We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs.

Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036).

The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Cite this article: Bone Joint J 2013;95-B:1673–80.

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries.

We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.

Introduction: One of the problems of high tibial valgus osteotomy is the loss of achieved correction, which, in turn, is associated with the deterioration of the patient’s symptoms.

Aim: The aim of the present retrospective study is the correlation of certain parameters of axial alignment of the knee joint with the possibility of varus recurrence, after high tibial osteotomy, with stable fixation.

Material – Method: For this purpose we studied 33 patients (37 knees), that had undergone high tibial osteotomy between 1989 and 1997. All the above patients had a follow up of at least 2 years, with a mean of 35 months. The axial parameters that were studied were the femoral condyle-femoral shaft angle, the tibial plateau-tibial shaft angle, the post operative valgus correction and the post operative medial joint space widening.

Results: Loss of femorotibial angle equal to or more than 3 degrees was regarded as recurrence. This was observed in 9 knees (24%). The possibility of recurrence was strongly associated (Logistic Regression Analysis), on the one hand, with a post operative valgus correction of less than 6 degrees, and, on the other hand, with a femoral condyle-femoral shaft angle of more than 84 degrees (varus orientation of the articular surface of femoral condyles).

Conclusion: It seems that both undercorrection of the femorotibial angle and varus orientation of the femoral condyles in the frontal plane do not allow the shift of the weight bearing axis of the lower extremity towards the lateral compartment and, thus, constitute risk factors for recurrence of the varus deformity.

Introduction: The results of high tibial osteotomy tend to deteriorate over time. Consequently, a certain percentage of these patients will ultimately undergo TKR for the symptomatic treatment of the osteoarthritis of their knees. High tibial osteotomy, on the other hand, produces anatomic alterations around ipsilateral knee joint, that might bring about technical difficulties during the performance of TKR procedure. One of these difficulties has to do with the alteration of relationship between tibial anatomic axis and ipsilateral plateau.

Aim: The radiographic evaluation of the alteration of the relative position of the tibial medullary canal with respect to the ipsilateral plateau, after high tibial, closed-wedge osteotomy, with stable fixation.

Material – Method: For this aim, we studied 49 knees (in 45 patients), that had undergone high tibial valgus osteotomy, between 1990 and 1997, in our Department. The relative change of tibial anatomic axis was determined by calculating the index of “tibial condylar offset” in the AP view of each knee during three follow up examinations done at the direct post operative period, three months post operatively and at least one year post operatively.

Results: There was a definite tendency of medialization of the tibial anatomic axis post operatively (and, consequently, of the tibial medullary canal) with respect to the centre of the ipsilateral plateau. This was in direct proportion to the degree of valgus correction. The mean percentage of post operative alteration of “tibial condylar offset”, in comparison to its preoperative value, was 19%.

Conclusions: The insertion of a stemmed tibial implant, in a knee that has previously undergone high tibial osteotomy, through the centre of the tibial plateau runs a certain risk of abutment on the lateral cortex, due to the medialization of the tibial medullary canal with respect to the centre of tibial plateau. The above observations show the importance of a thorough pre-op plan of every TKR procedure that has been preceded by high tibial osteotomy

Introduction: High tibial osteotomy is an established procedure for the mid-term treatment of unicompartmental osteoarthritis of the knee, especially in young patients. Nevertheless, its performance at the proximal end of the tibia, close to the site of insertion of the extensor mechanism of the knee, might produce anatomic alterations of the latter, which, in turn, could influence the final result.

Aim: The purpose of the present retrospective study is the radiologic evaluation of the anatomic changes of the extensor mechanism of the knee, caused by high tibial valgus osteotomy (closed-wedge step osteotomy, with internal fixation).

Material – Method: For this purpose we studied the X-rays of 44 kness (pre-op, p-op and 1 year p-op) that had undergone the above procedure. The assessed variables were the horizontal and vertical shift of tibial tubercle as well as the position of the patella (patellar vertical height, Linclau, Caton).

Results: We didn’t find any statistically significant difference of the postoperative position of the patella with respect to the preoperative one (p=0.88), whereas there was definite proximal and anterior shift of the tibial tubercle in a statistically significant degree (p< 0.01) with respect to the preoperative situation.

Conclusions: The certain type of high tibial osteotomy seems to impart an unloading effect on the patellofemoral joint (due to the anterior shift of the tibial tubercle). On the contrary, the vertical shift of the tibial tubercle seems to have no effect to the postoperative position of the patella.

Introduction: Modern nailing techniques are the gold standard in the treatment of multifragmentary fractures of femur. Nevertheless, the use of plate and screws, in accordance with the principles of biologic fixation, remains an effective alternative.

Aim: The purpose of this retrospective study is the evaluation of the results of biologic fixation, with plate and screws, of multifragmentary femoral fractures.

