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• Preliminary results of cannulated screw fixation for isolated pubic ramus fractures.

  Authors: Jasper Winkelhagen, Michel P J van den Bekerom, Hugo W Bolhuis, Mike Hogervorst

  Strategies in trauma and limb reconstruction (Online).

  Isolated pubic ramus fractures are common fractures in the elderly, and treatment is typically non-operative. Up to 35 % of patients have a prolonged hospital stay due to pain. A small number ofIsolated pubic ramus fractures are common fractures in the elderly, and treatment is typically non-operative. Up to 35 % of patients have a prolonged hospital stay due to pain. A small number of these patients do not respond to standard (non-operative) treatment. We retrospectively reviewed six patients with isolated pubic ramus fractures and persistent pain who were treated with percutaneous retrograde pubic ramus screw fixation. The study group consisted of six women with an average age of 81 years (72-86 years). Patients with symptomatic posterior pelvic ring injuries were excluded. All patients showed improvement after surgery, with three patients pain free and three patients with reduced pain. The mean time spent in the hospital was 9 days (range 3-18 days). There were complications post-operatively: two patients had pneumonia, two with confusional states, and one patient had a urinary tract infection. Despite these events, which are associated with surgery in patients with comorbidites from advanced age, retrograde pubic ramus screw fixation is an effective treatment option for patients with persistent pain from isolated pubic fractures.

• Outcomes and complications of fibular head resection.

  Authors: D K Agarwal, S Saseendar, D K Patro, J Menon

  Strategies in trauma and limb reconstruction (Online).

  The fibular head is often used as donor graft material for reconstruction of defects of the distal radius. However little is known on the safety of such a procedure. This report describes theThe fibular head is often used as donor graft material for reconstruction of defects of the distal radius. However little is known on the safety of such a procedure. This report describes the long-term donor-site morbidity following the procedure. Fourteen patients who underwent simple or marginal resections of the proximal fibula between 1990 and 2007 were reviewed. Subjective donor-site morbidity, knee and ankle range of motion and instability, presence of sensory or motor function loss, gait and fibular regeneration were assessed. The mean age at surgery was 25 years; six were male, eight were female and the mean follow-up was 11 years. Abnormal clinical findings were present in 10 patients (71.4 %): nine patients (64.3 %) had Grade 2 varus laxity at the knee confirmed by stress radiographs; one had sensory loss in the distribution of the superficial peroneal nerve. Patients with varus laxity had significantly higher mean age at surgery than those without varus laxity (p = 0.001). None had deformity at the knee or ankle. The range of joint movements was normal. All had a normal tibiotalar angle and none had proximal migration of the fibula. One patient demonstrated near-complete regeneration of the fibula. Donor-site morbidity following simple and marginal resection of the proximal fibula is acceptable. Older patients had a higher risk of demonstrable varus laxity at the knee but proximal fibula resection in children appears to be safe.

• The relationship between time to surgical debridement and incidence of infection in grade III open fractures.

  Authors: Jagwant Singh, Rohit Rambani, Zaid Hashim, Raghu Raman, Hemant Kumar Sharma

  Strategies in trauma and limb reconstruction (Online).

  OBJECTIVE: The purpose of this study was to determine the association between time to initial debridement and infection rate in high-energy (grade III) open fractures of tibia. METHODS: All patientsOBJECTIVE: The purpose of this study was to determine the association between time to initial debridement and infection rate in high-energy (grade III) open fractures of tibia. METHODS: All patients presenting with open fractures were included in the study. The inclusion criteria were Gustilo III A, B and C open fractures of tibia. Time of injury, time of arrival to the hospital, time of initial debridement and subsequent soft tissue procedures were recorded. The primary outcome measure was a diagnosis of infection or osteomyelitis at 1 year. Secondary outcome measure was fracture union at 1 year. RESULTS: Sixty-seven (67) patients with grade III open fractures were included; the mean age was 32.4 years (54 males and 13 females). Eight patients (12 %) in this study went on to develop a deep infection, and there were 6 (8.4 %) non-unions. The infection rate for patients in the group who underwent debridement in less than 6 h and those greater than 6 h was 13.1 and 10.8 %, respectively. No statistically significant difference could be demonstrated between the two groups (p = 0.56). While there was no significant relationship between grade of fracture and infection rate (p = 0.07), the relationship between grade of fracture and non-union was significant (p = 0.02). CONCLUSION: Our study shows that the risk of developing an infection was not increased if the primary surgical management was delayed more than 6 h after injury. Therefore, reasonable delays in surgical treatment for patients with open fractures may be justified in order to provide an optimal operating environment.

