The Gibson and Moore postero-lateral approach is one of the most often used in hip replacement. The advantage of this approach is an easy execution but it’s criticized because of its invasivity to muscletendinous tissues especially on extrarotators muscles and because of predisposition to posterior dislocation.

Since June 2003 we executed total hip replacements using a modified postero-lateral approach which allows to preserve the piriformis and quadratus femoris muscles and to detach just the conjoint tendon (gemelli and obturator internus). Articular capsule is preserved and it will be anatomically sutured at the end of the procedure as well as the conjoint tendon with two transossesous sutures. Piriformis and quadratus femoris muscles result untouched by this approach.

We have executed 500 surgeries with this modified approach.

We have used different stems (straight, anatomical, modular and short) and press fit cetabular cup with polyethylene or ceramic insert and we have always used 36 mm femoral heads when allowed by the cup dimensions. We have used any size both of stems and cups without limitation due to the surgical approach. The mean age is 61.8 y.o., 324 females and 176 males. Obese patients, hip dysplasia Crowe 3 and 4 and post traumatic arthrosis are exclusion factors for the execution of this approach. If possible we have maintained the capsulo-tendinous less invasivity. The BMI is not an excluding factor because it’s just the gluteus region that is an important factor to decide if to execute or not a less invasive approach.

Analyzing our 500 cases we didn’t have any case of malpositioning of the stem in varus or valgus (more than 5°) and considering acetabular cup we had the tendency to position it in valgus position (not more than 40°) in the first 20 cases.

No leg discrepancies more than 1 cm were observed.

Intra-operative blood loss have been reduced of about 30 % and 50% in the post-operative. All the patients were able to active hip mobilization within the first day after surgery with a mean range of motion of 0–70°. The patients were mobilized the first day after surgery and 80% of them were able to assisted walk within second day after surgery. The mean time of stay in hospital was 6.8 days.

After 4 weeks 98% of the patients were able to walk without crutches.

One case of deep infection were evaluated and then solved with surgical debridement; no wound dehiscence. We had 1 case of anterior hip dislocation in dysplastic arthrosis due to a technical mistake. In 1 case we had femoral nerve palsy, then solved, probably because of anterior retractor malpositioning. We had 5 cases of piriformis muscle contracture without sciatic nerve palsy, then solved. We think that for total hip replacement this conservative postero-lateral approach, thanks to capsuletendinous modification we have adopted, could be considered an anatomical approach, which doesn’t present more dislocation risks compared to other approaches to the hip also thanks to the introduction of 36 mm femoral head that gives more stability and proprioceptiveness. Besides this approach gives the possibility of a shorter rehabilitation as seen above and it could be consider optimal for total hip replacement.

What was the question? The treatment of multi-injured patients requires initial stabilization of general conditions and vital parameters. The first stage in orthopedic management of the fractures in trauma involves stabilization of the bone segments to reduce blood loss and allow nursing. External fixators are fast, versatile and essential in the emergency situation in cases of multiple fractures, especially with soft tissue loss. According to damage control orthopedics (DCO) concepts, it is possible to replace an external fixator (EF) with internal synthesis (ORIF) after a period of time to reduce the risks of ORIF. However, surgery can be difficult to perform and pin sites can be the source of bone infection, in which the EF as a definitive treatment option may be considered. How did you answer the question? In trauma surgery, instability of the hardware, fractures near the joint, frame extending across the knee and the ankle, initial fixation was converted to definitive treatment with circular frames according to the Ilizarov method. Fourteen patients (2 female and 12 males; age 24 to 80 yrs, average age 43,4 y/o) were treated with various circular framses as definitive treatment: Ilizarov (2), Sheffield (7), Taylor Spatial Frame (TSF) (4) and TrueLok (1) between November 2002 and December 2007 in multiply injured patients with ISS > 20. Seven cases were femoral and seven tibial. The femoral group had four knee spanning fixator configurations and three unilateral external fixators. The tibial group had 4 unilateral frames, 1 hybrid EF, 1 across the knee EF and 1 across the ankle EF. Five patients had temporary femoral and tibial hardwares in the same side. Three patients had unilateral tibial and femoral fractures. What are the results? All patients achieved consolidation. The mean duration of femoral EF was 7.6 months (5–9 months). One bone loss in a distal femoral shaft treated with Sheffield EF had lengthening (5 cm) after acute short-hening. Two patients had a gradual distal femoral fracture reduction and a mechanical axis correction by TSF. Three patients with tibial bone loss had 2 trifocal bone transport (17,5 and 9 cm) and 1 bifocal bone transport 5 cm. The TSF had no additional pre-operative planning and major post-operative frame adjustments. The intra-operative devices was easier for the TSF. What are your conclusions? Circular frame osteosynthesis following initial EF, is a reliable and effective strategy for treatment in severe open femur and tibia fractures and post traumatic reconstruction.

