We describe the treatment of traumatic anterior shoulder instability complicated with Hill-Sachs lesion, using a combined arthroscopic technique of anterior & posterior capsular fixation and infraspinatus tenodesis by means of suture-anchors, in order to fill the humeral head bone defect (i.e. “remplissage”).

We use 2 posterior portals introducing the arthro-scope through the upper one. A double-armed suture-anchor is inserted through each portal piercing the infranspinatous tendon & posterior capsule in an extra-articular mattress mode. The humeral head bone defect is filled with the aforementioned tissues.

18 patients with well established anterior instability were subject to this technique between March 2005 and December 2008. The follow-up time was 6 to 36 months (average 18 months). All were evaluated using the Rowe protocol for shoulder instability which assess stability, ROM & shoulder functionality.

In 13 patients the outcome was assessed as excellent, in 4 good & in 1 average. In one patient, post-op stiffness was developed which managed successfully with conservative means.

The arthroscopic technique of “remplissage” is an innovative choice in the armamentarium of treatment of anterior traumatic instability with concomitant Hill-Sachs lesion. The results of this technique are excellent regarding the recurrence rate of anterior instabiliy (in our series there was none episode of recurrent instability during the study period).

Aims: Fibular plating comprises a major component in the treatment of Pilon fractures with ORIF. However its necessity in fractures treated by EX.FIX has been questioned. In order to clarify this technical detail we carried out a retrospective study with Pilon fractures treated by circular þxators. Methods: Between 1992–2001, 65 pilon fractures were treated with circular þxators. Fractures were classiþed according to the systems of Ruedi Ð All-gower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Tension wire þxation at the fracture site was augmented by screws in 39 fractures. The lateral malleolus was internally þxed in 39(60%) patients. In 48(74%) patients the þxation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in þve fractures. Clinical and radiological results were evaluated. Results: Mean follow up was 3 years (1 to 10 years). On the basis of Ruedi-All-gower system, there was found negative correlation of the end result and þbular þxation in all the fractures types. However if Ovadia Beals system was used, þbular þxation was associated with better results in types II and III, but with inferior results in types IV and V. Conclusions: Ovadia Ð Beals classiþcation considers the metaphyseal defect and fracture comminution and should be chosen for the selection of the technique. In fractures with metaphyseal defect, þbular þxation does not allow acute shortening and makes bone transport more difþcult leading to poor results. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

Aims: Circular þxation has become increasingly popular for high-energy tibial plateau fractures (HETPF). These injuries are associated with comminution and soft tissue compromise and may require additional þxation to the femur. This study investigates the indications for bridging the knee joint and the appropriate type of the tibiofemoral construct. Methods: Between 1988 and 1999, 112 patients (mean age: 37; range: 18 to 67) underwent circular þxation for HETPF. There were 8 Schatzker type IV fractures, 11 type V, and 93 Schatzker type VI fractures. 40 fractures were open whereas 55 fractures had Tscherne type 1 or 2 damage of the soft tissues. 30 fractures underwent simple tibial þxation and 80 fractures required extension of the þxation to the femur for 6 weeks, using either þxed or mobile hinges. Mean follow up was 5 years (range, 28 months to 13 years). Results were evaluated according to the system of Honkonen and Jarvinen. Results: 93 (82%) injuries had at least one, and 65 (57%) more than one indication for tibiofemoral þxation. The most common indications were: extensive comminution (73 knees), soft tissue compromise (60 knees), and ligamentous injuries (58 knees). Patients with tibiofemoral þxation achieved better þnal axial alignment and knee stability than patients with tibial þxation. Fixed joint bridging resulted in the same knee ßexion but signiþcantly lower extension lag than mobile bridging. Conclusions: 80% of HETPF are associated with injuries that require knee bridging. Fixed tibiofemoral þxation offers better subjective, clinical, functional and radiological results.

Purpose: The retrospective evaluation of the results of the application of the ring and hybrid systems of external fixation for the management of the high energy injuries of the talus.

Material and Methods: Between 1990–2001, seventeen patients with complex injuries of the talus were treated with the application of ring or hybrid fixators. Eleven patients were males and six females. Isolated fracture of the talus was recorded in five patients, fracture- dislocation in four and pantalar dislocation in eight. The injury was open in twelve patients. Six patients had multiple injuries. To classify the talar injury we used the systems of Hawkins and Marti/Weber. Tension wire fixation with the use of either Ilizarov or hybrid frames was applied in all fractures. Additional internal fixation was performed in eleven fractures. The fixation was extended at the forefoot in all fractures. Results were assessed using Kiel’s evaluation system.

Results: The mean follow up was 42 months (range, 25 to 96). We had no cases with deep infection, wound break down, osteomyelitis, or septic arthritis. We had five excellent, eight good, three fair and one poor result. The final radiographic appearance was not satisfactory in six fractures. Avascular necrosis of the talus was diagnosed in four fractures (23.5%).

Conclusions: Using the ring and hybrid external fixation systems a satisfactory reduction of the high energy fractures and dislocations of the talus with the maximum respect of the anatomical architecture of the adjacent tissues can be achieved. The method offers an excellent stability of the fracture, diminishes the rate of the postoperative infection, and reduces significantly the risk of talus avascular necrosis.

Fibular plating comprises a major component in the treatment of Pilon fractures with open reduction and internal fixation. However, its necessity when Pilon fractures are treated by hybrid fixation has been questioned. A retrospective clinical study with 65 high energy pilon fractures treated by circular fixators between 1996 and 2001 was undertaken, in order to clarify this technical detail. The mean age was 35 years (range 21 to 69 years). The fractures were classified according to the systems of Ruedi -Allgower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Hybrid fixation (tension wire fixation at the fracture site augmented by screws) was performed in 39 fractures. The lateral malleolus was internally fixed in 39(60%) patients. In 48(74%) patients the fixation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in five fractures. Clinical and radiological results were evaluated.

Mean follow up was 3 years (range 1 to 10 years). On the basis of Ruedi-Allgower system, there was a negative correlation between the end result and fibular fixation in all the fractures types (p< 0.001). However, if Ovadia Beals system was used, fibular fixation was associated with better results in type II and III, but with inferior results in type IV and V.

We conclude that in fractures with metaphyseal defect, fibular fixation does not allow acute shortening and makes bone transport more difficult leading to poor results. Ovadia – Beals classification considers the metaphyseal defect and the fracture comminution and should be chosen for the selection of the technique. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.