Navigation-assisted suture anchor insertion for arthroscopic rotator cuff repair.

BACKGROUND: Suture anchor placement for subscapularis repair is challenging. Determining the exact location and optimum angle relative to the subscapularis tendon direction is difficult because of the mismatch between a distorted arthroscopic view and the actual anatomy of the footprint. This study aimed to compare the reliability and reproducibility of the navigation-assisted anchoring technique with conventional arthroscopic anchor fixation. METHODS: Arthroscopic shoulder models were tested by five surgeons. The conventional and navigation-assisted methods of suture anchoring in the subscapularis footprint on the humeral head were tested by each surgeon seven times. Angular results and anchor locations were measured and compared using the Wilcoxon signed rank test. Interobserver intraclass correlation coefficients (ICCs) were analyzed among the surgeons. RESULTS: The mean angular errors of the targeted anchor fixation guide without and with navigation were 17° and 2° (p < 0.05), respectively, and the translational errors were 15 and 3 mm (p < 0.05), respectively. All participants showed a narrow range of anchor fixation angular and translational errors from the original target. Among the surgeons, the interobserver reliabilities of angular errors for ICCs of the navigation-assisted and conventional methods were 0.897 and 0.586, respectively, and the interobserver ICC reliabilities for translational error were 0.938 and 0.619, respectively. CONCLUSIONS: The navigation system may help surgeons be more aware of the surrounding anatomy and location, providing better guidance for anchor orientation, including footprint location and anchor angle.

Osteolysis is observed around both bioabsorbable and nonabsorbable anchors on serial magnetic resonance images of patients undergoing arthroscopic rotator cuff repair.

OBJECTIVES: The objective of this study was to evaluate the incidence of osteolysis around the bioabsorbable and nonabsorbable anchors using serial magnetic resonance imaging (MRI) and to determine the relationship between osteolysis and the retear rate after arthroscopic rotator cuff repair. METHODS: From July 2012 to July 2014, 50 patients [28 men and 22 women; mean age, 56.4 (range: 45-56) years] underwent arthroscopic rotator cuff repair for a medium-to large-size tear with double-row suture-bridge technique. The bioabsorbable anchors used in the medial row comprised hydroxyapatite-polylactic acid enantiomer, and the nonabsorbable anchors in the lateral row were polyetheretherketone (PEEK)-type anchors. All patients underwent MRI evaluation at 3, 6, and 12 months postoperatively to determine osteolysis and identify any retear. RESULTS: The incidences of osteolysis at 3, 6, and 12 months postoperatively were 1%, 4%, and 6% with nonabsorbable anchors and 13%, 29%, and 39% with bioabsorbable anchors, respectively. The incidences of osteolysis were significantly higher with the bioabsorbable anchors than with the nonabsorbable anchors (P < 0.005 for all three follow-ups). There was no significant difference between osteolysis and non-osteolysis groups regarding the retear rate or retear size (P = 0.189 and 0.069, respectively). CONCLUSIONS: Osteolysis was common around bioabsorbable anchors used for arthroscopic rotator cuff repair, and it also occurred around the PEEK-type nonabsorbable anchors. The incidence of osteolysis of nonabsorbable anchors was significantly lower than that of bioabsorbable anchors. Osteolysis did not significantly affect rotator cuff retear after arthroscopic repair with either bioabsorbable or nonabsorbable anchors. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Humeral Diaphyseal Fracture Nonunion: An Audit of the Outcome from Intramedullary Nailing and DCP Plating.

PURPOSE: This study aims to compare the functional outcomes of nonunion humeral diaphyseal fractures following conservative treatment when managed surgically with either a plate or intramedullary (IM) nail fixation. METHODS: This was a retrospective study of 56 patients with nonunion humeral fractures following conservative treatment who underwent plate or IM nail fixation between 2007 and 2014. Comparison was made for short term profile (intraoperative blood loss, duration of surgery, and length of hospitalization) and long term clinical outcome with functional score (Constant-Murley score (CMS)) and Disabilities of the Arm, Shoulder and Hand (DASH) score). The union and complication rate were also compared. RESULTS: There were 36 and 20 patients included in plate and IM nail fixation group with the average of 36.14 ± 7.54-month follow-up time. The intraoperative blood loss, duration of surgery, and length of hospitalization were superior in IM nail group compared to plate group (p < 0.001, p < 0.001, and p < 0.001, respectively). The mean CMS and DASH score were superior in the plate group compared to the IM nail group (82.40 ± 16.84 versus 77.58 ± 12.96; 17.46 ± 11.05 versus 20.86 ± 11.63, respectively; with p = 0.246, p = 0.299, respectively). Plate fixation group showed higher union rate and complication rate compared to IM nail group (100% versus 90%, 13.8% versus 10%, respectively). CONCLUSIONS: IM nail and plate fixation demonstrated comparable clinical outcome. IM nail fixation showed superior short term result with lower complication rate which benefits the elderly group patients with significant comorbidities.