• Ankle reconstruction in type II fibular hemimelia.

  Authors: Hazem Mossad El-Tayeby, Amin Abdel Razek Youssef Ahmed

  Strategies in trauma and limb reconstruction (Online).

  Ankle reconstruction prior to limb lengthening for was performed in 13 patients with fibular hemimelia with complete radiological absence of the fibula (type II). There were different degrees ofAnkle reconstruction prior to limb lengthening for was performed in 13 patients with fibular hemimelia with complete radiological absence of the fibula (type II). There were different degrees of absence of metatarsal rays. The hindfoot deformity was a heel valgus in 12 patients and equinovarus in 1 patient. The patients' ages ranged from 9 to 26 months. Excision of the fibular anlage was performed with lateral subtalar and ankle soft tissue releases to restore the ankle and subtalar joint relationships. In all cases, the fibular anlage ended distally in a cartilaginous lateral malleolar remnant that was fused to the talus in two patients. This fibular remnant was advanced distally and fixed to the tibia with 2 Kirschner wires to recreate an ankle mortise. The period of follow-up ranged from 12 to 38 months. All patients had a stable ankle without tendency to valgus deformity or subluxation. The ankle range of movement was a mean of 27.3° plantarflexion (25-30) and 18° dorsiflexion (15-20). Reconstruction of the ankle in type II fibular hemimelia using advancement of the cartilaginous lateral malleolar remnant has produced encouraging results in the short-term but longer follow-up is needed.

• Proximal tibial osteotomies for the medial compartment arthrosis of the knee: a historical journey.

  Authors: I Esenkaya, K Unay, K Akan

  Strategies in trauma and limb reconstruction (Online).

  Several proximal tibial osteotomy techniques for the medial compartment arthrosis of the knee are described and traced in their development. These techniques are of the closed wedge, dome and openSeveral proximal tibial osteotomy techniques for the medial compartment arthrosis of the knee are described and traced in their development. These techniques are of the closed wedge, dome and open wedge types. We detail the differences in planning and surgery as well the need for different fixation devices. This historical and technical description will benefit those surgeons wishing to undertake the procedure as an alternative to joint replacement strategies.

• An aggressive aneurysmal bone cyst of the proximal humerus and related complications in a pediatric patient.

  Authors: Melih Güven, Murat Demirel, Turhan Ozler, Ibrahim Cumhur Başsorgun, Serdar Ipek, Sadullah Kara

  Strategies in trauma and limb reconstruction (Online).

