We present a case of a 19-year-old white female patient with neurofibromatosis type I who, 10 years ago, underwent free vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius.

An external fixator was applied for gradual distraction and correction of the deformity of the pseudarthrosic site for five weeks. Wide resection of pseudarthrosis with surrounding fibrotic and thick scar tissue and bridging of the gap with a free vascularized fibular graft followed. Four months postoperatively, union was established in both graft ends. At the last follow-up, 10 years postoperatively, the patient has excellent function with full wrist flexion-extension and forearm pronation-supination.

Free vascularized fibula transfer is considered the treatment of choice for congenital radial pseudarthrosis. It allows complete excision of the pathologic tissue and covering of the gap in one operation. Due to the vascularity of the free vascularized fibular graft both sides of fibula unite easily with no additional intervention.

Introduction: Digital nerve lesions with nerve gaps require reconstruction with the use of some form of graft or guide. Neurotube, a bioabsorbable polyglycolic acid (PGA) conduit, has been proposed as an effective solution for this kind of defect in emergency and planned surgery.

Methods: Nineteen posttraumatic lesions of common (5 cases) or proper (14 cases) palmar digital nerves were repaired by means of Neurotube from January 2003 till January 2006. The nerve gap size averaged 22 mm (range 15–35 mm). Thirteen lesions had associated vascular, tendon or osseous injury.

Results: Nerve regeneration was evaluated at a mean of 17 months postoperative interval. Positive results in recovery of sensibility were noticed in 73 % of the cases; static and moving two point discrimination was excellent (less than 6mm and 4mm respectively) in 9 cases and fair in 5 (7–15mm and 5–7mm respectively). Dysesthesia was present in 6 patients, cold intolerance in two, delayed wound healing in one and one patient complained for painful scar. There was no infection, conduit extrusion or allergic reaction.

Discussion and Conclusion: Bioabsorbable polyglycolic acid conduit presents an attractive and useful alternative for the reconstruction of digital nerve lesions with a small nerve gap, especially when a direct anastomosis of the two stumps is not possible, or when the suture appears to be in tension. Its use is simple, safe and also eliminates the donorsite morbidity associated with nerve-graft harvesting.

Traditionally open extensor tendon injuries in zones III to V (PIP to MP joints) have been treated with repair and immobilization in extension for 4 to 6 weeks. Early controlled motion protocols have been successfully used in zones VI and VII of the extensors. An early controlled mobilization protocol combined with strong repair for zones III to V extensor tendon lacerations was studied prospectively.

From 1999 to 2003, 27 extensor tendon lacerations in 26 patients, mean age 34 years (range 14–70), were treated using dynamic extension splinting. Inclusion criteria were zone III to V, complete lacerations involving the extensor mechanism and possibly the dorsal capsule (without associated fractures or skin deficits) in patients without healing impairment. All injuries were treated in the emergency department with a core Kessler-Tajima suture and continuous epitendon suture. After an initial immobilization in a static splint ranging from 5 days (for zone V) to 3 weeks (for zone III), controlled mobilization was initiated with a dynamic splint that included only the injured finger. The patient was weaned off the dynamic splint 5 weeks after the initial trauma. The patients were treated in an outpatient basis and did not attend any formal physiotherapy program.

The mean follow up was 16 months (range 10–24 months). No ruptures or boutoniere deformities were observed and no tenolysis was necessary. The mean TAM was 242deg for the fingers and 119deg for the thumbs. The mean grip and pinch strength averaged 85% and 88% that of the contralateral unaffected extremity. 77% of the patients achieved a good or excellent result in Miller’s classification. The mean loss of flexion was found to be greater than the mean extension deficit.

The protocol described above was found to be safe, simple, functional, cost effective and reproducible for zone III to V simple extensor tendon injuries. Success is based on strong initial repair, close physician observation and a cooperative patient. The addition of physiotherapy for patients with flexion deficits in the period immediately after dynamic splinting may ameliorate results.

Aim: To describe a new technique, the Ç Ioannina method È, which aims to improve the precision of targeting the lesion of the femoral head, thus increasing the survival of the femoral head in patients with osteonecrosis treated with a free vascularized þbular graft. Material: Twenty-seven patients (30 hips) with femoral head osteonecrosis were treated with this technique in our Orthopaedic Department during the last four years.