Introduction: External fixation has evolved from a mean to hold a bone in position to one that allows a gradual correction and lengthening. Platelet gel has been reported to be effective in enhancing osteogenesis. The association of these techniques could be effective in the treatment of pottraumatic bone loss fracture.

Materials and methods: Platelet gel has been obtained mixing 50 mL of autologous platelet concentrate to 2.5 mL of fibrin glue, produced from autologous FFP through CS-1 Cryoseal Thermogenesis.

Patient 1: Male, 39 years old, smoker, bearing tibial non-union with 17 cm bone loss has been treated by trifocal technique with platelet gel in the docking site procedure with autologous bone graft.

Patient 2: Male, 43 years old, smoker, suffering from exposed femoral fracture with sovracondilar bone loss, treated by acute shortening and proximal osteotomy in order to improve distractional ostogenesis according to Ilizarov method. Platelet gel had been positioned in the non-union sovracondilar site.

Results. Patient 1 has reached a good bone repair in the platelet gel application site within 4 months. Patient 2 has healed within 3 months.

Hig energy fractures of the lower limb are often associated with tibial or femoral bone loss, skin exposition with vascular and nervous injuries (Gustilo et al.).

The surgical procedure is a real challenge, consisting in a temporary stabilization of the fracture associated with a plastic and/or vascular reconstruction.

Once the skin and vascular injuries are recovered, the orthopaedic surgeon can remove the temporary stabilization performing a circular external fixation with bone lengthening by using the “bifocal” (one site of metaphiseal corticotomy and one site of compression) or “trifocal” (two sites of metaphiseal corticotomy and one site of compression) technique.

We use to do a “docking site” treatment when bone fragments are nearly in contact.

Our experience indicates that circular external fixation, by using the Orthofix system, is a very useful and safe technique in the management of severe lower limb injuries.

Our good clinical results lead us to suggest this surgical technique that allow to obtain a limb reconstruction, avoiding segment amputation.

Von langenbach first described the posterior approach for total hip arthroplasty in 1874. In recent years advances in operative techniques and instrumentation have allowed surgeon to perform total hip arthroplasty through incision much smaller. The primary goal of any joint replacement is to create a biomechanically arthroplasty with excellent prosthesis position and durable interfaces.

Many american authors propose a definition of minimally invasive hip replacement when the skin incision is between 7–10 cm.

For us, to be mini-invasive means saving non only the skin but saving capsule, muscle and tendons too.

We used a mini-posterolateral approach with a mean length of 7 cm. After incision of the gluteus maximus fascia and fascia lata, the gluteus maximus muscle is blunty split. The short external rotator tendons are located; we proceed to saving the piriformis and quadratus femoris tendons. The gemelli and obturator internus tendons are detached with electrocautery. A capsulotomy is performed. The capsule and obturator tendon are tagged with heavy bone-suture for reattachment. The difficulties of the operation can be reduced if instruments developed for the technique are used.

50 cases of minimal incision posterolateral total hip arthroplasties are performed. More rapid rehabilitation and more prompt return to activities of daily living are also some advantage.

