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PODIUM ABSTRACTS
PODIUM
ABSTRACTS
INDEX
Podium
4(%-).)-!,,9).6!3)6%5.)6%23!,%84%2.!,&)8!4/2&%-)5)./0%.4)")!,&2!#452%3 ................................................................................................................. 71
Podium (9"2)$%84%2.!,&)8!4)/.).42%!4-%.4/&#/-0,%84)")!,&2!#452%3 .......................................................................................................................................................... 71
Podium
OPEN TIBIAL SHAFT FRACTURES (GUSTILO TYPE IIIA,B) TREATED WITH EXTERNAL FIXATION .......................................................................................................................... 72
Podium !#54%!.$$%&).)4)6%42%!4-%.4/&/0%.4)")!,&2!#452%37)4(!.%7-5,4)&5.#4)/.$9.!-)#%84%2.!,&)8!4/2 ................................. 72
Podium !2%6)%7/&&5.#4)/.!,/54#/-%/&#)2#5,!2&).%7)2%&)8!4/2353%$&/2/0%.4)")!,&2!#452%3 ............................................................................. 73
Podium EXTERNAL FIXATION IN OPEN TIBIAL FRACTURES
............................................................................................................................................................................................................................ 73
Podium ACUTE SHORTENING AND DELAYED LENGTHENING WITHOUT FLAPCOVER FOR GUSTILO3B INJURIES WITH BONELOSS ............................................................ 74
Podium 2!$)#!,352')#!,42%!4-%.4/&/0%.4)")!,&2!'-%.4&2!#452%37)4(&/2-%$$%&%#430,!34)#).52'%.40%2)/$ .................................... 74
Podium 2%35,43/&"/.%,%.'4(%.).'7)4(-/./,!4%2!,%84%2.!,&)8!4/2!33)34%$7)4(!.).42!-%$5,,!29.!), ...................................................... 75
Podium ,%.'4(%.).'$%&/2-)49#/22%#4)/.53).')-.!),3 ..................................................................................................................................................................................................... 75
Podium LENGTHENING THEN NAILING ............................................................................................................................................................................................................................................................................ 76
Podium 3%#/.$!29).42!-%$5,,!29.!),).'&/,,/7).'2%#/.3425#4)/./&3%'-%.4!,"/.%$%&%#437)4(!.%84%2.!,&)8!4/2 .................... 76
Podium ,%.'4(%.).'/6%2).42!-%$5,,!29.!),).').#/.'%.)4!,!.$!$15)2%$$%&)#)%.#)%3 ................................................................................................................. 77
Podium &)8!4/2!33)34%$0,!4).'63&)8!4/2!33)34%$.!),).'&/24(%#/22%#4)/./&#/-0,%8,/7%2,)-"3$%&/2-)4)%3 ........................................ 77
Podium &)8!4/2!33)34%$0,!4).'#/-").!4)/./&&)8%8!.$!.',%34!",%0,!4).')./34%/4/-)%3/&4(%,/7%2,)-" ............................................... 78
Podium 4)")!,2%#/.3425#4)/.7)4(53%/&!-/./,!4%2!,%84%2.!,&)8!4/2!.$!.).42!-%$5,,!29.!), ............................................................................. 78
Podium $)342!#4)/./34%/'%.%3)3&/24(%42%!4-%.4/&#/3-%4)#,%',%.'4(%.).'53).'!-/./,!4%2!,%84%2.!,&)8!4/2
4(%!54(/23/7.4%#(.)15% .................................................................................................................................................................................................................................................................... 79
Podium 2!$)/'2!0()##,!33)&)#!4)/./&(!,&0)."/.%).4%2&!#%2%!#4)/.).).&%#4%$0/3442!5-!4)#4)")!$%&%#43
42%!4-%.453).'-/./,!4%2!,&2!-%3 ......................................................................................................................................................................................................................................... 79
Podium 4(%53%/&!.4)")/4)#)-02%'.!4%$#%-%.430!#%23).4)")!,/34%/-9%,)4)3 ........................................................................................................................................ 80
Podium 4(%53%/&34)-5,!.+)4).42%!4).'#(2/.)#/34%/-9%,)4)3 ................................................................................................................................................................................... 80
Podium .%74%#(.)15%3)."/.%'2!&4).'!#/.42/6%23)!,$)3#533)/./&34!4%/&4(%!2402/#%$52%3 ............................................................................... 81
Podium 42%!4-%.4/&-!33)6%"/.%,/33!&4%2/%34%/-9%,)4)34)")!"9-%$)!,&)"5,!242!.30/242%0/24/&4(2%%#!3%3 ................................ 81
Podium 42%!4-%.4342!4%'9&/2/34%/-9%,)4)353).'%84%2.!,&)8!4/2 ....................................................................................................................................................................... 82
Podium 4(%2%,!4)/.3()0"%47%%.4)-%4/352')#!,$%"2)$%-%.4!.$).#)$%.#%/&).&%#4)/.).'2!$%)))/0%.&2!#452%3............................................. 82
0ODIUM
42%!4-%.4/&).&%#4%$$%&%#4)6%03%5$/!24(2/3)3"96!3#5,!2):%$"/.%'2!&4!.$),):!2/6 ........................................................................................ 83
Podium #/-").%$0%2#54!.%/53).4%2.!,!.$%84%2.!,&)8!4)/. ......................................................................................................................................................................................... 83
61
Podium -)34!+%3!.$#/-0,)#!4)/.37(),%53).'#/-054%2!33)34%$%84%2.!,&)8!4)/.$%6)#%3 ...................................................................................................... 84
Podium THE NEW GIGLI SAW INSERTION GUIDES................................................................................................................................................................................................................................................... 84
Podium 42%!4-%.42%35,43/&/24(/0%$)#!.$42!5-!0!4)%.43"9-%4(/$/&#/.42/,,%$42!.3/33%/53/34%/39.4(%3)3 ............................... 85
Podium 7(9%84%2.!,&)8!4)/.).4(%-!.!'%-%.4/&&2!#452%3 ...................................................................................................................................................................................... 85
Podium %84%2.!,&)8!4)/.!34/02%6%.4!.$4/#!2%0/3442!5-!4)#34)&&.%33/&4(%%,"/7 .............................................................................................................. 86
Podium &5.#4)/.!,2%35,43/&%84%2.!,&)8!4)/.!.$#/-").%$#/-02%33)/.3#2%73#/-0!2%$7)4(#,!33)#!,/2)&
!.$0,!4%3&/23502!).4%2#/.$9,!2#!.$#&2!#452%3).!$5,43 ....................................................................................................................................................... 86
Podium $9.!-)#!8)!,&)8!4)/. ..................................................................................................................................................................................................................................................................................... 87
Podium !8)!,%84%2.!,&)8!4)/.&/24(%42%!4-%.4/&$)34!,4)")!,-%4!0(93%!,&2!#452%3490%!!2%6)%7/&#!3%3..................................... 87
Podium 2%#/.3425#4)/.&/,,/7).'-!,5.)4%$!.+,%&2!#452%3........................................................................................................................................................................................... 88
Podium PILON TIBIAL FRACTURES TREATED WITH EXTERNAL FIXATION............................................................................................................................................................................................... 88
Podium 0),/.&2!#452%3),):!2/642%!4-%.4/.42!5-!(/30)4!, ........................................................................................................................................................................................ 89
Podium ,!4%2!,-!,,%/,!2452.$/7.!002/!#(&/24(%-).)-!,,9).6!3)6%42%!4-%.4/&0),/.&2!#452%3 ...................................................................... 89
Podium 4)")!,0),/.&2!#452%342%!4-%.47)4(34!.$!2$):%$#)2#5,!2%84%2.!,&)8!4)/.4%#(.)15%!.$-!4%2)!,................................................... 90
Podium 42%!4-%.4/&#/-0,%84!23!,.!6)#5,!2&2!#452%37)4(%84%2.!,&)8!4)/.!2%0/24/&#!3%3 .............................................................................. 90
Podium 42%!4-%.4/&!24)#5,!2&2!#452%3/&4(%(%%,7)4(%84%2.!,&)8!4/2/52%80%2)%.#% ........................................................................................................ 91
Podium 4%2)0!2!4)$%!3!$*5.#4).4(%2%3/,54)/./&!#2/.)#).&%#4%$3(!&44)")!./.5.)/.42%!4%$"9!#-"/.%
42!.30/24!4)/.!.$&2%,!4)33)-53$/23)&,!0#!3%2%0/24................................................................................................................................................................................ 91
Podium ARTHRODIATASIS FOR TALAR OSTEOCHONDRAL LESIONS USING CIRCULAR EXTERNAL FIXATION ............................................................................................................... 92
Podium #/-").%$53%/&4(%-/./"/$9$9.!-)#%84%2.!,&)8!4/2!.$).4%2.!,&)8!4)/.&/2!.+,%!24(2/$%3)3......................................................... 93
Podium !.+,%!24(2/$)!34!3)3!./04)/.&/20/3442!5-!4)#/34%/!24(2/3)342%!4-%.4..................................................................................................................... 93
Podium !24)#5,!4%$!.+,%$)342!#4)/.&/,,/7).'!.+,%42!5-! ......................................................................................................................................................................................... 94
Podium EXTERNAL FIXATION FOR ANKLE ARTHRODESIS.................................................................................................................................................................................................................................. 94
Podium THE ROLE OF CIRCULAR EXTERNAL FIXATOR IN ANKLE AND SUBTALAR ARTHRODESIS ........................................................................................................................................ 95
Podium %80%2)%.#%7)4(4(%!24)#5,!4%$&)8!4/2).4(%-!.!'%-%.4/&3%6%2%).34!"),)49/&4(%%,"/7#!,)....................................... 95
Podium 3(/24%2$52!4)/./&),):!2/6%84%2.!,&)8!4)/.).42%!4-%.4/&).&%#4)/. ......................................................................................................................................... 96
Podium -!.)05,!4)/./&4(%).6/,5#25-&/2&%-/2!,2%#/.3425#4)/.!&4%2#)%2.9-!$%2490%)6/34%/-9%,)4)3...................................................... 96
Podium #/-").%$),):!2/643&-/$%).4(%42%!4-%.4/&4)")!,$%&%#43$5%4/).&%#4)/53!42/0()#./.5.)/. ............................................................... 97
Podium 3)-5,4!.%/5342%!4-%.4/&"/.%!.$3/&44)335%$%&%#437)4(4(%),):!2/6-%4(/$&/2#(2/.)#/34%/-9%,)4)3
/&&%-524)")!7)4(/54&,!0#/6%2!'% ...................................................................................................................................................................................................................................... 97
Podium ).4%2,/#+).'.!),7)4(!,/.'!#4).'!.4)")/4)#2%,%!3).'#/2%&/2#/.6%23)/.&2/-%84%2.!,&)8!4)/. ......................................................... 98
Podium 42%!4-%.4/&).&%#4%$"/.%,/337)4(),):!2/6%84%2.!,&)8!4/2 .................................................................................................................................................................. 98
Podium TRANSOSSEOUS OSTEOSYNTHESIS IN CHRONIC INFECTION ..................................................................................................................................................................................................... 99
Podium 4)")!(%-)-%,)!2%#/.3425#4)/.!.$,%.'(4%.).'!342%!4-%.4 ..................................................................................................................................................................... 99
62
Podium
&)"5,!2(%-)-%,)!42%!4-%.47)4(),):!2/6.......................................................................................................................................................................................................................... 100
Podium !"/544(%.%%$/&4(%2%3%#4)/./&4(%&)"5,!2!.,!'%).4(%42%!4-%.4/&#/-0,%4%&)"5,!2(%-)-%,)! ................................................... 100
Podium /0%2!4)6%42%!4-%.4/&4(%0!4)%.437)4(#/.'%.)4!,$%&%#4/&$)34!,4)")! .................................................................................................................................. 101
Podium 342!4%'9!.$/54#/-%/&,)-"2%#/.3425#4)/.&/2&)"5,!2(%-)-%,)!490%)) .............................................................................................................................. 101
Podium ,)-"2%#/.3425#4)/.02/#%$52%3).4)")!,(%-)-%,)! ............................................................................................................................................................................................... 102
Podium "/.%,%.'4(%.).').&)"5,!2(%-)-%,)! .................................................................................................................................................................................................................................... 102
Podium 3/&47!2%"!3%$/24(/356&2!-%/04)-!,!33%-",9&/2)-02/6%-%.4/&+.%%*/).42/-............................................................................................. 103
Podium *5$%415!$2)#%030,!349%80%2)%.#%!.$.%74)03 ......................................................................................................................................................................................................... 103
Podium #534/-+.%%$%6)#%#+$&/24(%42%!4-%.4/&+.%%&,%8)/.#/.42!#452%3!&4%2&%-/2!,,%.'4(%.).' ..................................................... 104
Podium -!.!'%-%.4/&%842!34)&&.%33/&4(%+.%%*/).4).%84%.3)/.3%#/.$!294/02/,/.'%$%84%2.!,&)8!4)/.*5$%4........................... 104
Podium +.%%!24(2/$%3)3!.$3)-5,4!.%/53"/.%,%.'4(%.).'.......................................................................................................................................................................................... 105
Podium
+.%%./5.)/.42%!4%$7)4(),):!2/63 ....................................................................................................................................................................................................................................... 105
Podium KNEE ARTHRODESIS USING BIPLANE EXTERNAL FIXATION AFTER INFECTION PROCESS IN TOTAL KNEE ARTHROPLASTY....................................................... 106
Podium 42%!4-%.4/&4)")!03%5$/!24(2/3)37)4(4(%),):!2/6%84%2.!,&)8!4/2 ............................................................................................................................................ 106
Podium 42%!4-%.4/&&%-5203%5$/!24(2/3)353).'$)342!#4)/.!.$#/-02%33)/./34%/'%.%3)34%#(.)15% ................................................................ 107
Podium #/-0,%8"/.%2%#/.3425#4)/.)34(%2%!0/33)"),)49&/2,!"/22%).3%24)/. ........................................................................................................................... 107
Podium #/-").%$4%#(.)15%).4(%42%!4-%.4/&03%5$!24(2/3)3/&4(%4)")! ................................................................................................................................................... 108
Podium
#/-0,%8./.5.)/./&,/.'"/.%3-!.!'%-%.47)4(),):!2/6 ........................................................................................................................................................................ 108
Podium #()00).'4%#(.)15%&/2./.5.)/.3$%&/2-)4)%3!.$$/#+).'3)4%3 ............................................................................................................................................................ 109
Podium #/-").%$4%#(.)15%&/24(%42%!4-%.4/&03%5$/!24(2/3)3/&4(%&%-52 ...................................................................................................................................... 109
Podium ARTHRODIATASIS FOR FREIBERGS DISEASE........................................................................................................................................................................................................................................ 110
Podium !.%74%#(.)15%&/2(!,,58,)-)45354),):).'%84%2.!,&)8!4)/.!.$!24(2/$)!4!3)3 ............................................................................................................. 110
Podium CIRCULAR EXTERNAL FIXATION FOR ANKLE ARTHRODESIS ..................................................................................................................................................................................................... 111
Podium USE OF UNILATERAL EXTERNAL FIXATION FOR ANKLE ARTHRODIASTASIS WITH ARTHROSCOPY AS SALVAGE PROCEDURE .................................................. 111
Podium THE USE OF HYBRID EXTERNAL FIXATORS IN DISTAL TIBIA FRACTURES ....................................................................................................................................................................... 112
Podium !.+,%!24(2/$%3)37)4(),):!2/6%84%2.!,&)8!4/2#!3%3%2)%3..................................................................................................................................................................... 112
Podium 4(%53%/&!24(2/$)!4!3)37)4(42!.3!24)#5,!2%84%2.!,&)8!4)/.).4(%42%!4-%.4/&!.+,%!24(2)4)3,/.'4%2-2%35,43 . 113
Podium -).)-!,,9).6!3)6%352'%29/&()'(%.%2'902/8)-!,4)")!&2!#452%3(9"2)$%84%2.!,&)8!4/2 ............................................................................... 113
Podium #/-0!2)3/."%47%%.(9"2)$&)8!4/2!.$,/#+).'0,!4%3).42%!4-%.4/&$)30,!#%$")#/.$9,!24)")!,0,!4%!5&2!#452%3 ........ 114
Podium 4(%#/22%#4)/./&$%&/2-)49).%842%-)4)%3/&4(%#(),$2%.7)4(7)4((%-)#!,,/4!3)302%,)-).!29345$9 ................................................ 114
Podium %22/23).4(%0,!..).'!.$%8%#54)/./&#/22%#4)6%/34%/4/-)%3/&,/7%2,)-"3 ................................................................................................................. 115
Podium 02/8)-!,&%-/2!,/34%/4/-9#/-").%$7)4(0%2#54!.%/53%84%2.!,&)8!4)/.).4(%42%!4-%.4/&$%&/2-)4)%3
OF THE HIP IN PALSY ............................................................................................................................................................................................................................................................................................. 115
63
Podium $)34!,&%-/2!,6!,'53$%&/2-)49#/22%#4)/.&)8!4/2!33)34%$.!),).'6%2353&)8!4/2!33)34%$0,!4).' .................................................... 116
Podium 3)-0,%-%4(/$/&!.'5,!2$%&/2-)4)%3#/22%#4)/."94(%53%/&()'(#!0!#)49%84%2.!,&)8!4/2 ........................................................................ 116
Podium 3502!!.$).&2!45"%2/3)494)")!,/34%/4/-9!.$%84%2.!,&)8!4)/.&/2#/22%#4)/./&#/-0,%84)")!,$%&/2-)49............................ 117
Podium 3502!-!,,%/,!2$%2/4!4)/./34%/4/-9/&4(%4)")!7)4(,/#+).'#/-02%33)/.0,!4%&)8!4)/.!.$-).)-!,,
INCISIONS, IN PATIENS WITH IDIOPHATIC INTERNAL TIBIAL TORSION ............................................................................................................................................................................... 117
Podium -/./,!4%2!,%84%2.!,&)8!4)/.).4(%42%!4-%.4/&,/7%2,)-"$%&/2-)4)%3)./,,)%23$)3%!3% ............................................................................. 118
Podium !#54%42!5-!4)#0%2)0(%2!,!24%2)!,).*52)%32/,%/&-5,4)$%4%#4/2#/-054%$4/-/'2!0()#!.')/'2!0(9 ........................................... 118
Podium 42%!4-%.4/&/0%.4)")!,&2!#452%7)4("/.%$%&%#4#!53%$"9()'(6%,/#)49-)33),%3!#!3%2%0/24 ............................................................ 119
Podium 4(%53%/&%84%2.!,&)8!4)/.&/2"/.%42!.30/24).4(%42%!4-%.4/&#/-0,%84)")!,&2!#452%3.......................................................................... 119
Podium -!.!'%-%.4/&3%'-%.4!,&2!#452%4)")!"9),):!2/6%84%2.!,&)8!4/2 .............................................................................................................................................. 120
Podium "/.%42!.30/24&/2-!.!'%-%.4/&3%6%2%,9#/--).54%$&2!#452%37)4(/54"/.%,/33 ............................................................................................ 120
Podium 3%'-%.4!,4)")!,&2!#452%342%!4%$7)4(4(%),):!2/6-%4(/$!2%42/30%#4)6%!.!,93)3 ................................................................................................ 121
Podium
4/4!,!.$35"4/4!,!-054!4)/./&,/7%2,)-"342%!4%$"93(/24%.).'2%6!3#5,)2!:!4)/.!.$,%.'4(%.).' .......................................... 121
Podium
#/22%#4)/./&0/3442!5-!4)#%15).53#/.42!#452%7)4(4!9,/230!4)!,&2!-% ......................................................................................................................... 122
Podium
()'(4)")!,!.$$)34!,&%-/2!,/34%/4/-953).'5.),!4%2!,%84%2.!,&)8!4/2).+.%%$%&/2-)49............................................................................ 122
Podium
$)34!,4)")!!.$!.+,%2%#/.3425#4)/.53).'!#/-").%$4%#(.)15%7)4(%84%2.!,&)8!4/2!.$,#00,!4%3.................................................. 123
Podium
&)8!4/2!33)34%$).4%2.!,&)8!4)/.&/2!#54%"/.9&%-/2!,$%&/2-)49#/22%#4)/.3 ............................................................................................................ 123
Podium
!#54%#/22%#4)/./&&%-/2!,!.'5,!2$%&/2-)4)%3"92%42/'2!$%).42!-%$5,,!29.!),).' ....................................................................................... 124
Podium
42%!4-%.4/&,)-",%.'4(%.).'!.$!8)!,$%6)!4)/.3 ................................................................................................................................................................................................ 124
Podium
&)8!4/2!33)34%$.!),).'&!............................................................................................................................................................................................................................................................... 125
Podium
&)8!4/2!33)34).'.!),).'&/2$)34!,&%-52$%&/2-)49#/22%#4)/. ............................................................................................................................................................. 125
Podium
0,!..).'/&,/7%2$%&/2-)49#/22%#4)/.7)4(02/&%33)/.!,'2!0()#3/&47!2%#/2%,$2!7'2!&()#35)4%38 ................................. 126
Podium
42%!4-%.4/&,!4%.%',%#4%$!$5,4$)3,/#!4)/./&4(%()07)4(!(9"2)$$)342!#4/2!.$4/4!,()02%0,!#%-%.4 ................................. 126
Podium
42%!4-%.4/&,%''#!,6%0%24(%3$)3%!3%#/-0!2!4)6%345$9"%47%%.&%-/2!,/34%/4/-9!.$!24(2/$)!34!3)3............................ 127
Podium
/0%2!4)6%#/22%#4)/./&!#%4!"5,!2$930,!3)!53).'),):!2/6&2!-%).#(),$2%./&3#(//,!'% ............................................................................. 127
Podium
),):!2/642%!4-%.4/&3,)00%$#!0)4!,&%-/2!,%0)0(93)3).!$/,%3#%.43 .......................................................................................................................................... 128
Podium
),):!2/642%!4-%.4/&0!4)%.437)4(,%''#!,6%0%24(%3$)3%!3%................................................................................................................................................................ 128
Podium
),):!2/62%#/.3425#4)/./&4(%&%-52!342%!4-%.44%#(.)15%&/20!4)%.437)4(/54#/-%3/&0%24(%3$)3%!3% ................................ 129
Podium
!242/$)!34!3)3).$)3%!3%/&,%''#!,6³0%24(%3.......................................................................................................................................................................................................... 129
Podium
/54#/-%/&()02%#/.3425#4)/./34%/4/-9......................................................................................................................................................................................................................... 130
Podium
FIBULAR TIBIALIZATION ACCORDING TO ILIZAROV IN THE PATIENTS WITH ACUTE TIBIAL SHAFT DEFECTS .......................................................................................... 130
Podium
FRACTURES OF THE TIBIAL PLATES TREATED WITH HYBRID FIXATION (ORTHOFIX) IN THE HOSPITAL CALDERÓN GUARDIA, CAJA .................................... 131
Podium
#!3%3/&3%6%2%/0%.&2!#452%3/&4(%,%'9%!23/&-/.)4/2).' ............................................................................................................................................... 131
64
Podium
/0%.).'&/#!,$/-%/34%/4/-9).4(%-!.!'%-%.4/&6!253'/.!24(2/3)3!33/#)!4%$7)4(-%$)!,,!8)49 ................................................ 132
Podium
(9"2)$&)8!4)/.).-!.!'%-%.4/&#/-0,%8&2!#452%353).'),):!2/6&,%8)",%.!),3........................................................................................................ 132
Podium
")/,/')#!,&)8!4)/./&3%'-%.4!,&2!#452%3/&4)")!"9),):!2/6&)8!4/2............................................................................................................................................. 133
Podium
42%!4-%.4/&,%'/0%.&2!#452%37)4(!.(/-/'%.%/5302/4/#/,................................................................................................................................................... 133
Podium
),):!2/6$/-%()'(4)")!,/34%/4/-9&!#4/23,%!$).'4/2%,)!",%2%35,43 ........................................................................................................................................ 134
Podium
53%/&!$5,4-%3%.#(9-!,34%-#%,,3).,)-",%.'4(%.).'!.$!24(2/$%3)302/#%$52%3 ............................................................................................. 134
Podium
!54/,/'/53"/.%-!22/7'2!&4).4(%-!.!'%-%.4/&0%2#54!.%/53&2!#452%342%!4%$7)4(%84%2.!,
&)8!4)/.#/-0,)#!4%$7)4(2%4!2$%$#/.3/,)$!4)/. .................................................................................................................................................................................................... 135
Podium
/34%/'%.%3)3&/2$)342!#4)/.-!22/7..................................................................................................................................................................................................................................... 135
Podium
%.(!.#%$"/.%(%!,).'"9,/#!,).&53)/./&&'&!.$")30(/30(/.!4%$52).'$)342!#4)/./34%/'%.%3)3................................................. 136
Podium
#/-0,)#!4)/.3/&$)&&%2%.4"/.%'2!&4).'4%#(.)15%3!#/.42/6%23)!, ............................................................................................................................................ 136
Podium
EFFECT OF TERIPARATIDE ON BONE REGENERATE AFTER DISTRACTION OSTEOGENESIS ................................................................................................................................ 137
Podium
-5,4),%6%,")/%.').%%2).'%80%2)%.#%/&#,).)#!,53%............................................................................................................................................................................................. 137
Podium
%.(!.#%-%.4/&"/.%(%!,).'$52).'$)342!#4)/./34%/'%.%3)37)4(0,!4%,%432)#(0,!3-!020 ..................................................................... 138
Podium
42%!4-%.4/&).&%#4%$).42!#!035,!203%5$!242(/3)3/&4(%$)34!,4)")!........................................................................................................................................ 139
Podium
42%!4-%.4/&).&%#4%$$%&%#4)6%./.5.)/."96!3#5,!2):%$"/.%'2!&4!.$),):!2/6........................................................................................................ 139
Podium
4(%43&$%6)#%).#/-0,%8&2!#452%./.5.)/.-!,5.)/.!.$).&%#4)/./&&2!#452%2%0/24/&#!3%3 ..................................................... 140
Podium
4(%42%!4-%.4/&4)")!,3%04)#./.5.)/.7)4(%84%2.!,&)8!4)/./52%80%2)%.#% ................................................................................................................... 140
Podium
42%!4-%.4/&3%04)#03%5$/!24(2/3)3/&4(%4)")!7)4().4%24)")/&)"5,!2'2!&42%6)%7/&#!3%3 ................................................................ 141
Podium
3%04)#./.5.)/.42%!4-%.47)4(-/./,!4%2!,%84%2.!,&)8!4)/. ............................................................................................................................................................ 141
Podium
INFECTED PSEUDOARTROSIS OF LONG BONES TREATED WITH THE ILIZAROV ........................................................................................................................................................... 142
Podium
ARTHRODESIS AFTER KNEE PROSTHESIS INFECTION................................................................................................................................................................................................................... 142
Podium
!.%74%#(.)15%&/2"2!#(9-%4!4!23)!2%0!)27)4(#/.#/-)4!.4!24(2/$)!4!3)3 .................................................................................................................... 143
Podium
EXTERNAL FIXATION IN 325 HALLUX VALGUS RECONSTRUCTIVE PROCEDURES ...................................................................................................................................................... 143
Podium
352')#!,-!.!'%-%.4/&#,5"&//4).#(),$2%./&3#(//,!'%"94(%-%4(/$/&42!.3/33%/53/34%/39.4(%3)3 ................................. 144
Podium
-%4!4!23!,,%.'4(%.).'&/2"2!#(9-%4!4!23)!!0,!.4!2!002/!#(/&/34%/4/-9.............................................................................................................. 144
Podium
!00,)#!4)/./&),):!2/64%#(.)15%).#/22%#4)/./&34)&&&//4$%&/2-)49#/-").%$7)4(3+).3#!2 ...................................................................... 145
Podium
&)"5,!2(%-)-%,)!-!'.%4)#2%3/.!.#%)-!').'632!$)/'2!0(94/$%4%2-).%&//4$%&/2-)4942%!4-%.4 ................................................ 145
Podium
!#54%,%.'4(%.).'/&3(/24)6-%4!4!23!,"/.% ............................................................................................................................................................................................................ 146
Podium
STRETCHINGS AND TRANSPORTATION OF BONES IN CHILDREN AND TEENAGERS ................................................................................................................................................. 146
Podium
#,).)#!,!.!,93)3/&0!4)%.437)4(&//4!.$!.+,%$%&/2-)4)%3#!53%$"930).!")&)$! ............................................................................................. 147
Podium
,)-"2%#/.3425#4)/./2!-054!4)/.&/23%6%2%&)"5,!2$%&)#)%.#9!47/#%.4%2#/-0!2)3/. ................................................................................ 147
Podium
%,/.'!4)/."/.9).!&4%2-!4(/&0/,)/..................................................................................................................................................................................................................................... 148
65
Podium
LENGTHENING BONE IN LOW SIZE............................................................................................................................................................................................................................................................... 148
Podium
$!-!'%#/.42/,)./24(/0!%$)#........................................................................................................................................................................................................................................................ 149
Podium
4(%-!.!'%-%.4/&0%,6)#&2!#452%37)4(%84%2.!,&)8!4)/./52%80%2)%.#%.............................................................................................................................. 149
Podium
$!-!'%#/.42/,/24(/0%$)#-!.!'%-%.4/&0/,942!5-!.................................................................................................................................................................................. 150
Podium
42%!4-%.4/&&2!#452%3/&4(%0%,6)3).3%6%2%-5,4)0,%42!5-! .............................................................................................................................................................. 150
Podium
3%'-%.4!,,)&4&%-5245"5,!22!),&)8!4/242%!4-%.4/&#(/)#%................................................................................................................................................................ 151
Podium
!.%7$%3)'.-5,4)&5.#4)/.$9.!-)#%84%2.!,&)8!4/23934%-&/2"/.%2%#/.3425#4)/.3 ........................................................................................... 151
Podium
35"3)$%.#%/&#!,,/4!3)3:/.%).$)342!#4)/./34%/'%.%3)3!&4%2%84%2.!,&)8!4/22%-/6!,-%!352%$"92!$)/34%2.................. 152
Podium
0!).3#/2%3/.2%-/6!,/&),):!2/6&2!-%3).#,).)# ................................................................................................................................................................................................. 152
Podium
%34(%4)##/22%#4)/.!.$2%#/.3425#4)/./&,/7%2%842%-)4933(!0%"9/2)').!,%84%2.!,&)8!4)/.$%6)#%3 .......................................... 153
Podium
4(%).42).3)#).34!"),)49/&4(%4!9,/230!4)!,&2!-%!.$4(%(%8!0/$2).'&)8!4/2 ................................................................................................................ 153
Podium
).4%242/#(!.4%2)#/34%/4/-9).#(),$2%.!.$!$/,%3#%.433)-0,)&)%$02/#%$52%53).'4(%),):!2/6&2!-% .......................................... 154
Podium
$%2/4!4)6%/34%/4/-9).#(),$2%."9-%!.3/&%84%2.!,&)8!4)/. .............................................................................................................................................................. 154
Podium
02/'2%33)6%#/22%#4)/./&2%#526!45-!.$6!,'53$%&/2-)49!&4%2!39--%42)#!,'2/74(!22%34/&02/8)-!,4)")! .................. 155
Podium
#,/3%$#/22%#4)/./&4)")!,4/23)/."94(%),):!2/64%#(.)15%9%!23&/,,/750 ................................................................................................................. 155
Podium
4(%$/5",%%,%6!4)/./34%/4/-9&/23%6%2%",/5.43$)3%!3%53).'4(%4!9,/230!4)!,&2!-%.................................................................................. 156
Podium
'5)$%$'2/74("9%)'(40,!4%&/2#/22%#4)/./&!.'5,!2$%&/2-)4)%3!2/5.$4(%+.%% ................................................................................................. 156
Podium
42!.3&/2-).'/&"2)$').'*/).4&2!-%).4/$9.!-)#&2!-%$52).').42!!24)#5,!2&2!#452%42%!4-%.4 ...................................................... 157
Podium
42%!4-%.4/&#/8!6!2!54),):).'%84%2.!,&)8!4/2 ..................................................................................................................................................................................................... 157
Podium
42%!4-%.4/&#/.'%.)4!,#/8!6!2!53).'),):!2/6%84%2.!,&)8!4/2 ...................................................................................................................................................... 158
Podium
ARTICULATED EXTERNAL FIXATOR IN SPASTIC HIP DISLOCATION ....................................................................................................................................................................................... 158
Podium
/54#/-%/&$/5",%&%-/2!,/34%/4/-)%3&/2()02%#/.3425#4)/. ........................................................................................................................................................... 159
Podium
42%!4-%.4/&()0$%&/2-)49!.$0%,6)#/",)15)49 ........................................................................................................................................................................................................... 159
Podium
-!.!'%-%.4/&#/-0,%8&%-/2!,&2!#452%/54/&4(%"/8!002/!#(.................................................................................................................................................. 160
Podium
()0&2!#452%3-!.!'%$7)4(%84%2.!,&)8!4)/. ............................................................................................................................................................................................................... 160
Podium
%84%2.!,&)8!4)/.63'!--!.!),&/24(%42%!4-%.4/&/34%/0/2/4)#42/#(!.4%2)#&2!#452%3 ............................................................................. 161
Podium
-5,4)0,!.%%84%2.!,&)8!4)/./&&%-52).).4%242/#(!.4%2)#&2!#452%3).4(%%,$%2,9.................................................................................................... 161
Podium
0##0).-!.!'%-%.4&2!#452%342/#!.4%2)#!3 ............................................................................................................................................................................................................... 162
Podium
42%!4-%.4/&02/8)-!,()0&2!#452%37)4(-/./,!4%2!,%84%2.!,&)8!4/2..................................................................................................................................... 162
Podium
),):!2/6!00,)#!4)/.).4(%-!.!'%-%.4/&#/-0,%8!#54%&%-/2!,&2!#452%3 ......................................................................................................................... 163
Podium
(5-%2!,./.5.)/.42%!4-%.47)4(),):!2/6-%4(/$-5,4)#%.4%2345$9 ............................................................................................................................................ 163
Podium
#/22%#4)/./&2!$)!,$%&/2-)4)%3!&4%2'2/74(!22%347)4(4(%4!9,/230!4)!,&2!-% .................................................................................................... 164
66
Podium
#,/3%$2%$5#4)/.!.$%84%2.!,&)8!4)/.),):!2/6490%).4(%42%!4-%.4/&02/8)-!,(5-%253&2!#452%3 ................................................... 164
Podium
42%!4-%.4/&(5-%25303%5$/!24(2/3)37)4(),):!2/6-%4(/$7)4(/54"/.%'2!&4............................................................................................................. 165
Podium
42%!4-%.4/&500%2,)-"$%&/2-)4)%37)4(%84%2.!,&)8!4)/. ......................................................................................................................................................................... 165
Podium
42%!4-%.4/&(5-%253$)!0(93)3./.5.)/.7)4(),):!2/6%84%2.!,&)8!4/2 ..................................................................................................................................... 166
Podium
2%#/.3425#4)/./&&/2%!2-).#/-0,%8&2!#452%3 .................................................................................................................................................................................................... 166
Podium
ELONGATION BONY AND ARTRODIASTASIS ........................................................................................................................................................................................................................................... 167
Podium
%!2,9#/-0,)#!4)/.3/&%.,!2'%-%.47)4(-/./,!4%2!,%84%2.!,&)8!4)/. .................................................................................................................................... 167
Podium
02/0(9,!#4)#).42!-%$5,,!292/$$).'!&4%2&%-/2!,,%.'4(%.).').#/.'%.)4!,&%-/2!,$%&)#)%.#9............................................................ 168
Podium
,%33/.3,%!2.4).4(%42%!4-%.4/&#/.'%.)4!,03%5$!24(/3)3/&4)")!!3).',%352'%/.3%2)%3/&#!3%3
OVER 20 YEARS ......................................................................................................................................................................................................................................................................................................... 168
Podium
&%-/2!,,%.'4(%.).'7)4(5.34!",%()0 .................................................................................................................................................................................................................................. 169
Podium
+.%%$)3,/#!4)/.!3!#/-0,)#!4)/./&&%-/2!,,%.'4(%.).' .......................................................................................................................................................................... 169
Podium
!.+,%#/-0,)#!4)/.3).,)-",%.'4(%.).'/&4(%4)")! .............................................................................................................................................................................................. 170
Podium
!2%6)%7/&#/-0,)#!4)/.3%.#/5.4%2%$$52).'&%-/2!,,%.'4(%.).'5.)0,!.!26%2353#)2#5,!2%84%2.!,&)8!4/2 ..................... 170
Podium
4(%53%/&),):!2/6-%4(/$&/2-!.!'%-%.4/&2%,!03%$#,5"&//4 ...................................................................................................................................................... 171
Podium
!.+,%2%#/.3425#4)/.).490%&)"5,!2(%-)-%,)! ...................................................................................................................................................................................................... 171
Podium
#/22%#4)/./&#/-0,%8&//4$%&/2-)4)%3"94!9,/230!4)!,&2!-% ............................................................................................................................................................ 172
Podium
!.+,%6!253).#(),$2%.#/22%#4)/."9%8&)8 .................................................................................................................................................................................................................... 172
Podium
AUTHORS CONCEPT OF APPLICATION OF THE HEXAPOD ILIZAROV APPARATUS AT FEET ................................................................................................................................... 173
Podium
EXTERNAL FIXATION FOR FLATFOOT EVANS RECONSTRUCTION........................................................................................................................................................................................... 173
Podium
BONE RECONSTRUCTION IN CHILDHOOD ............................................................................................................................................................................................................................................... 174
Podium
53).'4(%-%4(/$/&$)342!#4)/./34%/39.4(%3)3).42%!4-%.4/&#(),$2%.7)4(3(/24%.%$&).'%23 ............................................................... 174
Podium
().'%$%84%2.!,&)8!4)/.).4(%5.34!",%0/3442!5-!4)#!.+,% .................................................................................................................................................................. 175
Podium
!350%2)/24%#(.)15%&/22%0!)2/&02/8)-!,TH-%4!4!23!,&2!#452%54),):).'%84%2.!,&)8!4)/. ...................................................................... 175
Podium
#!,,/4!3)3).-%4!#!20!,3!.$-%4!4!23!,3).#(),$3 ............................................................................................................................................................................................. 176
Podium
,)'!-%.4/4!8)353).'%84%2.!,&)8!4/2&/2#/-0,%8&2!#452%3/&#!,#!.%5-!-).)-!,).6!3)6%4%#(.)15%........................................... 176
Podium
42!.3/33%/53/34%/39.4(%3)3).2%#/.3425#4)6%42%!4-%.4/&0!4)%.437)4(0/3442!5-!4)#&//4$%&%#43 ............................................ 177
Podium
KINESIOLOGICAL CORRECTION OF RECURRENT & NEGLECTED CLUBFOOT .................................................................................................................................................................. 177
Podium
%15).53#/22%#4)/.54),):).'%84%2.!,&)8!4)/. .............................................................................................................................................................................................................. 178
Podium
.%7%84%2.!,&)8!4)/.4%#(.)15%&/2#(%62/.490%/34%/4/-)%353).'3-!,,2!),&2!-%3........................................................................................... 178
Podium
%84%.3)6%,)-",%.'4(%.).').$7!2&)3-................................................................................................................................................................................................................................. 179
Podium
3/#)!,!$!04!4)/.2%,!4%$4/'%.%2!,(%!,4(34!453).,)-",%.'4(%.%$0!4)%.437)4(!#(/.$2/0,!3)! ....................................................... 179
Podium
,)-",%.'4(%.).').!#(/.$2/0,!3)!9%!232%35,43 .......................................................................................................................................................................................... 180
67
Podium
#/-").%$4%#(.)15%&/24(%#/22%#4)/./&,/7%2%842%-)49$%&/2-)4)%3#!53%$"9-%4!"/,)#"/.%$)3%!3%3...................................... 180
Podium
0%#5,)!2)4)%3/&4(%,/7%2,)-",%.'4(%.).').#(),$2%.7)4(!#(/.$2/0,!3)! ......................................................................................................................... 181
Podium
"),!4%2!,3)-5,4!.%/53,%.'4(%.).'/&,/7%2,)-"3).#(),$2%.7)4(!#(/.$2/0,!3)!.................................................................................................... 181
Podium
500%2,)-",%.'4(%.).').!#(/.$2/0,!3)!......................................................................................................................................................................................................................... 182
Podium
(5-%2!,,%.'4(%.).'7)4(5.),!4%2!,%84%2.!,&)8!4/2 ....................................................................................................................................................................................... 182
Podium
%.$/3#/0)#4%#(.)15%&/2"/.%'2!&4).'!4$/#+).'3)4%$52).'"/.%42!.30/2402%,)-).!292%0/24/&&/52#!3%3.................... 183
Podium
#/-02!3)/./&!#54%#/-02%33)/.2%,%.'4(%.).'!.$3%'-%.4!,"/.%42!.30/24&/24)")!03%5$/!242/3)3 ........................................ 183
Podium
42%!4-%.4&/2./.).&%#4)/53./.5.)/./&45"5,!2&2!#452%37)4(-/./&/#!,#/-02%33)/.$)342!#4)/.4%#(.)15% .................. 184
Podium
4(%).42!-%$5,,!29#!",%"/.%42!.30/247)4(4(%),):!2/62).'&)8!4/2).4)")!,"/.%$%&%#43 ............................................................................ 184
Podium
CHANGE IN WEIGHT BEARING INDEX DURING BONE TRANSPORT AND UNION IN TIBIA BONE DEFECTS. DOES THE WEIGHT BEARING ............................ 185
Podium
4)")!,"/.%$%&%#43$/%3!47/,%6%,#/24)#/4/-92%$5#%4)-%).&)8!4/2 .................................................................................................................................... 185
Podium
42%!4-%.4/&4(%3%'-%.4!,"/.%$%&%#43/&4(%4)")!7)4(4(%),):!2/63 ...................................................................................................................................... 186
Podium
TRANSPORTACION AND LENGTHENING BONE IN VON RECKLINHAUSEN DISEASE ................................................................................................................................................... 186
Podium
).&,5%.#%/&!54/,/'/53-%3%.#()-!,34%-#%,,3-3#!54/42!.30,!.4!4)/./.$)342!#4)/./34%/'%.%3)3 ......................................... 187
Podium
(%!,4(2%,!4%$15!,)49/&,)&%!&4%242%!4-%.4"94(%%84%2.!,&)8!4)/./&4(%,/7%2,)-",/.'4%2-2%35,43 ................................ 187
Podium
2%342)#4)/.3/.!#4)6)4)%3/&$!),9,)6).'!$,!&4%242%!4-%.4"94(%%84%2.!,&)8!4)/.,/.'4%2-2%35,43......................................... 188
Podium
0%2)0(%2!,.%26%'!02%0!)2"9'2!$5!,%,/.'!4)/./&"/4(.%26%345-03%80%2)-%.43).-!#!#!&!3#)#5,!2)3 .............................. 188
Podium
%&&%#4/&,)-",%.'4(%.).'/.3+%,%4!,-53#,%'%.%%802%33)/.02/&),% ........................................................................................................................................ 189
Podium
4(%2/,%/&%8/'%."/.%34)-5,!4/2).$%,!9%$!.$./.5.)/.3.................................................................................................................................................................. 189
Podium
")/-%#(!.)#!,34!"),)49/&%84%2.!,&)8!4/237)4(0!2!,,%,!.$7)4(#/.6%2'%.40).3!#/-0!2!4)6%!.!,93)3 ................................. 190
Podium
4/0%2&/2!4%/2./4-).)-!,).3%24)/.!.',%3(/5,$"%$%'2%%34/0!334(%42!.3#/24%87)4(+7)2%3 ............................................ 190
Podium
342!4%'9&/202%$)#4!",%,/7%2,)-"2%#/.3425#4)/.).#/.'%.)4!,,/.'"/.%$%&%#43"9$)342!#4)/./34%/'%.3)3 ................ 191
Podium
!33%33-%.4/&3%6%2%,/7%2,)-"$%&/2-)4953).'4(2%%$)-%.3)/.!,#/-054%$4/-/'2!0(9 ............................................................................... 191
Podium
#/22%#4)/./&,/7%2%842%-)49$%&/2-)4)%3!&4%2%0)0(93%!,).*52953).'%84%2.!,&)8!4/2!.$).42!-%$5,,!29'2 .................. 192
Podium
352')#!,42%!4-%.47)4(!#)2#5,!2%84%2.!,&)8!4/2&/2,!4%/.3%4",/5.4$)3%!3% ....................................................................................................... 192
Podium
4(%-%#(!.)#!,0(93%!,!.',%/&4(%02/8)-!,4)")!!3!4//,&/2%!2,9$)!'./3)3/&",/5.43$)3%!3% ........................................................ 193
Podium
GUIDED GROWTH UNDER THE AGE OF EIGHT YEARS ..................................................................................................................................................................................................................... 193
Podium
02%.!4!,$)!'./3)3/&#/.'%.)4!,&%-/2!,$%&)#)%.#9!.$&)"5,!2(%-)-%,)! .............................................................................................................................. 194
Podium
2%"/5.$!&4%22%-/6!,/&'5)$%$'2/74(3#2%70,!4%$%6)#%3 .................................................................................................................................................................. 194
Podium
42%!4-%.4/&0/3442!5-!4)#%,"/734)&&.%33"9!24(2/3#/0)#!24(2/,93)34(%.),):!2/6().'%$$)342!#4)/. .................................... 195
Podium
).42!!24)#5,!2$)34!,2!$)53&2!#452%342%!4%$"9%84%2.!,&)8!4/2/2%84%2.!,&)8!4/2!.$+7)2%3 ...................................................... 195
Podium
42%!4-%.4/&$)34!,2!$)53&2!#452%37)4(%84%2.!,&)8!4)/........................................................................................................................................................................ 196
68
Podium
0/33)"),)4)%3/&42!.3/33%/53/34%/39.4(%3)3!##/2$).'4/),):!2/6).-!.!'%-%.4/&0!4)%.437)4((!.$42!5-!...................... 196
Podium
4%22)",%42)!$/&4(%%,"/77)4(-/./,!4%2!,!24)#5,!4%$%84%2.!,&)8!4/2 .............................................................................................................................. 197
Podium
352')#!,42%!4-%.4/&(5-%2!,$)!0(93%!,&2!#452%37)4(%84%2.!,&)8!4)/.7(%.!.$(/7................................................................................. 197
Podium
#/-0,%8,%3)/.3/&4(%%,"/742%!4-%.47)4(!.%7!24)#5,!4%$%84%2.!,&)8!4/2 ............................................................................................................ 198
Podium
0%$)!42)##5")4536!253#/22%#4)/."9#/-054%2'5)$%$#)2#5,!2%84%2.!,&)8!4)/. .......................................................................................................... 198
Podium
#!,,53$)342!#4)/.4/42%!4)!42/'%.)#(!,,586!,'53#/-0,)#!4%$3(/24-%4!4!23!,3................................................................................................... 199
Podium
REPAIR OF SUBTALAR JOINT NONUNION WITH ANKLE PATHOLOGY WITH CIRCULAR EXTERNAL FIXATION .......................................................................................... 199
Podium
2%0!)2/&/34%/#54!.%/53$%&%#47)4(4(%4!9,/230!4)!,&2!-%).,/7%2,)-" ......................................................................................................................... 200
Podium
),):!2/6"/.%42!.30/246%23536!3#5,!2):%$&)"5,!2'2!&4).2%#/.3425#4)/./&0/3442!5-!4)#4)")!,"/.%$%&%#4 .................. 200
Podium
35"34!.4)!4)/./&#/-054%2!33)34%$/24(/356&2!-%/04)-5-#/.&)'52!4)/.!4$%&/2-)49#/22%#4)/./&&%-/2!, ................. 201
Podium
4(%42%!4-%.4/&4(%,/7%2%842%-)49$%&/2-)4)%3/52%80%2)%.#% ...................................................................................................................................................... 201
Podium
-/./,!4%2!,!8)!,%84%2.!,&)8!4)/.).4(%42%!4-%.4/&#/-0,%80/342!5-!4)#$%&/2-)4)%3................................................................................. 202
Podium
#/22%#4)/./&4(%0/,)/-9%),)4)3&//4$%&/2-)49"9),):!2/6 ........................................................................................................................................................................... 202
Podium
#/-0,)#!4)/.3/&,%.'4(%.).').&)"5,!2(%-)-%,)! ................................................................................................................................................................................................... 203
Podium
-!33)6%3%'-%.4!,"/.%,/33$5%4/0!.4)")!,/34%/-9,)4%3).#(),$2%.2%#/.3425#4%$"9-%$)!,&)"5,!242!.30/2 ................ 203
Podium
"),!4%2!,4/4!,!0,!3)!/&4(%4)")!$50,)#!4)/./&&)"5,!%!.$-)22/2&//4&)2342%#/.3425#4)/.7/2,$7)$%...................................... 204
Podium
).42!!24)#5,!2/34%/4/-9/&4(%$)34!,&%-52&/23%15%,!%/&.%/.!4!,3%03)3.................................................................................................................. 204
Podium
0%$)!42)#3(!&44)")!,&2!#452%342%!4%$7)4(%84%2.!,&)8!4)/./52%80%2)%.#%.................................................................................................................... 205
Podium
/52%80%2)%.#%).42%!4-%.4/&3%6%2%2%#522%.4",/5.43$)3%!3% ....................................................................................................................................................... 205
Podium
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USE OF ORTHOFIX RAIL FIXATORS FOR LENGTHENING LONG BONES ............................................................................................................................................................................... 207
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INTERNAL LENGTHENING PLATE ................................................................................................................................................................................................................................................................... 211
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NEUROPATIC PAIN IN LENGTHENING BONE ........................................................................................................................................................................................................................................... 212
69
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HEXAPOD ASSISTED ORTHOPEDICS SURGERY (CHAOS).............................................................................................................................................................................................................. 216
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34!'%$%84%2.!,&)8!4)/.42%!4-%.4!&4%23%6%2%7!2).*52)%34/%842%-)4)%3 ......................................................................................................................... 218
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TRUELOK EXTERNAL FIXATION FOR RECONSTRUCTION SURGERY ON THE SPINE ................................................................................................................................................... 221
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APPLICATION OF EXTERNAL FIXATOR IN FRACTURES OF THE DISTAL RADIUS ........................................................................................................................................................... 226
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70
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Podium (9"2)$%84%2.!,&)8!4)/.).42%!4-%.4/&#/-0,%8
TIBIAL FRACTURES
0RINCIPAL!UTHOR Filipescu, Neculai, MD
#ENTRE Spitalul Judetean de Urgenta Bacau
!UTHORS 1Popa, Dan, MD; 2Iftimie, Petrea, MD
#ENTRES 1Spitalul Judetean de Urgenta Bacau; 2Hospital de Sant
Pau i Santa Tecla de Tarragona
#OUNTRY Romania
0RINCIPAL!UTHOR Corina, Gianfranco, MD
#ENTRE PO Vito Fazzi di Lecce
!UTHORS 1Marsilio, Antonio, MD; 2Tartaglia, Nicola, MD; 1Rollo,
Giuseppe, MD
#ENTRES 1PO Vito Fazzi di Lecce; 2San Paolo Bari
#OUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
The main objective in open tibial fractures is the immediate and
efficient fixation, associated with quick reconstruction of soft
tissue. We support the use of the Minimally Invasive Universal
External Fixator (FEMIU-patented) for definitive osteosynthesis in
open tibial fractures.
2ESUME
Complex tibial fractures are multiple fragmented diaphysealmetaphyseal fractures which may be closed or exposed, with or
without compromised soft tissue.
-ATERIALANDMETHODOLOGY
Between September 2006-March 2009, twenty three patients
have been treated for high-energy open tibial fractures:10 car
accidents, 3 work accidents and 10 other causes. According to
the Gustilo classification there were:12 IIIA and 11 IIIB. 17 men
and 6 women, with an average age of 41 (19-74). Location:
3 tibial plateau, 16 shaft and 4 pilon. In all cases fixating,
centering and stabilizing the fracture was accomplished using
the FEMIU with 3 mm K-wires, the average time of assembly
being approximately 20 minutes. Reducing the fracture and
stabilizing the entire system is done after surgery, under
radioscopic guidance. Soft tissue defects have been treated
through plastic surgery procedures.
$ISCUSSION
Mean follow-up was 27 months (12-40). The mean hospital stay
was 5 weeks. In 21 cases (91,3%) FEMIU was maintained until
consolidation was accomplished, on average 18,7 weeks (8,748,7). In 2 cases (8,7%) minor additional surgery was necessary
to increase resistance in the distal tibia. In three cases (13%) it
was necessary iliac cortical cancellous bone graft and in another
case (4,3%) Papineau technique. Tolerance was perfect. There
were no superficial or deep infections -pins related recorded.
FEMIU is stable and balanced mechanically, overlapping, through
assembly, the tibia axis with the central long axis of the fixator. It
is low-weight and easy to assemble. The knee and ankle joints
remain always free. Removing the fixator takes 10 minutes, in
an ambulatory unit, without anesthesia. In twenty-one cases it
was achieved complete healing (91,3%) and as complications
there were: one case (4,35%) with post-traumatic ankle arthritis
and one patient presented (4,35%) tibial pilon osteitis.
#ONCLUSIONS
Based on the present study, the results and advantages that
FEMIU offers lead to the conclusion that it can be successfully
used in all open tibial fractures, regardless of fracture location.
These fractures can be treated using hybrid external fixation
with minimal synthesis where possible.
The Orthofix Hybrid External Fixation has been used to treat
complex tibial fractures on our ward since September 2004.
This fixation system has the following properties:
s ISMADEUPOFRADIOLUCENTCARBONCOMPONENTS
s HASAREDUCEDNUMBEROFINSTRUMENTSWITHNUMEROUS
assembly options;
s HASTHEADVANTAGESOFBOTHMONOAXIALANDCIRCULAREXTERNAL
fixation;
s ISMINIMALLYINVASIVEREDUCINGTOAMINIMUMTHERISKOF
infection and complications due to the fixation systems.
However it is a complex surgical technique requiring an
adequate learning curve.
The duration of surgery time and exposure to ionizing radiation
(fluoscopy) are comparable to those for monoaxial implants,
except in relation to a more complex and time consuming
positioning of the patient on operating table.
While closed reduction manipulations doesn’t allow to restore
the anatomical congruency of joint surfaces, in our considerable
experience we have obtained good clinical results by minimizing
invasiveness, that allows us to reduce the risk of infection
at minimum and delays in healing of surgical wounds. This
means that joint rehabilitation can be commenced earlier (the
morning after the surgery) and the joint can also be bear weight
at an earlier date than with more invasive methods. The range
of motion (ROM) of the most patients we examined is close
to normal, while the results in terms of arthrosis and axial
deformity are comparable to those of patients treated with other
fixation systems.
The authors provide notes on surgical technique and satisfying
clinical results at long term follow up.
71
Podium
OPEN TIBIAL SHAFT FRACTURES (GUSTILO TYPE IIIA,B)
TREATED WITH EXTERNAL FIXATION
0RINCIPAL!UTHOR Milenkovic, Sasa, MD
#ENTRE Medical Faculty, Clinic for Orthopaedic and Traumatology
#OUNTRY Serbia
/BJECTIVES
Tibial shaft fractures are one of the most common shaft
fractures of long bones. Among operative treatments, the
methods of external and internal fixations are applied. Due to
its subcutaneous localization, tibia is often exposed to injury,
but subcutaneous localization is very suitable for the external
fixation. Mitkovic’s external fixator type M 20 is unilateral, simple
and effective when used in treating all types of open tibial
shaft fractures and in treating closed fractures with damaged
soft tissues, comminution and fragments dislocation. The
apparatus is applied without any guidance, and pins are placed
convergently which allows three-dimensional stability of the
fixed bone
-ETHODOLOGY
The paper shows the results of treating 49 patients with open
tibial shaft fractures. All fractures were treated with the external
fixation method in the Orthopaedic&Traumatology Clinic Nis. The
fractures were fixed with Mitkovic’s external fixator, type M 20.
2ESULTS
The paper shows the results of the external fixation of 49 open
tibial shaft fractures (Gustilo type IIIA,B), 30 (61,22%) men and
19 (38,77%) women, average age 43,92 (16-84). The results of
the external fixation of the tibial shaft fractures are excellent and
good. The union rate was 83,68%. Nonunion rate was 12,24%.
There were 4 patients with the open tibial shaft fractures (2
Gustilo type IIIB (AO42A2,AO 42B2), 2 Gustilo type IIIA (AO
42B3,AO 42B3) and 2 patients with segment fractures, Gustilo
type IIIA,IIIB (AO 42C2). Malunion rate was 4,08%.
#ONCLUSION
The application of external fixator enables an almost perfect
control of the fracture, owing to a possibility of intraoperative
and postoperative reduction of the fracture. During the healing
of the fracture treated with the external fixation method there
is a possibility of adapting biomechanical condition of healingdynamization of the external fixator. The external fixation method
enables early postoperative rehabilitation and functioning of
extremities which reduces the time of treatment and provides
good results.
Podium !#54%!.$$%&).)4)6%42%!4-%.4/&/0%.4)")!,
&2!#452%37)4(!.%7-5,4)&5.#4)/.$9.!-)#
EXTERNAL FIXATOR
0RINCIPAL!UTHOR Suksathien, Yingyong, MD
#ENTRE Department of Orthopedic Surgery, Maharat Nakhon
Ratchasima Hospital
!UTHORS Suksathien, Rachawan, MD
#ENTRE Department of Rehabilitation Medicine, Maharat Nakhon
Ratchasima Hospital
COUNTRY Thailand
!IMANDPURPOSEOFTHESTUDY
To evaluate the clinical results of open tibial fractures treated
with a new design multifunction dynamic external fixator system
until healing.
-ATERIALANDMETHODOLOGY
A new design multifunction dynamic external fixator system was
developed for high energy open fractures and posttraumatic
reconstructions. The prospective study of 60 patients with
open tibial fracture treated with this external fixator system
for acute and definitive-treatment frame between 2005 and
2009. According to the system of Gustilo and Anderson, 14
fractures were classified as type II, 43 as type IIIA and 3 as
type IIIB. Partial weight bearing with crutches was instructed
when tolerable for dynamization. When there were evidences
of fracture healing both clinical and radiographic, the external
fixator was removed.
$ISCUSSION
With partial weight bearing, the external fixator system allowed
micromotion for dynamization to enhance bone healing. All
fractures united in a mean union time of 15.7 weeks (range,1024). The mean union time was 11.9 weeks (range,10-15) in
type II, 16.3 weeks (range,10-24) in type IIIA and 20.3 weeks
(range,20-21) in type IIIB. Iliac bone grafting was performed in
six cases at a mean time of 3.8 weeks to enhance bone union.
Dynamization has a benefit in increase union rate and decrease
time spent in external fixation frame, thereby, decrease rate of
pintract infection. There were only seven cases (12%) of pintract
infection was found. Almost patients had good response to local
pin care and oral antibiotic without external fixator removal. No
osteomyelitis was found. Ninety-five percent of fracture united
with less than 10 degrees angulation in all plane. The external
fixator system provided sufficient stabilization for patient early
mobilization, rehabilitation and maintained bony alignments
until union without instrumentation failure. The frame could be
reused.
#ONCLUSIONS
Base on the advantage of dynamization and the simplicity of
monolateral frame, the new design multifunction dynamic
external fixator system was successfully treated open tibial
fractures with good result and low complication rate. It’s simple,
safe and easy to use.
72
Podium !2%6)%7/&&5.#4)/.!,/54#/-%/&#)2#5,!2&).%7)2%
FIXATORS USED FOR OPEN TIBIAL FRACTURES
0RINCIPAL!UTHOR Javed, Mustafa, MD
#ENTRE Hull Royal Infirmary
!UTHORS Hadland, Yvonne, MD; Barron, Libby, MD; Marwah,
Simrat, MD; Sharma, Hemant K, MD
#ENTRE Hull Royal Infirmary
#OUNTRY United Kingdom
!IMSANDPURPOSEOFTHESTUDY
Open tibial fractures are associated with increased risk of
complications and low functional outcome with increasing
severity of bone and soft tissue injury. These also bear impact on
health economics.To evaluate functional outcomes of open tibial
fractures treated with circular fine-wire fixators.
-ATERIALANDMETHOLOGY
Retrospective review of 35 open tibial fractures treated with
circular fine-wire fixators {Ilizarov and Taylor Spatial Frame
(TSF)} in a teaching hospital. Patients were reviewed with x
rays and clinical outcomes measured using Iowa Knee Score
questionnaire, Olerud-Molander Ankle Scores (OMAS), Ankle
Evaluation Score and Euroqol EQ-5D descriptive system (generic
health questionnaire). Severity of open fractures was classified
using Gustilo & Anderson Classification.
$ISCUSION
Ilizarov frame was used for 19 (56%) and TSF was used for
16 (44%) patients. Mean patient age was 47.1 years. 74%
had high energy while 26% had low energy injury. 4 patients
(12%) had grade I, 3 (9%) had grade II, 27 (79%) patients had
grade III injury as per Gustilo & Anderson Classification. 14%
patients had proximal, 17% had mid-shaft, 67% had distal tibial
fractures respectively. Average time to union was 28.9 weeks.
12 (35%) had pin-track infection treated with antibiotics. Grade
IIIB fractures healed in 29.6 weeks. 17 required soft tissue
coverage and only two developed skin graft complications.
There were no cases of deep infection & mal-union. Patients had
good satisfaction scores (EQ-5D descriptive system) following
SURGERYMEAN4HEMEAN)OWA+NEE%VALUATION
score, OMAS and Ankle Evaluation score was 87.32, 73.48
and 74 respectively (maximum being 100). The ankle range of
movement was similar in operated and contra lateral normal
ankles.
Podium EXTERNAL FIXATION IN OPEN TIBIAL FRACTURES
0RINCIPAL!UTHOR Varsalona, Roberto, MD
#ENTRE Ospedale Umberto
!UTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
#ENTRE Ospedale Umberto
#OUNTRY Italy
/BJECTIVEANDPURPOSE
The tibial shaft is one of the most common sites of an open
fracture. The primary treatment is early operative debridement
and stabilization of the bone. The type of treatment selected for
open tibial fractures depends on the individual characteristics of
the fracture and the concomitant soft-tissue injury.
-ETHODS
Between 2007 and 2010, we treated 152 open tibial fractures
(G-A type I in 68 cases, G.-A type II in 56 cases, G-A-type III in
28 cases), of wich 84 was treated with external fixation (G-A
type I in 10, G.-A type II in 46 cases, G-A-type III in 28 cases).
2ESULTS
Only 69 of these 84 fractures achieved bone healing: 53 with
definitive external fixation and 16 after delayed intramedullary
nailing fixator. Fifteen fractures had complications: 1 amputation,
8 cases of septic non union, 3 osteomyelitis, 3 post-traumatic
deformity limb.
#ONCLUSIONS
External fixation offers several advantages in the treatment of
open tibial fractures. Generally, there is good access to the soft
tissues, and most forms of external fixation do not substantially
impair the range of motion of the knee or ankle. Open fractures
of the tibial shaft represent a limb-threatening, and potentially
life-threatening emergency. Optimum treatment involves
appropriate initial evaluation and administration of antibiotics;
urgent operative debridement and skeletal stabilization;
repeated soft-tissue debridements; and early soft-tissue closure
or flap coverage, or both. This intensive treatment allows early
functional rehabilitation and an improved clinical outcome for
patients who have an open fracture of the tibial shaft.
#ONCLUSIONS
Circular frame treatment for open tibial fractures results in high
union rate and very low deep infection; therefore we propose
circular frame treatment should be standard for all open tibial
fractures.
73
Podium ACUTE SHORTENING AND DELAYED LENGTHENING WITHOUT
FLAPCOVER FOR GUSTILO3B INJURIES WITH BONELOSS
0RINCIPAL!UTHOR Oleksak, Milan, MD
#ENTRE Gloucester Royal Hospital
#OUNTRY United Kingdom
2ESUME
Fifteen patients sustaining high energy Gustilo 3B injuries of the
tibia were treated from 2003 to 2009 with initial debridement
followed by application of an external fixation device allowing
immediate acute shortening of the bonegap. The bone defects
ranged from 3 cm to 5 cm. Wound management was achieved
with a vacuum assisted closure device (VAC) until granulation
tissue covering the exposed bone made coverage with split skin
grafting possible. A delayed progressive lengthening procedure
was used to equalize the leglength discrepancy after wound
cover has been achieved. The mean age was 30 years and
treatment times varied from 4 to 12 months. All fractures united
with acceptable alignment and equalization of the leglength
discrepancy. One patient required repeat procedures for a
pinsite infection by changing a wire. There was no deep sepsis.
This method is a satisfactory and safe alternative for the acute
management of the compound wound, when plastic surgery
skills are either unavailable or flap cover is contraindicated in
the presence of sepsis or as a salvage procedure following flap
failure. Wire placement needs to be carefully planned in order to
accommodate initial VAC placement, followed by final definitive
fixation after wound cover has been achieved.
Podium 2!$)#!,352')#!,42%!4-%.4/&/0%.4)")!,&2!'-%.4
&2!#452%37)4(&/2-%$$%&%#430,!34)#).52'%.4
PERIOD
0RINCIPAL!UTHOR Rushay, Anatoliy, MD
#ENTRE R&d Institute of Traumatology and Orthopedy of Donetsk
State Medical University named after M. Gorky
#OUNTRY Ukraine
!CTUALITY
Choice of volume of surgical treatment of open fragmental
tibial fractures still remains actuall question. In its decision it
is necessary to be guided by the principles based on modern
possibilities of traumatology.
0URPOSE
Improvement of results of treatment of the fragmental tibial
fractures patients is basised on radical sanitation of injured zone
and early plastic of formed defect.
-ATERIALSANDMETHODS
Under our supervision there were 47 victims with heavy highenergy open fragment tibial fractures. At 35 suffered (74,4%)
with developed bone necrouse, osteomyelitis and inflammation
of soft fabrics in period more than 3 weeks from the moment
of trauma necrote bone resection was made, defect was 5 sm.
Average terms of treatment in this group were about 15 months.
On the basis of reason development analysis of osteomyelitis at
victims with similar damages to the urgent period (till 3 weeks
after fracture) radical sanitation as segmentary resection and
early plastic of the formed defect by Ilizarov at 24 patients were
made. High-energy fragmental fractures with absence of fabric
feeding and defect of surrounding soft fabrics were indicators to
carrying out such treatment.
2ESULTSANDDISCUSSION
In development of complications at treatment of open highenergy fragmental tibial fractures important role is played by
insufficient radicalism of operative treatment. The greatest
complexity in practice is definition of border of soft fabrics
injured zone.
After carrying out of primary segmentary resection fragments
were fixed by the device allowing further to spend defect plastic.
For 7 days by us the tibial half-cloused osteotomy was carried
out; replacement of bone defect by Ilizarov began.
#ONCLUSIONS
Radical sanitation by segmentary resection type and early
plastic of the formed defect by Ilizarov by treatment of open
high-energy fragmental tibial fractures is proved already at early
stages.
Offered radical surgical treatment and early plastic has allowed
to reduce terms of stay in hospital.
74
Podium 2%35,43/&"/.%,%.'4(%.).'7)4(-/./,!4%2!,
%84%2.!,&)8!4/2!33)34%$7)4(!.).42!-%$5,,!29
NAIL
0RINCIPAL!UTHOR Martínez Martos, Sara, MD
#ENTRE Icatme. Instituto Universitario Dexeus
!UTHORS Ginebreda Martí, Ignacio, MD; Tapiolas Badiella, Jordi,
MD; Correa Vázquez, Eva, MD; Cáceres Palou, Enric, MD
#ENTRE Icatme. Institut Universitari Dexeus
#OUNTRY Spain
/BJECTIVEANDPURPOSEOFWORK
The aim of our study is to analyze the results of lengthening of
the femora or tibiae with monolateral external fixator, assisted
with intramedullary nail and analyze wich bone segment has
noted an earlier consolidation.
-ATERIALANDMETHODS
19 femora and 4 tibiae in 23 patients, 73.9% male, underwent
bone lengthening with an intramedullary nail and a unilateral
external fixator. The etiology was trauma in 15 patients, 4 of
them had congenital short femur, and other pathologies in the
remaining 4.3%. The mean amount of shortening was 40 mm
preoperative, and the mean preoperative mechanical axis was
31,4 mm. At the time of follow up deformity correction and bone
healing were assessed clinically and radiographically.
2ESULTSANDDISCUSION
The mean duration of the external fixator was 55 days, with
a mean amount of lengthening of 34 mm (17-70). The mean
bone healing index was 35.6 days/cm. The mean amount of the
mechanical axis deviation at the end of the treatment was 14,8
mm. Of the 23 patients, 4 had varus axis and 5 of them valgus;
at the end of the treatment correction of the axis was observed
in 6 of them. A higher rate of bone healing in the tibia (48.5 days
/ cm) compared with the femur (37.3 days / cm) was observed,
WITHOUTBEINGSTATISTICALLYSIGNIlCANTP4HEREWERENO
significant differences in the external fixation index between
FEMORAANDTIBIAEP
In the femur was obtained a mean NSA of 122º if the entry point
was the trochanter, compared with 126 º if it was the fossa,
WITHOUTBEINGSTATISTICALLYSIGNIlCANTP
#ONCLUSION
With this technique, the duration of the external fixation was
reduced, and the intramedullary nail prevented fracture and
deformation of the regenerated bone. We obtained correction of
the angular deviation in 6 of 9 patients. Tibiae has a higer rate of
the bone healing index. Trochanteric entry of the intramedullary
nail can be related with varus NSA.
Podium ,%.'4(%.).'$%&/2-)49#/22%#4)/.53).')-.!),3
0RINCIPAL!UTHOR Chaudhary, Milind, MD
#ENTRE Jaslok Hospital
#OUNTRY India
!IMS
To study the accuracy and safety of Lengthening and Deformity
correction using IM nails to reduce duration of external fixation
in Lengthening and eliminate it in deformity correction cases.
0ATIENTSANDMETHODS
51 Segments were treated since 1994 with these methods. 38
Tibiae, 7 Femora were lengthened over IM Nails. 6 Femora had
Deformity correction only. Length gain ranged from 1.5 cm to
9.8 cm and averaged 4.9 cm. Fixator duration averaged 17.8
days per cm. Deformities from 8º to 40º were corrected in the 15
segments. Ages ranged from 9 years to 55 years.
20 patients had Poliomyelitis, 25 had Congenital, Developmental
and Constitutional conditions, 6 had growth arrest.
Ilizarov fixator was used in tibiae and the LRS fixator was used
in 4 of the 7 femora.
Of 13 femur segments 7 had a retrograde & 6 had antegrade
entry point.
Tibia had standard IM nails in 23, modified Humerus nails in 14
and a modified Ender nail in 1.
Femur, had standard IM nails in 3, straight SupraCondylar Nails
in 8 and modified Humerus nails in 2.
The corticotomy was done in the upper diaphysis for lengthening
and was at apex of the deformity in the deformity correction
cases.
Poller screws were used for prevention of deformity. Flexible
reamers were used in lengthening and Straight reamers in
deformity correction.
Operative times ranged from 90 minutes to 320 minutes. 36
patients needed blood transfusions in the Post-op phase.
#OMPLICATIONS
One deep IM infection needed removal, reaming and antibiotic
coated nail and conversion to Ilizarov. 3 cases had poor
regenerate & one needed Grafting and 2 improved with
accordion manuvre. Premature consolidation was seen in 3
femora with standard nails & flexible reamers. Length fell short
in above 6.
3UMMARY
Lengthening and Deformity Correction using IM nails reduces
the need or duration of external fixation and can greatly enhance
patient comfort without significantly high complication rates.
Longer Operative time and special instruments are a must to
achieve accuracy of results.
75
Podium LENGTHENING THEN NAILING
0RINCIPAL!UTHOR Emara M, Khaled, MD
#ENTRE Ain Shams Univ. Hospitals
#OUNTRY Egypt
2ESUME
Short duration of external fixation can help to give the patient
more comfort & avoid complications of long duration of external
fixation, the aim is to compare the lengthening then nailing
technique to classic Ilizarov technique & the lengthening over
nailing technique.
25 cases of lengthening then nailing compared to matched
cases of Ilizarov lengthening & cases of lengthening over nail.
The complications encountered in the 3 groups are all were
managed with no long term equally but lengthening over nail
& lengthening then nailing helped the patient to get earlier to
normal life.
Lengthening then nailing can be safer than lengthening over nail
technique but it give the same result.
Podium 3%#/.$!29).42!-%$5,,!29.!),).'&/,,/7).'
2%#/.3425#4)/./&3%'-%.4!,"/.%$%&%#437)4(!.
EXTERNAL FIXATOR
0RINCIPAL!UTHOR Wozasek, Gerald, MD Professor
#ENTRE Department of Traumatolgy, Medical University Vienna
!UTHORS Hofbauer, Markus, MD
#ENTRE Department of Traumatolgy, Medical University Vienna
#OUNTRY Austria
0URPOSE
Segmental bone defect reconstruction by use of an external
fixator, is associated with several problems. Due to the
long period of external fixation and bulkiness, the patient’s
acceptance is small. The technique of secondary nailing after
lengthening (NAL) has been introduced to remediate these
problems. The present study investigates this combined
technique for lower limb reconstruction in traumatic patients
with complex lower limb fractures.
0ATIENTSANDMETHODS
Between 1996 and 2007, nine patients with an average age of
thirty-five years underwent secondary nailing of the femur (three
patients) and tibia (six patients), during the consolidation phase
following callus distraction using an external fixator device.
The segmental bone defects and the limb-length discrepancy
were first reconstructed with use of an external fixator. Upon
completion of limb-lengthening, the external fixator was
removed and intramedullary nailing was performed after an
average delay of fourteen days.
2ESULTS
At an average follow-up of twenty one months, functional
and radiographic results were evaluated according to the
criteria described by Paley. All cases achieved limb salvage
and satisfactory results for limb-length. Three patients had
minor pin-track infections, which responded to local treatment
and oral antibiotics. No serious infection occurred following
intramedullary nailing, mainly due to the fourteen day delay after
removal of the external fixation. In one patient re-nailing and
simultaneous autogenous bone grafting was performed due to
delayed fracture consolidation. Non union was not observed in
our series.
#ONCLUSIONS
Secondary intramedullary nailing following external fixation
can be safely used in segmental bone defect reconstruction
and appears to be an improvement to classic reconstruction
solutions. It reduces the duration of external fixation, allows
earlier rehabilitation thereby increasing patient acceptance, and
is associated with a low complication rate.
76
Podium ,%.'4(%.).'/6%2).42!-%$5,,!29.!),).').
#/.'%.)4!,!.$!$15)2%$$%&)#)%.#)%3
0RINCIPAL!UTHOR D’elia Moreta, Martín, MD
#ENTRE Cot
!UTHORS 1Miscione, Horacio, MD; 2Martínez Lotti, Gabriel, MD
#ENTRES 1Hospital Garrahan; 2Cot
#OUNTRY Argentina
2ESUME
Limb lengthening by distraction osteogenesis is worldwide used
for children and adults. New fixation devices, more stable, have
reduced the rate of complications, but time of external fixation
have still been too long. The use of intramedullary nailing,
asisting this procedure, have been presented as a confidence
method over time.
The objetive of this paper is to show the results and the surgical
technique. 22 patients are presented, 14 (65%) congenital
deficiencies, only lengthened; and 8 adquired deficiencies
(35%), with 3, only lengthened, and 5 used bifocal treatment,
simultaneously compression-distraction method. According
to the surgical technique, an intramedullary nail was inserted
first, subsequently the 6 mm half pins of the proximal and distal
clamps, the nail was temporaly retired, metaphyseal osteotomy
was performed, then, the nail was reinserted with proximal
locking and, finally, the external fixator frame was applied
and locked. In cases of bifocal treatment, all femur, an 8 mm
intramedullary nail was used, that allowed to use diaphyseal
half-pins of 4,5-5mm of the intermediate neutral locked clamp.
The average follow up was 52 months (range 22-94). The
distraction rate was 1mm/day initially, then, the speed was
adequate to radiologic callus formation. The compression rate,
bifocal cases, was 0,25 mm/day.
The results were measured by the lengthening coeficient, it was
1,1 months/cm (2-0,78). According to PaleyÂ’s score, 75% of
the patients have superficial infections, all treated with orally
antibiotics. None complications nor sequelaes were presented.
The presence of the intramedullary nail may affect the bloody
supply of the bone only for a few days, despite it was reamed
or not, with no clinical impairment in callus formation. The
presence of the nail avoid axis translation and| allows better
rigidity in the frame construction with less spanning of the
pins with delay of loosening and subsequent deep infection.
The lengthening across anatomical, although generates
an aproximately 7º difference with mecanical axis have no
clinical relevance in our patients. In conclusion, the use of this
procedure reduces the external fixation time over 50%, reduces
the complications rate and allows the aceptante of the treatment
by patients who could need several reconstruction procedures.
Podium FIXATOR ASSISTED PLATING VS FIXATOR ASSISTED NAILING
&/24(%#/22%#4)/./&#/-0,%8,/7%2,)-"3
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0RINCIPAL!UTHOR Khmyzov, Sergey, MD
#ENTRE Institute of Spine and Joint Pathology
!UTHORS 1Romanenko, Konstantin, MD; 2Tikhonenko, Alexander,
MD; 1Kikosh, Gennadiy, MD
#ENTRES 1Institute of Spine and Joint Pathology; 2Genesis Clinil
Simferopol
#OUNTRY Ukraine
!IMANDPURPOSE
Aim and purpose of the study is to analyze and discuss the
problems associated with the usage of different types of internal
fixation after ExFix removal in the cases of poor bone quality in
children.
-ATERIALANDMETHODOLOGY
Our work is based on the results of treatment of 12 patients
(13-19 years old). All of them required internal fixation after
treatment with ExFix (30 segments of lower limbs). The
deformities developed as a result of phosphate diabetes were
noticed in 8 cases and due to chondroplasia in 4 cases.
$ISCUSSION
The correction of deformity was performed in all cases followed
by intramedullar locking nailing in 3 patients (1 patient-4
segments, 2 patient-2 segments on each), plate stabilization
in 9 cases (2 patients-4 segments on each, 7 patients-both
femur). The indication for internal fixation in 6 cases was the
recurrence of deformity after ExFix removal and the presence
of stress-fracture in intact part of segment in 6 cases. The use
of intramedullar nailing has biomechanical advantage, but its
implementation requires the preparation of IM canal (even its
forming in some cases), that causes severe additional trauma
and blood lose. In some cases IM nailing is impossible because
of cavity absence or its extreme curvature. That is why the plate
usage in minimally invasive manner provides the advantage of
less additional trauma. The most significant complications of
IM nailing were 3 hardware loosening that demanded revision
osteosynthesis with bigger diameter nail. Plate osteosynthesis
resulted in fistula forming in 2 cases (due to severe scaring
surround the plate), but adequate fixation stability allowed full
weight-bearing.
#ONCLUSIONS
Poor bone quality implies the necessity of life-time internal
fixation. According to our experience plate osteosynthesis with
locking plates (LCP) provide better results due to less traumatic
procedure.
77
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0RINCIPAL!UTHOR Regenbrecht, Bertram, MD
#ENTRE Roland-Klinik Bremen
!UTHORS Wenda, Klaus, MD
#ENTRE Dr. Horst Schmidt Klinik Wiesbaden
#OUNTRY Germany
!IMANDPURPOSE
Angle stable plates are used routinely in osteotomies of the
lower extremities (Lobenhoffer et al. Orthopäde 2004 Feb; 33
(2): 153-60). The intraoperative use of an external fixator in
combination with definitive fixation with angle stable plates
should expand the possibilities of these implants improving
accuracy and versatility of the correction. This study shows
the possibilities of this method and looks at the accuracy of
correction.
-ATERIALANDMETHODOLOGY
15 consecutive patients with complex deformities (including
rotational deformities) underwent correction after exact analysis
(Paley, JPediatrOrthop 2000 May-June (3): 279-81) and were
included in this prospective study. In all cases the correction was
performed by fixator assisted plating. The fixator was assembled
according to the deformity and fixed to the bone. Then the fixator
is removed, leaving the Schanz-screws in place. After minimal
invasive osteotomy, the straightend fixator is re-attached to the
Schanz-screws. In this way, the correction of the deformity is
achieved in all three planes. With the fixator in place, the internal
implant can be fixed to the bone and then the external device is
removed.
FU at least 6 months with physical examination and long leg x
ray to perform axial analysis.
2ESULTS
8 femoral and 7 tibial corrections were performed.
Complications: 1 proximal cut out: consolidation after bicortical
refixation. 1 delayed consolidation after tibial correction (healed
after 12 months). 1 thrombosis.
The mean correction was 12,6 degrees, the mean difference to
the aim of correction was 1,3 degrees.
$ISCUSSION
Angle stable plates offer similar opportunities as external
fixators in osteotomies of lower extremities e.g. correction
with translation in the osteotomy, minimal invasive techniques,
avoiding of bone grafting (Pfeil et al. Orthopäde 2000 Jan; 29(1):
47-53). Nevertheless, the possibility of management of the bone
fragments is limited with the modern angle stable plate systems.
In this study we could achieve similar accuracy of correction as
in other fixator assisted methods.
#ONCLUSION
Fixator assisted plating combines the advantages (versatility and
accuracy) of external fixators with the advantages of internal
fixators (patient comfort).
78
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%84%2.!,&)8!4/2!.$!.).42!-%$5,,!29.!),
0RINCIPAL!UTHOR Río, Eduardo Manuel, MD
#ENTRE Hospital Italiano, Buenos Aires
!UTHORS Sancineto, Carlos, MD; Barla, Jorge, MD
#ENTRE Hospital Italiano, Buenos Aires
#OUNTRY Argentina
"ACKGROUND
The distraction osteogenesis technique using external fixation
alone is a well known procedure in tibia posttraumatic
reconstruction. Angular deformities, pin tract infections, pin
loosening and/or fracture after removal are some of the
complications related to the external fixator. Limb-lengthening
and bone transportation over an intramedullary nail has been
introduced to overcome these problems. The present study
shows our experience using this combined technique in tibia
reconstruction.
-ETHODS
Thirteen procedures were performed in twelve skeletal mature
patients between 2002 and 2009. A distraction osteogenesis
technique over an intramedullary nail using a monolateral
external fixator was used in eight cases of limb-length
discrepancy with an average shortening of 3.42 cm. In five
patients bone transportation was performed for an average
defect of 5.2 cm. External fixation time, external fixation index,
time to union and complications related to the external fixator
were documented. Paley’s score was used for both functional
and radiographic evaluation. The mean follow-up was forty-eight
months.
2ESULTS
The mean external fixation time was 72 days. The mean
external fixator index was 13.5 days/cm and the mean time
to consolidation was nine months. Pin loosening was seen in
one patient and treated by removal and change in positioning.
One pin tract infection was detected, treated and solved by oral
antibiotic treatment. Six of them required additional surgical
interventions. At a mean follow-up of 48 months, eight of
the twelve patients had an excellent result in both bone and
functional assessment, four regular result in both bone and good
functional results.
#ONCLUSIONS
The combined technique of external fixator and intramedullary
nailing for tibia reconstructions showed excellent and good
functional results in our series. Complications related to
the external fixator were seen in only two patients and only
one of them needed a surgical procedure for its treatment.
This technique reduces the external fixation time. This may
decreased the complication rate, improve rehabilitation and
patient’s comfort.
