Purpose. In stabilisations of atlantoaxial instabilities it holds risks to injure the A. vertebralis as well as neurological structures. Furthermore the posterior approach of the upper part of the cervical spine requires a huge and traumatic preparation of the soft tissue. However the anterior transarticular C1-2 fusion (ATF) is less traumatic and offers almost the same strengh of the stabilisation. Methods. Since the 01/2007 22 multimorbid patients with atlanto-axial instabilities of different entities were treated via the ATF, were regular examined radiologicaly (x-ray/CT) and the procedure critically judged. Results. C1-2 fusions were performed in 22 patients (17f, 5m, Ø 81,67 years). Main symptoms was pain radiating in the upper cervical spine and the occiput, 2 Patients complaining radiating pain with paraesthesia. The average operation-time took 64,5 min. Leftside the screws of Ø 39,5mm (32–44mm), rightside of 36mm (32–44mm) were inserted in addiction to the point of access and the angle of insertion (mediolateral angle Ø 32,0°, ventrodorsal Ø17,6°). No introperative complications occured, one revision had to be done because of p.o. bleeding, one because of screw dislocation. Postoperative x-ray and CT control of the upper cervical spine showed 30/44 screws in 22 patients in correct position. 8 (18,2%) screws were too long, 3 (6,8%) screws were placed too anterior and 3 (6,8%) too medial. 8 additional positionated dens-screws were in correct position. After a clear learning curve both screws of the 6th patient were positoinated correct. Two aspects are important for success: Correct entry point and right insertion of the angle in the coronar and sagittal view. A low intraoperative blood loss, a non traumatic access as well as an immediate pain decrease have to be valued positively for this procedure. Conclusions. The gentle procedure of the ATF requires-despite of the huge experience in anterior surgery of dens fractures - a learning curve, because of the more proximate insertion point, the flat insertion angle and the closeness of the A. vertebralis. If these aspects are going to be noticed, failed screw positioning and excessive length as well as injuries of the A. vertebralis can be avoided

Aim and Purpose of the study. The authors evaluate the efficacy of athrodiatasis as possible alternative to arthrodesis or arthroplasty in the treatment of ankle arthritis in young patients. They present the long term results (average 19 years) of a small series of patients (10 cases) treated with a monolateral transarticular external fixator associated to different open or athroscopic procedures. Material and Methodology. The patients have been revaluated with the Kitaoka scoring scale associated to the x-ray evaluation. The authors will compare these results with those reported for the same series at an early evaluation (2,5 y of follow up) and with those published in literature. Discussion. Arthrodiatasis of the ankle with distraction and movement of the joint under weightbearing can guarantee an intermittent Hydrostatic pressure that has a trophyc effect on residual cartilage. In 1995 a new interest in ankle distraction was promoted by a very active Duch group which in few years demonstrated that there was still space for this indication as alternative to the arthrodesis in very young and active patients because the functional and physical impairment, the pain and mobility of this joint can be improved also after the first year of follow up. Our good results with the same approach seems to confirm their conclusions after a long term follow –up even if there is no correlation between the functional and radiological findings. It is important to underline that frequently is necessary to associate to arthrodiatasis other ancillary arthroscopic or open procedures in order to optimise the results. Conclusion. Arthodiatasis as possible alternative to arthrodesis or arthroplasty in the treatment of ankle arthritis is still a valid option in selected cases because can guarantee good functional results even at a long term follow-up