The Role of Additional K-Wires on AO Type C Distal Radius Fracture Treatment with External Fixator in Young Population.

OBJECTIVES: Several methods have been proposed to treat AO type C distal radius fracture. External fixator has gained popularity for its simple procedure and rapid recovery. Some surgeons suggested that additional K-wires may play a critical role in the outcome. The purpose of study is to evaluate the role of additional K wires in treating distal radial fracture with external fixator regarding its outcome. MATERIAL AND METHODS: From January 2006 to January 2010, 40 patients with AO type C distal radius fracture were treated with external fixator, with (EF) or without additional K wires (EFK). Radiologic outcome parameters include radial inclination, volar tilt, radial length, and the presence of radiocarpal arthritis according to Knirk and Jupiter. Clinical outcomes include New York Orthopedic Hospital (NYOH) wrist scoring scale. RESULTS: Radiographic outcome showed significant difference in regard of articular congruency at the final follow-up with the EFK group showing the advantage in maintaining the articular incongruity. NYOH wrist scoring scale showed no significant difference between both groups at final follow-up. The amount of articular step-off was less in EFK group with significant statistical finding on the final follow up. CONCLUSION: Both EF and EFK technique were able to provide satisfactory result in treating AO type C distal radius fractures. We observed that EFK is superior in reducing the number of radiocarpal arthritic changes compared to EF group due to its superiority in reducing articular step-off.

First experiences with the Fitmore® hip stem: Early results of the 16-month monitoring.

Background/Aim: Fitmore® hip stem belongs to the group of short stem prostheses with the metaphysar stabilization, with its shape and form that protects the bone mass in the greater trochanter region and the distal part of the femur. The aim of this paper was to present the early postoperative results in patients with implanted Fitmore® hip stem and point out some of the advantages. Methods: A series of 10 patients with implanted Fitmore® hip stem, was included in this study. The average age of the patients was 54.5 (48­65) years. There were 5 women and 5 men. The total monitoring time was 16 months. To rate the condition of the hip joint we used The Western Ontario and Mc Master Universities Arthritis Index (WOMAC) score. We also monitored the degree of hip pain, hip flexion, heterotopic ossification and indentation in the stem of the prosthesis. Results: After 12 months of monitoring 9 (90%) of the patients had no pain in the thigh region, and only 1 (10%) experienced mild pain. The hip flexion rose from the average 89° to postoperative 114°. WOMAC score rose as well, from 49 to 94 average points. Indentation in the stem was registered 3 months after the operation in 2 (20%) of the patients ­ in one of the patients the indentation was 3 mm and in the other patient 5 mm. After the 16-month monitoring, the results were excellent. The monitoring period was short though it should be continued and the results should be presented after 5 and then after 10 years. Conclusion: Early results of the implantation Fitmore stem showed good bone ingrowth with excellent functional result.

Surgical treatment of dislocated fracture of the scapula column and glenoid: a 22-year follow-up.

INTRODUCTION: Most scapular fractures are caused by high-impact blunt injuries, often as the result of motor vehicle accidents, fall from height, etc. In 80% to 90% of cases, scapula fractures are associated with multiple injuries (clavicle fracture, rib fractures, humeral fracture, pulmonary injury, brachial plexus injury). CASE REPORT: We presented scapular fracture in a 27-years-old male who had sustained a work-related injury when a ground soil brick machine pressed him. Fracture line was identified on radiotherapy and computed tomography scan from the distal scapular angle enclosing scapular neck. The whole lateral part of the scapula was dislocated laterally from the scapular body. Scapular fracture was treated operatively. The posterior approach was used for reposition, while for fixation after reposition we used two Blunt clamps. We presented functional outcome 22 years after the injury and the surgical treatment. The patient can perform all physical activities, still works, and there is no need to remove the ostheosynthetic material as it causes no discomfort nor problems. The strength of the shoulder muscles is estimated as physician as the grade 5. CONCLUSION: Displaced intra- articular fractures of the scapula should be treated operatively, with open reduction and internal fixation.

