This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears.

In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001).

It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign.

Intra-articular shoulder pathology has been recognised in more detail following widespread use of shoulder arthroscopy. The purpose of this epidemiological study is to present the incidence and exact type of SLAP lesions in our operated population and to correlate them with the presence of other shoulder lesions.

Between 2004 and 2010 425 patients underwent shoulder arthroscopy in our department (311 for rotator cuff tears or subacromial impingement, 102 for shoulder instability, 12 for SLAP lesions). Eighty-two SLAP lesions (19.2% overall) were recognized during these procedures.

In 44 cases the lesion was SLAP type I (53.6%), in 10 type II (12.2%), in 1 type III (1.2%), in 1 type IV (1.2%), in 24 type V (29.26%) and finally in 2 type VI (2.43%). In more detail SLAP I lesions were associated in 8 patients with subacromial impingement syndrome, in 33 with RC tear and in 3 patients with anterior instability. Type II, III and IV were preoperatively diagnosed, while type V and VI lesions were found in patients with chronic anterior shoulder instability.

SLAP lesions are diagnosed more accurately during shoulder arthroscopy rather than with plain shoulder MRI scan. In our study population only 12 cases were accurately diagnosed with a pre-operative MRI scan, while the remaining 70 cases were missed. Additionally, there was significant correlation between rotator cuff problems and SLAP I lesions, while chronic shoulder instability was associated with SLAP V and VI (25.4% of patients with instability).

Shoulder arthroscopy not only has changed SLAP lesion diagnosis and treatment but also reveals the correlation of various SLAP lesion types with specific shoulder pathologies.

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.

Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.

Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.

Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively.

Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy.

Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears.

On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis).

Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients.

The use of a Shoulder Hemiarthroplasty for the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) is the subject of this study.

71 patients with 71 Proximal Humerus Fractures were treated with this method. Four were exluded from the study (they did not match the follow-up criteria). From the remaining 67, 60 were women and 7 men, aging from 38 to 96 years (average 67.13 year, S.D. 14,769s). Of these patients 22 were Neer 3 (1 with a dislocation) and 45 were Neer 4 (17 with a dislocation). There were 4 cases of a failed ORIF and in 8 cases the operation followed failed conservative treatment (2 non-unions and 6 AVN). Time between fracture and surgery ranged from 1 to 5 days in 54 cases, while in the rest it exceeded 8 weeks. The fracture classification was performed with the use of 3 plain X-rays (AP, Lateral and Axillary views) and the results were evaluated using the Constant Score. The mean follow-up was 55.75 months (range 36 to 105). The average Constant Score was 67.4 (S.D. 14.3). There were no significant statistical differences regarding sex and age in respect to the Constant Score (t 65 =.243, p =.81), range of motion (t 65 =.048, p =.96), strength (t 65 =.741, p =.46), activities of daily living (t 65 =.030, p =.97) and pain relief (χ2 [1] =.001, p =.98). On the other hand the group of patients with the higher pain relief scores presented higher Constant Score values and better shoulder joint function in respect to the group which presented lower pain relief scores.

In conclusion the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) with the use of a Shoulder Hemiarthroplasty is a good treatment method offering substantial pain relief, functional improvement of the joint leading to a faster rehabilitation in the majority of patients, regardless age and sex.

Purpose: The evaluation of the results of the interlocking intramedullary nailing in the treatment of open and closed femoral and tibial fractures.

Material-Methods: During the decade 1996–2005, 408 patients with 429 femoral and tibial shaft fractures were treated with interlocking intramedullary nailing. All the nails inserted after reaming. From the 182 femoral fractures, there were 155 closed,

10 open, 9 pathological fractures and 8 non-unions. Accordingly, from a total of 247 tibial fractures, 190 were closed, 27 were open and there were also 30 non-unions. The average age was 37 years. The patients were assessed clinically and radiologically according to a specific protocol. Follow-up 1–9 years (average of 4, 4 years).

Results: There were 291 men (71%) and 117 women (29%). The mechanism of injury was a car or motor-vehicle accident in 210 cases, fall from a height in 134, direct force injury in 73 and labor accident in 12 cases. The average period of hospitalization was 5, 2 days. The average time to union was 3, 3 months and it was longer in open than the closed fractures. The percentage of union in all the cases was 96%.

Conclusion: Reamed interlocking intramedullary nails have been associated with higher union rates and lower union time without increasing complications in either closed or open fractures These advantages support their application in the treatment of all the closed and most of the open femoral and tibial shaft fractures.

