Department of Epidemiology, ASL RM/E, Rome, Italy

School of Health and Social Care, University of Teesside, Middlesbrough, UK

Faculty of Health, Staffordshire University, Stoke on Trent, UK

Orthopaedic and Trauma Department, “Tzanio” General Hospital of Piraeus, Greece

University of Medical Sciences, Poznan, Poland

Department of Orthopaedic Surgery, Saitama Medical University, Kawagoe, Japan

Thriasio General Hospital, Athens, Greece

To evaluate the efficacy of bracing in adolescent patients with AIS.

Cochrane systematic review

The following databases were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINHAL and reference lists of articles. Extensive hand searching of grey literature was also conducted. RCT's and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces were included. Two review authors independently assessed trial quality and extracted data.

Two studies were included. There was very low quality evidence from one prospective cohort study including 286 girls¹indicating that braces curbed curve progression, at the end of growth, (success rate 74%), better than observation, (34%) and electrical stimulation (33%). Another low quality evidence from one RCT with 43 girls indicated that a rigid brace is more successful than an elastic one (SpineCor) at limiting curve progression when measured in Cobb degrees². No significant differences between the two groups in the subjective perception of daily difficulties associated with brace wearing were found.

There is very low quality evidence in favour of using braces, making generalization very difficult. The results from future studies may differ from these results. In the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes as well as measures such as Cobb angles. RCTs and prospective cohort studies should follow both the SRS and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies.

It was previously postulated that the IV disc wedging is a significant progressive factor for mild IS curves. The present report introduces an innovative comprehensive model of IS curves progression based on intervertebral disc (IV) diurnal variation and the subsequent patho-biomechanics of the deforming “three joint complex”, where vertebral growth occurs.

Throughout day and night, due to sustained loading and unloading, the scoliotic wedged IV disc expels fluid and imbibes it more convex-wise. The convex side of the IV sustains a greater amount of cyclic expansion than the concave side. Consequently the imposed, convex-wise, asymmetrical concentrated cyclical loads to the adjacent immature vertebral end plates and posterior elements of the spine lead to asymmetrical vertebral growth. More specifically the loading on the two facet-joins asymmetrically increases during the day, as the wedged IV space narrows due to expelled water and it asymmetrically decreases during the night, as the IV space swells due to imbibed water.

This 24 hour period cyclic asymmetric loading leads both to asymmetric growth of the end plates and wedging of the vertebral bodies, and to similarly asymmetric growth of the pedicles and arches posteriorly as an effect of Hüeter-Volkmann law. This model explains the well described anatomical findings of the more elongated pedicles and the larger facet joints in the convex side than in the concave in scoliotic spines

The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. In addition, school screening is a unique tool for research of IS in humans, as in most published articles, all aetiopathogenetic factors are studied in animals and not in humans.

Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS

The osteonecrosis of the medial femoral condyle, depending on the area occupied, causes pain and may progress into osteoarthritis. For the management of osteonecrosis numerous treatment methods have been described, as conservative, drilling, osteotomy and others.

The aim of our study is to evaluate the results of management of knee osteonecrosis with unicompartmental arthroplasty.

We studied 16 knees in 15 patients (all women) with osteonecrosis of the medial femoral condyle. The size of osteonecrosis was greater than 3.5 cm, as revealed by MRI. The mean age of patients was 72 years (range 64–80 years). The time elapsed from the onset of symptoms to surgical treatment ranged from 3 to 10 months.

All patients were followed clinically and by X-ray 1 to 6 years post-operatively and scored with Knee Society Score. The result in 14 patients was excellent and in 1 was good.

In conclusion, unicompartmental knee arthroplasty is a satisfactory method of treatment of osteonecrosis, which provides immediate relief from pain, long-term satisfactory outcome and avoids multiple operations

Melatonin’s concentration is high in early childhood and declines gradually thereafter. In the elderly serum melatonin levels are very low. Melatonin, the “light of night”, among other functions is involved in human sexual maturation and in osteogenesis.

Hormesis is the response of cells or organisms to an exogenous (eg drug or toxin) or intrinsic factors (eg hormone), where the factor induces stimulatory or beneficial effects at low doses and inhibitory or adverse effects at high doses [bimodal dose-response] or vice versa.