Unusual case of mixed form of femoroacetabular impingement combined with nonspecific synovitis of the hip joint in a young adult-- A case report.

INTRODUCTION: Minimal bone changes in the acetabulum and/or proximal femur, through mechanism known as femoroacetabular impingement, during flexion, adduction and internal rotation lead to early contact between femoral head-neck junction and acetabular brim, in anterosuperior region. Each additional pathological substrate which further decreases specified clearance provokes earlier onset of femoroacetabular impingement symptoms. CASE REPORT: We presented a 20-year-old male patient with groin pain, limping, positive impingement test, radiological signs of mixed form of femoroacetabular impingement and unrecognized chronic hypertrophic synovitis with earlier development of clinical hip symptoms than it has been expected. Open surgery of the left hip was done. Two years after the surgery, patient was asymptomatic, painless, and free of motion, with stable x-rays. CONCLUSION: Hypertrophic synovial tissue further reduces the distance between the femoral head-neck junction and the acetabulum, leading to the earlier onset of femoroacetabular impingement symptoms. Surgical treatment is the method of choice.

Surgical dislocation of the hip in patients with femoroacetabular impingement: Surgical techniques and our experience.

BACKGROUND/AIM: Arthrosis of the hip is the most common cause of a hip joint disorders. The aim of this study was to present our experience in the application of a safe surgical dislocation of the hip in patients with minor morphological changes in the hip joint, which, through the mechanism of femoroacetabular impingement, cause damage to the acetabular labrum and adjacent cartilage as an early sign of the hip arthrosis. METHODS: We have operated 51 patients with different morphological bone changes in the hip area and resultant soft tissue damage of the acetabular labrum and its adjacent cartilage. Surgical technique that we applied in this group of patients, was. adapted to our needs and capabilities and it was minimaly modified compared to the original procedure. RESULTS: The surgical technique presented in this paper, proved to be a good method of treatment of bone and soft tissue pathomorphological changes of the hip in patients with femoroacetabular impingement. We had no cases with avascular necrosis of the femoral head, and two patients had nonunion of the greater trochanter, 9 patients developed paraarticular ossification, without subjective symptoms, while 3 patients suffered from postoperative pain in the groin during more energetic physical activities. CONCLUSION: Utilization of our partly modified surgical technique of controlled and safe dislocation of the hip can solve all the bone and soft tissue problems in patients with femoroacetibular impingement to stop already developed osteoarthritis of the hip or to prevent mild form of it.

Early clinical results of surgical treatment of patients with femoroacetabular impingement.

INTRODUCTION: Surgical treatment is the treatment of choice in patients with symptoms and radiological signs of femoroacetabular impingement. OBJECTIVE: Our experience and early results of surgical treatment of patients with signs of femoroacetabular impingement and early hip osteoarthritis are reported. METHODS: The results of treatment of 21 patients aged 23-54 years with different types of femoroacetabular impingement are presented. Safe open surgical dislocation of the hip was performed in all patients. Before and after surgery, the WOMAC score was performed, clinical and radiographic data of the operated hips were evaluated and t-tests were used for statistical analyzes of data. RESULTS: The WOMAC score improved from 70.5 points (range 56.3 to 89.8 points) to 90.3 points (range 70.3 to 100 points) at one year of follow-up (p < 0.0001), anterior impingement test was negative in all operated cases, average hip internal rotation improved significantly, no complications were found, except trochanteric nonunion at the site of osteotomy, which was reaffixed. CONCLUSION: Postoperative results have shown that the surgical approach to treating patients with femoroacetabular impingement is the method of choice. Three operated patients, with advanced osteoarthritis of the hip, had to be converted to total hip replacement.

Contribution to the method for determining femoral neck axis.

