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.

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.