Introduction

Throughout the years treatment of patellar fractures have been held in much controversy and various treatment procedures have been described. In the literature, there are only a few studies that compare the results of the different treatment modalities.

INTRODUCTION

In recent years the age of world's population has risen and with it there has been a significant increase in the frequency of hip fractures in the elderly. These fractures are known to increase morbidity and mortality. However, little is known about the frequency and characteristics of patients who sustain a second hip fracture. We examined the incidence and the underlying associated medical disorders of patients with a second fracture in the other hip.

Introduction: There is still controversy regarding which method of internal fixation of intraarticular hip fracture is ideal. The purpose of this study was to evaluate the outcome and complications following the fixation of such fractures with cannulated cancellous screws with two different types of triangular configurations of these screws: one superior and two inferior and vice versa.

Methods: Between January 2006 and December 2008, one hundred and twelve femoral neck fractures in 125 patients (mean age of 67 years) were treated by closed reduction and internal fixation (CRIF) by titanium cannulated screws, using alternately these configuration types of fixation. Twelve patients were lost to follow-up. Ninety-eight fractures in 93 patients were followed to union or revision surgery, with a mean duration of follow-up of twenty one months. There were 52 Garden I fractures, 34 Garden II fractures and 12 Garden III and IV fractures. Fifty-one were treated with standard configuration of 2 inferior and one superior screws (group 1), while 47 were treated with reverse placement (group 2). There was no statistic difference regarding age, sex and Garden’s classification between the two groups. The quality of reduction, accuracy of implant placement and rates of nonunion and osteonecrosis were evaluated.

Results: 83/98 fractures (85%) had at follow-up good-to-excellent reduction and fifteen (15%) had a fair or poor reduction. There was a nonunion of seven fractures (7 %) and avascular necrosis of the femoral head (AVN) in five (5%). There were no deep infections. Seventy one patients (83%) had a good functional outcome (as compared to 85/93 Pts- 91% – prior to fractures). Six patients (four with nonunion and two with avascular necrosis) went through revision surgery (THR). There was no difference in the quality of reduction, number of nonunion and AVN and functional outcome between both groups of fixation. There was a difference in the outcome which depended on the Garden type of fraction and the accuracy of reduction. Most complications were observed in Garden’s III and IV fractures with inaccurate reduction.

Conclusions: Excellent reduction and accurate implant placement is the main reason for a good outcome after close reduction and internal fixation of intraarticular hip fractures. We didn’t find any difference in the outcome following fixation in two different configurations of the screws.

Introduction: Treatment of proximal humeral fractures is still controversial. Conservative treatment may result in malunion and shoulder stiffness. We present our experience with displaced or comminuted fractures of the proximal humerus treated by closed or open “minimal invasive osteosynthesis” or by open reduction and using of fixed plates or by hemiarthroplasty.

Patients and Methods: This study consists of 189 Pts. (18–89 year old, mean 58.5Y) followed for 2–10 years (mean 5.5Y), treated by closed reduction and percutaneous pinning (79), ORIF and minimal osteosynthesis (27), ORIF with rigid plates (17), ORIF by LCP plates (10), ORIF by proximal humeral nail (5) or by hemiarthroplasty (51). Patients were evaluated by the UCLH and by Constant’s shoulder grading score systems and radiographs.

Results: Overall results were excellent and good in 85% of patients with 2 and 3 parts fractures of the proximal humerus treated by “minimal osteosynthesis” techniques, with some better results in less comminuted fractures. 26/32 Pts with 4 part fractures treated surgically had good functional results. The other 8 had poor results and 4 of them developed AVN of the humeral head. 75% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but had only a moderate improvement in shoulder motion (active abduction or flexion of 30–90 degrees in 38/51).

Conclusions: “Minimal osteosynthesis” by K.W. techniques, lag screws, rush pins or proximal humeral nail, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture. ORIF by conventional plates may be used in young patients and by LCP (locked compression plates) in osteoporotic or comminuted fractures of older patients. In the elderly, hemiarthroplasty seems to be the treatment of choice.

