Introduction

Throughout the years treatment of patellar fractures have been held in much controversy and various treatment procedures have been described. In the literature, there are only a few studies that compare the results of the different treatment modalities.

INTRODUCTION

In recent years the age of world's population has risen and with it there has been a significant increase in the frequency of hip fractures in the elderly. These fractures are known to increase morbidity and mortality. However, little is known about the frequency and characteristics of patients who sustain a second hip fracture. We examined the incidence and the underlying associated medical disorders of patients with a second fracture in the other hip.

Introduction: There is still controversy regarding which method of internal fixation of intraarticular hip fracture is ideal. The purpose of this study was to evaluate the outcome and complications following the fixation of such fractures with cannulated cancellous screws with two different types of triangular configurations of these screws: one superior and two inferior and vice versa.

Methods: Between January 2006 and December 2008, one hundred and twelve femoral neck fractures in 125 patients (mean age of 67 years) were treated by closed reduction and internal fixation (CRIF) by titanium cannulated screws, using alternately these configuration types of fixation. Twelve patients were lost to follow-up. Ninety-eight fractures in 93 patients were followed to union or revision surgery, with a mean duration of follow-up of twenty one months. There were 52 Garden I fractures, 34 Garden II fractures and 12 Garden III and IV fractures. Fifty-one were treated with standard configuration of 2 inferior and one superior screws (group 1), while 47 were treated with reverse placement (group 2). There was no statistic difference regarding age, sex and Garden’s classification between the two groups. The quality of reduction, accuracy of implant placement and rates of nonunion and osteonecrosis were evaluated.

Results: 83/98 fractures (85%) had at follow-up good-to-excellent reduction and fifteen (15%) had a fair or poor reduction. There was a nonunion of seven fractures (7 %) and avascular necrosis of the femoral head (AVN) in five (5%). There were no deep infections. Seventy one patients (83%) had a good functional outcome (as compared to 85/93 Pts- 91% – prior to fractures). Six patients (four with nonunion and two with avascular necrosis) went through revision surgery (THR). There was no difference in the quality of reduction, number of nonunion and AVN and functional outcome between both groups of fixation. There was a difference in the outcome which depended on the Garden type of fraction and the accuracy of reduction. Most complications were observed in Garden’s III and IV fractures with inaccurate reduction.

Conclusions: Excellent reduction and accurate implant placement is the main reason for a good outcome after close reduction and internal fixation of intraarticular hip fractures. We didn’t find any difference in the outcome following fixation in two different configurations of the screws.

Introduction: Treatment of proximal humeral fractures is still controversial. Conservative treatment may result in malunion and shoulder stiffness. We present our experience with displaced or comminuted fractures of the proximal humerus treated by closed or open “minimal invasive osteosynthesis” or by open reduction and using of fixed plates or by hemiarthroplasty.

Patients and Methods: This study consists of 189 Pts. (18–89 year old, mean 58.5Y) followed for 2–10 years (mean 5.5Y), treated by closed reduction and percutaneous pinning (79), ORIF and minimal osteosynthesis (27), ORIF with rigid plates (17), ORIF by LCP plates (10), ORIF by proximal humeral nail (5) or by hemiarthroplasty (51). Patients were evaluated by the UCLH and by Constant’s shoulder grading score systems and radiographs.

Results: Overall results were excellent and good in 85% of patients with 2 and 3 parts fractures of the proximal humerus treated by “minimal osteosynthesis” techniques, with some better results in less comminuted fractures. 26/32 Pts with 4 part fractures treated surgically had good functional results. The other 8 had poor results and 4 of them developed AVN of the humeral head. 75% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but had only a moderate improvement in shoulder motion (active abduction or flexion of 30–90 degrees in 38/51).

Conclusions: “Minimal osteosynthesis” by K.W. techniques, lag screws, rush pins or proximal humeral nail, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture. ORIF by conventional plates may be used in young patients and by LCP (locked compression plates) in osteoporotic or comminuted fractures of older patients. In the elderly, hemiarthroplasty seems to be the treatment of choice.