Purpose: To evaluate the functional outcome following internal fixation of bicondylar distal humerus fractures (AO type C) using the ACUMED modified titanium plates.

Material-Methods: Fourteen patients (9 male, 5 female) aging 18 to 78 years (av. 54 y.) with bicondylar distal humerus fractures, between September 2002 and May 2004, were included in our study. All of them underwent open reduction and internal fixation. The articular surface was reduced through a transolecranic approach using one or two compression screws and the fractures was then fixated using the modified titanium ACUMED plates.

Results: Postoperative follow-up ranged from 6 to 24 months (av. 12 m.). The results were evaluated using the Mayo Clinic Score. The mean range of elbow flexion-extension was 115o. Nine patients had an excellent/good result, 3 had affair and 2 a poor result. One patient underwent a second procedure for symptomatic metalwork. In one case there was soft tissue infection that resolved successfully with antibiotic administration.

Conclusion: The internal fixation of bicondylar AO (type C) distal humerus fractures with the ACUMED plates through a transolecranic approach is an extensive but atraumatic operation that offers excellent reduction and a stable osteosynthesis leading to a good functional outcome.

Aim: In this study we present the results of the management of muskoloskeletal injuries accompanied by rupture of a main arterial vessel, focusing on the priorities in salvaging the affected limp.

Material – methods: In a period of 5 years (Sep.1999– Sep 2004), 24 patients having sustained multiple injuries were admitted with signs of poor vascularization distally to the lesion. 19 were male and 5 female, their ages ranging from 16 to 49 years (av. 28 years). The musculoskeletal injuries were: open III C humeral fracture in 2 patients, open III C femoral fractures 4, open III C tibial shaft fractures 10, knee joint dislocations 8 patients. All patients had a preoperative angiography in order to assess the severity of the vascular lesion. Immediate stabilization of the fracture with an external fixation system was performed, followed by restoration of the vascular injury by means of a by-pass, end-to-end suture or interposition of a “stent”.

Results: Postoperative follow-up ranged from 6 to 54 months (mean 34 mon.). Amputation was performed in 4 patients due to failure of the revascularization procedure 2 weeks postoperatively. External fixation was maintained as a final method of treatment in 7 cases, while in 13 cases we exchanged it to intramedullary nailing. In the 8 cases of knee dislocation, ligament reconstruction was imperative. Eventually 20 limps were salvage with a satisfactory functional outcome.

Conclusion: In polytrauma patients with both musculoskeletal and vascular injuries the immediate application of an external fixator represents a precausative for a successful vascular operation. Exchanging the external fixation system to interlocking intramedullary nailing accelerates the healing process.

Aim: Although several surgical procedures have been proposed for advancedstage Kienböck’s disease, it still remains a difficult therapeutic problem. This study documents the clinical, radiographic and MRI outcomes of ten patients, who underwent lateral closing wedge osteotomy of the distal radius by the same surgeon, after MRI confirmation of advanced Kienböck’s disease. Methods: Ten patients (6 men and 4 women) with a mean age of 28,7 years (range 21–66) were included in this study. Seven had Lichtman stage III-B and three stage IV disease. The lateral closing wedge osteotomy was performed at the distal metaphysis of the radius through a palmar approach and was fixed with a 3,5mm titanium T-plate. The average follow up period was 52 months (range 36–60 months). Results: Substantial pain relief, increase in grip strength and range of wrist flexion and extension were achieved. Clinical results were excellent in two patients, good in five, fair in two patients and poor in one patient according to Nakamura’s postoperative scoring system. Gadolinium enhanced MRI at the latest follow up revealed signs of revascularization of the lunate in 6 cases. Conclusions: Lateral closing osteotomy decreases radial inclination and pressure at the radiolunate joint, thus improving lunate coverage. It is a reliable extra-articular procedure for advanced Kienbock’s disease that provides pain relief while there is evidence that it may improve lunate vascularization.

Aims: The purpose of our study is to evaluate the results of the treatment of unstable upper humerus fractures with the implantation of the Plant-Tan Plate which is a combination of an internal fixator with a neutralization plate. Methods: In a period of 17 months (January2001–May2002), 10 fractures in 10 patients (7female – 3 male) were treated. Their ages ranged from 45 to 75 years (mean 67.8 years). Patients with unstable fractures (two to four according to Neer’s classification are include in the study. The Plant-Tan Plate was used. Two head screws were placed in all fractures. The follow-up ranged from 4 to 21 months (mean 14.5months). The ASES scoring system was used to evaluate the results. Results: All our patients achieved clinical and radiological union of the fractures in a period of 4 months. The average cumulative score of activities of daily living of ASES Scoring System was 23 out of 30 (76.66%). One superficial wound infection occurred which was resolved with the administration of antibiotics. Conclusions: The Plant-Tan Plate rapresents a new, promising method of internal fixation for fractures of the proximal humerus, which offers anatomical reduction and a stable osteosynthesis (provding angular and rotational stability), so that an early rehabilitation program can be instituted.

