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Abstract: Calcaneal fractures are rare in pediatric population, with more displaced intra-articular fractures encountered due to the increasing number of high-energy trauma. Operative interventions are gaining popularity because of the unsatisfactory outcomes of traditional conservative methods. This study investigated the clinical outcomes of a minimally invasive technique using the sinus tarsi approach and external fixator in the treatment of intra-articular calcaneal fractures in pediatric patients.Patients who underwent open reduction between January 2010 and January 2018 at our institute were included in this study and reviewed retrospectively. Radiological and clinical parameters were all recorded and analyzed.Overall, 29 patients were included in the study, including 23 boys and 6 girls (10.2 ± 2.2 years old). The average follow-up was 29.5 months postoperatively (range, 26-72 months). Bohler angle was 15.2 ± 3.3° preoperatively, and 34.0 ± 3.8° postoperatively (P < .001); Gissane angle was 101.8 ± 6.2 degrees preoperatively, and 129.7 ± 6.2° postoperatively (P < .001). The average length of incision was 3.4 ± 0.7 cm. At the last follow-up, all patients showed satisfactory clinical outcomes and the score was 90.0 ± 2.3 according to American Orthopedic Foot and Ankle Society Scale.Minimally invasive approach with external fixator is an effective method for treating displaced intra-articular calcaneal fractures in pediatric patients, with a lower incidence of wound-related complications and good cosmetic outcomes., Competing Interests: The authors have no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Staged leg lengthening allows achondroplastic dwarfs to reach nearly normal height, but it takes long periods of external fixation and it can be burdened by delayed unions. Between 2009 and 2013, eight achondroplastic dwarfs showed delayed unions in the callus formation during femoral lengthening stages in our institute. We performed in-situ injections of bone marrow-derived stem cell concentrates. Patients underwent monthly clinical and radiographic assessment for determination of the healing rate. All eight patients showed an improvement in the regenerated bone, with an average healing index of 23.1 days/cm (range: 18.7-23.8 days/cm). The complete recovery of the delayed consolidation took on an average of 5.2 months (range: 2-10 months). The use of cellular therapy in these patients could represent an innovative application.

The aim of this study was to compare clinical and radiographical results for treatment of lower limb multiaxial deformities±limb length discrepancy (LLD) of at least 2 cm with the Truelok hexapod fixator system (TL-HEX). All consecutive cases of lower limb multiaxial deformities were included. Patients were divided in two groups: group 1, lower limb angular deformity+LLD less than 2 cm, and group 2, lower limb angular deformity+LLD of at least 2 cm. Only patients with age younger than or equal to 20 years and follow-up of 6 months after removal of the external fixator were included. A total of 27 (six femur and 39 tibia treated) and 20 patients (12 femur and 19 tibia) were enrolled in groups 1 and 2, respectively. Complete correction of the deformity was achieved in 90 and 96% of the patients in groups 1 and 2, respectively. There were no differences in terms of external fixator, maturation, and distraction indexes between the two groups and between different anatomical sites. Good to excellent functional results (ASAMI score) were obtained in 93% of patients in group 1 and 75% in group 2 (P=0.01). Complication rate was similar between the two groups (7.4 vs. 10%, respectively). Average follow-up after removal of the external fixator was 25.6 (range: 7.0-54.0) months. The TL-HEX external fixator system allows a predictable correction of complex lower limb deformities regardless of the presence of LLD. Although complication rate is similar between the two groups, lower functional outcomes can be expected in patients with significant preoperative LLD.

