tested. Results. The interosseous membrane was 30% stronger than the interosseous ligament (1040 ± 183 N versus 798 ± 322 N, respectively; mean ± SD). Conclusion. The current biomechanical study found that the IM was 30% stronger than the IL. The interosseous membrane has considerable strength and may play a role in ankle stability

Purpose of the study: The slightest alteration of the antebrachial anatomic configuration, which constitutes a complex and precise biomechanical system, yields a limitation in pronosupination. Unlike the metaphysical region, little is known about rotational malunion involving the radial shaft. Kasten et all demonstrated in 30 cases that a rotational malunion of the radial shaft leads to significant loss in the pronosupination arc. If the proximal and distal radioulnar joints are intact, the interosseous membrane (IOM) probably plays an important role in this limitation. Material and methods: The purpose of our study was to evaluate the impact of releasing the IOM on the pro-nosupination arc in an experimental model with a rotational malunion of the radial shaft inducing pronation. Results: The study involved eight cadaver forearms free of all muscle structures and devoid of prior trauma. After stabilizing the elbow at 90°, the upper limb was fixed on a metal frame used as the reference to measure pronosupination. For each specimen, motion was measured initially, after osteotomy of the radius shaft to induce pronation then associated with longitudinal section of the IOM. A midshaft transverse osteotomy induced 78±7 pronation on average and was fixed with a DCP. Discussion: The mean pronosupination arc was initially 175 in our population (81 pronation, 94 supination). After the creating the rotational malunion, this arc decreased significantly to 126 (SD. p> 0.05) (99 pronation, 27 supination). Release of the IOM increased this arc significantly from 27 to 153 (SD, p> 0.05) (105 pronation, 48supination). Conclusion: Our study confirms the impact of rotational malunion on the pronosupination arc and shows the positive effect of releasing the IOM. Suppression of the IOM leads to a simpler biomechanics for the antebrachial system, allowing greater mobility of the bone one over the other. There are several clinical applications of this observation for the correction of shaft malunion of the antebrachial bones, but also certain corrective osteotomies for malpositions in the neurological patient

Purpose of the study: Investigate the longitudinal stability and instability of the forearm. Material and methods: The interosseous membranes of 30 formol-treated forearms were dissected under 4-fold magnification and translumination. The radial and ulnar heads wee resected to eliminate the two radioulnar articulations before performing sequential cuts to identify the different networks of the interosseous membrane. The ulna was maintained in a fixed position allowing proximal and distal displacement of the radius. We studied the medial border of 100 radii, noting the bony eminences and their relations with the configuration of the membrane. Cases of neglected fractures of the radial cup without injury to the distal radioulnar joint and cases of polyarthritis treated by double resection radioulnar and Sauvé-Kapandji) presenting good longitudinal stability were studied. The possiblity of using the extensor indicis for primary reinforcement of the interosseous membrane was studied on cadaver specimens. Applied to an acute case of Essex-Lopresti syndrome, this original technique provided good intraoperative stability. Results: The fibers of the interosseous membrane design two planes, an anterior and a posterior plane. The anterior fibrrs descend distally and medially from the radius. They can be divided into proximal (horizontal) descending fibers, intermediary (short oblique) descending fibers, and distal (long oblique) descending fibers. The posterior fibers rise proximally and medially from the radius to reach the ulna. They form two planes: proximal ascending (short oblique) fibers and distal (long oblique) ascending fibers which are inconstant. These planes are in relation with the origin of the extrinsic wrist extensors. The main fibers are: the intermediary descending fibers and the proximal ascending fibers. They insert on the interosseous tubercle of the radius, a constant eminence situated on the medial border of the radius 8.4 cm from the elbow. The thre groups of descending fibers limit proximal translation of the radius. The proximal fibers can limit excessive distal translation. The proximal and distal ascending fibers limit distal translation of the radius. A full thicknes tear of the anterior plane is necessary to achieve proximal displacement. Longitudinal stability is maintained in neglected fractures of the distal without rupture of the interosseous membrane and in operated polyarthritis with resection of the two radioulnar joints. Conclusion: The fibers of the interosseous membrane describe two planes where the fibers run in opposing directions. Each plane limits radial displacement in a different direction. The ideal reconstruction would restore the two planes, but it is essential to reconstruct at least the intermediary descending fibers and the proximal ascending fibers. However, in routine practice, translation of the radius is generally proximal, so reconstruction of the middle segment appears to be sufficient if it associated with a reinforcement transfer of the extensor indicis to the proximal radius

