We present a new inflatable self-locking intramedullary nailing system for the treatment of intertrocanteric and subtrochanteric fractures.

Material: We used this system in 63 cases with an average age of 81 yrs. 23 cases were intertrochanteric fractures and 40 cases subtrochanteric. A standard technique of closed reduction was used and the nail was implanted through an entry portal at the tip of the great trochanter.

Results. 38 patients were available for clinical and radiological examination. 13 patients were contacted by telephone and 12 patients could not be reached. The patients were mobilized with the instruction of weight bearing as tolerated. Each fracture was consolidated on average of 8 weeks. In two patients a cut out of the central peg was noted and the system was removed after fracture union. In three patients a mild malalignment was noted but without clinical significance. The mean blood loss was 90 cc and the mean operative time was 36 minutes.

Discussion The features of this system and the advantage of the technique include: fixation along the entire length of the nail, lack of distal interlocking screws, reduced exposure of the surgeon to x-ray and reduced operating time. Our results are very promising and it seems that this system is an innovative, effective, simple and minimally invasive treatment for fractures on the trochanteric region.

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 17 patients with an average age of 42 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but two fractures were closed. The level of the tibia fracture included midshaft (two), middle-distal third (ten), distal third (five). Eleven ankle fractures were classified as Weber B, five as Weber C and one Pilon. Two fractures were treated by cast immobilization, eleven with internal fixation of both fractures and four with a combination of internal and external fixation. Seven fractures were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty-three months. The non-operatively treated fractures resulted in a malunion and decreased ankle mobility. Of the cases managed operatively, nine had complete structural and functional recovery; two patients regained 70% of ankle mobility and one developed post-traumatic ankle arthritis. Discussion: The resulted experience from the treatment of these injuries showed their extremely unstable nature. It has been our experience that the nature of the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, progressive slippage of the fragments occurs. We believe that stable fixation of both fractures should be the treatment of choice

Aims: The purpose of this roentgenographic study is to quantify patellar tilt after total knee arthroplasty and substantiate which factors might affect it. Methods: We reviewed the þles of 446 patients with 485 primary total knee arthroplasties, solely on the diagnosis of degenerative osteoarthritis. Mean follow-up approximated 8.5 (range, 5–20) years. Resurfacing-type prostheses were exclusively used. Patellar resurfacing was accomplished in 51 (11.4%) knees. Patellar tilt was measured pre- and postoperatively using standard Merchant views. Chi-square analysis was used in an attempt to disclose any relationship of patellar tilt with variables like button positioning, lateral release, patellar thickness, limb alignment, joint line elevation, patellar height and posterior cruciate ligament retention or sacriþce. Results: Pre-operatively, 27%, 40% and 33% of patellae demonstrated neutral, lateral and medial tilt respectively. These þgures subsequently changed to 49%, 19% and 32% immediately post-op. However, at þnal follow-up, patellar tilt pattern looked much like the pre-operative one, namely, 31%, 38% and 31% respectively. A statistically signiþcant positive correlation was only documented for patellar thickness, buttonmedialization and pre-operative tilt. The rest of the parameters tested were found not to have any statistical signiþcance with post-operative tilt values. Conclusions: After knee arthroplasty, the patella has, on the long term, a tendency to revert laterally. Lateral release does not seem to ameliorate this tendency. Finally, pre-operative tilt does not correlate to post-operative external mechanism complications.

Introduction: Primary surgical treatment has been recommended for unstable clavicular fractures if consequences of non-union or malunion have to be avoided. A prospective study was undertaken to evaluate the results of a conservative treatment of very unstable fractures of the middle third of the clavicle, with emphasis to very early mobilization. Material: Patients to be included in the study had to met the following criteria: 1) Fractures of the middle third of the clavicle, severely displaced or comminuted, 2) Closed injuries, 3) No neurovascular complications, 4) No pneumothorax or hae-mothorax and 5) No other injury in the ipsilateral upper extremity. Twenty-three patients with an average age of 24 years included in the study. Each patient evaluated with AP and 45-degree cephalad-tilted views. All patients treated with an arm sling and strongly instructed for early mobilization. All patients were evaluated in a weekly interval and assessed with the American Shoulder and Elbow Surgeonñs shoulder evaluation form. Results: The average follow up was 21.4 months. All fractures were consolidated and all malunited; but no patient had residual symptoms or functional impairment of the limb. On patient developed mild hypesthesia in the ulnar nerve territory. Conclusion: The extremely encouraging results of our study, within the bounds of the above-mentioned follow up, indicate that conservative treatment with very early mobilization may be considered as a valid therapy. However it is a concern the functional result in a longer follow up as well as the cosmetic result.

Evaluations of 32 adults with 50 complete digital nerve injuries were made more than 1 year after surgery. Twenty patients were men and 12 were women. The mean age of the patients at operation was 30 years. The mean follow-up time was 2 years. Patients were excluded if they had a skin graft, had a second surgery after digital nerve repair or graft, were diagnosed with diabetes, had additional proximal nerve injuries, had postoperative infections, had a complete digital amputation or had a dorsal digital nerve injury. According to the initial injury mechanism, patients were classified into three grades : grade I was defined as a sharp, clean-cut injury, grade II was mild crush and grade III was a severe crush injury. Overall, there were 30 primary digital nerve repairs, 12 secondary repairs and 8 secondary nerve grafts. Moving and static two-point discrimination was determined on both lateral aspects of the injured and contralateral uninjured digits. Digits with primary repairs in mild or severe crush injuries had significantly worse two-point discrimination compared with digits that had a primary repair of a simple laceration. Futhermore, in mild crush injuries, digits with secondary nerve grafting had significantly better results than those with primary repair. Patients under 30 years age had better results than those over 30 years. These results support the hypothesis that better recovery is obtained if tension is avoided at the nerve repair site in mild crush injuries.