At the age around 10 years, when idiopathic scoliosis may appear, the circulating melatonin level is about 120 pg/ml – positive hormesis for menses – and menarche appears. Melatonin deficiency may result in a delay of the age at menarche and consequently the girl is susceptible to scoliosis. In these terms melatonin could be certainly involved in the scoliosis pathogenesis. Around the age of 45 years when the circulating melatonin levels are about 20 pg/ml – negative hormesis for menses, menopause starts and the woman has an increased risk for osteoporosis and fractures.

It is documented the bone-protecting effect of melatonin in ovariectomized rats which can depend in part on the free radical scavenging properties of melatonin. Additionally, melatonin may impair development of osteopenia associated with senescence by improving non-rapid eye movement sleep and restoring GH secretion. Whether modulation of melatonin blood levels can be used as a novel mode of therapy for scoliosis and augmenting bone mass in diseases deserves to be studied

This paper evaluates severe normal trunk asymmetry (TA) by higher and lower body mass index (BMI) values in 5953 adolescents age 11–17 years (boys 2939, girls 3014) whilst standing forward bending (FB) and sitting FB during screening for scoliosis. TA was measured as angle of trunk inclinations (ATIs) across the back (thoracic, thoracolumbar and lumbar) with abnormality defined as 2 standard deviations or more. The findings for sitting FB position are reported because the readings express TA free from any leg-length inequality. Relatively lower BMIs are associated statistically with

excess of abnormal TAs, and

BMI is known to be linked to puberty timing and energy balance but not to TAs in healthy students. Similar to girls with adolescent idiopathic scoliosis, we suggest that severe TA is caused by a genetically-determined selectively increased hypothalamic sensitivity to leptin with asymmetry as an adverse hormetic response, exacerbated by presumed lower circulating leptin levels associated with relatively lower BMIs. The asymmetry is expressed bilaterally via the sympathetic nervous system to produce left-right asymmetry in ribs and/or vertebrae leading to severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk

Aim: To study the postoperative results of an alternative method of pin placement for acute pelvic ring stabilization with an external fixation.

Introduction: External fixation for stabilization of pelvic ring fractures is the only and a safe method for emergency treatment. According to literature pins of the fixator should be placed urgently on the superior iliac rim and as soon as general condition of the patient permits, revision is required in order to manage in a finitive way the injury.

Material-Method: Inclusion criteria were high energy trauma, severe pelvic instability, heamodynamic instability, acute management of a pelvic fracture and minimum follow up of 2 years. Patients with a simultaneus major head, chest or abdominal injury were excluded from the study. Between 2000–01, 19 patients (15 male and 4 female with a mean age of 28 years old) underwent acute pelvic stabilization with an external fixation. In 12 patients, mechanism of injury was road accident and in 7 patients a fall from a height. Fracture type according to Tyle classification was 2 type A, 12 type B and 5 type C. In 6 patients the pins were placed in an oblique plane to the superior iliac rim (Group I) and in 13 patients there were placed in the sagital plane, just below the superior anterior iliac spine (Group II). The mean time for external fixation application was 15 min for group I and 22 min for group II.

Results: 14 patients were heamodynamically stabilized in the early postoperative period and 5 patients were transmitted to Intensive Care Unit. In 17 patients a rigid fixation of the pelvis was achieved and remained as a definite method of treatment and in 2 patients of Group I, replacement of the external fixator and an adjacent stabilization of posterior elements was required. No patient required adjacent posterior element stabilization as the primary reduction and stabilization was satisfactory. Mean time of stabilization was 7 weeks for type A, 10 weeks for type B and 11 weeks for type C fractures. 13 patients were totally recovered and returned to their previous occupation and 6 patients have minor problems that are attributed to the pelvic ring fracture.

Conclusions: External fixator’s placement for pelvic ring stabilization should be performed in a way that it will be a finitive method for osteosynthesis of the pelvis. We suggest pin placement in the sagital plane, below the superior anterior iliac spine instead of placement at the superior iliac rim.

We report our experience on complications of intra-medullary nailing on 150 femoral shaft fractures.

