The management of injury to the ulnar and radial collateral ligaments at the metacarpophalangeal joint of the thumb is complex. Treatment is dependent upon a number of factors with a wide variety of options for each ligament. Inadequate treatment has the potential to lead to a poor functional outcome. We present the relevant clinical anatomy, mechanism of injury, methods of treatment available and suggest a single treatment algorithm for use in the management of these injuries.

Bone and soft tissue malignancies are associated with serious diagnostic and therapeutic problems in every level of pubertal growth in children. Current treatment modality preferred in bone and soft tissue tumors is wide resection of tumor followed by the reconstruction of consequent defect by various methods. Chemotherapy and radiotherapy are applied for systemic effects to the patient pre- and post-operatively and for local effects that facilitate the surgical procedure. Mostly, it is very difficult to control problems following wide resection and reconstruction. In this study, our aim is to discuss the problems encountered in different resection and reconstruction approaches in childhood bone and soft tissue tumors, and the recommended solutions addressed to these problems. From 1990 to 2003, a total of 68 patients (38 female, 30 male) with a mean age of 13.1 (1.5–18) were included in the study. 85.3% of patients were diagnosed as osteosarcoma and the rest was Ewing's sarcoma. Seventy-five percent of patients had stage IIB disease. The lesions of 34 patients were detected to be in distal femur, 26 in proximal tibia and fibula, 4 in foot and ankle joint, and the remaining 4 in pelvis. As reconstructive surgery, 40 patients had modular prosthesis, vascularized fibular graft was performed in 13 patients, and 10 patients underwent arthrodesis with vascularized fibular graft. 20.6% of patients had shortened limb, infection was detected in 4 patients, laxity in 5, and restricted motion in 4 as complication of prosthesis. With sacrificed physis, 13 patients had a mean value of 4.6 cm limb shortness. Limb salvage surgery has been considered as the gold standard treatment in orthopedic oncological surgery. More understanding of the biology of sarcoma, introduction of new effective chemotherapeutic agents, development of new techniques concerning the surgical resection, advances in diagnostic methods, and improvements in reconstructive surgery all make a major contribution to limb salvage surgery. Since some problems are still encountered, we offer a therapeutic algorithm for complications in the management of childhood tumors that we have encountered so far.

We present the results of treatment of 100 patients (72 men, 28 women) by the Ilizarov method of bone transport using circular (55) and monolateral external fixators (45). A total of 26 femurs (18 monolateral, 8 circular) and 74 tibias (49 circular, 25 monolateral) was examined. There were no significant differences between the circular fixator and the monolateral fixator with regard to treatment time, complications in the treated bone segments or compliance with the presence of the fixator. The main complications (pseudoarthrosis at bone contact points after transport, insufficient ossification of lengthened bone, knee stiffness) were resolved with further treatment for all patients with the exception of one case which continued with repeated infections. The circular fixator allows for deformity corrections during bone transport but the monolateral fixator is tolerated better by patients, especially in those with femoral defects.

The callotasis lengthening technique was used to gradually lengthen the capitate after resection of the lunate in stage IIIa necrosis in 23 patients. Results of ten patients with a follow-up of at least 5 years showed rapid and sufficient callus formation in every patient regardless of age. The callotasis lengthening modification of the Graner II operation provides all advantages and avoids the major inconvenience of the traditional Graner II operation. There was no increased rate of disturbed fracture healing. Results of the DTPA-gadolinium MRI study did not show any significant impairment of vascularization within the region of the capitate bone. With the “intrinsic bone formation,” contrary to every other intercarpal arthrodesis at the wrist, there is no need for an additional bone graft.

