The frequent choice of treatment for tibial shaft fractures is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen with satisfied results.

Twenty-nine patients with complex, unstable tibial shaft fractures (13 males and 16 females) aged 18 to 76 years (mean age 49 years) were treated using Ilizarov external fixation, the last decade in our Department by the same surgeon. The indications were open Gustillo III fractures, comminuted fractures of the proximal or distal third tibia near metaphysis, concomitant plateau or pillon fractures and fractures after total knee arthroplasty (TKA). All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within2 weeks after surgery.

Union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit, 10 superficial pin tract infection treated with antibiotics and local care and 1 deep infection which needed surgical intervention.

Ilizarov external fixation gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing

Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years).

Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed.

Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients.

Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases

Introduction: the choice of treatment for tibial shaft fractures in adults is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen.

Patients and Methods: 29 patients with unstable tibial shaft fractures (13 males and 16 females; aged 18 to 76 years) were treated using Ilizarov technique, last decade, by the authors. The indications were open fractures type III Gustillo, comminuted fractures of the proximal or distal third near metaphysis, concomitant plateau or pillon fractures and fractures after TNR. All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within two weeks after surgery.

Results: union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit. As complications there were superficial pin tract infection in 10 patients treated with antibiotics and local care and one deep infection which needed surgical intervention.

Conclusions: Ilizarov technique gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing.

Purpose: The floating knee injuries are rare injuries and have severe complications. There is controversy in the literature regarding the gold standard of treatment. We present our experience treating 25 patients with this type of injury.

Materials and Methods: There were 23 males and 2 females, aged 18 to 65 years, with a mean ISS (injury severity score) 25 (ranged, 18 to 45). All patients were operated the day of admission. Based on Letts’ classification there were 8 fractures type A, 6 type B, 7 type C, and 4 type D. The management in type A and B in non polytrauma patients was external fixation of the tibia followed by intramedullary nail of the femur, while in type C and D external fixation of the femur followed by external or internal fixation of the tibia.

Results: The mean follow-up was 4 years (ranged 1–7 years). One patient died before the completion of the therapy. Fracture union was accomplished to all the patients. Three patients were reoperated for nonunion or malunion of the femur and one for nonunion of the tibia. There was no infection. The main complication was the knee stiffness but it was resolved without a second operation. Two patients had pulmonary embolism and one fat embolism. The final results based on Karlstrom and Olerud criteria were excellent in 5 patients, good in 14 and fair in 5.

Conclusion: The treatment of the floating knee injuries is based on ISS and the Letts classification. In type A and B in non polytrauma patients, we believe that the best way of treatment is external fixation of the tibia followed by intramedullary nail of the femur.

PURPOSE: There is an argument in the literature regarding the use of intramedullary nail or the external fixation followed by intramedullary nail in tibial fractures with severe damage of soft tissues, threatened compartment syndrome, open type IIIA fractures and in polytrauma patients. The purpose of this retrospective study was to evaluate the results of non-jointed external fixators as a definite treatment for these type of tibial shaft fractures.

MATERIAL AND METHOD: 86 patients (91 tibial shaft fractures) were treated at the authors’ institute with a non-jointed external fixator. The mean patient age was 35 years (range, 15–80). There were 70 male and 16 female patients. The average time of surgery from the accident was 10 hours. The indications for application an external fixator was: severe damage of the soft tissues in 11 fractures, an incipient compartment syndrome in 12 fractures, open type III Gustilo fractures in 57, and 11 tibia fractures in polytrauma patients. According to AO classification 46 fractures were type A, 32 type B and 13 type C.

RESULTS: The average follow up was 2.9 years (ranged, 1–5 years). The average operative time was 50 min. Complications included: 3 non-unions, 5 delayed unions, 1 malunions, 1 tibia shortening, 3 superficial infections of soft tissues in open fractures, 26 pin infections and 1 osteomyelitis in open fractures. In 2 patients fat embolism was diagnosed while pulmonary embolism was a complication in 2 patients. Deep venous thrombosis (DVT) developed in 5 patients. A re-operation was performed in 11 out of 91 fractures. Change of the method was necessary in 2 out of 91 fractures. The primary callus in 10 out of 91 fractures was due to the stiffness of the unilateral non-jointed external fixators and did not influence the final results. Mean time of fracture union for the open fractures that did not require change of the method nor bone graft was 25 weeks, while for the closed fractures was 18 weeks. The dynamization of the system and partial weight bearing was started at 6 weeks and all the patients had full weight bearing by the 12th week.

