The Gpsystem Medacta vision system is composed of an infrared camera that produces and receives infrared rays reflected by almost 3 reflectors mounted on different rigid body devices (F=femoral, T=tibial, G=guide), in order to determine its position with an error lower than 0.35mm. Data received from this vision system are than elaborated by the Cinetique Gpsystem Version 1.0 system in order to determine the correct cutting guide positioning both for the femur and the tibia. The cutting guide is moved on different planes by 5 electric engines applied on 5 no ending screws.

The first step of this system is determining, with the F and the T rigid bodies, patient’s lower limb kinematic in order to evaluate its mechanical axis, its flexion-extension range of movement and its pathological deviations. The second step is evaluating anatomical landmarks to find out the correct degrees of tibial and femoral cuts: these landmarks are the medial and lateral tibial glena, the distal femoral condyles, the posterior femoral condyles, the anterior femoral cortex, the tibial tuberosity, the Whiteside line and the epycondilar axis (each anatomical landmark is identified by multiple points in order to decrease possible errors). The third step is applying the cutting guide and the Grigid body on the femoral clamp in order to estimate the correct level for the tibial cut than, once the tibial osteotomy is done the vision system controls its correct execution and the soft tissue balancing of the knee. The fourth step is calculating with the Gpsystem the correct orientation of the femoral cutting guide and checking its positioning and cutting execution. The last step is applying the test-prosthesis verifying the mechanical axis of the knee and than assembling the definitive prosthesis.

Since now we have applied 10 Cinetique knee prosthesis with the Medacta computer navigation system with good results and good positioning of the prosthesis

Medacta computer navigation system for Cinetique knee arthroplasty is innovative for its simple cutting guide and movement device both in their hardware than in their way of using and for a simpler software interface; these characteristics allows faster surgeon technique learning, shortening of surgical time and a better prosthesis positioning.

Compromised patellar bone stock poses significant the chnical problems in primary and revision knee arthroplasty. In these situations, traditional approaches have included: non resurfacing, patellectomy, patellar bone grafting, ‘Gull-Wing’ osteotomy. A new material (Trabecular Metal) fabricated using a tantalum metal and vapor deposition techhnique that create a metallic strut configuration with 80%porosity, and physical and mechanical properties similar to bone has been introduced. The authors studied the short-term results following patellar resurfacing using trabecular metal patella in primary and revision total knee arhroplasty (TKA).

Nine patients undergoing primary (2 cases) or revision (7 cases) TKA with the use of a trabecular metal patella were evaluated at a mean of 16 months follow-up. All patients had marked patellar bone deficiency precluding resurfacing with a standard cemented patellar button. The all polyethylene patela was cemented into the trabecular metal base and the remaining patella bone stock; additional fixation was provided by # 2 non absorbable sutures through the peripheral holes on the metal shell.

Revision TKA may be complicated by severe patellar bone loss that preclude implantantion of a standard cemented patellar component. Several options including patellectomy, non resurfacing and osteotomy or grafting of remaining bony shell have been proposed. It is rare in primary knee arthroplasty that the patella has been so eroded that resurfacing is not feasible. Trabecular metall patella may be indicate in the complex revision or even primary knee arthroplasty in which all that remains of the patella is a thin shell of anterior cortical. The short-term results of patellar resurfacing with trabecular metal have demonstrated favorable results.

The authors studied the short-term results following patellar resurfacing using trabecular metal patella. Ten patients underwent primary (2 cases) or revision (8 cases) TKA with the use of a trabecular metal patella and were evaluated at a mean follow-up of 24 months. All patients had marked patellar bone deficiency or patellar absence precluding resurfacing with a standard cemented patellar button. The all polyethylene patella was cemented into the trabecular metal base and the remaining patella bone stock; additional fixation was provided by non-adsorbable sutures through the peripheral holes on the metal shell. No intraoperative complications occurred. There was no displacement of any trabecular metal patellar component and no patellar fractures. The fixation appeared excellent at three to six months radiographic evaluation with uniform bone contact in the peripheral regions in both lateral an Merchant radiographic views. The mean Knee Society scores improved in all patients.

Valgus knee is a complex deformity, characterised by varying degrees of flexion, external rotation and valgus deviation. Contracture of external ligamentous structures makes correction and soft tissue balance often difficult and may lead to persistent post-operative instability. Further problems include patellar tracking, bone defects, especially at the external femoral condyle, and the risk of external popliteal sciatic (EPS) nerve palsy after surgery. Krackow distinguished three types of valgus knee: type 1 with integral medial peripheral structures; type 2 with severe medial structure laxity and impossibility to correct passively; and type 3 which is the sequela of over-correction tibial osteotomy.