Introduction: Various surgical methods have been described to manage the problem of recurrent anterior dislocation of the shoulder. Older procedures Putti-Platt’s, Magnuson-Stack’s or Bristow;’s and Boytchev’s repair are not used today due to a high percentage of failure of 7%–17% incidence of recurrence associated with limited ROM. However, in the last decade the goal of treatment has changed. It is directed now towards restoration of normal function with full ROM of the affected shoulder, based mainly on arthroscopic stabilization or on “open” Neer’s capsular shift procedures combined with Bankart’s repair. However, during the last few years there are more and more papers dealing with a surprising unexpected high number of patients with shoulder instability following arthroscopic repair. The purpose of this study is to review the long term results of “open” Neer’s capsular shift procedure

Materials & Methods: This is a presentation of 87 (78M; 9F) consecutive patients, 19 to 47 year old (mean 23 Y) with a length of follow-up of 4Y–15Y (mean 6Y). 45 of them with traumatic recurrent anterior dislocation of the shoulder had a capsular shift procedure according to Rockwood’s modification. In 42 other patients that had a multidirectional instability with proved dislocations of the affected shoulder a Protzman’s modified capsular shift procedure was used.

Results: 82/87 patients had a stable shoulder without recurrent dislocation. 3 patients had an episode of traumatic shoulder dislocation within 2 months following operation. Two other patients of 42 with multidirectional instability had a recurrence of traumatic dislocation. One patient developed partial brachial plexus injury, most probably due to traction of the affected limb following operation. 78/87 had at follow-up normal shoulder function with full ROM, and the remaining 9 patients had only a slight limitation in shoulder abduction and in external rotation.

Conclusions: Based on this study, it is suggested that capsular shift procedure is an excellent method for repair of recurrent anterior shoulder dislocation, preferable to the “older” procedures, and allows restoration of shoulder stability with better functional results. This is suitable mainly for patients with structural hyperlaxity and multidirectional instability, whereas arthroscopic stabilization might be used in patients with true traumatic instability.

Introduction: The treatment of comminuted intra-articular fractures around the knee is one of most difficult areas of Orthopaedic traumatology. Open reduction and internal fixation is recommended by many authors. However, in severe comminuted fractures sometime it is difficult to achieve stable fixation and most cases need an additional cast immobilization following surgery. We present our experience with arthroscopic assisted closed reduction in severe comminuted knee fractures followed by fixation with Ilizarov frame.

Materials and Methods: Since 1998, 17 patients with comminuted intra-articular fractures around the knee were treated by this method. 8 patients had comminuted intra-articular fractures of the distal femur and 9 patients had comminuted fractures of the tibial plateau, one of them with fractures of both knees. There were 4 males and 4 females with femoral fractures (age: 22– 56Y; mean -31Y) and 8 males and 1 female with tibial plateau fractures (age: 34–68Y; mean – 51Y). Three fractures of the distal femur and 2 of the tibial plateau were open fractures. 5/17 Pts had polytrauma. We used AO classification for distal femoral fractures and Schatzker classification for tibial plateau fractures. All patients were operated within 48 hours after injury.

Results: In all patients, except two with unstable knee, closed reduction and Ilizarov external fixation was performed without knee immobilization, under knee arthroscopic control. In two cases split thickness skin graft was done following leg fasciotomies. Weight bearing was allowed 6 to 8 weeks following surgery. A second look arthroscopy was performed in 3 cases. The average time of fixation in Ilizarov frame was 4.5 months (range 3–6.5 months). On follow up of 2 to 8 years, 6/17 patients (35%) had excellent results, 8/17 patients (47%) had good results and 3 patients (17%) had fair results. No cases of osteomyelitis, neuro-vasular injuries or deep wound infection were observed.

Conclusions: Based on this study it seems that arthroscopic assisted closed reduction and Ilizarov fixation is very useful for severe intra-articular comminuted knee fractures. Arthroscopy of knee enables accurate reduction of these fractures, removal of free bone fragments and treatment of other intra-articular injuries. There is an early restoration of motion in injured knee, with short immobilization time, and there are no major complications.

Introduction: The optimal treatment of osteoarthritis of the medial compartment of the knee joint is still controversial. Optional procedures include arthroscopic knee debriedement, high tibial osteotomy, and total knee arthroplasty. In the last decade the use of unicompart-mental knee arthroplasty (UKA) for localized knee arthritis has become more and more common. This study reviews our experience with unicondylar meniscal bearing knee arthroplasty in patients with localized osteoarthritis of the medial compartment of the knee joint.

