Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intraarticular calcaneal fractures.

In a period of 3 years, 16 patients with 18 intraarticular fractures of calcaneus (eleven type III and seven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twelve patients were male and four female. The average age was 42 years (range 25 – 63 years). Three fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamento-taxis, and closed reduction of the subtalar joint were performed in 14 cases. In 4 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients.

The mean follow-up period was 1,5 years (range 1 – 3 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 79,8 (range 72 – 90). Six patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. One of the patients complained of heel pad pain. Nine (6.25%) grade II pin tract infections were detected from a total of 144 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done.

Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intraarticular calcaneal fractures

Whiplash vertigo syndrome is often seen in victims of rear-end vehicle collisions. These patients commonly complain of headache, vertigo, tinnitus, poor concentration, irritability, and sensitivity to noise and light.

Sixteen patients (medium age, 39,5 years) that they refered in orthopaedic examination because of long-lasting subjective complaints after cervical spine injury underwent clinical, laboratorial and psychometric examinations. The mean posttraumatic interval was 43 months. Ten patients were injured in road accidents, 5 during sports and one at work, all with mechanism trial of whip. Each patient was evaluated with otorhinolaryngologic examination, audiometry tests, CT: petrus – internal auditory meatus and cerebellopontine corner. Also each patient was evaluated with neurologic examination, psychological well-being scale (sf-36), and personality profile scale.

None of the patients had neurologic symptoms, and no lesions of the cervical spine were identified. All the patients had negative clinical, radiological and standard laboratorial control, but may be is a critical point that the eleven of these patients had pathologic OGTT (Oral Glucose Tolerance Test). Also did not exist differentiations from the mean values in psychological well-being scale (SF-36), and personality profile scale of healthy population. Test results were unrelated to the length of the post-traumatic interval. However, 2 distinct syndromes were identified. Ten patients had cervicoencephalic whiplash type syndrome (CES), characterized by headache, vertigo, tinnitus poor concentration, and disturbed adaptation to light intensity. Six patients had the lower cervical spine whiplash type syndrome (LCSS), characterized by vertigo, tinnitus cervical and cervicobrachial pain.

The verification of Whiplash Vertigo syndrome require more objective clinical means. This article proposes that exists an organic base for the syndrome, but does not promote that whiplash injury certainly cause it

To study the preliminary clinical results of patients submitted to kyphoplasty with an expandable titanium cage (OsseoFix).

Between 09-2008 and 02-2009 16 patients (6 men, 10 women, total 36 vertebrae) with a mean age of 67 (23 to 81) were submitted to kyphoplasty using a system involving the implantation of an expandable titanium cage (OsseoFix) for the treatment of fractures in the lower thoracic and lumbar spine. Five patients were submitted to kyphoplasty at one level, 4 at two levels, 5 at three levels, and 2 at four levels. Two patients additionally needed a posterior spinal fusion. The underlying causes for the spinal fractures were: secondary osteoporosis (7), recent acute trauma (5), and malignancy (4: 1 Hodgkin lymphoma, 1 Non-Hodgkin lymhoma, 1 metastatic breast cancer, 1 metastatic prostate cancer). In 8 patients biopsy specimens were harvested at the same procedure.

Mean follow-up time was 4 months (2 to 6). No intra-operative complication occurred. No bone cement leakage or pulmonary embolism was observed. The mean pain improvement, as measured with the VAS scale, was 5,12 (7,81 preop – 2,69 postop). The mean vertebral body height restoration was 19,5%, and the kyphotic angle was corrected by a mean of 2,24°.

The main advantage of using an expandable metal cage in kyphoplasty is the improved reduction of the vertebral body compression and the minimal risk of bone cement leakage. Especially in young patients, the maintenance of the reduction could potentially be achieved even without cementation, by the mere support provided by the cage. A longer follow-up time is needed for the safe validation of these preliminary encouraging results

Aim of our study was the investigation and the cross-correlation of various neurologic scales to estimate, comparatively with the functional results of patients after damage of spinal cord injuries.

Between 1989 – 2005, 115 patients were submitted in stabilization of Lower Cervical Spine that was judged unstable.

The neurologic situation was certified with the scales: Frankel, ASIA motor score, NASCIS motor score, FIM scale, and MBI scale.

In the protocol took part the 94 patients for that existed in neurologic details and long follow-up for at least two years.

