Objective: The purpose of this study was to compare the functional and workers compensation results of displaced intra-articular distal radius fractures treated with three diferent type of treatments.

Material and Methods: A randomized prospective study to evaluate 70 patients with displaced intraarticular distal radius fractures. The mean age were 40 years (range, 22–65 years) and all patients were medium or high level workers (40% dominant-hand). Three randomized groups were treated: 19 patients with close reduction and a cast (group 1); 24 patients with close reduction, percutaneous fixation with Kw and a cast (group 2); and 27 patiens with close reduction and external fixation and Kw (group 3).

Postoperative complications, pain (visual analogue scale), clinical and functional outcome based on DASH score, grip strength, X-ray evaluation, time to return to work and activity level were evaluated and compared at 3, 6 and 12 months of prospective follow-up.

Results: Consolidation was obtained in all cases at 7 weeks. Results at 12 months of follow-up: Pain evaluation score: 2.3 (group 1), 2.9 (group 2) and 1.5 (group 3); mean lost of ROM was 11° (group 1), 11° (group 2) and 23.9° (group 3); mean DASH score was 7 (group 1), 29 (group 2) and 12 (group 3). Average lost of pinch strength was 18.3% (group 1), 23% (group 2) and 35% (group 3). Non-aceptable X-ray parameters: 65% (group 1), 35% (group 2) and 50% (group 3).

Re-operations: 10% (group 1), 7.6% (group 2) and 14.8% (group 3). The average time to return to work (weeks) was 12 (group 1), 14 (group 2) and 19.3 (group 3). All patients return to the work and activity level they had before injury.

Conclusions: Similar results were obtained in the three groups at 12 months but better clinical results for the conservative group (group 1) at 3 and 6 months of FU. The orthopaedic treatment achieved better functional results with lesser lost of ROM, time out of work, more grip strength and better DASH score. Percutaneous fixation achieve better X-ray results at the end of FU with lesser re-operations. The functional and clinical outcomes after one year still are unknown. Hence, more and longer studies are required to confirm these results.

Objective: to study the surgical applicability and clinical results of the Vira^® system in treatment for severe fractures of the calcaneus.

Material and Method: 50 acute intraarticular fractures of the calcaneus treated with the Vira^® system over a two-year period were analyzed in 42 patients. The mean age was 41 years. Eight were bilateral fractures and 47 were closed fractures. According to the Sanders classification, most of the fractures were type IV, followed by type III AB, and the inferior cortical was broken in 42 cases. All the patients were evaluated, in a prospective manner, using the AOFAS scale, plain radiographs and CT scan studies.

Results: the average AOFAS score 12 months after surgery was 76.6 points (SD: 13.9). In 26% cases the results were very good, in 62% good, and in 12% mild and poor. The Böhler angle improvement after surgery was significant (p=0.05) though clinically irrelevant. Subtalar arthrodesis was achieved in all but two cases. The post-surgical complications were: 4 disorders of the plantar support, 4 cases of osteolysis at the tip of the screws, and 3 soft tissue problems.

Conclusions: The Vira system is a validated option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications.

Although modern operative intervention for calcaneal fractures has improved the outcome in many patients, there still is no real consensus on treatment, operative technique, or postoperative management. Vira® is a system for reconstruction-arthrodesis of severe calcaneal fractures, consisting in minimally invasive surgery using cannulation technique.

The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with severe calcaneal fractures.

The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

CPG include three phases determined from the physiopathology and biomechanical reasoning of surgical system (weeks after the surgery: 2^a–5^a, 5^a–14^a, 14^a–+/−24^a). Unfortunately, evidence related to the treatment of severe calcaneal fracture was sparse and often of poor methodologic quality. The recommendations that were included: early onset (2^a week after the surgery) with early mobility and loading, program of home exercises, manual therapy (articular and miofascial techniques), walking in swimming pool, continuous electromagnetic fields of 99Hz with an intensity of 99 Gaussian during 30 min/day; electrotherapy of the intrinsic muscles of the feet (80Hz; 8:12, 20 mi), a program of active exercises of the feet (dorsiflexion and plantarflexion, not supination and pronation) and resistive exercises of triceps surae muscle (7^a week), criotherapy and anti-inflammatory positions.

