A minimally-invasive procedure using percutaneous reduction and external fixation can be carried out for Sanders’ type II, III and IV fractures of the os calcis. We have treated 54 consecutive closed displaced fractures of the calcaneum involving the articular surface in 52 patients with the Orthofix Calcaneal Mini-Fixator. Patients were followed up for a mean of 49 months (27 to 94) and assessed clinically with the Maryland Foot Score and radiologically with radiographs and CT scans, evaluated according to the Score Analysis of Verona. The clinical results at follow-up were excellent or good in 49 cases (90.7%), fair in two (3.7%) and poor in three (5.6%). The mean pre-operative Böhler’s angle was 6.98° (5.95° to 19.86°), whereas after surgery the mean value was 21.94° (12.58° to 31.30°) (p < 0.01). Excellent results on CT scanning were demonstrated in 24 cases (44.4%), good in 25 (46.3%), fair in three (5.6%) and poor in two (3.7%). Transient local osteoporosis was observed in ten patients (18.5%), superficial pin track infection in three (5.6%), and three patients (5.6%) showed thalamic displacement following unadvised early weight-bearing.

The clinical results appear to be comparable with those obtainable with open reduction and internal fixation, with the advantages of reduced risk using a minimally-invasive technique.

Standard external fixators have always caused difficulties in visualising fracture fragments radiologically in both planes; for this reason multiple shots are often required, exposing patients and surgeons to high X-ray levels. Radiolucent external fixator X-calibre is composed of a new thermoplastic material reinforced by carbon fibres (PEEK-CA 30). The aim of this study is to evaluate the first 30 tibial fractures treated with this device.

Thirty external fixators X-calibre were used to treat 30 patients with tibial fractures with an average age of 40.4 years (range 21–60). According to the AO classification we have treated nine type A, 13 type B, and eight C fractures. Five were open fractures. The average follow-up was of 18 months. The time of healing was the same as seen using the standard fixator and the average time was 115 days (range 85 to 190). One tibial plafond fracture healed with 8° valgus deformity and persistence of pain during walking. There was loss of reduction on the third day after surgery due to erroneous evaluation of the fracture, which presented a butterfly fragment.

This new radiolucent fixator showed the following advantages: single use, sterile package, radiolucency, less X-ray exposure for patients and surgeons, deal mechanical performance for each use, reduced storage and sterilisation costs, less instrumentation, less weight and increased comfort for the patient, average healing time and results comparable to the existing radio-opaque system.

Different methods of filling bone defects are reported: shortening followed by lengthening or bone transplant. In both cases the resection and docking bone site (immediately or after transplant) has a high risk of delayed consolidation or non-union. The aim of this study was to evaluate the strategies to avoid this risk.

We studied 19 patients treated from 1997 to 2002: 11 (group 1) were treated with immediate shortening and proximal callotasis. In eight patients (group 2) we performed monofocal proximal-distal bone transplant. In seven patients of group 1 we performed only decortication of the docking site (group 1A); in four cases (group 1B) decortication was associated with an autologous bone graft. The docking site was checked radiologically and considered healed when we allowed full weight-bearing after fixator removal.

In two patients (28.5%) in group 1A, three (75%) in group 1B and two (25%) in group 2 healing was achieved without any other operations. Docking site refracture or pseudoarthrosis was treated in all patients by new decortication and autologous bone graft with an average healing time of 90 days.

We suggest performing acute bone loss shortening in combination with decortication and autologous bone graft when local conditions permit. After bone transplant it is not necessary to wait for spontaneous consolidation, but better to plan from the beginning another operation before the two the docking site fragments are in contact.

Now we are using AGF and BMP-7 (OP-1) for treatment of the docking site but the study is still underway.

We report our experience using an inflatable intramedullary nail in 20 diaphyseal humeral fractures. The nail is introduced without reaming and does not require proximal and distal locking, because it allows radial stabilisation of the fracture. The tip of the nail must be inserted 5 cm beyond the fracture line.

Since April 2002 we have applied 20 “Fixion” nails in 19 patients with humeral fractures. This is a stainless steel nail with a circular cross section reinforced by four bars, which can be inflated by saline solution through a dedicated pump. The average age of the 19 patients was 35.6 years, 15 were males and four female. Among these, 17 were closed fractures, three fractures open degree 1 (Gustilo Anderson class.). According to the AO classification, eight fractures were type A1 and A2, 10 were type A3 and two type B2. Nine fractures required reaming. Passive mobilisation is allowed 5 days after surgery, followed by active mobilisation 3 weeks later.

Eighteen of the twenty fractures consolidated in an average time of 3.5 months. Two of 20 cases showed delayed union at 4 weeks and were treated by increasing the immobilisation period. Final healing without complications in these cases was observed at 5 months. No peripheral neurological complications were observed.

“Fixion” nail is a new, easy method of intramedullary nailing. It helps to reduce operating time and in our experience it did not show any complications. It must be reserved for simple diaphyseal fractures where it is possible to achieve good stability and complete union.

The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical.

Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed.

The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia.

Elbow dislocations are difficult to treat because of the high incidence of short- (vascular and neurological lesions) and long-term (decreased range of motion and instability) complications. We report the results obtained in 20 elbow dislocations treated with hinged cast tutorisation or hinged external fixator.

We treated 20 patients with an average age of 45 years (range 16– 62 years). The average follow-up was 7 months (range 5–18 months). We divided the patients into two groups: patients treated by a hinged tutor for 4 weeks (group A), patients treated by hinged external fixator, removed after 5 weeks (group B). All the patients were evaluated clinically using the “Mayo elbow performance score” after 3 weeks, 1 month and 1 year.

Results were excellent in six elbows and good in 14; none of the patients had an insufficient or poor score. We observed deficit in prono-supination in three patients and deficit in flexion and extension in six patients; three patients complained of epicondylar pain when carrying something. At the end of the treatment none of the patients complained of instability.

According to our data normal function can be restored after early mobilisation. Our experience suggests that the most important aspect in the choice of treatment is the evaluation of joint stability after reduction. The results obtained with the external fixator are very good in terms of restoring function; the incidence of complications is very low and was equally distributed between the two groups.