Abstract Although nonoperative treatment is recognized as an effective treatment method for humeral shaft fractures, it is associated with an approximately 10% risk of nonunion and long-term impairments of the shoulder joint. There is a growing interest to treat even simple humeral shaft fractures operatively to avoid these problems. Intramedullary (IM) nailing has proven to be very effective in the treatment of femoral and tibial shaft fractures and the same method has been adopted for humeral shaft fractures. However, the results regarding union rate and shoulder joint function after antegrade insertion of an IM nail have been very controversial. The purpose of this study was to investigate fracture union, shoulder joint function and symptoms after antegrade IM nailing of humeral shaft fractures, to assess safety and results of IM nailing in pathological fractures, to evaluate the efficacy of exchange nailing and Ilizarov's technique in the treatment of nonunion after IM nailing and to find out, by comparing shoulder joint symptoms and function after antegrade IM nailing and dynamic compression (DC) plate fixation, whether antegrade access to the medullary cavity is the main reason behind shoulder joint problems. During the years 1987-1997, 126 humeral shaft fractures were operated upon in Oulu University Hospital using antegrade IM nailing. The nonunion rate was 22% and distraction of the fracture fragments was the most important risk factor associated with nonunion. The reoperation rate, for various reasons, was 25%. Shoulder joint pain and impairment of function was present in 37% of the patients. In the treatment of 18 pathological fractures IM nailing was a rapid and safe operation, associated with good pain relief. Exchange nailing of 13 cases of nonunion after IM nailing resulted in a union rate of 47% and this method is not useful in the humerus in contrast to tibial and femoral fractures. Permanent nonunion leaves the patient with severe impairment of the shoulder joint and a loose nail may lead to severe osteolysis of cortical bone. In complicated nonunion with poor bone quality, Ilizarov's technique, although associated with a high rate of minor complications and reoperations, worked well. When IM nailing was compared with DC plating it was found that there were no significant differences in shoulder pain, function scores, range-of-motion and strength. Antegrade insertion of the nail, if carried out properly, is probably not the main reason for shoulder joint impairment after IM nailing. Antegrade IM nailing of humeral shaft fractures is associated with several problems, e.g. shoulder joint impairment and difficulties in reconstruction after nonunion, and indications for this method may be exceptional, such as comminuted and pathological fractures.

<p>Kompleksnost visokoenergetskih preloma platoa i pilona tibije i njihova udruženost sa značajnim povredama mekog tkiva oko pripadajućeg zgloba veoma je dobro opisana. Lečenje ima za cilj da multifragmentarni prelomi platoa i pilona tibije postanu stabilni, artikularno poravnani, bezbolni, da koleno i skočni zglob budu pokretni i da se minimizira rizik do nastanka posttraumatskog osteoartritisa. Aparat po Ilizarovu sa nategnutim iglama, koristi opterećenje da stvori jedinstvenu podr&scaron;ku za zglob i stabilnu imobilizacju preloma da se postigne njegovo srastanje. Ovo omogućuje ranu pokretljivost zgloba bez rizika od gubitka redukcije. Cilj istraživanja je procena i poređenje rezultata lečenja unutarzglobnih vi&scaron;ekomadnih preloma kostiju proksimalnog i distalnog okrajka potkolenice tretiranih spoljnjim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu primenom ASAMI ko&scaron;tanog skoring sistema i funkcionalnog skoring sistema po Karlstrom &ndash; Olerudu.Takođe je jedan od ciljeva istraživanja bio da se uoče faktori koji utiču na različite rezultate lečenja unutarzglobnih vi&scaron;ekomadnih preloma kostiju gornjeg i donjeg okrajka potkolenice tretiranih spoljnim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu. Istraživanje je dizajnirano kao kontrolisana komparativna klinička studija a podaci su se prikupljali retrospektivno i delom prospektivno na osnovu medicinske dokumentacije od 2008. do 2013. godine. Studija je u potpunosti izvedena na Klinici za ortopediju i traumatologiju Kliničkog centra Vojvodina u Novom Sadu. Studija je obuhvatila ukupno 103 ispitanika kod kojih je u toku 2008 do 2013. godine postavljena dijagnoza unutarzglobnog vi&scaron;ekomadnog preloma gornjeg ili donjeg okrajka tibije. Ispitanici koji su obuhvaćeni ovim kliničkim istraživanjem razvrstani su u tri grupe: Prvu grupu od 53 ispitanika činili su oni sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo spoljnjim unilateralnim rigidnim fiksatorom. Drugu grupu ispitanika, njih 31, činili su oni sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo aparatom po Ilizarovu. Treću grupu činila su 19 ispitanika sa vi&scaron;ekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice koji su lečenje započeli spoljnjim unilateralnim rigidnim fiksatorom, a u kasnijem periodu zbog nastalih komplikacija (lo&scaron;e srastanje, produženo srastanje, nesrastanje, infekcija, pseudoartroza) lečenje nastavili konverzijom spoljnjeg unilateralnog rigidnog fiksatora u aparat po Ilizarovu. Osnovni izvor podataka za prikazano istraživanje bio je protokol formiran za svakog bolesnika pojedinačno, istorije bolesti i poliklinička evidencija. Za potrebe istraživanja dizajniran je protokol istraživanja gde su se prikupljeni podaci analizirali hronolo&scaron;ki : podaci o pacijentu, klinički nalaz na prijemu, postoperativni tok, monitoring aparata, klinički nalaz na otpustu i klinički nalaz na kontrolama od 6, 12 i 18 meseci. Kliničke nalaze na kontrolama na 6, 12 i 18 meseci beležili smo upotrebom skoring sistema ASAMI ( Udruženja za istraživanje i primenu metoda po Ilizarovu) &ndash; za ko&scaron;tane rezultate, i Karlstrom &ndash; Oleruda za procenu funkcionalnih rezultata. Neki do najvažnih rezultata dobijenih prilikom