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In the frontal plane, corrections with hooks have varied from 38% to 55% depending on the series. This percentage improves to 60% when the lumbar curvature is instrumented with screws. Like Suk and Harms, we have found greater than 70% correction when the entire curvature is screwed using lumbar and thoracic pedicular screws. In the sagittal plane, results of hook instrumentations have been less than satisfactory for many authors (Betz, Rhee...). The improvement obtained with pedicular screws results from two effects: the stability of the construct which remains stable during reduction manœuvres allowing application of strong force, and the polyaxis arrangement allowing inserting the rods in all the screws simultaneously and thus distributing the reduction forces. The long-arm screws are brought into contact with the rod progressively by tightening the nuts bringing the vertebrae into line with the rod. We have not had any complication after insertion of 550 screws. We have not used distraction which we consider dangerous for the neurological structures nor contraction at the thoracic stage which induces lordosis.
Since the time of Charles Darwin, it is known that three principles of regeneration explain the similarity of neo-formed tissues, the dependence of regeneration rhythm on age and the position of the animal in the evolutionary chain. The latter principle is know as the Weisman-Pschibram principle. Regeneration depends on several factors: level of tissue specialisation and differentiation, tissue resistance to hypoxia, and other manifestations of generally recognised biological regulation.
According to a fourth principle, the regenerative potential of different parts of the body depend on a cranio-caudal gradient which rhythms their postnatal growth and development. Distinction of this principle is of importance because of its practical applications. Experience with increasing the height of persons with achrondroplasty by lengthening different limb segments reveals that the femur has less regeneration potential despite its long length. Leg lengthening is preferred; saving muscle function, there is a 20% potential for lengthening.
Male subjects are generally considered to be short in height when there is a 10% growth retardation of the longitudinal dimension of the body. In female subjects, generative function is considered deficient if the length of the trunk is less than 73 cm. Using these criteria, experience has shown that leg malformations are not observed in subjects with a 10% growth retardation of the limb. The rate of growth retardation has to reach 40% before growth ceases.
The relative moment of posterior leg muscle force increases with increasing leg length (F = 0.063 x L – 0.7; r=0.965, n=123).
With a 10% growth deficit, the leg lengthening operation limits the amplitude of ankle movement 15% on average. With the same 10% growth deficit, lengthening the femur with the same technique decreases the amplitude of knee movement 22%. It has been noted that a 40% decrease in leg muscle force after leg lengthening does not affect locomotor function. The same decrease in thigh muscles after femur lengthening alters function.
Like the first three principles, the fourth has its exceptions. It is important however to distinguish the influence of biological factors from other, for example technical, factors. Thus orthopaedic surgeons prefer the humerus for lengthening the upper limb, but this results from the difficulty in preserving rotation movements when lengthening the forearm. The important advances obtained in recent years in patients with bony defects of the hand and foot are further arguments clearly in favour of the existence of a cranio-caudal gradient in regenerative potential of the limbs.
Nineteen patients aged 16–50 years with a single osteochondral lesion or osteochondritis dessicans involving the femoral condyle but who had no other knee anomaly were included in this trial. The graft was inserted via an arthrotomy. Patients were examined preoperatively then at 3, 6, 12 and 24 months after grafting. The main evaluation criteria was improvement in the IDCD score (ICRS item) at 24 months. Secondary evaluation criteria were MRI and arthroscopic aspect associated with biopsy of the repaired tissue performed at 24 months.
We identified a consecutive series of patients who had undergone knee replacement surgery for either osteoarthritis or rheumatoid disease between 1990 and 1995 under the care of a single surgeon using the same implant and surgical technique. There were ninety patients in each group. All were examined and underwent radiography of the anterior compartment. Data was collated for Hospital for Special Surgery (HSS) score, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score, a specific patellar score and a Visual Analog score (VAS).
The success of uncemented arthroplasty depends on the achievement and maintenance of implant stability. Despite the use of modern instrumentation to obtain an accurate implant fit during total knee replacement, small gaps often remain visible at the bone-prosthesis interface on high quality fluroscopically-assisted radiographs. Although the clinical significance of these gaps is unclear, their presence delays bony fixation of the implant.
In uncemented total hip arthroplasty, hydroxyapatite costing has been used to enhance early stability of the implant: bony apposition has been shown to occur rapidly even in the presence of a small gap between the implant and the bone. In addition, recent RSA (Radio-stereo-photogrammateric analysis) studies have shown reduced micromotion and enhanced implant stability with hydroxyapatite coating of both hip and knee prostheses.
The following study was designed to observe and investigate the phenomenon of ‘gap-healing’ around hydroxyapatite coated uncemented total knee prostheses.
Over a 15-month period a hydroxyapatite coated uncemented total knee prosthesis was implanted in 99 patients undergoing 108 primary knee arthroplasties. The patients were prospectively reviewed at regular intervals with an average follow up of 18 months and a minimum of 12 months. The implant-bone interface was evaluated by obtaining serial fluroscopically-assisted radiographs.
On the immediate postoperative radiographs, small gaps between the implant and bone were seen in most knee. These gaps were visible on average in 2.16 AKS (American Knee Society)zones per knee. Most of the gaps were seen in Femoral zones 2,3,5 and Tibial zones 1 & 4. The majority of the gaps were under 1mm depth. Gaps> 2mm were seen only in 6 patients. Healing of the gaps was first seen at 3 months postoperatively, the average number of zones involved per knee dropping to 1.54. There was good evidence of ‘gap healing’ occurring at all the bone-implant interface zones. At the end of the first postoperative year, only 0.8 zones per knee were involved.2mm gaps remained visible in 3 patients.
In animal experiments, hydroxyapatitie coated porous surfaces have shown an increased the rate of bone ingrowth for as many as 52 weeks after implantation. In our study, progressive bone ingrowth and gap-healing has been observed beyond this period, the average involved zones on 2 –year radiographs being 0.4 per knee.
During the study period, the American knee score improved from 39.52 preoperatively to 89.97 at 1 year postoperatively. No relation was found between the clinical scores and the presence or absence of gaps on follow-up radiographs.
This study demonstrates the phenomenon of ‘gap-healing’ following uncemented hydroxyapatitie coated primary total knee arthroplasty in an unselected group of patients. Gaps under 1 mm at the implant –bone interface heal readily. Healing of gaps> 2mm is less predictable.
Operation notes were analysed to confirm the type of procedure, underlying diagnosis, and thickness of tibial insert. Information was derived from patient records and postal questionnaire to all surviving patients, which included: WOMAC, SF-36, satisfaction scale and history of revision surgery.
As at September 2003 there were 153 patients (25%) still alive, using revision as an endpoint survivorship was 59.3% at a mean time since implantation of 17 years 8 months. Pain and function portions of the WOMAC questionnaire revealed mean scores of 37 and 47 out of 100.
Survival was significantly better in females, no effect from pre-operative diagnosis was seen. 73% of these patients had 6mm tibial inserts, we postulate that the deterioration in survival is related to accelerated poly-ethylene wear beyond 10 years.
Joint Position Sense (JPS) & sway were used as measures of proprioception performance. Both groups were assessed pre- and 6 months post-op. JPS was measured using an isokinetic dynamometer (KinCom, Chatanooga Ltd) as the error in actively and passively reproducing fi ve randomly ordered knee fl exion angles (30°, 40°, 50°, 60° and 70°). Sway (area, path and velocity) was measured during single leg stance using a Balance Performance Monitor (SMS Medical) for 30-second interval. Functional outcome was assessed using the Oxford Knee Score (OKS).
Pre-operatively, no differences in JPS or sway were found between limbs in either group. No differences existed between the two groups.
Post-operatively, both groups had signifi cant improvement of JPS in the operated limb only (Mean ± standard deviation for UKA 4.64±1.44° and for TKA 5.18±1.35°). No changes in JPS were seen in the control side. Group 2 patients showed signifi cant improvement in both sway area and path (p< .0001) for both limbs post-operatively. No signifi cant post-operative changes in sway occurred in either limb of Group 1 patients.
The OKS improved post-operatively in both groups, rising from 21.4 to 35.5 for Group 1 patients and from 23.9 to 38 for Group 2 patients.
The magnitude of PFO increased with age however there was no significant difference in PFO between males and females. The PFO was significantly greater for knees with a preoperative valgus deformity (p=0.006).
The radiological appearance of the tibial components were prospectively examined to for the appearance of bone lysis.
A previously published study has shown that if total knee replacement is performed without a tourniquet but using the suction cement technique an excellent cement mantle can reliably be produced.
Two hundred and eight consented patients (24.2%) were identified from 860 primary knee arthroplasties carried out over a 33-month period by a single surgeon. An LCS mobile bearing prosthesis was used in all cases. The mean valgus deformity measured 12.1 degrees (range 1–38). Fifty four percent of patients had a deformity of greater than 10 degrees. The patella was not resurfaced in any patient.
Of note 61 (29.3%) patients required a lateral patellar release for patellar maltracking. No patellar complications were noted. Mean patellar tilt was 1.1 degrees (sd=0.6 degrees) and mean patellar congruency 98% (sd=0.7%).
1. The aim of this study was to assess the safety and effectivness of Computer Assisted TKR through minimally invasive incisions.
2. Twenty-two patients underwent MIS CAS TKR surgery over a five-month period, using a Knee Navigation system and Specialist instruments developed for this technique. The length of surgery, time to achieve 90 Flexion, time from end of surgery to first walking, length of stay, blood loss and component alignment were assessed. Complications were also recorded.
The results show the range of surgical time from 100–180 minutes, the time to achieve 90 degrees flexion and SLR from 1–9 hours post surgery. Patients took from 3–12 hours to walk with a frame following surgery and stay as inpatients from 2–5 days. Blood loss ranged from 200–1180 mls. Femoral component varus/valgus ranged from 89–94 degrees, whilst tibial varus/valgus ranged from 87–91 degrees. There were 2 superficial wound infections, which resolved with antibiotics.
3. MIS CAS TKR surgeries can be performed safely and effectively with the aid of computer navigation to produce component alignment comparable to standard open techniques. However it has dramatically improved patient’s recovery after TKR surgery. The effects clearly warrant further investigation in the form of a multi-centre trial.
Knees of patients with chronic anterior cruciate ligament instability and who were awaiting surgery were examined with respect to increasing co-morbidity following diagnosis and subsequently during surgical reconstruction.
141 patients were included in this study. All had undergone initial arthroscopic evaluation of their unstable knees following diagnosis and subsequently a further arthroscopy was performed at a later stage during hamstring anterior cruciate ligament reconstruction. All injuries to the menisci and articular cartilage were recorded using a standardised evaluation form. The Lysholm and Tegner scores were obtained as well as knee stability using the KT-2000 arthrometer.
Successive deterioration in the Lysholm and Tegner scores and the arthrometric side to side difference was noted with time since injury. Initial arthroscopic examination of the knee revealed that 66 patients (46%) had at least one meniscal injury necessitating treatment whilst 67 (47.5%) had at least one chondral lesion on the femoral condyles. 22 patients (15.6%) presented with chondral lesions of the articular surface of the patella. During definitive ACL reconstruction when a second arthroscopy was performed, it was noted that 111 patients (78.7%) had meniscal pathology, 102 patients (72.34%) had intraarticular chondral lesions and the patella was affected in 41 cases (29%).
The delay between initial arthroscopy and stabilization was 16 +/− 5.2 months (range 7–19 months). The difference in the arthroscopic findings between the first and second arthroscopic inspections in terms of meniscal and chondral lesions was statistically significant.
Knee instability due to chronic ACL deficiency poses a serious threat to the menisci and the articular cartilage of the affected knee. The severity of these lesions increases with time since injury. ACL reconstruction should be undertaken as soon as possible in those individuals with uncompensated anterior cruciate ligament instability.
The thigh is placed over a bolster and the leg is allowed to hang over the end of the table.
The hamstring tendons are harvested through the pre-determined 2 centimetres horizontal incision on the posterior medial aspect of the thigh. The hamstring tendons which are individually identifiable at this point are isolated using a tendon hook. The fascial expansions of the tendons, which are easily accessible by this approach, are divided using dissecting scissors. A tendon stripper is then used to free the tendon from its muscular origin proximally and from its insertion at the pes anserinus distally.
Only a 5mm stab incision anteromedially is now required to make the tibial tunnel. The rest of the procedure is performed as described by EM Wolfe (
The mobile bearing prosthesis was surprisingly more sensitive to tibial tray external rotation. It suffered antero-lateral and posteromedial point loading on the polyethylene tray from 5–15° of tray rotation. Further increase caused the medial femoral component to lift off the polyethylene tray at 25° of rotation resulting in lateral femoral component loading. Simultaneously, there was lateral patella facet loading with medial facet lift off at the patellofemoral joint. The fixed bearing prosthesis did not experience impingement until 10° of rotation. At 25° of external tray rotation, there was posteromedial and antero-lateral point loading on the polyethylene but no lift off. The patellofemoral joint showed superior pole loading of the patella button but no medial/lateral loading.
The management of symptomatic single bundle Anterior Cruciate Ligament (ACL) ruptures is still a surgical dilemma. Preservation of the intact fibres of the ACL bundle is considered to be a possible source of reinnervation of the ACL autograft which reflects on better proprioceptive knee control after major ligament reconstruction. Results of a prospective study of 67 patients who had a double stranded but single bundle Anterior Cruciate Ligament (ACL) reconstruction for partial ACL ruptures are presented. There were 43 males and 24 females in this study with a mean age at the time of injury of twenty-five years (14 – 40). Eight played sport professionally and thirty-four played at a competitive level. A valgus twisting force was the most common mechanism of injury. Mean injury to operation time was 7.5 weeks (2–12). All procedures were done arthroscopically without using tourniquet, but using an arthroscopy pump and irrigation fluid containing adrenaline. The semitendinosis hamstring graft was used in all reconstructions. The mean follow-up period was 3.3 years (2–5.4). There was one major complication, who developed a reflex sympathetic dystrophy following a saphenous nerve neuroma. The Quality of Life (QOL) score was assessed using the Mohtadi index. The mean pre-operative QOL score of 30 (13–50) was improved to 93 (70–100) post-operatively. Fifty patients were able to return to their previous sporting level at a mean duration of 9 months (6–12).
Preservation of mechanoreceptors by performing a double stranded, single bundle ACL reconstruction in partial ACL ruptures in high demand patients yields good results and enables early return to high demand sports.
The incidence of osteoarthritis (OA) after an ACL reconstruction is not clear. Reports estimate between 12% and 61% at 8 years post ACL reconstruction. Single Photon emission Computed Tomography (SPECT) scanning (a 3 dimensional radionuclide bone scan) is a sensitive and quantitative method of assessing knee OA, with abnormalities appearing before plain xray and arthroscopic changes.
Do patients’ recollections of disease severity following joint replacement surgery accurately reflect their pre-operative disability? Oxford Knee score questionnaires were sent to 100 patients who had undergone primary knee replacement surgery between January 1998 and July 2000.They were asked to complete these in a manner reflecting their pre-operative disability. The results were then compared with actual scores completed by the same group of patients prior to their surgery. The response rate was 78%.The mean pre-operative score was 45 compared to the recall score of 46.9. The difference was not significant (p=0.77).We believe that recall of disability using a simple knee score is a reliable method of assessing pre-operative disability.
The Trent Arthroplasty Audit Group (TAAG) has been prospectively collecting data on primary knee arthroplasty since 1990 and revision procedures since 1992. To date details of 27 000 primary and 1300 revision knee arthroplasties, from both teaching and district general hospitals in the Trent region, have been contributed.
This provides us with a unique opportunity to look at the outcome of total knee arthroplasty across an English region, at 10 or more years of follow-up.
A questionnaire was designed, with assistance from the department of epidemiology and public health, including both generic (EuroQol) and knee specific questions. Patients who underwent primary knee arthroplasty from 1990–92 were included in the study (4420 patients). Surviving patients (65%) were traced using the NHSIA patient tracing service and the questionnaire was administered by post with a response rate was 55%.
The mean length of follow-up was 11 years 7 months and the mean age at the time of follow-up was 78 years. The vast majority (86%) of patients were satisfied with their joint replacement. Although 52 % took prescribed analgesia for pain in their knee, 22% still complained of pain often or all the time. 18% felt their knee totally or greatly interfered with their usual activities. 14% of patients reported re-operation on their knee, of which 11% were revision procedures.
This suggests that a significant number of patients experience pain and/or disability at 10 or more years following knee replacement. Since most GPs have a high threshold for re-referral in this group of patients, it is likely that the degree of morbidity has previously been underestimated in the orthopaedic community.
In 1999 a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Association for Surgery of the Knee (BASK) to provide a basis for regional and national auditable standards: we have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.
A direct comparison of data held on the North West Hip Arthroplasty Register for 2001/2002 and BASK/BOA guidelines was performed. 86 surgeons from 26 hospitals were included in the study. A mean of 93.3% of operations were performed in the surgeon’s usual theatre. All of these theatres had vertical laminar air flow systems. 42.2% of respondents routinely used exhaust suits. 68.1% of respondents routinely used impermeable disposable gowns. All surgeons use some form of anti-thromboembolic prophylaxis. 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin. 93.7% of surgeons routinely use antibiotic-loaded cement. The PFC and Kinemax prostheses were the most commonly used pros-theses. Interestingly, 97.7% of all first choice implants were cemented. Only 2 surgeons used uncemented TKR. 69.8% of surgeons used a posterior cruciate retaining design. A midline longitudinal skin incision is used by 87.2% of surgeons, a medial longitudinal skin incision by 7.0% and a lateral longitudinal skin incision by 5.8% 0f surgeons. A medial parapatellar capsular incision is preferred by 91.9% with the remainder using mid vastus or trivector retaining capsulotomy. Closure of capsulotomies is performed in flexion by 65.1% and in extension by 34.9%. In patients with osteoarthritis 38.4% routinely resurfaced the patella, 34.9% never resurfaced the patella and 26.7% selectively resurfaced. This was in direct contrast to practice for patients with rheumatoid arthritis in whom 66.3% routinely resurfaced the patella, 22.1% never resurfaced the patella and 11.6% selectively resurfaced.
This study has demonstrated considerable variation of practice in hip arthroplasty across the North West region and significant divergence from the BASK/BOA statement of best practice. The introduction of a properly funded national arthroplasty register will surely help to clarify the effect of such diverse practice on patient outcome.
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.
Multiple ligament deficiency in knees is usually the aftermath of high velocity trauma and leads to complex multidirectional instability, that can in turn greatly compromise the patient’s functional level if left untreated. The aim of this study is to evaluate the mid- and long-term functional outcome of patients who underwent complex reconstruction for multiple ligament deficiency.
Twenty-nine patients (21 male and 8 female) with an average age of 35.54 years (range 17–60) underwent arthroscopic or arthroscopically assisted multiple ligament reconstruction at an average of 2.1 years following their initial knee injury. Thirteen of them sustained a multiple ligament injury following an RTA, 11 during sports and 5 following a fall from a height.
They were followed for a period of 13 to 108 months (average: 45.8) and functionally evaluated according to Clancy’s criteria. The functional outcome was excellent in five patients (17.2%), good in ten (34.5%), fair in twelve (41.4%), while two reconstructions resulted in a failure (6.9%). Eleven patients returned to sporting activities and all but three returned to work, although sometimes in lighter duties.
Arthroscopic multiple ligament reconstruction is a complex and technically demanding procedure that should be carried out in specialised units. Although it rarely results in a “normal” knee, it offers in most cases a stable as well as functional knee.
Long term patient outcome data shows statistically significant differences (p< 0.05) between the best results, in patients with direct fixation of bony avulsions (mean = 89), followed by those who had early hamstring reconstruction (mean = 79), followed by those who underwent simple ligament repairs (mean = 65). There was a statistically significant difference (p< 0.05) between the overall scores for the operative group (mean = 80) compared with the non-operative group (mean = 50).
The ligament was then repaired using a suture and the tensile strength of this determined. The ligament was then reconstructed in three ways including: Biodegradable corkscrew anchors and two tendon techniques with interference screws. One method used a blind tunnel into the MFC, while the other passed through a tunnel in the femoral condyles. Both methods passed through tunnels in the patella.
The mean strength of the suture repair was 36.7 (SD 26.5) Newton. The biodegradable bone anchor gave a mean strength of 142.3 (SD 38.5) Newton. The blind tunnel hamstring reconstruction’s had a mean strength of 126 (SD 20.8) Newton. The double tunnel hamstring reconstruction’s failed at a mean of 195.0 (SD 65.6) Newton.
During the first stage knee arthroscopy using a superolateral approach, the cartilage specimens were taken from a minor load bearing area of either the central or superolateral trochlea using a 5mm gouge.
Clinical outcomes were assessed using a patient satisfaction score and the Lysholm knee score, taken both pre- and post- operatively at 3 months and annually thereafter.
The mean Lysholm score preoperatively was 98/100. Postoperatively eight patients had a reduced score (mean reduction 14) at twelve months follow up. In those patients with new knee symptoms at one year, analysis of the Lysholm score components showed the Locking and Limp categories to be the most frequent cause of a reduced score. Two patients had repeat knee arthroscopy at 18 months and 2 years postoperatively for symptoms of catching, anterior knee pain and swelling.
The procedure of cartilage harvest from the trochlea of the knee has an associated donor site morbidity which is present at one year. Ninety two percent of patients were pleased or extremely pleased with their ACI procedure, despite the requirement of surgery on their knee and it would seem that the amount of early knee morbidity these patients experience is outweighed by the improvement in symptoms in the treated joint.
Ideally to optimise cartilage repair less morbid techniques to obtain cartilage need to be identified or alternatively mesenchymal stem cells could be used as an alternative source, which has already had limited success in the knee and might also be applied to other joints.
This study reports our long-term results of arthroscopically assisted meniscal suture using an inside-out technique.
Between January 1990 and July 1997, 112 patients underwent 121 meniscal repairs in 112 knees. The average follow up is 8.7 years (range 5.4 to 12.9 years). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small posteromedial or posterolateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. Fibrin clot techniques were not used. 79% of patients had associated ACL reconstruction in addition to meniscal suture. All surgery was carried out by our senior author (PTM). Rehabilitation involved non-weight bearing in an extension splint for 3 weeks and partial weight bearing for a further 3 weeks followed by a progressive rehabilitation program.
The average age at surgery was 23.9 years (range 12.2 to 57.7 years). The average time from injury to surgery was 13.5 months (range 0 to 60 months). There were 74 males and 38 females. 51% of patients were professional or semi-professional athletes. Repair involved 79 medial menisci, 42 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12). Operative findings and procedure were entered prospectively into a database. Patients were assessed clinically until recovery and long-term follow up consisted of a detailed postal questionnaire.
The average Lysholm scores were 86.4, with 59% excellent, 16% good, 17% fair and 8% poor. IKDC subjective scores averaged 82.0, with 40% excellent, 21% good, 27% fair and 12% poor. Confirmed failure of meniscal repair (as indicated by MRI or re-arthroscopy) has been identified in 11.8% of patients. A further 10.8% have a probable failure based on a recurrence of mechanical symptoms. Of the failures 73 % were professional or semi-professional sportsman. There average return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months).
With an aggressive approach towards meniscal preservation we have achieved a success rate of 77.4% at an average follow-up of 8.7 years. The majority of these tears are vertical posterior horn or large bucket handle and associated with an ACL reconstruction. The majority of patients are young and involved in a high level of sporting activity.
The results of the first 20 consecutive patients have been compared with 20 standard TKR procedures. The mean age of 73.5 and BMI of 29 was not significantly different to the standard Group. Mean hospital stay was approximately halved (5 days versus 9 days). 75% of patients were discharged on day 4 without needing extra home support. Mean incision length was 13.5cm and only one of 20 required blood transfusion. Mean operative time was 12 minutes longer and post-operative CT alignment showed no mal-position of the implants.
Meniscus was considered to have healed if a) confirmed at arthroscopy or b) No mechanical symptoms after repair. 31 patients had repeat arthroscopy, 28 for ACL reconstruction, 2 for persistent mechanical symptoms and 1 following re-injury.
We report the use of CT with 3D reconstruction to determine the accuracy of knee arthroplasty.
Three different methods have been used to measure the position of the implant.
‘True’ anterior posterior views are reconstructed from the post-operative CT data and tibiofemoral angles computed. A wire frame model of the implants is registered to the post-op scan. This defines the orientation of the implant relative to bony reference points. The position of the prosthetic components in the post op scan is calculated. The post-op scan is registered with the pre-op scan.
We aim to assess the value of patellofemoral Computed Tomography in assessing patients with anterior knee symptoms. Anterior knee symptoms are often due to patellar malalignment. Plain axial radiography or (CT) can be used to investigate these abnormalities. We have evaluated the use of patellofemoral CT scanning in 63 patients and compared the CT findings with the patients’ symptoms. We compared patellar centralisation and patellar tilt angle with the symptom described for each of 126 knees. No difference could be detected in the CT appearances of affected and unaffected knees in those patients with unilateral symptoms (all patients have both knees scanned). A significant association between maltracking and osteoarthiritic changes was demonstrated.
The accuracy of prosthesis implantation is closely related to their function and longevity; we report the development of an active constraint robot for minimally invasive unicompartmental knee arthroplasty (UKA) using CT and knee scoring.
The Postoperative CT scan was compared with the preoperative plan. The distance of the joint line from the hip and ankle joint, and its angulation and rotation were compared to the preoperative plan. In addition, the position of the implants relative to their planned position has been computed.
On the imaging films, four measurements were made. They were patella subluxation, tilt, cartilage thickness and the Tibial Tubercle Trochlear distance (TTD). Patellar subluxation was classified as mild, moderate and severe. We found that a Tibial Tubercle Trochlea distance of 18mm had a specifity of 100% and a sensitivity of 89% for severe maltracking.
Mean tourniquet time was 118.6 mins (range 98–143 mins) in the navigation/robotic group, which was significantly longer than the conventional group (mean 96.2 mins and range 61–131 mins). Blood loss as estimated from the difference between pre and post op haemoglobin measurements was 3.2 g/dl (range 0.2–6.2 g/dl) in the navigation/robotic group as compared to 3.1 g/dl (range 1.0–6.6 g/dl) in the conventional group. Mean length of stay was 8.7 days post op and 8.9 days post op in the navigated/robotic and conventional groups respectively.
There were no physical surgical complications in the navigated/robotic group and 3 in the conventional group (1 superficial cellulitis, 1 haematoma and 1 case of temporary sensory loss to the sole of the foot). 3 cases from the navigated/robot-assisted group had to be completed with the conventional technique due to software/hardware failure intra-operatively.
Other factors to consider, which are difficult to quantify, but which were noted in the navigated/robotic group are:
Training of the surgeon Training of the theatre personnel Cost of the system Cleaning/sterilisation burden of the robot and tools, which have stringent requirements and long turn around times Requirement of technical assistance with equipment and software Radiographic assessment (need long leg films to accurately assess alignment)
This involves a retrograde intramedullary nail with a unique “cruciate” configuration of distal locking bolts which stabilise the fractured condyles in relation to the shaft.
The optimal geometrical configuration of the distal locking bolts has been developed using cadaver studies. Following finalisation of the design, mechanical bench testing of the implant and clinical trials have been completed according to a protocol agreed with the UK Medical Devices Agency.
So far 36 patients have been treated using the implant which has proved to be effective and easy to use. Much less soft tissue dissection is required than when using conventional blade plates or DHS, or even newer “percutaneous” plating methods.
Following completion of clinical trials, the Medical Devices Agency has granted approval for general use of the implant. It is anticipated that this will greatly facilitate the management of distal femoral fractures particularly those involving intercondylar fracture patterns.
Periarticular fractures of the proximal tibia are some of the most difficult fractures to manage as open reduction and internal fixation of the fractures is plagued with complications such as non-union, delayed union, infection and post-traumatic osteoarthritis.
We evaluated the results of 16 consecutive periarticular tibial fractures stabilised with the AO hybrid fixator using the Oxford Knee Score, American Orthopaedic Foot and Ankle Score (AOFAS) and X-rays of the tibia. Two patients were lost to follow up and 1 patient refused to take part in the study whose latest radiographs showed grade 4 degenerative changes.
The mean follow up was 34 months (range 12 to 57 months) and the mean age was 50 years. All fractures were closed and were graded as either Schatzker 5 or 6. The fixator was applied for an average of 12 weeks. The mean Oxford Knee score was 27.2/60 (mild to moderate knee arthritis) and the mean AOFAS was 71.9/100. There was no significant malunion however 37.5% had developed radiological evidence of grade 3 or 4 post-traumatic osteoarthritis with one requiring a total knee replacement. Forty four percent of patients developed a complication with pin site infection being the commonest complication and 25% required further surgery. There were 2 nonunions with one requiring a fibular osteotomy, which subsequently united.
Eighty eight percent of patients were satisfied with the procedure while 80% would recommend the procedure if required in future.
From our study we feel that hybrid fixation of proximal periarticular tibial fractures is satisfactory however preoperative counselling regarding complications and the possible need for further surgery must be emphasised to the patient prior to embarking on this type of fixation.
Deep infection complicating arthroplasty surgery carries a heavy fnancial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at £1 billion per year 1 by the National Audit Office.
Healthcare associated infection is an area currently under great scrutiny. Each NHS trust will have an Inspector of Microbiology, who will ensure the co-ordination of information required to diagnose healthcare associated infection.
The Alexandra Hospital, Redditch has developed a dedicated elective orthopaedic ward free from multi resistant staphylococcus aureus (MRSA). that delivers high quality and high volume major joint replacement surgery through rigorous infection control.
Between October 2001 and December 2002, the Alexandra hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005–0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p = 0.01 (CI 0.004–0.03).
The total number of joint replacements performed per year increased from 256 in 2000 to 629 in 2002.
We have developed a safe, effective and efficient orthopaedic unit within the framework of an NHS trust for a relatively modest investment. We believe the practical changes that have been made within our department can be repeated in other units around the country with relative ease.
The patients were scored pre operatively using Knee society score ( KSS) and Western Ontario and McMasters Osteoarthritis Index (WOMAC). Patients were assessed with same scoring system post operatively at 3 months, 1 year and annually there after. Post op x rays were reviewed by Knee society Radiological Evaluation.
To evaluate the functional outcome after anterior cruciate ligament reconstruction using bioabsorbable femoral cross-pin fixation
30 patients with chronic anterior cruciate ligament deficiency, treated by arthroscopic reconstruction using hamstring tendon autograft have been reviewed. 3.3mm bioabsorbable (polylactic acid) cross-pins (Rigidfix, Ethicon) were used for graft fixation in the femoral tunnel. Outcome assessment was performed using Lysholm score,Tegner activity level, KT-1000 Arthrometer laxity measurements, single legged hop test and SF-36 evaluation. There were 20 male and 10 female patients with an age between 17 and 45 years(mean 25.1 yrs).The mean follow up was 20.3 months (range12–29 months). The mean Tegner score was 5.5 with a range of 3 to 7. Lysholm scores averaged 88.27 with a range of 74 to 100. The range of movement in the operated knee was comparable to that in normal knee. The single legged hop was 93.4% of the unoperated side. The average KT-1000 side to side difference was 3.2 mm using a 30 lb force and 3.5mm on manual maximal load.
Biabsorbable femoral cross-pin fixation offers a viable and safe method of graft fixation in anterior cruciate ligament reconstruction and yeilds a satisfactory functional outcome.
The purpose of the study was to investigate the outcome of re-operations performed at this district general hospital on total knee replacements over a period of nine and a half years: we also compare the reasons for re-operation as well as their timing.
Total knee replacements performed at this hospital and other centres requiring re-operation involving an open procedure were included in this study (total number =58). Patients were assessed both before and after re-operation using the knee society score. Data was recorded with respect to the type of original pros-thesis, reason for and time to re-operation as well as the nature of the re-operation procedure itself.
Pre- and post-operative knee society scores showed a mean improvement of 20 with respect to the function scores and 65 with respect to knee scores. 50% of re-operations were for aseptic loosening with a further 25% each for infection and instability.
In conclusion, re-operation for total knee replacement is shown to have had a satisfactory outcome in most cases. The results for revision surgery using a two stage procedure, in the treatment of infected total knee replacements, showed this to be very effective.
We report a case of a 20-year-old microcephalic patient who suffered from symptomatic patellar dislocation since his early days. His patella was laterally dislocated from full extension to 40° of flexion and would remain subluxated thereafter. His CT-scan revealed excessive ipsilateral femoral neck anteversion (45°) that resulted in substantial internal femoral torsion and subsequently led to patella dislocation.
