The aims of the treatment of tibial infected nonunions with bone and soft tissue loss (generally consequent to open fractures) are: the healing of infection, the bone consolidation with preservation of lower limb length and the reconstruction of soft tissue loss. The epider-mato-fascio-osteoplasty according to Umiarov (a modification of bifocal or multifocal compression-distraction osteosynthesis) enables to treat wide areas of bone and soft tissue loss without a preventive sterilization of the infection neither soft tissues closure and without bone and skin grafts. An important point of the treatment is the prevention of complications such as: persistence of infection (due to an insufficient debridement), trouble in formation of bone regenerate and /or callus at the docking site (due to inadequate configuration of the external fixator, imperfect management of the phases of treatment, obstacles on bone transport), defect of skin coverage (due to an improper rate of bone and soft tissue transport), complications at the site of application of the device (inflammation or infection, breaking of the fixation elements), functional impairment (knee and ankle stiffness).

In the 54 patients treated the anatomical and functional results have been particularly favourable, thanks to an accurate preoperative planning and a careful postoperative management, diminishing the risks of complications.

Introduction and Aims: Distal radioulnar joint surgery in the past have been dominated by different types of partial or complete ulnar head excision. However, in the long run this can create a number of problems; hence we have used Herbert modular prosthesis to tackle these very difficult situations. This prosthesis comprises of a press fit stem in three sizes and a ceramic head also available in three sizes.

Method: In Wrightington Hospital upper limb unit, 61 patients underwent Herbert ulnar head replacement. Fifty-eight were clinically and radiologically reviewed. This is the largest series from a single centre of this type of surgery.

Between December 1998 and December 2002, 21 male and 27 female patients were operated. The mean age was 49.8 (range 28–72 years). Twenty-two left, eighteen right and two bilateral replacements were performed. The mean follow-up was 20.02 months (range 3–60 months).

An independent observer, using range of motion, grip strength and satisfaction as outcome, reviewed all patients.

Results: Primary diagnoses included failed Darrach, Bower, Sauve Kapandji and traumatic ulnar head excision. Forty-five patients were satisfied with the outcome. Pain score showed a mean improvement of four, with a range of 0–10. The grip strength compared to normal side was decreased in 50% of the patients. The range of motion compared to normal side improved by a mean of 10 degrees (range 3–20) in supination and 13 (range 4–23) in pronation.

Conclusion: Radiological review showed new bone (eight) and notch formation (nine). Stress shielding of 0–19mm was observed in distal ulna with revision or emergency stem. Complication occurred in eight patients: instability (four), RSD (one), implant failure (one) and two others. Twelve patients required further surgery. No loosening was observed at revision. There are no long-term results available at present.

Compression-distraction techniques (or circular external fixation methods) are a good alternative to other surgical methods based on bone grafts or bone substitutes, allowing “bone regeneration” through distractional osteogenesis and leading to a substantial advantage in the correction of long bone deformities, in selected bone tumours and in many types of non-unions.

Monofocal compression-distraction osteosynthesis is applied to correct long bone deformities in orthopaedics, basically through distraction epiphyseolisis, in which a gradual elongation of the epiphysis at the growth plate level is produced, and corticotomy-distraction, in which the gradual distraction is performed at metadiaphyseal level, after cortical osteotomy. In cases of hypertrophic non-unions (usually associated with limb shortening) the use of monofocal osteosynthesis basically relies on osteosynthesis with gradual distraction of the non-union site. These are cases where the fibrous or fibrocartilaginous tissue lying between the bone fragments is biologically active and gradual distraction highly affects its potential for regeneration.

Bifocal or plurifocal compression-distraction osteosynthesis is applied to correct wide bone defects through the technique of “internal lengthening” or “bone transport”. A corticotomy is performed at one of the two metaphyses of the affected long bone and the bone segment obtained by this corticotomy is gradually moved to fill the gap. In orthopaedics this technique shows its highest advantages in cases of bone tumours treated with segmentary resection, and in traumatology in atrophic non-unions and in infected non-unions with bone loss.

Between 1986 and 2003, distraction osteogenesis techniques were applied in 753 cases (638 patients) for several orthopaedic or traumatological problems. There were 430 men and 323 women. The average age was 24 years (min 3 years, max 48 years). The anatomical and functional results have been highly satisfactory, with a very low complication rate, and confirm the effectiveness of these techniques in selected cases in orthopaedics and traumatology.

