Introduction

Throughout the years treatment of patellar fractures have been held in much controversy and various treatment procedures have been described. In the literature, there are only a few studies that compare the results of the different treatment modalities.

Introduction: The treatment of comminuted intra-articular fractures around the knee is one of most difficult areas of Orthopaedic traumatology. Open reduction and internal fixation is recommended by many authors. However, in severe comminuted fractures sometime it is difficult to achieve stable fixation and most cases need an additional cast immobilization following surgery. We present our experience with arthroscopic assisted closed reduction in severe comminuted knee fractures followed by fixation with Ilizarov frame.

Materials and Methods: Since 1998, 17 patients with comminuted intra-articular fractures around the knee were treated by this method. 8 patients had comminuted intra-articular fractures of the distal femur and 9 patients had comminuted fractures of the tibial plateau, one of them with fractures of both knees. There were 4 males and 4 females with femoral fractures (age: 22– 56Y; mean -31Y) and 8 males and 1 female with tibial plateau fractures (age: 34–68Y; mean – 51Y). Three fractures of the distal femur and 2 of the tibial plateau were open fractures. 5/17 Pts had polytrauma. We used AO classification for distal femoral fractures and Schatzker classification for tibial plateau fractures. All patients were operated within 48 hours after injury.

Results: In all patients, except two with unstable knee, closed reduction and Ilizarov external fixation was performed without knee immobilization, under knee arthroscopic control. In two cases split thickness skin graft was done following leg fasciotomies. Weight bearing was allowed 6 to 8 weeks following surgery. A second look arthroscopy was performed in 3 cases. The average time of fixation in Ilizarov frame was 4.5 months (range 3–6.5 months). On follow up of 2 to 8 years, 6/17 patients (35%) had excellent results, 8/17 patients (47%) had good results and 3 patients (17%) had fair results. No cases of osteomyelitis, neuro-vasular injuries or deep wound infection were observed.

Conclusions: Based on this study it seems that arthroscopic assisted closed reduction and Ilizarov fixation is very useful for severe intra-articular comminuted knee fractures. Arthroscopy of knee enables accurate reduction of these fractures, removal of free bone fragments and treatment of other intra-articular injuries. There is an early restoration of motion in injured knee, with short immobilization time, and there are no major complications.

Introduction: Penetrating injuries of the foot are very common. Although apparently straightforward, inappropriate approach and treatment can lead to complications and unsatisfactory results. We present our diagnostic and therapeutic approach using an outcomes approach, clinical results and complication rate.

Patients & Methods: Between 2001 and 2003, 63 patients (57 M and 6 F; mean age- 38, range 8 to 63; follow-up: mean 2.5Y range of follow-up 2–4 years) were treated for penetrating foot injury. Each patient had a routine x-ray and foot sonography. The most common injuries were those that penetrated shoes (45/63 pts) – nails (39/45) and wood pieces (6/45), – or bare feet (18/63 Pts) – nails (10/18), glass (5/18), wood pieces (2/18) and even seashells (1/18). The medical files of all these patients were searched for the relevant parameters.

Results: The presence of a foreign body inside the foot tissues was detected in 58/63 Pts (92%) and they were operated upon by meticulous debridement and removal of FB. In the remaining 5 Pts we could not trace any FB and they were treated initially by IV antibiotics. In these 53 Pts (91%) penetrating foreign bodies were detected by sonography, most of them on arrival. Only 5% of the cases could be diagnosed initially by x-ray. The false negative rate of sonography was 19% (11/58 pts). In 6 of these 11 pts, the presence of FB was detected only by a second sonography. In the remaining 5 pts, foreign bodies were not detected even in the second sonography, but found only during surgery. Complete healing was observed in 62/63 (98%) of patients, although 6 /63 (9%) underwent secondary debridement. One patient (diabetic) developed chronic osteomyelitis of the second metatarsal bone and needed repeated surgical interventions.

Conclusions: In order to avoid complications and poor clinical outcome, penetrating injuries of the foot must be approached in an orderly and appropriate manner. The main purpose is to confirm the presence of a foreign body. Plain x-rays and sonography should be used in order to identify or rule out the presence of FB. Sonography is a good diagnostic technique, but it is operator dependent; thus a high index of suspicion must be maintained when the imaging study is negative and there is no clinical improvement despite appropriate systemic and local treatment. In our experience, repeated sonography and sometimes surgical exploration in such circumstances are likely to reveal the presence of a FB. It should be emphasized that injury through a shoe rather than a bare foot may result in local infection secondary to the penetrating object and also complications related to the additional presence of fiber, rubber or leather foreign body. Excellent results are observed following meticulous debride-ment combined with systemic antibiotics.

Introduction: The accepted treatment for unstable displaced tibial shaft fractures in adults is primary closed reduction and intramedullary nailing. However, this method poses a problem when treating young adolescents whose epiphyseal plates have not yet closed. We used the Ilizarov external fixation as an alternative method of treatment for these patients.

Patients and Methods: 13 patients with displaced unstable tibial shaft fractures (11 boys, 2 girls; age 13 to 16 yrs), of which 5 were open (Gustilo I–II), were treated by this method from 1995–2000. The Ilizarov frame was applied to 3 patients within the first 2 days of injury, a further 6 during the 1st week and 4 on the 2nd week or later.

All patients were allowed to weight bear from the first postoperative week. Physiotherapy was started immediately after operation and continued until normal knee and ankle function was regained. Dynamization was done in all cases 2 weeks before removal of frame. Following removal, the patients were advised to use crutches for an additional two weeks.

Results: A good or excellent alignment with full ROM in the ankle and knee joints was obtained in all patients. There were no cases of delayed or non-union. No cases of contractures or nerve injuries were reported. Superficial pin tract infection was seen in 6 patients, treated by antibiotics and local care. No cases of osteomyelitis or deep infection occurred. Length of fixation was 8–15 weeks (mean 11 weeks).

Conclusions: This method permits fixation without danger of injury to the epiphysis in growing adolescents. The stability of the fixator allows early weight bearing and leaves the adjacent joints mobile. There is no necessity for POP after removal of frame. Due to early weight bearing and an unrestricted joint movement less muscle wasting occurs. The healing time is relatively shorter than in other methods of the treatment and the complications rate was low in the presented series.

Introduction: During the last decade the Ilizarov method of limb lengthening has provided a solution for many patients with short stature, suffering not just from cosmetic problems, but having functional disability as well. The aim of this presentation is to discuss our experience of physiotherapy at all stages of treatment, from pre-operative evaluation to the final adaptation of the patient to his new limb condition and the problems that evolved and our solution to them.

Patients and Methods: Over the past six years, five patients underwent limb lengthening. Two had achrondoplasia, one had proximal focal femoral dysplasia and two had metaphysical dysplasia. Physiotherapy was given to prevent pulmonary complications, maintain joint mobility and muscle strength, stretch the soft tissue, encourage weight bearing and improve gait. The main complications that occurred were short quadriceps tendon, short Achilles tendon causing equines, excessive anterior pelvic tilt, restriction of the knee joint due to tightness of the iliotibial band and non-compliance of the patient.

Results: After the completion of treatment all patients walked independently and returned at least to their pre-operative functional level. Their posture and self-confidence were improved. Average lengthening of the lower limb was 28 cm.

Discussion: Careful selection of patients, maintenance of maximal range of motion of all joints involved at every stage of the treatment and long term physiotherapy after the removal of the external fixators are essential for success. It may be important to halt the lengthening process if adequate joint motion is not achieved. It can be concluded that despite the fact that this is a lengthy and painful procedure, the end results make it worthwhile.