With use of CAD-CAM the lesion is located and a custom-made metallic aiming device is manufactured. This aiming device is then used to place the graft in its optimal position in the center of the lesion. This group was compared with 20 patients with conventional targeting. Results: Outcome was evaluated both clinically and radiologically. The short-term results showed precision of targeting in 89% of the patients, compared to 55% with the conventional method. X-ray exposure and operative time were also signiþcantly reduced.

Conclusions: This technique is the result of more than 12 years of experience in the treatment of osteonecrosis with transfer of free vascularized þbular graft. It was designed and developed by the þrst of the authors and expresses the contemporary trend for precision in location and description of the lesion. It decreases X-ray exposure, minimizes operative time and optimizes the placement of the graft.

Aim: Although primary ßexor tendon repair in children yields satisfactory results, some children end up with poor function because of delay in diagnosis, technical difþculties and the inability to follow a structured rehabilitation program. The aim of this study is to evaluate the functional outcome after two stage reconstruction with the modiþed Paneva technique (which includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superþcialis in the þrst stage and reßecting the latter as a Ç pedicled È graft through the pseudosheath created around the silicone rod, in the second stage) in children. Methods: Nine patients (9 digits) with a mean age of 8,2 years (range 3 Ð15) were treated for zone II lesions. Their pre-operative status in the Boyes and Hunter scale was grade two in 3, grade three in 3, grade four in 1 and grade þve in 2 patients. Results: After a mean of 42 months of follow-up (minimum 12 months), according to the Buck-Gramco scale there were 4 excellent, 4 good and 1 poor result and according to the revised Strickland scale 3 excellent, 5 good and 1 poor. Children over the age of 10 had slightly improved Total Active Motion (mean +350) compared to younger ones. No signiþcant length discrepancies were noted. Two postoperative infections were treated and one graft-related re-operation was necessary. Conclusions: Staged ßexor tendon reconstruction in children is technically feasible and efþcient. Delaying such a reconstruction in younger children does not seem justi-þed.

Aims: In the present study we reviewed 105 patients who had had Galeazzi fractures with particular emphasis on classiþcation (þve types according to the fracture patterns), treatment, and þnal results. Methods: One hundred and þve cases (75 males and 30 females) were included in this study. Most of the fractures (70 cases) occurred in the distal third of radial shaft (Type I). Seventeen fractures were in the middle third (Type II), and 11 fractures were in the proximal third of the shaft of the radius (Type III). In four cases disruption of the distal radio-ulnar joint associated with fractures of both bones (Type IV). Finally three cases considered as Galeazzi-equivalent lesions (Type V). Results: The mean follow-up time was 7 years. The overall results were good in 81% of the patients, fair in 14% and poor in the 5% of the patients. Union achieved in 102 cases and non union in three cases (two had had primary conservative treatment and one case was treated surgically). Supination ranged from 40 to 90 degrees (average 77.5 degrees), and pronation from 50 to 90 degrees (average 81.6 degrees). Conclusions: The Galeazzi fracture is uncommon injury with an incidence varying from 3% to 6% of all forearm fractures. The key to satisfactory results in the treatment of the Galeazzi lesion is anatomic restoration of the length of the radius, with application of rigid internal þxation to maintain the reduction. Although most of the reports do not recommend exposing the distal radioulnar joint, we suggest that once the anatomic reduction is secured, anteroposterior and true lateral x-rays planes to control the distal radioulnar joint.

The most common management of open injuries of the extensor tendons in Zones III to V (PIP to MP joint) is tendon suturation and digit immobilisation in extension for 4 to 6 weeks. Dynamic splinting and early mobilisation has been already successfully tested in the treatment of extensor tendons injuries in Zones VI to VII. In the current study we performed a protocol, including strong suture technique of the lacerated extensor tendon in Zone III to IV in addition with early mobilisation.

From 1999 until 2002, 23 lacerated extensor tendons (Zones III – V) in 22 patients were managed at the Orthopaedic Department of the Univercity of Ioannina. The mean age of the patients was 36 years old (14 – 70 years). The principle treatment has taken place at the emergency room and included suture of the lacerated central slip, using the Kessler-Tajima technique, plus continuous suture of the epitenon. Injuries of other structures (lateral bands, sagittal band, joint captule) were also managed by suturing. After a period of 5 days (Zone V) to 3 weeks (Zone III) of immobilisation in a static splint, injured digit mobilisation started using a dynamic extensor splint until the 5th week after injury.