  Clinical behavior of aneurysmal bone cyst (ABC) in younger patients can be more aggressive than that in older children and adults. Angular deformity and shortening can occur due to growth plateClinical behavior of aneurysmal bone cyst (ABC) in younger patients can be more aggressive than that in older children and adults. Angular deformity and shortening can occur due to growth plate destruction or tumor resection. A 11-year-old boy who had been operated twice in another center for an ABC located in the left proximal humerus presented to the author's institution with complaints of pain, deformity and shortening of the left arm. Plain radiographs revealed left proximal humerus nonunion with a large defect. Reconstruction with nonvascularized fibular autograft was applied and left upper extremity was immobilized in a velpou bandage. At the third-month follow-up, graft incorporation was observed in the distal part; however, proximal part did not show adequate healing on radiographs. Additional immobilization in a sling for 3 months was advised to the patient and his family. However, they were lost to follow-up and readmitted to the author's institution at the 12th month postoperatively. Radiographs showed failure of the fibular graft fixation and nonunion of the humerus. Autogenic bone grafts, either vascularized or nonvascularized are the best treatment method for the large defects after tumor curettage or resection. Nonvascularized grafts are technically much easier to use than vascularized grafts and provide excellent structural bone support at the recipient side. However, they may take several months to be fully incorporated. In addition, good therapeutic outcomes require patience and collaboration with the patient and parents. Most importantly, the patient should be monitored closely.

• Union of an intra-articular distal radius fracture after successive failures of three locking plates: a case report.

  Authors: S K Khan, C Gozzard

  Strategies in trauma and limb reconstruction (Online).

  We report a case of a 30-year old male, who presented with a right distal radius intra-articular fracture complicated by compartment syndrome. He was treated with fasciotomies and fracture fixationWe report a case of a 30-year old male, who presented with a right distal radius intra-articular fracture complicated by compartment syndrome. He was treated with fasciotomies and fracture fixation with a 3.5 mm LCP (Synthes(™)), followed 7 days later by skin graft. Repeat radiographs 8 weeks later showed a break across the plate at the level of an unfilled screw hole over the fracture. He underwent exchange plating with a 2.4 mm LCP Distal Radius Plate (Synthes(™)). This revision was complicated by an infected wound dehiscence 2 weeks later requiring multiple procedures. Radiographs at 20 weeks showed broken distal screws. A second revision was performed. At 12 months, the fracture had healed clinically and radiologically, but the three distal screws had broken. We discuss the multifactorial failures of the these three attempts at osteosynthesis, and which factors helped achieve osseous union. We also discuss the literature on volar locking plate breakage and conclude with the recommendations to avoid this rare complication.

• Congenital radial head dislocation with a progressive cubitus valgus: a case report.

  Authors: Laurens Kaas, Peter A A Struijs

  Strategies in trauma and limb reconstruction.

  Congenital dislocation of the radial head is rare, although it is the most common congenital anomaly of the elbow. A concomitant progressive cubitus valgus of the elbow has not previously beenCongenital dislocation of the radial head is rare, although it is the most common congenital anomaly of the elbow. A concomitant progressive cubitus valgus of the elbow has not previously been described in literature. We describe a case of an 8-year-old girl with an unilateral congenital radial head dislocation with a progressive cubitus valgus of 35°, caused by a prematurely closing physis of the lateral humeral condyle. This might be caused by an increased pressure on the lateral physis by the anteriorly dislocated radial head. As no complaints or limitations were present, treatment was non-operative with clinical observation, with satisfactory results after a follow-up of 18 months. A concomitant progressive cubitus valgus can be present in patients with a congenital radial head dislocation. Non-operative treatment can provide satisfactory results.

• Management of forearm nonunions: current concepts.

  Authors: Peter Kloen, Geert A Buijze, David Ring

  Strategies in trauma and limb reconstruction.

  Forearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location andForearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location and complexity, patient characteristics and surgical technique. Treatment of diaphyseal forearm nonunions differs from that of other type of diaphyseal nonunions because of the intimate relationship between the radius and ulna and their reciprocal movement. There is a wide variation of surgical techniques, and the optimal choice of management remains subject to debate. In this review, we aim to summarize the available evidence in the literature on forearm nonunions and combine it with practical recommendations based on our clinical experience to help guide the management of this complex problem.

• "Asymmetric scalloping of the regenerate": a radiological sign of pseudoaneurysm in distraction osteogenesis.

  Authors: J Fagg, A Gulihar, J A Fernandes

  Strategies in trauma and limb reconstruction (Online). 6(3):159-62.