Introduction. Posterolateral tibial plateau fractures account for 7 % of all proximal tibial fractures. Their fixation often requires posterolateral buttress plating. Approaches for the posterolateral corner are not extensile beyond the perforation of the anterior tibial artery through the interosseous membrane. This study aims to provide accurate data about the inferior limit of dissection by providing measurements of the anterior tibial artery from the lateral joint line as it pierces the interosseous membrane. Materials and Methods. Forty unpaired adult lower limbs cadavers were used. The posterolateral approach to the proximal tibia was performed as described by Frosch et al. Perpendicular measurements were made from the posterior limit of the articular surface of the lateral tibial plateau and fibula head to the perforation of the anterior tibial artery through the interosseous membrane. Results. The anterior tibial artery coursed through the interosseous membrane at 46.3 +/− 9.0 mm (range 27–62 mm) distal to the lateral tibial plateau and 35.7 +/− 9.0 mm (range 17–50 mm) distal to the fibula head. There was no significant difference between right or left sided knees. Discussion. This cadaveric study demonstrates the safe zone (min 27 mm, mean 45mm) up to which distal exposure can be performed for fracture manipulation and safe application of a buttress plate for displaced posterorlateral tibial plateau fractures. Evidence demonstrates quality of reduction correlates with clinical outcome and the surgeon can expect to be able to use a small fragment buttress plate of up to 45mm as this is the mean

Syndesmotic stability in ankle fractures is usually assessed by pulling on the fibula with a bone hook in the coronal plane (“hook test”). Our clinical observations have suggested that instability may be more marked in the sagittal plane. Our aim was to compare movement at the tibio-fibular syndesmosis in the sagittal and coronal planes after sequential ligament division in a cadaver model. Seven specimens were used. A blinded subject was asked to perform the hook test both in the sagittal and coronal planes. Movement was assessed by measuring the displacement of parallel k-wires three consecutive times. In all specimens, the anterior tibio-fibular, interosseous and posterior tibio-fibular ligaments were sequentially divided and movement tested. In three specimens the deltoid ligament was then divided and the interosseous membrane in another three. After division of all three syndesmosis ligaments the mean displacement was 8.8mm (±3.9) in the sagittal plane and 1.5mm (±0.4) in the coronal plane. When the deltoid ligament was then divided, the displacement increased to 11.7mm (±2.4) and 3.2mm (±0.5) respectively. When the interosseous membrane was divided the measurements were 12.7mm (±4) and 3.1mm (±1.5). We conclude that distal tibio-fibular instability should be assessed in the sagittal plane