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Podium RADIOGRAPHIC CLASSIFICATION OF HALF PIN/ BONE
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0RINCIPAL!UTHOR Kostic I, MD
#ENTRE University Hospital Nis, Clinic of Orthopaedics and
Traumatology
!UTHORS Mitkovic BM, MD, PhD; Mitkovic MM, MD; Radenkovic
M, MD
#ENTRE University Hospital Nis, Clinic of Orthopaedics and
Traumatology
#OUNTRY Serbia
0RINCIPAL!UTHOR Luzzi, Richard, MD
#ENTRE Hospital Universitario Cajuru
!UTHORS Valenca, Ricardo, MD; Guasque, Joana, MD
#ENTRE Hospital Universitario Cajuru
#OUNTRY Brazil
"ACKGROUND
Cosmetic leg lengthening procedures has been used to give
people with constitutional short stature, and refers to people
who are in the bottom fifth percentile of height in their region.
After they finished bone growth, and do not display any
deformities common with dwarfism.
#ASEREPORT
Billateral cosmetic leg lengthening of twenty-eight years old
male patient with congenital short stature (height 149 cm)
is shown. Monolateral external fixator with compressiondistraction device constructed by professor Mitkovi´c was
used, with distraction rate of 1mm per day for the period of 10
weeks, and that was adequate for achieving desiring cosmetic
leg lengthening. A new bone formation at distraction site was
achieved for period of nine months and average bone formation
was 6,3 cm.
#ONCLUSION
The author’s technique of distraction osteogenesis, using a
monolateral external fixator with compression-distraction device
with a distraction rate of 1 mm per day (0,33 mm three times
daily) as a lengthening apparatus adequately treated cosmetic
leg lengthening and was safe, technically easy to perform and
cost-effective.
2ESUME
To describe radiographic classification of half pin/bone interface,
and the relationship of those pins to maintain stability during
bone healing, were reviewed charts of 24 patients with infected
post traumatic tibia defects (17 at middle third, 4 at distal
third, and 3 at proximal third), submitted to bone transport (17
proximal to distal, and 7 distal to proximal), with monolateral
frame (LRS®-Orthofix, Italy), in a single osteotomy, from 2005 to
2009. Half pins (HP) were separated in groups according place
of insertion (A: proximal metaphysis; B: diaphyisis; C: distal
metaphysis), and AP view radiographic HP/bone interface (5:
normal appearance, no periosteal reaction; 4: osteolisis at cis
cortex and normal appearance at trans cortex; 3: osteolisis at
cis and trans cortices; 2: osteolisis and periosteal reaction at cis
cortex and osteolisis at trans cortex; 1: osteolisis and periosteal
reaction at cis and trans cortices or clear evidence of loosening).
The worse pin score in every group was considered. Averages
of bone defect was 7,39 cm (3 cm-16 cm), and of treatment
time was 395.5 days (139-699). Only 2 patients needed pins
change due loosening. Scores were decreasing with time but
even with grade 3 at positions A and C, or score 2 at position B,
alignment was the same in the end of treatment as just after pin
insertion. We recommend pin change only in scores 2 and 1 at
positions A and C, or score 2 at position B due possibility of lost
of alignment or non union due instability.
+EYWORDS
Distraction osteogenesis, monolateral fixator, cosmetic limb
lengthening.
79
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4)")!,/34%/-9%,)4)3
Podium 4(%53%/&34)-5,!.+)4).42%!4).'#(2/.)#
/34%/-9%,)4)3
0RINCIPAL!UTHOR Amaya Figuero, Julio Eduardo, MD
#ENTRE Clínica Arizu
!UTHORS Rubies San Miguel, Gonzalo Fernando, MD
#ENTRE Clínica Arizu
#OUNTRY Argentina
0RINCIPAL!UTHOR Saghieh, Said, MD
#ENTRE Aubmc
!UTHORS Murtada, Ali, MD; Taha, Abdel Majid, MD; Masrouha,
Karim, MD
#ENTRE Aubmc
#OUNTRY Lebanon
/BJECTIVE
To evaluate the importance of the use of antibiotic-impregnated
cement spacers with metal endoskeleton in cases of bone
reconstruction by means of distraction osteogenesis.
-ATERIALANDMETHODS
Twenty-four patients with tibial osteomyelitis that were treated
between March of 1998 and 2008 were studied retrospectively.
Treatment protocol included: bone resection with debridement
of dead bone and involved soft tissue; a proximal and distal
security margin of 3 cm; stabilization with an external skeletal
fixation device; and the use of an antibiotic-impregnated cement
spacer with a metallic endoskeleton associated with antibiotic
therapy. Once the infection was clinically under control, including
negative bacteriological cultures, a tibial metaphyseal osteotomy
was performed along with a 4 cm resection of the cement
spacer. 10 days later, distraction was initiated at a rate of 1 cm/d
until a gain of 4 cm was achieved, and the number of stages
depended on the extent of the defect to be reconstructed.
2ESULTS
Twenty-two cases presented excellent clinical outcomes,
including total reconstruction of the limb’s length and negative
test results for infection (cultures, Ga/Tc bone scintigraphy). One
case registered another infectious episode at the osteogenesis
focus and only one other required amputation.
#ONCLUSIONS
The use of antibiotic-impregnated cement spacers with metal
endoskeleton has proven to be effective in cases of bone
reconstruction by means of distraction osteogenesis. This
type of spacer increments frame stability by impeding micromovements of the bone extremities during the initial stages
of the procedure. The cement occupies the free space left
behind by the necrotic tissue and the antibiotic delivery is far
more effective when compared to oral or intravenous use.
Vascularization is also enhanced during the limb lengthen
process thanks to the distraction ostegenesis.
80
2ESUME
Osteomyelitis is a pivotal issue for orthopaedic surgeons,
especially in the developing world where availability of treatment
is not always optimal, and risk factors are not always controlled.
This study aims to evaluate the use of the Stimulan Kit (Calcium
sulfate impregnated with antibiotics) for the treatment of
infected non-unions. The treatment of 12 patients with infected
non-union at our institution between March 2002 and May
2007 was retrospectively reviewed. Eleven of 12 patients had
culture-positive long bone infections. All patients underwent
surgical debridement followed by application of the Stimulan-K
bone graft substitute impregnated with vancomycin. Infection
resolved in all patients as assessed by a drop in ESR, decreased
pain at the site of infection, and resolution of draining sinuses.
Union was achieved in all patients as documented by followup radiographs. All patients were interviewed using the SF-36
health survey to capture valid information about functional
health and well-being. Since it is resorbable and possesses
osteoconductive properties, calcium sulfate promoted bone
growth and subsequently bone union in all patients. It also
provided a matrix in which adequate concentrations of
antibiotics were delivered locally, achieving eradication of the
infection without the harmful effects of systemic antibiotics.
Podium .%74%#(.)15%3)."/.%'2!&4).'
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PROCEDURES
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CASES
0RINCIPAL!UTHOR Kovar, Florian M, MD
#ENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
!UTHORS 1Herzenberg, John E, MD; Wozasek, 2Gerald E, MD
#ENTRES 1International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital; 2Department
of Traumatology, General Hospital Vienna, Medical University
Vienna
#OUNTRY United States
0RINCIPAL!UTHOR Hassan El-Gafary, Kamal, MD
#ENTRE Assiut University Hospital
!UTHORS Yousef El-Adly, Wael, MD; Khaled Hassan,
Mohamed, MD
#ENTRE Assiut University Hospital
#OUNTRY Egypt
0URPOSE
Iliac crest bone graft and intramedullary bone graft are
frequently used in limb deformity cases. Many existing papers
discuss different harvesting techniques, but only a few
evaluate the osteogenic potential of the harvested bone graft.
We reviewed the current literature relative to the osteogenic
potential of harvested bone graft.
-ETHODS
We reviewed papers that were published in the last 20 years
that investigated the osteogenic quality of harvested bone
graft. The bone growth enhancers that were reported included
bone morphogenetic protein (BMP), parathyroid hormone,
transforming growth factors (e.g., TGF-b1), insulin-like growth
factor-1 (IGF-1), fibroblast growth factor-a (FGFa), fibroblast
growth factor-b (FGFb), platelet derived growth factor-BB (PDGFBB), and vascular endothelial growth factors (VEGF).
2ESUME
Massive tibial bone loss from infection is a limb threatening
situation. Many options had been described to treat this difficult
problem. We report three patients with massive tibial bone
loss after diphysectomy after chronic osteomyelitis tibia. These
patients are treated by gradual medial transport of the ipsilateral
fibula with olive wires and in one case we did hemifibular
tansport.
All patients was satisfied with the results and hypertrophy of the
transported fibula occured in all patients and joint motion was
maintained like preoperative level. Limb length was equal in two
patient and the third one needed lengthening to correct limb
length descrepancy by oateotomy of the transported fibula.
We conclude that ilizarov method is a good option for limb
salvage in patient with massive tibial bone loss after chronic
osteomyelitis of the tibia.
2ESULTS
We related the quality of harvested bone graft to different
harvesting techniques and harvest locations. Growth factors
such as BMP-2, TGF-b1, IGF-1, FGFa, FGFb, and PDGF-BB were
higher in reamings created with the Reamer/Irrigator/Aspirator
(RIA) System than in bone graft from the iliac crest. However,
contrary to those results, iliac crest bone graft had higher levels
of VEGF and FGFb.
#ONCLUSIONS
There are many factors to consider when harvesting autogenous
bone graft. Surgical factors (e.g., location, pain, complication
rate, quantity harvested, cost of special equipment) and
osteogenic factors (e.g., osteogenic potential of bone graft
obtained from different locations) should be considered. Based
on the literature, a relationship exists between the osteogenic
potential of bone graft and the donor site and harvesting
technique. Future research should not only be concerned with
investigating different surgical approaches for harvesting
bone graft but also focus on the molecular biologic pathways
of osteogenesis. It is important to understand the different
pathways in new bone formation and the interaction of
harvested bone marrow at nonunion sites.
81
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FIXATOR
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AND INCIDENCE OF INFECTION IN GRADE III OPEN FRACTURES
0RINCIPAL!UTHOR Matsubara, Hidenori, MD
#ENTRE Kanazawa University
!UTHORS Koji, Watanabe, MD; Munetomo, Takata, MD; Issei,
Nomura, MD; Hiroyuki, Tsuchiya, MD
#ENTRE Kanazawa University
#OUNTRY Japan
0RINCIPAL!UTHOR Singh, Jagwant, MD
#ENTRE Hull Royal Infirmary
!UTHORS Hashim, Z, MD; Marwah, S, MD; Rambani, Rohit, MD;
Raman, R, MD; Sharma, HK, MD
#ENTRE Hull Royal Infirmary
#OUNTRY United Kingdom
!IMANDPURPOSEOFTHESTUDY
Infected nonunion, osteomyelitis, and suppurative arthritis
are difficult to be treated and often need to be operated. We
usually use external fixator to treat these infection diseases. The
purpose of this study is to show our results of the treatment for
osteomyelitis using external fixator according to our strategy.
)NTRODUCTION
Urgent debridement of open fractures has long been considered to
be of paramount importance in preventing subsequent infections.
Some recent literature however does not support this rationale. The
policy of treating open fractures within 6 hrs can result in complex
operations being performed under sub optimal conditions.
-ATERIALANDMETHODOLOGY
We are using Cierny classification to decide the operation
for osteomyelitis. Type I: Medullary type was treated with
intramedullary curettage and cement rod containing antibiotics.
If patients has the instability after subsiding the infection, we
fixed it with external fixator (6 cases). Type II: Superficial type,
Type III: Localized type were treated with curettage and filled
with Calcium Phospate Cement (CPC) containing antibiotics
with or without external fixator (6 cases). External fixator was
used only for the patient with instability after filling CPC. Type IV:
Diffuse type was treated with resection of infection focus and
reconstructed using bone transport or shortening-distraction
technique (20 cases).
The purpose of this study was to determine the association
between time to definitive surgical management and rate of
infection in high energy (Grade III) open fractures of Tibia.
2ESULT
All patients were healed at the final follow-up. Additional
procedures were done for 5 patients in type IV. Bone graft was
performed for 2 cases of delayed union, deformity correction
for 2 cases of deformity during lengthening, and CPC containing
antibiotics augmentation and flap for one patient.
The primary outcome measure was a diagnosis of infection or
osteomyelitis at one year. A second measure of outcome was
fracture union at one year.
$ISCUSSION
Here are the advantages of our methods for each types of
osteomyelitis.
s 4YPE)!NTIBIOTICSCEMENTRODCANSUPPLYTHELOCALANTIBIOTICS
concentration using sustained release, augment the stability
which helps subside an infection.
s 4YPE)))))3INCE#0#ISBIOACTIVITYSUBSTANCEWHICHHAS
osteoconductivity, it can be filled at a fracture or bone defect
site. And it has excellent ability of controlled-release which
supply the antibiotics locally. Furthermore it can strength the
stability.
s 4YPE)6"YUSINGDISTRACTIONOSTEOGENESISDESIREDLENGTH
can be obtained, shortening and deformity correction can be
treated. Therefore infection site can be resected thoroughly.
And distration osteogenesis brings increase of blood supply
which helps to subside an infection.
#ONCLUSIONS
Infection level and site should be evaluated precisely,
and treatment choice should be determined according to
that. External fixator is very beneficial for the treatment of
osteomyelitis.
82
-ETHODOLOGY
The medical records of all patients presenting with open
fractures were revieved. The inclusion criterions for the current
study were Gustillo III A,B and C open fractures of tibia. Patients
who were referred from other hospitals and those who were
followed up in other centres were excluded.
Time of injury, time of arrival to the hospital, time of initial
debridement and subsequent soft tissue procedures were recorded.
Patients were divided into two groups, those who had
debridement within 6 hrs (<6hrs) and those who waited for
more than 6 hrs (>6hrs)
2ESULTSDISCUSSION
67 patients with grade III open fractures were included in the
study. The mean age was 32.4 years (54 males and 13 females).
There were 26 type IIIA fractures (39%) and 39 type IIIB
fractures (58%).
Eight patients (12%) in this study went onto develop a deep
infection and there were 6 (8.4%) non-unions.
5 patients (13.1%) developed infections in the < 6 hrs group
whereas 3 patients (10.8%) developed infection in the >6
hrs group.No statistically significant difference could be
DEMONSTRATEDBETWEENTHETWOGROUPSP
There was no significant relation between grade of fracture and
RATEOFINFECTIONP
#ONCLUSION
Our study shows that the risk of developing an infection was
not increased if the primary surgical management was delayed
more than 6 hours after injury. Therefore, reasonable delays
in surgical treatment for patients with open fractures may be
justified in order to provide an optimal operating environment.
Podium
42%!4-%.4/&).&%#4%$$%&%#4)6%03%5$/!24(2/3)3"9
6!3#5,!2):%$"/.%'2!&4!.$),):!2/6-%4(/$
0RINCIPAL!UTHOR Yamano Yoshiki, MD
#ENTRE Prof. Emeritus Y. Yamano
!UTHORS Sakanaka Hideki, MD
#ENTRE Sakanaka, MD
#OUNTRY Japan
/BJECT
Treatment of infected defective pseudarthrosis has been
challenging and very difficult problem for Orthopedic surgeon.
This consists of eradication of the infection, the achievement of
bone union, and in many cases, the correction of various bone
deformity and/or shortening. Combined Ilizalov external fixater
with vascularized bone grafting enabled us to treat infection,
bone defect, and also bone deformity/shortening one stage.
-ATERIALSANDMETHODS
Thirty eight cases (Mean age: 41.5 y.o. ranged from 17 to 71
y.o.) of infected defective pseudoarthosis were treated with this
methods (Follow up; 1 to 5 years). After the thorough curettage
of infected tissue, vascularized composite bone grafting was
performed into the defect. Consequently, remaining deformities/
shortenig of bone were corrected with Ilizarov technique.
Successful vascularized bone grafint and skin coverage with
iradication of the infection were primarily performede in all
cases but one. In one cases reoperation was necessary due to
the necrosis of vascularized composite graft.
$ISCUSSION
Vascularized bone grafting into infective tissue is controversial
especially when the infection is active. We have shown here
that, in spite of the active infection, vascularized bone graft
can be successfully perfoemed with assistance of antibiotics.
The theoretical advantages of this methods are as follows.
First, because of good blood supply, the antibiotics are well
transported to the target tissues and subside the infection.
Second, the existence of living bone graft leads rapid bone union
and bone formation according to Ilizarov’s tension stress effect.
The cases where bone lenghening are necessary, may increas
the blood supply to the grafted vascularized bone accelerating
bone formation. And also another important advantages of this
method are that the correction of rotational deformity as well as
angular deformity in these pseudoarthrosis.
Podium #/-").%$0%2#54!.%/53).4%2.!,!.$%84%2.!,
FIXATION
0RINCIPAL!UTHOR Manca, Mario, MD
#ENTRE Ospedale Versilia Toscany Italy
!UTHORS Digrandi, Giuseppe, MD; Palommba, Michele, MD
#ENTRE Ospedale Versilia Toscany Italy
#OUNTRY Italy
)NTRODUCTION
Complex tibial plateau fractures represent a challenge. The aim
of this study is to review the results of a surgical technique
consisting of closed reduction and combined percutaneous
internal and external fixation.
-ATERIALSANDMETHODS
64 type C2 and C3 tibial plateau fractures were included. 55
fractures were closed, 6 were open. The age ranged from 2181 years. Surgical Technique: The patient is positioned on the
operating table with the knee flexed at 30º in transcalcaneal
traction. Through a small skin incision over the antero-medial
aspect of the tibial shaft, a small hole was made. A blunt
tipped curved 3 mm Kirschner wire is inserted through the
hole up to the articular fragments, which are elevated under
image intensifier control. 1 or 2 Kirschner wires are inserted to
stabilize the reduced fragments and 1 or 2 cannuled screws are
introduced over them. After reduction of the articular fracture, an
Orthofix hybrid or axial external fixator is applied. Post operative
care: immediate knee mobilisation. Patients were discharged
between the 3rd and 7th day. Progressive weight bearing was
allowed between the 8th and 12th week. All patients were
checked in the outpatient department. The external fixator was
removed between 15 and 21 weeks. All patients were clinically
and radiographically evaluated at a mean follow up of 48
months (range 38-57). Clinical results were evaluated according
to the Knee Society clinical score. Results: 62 fractures healed.
Average healing time was 15 weeks (11-21). In 2 patient a nonunion occurred. In 2 patients a varus knee deformity occurred.
There were no postsurgical complications. Mean knee range of
motion was 105º (75-125) and mean Knee Society clinical score
was 89. 49 results were scored as excellent, 7 good, 6 fair and
2 poor.
#ONCLUSION
Closed reduction and combined percutaneous internal and
external fixation enables careful management of the soft
tissue injury. Good reduction of the joint can be obtained. Knee
rehabilitation starts immediately. These factors were responsible
for the optimal clinical long-term results.
83
Podium -)34!+%3!.$#/-0,)#!4)/.37(),%53).'#/-054%2
ASSISTED EXTERNAL FIXATION DEVICES
0RINCIPAL!UTHOR Vilensky, Viktor A, MD
#ENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
!UTHORS 1Solomin, Leonid N, MD; 2Utekhin AI, MD
#ENTRES 1Vreden Russian Research Institute of Traumatology
and Orthopedics; 2Ortho-Suv Ltd
#OUNTRY Russian Federation
!IM
To analyze potential mistakes at computer-assisted devices
application, their causes and the ways of their elimination.
-ATERIAL
Nowadays three computer-assisted external fixation devices are
used: Taylor Spatial Frame, Ilizarov Hexapod System and OrthoSUV Frame (http://www.rniito.org/download/ortho-suv-frameeng.pdf). In bench tests (50 series) and in clinic (96 cases)
specific for these devices mistakes were revealed. The ways of
these mistakes elimination were suggested.
$ISCUSSION
In hexapods use there are reduction mistakes caused
by external supports instability following ignorance of
recommendations on rigidity of bone fragments fixation. While
bone fragments reduction interfragmentary diastasis 3-5 mm
should be done initially. Ignorance of this rule can lead to
reduction difficulties caused by “hitching” of bone fragments.
Also each of the hexapods has its specific features. Nonorthogonal placing of the “corresponding” support to the bone
fragment in TSF can lead to improper deformity correction in
spite of proper data input. Making of the x-rays with not definite
keeping of beam orthogonality to the corresponding support
also leads to improper bone fragments translation. Visualization
of bone fragments in two cylinders-imitators, making all the
measures on the external frame and x-rays manually can reduce
to zero all the advantages of hexapod. While using IHS the
supports are to be placed at prescribed distance. Translation of
adapters fixation to the ring for more then 2 holes distance can
lead to negative results because of limited length of struts. Use
of Ilizarov device supports with number of holes different from
standard makes calculation in the software impossible. Absence
of bone fragments visualization in IHS software, making all the
measurements manually, imperfection of user mistake control
can lead to mistakes on the stage of data input. While OrthoSUV application user is protected from mistakes on the stage of
data input. Mistakes are possible only on the stage of external
frame placing when the recommendations on its assembling are
ignored as well as the following warnings of the software.
#ONCLUSIONS
Using of new software-based external fixation device OrthoSUV is prospective in treatment of deformities and long-bone
fractures because its user-mistake control system is the most
functional.
84
Podium THE NEW GIGLI SAW INSERTION GUIDES
0RINCIPAL!UTHOR Kucukkaya, Metin, MD
#ENTRE Istanbul Bilim University
!UTHORS Armagan, Raffi, MD; Sever, Cem, MD; Karakoyun,
Ozgur, MD; Kuzgun, Unal, MD
#ENTRE Istanbul Bilim University
#OUNTRY Turkey
2ESUME
Gigli saw insertion technique is well described by the using
clamp and suture in performing the long bone osteotomy. We
designed a new “Gigli saw insertion guides”. Its provide easy,
quick and safe insertion of the Gigli saw with smaller insicion
in all anatomic areas. By the using these guides, both clamp
and suture are not necessary. Also, these guides preserve soft
tissues from the Gigli saw damage during the osteotomy.
These guides is a periosteal elevator which also has a groove
on bone site. After insicion, periosteum is elevated, guides are
inserted and Gigli saw passed through the groove of the bone
site of the guides. This groove prevents slippage of the saw
during pass around the tibia. Then, the osteotomy is completed
while the guides are placed to protect the soft tissues. In the
tibia two smaller standart postero-medial and antero-lateral
insicions are used. In the femur, hovewer, three insicions
(postero-lateral, antero-medial and antero-lateral) are used.
We used our new Gigli saw insertion guides for 38 osteotomies.
Twenty-three osteotomies were in tibia (proximal methaphysis in
19, distal in 4), 15 osteotomies were in femur (distal metaphysis
in 11, proximal in 4). The mean age of the patients was 24 (1058) years.
All osteotomies have united. There were no neurovascular
complications.
The new “Gigli saw insertion guides” provide easy, quick
and safe insertion of the Gigli saw with smaller insicion in all
anatomic areas. By the using these guides, clamp and suture
are not necessary. Also, these quides preserve soft tissues from
the Gigli saw damage during the osteotomy. Case examples and
illustrations will be presented.
Podium 42%!4-%.42%35,43/&/24(/0%$)#!.$42!5-!
0!4)%.43"9-%4(/$/&#/.42/,,%$42!.3/33%/53
OSTEOSYNTHESIS
0RINCIPAL!UTHOR Ismaylov, Guseynali, MD
#ENTRE Hospital Milad
#OUNTRY Iran
)NTRODUCTION
The treatment methods for orthopedic and trauma patients,
elaborated by Academician G.A. Ilizarov and his students, have
found wide scientific and clinical application and have been
approved by the leading specialists of the world.
-ETHODANDMATERIAL
The present work is based on the experience of treatment of
4.678 patients with acquired (58,5%) and congenital (41,5%)
pathologies of upper and lower limbs. The treatment was
provided starting in 2001 until present in UK, Azerbajdzhan
and the Near East. 90% of all orthopedic and trauma patients
were operated on with traditional methods. 29,4% of operated
patients had osteomyelitis complications; 23% of patients
were in remission condition. 34,7% of patients had extended
scar changes of soft tissues and skin, some scars were fused
with bone as a trauma consequence, so as the result of
surgery. 49 patients were suggested to amputate the limbs.
The complex system of transosseous distraction-compression
osteosynthesis treatment is performed by the stable fixation of
all bone fragments, possibility of their gradual transportation
in the different planes in post-operative period. The method
is based on original methods and techniques of surgical
intervention with utilization of different modifications of external
fixation devices, excluding the causes of scar changes and
inflammatory processes. This method allows for refusing of all
types of transplants and promotes the elimination of pathology
recurrence. The methods applied for surgical treatment of
patients were dependant on anatomic, functional and cosmetic
pathologies of segments of locomotor system. The period of stay
in the hospital is average 3-4 days, and the following treatment
was performed on out-patient basis. The control during
treatment allowed for elimination of any complications. The
possibility of using of the device provided for early functional
weight-bearing.
2ESULTS
Treatment results was followed in the periods from 1,5 months
to 8,5 years and are evaluated by us and patients as positive:
good-96%, satisfactory-4%.
#ONCLUSION
After the conduction of reconstructive and restorative treatment
in all cases we received positive outcomes, which proved
that the application of controlled transosseous osteosynthesis
provides for organic and impeccable restoration of limbs in
world practical medicine.
Podium 7(9%84%2.!,&)8!4)/.).4(%-!.!'%-%.4/&
FRACTURES?
0RINCIPAL!UTHOR Aybar Montoya, Alfredo, MD
#ENTRE Universidad San Marcos
#OUNTRY Peru
/BJECTIVEANDPURPOSE
Emphasize the Academic and Scientific Fundamentals that
external fixation is an excellent alternative in the treatment of
fractures.
-ATERIALANDMETHODS
Contrast of the fundaments of the techniques of osteosynthesis
and conservative treatment versus external fixation techniques.
$ISCUSSION
There are two classical concepts in the treatment of fractures:
(1) procedures “conservative”, ie without surgery, and (2)
procedures “surgical” approaches using through soft tissue up
to the outbreak of the injury. Each one has its advocates. Each
one has its advantages and disadvantages. The truth is that,
whatever the fracture is, when presented with displacement,
primarily it must be “accommodates” (reduced). This is the
first scientific and technical problem. After this is achieved,
secondary the fracture must be immobilized. This is the second
scientific and technical problem. At this point it is involved the
application of devices, implants or apparatuses from a variety
of ways to maintain that has been reduced to the healing callus.
Real biological process called bone healing. With any device
(method, technique) that would achieve these goals, everything
will have a good end. This can not be questioned, pending
further damage is done. Here are the concepts of minimally
invasive method and postoperative quality of life (early departure
of disability) that should be scientifically supported with the
selected method. Academically and scientifically it is true that
there is only one treatment regimen: to reduce and immobilize.
The rest are techniques that seek these goals. The big problem
of management it depends of the specific characteristics of the
bone fracture with their soft tissue.
#ONCLUSIONS
External fixation, ie the introduction of pins percutaneously near
or far from the focus of injury, it is, scientifically, a minimally
invasive procedure. With the external fixator it is also achieved
the goals of reducing the fracture and meet either scientifically
maintain the reduction achieved to allow bone healing. At
present certain cases, requires combining immobilizers means
–plus internal implants–. Expectations are in the performance
of these devices (combinations). External Fixation therefore
becomes eligible as an alternative treatment of fractures.
85
Podium EXTERNAL FIXATION AS TO PREVENT AND TO CARE
0/3442!5-!4)#34)&&.%33/&4(%%,"/7
0RINCIPAL!UTHOR D’Amico, Salvatore, MD
#ENTRE S Anna Hopital
!UTHORS Zottola, Vincenzo, MD
#ENTRE S Anna Hopital
#OUNTRY Italy
2ESUME
It is well recognized that early range of motion after surgery can
facilitate fracture healing, cartilage regeneration, and rehabilitate
atrophic or contracted soft tissues.
Early range of elbow motion is required soon after injury or
surgery to prevent stiffness and achieve a maximum arc of
motion. Unfortunately, surgical release of contractures or
acute injuries can create instability that makes unprotected
movements risky or impossible.
External fixation associated with ORIF or soft tissue release
helps to achieve the range of motion reached for the patient.
Authors shows different cases (fracture-dislocations with
compartimental instability, posttraumatic stiffness) to point out
the external fixation as support after ORIF or surgical release.
Podium &5.#4)/.!,2%35,43/&%84%2.!,&)8!4)/.!.$#/-").%$
#/-02%33)/.3#2%73#/-0!2%$7)4(#,!33)#!,/2)&
!.$0,!4%3&/23502!).4%2#/.$9,!2#!.$#
FRACTURES IN ADULTS
0RINCIPAL!UTHOR Ayala Hernández, Enrique, MD
#ENTRE Traumatology Hospital Victorio de la Fuente, Social
Security Mexican Institute
!UTHORS Arellano Valle, Jesús, MD; García Lozano, Mario, MD;
Vázquez Talavera, Manuel, MD; Bermúdez Soto, Ignacio, MD
#ENTRE Traumatology Hospital Victorio de la Fuente, Social
Security Mexican Institute
#OUNTRY Mexico
!IMANDPURPOSE
Compare functional results and complications (measured as
safety-efficacy) with a combined external fixation (uniplanar,
unilateral-tubular external fixator and interfragmentary
compression screws) describing the surgical technique
compared with the standard ORIF with double plate in closed
supra-intercondylar humeral fractures in adults.
-ATERIALANDMETHODS
Prospective, control study. Were included 48 patients, both sexes
with 13 C2 and C3 fractures of the AO classification. Group 1
treated by the combined method described before (24 cases)
and Group 2 treated by the gold-standard method of ORIF and
plates (24 cases). Follow up at least 12 months. The measures
(range of motion, level of post-surgical patient satisfaction,
complications and fracture union) were done by two blinded,
standardized observers. Statistical analysis was applied with
homogeneity test, and inferential with Student t and Chi square
tests, significant difference was considered with p value minus
0.05.
2ESULTSANDDISCUSSION
Female/Male ratio 1:1. Mean age 47.2 ± 19.5 years old. Type
of fracture according to AO classification were 13C2 50% and
13C3 50% in both study groups. Bone healing in all cases, no
deep infections, 2 superficial infections treated by medical ways.
Cubital neuropathy in 2 cases, one in each group. No other
mayor complications. Functional results : 130º of elbow flexion
and -10º of extension in the group of external fixation; 125º
of elbow flexion and -10º of extension in the ORIF with plates
group. Very similar results in both groups using the American
Shoulder and Elbow Surgeons (ASES) functional outcome
rating system. No intra-operative conversion to total elbow
arthroplasty.
#ONCLUSIONS
External Fixation combined with compression screws is a safe
and effective method of treatment for these kinds of fractures.
The results are very similar compared with ORIF using plates
the so called “gold standard” of treatment. This option should
be considered in the low profile distal humeral fractures due to
difficult plate application to ensure stability.
86
Podium $9.!-)#!8)!,&)8!4)/.
0RINCIPAL!UTHOR Pareja, Carlos, MD
#ENTRE Caja de Seguro Social
#OUNTRY Panama
2ESUME
From all known that in 21st century external fixation is one of
the most used in the muscle-skeletal system, ranging from open
or closed fracture injuries osteosynthesis methods (the concept
of using exclusively in severe open fractures is deprecated
nowadays), until member reconstruction and resolution of many
cases of pseudoartrosis. Dynamic axial fixer daf was developed
at the university of verona (g. De bastiani, aldagheri r and l renzi
brivio) in the year 1979. Characterized by a central body and
fasteners or bearings which are axially coupled with spherical
joints. Also includes a detachable compresion-distraccion of the
central body system. The screws to attach to bone are conical
trunk of 6 mm in diameter. The basic philosophy of fractures
with the daf management is to “respect and promote the natural
physiological process of consolidation of these injuries”. This
system, although rigid in its early stages, enables micro moves
needed to ensure a secondary consolidation or callus.
%XTERNALBRIDGE0RINCIPLES
1 Minimum disturbance focus of fracture.
2 Callus external bridge by induction of movements or
dynamization, which can be of two training stimulation forms:
cyclic to-.movimiento. (b)-progressive.carga. 3-.minimiza
complication to respect bone biology. 4-.curva small learning,
your application is very easy and can be removed in the
office. Experience: began the use of this system in 1996
(previous experiences with roger anderson, hoffman-vidalralca-orthoframe) and now our service in david, chirquí, rep
experience. Panama, more than 1,500 cases with success in
more than 95% of cases. Conclusion: external fixation is kind,
after that complies with the principles of stability and facilitate
normal healing bone which requires micromovimientos the
focus of the injury, is an ideal in many injuries that affect the
system skeletal muscle and allow recovery to 100% method if
they are well used.
Podium !8)!,%84%2.!,&)8!4)/.&/24(%42%!4-%.4/&$)34!,
4)")!,-%4!0(93%!,&2!#452%3490%!
A REVIEW OF 40 CASES
0RINCIPAL!UTHOR Manca, Mario, MD
#ENTRE Ospedale Versilia Toscany
!UTHORS Digrandi, Giuseppe, MD; Palomba, Michele, MD
#ENTRE Ospedale Versilia Toscany
#OUNTRY Italy
)NTRODUCTION
Displaced distal tibial metaphyseal fractures, type A, are a
challenge. Complications up to 84% are reported with traditional
internal fixation. The aim is to review the results of external
fixation treatment with a closed, minimally invasive technique.
-ETHODS
40 type A fractures were reviewed, aged 11 to 89 years, after
stabilisation with an external fixator using Hydroxyapatite coated
screws, and were reviewed clinically and radiographically at an
average of 7 years (range 3-11).
Results were evaluated according to the IOWA knee and ankle
rating system. Radiographically we considered good results
with deviations in varus/valgus <5º, ante/recurvatum <10º,
shortening <1cm.
2ESULTS
All fractures healed. Removal of the fixation device at an
average 158 days. Fractures had average scores 98 (knee) and
95 (ankle). No cases of deep infection, skin necrosis, nonunion
or articular stiffness were recorded.
$ISCUSSIONANDCONCLUSION
These results show that external fixation is a valid option. It
guarantees good stability at the fracture site allowing early
physiotherapy, leaving joints free and allowing weightbearing.
87
Podium 2%#/.3425#4)/.&/,,/7).'-!,5.)4%$!.+,%
FRACTURES
0RINCIPAL!UTHOR Saleh, Michael, MD
#ENTRE University of Sheffield
#OUNTRY United Kingdom
!IMANDPURPOSEOFTHESTUDY
Bimalleolar and trimalleollar ankle fractures are normally
treated by open reduction and internal fixation. The mortice
joint of the ankle must be accurately reconstructed in order to
avoid instability and degenerative change. The most commonly
observed deformity is lateral translation of the talus (diastasis)
secondary to a combination of medial ligament incompetence,
diastasis and valgus angulation and shortening of the fibular
malleolus.
A Weber B fracture is oblique and without support it will
angulate and shorten 2-5mm). A Weber C fracture may shorten
considerably more up to 10 or even 15 mm. In this series a
painful ankle associated with AP/ML laxity or rotational deformity
and weight bearing X-rays showing a diastasis, torsional
incongruence, abnormal radiographic malleollar indices and
malnonunion of the medial malleollus were taken as indications
for surgery. With modern surgical techniques reconstruction by
means of corrective osteotomy and ligament augmentation is
possible.
-ATERIALSANDMETHODS
Twelve patients operated on between August 2003 and January
2010 have been reviewed. There were 7 females and 5 males
age range 29-55 years. The procedures in seven patients
INCLUDEDCORRECTIVElBULAOSTEOTOMYlBULALENGTHENING
diastasis and medial ligament repair. Two of these patients had
external fixators applied to lengthen the fibula by 8 mm and
15 mm following Weber C fractures. Five patients underwent
articulated distraction using circular external fixation with
adjunctive surgery such as fibula lengthening and syndesmotic
repair. In late presentations excision of osteophytes was
performed.
$ISCUSSION
Satisfactory results were achieved in 9 cases representing all of
the cases where anatomical reconstruction was achieved. Poor
results were achieved in 3 more severe cases of long standing
deformity who underwent articulated distraction.
#ONCLUSIONS
Correction of malnonunion following bimalleollar and trimalleolar
fractures is worthwhile.
Podium PILON TIBIAL FRACTURES TREATED WITH EXTERNAL FIXATION
0RINCIPAL!UTHOR Greco, Andrés Luciano, MD
#ENTRE Hospital Municipal Dr. Eduardo Wilde
!UTHORS Beltrán, Jorge Roberto, MD; Colletta, Daniel, MD; Vivas,
Mauro Rafael, MD; Rujlin, Matías Sebastián, MD
#ENTRE Hospital de Wilde
#OUNTRY Argentina
/BJECTIVEANDPURPOSEOFLABOR
Pilon tibial fractures the wounds are serious and the risk of
complications is high. Constitute less than 10% of all lower limb
fractures and are more common in males than in females.
They are caused by axial overload, and the time of fracture
great energy is released causing soft tissue injury. The goals
of treatment are to prevent complications and achieve a
good alignment of the tibial shaft and a congruent ankle joint,
obtaining fragments by reducing ligamentotaxis controlled
without harming the fracture focus and thus conserving
biological principles of bone healing.
In this study demonstrate the benefits of external fixation in such
pathology.
-ATERIALSANDMETHODS
During the period between march 1997 and july 2009 were
treated 43 pilon fractures.
Retrospectively analyzed this group of patients and were
included for study those cases with closed fractures and
exposed, displaced and unstable with a follow up 6 months.
Of the 43 patients treated the age range was 41st 78 years
with a mean age of 50 years. The indications of the type of
external fixator used was based on the severity of the fracture,
degree of soft tissue injury and the degree of displacement and
comminution of the outbreak. The types of fasteners used were
the Ilizarov circular fixator, and a monolateral fixator of spherical
bearing. The circumstances of the accident was in 31 patients a
fall from height 72,10% and 12 patients per accident 27,90%.
$ISCUSSION
The gains in the election rate monolateral and circular external
fixator are: safe method with minimal incisions without
increasing the soft tissue injury, initial and definitive treatment
with the fixative without further surgery with internal fixation
material, provides stability and elasticity to the fracture focus,
lower complication rates, and preserve the principles biological
consolidation of fractures.
#ONCLUSIONS
Our conclusions are as follows: treatment alternative, non
invasive method which respects the biological principles of
healing of fractures, assembly respecting the anatomical levels,
early rehabilitation of joint mobility, only surgery and most
importantly avoid soft tissue complications.
88
Podium 0),/.&2!#452%3),):!2/642%!4-%.4/.42!5-!
HOSPITAL
Podium ,!4%2!,-!,,%/,!2452.$/7.!002/!#(&/24(%
-).)-!,,9).6!3)6%42%!4-%.4/&0),/.&2!#452%3
0RINCIPAL!UTHOR Nogueira Silva, Wagner, MD
#ENTRE Hmal-Fhemig
!UTHORS Martins Henrique, Luciano, MD; Barros Souza Gomes,
Leonardo, MD; Cunha Milton, Fernando, MD; Brito Souza, Roberta,
MD
#ENTRE Hmal-Fhemig
#OUNTRY Brazil
0RINCIPAL!UTHOR Lahoti, Om, MD
#ENTRE Kings College Hospital
!UTHORS James, Kyle, MD
#ENTRE Kings College Hospital
#OUNTRY United Kingdom
/BJECTIVE
Show the results of 16 patients –high energy pilon fractures–
treated with Ilizarov method, between july 1998 and octuber
2002, classified based on ruedi algover, aoasif and gustilloanderson tables, with results and complications analized by
aofas criterion.
-ATERIAL
The medium age was 41 years, majority males, all the fratctures
were got after high impact force, prevalent after height fall.
8 of them were open fractures and 8 had associated lesions.
For 2 pacients was necessary the use of bioceramic graft, in 2
patients were used peri-articular interfragment screw at urgency
assistency. All of them had been treated with ilizarov external
fixation.
2ESULTS
100% of consolidation, follow up minimun of 13 months
after frame remotion and maximum of 6 years. Complicatios:
soft tissue necrosis, residual deformities, infection and ankle
arthosis.
!NKLEMOTIONINDEGREESEXTENSIONTOmEXIONTO
&OOTMOTIONDEGREESPRONATIONTOSUPINATIONTO
6ALGUSDEFORMITYMORETHANDEGREES
7ITHOUDISCREPANCY
#ONCLUSIONS
High energy pilon fractures showed good results after Ilizarov
treatment, they consolidated with many complications and
arthrosis can be expected after many years.
!IM
We describe a new surgical approach designed for use with
minimally invasive fixation and a circular frame. Tibial pilon
injuries are often associated with significant soft tissue injury,
which may not be evident at the time of injury. In such cases
standard surgical approaches can lead to problems with wound
healing, thus increase the risk of deep infection. AO Type C
valgus fractures are commonly associated with fibula fractures.
We found that the anterior syndesmotic ligaments are often
disrupted with sparing of the lateral soft tissue envelope.
-ATERIALSANDMETHODOLOGY
Our technique utilizes a direct lateral approach to expose
the lateral malleolus/distal fibula, which is reflected posterolaterally through the fracture and intact posterior syndesmotic
ligaments. This creates a direct view of posterolateral and
anterolateral comminution and talar dome allowing direct
fixation of fragments with minimal internal fixation. Fibula
fixation is performed with a 1/3rd tubular plate and the anterior
syndesmotic ligaments are repaired.
From 2007-2009, we have used this approach in 12 patients
(male 9: female 3; age range 19-42) with AO Type C3 fractures
WITHSIGNIlCANTSOFTTISSUEINJURYOPENCLOSED4SCHERNE
'RADE'RADE7EUSEDCIRCULARFRAMESTABILIZATIONIN
all cases (in four patients an additional foot frame was applied to
protect the articular surface).
2ESULTS
All fractures united in satisfactory alignment. Wound healed well
in all cases. One case of gouty arthritis developed superficial
infection, which went on to heal after wound wash out and oral
antibiotic therapy. Follow-up (minimum 3 months and maximum
2 years) showed no ankle instability. Clinical evaluation revealed
a mean dorsiflexion of 10º (5-15º) and mean plantar flexion of
35º (15-60º).
#ONCLUSIONS
We conclude that transfibular approach gives good exposure of
lower tibial articular surface in selected cases of pilon fractures
with least soft tissue disruption.
89
Podium 4)")!,0),/.&2!#452%342%!4-%.47)4(34!.$!2$):%$
#)2#5,!2%84%2.!,&)8!4)/.4%#(.)15%!.$-!4%2)!,
Podium 42%!4-%.4/&#/-0,%84!23!,.!6)#5,!2&2!#452%3
WITH EXTERNAL FIXATION. A REPORT OF 8 CASES
0RINCIPAL!UTHOR Santoro, Daniele, MD
#ENTRE Sosd Patologia Traumatica del Bacino E Fissazione
Esterna (dr. Renè Negretto)-Cto Torino
!UTHORS Aloj, Domenico, MD; Désayeux, Selena, MD; Petruccelli,
Eraclite, MD; Biasibetti, Antonio, MD
#ENTRE Sosd Patologia Traumatica del Bacino E Fissazione
Esterna (dr. Renè Negretto)-Cto Torino
#OUNTRY Italy
0RINCIPAL!UTHOR García López, José, MD
#ENTRE Hospital Asepeyo
#OUNTRY Spain
0URPOSEOFTHESTUDY
In high energy tibial pilon fractures axial compression causes
a severe bone involvement, while capsule and ligaments
are partly spared, allowing for ligamentotaxis. ORIF is risky
in terms of infections and soft tissues. Ex Fix, by means of
the ligamentotaxis, associated or not to minimally invasive
procedures, offers similar outcomes. We describe a Circular Ex
Fix technique, focusing on a good joint and diaphysis reduction,
that can be standardized and is repeatable.
-ETHODSTEPBYSTEPTECHNIQUE
I) Frame construction and its rationale:
1 a foot support (FS) fixed to the heel is the distal end for
ligamentotaxis spanning the ankle joint.
2 an epiphyseal ring allows for minimally invasive reduction and
fixation of the articular fragments after ligamentotaxis has
been performed. This ring is identified as number 1(R1).
3 on the metaphyseal ring, number 2 (R2), reduction and fixation
of metaphysis and diaphyseal extension is possible with close
procedure according to Ilizarov technique.
4 the diaphyseal ring, number 3 (R3), is the proximal end for
ligamentotaxis and the site of proximal final fixation of the
frame.
II) Procedure: distraction done between FS and R3 and
maintained with long threaded bars FS-R2. R1 is released and
centered on the epiphysis after ligamentotaxis and fixed in this
position. Under Xray epiphyseal reduction and stabilization. On
R2 metaphyseal reduction. Proximal fixation on R3.
)NDICATIONS
s )NDICATIONSOFNECESSITYOPENFRACTURESSKINCONCERNING
conditions.
s %LECTIVEINDICATIONSARTICULARFRAGMENTATIONUNCERTAIN
possibility to carry out the anatomical reconstruction),
diaphyseal irradiation: types B3.3-type C1.3-types C2-C3
according to AO classification.
-ATERIAL
From 01 to05 52 surgical procedures. 37 ex-fix; AO 43C1:943C2:15(4 open)-43C3:28(9 open); age 40.3(23-73);type of
frame 11orthofix (9fixed,2 hinged)-18 Ilizarov-8monolateral
converted to Ilizarov; f-up at 27m (8-40); healing 26 w (a);
Complications: 1deep infection>sequestrectomy; 2articular
fusions; no malunions>10º; 20% pin track infections (healing
after removal).
#ONCLUSIONS
Ex-fix as standardized method can be used in tibial pilon
fractures with defined indications with less complication than
ORIF and with similar results.
90
"ACKGROUND
Nowadays complex tarsal navicular fractures represent a
challenge for orthopaedics surgeons because of their difficult
management and high rate of complications. No uniform
criterion regarding the treatment of this kind of fractures exists.
-ETHODS
Evolution and complications of eight cases of complex tarsal
navicular fractures treated with external fixation and minimal
osteosynthesis are analyzed.
2ESULTS
A high rate of complications appeared during the process and
therefore a midfoot arthrodesis was necessary in one third of the
patients.
#ONCLUSIONS
The association of external fixation and minimal ostheosynthesis
may be considerated as an effective treatment for complex
tarsal navicular fractures.
Podium 42%!4-%.4/&!24)#5,!2&2!#452%3/&4(%(%%,7)4(
%84%2.!,&)8!4/2
OUR EXPERIENCE
0RINCIPAL!UTHOR Corina, Gianfranco, MD
#ENTRE PO Vito Fazzi di Lecce
!UTHORS 1Marsilio, Antonio, MD; 2Tartaglia, Nicola, MD; 1Rollo,
Giuseppe, MD
#ENTRES 1PO Vito Fazzi di Lecce; 2PO San Paolo Bari
#OUNTRY Italy
2ESUME
Treatment of fractures of the heel is still a controversial and
much-debated subject today.
Several different techniques are used to treat complex fractures
which may be articular or extra-articular.
It is widely believed that that the gold-standard is open
reduction and internal fixation (ORIF) using plates and screws
implanted laterally, less invasive techniques are gaining
increasingly significant recognition, especially when patients
show compromised soft tissues or local and/or systemic
contraindications.
Since May 2009 we have treated XX complex calcaneum
articular fractures (in 19 patients) with Orthofix external fixator.
The fractures were classified according to the Sanders fracture
classification system.
The Maryland Foot Score method were used to functionally
evaluate the patients and xrays and CT scans were performed at
different stages of the treatment.
Over a short period of time we are able to observe excellent
functional results in most cases and patients were fully satisfied.
We therefore believe the surgical technique described to be an
optimal solution for the treatment of calcaneum fractures.
The authors provide notes on surgical technique, clinical cases,
results and complications linked to the method.
Podium
TERIPARATIDE AS ADJUNCT IN THE RESOLUTION OF A CRONIC
).&%#4%$3(!&44)")!./.5.)/.42%!4%$"9!#-"/.%
42!.30/24!4)/.!.$&2%,!4)33)-53$/23)&,!0#!3%
REPORT
0RINCIPAL!UTHORCorella, F, MD
#ENTRE Servicio Cirugía Ortopédica y Traumatología Hospital
Infanta Leonor
!UTHORS1Pérez-España, M, MD; 3Del Cerro, M, MD; 2Sánchez,
B, MD; 1Ocampos, M, MD; 1García Bógalo, R, MD; 1LarrainzarGarijo, R, MD
#ENTRES 1Servicio Cirugía Ortopédica y Traumatología Hospital
Infanta Leonor; 2Servicio de Medicina Interna Hospital Infanta
Leonor; 3Servicio Cirugía Ortopédica y Traumatología Gregorio
Marañón
#OUNTRY Spain
#LINICALCASE
33 years old male patient who suffered a tibia shaft fracture
initially treated by a nail. In 2006 he had a new fracture with
the break of the nail. At that moment their surgeons decided
to treat this situation using a plate keeping the original broken
nail. In 2008 the diagnosis of nonunion was established so
they remove and implanted a new intramedullary nail. Later
on he was diagnosed of chronic osteomyelitis treated with
local sequestrectomy keeping the endomedular nail. At the
moment the patient was referred to our hospital he had two
active fistulas in the distal third of tibia with chronic drainage,
extensive involvement of soft tissue and tibia bone exposure.
4REATMENTFOLLOWEDINOURCENTER
As we focus on the main problem: chronic infection, we remove
the intramedular nail and an external fixation was used for bone
stabilization followed by aggressive debridement of the focus of
the infected nonunion. The bone defect after debridement was
10 cm and we started out a bone transport. A free latissimus
dorsi flap resolved the skin defect. The patient began medical
adjunct treatment with teriparatide and calcium/Vitamin D
during all the transportation process to achieve bone formation
as soon as possible exploiting the probe potential of this drug.
Throughout this process the patient was examined and treated
by the infectious section of our Institution Internal Medicine
Service receiving several cycles of antibiotic therapy until
resolution of infection.
$ISCUSSION
The sewage treatment for chronic osteomyelitis of the tibia
includes treatment by aggressive debridement of bone and soft
tissue followed by skin coverage with medical treatment by
appropriate antibiotic therapy. This complex disease requires
a multidisciplinary approach. The Cierny-Mader classification
is the most commonly used to describe bone infection. These
were classified as type I: medullary, type II: superficial, type
III: localized, type IV: diffuse. The infected nonunion of the
tibia is a type IV, requires massive resection of all infected
tissue of both bone and soft tissue (fistulas, fibrous tissue,
etc.). The penetration of antibiotics to them is very limited
and without a surgical treatment is impossible. The surgical
technique is similar to that used for musculoskeletal tumor
and the necessary reconstruction as complex as those. The
reconstruction of soft tissue defects in the distal tibia (as the
case) is usually performed with a free muscle flap. This has two
91
benefits, firstly provides good coverage of large skin defects
and the other allows a good blood supply to the infected focus,
which will get access of antibiotics and cure of the infection.
The reconstruction of a bone defect greater than 6 cm (10 cm
in the case presented) is usually made either by vascularized
bone grafts (fibula most common), or by a bone transport.
The latter has two main advantages compared to the bone
graft: first because of the better bone quality of the new bone,
fracture rate is less than a fibula (which takes a long time to
hypertrophy and get adequate resistance) and the other allows
a sooner weight bearing of the affected limb. On the other hand
it also has a clear disadvantage because requires the use of
an external fixation and the possible infection of the pins. The
use of anabolic therapy has probed effective anti-fracture,
and in experimental studies Teriparatide has showed a great
osteogenic power that can be useful in delays of consolidation
and generally in those processes requiring bone formation.
However, as far as we know, this osteogenic role had not been
oriented to accelerate the process of bone formation associated
with bone transport. In the case presented it is well showed the
osteogenic power of the anabolic therapy (Teriparatide) although
has not been achieved a shorten time the get the 10 cm bone
transportation. The explanation for this phenomenon may be due
to that the continuous distraction of the fracture callus limits
the differentation of mesenchimal cells to bone cells or due to
the local changes after several surgeries altered the molecular
processes associated to the osteoblastic effect. Anyway our
case is interesting because of the good results obtained in
a delicate clinical situation and the association of a medical
adjunct (Teriparatide: bone anabolic agent) to complex surgical
treatment.
Podium ARTHRODIATASIS FOR TALAR OSTEOCHONDRAL LESIONS
USING CIRCULAR EXTERNAL FIXATION
0RINCIPAL!UTHOR Wang, James, MD
#ENTRE Santa Monica Ucla Orthopaedic Hospital
#OUNTRY United States
!IMANDPURPOSE
To present a surgical technique for osteochondral talar lesions,
utilizing circular external fixation and arthrodiatasis. To prevent
ankle arthroplasty and arthrodesis, utilizing an alternative
procedure.
-ATERIALSANDMETHODOLOGY
95 patients underwent ankle arthroscopy with debridement of
osteochondral talar lesions, packing with adult mesenchymal
stem cells and an ankle arthrodiatasis. Patients were distracted
one centimeter on the operating room table with a circular
external fixator for six weeks. Patients were encouraged to
weightbear as soon as possible after the surgery. The frames
were static and did not have hinges in the construct.
$ISCUSSION
Osteochondral lesions of the talus are difficult to manage.
Treatment options have ranged from bone grafting to cartilage
transplantation. The author has found that historically these
options are not highly successful unless the joint is distracted.
Arthrodiatasis with weightbearing allows fluctuations in intraarticular joint pressure, which provides a favorable environment
for chondrocytes, which can lead to reparative activity. Average
follow up was for 7.4 years and no patients went on to ankle
arthroplasty or arthrodesis. Three patients required an additional
ankle arthroscopy.
#ONCLUSION
Ankle arthrodiatasis with supplemental adult mesenchymal
stem cells is a viable method to successfully treat painful,
osteochondral talar lesions. Circular external fixation allows
one to perform this technique and prevent ankle arthroplasty or
arthrodesis.
92
Podium #/-").%$53%/&4(%-/./"/$9$9.!-)#%84%2.!,
FIXATOR AND INTERNAL FIXATION FOR ANKLE ARTHRODESIS
Podium !.+,%!24(2/$)!34!3)3!./04)/.
&/20/3442!5-!4)#/34%/!24(2/3)342%!4-%.4
0RINCIPAL!UTHOR Kimmel, Howard, MD
#ENTRE Department of Veterans Affairs
#OUNTRY United States
0RINCIPAL!UTHOR Targa Hamilton, Walter, MD
#ENTRE Hospital Das Clinicas-Fmusp
!UTHORS Reis Roberto, Paulo, MD; Gaiarsa, Guilherme, MD;
Rodrigues, Franklin, MD; Moreno, Patricia, MD; Felix Monterroso,
Alessandro, MD
#ENTRE Hospital Das Clinicas-Fmusp
#OUNTRY Brazil
"ACKGROUND
Numerous techniques for ankle arthrodesis have been
described in the literature. Various methods for internal fixation
including plates, screws and intermedullary nails, while various
apparatuses for external fixation such as Illizarov, Charnley,
Hoffman and Calandruccio have also been described in the
literature. There has only been one paper published describing
the combined use of both internal and external fixation using
screws and a Charnley external fixation device. The primary use
for the monobody dynamic articulating fixator has been for pilon
fractures and other complicated tibial fractures. These devices
allow for simultaneous correction of deformities in more than
one plane.There use in non-traumatic procedures has been
limited, but they have been used in lengthening and deformity
correction procedures of the humerus and the femur. The author
will show the benefit of using the combined technique of internal
fixation and these external fixators.
-ETHODS
Six patients had a combination of fixation as described above.
Four patients had plates and screws as internal fixation and two
patients had just screws as internal fixation. The average age
of the patient was fifty six with one female and five males. All
patients had post-traumatic arthritis. Two patients had removal
of all hardware due to infection. Procedure consisted of a lateral
approach with removal of the fibular malleolus, which was not
replaced. The external fixator was put on prior to preparation of
the fusion site to allow for distraction of the joint. Patients were
allowed to be partial weight bearing at 4 weeks.
2ESULTS
The average time to fusion was 9 weeks. There was no
statistical difference between the two types of internal fixation.
3UMMARY
Arthrodesis is the gold standard treatment for ankle arthrosis
pain. Arthroplasty is a recent solution with a high rate of
complications and without long-term results. Arthrodiastasis
appears as an option with fewer surgical complications,
preserving the joint. This poster is designed to show the results
with this treatment.
-ETHODS
We performed arthrodiastasis on 17 patients with severe and
painful post-traumatic ankle arthrosis: 8 cases with unilateral
external fixator and 9 with circular fixator. Distraction was
performed during surgery at no more than 10 mm, ankle
mobility was preserved and the fixator was maintained for
twelve weeks, allowing total load on the limb during this period.
2ESULTS
All the patients experienced improvement of pain profile and of
range of motion. In 12 cases the improvement lasted for over
36 months. There was no improvement of radiographic aspect.
No case underwent arthroplasty or arthrodesis in 5 years of
follow-up. One case presented a profile of complex regional pain
syndrome and another presented infection on the Schanz pins
track, requiring antibiotics.
#ONCLUSION
It is a procedure with few complications, important improvement
of pain and function, scarcely invasive and that allows other
surgeries afterwards.
#ONCLUSION
The advantage of using the combined technique allows for early
weight bearing and dynamization of the fusion site. Utilizing
the monobody dynamic articulating fixator not only allows the
surgeon to distract and compress the joint, but also allows for
alignment adjustment after the procedure. The benefit of the
combined technique allows for extreme rigidity and compression
of the arthrodesis site.
93
Podium ARTICULATED ANKLE DISTRACTION FOLLOWING ANKLE
42!5-!
0RINCIPAL!UTHOR Saleh, Michael, MD
#ENTRE University of Sheffield
#OUNTRY United Kingdom
!IMANDPURPOSEOFTHESTUDY
Soft tissue injury and ankle fracture may lead to pain, instability
and arthrosis. Nowadays patients are reluctant to consider ankle
arthrodesis and arthroplasty has not been that successful in
younger patients.
Articulated distraction has been used to try and recover
movement and reduce pain in many joints. In the ankle it has
been successful in cases of primary arthrosis and to a lesser
extent for post trauma arthrosis.
Following ankle injury the tibio-fibiular relationships may be
changes and there may well be secondary hindfoot and forefoot
contractures.
-ATERIALANDMETHODS
10 patients (age 33-61 years) with documented ankle
injuries were treated with ankle distraction combined with
fibula osteotomy and lengthening, syndesmotic repair and
debridement. Post-operatively a regime of ankle articulation
in the frame was carried out and orthotic adjustment of the
hindfoot and forefoot were added after fixator removal.
The fixators were left in place for a mean of 14 weeks. There
were 5 good results, 1 fair result and four patients went on
to ankle fusion. This was an unselected series and poorer
results were seen in the multiply operated and when severe
chondrolysis or instability persisted. Although small, this series
does give some indication as to the criteria leading to success
and those leading to poor results.
$ISCUSSION
The technique and adjunctive surgeries is described. The
importance of careful patient selection and adjunctive
reconstruction is emphasised.
#ONCLUSION
This technique has merit if movement is spared and instability/
pain reduced. It may have a limited role in controlling the late
sequelae of ankle injury.
94
Podium EXTERNAL FIXATION FOR ANKLE ARTHRODESIS
0RINCIPAL!UTHOR Burny, Franz, MD
#ENTRE Cliniques Universitaires Hopital Erasme
!UTHORS 1Donkerwolcke, Monique, MD; 2Portilla, Álvaro, MD
#ENTRES 1Cliniques Universitaires de Bruxelles; 2Clinica Erasmus,
Valledupar
#OUNTRY Belgium
/BJECTIVEANDPURPOSE
We propose a review of the technique and a discussion of some
results. We describe a surgical technique for ankle arthrodesis
using an anterior approach to the joint and external fixation.
-ETHODSANDMATERIALS
We treated tibia fractures with the Hoffmann external fixation
since the ‘60 and extended the technique to the arthrodesis
of the ankle. The mains indications are osteoarthritis and
severe fracture-dislocations. We propose a triangular frame
configuration between the tibia and the calcaneus, using two
5 mm (S50) pins in the distal tibia and two transfixing pins
(T50) in the lateral aspect of the calcaneus. Through an anterior
approach we remove the cartilage and fill the gap by cancellous
bone grafts, before tightening the frame in a correct position.
Ideal position of fusion is neutral flexion extension, with slight
valgus position of the hind foot (5 degrees and 5 to 10 degrees
of external rotation).
2ESULTS
We report 30 cases (mean age 39), 32 males and 9 females. The
external fixation was, most of the time, maintained until fusion
(median 137 days). A non-union was observed in two cases
(6.7%). The mean follow up was 4.4±1.5 years (median: 1.1
years). The results are rated excellent en good (80%), fair (10%)
and bad (13%).
#ONCLUSION
The surgical technique is simple, easily reproducible and gives
excellent clinical results with a high rate of union. External
Fixation represents a useful and easy system of fixation.
Podium THE ROLE OF CIRCULAR EXTERNAL FIXATOR IN ANKLE AND
SUBTALAR ARTHRODESIS
0RINCIPAL!UTHOR Sarras, Emmanuil, MD
#ENTRE Kat Hospital Athens
!UTHORS Christodoulou, Evagelos, MD; Korres, Nectarios, MD;
Chrysikopoulos, Theodoros, MD; Baltopoylos, Panagioths, MD
#ENTRE Kat Hospital Athens
#OUNTRY Greece
)NTRODUCTION
We evaluate the results of ankle and subtalar arthrodesis
performed with circular external fixator in patients with
secondary tibiotalar and subtalar arthritis.
-ATERIALMETHODS
10 ten patients with secondary tibiotalar and subtalar arthritis
were treated by circular external fixator. We evaluated the
radiological results and also the clinical results pre and
postoperative.
2ESULTS
Radiological assessment showed complete bony union in ankle
and subtalar in 7 patiens (70%) and partial bony union in the
ankle and subtalar in two cases (20%) in one case we need
to do revision surgery with intramedulary nail.The clinical and
subjective outcome was satisfactory. The average score in
Mazur grading was 74 points.
#ONCLUSION
The clinical and radiological results evaluation revealed that
circular external fixator is a suitable surgical procedure for ankle
and subtalal arthrodesis.
+EYWORDS
Ankle arthrodesis-subtalar arthrodesis-circular external fixatorclinical and radiological outcome.
Podium EXPERIENCE WITH THE ARTICULATED FIXATOR IN THE
-!.!'%-%.4/&3%6%2%).34!"),)49/&4(%%,"/7#!,)
0RINCIPAL!UTHOR Zuluaga Botero, Mauricio, MD
#ENTRE Hospital Universitario del Valle
!UTHORS Machado, Andrés, MD
#ENTRE Hospital Universitario del Valle
#OUNTRY Colombia
/BJECTIVE
To describe the experience of the last nine years with hinged
fasteners used in the management of severe trauma of the
elbow after the release of joint contractures and dislocations
abandoned.
-ATERIALSANDMETHODS
We conducted a retrospective descriptive case series of patients
who were fitted with an articulated elbow fixator between 2000
and 2009. We reviewed the medical records of 20 patients
and were recorded on a form designed for this purpose. After
treatment was applied for elbow functional index of the Mayo
Clinic to make an objective assessment.
2ESULTS
The average time the fixator was 3.2 months (0.7 to 9). Eleven
patients attended the final check and we applied the functional
index found the following results: excellent in 63.6% of cases,
good in 27.2% and moderate in 9%. Guests arches articulate
Ability spent an average of 35.4 to 84.8º and 70.8º to 133º in
flexion-extension and supination respectively. Thirteen patients
required one or more additional procedures for the placement
of the fixator. In 7 patients (35%) had complications, the most
frequent was tract infection of the nails (osteitis).
#ONCLUSIONS
Articulated elbow fixator provides a viable alternative for the
management of complex lesions such as acute or chronic soft
tissue protection when performing release of contractures.
The advantage of fixer, to be designed according to the
biomechanics of the joint, which allows an early onset of
mobility.
+EYWORDS
Elbow joint instability, external fixators, dislocations.
95
Podium SHORTER DURATION OF ILIZAROV EXTERNAL FIXATION IN
42%!4-%.4/&).&%#4)/.
0RINCIPAL!UTHOR Emara M, Khaled, MD
#ENTRE Ain Shams Univ. Hospitals
!UTHORS Abd El Ghafar, Khaled, MD; Motasem, Elhosain, MD
#ENTRE Ain Shams Univ. Hospitals
#OUNTRY Egypt
2ESUME
Ilizarov external fixation is an effective tool in treatment of
infection and limb lengthening and reconstruction, but the long
duration of discomfort associated with Ilizarov frame prevent
many patients from getting this type of treatment. We present
our experience in the use of different methods to make the
duration of treatment shorter and with less complications.
We present our patients of hemicorticotomy and patients with
lengthening then nailing in tretament of infection.
Duration of treatment and complications are less but many
details need to be recognized.
It is a safe technique and effective but risks need to be
addressed.
Podium -!.)05,!4)/./&4(%).6/,5#25-&/2&%-/2!,
2%#/.3425#4)/.!&4%2#)%2.9-!$%2490%)6
/34%/-9%,)4)3
0RINCIPAL!UTHOR Mahran A, Mahmoud, MD
#ENTRE MD (ortho), Mrcs (england), Lecturer, Ain-Shams
University, School of Medicine
!UTHORS Thakeb Fouad, Mootaz, MD; Hefny M, Hany, MD; Eid,
Mahamed, MD
#ENTRES MD (ortho) Ain-Shams University, School of Medicine
#OUNTRY Egypt
"ACKGROUND
The pathological features of chronic osteomyelitis are the
formation of sequestra, and chronic sinus tracts. In addition,
the condition either ends in the formation of pseudarthrosis and
a bone defect or formation of an involucrum depending on the
viability of the periosteal envelope. Especially for larger bone
defects, there is reported high complication rate for segment
transfer by Ilizarov technique.
$ESCRIPTIONOFTECHNIQUE
The Ain Shams University classification scheme (ASU) is
developed to radiologically characterize the involucrum in type
IV (diffuse) femoral osteomyelitis and suggest a management
algorithm depending on involucrum morphology.
0ATIENTSANDMETHODS
Six patients with type IV chronic femoral osteomyelitis (5
males and one female) who showed radiological evidence of
involucrum formation were operated upon. Three involucra were
ASU type II, two were type IA1 and one was type IB1 involucrum.
After adequate debridement, the involucrum was manipulated
according to the proposed algorithm scheme by Ilizarov external
fixator to span the post resection defect. At the end of treatment
the external fixation time was compared to the same situation
if the involucrum was absent and bifocal bone transport was
attempted.
%ARLYRESULTS
Mean external fixation time was 97.5 (range: 60-135 days)
compared to an expected mean external fixation time of 221.25
(range: 90-450 days) if involucrum was absent and bifocal bone
transport was attempted. Manipulation of an existing involucrum
decreased external fixation time by a mean of 123.75 (range:
30-315 days).
#ONCLUSIONS
Involucrum manipulation with the Ilizarov frame can successfully
reconstruct femoral bone gaps with significant decrease in
external fixation time and consequently less complication rate.
96
Podium #/-").%$),):!2/643&-/$%).4(%42%!4-%.4/&4)")!,
$%&%#43$5%4/).&%#4)/53!42/0()#./.5.)/.
0RINCIPAL!UTHOR Sala, Francesco, MD
#ENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
!UTHORS Castelli, Fabio, MD; Capitani, Dario, MD; Agus, María
Alice, MD; Valentinotti, Umberto, MD; Fogliani, Tiziana, MD
#ENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
#OUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
Gradual bone transport with external fixators applies the concept
of compression-distraction and provides a large diameter bone
with intact blood supply to fill the bony defects. TSF uses virtual
hinge concept through the use of specialized computer program
to simultaneously correct all aspects of deformity. The aim of
study is to report our experience of the application of combined
Ilizarov/TSF for treatment of tibial infectious segmental bone
defects.
-ATERIALANDMETHODOLOGY
A total of 12 patients with atrophic non-union with infection,
between 2005 and 2007 were available for the study. The
study population included 8 men and 4 women. The average
age at surgery was 44.1 years (19-79 years). The non-union
locations were: proximal metaphysic (3), diaphysis (3) distal
metaphysis of the tibia (5). Patients’ data were collected from
medical records and radiographs. Complications encountered
intra-operative and during treatment were grouped using Paley’s
Asami criteria. The mean follow-up period was 16 months (12
to 24). The mean bone transport lengthening was 7.96 cm (3.0
to 12.0), the mean external fixation time was 418 days (300 to
600). The mean lengthening index was 1.98 months/cm (1.05 to
4.0). Five cases were treated with bifocal techniques and seven
patients had trifocal technique. According to the ASAMI outcome:
the final bone results were: excellent in 83% (10/12) and good
in 17% (2/12). The final functional results were excellent 50%
(6/12), good 42% (5/12) and fair 8% (1/12) (table 3). A total of 7
difficulties were encountered in this study. There were problems
(3), obstacles (2) and minor complications (2).
$ISCUSSION
The goals of the treatment of infectious tibial bony defect are
to achieve union, soft tissue coverage, prevent or treat axis
deviation of the limb, equalize limb length discrepancy, prevent
or treat established infection while allowing functional recovery.
In the current study, the union rate for complex atrophic tibial
non-unions was 100%.
0/$)5-
3)-5,4!.%/5342%!4-%.4/&"/.%!.$3/&44)335%
$%&%#437)4(4(%),):!2/6-%4(/$&/2#(2/.)#
/34%/-9%,)4)3/&&%-524)")!7)4(/54&,!0#/6%2!'%
0RINCIPAL!UTHOR Chen, Chuan-Mu, MD
#ENTRE Taipei-Veterans General Hospital
#OUNTRY Taiwan
!IMANDPURPOSEOFTHESTUDY
Radical debridement is a perquisite of eradication of the
infection of chronic osteomyelitis of femur & tibia. Resection
of necrotic tissues includes devitalized soft tissues & necrotic
bones ensure adequate management of this kind of diseases.
Residual soft tissues & bone defect need many surgical
strategies for reconstructions. We review our past thirteen years’
experience to provide spontaneous wound healing using wetto-dry dressing following simultaneous distraction-compression
osteogenesis using Ilizarov’s technique to restoration the defect
of soft tissue & bony gap without further flap coverage.
-ATERIALANDMETHODOLOGY
Forty eight cases of infection at the femoral & tibial shaft had
bone & soft tissue defect following radical debridement between
July 1997 and December 2009 were reviewed in our institute.
There was forty two male & age was average thirty eight
(range 18-70) years. Six cases involve the femur & forty two
involved the tibia. The average soft-tissue & bone defect after
debridement was 12 (range 6-30) cm and 8 (range, 3-20) cm
respectively. Multilevel osteotomy performed in cases of bone
defect more than 6 cm & skin graft in two cases. There was
thirty cased need further distraction to ensure equal leg length
after spontaneous wound healing. Autogenous bone grafting to
the docking site were performed in all cases.
$ISCUSSION
Ilizarov method is a MIS procedure under poor biological
condition. The technique provides the function of
osteoregeneration & osteovascularization along with
osteostabilization. There are many surgical strategies for
obliteration of dead spaces following radical debridement in
case of chronic osteomyelitis of femur & tibia; exteriorization,
plombage, cancellous bone grafting & transfer of living tissue.
Our methods provide simultaneous reconstruction of bone & soft
tissue defect without flap coverage.
2ESULTANDCONCLUSION
All cases were united without morbidity. The Ilizarov method
provides successful simultaneous reconstruction for bone & soft
tissue defects without flap coverage.
#ONCLUSIONS
Combined Ilizarov/TSF are very useful tool in treatment of
infectious segmental tibial bone defects. TSF allows six axes
deformity correction after docking to restore the normal
alignment of limb axis.
97
Podium INTERLOCKING NAIL WITH A LONG ACTING ANTIBIOTIC
2%,%!3).'#/2%&/2#/.6%23)/.&2/-%84%2.!,
FIXATION
0RINCIPAL!UTHOR Craveiro-Lopes, Nuno, MD
#ENTRE Orthopedic Dpt, Garcia de Orta Hospital
!UTHORS Escalda, Carolina, MD; Villacreses, Carlo, MD
#ENTRE Orthopedic Dpt, Garcia de Orta Hospital
#OUNTRY Portugal
)NTRODUCTION
Intramedullary nails with PMMA cement impregnated with
antibiotics are an attractive method for the treatment of long
bone infections. The authors carried out a experimental and
clinical work to assess the rigidity of the nail, the levels of
release of antibiotic and the clinical efficacy of a modified
interlocking nail with a core of PMMA impregnated with
vancomycin.
-ETHODS
To test the release of the antibiotic, a perfurated femoral
interlocking nail with PMMA mixed with 1 g of vancomycin,
was introduced in a test tube with a elution liquid, replaced in
intervals and sampled for antibiotic concentration titulation.
For the tests of resistance to bending, we used a standard
femoral interlocking nail and another perfurated and filled with
PMMA.
2ESULTS
The concentration of vancomycin, showed a release up to 10,4
ug/ml during the first 12 hours and maintaining a level of 7.7
to 9.8 ug/ml over 2 months of experimentation. Observation of
the cement-metal interface showed the existence of a space
in between the cement and the interior wall of the nail. When
subjected to a transverse pressure of 0.4 kN, the original
nail had a deformation of 2.4 mm and at pressure of 1 kN, of
6mm. The perforated nail with PMMA presented at 0.4 kN a
deformation of 2.2 mm and at 1 kN, of 6mm.
$ISCUSSION
This experimental work showed that the percentage of antibiotic
released from inside the nail is similar to the one from a cylinder
of cement, due to the existence of a gap between the cement
and the interior of the nail. Within the levels of bending forces on
a normal femur during walking, the perforated nail with PMMA
have shown to have better mechanical behavior compared to
the original nail, with an increase of resistance of about 10%.
On the 12 patients operated on with this technique, we
prevented or cured the infection except in one case. We have
not detected intolerance or breakage of the implant, adverse
reactions or other complications.
#ONCLUSIONS
The authors conclude that this new device represents an added
value for the treatment of open fractures, conversion of external
fixation and treatment of bone infection.
98
Podium 42%!4-%.4/&).&%#4%$"/.%,/337)4(),):!2/6
EXTERNAL FIXATOR
0RINCIPAL!UTHOR Sagarnaga Alcoreza, Daniel, MD
#ENTRE Hospital de Clínicas
#OUNTRY Bolivia
2ESUME
I report the experience from the last six years done in my
practice at the Hospital de Clinicas of La Paz and private
practice, the treatment of massive tibial and femoral bone
defects by the use of bone transport and compression and
distraction using the Ilizarov fixator. Nineteen patients were
treated since October/2003 until February/2010, using these
techniques. The patients were 8 females and 11 males. The
defect size ranged between 2,5 and 15 cm (average: 6.05). The
age ranged between 14 and 70 years (average 38). Etiology was
infected nonunion in all of them. The affected place was the
tibial diaphysis in 13 patients, the femoral diaphysis in 4 and
2 in epiphysis/methaphysis. The external fixation time ranged
FROMTOMONTHSAVERAGE!LLACTIVECASESNWERE
treated by debridement with resection of necrotic bone including
removal of implants in infected osteosynthesis.
We had complications as rigidity of joints, which improve with
physical therapy (four patients). Superficial infection (4) at less
1 of the wires or pines or both and this was successfully treated
by oral antibiotic therapy and a every 24 or 48 hours cure at
the emergency of the wire or pine. The method of treatment
was defined between bone transport and compression at the
place of bone defect and lenghthening at the proximal or distal
methaphysis.
The treatment that we used it is so grateful for the patients, who
just had one or two alternatives before reach the amputation.
This method is for us the best to fill massive bone defects.
2ESULTS
The cases were followed up for one to three years and the
results were evaluated by Paley criteria of bony and functional
results.
$ISCUSSIONANDCONCLUSION
Ilizarov methodology produced a good results. The results
were comparable being more satisfactory the treatment with
compression-distraction, needing fewer interventions than the
bone transport. Even though the long time that is necessary to
have a satisfactory result, it is not a loss time.
Podium TRANSOSSEOUS OSTEOSYNTHESIS IN CHRONIC INFECTION
0RINCIPAL!UTHOR Kliushin, Nikolay, MD
#ENTRE Russian Ilizarov Scientific Center for Restorative
Traumatology and Orthopedics
#OUNTRY Russian Federation
0URPOSEOFSTUDY
Analysis of the treatment results in patients with chronic
osteomyelitis of long bones including simultaneous arrest
of infection in tissues of the involved segment and solving
orthopedic tasks by the method of controlled transosseous
compression and distraction osteosynthesis.
-ATERIALANDMETHODS
We present clinical cases of application of transosseous
osteosynthesis according to Ilizarov in management of patients
with chronic osteomyelitis associated with various orthopedic
and trauma pathology.
The introduced techniques of transosseous osteosynthesis
allow complex solution of the tasks on stable arrest of the
infection process and recovery of supportability and function
of the involved segment. Discovered laws of stimulation of
regeneration processes and tissue growth under the influence
of stress and also the effect of increase of bactericide activity of
tissues lie at the bottom of these potentialities of the method.
$ISCUSSION
Among all of the presented patients in 97.1% of cases we
achieved stable arrest of the chronic osteomyelitic process with
simultaneous complete or partial solution of orthopedic and
trauma goals: fracture and non-union healing; filling in bone
defects without use of free bone graft; correct shortenings and
equalize limb length; do arthrodesis and reconstructive surgeries
in joints; fill in osteomyelitic cavities.
#ONCLUSIONS
Transosseous osteosynthesis according to Ilizarov in patients
with chronic osteomyelitis is a method of choice and results
in successful and stable arrest of chronic osteomyelitis and
achievement of maximally possible anatomic and functional
results.
Podium 4)")!(%-)-%,)!2%#/.3425#4)/.!.$,%.'(4%.).'!3
42%!4-%.4
0RINCIPAL!UTHOR Nogueira Silva, Wagner, MD
#ENTRE Hospital Da Baleia-Bh-Brasil
!UTHORS Mendonça Àlves, Gustavo, MD; Baiao Ribeiro, Fabio,
MD; Junior Gonçalves, Ronaldo Tiago, MD
#ENTRE Hospital Da Baleia-Bh-Brasil
#OUNTRY Brazil
/BJECTIVE
To present the results of the treatments carried out with
reconstruction and bone lengthening of the patient bearers
of hemimelia tibial and to put to spread the classification of
Michael Weber.
-ATERIALSANDMETHODS
Eigth patients were treated from march of 1995. Three cases
are of the type I of Michael Weber and they were subjected
to bone lengthening of the bones of the leg and reduction of
the articulation proximal. One case of the type II and when
the bone lengthening was carried out so much sinostose
tibial-fibular distal and 04 cases of the type III (01 A and 03 B)
being subjected to tepid sinostose tibial-fibular proximal with
centralization distal of the fibula, stabilization of the ankle and
station plantigrade of the foot. All the lengthenings were carried
out by external fixation of Ilizarov. Seven patients (87,5%)
present evil-formation skinny-muscle when what were not
impediments to the treatment were associated, being corrected
when necessary.
2ESULTS
One patient was not re-valued recently. In 06 patients of the
reevaluated 07 we have plantigrade feet, in all of them normal
function of knee and with foresight of equivalence of length
of inferior members in all the cases to the end of the skinny
maturity. At present, the discrepancy varies from 0 to 14
centimetres with average of 3,9 cm.
$ISCUSSION
With the evolution of the techniques of reconstruction and
bone lengthening there was allowed the treatment of the tibial
hemimelia, presenting good results with improvement principally
of the auto-esteem of patients.
#ONCLUSION
The reconstruction and bone lengthenings must be seen as a
therapeutic effective method in the tibial hemimelia, since quite
hard-working and with regular controls to prevent complications.
Relatives and patients must have science of the difficulties and
complications during this treatment.
99
Podium
&)"5,!2(%-)-%,)!42%!4-%.47)4(),):!2/6-%4(/$
0RINCIPAL!UTHOR Nogueira Silva, Wagner, MD
#ENTRE Hospital Da Baleia
!UTHORS Ribeiro Baiao, Fabio, MD; Coelho Albeny, Luiz Felipe,
MD
#ENTRE Hospital Da Baleia
#OUNTRY Brazil
/BJECTIVE
To analyze the results of the treatment by the Ilizarov method in
carriers of Longitudinal Deficiency of the Fibula (LDF).
-ATERIALANDMETHODS
21 (21 limbs), of 35 patients, with LDF treated by the Ilizarov
method between 1990 December and January of 2004 were
studied, with average age of two years and nine months. From
21 patients, only seven patients had finished the treatment. All
21 patients had been submitted to an evaluation where physical
and radiological examinations had been carried through,
studying the amplitude of movement of the hip, knee, ankle and
foot beyond the residual discrepancy of the limbs.
2ESULTS
The average discrepancy was 4,3 cm, being of 2,24 cm between
those who had finished the treatment. All the analyzed joints did
not have a significant difference between the initial and final
function (P >> 0,05).
#ONCLUSION
The Ilizarov method is an efficient option between the
radical treatment in the management of the difficult cases of
longitudinal deficiency of fibula and a good option in the mild
and moderate cases of the disease.
+EYWORDS
Longitudinal deficiency of the fibula, Ilizarov method,
lengthening.
Podium ABOUT THE NEED OF THE RESECTION OF THE FIBULAR ANLAGE
).4(%42%!4-%.4/&#/-0,%4%&)"5,!2(%-)-%,)!
0RINCIPAL!UTHOR Schwering, Ludwig, MD
#ENTRE Universitätsklinik, Dot, Sektion Kinderorthiopädie
!UTHORS Vohrer, Michael, MD
#ENTRE Universitätsklinik, Dot, Sektion Kinderorthopädie
#OUNTRY Germany
!IMANDPURPOSEOFTHESTUDY
The resection of the fibular anlage is a standard procedure in
the first months of the treatment course in complete fibular
hemimelia in our pediatric –orthopaedic– section. Even if in
the literature tips to this procedure are rare to be found. This
procedure has not found entrance in universal valid pediatricorthopaedic procedures
-ATERIALANDMETHODOLOGY
In the years from 1990 to 2009 22 children with complete fibular
hemimelia were treated surgically. The postpartale arrangement
starts with redressing theramocast splints. The resection of
the fibular anlage belongs to the plan with lengthening of
contracted tendons as well as the aftertreatment with orthotics
to ambulation.
$ISCUSSION
In 17 primary-treated children only in one child no resection of
the fibular anlage was necessary due to clinical and radiographic
reasons. In this special case no axial deviation pointed to the
existence of a fibular anlage. With 4 of 16 patients the fibular
anlage had to be resected a second time because of incomplete
primary resection or recurrence due to scarring tissue. In 5
primary untreated children the omission of the resection lead to
the heaviest contractures in the area of the knee and ankle joint.
During revision operation of these children the fibular anlage
was found as the reason for the deformity and joint malposition
in any case. Without this resection a reconstruction would not
have been conceivable for the purposes of the restitution.
#ONCLUSION
Because the resection of the fibular anlage was not necessary in
only one of 22 cases, this procedure must be taken into account
for all complete fibular hemimelias to avoid complications and to
reach an acceptable functional result.
100
Podium /0%2!4)6%42%!4-%.4/&4(%0!4)%.437)4(#/.'%.)4!,
DEFECT OF DISTAL TIBIA
Podium 342!4%'9!.$/54#/-%/&,)-"2%#/.3425#4)/.&/2
&)"5,!2(%-)-%,)!490%))
0RINCIPAL!UTHOR Chegurov, Oleg, MD
#ENTRE Russian Ilizarov Scientific Center
!UTHORS Makushin, Vadim, MD
#ENTRE Russian Ilizarov Scientific Center
#OUNTRY Russian Federation
0RINCIPAL!UTHOR Takahashi, Mitsuhiko, MD
#ENTRE Department of Orthopaedics, The University of
Tokushima
!UTHORS Kawasaki, Yoshiteru, MD; Yasui, Natsuo, MD
#ENTRE Department of Orthopaedics, The University of Tokushima
#OUNTRY Japan
0URPOSE
Is to study the efficiency of the patients’ rehabilitation with maldevelopment of tibial bone using Ilizarov method.