Background: Metacarpal lengthening by distraction osteogenesis has been well documented in pediatric patients but limited in older patients. Fewer studies have assessed the success of the procedure through outcome measure scores. The purpose of this study is to assess the outcomes of distraction osteogenesis in skeletally mature adults with brachymetacarpia and patients' perspectives on their satisfaction through outcome measure scores., Methods: Retrospective chart review of a consecutive series of metacarpal lengthenings for the treatment of brachymetacarpia was performed. Key parameters collected include starting metacarpal length, amount lengthened, range of motion of metacarpophalangeal joint, type of fixator used, distraction time, and total time in fixator. Relevant comorbidities and complications encountered were recorded as well. The Body Image Quality of Life Inventory (BIQLI) and Limb Deformity Modified Scoliosis Research Society (LD-SRS) score were given to evaluate patients' perspectives on their satisfaction of surgery., Results: Seven metacarpal lengthenings were performed in 4 adult females (average age: 22.8 years) between 2005 and 2016. The average amount lengthened was 1.5 cm (range, 1.2-2.1 cm), corresponding to a mean percent lengthening of 44.4% (range, 33.3%-57.1%). The mean distraction rate was 0.432 mm/day (range, 0.286-0.724 mm/day). The mean distraction time was 38 days (range, 28-55 days). External fixation index was 71.8 days/cm (range, 53.5-99.2 days/cm). No functional loss was observed., Conclusions: Progressive distraction osteogenesis can obtain functionally successful results and improvement in aesthetics and body image without severe complications in skeletally mature adults with brachymetacarpia.

The treatment of a missed Monteggia (MM) fracture dislocation is still controversial. We describe our initial experience with ulnar osteotomy and progressive correction with unilateral external fixator in MM. We retrospectively evaluated 20 children undergoing ulnar osteotomy and progressive distraction angulation by unilateral external fixator to treat MM. Nine patients had closed reduction, whereas 11 patients had simultaneous open reduction, repair, or reconstruction of the annular ligament and K-wire stabilization of the radiocapitellar joint. Patients were followed for an average of 3 (1-11) years. Three children developed aseptic nonunion and one child had delayed union. A distal level of the osteotomy significantly increased the rate of nonunion or delayed union. At the final follow-up, eight children had complete reduction of the radial head, six children had partial reduction, whereas in six cases, the radial head remained dislocated. The angulation and the level of the osteotomy significantly influenced the relocation, whereas the open reduction had no significant effect on the final position of the radial head. At the final follow-up, the Kim's score averaged 93.25. The flexion-extension arc significantly improved postoperatively, and it was positively correlated with the angulation. The ulnar osteotomy and progressive traction-angulation by unilateral external fixator can achieve satisfactory results in MM, if a meticulous surgical technique is applied; care must be taken regarding the level of osteotomy and the progressive traction-angulation.

Multiple versions of ring fixators are currently available to orthopaedic surgeons. Although the traditional Ilizarov-type ring fixator is still available, many surgeons are now using computer-assisted hexapod frames. There has been a recent surge in the number of different hexapod ring fixators on the market. This article will review some of the new trends in ring fixator hardware and software as well as discuss possible future directions of ring fixator development.

Objectives: No studies have assessed the effects of parameters associated with insertion temperature in modern self-drilling external fixation pins. The current study assessed how varying the presence of irrigation, insertion speed, and force impacted the insertion temperatures of 2 types of standard and self-drilling external fixation half pins., Methods: Seventy tests were conducted with 10 trials for 4 conditions on self-drilling pins, and 3 conditions for standard pins. Each test used a thermocouple inside the pin to measure temperature rise during insertion., Results: Adding irrigation to the standard pin insertion significantly lowered the maximum temperature (P <0.001). Lowering the applied force for the standard pin did not have a significant change in temperature rise. Applying irrigation during the self-drilling pin tests dropped average rise in temperature from 151.3 ± 21.6°C to 124.1 ± 15.3°C (P = 0.005). When the self-drilling pin insertion was decreased considerably from 360 to 60 rpm, the temperature decreased significantly from 151.3 ± 21.6°C to 109.6 ± 14.0°C (P <0.001). When the force applied increased significantly, the corresponding self-drilling pin temperature increase was not significant., Conclusions: The standard pin had lower peak temperatures than the self-drilling pin for all conditions. Moreover, slowing down the insertion speed and adding irrigation helped mitigate the temperature increase of both pin types during insertion.

