Objectives

The most prevalent disorders of the shoulder are related to the muscles of rotator cuff. In order to develop a mechanical method for the evaluation of the rotator cuff muscles, we created a database of isometric force generation by the rotator cuff muscles in normal adult population. We hypothesised the existence of variations according to age, gender and dominancy of limb.

Introduction: Tibial plateau fracture is an intra-articullar complex fracture. Surgery aim is to restore articular surface height, preserve knee joints stability and alignment in order to obtain maximal range of motion and to prevent future joint degenerative changes. Ilizarov external frame using ligamentotaxis, minimal invasive techniques, smooth or olive wires (sometimes augmented by screws) allows articular surface reconstruction and stabilization. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring.

Study Aims: To assess the results of complex tibial plateau fracture treated with Ilizarov external fixator.

Materials and Methods: Between 1997–2005, twenty five patients with complex fractures of the tibial plateau, Schatzker type V–VI fractures (all closed), average age 45 years old (range 30–78) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. 11 out of 25 patients were treated with ligamentotaxis using extension of the frame to the femur with hinges on the center of joint rotation. Some of these patients (10 out of 11) required lateral minimal opening for joint surface elevation. 8 out of the 25 patients needed additional bone graft/ substitute supplementation. One needed 6.5 mm canulated cancellous screw augementation. Patients with below knee frame remain non-WB for 6 weeks and partial WB for another 6 weeks. Patients with above knee frame were allowed full WB. In 3 months the frame was removed under anesthesia and the knee was manipulated. Patients were placed in a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: All fractures united with an average time of 12 weeks. 22 patients had full extension with 100 degree of flexion or more. 3 patients had extension lag of 10–20 degree, one of them had 20 degree of posterior slop of the tibial plateau. All patients had normal axial alignment, except one case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient). One had mild unstable knee. One patient developed posttraumatic osteoarthrosis. There were no cases of postoperative infection, septic arthritis or neuro-vascular complications were reported. Pin site infection was resolved locally.

Conclusion: The use of Ilizarov external fixation in the management of complex tibial plateau fractures results in satisfactory out come as an alternative to the traditional tibial plateau open surgery. This minimal invasive intervention allowed the surgeons to reduce and fixate the tibial articular surface with out further damaging the soft tissue envelope.

Introduction: The mitochondrial Translocator Protein 18 kDa (TSPO, previously named as the peripheral benzodiazepine receptor - PBR) is involved in cellular respiration, steroidogenesis and apoptosis. In our recent study we reported on the role of the synthetic pharmacological ligands to the TSPO in enhancing human osteoblast catabolism. There is also a previous evidence of the existence of an endogenous ligands to the TSPO, but their role in the human osteoblast physiology hasn’t been verified yet. Porphyrine IX has been found having affinity to the TSPO. Therefore we hypothesize that human osteoblast metabolism might be mediated by the porphyrine IX and the mode of its action is similar the synthetic ligand to the TSPO.

Methods: Cell cycle of the cultured human derived osteoblast- like cells, following exposure to Porphyrine IX, endogenous ligand to TSPO, and N,N-di-n-hexyl 2-(4- fluorophenyl)indole-3-acetamide (FGIN-1–27), synthetic ligand to the TSPO, was determined by flow cytometry (FACS). These ligands’ affect on cell number, metabolic activity, i.e. cellular fluorodeoxyglucose ([¹⁸F]-FDG) incorporation and alkaline phosphatase activity, and cell death rate, i.e. LDH activity in the culture media, were assayed. The semi-quantitative response of TSPO to exposure to these ligands was estimated by Western blotting. Six samples of cultured cells for each condition were used. The t test was implemented for the statistical analyses. P values below.05 considered as statistically significant

Results: Cell count significantly decreased following exposure to FGIN-1–27 or porphyrine IX. Cellular [¹⁸F]-FDG incorporation and alkaline phosphatase activity were suppressed by both ligands. Cell cycle analysis showed a significant decrease in the fraction of cells in the G1 and G2/M phases when exposed to each ligand with a higher proportion of necrotic and apoptotic cells.

Western blotting showed a decrease in TSPO abundance following treatment by both ligands. LDH activity in culture media significantly increased following exposure to FGIN-1–27 or porphyrine IX.

Discussion: We show that FGIN-1–27 and porphyrine IX have a similar cell death inducing affect on human osteoblast-like cell in vitro. This affect is parallel to the inhibition of the cellular metabolism. Since both ligands similarly reduce the availability of TSPO we postulate that their mode of action is similar by affecting this mitochondrial structure with sub sequential induction of cell death, i.e. apoptosis and necrosis. Therefore we suggest that human osteoblast metabolism and cell cycle are mediated through TSPO and that porphyrine IX might be an active endogenous ligand to the TSPO having a regulatory affect on the human bone cell cycle.