The mean follow up was 7 months (3–24 months). There have been no ruptures of the extensor mechanism nore permanent digit deformities. Minimal (until 30o) loss of MP flexion or DIP extension has been regarded in 5 patients. The grip strength has been affected in 4 patients, and the grip strength between the 1st and 2nd digit (“the key pinch strength”) has been affected in 12 patients, compared with the contralateral hand. No further operation for tenolysis has been necessary.

Satisfactory results have been obtained, by early mobilisation using dynamic splinting, in the treatment of open injuries of extensor tendons in Zones III – IV under the following conditions: using strong suture technique, a co-operative patient and weekly examination of the patient. Using a dynamic splint only for the injured digit is better accepted by the patient.

Complex hand injuries are those which involve more than one functionally significant anatomic structure of the hand (i.e vessels, nerves, tendons, bones). The epidemiologic and management characteristics of these injuries, encountered in a specialized center covering an urban and agricultural population, were recorded and studied.

Between 1997 and 2002 the Orthopaedic Department of the University of Ioannina surgically treated 211 complex hand injuries in 190 patients with a mean age of 35 year (range 2.5–73). The majority of patients were male (89%). The incidence of these injuries was low at the extremes of the age distribution (children and adults over 60 years old). The greatest incidence was in the 15–30 year old age group. The mechanism of the injury was found to be clean cut trauma in 31% and avulsion or crushing in 69%; with the later being frequent agricultural injuries. Fifty-nine per cent of the injuries were viable, while 41% where non-viable (complete amputation in 63% and incomplete in 37%). Of the non viable injuries 66% eventually underwent stump configuration. Primary repair of only one anatomical structure was performed in 58%, most commonly osteosynthesis and tendon suturing. In 42% primary repair of more than one structure was performed, most commonly osteosynthesis and tendonorrhaphy in avulsion injuries and neuroraphy combined with tendonorrhaphy in clean cut injuries.

Complex hand injuries are frequently seen in young male adults and the most common mechanism of injury is avulsion-crushing. Most of them are work-related accidents, so prevention should focus on adherence to safety guidelines. Management of such injuries requires special surgical techniques and expertise, necessary for staged reconstruction.

Purpose: Vascular injuries occur in approximately 3% of all patients with major civilian trauma and peripheral vascular injuries account for 80% of all cases of vascular trauma. Upper extremity arterial injuries represents about 30% of all cases arterial trauma. The present study was designed to document and analyze the respective role of arterial damage and associated injuries on functional outcomes after upper extremity arterial trauma.

Material and Methods: Excluding the arterial injuries resulting in immediate amputation there were 57 patients who sustained arterial trauma of the upper extremity. Their mean age was 33 years (range 4–68 years), and 40 were males and 19 were females. The most frequently injured vessel was the ulnar artery (42%) followed by the brachial artery (29.8%), radial artery (26.3%) and axillary artery (1.7%). Concomitant fractures or nerve injuries were present in 54% and 45% respectively.

Results: An average of 5.6 hours elapsed between the time of injury and the time of vessel reconstruction. The most common method of surgical management was end to end anastomosis. Twenty one autogenous vein grafts were employed. Primary nerve repair was carried out in 29 patients and in another 18 secondary repair was performed. None of patients had any residual compromise from the arterial injury.

Discussion: Vascular injuries are potentially limb threatening. Improvements in the technical ability to revascularize injured extremities and advances in microsurgery, resulting in the low present day limb loss rate associated with attempted vascular repairs. Associated injuries, rather than vascular injuries, cause long-term disability in the trauma of the upper extremity. Persistent nerve deficits, joint contractures and pain are principal reasons for functional impairment

Purpose: The first 50 free flap operations performed at our clinic by the same surgical team were reviewed and assessed as to the cause and location of the defects, donor sites, complications and results. An attempt was then made to determine what could be learned from this experience.

Material and Methods: There were 46 males and 4 females who underwent free flap operations (mean age, 28.5 years; range 6 to 56 years). The lower extremity was the most frequent site of defect (72.5%). The next most frequent sites were the arm and the hand (27.5%). Trauma was by far the most common cause. Latissimus dorsi and forearm flap were the most useful flaps. Fractures in the wound were present in 26 patients.

Results: The fate of the flaps has been analysed. In two latissimus dorsi flap emergency re-exploration was performed and were successfully managed. Two flaps, underwent necrosis, due to thrombosis at the site of arterial anastomosis. Two flaps were lost due to inappropriate blood flow of the recipient vessels. Other complications included pressure ulcer, infection, and hematoma. The overall survival rate of the 50 cases was 92%.

