Our approach to reconstructing forefoot deformities in patients with rheumatoid arthritis was as follows. In the lateral toes with mild or moderate joint destruction, shortening oblique osteotomy of the metatarsals is performed. With severe joint destruction, metatarsal head is resected. Arthrodesis of the first MTP joint is performed as a rule with resection arthroplasty in the lateral toes. When shortening oblique osteotomy in the lateral toes is indicated, the great toe is managed as follows: in young patients with mild joint destruction in the great toe (Larsen grades I and II) and who are able to ambulate well, Mitchell’s osteotomy is done. In older patients, or in patients with moderate or severe joint destruction (Larsen grades III to V), flexible hinge toe prosthesis is implanted.

Between 1987 and 2000, Mitchell’s osteotomy was performed on 47 feet in 31 patients, whose mean age was 53 years, Larsen grade was 2.5 and hallux valgus angle (HVA) was 35.0 (SD11.9). Arthroplasty with flexible hinge toe prosthesis was performed on 31 feet in 23 patients, 58 years, Larsen grade was 3.7 and HVA was 45.3 (SD12.9). After 1995, grommets were used in 17 feet. In 2002, we studied clinical results of them. 40 feet of Mitchell’s osteotomy had no pain and 7 feet had some pain. 26 feet of arthroplasty with flexible hinge toe prosthesis had no pain and 5 feet had some pain. Radiologically, HVA was 17.2 (SD10.3) in Mitchell’s osteotomy and 12.1 (SD6.3) in arthroplasty with flexible hinge toe prosthesis. Maintenance of correction by arthroplasty with flexible hinge toe prosthesis was better than Mitchell’s osteotomy significantly, especially more than 30 degrees of HVA. Without grommets, grade 0 was 8 feet, grade I was 3, and grade II was 3 feet judged by Granberry’s grade. But no revision surgery was performed by silicone synovitis or fracture of implant. With grommets, there were no fractures.

We added degree of HVA to management of operation after 2002. More than 40 degrees of HVA was considered flexible hinge toe prosthesis. After 2002, Mitchell’s osteotomy was performed on 7 feet in 6 patients, 53.7 years, Larsen grade was 2.4 and HVA was 32.3 (SD6.8). Arthroplasty with flexible hinge toe prosthesis was performed on 14 feet in 10 patients, 60.7 years, Larsen grade was 3.9 and HVA was 42.5 (SD7.5). Radiological result in these patients at 2005, HVA was 14.6 (SD4.9) in Mitchell’s osteotomy and 14.9 (SD2.5) in arthroplasty with flexible hinge toe prosthesis.

The purpose of this study is to introduce our technique of free hand screw insertion for scaphoid fractures and clarify the indications of this procedure.

From 1988 to date, we performed this method in 86 cases (75 males and 11 females). Ages ranged from 11 to 73 years (av.: 29). There were 24 cases of acute stable type, 46 of acute unstable and 16 of delayed fibrous union. Screws used were original Herbert screws in 48, other cannulated type screws in 38.

Using an image intensifier, from a small skin incision over the scaphotrapezium joint, a Kirschner wire is inserted to stabilize the fracture temporarily. The wire is pulled volarward to rotate the scaphoid and a second wire is inserted along the intended line of the screw. With the original Herbert screw, after removing the wire, the screw is inserted free-hand. With the other cannulated screws, the second wire is used as guide pin.

Results of 82 cases with follow-up times over 6 months were reviewed. In one case, bony fusion was achieved but revealed symptomatic malunion. In two cases, bony fusion was not achieved. In one of them, an additional bone graft was performed, and good bony union was achieved. In the remaining 79 cases, good bony fusion and good clinical results were achieved.

The best indication for this method is an acute unstable fracture. For acute stable fractures, we recommend this method for three types of patients: those who cannot accept long term immobilization, those who desire to return to athletic activities as soon as possible, and those who also have another fracture in the forearm. It can also be used in cases of delayed fibrous union when good alignment can be achieved and a bone graft is unnecessary.

Vascularized bone grafts (VFG) have brought great benefits in the field of reconstruction of the lower extremity. However, complications such as fracture of the grafted fibula and delayed union are sometimes seen. Not only to prevent these complications but also for stability after fracture of the grafted fibula, the Ilizarov external fixator is a very useful option. We report here the clinical results of cases treated by VFG combined with Ilizarov external fixator for reconstruction of the lower extremity.

We have performed 53 vascularized fibula transfers to reconstruct lower extremities. An Ilizarov external fixator was used for the initial immobilization in 7 (2 femur, 5 tibia) and for delayed union or fracture of the grafted fibula in 2 cases of congenital pseudoarthrosis of the tibia.

All patients achieved good bone reconstruction. All are able to walk without a brace except for one congenital case. The average period to achieve bony fusion was 13 months in femur cases, 6 months in adult tibia cases and 2 months in congenital cases. The average periods to walk without a brace were 14 months, 8 months and 10 months respectively. However, it took 9 months and 28 months to achieve bony union in the cases with delayed union or fracture of the grafted fibula.

In the reconstruction of the lower extremities using VFG, the determining factor in method selection is whether sufficient mechanical support is available. An Ilizarov external fixator for immobilization permits the patient to walk as soon as possible. Dynamization from this semi-rigid external fixator causes bone hypertrophy and improved incorporation of the graft.