Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 %84%2.!,&)8!4)/.).42%!4-%.4/&#(),$2%.&2!#452%3 .......................................................................................................................................................................................... 206 Podium #/22%#4)/./&,/7%2%842%-)49$%&/2-)4)%3).0%$)!42)#0!4)%.4353).'4(%0!,%9"!,4)-/2%-!,!,)'.-%.44%34............................... 206 Podium %84%2.!,&)8!4)/.-%4(/$&/24(%42%!4-%.4/&-5,4)0,9).*52%$#(),$2%. .................................................................................................................................. 207 Podium USE OF ORTHOFIX RAIL FIXATORS FOR LENGTHENING LONG BONES ............................................................................................................................................................................... 207 Podium 4(%).&,5%.#%/&$)2%#4!.$).$)2%#4,/!$).'/.4(%42%!4-%.47)4(4(%),):!2/6&)8!4/2 .............................................................................................. 208 Podium !30%#)!,$2),,'5)$%&/20%2#54!.%/53-5,4)$2),,).'/34%/4/-9&/2,)-",%.'4(%.).'................................................................................................ 208 Podium ,%.'4(%.).').$%8!.!,93)3).0!4)%.4342%!4%$7)4(),):!2/6-%4(/$.................................................................................................................................................... 209 Podium (/7#!.9/5$%4%2-).%4(%4)-).'/&2%-/6!,/&4(%%84%2.!,&)8!4)/.-%#(!.)#!,%6!,5!4)/."9!% ........................................................ 209 Podium !.!4)/.!,3526%9/&).3425-%.43(!20%.).''5)$%,).%3 ..................................................................................................................................................................................... 210 Podium #/-0!2)3/."%47%%.&5,,9)-0,!.4!",%-/.)4/2/3%$!.$-%#(!.)#!,$)342!#4)/..!),3!-!4#(%$0!)23!.!,93)3 ......................... 210 Podium INTERNAL LENGTHENING PLATE ................................................................................................................................................................................................................................................................... 211 Podium 4(%),):!2/6-%4(/$)../.5.)/./&,/.'"/.%&2!#452%3 .................................................................................................................................................................................. 211 Podium NEUROPATIC PAIN IN LENGTHENING BONE ........................................................................................................................................................................................................................................... 212 69 Podium /54#/-%/&3).',%34!'%42%!4-%.4/&#(2/.)#/34%/-9%,)4)3...................................................................................................................................................................... 212 Podium $)3,/#!4)/.!.$#/-0,%8&2!#452%3/&+.%%42%!4-%.47)4(!.%72!$)/,5#%.4!24)#5,!4%$%84%2.!,&)8!4/2 ................................... 213 Podium ,/7%2,)-",%.'4(%.).'"9),):!2/64%#(.)15%!.$,%.'4(%.)'/6%2.!),!#/-0!2!4)6%345$9 ................................................................................ 213 Podium 4(%53%/&(9"2)$%84%2.!,&)8!4/23).02/8)-!,4)")!&2!#452%3 ............................................................................................................................................................... 214 Podium 47%.494(/53!.$!00,)#!4)/.3/&5.),!4%2!,$()'(-/"),%%84%2.!,&)8!4)/.3934%- .................................................................................................... 214 Podium #/.6%23)/.&2/-4%-0/2!29%84%2.!,&)8!4)/.4/$%&).)4)6%&)8!4)/.7(%.!.$(/7........................................................................................................... 215 Podium 4%-0/2!29%84%2.!,&)8!4)/./&0),/.&2!#452%3!.$4)-).'/&3/&44)335%42%!4-%.4..................................................................................................... 215 Podium )-.!),63#)2#5,!2&2!-%3#/-0!2)3/./&&!#4/23).&,5%.#).'&2!#452%(%!,).'/&/0%.4)")!,&2!#452%3 ........................................... 216 Podium 6!,)$!4)/.!.$!##52!#9/&4(%43&).4(%(4//.3!7"/.%302%3%.4!4)/.3/&!#,).)#!,#!3%345$9/.#/-054%2 HEXAPOD ASSISTED ORTHOPEDICS SURGERY (CHAOS).............................................................................................................................................................................................................. 216 Podium #)2#5,!2%84%2.!,&)8!4)/.-%4(/$&/2#/-0/5.$&%-52&2!#452%).$!-!'%#/.42/,/24(/0%$)#30%230%#4)6% ............................ 217 Podium %-%2'%.#934!"),):!4)/./&5.34!",%0%,6)#&2!#452%37)4(3502!!#%4!"5,!2#/-02%33)/.%84%2.!,&)8!4)/.................................... 217 Podium &5.#4)/.!,/54#/-%/&0%,6)#2%#/.3425#4)/.).!$5,43"90%,6)#3500/24/34%/4/-97)4(),):!2/6-%4(/$ .......................................... 218 Podium 34!'%$%84%2.!,&)8!4)/.42%!4-%.4!&4%23%6%2%7!2).*52)%34/%842%-)4)%3 ......................................................................................................................... 218 Podium %84%2.!,&)8!4)/.#/-").%$7)4().4%2.!,&)8!4)/.).42%!4-%.4/&6%24)#!,,95.34!",%0%,6)#&2!#452%3 ................................................ 219 Podium -).)-!,,9).6!3)6%&)8!4)/./&!#%4!"5,!2&2!#452%3 ............................................................................................................................................................................................... 219 Podium ")/-%#(!.)#!,"!#+'2/5.$&/2%84%2.!,42!.30%$)#5,!2&)8!4)/.).30).!,$%&/2-)49#/22%#4)/.................................................................... 220 Podium #522%.4!002/!#(%34/4(%42%!4-%.4/&0!4)%.437)4(3#/,)/3)3 ............................................................................................................................................................. 220 Podium !00,)#!4)/./&%84%2.!,42!.30%$)#5,!2&)8!4)/.&/230).!,$%&/2-)4)%3 ......................................................................................................................................... 221 Podium TRUELOK EXTERNAL FIXATION FOR RECONSTRUCTION SURGERY ON THE SPINE ................................................................................................................................................... 221 Podium #,/!#!,%8342/0(942%!4%$"90%,6)#/34%/4/-9!.