Introduction: Chronic ruptures of the distal biceps tendon are relatively infrequent and are complicated by the retraction of the tendon and extensive scar formation, which preclude satisfactory repair. Bibliographical data presents different surgical procedures for the reconstruction of chronic ruptures using allograft soft-tissue constructs with varying results. The purpose of this study was to describe the surgical technique for reconstruction of the tendon with local soft tissue as graft and to report our experience with this procedure.

Methods: 17 patients with an average age of 54 years underwent surgical reconstruction of a chronic disruption of the distal biceps tendon. The mean interval between tendon rupture and reconstruction was 14 months. In all patients a flap from lacertus fibrosus was used in continuation with the remnants of the tendon. A based distally strip of the biceps was reversed and entubulated in the lacertous fibrosus flap and the whole construct was then advanced to the bicipital tuberosity. 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 tuberosity.

Results: After an average duration of follow-up of 3.5 years, all patients had an excellent subjective result and they had all returned to their previous occupation. Furthermore, the strength of flexion and supination was comparable with that on the contralateral side in 13 patients. According to the Mayo Elbow performance score, the results were excellent in 9 patients, good in 4 and fair in 4. Complications that were encountered included a superficial infection which resolved with oral antibiotics, a transient median nerve palsy and a case of puncture wound of the brachial artery.

Conclusions: The aforementioned technique yields satisfactory postoperative results for this challenging problem with almost equal development of force and functionality on both sides and with a minimal possibility of re-rupture.

Aim: Postraumatic elbow stiffness is a common condition after elbow trauma. Sometimes it is a quite disabling symptom not responding to conservative measures. We present the surgical treatment of such cases of posttraumatic elbow stiffness.

Material: Twenty three patients, fourteen male and nine female with an average age of 34 yrs, underwent a surgical treatment of their stiff elbow. The average preoperative range of motion regarding elbow flexion-extension was 65° and the average rotational movement was 123°. All patients had received a resection of the anterior capsule, release or resection of posterior elements, removal of loose bodies and resection of osseous beaks if it was necessary. Two patients received a triceps lengthening. The results evaluated with the Mayo Elbow Performance Score.

Results: The average follow up was twenty nine months. All the patients were available for clinical assessment. There was an improvement of the average ROM to 115°, regarding flexion extension and to 164° regarding supination pronn. Postoperatively a dynamic elbow splint was used in twenty patients and a hinged external fixator in the remaining patients. Revision elbow release was performed in three patients and in one patient the elbow stiffness was deteriorated. Sixteen patients had an excellent or good result, and seven had a fair or poor one.

Conclusion: Elbow stiffness is an extremely disabling condition causing a functional impairment. Surgical elbow release is quite reliable, and relatively safe procedure given the fact that the patient follows strictly the rehabilitation protocol.

Aim: To retrospectively review the results of the use of adductor digiti quinti flap in failed cases of primary carpal tunnel tunnel release. The concept under this procedure is to provide a highly vascularised bed for axonal regeneration.

Material: Twenty cases of failed carpal tunnel release included in the study. The average age of patients was 43 years. There were thirteen female and five male patients. In two cases, one male and one female the procedure performed bilaterally.

All patients had a repeat of release ading a neurolysis of the median nerve. The adducor digiti quinti flap was dissected up to its neurovascular bundle and flipped over..

Results: In thirteen cases the procedure was successful as this was detected objectively and subjectively. In four cases the situation was unchanged and in three a revision surgery required for decompression of the nerve. Complex regional pain syndrome developed in three cases.

Conclusion: Although postoperative healing and rehabilitation time is lengthy due to more extensile dissection, pain relief, motor and sensory improvement, and hand dexterity justify the procedure.

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

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.

Introduction: Common misconceptions about distal radius fractures result in undertreatment, particularly in active population.Loss of reduction can cause a symptomatic malunion. The aim of the study is to present the clinical consequences of a dorsally malunited distal radius fractures and the results of a corrective osteotomy for the treatment of this problem

Material: 18 patients with distal radius fractures healed in a dorsal angulation and a mean age of 39 years, treated with a corrective osteotomy. 13 patients had been treated by closed means, and 5 had undergone a earlier surgical procedures without success. 11 patients had a DISI instability of the wrist. 12 patients underwent a radius corrective osteotomy alone, 4 had a cpmined radial osteotomy amd ulnar shortening osteotomy, and 2 underwent only a Sauve-Kapandji procedure.

Results: The average follow up was 26 months. All the osteotomies healed. 15 of the deformities were corrected. 7 patients with DISI deformity were regained normal wrists whereas the rest 4 remained with DISI instability. One patient with normal wrist led to DISI instability postop.

Conclusion: Distal radius corrective osteotomy is a technically demanding operation, and by no means can guarantee a postop normal anatomy. Furthermore and despite the functional improvement it is unknown the remote consequences wth a ersidual DISI deformity.

Introduction: Various surgical techniques existed for the treatment of three and four part proximal humeral fractures with variable outcomes. The aim of this study is to present a technique using small materials, to preserve all the biologic principles of fracture fixation, in the treatment of these challenging injuries.

Material: We perform a study taking as inclusion criteria: 3 and 4 parts proximal, closed, humeral fractures, treated surgically by open reduction and a modular biological internal fixation.

Surgical technique: Through a standard deltopectoral approach the fragments reduced, taking care to preserve the periosteum and manipulate meticulously the soft tissues. All the fractures were fixed with a combined system of Kirschner wires inserted to the proximal fragments, connected by “bone clips” forming a modular construction and fixed to the main distal fragment by AO screws.

Results: 24 patients complied with the inclusion criteria and were followed up a mean of 18 months. All patients achieved a satisfactory result except a fracture-dislocation that developed AVN and was revised into a shoulder arthroplasty and two demented elderly patients with metalware failure that were also revised.

Conclusion: In this first series of non-selected cases the outcome of fracture consolidation is promising. Although this technique is in its embryonary phase of development and the functional results are currently been assessed, the radiological outcomes suggest that the technique described is a valid alternative to the treatment of these fractures if we indicate an osteosynthesis method that combines biology and stability.

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 11 patients with an average age of 40 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but one fracture ware closed. The level of the tibia fracture included midshaft (two), middle-distal third (seven), distal third (two). Seven of the ankle fractures were classified as Weber B, three as Weber C and one Pilon. One fracture was treated by cast immobilization, eight with ORIF of both fractures and two with a combination of internal and external fixation. Of the patients treated operatively, five 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 fracture resulted in a mal-union and a severe loss of ankle mobility. Of the cases managed operatively, seven had complete structural and functional recovery, two patients regained 70% of ankle mobility and one developed ankle arthritis.

Discussion: The resulted experience from the treatment of these injuries shows their extremely unstable nature. It has been our experience that 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, a progressive slippage occurs over the time. We believe that stable fixation of both fractures should be the treatment of choice.

Purpose: The purpose of the study is to compare the disease severity at the time of surgical intervention between patients undergoing primary joint replacement under the National Health Service and Private Health-care Systems.

Materials: 166 patients were included in the study – 101 NHS and 65 Private. Inclusion criteria were: 1) hip or knee osteoarthritis, 2) primary joint replacement, and 3) informed consent of the patient. Patients with arthropathy of inflammatory, infectious or neoplastic aetiology were excluded. Physician evaluation included medical history, calculation of Charleson Comorbidity Scores, and Knee Society rating. Patients were given self-assessment health questionnaires including WOMAC, SF-36, and Nottingham Health Profile.

Results: Mean age was 69.4 years and did not vary significantly between NHS and Private groups. Charleson Comorbidity Scores were significantly worse in the NHS group than in the private. Health assessment questionnaire scores were all adjusted for age, sex, and comorbidity. In NHS patients undergoing TKR, we demonstrate significantly worse pre-operative comorbidity than in private group for indices of function and pain. Patients undergoing THR showed little difference in pre-operative comorbidity.

Conclusion: NHS patients undergoing primary TKR have significantly more advanced disease than their counterparts who are privately insured. Access to TKR surgery is determined by the healthcare delivery system rather then a threshold level of disease severity. Further follow-up of the outcomes of TKR in these two groups needs to be carried out to determine the long-term effects of accessing surgical care at a more advanced stage of disease.

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.

Introduction: Pelvic ring injuries represent a complex injury pattern and sometimes have significant consequences. The aim of this retrospective study is to delineate the indications of surgical treatment with emphasis in the anatomic reconstruction.

Materials and Methods: 85 patients with pelvic ring fracture with or without acetabular fracture reviewed retrospectively. The average patient age was 34 years. Operative treatment was provided to 26 patients. Six isolated acetabular fractures were treated by ORIF. Twenty pelvic ring fractures were treated, by anterior Ex-Fix in five cases, Ex-Fix plus sacroiliac screws in three, anterior reconstruction plate plus sacroiliac screws in two, anterior plate plus sacral bars in three. The remaining seven patients with an additional acetabular fracture treated with anterior plate for the pelvis and plates for the acetabulum.

Results: All the acetabular fractures were anatomically reduced. All fractures consolidated and no patient has developed hip AVN or post-traumatic arthritis. Brooker’s grade III ossifications complicated two patients. Partial neurological deficit of sciatic nerve was seen in three cases of acetabular fractures that improved spontaneously. A case of vertical shearing sacral fracture through the foramina presented with lumbosacral plexus paresis that recovered near normal function in 6 months. Deep infection complicated a case that subsided at 2 weeks on antibiotics and serial surgical debridement.

Conclusions: The strict application on rational criteria and an exquisite surgical technique caring of the soft tissues produce satisfactory outcome of these injuries. The above-described surgical treatment shortens the hospital stay and allows early physiotherapy to restore function.

Introduction: Management of supracondylar fractures above a TKR is a difficult problem, aggravated by the increasing number of arthroplasties carried out and the increase of the ageing population. The aim of this paper is to determine the limb function after treatment of these fractures.

Materials and Methods: We performed a retrospective study of the outcome of the treatment of suprandylar fractures above an ipsilateral TKR. All fractures were classified according to the Lewis & Rorabeck System. Conservative treatment was provided to eight fractures. Osteosynthesis using a Dynamic Condylar Screw (DCS) was performed to five patients. The largest group of twenty patients was treated with a retrograde supracondylar nail. Three patients underwent a revision surgery.

Results: Four out of eight fractures treated conservatively had a satisfactory outcome. All patients treated with a DCS achieved a satisfactory result. Seventy five percent of patients treated with a supracondylar nail gained adequate functional and anatomical result. Revision surgery was satisfactory in all cases.

Conclusion: The above-described fractures are still not very frequent, but represent a high risk of important complications, with potentially disastrous consequences. For those reasons and the poor bone stock in the elderly its management is controversial. The challenge for the surgeon is to achieve the goals of consolidation of the fracture, preservation of a painless TKR, and, restoration of the previous functional status. A complex group of factors, such as fracture pattern, implant status, bone quality and general condition of the patient, need to be assessed.