Instability of the thumb trapeziometacarpal joint is a major factor in the cause of degenerative disease. Surgically stabilized joint should be subject to less shear forces and hence, will be less likely to develop degenerative changes. The results of volar ligament reconstruction were assessed in 12 patients (8 men- 4 women). The average age at surgery was 35 years. All thumbs were radiographic stage I. All had failed conservative treatment with splinting and anti-inflammatory medication. Operativelly a strip of Flexor Carpi Radialis tendon was used for ligament reconstruction according to the technique described by Eaton, Glickel and Littler. The follow-up period averaged 7 years. At final follow-up 8 thumbs were stage I, 3 were stage II, and one was stage III. Ten patients were at least 90 % satisfied with the results of the surgery and only two had symptomatic thumb basal joint.

Between 1988 and 1998, a total of 12 patients (6 men and six women, of average age 36 years) underwent surgery for schwannoma of the peripheral nerves of the upper extremity. The incidence according to the involved nerve was analyzed and the follow-up results and complications after surgical treatment were reviewed. The median nerve was most frequently involved (6 cases), followed by the ulnar nerve (4 cases) and the radial nerve (2 cases). The average duration of symptoms was 2 years (3 months-8 years). Pain or painful paresthesias were usually the main complains. None of the patients suffered from Recklinhausen’s disease. Magnetic resonance imaging is the preferred exploration technique, particularly useful in case of deep tumor. EMG studies were carried out in all patients. Preservation of nerve continuity is the underlying goal of the therapeutic strategy. Marginal excision was performed in all cases. The tumors were extricable displacing the nerve fiber bundles without penetrating into the bundle itself and it was possible thus to be resected without interrupting the nerve continuity. Postoperatively, 7 patients were pain free, while 5 improved. Neurological deficits were favourably influenced by the operation. Out of 4 patients with motor deficits 3 had complete and 1 had partial recovery. Three out of 6 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. One patient developed new motor and another one new sensory deficits. New deficits developed predominantly in patients with large tumorsor longstanding symptoms. There was no reccurence or malignant transformation until the average of 52 months of follow-up.

We reviewed the functional outcome of cominnuted intraarticular fractures of the distal humerus managed with internal fixation with plates and screws. 15 patients (10 men-5 women) were reviewed over a mean of 29 months postoperatively. The age of the patients at operation ranged from 18 to 72 years. Patients were treated within 7 days of injury, using a posterior approach,with or without olecranon osteotomy and with anterior transposition of the ulnar nerve. Bone grafting was used in 7 cases in addition to internal fixation. Postoperative mobilisation was prompt in all patients,who were meticously reviewed for : 1)Function of the upper extremity,with the aid of the scale of DASH (Disabilities of the arm,shoulder and hand), 2)Ulnar nerve (pain, sensitive and movement dissability, functionality), 3)Range of elbow motion, 4) strength of the muscles controlling the elbow, wrist and hand. 5)Post-operative radiographic appearance, 6)Subjective evaluation, 7)Complications. All the patients were satisfied with the outcome of the operation,as well as with the activities which could postoperatively be undertaken. The mean range of motion for elbow (flexion-extension) was 118° in average,while muscle strength for elbow motion was moderately reduced. No case of ulnar neuropathy was observed. On the other hand postoperative complications were considerably frequent, yet they were mild and subsided eventually without further operation.

Introduction: The aim of this study is to present a modification of the single tension band technique for the treatment of olecranon fractures, using a double tension band with smaller wires, preserving all the biological parameters for fracture fixation, in an effort to decrease related complications.

Material: Thirty-three patients with olecranon fractures treated with a double tension band fixation. Surgical Technique: Through a posterior approach the fracture is reduced keeping all principles for biologic fixation and stabilized with two parallel small K-wires inserted from the olecranon process and exit through the anterior cortex of the ulna. Then the extensor carpi ulnaris and flexor carpi ulnaris are partly elevated from the ulna and two 1.5-mm transverse drill holes are made through the ulna 3 and 4 cm distal to the fracture. Two 22-gauge wires are passed through the proximal and distal holes, bent into a figure of 8 over the dorsal ulna and simultaneously tightened. The proximal ends of the K-wires are bent and impacted into the olecranon process.

Eleven patients needed supplemental fixation with screws. All patients mobilized the first postop day.

Results: All the fractures consolidated. All patients but two regained full range of motion. No hardware failure was noted except one patient in whom one band was broken but without clinical relevance.

Conclusion: It seems that a double tension band fixation despite the smaller material utilized, provides a very stable construct, permitting early mobilization. Furthermore two bands tensioned independently provide greater compression forces at the fracture site and offer a back up in case that one band fails.