Ankle fractures are among the most common injuries treated by orthopaedic surgeons, and surgical treatment is often required to optimise the results. This retrospective study was undertaken to assess the effectiveness of the TRIMED ankle fixation system in the treatment of malleolar fractures.

During the last ten months, fifteen patients with an average age of 63 years underwent open reduction and internal fixation of a bimalleolar ankle fracture with the TRIMED fixation system. A standart surgical approach was used for both the medial and lateral malleolus. Regarding the lateral malleolus, a TRIMED Sidewinter plate which requires no additional interfragmentary screw was applied. Based on the morphology of the fracture of the medial malleolus, either interfragmentary screws or the sled- like medial malleolus fixation system was applied. One patient underwent in addition open reduction and internal fixation of the posterior malleolus.

All fractures proceeded to uncomplicated union in an average healing time of 6 weeks. Excellent functional restoration of the ankle joint, comparable to the ipsilateral ankle, was achieved.

The TRIMED ankle fixation system represents a good alternative method in malleolar fracture fixation which simplifies the fracture reduction and obliterates the need for a lag screw, thus preserving the biology of the fracture site. Furthermore, it can be used for the reconstruction of distal fractures of the lateral malleolus. However, further long-term studies are recommended to evaluate the success of the TRIMED fixation system.

Chronic distal biceps tendon rupture is a relatively uncommon situation with difficulties in treatment. Surgical treatment with allograft has been described in the literature with varying results. The purpose of this study was to describe 9 cases of chronic distal biceps tendon rupture which have been treated in our unit with local soft tissue as a graft.

All patients were male with an average age of 54 years. The mean interval between tendon rupture and reconstruction was 11 months. In all patients a flap from lacertus fibrosus was used in continuation with the remnants of the tendon. The flap was entubulated and advanced to the bicipital tuberocity. The biceps was released and mobilized as necessary. In addition, 3 patients underwent a fractional lengthening of the muscle. All procedures were performed through a single anterior approach. Anchors and anchor sutures were used to stabilize the tendon to the tuberocity.

The mean follow up was 3 years. No complications were encountered except for a superficial infection which resolved with oral antibiotics. All patients returned to their previous occupation. Furthermore, they all achieved 5/5 muscle strength regarding flexion and supination on manual testing. According to the Mayo Elbow performance score, the results were excellent in 8 patients, and fair in one.

We believe that the aforementioned technique is useful in treating chronic biceps ruptures. It requires no additional cost and also the risk, even if marginal, of transmitting diseases with allografts, such Achilles tendon is avoided. Furthermore, the possibility of rerupture is minimal compared to the techniques using allograft or free autografts, since a revascularisation process during which the risk for failure is high does not take place as in other types of allografts.

Elbow contracture is a well recognised sequel of neuromuscular disorders and can be a rather debilitating condition. Non operative treatment, such as physiotherapy and splinting, results in an improved range of motion, but since musculoskeletal pathology in neuromuscular diseases is progressive, an open surgical release of the elbow is often required. Therefore, the purpose of the present study was to assess the results of surgical treatment of elbow stiffness in patients suffering from neuromuscular disorders.

Between January 2000 and October 2008, 11 patients with neuromuscular diseases underwent surgical treatment of elbow contracture. The mean age of the patients was 21 years. Eight patients had cerebral palsy, 2 arthrogryposis and 1 brachial plexus palsy. Pre-operatively the lag of elbow flexion and extension was 45° and 38° respectively. In 6 patients releases were performed through a lateral approach, while 3 required an additional medial incision. In 2 patients the pathology was addressed through a posterior approach.

The mean follow up was 26 months. Postoperatively one patient developed skin necrosis which was treated conservatively. Furthermore, another patient developed transient ulnar neuritis, and finally one more presented with medial collateral ligament insufficiency. All patients had an improved functional arc of motion. Namely, the lag of elbow flexion and extension was reduced to 22° and 10° respectively. At the final follow up the patients maintained 90% of the range of motion that was achieved immediately postoperatively.

Open release of the elbow contracture in neuromuscular diseases yield satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion.

Forefoot involvement in rheumatoid arthritis (RA) is extremely common and the majority of the patients with RA have active foot symptoms and signs of the disease. This rertospective study was undertaken to assess the outcomes and complications in the surgery of the forefoot RA.

Seventeen patients (27 feet) with RA underwent surgical correction for the forefoot deformities. Antero-posterior and lateral weight bearing radiographs of all feet were taken preoperatively. The forefoot deformities seen with RA varied and included hallux valgus with subluxed metatarsophalangeal (MTP) joint in 23 feet, hallux valgus with dislocation of the MTP in 4, hammer or claw toes in 12 and 8 feet respectively. In addition, all 27 feet presented with variable levels of intermetatarsal deviations or widening. All the patients with hallux valgus underwent first MTP joint arthrodesis with various techniques. Deformities of the lesser toes were treated in all but 3 cases with resection arthroplasty, while the remaining 3 feet received a Weil osteotomy. Postoperatively the toes and the MTP joints were stabilised with K-wires for 6–8 weeks.

All patients have been studied for a minimum follow up of 9 months. Twenty six patients were satisfied by the outcome of the surgical treatment. Only one patient complained of persistent metatarsalgia postoperatively. The surgical complications included 2 cases of delayed union, 5 cases of delayed wound healing, 2 cases of wound infection, and 4 cases of plantar callosity. Overall, 4 patients required reoperation.