-ATERIALSANDMETHODS
We observed 21 patients with congenital defect of distal
tibia (from 40 to 90%) aged from 5 to 14 years. All patients
underwent clinical and radiological examination.
In majority of the cases (12) the amount of the defect didn’t
exceed 60% (hypertrophic and hypotrophic long shape of the
proximal tibial rudiment). In these cases the defect was filled in
by lengthening of proximal tibial rudiment with Ilizarov frame
including 10 cases after its osteotomy and 2 cases using
distraction epiphysiolysis of the proximal growth zone of the
vestige.
The patients (9) with tibial defect exceeding 60% underwent
fibular tibialization that presumed simultaneous transport of
the fibula and foot with correction of their mal-position using
Ilizarov frame followed by formation of tibiofibula and fibula-talar
synostoses in functional position of tibia and foot.
$ISCUSSION
Restorative treatment can be prolonged for many years,
therefore, some orthopaedic surgeons prefer radical invasions,
i.e. tibial amputation followed by prosthesis of the limb. But our
patients and their parents greatly desired to save the limb.
The purpose of the first treatment stage was correction of tibia
and foot mal-position, restoration of tibiofibular alignment and
formation of supportability of the limb with rational orthosis.
Following treatment stages included lower limb segment
lengthening with correction of their secondary deformities and
foot reconstruction.
In all cases late follow-ups indicated positive treatment results.
#ONCLUSIONS
Therefore, operative treatment of the patients with congenital
defect of distal tibia according to the techniques elaborated
at Russian Ilizarov Center is an alternative to amputation,
limb salvage trend in restorative orthopaedics and represents
effective stage-by-stage system of rehabilitation.
2ESUME
Fibular hemimelia is a complicated limb deficiency involving
not only the fibula but the entire limb. Fibular hemimelia type
II, which is described as complete absence of the fibula by
Achterman and Kalamchi, shows severe deformity of the
affected knee through foot, and early amputation with prosthetic
fitting has been recommended for the treatment. We have
performed limb reconstruction by using Ilizarov method in all the
cases. In this study, we reviewed 9 limbs out of 7 patients with
fibular hemimelia type II, who were treated in our institute.
Four cases are skeletally mature and considered to complete the
series of reconstructive treatments, and the other three cases
(ages ranged 8-11) are currently under management. All of the
cases presented equinovalgus deformity of the ankle with tarsal
coalition, anteromedial bowing of the tibia with hypoplasia,
and soft tissue atrophy of the affected limb and mild femoral
shortening with various degree of genu valgus. Absence of the
lateral rays of the foot was observed in 8 limbs. Ablation of the
posterolateral soft tissue including the fibrous anlage would be
the first step in order to gain plantigrade foot. Consequently,
the ankle joint (and often the knee joint) must be stabilized with
the apparatus during the deformity correction. Relapse of the
deformity occurred frequently while skeletal growth and several
operations were performed until skeletal maturation.
Among the four patients who completed the treatments, three
had had previous treatments in other institutes. The number
of operations performed in our institute was one to three. One
had to undergo ankle fusion due to severe valgus instability of
the ankle. However, all have gained functional limbs with stable
plantigrade feet and do not need any orthoses for daily activity.
Length discrepancy was solved and the knee joint range of >
90º was achieved in all cases.
Fibular hemimelia type II cannot be managed simply by
lengthening or osteotomy alone. The most important point
during the management of fibular hemimelia type II is to gain a
plantigrade foot with stable ankle and knee joints, which would
have priority over achieving limb length equality.
101
Podium ,)-"2%#/.3425#4)/.02/#%$52%3).4)")!,(%-)-%,)!
Podium "/.%,%.'4(%.).').&)"5,!2(%-)-%,)!
0RINCIPAL!UTHOR Rady Abdallah, Yehia, MD
#ENTRE National Medical Institute In Damnhour
#OUNTRY Egypt
0RINCIPAL!UTHOR Cakmak, Mehmet, MD
#ENTRE Istanbul Medical Faculty
!UTHORS Kilicoglu, Onder, MD; Kocaoglu, Mehmet, MD; Eralp,
Levent, MD; Yildiz, Fatih, MD; Bilsel, Kerem, MD
#ENTRE Istanbul Medical Faculty
#OUNTRY Turkey
2ESUME
It is longitudinal deficiency of the tibia which either complete
or partial, its prevalence is estimated to be one per million live
birth, 30% of the cases bilateral. It may present as an isolated
anomaly or be associated with variety of skeletal or extraskeletal
malformations.
The aim of the treatment was to reconstruct weight bearing
bone with controlled knee function, to equalize the limb length
discrepancy, and to correct any foot deformity.
Fourteen cases with different types of tibial hemimelia, 8 boys
and 6 girls. In 7 cases the left side was affected, the right side in
6 cases, and bilateral affection in one case.
The procedures used were suited separately for every type and
include: traditional surgical techniques to centralize the fibula at
the knee and ankle, to reconstruct knee extensor mechanism,
and to reconstruct deficient ligaments
Specific Ilizarov techniques to centralize the fibula, to correct
foot deformities, and to overcome limb length discrepancy.
The overall results obtained were satisfactory in all cases.
The main complications met other than those due the use of
Ilizarov apparatus was infection in one case that resolved with
appropriated treatment
The results obtained encourage us to recommend these
techniques in treatment of tibial hemimelia.
!IM
To report the results and complications of bone lengthening in
fibular hemimelia patients.
0ATIENTSANDMETHODS
Between January 1994 and July 2007, 42 segments (31 tibiae,
11 femora) of 39 patients (median age of segments 12 years,
range 2.5-44) were lengthened using distraction osteogenesis
technique. In addition to the index operations, 10 segments
of 10 patients required one and 4 of 4 required two more
lengthening procedures, resulting in a total of 60 segments.
According to Achterman-Kalamchi, 22 patients (56.4%) were
classified as type 1A, 4 patients (10.2%) as type 1B and 13
patients (33.3%) as type 2.
2ESULTS
Sixty segments (48 tibial and 12 femoral) were followed for a
mean period of 41.9 months (range 1.3-134.2 months). The
mean lengthening was 6.41±2.21 cm for tibiae (from 25.3
cm preoperatively to 30.8 cm postoperatively) and 6.96±2.75
cm for femora (from 31.5 cm to 38.5 cm). The lengthening
indexes were 21.5 days/cm for 33 tibial segments with unifocal
lengthening, 20.1 days/cm for 24 tibial segments with bifocal
lengthening, 19.24 days/cm for 11 femoral segments with
unifocal lengthening and 9.4 days/cm for 1 femoral segment
with bifocal lengthening. The fixator indexes were 42.3 days/
cm, 41.9 days/cm, 35.2 days/cm and 17 days/cm respectively.
A total of 134 complications were observed in 44 of 45 tibial
segments (3.0 complications per segment) and 28 complications
in 12 of 12 femoral segments (2.3 complications per segment)
(p>0.1). These complications were classified as 112 problems,
31 obstacles, requiring 37 additional interventions and 19
sequalae. The complication rate was significantly higher in
secondary lengthening procedures of tibial segments (42
complications in 13 segments; 3.2 complications per segment)
compared to primary procedures (79 complications in 28
segments; 2.8 complications per segment) (p<0.05).
#ONCLUSIONS
Limb lengthening procedures in fibular hemimelia cases are
performed in a relatively younger patient group with a high
incidence of additional interventions. The higher complication
rates observed in secondary lengthening procedures should also
be taken into consideration for timing of operations.
102
Podium 3/&47!2%"!3%$/24(/356&2!-%/04)-!,!33%-",9
&/2)-02/6%-%.4/&+.%%*/).42/0RINCIPAL!UTHOR Solomin, Leonid N, MD
#ENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
!UTHORS Korchagin Kl, MD; Utekhin AI, MD
#ENTRES Vreden Russian Research Institute of Traumatology and
Orthopedics; Ortho-SUV Ltd
#OUNTRY Russian Federation
!IMANDPURPOSEOFTHESTUDY
The aim of the study was to investigate the optimal assembly
of Ortho-SUV Frame (http://www.rniito.org/download/ortho-suvframe-eng.pdf) for increasing of knee joint motion rate and/
or knee joint stiffness elimination. The advantage of Ortho-SUV
Frame is opportunity of accurate reproduction of tibia bone
proximal end towards femur bone distal end motion mechanics.
-ATERIALANDMETHODOLOGY
122 series of graphic modeling, 3 series of mechanic modeling
and 6 series of tibia and femur osteosynthesis rigidity testing by
Ortho-SUV Frame in comparison with Volkov-Oganesjan device
were performed.
$ISCUSSION
It was revealed that for assembling Ortho-SUV used for working
out the motions in the knee joint with amplitude 120/0/0 and
more application of ellipse supports is advisable. The proximal
support must be placed at the distance 200-210 mm from the
knee joint space, distal support must be placed at the distance
120 mm. The angulation of proximal support to the bone must
be 90º, of distal-60º. The rigidity of investigated assembly of
Ortho-SUV Frame exceed the rigidity of tibia and femur fixation
by Volkov-Oganesjan device in 1,5 times. Ortho-SUV frame is
successfully applied in treatment of 4 patients with knee joint
pathology.
#ONCLUSIONS
Using Ortho-SUV Frame is prospective in treatment of patients
with knee joint pathology.
Podium *5$%415!$2)#%030,!349%80%2)%.#%!.$.%74)03
0RINCIPAL!UTHOR Elbatrawy, Yasser, MD
#ENTRE Azhar University
!UTHORS 1Saied El-Gharieb, El-Mohamady, MD; 2Mahran A,
Mahmoud Mahran, MD; 2Elgebeily, Mohamed, MD; 2Abdel
Magied Samir, Wael, MD; 1Alsobhi El-Sayed, Gamal, MD
#ENTRES 1Azhar University; 2Ain Shams Universrity
#OUNTRY Egypt
)NTRODUCTION
Extension contracture of the knee and inability to flex it as usual
is a rare problem that could happen after trauma, operation
or after application of external fixation without respecting the
pins or wires safe collidores. It could happen due to tethering
or presence of adhesion of the soft tissue to the Femoral bone
preventing the normal sliding action of the muscles during knee
flextion specially the vastus intermedius.
!IMOFTHESTUDY
To evaluate a new technique that decrease incidence of
recurrence of adhesions after Judet Quadricepsplasty done for
extension contracture with failure of physiotherapy for twelve
months to solve the problem of inability of the patient to flex his
or her knee as he used to do before injury or operation.
-ATERIALSANDMETHODS
7 cases of knee extension contracture after Ilizarov that
applied in other hospitals than ours were treated by Judet
quadicepsplasty. There was 6 males and 1 female mean age
was 24 (range from 15 to 41). Ilizarov frame was applied
for femoral lengthening in all cases; 1 case had congenital
short femur, 2 cases had femoral shortening due to fracture
complications; 1 case due to malunion with shortening and 3
cases were after pelvic support osteotomy operation. Patients
were operated upon by modified Judet quadricepsplasty
through the standard posterolateral incision and an additional
medial parapatellar incision. A mesofilm of Biomet was
used at the interval between the old regenerate site and the
vastus intermedius after removal of the adhesion to decrease
recurrence of adhesions and facilitate early rehabilitation.
Preoperative, Intraoperative, and post operative flexion at six and
twelve months marks were recorded. Use of CPM for 3 weeks
after the operation was done in all cases. End results at one
year post-operatively were evaluated by the HSS knee scoring
system. Good to excellent results were achieved in all cases.
#ONCLUSIONS
Judet quadricepsplasty remains a valuable option in treating
knee extension contracture. Application of a lubricating mesofilm
decreases incidence of recurrence of adhesion, facilitate early
rehabilitation and maintenance of flexion angle achieved intra
operatively.
103
Podium #534/-+.%%$%6)#%#+$&/24(%42%!4-%.4/&+.%%
&,%8)/.#/.42!#452%3!&4%2&%-/2!,,%.'4(%.).'
0RINCIPAL!UTHOR Herzenberg, John, MD
#ENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
!UTHORS Baker, Erin, MD; Bhave, Anil, MD; Specht, Stacy C, MD
#ENTRES International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
#OUNTRY United States
)NTRODUCTION
One of the common complications of lengthening the femur
with an internal device, is the development of knee flexion
contractures (KFC). Conservative treatment includes physical
therapy modalities, serial casting, and low-load prolonged
stretch with commercially available splinting systems.
Commercially available splints are expensive ($2400 to $3800)
and are time consuming to construct. The authors have
developed a custom molded, low-cost, ($70) custom knee
device (CKD) using polyester synthetic casting material to
effectively treat knee flexion contractures.
-ETHODS
A retrospective study of 24 subjects (27 limbs) who underwent
lengthening with an internal device for the treatment of a limb
length discrepancy were included in our study. All patients
developed a knee flexion contracture during the lengthening
process and were treated with the CKD.
2ESULTS
Twenty three subjects (27 femora) ranging in age from 11-58
years (average, 25 years) who developed KFC after lengthening
with an internal fixator were treated with the above-mentioned
protocol. The average amount of length obtained was 5.4 cm
(range 3.3-7.5 cm), and the average KFC was 36 degrees
(range, 10-90 degrees). Fourteen (52%) of 27 demonstrated
mild posterior subluxation of the knee at the time of the CKD
application. Five (19%) required biceps femoris lengthening
in order to completely resolve the contracture, while 22 (81%)
regained full extension with the protocol alone. Among these 22
femora, full extension was achieved in an average of 8 weeks
(range, 5-11 weeks).
#ONCLUSION
The CKD is a inexpensive and effective method for treating KFC
after lengthening with an internal device.
104
Podium -!.!'%-%.4/&%842!34)&&.%33/&4(%+.%%*/).4).
EXTENSION SECONDARY TO PROLONGED EXTERNAL FIXATION
JUDET
0RINCIPAL!UTHOR Zuluaga Botero, Mauricio, MD
#ENTRE Hospital Universitario del Valle
#OUNTRY Colombia
2ESUME
Management of extra stiffness of the knee joint in extension
secondary to prolonged external fixation between 2002-2010
Cuadriceplastia Judet in Cali, Colombia.
0URPOSE
Evaluation of results of the Judet cuadriceplastia for extra
stiffness of the knee joint secondary to prolonged treatment with
external fixation with bone transport and lengthening femoral
Basic.
0ROCEDURE
A descriptive study case series of 35 patients with knee
extension deformity extra articular contracture in extension
secondary to prolonged external fixation in the femur by
lengthening or transport and are managed with Judet
cuadriceplastia.
-AINlNDINGS
Average age 39 years, 30 men and 5 women, average time
of external fixation for 1 year. Restriction average of 0º to 15º.
Improvement with the procedure 75º. Excellent results in 20,
good and fair in May 10, infectious complications occurred in 3
patients, 8 patients had weakness in extension and all patients
wander without aid.
#ONCLUSIONS
Judet cuadriceplastia is the procedure of choice in patients with
rigidity secondary to severe trauma to the femur and prolonged
external fixation.
+EY
Stiff knee cuadriceplastia.
Podium +.%%!24(2/$%3)3!.$3)-5,4!.%/53"/.%,%.'4(%.).'
Podium
+.%%./5.)/.42%!4%$7)4(),):!2/63-%4(/$3
0RINCIPAL!UTHOR Zuluaga Botero, Mauricio, MD
#ENTRE Hospital Universitario del Valle
!UTHORS Machado, Andrés, MD; Calvache, Gustavo, MD
#ENTRE Centro Médico Imbanaco
#OUNTRY Colombia
0RINCIPAL!UTHOR Salas Fuentelzas, Juan Manuel, MD
#OUNTRY Chile
/BJECTIVE
To describe the knee arthrodesis with simultaneous limb
lengthening using external fixator as an adequate limb salvage
procedure.
-ETHODS
A retrospective case series study was done in the Hospital
Universitario del Valle and the Centro Medico Imbanaco between
2001 and 2009. Eighteen patients with knee arthrodesis using
external fixation were selected; they had bony defects greater
than 5 cm and require simultaneous lengthening or bone
transport to recover the limb length. At the end of treatment,
the patients filled out the SF-36 v2 score in Spanish for the
outcomes about quality of life and function.
2ESULTS
Bony fusion of arthrodesis was obtained in all patients (100%).
In 2 patients the bone lengthening was suspended because
they didn’t tolerate the external fixation. The average time with
the frame was 11 months. The average of lengthening was 7.8
cm (1-13 cm). The external fixation index was 1.2 months/cm
(0.8-3). With the SF-36 v2 score, values above 50 points in 4 of
the 8 dimensions were obtained, especially in the general health
and bodily pain.
#ONCLUSIONS
Knee arthrodesis with simultaneous limb lengthening is an
adequate limb salvage procedure in complex wounds of the
lower extremity and becomes an alternative to amputation.
Distraction osteogenesis for knee arthrodesis is useful because
it allows a functional limb with an adequate length, improving
patients’ quality of life.
+EYWORDS
Arthrodesis, knee joint, limb salvage, bone lengthening, bone
transport, external fixators.
/BJECTIVE
The aim of the work is to describe the results obtained in 9
patients treated with knee arthrodesis using the external circular
hybrid tutor Ilizarov’s method.
-ATERIALSANDMETHODS
A retrospective study of patients with knee no-union whom
underwent the knee arthrodesis with the forementioned method
was carried out between 2002 and 2009, evaluating clinical
results, postoperative complications and final outcome of this
technique.
Gender relations were 6 women and 3 men between 48 and
89 years old, 63 years old average. From these patients, 6
had infected knee total arthroplasty, 2 rheumatoid arthritis
with secondary deformities and alteration of axis, and 1 had
secondary deformity to degenerative osteoarthritis with lack
of bony stock. In all the cases were performed a no-union
resection; Ilizarov circular external fixator were used to axis
correction (in patients whom required), and for the gradual
intermittent compression of the no-union in all cases; one
patient (with infected knee arthroplasty no-union) underwent
simultaneous bone enlargement.
It was possible a complete fusion in all the arthrodesis cases
with an average time of tutor use of 5.3 months in a range of
4-9 months. There was a shortening of 4 cm average (range
of 2 to 7 centimeters). All the patients suffered transitory
superficial infection of Schanz needles, with total remission with
the administration of oral antibiotics and periodic curations.
It is worth mentioning that before the operation tool place,
the patients did not accept to mend the shortening due to the
important amount of tutor material and the extra time needed for
the bony consolidation.
$ISCUSSION
Our results for this technique are comparable with the
international literature reports for this type of treatment in this
kind of pathology, obtaining complete fusion in all cases.
#ONCLUSION
From the results of this study, it is possible to say that the
external circular hybrid tutor Ilizarov’s method is an alternative
to provides good results in knee arthrodesis consolidation in
patients with this kind of complex pathologies.
105
Podium KNEE ARTHRODESIS USING BIPLANE EXTERNAL FIXATION
AFTER INFECTION PROCESS IN TOTAL KNEE ARTHROPLASTY
Podium 42%!4-%.4/&4)")!03%5$/!24(2/3)37)4(4(%),):!2/6
EXTERNAL FIXATOR
0RINCIPAL!UTHOR Rius Moreno, Xavier, MD
#ENTRE Hospital Universitari de Bellvitge
!UTHORS 1Cabo Cabo, Xavier, MD; 2Gómez Roig, C, MD; 1Pedrero
Elsuso, S, MD; 1Moranas Barrero, J, MD; 1Pereferrer Sánchez,
C, MD
#ENTRES 1Hospital Universitari de Bellvitge; 2Hospital Universitari
Joan XXIII Tarragona
#OUNTRY Spain
0RINCIPAL!UTHOR Cakmak, Mehmet, MD
#ENTRE Istanbul Medical Faculty
!UTHORS Yildiz, Fatih, MD; Tunali, Onur, MD; Sariyilmaz, Kerim, MD
#ENTRE Istanbul Medical Faculty
#OUNTRY Turkey
)NTRODUCTIONANDOBJECTIVES
Evaluating the results of knee arthrodesis using external fixation
dual plane.
-ATERIALANDMETHODS
We reviewed 36 cases (35 patients) of knee arthrodesis
following total hip arthroplasty, aged between 59 and 85 years
(73.3). We practiced osteotaxis in the frontal and sagittal planes,
with models Hoffman II and Wagner, in all patients. Except in
two cases, the intervention was performed after an initial time of
prosthesis removal and placement of antibiotic cement spacer. If
the contact gap was above 30%, autologous graft was used. All
patients were covered with intravenous antibiotics (according to
antibiogram) for a minimum period of six weeks.
2ESULTS
The healing time varied between 3 and 9 months, with an
average of 6. In two cases aimed to nonunion, without revision
surgery. In other two cases residual infection was diagnosed,
which resolved with curettage or occlusion cavity with antibiotic
cement.
#OMMENTSANDCONCLUSIONS
Knee arthrodesis using osteotaxis is a useful and reliable in the
salvage treatment of total knee arthroplasty when the prosthetic
replacement is contraindicated. The rate of reoperation,
nonunion and recurrence in our series is low.
!IM
To report the results and complications of Ilizarov technique
performed for the treatment of tibia pseudoarthrosis.
0ATIENTSANDMETHODS
Between 1993 and 2008, Ilizarov external fixator was performed
in 75 patients with a mean age of 42.4 years (range 6-79) for
the treatment of tibia pseudoarthrosis. The number of atrophic,
hypertrophic and infected nonunion were 27, 22 and 26
respectively. According to the pseudoarthrosis classification by
Paley, 13 patients were classified as Type A, 9 patients as A2a,
16 patients as A2b, 5 patients as B1, 17 patients as B2 and
15 patients as B3. Twenty four patients had open tibia fracture
and 2 of the nonunions were after high tibial osteotomy. For
infected nonunions, antibiotic added bone cement was inserted
after radical bone and soft tissue debridement and a temporary
external fixator was used for the first step treatment. Free
latissimus dorsi musculocutaneus flap was necessary for 3
patients. Unifocal compression osteogenesis was performed in
42 patients, bifocal compression and distraction osteogenesis
was performed in 15 patients with the Ilizarov external fixator
and bone segment transport over an intramedullary nail
technique was preferred in 18 patients.
$ISCUSSION
Seventy-five patients were followed for a mean period of 39.3
months (range 8-120 months). The mean fixator time was 235.5
days (range 60-915). At the time of last follow-up, the bone
results were 56 excellent, 14 good, 3 fair and 1 poor; and the
functional results were 51 excellent, 19 good and 5 fair. Thirtyone patients had grade 2 pin tract infection, 10 patients had
transient knee movement restriction, 6 patients had equinus
deformity, 12 patients had residual deformity more than 5
degrees and one patient had intraoperative peroneal nerve
injury. Five patients had recurrent nonunion and 3 patients were
treated with Taylor Spatial Frame (TSF) and 2 patients with
intramedullary nailing.
#ONCLUSION
In patients with tibia pseudoarthrosis, deformity and limb length
discrepancy can be treated simultaneously with nonunion
using the Ilizarov method. All cases of tibia pseudoarthrosis
can be treated successfully with Ilizarov method if it is applied
according to the principles and correct technique.
106
Podium 42%!4-%.4/&&%-5203%5$/!24(2/3)353).'
$)342!#4)/.!.$#/-02%33)/./34%/'%.%3)34%#(.)15%
Podium #/-0,%8"/.%2%#/.3425#4)/.
)34(%2%!0/33)"),)49&/2,!"/22%).3%24)/.
0RINCIPAL!UTHOR Cakmak, Mehmet, MD
#ENTRE Istanbul Medical Faculty
!UTHORS Sariyilmaz, Kerim, MD; Yildiz, Fatih, MD; Korkmaz,
Murat, MD; Tunali, Onur, MD
#ENTRE Istanbul Medical Faculty
#OUNTRY Turkey
0RINCIPAL!UTHOR Chaparro, Germán Andrés, MD
#ENTRE Clínica Arizu Mendoza
!UTHORS Amaya, Julio, MD; Rubies, Gonzalo, MD; Carra, Joaquín,
MD; Abdo, Pablo, MD; Polito, Roque, MD
#ENTRE Clínica Arizu
#OUNTRY Argentina
!IM
The aim of the study is to summerize our clinical experience
with external fixators for the treatment of femur pseudoarthrosis.
!IM
To analyze the labor re-insertion of patients with complex bone
reconstructions, 5 years after of the accident.
-ATERIALANDMETHOD
Between 1993 and 2008, Ilizarov external fixator was performed
in 66 patients with a mean age of 42.3 years (range 9-78)
for the treatment of femur pseudoarthrosis. The number of
hypotrophic, hypertrophic and infectious pseudoarthrosis were
24, 31 and 11 respectively. According to the pseudoarthrosis
classification by Paley, 20 patients were classified as Type
A1, 14 patients as A2a, 13 patients as A2b, 7 patients as B1,
3 patients as B2 and 9 patients as B3. Thirteen patients had
open femur fracture. Antibiotic added bone cement was used
after radical bone and soft tissue debridement and a temporary
external fixator was performed for the first step treatment of
infected cases. Longitudinal compression was performed in 37
patients and bifocal compression and distraction osteogenesis
was used for 16 patients with Ilizarov external fixator. Bone
segment transport over an intramedullary nail technique was
performed for 13 patients in second session.
-ATERIALSANDMETHODS
33 patients who had reconstructive surgeries of the lower
limb between January of 1998 and December of 2004 were
evaluated retrospectively. Those patients who suffered workrelated accidents were excluded from the study. A semistructured questionnaire with open questions was designed to
include work and recreational activities. An analysis of the age
groups, gender, type of intervention, health insurance coverage,
and home income was also performed.
$ISCUSSION
Sixty-six patients were followed for a mean period of 39.1
months (range 8-156 months). The mean fixator time was 225.8
days. The results were appraised according to Paley’s functional
and radiological criteria. The radiologicel results were excellent
in 45 patients, good in 15, fair in five and poor in one. The
functional results were excellent in 40, good in 17, fair in six and
poor in three. Twenty-six patients had grade 2 and two patients
had grade 3 pin tract infection. Twelve patients had transient
knee movement restriction resolved by physical therapy. One
patient had recurrent nonunion and union was achieved with
an AO plate. One patient had refracture after removal of the
fixator and union was obtained using iliac bone autograft and
monofocal compression osteogenesis by Ilizarov external device.
#ONCLUSION
In patients with femur pseudoarthrosis, deformity and limb
length discrepancy can be treated simultaneously with nonunion
using the Ilizarov method. All cases of femur pseudoarthrosis
can be treated successfully with Ilizarov method if it is applied
according to the principles and correct technique.
$ISCUSSION
Generally these patients acquire particular personality
characteristics throughout their recovery period, and together
with their diminished psychophysical aspects and the high
competitiveness of the labor market define a set of negative
factors that affects both themselves and their relationships.
Patients who benefitted from bone reconstruction improved their
possibilities of labor reintegration; at 5 years, 80% were either
re-instated or held similar job positions as those held at the
moment of the accident. Although amputees presented major
difficulty in the accomplishment of a physical activity as well as
for labor reintegration, the majority who performed some type of
specific physical activity was able to sustain it at a lower level of
difficulty after the 5 years of the accident.
#ONCLUSIONS
The high degree of labor reintegration of the patients, who had
bone reconstruction, facilitates the generation of their own
income that allows for covering their needs and reinforces their
sense of belonging to the society. This labor insertion constitutes
an important factor of social integration for the operated
patients. It also encourages to us to choose to reconstruct a
member under doubtful situations.
107
Podium #/-").%$4%#(.)15%).4(%42%!4-%.4/&
PSEUDARTHROSIS OF THE TIBIA
Podium
#/-0,%8./.5.)/./&,/.'"/.%3-!.!'%-%.4
7)4(),):!2/6-%4(/$
0RINCIPAL!UTHOR Kocaoglu, Mehmet, MD
#ENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
!UTHORS 1Sen, Cengiz, MD; 2Eralp, Levent, MD; 2Dikmen, Göksel,
MD; 2Balci, Halil Brahim, MD
#ENTRES 1Lütfi Krdar Kartal Training and Research Hospital
Istanbul; 2Istanbul University Istanbul Medical Faculty
Department of Orthopaedics and Traumatology
#OUNTRY Turkey
0RINCIPAL!UTHOR Makhdoom, Asadullah, MD
#ENTRE Liaqaut University of Medical & Health Sciences
Jamshoro Sindh Pakistan
!UTHORS 1Qureshi, Abdul Latif, MD; 2Jokhio, Muhammad Faraz,
MD; 2Siddiqui, Khaleeque Ahmed, MD
#ENTRES 1Isra Medical University Hyderabad; 2Liaquat University
of Medical & Health Sciences Jamshoro Sindh Pakistan
#OUNTRY Pakistan
!IM
We present our clinical experience with distraction osteogenesis
performed with an external fixator in combination with an
intramedullary nail for the treatment of both infected and noninfected tibial pseudarthroses.
-ATERIALANDMETHODS
Between 2000 and 2009, 16 patients, with a mean age of 33
years (19-50) underwent tibial reconstruction with use of an
external fixator and an intramedullary nail to treat 10 infected
and 6 non-infected nonunions of the tibia with a mean bone
loss of 8,3 cm (range, 1 to 17 cm). We had eight type B3, four
type B2, three type A2-2, and one type A2-1 pseudarthroses
according to Paley’s classification. Radical debridement,
temporary external fixation and antibiotic-impregnated cement
were used for the first step of infected cases. Free latissimus
dorsi flap was required in three patients, and local soleus flap
was performed in one patient. Ilizarov bone transport technique
was used in 10 patients, and bifocal compression-distraction
was used in six patients, followed by lengthening over an
intramedullary nail as a second session. Free nonvascularized
fibula and iliac crest grafts were used in one case.
$ISCUSSION
The mean duration of follow-up was 40 months (range, 10 to 72
months). The mean external fixation time was 144 days (range,
30-225), and the mean external fixation index (EFI) was 20,7
days/cm (range, 10-30,7). According to Paley’s bone score we
had 15 excellent, 1 poor and according to Paley’s funcutional
socre we had 13 excellent, 2 good, 1 fair score. We had 5
problem, 2 obstracles and no sequelae according to Paley’s
classification of complication included; three grade 2 pin tract
infection and 2 transient knee movement stiffness, one delayed
union of docking site an done grade 3 pin tract infection. There
was a one recurrence of infection necessitating nail removal and
underwent revision with an Ilizarov fixator.
#ONCLUSIONS
The combined technique may provide an improvement on
patients satisfaction, because of the earlier removal of external
fixator and low complication rate facilitating more rapid
rehabilitation.
108
"ACKGROUND
Complex non union may be defined when it is associated with
the infection, bone defect, failed previous internal or unstable
external fixation, deformity and improper selection of implant.
It may follow severe comminuted open fractures due to Road
Traffic Accident, fall, fire arm injury, resection due to tumour and
chronic osteomyelitis.
/BJECTIVE
To achieve the bone union and functional outcome after
resection of bone and eradication of infection with Ilizarov
method.
-ATERIALANDMETHODS
This study was conducted at Department of Orthopaedic Surgery
& Traumatology Liaquat University of Medical & Health Sciences
Jamshoro Sindh Pakistan from April 2006 up to March 2009. We
managed 84 patients with complex non-union of long bones, of
either sex, with age group of 14 to 60 years were included in
the study. Ilizarov external fixator was used and bi and tri focal
osteotomies were done to transport the bone after resection of
non united bone. For evaluation of bone and functional result
ASAMI criteria was followed.
2ESULTS
Out of 84 patients the complex non-union of tibia were in 49
(58.33%), femur 22 (26.19%), humerus 08 (9.52%) and radius
and ulna were 05 (5.95%). The range of bone defect was 1 to 12
cm and limb length discrepancy was 1 to 10 cm.
According to ASAMI criteria the bone results were excellent in
62 (73.80%), good 17 (20.23%), fair 03 (3.57%) and poor 02
(2.38%). The functional results were excellent in 57 (67.85%),
good 21 (25%), fair 5 (5.95%) and poor 01 (1.19%).
#ONCLUSION
Ilizarov fixator gives excellent results in complex non union of
long bones, by eradicating the infection and filling the defect
with bone transport.
Podium #()00).'4%#(.)15%&/2./.5.)/.3$%&/2-)4)%3!.$
DOCKING SITES
Podium #/-").%$4%#(.)15%&/24(%42%!4-%.4/&
03%5$/!24(2/3)3/&4(%&%-52
0RINCIPAL!UTHOR Matsushita, Takashi, MD
#ENTRE Dept. of Orthop Surgery, Teikyo Univ. School of Med
!UTHORS Takenaka, Nobuyuki, MD
#ENTRE Dept. of Orthop Surgery, Teikyo Univ. School of Med
COUNTRY Japan
0RINCIPAL!UTHOR Sen, Cengiz, MD
#ENTRE Gaziosmanpasa University
!UTHORS Bostan, Bora, MD; Erdem, Mehmet, MD; Gunes, Taner,
MD; Kurnaz, Recep, MD
#ENTRE Gaziosmanpasa University
#OUNTRY Turkey
2ESUME
Although chipping technique was originally thought up to treat
nonunions without doing free cancellous bone graft, it is also
useful to correct deformities and to achieve bone union at
docking sites.
From a small incision, osteotome is inserted to a bone directly,
and the entire cortical bone around the affected site is chipped
into small pieces using a hummer and osteotome. The most
important point with this technique is not to separate the
chipped bone fragments from the surrounding soft tissues
for maintaining blood supply to the chipped bone fragments.
The angular and rotational deformities can be corrected at
the chipped site. If the soft tissue is over-stretched it can be
adjusted by acute shortening. Gradual lengthening is performed
at the chipped site if needed. In case of hypotrophic nonunions,
lengthening can be performed at intact metaphysis instead of
the chipped site.
This method was applied to 77 cases, 41 femurs, 35 tibias and
1 humerus. In 12 cases this method were performed to treat
deformities without nonunion, and in 10 cases to treat only
nonunions, in 16 cases to treat deformities with nonuinons, and
in 39 cases to achieve bone union at docking sites.
All cases except one case healed successfully.
The chipping technique is a useful method which can solve
many post-traumatic problems at the fractured sites without
harming any other healthy sites as donors.
)NTRODUCTION
Pseudoarthrosis of the femur is a substantial reason for
disability. In the present study, the outcomes of acute shortening
and intramedullary nail fixation and lengthening with unilateral
fixator were evaluated.
-ATERIALSANDMETHODS
Five patients (2 female, 3 male) with a mean age of 39 years
(range, 36-42) and with mean 2.3 (1-4) previous surgery were
enrolled in the study. Mean preoperative shortening was 4 cm
(range, 1-7 cm). Surgical technique consists of acute resection
of the pseudoarthrosis and fixation of the segment with
intramedullary nail and gradual lengthening over the unilateral
fixator through the proximal femur.
2ESULTS
Mean resection through the pseudoarthrosis was 5 cm (range,
4-6). The rate of lengthening was 4x0.25 mm/day. Mean
lengthening was 7 cm (range, 7-8 cm). Mean time of fixator
removal, mean external fixator index and mean follow up was
13,6 months (range, 13-14 months), 1.8 month/cm (range
1.75-1.8) and 37.6 months (range, 28-43 months) respectively.
Postoperative mean limb length discrepancy was 1.5 cm (range,
1.0-2.0 cm). Union observed in all patients.
#ONCLUSION
Advantages of acute shortening and intramedullary nail fixation
and lengthening with unilateral fixator are; high union rate,
repairing femoral alignment, eliminating limb length discrepancy
and availability of early functional using of the extremity. We
suggest that in selected patients using meticulous surgical
technique, acute shortening and intramedullary nail fixation and
lengthening with unilateral fixator is an alternative treatment of
choice.
109
Podium ARTHRODIATASIS FOR FREIBERGS DISEASE
0RINCIPAL!UTHOR Wang, James, MD
#ENTRE Santa Monica Ucla Orthopaedic Hospital
#OUNTRY United States
!IMANDPURPOSE
Utilizing external fixation in the treatment of Freibergs disease
of the second metatarsophalangeal joint with an arthrodiatasis.
Prevents joint destructive surgical procedures.
-ATERIALANDMETHODOLOGY
Twenty-three patients underwent surgical repair and
reconstruction of second metatarsal head joint surfaces
for various stages of Freibergs disease. This varied from
microfracture of cartilaginous surface to rounding of the
metatarsal head but all included arthrodiatasis of the joint of one
centimeter.
The joints were distracted for six weeks and upon removal a
manipulation of the joints were also performed.
$ISCUSSION
Freibergs disease of the second metatarsal can be a challenging
dilemma for surgeons. Arthrodiatasis with a mini external fixator
was beneficial in that none of the study group required further
surgery after an average follow up of 7.5 years.
#ONCLUSION
Arthrodiatasis with external fixation is a beneficial treatment for
Freibergs disease of the second metatarsal head.
Podium !.%74%#(.)15%&/2(!,,58,)-)45354),):).'%84%2.!,
FIXATION AND ARTHRODIATASIS
0RINCIPAL!UTHOR Wang, James, MD
#ENTRE Santa Monica Ucla Orthopaedic Hospital
#OUNTRY United States
!IMANDPURPOSE
To introduce a new and effective method to treat hallux limitus,
utilizing external fixation to treat the etiology and perform a
simultaneous arthrodiatasis.
-ATERIALSANDMETHODOLOGY
75 patients underwent surgical treatment for hallux limitus.
The patients presented with hypermobile first rays and first
metatarsophalangeal joint pathology. This consisted of severe
hypertrophic spurring and some had osteochondral defects. All
patients had a fusion of the first metatarsal-medial cuneiform
joint as well as a first metatarsophalangeal joint arthrodiatasis.
This was accomplished with a three level mini fixator. The joint
was cleaned of all osteophytic spurs and all osteochondral
defects were drilled and repaired. The external fixator was
used to acutely distract the first metatarsophalangeal joint one
centimeter. The external fixator allowed patients to walk the day
of surgery and the fixators were kept on for six weeks.
$ISCUSSION
There were no delayed or non unions of the fusion site. Patients
had a manipulation of their first metarsophalangeal joints when
the fixators were removed. The arthrodiatasis allowed the
patients to immediate weightbear, which provided the most
favorable environment for the healing of the joint.
None of the patients have required a follow up surgical
procedure with an average follow up of 7.5 years.
Stabilizing the first ray at the first metatarsal cuneiform joint
is the key to recurrence of the first metatarsophalangeal joint
pathology.
#ONCLUSION
Utilizing a multi level external fixator is a new and effective
method to treat the etiology and structural problems of
hallux limitus. This also allows the patient also to undergo a
simultaneous arthrodiatasis which can benefit any intra articular
problems.
110
Podium CIRCULAR EXTERNAL FIXATION FOR ANKLE ARTHRODESIS
0RINCIPAL!UTHOR Wang, James, MD
#ENTRE Santa Monica Ucla Orthopaedic Hospital
#OUNTRY United States
!IMANDPURPOSE
Utilizing circular external fixation for ankle arthrodesis. Allows
for a strong, stable construct that allows patients to immediately
weightbear without compromising arthrodesis outcomes.
-ETHODSANDMETHODOLOGY
70 patients underwent ankle arthrodesis as a salvage procedure
with circular external fixation. All patients had a singular lateral
incision and no internal fixation. Patients were encouraged to
immediately weightbear. All patients fused without any incidence
of delayed or nonunion. The frames were removed at an average
of 6.6 weeks.
$ISCUSSION
The singular incision allowed for exposure of the arthrodesis
site and the circular frame allowed for adjustable compression
and immediate weightbearing. Allowing a patient to weightbear
allows for six times more blood flow to the lower extremity
than internal fixation and immobilization. This allowed for no
incidences of delayed or nonunion.
#ONCLUSION
Circular external fixation with minimal incisions is a viable
technique for ankle arthrodesis. It allows the patient to
immediately weightbear without jeopardizing and actually
enhancing the arthrodesis outcome.
Podium USE OF UNILATERAL EXTERNAL FIXATION FOR ANKLE
ARTHRODIASTASIS WITH ARTHROSCOPY AS SALVAGE
PROCEDURE
0RINCIPAL!UTHOR Donate, Guillermo, MD
#ENTRE Bay Pines Va Healthcare System
#OUNTRY United States
)NTRODUCTION
Ankle pain is a very common and painful occurrence. Different
treatment modalities exist to improve function and alleviate pain.
Arthroscopic procedures are among the most common surgical
ways to help patients improve symptoms while avoiding more
invasive procedures such as ankle arthrodesis. Here we report a
patient series using ankle arthroscopy in conjunction with ankle
arthrodiastasis as an alternative option to a joint destructive
procedure and to improve plain arthroscopic results.
-ATERIALSANDMETHODS
Ankle distractions with arthroscopies were performed on 10
patients suffering from ankle pain. After the unilateral external
fixator was applied to the ankle and leg the joint was distracted
manually then the arthroscopy was performed. The patients
were seen through their regular post-operative schedule and
the external fixators removed at 4-5 weeks. X-Rays were taken,
pre-operatively, immediately post-operatively and after fixator
removal. Patients returned to walking using a post-operative
boot for one month and gradually returned to regular shoe gear
and exercise.
2ESULTS
This ten-patient series using large unilateral external fixation
for ankle arthrodiastasis immediately followed by ankle
arthroscopy shows improved pain relief and function. Distracting
the ankle intra-operatively allowed for better viewing and
access to the ankle joint during the arthroscopy. Maintenance
of the distraction for one month also allowed time for healing
of cartilage to occur and stretch of the contracted soft tissue
structures. All of the patients in our series had their external
fixator removed within 4-5 weeks and returned to ambulation
and activities with-in 2-3 months.
#ONCLUSION
External fixation has been used for a number of different
surgical situations. This type of fixation is extremely stable and
increases ease of arthroscopic procedures by allowing better
viewing of the ankle joint. Arthroscopy is a well established
procedure performed on patients with a variety of symptomatic
joint problems. Traditionally distraction of the ankle has been
done only intra-operatively but not maintained through the
post-operative period. With the use of the external fixator, joint
distraction and stability can be assured with further distraction
attainable if desired. Increased stretch of soft tissues allows for
better post-operative results and improved function.
111
Podium THE USE OF HYBRID EXTERNAL FIXATORS IN DISTAL TIBIA
FRACTURES
Podium ANKLE ARTHRODESIS WITH ILIZAROV
%84%2.!,&)8!4/2#!3%3%2)%3
0RINCIPAL!UTHOR Varsalona, Roberto, MD
#ENTRE Ospedale Umberto
!UTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
#ENTRE Ospedale Umberto
#OUNTRY Italy
0RINCIPAL!UTHOR Sen, Cengiz, MD
#ENTRE Gaziosmanpasa University
!UTHORS Erdem, Mehmet, MD; Gunes, Taner, MD; Bostan, Bora,
MD; Sahin, Ahmet, MD; Balta, Orhan, MD
#ENTRE Gaziosmanpasa University
#OUNTRY Turkey
/BJECTIVEANDPURPOSE
There has been recent interest in the use of external fixation
for the treatment of distal peri-articular fractures. The current
study was undertaken to evaluate the role of the hybrid external
fixation system in the treatment of the distal tibial fractures.
!IM
In the present study we evaluated the results of ankle
arthrodesis performed with Ilizarov external fixator.
-ETHODSANDMATERIALS
Between 2005 and 2010, we treated 151 fractures of the distal
tibia, of which 54 were treated with hybrid external fixation. The
indication for this method of treatment was in the presence of
an unstable extra-articular fracture and/or a severe comminution
of the distal tibia, as well as an associated severe soft-tissue
injury. Routine demographic data, clinical and radiographic
findings as well as reduction, outcomes and complications were
recorded. Patients were evaluated with outcome scale of Ovadia
and Beals.
2ESULTS
There were 21 closed fractures and 33 open. Twenty-five
extra and twenty-nine intrarticular fractures were managed
with a Hybrid Fixator. All fractures achieved complete healing.
Reductions of C-type fractures were within 0-2 mm in 21 cases
and 3-5 mm in 7 cases and >5 mm in 4 patients. The Hybrid
External fixator was removed at an average of 17.5 weeks. Full
weight bearing was achieved at a mean of 7.8 weeks. There
were no intraoperative injuries to nerves or major vessels. Using
the outcome scale of Ovadia and Beals, good-excellent results
WEREACHIEVEDINNSUBJECTIVELYANDN
objectively. Two poor results occurred in patients with a varus
malunion.
#ONCLUSIONS
External fixation is a satisfactory method of treatment for
fractures of the distal tibia and is associated with fewer
complications than internal fixation, because it limits the amount
of soft tissue.
112
0ATIENTSANDMETHODS
Six ankle of five patients were treated with ankle arthrodesis
performed with Ilizarov external fixator. Etiologies were as
follows: posttraumatic arthrosis (8 cm bone loss), talus avascular
necrosis (4 cm bone loss), peripheral neuropathy (bilateral flask
paralysis), cerebral palsy, posttraumatic peroneal nerve lesion.
Mean age was 27.5 years (range, 18-42 years). Four patients
were treated with tibiotalar arthrodesis and one patient was
treated with tibiocalcaneal arthrodesis.
2ESULTS
Mean time for external fixator removal was 6.5 months (range,
3-13 months). Eight and four cm lengthening was performed
in two patients with bone loss, the mean external fixator index
of whom were 0.6 month/cm ve 0.5 month/cm respectively.
Mean follow up was 39.3 months (range 15-68 months). Solid
arthrodesis was achieved in all patients. Pin tract infection
was detected in three patients one of which was grade 3 and
healed with removal of the screw, oral antibiotherapy and local
care. Grade 2 infection of the two patients healed with oral
antibiotherapy and local care. Residual forefoot equine deformity
was detected in one patient. According to Hawkins criteria, good
results were detected in five feet of 4 patients and one patient
had fair result.
#ONCLUSION
Ankle arthrodesis with Ilizarov external fixator yielded successful
results and have the advantages of lengthening the extremity in
cases shortening, stabile fixation and early full weight bearing.
Podium 4(%53%/&!24(2/$)!4!3)37)4(42!.3!24)#5,!2
%84%2.!,&)8!4)/.).4(%42%!4-%.4/&!.+,%!242)4)3
,/.'4%2-2%35,43
0RINCIPAL!UTHOR Pizzoli, Andrea, MD
#ENTRE Orthopedic Department, C Poma Hospital
!UTHORS 1Bortolazzi, Riccardo, MD; 2Bettinsoli, Pierfrancesc, MD;
1
Renzi Brivio, Lodovico, MD
#ENTRES 1Orthopedic Department, C Poma Hospital; 2Orthopedic
Department, Spedali Civili, Brescia University
#OUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
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.
-ATERIALANDMETHODOLOGY
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.
$ISCUSSION
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.
Podium -).)-!,,9).6!3)6%352'%29/&()'(%.%2'902/8)-!,
4)")!&2!#452%3(9"2)$%84%2.!,&)8!4/2
0RINCIPAL!UTHOR Dalla Rosa Nogales, Jaime, MD
#ENTRE EP Hospital Costa del Sol
!UTHORS Bertrand García, María Luisa, MD; Guerado Parra,
Enrique, MD
#ENTRE EP Hospital Costa del Sol
#OUNTRY Spain
/BJECTIVEANDPROPOSAL
We consider that this sort of minimally invasive treatment with
hybrid external fixator is the gold standard for high-energy
proximal tibia fractures. We show the results of functionality,
return to work and complications.
-ATERIALANDMETHODS
From 1999 we have operated 56 Schatzker’s V and VI fractures
with at least one year of follow up. Surgical technique: indirect
reduction of joint surface. Joint stabilization with percutaneous
cannulated screws of 7 mm. Metaphyseal-shaft reduction with
ligamentotaxis and fixation with hybrid external fixator.
$ISCUSSION
High-energy injury fractures had increased notabilly in last
years because of the practice of high risk sports and traffic
accidents. This fractures (Schatzker V and VI) are characterized
of being unstable with a lot of comminution and the high joint
incongruency, always followed by a high soft tissues affectation.
Classically, this sort of fractures needed double surgical
approach with double plating to avoid axial collapse of the
fracture. This kind of treatment had a lot of complications.
#ONCLUSSIONS
We propose treatment with closed reduction, precutaneous
stabilization and external fixation with hybrid external fixator
in high-energy proximal tibia fractures as a safe, effective and
reproducible method.
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.
#ONCLUSION
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.
113
Podium #/-0!2)3/."%47%%.(9"2)$&)8!4/2!.$,/#+).'
0,!4%3).42%!4-%.4/&$)30,!#%$")#/.$9,!24)")!,
PLATEAU FRACTURES
0RINCIPAL!UTHOR Kashyap, Sandeep, MD
#ENTRE Dept of Orthopaedics
!UTHORS Lal, Mukand, MD; Thakur, Manoj, MD
#ENTRE Indira Gandhi Medical College Shimla
#OUNTRY India
!IM
To assess and compare the final outcome of displaced
bicondylar Tibial Plateau fractures with Locking plates and
hybrid fixator. To our knowledge, this study has not been done
before.
-ATERIALSANDMETHODS
A total of 72 patients returned specifically for study in whom
Hybrid fixator was applied in 35 patients and 37 patients had
ORIF with upper Tibial locking plates between 2006 and 2008
in our institution. All these patients had displaced bicondylar
Tibial plateau fractures (Schatzker Type V and VI and OTA type
C1,C2,C3). The mean age was 44.7 years with mean follow up
was 27.4 months. The clinical outcome was assessed using HSS
and Rassmussen’s score and Short Form 36 scoring for general
health assessment was done.The mean knee arc of motion was
125 degree in the hybrid fixator group and 110 degree in plating
group. The mean Rasmussen radiological and functional score
score was 15 (range 11-18) and 25 range (17-29) respectively
in hybrid fixator group compared to 14 (range 9-16) and 23
range (15-27) respectively in plating group. Patients more than
40 years had better knee and SF-36 scores in the hybrid fixator
group as compared to plating group. Patients in the hybrid
fixator group had less surgical duration, less intraoperative blood
loss, less hospital stay and early return to function The quality of
reduction was comparatively better in the plating group (<2mm
articular incongruity). Complications included superficial pin tract
infections in 5 patients, wound dehiscence with exposed plates
in 7 patients and loss of reduction in 2 patients in hybrid fixator
group.
$ISCUSSION
Although low profile locking plates were used to minimise
complications and despite better articular congruity the overall
final outcome was good in hybrid fixator group. Locking plates
have benefit in extensively comminuted fractures where the
olive wires cannot get purchase in fracture fragments. In our
experience stiffness is more debilitating as evident by late return
to function in the plating group.
#ONCLUSION
Hybrid fixator in proximal tibial fractures results in early return
to function without significant complications and satisfactory
results in most patients. Overall knee scores correlated with
SF-36 scores.
114
Podium 4(%#/22%#4)/./&$%&/2-)49).%842%-)4)%3/&4(%
#(),$2%.7)4(7)4((%-)#!,,/4!3)302%,)-).!29345$9
0RINCIPAL!UTHOR Gutiérrez Carbonell, Pedro, MD
#ENTRE Hospital General Universitario Alicante
!UTHORS Navarro Amorós, Pedro, MD; Domenech Fernández,
Pedro, MD
#ENTRE Hospital General Universitario Alicante
#OUNTRY Spain
)NTRODUCTION
The hemicallotasis technique was described in 1987. It has the
advantage of being able to correct the deformity and to preserve
the bone morphology.
-ATERIALANDMETHODS
Between 2007-10 we have realised 15 hemicallotasis in 9
patients: 5 with valgus in femur and 9 and 3 with varus in
tibia and ankle respectively. The etiology was: bone dysplasia
(2 cases), idiopathic (4 cases), post-traumatic (1 case), septic
postarthritis (1 case) and multiple osteochondromatosis (1
case). The mean age was 15 years (range 13-18). Five were
girls (55.5%) and 4 boys (44.5%). Nine left side (60%) and 6
right (40%). The osteotomies was performed always in Center of
Rotation of Angulation (CORA) of the deformity. T-Garches model
was ever used. The angular correction begun to the 2.9 days
after osteotomy (range 2-4 days). The distraction rate was 0.25
mm every 6 hours. The tibial varus preoperative was 9.5º and
18.3º the one of ankles. The preoperative valgus of the femur
was 17º. Follow-up was 22.1 months (range 12-40). Statistic:
descriptive.
2ESULTS
The fixator was removed 3 months and 16 days (range 2-5
months). The varus of tibia and ankle was corrected in 17
and 19 days respectively. The femoral valgus in 21 days. The
postoperative ankle valgus was 2.3º and 5º respectively and
of 0.8º the femoral varus. The Insall-Salvati ratio was 1.2
and 0.87 preoperatively in tibia and femur and 0.89 and 0.87
postoperative, respectively. Complications: Track pin infection
in 4 cases (26.7%). In one case was change the fixator locking
system (6.7%) in femur and loss of 8% of flexion movement in
knee in the femoral valgus correction in two cases (13.3%).
#ONCLUSIONS
The hemicallotasis, when realised osteotomy in the CORA,
aligned deformities in children limbs, without to change the bone
morphology.
Podium ERRORS IN THE PLANNING AND EXECUTION OF CORRECTIVE
/34%/4/-)%3/&,/7%2,)-"3
0RINCIPAL!UTHOR De Pablos Fernández, Julio, MD
#ENTRE Hospital San Juan de Dios
!UTHORS Bravo Corzo, Flavio, MD
#ENTRE Hospital San Juan de Dios
#OUNTRY Spain
/BJECTIVE
To retrospectively study our cases of lower limb angular
deformity correction and identify the main factors associated
with unsatisfactory results.
-ATERIALANDMETHODS
We reviewed 59 corrective osteotomies in 47 patients with
long-bone angular deformities in the lower limbs, aged between
8 and 65, and operated on between 1987 and 2009. The
preoperative planning and the results were studied according
to the following parameters: mechanical/anatomical axes of the
bone segments; knee-ankle epiphyseal-metaphyseal angles;
and orientation of their joint interline.
2ESULTS
Discounting the errors caused by under and over-correction,
the unsatisfactory results (n:23) were classified according to
their cause as planning errors and/or execution errors. In the
first group, correction outside the apex was the most common
mistake (n:8), followed by intervention in the wrong segment
(n:5) and the presence of a previously unnoticed multiple
deformity (n:4).
The cases classified as errors in the execution (n:10) due to
faulty application of the correction techniques or instrumentation
were not entirely exempt of problems caused by poor planning
(n:4).
#ONCLUSIONS
The theoretical approach and the surgical correction of angular
deformities require knowledge of the natural history of the
disease and the correct indication for the technique and the
instrumentation.
Meticulous preoperative planning involving the correct
identification of the osteotomy site (apex) and the anatomical
segment in which it is situated is of vital importance for
obtaining satisfactory angular correction.
Podium 02/8)-!,&%-/2!,/34%/4/-9#/-").%$7)4(
0%2#54!.%/53%84%2.!,&)8!4)/.).4(%42%!4-%.4/&
$%&/2-)4)%3/&4(%()0).0!,39
0RINCIPAL!UTHOR Salom Ramos, José, MD
#ENTRE Orthopaedic Surgeon
!UTHORS 1Mora Aular, Arelis, MD; 2Terrizzi Spadaro, Carmela, MD;
3
Salazar Sánchez, Joanna, MD; 1Pérez Tovar, Juan, MD; 1Orta
Martínez, Héctor, MD
#ENTRES 1Orthopaedic Surgeon; 2Pediatric Physician; 3Resident
Student
#OUNTRY Venezuela
2ESUME
The Children Cerebral Palsy (CCP) is characterized by muscle
contractions that predispose permanent rotational and angular
deformities of the hip in paralytic child that alter the normal
biomechanics of this joint by changes in bone alignment and
orientation difficult to walk.
/BJECTIVE
To evaluate the effectiveness of Ilizarov type external fixation
combined with percutaneous femoral corrective osteotomy in
the treatment of hip deformities in patients with CCP.
-ATERIALSANDMETHODS
69 patients with CCP, rotational and angular deformities in the
proximal femur, and a total of 110 hips operated on because
of that 41 patients had bilateral deformity. The technique
consisted of osteotomy oblique or transverse intertrochanteric
subtrochanteric according to the deformity in each patient,
using minimal approach under fluoroscopy in combination with
a special external fixator designed for research as synthetic
material. With a follow-up period of 2 to 47 months.
2ESULTS
Most cases were between 4 and 9 years of age (63.8%) 44
children, female sex was predominant in 52.2%. The subtype
SPASTICDIPLEGIAINNWASTHEPRINCIPALDIAGNOSIS
followed by spastic quadriplegia by 34.8%. Preoperative
CERVICALDIAPHYSEALANGLEDECREASEDINN4HE
angle of femoral anteversion decreased by 75.5% of cases.
The consolidation time was between 9 to 12 weeks in 86.4%.
Only 11 patients presented complications, being more frequent
REINTERVENTIONBYNTHELOSSOFVALGUSCORRECTIONBY
NTRACTINFECTIONANDPINLOOSENINGOFTHESAMEAT
NFOREACHRESPECTIVELY
#ONCLUSIONS
By using this minimally invasive technique and a suitable
fastening system, is achieved by correcting the spastic hip
deformities, with 90% of excellent results achieved improved
biomechanical function of the patient’s hip with CCP. Decreasing
the risk of surgery and blood requirements inherent in surgery.
+EYWORDS
Osteotomy, external fixation, children cerebral palsy, deformities,
hip.
115
Podium $)34!,&%-/2!,6!,'53$%&/2-)49#/22%#4)/.
&)8!4/2!33)34%$.!),).'6%2353&)8!4/2!33)34%$
PLATING
0RINCIPAL!UTHOR Kovar, Florian M, MD
#ENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
!UTHORS Standard, Shawn C, MD; Herzenberg, John E, MD
#ENTRES International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
#OUNTRY United States
)NTRODUCTION
Fixator-assisted nailing (FAN) and fixator-assisted plating (FAP)
can be used to correct femoral valgus deformities. Although FAN
can be performed through a small incision, it is an intraarticular
procedure. FAP requires a large incision but is an extraarticular
procedure. We compared the accuracy of correction of FAN
versus FAP.
-ETHODS
We reviewed medical records and radiographs of all patients
who underwent surgery for correction of femoral valgus
deformities between 2002 and 2009. A single investigator
measured the radiographs.
2ESULTS
FAN: Twenty extremities (18 subjects) were treated with FAN.
Seven male and 11 female subjects with an average age of 36
years (range, 14-68 years) were included in the study. Average
pre-and post-operative mechanical lateral distal femoral angle
(mLDFA) was 81º (range, 67-86º) and 89º (range, 80-100º),
RESPECTIVELYP&OLLOWUPWASMONTHSRANGE
months).
FAP: Seven extremities (six subjects) were treated with FAP.
Two male and four female subjects with an average age of 16
years (range, 15-19 years) were included in the study. Average
pre-and post-operative mLDFA was 80º (range, 71-87º) and 88º
(range, 81-94º), respectively (p<.001). Average follow-up was
11 months (range, 2-56 months).
Although the average correction of mechanical axis deviation for
the FAP group was greater than the FAN group (32 mm and 27
MMRESPECTIVELYITWASNOTSTATISTICALLYSIGNIlCANTP
#ONCLUSION
Both methods are safe and effective surgical techniques. Based
on our results, FAP may be a more accurate technique for distal
femoral valgus deformities.
116
Podium 3)-0,%-%4(/$/&!.'5,!2$%&/2-)4)%3#/22%#4)/."9
THE USE OF HIGH CAPACITY EXTERNAL FIXATOR
0RINCIPAL!UTHOR Mitkovic, Milorad, MD
#ENTRE Ortopedsko-Traumatoloska Klinika
!UTHORS Milenkovic, Sasa, MD; Micic, Ivan, MD; Mladenovic,
Desimir, MD; Golubovic, Zoran, MD; Mitkovic, Milan, MD
#ENTRE Ortopedsko-Traumatoloska Klinika
#OUNTRY Serbia
)NTRODUCTION
It is shown simple and safe method of angular deformity
correction using external fixation.
-ETHOD
We used 3D unilateral Mitkovic external fixation device which
consists of components: telescopic and articulating bar, carrier
and clamp. This device is suitable for all angular correction
including varus, valgus, antecurvatum, recurvatum and
combination of these deformities with shortening of: tibia, femur,
radius, and humerus. Method is simple and consists of 2 pins
application in each fragment in any desirable direction (not
necessary to be parallel). After partial corticotomy (40-80%),
correction starts 6 days after the operation, producing opening
wedge effect. If deformity overcorrected it is very simple to
return, by screw unscrewing. Patient can walk with full weight
bearing immediately after the operation. Frame can be removed
after 10-12 weeks in tibia and pins one week later.
2ESULTS
In series of 118 patients we successfully corrected deformities
in tibia (72), femur (10), radius (15), humerus (12) and fingers
(9). There were no complications except 2 recurrent of varus
deformities on tibia because of early frame removal (after 10
weeks). These 2 cases have been resolved by returning of frame
for additional 3 weeks.
$ISCUSSIONANDCONCLUSION
In most of angular deformities, it can be used open wedge
external fixation technique. Device we used is very simple
for use as it is not necessary to take big care during pins
application. It is important only, to adjust plane of articulating
unit. Results obtained in correction of angular deformities alone
or with shortening, have shown that this method is suitable
for routine use, especially if surgeon is not very familiar with
accurate fixator application.
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$%&/2-)49
0RINCIPAL!UTHOR Casas Placer, José, MD
#ENTRE Hospital Central de Maracay Aragua Venezuela/jefe de
sevicio de Traumatología y Ortopedia
!UTHORS Rodríguez de Casas, Verónica, MD; Mendoza, Daniel,
MD; Mancera Alcalá, Alexander, MD
#ENTRE Hospital Central de Maracay Aragua Venezuela
#OUNTRY Venezuela
/BJECTIVE
To determine the effectiveness of the supra and infra-tuberosity
tibial osteotomy in “L” with gigli saw and osteotomo plus fixation
with multiplanar external fixator for the correction of triplanar
congenital deformity of the tibia bilateral, characterized by Q
Angle increased, tibial varus and external tibial torsion (AQTEVA)
in patient with chronic pain of knee.
-ATERIALSANDMETHODS
Prospective-descriptive study with application of surgical
method with established antecedents, analysis of results and
conclusions based on the evidence of the sample in study. The
method was applied on 5 patients with its written consent, for to
total of 10 tibias, all presented antero-medial pain of knee and
limitation for sport and recreational activities.
2ESULTS
5 patients (10 tibias) with age 19 year-old average, 4 of male
sex, all with abnormal increase of Q angle between 27º and
ŽEXTERNALTIBIALTORSIONBETWEENANDŽTIBIALVARUS
with medial desviation of mechanical axis of inferior extremity
BETWEENANDMM3URGICALCHEATSOFMINUTEONTHE
average. All the osteotomys was stabilized using external fixator
with two hoops and 4 pines of 5,0 mm. Correction of Q Angle,
External Tibial torsion, Tibial varus and mechanical axis was
achieved until normal limits in all the cases. The consolidation
was achieved on the average in 14.6 weeks. There were not
bigger complications. Infection of pin itinerary was presented in
2 cases. After pursuit average of 28 months was stayed clinical
and radiological correction of the deformity, pain absence in
knee and excellent physical acting.
#ONCLUSIONS
The supra and infra-tuberosity osteotomy in “L” plus the fixation
with multiplanar external fixator represented lives to sure,
reliable and effective method in the patients in study for the
treatment of the complex triplanar tibial deformity type AQTEVA.
Podium 3502!-!,,%/,!2$%2/4!4)/./34%/4/-9/&4(%4)")!
7)4(,/#+).'#/-02%33)/.0,!4%&)8!4)/.!.$-).)-!,,
INCISIONS, IN PATIENS WITH IDIOPHATIC INTERNAL TIBIAL
TORSION
0RINCIPAL!UTHOR Galbán G, Miguel Ángel, MD
#ENTRE Pediatric Orthopaedic Surgery and Limb Reconstruction
Surgery, Caracas
!UTHORS Villanueva, Roceli, MD; Santana, Adolfredo, MD
#ENTRE Hospital Ortopédico Infantil, Caracas
#OUNTRY Venezuela
2ESUME
In spite of a tendency for rotational deformities of the tibia in
children to improve spontaneously over time, some persist
and require corrective derotation osteotomy. Internal tibial
torsion is frequent in patients with cerebral palsy, clubfoot and
neurological injuries. The idiopathic internal tibial torsion is a
frequent cause of gait disturbance in normal children. To treat
this deformity has been proposed the supramalleolar osteotomy
of the tibia with or without concomitant fibular osteotomy. The
method of fixation has been described with cast, kirschner wire,
steinmann pin, staple, intramedular nail, dynamic compression
plate (DCP) and external fixation. To our knowledge no one
has described Supramalleolar Derotation Osteotomy fixed with
locking compression plate (LCP) in combination with minimal
incisions (MIPO). We evaluated 29 patients, 54 tibias with
idiopathic internal tibial torsion treated between February 2008
and January 2010. The mean age at the time of surgery was
12.9 years (5 to 68). All osteotomies were fixed with straits LCP
and 4 locking screws (2 proximal and 2 distal), 3.5 mm or 5 mm
systems. The LCP was placed distal and laterally. We used three
minimal incisions, two laterals of 3 centimeters for proximal and
distal screws and a third antero-medial incision of 5 millimeters
for percutaneous osteotomy. 62% were male. 4 Cases unilateral,
25 cases bilateral. 61% needed casting for three weeks in those
cases where lengthening of the Achilles tendon was done. The
remaining patients did not use any immobilization and were free
to move. All patients were aloud to full weight bearing at three
weeks and they started to walk. Bone healing was obtained in
all patients except two in a mean period of seven weeks (5 to
12). No loss of reduction at the site of the osteotomy developed.
Supramalleolar osteotomy of the tibia without fibular osteotomy
and fixed with lateral strait LCP and minimal incisions is a safe
and simple surgical procedure, and more important it is a more
comfortable method.
7ORDSKEY
Q Angle, external tibial torsion, tibial varus, tibial osteotomy in
“L”, AQTEVA.
117
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,/7%2,)-"$%&/2-)4)%3)./,,)%23$)3%!3%
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-5,4)$%4%#4/2#/-054%$4/-/'2!0()#!.')/'2!0(9
0RINCIPAL!UTHOR Gil Albarova, Jorge, MD
#ENTRE Hospital Universitario Miguel Servet, Zaragoza
!UTHORS 1Gómez Palacio, María Victoria, MD; 2Espallargas,
Teresa, MD; 3Bregante Baquero, Juan, MD;
#ENTRES 1Hospital San Millan-San Pedro, Logroño; 2Hospital
Obispo Polanco, Teruel; 3Hospital Universitario Miguel Servet,
Zaragoza
#OUNTRY Spain
0RINCIPAL!UTHOR Abou Issa, Ahmed Haroun Mohamed, MD
#ENTRE Mansoura University Hospitals
!UTHORS 1Obeid, Makram Radwan, MD; 2Morsy, Amro Hamdy,
MD; 3Ezzat, Amany, MD; 3Alganayni, Fady, MD
#ENTRES 1Zagazig University; 2Alminia University; 3Mansoura
University Hospitals
#OUNTRY Egypt
/BJECTIVEANDPURPOSEOFTHESTUDY
The assessment of Monolateral External Fixation (MEF) as a
suitable method in the correction of lower limb discrepancies
and deformities in children with Ollier’s disease.
-ATERIALANDMETHODS
Two patients with Ollier’s disease underwent treatment using
distraction osteogenesis. Patient 1. A 10 years old girl presents
a comparative right femoral shortening (5 cm) and varus
(10º). Limb discrepancy correction by means distractional
osteogenesis, in a light valgus axis to compensate previous
varus deformity, was done by means of percutaneous proximal
femoral osteotomy and pin placement in healthy bone.
Distraction started after 8 days and a 6 cm leg lengthening
was achieved after 6,5 months of MEF. Patient 2. A 6 years old
boy presents a comparative shortening (3 cm), varus (22º) and
external rotation (35º) of the right tibia. A proximal percutaneous
tibial osteotomy was done for bone lengthening. Moreover, a
distal open fibular resection osteotomy of a diaphyseal cylinder
1,5 cm in length, and distal tibio-fibular fixation by means of
a transindesmal screw was associate. Furthermore, a distal
percutaneous tibial osteotomy was done for intraoperative
varus and rotational correction. Some pin placement through
intralesional bone was done. Distraction started after 6 days
and a 3,5 cm tibial lengthening was achieved after 4,5 months
of MEF. Walk with crutches with progressive weight bearing
was allowed from the firs postoperative day. Dinamization of
MEF was done 4 months after surgery in the first patient and 3
months after surgery in the second one.
$ISCUSSION
Treatment of limb deformities in Ollier’s disease should have
the objective of mechanical axis improvement and leg length
discrepancy correction. In our experience, pin placement through
intralesional bone offers sufficient stability to obtain these
purposes. Although intralesional osteotomy has been used by
several authors, we prefer to perform the osteotomy in healthy
bone. However, this option may frustrate the correction at the
exact level of the center of rotation and angulation.
#ONCLUSION
Lower limb deformities and discrepancies in Ollier’s disease in
children may be treated by distraction osteogenesis and MEF,
even if pins are inserted intralesionally.
118
"ACKGROUNDANDAIMOFTHEWORK
Peripheral vascular injuries may occur through multiple
mechanisms. With marked increasing violence in the cities, both
blunt and penetrating injuries to blood vessels are on the raise.
These injuries may be difficult to detect, may cause serious
morbidity or occasionally be life-threatening. Therefore, having
a rapid diagnosis and treatment of such injuries is important
to prevent a potentially catastrophic effect. This study aims
to evaluate the role of multi-detector computed tomographic
angiography in patients with suspected acute peripheral arterial
injury compared to surgical findings and patient’s outcome.
0ATIENTSANDMETHODS
Thirty five patients (33 males and 2 females, age range 8-58
years) with clinically suspected arterial injury underwent 64Multi-detector computed tomographic angiography (MDCTA).
Main indications were history of previous bleeding at scene
of accident, impalpable/weak pulse, ipsilateral multilevel
fractures, changes in Ankle/Brachial (A/B) index and palpable
thrill or audible bruit. Immediately after acquisition of axial
images, interactive two-dimensional (2D) reformations and
three-dimensional (3D) volume rendered images were done.
Preliminary verbal report about peripheral vessels was provided
to attending surgeons then, all images & reformations were
sent to PACS as soon as possible to help surgeons choose
appropriate management plan. Once vascular injury diagnosed
and plane decided, we started as a team orthopaedic surgeon,
vascular surgeon and may be plastic surgeons to early manage
that catastrophic problem.
2ESULTS
Forty arterial injuries were encountered in 35 patients with 46
related fractures. Results were compared with surgical findings
and then by clinical, and radiological records., MDCTA findings
in acute injuries included occlusion in 67.5%, spasm in 27.5%
and active extravasations in 5% with sensitivity 97.5%. Only one
case necessitated amputation after vascular repair with success
rate of 97.5%.
#ONCLUSION
MDCT angiography is a non-invasive, rapid and reliable modality
that can be used to diagnose arterial injuries to the extremities
in the setting of trauma with high sensitivity as regards to
surgical findings and patient’s outcome.
Podium 42%!4-%.4/&/0%.4)")!,&2!#452%7)4("/.%$%&%#4
#!53%$"9()'(6%,/#)49-)33),%3!#!3%2%0/24
Podium THE USE OF EXTERNAL FIXATION FOR BONE TRANSPORT IN
4(%42%!4-%.4/&#/-0,%84)")!,&2!#452%3
0RINCIPAL!UTHOR Golubovic, Zoran, MD
#ENTRE Clinic for Orthopaedic Surgery and Traumatology, Clinical
Center Nis
!UTHORS Stojiljkovic, Predrag, MD; Golubovic, Ivan, MD;
Karalejic, Sasa, MD; Mitkovic, Milorad, MD; Vidic, Goran, MD
#ENTRE Clinic for Orthopaedic Surgery and Traumatology, Clinical
Center Nis
#OUNTRY Serbia
0RINCIPAL!UTHOR Maturana Merino, Felipe, MD
#ENTRE Ist Viña del Mar
!UTHORS Jackson Salinas, Anthony, MD; Staub Feller, Ricardo,
MD; Cardenas, Gabriel, MD
#ENTRE Ist Viña del Mar
#OUNTRY Chile
2ESUME
The study represents a case of a patient, 34 years old, wounded
at close range by a semi-automatic gun missile (7.9 mm
caliber). He was wounded in the distal area of the left tibia and
suffered a massive defect of the bone and soft tissue. After the
primary treatment of the wound, the fracture was stabilized with
an external fixator type Mitkovic, where two pins are placed in
the proximal fragment of the tibia, one in the distal fragment and
one in the heel bone. Immediately after admission, antibiotic,
analgesic (diclorapid) and anticoagulant (fraxiparine) therapy
were also started. Two weeks after the primary treatment of
the wound the pin in the heel bone is removed and a new one
is placed into the distal fragment of the tibia just above the
ankle. The wound in the medial region of the tibia is closed
with the secondary stitch, whereas the wound in the lateral
area is closed with a skin transplant after Tirsch. Due to a
massive bone tissue defect we placed a reconstructive external
skeletal fixator type Mitkovic and performed a corticotomy in
the proximal metaphysar area of the tibia. By the method of
distractive osteogenesis, the bone defect of the tibia at the
point of fracture has been replaced. After the healing of the
fracture, the fixator was removed and the patient was admitted
into physical therapy. Surgical treatment of wounds, external
fixation, performing necessary debridements and early soft and
bone tissue restoration are essential in achieving good results
in patients with open tibial fracture with bone defect caused by
high velocity missiles.
)NTODUCTION
The managment of open fractures of the tibia has many edges,
it is very important to have an operative planning from at the
time of the damage control surgery, in order to provide soft
tissue recovery and ensure bone healing. The necrotic tissue can
disturb the healing leading to a large number of surgerys.
0ATIENTSANDMETHOD
The present work is a restrospective analisis of 11 cases of
open tibial fracture treated with with bone transport, at the IST
of Viña del Mar Chile. All patients where treated by the same
surgical team, using an uni-planar configuration external fixatior.
All patients where male and the mean age was 35 and the mean
follow u was 2 years. The time for bone healing, as the use of
the ex-fix was considered, also the need of bone grafting in a
second operation, and the complicatios where studied.
Also all patients where evaluated with functional score.
2ESULTS
All patients healed in the double time that they were enlarged,
there was need for bone grafting in 5 cases, pins infection in
6 cases but there was no need for ex-fix extraction. The mean
transport length was 6 cm. There were 3 TVP that respond to
medical treatment and 3 cases of region pain sidrome. There
were a good functional outcome in 7 patients and excellent in 3.
#ONCLUSION
The bone transport method for open tibial fractures used from
the first surgery offers a good soft tissue managment, and
provides the conditions for bone healing in an expected period
of time with low rate of complication and a good functiona
outcome.
119
Podium -!.!'%-%.4/&3%'-%.4!,&2!#452%4)")!"9),):!2/6
EXTERNAL FIXATOR
Podium "/.%42!.30/24&/2-!.!'%-%.4/&3%6%2%,9
#/--).54%$&2!#452%37)4(/54"/.%,/33
0RINCIPAL!UTHOR Elmoghazy, Nabil, MD
#ENTRE Mansoura University
!UTHORS Elalfy, Barakat, MD
#ENTRE Mansoura University
#OUNTRY Egypt
0RINCIPAL!UTHOR Thakeb Fouad, Mootaz, MD
#ENTRE Faculty of Medicine Ain Shams University
!UTHORS Mahran, Mahmoud, MD; El Moatasem, El Hussein, MD;
Hefny, Hany, MD
#ENTRE Faculty of Medicine Ain Shams University
#OUNTRY Egypt
2ESUME
Segmental fracture was defined as a two-level tibial fracture
with an intact circumferential cortex of the intermediate
segment. Segmental fracture of the tibia is a rare injury. It is
usually follows high-energy trauma and is often associated with
a significant soft tissue injury.
The purpose of this study is to evaluate the results of treatment
of segmental fracture tibia by Ilizarov external fixator.
Twenty five patients with segmental tibial fractures (3 female &
23 male) were treated using Ilizarov external fixator, twenty were
open with a mean age of 35.08 years (range 21-65 years) with a
mangled extremity severity score less than 6. Four patients were
initially treated by interlocking nail; five patients were treated
conservatively in plaster and two with monolateral external
fixator. The mean length of the intermediate segment was 10.5
cm (range 4.5 to 18 cm). Soft tissue coverage was required in
15 cases. Ipsilateral femoral fractures in 3 cases, interaarticular
involvement occurred in 6 cases (4 plateaus & 2 plafond). Five
cases of compartment syndrome treated by fasciotomies, two
cases with vascular injury required vascular repair. Five cases of
infection, two of them after nailing which required nail removal
and excision of non viable segment and bone transport, other
two cases were superficial infection treated by debridement and
antibiotics. One case required amputation due to uncontrolled
infection. Eighteen patient required second operative procedure
(soft tissue coverage, bone grafting, excision of dead segment
and bone transport).
Ilizarov external fixator was applied in all cases. The results were
evaluated according to ASMI classification. The mean follow up
was 40.32 months, range (10-84).
The mean time of union of the proximal segment was 36.62
weeks and 42.2 weeks for the distal segment. Non union in 2
cases required nailing and bone grafting. Limited knee motion
less than 90º was seen in 3 cases and equines foot deformity of
10º in one case.
The treatment of segmental fracture tibia is challenging due to
associated high energy trauma and interrupted blood supply
to the intermediate segment and associated high incidence of
non union and infection, Ilizarov external fixator can treat these
problems.
120
2ESUME
The aim of this study is to deal with severely comminuted
fractures in a biologic way without the need for extensive
exposure to achieve anatomic reduction and obtaining bone
healing in a relatively shorter period of time.
10 tibiae and 2 femora in 12 patients were treated by bone
transport for severely comminuted fractures without bone
loss, no open wounds related to the fracture were present
in all patient. 9 of the tibiae fracture were metaphyseal and
1 diaphyseal. The 2 femora fractures were supracondylar.
An Ilizarov frame applied to the affected segment that was
stabilized first, a corticotomy was done to do bone transport to
fill the comminution gap. Segment transfer ranged from 2 to 5
cm. Transfer was stopped when there was apparent good bony
contact as seen on follow up X-rays. Frame was then kept on
statically till full healing. The time of treatment ranged from 4 to
9 months.
Bone transport is a well known technique in management of
bone loss whether traumatic or pathologic. Severely comminuted
fractures with widely displaced fragments are challenging
and difficult to treat. Segmental defects more than 2 cm are
unlikely to heal spontaneously following bone stabilization
alone and those involving more than 50% of the circumference
often require an additional treatment to restore normal volume
and strength. These types of fracture should be considered as
a contained bone defects that requires filling the gap. Bone
transport was chosen as a technique to fill the comminution gap
and to the best of our knowledge there is no previous work on
this technique. 11 patients 2 with femora fractures and 9 with
tibiae fractures tolerated well the procedure with good healing
at the end, 1 patient with the diaphyseal fracture did not tolerate
the frame that was removed prematurely.
Bone transport to treat severely comminuted fractures without
bone loss was an effective way to achieve good healing in a
good period of time. Reducing a defect size using bone transport
will decrease healing time. Fragments should be widely
displaced to accommodate the transported segment. Better to
be used for metaphyseal comminuted fractures.
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-%4(/$!2%42/30%#4)6%!.!,93)3
0RINCIPAL!UTHOR Konstantinos Tilkeridis, MD
#ENTRE Sheffield Teaching Hospitals
!UTHORS Adrian J. Owen, MD; Simon L Royston, MD; Michael J
Dennison, MD; María Vincent, MD; Girish Vashista, MD
#ENTRE Sheffield Teaching Hospitals
#OUNTRY United Kingdom
2ESUME
The Ilizarov method and fixation is a well establish treatment in
lower limb reconstruction, but on a search of the literature there
was little known about the outcome of its use in the treatment of
segmental tibial fractures.
!IM
To review a single unit’s experience of the Ilizarov method in
segmental tibial fractures.
-ATERIALSANDMETHODS
26 patients were managed with an Ilizarov fixator were reviewed
retrospectively after the completion of treatment. The patients
were asked to complete a Lysholm knee scale and Tegner
activity level scale to assess knee function before and after the
fracture was sustained, an Olander and Moldeavia Ankle score to
assess ankle function before and after the fracture and a SF-36
to assess overall mental and physical state. The patients notes
were then reviewed for grade of fracture, the period spent in the
fixator, if secondary operations were required, and if significant
complications occurred.
2ESULTS
17 patients, 65%, had open fractures, these were all graded
as Gustilo-Anderson IIIb. The mean time spent in frame for all
patients was 181 days. Non-union occurred in 3 cases, these
were corrected with the application of a second frame. Malunion
was reported in 4 cases, 3 of these were corrected with
adjustment or reapplication of the frame. In total 11 patients
required secondary operations. 8 patients reported significant
pin site infection requiring antibiotics, of these one patient was
found to have MRSA. 2 patients suffered osteomylitis, one of
which could be treated with excision ring sequestrum. One case
of DVT was reported. There was no incidence of compartment
syndrome. The mean Lysholm knee score dropped from 90 to
57, the mean Tegner activity score dropped from 5.5 to 2.4, and
the mean Olander and Moldeavia ankle score dropped from 75
to 51 before and after the fracture. The SF-36 scoring gave a
mean PCS of 38.8 and MCS of 50.6.
Podium
4/4!,!.$35"4/4!,!-054!4)/./&,/7%2,)-"3
TREATED BY SHORTENING REVASCULIRAZATION AND
LENGTHENING
0RINCIPAL!UTHOR Kovoor, Cherry Cheriyan, MD
CENTRE Specialist Hospital
AUTHORS Jayakumar, R, MD; Viswanath, Sabin, MD; Guild, AJ,
MD; George, Vv, MD
CENTRE Specialist Hospital
COUNTRY India
!IM
To present the results of twelve patients who had sustained
Gustillo type III C open fractures of the lower limb who were
treated with acute shortening, neurovascular repair and
subsequent lengthening with Ilizarov ring fixation.
-ATERIALANDMETHODOLOGY
Twelve patients were retrospectively studied. The mean age
was 28.4 yrs. All injuries except one occurred in the tibia.
There were four cases of complete amputation, seven cases
of incomplete amputation and one case of vascular injury with
open fracture. The average warm ischemia time was 4 hours,
and mean time from injury to revascularization was 7 hours.
The mean shortening done to enable vascular repair was 7.1
cm. Temporary mono-lateral external fixation was applied to
stabilize the fracture. The mean time interval between injury and
Ilizarov ring fixation was 5.6 weeks. An all wire Ilizarov frame
was applied in two cases and hybrid Ilizarov frame applied in 10
cases.
2ESULT
Union occurred in all cases. Residual shortening was present
in two cases and residual infection was present in one case.
Nine patients returned to work. Five patients had reduced touch
and pain sensation of the foot, two patients had increased pain
sensation and five patients had almost normal sensation of the
foot. No patient developed trophic ulcers on the foot. Two of
the patients had residual ankle pain and one patient residual
knee pain. Five of the patients obtained ten degrees of ankle
movement.
#ONCLUSION
We conclude that acute shortening, neuro-vascular repair and
subsequent lengthening gives good functional results in most of
these cases.