INTRODUCTION: Femoral neck axis plotting is of great significance in measuring parameters that define femoral head-neck junction sphericity in the group of patients with the femoroacetabular impingement. Literature methods of femoral neck axis determination have weaknesses associated with the risk of obtaining inaccurate values of certain parameters. OBJECTIVE: Method of plotting of the femoral neck axis by two parallel lines that belong to the medial quarter of the femoral neck is proposed. Method was tested on the anatomic specimens and the respec tive radiograms. METHODS: A total of 31 anatomic specimens of the proximal femur and respective radiographs were used, on which three axes of the femoral neck were plotted; accordingly, alpha angle value was determined and tested with corresponding parametric tests, with the measurement error of less than 5% and the strength of the applied tests of 80%. RESULTS: Alpha angle values obtained by plotting femoral neck axis using the literature and methods we have proposed were not significantly different in our series, and, in more than a half of the specimens, the two axes overlapped each other. CONCLUSION: The advantage of the proposed method does not depend on the position of the femoral head rotation center in relation to the femoral neck, which favors proposed method for measuring the angles of femoral head sphericity in patients with the femoral head translation. Disadvantage of the study is a small sample size for valid conclusions about the applicability of this method in clinical practice.

Does timing of surgery affect the outcome of open articular distal humerus fractures.

BACKGROUND: Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient's quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes. PATIENTS AND METHODS: Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in <6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30-100); in the second, mean MEP was 64.3 (range 25-100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8-77.5). There were no statistically significant differences between two groups, MEP t(28)=0.935, p<0.358; DASH t(28)=-0.636, p<0.530. CONCLUSION: Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications.

Nature and results of treatment of war wounds caused by cluster bombs.

The aim of this study is to describe the nature of war wounds with fracture caused by cluster bombs and to suggest treatment options for such injuries. The nature of wounds caused by cluster bombs differs from those caused by conventional arms (they are more severe). The sides of the wounds are represented by conquasated soft tissues (such as fat and muscle) with thick dead tissues, ordinarily with a thickness of 0.5-4.5 cm. Another main characteristic of such injuries is the high percentage of amputations needed due to the high rate of neurovascular damage. This paper investigates the cases of 81 patients who sustained a total of 99 war wounds with fractures. The average age of the patients was 32.7 years while the youngest was 20 and the oldest, 77. According to The International Committee of the Red Cross (ICRC) classification of war wounds, 14 patients had grade I injuries, 48 patients grade II, and 29 patients, grade III. Mitkovic external fixation system, known also as the "War Fixator" was used for all fractures fixation. One protocol, which was a modification of the ICRC's protocol adapted to our specific conditions, was used throughout the study. For solving soft tissue defects, a rotator fasciocutan flap was the most frequently used. For solving of bones defect Mitkovic reconstructive external fixation device was used. All fractures we treated healed. We concluded that shortening the procedural time and being a very simple, immediate using of Mitkovic versatile external fixator ("War Fixator") is, leads to desirable results.

Surgical treatment of the unstable type C pelvic injury.

Rotationally and vertically unstable injuries to the pelvic ring (Type C) require stabilisation of the anterior and posterior pelvic ring complex. Inadequate treatment of these injuries leads to chronic instability of the pelvic ring, which can finally cause permanent disability. Open reduction and stable internal fixation of the anterior and posterior complex of unstable pelvic ring injuries are standard procedures in the treatment of hemodynamically stable patients with (Type C) pelvic injuries. Our aim is to show that this type of treatment achieves excellent and good results. All patients were operated on using the method of open reduction and anterior plate fixation of sacroiliac complex as well as fixation of the pubic symphisis. We present a retrospective study of the results concerning the treatment of 19 patients with (Type C) unstable pelvic injuries. The average age of the patients was 43,21 years old. The final functional results, 2 years post-surgery according to the Majeed scoring system and the results were excellent in 11 (57.89%) and good in 8 (42.1%) patients. There were no bad results to report. Type C pelvic ring injuries are unstable and unless they are adequately treated, they can lead to permanent consequences. Surgical treatment that includes open reduction and stable internal fixation of the anterior and posterior pelvic ring complex leads to excellent and good results. The patients that were treated surgically by fixation of the anterior and posterior pelvic ring complex return to their everyday lives and work activities.

[Minimally invasive treatment of bilateral femoral shaft fractures in polytrauma patient using selfdinamisibile internal fixator. A case report].