The application of lessons learned on the battlefield for timely surgical control of lower extremity hemorrhage secondary to blast injuries to the civilian practice for similar wounding patterns from industrial accidents or terrorist activities is imperative. Although simple cut-down procedures are commonly sufficient for the control of blood vessels for distal extremity traumatic amputations, high-thigh or disarticulation wounding patterns often require more complex surgical methods. The following details both the decision-making process and operative techniques for controlling hemorrhage from lower extremity blast injuries., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Background: Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality., Surgical Management: The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality., Conclusion: Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use., (Copyright © 2016 John Wiley & Sons, Ltd.)

With the increased number of diabetics worldwide and the increased incidence of morbid obesity in more prosperous cultures, there has become an increased awareness of Charcot arthropathy of the foot and ankle. Outcome studies would suggest that patients with deformity associated with Charcot Foot arthropathy have impaired health related quality of life. This awareness has led reconstructive-minded foot and ankle surgeons to develop surgical strategies to treat these acquired deformities. This article outlines the current clinical approach to this disabling medical condition., (Copyright © 2016 John Wiley & Sons, Ltd.)

Dr. Raoul Hoffmann of Geneva, Switzerland with the collaboration of Henri Jaquet developed the original Hoffmann external fixateur as a system for treating broken bones without necessarily opening a fracture site to reposition the bone ends. This system has evolved to a more flexible, modular concept with input from surgeons and engineers. In this chapter the modifications of the Hoffmann family of fixators are traced and the important steps in the development of the concept and the instrumentation emphasized., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Fractures with related problems including intercalary bone defect, shortening, and malunion are still major problems in orthopedic practice. The Ilizalov's circular external fixator device has several advantages for bone reconstruction but also has certain drawbacks such as its bulkiness and complicated mounting. To maintain the advantages of Ilizalov's original concept and combine with the simplicity of monolateral frame, a new design multifunction dynamic external fixator system was developed to overcome the drawbacks., Objective: To evaluate the clinical results and complications of a new design multifunction dynamic external fixator system for bone reconstructions., Material and Method: Twenty patients requiring reconstructions between 2006 and 2009 participated in this study. The new design multifunction dynamic external fixators were used in 11 tibial and two femoral intercalary defects for bone transportation, three tibial and one femoral lengthening, and three tibial malunion correction (45, 60 and 75 degrees)., Results: In bone transportation, new bone formation and union at the docking site were achieved in all patients. The mean new bone formation was 5.8 cm (range 3.5-14) in tibia and 4.3 cm (range 3.5-5) in femur. The mean healing index was 46.3 days/cm (range 42-60) in tibia and 93.9 days/cm (range 85.7-102) in femur. In bone lengthening, new bone formation and union were achieved in all patients. The mean amount of elongation was 3.5 cm (range 3-4) in tibia and 5 cm in femur. The mean healing index was 71.1 days/cm (range 68.6-76) in tibia and 73 days/cm in femur. In malunion correction, the mean correction time was 65 days (range 35-84) and the mean healing time was 187.3 days (range 154-212)., Conclusion: The new design multifunction dynamic external fixator system was successfully used for bone transportation, bone lengthening, and malunion correction with good results and low complications. It is simple, safe, and easy to use.

Phalangeal fractures and osteoarticular infections can be challenging injuries to manage, and their treatment is frequently complicated by deformity and stiffness. External fixation techniques have a well-established role in the treatment of these injuries. The mini-Hoffman external fixator is a particularly simple apparatus in design and in application. We report a technique of digital external fixator with a new original material developed in the service. It is an inexpensive and simple technique with good stability. The technical procedure is simple, consisting of two joints, Kirchner pins, 4mm diameter screwdrivers and a motor. Between 2001 and 2006, we used this method to treat 24 patients in a prospective study. The mean age was 35 years (range 16 to 68 years) with a male predominance, left hand predominance (14 cases), and carpenter's hand was the most frequent indication (11 cases). Mean duration of follow-up was two years (6 months to 5 years). Functional results were excellent in 12 cases and bad in six cases. Complications included a case of ischemic necrosis of the finger, two cases of secondary displacement, three cases of sepsis, two cases of algodystrophy and a case of pseudoarthrosis., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Dislocations and fracture dislocations with their typical fracture patterns may substantially affect the complex anatomy and integrity of the elbow joint. The more components of the joint are injured, the more technically demanding is the therapy. Standardized diagnostic and therapeutic algorithms help to avoid misinterpretations regarding the severity of the injury and the subsequent complications. In elbow dislocations and fracture dislocations with persistent instability the hinged external fixator is an excellent device to improve joint stability and allows physiotherapeutic assistance at an early stage.