Background: Fractures of the distal radius are among the most common fractures encountered.

In the US these fractures account for 20% of all fractures treated at emergency care units. Methods for fixation of distal radius fractures include: casting, external fixation devices, plating, and percutaneus pinning.

In the prospective, randomized study by Strohm et al., the results of conventional Kirschner wire osteosyn-thesis were compared with those of a modified Kapandji method (“intrafocal pinning”). The functional and radiographic results of the Kapandji method were superior to those of the other technique.

We utilized a modification of the Kapandji method on a broad spectrum of distal radius fractures, including intra-articular fractures. The primary results and current follow up are presented.

Materials and Methods: 14 patients were treated. Fractures were classified according to Frykman’s classification system, ranging from Frykman’s 1 to 8. The inclusion criteria were all distal radius fractures, which had failed an initial closed reduction. Reduction was accomplished by inserting Kirschner wires percutaneusly through the fracture (intrafocal pinning) and utilizing them as levers to reduce the fragments. The wires were then advanced to be anchored in the proximal cortex. Additional wires were inserted after reduction, through the distal and proximal fragments. The forearm was fixed in a short cast for six weeks after which the Kirschner wires were removed and wrist motion exercise begun. Results were judged according to:

Roentgenographic appearance (early post op, and at follow up) according to the text book reduction criteria.

Results: Follow-up duration was 3–19 month. Reduction was graded “good” in 11 cases and “fair” in the remaining 3. All fractures united. Time to union was 4–9 weeks. Fracture reduction was maintained until union, in all cases. None of the patients needed an additional surgical corrective procedure. Functional results were satisfactory (with the limitations of too short follow-up in some of the cases). There were no cases of infection at pin site, deep or superficial.

Conclusions: The modified Kapandji method for percutaneus pinning of distal radius fractures is a useful tool for reduction and fixation of almost any sub-type of distal radius fractures, including intraarticular displaced fractures.

This technique has become our first choice of treatment, when closed reduction and cast fixation had failed to achieve or maintain reduction.

Introduction: Fractures of the elbow constitute about 7% of adult fractures; distal humerus fractures account for less than half of all elbow fractures.

There is evidence, however, that incidence is increasing.

Investigators in Finland performed a retrospective review of hospital admission records between 1970 and 1995 and found that the age-adjusted increase in incidence in women older than 60 years had more than doubled.

Treatment of intraarticular comminuted distal humeral fractures is a surgical challenge, adequate reduction of the joint surface demands avoidance of residual step or gap of the articular surface and providing a stable fracture fixation.

Aim: To evaluate our initial experience in internal fixation by using bioabsorbable screws by treatment of patients suffered from comminuted distal humeral fractures.

Material and methods: 5 patients with sever intraarticular comminuted distal humeral fractures were treated using bioabsorbable screws. A standard transolecranon approach was used. Internal fixation was performed using lateral and medial plates. Additional bioabsorbable screws (pins) were used to fix separate intraarticuar fragments of the distal humeral bone.

Results: By follow up all fractures were healed with out secondary displacement of fractures. All five patients returned to the preoperative activity, ROM of operated joints was in functional limits. Insertion bioabsorbable screws thorough articular surface allows preserve intraarticular bone fragments on the place until solid consolidation without need in additional operative procedure of removing implanted devices.

Conclusion: Our experience suggests that the bioabsorbable screws can serve as useful augmentation in surgical repair of severe intraarticular comminuted fractures of the elbow joint. Future clinical study

Introduction: The diagnosis of cuff tendon pathology is usually based on physical examination, which has a limited predictive value. The ultimate cost effective diagnostic tool for this purpose should combine the simplicity and low cost of the physical examination with precision of the imaging scans. Since the pathological process involving the rotator cuff structures is usually intrinsic to the muscle and tendon tissue, one of its main expressions, apart of pain, will be weakness of the muscle involved. Measurements of muscle strength may potentially provide a valuable diagnostic tool for evaluation of integrity of a specific muscle or a group of muscles. The purpose of the study is to evaluate the normal patterns of the isometric strength curves of the rotator cuff muscles.

Methods: Isometric time-force distribution for suspraspinatus, infraspionatus and subscapularis muscles in 400 healthy volunteers was measured, i.e.. 50 healthy individuals of both sexes for every decade of age from twenty to sixty years of age were evaluated. Specially designed dynamometer with measurement rate of 5 Hz was used. The measurements were done in a standard body-arm positions in order to eliminate the influence of the synergistic contribution of other muscles. The force- time curves were presented as moment of force values normalized to the lean body mass of the examinees. The characteristics curves of the study groups were compared by non parametric statistical analysis, since not normal distribution of values was found.

Results: Isometric strength of each of the rotator cuff muscles was higher in dominant limbs, higher in men in every age group and gradually rises from second to fifth decade of life in both sexes. The significant drop in muscle force was evident only in the sixth decade of life in both sexes. The force-time curves were characteristic and different in the different studied groups.