  Pseudoaneurysm formation is an uncommon but well-recognised and important complication in limb reconstruction surgery. Postoperative diagnosis is usually clinical or an incidental finding. We presentPseudoaneurysm formation is an uncommon but well-recognised and important complication in limb reconstruction surgery. Postoperative diagnosis is usually clinical or an incidental finding. We present an 11-year-old girl, who underwent two-stage limb lengthening with a circular fixator, for a previously treated pseudoarthrosis of the tibia. During the lengthening plan, a concave defect was noted on one side of the regenerate, which was found to be due to extrinsic compression by a pseudoaneurysm. Normal regenerate formation was seen after selective embolisation of the pseudoaneurysm. This concave appearance on one side of the regenerate has previously been described secondary to a difference in stability on the two sides of the osteotomy, when a monolateral fixator is used, but not due to extrinsic compression by a pseudoaneurysm. The authors propose that this radiographic appearance of "asymmetrical scalloping" on one side of the regenerate may represent a radiological sign of a pseudoaneurysm formation and should provoke investigation for the same.

• Locked intramedullary femoral nailing without fracture table or image intensifier.

  Authors: Rajesh Rohilla, Roop Singh, Seema Rohilla, Narender K Magu, Ashish Devgan, Ramchander Siwach

  Strategies in trauma and limb reconstruction (Online). 6(3):127-35.

  The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table orThe present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18-70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist-Hansen types I and II) diaphyseal fractures of the femur.

• High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results.

  Authors: P M Robinson, M C Papanna, B V Somanchi, S A Khan

  Strategies in trauma and limb reconstruction (Online). 6(3):137-45.

  We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9 patients with medial compartment OA and varus deformity underwent TSF application and medial opening wedge HTO. Pre- and post-operative Oxford knee scores, SF-12 and visual analogue pain scores were recorded along with radiographic outcomes. Median follow-up was 19 months (range 15-35). Mean age at operation was 49 years (range 37-59). The median time spent in the frame was 18 weeks (range 12-37). The mean preoperative Oxford knee score was 28.7. This improved to a mean of 35.4 post-operatively (P = 0.0142). 6 (67%) patients had a documented pin-site infection. With TKR as an end point, the survival rate of HTOs was 88.9% at a median of 19 months follow-up. This study demonstrates that in selected patients the TSF provides a viable treatment option for performing HTO in medial compartment OA with varus deformity.

• The repair of the Achilles tendon rupture: comparison of two percutaneous techniques.

  Authors: G Taglialavoro, C Biz, G Mastrangelo, R Aldegheri

  Strategies in trauma and limb reconstruction (Online). 6(3):147-54.

  This study proposes a comparison between two percutaneous techniques of subcutaneous Achilles tendon rupture by evaluating the risk of lesion developing, the morbidity of the surgical techniqueThis study proposes a comparison between two percutaneous techniques of subcutaneous Achilles tendon rupture by evaluating the risk of lesion developing, the morbidity of the surgical technique adopted and the effectiveness of each technique. Sixty patients were operated at Padua Orthopaedic Clinic by using the two different procedures: (1) Ma and Griffith in 30 cases and (2) Tenolig in 30 cases. Risk of rupture developing has been evaluated in relation to sex, age, side, kind of trauma, work and presence of preoperative risk factors. The Morbidity of surgical technique has been evaluated in with respect to surgical time, hospital permanence, immobilization, active nonweight-bearing mobilization, assisted weight bearing until the full one, number of early and late complications before and after hospital discharge. Effectiveness has been evaluated in relation to return time to common life, work and sport; anatomical and functional features have been evaluated using McComis score, rating results as: very good (from 80 to 70), good (from 69 to 60), fair (from 59 to 50) and poor (<50). Tenolig group shows shorter average time from hospital admission and operation, hospital permanence and immobilization (P < 0.05), and it results in an easier and quicker execution and functionally stimulates the tendon healing in a short time. Effectiveness was the same for both techniques because average McComis score was good (P = 0.35), and there was no significant differences in common life returning time (P = 0.12). Tenolig technique seems to be preferable to Ma and Griffith.