Revision knee arthroplasty for infection poses a treatment challenge. The presence of massive osteolysis limits the treatment options in this cohort. Controversy exists in the management of these patients. Direct exchange arthroplasty has provided good results in the presence of infection, but whether this is appropriate in the presence of massive bone defects associated with the infection is undetermined. We present our experience in revision knee arthroplasty for infection associated with massive bone defects. The aim of the study is to present the preliminary results of a direct exchange endoprosthetic reconstruction with tumour prosthesis for periprosthetic infection associated with segmental bone defects. This is a retrospective study of prospectively collected data, involving six patients with periprosthetic infection and massive bone defects treated by direct exchange tumour prostheses between 2003 and 2007 (four distal femoral replacements and two total femoral replacements). The mean age and follow-up were 74.2 (±5.2) years and 32.5 (±8.2) months respectively. Each patient had an infected revised knee arthroplasty at the time of referral to our institution. Staphylococcus aureus was the most common causal organism. The mean duration of antibiotics was 6 weeks intravenous therapy followed by 3.5 months oral. The recurrences of infection, pain or immobility were outcome criteria considered failures. Our success rate was 80%. Salvage of infected revised knee arthroplasty by direct exchange endoprosthetic reconstruction has provided an effective means of pain relief, joint stability and improved mobility in our cohort. It reduces morbidity through earlier mobilisation and avoids a second major operation.

Sixteen patients underwent minimally invasive subtalar arthrodesis through a mini-invasive approach with posterior iliac graft between 2004 and 2006. No hardware was used to transfix the arthrodesis and partial weight bearing was allowed immediately. The primary indication for surgery was the squeal of fracture os calcis in terms of subtalar joint arthritis, loss of heel height, malalignment of the hindfoot, and pain with weight bearing. There were 12 male and 4 female patients with a mean age of 30 (range 17–52). Patients were followed up for a period of 40.8 months (range 36–48 months). The mean interval from injury to fusion was 2 (+0.6) years ranging from 6 months to 6 years post fracture. The average clinical rating scale based on the American Orthopaedic Foot and Ankle Society (AOFAS) improved from 36 preoperatively to 78 at the latest follow-up (P < 0.05). Union rate was 94%. Radiographic evaluation revealed a mean increase in calcaneal inclination of 6.25 + 8.3° (P < 0.07) and a mean increase in the lateral talocalcaneal angle of 7.42 + 10.2° (P < 0.08). Complications were graft nonunion in 1 patient and transient tendoachilles tendinitis in another. This technique can be used to decrease the morbidity associated with the late complications of os calcis fractures by aligning the hindfoot, restoring the heel height and correcting calcaneal and talar inclination. It offers the advantage of early weight bearing while avoiding hardware complications.

We report a case of a 27-year-old man who was involved in a high-speed car accident. He sustained multiple organ damage including multiple brain petechiae suggesting diffuse axonal damage, aortic dissection, retroperitoneal haematoma and a fracture-dislocation of the right hip with a femoral head fracture and an ipsilateral intertrochanteric fracture. Due to the general condition of the patient, physiological stabilisation was prioritized, and at 2 weeks the fracture-dislocation of the hip was treated with a proximal femoral nail for the intertrochanteric fracture and Herbert screws for the femoral head fracture. Postoperatively, two episodes of recurrent hip dislocation occurred, and this was stabilized eventually with a Steinman pin inserted across the hip joint and taken out 1 month later. Weight-bearing was allowed according to clinical and radiographical assessments. Heterotopic ossification developed around the hip joint, but without evidence of AVN or osteoarthritis. At 18-months follow-up, the fractures had healed and the patient had a Harris Hip score of 79.1. Anatomical reduction and stable fixation of fracture-dislocations of the hip are important for achieving an acceptable result.

Tuberculous dactylitis is an uncommon condition which is particularly difficult to differentiate from other lesions, particularly tumors. We report the case of a 56-year-old, healthy, left-handed person who consulted for progressive painful swelling of 8-month duration in the right thumb, which had developed after direct trauma. The plain radiograph of the thumb revealed extensive destruction of the proximal phalanx associated with pathological fracture. Magnetic resonance imaging (MRI) showed replacement of the affected phalanx with prominent soft tissue mass with extension outside the bone margins. The diagnosis of tuberculous dactylitis was based on histological characteristics and positive acid fast bacilli using Ziehl-Neelsen stain. Surgical debridement and anti-tuberculous chemotherapy eradicated the infection. Seven years post treatment, the patient had good function of the thumb with no significant disability interfering with his daily activity.