$%84%2.!,&)8!4)/. .............................................................................................................................................. 222 Podium %84%2.!,&)8!4)/.&/2-!.!'%-%.4/&#/-0,)#!4)/.3!33/#)!4%$7)4(-53#5,/3+%,%4!,45-/23!.$2%,!4%$352'%29 ............... 222 Podium 42%!4-%.4/&2%#522%.4')!.4#%,,45-/2!.$/2!''2%33)6% ....................................................................................................................................................................... 223 Podium -!.!'%-%.4/&')!.4#%,,45-/2'#47)4(),):!2/62).'&)8!4/2 .............................................................................................................................................................. 223 Podium 2%#/.3425#4)/./&"/.%).4(%$%&).)4)6%42%!4-%.4/&45-/23................................................................................................................................................................... 224 Podium !00,)#!4)/./&42!.3/33%/53/34%/39.4(%3)3).42%!4-%.4/&0!4)%.437)4($)3%!3%3!.$).*52)%3/&500%2,)-" ............................ 225 Podium -/./,!4%2!,%84%2.!,&)8!4)/.).42%!4-%.4/&%842!24)#5,!2&2!#452%3/&(5-%253 .................................................................................................... 225 Podium APPLICATION OF EXTERNAL FIXATOR IN FRACTURES OF THE DISTAL RADIUS ........................................................................................................................................................... 226 Podium !$6!.4!'%3/&-/./,!4%2!,&)8!4)/.).500%2%842%-)492%#/.3425#4)/. ........................................................................................................................................ 226 Podium !##52!#9/&4(%02%/0%2!4)6%#,).)#!,%8!-).!4)/./&',!33).*5294/4(%72)34!.$&/2%!2- ............................................................................... 227 Podium #/22%#4)6%/34%/4/-9&/20/3442!5-!4)#$%&/2-)4)%3!2/5.$4(%%,"/7 ....................................................................................................................................... 227 Podium 42%!4-%.4/&4(%#(2/.)#0%$)!42)#-/.4%'')!,%3)/.7)4(%84%2.!,&)8!4/2............................................................................................................................... 228 70 Podium 4(%-).)-!,,9).6!3)6%5.)6%23!,%84%2.!,&)8!4/2 &%-)5)./0%.4)")!,&2!#452%3 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 $%&/2-)4)%3 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 Podium &)8!4/2!33)34%$0,!4).' #/-").!4)/./&&)8%8!.$!.',%34!",%0,!4).'). /34%/4/-)%3/&4(%,/7%2,)-" 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. $ISCUSSION Angle stable plates offer similar opportunities as external fixators in osteotomies of lower extremities e.g. correction with translation in the osteotomy, minimal invasive techniques, avoiding of bone grafting (Pfeil et al. Orthopäde 2000 Jan; 29(1): 47-53). Nevertheless, the possibility of management of the bone fragments is limited with the modern angle stable plate systems. In this study we could achieve similar accuracy of correction as in other fixator assisted methods. #ONCLUSION Fixator assisted plating combines the advantages (versatility and accuracy) of external fixators with the advantages of internal fixators (patient comfort). 78 Podium 4)")!,2%#/.3425#4)/.7)4(53%/&!-/./,!4%2!, %84%2.!,&)8!4/2!.$!.).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. Podium $)342!#4)/./34%/'%.%3)3&/24(%42%!4-%.4/& #/3-%4)#,%',%.'4(%.).'53).'!-/./,!4%2!, %84%2.!,&)8!4/24(%!54(/23/7.4%#(.)15% Podium RADIOGRAPHIC CLASSIFICATION OF HALF PIN/ BONE ).4%2&!#%2%!#4)/.).).&%#4%$0/3442!5-!4)#4)")! $%&%#4342%!4-%.453).'-/./,!4%2!,&2!-%3 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 Podium 4(%53%/&!.4)")/4)#)-02%'.!4%$#%-%.430!#%23). 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).' !#/.42/6%23)!,$)3#533)/./&34!4%/&4(%!24 PROCEDURES Podium 42%!4-%.4/&-!33)6%"/.%,/33!&4%2/%34%/-9%,)4)3 4)")!"9-%$)!,&)"5,!242!.30/242%0/24/&4(2%% 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 Podium 42%!4-%.4342!4%'9&/2/34%/-9%,)4)353).'%84%2.!, FIXATOR Podium 4(%2%,!4)/.3()0"%47%%.4)-%4/352')#!,$%"2)$%-%.4 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. Podium 3502!!.$).&2!45"%2/3)494)")!,/34%/4/-9!.$ %84%2.!,&)8!4)/.&/2#/22%#4)/./&#/-0,%84)")!, $%&/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 EXTERNALTIBIALTORSIONBETWEENANDTIBIALVARUS 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 Podium -/./,!4%2!,%84%2.!,&)8!4)/.).4(%42%!4-%.4/& ,/7%2,)-"$%&/2-)4)%3)./,,)%23$)3%!3% 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 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. Podium 3%'-%.4!,4)")!,&2!#452%342%!4%$7)4(4(%),):!2/6 -%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 ()'(4)")!,!.$$)34!,&%-/2!,/34%/4/-953).' 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 !#54%#/22%#4)/./&&%-/2!,!.'5,!2$%&/2-)4)%3"9 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)!,$%6)!4)/.3 0RINCIPAL!UTHOR Salameh, Ghassan, MD CENTRE Center for Limb Lengthening and Reconstruction AUTHORS Schmidt, Michael, MD CENTRE Center for Limb Lengthening and Reconstruction COUNTRY Syria 2ESUME For the treatment of limb lengthening and correction of axial deviations a special external hinge distraction system has been developed, which allows the combined Treatment of congenital and acquired complex deformities of lower and upper limbs. Since 1995 to 2009 this new system was used in 450 patients with deferent indications in the lower limbs they presented with limb length discrepancies and axial deviations. The External Fixation Hinge System/SLDF1; Salamehfix 1/; is an arch hinged system consists of arches with a various diameters and perimeters, to assemble the deferent sizes of the limb in the upper and distal part with connecting special hinges, deferent sizes of arcs to choose a special size for each patient with keeping an excellent technical functions; multiplanar multidirectional corrections; makes the fixator more suitable to each patient in size and allows the patient to move his joints freely, Stable fixation because of insertion wires and screws in nearly right angels, the insertion of wires and half pens in a minor painful regions makes the tolerance to the fixator is more acceptable. X- Ray control is easy. Complications where mostly superficial pin infections. No nerve or vascular injuries. The new developed hinges are easy to use and allow the treatment of complex deformities with lengthening. Podium &)8!4/2!33)34%$.!),).'