Material & Methods: Between 2001–2004, 26 Pts. (17F, 9M; 52–74 year old, mean 63Y) underwent surgery using the Medial Oxford Unicompartmental Knee. Four of them had since been operated on their other knee, usually 1–2 years after the first UKA. The mean age at surgery was 63 years (52–74). There were 17 women and 9 males. All patients had a stable knee and their preoperative ROM was between −10 degrees to full extension and between 100 to 120 degrees of flexion. Patients were followed for 1.5 – 4 years (mean 2.5Y), and evaluated by the Knee Society Score and radiographs.

Results: 24/26 (92%) patients, including the four patients who had staged bilateral procedures of both knees, had satisfactory results, of them 16/26 (61%) had excellent results and 8/26 (31%) had good results. They were almost free of pain, and most of them had marked improvement in knee function. Similar results were observed in each of both knees of the patients who had staged bilateral unicondylar knee arthroplasty. The remaining 2 patients (8%) had fair results. A second look arthroscopy of these patients revealed a progressive development of degenerative changes of the lateral compartment in one patient, and development of degenerative changes of the patella and patellar groove in the second patient.

Conclusions: Based on this study it seems that unicondylar knee arthroplasty is a favourable procedure in patients with localised arthritis of the medial compartment. This procedure allows replacement of only the affected joint compartment with less bone loss, and therefore enables preservation of healthy tissue and bone. Recovery following surgery is fast, rehabilitation is quick and ambulation is early. The ideal patient for UKA is a relatively young patient with localized degenerative changes, who has a stable knee, a flexion contracture less than 15 degrees and a mechanical axis of less than 10 degrees from neutral for a varus knee, or less than 5 degrees for a valgus knee.

Introduction: Meniscal tears are common in young athletes, usually result from a twisting injury during sport and may occur in the anterior or posterior horns. Injured menisci may be treated arthroscopically by excision of the torn fragments. However, in patients with peripheral meniscal detachment, located at the “vascular zone”, operative repair is feasible and usually successful. Meniscal repair may be done by open direct suture of peripheral tears or by arthroscopic techniques as “Outside-In”, “Inside-Out” or “All-Inside”. We present our experience with arthroscopic suture of completely detached menisci.

Patients & Methods: This study consisted of 33 male patients (14-48Y; mean 25Y; Follow-up: 2-6Y; mean 3.5Y). Inside-Out technique was used in 31 patients and Outside-In technique in two patients. 16/33 patients had detachment of the peripheral half of the meniscus (14-medial; 2-lateral); 13/33 patients had peripheral detachment of almost two thirds of meniscus (10-medial; 3-lateral) and 4/33 patients had detachment of one third of the meniscus (3-lateral; 1-medial injuries; all combined with fractures of the tibial plateau). 15 patients with medial meniscus detachment had complete (5 Pts) or partial (10 Pts) tear of ACL. Two other patients with medial meniscus detachment had associated small radial tears of the affected meniscus. Two of the patients with complete ACL tear had later been operated upon for reconstruction of ACL. Results were assessed by the Knee Society Knee score and by Lysholm Scoring Scale.

Results: 25/33 patients (76%) had good and excellent results. Four of them developed re-tear and detachment of medial meniscus during other later additional sport injuries, usually between 1–2 years following initial treatment. Four other patients had a “second” arthroscopic look 1–2 years later following another sport twisting injury and in all of them a stable peripheral attachment of the sutured menisci was observed. Results were better in patients who had ACL reconstruction a few months following meniscal repair. 5 patients had fair results (15%) and 3 patients had poor results (9%).

Conclusions: Based on this study it is suggested that meniscal suturing for peripheral tears is a satisfactory procedure. Meniscal tears suitable for repairs are those within the vascular zones (the outer third of the menis-cus), unstable on probing, are longer than 7mm and without major surgical damaging. Tears of posterior segments are the most difficult to suture and often require open arthrotomy. ACL reconstruction combined with meniscal repair appears to increase the healing rate of the meniscus. There are also adjuvant techniques for meniscal repair such as: fibrin clot or laser (both are weaker than suture alone) and adhesives. However, there is still not enough data.