#ONCLUSION
The Ilizarov treatment of segmental tibial fractures can lead to
good results, with an acceptably low incidence of complications
and secondary operations. Given the high velocity nature of the
injuries the ultimate function of the limb that can be achieved is
acceptable.
121
Podium
#/22%#4)/./&0/3442!5-!4)#%15).53#/.42!#452%
7)4(4!9,/230!4)!,&2!-%
Podium
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5.),!4%2!,%84%2.!,&)8!4/2).+.%%$%&/2-)49
0RINCIPAL!UTHOR Lahoti, Om, MD
CENTRE Kings College Hospital
AUTHORS Abhishetty, Naveen, MD
CENTRE Kings College Hospital
COUNTRY United Kingdom
0RINCIPAL!UTHOR Milenkovic, Sasa, MD
CENTRE Medical Faculty, Clinic for Orthopaedic and Traumatology
COUNTRY Serbia
!IMANDPURPOSEOFTHESTUDY
Post traumatic equinus contracture is not an unusual
complication of significant musculoskeletal injury to lower limbs.
Majority of minor deformities respond to physiotherapy but
severe deformities resulting from musculo-tendinous fibrosis,
particularly as a result of compartment syndrome and prolonged
treatment of tibial fractures are often resistant to non-operative
treatment. We present our technique of using minimal soft tissue
release and gradual correction of deformity in Taylor Spatial
frame in five cases.
-ATERIALSANDMETHODOLOGY
We have treated five cases of severe and resistant equinus
contracture (20-30 degrees) between 2005 and 2010. All
cases resulted from severe soft tissue injury and compartment
syndrome of affected limb. They had undergone prolonged
treatment for open fracture of tibia prior to referral to our
institute and failed to respond to at least six months of
aggressive physiotherapy. In all cases fractures did not involve
ankle articular surface and all tibial fractures had united.
Three out five cases also had associated peroneal nerve palsy.
Our procedure included Tendo Achilles Lenthening, ankle and
subtalar capsulotomy and application of two-ring Taylor Spatial
Frame. We used long bone module to correct the deformity
gradually. All deformities were over corrected by 5-10% to
prevent recurrence.
2ESULTS
We successfully corrected equinus deformity in all cases. Follow
up ranged from three months to five years and we found no
recurrence. Patients with peroneal palsy were provided with
ankle foot orthosis (AFO).
$ISCUSSION
We describe a technique of Taylor Spatial Frame application to
gradually correct the equinus deformity without causing any
damage to ankle joint. Equinus movement is always associated
with appropriate degree of supination because the axis of
rotation of ankle is oblique. Pure rotational correction based on
the centre of talus corrects the equinus deformity but leaves
the foot in supination. We have utilized long bone module
of correction to correct equinus and supination successfully
without damaging the ankle joint.
#ONCLUSION
Taylor Spatial Frame treatment provides a safe, finely
controllable, accurate and reproducible method of correcting soft
tissue equinus deformity.
122
)NTRODUCTION
Angular knee deformities bring about the appearance of an
early knee arthrosis. In the treatment of knee deformity various
methods can be applied. One of them is open wedge osteotomy
and hemicallotasis by means of external fixator.
-ETHODS
This paper shows outcomes of the treatment 24 patients with
knee arthrosis accompanied by varus and valgus deformity
(15 varus & 9 valgus deformity). All patients were operated in
Orthopaedic & Traumatology Clinic Nis with external fixation
method.
2ESULTS
Open wedge osteotomy of the varus deformity is performed
on the proximal tibia, and in case of valgus deformity on the
distal femur. The patients who were operated on had a knee
varus larger than 10 degrees and the knee valgus larger than
12 degrees. After a one year follow-up, the final outcomes were
positive in all patients.
#ONCLUSION
The method is minimally invasive and relatively easy applied.
The unilateral External fixator M 20 CD-V allow continuous
hemicallotasis (callus distraction) with a simultaneous correction
of the varus or valgus knee deformities.
Podium
DISTAL TIBIA AND ANKLE RECONSTRUCTION USING A
#/-").%$4%#(.)15%7)4(%84%2.!,&)8!4/2!.$,#0
PLATES
0RINCIPAL!UTHOR Mora, León, MD
CENTRE Hospital Pablo Tobón Uribe
COUNTRY Colombia
"ACKGROUND
The present study combine two techniques, circular external
fixator (Ilizarov device) and LCP Plate with the goal to diminution
the time of use the external fixation.
Larger bone defects are associated with difficult reconstructions
and less certain long-term outcomes. Tibial Pilon fractures with
segmental bone loss become complicated by chronic infections,
and often bone resection is necessary to control the infection.
Reconstruction is particularly challenging in patients with
deformity, infection, soft-tissue loss, leg-length discrepancy and
irreparable ankle joint damage. Several methods of treatment
have been described: Amputation, debridement and resection
of bone followed by vascular muscle transfer and bone grafting,
bone grafting followed by internal fixation and bone transport
with external fixation. These techniques can take a long time and
have sometimes unpredictable results and many complications.
-ETHODS
The Protocol of Reconstruction included two surgical steps, 1st
Step: Radical debridement, cultures and antibioticotherapy, bone
stabilization, soft tissues coverage, acute bone shorthening
and limb lengthening with external fixator to equalize the limb
discrepancy and ankle arthrodesis. The 2nd Step was early
exchange the external fixator to LCP Plate for stabilization of
callotasis and arthrodesis with decrease the EFI (External Fixator
Index) to 0,5 month/cm.
Podium
FIXATOR ASSISTED INTERNAL FIXATION FOR ACUTE BONY
&%-/2!,$%&/2-)49#/22%#4)/.3
0RINCIPAL!UTHOR Oleksak, Milan, MD
CENTRE Gloucester Royal Hospital
COUNTRY United Kingdom
2ESUME
The acute correction template has been developed for
multiplanar deformity corrections, with or without lengthening,
using a monolateral external fixation system such as the limb
reconstruction system (LRS). Pin placement is achieved by
marrying the template with the particular deformity in all planes,
so that after the osteotomy the fragments can be manipulated
to permit application of the LRS rail system, allowing acute and
precise femoral deformity correction.
This concept has been useful in correcting multiplanar
deformities intra operatively. It is followed by internal fixation
and removal of the external fixator at the end of the procedure.
The technique simplifies complex procedures, following careful
pin placement. The fragments are compressed and the axis
checked before definitive internal fixation.
35 patients were treated between 2003 and 2009, and reviewed
following acute correction of femoral deformities. The procedure
was assisted temporarily with the LRS template and rail system.
All osteotomies united within the expected timeframe of 12-16
weeks. The alignment was restored accurately (< 5 degrees) in
all but two of our earlier cases.
2ESULTS
Between 2005 and 2009, we perform reconstructive procedures
in 25 patients, 8 months of follow up, the mean size of bone
defect was 6 cms (4-15), the average use external fixator
3 months with EFI index 0,5. Patient age average 26 years,
complications 10%. All cases had successfully arthrodesis with
recover functional walk without pain or instability.
#ONCLUSIONS
The goals of treatment were independent function without ankle
pain, don’t significantly limb discrepancy; all patients qualify
how successfully treatment, preferred the reconstruction versus
amputation, 60% had excellent and 40% good results. We
recommend this proceeding in patients with several damage of
ankle joint and distal Tibial Pilon Fractures; it’s safe, reliable and
successful method.
This study confirms potential advantages in terms of a
decreased time of external fixator. Additional controlled trials are
needed to clarify the appropriate indications for this Protocol of
Reconstruction.
,EVELEVIDENCE
Level IV Therapeutic
123
Podium
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2%42/'2!$%).42!-%$5,,!29.!),).'
0RINCIPAL!UTHOR De Pablos Fernández, Julio, MD
CENTRE Hospital San Juan de Dios
AUTHORS Bravo Corzo, Flavio, MD
CENTRE Hospital San Juan de Dios
COUNTRY Spain
/BJECTIVE
To study and put forward this corrective treatment alternative
in angular deformities (AD) of the mid and distal femur and
compare it with other methods.
-ATERIALANDMETHODS
The cases of 31 mid-distal femoral AD in 31 patients aged
between 14 and 42 were evaluated. There were 8 varus (VR)
AD, 10 valgus (VL), 4 flexion (FL) and 10 combined in 2 planes.
An associated rotational deformity was detected in 6 cases.
In 2 cases, the cause of the deformity was non-union. The
corrections were all acute and mean follow-up was for 26
months (47-18). A classic IM nail was used with retrograde
application in all cases.
2ESULTS
Opening-wedge osteotomy was used in the majority of cases
(26) and with no graft (28 cases). The acute correction was
performed without difficulty in all cases and there were no
incidences of treatment-related vascular/nerve damage. We
managed to improve the epiphyseal-diaphyseal angle in all the
patients but in 4 cases the correction was insufficient (outside
normal range). The patients were able to lead a normal life in an
average of 4 months post surgery.
The most common complication was transitory pain and
stiffness in the knee due to protrusion of the nail (5). The IM nail
has been removed in 15 cases, this procedure being the most
difficult part of the treatment.
$ISCUSSION
One of the main advantages of this method is the alignment
achieved between the intercondylar notch and the anatomical
axis of the femur, as this helps make the correction more
accurate. Other advantages are the position of the patient during
surgery, the option of using ischaemia in the intervention, the
smaller incision and the lack of conflict with the fascia lata.
Additionally, for osteotomies in the distal femur, the fragment
control offered by the retrograde IM nail is far better than that of
other means of synthesis.
The greatest disadvantage is the invasion of the knee joint and
this technique is also more demanding than others as there is
no room for error.
#ONCLUSIONS
The technique we are presenting is an effective method which
has added benefits with respect to other more conventional
methods in the treatment of AD of the distal femur. Long-term
follow-up is still lacking, in particular to evaluate knee function
after this treatment.
124
Podium
42%!4-%.4/&,)-",%.'4(%.).'!.$!8)!,$%6)!4)/.3
0RINCIPAL!UTHOR Salameh, Ghassan, MD
CENTRE Center for Limb Lengthening and Reconstruction
AUTHORS Schmidt, Michael, MD
CENTRE Center for Limb Lengthening and Reconstruction
COUNTRY Syria
2ESUME
For the treatment of limb lengthening and correction of axial
deviations a special external hinge distraction system has been
developed, which allows the combined Treatment of congenital
and acquired complex deformities of lower and upper limbs.
Since 1995 to 2009 this new system was used in 450 patients
with deferent indications in the lower limbs they presented with
limb length discrepancies and axial deviations.
The External Fixation Hinge System/SLDF1; Salamehfix 1/; is an
arch hinged system consists of arches with a various diameters
and perimeters, to assemble the deferent sizes of the limb
in the upper and distal part with connecting special hinges,
deferent sizes of arcs to choose a special size for each patient
with keeping an excellent technical functions; multiplanar
multidirectional corrections; makes the fixator more suitable to
each patient in size and allows the patient to move his joints
freely, Stable fixation because of insertion wires and screws
in nearly right angels, the insertion of wires and half pens in a
minor painful regions makes the tolerance to the fixator is more
acceptable. X- Ray control is easy. Complications where mostly
superficial pin infections. No nerve or vascular injuries.
The new developed hinges are easy to use and allow the
treatment of complex deformities with lengthening.
Podium
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0RINCIPAL!UTHOR Fernando Mena, Luis, MD
CENTRE Hospital San Rafael de Itagui
COUNTRY Colombia
2ESUME
Fixator-assisted nailing (FAN) is a Technique described en 1997
for the doctors Paley and Hesemberg. This technique is used
in patients requiring femoral or tibial osteotomy to correct
malalignment secondary to malunion or congenital deformities,
genu varus or valgus of different etiologies, and consists of
placing provisional external fixation during surgery which aims
to maintain stable osteotomized segments, attend angular
correction and facilitate the passage of the intramedullary
nail, In the present study was performed 28 osteotomies in
26 patients (14 women, 12 men) achieving the realignment
of anatomical and mechanical axes in all cases with excellent
results.
Podium
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$%&/2-)49#/22%#4)/.
0RINCIPAL!UTHOR Luzzi, Richard, MD
CENTRE Hospital Universitario Cajaru
AUTHORS De Paula, Lucio, MD; Mariuba, Eduardo, MD
CENTRE Hospital Universitario Cajaru
COUNTRY Brazil
2ESUME
Fixator assisting nailing (FAN) is a technique used for acute
deformity correction, helping to facilitate rehabilitation,
minimizing morbidity of external fixator during bone healing. We
analyzed retrospectively charts of 12 patients (13 segments)
submitted to distal femur correction using FAN from February
2009 to January 2010. In all of them, CORA was located at
metaphysis or epiphysis, and deformities were secondary to
rickets, polio or post-trauma, in adult patients (18 to 26 years
old). Initial averages were for angular deformity 20.97º±7.71º,
and for translation 8,14mm±15,46mm. Half pins, manually
inserted parallel to posterior cortex, two proximally and two
distally to a metaphyseal percutaneous osteotomy, to not
interfere with insertion of retrograde femoral nail (DFN®,
Synth es-USA; CentroNail Supracondilar®, Orthofix-Italy) after
acute deformity correction. To temporarily stabilize correction,
a modular external fixator was used (Large External Fixator®,
Synthes-USA; PreFix®, Orthofix-Italy). X-rays were taken right
after nail insertion and ex-fix removal, and averages were for
angular deformity 0.84º±2.47º (P<0.001), and translation 1,15
mm±2,82 mm. After bone healing, averages were for angular
deformity 2.85º±4.11º (P<0.001 when compared with initial
deformity and P>0.05 when compared with post operative
deformity), and translation 1,23 mm±2,8 mm. All osteotomies
healed and no infection was observed. In conclusion, FAN is
a very precise method for acute deformity correction in distal
femur, and nails were able to maintain correction until bone
healing occurs.
125
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PROFESSIONAL GRAPHIC SOFTWARE (CORELDRAW GRAFHIC
SUITES X 4)
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OF THE HIP WITH A HYBRID DISTRACTOR AND TOTAL HIP
2%0,!#%-%.4
0RINCIPAL!UTHOR Thaller, Ph, MD
CENTRE Clinical Center University of Munich
AUTHORS Weidert, S, MD; Delhey, P, MD
CENTRE Clinical Center University of Munich
COUNTRY Germany
0RINCIPAL!UTHOR Craveiro-Lopes, Nuno, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
AUTHORS Escalda, Carolina, MD; Villacreses, Carlo, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
COUNTRY Portugal
)NTRODUCTION
Preoperative planning for lower limb deformity correction
surgery should be exact, but also simple and quick to realise.
It used to be performed manually on long standing radiographs
with the help of a pencil, transparent goniometer and a long
ruler. Simulations for corrective cuts and osteotomies are usually
made by coping the radiographs on tracing papers and making
the required cuts and corrections on these papers. The digital
radiographs and powerfull computers allow more and more
digital planning and measurements of complex deformities of
the lower limbs. Digital planning software is expensive and not
available in most hospitals.
)NTRODUCTION
Treatment of late neglected hip dislocation on the adult patient
has a difficult solution. Generally it is accepted that the best
results are obtained when the total hip replacement (THR) is
fitted on the original acetabulum.
-ETHODS
In this study, a comparison was made between the conventional
planning method and the digital planning method whit
professional graphics software (CorelDRAW Graphics Suite X4;
Fremont, CA; USA) in 7 patients. The accuracy and the time for
planning were evaluated. A statistical analysis was performed
using ANOVA.
2ESULTS
The digital planning method had equal results to the
conventional method. The time for planning was shorter in digital
planning, in comparison to conventional planning, especially in
case of errors.
$ISCUSSIONANDCONCLUSION
We offer an exact digital planning method angle and length
measurement, analysis of deformity, estimation of CORA,
simulating osteotomies or simulate nailing with commercial
available professional graphics software (CorelDRAW Graphics
Suite X4). Because of digital planning we can achieve a more
precise planning. Errors can be corrected fast and convenient
without new drawing. Digital data storage is possible.
When more than 4 cm of overriding exists, diaphyseal resection,
reconstruction of the proximal femur, grafting of the acetabulum
and THR fitting, is the standard treatment.
Since this kind of treatment leads to a leg length discrepancy
and is technically difficult, we develop a treatment protocol
including a first stage of hip distraction utilizing a hybrid Ilizarov/
monolateral distractor, allowing the fixation of two pair of heavy
pins on the supra-acetabular region, two anterior and two
posterior to the greater trochanter and two pair on the distal
femur, obtaining this way a much more stable fixation, which
permits a smooth hip distraction in a ambulatory basis.
-ATERIALANDMETHODS
From 2002 to 2007 we have treated 7 female patients
presenting neglected hip dislocations by congenital, septic
or necrosis sequel, which were never treated before. 5 were
Caucasians, 45 to 51 years old from Portugal and two Black, 17
and 24 years old from Angola, Leg length discrepancy was 4 cm
to 6.8 cm.
Treatment protocol included a Girdlestone type procedure and
fitting of the hybrid Ilizarov/monolateral distractor. Then patient
began gradual distraction in a ambulatory outpatient way, until
the tip of the greater trochanter reaches the acetabular level.
Then, the frame was removed and after 15 days in bed traction
a standard Corail-Duraloc THR with HAC coating and ceramicceramic interface was fitted.
Distraction period was 21 to 48 days and follow up is mean 6
years (3 to 8 years).
#ONCLUSIONS
This methodology allowed on those 5 cases the precise
correction of the leg length discrepancy, with the fitting of a
standard THR on the original acetabulum, without technical
difficulties or complications, namely neurological, infection or
loosening of the implant.
126
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#/-0!2!4)6%345$9"%47%%.&%-/2!,/34%/4/-9!.$
ARTHRODIASTASIS
0RINCIPAL!UTHOR Craveiro-Lopes, Nuno, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
AUTHORS Escalda, Carolina, MD; Villacreses, Carlo, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
COUNTRY Portugal
2ESUME
The authors compare the results of a group of 7 patients treated
by arthrodiastasis with an Ilizarov frame (ADT) with a group of
11 patients treated by femoral intertrochanteric osteotomy of
triple effect (OTM), stabilized with plate and screws.
The ADT group was treated between 2000 and 2008 and
consisted of 6 male and one female. The mean follow-up was
4 years. OTM group consisted of 10 boys and 1 girl and was
intervened between 1979 and 1989, having a mean follow up of
6 years.
To proceed to arthrodiastasis, we used a a frame with 2 Ilizarov
arches fixed with 4.5 mm pins, respectively in the supraacetabular and proximal femur zones, maintaining an articular
distraction of 8-10 mm during an average of 3 months. The
technique of intertrochanteric osteotomy, included an effect
of varus, flexion and medial rotation of the proximal segment,
stabilized with a T profile children plate (Synthes@).
This comparative study between 2 homogeneous groups of
patients with the same type of injury treated by intertrochanteric
osteotomy or arthrodiastasis, showed with evidence data based
that the ADT group:
s0RESENTEDSLIGHTLYBETTERRESULTSBUTNOTSTATISTICALLYSIGNIlCANT
with regard to congruence and joint deformity, sphericity of
the head and neck length.
s3HOWEDSIGNIlCANTLYLOWERRESIDUALSEQUELAEWITHRESPECTTO
the existence of varus deformity and leg length discrepancy.
s(ADSIGNIlCANTLYBETTERFUNCTIONALOUTCOMEASSESSEDUSING
the Harris Hip Score.
s5NLIKETHE/4-GROUPSHOWEDNOCOMPLICATIONSORSEQUELAE
requiring new interventions in the short or medium term.
s4HESURGICALPROCEDUREWASSIGNIlCANTLYFASTERHADNOBLOOD
loss, patients started walking with weight bearing significantly
earlier and did not required a second surgery for hardware
removal.
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OPERATIVE CORRECTION OF ACETABULAR DYSPLASIA USING
),):!2/6&2!-%).#(),$2%./&3#(//,!'%
0RINCIPAL!UTHOR Tyoplenky, Michail, MD
CENTRE Russian Ilizarov Scientific Center
AUTHORS Makushin, Vadim, MD
CENTRE Russian Ilizarov Scientific Center
COUNTRY Russian Federation
0URPOSE
To study the efficiency of transosseous osteosynthesis
application in children of the school age with hip dysplasia.
-ATERIALSANDMETHODS
We analyzed treatment results of 63 children (68) joints aged
from 7 to 16 years with acetabular dysplasia. The disorder of
articular relations was diagnosed in all observations. In 18 joints
marked incongruence of articular surfaces caused by their
deformities was noted.
Ilizarov fixator was used in all patients undergoing reconstructive
operations. In the majority of the cases the following re-orienting
operations was performed for acetabular correction: L-shaped
osteotomy of the iliac bone 923 Joints), double pelvic osteotomy
(4 joints) and triple pelvic osteotomy (34 joints). Peri-acetabular
osteotomy was carried out in 7 cases due to incompatible size
of the head to the volume of acetabulum. Additional invasion in
proximal femur was produced in 49 observations.
$ISCUSSION
Results were followed at the intervals from 1.5 to 8 years.
Clinical evaluation according to Colton criteria was as follows:
good result (13-15 points)-43 joints, satisfactory ones (10-12
points)-20 joints, poor outcomes (less than 10) were in 5 joints.
The joints were distributed according to CSeverin criteria as
follows: II type-56 joints, III type-9 joints, IV type-3 joints. In there
joints the signs of III grade arthrosis according to Tonnis were
revealed. The ration of good results made up 63.2% and the
poor ones was 8.8%.
#ONCLUSIONS
The application of transosseous osteosynthesis technologies
allows to extend up to certain range the indications for
reorienting reconstructive operations, to provide sufficient
mobility of the acetabular fragment without increase of technical
complexity and invasiveness and to create the conditions for
adaptation of the articular surfaces after restoration of articular
relations.
127
128
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EPIPHYSIS IN ADOLESCENTS
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,%''#!,6%0%24(%3$)3%!3%
0RINCIPAL!UTHOR Tropin, Vasily, MD
CENTRE Russian Ilizarov Scientific Centre
COUNTRY Russian Federation
0RINCIPAL!UTHOR Tropin, Vasily, MD
CENTRE Russian Ilizarov Scientific Centre
COUNTRY Russian Federation
2ESUME
Based on the principles of controlled transosseous
osteosynthesis original Ilizarov techniques have been developed
for treatment of slipped capital femoral epiphysis at the
Russian Ilizarov Centre. Application of the approach provides
mechanical and biological conditions to optimize reparative bone
regeneration and the possibility for gradual transformation in the
pathological nidus of femur to regain normal anatomical shape,
size and spatial position of femoral head and neck. The practice
is differentiated according to stages of pathological process,
degree of displaced epiphysis and sort of the relationship
between the epiphysis and the neck. The technique devised
for SCFE early stage with displaced bone and no stable union
includes closed epiphyseal reduction, transacetabular fixation
followed by correction in distal femur to achieve normal
anatomical relationship between femoral head and neck. Then
external fixation device is mounted to unload the hip with
femoral head and neck diafixed. Application of the techniques
allows us to produce accurate reduction of severely displaced
femoral fragments and keep the bone in a complete contact until
stable consolidation achieved, and therefore, restore hip function
and prevent early coxarthrosis. In case of SCFE sequelae with
rigidly malunited femur the practice facilitates consecutive
procedure of breaking femoral neck by closed osteosclasia,
reducing the bone, gradual distraction to obtain normal cervical
size followed by stable fixation. For patients with considerable
anatomical femoral shortening correction-elongation osteotomy
can be added to the proximal reconstruction. The technique
provides better anatomical and functional results due to restored
cervical size which is important for normal muscular and
ligament functioning, biomechanics of the hip and elimination
of anatomical limb shortening. Thirty-seven patients aged
from 12 to 16 years were treated for slipped capital femoral
epiphysis at RISC RTO between 1999 and 2009. Excellent and
good results were obtained at early stages of the disease;
the femoral neck was lengthened from 1.0 cm to 3.0 cm in 6
patients. No poor outcomes were observed at eight-year followup. The techniques proposed have shown to be effective in the
treatment of SCFE cases providing restoration of the hip function
and prevention of early coxarthrosis and can be recommended
for clinical practice.
2ESUME
A complex system for the treatment of patients with LeggCalve-Perthes disease has been developed at the Russian
Ilizarov Scientific Centre “Restorative Traumatology and
Orthopaedics” (RISC RTO). The scheme includes the procedure
aimed at simultaneous restoration of the bone structure
and orthopaedic status of a patient in conditions of guided
stimulation of reparative processes using both the direct
mechanical stress applied at the pathological site and the
current medication therapy. The system includes controlled
decompression of the hip joint using external fixation device and
gradual stage-dependent mechanical stress at the pathological
site combined with timely differentiated medication- and
physiotherapy administered solely or in a combination. A course
of myorelaxants, bone resorption inhibitors, angioprotectors
and biostimulators is prescribed at a strictly defined stage.
Physiotherapy mostly conducted along with biostimulator
course includes intermittent application to autonomic ganglion
of the lumbar spine and pelvis and trochanteric muscles. The
system has been shown to be most effective in early stages
of Perthes disease with the possibility to both get the whole
pathological process arrested, the patients completely recovered
and interrupt the known stages thus leading to reduced period
of medical rehabilitation of the patients. Sixty-seven Perthes
patients (79 hips) aged from 4 to 12 years were treated at RISC
RTO between 1997 and 2007 using the proposed scheme.
There were 51 boys and 16 girls with bilateral involvement in
12 cases. Twenty-four hips had stage I-II, and 55 had stage
III-IV. The average length of treatment was 103±10 days. All
the patients showed a strong tendency to normalising bone
structure at the nidus and restoring anatomical spherical shape
of the femoral head and relationship in the hip joint at the end of
the treatment. Eighteen patients had stages of the pathological
process eliminated which meant the transition from the stage of
impression fracture to healing stage.
The results of treatment have been followed up from 1 to 10
years with 19 observations assessed as excellent, 41 good and
7 fair outcomes. The system has proved to be effective for the
treatment of patients with Legg-Calve-Perthes disease.
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4%#(.)15%&/20!4)%.437)4(/54#/-%3/&0%24(%3
DISEASE
0RINCIPAL!UTHOR Tropin, Vasily, MD
CENTRE Russian Ilizarov Scientific Centre
COUNTRY Russian Federation
2ESUME
Treatment of patients with outcomes of Perthes disease
remains a complicated clinical issue due to a high incidence
of the untreated and/or maltreated condition and delicacy of
orthopaedic evidence. The condition can also lead to early
coxarthrosis followed by stable disability and a need of
arthroplasty of the involved joint. A treatment technique for
aseptic necrosis of the femoral head accompanied by the
proximal femur deformity patients has been developed at the
Russian Ilizarov Scientific Centre “Restorative Traumatology and
Orthopaedics” (RISC RTO). The practice includes decompression
of the hip joint using external fixator combined with the medial
shift of the distal fragment and correction maneuver of the
proximal femoral fragment following intertrochanteric osteotomy
and correction-lengthening osteotomy of the shaft. The
technique has shown to be effective for patients with outcomes
of Perthes disease. The technology was applied to treat 23
patients aged from 14 to 18 years at RISC RTO. The patients
reported limping, limited motion in the hip joint, abduction in
particular, pain and short limb. Considering an average length
increase of 3 cm the treatment period was 9810 days.
Radiographs exhibited better relationship between the femoral
head and acetabulum, with the proximal femur being in a more
favourable functional position on discharge. Clinically the pain
was arrested, range of motion increased by 150-200 in the hip
joint including abduction. The patients showed good alignment
in the lower limb and no limping. Long-term results were
followed up from 3 to 10 years. The achieved result persisted
in 21 cases; two patients developed coxarthrosis degree I, II at
eight -and nine- year follow-up. The technique is performed in
a differentiated manner depending on severity of the deformity
components and amount of femoral shortening and allows us to
prevent secondary deformity of the femoral head and improve
anatomical and functional results of treatment due to alignment
and limb length equalisation.
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0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszanne Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez
Pujay, Edilberto, MD; 5Lamas Calderón, María Caridad, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios; 5Instituto de
Medicina Legal
COUNTRY Peru
/BJECTANDPURPOSEOFTHESTUDY
Disease characterized by ischaemia of the femoral head, whose
etiology is unknown at this time. There is no defined treatment
of the disease. The femoral head deformity occurs during the
phase of fragmentation. The evolution of the disease is variable
in patient groups, a large group of patients untreated evolve
with a functional hip, another group evolves with painful, little
functional hip and deformation of the femoral head. There is no
consensus on the classification of this disease.
Purposes of giving a better quality of life and have an option of
treatment with observation bases biomechanical, physiological
and biological proposes and performs artrodiastasis
femoroacetabular in the disease of Legg-Calvé Perthes.
-ETHODSANDMATERIALS
8 patients are included with the diagnosis of disease of LeggCalvé Perthes, between 2006 and 2009. Treatment indications
are functional limitations for ambulation and deformation. They
were the following:
s!RTRODIASTASIS
s3PLINTINGBRACING
s3OFTTISSUE4ENOTOMIAADDUCTORANDPSOAS
s2ELEASEDISTRACTIONUSINGMONOPOLAREXTERNAL&IXERWITHHYBRID
articulation: distraction 0.5 mm twice a day (1 mm per day) until
that line Shenton is 1 cm less than its normal level. The fixative
is left for 6 months on average.
$ISCUSSION
Presented pain handled with analgesics in all distraction during
was 15 to 25 days. 8 Patients were male, between 8 and 15
years of age. All classified in Group 4 of the classification of
Caterall and Herring C. Artrografia and release of soft tissue was
conducted. Tracking patient between 10 and 24 months, with an
average of the fixer time was between 6 months and 8 months.
In all cases the range improvement is evident articulate.
#ONCLUSSIONS
The treatment of the Region is based on the containment of the
femoral head in the acetabulum to decrease the pressure in this.
Artrodiastasis to not let pass the ischemic combines a
mechanical loads is appropriate treatment until the femoral head
reconstituya.
It is a procedure more smoothly by the environment, and the
patient can attend the school or be immersed in its activities.
129
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0RINCIPAL!UTHOR Raza, Hasnain, MD
CENTRE Aga Khan University
AUTHORS Rashid, Haroon Ur, MD; Umer, Masood, MD
CENTRE Aga Khan University
COUNTRY Pakistan
"ACKGROUND
Instability of the hip joint can be secondary to congenital
pathologies like dysplatic dislocated hips (DDH) which are
neglected and proximal femoral focal deficiency or acquired
such as sequelae of infective or neoplastic process. An unstable
hip is usually associated with loss of bone from the proximal
femur, proximal migration of the femur, lower-extremity
length discrepancy, abnormal gait, and pain. In this study we
report our results in the treatment of the unstable hip joint
by hip reconstruction osteotomy using the Ilizarov method.
This includes an acute valgus and extension osteotomy at the
proximal part of the femur combined with gradual distraction for
realignment and lengthening at a second, more distal, femoral
osteotomy.
/BJECTIVE
To review our clinical results of hip reconstruction osteotomy by
Ilizarov method for unstable hip joint.
-ETHOD
We performed a retrospective review of a series of 16
consecutive patients who underwent hip reconstruction
osteotomy for unstable hip at The Aga Khan University Hospital,
Karachi between May 2005 and July 2008. Six males and 10
females were operated with an average age of 18.1 yrs at
time of surgery. Seven left sided hips, eight right sided and one
bilateral were operated. They have various etiologies, six hips
were diagnosed as neglected dysplatic dislocated hips (DDH),
six were sequele of septic arthritis, 2 had history of tuberculous
arthritis and one case of Giant cell tumour of proximal femur
and proximal femoral focal deficiency each. Outcomes were
evaluated clinically and radiographically. The clinical evaluation
included gait analysis and the use of a modified Harris hip score.
2ESULTS
At the time of follow-up, at a mean of 18 months, the post
operative Harris hip score was significantly improved as
compared to preop. All extremities were well aligned. Details of
results will be presented later.
#ONCLUSION
The Ilizarov hip reconstruction can successfully correct a
Trendelenburg gait and simultaneously restore knee alignment
and correct lower-extremity length discrepancy.
130
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FIBULAR TIBIALIZATION ACCORDING TO ILIZAROV IN THE
PATIENTS WITH ACUTE TIBIAL SHAFT DEFECTS
0RINCIPAL!UTHOR Martel, Ivan, MD
CENTRE Russian Ilizarov Scientific Center restorative
Traumatology and Orthopaedics
COUNTRY Russian Federation
2ESUME
During the last decades frequent technogenic and natural
disasters, as well as local military conflicts and wars led to the
sharp increase of the open and gun-shot limb injuries incidence
with considerable destruction and defects of the tissues.
The purpose of this study is to show the possibilities of Ilizarov
transosseous osteosynthesis in the management of severe tibia
tissues destruction that allows us to produce radical surgical
debridement of the soft tissue and bone wounds creating
“comfortable” conditions to fill in the tissues defects using
fibular transposition within one stage of treatment.
-ATERIALSANDMETHODS
We’ve analyzed treatment experience according to Ilizarov of
15 patients aged from 10 to 63 years with severe open tibial
injuries combined with sub-compensated ischemia of the tibial
and foot tissues.
Tibial defect in 12 cases has formed after debridement of
crushed and dead tissues of tibia and primary defect has
formed only in 3 cases either at the moment of trauma or
during transportation. 10 to 22 cm tibial defect has formed in all
patients after debridement combining with fibular fracture at one
or two levels and sub-compensated trophic disorder of tibia. We
applied Ilizarov tibial frame with transposition of one (11) or two
(4) cylindrical fragments of fibula into area of tibial shaft defect
depending on the level and number of fibular fracture.
$ISCUSSION
Fibular fragments were transported gradually according to
Ilizarov principles, without its exposure and dissection, in
all cases of subtotal defect of tibia. Transposition of fibular
fragment lasted from 14 to 36 days, up to the docking with tibial
fragments. Further fixation up to achieving tibial integrity took
from 2.5 to 3.5 months at the proximal docking site, and from 3
to 4.5 months at the distal one. Timing of osteosynthesis made
up from 7 to 10.5 months.
Positive treatment outcomes were obtained in all clinical cases
of above techniques application.
#ONCLUSION
The analysis of subtotal tibial defects filling outcomes when
transosseous osteosynthesis was applied confirms the necessity
of more reserved attitude to the tibial amputation in such cases.
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FRACTURES OF THE TIBIAL PLATES TREATED WITH HYBRID
FIXATION (ORTHOFIX) IN THE HOSPITAL CALDERÓN GUARDIA,
CAJA
0RINCIPAL!UTHOR Castro Rivera, Luis Alfonso, MD
CENTRE Sociedad Latinoamericana de Fijación Externa
AUTHORS Valverde Retana, Alexander, MD
CENTRE Sociedad Latinoamericana de Fijacion Externa
CoUNTRY Costa Rica
2ESUME
It’s a restrospective study that took place at Hospital Calderón
Guardia, which belongs to the Caja Costarricense de Seguro
Social in San José, Costa Rica. 12 cases were compiled and
were followed for 2 years (medical file) and the age range
was between 20 and 32 years old with pain according to the
analog visual scale of 10 and with previous pathologies of
evolutionary hip dysplasia, Perthes disease and luxations of
the hip or fractures. A Girdlestone procedure was performed
on them (redirection of the femoral head) and placement of a
hip arthrodiastasador (Orthofix) for 12 weeks, allowing support
on the third day and following the progress every 15 days
evaluating the arcs of movement and the pain as the patient
evolves with time.
The results presented in these cases: pain, hip movement,
complications, etc.
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34 CASES OF SEVERE OPEN FRACTURES OF THE LEG. 28
9%!23/&-/.)4/2).'
0RINCIPAL!UTHOR Aybar Montoya, Alfredo, MD
CENTRE Universidad San Marcos
COUNTRY Peru
/BJECTIVEANDPURPOSE
Show the results of “very serious” open fractures in the leg
reconstructed with external fixation.
-ATERIALANDMETHODS
34 cases were operated since 1981 to 2001. Four women
and 30 men. The ages ranged between 15 and 75 years
(mean 11.31). None was treated in the acute (within 12 hours
post injury). The characteristics of the lesions were classified
according to a model different from the Gustilo-Anderson model.
In the classification the fracture pattern was crisscrossed with
the characteristics of soft tissue damage. The external fixation
technique was a quadrilateral framework (Vidal). Sixteen
were treated as axial compression and 13 as osteogenesis by
distraction.
$ISCUSSION
Open leg fractures considered “very serious” are commonly
referred to as “III-B or III-C according to Gustilo-Anderson,
however, sometimes the fracture pattern is not always complex,
being in these cases, better prognosis than those which have
severe comminution, including bone loss, and vice versa,
also the soft tissue damage is not always as severe. The
classification served to clarify the risks and complications on
regard to the procedures of reduction and bone fixation, and the
achievement of coverage. For all fracture patterns and grades of
injury, the disposable external fixation method was sufficient.
#ONCLUSIONS
From the 34 fractures, one patient was attended after 18 hours
of the accident in a state of distal ischemia, and ended in
amputation. Sixteen patients were offered an “early therapeutic
amputation” and was accepted only by four. The 29 patients
followed the protocol reconstruction. A patient of 75 years,
cured, died five years later. All consolidated between 8 and
29 months, mean 13.96 months, without infection, without
deformities. Fourteen remained with shortening, two with
three centimeters, six with two centimeters, and six with
one centimeter. Ten cases in shortening then continued their
elongation, three cases of transportation. Eleven cases with
dysfunction ankle. In none was made micro-vascular free flaps.
Currently, 28 patients, even scarred are working in different jobs
and are totally satisfied with their rebuilt legs.
131
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(9"2)$&)8!4)/.).-!.!'%-%.4/&#/-0,%8&2!#452%3
USING ILIZAROV & FLEXIBLE NAILS
0RINCIPAL!UTHOR Sen, Cengiz, MD
CENTRE Gaziosmanpasa University
AUTHORS Gunes, Taner, MD; Erdem, Mehmet, MD; Bostan, Bora,
MD; Asci, Murat, MD
CENTRE Gaziosmanpasa University
COUNTRY Turkey
0RINCIPAL!UTHOR Rady Abdallah, Yehia, MD
CENTRE National Medical Institute In Damnhour
COUNTRY Egypt
)NTRODUCTION
Medial laxity may be associated with varus gonarthrosis. In
knees with varus gonarthrosis, medial laxity contributes to the
progression of arthrosis thus it is recommended to manage
medial laxity during the course of correction of the alignment
of the lower extremity. In the present study we report the shortterm results of opening focal dome osteotomy in the treatment
of varus gonartrosis associated with medial laxity.
-ATERIALANDMETHODS
17 knees of 16 patients with varus gonarthrosis associated with
medial laxity (15 female, 1 male; mean age 51.6 year) were
managed with opening focal dome osteotomy. Alignment of the
lower extremities and medial laxity were evaluated before and
after the operation. Besides patients were evaluated clinically by
Knee society knee scores (KS) and Hospital for Special Surgery
(HSS) knee scores.
2ESULTS
Mean follow up was 27 months (range 12-44 months).
Postoperatively average 13.8±3.3º of mechanical femuro-tibial
ANGLEM&4!CORRECTIONWASACHIEVEDP!VERAGE
preoperative mechanical varus was 9.9±3.1º whereas the mean
POSTOPERATIVEMECHANICALVALGUSWAS¢ŽP
Average 2.6±1.2 mm reduction in medial laxity was detected.
Preoperative joint line convergence angle (JLCA) with a mean of
6.2±1.7º° was reduced to 3.2±1.1º postoperatively which was
STATISTICALLYSIGNIlCANTP0REOPERATIVE+3KNEESCORE
and function score was 49±9 and 44±11 respectively wheraes
postoperative these values was 89±6 and 84±8 respectively.
These values represents an average of 40±12 improvement
P0REOPERATIVEANDPOSTOPERATIVE(33SCOREWAS
61±8 and 88±7 respectively representing an average of 27±11
IMPROVEMENTP
#ONCLUSION
Medial laxity is observed in majority of patients with varus
gonarthrosis. Opening focal dome osteotomy can achieve a
correction in the mechanical alignment and also decreases
medial laxity effectively.
132
2ESUME
The complex fractures usually represent problems in their
management, the use of Ilizarov external fixator is the most
reliable procedure, however the difficulty in: controlling
comminuted shattered long bone segment, moving a bone
segment for a long distance in fracture with segmental bone
loss, reducing and maintain neglected displaced and unstable
fractures, and in providing rigid stable frame in severely porotic
and infected bone still in need for augmentation.
The use of Ilizarov external fixator in addition to malleable intramedullary nails “hybrid fixation” probably represents a solution.
The objective is to investigate the reliability of this new hybrid
fixation.
The material of this work include 34 cases of them 18 cases
comminuted shattered long bone segment, 4 cases with
segmental bone loss, 9 cases with neglected displaced and
unstable fractures, and 3 cases severely porotic and infected
bone. All cases were fixed by malleable intra-medullary nails
under the control of the image intensifier in addition to the
Ilizarov frame.
The results obtained were satisfactory in all cases, the shortest
time for union was 12 weeks and the longest was 28 weeks
with average 18.3 weeks. Bone marrow injections were needed
in 6 cases to enhance union. Rod migration from bone was
occurred in one case. The pre-bended rod penetrated the skin in
one case during segment transportation, and this necessitates
rotation of the rod to redirect the distal end.
The use of intra-medullary rods preserve bone alignment in
comminuted segmental fractures, it is a good guide on which
we can transport a bone segment for a long distance, it reduce
the number of rings needed for stable fixation, and allow early
removal of the frame.
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ILIZAROV FIXATOR
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0RINCIPAL!UTHOR Saied, Almohamady, MD
CENTRE Azhar University
AUTHORS Elbatrawy, Yasser, MD
CENTRE Azhar University
COUNTRY Egypt
0RINCIPAL!UTHOR Aloj, Domenico, MD
CENTRE Sosd Patologia Traumatica Del Bacino E Fissazione
Esterna (dr. Renè Negretto)-Cto Torino
AUTHORS Santoro, Daniele, MD; Désayeux, Selena, MD;
Petruccelli, Eraclite, MD; Biasibetti, Antonio, MD
CENTRE Sosd Patologia Traumatica Del Bacino E Fissazione
Esterna (dr. Renè Negretto)-Cto Torino
COUNTRY Italy
2ESUME
Segmental Fracture of the tibia is one of the most challenging
fractures in their treatment options, and there are many factors
that contradict the use of standard options of treatment as
biological plating or nailing. Seventeen patients with segmental
fractures of their tibiae, 16 males and one female with mean
age of 41.7 years were managed by closed reduction under
image intensifier and fixed by Ilizarov fixator. The fixation of
fracture was stable that allows a range of joint motion, and
early weight bearing as tolerated. The mean healing time was
26.7 weeks, and there was only one re-fracture at distal site
due development of osteomyelitis. The purpose of this work
is to judge reliability, union rate and associated complications
using this technique in management of segmental fractures.
Ilizarov external fixator offers a reliable and a biological method
for management of these difficult fractures especially those
with compromised soft tissues with high rate of union and less
complications than all other treatment options.
0URPOSE
The satisfying results of the treatment of 58 open leg fractures
are due to strictly following the Gustilo 1990 protocol.
-ATERIALANDMETHODOLOGY
Open fractures are a surgical emergency. Life-threatening
injuries must be detected due the frequency of politrauma;
antibiotic therapy, immediate wound debridementand,
stabilization with external fixation are always performed in
emergency. From January, 1, 2006 to december, 31, 2008
58 open leg fractures have been treated according Gustilo
90 protocol. Age 44.7y (14-82).32/52 RTA. 6 cases etiology
not detected. Classification:19 GII, 11 GI, 4 GIII, 5 GIIIA, 2
GIIIB, 4 GIIIC (Total 15 GIII). 13/58 exposition not recorded.
Antibiotic therapy given in all cases but recorded in53/58:
TYCARCILLINECLAVULAMICACIDFORDOTHER
associations 20 for 48.5d (5-90); cyclosporine III 2; 1 treated
in Burn Unit. Fixation always done with ex.fix.: 30 monolateral
orthofix, 24 hoffman, 4 Ilizarov. Emergency fixation changed in
the treatment:18 into Ilizarov, 1 into orthofix.
Plastic treatment, when necessary, always delayed with VAC,
local flap, thin graft, DPS. Free flaps has never been used in
this series. Six bone transports to fill bone loss from 3 to 6 cm.
No autologous bone grafts used in fracture side nor in docking
point. Three dock.p. treated with BPM 7(Osigraft).
2ESULTS
Two amputations in IIIC lesions; 4 lost at fw. 51 healings in 5.7m
(2-15.5). No Cierny 1 and 4 infections; 1 procurvatum>10º late
treated with Ilizarov.
#ONCLUSIONS
Open fracture must be treated according to a standard protocol
followed step by step. Random treatment is not allowed.
Main points are: immediate debridement, antibiotic and
fixation. Ex Fix is the tool of choice for the emergency and final
treatment.
133
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TO RELIABLE RESULTS
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LENGTHENING AND ARTHRODESIS PROCEDURES
0RINCIPAL!UTHOR Chaudhary, Milind, MD
CENTRE Jaslok Hospital
COUNTRY India
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
!IMSOFSTUDY
To report accuracy of correction and pain relief with the Ilizarov
fixator for correction of tibial varus in Medial Gonarthrosis with
an InfraTuberosity Focal Dome High Tibial Osteotomy over the
last 18 years.
!IMANDPURPOSE
To introduce the use of adult mesenchymal stem cells in callus
distraction and arthrodesis procedures to see if they increase
callus formation, decrease distraction time and decrease fusion
time.
0ATIENTSANDMETHODS
132 high tibial osteotomies in121 patients were performed
percutaneously as a distally convex dome below the tuberosity.
13 patients had bilateral osteotomies. Ages ranged from 24
to 73 years. 12 had primary Osteoarthritis and 11 had OA
secondary to a malunited fracture. The mean Pre-Op MPTA was
82º and Mean PreOp Mechanical axis deviation was 4%. PostOp MPTA being 94.2º and Mean PostOp MAD was 65.0%.
-ETHODSANDMETHODOLOGY
60 patients had fusions peformed with external fixation and
adult mesenchymal stem cells and 25 patients had callus
distraction of long bones with external fixation and adult
mesenchymal stem cells. The fusion patients had adult
mesenchymal stem cells placed into the fusion sites and were
compressed and maintained with either a monolateral or circular
external fixator.
2ESULTS
All osteotomies united. Average angular correction achieved was
16.9º (range of 8º to 40º). Follow-Up has ranged from 1 to 17
years.
The callus distraction patients had their corticotomies displaced
acutely 6-7 mm and back filled with adult mesenchymal stem
cells. After 5 days normal distraction of one mm per day was
undertaken.
Average time to union was 14 weeks. 20% patients needed
between 16 to 19 weeks to unite.
$ISCUSSION
With the 60 fusion patients none of them had a delayed or
nonunion. Radiographic and clinical fusion was attained
approximately 20% faster than compared to identical arthrodesis
procedures without adult mesenchymal stem cells.
There were 4 problems related to the proximal fibular osteotomy
which needed repeat ostectomy.
There were no deep wound infections. None had a nerve or
vessel injury or a compartment syndrome. All except 5 patients
had significant pain relief. There was severe intolerance of the
fixator in 2 patients. In 3 patients a significant antecurvation
deformity of 8º, 14º and 18º persisted at the osteotomy site
leading to a poor result and dissatisfaction.
A patello-femoral release was added in 18 of the last 28
patients, for relief of peri-patellar pain.
!DVANTAGES
It is inherently stable and prevents sagittal plane mal-alignment.
The dome Osteotomy allows a large angular correction without
bony resection. It enhances lateral shift of the mechanical axis.
It has a large bony area of contact, leading to reliable union
without the need for bone graft or substitute.
The Ilizarov fixator achieves accurate deformity correction and
can compensate for the Lateral Thrust by overcorrection.
3UMMARY
The Infra-tuberosity Ilizarov High tibial osteotomy gives reliable
pain relief in Medial gonarthrosis over the long term.
134
With the callus distraction patients the total distraction time
and callus formation was 25% faster compared to non adult
mesenchymal stem cells.
#ONCLUSION
The use of adult mesenchymal stem cells in fusion and callus
distraction procedures can accelerate arthrodesis rates,
decrease distraction time and increase callus formation. The
clinical use of adult mesenchymal stem cells will only continue
to prove beneficial in orthopedic surgical procedures.
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&)8!4)/.#/-0,)#!4%$7)4(2%4!2$%$#/.3/,)$!4)/.
0RINCIPAL!UTHOR Salom Ramos, José, MD
CENTRE Orthopaedic Surgeon
AUTHORS 1García Parra, Carlos, MD; 1Salazar Sánchez, 2Joanna,
MD; 3Terrizzi Spadaro, Carmela, MD; 3Orta Martínez, Héctor, MD;
3
Mora Aular, Arelis, MD
CENTRES 1Resident Student; 2Pediatric Physician; 3Orthopaedic
Surgeon
COUNTRY Venezuela
2ESUME
The growing complexity of reconstruction procedures and the
availability of musculoskeletal tissue from human donors, has
promoted the increased use of grafts in orthopedic surgery. It is
important the role played by the physico-chemical and biological
implications of using these materials.
/BJECTIVE
To evaluate the efficacy of percutaneous application of
autologous bone marrow graft (ABMG) in fractures treated with
external fixation with delayed consolidation complicated.
-ATERIALSANDMETHODS
A total of 30 patients with fractures who were treated with
external fixation with delayed consolidation Ortopedica del
Department of Surgery Hospital Universitario “Ruiz y Páez”
Ciudad Bolivar from January 2007 to August 2009. The
technique consisted of taking 10 to 20 cc of ABMG portion
proximal metaphyseal tibia and applied percutaneously under
fluoroscopy on the fracture at 3, 6 and 9 weeks respectively with
regular X-rays of the affected limb.
2ESULTS
Most cases were between 21-40 years of age 66% (20 cases),
the most frequent sex was male 73% (22 cases), the most
frequently affected bone was the femur 57% (17 cases),
followed by warm 23% (7 cases), being the most common
anatomical location was 1 / 3 distal 63% (19 cases), followed
by 1 / 3 half 37% (11 cases). The line of fracture was the most
frequent transverse 53% (16 cases), all cases were treated with
external fixation 100% (30 cases). The number of grafting in
patients with delayed union was mostly 3 times 57% (17 cases),
26% (8 cases) 2 times, 7% (2 cases) was applied only 1 time.
The training time in the fracture callus in patients autograft was
applied in 67% (20) in> 3 months in 26% (8 cases) in 2 months
and 7% (2 cases) only 1 month had callus formation. It was
observed that in 83% (25 cases) consolidation was satisfactory.
#ONCLUTION
The use of ABMG to stimulate callus formation in delayed
consolidation is an effective, technically simple and
advantageous with low cost.
Podium
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0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suzsane Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez Pujay,
Edilberto, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios
COUNTRY Peru
/BJECTANDPURPOSEOFTHESTUDY
Is has a study retrospective, in Clinic Home “St. John of God
Lima-Peru, during the period 1993-2010, studying a total of
253 lower members of diverse etiology discrepancy patients.”
Limb elongation was callotasis with a fixative axial dynamic
monolateral (Orthofix).
-ATERIALANDMETHODS
A total of 253 patients, of which 18 are lengthening (elongation
21 segments), 28 corticalizacion (29 elongated segments) and
207 patients (265 elongated segments) finished treatment are
included in the work. Equivalence between with 132 male and
female with 121. The median age was 15.99 years youngest
2.33 years and largest 61.91 years. Lower limb shortening
causes were diverse, with those of acquired etiology 133 cases
and congenital in 120 cases. He was the elongation femur or
tibia, femur, 117 procedures 94 tibia and 52 cases in the two
femur, tibia. The patients included in this paper presented a
shortening of 61.056 mm average range under 20 mm and over
250 mm.
$ISCUSSION
The duration of the smear was on average 11.51 sem, being the
youngest of five sem and 30 sem largest. Achieved elongation
was 59.5 mm with a range of 20-135 mm. Corticalizacion
was on average 28.81 weeks between 5 and 65 weeks. The
complication more frequent was the superficial infection,
axial deviations, algodistrofia, venous vascular insufficiency,
periostitis, fracture by fall. Some patients underwent surgery as
a result of complications.
#ONCLUSIONS
This procedure allows us to improve the quality of life of
the patient and to optimize their performance in everyday
life, prevents or lower inherent in the limb loss of Member
complications that arise if it is that you are not given treatment
is different.
The procedure is feasible to do this on an outpatient basis, so
home conditions permitting. It is imperative to have permanent
Fisica therapy
+EYWORDS
Autologous bone marrow graft, delayed consolidation, fractures,
external fixator.
135
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BISPHOSPHONATE DURING DISTRACTION OSTEOGENESIS
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0RINCIPAL!UTHOR Yasui, Natsuo, MD
CENTRE University of Tokushima
AUTHORS Takahashi, Mitsuhiko, MD; Yukata, Kiminori, MD;
Abbaspour, Aziz, MD; Takata, Shinjiro, MD; Sairyo, Koichi, MD
CENTRE University of Tokushima
COUNTRY Japan
0RINCIPAL!UTHOR Herzenberg, John E, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
AUTHORS Kovar, Florian M, MD; Conway, Janet D, MD
CENTRES International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
COUNTRY United States
!IM
To investigate the basic mechanism of distraction osteogenesis,
we have established the rabbit, rat and mouse models of limb
lengthening. To detect gene expression of bone forming cells
during distraction, in situ hybridization and northern blot analysis
was achieved. To enhance bone healing of the lengthened
segment, fibroblast growth factor-2 (FGF2) and/or alendronate
were infused locally into the lengthened segment using an
osmotic pump at various stages of distraction.
-ATERIALSANDMETHODS
Experimental limb lengthenng was achieved in 72 rabbits, 57
rats and 24 mice. In each model, osteotomized bone segments
were gradually distracted 7 days after osteotomy using either
a monolateral or a circular external fixator. Morphological
and mechanical properties of the lengthened segments were
assessed by bone mineral density, pQ-CT, histomorphometry and
three-point bending test.
2ESULTSANDDISCUSSION
The lengthened segments showed common radiological
structures consisting of a central radiolucent zone bounded by
proximal and distal sclerotic zones. Histologically, the central
radiolucent zone consisted of longitudinally oriented fibrous
tissues, while the sclerotic zone contained fine cancellous
bone. New bone was formed at the boundary between fibrous
interzone and two sclerotic zones by endochondral ossification
in the early stage of lengthening, and by intramembranous
ossification in the advanced stage of distraction. Meantime,
there was the third mechanism of ossification, termed transchondroid bone formation. Chondroid bone is an intermediate
tissue between bone and cartilage, and is rapidly resorped by
osteoclasts. Bone morphogenetic proteins (BMPs) were overexpressed in the lengthened segment during distraction. The
expression declined soon after completion of distraction. Local
infusion of FGF2 and/or alendronate enhanced bone healing of
the lengthened segment by stimulation of bone formation and/or
inhibition of bone resorption, respectively. Synergic and dramatic
effects of FGF2 and alendronate were observed on bone healing.
#ONCLUSION
Continuous local administration of FGF2 and/or alendronate
dramatically shortened the overall treatment time of distraction
osteogenesis. Two drugs enhanced bone healing synergically.
136
0URPOSE
Autologous bone graft is the gold standard for treating
nonunions or bone defects. There are many anatomic sites
potentially capable for bone harvest: anterior iliac crest (AIC),
posterior iliac crest (PIC), distal radius, olecranon, proximal tibia,
distal tibia, distal femur, calcaneus, and ribs. However, the most
common site is the iliac crest. Iliac bone crest harvesting allows
either tricortical structural grafts or large volumes of cancellous
bone. Recently, intramedullary (IM) bone graft harvest from
the tibia and/or femur has become popular. We retrospectively
reviewed the literature to compare iliac crest with intramedullary
donor sites.
-ETHODS
Retrospective literature published in 2010 or earlier was
analyzed to determine graft volume and complications.
Parameters studied included: graft volume, time to harvest,
blood loss, pain, gait abnormalities, and rate of minor/major
complications.
2ESULTS
IM graft has the least donor site morbidity but cannot provide
structural tricortical graft. Fracture of the bone has been
reported. Volumes harvested are greater for IM than for PIC than
for AIC method. Pain levels are greatest for AIC. Intermediate
pain is described for PIC. IM harvesting is associated with the
least amount of pain. Complications are highest for the AIC,
intermediate for the PIC, and lowest for the IM method.
#ONCLUSIONS
Intramedullary harvesting is increasingly popular when structural
graft in not required. However, IM harvesting requires expensive
proprietary disposable equipment costing about $450/case.
Podium
EFFECT OF TERIPARATIDE ON BONE REGENERATE AFTER
DISTRACTION OSTEOGENESIS
0RINCIPAL!UTHOR Umer, Masood, MD
CENTRE Aga Khan University
AUTHORS Ahmad, Tashfeen, MD; Habib, Sadia, MD; Rehman,
Rasham, MD
CENTRE Aga Khan University
COUNTRY Pakistan
"ACKGROUND
The parathormone analogue teriparatide (PTH 1-34) has been
used clinically to increase bone mass and reduce fracture risk in
osteoporosis; there is increasing evidence that it may promote
fracture healing.
/BJECTIVE
To determine the effect of teriparatide on new bone formation in
a rat model of distraction osteogenesis.
-ATERIALS
12 male Sprague-Dawley rats (weight ~250 gm) were allocated
to two treatment groups, teriparatide and saline, both given
subcutaneously for 3 weeks. Femoral distraction was done at a
rate of 0.4 mm/day for 3 weeks, followed by a further 4 weeks
for consolidation. New bone formation was assessed using Xray,
DEXA and histology.
2ESULTS
Xray: In the control group there was no new bone formation
in two of the six rats, while in the teriparatide group all rats
showed new bone formation. Scoring according to modified
Lane and Sandhu system confirmed higher score in the
teriparatide group. DEXA: The area (size) of new bone formed
adjacent to the margins of the osteotomy site as well as the
total bone mineral content of that new bone was significantly
higher (p<0.05) in teriparatide group as compared to saline.
HISTOLOGY: The teriparatide group appeared to have larger area
of woven and trabecular new bone compared to controls, though
statistical significance was not reached.
#ONCLUSION
Our results suggest a promising role of parathyroid analogue
therapy in distraction osteogenesis for promoting regenerate
formation and consolidation.
Podium
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0RINCIPAL!UTHOR Karlov, Av, MD
CENTRE Interregional Orthopedic Centre of Federal MedicalBiological Agency
AUTHORS Popkov, Av, MD; Popkov, Da, MD
CENTRE Interregional Orthopedic Centre of Federal MedicalBiological Agency
COUNTRY Russian Federation
2ESUME
The traumatism rate in Russia reached 88.5 per 1000
individuals and the incapacitation rate enhanced from 46.7% to
56.9%.
At that time the complete rehabilitation of disabled people
decreased from 20.9% to 15.4%. These numbers first of all
indicate the failure of common treatment and rehabilitation
methods. Up to 98% of disabled people after traumas and up to
99% patients with the diseases of musculoskeletal system need
rehabilitation (LA Popova, 1994, 2003).
The same situation is with the orthopedic diseases. The
frequency of birth of children with congenital limbs malformation
varies significantly in accordance to the data of different
authors. In Russia more than 219 children from 10 000 infants
have congenital malformations (OA Malahov, 2002). According
to JM Clovert (2000) the frequency of this pathology reaches
1:15000 in Europa. Nowadays among Russian children there are
more than 500 000 invalids with the musculoskeletal system
pathology, who need rehabilitation.
It is considered, that the orthopedic treatment is hopeless in
most cases. Even in 2000 H Carlioz et C Court (France) claimed
that “each effort of limbs lengthening is an adventure”.
We suggest to start treatment at the age of 2 years old in order
to perform the following tasks.
s 4OINDUCETHEHISTOGENESISOFBONETISSUE
s 4ORESTORETHEANATOMYOFLIMBSEGMENTMOREOVERTHE
existence of false joint is not a contraindication for the
reconstructive operations, when it is possible to restore the
support ability of the limb and to extend the affected segment
by 40-50%.
In case of limb malformation the induction of the enchondral
osteogenesis is a principal beginning of the pathogenetic
treatment of this complex congenital pathology.
We develop a number of methods of reparative osteogenesis
stimulation. In this regard we consider the development of
the technologies with use of implants with calcium phosphate
nanocoating to be the most prospective (AV Karlov, 2004; AV
Popkov; DA Popkov, 2005-2007).
We created a whole series of implants for extraosseous and
transosseous osteosynthesis, instruments for a minimally
invasive insertion and elimination of implants.
The use of implants in traumatology enabled to remove the
external fixation after 17-19 days in tibial diaphyseal fractures.
137
In case of intertrochanteric fractures of the femur even
for elderly and geriatric patients special rods-screws and
instruments were used. The patients were able to move in bed
after 2 days, after 2 weeks they started to go on foot, after 2
months the consolidation occurred and the external fixation
apparatus was removed.
In case of delayed consolidation of the fractures, false joint’s
treatment and in case of limbs lengthening we used wire
intramedullary implants. Osteoconductive and osteoinductive
properties of such implants encourage directed growth of
new bone tissue into diastasis area in limbs lengthening, in
systemic diseases (Osteogenesis Imperfecta, Oilier disease,
fibrous dysplasia of bone, rickets-like diseases), in bone cysts
replacement; encourage completing bone histogenesis in
postnatal period in the place of cartilage and connective tissue
matrix.
The main advantages of intramedullary reinforcement using
wires with bioactive coating:
s 3TIMULATIONOFREPARATIVEOSTEOGENESISANDTHEREAFTER
significant shortening (by 2-4 times) of external
osteosynthesis period.
s 2EINFORCEMENTAFTERAPPARATUSREMOVALISANADDITIONALWAYTO
prevent secondary deformations and regenerate fractures.
s 2EINFORCEMENTPROVIDESEARLIERBEGINNINGOFFUNCTIONAL
rehabilitation period.
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0RINCIPAL!UTHOR Elbatrawy, Yasser, MD
CENTRE Azhar University
AUTHORS Latalski, Michal, MD; Thabet, Ahmed, MD
CENTRE Azhar University
COUNTRY Egypt
)NTRODUCTION
Gradual limb lengthening with external fixators using distraction
osteogenesis principles is the gold standard for treatment of
limb-length discrepancy. However, long treatment time is a
major disadvantage of the current lengthening procedures.
Efforts to decrease the treatment include biological and
biomechanical factors. Injection of platelet-rich plasma (PRP) is
a biological method to enhance bone healing during distraction
osteogenesis. We hypothesized that PRP can enhance bone
healing during limb lengthening.
0ATIENTSANDMETHODOLOGY
We report our experience with the use of PRP during distraction
osteogenesis. Our retrospective study included 19 patients
divided into the standard group of 10 patients who did not
receive PRP and the PRP group of nine patients who received
PRP at the end of the distraction phase. The study variables
included external fixator time, external fixation index, and
complications during treatment. The PRP group had statistically
SIGNIlCANTLYSHORTERTREATMENTTIMEP
#ONCLUSION
Injection of PRP into regenerate bone might be an effective
method to shorten treatment time during limb lengthening
and lead to better functional outcomes and improved patient
satisfaction.
,EVELOFEVIDENCE
Level IV, therapeutic study.
138
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PSEUDARTRHOSIS OF THE DISTAL TIBIA
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0RINCIPAL!UTHOR Eralp, Levent, MD
CENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
AUTHORS Kocaoglu, Mehmet, MD; Bilen, Erkal F, MD; Dikmen,
Göksel, MD; Sen, Cengiz, MD
CENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
COUNTRY Turkey
0RINCIPAL!UTHOR Yoshiki, Yamano, MD
CENTRE Prof. Emeritus Y. Yamano
AUTHORS Hiroyuki Gotani, MD
CENTRE Osaka Microsurgery Center
COUNTRY Japan
!IM
We want to summarize our clinical results with distraction
osteogenesis for the treatment of infected tibial pseudarthrosis
around the ankle joint.
-ATERIALANDMETHODS
Between 1994 and 2009, 13 patients, with a mean age of
50 years (range, 27-79) underwent tibial reconstruction to
treat infected intracapsular nonunion of the distal tibia with
a mean bone loss of 4,8 cm (range, 1 to 7 cm). The mean
previous operation number was 1.77 times (range, 1-4). We
had eight type A1, two type B2, two type B3, and one type
A2-1 pseudarthrosis according to Paley’s classification. We
used bifocal compression and distraction technique in five
cases, compression with Ilizarov external fixator in five cases,
and Taylor spatial frame in one case. Radical debridement,
temporary external fixation and antibiotic-impregnated cement
were used for the first step in two cases. Ilizarov bone transport
technique over an intramedullary nail as a second session
was used in these two patients. Free latissimus dorsi flap was
required in one patient. At the time of last follow-up, functional
and radiographic results were evaluated according to the criteria
of Paley et al.
$ISCUSSION
The mean duration of follow-up was 36 months (range, 16 to
70 months). The mean external fixation time was 198 days
(range, 120-300), and the mean external fixation index (EFI)
was 29 days/cm (range, 19,2-36,2). According to Paley’s bone
scoring system we had 10 excellent, 2 good,1 poor results, and
according to Paley’s functional scoring system there were 5
excellent, 6 good, 2 fair results. We had 11 problem, 5 obstracles
and 1 sequel according to Paley’s classification including; seven
grade 2 pin tract infection, 1 transient knee joint stiffness, three
ankle joint stiffness, two grade 3 pin tract infection and three
equinus deformity. There was one recurrent nonunion which was
reconstructed with Taylor frame system and underwent revision
with an retrograde intramedullary nail.
/BJECT
Treatment of Infected defective non-union has been challenging
and very difficult problems for Orthopedic surgeons. This
consists of erdication of the infection, the achievement of bone
union, and in many cases, the correction of bone deformity and/
or shortening. Combined with Ilizarov technique, vascularized
bone grafting enabled us to treat infection, bone defect, and also
bone deformity/shortenig one stage.
-ATERIALSANDMETHODS
Thirty eight cases (Mean age; 41.5 y.o. ranged from 17 to 71
y.o.) of infected defective non-unions were treated with this
methods (Follow up; 1 to 5 years). After the thorough curattage
of infected tissue, vascularized composite bone grafting was
performed into the defect. Consequently, remaining deformity/
shortening of bone was corrected with Ilizarov technique.
Successful vascularized bone grafting and skin coverage with
eradication of the infection were primarily performed in all
cases but one. In one case, reoperation was necessry due to the
necrosis of vascularized compsite graft.
$ISCUSSION
Vascularized bone grafting into infective tissue is controversial
especially when the infection is active. We have shown here
that, in spite of the active infection, vascularized bone graft
can be successfully performed with assistance of antibiotics.
The theoretical advantages of vascularized bone grafts in
these cases are as follws. First, because of good blood supply,
the antibiotics are well transported to the target tissues and
subside the infection. Second, the existence of living bone graft
leads to rapid bone union and bone formation according to
Ilizarov’s tension stress effect. The cases where bone lengthenig
is necessary, may increase the blood supply to the grafted
vascularized bone accelerating bone formation. And also another
important advantages of this method are that the correction of
the rotational deformity as well as angilar deformity in these
infective defective non-union cases.
#ONCLUSIONS
External fixation technique addressed an appropriate solution
to all problems, union was acieved in all patients with no limb
length discrepancy. However, the treatment of the infected
nonunions at the intracapsular region is very complex and
technically demanding.
139
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0RINCIPAL!UTHOR Sala, Francesco, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
AUTHORS Agus, Maria Alice, MD; Pesenti, Giovanni, MD; Castelli,
Fabio, MD; Guarnerio, Chiara, MD; Capitani, Dario, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
#OUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
Limb reconstruction techniques, severe grades of open fracture
as well as segmental and comminuted fractures treatment rely
on stable external fixation and bony alignment to provide early
limb function after major long bone injury. The Taylor Spatial
Frame (TSF) is a hexapod frame that differs from the wellknown Ilizarov fi xator in that it works in conjunction with special
software programs and can simultaneously correct 6 axes of
deformity. The purpose of this retrospective study is to analyze
the results of complex fracture treatment and post traumatic
reconstruction of the lower limb using TSF.
-ATERIALANDMETHODOLOGY
From January 2005 through May 2009, 53 TSF were applied to
the lower limbs of 49 patients (42 males and 7 females). Patient
ages at the time of frame removal ranged from 10 to 94 years
(mean age, 41.6 years). The hybrid advanced technique of frame
application with the use of wires and half-pins was applied in
all cases. All patients were treated and followed by the senior
author (F.S.).
$ISCUSSION
Circular fixators may be selected in preference to monolateral
devices for complex fractures, bone transport and deformity
correction where strong durable metaphyseal fixation is
required. The use of screws can decrease the number of pinrelated and soft tissue complications and can improve the
comfort of the patient and the tolerance of the treatment. In
recent times excellent results are reported in literature using
TSF for difficult cases of deformity, malunion, nonunion and
displaced lower limb fracture.
#ONCLUSION
In our series 49 cases (92.5%) achieved the bony consolidation
subsequently to the first treatment. TSF devices proved effective
in many situations. It seems likely that refined computer
exapode frame supercedes conventional techniques in the
fracture and limb reconstruction management. We believe that
the TSF is easy to apply and can be pulled together quickly. The
only drawbacks we noted are that the inaccurate screw/wire
fixation could interfere with the six strut- bars action and that
the fi nancial cost is comparatively high than the conventional
Ilizarov frame.
140
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0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
/BJECTIVEEPURPOSE
The septic non-union remain a common problem in orthopaedics
practice. The treatment strategy is antibiotic therapy associated
to surgical treatment. The principles of our treatment has divided
in two steps: the first step was eradication of the infection
by means of surgery (resection of infected bone) combined
with local and sistemic antibiotics, creation of a viable and
stable soft-tissue enviroment, application of cemented spacer,
and stabilization of the skeleton. The second step was the
reconstruction of the bone after 4-6 weeks. The aim of this study
is to report our experience about treatment of tibial septic nonunion through resection and callus distraction by external fixator.
-ETHODSANDMATERIALS
Between 2007 and 2010, we treated 23 patients with tibial
septic non union. We treated bone gaps until 5 cm with acute
shortening followed by intermittent distraction. For longer defect,
we used a bone segment transport or an acute shortening until
5 cm and after a progressive lengthening of the tibia with the is
used. After corticotomy, the bone was distracted at the rate of 1
mm for day (0.25 mm/step).
2ESULTS
The mean follow-up period was 15.2 (6-95) months after fixator
removal. The mean new bone formation was 7.1 (2.2-12)
months. The mean healing index was 43.5 (18-94) days/cm,
and average healing time was 256.7 days (range, 95-850). In 12
cases we used plastic surgery to cover the soft-tissue defects
(4 free flaps and 8 transfer flaps). Union with acceptable limblength difference (<2 cm) was achieved in 17 limb. The bone
result was excellent in 15 tibias, good in one and poor in one.
Seventeen limbs had an excellent and one a good functional
result.
#ONCLUSIONS
The use of the external fixation associated to specific antibiotic
therapy in septic non-union is a good treatment to obtain
healing; weekly medication of pin site and X-ray follow-up is
basic step to achieve good results, because there are many
complications during the treatment.
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INTERTIBIO FIBULAR GRAFT, REVIEW OF 52 CASES
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EXTERNAL FIXATION
0RINCIPAL!UTHOR Pedrero Elsuso, Salvador, MD
CENTRE Hospital de Bellvitge
AUTHORS Cabo Cabo, Javier, MD; Moranas Barrero, José, MD;
Portabella Blavia, Federico, MD; Ezagui Bentolila, León, MD;
Pérez Fernández, Albert, MD
CENTRE Hospital de Bellvitge
COUNTRY Spain
0RINCIPAL!UTHOR Pizzoli, Andrea, MD
CENTRE Orthopedic Department, C. Poma Hospital
AUTHORS Renzi Brivio, Lodovico, MD
CENTRE Orthopedic Department, C. Poma Hospital
COUNTRY Italy
2ESUME
The intertibio-fibular graft was first described by Miclh and
Merlé D’Aubigne for the treatment of tibial pseudoarthrosis.
It´s a cortical and spongy bone graft from the iliac crest,
recessed between the tibia and fibula and stabilized with an
external fixation. It´ s a complex technique that requires great
experience, that once obtained, it provides optimum results of
fracture consolidation.
We present series of 52 cases, 51 patients (1 bilateral), 45 of
them men and 6 women with middle ages of 33.6 years.
About their previous pathologies we have 43 cases of septic
pseudoarthrosis, 1 aseptic pseudoarthrosis, 4 cases of III
grade open fractures, and 4 cases of reinforcement for tibial
osteomyelitis. External fixation is performed associated with
this technique to maintain stability on the graft zone, if it is
necessary.
The intertibio-fibular graft its an excellent technique for the
treatment of septic pseudoarthrosis of the tibia.
It’s indicated even if severe segmentary bony defects are found,
but not if massive. It’s also very useful as a reinforcement
bone graft in chronic tibial osteomyelitis that requires great
resections.
!IMANDPURPOSEOFTHESTUDY
The authors will evaluate the results obtained in the treatment
of septic non union of the lower limb with monolateral external
fixation following a dedicated protocol based on type of lesio and
the type of infection.
-ATERIALSANDMETHODOLOGY
The treatment strategy is based on the use of a monolateral
external fixator as temporary or definitive fixation associated
to debridement, VAC therapy, bone graft or Orthobiology. When
is present bone loss the fixator is used as instrument for
distractional osteogenesis.
We reviewed a population of 38 patients with a septic non union
of the tibia treated with this approach, evaluating functional
and radiological outcome in relation to union rate and infection
recurrence rate.
$ISCUSSION
Infected non union is one of the worse complication of fractures
of the lower limbs in particular after open fractures. It is not
frequent but difficult to treat in relation to the local bone and soft
tissues conditions and to the general conditions of the patients.
Many times there is a biological problem related to the infection
associated to a mechanical problem due to hardware failure,
bone gap or soft tissues interposition. The use of a differentiated
strategy of treatment, mainly based on the use of monolateral
external fixator, allowed the authors to obtain, in a population of
38 patients with a type II septic non union a 92% consolidation
rate and infection healing.
#ONCLUSIONS
The application of external fixation principles for the treatment
of septic non union with a monolateral frame permitted the
authors to obtain a good rate of bone healing (92%) associated
to infection healing in a population of 38 patients.
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INFECTED PSEUDOARTROSIS OF LONG BONES TREATED
7)4(4(%),):!2/6-%4(/$
0RINCIPAL!UTHOR Casas Placer, José, MD
CENTRE Hospital Central de Maracay Aragua. Jefe de Servicio de
Traumatologia y Ortopedia
AUTHORS Rodríguez de Casas, Verónica, MD; Mancera Alcalá,
Alexander, MD; Mendoza, Daniel, MD
CENTRE Hospital Central de Maracay Aragua
COUNTRY Venezuela
/BJECTIVEANDPURPOSEOFTHEWORK
To establish the effectiveness of the “Ilizarov” method in the
treatment of the infected Pseudoartrosis of long bones in the
central hospital of Maracay in the period 2004-2008.
-ATERIALANDMETHOD
Prospective study; we carries out treatment with the “Ilizarov”
method and pursuit of 21 cases of patients with “Infected
Pseudoartrosis of long Bones”. It was Considered: age, sex,
affected bone, open fracture or postsurgery, number of previous
surgeries to the treatment with the “Ilizarov” method, Time of
cure of the infection and bone length recovered (cm) since the
implementation of the method, Index of bone consolidation, Time
average with tutor.
2ESULTS
!GEYEARSYEARS
OTHER3EX-ALE&EMALE
!FFECTED"ONE&EMUR4IBIA
/PEN&RACTURE0OSTSURGERY
57%). Number of previous surgeries: between 2 and 8, average
of 5; Time of cure of the infection and bone lenght recovered:
between 2 and 10 months, with average of 6 (without associate
surgeries and with 100% of cure of the infection) and between
5 and 17 cm of recovery of bone defect, average of 11.
Consolidation index: 1,5 month/centimeter. Time Average whit
tutor: 8 months.
$ISCUSSION
The treatment of the infected Pseudoartrosis of long bones in
any Orthopaedics and Traumatology services at world level
are debate matter due to the wide range of solutions therapies
proposals for the same one; reason one is necessary to establish
an effective treatment rule and chord to the necessities of each
services.
#ONCLUSIONS
In our means the young adults of the male sex are those that
most present infected pseudoartrosis of long bones, prevailing
the tibia due to open fractures; representing the “Ilizarov”
method an effective, sure and reliable treatment for the patients
in study with this pathology.
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ARTHRODESIS AFTER KNEE PROSTHESIS INFECTION
0RINCIPAL!UTHOR Bongiovanni, José Carlos, MD
CENTRE Universidad Mogi Das Cruzes
AUTHORS Engelen, Cl, MD; Preti Aurelio Marco, MD
CENTRE Universidad Mogi Das Cruzes
COUNTRY Brazil
"ACKGROUND
Knee arthrodesis in many cases is the only indication of failure
in the treatment of infected total knee arthroplasty. Because
it is an infected nonunion of resultibilidade artrofica type is
difficult to solve by conventional methods with respect to cure
the infection and healing. In general, you can divide into three
groups: intra-articular arthrodesis with bone grafting, intraarticular arthrodesis with internal fixation and intra-articular
arthrodesis with compression by external fixation. Technological
advances in the field of antibiotics, anesthetics and implants
allows the increase of spectrum for surgical arthrodesis of the
knee.
/BJECTIVE
To present the results of the analysis of the use of circular
external fixation in arthrodesis of the knee after infected
arthroplasty, a particularly serious situation taking into account
local and global, since patients are often elderly associated with
other clinical problems.
-ATERIALANDMETHODS
We treated 53 patients (54 knees) of patients with infected
knee arthroplasty with a female predominance (62.9%). The
average age was 61 years. The most common infectious agent
was Staphylococcus aureus in 35 knees (64.8%). The pathology
that led to the indication of arthroplasty was 59.2% of cases
of primary knee osteoarthritis, 35% with 0.3 osteoarthritis
secondary to rheumatoid arthritis and 5.5% with knee
osteoarthritis secondary to pyoarthritis monofocal in childhood
The methodology used is the same as the previous scar, held
in joint replacement. careful debridement with removal of all
cement and necrotic tissue, a good contact between the femoral
and tibial surfaces with circular fixator and compression were
the main time of surgery.
2ESULTS
Consolidation in 52 knees (96.3%) with recurrence of infection
in only 3 cases (5.5%). The average duration of external fixator
was 7.2 months and median of 6.7 months of consolidation. The
most common complication was pain and superficial infection in
the way of the cables and plugs in 45 knees (85%).
#ONCLUSIONS
Treatment of infected total knee arthroplasty with arthrodesis,
performed by the method of circular external fixation, had
achieved 96.3% of the knees, with healing of the infection in
51 knees (94.5%). The healing time, 6.7 months, was relatively
short, due to the complexity of the disease and in some cases
there was a need to supplement with bone lengthening.
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EXTERNAL FIXATION IN 325 HALLUX VALGUS
RECONSTRUCTIVE PROCEDURES
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
!IMANDPURPOSE
To introduce a new method for brachymetatarsia repair that
is faster and more effective than traditional external fixation
methods and prevents metatarsophalangeal joint arthrosis.
!IMANDPURPOSE
Utilizing external fixation with adult mesenchymal stem cells
in the Lapidus bunionectomy in 325 patients. The external
fixators allowed the patients to weightbear immediately after
surgery and the procedure could be performed simultaneously
which was done in 120 patients. This technique allows for
a faster fusion rate than traditional methods and immediate
weightbearing which cannot be done with internal fixation.
To perfect a method for brachymetatarsia repair, utilizing
external fixation with minimal complications and positive
outcomes. Many surgical reconstructions are successful at
re-establishing metatarsal length but have postoperative
stiffness and joint damage at the metatarsophalangeal joint.
-ATERIALSANDMETHODOLOGY
48 patients underwent brachymetatarsia repair utilizing external
fixation that allowed for bone transport and concomitant
metarsophalangeal joint arthrodiatasis.
This was performed with a minimal incision at the proximal
metaphyseal area of the metatarsal utilizing a multi-level
external fixator. No dissection or surgery was performed at the
level of the metatarsophalangeal joint.
The corticotomy site was immediately distracted an average of
6 mm on the operating room table and adult mesenchymal stem
cells were back filled into the site.
The metatarsophalangeal joint was also distracted acutely in the
operating theater one centimeter.
Patient distraction commenced 5 days postoperatively and
was at a rate of one mm a day for both the metatarsal and the
metatarsophalangeal jont.
$ISCUSSION
There had to be an alternative to preventing
metatarsophalangeal joint stiffness and pain following
brachymetatarsia repair utilizing external fixation.
Traditional methods used a mini external fixator proximally
and an intramedullary Kirschner wire distally across the
metatarsophalangeal joint.
-ETHODSANDMETHODOLOGY
325 patients underwent a lapidus bunionectomy with 120 of
them having it performed bilaterally. A mini external fixator
was placed and patients were walking the day of surgery. Adult
mesenchymal stem cells were placed into the arthrodesis site of
the first metatarsal-medial cuneiform joint before compression
with the mini external fixator.
$ISCUSSION
All patients fused at an average of 5.4 weeks with the fixators
removed at an average of 5.6 weeks. There were no incidences
of delayed or nonunion. Traditional methods of fixating the
Lapidus bunionectomy require a patient to be nonweightbearing
for six to eight weeks. The immediate weightbearing allows
greater than six times more blood flow which was responsible
with the adult mesenchymal stem cells for the accelerated
fusion rate. The dissection also is 80% less than with internal
fixation.
#ONCLUSION
Utilizing external fixation with adult mesenchymal stem cells
allows for a faster arthrodesis rate than traditional methods.
These can be also performed bilaterally and the patient can be
weightbearing immediately without jeopardizing the arthrodesis
outcome.
While successful at lengthening the metatarsal the damage at
the metarsophalangeal joint is prevalent. All 48 patients were
successful at re-establishing the metatarsal length and parabola
and more importantly improving the metatarsophalangeal
joint space and function. The adult mesenchymal stem cells
also accelerated the healing time of the lengthening by 30%.
There were no incidents of delayed or nonunion or early fixator
removal.
#ONCLUSION
To introduce a new technique for brachymetatarsia repair
that is faster than traditional external fixation methods and
prevents metatarsophalangeal joint arthrosis by a concomitant
arthrodiatasis.
143
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OSTEOSYNTHESIS
0RINCIPAL!UTHOR Neretin, Andrey, MD
CENTRE Russian Ilizarov Scientific Center for Restorative
Traumatology and Orthopaedics
AUTHORS Ivanov, Gennadiy, MD
CENTRE Russian Ilizarov Scientific Center for Restorative
Traumatology and Orthopaedics
COUNTRY Russian Federation
0URPOSEOFTHESTUDY
Congenital clubfoot takes one of the first places among diseases
of the locomotor system.
-ATERIALANDMETHODOLOGY
From 1999 to 2009 our hospital treated 145 patients (158 feet)
with congenital clubfoot aged from 7 to 18. Among them there
were 69 people (81 feet) aged 7-13, 76 people (77 feet)-aged
from 14 to 18. All patient sustained standard intervention in the
soft tissues including subcutaneous Achilles tendon tenotomy,
capsulotomy of metatarsophalangeal joints and plantotomy with
subsequent application of the Ilizarov apparatus in the tibia and
foot with fixation of the toes.
Patients aged from 7 to 12. Patients of this group depending on
the degree and form of the pathology in the postoperative period
were treated by closed deformity correction or after osteotomy
of the midfoot and calcaneus. In bone type of congenital
clubfoot, triple arthrodesis was done after correction of the limb
deformity.