Discussion: A data base of normal isometric strength values of rotator cuff muscles in healthy adult population was established. This provides an effective comparative tool for the further evaluation of force-time curves in patients with rotator cuff pathology. The unpredictable evidence of significant rise of rotator cuff muscles’ strength with increasing age challenges the present concepts of the understanding of rotator cuff degeneration pathophysiology and its treatment. The decrease in rotator cuff isometric strength in the sixth decade of life is consistent with the higher incidence of non symptomatic rotator cuff intrinsic pathology at this age

Background: Hip fractures are common among the aged population, with high mortality and morbidity rates. It ‘s annual cost in the United States is expected to double by the year 2040 to about 16 billion U.S Dollars. Of those, approximately 50% are inter-trochanteric fractures. Among them, 50 to 60% are categorized as unstable fractures. Unstable intertrochanteric fractures are defined as 1) fractures with comminution of the posteromedial buttress which exceeds a simple lesser trochanteric fragment; 2) fractures with evidence of subtrochanteric fracture lines; and 3) reverse oblique fractures of the femoral neck. Review of the literature reveals large variations in the amount of complications after surgical treatment of unstable intertrochanteric fractures, among various medial institutes. Infection rates winds from fewer than 1% and up to 15% of cases, and reports of cutout events range from % to 20%. Other complications, such as non-unioin, femoral shaft fractures, and painful hardware, are much less common.

Purpose: To investigate the rate of complications after surgical treatment of unstable inter-trochanteric fractures, in our department.

Method: Retrospective review of 61 patients who were admitted in our department due to unstable intertro-chanteric fractures, after simple falls, between May 2001 to August 2006, and were treated with intramedullary sliding hip screw. Most of the hardware (90%) were A.O nails (PFN, proximal femoral nail).

Results: There were 4 cases of infections, which are 4.9% of cases. Three of them required removal of the hardware. One admission was due to superficial surgical wound infection. There were 3 cases of mechanical cutout of the femoral head screw, which are 6.5% of the cases. No cases of non-union, femoral shaft fractures, or painful hard are noted.

Conclusions: To our experience, intramedullary sliding hip screw is a safe and effective treatment for unstable intertrochanteric fractures. Complication rates to our experience are at the lower third compared to reports from medical institutes over the world.

Introduction: There is a controversy regarding the treatment of the intra articular fracture of the distal radius. Plating for anatomical reduction vs the minimally invasive method by mini external device and K wires. We report our experience with the minimal invasive technique.

Materials and Methods: Between January 2003 and march 2005, 43 patients with intra articular fracture of distal radius were treated. 22 females, 16 males were followed. Age range 23–81 (mean 55 years). All cases were uni lateral. 38 patients were followed out of 43 fractures. Causes: 23 fall, 9 RTA, 6 sport accidents. The fractures were classified according the Frykman classification: 5 F3, 6 F4, 6 F5, 9 F6, 5 F7 and 7 F8. Follow up was 6 weeks after treatment and 6 months later. A Lateral and PA views were performed and the angles were measured. The V.A.S. was used to quantify the painful level. The Lidstrom criteria scale was used to evaluate the functional outcome. The surgical procedure was performed on the same day or one day later. In all cases the mini external device of AO (2 threaded rods in the second metacarpal and another 2 rods in the radius) was used. In 20 cases, 1 or 2 K wires were inserted in addition from the radial styloid to stabilize the fracture. The mini external was removed 6 weeks later.

Results: According to Lidstorm criteria, 12 patients (31%) had excellent results, 23 (61%) good, 2 (5.5%) fair and 1 (2.5%) poor outcome. The results of the VAS were good: 33 had less than 3, 4 patients less than 5 and one patient chose the number 9 to quantify his pain. At the follow up, 35 patients restored a very good range of motion (ROM) of the wrist, while 3 patients had markedly reduced ROM. The best outcome is shown in the younger population, except one case, a young man 33 years old, who was unable to return to work 6 months later. Four patients (1%) had a pin tract infection treated by PO antibiotics.

Conclusion: In our hands, the minimally invasive technique seems to be a satisfactory procedure. In the young population, the restoration of the range of motion was very good. The loose of few degrees in the arc of motion in the elderly population didn’t disturb there functional performance. We think that the mini-invasive method is excellent tool for treating intra-articular fractures of the distal radius; the procedure is shorter and there is less chance of infection and less damage to the surrounding tissues.