Proper timing and surgical method in management of femur fractures in polytrauma patients can greatly reduce the mortality, morbidity and disability. The aim of this paper is to present the treatment of bilateral femoral fractures in polytrauma patient with dominant chest trauma by selfdynamisable internal fixator Mitkovic (SIF) as a definitive method of fractures treatment. A 23 years old female was injured in a traffic accident. After resuscitation and treatment of the dominant chest injuries, surgical treatment of bilateral femur fractures performed on the fourth day after the injury. Length of surgery was 65 minutes. There was not blood substitution during the intervention and blood loss through the operative wounds drainage. There was no worsening of the pulmonary function after orthopaedic surgery. The patient discharged from hospital postoperative day ten. Postoperative follow-up was 9 months. The fractures healed with an excellent functional result. Application of selfdynamisable internal fixator (SIF) with minimally invasive technique for the treatment of bilateral femoral fractures in polytrauma patients is a good operative method because poses minimally additional operative trauma and provides excellent biomechanical conditions for fracture healing.

[Avascular necrosis of the femoral head in the patients with posterior wall acetabular fractures associated with dislocations of the hip].

INTRODUCTION: Acetabular fractures are severe injuries, mostly occured in young patients after traffic accident or fall from heights. Of the all acetabular fractures, posterior wall acetabular fractures are the most often observed. Regarding to mechanism of the injury, about 30% of these fractures are associated with posterior hip dislocation. MATERIAL AND METHODS: The incidence of AVN in 18 patients with posterior wall acetabular fractures associated with dislocations of the hip is presented. Thompson-Epstein Scale (type I-V) was used as the classification of the injury. Kocher-Langenbeck surgical approach was achieved in all patients. RESULTS: Average following time after surgery was 22, 66 months (8-36 months). After that period the incidence of femoral head AVN was observed in 33.3%. Femoral head AVN was observed in 5.55% of patient who was treated by the reduction of hip dislocation in first 24 hours after injury, while in patients with later reduction, femoral head AVN were observed in 27.77%. CONCLUSION: Posterior wall acetabular fractures associated with hip dislocation are severe injuries. Urgent, closed reduction of the hip, early definitive stable osteosynthesis of acetabulum and the experience of surgical team are factors that greatly decrease the possibility for AVN occurence. Later reduction, comminution of posterior wall of the acetabulum (Thompson- Epstein III et IV), impaction, chondral lesion of the femoral head and associated fractures of femoral head, increase the possibility for AVN occurence.

[Knee angular deformity correction using unicorticotomy and callus distraction by external fixation method and presentation of new external fixation device for varus correction of proximal tibia].

The main goal of this paper is to present clinical results of surgical correction of angular (varus and valgus) deformities of knee area. Goal is also to present new external fixation device for surgical treatment of varus deformity of proximal tibia. As material it has been used series of 70 patients treated during the period of 6.5 years in University Orthopaedic and traumatology clinic. Biomechanical investigation of 80% cut bone model fixed by new external fixation device was performed in the measurement laboratory of Mechanical Faculty University of Nis. Clinical results of treatment of 58 high tibial surgeries (49 varus and 9 valgus) and 12 distal femur surgeries (2 varus and 10 valgus) showed that unicorticotomy and callus distraction by the use of Mitkovic external fixation device leaded to correction and bone union. Superficial pin tract infection happened in 9 patients and has been successfully treated without pins removal. Biomechanical investigation of new device showed that during axial loading of bone model by 690 N (70 kg) movement of medial distal end of bone model was 0.30 mm while posterior distal end of bone model was 0.26 mm. From results obtained in can be concluded that unicorticotomy and gradual callus distraction by the use of external fixation is one reliable method. Biomechanical testing of new external fixation device showed that it is more stable in control of varus and posterior position of proximal tibial fragment.

The effect of short-term low-energy ultraviolet B irradiation on bone mineral density and bone turnover markers in postmenopausal women with osteoporosis: a randomized single-blinded controlled clinical trial.