Patients aged 13-18. We divided this group of patients into two
subgroups: foot deformity without shortening and foot deformity
with shortening.
Depending on the severity of the deformity and shortening
we did acute correction of the foot deformity by triple
arthrodesis and gradual correction and lengthening through foot
osteotomies. The deformity was corrected gradually in case of
the III-IV degree deformity. Then, with the apparatus on, we did
triple arthrodesis of the foot. Transfer of the place of attachment
of tibial muscles to the lateral side of the foot was done upon
indications.
$ISCUSSION
All complications were corrected during treatment and did
not influence the final result. Motions in the ankle recovered
on average in 3-4 weeks after apparatus removal. Short-term
follow-ups were evaluated as good in all the patients within 2 to
9 months, long-term -in 112 patients (77.67%). Among the latter
good results were achieved in 101(69.7%) patients, satisfactory
-in 39(26.9%) patients, poor results -in 6(3.9%) patients. Criteria
of evaluation were: clinical, radiographic and physiological
examination.
#ONCLUSIONS
Application of the method of transosseous osteosynthesis
according to Ilizarov in management of patients with congenital
clubfoot leads to good treatment result and minimizes the
recurrence possibility.
144
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0,!.4!2!002/!#(/&/34%/4/-9
0RINCIPAL!UTHOR Kang, Qinglin, MD
CENTRE The Sixth People’s Hospital of Shanghai
AUTHORS 1Xia, Hetao, MD; 2Cheng, Dong, MD
CENTRES 1Beijing Institute of External Skeletal Fixation
Technology; 2The Sixth People’s Hospital of Shanghai
COUNTRY China
"ACKGROUNDANDPURPOSE
Distraction osteogenesis may be used for the treatment of
brachymetatarsia. However, the dorsal incision for osteotomy
will remain obvious scar, which is a dilemma for female patients
to accept this kind operation. We explore a noval metatarsal
osteotomy approach, and decrease the scar size of dorsal pedis,
and get a better cosmetic outcomes. We evaluated this noval
plantar approach of osteotomy.
0ATIENTSANDMETHODS
10 patients (14 feet) underwent distraction osteogenesis for
fourth brachymetatarsia. Mean age at time of surgery was 21
(15- 32) years. Four half-pin were directly inserted into the
metatarsal without predrilling. A unilateral external fixator was
fixed at the dorsal pedis. The plantar aspect was dissected in
the corresponding interposition of the second and third half-pin.
A sharp and narrow-edge osteotome was used to separate the
metatarsal near metaphysic region. In order to minimize the
pin-path scar during distraction, the metatasophalangeal joint
should be kept dosal-flexation while the pins were inserted,
which can reserve more skin between the distal and proximal
pins for subsequent spreading.
2ESULTS
The patients were followed up for a mean period of 70 months
(28 to 108). There were only 4 point scar left by pin tract in
dorsal pedis, the scar was very small and negligible. All patients
regained a nearly normal fourth metatarsal length and were
satisfied with the cosmetic results. All patients can walk and
run as normal. Average degree of metatarsal lengthening was
36% (28-43), and the average lengthening index was 65 (39-73)
days/cm. The most common complication was stiffness of the
metatarsophalangeal joint (12 feet). The complications were pin
tract infection in 2 feet.
#ONCLUSIONS
The plantar osteotomy technique is straightforward and
produces good cosmetic results. Satisfactory bony union
is achieved, morbidity is low. This noval method should
be recommended in the metatarsal lengthening for
brachymetatarsia.
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0RINCIPAL!UTHOR Qin, Si-He Qin, MD
CENTRE Beijing Cuiyangliu Hospital
AUTHORS Ge, Jian-Zhong, MD
CENTRE Yangquan First People’s Hospital
COUNTRY China
0RINCIPAL!UTHOR Herzenberg, John E, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
AUTHORS 1Shahulhameed, Abdulsalam, MD; 2Standard, Shawn C, MD
CENTRES 1Kuppusamy Naidu Memorial Hospital; 2International
Center for Limb Lengthening, Rubin Institute for Advanced
Orthopedics, Sinai Hospital
COUNTRY United States
0URPOSEOFTHISSTUDY
To explore the effectiveness of Ilizarov technique in the
correction of stiff foot deformity combined with skin scar.
-ATERIALANDMETHODOLOGY
From February 2004 to May 2007, 12 patients were treated
with the Ilizarov device according to the Ilizarov’s principle of
tension-stress. There were 10 cases of talipes equinovarus
and 2 cases of talipes equinovalgus. Nine cases underwent
limited tarsal osteotomy, 3 cases had tendon transfer to restore
muscle balance and 1 case had tibial lengthening. The threedimensional structures of the apparatus were adjusted 5
days after the operation by telescopic rods. In cases of varus
deformity, the varus at the forefoot was corrected first and foot
drooping corrected later. The valgus deformity was corrected
in the opposite direction. X-ray films were taken regularly to
observe the ankle joint and avoid its dislocation. The patients
were encouraged to have weight-bearing during the treatment
period. The post-operative distraction lasted for an average of
78 days which was followed by a weight-bearing for an average
of 69 days and a walking with a foot brace for 2-3 months
after the removal of fixators. Twelve patients were followed
up for 5 months to 2 years and 4 months. Eight patients had a
satisfactory correction of the deformity with good walking on the
whole foot. Four cases had partial recurrence of foot drooping
for which 3 cases had a second application of fixators. Finally
11 cases achieved excellent results. The stiff skin scar became
softer and blood circulation improved after the distraction. No
infection in the pin sites and incisions, no dislocations in the
ankle joint and no damage to nerves and blood vessels occurred.
$ISCUSSION
Limited tarsal osteotomy is needed for bony deformity with a
slow distraction of Ilizarov device. Weight-bearing with a fixator
on the foot for more than 8 weeks is necessary for avoiding the
recurrence of foot deformity. Distraction may lead to improved
blood circulation and regenerated tissue for the skin scar.
#ONCLUSIONS
Ilizarov technique is a minimally invasive and effective method
of correcting stiff foot deformity combined with skin scar.
)NTRODUCTION
Equinovalgus deformity is common in severe fibular hemimelia.
Successful reconstruction requires foot deformity correction
followed by tibial lengthening. Valgus may originate in the ankle,
subtalar joint, or both. Unlike radiography, magnetic resonance
imaging (MRI) helps visualize non-ossified bones.
-ETHODS
Nine children with severe deformity underwent treatment
between 2000 and 2009. MRI evaluation was obtained at age
20.6 months (range, 16-26 months); surgery was performed at
age 25.1 months (range, 17-50 months). Retrospective review
of MRI scans and plain radiographs identified seven parameters
that helped in surgical decision making: lateral distal tibial
angle, shape of the distal tibial epiphysis, presence or absence
of fibular anlage, relationship of talus to calcaneus, presence of
coalition, anterior distal tibial angle, and Meary angle.
2ESULTS
MRI evaluation helped identify the seven parameters and helped
determine fibular hemimelia classification in all nine patients.
Three patients had equinovalgus ankle (type IIIa), four had
subtalar joint deformity (type IIIb), and two had clubfoot type of
fibular hemimelia (type IV). Four patients with subtalar deformity
underwent talocalcaneal osteotomy and ankle reconstruction.
Four patients underwent supramalleolar osteotomy (three
patients with ankle deformity and one with clubfoot deformity),
and one had an osteotomy through the talar neck for clubfoot
deformity. Plain radiographs helped determine only the presence
or absence of the fibula and provided minimal information about
detailed foot and ankle morphology.
#ONCLUSION
MRI evaluation provides more useful information than
radiographic evaluation of severe ankle and subtalar
deformities in young children. Because of the complex nature
of the deformity, we conclude that MRI evaluation is helpful
preoperatively to aid in surgical decision making.
145
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!#54%,%.'4(%.).'/&3(/24)6-%4!4!23!,"/.%
0RINCIPAL!UTHOR Shadi, Milud, MD
CENTRE Department of Pediatric Orthopedics
AUTHORS Koczewski, Pawel, MD
CENTRE Department of Pediatric Orthopedics
COUNTRY Poland
2ESUME
Shortening of the 4th metatarsal bone usually congenital, is the
most common shortening among the metatarsal bone. Most of
the cases are bilateral and leads to cosmetic disability of the foot
which is not accepted by young female patients. Lengthening of
the metatarsal bone can be done by distraction osteogenesis or
with acute lengthening and grafting.
-ATERIAL
8 female patients, age from 15 to 29 years (mean 16) with
congenital 4th brachymetatarsia in 2002-2009. 5 patients were
bilateral, 3 unilateral. 12 metatarsal bone were lengthened. The
indication in all cases was mainly cosmesis.
-ETHOD
Surgical application of monolateral mini-fixator (Pumed-5,
Orthofix-3). Diaphyseal osteotomy of the metatarsal bone.
Gradual distraction and soft tissue release until the desired
lengthening achieved intraoperatively. Lengthening ranged 1.72.5 cm (mean 2.0). Semitubular bone graft from the ipisilateral
fibula was inserted in the gap. The procedures was done one
stage bilaterally (4), the fixator in two of them was removed
intra operatively and the graft fixed with K wires for 6-8 weeks
(Distractor was used only for acute distraction). Short plaster
cast was applied, and patients allows to weight bearing on the
hindfoot. The cast and the external fixator were removed after
radiological signs of bone graft union which was usually after 4
months.
2ESULTS
Union of the bone graft obtained in all patients. Average
lengthening was 2 cm, which gives satisfactory functional
and cosmetic results. All patients showed limitation of
metatarsophalangeal joint motion at stabilization and shortly
after removal of fixation. In 3 cases with K wire graft fixation,
small angulations of bone graft occurs, but without negative
influence on the results. In one case fracture of the graft donor
site was observed which healed without need of additional
treatment.
#ONCLUSIONS
1. Acute lengthening of the 4th metatarsal bone is effective
method.
2. To avoid difficulty of small diameter of bone graft fixation with
K wire and angulations we recommend to use mini external
fixator for stabilization of the bone graft.
3. Acute lengthening can be used as alternative technique to
distraction osteogenesis for brachymetatarsia lengthening.
146
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STRETCHINGS AND TRANSPORTATION OF BONES IN CHILDREN
AND TEENAGERS
0RINCIPAL!UTHOR Solís Cruzado, Óscar, MD
COUNTRY Peru
/BJECTIVE
It is to show the results applying the methodology of the
“Hypothesis of the bone consolidation of the school of external
Fixation descartable and the tension Gavii Abranovich’s
compression Ilizarov” in the bones stretching.
-ATERIALANDMETHODS
40 patients have been treated, 30 males and 10 women, the
average age are between 2 and 17 years old, with shortening
from 3 to 18 cm.
We have treated discrepancies and members’ deformations:
s 3EQUELOFEXPOSEDFRACTURESOFLEGOFTHE)))RDŽCASESOFTHE
Group 4 to one case, Group 4 b five cases, Group 3 one case.
s 3EQUELOFEXPOSEDFRACTURESOFFOOTOFTHE)))RDŽ'ROUPOFTWO
cases.
s 3EQUELOFOSTEOMIELITISCHRONICLEANDPSEUDOMATROSIS
degenerative osteoarthritis,total cases are nine: five cases of
tibia, three cases of femur and one of humerus.
s 3EQUELOFMEMBERSFORMATIONFOROSTEOMIELITISlVECASES
s 9OUFRACTUREBADLYCONSOLIDATEDTOTALSEVENCASESlVECASES
of femur and two cases of tibia.
s 3EQUELOFCONGENITALMALFORMATIONOFLEGJUSTONECASE
s 3EQUELOFTHElSISTOTALSIXCASESTHREECASESOFFEMURAND
three cases of leg.
s 3EQUELOFCONGENITALMALFORMATIONOFLEGONECASE
s 0OLIOOFFEMURANDLEGONECASE
s 3EQUELOFTUMOROFTIBIAANDPSEUDODEGENERATIVE
osteoarthritis, one case.
#ONCLUSION
The hypothesis of the bone consolidation has been of that the
cell that is multipotential and fibroblasto receives a correct
information and is very immobilized and exist micro movements
between 0,5 and 2 mm one will turn in osteoblasto that for
an influence bioeléctrico together with the osteocito will form
the bone corn will be a consolidation per give prior only when
always is reduced, immobilized and exist micro movements of 0
mm to 0,5 mm.
A consolidation periosteal if this one is very limited and
immobilized but micromovements exist up to 2 mm.
The tension hypothesis Gavi Abranovich’s compression Ilizarov
that the alive fabric submitted to gradually stress becomes
active from point of view metabolic experimenting through a
process of regeneration and growing active.
Both hypotheses have been of great benefit to the development
of this work.
2ESULTS
The results were good depending on the degree of soft tissue
injury, bone injury type and size of the elongation.
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CLINICAL ANALYSIS OF 107 PATIENTS WITH FOOT AND ANKLE
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0RINCIPAL!UTHOR Qin, Si-He, MD
CENTRE Beijing Cuiyangliu Hospital
AUTHORS Ge, Jian-Zhong, MD; Guo, Bao-Feng, MD
CENTRE Beijing Cuiyangliu Hospital
COUNTRY China
0RINCIPAL!UTHOR Paley, Dror, MD
CENTRE St. Mary’s Medical Center
AUTHORS 1Birch, John, MD; 2Specht, Stacy, MD; 1Morton, Anne,
MD; 1Ward Shana, MD; 1Tulchin, Kirsten, MD
CENTRES 1Texas Scottish Rite Hospital for Children; 2Rubin
Institute for Advanced Orthopedics
COUNTRY United States
2ESUME
Purpose of the study was to analyze the incidence, deformity
categories and treatment status of foot and ankle deformities
caused by spina bifida,and to raise awareness about this
disease in the field of orthopedics.
-ATERIALANDMETHODOLOGY
The information of the 107 patients surgically treated with
foot and ankle deformities caused by spina bifida in our
department between January 1990 and July 2009 were
analyzed retrospectively. There were 44 men and 63 women
(age range,1.3-52 years, average age 17.7 years). There were
54 patients with spina bifida occulta and 53 patients with
spina bifida manifesta. Among them 106 patients suffer from
Lumbosacral vertebrae cleft and one case was ill with thoracic
spinal bifida. Among a total of 165 feet,unilateral foot was
involved in 49 cases (22 cases on the left side, 27 cases on
the right side) while bilateral foot was involved in 58 cases.
Combined type of ankle-foot deformity included 76 varus talipes,
23 talipes valgus, 15 flail feet, and 51 other foot deformity. Other
parts deformities involved by spina bifida included 4 cases
with the knee flexion or anti-flexion deformity, 17 cases with
hip deformity and 30 cases with dysfunction of urination and
defecation.
$ISCUSSION
Origin of Spina bifida is developmental abnormalities of spinal
cord and spinal nerve. Malformation is mainly located on foot
and ankle. 29 of 54 cases with spina bifida occulta failed to be
diagnosed in other hospitals. Corrective surgery was performed
only in 26 patients. There were 54 patients (over 18 years
of age) with severe foot and ankle deformities due to failing
reasonable surgical treatment. Early diagnosis of this disease
belongs to department of neurosurgery,pediatric department,or
surgical department. Treatment belongs to orthopedic
department. Diagnosis and treatment involves many clinical
specialities.
#ONCLUSIONS
Some young orthopedic surgeons who are lack of awareness
of the disease due to superfine specialty easily delay diagnosis
and treatment of the disease, the set of data should arouse the
attention of Orthopedic scholars.
)NTRODUCTION
Children with severe fibular deficiency may undergo amputation
or limb reconstruction.
-ETHODS
Twenty children who underwent amputation at one center were
compared with 22 children who underwent limb reconstruction
at a second center. Average evaluation age was 9 years (range,
5-15 years) and included psychosocial status, quality of life
(QOL) characteristics, and patient/parent satisfaction surveys
and gait analysis with timed 25-yard dash.
2ESULTS
Parents of males who underwent amputation perceived a lower
QOL for their child (p<0.05). No other differences between the
two groups or between the groups and a healthy population
were observed in psychosocial and QOL surveys. All patients and
parents would select the same treatment. Statistically significant
differences in some parameters were identified between the
groups by gait analysis at self-selected walking speed, and no
significant differences in average performance for timed 25-yard
dash. Two patients with amputation underwent three additional
surgical procedures. Twenty-two patients who underwent
reconstruction had an average 3.4 surgical procedures (range,
2-7). Patients required an average of 2.2 prosthetic adjustments/
year and 0.84 prostheses/year (estimated average cost $8,863
per prosthesis). Mean surgical costs for patients undergoing
reconstruction were $24,800 (range, $15,000-$33,600) per
reconstructive procedure and $3,300 (range, $2,600-$4,600) for
removal of lengthening devices.
$ISCUSSION#ONCLUSION
Function, psychosocial adjustment, and QOL after primary
amputation or limb reconstruction in patients with severe
fibular deficiency are comparable and within normal limits for a
healthy population. Parents and surgeons must weigh life-long
prosthetic requirements against increased surgical intervention
for limb reconstruction when treating severe fibular deficiency.
147
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LENGTHENING BONE IN LOW SIZE
0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszanne Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez
Pujay, Edilberto, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios
COUNTRY Peru
0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszanne Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez
Pujay, Edilberto, MD; 5Lamas Calderón, María Caridad, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios; 5Instituto de
Medicina Legal
COUNTRY Peru
/BJECTANDPURPOSEOFTHESTUDY
Presents a study of how retrospective of the unit costing
external, reconstruction and bone lengthening, between the
years 1993-2010, in patients with lower limb poliomyelitis
sequel.
Elongation of bone segments made by with fixative external axial
dynamic monolateral (Orthofix).
%QUIPMENTANDMETHODS
Are included in the work a total of 35 patients), with 57 bony
segments long in total and complete treatment. They were 22
female patients (61.5%), and 13 male patients (38.5%). The
median age was 17.09 years youngest 10.42 years and largest
22.66 years. In 22 patients (61.5%) was bone lengthening femur
and tibia (two segments). Lengthened in total 32 femur (53.8%)
and 25 warm (46.6%). Presented a shortening of 39.28 mm on
average with a minor of 10 mm and larger de107 mm. Use of
some form of upside to compensate for lower limb discrepancy
(taco upwards and sole, Orthotics, etc.). Deambulaban on their
own, either by using canes, crutches or without them.
$ISCUSSION
Of the smear length was 12.57 average sem, (6 to 22 weeks).
Achieved lengthening averaged 46.27 mm (20 to 90 mm).
Corticalizacion (bone formation) duration was on average 30.02
weeks (between 6 and 65 weeks). The total time agreed with
external Fixer (Orthofix) was 44.85 sem average (between
24 and 77 weeks). During the bone lengthening 21 patients
required some type of surgery.
#ONCLUSIONS
Sequels of Poliomielitis, although it says that already it
is eradicated, continues being a great problem and a
great challenge for the Ortopedista Surgeon, by the own
characteristics of the disease and by the invalidante condition
that leaves in many cases, it is for that reason that in the
present work it is to give a solution to the dismetria of inferior
members, but from the functional and biomechanic point of
view, when coming up and avoiding pathologies of hips and
column, and what is but important, improving the quality of life
of these patients and who can be useful to if same and to the
society.
148
/BJECTANDPURPOSEOFTHESTUDY
Low size is a big problem in societies like ours (third), and is
associated with obtaining a social position in many cases, so
currently the bone to gain height, lengthening is becoming
popular, so should be considered a serious, professional and
very strict evaluation to decide on the procedure to be carried
out. Stature without another pathology Association term is taking
as such, depending on the social circle develops the patient, it
even assumes it as such with sizes greater than 1.60 m, then
reach the conclusion that it is an aesthetic bone lengthening.
The patient should be subjected to a thorough psychological
evaluation, should study its social, economic and family
environment.
-ETHODSANDMATERIALS
Introducing six patients between 22 and 32 years, 3 women
and 3 men. Them is bone lengthening in 4 bone segments
each: bilateral tibia and femur. Osteotomy is subtrocanterica in
the proximal shaft of tibia and femur. Monolateral axial Fixer is
placed. It makes physical therapy and rehabilitation from the
immediate surgical post to withdrawal of external Fixer.
$ISCUSSION
Successfully stretch between 9 and 15 cm. Remained range
articulate knees. The main complication was pain in 100% of
patients.
#ONCLUSSIONS
Consideration should be the need for smearing bone to increase
the stature of the patient which thus requires it, taking into
account the complications that this procedure involves, and
whereas the satisfaction that will produce the result in these
six patients presented, despite all the complications introduced,
showed the happiness of the goal.
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0RINCIPAL!UTHOR Pareja, Carlos, MD
CENTRE Caja de Seguro Social
COUNTRY Panama
2ESUME
Damage control is the appropriate handling for a politraumatized
patient to minimize the organic reaction of local defense
avoiding a systemic reaction. Damage control should also
provide stabilization of the muscle skeletal injuries of the patient
minimizing morbility-mortality, and requires the following:
1. Stabilization of muscle skeletal injuries by external fixation.
2. Advanced Life Support and transfer to Intensive Care Units.
3. Definitive treatment of excellency at the right moment.
We are talking about early total care looking for not doing more
damage “PRIMUN NON NOCERE” SAVING LIFE AND FUNCTION
OF THE PATIENT. Stabilizing the affected segments with
immediate external fixation preferably, it will guarantee:
1. Optimize the local and systemic blood flood.
2. Adequate oxygenation of the affected tissues guaranteeing
desired aerobic metabolism. This will minimize additional
lesions in other organs at distance.
Damage control is applied to injuries which are over 25 in ISS
scale (other scales are used too) where life of patient is under
risk. Our goal is to:
1. Immediate identification of patients that require Damage
control.
2. Adequate ventilation-hemorrhagic salvatage and
contamination control.
3. Debridation when required and immediate external fixation.
4. Advanced Life Support and Intensive Care handling.
5. Surgical treatment (osteosynthesis) when conditions are
optimized.
Damage control in Orthopaedics is Important.
1. It became obvius that these patients P.T. were suffering mortal
complications when they were handled with prolonged and
complex early reconstructions.
2. But these mortal complications could be present when
patients were not early stabilized.
Muscle-Skeletal injuries require Damage control:
1. Unstable pelvic fractures.
2. Open femur fractures correlated to severe tissue injury and
significant bleeding.
3. Polifractures or closed bilateral femoral fractures.
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0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
/BJECTIVEANDPURPOSE
Pelvic ring disruption resulting from high energy trauma is
associated with multiple injuries and significant morbidity and
mortality. External skeletal fixation was introduced more than
50 years ago, but used only sporadically until the 1970s when
this form of stabilization gained acceptance. The author analyses
if an external skeletal fixator have any role in the definitive
management of disruption of the pelvic ring.
-ETHODSANDMATERIALS
At the Orthopaedic and Traumatologic Department Umberto I
Hospital of Syracuse, from 2006 to 2010, 25 patients (15 male
and 10 female), range of age 16-68 years old, average ISS 17.4,
were treated with external fixation. The mean follow up was of
about 2 years (range 1-4 years).
2ESULTS
In patients with partially stable open-book (type B-1) injury, it
may be a safer alternative than open reduction and internal
fixation of the symphyseal area. The surgeon must be absolutely
certain, however, that the posterior injury is not unstable or
displacement will occur. In those with the partially stable lateral
compression (type B-2) injury, the outcome is more related to
the pattern of fracture than to the management, and is usually
satisfactory. Many of these fractures can be treated nonoperatively, but in multiple injuries an external frame in the early
phase may be indicated to relieve pain and allow ease of nursing
care. External fixation alone has little place in the definitive
management of the grossly unstable (type-C) injury. In critical
patients and when open reduction and internal fixation may be
delayed, the anterior external fixation should maintain reduction
and is also important in patients being transferred from one
centre to another.
#ONCLUSIONS
The management of disruption of the pelvic ring should be
considered in two phases, life-saving and then the definitive
management of the fracture. In modern methods of treatment,
these phases may be less distinct and may take place
simultaneously.
3UMMARY
1. Politraumatized patient with muscle skeletal injuries require
external fixation and/or debridation and advanced life support
ICU as first handling procedure.
2. Osteosynthesis or definitive treatment must be applied to on
the first adequate stage present between the 5th and 10th day
after trauma.
3. Definitive treatments and osteosynthesis should be avoided
between the 10th and 20th day since it is a risky immunodeppressive period and unfavorable results may arise.
149
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-5,4)0,%42!5-!
0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
0RINCIPAL!UTHOR Lias, Ariel, MD
CENTRE Hospital El Cruce
AUTHORS Romano, Osvaldo Aníbal, MD; Rodríguez, Leonardo,
MD; Viejo Estuard, Silvia, MD; Giammello, Alejandro, MD
CENTRE Hospital El Cruce
COUNTRY Argentina
/BJECTIVEANDPURPOSE
In recent years, the polytraumatized management has changed
considerably, moving from the initial concept of Early Total Care
(ETC), which provided an early and definitive stabilization of
lesions, the search for less invasive surgical methods applied
in emergency to ensure the survival of patients with high
surgical risk. The aim of our study was to provide an appropriate
definition of the DCO, to perform a meta-analysis of literature
on its claims and analyze our results after application of this
principle, identifying clear guidelines based on rationales that
allow algorithms to prepare standards to improve the approach
to the patient polytraumatized.
/BJECTIVEANDPURPOSEOFWORK
Fractures unstable pelvic injuries occur for high energy, implies
multiple associated injuries.
-ATERIALSANDMETHODS
At the Orthopaedic and Traumatologic Department Umberto
I Hospital of Syracuse we treated from 2006 to 2010, 46
polytrauma patients with a mean age of 37 years, 31 males
and 15 females, with skeletal involvement of 75 segments,
distributed as follows: 5 humerus, forearm 6, 20 femoral,
30 tibial and 14 pelvis and acetabulum. Not associated with
orthopedic injuries were distributed as follows: head injury 6 /
46, Shock 4 / 46, thoraco-abdominal injuries and other injuries
22/46 14/46. The average Severity Index Score (ISS) which is
derived was 23.8.
2ESULTS
Of the 20 fractures of the femur, 18 were treated with
intramedullary Osteosynthesis (including 5 for retrograde) with 2
cases of delayed consolidation and 1 case of osteomyelitis, and
2 were stabilized with external fixation with good results.
The initial stabilization with external fixator helps to reduce
bleeding by reducing the intrapelvic volume, but it does not
control the posterior ring injury.
In our department we carry out the treatment with external
fixators in emergencia associated with skeletal traction in cases
of promotion of a hemiplevis.
In reconstructive phase (before three weeks), combined
percutaneous fixation of posterior ring, and ring lesions above
the combination of internal and external fixation, as the case to
be treated.
-ATERIALANDMETHODS
Since May 2009 to May 2010 we treated in our department 14
pelvic fractures, in whole traffic accidents, eight males and six
females. The age range was between 15 and 34. Of the total, 12
patients were initially treated with external fixation.
Were evaluated by panoramic Rx pelvis, projecting out-let
and in-let, and TAC, following the classification of AO Tile in
deciding treatment. We use external tutors, cannulated screws
and reconstruction plates. We combined treatment with
percutaneous external tutor in 4 cases, internal fixation with
percutaneous fixation 6 cases, internal fixation in 2 cases and
external fixation, percutaneous fixation and internal fixation 2
cases.
Were 30 tibial fractures, 10 treated with intramedullary
Ostosintesi, 4 of which met with delayed consolidation and
1 with osteomyelitis and 20 with FE with 5 cases of delayed
consolidation and 2 of osteomyelitis.
Evaluated progress, pain, joint mobility, discrepancies,
neurological damage, returning to work.
With regard to hip fractures, 4 were treated by open fixation
(ORIF), with only one case of delayed consolidation, and 10 with
external fixator, with one case of conversion all’ORIF. There were
no cases of osteomyelitis.
$ISCUSSION
The initial external fixation is of great value for the stabilization
and control of bleeding. Combining it with internal fixation and/
or percutaneous the anatomic and we functional, as well as
early rehabilitation. We avoid large incisions, using minimally
invasive techniques and by reducing infectious complications
and bleeding during surgery.
#ONCLUSIONS
The polytraumatized must be regarded as a “systemic disease”,
which is why the success of treatment requires a thorough
understanding of the pathophysiology of post-traumatic of
resuscitation, triage and timing of intervention.
#ONCLUSION
We believe the combination of internal and external methods
help complete anatomical and functional recovery of these
patients, achieving a rapid social integration.
We also stress with minimally invasive techniques reduce the
risk of infectious and neurovascular complications.
150
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OF CHOICE
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0RINCIPAL!UTHOR Mukherjee, Amit, MD
CENTRE Sisir Sewa Kendra
AUTHORS Mukherjee, Divyashree, MD
CENTRE Sisir Sewa Kendra
COUNTRY India
0RINCIPAL!UTHOR Suksathien, Yingyong, MD
CENTRE Department of Orthopedic Surgery, Maharat Nakhon
Ratchasima Hospital
AUTHORS Suksathien, Rachawan, MD
CENTRE Department of Rehabilitation Medicine, Maharat Nakhon
Ratchasima Hospital
COUNTRY Thailand
!IM
To establish the best treatment modality for diaphyseal
segmental bone loss in Femur.
-ATERIALANDMETHODOLOGY
Fifteen consecutive cases of grade 3 compound fractures with
segmental bone loss treated by the author, using the Ilizarov
frame, and twenty two similar cases with Tubular rail fixator,
with a minimum follow up of 2 years, were selected and
subjected to a comparative study of the following parameters:
Superficial and deep pin tract infections, patient discomfort level,
knee mobility achieved at the end of two year follow up, total
time required for consolidation of the fracture after completion
of the lift, necessity of a secondary procedure like bone grafting
or IM nailing.
$ISCUSSION
Ilizarov fixator has conventionally been used for segmental
lifts due to bone loss arising out of numerous causes like
in treatment of tumours, infections & compound fractures
involving diaphyseal bone loss in Femur. The advantages- Three
dimensional stable fixation, good quality of callous formation,
possibility of lift over a nail, lesser chances for the need of
grafting, early weight bearing. It, however, has some overriding
disadvantages which led to some surgeons use the other
alternative- Tubular rail fixator. The huge advantage, of the level
of patient comfort, lesser pin tract infection and statistically
significant improvement in the degree of knee flexion has tilted
the balance in favor of the rail fixator.
2ESULTS
Of the 15 patients treated using Ilizarov frame 10 had
superficial pin tract infection of which 2 became deep infections
necessitating removal of pins. Only 4 of the 15 in rail fixator
group had superficial infections. Discomfort level recorded on
a score of 5, showed significantly higher levels in cases where
Ilizarov fixator was used. Callus maturation time was, however,
slightly lower in cases of Ilizarov. Range of Knee flexion was
almost complete in rail fixator group as opposed to a 24% loss
in cases treated by Ilizarov. In conclusion, rail fixators were
found to be more suitable for treatment of segmental loss
in femur except in cases where lift had to be done over an
intramedullary devise due to complexity of the fracture.
!IMANDPURPOSEOFTHESTUDY
To evaluate the clinical results and complications of a new
design multifunction dynamic external fixator system for bone
reconstructions.
-ATERIALANDMETHODOLOGY
A new design multifunction dynamic external fixator
system was developed for high energy open fractures and
posttraumatic reconstructions. Twenty-five patients that
required reconstructions between 2005-2008 were included
in this prospective study. There were 9 tibias and 1 femur
intercalary defects for bone transportation, 1 tibial and 1 femoral
lengthening, 3 tibial malunion correction (45, 60 and 75 degrees)
and 10 cases of infected nonunion treatment (7 tibias, 2 femurs
and 1 humerus).
$ISCUSSION
Base on the advantage of Ilizalov’s concept, the new design
multifunction dynamic external fixator system is a monolateral
frame which can be used for bone reconstructions with good
results. In bone transportation, the average new bone formation
was 5.8 cm. (range, 3.5-14) in tibia and 5 cm in femur. The
average healing index in tibial transportation was 44.5 days/cm.
(range, 34.3-60) and the average healing time was 34.5 weeks
(range, 21-64). The healing index in femoral transportation
was 102 days/cm and the healing time was 72 weeks. In bone
lengthening, the tibia was lengthened 3.5 cm in 8 weeks and
the union time was 30 weeks. The femur was lengthened 5 cm
in 16 weeks and the union time was 52 weeks. In malunion
correction, the mean duration for correction was 9.3 weeks
(range, 5-12) and the mean union time was 26 weeks (range,
22-28). From the advantage of dynamization, this external fixator
system can be used to treat infected nonunion with good results.
The mean union time was 30.4 weeks (range, 12-44) in tibia,
24 weeks (range, 22-26) in femur and 12 weeks in humerus.
Pintract infections were found in 1 tibia and 1 femur but good
response to oral antibiotic. No serious complication was found
and no instrumentation failure in this study.
#ONCLUSIONS
Base on the advantages of Ilizalov’s concept, dynamization
and the simplicity of monolateral frame, the new design
multifunction dynamic external fixator system was successful
used for bone transportation, bone lengthening, malunion
correction and infected nonunion treatment with good results
and low complication.
151
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SUBSIDENCE OF CALLOTASIS ZONE IN DISTRACTION
/34%/'%.%3)3!&4%2%84%2.!,&)8!4/22%-/6!,
-%!352%$"92!$)/34%2
0RINCIPAL!UTHOR Gunderson, Ragnhild B, MD
CENTRE Oslo University Hospital Rikshospitalet, Radiology
AUTHORS Steen, Harald, MD; Horn, Joachim, MD; Kristiansen, Leif
Paal, MD
CENTRE Oslo University Hospital Rikshospitalet
COUNTRY Norway
!IMANDPURPOSE
This study was designed to investigate if there is subsidence
of the callus in a lengthening zone after removal of the external
device in distraction osteogenesis (DO).
-ATERIALANDMETHODOLOGY
Radiostereometric Analysis (RSA) is a powerful method which
may be used to detect small movements between fragments. At
surgery small tantalum markers are inserted into the two bone
segments (or more often a bone and a prosthesis component)
to be investigated. The RSA system consists of stereometric
X-ray equipment and a calibration cage. The resulting data
are analyzed by a software program, enabling a calculation of
relative movement between the two segments over time.
We report a study of 16 patients who underwent 17 segmental
LENGTHENINGOPERATIONSONTHETIBIANORFEMURN23!
was performed at the end of the consolidation period before
the external fixation device was removed and later repeated at
a median time of 11 (range 4-32) weeks after frame removal.
The distance between the two intact bone segments, above
and below the callotasis, was measured at each point in time
and the change in this distance between two subsequent
examinations was calculated.
2ESULTS
!MEDIANLONGITUDINALCHANGEOFRANGE
mm across the lengthening zone was observed. Accuracy and
repeatability of the measurements were calculated to be 0.30
mm and 0.43 mm, respectively.
$ISCUSSION
Dealing with RSA in patients with an external fixation device
is a great challenge. Lots of metal increase the risk of hiding
the tantalum markers, which is an obstacle to obtain optimal
analyses.
#ONCLUSIONS
In DO on the femur and tibia no subsidence of clinical interest
occurs after frame removal.
152
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0RINCIPAL!UTHOR Vincent, Maria, MD
CENTRE Northern General Hospital Trust
AUTHORS Wayper, Emma, MD; Dennison, Michael, MD; Royston,
Simon, MD
CENTRE Northern General Hospital
COUNTRY United Kingdom
/BJECTIVES
To evaluate patient satisfaction and pain experienced on removal
of Ilizarov frames in an outpatient setting.
-ETHOD
Seventy consecutive patients who had their frames removed in
the Out Patients Department, had their level of pain scored using
a Visual Analogue Score (VAS) and a simple questionnaire.
2ESULTS
The mean score for frame removal was 4.7 on the VAS. There
was no difference between male and female scores. The age
of the patient does make a difference in the pain score. Pain
increases when there are 4 or more Olive wires to be removed.
#ONCLUSION
Removal of Ilizarov frames in the Outpatient department is a
moderately painful but well tolerated procedure.
Podium
ESTHETIC CORRECTION AND RECONSTRUCTION OF LOWER
%842%-)4933(!0%"9/2)').!,%84%2.!,&)8!4)/.
DEVICES
0RINCIPAL!UTHOR Solomin, Leonid N, MD
CENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
AUTHORS Kulesh Pn, MD
CENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
COUNTRY Russian Federation
2ESUME
In basis of “esthetic” deformity frequently lays “true” orthopedic
pathology. However the aim of these surgeries is not restoration
of proper relations between referent lines of lower extremities
but to achieve the optimal, according to patient’s opinion, shape
of the lower extremities.
The term “esthetic correction” should be used in the cases,
when as the result of surgery referent lines relations and
mechanical axis deviation (MAD) have normal range. The term
“esthetic reconstruction” should be used in cases when to
satisfy patients wish is necessary to brake right relationships
between referent lines and (or) worsen the MAD till abnormal
meanings.
External fixation device allows making correction in
postoperative period with active participation of the patient and
cooperation with him. According to our opinion the obligatory
requirement in treatment of such patients is opportunity
of bringing together both legs till the full contact in early
postoperative period. We have investigated ExFix assembly
which satisfies this requirement. Bench tests have shown
that these ExFix assemblies provide sufficient reduction and
fixation qualities. Use in the assembly combination of straight
and curved half-pins allows using only referent positions for
transosseus elements insertion.
Using these devices we made correction of lower legs shape
in 25 cases. Besides valgization, while having indications,
medialization of tibial bone distal fragment and derotation were
performed. While correction of multicomponent deformity on the
first stage we used new software-based ExFix device Ortho-SUV
Frame (http://www.rniito.org/download/ortho-suv-frame-rus.
pdf). In 20 cases desired result was achieved. In one case
after dismantling of the devices slumping of the regenerates
happened. Pin-hole infection caused its reinsertion happened in
3 cases.
Podium
4(%).42).3)#).34!"),)49/&4(%4!9,/230!4)!,&2!-%
AND THE HEXAPOD RINGFIXATOR
0RINCIPAL!UTHOR Dominik, Seybold, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
AUTHORS Jan, Geßmann, MD; Hinnerk, Baecker, MD; Birger,
Jettkant, MD; Gert, Muhr, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
COUNTRY Germany
)NTRODUCTION
Deformity correction in orthopeadic surgery has become a
new dimension since hexapod based external ringfixators
are available. The hexapod based fixators are widely used in
deformity correction of the lower limb. They are used for primary
deformity corrections and secondary posttraumatic deformity
corrections of the femur, tibia and food and as well in the upper
extremity. The ability of hexapod based fixators to correct all
aspects of a six-axis deformity simultaneously comes with
a side effect of some intrinsic instability of the frames. The
intrinsic instability is defined as the sum of the slackness of all
six telescopic struts and there connection bolts to the rings of
the fixator. Our goal was to determine the amount of intrinsic
instability of the Taylor Spatial Frame and the Hexapod and to
find out how to decrease the system slackness.
-ETHOD
A Hexapod and a Taylor Spatial Frame was tested each on a
universal testing machine UTS Mod. 10 (Ulm, Germany) for axial,
translational and rotational slackness up to 150 N ten times.
Different strut lengths and types were tested. The slackness was
measured by using three displacement transducers (W10TK and
W20TK HBM, Germany) with measuring amplifiers MGC MC55
(HBM, Germany).
2ESULTS
The axial, translational and rotatory slackness was significantly
higher for the TSF than the Hexapod fixator. Both fixators
showed a decrease of the axial instability with longer strut
lengths and an increase of the translational instability. The
rotatory instability was not dependent of the different strut
lengths. The slackness of a single strut of the Hexapod was 0,25
mm and the slackness of a single TSF strut was 0,60 mm.
#ONCLUSION
The Hexapod fixator showed a significant lower intrinsic
instability then the TSF. To reduce the intrinsic instability longer
strut lengths should be used especially to diminish the axial
slackness, which affects the patient’s comfort most.
153
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!$/,%3#%.433)-0,)&)%$02/#%$52%53).'4(%),):!2/6
&2!-%
0RINCIPAL!UTHOR Craveiro-Lopes, Nuno, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
AUTHORS Escalda, Carolina, MD; Villacreses, Carlo, MD
CENTRE Orthopedic Dpt, Garcia de Orta Hospital
COUNTRY Portugal
)NTRODUCTION
Treatment of hip pathology in children and adolescents includes
frequently an intertrochanteric osteotomy, with correction of
deformities in different planes of the space. Usually this type
of surgery is done with a large open, wedge osteotomy with
plate fixation, requiring a second stage surgery for removal of
hardware.
The authors describe a new procedure to perform
intertrochanteric osteotomies in 3 or 4 planes, using a
percutaneous linear osteotomy and fixation with a preassembled Ilizarov frame.
A comparative study was done between the patients operated
on with this technique and a group of patients operated with
plate fixation.
-ATERIAL
The group of 10 patients operated by the Ilizarov procedure (ILI),
aged between 10 and 17 years, were operated between 2002
and 2009 and had a mean of 3 years of follow-up.
The group of 10 patients operated with wedge osteotomy
and plate fixation (OTM), aged between 8 and 18 years, were
operated between 1992 and 2001 and had a mean follow-up of
5 years.
2ESULTS
Results of the comparative study have shown that surgical time
(OTM mean 103 min, ILI mean 52 min) and blood loss (OTM
mean 650cc, ILI mean 64cc) were statistically very different, and
hospital stay statistically different (OTM mean 6.2 days, ILI mean
4.5 days). Consolidation was achieved in all cases of the two
series. Deep infection aroused in a case in each group, leading
to early hardware removal and loss of correction in the ILI case.
Hardware removal was done in all cases of the OTM group,
after consolidation of the osteotomy. In 2 cases a trochanteric
fracture was done because of difficulty on removal of the plate
and screws.
#ONCLUSION
The authors believe that with this procedure, surgery become
simpler, quick and without blood loss. The little surgical trauma
and stability of the assembly allow the patient to walk on the
day following surgery, with partial weight bearing and immediate
functional recovery of hip and knee. The hospital stay is short
and there is no need for 2nd intervention for hardware removal.
154
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EXTERNAL FIXATION
0RINCIPAL!UTHOR Gil Albarova, Jorge, MD
#ENTRE Hospital Universitario Miguel Servet, Zaragoza
AUTHORS 1Gil Albarova, Raúl, MD; 2Gómez Palacio, María Victoria,
MD; 3Iglesias Aparicio, Daniel, MD
CENTRES 1Centro de Rehabilitación y Recuperación de Levante,
Valencia; 2Hospital San Millán-San Pedro, Logroño; 3Hospital
Universitario Miguel Servet, Zaragoza
COUNTRY Spain
/BJECTIVEANDPURPOSEOFTHESTUDY
The assessment of Monolateral External Fixation (MEF) as a
useful method in the osteosynthesis of derotative osteotomies in
childhood.
-ATERIALANDMETHODS
We evaluate 7 patients (5 boys and 2 girls) aged 6 to 13 years,
who underwent percutaneous derotative osteotomy stabilized
by means of MEF. Aetiology was Braquial Plexus Birth Palsy in
two patients (humerus), Posttraumatic deformity in one patient
(femur), Ollier’s disease in one patient (tibia), and Congenital in 3
patients (1 femur and 2 tibias). Leg lengthening was associated
in cases of posttraumatic deformity and Ollier’s disease. Average
Hospital stay was 2 days. Free movement of the operated
extremity was allowed and encouraged during postoperative
period, in order to early functional recovery.
Patients were revised monthly with X-ray study. After simple
osteotomy, MEF remotion was performed 8 weeks after surgery
in humerus, 10 weeks after surgery in tibia and 12 weeks after
surgery. After osteotomy and lengthening, MEF remotion was
performed 18 weeks after surgery. No complications were
observed.
$ISCUSSION
MEF was well tolerated by all patients, who were joining to
school activities during first postoperative week. Progressive
sports activities were allowed two months after MEF remotion
in upper extremities osteotomies, and after four months in lower
extremities. Both, patients and parents were satisfied by the
functional and aesthetic results.
#ONCLUSION
MEF is a effective method of bone fixation in derotative
osteotomy during childhood. As advantage, progressive bone
lengthening may be associated if needed. In our experience,
MEF in combination with percutaneous osteotomy allows
excellent functional and aesthetic results.
Podium
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02/8)-!,4)")!
0RINCIPAL!UTHOR Gil Albarova, Jorge, MD
CENTRE Hospital Universitario Miguel Servet, Zaragoza
AUTHORS Iglesias Aparicio, Daniel, MD; Bregante Baquero,
Juan, MD
CENTRE Hospital Universitario Miguel Servet, Zaragoza
COUNTRY Spain
/BJECTIVEANDPURPOSEOFTHESTUDY
Monolateral external fixation (MEF) in combination with
progressive distraction of a percutaneous osteotomy was
evaluated as a suitable method of progressive correction of a
combined deformity of the knee (in both, sagital and coronal
plane) in children who suffered a growth arrest of the physis
located under tibial tubercle.
-ATERIALANDMETHODS
We present two boys aged 14,6 years, in whom asymmetrical
closure of the left proximal tibial physis occurred without a
clear aetiological factor. Light comparative tibial shortening
was observed in all cases (10-15 mm). Both patients showed
a history of progressive deformity, with pain located in the
anterior and lateral aspect of the left knee after sports activity
(football), without any previous history of significant injury. A
moderate hyperextension of the knee (15-20º) combined with an
external tibial rotation (5-15º) and valgus deformity (15-20º) was
observed in both patients.
Both two underwent a progressive deformity correction using
MEF, after tibial percutaneous osteotomy. Distraction began
after a delay period of 6 days (0,5 mm/12 hours), dinamization
of the external device began 6 weeks after surgery and MEF
was removed 12 weeks after surgery. Walk with crutches
and progressive weight bearing was allowed from the first
postoperative day, and prolonged 3 weeks more after MEF
remotion. Progressive sports activity was allowed 6 months after
surgery.
Podium
CLOSED CORRECTION OF TIBIAL TORSION BY THE ILIZAROV
4%#(.)15%9%!23&/,,/750
0RINCIPAL!UTHOR Lapidus, Lev, MD
CENTRE Assaf Harofe Medical Center, Zerifin
AUTHORS Odessky, Jacob, MD; Shitrit, Reuven, MD; Copeliovich,
Leonel, MD
CENTRE Assaf Harofe Medical Center, Zerifin
COUNTRY Israel
/BJECTIVES
On the previous meeting in St. Petersburg we have presented
our concept for treating pathological Tibial Torsion in young
children. In this study we present a 4 year follow-up following
closed correction of Tibial Torsion.
-ETHOD
The aim of the study was to find a less traumatic way to correct
pathological Tibial Torsion in children. Our basic concept was to
use the plastic property of immature bone. We treated 8 children
with Congenital Clubfoot and residual Internal Tibial Torsion by
means of closed derotation using the Ilizarov technique. The
age range was 4-7 years, the mean correction was 22 degrees
and the rate of correction was 1 degree per day. Fixation after
complete correction was 6 weeks long. We used a standard
frame of Ilizarov apparatus with Hexapod Set. All patients had a
good correction. The average follow up was 48 months (range
36-83 months). In all cases the correction was maintained
throughout the follow up period.
#ONCLUSIONS
This correction method of Tibial Torsion was found to be
minimally invasive and safe. A good correction was achieved
and improvement in gait pattern that was maintained throughout
the follow up period.
$ISCUSSION
During skeletal maturation, the anterior part of the proximal
tibial epiphyseal growth plate is the most vulnerable to injury,
due to the not uniform histological structure of this area.
Repetitive trauma may be a factor in premature physeal closure
in adolescents. In our patients MEF allows continuous and
progressive correction. Preoperative planning to allow correction
in both coronal and sagital plane is necessary. Precise location
of pins, osteotomy design and meticulous placement of MEF are
mandatory.
#ONCLUSION
Although other methods as physeal bar resection has been
proposed for young children, MEF in combination with
progressive distraction of a percutaneous tibial osteotomy was
a suitable method of progressive correction of this combined
deformity of the knee in older children.
155
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0RINCIPAL!UTHOR Langendoerfer, Micha, MD
CENTRE Olgahospital Stuttgart
AUTHORS Eberhardt, Oliver, MD; Wirth, Thomas, MD
CENTRE Olgahospital Stuttgart
COUNTRY Germany
0RINCIPAL!UTHOR Elbatrawy, Yasser, MD
CENTRE Azhar University
AUTHORS Elgebeily, Mohamed, MD; Mahran, Mahmoud, MD
CENTRE Ain Shams
COUNTRY Egypt
2ESUME
The appropriate treatment of severe cases of Blount’s
disease requires a complete correction of the bifocal varus
deformity in the lower leg. The first level of the deformity is
the pathognomonous depression of the medial tibial plateau
causing also collateral ligament laxity. The second level is the
metaphyseal varus in combination with an torsion inwards and
an overall leg length discrepancy.
!IMOFTHESTUDY
Evaluation of the guided growth principle in correction of angular
deformities around the knee in skeletally immature patients.
Three patients (six extremities) were treated by a tibial,
intraligamentous Langenskiöld’s hemiplateau elevation and by
a proximal, metaphyseal osteomy of the tibia using the Taylor
Spatial Frame for further deformity correction. In the first case
the hemiplateau elevation was performed separately, followed
by the fixateur assisted correction at subtuberosity level. The
following four extremities were treated by a simultaneous
correction. In two patients Langenskiöld grade V of Blount’s
disease was found, in the third patient epiphyseal dysplasia
with Blount-analogous morphology in the lower legs could be
described.
The mean age was 9 years (6,5-12 y.), the initial amount of
deformity was 15º (13-17º) of proximal tibial varus, 28.3º
(18-35º) tibial plateau angle, 16.7º (10-20º) inwards torsion
deformity. A complete correction of the mechanical axis to
0-3º of valgus could be reached in all cases with a MPTA of
87-90º and an average lengthening of 2.3 (2-3) cm. A knee
arthrography was added to validate the correct elevation of the
tibial hemiplateau.
The Double-Elevation Osteotomy in combination with the Taylor
Spatial Frame is a safe and the multidimensional deformity of
Blount’s disease ideally addressing procedure.
-ATERIALANDMETHODOLOGY
Our series included application of 43 eight-plates in 22 patients,
14 patients were males and 8 were females, the average age
at surgery was 6.1 years, and average follow up was 3.4 years.
14 cases had genu varun and 8 genu valgum. 13 cases were
bilateral of which 4 cases the deformity was both femoral and
tibial. Evaluation of the source of the deformity either proximal
tibial or distal femoral or combined were done in all cases.
The Levine angle or the metaphyseal diaphyseal angle in distal
Femur were measured in all cases. Also MRI was done in cases
that were suspected to have Bar or permanent fusion of the
physis on one side. Original 8 shaped plate of Orthofix was
applied to the opposite side of the physeal plate, exactly with
two parallel cannulated screws, one in the metaphysis and one
in the epiphysis to stop or decrease the growth rate on that
side temporary, aiming for gradual correction of the deformity.
Clinical and X-ray evaluation were done every 6 months before
deciding the proper time for plate removal after correction of the
deformity.
2ESULTS
Full correction were achieved in 31 physes out of 43 plates
applied to them. Partial correction were achieved in 8 physeal
deformities. And 4 achieved no correction at all.
$ISCUSSION
We used to do osteotomy and gradual or acute correction and
use either cast, external or internal fixation to treat these cases
before evolution of the 8 plate guided growth principle.
#ONCLUSION
8 plate is a valuable tool to correct physeal problems around
the knee in skeletally immature patients without the need to do
massive operation with osteotomies or devices application in
many cases and guided growth principle is proved to be safe
and effective in treatment of angular deformities around the
knee with advantages over other commonly used techniques.
156
Podium
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0RINCIPAL!UTHOR Mitkovic, Milorad, MD
CENTRE Ortopedsko-Traumatoloska Klinika
AUTHORS 1Milenkovic, Sasa, MD; 2Micic, Ivan, MD; 1Mladenovic,
Desimir, MD; 1Golubovic, Zoran, MD; 1Mitkovic, Milan, MD
CENTRES 1Ortopedsko-Traumatoloska Klinika; 2Ortopedska
Klinika, Nis
COUNTRY Serbia
)NTRODUCTION
Bridging external fixation frame leads to joint stiffness and
cartilage damage. It is presented one simple method of
transforming bridging frame to dynamic frame providing so
normal joint motion in the treatment of complex intraarticular
fractures.
-ETHOD
As a clinical material we have used 52 patients with rigid or
dynamic external fixation of ankle and knee joints. As external
fixation device we have used Mitkovic external fixation system
which consists of only 3 components: bar, carrier and clamp.
The same system is suitable for axial dynamic fixation of bones,
and for dynamic fixation of different joints, providing flexionextension bat preventing varus-valgus. We also used original
device for joint axis rotation finder. Minimal internal fixation has
been used in 51 fractures.
2ESULTS
Average time of healing was 1-4.5 months, depending of joint
(shortest in wrist and longest in knee joint). End functional
results in intraarticular fractures were: very good 20%, good
58%, fair 18%, and poor 4%.
$ISCUSSIONANDCONCLUSION
Intraarticular fractures include severe injuries, with the
comminution and displacement of fragments with damages
of soft tissue. Rigid bridging frame is suitable for short time
fixation but dynamic bridging frame is one of the best solutions
for these fracture treatment. According to our experience, the
best results have been obtained after transforming of rigid to
dynamic bridging frame or after excluding bridging part of frame
and engaging pins in epiphyseal or metaphyseal area. This
procedure is performed after 2-4 weeks depending of the joint.
Procedure is ordinary done in out patient clinic as it is painless.
The external fixation system we used provides these possibilities
without additional components regardless of pins position.
Special axis rotation finder provides additional possibilities for
accurate frame positioning, if dynamic bridging frame used. It
can be concluded that dynamic external fixation of joint gives
promising results in intraarticular fractures treatment.
Podium
42%!4-%.4/&#/8!6!2!54),):).'%84%2.!,&)8!4/2
0RINCIPAL!UTHOR Hefny, Hany, MD
CENTRE Ain Shams University
AUTHORS Elgebeily, Mohamed, MD
CENTRE Ain Shams University
COUNTRY Egypt
!IMANDPURPOSEOFTHESTUDY
Evaluation of the Ilizarov method in managment of coxa vara,
and illustrating its advantages over other methods.
-ATERIALANDMETHODOLOGY
Our series included 9 patients, two cases were bilateral, 4
patients were males and 5 cases were females, the average age
at surgery was 7.6 years, and average follow up was 3.4 years.
Monolateral LRS fixator was used in 3 cases and 5 cases with
Ilizarov fixator. There were 5 patients with infantile coxa vara,
one patient had fibrous dysplasia and one patient had proximal
femoral focal deficiency.
$ISCUSSION
A total of 11 subtorochanteric osteotomies were performed.
2 cases had failed subrochanteric osteotomies with plate and
screws. All of the procedures had greater than 2 years follow up,
all osteotomies healed without need for revision except one case
with fibrous dysplasia which was done twice due to fracture of
osteotomy site after falling on her side. The neck shaft angle
was corrected from the preoperative value of 20º to a final value
of 120.5 and HE angle was improved from 75-34.3º.
#ONCLUSION
Our technique proved to be safe and effective in treatment
of proximal femoral deformity (coxa vara) and limb length
discrepancy, with advantage over commonly used open
techniques providing available alternative fixation method.
157
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42%!4-%.4/&#/.'%.)4!,#/8!6!2!53).'),):!2/6
EXTERNAL FIXATOR
Podium
ARTICULATED EXTERNAL FIXATOR IN SPASTIC HIP
DISLOCATION
0RINCIPAL!UTHOR Rady Abdallah, Yehia, MD
CENTRE National Medical Institute In Damnhour
COUNTRY Egypt
0RINCIPAL!UTHOR Llusa Pérez, Manuel, MD
CENTRE Hospital Vall D’Hebron
AUTHORS 1Pacha Vicente, Daniel, MD; 1Morro Martí, María Rosa,
MD; 2Pérez Montoya, Marta, MD; 1Nardi Vilardaga, Joan, MD
CENTRES 1Hospital Vall D’Hebron; 2Asepeyo
COUNTRY Spain
2ESUME
Coxa vara is a decrease in the femoral neck/ shaft angle which
varies between 135º and 145º in children. It may be acquired
secondarily to SUCE, Perthes, disease, sepsis, rickets, or fibrous
dysplasia and all of which has a peculiar radiological features.
Coxa vara may be a present as a part of manifestations of a
generalized growth disturbance or CFD.
Infantile, or congenital coxa vara was differentiated by Fairbank
in 1928 by specific radiological appearance in which a triangular
portion of the inferior part of the femoral neck adjacent to the
head is separate from the remainder of the neck a feature not
usually seen in other types of coxa vara.
The first description of infantile coxa vara was by Fiorani
(1881), and Hofmeister (1894) was the first one who coined the
term coxa vara. It is uncommon condition, its incidence was
estimated to be 1: 250,000 live births. Unilateral involvement is
more common than bilateral in ratio 2:1.
Sixteen patients with infantile coxa vara constitute the material
of this study, 10 boys and 6 girls, their age ranged between
5 and 16 years with average 8.34 years. The right side was
affected in 7, the left in 4, while the affection was bilateral in 5
patients. The ratio of unilateral to bilateral affection was 2.5: 1.
The main indication for surgery neck/shaft angle is 90º or
less, or epiphyseal/Hilgenreiner angle is 60º or more. Through
direct lateral approach to the proximal femur an oblique
subtrochanteric osteotomy, fixation by Ilizarov arches and half
pins with restoration of the neck/shaft angle to the most possible
near normal angle. Dega osteotomy was needed in one patient
to restore the acetabular dimension prior to the subtrochanteric
osteotomy. The postoperative include ambulation from the first
postoperative day.
The results were satisfactory in all patients. One patient need
bone graft due to delay union at the site of osteotomy.
Treatment of infantile coxa vara by subtrochanteric osteotomy
and Ilizarov external fixation allow correction of severe angle
deformities, continuous angle adjustment until complete
union achieved and so there was no need for another surgical
interference.
/BJECTIVEANDPURPOSEOFTHERESEARCH
Hip alterations in patients with spastic cerebral palsy represent
an important and relatively frequent problem. In patients
who can walk a painless and stable hip is required, with an
acceptable range of motion. In patients who can not walk a
painless hip is also required to provide a certain range of motion
in abduction and flexoextension which permits them to sit and
gain an appropriate hygiene.
Chronic and painful luxation are problems of difficult solution.
We present the use of articulated external fixator placed from
the pelvis to the femur as an alternative method to control the
postoperative period until healing of soft tissues and to allow
mobility after performing the subtrochanteric exeresis of the
proximal femoral epiphisis, in case of inveterate painful hip
luxation in spastic cerebral palsy.
-ATERIALANDMETHODS
We present 10 clinical cases of patients with spastic hips
dislocation.
The surgical technique was performed with the patient supine
through a lateral approach to the hip. The proximal epiphisis
of the non-reductible posteriosuperior dislocated femur was
identified and the capsule was opened. The articular surfaces
were identified verifying the cotyle dysplasia and deformity with
articular destruction of the femoral head.
$ISCUSSION
We think that the use of an articulated external fixator, can
be a good alternative to stop the deforming force produced
by the spastic musculature. It also permits the control of the
femoral stump and avoids shortening of the extremity, keeping
the femoroacetabular space filled by the myoplasty until the
healing of the soft tissues. At the same time, as the external
fixator is articulated, it is possible to mobilize the patient from
the decubitus position to a chair. An associated bandage is not
needed, hygiene is possible, and inspection of the cutaneous
condition, postural changes are easy. In general, the handling of
these complex patients improve.
#ONCLUSION
To conclude, we think that the association in spastic patients of
an external fixator articulated, in subtrochanter exeresis of the
proximal femoral epiphisis in chronic painful luxation of the hip,
can be an alternative worth to be considered.
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RECONSTRUCTION
0RINCIPAL!UTHOR Saied, Almohamady, MD
CENTRE Azhar University
AUTHORS Alsobhi, Gamal, MD; Elbatrawy, Yasser, MD
CENTRE Azhar University
COUNTRY Egypt
2ESUME
Hip joint instability in the young adult is a difficult problem.
Patients with an unstable hip secondary to septic epiphysitis,
ununited fracture neck femur or post traumatic neglected
dislocation hip usually have loss of boney fulcrum from the
proximal femur associated with shortening of the limb and
positive trendlenberg gait.
In this work we report our results by pelvic support osteotomy
using the Ilizarov method. From 1999 to 2007, 12 patients (9
females and 3 males) with an unstable hip joint were treated in
the orthopaedic department of Al-Azhar University. Their mean
age was 21.1 years (range: 9 to 35). The main complaints were
pain, leg length discrepancy, limping, and limited abduction
of the hip. All patients underwent proximal femoral valgus
extension osteotomy and distal femoral varus osteotomy for
lengthening and alignment adjustment. The average follow-up
ranged from 2 to 7 years. All hips were pain free at follow-up
except one. The Trendelenburg sign became negative in 11
patients. The limb length dicrepancy was corrected, and the
alignments of the affected limb were re-established. One patient
had a lurch gait.
The Ilizarov technique for hip reconstruction includes double
femoral osteotomies. Proximal valgus extension osteotomy
which provides stability of the affected limb under the pelvis
and maintained some motion of the hip joint, while the distal
osteotomy allows for correction of limb length discrepancy and
eliminating the secondary valgus effects created by the proximal
osteotomy. This operation is recommended for young age patient
in which joint replacement has no role.
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0RINCIPAL!UTHOR Salameh, Ghassan, MD
CENTRE Center for Limb Lengthening and Reconstruction
COUNTRY Syria
2ESUME
Treatment of pelvic obliquity often depends of hip deformity
and consider a special method for correction, hip and knee axis
need a special correlation of alignment for this reason a special
hinges are modified for treatment of either isolated hip, knee
deformities or combined, a special hinges modified for treatment
both of hip and knee deformities, the used hinges are modified
system of Salamehfix4, [SLDF4].
From 2002 to 2009, 90 cases where treated with various hip
and knee deformities.
Cases which treated are congenital or acquired femur
deformities, neglected hip dislocations or subluxations or post
traumatic and post paralytic hip mal alignment and the main
principal procedure done it’s the pelvic support osteotomy
according to Ilizarov principal in treatment of Neglected
dislocations in order to restore femur length and hip and knee
alignment, the same principal was used in treatment some
of hip post paralytic problems, because of muscle and bone
insufficiency we have to make bony support to the pelvis or
even changing the hip angel in order to replace some of muscle
paralyses insufficiency this will decrees of Trandelenburg gait
and limping and at the same time we can restore limb length
inequality and correction of knee deformity. Other cases where
treated are some of hip and knee post traumatic or congenital or
even some cases of Osteoarthritis.
Complications where mostly superficial pin infection which
treated locally.
#ONCLUSIONS
Correction of hip deformity is very essential for treatment of
pelvic obliquity and the used system is differs by simplicity,
small size in correlation to its functional hinges and stability of
fixation and gives good results.
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THE BOX APPROACH
0RINCIPAL!UTHOR Abbas, Kashif, MD
CENTRE Aga Khan University Hospital
COUNTRY Pakistan
)NTRODUCTION
Wide varieties of treatment modalities are available in the
management of acute femoral trauma. External fixation using
hybrid circular system is an excellent device for difficult
fractures with limited treatment options. We intended to evaluate
management of complex femoral fracture treated with Ilizarov
apparatus and their final outcome.
/BJECTIVES
Aim of study is to determine outcome of patients with acute
complex femoral trauma managed with circular external fixator.
-ATERIALSANDMETHODS
The clinical and radiological outcome of 21 patients and 22
femur treated between Jun 2005-Dec 2008 at Aga Khan
University were assessed. Mean follow up of 20 months is
available for these patients. Sander’s score was used to evaluate
the clinical results.
2ESULTS
All cases had fresh comminuted fractures of either the proximal
or distal femur. Majority had open grade III injury. They were
non-reconstructable with standard AO options. Complications
are recorded as minor and major depending on repeat operating
room visit. Only one patient required surgery for knee stiffness,
rest was managed in an outpatient setting. Overall assessment
of recovery was based on Sander et al functional outcome rating
system. It was graded excellent in 8 patients, good in 6 patients
and fair in 6 and one poor as he died 2 weeks after surgery due
to multiple organ dysfunction.
#ONCLUSIONS
We recommend use of circular external fixator for salvage of
severely comminuted and open fractures of femur with extensive
soft tissue injury where alternate methods are expected to fail.
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0RINCIPAL!UTHOR Aybar Montoya, Alfredo, MD
CENTRE Universidad San Marcos
COUNTRY Peru
/BJECTIVEANDPURPOSE
Show experiences in hip fractures, laterals and medials, with
external fixation. Alternative to internal fixation procedures.
-ATERIALANDMETHODS
Since 1984 to 1994, it was handled 62 fractures, 13 medials
and 49 laterals. 35 women and 27 men. Their ages ranged
from 13 to 94 years. Fifty-four were reduced and fixed without
surgical approach. For the surgical procedure was sufficient the
common table operations, requiring a perineal support of cloth
tied to the operating table for reduction maneuvers. In all cases
we worked with radiographs (C Arm). The external fixator used
was the one called “disposable”.
$ISCUSSION
The classic procedure for hip fractures is the surgical approach
and fixation with implant osteosynthesis varieties. In elderly
patients -medial fractures- prosthetic replacements are
preferred. External fixation nails introducing percutaneous
are minimally aggressive when compared with the classic
osteosynthesis. When applied within the first days of the
accident an adequate reduction and sufficient fixation are
achieved until union. Since the immediate postoperative the
patient can move relatively. Within the fourth to sixth week
they can walk with support. Although external fixation can be
uncomfortable, well tolerated by patients until his retirement.
#ONCLUSIONS
Fifty-three fractures healed in an average of 6.85 months. The
medial fractures corresponded to children and adult patients
younger than 60 years (median 35 years). Seven died during
their evolution, other causes, between 22 and 90 days after
surgery (mean age 86 years). The first case was an 84-years
old woman with fracture basicervical temporarily immobilized
for two months that she made a total prosthesis. A subcapital
case, did not union (male, 40 years, operated at 32 days of the
accident, gunshot wound). In general, trochanteric fractures took
less time to consolidate (average 5.8 m). In no case, patients
demanded the removal of fixator or to exchange it for another
procedure. We currently have over 200 cases and combined,
where possible, with percutaneous intramedullary nail or
screws.
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OF OSTEOPOROTIC TROCHANTERIC FRACTURES
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INTERTROCHANTERIC FRACTURES IN THE ELDERLY
0RINCIPAL!UTHOR Christodoulou, Evangelos, MD
CENTRE General Hospital of Karpenisi
AUTHORS Saras, Emanouil, MD; Chrysikopoulos, Theodoros, MD
CENTRE General Hospital of Karpenisi
COUNTRY Greece
0RINCIPAL!UTHOR Salom Ramos, José, MD
CENTRE Orthopaedic Surgeon
AUTHORS 1Nazzoure Nazameh, Marcos, MD; 1Pérez Tovar, Juan,
MD; 1Orta Martínez, Héctor, MD; 2Terrizzi Spadaro, Carmela, MD;
3
Salazar Sánchez, Joanna, MD
CENTRES 1Orthopaedic Surgeon; 2Paediatric Physian; 3Resident
Student
COUNTRY Venezuela
)NTRODUCTION
The Osteoporotic Trochanteric fractures should be treated with
minimal surgical trauma, leaving intact the soft tissue envelop.
In the same time there is a need for early rehabilitation in order
to avoid other systemic disorders in the elderly. The new external
fixators combined with hydroxyapatite-coated pins promise
good stability and no pin loosening.
-ATERIALANDMETHOD
32 patients were treated with a gamma-nail or an external
fixator. They were included in this study according these criteria:
age over 75, female, T-score lower than -2.5 and AO type A1 or
A2. We evaluated the postoperative fracture stability, the loss or
no of the reduction, the need for blood transfusion, the operative
time and the patient’s satisfaction.
2ESULTS
The mean operative time for the gamma-nail was 29±6
min. and 41±5 for the external fixation. The need for blood
transfusion was minimal for both groups. The achieved fracture
reduction was very good and there was no loss of reduction
until fracture’s healing in both groups too. Early weight bearing
was allowed only in the patients treated with gamma nail. The
patients think the external fixator made their living difficult
(discomfort with the clothes and need of keeping the Ex-Fix
clean). We had three cases with pin track infection.
#ONCLUSION
The external fixation has some advantages only when it is
compared with the Dynamic Hip Screw (short operative time,
minimal blood loss, minimal trauma). Gamma-nail is fastest,
stable for immediate weight bearing and is better tolerated by
the patients.
/BJECTIVE
To demonstrate the effectiveness of external fixation as
definitive treatment of intertrochanteric fracture of femur (FIF) of
the elderly.
-ATERIALSANDMETHODS
A prospective study of patients aged between 60 and 105 years
with a diagnosis of FIF treated with Ilizarov external fixator type
who were admitted to Department of Orthopedic Surgeon at
the Hospital Universitario Ruiz y Páez during the period January
2006 to December 2009. A total of 68 elderly patients with FIF
were operated after spinal anesthesia, reduction was performed
under fluoroscopy by a percutaneous technique and placement
of Ilizarov external fixator type specially designed for this study,
which included a hinge system.
2ESULTS
The average predominant age was between 71 and 100 years.
The type III FIF Kyle and Gustilo classification was the most
frequent (59%). Most of these patients had associated diseases,
the most frequent being hypertension, pulmonary and heart
disease. The duration of surgery was between 30 and 90
minutes. Most of these patients could be deployed and tested
their joint movements during the first 72 hours after surgery.
The consolidation time was 9 to 12 weeks in 100% of cases.
Only 3% had complications such as loosening of the pin, 7
patients died during the first six months and one case presented
postoperative osteonecrosis deserve a partial joint replacement
prosthesis Thompson. The Quality of Life Scale as Harris
was good in 62% of cases operated on with this technique.
Postoperative cervical diaphyseal angle was in the normal
range in 62% of cases, 35% with coxa vara with some degree
of shortening that did not limit ambulation, joint ranges were
functionally acceptable in most cases.
#ONCLUSION
External fixation in the definitive treatment of the FIF in the
elderly is a minimally invasive technique that guarantees high
mechanical stability of the fracture, thus allowing for early
mobilization and rehabilitation of the patient, minimizing the
general and local complications. The results are similar or
superior to those obtained by conventional techniques reported
in the literature.
+EYWORDS
Elderly, femur, intertrochanteric fracture, multiplanar external
fixator.
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0RINCIPAL!UTHOR Pareja, Carlos, MD
CENTRE Caja de Seguro Social
COUNTRY Panama
2ESUME
Fractures in the area trocantericas constitute a problem for
health is published implants extramedullary led by dhl traditional
intramedullary by gamma, nail resolve these cases, but with
25-30% of mechanical failures (collapse-cut out) particularly in
unstable fractures.
%PIDEMIOLOGY
Elderly patients have submitted a considerable increase in these
injuries and usa 400,000 occupy year 25% of the beds. We talk
about 1.7 million in 1990, this figure was 6.3 million in 2050.
Surgical treatment 99% of cases with implants troops, which
avoid the prostration and minimize the mortality of about 30% in
first year with other methods, providing acceptable quality of life.
"IOMECHANICS
The trocanterica area supports highly complex forces,
comportandose as a column of loads, where forces act
excentricamente to its centreline, why the high failure %
mechanical with the dhl or gamma nails the standard goal in
many countries.
Our experience: in june 2004, in our hospital rafael hernandez of
social security of panama, inciamos the use of the implant called
pccp. Developed by dr and godfried of israel, which consists
of a plate and two screws for the neck of the femur with an
instrumental really honored that is concoe as surgery minimum
invasive fractures of the hip.
!DVANTAGES
1. Surgery minimum actual invasive (minimum damage to all
tissues) because it is two wounds of 2 cm, each one-only.
2. Minimum quirurgico-anestesico time of no more than 30
minutes (skin to skin). What significaria “minimum morbimortality”.
3. You need to apply blood to the patient.
4. Apoyo to 24 with walker (walker).
5. Minimum pain in surgical post.
6. Alta hospital in 72 hours of operated.
7. Bajos costs for the institution.
#ONCLUSIONS
Our experience on passed 600 cases in > 5 years, with positive
results, we are encouraged to continue this type of management
in trocantericas, injuries where not affected the side wall or
involved are the area sub-trocanterica.
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0RINCIPAL!UTHOR Greco, Andrés Luciano, MD
CENTRE Hospital Municipal Dr. Eduardo Wilde
AUTHORS Colletta, Daniel, MD; Vaccarelli, Alberto Manuel, MD;
Guerrero, Claudio Héctor, MD; Garofalo, Mario, MD
CENTRE Hospital de Wilde
COUNTRY Argentina
/BJECTIVEANDPURPOSEOFLABOR
Most of these fractures in our department are decided by
internal fixation as a method of choice, but still a percentage
of them, where the clinical condition threatening the life of
the patient (severe multiple trauma, elderly patients with the
anesthesia, etc.). We make use of monolateral external fixation
as alternative treatment, thereby minimizing complications
further increase the risk of life.
The presence of these complex patients motivated to carry out
research and development of a monolateral external fixation
system in order to:
s $ECREASEDANESTHETICTIME
s 0LACEMENTOFEXTERNALlXATORASSISTEDLOCALANESTHESIA
s $ECREASEDSURGICALTIME
s %ARLYMOVEMENTSOFTHEPATIENT
We classify the signs as:
s !BSOLUTEOPENFRACTUREOFTHEPROXIMALFEMURSEVERETRAUMA
patients, the anesthesia.
s 2ELATIVECOMMINUTEDFRACTURESDELAYEDINTERNALlXATION
material or lack of such material.
-ATERIALSANDMETHODS
From march 1992 to january 2010 were treated 89 cases with hip
monolateral external fixator, of which 39 cases (43.82%). Were
females and 50 cases (56.17% ) Male. The mean ages for females
was 78 years (60-96 years) and for males 61 years (40-82 years).
7ITHRESPECTTOCLAIMS
l-36 cases (40.44%) had contraindication to general anesthetic.
ll-38 cases (42.69%) delay in obtaining the osteosynthesis
material. III-15 cases (16.85%) comminuted fracture.
Regarding the postoperative protocol we have taken as active
mobilization in bed at 24 pm., sitting on the edge of the bed at
48 pm. and within 72 hours get out of bed on crutches a month
without charge support and 30% with crutches after external
fixator removal indicated full support without the crutches.
$ISCUSION
The monolateral external fixator in fractures of the hip
side a valid alternative, this is not to supplant the internal
osteosynthesis commonly used but reduce morbidity in elderly
patients with high surgical risk and severe multiple trauma.
#ONCLUSION
From our experience we believe, without discarding the
internal synthesis methods that external fixation is a valid
alternative for the resolution of such fractures when the patient’s
circumstances do not permit major surgery.
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0RINCIPAL!UTHOR Abbas, Kashif, MD
CENTRE Aga Khan University
AUTHORS Umer, Masood, MD; Rashid, Haroon, MD
CENTRE Aga Khan University
COUNTRY Pakistan
0RINCIPAL!UTHOR Nogueira Silva, Wagner, MD
CENTRE Hospital Da Baleia-Bh
AUTHORS 1Oliveira Gustavo, Andre, MD; 1Silva Senna, Guilherme,
MD; 2Lovisetti, Luigi, MD; 2Catagni Angelo, Maurizio, MD
CENTRES 1Hospital Da Baleia-Bh; 2Ospedale Di Lecco
COUNTRY Brazil
)NTRODUCTION
Wide varieties of treatment modalities are available in the
management of acute femoral trauma. External fixation using
hybrid circular system is an excellent device for difficult
fractures which cannot be fixed with conventional AO implants.
This happens in delayed presentation of open fractures or
juxta-articular fractures proximally and distally. We intended to
evaluate management of such complex femoral fracture treated
with Ilizarov apparatus and their final outcome.
/BJECTIVES
Aim of study is to determine outcome of patients with acute
complex femoral trauma managed with circular external fixator.
-ATERIALSANDMETHODS
The clinical and radiological outcome of 14 patients treated
between Jun 2005-Dec 2008 at Aga Khan University were
assessed. Mean follow up of 20 months is available for these
patients.
2ESULTS
All cases had fresh comminuted fractures of either the proximal
or distal femur. They were non-reconstructable with standard AO
options. Minor complications related to frame were managed in
outpatient setting. Overall assessment of recovery was based
on Sander et al functional outcome rating system. It was graded
excellent in 6 patients, good in 4 patients and fair in 4.
#ONCLUSIONS
We recommend use of circular external fixator for salvage of
severely comminuted and open fractures of femur with extensive
soft tissue injury where alternate methods are expected to fail.
2ESUME
Pseudoarthrosis of the humerus: treatment with Ilizarov’s
technique.
/BJECTIVE
The Ilizarov’s method must be reserved to treat lesions with the
classic hasn’t good results.
-ATERIAL
The authors present the results obtained in 158 patients with
nonunion of the humerus after treatment with Ilizarov’s external
fixator being 70 patients treated in Orthopeadics Service of Prof.
Matta Machado-Hospital da Baleia-FBG-Belo Horizonte, Brazil
and 88 patients treated in Orthopeadics Service of Ospedale
Generale di Lecco, Italy.
-ETHOD
We analyze biomechanical principles, basic burviilding, and the
safe conditions for the removal of the apparatus. We discuss
the surgical indications for acute humeral fractures and for the
classical treatment for humeral non union.
2ESULTS
Time of frame.
Brasil 7,4 months.
Italy 5,6 months.
Consolidation 96%.
Bone transport 4 patients.
#OMPILCATIONSMEDIANNEUROPRAXIADURINGBONETRANSPORT
2EFRACTUREPATIENTSTREATEDSWITHOTHERFRAMEAND
consolidation.
Shadow and elbow rom-no diference after frame remotion.
163
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CLOSED REDUCTION AND EXTERNAL FIXATION ILIZAROV TYPE
).4(%42%!4-%.4/&02/8)-!,(5-%253&2!#452%3
0RINCIPAL!UTHOR Dominik, Seybold, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
AUTHORS Jan, Geßmann, MD; Hinnerk, Baecker, MD; Gert, Muhr, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
COUNTRY Germany
0RINCIPAL!UTHOR Salazar Sánchez, Joanna, MD
CENTRE Hospital Universitario Ruiz y Páez
AUTHORS Salom, José Gregorio, MD; Orta, Héctor, MD; Pérez
Tovar, Juan, MD; Martínez, Carlos, MD
CENTRE Hospital Universitario Ruiz y Páez
COUNTRY Venezuela
)NTRODUCTION
Forearm fractures are one of the most common injuries in
children. Growth disturbance of the injured physis after distal
radius fractures occur in 4% to 7%. The resulting deformity
resembles Madelungs deformity. This deformity leads to
ulnocarpal impaction and dorsal dislocation of the distal
radioulnar joint. The Taylor Spatial Frame (TSF) is a hexapod
based external ring fixator, which is widely used to perform sixaxis deformity corrections of the lower limb. TSF-planning is only
available for lower extremities. The purpose of this study was to
apply the TSF to the upper extremities.
-ETHODANDPATIENTS
To correct bony deformities with the TSF, one must determine
the deformity parameters, the frame parameters, and mounting
parameters for the web based planning program. To use the
TSF on the forearm, one must transfer the nomenclature of
the deformity parameters and the mounting parameters to the
nomenclature of the forearm. With the transferred nomenclature,
one can correct forearm deformities with the correction mode
Long Bone.
Two boys (Patient 1, 13 years, Patient 2, 14 years old) and two
girls (Patient 3, 8 years, Patient 4, 7 years) were seen in our
clinic with progressive pseudo-Madelung deformities after an
epiphysial fracture of the distal radius at age 12 in the boys and
6 in the girls.
2ESULTS
In the two patients, the multiplanar deformitiy of the distal
radius could be corrected anatomically with the TSF. Patient 2
was slightly overcorrected because of some growth in the distal
ulnar growth plate. During the distraction, each patient had two
low-dose CT scans for better visualization of the radiocarpal and
radioulnar joint. No further immobilization after frame removal
was required. The one-year follow-up showed an anatomic
aligned forearm/hand relation with increased pronation and
supination compared to the preoperative range of motion in all
patients.
#ONCLUSIONS
In conclusion, the power of the TSF with the ability to move
two fragments precisely can be transferred to the forearm.
This allows for the correction of multiplanar radial deformities
simultaneously without the need for frame modifications of
rotational and translational deformities, as is necessary with the
standard Ilizarov system.
164
/BJECTIVE
The objective of this study was to evaluate the efficacy in the
treatment of proximal humerus fractures with closed reduction
techniques and percutaneous fixation with Ilizarov type external
tutor in displaced fractures.
-ATERIALSANDMETHODS
We performed a prospective study, which evaluated 22
patients aged between 30 and 89 years follow up for 18 to 60
months, all displaced proximal humerus fractures according to
Neer classification, using the reduction technique closed and
percutaneous fixation with Ilizarov type external tutor specially
designed for the investigation, under fluoroscopy. With a time
of immobilization guardian of 8 to 16 weeks with average of 12
weeks, all patients were evaluated from the standpoint of clinical
and radiological assessment in order to fracture consolidation
and range of motion. the rehabilitation begun at 7 days after
surgery.
2ESULTS
All patients were treated surgically with closed reduction and
percutaneous fixation with external tutor all displaced fractures
into two fragments 10 patients (45.4%), three fragments in
09 patients (49.9%) and 2 patients (9.09%) with fracture four
fragments, obtaining good results in 18.1% and excellent
in 81.9%, with female predominance of 68.2% (15 cases),
anatomical reduction was obtained in 90.9%, with an average
time for surgery was 17.5 hours, and the Fracture healing
from 8 to 12 weeks in 16 patients (72.7%), rehabilitation was
started from day 7 after surgery in 90.9% (20 cases) and two
patients who started on the third postoperative day. with gradual
recovery of joint mobility. It was 4.5% (1 case) of complications
due to incomplete recovery of joint ranges. Follow-up time of
patients was 6 to 36 months.
#ONCLUSIONS
External fixation is an effective alternative, versatile and safe
for the treatment of displaced proximal humerus fractures, due
to poor soft tissue compromise and early rehabilitation of the
patient.
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WITH EXTERNAL FIXATION
0RINCIPAL!UTHOR Kirienko, Alexander, MD
CENTRE Istituto Clinico Humanitas
AUTHORS Peccati, Andrea, MD
CENTRE Istituto Clinico Humanitas
COUNTRY Italy
0RINCIPAL!UTHOR Salameh, Ghassan, MD
CENTRE Center for Limb Lengthening and Reconstruction
AUTHORS Schmidt, Michael, MD
CENTRE Waldhof Praxies
COUNTRY Syria
!IM
Aim of the study was to evaluate the effectiveness of the Ilizarov
method in the treatment of pseudoarthrosis of the humerus as
an alternative of use the bone grafts.
2ESUME
For treatment of upper limb deformity and lengthening a
modified special external hinge distraction system has been
developed, which allows the combined Treatment of congenital
and acquired complex deformities of the upper limbs.
0ATIENTSANDMETHODS
Between 1994 and 2009 fifty eight patients ranging in
age from 18,9 to 82 (mean 52,4) were treated for humeral
pseudoarthrosis (atrophic in 36 cases, hypertrophic in 11,
infected in 6, with bone defect in 5). 55 of these patients
(94,8%) had been treated previously (1,7 procedures per
patient): 53 by internal fixation using compression plates,
33 by intramedullary nailing and 7 by external fixation, 3
nonoperatively. Treatment with extracorporeal shock waves was
used in 6 cases. Six patients had radial nerve palsy and three
had unlar nerve palsy. 62 surgical procedures (4 patient have
two surgery) were performed. In one step surgery was removal
previous fixation device and was done stabile fixation with the
circular frame (proximal semicircular arch). Open surgery has
been used in 33 cases with plates osteosinthesis and in the
cases with infection: excision of fibrous tissue at the non-union
site, opening of the intramedullary canal, excision of avascular
bony ends. In 25 cases with previous treatment with the nail,
percutaneus longitudinal osteotomy in the non union site and
compression in longitudinal and transverse direction was done.