Introduction: Management of displaced comminuted fractures of the proximal humerus in the elderly is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Rigid fixation of these fractures by plates may offer stability in anatomic position, but requires in most cases extensive soft tissue exposure and may result in a relatively high incidence of avascular necrosis of the humeral head. Therefore, many authors are today of the opinion that hemiarthroplasty of the shoulder joint in such fractures is preferable to rigid fixation. This study reviews our experience with hemiartroplasty of the shouldere in elderly patients with comminuted fractures of the proximal humerus.

Material & Methods: This study consists of 39 Pts. (27F, 12M; 72–89 year old, mean 76.5Y; 12 with 3 parts fractures and 27 with 4 parts fracture) treated by hemiarthroplasty of the proximal humerus. Patients were followed for 2–8 years (mean 4Y), and evaluated by the Neer‘s shoulder grading score and radiographs.

Results: 74% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but most of them had only a moderate improvement in shoulder motion (active abduction or flexion of 110–130 degrees were observed in 4/39, of 90–110 degrees in 7/39, of 50–90 degrees in 17/39 and of 30–50 degrees in 11/29).

Conclusions: Based on this study it seems that pain relief by hemiarthroplasty may be achieved in most older patients with comminuted fractures of the proximal humerus, but the gain in shoulder function is relatively limited.

Purpose: A retrospective study was performed in order to evaluate the results of fixation of displaced unstable fractures of both bones of the forearm in children by intramedullary pins.

Materials and methods: During the last fifteen years 121 children with displaced midshaft fractures of the forearm were treated by open or closed reduction and smooth intramedullary pin fixation. The age range was 5–16 years, the mean 11 years. Seventy five children (62%) were operated upon primarily because of an irreducible fracture, and the remaining 46 (38%) were operated upon within two weeks after failed closed reduction. The arm was then immobilized in a plaster cast extending above the elbow. The average time for fracture healing and cast removal was 8 weeks. Afterwards the children were encouraged to move the elbow and wrist joints. The hardware was removed following a period of between 6 weeks to 5 years (average 5.5 months), under sedation or general anesthesia.

Results: Follow up was available in 91 of the 121 children for between 6 months to 15 years (mean 5.5 years). Using the grading scheme of Price, functional results at follow up were excellent in 79/91 patients (87%) and good in 12/91 children (13%). There were no fair or poor results. Of them, in 80 cases (88%), within one year from injury, a full range of movement was obtained in the elbow and wrist joints. 11 patients (12%) had an average loss of 10 degree of supination. In two cases there was a neuropraxia of interosseous nerves which disappeared spontaneously within 3 months. In one patient, a 16 year old boy, there was a delayed union of 6 months until solid healing. 4 patients had a mild degree of angulation of the distal third of the forearm. There were no incidences of deep infection, nonunion or damage to the epiphyseal plate.

Conclusion: In conclusion we found that smooth intra-medullary pinning for displaced midshaft fractures of the forearm in children is a good, simple and safe method.

Introduction: The treatment of fractures of the proximal humerus is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Open reduction and rigid fixation requires extensive soft tissue exposure, which may results in a high incidence of avascular necrosis of the proximal humerus. We present our experience with “minimal invasive” surgical techniques of such fractures.

Materials & Methods: This study consists of 128 Pts. (52 M, 76 F, 18–84 year old, mean 53.5Y) followed for 2–7 years (mean 3.5Y), treated by closed reduction and percutaneous pinning (55), by ORIF and minimal osteosynthesis by screws (27), by ORIF with rigid plates (7), and by hemiarthroplasty of the proximal humerus (39). Patients were evaluated by the Neer’s shoulder grading score and radiographs.

Results: Overall results were excellent and good in 85% of patients with 2, and 3 parts fractures of the proximal humerus treated by “minimal invasive” fixation techniques, with some better results in less comminuted fractures. 9/14 young patients with 4 part fractures had good functional results. The other 5 patients had poor results and 3 of them developed AVN of the humeral head. 75% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but most of them had only a moderate improvement in shoulder motion.

Discussion: Based on this study it seems that “minimal osteosynthesis” by K.W. techniques, lag screws or rush pins, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture. In the elderly, hemiarthroplasty should be considered in such pathology as the treatment of choice.