Longer follow-up is required to determine the long-term outcome but, our results encouraged to performed a mini-approach for total hip arthroplasty in patients selection.

Introduction The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have substained a several general trauma or an high energy scheletral trauma upper limbs.

Treatment In a period from 24 july 2002 to today 8 october 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient.

4 patients bilaterally, 3 patients have substained a secondary reprease for lacking the initial reduction and 2 in two programmed timing.

46 wrists with radial internal fixation single or double plate (in one case trhee plate)

12 plate with pin or single screw in augmentation

3 cases with only screw artroscopically assisted

14 cases with only external fixator with or without pin

18 wrist with a combination of radial internal fixation (plate) and external fixation with Pennig, in complex distal radial-ulna fracture (2 exposed)

In 5 wrists there were associated and treated navicular fracture or intracarpal ligaments injury

1 pazient have sustained an ipsilateral forearm fracture, epiphiseal distal radial fracture, trans scapho-lunate dislocation and controlateral transcapho-lunate dislocation

1 patient have sustained ipsilateral navicular-fisrt metacarpal-radial and ulna fracture

The most patients (...) have been treated from the first Author.

The patients were controlled from minimum of 6 month up a maximum of 39 months

We have adapted in our evaluation the Dash score system

The main problem, in the follow up results is a lack of prono-supination that stresses the importance of a perfect reduction of distal radio-ulnar joint to begin early a phisiotherapy

Clinical results In conclusion our experince in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severly injured pazients are respected

We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the terapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time protocol of high energy trauma to distal forearm, in particular in politraumatized patients is:

- closed reduction and short cast or external fixator if exposed or severe instable, on the day of injury during or just following generally stabilization

Introduction: Proximal tibial fractures continue to be problematic for orthopaedic surgeons.

Continued problems in their managment include infection, soft tissue problems, failure of fixation and joint stiffness.

Combining the concept of “biological plating” and locked internal fixators, the LISS (Less Invasive Stabilization System) has been developed.

Material and methods: The Lis-system is an extramedullary internal fixator that proposes the advantage of indirect reduction and percutaneous, submuscular implant placement.

The Lis-system is indicated for fractures of the proximal tibia that involve both the medial and lateral columns. They include AO/OTA Type A2, A3, C1, C2, C3 and type B in selected cases. For the reduction, we put the lower limb in the calcaneal-traction.

For intra-articular fractures the prime objective is to achieve anatomic reconstruction of the joint. This study is a prospective evluation of the Lis-System for the treatment of high-energy tibial plateau and proximal tibial fractures treated between October 2002 and Febrary 2004. Twenty-five patient (18 male and 7 female) were treated. The fracture were classified according to the AO classification.

The follow-up period between 3 months and 16 months (mean 8.9 months).

Results: The fractures treated were 10 intrarticular (AO 41C or 41B) and 15 metaphyseal (AO 41 A); two of these fractures presented with open soft tissue damage. The average age of the patients was 43 years. There were five cases of polytraumatized and four patinetsa with multiple fractures. The mean range of motion was 2 degree (R= 0–13) to 110 degree (R= 80–150). The mean time to full weight-bearing was 16.2 weeks (R= 10–19).

There where no non-union. In one case, there was a valgus malunion of about 5 degree, in 2 case a valgus malunion of less of 5 degree and anyone of more of 5 degree.

The tecnique of osteosyntesis with the LISS allows a minimally invasive approach, minimizing additional trauma to the soft tissue.

There were no cases of varus malunion, of failure or of loss of reduction. One patient developed superficial infection that we treat with antibiotics terapy. No syndrome compartiment were see.

Conclusion: In conclusion with the new methods of percutaneus plate osteosyntesis we see decreased soft tissue complication and the time of healing.

The Less Invasive Stabilizzation System in our opinion is the goal standard for multisegmentary or comminnuted fractures of the proximal tibia with distal long extensions in patients with politrauma.