• Treatment of a fibular autograft non-union with a resulting deformity by stabilization, progressive correction and callotasis using an Ilizarov fixator: a case study.

  Authors: Yasser Elbatrawy, Giby C Philips

  Strategies in trauma and limb reconstruction (Online). 6(3):167-71.

  Bone tumours present a challenge to reconstructive surgery when the tumour breaches the physeal and periphyseal region of the growing bone. Though a host of options are available, these are notBone tumours present a challenge to reconstructive surgery when the tumour breaches the physeal and periphyseal region of the growing bone. Though a host of options are available, these are not without complications. We report one such case of osteosarcoma of the tibia treated initially with wide resection of the tumour and intercalary fibular strut grafting using plate and screws. The operation was complicated by a non-union at the proximal tibio-fibular autograft junction. This leads to a multiplanar deformity with severe procurvatum at the proximal tibio-fibular graft junction, which was successfully treated by callotasis using an Ilizarov fixator. Appropriate consent was obtained from the patient and parents to publish this case report.

• Lateral tibial condyle reconstruction by pedicled vascularized fibular head graft: long-term result.

  Authors: Syed Kamran Ahmed, Boris Kwok Keung Fung, Wing Yuk Ip, Shew Ping Chow

  Strategies in trauma and limb reconstruction (Online). 6(3):163-6.

  The technique of pedicled vascularized fibular graft for lateral tibial condyle reconstruction after en bloc resection of aggressive giant cell tumours was described by SP Chow et al. Early follow-upThe technique of pedicled vascularized fibular graft for lateral tibial condyle reconstruction after en bloc resection of aggressive giant cell tumours was described by SP Chow et al. Early follow-up of two patients was presented in 1986. We present the 25 years follow-up of one patient with a literature review of alternative present day treatment options. The patient maintained community ambulant status despite developing late stage osteoarthritis. Although this procedure is performed rarely, it remains an alternative to the more sophisticated treatment options making it a useful method in centres with limited facilities and expertise.

• The reciprocal ledge closing wedge osteotomy for post traumatic coxa vara.

  Authors: Shabir Ahmed Dhar, Tahir Ahmed Dar, Asif Sultan, Abdul Rouf Malik, Mohammed Ramzan Mir

  Strategies in trauma and limb reconstruction (Online). 6(3):155-8.

  To report a proximal femoral osteotomy with retention of bone ledges in a reciprocal position to increase bone contact and stability. The method was applied to 5 patients over a 3-year period. AllTo report a proximal femoral osteotomy with retention of bone ledges in a reciprocal position to increase bone contact and stability. The method was applied to 5 patients over a 3-year period. All patients had coxa vara. The average length gained was 1.5 cm, and the average neck shaft angle improvement was 30°. The Harris hip score improved from an average of 63 to 82. The reciprocal ledge osteotomy is technically less demanding and also allows conversion of normal shear forces around the upper femur to stabilizing forces. This method allows easier use of the DHS implant as potential rotation about the axis of the screw is negated by the ledges and the dynamic forces.

• Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device.

  Authors: Jaime L Bellamy, Courtney A Holland, Mark Hsiao, Joseph R Hsu

  Strategies in trauma and limb reconstruction (Online). 6(3):173-6.