CONCLUSION: The unilateral external fixators were the definite treatment in 88 out of 91 fractures. The unilateral external fixators can be used as a definite treatment for tibial shaft fractures in the majority of the cases. Re-operation or change of the method is unusual and must be performed only when there is a delay in callus formation.

Aim: To study the postoperative results of an alternative method of pin placement for acute pelvic ring stabilization with an external fixation.

Introduction: External fixation for stabilization of pelvic ring fractures is the only and a safe method for emergency treatment. According to literature pins of the fixator should be placed urgently on the superior iliac rim and as soon as general condition of the patient permits, revision is required in order to manage in a finitive way the injury.

Material-Method: Inclusion criteria were high energy trauma, severe pelvic instability, heamodynamic instability, acute management of a pelvic fracture and minimum follow up of 2 years. Patients with a simultaneus major head, chest or abdominal injury were excluded from the study. Between 2000–01, 19 patients (15 male and 4 female with a mean age of 28 years old) underwent acute pelvic stabilization with an external fixation. In 12 patients, mechanism of injury was road accident and in 7 patients a fall from a height. Fracture type according to Tyle classification was 2 type A, 12 type B and 5 type C. In 6 patients the pins were placed in an oblique plane to the superior iliac rim (Group I) and in 13 patients there were placed in the sagital plane, just below the superior anterior iliac spine (Group II). The mean time for external fixation application was 15 min for group I and 22 min for group II.

Results: 14 patients were heamodynamically stabilized in the early postoperative period and 5 patients were transmitted to Intensive Care Unit. In 17 patients a rigid fixation of the pelvis was achieved and remained as a definite method of treatment and in 2 patients of Group I, replacement of the external fixator and an adjacent stabilization of posterior elements was required. No patient required adjacent posterior element stabilization as the primary reduction and stabilization was satisfactory. Mean time of stabilization was 7 weeks for type A, 10 weeks for type B and 11 weeks for type C fractures. 13 patients were totally recovered and returned to their previous occupation and 6 patients have minor problems that are attributed to the pelvic ring fracture.

Conclusions: External fixator’s placement for pelvic ring stabilization should be performed in a way that it will be a finitive method for osteosynthesis of the pelvis. We suggest pin placement in the sagital plane, below the superior anterior iliac spine instead of placement at the superior iliac rim.

We report our experience on complications of intra-medullary nailing on 150 femoral shaft fractures.

Material concerns 147 patients (103 men and 44 women) that were operated in a 7 years period. Mean age was 37 years old (15–77). Thirty patients were older than 65 years. Indications for femoral intramedullary nailing were 120 acute fractures (7 pathological), 9 non-unions, 2 malunions and 19 fractures with delayed union previously operated by another method. Twenty two were polytrauma patients. Twenty one fractures were open (grade a and b). Various types of reamed long antegrade nails were used in 117 cases and a long g-nail in 33 cases.

Main complications were: shortening 10, heterotopic ossification 6, knee stiffness 8, fat embolism 2, deep venous thrombosis 4, pulmonary embolism 2, superficial wound infection 8, deep infection 1, lengthening 4, rotational deformity 10, nonunion 0, missed distal screw targeting 10, drill breakage 7, malposition of the nail 7, additional intraoperative fracture occurrence 7. In 60 cases the insertion of the guide was performed by a small incision at the fracture site. Mean union time was approximately 4 weeks shorter when a closed reduction was performed.

Technical complications in the majority of cases affected fractures that were operated after midnight. Elderly patients (> 65 years old), were most probably to be subjected a complication while less complications occurred in younger patients. A well prepared operating room and prevention of surgeons fatigue is needed to reduce complications.

The attempt to achieve and institude the potential less minimal invasive hip hemiarthroplasty by using common instruments is the aim of our study.

We report on a randomly selected group of 80 patients, 40 of which were operated by a small incision 5–10 cm (group A) and 40 by a standard incision 15–20 cm (group B). The approach was through the gluteus medius muscle (lateral-Hartinge) in all of the cases. In group A an additional small transverse incision of the fascia was needed without any other inside extension. There were no statistical differences in gender, age (mean age 80 and 79 years old respectively), weight of the patients (average BMI 27,5 kg/m2 and 27 kg/m2 respectively) and implant type.

The operations were supervised by the same surgeon. PMMA was used in 18 of the cases in each group.