No bone graft was used.
Since 1995 to 2009 this new system was used in 120 patients
with deferent indications in the upper limbs they presented
with upper limb length discrepancies and axial deviations and
deformities. The hinges where used are modified system of /
SLDF1; Salamehfix/which had the PCT.
2ESULTS
The used hinge system allows multiplanr corrections, deferent
size of used arcs makes it more suitable in shape and allows
joint movements freely, the insertion of wires and pens in a
nearly right angels makes the fixation more stable in addition
to insertion in a minor painful regions makes it more tolerable,
good correction and x-ray control is easy.
#ONCLUSION
The new developed hinges are easy to use and allow the
treatment of complex deformities of the upper limbs.
2ESULTS
The mean time in frame has been 8.2 months (range from 1.3
to 19.1), and bone healing was achieved in all cases. We have
had complications in 21 cases (36%); the most common has
been pin site infection (15 cases), but it has never influenced the
healing process. Deviation of the humerus axis was observed in
two cases. Other complications include pain, elbow stiffness and
hand dysesthesia. All patients had good or excellent functional
outcomes and range of shoulder and elbow movements as rated
by the Lammens scoring system.
$ISCUSSIONANDCONCLUSION
Ilizarov circular frame fixation without bone graft is a reliable
method for the treatment of atrophic nonunion of the humerus,
even after failed previous surgery, it remain the last possible in
patients treated by other fixation means.
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ILIZAROV EXTERNAL FIXATOR
0RINCIPAL!UTHOR Cakmak, Mehmet, MD
CENTRE Istanbul Medical Faculty
AUTHORS Yildiz, Fatih, MD; Tunali, Onur, MD
CENTRE Istanbul Medical Faculty
COUNTRY Turkey
!IM
To summerize treatment of humerus saft pseudoarthrosis with
Ilizarov external fixator.
-ATERIALANDMETHODS
Between 1994 and 2008, Ilizarov external fixator was performed
in 38 patients with a mean age of 41.7 years (range 15-77
years) for the treatment of humerus diaphysis pseudoarthrosis.
Thirty-six patients had a mean number of 1.3 operations
previously but two patients have followed conservatively
for humerus fracture. The number of atrophic, hypertrophic
and infected nonunion were 25, 11 and 2 respectively.
Preoperatively, three patients had temporary radial nevre
paralysis and one patient had temporary ulnar nevre paralysis
but one patient were necessitated tendon transfer for sequale of
radial nevre injury. One patient had intraoperative radial nevre
injury healed spontaneously. Radical debridement and antibiotic
added bone cement and temporary external fixator were
performed in infected two cases in the first session and acute
shortening and bifocal distraction and compression osteogenesis
in the second session. Monofocal compression and distraction
osteogenesis was perdormed for noninfected pseudoarthrosis.
$ISCUSSION
Thirty-eight patients were followed for a mean period of 26.3
months (range 6-72). The mean fixator time was 161.6 days
(range 51-300). Three patients had recurrent nonunion. One
patient underwent monolateral external fixator and iliac bone
grafting but resulted recurrent nonunion and treated with an
intramedullary nail, one patient treated with intramedullary
nail and one with Ilizarov device. One patient had regenerate
fracture after fixator removal and treated by bone grafting and
monolateral external fixator. Nine patients had grade 2, two
patients had grade 3 pin tract infection, and one patient had
chronic osteomyelitis. Fixator revision was necessary in four
patients. Eleven patients had elbow and 7 patients had shoulder
movement stifness and four patients had residual deformity.
#ONCLUSION
The Ilizarov method in the treatment of infected and noninfected humeral saft pseudoarthrosis is a successful technique
but difficulties and complications of the procedure should be
taken into acount.
166
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2%#/.3425#4)/./&&/2%!2-).#/-0,%8&2!#452%3
0RINCIPAL!UTHOR Satizabal Azuero, Carlos, MD
CENTRE Hospital Militar Central
COUNTRY Colombia
2ESUME
The main objective of this paper is to show the experience
acquired at The Military Central Hospital of Bogotá on the
forearm reconstruction with bone and soft tissue complex
injuries.
Due to the little information and literature available on which
treatment to use when facing complex fracture of forearm
because of several reasons, such as bone loss of one or
two bones (radius or cubitus), our main purpose of this oral
communication is proposing a rational approach of the handling
of such kind of fractures.
Having complex fractures in forearm is always a challenge
for the orthopedist, when approaching the surgical treatment,
specially determining the steps to follow from the very same
moment when the patient arrives at our hospital, prioritizing the
treatment towards an acute reconstruction in order to maintain
the best function; this includes deciding whether it’s necessary
to use an external fixator, or, on the contrary, an early internal
fixation.
It’s also possible to do acute shortening when there is bone
loss in both radius and cubitus, by making osteosynthesis in
the one with the least bone loss, and transport or graft plus
ostosynthesis in the other affected segment. Making acute
shortening would be even more indicated if we have cutaneous
defects or injuries.
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ELONGATION BONY AND ARTRODIASTASIS
0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszanne Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez
Pujay, Edilberto, MD; 5Lamas Calderon, María Caridad, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios; 5Instituto de
Medicina Legal
COUNTRY Peru
/BJECTANDPURPOSEOFTHESTUDY
Gorlin use the term “popliteal pterigium syndrome” for the
first time in 1968. First case described in 1969 by Trelat.
Incidence of 1 300 000 live births. Characterized by variability
inter intrafamilias concerning its phenotypic expression and
penetrance and families. Be placed in any area. Presence of
a “wing” in the popliteal region, that can extend from the calf
to the ischial tuberosity. We have undergone treatment with
monolaterales external locking in the home Clinic St. John of
God in Lima, Peru, and by lengthening bony and artrodiastasis 5
patients.
-ETHODSANDMATERIALS
Treatment indications are functional limitations for ambulation
and deformation. They were the following:
s !RTRODIASTASIS
s 3PLINTINGBRACING
s 3OFTTISSUE:PLASTIAS
s 2ELEASEDISTRACTIONUSINGMONOPOLAREXTERNAL&IXERWITHHYBRID
articulation.
s $ISTALFEMORALEXTENSION
s /STEOTOMIA
s 4ENDINOUSTRANSPOSITION
s %LONGATION!CHILLES
$ISCUSSION
In two patients turned knee flexion but he is handling with
splints. The range articulate in 1 patient has been lost. In 4
patients range articulate is acceptable. Got bone stretching
between 5 and 20 cm.
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%!2,9#/-0,)#!4)/.3/&%.,!2'%-%.47)4(
-/./,!4%2!,%84%2.!,&)8!4)/.
0RINCIPAL!UTHOR Correa Vázquez, Eva, MD
CENTRE Institut Universitari Dexeus
AUTHORS Isart Torruella, Anna, MD; Miquel Noguera, Joan, MD;
Martínez Martos, Sara, MD; Ginebreda Martí, Ignacio, MD
CENTRE Institut Universitari Dexeus
COUNTRY Spain
)NTRODUCTIONANDOBJECTIVES
The objective of this study is the revision of the complications
found in patients who present different pathologies which
require femoral, tibial or humeral enlargement with a
monolateral external fixator.
-ATHERIALANDMETHOD
$ESCRIPTIVEANDRETROSPECTIVERESEARCHNPATIENTS
men and 21 women. These patients were diagnosed of
achondroplasia, pseudoachondroplasia, PFFD, fibular agenesis or
multiple metaphyseal dysplasia and treated by limb enlargement
from June2008 to November 2009. The femoral, tibial or
humeral enlargement is achieved by the use of monolateral
external fixation and pins with and without hidroxiapatite.
2ESULTS
13 of the 38 patients treated with the monolateral external
fixation presented complications. Seven complications were
on the tibia and six on the femur. Amongst the complications
we find five premature femoral consolidation, two premature
fibular consolidation, five required wound debridement and
recuperation of the external fixation and two equine feet. Three
complications required surgery: One of the premature femoral
consolidation, one pin loosening which was replaced and one
equine foot which needed a tenotomy.
#ONCLUSION
During the early followup after enlargement surgery of superior
and inferior limbs an important number of complications is
found. Although most of them can be treated by a conservatively.
#OMPLICATIONS
s h7INGvRECURRENCE
s 0ALSYPERONEA
s 4HICKSKINBANDS
s &EMORALFRACTURES
s 3UBLUXATIONOFTHEKNEE
#ONCLUSSIONS
Treatment of this syndrome, dramatically improves the quality
of life of the patient, although evaluation articulate long-term
perhaps is not very satisfactory.
167
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02/0(9,!#4)#).42!-%$5,,!292/$$).'!&4%2&%-/2!,
,%.'4(%.).').#/.'%.)4!,&%-/2!,$%&)#)%.#9
0RINCIPAL!UTHOR Herzenberg, John E, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
AUTHORS 1Abdelgawad, Amr, MD; Standard, Shawn C, MD; 2Paley,
Dror, MD
CENTRES 1Texas Tech University Health Science Center at El
Paso; 2St. Marys Hospital
COUNTRY United States
)NTRODUCTION
The incidence of femoral fracture after lengthening for
congenital femoral deficiency (CFD) was 34% in a previous study
conducted at this center. We introduce a method of prophylactic
intramedullary (IM) rodding after lengthening for CFD to prevent
femoral fracture.
-ETHODS
Forty-five femoral lengthenings (43 patients) were performed
using external fixation. At the time of frame removal (or shortly
after), prophylactic intramedullary rods were inserted. Rod
insertion was facilitated by hand reaming with bent tip reamers.
Mean age at time of surgery was 9.4 years (range, 4.4 -40.4
years). Mean duration of treatment with external fixation was
184 days. Mean follow-up was 22 months (range, 7-53 months).
2ESULTS
Three cases (7%) developed infection. All were treated by
debridement and rod removal. All healed without recurrent
infection. Eight cases (18%) developed fracture despite rodding
(one case with high-energy trauma, three during physical
therapy, and four spontaneously). Only four of eight fractures
required intervention. Two patients had mild discomfort over the
trochanteric region that required rod removal. Fractures were
attributed to undersized rods or cortical perforations during rod
insertion.
#ONCLUSION
Prophylactic IM rodding after lengthening for CFD reduced the
incidence of fracture from 34% to 18% at the same institution.
Infection developed in 7% of cases but was easily treated.
Fractures can occur despite rodding; however, they are more
easily treated because the rod braces the fracture. Prophylactic
IM rodding after lengthening for CFD is an effective method to
reduce the incidence of femoral fracture.
168
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,%33/.3,%!2.4).4(%42%!4-%.4/&#/.'%.)4!,
PSEUDARTHOSIS OF TIBIA, A SINGLE SURGEON SERIES OF 43
CASES OVER 20 YEARS
0RINCIPAL!UTHOR Chaudhary, Milind, MD
CENTRE Jaslok Hospital
COUNTRY India
)NTRODUCTION
To compare the results of different modalities of treatment using
the Ilizarov method in Congenital Pseudarthrosis of Tibia.
-ETHODS
Patients & methods: 39 patients (age 1.5 years to 56 years)
were operated with the Ilizarov method over the last 18 years.
Severity by Crawfords Criteria was: Gr IV in 9, Gr III in 26, Gr II in
3, Gr I in 1.
The Etiology was Idiopathic in 3, Fibrous Dysplasia in 2 and
Neurofibromatosis in 34.
46 Ilizarov procedures were done with the foll. Modality 3 had
Bone Transport, 15 had Monofocal compression, 15 had Bifocal
#OMPRESSION$ISTRACTIONHAD)-2OD0ERIOSTEAL'RAFTING
"ONE'RAFTING,ENGTHENINGHAD-ONOFOCAL$ISTRACTION
1 had Microvascular Fibular Grafting. 5 patients needed 5
additional procedures. The current modality of choice is IM nail
with Inner table Iliac crest Periosteal and bone grafting with
proximal tibial lengthening and compression using the Ilizarov
device. Lengthening of 2 to 9 cm was done in 28 patients (avg
3.6 cm), Regenerate was Normotrophic in 21, Hypotrophic
in 3,and Premature consolidation in 2, Pseudarthrosis in 1.
Distraction Epiphyseolysis was done in two distal physes. A Foot
frame was applied in all patients.
2ESULTS
Sustained compression helped achieve union in 33 patients.
Average duration of frame was 6.8 months.
Early Refracture occured in 4, (3 remain ununited and are
included in the failures). Late Refracture occurred in 5 of
whom 4 united (2 with repeat Ilizarov application and 2 with
conservative treatment).
$ISCUSSIONANDCONCLUSION
Congenital Pseudarthrosis of Tibia presents at different ages
with variable geometry at site of Pseudarthrosis. The treatment
should be individualized to suit the patient. We have given
up using classical bone transport for this method. Monofical
Compression may be used judiciously in some cases. Bifocal
Distraction Compression Arthrodesis works well but can have
a significant rate of refracture. Current modality of choice is IM
Rod with Iliac Crest Periosteal as well as Bone Graft with Bifocal
Ilizarov as this has given highest rate of union.
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&%-/2!,,%.'4(%.).'7)4(5.34!",%()0
0RINCIPAL!UTHOR Koczewski, Pawel, MD
CENTRE Department of Pediatric Orthopedics
AUTHORS Koczewski, Pawel, MD; Shadi, Milud, MD
CENTRE Department of Pediatric Orthopedics
COUNTRY Poland
)NTRODUCTION
In severe defects of proximal femur (postseptic hip luxation
Hunka IVb and V, PFFD Pappas III and IV) Schanz pelvic
support osteotomy (with optional femoral lengthening) can
be considered. There are no reports about isolated femoral
lengthening with complete hip dislocation.
'OAL
To present results of Ilizarov femoral lengthening with unstable
hip of different etiology.
-ATERIAL
Consists of 7 patients with femoral shortening associated with
unstable hip as a result of septic arthritis in neonatal period (hip
luxation Hunka type V) in 4 cases, PFFD in 2 cases and DDH in
1.Mean age at the operation time was 15 years (from 10 to 26).
Mean shortening was 7.2 cm (from 5 to 10).
-ETHOD
In 6 cases Ilizarov device was used while monolateral distractor
in one.
Follow up time ranged from 0,5 to 4 years (mean 2.2).
2ESULTS
Mean duration of distraction time was 66 days (from 25 to 105)
and achieved lengthening varied from 2 to 6.5 cm (mean 4.6).
Total time in frame ranged from 91 to 238 days (mean 189) and
mean lengthening index was 1.4 months/cm (from 1.2 to 1.6). In
all cases hip joint didn’t migrate proximally during lengthening
and in observation. In final examination the range of hip motion
remains the same as preoperatively. Knee motion during
lengthening severely decreased in all cases, but in 6 of them
returned to preoperative value.
#OMPLICATIONS
The most serious complication in one case was severe limitation
of knee movement as a result of posterior knee subluxation at the
end of distraction. It was treated by intensive physiotherapy which
was not effective. One year after frame removal closed, gradual
reduction of the knee with Ilizarov frame was performed achieving
full extension and 100 flexion. In one case premature regenerate
consolidation needs closed osteoclasia. In other 60 knee flexion
contracture, distraction was stopped to prevent subluxation
achieving 2 cm lengthening out of 9.5 cm shortening.
#ONCLUSION
Unstable (luxated) proximal femur combined with postseptic or
congenital shortening can be treated with Ilizarov lengthening
without risk of hip ROM limitation and proximal migration of
femur.
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+.%%$)3,/#!4)/.!3!#/-0,)#!4)/./&&%-/2!,
LENGTHENING
0RINCIPAL!UTHOR Koczewski, Pawel, MD
CENTRE Department of Pediatric Orthopedics
AUTHORS Shadi, Milud, MD
CENTRE Department of Pediatric Orthopedics
CoUNTRY Poland
2ESUME
Knee dislocation is one of the most serious complication of limb
lengthening by Ilizarov technique.
The aim of the study is to analyze the frequency and the causes
of knee dislocations as a complication of femur lengthening with
Ilizarov technique.
-ATERIAL
Since 1995 to 2009 we treated 221 patients aged between
4.6 and 48 years (mean 15.9) with 227 femoral lengthening
procedures due to femoral shortening of various etiology.
Shortening ranged from 2.5 to 18cm (mean 5.9) and the
achieved lengthening was 2 to 12cm (mean 5.4). Simultaneously
with lengthening in 93 patients axial deformity correction from
10º to 50º (mean 20º) was preformed.
-ETHOD
Ilizarov device was used in 221 procedures, monolateral external
fixation in 6 (in 3 of them with lengthening over the nail). In
6 patients double level osteotomy was made. In 8 patients
with knee instability and the risk of dislocation, knee joint was
primary fixed. In one of them primary stabilization of hip (after
septic arthritis in neonatal period) was performed. In 2 of them
permanent knee ROM limitation occurred despite of primary
stabilization.
2ESULTS
In analyzed material 11 patients demonstrate signs of knee
subluxation. In 6 cases anatomical alignment and preoperative
ROM were restored after physiotherapy with reduced or stopped
distraction. 2 other cases were treated with extension of Ilizarov
device for knee stabilization and arthrodiastasis with good
results. Other 2 patients were treated surgically after frame
removal with posterior knee capsulotomy, open reduction and
cast immobilization. The result was satisfactory achieving full
extension and flexion 130 and 90. Last patient was treated with
closed knee reduction assisted with Ilizarov device with full ROM
recovery.
#ONCLUSIONS
1. Knee joint is at risk of subluxation during femur lengthening,
thus the joint condition should be closely observed not only
during lengthening but also after device removal.
2. Stabilization of the hip and knee with arthrodiatasis do not
give enough protection against joint dislocation.
3. Observation of early signs of knee joint subluxation and
application of appropriate vigorous conservative treatment
allows full restoration of knee joint functions.
In this group knee joint complication rate is relatively high.
169
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!.+,%#/-0,)#!4)/.3).,)-",%.'4(%.).'/&4(%4)")!
0RINCIPAL!UTHOR González Herránz, Pedro, MD
CENTRE Hospital Materno Infantil-La Coruña
AUTHORS Rodríguez Rodríguez, Mª Llanos, MD; Castro Torre,
Miguel, MD
CENTRE Hospital Materno Infantil-La Coruña
COUNTRY Spain
)NTRODUCTION
Limb lengthening is a typical treatment of limb discrepancy
that exceeds 3 or 4 cm. Results usually show the magnitude
obtained, the percentage of the bone that has been elongated
and the Healing Index. Complications related with limb
lengthening are axial deviations, consolidation delay and
fractures. Poor attention is given to ankle and foot complications.
-ATERIALSANDMETHODS
We reviewed cases treated by limb lengthening with two
different procedures (Ilizarov and callotasis) between 1976 and
2009. We analyze clinical changes and radiological changes pre
and post tibial lengthening by PA x-ray stand-up focusing on
proximal migration of distal fibula (> 5 mm), ankle medial gap (>
2 mm), and R.O.M and Achilles retraction. The authors compare
the usefulness of temporary synostosis and prophylactic Achilles
tenotomy.
2ESULTS
220 tibial lengthening processes were performed, 170 of them
by the callotasis method and 50 by the Ilizarov method. The
average of tibia lengthened was 5.4 cm. Temporary synostosis of
the distal tibio-fibular joint was performed in 84% of the cases
and prophylactic tenotomy and short cast ankle immobilization
during elongation period in 65% of them.
Proximal migration of the distal fibula was observed in 9% of
the cases (20 cases), 4 cases shown an ankle subluxation.
With regard to equinus deformity, it was present on the
38% of the cases (83 cases); half of them required surgical
Achilles lengthening. When prophylactic Achilles tenotomy
was performed only in 2% was necessary surgical Achilles
lengthening.
Other complications that were observed were ankle
algodistrophy, cutaneous adherences on the Achilles tenotomy
site…
#ONCLUSSIONS
1. Ankle Changes after tibial limb lengthening are frequent.
2. Prophylactic Achilles tenotomy show great efficacy to prevent
equinus deformity during lengthening.
3. Temporary tibio-fibular fixation must be done routinarily and
preferably with a 4 cortical screw.
170
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!2%6)%7/&#/-0,)#!4)/.3%.#/5.4%2%$$52).'
&%-/2!,,%.'4(%.).'5.)0,!.!26%2353#)2#5,!2
EXTERNAL FIXATOR
0RINCIPAL!UTHOR Eralp, Levent, MD
CENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Trauvmatology
AUTHORS 1Kocaoglu, Mehmet, MD; 2Bilen, Erkal F, MD; 1Balci,
Halil Brahim, MD; 1Ahmed, Syed Kamran, MD
CENTRES 1Istanbul University, Istanbul Medical Faculty
Department of Orthopaedics and Traumatology; 2Acibadem
University Medical Faculty, Department of Orthopaedics and
Traumatology
COUNTRY Turkey
!IMANDPURPOSEOFTHESTUDY
Research over the last 20 years indicate a consensus regarding
the superiority of the circular type external fixator over uniplanar
fixators for lengthening of the tibia, but femoral lengthening
is still subject to the surgeon’s preference. No studies have
compared the complications associated with the use of the
circular type external fixator, and those associated with use of
uniplanar fixators in femoral lengthening. This study compares
significant problems, obstacles and sequelae between these two
groups.
-ETHODS
The study includes patients who underwent femoral lengthening
between September 1994 and January 2007. 50 patients
(29 male, 21 female), with a mean age of 20 years were
lengthened with the circular type fixator (54 femora), whereas
60 patients (29 male, 31 female), with a mean age of 20 years
were lengthened with the uniplanar fixator (67 femora). The
significance of complications between the two groups was
statistically analyzed and compared with the results reported in
the literature.
2ESULTS
The incidence of knee stiffness was significantly higher in the
circular type external fixator group compared to the unilateral
fixator group (0.31 per femur versus 0.13 per femur) (p<0.05).
The incidence of pain during lengthening was also higher in
the circular type Ilizarov external fixator group and patient
satisfaction was higher in the uniplanar external fixator group.
The comparison of total complications per lengthened femur
yields better results for the uniplanar external fixator group.
#ONCLUSIONS
On the basis of our observations and experience, we
recommend the uniplanar external fixator as a preferable device
for femoral lengthening.
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RELAPSED CLUB FOOT
0RINCIPAL!UTHOR Ahmed, Amin, MD
CENTRE Al Hadra University Hospital-Alexandria University
COUNTRY Egypt
2ESUME
The Ilizarov technique with or without soft tissue release and/
or osteotomies is a good option for management of recurrent
clubfoot deformity. It is less invasive and allows for simultaneous
correction of all components of the deformity without shortening
of the foot.
!IMOFTHESTUDY
To evaluate the results of management of relapsed club foot
using a simple fram construct of Ilizarov external fixator.
0ATIENTSANDMETHODS
Between 2003 and 2008, eighteen feet in 13 patients with
relapsed club feet were treated by Ilizarov external fixator. All
patients had undergone previous surgery (1-3 operations). The
average age of the patients at the time of the operation was
5.5 years and the average follow up period was 15.8 months.
Midtarsal osteotomy was undertaken in 3 feet and soft tissue
distraction was undertaken in 15 feet without soft tissue release
except in 3 feet which needed tendoachillis lengthening. The
average time of fixator applications was 4.5 months.
The results were graded based on the correction of the
deformity and the function into:
1. Excellent: painless, plantigrad foot with no functional
limitations.
2. Good: plantigrad foot in a patient able to ambulate long
distances with mild pain
3. Fair: mild residual deformity, required bracing and/or had
some functional limitations but an active live.
4. Poor: significant residual deformity, pain and activity
limitations.
2ESULTS
Out of 18 feet, 2 feet (11.1%) were rated as excellent, 11
(61.1%) as good, 4 (22.2%) as fair and one foot (5.6%) had poor
outcome. Excellent and good results (72.2%) were considered as
satisfactory. While fair and poor results (27.8%) were considered
as unsatisfactory.
Pin tract infections occurred in all patients and treated by local
care and antibiotics. Wire breakage occurred in one case also
cutting through of the calcaneal wire occurred in one case.
Skin sloughing over the tendoachillis occurred in one case
and treated conservatively. Metatarso-phalyngeal subluxation
occurred in 2 cases and spontaneously reduced after frame
removal.
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!.+,%2%#/.3425#4)/.).490%&)"5,!2(%-)-%,)!
0RINCIPAL!UTHOR Ahmed, Amin, MD
CENTRE Al Hadra University Hospital-Alexandria University
AUTHORS El-Tayeby, Hazem, MD
CENTRE Faculty of Medicine-Menufia University
CoUNTRY Egypt
)NTRODUCTION
Fibular hemimelia is the most common longitudinal deficiency
in which the tibia is usually short with an axis deviation
(anterolateral bowing and valgus deformity). In fibular
hemimelia, hindfoot lacks lateral support from the fibular
malleolus with reconstruction of the leg, the surgeon is usually
confronted by the risk of luxation of the ankle when the lateral
malleolus is completely absent.
Many efforts are made to prevent luxation and increase the
stability of the ankle joint.
0ATIENTSANDMETHOD
Ankle reconstruction prior to lengthening in fibular hemimelia
with complete radiological absence of the fibula (type 2) was
performed in 12 patients with different degrees of absence
of metatarsal rays. The ankle deformity was valgus of the
heel in 11 patients and equinovrus in only 1 patient. The age
ranged from 9 to 13 months. Excision of the fibular anlage was
performed with lateral subtalar and ankle soft tissue release
to restore the ankle and subtalar relationship. In 9 cases the
fibular anlage ended distally with a cartilaginous lateral maleolar
remnant that was fused to the talus in 2 occasions adding
to the proximal deforming force of the anlage. This fibular
remnant was advanced distally and fixed by 2 k- wires to the
tibia to reconstruct an ankle mortise trapping the talus and
regaining the ankle anatomy. Elongation of the tendoachillis and
osteotomy to correct the anterior angular deformity of the tibia
was done and fixed by a trans ankle k- wire proceeding through
the oscalsis proximally into the intramedullary canal of the
tibia. In case a fibular remnant was not available (3 cases) the
contralateral fibular head was harvested and fixed to the tibia.
2ESULTS
The period of follow up ranged from 9 to 28 months with
promising results regaining the ankle mortise with reasonable
range of movement.
#ONCLUSION
Reconstruction of the ankle in type 2 fibular hemimelia using
the cartilaginous lateral maleolar remnant or the contralateral
fibular head is a good method. At a short period of follow up the
results were promising without any recurrence of the deformity,
but longer follow up is recommended for a long term evaluation
of this method.
#ONCLUSION
Ilizarov technique gave satisfactory results in cases of relapsed
club foot which were difficult to be treated by the conventional
methods. But longer follow up is needed to assess the achieved
correction and to detect any recurrence of the deformity by time.
171
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4!9,/230!4)!,&2!-%
0RINCIPAL!UTHOR Eidelman, Mark, MD
CENTRE Rambam Hospital
AUTHORS Zaidman, Michael, MD; Katzman, Alexander, MD
CENTRE Rambam Hospital
COUNTRY Israel
)NTRODUCTION
The Taylor spatial frame (TSF) is a relatively new external fixator
able to correct six axis deformities with computer accuracy
using a virtual hinge. This device gained tremendous popularity,
but the use of TSF for the correction of foot deformities is still
limited. Various ring configurations and new TSF foot software
have recently became available and allow performing correction
of the most difficult foot deformities. The purpose of the present
study was to determine the effectiveness of TSF for correction of
complex foot deformities in children and adolescents.
-ETHODS
We describe the results of 18 patients (23 frames) with various
foot deformities treated in our institution by three different TSF
configurations (standard rings construction, mitter, and butt
frame). The study group comprised 12 boys and 6 girls (mean
age at the time of procedure 8 years, range 3.5-14). Eleven
patients had residual clubfoot deformities, 3 had arthrogryposis
with rigid equinovarus, 2 had foot deformities due to
posttraumatic growth arrest, 1 had rigid equinovarus secondary
to spina bifida, and 1 had clubfoot with fibular hemimelia.
2ESULTS
Treatment goals were achieved in 16 patients, while mild
residual deformity persisted in two patients. Most complications
during treatment consisted of pin tract infections, one
premature consolidation which was treated by additional
midtarsal osteotomy, one MP joint subluxation treated by
tendon lengthening and pining of the joint, and one case of talar
subluxation.
#ONCLUSION
Based on our experience we believe that TSF is a very powerful
and accurate surgical modality for the correction of the most
difficult foot deformities with a relatively short learning curve.
172
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0RINCIPAL!UTHOR González Herránz, Pedro, MD
CENTRE Hospital Materno Infantil-La Coruña
AUTHORS Fontao Fernández, Lorena, MD; Rodríguez Rodríguez,
Mª Llanos, MD; Castro Torre, Miguel, MD
CENTRE Hospital Materno Infantil-La Coruña
COUNTRY Spain
)NTRODUCTION
Ankle varus is a tipical deformity after physeal fractures or
infection around the ankle. The authors review cases treated by
external fixation.
-ATERIALANDMETHODS
We review 15 ankle varus deformity cases. The patients were
studied clinical and radiologically with tele RX stand-up and
were treated by monolateral external fixation. We analyze
etiology of the deformity, angular deformity magnitude, type of
treatment and complications.
2ESULTS
The most frequent etiologies of the ankle varus deformity
were a physeal fracture type III-IV S-H or a sequels of infection
The correction methods employed were physeal distraction
when physis were open (hemi-condrodiatasis) or asymetrical
distraction of the callus (hemicallotasis). In two patients was
performed acute correction and limb lengthening in order to
treat limb discrepancy. The most frequent complication were
infection around the pins and ad latum displacement during
gradual correction after osteotomy.
#ONCLUSIONS
1. Varus deformity in children after ankle physeal fractures types
III-IV are frequent.
2. Asimetrical physeal distraction before maturity is the best
method of treatment.
3. In order to prevent the impingement of the lateral aspect of
the ankle distal Fibula osteotomy is recommended.
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AUTHORS CONCEPT OF APPLICATION OF THE HEXAPOD
ILIZAROV APPARATUS AT FEET
0RINCIPAL!UTHOR Odessky, Jacob, MD
CENTRE Assaf Harofeh Medical Center
COUNTRY Israel
!IMANDPURPOSEOFTHESTUDY
Feet deformities continue to present a problem even for
orthopedists having experience with the Ilizarov apparatus
and TSF. The purpose of this study is developing the design of
Hexapod Ilizarov apparatus allows simultaneous or independent
correction of forefoot and hindfoot deformities.
-ATERIALANDMETHOD
This series includes 12 patients (14 feet); aged 5-17 that were
treated in our institution between 2006-2010. 8 of them had
clubfoot, 4 plano-valgus feet. 5 were female and 7 male.10
feet were Rt, 4-Lt. The overage deformity was: forefoot (pro/
supination 30º, abduction/adduction – 30º) hindfoot (supination
35º, probation 30º, equinus 40º). Closed correction was
performed in 4 cases, V-osteotomy-3 and 3-ple arthrodesis in
7 feet. We apply the Ilizarov apparatus consisting of 2 systems
posterior and anterior. The posterior one for deformity correction
of the hind foot consists of a base tibial ring and a half ring
on the calcaneus. Anterior system includes the additional
ring, attached to base ring and 3/4 arch placed parallel to
metatarsal bones. At 5-7 postoperative day two Hexapod sets
were connected, and independent correction of deformities of
forefoot and hind foot was started. When independent correction
was finished, anterior and posterior half rings were connected
with standard Ilizarov particles, anterior system was destroyed
by removal of additional ring and anterior Hexapod set. And
foot equinus was corrected in constrain regime of fixation with
posterior Hexapod set.
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EXTERNAL FIXATION FOR FLATFOOT EVANS RECONSTRUCTION
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
!IMSANDPURPOSE
Use of external fixation in the Evans calcaneal procedure for
flatfoot reconstruction. This method uses an external fixator for
callus distraction while preserving the calcaneal cuboid joint.
-ETHODSANDMETHODOLOGY
40 patients underwent surgery for flatfoot reconstruction
utilizing an external fixator for lateral column lengthening. These
patients had the procedure introduced by Evans but modified
in these cases by using callus distraction. The external fixator
prevented calcaneal cuboid joint compression while attaining a
predictable lengthening of the calcaneus.
$ISCUSSION
The problem with the Evans procedure for flatfoot reconstruction
is that one will get calcaneal cuboid joint impingement and
arthrosis as a result of the acute lengthening. Also the initial
length attained can shorten by graft resorption and the patient
must be non weighbearing. The use of an external fixator
prevents calcaneal cuboid joint arthrosis by protecting the joint.
All of the patients had successful lateral column lengthening
without any calcaneal cuboid joint symptoms or pain with an
average follow up of 8 years.
#ONCLUSION
Utilizing external fixation is a effective means for predictable
lateral column lengthening in flatfoot reconstruction and
preventing calcaneal cuboid joint pathology.
$ISCUSSION
The main problem of using the Ilizarov apparatus in feet is
the correct placement of hinges. Hexapod systems allow
simultaneous correction of all components of deformities and
precise placement of virtual hinge. But technical problems
very complicated their using. We offered design of apparatus,
technical and program changes that allow to resolve the
problems. All feet was corrected as preplanned, the average
apparatus period was 3 m.
#ONCLUSIONS
Offered system allows simultaneous or consecutive correction
of feet deformities in all planes, free modification of the device
depending on medical tactics, accurate and exact correction of
complex deformities through its software support, preserves the
independence and universality of the original Ilizarov apparatus.
173
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BONE RECONSTRUCTION IN CHILDHOOD
0RINCIPAL!UTHOR Wozasek, Gerald, MD
CENTRE Department of Traumatolgy, Medical University Vienna
AUTHORS Hobohm, Lukas, MD; Baumbach, Stefan, MD
CENTRE Department of Traumatolgy, Medical University Vienna
COUNTRY Austria
0URPOSE
Reconstruction of large skeletal defects in children is a
challenging problem as it often includes limb length discrepancy
(LLD), axial deformity, infection and critical soft tissue conditions.
The aim of this retrospective study was to outline the complexity
of treatment options which require an individual “a la carte
approach” in most cases.
0ATIENTSANDMETHODS
Between 1990 and 2007 seven patients with an average age
of ten years with nine deformed extremities were included in
OURSTUDY2EASONSFORRECONSTRUCTIONWEREOSTEOMYELITISN
SEQUELEAOFRICKETSNPHYSEALDAMAGENPOSTTRAUMATIC
NANDCONGENITALDEFORMITYN#ALLUSDISTRACTIONN
PHYSEALDISTRACTIONNANDCORRECTIVEOSTEOTOMIESNWERE
PERFORMED)NTHESEOPERATIONSTHE)LIZAROVFRAMENTHE
4AYLOR3PATIAL&RAMENTHE(OFFMANN&IXATEURNAND
INTRAMEDULLARYlXATIONNWEREAPPLIED
2ESULTS
In all cases limb salvage and satisfactory limb function were
achieved without a recurrence of infection. In one case of
external fixation, a refracture of the operated limb necessitated
a new application of an external frame. Bone continuity was
achieved in all cases.
#ONCLUSION
Limb reconstruction in childhood is time-consuming and only
possible with the personal commitment of surgeon, patient
and their family. Bone reconstruction and axis realignment
without soft tissue consolidation is not feasible. Therefore the
treatment protocol has to be adapted in most cases to resolve
complications during the healing phase.
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53).'4(%-%4(/$/&$)342!#4)/./34%/39.4(%3)3).
42%!4-%.4/&#(),$2%.7)4(3(/24%.%$&).'%23
0RINCIPAL!UTHOR Zavarukhin, Vladimir, MD
CENTRE The Turner Scientific and Research Institute for
Children’s Orthopedics
COUNTRY Russian Federation
2ESUME
Shortening the length of fingers is observed in congenital and
acquired conditions in children, leading to varying degrees
of functional disorders and cosmetic defect that causes the
relevance of this problem.
Purpose of research is improving treatment results for
children with a shortening of the length of fingers, developing
customized for children hand distraction devices, optimization of
postoperative management of patients.
-ATERIALSANDMETHODS
In the clinic of reconstructive microsurgery and hand surgery
of the Turner Scientific and Research Institute for Children’s
Orthopedics for the past 30 years were operated on over 500
patients with a shortening of the fingers using the method of
distraction osteosynthesis. Initial age of this group of patients
was 4 years.
The last two years in our department is the development and
use of small-sized distraction devices for monolateral fixation.
Developed models permit to use a method of distraction
osteosynthesis in osteotomy of the bone length from 0.8 cm.
The earliest age of the child, who was treated using the method
of distraction osteosynthesis, was 1,2 years. To optimize the
processes of bone developed algorithms for choosing the
operative technique and postoperative management of patients.
$ISCUSSION
Comparative evaluation of patient outcomes showed that the
using of monolateral osteosynthesis in hand child surgery more
comfortable in the postoperative period for the patient, allows
the use of this method for small bones in the lower ages. Best
treatment results obtained in the early age group.
#ONCLUSIONS
The use of monolateral osteosynthesis preferably in the
treatment of children with shortened fingers. The best results
can be achieved by early treatment from 1-1,5 years of age.
Choosing the tactics of postoperative management should be
individual for each patient.
174
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HINGED EXTERNAL FIXATION IN THE UNSTABLE POST
42!5-!4)#!.+,%
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!350%2)/24%#(.)15%&/22%0!)2/&02/8)-!,TH
-%4!4!23!,&2!#452%54),):).'%84%2.!,&)8!4)/.
0RINCIPAL!UTHOR D’Amico, Salvatore, MD
CENTRE S Anna Hopital
AUTHORS Zottola, Vincenzo, MD
CENTRE S Anna Hospital Como
COUNTRY Italy
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
/BJECTIVE
The purpose of this study is to show a new surgical approach to
unstable post traumatic ankle with the Hinged external fixation
and report the clinical outcomes of this technique in 18 patients.
$ESIGN
Retrospective.
3ETTING
Case studies.
0ATIENTS
18 patients between 2007 and 2008 were treated using a
Hinged external fixation surgical approach to the ankle. 18
patients presented unstable ankle fracture dislocation. There
were 6 females and 11 males, from 25 to 70 years of age (mean
53 years).
-AINOUTCOMEMEASUREMENTS
External rotation stress test in radiograph was used to assess
ankle stability. The Foot and Ankle Outcomes Questionnaire was
used to evaluate postoperative ankle pain, function, stiffness
and swelling, and giving way. Posttraumatic osteoarthritis was
assessed using an adapted 4-point radiographic grading system.
2ESULTS
Follow-up data on 18 patients were obtained at a mean interval
of 6 mounth. The average of stress test for ankle stability is
good. The average global foot and ankle score was 71,1 points
(range 35-100 ). There were no wound complications. The
degree of arthrosis was grades 0 in all ankles.
#ONCLUSIONS
Hinged external fixation allows early mobilization and restoration
of activity by an average of 6 weeks by removing the external
fixation to 5 weeks. External rotation stress test is negative in all
cases at 6 months follow up.
!IMANDPURPOSE
To introduce external fixation as a superior method compared
to internal fixation to treat fifth metatarsal base fractures and to
prevent any immobilization. This method allows the patient to
weightbear immediately and not jeopardize the healing of these
fractures.
-ATERIALSANDMETHODOLOGY
A mini fixator was used in treating 65 fifth metatarsal base
fractures. All patients were fixated percutaneously with one
tapered screw in the basilar fragment and one into the cuboid
for added stability. Two screws were placed distally to the
fracture site into the fifth metatarsal diaphysis.
Patients were encouraged to weightbear immediately and
the average time the fixators were removed at 5.5 weeks
postoperatively. There was no placement of a splint or cast on
these patients.
$ISCUSSION
Traditional methods of fixating fifth metatarsal base fractures
utilize internal fixation and require prolonged immobilization
and nonweightbearing. Using a mini external fixator allows the
patient to start weightbearing immediately and does not require
any immobilization. All 65 patients healed before six weeks and
there were no incidents of delayed or nonunion. The external
fixator is extremely stable and counteracts the longitudinal
forces of the peroneus brevis. The fixator can also be further
compressed during the postoperative period.
#ONCLUSION
Utilizing a mini external fixator is a superior alternative to
traditional methods of fixating fifth metatarsal base fractures.
The immediate weightbearing enhances healing and prevents
delayed or nonunions. Patients also do not require an incision or
have retained internal fixation.
175
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#!,,/4!3)3).-%4!#!20!,3!.$-%4!4!23!,3).#(),$3
0RINCIPAL!UTHOR Gutiérrez Carbonell, Pedro, MD
CENTRE Hospital General Universitario Alicante
AUTHORS Domenech Fernández, Pedro, MD; Navarro Amorós,
Manuel, MD
CENTRE Hospital General Universitario Alicante
COUNTRY Spain
)NTRODUCTION
The callotasis in metacarpals and metatarsals bones to get
normal morphology in hand and normal metatarsal arc in the
foot.
/BJECTIVES
To study results of the callotasis in metacarpals and metatarsals
bones and their complications.
-ATERIALANDMETHODS
We study 14 callotasis performed between 2000-2005. Six
cases in metacarpals (42.8%) and 8 in metatarsals (57.2%)
bones. Follow-up was of 24 months (range 10-34). The mean
age was 8.5 and 9.5 years (range 2-13) in metacarpals and
metatarsals, respectively. We used minifixator Hoffmann II in
all the cases. The latency time to begin the callotasis was 2.5
days (range 1-4 days). The distraction rate was of 1mm/day
in 9 cases and 0.75 mm/day in 5 cases. The most frequently
metacarpals lengthening were: 4º (4 cases, 28.6%) and 5º (3
cases, 21.4%) and the metatarsianos 3º (2 cases, 14.3%) and 4º
(5 cases, 35.7%).
2ESULTS
The percentage of lengthening of bone with respect to the initial
length was 36.2% in metacarpals and 28.1% in metatarsals.
The consolidation index was 6 days/mm in metacarpals and
8.2 days /mm in metatarsals. The mean time until remove
the fixator device was 2.5 months in hands and feet (range
2-3.5). Complications: There were not neurovascular injuries,
pseudarthrosis or breakage of pins. There were 3 cases
(21.2%) with deficit of metatarsophalangeal joint mobility and
2 with postoperative metatarsalgia. Three cases (21%) had
hypertrophic scars. Two cases (14%) had postoperative angular
deformity. Three mechanical failures with loosening of the
minifixator and 3 superficial infections of the track of the pins
(21%). A case (7.1%) consolidate before obtaining the wished
length and needed new osteotomy.
#ONCLUSIONS
The patients and their familiar surroundings are satisfied with
the results. We think that the period of latency must be shorter
(1-4 days) in these bones. The complications normally are not
serious, but are frequents.
176
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,)'!-%.4/4!8)353).'%84%2.!,&)8!4/2&/2#/-0,%8
&2!#452%3/&#!,#!.%5-!-).)-!,).6!3)6%4%#(.)15%
0RINCIPAL!UTHOR Singh, Ajai, MD
CENTRE Department of Orthopaedics, CSM Medical Univerity,
Lucknow
COUNTRY India
!IMSANDPURPOSEOFSTUDY
Controversies in literature exists regarding complex calcaneum
fractures management. Such complex Calcaneal fractures
managed by ligamentotaxis using external fixator were analysed
to evaluate its efficacy.
-ETHODOLOGY
Sixty-five complex (comminuted, intra-articular fracture with
compromised soft tissue) fractures calcaneum were treated by
fixator based on ligamentotaxis, where fractured calcanea were
distracted gradually; without fracture opening (which brought
articular margins together to maintain both alpha and beta
angles into normal range) for a mean period of 13 days. After
achieving normal range of above angles, the assembly was held
in static position for average 6.1 weeks. Twenty three (35.4%)
patients had undergone additional bone grafting (cancellous
autograft) with elevation of posterior facet, under the image
intensifier by making a small window (average size 1.5 X 1 cms)
on lateral surface of calcaneum. Patients were evaluated for
their functional outcomes by American Orthopaedic Foot and
Ankle society (AOFAS) Score for the ankle and hind foot. Average
time of union was 10.3 weeks with range of 8.5 to 12.3 weeks.
Mean follow-up was 61.5 months.
$ISCUSSION
Improved angles were statistically significant in both types of
Essex-Lopresti fracture patterns. The angles achieved remain
maintained till fixator removal. No collapse of posterior facet
or reversal of angle correction achieved, till the end of follow
up was found. Sixty-two (95.4%) of patients did well with
the ligamentotaxis. On evaluating final outcomes by AOFAS,
approximately 71% of cases showed good results. Only 21
patients (29.2%) complained of persistent heel pain in the long
term follow up. Out of these eighteen (85.7%) were those who
had badly smashed calcaneum (severe comminution with almost
total loss of calcaneal height). Long-term follow up showed that
no patient suffered from such severe pain so as to compel him
to change his activities. The origin of heel pain was not subtalar
joint in all of these patients as it could not be relieved by local
anaesthetic infiltration into joint. No patient complained about
the change in size/shape of foot wears.
#ONCLUSION
Ligamentotaxis by fixator provides a viable and user-friendly
alternative method of management of complex calcaneal
fractures.
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TRANSOSSEOUS OSTEOSYNTHESIS IN RECONSTRUCTIVE
42%!4-%.4/&0!4)%.437)4(0/3442!5-!4)#&//4
DEFECTS
0RINCIPAL!UTHOR Martel, Ivan, MD
CENTRE Russian Ilizarov Scientific Center Restorative
Traumatology and Orthopaedics
AUTHORS Ivanov, Gennadiy, MD; Naritsin, Vitaliy, MD
CENTRE Russian Ilizarov Scientific Center restorative
Traumatology and Orthopaedics
COUNTRY Russian Federation
0URPOSE
Posttraumatic foot bone defects cause big disorders of locomotor
function of the lower limb. Depending on their location were
differentiate between defects of the forefoot, hindfoot, and “root”.
The suggested classification determines tactics of surgical
intervention, corresponding to clinical and radiological picture.
The clinic of the Center determined principles and suggested a
number of techniques of transosseous osteosynthesis with the
Ilizarov apparatus in reconstructive and restorative treatment for
management of patients with the above-mentioned pathology.
-ATERIALANDMETHODS
The work presents analysis of 45 patients treated in the hospital
since 2000. They aged from 16 to 63 and had posttraumatic foot
bone defects, both “acute” (16)-made by trauma (4) or resulting
from radical surgical treatment of open or gunshot wound of foot
bones (12), and chronic (29).
All the patients were treated by the method of transosseous
osteosynthesis with the Ilizarov apparatus.
21 patients had osteotomy through the talus neck and calcaneus
to fill in the defect of forefoot bones.
In 3 patients with a total defect hindfoot was formed by cutting
off a tibial fragment or a talus fragment and their transport
posterior according to the pre-determined trajectory. In other
cases (6 patients) calcaneal defect was filled in after osteotomy
of the remaining part of the calcaneus.
In posttraumatic defects of the talus (15 patients) we did
compression (8), distraction, lengthening (7) arthrodesis.
2ESULTS
Efficacy of the rehabilitation treatment was studied not in
all patients, including follow-up in 67% of patients. During
evaluation we considered recovery of the support ability of the
limb, absence of shortening and foot deformity, pain at physical
stress. Outcomes of rehabilitation were evaluated as positive
in 97,1% of cases in the group with “acute” and in 98% in the
group with chronic foot bones defects.
#ONCLUSION
Method of transosseous osteosynthesis with the Ilizarov
apparatus in case of a differentiated approach in management
of patients with posttraumatic defects of foot bones allows not
only effective filling in of defects of various parts of the foot, but
also simultaneous recovery of support ability and improvement
of the locomotor function of the lower limb.
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KINESIOLOGICAL CORRECTION OF RECURRENT & NEGLECTED
CLUBFOOT
0RINCIPAL!UTHOR Chaudhary, Milind, MD
CENTRE Jaslok Hospital
COUNTRY India
!IMS
To correct Recurrent and Neglected Clubfeet in older children
and adults with the Ilizarov fixator using Ponseti principles.
-ETHODS
31 feet in 23 patients have undergone correction of clubfoot
using the Ilizarov fixator over 8 years. 4 feet were completely
neglected, 3 were treated with previous casting, 23 with
previous soft tissue releases and 3 with previous external
fixation. 21 of the feet had Idiopathic clubfeet, 7 were due to
Arthrogryposis and 3 due to myelomeningocoele. Ages ranged
from 5 years to 33 years. Criteria for selecting this method
of soft tissue distraction was a spherical Talar dome in the
Idiopathic cases. Many arthrogrypotics had a incongruous talar
dome but were treated to achieve a plantigrade foot.
The Ilizarov fixator was applied to the tibia with two full rings, to
the talus as a dropped Olive wire, to the forefoot and calcaneus
with half rings.
Initial correction consisted of supination of the forefoot with a
force-couple construct dropped off of the tibial rings. Thereafter
Forefoot abduction was done with motors from postero-medial
side of tibial rings. The hindfoot ring was kept free to allow
the calcaneus to rotate into abduction. Finally, equinus was
corrected by attaching motor rods to the hindfoot ring, angled
to be perpendicular to the moment arm of the Ankle Centre of
Rotation.
Correction took 8 to 12 weeks. On removal a Plaster cast fixation
was maintained for 6 weeks followed by Bracing for several
months.
2ESULTS
Excellent correction was achieved in all idiopathic clubfeet.
except two feet, who had mild undercorrection. There were no
complications like ankle subluxation or crushing of talo-tibial
joint. The sphericity of the talus was maintained in idiopathic and
Myelomenignocoele cases, as was Ankle ROM. In many of the
arthrogrypotic patients, the talus was flattened or incongruous,
but treatment resulted in a plantigrade foot.
#ONCLUSION
Ponseti sequence of manipulation can be accurately replicated
with the Ilizarov fixator to correct recurrent and neglected
clubfeet, respecting the Kinesiology of ankle and subtalar joints.
Better results can be expected in Idiopathic clubfeet. Recurrence
can be a problem in Myelomeningocoele and Arthrogryposis
cases.
177
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%15).53#/22%#4)/.54),):).'%84%2.!,&)8!4)/.
0RINCIPAL!UTHOR Morgan, Kenneth, MD
CENTRE Colorado Foot & Ankle Clinic
AUTHORS Hahn, David, MD
CENTRE Colorado Foot & Ankle Clinic; Limb Preservation
COUNTRY United States
2ESUME
With the evolution of external fixation from the Ilizarov circular
ring fixator to more recent and versatile ring external fixators,
the ability to correct deformities of the foot and ankle has
also evolved. We present 8 cases involving ankle equinus
deformities that were corrected using an adaptable ring external
fixator. The contractures were gradually corrected following
application of the external fixator with concomitant performance
of a percutaneous Achilles tendon lengthening. The average
time to complete correction was 12 (range, 5-17) weeks.
Complications included pin tract infection, minor pin wounds,
and broken struts. None of the complications necessitated pin
or frame removal. Average follow-up duration was 13 (range,
8-16) months. The multifunction ring external fixator used
in this investigation offers foot and ankle surgeons a useful
tool for the gradual correction of severe deformities involving
the foot and ankle, and diminishes the risk of morbidity that
often accompanies attempts at acute correction of advanced
deformities.
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.%7%84%2.!,&)8!4)/.4%#(.)15%&/2#(%62/.490%
/34%/4/-)%353).'3-!,,2!),&2!-%3
0RINCIPAL!UTHOR Donate, Guillermo, MD
CENTRE Bay Pines Va Healthcare System
COUNTRY United States
)NTRODUCTION
Bunions are a common and painful occurrence in the general
population. Several techniques exist to fix these based on
the site of the osteotomy. Proximal metatarsal osteotomies
for bunion fixation (Lapidus arthrodesis) have been reported
as being fixed both with internal as well as external fixation.
Metatarsal head osteotomies (chevron-type) for bunion
correction have only been reported using a variety of internal
fixation techniques such as screws, pins and/or plates. Here we
report a new fixation technique for metatarsal head osteotomies
(chevron-type) using small rail external fixation. To date this type
of fixation has only been limited to the Lapidus procedure for
bunion correction.
-ATERIALSANDMETHODS
Chevron osteotomies were performed on 2 patients suffering
from bunion deformities. After the osteotomies were performed
they were fixated using a small rail external fixator and followed
as outpatients. The patients were seen through their regular
post-operative schedule and the rails removed at 7-8 weeks.
X-Rays were taken immediately post-op and after rail removal.
2ESULTS
This two-patient series using small rail fixation for chevron-type
bunionectomies of the distal first metatarsal shows correction of
the deformity without leaving a biologic footprint. Because of the
increased stability of the external fixator, minimal to no callus
formation was seen at the osteotomy site post-operatively.
#ONCLUSION
External fixation has been used for a number of different
surgical situations. This type of fixation is more stable than
traditional internal fixation and allows patients to bear weight if
needed. Chevron-type osteotomies of the distal first metatarsal
used to correct bunion deformities have traditionally been
fixated using internal fixation. With the use of small rail external
fixation stability can be assured and further compression can
be attained. Both of the patients in our series were healed
within 8 weeks with minimal signs of callus formation around
the osteotomy site secondary to the increased stability and
continued compression of the external fixator.
178
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%84%.3)6%,)-",%.'4(%.).').$7!2&)30RINCIPAL!UTHOR Chaudhary, Milind, MD
CENTRE Jaslok Hospital
COUNTRY India
!IMSOFSTUDY
We studied the results of the 80 lengthening regenerates in 69
limb segments in 19 patients with Dwarfism to increase height.
Extensive Limb Lengthening can be a safe method to increase
height in dwarfs to improve quality of life.
0ATIENTSAND-ETHODS
19 patients suffering from Dwarfism (Achondroplasia-12,
Chondrometaphyseal Dysplasia-3, Osteogenesis Imperfect-1,
Hypochondroplasia-1, Turner’s Syndrome-1) were treated at our
institute between 1990 and 2009 for extensive limb lengthening.
Ages ranged from 4 years to 32 years. 55 Tibial Lengthenings,
17 Femoral and 8 Humeral lengthenings were done. 16
Tibiae had double level lengthening and 23 tibiae had single
level lengthenings. All Femora and Humeri had single level
lengthenings.
All Tibiae were lengthened with Ilizarov fixator, 4 of 17 femora
and 2 of 8 Humeri were lengthened with the LRS fixator. All had
percutaneous corticotomies with latency period of 4 to 6 days.
2ESULTS
Height gain ranged from 7.5 cm to 26 cm in one to three
stages. Tibial Double level lengthenings achieved a minimum
of 10 cm and maximum of 18 cm in one stage. Tibial Single
level lengthenings achieved 4 to 12.5 cm of length. Percentage
Lengthening ranged from 31 to 96% of original length in Tibia
and 36% to 75% in Femur. Humeral Lengthening ranged
between 7 and 9 cm.
#OMPLICATIONS
No patients had vascular complications or dislocations of any
joints. There was one anterior subluxation of the Knee due to
extension contracture and was treated successfully by fixator
application and casting. There were 6 temporary ankle equinus
contractures of which 2 resulted in partial ankle stiffness. One
varus deviation of 16º and another valgus of 14º in two tibiae
needed repeat osteotomy for correction. There was limb Length
discrepancy in two patients of 6 mm and 10 mm only.
Premature consolidation was seen in 2 femora and 3 tibiae and
needed repeat corticotomy. None needed bone grafting.
3UMMARY
There was very high patient satisfaction and very few significant
complications in extensive limb lengthening for Dwarfism.
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SOCIAL ADAPTATION RELATED TO GENERAL HEALTH STATUS IN
,)-",%.'4(%.%$0!4)%.437)4(!#(/.$2/0,!3)!
0RINCIPAL!UTHOR Miquel Noguera, Joan, MD
CENTRE Icatme-Usp IU Dexeus
AUTHORS Martínez Martos, Sara, MD; Correa Vázquez, Eva, MD;
Isart Torruella, Anna, MD; Ginebreda Martí, Ignacio, MD; Cáceres
Palou, Enric, MD
CENTRE Icatme-Usp IU Dexeus
COUNTRY Spain
/BJECTIVE
To describe social adaptation related to general health status
in patients with achondroplasia, treated with three-segments
lengthening.
-ATERIAL
17 patients with achondroplasia treated with three-segment
(tibial, femoral and humeral) lengthening, with a 40 months
follow-up. Patients were assessed with SF-36 v.2 spanish
version and a questionnaire of different social items related
to daily life activities; such as laboral environment, marital
status or house adaptation to the stature. All items of the
cited questionnaire were related to general health status -SF36 standardized for US population: Mental component scale
(US-MCS), and Physical component scale (US-PCS) -through
multivariable analysis. (Spearman’s-rho test).
The sample included 11 men an d 6 women, mean age was
30.55 (17-44), mean stature 152.3 cm, and mean weight was
53.6 kg.
2ESULTS
15 of 17 patients are actively employed, and two of them
perceive contributory pension.
Household physical adaptation was not required for 11 of
17 patients, while only one of 17 patients required help for
domestic tasks. 13 of 17 patients required phsycological
attention at least once in their life.
Patients showed a mean US-MCS of 52.21, and US-PCS of
52.821.
Patient living with someone else reported better general health
status compared to those living alone (p<,05).
#ONCLUSIONS
Patients with full-segment lengthening don’t need physical
adaptation to daily life activities. Living with another person is
related to better general health status.
179
0/$)5-
,)-",%.'4(%.).').!#(/.$2/0,!3)!9%!232%35,43
0RINCIPAL!UTHOR D’elia Moreta, Martín, MD
CENTRE Cot
AUTHORS Martínez Lotti, Gabriel, MD
CENTRE Cot
COUNTRY Argentina
2ESUME
Low dysarmonic stature impaires normal social development in
every human being who intent to have succesfull life in terms
of almost complete integration in the society. Achondroplasia
has the higher incidence over the other bone dysplasias and its
importance let us to show the results of lengthening method.
The objective of this paper is to present the technique and
results of lengthening in achondroplastic patients.
We present 42 patients, the average age at the time of the
surgery was 9,2. We performed 182 lengthenings (84 femurs, 72
tibias, 22 humerus). The surgical technique involved monoplanar
external fixators using Wagner, Lazo-Cañadell and Orthofix.
The osteotomy was mediodiaphyseal and percutaneous as
Illizarov´s under fluoroscopic control. In thighs we done rectus
femoris tenotomy, in legs percutaneous Achilles tenotomy and
ankle suprasyndesmotic fixation at the initial surgery. We started
with 1mm/day bilateral and simetric lengthening at 8 day after
the surgical procedure. The controls were initially weekly during
the first month, every 15 days during the distraction and monthly
till the the fixators were taken off.
The average femoral lengthening was 11,6 cm, tibial 10,6 cm
ANDHUMERALCM4HEAVERAGEFOLLOWUPWASYEARS
All the patients with femoral lengthenings have an improvement
in their hyperlordosis. During the treatment the complications
founded were delay and early consolidation, femoral varus, tibial
valgus, temporary nerve paresia, callus fracture, early knee
arthritis, among others.
The achondroplasia produces a dysarmonic dwarfism, with
prominent forehead, proportional small face, bulky abdomen
due to hyperlordosis and ryzomelic short limbs. The lengthening
procedure increases their height, correct their hyperlordosis,
restores the normal ratio femur-tibia (~70) in lower limbs and
the relationship forehead-face. Although certain achondroplastic
stigmata have not change, the improvement in their social,
affective and life quality is proved.
But the treatment affects physeal grow, alters walk pattern,
produces knee pain because of early cartilage damage due
to hyperpresion and time of external fixation. So that, in the
last years, we start to priorize the angular correction to huge
lengthenings, reducing them to a maximum of 10cm per
procedure, and doing them over nails to reduce the external
fixation time.
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DISEASES
0RINCIPAL!UTHOR Kocaoglu, Mehmet, MD
CENTRE Istanbul University, Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
AUTHORS 1Sen, Cengiz, MD; 2Eralp, Levent, MD; 3Bilen, Erkal F,
MD; 2Balci, Halil Brahim, MD
CENTRES 1Lütfi Krdar Kartal Training and Research Hospital
Istanbul; 2Istanbul University Istanbul Medical Faculty
Department of Orthopaedics and Traumatology; 3Acbadem
University Medical Faculty Department of Orthopaedics and
Traumatology
COUNTRY Turkey
!IMANDPURPOSEOFTHESTUDY
Metabolic bone diseases result in significant bone deformities,
especially in the lower extremities. We are presenting the results
of the fixator assisted nailing and lengthening over nail for the
treatment of lower extremity deformities caused by metabolic
bone diseases.
-ETHODS
Between 2001 and 2009, 43 lower extremity segments (27
femora and 16 tibiae) of 18 (5 male, 13 female) patients with
a mean age of 25.6 years (range, 14-57 years) were acutely
corrected, and the segment was stabilized by intramedullary
locked nailing. Three segments with shortening were
subsequently lengthened by distraction osteogenesis. Diagnosis
was hypophosphatemic rickets in 16 patients and renal
osteodystrophy in two patients. The surgery was planned once
the laboratory parameters return to normal after a medical
treatment in the endocrinology department.
2ESULTSANDDISCUSSION
The mean follow-up time was 60 months (range, 18-120
months). In varus knees, the mechanical axis deviation (MAD)
improved by an average of 57 mm, the lateral distal femoral
angle (LDFA) improved by an average of 19 degrees, and the
medial proximal tibial angle (MPTA) improved by an average of
10 degrees postoperatively. In valgus knees, the MAD improved
by an average of 48 mm,the LDFA improved by an average
of 15.6 degrees, and the MPTA improved by an average of 10
degrees postoperatively. The mean external fixation time (EFT)
was 78.9 days, and for the lengthened segments the mean
external fixation index (EFI) was 14.34 days/cm and the average
bone healing index (BHI) was 38.32 days/cm. There were five
grade one pin track infections, screw cut-out in two patients,
and loss of correction in two patients.
#ONCLUSION
This combined technique provided good patient comfort because
the external fixator was removed either at the end of surgery or
at the end of the lengthening period.
Furthermore, early mobilization and weight bearing were
possible due to the strong fixation provided by the locked IM
nail. The usage of the intramedullary nail also prevented the
recurrence of the deformity and refracture in the mid-term
follow-up period.
180
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CHILDREN WITH ACHONDROPLASIA
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CHILDREN WITH ACHONDROPLASIA
0RINCIPAL!UTHOR Aranovich, Anna, MD
CENTRE Russian Ilizarov Scientific Center
AUTHORS Schukin, Alexander, MD; Klimov, Oleg, MD
CENTRE Russian Ilizarov Scientific Center
COUNTRY Russian Federation
0RINCIPAL!UTHOR Dikmen, Göksel, MD
CENTRE Istanbul University, Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
AUTHORS Kocaoglu, Mehmet, MD; Eralp, Levent, MD; Balci, Halil
Brahim, MD; Bilen, Erkal, MD
CENTRE Istanbul University, Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
COUNTRY Turkey
2ESUME
Low height and body disproportion in achondroplasia are
caused by the fact that enchondral growth disorders results
in shortening of tubular bones and bone and joint deformities
achieving 35-40 cm. The common techniques of bifocal
osteosynthesis elaborated at Russian Ilizarov Scientific Center
are used in multi-stage treatment of achondroplasia patients.
Therefore, the purpose of the study is to show the possibilities
of tibial lengthening using minimally invasive techniques in
children.
-ATERIALANDMETHODOLOGY
We studied treatment results of over 600 patients with this
pathology who underwent stage-by-stage lengthening of the
lower limb for 30-32 cm and the same of humerus for 9-11 cm.
$ISCUSSION
It is better to start operative lengthening in achondroplasia at
the age of 6-8 years using the stage of consecutive distraction
of tibia for the amount of 7-8 cm followed by two-stage cross
lengthening of tibia and femur up to 20-2 cm. This allows us to
achieve more anatomically and esthetically significant results
and body proportions close to the normal ones. In children
of elderly age and juveniles the lower limb lengthening is
performed within two stages using the technique of cross bifocal
distraction osteosynthesis of tibia and contra-lateral femur.
We offer to carry out tibial bone lengthening bifocally and
fibular bone one monofocally in distal area in children aged 6-8
years. While choosing fibula lengthening area we were guided
by the fact that the deformity in the distal tibial metaphysis
was more severe and required complete correction. Also, the
peroneal nerve is very close to fibula in the proximal part and
the possibility of its mechanical damage is rather high during
osteotomy performance. The lateral group of the muscles is
left intact since the wires in the middle tibia are inserted only
through tibial dyaphysis and osteotomy and further lengthening
of fibula are carried out at distal level with slow rate and early
completion of the distraction.
#ONCLUSIONS
Application of bifocal distraction tibial osteosynthesis and
monofocal distal fibular one reduces the invasiveness of
operation and creates favorable conditions for soft tissue
component of tibia during lengthening and further restorative
period.
!IM
Achondroplasia is the most common cause of dwarfism with
angular deformities. It is time consuming for child and for
parents to lengthen the lower limb segments separately. We
present the results of the bilateral femoral and tibial lengthening
procedure (four segments of the lower extremities operated
simultaneously) in achondroplasia patients and assessed the
outcomes.
-ATERIALANDMETHODS
A total of 76 segment lengthening procedures were performed in
19 achondroplasia patients. The mean age was 6,1 years (range,
3-11 years). All patients underwent bilateral simultaneous
lengthening of both femora and tibiae, Orthofix LRS type external
fixators were used for femoral segments and circular type
external fixators were used for tibial segments. Bilateral hip
flexor release and percutaneus Achilles tendon lengthening were
also performed in 13 patients.
$ISCUSSION
The mean follow up was 28,3 months (9-76 months), the mean
lengthening was 6,85 cm (range, 4 to 11.0 cm), or 44% (range,
23 to 70%) of the original femoral length for femora and 6,45
cm (range: 3 to 9 cm) or 48% (range, 23 to 69%) of the orginal
tibial length for tibiae. The mean EFI was 33,4 day/cm for femora
and 37,4 day/cm for tibiae. The mean lengthening per patient in
one session was 15,4 cm (range: 9-22 cm). We had 7 problems,
2 obstacles (late varus deformity/ knee contracture) and one
sequela. We observed 4 transient fibular paralyses, 4 regenerate
fractures. The bone score results were excellent in 68, good in 6,
fair in 1, and poor in 1 segments and the functional scores were
excellent in 66, good in 8, fair in 1, and poor in one segment
according to Paley’s classification.
#ONCLUSIONS
Bilateral simultaneous lengthening of 4 segments of the lower
limbs is a complex and prolonged procedure and requires
technical experience. However it provides a great amount of
lengthening in a short time period. Preoperative preparation with
a template, experience with external fixators and postoperative
rehabilitation is necessary for excellent results.
181
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0RINCIPAL!UTHOR De Pablos Fernández, Julio, MD
CENTRE Hospital San Juan de Dios
AUTHORS Bravo Corzo, Flavio, MD
CENTRE Hospital San Juan de Dios
COUNTRY Spain
/BJECTIVE
To retrospectively study our cases of upper-limb lengthening
in achondroplasia and assess the appropriateness of this
controversial treatment.
-ATERIALANDMETHODS
Fifty (50) cases of humeral lengthening have been reviewed
(no forearms were lengthened) in 25 achondroplasia patients
aged between 9 and 17. All were lengthened by callotasis and
unilateral external fixation (UEF). Minimum follow-up was 24
months.
2ESULTS
The mean increase in length obtained was 9 cm (52% original
length). The healing index was 0.85 months/cm. There was no
pseudoarthrosis and no plasters were necessary after removing
the UEF.
The norm was functional improvement in the upper limbs
operated on without affecting the joint balance in shoulders/
elbows.
#OMPLICATIONS
One radial neurapraxia was detected, pin-tract infection
occurred in 22% of cases and there was one mechanical failure
of the regenerated bone, none of which prevented the treatment
from being completed.
Long-term complications included 3 cases of delayed
consolidation, 3 of worsening of preoperative elbow flexion and
2 of psychological intolerance, all these occurring in 4 patients.
Factors particularly influencing these last complications were
initial displacement of the fragments and being over 15.
#ONCLUSIONS
s (UMERALLENGTHENINGINACHONDROPLASIAWASSEENBYTHE
patients as beneficial and satisfactory without an excessive
complication rate.
s )NTRAOPERATIVEDISPLACEMENTOFTHEFRAGMENTSAFTEROSTEOTOMY
should be avoided and adolescent patients should be followed
up very closely.
182
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FIXATOR
0RINCIPAL!UTHOR Kocaoglu, Mehmet, MD
CENTRE Istanbul University, Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
AUTHORS Eralp, Levent, MD; Balci, Halil Brahim, MD; Dikmen,
Göksel, MD; Bilen, Erkal F, MD
CENTRE Istanbul University, Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
COUNTRY Turkey
!IMANDPURPOSEOFTHESTUDY
Shortening of the humerus causes not only cosmetic and
psychologic problems but also functional problems. Limitation of
upper limb function, self service and personal hygiene deficiency
becomes more evident as spinal flexibility decreases by aging.
Humerus lengthening with a circular type external fixator, which
is not comfortable, was succesfully demonstrated. The aim of
this study was to demonstrate the effectiveness of humeral
lengthening with a unilateral external fixator.
-ATERIALANDMETHODOLOGY
Between 2001 and 2009, 27 humeri of 18 patients, 9 bilateral (7
achondroplasia and 2 epiphyseal dysplasia) with a median age
of 11.9 (range, 30-4) years underwent lengthening with use of a
unilateral external fixator after prophylactic radial nerve release.
9 patients (4 septic artritis, 2 tumor sequelae and 3 hemimelia)
had shortening according to other side. Exluding the patients
elbows with hemimelia, the range of motion of the elbow was
within physiologic limits
2ESULTANDDISCUSSION
The mean duration of follow-up was 49 months (range, 11-104
months). The mean external fixation time was 216 days (range,
120-510 days ), and the mean external fixation index (EFI) was
33,1 days/cm (range, 19-50 days/cm). The mean lengthening
was 7,26 cm (range, 3,7-12 cm). The mean lengthening rate
(according to prelengthening bone segment) was 56% (25-95%)
and 66% in patients with achondroplasia. Paley’s functional
scores were excellent in 11, good in 15, fair in 1 humeri. Paley’s
bone scores were excellent in 22 and good in 5 humeri. We
had 7 problems, 3 obstacles and no sequelae according to
Paley’s classification; 3 regenerate fractures were treated with
intramedullary rush pins, 3 radial nerve palsy that occured
during the lengthening process, but spontaneously resolved in 3
months, 2 grade 2 and 2 grade 1 pin tract infection were treated
with oral antibiotics and wound dressings. We had no sequelae.
#ONCLUSION
Humeral lengthening can be achieved by a unilateral external
fixator with a low complication rate, and the range-of-motion of
the adjacent joints are preserved.
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FOUR CASES
0RINCIPAL!UTHOR Sala, Francesco, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
AUTHORS Marinoni, Enzo, MD; Capitani, Dario, MD; Pace, Fabrizio,
MD; Agus, Maria Alice, MD; Fogliani, Tiziana, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
COUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
Docking site non union often occurs in distraction osteogenesis
procedures in the treatment of traumatic bone loss of the tibia.
Fibrocartilaginous capping of the bone ends, sealing of the
medullary canal and invagination of skin and subdermal tissues
are the main causes. Injury pattern may affect also soft tissues.
Pedicle tranfers and flaps are often needed for reconstruction
of soft tissue defects. Revision surgery at the docking site
non union is complicated also by the in situ hardware. A miniinvasive and tissues sparing technique is needed to perform the
docking site revision and the bone grafting.
-ATERIALANDMETHODOLOGY
An endoscopic approach in four cases was performed during
tibial docking site revision. Non union occurred following
compound tibial fractures treated by circular external fixation.
All were complicated by severe skin damage. After acute
distraction with the circular frame, two little skin incisions
were created in order to reach the docking site with an usual
arthroscopic instrumentation. Low pressure-low flow saline
irrigation was obtained by mean of MFS arthroscopic pump. A
30° arthroscope and a motorized 5 mm. shaver/abrader were
used. Fibrous tissue was removed, the bone ends abraded and
the bone canal cleaned. Bone graft was obtained from the iliac
crest in three cases and in other case from the ipsilateral medial
femoral condyle using osteochondral transfer instrumentation
(Makar Inst.). No tourniquet was used on the limb. At the end a
realignment and acute compression was performed.
$ISCUSSSION
The procedure was possible with good direct vision of the site,
small surgical approach and no complications like bleeding or
compartimental syndrome. It took 60 minutes in mean time for
operative procedure.
#ONCLUSIONS
The endoscopic approach provided minimal incision, accurate
debridement, precise bone grafting, minimal vascular injury to
the surrounding tissues, fewer complication, minimal hospital
stay, less expensive procedure obtaining rapid bone union.
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0RINCIPAL!UTHOR Sen, Cengiz, MD
CENTRE Lütfi Krdar Kartal Training and Research Hospital
Istanbul
AUTHORS Kocaoglu, Mehmet, MD; Eralp, Levent, MD; Dikmen,
Göksel, MD; Erdem, Mehmet, MD; Aç, Murat, MD
CENTRE Istanbul University, Istanbul Medical School Department
of Orthopaedics and Traumatology
COUNTRY Turkey
!IM
Comparison of the treatment of infected and non-infected tibia
pseudoarthrosis with acute compression-relengthening and
bone segment trasport techniques performed in our clinical
experience.
-ATERIALANDMETHODS
The group A; Acute compression-relengthening group had 22
patients, with a mean age of 33,6 years (10-53) underwent
tibial reconstruction to treat 12 infected and 10 non-infected
nonunion of the tibia with a mean bone loss of 4,8 cm (3-10).
The group B; segmental bone transport group had 21 patients,
with a mean age of 33,1 years (15-60), 16 infected and 5 noninfected nonunion of tibia with a mean bone loss 7,5 cm (2-17).
Radical debridement, temporary external fixation and antibioticimpregnated cement were used for the first step of infected 12
cases in group A and 16 case in group B. Free latissimus dorsi
flap was performed for one patient in group B.
$ISCUSSION
The mean duration of follow-up was 34,9 months (13-80) in
group A and 25,6 months (12-66) in group B. The mean external
fixation index (EFI) was 1,42 days/cm (1,1-2,3) in group A and
47,23 days/cm (35-108) in group B. The mean simultaneous
lenghtening was 7,48 cm (3,5-12) in group A. According to
Paley’s bone score we had 17 excellent, 4 good, 1 fair in the
group A and 15 excellent, 2 good, 4 poor in group B. According
to Paley’s functional socre we had 15 excellent, 6 good, 1
fair score in group A and 10 excellent, 6 good,1 fair, 4 poor in
group B. We had 3 problem, 2 obstacles (modification of frame
and achille tendon lengthening) and 2 sequelae (LLD > 2.5
cm and recurvatum > 5 degrees) in group A, while 3 problem,
9 obstacles, and 4 sequelae in group B according to Paley’s
classification of complication.
#ONCLUSIONS
The acute compression-relengthening technique may provide
improvement on patients satisfaction in appropriate cases,
because of the earlier removal of external fixator and low
complication rate facilitating more rapid rehabilitation. However,
during bone transport surgeons may attend to difficulties and
complications more than acute compression technique.
183
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0RINCIPAL!UTHOR Teng, Xing, MD
CENTRE Jishuitan Hospital, Beijing, China
AUTHORS Huang, Lei, MD; Yang, Shengsong, MD; Zhao, Gang,
MD; Wang, Manyi, MD
CENTRE Jishuitan Hospital, Beijing
COUNTRY China
!IMANDPURPOSEOFTHESTUDY
Treating noninfectious nonunion of tubular bone fractures with
monofocal compression-distraction-compression technique
without grafting.
-ATERIALANDMETHODOLOGY
5 noninfectious nonunions (4 femurs and 1 tibiofibule) were
stabilized with external fixators with distraction device.
Nonunions were compressed for 2 weeks, followed by
distraction with 1 mm per day divided by 4 times until 1014mm separation was available. After 2 weeks at the maximal
distraction, shortening with the same speed and rhythm was
performed until a second compression. Then the nonunion site
was compressed till union if osteogenic activity was present
radiographically. One or two more compression-distraction
cycles (so-called “accordion technique”) were needed with poor
osteogenic response in X ray until union. Pin-tract infection
and loosening happened in a tibiofibular nonunion and led to
malapposition. Varus and recurvatum deformity was present in
a femal nonunion at the time of the 2nd compression. No other
complications were noticed except pin tract problems. After
corresponding treatment, all five nonunions healed with average
healing time of 7.6 months (6-10 months). No refractures were
found with average following-up of 5.8 months (1-10 months)
after fixator removal.
184
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ILIZAROV RINGFIXATOR IN TIBIAL BONE DEFECTS
0RINCIPAL!UTHOR Dominik, Seybold, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
AUTHORS Jan, Geßmann, MD; Melanie, Leber, MD; Marcel,
Dudda, MD; Hinnerk, Baecker, MD; Gert, Muhr, MD
CENTRE Universitätsklinikum Bergmannsheil Bochum
COUNTRY Germany
)NTRODUCTION
Segmental bone transport anterograde or retrograde is a wellestablished method for tibial bone defect reconstruction to
achieve bone continuity. Different external Fixations devices
are in use. All external fixators are dealing with the problem of
driving wires through the soft tissue when pulling the segment.
The classic extramedullary cable transport is reducing the
skin problem but is still cutting through the soft tissue. This
is problematic after free flap soft tissue reconstruction. A
new method is described of a complete intramedullary cable
transport.
-ETHODANDPATIENTS
20 patients with a metaphyseal and diaphyseal bone defect
of the tibia after open trauma and posttraumatic infection
were treated with debridement, bone resection and soft tissue
coverage by local and free flaps. After soft tissue healing the
monolateral external fixation was replaced in each patient by
a four ring ilizarov fixator with a proximal percutaneous tibia
osteotomy. For bone transport a flexible cable was placed
around the distal part of the segment and passed intramedullarly
through the distal segment out of the tibia and on to the
Ilizarov fixator and the transport clickers. The bone segment
was transported after a delay of 7 days anterograd by the
intramedullar placed cable one mm per day.
$ISCUSSION
Necrosis and inflammation led by compression will increase
osteogenic activity. Tension stress caused by gradual distraction
to living fibril tissue and fibrocartilage will stimulate bone
regeneration. Consecutive compression-distraction-compression
works with combination of such two different kinds of
mechanical principles. This technique is indicated to those
without obvious leg length discrepancy, with good contact area
and optimal configuration for efficient compression.
2ESULTS
In all patients the bone defect was closed by the bone transport.
In one patient early consolidation of the regenerate occurred
and a rupture of the cable. Two patients had an insufficiency
of the callus. The distal docking site was augmented in all
patients after the segment transport with iliac bone graft
for consolidation. The one patient with early consolidation
was treated by a second osteotomy; the two patients with
insufficiency were augmented during the docking operation with
iliac bone graft.
#ONCLUSIONS
Noninfectious nonunions of tulular bone fractures can be
treated successfully with monofocal compression-distractioncompression technique. By this technique we can decrease
hemorrhage and soft tissue stripping during operation, as well
as avoid grafting.
#ONCLUSIONS
The intramedullar cable transport is a new modification of the
bone transport with the ilizarov ringfixator. The main advantage
is the soft tissue spearing and protecting transport mechanism
enabling bone transports after free flap soft tissue coverage with
micro vascular anastomosis.
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CHANGE IN WEIGHT BEARING INDEX DURING BONE
TRANSPORT AND UNION IN TIBIA BONE DEFECTS. DOES THE
WEIGHT BEARING
0RINCIPAL!UTHOR Kovoor, Cherry Cheriyan, MD
CENTRE Eranakulam Medical Centre
AUTHORS 1George, Vv, MD; 2Viswanath, Sabin, MD
CENTRES 1Eranakulam Medical Centre; 2Specialist Hospital
COUNTRY India
2ESUME
Aim to study the relationship between the weight bearing index
and union of docking site and regenerate consolidation during
bone transport for tibial defects.
-ATERIALANDMETHODOLOGY
A prospective study of 32 adult patients with tibial bone defects
treated with Ilizarov fixator was done. The mean age was 34.6
years. The mean bone defect was 5.9 cm. 21 cases were
treated with single corticotomy and twelve cases with double
corticotomies. Using a simple weighing machine the full weight
of the patient was taken and then the patient was asked to load
the affected limb as much as possible. The readings were taken
and weight bearing index calculated by the percentage of weight
borne on single limb to total body weight.
2ESULTS
The mean weight bearing index at start of treatment was
34.2%. At the time of docking it was 45.1%. At the time of
fixator removal the mean weight bearing index was 95.6%.
Thirty patients showed values above 91%. There were two false
positives and one false negative.
#ONCLUSION
We conclude that weight bearing index measurement co-relates
well with bony union in tibial bone defect cases.
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0RINCIPAL!UTHOR Kovoor, Cherry Cheriyan, MD
CENTRE Eranakulam Medical Centre
AUTHORS 1George, Vv, MD; 2Viswanath, Sabin, MD
CENTRES 1Eranakulam Medical Centre; 2Specialist Hospital
COUNTRY India
!BSTRACT
Aim to study if a double level corticotomy reduces the time in
ring fixator in tibial bone defects.
-ATERIALANDMETHODOLOGY
Thirty eight patients were included in the study. They were
equally divided into group A, double level corticotomy, and group
B, single level corticotomy. The mean age of patients in group A
and B were 41 and 29 yrs respectively. The mean bone defects
in group A and B were 8.9 and 5.6 cm. All the patients in group
A had either two corticotomies in proximal fragment or one
corticotomy in proximal and distal fragment. Group B patients
all had proximal corticotomies. The ring fixator was removed
when there was union of the docking site and consolidation of
regenerate and external fixation index [EFI] was calculated by
diving the number days in the fixator by the bone defect.
2ESULTS
The mean period in the ring fixator for group A was 477.8 days
and in group B was 346.4 days. The mean EFI in group A was
69.8 days/cm and in group B was 98.5 days/cm. Five patients
in group A had unplanned surgeries while in group B one patient
had unplanned surgeries. There was no statistical difference in
%&)BETWEENTHETWOGROUPS;P=
#ONCLUSION
There is no statistically significant differences in EFI with single
and double level corticotomies.
185
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TRANSPORTACION AND LENGTHENING BONE IN VON
RECKLINHAUSEN DISEASE
0RINCIPAL!UTHOR Iriarte Vincenti, Sergio, MD
CENTRE Department of Orthopedics and Traumatology Clínica del
Sur
COUNTRY Bolivia
0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszane Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez Pujay,
Edilberto, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios
COUNTRY Peru
)NTRODUCTION
A severe complication of the fractures of the tibia is the bone
defect that associated to infection, makes worst the prognosis.
The chronicle bone infection is because of a not well treated
acute infection. The fragments of necrotic bone in an infected
atmosphere become a chronic infection. We are in front of an
atrophic nonunion. The general principles in the treatment of
this pathology and the execution of the assemblies are similar to
those described in the aseptic nonunion.
-ATERIALANDMETHOD
A great part of our treated patients that presented segmental
bone defects had as important antecedents: Comminuted open
fractures, open fractures with bone loss (some associated to
infection), infected osteosynthesis, hematogenous osteomyelitis,
among others.
The treatment of 52 patients was analyzed, from April 1993 to
April 2010 with bone defects of different length, different chronic
forms of bon infection, corresponded to the groups B1, B2 and
B3. In all of them were carried out a clinical and radiological
exam, and in the patients in those that there was infection was
carried out bacteriologic identification.