  Pyoderma gangrenosum is a rare autoinflammatory syndrome manifested by skin lesions eventually creating ulcers. Surgical management can lead to scarring and contracture at the site of the lesion duePyoderma gangrenosum is a rare autoinflammatory syndrome manifested by skin lesions eventually creating ulcers. Surgical management can lead to scarring and contracture at the site of the lesion due to the pathergy phenomenon. A 43-year-old woman presented with a 5-year history of severe equinovarus deformity due to chronic pyoderma gangrenosum on her posteromedial ankle. She underwent a staged fusion. A gradual "closed" correction was performed in a Taylor spatial frame for 8 weeks in order to obviate the need for a surgical release in the area of the ulcer. She was ambulatory and full weight-bearing within 4 weeks of her frame removal. She maintained her correction with an accommodative foot orthosis until she had an uneventful tibiotalar calcaneal fusion with an intramedullary device. This case represents the success of using a Taylor spatial frame for staged fusion involving soft-tissue correction of severe, rigid equinovarus deformity due to pyoderma gangrenosum.

• Necrotizing fasciitis of the extremities: a prospective study.

  Authors: Ramin Espandar, Siamak Yousef Sibdari, Elham Rafiee, Shideh Yazdanian

  Strategies in trauma and limb reconstruction (Online). 6(3):121-5.

  Necrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortalityNecrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortality rate is still high. Between September 2007 and August 2009, we prospectively studied twenty-four histopathologically proven necrotizing fasciitis patients to assess the prognostic factors that indicate the outcome. Mortality rate was 20.8%. Twelve patients (50%) improved, while seven patients (29.2%) were complicated by limb loss. Mortality rates related to upper and lower limb involvement were similar (20% vs. 22.2%). The rates of gangrene and amputation in patients with diabetes mellitus were significantly higher than other comorbidities. Patients with gram-positive infections had significantly lower rates of amputation (15.4% vs. 54.5%, P = 0.04). Mean band cell count and serum potassium level were significantly higher in the nonsurvivors same as leukocyte count in the patients with gangrene, while serum sodium level was significantly lower in nonsurvivors. We conclude that hyponatremia, hyperkalemia, and increased band cells in the peripheral blood of patients may be useful parameters in distinguishing life-threatening necrotizing fasciitis; hence, we recommended lower threshold to amputation during surgery for this group of patients.

• Correction of poliomyelitis foot deformities with Ilizarov method.

  Authors: Alexander Kirienko, Andrea Peccati, Ibrahim Abdellatif, Yasser Elbatrawy, Zayed Mahmoud A Mostaf, Valentina Necci

  Strategies in trauma and limb reconstruction (Online). 6(3):107-20.

  Poliomyelitis is an infectious disease caused by a neurotrophic virus targeting anterior horn cells of lower motor neurons resulting in flaccid paralysis and represents a common condition inPoliomyelitis is an infectious disease caused by a neurotrophic virus targeting anterior horn cells of lower motor neurons resulting in flaccid paralysis and represents a common condition in developing countries, and even nowadays, most of both treated and untreated cases result in foot deformities. Between 1994 and 2007, 27 patients were treated by classic ring Ilizarov fixator, aiming at producing a stable plantigrade and cosmetically acceptable foot and followed up for meanly 7.17 years. Additional procedures were performed if needed. The mean time in frame was 4.2 months. All the patients were satisfied with their gait, compared to preoperative status. A painless and plantigrade foot was obtained in all patients, and limb-length discrepancy was always corrected where present. No major complications were encountered. In conclusion, the Ilizarov method allows simultaneous progressive correction of all components of severe foot deformities associated with limb-lengthening discrepancy with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding important shortening of the foot.

• Reconstructive osteotomy of fibular malunion: review of the literature.

  Authors: Remco J A van Wensen, Michel P J van den Bekerom, René K Marti, Ronald J van Heerwaarden

  Strategies in trauma and limb reconstruction (Online). 6(2):51-7.