Discussion: Limb reconstructive surgery has significantly improved and expanded with the use of microsurgical techniques. Evaluation of the recipient vessels is always the first priority. The choice of the flap, specially regarding the length and size of the pedicle is also very crucial in order to achieve good results. In addition important factors seemed to be: improvement in techique of micro-vascular anastomosis, diseased vessels, vascular spasm, hypotension, postoperative edema, and hematoma. We believe that an “orthoplastic” approach in covering soft tissue defects is beneficial.

Aim: This study describes the clinical features and treatment of 94 patients with skeletal osteochondroma during the last 20 years.

Materials-methods: A retrospective review of various size solitary osteochondroma was evaluated. There were 51 males and 44 females with mean age 21 years. The mean follow-up was 8 years (1–12). There were 40 lesions in the distal femur, 6 in the greater trochanter, 19 in the proximal tibia, 1 in the proximal fibula, 1 in the calcaneus, 3 in the lateral malleolus, 1 in the medial malleolus, 3 in the talus, 2 in the tarsus, 3 in the metatarsals, 3 in the scapula, 4 in the humerus, 1 in the elbow,1 in the radius, 6 in the fingers. The lesions were diagnosed by history and plain radiographs. In two patients with large lesions around the knee an angiography was done

Results: Pain and local tenderness were the main symptoms. The treatment was en bloc excision of the tumor. There were no recurrence. Two patients had wound infection which was dealt with antibiotic.

Conclusion: The site and the results of this study are similar with the literature. The radiologic image is pathognomic for the tumor. The treatment consisted of en bloc excision. There is high possibility of recurrence in case of insufficient excision.

Although primary flexor tendon repair in children yields satisfactory results, some children end up with poor function because of delay in diagnosis, technical difficulties and the inability to follow a structured rehabilitation program. The aim of this study is to evaluate the functional outcome after two stage reconstruction with the modified Paneva technique (which includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superficialis in the first stage and reflecting the latter as a “pedicled” graft through the pseudosheath created around the silicone rod, in the second stage) in children.

Nine patients (nine digits) with a mean age of 8.2 year (range 3–15) were treated for zone II lesions. Their pre- operative status in the Boyes and Hunter scale was grade 2 in three, grade 3 in three, grade 4 in one and grade 5 in two patients.

After a mean of 42 months of follow-up (minimum 12 months), according to the Buck-Gramco scale there were four excellent, four good and one poor result and according to the revised Strickland scale three excellent, five good and one poor. Children over the age of 10 had slightly improved Total Active Motion (mean +35°) compared to younger patients. No significant length discrepancies were noted. Two postoperative infections were treated and one graft-related re-operation was necessary.

Staged flexor tendon reconstruction in children is technically feasible and efficient. Delaying such a reconstruction in younger children does not seem justified.

In late cases of brachial plexus palsy or when nerve reconstruction was not that beneficial, pedicled or free neurotized muscles i.e. latissimus dorsi are used to restore or enhance important functions i.e. elbow flexion or extention.

During the last three years, 43 patients with brachial plexus injuries were operated in our Clinic to reconstract the paralysed extremity. In nine of them, the ipsilateral latissimus dorsi was transferred as pedicled neurotized muscle to restore elbow flexion (seven patients) and elbow extension (two patients). Two patients had free latissimus dorsi transfer, which was neurotized directly via three intercostals. The neurovascular pedicle was dissected proximally up to the subclavian vessels and posterior cord, and the muscle was raised from its origin to its insertion and tailored to simulate the shape of biceps or triceps. Then it was passed via a subcutaneous tunnel on the anterior or posterior arm. The reattachment was done with Mitek anchors on the clavicle and the radial tuberosity (elbow flexion) or on the posterior edge of the acromion and the olecranon (elbow extension). The arm was immobilized in a prefabricated splint, which was removed after six to eight weeks.

After the first three months all patients had a powerful elbow flexion or extension. One of the free muscle transfers started to have elbow flexion after eight months and he is still progressing. In one patient skin necrosis and infection occurred near the elbow. The patient after IV antibiotics needed another operation to restore the distal insertion, using fascia lata.

Ipsilateral latissimus dorsi, if strong enough (at least M4), is an excellent transfer for elbow flexion or extension restoration or enhancement, in late cases of brachial plexus paralysis. Contralateral latissimus is an option when the ipsilateral is weak but it takes more time to function since there is a waiting period for reinnervation.