From the study of course of scores of all scales was not found statistically important difference between ASIA, NASCIS and other motor scales. However 12 patients with important improvement of mobility at ASIA motor score and NASCIS motor score they have not difference in Frankel scale, despite the make that the MRP (Motor Percentage Recovery) was improved: 21.5%

Also 8 patients with relatively big improvement in their total scores did not have corresponding functional improvement (FIM scale, and [MBI] scale)

A lot of neurologic methods – scales were used and are used today. However for the essential and modern follow-up of patients with spinal cord injuries, it needs certification with a scale of classic team of (measurement of mobility) and a scale of functional faculties of the patient

Aim: End result study of closed intramedullary nailing of humerus fractures.

Materials & methods: Between 1995–2003, 42 patients with fracture of the humeral shaft, were selected to be treated by I.N. The average age was 48 years old (17years–82years) The Selection criteria were: α) loss of closed reduction (24 patients), b) pathological fractures (5 patients), c) non-union following external fixation (2 patients) and d) delay of union (7 patients). The intramedullary nail was inserted through a proximal entry point via a transdeltoid incision. In 25 cases the entry point was below the greater tuberosity to avoid rotator cuff injury and in 18 cases the entry point was intraarticular. All nails were locked either proximal (41) or distally (1). Open technique was required for 21 cases. Passive full range of motion of elbow and shoulder joint was encouraged after the second postoperative day. Active assisted exercises were initiated the second postoperative week. Bone healing was confirmed by clinical and radiological findings. Shoulder mobility was evaluated by the Constant-Murley scoring system.

Results: The average follow-up time was 21 months (9 months–8 years).All fractures were finally healed. The average healing time was 13 weeks (8weeks–13weeks). Patients with extraarticular entry point of the nail had full passive shoulder motion between the 2th and the 4th postoperative week, whereas patients with intraarticular nail application presented delayed passive shoulder motion with final limitation of the normal range of motion. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with neurapraxia of the radial nerve installed posttraumatic, who had full recovery 3 months later. There was one proximal migrated nail, which required revision. None of the patients required nail removal.

Conclusions: Intramedullary nailing of humeral shaft fractures seems to be a reliable method of treatment. Shoulder mobilization after anterograde insertion of the nail can be easily restored with proper choice of entry point and proper physiotherapy program. The advantages of this method include: shorter operative time, less blood loss, small incision with minimal soft tissue damage. Extraarticular nail insertion should be the entry point of choice as there is no trauma to the rotator cuff.

Aims: The evaluation of blood supply of the humeral head in displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus. Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4û and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fracture þxation was achieved with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation. Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2 ) were about the same (p< 0.01) in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement. Conclusions: Although the small number of cases, transosseous suturing þxation of 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement.

Aim: To evaluate time of union and functional recovery of the shoulder joint in humeral shaft fractures treated with antegrade intramedullary nailing.

Methods: During 1998–2002, 29 patients (16 male and 13 female, mean age 43.7 years) with humeral shaft fractures underwent antegrade, proximal locked, intramedullary nailing. A modified extra-articular entry point, 1 cm below the greater tuberosity, was used to avoid rotator cuff damage. The nail, after accurate measurement of its length and proximal metaphysis enlargement up to 10 mm, was impacted into the narrow, cone-shaped, distal part of the humerus, without the necessity of distal screw interlocking. Passive motion of the shoulder joint was initiated from the 2nd postoperative day and active assisted exercises after the 2nd postoperative week.

Results: Mean follow up period was 27 months. Solid callus formation was noted in all fractures, between the 14th and 18th postoperative week. No cases of intra-operative fractures, nerve irritation, rotational instability, nail migration and loss of distal impaction were noted. Mean Constant-Murley score was 93 points at the 16th postoperative week.

Conclusion: Antegrade intramedullary nailing is a reliable and beneficial procedure for the treatment of humeral shaft fractures, regarding union and functional recovery of the arm. The extra-articular entry point should be preferred to avoid rotator cuff and articular surfaces damage whereas the accurate measurement of the nail length and the firm impaction of it at the olecranon fossa makes distally interlocking unnecessary, decreasing significantly the overall operative time and the associated complications.

