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.
Although pedicle screw instrumentation for the treatment of idiopathic scoliosis is very popular, hybrid constructs remain a safe and effective method of scoliotic curve correction. This retrospective study was undertaken to assess the outcomes of hybrid instrumentation in the treatment of idiopathic scoliosis. Forty three children underwent surgical correction for idiopathic scoliosis. Patients were evaluated at a minimum 2-year follow-up (range 2–9 years). Clinical and radiographic assessment was performed for all patients preoperatively, immediately postoperatively, one year after surgery and at the final follow up. Radiographic parameters assessed included Cobb’s angle, coronal balance, translation of the apex vertebra, kyphosis, lordosis, angle in the T10 – L2 region and sagittal balance. Idiopathic scoliosis was classified according to the King classification system. All patients underwent posterior spinal fusion using hybrid instrumentation while 6 received, prior to the posterior fusion, anterior thoracic discectomies. Postoperatively overall Cobb’s angle correction was 59.5%. At the final follow-up an average loss of the correction of 9.5% was recorded. Nevertheless, there was an overall correction of the translation of the apex vertebra and a satisfactory coronal balance improvement at the final follow up compared to the immediate postoperative follow-up. Although a trend toward improved sagittal balance was noted, it was not statistically significant. The surgical complications included 2 cases of deep wound infection. In addition one patient required revision and a longer fusion distally. Operative treatment of adolescent idiopathic scoliosis with hybrid instrumentation yields satisfactory clinical and radiological results. Therefore, it can be considered as a safe and effective method of treatment of adolescent spinal deformity
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
Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries. Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement. The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4. In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management.
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.
Among the most popular techniques for the management of radial nerve palsy is the transfer of the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB), of the Flexor Carpi Radialis (FCR) to the Extensor Digitorum Communis (EDC) and of the Palmaris Longus (PL) to rerouted Extensor Pollicis Longus (EPL). This retrospective study was undertaken to assess the outcome of flexor carpi radialis transfer in the treatment of radial nerve palsy. Twenty patients with a mean age of 36 years were included in this study. Surgical management, as described above, was decided since all patients had irreparable damage to the nerve. Parameters that were assessed included range of wrist motion, dynamic power of wrist flexion and extension, and radial and ulnar deviation and function. The average follow-up was 4.5 years. Compared to a control group of 10 volunteers of similar characteristics, all patients achieved a functional range of motion and satisfactory power of wrist motion. All patients returned to their previous occupation. Transfer of Flexor Carpi Radialis tendon for irreparable radial nerve palsy yields satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion as well as an adequate strength of motion.
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.