Material concerns 147 patients (103 men and 44 women) that were operated in a 7 years period. Mean age was 37 years old (15–77). Thirty patients were older than 65 years. Indications for femoral intramedullary nailing were 120 acute fractures (7 pathological), 9 non-unions, 2 malunions and 19 fractures with delayed union previously operated by another method. Twenty two were polytrauma patients. Twenty one fractures were open (grade a and b). Various types of reamed long antegrade nails were used in 117 cases and a long g-nail in 33 cases.

Main complications were: shortening 10, heterotopic ossification 6, knee stiffness 8, fat embolism 2, deep venous thrombosis 4, pulmonary embolism 2, superficial wound infection 8, deep infection 1, lengthening 4, rotational deformity 10, nonunion 0, missed distal screw targeting 10, drill breakage 7, malposition of the nail 7, additional intraoperative fracture occurrence 7. In 60 cases the insertion of the guide was performed by a small incision at the fracture site. Mean union time was approximately 4 weeks shorter when a closed reduction was performed.

Technical complications in the majority of cases affected fractures that were operated after midnight. Elderly patients (> 65 years old), were most probably to be subjected a complication while less complications occurred in younger patients. A well prepared operating room and prevention of surgeons fatigue is needed to reduce complications.

Aim: The study of quality of life in adolescents with Idiopathic Scoliosis (IS) that are treated conservatively with a brace.

Introduction: Study of patients’ quality of life, especially of those suffering a chronic disease that requires long term treatment, is of great interest in recent years. Although there are a lot of studies for psycological sequences in IS, only a few papers in the available literature are dealing with quality of life measurement. SF-36 generic questionnaire provides the physician with valuable outcomes of treatment in patients over 14 years old.

Material-Method: Inclusion criteria were diagnosis of IS, a curve between 20o–40o, age of the child between 14–16 years old, follow up by the same physician or team, conservative treatment of IS and minimum duration of brace treatment for 2 years. Twenty-eight children, 25 girls with a mean age 14.8 years old and 3 boys with a mean age 15 years old were included in the study and filled the form of SF-36 questionnaire. All children are still wearing the brace. A control group of 30 children were also filled SF-36 form.

Results: Mean score of SF-36 questionnaire was 76.29 (SD 9.105). Most negatively affected domains are Mental Health (mean score 54.3, SD 11.5) and Vitality (mean score 62.86, SD 16.5). Physical Functioning (mean score 79.3, SD 20.7), Role limitation due to Emotional problems (mean score 76.3, SD 25.23), Social Functioning (mean score 77.9, SD 17.13), Bodily Pain (mean score 79.6, SD 19.5) and General Health Perception (mean score 77.1, SD 19.94) are less affected domains. Best scores are achieved in Role limitation due to Physical problems (mean score 96.4, SD 9.45) and Change in Health (mean score 82.1, SD 23.78) domains.

Discussion-Conclusion: This report appears that brace treatment has negative effect on childrens’ quality of life. The use of SF-36 questionnaire through detection of most affected domains provides the physician a measurable outcome for child’s quality of life in order to 1) interfere with the selected method of conservative treatment and its modalities in a way that it would less affect the child and 2) provide the child specific psychological support by the doctor, the orthotist, the parents and the various voluntary organizations.

The attempt to achieve and institude the potential less minimal invasive hip hemiarthroplasty by using common instruments is the aim of our study.

We report on a randomly selected group of 80 patients, 40 of which were operated by a small incision 5–10 cm (group A) and 40 by a standard incision 15–20 cm (group B). The approach was through the gluteus medius muscle (lateral-Hartinge) in all of the cases. In group A an additional small transverse incision of the fascia was needed without any other inside extension. There were no statistical differences in gender, age (mean age 80 and 79 years old respectively), weight of the patients (average BMI 27,5 kg/m2 and 27 kg/m2 respectively) and implant type.

The operations were supervised by the same surgeon. PMMA was used in 18 of the cases in each group.

Blood loss was less in group A (mean 200cc less) and 21 patients were not transfused at all intraoperatively. A second assistant was necessary in educational operations. Four of the patients had postoperatively bruises and skin scratches. Early postoperative pain was less in the first group, but was the same two months postoperatively. Thirteen patients slept on the operated leg on the 2nd and 3rd postoperative day. Discharge from the hospital was available two days earlier in the first group. We had one hip dislocation in the first group in a psychiatric patient who had also DVT.