&!. 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 &)8!4/2!33)34).'.!),).'&/2$)34!,&%-52 $%&/2-)49#/22%#4)/. 0RINCIPAL!UTHOR Luzzi, Richard, MD CENTRE Hospital Universitario Cajaru AUTHORS De Paula, Lucio, MD; Mariuba, Eduardo, MD CENTRE Hospital Universitario Cajaru COUNTRY Brazil 2ESUME Fixator assisting nailing (FAN) is a technique used for acute deformity correction, helping to facilitate rehabilitation, minimizing morbidity of external fixator during bone healing. We analyzed retrospectively charts of 12 patients (13 segments) submitted to distal femur correction using FAN from February 2009 to January 2010. In all of them, CORA was located at metaphysis or epiphysis, and deformities were secondary to rickets, polio or post-trauma, in adult patients (18 to 26 years old). Initial averages were for angular deformity 20.97º±7.71º, and for translation 8,14mm±15,46mm. Half pins, manually inserted parallel to posterior cortex, two proximally and two distally to a metaphyseal percutaneous osteotomy, to not interfere with insertion of retrograde femoral nail (DFN®, Synth es-USA; CentroNail Supracondilar®, Orthofix-Italy) after acute deformity correction. To temporarily stabilize correction, a modular external fixator was used (Large External Fixator®, Synthes-USA; PreFix®, Orthofix-Italy). X-rays were taken right after nail insertion and ex-fix removal, and averages were for angular deformity 0.84º±2.47º (P<0.001), and translation 1,15 mm±2,82 mm. After bone healing, averages were for angular deformity 2.85º±4.11º (P<0.001 when compared with initial deformity and P>0.05 when compared with post operative deformity), and translation 1,23 mm±2,8 mm. All osteotomies healed and no infection was observed. In conclusion, FAN is a very precise method for acute deformity correction in distal femur, and nails were able to maintain correction until bone healing occurs. 125 Podium 0,!..).'/&,/7%2$%&/2-)49#/22%#4)/.7)4( PROFESSIONAL GRAPHIC SOFTWARE (CORELDRAW GRAFHIC SUITES X 4) Podium 42%!4-%.4/&,!4%.%',%#4%$!$5,4$)3,/#!4)/. 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 Podium 42%!4-%.4/&,%''#!,6%0%24(%3$)3%!3% #/-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. Podium 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. $ISCUSSION Results were followed at the intervals from 1.5 to 8 years. Clinical evaluation according to Colton criteria was as follows: good result (13-15 points)-43 joints, satisfactory ones (10-12 points)-20 joints, poor outcomes (less than 10) were in 5 joints. The joints were distributed according to CSeverin criteria as follows: II type-56 joints, III type-9 joints, IV type-3 joints. In there joints the signs of III grade arthrosis according to Tonnis were revealed. The ration of good results made up 63.2% and the poor ones was 8.8%. #ONCLUSIONS The application of transosseous osteosynthesis technologies allows to extend up to certain range the indications for reorienting reconstructive operations, to provide sufficient mobility of the acetabular fragment without increase of technical complexity and invasiveness and to create the conditions for adaptation of the articular surfaces after restoration of articular relations. 127 128 Podium ),):!2/642%!4-%.4/&3,)00%$#!0)4!,&%-/2!, EPIPHYSIS IN ADOLESCENTS Podium ),):!2/642%!4-%.4/&0!4)%.437)4( ,%''#!,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. Podium ),):!2/62%#/.3425#4)/./&4(%&%-52!342%!4-%.4 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. Podium !242/$)!34!3)3).$)3%!3%/&,%''#!,6³0%24(%3 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 Podium /54#/-%/&()02%#/.3425#4)/./34%/4/-9 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 Podium 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. Podium 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. Podium 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. $ISCUSSION Open leg fractures considered “very serious” are commonly referred to as “III-B or III-C according to Gustilo-Anderson, however, sometimes the fracture pattern is not always complex, being in these cases, better prognosis than those which have severe comminution, including bone loss, and vice versa, also the soft tissue damage is not always as severe. The classification served to clarify the risks and complications on regard to the procedures of reduction and bone fixation, and the achievement of coverage. For all fracture patterns and grades of injury, the disposable external fixation method was sufficient. #ONCLUSIONS From the 34 fractures, one patient was attended after 18 hours of the accident in a state of distal ischemia, and ended in amputation. Sixteen patients were offered an “early therapeutic amputation” and was accepted only by four. The 29 patients followed the protocol reconstruction. A patient of 75 years, cured, died five years later. All consolidated between 8 and 29 months, mean 13.96 months, without infection, without deformities. Fourteen remained with shortening, two with three centimeters, six with two centimeters, and six with one centimeter. Ten cases in shortening then continued their elongation, three cases of transportation. Eleven cases with dysfunction ankle. In none was made micro-vascular free flaps. Currently, 28 patients, even scarred are working in different jobs and are totally satisfied with their rebuilt legs. 131 Podium /0%.).'&/#!,$/-%/34%/4/-9).4(%-!.!'%-%.4/& 6!253'/.!24(2/3)3!33/#)!4%$7)4(-%$)!,,!8)49 Podium (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¢P 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. Podium ")/,/')#!,&)8!4)/./&3%'-%.4!,&2!#452%3/&4)")!"9 ILIZAROV FIXATOR Podium 42%!4-%.4/&,%'/0%.&2!#452%37)4(!. (/-/'%.%/5302/4/#/, 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 Podium ),):!2/6$/-%()'(4)")!,/34%/4/-9&!#4/23,%!$).' TO RELIABLE RESULTS Podium 53%/&!$5,4-%3%.#(9-!,34%-#%,,3).,)-" 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. Podium !54/,/'/53"/.%-!22/7'2!&4).4(%-!.!'%-%.4 OF PERCUTANEOUS FRACTURES TREATED WITH EXTERNAL &)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 /34%/'%.%3)3&/2$)342!#4)/.