This novel modification of the posterior approach allows a low hazard exposure and easier surgery to the radial head. Methods and Materials: The most commonly used approaches are from the lateral aspect. The limitations of this approach in particular for radial head replacement is that it is a tight exposure, there is a risk of damage to the posterior interosseous nerve and there is always a difficulty in dislocation due to the presence of the interosseous membrane. The posterolateral approach to the proximal radius and ulna was described by Boyd, Gordon and Thompson. This approach avoids damage to the posterior interosseous nerve but the annular ligament requires incision and repair. Approach: Position the forearm in pronation aligning the ulnar styloid with lateral epicondyle of the humerus. A tencentimetre long incision is then made on the lateral border of the ulna exposing deep fascia. Following this a 1cm flap of fascia is left on the ulna and anconeus is lifted off the bone. This exposes underlying radial head, annular ligament and interosseous membrane. After identifying the ulnar insertion of annular ligament a 0.5 cm bone is osteotomised with annular ligament attached from the supinator tuberosity. The radial head osteotomy is performed with the radial head in pronation to align it with shaft of radius using specially designed jig. Osteotomy of the radial head has to be at right angles to the axis of the forearm. This is a line between centre of the radial neck to the ulnar styloid process. Radial head can now be subluxed out of the wound and preparing for a replacement. The trial prosthetic radial head is then inserted and reduced. The bone fragment with annular ligament attachment is then reduced back into the original slot. This allows one to judge the size of prosthetic radial head if ligament is too tight a small diameter implant is required. The bone fragment is reattached using especially devised washer with, wire holes and a 2mm AO screw. Results: This approach is easier, safer and reproducible. When compared to lateral approach it provides an easier access and excellent stability in radial head replacement. We recommend this approach for radial head replacements and difficult trauma cases

The Interosseous Membrane (IOM) of the forearm is made up of ligaments, which are involved in load balancing of the radioulnar joint and the shaft. Motion models of the forearm are necessary for planning orthopedic surgeries, such as osteotomies, which aim at solving limit of the range of motion or instabilities. However, existing models focus on a pure kinematic approach, omitting the physical properties of the ligaments, thus limiting the range of application by missing dynamical effects. We developed a model that takes into account the mechanical properties of the IOM. We simulated the pro-supination by creating an elastic coupling to the desired motion around the standard axis of rotation. We tested our model on a healthy subject, using CT-reconstructed bone models, and literature data for the ligaments. Multiple parameters, including forces of ligaments and positions of landmarks, are output for analysis. The length of the ligaments over pro-supination was in agreement with the literature. Their rest lengths must be recorded in future anatomical studies. The IOM helps in maintaining the contact with cartilage, except in late pronation. Scarring of the central band increases the force generated along the axis of rotation toward the wrist, while scarring of the proximal part does the opposite in pronation. In contrast to kinematic models, the proposed model is helpful to study the effect of physical properties of the IOM, such scarring, on the forearm motion. Future work will be to apply our model to pathological cases, and to compare to clinical observations

Background. Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all?. Methods. The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden's classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results. During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion. Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise

There are numerous causes of cavovarus feet, the most common of which are the hereditary motor and sensory peripheral neuropathies. Regardless of the underlying aetiology, cavovarus feet are caused by muscle imbalance. Often the imbalance is between a relatively strong tibialis posterior acting against a weaker peroneus brevis, and a relatively weak tibialis anterior being over powered by peroneus longus. Intrinsic muscle weakness and gastro-soleal tightness is common. After the failure of non-operative management, flexible deformity can be corrected with a combination of tendon transfers and osteotomies. Frequently surgical management of cavovarus feet involves a combination of calcaneal and first metatarsal osteotomies, peroneus longus to brevis transfer, transfer of tibialis posterior through the interosseous membrane to the dorsum of the foot, tendo-Achilles and plantar fascia lengthening and correction of toe deformities. The post-operative recovery is slow, but most patients achieve good functional results and report improvements in their activities of daily living

In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively. We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC. The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one. We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result