Even though complications occur in patients with RA who undergo surgical correction of the forefoot deformities, most of these complications can be treated successfully. Thus, the overall outcome of the surgical treatment is good leading to satisfactory correction of the forefoot deformities and to pain elimination

Simultaneous compression of the median and ulnar nerve at the elbow is rather uncommon. The aim of this study was to describe 10 such cases which have been treated in our unit.

The patients presented with a combination of ulnar neuritis symptoms at the elbow with a pronator syndrome. Five patients were female and 5 male with an average age of 33 years. All patients were manual workers. Regarding the cubital tunnel syndrome, all patients complained for hypesthesia in the ulnar nerve’s distribution in the hand and 6 for additional night pain in the medial aspect of the elbow. Regarding the pronator syndrome, the patients complained for mild tenderness or pain at the proximal forearm as well as hypesthesia or paresthesias at the digits. Nerve conduction studies were positive only for the ulnar nerve compression neuropathy. Six patients were treated by decompressing both nerves at the same time through the same medial incision, creating large medial flaps. The ulnar nerve underwent a simple decompression. In one case that the symptoms were initailly attributed to ulnar nerve, a second operation for medial nerve decompression was required.

In all patients symptoms subsided following surgical decompression. Four patients developed an ugly scar and 2 a hematoma. All returned to their previous occupation. Clinical tests and nerve conduction studies were performed postoperatively to evaluate the results; all of them turned out negative for ulnar and median nerve compression neuropathy.

Simultaneous compression of the median and ulnar nerve at the elbow is rather rare. Careful evaluation of the patient’s symptoms as well as thorough clinical examination are the keystones for the correct diagnosis. Although decompression can be performed through the same medial incision, extensive dissection may be required.

Hinged external fixators of the elbow joint can be a valuable tool in managing complicated trauma associated with instability, instability after contracture release, and distraction interposition arthroplasty or distraction arthroplasty alone. This retrospective study focuses on the performance of the device in acute and chronic elbow instability associated with complex injuries around the elbow.

Thirteen hinged external fixators were applied in 13 patients with an average age of 46 years. All fixators were applied for various types of fractures around the elbow joint associated with elbow dislocation. In 12 patients prior to the application of the fixator, a formal open reduction and internal fixation was performed so as to neutralise the whole construct and permit early mobilisation of the joint. In one patient with a minimally displaced fracture which required no internal fixation the fixator was used to permit early mobilisation. A circular multiplanar frame was used in 4 patients and a unilateral one in the rest of them.

Eight out of 13 patients with fracture-dislocation had an uneventful outcome. Three patients required a revision surgery to correct a fracture malalignment and a subluxation of the joint. The results were evaluated according to the Mayo Elbow Performance score. Complications included 4 cases of pin tract infection and 2 of transient ulnar neuritis.

Despite the complexity of its application and the complications that may follow such device, an articulating external fixator can be a valuable tool in treating complex elbow instability.

Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury.

Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement.

The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient.

Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results.

Introduction: The aim of this retrospective study is to identify factors that might influence the final result in the treatment of volarly displaced distal radius fractures

Material : 31 patients with an average age of 39 years and a volarly displaced distal radius fracture were treated by ORIF. According to the Comprehensive classification of fractures thee were 3 B3.1, 7 B3.2, and 21 B3.3. All the fractures approached volarly and fixed with a T plate. 3 patients required bone graft. All patients were evaluated with postop radiographs and results were assessed according to the system described by Gartland and Werley.

Results: The average follow up was 50 months. There were twenty excellent, six good and five poor results. Although all fractures healed, six patients had evidence of osteoarthrosis, and there were four early and six late complications, which adversely influenced the final result. Reversal of the volar tilt and evidence of osteoarthrosis found to have a significant association with a fair or poor outcome.

Conclusion: Treatment of such injuries require careful preoperative evaluation and identification of fracture morphology, otherwise the postoperative rate of complications can be quite high, a factor that may negatively influence the final result.

Introduction: Traumatic injury to a peripheral nerve with loss of continuity is a disabling condition due to denervation. Traditional treatment consists of nerve grafting with the consequence of unwanted side effects at the donor site (sural nerve).

Aims: To present an alternative treatment using two different biomaterials as implants bridging both ends of nerve.

Materials and Methods: The same hand surgeon treated twenty-one patients with traumatic laceration of less than 3 cm in the upper limb. Two different kind of flexible tubular sheaths were implanted: 18 patients with one and 3 with other. An independent observer assessed McKenney’s and two points discrimination tests for functional out come. We describe the surgical technique and report the full data.

Discussion: Polyglicolic acid is designed to create a conduct for axonal growth across a nerve gap making it unnecessary to carry out a nerve grafting. Its use is feasible in clean wounds less than 3 cm in length. It is technically easy to implant and reabsorbed within 3 months.

Conclusions: The satisfactory results in terms of functional recovery suggest the convenience of this technique to shorten the operating time and avoid donor site side effects.

Introduction: The aim of the study was to review the treatment of twenty six patients who had non union of a fracture or osteotomy of the clavicle, with specific attention to the complications of the non union, the techniques used at operation and the outcome of treatment.

Material: There were twenty six patients with clavicular non union. Twenty two patients treated by open reduction and internal fixation, three with partial resection of the clavicle and one with total resection.

Results: The average follow up was 23.4 months. Twenty patients were led to union. Thirteen patients were pain free, whereas the rest had some mild pain. Normal shoulder mobility was noted in fourteen patients. In two patients was necessary to resect the first rib because of symptoms of thoracic outlet syndrome.

Conclusion: Clavicular non-union can cause major functional problems, requiring treatment. Careful evaluation is mandatory in order to decide if the non union is amenable to reconstruction procedure or to salvage operation or to non treatment.