-!22/7 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. $ISCUSSION The duration of the smear was on average 11.51 sem, being the youngest of five sem and 30 sem largest. Achieved elongation was 59.5 mm with a range of 20-135 mm. Corticalizacion was on average 28.81 weeks between 5 and 65 weeks. The complication more frequent was the superficial infection, axial deviations, algodistrofia, venous vascular insufficiency, periostitis, fracture by fall. Some patients underwent surgery as a result of complications. #ONCLUSIONS This procedure allows us to improve the quality of life of the patient and to optimize their performance in everyday life, prevents or lower inherent in the limb loss of Member complications that arise if it is that you are not given treatment is different. The procedure is feasible to do this on an outpatient basis, so home conditions permitting. It is imperative to have permanent Fisica therapy +EYWORDS Autologous bone marrow graft, delayed consolidation, fractures, external fixator. 135 Podium %.(!.#%$"/.%(%!,).'"9,/#!,).&53)/./&&'&!.$ BISPHOSPHONATE DURING DISTRACTION OSTEOGENESIS Podium #/-0,)#!4)/.3/&$)&&%2%.4"/.%'2!&4).' 4%#(.)15%3!#/.42/6%23)!,$)3#533)/. 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 -5,4),%6%,")/%.').%%2).'%80%2)%.#%/&#,).)#!,53% 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. Podium %.(!.#%-%.4/&"/.%(%!,).'$52).'$)342!#4)/. /34%/'%.%3)37)4(0,!4%,%432)#(0,!3-!020 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 Podium 42%!4-%.4/&).&%#4%$).42!#!035,!2 PSEUDARTRHOSIS OF THE DISTAL TIBIA Podium 42%!4-%.4/&).&%#4%$$%&%#4)6%./.5.)/."9 6!3#5,!2):%$"/.%'2!&4!.$),):!2/6-%4(/$ 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 Podium 4(%43&$%6)#%).#/-0,%8&2!#452% ./.5.)/.-!,5.)/.!.$).&%#4)/./& &2!#452%2%0/24/&#!3%3 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 Podium 4(%42%!4-%.4/&4)")!,3%04)#./.5.)/.7)4( %84%2.!,&)8!4)/./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 /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. Podium 42%!4-%.4/&3%04)#03%5$/!24(2/3)3/&4(%4)")!7)4( INTERTIBIO FIBULAR GRAFT, REVIEW OF 52 CASES Podium 3%04)#./.5.)/.42%!4-%.47)4(-/./,!4%2!, 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. 141 Podium 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. 142 Podium 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. Podium !.%74%#(.)15%&/2"2!#(9-%4!4!23)!2%0!)27)4( #/.#/-)4!.4!24(2/$)!4!3)3 Podium 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 Podium 352')#!,-!.!'%-%.4/&#,5"&//4).#(),$2%. /&3#(//,!'%"94(%-%4(/$/&42!.3/33%/53 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 Podium -%4!4!23!,,%.'4(%.).'&/2"2!#(9-%4!4!23)!! 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. Podium !00,)#!4)/./&),):!2/64%#(.)15%).#/22%#4)/./& 34)&&&//4$%&/2-)49#/-").%$7)4(3+).3#!2 Podium &)"5,!2(%-)-%,)!-!'.%4)#2%3/.!.#%)-!').'63 2!$)/'2!0(94/$%4%2-).%&//4$%&/2-)4942%!4-%.4 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 Podium !#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 Podium 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)))RDCASESOFTHE Group 4 to one case, Group 4 b five cases, Group 3 one case. s 3EQUELOFEXPOSEDFRACTURESOFFOOTOFTHE)))RD'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. Podium CLINICAL ANALYSIS OF 107 PATIENTS WITH FOOT AND ANKLE $%&/2-)4)%3#!53%$"930).!")&)$! Podium ,)-"2%#/.3425#4)/./2!-054!4)/.&/23%6%2% &)"5,!2$%&)#)%.#9!47/#%.4%2#/-0!2)3/. 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 Podium %,/.'!4)/."/.9).!&4%2-!4(/&0/,)/ Podium 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. Podium $!-!'%#/.42/,)./24(/0!%$)# 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. Podium 4(%-!.!'%-%.4/&0%,6)#&2!#452%37)4(%84%2.!, &)8!4)/./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 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 Podium $!-!'%#/.42/,/24(/0%$)#-!.!'%-%.4/& 0/,942!5-! Podium 42%!4-%.4/&&2!#452%3/&4(%0%,6)3).3%6%2% -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 Podium 3%'-%.4!,,)&4&%-5245"5,!22!),&)8!4/242%!4-%.4 OF CHOICE Podium !.%7$%3)'.-5,4)&5.#4)/.$9.!-)#%84%2.!,&)8!4/2 3934%-&/2"/.%2%#/.3425#4)/.3 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 Podium 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 Podium 0!).3#/2%3/.2%-/6!,/&),):!2/6&2!-%3).#,).)# 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 Podium ).4%242/#(!.4%2)#/34%/4/-9).#(),$2%.!.$ !$/,%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 Podium $%2/4!4)6%/34%/4/-9).#(),$2%."9-%!.3/& 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 02/'2%33)6%#/22%#4)/./&2%#526!45-!.$6!,'53 $%&/2-)49!&4%2!39--%42)#!,'2/74(!22%34/& 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 Podium 4(%$/5",%%,%6!4)/./34%/4/-9&/23%6%2%",/5.43 $)3%!3%53).'4(%4!9,/230!4)!,&2!-% Podium '5)$%$'2/74("9%)'(40,!4%&/2#/22%#4)/./& !.'5,!2$%&/2-)4)%3!2/5.$4(%+.%% 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 42!.3&/2-).'/&"2)$').'*/).4&2!-%).4/$9.!-)# &2!-%$52).').42!!24)#5,!2&2!#452%42%!4-%.4 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 Podium 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. 158 Podium /54#/-%/&$/5",%&%-/2!,/34%/4/-)%3&/2()0 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. Podium 42%!4-%.4/&()0$%&/2-)49!.$0%,6)#/",)15)49 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. 159 Podium -!.!'%-%.4/&#/-0,%8&%-/2!,&2!#452%/54/& 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. 160 Podium ()0&2!#452%3-!.!'%$7)4(%84%2.!,&)8!4)/. 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. Podium %84%2.!,&)8!4)/.63'!--!.!),&/24(%42%!4-%.4 OF OSTEOPOROTIC TROCHANTERIC FRACTURES Podium -5,4)0,!.%%84%2.!,&)8!4)/./&&%-52). 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. 161 Podium 0##0).-!.!'%-%.4&2!#452%342/#!.4%2)#!3 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. Podium 42%!4-%.4/&02/8)-!,()0&2!#452%37)4( -/./,!4%2!,%84%2.!,&)8!4/2 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. 162 Podium ),):!2/6!00,)#!4)/.).4(%-!.!'%-%.4/&#/-0,%8 !#54%&%-/2!,&2!#452%3 Podium (5-%2!,./.5.)/.42%!4-%.47)4( ),):!2/6-%4(/$-5,4)#%.4%2345$9 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 Podium #/22%#4)/./&2!$)!,$%&/2-)4)%3!&4%2'2/74( !22%347)4(4(%4!9,/230!4)!,&2!-% Podium 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. Podium 42%!4-%.4/&(5-%25303%5$/!24(2/3)37)4(),):!2/6 -%4(/$7)4(/54"/.%'2!&4 Podium 42%!4-%.4/&500%2,)-"$%&/2-)4)%3 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. 165 Podium 42%!4-%.4/&(5-%253$)!0(93)3./.5.)/.7)4( 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 Podium 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. Podium 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. Podium %!