Introduction: In this work a bioactive glass-ceramic (GC) in the system SiO2-CaO-P2O5 was evaluated as bone substitute biomaterial. In this sense, the capacity of mesenchymal stem cells (MSCs) to adhere, proliferate and differentiate into osteoblast (OBs) with or without GC was investigated. Two types of culture medium, i.e. growth medium (GM) and osteogenic medium (OM), were evaluated.

Materials and Methods: The GC was obtained by heat treatment of a bioactive glass obtained by the sol-gel method. Isolation and culture of MSCs: The adult MSCs were isolated from bone marrow of adult rabbits obtained by direct aspirations of ileac crest. Isolation and culture of OBs: The OBs used as control were obtained by enzymatic digestion. Behavior of MSCs on GC: For the study of the behavior of isolated MSCs on the GC, two series of 96-well plates were seeded, one plate with GM and the other one with OM. The number of cells was evaluated through the XTT assay. OC production and CD90 expression of cells cultured in both media were measured to evaluate the differentiation of MSCs into OBs. Statistical analysis: A variance analysis (ANOVA) was carried out.

Results: The number of cells growing in OM and GM, there were no significant differences between them. The MSCs under the conditions of this study expressed an osteoblastic phenotype (OC production, decrease CD90 expression, mineralized extracell matrix). These two effects took place by either the action of exposing the MSCs to a MO and by the effect of the GC.

Introduction and purpose: The purpose of this study was to assess the functional results of ankle arthrodesis as a treatment of posttraumatic sequelae.

Materials and methods: We carried out a retrospective study from the 1st of January 2000 to the 31st of December of 2005 with a total of 55 patients that underwent posttraumatic ankle arthrodesis, with a mean follow-up of 5 years (range: 1–7 years). The mean age of the patients was 40 years (range: 18–61). There were 52 men and 3 women, the right side (40) predominated over the left (15). Seventy-eight percent of trauma sustained was high-energy with a predominance of fracture of the tibial pilon (type C3 fractures on the AO classification). There were 35% open fractures. The predominant type of surgical technique performed used cannulated screws without any iliac crest grafts. The mean time from surgery to discharge was 9 months (range 4–19).

Results: Repeat arthrodesis was necessary in 16% and an infrapatellar amputation was necessary in 1 case. Only 1 patient returned to their workplace without limitations, the rest were discharged to a medical board for sequelae. The use of crutches/insoles and subjective assessment of pain were related to a lateral tibiotalar angle greater than 90° and varus deformity.

Conclusions: Tibiotalar arthrodesis is a useful rescue technique in patients with severe posttraumatic ankle sequelae. It eliminates pain and increases stability but is the cause of a significant loss of function of the lower limb.

Introduction and purpose: The VIRA system allows reconstruction of the fractured bone and its arthrodesis with the talar bone eliminating all movement of the subtalar joint by means of a minimally invasive approach. The aim is to restore the shape of the foot and prevent joint degenerative changes in the long term without the complications and sequelae of open surgery.

Material and methods: Between November 2004 and June 2006, 30 intraarticular calcaneal fractures in 25 patients were treated surgically by means of the Vira System. Using Sanders’ classification 6 cases were classified as type II, 13 as type III and 11 as type IV. Five patients had open fractures. There was a mean period of 8.7 days between the accident and surgery. Seven cases had associated lesions and fractures in other locations. Only 2 cases required iliac crest grafts in the operated area.

Results: All patients except 10 have returned to their usual occupations. Eight cases evolved favorably but have had a short follow-up. Two cases experienced a delayed healing of the subtalar arthrodesis and had to be reoperated; they required an autologous graft. The mean period of temporary disability in patients discharged from hospital was 163.7 days. Clinical assessment using the AOFAS scale reached a mean value of 76.6 points. No surgical or post-surgical complications were seen in the group studied.

Conclusions: The VIRA System seems capable of achieving its purpose in the first series of patients operated. It allows a quick recovery both postoperatively and in the subsequent evolution without any associated complications. It accelerates the patients’ return to work by decreasing convalescence and minimizing sequelae.