Purpose. The anterior inferior tibiofibular ligament (AiTFL) is the primary lateral ligamentous stabilizer of the ankle syndesmosis. Current syndesmosis repair techniques traverse the tibia and fibula, but do not anatomically reconstruct the AiTFL. We compared a novel AiTFL anatomic repair technique (ART) to rigid syndesmosis screw fixation (SCREW). Method. Twelve cadaveric below knee specimens were compared radiographically and using a biomechanical testing protocol. All specimens underwent a CT scan of the ankle joint prior to testing. Next, the AiTFL, interosseous membrane and deltoid ligament were sectioned, and the posterior malleolus osteotomized, to recreate a trimalleolar-equivalent ankle fracture. The posterior malleolus was repaired with the posterior ligamentous insertions intact and functional (PMALL). Ankles were examined under fluoroscopy with an external rotation stress exam and the medial clear space (MCS) measured. Specimens were then randomized to receive either a conventional syndesmosis screw (SCREW), or the novel anatomic repair technique (ART). External rotation stress fluoroscopy was repeated. A second CT was completed and the fibular position compared to the pre-injury CT. Each specimen was then loaded in external rotation until failure using a custom biomechanical jig. Results. The MCS during stress examination increased by 1.04 0.31mm in the PMALL group. MCS increased significantly less at only 0.300.07mm (p=0.002) in the ART group. The SCREW fixation method demonstrated a delta MCS of 0.280.16mm (p=0.008). Post repair CT showed that 33% of specimens were subluxed from the SCREW group compared to 0% for the ART. Mean torque at failure for ART was 24.85.5Nm compared to 16.85.8Nm for SCREW (p=0.01). Conclusion. Repair of the posterior malleolus alone demonstrated a greater than 1mm of medial clear space widening and is not sufficient to re-establish syndesmotic stability. Addition of the ART or SCREW technique restored syndesmotic stability. None of the ART specimens demonstrated fibular subluxation, while 33% of SCREW specimens were subluxed anteriorly on CT. Biomechanical strength of the ART was found to be greater than that of rigid screw fixation

We evaluated 28 patients, 52 feet with flaccid paraparesis (27 MMC, 1 neonatal paraplegia) in which a posterior transference of the tibialis anterior was performed for talus deformities. Between 1987 and 2001 in two institutions. Mean age at surgery 6+6 ( from 0+4 to 12+10) 16 males, 12 females,. Neurological last level functioning was 1 Toracic, 2 lower lumbar, 25 sacral. Technique: through minimal incisions the muscle is transferred posteriorly opening bluntly the interosseous membrane and weaved to the aquiles tendon if present and fixed to the top of the os calcis in 10° of equinus. There where 23 bilateral cases. Asociated surgeries 17 extension calcaneal osteotomies 5 peroneal z plasties, 4 short peroneal to posterior tibialis transfer, 2 vertcal talus correction, 2 Evans lenghtenings, 1 IF arthrodesis. Follow up in 25 patients (3 lost) was 3+11 (0+3 to 12+1). Complications: 1 late calcaneal osteomielitis, ,2 severe valgus feet in a vertical talus. Results: we measured calcaneal pich in 26 feet in a lateral xray. Mean preop measure 34*(20 to 50 ) postp 21* (15 to 25). All patients were independent walkers at follow up. Conclusion: Posterior transfer of the tibialis anterior is an excellent operation that prevents talus progression in the absence of planta flexors alone or in conjuction with extension calcaneal osteotomy in older children, the better position lessens trhe chance for the habitual skin lesions in this patients

Dynamometric measurement of the grasp strength is commonly used in wrist assessment. On the other hand measurement of the pronation-supination (PS) strength has been few studied. The longitudinal forearm rotation needs integrity of the two radioulnar joints and of the antebrachial interosseous membrane. The strength developed during PS assesses also trophicity of pronator and supinator muscles. A PS dynamometer (Baseline ®, AREX) is now available for such measurements. The aims of this study were: 1) to study the best way to neutralize the shoulder movements of abduction-adduction, 2) to find the values of PS Strength in a healthy population, and 3) to study correlations between this PS force and several biometric items. A first series of measurements des PS strength was performed thanks to the Baseline dynamometer in 8 people, in association with two devices neutralizing the shoulder movements of abduction-adduction, in repeated campaigns allowed the authors to determine and keep the better one for optimal measurements following campaigns. To assess the normal values of PS Strength in a healthy population, 38 healthy volunteers from both genders and different ages, classified according their age class, from three different forearm position: neutral, from 90 ° of supination and 90 ° of pronation. Finally, statistical analysis looked for correlations between PS strength and some biometric data. Manipulations beginning from a neutral position of forearm were the most reliable. The mean strength within the whole studied sample (76 wrists, 17 male, 21 female) was 10.6 N.m (standard deviation SD 3.26) for the supination and 13.9 N.m (standard deviation 4.19) for the supination. The dominant side exhibited a PS strength superior by 7.5% to that of the non-dominant side. Male gender, the height and weight of the body, forearm circumference displayed positive relationships with PS strength. Mean values of PS strength, measured from a neutral forearm rotation and with the best device to neutralize the shoulder movements, in a healthy population of 38 volunteers, allowed the authors establishing reference values. They will allow precise comparisons between the values found in patients suffering from forearm and/or wrist pathology and the healthy population, taking into account the age, gender and hand dominance