We apply the Ilizarov’s assembling according to the nonunion
type, bone defects smaller than 5cm, a single corticotomy and
bifocal osteosynthesis. In defects bigger than 5cm, double
corticotomy and osteosynthesis trifocal, etc.
The management of the skin was fundamental, in some cases
we use pearls like spacers, to avoid the skin retraction and
scarring to deeper tissue layers obstructed bone transport.
2ESULTS
Cure of the infection in 52 patients, 100% of effectiveness of the
method; bone consolidation in 51 patients 98.07%, correction
of the bone defect in 52 patients, 100%, correction of angular
deviations in the great percentage, restoration of the function of
the limbs, among others.
$ISCUSSIONANDCONCLUSION
Many of our patients had been treated with other methods,
as internal fixation, external fixation (other systems) and other
techniques. Some patients had as antecedent: multiple previous
surgeries. The Ilizarov’s method is a valuable resource of our
orthopedic therapeutic arsenal in the treatment of the segmental
bone defects, as consequence of the own traumatism or the
failure of previous treatments.
186
/BJECTANDPURPOSEOFTHESTUDY
The Neurofibromatosis or Von Recklinghausen disease, is an
inherited disorder characterized by alterations in the supportive
tissue systems nervous central and peripheral associated
with several anomalies of the skeleton, skin and soft tissue
multisistemico. Transmits a dominant regional basis but
mutations occur.
The incidence is 1 of each 2500 to 3000 live births.
The findings of soft tissue include Brown with milk, nodules
(dermal neurofibromas), nevus (hyperpigmentation),
Hypertrophic villi (elephantiasis), plexiformes neurofibromas,
verrugosas hyperplasia and axillary freckles stains.
Spinal deformities, the discrepancy in limb length and tibia
pseudoartrosis frequently require orthopaedic treatment.
We present 10 patients treated in home Clinic St. John of God
Peru with the tibia by Neurofibromatosis, bone transportation
with external fixative monopolar pseudoartrosis diagnosis.
-ETHODSANDMATERIALS
10 patients with Neurofibromatosis tibia pseudoartrosis are
presented. The age in which were operated is between 5 and 15
years. We used a monolateral axial external fixative with three
heads. Subtraction osteotomy is the focus of pseudoartrosis and
compression, bone transportation than the previous tuber of
the tibia. Bone shortening was between 6 and 12 cm. Electrical
stimulation is the focus of pseudoartrosis and bone lengthening.
Physical therapy is performed from the immediate postoperative
period.
$ISCUSSION
Successfully bone lengthening between 6 and 10 cm.
Maintaining range articulate knee. Consolidation of the
pseudoartrosis time is twice or more than one bone is not by this
pathology. 3 Patients had to perform grafting and osteosynthesis
with plate screws and low contact. The focus of pseudoartrosis
fracture was presented in 3 patients.
#ONCLUSSIONS
While successfully solve the problem of the pseudoarthrosis,
long-term outcome is uncertain, and therefore has to do serial
and continuous controls to limit physical activity and sometimes
indicate the use of protection orthotics.
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OSTEOGENESIS
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RESULTS
0RINCIPAL!UTHOR Shchepkina, Elena A, MD
CENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
AUTHORS 1Solomin, Leonid N, MD; 2Polyntsev, Dmitry G, MD;
2
Zaritsky, Andrey U, MD
CENTRES 1Vreden Russian Research Institute of Traumatology
and Orthopedics; 2St. Petersburgs State I Pavlov Medical
University
COUNTRY Russian Federation
0RINCIPAL!UTHOR Wioleta, Ostiak, MD
CENTRE Department of Paediatric Orthopaedics and
Traumatology-University of Medical Sciences
AUTHORS 1Pawel, Koczewski, MD; 1Milud, Shadi, MD; 2Marek,
Napiontek, MD; 2Roma, Krzyminska, MD
CENTRES 1Department of Paediatric Orthopaedics and
Traumatology-University of Medical Sciences; 2Ortop PolyclinicPoznan; Student
CoUNTRY Poland
!IM
To investigate the influence of MSC on organotypic remodeling
of distraction regenerate.
0URPOSE
Analysis of long-term health-related quality of life (QOL)
restrictions after treatment by external fixation.
-ATERIALSANDMETHODS
Autologous mesenchymal stem cells (MSC) with phenotype
#$#$#$#$#$#$WERE
extracted from patient’s bone marrow and cultivated in vitro
till 4 passages. These cells were inserted in the area of
regenerate after finishing of distraction in suspension on 10%
autoserum, the dosage was 7-10 mln. on 1 cm³ of regenerate.
The MSC suspension was inserted threw 4 injections in
different directions under fluoroscopy control. X-rays, CTscans, densitometry was performed before MSC insertion and
after it with interval 1 month. Dismantling of ExFix device was
performed after estimation of x-ray data and clinical testing.
No cast immobilization was performed after dismantling.
Comparative assessment of normothrofic distraction regenerates
after MSC insertion in 10 cases with analogous control group
without MSC insertion was performed.
-ATERIALS
50 patients aged 17 to 70 (mean 26.9).
$ISCUSSION
In analysis of x-rays and CT-scans data in the area of
regenerates after MSC insertion more steady ossification in the
area of regenerate, earlier formation of bone cortex were found
in comparison with control group. ExFix devices dismantling in
basic group was performed earlier. Fixation index in basic group
WASDAYSCM)NCONTROLGROUPTHISINDEXWASHIGHER
DAYSCM)NCOMPARISONOFTHEDATACONlDENCE
COEFlCIENTFORMEANQUANTITYCOEFlCIENTTWASWITHP
0,0415.
#ONCLUSION
Found data allow to make conclusion that MSC stimulate
distraction osteogenesis when they are inserted after finishing of
distraction. Also application of MSC is prospective for decreasing
of treatment period in long bone lengthening and building of
segmental defects.
-ETHODS
QOL Scale questionnaire, which consists of 8 domains: vigour,
pain, sleeping, emotional reactions, social life, fulfilling the roles,
recreation and leisure time, relations with family and friends.
The study was done five times, the last, on average 40 months
after fixator removal. The group was divided according to type
of fixator (Ilizarov apparatus-44, monolateral fixator-6), fixator
localization (femur-23, tibia-27), type of treatment (lengthening35, axis correction-6, stabilization of non-union of fracture-9)
and etiology: congenital limb deficiencies-9, non-union-7, post
traumatic deformities-16, post-septic deformities-11, others-7.
2ESULTS
Quality of life improvement is noticed in every category
during long-term observation, the best, in comparison to
first examination, is in categories: “emotional reactions” and
“recreation and leisure time” - increase by 19%, “social life”
and “pain” - by 10%. What is more, that improvement was the
most significant in all categories in patients with non-union
(“recreation and leisure time” increased even by 60%).
#ONCLUSION
Time is a beneficial factor in quality of life improvement.
Contrary to functional status, which most patients improved
finally over the 6 months after fixator removal, quality of life had
improved throughout the whole period of observation.
187
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FASCICULARIS
0RINCIPAL!UTHOR Wioleta, Ostiak, MD
CENTRE Department of Paediatric Orthopaedics and
Traumatology-University of Medical Sciences
AUTHORS 1Pawel, Koczewski, MD; 1Milud, Shadi, MD; 2Marek,
Napiontek, MD; 2Roma, Krzyminska, MD
CENTRES 1Department of Paediatric Orthopaedics and
Traumatology-University of Medical Sciences; 2Ortop
Polyclinic-Poznan; Student
COUNTRY Poland
0RINCIPAL!UTHOR Ochiai, Naoyuki, MD
CENTRE University of Tsukuba
AUTHORS Hara, Yuki, MD; Amano, Kuniaki, MD; Nozawa, Daisuku,
MD; Ishii, Tomoo, MD; Nishiura, Yasumasa, MD
CENTRE University of Tsukuba
COUNTRY Japan
0URPOSE
Distant evaluation of restrictions on ADL’s after treatment by
external fixation of the lower limb.
-ATERIALS
50 patients aged 17 to 70 (mean 26.9).
-ETHODS
OFC functional assessment questionnaire (multidimensional
ADL: locomotion, toilet, dressing, hygiene, eating, social
independence). The study was done five times, the last, on
average 40 months after fixator removal. The group was divided
according to type of fixator (Ilizarov apparatus-44, monolateral
fixator-6), fixator localization (femur-23, tibia-27), type of
treatment (lengthening-35, axis correction-6, stabilization
of non-union of fracture-9) and etiology: congenital limb
deficiencies-9, non-union-7, post traumatic deformities-16,
post-septic deformities-11, others-7.
2ESULTS
“Locomotions” and “social independence” had the most
statistically significant differences. Long-term results of the
whole group equalled the first score in “locomotion”, and
improved more in “social independence”. The best improvement
in “locomotion” in a few-year follow-up is observed in patients
with non-union (from 73% in the first examination to 93% in the
fifth one). In “social independence” results were very similar.
However long-term scores in “locomotion” deteriorated in the
congenital limb deficiencies and post septic deformities patients.
There were no significant changes in the final results of the
others groups in comparison to the first score.
#ONCLUSION
1. Most patients achieved functional improvement within the 6
months after fixator removal. They regain functional abilities
from before the treatment.
2. The passage of time from external fixator removal, is a
beneficial factor in functional recovery, but only at the
beginning. Later there is no improvement on activities of daily
living, except patients with non-union.
188
!IMANDPURPOSEOFTHESTUDY
We tried the Ilizarov method for repairing peripheral nerve
segmental defect. When rat sciatic nerves were elongated
indirectly during limb lengthening, the gradually lengthened
sciatic nerve showed mainly paranodal degeneration and
recovered in time with elongated internodal length.
Next we confirmed that when pulling proximal stump, axon
generated near the stump and at the more proximal part nerve
adjusted as same as indirect elongation. When pulling distal
stump, nerve adjusted by continuous proliferation of Schwann
cells and elongation of Buengner band. We compared free nerve
graft and our new method to repair segmental nerve defect. The
new method was not inferior to grafting. We confirmed same
results in rabbits.
This time we applied the new method to primate as a preclinical
phase.
-ATERIALSANDMETHODOLOGY
In 6 adults macaca fascicularis we made a 20mm defect in
THEMEDIANNERVEATTHEMIDPARTOFFOREARM)NGROUP,N
neurorrhaphy was done in end-to-end fashion after both
proximal and distal stumps were elongated in rate 1mm/day
step by step using handmade external fixator. During elongation
without sedation they showed no behavior relating to pain. In
GROUP'NTHESURALNERVEWASHARVESTEDANDIMPLANTED
into the gap. The results were evaluated 16 weeks after initial
operation by measuring NCV, amplitude of CNAP, muscle wet
weight of the abductor pollicis brevis, average axon diameter
and number of axon in the recurrent branch.
2ESULTS
In NCV Group L recovered significantly better than group G. In
other parameters Group L exceeded group G but not significant
statistically.
$ISCUSSIONANDCONCLUSION
The new method is at the ready to apply in clinical practice.
The merits are 1. no need of auto-nerve graft, 2. neurorraphy in
single part. Demerits are 1. annoyance using external fixator, 2.
several times operations.
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NON UNIONS
0RINCIPAL!UTHOR Makarov, Marina, MD
CENTRE Texas Scottish Rite Hospital for Children
AUTHORS Birch, John, MD; Samchukov, Mikhail, MD
CENTRE Texas Scottish Rite Hospital for Children
COUNTRY United States
0RINCIPAL!UTHOR Sarmah, Sasanka, MD
CENTRE Hull Royal Infirmary
AUTHORS Fenton, Carl, MD; Raman, Raghu, MD; Roy, Niloy, MD;
Gopal, Shiva, MD; Sharma, Hemant, MD
CENTRE Hull Royal Infirmary
COUNTRY United Kingdom
0URPOSE
Skeletal muscles produce substantial resistance to distraction
and are the major limiting factor for successful limb lengthening
outcome. To better understand mechanisms of such insufficient
compliance, potential biological relevance of global gene
expression patterns was investigated in muscles immediately
after distraction.
-ATERIALSANDMETHODOLOGY
Fifteen skeletally mature goats underwent standard 20% tibial
lengthening. Samples of peroneus tertius (PT) myotendinous
junctions (MJ) and muscle belly (MB) were harvested from
experimental and control limbs. Cross-species hybridization
to human Affymetrix HU133A or HG-U133 Plus microarrays
containing 22,284 and 54,675 human gene transcripts,
respectively, were used to investigate gene expression.
Quantitative RT-PCR was used to confirm differential expression
of particular genes. Three muscles from each anterior (PL, EDL,
PT) and posterior (SDF, GL, SOL) compartments were analyzed.
2ESULTS
Muscle tissue from MJ and MB revealed that 23% and 30%
of gene transcripts, respectively, were flagged present in both
control and experimental muscles. Genes differentially expressed
between lengthened and control groups included MYOZ2
(Myozenin 2), MYL4 (embryonic myosin alkali light chain), CRYAB
(crystalline, alphaB), CFL2 (cofilin 2), MLC1SA-embrionic (myosin
light chain 1 slow A). Although both MJ and MB of lengthened
limbs yielded up-regulation of similar genes, there were genes
differentially expressed in MJ but not expressed in MB and vice
versa. MYOZ2 was the most highly over expressed gene in both
MJ and MB. Antagonistic muscle groups showed clear difference
in the level of MYOZ2 expression. Anterior muscles with greater
length increase after distraction showed statistically significant
up-regulation of MYOZ2 while posterior muscles showed a trend
toward its down-regulation. Cloning and sequencing of the
complete goat MYOZ2 ortholog revealed 92% nucleotide identity
to human MYOZ2, validating our ability to detect this gene using
human microarray.
#ONCLUSIONS
Differential expression of gene transcripts was found between
distracted and control muscles (p<0.05) as well as between
different regions of the same muscle. Muscles with especially
high level of MYOZ-2 up-regulation showed evidence of active
sarcomerogenesis and better adaptation to distraction. These
results identify genes of biological relevance during limb
lengthening and provide insights into pathways controlling
muscle response to distraction.
!IMANDPURPOSEOFSTUDY
Non union and delayed union always has been a challenge for
the surgeon as 5% to 10% of fractures do not heal even with
the most advanced modality of treatment available. Lately low
intensity pulsed ultrasound is gaining popularity with a success
rate of 70% to 86%.
The aim of this study is to evaluate the role of low intensity
pulsed ultrasound, Exogen Smith & Nephew; in the treatment of
delayed and non unions.
-ATERIALANDMETHODOLOGY
We conducted a retrospective study of 292 patients who has
had Exogen treatment for delayed and non union from 2005 to
2009. Patient’s age, sex, associated co morbidities, smoking
history, medications, type of fractures (open/closed), infection
and site of fractures were sought for. 271 patients’ data (255
delayed and 16 non unions) were available during the study with
mean age of 53.5.
Exogen therapy was initiated at 3-4 months for delayed unions
and 9-12 months for non unions in 61 tibia (15 open); 31 femur
(2 open); 20 scaphoid; 38 5th metatarsal; 31 ankle (2 open);
17 ulna (1 open); 15 radius (3 open); 29 humerus (2 open);
16 clavicles; 6 olecranon; 4 pilon (2 open) and 2 metacarpel
fractures. The following co morbidities were recorded, Diabetes
(16), Ischemic heart disease (11), hypertension (18), Ca lung (1)
and rheumatoid arthritis (2).
$ISCUSSION
Union was achieved in 196 patients (72.3%) of which 11 (5.6%)
were smokers. In 73 (26.9%) patients union was not achieved
of which 53 (72%) were smokers. The mean healing timing after
application of Exogen was 16 weeks for delayed union and 26.6
weeks for non union. 5 out of 16 in the diabetic group went into
non union (31.2%).
#ONCLUSION
In our study we found an accelerated union rate with Exogen
therapy in delayed union, however smoking is a negative
predictor for bone healing which appears to be unaltered despite
Exogen therapy. Prescribing Exogen therapy early in delayed
unions may be potentially beneficial to prevent an established
non union.
189
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ANALYSIS
0RINCIPAL!UTHOR Mitkovic, Milan, MD
CENTRE Ortopedsko-Traumatoloska Klinika
AUTHORS Mitkovic, Milorad, MD
CENTRE Ortopedsko-Traumatoloska Klinika
COUNTRY Serbia
)NTRODUCTION
The aim of this study was comparing of stabilities of external
fixator with paralel pins, with the position in the same plane, and
external fixator with convergently oriented pins, with position in
different planes.
-ATERIALANDMETHOD
As material we used external fixator which provides 4 pins to be
inserted in the same plane, and external fixator which provides
4 pins to be inserted in different planes. These fixators were
applied on tube like long bone model, made of wood, cut on the
middle with gap of 8 mm. On these bone models 100 N of force,
in 2 directions perpendicular on long axis of bone models have
been applied. The plane A and plane B were perpendicular to
each other wich pass throw long axis of bone model: in the use
of fixator with parallel pins one of these directions was in the
plane of all pins, and in the use of fixator with convergent pins
each of these directions was in the plane of one of pair of pins.
At the same time there were measured fragments movements
produced by the used loads.
2ESULTS
It has been obtained following results: in fixator with parallel
pins, all in one plane, stability is 4 times bigger in the plane
of the pins then in perpendicular plane, while stability in 90
degrees convergent orientation stability is nearly same.
$ISCUSSIONANDCONCLUSION
External fixators with pins can have pins in one plane and
parallel or pins in different direction. External fixation device with
90 degrees convergent pins gives balanced 3D stability similar
to natural long bone biomechanical conditions.
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0RINCIPAL!UTHOR Colak, Mehmet, MD
CENTRE University of Mersin
AUTHORS Gurer, Burak, MD; Eskandari, Metin Manouchehr, MD
CENTRE University of Mersin
COUNTRY Turkey
)NTRODUCTION
Although Kirschner wires are the most widely used tool for
temporary or permanent fixation of fractures or osteotomies,
unknown aspects of their biomechanical behavior still exists.
There is some information about the effects of tip configuration
and obliquity of wire insertion on slippage of the wires over the
cis cortex. In practice we observed that slippage of the wires
over the trans cortex is also frequent and can lead to insufficient
fixation stability. This in vitro biomechanical study was planned
to investigate the appropriate angles of wire insertion which lead
to trans cortex perforation in sheep humeri.
-ATERIALSANDMETHODS
We obtained humeral bones of adult sheep from a local butcher
within six hours of slaughter. The soft tissues were removed.
Because the question was focused on trans cortex perforation,
all humeri were cut longitudinally in two pieces. Trochar point
pins in four different diameters (1.5, 1.8, 2.0, 2.2) were used
in the study. Each pin was introduced from endosteal side with
the aid of a specially designed frame in angles starting from 30
degrees (always causes slippage) and 5 degrees of increments
until perforation. When perforation was achieved the angle
was recorded. After working with five pins in same diameter
drilling speed was changed from 400 to 1300 and procedure
was continued with five new pins. The test was repeated by
two other orthopaedic surgeons on separate bones. Two-way
factorial ANOVA and ROC curve analyses were performed for
statistical analyses.
2ESULTS
Main effects of wire diameter and drilling speed on perforation
ANGLESWERENOTSIGNIlCANTSTATISTICALLYPAND
respectively). Interaction between wire diameter and drilling
SPEEDALSODIDNOTCAUSEASIGNIlCANTDIFFERENCEP
Angles of 45 degrees or higher provided penetration with a
PERCENTAGEOF#)P
#ONCLUSION
In practice we sometimes aim the wire or nail walk along the
endosteum (for intramedullary fixation) but it reluctantly occurs
during bicortical applications. Our study demonstrated that
regardless of wire diameter or drilling speed 45 degrees or
higher insertion angles are required for perforation of trochar
pointed wires on the far (trans) cortex.
190
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IN CONGENITAL LONG BONE DEFECTS, BY DISTRACTION
OSTEOGENSIS
0RINCIPAL!UTHOR Shrivastava, Sandeep, MD
CENTRE Datta Meghe Institute of Medical Sciences, University
AUTHORS Dulani, Rajesh, MD; Singh, Pradeep, MD
CENTRE Datta Meghe Institute of Medical Sciences
COUNTRY India
!IMANDPURPOSE
This study is under taken to formulate a predictable strategy
for successful reconstruction of lower limb long bones in rare
congenital defects, with the help of ring fixator/distraction
Osteogenesis.
-ATERIALANDMETHOD
Between Oct 1992-Sept 2009 the author treated 22 children of
rare congenital long bone defects of lower limb like Proximal
Femoral Femur Deficiency, Dysplasia of hip with extreme
shortening, Congenital shortening of femur/tibia, Congenital
psuedoarthosis of tibia, Tibial hemimelia, Spondyloepiphyseal
Dysplasia etc., with the help of ring fixator following the
principles of distraction osteogenesis.
The observations are analyzed in terms of amount of deformity
corrections, limb lengthening; problems and difficulties faced
including psychological ones; and functional outcome etc. The
results are also discussed as per the current trends in the recent
literature.
$ISCUSSION
These rare congenital defects are associated with many
challenges in terms of very small limb, extreme shortenings
(more than 10 cms/50%), complex deformities, non-unions etc.
Approaching these corrections is a big challenge. Ring fixator
offers the advantage of addressing many of these problems
simultaneously but is associated with quite a few difficulties
and complications. This study identifies these issues including
difficulties in fixator application in small limb, corticotomy, too
much of lengthening and long duration of wearing, so that an
effective strategy for predictable outcome can be formulated.
#ONCLUSIONS
In these extremely deformed lower limbs in pediatric age
group a successful treatment strategy can be planned with the
help of ring fixator. The key is recognizing and being aware of
the forthcoming difficulties and problems, and dealing them
promptly and timely.
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0RINCIPAL!UTHOR Kawasaki, Yoshiteru, MD
CENTRE Department of Orthopedics, The University of Tokushima
Graduate School
AUTHORS Mitsuhiko, Takahashi, MD; Natsuo, Yasui, MD
CENTRE Department of Orthopedics, The University of Tokushima
Graduate School
COUNTRY Japan
2ESUME
To correct lower limb deformities, exact understanding of
deformities is necessary. The gold standard for radiographic
assessment and correction planning of lower limb deformities
is the long standing radiograph. In a filmless environment,
measurement tool on the displayed image is useful in
performing limb deformity assessment and corrective surgery
planning. We developed the custom-made measurement tools
which were more convenient in preoperative planning for
deformity correction. However, for severe combined angulation
and rotation deformities of the lower limb, true AP and LAT
radiographs of the lower leg is not always obtained, and
accurate assessment is difficult. Furthermore, radiological
method is not available for measuring the magnitude and
direction of the rotation deformity. For such cases, three
dimensional computed tomography (3DCT) is useful. In this
report, we describe radiological measurement tool in a filmless
environment and 3DCT assessment for severe lower limb
deformities, while showing cases.
Using measurement tool on the displayed image, we can
perform malalignment test and find CORA easily in the frontal
and sagittal planes. In addition, this system offers procedure
simulation capabilities for osteotomy, deformity correction and
lengthening.
For severe deformities, 3DCT of the lower limb is taken. Using
an Aquarius Net Viewer workstation (TeraRecon, Inc., San
Mateo, CA), the volume rendered image is rotated to the patella
forward position which is a true frontal image. A sagittal image
of the lower limb is obtained 90° to the patella forward position.
Malalignment test is performed by drawing joint and mechanical
axis lines on these 3DCT images. For assessment of the rotation
deformity, bird’s eye view is benefit. The observer looks down
the image from the proximal or distal side by rotating the 3DCT
image. Overlay image of hip and knee is used for calculating
femoral torsion, and knee and ankle for tibial torsion. 3DCT
image is also useful to understand the location and course of
the muscles and tendons by changing the rendering image to
highlight them.
Although the level of radiation exposure from 3DCT scan is
higher than that from simple radiology, 3DCT is useful to assess
severe limb deformities.
191
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EPIPHYSEAL INJURY USING EXTERNAL FIXATOR AND
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0RINCIPAL!UTHOR Takata, Munetomo, MD
CENTRE Graduate School of Medicine Kanazawa University
AUTHORS Watanabe, Koji, MD; Matsubara, Hidenori, MD; Takato,
Kei, MD; Tsuchiya, Hiroyuki, MD
CENTRE Graduate School of Medicine Kanazawa University
COUNTRY Japan
!IMANDPURPOSEOFTHESTUDY
Epiphyseal injuries can occur the deformity and limb length
discrepancy. In this study, we evaluated the type of deformity
and assess the result of various treatments.
-ATERIALANDMETHODOLOGY
39 limbs in 29 cases (18 males, 11 females) were included in
this study. The mean age at the injury was 6.6 years old (range
0-13). The mean age at the operation was 21 years old (range
6-69). The average follow up period was 55 months (range
7-147). The Ilizarov frame was used in 19 limbs, Taylor Spatial
Frame in 6, unilateral fixator in 9 and Albizzia gradual elongation
nail in 5. The causes of the injury included trauma in 5 cases,
infection in 5, and invasion of operation in 2. The symptoms at
the time of operation included 14 limpings, 13 arthralgias and
5 low back pains occurred from compensatory scoliosis due to
limb length discrepancy.
2ESULTS
Deformity varied in each case. Average shortening deformities
were 53 mm in distal femur (range 25-60), 132 mm in knee joint
(combined of distal femur and proximal tibia) (range 43-87), 28
mm in proximal tibia (range 21-35), and 44 mm in distal tibia
(range 22-90). Other deformities which included varus, valgus,
rotation of internal and external, flexion and recurvatum varied
most in distal femur. There was no apparent difference in the
post-operative ability between the devices. Average number of
operation times was 1.3 (range 1-4) due to excess growth. There
was no severe complication which required additional operation.
$ISCUSSION
It is difficult to make decision when we perform an operation
on a case with growing deformity. We should predict the limb
length discrepancy in the future, consider symptoms and also
pay attention to the individual social situation. Because the
deformity varies, there is no universal strategy. Usually with
the complicated deformity, Taylor Spatial Frame is useful which
enables us to correct in one step.
#ONCLUSIONS
We treated 39 limbs of deformity after the epiphyseal injury
using external fixators and elongation nail. Because the
deformity varies, Taylor Spatial Frame which corrects any kind of
deformity simultaneously is valuable.
192
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&/2,!4%/.3%4",/5.4$)3%!3%
0RINCIPAL!UTHOR Watanabe, Koji, MD
CENTRE Dept. of Orthopaedic Surgery, Kanazawa University
AUTHORS Shirai, Toshiharu, MD; Matsubara, Hidenori, MD; Kei,
Takato, MD; Takata, Munetomo, MD; Tsuchiya, Hiroyuki, MD
CENTRE Dept. of Orthopaedic Surgery, Kanazawa University
COUNTRY Japan
"ACKGROUND
The purpose of this study was to evaluate the results of surgery
for late-onset Blount disease that is a rare condition in Japanese
population.
-ETHODS
We treated eight consecutive patients (twelve tibiae) with lateonset Blount disease using acute or gradual correction with a
circular external fixator. Two patients (three tibiae) underwent
limb lengthening postoperatively. Four of eight patients were
suffered monolaterally. There was no obese patient over BMI 30
kg/m2. The mean age of the patients at the time of surgery was
18.4 years. Standing anteroposterior and lateral radiographs
were made preoperatively and at the time of the final follow-up.
Preoperatively, the mean mechanical axis passed through 96%
medial point from the center of knee joint, the mean mechanical
medial proximal tibial angle was 74.2-degree, and the mean
posterior proximal tibial angle was 87.1-degree. We used the
Ilizarov external fixator for nine tibiae and the Taylor Spatial
Frame for three tibiae. Acute correction was performed for six
tibiae and gradual correction was done for six tibiae.
2ESULTS
After a mean duration of follow-up of 8.8 years, the mean
mechanical axis deviation had improved to -1.0% medial
point from the center of knee joint (range, -9.5% to 8.6%), the
mechanical medial proximal tibial angel had improved to 87.8degree (range, 87-degree to 89-degree), and, the posterior
proximal tibial angel had improved to 80.7-degree (range, 79degree to 82-degree). The external fixator was removed at a
mean of 4.5 months in the correction group and 12.6 months
in the correction-lengthening group. No wound infections,
nonunions, or neurovascular complications occurred. No patient
was observed osteoarthritis in radiograph.
#ONCLUSIONS
The goal of treatment of Blount disease is to attain a normal
aligned lower extremity with normal joint orientation and equal
limb lengths at skeletal maturity. We believe proximal tibial
osteotomy followed correction with a circular external fixator is
the most reliable treatment for late-onset Blount disease.
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4(%-%#(!.)#!,0(93%!,!.',%/&4(%02/8)-!,4)")!!3
A TOOL FOR EARLY DIAGNOSIS OF BLOUNT’S DISEASE
0RINCIPAL!UTHOR Mora Rojas, Raúl, MD
CENTRE Hospital Nacional de Niños
AUTHORS Mora Rojas, Raúl, MD; Matamoros Álvarez, Óscar, MD
CENTRE Hospital Nacional de Niños
COUNTRY Costa Rica
/BJETIVEANDPURPOSEOFTHEWORK
The purpose of this study was to establish a new measurement,
the mechanical physeal angle of the proximal tibia (AMFPT) on
radiographs, taking into account the structures and concepts
that are altered in patients with Blount’s disease, as are the
proximal tibial physis and the mechanical axis of the tibia, which
has not been taken into account in any measure described
before.
-ATERIALSANDMETHODS
We identified patients diagnosed with bilateral Blount’s disease,
we conducted a series of radiographs (between 3 and 10 to
each patient with Blount disease) to a total of 684 patients in
different age groups and in each of these films was measured as
the AMDPT both AMFPT. We performed a calculation of logistic
regression to identify the level of inference in the diagnosis of
the disease if they had alteration in one or other measure. Based
on these values, we proceeded to calculate the relative risk for
each age group by sex and also applied the t-Student method to
define the probability of accepting the alteration of AMFPT as a
tool in the diagnosis Blount’s Disease.
$ISCUSSION
After applying the calculation of logistic regression showed that
the likelihood of developing Blount’s disease is higher in patients
with impaired AMFPT than in those with impaired AMDPT,
then we proceeded to calculate the relative risk of reaching
Blount’s disease for each group according to age and sex, with
a confidence interval of 95%, which if taken as a measure the
AMDPT or AMFPT, we found that is a higher rate of diagnosis
when using the AMFPT, then we applied the t-Student test to
determine whether there was difference in the possibility of
diagnosis of Blount’s disease while using AMFPT or if we use the
AMDPT which were higher using AMFPT.
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GUIDED GROWTH UNDER THE AGE OF EIGHT YEARS
0RINCIPAL!UTHOR Schwering, Ludwig, MD
CENTRE Universitätsklinik, Dot, Sektion Kinderorthopädie
AUTHORS Vohrer, Michael, MD
CENTRE Universitätsklinik, Dot, Sektion Kinderorthopädie
COUNTRY Germany
!IMANDPURPOSEOFTHESTUDY
Meanwhile the use of the 8-plate for guided growth in the
correction of axial deformities has become a standard procedure
in pediatric orthopaedics. The application of 8-plates in children
under the age of 8 years has been seen critically in the German
speaking countries. Occasionally it was warned to use this
method in children under 8 years. This study shall demonstrate
the security of this intervention in this age.
-ATERIALUNDMETHODOLOGY
During the years 2005 to 2009 4 girls and 11 boys with a mean
age of 4 11/12 years were treated by Steven’s method of guided
growth for the correction of axial deformities in the lower limb.
In particular 18 genua vara and 6 genua valga were operated
on and the follow up was observed by clinical and radiographic
means. The mean follow-up is 24 months. Complications were
evaluated by Paley´s score in problems, obstacles, minor and
major complications.
$ISCUSSIONS
The mean operation time was 28 minutes for one deformity.
Intraoperative complications were not observed. Postoperative
limitations in the range of movement were lost in one week
after surgical intervention. In all cases a complete correction
of the deformity was achieved. In one Patient a recurrence of
the deformity was seen because of the primar disease, which
led to a second treatment with 8-plates. Finally a complete
correction could be reached in this case also. After removal of
the hardware, after 10 months in mean, no negative influence
was seen on the growth plate.
#ONCLUSIONS
Especially children under the age of 8 will take profit from
a guided growth procedure because the disadvantages of
osteotomies can be avoided.
#ONCLUSIONS
The use of AMFPT is a suitable tool for the diagnosis of Blount’s
disease, as this is more likely to predict the onset of the disease
that AMDPT.
193
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!.$&)"5,!2(%-)-%,)!
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PLATE DEVICES
0RINCIPAL!UTHOR Herzenberg, John E, MD
CENTRE Orthopaedic Hospital Speising
AUTHORS Myers, Abigail K, MD; Hunter, Renee, MD; Radler,
Christof, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
COUNTRY United States
0RINCIPAL!UTHOR Boyce-Nichols, Reid, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
AUTHORS Herzenberg, John E, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
COUNTRY United States
)NTRODUCTION
Congenital femoral deficiency (CFD) and fibular hemimelia
(FH) can be detected during prenatal ultrasonography. Despite
published studies on prenatal diagnosis, the detection rate has
never been reported. It is unknown whether mothers prefer
prenatal diagnosis.
)NTRODUCTION
Guided growth with the screw-plate system has become
increasingly popular in young patients. When used in young
patients, the screw-plate device must be removed before
skeletal maturity. We analyzed cases in which rebound
deformities occurred after removal of screw-plate devices.
-ETHODS
A survey was created to examine the detection rate and to
determine mothers’ opinion towards prenatal CFD and FH
diagnosis. Surveys were mailed to mothers seen in our clinic
who gave birth to children with CFD and/or FH between January
2000 and December 2008. Exclusion criteria were underlying
genetic syndrome or multiparity. Postnatal radiographs were also
analyzed.
-ETHODS
We reviewed cases of hemiepiphysiodesis about the knee
performed at a single institution between 2005 and 2009.
Measurements were obtained from preoperative and 10-month
post-removal radiographs. Rebound was considered to be a
change of greater than 3 degrees in the lateral distal femoral
angle or medial proximal tibial angle after screw-plate removal.
2ESULTS
Surveys were sent to 171 mothers; 61 surveys were completed.
Detection rate was 36% (true positive). Detection rate was 33%
INCASESOFCOMBINED#&$AND&(NINCASESWITH
ISOLATED#&$NANDINCASESOFISOLATED&(N
Overall, 62% of mothers preferred prenatal diagnosis, 33%
preferred postnatal diagnosis, and 5% had no preference. Of
22 mothers who received a prenatal diagnosis, 86% wanted to
know before birth. Of 39 mothers who did not receive a prenatal
diagnosis, 48% preferred a prenatal diagnosis, 44% preferred a
postnatal diagnosis, and 8% were undecided.
#ONCLUSIONS
Our study suggests that when a prenatal diagnosis is made,
mothers seem to appreciate having this information. Prenatal
diagnosis including evaluation of limb length allows for
estimation of limb length discrepancy at birth and at maturity.
It also allows the mother time to explore treatment options.
We recommend that ultrasonographers carefully measure both
lower limbs to increase prenatal detection rates.
194
2ESULTS
Thirty-one screw-plates (23 patients) were inserted: 17 in
medial distal femora and 14 in medial proximal tibiae. Etiologies
included 16 congenital cases and 15 developmental cases.
Diagnoses included congenital femoral deficiency (3), fibular
hemimelia (7), both congenital femoral deficiency and fibular
hemimelia (4), Marfan syndrome (1), chromosomal deletion (1),
poliomyelitis (1), and idiopathic angulation (6). Eighteen (58%) of
31 cases experienced rebound. All ten cases of congenital distal
FEMORALVALGUSREBOUNDEDP4WOOFlVECONGENITAL
proximal tibiae rebounded. In the developmental cases, 3 (43%)
of 7 femora and 3 (38%) of 8 tibiae rebounded. Average age at
removal was 10.6 years (range, 6.1-13.9 years).
$ISCUSSION
Relapse after screw plate removal is a significant problem,
particularly in the valgus femur. Risk factors for relapse may
include younger age, congenital etiology, and insertion of
femoral plates.
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42%!4-%.4/&0/3442!5-!4)#%,"/734)&&.%33"9
ARTHROSCOPIC ARTHROLYSIS THEN ILIZAROV HINGED
DISTRACTION
0RINCIPAL!UTHOR Youssef, Amin, MD
CENTRE Orthopaedic Department Alexandria University
COUNTRY Egypt
)NTRODUCTION
Post-traumatic elbow stiffness represents a difficult therapeutic
challenge. Treatment options include non-operative and
operative techniques, all attempting to provide pain relief and
restoration of function. If nonsurgical treatment fails, operative
intervention is indicated. Treatment of the stiff elbow by
arthroscopic capsular release is a relatively new and effective
procedure; however, the surgery is technically demanding
and alone may not achieve the full extension. One method of
operative treatment is the concept of distraction arthroplasty.
The principle is to provide early joint motion as well as stability.
The aim of this study was to evaluate the results of treating
post-traumatic elbow stiffness by arthroscopic arthrolysis
followed by Ilizarov hinged distraction of the elbow.
-ETHODS
Twelve patients with post-traumatic elbow stiffness were
treated by arthroscopic capsular release through anterolateral
and anteromedial elbow portals, using arthroscopic ablation
device and shaver. Posterior and posterolateral portals were
used to removal loose bodies, debris or scar tissue in the
olecranon fossa. Then Ilizarov frame was applied to the arm and
the forearm with hinges at the elbow, putting the elbow at the
position that was achieved intraoperatively followed by gradual
distraction postoperatively.
The patients were prospectively followed up clinically for a mean
of 12 months (range, 9-15 months). The clinical assessment was
performed with the Mayo Elbow Performance score.
2ESULTSANDDISCUSSION
Ten patients have been satisfied with the outcome. There was
significant improvement in the range of motion as well as
reduction of pain. The mean Mayo Elbow Performance score was
significantly improved from a mean of 42.6 preoperatively to
94.4 postoperatively.
There are many studies in the literature about either
arthroscopic arthrolysis or Ilizarov hinged distraction to treat
posttraumatic elbow stiffness, but no studies were found about
combining both techniques.
#ONCLUSION
Our preliminary results with Arthroscopic release combined with
hinged Ilizarov distraction provide symptomatic improvement in
most patients with post-traumatic elbow stiffness. It shortens
the time to achieve a good function. Moreover, it helps in
attaining the full extension that may not be reached with either
technique alone.
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%84%2.!,&)8!4/2/2%84%2.!,&)8!4/2!.$+7)2%3
0RINCIPAL!UTHOR Micic, Ivan, MD
CENTRE Clinic for Orthopaedic Surgery and Traumatology, Clinical
Center Nis
AUTHORS Stojiljkovic, Predrag, MD; Mladenovic, Marko, MD;
Mitkovic, Milan, MD; Golubovic, Ivan, MD; Jeon, In-Ho, MD
CENTRE Clinic for Orthopaedic Surgery and Traumatology, Clinical
Center Nis
COUNTRY Serbia
/BJECTIVEANDPURPOSE
External fixation has been the traditional technique for surgical
fixation of unstable distal radius fractures. We performed
a prospective randomized study to determinate the role of
percutaneous fixation by K-wires in treatment of dorsally
displaced intra-articular distal radius fractures by external
fixator.
-ETHODSANDMATERIALS
60 patients with dorsally displaced AO type C intra-articular
distal radius fractures were randomized into 2 groups: (group
A) closed reduction and external fixation or (group B) closed
reduction and external fixation and K-wires. Patients with any
associated soft-tissue or skeletal injury to the same limb were
excluded from the study. They were followed prospectively,
according to internal board review protocol; the mean was 36
months.
2ESULTS
No significant difference was found in the Disabilities of Arm,
Shoulder, and Hand scores. 15 patients (group A) and 18
patients (group B) had excellent result according to the scoring
system of Gartland and Werley. Good result was recorded in 8
patients (group A) and in 6 patients (group B). 4 patients (group
A) and five patients (group B) had fair result. Three patients
(group A) and one patient (group B) had poor result. Distal radius
joint incongruity was recorded in 11 patients (group A) and in
5 patients (group B). At the end of treatment osteoarthritis was
found in 9 patients (group A) and in 5 patients (group B). No
significant difference was found in the pain, mobility, and grip
strength between the groups. Superficial pin track infection was
observed in two patients (group A) and in four patients (group B).
$ISCUSSIONSANDCONCLUSIONS
Results from this study show that external fixator and K-wires
are reasonable methods for treating intra-articular fractures
of the distal radius. At final follow-up evaluation, patients had
mostly excellent results with preserved congruity of the distal
radial joint and minimal posttraumatic osteoarthritis compared
with patients treated by external fixator only.
195
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FIXATION
0RINCIPAL!UTHOR Tsourvakas, Stefanos, MD
CENTRE Orthopaedic Department General Hospital of Trikala,
Greece
AUTHORS Alexandropoulos, Christos, MD; Papachristos, John,
MD; Tselios, Athanasios, MD; Tsiakoumis, Grigoris, MD; Ameridis,
Nikolaos, MD
CENTRE Ortopaedic Department, General Hospital of Trikala
COUNTRY Greece
!IM
Most fractures of the distal radius can be treated by
conservative means; however, unstable distal radius fractures
require surgical fixation and recent reports of attempts at
improving the anatomical and clinical results have been
concerned with external fixation. The objective of this study is
to evaluate clinical and radiological outcomes of distal radial
fractures treated with closed reduction and external fixation.
-ETHODS
Sixty-eight (70 fractures) patients (29 males, 39 females; mean
age 54 years; range 17 to 82 years) with distal radius fractures
were treated with external fixation. 12 patients had open
fractures. According to the AO classification, the fractures were
A2 (10 fractures), A3 (10), B2 (10), B3 (2), C1 (14), C2 (16) and
C3 (8). The fractures were reduced by longitudinal traction under
fluoroscopic control, and the reduced position was retained by
an Orthofix external fixation system. The fixator was used for a
mean of 6.2 weeks (range: 5 to 7 weeks) and mean follow-up
was 13.2 months (range: 5 to 31 months). A modified Sarmiento
scoring system was used for radiologic-anatomic assessment.
For functional assessment, the scoring system proposed by
Sarmiento et al, which was based on the Gartland and Werley’s
system, was used.
2ESULTS
There was one pseudarthroses treated with ORIF. From the
remaining 67 patients, radiologic assessment indicated that
anatomical results were excellent in 32 patients (46.4%),
good in 28 (42%), fair in 6 (10%) and poor in 1 patient (1.6%).
Functional results were excellent in 37 patients (55.2%),
good in 17 (25.3%), fair in 10 (15%) and poor in 3 patients
(4.5%). Complications included pin tract infections (8 patients),
early transient reflex sympathetic dystrophy (2 patients) and
hypoesthesia along the superficial branch of the radial nerve (2
patients).
#ONCLUSIONS
This study shows, in a representative number of cases, that
the treatment of distal radius fractures with external fixation
is a safe and effective treatment modality and provides almost
normal radiological and clinical parameters with a minimal
invasive technique.
196
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POSSIBILITIES OF TRANSOSSEOUS OSTEOSYNTHESIS
!##/2$).'4/),):!2/6).-!.!'%-%.4/&0!4)%.43
7)4((!.$42!5-!
0RINCIPAL!UTHOR Shikhaleva, Natalia, MD
CENTRE Russian Ilizarov Scientific Center for Restorative
Traumatology and Orthopaedics
COUNTRY Russian Federation
0URPOSEOFTHESTUDY
Elaboration of treatment techniques for patients with hand
trauma using Ilizarov apparatus; development and analysis
of the efficacy of combined application of the apparatus and
microsurgical technique.
-ATERIALANDMETHODS
We have treatment experience of 605 patients with closed
fractures and 271 with open hand trauma. 395 of the closed
fracture patients had damage of one bone, 210 patients damage
of two or more bones. Open hand trauma patients included
172 cases with one bone fracture, 99 patients with multiple
bones injury; among them 28 had complete or partial loss of
hand segments. Most of the patients of the second group had
associated injury of bones, tendons, vessels and nerves, and
10% of the patients had extensive defects of hand investing
tissues.
In management of closed fractures our goal was acute reduction
and stable fixation of bone fragments. For this purpose we used
a universal mono-lateral apparatus for small bones developed in
1986 by academician G.A.Ilizarov and co-authors.
In open fractures the surgical intervention includes primary
surgical treatment of the wound, osteosynthesis with the
Ilizarov apparatus to create good condition for wound healing
by temporary change of the shape, length and position of the
segment. With that we widely use microsurgical technique. We
used free and non-free vascularized tissue complexes to fill-in
investing tissues defect.
Postoperative complications occurred in 54 patients (6.1% of
the total number of patients). These complications resulted
from technical and treatment errors. All the complications were
corrected during treatment.
Treatment results in the group of closed hand fractures were
good in 97.3%; satisfactory in 2.7%. Open trauma patients
had 64% of good results and 34% of satisfactory results. Poor
results occurred in 2%.
#ONCLUSION
Application of transosseous osteosynthesis in management
of hand trauma with bone pathology showed efficacy of this
method, due to precise reduction and stable fixation of bone
fragments of any size, and early and full-value function of the
adjacent joints. In severe hand trauma combined application of
microsurgical technique and transosseous osteosynthesis leads
to good treatment results in the majority of cases.
Podium
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ARTICULATED EXTERNAL FIXATOR
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&2!#452%37)4(%84%2.!,&)8!4)/.7(%.!.$(/7
0RINCIPAL!UTHOR Reis Roberto, Paulo, MD
CENTRE Hospital Das Clinicas-FMUSP
AUTHORS Targa Hamilton, Walter, MD; Gaiarsa, Guilherme, MD;
Felix Monterroso, Alessandro, MD; Rodrigues, Franklin, MD;
Moreno, Patricia, MD
CENTRE Hospital Das Clinicas-FMUSP
COUNTRY Brazil
0RINCIPAL!UTHOR Manca, Mario, MD
CENTRE Ospedale Versilia Toscany Italy
AUTHORS Palomba, Michele, MD; Lacopinelli, Marco, MD;
Digrandi, Giuseppe, MD
CENTRE Ospedale Versilia Toscany Italy
COUNTRY Italy
3UMMARY
Posterior elbow dislocation with radial head fracture and
coronoid avulsion (terrible triad-TT) is a difficult condition
to treat, without consensus in literature, with a high rate of
complications, usually evolving with instability or stiffness. This
poster aims to show results of TT treatment with reconstruction
of the lateral column of the elbow and use of immediate
monolateral articulated external fixator.
-ETHODS
A monolateral articulated external fixator was the treatment
option in 13 cases of TT from Jan 2008 to Dec 2009. The
lateral column was reconstructed in all patients: Synthesis
was performed in 7 and radial head arthroplasty in 6 cases.
The fixator was positioned at the center of rotation of the
elbow using a Kirchner wire passed through the center of the
capitulum positioned by radioscopy. The fixator was maintained
for 12 weeks allowing mobilization. Results: The patients
evolved with stability without joint pain. The mean range of
motion was from 5 to 110 degrees at the end. Two patients
evolved with Schaz pins track infection requiring antibiotics.
#ONCLUSION
This procedure can be indicated in fractures, dislocations or
persistent instability after surgical repairs, reduces risk of
instability and joint stiffness and causes little damage to soft
parts.
2ESUME
Fractures of the humerus can be conservatively treated with
good results. The scope of this study was to evaluate if external
fixation offers a valid surgical alternative. External Fixation is a
minimally invasive surgical option which offers the benefit of
stable fixation with respect of the biology.
When: severe open fractures, fractures with soft tissue damage,
polytrauma patients, fractures of the humeral distal third.
How: the fracture is temporarily reduced, the distal bone screws
are inserted first. The first bone screw is inserted immediately
above the olecranic fossa. The second bone screw is inserted
more proximally at the 3rd or 4th screw seat in the Orthofix
bone screw clamp or at circa 4 cm proximally to the first bone
screw through a stab incision. The proximal bone screws are
positioned on the antero lateral plane at the level of the insertion
of the deltoid muscle.
-ATERIALSANDMETHODS
We have treated 55 humeral fractures, 35 male and 20 female,
average age 19-82. 18 politrauma patients, 6 open fractures.
Early mobilisation of the shoulder and elbow in all patients,
follow up controls every 4-6 weeks. Early dinamization. Results:
54 fractures healed. 1 delayed union, 1 refracture after fixator
removal was treated with a functional cast. 1 pesudarthrosis in
an obese patient, with severe osteoporosis due to corticosteroid
in severe C.O.B.P. Average healing time: 100 days, 125 days in
open fractures. Final ROM of shoulder and elbow same as the
controlateral limb.
#ONCLUSIONS
External fixation in diaphyseal fractures of the humerus offers an
excellent surgical option with the possibility of closed reduction,
good stability and rapid functional recovery. It is contraindicated
in severe osteoporosis, severe obesity and non reliable patients.
197
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#/-0,%8,%3)/.3/&4(%%,"/742%!4-%.47)4(!.%7
ARTICULATED EXTERNAL FIXATOR
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PEDIATRIC CUBITUS VARUS CORRECTION BY
#/-054%2'5)$%$#)2#5,!2%84%2.!,&)8!4)/.
0RINCIPAL!UTHOR Pizzoli, Andrea, MD
CENTRE Orthopedic Department, C Poma Hospital
AUTHORS Renzi Brivio, Lodovico, MD
CENTRE Orthopedic Department, C. Poma Hospital
COUNTRY Italy
0RINCIPAL!UTHOR Herzenberg, John E, MD
CENTRE International Center for Limb Lengthening, Rubin
Institute for Advanced Orthopedics, Sinai Hospital
AUTHORS 1Belthur, Mohan V, MD; 2Lobst, Christopher, MD; 3Jindal,
Gaurav, MD; 4Bor, Noam, MD
CENTRES 1Texas Children Hospital and Shriners Hospital for
Children; 2Miami Children Hospital; 3Pushpanjali Crosslay
Hospital; 4Emek Medical Center
COUNTRY United States
!IMANDPURPOSEOFTHESTUDY
The aim of the study is to show the biomechanical and clinical
performances of a new radiolucent articulated external fixator
in the treatment of chronic or acute instability of the elbow after
dislocation or complex fractures.
-ATERIALANDMETHODOLOGY
The authors will present their preliminary clinical results with a
new radiolucent, hinged external fixator designed to allow full
range of motion associated, when necessary, to distraction.
The possibility to allow early joint movement, prevents
posttraumatic stiffness and protects joint ligament
reconstruction and or joint surface reduction. The possible
indication, the technique of application and the results of more
than 10 cases will be presented and discussed.
$ISCUSSION
The treatment of traumatic lesions of the elbow should be based
on a correct preoperative assessment of bone and/or soft tissue
to distinguish the different patterns of instability. Open surgery
and ligament reconstruction are often difficult and sometimes
associated to majour complications like septic arthritis, wound
failures or bone fragment necrosis in particular in highly
comminuted fractures, bad bone quality or multiple ligaments
lesions.
In these conditions an articulated ex fix guarantees joint stability,
joint neutralisation with distraction and early joint movement.
The articulated clamp of the fixator is alligned to the flexionextension axis of the elbow, is radiolucent and stable enought
to protect a minimal internal fixation of the distal humerus
the olecranon or the radial head and to permit isometric
ROM necessary to protect ligaments healing or ligaments
reconstruction.
#ONCLUSIONS
The use of a radiolucent articulated external fixator can be
considered the elective indication in all chronic or acute
instability of the elbow and a possible alternative to traditional
open reduction and internal fixatio (ORIF) as support to minimal
percutaneous fixation or in patient with bad bone or in open
fractures.
198
0URPOSE
Cubitus varus malunion is a common outcome of supracondylar
elbow fractures. Methods of correcting cubitus varus involve
complex wedge osteotomies that have a high complication
rate and require a large exposure and challenging fixation. We
designed a minimally invasive technique with gradual correction
using computer-guided circular external fixation.
-ETHODS
Seven patients presented for deformity correction at two
centers: three patients were treated at one center and four
were treated at another center. All had an extension-type
supracondylar fracture during childhood. Average age at
corrective surgery was 10 years (range, 5-21 years). Three were
treated with half-pins in the distal segment and four with wires.
2ESULTS
Average preoperative carrying angle was 20 degrees varus
(range, 10â “30 degrees). Average postoperative carrying
angle was 4 degrees valgus (range, 0â “7 degrees). Average
preoperative and postoperative range of motion were the
same (133 degrees). Average external fixation time was 10
weeks (range, 9â “12 weeks). No neurovascular or other major
complications were observed. All patients were happy with the
final appearance.
#ONCLUSION
This technique to correct cubitus varus deformity after pediatric
supracondylar fracture is predictable, effective, well tolerated,
adjustable, and technically easier than large open osteotomies.
We report a new pattern of distal humeral half-pin fixation that
allows for a very distal metaphyseal osteotomy, close to the
deformity apex. This biplanar delta configuration straddles the
olecranon fossa and is applicable to children and adults.
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CALLUS DISTRACTION TO TREAT IATROGENIC HALLUX VALGUS
#/-0,)#!4%$3(/24-%4!4!23!,3
Podium
REPAIR OF SUBTALAR JOINT NONUNION WITH ANKLE
PATHOLOGY WITH CIRCULAR EXTERNAL FIXATION
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
0RINCIPAL!UTHOR Wang, James, MD
CENTRE Santa Monica Ucla Orthopaedic Hospital
COUNTRY United States
!IMANDPURPOSE
Use of external fixation with callus distraction to correct short
first metatarsals following iatrogenic failed hallux valgus
correction.
!IMANDPURPOSE
Use of circular external fixation to repair chronic subtalar joint
nonunions with ankle joint arthrosis. To provide a surgical
procedure to provide compression and stability at the subtalar
joint, while distracting the ankle joint simultaneously.
-ATERIALSANDMETHODOLOGY
30 patients underwent callus distraction for iatrogenic shortened
first metatarsals following failed hallux valgus surgery. These
patients all had shortened first metatarsals and contracted first
metatarsophalangeal joints. A three or four level external fixator
was used to callus distract the short first metatarsals while
simultaneously performing an arthrodiatasis. Patients were able
to weightbear immediately.
$ISCUSSION
All of the patients had a re-establishment of first metatarsal
length and a normal metatarsal parabola. Also the patients had
a resolution of the contracted first metarsophalangeal joints.
Shortened first metatarsals following hallux valgus surgery
can cause severe lesser metatarsalgia and altered gait. It is
paramount to re-establish the normal length and joint space of
the first ray.
#ONCLUSION
The use of an external fixator to correct short first metatarsals
following failed hallux valgus surgery is a unique and effective
method. One can also perform a simultaneous arthrodiatasis of
the first metatarsophalangeal joint.
-ATERIALSANDMETHODOLOGY
25 patients underwent revisional subtalar joint arthrodesis with
concomitant ankle joint arthrodiatasis. A circular frame was used
to compress the subtalar joint at one level and distract the ankle
joint proximally. Average length of subtalar nonunion was 8.2
months. All patients also had ankle joint arthrosis and pain.
$ISCUSSION
All the patients fused at six weeks and had a concomitant
ankle arthroscopy with ankle joint arthrodiatasis with a circular
external fixator. Patients were encouraged to weightbear as soon
as possible after surgery. There were no delayed unions and
no patients were lost to follow up. The circular external fixators
were removed at an average of 7.2 weeks and the ankle joints
were manipulated at that time.
#ONCLUSION
With long standing nonunions of the subtalar joint, patients can
also have ankle joint pathology, pain and arthrosis. Use of a
circular external fixator is a viable technique for success and
allow the patient to weightbear immediately and allow a multi
level of correction without jeopardizing the arthrodesis outcome.
199
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REPAIR OF OSTEOCUTANEOUS DEFECT WITH THE TAYLOR
30!4)!,&2!-%).,/7%2,)-"
0RINCIPAL!UTHOR Sala, Francesco, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
AUTHORS 1Pantaloni, Marcello, MD; 2Castelli, Fabio, MD; 2Agus,
Maria Alice, MD; 2Capitani, Dario, MD; 2Albisetti, Walter, MD
CENTRES 1Department of Plastic Surgery-Santa Chiara HospitalPisa; 2Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
COUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
Lower limb reconstruction is a surgical challenge. We try to
explain our surgical strategies for different kind of clinical
situations. Could the Taylor Spatial Frame (TSF) give an answer
for each patients?
-ATERIALANDMETHODOLOGY
The TSF used with the principles of the Ilizarov method, lead
us to obtain excellent results in very difficult cases of limb
reconstruction. We used the monofocal, bifocal or trifocal
compression-distraction technique to obtain bone healing,
associated with the plastic procedures for skin reconstruction,
as rotational/free flap coverage and of Vacuum Assisted
Clousure (VAC) system. Multidisciplinary surgical equipe can
be considered as the gold standard to obtain the best results
in very difficult cases. What are the results? We had a series of
8 patients with hig grade soft tissue damage with bone loss:
six cases of the tibia and two femurs. All Patients underwent
surgical procedures for bone and skin reconstruction with
multidisciplinary equipe (orthopaedic and plastic surgeon).
The surgical strategy was different for the different skin and
bone conditions. In 2 cases we have an acute shortening of the
bone with primary soft tissue and skin closure, followed by a
progressive lengthening by using bifocal thecnique. One femoral
reconstruction (20 cm bone loss) had bifocal lenghthening with
at the beginning a gradual partial shorthening (5 cm). A free
muscle flap missed. Soft tissue transport was performed with a
sequential debridment and placement of VAC. The granulation
tissue was successfully covered with a skin graft. In other 5
tibial cases we mantain the limb length by positioning of the
external fixator, we perform a VAC procedure or flap coverage
and then we started with a bifocal or trifocal bone transport.
$ISCUSSSION
All patients had a good clinical and radiografic results. We can
conclude that TSF is a salvage procedure that lead to stabilize
the fracture, to mantain the limb lenght and to bridge large bone
defects by transferring bone segments.
#ONCLUSIONS
A multidisciplinary equipe, including orthopaedic and plastic
surgeon, is the best way to treat these so difficult and complex
cases.
200
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ILIZAROV BONE TRANSPORT VERSUS VASCULARIZED
FIBULAR GRAFT IN RECONSTRUCTION
/&0/3442!5-!4)#4)")!,"/.%$%&%#4
0RINCIPAL!UTHOR Ahmed, Amin, MD
CENTRE Al Hadra University Hospital-Alexandria University
AUTHORS Semaya, Ahmed, MD
CENTRE Al Hadra University Hospital-Alexandria University
CoUNTRY Egypt
)NTODUCTION
Traumatic bone defects may be primary, following open
fractures, or secondary to an aseptic or septic nonunion.
Vascularized bone grafts (VFG) and bone transport according to
the Ilizarov technique have much better results. However, each
has its advantages and disadvantages.
0ATIENTSANDMETHODS
Between 2001 and 2008 we treated 32 patients with
posttraumatic tibial bone defects divided into 2 groups: group
1 included 17 patients and were treated by Ilizarov bone
transport and group 2 included 15 patients, they were treated by
vascularized fibular graft.
The average age of the patients at the time of the surgery was
39.9 years in group 1 and 29.7 years in group 2. The mean
length of the bone defect was 4.1 cm in group 1 and 7.6 cm in
group 2. All patients were undergone previous surgeries (1 to 4
operations).
2ESULTS
The mean amount of filled defect was 4.1 cm with Ilizarov bone
transport and 7.6 cm with VFG. EFT in group 1 was 6.9 months.
The average time to achieve union in group 2 is shorter than
group 1 (4.8 months) while the average time to full weight
bearing is 8.7 months. At an average follows up of 10.9 months
in bone transport group and 17.6 months range in VFG. The bone
results and functional results of the Ilizarov bone transport were
excellent in 64.7% and 29.4%, good in 17.6% and 41.2%, fair
in 5.9% and 17.6%, poor in 11.8% and 11.8%, respectively,
whereas those of the VFG were excellent in 73.3% and 6.7%,
good in 13.3% and 73.3%, fair in 6.7% and 13.3%, and poor in
6.7% and 6.7% respectively.
#ONCLUSIONANDRECOMMENDATIONS
Ilizarov bone transport is a good method for management of
posttraumatic tibial defects especially in short defects, also bone
grafting of the docking site is necessary in all cases to achieve
union and to shorten the time of external fixator application.
While vascularised fibular graft gave better result in longer
defects with shorter time needed for union, but non weight
bearing is mandatory till graft hypertrophy in order to avoid the
stress fracture which was the main problem in our series.
Podium
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356&2!-%/04)-5-#/.&)'52!4)/.!4$%&/2-)49
#/22%#4)/./&&%-/2!,
0RINCIPAL!UTHOR Solomin, Leonid N, MD
CENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
AUTHORS Skomoroshko Pv, MD
CENTRE Vreden Russian Research Institute of Traumatology and
Orthopedics
COUNTRY Russian Federation
!IM
To develop optimum Ortho-SUV Frame (http://www.rniito.org/
download/ortho-suv-frame-eng.pdf) assemblies for deformity
correction and fracture healing of distal third of femoral bone
shaft.
-ATERIAL
On the basis of 260 bench tests (26 models) dependence of
Ortho-SUV Frame reduction possibilities (distraction, translation,
angulation, rotation) from diameter of external supports, distance
between them and places of struts fixing were investigated.
At the description of frame configurations the method of the
unified designation of external fixation (http://rniito.org/solomin/
download/mudef.zip) is used. The developed configurations are
approved at treatment of 10 patients.
$ISCUSSION
Optimum positions for struts fixation while using of pairs support
in diameter 200 mm and 180 mm, 220 mm and 200 mm are the
following:
s TOPROXIMALSUPPORTFORSTRUTAPOSITIONFORSTRUT
BETWEENPOSITIONSANDANDFORSTRUTAPOSITION
s TODISTALSUPPORTFORSTRUTAPOSITIONFORSTRUTA
POSITIONFORSTRUTAPOSITION
Maximum reduction possibilities are available (reached) for
frame assembly when distance between supports is 150
mm: 48-85 mm translation, 18-36 degrees angulation, 10-23
DEGREESROTATION5SEOF:SHAPEDPLATESFORSTRUTSAND
fixation allows increasing reduction possibilities by 21-36%. It
is enough of it for correction of difficult kind of deformations
(http://rniito.org/solomin_eng/deform_class.jpg).
#ONCLUSION
In all cases of Ortho-SUV Frame clinical application right bone
fragment position were achieved. It confirms correctness of the
spent researches of the presented investigation.
Podium
4(%42%!4-%.4/&4(%,/7%2%842%-)49
$%&/2-)4)%3/52%80%2)%.#%
0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
/BJECTIVEANDPURPOSE
The lower extremity deformities are the result of a changed
process of healing for insufficient bony reduction, failure of
osteosynthesis, level of lesions or the age of the patients. In
fact the bone healing could occur with axial defects, on the
frontal or lateral planes, or with rotational defects. In particular
plurifragmentary fractures it is possible to obtain a limb length
discrepancy.
In the post-traumatic deformity, the evolution take to not correct
distribution of the weight-bearing on the proximal and distal
articular surfaces, causing a degenerative arthritis.
The treatment of the lower limb deformities became necessary,
just before an accurate planning, locating the deformity planes.
The aim of this work is to report our experience in the treatment
of femoral and tibial post-traumatic deformities.
-ETHODSANDMATERIALS
At the Orthopaedic and Traumatologic Umberto I Hospital of
Syracuse, from 2006 to 2010, 18 lower limb deformity in
18 patients (13 males and 5 females) were treated using
progressive or acute correction with External Fixation.
The average was 23.7 years old (range 14-57). Seven
femoral deformities and 11 tibia (9 axial, 2 rotational and 7
complex deformities) were evaluated using Paley-Tetsworth
malaligneament test.
2ESULTS
In all cases, successful correction of angular and rotational
deformities was achieved. The pain was eliminated in all
patients having preexisting chronic joint pain. There were
no cases of deep infection or nonunion. Complications were
frequent, particularly pin site and soft-tissue sequelae, but they
rarely prevented a successful result.
#ONCLUSIONS
External fixation is used when it is preferable or safer to correct
the deformity gradually to avoid stretch injury to soft tissues,
such as nerves or blood vessels.
201
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-/./,!4%2!,!8)!,%84%2.!,&)8!4)/.).4(%42%!4-%.4
/&#/-0,%80/342!5-!4)#$%&/2-)4)%3
Podium
#/22%#4)/./&4(%0/,)/-9%),)4)3&//4
$%&/2-)49"9),):!2/6
0RINCIPAL!UTHOR Manca, Mario, MD
CENTRE Ospedale Versilia Toscany Italy
AUTHORS Digrandi, Giuseppe, MD; Palomba, Michele, MD;
Lacopinelli, Marco, MD
CENTRE Ospedale Versilia Toscany Italy
COUNTRY Italy
0RINCIPAL!UTHOR Abdelltaif Kirienko, Ibrahim E, MD
CENTRE Instituto Clinico Humanitas Hospital
AUTHORS 1Kirienko, Alexander, MD; 2Elbatrawy, Yasser, MD
CENTRES 1Instituto Clinico Humanitas Hospital; 2Azhar University,
Cairo
COUNTRY Italy
)NTRODUCTION
The incidence of axial and torsional post-traumatic deformities
reported in the literature is variable and depends on the type of
primary treatment. It remains however high following both non
surgical and surgical internal and external fixation.
)NTRODUCTION
Poliomyelitis first occurred nearly 6000 years ago in the
time of the ancient Egyptian. Poliomyelitis is still a common
condition in developing countries. With skeletal growth, fixed
soft tissue and deformities develop in the foot in poliomyelitis.
Conventional operative treatment of this deformity involves
corrective osteotomies, arthrodesis, extensive tissue release,
tendon transfers, may result in neurovascular injury and soft
tissue problems. Leg shortening and complex foot deformity are
common in patients with deformity after poliomyelitis.
The objective of surgical treatment is to restore the normal
anatomical and functional conditions before trauma.
-ETHODANDMATERIALS
We have considered complex those deformities associated
to shortening, pseudarthrosis or with multilevel deformities.
Preoperative planning was conducted on the basis of long leg
standing AP and lateral X-rays, CT scan with overprojection of
the femoral neck, knee and ankle, if clinical malrotation was
evident.
2ESULTS
We have treated 25 cases of complex posttraumatic deformities.
In 22 cases length, axial and torsional deformities were
completely corrected. In one case a hyper correction in valgus
residuated, in one case shortening of 1 cm remained, 1 failure
was due to bone screws breakage.
#ONCLUSIONS
Monolateral axial external fixation is a valid surgical option in
multiplanar deformities. The fixator can correct axial but not
torsional deformities. For this reason torsional deformities are
acutely corrected. The fixator is useful for axial correction and
possible lengthening with the possibility of further corrections
during treatment.
This study aims to find out the special technique for deformity
correction of the foot for restore plantigrade foot and improve
ambulation.
The Ilizarov method of gentle, gradual correction of this
deformity has become a treatment option for poliomyelitis foot
deformity. This method is considered to be safe than traditional
methods of the treatment.
-ATERIALANDMETHODS
Between 1994 and 2009 a total of twenty five rigidly deformed
feet belonging to twenty five patients. All cases were treated
with classic ring Ilizarov fixator. The average age the patients
was 34 years. Ten of twenty five patients undergo previous
surgical intervention. The types of deformities observed before
surgery were: equinus foot 6 cases, equinovarus 4, equinovalgus
5, supinated equinovarus 2, equinocavovarus 3, and vertical
calcaneus with calcaneovalgus 2 cases. In fifteen cases were
observed limb-length discrepancy ranged from 2 to 6 cm.
$ISCUSSION
The neurological foot deformity with sever joint stiffness and
soft tissue contraction with the multidirectional aspects of the
deformity are a significant limitation of use of conventional
corrective methods, which leads to a great risk of damage
the neurovascular bundle and which usually is surrounded by
adherent scar tissue. These methods can reduce the height of
the foot, lower the malleolus and cause difficulty in fitting shoes.
The Ilizarov method has some advantages over conventional
methods. All these problems can be treated with the Ilizarov
method at the same time.
#ONCLUSION
Ilizarov technique has proved efficiency in the management
of poliomyelitis complex foot deformities, when conventional
techniques have failed. The Ilizarov apparatus is rigid yet
versatile, and the minimal nature of the surgical intervention. A
painless and plantigrade foot was obtained in all patients.
202
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#/-0,)#!4)/.3/&,%.'4(%.).').&)"5,!2(%-)-%,)!
0RINCIPAL!UTHOR Shadi, Milud, MD
CENTRE Department of Pediatric Orthopedics
AUTHORS Koczewski, Pawel, MD
CENTRE Department of Pediatric Orthopedics
COUNTRY Poland
'OAL
To analyze true complications and obstacles (according to Paley
classification) in FH patients.
-ATERIAL
- 29 patients (17 male, 12 female). Mean age - 10,2 years
(from 3,3 to 20,7). Achterman-Kalamchi type II - 24, IA - 3,
IB - 1. 45 segments were treated (36 tibia, 9 femur) in different
strategies (17 - single lengthening, 8 - two procedures, 4 - three
procedures). The age at surgery ranged from 3,3 to 20,7 years
(mean 10,2). Mean shortening - 7,2cm (ranged from 3 to 14).
Valgus deviation in 27 patients, in two of them combined with
rotational deformity.
-ETHOD
Ilizarov tibial lengthening - 35 segments, Orthofix - 1. Hindfoot
prophylactical stabilization - 19 patients, hindfoot and forefoot
stabilization for foot correction - 1. Femoral Ilizarov lengthening 8 patients, LON - 1. Follow up from 0,6 to 12,2 years (mean 5,3).
2ESULTS
Achieved lengthening ranged from 3 to 8cm (mean 5,2). Axial
deviation (valgus - 27, detorsion â “ 2) was corrected in 23
patients (at distraction osteotomy site - 21, by additional
osteotomy - 6). In 4 cases minimal axial deformity remains.
Mean time in frame was 233 days (from 70 to 439). Lengthening
index ranged from 0,8 to 3,9 months/cm (mean 1,6).
Podium
-!33)6%3%'-%.4!,"/.%,/33$5%4/0!.4)")!,
/34%/-9,)4%3).#(),$2%.2%#/.3425#4%$"9-%$)!,
FIBULAR TRANSPOR
0RINCIPAL!UTHOR Aziz, Amer, MD
CENTRE Medical and Dental College, Lahore, Pakistan
COUNTRY Pakistan
2ESUME
The purpose of the study was to determine the rate of union in
the transported fibula. The union was assessed clinically and
radiologically. This descriptive study was conducted five patients
having mean age of 12 years in the department of Orthopaedic
and Spine Surgery Lahore Medical and Dental College, Lahore,
Pakistan. The duration was one year. Patients fulfilling the
inclusion criteria were subjected to surgery after taking written
informed consent.
In first stage excision of all dead bone performed and ilizarov
without traction apparatus applied. In second stage usually
after one month reconstruction with gradual medial transport
of the ipsilateral fibula using an Ilizarov traction apparatus with
olive wires after proximal and distal fibular osteotomies was
done. This method has the advantage of early mobilization,
early weight bearing, infection control and avoiding surgery
on contralateral limb. Hypertrophy of the transported fibula
accompanied by full weight bearing and satisfactory joint
motion occurred in all patients. The minimum follow up was of
one year. The results were analysed using SPSS 11.0 version
and P-values of <.05 was considered significant. We think the
Ilizarov frame for pantibial osteomylites with bone excision and
medial fibular transport is an excellent option for limb salvage in
patient with massive tibial bone loss.
#OMPLICATIONS
There were 14 complications and 4 obstacles in whole material.
Fracture at bone regenerate (3). Two of them were treated
surgically with intramedulary Rush pin and one - conservatively.
Supracondylar femoral fracture after tibial frame removal (2)
treated conservatively. Valgus deformity (4) treated surgically in
2. knee ROM limitation and posterior subluxation during femoral
lengthening (2) needs additional surgery. Late local infection
(annular sequester) (2) debridgement. Knee stiffness after
simultaneous femoral and tibial lengthening needs quadriceps
plasty (1).
Obstacles: Femoral fractures during tibial lengthening (2) treated nonsurgicaly. Varus angulation corrected operatively
by frame modification (1). Premature consolidation (1) during
simultaneous femoral and tibial lengthening needs open femoral
osteotomy.
#ONCLUSION
Treatment of limb shortening and deformity in FH is associated
with various complications and should be accomplished by
multiple stages. Single stage, double segment lengthening might
be combined with higher rate of complication.
203
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BILATERAL TOTAL APLASIA OF THE TIBIA, DUPLICATION
/&&)"5,!%!.$-)22/2&//4&)2342%#/.3425#4)/.
WORLDWIDE
0RINCIPAL!UTHOR Schwering, Ludwig, MD
CENTRE Universitätsklinik, Dot, Sektion Kinderorthiopädie
AUTHORS Vohrer, Michael, MD
CENTRE Universitätsklinik, Dot, Sektion Kinderorthopädie
CoUNTRY Germany
!IMANDPURPOSEOFTHESTUDY
There are only a few publications in the world literature that
describe the diplopadia and fibular doubling and simultaneous
deficiency of the tibia. The very few cases described were
treated by knee amputation and prosthetic supply.
Only Igou et al. performed a fusion between the distal femur and
the proximal fibulae in a 16 year old girl.
We report about the first reconstructive attempt in a three year
old Dutch girl suffering from the previous described deformity
and a duplication of the aortic arc.
-ATERIALANDMETHODOLOGY
During the first intervention in the right leg a dorsal release
of the knee with lengthening of the contracted soft tissue and
tendons was performed. Simultaneously the super numerous
skeleton of the foot was resected and with the os calcis the
subluxated extensor apparatus of the knee was reconstructed
by fusion between the proximal parts of the fibulae. With the
super numerous cuboid a substitute for the missing patella
was created. The aftertreatment consisted of immobilization
in an above knee cast for six weeks and then the patient was
mobilized in an above knee splint with a Swiss locking hinge
for knee stabilization. During the interval until the second
intervention in the same way on the opposite side the left leg
was supported by the means of an orthoprosthesis and so for
the first time it was possible for the girl to walk on her own legs.
#ONCLUSIONS
By the described interventions a three year old girl with bilateral
complete deficiency of the tibia, fibular duplication and mirror
foot was mobilized on her own legs. Active flexion and extension
with and without orthotic support reached a range of motion of
90-0-0. At present there is tendency for anterior subluxation of
both proximal lower legs which improves from one presentation
to the other. The walking ability is 1000 m in 25 minutes only
with orthotic support.
$ISCUSSION
The described method was the first attempt of a reconstruction
of the previous mentioned deformity with full mobilization of the
patient.
204
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).42!!24)#5,!2/34%/4/-9/&4(%$)34!,&%-52&/2
3%15%,!%/&.%/.!4!,3%03)3
0RINCIPAL!UTHOR Paley, Dror, MD
CENTRE St. Mary’s Medical Center
AUTHORS Shengde, Vithal, MD
CENTRE Rubin Institute for Advanced Orthopedics
COUNTRY United States
0URPOSE
Sequalae of the neonatal sepsis lead to complex deformities
of the knee including instability, subluxation, multiplanar
angulation, and limb length discrepancy. Patients often present
with progressive deformity, pain and limp. Treatment options
include knee fusion, bracing, joint replacement, and amputation.
We present 7 patients who underwent intra-articular distal
femoral osteotomy and ligament reconstruction to provide a
stable and painless knee with functional range of motion.
-ETHODS
We retrospectively reviewed the charts and radiographs of seven
symptomatic patients with neonatal sepsis sequelae who were
treated with an intra-articular distal femoral osteotomy between
2001 and 2008 Associated deformities included depression of
the medial tibial plateau, fixed flexion deformity of the knee,
rotatory subluxation of the tibia, dislocated patella, femoral
diaphyseal deformity and limb length deformity.
2ESULTS
All patients had satisfactory subjective and objective results
including a painless, stable knee with functional range of motion
(ROM). The mean preop ROM was 9ï‚° and postop ROM of was
68ï‚°.
#ONCLUSION
The surgical technique of performing an intra-articular
osteotomy of the femur and/or the tibia is a very effective way
to treat patients with neonatal sepsis sequellae. It increases
the surface area of weightbearing by widening, leveling and
realigning the condyles of the femur and tibia to match each
other. This technique also stabilizes and reduces the knee
and patella. Leading to more normal gait and relief of pain. By
improving knee function and stability treatment considerations
such as limb lengthening become feasible. This technique
obviates the need for bridge burning procedures such as knee
fusion or amputation or even knee replacement at a young age.
3IGNIlCANCE
This is the first report of intra-articular osteotomy of the
distal femur for correction of intercondylar malalignment of
the knee joint characteristic of neonatal sepsis of the knee.
While technically challenging this method is very successful in
producing a functional stable knee joint.
Podium
PEDIATRIC SHAFT TIBIAL FRACTURES TREATED WITH
%84%2.!,&)8!4)/./52%80%2)%.#%
Podium
/52%80%2)%.#%).42%!4-%.4/&3%6%2%2%#522%.4
BLOUNTS DISEASE
0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
0RINCIPAL!UTHOR Cherkashin, Alexander, MD
CENTRE Texas Scottish Rite Hospital for Children
AUTHORS Samchukov, Mikhail, MD; Birch, John, MD; Da Cunha,
Anna Laura, MD
CENTRE Texas Scottish Rite Hospital for Children
COUNTRY United States
/BJECTIVEEPURPOSE
The diaphyseal fractures of the tibia, in subjects of paediatric
age, are relatively frequent. The therapeutic approach is based
on several options and mainly on age of patient, type of the
fracture, concomitant pathologies, surgeon experience and the
ability, parents expectations.
0URPOSE
External circular fixation remains one of the efficient and reliable
methods for treatment of patients with severe Blount’s disease,
especially in cases with previously failed correction often
after multiple attempts or in morbidly obese patients. Usually,
this group of patients has a very high risk of complications.
The purpose of this study was to analyze our experience and
complications in treating the patients with severe recurrent
Blount’s disease.
Aim of the present study was to evaluate clinically and
radiographically the diaphyseal fractures of the tibia in subjects
of paediatric age treated with external fixation and early
mobilization.
-ETHODSANDMATERIAL
At the Orthopaedic and Traumatologic Department Umberto I
Hospital of Syracuse, between January 2007 and December
2009, 36 subjects, range of age 5-16 years, were treated with
external fixation. The mean follow up was of about 2 years
(range 1-4 years).
2ESULTS
All the fractures consolidated in a mean time of 76 days. Minor
complication was infection of the fiches in 14% cases, while
major complications included rifracture (3%) and delay of
consolidation (3%) following low energy trauma.
#ONCLUSION
External fixation after tibia diaphyseal fractures in pediatric
age can be considered a valid choice of treatment with
good results, both clinically and radiographically, without
important complications, and showed to reduce the times of
immobilization and hospitalization.
-ATERIALSANDMETHODOLOGY
Results of treatment of 31 patients with infantile (18) and
adolescent (13). Blount’s disease were studied retrospectively.
Twenty-two of them had previous surgical attempts to correct
deformity. All our patients underwent 34 surgeries for proximal
tibial deformity correction using TrueLok circular external
fixation and our standard distraction protocol. The follow up
range is from 2 to 17 years. We define a complication as an
unexpected deviation from the original treatment plan, which
without appropriate corrective measures would lead to the
deterioration of patient’s condition. All complications were
divided in 3 categories according to the success of corrective
measures. Category I complications -treatment goals were
achieved with minimal adjustment of treatment plan. Category
II –goals of treatment s were achieved with the revision of the
initial treatment plan. Category III -goals treatment goals were
not achieved or patient had developed a new condition.
2ESULTS
Tibial deformities were successfully corrected in all patents,
with average time in frame 18 weeks for infantile group and 21
weeks for adolescent. Mechanical axis deviation at last follow up
ranges from -10 to 20 mm. Six complications were identified as
category III, including partial defect and fractures of regenerate
(4), lack of patient compliance (1), intraoperative femoral
fracture (1). All of these patients required revision of treatment
plan and additional interventions.
#ONCLUSIONS
External circular fixation can successfully be used for treatment
of patients with severe Blount’s disease. Although patients with
Infantile Blount’s all have previous surgeries and patients with
Adolescent Blount’s were more challenging due to obesity and
greater deformities, in 80% of all developed complications
treatment goals were successfully achieved with minimal
modification of the treatment plan.
205
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%84%2.!,&)8!4)/.).42%!4-%.4/&#(),$2%.&2!#452%3
0RINCIPAL!UTHOR Tartaglia, Nicola, MD
CENTRE Ospedale San Paolo Di Bari
AUTHORS 1Corina, Gianfranco, MD; 2Brina, Luigi, MD; 1Marsilio,
Antonio, MD; 1Rollo, Giuseppe, MD; 2Gismondi, Tommaso, MD
CENTRES 1Ospedale Vito Fazzi Di Lecce; 2Ospedale San Paolo
Di Bari
COUNTRY Italy
2ESUME
The operative treatment of displaced femoral and tibial fractures
in children requires implants that do not violate open physes
while maintaining a stable fracture reduction with the correct
length and alignment. In displaced diaphyseal fractures there are
two possible options of surgical treatment: plating and external
fixation. The surgical decision therefore lies between the choice
of a minimally invasive technique (external fixation) and a more
aggressive one (ORIF). In articular and periarticular fractures
external fixation is preferred in order to reduce and stabilize
the anatomy of the growth plate possibly allowing the growing
process to restore.
Monolateral, hybrid and circular external fixation frames are
possible depending on the type of fracture. In articular and
periarticular fractures the authors’ preferred frame configuration
is a ring with multiple wires allowing good and stable reduction
which allows to bypass the growth physes and preserve them
from possible surgical damage.
We present a combined series of 15 cases treated in two
hospitals in the South of Italy (Bari and Lecce) of complex
femoral and tibial fractures in children treated with the Orthofix
External Fixator.
Results were assessed on the basis of healing time (monthly
x-rays), functional outcome, patients’ compliance, complications,
yearly x-ray of inferior limb length to check the grown physes in
the cases of articular and periarticular fractures.
All fractures healed within 3 months. No major complications
were observed. In the few cases of articular and periarticular
fractures, the growth plate restored its growing activity even
after a major trauma.
External Fixation is a good surgical option to stabilize children
fractures whilst preserving the growth plate. In complex
fractures with associated trauma of the growth physes, external
fixation is a brilliant minimally invasive surgical option to reduce
and stabilize the physes whilst giving the growing process the
possibility to recover.
Podium
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0RINCIPAL!UTHOR Mellado Castillero, José Miguel, MD
CENTRE Hospital Universitario Virgen del Rocío
AUTHORS Downey Carmona, Javier, MD; Farrington Rueda, David,
MD; Tatay Domínguez, Ángela, MD; Quintana Jiménez, José, MD
CENTRE Hospital Universitario Virgen del Rocío
COUNTRY Spain
)NTRODUCTION
We reviewed our inicial experience in the correction of lower
extremity deformities in pediatric patients treated with two
external fixation methods.
-ATERIALANDMETHODS
Using the Paley/Baltimore malalignment test, we measured the
deformity and found the center of rotation of angulation (CORA)
that determined our osteotomy level. We used two external
fixation systems: a monolateral system (Limb Reconstruction
System (LRS), Orthofix) and a circular system (Taylor Spatial
Frame (TSF), Smith and Nephew). When we decided to apply the
TSF, we used the web-based computer program to correct the
deformity.
2ESULTS
From November 2006 to November 2009 we treated a total
of 25 pediatric-aged patients (14 boys and 11 girls). The
mean age was 12 years old (range 8-16 years old). The most
frequent deformity corrected was genu varum (14 patients),
followed by limb length discrepancy (7 patients), genu valgum (3
patients) and ankle valgus (2 patients). We had two cases with
deformities of both lower limbs. The most frequent cause was
physeal closure due to secuelae of meningococcical sepsis (5
patients) followed by neoplasic (3 patients) and post-traumatic
(3 patients) deformities and finally fibular hemimelia (2 patients).