The use of external fixation in the upper limb requires detailed anatomical knowledge. The centre of rotation in the elbow joint has to be understood and the bony landmarks have to be identified. The joint mechanics and the mechanics of the external fixation device have to be collinear in a wide range of the natural motion capacity. Insertion of humeral and ulnar pins considering the specific anatomy is described and post-operative diagnostic aspects are illustrated.

Elbow stiffness may result from trauma, burns and head injuries. It is defined as a total range of motion of <100° with no relevant loss of forearm rotation. Of particular relevance is the flexion deficit. A detailed analysis regarding the development of the elbow stiffness is required together with an exact diagnosis in order to plan the surgical intervention. Closed distraction of the elbow joint as arthrodiatasis with an external fixator is described and evaluated. Adequate long-term results can be achieved with this technique, which reflects proper selection of patients as well as coordination between surgeon, aftercare and physiotherapist. Contraindications are poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection and acute articular infection.

Closed and open dislocations of the knee joint with vascular and nerve injuries are treated immediately and may present an indication for external fixation. In acute trauma definitive treatment and reconstruction of the complex capsule and ligamentous injuries are often impossible. The application of a medial transarticular external fixator with motion capacity combines the treatment of remaining joint instability with the benefit of early joint movement. Disadvantages of prolonged joint immobilisation until definitive stabilisation of the knee are reduced.

The rising incidence of distal intra-articular humeral fracture in elderly patients associated with osteoporosis frequently leads to difficulties in acute reconstruction and may result in early failure of internal fixation. The biomechanics of the elbow joint and especially the flexor group as well as the brachioradialis muscle as part of the extensor group is analyzed. The complex motion pattern of the transarticular muscle groups increases the load on internal fixation and may affect the interface between implant and osteoporotic bone. An external fixator with motion capacity serves to protect the internal osteosynthesis and secures the fixation in osteoporotic bone.

Both the radiocarpal and distal radioulnar joints are often affected in"distal radius fractures". The incidence of this injury increases markedly among women over the age of 40. Bearing in mind the wide variety of distal radius fractures, a fixation system should be used which permits trans- and extra-articular application and subsequent reduction by means of distraction, as well as wrist mobilization. It is important that both reduction and position of the carpal bones can be checked. The possibility of extra-articular (radioradial) fixation should always be considered. AO group A2 and A3 fractures with sufficiently large fragments are suitable for this procedure. In other cases, transarticular application is advised. Complementary measures are justified in the case where two or more cortices in AP and lateral X-rays are destroyed. Adequate implants are also used to stabilize the articular surface. Large bone defects should be filled with corticocancellous material.

105 patients with intra- and periarticular fractures of the knee joint were operated on with the use of nail and spin-nail apparatus constructed by A.I. Gorodnichenko. The possibility of atraumatic closed bone fragments fixation allowed quick patients' activization, and, as follows, improved their life quality, decreased the hospital stay and minimized complication rate. Fracture consolidation was achieved in all cases, the only complication registered was skin inflammation around the nail in 5 patients.