Purpose: We report our experience with ankle arthrodesis using Ilizarov External fixator in 18 patients with extensive damage of the ankle joint, mainly with post traumatic osteoarthrosis, during the last 7 years.

Materials and Methods: The mean age of the patients was 36 years (range 21–54 years). 14 Pts had posttraumatic arthrosis following complicated intraarticular fractures, 3 Pts had extensive osteochondritis dissecance and 1 had failure of union after RAF arthrodesis of ankle. No cases of osteomyelitis of ankle were included in this seria. All procedures were done with open arthrotomy, 6 through lateral approach and 12 through anterior approach. Bone grafting was used in 3 cases due to extensive damage of talar bone. Temporary fixation by Steinman pin was done in all cases after open alignment of ankle joint, and then Ilizarov external fixator was applied, followed by removal of the temporary fixation. Full weight bearing was allowed from the 3^rd or 4th postoperative day. Time in fixator ranged from 6 to 14 weeks (average 9,5 weeks).

Results: Solid arthrodesis was achieved in all cases. 15 patients were free of pain, 2 patients continued to complain of pain due to degenerative changes in subtalar joint which presented before surgery. 1 patient developed RSD and was treated successfully by analgesics and physiotherapy. 5 cases of superficial pin tract infection were observed and treated with antibiotics. There were no cases of deep wound infection in this series.

Conclusions: This method has been proven useful for primary arthrodesis of ankle joint, mainly for complicated cases after multiple surgeries, or in patients with advanced post-taumatic changes.

Aims: Foot and leg infections and osteomyelitis are common findings in diabetic patients. The primary goal at present is limb salvage. This study reviews our experience with this pathology. Methods: This is a study of 2–6 years of 458 consecutive diabetic patients with foot or leg infections. 29% of them had IDDM (Type I) and 71% had NIDDM (Type II). Initial treatment consisted of a meticulous surgical eradication of the infection combined with antibiotic treatment (26%-plantar incision, 14%-amputation of a single or more toes, 32%-amputation of a single or more metatarsals, 19%-below knee amputation and 9%-an above knee amputation. Follow-up consists of 410 Pts. The remaining 48 Pts died prior to the end of the study. Results: 357 patients (87%) had a complete healing of the infection following a single surgical intervention. 17 Pts had also reconstructive vascular procedures. 53 Pts (13%) had 2 or more surgical interventions, during one or more hospitalizations, mainly of “a proximal amputation” The percentage of successful foot salvage following initial foot surgery was 90% (267/296). The remaining 10% patients with initial foot infection, had a secondary below knee or above knee amputations. Conclusions: Based on this study it is suggested that meticulous debridement of the source of infection by “minor” amputations, combined with I.V antibiotics, have yielded a relatively high percentage of success of limb salvage and reduced the necessity for initial above or below knee amputation. It is further suggested that the NIDDM patients are more prone to leg and foot infections than the IDDM patients; hence, they should be observed regularly.

Aims: A retrospective study was performed in order to evaluate the results of þxation of displaced unstable fractures of both bones of the forearm in children by intramedullary pins. Methods: 121 children (5–16 year old; mean 11 years) with unstable displaced midshaft fractures of the forearm were treated by smooth intra-medullary pin þxation. 75 (62%) were operated upon primarily because of an irreducible fracture. 46 (38%) were operated upon within 2 weeks after failed closed reduction. The arm was immobilized in a plaster cast extending above the elbow for about 6 weeks. Pins were removed between 6 weeks to 5 years (average 5.5 months). Results: Follow up (1Ð15 years; mean 5.5 years) was available in 91/121 children. Using the grading scheme of Price, functional results at follow up were excellent in 79/91 (87%) and good in 12/91 (13%). There were no fair or poor results. 80 Pts (88%) had within one year a full range of movement of the elbow and wrist joints. 11 Pts (12%) had an average loss of 10 degree of supination. 4 Pts. had a mild degree of angulation of the distal third of the forearm. 2 Pts had a temporary neuro-praxia of the interosseous nerves. 2 Pts had re-fractures following early removal of pins. There was one case of non union treated successfully by plating. One of the patients had a delayed union of 6 months until solid healing. One had a deep wound infection. There were no other complications. Conclusions: In conclusion we found that smooth intramedullary pinning for displaced midshaft fractures of the forearm in children is a good, simple and safe method.