Dislocation of the distal radioulnar joint (DRUJ) in association with fractures of both bones of the forearm has received relatively little attention in the literature. The purpose of this study was to evaluate the integrity of DRUJ and evaluate the association between the level of fracture and instability of DRUJ following fracture both bones of forearm. This was a prospective study of 65 patients, over 3 years followed up for 12 months. All patients were treated with open reduction and internal fixation of radius and ulna. The mean age of the patients was 34.8 years (15–68 yrs). There were 51 males and 14 females. There were 18 fractures involving distal third of forearm, 42 fractures in the middle third and 5 fractures of the proximal third. 38 fractures (58.4%) had subluxation of the DRUJ and 27 had no DRUJ subluxation. All subluxations were dorsal. Post-operatively, 30 of the 38 fractures (78.9%) had persistent DRUJ subluxation. Of the 27 fractures, which had no pre-operative DRUJ subluxation, 10 fractures (37%) revealed dorsal subluxation in the post-operative radiographs. All fractures were immobilised in above elbow plaster casts for 6 weeks. All patients were followed up at 3, 6 and 12 months. Patients were assessed clinically, radiologically with standardised radiographs and functional assessment of grip and pinch strength using Jamar dynamometer. At 12 months, 12 patients had significant symptoms associated with DRUJ. Of these, 4 had functional restriction, which were related to complex DRUJ dislocations. DRUJ dislocations are more common in fractures, which are in the direction of the interosseous membrane (p< 0.002). They are commonly associated in fractures involving the middle and distal third of the forearm. There is a tendency for under-reporting of DRUJ dislocations in fractures of both bones of forearm and hence, more attention should be paid to this entity

Purpose of the study: Balistic nerve injury is not common in civil medicine. We analyzed a series of 30 patients who underwent surgery for this type of injury suffered in the Gaza strip between 2002 and 2004. All patients presented paralysis of the sciatic nerve or one of its major branches. All injuries were caused by war weapons. Material and methods: The series included 28 men and two women, mean age 22 years (range 2.5–65). The injury had occurred more than one year earlier for 33% of patients. The injury was situated at the knee level in twelve patients and in the thigh in ten. Complete nerve section was observed in 12 patients and partial section in two. Loss of nervous tissue was significantly greater for lesions around the knee. Nineteen patients underwent surgery for: neurolysis (n=3), direct nerve suture (n=8) and nerve grafts (n=8). Eleven patients were reviewed at mean 13.7 months (range 3–30 months). There were no failures. Results of reinnervation of the tibial nerve territory were better than for the fibular nerve. Sixteen patients underwent palliative transfer for a hanging foot for more than six months: 15 transfers of the posterior tibial muscle through the interosseous membrane and hemitransfer of the Achilles tendon. Seven patients underwent Achilles tendon lengthening at the same time and five had a reinnervation procedure on the common fibular nerve. Results: Seven patients were reviewed with a mean follow-up of 1.8 years (range 4–30 months. None of the patients used an anti-equin orthesis. There were three cases of forefoot malposition. The overall Stanmore score was good at 75.4/100 (range 59–100). Discussion: High-energy ballistic trauma creates a specific type of injury. Nervous surgery can be indication early to favor spontaneous recovery. Palliative surgery for fibular lesions provides regularly good results. Conclusion: Nerve injuries due to ballistic trauma should be explored surgically because of the possibility of direct nerve repair. In addition, depending on the type of paralysis, reliable palliative surgery can be proposed