Introduction Efficient control of osteoblast metabolism is crucial for the development of methods for enhancement of bone fracture repair and in the treatment of osteoporosis. If extracellular matrix elaboration by osteoblast could be controlled on the cellular level, new theurapeutical means might be developed. The current methods for osteoblast metabolic manipulation include mechanical, electromagnetic, hormonal and biochemical, i.e. growth factors and cytokines, means. All this methods have different degrees of therapeutic success. Finding of additional pathways of metabolic stimulation of osteoblast will provide an important insight for the understanding of human bone mass maintenance. The recent report of the existence of peripheral ben-zodiazepine receptor(PBR) in mammalian fibroblast arises the possibility of the existence of an unknown cellular pathway for mesenchymal cells metabolic regulation through this receptor. The PBR is a part of the mitochondrial permeability transition complex with important role in cell proliferation, differentiation, steroidogenesis, immunity and apoptosis, i.e. this complex is involved in most of the cellular metabolic activities. The PBR was identified in various organs, especially with enhanced steroidogenetic activity, but never has been investigated in bone. Therefore PBR’s identification in the human osteoblast may reveal a new cellular pathway of its metabolism.

Methods Cultures of confluent layers of osteoblast-like cells originated from human cancellous bone from distal femur. The samples were taken during osteoarthritic knee replacements. Chips of cancellous bone, 2 – 3 grams in total, were incubated in DMEM with heat-inactivated fetal calf serum (10%), 20mM HEPES buffer, 2mM L-glutamine, 100 μ M ascorbate-2-phosphate, 10nM dexam-etasone, 50 U ml-ml penicillin, 150μml-ml streptomicin at 37°C in humidified atmospheric environment of 95% air with 5% CO₂ ( v:v ) for 30 days. Human osteoblast-like cells grew out from the chips as adherent to the plastic culture plates until confluency. The human bone cell cultures obtained by this method have been shown previously to express osteoblast-like characteristics.

The PBR in the homogenized osteblast-like cells was identified by using its selective ligand PK11195. The affinity and density of the PBR was estimated by the scatchard analysis.

Results We found that binding of the ligand [³H]PK11195 to the human osteoblast PBR is saturable with a single population of binding sites (r=0.92 – 0.95). The equilibrium dissociation constant (K_d) equaled 9.15-9.34 nM and density of receptors (B_max) was 7,672–7,691 fmol/mg protein.

Discussion The PBR receptor was identified in the human osteoblast with affinity to the PK11195 in the same magnitude as previously found in other tissues. The density of the PBR in the osteoblast appeared higher comparing to uterus, kidney, brain and placenta from different mammalian origin. PBR’s density in osteoblast is comparable only to the adrenal tissue, that is known to have its highest values. PBR density in the human osteoblast is also higher than in the rat’s skeletal fibroblast, and although this may suggest a higher differrention of the osteoblast, the interspecies comparison might be misleading. These data suggest that the human osteoblast is one of the important sites rich with PBR. The exact role of the PBR in the human osteoblast metabolism is not known yet and will be further investigated.

Introduction: The introduction of bioabsorbable materials has improved the ability to offer a simple, fast and friendly user solution, to specific meniscal tears. The technique of meniscal suture with bioabsorbable tacks is associated with lower morbidity and lower complication rate.

Methods: Between 1997 and 2004, 14 patients underwent arthroscopic all-inside meniscus repair. We used Biofix bioabsorbable tacks fixation technique. Fourteen patients were followed-up: 11 males and 3 females. Their mean age was ~23 years (range 16–34). Follow-up average ~35 (range 6–72) months. Sport injuries were the main cause of meniscal tears (60%). Other causes included: work accidents (20%) and military accidents (20%). All the tears were located in red-on-red and red-on-white area. The mean length of tear was 9.6 mm. we used in average 2.5 tacks per meniscus tear. Furthermore, 4 patients had an associated ACL tear.

Results: The evaluation was based on Lisholm score. The results were excellent in 10 patients (71%), good in 1 patient (7%), fair in 2 patients (15%) and poor in 1 patient (7%). One patient suffered from transitory tender point on the medial aspect due to a protruded tack. One patient needed a menisectomy due to unresolved symptoms. One patient underwent ACL reconstruction.

Conclusion: This technique is an easy and reproducible procedure as compared to the classical meniscal suture techniques. It seems to be of a lower complication rate and further studies are needed to establish any associated morbidity.

Purpose: Midterm follow up of complete knee dislocation and clinical outcome evaluation.

Materials and Methods: Between 1990–2004, we retrospectively reviewed the records of patients with complete knee dislocation. Eighteen patients, 19 knees were followed. Twelve males and 6 females. The average age at follow up was 40.7 years. Treatment consisted of primary knee stabilization with tutor cast in 10 knees and 9 by external fixation for 6 weeks. Following rehabilitation program, further surgical treatment was according to clinical relevancy. Functional and subjective evaluation was registered by the WOMAC questionnaire.