Background: Mandibular distraction has evolved from the use of external to the use of intraoral and semiburied devices. The authors highlight the evolution of the semiburied technique. The authors evaluate advantages and limitations, and report perioperative events for external and semiburied techniques to establish the indications for selection of the different devices., Methods: A retrospective review was conducted of patients undergoing mandibular distraction at the New York University Langone Medical Center from the authors' introduction of mandibular distraction in May of 1989 to June 30, 2009. Perioperative events were stratified into three groups: minor incidents, moderate incidents, and major incidents., Results: A total of 211 mandibular distraction procedures were performed: 129 external procedures on native bone, 37 external procedures on grafted bone, and 45 semiburied procedures on native bone. Minor incidents were more common with the semiburied device (62 percent) compared with external devices on native (26 percent) and grafted (38 percent) bone. There were fewer moderate incidents with the semiburied device (18 percent) than with the external device on native (22 percent) and grafted (30 percent) bone. In contrast to the external technique, no major incidents were seen with semiburied distraction., Conclusions: The semiburied device reduces scarring and has the mechanical advantages of being applied directly to the bone, less vulnerable to dislodgment, and more favorable for a vertical vector. However, its use requires more bone stock and it has the disadvantage of requiring a second operation for removal. Semiburied distraction is safe, reliable, and indicated for lengthening of the hypoplastic mandible where there is adequate bone stock for its attachment., (© 2010 American Society of Plastic Surgeons)

Odontoid fractures currently account for 9-15% of all adult cervical spine fractures, with type II fractures accounting for the majority of these injuries. Despite recent advances in internal fixation techniques, the management of type II fractures still remains controversial with advocates still supporting non-rigid immobilization as the definitive treatment of these injuries. At the NSIU, over an 11-year period between 1 July 1996 and 30 June 2006, 66 patients (n = 66) were treated by external immobilization for type II odontoid fractures. The medical records, radiographs and CT scans of all patients identified were reviewed. Clinical follow-up evaluation was performed using the Cervical Spine Outcomes Questionnaire (CSOQ). The objectives of this study were to evaluate the long-term functional outcome of patients suffering isolated type II odontoid fractures managed non-operatively and to correlate patient age and device type with clinical and functional outcome. Of the 66 patients, there were 42 males and 24 females (M:F = 1.75:1) managed non-operatively for type II odontoid fractures. The mean follow-up time was 66 months. Advancing age was highly correlated with poorer long-term functional outcomes when assessing neck pain (r = 0.19, P = 0.1219), shoulder and arm pain (r = 0.41, P = 0.0007), physical symptoms (r = 0.25, P = 0.472), functional disability (r = 0.24, P = 0.0476) and psychological distress (r = 0.41, P = 0.0007). Patients >65 years displayed a higher rate of pseudoarthrosis (21.43 vs. 1.92%) and established non-union (7.14 vs. 0%) than patients <65 years. The non-operative management of type II odontoid fractures is an effective and satisfactory method of treating type II odontoid fractures, particularly those of a stable nature. However, patients of advancing age have been demonstrated to have significantly poorer functional outcomes in the long term. This may be linked to higher rates of non-union.

Conservative treatment still has an important role to play, despite the increasing possibilities of surgical treatment. Treatment starts at the site of trauma. Transportation and immobilisation in braces are discussed. Skeletal skull traction can be used for realignment and reduction, and eventually used in halo-vest treatment. The advantages and disadvantages of these different treatment options are discussed.

Background: The market-release of a modified 'mandible external fixator' appliance prompted us to reconsider the issues of pin fixation., Materials and Methods: The first product line of the 'mandible external fixator set-Phase1' (Synthes Maxillofacial, Paoli, USA) contains the three classical basic components: percutaneous pins, clamps, and pre-bent connecting rods. The innovative features are a lightweight titanium construct and the snap-on design of the clamps. The framework is assembled by a single connecting bar (monofixator) in the so-called visor-style technique., Indications: The indication was restricted to: (1) pathological fractures, e.g., in infected osteoradionecrosis; (2) resectional defects; and (3) emergency care of mandible fractures in a multi-piece, heavy comminution, or defect pattern., Patients: The mandible external fixator was used in a series of ten patients (all male, 39-73 years), for head and neck tumor sequelae in eight cases (n = 5-curatively, n = 3-palliation) and in two polytrauma cases., Results: All patients had benefited from the functional restitution of the mandibular continuity avoiding major surgical exposure and additional soft tissue damage. The application using a 'visor-style technique' was appropriate for bridging defects or single comminution zones (n = 9). In the emergency care of a polytraumatized patient with multifragmentation all over the mandible divisions, it did not contribute to an adequate realignment. In curative tumor treatment (patients n = 5), a conversion either to internal fixation (n = 2) or revascularized bone grafting (n = 3) ensued after prolonged intervals of 40-170 days. Pin track infections or loosening did not occur., Conclusion: The hallmark of external pin fixation is its atraumatic soft tissue management. Hence, it offers peculiar options in singular comminution or defect areas associated with bone pathology and/or soft tissue alterations.