From 1996 to 2003 we performed 64 fusions due to valgus knee in 41 females and 23 males, aged between 55 and 76 years (mean 67.5). Of these, 52 deformities were type 1, nine type 2, and three type 3. For type-1 lesions we always used prostheses with posterior stabilisation (PS), and balanced the capsulo-ligamentous structures. In type-2 lesions we used a vincolo condilare prosthesis with CCK in two cases and a cerniera prosthesis in two cases, whereas in the remaining five cases we used a PS prosthesis. In type-2 deformities we used a PS prosthesis with a modular tibial component with metal augments. Mean follow up was 45 months.

Radiographically, valgus deformity fell from 22.4° (10° min – 35° max) to 5.4° (3° min – 9° max). Post-operative results, according to the HSS score, were excellent in 51 cases, fair in 11 cases, and poor in two cases, due to the need to perform revision in two stages in an infected prosthesis 6 months after surgery in one case, and aseptic loosening in another.

Valgus knee due to arthritis can be successfully treated by total knee arthroplasty using various techniques, according to the clinical severity. EPS nerve palsy has been cited as a potential problem in total knee arthroplasty. We did not observe this complication in our series, probably because we maintain the knee in continuous slight flexion for the first 18–24 h.

Patellar tracking is the most common complication observed following total knee arthroplasty. It may constitute a minor disorder or even frank dislocation. Its main cause is a rotation defect in the prosthetic components. CT is the most reliable instrumental test to assess this rotation defect, and an excellent aid for planning a possible revision operation.

From January 1999 to November 2003 we treated 33 patients with a total of 35 painful knees using TC prostheses. Ten patients were male and 33 female. Mean age was 66 years. We performed CT scanning using a modified Berger technique. The lower limbs were extended and scans were performed perpendicular to the mechanical axis of the knee from the supracondylar region of the femur to the plane passing under the distal end of the tibial component up to the anterior tibial tuberosity. Reference lines to assess the rotation of each prosthetic component were drawn electronically on the scan planes.

Adding together the rotation values of the prosthetic components, we observed that when total internal rotation was between 10° and 4°, there was subluxation or frank dislocation. When total internal rotation was between 1° and 4° the disorder was not severe, such as patellar tilt. When total internal rotation was less than 1° or when the components were externally rotated, no femorotibial compartment disorders were observed. The modified Berger technique enabled us to correlate the degree of prosthetic internal rotation with the severity of the disorder and further demonstrate the benefits of femoral component external rotation on patellar glide and ligament balance of the prosthesis.

The authors believe that using CT with the helicoidal technique, by modifying Berger’s technique, enables an accurate assessment of prosthetic component rotation, subsequent correlation with femoro-patella symptoms, and adequate pre-operative planning in case of revision surgery.

The role of radiotherapy and/or surgery in the local treatment of Ewing’s sarcoma has still to be determined. The outcome of Ewing’s sarcoma may differ according to its location and a selection bias towards surgery limits the ability to compare methods of local treatment. We have carried out a retrospective review of 91 consecutive patients treated for non-metastatic Ewing’s sarcoma of the femur. They received chemotherapy according to four different protocols. The primary lesion was treated by surgery alone (54 patients), surgery and radiotherapy (13) and radiotherapy alone (23). One was treated by chemotherapy alone.

At a median follow-up of ten years, 48 patients (53%) remain free from disease, 39 (43%) have relapsed, two (2%) have died from chemotherapeutic toxicity and two (2%) have developed a radio-induced second tumour.

The probability of survival without local recurrence was significantly (p = 0.01) higher in patients who were treated by surgery with or without radiotherapy (88%) than for patients who received radiotherapy alone (59%). The five- and ten-year overall survival rates were 64% and 57%, respectively. Patients who were treated by surgery, with or without radiotherapy, had a five- and ten-year overall survival of 64%. Patients who received only radiotherapy had a five- and ten-year survival of 57% and 44%, respectively.

Our results indicate that in patients with Ewing’s sarcoma of the femur, better local control is achieved by surgical treatment (with or without radiotherapy) compared with the use of radiotherapy alone. Further studies are needed to verify the impact of this strategy on overall survival.