Three cases of patients affected with massive bone defects are reported, in which over 50% of the segments are involved. The treatment options considered were original and not yet described in literature. The patients were affected with: partial agenesia of the tibia, congenital hypoplasia and pseudoarthrosis of the femur, and massive post-traumatic bone defect. In all these cases the Ilizarov’s method was applied. In the first case, instead of carrying out an osteotomy and callotasis of the residual bone tissue, an osteotomy was performed close to the tibiofibular syndesmosis and a distraction at this level was executed. In the second case of pseudoarthrosis with antecurvatum of the proximal femur of 135°, varus of 100°, length discrepancy of 63%, a multiplanar gradual correction of the proximal deformity of the femur was carried out followed by a distal lengthening.

The third case concerning the pluri-fragmented exposed diaphyseal fracture of the tibia and fibula, with massive bone loss, was treated by restoring all the small fragments, even those without periosteal connections, to increase the proximal and distal bone mass. Once the fusion of the fragments occurred, a proximal osteotomy and callotasis was performed to rejoin the fracture’s segments.

Dysplasia epiphysealis hemimelica is a rare congenital abnormality of enchondral ossification of one or more epiphyses, thus determining an asymmetrical growth in that bone district. We are here considering 2 cases. The first case regards a 4-month-old female baby with an irreducible flexion of the right knee. The X-rays highlighted an area of different density with irregular contours and multiple ossifications; the MRI showed a bone lesion with osteocartilaginous structure in contiguity with the medial condyle; during the operation a osteocartilaginous formation partially fused with the medial condyle was observed. The second case regards a 10-month-old male baby, with a medial malleolus swelling. The X-ray highlighted an area of different density with irregular contours and multiple ossifications, medial to the epiphyseal nucleus of the talus; the MRI showed an osteocartilaginous lesion in contiguity with the talus; during the operation an osteo-cartilaginous formation fused with the talus was observed. The histological findings confirmed in both cases the presence of cartilaginous and bone tissue in absence of pathological lesions.

Being a lesion of malformative origin, the early removal of the abnormal ossification nuclei will permit to avoid the secondary lesions described in literature, like asymmetrical growth of the limb and functional limitation.

The fibrocartilaginous labrum acetabulare enlarges the acetabular socket and contributes to the stability of the femoral head. In DDH the labrum is everted and pushed upward by the femoral head. In the dislocated hip the labrum is often inverted into the acetabular cavity and obstructs anatomic reduction. In the past, excision of the labrum was performed to allow the reduction of the femoral head. The aim of this study was to evaluate the position of the labrum in early detected decentered hips and its role in the early treatment of DDH. During the eleven-year period from 1992–2002, 21,709 neonates (43,418 hips) were examined both by ultrasound and by Ortolanis test to establish the diagnosis of DDH. According to Grafs classification the following hips were present: 298 type D-hips, 252 type IIIa, 4 type IIIb and 20 type IV. Therefore 431 of the patients (356 females and 75 males) showed 574 sonographically unstable hips affected by DDH (1.32%). Due to its echogenic structure, the fibrocartilaginous labrum is clearly visible by ultrasound. In type D, type IIIa, and type IIIb it was always located cranially to the femoral head; in type IV it was located medially to the femoral head. The average age of the children at the time of the diagnosis was 42 33 days (mean value SD). Ortolanis test was positive in 61 hips (10.63%) and negative in the remainder of the hips (89.37%). 21.5 % of the cases were diagnosed within the second week of life, 52.9 % between the third and the eighth week, and 25.5 % after the eighth week. The labrum was not inverted in any of these cases, nor was an open reduction necessary in order to remove it as an obstacle to the closed reduction. Only the ultrasound examination allowed the early diagnosis of the unstable decentered hips. The importance of the labrum decreases when an early diagnosis can be made and an early treatment can be performed.

After gaining experience from 1990 to 2003 using the Cincinnati incision in the surgical treatment of congenital clubfoot, we were able to extend its use to the early surgical treatment of congenital vertical talus (CVT). Eight of the 172 feet were affected by CVT; four were idiopathic, three were associated with arthrogriposis and one with cerebral palsy. The average age of the six children at the time of the operation was 13.5 months (range 6–27 months). We performed a posterior, medial and lateral release of the subtalar joint and of the talona-vicular joint. The reduction of the talus was performed using a K-wire placed through the posterolateral aspect of the talus in its longitudinal axis. After the calcaneus was reduced from its everted position, a second K-wire was placed through the calcaneus and into the talus. The medial talonavicular joint capsule was opened and the redundant capsule reconstructed. Peroneal tendon lengthening was performed in five cases. The radiological evaluation, according to Hamanishi, showed preoperatively a talo-first metatarsal angle of 94° (NV: 3.3 ± 6.4 SD) and a calcaneal-first metatarsal angle of 54° (NV: −9 ± 4.5 SD); postoperatively the values were 24° and 7°, respectively. There were no wound complications or avascular necrosis of the talus.

With the Cincinnati incision we were able to visualise the talo-calcaneal and talo-navicular dislocation in all three spatial planes. It also allowed us to correct the deformity in all three mentioned planes and in a single-step procedure.

From 1990 to 2003 the Ilizarov technique was used to treat 41 patients affected by the following congenital or acquired deformities : post-poliodeformity (n=8), hemimelia (n=6), pseudoachondroplasia (n=5), idiopathic genu valgum/varum (n=5), hypoplasia (n=3), osteomyelitis with growth arrest (n=3), DDH (n=2), rickets (n=2), Blount disease (n=2), Ollier disease (n=1), Perthes disease (n=1), arthrogryposis (n=1), hypochondroplasia (n=1) and congenital genu flexum (n=1). Post-traumatic deformities and simple leg-length discrepancies were excluded. The majority of the patients (26/41) presented with multi-planar deformities with the following average degrees: varus 22°, valgus 21°, internal rotation 36°, external rotation 42°, antecurvatum 20° and recurvatum 15°. The average leg-length discrepancy was 6 cm (range 2–10 cm). In total, 66 segments (30 femurs and 36 tibias) in 50 limbs were treated. The rotational corrections were performed at a rate of 4 mm/day; the angular corrections at the rate of 1.5 mm/day on the concave side and 0.75 mm/day on the convex side. The rotational correction occurred on the regenerate. The average correction time was 44 days, the healing time 86 days.The results were: excellent (correct mechanical axis, normal ROM and no limping) in 14 cases, good (correct mechanical axis, limping and reduced ROM) in 24 cases, fair (residual deformity, limping and joint contracture) in three cases, poor (residual deformity, limping and rigid joints) in none. The complications were: five pin tract infections and three fractures.