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: 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 traditional methods for the treatment of femoral shaft fractures of children consists of closed reduction and either spica casting or fixation by external fixator. There are also reports on the treatment of such injuries by open reduction and internal fixation by plate. In the last years the method of minimal invasive fixation of such fractures with elastic nails became popular in children over 6–7 year old. The purpose of this paper is to present our experience with elastic nail fixation of femoral shaft fractures of children.

Material and Methods: We present a series of 43 children aged 3–13 year old, mean age: 6.5y, follow-up 2–4 years, mean 2.5 years) with shaft fractures of the femur. 12 children were under 5 year of age. Seven of them were poly-trauma patients. There were no open fractures. Each patient was treated by closed reduction and percutaneous nail insertion under C-arm imaging intensifier control. Fixation was accomplished by a knee immobilizer alone. Early non-weight-bearing mobilization was encouraged until appearance of callus formation. Subsequently, weight-bearing was encouraged.

Results: The results of all cases were excellent. All fractures were united within 7–14 weeks, with an average of 9 weeks. There were not any cases of femoral fractures through nail insertion. There was no decrease in the range of hip and knee motion. None of the patients had complications such as infection, malalignment or neurovascular injury. There was two cases of bursitis around the tip of the nail in the supracondylar region, which was resolved by early pin removal. Removal of the pins was done 6–9 months following operations.

Conclusions: Closed reduction and minimal invasive fixation of femoral shaft fractures by use of Nancy Nails is safe, simple and useful in children with femoral shaft fractures, even in young children under the age of 5 years, and especially in cases of poly-trauma. This minimally invasive procedure allows for early mobilization with no loss of range of motion or associated 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: 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.

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.

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.