In conclusion , minimal invasive surgery in hip hemi-arthroplasty is possible to be performed with the use of common instruments and it is worth once while. Experience of the surgical team is necessary for reducing operative time and further research is needed for establishing possible contraindications.

Aim: To evaluate the results of management of Char-cot foot and ankle deformities by the use of the Ilizarov apparatus.

Material-Method: This is a retrospective study of 11 cases (9 patients) aged from 39 to 60 years old (mean 44 years), all suffering from Charcot foot neuroarthropathy. All cases showed established midfoot breakdown. In four cases hindfoot deformity coexisted. Three feet were ulcerated. In six cases the Iizarov frame was applied using complex hinges and closed compression fusions were performed, utilizing the bent wire technique. In five cases the correction of the deformities was performed acutely with the use of percutaneous cannulated screws. In the later cases the Ilizarov frame neutralized the former osteosynthesis method. The Ilizarov device remained attached for 8 weeks, regardless the presence of other osteosynthesis hardware. The Maryland Foot score (MFS) was utilized for objective assessment by the physician and the SF-36 questionaire for subjective assessment by the patient.

Results: A statistically significant improvement in MFS and SF-36 score was recorded. In all cases the aim for a stable and painless extremity was achieved. All patients returned to their previous activities and kept using normal shoe wear.

Conclusions: A lot of references are found in the literature describing failure in the treatment of Charcot foot deformity with the use of internal fixation. This is justified by the poor bone quality and decreased bone density of the diabetic and alcoholic patients. The use of tensioned wires in multiple levels provides adequate fixation in cases where a frame is used solely and safe neutralization where a frame is combined with internal fixation.

Aims: The purpose of our study is to present the results of the use of external þxation, as a þnal method of treatment for tibial shaft fractures. Methods: In 5 years period, we treated 143 tibial shaft fractures in 135 patients. 112 were male and 23 were female, aged 15 to 80 years old (mean 35 y.o.). Our indications were: 16 closed fractures with severe soft tissue injury, 19 closed fractures with threatened compartment syndrome, 90 open fractures, Gustilo type II or III, 18 closed fractures in polytrauma patients. Results: Union, without the need of changing method was achieved in 121 fractures. The mean time of union was 22 weeks for closed fractures, 25 weeks for type II open fractures and 28 weeks for type III open fractures.

The main complications were 13 nonunions, 40 super-þcial pin infection, 2 malunions, 2 osteomyelitis, 2 patients with fat embolism syndrome and 3 deaths due to pulmonary embolism. Conclusions: External þxation is a proper deþnite treatment for tibial shaft fractures according to the indications mentioned above. Technically it is easy to apply and there is no need of surgery to remove it. The procedure of normal union is not disturbed. Most of the complications can be managed without removing the device. The advantages of the method make it comparable or superior to intramedulary nailing although there is a delay in full weight bearing.

Purpose: The purpose of this study was to investigate the results of the surgical treatment of intra-articular calcaneum fractures according to the Ilizarov method or in combination with mini open reduction.

Materials and Methods: In the period 1996–2003, 17 patients with 19 calcaneal fractures (14 men and 3 women) were surgically treated by the Ilizarov method. 2 patients had calcaneum fractures on both sides. 15 fractures were caused by fall, whereas 4 of them by car accident. Fractures were classified according to the Saunders CT classification: 12 fractures were type II, 5 type III and 2 type IV.

The device consisted of two rings applied at the distal tibia and a foot plate. The closed reduction of the calcaneum fracture was achieved with the use of a 1,8 mm pin in the posterior side of the calcaneum body, which improved the Bohler angle, along with the Gissane angle. In cases where necessary a short approach to the posterior subtalar joint was implemented for the reduction of the articular surface. The patients were encouraged to partially load their foot from the 1st postoperative day.

Results: Results were evaluated according to the Maryland Foot Score. 7 fractures gave excellent results, 10 gave very good results, 1 fracture good result and 1 poor result.

Conclusion: Traditional methods of open reduction and internal fixation of calcaneum fractures are usually a contraindication in cases of severe fractures and severe soft tissue damage. According to several authors the use of pins in the reduction of fractures is comparable to the open reduction.

From this study the Ilizarov method was found to be particularly safe and can be used in cases associated with severe soft tissue damage offering a quick surgical treatment.

Abstract: The effect of a modified Boston Brace with antirotatory blades upon the fate of idiopathic scoliotic (IS) curves, mainly right thoracic with a compensatory left lumbar, is studied. This report refers to curves within the generally accepted range of Cobb angle (20° – 40°) appropriate for conservative treatment.

Method and Material: Out of 166 children suffering IS with Cobb angle > 10°, 67 (61 girls, and 6 boys), having a mean follow up 2,3 years (4 months to 7 years), were studied. A brace of Boston type with antirotatory blades was applied in 36 scoliotic children. The curve type was: 18 thoracic (T) right (rt) + Lumbar (L) left (lt) in children with a mean age 13,1 years, 3 T lt + L rt in children with a mean age 16,3 years, 7 T rt in children with a mean age 13 years and 8 thoracolumbar (TL) rt curves in children with a mean age 12,1 years. Full documentation during the FU had 23 out of the 36 children with 14 T rt + L lt, 1 T lt + L rt (15 in total – double curve group), 4 T rt (thoracic group) and 4 TL curves (thora-columbar group). Traditionally deterioration (increase) or improvement (decrease) of a curve is considered a change of 5ï Cobb compared with the initial reading.

Results: In the 15 double curve group children the mean FU was 28 months. In this group 5 curves were improved, 6 remained stable and 4 were increased. For the 4 thora-columbar curves with a mean FU 8 months, 3 remained stable and 1 improved. For the 4 thoracic curves with a mean FU 9 months, 2 were stable and 2 improved. During the final FU of the above 23 scoliotic children, when the assessment of Cobb angle was made with children out of the brace, 8 curves were improvement, 11 remained stable and 4 deteriorated (one patient out of 4 (4,3%) was operated upon). All the deteriorated curves were double (T rt + L lt). When the assessment of Cobb angle was made with children in the brace, 10 curves were improved, 12 remained stable and 1 deteriorated

Discussion: The brace treatment affected more the double curves while single curves remained unaffected. Rotation remained unchanged in all curve types except in the lumbar component of double (right thoracic-left lumbar) curves. A composite spiral trunk rotator muscle has been proposed, (consisted of the ipsilateral scapular elevator and rhomboid, the anterior serrated, external oblique and contralateral internal oblique abdominal muscle, (Benninghoff 1985, Wemyss-Holden 1990), which is considered that have an effect on the trunk rotation during gait. Asymmetry of one or more constituent muscles creates scoliosis. These findings are consistent with the view that neuromuscular factors are responsible for the initiation of idiopathic scoliosis. The antirotatory blades of the brace are acting upon the above described composite spiral trunk rotator muscle blocking the deterioration of the scoliotic curve or improving the double curves thus supporting the above aetiologic view. In conclusion the conservative treatment using this brace is beneficially affecting the natural history of the IS in children 12–15 years of age.

Purpose: The purpose of this study is the analysis of the results of the surgical treatment of complex and displaced acetabular fractures.

Material: We have the results of thirty four comminuted acetabular fractures that were treated with open reduction and internal fixation. Most of them concerned fractures of both columns.

Method: Thirty two of the fractures were operated through one technique (Kocher-Langenbeck, ilioinguinal, expansive iliofemoral, or lateral by lifting the greater trochanter).The other two were operated with a double procedure (Kocher-Langenbeck and ilioinguinal). For the internal fixation reconstruction plates were used together with free screws and sometimes hook like wires.

Results: Anatomic reduction was performed in 24 cases. The result was graded as excellent in 42%, good in 34%, fair in 16%, and poor in 8% of the cases. Posttraumatic arthritis was seen in cases were anatomic reduction was not possible and the level of the arthritis was in absolute relationship with the quality of the reduction. In cases were the reduction was anatomic, posttraumatic arthritis was rare. The clinical results were in absolute relationship with the quality of the reduction and they were satisfactory as soon as the relationship of the weight bearing surface of the acetebulum and the femoral head is regular. Avascular necrosis of the femoral head was seen in two cases.