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 Podium 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 Podium ,%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. Podium &%-/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. Podium +.%%$)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 Podium !.+,%#/-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 Podium !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. Podium 4(%53%/&),):!2/6-%4(/$&/2-!.!'%-%.4/& 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. Podium !.+,%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 Podium #/22%#4)/./&#/-0,%8&//4$%&/2-)4)%3"9 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 Podium !.+,%6!253).#(),$2%.#/22%#4)/."9%8&)8 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. Podium 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. Podium 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 Podium 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. Podium 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 Podium HINGED EXTERNAL FIXATION IN THE UNSTABLE POST 42!5-!4)#!.+,% Podium !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. $ISCUSSION Traditional methods of fixating fifth metatarsal base fractures utilize internal fixation and require prolonged immobilization and nonweightbearing. Using a mini external fixator allows the patient to start weightbearing immediately and does not require any immobilization. All 65 patients healed before six weeks and there were no incidents of delayed or nonunion. The external fixator is extremely stable and counteracts the longitudinal forces of the peroneus brevis. The fixator can also be further compressed during the postoperative period. #ONCLUSION Utilizing a mini external fixator is a superior alternative to traditional methods of fixating fifth metatarsal base fractures. The immediate weightbearing enhances healing and prevents delayed or nonunions. Patients also do not require an incision or have retained internal fixation. 175 Podium #!,,/4!3)3).-%4!#!20!,3!.$-%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 Podium ,)'!-%.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. Podium 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. Podium 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 Podium %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. Podium .%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 Podium %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. Podium 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. Podium #/-").%$4%#(.)15%&/24(%#/22%#4)/./&,/7%2 %842%-)49$%&/2-)4)%3#!53%$"9-%4!"/,)#"/.% 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 Podium 0%#5,)!2)4)%3/&4(%,/7%2,)-",%.'4(%.).'). CHILDREN WITH ACHONDROPLASIA Podium "),!4%2!,3)-5,4!.%/53,%.'4(%.).'/&,/7%2,)-"3). 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 Podium 500%2,)-",%.'4(%.).').!#(/.$2/0,!3)! 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 Podium (5-%2!,,%.'4(%.).'7)4(5.),!4%2!,%84%2.!, 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. Podium %.$/3#/0)#4%#(.)15%&/2"/.%'2!&4).'!4$/#+).' 3)4%$52).'"/.%42!.30/2402%,)-).!292%0/24/& 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. $ISCUSSSION The procedure was possible with good direct vision of the site, small surgical approach and no complications like bleeding or compartimental syndrome. It took 60 minutes in mean time for operative procedure. #ONCLUSIONS The endoscopic approach provided minimal incision, accurate debridement, precise bone grafting, minimal vascular injury to the surrounding tissues, fewer complication, minimal hospital stay, less expensive procedure obtaining rapid bone union. Podium #/-02!3)/./&!#54%#/-02%33)/.2%,%.'4(%.).'!.$ 3%'-%.4!,"/.%42!.30/24&/24)")!03%5$/!242/3)3 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. $ISCUSSION The mean duration of follow-up was 34,9 months (13-80) in group A and 25,6 months (12-66) in group B. The mean external fixation index (EFI) was 1,42 days/cm (1,1-2,3) in group A and 47,23 days/cm (35-108) in group B. The mean simultaneous lenghtening was 7,48 cm (3,5-12) in group A. According to Paley’s bone score we had 17 excellent, 4 good, 1 fair in the group A and 15 excellent, 2 good, 4 poor in group B. According to Paley’s functional socre we had 15 excellent, 6 good, 1 fair score in group A and 10 excellent, 6 good,1 fair, 4 poor in group B. We had 3 problem, 2 obstacles (modification of frame and achille tendon lengthening) and 2 sequelae (LLD > 2.5 cm and recurvatum > 5 degrees) in group A, while 3 problem, 9 obstacles, and 4 sequelae in group B according to Paley’s classification of complication. #ONCLUSIONS The acute compression-relengthening technique may provide improvement on patients satisfaction in appropriate cases, because of the earlier removal of external fixator and low complication rate facilitating more rapid rehabilitation. However, during bone transport surgeons may attend to difficulties and complications more than acute compression technique. 183 Podium 42%!4-%.4&/2./.).&%#4)/53./.5.)/./&45"5,!2 &2!#452%37)4(-/./&/#!,#/-02%33)/.$)342!#4)/. 4%#(.)15% 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 Podium 4(%).42!-%$5,,!29#!",%"/.%42!.30/247)4(4(% 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. Podium 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. Podium 4)")!,"/.%$%&%#43$/%3!47/,%6%,#/24)#/4/-9 2%$5#%4)-%).&)8!4/2 0RINCIPAL!UTHOR Kovoor, Cherry Cheriyan, MD CENTRE Eranakulam Medical Centre AUTHORS 1George, Vv, MD; 2Viswanath, Sabin, MD CENTRES 1Eranakulam Medical Centre; 2Specialist Hospital COUNTRY India !BSTRACT Aim to study if a double level corticotomy reduces the time in ring fixator in tibial bone defects. -ATERIALANDMETHODOLOGY Thirty eight patients were included in the study. They were equally divided into group A, double level corticotomy, and group B, single level corticotomy. The mean age of patients in group A and B were 41 and 29 yrs respectively. The mean bone defects in group A and B were 8.9 and 5.6 cm. All the patients in group A had either two corticotomies in proximal fragment or one corticotomy in proximal and distal fragment. Group B patients all had proximal corticotomies. The ring fixator was removed when there was union of the docking site and consolidation of regenerate and external fixation index [EFI] was calculated by diving the number days in the fixator by the bone defect. 