INTRODUCTION: The importance of vitamin D on bone health and osteoporosis was studied by many researchers. The main role of the Vitamin D is to absorb calcium and phosphate and increase bone mineralization. Older people are at an increased risk of the inadequate vitamin D production in the skin because of lower sun exposure and reduced ability of the skin to synthesize vitamin D. OBJECTIVE: The aim of this clinical trial was to evaluate the efficacy and tolerability of short-term (2 weeks) low energy UVB irradiation in postmenopausal women with osteoporosis using bone mineral density and bone turnover markers. METHODS: A three-month, single-blinded, randomized, placebo-controlled clinical trial was conducted at the University hospital in Daegu, Republic of Korea. Fifty-two postmenopausal Korean women (older than 65 years) with osteoporosis were randomly allocated to have either low energy UVB or placebo for 30 minutes a day for two weeks of treatment during winter. Laboratory analysis and physical examination before and 4, 8 and 12 weeks after treatment were carried out and BMD was measured before and 8 and 12 weeks after treatment. The effects of time and treatment interaction between these two groups were evaluated by repeated-measure two-factor analysis, and subgroup analysis was performed to examine UVB effect on the vitamin D insufficient group [serum 25(OH)D3 concentration < 30 ng/mL]. RESULTS: In vitamin D insufficient group, the effect of UVB irradiation on vitamin D and bone ALP as well as additional benefit on bone formation was confirmed. The vitamin D insufficient group showed statistically significant increment in serum 25(OH)D3 compared with the normal group (p < 0.05). However, there was no significant difference between two groups in the other bone turnover markers, such as serum calcium, PTH-C, serum osteocalcin, serum CTX and BMD. CONCLUSION: Low-energy-short-term UVB radiation for postmenopausal women may be of use in vitamin D synthesis. There was a modest benefit in change of bone ALP especially in women with the insufficient vitamin D.

Distal tibial pilon fractures (AO/OTA type B, and C) treated with the external skeletal and minimal internal fixation method.

BACKGROUND/AIM: Distal tibial pilon fractures include extra-articular fractures of the tibial metaphysis and the more severe intra-articular tibial pilon fractures. There is no universal method for treating distal tibial pilon fractures. These fractures are treated by means of open reduction, internal fixation (ORIF) and external skeletal fixation. The high rate of soft-tissue complications associated with primary ORIF of pilon fractures led to the use of external skeletal fixation, with limited internal fixation as an alternative technique for definitive management. The aim of this study was to estimate efficacy of distal tibial pilon fratures treatment using the external skeletal and minimal internal fixation method. METHODS: We presented a series of 31 operated patients with tibial pilon fractures. The patients were operated on using the method of external skeletal fixation with a minimal internal fixation. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. RESULTS: This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. The average follow-up was 21.86 (from 12 to 48) months. The percentage of union was 90.32%, nonunion 3.22% and malunion 6.45%. The mean to fracture union was 14 (range 12-20) weeks. There were 4 (12.19%) infections around the pins of the external skeletal fixator and one (3.22%) deep infections. The ankle joint arthrosis as a late complication appeared in 4 (12.90%) patients. All arthroses appeared in patients who had type C fractures. The final functional results based on the AOFAS score were excellent in 51.61%, good in 32.25%, average in 12.90% and bad in 3.22% of the patients. CONCLUSION: External skeletal fixation and minimal internal fixation of distal tibial pilon fractures is a good method for treating all types of inta-articular pilon fractures. In fractures types B and C dynamic external skeletal fixation allows early mobility in the ankle joint.

[External fixation in the treatment of shooting proximal humeral fracture with bone defect: a case report].

INTRODUCTION: Shooting injuries of shoulder with destruction of proximal humerus are rare and severe orthopaedic injuries. CASE OUTLINE: A 74-year-old patient was wounded at close range by a shotgun. He was wounded in the left shoulder and suffered a massive defect of the proximal humerus and soft tissue. The neurocirculatory finding of the injury extremity was normal. After a short resuscitation, x-ray of the thorax and the left shoulder registered a complete destruction of humeral head. After the primary treatment of the wound under general endotracheal anesthesia, the shoulder was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins, where two pins were placed in the neck of scapula and two in the humeral shaft, because the left scapular acromion was fractured by shotgun projectiles. CONCLUSION: After radical wound debridement, external fixation is the method of choice for shoulder stabilisation in shooting injury of shoulder with bone defect. If this is not possible, pins of the left external skeletal fixator should be placed into the coracoid process and acromion. The pins can be also placed into the humeral shaft, as done in the presented case, and by which a good stability of the injured proximal humerus, easy approach to the wound for bandaging and reconstructive surgery can be achieved.