Aims: This experiment study was undertaken to evaluate the differences, in bone response to various grafts.

Methods: Ninety, 3.5 months New Zeland white rabbits, weighing 4kg, were divided randomly in 6 groups of 15 animals. Under anesthesia, a 4.5mm hole was drilled in the 2 posteriors femoral condyles of each rabbit, in totaling 180 condyles. Holes were filled with various grafts as follow: Group I-autograft, Group II-xenograft (Lubboc®), Group III-allograft DBM (Grafton®), Group IV-substitute calcium sulfate (Osteoset®), Group V-substitute calcium phosphate hydroxyapatite (Ceraform®), Group VI- was used control. After the implantation, the animals were sacrificed at 1, 3 and 6 months intervals tissue samples from the implanted areas were processed for histological evaluation.

Results: Group I: At 1 month, autologous grafts were lined with activated osteoblasts and osteoclasts. Lamellar bone and cartilage were evident. Neoangiogenesis was prominent. At 3, 6 months defects were filled with mature bone. Group II: Lubboc® displayed moderate (1 month) to intense (3 months) remodeling activity and pronounced neoangiogenesis. At 3 months, endochondral osteogenesis and lamellar bone production were more prominent. At 6 months graft material was significantly restricted and lamellar had considerably replaced woven bone. Group III: Grafton® putty was present at 1, 3 months. There were few osteoblasts and numerous multinuclaeated cells rimming implant surfaces. Endochondral ossification foci, new bone formation and neovascularisation were observed (1, 3 months). At 6 months DBM fibers were absent. Lamellar and woven bone was evident. Group IV: At 1 month new bone (mostly woven) was present, lined with activated osteoblast and few osteoclasts. Endochondral ossification and angiogenesis were evident. At 3, 6 months bone remodeling was augmented, and Osteoset® graft was diminished. Complete closure of defects was observed, at 6 months. Group V: Ceraform® exhibited almost the same properties as Osteoset®. However, endochondral osteopoiesis and bone remodeling were less intense. Additionally, after 6 months, Ceraform® was still evident. Group VI: The defect areas were clearly observed at 1, 3 months.

Conclusion: Autografts are the most effective graft materials. Although Lubboc® is not totally resorbed, it seems to induce lamellar bone synthesis stronger than Grafton®. Bone substitutes are inferior to allografts.

Aims: To investigate the effect of tibial reamed intramedullary nailing in treating tibial shaft aseptic nonunion. Method: Between 1990 to 2002, the intramedullary nailing was used in100 patients with aseptic tibial nonunion. Seventy-þve were men and 25 women with a mean age of 31 years (ranging from 18 to 76 years). Thirty-eight (38%) of the fractures were initially open (A:9, B:12, C:15) according to Gustilo-Anderson classiþcation. Sixty-seven (67%) cases were initially treated with external þxation, 13 (13%) with plate and screws, 6 (6%) with I.N., and 14 (14%)with plaster of Paris. The time that elapsed from injury to intramedullary nailing ranged from 6 months to 7 years (mean 15,6 months). Fibular osteotomy was performed in 76 cases through a separate incision. In 6 cases bone grafts from the iliac crest were used. Results: During a follow-up period of one to seven years (mean: 2 years), all of the cases achieved consolidation an average of 6 months after nailing. In 4 cases a late infection was observed which settled after nail removal. One patient developed impending compartment syndrome which was detected on the þrst post-operative day and was treated with a fasciotomy. Transient peroneal nerve palsy occurred in one patient and this recovered in 3 months. In nine patients a clinically acceptable deformity was noticed. Conclusions: Because of its high union rate and low complication rate, we believe that the reamed nailing technique should be considered preferentially for all aseptic tibial shaft nonunion cases.