Purpose: We reviewed retrospectively 22 patients with recent and old fractures of the radial head treated with the GUEPAR radial head prosthesis which has a mobile metal cup derived from the GUEPAR gliding total elbow prosthesis. Material and methods: Among the 22 patients, 13 underwent surgery in an emergency setting and four underwent a secondary procedure. Mean age was 41 years and follow-up was 18 months. The Mayo Clinic score was noted. Fractures were total or disengaged cervical fractures and in 72% of the elbows dislocation was associated. The coronoid process was fixed in one elbow, the olecranon in one and the medial ligaments were repaired in five. The status of the humeral condyle was examined in detail before insertion of the prosthesis. We also were particularly attentive concerning the height position of the prosthesis. Results: There were no complications. Outcome was good among the patients undergoing an emergency procedure with a mean Mayo Clinic score of 83/100, mean force 75%, good motion, particularly 77° pronation, and 79° supination, with good stability and absence of wrist problems. The patients who underwent a secondary procedure had less satisfactory results, particularly for motion (44° pronation and 54° supination). The distal radioulnar index was not perfectly restored. Finally four patients had arthrolysis for limited flexion/extension, three of them in the secondary group. Discussion: Resection of the radial head is an alternative for complex fractures that has its inconveniences. The first is that it destabilises the elbow in valgus position in the event of injury to the medial ligaments and the second is the ascension of the radius in the event of injury to the interosseous membrane. Fixation is another alternative, but it is difficult and has not provided good results in our hands or in the literature (we have compared this series with a series of 20 fixations for equivalent fractures). The prosthesis appears to be a good solution: it stabilises the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective outcome, particularly in emergency cases

Purpose: The Sauvé-Kapandji procedure is often performed for the treatment of posttraumatic degeneration of the distal radioulnar joint. Few studies have been devoted specifically to the proximal stump of the ulnar after this procedure. The aim of our study was to conduct a radioclinical evaluation of the dynamics of the proximal ulnar stump. Material and methods: This retrospective analysis involved fourteen patients (four women and ten men), mean age 48 years who underwent the procedure between January 1991 and March 2002. All presented posttraumatic degradation of the distal radioulnar joint. The operation took place twelve months after trauma on average. Mean ulnar resection was 11 mm, performed as distally as possible. The pronator quadratus was not advanced into the false joint. Pronation-supination rehabilitation exercises were instituted shortly after surgery. A static and dynamic x-rays protocol was designed for analysis. Results: Patients were reviewed at five years two months on average. There were two complications: fusion of the intentional ulnar pseudarthrosis and one pseudarthrosis of the distal radioulnar joint. Time to resumption of former activity was nine months on average. Two patients could not resume their former activity. Seven patients complained of mechanical pain at the ulnar resection. Three patients reported cracking sounds along the ulnar border of the wrist and two patients presented an objective snap during pronosupination. Clinically, the ulnar stump was unstable in the sagittal plan in all cases. Radiographs confirmed this instability. Clinically, there was also an instability in the frontal plane in three patients. The dynamic films did not confirm frontal instability. Discussion: Although less so than after the Darrach procedure, the proximal ulnar stump is the principle complication of the Savué-Kapandji procedure. Preservation of the structures stabilising the distal ulnar stump is crucial: periosteum, interosseous membrane, ulnar extensor of the carpus, pronator quadratus. Our use of a shorter resection made as distally as possible was only able to avoid a certain degree of instability which was nevertheless well tolerated. Conclusion: The Sauvé-Kapandji procedure provides very satisfactory results for pain and motion. All patients appeared to have some degree of distal ulnar stump instability which was as a rule well tolerated. Nevertheless, one patient required a revision for stabilisation. This instability remains an unsolved problem which apparently cannot be prevented even with a very rigorous technique

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Number one in frequency of all fractures in children is the distal forearm fracture. The most common green-stick fracture with minor or no dislocation is treated by short or long arm cast. Depending on the age 4 or six weeks of immobilization is sufficient. Displaced fractures of the distal radius and ulna are treated by closed reduction under general anaesthesia or lighter forms of analgesia. Reduction is followed by fixation in the “Schede position” (flexion, ulnar abduction) with obligatory change of cast after 10–14 days. Healing can be expected after 6 weeks. As an alternative percutaneous pinning of the reduced fracture allows immobilization in a short arm cast and without the the unpleasant flexion and ulnar abduction (. Voto et al 1990. , . Mani et al 1993. , . Gibbons et al 1994. , Choi et al 1959). There is currently a prospective randomised study running organized by Mr Clarke from Southampton, to the advantages and disadvantages after use of pins or abstaining from them apparent risks. For midshaft forearm fractures closed reduction and long arm cast immobilisation had been treatment of choice in the past. Remanipulation under anaesthesia because of lack of retention of both bone fractures have been common. Concerns came up mainly in the age group above 10 years with a high rate of unsatisfactory results (. Kay et al 1986. ). Plate fixation of both bones is a difficult procedure and causes damage to the interosseous membrane and can enhance rotatory deficits. In addition ugly scars are not unusual. Intramedullary nails seemed advantageous. (. Amit et al 1985. ). J.L. Morote and the Spanish school of Sevilla were the first to use a minimal invasive method of reduction and K-wire fixation of midshaft and proximal forearm fractures. (Perez-Sicilia et al 1977). The French group in Nancy and Metz had the some years later and developed their elastic stable intramedullary system for forearm fractures . Metaizeau 1988. , . Lascombes et al. 1990. ). A high rate of excellent outcomes and hardly any complications were observed. Intramedullary fixation with elastic stable nails even permits immediate motion (. Verstreken et al 1988. ). The surgical technique of Morote using blunt-ended 1,6 to 1,8 mm K-wires is described in “Operative Technique in Orthopaedics and Trauma” (. Parsch 1990. ) The results were confirmed by Kaye Wilkins (1996), . Luhmann et al 1998. , and . Richter et al 1998. An unacceptable high rate of complications was seen in groups, who used pins, which were not buried, who removed pins to early and before consolidation or who had fixed only one bone (. Cullen et al 1998. , . Shoemaker et al 1999. ). We recommend the intramedullary system for all displaced forearm fractures of children above 6 years until closure of the growth plate.(. Parsch 1990. ). The learning curve is short, the time of surgery an average of 40 minutes. The radiation exposure can be limited by the use of short impulse image intensifier. There is virtually no blood loss. With the learning curve more than 80 % can be fixed by closed means. Open reduction might be necessary in adolescents, or in delayed fracture care. Postoperative immobilisation is a plaster shell or brace is used for 2 weeks, this is not obligatory. Postoperative infections have not been observed after this minimal invasive method. Skin irritations can be avoided by complete bending of the K-wire ends. In unacceptable malunion after conservative treatment closed or open realignment of the fractures followed by intramedullary Morote pinning is the treatment of choice. Refractures may happen with wires in place shortly or a long time after removal of the hardware. They are not associated to the system, but rather to the fact that some children are subject to repeated falls, liable to break an arm. Acute Monteggia fractures have the radial head reduced conservatively, usually under general anaesthesia. (. Bado 1967. ). The ulnar fracture is reduced and than fixed by intramedullary K-wires (. Fowles et al 1983. ). In late reconstruction of Monteggia lesions we prefer plate fixation of ulna osteotomy