2ESULTS The mean period in the ring fixator for group A was 477.8 days and in group B was 346.4 days. The mean EFI in group A was 69.8 days/cm and in group B was 98.5 days/cm. Five patients in group A had unplanned surgeries while in group B one patient had unplanned surgeries. There was no statistical difference in %&)BETWEENTHETWOGROUPS;P= #ONCLUSION There is no statistically significant differences in EFI with single and double level corticotomies. 185 0/$)5- 42%!4-%.4/&4(%3%'-%.4!,"/.%$%&%#43/&4(%4)")! 7)4(4(%),):!2/63-%4(/$ Podium 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. $ISCUSSION Successfully bone lengthening between 6 and 10 cm. Maintaining range articulate knee. Consolidation of the pseudoartrosis time is twice or more than one bone is not by this pathology. 3 Patients had to perform grafting and osteosynthesis with plate screws and low contact. The focus of pseudoartrosis fracture was presented in 3 patients. #ONCLUSSIONS While successfully solve the problem of the pseudoarthrosis, long-term outcome is uncertain, and therefore has to do serial and continuous controls to limit physical activity and sometimes indicate the use of protection orthotics. Podium ).&,5%.#%/&!54/,/'/53-%3%.#()-!,34%- #%,,3-3#!54/42!.30,!.4!4)/./.$)342!#4)/. OSTEOGENESIS Podium (%!,4(2%,!4%$15!,)49/&,)&%!&4%242%!4-%.4"9 4(%%84%2.!,&)8!4)/./&4(%,/7%2,)-",/.'4%2- RESULTS 0RINCIPAL!UTHOR Shchepkina, Elena A, MD CENTRE Vreden Russian Research Institute of Traumatology and Orthopedics AUTHORS 1Solomin, Leonid N, MD; 2Polyntsev, Dmitry G, MD; 2 Zaritsky, Andrey U, MD CENTRES 1Vreden Russian Research Institute of Traumatology and Orthopedics; 2St. Petersburgs State I Pavlov Medical University COUNTRY Russian Federation 0RINCIPAL!UTHOR Wioleta, Ostiak, MD CENTRE Department of Paediatric Orthopaedics and Traumatology-University of Medical Sciences AUTHORS 1Pawel, Koczewski, MD; 1Milud, Shadi, MD; 2Marek, Napiontek, MD; 2Roma, Krzyminska, MD CENTRES 1Department of Paediatric Orthopaedics and Traumatology-University of Medical Sciences; 2Ortop PolyclinicPoznan; Student CoUNTRY Poland !IM To investigate the influence of MSC on organotypic remodeling of distraction regenerate. 0URPOSE Analysis of long-term health-related quality of life (QOL) restrictions after treatment by external fixation. -ATERIALSANDMETHODS Autologous mesenchymal stem cells (MSC) with phenotype #$#$#$#$#$#$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 Podium RESTRICTIONS ON ACTIVITIES OF DAILY LIVING (ADL) AFTER 42%!4-%.4"94(%%84%2.!,&)8!4)/.,/.'4%2- RESULTS Podium PERIPHERAL NERVE GAP REPAIR BY GRADUAL ELONGATION /&"/4(.%26%345-03%80%2)-%.43).-!#!#! 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. $ISCUSSIONANDCONCLUSION The new method is at the ready to apply in clinical practice. The merits are 1. no need of auto-nerve graft, 2. neurorraphy in single part. Demerits are 1. annoyance using external fixator, 2. several times operations. Podium %&&%#4/&,)-",%.'4(%.).'/.3+%,%4!,-53#,%'%.% EXPRESSION PROFILE Podium 4(%2/,%/&%8/'%."/.%34)-5,!4/2).$%,!9%$!.$ 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 Podium ")/-%#(!.)#!,34!"),)49/&%84%2.!,&)8!4/237)4( 0!2!,,%,!.$7)4(#/.6%2'%.40).3!#/-0!2!4)6% 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. $ISCUSSIONANDCONCLUSION External fixators with pins can have pins in one plane and parallel or pins in different direction. External fixation device with 90 degrees convergent pins gives balanced 3D stability similar to natural long bone biomechanical conditions. Podium 4/0%2&/2!4%/2./4-).)-!,).3%24)/.!.',%3(/5,$ BE 45 DEGREES TO PASS THE TRANS CORTEX WITH K WIRES 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 Podium 342!4%'9&/202%$)#4!",%,/7%2,)-"2%#/.3425#4)/. 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. $ISCUSSION These rare congenital defects are associated with many challenges in terms of very small limb, extreme shortenings (more than 10 cms/50%), complex deformities, non-unions etc. Approaching these corrections is a big challenge. Ring fixator offers the advantage of addressing many of these problems simultaneously but is associated with quite a few difficulties and complications. This study identifies these issues including difficulties in fixator application in small limb, corticotomy, too much of lengthening and long duration of wearing, so that an effective strategy for predictable outcome can be formulated. #ONCLUSIONS In these extremely deformed lower limbs in pediatric age group a successful treatment strategy can be planned with the help of ring fixator. The key is recognizing and being aware of the forthcoming difficulties and problems, and dealing them promptly and timely. Podium !33%33-%.4/&3%6%2%,/7%2,)-"$%&/2-)4953).' 4(2%%$)-%.3)/.!,#/-054%$4/-/'2!0(9 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 Podium #/22%#4)/./&,/7%2%842%-)49$%&/2-)4)%3!&4%2 EPIPHYSEAL INJURY USING EXTERNAL FIXATOR AND ).42!-%$5,,!29'2!$5!,%,/.'!4)/..!),3 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. $ISCUSSION It is difficult to make decision when we perform an operation on a case with growing deformity. We should predict the limb length discrepancy in the future, consider symptoms and also pay attention to the individual social situation. Because the deformity varies, there is no universal strategy. Usually with the complicated deformity, Taylor Spatial Frame is useful which enables us to correct in one step. #ONCLUSIONS We treated 39 limbs of deformity after the epiphyseal injury using external fixators and elongation nail. Because the deformity varies, Taylor Spatial Frame which corrects any kind of deformity simultaneously is valuable. 192 Podium 352')#!,42%!4-%.47)4(!#)2#5,!2%84%2.!,&)8!4/2 &/2,!4%/.3%4",/5.4$)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. Podium 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. Podium 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. $ISCUSSIONS The mean operation time was 28 minutes for one deformity. Intraoperative complications were not observed. Postoperative limitations in the range of movement were lost in one week after surgical intervention. In all cases a complete correction of the deformity was achieved. In one Patient a recurrence of the deformity was seen because of the primar disease, which led to a second treatment with 8-plates. Finally a complete correction could be reached in this case also. After removal of the hardware, after 10 months in mean, no negative influence was seen on the growth plate. #ONCLUSIONS Especially children under the age of 8 will take profit from a guided growth procedure because the disadvantages of osteotomies can be avoided. #ONCLUSIONS The use of AMFPT is a suitable tool for the diagnosis of Blount’s disease, as this is more likely to predict the onset of the disease that AMDPT. 