Material – Methods: Our material consists of 32 multifragmentary subtrochanteric and diaphyseal femoral fractures that were treated in our department, between 1992 and 2000, in accordance with the principles of biologic fixation with plates and screws. All fractures were reduced indirectly with traction on the fracture table without any direct manipulation at the comminution zone. Emphasis was given to the restoration of the proper length, axial and rotational alignment of each fracture. The exposure of the femur was done proximally and distally to the fracture site through two separate incisions of the vastus lateralis near its insertion to the linea aspera. There was no direct exposure of the comminution zone. The fixation was done with a long bridge plate, without the use of interfragmentary screws. No iliac bone graft was used in the primary procedures.

Results: Twenty nine of the fractures (91%) united, without serious complications, within 3–5 months. One fracture failed to unite and had to be operated upon with a new plate and screws and additional bone grafting. In another one, the plate was bent, due to early weight bearing, and had to be exchanged with a nail. The third fracture united in a mild varus position, as some of the screws were broken and the plate was mildly bent.

Conclusions: The bio-“logic” use of plate and screws in the treatment of multifragmentary fractures of femur gives excellent results, comparable with those of the modern nailing techniques.

Introduction: Heterotopic ossification around the tip of intramedullary nail is a well-known complication of the nailing technique, since the time of Kuntscher. Nevertheless, little attention has been given to it in the current literature.

Aim: The evaluation of the incidence, clinical significance and possible risk factors of this complication after intramedullary nailing of femur with reaming.

Material – Method: For this purpose we studied the X-rays and medical charts of 30 patients who had undergone the above procedure at the Orthopaedic Departments of both Institutions mentioned above, between 2000 and 2002. The preoperative diagnoses were diaphyseal fracture: 13 patients, subtrochanteric fracture: 7 patients, refracture of femur: 1 patient, non-union: 5 patients, imminent fracture (due to intraosseous lesion): 2 patients, failure of previous fixation: 2 patients. In 18 cases the G.K. nail was used, whereas, in the remaining twelve, the long gamma nail was used. The patients’ follow-up ranged from 6 to 18 months (mean: 11 months). The presence of heterotopic bone around the proximal tip of the nail was graded according to the grading system of Brumback et al.

Results: In 12 patients (40%) there was no development of heterotopic bone around the proximal tip of the nail. In 14 patients (47%) minimal and moderate grade of heterotopic ossification was developed (grade I and II). Finally, in 4 patients (13%) there was significant heterotopic bone formation (grade III). None of the above patients presented with any significant limitation of ipsilateral hip joint motion. There was no correlation between type of fracture, type of nail fixation, presence of concomitant injuries, nail prominence above the tip of greater trochanter and the formation of heterotopic bone. The only positive correlation was between male sex and the presence of heterotopic ossification.

Conclusion: Heterotopic ossification of minimal and moderate grade is a common complication of the technique of intramedullary nailing of femur, without any further clinical significance. The formation of heterotopic bone of significant degree in the hip region, though it does not results in serious clinical problems for the patient, it will surely make future extraction of the nail difficult.

Purpose: The aim of this study is the evaluation of the use of plate and screws without restoration of the opposite cortex and without the use of bone graft in the treatment of multifragmentary fractures of femur.

Material and Methods: For this purpose, we retrospectively studied 26 multifragmentary femoral fractures that were treated in our department in accordance with the above principles, between 1992 and 2001. All fractures were reduced indirectly with traction on the fracture table without any direct manipulation at the comminution zone. Emphasis was given to the restoration of the proper length, axial and rotational alignment of each fracture. The fixation was done with a long bridge plate, without the use of interfragmentary screws.

Twenty five of the fractures (96.5%) united, without any serious complication, within 3–5 months. In one fracture the fixation failed and had to be revised.

Conclusions: The use of plate and screws in the treatment of multifragmentary fractures of femur, once it is done with complete respect to the fracture biology leads to speedy fracture union, high union rate and a very low complication rate.

Introduction: High tibial osteotomy is an established procedure for the mid-term treatment of unicompartmental osteoarthritis of the knee. Nevertheless, it produces anatomic alterations of the proximal part of tibia, which might affect the later performance of TKR. These anatomic changes are basically patella infera and medialization of the tibial medullary canal with respect to the tibial plateau (tibial condilar offset).

Material and Method: The purpose of the present retrospective study is the evaluation of the above mentioned anatomic changes, caused by high tibial valgus osteotomy (Mittelmeier’s technique). For this purpose we studied the X-rays of 44 kness (pre-op, p-op and 1 year p-op) that had under gone the above procedure.

Results: We didn’t find any statistically significant difference of the postoperative position of the patella with respect to the preoperative one, whereas there was definite medialization of the tibial anatomic axis with respect to the preoperative situation. The latter change was directly correlated with the degree of valgus correction. The mean change of the tibial anatomic axis (as estimated by the value of the tibial condylar offset ratio) was 15%.

Conclusions: Although Mittelmeier’s high tibial valgus osteotomy does not cause any significant alteration of the position of the patella, it does alter the relationship of the tibial medullary canal with respect to the tibial plateau in direct correlation with the degree of valgus correction. Thus, the performance of TKR after proximal tibial osteotomy necessitates a thorough preoperative plan and the selection of the appropriate implant.