Aim: The evaluation of the middle term behaviour of the Wagner-type stems in dysplastic femurs and the presentation of the technical and surgical differences with the implantation of a Wagner stem.

Materials and Methods: Between 1997 and 2008 we implanted 64 Wagner stems in 58 patients. Average age at the time of implantation was 64 years. 52 patients was operated because of DDH, and 12 had had previous osteotomy. All patients were prospectively evaluated radiographically and clinically at annual intervals. Functional outcome was assessed with Harris Hip Score and Oxford Score.

Results: Mean follow-up of these series was 4 years (11-1)One stem was revised because of fracture of the lesser trochander and two more patients were re-operated for open reduction. With the re-operation as end-point and 95% Confidence Interval survivorship rate was 98, 5%. There were no progressive radiolucent lines. Stem migration was at an average 2mm (1–6) during the first two years and remained stable thereafter. There was no deep infection in these series. After the second year a dense zone is evident in all Gruen zones at the implant –bone interface with a width of 2–3 mm.

Discussion: Dysplasia of the proximal femur may pose significant technical problems during THA due to the distortion of the geometry and the narrowing of the femoral canal. The sort, conical Wagner type stems can offer a very good alternative is such patients. They allow control of the anteversion and they are able get a good press-fit despite the metaphyseal/diaphyseal mismatch and the femoral bowing.

Conclusions: Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs

Introduction: The aim of this study is to present the effect of various local anaesthetics, in particular solution concentrations, in peri- and post-operative analgesia in patients with carpal tunnel syndrome (CTS).

Material and Method: 105 patients with CTS (81 female, 24 male, ages 27–79) underwent carpal tunnel release under local anaesthesia. The patients were divided into 5 groups (xylocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, chirocaine 0.25%). A tablet of Gabapentin (Neurontin) 400mg was administered to some patients of each group (41 pts of the 105pts) 12 hours prior to surgery. All patients were evaluated immediately after surgery, in 2 weeks and 2 months postoperatively according to VAS pain score, grip strength, finger active motion and two point discrimination. Postoperative complications were also reported.

Results: Anesthesia was immediate after the local injection. All patients improved postoperativelly regarding relief from pain and paresthesias. There was no statistically significant difference in grip strength before and after surgery. Only 10 patients used paracetamol immediately after surgery, without any statistically significant correlation to any group of patients. 1 patient developed complex regional pain syndrome 2 months after surgery.

Conclusion: The use of local anaesthesia in carpal tunnel release surgery is beneficial in providing immediate intraoperative effect and recovery and mobilization after surgery. Rehabilitation seems to be irrelevant of the type of local anaesthetic that was used during the procedure. Small solution concentrations of local anaesthetics (ropivacaine 0.375%, chirocaine 0.25%) provide adequate analgesia during surgery and provide a normal postoperative course.

Introduction: The value of arthroscopy, fluoroscopy, and e-learning courses (focusing on minimally invasive surgical techniques) for the treatment of intra-articular distal radius fractures (I-ADRF), remains controversial. This study compares the outcomes after fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures, with or without concomitant arthroscopic evaluation.

Materials and Methods: Forty-seven patients with I-ADRF underwent FA external fixation and percutaneous pinning. Among them 23 had additional arthroscopic evaluation of their wrist. For teaching purposes procedures with the use of fluoroscopy and arthroscopy were recorded and adapted as a course for the On-line Performance Support Environment for Minimally Invasive Orthopaedic Surgery (“OnLineOrtho” EU- sponsored project). The context of these courses was incorporated in an intelligent medical performance support environment. The duration of the procedure, the surgical findings and the outcomes were recorded.

Results: The follow-up period ranged from 24 to 62 months and the patients were evaluated at 3, 6, 12 and 24 months. The addition of arthroscopy prolonged the procedure by 25 minutes but diminished the number of images obtained by the image intensifier by 5. After arthroscopic evaluation the placement of subchon-dral pins was changed, because of step-off, in 11 of 23 patients. Also tears of the TFCC (14 of 23 patients), perilunate ligaments (16) were depicted. Patients who underwent additional arthroscopic evaluation had significantly better supination, extension and flexion at all time points than those who had only fluoroscopically assisted surgery. The value added by e-courses and the online performance support system is highlighted through the recognition of the systems effectiveness in e-training.

Discussion: During reduction and fixation of I-ADRF, arthroscopy is a very useful tool for the inspection of the articular surface, the ligaments and the TFCC. Long-term evaluation revealed that patients with additional arthroscopy returned to their previous activities in shorter periods and had better supination, flexion, and extension than patients with FA procedures. Fluoroscopy is essential for the minimally invasive surgical treatment of intra-articular distal radius fractures, whereas arthroscopy is an additional valuable tool that improves the outcome, and e-courses are useful adjuncts for teaching purposes.