  The treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion toThe treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion to reconstruct. The most frequent malunions of the fibula are shortening and malrotation resulting in widening of the ankle mortise and talar instability, which may lead to posttraumatic osteoarthritis. The objective of this article is to review the literature concerning the results of osteotomies for correcting fibular malunions and to formulate recommendations for clinical practice. Based on available literature, corrective osteotomies for fibular malunion have good or excellent results in more than 75% of the patients. Reconstructive fibular osteotomy has been recommended to avoid or postpone sequela of posttraumatic degeneration, an ankle arthrodesis or supramalleolar osteotomy. The development of degenerative changes is not fully predictable; therefore, it is advisable to reconstruct a fibular malunion soon after the diagnosis is made and in presence of a good ankle function. Recommendations were made for future research because of the low level of evidence of available literature on reconstructive osteotomies of fibular malunions.

• Sensate composite calcaneal flap in leg amputation: a full terminal weight-bearing surface-experience in eight adult patients.

  Authors: Bruno Livani, Gabriel Castro, Jose Roberto Tonelli Filho, Tâmara Ramos Morgatho, Mauricio Leal Dias Mongon, William Dias Belangero, Michael Davitt, Jose André Carvalho

  Strategies in trauma and limb reconstruction (Online). 6(2):91-6.

  Despite modern reconstruction techniques and replantation, the preservation of a severely traumatised limb, or even a limb affected by a congenital malformation, usually gives poorer functionalDespite modern reconstruction techniques and replantation, the preservation of a severely traumatised limb, or even a limb affected by a congenital malformation, usually gives poorer functional results compared with amputation and prosthetisation. The aim of this study was to describe a hind foot (including the calcaneum and fat pad) sensate flap with a surface that allows full terminal weight bearing in transtibial amputations in adults. Between June 2007 and September 2008, eight patients underwent leg amputations with a sensate composite calcaneal flap reconstruction of the stump. Patients consisted of four men and four women with a mean age of 46.5 (26-66) years. All amputations were unilateral. The mean follow-up was 28.3 (25-42) months. There were no complications. Calcaneum tibial fusion was observed in all patients in a mean time of 3.5 (3-4) months. A below-knee prosthesis was adapted at 16 weeks postoperatively in all cases, and no need for stump revision occurred in this series during the entire follow-up period. A transtibial amputation covered with a sensate plantar flap preserving the calcaneum was proposed. In theory, the anatomic structures spared in this technique provide a strong, full, weight-bearing terminal surface of the stump that will last a lifetime.

• Subperiosteal resection of mid-clavicle in Sprengel's deformity correction.

  Authors: Freih Odeh Abuhassan

  Strategies in trauma and limb reconstruction (Online). 6(2):59-67.

  We report the results of fifteen cases of Sprengel's deformity treated surgically by initial subperiosteal resection of the middle third of the clavicle in conjunction with surgical release of allWe report the results of fifteen cases of Sprengel's deformity treated surgically by initial subperiosteal resection of the middle third of the clavicle in conjunction with surgical release of all attachments of the scapula to the spine, excision of any omovertebral bone and resection of prominent supraspinous process of scapula. The patients included ten female and three male patients (age range at the time of operation, 3.3-10 years; mean: 6.11 years). The deformity involved the left shoulder in eight patients, the right shoulder in three and two were bilateral. All patients were followed for an average of 5.9 years (range 4-11 years). Preoperatively, the arc of total abduction (glenohumeral and scapulothoracic) ranged from 80 to 140°, and the average was 110°. The shoulders were level, and the range of motion was dramatically improved with an average range of abduction of 166.5° (range 140-180°). The age of the patients and the presence of an omovertebral bone did not influence the results. All patients and their parents expressed satisfaction with the operative results. We feel that our procedure is a simple one, which helps to improve the degree of correction, avoid neurovascular complications and has the advantage of complete regeneration of the clavicle. The technique provides an easy, safe method of repositioning the scapula at its normal level.

• Complex elbow dislocation associated with radial and ulnar diaphyseal fractures: a rare combination.

  Authors: Subramaniam Ramesh, Yi-Jia Lim

  Strategies in trauma and limb reconstruction (Online). 6(2):97-101.