Introduction and purpose: The non-reestablishment of normal scaphoid anatomy is related to instability, loss of function and secondary arthritis. The most appropriate treatment for unstable non-unions with scaphoid deformity is the use of a trapezium-shaped bone graft and internal fixation. We present our experience and the results obtained by treatment of this condition.

Materials and methods: We retrospectively studied 35 patients (34 males and 1 female) with unstable scaphoid non-union treated by curettage, trapezium-shaped iliac crest bone graft and internal fixation, with a mean follow-up of 24 months (range: 12–52 months). Mean age of the patients was 29.8 years (range: 18–52) and all had medium to high functionally demanding jobs. In 48% of cases it was the dominant wrist that underwent surgery. In 3 cases there was a previous history of union of scaphoid fracture. To fixate the graft different devices were used: metal cannulated screws (54%), Kirschner wires (22%) and biodegradable screws (22%). Growth factors were used in 5 cases (PRP) and the wrist was immobilized for 8 weeks. We assessed complications, range of movement, union on x-ray, Green and O’Brien’s scale and return to work at the end of follow-up.

Results: Complete union was obtained in 68.6%, partial in 14.3% and incomplete in 17.1%. Four patients (13.8%) required repeat surgery: 2 four-corner arthrodesis, 1 a conventional graft and 1 a vascularized graft. The mean flexion-extension arc was 99.6°; radio-ulnar deviation was 48.6°. According to the modified Green-O’Brien scale, 93% of the patients had excellent to good results. Time off work after surgery was 21 weeks (9-50 weeks). Ninety-five percent of patients returned to their former job. There were no statistically significant differences with reference to the location of the non-union of the fixation used, although cannulated tapered screws had a lower union rate and a greater number of complications. The worst results were associated with previous surgery and signs of radiocarpal degeneration.

Conclusions: Restoration of normal scaphoid morphology by means of a trapezium-shaped graft results in good outcomes and allows an optimum return to work in manual workers. Previous surgery, signs of radiocarpal degeneration and voluminous implants cause the worst functional results. Even if complete union is not seen on x-rays, the functional result may be optimum.

We present in this work our experience with the sural fasciocutaneous flap to treat coverage defects following a lower limb posttraumatic lesion. This work is a review of the fasciocutaneous sural flaps carried out in different centres between 2000 and 2005. The series consist of 14 patients, 12 men and 2 women with an average age of 38 years (23–54) and with a medium follow-up time of 2 years (12–48 months). In all of the cases, aetiology was a lower limb injury being the most frequent the distal tibial fracture (eight patients), followed by sequelae from Achilles tendon reconstruction (two patients), fracture of the calcaneus (two patients) and osteomyelitis of the distal tibia (two patients) secondary to an open fracture. Associated risk factors in the patients for performing a fasciocutaneous flap were diabetes (1 case) and cigarette smoking (4 cases).

The technique is based on the use of a reverse-flow island sural flap with the superficial sural artery dependent on perforators of the peroneal arterial system. The anatomical structures which constitute the pedicle are the superficial and deep fascia, the sural nerve, external saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin.

The flap was viable in 13 of 14 patients. Only in one case, a diabetic patient, the graft failed. No patient showed signs of infection. Slight venous congestion of the flap occurred in two cases. No further surgical intervention of the donor site was required because of morbidity. In two cases partial necrosis of the skin edges occurred which resolved satisfactorily with conservative treatment.

The sural fasciocutaneous flap is useful for the treatment of complex injuries of the lower limbs. Its technical advantages are: easy dissection with preservation of more important vascular structures in the limb, complete coverage of the soft tissue defect in just one operation without the need of microsurgical anastomosis. All of that results in a well vascularised cutaneous islet and thus a reliable flap

Introduction and purpose: When treating for loss of mobility in the elbow, after at least six months of conservative treatment following an injury we should consider surgery. The purpose of this study is to evaluate the improvement in range of motion after surgery.

Materials and methods: We reviewed the cases of elbow arthrolysis carried out in our hospital from 1999 to 2004, analysing the following variables: personal data (sex, age, type of work) and information on the injury (type, location, associated lesions and degree of stiffness). The main variables were degree of mobility in flexion/extension (F-E) and pronation/supination (P-S) before and after surgery, in addition to functional and occupational results.