Background: The purpose of this study was to evaluate the mid and long-term results of the open repair of the rotator cuff tears in patients where pain of the shoulder was the primary and function the secondary consideration.

Material – Method: the study includes 48 patients, out of a total 64, operated on during the period 1985–2001 for full-thickness massive tears of the rotator cuff. The average age was fifty-two years. In all but six the main symptom was persistent pain resulting from a chronic tear. This group had clinical evidence of a rotator cuff defect in the form of weakness and limited range of active motion. The six additional patients suffered from acute tears following trauma and were led to early surgical repair. Their characteristic sign was extensive limitation of active motion, whereas the passive movements were near normal. The operation performed was the anterior acromioplasty with cuff repair through an anterosuperior incision. Several techniques were employed to advance the retracted tendons to their insertions, in the large and massive chronic tears. No patient had transfer of the latissimus dorsi tendon to bridge the gap in the rotator cuff.

Results: The clinical evaluation according to the rating system of UCLA showed 36 excellent, 9 good and 3 fair results. There was no poor result after an average follow-up 7,4 years.

Conclusions: The present series indicates that reconstruction of a torn rotator cuff can be successful in the majority of patients. Careful preoperative evaluation and planning is of great value in arranging the surgical technique. In large and massive chronic tears the retracted infl exible muscles do not allow easy advancement of their tendons in order to be securely fixed to the greater tubercle. Therefore the surgeon should be familiar with special techniques to achieve a so-called watertight repair, which is necessary for a long-lasting good result.

Aim: The purpose of our study is to evaluate the results of interlocking intramedullary nailing for femoral shaft fractures giving special attention in the number of the distal bolts.

Materials – methods: In a period of 3.5 years (6/1999 – 12/2002), 74 patients with femoral shaft fractures were treated with the Russell – Taylor interlocking intramedullary nailing. 46 were male and 28 female; their ages ranging from 16 to 79 years (mean 37.5years). According to the A.O. Classification 21 were type A, 25 type B and 29 type C. The Russell-Taylor Nail was used. Reaming was performed in all cases. The distal bolts were inserted using the “FREE-HAND” technique. One screw was inserted in 44 cases and two in 30 in a random manner.

Results: No postoperative complications occurred. Follow-up ranged from 6 to 36 months (mean 18 months). In the cases where two distal bolts were inserted the fractures united in a period of 4 to 6 months (average 4.8 m.), while these where one screw was placed healed in a period of 4 to 10 months (average 6.5 m.).

Conclusion: The Russell-Taylor interlocking itramedullary nail is an efficient method of treatment for femoral shaft fractures. The insertion of two distal screws offers additional stability, which accelerates the healing process and is advocated for all femoral shaft fractures.

Humeral diaphysis fractures consist a rather frequent injury. The aim of our study is to evaluate the results of the treatment of humeral diaphysis fractures with the use of an interlocking intramedullary nail.

During the period March 1999 – December 2001, 25 intramedullary nailings were performed in 24 patients with a humeral fracture (16 women and 8 men), aged 26–81 years (Average: 57.1 years) using a Russell-Taylor humeral nail. There were 16 cases of acute humeral fractures, 3 cases of pathologic fractures, and 6 cases of delayed union or non-union. Follow-up ranged from 6 to 36 months (Average: 20 months). Fracture union was recorded, and the results were evaluated according to the scoring system of Neer.

No immediate postoperative complications were recorded. The final result was excellent in 9 cases (36%), good in 12 (48%), unsatisfactory in 3 (12%), while there was one failure (4%), where a reoperation was required. Fracture union was achieved within 4 months in 21 cases (84%), while 2 cases of delayed union and 2 non-unions were recorded.

Interlocking intramedullary nailing offers a dependable solution in the treatment of humeral diaphysis fractures, providing a very satisfactory functional outcome and a high union rate. It offers an excellent option in the treatment of pathologic fractures of the humerus, as well as in severely comminuted fractures and humeral fractures in polytrauma patients.