  We illustrate a rare complex dislocation of the elbow involving a posterior ulno-humeral dislocation associated with open diaphyseal fracture of the ulna, radial shaft fracture, Type 1 coronoidWe illustrate a rare complex dislocation of the elbow involving a posterior ulno-humeral dislocation associated with open diaphyseal fracture of the ulna, radial shaft fracture, Type 1 coronoid fracture and neuropraxia of the deep branch of the radial nerve. The isolated ulno-humeral dislocation without radio-capitellar involvement, and ulnar diaphyseal fracture, makes this "reverse Monteggia" type of injury pattern very unique. This patient was managed with an initial reduction of his ulno-humeral joint and stabilization of his radius and ulna fractures. He underwent a delayed medial collateral ligament reconstruction a few days later. His fractures went on to unite fully, his elbow joint remained stable, and he achieved good range of motion of his elbow.

• Guided growth for correction of knee flexion deformity: a series of four cases.

  Authors: B A Macwilliams, B Harjinder, P M Stevens

  Strategies in trauma and limb reconstruction (Online). 6(2):83-90.

  Fixed knee flexion deformity can present as an insidious and significant problem in diverse etiologies, most commonly in cerebral palsy. Traditional surgical intervention has included posteriorFixed knee flexion deformity can present as an insidious and significant problem in diverse etiologies, most commonly in cerebral palsy. Traditional surgical intervention has included posterior capsulotomy and supracondylar femoral osteotomy, both of which carry significant associated morbidity and risks. In the skeletally immature patient, guided growth may be used to correct or substantially diminish the deformity. We are presenting our early experience encompassing four subjects who completed instrumented gait analysis both prior to and after distal femoral anterior guided growth (hemiepiphysiodesis). Changes in gait and function resulting from surgery in each individual are reported. Outcomes indicate improved knee range of motion and alleviation of crouch at the knee with secondary improvements in the ankle, hip and pelvis. Three subjects with initially slow gait velocity improved to within normal limits by demonstrating increased stride length. A measure of overall gait kinematics showed improvements in all limbs. Anterior guided growth (hemiepiphysiodesis) of the distal femur resulted in positive quantitative changes in all four patients, though degree and types of changes were variable in this small series. Encouraged by these findings, we now prefer guided growth to extension supracondylar osteotomy for the skeletally immature patient with fixed knee flexion deformity.

• Reconstruction nailing for ipsilateral femoral neck and shaft fractures.

  Authors: Alexandros Tsarouhas, Michael E Hantes, Theohilos Karachalios, Konstantinos Bargiotas, Konstantinos N Malizos

  Strategies in trauma and limb reconstruction (Online). 6(2):69-75.

  The surgical management of ipsilateral fractures of the femoral neck and shaft presents a difficult and challenging problem for the orthopaedic surgeon. The purpose of the present study was to reportThe surgical management of ipsilateral fractures of the femoral neck and shaft presents a difficult and challenging problem for the orthopaedic surgeon. The purpose of the present study was to report the mid-term results and complications in a series of patients who sustained ipsilateral femoral neck and shaft fractures and treated in our trauma department with a single reconstruction nail for both fractures. Eleven patients were included in the study with an average age of 46.4 years. The mean follow-up was 47 months (range, 15-75 months). There were no cases of a missed diagnosis at initial presentation. The mean time to union was 4.5 months for the neck fracture and 8.2 months for the shaft. There were no cases of avascular necrosis of the femoral head or non-union of the neck fracture. The mean Harris Hip Score was (85 ± 4.3). Complications included two cases of shaft fracture non-union and one case of peroneal nerve palsy. Heterotopic ossification at the tip of the greater trochanter was evident in two cases without causing any functional deficit. The current study suggests that reconstruction nailing produces satisfactory clinical and functional results in the mid-term. The complications involved only the femoral shaft fracture and were successfully treated with a single operative procedure.

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