Statistical analysis: Percentage estimate and by 95% confidence intervals, and analysis of increased mobility after surgery in F-E and P-S using Student’s t-test of repeated measures.

Results: 52 patients who underwent arthrolysis (86% males, mean age 37.2 years) whose jobs required average exercise and with grade II stiffness in 46.2% of the cases. The average preoperative ranges of motion for F-E and P-S were 74.52 (SD 32.3) and 120.10 (SD 66.6) degrees, respectively. The postoperative estimates for both parameters were 96.5 (SD 29.5) for F-E and 158.9 (SD 39.8) for P-S. The increases were statistically significant (p< 0.00001). The increased motion in P-S was slightly better than for F-E (p=0.054).

Conclusions: After our study, we can confirm that arthrolysis is an effective surgical procedure to improve mobility in stiff elbows. It is indicated when the joint interline is preserved. The lateral approach is the most common because it enables access to the anterior and posterior aspects of the capsule. Good functional and occupational outcome in a high percentage of cases.

Introduction and objectives: This is a complex type of lesion that is frequently confused with Monteggia fracture. The objective of this paper is to analyse the experience of the Hospital Cl co San Carlos, in Madrid, in the management of the transolecranon fracture-dislocation of the elbow.

Methods and material: Between 1988 and 2001 a total of 23 cases have been revised, 7 of them presenting an oblique simple fracture of the olecranon and the other 16 cases with a comminute one (with fracture of the coronoid process in 9 patients). There was also a radial head fracture associated in 7 patients. Two cases showed ulnar nerve palsy before surgery. Fifthteen of the 21 cases were males and 8 females, with a mean age of 37, 3 years (range: 17–71). The mean follow up was of 56 months (range: 22–122 months). The etiology was a traffic accident (bicycle, motorbike, car) in the 47, 6%, a casual fall in the 23, 8%, a sport accident in the 14, 2% and a precipitation in the 9, 5%. All of them were treated with open reduction and internal fixation, with plate and screws in 17 cases and tension-band wiring in 4 patients. When a radial head fracture was associated, reconstruction was performed with screws in 5 cases and radial head excision in 1 case. Anatomic reduction was achieved in 11 cases.

Results: With the scale of Broberg and Morrey, excellent result was obtained in 6 cases, good in 8, fair in 6, and poor in the remaining 3. The most frequent complication was loss of motion (6 cases), followed by non-union in 2 cases (with hardware fatigue failure in 1 of them) and infection in other case. The two cases with preoperative ulnar nerve palsy resolved over a period of 4 months. Eleven patients needed a reoperation, performing a new internal fixation with bone grafting in 2 cases, a radial head prosthesis implanting in 1 case, and hardware removal in 8 cases.

Discussion and Conclusions: Although the transolecra-non fracture-dislocation of the elbow can be included in several classifications (AO, de Cotton, de Schatzker, etc.), none of them accommodate it satisfactorily, because of the complexity of the lesion. Our results show a statistically significative relation (p < 0.05) between the anatomic reduction obtained and excellent or good results and a high frequency of joint stiffness in this severe lesion.

Introduction: Traumatic injury to a peripheral nerve with loss of continuity is a disabling condition due to denervation. Traditional treatment consists of nerve grafting with the consequence of unwanted side effects at the donor site (sural nerve).

Aims: To present an alternative treatment using two different biomaterials as implants bridging both ends of nerve.

Materials and Methods: The same hand surgeon treated twenty-one patients with traumatic laceration of less than 3 cm in the upper limb. Two different kind of flexible tubular sheaths were implanted: 18 patients with one and 3 with other. An independent observer assessed McKenney’s and two points discrimination tests for functional out come. We describe the surgical technique and report the full data.

Discussion: Polyglicolic acid is designed to create a conduct for axonal growth across a nerve gap making it unnecessary to carry out a nerve grafting. Its use is feasible in clean wounds less than 3 cm in length. It is technically easy to implant and reabsorbed within 3 months.

Conclusions: The satisfactory results in terms of functional recovery suggest the convenience of this technique to shorten the operating time and avoid donor site side effects.