Aims: Outcome of the distal tibial fractures treated with interlocking nail. Method: We reviewed 108 patients with distal tibial fractures which were treated in our clinic between 1990 using interlocking intramedullary nailing. 94 patients (63 men and 31 women) were found in the recent follow up. AO fracture classiþcation system was used Seventy-eight patients had concomitant fractures of the lateral malleolar and 4 had medial malleolar fractures. Eight (8,5%) of the fractures were open grade I. All fractures were managed with closed reamed nailing. In fourteen cases the nail had to be shortened. The lateral malleolar fractures were þxed before tibial nailing to ensure overall alignment. Results: Union was achieved in 89 (94,6%) fractures with a mean time of union of 4,2 months (range:3–10 months). One deep infection (1,06%) lead to nonunion. Three aseptic cases had delay union which required nail dynamization. In one more nonunion case bone grafting and þbulectomy required. Postoperative transient peroneal palsy occurred in 2 (2,12%) patients which were fully recovered. One patient developed deep posterior compartment syndrome leading to FHL conctracture, needed tendon lengthening. Conclusions: Interlocking intramedullary nailing is a reliable, safe and effective method of managing distal tibial fractures with or without minimal ankle joint involvement.

Aims: To evaluate the functional recovery of the complex tibial plateau fractures Schatzker type V and VI treated with hybrid ex. þx. Methods: Twenty-eight patients with intra-articular fractures of the proximal tibia were treated with hybrid external þxation in a three years period (1998–2001). The mean age was 35 years (17–76). According to Schatzker classiþcation, there were 11(39.3%) fractures type V and 17(60.7) type VI, whereas 5(17.8%) fractures were open. Complex injury was recorded in 15(53.5%) patients. Closed reduction and hybrid external þxation was achieved in 21 (75%) fractures. Additional limited internal þxation was performed in 9(32%) cases. Open reduction was necessary in 7(25%) patients. Mobilization of the injured articulation was started at the 3rd postoperative day. Results: Mean follow up period was 18 months. All fractures but one united at an average of 13.5 weeks (range from 11 to 18 weeks). The results were assessed according to the criteria of Honkonen and Jarvinen. An overall 22(78%) excellent and good results was recorded at the þnal follow up. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and þve pin tract infections. Conclusions: The use of hybrid external þxation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow early mobilization and functional recovery of the knee joint.

Aims: To evaluate the functional recovery of the complex tibial plateau fractures Schatzker type V and VI treated with hybrid ex. fix..

Methods: Twenty-eight patients with intra-articular fractures of the proximal tibia were treated with hybrid external fixation in a three years period (1998–2001).The mean age was 35 years (17–76). According to Schatzker classification, there were 11(39.3%) fractures type V and 17(60.7) type VI, whereas 5(17.8%) fractures were open. Complex injury was recorded in 15(53.5%) patients. Closed reduction and hybrid external fixation was achieved in 21 (75%) fractures. Additional limited internal fixation was performed in 9(32%) cases. Open reduction was necessary in 7(25%) patients. Mobilization of the injured articulation was started at the 3rd postoperative day.

Results: Mean follow up period was 18 months. All fractures but one united at an average of 13.5 weeks (range from 11 to 18 weeks). The results were assessed according to the criteria of Honkonen and Jarvinen. An overall 22(78%) excellent and good results was recorded at the final follow up. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and five pin tract infections.

Conclusions: The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V,VI), insure good restraining and early union, avoid major soft tissue complications and allow early mobilization and functional recovery of the knee joint.

The purpose of this study is to determine the indications and effectiveness of hybrid external fixation in the treatment of tibial plateau fractures and to evaluate the patient’s functional recovery.

Twenty-seven patients with 28 intra-articular fractures of the proximal tibia were surgically treated with hybrid external fixation in a two years period (1999–2001). There were 25 patients (19 men and 6 women) available for the last follow up evaluation. The mean age was 35 years (17–76). According to Schatzker classification, there were 6 fractures type V and 22 type VI. Three of them were open fractures. The method included, indirect reduction based on ligamentotaxis and compression of the fractured segments with olive pins, in most patients. Additional limited internal fixation with free screws was also performed in 5 cases. Open reduction was necessary in 6 patients. Mobilization of the injured articulation was started at the third postoperative day, while full weight bearing was allowed after three months. The fixator was removed in average 12th week. Final evaluation was done according subjective, functional, clinical and radiological criteria. Mean follow up period was 14 months.

All fractures except one united at an average time of 13, 5 weeks. Twenty-two patients (77.6%) graded as excellent and good, hi detail, subjective results were acceptable in 72%, functional in 84%, clinical in 70% and radiological in 80%. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and superficial pin path infections.

The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow quick mobilization and functional recovery of the knee joint. Moreover it is an application rather atraumatic because, only occasionally requires open reduction.