Conclusion: The anatomic reduction of displaced complex acetebular fractures prevents posttraumatic arthritis and ensures satisfactory clinical results. The aim of the operation must always be the anatomic reduction of the acetabular cup and the bone structures around it. When this is not technically possible we have to try for the restoration of the relationship between the femoral head and the acetabular roof.

There are a few reports in the literature that compare the results of medial and lateral meniscectomy, especially in older patients.

Eighty three patients that underwent partial menis-cectomy were studied (45 men, 38 women), all older than 45 years. Forty eight cases considered medial and 35 cases lateral meniscectomy, mainly of the posterior horn. According to Outbridge and French Arthroscopic system criteria, there was not significant difference for the osteoarthritic changes that were found arthroscopically. 48% of the patients had no arthritic damage. Radiological evaluation of the results was done with Fairbank classification and International Knee Documentation Committee criteria, pre and postoperatively. Preoperatively, 50% of the patients had no pathologic radiological findings and postoperatively, both groups had similar radiological results. Tapper – Hoover criteria and Lysholm II Score were used for the evaluation of clinical results. 83% of medial and 78% of lateral meniscus tear’s repair had satisfactory clinical results and no statistical significance was documented in our series, despite reports from the literature of poorer clinical results for lateral meniscectomy. In both groups, clinical results were not influenced by the severity of cartilage lesions or by the age of patients, but by the amount of meniscus removal and the delay of arthroscopy, greater than 2 months.

The surgical treatment of scaphoid nonunion is controversial.

The purpose of this study is to present our experience from the surgical treatment of 16 scaphoid nonunions in heavy manual workers.

Sixteen patients with sixteen nonunions of the scaphoid were treated during the last 6 years (13 male and 3 female). Established nonunion was present in 7 months to 7 years. Five nonunions were Alnot stage I, 5 were IIa, 5 were IIb and 1 nonunion was stage IIIa. One case considered the distal pole and 15 the proximal pole of the scaphoid. In 5 patients there was avascular necrosis of the scaphoid and in 6 patients DISI was present. All sixteen patients complained about pain, resulting to disability to work.

All patients were treated with an autocompression screw and small autologus cancellus bone grafts. In one case with a proximal third non-union, screw fixation was not achieved. The mean time of union was 70 days. Mean follow up was 3 years. All patients returned early to their occupation without pain. Grip strength reached 90% (70% preoperatively) and range of motion reached 95% (80% preoperatively), compared to the contralateral side. Excellent functional results were in eleven patients, good in four and average in one patient. In four cases there was a previous carpal dislocation.

Symptoms of non-union of the scaphoid appear earlier in heavy manual workers and their surgical treatment should not be delayed. We believe that the use of autocompression screws and cancellous bone grafts is the first choice of treatment for nonunions (Alnot stage I and II) of middle and distal third of the scaphoid.

1. Introduction. A significant correlation between handedness and laterality of the curve in scoliotic children is reported in the literature. This correlation is implicating cortical function as an aetiologic factor for scoliosis, (Goldberg and Dowling 1990). The truncal asymmetry expressed as a hump, is the sign at the presence of which there is a suspicion of a scoliotic curve. The above issue stimulated the search of existence of a possible correlation between handedness and the increasing truncal asymmetry, the existence of which represents a risk factor for development of scoliosis. Thus the aim of this study is the appraisal of the correlation of the existence of a truncal asymmetry as it is checked by the use of a scoliometer during the forward bending test and the handedness in schoolmates who were screened at school for scoliosis.

2. Material and Method

2.1 The examined children. 4345 students (2183 girls and 2158 boys), 6 – 18 years of age were examined during the school-screening program for scoliosis.

2.2 The measurements. A protocol with a checklist is filled for each student in which handedness and truncal asymmetry is included. The probability of existence of scoliosis in the child and the recommendation for further clinical and radiological assessment at hospital is based on the amount of the recorded truncal asymmetry. The sitting and standing forward bending test is performed using the Pruijs scoliometer, on which reading ≥7° is a threshold for recommendation for reexamination. Truncal asymmetry was recorded for thoracic, thoracolumbar and lumbar region.

2.3 The statistical analysis. The techniques used for the study of the sample of children included cross tabulation and ÷2.