Introduction: Avascular necrosis (AVN) of the femoral head (FH) is a painful disorder of the hip that leads to hip collapse. The pathology of AVN involves ischemic events leading to the death of bone. Several biological substances participate in the balance between osteoclasts and osteoblasts, like osteoprotegerin, RANK and RANKL. The expression of these genes affects the maturation and function of osteoblasts and osteoclasts and determines the rate of bone remodeling. In this study, we investigate the expression of OPG, RANK and RANKL in osteonecrotic FHs derived from 44 patients with AVN.

Methods and Materials: RNA and proteins were isolated from both necrotic and normal site of FHs of 44 patients diagnosed with AVN.

Quantitative RT-PCR was performed for OPG, RANKL and RANK molecules by using the Light Cycler FastStart DNA Master Hybridization Probes kit (Roche).

Western Blotting: 22 bone tissues were run on 4–12% NuPAGE gel (Invitrogen). Anti-OPG, anti-RANKL and anti-actin antibodies were used and membranes were immersed in ECL.

Results: Quantitative RT-PCR: The mRNA levels of OPG were higher in the necrotic (median: 5.25) than the normal site (median: 4.19) of the FHs and their difference was statistically significant (p< 0.05). The expression of RANK and RANKL was significantly lower than that of OPG following a similar pattern between the necrotic and normal site. The mRNA values of RANK and RANKL were higher in the necrotic sites [necrotic median: 1.0/normal median: 0.85, necrotic median: 0.8, normal median: 0.3, respectively] than the normal, although they were not statistically significant.

Western Blotting analysis: Normal sites from all FHs showed comparable OPG protein levels (median: 0.57) which were similar to those of normal (median: 0.63). Similar pattern to that of OPG was observed also for RANKL protein expression, where the median value for RANKL/F-actin ratio was 0.49 and 0.5 in normal and necrotic sites of FHs, respectively.

Discussion: OPG, RANK and RANKL are key genes for maintaining the balance between osteoblasts and osteoclasts. Our results show marked differences in the expression of OPG between the necrotic and the normal sites of the FHs; however, mRNA levels of RANKL varied insignificantly between normal and necrotic part of FH while mRNA levels of RANK gene remain similar in both sides of FHs. In contrast, the production of OPG and RANKL at the protein level showed no remarkable divergence. This indicates that the expression and production pattern of RANK may play the key role in the maintenance of the balance between osteoblasts and osteoclasts in AVN.

Introduction: Periosteum is a tissue with pluripotential mesenchymal cells (MSCs). During fracture repair several growth factors are released from periosteum, including bone morphogenetic proteins (BMPs), which induce the differentiation of bone marrow stromal cells towards the osteoblastic lineage, therefore increasing the pool of mature bone forming cells and enhance the differentiated function of osteoblasts.

The purpose of our study is to evaluate the expression of periosteal BMPs mRNA from fracture samples, collected within 24 hours of fracture and to compare it with BMPs expression from periosteal samples of normal (non-fractured) bones.

Materials and Methods: Periosteum samples were collected from 25 patients with recent fracture (during the past 24 hours) (age: 12–80) and 25 individuals without fracture (age: 10–73). BMPs (BMP2, BMP4, BMP6) mRNA levels were analysed by Real Time RT-PCR by using the Light Cycler machine and PBGD as a housekeeping gene.

Results: BMP2 mRNA levels were significantly higher (p< 0.05) in normal samples (median:12.15) than in fracture (median:4.39). BMP6 and BMP4 mRNA expression followed similar pattern to that of BMP2 but in significant lower levels. In normal samples, BMP4 mRNA median levels were 1.99, while in fracture samples the levels were significantly lower (median:0.35), (p< 0.05). BMP6 mRNA levels were also higher in normal samples (median:2.21) than in fractures (median:1.87) (p> 0.05). Furthermore, the decrease of BMPs mRNA levels in fracture samples was higher for BMP4 followed by BMP2 and BMP6.

Discussion: Our results indicate high BMP2 mRNA levels expressed from periosteal cells. In recent fractures there is a significant reduction of BMP2 compared to normal samples; however, the expression of BMP2 remains more elevated in comparison to the other BMPs highlighting the potential role of BMP2 at the initiation of healing process of fractures. BMP6 and BMP4 expression was similar among normal periosteal cells while levels of BMP6 were higher than BMP4 in fracture periosteal cells. The suppression of BMP6 expression was minimum and less significant than BMP2 and BMP4 suppression indicating the potential role of BMP6 at the early stages of MSCs differentiation in periosteum. On the other hand, BMP4 remains in low levels in any confrontation and seems that plays a minor role in early healing process of fracture. BMPs are considered to play central role in fracture response and bone remodelling but further investigation has to be done as much in their correlation and toward other growth factors as in their expression levels during bone fracture repair process.

Aim: To determine the quantity and the quality of the bone bridge between the bone tunnels, in both the femoral and tibial side, after double-bundle anterior cruciate ligament (ACL) reconstruction.

Material and methods: Twenty-seven patients undergoing primary double-bundle ACL reconstruction with hamstring tendon autograft were included in this prospective study. Computed tomography (CT) was performed in all patients at a mean of 13 months postoperatively. The amount of the bone bridge between the bone tunnels was measured, in both the femoral and tibial side, on an axial plane at three locations:

at the level of the joint line

In addition, the bone density of the bone bridge was measured in Hounsfield units (HU) in the same locations. Bone density of the anterior tibial cortex lateral femoral condyle, and adjacent cancellous area, and were measured for comparisons.

Results: CT confirmed that the bone bridge was triangular in shape in all cases in both the femoral and tibial side. On the femoral side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.7 mm, at the mid-portion the mean thickness of the bone bridge was 3.7 mm and at the base of the bone bridge the mean thickness was 7.1 mm. On the tibal side, at the level of joint line (apex of the bone bridge) the mean thickness of the bone bridge was 1.5 mm, at the mid-portion the mean thickness of the bone bridge was 3.2 mm and at the base of the bone bridge the mean thickness was 6.5 mm. Bone density at the mid-portion and at the base of the bone bridge was similar to the cancellous bone for both the femoral and tibial side. However, the bone density of the bone bridge, at the level of the joint line, for the femoral side was 860 HU and this was not statistically significant in comparison to the density of the lateral femoral cortex (960 HU). Similarly, the bone density of the bone bridge, at the level of the joint line, for the tibial side was 885 HU and this was not statistically significant in comparison to the density of the anterior tibial cortex (970 HU).

Conclusions: Our study demonstrated one year after double-bundle ACL reconstruction the thickness of the triangular bone bridge between the bone tunnels is sufficient at the mid-portion and at the base of the triangle but is thin at the level of the joint line. However, the bone bridge at the apex of the triangle is very strong since its density is similar to that of cortical bone. We believe that the “corticalization” of the bone bridge at the level of the joint line on both the femoral and tibial side is important and contributes significantly to avoid communication of the bone tunnels.

Aim: According to the literature, mortality rate after hip fracture (HF) approaches 20% per year. Morbidity, mortality and rehabilitation after HF are the objectives of this study.

Material: We followed 192 patients (72 men −120 women, age: 78.6 years), who suffered from HF: intertrochanteric (64%), subcapital (30%) or subtrochanteric (6%). Before the injury 70% of the elderly lived with relatives, yet self-assisted, 17% with relatives but were unabled, 10% completely independent and 3% unabled and alone or instituted. Gait before injury was independent in 50%, while 48% used a walking aid and 2% were in bed.

Results: In a minimum postoperative 12-month follow-up, 75% of the patients were questioned. Mortality rate was 21,8% (men 37,5% - women 12,5%): 7% deceased while in hospital, 57% during the 1st trimester and 36% in the next 9 months. Mean average hospital stay: 8,3 days and the mean interval from injury to operation: 2,7 days (0–13). Direct postoperative complications were recorded in 26,5%. Rehabilitation was continued for 32% of patients in specialized centers and for 7% at home and 35% of patients regained their pre-injury functional level, whereas 37% needed a walking frame. Family members modified their activities in 40% of cases.

Conclusions: Mortality and morbidity in elderly patients with HF overcome 21% and 26% respectively, whereas only 35% of patients regained their pre-injury functional level. Despite the beneficial effect of family support, the lack of organized rehabilitation program and the delay of operation are potential negative factors for the patients outcome.

Aims: Previous work at this institution has demonstrated that perfusion beneath circumferential negative pressure wound therapy (NPWT) is decreased, which conflicts with most studies on NPWT and perfusion. This study investigates perfusion beneath non-circumferential NPWT in humans and also discusses the potential methodology flaw common to all previous research in this field.

Methods: Tests were conducted on both lower limbs of six volunteers (N=12). Volunteers were sequentially randomised into two groups, which would receive different suction pressures (−400 mmHg and −125 mmHg). A doughnut shaped NPWT dressing was placed over the shin of each leg. The central hole allowed for measurement of the transcutaneous partial pressure of oxygen (tcpO2), an indirect measure of perfusion. Readings were taken every five minutes throughout the experiment. After acquiring readings for 15 minutes to establish a baseline, suction was switched on and readings were taken for another 15 minutes. Suction was then disconnected and readings were taken for 15 minutes. Suction was then reapplied and the sequence was repeated. Data were analysed using the Wilcoxon and Mann-Whitney tests.

Results: On applying suction pressures of −400 mmHg, there was a significant reduction of the tcpO2 (mean reduction 7.35 mmHg, SD 7.4, p< 0.0005). At −125 mmHg, there was also a significant reduction of the tcpO2 (mean reduction 5.10 mmHg, SD 7.4, p< 0.0005). Although there was a tendency for greater reductions in the −400 mmHg group this was not significantly different to the −125 mmHg group (p=0.07).

Conclusion: NPWT reduces tissue perfusion, with higher suction pressure resulting in greater reductions in perfusion. Studies on perfusion using laser Doppler, which report findings contrary to these, may be flawed due to the measuring technique of this device. The compressive forces of NPWT are likely to result in false increased readings on application of suction when using the laser Doppler.

This represents a paradigm shift in our understanding of NWPT and that these dressings should be used with caution on tissues with compromised perfusion.

Foot osteomyelitis is a common problem for which management is variable and few guidelines exist.

To present our treatment protocol and the results in 36 patients (20 men, 16 women, mean age: 49.5 years) with osteomyelitis distal to the ankle, followed up for 17.6 months (range: 3–64).

Bone infection involved toes (n=4), lesser metatarsals (n=11), hallux (n=3), midfoot (n=4), calcaneus (n=9), whereas 4 cases presented as generalised osteomyelitis. Postoperative infection was the cause in 10 cases. Eleven patients were classified as host-type A, 14 as B and 11 as C. A draining sinus was present in 28 cases. The treatment protocol included surgical debridement, the bead-pouch technique for local antibiotic administration and closure primarily (n=27), or by secondary healing (n=5), skin graft (n=2), local fasciocutaneous (n=1), or free vascularised muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Generalized Charcot osteomyelitis was an indication for amputation.

Mean hospital stay was 13.8 days (range 1–34) and 2.7 (range 1–7) surgical procedures per patient were recorded. Infection control was achieved in 26 cases (72.2%), whereas amputations were performed in 10 cases (27.8%). Below-knee amputation was undertaken in 4 host-type C patients with Charcot osteomyelitis of the foot. Ray amputations were performed in 4 diabetic feet. Six amputees were classified as host-C and 3 as host-B. One host-type A patient with recurrent post-traumatic toe osteomyelitis, underwent a distal phalanx amputation as definitive solution. Amputation rates were 55% among host-C, 22% among host-B and 9% among host-A patients (p< 0.001).

Diffuse foot osteomyelitis in systemically compromised patients resulted in high amputation rates. Better results were obtained in non-compromised hosts and focal osteomyelitis.

It is known that wide variability exists among patients in the susceptibility to and outcome from infection. Polymorphisms in genes coding for proteins involved in the response to bacterial pathogens as tumor necrosis factor-alpha(TNF-a), interleukin (IL)-1alpha, IL-1beta, IL-1 receptor agonist, IL-6, IL-10 can influence the amount or function of the protein produced in response to bacterial stimuli. These genetic polymorphisms may influence the susceptibility to and outcome from infection.

The aim of the study was to investigate whether genetic variation in genes coding for components of the innate immune response might be a critical determinant of the inflammatory response and the risk for and outcome from severe bacterial infection in individuals with musculoskeletal infections. The relationship between single nucleotide polymorphisms (SNPs) in the above mentioned genes and susceptibility to infection was evaluated.

Forty patients with musculoskeletal infections hospitalised at the Orthopaedic Clinic of University Hospital of Larissa, as well as 80 healthy controls were included in the study. Genomic DNA was isolated from peripheral blood from all cases and controls and was extracted according to standard procedures. The following genes with their polymorphic positions were studied: IL 1α (IL 1α promoter −889), IL 1β (IL 1β promoter −511, pos. +3962), IL 1R (IL 1R pos. pst1 1970), IL 1RA (IL 1RA pos. mspa1 11100), IL 4Rα (IL 4Rα pos. +1902), IL 12 (IL 12 promoter −1188), TGF-β (TGF-β exon 1 codon 10, codon 25), TNF-α (TNF-α promoter −308, −238), IL 2 (IL 2 promoter −330, pos. +166), IL 4 (IL 4 promoter −1098, −590, −33), IL 6 (IL 6 promoter −174, pos. +nt 565) and IL 10 (IL 10 promoter −1082, −819, −592). Genotype distribution and allele frequencies in patients and controls were evaluated.

There was a significant difference in genotype and allele frequency of IL-1a (T/C −889) p=0.000 (CC, TC) between patients and the control group. Moreover, 2 SNPs of interleukin 4 [IL-4 (T/G −1098) p=0.000 (GG, GT) p=0.009 (TT) and IL-4 (T/C-590) p=0.000 (CC, CT) p=0.006 (TT)] showed significant genotypic and allelic differences between the two groups. Finally, 2 SNPs of interleukin 6 [IL-6 (G/C-174) p=0.000 (CC) p=0.014 (GG), IL-6 G/A nt565) p=0.000 (AA,GA,GG)] and TNF-a [(G/A-308) p=0.034 (AG)] showed significant differences in genotype and allele frequencies between patients and the control group.

We observed, for the first time, significant differences in genotype and allele frequencies of TNF-a (G/A-308), IL-1a (T/C -889), IL-4 (T/G -1098), IL-4 (T/C-590), IL-6 (G/C-174) and IL-6 G/A (nt565) in patients with musculoskeletal infections, a fact which points towards the involvement of cytokine gene polymorphisms in the pathogenesis of infection.

Distal tibia and ankle sepsis can threaten the viability of the limb. We present the management protocol and results in 37 patients with chronic infection of the distal tibia and ankle, followed up for a mean of 4 years.

The mean age was 45.6 years. Host type A were 21 patients, type B were 9, and type C were 7 patients. Treatment included radical debridement, multiple cultures sampling and local antibiotic application. Twenty seven patients required bone stabilisation, whereas 3 host C patients were amputated. Soft tissue coverage included 5 free muscle flaps, 3 soleus flaps and 5 pedicle fasciocutaneous local flaps. Bone defects of a mean of 6.3 cm (3–13cm) in 20 cases were treated with distraction histogenesis (13 cases) or the free fibula vascularised graft (7 cases).

Mean hospitalisation time was 26.2 days (host-A: 19.6 vs. host B/C: 32.2, p=0.036). Host-A patients required 2.3 operative procedures whereas host-B/C 3.9 (p=0.01). Union occurred in 26/27 (96%) of cases requiring fixation (one ankle arthrodesis revision/host-B patient). External fixation frames were kept in situ for a mean of 31.7 weeks (12–85). Mean leg length discrepancy was 0.6 cm. Ankle arthrodesis was performed in 7 patients (5% among host-A patients vs. 38% among B/C). Independent ambulation was achieved in (35/37) 95%. All patients were satisfied with the result. Bacteriology revealed Staph. aureus in 71%, whereas 38% were polymicrobial (7% in host-A vs. 88% in B/C patients, p< 0.001). Infection recurrence occurred in 5.4% (none in host-A vs. 13% in B/C patients, p=0.03), whereas the overall complication rate was 43% (24% in host-A vs. 75% in B/C patients, p=0.02).

Functional limb salvage without leg length discrepancy was possible in 92% of cases. Systemically compromised patients required longer hospitalisation, more operative procedures, had frequently polymicrobial infections and more complications.

Deep infection following total knee arthroplasty (TKA) is a devastating complication for the patient and a costly one for patients, surgeons, hospitals and payers. The aim of this study is to compare revision TKA for infection, revision TKA for aseptic loosening and primary TKA with respect to their impact on hospital and surgeon resource utilisation. The evaluation of hospital cost was carried out on a microeconomic basis in order to best evaluate the true cost.

Demographic, clinical and economic data were obtained for 25 consecutive patients with an infection after TKA who underwent a two-stage revision arthroplasty (Group 1), 25 consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and 25 consecutive patients who underwent a primary TKA (Group 3), all of which where admitted at our institution between January 2000 and December 2005. The economic evaluation included both surgical treatment and hospitalisation cost. Because fixed charges do not depict accurately real resource consumption, total cost was calculated through direct cost analysis. All direct health sector costs such as medical supplies, drugs, implants, laboratory and radiology tests, salaries and wages and overhead expenses, including equipment and plant depreciation were calculated. All patients were followed up for a twelve-month period.

Revision procedures for infection were associated with longer operative time, more blood loss and a higher total number of operations compared with both revisions for aseptic loosening and primary TKA. Furthermore, revisions for infection compared to revisions due to aseptic loosening and primary TKAs were associated with twofold and 2.6 times higher total number of hospitalisations, 2.5 and 5.6 times higher total number of inpatient days, 10.2 and 53.8 times higher cost of inpatient drugs and 1.2 and 2.37 times higher cost of implants, respectively. The costing evaluation of the three operative techniques is still on progress.

Patients’ treatment with an infection after TKA is associated with significantly greater hospital and physician resource utilisation compared with that used for patients with a revision due to aseptic loosening or a primary TKA.

Two-staged revision TKA is a common strategy for the management of infected TKA (i-TKA) in properly selected patients. However, there is considerable variation in the parameters (e.g. the duration of intravenous administration of antibiotics and of the time interval between the stages, the intraoperative use of frozen sections, the use of knee aspiration etc.) of the treatment protocol among Orthopaedic Centres making the comparative evaluation of results difficult. The aim of this study is to present a standardised two-staged revision protocol with satisfactory mid-term clinical outcome.

Thirty-four consecutive cases of infected primary TKAs were treated in our department between 2000 and 2006. For 24 of them the postoperative follow-up is greater than 2 years. All patients underwent the same treatment protocol: knee aspiration prior to implant removal and surgical debridement, more than 5 specimens for frozen sections and cultures (aerobic, anaerobic and fungi) during the first stage, custom antibiodic impregnated cement spacers, intravenous administration of antibiotics for 3 weeks followed by 3 weeks of per os administration based on culture and antibiogram, a 6-week interval free from antibiotics, second aspiration and second stage with repetition of frozen sections and cultures. In the case of positive frozen section specimens during the second stage the implantation of a new prosthesis was cancelled and a different management strategy was introduced. Preoperative and postoperative data were collected in the form of Total Knee Society Score (knee score and functional score), Oxford-12 Score, laboratory parameters and radiographs at regular intervals.

At the final follow-up 22 out of 24 patients were free of infection. In four patients (2 Host C and 1 Host B) the 2nd stage was repeated (2–6 times) due to polymicrobial infection and positive intraoperative frozen sections. In one of them a knee arthrodesis was finally performed. The diagnostic accuracy of knee aspiration before the 1st stage was low. Total Knee Society Score rose from a preoperative average of 64 (50 to 95) to a postoperative average of 145 (130 to 180). The Oxford 12 score also rose from a preoperative average of 52 (44 to 58) to a postoperative average of 30 (23 to 38). At the final follow-up no radiological signs of implant loosening were observed.

The above standardised protocol of two-staged revision in i-TKA, when indicated, can provide satisfactory mid-term clinical results.

Flaps constitute an integral part of the treatment of soft tissue and skeletal infections of the extremities, focusing on the coverage and augmentation of the local biology.

In a 6-year period, a total of 33 septic defects of the upper (6) and lower (27) extremities were treated with 4 free and 29 pedicled flaps, after extensive surgical debridement of the septic site. In the lower extremity, treatment included 3 free (2 latissimus dorsi and 1 serratus anterior), and 24 pedicled flaps (5 heads of gastrocnemius, 7 soleus, 1 abductor hallucis, 9 reverse fasciocutaneous, 1 combined medial head of gastrocnemius and soleus and 1 extensor longus hallucis) for 3 cases of soft tissue sepsis and 24 septic defects of the skeleton. In the upper extremity, 1 free vascularised fibular graft (combined with muscle-skin) and 5 pedicled flaps (2 homodigital, 1 heterodigital, 1 cross-finger, 1 periosteal) were used for 3 soft tissue and 3 skeletal septic defects. All but one flaps of the lower extremities were covered with split thickness skin (simultaneously or within 7 days), whereas flaps of the upper extremity included skin in all cases.

Three flaps (2 reverse fasciocutaneous and one soleus) were revised (with latissimus dorsi, serratus anterior and extensor longus hallucis flaps respectively) in a mean period of 4 months due to persistent infection and 4 skin grafts were revised due to superficial infection. In a minimum follow-up period of 9 months (9–60 months) full coverage of the defect and treatment of infection was accomplished in all patients, resulting in a good functional and aesthetic outcome. Except for 2 patients, all were able to walk and use their extremity and returned to previous activities.

The use of flaps in the treatment of septic skeletal or soft tissue defects leads to a functional upper or lower extremity and successfully prevents amputation.

In order to evaluate the short- and long-term clinical and radiological results of MIS in TKA, a prospective randomized trial was designed in our department. All patients admitted to the department under the care of one surgeon specializing in Joint Replacement surgery were assigned to participate in the study, signed a concern form, and randomly allocated into two groups. For patients of group A, a TKA was performed using the mini mid-vastus approach; for patients of group B the surgery was performed using a conventional medial parapatellar incision. The Genesis II prosthesis and MIS instrumentation were used for all patients.

Pre and postoperative clinical and radiological data were collected for all patients at regular time intervals (pre, 1st d, 3rd d, 6th d, 3rd w, 6th w, 3rd m, 6th m, 9th m, 1st y, and every year thereafter). Early postoperative pain was also evaluated using a VAS scale and the ability of early SLR was also recorded.

Until now 80 patients (40 MIS, 40 Controls) have entered the study with a follow-up of more than 6 months. In 5 patients (12.5%) of group A the MIS surgery was abandoned in favor of conventional surgery due to technical problems.

Patients in MIS group A had knees with greater range of motion at 3 w, 6 w and 3 months, better function at 3 and 6 months, and less blood loss. In contrast, the same patients experienced greater pain during the first 3 postoperative days. Surgery lasted 16 minutes more on average for the MIS group A. On radiological evaluation technical errors were observed in 5 patients of MIS group A.

Introduction: TKA is usually performed under general or spinal anaesthesia (SA). Most of the patients who undergo this procedure are old and their postoperative rehabilitation could be compromised due to the adverse effects of the relevant anaesthesia. Lumbar Plexus and Sciatic nerve Block (LPSB) have been increasingly applied for intraoperative and postoperative analgesia. The aim of this study is to compare the time required for the performance of the anaesthesia technique, the quality of intraoperative anaesthesia and postoperative analgesia, the incidence of intraoperative or postoperative complications, the blood loss at the recovery room and the required intraoperative intravenous (IV) administration of fluid volume.

Material & Methods: Fifty (50) patients, mean age 70± 5years, ASA I-III were randomly divided into two groups to receive spinal anaesthesia (group A) or LPSB (group B). Patients in group A (n=25) received hyperbaric Bupi-vacaine 0.5% plus 15mcq Fentanyl through atraumatic 25g needle. Lumbar plexus and sciatic nerve block were performed with a 15cm insulated needle (Brown) and nerves were identified by a peripheral electric nerve stimulator. 30 and 15 ml of Ropivacaine (0.5%) were used for each block respectively. All patients received 0.2mg/ Kg of Midazolam and 50μg of Fentanyl IV. The success of the technique was defined as a complete sensory and motor block. All patients received postoperatively Patient-Controlled Anaesthesia (PCA) with morphine intravenously. Time to perform blockade, sensory and complete motor block, hemodynamic parameters, blood loss, IV fluid volume, postoperative analgesic requirements and satisfaction score were recorded. Results were analyzed with Chi Square test and Student’s t-test (level of significance: p< 0.05).

Results: Demographic data, operating time and hemo-dynamic parameters were similar in both groups. Three patients (group B) had insufficient blocks and were converted to general anaesthesia. Although SA is performed and accomplishes complete motor and sensory blockade faster (p< 0,05), LPSB leaded to decreased necessity of intraoperative fluid loading and blood loss at the recovery room (p< 0,05). Overall patient’s satisfaction till leaving the recovery room, Visual Analogue Score (VAS) intraoperatively, 4 and 8hours postoperatively and analgesic counts (recorded through the PCA) in the first 24hours were statistically significant between two groups, in favor of patients with LPSB.

Conclusion: PLSB is an effective alternative to spinal anesthesia taking into account basic clinical and anaesthesiological parameters intraoperatively and immediate postoperatively. Concerning postoperative pain and required administration of analgesics during the first 24hours, LPSB is more efficient compared to SA, underlining the importance of overall patient’s satisfaction during the first postoperative day.

Introduction The aim of this study was firstly to investigate the prevalence of icaABCD-operon which codes the production of the polysaccharide intracellular adhesin(PIA), responsible for biofilm production, in a collection of clinically significant staphylococci isolated from orthopaedic infections and secondly to assess the relationship between biofilm production and the presence or not of ica-operon.

First Step – Material & Methods Between 1/2003 and 12/2005 200 CoNS were isolated from orthopaedic patients associated with soft tissue and bone infections(group I) and 200 CoNS from blood cultures of hospitalized patients from different wards of the same Hospital(group II). Identification was carried out by Gram-stain, catalase and coagulase tests and the API Staph System. Detection of icaADBC genes was performed by PCR. Production of biofilm was tested by the method of Christensen.

Results In group I, 62(31.37%) carried the entire ica-operon; from these isolates biofilm formation was detected in 35(17.5%). 5 isolates, despite biofilm production, did not carry any gene of ica-operon. In group II, 70(35.5%) carried entire the ica-operon; biofilm formation was detected in 37(18.5%) of these isolates. 3 S. capitis, 1 S. epidermidis and 1 S. hominis carried only the icaADB, icaA and icaB genes respectively.

Second Step – Material & Methods Based on the observation of PIA-production only in (50%) of ica(+) CoNS, 20 S. epidermidis isolates recovered from clinical specimens (pus) of orthopaedic patients and belonging to distinct PFGE clones, were selected on the basis of the presence of the entire ica operon. Nevertheless, only 10 of them produced biofilm. Nucleotide sequence analysis of ica-operon was carried out in all isolates; expression of icaADBC genes was also tested by RT-PCR.

Results Sequencing analysis revealed that all isolates carried an intact ica-operon, without point mutations. Concerning icaADBC mRNA production, all genes of ica-operon were expressed in biofilm-producing isolates, whereas in the no-biofilm producing strains the icaA and icaC genes were not expressed, while a faint expression was observed for the icaB and icaD genes.

Discussion Biofilm-forming capacities of CoNS from orthopaedic infections was not significantly greater than those from other infections (p> 0,05). The capacity of ica-operon(+) staphylococcal isolates to form biofilm seems to be dependent on the expression of ica-genes, specifically of icaA and icaC. The inability of ica(+) isolates to produce biofilm emphasizes that some unknown mechanisms influence icaADBC expression. Finally, the recognition of biofilm-producing CoNS without carrying any gene of ica operon underlined the existence of unidentified also mechanisms controlling biofilm production, apart from icaADBC expression.

Introduction: Management strategies and results in 30 cases of foot osteomyelitis are presented.

Patients-Methods: From 1/2003 – 1/2006, 30 patients (15 men, 15 women, mean age 47.7 years, range 1.5–82) presenting with foot osteomyelitis were treated. Mean hospital stay was 12.6 days (range 1–45) and 1.3 hospital admissions were recorded (range 1–4). The follow-up period averaged 15.7 months (range 3–56). Bone infection involved the toes in 3 cases, the metatarsals in 9, the head of the hallux in 2, the midfoot in 3, the calcaneus in 9, whereas 3 cases presented as generalized charcot’s osteomyelitis. Eleven patients were classified as host-type A, 10 as B and 9 as C. Nine patients were diabetic, one rheumatoid, four had vascular insufficiency, two had insensate feet. An open calacaneal fracture was the cause in two cases, whereas ORIF of a closed calacaneal fracture in one, ORIF of metatarsal fractures in one and hallux valgus corrective surgery in two. One paediatric patient with calcaneal osteomyelitis developed subtalar arthritis. A draining sinus/wound was present in 24 cases. Each patient underwent an average of 2.3 surgical procedures (range 1–7). The treatment protocol included surgical debridement, use of the bead-pouch technique for local antibiotic administration and closure primarily (n=23), or by secondary healing (n=3), skin graft (n=2), local fasciocutaneous (n=1), or free vascularized muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Amputation was undertaken if salvaging or reconstructive procedures could not be undertaken.

Results: Infection control (salvageable cases) was achieved in 23 cases (76.7%), whereas amputations were performed in 7 cases (23.3%). Four amputees were classified as host C (57.1%), whereas a significantly lower rate of patients successfully treated (21.7%) were host-C (p=0.0008). A below knee amputation was undertaken in two host-type C patients with generalized osteomyelitis of the foot. One 1st ray and two 1st and 2nd ray amputations were performed for not salvageable diabetic feet infections. Finally in 3 cases of posttraumatic chronic toe osteomyelitis in host-type A patients, a distal phalanx amputation was the definite solution. One patient developed a septic TKR in the contralateral leg and one diabetic patient developed osteomyelitis at a different location in the earlier affected foot.

Conclusions: The treatment strategy of radical debridement, local antibiotic delivery by the bead-pouch technique and use of flaps if needed, successfully treated salvageable feet. Amputation was the solution in neglected cases and in immunocompromised patients.

INTRODUCTION: The process of ligamentization includes the histological and structural remodelling of the tendons graft to ligamentous tissue. There is little information documenting the mechanism of ligamentization process in molecular level. A number of essential genes are involved in this process and their expression can be regulated through complex biochemical pathways. Animal studies have shown that transcutaneous application of low intensity pulsed ultrasound (LiUS) accelerate the tendon and ligament healing process and recent reports have proven the efficacy of the transosseous application of LiUS for both enhancement and monitoring of the bone healing. The purpose of this study is to investigate the effect of transosseous low-intensity pulsed ultrasound (LiUS) during lingamentization process on the healing at tendon graft-bone interface in rabbits, by examining the expression levels of TGF-β1, biglycan and collagen I using semi-quantitive RT-PCR.

MATERIALS AND METHODS: Twenty-eight New Zealand rabbits were used in this study. The anterior cruciate ligament was excised and replaced with the long digital extensor. Custom-made ultrasound transducers were implanted onto the bone fragment and along the surface of the bone tunnel at the right knees of the rabbits (study group). The LiUS-treated animals received 200-μsec bursts of 1 MHz sine waves with pulse repetition rates of 1 KHz and average intensity of 30 mW/cm2, for 20 minutes daily, while the left knee received no LiUS (control group). Semi-quantitative RT-PCR was performed from RNA samples representing both study and control groups at 1, 2, 3, 5, 7, 8, 9, 12, 14 and 21 days, using specific primers.

RESULTS: Analysis of the RT-PCR products showed that there is significant up-regulation of biglycan and collagen-encoding genes in the study group compared to the control group. In addition, TGFb1-encoding gene exhibits a bimodal profile. In the study group, it represses its mRNA levels from day 1 until day 9 and then the initial expression levels are restored. The control group showed no essential alteration of expression levels for TGFb1.

DISCUSSION: Transosseous LiUS treatment affects the expression levels of significant genes like TGF-β1, big-lycan and collagen type I. All the above studied genes mediate important biochemical pathways in lingamentization process and possibly enhance the healing rate of the tendon graft-bone interface in a bone tunnel in rabbits. The present report is supportive of the hypothesis that transosseous application of LiUS enhances tendon graft healing to bone through effects on molecular level. These present findings suggest that indeed ultrasound treatment after joint ligament reconstruction may facilitate earlier rehabilitation.

Aim: We present the surgical technique and early functional and radiological results of cementless acetabular reconstruction with Monoblock Trabecular Metal (MTM) (Zimmer Warsaw, Indiana) cups in patients with Developmental Dysplasia of the Hip (DDH).

Materials and Methods: From 1997 to 2004, 70 hips (57 patients) with DDH were received an MTM acetabular component. There where 7 men and 49 women. Average age was 50 years (range 35 to 77). According to the classification of Hartofilakidis et al there where 14 hips with high dislocation, 15 with low type I, 16 with low type II, 8 with low type III dislocation and 17 with hip dysplasia. In all patients a MTM cup was implanted in the true acetabulum through a standard posterior approach. Morselized graft was used in 6 cases and a structural graft only in one. Diameter of the cup was ranging from 42 to 56 mm with 54 out of 70 cups being smaller than 50 mm. Screws where used in 12 out of 70 cases A femoral shortening osteotomy was utilized in only two high dislocation cases.

All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).

Results: Average follow up was 50 months (range 103 to 24). There were no revisions for aseptic loosening, radiologic loosening or cup migration during last evaluation. Two patients developed non-progressive radiolucencies in zone one.

There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.

Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.

Conclusion: MTM acetabular component achieved adequate initial stability in this demanding group of patients and they have excellent radiological and clinical results. Posterior approach without femoral osteotomy provided adequate exposure in almost all cases.