Blood loss was less in group A (mean 200cc less) and 21 patients were not transfused at all intraoperatively. A second assistant was necessary in educational operations. Four of the patients had postoperatively bruises and skin scratches. Early postoperative pain was less in the first group, but was the same two months postoperatively. Thirteen patients slept on the operated leg on the 2nd and 3rd postoperative day. Discharge from the hospital was available two days earlier in the first group. We had one hip dislocation in the first group in a psychiatric patient who had also DVT.

In conclusion , minimal invasive surgery in hip hemi-arthroplasty is possible to be performed with the use of common instruments and it is worth once while. Experience of the surgical team is necessary for reducing operative time and further research is needed for establishing possible contraindications.

Aims: The purpose of our study is to present the results of the use of external þxation, as a þnal method of treatment for tibial shaft fractures. Methods: In 5 years period, we treated 143 tibial shaft fractures in 135 patients. 112 were male and 23 were female, aged 15 to 80 years old (mean 35 y.o.). Our indications were: 16 closed fractures with severe soft tissue injury, 19 closed fractures with threatened compartment syndrome, 90 open fractures, Gustilo type II or III, 18 closed fractures in polytrauma patients. Results: Union, without the need of changing method was achieved in 121 fractures. The mean time of union was 22 weeks for closed fractures, 25 weeks for type II open fractures and 28 weeks for type III open fractures.

The main complications were 13 nonunions, 40 super-þcial pin infection, 2 malunions, 2 osteomyelitis, 2 patients with fat embolism syndrome and 3 deaths due to pulmonary embolism. Conclusions: External þxation is a proper deþnite treatment for tibial shaft fractures according to the indications mentioned above. Technically it is easy to apply and there is no need of surgery to remove it. The procedure of normal union is not disturbed. Most of the complications can be managed without removing the device. The advantages of the method make it comparable or superior to intramedulary nailing although there is a delay in full weight bearing.

There are a few reports in the literature that compare the results of medial and lateral meniscectomy, especially in older patients.

Eighty three patients that underwent partial menis-cectomy were studied (45 men, 38 women), all older than 45 years. Forty eight cases considered medial and 35 cases lateral meniscectomy, mainly of the posterior horn. According to Outbridge and French Arthroscopic system criteria, there was not significant difference for the osteoarthritic changes that were found arthroscopically. 48% of the patients had no arthritic damage. Radiological evaluation of the results was done with Fairbank classification and International Knee Documentation Committee criteria, pre and postoperatively. Preoperatively, 50% of the patients had no pathologic radiological findings and postoperatively, both groups had similar radiological results. Tapper – Hoover criteria and Lysholm II Score were used for the evaluation of clinical results. 83% of medial and 78% of lateral meniscus tear’s repair had satisfactory clinical results and no statistical significance was documented in our series, despite reports from the literature of poorer clinical results for lateral meniscectomy. In both groups, clinical results were not influenced by the severity of cartilage lesions or by the age of patients, but by the amount of meniscus removal and the delay of arthroscopy, greater than 2 months.

The surgical treatment of scaphoid nonunion is controversial.

The purpose of this study is to present our experience from the surgical treatment of 16 scaphoid nonunions in heavy manual workers.

Sixteen patients with sixteen nonunions of the scaphoid were treated during the last 6 years (13 male and 3 female). Established nonunion was present in 7 months to 7 years. Five nonunions were Alnot stage I, 5 were IIa, 5 were IIb and 1 nonunion was stage IIIa. One case considered the distal pole and 15 the proximal pole of the scaphoid. In 5 patients there was avascular necrosis of the scaphoid and in 6 patients DISI was present. All sixteen patients complained about pain, resulting to disability to work.

All patients were treated with an autocompression screw and small autologus cancellus bone grafts. In one case with a proximal third non-union, screw fixation was not achieved. The mean time of union was 70 days. Mean follow up was 3 years. All patients returned early to their occupation without pain. Grip strength reached 90% (70% preoperatively) and range of motion reached 95% (80% preoperatively), compared to the contralateral side. Excellent functional results were in eleven patients, good in four and average in one patient. In four cases there was a previous carpal dislocation.

Symptoms of non-union of the scaphoid appear earlier in heavy manual workers and their surgical treatment should not be delayed. We believe that the use of autocompression screws and cancellous bone grafts is the first choice of treatment for nonunions (Alnot stage I and II) of middle and distal third of the scaphoid.