3. Results. The statistical analysis revealed that there is no statistical difference for handedness between boys and girls therefore the correlation between handedness and truncal asymmetry was performed for both sexes together. 91% children were right-handed (1932 boys and 1996 girls), while 9% left-handed (218 boys and 169 girls) respectively. A significant statistical correlation of truncal asymmetry and handedness was found both in boys and girls at thoracic (p < 0.022) and thoracolumbar (p< 0.027), but not at the lumbar region.

4. Discussion. These findings show that there is significant correlation of truncal asymmetry and the dominant brain hemisphere in terms of handedness, in children who are entitled at risk to develop scoliosis. Thus, the correlation of the handedness and the truncal asymmetry (the scoliosis convex) is present not only at scoliotic children but and at those being at risk that is before the development of the disease. These findings correlate cortical function and the truncal asymmetry, probably as a prodrome state of scoliosis and it is of aetiologic importance.

The aim of this study was to evaluate the results of total hip arthropiasty in osteoarthritis secondary to congenital hip disease.

During the period 1986 to 1999, we performed 48 hip replacements with congenital hip disease. According to classification of Chanophylakidis there were 18 dysplastic hips without dislocation, 17 hips with low dislocation and 12 hips with high dislocation The mean age of the patients was 49 years (range from 31 to 64) Depended on the pathology of each case, different types of prostheses or combinations of them were used. The acetabular cup was placed in the anatomic position and in the majority of cases a component of 22 aim was used. In 28 cases the bottom of the acetabulum was fractured and protruded in order to fit the cup (acetabuloplasty). In these cases copious amounts of auto- and aiiografts were used and the cup was fixed with PMMA, Special femoral stems for CDH were used and in the majority of cases they were fixed with PMMA. In 17 cases with good acetabular bone stock and good femoral canal a standard prosthesis was used without PMMA. In 31 cases the hip was approached after osteotomy of the grater trochader and in 17 cases an anterolateral approach was used.

Intra-operatively there were many problems and difficulties but we had no true complications. Early postoperative complications presented in eight patients and had to do with 2 haematomas, 3 DVT, 1 mild PE and 2 superficial infections. There was no case of deep infection, neurovascular damage, dislocation or fracture. The late results after a mean of 6, £ years were very satisfaaory. There was improvement of the HIP SCORE from 38 to 83 and subjective satisfaction of nearly all the patients. The late complications were limited and they concerned three migrations of the acetabular cup, one aseptic loosening of the femora) stem and one extensive osteoiysis the proximal femur. All the above cases were revised successfully.

In this paper the results of correction of bone deformities using the llizarov methods, are presented.

Fifty-nine patients, 42 with malunion and 17 with mal-nonunion of tibia or femur were operated upon using the llizarov circular fixator. Another 28 cases were corrected using a unilateral device. There were: a) 30 angular deformities, 18 of which were combined with shortening, b) 21 angular deformities associated with translation and c) 36 complex, deformities including angulation, translation, shortening and malrotation.

Two rings above and two below the apex of the deformity were always required. Different types of hinges were used between them, depending on the type of the deformity. The corticotomy was performed at the apex of the deformity for the majority of the cases. In 18 patients with hypovascular and eburnated bone, or bone covered with soft tissue of poor quality, the corticotomy was done more proximal or more distal to the apex of the deformity. In complex deformities the correction sequence was: 1) correction of angulation and shortening simultaneously, 2) correction of rotation, 3) and finally correction of translation. The true plane of the deformity and the plane of placement of the hinges were determined by a computerized formula that we developed.

The deformities were corrected in all cases in which the hinges were placed at the correct position but in 5 cases we had to re-orient the hinges in order to achieve the correction. The corticotomy or pseudarthrosis consolidated in all cases. Residual leg length discrepancy remained in three patients, not exceeding 135 cm. Great care was taken to prevent complications during operation as well as during the post operative period. However, there were numerous obstacles, problems and true complications. All these were managed aggressively as soon as they appeared. The final results were very satisfactory.

We conclude that the revolutionary llizarov methods can solve bone deformity problems that cannot be faced by the traditional methods. It is critically important to place the hinges at the correct position in order to achieve the desired correction. Our computer program definitely helps to this purpose. The surgeon must always be vigilant in order to prevent complications and to deal with them immediately.