Results: Eleven were multiple trauma patients, involved in RTA, 2 had a crush injury, one patient involved in aviation accident had bilateral dislocation and 4 patients had low energy injury. Out of 7 patients, 8 knees had isolated dislocation. One died, 3 were not available for clinical follow up. Twelve patients returned the questionnaire. The average result of the WOMAC score was 46.5, range 7–91. Four knees presented advanced osteoarthritis with painful stiffness. Eight knees presented at the end of the follow up with instability as chief compliant. Five patients underwent later reconstructive procedures. One patient underwent knee arthrodesis.

Conclusion: In patients with knee dislocation, associated polytrauma should be regarded as a bed prognostic sign. The results suggest the need to revaluate the initial treatment strategy. The overall outcome shows that nearly all patients were able to perform daily activities, no patients in our study attempted any strenuous activity.

Introduction: There is a controversy regarding conservative or surgical treatment of calcaneal fracture. We report our experience in surgical treatment of calcaneal fractures.

Materials and Methods: Between March 1998 and May 2004, 30 patients with 32 calcaneal fractures were treated surgically in our departments. Twenty four fractures were caused after a fall from height, 4 fractures were consequence of a road accident, 2 fractures after a blast injury and one after a football injury. There were 4 females and 26 males. Two cases were bi-lateral fractures. Age range 20–66 (mean 33). Follow-up time 7 to 72 months (mean 24 months). The fractures were classified according to Sanders classification: there were 22 patients with Sanders III, 8 patients with Sanders IV and one patient with Sanders II. All patients were operated with the same procedure and the same surgeon. The surgical procedure was delayed from 10 to 14 days post trauma, until swelling subsided. Open Reduction Internal Fixation was performed using lateral approach, “L” shape with subperiosteal dissection of lateral wall, and using a calcaneal reconstruction plate.

Results: The functional outcome was evaluated according to Rowe Score. The clinical results were excellent in 3 patients (10%), good in 22 patients (70%), fair in 4 patients (14%) and poor in 2 patients (6%). The Boehler angle was reconstructed in 29 of 32 calcaneus. 3 patients returned to their previous level of activity, 9 patients returned to work, 14 patients mentioned some pain in the site of the operation. Two patients were treated successfully with oral antibiotics for superficial wound infection. Six patients suffered from peripheral nerve damage. One patient experienced subtalar pain, and underwent a subtalar arthrodesis, furthermore the patient developed Complex Regional Pain Syndrome (CRPS), finally he underwent below knee amputation (BKA). One patient had a flap necrosis and underwent sural flap coverage with excellent results. All the patients were recognized in a process to be recognized as disabled by the social security.

Conclusion: Our results were good in majority of patients according to the known classification systems. However, the recovery period from calcaneal fractures is long and the majority of patients do not achieve their previous functional level. The secondary gain might bias the results.

Purpose: The purpose of this paper is to evaluate the results of One or Two-Stage revision surgery, in the treatment of infected Total Knee Arthroplasty.

Materials and Methods: Between 1978 and 2003, 43 cases of infected TKA were operated. Forty-one cases were followed more than one year. Twenty two patients were males and 19 females. Average follow-up (F-U) time was 8 years (range 1–25). Nine were diagnosed during the first six months postop and 32 cases were late infections. All patients were given intravenous antibiotics for 6 weeks according to culture.

One stage procedure was performed in 20 patients with a painful knee without purulent discharge. Of them, 9 patients were infected with Staph Aureus (45%), 2 Enterococcus, 1 Strep Viridans, 1 Brucella. Seven were clinically infected without positive cultures (35%). Average age at revision was 75.6Y, with 1.9 co-morbidities. Average time interval between primary and revision was 45.6 months. Gallium bone scan was positive in 40%, WBC was above 11000 in 20%, increased ESR in 25% and CRP values above 3 mg/L in 80%. Intra-operative loosening was found in 60% of femoral and tibial components.

Two stage procedure was performed in 21 patients, when pus was present during the operation. Interposed cement impregnated with antibiotics was left between bone ends and at least six weeks of IV antibiotics were given. Average age at revision was 68Y,with 2 co-morbidities. Average time interval between primary and revision was 20 months. Positive Gallium bone scan was in 100%, WBC above 11000 in 80%, increased ESR in 80% and CRP values above 3 in 63%. Twelve patients were infected with Staph Aureus (60%), 4 Enterococcus, 1 Strep Haemolyticus, 1 Candida and 3 clinically infected cases without positive cultures (14%). Intraoperative loosening was found in 43% and 79% of femoral and tibial components, respectively.

Objective result was graded according to HSS score. The differences between ‘one-stage’ and ‘two stage’ groups were checked by t-test of variance.

Results: Twenty four patients out of 41 (60%) were available for F-U, 11 among One Stage group and 13 among Two Stage group. Eleven patients died and 6 were lost for F-U. Subjective satisfaction was reported by 80% of patients. Overall, HSS score increased from 48.3 preoperatively to 80 postoperatively, with 30% excellent result, 48% good, 13% fair and 9% poor.