193 Podium 02%.!4!,$)!'./3)3/&#/.'%.)4!,&%-/2!,$%&)#)%.#9 !.$&)"5,!2(%-)-%,)! Podium 2%"/5.$!&4%22%-/6!,/&'5)$%$'2/74(3#2%7 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. Podium 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. 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 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). $ISCUSSIONSANDCONCLUSIONS Results from this study show that external fixator and K-wires are reasonable methods for treating intra-articular fractures of the distal radius. At final follow-up evaluation, patients had mostly excellent results with preserved congruity of the distal radial joint and minimal posttraumatic osteoarthritis compared with patients treated by external fixator only. 195 Podium 42%!4-%.4/&$)34!,2!$)53&2!#452%37)4(%84%2.!, 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 Podium 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 4%22)",%42)!$/&4(%%,"/77)4(-/./,!4%2!, ARTICULATED EXTERNAL FIXATOR Podium 352')#!,42%!4-%.4/&(5-%2!,$)!0(93%!, &2!#452%37)4(%84%2.!,&)8!4)/.7(%.!.$(/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 Podium #/-0,%8,%3)/.3/&4(%%,"/742%!4-%.47)4(!.%7 ARTICULATED EXTERNAL FIXATOR Podium 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. Podium 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 Podium 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. $ISCUSSSION All patients had a good clinical and radiografic results. We can conclude that TSF is a salvage procedure that lead to stabilize the fracture, to mantain the limb lenght and to bridge large bone defects by transferring bone segments. #ONCLUSIONS A multidisciplinary equipe, including orthopaedic and plastic surgeon, is the best way to treat these so difficult and complex cases. 200 Podium ILIZAROV BONE TRANSPORT VERSUS VASCULARIZED FIBULAR GRAFT IN RECONSTRUCTION /&0/3442!5-!4)#4)")!,"/.%$%&%#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 35"34!.4)!4)/./&#/-054%2!33)34%$/24(/ 356&2!-%/04)-5-#/.&)'52!4)/.!4$%&/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 Podium -/./,!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 Podium #/-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 Podium 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. $ISCUSSION The described method was the first attempt of a reconstruction of the previous mentioned deformity with full mobilization of the patient. 204 Podium ).42!!24)#5,!2/34%/4/-9/&4(%$)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 Podium %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 #/22%#4)/./&,/7%2%842%-)49$%&/2-)4)%3). 0%$)!42)#0!4)%.4353).'4(%0!,%9"!,4)-/2% -!,!,)'.-%.44%34 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). $ISCUSSION Using the malalignment test, we were able to determine the where the deformity was and where to perform the osteotomy determined by the CORA, in an easily and reproducible fashion. The LRS was quicker to apply better tolerated in our patients. However, some residual deformity had to be accepted. With the TSF, we were able to correct multiplanar deformities without having to take the patient back to the operating room. In conclusion, we prefer the LRS for uniapical femoral deformities and femoral lenghtenings and the TSF for multiapical deformities and tibial lenghtenings. 206 Podium %84%2.!,&)8!4)/.-%4(/$&/24(%42%!4-%.4/& -5,4)0,9).*52%$#(),$2%. 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 Podium THE INFLUENCE OF DIRECT AND INDIRECT LOADING ON THE 42%!4-%.47)4(4(%),):!2/6&)8!4/2 Podium !30%#)!,$2),,'5)$%&/20%2#54!.%/53-5,4)$2),,).' /34%/4/-9&/2,)-",%.'4(%.).' 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 ),):!2/6-%4(/$ Podium (/7#!.9/5$%4%2-).%4(%4)-).'/&2%-/6!,/&4(% %84%2.!,&)8!4)/.-%#(!.)#!,%6!,5!4)/."9!% 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 Podium !.!4)/.!,3526%9/&).3425-%.43(!20%.).' 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 Podium #/-0!2)3/."%47%%.&5,,9)-0,!.4!",%-/.)4/2/3%$ !.$-%#(!.)#!,$)342!#4)/..!),3!-!4#(%$0!)23 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. Podium 4(%),):!2/6-%4(/$)../.5.)/./&,/.'"/.% 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 Podium 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. Podium /54#/-%/&3).',%34!'%42%!4-%.4/&#(2/.)# /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. Podium $)3,/#!4)/.!.$#/-0,%8&2!#452%3/&+.%% 42%!4-%.47)4(!.%72!$)/,5#%.4!24)#5,!4%$ 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. $ISCUSSION The management of dislocation and complex fractures of the knee has been always troublesome in relation to soft tissue problems (open lesions, dislocations, neurovascular lesions) and or to bone lesions (fragment displacement, comminution, poor bone quality). The use of a bridging fixator as support to soft tissue or bone healing has still some indication in complex trauma but has to be converted in few weeks to another osteosinthesis in order to avoid joint stiffness. An articulated knee external fixator can avoid this complication but has to be designed to cope the biomechanic of this joint. This new device demontrated to be valid in relation to the joint movement, and stability and to the patient tolerance during the treatment of complex articular lesions. Podium ,/7%2,)-",%.'4(%.).'"9),):!2/64%#(.)15%!.$ ,%.'4(%.)'/6%2.!),!#/-0!2!4)6%345$9 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 Podium 4(%53%/&(9"2)$%84%2.!,&)8!4/23).02/8)-!,4)")! FRACTURES Podium TWENTY THOUSAND APPLICATIONS OF UNILATERAL 3D HIGH -/"),%%84%2.!,&)8!4)/.3934%- 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. Podium #/.6%23)/.&2/-4%-0/2!29%84%2.!,&)8!4)/.4/ $%&).)4)6%&)8!4)/.7(%.!.$(/7 Podium 4%-0/2!29%84%2.!,&)8!4)/./&0),/.&2!#452%3!.$ 4)-).'/&3/&44)335%42%!4-%.4 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 Podium )-.!),63#)2#5,!2&2!-%3#/-0!2)3/./&&!#4/23 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. $ISCUSSION 31(100%) fractures in the frame group and 49 (72%) in the IM nail group achieved union. Mean age was 42.4 and 32.4 years in IM nail group and frame group respectively. 