Objectives: To determine if indications for external fixator treatment of radial and tibial fractures, management of the fractures, or outcomes have changed over three decades., Methods: Three groups of dogs were identified from discrete time spans within three decades and the medical records and radiographs were evaluated. The groups were compared in order to determine whether indications (signalment, etiology, fracture type and configuration), reduction method, equipment and implants, frame types and pin numbers, numbers of radiographic reevaluations, use of destabilization, frequency of pin track osteolysis, frame removal times and percentage of complications remained the same over the decades., Results: The indications for external fixator treatment of radial and tibial fractures remained consistent over three decades. The equipment and implants changed over the decades. Frame construction changed from the predominately Type II frames constructed in the 1980's and 1990's to a variety of modified Type II, Type Ia, Type Ib and hybrid frames constructed in the 2000's. The frequency of pin track osteolysis decreased significantly over the decades. Frame removal times have not changed significantly over the past three decades. Complications (nonunion, delayed union, osteomyelitis, implant failure and premature frame loss) have decreased over this time., Clinical Significance: Improvements in techniques and equipment have led to decreased complications with external fixators.

Background: In the management of basilar invagination, traction therapy may help by pulling down the odontoid process away from the brain stem that may result in clinical and radiological improvement. We aimed to discuss the role of the halo vest apparatus traction on the reduction of severe anterior compression pathologies in basilar invagination., Case Description: We describe a simple and safe cervical traction method by the halo vest apparatus that is followed by rigid posterior occipitocervical fixation and foramen magnum decompression in a patient who presented with basilar invagination and symptoms of severe brain stem compression. An MR-suitable halo vest apparatus was used for reduction of the deformity. The reduction of the basilar invagination was achieved gradually by distracting the halo crown in stages., Conclusion: The halo vest apparatus can be safely used in complex craniocervical junction anomalies. An effective cervical traction can be performed in basilar invagination, and reduction of the deformity may be achieved without the risk of overdistraction. In some cases, even partial reduction of the deformity may facilitate brain stem and spinal cord relief without any need of posterior decompression. Patients may benefit from ambulatory functions because bed rest is eliminated in this procedure. Neurovascular structures and the degree of the reduction can be observed on MRIs when an MR-suitable device is used.

Although the basic design of external fixators has changed little in the last 50 years, advances in pin engineering are decreasing rates of infection and loosening. Newer limb-specific frames are easier to apply to the ankle and novel designs in ring fixators are improving the field of deformity correction. Just as important as any technical improvement, though, is a more refined understanding of the merits and weaknesses of the technique. There are many applications in which external fixation is the best option and others in which it is the only surgical option. Because of this, external fixation will remain an essential tool for future orthopedic surgeons.

Operative repair in ruptures of the extensor mechanism of the knee joint mostly requires additional external or internal fixation by plaster, transfer of tendons or encircling wires. Reconstruction of initially undiagnosed ruptures has to solve the problems of fixed proximal or distal migration of the patella and tendenous shortening. This can be performed with a tibiopatellar external fixator which allows gradually reduction of the patella in an anatomical position before operative reconstruction by suturing or reinsertion. During this period as well as a post-operative protection this fixator enables patients to maintain motion of the knee joint and full weightbearing. This technique can avoid poor functional results caused by long periods of immobilisation and is helpful in patients with marked displacement of the patella and inability to manually reduce the patella distally when delayed repair is necessitated.