For One Stage group, postoperative subjective satisfaction was reported by 78% of patients and HSS increased from 49.9 to 81.4. Average arc of motion was 93°. There were 4 patients with recurrent infection (20%), 2 of them were treated with antibiotics and 2 needed second revision (10%).

For Two Stage group, postoperative subjective satisfaction was reported by 82% of patients and HSS increased from 47.3 to 78.6. Average arc of motion was 85°. No re-infection was recorded in this group.

No significant difference between the two groups was found in relation to postoperative HSS score and arc of motion. However, remarkable difference is reported regarding reinfection rate.

Discussion and Conclusion: In this series with an average of 8 years follow-up, HSS score in revision of infected TKR is lower (30% excellent and 48% good) than expected result in primary TKR. The ‘Two-Stage’ procedure was more effective in our hands than ‘One-Stage’ as for eradication of infection in Total Knee Arthroplasty.

Purpose: The purpose of this study is to evaluate the results of the treatment by severe blast injuries to limbs.

Materials and methods: Twenty-seven patients after blast injuries were treated. There were 13 patients with tibial fractures, 7 fractures of the femur, 4 – fractures of the humerus and 3 with fractures of the forearm bones. According to Gustilo all fractures were open grade 3B and 3C. According to MESS a median value was 4,7 points (range 3 – 7). Six had on admission vascular injuries, and 12 had peripheral nerve injuries. There was other major organ trauma in 55,5% of patients.

On admission, the fractured bones are realigned and stabilized with an AO tubular external fixation frame followed by immediate thorough soft tissue debridement, vascular reconstruction. In patients with peri-articular fractures temporary trans-articular bridging was needed.

After 5 to 7 days or when wound condition permits, delayed primary sutures, the application of skin grafts or free tissue flaps are performed. At this stage, the tubular fixator is exchanged for a circular frame that allows stability, sufficient for full weight bearing by minimal invasive fixation and meticulous attention to freeing the previously bridged joints. Hybrid frames allows combination of advantages of each type of external fixators. Closed reduction of fractures was performed in most patients by ligamentotaxis and use thin wires with olives. Fixation in elastic frame combined with cyclic loading provide favorable biomechanical environment for fracture healing.

In patients with high-energy “floating elbow” injuries the hybrid circular devices of the humerus and forearm were connected by hinges to allow immediate elbow joint movements. The separate fixation of the forearm bones was performed to allow early pronation/supination motions.

Results: In all patients the external fixation was the definitive treatment. Fracture union was achieved at median time of 240 days (range 90 – 546). Throughout the period of fracture healing the patients were fully ambulatory, living at home. In three patients with bilateral highly complex blast injuries of lower extremities, where one limb had to be amputated, the Ilizarov device for severely injured contralateral limb provided the conditions necessary for early prosthetic fitting. There was one non-union and one patient developed chronic osteomyelitis treated by serial debridement and sequestrectomies.

Conclusions: Based on this experience, we suggest that the stabilization in ring frame with radical debridement and early tissue transfer provides fracture healing and good functional results in extensive compound blast injuries of the extremities even in limbs categorized as high risk.

The treatment of the multi-trauma, hemodynamically unstable patient, with pelvic fractures is a major challenge for the trauma team. The use of selective embolization, in early stage when hemodynamic instability persists despite control of other sources of bleeding, is well established. In these cases bleeding from an injured artery, cannot be controlled through indirect means such as an external fixation device, and must be directly addressed, through laparotomy and retroperitoneal packing or direct embolization of the bleeding artery. This procedure is part of the C phase of the ATLS, and therefore must be carried out in an emergency setup requiring a well trained team that can be alerted 24 hours a day. We present our experience and preferred protocol for the treatment of these complex injuries.

Material and Methods: Between the years 2000 and 2004, 732 patients with pelvic fractures were treated in our center. Of these, 11 patients with complex pelvic fractures required emergency arteriography and embolization. All the cases involved high energy injuries, eight motor vehicle accidents, two falls from height and one crush injury.

The average age was 32 (range 21 to 78). The pelvic fracture type was an anterior posterior mechanism in eight cases where the artery injured was the pudendal artery. In three cases iliac wing injury in a lateral compression or sheer mechanism, caused a gluteal artery injury. Timing of treatment: in 5 cases angiography was performed directly after an initial CT, in 4 cases the embolization was performed following an emergent laparotomy. In the remaining two cases, instability was recognized later in the course of treatment, one following amputation of a mangled leg and the second after secondary deterioration in a head injured multi-trauma patient.

Five patients went through pelvic fixation by an external fixation device, applied prior to angiography of which two were surgically applied and three were treated with a pelvic belt.

In five patients no pelvic fixation was needed either initially or definitively.