He was treated in one stage with a stepwise procedure, that involved arthroscopic assessment of patellar tracking followed by derotational femoral shaft osteotomy. Tracking was reassessed arthroscopically and although improved was still suboptimal. Therefore an arthroscopic lateral release and an Elmslie-Trillat tibial tubercle transfer were undertaken. This led to very satisfactory patellar tracking.
One year postoperatively he had significant functional improvement, no further episodes of patellar dislocation and a ROM of 0–110°. His Lysholm score improved from 45 to 88, his Tegner activity scale from 2 to 4 and his Knee Outcome Score from 38/80 to 70/80.
This complex case highlights excessive femoral neck anteversion as a causative factor for patella dislocation. A combination of proximal and distal bony realignment procedures is proposed and the role of arthroscopy is emphasised.
We describe a previously unreported method of positioning to allow bilateral procedures.
Fifteen patients have undergone bilateral medial unicompartmental replacements (ie 30 knees), using the minimally invasive approach, with our appropriate positioning technique.
Early results in terms of complications, post-operative radiographs and Oxford knee score were noted. A comparison with groups of an age and sex-matched bilateral total knee replacement group and a group of single unicompartmental knees was also undertaken.
There were no noted complications in the operative or early post-operative periods. Review of the radiographs demonstrates 4 minimally malpositioned implants with no symptomatic correlation. In early follow, from 6 months to 2 years, there has been 1 moderate result, with a patient requiring an MUA for 1 knee. 12 of 15 patients report good or excellent post-operative results in both knees. Three patients report problems with 1 knee only. The age matched group of bilateral total knee replacements had longer hospital stays, greater blood transfusion requirements and minor post-operative complications. There were a similar number of radiographic abnormalities and 1 re-operation in the single unicompartmental group.
Clinical improvement was better in the control group compared to the study group. Patients with isolated bone bruising were doing better than those with associated ID.
Radiololgically there was a tendency for the bone bruise (BB) to progress in the first six weeks but the majority started resolving by three months time. All isolated BB were resolved by six months but there was delayed resolution of BB associated with internal derangement.
Weight bearing status did not influence clinical or radiological course of bone bruising.
The average wait for a MRI Scan of the knee for an elective knee complaint is 12–18 months. This has a vast impact on family economy and quality of life considering the affected patients are young. We retrospectively reviewed 85 knee arthroscopies performed by a single surgeon during a one year period. We correlated the arthroscopy findings with the provisional diagnosis made in the clinic. There were 49 males and 36 females. The average wait for surgery was 4.6 months.The diagnosis was correct in 49 (60%), correct with additional findings in 18 (20%) and incorrect in 18 (20%). In a district general hospital setting where acces to MR Scan is difficult with a long waiting time, physical examination is reliable and arthroscopy can be performed after informed consent.
8/39 of revisions were for resurfacing the patella (20%). One patient who had a complex patella fracture needing patellectomy later had further revision surgery for instability requiring posterior stabilised components. In no patient was the revision surgery compromised or made reconstructable due to delayed presentation. In total 3 patients required bone grafting of contained cavities and only 5 knees with aseptic loosening required revision implants with stems.
Overall levels of patient satisfaction and function were good. Testing the data with a one-sample t-test showed that donor graft patients showed higher levels of satisfaction, higher knee scores and less pain than autologous graft patients (p< 0.01).
These data suggest that although autologous grafts are more commonly performed, there is an improved outcome in the group of patients following donor grafting of the ACL.
The term ‘posterior condylar offset’ (PCO) is defined as the distance from a line projected along the posterior cortex of the femur to the maximum convexity of the posterior condyles. Furthermore its magnitude has been found to correlate with final flexion following PCL-retaining TKA, if reduced by more than 3mm post-operatively
Of the three patients whose PCO was reduced by more than 3mm, one had exactly the same flexion 1 year post-operatively, one had an increase of 14 degrees, and unfortunately the third died before their 1 year review.
Using regression analysis, the strongest predictor of one-year flexion for this study group was the preoperative flexion value. The difference in PCO before and after TKA had no significant influence on one-year flexion.
Hb drop = Pre-op Hb – (Day 3 Hb + No. of units of blood received)
(We assumed that one unit of blood equates to one gram increase in circulating haemoglobin).
2 stage revisions of infected knee replacements using a static spacer are complicated by poor patient mobility between stages and the need for extensive soft tissue releases at the second stage. In this study we hypothesised that the use of the resterilsed components as temporary functional spacers, maintains patient function, and reduces soft tissue releases at second stage without reducing the rate of septic failure and obviating the need for expensive purpose made spacers.
The mean, maximum patella maltracking in extension for the TKA group as compared to the patelloplasty group (p=0.025), reduced to near normal with the augmentation patella (p=0.301).
Investigation patella tracking, we found a statistically significant difference between the TKA before and after patelloplasty, that was rectified by the insertion of the augmentation patella.
Recent history of injury associated with one or more of the following:
Acute haemarthrosis Clinical instability Disproportionate pain Locking
Referrals were assessed as fulfilling or not fulfilling the criteria, and also as to the ultimate diagnosed pathology.
Part II: From the results of these two audits, a multidisciplinary treatment proforma was created and distributed to Accident and Emergency. This included physiotherapy as a primary treatment option. Referrals were then reassessed as in the previous audits for a 4-month period.
There was a significant increase in patients referred directly from Accident and Emergency to the physiotherapy department, which means minor injuries receive physiotherapy earlier than if they initially came to clinic.
The proforma was well received by the junior doctors in Accident and Emergency due to its simplicity.
Overall the use of the proforma has improved the standard of care at our unit.
A systematic review was performed to determine the advantages and disadvantages of patellar resurfacing during total knee replacement for osteoarthritis. 3 randomised controlled studies were analysed. These studies recruited 302 knees and 277 knees (92%) were reviewed at least 5 years postoperatively (range 5 to 10 years). Patients undergoing patellar resurfacing received a cemented all polyethylene patella component. A patelloplasty was performed in some of the unresurfaced knees.
Each outcome measure tested was assessed for heterogeneity using the Cochran Q test. If significant heterogeneity was present (P< 0.10), data from the studies was not combined and the studies were examined for possible explanations. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z test was performed to test the overall effect. Reoperation for patellofemoral problems was significantly more likely in the unresurfaced group (p=0.003). The overall rate for reoperation for a patellofemoral problem was 0.7% in the resurfaced group and 12% in the unresurfaced group. Study data on clinical knee scores and anterior knee pain could not be analysed together as there was significant heterogeneity. There was no difference between the two groups in terms of revision. This study found no mid- to long-term benefit to leaving the patella unresurfaced.
The choice of graft for anterior cruciate ligament reconstruction remains controversial. A systematic review was performed to compare bone-patella tendon-bone and 4-strand hamstring grafts. Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 6312 possible articles but only 6 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasirandomised, comparing 4SHS and central third BPTB autografts, inserted using an arthroscopically assisted technique and have a minimum 2-year follow up for all patients. These studies recruited 526 patients and 475 were followed for at least 2 years with 235 patients receiving a bone-patella tendon-bone graft and 240 receiving a 4-strand hamstring graft. Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased patellofemoral joint pain (p=0.09) with a patella tendon graft. With a 4-strand hamstring graft there is a greater loss of hamstring power (p=0.008) and a trend towards an increased chance of a pivot shift > 1 (p=0.12). There was no difference between the 2 groups in terms of lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications.
Statistical analysis showed that ACL injury was common in those with lax joints and with knee hyperextension with a p < 0.001
During the routine arthoscopic examination of the knee, the intraarticular part of the popliteal tendon can be inspected. The tendon is inserted into the lateral aspect of the lateral femoral condyle just distal and inferior to the lateral epicondyle. It exits the knee lateral to the lateral meniscus through a synovial tunnel that passes posteriorly and inferiorly. A synovial fold passes over the tendon as it descends inferiorly and posteriorly out of the knee. If the posterolateral ligament complex has been damaged, the roof over the tendon is baggy and does not form the tight covering normally observed.
A scale of −2 to +2 was used to measure different degrees of skin hypo or hyperaesthia. A purpose-designed grid, designed to fit different knee sizes, was used to record sensations. A computer programme was created to record all patients’ data including the length and shape of the incision in relation to anatomical landmarks.
A parallel histological study was carried out on 12 skin specimens taken from the 2 standard incisions. The specimens were prepared and stained for nerve endings. The number of nerve endings in each incision was calculated.
The midline incision average length was 17.85 cm with an average post-operative time of 4.7 yrs and a numb area of 73.7 cm square.
The short medial incision used for UKR averaged to be 9 cm in length with an average post operative time of 3.9 yrs and an area of numbness of 48.1 cm square.
Histologically less cutaneous nerve endings were seen in specimens from midline incisions than medial incisions.
The anatomy of the posterior septum makes it inaccessible to routine arthroscopic examination. It has close proximity to the vascular structures. We approached the posterior septum from the anterior portals through the intercondylar notch. The ganglion was successfully excised.
The bone defects on the tibia and femur were as follows: (Obtained from operative records. Classified according to Anderson Orthopaedic Research Institute classification)
Type I
Type IIA
Type IIB
Type III
TIBIA
3
1
2
1
FEMUR
2
3
2
0
The tibial defects were corrected by impaction grafting and femoral condyle defects were corrected by using bovine bone as bulk grafts. Semi-constrained constrained stemmed cemented modular knee prostheses (TC3, Depuy) were used in all. Clinical outcomes were recorded by the Oxford Knee Score. Serial radiographs were evaluated for graft density, integration, implant loosening, alignment and subsidence.
Early results are encouraging but long-tem follow-up is needed.
A prospective study of the relationship of first day straight leg raise (SLR) to end range of movement took place. The ability to do SLR was used to measure patients’ motivation.
A standard medial parapatellar approach was used, all patients has osteoarthritis.
Responses from 100 patients were analyzed (divided into 3 groups)
-Flexion on discharge (mean) was 74° -Flexion at end follow up (mean) was 104°
Group II: 27% of patients SLR at day two postoperatively,
-Flexion on discharge (mean) was 66° -Flexion at end follow up (mean) was 97°
Group III: 26% of patients SLR at day 3 or more postoperatively,
-Flexion on discharge (mean) was 66° -Flexion at end follow up (mean) was 95°
Functional scores including WOMAC, SF-36 and pre-operative deformity did not vary even though Group I shows statistically significant increase in flexion at end follow up.
The patient fell whilst mobilising indoors at home during the fifth post operative week and sustained rapid hyperflexion injures to both knees. Ultrasound scans of the knees demonstrated bilateral discontinuities of the quadriceps mechanisms and a large fluid collection filling the defect.
The patient returned to the operating where a direct repair was achieved. Post operatively the patient was rested in bilateral cylinder casts until the sutures were removed at two weeks. For two week periods the knees were then mobilised in a hinged cast brace allowing 0–30, 0–60 and 0–90 degrees making the total time in cast 8 weeks
At the time of removal of the casts the patient had 110 degrees of flexion in the right leg and 85 degrees of flexion in the left. At six months postoperatively the patient flexes freely to over 100 degrees
The purpose of this study was to evaluate the effect on movement under load of different techniques of reattachment of the humeral tuberosities following 4-part proximal humeral fracture.
Biomechanical test sawbones were used. 4-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used – 1)tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis, 2)as 1 without cerclage suture, and 3)tuberosities attached to the prosthesis and to the shaft. All methods used a number 5 ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two Digital cameras formed an orthogonal photogrammetric system allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured.
Techniques 1 and 2 were the most stable constructs with technique 3 allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique 3 (p< 0.05). The cerclage suture used in technique 2 added no further stability to the fixation.
In conclusion, our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.
This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union.
Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients.
The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union.
All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed.
Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union.
The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1.
Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture.
Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques.
If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit.
3 failures were noted in the Rheumatoid group. 2 patients needed revision to hemiarthroplasty within 4 years of surgery for rotator cuff insufficiency with superior head migration but without loosening of glenoid. One other shoulder was revised at 11 years for glenoid component loosening with a worn out polyethylene liner. All 3 failures occurred in patients more than 60 years of age. Rheumatoid patients under 60 had a significant improvement in the range of external rotation from a mean of 24.2 to 30.6 degrees (p= 0.03, 95% CI = −21.4 to −1.1). The range of forward flexion improved from a mean of 71.2 to 73.3 degrees which was not statistically significant (p=.767). Rheumatoid patients over 60 years of age did not have a statistically significant improvement in the range of external rotation( p= 0.712) or in their range of forward flexion (p=.757).
Cases were identified from theatre and implant records. 61 implants in 53 patients were identified. Complication and revision rates were established from case sheets. Of this group 19 patients had died leaving 40 implants in 34 patients suitable for review. Case notes were analysed. Patients were contacted by post and were asked to fill out a DASH form. 30 patients (34 implants) responded. 26 patients (30 implants) attended a review clinic.
Mean follow up was 74 months (range 36–120). Mean DASH score at follow up was 48.7 (range 4.5–81.8).
Despite the literature reporting a high complication rate tension band wiring remains a common technique for the fixation of olecranon fractures.
In our unit 44 patients who underwent tension band wiring of olecranon fractures between May 1998 and May 2002 were reviewed specifically with regards factors that might be responsible for a poor outcome. The patient’s age at the time of injury, mode of injury and fracture configuration were recorded. In addition the adequacy of reduction was assessed and the position of the k-wires (parallel/non-parrallel, anterior cortex fixing/intramedullary) length of wire beyond the fracture line and number of circlage wire twists noted.
All patients had a minimum follow-up of 12 months. 22 patients (50%) had complications following the index procedure of which 8 had wire back out, 7 had pain and discomfort requiring removal of the metalwork and 4 had wound infections. Fixation of the radius occurred in 1 patient and 2 patients developed a non-union. In all further surgery was needed in 18 patients (41%).
No common features were identified in patients developing complications and in particular no statistical difference was found when k-wire position (P=0.35) length of k-wire beyond the fracture line (P=0.34) and number of circlage wire twists (P=0.33) were analysed.
Using Kaplan-Meier analysis the patients who required wire removal were likely to undergo their surgery within 6 months of fracture fixation.
The high complication rate begs the question: Is this an appropriate modern method of fracture fixation?
Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast.
Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections.
Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%.
Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder.
Patients were assessed using the Constant-Murley (CM) Score, the corrected Constant-Murley (CM) Score and the American Shoulder and Elbow Society (ASES) function score pre and post-operatively. Pain was measured on a reverse Visual Analogue Scale (VAS) and a range of movement was clinically assessed. All these parameters including standard radiographs were regularly assessed during the follow up period.
There have been steady and significant improvements in all parameters over the follow up period. Improvements have been sustained and continue to increase the longer the prosthesis has been in situ. The pain score is measured on a reverse analogue score, which accounts for the increasing scores. There have been 2 cases complicated by deep infection requiring revision and 2 cases of peri-prosthetic fracture.
The diagnosis of subacromial impingement of the shoulder is generally a clinical diagnosis, with no well defined diagnostic criteria. A number of tests have been described. Neer and Hawkins signs are the most common with reported sensitivities for subacromial impingement of 75% and 92% respectively.
The senior author was taught another impingement test by Mr S Copeland during his Fellowship in Reading, UK. The Copeland Impingement test is an extension of the Neer’s impingement sign, where abduction in the scapula plane with the shoulder in internal rotation causes mid-arc pain which is abolished with abduction in external rotation.
In a retrospective study we analysed the clinical data of twenty-nine patients diagnosed with subacromial impingement of the shoulder. The diagnosis was determined by the clinician’s final diagnosis. This was based on the clinical findings and response to a subacromial injection (Neer’s Test). The clinical tests included were: Hawkin’s test, Mid-arc impingement pain, Neer’s sign, Neer’s test and the Copeland impingement test. The sensitivity and specificity of each test was determined and the values statistically analysed for any significance.
The Copeland test was the most sensitive, with 95% sensitivity. Using the Wilcoxon’s signed ranks test the Copeland test was significantly more sensitive than the Neer’s and Hawkin’s tests for subacromial impingement.
In conclusion the Copeland test is an effective clinical test in the diagnosis of subacromial impingement and more sensitive than the traditional tests.
The purpose of our study was to prospectively evaluate the effectiveness of Botulinum toxin in patients with involuntary positional instability who had failed a specific rehabilitation programme.
Patients with Involuntary Positional Instability present with a muscle patterning problem that results in active dislocation of the glenohumeral joint. Botulinum toxin is used to inhabit the patterning muscle and therefore facilitate rehabilitation of optimal movement patterns.
Our review highlights the need for a stricter adherence to indications, surgery should not be under-estimated and devolved to trainees, and our understanding of the radial axis of the elbow and forearm remains relatively rudimentary.
This is the largest reported natural history study of frozen shoulder. 500 patients were identified from a specialist shoulder clinic register with a diagnosis of frozen shoulder based on Codman’s criteria. 273 patients with primary frozen shoulder replied to a detailed postal questionnaire regarding their condition. Mean follow up from symptom onset was 52 months (range 12–240months), with 89% of shoulders followed up for a minimum of 3 years. A positive family history was identified in 20% (n=45) of 1st degree relatives. The relative risk to siblings compared with a control population was 4:1. Patients with mild to moderate symptoms recovered more quickly than those with severe or unbearable symptoms. The mean age of onset was 53 years (range27–85yrs). The female to male ratio was 1.6:1. The condition was bilateral in 20%, with no incidence of ipsilateral recurrence. 22% of patients reported a history of minor trauma to the upper limb prior to the onset of symptoms. 16% were diabetic and 4% reported a history of Dupuytren’s contracture. Right and left arms were affected equally with no relationship to hand dominance. 61% reported slow, and 39% reported sudden onset of symptoms. Generally pain and stiffness improved with time but at 3 and 4 years after onset 13% and 9% respectively still had symptoms.
Frozen shoulder affects people mainly in their 6th decade. Genetic factors play an important role in the aetiology. The natural history is for improvement with time, with the less severe symptoms at onset improving most quickly. 9% of patients were still symptomatic at 4 year follow up.
The purpose of this study was to investigate the association of endocrine disease with calcific tendinitis and the effects that such disease has on its natural history.
A retrospective observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Seventy-three (71.6 %) female, 29 (28.4 %) male. Compared with population prevalences, significant levels of endocrine disorders were found in our study cohort. Sixty-six patients (81 shoulders, 62 female (93.9 %), 4 male (6.1 %), mean age 50.3 years) with associated endocrine disease were compared with 36 patients (44 shoulders, 11 female (30.6 %), 25 male (69.4 %), mean age 52.4 years) without endocrine disease. The endocrine cohort were significantly younger than the non-endocrine cohort when symptoms started (mean 40.9 years and 46.9 years respectively, p=0.0026), had significantly longer natural histories (mean 79.7 months compared with 47.1 months, p=0.0015) and a significantly higher proportion underwent operative treatment (46.9 % compared with 22.7 %, p=0.0014).
Disorders of thyroid and oestrogen metabolism may contribute to calcific tendinitis aetiology. Classifying calcific tendinitis into Type I idiopathic and Type II secondary or endocrine-related aids prognosis and management.
Little is known about how arthroscopic knots behave in terms of reverse slippage and creep during the first few hours following a Bankart repair. We aimed to assess differences between knot types tied with a variety of suture materials when exposed to loading which might be expected during the first 12 hours following a repair.
This study uses an apparatus to model the tensioning of a slipknot, the closing of a Bankart lesion and any reverse slippage occurring on removal of the tensioning force. Eight examples each of the Duncan loop and SMC knots were tied by an experienced surgeon using 4 different suture materials (PDS, Ethibond, Panacryl, Fibrewire). An arthroscopic knotting technique was used utilising a knot pusher. Each knot was locked with 3 half-hitches alternating direction and post each time. Any reverse slippage occurring during the tying process was recorded. Each knot was then left in situ for 12 hours under loads equivalent to a repaired Bankart lesion and any subsequent reverse slippage was recorded at the end of this period.
After initial passing of the Duncan loop the sutures were ranked inversely to size of suture loop (resistance to slippage) in order Panacryl (5.08±0.15mm); Fibrewire (5.7±1.03mm); Ethibond (7.22±3.47mm) and PDS (8.2±5.16mm). After passing of locking hitches, they ranked Ethibond (5.13±0.24mm); PDS (5.15±0.09mm); Panacryl (5.17±0.13mm) and Fibrewire (5.66±0.5mm – significant p< 0.05). After 12 hrs, some evidence of reverse slippage was noted, Ethibond (5.23±0.27mm); PDS (5.27±0.13mm); Panacryl (5.3±0.16mm) and Fibrewire (5.66±0.5mm – significant p< 0.05). The SMC knot showed similar results.
If a slip-knot back slips it can be tightened with the first locking hitch. After this further hitches do not tighten the knot further. Some slippage was noted during the first 12 hrs. Using arthroscopic techniques, Fibrewire performs less well than other materials.
The purpose of this study was to investigate the role that genetics play in the aetiology and symptomatology of full thickness tears of the rotator cuff.
From a retrospective, cohort study of 205 patients diagnosed with full thickness rotator cuff tears, we determined, using ultrasound, the prevalence of full thickness tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full thickness rotator cuff tear in siblings v controls was 2.42 (p< 0.0001, 95 % CI 1.77 to 3.31). The relative risk of symptomatic full thickness rotator cuff tear in siblings v controls was 4.65 (p< 0.0001, 95 % CI 2.42 to 8.63).
The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full thickness tears of the rotator cuff.
A systematic review of the English language literature has suggested that the performance of linked and unlinked elbow replacement implants differ in terms of function, survival and mode of failure; however, in this review, only one comparative series using contemporary implants was identified. We have performed a cohort study of Kudo, Souter-Strathclyde and Coonrad-Morrey elbow replacements performed at a single centre by or under the direct supervision of a single Consultant shoulder and elbow surgeon to see if these findings were reflected in clinical practice. The first forty implantations in patients with Rheumatoid arthritis for each device have been reviewed with respect to surgical complications, elbow function and implant survival. The follow-up was shorter for the Coonrad-Morrey cohort. In terms of pain relief and range of motion, the performance of the implants was comparable. The mode of failure was different, with no dislocations/ instability seen with the linked Coonrad-Morrey implants. The loosening rate of the Coonrad-Morrey implants (both clinical and radiographic) was lower, albeit with a shorter follow-up period. The loosening rates seen in this series were higher than those previously reported in the English language literature. We conclude that the functional performance of the implants, at similar stages of the surgical learning curves, are similar in patients with Rheumatoid arthritis, but that use of a linked implant removes the risk of post-operative instability and may reduce the risk of the radiographic and clinical loosening.
Surgical outcome has been linked to frequency of the surgical procedure with increased complications among surgeons with low volume. Shoulder arthroplasty is a relatively low volume procedure compared to hip or knee replacement. A recent papers has shown that in 1999 only 3% of surgeons perform 10 or more shoulder arthroplasties in New York State (
Hospital Episode Statistics(HES) data for the year April 2002 to April 2003 was analysed for Total hip replacement, Elbow replacement and Total and Hemi- shoulder arthroplasty. Consultant codes were matched for surgical codes for the procedures.
338 (61%) of surgeons doing shoulder arthroplasty performed 2 or less procedures during the study year. 13 surgeons (2.4%) performed more than 20 shoulder arthroplasties. This contrasted with shoulder and knee arthroplasty where volumes per consultant were higher (vide infra).
The majority of surgeons who performed shoulder arthroplasty during the year 2002/2003 did 2 procedures or less. The authors raise concern about the outcome of surgery among surgeons with such low volumes.
All patients diagnosed with muscle patterning disorder received specilalist physical therapy using biofeedback. Symptomatic improvement or stability was achieved in 76% of patients with anterior instability but with no previous surgery, and in 53% of patients with previous surgery. Posterior instability was eliminated in 85% of cases.
All patients underwent examination under anaesthesia, arthroscopic repair of labral tears using the metallic knotless suture anchors, thermal capsulorraphy and closure of the rotator interval. Subacromial decompression was performed when indicated. Rehabilitation consisted of sling immobilisation for four weeks followed by gradual strengthening program over three months with the physiotherapist. Contact sports were allowed at 1 year.
The aim of the study is to assess the use of patient-based questionnaires in the evaluation of shoulder surgery using a specifically designed database.
The patient based questionnaires used in this study were the Oxford Shoulder Score, used to assess shoulder pain and the Oxford Instability Score, used to assess shoulder instability.
Two hundred and ninety-five patients were recruited between October 2001 and October 2003. They were prospectively assessed prior to surgery and at regular intervals post operatively.
The results demonstrate a high degree of compliance with regard to completion of the questionnaires. Differences in outcome were noted between patients in different diagnostic groups. The specifically designed database allows presentation of outcome information either by individual patient (Figure1) or by procedure group.
Patient based questionnaires can be effectively used to audit shoulder practice. A customised database allows rapid and clear presentation of outcome results for both individual patients and groups of patients.
The needle was inserted into the supraspinatus tendon of patients with massive, large, medium and small full thickness rotator cuff tears and patients with partial thickness and no tears. Patients undergoing open stabilisation were used as controls. Measurements were made at a number of quantifiable points from the tendon edge to allow the creation of a topographical map of tissue metabolism. Oxygen consumption was calculated using measured oxygen and nitrous oxide levels at each point.
Patients with impingement syndrome but no evidence of a rotator cuff tear also showed a decreased level of oxygen consumption in the anterior part of supraspinatus, but this was significantly higher than the levels seen in the torn tendon.
The control group showed no significant alteration in oxygen levels
We report the results of a method of reconstructing massive rotator cuff (RC) tears and reinforcing the repaired RC tendons with re-tensioning of the cuff to effect reconstruction of tears which were previously considered non-repairable.
Our study examines a group of patients less than fifty years of age who underwent Total Elbow Arthroplasty with the Souter Strathclyde Elbow Replacement and compares their survivorship with a dataset of older group of patients.
309 patients were who underwent standard long stemmed Souter Implants as a primary procedure for rheumatoid arthritis over the last 16 years were included in this study. Patients were divided into two groups according to the their age at the time of surgery. In the first group of older patients greater than or equal to 50 years of age (Mean Age =64.4 years) there were 263 patients with a mean follow up of 7.3 years. The second group consisted of patients less than 50 years of age (Mean Age 42.04 years) who had a longer mean follow up period of 9.3 years. The survivorship of the implants for three different failure events was compared for both groups. The radiographs were evaluated using the Kaplan-Meir survival analyses, to produce survival curves for revision, revision due to aseptic loosening of the humeral component and finally gross loosening of the humeral implant (Hidex> 1). For each terminal event there were two curves and the age group analyses were all non-significant when log rank tested. The rates of loosening/revision were comparable in all curves.
We set out to determine the role of age as predictive factor for loosening. Our conclusions were that Total Elbow Arthroplasty is suitable for younger patients with rheumatoid elbow. Using survivorship data there does not appear to be any difference in loosening when compared to patients of an older age group. As previously published the position of the humeral component within the humerus is crucial for long-term survivorship. Thus age alone should not be the sole discretionary factor for withholding the benefits of elbow Arthroplasty in younger patients.
Traditionally midshaft clavicle fractures have been treated conservatively. It is recognized that displaced and shortened fractures may be better treated operatively. In particular, patients with greater than 20 mm of shortening and 100 percent displacement have a symptomatic non union rate of 30 percent. The standard technique used previously has been via plate fixation with LC-DCP or DCP. However in the last 5 years intramedullary fixation has been popularized. “Rockwood intramedulary clavicular pin” remedies the past treatment issues including poor blood supply, painful prominent hardware and stress raiser related to removal of metal work.
Two patients needed conversion of shoulder hemi-arthroplasty to total shoulder replacement due to subsequent erosion of the glenoid. One elbow replacement was revised because of recurrent dislocations. There were four patients who developed ulnar neuropathy, of which two were permanent. There were no peri-prosthetic fractures in this series. One patient needed custom-made short-stemmed shoulder prosthesis due to the presence of a long-stemmed humeral component of total elbow prosthesis in situ.
The Constant-Murley score has gained wide acceptance for evaluation of shoulder function. The strength component of the Constant score accounts for 25 out of 100 points. It has been criticized for lack of consistency in defined measurement method.
The aim of this study was to evaluate the effect of various variables on the strength component measurement of the Constant score.
The readings of the EZ force and the Isobex myometer were comparable.
No influence was found as well to the device being either fixed to an immobile platform or fixed to the floor by the examiner’s foot. These make these measurements easy to perform and reproducible using the newly designed digital force gauge (EZ force).
The mean Constant score was 88 (s.d. 12). The mean Imatani score was 86 (s.d. 16). Most patients were satisfied with the operation (90%). There was one case of rupture through the central portion of the Surgilig, and following extensive laboratory analysis, the ligament has been modified since. One patient had a fracture of his coracoid while lifting heavy weights. In 4 patients there was clinical and radiological evidence of loosening of the screw but only 1 complained of this being a problem.
This study was carried out to determine the incidence of shoulder injuries in the ipsilateral shoulder of patients who attended our unit with fractures of the humeral diaphysis.
This was a prospective study. 22 patients with fractures of the humeral diaphysis had an early (within 10 days of injury) MRI scan of the shoulder. The contralateral shoulder was also scanned as an internal control. There were 10 male and 12 female patients. The average age was 45 years. 20 were treated non-operatively, and 2 had retrograde intra-medullary nailing of the humerus. 6 patients in our study had a symmetrical MRI scan. The remaining 16 patients had some acute abnormality evident in the ipsilateral shoulder. 11 patients had a significant subacromial bursitis. 2 of these patients had a tear of the supraspinatus tendon. 1 patient had an undisplaced fracture of the coracoid process. The remaining 4 patients had significant AC joint inflammation, 3 being acute, the 4th being acute-on-chronic.
This study shows a high incidence of asymmetrical MRI scans, indicating a definite shoulder injury sustained at the time of the fracture of the humeral diaphysis. We therefore surmise that shoulder pain and dysfunction post antegrade intra-medullary nailing of the humerus may not be due to iatrogenic causes, but may in fact result from concomitant ipsilateral shoulder injury. To our knowledge, this is the first study demonstrating such an association.
The aim of this study was to determine the position of the glenoid’s “Bare Spot” in a large number of cadaver specimens.
The “Bare Spot” area of the glenoid has been used to determine the presence and size of a bony lesion at arthroscopic assessment of a patient following gleno-humeral dislocation; it has been assumed that this spot is placed centrally on the face of the glenoid.
Fifty cadavers were obtained from the Anatomy Department and none had known bone or joint pathology. Both shoulders were dissected open. In two there was evidence of bone pathology and one had a rotator cuff tear on one side. The size of the glenoid and the “Bare Spot” was measured with a micrometer and the position of the “Bare Spot” was measured from its centre to the anterior and posterior glenoid rims and to the antero-inferior glenoid rim (were bony lesions most often occur).
The “Bare Spot” was present in 88 of 100 shoulders. Its diameter was 4.5mm with a range from 2.4mm to 9 mm and inter-quartile range from 3.35mm to 6.1mm. The “Bare Spot” is often present and is centrally placed in the antero-posterior plane, but the antero-inferior glenoid rim is further away. This is of vital importance in planning surgery as inappropriate soft tissue surgery may be performed if the “Bare Spot” is assumed to be centrally placed in the glenoid
This aim of this study is to evaluate the efficacy of the Plant Tan plate, a new implant introduced for comminuted proximal humerus fractures. This paper presents the results of 10 patients who underwent the procedure over a two year period.
Ten patient had plant Tan plate fixation for proximal humerus fractures from January 2002 till January 2004. Details including patient demographics, the type of fracture, the bone quality, significant co morbid factors, the surgical approach union rate and complications were noted. Outcome was assessed using the Constant score and comparing with the opposite side and the Oxford shoulder questionnaire.
The purpose of the study was to reduce peak cement mantle stresses occurring at the tip of the keel for an all-polyethylene cemented glenoid component using finite element (FE) techniques.
Loosening of the glenoid component remains to be one of the most determinant factors in the outcome of total shoulder arthroplasty. Due to the off-centre loading that occurs, there is bending of the glenoid component with high shearing forces. These forces are transmitted to the underlying cement mantle and bone. It has been reported in previous FE studies that high cement mantle stresses occurs at the tip of the keel and at the edges of the cement flange. These stresses at the bone-cement interface can exceed the fatigue life of the cement, therefore initiating crack formation and damage accumulation. This results in loosening of the component and thus failure.
A three-dimensional (3D) model of the scapula was developed using CT data. Surfaces of the inner and outer contours of the cortical shell were created within commercially available software, using a threshold algorithm. The glenoid bone geometry was then produced. Material properties for the reconstructed glenoid were taken from literature, using four differing material properties. The articulating surface of the keeled glenoid component was modelled with a 3mm radial mismatch. This was positioned in the glenoid bone with a uniform cement mantle thickness of 2mm. The resulting FE mesh consisted of solid parabolic tetrahedral elements.
The effect of varying the angle on the keel of the component in the superior/inferior (S/I) direction was studied with uniform cement mantle thickness. The S/I length of the keel at the lateral end where it meets the back face of the component was maintained (juncture with flange), whilst the S/I length of the keel at the medial end (tip of the keel) was reduced as the change in angle increased. Two load cases were studied, involving a physiological load for 90 degrees of abduction and a central load of same magnitude.
It was found that by increasing the angle of the keel, where the S/I length at the tip of the keel was reduced, resulted in lower cement mantle stresses in this area of interest. This can be attributed to it being further away from the stiffer cortical bone where high tensile stresses exist due to inherent bending of the glenoid construct under loading. Therefore by reducing these high cement mantle stresses at the tip of the keel, fatigue failure of the cement mantle could be reduced.
To investigate the relationship between age and the Constant score: A formula to correct for age.
Corrected score= actual score −[(age-44)( −0.1)].
We have undertaken to review Bankart stabilisations performed by the senior author in Newcastle since 1998.
We employ a modification of the technique as described by Rowe et al, but without a coracoid osteotomy and using suture anchors. Where there is also an element of inferior instability this was combined with a capsular shift at the same time. We performed a retrospective case note review of all patients in the study period, following this all patients were sent out a postal questionnaire based on the Oxford Instability Score (OIS).
A total of 50 Bankart repairs were performed in the study period, no significant wound infections or haematomas were recorded. 3 patient had further dislocations and required revision surgery; a further 2 patients had ongoing symptoms of instability one of which has had revision.
Response rate to the questionnaire was 62%. Mean OIS for patients following primary stabilisation was 21.7 (possible scores from 12 – excellent outcome to 60 – poor outcome). OIS following Bankart stabilisation of the shoulder has not been previously reported. These results compare favourably to original scores published by Carr et al (1999) who included both patients treated by surgery and physiotherapy alone.
The OIS was shown to be very sensitive in detecting instability symptoms noted at clinical review. The response pattern of the scores closely mirrored that from Carr and co-workers.
To examine the minimal detectable change in two patient –based questionnaires for patients with shoulder instability, managed conservatively.
Oxford Instability Shoulder Score (OISS) and Shoulder Rating Questionnaire (SRQ) were administered to 93 patients (100 shoulders) attending physiotherapy. Scores were transformed to percentages to allow comparison. Questionnaires were collected at nine months with 5 subjective response categories from “much worse” to “much better”. Score changes were related to subjective response categories and data calculated to ascertain minimal detectable change (MDC) using the method of
60 patients (64 shoulders) returned questionnaires at nine months.
34 patients (38 shoulders) reported the shoulder was “much better”. The percentage change scores for these patients were significantly different to all other patients (OISS=26%, p< 0.05 and SRQ =20%, p< 0.05).
The minimal detectable change score was calculated as 14% for OISS and 10.5% for SRQ. Of the 38 ‘much better’ responses, 32 (i.e. 84%) had a change score > 14% for the OISS and 27 (i.e. 71%) > 10.5% for the SRQ. Of those 7 who responded with ‘no change or worse’, 2/7 (29%) scored > 14% for OISS and 1/7 (14.2%) scored > 10.5%
Minimal detectable change scores have been calculated for the OISS and SRQ in patients with shoulder instability. These may help determine change, which is clinically important in outcome research.
The aetiology and pathophysiology of frozen shoulder is poorly understood. The macroscopic pathological finding is dense fibrosis of the glenohumeral capsule and ligaments. Cellular histological studies reveal active proliferation of fibroblasts and their transformation to myofibroblasts, resulting in a dense matrix of disorganised collagen, causing capsular contracture. To further elucidate these pathological changes we arthroscopically examined 45 consecutive frozen shoulders immediately prior to performing arthroscopic release.
The distinctive finding in all cases was new blood vessel formation or angiogenesis in the synovium and capsule. There were five distinct angiogenic patterns: 1.vascular synovial proliferation at the base of the anchor of the long head of biceps tendon (most common); 2.petechial haemorrhagic spots widely spread across the synovium, in the rotator interval and even on the labral surface; 3.capillary loops and spirals, appearing like “lava flow”; 4.dense red vascular synovitis; 5.spectacular capillary whorls, similar in appearance to glomeruli (least common). High quality arthroscopic digital images will illustrate these findings.
The vascular changes seen in the shoulder joint in frozen shoulder are pathognomonic and similar to those seen in the formation of hypertrophic and keloid scarring of the skin, diabetic retinopathy, a variety of auto-immune disorders and tumours, rheumatoid arthritis and many other disease processes. The ability to therapeutically inhibit angiogenesis via inhibition of cytokines or adhesion molecules in these diseases suggests a possible role for these developing non-surgical treatments in frozen shoulder.
Urgent hospital follow – up was arranged for patients requiring it depending on their level of progress and problems identified.
Patients’ satisfaction and opinions with regards to the use of the telephone as a method of post-operative follow -up were ascertained by an independent researcher.
Patients were satisfied by the level of information they were provided with and their subsequent management as a result of the telephone clinic. Patients particularly commented on the advantages of getting information at home with the avoidance of problems associated with attending for a hospital appointment.
Three patients were given an urgent follow-up appointment as a result of the information gleaned during the telephone clinic. These included a patient with a stitch abscess and two with adhesive capsulitis.
Displaced proximal humeral fractures are notoriously difficult to treat. We performed internal fixation of 55 such fractures with the Polarus locked intramedullary nail. 43 (78%) were women; the mean age was 74 (range 15–91). The mechanism of injury was RTA in four, sporting injury in a further four and a simple fall in 47 (85%). According to Neer’s classification, 25 were two part fractures, 20 three part and 10 four part. 47 fractures were fixed acutely (within seven days).
The average operative time, including patient positioning was 60 minutes. In 43 cases the standard size nail was used (11mm diameter, 150mm length). In the majority of cases (80%) either two or three proximal locking screws were used. In 15 cases (27%) open reduction was necessary.
Patients were followed up for an average of eight months. Three patients needed removal of backed out proximal screws under local anaesthetic. In one patient the nail migrated superiorly and was removed once the fracture had united. One patient developed symptomatic avascular necrosis of the humeral head, successfully treated by removing the proximal screws. Two patients developed fracture malunion and underwent conversion to hemiarthroplasty. One patient required arthroscopic release of a secondary frozen shoulder.
Patients completed an Oxford Shoulder questionnaire at an average of 18 months postoperatively (range 5–42 months). The median Oxford Shoulder score was 33 (95% CI 25–38) with a mean score of 34.6
Previous studies of Polarus nailing have reported satisfactory results, but with limited follow up of a small number of patients. Our study of 55 cases with an average 18 month follow up confirms good functional rapid recovery in the majority of patients. Only five patients required removal of the metalwork and only two patients required conversion to hemiarthroplasty. We recommend the Polarus nail as a useful addition to the shoulder trauma surgeon’s armamentarium.
The operative method was similar in all cases: the non-union was exposed through a delto pectoral approached and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone a T-plate could then be applied to the humerus with the screws directed into the intramedullary fibular peg. Cortico-cancellous bone from the Iliac crest was supplemented.
Pre-operative constant scores: Average 26
Post-operative constant scores: Average 75
The most significant increase in constant score was the ability to actively elevate the arm. Decrease in pain levels did play a role but was not as dramatic as the increase in function.
Systematic studies are required to examine the effects on outcomes of alternative treatments and surgical techniques in the management of Orthopaedic conditions. Functional outcome scores provide reliable and valid judgments of health status and benefits of the treatment. We undertook a prospective study to assess the functional outcome in patients treated conservatively for proximal humeral fractures.
103 patients treated conservatively for a proximal humeral fracture were followed prospectively. Constant shoulder score and Oxford shoulder score were recorded at 3 months and 12 months follow-up.
A trend towards lesser degrees of improvement in the outcome scores was noted with increasing age. The degree of improvement in the outcome scores was not affected by sex, limb dominance or fracture type (Neer’s classification).
This information gives a guide to average behaviour in different groups of individuals with conservative treatment for proximal humeral fractures. We could then using this data postulate what would constitute a clinically relevant difference and calculate study numbers required while assessing other form of treatments for such fractures
Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5 % (range 23.8–67.2). The mean postoperative ROM was 85.4% (range 56.2 – 99.3). External rotation improved from 41.7% (range 23.5 – 81.5) of the unaffected side preoperatively to 77.7% (range 44.1 – 105.3) at final review. Abduction improved from 47.4 % (range 23.3 – 70.6) to 85.4% (range 49.7 – 100) and forward flexion improved from 59.1% (range 33.5 – 73.9) to 90o (range 64.3 – 100.6). No patients required further manipulation.
Certain sub-groups of humeral shaft fractures can be very difficult to treat. These ‘complex fractures’ include fractures in very osteoporotic bone, those associated with shoulder or elbow prosthesis, non-unions and those associated with intra articular extensions and dislocations.
The AO limited contact plate (LCP) is a new form of fixation whether the screw heads lock into the holes in the plate. The plate is not designed to cause compression and does not need to lie perfectly adjacent to the bone.
Average follow up was 47 months (range 22–65 months). The arc of elbow motion was 1040 (range 680_1400), with an average extension deficit of 230 (range 00–500) and an average flexion deficit of 200 (range 100–400). The average arc of forearm rotation was 1300 (range 00–1400), with an average supination of 660 (range 00–750), and an average pronation of 680 (range 00–800 ). The complications (N=17/32) included superficial skin infection (n=2), transient posterior interosseous nerve palsy (n=4), broken T -plate (n=1), intra-articular placement of a screw (n=1), loose and backed out screw (n=1), non-, union of radial head (n=2). Fixed flexion deformity if elbow (n=4) and mild elbow in stability (n=2). Second surgery was preformed in 18.7 % (n=6/32)(radial head replacement n=1, anterior capsulectomy n=4 and removal of screw n=1).
All were operated on by the same surgeon. 6 elbow (19%) had a pre-discharge complication, 4 ulna nerve palsies and 2 superficial wound infections. No cases of proven deep prosthetic infection. 1 case of symptomatic loosening after 12–24 months, awaiting revision. 1 case of loosening seen on X-ray after 5 years, the patient is asymptomatic but still under follow up. 21 of the 22 patients reported to be very satisfied with the outcome with only 4 elbows not allowing improvement in ADLs. Documented range of movement improved on an average by 200 of extension and 110 of flexion.
Diseased RC were sub grouped into mild (B1), moderate (B2) and severe (*B3 – cuff tear) impingement grades (Copeland – Levy Classification). The arthroscopy, grading, and probe placement were made by the senior authors. LDF flux (LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was then calculated (LDF flux – an arbitrary unit of measurement of the perfusion).
The LDFf was lowest in the moderate grade with a significant increase at the edges of a cuff tear.
Patients were assessed with constant and age adjusted Constant scores, radiographs and subjective questionnaire and whether they were satisfied at 6 weeks, 3, 6, 12, 24 months.
The data was analysed to determine if the presence of a full thickness rotator cuff tear influenced functional outcome in these patients.
The null hypothesis has not been disproved. There is no statistically significant difference in outcome with presence of an associated full thickness rotator cuff tear with proximal humeral fractures.
Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna.
Systematic and prospective collection of data (Registro degli Interventi di Protesi d’Anca – RIPA-L) on hip replacement operations is underway in the Lazio Region (Italy) as part of a multi-regional registry on orthopaedic prosthetic surgery. The project is partially funded by the Ministry of Health and includes five regions of Italy, coordinated by Istituti Ortopedici Rizzoli, Bologna, in co-operation with the Italian National Institute of Health. The aim of the project is to create – as a first attempt in Italy – a national database on hip replacement operations in order to monitor adverse events related to orthopaedic prostheses. First, in the Lazio region, standardised methods and data collection instruments were developed and assessed in a pilot study at three hospitals in Rome (teaching, public and private). The case report form (CRF) includes identification data, clinical findings, details of the operation (duration, grade of surgeon, and operative technique) and characteristics of the prosthesis. A web-based CRF facilitates data registration (
RIPA-L represents an important instrument to monitor the quality of hip replacement surgery in the Lazio region and to collect information on types of orthopaedic prostheses, contributing to the national database and, more generally, promoting quality in orthopaedic surgery.
Spasticity is a complex syndrome requiring extensive and complete treatment. Injections of botulinum toxin type A decrease muscle tone in spastic muscles of the hand and improve the use of the upper limb. However, rehabilitation and different non-invasive treatments should also be considered.
Shock waves are defined as a sequence of single sonic pulses characterised by high peak pressure (100 MPa), fast pressure rise (< 10 ns) and short duration (10 μs). Twenty patients, with upper limb spasticity post stroke were enrolled in the study. The patients (12 men and eight women) had a mean age of 63 years (36–76 years). An electromagnetic coil lithotriptor (Modulith SLK® by Storz Medical AG) provided with in-line ultrasound, radiographic, and computerised aiming (Lithotrack® system) was used. Flexor muscles of the forearm were treated with 1500 shots, and 3200 shots were used for interosseous muscles of the hand (800 for each muscle). The energy applied was 0.030 mj/mm. The protocol consisted of one placebo treatment session in which no shock waves were applied, followed 1 week later by one active shock wave treatment session. The Ashworth Scale was used to study the muscle tone activity in patients. No changes in the Ashworth score were noted in hand and wrist flexion after placebo stimulation. After real treatment the hand muscles and finger flexion in particular showed a marked reduction in spasticity with a change in the Ashworth scale from 3 to 0. At 1, 4, and 12 weeks, a slight increase in muscle tone was observed for all subjects. Needle EMG was performed at 4 weeks. No denervation was observed.
The main finding of this preliminary study is that a single active treatment of shock wave therapy in spastic muscles in a patient affected by stroke resulted in a significant reduction in muscle tone. In contrast, no effect was noted after placebo stimulation. Nitric oxide synthesis has been suggested to be one of the most important mechanisms to explain the effectiveness of shock waves in the treatment of different soft tissue diseases. Shock wave therapy appeared to be safe, non invasive and without complications. Our findings suggest that shock wave therapy may be useful in decreasing flexor tone and functional disability in patients with spasticity of the hand, with a long-lasting effect. This therapy could open a new field of research in the treatment of spasticity. Further studies with a larger group of patients are, therefore, necessary.
Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible.
The authors present case histories relating to experience gained over 18 months of using deantigenic osseous grafts together with platelet growth factor for posterior spine arthrodesis. The spinal column was the last section of the skeleton to recover from the use of this kind of bone graft to promote spinal fusion. This is due to the negative experience encountered during the proposals bought forward during the 1960s and 1970s by French orthopaedic surgeons who used heterologous lyophilised bone for long vertebral arthrodesis.
The high incidence of pseudoarthrosis developed as a result of difficulties in absorption of the skeletal implant, which, in order to ensure sufficient mechanical resistance, should have been thicker (8 mm). Therefore it could not be assimilated. This then resulted in relying only on external protection (plastered brace) to provide the necessary rigidity during the process of fusion.
The beginning of stable synthesis obtained with transpeduncular fixation and double instrumentation as used in the Cotrel Doubousset technique and methods derived from it made it possible to maintain primary stability over time, therefore positively influencing the process of consolidation. This is why the practice of exclusively using osseous derivations has grown only in the past few years in vertebral surgery, preferring to implant small chips which can be assimilated much easier and to avoid having to search for mechanically resistant areas for bone replacement.
In conclusion, the use of heterologous bone grafts in the vertebral column represents a situation similar to that in other mobile osseous areas, in which the immobilisation depends on the use of a mechanical instrument (when it concerns short arthrodesis 2–3 segments). In the case of long spinal fusion such as in correcting vertebral deformity (scoliosis and kyphosis), the problem is more complicated, even though today’s new biological tools (large extension of the bed of arthrodesis) make this possible and offer the advantages of the lack of problems at the donor site. In these cases it is particularly suitable to routinely combine heterologous bone replacement with growth factors (osteoinductive bone proteins) for treatment, which according to our preliminary results should notably shorten the period of assimilation and the fusion healing.
Xenografts of bovine bone were used successfully for years with a minimum acceptable rate of side effects in total hip revision arthroplasty for filling large bone defects. The great majority of them was withdrawn from the market when any biological product of bovine origin was considered as a potential carrier of prions infection. However, current EEC regulations permit their surgical therapeutic use if obtained from cattle under 6 months of age, which are supposed to be not at risk of prion transmission. Lubboc, a purified trabecular bone matrix containing only type-1 collagen and hydroxyapatite, fulfils this requirement. From 2001 to 2003 we used this product in fragments (chips) to fill bone defects of the acetabulum before screwing the acetabular rings in 37 patients. No massive grafts were implanted. Minimum follow-up was 12 months, maximum 27 months. Four subjects were lost to follow-up. The fate of the grafts was evaluated for evidence of union, remodelling, resorption, migration of the rings or fracture of the newly formed bone. No significant adverse events were registered. If the risk of transmitting infectious agents is excluded or minimised according to the present legislation, it seems unjustified to remove xenografts from the options available to orthopaedic surgeons, considering the problems of bone stock deficiency and reconstruction in hip arthroplasty revision surgery.
The use of stems with constrained condylar knee (CCK) prosthesis components has been advocated both for primary and revision total knee arthroplasty (TKA). CCK “nonmodular” implants without diaphyseal stems reduce the invasion of the medullary canal, thereby reducing operative time and costs; render a subsequent revision procedure easier, and avoid possible stem pain. The present study is the first report on mid-term results of stemless CCK for primary TKA.
This cross-sectional study reviewed the outcome for 248 knees (180 patients) in which primary TKA was performed using the Exactech nonmodular CCK between 1997 and 2001. The patients had an average age of 68 years and the preoperative diagnosis was osteoarthritis in 94%. Preoperative deformity was severe (82% Ahlback grade 4–5). Valgus deformity was present in 59% and averaged 15° (7–33°). Varus deformity, present in 41% of the patients, averaged 13° (5–22°). Fifty-seven percent of the patients had multiple joint involvement (category C).
Clinical and radiological follow-up at an average of 47 months (range, 24–72 months) was obtained for 192 TKAs (148 patients). Of the total group, there were 15 deaths and 17 patients were lost to follow-up. The Knee Society score improved from 36 to 89 and the functional score from 42 to 76 postoperatively. Varus-valgus laxity improved from 11° (range: 0–30°) to 2° (range:0–6°). Nonprogressive radiolucent lines were present in 16%. Failure rate, defined as revision, was 3% (two infections, two aseptic loosenings, one broken post, and one supra-condylar femoral fracture). In six knees (3%) patello-femoral complications developed: five patellar clunks and one dislocation.
Use of a stemless “nonmodular” CCK for primary severely damaged knees demonstrated reliable mid-term results with a low complication rate.
In this work we report our experience, which began in 1981, with 200 patients in the correction of complex deformities (rotational and angular) of the inferior limbs by using the IIizarov method. In our case histories, we demonstrate the advantages of treatment of complex deformities using correction techniques such as epiphysiodesis operations performed in open surgery access or by using percutaneous stapling or osteotomic corrections, which in our experience are only indicated in single plane lower limb deformities.
On the other hand, we demonstrate the complete validity of the IIizarov method in the progressive correction of the multi-planar deformities. Such methods allow progressive correction of the deformities in three different spatial planes, resulting, in addition to the possible improvement in the angular defects, in the simultaneous correction of the torsional defects.
The critical analysis of our experience also demonstrates the possible complications inherent in the IIizarov method and which have been subdivided into further and greater complications, such as in the acute treatment of serious deformities (joint stiffness, nerve paralysis, and deep pin track infection) and in minor complications (superficial pin track infection).
In this retrospective study, we re-evaluated the case histories of patients treated for diaphyseal and meta-epiphyseal fractures of the humerus by fasciculated nailing, using the Hackethal method. Our experience, beginning in 1992 through to the present, includes over 400 cases of fractures treated using this method. Among these cases, there were 250 meta-epiphyseal fractures and 200 diaphyseal fractures. Follow-up was possible in 250 cases.
The number of complications encountered in the case studies considered was relatively low, including five cases of a delayed union and four cases of non-union. There were no deep or articular infections, five cases of superficial infection, four cases of fracturing of the means of synthesis, 10 cases of procidence of the wires at the level of the insertion site, and two cases of distal migration at the level of the articular cartilage of the humeral head. We did not encounter any cases of periarticular ossification or iatrogenic palsy of the radial nerve.
Our methodology foresaw in all cases closed reduction of the fracture as well as epicondylar access distal to the humerus, which in some instances of multi-fragmented fractures was performed bilaterally, with the Eiffel Tower assembling method and four or five retrograde bundle wires. By using the epicondylar point of insertion, the fracture could be reduced and and torsional stability obtained, which together with the bone defect filling contributed to the primary stability of the fracture.
In this retrospective study, we wanted to demonstrate the validity of the bundle nailing according to Hackethal’s method, which is distinguished by being a minimally invasive technique as well as by providing good consolidation and a low rate of complications.
Today there is a great interest in the use of the autol-ogous platelet growth factors (APGF) in the field of orthopaedic surgery. The platelets are like a cellular laboratory and secrete, store, and leave many growth factors. These APGF are able to increase the reproduction of futtock, mesenchymal, fibroblast, osteoblast, and endothelial cells, which have a homothetic effect on macrophages and mono- and polymorphonuclear cells.
Between 2001 and 2003 about 60 patients were treated with APGF in the form of gel. It was used for osteosynthesis of high energy fractures with soft tissue and bone loss, in arthrodesis of scoliotic spine, and in the emergency treatment of hand trauma. The platelet gel was used for 4 weeks. The average time for recovery was about 1 month for the soft tissue lesions.
The use of APGF enables a speedy recovery and quick resumption of work. The healing time of the fractures decreases by 50% and the fingertip lesions with exposed bone can be treated with APGF without shortening or plastic surgery being necessary.
It is possible to use platelet gel for replacement of soft tissue, for osteosynthesis of fractures, and to fill up defect cavities. Thus, this opens new perspectives for treatment in orthopaedic surgery.
The patients could return to normal daily activity in a short time and it is possible to reach good results, offering a better quality of life.
The treatment of complex tibial plateau fractures is often difficult because in these fractures the nature of the articular damage is always important, the reduction is not easy, often entailing extensive exposure, and the collapse of the metaphyseal bone, located beneath the reconstructed articular surface, makes the osteosynthesis mechanically unsafe for 10 or 12 weeks.
There are three fundamental objectives of percutaneous surgical treatment: to be minimally invasive, to result in a good reduction and to achieve stable fixation. Through a small skin incision at the metaphysis, a leever was inserted across a small door made on the cortical metaphyseal bone and the articular fragments were elevated and held in the reduced position. Temporarily the fragments were fixed with a Kirschner wire and definitely fixed with one or more cannulated screws. Norian S.R.S was used to fill the bone gap that resulted from the traumatic collapse of the metaphyseal bone: with its initial mechanical strength the joint fragment reduction and the developing ostheosynthesis can be stabilised, thus shortening the functional recovery time.
Between 1997 and 2002 we operated 52 patients with tibial plateau fractures using this percutaneous technique and application of the mineral bone substitute Norian. Of these, 42 fractures were unicondylar, 16 type B2 and 26 Type B3 according to the AO classification, and 10 fractures bicondylar 4 type C2 and 6 type C3 according to the AO classification. The minimum follow-up was 1 year. For clinical evaluation we used the Hohl assessment form, for the radiographs the criteria of Rasmussen X-rays. The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 26 cases can be considered excellent (50%), 12 good (23%), 11 fair (21 %) and three poor (6%).
In conclusion, Norian offers a real advantage in the treatment of displaced tibial plateau fractures, because it offers an unlimited supply of bone substitute, is an optimal filling for the irregular defects of the cancellous bone and gives immediate mechanical support to the joint, integrating the ostheosynthesis perfectly. The recostruction of the tibial plateau with minimally invasive surgery such as percutaneous indirect reduction by elevation and percutaneous osteosynthesis, with mechanical stability assured by Norian SRS, is an important improvement. The functional recovery time is reduced, with great benefit for patients.
The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head.
During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months.
The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity.
In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA.
In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields.
In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.
The identification of different substances able to promote a cellular response in terms of proliferation and differentiation the so-called “morphogenetic proteins”, has expanded research, aiming to identify the cellular elements that produce these proteins, in order to find a source for clinical application.
Platelets have been identified as the main source of morphogenetic protein production: they can be separated in human blood samples and thus it is possible to create a concentration of these elements that, used both in bone as well as in soft tissues, promote a cellular response useful for tissue repair in terms of bone formation and soft tissue regeneration.
Our experience takes into account different fields of application of this new technology: revision surgery, non-union treatment and repair of soft tissue in 18 patients.
The same manufacturing process was utilized for all cases: ”Haemonetics” MCS”+ technology for apheresis, concentration of platelets and plasma/cryoprecipitate obtained, then mixed with autologous thrombin and calcium gluconate to obtain a gel. Usually, for bone surgery, platelet gel is mixed with an autologous iliac crest bone graft or, in some instances, with a homologous bone bank graft, usually morcelized chips.
For soft tissue applications, after surgical débridement, the gel is directly applied over the site and covered by a soft bandage. No adverse effects have been observed: good results, in terms of bone healing and soft tissue repair, were obtained in all cases.
We report on a case of bilateral medial patellar dislocation, studied with hip/knee/ankle TC for evaluation of torsional defects and treated four times with distal derotative femoral osteotomy and cuneiform subtractive osteotomy of the lateral part of the femoral trochlea.
The patient, a woman 18 years of age at the beginning of treatment, presented with femoral neck anteversion of 30° dx and 25° sx referred to the plane passing posteriorly to the distal femoral condyles; the trochlear angle was 140° dx and 144° sx with medial inclination of trochlea due to medial hypoplasia. The patellae were facing medially, and clinically the patient had suffered medial dislocation of the patella several times.
The treatment lasted 4 years: the femoral derotation of 10° was executed by Orthofix monoassial external fixator; the lateral bone wedge removed from the trochlea was about 10 mm and we used reabsorbable nails for fixation.
Current values are 17° of femoral neck anteversion bilaterally, and the trochlear angle is 151° dx and 150° sx. The patient, now 26 years old, has not had any more dislocations and her knees have complete mobility with no pain.
The good result demonstrates the importance of femoral neck anteversion in the genesis of knee disorders. In this case the absence of specific abnormalities of the extensor mechanism (valgus knee, lateralisation of tibial apophyisis) probably caused the hypoplasia of the medial part of the trochlea and the resulting, rare medial patellar dislocation.
Proximal juxta-articular leg fractures are often high-energy injuries, involving the tibial articular surface as well as diaphyseal segments. Young, active people are frequently affected, and optimal reduction, effective stabilization, early function and a rapid return to daily-life are the goals of treatment.
These fractures are, as well known, difficult to treat, because of the frequent articular involvement, fragment comminution and extension of the fracture rim: if not adequately treated, they might result in mal-union, non-union, articular stiffness and late arthrosis.
Mal-union, both angular and rotational, are, in many cases, very difficult lesions to treat, almost always requiring osteotomies, osteointegration and stable fixation: we present our experience in the treatment of these lesions, with the results obtained in 31 cases treated with a minimum of 1 year of follow-up. The same protocol was used in all patients: direct surgical approach to the lesion, removal of any implanted device, careful débridement of the mal-union site (mainly directed to complete interposed fibrous tissue removal), deformity correction, stable internal fixation and osteointegration, whenever necessary, by autologous or homologous bone. We evaluated all cases in terms of patient satisfaction, deformity correction, bone healing and functional recovery: one major complication occurred (nail failure); delayed skin healing was seen in three patients (one requiring re-operation), and one patient there was rupture of a distal locking screw. In conclusion, this method is effective in the treatment of these lesions.
Human mesenchymal stem cells (hMSC), residing in the bone marrow, can be purified, expanded in cell culture and under appropriate stimuli may differentiate along the osteogenic, chondrogenic and adipogenic lineages. The aim of this study was to investigate the expansion capability and differentiation potential of MSCs obtained from femur, pelvis and acetabular cancellous bone of aged patients in order to establish whether these cells, isolated and expanded in vitro, can be used in a new approach in orthopaedic revision surgery.
In this preliminary study we enrolled 33 patients undergoing hip arthroplasty in order to investigate CFU-F frequency, expansion ability and differentiation potential of hMSC derived from three different anatomical sites: femural, pelvic and acetabular cancellous bone (ACB).
CFU-F frequency (CFU-F/10 6 MNC) was 63 for pelvis (range 7–122), 90 for bone (39–132) and 47.5 for femur (7–124).CFU-F frequency was higher in ACB than in either pelvis (p=0.04) or femur (p=0.001). The patients were divided into three age groups: G1 ≤50 years (n=6), G2 50 −65 years (n=11), and G3 ≥65 years (n=16); however, CFU-F frequency did not show any statistically significant difference, although the frequency was lower at higher age.
We expanded in cell culture MSC of 16 patients from the three considered sites until the fourth passage. At the first passage there was a higher MSC recovery in ACB (median 12%) than in pelvis (median 8%; p< 0.004) and femur (median 3.8%; p< 0.0004). MSC recovery from pelvis was higher than in femur (p< 0.04). At the second and third passage MSC expansion was found to be significantly higher in ACB than in pelvis alone (median 3.1 vs 1.6, p< 0.01; 1.8 vs 1.2, p< 0.005, respectively), while at the fourth passage it became higher than in pelvis and femur (median 2.6 vs 1.4, p< 0.03; 2.6 vs 1.6, p< 0.0, respectively). At each culture passage, cells showed MSC features as supported by flow cytometry and by the multilineage differentiation potential.
hMSCs seem to have higher frequency in close association with bone; moreover, they show an increased expansion ability in vitro which is still mantained in elderly patients. As these progenitors can differentiate in bone, they seem to be the best choice for the effective repair of bone defects in revision surgery.
Acquired pilon deformities are often a combination of axial deviation, translation, rotational defects and leg length discrepancy. Correction of a deformity pattern with a percutaneous rectilinear supramalleolar osteotomy and an external fixation by Ilizarov apparatus aims to reduce misalignment progressively, simultaneously and minimally invasively.
From 1994 to 2004, 27 patients were treated for pilon tri-planar deformity of the leg. The mean age was 27 years (range 16 to 49 years); 15 were males and 12 females. Type and level of the deformity were determined by preoperative X-rays. For the procedure, two rings of Ilizarov apparatus are positioned in the segment of the limb proximal to the osteotomy: one at the level of the proximal tibial metaphysis and the other 3–4 cm beyond the osteotomy. A third ring is positioned at the level of the tibial pilon, parallel to the articular edge of the ankle. In order to maintain stability of the ankle, a half ring or horseshoeshaped component should be placed on the calcaneus and metatarsals with opposing olive wires. The positions of the mobile joints between the rings depend on the location of the correction axis. Closed metaphyseal osteotomy is performed in order to correct tri-planar deformities in a progressive way, through angulations and translation in an oblique plane. The half ring on the foot maintains distraction in the ankle, which is necessary to reduce articular compression and to avoid soft tissue damage and muscular contractures in this region.
In all cases we achieved correction of the angular or rotational deformities. Bleeding was never over 100 ml. We have not observed any soft tissue damage. Controlled weight-bearing was practised on the first day postoperatively, and the mean hospitalisation time was 4 days. Time required to reach the correction was in a range of 3–6 weeks. In 20 patients the total leg discrepancy was in a range of 1.5–6 cm. We reported no case of infection nor union. The devices were removed after a mean time of 11 weeks (range 8–15 weeks). Corrections of tri-planar deformity of the pilon by the Ilizarov apparatus are progressive and minimally invasive. In addition, it is possible to treat misalignment and lengthening by a single operation. With the apparatus layout combining foot fixation and ankle distraction soft tissue and secondary deformities can be corrected and finally a rapid recovery of weight bearing is possible.
The principle of open reduction and internal fixation developed during the last few decades provides satisfactory alignment and articular function. The disadvantages of this technique are a large area of surgical exposure with risk of bone avascular necrosis, non-union, infection and stiffness. With LISS (Less Invasive Stabilisation System) the percentage of these problems can be reduced.
Over the period January 2003–March 2004, at the Orthopaedics and Traumatology Operative Unit of Maggiore Hospital in Bologna, Italy, 15 patients with distal femur fractures were treated by the use of LISS. Two of them were excluded at the time of follow-up: they died 2 and 12 months after the operation. Thus, we studied outcome in the remaining 13 patients. The average age was 49.7 years (range 18 to 88). According to the AO classification system we had four type 33.A1 fractures, six type 33.A3 fractures, two type 33.C2 fractures, one type 33.C3 fracture and one type 32.A3 open fracture. The mean follow-up was 9.8 months (range 3 to 17 months). Clinical and radiographic assessment was performed using the Neer-Grantham-Shelton score. The mean final score was 70.9/100. The average time of bony union was 12 weeks. We had three complications. In one patient there was a proximal pull out a few days after surgery; however, a satisfactory bony union was obtained with a second operation by a new LISS and a bone graft performed 1 month after the first operation. In the other two patients we had to remove the LISS because of pain at 2 and 14 months after surgery. These complications can be easily explained by the lack of experience in applying this kind of implant and the peculiarity of the cases.
We conclude that LISS is an effective system for healing distal femur fractures, with no direct surgical exposure of the fracture site, little bleeding, and early mobilisation and union.
It has been shown that mesenchymal stem cells (MSCs) and BMP are involved in bone formation. The aim of the study was to evaluate the osteogenic potential of human bone marrow (hBM), human expanded MSC (hexp-MSC), BMP-7, and hexp-MSC plus BMP-7, to treat a rat femoral segmental defect.
Sprague-Dawley (SD) and athymic rats (Nu) were used. SD rats where used in order to define surgical technique. Nu rats groups consisted of: G1-autoclaved bone and human bone marrow (hMNC); G2-bone and hexp-MSC; G3-bone with BMP-7 only; and G4-bone and hexp-MSC with BMP-7. A plate was attached to the femoral diaphysis with two cerclage wires. Then a 6-mm femoral gap was made and filled with a different graft. At regular intervals, the femoral defect was evaluated with radiographs, using a modified six-grade Cook classification.
At 8 weeks G1 showed non-visible new bone formation; G2 minimal new disorganised bone; G3 disorganised new bone bridging the graft to host at both ends; and G4 significant new bone and graft remodelling. Histological analysis confirmed these results.
Our results showed that although the osteogenic activity may be improved by hMSC (G2) as well as by BMP-7 (G3), the association hexp-MSC plus BMP-7(G4) produced graft osteointegration at 8 weeks after surgery. This may have a remarkable impact on future orthopaedics surgery strategies.
From 1994 to 2004, the authors treated 17 patients (nine males and eight females) with Blount disease admitted to the Disabled Children’s Home in Naro Moru (Kenya). Age at intervention ranged from 2 to 16 years (mean 8). In sevencases, the deformity was unilateral and mean age was 8.9 years; in the remaining 10 the deformity was bilateral and mean age was 8.5 years. Tibial proximal metaphyseal corticotomy was performed in 13 cases, and it was associated with calf bone osteotomy in patients aged over 5 years. In eight cases, metaphyseal osteotomy was associated with bone graft from homolateral calf bone and synthesis with Kirschner wire or “staples”, in nine it was performed without bone graft, and in one with axial external fixation. Complications included the following: infection with common peroneal nerve paresis treated with antibiotic therapy and transposition of tibialis posterior to tibialis anterior (one case); relapse of deformity treated with a new osteotomy (one case); incomplete correction (two cases); and pseudoarthrosis with loss of correction treated with a new osteotomy, removal of the pseudoarthrosis area and axial external fixation (one case). Nine patients for a total of 15 tibias were followed up at 1–10 years (mean 5.2). Results were good in 10 cases, with aligned limb and stable knee, fair in three cases, with X-ray evidence of varus deformity < 15° and/or knee instability in orthostasis, and poor in two cases with deformity > 15°, knee instability, length discrepancy > 3 cm. Age at operation and consequent severity of joint deformity influenced the results. Good results were obtained mainly in patients with Blount disease degree 1–3, whereas poor results were obtained in most patients with epiphyseal deformity > degree 4.
Thanks to recombinant DNA technique it is now possible to synthesise recombinant human osteogenic protein 1 (rh OP1), one of the best documented osteogenic proteins. This protein, linked to type 1 collagen as carrier, is the first drug with proven osteoinductive and osteoconductive properties approved for clinical use.
Osigraft (the commercial name of OP-1 and collagen) is also biocompatible, bioresorbable and lacks the risk of disease transmission. In the most challenging non-union, tibial non-union, the drug showed 80% efficacy as autograft with a better tolerability (i.e. lack of donor site complications) also in patients with previously failed autograft. Higher rates of success were also reported in recalcitrant long bone non-unions, i.e. a mean of 5 years of length of disease, incresaed number of previous surgeries.
Osigraft, also considering its physical characteristics, has to be implanted during the surgical procedure, with direct positioning at the non-union site; furthermore, its use is contraindicated in cases of infection of bone and infection/poor condition of surrounding soft tissues.
In our department we have treated up to now five patients with complex non-union of femoral neck and tibia; in three cases serious soft tissue conditions were present (crushing, infected necrosis) and one patient required plastic surgery. In all case we registered complete clinical and radiological healing after 3.5–7 months.
We also describe two cases of closed application of Osigraft, pushing the drug into the non-union site via a holed cannulated nail with the help of a probe under radioscopic control.
The authors present their experience using osteogenic protein 1 (OP-1; “Osigraft”) in the treatment of recalcitrant atrophic pseudoarthrosis (PA) of the limbs in patients in whom osteosynthesis surgery failed at least two to four, and more, times. All patients with PA who were treated showed a preoperative radiographic pattern of severe bone atrophy surrounding the peri-fracture zone, without evident signs of reparative activity. All osteosynthesis hardware showed clear evidence of mechanical failure (rupture or mobilisation) so they were changed in all patients during the surgery. From January 2003 to February 2004 we used Osigraft to treat 10 patients with an atrophic PA at the following level: two femurs, three humera, one forearm, three tibiae (1/4 distal) and one tibia (1/3 medium). Osigraft was associated in seven patients with an autograft and in three patients with an allograft plus platelet growth factors (one distal femur, one distal tibia and one humerus). Mean age of patients was 38 years (range: 22–54) and mean duration of disease from the initial trauma was 36 months (range 26–40).
The radiological aspect of the newly formed bone, both endostal and periostal, was very similar to that observed in primary healing, with an inter-fragmentary callus as observed in similar cases treated since the beginning with the most appropriate therapy and that healed after the first operation. In all cases we observed healing of the PA focus in a time period of 6–11 months (mean 8.5) with a satisfactory functional recovery in eight cases; in two cases residual articular stiffness, one knee and one ankle, will require arthroscopic surgery.
Because of the limited number of patients treated with this new method, we can only draw preliminary conclusions. However, compared with our previous experience, we can confirm that Osigraft (OP-1) significantly contributes to bone healing whenever biological reparative potential is strongly compromised because of the type of original trauma, the long time elapsed since then and the many preceding surgeries. Healing times, even if they appear to be quite long, are actually short considering the severity of our cases, usually requiring further surgery for PA not healing after the third intervention (more than 30 %) and cured, if reached, in 12–18 months.
For several years now at the Gaetano Pini Institute of Milan, Italy, we have been improving upon an original instrumental protocol (by means of several radiographic examinations and TC) to understand both congenital and acquired deformations of the lower limbs. Thanks to this technique, it is possibile to evaluate the specific degree of the deformation from any perspective, also from the rotational one; it gives us the possibility to state precisely the dysmorphic pathological consequences on the hip, on the knee and on the ankle joints. This tested kind of interpretation also makes it possible to establish more accurate suggestions regarding surgical correction. If this final correction is achieved in more than one phase, it may be possible to improve the surgical treatment if the contemporary action on the three reference spatial planes is considered. We have already collected data on numerous cases of post-traumatic deformations or congenital dysmorphisms studied by several techniques.
Based on the concepts of White and Panjabi of 1990 we have classified vertebral instabilities into congenital and acquired. The congenital instabilities are due to evident bone alterations that bring about mechanical instability, such as in spondylolisthesis and bone defects of formation and segmentation, or are caused by alteration of the elastic stability of the spinal column, such as in ligamental luxation of the Ehlers-Danlos syndrome or neuromuscular asthenia. Acquired vertebral instabilities include the extensive and much discussed issue of degenerative instabilities and secondary instabilities associated with rheumatoid arthritis, traumatic pathology, neoplastic, iatrogenic instabilities, etc.
The spine is a complex structure in elastic equilibrium between functional demand and the physiological resistance of the motor segments, that is the articulations, capsules and ligaments, and the muscles. Like Aulisa and Vinciguerra (1994) we are inclined to refer to stable and unstable equilibrium of the spine and to distinguish “mechanical” stability from “biological” stability. There are authoritative cases of evident macro-instability where the functional units, even though affected by serious mechanical alteration, are able to conserve a totally asymptomatic vertebral column in a state of elastic compensation for a long time.
We have classified our cases according to Christian Pfirrmann’s classification of lumbar intervertebral disc degeneration (2001), completing it with the three types of disc degeneration that Modic suggested in 1998. We present our case histories from 2001 to 2002 of macro-instabilities of lumbo-sacral spine treated with stabilisation, PLIF and fusion and of micro-instabilities treated with dynamic stabilisation in neutralisation without fusion.
In instabilities when one or more motor segments do not respond to permanent stress and the discs begin to change structurally and demonstrate phenomena of fissuring and dehydration, to the point of assured degeneration and collapse, we have developed a two-fold method of treatment:
MICRO-INSTABILITY: when the degenerative phenomena are still in progress and TAC, RMN and functional radiographs can identify an early phase, we propose dynamic stabilisation in neutralisation in order to restore the height of the disc and cancel the disc-radicular conflict, thus maintaining the capacity of movement of the functional unit. MACRO-INSTABILITY: when the clinical examination and imaging study show late-stage degenerative instability with collapse of the disc space and insufficiency of level with evident somatic traction spurs and reactive sclerosis of vertebral plates, then we believe that today only fusion can relieve the painful symptoms.
The scaphoid fractures treated in our series are classified as type A1, B1 and B2 according to the Herbert classification. We analyse the advantages of the percutaneous technique in comparison to the open reduction technique, as well as the advantages in comparison to conservative treatment. A total of 36 patients (33 males; three females) with scaphoid fractures were treated by the percutaneous technique, by insertion of a 3-mm AO screw and a 5.5-mm washer. Of these, 35 patients had an acute fracture and one patient had suffered the fracture 1 month prior to treatment. Mean age was 30.9 years (range 14–64 years). One patient had an associated radial fracture, and one patient suffered multiple fractures of the upper extremity. The fractures were classified according to Herbert as follows: type A2, n=7; type B1, n=7; and type B2, n=22. Of the 36 patients, 33 returned for follow-up. Mean follow-up was 23 months (range 3–39 months). Duration of surgery was an average of 40 min (range 18–70 min). Results were evaluated according to a scheme that analysed pain, mobility, strength, radiographic consolidation of fracture fragments, return to work or sport activities. Our results were optimal in 28 patients, good in 5. We did not observe any cases of non-union or infection.
Graft fixation in anterior cruciate ligament reconstruction is a basic criterion for the outcome of the surgical procedure. Several solutions have been proposed; each of them had advantages and disadvantages, and the choice of a surgical technique often represents the surgeon’s opinion.
The goal of the fixation is stability and incorporation of the graft in the bone tunnels. Bone-patellar tendon-bone graft has the advantage of bone to bone fixation, which is impossible using tendon grafts. Femoral fixation techniques for hamstrings can be classified as follows: compression techniques, expansion techniques and suspension techniques (cortical or cancellous).
Top Traction System (TTS) is a new technique for femoral fixation using hamstrings. Here, a retrograde screw is fixed to the anterolateral cortex of the femur. A ring is fixed to the screw to pass the tendons.The screw is self-threading, 28 mm long and 6.5 mm in diagmeter; its pull-out strength is 1350 N. The screw is made from a titanium alloy and only available in one size.
Surgical technique is simple and reproducible and the instruments are easy to use. The positioning of the screw is fully guided by instruments that minimise errors.
With this fixation device further graft traction is possible after tibial fixation without twisting the hamstrings. Results are good at the short-term evalutation but a long-term follow-up is required before a final recommendation can be made.
A clinical retrospective study was conducted. Results of isolated decompression for degenerative lumbar stenosis was compared with the outcome in patients who underwent decompression-stabilisation.
From January 1992 to December 2002, 127 patients (average age 65.5) with lumbar degenerative stenosis surgically treated were studied. In all patients the Roy-Camille technique was used for decompression; in 41 patients decompression and posterior stabilisation procedures were carried out. Average follow-up was 6 years (range 2–11 years).
The outcomes, evaluated according to Lassale classification, were satisfactory in 81% of the decompressed group while improved to 88% in the stabilised–decompressed group. Three patients of the first group required stabilisation for intractable low back pain (one patient) and lumboradicular symptoms (two patients), while problems related to the device (one hardware failure) and two instances of adjacent segmental instability were seen in the second group.
Decompression alone is associated with an increased rate of residual low back pain (one patient in this cohort required fusion). The decompression–stabilisation procedure reduces the incidence of low back pain but is associated with other complications such as significant blood loss, possible wound infections, urinary tract infections (due to increased surgical time), device failures, root impingement and late adjacent segmental pathologies.
The Roy Camille technique is effective for achieving adequate decompression. The surgeon should always be aware of patients who might require fusion. The instrumented stabilisation should be reserved for patients with chronic low back pain and evident instability, degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis.
Mitchell – Hawkins osteotomy is a widely used technique for correction of mild to moderate hallux valgus. Several authors have recognised that, for a good result, the osteotomy must be stable enough to prevent excessive shortening or displacement of the distal fragment. Several fixation techniques have been proposed: sutures, staples, K-wires and screws. The aim of the study is to define whether the use of a screw could give better results than a single K-wire in the fixation of the osteotomy. We studied prospectively 30 patients with moderate hallux valgus operated on consecutively at our institute using the Mitchell osteotomy. In 15 patients (Group A) fixation was achieved with a single K-wire inserted through the tip of the toe and driven medial to the metatarsal head into the first metatarsal shaft, while in the others (Group B) a Herbert screw was used. All procedures were identical except for the fixation device and were carried out by the same surgeon. Weight bearing was allowed from the first day after surgery with a postoperative shoe. The K-wire was removed at the fifth postoperative week. In Group B the correct position of the great toe was maintained with a dressing, renewed weekly for 8 weeks after surgery. Patients were evaluated clinically with the AOFAS score and radiologically either before surgery and at the follow-up. The mean follow-up time was 10 months. We did not find any difference between the groups in correction of the intermetatarsal angle and of the valgus angle or in the improvement of the AOFAS score. No symptomatic displacement of the distal fragment occurred in either group. Five patients of Group A complained of a pin tract infection of the K-wire, which was treated successfully with oral antibiotics. No deep infection occurred. All the patients were satisfied with the treatment received but the majority of those of Group A (10/15) complained of discomfort in leaving the K-wire in place for such a long time. The Mitchell – Hawkins osteotomy can be fixed either with a K-wire or a screw with similar results in terms of angle correction and clinical scores. Patients felt more comfortable without protruding fixation devices, but for a successful procedure with the use of a screw, repeated dressing of the foot is required, which is time-consuming for both the surgeon and the patient.
We present results obtained in patients treated in Italy with BMP7/OP-1, Eptotermin alpha) carried by type 1 collagen (Osigraft) in an observational, prospective, multicentre, non-randomised study. OP-1/collagen is the first human recombinant BMP/OP approved for clinical use in tibial non-union refractory to autograft (Europe) or in long-bone non-unions (US, Australia and Canada). A prospective, randomised, controlled clinical study demonstrated that OP-1 has clinical and radiographic efficacy in tibial non-union comparable to autograft, with better tolerability. Non-randomised trials have shown a high clinical efficacy of OP-1 in complex recalcitrant long-bone non-unions as well.
Data on some of the patients treated in Italy with OP-1 from June 2002 –to December 2003 have been collected; we evaluated the data from 45 patients (18 surgeons) with a diagnosis of long-bone non-union (69%, in 81% atrophic/oligotrophic), delayed union (18%) or bone defect/cyst (7%). The mean age was 43±17 years (range 5–76 years) and the mean number of previous surgeries was 2.3±2.3 (range 0–13), with a disease duration from the original trauma of 18.9±20 months (range 1–93 months). Of the patients, 25% had previously received an autograft. In some patients (34%) complications were present (osteomyelitis, infections etc); in 53.3% of cases OP-1 was mixed with other agents (including 31% association with iliac crest autograft).
Radiographic analysis at 9 months (in PA patients only) has shown that Osigraft is efficacious in 78.6% of patients (67.9% union and 3.7% marked bone bridges); radiographic unions were reported in 34.8% at 4–5 months and in 60% at 6–8 months. In Osigraft-only treated patients, radiographic union at 9 months was 82.4% (plus 3.6 % marked bone bridges). Treatment failure was reported in eight of 45 patients (19.5%), including four cases in which Osigraft was mixed with iliac crest autograft; in four patients mechanical stability was insufficient,in three postoperative osteomyelitis developed and in one a silent osteomyelitis was present and considered the cause of the failure. No adverse events (AE) were reported.
Even if this study has limitations because it is observational, not randomised and no protocol was applied, as all naturalistic studies, it give us information about current clinical practice. The radiographic results observed were comparable with those reported in the literature in randomised and non-clinical series, indicating an efficacy of Osigraft close to 80 %, expecially in cases where the drug was used without autograft. The complete absence of AE is also relevant. The analysis of the failures reaffirm some basic principles that have to be respected such as mechanical stability, bone continuity and contact with vital/non-infected bone tissue.
Primary synovial chondromatosis (PSC) is a rare benign disorder characterised by development of foci of cartilage in the synovial membrane of the joint, bursa or tendon sheath that was first described by Reichel in 1900. The disorder has traditionally been considered as a metaplastic condition, but was recently assoicated with structural chromosomal abnormalities, suggesting a neoplastic origin. The aim of the present study was to evaluate the clinical, arthroscopic and histopathological aspects of PSC involving both the glenohumeral joint and tendon sheath of the biceps.
An 18-year-old, right-hand dominant boy presented with right shoulder pain. There was no history of trauma. Pain began in his shoulder about 1 year prior to his clinical visit. Physical examination revealed an active range of motion of the affected side measuring 90 ° of abduction and 150° of forward flexion; internal rotation to the greater trochanter of the hip and external rotation were slightly limited. Plain radiographs revealed multiple calcific nodules in the right glenohumeral joint, the subcoracoid recess, and anterior to the humeral head. There appeared to be mild degenerative changes in the gleno-humeral joint.
Magnetic resonance imaging was performed to assess the location of the loose bodies and evaluate intra-articular degenerative changes. It demonstrated multiple loose bodies within the glenohumeral joint, the proximal tendon sheath of the biceps, and also in the subscapularis bursa. There was irregularity involving the anterior aspect of the humeral head consistent with erosive changes.
The patient underwent arthroscopic surgery to remove the loose bodies, arthroscopic partial synovectomy and decompression of the biceps tendon sheath, with removal of multiple loose bodies. For partial synovectomy a motorized suction-cutting device alternated between anterior and posterior portals. The biceps tendon was identified through an anterior deltopectoral incision and multiple loose bodies were removed from within the tendon sheath. Specimens for histological analyses were stained with haematoxylineosin (H& E) and safranin-O. Polyclonal anti-type II collagen was used at 1:100 dilution for immunohistological analyses
At 2–year follow-up examination the patient was asymptomatic and there was no clinical or radiographic evidence of recurrence. Lobulated areas of hyaline cartilage just below the synovial surface were easily identified. Chondrocytes were clustered together in nests and were not uniformly distributed throughout the ground substance. Safranin-O staining showed evident meta-chromasia of the cartilaginous matrix. Immunolabelling for type II collagen was observed in cartilaginous areas with marked cytoplasmic staining.
We believe that arthroscopy is an easy and safe method for the management of this disorder and that the support of an experienced pathologist is necessary to avoid differential diagnostic problems with the uncommon malignant transformation.
Nowadays it is well known that both a clinical examination and an imaging investigation (MRI/CT scans) are useful in order to provide surgeons with complete informations about the proposed treatment for shoulder pain. The purpose of this study was to evaluate the diagnostic sensitivity of the Neer, Hawkins, Jobe, Lift-off and Infraspinatus tests in diagnosing rotator cuff tears and compare this with what was found during surgery.
From 2001 to 2003, data from 430 patients who underwent shoulder open surgery, performed by a single surgeon, were documented. The results showed that the Jobe test has a sensitivity of 97.5% and positive prognostic value (PPV) of 80.3% and negative prognostic value (NPV) of 90.9% for the presence of a supraspinatus lesion; the Neer, Hawkins and Yokum tests have a sensitivity close to 95% for assessing subacromial bursitis; the Lift-off and Infraspinatus tests have a sensitivity close to 70% for assessing the degree of lesion and identify a severe lesion with a NPV over 83%. The Lift-off and Infraspinatus tests also provide information concerning muscular trophism and concerning retraction and degeneration of tendons.
According to our results, clinical evaluation of shoulder pain should be supported by imaging investigations for diagnosis of rotator cuff tear.
Two-part surgical neck fractures, two-part greater tuberosity fractures and three- and four-part fractures of the proximal humerus represent a frequently encountered clinical problem. Many types of conservative treatments have been proposed, with a poor functional outcome, however; when the fracture fragments are displaced, surgery is required.
Because the open reduction and the internal fixation disrupts soft tissue and increases the risk of avascular necrosis of the humeral head, closed or minimally open reduction and percutaneous pin fixation should represent an advantage.
We report on 31 patients affected by fractures of the proximal humerus (n=6, two-part surgical neck fractures; n=5, with two-part greater tuberosity fractures; n=10, three-part fractures; and n=11, four- part fractures) treated with minimally open reduction and percutaneous fixation. The average age was 57 years. Most of the four-part fractures were of the valgus type with no significant lateral displacement of the articular segment. A small skin incision was performed laterally at the shoulder and a rounded-tipped instrument was introduced to obtain the fracture reduction; this latter was stabilised by percutaneous pins and cannulate screws.
A satisfactory reduction was achieved in most cases. The average follow-up was 24 months (range 18–47). Only one patient, with four-part fractures associated with lateral displacement of the humeral head, showed avascular necrosis and received a prosthetic implant.
Minimally open reduction and percutaneous fixation is a non-invasive technique with a low risk of avascular necrosis and infection. This surgical technique allows a stable reduction with minimal soft tissue disruption and facilitates postoperative mobilisation.
Since several spinal conditions are currently treated with spinal fusion, alternatives to autogenous bone graft in spinal surgery have been under study for many years. Results have shown that, compared to other non.-spinal conditions, such as filling bone cavities, spinal fusion, in particular posterolateral fusion, is much more challenging due to the reduced area of the graft bed. As a result, most of the bone substitutes are still under investigation and their effectiveness in the clinical setting has yet to be demonstrated.
In recent years the authors analysed several bone graft substitutes using an animal model which has been widely used in experimental spinal fusion. In particular, porous ceramics have been used alone or with osteoin-ductive material such as fresh bone marrow or cultured mesenchymal stem cells. The results of these studies have shown that with ceramic alone a percentage of solid fusion similar to that with autogenous bone graft cannot be achieved. However, compared to the latter, more favorable results have been obtained when ceramics are loaded with mesenchymal stem cells. The addition of fresh bone marrow to ceramics also increases the fusion rates; however, in this case new bone formation was mainly found in the peripheral portions of the graft and to a lesser extent than when cultured mesenchymal stem cells were used.
The surgical approach to compressive syndromes of the thoracic outlet of vascular or nervous origin represents, for anatomical and historical reasons, an important issue for orthopaedic surgeons. Today’s angiographic techniques give an easy and unequivocal insight of the vascular and non-vascular (indirect) nature of the disease and, consequently, give more solid indications for surgery than before. A series of 35 cases, 21 women and 14 men with an average age of 39 years, of thoracic outlet syndrome (TOS) of vascular origin is presented here. The causes of compression were cervical rib (n=24), soft tissue anomalies (n=10) and scar tissue after clavicular fracture (n=1). During surgery, two subclavian artery aneurysms containing intraluminal thrombus and one subclavian artery occlusion were found. Presenting features of cases with arterial TOS included: hand ischaemia (n=32), transient ischaemic attack (n=3) and claudicatio or vasomotor phenomena during the arm in hyperabduction (n=3). Two patients with venous TOS developed hand oedema during arm hyperabduction, and another patient had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approachs were performed. Decompression were achieved by cervical rib excision (n=24), combined cervical and first rib excision (n=10) and first rib excision (n=1). In all cases, division of all tissue elements was also accomplished. Associated vascular procedures included resection and replacement of two subclavian aneurysms.
The mean follow-up period was 3 years and 2 months (range 1–6). Complete resolution of symptoms with a return to full activity was achieved in all cases. The medium-term clinical results suggest that the surgical indication for TOS, if supported by digital angiography, is justified and effective.
The surgical technique for treatment of massive rotator cuff tears, more than 5 cm, with loss of substance and tendon retraction, is still not well defined by the international orthopaedic community. A specific rehabilitation regimen or arthroscopic débridement may be insufficient in active patients who continue to suffer from pain and muscular fatigue in active forward elevation. We treated 20 patients, 14 men and 6 women, with an average age of 52 years (range 40–69) with the surgical technique consisting in acromion decompression, stabilisation of the cuff lesion with anchors, application of a prolene membrane and using a deltoid muscular flap as reinforcement. Deltoid flap is created by splitting the deltoid muscular fibres in front of the anterior border of the acromion. The inferior part of deltoid is sutured to the tendon above the synthetic membrane.
The mean patient follow-up was 24 months. The pain was completely relieved in 85% of subjects, The joint mobility increased significantly in flexion, abduction and external rotation; however, the internal rotation did not improve.
We propose this surgical technique as the procedure of choice for treating retracted ruptures of the supraspinatus associated with lesions of the supra- and the infra-spinatus.
Arthroscopic meniscal repair is still the subject of discussion. The first meniscal repair was performed by Hannandale in 1883 and the first arthroscopic repair by Ikeuchi in 1969. Today, arthroscopic meniscal repair is easy to perform, thanks to the many kind of devices in use. However, even though some colleagues such as Dehaven and Morgan report 20 years of experience, many others do not perform this type of procedure.
The purpose of this paper is to report our experience with two different techniques for all-inside repair; Linvatec Suture Hook and Smith-Nephew Fast Fix device. Since May 2001 we have performed 41 arthroscopic meniscal repair procedures (23 with the Fast-Fix device) in young people with a recent mural lesion, with no axial defect, with or without combined anterior cruciate ligament (ACL) reconstruction.
The post-operative rehabilitation consisted in 15 days of isotonic and isometric physiotherapy without weight bearing; after this period progressive weight bearing is allowed to improve muscle.
Patients operated for meniscal repair only can resume work after 30–40 days and take up sport activity after 50–60 days. Patients with both meniscal repair and ACL reconstruction performed a standard rehabilitation protocol for ACL reconstruction and get back to sports such as swimming after 3 months and football after 6 months.
We did have a patient with swelling and pain for 60 days after operation but which disappeared spontaneously after this period, and we have a patient who, after 11 months, still has persistent pain in the posterior compartment with a loosening 10° of flexion without synovitis or any other kind of complication.
We consider the suture hook device very useful, but difficult to use in small knees with very posterior lesions, and in which an accessory arthroscopic portal is often required. Fast-Fix devices allow fast repair and are also easy to use in posterior horn lesions, but they are non-absorbable and thus care must be taken to avoid errors in technique, with the risk of loosening the darts in the joint. They are also much more expensive.
In conclusion, both techniques are useful for meniscal repair and both can be used alone or together, depending on the lesions.
Unicompartmental knee arthroplasty (UKA) surgery has had a troubled history. In the late 1970s high failure rates and the success of bicondylar knee replacement made UKA less popular. Failures were mainly caused by improper implant design, incorrect patient selection and inadequate instrumentation. In the last few years the advent of guiding systems for more accurate alignment, new implant design and better patient selection have improved results and renewed interest in UKA.
We present a retrospective study of two consecutive series of 60 cases of UC-PLUS SOLUTION UKA and 60 cases of SEARCH AESCULAP computer-assisted total knee arthroplasty (TKA) using ORTHOPILOT software navigation, performed between September 1999 and September 2001. The patients, 45 men and 75 women, had a mean age of 69.5 years (47–85) and the two groups were comparable in terms of age, sex, size, weight (60–85 kg), aetiology, pre-operative range of motion (mean flexion: 100°; range: 90°–140°), pre-operative IKS score, mechanical axis and Alhlback radiographic degrees. The mean femoral-tibial angle was 175° (range:167°–195°). All the operations were performed by the same surgeon. Aim of the surgical procedure was to obtain an ideal femoral-tibial angle of 180°, relieve the pain and restore a better range of motion.
The results showed an excellent alignment of the limbs with the computer-assisted system, but a better IKS score in the UKA group as regards range of motion, pain and walking.
In congenital and acquired angular deformities of the coxofemoral joint, hip prosthesis presents considerable difficulties. The aim of this study is to analyse the different surgical solutions for this problem.
In the geographical area of G. Pini Institute, where congenital hip dysplasia is endemic and where also historically the surgical outcome of various types of osteotomy (both acetabular and femoral) have been investigated, this problem has often been encountered. We have evaluated several parameters, also with respect to particular cases in which tailored prosthetic solutions were required, to establish which kind of prosthetic treatment is most reliable today.
From 1994 to 2002 more than 6000 surgical hip prosthesis procedures were carried out at our institute: 750 in dysplastic hips and 112 after osteotomy. In our clinical division we also evaluate patientsin the pre-surgical phase with the DEXA, which gives qualitative and quantitative data about peri-prosthestc bone. After the first period of using standard, customised prostheses with no modular neck, we have progressively increased the use of a modular stem with press-fit cups that guarantee minimal bone sacrifice and a good recovery of articular biomechanics. In particular, with the use of modular components for the head and neck it is easy to reinstate the centre of rotation and achieve good offset and good lower limb length, without “escamotages” such as the use of a larger stem not perfectly inserted in the femoral diaphysis and the non-physiological cup position to avoid the risk of luxation.
We have progressively abandoned the use of PE, which is the cause of debris and should be avoided in angular deformities: in patients under 65 years of age we use ceramic-on-ceramic bearing surfaces with monob-lock insert, whereas in patients over 65 we prefer to use metal-on-metal bearing surfaces (always monoblock).
Deformities caused by the same pathological condition resulting in surgical osteotomy make implantation of standard prosthetic models impossible; our surgical experience suggests the use of different prosthetic models.
The use of custom-made prostheses has progressively been reduced thanks to the development of suitable modular prostheses which suit these patients perfectly.
In the past few years the use of cemented prostheses in these patients has decreased: according to our experience the use of cementless prostheses in relatively young subjects allows a good range of motion but above all it is useful to preserve bone in view of a possible future revision.
Numerous growth factors, together with bone morphogenetic proteins (BMP), are involved in the biological mechanism of bone induction. BMP 7 combined with collagen type 1 has shown to be effective in triggering the osteoinductive mechanism in the presence of bone defects as an alternative to bone graft. The aim of the present study is to present the experience gained at the Orthopaedic Clinic of Catania with BMP in lower limb non-union or pseudoarthrosis with bone defect after skeletal stabilisation.
From December 2003 to May 2004 at the Orthopaedic Clinic Of Catania four patients were treated using OP 1. The study group comprised three women and one man with a mean age at the time of operation of 27 years (range 23– 32 years). One subject presented with non-union, two patients with normotrophic pseudoarthrosis and one with atrophic pseudoarthrosis. In all cases the bone defect was localised at the tibia. All patients were treated surgically with skeletal stabilisation (one with a monolateral external fixator, one with a T2 intramedullary nail and two with a Gross-Kempf nail) always after decortication of Judet.
Three patients healed with a mean follow-up of 5 months. One subject is still under treatment. None of the patients have any pain and demonstrate complete weight bearing and functional capacity. X-rays showed good consolidation of bone defect.
Clinical and radiographic results obtained at this point are more than fair. Healing time was short without any side effects. It is important to verify whether, in the treatment of lower limb non-union and or pseudoarthrosis, the osteoinductive capacity of the OP 1 could provide the same valid results without good reduction and skeletal stabilisation. The use of OP 1 is extremely interesting for many reasons. However, it would be extremely important to test whether the biological effect is not exclusively related to an optimal mechanical stability.
Spinal fusion still is considered to be the most appropriate treatment for lumbar spinal disease not responding to conservative measures. Various forms of lumbar instability require surgical stabilisation. As an alternative to fusion, mobile, dynamic stabilisation restricting segmental motion would be advantageous under certain conditions, allowing greater physiological function and reducing the inherent disadvantages of rigid instrumentation and fusion. The “Dynamic Neutralization System for thèeSpine” is a pedicle screw system for mobile stabilisation, consisting of titanium alloy screws connected by an elastic synthetic compound, controlling motion in any plane (non-fusion system). Clinical success after solid fusion is unpredictable because it does not necessarily prevent painful loading across the disc, and it may also interfere with maintenance of sagittal balance in various postures. This system reduces movement both in flexion and extension and appears to be better. These study results compare well with those obtained by conventional procedures; in addition to which, mobile stabilisation is less invasive than fusion. Long-term screw fixation is dependent on correct screw dimensions and proper screw positioning. The natural course of polysegmental disease in some cases necessitates further surgery as the disease progresses. Dynamic neutralisation proved to be a safe and effective alternative in the treatment of unstable lumbar conditions.
Malalignment in total knee replacement (TKR) is frequently associated with early failure and poor functional results. It has been suggested that errors in tibial and femoral alignment of > 3° occurs in at least 10% of TKR. Since 1999 we have been using a computer-based alignment system (Orthopilot;Aesculap,Tuttlingen,Germany) for TKR in more than 300 implants. The aim of this retrospective study is to present our experience in comparison with traditional alignment systems for TKR.
Patients receiving TKR with different alignment systems were enrolled in the study and assigned to three different groups. In group A (38 cases) TKR was performed using a computer-assisted alignment system, in group B (40 cases) TKR was performed using a totally intramedullary alignment system and in group C (37 cases) TKR was performed using a totally extramedullary alignment system. The criteria for inclusion were a diagnosis of primary osteoarthritis, a pre-operative mechanical frontal axis (MFA) ranging from 165° to 195°, and a pre-operative knee flexion deformity not exceeding 10° calculated according to pre-operative radiographs. The radiographs were assessed for the alignment of the femoral and tibial component and the lower limb alignment, considering the lateral femoral component angle (FCA), the medial tibial component angle (TCA), respectively.
The surgical time was statistically longer in the computer-assisted group. The results did not show statistically significant differences in FCA, TCA and MFA among the three groups. However, in the extramedullary aligned group there was a statistically higher percentage of TKRs with both an abnormal FCA and MFA compared to the computer-based alignment group. Furthermore, in the computer-based alignment group all the implants were aligned within 4° of an ideal MFA.
Our results demonstrate the significant improvement in the accuracy of implant alignment using a computer-assisted system compared to an extramedullary one. Furthermore, we underline how stressing the knee during all the phases of the registration process for the navigated implant can demonstrate how much of the deformity can be corrected and thus guide the soft-tissue release.
We report our experience using an inflatable intramedullary nail in 20 diaphyseal humeral fractures. The nail is introduced without reaming and does not require proximal and distal locking, because it allows radial stabilisation of the fracture. The tip of the nail must be inserted 5 cm beyond the fracture line.
Since April 2002 we have applied 20 “Fixion” nails in 19 patients with humeral fractures. This is a stainless steel nail with a circular cross section reinforced by four bars, which can be inflated by saline solution through a dedicated pump. The average age of the 19 patients was 35.6 years, 15 were males and four female. Among these, 17 were closed fractures, three fractures open degree 1 (Gustilo Anderson class.). According to the AO classification, eight fractures were type A1 and A2, 10 were type A3 and two type B2. Nine fractures required reaming. Passive mobilisation is allowed 5 days after surgery, followed by active mobilisation 3 weeks later.
Eighteen of the twenty fractures consolidated in an average time of 3.5 months. Two of 20 cases showed delayed union at 4 weeks and were treated by increasing the immobilisation period. Final healing without complications in these cases was observed at 5 months. No peripheral neurological complications were observed.
“Fixion” nail is a new, easy method of intramedullary nailing. It helps to reduce operating time and in our experience it did not show any complications. It must be reserved for simple diaphyseal fractures where it is possible to achieve good stability and complete union.
The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical.
Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed.
The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia.
Elbow dislocations are difficult to treat because of the high incidence of short- (vascular and neurological lesions) and long-term (decreased range of motion and instability) complications. We report the results obtained in 20 elbow dislocations treated with hinged cast tutorisation or hinged external fixator.
We treated 20 patients with an average age of 45 years (range 16– 62 years). The average follow-up was 7 months (range 5–18 months). We divided the patients into two groups: patients treated by a hinged tutor for 4 weeks (group A), patients treated by hinged external fixator, removed after 5 weeks (group B). All the patients were evaluated clinically using the “Mayo elbow performance score” after 3 weeks, 1 month and 1 year.
Results were excellent in six elbows and good in 14; none of the patients had an insufficient or poor score. We observed deficit in prono-supination in three patients and deficit in flexion and extension in six patients; three patients complained of epicondylar pain when carrying something. At the end of the treatment none of the patients complained of instability.
According to our data normal function can be restored after early mobilisation. Our experience suggests that the most important aspect in the choice of treatment is the evaluation of joint stability after reduction. The results obtained with the external fixator are very good in terms of restoring function; the incidence of complications is very low and was equally distributed between the two groups.
The reconstruction of a skeletal defect after resection of a bone tumour represents a challenge for the orthopaedic surgeon. Age, site of the lesion and extension of the disease often limit the choice of surgical technique for a conservative procedure, but several options are available, mainly modular, composite or custom prostheses, massive bone allografts with or without autologous vascularised fibular grafts (AVF), and arthrodeses.
An interesting reconstructive technique uses the AVF graft, with microsurgical technique, alone or associated with a massive allograft. The association of a fibular transplant with an allograft increases the mechanical strength of the reconstruction, also promoting more rapid integration. The fibula is a cortical bone and it may provide mechanical strength in the reconstruction of a large segmental bony defect if employed as a viable biological rod.
In the present paper the authors discuss their experience with 17 patients treated at the Oncological Orthopaedic Unit of the G.Pini Orthopaedic Institute, for bone tumour resection and reconstruction using AVF graft, almost always combined with a bone allograft.
No treatments were performed as augmentation in osteoarticular massive allografts. Subjects’ ages ranged from 7 to 66 years (mean 25.2 years). Most of the patients were referred for a diagnosis of malignancy (15 of 17 cases) and in only two patients were the tumours not aggressive. In 11 patients the AVF was transplanted immediately after tumour resection, while in the others it was used after problems of previous reconstruction.
The authors report two cases of deep infection and four mechanical fractures (all healed after a period of cast immobilisation with or without bone bridging). All the AVF survived and healed with a good functional result for the patients except for two recurrences that required an amputation.
Standard external fixators have always caused difficulties in visualising fracture fragments radiologically in both planes; for this reason multiple shots are often required, exposing patients and surgeons to high X-ray levels. Radiolucent external fixator X-calibre is composed of a new thermoplastic material reinforced by carbon fibres (PEEK-CA 30). The aim of this study is to evaluate the first 30 tibial fractures treated with this device.
Thirty external fixators X-calibre were used to treat 30 patients with tibial fractures with an average age of 40.4 years (range 21–60). According to the AO classification we have treated nine type A, 13 type B, and eight C fractures. Five were open fractures. The average follow-up was of 18 months. The time of healing was the same as seen using the standard fixator and the average time was 115 days (range 85 to 190). One tibial plafond fracture healed with 8° valgus deformity and persistence of pain during walking. There was loss of reduction on the third day after surgery due to erroneous evaluation of the fracture, which presented a butterfly fragment.
This new radiolucent fixator showed the following advantages: single use, sterile package, radiolucency, less X-ray exposure for patients and surgeons, deal mechanical performance for each use, reduced storage and sterilisation costs, less instrumentation, less weight and increased comfort for the patient, average healing time and results comparable to the existing radio-opaque system.
Different methods of filling bone defects are reported: shortening followed by lengthening or bone transplant. In both cases the resection and docking bone site (immediately or after transplant) has a high risk of delayed consolidation or non-union. The aim of this study was to evaluate the strategies to avoid this risk.
We studied 19 patients treated from 1997 to 2002: 11 (group 1) were treated with immediate shortening and proximal callotasis. In eight patients (group 2) we performed monofocal proximal-distal bone transplant. In seven patients of group 1 we performed only decortication of the docking site (group 1A); in four cases (group 1B) decortication was associated with an autologous bone graft. The docking site was checked radiologically and considered healed when we allowed full weight-bearing after fixator removal.
In two patients (28.5%) in group 1A, three (75%) in group 1B and two (25%) in group 2 healing was achieved without any other operations. Docking site refracture or pseudoarthrosis was treated in all patients by new decortication and autologous bone graft with an average healing time of 90 days.
We suggest performing acute bone loss shortening in combination with decortication and autologous bone graft when local conditions permit. After bone transplant it is not necessary to wait for spontaneous consolidation, but better to plan from the beginning another operation before the two the docking site fragments are in contact.
Now we are using AGF and BMP-7 (OP-1) for treatment of the docking site but the study is still underway.
From 1990 to 2003 the Ilizarov technique was used to treat 41 patients affected by the following congenital or acquired deformities : post-poliodeformity (n=8), hemimelia (n=6), pseudoachondroplasia (n=5), idiopathic genu valgum/varum (n=5), hypoplasia (n=3), osteomyelitis with growth arrest (n=3), DDH (n=2), rickets (n=2), Blount disease (n=2), Ollier disease (n=1), Perthes disease (n=1), arthrogryposis (n=1), hypochondroplasia (n=1) and congenital genu flexum (n=1). Post-traumatic deformities and simple leg-length discrepancies were excluded. The majority of the patients (26/41) presented with multi-planar deformities with the following average degrees: varus 22°, valgus 21°, internal rotation 36°, external rotation 42°, antecurvatum 20° and recurvatum 15°. The average leg-length discrepancy was 6 cm (range 2–10 cm). In total, 66 segments (30 femurs and 36 tibias) in 50 limbs were treated. The rotational corrections were performed at a rate of 4 mm/day; the angular corrections at the rate of 1.5 mm/day on the concave side and 0.75 mm/day on the convex side. The rotational correction occurred on the regenerate. The average correction time was 44 days, the healing time 86 days.The results were: excellent (correct mechanical axis, normal ROM and no limping) in 14 cases, good (correct mechanical axis, limping and reduced ROM) in 24 cases, fair (residual deformity, limping and joint contracture) in three cases, poor (residual deformity, limping and rigid joints) in none. The complications were: five pin tract infections and three fractures.
Maintenance of the bone stock is a primary goal in hip surgery. The idea of a resurfacing hip prosthesis had already been proposed in the past without success. The improvement in prosthetic materials, however, has mades it possible to reconsider the use of resurfacing prostheses. We report our experience with the Birmingham hip resurfacing (BHR) prosthesis.
We operated on 58 patients (60 hips, two bilaterally), 31 men, 27 women, with a mean age of 47.9 years (25–76) and a mean follow-up of 27 months (1–42). We used the posterolateral approach with the patient in lateral decubitus. We performed a clinical and radiographic examination before surgery and at 1 and 6 months postoperatively. We recorded a statistically significant improvement in the clinical score at 6 months after surgery, with respect to the preoperative examination. Major complications were two fractures of the femoral neck and one infection. We recorded also peri-prosthetic calcifications in two patients, calcifications of the ileopsoas in two and ileopsoas tendinitis in one.
In conclusion, in our experience, the BHR prosthesis reproduced the biomechanics of the hip and minimised the risk of luxation. The preliminary clinical results are encouraging, also for difficult cases.
The use of conventional stems in hip arthroplasty may be difficult in cases of dysplasia, coxa vara or coxa valga, after fracture or proximal femur osteotomy. In fact the morphologic alterations of the proximal femur might require prosthetic components characterised by small size and different neck angles to restore correct joint biomechanics. In these cases we are often compelled to compromise between the ideal implant aneiversion and fit and what we can really achieve. An alternative to conventional prostheses is represented by custom-made prostheses.
For 3 years we have been using the Modulus stem in the treatment of morphologic disorders of the hip. The conic shape of the stem easily fits the different morphologies of the proximal femur, whereas the modularity of the neck makes it possible to correct length, inclination and declination of the femural neck. We studied 59 patients by clinical and radiographic examination before surgery and 1, 3, 6 and 12 months postoperatively. We recorded a statistically significant improvement in the clinical score already at 1 month but this was even better at 6 months after surgery, with respect to the pre-operative examination.
With the use of this prosthesis, the recovery of correct joint biomechanics together with high tribologic standards could improve the implant survival, leading to cost reduction and patient satisfaction.
The increase in knee arthroscopy performed on an out-patient basis, along with the need for cost reduction and a safe and rapid patient discharge, has underlined the importance of adequate anaesthesia techniques. We designed this study to compare efficacy, efficiency and surgeon’s satisfaction of total intravenous anaesthesia with propofol and remifentanil with those of spinal or peripheral nerve blocks for outpatient knee arthroscopy.
A total of 120 patients undergoing elective outpatient knee arthroscopy were randomly allocated to receive total intravenous anaesthesia with propofol and remifent-anil (n=40), combined sciatic-femoral nerve block (n=40) or spinal anaesthesia (n=40). Preparation times, surgeon’s satisfaction, discharge times and anaesthesia-related costs with the three anaesthesia techniques were analysed.
Preparation time was shorter with general anaesthesia (13 min) than with spinal anaesthesia or sciatic-femoral block (15 min; p=0.006). Surgeon’s satisfaction was similar in the three groups. Furthermore, 17 patients receiving peripheral nerve block (42%) and 12 receiving spinal anaesthesia (30%) by-passed the post-anaesthesia care unit after surgery as compared with only two general anaesthesia patients (5%; p=0.01). Discharge from the post-anaesthesia care unit was more rapid after peripheral block; however, stay in the Day Surgery Unit was shorter after general anaesthesia than peripheral or spinal blocks (p=0.026). Urinary retention was reported in three spinal anaesthesia patients only (8%; p=0.03).
Regional anaesthesia techniques reduce the rate of admission and the duration of stay in the post-anaesthesia care unit as compared with general anaesthesia. Peripheral rather than spinal nerve blocks should be preferred to minimise the risk of urinary retention.
The authors describe a new, original technique of intra-medullary nailing (originally designed for the Gamma nail system, now also suitable for other nailing systems) for the management of pertrochanteric and subtrochanteric fractures using a minimally invasive approach to the proximal femur. In this approach, the intramedullary nail is placed using a percutaneous Kirschner wire as a guide, so that the procedure has been called “Percutaneous Nailing System” (PNS).
The entry portal is selected at the proximal femur using the Kirschner wire, then a series of cannulae is placed through a small cutaneous incision (15 mm). This dilatator system protects the soft tissue during the reaming procedure (usually only necessary in the proximal femur, not in the diaphysis) and the insertion of the femoral nail.
From April 2001 to January 2004, 120 patients were treated with this new technique. They have been followed up and retrospectively compared to 60 patients operated with the standard technique. The comparison between the two groups was based on the surgical procedure (operation time and total blood loss) and the post-operative period (complications, length of hospitalisation).
With the minimally invasive technique the operation time was on average 15 min and the blood loss, measured as the difference in pre- and postoperative haemoglobinaemia, was on average 1 point, with no need for blood transfusion: these values were less than half in comparison to the standard technique.
The study shows the advantages of this minimally invasive technique, which can also be applied to fractures of the femoral diaphysis.
Numerous sequelae are reported after treatment, conservative or surgical, for proximal humerus fractures, which may result in shoulder pain and disability. The treatment of these conditions is still controversial. The aim of the present study was to evaluate the results achieved with the use of non-constrained shoulder prostheses.
Twelve patients (seven men, five women) were included in the study. The indications for prosthetic shoulder replacement were pain and loss of function that did not respond to medical and physical therapy. All the patients were clinically evaluated preoperatively and postoperatively with the Constant scoring system and by X-ray.
Fracture sequelae were grouped in type A, humeral head collapse (n=5); type B, locked fracture/dislocation (n=3); type C non-union of the surgical neck (n=2); and type D malunion of the tuberosity (n=2). In all the patients the same prosthetic implant (Aequalis, Tornier, France), and the same post-operative rehabilitation programme were employed. The mean follow-up was 4 years.
The best results were observed in the sequelae grouped as type A and B with an impressive reduction in pain and good recovery of activity. At the last follow-up no radiological signs of implant mobilisation were registered.
In our small series shoulder replacement seems to be the treatment of choice, in particular for sequelae of intracapsular impacted fractures of the proximal humerus. A larger series and a longer follow-up are still required to clarify these results.
After gaining experience from 1990 to 2003 using the Cincinnati incision in the surgical treatment of congenital clubfoot, we were able to extend its use to the early surgical treatment of congenital vertical talus (CVT). Eight of the 172 feet were affected by CVT; four were idiopathic, three were associated with arthrogriposis and one with cerebral palsy. The average age of the six children at the time of the operation was 13.5 months (range 6–27 months). We performed a posterior, medial and lateral release of the subtalar joint and of the talona-vicular joint. The reduction of the talus was performed using a K-wire placed through the posterolateral aspect of the talus in its longitudinal axis. After the calcaneus was reduced from its everted position, a second K-wire was placed through the calcaneus and into the talus. The medial talonavicular joint capsule was opened and the redundant capsule reconstructed. Peroneal tendon lengthening was performed in five cases. The radiological evaluation, according to Hamanishi, showed preoperatively a talo-first metatarsal angle of 94° (NV: 3.3 ± 6.4 SD) and a calcaneal-first metatarsal angle of 54° (NV: −9 ± 4.5 SD); postoperatively the values were 24° and 7°, respectively. There were no wound complications or avascular necrosis of the talus.
With the Cincinnati incision we were able to visualise the talo-calcaneal and talo-navicular dislocation in all three spatial planes. It also allowed us to correct the deformity in all three mentioned planes and in a single-step procedure.
Preoperative autologous blood donation (PABD) is widely practised in elective orthopaedic surgery, but few data are available as regards recombinant human erythropoietin (rHuEpo) support during a PABD programme in children.
In January 1999 we introduced a PABD protocol with erythropoietin (10000 U s.c. twice weekly during the 3 weeks preceding surgery) in children who were scheduled for corrective surgery of scoliosis. Between January 1999 and November 2003, 23 consecutive patients (five males and 18 females, median age 15.1 years) were enrolled. Preoperative haemoglobin (Hb) levels, the numbers of collected and of autologous and allogeneic blood transfused units were determined. The results were compared with a historical group of 28 consecutive patients (seven males and 21 females, median age 15.4 years) who underwent spinal surgery between January 1994 and December 1998 and who differed from the first group only by the absence of concomitant erythropoietin therapy.
Administration of rHuEpo allowed all patients to complete the PABD programme, whereas 36% of patients in the non-treated group had to stop predeposit because they developed anaemia. Furthermore, significantly higher numbers of collected blood units and haemoglobin levels were measured. A significantly lower requirement for allogeneic blood was observed in the rHuEpo-treated group: 1/23 vs. 9/28 patients (4.3%–32.1%, p < 0.001).
The present study documents the efficacy of presurgical rHuEpo in facilitating autologous blood collection, thus reducing exposure to allogeneic blood, in paediatric patients undergoing corrective spinal surgery.
The surgical treatment of typical pathological conditions of the knee combined with deflections along the sagittal axis is complex, especially when the angles of such deflections are considerable in size.
Prior to treatment, the first problem concerns detecting the origin of the deflection, whether it is osseous, ligamentous or mixed, especially in cases of knee recurvation. The possibility of finding patients with what is known as “prophylactic” correction of the deflection is very rare.
Orthopaedic surgeons may encounter some cases in which deformation along the sagittal axis represents the primum movens of the pathology and others in which this deflection represents a further problem in curing the condition. The different situations may require the following different treatments: (a) Correction of the deflection; (b) correction of the deflection and the pathological condition; and (c) correction of the pathological condition and not the deflection.
We believe that, in the most serious cases, the deflection must be corrected and then meticulous pre-operative preparation is required. However, in order to select the most appropriate treatment, it is essential, in our opinion, to determine the cause of the deflection along the sagittal axis.
In our experience, the treatment of pathological conditions of the knee such as ligamentous reconstruction, knee arthroplasty and corrective osteotomies combined with deflection along the sagittal axis increase the difficulties of surgery, especially in cases of relevant knee recurvation, both osseous and ligamentous.
The biomechanical objective in total knee prostheses with mobile bearings was, and still is, to reduce UHMWPE wear and fracture. This does not mean that such prostheses do not produce polyethylene debris.
In our clinical experience we have used several types of prosthesis, in which over time, plastic materials have become diversified and various methods of sterilisation have been used, the prostheses becoming more and more sophisticated.
In our work we present the results of using a posterior cruciate ligament-retaining prosthesis with two mobile bearings (follow up 7–14 years), a posterior cruciate ligament-sacrificing prosthesis with a rotating platform (follow up 10 years to today) and a posterior cruciate ligament-retaining prosthesis with a rear-front translation platform (follow up 7 years to today).
Data on fractures and dislocation are only presented for the posterior cruciate ligament-retaining prosthesis with two mobile bearings. In no other cases were fractures or dislocation observed, except for one patient who had a dislocation after suffering a rotational tendon tear.
Our results show that larger surfaces tolerate the prosthesis stress better, although the type of polyethylene (with or without stearate, more or less crosslinked, sterilisation with or without air, sterilisation by high energy radiation or using gamma radiation, etc.) can influences debris production.
This study presents the results of 1188 original and innovative posteriorly stabilized TKA procedures in which the femoral bone stock is preserved with a shallow compartment insofar as possible. The TKA procedure is directly derived from Insall’s original technique, except for the posterior stabilisation design, where a third median condyle starts working at 30° of knee flexion.
A total of 1188 primary TKA procedures were consecutively performed in a university hospital. Average follow-up was 30 months (0–168 months). The implants were cemented (except for 35 femoral components) and the patella resurfaced (except for nine cases). Clinical results were assessed using the IKS Score. The quality of the implantation was analysed on long-leg X-rays (1175 preoperative and 883 postoperative long-leg films available at follow-up). The results showed that 95% of patients were very satisfied or at least satisfied. Knee score and functional scores were 44 and 54 preoperatively and 90 and 78 postoperatively. Mean range of motion was 116°. On X-ray analysis, the average mechanical femorotibial angle was 179° postoperatively. Survival of the implant for revision was 94.2% at 14 years. We performed 83 re-operations (nine patellar fractures, 14 infections, 12 cases of stiffness and 11 clunck syndromes), including 33 component revisions.
Clinical results compared favourably with the literature. This original posterior stabilisation design confirmed the good and excellent results at follow-up. We obtain good range of motion, and no revision was due to polyethylene wear.
Seven patients who had malignant proximal femoral tumours were selected for resection and limb salvage with a modular megaprosthesis. Histopathological diagnosis confirmed one solitary bone metastasis from renal cell carcinoma, one dedifferentiated chondrosarcoma, two primary non-Hodgkin lymphomas non-responsive to adjuvant chemo- and radiotherapy and three low-grade chondrosarcomas. The mean age at the time of surgery was 53.5 years. Post-operative survival averaged 54.5 months. The mean functional status score was satisfactory. There was no local tumour recurrence or dislocation of the prosthesis. There were one superficial wound infection and one post-surgical haematoma. Care must be taken in selecting patients to for resection of the proximal femur and implantation of modular megaprostheses. We reserve such treatment only for tumours that, because of the histopathological diagnosis and spread, chemotherapy or radiotherapy alone is not enough. Modular megaprosthesis is currently the method of choice in the treatment of malignant proximal femoral tumours. With this implant joint function can be restored after wide resection, too, offering a valid alternative to the bony massive allografts that are characterised by a high rate of complications and failure.
Pain and kyphosis in vertebral body compression fractures (VBCF) impair quality of life. Conservative treatment has been the proposed solution up to now. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps (IBT) into the vertebral body by a trans-pedicle approach. The purpose of IBT is to restore the original height of the vertebral body while creating a cavity that can be filled with highly viscous methylmethacrylate. We prospectively evaluated the safety and efficacy of kyphoplasty in the treatment of pain related to pathological vertebral body compression fractures resulting from osteoporotic collapse, multiple myeloma, primary malignant tumours (lymphoma) and metastatic cancer. Clinical results show immediate and maintained pain relief in all patients who received this treatment and a more rapid improvement in function. Pain relief may be related to spinal realignment by restoring the weight-bearing on the anterior column and to biological factors such as damage of pain-receptors due to the high temperature of cement polymerisation.
OP-1 is a bone morphogenetic protein which induces bone formation. For this reason, this protein is used to treat congenital pseudoarthrosis and post-traumatic non-union as well as to improve healing of bone grafting in orthopaedic surgery. In the present study we report the results of treatment in 10 patients in whom OP-1 was used to improve bone healing. Four patients were operated because of post-traumatic non-union, one because of congenital pseudo-arthrosis and four because of spinal arthrodesis, whereas one had a tibial lenghthening with poor bone formation. At follow-up, ranging from 6 to 16 months after the operation, we observed satisfactory bone formation in all cases. Although the number of our cases is limited, our results confirm the effectiveness of OP-1 in the treatment of post-traumatic non-union and spinal arthrodesis.
Haematogenous vertebral osteomyelitis (HVO) is a relatively rare disorder which accounts for 2–4% of all cases of infectious bone disease. In recent years, the incidence of spinal infections seems to have increased according to the growing number of intravenous drug users in young people and with the use of intravenous access devices, genitourinary surgery and manipulation in the elderly. Men are more frequently affected than women, with an average age of onset in the fifth and sixth decade of life. The onset of symptoms is typically insidious, with neck or back pain often underestimated by the patient. The early diagnosis is also difficult due to the non-specific nature of laboratory and radiographic findings. The frequent observation of back pain also makes the diagnosis a challenge in most cases. Several studies in the literature report an average delay in the diagnosis of HVO from 2 to 6 months after the beginning of the symptoms. In this article we review the clinical features and the diagnostic approach to HVO in order to optimise treatment strategies and follow-up assessment.
From 1997 to 2003 we treated 153 patients affected by vertebral osteomyelitis. The localisation was cervical in 11.5% of the cases, thoracic in 31% and lumbar in 57.5% cases. In all, 92 CT needle biopsies were performed without any complications. We were able to identify the microbiological pattern in 57% of cases (the most represented bacteria were Staphylococcus aureus and Mycobaterium tuberculosis) whereas in 47% of cases we could not identify any micro-organismus. Treatment was conservative in 112 cases and surgical in 41 cases.
Most of the studies in the literature consider HVO as a challenge for the physician: symptoms are not specific and sub-acute or chronic presentation is most common. In general, a delay in diagnosis is the rule rather than the exception. This is an easily missed infectious process, particularly in the elderly, in whom degenerative radiographic changes and conditions resulting in back pain, such as osteoporotic fractures or spinal metastases, are common and signs of sepsis may not become manifest. However, persisting localised back pain and tenderness with elevated ESR should prompt the physician to also consider HVO, although fever and leucocytosis may often not be present.
Once HVO is suspected, a long series of imaging and laboratory tests, and if necessary surgical procedures, must be initiated. The purpose of this study is to formulate a systematic, comprehensive and simple approach to the management of this disease following the diagnostic algorithm suggested.
Anterior stabilisation has been shown to be superior in the treatment of the lumbar and thoraco-lumbar scoliosis, both in regard to the correction of the curves and to the number of fused vertebrae. Since 1995, with the emergence of third-generation locking devices, we have extended the indication of anterior fixation to double major scoliosis with lumbar predominance, operating exclusively on the lumbar curve and allowing the thoracic curve to correct itself. We report this experience with respect to 12 patients.
The patients consisted of 11 girls and one boy, mean age 16.6 years (range 12–29). The mean preoperative Cobb angle was: lumbar: 51° (41–72), dorsal 28° (range 21–45). All patients showed a lateral deviation of the trunk with asymmetry of the lumbar region.
Of the 12 patients, 11 received stabilisation by EUROS instruments from D11 to L3 and one from D10 to L3. The mean follow-up is 44 months (range 15–77 months).
A vertebral fusion was achieved for 94 % of the spaces (46/49). In the fixation zone, a 72% correction rate was achieved, whereas in the non-treated zone of the dorsal rachis, the rate of spontaneous correction was 32 %. In total the angle loss has been on average 4°. The study assessed the horizontal position of the disk underlying the zone of the arthrodesis; in other words the L3 – L4 disk showed the presence of an average gradient angle of 7° with a range from 0° to 17°. No post-operative complications were observed, but 7 of 12 patients have had immediate and transient sympathectomy after-effects, with a modification of the ipsilateral limb temperature at the level of the instrumental access site.
Anterior stabilization of the thoracolumbar curve in double major scoliosis with lumbar predominance seems to be preferred to posterior correction. This technique, by preserving the posterior musculature, makes it possible to save from 1 to 2 disk downwards. In turn, this makes it possible to correct the lateral translation and the realignment of the trunk starting with fusion limited to the lumbar spine. It is imperative to avoid hypercorrection of the thoraco-lumbar curve and even leave a bit of curve in the in situ modelling of the rod. Then the lumbar curve can be balanced with the dorsal curve and avoid an increase in the lumbosacral counter-curve with the risk in of rotatory dislocation in adult age. Since we have started using this technique, we have not had to perform double correction, anterior and posterior, for double major scoliosis with lumbar predominance.
The object of this work was to retrospectively study the recommendations and the results of cruent reduction of idiopathic congenital displacement of the hip following ineffective orthopaedic treatment.
From 1993 to 2001, 15 cruent reductions were performed in 11 children (seven girls and four boys). Initially, the 15 hips were treated by orthopaedic techniques (Pavlik harness and/or slow reduction according to the Sommerville-Petit method). Four of these have benefitted from surgical treatments after orthopaedic treatment proved to be ineffective (psoas tenotomy, Salter osteotomy). At the time of the cruent reduction the mean age was 24 months (range 9 months to 5 years). For the surgical reduction, always associated with a shortening-derotation osteotomy of femur, the Smith-Petersen antero-medial approach was used. In five of these cases, the cruent reduction was complemented by Salter osteotomy.
The mean post-surgical follow-up is 5.6 years (from 1 to 9 years). In none of the hips studied was recurrence of the dislocation observed. The functional outcome, studied by Mackay criteria, is good for all the hips. No significant dysmetria of the lower limbs was present. According to the radiological criteria in the classification of Severin outcome was good or excellent in 12 hips and average in three hips. According to the Bucholz and Ogden classification, six hips showed signs of necrosis as a result of the orthopaedic treatment. The surgical treatment did not cause necrosis in the remaining nine hips.
Recourse to a surgical procedure can result because of the anatomical obstacles typical of specific dislocations. Surgical reduction must be considered as an operation to preserve the hip; this operation is suitable at about 1 year of age if progressive orthopaedic practices are ineffective. Before 2 years of age, the cotyloid cavity can continue to develop after femoral head reduction, whereas, after this age, it is preferable to integrate a Salter osteotomy with the cruent reduction.
Homoplastic bone has been produced and used at the Rizzoli Orthopaedic Institute since 1998. Bone grafts are treated following the “freeze-dry” technique developed by the Rizzoli Bone Bank. Up to now, 111 patients have been surgically managed by using lyophilised bone grafts at the Division of Spine Surgery.
With a follow-up of more than 12 months, the authors reviewed 81 subjects affected with scoliosis (45 cases – group A), lumbar diseases (34 cases – group B) and segmental cervical degenerative stenosis (two cases – group C). Group A consisted of 20 patients, mean age 14 years, affected with progressive or congenital idiopathic scoliosis; 12 patients, mean age 34.5 years, affected with adult symptomatic scoliosis; 10 patients, mean age 14.4 years, affected with neuromuscular scoliosis; and the remaining three, mean age 37 years, who had already undergone surgery) presenting with pseudarthrosis. Surgical technique was circumferential arthrodesis in paediatric congenital scoliosis and posterior arthrodesis in adult and adolescent idiopathic scoliosis. Fusion was extended to the sacrum and iliac crests in five cases of neuromuscular scoliosis. Patients of group B (16 spondylolisthesis and 18 degenerative lumbar instability), aged 42 years on average, underwent posterior arthrodesis with pedicle fixation. Only two patients in group C were treated with bone graft anteriorly placed at the cervical level to supplement the intersomatic fusion with cage. At a mean follow-up of 28 months, solid fusion was observed in 79 cases (97%); a clearly visible pseudarthrosis was seen only in two cases (3%) (an infantile scoliosis and reintervention for neuromuscular scoliosis in an adult patient). A deep infection with Staphlylococcus aureus was encountered in one patient (1.2%) with degenerative lumbar instability treated with arthrodesis and L2-S1 pedicle fusion: the infection resolved after surgical reintervention (leaving the instrumentation in situ) and drainage.
Lyophilised bone, either used as wedge grafts anteriorly or morcellised grafts posteriorly, provides good resistance and integration. Safety, ready availability and possibility to be stored at environmental temperature are further advantages offered by these bone grafts, which make them particularly suitable for application in spinal surgery, above all when surgical times are long and the risk of complications is high.
Percutaneous compression plates (PCCP) used in the treatment pertrochanteric fractures are made of stainless steel, available in one size only and have two threaded oblique proximal holes for the telescopic cephalic (femoral neck) screws and three distal holes for the shaft self-tapping screws.
The plate is inserted at right angles to the femoral diaphysis through a small incision and rotated so that its axis is parallel to the diaphysis. By means of small movements it is advanced along the bone, positioned between the vastus lateralis muscle and the periosteum and then fixed with the proximal and distal screws. The neck screws are telescopic and they provide a double axis fixation in the femoral neck, which increases rotational stability by allowing fracture compression and preventing collapse of the neck and subsequent cut-out.
Surgery takes about 30 min and consists of two small longitudinal incisions; thus the procedure is associated with only minimal blood loss. From March 2003 to May 2004 we treated 101 patients with PCCP: 73 women and 28 men with an average age of 82 years (range 26–101 years). The average blood loss was 92.4 ml. Of the patients, 31 (29.8%) did not receive blood transfusions and of the remaining 70 patients (70.2%), 26 received one unit of blood, 35 two units and nine two units operatively and two post-operatively. When possible, weight-bearing was allowed on the third postoperative day, thus achieving a functional recovery. The healing times are similar to those of other methods. No incidence of fracture collapse or screw cut-outs was seen in this series.
The search for bone substitutes has stimulated the study of growth factors with osteoinductive properties. Bone morphogenetic proteins (BMPs) have been shown to have a central role in endochondral and intramembranous bone formation and are thought to promote normal bone healing. Recent studies demonstrated that platelet-rich plasma (PRP) can provide several growth factors and stimulate osteogenesis. The aim of the present study was to analyse the in vitro effects of rhBMP-7 and PRP on phenotype and proliferation of cells from the site of non-union and from non-affected bone.
During the surgical treatment of seven cases of non-union, normal cancellous bone and tissue from the non-union site were harvested. Osteoblast-like cells and fibroblast-like cells were isolated and characterised. Mesenchymal cells were obtained from bone marrow of the same patients. Each cell type was incubated with rhBMP-7 and PRP at different concentrations. Proliferation rate and alkaline phosphatase activity were assessed at 3, 7, 15 and 30 days. Histochemical and immunohistochemical analyses were performed at 15 and 30 days.
The proliferation rate of osteoblast-like cells and mesenchymal cells wasalways higher than that of fibroblast-like cells from the non-union site. Growth factors induced mesenchymal cells to express osteoblast phenotype markers.
The results suggest that fibroblast-like cells from the site of non-union are poorly responsive to growth factors, even at highest stimulation. In surgical practice these data strongly suggest adding osteoblast-like cells and mesenchymal cells from non-affected sites at the non-union site to enhance the osteogenic response to growth factors.
The present investigation was undertaken to explore the possible association between lower limb torsional abnormalities and some disorders of the knee, such as patellofemoral malalignment and Osgood-Schlatter disease.
Four groups of patients were subjected to clinical, radiographic and CT evaluation: 20 male and 20 female asymptomatic subjects, 27 girls affected with patellofemoral malalignment and 21 boys affected with Osgood-Schlatter disease. With CT femoral anteversion, patellar congruence angle, patellar tilt angle, condylomalleolar angle, the distance between the anterior tibial tuberosity and the trochlear groove and external tibial rotation angle could be measured. Statistical analysis was carried out by ANOVA and Student’s t-test.
In the patellofemoral malalignment group, the femoral anteversion and rotation were significantly greater than in comparison the other symptomatic or control groups. In the Osgood-Schlatter group the condylomalleolar angle and tibial rotation angle were higher than in controls.
Several authors have demonstrated the influence of changes in the torsional alignment of the leg on the genesis of many disorders of the knee. The present CT study, employing a method that is the most accurate to measure lower limb rotation, documents a close association between patellofemoral malalignment and femoral rotation and between Osgood-Schlatter disease and increased external tibial torsion. These associations does not imply a cause-effect relationship; nevertheless, it is conceivable that these torsional abnormalities, probably in conjunction with other factors, can be predisposing mechanical factors for the onset of anterior knee pain related to patellofemoral malalignment or Osgood-Schlatter disease.
Renal failure in children is associated with a wide range of musculoskeletal disorders such as osteonecrosis, stress fractures, brown tumours, epiphysiolysis, joint infections and angular deformities. In this paper the authors report their experience concerning the surgical treatment of the angular deformities of the lower limbs in renal osteodystrophy (RO).
Between 1995 to 2003, 10 children (five girls and five boys) with RO underwent surgical correction of angular deformities of the lower limbs. Of these, seven had femoral osteotomies because of knee deformities (three genu valgum, four genu varum) and three had osteotomies because of tibial angular deformity. The average age at surgery was 5 years (min. 2 years, max. 12 years). Different types of osteosynthesis were used (staples and cast, Ortho-fix and Ilizarov frames) according to the age of the child and the degree and the site of the angular deformities.
All osteotomies healed without complications and the surgical correction was considered appropriate at the end of treatment. At an average follow-up of 4.5 years there was no significant relapse and no need for second surgery.
Simple osteosynthesis (staples and cast) was most appropriate in the youngest children and in mildest deformities (particularly at the distal tibial metaphysis). External devices were more suitable in the oldest children and for genu valgum/varum deformities. To optimise the time of consolidation close collaboration with the paediatricians is required in order to perform surgery under the best metabolic conditions (elevation of the serum alkaline phosphatase concentration above 500/l is a good marker of bone metabolic healthy).
Unstable knee caused by an axial deformity mainly occurs in serious valgus cases, which is the result of a femoral external hypoplastic condylus defect and often seen in association with marked debris of the tibial plate and bone –loss. Tibial rotation related to the deficit causes lateral patellar subluxation, and soft tissue retraction fixes the deformity while the preconditions for an anteromedial ligamentous laxity are being created. On replacement the deformities develop because of bone-stock defects as well as ligamentous defects, which are often secondary to debris and/or to primary component misrotations.
In primary surgery the approach is medial for varus and lateral for valgus, in order to help the release. We use the GAP technique to implant semibonded prostheses. In revisions the previous approach is always followed. From 2000 to 2003 52 LCCK Zimmer were implanted. Tuberosity detachment was required in 20 cases.
The increase in TKS was significant.: from 40 to 180. The radiographic alignment supported by taproots centrage is excellent, and there are no signs of radiographical mobilisation in any of the cases.
There were two cases of intolerance, with decubitus of a screw utilised for the tibial tuberosity synthesis. A flexion-extension defect had to be repaired afterwards by surgery and two cases of endostal reaction to the tibial taproot were observed.
Despite the difficulty of treated cases, results appear promising; the combination between prosthesis type and GAP technique confers high stability to the system.
Torsional changes in the lower limbs represent a serious clinical problem. The evaluation of the physiological development of the relationship between femur and tibia in the axial plane is necessary for final assessment.
The authors observed 940 patients aged from 4 to 15 years to identify the most important modifications of torsion of the lower limbs during paediatric age. Clinical examination includes assessment in the standing and supine position and observation of the gait features so that the physiological-pathological borderline can be defined, along with peculiar aspects of single and combined deformities, in order to identify indications for osteotomy.
The types of torsion are classified as: (1) isolated augmentation of femoral anteversion; (2) isolated reduction of femoral anteversion; (3) isolated medial tibial torsion; (4) isolated lateral tibial torsion; and (5) combined torsion (femoral anteversion combined with lateral tibial torsion).
The anatomy and the natural progression of femoral and tibial torsion can be assessed by clinical methods. Radiographic methods such as axial CT views are indicated in cases in which clinical examination does not provide clear information and, in particular, if qualitative and quantitative diagnosis is required in order to establish the therapeutic protocol.
The authors conclude by suggesting that the physiological development of torsion should be followed up to skeletal maturity in order to make a general evaluation and to decide on treatment.
The first proposal of high tibial osteotomy to align a varus knee caused by osteoarthritis was ascribed to Steindler in the 1940. The technique was followed by many surgeons because it re-established the load equilibrium in the medial and lateral compartment, reduced the progression of the osteoarthritis and improved the clinical symptoms.
However, as a result of the quick spread of total knee replacement and unicondylar arthroplasty this corrective operation was forgotten. In recent years osteotomies were resumed for two main reasons: (a) the increased diagnosis of knee osteoarthritis in patients of middle age; and (b) the improvement of the technique and improvement of long-term results.
The authors analysed the literature regarding the main techniques utilised in the correction of the axial and torsional deformities of osteoarthritic knee (linear or cuneiform osteotomies). The results of these various methods are similar. This could be due to the importance of common biological effects (early and late) related to the mechanical effect however it is obtained. In conclusion, the authors suggest that osteotomy must be resumed and applied with revised indications (patients in so-called middle age and unicondylar osteoarthritic knee).
Tissue engineering in the treatment of cartilage lesions utilises chondrocytes or mesenchymal stem cells (MSCs) seeded on tridimensional scaffolds. These methods are associated with high costs and two surgical procedures. Aim of this study was to evaluate the healing process of osteochondral lesions treated by drilling (in order to permit the migration of MSCs) and collagen membrane implant (to facilitate cell proliferation and differentiation).
Bilateral ostechondral lesions of the knee were induced in 24 sheep: two lesions 5 mm in diameter at the femoral condyle and two at the throclear groove in each knee. The lesions were treated as follows: drilling and typeI/II collagen membrane implant. Control lesions were treated by drilling alone. Macroscopic, histoimmunohistochemical and histomorphometric analyses were performed at 1, 6 and 12 months after operation.
The treated lesions were repaired with a hyaline-like tissue at 12 months, in comparison to control lesions which showed incomplete filling with fibrous tissue.
The use of collagen membranes covering articular defects avoids cell dispersion and maintains the necessary tissue permeability. Chondrocytes or MSCs seeded on these membranes proliferate and express differentiated phenotypes. The present study showed in an experimental model that drilling and collagen membrane implant represents a surgical approach to osteochondral lesions which produces a hyaline-like scar tissue.
The Q angle is defined as the angle formed by a line passing from the anterior-superior iliac spine and the centre of the patella and another line passing this point to the centre of the tibial tuberosity. Normal values reported in the literature for the Q angle widely range between 12.7° (± 0.72°) and 18.8° (± 4.7°). This variability depends on individual anatomical variations and method of measurement as well. In fact, several factors can affect the measurement of Q angle. The correct evaluation is carried out with a goniometer, in supine position and the knee in full extension. Q angle evaluation can be biased by standing position and quadriceps contraction, which can increase the Q angle; in contrast, knee flexion can reduce it. Furthermore, it has been demonstrated that the Q angle increases from external to internal rotation of the tibia, while it decreases from pronation to supination of the foot. Finally, patellar malalignment in the horizontal plane, such as subluxation or dislocation, causes a decrease in the Q angle, as the centre of the patella is laterally shifted. The accuracy of Q angle measurement can be also affected by an error in identifying the anatomical landmarks. An error in Q angle measurement below 5° requires an error in setting the anatomical landmarks of no greater than 2 mm. Several authors have shown that the Q angle is greater in females, as the proximal landmarks are more lateral and a greater valgus alignment is necessary to reestablish a correct mechanical axis of the limb. According to the side, there is no evidence that Q angle is symmetric.
The clinical significance of the Q angle is controversial. An increased Q angle was considered for a long time as the main cause of anterior knee pain and an important risk factor for patella subluxation or dislocation. Some authors showed a correlation between Q angle increase and symptomatic patellar chondromalacia. However, others showed no significant differences in Q angle values between symptomatic and asymptomatic patients. Presently, there is not sufficient clinical evidence that an increased Q angle predisposes to knee problems. Furthermore, it is impossible to assert that all the alterations of the extensor mechanism are exclusively due to an increase in the Q angle, as they can depend on other factors, such as: functional overloading of the knee, muscle and ligament insufficiency, bone and chondral morphological changes, malalignment or asymmetric length of the inferior limbs and foot alterations.
In conclusion, a homogeneous method of measurement and correct data interpretation are necessary to clarify the conundrum of Q angle. Moreover, it is important to understand that patellofemoral malalignment is not always the cause of knee pain and instability. This can reduce the risk of performing surgical procedures of extensor mechanism realignment that are technically perfect but potentially harmful.
In recent years, the use of computed tomography (CT) has made it possible to obtain without distortion images of axial sections of the patella with the knee in the first 15°–20° of flexion.
We performed CT examinations on 27 patients aged between 11 and 17 years. We considered patients who had anterior knee pain with or without a feeling of patellar instability. CT examinations were performed with the knee flexed to 15° with and without quadriceps contraction. The tomograms obtained were analysed considering: (1) the congruence angle (CA), (2) the patellar tilt angle (PTA), (3) the sulcus angle (SA) and (4) trochlear depth (TD). We performed CT examinations on a control group of 20 patients aged between 11 to 17 years. Statistical analysis was performed by using the analysis of variation (ANOVA) test or the Student’s t-test on paired or unpaired data.
The difference between control knees and symptomatic knees was significant for all of the CT variables (unpaired t-test). Malalignment detected with the quadriceps relaxed was typed according to the classification of Schutzer et al. as follows: type I – lateralised patella, 13 knees (24.1%); type II – lateralised and tilted patella, 24 knees (44.4%); and type III – tilted patella, 12 knees (22.2%). In 26 knees (48.2%), CT examination with quadriceps in contraction gave the same findings as CT examination with the quadriceps relaxed, i.e. type and severity of malalignment were identical. In the remaining 28 knees (51.8%), CT examination with the quadriceps in contraction gave different results from the CT examination with the quadriceps relaxed.
The greater sensitivity and specificity of CT as compared with conventional radiographic methods in the diagnosis of patellofemoral malalignment have been demonstrated. Our results show that there is a relationship between clinical findings and CT data. CT assessment with the quadriceps relaxed permitted us to divide the knees into three types of patellofemoral malalignment. To our knowledge, not many studies have been performed with the quadriceps contracted. In the present study, in 48.2% of knees there were no differences between CT assessment with the quadriceps relaxed and with the quadriceps contracted in either type or severity of malalignment. In contrast, in the remaining 51.8% of symptomatic knees we found differences.
Before planning an operation in patients with anterior knee pain with or without patellar instability, CT assessment both with the quadriceps relaxed and contracted permits a reliable documentation of malalignment, permitting the surgeon to select the optimal treatment.
Large bone defect repair has always presented a difficult treatment problem. Marrow-derived osteogenic progenitor cells combined with hydroxyapatite (HA) were used for segmental bone reconstruction. The validity of this model has been shown for the repair of bone defects of critical size in large animal models. We used this cell-based therapeutic approach to treat three patients with large bone defects.
The patients were 41, 22 and 16 years old and had large tibial, ulnar and humeral diaphyseal gaps that ranged in size from 3.0 to 28.3 cm3. Marrow samples were harvested from the iliac crest and osteogenic progenitors isolated and expanded “ex vivo”. The expanded cells were then combined with a highly macroporous bioceramic scaffold whose size and shape reflected each individual bony defect. The cell/bioceramic composites were implanted at the lesion sites. External fixation was used to stabilise the grafts.
At present all patients have been followed up for 4–5 years. Already after the first month after surgery an initial integration at the bone/implant interface was evident. Bone formation in the implants, assessed by X-ray, progressed steadily in the follow-up period. Two patients achieved full functional recovery at 6 months after surgery, one patient at 12 months after surgery. The present report shows that large segmental bone reconstruction can be achieved in humans using osteoprogenitor cells. This technique can be improved by a more biodegradable and more biomechanically resistant scaffold use.
Autologous chondrocyte transplantation has become a possible solution for the treatment of chondral knee lesions. Recently an autologous tissue engineered cartilage (Hyalograft C), using biodegradable scaffolds for cell proliferation, was successfully developed. In osteochondritis dissecans (OCD) the lesion also involves subchondral bone. For this reason we began to use a two-step technique: arthroscopic autologous bone grafting followed by autologouos condrocyte Hyalograft C transplantation after 4–6 months. We treated five patients affected by OCD.
All the patients were clinically evaluated and analysed according to the International Repair Cartilage Society score at 12 and 24 months. The ICRS score showed highly satisfactory clinical results in all treated patients at 12 and 24 months; CT and MRI evaluation had demonstrated a good articular surface reconstruction with complete bone defect restoration at a short 12-month follow-up period. The autologous chondrocyte transplantation provides highly satisfactory clinical results.
This second-generation autologous tissue-engineered cartilage transplantation avoids the use of periosteal flap, simplifies the surgical procedure and permits use of an arthroscopic approach. In association with autologous bone grafting, bone loss can also be restored in order to recreate a perfect articular surface. The preliminary clinical and histological results are encouraging but longer follow-up is required to better evaluate this technique.
There can be no doubt that bone morphogenetic proteins play a hierarchic role in the osteogenetic cascade. Pre-clinical and clinical trials have confirmed their decisive role in achieving anterior lumbar fusion, as they direct mesenchymal stem cells toward osteoblastic lineages.The present study is concerned with initial experience in the application of autologous mesen-chymal stem cells and various growth factors (BMP-7,VEGF,TGFbeta) in the treatment of paediatric spinal pathologies.
Eleven patients affected by serious forms of congenital infantile scoliosis, idiopathic scoliosis and grade I spondylolisthesis received surgical treatment. In three patients with congenital infantile scoliosis, ages ranging from 3 to 12 years, the surgical procedure was an anterior and posterior fusion at the level of the hemiver-tebra, extending it to a level above and below it by means of in situ decortication of the vertebral plates and laminae on the convex side and delivery of stem cells taken from the iliac bone and applied in situ by means of bovine collagen sponge (Healos system). No fixation device was added. Plaster and brace were used during the postoperative course for 9 months. In two cases of intertransverse in situ fusion for grade I spondylolisthesis the age of the patients was 13 and 16 years, respectively, and the surgical procedure consisted in the standard technique to which was added delivery of a mixture composed of small bone chips obtained from decortication, 3.5 mg of eptotermin alpha (Op-1, BMP7), and autologous stem cells taken from iliac bone. A special form of informed consent was obtained for these two patients because of their incomplete bone maturity. TLSO was used in the postoperative course for 2 months. In the six patients with idiopathic scoliosis, ages ranged from 13 to 15 years and the treatment consisted in posterior instrumentation and fusion by means of rods, transpedicular screws and hooks; standard fusion techniques were supported by local bone chips obtained from decortication, placed on collagen sponges and combined with autologous stem cells taken from iliac bone with the addition of platelet gel derived from the autologous preoperative blood collection. No bone chips were taken from iliac wing. The results were evaluated by X-rays and CT at intervals of 1, 2, 4, 6 and 12 months.
In the cases of congenital scoliosis a solid fusion area was obtained only for posterior hemiephysiodesis, without a parallel bone signal of fusion at the anterior level. In the cases of intertransverse in situ fusions for spondy-lolisthesis there was a beginning fusion already visible on the first X-ray control 1 month postopoeratively, confirmed at successive check-ups and maintained in the follow-up. The cases of idiopathic scoliosis showed an initial ossification of the grafts and signals of fusion at the 6-month check-up.
The isolated use of stem cells, although promising from a theoretical point of view, did not prove encouraging in the cases of anterior fusion. It is most probable that the absence of instrumentation induced a defect in the stable fixation of the fused segments, the latter being a crucial factor.The cases of in situ fusion for spondylolisthesis confirm the hierarchic role of the bone morphogenetic protein 7 in inducing the mesenchymal stem cells, released in situ from decortication, toward osteoblastic lineage. To our knowledge these represent the first two cases of use of OP-1 in patients younger than 18 years. In the fusion areas which are more extensive in length (idiopathic scoliosis) the added use of autologous stem cells mixed with platelet gel seems to improve the physiological processes of fusion. It will be necessary to monitor the long-term results of these procedures with special regard to loss of correction and weakness of the fusion area causing torsional or flexion-extension stress. These possible costs have to be compared with the verified benefits of a better use of blood in its capacity to save on corresponding haemotransfusion, combined with the absence of comorbidity related to the donor site of iliac bone chips.
A tissue engineering-based approach has become a possible solution for the treatment of chondral lesions. Actually, autologous chondrocytes seeded on biodegradable scaffolds for cell proliferation were successfully developed. However, these techniques promote cartilaginous but not bony regeneration. Therefore a new experimental approach involving mesenchymal stem cells (MSC) has been introduced.
A 31-year-old man affected by massive osteonecrosis of the right femoral head was selected to begin this study. The MSC were isolated from the bone marrow harvested from the patient’s iliac crest. After a 3-week monolayer expansion, cells were seeded and cultured onto hyaluronan-based three-dimensional scaffolds and DBM spongy chips, used to regenerate the cartilaginous and the bony portion, respectively. After a 2-week cultivation, constructs were implanted inside the osteochondral defect using the transtrochanteric approach under arthroscopic control. The patient underwent clinical, X-ray and MRI control during the first 6 months after operation.
Pluripotent MSC may be a promising strategy for osteochondral defect reconstruction due to their capacity to differentiate in vivo along chondrocytic and osteoblastic lineages. This ability, combined with two different kinds of three-dimensional scaffolds, permits simultaneous bone and cartilage tissue regeneration. The preliminary results are encouraging but a more precise judgement of the effectiveness of this method requires longer follow-up.
In patients younger than 60 years, high tibial osteotomy (HTO) is a satisfactory therapy for varus gonarthrosis. HTO may afford young patients substantial relief of pain and does not restrict activity. However, the indication for HTO is currently under discussion due to the fact that closing (CWO) and opening (OWO) wedge osteotomy produce opposite changes in patellar height and inclination of the proximal tibial articular surface. Consequently this can possibly affect outcome of knee surgery.
The aim of this study was to compare the variations both in patellar height and inclination of the proximal tibial plateau produced by the two more common proximal tibial osteotomy techniques. We analysed 60 patients with unicompartmental osteoarthitis and angular deformity of the knee divided into two groups: group 1 (30 patients) treated with CWO using a plate VCO and group 2 (30 patients) treated with OWO using Puddus’s plate. Patients were comparable in age, gender and knee deformity. Patellar height was evaluated by Caton’s method. The inclination of the proximal tibial plateau was measured as the angle between the articular surface and the lateral longitudinal axis of the tibia.
Patellar height before CWO surgery was 0.98 ± 0.128, after surgery 1.01± 0.195. Patellar height before OWO surgery was 0.99 ± 0.134, after surgery 0.91± 0.125. Posterior tibial inclination before CWO surgery of was 7.5° ± 4°, after surgery 3.5° ± 5°. Posterior tibial inclination before OWO surgery was 7.5° ± 4°, after surgery 8° ± 5°. Unexpectedly, CWO did not modify, wheras OWO significantly decreased the height of the patella. The inclination of the proximal tibial plateau increased after OWO, but decreased after CWO. Lack of variation in patellar height after CWO could be explained by fibrosis and patellar ligament contracture, whereas in OWO, the decreased distance between patella and tibio-femoral joint line was derived from joint line elevation.
Following a tibial osteotomy both the height of the patella after OWO or the reduced inclination of the proximal tibial plateau may have deleterious consequences for patellofemoral biomechanics and complicate subsequent total knee arthroplasty.
Osteoporosis is an underdiagnosed and often neglected disease, with a huge impact on social costs arising from fracture management that could be avoided with an appropriate prevention programme. The approach to diagnosis is not always efficacious and cost-optimised, often suggesting instrumental densitometry in a somehow irrational way.
The objective of this study is to evaluate the introduction and use of a simple score system, in order to optimise the access to instrumental diagnosis with quantitative ultrasound (QUS) densitometric technique for those patients at risk.
We used the OSIRIS score system questionnaire in order to have a simple tool to manage the osteoporosis screening of patients in our centre from January to December 2003 (more than 2000 patients in total). The score risk derived for each patient was used to recommend the instrumental densitometric measurement (heel QUS) and the need for vertebral X-ray scan and morphometric evaluation. In a further analysis on a more limited number of patients, we searched for correlations between densitometry with other score systems (O.R.A.I.,N.O.F.,S.C.O.R.E.,A.B.O.N.E.) and with pre-existing fragility fractures (vertebral and non-vertebral).
Our data suggest that a correlation exists between OSIRIS score risk and heel QUS densitometric T-score, suggesting the usefulness and validity of such a score system in order to optimise the access to instrumental diagnosis of osteoporosis.
Tibial and femoral deformities might cause patellofemoral problems, but they do not have to be modified every time to obtain good results. We have evaluated external tibial rotation characterised by an external tibial deformity in varus, worsening in parallel feet position. In these patients the only surgical treatment is tibial osteotomy, justified by a positive effect on the knee joint mechanics. From 1990 to 2002 we performed 25 derotation tibial osteotomies as an isolated procedure or associated with a closed wedge osteotomy. We reviewed 15 patients (16–28 years old at surgery) with special reference to pain, aesthetic criteria and functional assessments, and we reported possible negative effects of derotation (recurvation and external tibial rotation). In all the patients we found an external rotation higher than standard range and moderate varus. All patients had remission of pain; this was complete in five and partial in six. Ten patients showed an increased tibial rotation and eight of those showed even recurvation without functional sequelae. At 2–12 years of follow-up, our results are satisfactory.
In order to improve hydroxyapatite (Ha) quality as a bone substitute, two types of Ha were developed based on a new and original technique: Ha with graduated porosity (G-Ha) and porous “carbonated” Ha (C-Ha). Ha cylinders were implanted into the femoral diaphysis of NZW rabbits. Before implantation the materials were characterised by XRD, porosimetry, SEM and thermic and mechanical analysis. Macroscopic, radiographic and histologic analysis were performed on the specimens at standard intervals after surgery (1-3-6- and 12 months).
G-Ha proved to be morphologically more similar to bone tissue because of the graduated porosity that mimes the two natural components of bone (cortical-scarce porosity and spongious-high porosity). The C-Ha was chemically more similar to bone because of the CO3- substitution, which is a normal substitute in natural bone.
Both materials achieved good mechanical strength, in particular the pseudo-cortical portion of G-Ha. Interconnected porosity was also observed in both materials. Newly formed bone appeared earlier in C-Ha (1–3 months). At 1 year C-Ha demonstrated quiescent bone and significant degradation. The G-Ha was scarcely reabsorbed but showed active osteogenesis in the surrounding living bone. Graduated porosity improved the mechanical interaction with bone over time, while the carbonation improved the temporal interaction and Ha resorption.
Porous Ha was found to be a promising bone substitute and also a reliable drug-delivery carrier.
Congenital or acquired recurvatum genu might be caused by bone and/or soft tissue disorders. In bone recurvation, tibial deformity is more common; femoral deformity has clinical and X-ray features that are less important and often unidentified. We found this type of deformity in only four of 40 cases of bone recurvation.
Bone recurvation can follow a tibial or femoral fracture as well as injury with no X-ray signs. Some months later an anterior epiphysiolisis might be recognised on X-ray. This fact allows a retrospective diagnosis of fifth type Salter-Harris epiphysiolisis. Clinically a harmonious recurvatum genu would be recognised, which is difficult to distinguish from a capsulo-ligamentous disorder.
According to a subjective profile, it is featured with no objective laxity. On X-rays there are no peculiarities in the anterior view, but on the lateral view femoral condylar flattening with anterior rotation, in particular in the lateral one, can be observed. It might be useful to compare the X-ray findings to define a geometrical point termed the femoral diaphysealintercondylar angle. This has been already described and is measured between two lines, one which represents the axes of the femoral shaft, the other one the Blumensaat line; in a normal knee this angle measures 33° (±3). In knees with femoral recurvation this is higher: in our four patients the range of the angle was 45°–58°.
Procurving femoral osteotomy is the gold standard; in fact femoral closed wedge osteotomy allows a complete correction. Surgeons must avoid an overcorrection with subsequent femoral trochlear rotation and at the same time a tibial osteotomy must be avoided, which would lead to a double articular deformity, wherever it would fit with a capsulo-ligamentous recurvation.
The aim of hip revison surgery is to restore biomechanical parameters: rotation centre, muscle arm lever and leg length; homologous bone grafting is often necessary. It is possible to bioenhance grafts, resulting in better osteointegration speed and quality. We propose the use of our platelet gel protocol. Care was given to assess the cost-benefit rate of the method. We performed densitometric analysis of homologous bioenhanced grafts vs homologous grafts, with a specific acetabular bone loss indication, randomising two groups of patients (rct study). The “intention to treat” was to decide the benefit of the method in order to extend use to all patients. Densitometric analysis was implemented with radiographic analysis using a modified Cook’s scale. We used clinical scores, too. The clinical and plain radiographic results did not differ significantly between the two groups or with our historical group (7 years/23 implants, already published). The synthesis of all instruments used indicates that the use of bioenhanced bone is promising for enhanced osteointegration; however, the study group must be extended and observed for a longer time to achieve appropriate study power.
In the last few years the number of women who practise sport activities has substantially increased and this has led to an increase in the incidence of ACL tear in females. The aim of this study is to assess outcome differences at a minimum 3-year follow-up after ACL reconstruction in women using either a patellar tendon (BPTB) or a quadrupled-looped hamstring (DSTG) autograft fixed with modern devices.
Fifty women with a chronic, isolated ACL tear were randomised to receive a DSTG or BPTB graft for ACL reconstruction. Both groups were comparable as to age, injury-surgery, activity level, meniscal tears, surgical technique and reabilitation. All patients were prospectively evaluated by an independent observer using the IKDC form, the FKSAKP Score, the KT-1000 arthrometer and the Cybex NORM dynamometer. A radiographic study was performed to investigate tunnel widening.
All but two patients were satisfied with the reconstruction. The average side-to-side difference in anterior tibial translation was 2.4 mm in the BPTB group and 2.5 mm in the DSTG group. The final result was A (normal knee) in 56% and in 60% of the BPTB and the DSTG knees, respectively. A failure (4%) was present in each group. Muscle strength deficits at 60°/s, 120°/s and 180°/s were within 10% for extensors and within 5% for flex-ors in both groups. No statistically significant differences were found in terms of subjective satisfaction, objective evaluation, knee stability and muscle strength recovery. The BPTB group showed a higher incidence of postoperative kneeling discomfort (p< 0.05) and a larger area of decreased skin sensitivity (p< 0.001). The DSTG group showed a higher incidence of femoral tunnel widening (p=0.02).
Using strong and stiff fixation devices, ACL reconstruction in women is not influenced by the graft choice.
Recurvatum genu can develop as a results of both chronic diseases “maladie des enfants alités” (Lefort), though rarely, and after trauma, which occurs more often. Surgical treatment might consist either in a de-epiphysiodesis according to Langenskield, when a bone bridge is present, or by Ilizarov technique, which allows a correction of segmentary shortening.
This kind of trauma often occurs after bone growth has ceased and this is why in our study we performed osteotomies. Femoral osteotomies are all closed wedge procedures with medial access and 90° angle blade-plate fixation. This allows early mobilisation and avoids overcorrection. Without performing this kind of procedure posteriorisation of the trochlea might occur and, consequently, over time, patellofemoral arthritis could develop. For the tibia we applied an anterior open wedge osteotomy with ATT avulsion, according to Lecuire, with which secondary low patella can be avoided. As fixation we first used screws, actually a plate to correct the co-existing valgus.
The good results of this kind of surgery justify autologus bone graft. We have not employed the the procedure described by Bowen.
Mechanical methods of deep vein thrombosis (DVT) prophylaxis rely on the prevention of venous stasis – one of Virchow’s triad of cause of DVT. Mechanical methods, such as the A-V Impulse System (Orthofix Vascular Novamedix, Andover, UK) are used widely in orthopaedic surgery for the prevention of DVT, especially after elective orthopaedics.
The evidence for the use of the A-V Impulse System in elective orthopaedics is widely accepted and is considered a Grade A Recommendation by the International Consensus Statement. These data are reviewed and critiqued.
More recent studies show how mechanical methods can offer benefits to the patient outside of hip and knee replacement surgery. Data are presented on how such devices can effectively reduce swelling, DVT, compartment pressure and pain associated with trauma, based on over 20 years of practical experience. The practical implications of using these devices is discussed.
Alumina and zirconia are known for their general chemical inertness and hardness. These properties are exploited for implant purposes, where they are used as an articulating surface in hip and knee joints. Their ability to be polished to a high surface finish make them an ideal candidate for such wear applications, where they compete against materials such as ultra-high-molecular-weight polyethylene.
Alumina is a highly inert material and resistant to most corrosive environments. The term high alumina ceramics refersr to materials that have a minimal content of 97% of alumina. If there is a 99% minimal percentage of alumina it is called high purity alumina ceramics. In its _ phase (more famous than corundum), characterised by its particular structure and stability, high purity alumina has been being used in orthopaedics since 1970, in the articulations of the hip prostheses.
BIOLOX®forte (commercially available since 1994) is high purity alumina (ca 99.7 %) with a small percentage of magnesium oxide (MgO). Approximately 50 years ago, MgO was introduced during the sintering phase of alumina because it was discovered that a small amount of this additive prevented the increase in grains of alumina during the sintering process. It was therefore possible to have a more homogenous and dense microstructure; both characteristics directly correlated with the mechanical resistance. The suffix forte derives from the increased mechanical characteristic and continuous optimisation of the fabrication technology.
One of the main factors involved in wear reduction is the characteristic molecular structure of alumina. Its superficial layer is composed of oxygen atoms that create a residual electric power which interacts with polarized molecules of the lubricant, tying it to the surface by strong Van der Waals ties. Therefore the presence of a fluid film that reduces the coefficient of clutch between the two surfaces involved during the articulation is guaranteed.
The colour of alumina components varies. Originally it is ivory, but it can easily become brown after sterilization with gamma beams that interact with the free valences introduced by the MgO. This change in colour does not change the mechanical characteristics. Currently the systems are completely modular and allow a wide choice of couplings. In 1984 and subsequently in 1995, the introduction of ISO norms for the production of ceramics ball-heads and inserts and the concept of conical fixation has provided higher reliability.
Today, the alumina BIOLOX®forte components are prepared in clean-rooms, sintered with high quality control processes, laser marked and accurately inspected and tested. The tolerances between ceramics (ball-heads and inserts) and metallic parts (taper and metal shell) are fundamental for increasing implant reliability. It is important to control and validate the stems and cups which the ceramic parts are applied on. Correct assembly and the respect of the compatibilities between parts (angle, material, producer) guarantee the longevity of the implants.
Actually, in the orthopaedic field, alumina is mainly used in standard applications of hip prostheses. Ball-heads of 22 mm in diameter, lengths of neck type XL, and the knee prostheses are not possible because the mechanical characteristics of alumina do not allow for the elevated stress values requested for these special applications.
Between 1975 and 1977, it was discovered that the strength and toughness of alumina could endure a remarkable increment by developing composites with oxide of zirconium (zirconia). In zirconia, during the phase of cooling from temperatures over 1170°C, the grains go through a change of phase (from tetragonal to monoclica), with an increase of 3% of volume. At ambient temperatures the monoclica phase is stable. This transformation is martensitic, with energy absorption, and involves a heat-proof change of the symmetry of the structure. In the case of dispersed grains of zirconia in the alumina matrix, the transformation absorbs the energy of the crack and the strength of the ceramics increases. With the use of yttria (Y2O3) to stabilise the zirconia the problem of the structure defects can be resolved.
A percentage of zirconia stabilized with yttria (Y-TZP) was introduced in the alumina matrix and other mixed oxides to counterbalance the reduction of the hardness caused by particles of zirconia and to create lengthened particles during the sintering.
All these studies have been used to create the new ceramic BIOLOX®delta. Tests of biocompatibility in agreement with norms EN 30993 have been carried out, so that implants can be made of these new composite ceramics.
Since 1970, more than 3,500,000 ball-heads and 350,000 inserts of alumina BIOLOX® have been implanted. Owing to the grain size, currently reduced to values under 2 μm, the value of the mechanical resistance has been raised to about 580 MPa. The increase in the mechanical characteristics, the new shapes and the conical fixation have reduced the risk of fracture of the BIOLOX®forte ball-heads and inserts to around 0.01% (Ø28 mm), maintaining the excellent tribology and wear characteristics. Many laboratory tests and clinical cases have shown that the wear rate of the alumina-alumina bearing complex is extremely low (0.001 mm/year). If compared with metal-polyethylene (0.2 mm/year) it shows a drastic reduction of particles of debris and therefore of the osteolysis problem
BIOLOX®delta has a bending strength of around 1000 MPa, which is more than double that of the alumina ISO (400 MPa). In the minimum fracture load test, ball-heads of 28 mm Ø millimeter (neck L) have achieved values of around 100 KN, well beyond the 46 KN requested by the FDA. Multiple cycles of sterilisation in autoclaves have demonstrated that the the mechanical and tribological characteristics of BIOLOX®delta are not altered.
On the basis of these results, BIOLOX®forte can be considered a reliable alternative to other materials in standard applications and the new alumina composite BIOLOX®delta will allow the realization of medical ceramics devices, already in the study phase, such as knee prosthesis, 22-mm ball-heads and thinner wall-thickness of inserts, which could not be developed up to now with the available ceramic materials.
One hundred-one knees with medial compartmental osteoarthrosis were treated by unicompartmental arthroplasty with the Oxford Knee. The strict selection criteria were: (1) the presence of functioning anterior cruciate ligament, (2) correctable deformity and (3) full thickness of articular cartilage in the lateral compartment. The mean elapsed time from surgery was 28 months. One knee required revision for a loose tibial component; one had meniscal bearing dislplacement 1 month after the operation and was revised succesfully by replacing the meniscal implant with a thicker one. One implant was revised to a tricompartmental prosthesis.
The femoral component has a spherical articular surface. The meniscal bearing is made of high-density polyethylene and is concave superiorly and flat inferiorly to fit exactly the metal femoral and tibial components. The meniscal bearing is not attached to either metal component but is held in place by its reciprocal shape and the tension in the ligaments. The bearing, which is avaliable in nine thicknesses, is inserted after the metal components have been fixed, allowing the ligaments to be restored to their physiologic tension.
No femoral component was radiographically loose. Loosening was observed in two cases only in the tibial component. There were radiolucent lines more than 2 mm thick around two other tibial components, involving less than 15% of the component’s surface in each case. In none of these cases was the leg misaligned. There was no radiographic evidence of disease progression in the lateral compartment of any joint and the Ahlback grades remained unchanged.
All the patients were evaluated 2 years after surgery according to the Oxford Knee Score. Our scores ranged from 40 to 48.
In our opinion medial unicompartmental arthroplasty is the appropriate treatment in approximately one third of patients undergoing surgery for osteoarthrosis of the knee. Key point of this operation is: the surgical technique is less invasive and preserves all the structures of the knee so that a short patient recovery time is allowed. Furthermore, unicompartmental implants cost less than tricompartmental prostheses and revision surgery is relatively easy if performed early and before extensive bone erosion has occurred.
Pain is the main symptom of acetabular osteolysis and is frequently associated with pathologic fractures. Surgical procedures requiring an aggressive approach, and as a consequence high morbidity, are rarely indicated. The minimally invasive approach may be effective in treating tumours and is capable of reducing the mechanical pain. PMMA has been widely used in neoplastic and spinal surgery as a bone filler because of its mechanical and biologic behaviours. Recently percutaneous injection of PMMA was proposed for the treatment of neoplastic acetabular osteolysis.
The technique was tested in four patients affected by secondary ostheolytic lesions. The patients were evaluated clinically (HHS, Womac, SF-12) and radiographically (X-ray and CT) at 18 months.
All the patients demonstrated a durable and significant improvement in terms of pain and restoration of function. The radiographic examinations (X-ray and CT) confirm these results. Complications (temporary increase in pain and fever) were only observed in one patient.
The preliminary results demonstrate the reliability and effectiveness of this procedure. Clinical results showed a significant reduction in pain and the capability of restoring function. The indications can be extended also to the acetabular lesion at a distance from the weight-bearing zone, reducing pain and the risk of pathologic fractures.
The technique was demonstrated to be effective and showed only minor and self-resolving complications. It is useful in patients in whom major surgery is contraindicated and clinical improvement is necessary to improve the quality of life.
Arthoscopic biopsy provides adequate tissue for most diagnostic requirements. Examination of endoarticular tissue can assist in the diagnosis of some joint infections; sometimes cultures of synovial tissue may be positive even when blood and synovial fluid cultures have been negative. In chronic infections such as tuberculosis and fungal disease, and characteristic synovial lesions, such as granuloma, it may be advised. Both gout and pseudo-gout can demonstrate tophus-like deposits in synovial tissue. Synovial biopsy can have a major role in the diagnosis of synthetic arthritis after ACL reconstruction with synthetic ligaments to identify a foreign body granulomatous reaction to particulate material implant or to verify the arthroplasty effect after loosening of a knee prosthesis.
There is a lack of association between arthroscopic findings and clinical laboratory and radiological features of arthritis. The general diagnosis of rheumatoid arthritis (RA) is usually based on characteristic clinical, radiological and serological manifestations. Synovial biopsy in RA is not normally required for diagnosis because the appearance is not specific, but it may provide important prognostic information. Synovial chondromatosis and pigmented villonodular synovitis are tumours of the synovial membrane that require biopsy for diagnosis. The biopsy of articular cartilage is useful to evaluate the capacity of chondrocytes to proliferate and to test the regeneration of cartilage after resurfacing by autologous chondrocytes implantation or other techniques. Histological confirmation could improve the prognosis of the knee during arthrofibrosis (percentage of elastic fibres), fibrosis of Hoffa disease and cyclop lesion. Another application is study of ligamentisation phenomena after anterior cruciate reconstruction and the presence in osteoarthritic knees with degenerative changes in posterior cruciate ligament.
The management of infected total hip replacements is a challenging problem in orthopaedic surgery. Two-stage revision procedures usually involve the application of a temporary antibiotic-loaded polymethylmethacrylate spacer. A preformed spacer which allows weight-bearing and joint motion while ensuring a sustained antibiotic release was evaluated.
From September 1996 to March 2002, 26 consecutive patients with an infected total hip arthroplasty were treated by the insertion of an industrially preformed temporary spacer (Spacer-G®). This device comprises a cylindrical stainless-steel rod coated with bone cement supplemented with gentamicin (1.9% w/w) and vancomycin (2.5% w/w). The spacer is currently available in three sizes of head diameter, each size with two stem lengths. Joint mobilisation and assisted weight-bearing were permitted when the bone stock provided adequate mechanical stability of the spacer. Patients’ evaluation included clinical assessment and standard X-ray and laboratory parameters. Reimplantation was performed when serological parameters had normalised.
The spacer remained in situ for an average of 155 (70–272) days, allowing healing of the infection in 24 cases. Five patients required resection arthroplasty (two persistent infections, two inadequate local bone conditions and one acute recurrence of infection). A second spacer was implanted after 4 months in one subject. In four cases the spacer dislocated, because the head diameter was too small or because of a rotational instability of the stem in the femur. The successfully-reimplanted patients (21) were assessed with a mean 53 (22–88) months of follow-up, showing no clinical or bio-humoral signs of infection recurrence. Functional outcome was satisfactory with a mean value of Harris Hip Score of 79 (53–100), and no radiographic aspects of loosening were observed.
The Spacer-G® used in the two-stage revision of infected total hip replacements permitted an effective local antibiotic release together with some range of joint motion, which improved the quality of life of the patients during treatment of infection and accelerated recovery of function after reimplantation.
Implantation of metatarso-phalangeal prostheses or spacers has been widely indicated for the replacement of the articular surfaces in severe hallux rigidus. Giannini proposed a reabsorbable device in poly(D-L-lactic acid) (PDLLA) which is dome-shaped with a stem for implantation into the first metatarsal, avoiding any resection of the base of the proximal phalanx.
The rationale for the reabsorbable spacer is to maintain the distance between the articular surfaces for a predictable time and to provide a sliding surface suitable for articulation with the proximal phalanx. It is then reabsorbed by fragmentation and replaced by fibrous tissue, which maintains the articular space, allows motion and relieves pain.
Twenty-three reabsorbable spacers have been inserted for severe hallux rigidus in 20 patients aged from 26 to 76 years (average 58). Patients were reviewed with a follow-up ranging between 24 and 50 months (average 36). The results were assessed using the American Orthopaedic Foot and Ankle Society (A.O.F.A.S), hallux-metata-tarsophalangeal-interphalangeal scale. Anteroposterior and lateral weight-bearing X-rays were made preoperatively and at follow-up, evaluating the dimensions of the articular space and the length of the first metatarsal. The chronology of device reabsorption was studied in 10 patients with M.R.I., assessing complete reabsorption within 4 months of the operation.
Excellent and good results were obtained in 91% of patients. The A.O.F.A.S. score was 43.7±20.6 pre-operatively and 82±10.3 post-operatively. The reabsorbable spacer confirmed the expectations of its supporters. This procedure would appear to be an alternative to arthrodesis of the first metatarso-phalangeal joint or traditional permanent implants and represents an intermediate technique between an implant and resection arthroplasty.
In the period from 1999 to 2003 bacterial contamination of explanted cadaver bones and tendons from the Regional Tuscan Tissue and Cell Bank was studied. During this period 1124 explants from 402 donors were taken, of which 311 donors whose heart was beating and from 91 whose heart was not beating.
The bone explantation procedure followed a standardized protocol.
Al the samples were explanted in the operation room by a team of two surgeons and a nurse during the first 24 hours after death. The protocol concerning the sterility of the explanting procedure was standardized and followed accurately. The bacteriological examination was performed immediately after the explantation and before the samples were treated with antibiotic solution. Three different tests were used: superficial microbiological swabs of the bone surface, one from the medullar canal and a small bone or soft tissue sample. The samples were inoculated immediately in culture medium and incubated for at least 10 days. From 1124 explanted samples 430 were contaminated: 99 with pathological bacteria such as Staphylococcus aureus, Enterococcus, Escherichia coli etc., 331 with nosocomial bacteria such as coagulase neg. Staphylococcus, Corynebacteria, etc. The samples that were contaminated with pathological bacteria were excluded from the study. The other contaminated group was re-processed and re-tested for contamination.
The factors influencing the results of contamination were anatomical location of the explants and the experience of the surgical team. In contrast, the donor type (heart beating vs. heart not beating) did not play any role.
From 1999 to 2003 the University Hospital of Careggi in Florence, Italy, used 721 explants from which 624 were retrieved from the Regional Tuscan Tissue and Cell Bank, 72 from foreign banks and 14 from another national bank. The explants from foreign banks were all re-tested according to our standards. Among those, 699 samples were sterile and 22 samples (3%) were contaminated. Seventeen (2.3%) of the 22 samples were contaminated with pathological bacteria with low morbidity and 5 (0.7%) with medium morbidity. Compared to the control group contamination of the explants retrieved from the Regional Tuscan Tissue and Cell Bank was 2.8%.
However, the contamination of samples of an explant is not necessarily correlated with a true infection of the specimen. This study shows that factors such as retrieval techniques, contamination factors in the operating room and laboratory mistakes can cause false-positive contamination results. In fact, only three of 604 patients who were operated in major orthopaedic procedures using bone and soft tissue allografts developed clinical evidence of infection (0.5%). In conclusion, the infection rate of our allografts in this study is not higher than the standard infection risk of any other major orthopaedic procedure (0.5%).
Distal osteotomy of the first metatarsal can be performed by a percutaneous minimally invasive procedure when indicated for the surgical treatment of hallux valgus. The intermediate-term results of percutaneous distal uniplanar osteotomy of the first metatarsal were assessed in 118 feet in 82 patients (36 bilaterally) to determine the effectiveness of the percutaneous procedure.
A modified Lamprecht – Kramer – Boesh technique was performed under distal nerve trunk anaesthesia (ankle block) without a tourniquet, using a K-wire for stabilisation of the osteotomy. No surgical approaches and no soft-tissue procedures were required. Post-operatively adhesive tape was applied and immediate weight-bearing allowed.
The patients were followed for an average of 36 months (range 24 to 78 months). Clinical assessment was based on the American Orthopaedic Foot and Ankle Society, hallux-metatarsal-phalangeal-interphalangeal (AOFAS) scale. Anteroposterior and lateral weight-bearing radiographs were performed pre- and post-operatively, and the hallux valgus angle, the first intermetatarsal angle, the distal metatarsal articular angle (DMAA) and the position of the sesamoid were recorded. The average score according to the AOFAS scale was 86.6±12.9. Patients were satisfied with the result of the procedure in 90.7% of cases. The results confirm the effectiveness of the percutaneous procedure to achieve a satisfactory distal osteotomy of the first metatarsal without the need for soft-tissue procedures in the surgical management of symptomatic hallux valgus.
The compressive stiffness of cartilage is primarlly determined by proteoglycan, whereas the tensile properties are determined by collagen fibres. The first alteration in cartilage structure during cartilage degeneration is the decrease in proteoglycan content and increase in interstitial water; consequently, cartilage becomes softer and cartilage stiffness decreases. The pupose of our study was to evaluate arthroscopically the compressive stiffness of cartilage in different areas of living human knee joints. Detection of softening is revealed in vivo by using an indentation instrument (artscan 200). The instrument is composed of a measurement rod joined to the handle; in the distal end of the rod, there is an inclined flat surface with a separate plane –ended cylindrical indenter. During measurement the distal end of the instrument is pressed against the articular surface while the indenter imposes constant deformation on the cartilage. The maximal indenter force, by which the tissue resists the constant deformation, is measured with strain gauge transducers. We performed indenter tests in knees joints in which cartilage was diagnosed as normal; stiffness of articular cartilage was also measured during arthroscopy in knees before ACL reconstruction, in knees with closed chondromalacia (ICRS grade 0–1) and in osteochondral lesions (ICRS OCD grade 1) and the data compared with areas of normal cartilage.
Nowdays bicompartmental arthritis of the knee in patients younger than 60 still remains a challenge for the orthopaedic surgeon. In these selected cases, the authors present their experience in performing a minimally invasive bi-unicompartmental knee replacement assisted by computer navigation.
From January to December 2003, the authors treated seven patients (seven knees) with bicompartmental arthritis of the knee. The mean age was 66 and in all the cases an arthritis deformity was present but with no ligament deficiency and a pain-free femur-patella joint. The Orhophilot (4.0 version) navigation system was used during the surgery to assist prosthesis placement. In all the cases a minimally invasive surgical approach was used (7- to 9-cm skin incision). The patients were assessed using a UKR dedicated outcome score (GIUM Score), pre-operatively and at the latest follow-up. Pre-operatively the mean GIUM score was 49.1 (range 26–63)
At the lastest follow-up the mean GIUM score was 80.2 (range :75–94). The average femoral-tibial angle was 179° (range 177°–181°). In all the cases a good ligament balancing was achieved using a computer-assisted spreader device. All the patients were satisfied and had returned to their previous occupation soon.
The authors underline how the computer navigation system supports ligament balancing and correct prosthesis alignment. They did not register any fracture of the tibial intercondylar eminence because of wrong balancing and incisions. They emphasise this truly minimally invasive surgical approach to the cure of knee arthritis, above all in young patients with post-traumatic deformities.
Tibial opening wedge osteotomy is still a worthwhile surgical procedure in the treatment of tibial varus deformity to prevent knee arthritis. However, it requires a long period without weight-bearing because of the need of bone harvesting substitution at the osteotomy site. The authors present their experience with endoscopic injection of Norian SRS calcium phosphate cement to speed patient recovery and to avoid any potential in soft tissue complications.
From January 2001 the authors performed 13 tibial opening wedge osteotomy in 12 patients. All the patients previously underwent to a knee arthroscopy. The average age was 51 years (range 35–56). In all cases the injection of Norian SRS calcium phosphate cement was controlled arthroscopically and the fixation was maintained with a Puddu’s plate. The patients were assessed using the GIUM Score, pre-operatively and at the latest follow-up.
The authors did not register any problems due to the Norian SRS calcium phosphate cement. Total weight-bearing was allowed after an average of 26 days. Radiographically the bone substitute appeared well integrated at the latest follow-up. Pre-operatively the mean GIUM score was 56.1 (range 36–68). At the latest follow-up the mean GIUM score was 94.2 (range 84–98). All the patients were satisfied and had returned to their previous occupation.
The authors suggest Norian SRS calcium phosphate cement to speed patientrecovery after tibial opening wedge osteotomy
It is well known that articular cartilage in adults has a limited capacity for self-repair. Numerous methods have been devised to augument its natural healing response, but these methods generally lead to filling of the defect with fibrous tissue or fibrocartilage, which lacks the mechanical characteristics of articular cartilage and fails with time. Tissue engineering combines aspects of cell biology, engineering, material science and surgery to generate new functional tissue and provides an important approach to the repair of articular cartilage lesions and, ultimately, functional success. The purpose of our study was to perform experimental resurfacing of articular cartilage in 18 sheep using different techniques: before implantation in all sheep a full-thickness chondral lesion of medial femoral condyle was created; subsequently, autologous chondrocytes seeded into the matrix were implantd into five sheep; a periosteum flap was implanted in five sheep; and, as source of growth factors, adipocytes by vascular peduncle of Hoffa tissue were implanted in five sheep. The reparative tissue of the chondral lesion was compared with uninjured contralateral knee. The results present the bonding between implantation tissue and host tissue, preservation of phenotypic stability of chondrocytes culture, standard dosage of growth factor secreted by adipocytes and characterisation of the histological properties of reparative tissue, comparing different surgical techniques.
We appraised whether deformity of the inferior limbs, routinely treated with external fixation (EF), can be corrected when synthesis with locked intramedullary nails is associated with the synthesis and what the indications are.
In all, 24 patients with a deformity of the inferior limbs treated between 1997 and 2003 were included in the study and divided into two groups: (1) patients with external fixation, average 23 years, deformity axial 20° (9–28°); and (2) patients with osteotomy and interlocked nailing. average 35 years, deformity axial 16° (10–25°). The indications for treatment with interlocked nail were set according to the following criteria: (a) possibility to correct the deformity with only restoration of the anatomical axis without necessity of lengthening; (b) previous use of EF; (c) EF refused by the patient, and (d) physeal closure.
In both groups complete correction of the deformity was achieved. In the group of patients treated with EF the time of consolidation was on average 5.5 months (range 4–8 months). In this group the time of consolidation proportionally increased to time required to effect a bone lengthening.
In the group of patients treated with osteotomy and nailing the times of consolidation were different with respect to age, to the side and the type of osteotomy and to the type of deformity. The time of consolidation was 7 months (range 3–12 months). The most rapid consolidation corresponds to the congenital deformities treated with oblique osteotomy.
Correction of deformities by osteotomy and interlocked nail introduces the advantage of not limiting joints and immediate correction of the angular and rotatory deformity. The indication for this technique is that there is no residual hypometry. In this case the treatment of choice is corticotomy and external fixation.
Osteogenic protein 1 (OP-1) is involved in physiologic bone formation during development and promotes normal healing process after fractures. The protein has been produced in cells with genetic engineering techniques: recombinant human OP-1 (rhOP-1). The safety and effectiveness of rhOP-1 in healing tibial non-unions has been demonstrated in a clinical study: OP-1 provided clinical and radiographic results comparable with those achieved with iliac crest autograft, the gold standard in the treatment of non-unions. Furthermore, several publications have shown its efficacy in resistant long bone non-unions, too.
OP-1 was introduced into clinical routine in Italy in August 2002. In the Ospedale Marino of Alghero the authors have utilised OP-1 since October 2002 and present the first eight patients treated up to October 2003. The eight patients had a diagnosis of non-union dated from 4 to 20 months. Three patients had diaphyseal humeral non-union, three diaphyseal radial non-union, one meta-epiphyseal tibial non-union and one femoral non-union at 1/3 distal segment. Non-unions were exactly divided into atrophic and hypertrophic. In all patients synthesis was suitable (IM nail, n=5; plates, n=2; and staple, n=1). In six out of eight cases the synthesis was substituted for a non-suitable one. All but one patient (not previously treated fracture) had undergone one or two previous operations. In four cases OP-1 was mixed with fibrin glue (Tissucol) to help the placing. In all patients union was achieved after a mean of 5.5 months. No adverse event has been recorded.
A new class of soybean-based biomaterials has been presented to the scientific community (patent PCT/GB01/03464) that shows good mechanical properties and an intrinsic anti-inflammatory potential, probably related to the phyto-hormone Genistein. This plant iso-flavone is also reported to inhibit osteoclastic activity.
De-fatted soybean curd was prepared into granules which were subsequently implanted in a cylindrical cavity drilled into the femoral canal of New Zealand White rabbits. Retrieved femurs were embedded in polymethyl-meta-acrylate and samples were analysed by back-scattered electron microscopy (BSEM). Retrieved, operated femurs showed a macroscopic appearance similar to the non-operated controls. BSEM showed that granules were still present at the site of implantation after 8 weeks, but a clear progressive degradation took place from the periphery to the centre of the femural canal already after 3 weeks. The degradation of the granule was accompanied by the production of new trabeculae apposed to the surface of the material.
It can be hypothesised that the released Genistein shifts the metabolic balance towards bone production by inhibiting the macrophagic and osteoclastic activities and that the material degrading surface supports the apposition and mineralisation of the newly formed bone.
Coatings for endo-osseous implants have been developed based on phospholipids. Such coatings promote the formation of a very thin superficial rim which is highly enriched with calcium phosphates.
Two phospholipid-based preparations have been compared with a standard hydroxyapatite coating. Preparation S was based on phosphatidyl-serine; preparation C was based on a mixture of phosphatidyl-serine, phosphatidyl-choline and cholesterol. Titanium cylinders spammed with titanium foam were the metallic substrate for the coatings; they were implanted in the femoral canal of New Zealand White rabbits and retrieved after 4, 8 and 26 weeks. A back scattered electron microscopy analysis followed.
Both phospholipid preparations were shown not to have any inhibitory action on bone apposition and growth and did not elicit any adverse fibrous reaction. Pictures of bone in-growth into the cavities of the titanium foam are present. A truly tight apposition between bone and coating was evident only in the comparative group sprayed with hydroxyapatite, but this latter coating was often fragmented and its constituent granules were evident. The phospholipid-based coatings did not show inhibitory action on bone apposition and growth and did not elicit any adverse fibrous reaction.
The rationale for a degradable bioactive glass coating is to lead the bone to appose gradually to the metal without the release of non-degradable particles. Two formulations of bioactive glasses, already described in the literature, have been studied: bg A and bg F. A non-bioactive glass (glass H) was sprayed as a control. Glass-coated Ti6Al4V cylinders were implanted in the femoral canal of New Zealand White rabbits. Samples were analysed by back scattered electron microscopy (BSEM) and electron dispersive analysis (EDX).
Bone was in tight apposition with the coating. As time progressed, images were found where bone showed features of physiological remodelling (newly formed bone filling areas of bone resorption) close to the coating. At the interface the apposition was so tight that it was not possible to discern a clear demarcation, even at higher magnification (more than 2500x). There was a gradual degradation during time and at 10 months bone was found apposed directly to the metal in more than half of the samples. In contrast, the non-bioactive glass coating showed complete integrity at any time examined and a clear demarcation with the coating was evident. Two peculiar features of the behaviour of bioactive glass coatings in vivo are: (a) degradation during time; and (b) promotion of a tight apposition with the newly formed bone.
A case is reported of an 18-year-old man with a post-traumatic radial shortening of about 10 cm with 40° of radial deviation as a consequence of an epiphyseal arrest that occurred when the patient was 8 years old. In the past the patient and his parents had refused all corrective treatment which would result in a permanent shortening; then a treatment by the Ilizarov external fixator was proposed. The forearm assembly was made by two fixed rings (one proximal and one medial) and one hinged distal ring. A closed corticotomy was performed parallel to the distal ring, whose fulcrum was at the ulnar styloid. Correction and lengthening were obtained by elongating two opposite threaded bars about 0.5 mm per day. Minor revisions were made on an out-patient basis. Time of correction and lengthening was 113 days, followed by 70 days in the fixator and a further 44 days of plaster cast after fixator removal. The complete correction of deformity and concurrent lengthening showed that Ilizarov‘s method is a definite but very demanding option in the treatment of severe deformities of the upper limb.
Distal radius fractures characterised by the destruction of cortico-cancellous bone at a meta-epiphyseal site represent an extreme instability with possible secondary displacement. Therefore, in order to increase the surgical implant stability, we have started to use Norian SRS, this also because of the encouraging results obtained with bone graft. This material is like a paste; when injected in a site presenting loss of bone, it hardens within 10 min in a crystallisation process and after 24 h achieves a compressive strength equal to 55 Mpa. Norian is similar to the mineral phase of human bone and it is able to undergo remodelling and replacement by host bone through normal biological processes.
From January 1998 to August 2003 we have treated 57 distal radius fractures in patients between 30 and 77 years old; 36 were women and 21 men. Fractures were classified using the AO classification. The results were evaluated using the Mayo Wrist Score and the DASH questionnaire. Norian has been associated with different hardware. At first we used a percutaneous pinning, then the external fixation and lastly the internal synthesis with Tri-Med technique. With this a stable synthesis can be obtained that neutralizes the shear strengths that are the main causes of Norian destabilisation. Norian’s mechanical and biological features (osteoinductivity and osteoconductivity) and the synthesis stability complement each other and provide an extremely stable implant, which promotes early rehabilitation.
Many surgical techniques based on a distal osteotomy are used for the treatment of the symptomatic hallux valgus. We review the results of percutaneous distal osteotomy retrospectively.
Between 1998 and 2003, 52 patients were operated on using a distal osteotomy for symptomatic hallux valgus. We investigated 35 females and nine males for a mean follow-up time of 4.6 years. We performed a percutaneous distal osteotomy (PDO) with a 2-mm Kirschner wire. Radiological analysis consisted of measuring the hallux valgus angle (HV) and the angle between the first and the second metatarsal (M). Clinical evaluation was performed with the AOFAS scale.
Good bony contact was achieved and all the osteotomies united and no aseptic necrosis was found. According to the questionnaire, the pre-operative AOFAS score was 44.3 and 92.5 at the follow-up examination. Radiological analysis showed that the pre-operative HV angle was 13.7° and 9.8° at follow-up. The pre-operative M angle was 24.1° and 13.6° at follow-up.
The PDO technique gives good results at a mean follow-up of 4.6 years. The positive aspects of this technique are: short surgical time, low incidence of complications and high patient compliance. A single 2-mm Kirschner wire is enough to achieve adequate stabilisation of the osteotomy, is less expensive than other surgical instruments for hallux valgus and is very easy to remove.
In the past, the clinical outcome of earlier types of resurfacing hip arthroplasty was often characterised by a high percentage of failures and early mobilisations. An implant retrieval of a Co-Cr head and UHMWPE cup cemented resurfacing hip prosthesis was analysed. The implant was in place 11 years, without any clinical problem for nearly 10 years. The cup was highly worn. There was a complete fracture of the interface between cement and bone at the base of the femural neck. A significant hyperplastic reaction was present at the level of the synovial membrane, with fibrin deposits, hyperplasia of lining cells and a cellular infiltrate formed mostly by macrophages, with occasional giant cells and localised groups of perivascular lymphocytes. Immunohistochemical analysis showed that all lymphocytes were of the T type and that the largest part of macrophages containing debris were not activated. Inside the prosthetic head there were only traces of ossified tissue. This picture indicated that for a long time no viable bone tissue had been in contact with the cement and bone rarefaction was massive.
The study shows an important cause of the failure of earlier types of hip resurfacing arthroplasty, namely the abnormal stress distribution that caused the complete bone rarefaction.
We performed 55 operations in 40 patients affected by diabetic foot and referred to the Diabetic Day Hospital from 1998 to 2003. Surgical procedures can be grouped as: (a) emergency operations: mostly for surgical debridment; (b) operations such as functional amputation of the limb at various levels; and (c) conservative operations such as preventive correction of deformities or restoration of morphology and function.