We performed 13 tibial and twelve femoral osteotomies. In one
patient we performed one femoral and one tibial osteotomy of
the same limb in one surgical setting.
The mean hospital stay was 3 days. The mean time in fixator
was 175 days (range 53-342 days). The mean followup time
was 21 months (range 7-45 months).
$ISCUSSION
Using the malalignment test, we were able to determine the
where the deformity was and where to perform the osteotomy
determined by the CORA, in an easily and reproducible fashion.
The LRS was quicker to apply better tolerated in our patients.
However, some residual deformity had to be accepted.
With the TSF, we were able to correct multiplanar deformities
without having to take the patient back to the operating room.
In conclusion, we prefer the LRS for uniapical femoral
deformities and femoral lenghtenings and the TSF for multiapical
deformities and tibial lenghtenings.
206
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Podium
USE OF ORTHOFIX RAIL FIXATORS FOR LENGTHENING LONG
BONES
0RINCIPAL!UTHOR Khmyzov, Sergey, MD
CENTRE Institute of Spine and Joint Pathology
AUTHORS 1Skrebtsov, Vladimir, MD; 2Tikhonenko, Alexander, MD
CENTRES 1Yalta City Hospital; 2Genesis Clinik Simferopol
COUNTRY Ukraine
0RINCIPAL!UTHOR Shtarker, Haim, MD
CENTRE Western Galilee Hospital Nahariya
AUTHORS Volpin, Gershon, MD; Kaushansky, Alexander, MD
CENTRE Western Galilee Hospital Nahariya
COUNTRY Israel
!IM
Aim and purpose of the study is to reveal an effectiveness of
External Fixation method for the treatment of multiply injured
children.
2ESUME
We report our experience during the past 5 years with
lengthening of long bones using Rail external fixators.
-ATERIALANDMETHODOLOGY
36 multiply injured patients were involved in the investigation.
Their age ranged from 9 to 14 years, 21 patients had open
fractures. In all cases fragments were fixed with ExFix. AO
tubular ExFix for pelvic fractures and originally designed
monolateral ExFix for long bones fractures were used.
In 1 case we used 2 screws for the fixation of acute traumatic
slipped proximal femoral epiphysis. LCP plating was used in 2
cases only for secondary stabilization of fractured femur.
Special case: 14 y.o. patient was admitted with displaced
fracture of both pubic & sciatic bones (rotationally unstable
pelvis fracture), comminuted fracture of the femoral shaft,
displaced tibial fracture of the right leg, open displaced tibial
fracture of the left leg, multiple left lower limb soft tissues
damages, brain contusion, traumatic shock.
Firstly the complex therapy of traumatic shock combined with
adequate infusion therapy and surgery for soft tissue damages
were performed.
The stabilization of bone fragments was performed using AO
ExFix for pelvic fracture, ExFix of original design for right femoral
shaft fracture and both tibial fractures. Plating was used as final
stabilization method for femoral shaft.
$ISCUSSION
We obtained recovering in all cases (36 patients) with good
functional and anatomical results.
#ONCLUSIONS
Use of ExFix is the reliable method for the treatment of
multiply injured children. The most advantages were noticed in
haemodynamically unstable patients and in orthopedic damage
control surgery. ExFix method should be chosen as the final
method of damage stabilization in pediatric trauma due to the
fact of enhanced bone healing in children.
13 patients and 14 limb segments were lengthened by Orthofix
Rail frame.
Three different sizes of device were used depending upon age
and size of patient limb.
The average age of patients was 20 (7-44) years.
Two patients underwent humeral lengthening, one due to growth
arrest and another one for Erb palsy. Eight patients had femoral
lengthening, one of them bilateral. Three patients were operated
due to posttraumatic severe limb length discrepancy.
In two cases lengthening was performed after bone resection
due to chronic osteomyelitis-bone transport. One of them had
bone transport on intramedullary nail.
Average amount of lengthening was 6.8 cm (4-14 cm) with a
lengthening index of 1.2 (0.9-1.9) months/cm. Good bone axis
was achieved in each lengthened segment.
In one case of bone transport with lengthening for 14 cm bone
grafting of middle portion of regenerate was performed.
In another case of congenital short femur, fracture of regenerate
was diagnosed and percutaneous LCP plating was done.
In 4/13 patients superficial pin tract infection was treated locally
and by oral antibiotics.
All patients returned to full weight bearing after completion of
treatment.
No joint contractures were noted after lengthening except in two
posttraumatic patients who had severe knee contracture before
lengthening.
Rail frame is a reliable device for bone lengthening, as it allows
easy management during lengthening procedure.
The fixators are very stable and simple to apply during surgery.
The device allows correction of regenerate deviation during
lengthening. A high level of patient satisfaction was noted.
207
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THE INFLUENCE OF DIRECT AND INDIRECT LOADING ON THE
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0RINCIPAL!UTHOR Gessmann, Jan, MD
CENTRE Bg Universitätsklinikum Bergmannsheil
AUTHORS Baecker, Hinnerk, MD; Jettkant, Birger, MD; Muhr, Gert,
MD; Seybold, Dominik, MD
CENTRE Bg Universitätsklinikum Bergmannsheil
COUNTRY Germany
0RINCIPAL!UTHOR Yasui, Natsuo, MD
CENTRE University of Tokushima
AUTHORS Takahashi, Mitsuhiko, MD; Kawasaki, Yoshiteru, MD
CENTRE University of Tokushima
CoUNTRY Japan
!IM
In the treatment with the Ilizarov external fixator it is often
necessary to transfix the foot within the ring construction.
For some patients full weight bearing can only be achieved in
assembling a weight bearing platform on the distal ring which
leads to an indirect loading of the axial compressive forces. The
aim of this biomechanical study was to investigate the effect of
indirect force transmission in comparison to the direct weight
bearing on fixator stiffness, the osteotomy and wire tension.
-ATERIALSANDMETHODS
On the basis of a standarized Ilizarov external fixator (4 rings,
160 mm diameter) with two 1,8 mm wires per ring in anatomical
position applied on composite tibiae (3rd Generation Sawbones)
direct and indirect loading was analyzed using a universal
testing machine (model 10, UTS). A middiaphyseal osteotomy of
3,5 mm was performed. The following parameters were studied:
micromotion at the osteotomy, relative movement between bone
and rings, compressive forces at the osteotomy and strain of the
wires. Each experimental setup was tested ten times with 1000
N maximal axial loading.
2ESULTS
The osteotomy gap closure occurred at 275 N at direct loading
and at an average of 730 N at indirect loading. The compressive
forces at the osteotomy were significantly higher at direct
loading. The degree of initial axial micromotion at the side of
the osteotomy was larger in the direct loading setup but more
relative motion between rings and bone was found at indirect
loading. The stress on the wires was up to four times higher on
the proximal wires and up to twice as high on the distal wires
when the weight bearing platform was applied on the distal ring
for indirect loading compared to direct loading.
#ONCLUSION
The indirect loading has a substantial influence on the
biomechanical characteristics of the Ilizarov fixator which
determines the biomechanical environment of the osteotomy/
fracture. The results showed a higher mechanical load on the
fixator/wires while achieving less compressive forces at the side
of osteotomy. In the case the weight bearing platform is needed
to enable ambulation we suggest to apply additional wires/halfpins at least in the distal fragment.
208
2ESUME
We previously developed a special drill guide to achieve
percutaneous multi-drilling osteotomy for limb lengthening
and/or deformity correction (J. Orthop Science 5:104-7, 2000).
The drill guide consisted of a stainless rod and a tube united in
parallel. The outer diameter of the rod and the inner diameter of
the tube were both 3.2 mm or 4.0 mm. The rod was 1 cm longer
than the tube. After the first drill hole is opened by free hand
technique, the tip of the special drill guide (rod) is inserted into
the drill hole, so that the second drilling is made adjacent to the
first drill hole without migration. Then the drill guide is rotated
180 degrees and the third drill hole was made at opposite side
of the first drill hole. By changing the rod position, the forth and
fifth drill holes were made very easily. Usually 4-6 drill holes
were made through 1 cm skin incision for the tibial and the
femoral osteotomy. Then the drill holes were connected with a
small chisel through the same the incision. Using this technique,
minimum invasive percutaneous osteotomy was possible very
close to the external fixation pins.
Recently we have developed a new drill guide consisting of two
identical stainless tubes united in parallel. Cross section of the
new drill guide shows the figure of eight. The “eight guide” has
three sizes with a inner diameter of 2.4 mm (small), 3.2 mm
(middle), and 4.0 mm (large). The first drill hole is made using
one side of the eight guide tube. Then the drill driver is removed
with the drill bit left in the drill guide. The second drilling is
achieved using the other side of eight guide. By rotating the
eight guide, the third and the forth, then fifth drill holes are
made. The surgeon do not need to seek the previous drill hole in
this technique.
The above two methods both provide with a minimum invasive
osteotomy through 1 cm skin incision. Through over 100
osteotomy with this technique, we have not experienced any
unfavourable bone crack near the external fixation pins.
0/$)5-
LENGTHENING INDEX ANALYSIS IN PATIENTS TREATED WITH
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0RINCIPAL!UTHOR Koczewski, Pawel, MD
CENTRE Department of Pediatric Orthopedics
AUTHORS Milud, Shadi, MD
CENTRE Department of Pediatric Orthopedics
CoUNTRY Poland
0RINCIPAL!UTHOR Nobuyuki, Takenaka, MD
CENTRE Department of Orthopaedic Surgery, Teikyo University
School of Medicine
AUTHORS Akira, Yoshino, MD; Mari, Maruishi, MD; Narutaka, Kato,
MD; Yoshinobu, Watanabe, MD; Takashi, Matsushita, MD
CENTRE Teikyo University School of Medicine
COUNTRY Japan
2ESUME
Effectiveness of distraction osteogenesis means as dynamics
of regenerate formation and consolidation varies according to
different parameters and leads to variations of treatment time.
Lengthening index is the main parameter that describe this
situation.
'OAL
To assess effectiveness of distraction osteogenesis on the base
of lengthening index (LI) analysis in relation to: age, etiology,
segment, axial correction and achieved lengthening.
Material consists of 251 patients at the age ranged from 3 to
50 years (mean 15.3) treated with Ilizarov method because of
leg LLD. 319 lengthening procedures were analyzed (tibia-155,
femur-164).
-ETHOD
In all patients total treatment time (time in frame) and amount
of lengthening were recorded to calculate LI (months per 1cm
of lengthening). Patients were divided into groups according
to: etiology, age, segment, axial correction and amount of
lengthening.
2ESUME
Acoustic emission testing is a well-established method for
assessment of the mechanical integrity of general construction
projects. The purpose of this study was to investigate the
usefulness of acoustic emission technology in monitoring
the yield strength of healing callus during external fixation.
One hundred twenty patients with 122 long bones treated
with external fixation were evaluated for elongated bone by
monitoring load for the initiation of acoustic emission signal
(yield strength) under axial loading. The major criteria for
functional bone union based on acoustic emission testing was
as follows, no acoustic emission signal on 110% full weight
bearing, The yield strength monitored by acoustic emission
testing increased with the time of maturated. The external fixator
could be removed safely and successfully in 98% of the patients.
Thus, acoustic emission method has good potential as a reliable
method for monitoring the mechanical status of mature bone.
2ESULTS
Mean LI in all material was 1.6 months/cm (from 0.7 to 5.9).
The lowest LI (1.4) was recorded in youngest patients (from 3
to 9 years) and increased with age: 1.6 -in group from 10 to
17 years, 1.7 -from 18 to 21 and 2.4 -from 22 to 50 years. The
mean LI in femoral lengthening was lower (1.5) than in tibias
(1.8). In group of 63 lengthening that not exceed 4cm LI was
2.3. In second group (from 4 to 7 cm 189 procedures) LI was
lower (1.6), and in last group (more than 7 cm) -1.2. There were
no difference in mean LI between groups with and without axial
correction, in a contrary to etiology groups. In achondroplasia
patients mean LI was 1.2, postseptic and Ollier disease -1.4,
congenital deformities -1.6, posttraumatic -1.8, neurogenic and
clubfoot -2.0. To assess learning curve mean LI was analyzed
in patients treated in first 5 years of using Ilizarov method in
our department comparing to others. There was no difference
between these groups as well as between groups operated by
both authors.
#ONCLUSION
According to lengthening index analysis effectiveness of
distraction osteogenesis is related to the age, etiology, segment
and amount of lengthening, although is not related to axial
correction.
209
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GUIDELINES
0RINCIPAL!UTHOR Singh, Jagwant, MD
CENTRE Hull Royal Infirmary
AUTHORS Davenport James, MD; Pegg, Derek, MD
CENTRE Leighton Hospital
COUNTRY United Kingdom
)NTRODUCTION
Most orthopaedic procedures involve high-speed tools, which
can cause thermal necrosis of bone. Blunt instruments are
likely to generate more heat, thereby increasing the chances
of thermal necrosis. This could lead to loosening of pin sites,
The stability of orthopaedic fixation depends on the quality
and quantity of host bone. Orthopaedic surgery involves many
occasions when bone, after being cut, is expected to heal with
another bone surface e.g. osteotomies.
This can greatly compromise the operative outcome even in
good surgical hands. In today’s age a lot of emphasis is laid on
high performance and longevity of the implant. Therefore, it is
worthwhile that we consider the relevance and importance of
instrument sharpening.
We carried out this survey across 40 hospitals in UK to find out
whether they follow any guidelines or protocol with regards to
instrument sharpening.
-ETHODS
The questionnaire were mainly directed at finding out whether
there were any guidelines regarding instrument sharpening, how
were the blunt instruments identified and picked for sharpening
or replacement. Questions related to quality checks on
instruments and manufacturers guidelines were also included.
2ESULTS
We had replies from all the hospitals and 75% of hospitals
denied any guidelines with regards to instrument sharpening.
The remaining 25% which said yes to guidelines had guidelines
only concerning labeling and identification of blunt instruments.
Regarding monitoring of instruments only eight hospitals (20%)
carried out some sort of quality checks on instruments. Only
33% of hospitals were abiding by the manufacturers guidelines
regarding instrument sharpening.
#ONCLUSION
This implies that there could be a significant risk of suboptimal
outcome due to unnecessary osteonecrosis that can affect most
operative orthopaedic interventions. Our study brings to light the
fact that there seems to be no consensus on this issue and there
is theoretically a significant risk of suboptimal outcome because
of unnecessary osteonecrosis. There is scope for potential
improvement by following a protocol or guideline with regards to
instrument sharpening.
210
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ANALYSIS
0RINCIPAL!UTHOR Thaller, Ph, MD
CENTRE Clinical Center University of Munich
AUTHORS Zoffl, F, MD; Delhey, P, MD
CENTRE Clinical Center University of Munich
COUNTRY Germany
)NTRODUCTION
Limb lengthening with various types of external fixators is
performed on patients who have different causes of limb-length
discrepancy. The use of external fixators is associated with pin
site infections and pain because of soft tissue transfixation.
Different fully implantable distraction nails have been developed.
In comparison with motorised distraction nails, some authors
reported that control of mechanical distraction nails is less
reliable during lengthening. This might give the impression that
the complication rate with motorised systems could be less,
then with mechanical systems.
-ETHODS
12 patients with fully implantable mechanical distraction nails
(ISKD, Orthofix, McKenney, TX, USA) operated in our hospital
were compared with 12 fully implantable motorised distraction
nails (Fitbone, Wittenstein, Igersheim, Germany) operated by the
same surgeon. The patients were matched for age, location and
length of the distraction. A statistical analysis was performed
using univariate analysis. The outcome parameters were early
arrest, accelerated nail, rewinding nails, biocompatibility and
breakage of nail, cable or bolts.
2ESULTS
In the group of mechanical distraction nails there was 1 early
arrest and 1 accelerated nail. There were no breakages of nails
or breakage of bolts. In the group of motorised distraction nails
there were 4 rewinding nails (>2mm), tumorigenic bone reaction
in one patient, breakage of cable in 1 patient. There were no
breakages of nails or bolts.
$ISCUSSIONANDCONCLUSION
With accurate preoperative planning and advanced operative
technique, complications like accelated mechanical distraction
nails can be reduced. The fully implantable systems have
different, but comparable complication rates compared to
mechanical systems.
Podium
INTERNAL LENGTHENING PLATE
0RINCIPAL!UTHOR Emara M, Khaled, MD
CENTRE Ain Shams Univ. Hospitals
COUNTRY Egypt
2ESUME
Bone lengthening using gradual distraction proved to be
effective technique in treatment of many orthopaedic problems
like congenital and pediatric bone problems and old maleunited
fractures and after tumor surgery and many other bone diseases
The technique was developed by Ilizarov & used all around the
world since the mid 80 s with great success. But with the use
of external fixation devices. These devices are associated with
very high complication rate & sever discomfort and complicated
treatment protocol.
During the last few years there are some trials to improve
the treatment by the use of internal lengthening devices
using intramedullary motorized and non-motorized nails
that are inserted inside the bone with more comfort and less
complication than external fixation devices. But the available
implants are designed to be put inside the bone (intramedullary)
& the designs are not suitable for most of the bone diseases
and the conditions that need this type of treatment. Also cant
be used in children & small or deformed bone. Our design of
a motorized bone lengthening plate (E plate) solve all these
problems and make limb lengthening easier to the patient with
less complications and easier to the doctor to apply as it can
be applied to any bone size and even deformed bone and well
controlled. It is composed of a motor that controlled from out
side the body by remote control, and a telescopic plate that fixed
to the bone by 4-6 screws. The motor make gradual distraction
till the patient get the required lenth.
We got the PCT for this design, and mechanical and biological
testing is to be continued.
It is a mechanically stable design, with high safety, and reliable
to sove many orthopaedic conditions.
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FRACTURES
0RINCIPAL!UTHOR Baloch, Naveed, MD
CENTRE The Aga Khan University Hospital
AUTHORS Shamshad Ali, Haroon-Ur-Rahid, MD; Umer, Masood, MD
CENTRE The Aga Khan University Hospital Karachi/section of
Orthopedics
COUNTRY Pakistan
!IMANDPURPOSEOFTHESTUDY
Despite recent developments in fracture treatment, cases of
failed union after a long bone fracture still are encountered.
Nonunion and repeated surgeries are a cause of considerable
pain and disability in these patients because of stiffness of
neighboring joints, deformity, and limb length discrepancy.
Secondary procedures are often required for correction of bone
defects and deformity.
Ilizarov method addresses all the above problems
simultaneously and offers a treatment solution especially for
infected non-unions. The stability of the fixation and provision for
bone transport allows bridging of bone defects, limb lengthening,
early weight bearing ambulation and joint mobilization.
-ATERIALANDMETHODOLOGY
We retrospectively reviewed those patients who had non-union
of long bone fractures and were treated with Ilizarove fixator
application between January 2004 to May 2008. Apart from
demographic data, type of nonunion, any additional intervention
including bone graft, complications and duration with fixator
recorded. Radiological outcome measured according to ASAMI
criteria.
$ISCUSSION
We identified twenty patients with long bone nonunion who
underwent treatment with Ilizarov during this time period. Five
patients excluded due to incomplete follow-up. Out of fifteen
ten were male and five were female patients. Eleven patients
had femur non-union and four had tibia non-union. Union was
achieved in all cases with two patients required additional
procedure for readjustment of fixator and two patients required
bone grafting. Four patients developed superficial pin tract
infection treated with oral antibiotics and local care without any
consequences.
#ONCLUSIONS
Treatment of non-unions of long bones with Ilizarov ring
fixation is effective, with reducing number of procedures and
good outcome. Early referral, patient selection and education
regarding the duration of treatment, emotional, financial and
social support are absolutely essential.
211
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NEUROPATIC PAIN IN LENGTHENING BONE
0RINCIPAL!UTHOR Ramírez Romero, Julio César, MD
CENTRE Clínica Los Andes
AUTHORS 1Ramírez Lamas, Julio César, MD; 2Ramírez Lamas,
Suszanne Pamela, MD; 3Zagal Rosales, Luis, MD; 4Martínez
Pujay, Edilberto, MD; 5Lamas Calderón, María Caridad, MD
CENTRES 1Hospital San José; 2Clínica Los Andes; 3Hospital
Casimiro Ulloa; 4Hogar Clínica San Juan de Dios; 5Instituto de
Medicina Legal
COUNTRY Peru
/BJECTANDPURPOSEOFTHESTUDY
The primary complication in the bone lengthening is pain that
occurs, the management is very important and the diagnosis
appropriate, determine the type of pain that must be addressed.
In this paper we present 49 patients who have received mixed
therapy in the treatment of pain.
-ETHODSANDMATERIALS
In this study include 49 patients undergoing bone lengthening
of tibia and/or femur, of being subjected to an evaluation
questionnaire DN4 (evaluated with a sensitivity of the 82.9
neuropathic pain % and a specificity of the 89.9%), and in which
qualified whit 4 points or more.
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/34%/-9%,)4)3
0RINCIPAL!UTHOR Singh, Jagwant, MD
CENTRE Hull Royal Infirmary
AUTHORS Marwah, Simran, MD; Platt, Alistair, MD; Barlow, G, MD;
Raman, R, MD; Sharma, HK, MD
CENTRE Hull Royal Infirmary
COUNTRY United Kingdom
!IM
Chronic osteomyelitis still remains challenging and expensive to
treat inspite of advances in antibiotics and operative techniques.
We present our experience with free muscle flap after radical
debridement of chronic osteomyelitis, performed as a single
stage procedure.
-ETHODS
We retrospectively identified eight patients (5 females) with
mean age of 63 yrs (range 40- 71 yrs).
Case notes were reviewed for co morbidities, Pre and post
treatment inflammatory markers (plasma viscosity and CRP) and
clinical staging.
Mean follow up was 3 yrs (range 1-6 yrs)
s 4HEPAINISACCENTUATEDORPRESENTSMOREINTENSIVELYONTHE
cm as average.
s 4HEPAINISACCENTUATEDBYNIGHTBY
s 4HEPAINASSOCIATEDWITHHYPEROXIADEPRESSIONIRRITABILITY
insomnia.
s )TISASSOCIATEDBYTOALGODISTROlA
Treatament with pregabalin (Lyrica) 75 to 150 mg per day for
5-10 days, associated with the Association of Tramadol 37.5 mg
and acetaminophen 325 mg (Zaldiar) 2 to 4 times a day.
$ISCUSSION
Pregabalin Tramadol and acetaminophen, Association managed
to decrease pain to tolerable limits in 100% of patients, to
discontinue the medication in 2 to 5 days pain returned to
appear under the home features.
Management of the Association produces drowsiness that
decreases with its use.
The cooperation of the patient improves for physical therapy and
rehabilitation.
All the patients were jointly operated by orthopaedic and plastic
surgeons and underwent thorough debridement and muscle flap
(Seven free flaps and one rotational flap) in the same sitting. All
the patients were reviewed regularly by plastic and orthopaedic
surgeons.
Seven patients had free Gracilis flap and one had Triceps flap.
Clinical assessment of reinfection was made on presence of
erythema, wound discharge, pain and swelling. Primary outcome
measure was resolution of infection.
$ISCUSSION
Seven patients had full resolution of osteomyelitis as evident by
clinical examination and inflammatory markers. Three patients
had graft problems to start with, but these settled within six
months.
One patient had minor wound discharge at three years which
settled with conservative management. One further patient
developed eczematous dermatitis around the flap which was
managed successfully by the dermatologist.
To reduce pain patient thrives and sleep better.
#ONCLUSSIONS
Use associated of these drugs, dramatically reduces pain, and
improves the quality of life of the patient, which means a better
result in the bone lengthening.
212
#ONCLUSIONS
We believe this to be the only study in which both the
procedures (debridement and muscle flap) are performed in
one sitting. This technique is a successful and useful addition to
the armamentarium of surgeons in the management of chronic
osteomyelitis. Though our study is small but our results are
encouraging.
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EXTERNAL FIXATOR
0RINCIPAL!UTHOR Pizzoli, Andrea, MD
CENTRE Orthopedic Department, C. Poma Hospital
AUTHORS Renzi Brivio, Lodovico, MD
CENTRE Orthopedic Department, C. Poma Hospital
CoUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
The aim of the study is to evaluate the biomechanical and
clinical performances of a new radiolucent articulated external
fixator in the treatment of dislocation and complex fractures of
the knee, trying to describe the possible clinical indication to
articulated external fixation of this joint.
-ATERIALANDMETHODOLOGY
The authors will present their preliminary clinical results using a
new radiolucent, hinged external fixator designed to allow joint
motion from 0 to 90º of flexion and to apply to the knee joint
different amounts of distraction. The particular design of the
radiolucent articulated body of the fixator allows motion around
a variable center of rotation and a good view of joint surface
during movement. The possibility to allow early joint movement
avoiding posttraumatic stiffness and to protect joint ligament
reconstruction and or joint reduction are the two main goals of
this device. The possible indication, the technique of application
and the results of the first 10 cases will be presented and
discussed.
$ISCUSSION
The management of dislocation and complex fractures of the
knee has been always troublesome in relation to soft tissue
problems (open lesions, dislocations, neurovascular lesions)
and or to bone lesions (fragment displacement, comminution,
poor bone quality). The use of a bridging fixator as support to
soft tissue or bone healing has still some indication in complex
trauma but has to be converted in few weeks to another
osteosinthesis in order to avoid joint stiffness. An articulated
knee external fixator can avoid this complication but has to be
designed to cope the biomechanic of this joint. This new device
demontrated to be valid in relation to the joint movement, and
stability and to the patient tolerance during the treatment of
complex articular lesions.
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0RINCIPAL!UTHOR Botter Montenegro, Nei, MD
CENTRE Sao Paulo University Medical School
AUTHORS Hamilton de Castro, Walter, MD; Guarniero, Roberto, MD
CENTRE Sao Paulo University Medical School
COUNTRY Brazil
2ESUME
The authors studied one hundred and two lower limb
lengthenings, in adults and children, from 1988 to 2008;
51 patients were treated by the Ilizarov apparatus, with leg
length discrepancy -LLD- do to congenital (34) and acquired
(17) pathologies, with 34 femora (average about 5.6 cm, from
3 to 14 cm) and 17 tibiae lengthening (average 4.7 cm; 2.5
to 11 cm). The lengthenig index average was 1.77 month/
cm. The difficulties found were 45 problems (24 superficial
infection, 11 with delayed union, 9 articular stiffness and 1
fibular neuropraxis), 24 obstacles (14 articular deformities, 11
knee flexion and 3 ankle equinus, 3 early bone healing and 4
abscesses, and 3 delayed union. The complications (27) found
were 12 definitive knee stiffness, 6 definitive ankle stiffness,
3 knee subluxations, 3 lengthening interruption by pain and
2 blood hemorrhage (Paley classification, 1990). The average
external fixation time were about 9 months.
The other 51 patients were submitted to lengthening over nail,
done with monolateral external fixator. There were 39 femora
and 12 tibiae, with follow-up time about 1 to 11 years p.o.,
(average: 6.5 y.), LLD do to adquired (29) and congenital (22)
patologies. The bone lengthening were from 3.5 to 9.5 cm
(average: 5.6 cm) and the external fixation average time were
2.5 months. The lengthenig index average was 1.6 month/cm
and the difficvulties observed were 9 problems (9 superfficial
infections), 5 obstacles (2 calcaneus tendon lengthening, 1
premature consolidation, 1 delayed union and 1 deep infection)
and 3 complications (2 knee deformities and 1 lengthening
interruption. The authors conclusions were that lengthening
over nail with monolateral external fixation, reducing external
fixation time, was able to keep articular range of motion, bone
alignement and decreases fracture risk after bone lengthening
and is a good option for bone lengthening in adults and children.
#ONCLUSIONS
The use of this new radiolucent articulated knee external
fixator can be considered a possible alternative to traditional
bridging fixators or to traditional open recontruction of
knee complex lesion because allows early joint movement
avoiding posttraumatic stiffness and protects joint ligament
reconstruction and or reduction of comminuted articular
fractures.
213
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FRACTURES
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0RINCIPAL!UTHOR Varsalona, Roberto, MD
CENTRE Ospedale Umberto
AUTHORS Salvatore, Caruso, MD; Fabio, Colantonio, MD; Fabio,
Sirugo, MD; Fulvio, Carluzzo, MD
CENTRE Ospedale Umberto
COUNTRY Italy
0RINCIPAL!UTHOR Mitkovic, Milorad, MD
CENTRE Ortopedsko-Traumatoloska Klinika
AUTHORS Micic, Ivan, MD; Milenkovic, Sasa, MD; Mladenovic,
Desimir, MD; Golubovic, Zoran, MD; Mitkovic, Milan, MD
CENTRE Ortopedsko-Traumatoloska Klinika
COUNTRY Serbia
/BJECTIVEANDPURPOSE
Severe proximal tibia fractures, which include intra- and
extraarticular fractures with metaphyseal-diaphyseal
dissociation, pose a difficult treatment problem for the surgeon
with significant complication rates. The aim of this study is
to report the experience with a series of consecutive severe
proximal tibial fractures treated with hybrid external fixators.
)NTRODUCTION
We present 3D concepts in external fixation mainly relating to
fractures treatment.
-ETHODS
Between 2005 and 2010, we treated 132 cases of proximal
tibia fractures of which 66 were treated with hybrid external
fixation. Inclusion criteria for hybrid treatment was severe softtissue injury, intra-articular displacement, and unstable fracture
patterns involvement. In addition to routine demographic
data, objective data collected included healing, deformity,
complications, and motion. Patient were also evaluated with an
SF-36 12 months after healing.
2ESULTS
All proximal tibial fractures healed without additional
procedures. Most patients demonstrated healing by 16 weeks.
Accuracy of reduction was 0-1 mm in 36 patients, 2-3 mm in
23 patients, and 4-5 mm in 6 patients and greater than 5 mm
in 1 patient. Only 6 (10%) of the 66 patients had an angular
malunion greater than 6°. One case had a loss of reduction.
Four patients developed a mild varus deformity. Radiographic
and clinical evidence of degenerative arthritis was seen in 17/66
(25%) patients 18 months after healing. The SF-36 profilese
were health state/rate, daily activity, work activity, emotional
problems, pain.
#ONCLUSIONS
We found that hybrid external fixation is a good alternative
method for treatment of meta- and/or epiphyseal fractures. The
technique and post-op management we describe respects softtissue and bone biology and allows early articular mobilization.
214
-ATERIALANDMETHOD
We have used Mitkovic external fixation system consists of three
components only: clamp, carrier of the clamp and bar. Each
clamp can be combined with other two components on different
manner. Chess-like possibilities of combining of these three
components it is possible to make different frames. This creative
feature provides big freedom for surgeon in resolving variety of
different fractures. The main idea of the system is convergent
configuration of pins. It provides balanced 3D stability, which
has been proven as big advantage in fracture healing. Also
this system can be used as accurate reduction device and it is
provided possibility of dynamic joint bridging frame. Materials for
these different frames were stainless steel, Al alloys, Titanium,
carbon fiber and plastic. Biomechanical investigations of this
system have been performed in Laboratory for measurement of
the Mechanical faculty university of Nis (Serbia) and AO institute
in Davos (Switzerland). It has been used in all segments.
2ESULTS
This system is in wide clinical use and has already been applied
to 20 thousand patients but here is presented results of series
of 512 patients with tibial fractures. Mean union time was 11.3
weeks (8-24 weeks). Mean application time was 12 min (5-56
min). Superficial pin tract infection rate was 12.6% and deep
infection 0.8%. There were no other complications as DVT, joint
stiffness, neurovascular injuries.
$ISCUSSIONANDCONCLUSION
This high mobile external fixation system is more simple in
comparison to other existing systems, high mobile providing
optimal biomechanical conditions for fractures healing. It has
advantages to other external fixation systems as: it simple,
3D balanced biomechanical stability, can be used as accurate
reduction device and all pins can be applied using free hand
technique.
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0RINCIPAL!UTHOR Manca, Mario, MD
CENTRE Ospedale Versilia Toscany Italy
AUTHORS Digrandi, Giuseppe, MD; Palomba, Michele, MD;
Lacopinelli, Marco, MD
CENTRE Ospedale Versilia Toscany Italy
COUNTRY Italy
0RINCIPAL!UTHOR Manca, Mario, MD
CENTRE Ospedale Versilia Toscany Italy
AUTHORS Digrandi, Giuseppe, MD; Palomba, Michele, MD;
Lacopinelli, Marco, MD
CENTRE Ospedale Versilia Toscany Italy
COUNTRY Italy
2ESUME
Temporary external fixation (exfix) is indicated in unstable
polytrauma patients following damage control indications and
in articular fractures. This approach is particularly useful in the
treatment of complex pilon fractures and plateau fractures to
allow soft tissue recovery and limit the risk of deep infections
following open surgery.
2ESUME
Complex pilon fractures are intraarticular fractures with
metaphyseal involvement and associated boneloss. Open
reduction and internal fixation of these fractures has lead
to a reported high percentage of deep infections and skin
necrosis. The final result depends on the energy level of the
trauma, soft tissues involvement and surgeons’ experience.
Damage of the soft tissues increases with the severity of the
fracture type and is correlated to the forces and the energy of
trauma. The presence of serous blisters indicates a superficial
damage of the skin, haemorragic blisters indicate deep damage
with necrosis down to the bone. Surgical timing is the key to
success. If a staged approach is not followed, ORIF can lead
to major complications from 6% to 55%. Scope of this study
was to evaluate the relevance of surgical timing by following a
two stage protocol. With a minimum wait of 14 days between
temporary fixation and definitive fixation, complications were
reduced to less than 5%, Materials and methods: we treated
23 patients in three years. A temporary fixator was applied and
once the soft-tissue evelope was ready for surgery, definitive
fixation was carried out. Temporary exfix aids ligamentotaxis.
The exfix bone screws must be positioned away from the
possibile surgical incisions for definitive fixation. The fixator
assembly is simple with a surgical time of about 15’. One or
two bone screws are inserted in the tibial diaphysis and one
pin in the calcaneus. These are then connected with bars in a
“triangular” type frame by applying some traction. Temporary
exfix should be considered as “portable traction” which allows
CT scans in traction. Blisters should be emptied and covered
sterily. The patient can be discharged with the temporary
fixator and readmitted for definitive surgery once skin wrinkles
reappear. In open fractures a VAC therapy is carried out. In
15 fractures definitive fixation was carried out with ORIF. In 8
fractures we carried out ORIF of the articular surface and fixation
of the metaphysis with an external hybrid fixator. Results: No
deep infections were recorded in this series and all fractures
have healed with no further procedures.
The scope of this study was to provide indications of when and
how to convert temporary exfix to definitive fixation. When: in
polytrauma patients the frame should be converted between the
5th and 10th day (window of opportunity) or after the 21st day
when the period of immuno suppression is assumed finished.
How: there are three conversion possibilities, from temporary
exfix to locked intramedullary nailing or to plating or to definitive
exfix.
The intramedullary nail can be implanted before any “pin tract
infections” may present, usually within the first 15 days. By
following some rules, the risks of intramedullary nailing are
comparable to those of primary nailing. Should nailing follow
temporary exfix the following steps should be taken: removal
of the external fixator, coltural exam of the pin sites, cast for 15
days monitoring the inflammation index followed by nailing. For
femoral fractures these should be put again into traction.
If necessary, a leuco scan scintigrafy should be taken. There are
no differences between reamed and unreamed nails in terms of
infection. If conversion to a intramedullary nail is not possible
due to critical general or local conditions, a definitive external
fixator can be used.
In complex pilon fractures or in plateau tibial fractures surgery
should be delayed over a week, generally 15 days, when the
soft tissues present creases. Materials and method: with the
treatment of termporary exfix converted to definitive fixation
we have treated 41 patients over the last three years. 12
cases were converted from temprary exfix to nailing, 18
from temporary exfix to plate and 11 from temporary exfix to
definitive exfix. Results: we have had only one case of deep
infection following intramedullary nailing of the femur which
resolved with medical therapy until healing and nail removal. All
other fractures healed without infection problems.
215
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INFLUENCING FRACTURE HEALING OF OPEN TIBIAL
FRACTURES
0RINCIPAL!UTHOR Javed, Mustafa, MD
CENTRE Hull Royal Infirmary
AUTHORS Javed, Mustafa, MD; Singh, Jagwant, MD; Simpson,
Krystyna, MD; Cooper, Emily, MD; Sharma, Hemant K, MD
CENTRE Hull Royal Infirmary
COUNTRY United Kingdom
!IMS
Traditionally IM nailing, proposed as standard treatment, have
higher infection & non union rate in severe open tibial fractures.
To analyse and compare various predictors affecting union for
open tibial fractures when treated with either an IM nail or a
circular frame & specifically analyse incidence of deep infection.
-ATERIALANDMETHOLOGY
Retrospective review of 31 and 68 open tibial fractures treated
with circular frames and IM nails. Two groups were compared
for severity of injury, fracture characteristics along with
postoperative complications for the two treatment modalities
(frame group and IM nail group) affecting healing. Open
fractures were classified using Gustilo & Anderson Classification.
Simple anatomic classification of proximal, middle and distal one
third was used.
$ISCUSSION
31(100%) fractures in the frame group and 49 (72%) in the IM
nail group achieved union. Mean age was 42.4 and 32.4 years in
IM nail group and frame group respectively. 35.4% in the frame
group (union in 26.6 weeks) and 49% in the IM nail group (union
in 33.3 weeks) had co-morbidities. Incidence of superficial
infection was 32.3% in frame group and 10.2% in nail group,
with union time of 30.2 and 42.4 weeks respectively. In high
ENERGYTRAUMAFRAMENPATIENTSTOOKLONGER[WEEKS
#)]TOHEALASCOMPAREDTOTHE)-NAILGROUP
NWEEKS#)/THERMECHANISMS
of injury like twisting, fall from height and direct impact took
29.6, 27 and 23.5 weeks respectively in the frame group and
31, 28.2 and 32.8 weeks respectively in the IM nail group. There
was no statistical difference amongst both groups however
in the presence of infection, the healing was slower in the IM
NAILGROUPP'RADEAANDBOPENFRACTURESINTHE
frame group (union in 29.7 and 30.1 weeks respectively) was
comparable to the IM nail group (union in 27.6 and 31.2 weeks
respectively).
#ONCLUSIONS
We conclude no statistical difference with regards to time to
union although presence of infection delays union which is
statistically significant IM nail group. We propose fine fixator is a
better treatment option as compared to nail.
216
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VALIDATION AND ACCURACY OF THE TSF IN THE HTO ON SAW
BONES. PRESENTATIONS OF A CLINICAL CASE STUDY ON
#/-054%2(%8!0/$!33)34%$/24(/0%$)#3352'%29
(CHAOS)
0RINCIPAL!UTHOR Thaller, Ph, MD
CENTRE Clinical Center University of Munich
AUTHORS Delhey, P, MD; Buerklein, D, MD
CENTRE Clinical Center University of Munich
COUNTRY Germany
)NTRODUCTION
The high tibial osteotomy (HTO) is one of the established
therapies in varus gonarthrosis and intact lateral compartment.
The internal fixation with interlocking implants has developed
as to be standard procedure. The tibial retroversion (Slope)
can be changed by HTO and therefore has to be observed
three-dimensionally during correction of the varus or valgus
knee. So far, only a few procedures (Computer-navigated and
manual correction) exist to achieve an exact correction of the
axis. The Taylor Spatial Frame (TSF) can be used as an accurate
computerbased system, allowing intraoperative modifications
#(!/3#OMPUTER(EXAPOD!SSISTED/RTHOPEDIC3URGERY
In this study, the technique of Chaos should be validated using
standardized HTO at saw bones. Furthermore, we present an
intraoperative implementation of this technique.
-ETHODS
HTO was performed at 14 saw-bones (artificial bones) with the
TSF. In the first group 7 bones were corrected into 7 valgus and
the slope was increased 5 into retroversion. In the second group
the HTO was planted with 11º valgus and 9º tibial retroversion.
After osteotomy and indentification of the mounting parameters
the correction was performed with the TSF. Subsequently,
a Tomofix was used for internal fixation and the fixator
was removed. CT-scans were done and with standardized
measurement the accuracy of the HTO and the correction of the
slope were analyzed.
Clinical case: Post-traumatic recurvatum (15º) and varus (10)
of a femur was corrected intraoperatively using TSF (CHAOS),
afterwards an internal fixation with LISS-plate (Synthes) was
performed.
2ESULTS
In the first group a correction of axis was achieved with 6.3º
varus (SD 0,8º) and the slope changed by 4.9º (SD 1.3º). In the
second group we reached 10.3º varus (SD 0.9º), the slope was
corrected 7.4º (SD 1.1º). Clinical case: Intraoperative correction
of the distal femur of the recurvatum and varus deformity was
successful. After determining the mounting-parameters the
deformity was corrected completely, in accordance with the
preoperative planning.
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PERSPECTIVE
0RINCIPAL!UTHOR Sala, Francesco, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
AUTHORS Agus, Maria Alice, MD; Talamonti, Tazio, MD; Castelli,
Fabio, MD; Capitani, Dario, MD; Fogliani, Tiziana, MD
CENTRE Department of Orthopedic Surgery and Traumatology,
Niguarda Hospital-Milan
COUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
The timing of definitive fixation for major fractures in polytrauma
patients is controversial. This study validates the outcome of
Sheffield hybrid system (SHF) and Taylor spatial frame (TSF)
used for alignment of displaced bone fragments and limb
reconstruction.
-ATERIALANDMETHODOLOGY
We report a series of 23 patients (18 men and 5 women); ages
11 to 77 years (average age 37.1 yrs) with femoral fractures
treated from 2003 to 2009 with an injury severity score >
16. We found 11patients treated by SHF vs 12 with TSF. The
inclusion criteria were an Injury Severity Score (ISS) greater
than or equal to 16, open femoral fractures, early operative bone
stabilization with temporary external fixator in view of damage
control orthopaedic (DCO), definitive conversion with circular
SHF/TSF. The esclusion criteria were pathological fractures
or fractures in children. The radiographs were reviewed for
union and lower limb axis alignment as well. External fixator
time (length of time in external fixator), was calculated. The
results were assessed using the functional and radiological
scoring system described by Paley and Maar. Fracture union
was achieved in all patients. The time in the fixator (i.e. duration
of treatment) averaged 23.8 weeks (range 10-64 weeks).
According to Paley and Maar’s criteria 22 patient had excellent/
good result vs one fair with clinical and radiological union. The
functional result was excellent in six patients, good in ten, fair in
six and poor in one.
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0RINCIPAL!UTHOR Chana Rodríguez, Francisco, MD
CENTRE General University Hospital Gregorio Marañón
AUTHORS Crego Vita, Diana, MD; Villanueva, Manuel, MD; Pérez
Mañanes, Rubén, MD; Narbona, Javier, MD; Vaquero Martín,
Javier, MD
CENTRE General University Hospital Gregorio Marañón
COUNTRY Spain
/BJECTIVEANDPURPOSE
Pelvic fractures account for 1-3% of all skeletal fractures and
2% of orthopedic hospital admissions. In the acute phase
many advocate external fixation, as a temporary device, to
achieve stabilisation of the pelvic fractures and a positive effect
on haemorrhage. Biomechanical and anatomic studies have
focused on pin placement lower on the pelvis, specifically in the
supra-acetabular region. We present our experience in fractures
type B.
-ETHODSANDMATERIALS
Prospective analysis of 20 supra-acetabular external fixator
applications to stabilize the anterior pelvic ring in 10 type B
injuries. Bilateral percutaneous insertion of Schanz screws into
the supra-acetabular area of iliac bone. Closed reduction and
stabilization of the pelvic ring by compression and application of
a connecting rod under image intensification.
2ESULTS
No iatrogenic lesions of the lateral femoral cutaneous nerve.
No pin site infection. In one patient primary perforation of
the Schanz screw into the small pelvis not necessitating any
treatment. No secondary displacements of the anterior or
posterior pelvic ring.
#ONCLUSION
Placing the pins in the supra-acetabular bone improves stability
in fractures type B and is safe, if insertion is carried out under
fluoroscopic guidance.
$ISCUSSION
We found that SHF/TSF for complex fractures of the femur
combine maximum support for the bone and preservation of
soft tissues. SHF/TSF are an effective technique compared to
internal nails and earlier external fixator devices, attributable
to its advantages such as continuity of frame till union, early
mobilisation and restoration of primary defect due to bone
loss by differential distraction osteogenesis without additional
surgery.
#ONCLUSIONS
The authors advise conversion from TEF to SHF/TSF femoral
definitive synthesis in complex fractures. With this technique
diaphyseal and distal femoral fractures can be securely
stabilized with perfect reduction.
217
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0RINCIPAL!UTHOR Aziz, Amer, MD
CENTRE Medical and Dental College, Lahore
COUNTRY Pakistan
2ESUME
Treatment of neglected hip problems is difficult in adults. The
two main treatments for severe pain and limp, caused by hip
problems in adolescents and adults, are total joint replacement
or pelvic support osteotomy. The purpose of the study was to
determine the amount of pain relief (using Denis Pain Scale) and
improvement in leg length discrepancy and Trendelenburg sign.
This descriptive study was conducted last year on 25 patients
having mean age of 20 years. Patients fulfilling the inclusion
criteria were subjected to surgery after taking written informed
consent. We performed hip reconstruction osteotomy, consisting
of a proximal abduction and extension osteotomy, and a distal
lengthening osteotomy, utilizing Ilizarov external fixator. The
most frequent preoperative complaints were pain, leg-length
discrepancy and limp. All patients were evaluated according to
pre- and post-operative hip pain, Trendelenburg sign, leg length
discrepancy. After an average follow-up of 6 (3-9) months, the
outcome was satisfactory; pain subsided in all patients, the
Trendelenburg sign became negative in all but 2 patients and no
patient had limb-length discrepancy. The results were analysed
using SPSS 11.0 version and P-values of <.05 was considered
significant.
In our opinion pelvic support osteotomy is an excellent method
for pelvic reconstruction in adults.
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0RINCIPAL!UTHOR Lerner, Alexander, MD
CENTRE Ziv Medical Center, Zefat
COUNTRY Israel
2ESUME
The purpose of this study is to evaluate the results of the
treatment by severe war injuries to limbs.
Fifty-five patients suffered after 74 high-energy open blast and
gun-shot fractures were treated. There was other major organ
trauma in 60% of patients. The patients were treated according
to staged protocol, based on principles of damage control.
In admission, the fractured bones are realigned and stabilized
with an unilateral tubular external fixation frame followed by
debridement. In patients with peri-articular fractures temporary
trans-articular bridging was needed.
Final coverage was performed after 5 to 7 days with conversion
from tubular for a circular frame. Closed reduction of fractures
was performed in most patients. In patients with high-energy
“floating joints” injuries fixators were connected by hinges
to allow immediate movements. The separate fixation of
the forearm bones was performed to allow early pronation/
supination.
Early walking was possible even in patients with bilateral
complex injuries to lower extremities. The Ilizarov external fixator
in most of the patients was the definitive treatment. One of
the patients was need amputation due to acute foot ischemia.
Fracture union and functional restoration was achieved in most
treated patients; there were three patients with functional nonunions in the upper limbs.
Based on this experience, we suggest, that protocol of staged
external fixation treatment with radical debridement and early
tissue transfer provides fracture healing and good functional
results in extensive compound war injuries of the extremities.
This enhanced limb salvage even in limbs categorized as high
risk.
218
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0RINCIPAL!UTHOR Mladenovic, Desimir, MD
CENTRE Clinic of Orthopedics and Traumatology of the Clinical
Center Nis
AUTHORS Mitkovic, Milorad, MD; Micic, Ivan, MD; Karalejic, Sasa,
MD; Mladenovic, Marko, MD; Stojiljkovic, Predrag, MD
CENTRE Clinic of Orthopedics and Traumatology of the Clinical
Center Nis
COUNTRY Serbia
2ESUME
Pelvic fractures are rare injuries. They most frequently occur as
a result of high energy blunt trauma in traffic accidents or fall
from the heights. Pelvic fractures are rare isolated injuries, in
60-80% they are in association with multiple injuries. Successful
surgical treatment of multiple injuries patients requires an
approach based on prioritizing injuries.
We present a group of 16 patients with verrtically unstable pelvic
fractures surgical treated. In the our group, the male subjects
prevailed. There were 12 male and 4 female subjects. The mean
patient age was 39.4 years.
In all the patients external fixation combined with internal
fixation was applied. In all the patients pelvic ring was stabilized
with an external fixator type Mitkovic, where the pins are placed
in the iliac crista and supra acetabular. In 7 (43.7%) patients
plating of symphysis pubis were done. In 14 (87.5%) patients
posterior pelvic reduction were performed using internal fixation
techniques by anterior approach and in 2 (12.5%) patients by
posterior approach.
Verticalistion of the patients was allowed after 6 weeks. The
average time of removing external fixator was 7 week.
Anatomical reduction of fracture of pelvis were achieved in 12
(75%) patients.
Complications were recorded, as well as pain in 5 (31%)
patients and partial damage of n. ishiadicus in 3 (18.7%).
External fixation combined with internal fixation is a useful
technique in the management of vertically unstable pelvic
fractures.
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0RINCIPAL!UTHOR Bettinsoli, Pierfrancesco, MD
CENTRE Orthopaedic and Traumatology Department, Spedali
Civili, Brescia University
AUTHORS Pizzoli, Andrea, MD; Renzi Brivio, Lodovico, MD
CENTRE Orthopaedic and Traumatology Department, C Poma
Hospital Mantova
COUNTRY Italy
!IMANDPURPOSEOFTHESTUDY
The aim of the study is to evaluate if is possible to obtain
good result in terms of functional recovery and low rate of
complications using a minimal invasive strategy of treatment in
some selected cases of acetabular fractures.
-ATERIALANDMETHODOLOGY
Between 2001 and 2006 we performed MIPO techniques for
acetabular fractures in 15 patients; the reduction has been
evaluated with fluoroscopy during the operation and with
CT after the operative procedure. In almost all the cases
the reduction has been achieved and maintained using an
ileo-femoral external fixator according to the ligamentotaxis
technique associating whenever possible percutaneous
cannulated 4 mm screws to optimise the reduction and obtain
fragment fixation. The fixator is left in place from a minimum of
20 days to a maximum of 40 days.
$ISCUSSION
Anatomical reduction of the joint is the primary aim in the
treatment of acetabular fractures as any other articular
fracture. The current standard of care provides open reduction
and internal fixation (O.R.I.F.) through differentiated surgical
approaches which have been associated with relatively high
complications rate such as haematomas, superficial and
deep infection, and neuro-vascular lesions. Moreover these
procedures need long operative times with significant blood loss.
To avoid these general and local complications, that sometimes
compromise the functional outcome of the operation and
the possibility to perform a future arthroplasty, some authors
advocated a minimally invasive percutaneous osteosynthesis
(MIPO). This approach can also be considered a valid alternative
to O.RI.F. in all those cases in which the standard approaches
are contraindicated as in open fractures, comminuted fractures
in osteoporotic patients or fractures in high risk patients.
#ONCLUSION
Following the strategy of a low invasive surgery using the a
bridging fixator associated to a minimal internal fixation is
possible to achieve good reduction and fracture stability in
some selected acetabular fractures, avoiding the poor results of
conservative treatment or the risk of major complications related
to ORIF.
219
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42!.30%$)#5,!2&)8!4)/.).30).!,$%&/2-)49
CORRECTION
0RINCIPAL!UTHOR Khudiaev, Alexander, MD
CENTRE Russian Ilizarov Scientific Centre
AUTHORS Kovalenko, Pavel, MD; Prudnikova, Oxana, MD;
Mushtaeva, Yulia, MD
CENTRE Russian Ilizarov Scientific Centre Restorative
Traumatology and Orthopaedics
COUNTRY Russian Federation
Introduction
External transpedicular fixation allows for gradual correction
of all components of spinal deformity in patients with spinal
diseases and injuries due to external fixation with controlled
parts of the construct.
-ATERIALANDMETHODS
Osteosynthesis of the spine includes pedicle screw placement
into vertebral body with screws fixed to supporting plates. The
supporting plates are incorporated into blocks of at least 2
plates. A choice of osteosynthesis would depend on a type of
deformity that would create most favourable biomechanical
conditions for scoliosis correction. Blocks of the frame are
applied at the base of the curvature arch in thoracic spine, at
the apex of the deformity, and at the base of curvature arch in
lumbar spine and iliac wings for correction of C-shaped scoliotic
deformity. The deformity is corrected due to multidirectional
distraction-compression forces between the blocks of the frame.
Blocks of the frame are located at the base of the curvature
apex in thoracic, thoracolumbar spine, and pelvic bones for
correction of S-shaped deformity. This type of scoliosis is
corrected due to distraction-compression forces using damper
frame with gradual loading. Results of treatment were assessed
in 290 patients with scoliosis aged from 12 to 26 years.
Deformity was graded as III-IV (Chaklin V.D., 1965). S-shaped
scoliosis was diagnosed in 62.5%, and C-shaped deformity
in 37.5%. All patients showed good cosmetic effect with the
symmetry of shoulder girdle and waist triangle achieved, no
rib hump, and the line of spinous process approximated to
vertical line of the body. Deformity correction degree at the end
of treatment was 80 to 90% of the original values of C-shaped
deformities and 90 to 102% with S-shaped deformities.
$ISCUSSION
Gradual correction of spinal deformities allowed us to avoid
neurological complications and achieve maximum spinal
realignment external and internal transpedicular osteosynthesis
allows for effective management of complicated orthopaedic
pathology. External controlled construct allowed for prevention of
pelvis and shoulder girdle obliquity.
#ONCLUSION
Accurate screw placement and the block connection allows
for even distribution of tension between the elements of the
construct, prevention of screw breakage and rational scoliosis
correction considering spinal biomechanics.
220
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#522%.4!002/!#(%34/4(%42%!4-%.4/&0!4)%.43
WITH SCOLIOSIS
0RINCIPAL!UTHOR Khudiaev, Alexander, MD
CENTRE Russian Ilizarov Scientific Centre
AUTHORS Prudnikova, Oxana, MD; Mushtaeva, Yulia, MD
CENTRE Russian Ilizarov Scientific Centre
COUNTRY Russian Federation
0URPOSEOFSTUDY
Review of results with differential approach to the treatment of
patients with scoliosis.
-ATERIALANDMETHODS
With a diversity of techniques and constructs applied to
eliminate scoliosis the problem of correcting and maintaining
the achieved correction is still challenging. The method
of distraction osteosynthesis has been developed at RISC
RTO to correct scoliosis. External transpedicular fixation
allows for gradual correction of complex spinal deformities
under radiological control avoiding vascular, neurological
complications associated with traction of spine and vertebral
canal and prevention and gives the possibility to prevent and
correct such negative aspects of spinal deformity correction
as pelvis and shoulder girdle obliquity. Differential approach
was employed for osteosynthesis and scoliosis correction.
Recessing transpedicular systems and acute correction was
used for degree II-III scoliosis. Multi-staged operative treatment
including resection of rib hump, spinal osteosynthesis with
external transpedicular fixation for gradual correction of all the
components of the deformity and fixation spondylodesis with
recessing transpedicular systems was applied for degree III-IV
scoliosis.
Results of treatment were evaluated in 38 patients with degree
II-IV thoracolumbar dysplastic scoliosis. On admission the
patients presented with thoracolumbar scoliosis, asymmetric
shoulder girdle and waist triangle, rib hump. No severe
neurological disorders were revealed.
$ISCUSSION
Acute deformity correction with internal transpedicular fixation
was performed in 12 cases, and gradual scoliosis correction
with external transpedicular fixation followed by spondylodesis
with internal fixation devices produced in 26 patients. All the
patients showed good results. Degree of scoliosis correction was
80 to 100%. The achieved result persisted during the follow-up
period. Loss of correction at one-year follow-up did not exceed
3%. No complications associated with disturbed stability of the
construct occurred.
#ONCLUSION
Differential approach to spinal osteosynthesis and external
transpedicular fixation device in correction of complex
multiplanar spinal deformities allows us to achieve effective
treatment in the cohort of patients.
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APPLICATION OF EXTERNAL TRANSPEDICULAR FIXATION FOR
30).!,$%&/2-)4)%3
Podium
TRUELOK EXTERNAL FIXATION FOR RECONSTRUCTION
SURGERY ON THE SPINE
0RINCIPAL!UTHOR Khudiaev, Alexander, MD
CENTRE Russian Ilizarov Scientific Centre
AUTHORS Prudnikova, Oxana, MD; Diachkov, Alexander, MD
CENTRE Russian Ilizarov Scientific Centre
COUNTRY Russian Federation
0RINCIPAL!UTHOR Samchukov, Mikhail, MD
CENTRE Texas Scottish Rite Hospital for Children
AUTHORS Birch, John, MD; Richards, Stephen, MD; Rathjen, Karl,
MD; Cherkashin, Alexander, MD
CENTRE Texas Scottish Rite Hospital for Children
COUNTRY United States
2ESUME
Attainment of spinal stability is an important factor in treatment
of several spinal diseases, and an essential element for complex
reconstructive procedures.
With a diversity of techniques and constructs applied to
eliminate spinal deformities of various genesis the problem
is still challenging. The method of distraction osteosynthesis
devised at the Russian Ilizarov Centre is applied for patients
with spinal diseases and injuries. External transpedicular type
of fixation allows for gradual correction of complicated spinal
deformities in patients with radiological control that allows us
to avoid vascular, neurological complications associated with
traction of vertebral column and spinal canal.
Treatment of patients with complicated fractures of thoracic
and lumbar spine in acute, intermediate and late periods of
traumatic disease of the spinal cord includes decompression of
the spinal cord, osteosynthesis of the spine with spinal deformity
correction and fixing spondylodesis of the injured segment.
The method of transpedicular external fixation is used to treat
patients with evident traumatic spinal deformity (compression
degree II-III, scoliosis of over 15º). Internal transpedicular
systems are applied for unexpressed traumatic spinal deformity
to fix the injured segment.
Treatment of patients with dysplastic scoliosis includes several
stages of operative treatment: resection of a rib hump, spinal
osteosynthesis with external transpedicular fixation device
followed by deformity correction using the frame and fixing
spondylodesis of thoracolumbar spine. Three-dimensional
triplanar spinal deformity correction is produced under control of
neurological status of the patient and radiological data. Internal
transpedicular systems are employed to stabilize the achieved
result.
Differentiated approach to the choice of spinal osteosynthesis
and possibilities with external transpedicular fixation in
correction of complicated multiplanar spinal deformities allow us
to achieve effective treatment of patients.
0URPOSE
Unsalvageable infected pseudoarthrosis and severe deformity
of the spine remain a significant challenge. The purpose of
this study was to evaluate the stability of spinal deformity
correction using TrueLok external fixation in children with
myelomeningocele and analyze remodeling of distraction spinal
regenerates at the long-term follow up.
-ATERIALANDMETHODOLOGY
Seven patients with myelomeningocele (4 girls and 3 boys)
underwent TrueLok external fixation of the spine. Three patients
had life-threatening mobile infected spine pseudoarthrosis
in association with kyphotic deformity developed either
spontaneously (1) or due to loss of fixation after failed
posterior spinal instrumentation (2). In the other 4 patients,
external fixation was applied for gradual correction of severe
hyperlordosis (3) or kyphosis (1) of the spine. Typically, proximal
(thoracic spine) fixation block included 3-4 interconnected
arches with 6-8 pedicular half pins. Distal fixation block
consisted of the large diameter ring attached to the pelvis with
2-3 cross olive wires and 2-4 half pins. In cases with infected
pseudoarthrosis, proximal and distal fixation blocks were
connected after necrotic tissue debridement with compression
threaded or telescopic rods. In one patient, the frame was
extended proximally to provide halo-spine-pelvic fixation.
Angular deformity correction in patients with hyperlordosis
was achieved after anterior and posterior releases by TrueLok
hinges and angular distractor, which were replaced during the
consolidation period with the telescopic rods. In one patient,
posterior spinal instrumentation was applied after frame removal
to prevent recurrence of the deformity.
2ESULTS
One patient with kyphosis was eliminated from the study
because of the loss of fixation 2 weeks after frame application
due to inadequate bone stock. Long-term follow up in other
patients ranged from 1 to 6 years. All patients achieved excellent
stable fusion and no loss of the deformity correction at the longterm follow up. Distraction bone regenerates formed in the area
of the spine demonstrate adequate remodeling with gradually
increased density of bony tissues.
#ONCLUSION
Treatment of infected pseudoarthrosis of the spine and gradual
correction of severe spinal deformities with TrueLok external
fixation system can be successfully used in children with
myelomeningocele providing stable clinical and radiographic
results.
221
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EXTERNAL FIXATION
0RINCIPAL!UTHOR Albergo, José, MD
CENTRE Hospital Italiano
COUNTRY Argentina
)NTRODUCTION
Cloacal exstrophy is a congenital and infrequent anomaly that
affects principally the low intestinal system, the urinary system
and the pelvis. Without treatment the mortality rate is over
75%. The objective of our work is to present three patients with
cloacal exstrophy treated with pelvic osteotomy and external
fixation.
0ATIENTSANDMETHODS
During the period among 2005-2007 three patients with cloacal
exstrophy were treated in our service. There were 2 girls and 1
boy. The mean follow- up was 44.5 months. In the three patients
pelvic osteotomy and external fixation was carried out. Any
complications were reviewed. Anteroposterior radiographs of
the pelvis taken before operation, at four to eight weeks after
surgery and at the latest follow up were analysed.
2ESULTS
A correction of the synphyseal diastasis was obtained in all
patients with out any complication during the follow-up. No
pelvic instability was detected on stressing the pelvis. All
patients and parents were satisfied with the treatment. In the
three children there were no limitation of gait.
#ONCLUSION
Pelvic osteotomy and external fixation has an important role in
the reconstruction of the cloacal exstrophy. According to our
results, it allows a correction of the synphyseal diastasis with a
low rate of complications and we believe it can be a major help
in securing mild-line closure.
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%84%2.!,&)8!4)/.&/2-!.!'%-%.4/&#/-0,)#!4)/.3
!33/#)!4%$7)4(-53#5,/3+%,%4!,45-/23!.$2%,!4%$
SURGERY
0RINCIPAL!UTHOR Eralp, Levent, MD
CENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Traumatology
AUTHORS Toker, Berkin, MD; Akgül, Turgut, MD; Kocaoglu,
Mehmet, MD; Özger, Harzem, MD
CENTRE Istanbul University Istanbul Medical Faculty Department
of Orthopaedics and Trauvmatology
COUNTRY Turkey
/BJECTIVES
We evaluated the results, and the course of treatment with,
external fixation in treating complications associated with bone
tumors and related surgery.
-ETHODS
Eighteen patients (9 males, 9 females) who were treated with
external fiksator were evaluated in three groups. The first group
were treated for infection with nonunion or deformity following
surgery. The second group were treated for shortening and
nonunion secondary to tumor surgery. The third group were
deformity and shortening due to tumor itself. The mean age 19
YEARS(ISTOLOGICDIAGNOSISWEREOSTEOSARCOMAN
%WINGSSARCOMANHEREDITARYMULTIPLEEXOSTOSISN
CHONDROSARCOMANSYNOVIALSARCOMAN/LLIERSDISEASE
giant cell tumor of bone, desmoid fibroma, chondromyxoid
fibroma and enchondroma.
2ESULTS
The first group included eight patients. The mean shortening
was 10.6 cm, the mean lengthening was 9.7 cm, and the mean
external fixator index was 48.8 days/cm. Complication were
free vascularized fibula graft fracture, nail brokage after external
fixator removal and amputation was required in two patients.
Infection was treated successfully. The second group consisted
of six patients. The mean shortening was 7.5 cm, the mean
lengthening was 6.5 cm, and the mean external fixator index
was 28 days/cm. Complications were nail brokage and knee
STIFFNESS4HETHIRDGROUPINCLUDEDMULTIPLEEXOSTOSISNAND
Ollier’s disease. The mean shortening was 7.5 cm, the mean
lengthening was 6.5 cm, and the mean external fixator index
was 57.2 days/cm. Ulnar shortening of 2 cm after growth at one
patient.
#ONCLUSION
The use of external fixator in the management of complications
associated with bone tumors and related surgery yields
successful results especially in young patients.
222
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42%!4-%.4/&2%#522%.4')!.4#%,,45-/2
AND/OR AGGRESSIVE
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-!.!'%-%.4/&')!.4#%,,45-/2'#4
WITH ILIZAROV RING FIXATOR
0RINCIPAL!UTHOR López Mejía, Gerardo, MD
CENTRE Hospital Christus Muguerza Saltillo
COUNTRY Mexico
/BJECTIVEANDPURPOSEOFWORK
Show the surgical treatment for limb salvage TCG with recurrent
and/or aggressive elongation through bifocal (femur and tibia)
ending in a fusion (artrodesis).
0RINCIPAL!UTHOR Pirwani, Mehtab, MD
CENTRE Liaquat University of Medical & Health Sciences,
Jamshoro
AUTHORS Bhutto, Irshad Ahmed, MD; Rehman Shaikh, Adbul
Prof., MD
CENTRE Liaquat University of Medical & Health Sciences,
Jamshoro
CoUNTRY Pakistan
-ATERIALANDMETHODS
TCG patients with recurrent and/or aggressive regardless of sex,
age, occupation and location. No systemic disease aggregate.
/BJECTIVES
To study the results of management of Giant Cell Tumor by
Ilizarov ring fixator.
$ISCUSSION
The TCG is a low-grade neoplastic lesion that appears in the
epiphyseal and metaphyseal region of long bones, although is
benign it tends to destruction. Appears in patients between 20
and 50 years of age. There are multiple surgical management
so it is a high rate of recurrence taking into account that
the malignant usually take the form of pure fibrosarcoma or
osteogenic sarcoma, for that is this management that consists of
en bloc resection and transportation bifocal bone, preserving the
affected extremity.
-ATERIALANDMETHODS
s 4OTALNUMBEROFPATIENTS
s !GEYEARS
s -ALE&EMALERATIO
s -EANFOLLOWUPYEARS
#ONCLUSION
It demonstrated the effectiveness of the technique of en bloc
resection with transportation and ending bifocal fusion and thus
the limb salvage. This demonstrates the efficacy of tissue culture
through the bifocal bone elongation despite the inconvenience
that the use of extern fixation cause. Management through
tumor prosthesis is good but taking into account that most
patients with this disease are young and active patients the
duration of the prosthesis is not much. The final question would
be is an amputation and a prosthetic posterior pelvic limb vs a
single rigid leg.
0ROCEDURE
s 0REOPERATIVECLINICALRADIOLOGICALASSESSMENT
s 2ADICALRESECTIONOFDISEASEDSEGMENT
s NAVIGATIONWIRESPASSED
s 7OUNDCLOSED
s 4RIFOCALASSEMBLYOF)LIZAROVRINGlXATORAPPLIED
s $ISTRACTIONSTARTEDONth day @ 0.25mm/8 hours at the
corticotomy sites and compression at the resected site @ 0.5
mm/8 hours.
s &RAMELEFTINPLACETILLARTHRODESISANDMATURITYOFREGENERATE
s !FTERREMOVALOFFRAMELIMBREMAINEDINCASTFORWEEKS
s +&/OR!&/ADVISEDLATERON
2ESULTS
s #LINICAL2ESULTS%XCELLENTTOGOODIN
s &UNCTIONAL2ESULTS%XCELLENTTOGOODIN
#ONCLUSION
Ilizarov ring fixator is one of the best tools, in the experienced
hands, in limb salvage after Giant Cell Tumor.
223
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RECONSTRUCTION OF BONE IN THE DEFINITIVE
42%!4-%.4/&45-/23
0RINCIPAL!UTHOR Bongiovanni, José Carlos, MD
CENTRE Universidad Mogi Das Cruzes
AUTHORS Preti, Aurelio Marco, MD
CENTRE Universidad Mogi Das Cruzes
COUNTRY Brazil
)NTRODUCTION
The treatment of bone tumors is still a challenge for orthopedics
to save the affected limb. Be the aggressiveness of the tumor,
with destruction of tissues in different regions of the state or
by the small number of specialized centers for the treatment
of these lesions. But the biggest challenge is in making early
diagnosis of bone-muscular disease. Patients undergoing
treatment for an oncological resection margin of primary bone
tumors, childhood and adolescence (patients who have not
completed their growth spurt) had, over the years, discrepancies
incompatible with the functionality of the lower extremity.
In these cases, in a not too distant past, the first treatment
given was total resection of the limb (amputation). Among the
difficulties in treating bone tumors there is a defect, usually
generated by large tumor resection and even joint participation
and limb function. The advent of the Ilizarov method and
in particular its use in bone transport, have obtained good
results in bone loss due to the large correct the aftermath of
trauma, infection, tumor and bone lesions. The bone transport
according to Ilizarov principles is demonstrably good choice for
the treatment of large bone defects and should be considered
as a reconstructive procedure in these cases. Besides being a
biological method, with particular respect assaulted vascular
segment, allows the patient to walk soon, with all the benefits
inherent in being able to walk without assistance.
/BJECTIVES
Present the results of analysis of the treatment of serious
injuries with external tumorai, set as a biological method final.
-ETHOD
We have treated 14 patients (6 femur and tibia 8), 8 (57%)
males and 6 (43%) femininos. O left side in 8 (57%) of cases
with six (43%) right side, with two (14%) of non-white and 12
(86%) the average age of patients was 21.6 s branca. A anos.
Quanto the aetiology, we had six patients (42.9%) osteosarcoma,
four patients (28.6%) with Ewing’s tumor, 3 patients (21.4%)
with GCT and one patient (7.1%) of Paget.
2ESULTS
Total consolidation of the transport segment in 12 (85.7%),
healing of the infection in 14 patients (100%), total correction of
the discrepancy in 7 (50.0%), correction of deformities in total
10 (71.4%).
#OMPLICATIONS
During treatment the most common complication was superficial
infection of drivers in 92.8% and after treatment for lower limb
shortening acomentido than 3 cm in 42.8% of cases.
224
#ONCLUSIONS
s 4HEUSEOFEXTERNALlXATIONHASBEENEFFECTIVEINTHEDElNITIVE
treatment for bone reconstruction in resection of tumors, the
lengthening and correction of deformities of the bones in the
same duration of chemotherapy and radiotherapy.
s 4HEMETHODISMAINLYINDICATEDINCASESWHEREA
contraindication for implant arthroplasty (as low age, the
likelihood of complications such as infection, etc.). In the
presence of deformities and correction of discrepancies and
the technical difficulties of allografts, micro grafts and surgical
instruments, etc.
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APPLICATION OF TRANSOSSEOUS OSTEOSYNTHESIS IN
42%!4-%.4/&0!4)%.437)4($)3%!3%3!.$).*52)%3/&
500%2,)-"
0RINCIPAL!UTHOR Ismaylov, Guseynali, MD
CENTRE Hospital Milad
COUNTRY Iran
)NTRODUCTION
High frequency of diseases and injuries of upper extremity,
complexity of treatment and considerable percentage of
unsatisfactory results create social and medical importance
of the problem. The progress in surgical developments for
treatment of invalids and patients with limited work abilities
allowed for improving of functional possibilities for self-services
thanks to the method of controlled transosseous osteosynthesis.
-ETODANDMATERIAL
The present work is based on the experience of treatment of
847 patients (1126 segments and joints) with open and closed
injuries and diseases of congenital and acquired etiology, aged
1,2 years to 76 years. Pathologies located in shoulder girdle,
shoulder, forearm, arm and joints of upper limb. All patients had
severe degrees of injuries: different kinds and localizations of
fractures, joint injuries, mal-united fractures, limb shortenings,
deformities, pseudoarthroses, defects and contractures of joints.
27,3% of injuries had a concomitant character. 86% of patients
were operated on several times, which resulted in vivid scar
changes (38,1%) and osteomyelitis complications (23,5%).
The functional mobility limitation increased the number of
patients with joint contractures (47%). The tactic of patients’
treatment was based on individual approach, depending on
etiology of disease, character and complication of preceding
treatment, condition of tissues and function of joints. The
method of controlled transosseous osteosynthesis allowed
for complex solving of problem of treatment for the given
patients’ groups, providing good conditions for regeneration
and restoration of functions, reducing the trauma of surgical
intervention, preserving the innervations and blood supply of
segments, regulating the optimal rate and rhythm of distraction
and possibility of early functional weight-bearing in the process
of treatment. The methods and different devices applied during
treatment not only allowed to eliminate the complications, but
also provided the possibility of treatment of all patients on outpatient basis.
2ESULTS
In all cases we were able to obtain good anatomic, functional
and cosmetic treatment result: good: 94,6%, satisfactory - 5,4%.
#ONCLUSION
Thus, multifunctional character of Ilizarov device and its different
modifications, possibility for gradual correction, sparing regimen
of treatment by the method of transosseous osteosynthesis
allows for achieving of the treatment task.
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%842!24)#5,!2&2!#452%3/&(5-%253
0RINCIPAL!UTHOR Tartaglia, Nicola, MD
CENTRE Ospedale San Paolo Di Bari
AUTHORS 1Corina, Gianfranco, MD; 2Scattarella, Fabio, MD;
1
Marsilio, Antonio, MD; 1Rollo, Giuseppe, MD; 2Gismondi,
Tommaso, MD
CENTRES 1Ospedale Vito Fazzi Di Lecce; 2Ospedale San Paolo
Di Bari
COUNTRY Italy
2ESUME
Extrarticular displaced fractures of the humerus have different
options of treatment: conservative treatment with a plaster cast
after manipulation, ORIF, intamedullary nails and external fixation
(ex-fix).
However, while conservative treatment spares the patient from
having surgery, it keeps the fracture unstable and it needs a
long period of immobilization often producing a stiff elbow and
shoulder at the end of treatment. ORIF and intramedullary nails
are good surgical solutions to obtain stable reduction but they
are often aggressive surgical ways which do not spare the
patient from a second surgery under total anaesthesia to remove
the metalwork.
Ex-fix is a minimally invasive surgical technique with good
functional outcome.
We present 20 cases of extrarticular fractures of the humerus
(proximal, middle shaft and distal third; transverse, oblique and
comminuted) treated with the Orthofix Monolateral External
Fixator in two hospitals (same protocol) in the South of Italy (Bari
and Lecce).
Results where assessed by quality of reduction (post-op
x-ray), time spent in surgery, healing time (monthly x-rays),
complications (infections, late consolidations, non-union,
metalwork mobilization), functional outcome of upper arm
(weekly Constant Score), compliance of patient (patient’s
questionnaire).
All surgeries were performed within 30 minutes. Fractures
healed within 3 months (time of fixator removal) with good
functional outcome and high compliance for patients who
appreciated having the upper limb free to move with minimal
pain during healing. No complications were observed apart from
one late consolidation (6 months).
Authors believe that monolateral ex-fix of extrarticular fractures
of the humerus is a good surgical option: it offers the benefit
of obtaining stable reductions with quick minimally invasive
surgery, it allows fixator removal under local anaesthesia and
restores high functional outcome with good patient compliance.
225
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APPLICATION OF EXTERNAL FIXATOR IN FRACTURES OF THE
DISTAL RADIUS
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!$6!.4!'%3/&-/./,!4%2!,&)8!4)/.).500%2
%842%-)492%#/.3425#4)/.
0RINCIPAL!UTHOR Iriarte Vincenti, Sergio, MD
CENTRE Department of Orthopedics and Traumatology Clínica del
Sur
COUNTRY Bolivia
0RINCIPAL!UTHOR Khmyzov, Sergey, MD
CENTRE Institute of Spine and Joint Pathology
AUTHORS 1Harbuzniak, Irina, MD; 2Tikhonenko, Alexander, MD
CENTRES 1Institute of Spine and Joint Pathology; 2Genesis Clini
Simferopol
CoUNTRY Ukraine
)NTRODUCTION
The fractures of the distal end of the forearm are more frequent
in adults than in children. In the last decades there has been a
bigger concern about the classification, the treatment and the
rehabilitation of these fractures, since the sequels that they
leave are reason of great concern, especially in young people
and for the working laws. The indications of monolateral external
fixator were necessary.
-ATERIALANDMETHOD
The patients treated with Monolateral External Fixator in our
Department, presented unstable or Intra-articular fractures of
the distal end of the radius, accompanied or not of fracture of
the ulnar styloid, they corresponded to the types: V to VIII of
the classification of Frykman or: 2.3 A-3, C-1, C-2, C-3 and
exceptionally type B-3 of the Classification of Müller from the
AO. Other indications were: Loss of the reduction of the fracture
with other methods, exposed fractures and bilateral fractures.
We use monolateral Fixator with four penetration points, two in
the lower shaft of the radius and two in the second metacarpal.
In some cases there was necessity to fill the space with
cancellous iliac bone graft. In most of the cases the maintenance
of the reduction was carried out distraction and stabilization
with the monolateral fixator. In some cases we used additional
Kirschner wire or screws.
The treatment of 146 patients was analyzed, 10 of them
presented bilateral fracture, in total 156 wrist fractures, from
April 1993 to April 2010; the age variation was from 16 to 81
years old with a 35 year old age average. Man prevalence 86%.
In all of them were carried out clinical and radiological exam.
2ESULTS
Consolidation in 100% of the cases; deformity absent or discreet
95%; functional result: excellent or good 75%; time of treatment
from 6 to 8 weeks; time of consolidation 6 weeks.
$ISCUSSIONANDCONCLUSION
The method determines good stability; good control of the forces
of lateral angulation and torsional deformity, the elasticity of
the assembly favors the formation of bone callus, possibility
of controlled traction, early mobilization, and short time of
treatment.
226
2ESUME
The circular ExFix has the best reposition features, but they are
cumbersome and sometimes eliminate ROM.
Aim and purpose of the study is to work out monolateral
multifunctional ExFix for the realignment of upper extremities
deformities.
-ATERIALANDMETHODOLOGY
The study was based on the treatment results of 139 patients
with 63 humeral and 103 forearm correction and lengthening
procedures. Mean age was 12.5 years old (from 8 to 15 y.o.).
The average lengthening was 4,2 cm (ranged from 3 to 14
cm) on humerus and 3,5 cm (ranged from 2,5 to 10 cm) for
forearm. Monolateral originally designed halfpin ExFix were used
for all cases. The frame of this ExFix allows providing precise
correction and lengthening. The mean healing index (HI) was 27
days for humerus and ulna, 29 days for radius.
$ISCUSSION
The most important problem for any deformity correction is
joint stiffness development. Massive circular frame restricts
ROM while fixing on the proximal humerus. Standard variants
of monolateral halfpin devices do not allow perform precise
correction. The special negative feature of circular ExFix used
for forearm deformity correction is the absence pro-supine
movement within fixation period and their restriction after ExFix
removal. Separate fixation of ulna and radius allows continuing
pro-supine movements within all the treatment period. The
results of treatment of 139 patients were the obtaining of
planned correction and lengthening in all cases with average
restriction of ROM for shoulder no more than 25 degrees and no
significant pro-supine contractures for forearm.
#ONCLUSIONS
The use of monolateral originally designed halfpin ExFix for the
purpose of upper limb realignment and lengthening shows good
anatomical and functional results.
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0RINCIPAL!UTHOR Shemshaki, Hamidreza, MD
CENTRE Al-Zahra University Hospital/MD
AUTHORS Dehghani, Mohammad, MD; Eshaghi, Mohammad
Amin, MD; Laripour Tehranfar, Amirreza, MD
CENTRE Al-Zahra University Hospital
COUNTRY Iran
0RINCIPAL!UTHOR Zuluaga Botero, Mauricio, MD
CENTRE Hospital Universitario del Valle
AUTHORS Persico, Federico, MD
CENTRE Hospital Universitario del Valle
CoUNTRY Colombia
!IM
A glass injury to the wrist and forearm is a common condition
in adult and children that may cause significant discomfort and
disability. We evaluated the accuracy of the preoperative clinical
examination in depicting lesions of the tendons, arteries, and
nerves caused by penetrating wounds of the volar or dorsal
sides of the wrist or forearm, with surgical exploration expansion
as the standard reference.
-ETHODS
One hundred and fifty patients with glass injury to the wrist and
forearm enrolled in this study and each patient gave written
informed consent. After patient’s data registration, careful
clinical examination and routine exploration without expansion of
wound was done by orthopaedic specialist and in the operation
room surgical exploration was done by the same surgeon. The
evaluated information was obtained and compared before and
after operation.
$ISCUSSION
Despite the enough accuracy of preoperative examination in
glass injury of dorsal side of wrist and forearm (p < 0.05),
the preoperative examination significantly underestimated
the amount of damage to tendons, nerves and arteries on the
volar side of forearm and wrist (p < 0.05). The most frequent
soft tissue lesions were the flexor digitorum superficialis 60%,
median nerve 18% and Flexor carpi ulnaris 16% on the volar
side and Extensor digitorum tendons on the dorsal side of
forearm and wrist.
2ESUME
Cubitus varus is the most common complication of
supracondylar fractures in children.
In general, function is not affected, and the correction is
performed for cosmesis.
Cubitus valgus is the result of a mal-united lateral condyle
fracture. The most frequent indications for surgical management
are: pain, instability, decreased function or cosmesis.
There is little information about the preoperative evaluation,
surgical techniques and the outcome achieved in these
procedures.
We analyze 6 patients who underwent a reconstructive surgery
around the elbow in a 4 year period with a follow up of 18
months. The diagnoses were 4 supracondylar fractures and 1
fracture of the medial condyle, with an average period of 5 years
between trauma and reconstruction. The procedures were 5
dome and 1 lateral closing wedge osteotomy. The most frequent
complication was transient ulnar neuropraxia, functional
outcome evaluated with the Mayo Clinic functional score was
more than 90 points in 5 out of 6 patients.
The reconstruction surgery around the elbow is in constant
evolution, there are few reports about these topics and there is
not a gold standard to choose the reconstructive procedure. You
should individualize every patient to ensure the best functional
result avoiding associated complications.
#ONCLUSIONS
It seemed that the preoperative examination, even when
specifically evaluating for deficiencies in dorsal side of wrist
and forearm, significantly underestimates the extent of glass
injury to volar side. So precise surgical evaluations considered
in patients with glass injury especially in patients with volar side
injuries.
227
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WITH EXTERNAL FIXATOR
0RINCIPAL!UTHOR Marchesini Reggiani, Leonardo, MD
CENTRE Istituto Ortopedico Rizzoli
AUTHORS Antonioli, Diego, MD; Lampasi, Manuele, MD; Bettuzzi,
Camilla, MD; Di Gennaro, Giovanni Luigi, MD; Donzelli, Onofrio, MD
CENTRE Istituto Ortopedico Rizzoli
COUNTRY Italy
2ESUME
Chronic Monteggia lesion in child are quite rare but is not
uncommon the misdiagnostic of the radial head luxation in the
emergency room. Many different treatment options have been
proposed for the treatment of the chronic Monteggia lesions.
Some authors suggest the radial shortening osteotomy with the
anular ligament reconstruction but results are not always good.
Exner in 2001, published the results of a 2 cases of chronic
Monteggia lesions treated with ulna lengthening using an
external fixator. This technique is made into two steps: the first
step in which he perform ulnar osteotomy and the application
of a ulnar external monoaxial fixator to progressive lengthening
the ulnar bone. Then the radial head can regain enough space to
reduce cruently with the reconstruction of the anular ligament or
incruently with an angulation of the external fixator. We perform
this technique in 5 cases with good results in 4 patiens.
In conclusion, external fixator to progressive lengthening ulna
can be a valid option in the treatment of chronic Monteggia
lesions.
228