Discussion: When available angiographic embolization can be used affectively in these selected cases. Pelvic fractures can present with arterial injury even with a clinically stable pelvic ring. An arterial injury must be considered in all severe pelvic injuries regardless of the pelvic ring stability. We recommend strongly to use the belt as an intermittent way of controlling the hemodynamic instability and not to delay direct means of hemorrhage control such as laparotomy or embolization – if there is a team ready in the hospital. We must consider that the delay in treatment, short as it may be, needed for application the external fixation devices, may be crucial for the survival of the patient.

Aims: To evaluate the clinical outcome of the treatment of severe high-energy war injuries to limbs using circular external þxation frames. Metods: 43 patients after war injuries with 57 high-energy fractures were treated. According to Gustilo and Anderson all fractures were open grade 3B and 3C. There was other major organ trauma in 52,8% of patients. On admission, the fractured bones were stabilized with an AO tubular external þxation frame followed by thorough extensive soft tissue debridement, vascular reconstruction if needed. After 5 to 7 days the tubular þxator is exchanged for a circular frame that allows receiving stability, sufþcient for full weight bearing by minimal invasive þxation and freeing the previously bridged joints, in order to preserve their range of movement. Closed reduction of fractures was performed in most patients by successful implementation of ligamentotaxis and use thin wires with olives. In patients with high-energy Ç ßoating joint È injuries the circular devices were connected by hinges to permit early initiation of joint motions and functional treatment. In patients with upper limb injuries a separate bone þxation was used to allow early ßexion/ extension and pronation/supination motions. Results: In all patients the circular external þxation was the deþnitive treatment. Bone grafting was not necessary in any patient because of compression-distraction possibility. Fracture union was achieved at median time of 8 months (range 3 60). Throughout the period of fracture healing the patients were ambulatory, living at home. Conclusion: The circular þxation frame allows perform successful skeletal stabilization and functional restoration of limbs in patients with extensive bone and soft tissue loss, even in limbs of the risk.

With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.

Methods: During a three-year period, all patients with major anterior pathology at the T11, T12 or Ll level, were operated using the retrodiaphragmatic anterior approach. This involved an 10th or 11th rib thoracotomy with the patient in a lateral decubitus position. Following rib resection, blunt dissection of the diaphragm from the chest wall was performed without its surgical incision. The parietal pleural was mobilized medially and left intact and the thoracolumbar spine was exposed for the procedure. In case of a major pleural defect, a chest drain was inserted.

Results: Fifteen patients (10 males and 5 females, mean age: 32.6y) made up by study group. This included six patients who had a thoracolumbar fracture, five patients who were diagnosed as having idiopathic scoliosis and four patients who presented with metastatic disease in the thoracolumbar region. Adequate decompression was achieved in all patients as well as stable fixation of the involved segment. Mean operating time was 4.5 hours, average hospitalization length was six days. Three patients (20%) required a chest drain following the procedure. The drain was removed within three postoperative days of the operation. In five cases (40%) blood transfusion was required. Mainly for the underlying disease. The average decrease in the hemoglobin values, in the patient subgroup not requiring blood transfusion, was 3mg% at discharge comparing to the preoperative level. No intra-operative complications related to the surgical technique or instrumentation, were noted, nor any case of mortality. Complications such as respiratory distress, neurological damage, infection, hardware loosening or failure, pseudoarthrosis or hernia in scar were not observed during the post operative follow-up.

Conclusion: The retrodiaphragmatic approach to the thoracolumbar spine is safe and technically easy to apply in cases where ventral exposure of the spine is needed. This technique spares the need for diaphragmatic incision and in most cases, leaves the pleural cavity intact.

Antibiotic polymethylmethacrylate (PMMA) beads are known as an effective drug delivery system for local antibiotic therapy in bone and soft tissue infections. Over the years it has become an efficient method to treat osteomyelitis and other infections in orthopaedic surgery. Whilst this method has gained popularity primarily in infected arthroplasty, trauma and chronic osteomyelitis, its application in spine surgery is less known.

Methods: From 1997 to 2000 we have followed prospectively all patients who developed severe purulent wound infection following various types of instrumented spine fusion. Any patient, who had the typical presentation of surgical wound infection was enrolled into the study. Revision consisted of radical debridement of all necrotic tissue from the surgical wound, jet irrigation with saline and application of antibiotic contained PMMA beads. Primary closure over a suction drain was done in all cases and the patient was treated with parenteral antibiotic therapy. Following first revision, patients were treated with broad-spectrum parenteral antibiotic therapy, which was converted to culture-sensitive antibiotic. Suction drains were removed when the output was less than 50cc/24hr. Patients were returned for a second revision when local and systemic parameters showed no evidence of active infection.

This revision consisted of PMMA bead removal, debridement as necessary and irrigation. Primary closure over a suction drain was performed in all cases. No hardware removal was done in any of the cases. Follow up studies included radiographs and gallium bone scan.