Introduction: Various surgical methods have been described to manage the problem of recurrent anterior dislocation of the shoulder. Older procedures Putti-Platt’s, Magnuson-Stack’s or Bristow;’s and Boytchev’s repair are not used today due to a high percentage of failure of 7%–17% incidence of recurrence associated with limited ROM. However, in the last decade the goal of treatment has changed. It is directed now towards restoration of normal function with full ROM of the affected shoulder, based mainly on arthroscopic stabilization or on “open” Neer’s capsular shift procedures combined with Bankart’s repair. However, during the last few years there are more and more papers dealing with a surprising unexpected high number of patients with shoulder instability following arthroscopic repair. The purpose of this study is to review the long term results of “open” Neer’s capsular shift procedure

Materials & Methods: This is a presentation of 87 (78M; 9F) consecutive patients, 19 to 47 year old (mean 23 Y) with a length of follow-up of 4Y–15Y (mean 6Y). 45 of them with traumatic recurrent anterior dislocation of the shoulder had a capsular shift procedure according to Rockwood’s modification. In 42 other patients that had a multidirectional instability with proved dislocations of the affected shoulder a Protzman’s modified capsular shift procedure was used.

Results: 82/87 patients had a stable shoulder without recurrent dislocation. 3 patients had an episode of traumatic shoulder dislocation within 2 months following operation. Two other patients of 42 with multidirectional instability had a recurrence of traumatic dislocation. One patient developed partial brachial plexus injury, most probably due to traction of the affected limb following operation. 78/87 had at follow-up normal shoulder function with full ROM, and the remaining 9 patients had only a slight limitation in shoulder abduction and in external rotation.

Conclusions: Based on this study, it is suggested that capsular shift procedure is an excellent method for repair of recurrent anterior shoulder dislocation, preferable to the “older” procedures, and allows restoration of shoulder stability with better functional results. This is suitable mainly for patients with structural hyperlaxity and multidirectional instability, whereas arthroscopic stabilization might be used in patients with true traumatic instability.

Introduction: Meniscal tears are common in young athletes, usually result from a twisting injury during sport and may occur in the anterior or posterior horns. Injured menisci may be treated arthroscopically by excision of the torn fragments. However, in patients with peripheral meniscal detachment, located at the “vascular zone”, operative repair is feasible and usually successful. Meniscal repair may be done by open direct suture of peripheral tears or by arthroscopic techniques as “Outside-In”, “Inside-Out” or “All-Inside”. We present our experience with arthroscopic suture of completely detached menisci.

Patients & Methods: This study consisted of 33 male patients (14-48Y; mean 25Y; Follow-up: 2-6Y; mean 3.5Y). Inside-Out technique was used in 31 patients and Outside-In technique in two patients. 16/33 patients had detachment of the peripheral half of the meniscus (14-medial; 2-lateral); 13/33 patients had peripheral detachment of almost two thirds of meniscus (10-medial; 3-lateral) and 4/33 patients had detachment of one third of the meniscus (3-lateral; 1-medial injuries; all combined with fractures of the tibial plateau). 15 patients with medial meniscus detachment had complete (5 Pts) or partial (10 Pts) tear of ACL. Two other patients with medial meniscus detachment had associated small radial tears of the affected meniscus. Two of the patients with complete ACL tear had later been operated upon for reconstruction of ACL. Results were assessed by the Knee Society Knee score and by Lysholm Scoring Scale.

Results: 25/33 patients (76%) had good and excellent results. Four of them developed re-tear and detachment of medial meniscus during other later additional sport injuries, usually between 1–2 years following initial treatment. Four other patients had a “second” arthroscopic look 1–2 years later following another sport twisting injury and in all of them a stable peripheral attachment of the sutured menisci was observed. Results were better in patients who had ACL reconstruction a few months following meniscal repair. 5 patients had fair results (15%) and 3 patients had poor results (9%).

Conclusions: Based on this study it is suggested that meniscal suturing for peripheral tears is a satisfactory procedure. Meniscal tears suitable for repairs are those within the vascular zones (the outer third of the menis-cus), unstable on probing, are longer than 7mm and without major surgical damaging. Tears of posterior segments are the most difficult to suture and often require open arthrotomy. ACL reconstruction combined with meniscal repair appears to increase the healing rate of the meniscus. There are also adjuvant techniques for meniscal repair such as: fibrin clot or laser (both are weaker than suture alone) and adhesives. However, there is still not enough data.

Purpose: A retrospective study was performed in order to evaluate the results of fixation of displaced unstable fractures of both bones of the forearm in children by intramedullary pins.

