Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Aims

Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures.

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)

Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb. Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb. Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases. Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities. Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery. The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect. Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient

Purpose: Treatment of complex diaphyseal malunions is challenging. It requires extensive preoperative planning and precise operative technique. A single technique has not been generalizable secondary to the limitations of each type of osteotomy. A simpler method was developed to manage these deformities.

Method: Ten patients with complex diaphyseal mal-unions (4 femoral, 6 tibial) underwent a clamshell osteotomy. Indications for surgery included pain at adjacent joints and deformity. Preoperative evaluation included deformity characterization. The malunited segment was identified on biplanar radiographs. After exposure the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized about its long axis and wedged open with a lamina spreader, similar to opening a clamshell. The surgical approach was sealed to retain the subsequent reamings. The proximal and distal segments of the diaphysis were aligned using the intramedullary nail as an anatomic axis template and the opposite extremity as a length and rotation template. Partial weight-bearing mobilization with crutches began immediately and progressed based on clinical and radiographic evaluation. Followup ranged from 6–52 months.

Results: Radiographic angular corrections were complete in each case and ranged from 2–20 degrees in the coronal plane, 0–32 degrees in the sagittal plane, and 0–25 degrees in the axial plane (rotation). Correction of length ranged from 0–5 centimeters, restoring leg length to within 2 centimeters in all cases. All osteotomies were healed both clinically and radiographically by 6 months. All patients were ambulatory without assistive devices by the time of the most recent followup.

Conclusion: The proposed osteotomy provides a generalizable way to correct many forms of diaphyseal mal-unions by acting as a bypass in realigning the anatomic axis of the long bone using a reamed intramedullary nail as a template.

In this retrospective study, using the prospectively collected database of the AO-Documentation Centre, we analysed the outcome of 57 malunited fractures of the ankle treated by reconstructive osteotomy. In all cases the position of the malunited fibula had been corrected, in several cases it was combined with other osteotomies and the fixation of any non-united fragments. Patients were seen on a regular basis, with a minimum follow-up of ten years. The aim of the study was to establish whether reconstruction improves ankle function and prevents the progression of arthritic changes.

Good or excellent results were obtained in 85% (41) of patients indicating that reconstructive surgery is effective in most and that the beneficial effects can last for up to 27 years after the procedure. Minor post-traumatic arthritis is not a contraindication but rather an indication for reconstructive surgery. We also found that prolonged time to reconstruction is associated negatively with outcome.

Aims: To evaluate one of the surgical options for treating femoral fractures in children. Methods: In a consecutive and prospective study during the period 1993–2000, 96 children aged 3–15 years with 98 displaced fractures femoral fractures were treated with external fixation and early mobilization. Results: All fractures healed. Minor complications included pin tract infections (18%) and clinical insignificant malunions. Major complications (6%) included 2 refractures after significant trauma and three plastic deformations after premature fixator removal. Malunions remodelled almost completely, overgrowth was far less than expected. Isokinetic muscle strength was tested for both hamstrings and quadriceps and showed no residual weakness. Conclusions: External fixation of displaced femoral fractures can be used as surgical alternative in children aged 3–15 years. The treatment provides satisfactory results with a low rate of major complications. Early mobilization seems to prevent residual muscle weakness. The treatment reduces the number of days in hospital for the child and the number of days of sick leave for the parents

In this paper the results of correction of bone deformities using the llizarov methods, are presented.

Fifty-nine patients, 42 with malunion and 17 with mal-nonunion of tibia or femur were operated upon using the llizarov circular fixator. Another 28 cases were corrected using a unilateral device. There were: a) 30 angular deformities, 18 of which were combined with shortening, b) 21 angular deformities associated with translation and c) 36 complex, deformities including angulation, translation, shortening and malrotation.