The early clinical result optain in our experiance indicate that the Less invasive Stabilizzation System combine efficent bone stabilization with the advantage of minimally invasive operative technique.

Introduction A complex challenge to trauma surgeon is the choice of clinical pathway management in hemodynamic unstable patients with pelvic ring disruption and potential intraperitoneal or other extrapelvic hemorrhage.

Aim of the study In multi-trauma bleeding patients with pelvic ring injuries causing increased pelvic volume, the main source of hemorrhage is the fracture itself; in biomechanical stable the priority is to search and to treat extrapelvic sources of hemorrhage; CESCT is critical in the selection of appriopriate therapeutic approach in the case of bleeding pelvic injury.

Material and Methods Patients admitted as major trauma are immediately evaluated by a multidisciplinary team in a dedicated room where ABC resuscitation, plain radiographs, abdominal ultrasound/DPL may be all performed. The comprehensive Tile pelvic disruption classification combines the mechanism of injury and the degree of pelvic stability. Previous works correlated pelvic fracture pattern with the risk of pelvic fracture hemorrhage. Classically, APC and VS mechanisms were associated with pelvic hemorrhage and LC mechanims with abdominal organ injuries. In this work we included in group A patterns of pelvic fracture where increased pelvic volume and major ligamentous disruption (Tile B1, B3 and C or APC and VS), Patterns of pelvic fractures with low risk of bleeding, such as those without ligament lacerations (Tile A) or with reduced pelvic volume (Tile B2 or LC) or isolated acetabular fractures, have been included in group B.

Results Between October 2002 and January 2004, significant bleeding was observed in 87 of 142 pelvic fractures (61.26%).

Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B

All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p< .001).

Conclusion Pattern of pelvic seems to be suggestive of the predominant site of bleeding; early application of measures of temporary pelvic stabilization should be considered a completion of resuscitation protocol; CESCT is the best diagnostic tool to choice the appropriate way to manage bleeding pelvic injuries and associated intraperitoneal injuries; availability of equipped CT scan and angiographic suitesand of short response time interventional radiologist is a crucial point for this diagnostic and therapeutic work-up.

Dislocation and carpal fracture-dislocation are a rare injury, interesting capsula and ligaments, with a variable damage of the vascularization. Classification is difficult for the complexity on this lesion.

The aim of our work is to underline how the best final clinical result is achieved after an immediate treatment of reduction and stabilization of bone injury.

We considered two groups:

A: 8 patients, who have been observed since july ’93 until 1996 ; all the patients were men who had work or car accidents, with outstretched upper extremity. The ages of the patients ranged from 19 to 34 years.. All patients were followed for an average of 8 years

1 is bilateral

3 wrists reoperated for lacking initial reduction or for the general initial condition

Assesment of the patients includeds clinical rating and roentgenografich analysis. The clinical scoring included pain, functional status, range of motion and grip strength.

Among the various classifications, we took into account the one proposed by Allieu, based on the radio-lunate ligament, consequently this classification offers an important prognostic factor.

In one of our cases there was assocciated a fracture of the radial stiloid, and in other one a posterior dislocation of the elbow.

We treated all the patients with a volar approach, the stabilitation of the carpus and scaphoid was achieved utilizing K wires in four cases, microscrew in two patients for scaphoid’s fracture and in other one the Herbert screw in the A group

In the B recent group we used in all cases K wiring, and herbert screw in 8 wrists, microscrews in one , and internal capsulodesis in the 2 last for perilunate isolated dislocation

The initial failing of reduction is due to an unstable reduction in very injured patient ( we use only k wire for the navicular)

10 patients in the second B group have been treated by the same first Author

After surgery treatment, the wrist was immobilizated in a splint for 6 weeks, then a careful mobilitation was started.

Finally we think that is necessary, to avoid the instability and pseudoartrosis on the scaphoid, to treat all the transcapho-lunate dislocation with open reduction and stabilitation, as agreed with literature.