ovog istraživanja jesu da je najbrže vreme srastanja imala grupa Ilizarov, nakon 16&plusmn;2 nedelja. Grupa konverzija zabeležila je prosečno vreme srastanja u 17&plusmn;2 nedelji, dok je kod ispitanika u grupi fiksator zabeženo srastanje u 21&plusmn;4 nedelji. Pojava povr&scaron;nih i dubokih infekcija značajno je veća kod grupe tretiranih spoljnim unilateralnim fiksatorom nego kod grupa tretiranih aparatom po Ilizarovu. Vreme postizanje ranog, punog oslonca na operisani ekstremitet je značajno kraće kod grupe Ilizarov i konverzija nego kod grupe fiksator. Procena ko&scaron;tanih rezultata kori&scaron;ćenjem ASAMI bodovnog sistema ko&scaron;tanog srastanja ukazuje na statistički značajno bolje rezultate kod grupa Ilizarov i konverzija u odnosu na grupu spoljnji fiksator u periodu praćenja i analize na 6,12 i 18 meseci. Funkcionalni rezultati primenom sistema funkcionalne evaluacije po Karlstrom &ndash; Olerudu govore u prilog značajno statistički boljim rezultatima kod grupe Ilizarov i konverzija u odnosu na grupu spoljni fiksator u periodima praćenja i analize na 6,12 i 18 meseci. Na osnovu dobijenih rezultata dolazimo do zaključka da je tretman ispitanika sa multifragmentarnim, intraarikularnim prelomima gornjeg i donjeg okrajka kostiju potkolenice znatno efikasniji aparatom po Ilizarovu &scaron;to sveukupno daje smernice za brži i kvalitetniji oporavak ispitanika i njihov povratak svakodnevnim aktivnostima sa &scaron;to manjim posttraumatskim sekvelama.</p> / <p>The complexity of high-energy fractures of the tibia plateau and pilons and their association with significant violations of the soft tissue around the corresponding joint is well described in the literature. Main aim of the treatment is to multiple fractures of the tibia plateau and pilon become stable, articularly aligned, without pain, and with full motion in the knee and ankle joint with minimum risk for post-traumatic osteoarthritis. Ilizarov apparatus with taut needles is used to create a unique load support for the ankle and create conditions for good healing. This strong stability allows early joint movement, without risk of loss position of fracture parts. The aim of this research is assessment and comparation of the results of treatment, for intraarticular multiple fractures of the proximal and distal part of lower leg tretaed with unilateral external rigid fixator and Ilizarov apparatus, with ASAMI bone scoring system and functional scoring sistem by Karlstrom &ndash; Olerud. One of the goals of the study was to detect factors which affecting different treatment results of the intraarticular multiple fractures of the proximal and distal part of lower leg, tretaed with unilateral external rigid fixator and Ilizarov apparatus. The study was designed as a controlled comparative clinical study and data were collected retrospectively and prospectively form medical records from 2008 to 2013. The study has been fully implemented at the Department for orthopedic surgery and traumatology in the Clinical Center of Vojvodina in Novi Sad and included 103 patients who had intraarticular multiple fractures of the proximal and distal part of tibia. Subjects covered in this clinical study were classified into three groups: The first group of 53 patients were with intraartiulary multifragmentary open or closed fractures of the upper or distal part of lower leg, treated exclusively with unilateral external rigid fixator. The second group included 31 patients with intraarticular open or closed fractures of the upper or distal lower leg, treated exclusively with Ilizarov apparatus. 19 patients made the third group with intraarticulary open or closed fractures of the upper or distal lower leg, which were treated at the begining with unilateral external rigid fixator and later because of the complications (poor or prolonged healing, nonunion, infection and pseudoarthrosis) tretment was continued by Ilizarov apparatus. The main source of data for this study was protocol wich was established for each patient individually. In this protocol collected data analyzed by date: patient data, clinical findings at admission, postoperative course, monitoring apparatus, clinical findings at discharge and clinical findings at the controls which were at 6, 12 and 18 months after surgery. Clinical findings at control examinations (6, 12 and 18 months after surgery), we recorded by scoring system ASAMI (Association for the Study and Application of the Methods of Ilizarov) - that represent the results of the bone healing, and Karlstrom - Olerud for assessment functional outcomes. The most important results were: the fastest time of bone union was in the group of Ilizarov, and it was after 16 &plusmn; 2 weeks and the third group (conversion group) recorded an average time after 17 &plusmn; 2 weeks, while the patients in the first group (external fixator) had average time of union after 21 &plusmn; 4 week. The appearance of superficial and deep infection was significantly higher in the group treated with unilateral external fixator than in the group treated by the Ilizarov apparatus. Fastest full weight bearing on the injured leg, had patients in the group treated with Ilizarov apparatus. Evaluation of results using bone ASAMI fusion scoring system indicating a statistically significantly better results in the conversion and Ilizarov group compared to the group of external fixator in the period of monitoring at 6,12 and 18 months after surgery. Functional results by Karlstrom - Olerud scoring system show statistically significantly better results in the Ilizarov and conversion group contrary to the external fixator group in periods of monitoring at 6,12 and 18 months. Based on these results we conclude that the treatment of subjects with intraarticulary, multifragmentary fractures of the upper and lower part of the lower leg are more efficient after Ilizarov apparatus which provides overall guidance for faster and better recovery of patients and their return to their daily activities with minimal post-traumatic sequelae.</p>