Planning of surgical correction in sequelae of vitamin D-resistant rickets preliminarily requires the management of the metabolic defect with appropriate measures. In fact, surgery perfomed with the patient in a compensated metabolic condition greatly contributes to the prevention of recurrences.

The deformity most frequently observed is genu varum (where femur, tibia and fibula are usually all deformed), often combined with internal torsion. Compression-distraction systems (or circular external fixators) provide an easy control of the corticotomy fragments and a gradual correction of all kinds of deformity during the operative and post-operative phases. Careful pre-operative planning is necessary, which may require a multi-stage and/or a sequential strategy of management.

Between 1988 and 2002, 16 cases of sequelae of vitamin D-resistant rickets, with combined angular and torsional lower limb deformities, were treated with monofocal or bifocal tibial or femoral corticotomy and gradual correction with compression-distraction devices. There were nine men and seven women, with a mean age of 15 years. The Ilizarov system was used in 14 cases; in two cases the Volkov-Oganesian system was employed. The mean follow-up time was 8 years (range 1 – 15 years).

The anatomical and functional results have been highly satisfactory, with a very low complication rate. These techniques thus represent an excellent option in the management of such complex diseases.

This study describes percutaneous method of tennis elbow release and medium term results.

Materials and Methods: Eighteen patients (20 elbows) were reviewed following percutaneous tennis elbow release. All patients in this series underwent non-operative management with limited or no relief prior to surgery. The mean duration of treatment was 34.04 months prior to surgery. A percutaneous release of common extensor origin was performed under local anaesthetic. A small 1 cm skin incision was employed in all cases. Mean follow- up was 73 months with a range of 8–121 months. All patients except returned to work and normal level of activity. There was one poor result. The mean time to return to work was 5 weeks, with a range of 1 day –12 weeks. Thirteen patients (fifteen elbows) have been clinically examined. Five patients were contacted by phone.

Results: Pain after surgery was evaluated with a visual analogue scale. Eighteen elbows (90% of cases) had an excellent result. Pain was rated at zero in seventeen cases. One case rated at zero at rest and two after heavy activity. One elbow (5%) had a good result with pain at zero at rest and raising four on the visual analogue scale after sporting activities (playing tennis for more than one hour). There was no improvement in one case (5%) with a visual analogue score of eight before and after surgery. There were no complications recorded. These results prove that percutaneous elbow release is a viable option in treatment of failed conservative tennis elbow management though astringent selection criteria should be observed.

This novel modification of the posterior approach allows a low hazard exposure and easier surgery to the radial head.

Methods and Materials: The most commonly used approaches are from the lateral aspect. The limitations of this approach in particular for radial head replacement is that it is a tight exposure, there is a risk of damage to the posterior interosseous nerve and there is always a difficulty in dislocation due to the presence of the interosseous membrane. The posterolateral approach to the proximal radius and ulna was described by Boyd, Gordon and Thompson. This approach avoids damage to the posterior interosseous nerve but the annular ligament requires incision and repair.

Approach: Position the forearm in pronation aligning the ulnar styloid with lateral epicondyle of the humerus. A tencentimetre long incision is then made on the lateral border of the ulna exposing deep fascia. Following this a 1cm flap of fascia is left on the ulna and anconeus is lifted off the bone. This exposes underlying radial head, annular ligament and interosseous membrane. After identifying the ulnar insertion of annular ligament a 0.5 cm bone is osteotomised with annular ligament attached from the supinator tuberosity. The radial head osteotomy is performed with the radial head in pronation to align it with shaft of radius using specially designed jig. Osteotomy of the radial head has to be at right angles to the axis of the forearm. This is a line between centre of the radial neck to the ulnar styloid process. Radial head can now be subluxed out of the wound and preparing for a replacement. The trial prosthetic radial head is then inserted and reduced. The bone fragment with annular ligament attachment is then reduced back into the original slot. This allows one to judge the size of prosthetic radial head if ligament is too tight a small diameter implant is required. The bone fragment is reattached using especially devised washer with, wire holes and a 2mm AO screw.

Results: This approach is easier, safer and reproducible. When compared to lateral approach it provides an easier access and excellent stability in radial head replacement. We recommend this approach for radial head replacements and difficult trauma cases.