35.4% in the frame group (union in 26.6 weeks) and 49% in the IM nail group (union in 33.3 weeks) had co-morbidities. Incidence of superficial infection was 32.3% in frame group and 10.2% in nail group, with union time of 30.2 and 42.4 weeks respectively. In high ENERGYTRAUMAFRAMENPATIENTSTOOKLONGER[WEEKS #)]TOHEALASCOMPAREDTOTHE)-NAILGROUP NWEEKS#)/THERMECHANISMS of injury like twisting, fall from height and direct impact took 29.6, 27 and 23.5 weeks respectively in the frame group and 31, 28.2 and 32.8 weeks respectively in the IM nail group. There was no statistical difference amongst both groups however in the presence of infection, the healing was slower in the IM NAILGROUPP'RADEAANDBOPENFRACTURESINTHE frame group (union in 29.7 and 30.1 weeks respectively) was comparable to the IM nail group (union in 27.6 and 31.2 weeks respectively). #ONCLUSIONS We conclude no statistical difference with regards to time to union although presence of infection delays union which is statistically significant IM nail group. We propose fine fixator is a better treatment option as compared to nail. 216 Podium VALIDATION AND ACCURACY OF THE TSF IN THE HTO ON SAW BONES. PRESENTATIONS OF A CLINICAL CASE STUDY ON #/-054%2(%8!0/$!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. Podium #)2#5,!2%84%2.!,&)8!4)/.-%4(/$&/2#/-0/5.$ &%-52&2!#452%).$!-!'%#/.42/,/24(/0%$)#3 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. Podium %-%2'%.#934!"),):!4)/./&5.34!",%0%,6)#&2!#452%3 7)4(3502!!#%4!"5,!2#/-02%33)/.%84%2.!,&)8!4)/. 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. $ISCUSSION We found that SHF/TSF for complex fractures of the femur combine maximum support for the bone and preservation of soft tissues. SHF/TSF are an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. #ONCLUSIONS The authors advise conversion from TEF to SHF/TSF femoral definitive synthesis in complex fractures. With this technique diaphyseal and distal femoral fractures can be securely stabilized with perfect reduction. 217 0/$)5- &5.#4)/.!,/54#/-%/&0%,6)#2%#/.3425#4)/.). !$5,43"90%,6)#3500/24/34%/4/-97)4(),):!2/6 -%4(/$ 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. Podium 34!'%$%84%2.!,&)8!4)/.42%!4-%.4!&4%23%6%2%7!2 ).*52)%34/%842%-)4)%3 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 Podium %84%2.!,&)8!4)/.#/-").%$7)4().4%2.!,&)8!4)/.). 42%!4-%.4/&6%24)#!,,95.34!",%0%,6)#&2!#452%3 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. Podium -).)-!,,9).6!3)6%&)8!4)/./&!#%4!"5,!2&2!#452%3 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. $ISCUSSION Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard of care provides open reduction and internal fixation (O.R.I.F.) through differentiated surgical approaches which have been associated with relatively high complications rate such as haematomas, superficial and deep infection, and neuro-vascular lesions. Moreover these procedures need long operative times with significant blood loss. To avoid these general and local complications, that sometimes compromise the functional outcome of the operation and the possibility to perform a future arthroplasty, some authors advocated a minimally invasive percutaneous osteosynthesis (MIPO). This approach can also be considered a valid alternative to O.RI.F. in all those cases in which the standard approaches are contraindicated as in open fractures, comminuted fractures in osteoporotic patients or fractures in high risk patients. #ONCLUSION Following the strategy of a low invasive surgery using the a bridging fixator associated to a minimal internal fixation is possible to achieve good reduction and fracture stability in some selected acetabular fractures, avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. 219 Podium ")/-%#(!.)#!,"!#+'2/5.$&/2%84%2.!, 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 Podium #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. $ISCUSSION Acute deformity correction with internal transpedicular fixation was performed in 12 cases, and gradual scoliosis correction with external transpedicular fixation followed by spondylodesis with internal fixation devices produced in 26 patients. All the patients showed good results. Degree of scoliosis correction was 80 to 100%. The achieved result persisted during the follow-up period. Loss of correction at one-year follow-up did not exceed 3%. No complications associated with disturbed stability of the construct occurred. #ONCLUSION Differential approach to spinal osteosynthesis and external transpedicular fixation device in correction of complex multiplanar spinal deformities allows us to achieve effective treatment in the cohort of patients. Podium APPLICATION OF EXTERNAL TRANSPEDICULAR FIXATION FOR 30).!,$%&/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 Podium #,/!#!,%8342/0(942%!4%$"90%,6)#/34%/4/-9!.$ 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. Podium %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 Podium 42%!4-%.4/&2%#522%.4')!.4#%,,45-/2 AND/OR AGGRESSIVE Podium -!.!'%-%.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 Podium 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. Podium 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. Podium -/./,!4%2!,%84%2.!,&)8!4)/.).42%!4-%.4/& %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 Podium APPLICATION OF EXTERNAL FIXATOR IN FRACTURES OF THE DISTAL RADIUS Podium !$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. $ISCUSSION The most important problem for any deformity correction is joint stiffness development. Massive circular frame restricts ROM while fixing on the proximal humerus. Standard variants of monolateral halfpin devices do not allow perform precise correction. The special negative feature of circular ExFix used for forearm deformity correction is the absence pro-supine movement within fixation period and their restriction after ExFix removal. Separate fixation of ulna and radius allows continuing pro-supine movements within all the treatment period. The results of treatment of 139 patients were the obtaining of planned correction and lengthening in all cases with average restriction of ROM for shoulder no more than 25 degrees and no significant pro-supine contractures for forearm. #ONCLUSIONS The use of monolateral originally designed halfpin ExFix for the purpose of upper limb realignment and lengthening shows good anatomical and functional results. Podium !##52!#9/&4(%02%/0%2!4)6%#,).)#!,%8!-).!4)/. /&',!33).*5294/4(%72)34!.$&/2%!2- Podium #/22%#4)6%/34%/4/-9&/20/3442!5-!4)# $%&/2-)4)%3!2/5.$4(%%,"/7 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 Podium 42%!4-%.4/&4(%#(2/.)#0%$)!42)#-/.4%'')!,%3)/. 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