We retrospectively reviewed 60 fractures of the tibial plafond treated by either an ankle-sparing diaphyseal-epiphyseal technique using the Ilizarov ring fixator or by an ankle-spanning technique using a monolateral articulated external fixator. The Ilizarov ring fixator was applied in 24 fractures and the monolateral articulated transarticular external fixator in 20. Both techniques were combined with limited open reduction and internal fixation of the articular surface if necessary. Between three and nine years after the injury, all patients returned for clinical and radiological assessment and evaluation of ankle function using the modified Mazur score. There were no significant differences between the two groups in terms of age, gender, mechanism of injury, type of fracture or length of follow-up. The mean functional ankle score was 86 points for the Ilizarov group and 82 points for the articulated fixator group. The difference was not significant (p = 0.07). There were no significant differences between the groups with regard to the radiographic score and late complications. Patients treated with the Ilizarov ring fixator had significantly better ankle and subtalar movement. We conclude that both techniques of external fixation are satisfactory methods of treatment for fractures of the tibial plafond, but that the total arc of movement of the joint is preserved better without bridging the ankle

Introduction. Chronic radial head dislocation in children after trauma is a serious condition. Often the dislocation is overseen initially and is a part of the Monteggia fracture complex with anterior bowing of the ulna. Typical complaints are pain, decreased ROM and cubitus valgus. Radial head dysplasia often occurs. The treatment of this condition is debated. Only few series of patients treated with open reduction and ulnar osteotomy exists with long-term follow up. We present a group of rare patients with long-time follow-up treated by only two surgeons through a period of 16 years. Materials and Methods. All 16 patients had anterior radial head dislocation (Bado type 1). Mean age at the time of traumatic dislocation was 6 years ranging from 2 to 9. We found a mean delay of 17 (range 1–83) months before open reduction and ulnar open wedge osteotomy. In 8 cases reconstruction of the annular ligament was performed and in 6 patients temporary transarticular fixation of the radial head with a k-wire was performed. Follow-up time was 8 (range 3–17) years postoperatively. Patients were investigated with bilateral x-ray, arthrosis status, congruency of the radiocapitellar joint, Oxford Elbow Score, force measurements and range of motion. Results. There were no major complications to surgery such as infection, nerve palsies or pseudarthrosis. Radiological results showed 9/16 with reduction of the radial head and with no arthrosis, 4/16 with arthrosis or subluxation, and 2/16 with a dislocated radial head. We found a significant correlation between radiological outcome and delay to ulnar osteotomy (p = 0.03). At follow up the mean Function score was 92 (SD 9), Social/psychological score 83 (SD 14) and Pain score was 88 (SD 15). None of the patients with fully reduced radial head had progressed in increased valgus deformity. In contrast, one of two patients with postoperative secondary dislocation of the radial head had an increase in carrying angle on 25 degrees. Typical clinical findings were a small but significant extension deficit and median loss of supination on 10 grades ranging from 0–90 (p = 0.008). Five patients had subsequent surgery, of which one had an excision of the radial head 8 years after primary surgery. Ligament reconstruction or transfixation of the radial head did not influence the radiological or clinical outcome. Discussion and Conclusion. Case reports of similar patients treated conservatively demonstrate high morbidity and therefore open reduction and ulnar osteotomy is justified given the good clinical longterm outcome in the present study. However, this study underlines the importance of minimising the delay between trauma and open reduction. If surgery is performed before 40 months after trauma good to fair longterm radiological results can be obtained. After 40 months there is a high risk of recurrent luxation of the radial head

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight.

The mean external fixation time was 309.8 days. According to Paley’s grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.

The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy.

Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

We have reviewed 20 women and three men aged 22 to 73 years, who had sustained a Mason type-IIb fracture of the neck of the radius 14 to 25 years earlier. There were 19 patients with displacement of the fractures of 2 mm to 4 mm, of whom 13 had been subjected to early mobilisation and six had been treated in plaster for one to four weeks. Of four patients with displacement of 4 mm to 8 mm, three had undergone excision and one an open reduction of the head of radius. A total of 21 patients had no subjective complaints at follow-up, but two had slight impairment and occasional elbow pain. The mean range of movement and strength of the elbow were not impaired. The elbows had a higher prevalence of degenerative changes than the opposite side, but no greater reduction of joint space.

Mason type-IIb fractures have an excellent long-term outcome if operation is undertaken when the displacement of the fracture exceeds 4 mm.

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma.