Aims

Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells.

Aims

The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray.

Aim

Irrigation is a major step during debridement surgery in the context of Prosthetic Joint Infections (PJI), but its effects on biofilms are poorly described.

The present study aims at evaluating the effect of PW alone or followed by antibiotics on MSSA and MRSA biofilms grown on Ti6Al4V coupons in-vitro.

Aim: To determine the viability and long term survival of a unique Patellar reconstruction technique, using the posterior femoral condyle, at primary TKR, in patients with previous patellectomy.

Methods: The posterior lateral femoral condyle cut during total knee replacement was used as a non- vascularised bone graft to reconstruct the patella. A medial para- patellar incision was used to create a Patellar pouch. The patient was examined clinically at operation, 6 weeks, 12 months, 2 years and 4 years from operation. Clinical examination and radiographic evidence of patellar position and survival were used.

Results: The patient has a stable, well positioned patella, with no pain from the graft and no clinical evidence of Mal- tracking. Radiographs show excellent survival of the graft and good position at 4 years.

Conclusion: Patellar reconstruction using non- vascularised bone graft via a medial patellar pouch is a viable alternative surgical option to aid stability in those patients undergoing primary TKR with previous patellectomy.

Introduction and purpose: The purpose of our study is to make a critical review of our experience and find a method of systematised, objective therapeutic strategy in the treatment of vertebral metastases.

Materials and methods: We reviewed 38 cases of vertebral metastasis (1995–2004) from primary tumours: lung 21%, breast 21%, prostate 12%, renal 12%, ovary 8%, tongue 4%, cavum 4%, melanoma 4%, unknown primary tumour 17%.

24 cases were treated surgically in terms of the clinical criterion agreed between oncologist and traumatologist.

We reviewed the follow-up of the cases (treatment, complications, mortality) and the subsequent application of the Tokuhashi prognostic index and the Tomita therapy protocol with two objectives: to evaluate our results and assess these two methods as working tools.

Results: 74% of the patients had preoperative radiotherapy. The surgical treatment was corporectomy and dorsal decompression (17%), partial corporectomy and dorsal decompression (29%), decompression and dorsal instrumentation (37%) and non-instrumented decompression laminectomy (17%).

The mean survival was 17 months. The surgical treatment controlled pain in 87%; there was neurological improvement in 21%, control in 54% and progression in 25%.

Conclusions: Our results were not as good as those found in the literature, in which the usefulness of postoperative radiotherapy is emphasised.

Preoperative radiotherapy may have made tumour excision more difficult which, together with the delayed decision-making, influenced the loss of efficacy in our cases.

We need more prospective studies to validate the Tokuhashi index and the Tomita protocol, which we think are very useful in taking therapy decisions.

Objective: Analysis of the influence in shoulder function of restoring total humeral length (THL) in proximal humeral fractures (PHF) treated with hemiarthroplasty and comparing the data with a control group of proximal fractures treated with osteosynthesis.

Material and method: Prospective study involving 56 patients, twenty-nine 2 and 3 part PHF treated with osteosynthesis and twenty-seven 3 and 4 part fractures treated with hemiarthroplasty. Clinical assessment through Constant Score and radiological exam of the THL of both humerus as well as CT scans to analyze position of the tuberosities at 1-year follow-up.

Results: Osteosynthesis group: mean Constant Score of 77.37. In all cases greater tuberosity consolidated in good position. When differences in THL were higher than 2 cm Constant Score values significatively decreased to mean of 67, when ranging from 0 to 2 cm did not differ significatively from mean Constant Score.

Hemiarthroplasty group: mean Constant Score of 55.76. In 5 cases THL was increased (mean 0.87 cm) with a mean Constant Score of 63.5 and among them the greater tuberosity consolidated in place in 3 cases and posteriorly in 2. In 20 cases THL was decreased (mean 1.03 cm) with a mean Constant Score of 54.25 and among them if the difference was minor than 1 cm the greater tuberosity consolidated in place in 3 cases, consolidated posteriorly in 4 and absent in 1 case, and if the difference was greater than 1 cm, the greater tuberosity consolidated in place in 4 cases, consolidated posteriorly in 6 and absent in 2 cases . In 2 cases no differences in THL.

Conclusions: In PHF treated either with osteosynthesis or hemiarthroplasty, the greater tuberosity can be properly reattached if THL differences are less than 2 cm.

Constant Score correlates with greater tuberosity position at any difference of THL less than 2 cm.

Purpose: To document the recovery of knee function following Medial Collateral Ligament (MCL) injury of the knee.

Methods and Results A cohort of 38 consecutive patients with MCL injuries were followed prospectively from the time of injury for a period of one year. There were 13 grade I MCL sprains and 25 grade II sprains. Twelve patients had a concomitant ACL tear. Patients were treated in a hinged knee brace with full extension and 90 degrees of knee flexion for 6 weeks from the date of injury. All patients had an identical rehabilitation programme. Clinical outcome was assessed using two standard functional knee scores (International Knee Documentation Committee (IKDC) score and Knee Outcome Orthopaedic Score (KOOS)). Quadriceps and hamstring muscle function was tested isokinetically using a dynamometer. Outcome assessments were carried out at 2 weeks, 6 weeks, 3 months, 6 months and 1 year.

At 2 weeks the average range of motion (ROM) difference from the normal side was 31%. Twenty-five patients (66%) restored a functional range of motion (5–120 degrees) by 6 weeks. Thirty-five patients (92%) had a normal ROM by 3 months. Peak torque, average power and total work of quadriceps and hamstring muscle groups were normal in 4 patients (11%) at 6 weeks. At 3 months 11 patients (29%) had restored normal muscle function. At 6 months 46% of patients had normal muscle function. At 1 year 11 patients (29%) still had abnormalities of muscle function on isokinetic testing.

Conclusions: Patients with MCL injuries can be advised that range of motion can be expected to return to normal in the majority of cases by 3 months but muscle function recovers more slowly over 12 months following injury.

Aims: To determine the pathological changes in the femur following resurfacing hip arthroplasty and identify possible causes of early failure. Methods: Bone samples from 8 femoral heads at several levels were examined histologically following removal of cemented femoral head surface replacement following aseptic early failure: 4 neck fractures (no history of fall), 3 persistent severe pain and 1 cup loosening. Intra-operatively no obvious macroscopic causes of failure (including notching the neck) were noted. In all patients, the initial diagnosis had been osteoarthritis. None had known risk factors for osteonecrosis. Results: In the patients who had recent fracture, the bony changes were suggestive of relatively longstanding osteonecrosis with degenerative, necrotic and þbrotic changes in the bone marrow and loss of osteocyte nuclei in the trabeculae. There was appositional new bone formation at the surface of the necrotic bone trabeculae. The changes were consistent with osteonecrosis of more than 2 weeks duration and probably preceded the fracture in all cases. In the patients who underwent revision for non-fracture, some osteonecrosis was seen, but this was a lot less than when a fracture had occurred. Conclusion: Osteonecrosis of the femoral head is seen following resurfacing hip arthroplasty and may be a predisposing factor in patients who subsequently fracture.

Aim: To evaluate the role of selective arterial embolization of Aneurysmal Bone Cyst of the mobile spine (C1-L5). Ten to 35% of aneurysmal bone cyst arises from the mobile spine. The course of the disease depends on the aggressiveness of the tumor, as well as the treatment. No previous series analyses this aspect. Methods: Fourteen cases of Aneurysmal Bone Cyst of the mobile spine were retrospectively reviewed. All charts, radiographs, and images were reviewed allowed for oncologic and surgical staging of these cases. The mean follow-up was 3,5 years (2,5y Ð 11y) and the mean age at diagnosis was 22 years. Lumbar and cervical spine was more frequently involved (5 cases cervical and 5 lumbar). Histologic diagnosis was obtained in all cases. A slow and gradual onset of pain was the constant symptom. In all cases an arterial study was performed and in thirteen cases a selective arterial embolization (SAE) was performed. Six of them were repeated Results:Only two patients shows complete ossiþcation of the cyst without surgery (T10 and T1) and was curative. All the others patients received surgical treatment (curettage or en bloc excision) In three of them a recurrence of disease was diagnosed 6, 8 and 12 months later. Two of the most recent cases shows a little lityc area without symptoms Conclusions: Selective arterial embolization seems NOT be sufþcient to obtain ossiþcation of Aneurysmal Bone Cyst o mobile spine

Introduction and Objectives: This is a retrospective study on the treatment of lumbar degenerative disk disease (LDDD) using intervertebral arthroplasty. The lack of uniformity in the treatment of LDDD, persistence of pain even with solid fusion, and the possibility of changes over the fusion site have encouraged us to seek other solutions for this condition. Total intervertebral arthroplasty has been proposed as a possible alternative for selected cases of LDDD.

Materials and Methods: Between November 1999 and July 2002, 16 patients with LDDD were treated surgically using third-generation total intervertebral arthroplasty (Link SB Charité III) with a chromium-cobalt alloy and ultra-high molecular weight (UHMW) poly-ethylene. Average follow-up time was 14 months (6-36 months), and average age was 42 years (35–52). There were 11 females and 5 males. All patients underwent radi-olographic studies, CT scan, MRI, and discography (minimum 2 levels). Indications included LDDD of one to three segments, absence of root tension signs, absence of complete disc collapse, and iconography including concordant discography. LDDD was primary in 11 cases and post-discectomy in 5 cases. Surgery was indicated when at least 6 months of conservative treatment failed to yield results. Blood loss and length of hospital stay were compared to a similar group that underwent posterolateral arthrodesis. Pain, function, and degree of disability were evaluated before and after surgery using GEER (1999) instruments for the evaluation of degenerative lumbar pathology. Increase in height of the posterior intervertebral space and segmentary lordosis were also measured.