Two rings above and two below the apex of the deformity were always required. Different types of hinges were used between them, depending on the type of the deformity. The corticotomy was performed at the apex of the deformity for the majority of the cases. In 18 patients with hypovascular and eburnated bone, or bone covered with soft tissue of poor quality, the corticotomy was done more proximal or more distal to the apex of the deformity. In complex deformities the correction sequence was: 1) correction of angulation and shortening simultaneously, 2) correction of rotation, 3) and finally correction of translation. The true plane of the deformity and the plane of placement of the hinges were determined by a computerized formula that we developed.

The deformities were corrected in all cases in which the hinges were placed at the correct position but in 5 cases we had to re-orient the hinges in order to achieve the correction. The corticotomy or pseudarthrosis consolidated in all cases. Residual leg length discrepancy remained in three patients, not exceeding 135 cm. Great care was taken to prevent complications during operation as well as during the post operative period. However, there were numerous obstacles, problems and true complications. All these were managed aggressively as soon as they appeared. The final results were very satisfactory.

We conclude that the revolutionary llizarov methods can solve bone deformity problems that cannot be faced by the traditional methods. It is critically important to place the hinges at the correct position in order to achieve the desired correction. Our computer program definitely helps to this purpose. The surgeon must always be vigilant in order to prevent complications and to deal with them immediately.

Background: The Ilizarov external fixation is considered to be a unique technique in limb surgery for mal-nonunion and limb deformities with or without length discrepancy. The theory suggests that the tension stress and the subsequent distraction osteogenesis, “opens a window” over hypervascularized- hypertrophic non-union for consolidation, and stimulates vascularization and osteogenesis in the avascular nonunion. Also, post traumatic bone deformities and axial deviations can be corrected by using special hinges incorporated in the device for uniplanar or multiplanar deformities. Recently, there are encouraging reports of high rate of consolidation using a non-bone grafting technique even in atrophic nonunions. However, the bifocal treatment is still preferable. In our study we will review 28 patients suffering from mal- nonunion, whom were treated by an Ilizarov external fixation, and the results of the treatment concerning radiological alignment and consolidation rate. Methods: Twenty-eight patients have been operated in our department during the last eight years due to mal-union (19 patients), mal- nonunion (3 patients) and non-union (6 patients) of fractures. Malunions were treated either with acute or gradual correction of the deformity, following low energy osteotomy. For hypertrophic nonunion and mal-nonunion in general only distraction compression technique (mono-focal) was used. Atrophic and infected nonunion were treated with a bifocal technique (so-called bone transport), except for one case treated with monofocal technique only. Results: The average age of the patients at operation was 31 years old (12–71), six female and 22 males. The average time in the device was 4 months (2–8) and average rate of consolidation was 3.6 mo. (2–7.5). All fractures and osteotomies healed thoroughly. Still, three cases of the mal unions remained suffering from residual deformity. Two patients had fracture of the regenerate after minimal trauma just after removal of device and treated with IMN. The most prevalent complication was pin tract infection, 24 out of 28 patients, all managed with P.O. antibiotics besides two patients who needed to be admitted for intravenous antibiotics. Two cases of lateral compartment muscle herniation of the leg appeared after fibular osteotomies, treated later by large fasciotomy. Conclusions: The treatment of the different types of nonunion and malunion following fractures is a real challenge for the orthopedic surgeon. Many times the nonunions are the result of poor vascular supply to the involved limb. While the surgeon is facing old scars and poor nourishment of the entire limb, the Ilizarov external fixation, in most of the cases, enables us to deal with these difficult cases with minimal surgical exposure. In case of malunions, Ilizarov technique enables to achieve accurate angular correction of the deformities

Malunion of fractures of the forearm in children can lead to permanent disability. The capacity of the radius and ulna to remodel spontaneously after malunion has been assessed in this study. Forty-nine children who had malunited fractures of the forearm were examined when the remodelling process was complete. It was noted that fractures of the distal third of the radius and ulna led to fewer problems than those of the diaphysis. It was concluded that malunion of the distal third of the radius and the ulna will remodel satisfactorily providing the child is less than 14 years of age. Gross malunion of the midshaft of the radius and ulna will spontaneously correct in an infant but little useful correction of deformity can be anticipated in diaphysial fractures when the child is aged eight years or more