Results: There were five patients in the study group. Of these, two had posterior spinal fusion for trauma; the remaining three had fusion for a various etiologies (tumor, corrective osteotomy in ankylosing spondylitis and lumbar instability). Causative organism was staphylococcus aureous (2 patients) and MRSA (3 patients). Mean interval from primary surgery to the first revision was 12 days and 19 days until the second revision. None of the patients had a third revision. There was no evidence for exacerbation of the infectious disease during follow up nor any pain or other signs which could mark the beginning of chronic osteomyelitis. No systemic or local complications related to the surgical technique or the PMMA beads were noted during the period between revisions. Galium scan was performed in only three of the five patients for a different reason. Scan results were negative in all three.

Conclusion: Two-stage revision surgery with PMMA antibiotic beads in a purulent surgical wound infection following spinal fusion, is a highly efficient method. This approach can assure proper healing of the surgical wound with no need for instrumentation removal or prolonged secondary healing of the surgical

Introduction: Treating tibial plateau fractures extreme care should be given to restore articular surface height preserving knee joint stability to be able to obtain maximal range of movement and to prevent future joint degenerative changes. Preoperative evaluation with CT and 3-D reconstruction is mandatory to understand the topography of the fracture for surgical planning. Traditional bone grafting techniques together with newer bone substitutes should be utilized in addition to ligamentotaxis when necessary. Fixation with smooth or olive wires (in occasions with washers for wider contact), sometimes augmented by screws is used with the Ilizarov external frame for stabilization avoiding extended incisions. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring. Guided by these principles, complex tibial plateau fractures were treated in our department and the results are reported.

Materials and Methods: Ten patients 40.6 years old on average (30–70) with Schatzker type V–VI fractures (all closed) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. Six were treated by ligamentotaxis and Ilizarov fixation alone and minimal opening for joint surface elevation when needed. The remaining 4 needed 6.5 mm canulated cancellous screw augmentation and 2 of them additional bone graft supplementation. Two patients needed extension of the frame to the femur with hinges on the center of joint rotation. All patients remain non-WB for 6 weeks and partial WB for another 6 weeks. Within 3 months the frame was removed and replaced by a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: The results were analyzed over an average follow-up period of 22.6 months (range 3–53). All fractures healed in an average of 12 weeks. Range of motion in all patients included full extension with 90° of flexion or more. No postoperative infections, septic arthritis or neurovascular complications were reported. Pin site infection was resolved locally. One case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient).

Discussion: Ilizarov external fixation for complex tibial plateau fractures offers the advantage of minimal invasive interventions with a high level of functionality since the early post operative period. The combination with minimal invasive opening for joint surface elevation and additional screws or bone graft extends even more the scope of the treatment. Functional results were similar to previous reported series. The good observance of traditional tibial plateau surgery principles should guide the surgeons when using this modality of treatment for optimal results.

Correction of spinal deformities such as those seen in idiopathic scoliosis, are one of the challenging aspects of the spine surgeon’s routine. A significant progress has been made in sense of the surgical approaches, implants design and methods of correction during the last two decades. Since the pioneer conception of Paul Harrington that a scoliotic curve can be corrected by distraction, other methods such as derotation and translation came out as an alternative ways to get a straight and balanced spine. Recently, a new concept of correction for spinal deformities named in-situ contouring, has brought to our attention. This method is based on a 6mm Titanium rod (SCS Eurosurgical Inc.) connected to the spine with a multiple hooks and screws system. The rod is bend according to the curve in the coronal plane and loosely secure with setscrews. Following primary application of the rod, the surgeon begins to bend it manually in situ, in a contrary direction to the curve’s shape. By applying a combination of a sagittal and coronal plane forces, the surgeon is able to achieve a final result of a straight and nicely balanced spine.

Methods: The medical records of patients with idiopathic scoliosis, who had surgery during the last three years, were reviewed. Patients, whose operation evolves using of the SCS system, enrolled into the study group. Clinical as well as radiographical data were retrieved from the hospital charts. Curves were classified according to King et al., measurements were taken using the Cobb’s method.

Results: There were 10 patients in the study group (7 females, 3 males, mean age: 16.6 years). All curves were primary thoracic from which 9 were type II and only one was type III. Mean pre-operative angle of the primary curve was 56°, mean post-operative angle was 22° with a 61% correction rate. Patients were followed for an average period of 12 months. No complications related to surgery, correction techniques, or neurological status was noted.

Conclusions: The in-situ contouring system has no drawbacks compare to other known methods. Our feeling is that this new technique gives the surgeon an ability to achieve the final position of the corrected spine, by a slow and gradual manipulation. This is taking a crucial advantage of the elastic property of the spine in order to get good correction and to avoid neurological complications or hooks pull out.