Aim: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing fixation

Methods: 52 patients (34 female, 18 male, mean age 49,5y) with displaced 4-part “valgus impacted” fractures of the proximal humerus, were operatively treated between 1993–2002. The average impaction angle was 42.4° and the lateral displacement of the humeral head between 1–7 mm. In situ, stable fixation of the tuberosities to each other, to the articular part of the humeral head and to the metaphysis at a level below the top of the head, was achieved with heavy non-absorbable sutures, avoiding reduction maneuvers and any use of hard material. Early passive motion with pendulum exercises was applied at the 2nd postoperative day, followed by active assisted exercises after the 6th postoperative week and final strengthening exercises after the 3rd postoperative month

Results: Long term results (mean follow up 5.6 years), were evaluated according to Constant-Murley Scoring System. 45 patients (86.5%) had very good result (Constant score > 80) without pain and satisfactory motion (up to 160° forward elevation, 60° to 80° external rotation and internal rotation up to T12). The incidence of avascular necrosis was 5.7 %. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossifications and 2 nonunions revised to hemi-arthroplasty and plate osteosynthesis respectively

Conclusions: Advantages of this minimally invasive technique are shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable fixation with tension band effect and adequate rotator cuff repair, allowing for early joint motion

Aim: A comparison of two different techniques of acro-mioclavicular joint reduction in complete AC disruption.

Methods: During 1992–2001, 59 patients (50 male; 9 female; average 32.3y), underwent surgical reconstruction for complete (Allman-Tossy III) AC dislocation. Fixation of the joint was achieved in all patients by double-banded coracoclavicular stabilization, using heavy nonabsorbable sutures in a double-banded ligamentous substitution manner. In 35 patients (group I) a temporary acromioclavicular fixation was done (with K-W, removable at 6th postoperative week), whereas in the rest 24 patients (group II) an additional fixation of the acromioclavicular disruption, with nonabsorbable sutures, without using K-W was performed.

Results: Mean follow-up period was 6.4 years. Our results according to Constant-Murley score were excellent or very good in 25 patients (71.4%) of group I and 21 (87.5%) patients of group II. Loss of reduction (3), calcification (5) and superficial pin infection (2) were noted with greater frequency in patients of group I. Three of them reoperated because of K-W migration or breakage. Complications of group II included 1 superficial infection, 1 calcification with restriction of joint motion and 1 case with slight loss of reduction.

Conclusions: Reduction of the acromioclavicular joint in association with adequate retention of the coracoclavicular joint are the cornerstones for a good surgical result. Double banded coracoclavicular fixation and acromio-clavicular repair with heavy nonabsorbable sutures and no use of K-W, seems to be the best surgical technique provided adequate stabilization of acromioclavicular joint, preservation of clavicular rotation, no risk of implant migration and no need of material removal.

Purpose: The evaluation of blood supply of the humeral head in displaced 4-part “valgus impacted” fractures with digital angiographic image processing.

Material-Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4o and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fixation of the fracture was achieved with in situ transosseous suturing fixation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any reduction maneuvers and use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation.

Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2) were about the same in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement.

Conclusions: Although the small number of cases, in situ transosseous suturing fixation of the 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement.

The purpose of this study is to evaluate the results of the treatment of displaced greater-tuberosity fractures by open reduction and stable fixation with heavy non absorbable sutures and early passive motion. Thirty-six patients, 21 male (average age 50 years) and 15 female (average age 62 years) underwent open reduction and internal fixation for a displaced greater-tuberosity fracture of the proximal humerus, between 1992–2000. Main indication for operative treatment was at least 1 cm displacement of the tuberosity. Reduction and stable fixation of the greater tuberosity with its rotator-cuff attachments, was performed by a lateral approach using heavy transosseous nonabsorbable sutures. Passive motion was started at the second postoperative day followed by active range of motion after the fifth postoperative week.

All patients were examined periodically using clinical and radiological criteria. All fractures were healed without any displacement within 3 months. Final assessment was performed according to Neer’s criteria for pain, motion, function, strength and patient’s satisfaction, in a mean follow-up period of 4 years. Twenty seven patients (75%) rated excellent, without pain, showing active forward elevation at 160 to 180°, external rotation at 60 to 80° and internal rotation up to tiq level. Nine patients (25%) rated very good, had only minor pain problems.

We conclude that, if displaced fractures of the greater tuberosity are not diagnosed and treated promptly, may result in limitation of motion and functional disability. To our experience open reduction and stable fixation with transosteal suturing, allowing early passive motion of the joint, gives excellent to very good final results.