Results: Preoperative VAS: 7.8; postoperative VAS: 2.3. Disability index (Oswestry) was 41.3% preoperative and 10.8% postoperative. Average increase in height of posterior intervertebral space was 2.4mm, and mean segmental lordosis was 19.5°, which remained constant through the end of the follow-up period. Average hospital stay was 4.8 days (3–15) compared with 7.5 (5–18) for a group of patients who underwent suspended arthrodesis of L4–L5 with a much smaller quantity of blood loss. No infections were found. Complications: One patient developed an epidural haematoma, which was treated conservatively. Another developed a postoperative retroperitoneal haematoma, which was also treated conservatively. In neither case was there an adverse effect on the outcome of the procedure. One patient showed malpositioning of the prosthetic components on follow-up radiographs, with poor clinical progression at one year postoperative. The patient was treated with posterolateral fusion and right L5 foraminotomy. No infections were seen.

Discussion and Conclusions: Treatment of LDDD with intervertrebral arthroplasty was shown to be effective in the short term, if strict guidelines are followed. Aggressive surgical management is highly inferior to conventional arthrodesis. A longer follow-up period is needed to confirm the validity of this treatment. Technical error in malpositioning of the components in one case caused a poor result.

We performed a prospective clinical study in order to assess the effectiveness of repair of the short hip rotators, divided in the course of total hip replacement by the posterior approach, by the use of radio-opaque markers.

Fifteen patients, each with a diagnosis of osteoarthritis of the hip, were selected consecutively from a single surgeon’s operating list. Uncemented Duraloc® acetabular components and custom made cemented femoral components were implanted via the posterior approach in all patients.

Following implantation, the capsule and the short rotator tendons were sutured on to tendinous soft tissue around the greater trochanter using No 1 Vicryl. One radio-opaque marker clip was attached to the short rotators and capsule and a second marker was attached to the greater trochanter.

Standard antero-posterior pelvic X-rays were taken at three to five days post-operatively, and at three months following surgery. Significant separation of the radio-opaque markers in fourteen of the fifteen patients was demonstrated on the day three to five X-ray, indicating failure of the repair.

We conclude that this soft tissue repair is unsatisfactory. It may be of value to develop a more effective repair technique, with the overall aim of reducing total hip replacement dislocation, and as such we are currently investigating a soft tissue to bone repair.

Thirty-one patients (33 knees) with symptomatic patello-femoral osteoarthritis and minimal tibiofemoral changes underwent LCS total knee replacement without patellar resurfacing.

Average age was 73 years (range, 58–89 years) with a female to male ratio of 5:1. Average follow-up was 20 months (range, 12–40 months). All except four patients had grade 3 or 4 patello-femoral osteoarthritis.

Preoperatively all patients had significant knee pain. Sleep disturbance was reported in 21 patients. All but 10 patients required walking aids. Average range of motion was 1080 (80–125).

At latest review, 21 knees are pain-free, the remaining 12 knees describing only occasional knee pain. Two patients continue to have night pain. Average range of motion was 1040 (70–1350). Lateral patellar tilt improved in all but five knees by an average of 70 (1–260). Patellar congruency improved in all but three knees by an average of 18% (3–63%). None of the patients to date have required revision surgery.

We suggest that knee arthroplasty without patellar resurfacing is an effective option in older patients with isolated patello-femoral osteoarthritis.

We report on a minimum 5-year follow-up (mean 7 years) of 28 patients who underwent arthroscopically assisted ACL reconstruction using a patellar tendon graft. Knee function was assessed using Lysholm and Tegner scores and AP translation of the tibia was measured using a Stryker Laxity Tester, comparing the symptomatic with the normal knee. All measurements were made preoperatively and at the latest follow-up. In addition, all patients had standardised weight-bearing radiographs of the knee to assess joint space narrowing using the IKDC radiographic grading.

The mean preoperative Lysholm score of 71 (range 46–95) improved to 88 (range 57–100) at follow-up. The mean Tegner Activity score increased from 4.1 (range 1–6) to 7.2 (range 5–10). Preoperatively 17 patients had increased tibial translation of more than 5mm, 9 had 3–5mm and 2 had less than 3mm. At follow-up, 22 knees had less than 3mm tibial translation and 6 had 3–5mm. No patients had more than 5mm of tibial translation compared to the opposite knee. The IKDC radiographic grading of joint space narrowing revealed 14 patients with no narrowing, 11 with a joint space of more than 4mm and knees with a joint space of 2–4mm. Joint space narrowing was seen in patients who had partial or total meniscectomy before or at the time of ACL reconstruction.

These results indicate that the satisfactory outcome of ACL reconstruction using contemporary methods is maintained beyond 5 years. However, the 50% incidence of joint space narrowing associated with previous meniscectomy is a cause for concern.