Materials and methods: During the last fifteen years 121 children with displaced midshaft fractures of the forearm were treated by open or closed reduction and smooth intramedullary pin fixation. The age range was 5–16 years, the mean 11 years. Seventy five children (62%) were operated upon primarily because of an irreducible fracture, and the remaining 46 (38%) were operated upon within two weeks after failed closed reduction. The arm was then immobilized in a plaster cast extending above the elbow. The average time for fracture healing and cast removal was 8 weeks. Afterwards the children were encouraged to move the elbow and wrist joints. The hardware was removed following a period of between 6 weeks to 5 years (average 5.5 months), under sedation or general anesthesia.

Results: Follow up was available in 91 of the 121 children for between 6 months to 15 years (mean 5.5 years). Using the grading scheme of Price, functional results at follow up were excellent in 79/91 patients (87%) and good in 12/91 children (13%). There were no fair or poor results. Of them, in 80 cases (88%), within one year from injury, a full range of movement was obtained in the elbow and wrist joints. 11 patients (12%) had an average loss of 10 degree of supination. In two cases there was a neuropraxia of interosseous nerves which disappeared spontaneously within 3 months. In one patient, a 16 year old boy, there was a delayed union of 6 months until solid healing. 4 patients had a mild degree of angulation of the distal third of the forearm. There were no incidences of deep infection, nonunion or damage to the epiphyseal plate.

Conclusion: In conclusion we found that smooth intra-medullary pinning for displaced midshaft fractures of the forearm in children is a good, simple and safe method.

Purpose: Biomechanical studies have shown that fixation by two lateral pins of supracondylar fractures in children provide less stability than crossed pin fixation from lateral and medial sides. However, closed percutaneous medial pin fixation may be associated with ulnar nerve injury. Soft tissue edema or excessive mobility of ulnar nerve may be predisposing factors for iatrogenic ulnar nerve injury. We present our experience with the use of nerve stimulator in preventing such complications during surgery.

Material and Methods: During the last two years 22 children with supracondylar fractures (20- extension type; 2- flexion type) underwent surgery by closed reduction and percutaneous crossed KW fixation. The average age was 5.3 years (range 3–9 years). Detection of the ulnar nerve location was made possible by continuous intraoperative use of nerve stimulator, connected to the medial pin during its insertion. In 4/22 Pts irritation of ulnar nerve during pin insertion was observed by the appearance of clear contractions of forearm and hand muscles, and therefore, the location of the medial pin was immediately changed.

Results: In all cases anatomic reduction was achieved. No cases of nerve or vascular injury were observed. No cases of secondary fracture displacement were noted.

Conclusions: Based on this study it seems that the use of intraoperative nerve stimulator, during percutaneous crossed pin fixation of supracondylar fractures in children, may assist in localizing the nerve and prevent its injury during medial pin insertion. Changes in original setting of the standard anesthesiology nerve stimulator may be performed easily in order to allow such monitoring. The use of nerve stimulator during such procedures is very simple, even in cases of emergency. Monitoring of ulnar nerve by nerve stimulator is reliable and enables safe pin placement, decreasing the risk of nerve injury.

Aims: A retrospective study was performed in order to evaluate the results of þxation of displaced unstable fractures of both bones of the forearm in children by intramedullary pins. Methods: 121 children (5–16 year old; mean 11 years) with unstable displaced midshaft fractures of the forearm were treated by smooth intra-medullary pin þxation. 75 (62%) were operated upon primarily because of an irreducible fracture. 46 (38%) were operated upon within 2 weeks after failed closed reduction. The arm was immobilized in a plaster cast extending above the elbow for about 6 weeks. Pins were removed between 6 weeks to 5 years (average 5.5 months). Results: Follow up (1Ð15 years; mean 5.5 years) was available in 91/121 children. Using the grading scheme of Price, functional results at follow up were excellent in 79/91 (87%) and good in 12/91 (13%). There were no fair or poor results. 80 Pts (88%) had within one year a full range of movement of the elbow and wrist joints. 11 Pts (12%) had an average loss of 10 degree of supination. 4 Pts. had a mild degree of angulation of the distal third of the forearm. 2 Pts had a temporary neuro-praxia of the interosseous nerves. 2 Pts had re-fractures following early removal of pins. There was one case of non union treated successfully by plating. One of the patients had a delayed union of 6 months until solid healing. One had a deep wound infection. There were no other complications. Conclusions: In conclusion we found that smooth intramedullary pinning for displaced midshaft fractures of the forearm in children is a good, simple and safe method.