We performed 39 amputations; 15 conservative procedures (including ring external fixation in “Charcot foot”); and one emergency procedure (sepsis). We never used local ischaemia while operating diabetic patients. Patients follow-up ranges from 6 months to 6 years. One fourth of patients died for reasons not directly associated with diabetic foot but often related to the diabetes. The vast majority of patients mantained adequate control of the disease, wore special “diabetic shoes”, and judged the result of the operation very positively and consider their situation much improved after the operation. Surgical wound closure took from 2 to 20 weeks (mean 6 weeks). More than half of the patients can walk without support. It is relevant to note that about half of the patients had previous operations for the same problem but about 90% of the patients required no further operation after the one we performed.
Orthopaedic surgical treatment may effectively restore walking ability in those patients who lost it because of diabetic foot problems.
The authors studied the characteristics that would be desirable for a metacarpo-phalangeal joint prosthesis to be used in patients with rheumatoid disease. In these patients the severe destruction of the capsulo-ligamentous structures of the joint often makes prosthetic substitution dissatisfactory, particularly for the index finger.
Such a prosthesis should be restricted in its range of motion, actually abolishing any ulnar deviation. Axial rotaion should be coupled to flexion-extension and radial deviation to gain an adequate stress dissipation at the interface. Both distal and proximal stems should be conical, for the best possible distribution of shear stresses at the interface. A flattening surface should accommodate properly the externsor apparatus without interfering with it. The greatest possible congruence should be required for the articulated components.
The rationale of such a design for a rheumatoid patient lies in the fact rheumatoid arthritis is the most important indication for a metacarpo-phalangeal joint arthroplasty, due to the highly incapacitating condition that may ensue. Then, despite limitations required by the proposed design, an improvement in the functional ability of the rheumatoid patient will be obtained.
A prospective study on 24 patients (33 hip arthroplasties) affected by painful total hip replacement was conducted. All patient had a blood test, X-rays, ultrasound scan, cultures, Tc 99m bone scan (SPECT), and F18FDG-PET. Fifteen patients were operated on (nine two-stage revisions, six débridements). During operation, cultures were repeated and bone biopsy was performed at the sites of increased PET uptake. Bone and soft tissue débridement was specifically performed at the site of PET uptake with maximal preservation of bone stock.
There were 20 infected prostheses. Infection was demonstrated by positive culture in all cases and positive biopsy in operated cases. Sensibility and specificity of PET were 100% and 92%, respectively. All patients who were operated on were reviewed with a mean follow-up of 7 months. The nine patients who had revision were free of infection at follow-up.
In our experience PET is easy to perform, has an excellent sensitivity and good specificity and can be placed at the end point of the flow-chart for diagnosis of total hip replacement infection. Moreover, PET scan could be useful in pre-operative planning of revision surgery as it has better anatomical definition than traditional scans. Presently, it involves high costs and should only be used in selected cases. Its real usefulness in revision surgery has to be confirmed by a longer follow-up of treated cases.
The purpose of this paper is to investigate the relative contribution of each component in the ultimate strength and stiffness of the Evolgate (Citieffe), which is presently a widely used fixation device in DGST ACL reconstruction. The three components of the Evolgate were tested using fresh frozen animal tissue stored at −20° Celsius. Common extensor tendons were harvested from 20-month-old bovine forelimbs. Twenty-four tests were performed for each of the following configurations: six tests using Evolgate complete, six tests using screw alone, six tests using screw and washer and six tests using screw and coil. A randomised t-test was used; differences were considered significant when p< 0.05. The mean strength was: Evolgate complete 1314±194N; coil and screw 700±152N; screw alone 408±86N; and screw and washer 333±93N. There was a significant difference between fixation strength of Evolgate and the other devices, none between screw alone and screw and washer. The mean slippage of the Evolgate was significantly lower than the other devices. The mean stiffness of the Evolgate (269±14 N/mm) was significantly greater than the other devices. On the basis of the results of the present study, the coil appears to be the most important component of the Evolgate, resulting in a significant increase of the fixation strength of the screw. However, it is important to note that, as the washer alone does not improve the strength of the screw, if a washer is associated with a coil a further significant increase in strength and stiffness of the device is observed.
Valgus deformity is a relatively common occurrence in rheumatic or degenerative disease of the tarsus. Frequently the angular deformity can exceed 25° ; in these situations dislocations of talo-calcaneal and/or talo-navicular joints can be observed. These conditions are usually progressive and affect the walking ability of the patient The goal of the study is to present a series of patients surgically treated in order to evaluate the best solutions and the problems of the surgical technique.
In the period 1996–2002, 22 patients were treated for significant valgus deformity of the rearfoot; 16 were affected by rheumatoid arthritis and six by a degenerative pathology. In all cases combined talo-navicular and talo-calcaneal arthrodesis was performed. In seven patients a bone graft was used to fill bone defects. The follow-up was 5.3 years. The results were evaluated using the AOFAS score for rearfoot; fusion was achieved in all but one case (talo-navicular joint). All patients were satisfied regarding subjective results (pain and function).
Combined arthrodesis of talo-calcaneal and talo-navicular joints is an effective method of treating significant valgus deformity of the hindfoot; fixation by screws for talo-calcaneal joint and by staples or screw for talo-navicular joint is the recommended method for synthesis.
Our clinical experience in treating lower limb deformities by external fixation started in 1982 by applying an Ilizarov external fixation frame. Correcting lower limb deformity by gaining the proper length and the optimal mechanical performance is of the outmost importance and essential for valid restoration of the articular function. We treated 145 patients: 25 patients affected by post-traumatic deformities; 12 patients affected by axial deviation of the knee; 82 patients affected by limb shortening and associated limb deformities; eight patients with lower limb deformities and shortening following pathological hip alterations; and 18 patients affected by severe foot deformities.
It is important to stress that in congenital lower limb deformities both axial deviation and limb shortening contribute to the final picture of the deformity. Combined (hybrid) external fixation provides an adequate correction of the mechanical axis and a proper lengthening of the shorter limb by a corticotomy followed by a gradual distraction.
The purpose of our study was to determine the effect of 4 weeks and 12 weeks of implantation on the strength of a tendon graft in a bone tunnel using a low-profile fixation device, Evolgate, in an extra-articular ovine model. Moreover, we evaluated the histological changes.
The common digital extensor tendon was detached from the lateral femoral condyle and fixed with the Evolgate device in a 30-mm-long tunnel placed obliquely across the dense metaphyseal bone of the proximal tibia. We performed either biomechanical or histological study. Three sheep were sacrified at time 0 and their posterior limbs were used for biomechanical tests. Six sheep were used for biomechanical tests at time 1 (4 weeks) and at time 2 (12 weeks). The other three sheep were used for histological evaluation after 4 and 12 weeks of implantation. The biomechanical tests included a 50 N preload applied for 10 s and a cyclic load test in 50-N increments until failure to evaluate the ultimate failure load. We used a paired t-test to evaluate the difference between group at T1 and group at T2 with the control group at time 0, respectively. Tests were performed using an electromechanic machine (Zwick-Roell Z010, Zwick-Roell, Ulm, Germany). Data were recorded with dedicated software (Textexpert 8.1, Zwick-Roell).
The biomechanical results show an improvement of about 50% in strength after 4 and 12 weeks post-implantation, respectively. The histological evaluation shows a layer of cellular, fibrous tissue between the tendon and the bone, along the length of the bone tunnel; this layer progressively matured and reorganised during the healing process. The collagen fibres that attached the tendon to the bone resembled Sharpey fibres.
The strength of the interface was noted to have significantly and progressively increased between the second and the 12th week after the transplantation. The progressive increase in strength was correlated with the degree of bone ingrowth, mineralisation, and maturation of the healing tissue, noted histologically.
The purpose of this study is to biomechanically compare Evolgate and Intrafix using cyclic loading with final pull-out tests. Five pairs of double looped bovine digital extensor tendons and 10 porcine tibias were used. We evaluated the displacement at 1, 10, 100, 250, 500, 1000 and 1500 cycles. We used cyclic tests (1500 cycles between 50 and 200 N with final pull-out). Biomechanical tests were performed with use of a Zwick-Roell Z010 mechanical testing machine (Zwick-Roell, Germany), and the testing data were recorded with the accompanying software package (Testexpert 8.1, Zwick-Roell). A paired t-test was performed for statistical evaluation. There was no statistically significant difference in slippage between the two devices. The mean ultimate failure load at pull-out after 1500 cycles was 832±156 N for Intrafix and 1058±130 N for the Evolgate.The mean stiffness at pull-out was 269±86 for Intrafix and 247±44 for the Evolgate, and there were no statistically significant differences (p> 0.05). At statistical evaluation there was a difference in ultimate failure load between the IF and the EV (p< 0.05). Although further studies are needed to investigate bone growth into the tibia tunnel, Evolgate seems to be a good choice for tibial fixation of hamstring tendons. Moreover, Evolgate has higher values of strength than Intrafix.
Unicompartmental knee prosthesis (UKP) has been used for 40 years but it is still controversial. Nevertheless, this procedure is positive and it can be a good alternative if it is correctly indicated.
From January 2001 we implanted 51 UKP in 47 patients. The diagnoses were: primary arthritis in 45 cases, post-traumatic degeneration in five and arthritis secondary to meniscectomy and ACL reconstruction in one. The mean age was 64.5 (range 49–81), 32 women and 15 men. Mean follow-up was 26 months (range 6–36). Post-operative recovery starts with physical rehabilitation, rarely with kinetics, and full weight-bearing walking the first day. DVT is prevented by treatment with low-molecular-weight heparin for 25 days and elastic stockings. From September 2002 we performed this procedure by minimally invasive surgery with an 8-cm incision and extramedullary intraoperative tools. We did not observe any infections or loosening: we performed just one revision of the femoral component because of a technical error. In four other cases a malpositioning of the femoral component was reported that was pain-free at follow-up.
Current studies are starting to show valid and encouraging results at mid- and long-term follow-up, too. The best candidates for UKP are patients over 60 years who are not overweight, with asymptomatic patellar degeneration and no anterior instability and who perform light sport activity. In comparison with high tibial osteotomy (HTO), UKP shows some advantages, such as faster recovery and better mid-term results. In comparison with total knee arthroplasty (TKA), UKP gives better range of motion, faster postoperative recovery and an easier operation in case of infection or loosening. Some features should be evaluated and the surgical technique should employ state-of-the-art hardware. We evaluate the advantages of this procedure with particular emphasis on the minimally invasive technique.
In conclusion, although our study is still in progress, correct patient selection, the surgical technique and the updated design of the new prosthesis can give satisfactory results and represent a valid alternative to HTO and TKA. In addition, compared to TKA, UKP shows a real economic advantage.
Acetabular loosening is often dangerous because the patient is pain free for several years. The subsequent bone loss may represent the greatest challenge in revision surgery. The extension of the bone loss may be small or wide, but it could also be associated with several defects. Usually, the most affected district is the dome, especially because the cup leans to migrate proximally. The object of this study is to evaluate the use of an iliac stem cup (Link®) associated with impacted bone grafts in acetabular loosening and congenital hip dysplasia (CDH).
The surgical technique requires a posterolateral approach, dedicated cannulated hardware tools to improve iliac stem positioning, intraoperative C-arm and bone grafts to enhance primary stability. We performed 21 implants in 18 cases of acetabular loosening (10 grade 2 and 8 grade 3 according to Paprosky) and three CDH: average age was 68 years old in 14 women and seven men. Mean follow-up was 21 months. We used bone grafts in 17 cases. In one case we cemented the McMinn cup because of poor initial stability with no complications at 18 months. We noted radiolucency lines < 2 mm in one case and bone resorption in two cases. Mean Harris Hip Score (HHS) was 60 preoperatively and 88 postoperatively. The complications were: malpositioning of the stem (1%), sacroiliac pain (4%), superficial infection (2%) and DVT (1%).
The primary cementless stability is achieved by the aid of an iliac palpator checked by fluoroscopy: the palpator works as a guide for the iliac stem to avoid malpositiong or wrong inclination. In addition, the dedicated cup trials could also function as an impactor for chips bone grafts in the so-called “impaction grafting technique”. In conclusion, we confirm that the McMinn cup, despite a demanding surgical technique, represents a valid alternative to acetabular revision surgery because of the good initial stability and the respect of loading lines and it also allows the use of pressurised bone chips. Furthermore, the hip centre is restored in acetabular loosening and CDH.
Secure tendon-to-bone fixation is essential for successful rotator cuff repair. Thus, the biomechanical properties of devices used in rotator cuff repair should be better understood. This controlled laboratory study was performed to evaluate response to incremental cyclic loading of six different anchor-wire complexes commonly used in rotator cuff repair.
Two absorbable anchors 5 and 6.5 mm in diameter and one metallic anchor, coupled with both ethibond or fibrewire (FW) were tested on five pairs of fresh-frozen human cadaveric shoulders. An incremental cyclic load was applied until failure using a Zwich-Roell Z010 electromechanical testing machine. The ultimate failure load and mode of failure were recorded. A t-test was used for statistical analysis.
The FW suture coupled both with absorbable and metallic anchors provides a statistically significant stronger fixation. However, while the metallic anchors in most cases fail due to the slippage of the anchor, absorbable anchors fail due to rupture of the loop. The FW seems to increase the strength of fixation devices under cyclic load both using absorbable or metallic anchors with relevant differences in failure mode (slippage of the metallic anchor and loop failure in absorbable ones). Using a FW suture, the risk of metallic anchor migration might increase.
The purpose of this study is to biomechanically evaluate how four different fixation devices (two femoral and two tibial) associated in three different combinations, using cyclic loading with final pull-out test, affect the strength and the stiffness of the femur-graft-tibia complex.
We conducted a controlled laboratory study and tested, using cyclic loading with final pull-out, two femoral devices (Swing- bridge and Endobutton CL) and two tibial device (Evolgate and BioRCI screw) in three different combinations: Group A, EB-Bio RCI; Group B, EB-Evolgate; and Group C, SB- Evolgate.
We used porcine knees and bovine digital extensor tendons and evaluated the stiffness and strength at the final pull-out, and the displacement at the 1st, 100th, 300th, 500th and 1000th cycle.
A t-test was used for statistical evaluation.
There was a statistically significant difference in ultimate failure load between group A and group B (p=0.03) and group A and group C (p=0.0007) but no difference between group B and group C (p=0.72). There was a statistically significant difference in ultimate failure load between group A and group C (p=0.02) and group B and group C (p=0.01) but no difference between group A and group B (p=0.88).
Due to the biomechanical properties of the F-G-T complex the combination of Swing-Bridge and Evolgate seems to be a good alternative when an accelerated post-operative rehabilitation is planned after ACL reconstruction using DGST.
The evaluation of the lumbar spine by CT or MR in supine position provides excellent information about the morphology of the spinal structures (inside and outside the spinal canal) but of course cannot give dynamic information. By Newton’s Third Law we know that every axial vector acting on a functional spine unit corresponds a second vector of equal intensity but of opposite direction that counterbalances the first one and brings all the structures in a dynamic equilibrium. The definition of spinal instability by White and Panjabi is well known and X-ray plain film with dynamic testing is not always satisfactory for diagnosis.
From April 2003 through May 2004 we evaluated 45 patients with with a dedicated device able to produce an axial load on the patient with a dynamometer to measure the load applied. The study can be performed in all patients in whom spinal instability is clinically suspected, even if the patients underwent spine surgery. The study was performed by CT or MR but always before in rest and stress conditions. The applied load is 60–70 % of body weight, based on literature data regarding orthostatic load at the L3 S1 level. A spiral multi-slice acquisition technique must be used to obtain thin scans with which excellent 2D multiplanar (MPR) and 3D reconstructions can then be achieved.
Under normal conditions, under an axial loader, we do not see significant changes in spine morphology except for pseudo-protrusion of the disks. In pathologic conditions (38 patients) we must pay attention to the following: disc modifications (appearance or disappearance of vacuum phenomenon, volumetric increasing/appearance of protrusions or herniations); intersomatic findings (increment of the lysthesis, narrowing or widening of disc space, rotational movements, posterior translation of the vertebral body); interarticular joints modifications and neural foramina narrowing; and thickening of the ligamenta flava and narrowing of interspinous spaces and hypermobility of the spinous process.
We believe the CT/MR axial loader currently represents the only way to gain dynamic information in patients in whom spinal instability is clinically suspected.
The utility of vertebroplasty in the treatment of spinal pain has been accepted worldwide. In this co-operative study we show the success and failure rates related to the pathological condition treated (porotic, metastatic or angioma), the incidence of new vertebral fractures adjiacent to the previously treated one, and the incidence of symptomatic and asymptomatic side effects.
In all, 898 patients were treated from April 2001 through January 2004 for a total of 1796 vertebral bodies. Of these, 654 patients (73%) were treated for porotic abnormalities, 213 patients (24%) had neoplastic disease and 27 patients (3%) presented with compressive or painful angioma. Different types of cement were used. All patients were treated after MR and CT examination or, as an alternative to MR, bone nuclear medicine scan, always associated with clinical evaluation. The patients were treated under CT and C-arm fluoroscopy control (2 centres) or under fluoroscopy in an angiography suite (five centres). We never perfomed general anaesthesia, only local sedation or administration of neuroleptic drugs. Blood tests were always performed before the treatment to exclude coagulopathy. Only the presence of local or systemic infection was considered to be a real contraindication.
We had a 93% success rate in patients with porotic abnormalities, one of 73% in patients with neoplastic disease and of 100% in patients with angioma. Asymptomatic venous leak was seen in 135 patients (15%) and CT demonstrated asymptomatic pulmonary embolus in eight patients (0.9%). No symptomatic venous and pulmonary emboli were identified. New fractures adjacent to a previously treated vertebral body developed in 14 patients (1.3%) while six patients showed radiculopathy (0.6%) due to posterior leakage in the lateral lumbar recess that was treated and resolved with medical therapy in 3 weeks. In six patients we also had psoas haematoma treated with medical therapy; no instance of cord compression was found. Mild disc leakage developed in 90 patients (10%) but we did not find any relation with new adjacent vertebral fracture.
Vertebroplasty represents a safe technique in the treatment of spinal pain related to porotic, neoplastic changes or angioma. The technique must be performed with high performance technology. The incidence of symptomatic effects and new fractures related to previously treated vertebrae or disc leakage is very low.
Surgical treatment of adult kyphosis is an old procedure (Ferguson, Hallock, Roaf, Moe). According to conventional concepts, surgery should be reserved for adolescents with curvatures exceeding 75° or with rapidly progressive kyphoses despite treatment with braces or casts and adults with symptomatic curves greater than 65°. Therefore, it is important to evaluate these factors, in addition to the angular level of the kyphosis, to determine the most suitable type of treatment.
The presence of pain should not be considered an absolute indication for treatment in view of the disease’s benign natural evolution. Thus, the only true indication for treatment is the severity of the angle of the curvature, which has been shown to progress over time. Generally, in Scheuermann kyphosis it is suggested that three or four double pedicular transverse or laminar hook configurations be used on the spine above the apex of the kyphosis; this gives an excellent hold on the posterior arch and minimises the risk of neurologic impairment. The use of a transpeduncular screw in the first two lumbar levels increases the stability of the assembly.
In cases of extreme vertebral rigidity posterior multilevel osteotomy is also indicated. In cases of extreme vertebral rigidity anterior arthrodesis is indicated. This is performed by means of an intrathoracic approach or thoracoabdominal retropritoneal approach. The technique makes it possible to resect the anterior longitudinal ligament and to perform multiple discectomies at apical vertebral levels. It is also possible to perform combined anterior and posterior arthrodesis.
Compression-distraction techniques (or circular external fixation methods) are a good alternative to other surgical methods based on bone grafts or bone substitutes, allowing “bone regeneration” through distractional osteogenesis and leading to a substantial advantage in the correction of long bone deformities, in selected bone tumours and in many types of non-unions.
Monofocal compression-distraction osteosynthesis is applied to correct long bone deformities in orthopaedics, basically through distraction epiphyseolisis, in which a gradual elongation of the epiphysis at the growth plate level is produced, and corticotomy-distraction, in which the gradual distraction is performed at metadiaphyseal level, after cortical osteotomy. In cases of hypertrophic non-unions (usually associated with limb shortening) the use of monofocal osteosynthesis basically relies on osteosynthesis with gradual distraction of the non-union site. These are cases where the fibrous or fibrocartilaginous tissue lying between the bone fragments is biologically active and gradual distraction highly affects its potential for regeneration.
Bifocal or plurifocal compression-distraction osteosynthesis is applied to correct wide bone defects through the technique of “internal lengthening” or “bone transport”. A corticotomy is performed at one of the two metaphyses of the affected long bone and the bone segment obtained by this corticotomy is gradually moved to fill the gap. In orthopaedics this technique shows its highest advantages in cases of bone tumours treated with segmentary resection, and in traumatology in atrophic non-unions and in infected non-unions with bone loss.
Between 1986 and 2003, distraction osteogenesis techniques were applied in 753 cases (638 patients) for several orthopaedic or traumatological problems. There were 430 men and 323 women. The average age was 24 years (min 3 years, max 48 years). The anatomical and functional results have been highly satisfactory, with a very low complication rate, and confirm the effectiveness of these techniques in selected cases in orthopaedics and traumatology.
Planning of surgical correction in sequelae of vitamin D-resistant rickets preliminarily requires the management of the metabolic defect with appropriate measures. In fact, surgery perfomed with the patient in a compensated metabolic condition greatly contributes to the prevention of recurrences.
The deformity most frequently observed is genu varum (where femur, tibia and fibula are usually all deformed), often combined with internal torsion. Compression-distraction systems (or circular external fixators) provide an easy control of the corticotomy fragments and a gradual correction of all kinds of deformity during the operative and post-operative phases. Careful pre-operative planning is necessary, which may require a multi-stage and/or a sequential strategy of management.
Between 1988 and 2002, 16 cases of sequelae of vitamin D-resistant rickets, with combined angular and torsional lower limb deformities, were treated with monofocal or bifocal tibial or femoral corticotomy and gradual correction with compression-distraction devices. There were nine men and seven women, with a mean age of 15 years. The Ilizarov system was used in 14 cases; in two cases the Volkov-Oganesian system was employed. The mean follow-up time was 8 years (range 1 – 15 years).
The anatomical and functional results have been highly satisfactory, with a very low complication rate. These techniques thus represent an excellent option in the management of such complex diseases.
In acquired knee deformations the usefulness of arthroscopy is strictly correlated with the degree of axial defomation and cartilaginous degeneration. The authors comparatively consider two groups of patients (the first one Albach I and II and the second one Albach III and IV) treated with arthroscopic débridement (washing and curettage), in relation to the joint’s degeneration stage. A minimum 6-month follow-up, using KSKSS grading revealed satisfactory medium-term results.
This study was undertaken to evaluate the efficacy and reliability of posterior intra-operative reduction and fusion by pedicle screw fixation in the treatment of children and adolescents for severe lumbosacral spondy-lolisthesis.Researchers identified 21 patients who underwent reduction of their high-grade spondylolisthesis at our Institution between 1993 and 2000. Recent clinical and radiograph data were available for all patients. Indications for surgery were severe back pain in 21 patients, leg pain in 17, cosmetic appearance in 16 and progression of slippage in 15. There were 11 females and 10 males, aged 16 years on average (range, 11–18 years). Seven patients had grade III slippage, nine grade IV and five grade V. The slippage was at L4-L5 level in one patient and at L5-S1 in the remaining cases. The instrumented levels were 2 (L4-S1) in 12 patients and 1 in nine (L5-S1). The patients underwent surgery using a single posterior surgical procedure. After removal of the loosened arch and complete discectomy, gradual distraction and posterior translation of the anteriorly displaced vertebral body were performed using a temporary device (Harrington rod) placed bilaterally between L1 and the sacral wings. Reduction was followed by a posterior interbody strut graft or placement of titanium cages and pedicle segmental fixation.
At a mean follow-up of 5 years (range, 1–10 years) a complete remission of back pain was observed in 18 cases and incomplete in three; all presented solid fusion radiographically. The mean correction of the slippage was 33.1%.(from 78.3% to 41%) and that of the slippage angle 51% (from 35.2° to 17°). Complications included two skin protrusions of a sacral screw, two transitory neurological deficit (L5-S1). Two patients with screw pullout underwent instrumentation revision and reinsertion of screws; another two patients underwent anterior interbody fusion since slippage exceeded 50% after posterior reduction.
Reduction of high-grade spondylolisthesis may be considered for patients with a high degree of lumbosacral kyphosis, an unacceptable clinical appearance, and/or neurological deficit. With the advent of pedicle screw fixation, posterior instrumentation and reduction appears feasible. We found that using the gradual reduction by temporary Harrington rod incurs less risk than other options for treating high-grade spondylolisthesis. This procedure provides a controlled method of reduction where continuous visualisation of nerve roots is possible and internal fixation is achieved.
The authors review the currently available treatments according to analysis of the literature. In the event of prosthetic infection, protocols available at the moment are: specific antibiotic therapy without débridement, débridement with conservation of the prosthesis, one-stage replacement of the prosthesis, débridement with definitive prosthesis removal, arthrodesis,amputation or disarticulation. The choice of the treatment must be based on the analysis of local and general factors: type of infection, clinical presentation, quality of soft tissues, prosthetic implant condition, pathogens involved, function of the knee extensor mechanisms and patient’s expectations and functional requirements.
We re-evaluated the literature reports. Antibiotic therapy in infected hip prostheses yielded a successful outcome in 64% of the cases. Arthrotomic débridement in total hip prostheses showed a successful outcome in a variable percentage from 74% to 14%; in contrast, arthroscopic débridement showed a successful outcome in 100% of cases. In total knee replacement the arthrotomic débridement showed a success rate of 32.6% and arthroscopic débridement 52.2%.
The mean percentage of success in replacement in one stage with antibiotic cement and preoperative antibiotic therapy was 82% in THA [1], and 71% in TKA [6]. The mean percentage of success in replacement in two stages with spacer cement and perioperative antibiotic therapy was more than 90% in THA and 91% in TKA. Prosthesis replacement in two stages showed the best rate of positive results. The antibiotic therapy was effective in all patients with positive cultures intraoperatively.
Arthrotomic or arthroscopic débridement is a valid procedure, but must be performed within 2 weeks from the appearance of the symptoms. Knee arthrodesis is preferable in the presence of pathogens resistant to antibiotics and is indicated in patients with high functional requirements. The Girdlestone arthroplasty is indicated in hip treatment when antibiotic-resistant pathogens are involved. Amputation and disarticulation are indicated only in patients with a poor survival prognosis.
The management of prosthetic infections represents a challenge to the entire multi-disciplinary team (i.e. specialists in microbiology, radiology, infectious diseases and orthopaedics) both in achieving a correct diagnosis (infection versus aseptic loosening) and in choosing an adequate therapeutic strategy.
We considered three different device systems for the treatment of lumbar and lumbosacral instability. From a prospective database in use in our Institution, we obtained a 45-patient cohort of individuals who received a one-level lumbar or lumbosacral fusion procedure between 1995 and 1998. All patients had presented with disabling back and/or radicular pain and severe degenerative changes at one disc level or low-grade spondylolisthesis.
First group: 15 patients, six male and nine female, with an average age of 41 years, were treated by an interbody fusion using cylindrical threaded cages; the levels fused were L5-S1 in 10 patients and at L4-L5 in five.
Second group: 15 patients, eight male and seven female, with an average age of 39 years were treated by nine cylindrical, threaded cages and seven square cages, combined with posterior pedicle screws; the levels fused were L5-S1 in 11 and L4-L5 in four.
Third group: 15 patients, eight male and seven female, with an average age of 40 years, underwent posterolateral fusion with posterior pedicle screws instrumentation alone; the levels fused were L5-S1 in 10 and L4-L5 in the remaining five.
At a mean follow-up of 8 years in the first group, eight patients (53%) required a second operation (five posterior instrumentation, two root decompression and one repair of dural tear). The clinical results were fair in six patients (40%) and poor in three (20%); five patients (33%) presented uncertain fusion signs. In the second group, two patients (13%) required a second operation (one root decompression and one dural repair). All patients (100%) presented definite fusion signs. The clinical results 6.5 years after primary surgery were fair in two (13%) patients and poor in two (13%). In the third group, two patients (13%) required a second operation (one dural repairand one implant removal). The clinical results were fair in two cases (13%) and no poor results were seen. At a mean follow-up of 6.5 years, 14 patients (93%) showed definite fusion signs.
According to the present data, we can conclude that in terms of fusion success, clinical outcome and complication rates, the use of posterior interbody cages alone is not as safe and effective for the management of one level degenerative disc disease or low-grade spondylolisthesis as the posterior pedicle screw instrumentation combined with two posterior cages or the stand-alone pedicle screw instrumentation.
The aim of this study is to present and discuss some preliminary applications of tricalcium phosphate “Norian” in children and adolescents with different skeletal disorders. From 1997 to 2002 Norian was used as a biological bone substitute in 10 patients (six girls and four boys; mean age 11 years). The indications were four calcaneal cysts, one phalangeal enchondroma of the hand, one chondromyxoid fibroma of the tibia, one eosino-philic granuloma of the femur and one aneurysmal cyst of the tibia. Norian was also used as a bone graft in two Dega’s pelvic osteotomies. Follow-up was performed radiologically and clinically.
There was one deep infection in a calcaneal cyst which completely healed after curettage and antibiotic therapy and one soft tissue transitory painful reaction to Norian. All cases healed without complication and there was progressive osteointegration at radiological follow-up.
This preliminary study, even with different pathologies and a short follow-up, shows good biocompatibility of the material in the short- and mid-term, with satisfactory clinical results. Mechanical stability under compressive and shearing loads was detected when load bearing was allowed after 30 days in all cases.
Norian tricalcic phosphate is a good and strong bone substitute when a large autologus graft is needed as seen with distal fractures of the radius, tibial plateau and Dega’s pelvic osteotomy.
The authors present their experience in bone fusion with blood stem cells, growth factors, AlloMatrix Injectable Putty (Wright Medical Technology, Inc, Arlington, Tenn) and cancellous chips allograft combined in the treatment of compressive vertebral fractures (VCFs).
Eight traumatic vertebral compression fractures at risk of kyphosis were treated by means of transpedicular bone fusion with blood stem cells, growth factors, AlloMatrix Injectable Putty (Wright Medical Technology, Inc, Arlington, Tenn) and cancellous chips allograft. In five patients (group A), mean age 34 years, mean follow-up 13 months, a minimal transpedicular screw fixation was added (two levels). In the other three patients (group B), mean age 26 years, mean follow-up 8 months, the percutaneous fusion was performed by means of vertebroplasty instrumentation. All patients underwent X-ray examination and CT at 45 days, 3 months and 6 months after surgery. In all cases fusion was reached earlier with excellent clinical outcome, especially in group B.
Blood stem cells, growth factors, AlloMatrix Injectable Putty (Wright Medical Technology, Inc, Arlington, Tenn) and cancellous chips allograft combined in the treatment of compressive vertebral fractures seem to be an excellent method even though further studies and more detailed statistical validation are needed.
Treatment with external fixation in lower-limb deformities is quite effective, even in severe deformities, since the progressive distraction and/or rotation strongly reduce risks for soft tissues, nerves or arterial lesions.
We have employed the Ilizarov circular frame in 53 patients affected with multi-planar deformities and a uni-lateral fixator in 21 patients affected with angular deformities only from 1984 to 2000 in the Orthopaedic Clinic of the University and C.T.O. of Firenze and from 2001 up to the present in the Poggibonsi Hospital.
Multi-planar deformities include various associations of angulation also in different planes, rotational malalignment and length discrepancies in congenital, post-traumatic or neurological disorders.
A uni-lateral fixator was used mainly for varus tibia or valgus femur deformities in patients under 30 years of age for severe angular deviation following congenital, post traumatic or rickets pathologies.
The results obtained in our series were better, regarding both the treatment time and achieving the desired correction, for uni-planar deviations than for more complex deviations where shortening and rotational defects were combined. These cases require longer treatment time and show a 9% rate of fair results. We did not achieve poor results and bone consolidation was always seen at the follow-up.
The purpose of this study was to assess the physical, biochemical and biomechanical properties of a cartilage matrix-chondrocyte-fibrin glue composite as biological tool for cartilage repair.
Chondrocytes were enzymatically isolated from pig joints and resuspended in fibrinogen solution. Articular cartilage was harvested from pig joints, chopped into small chips and lyophiliaed. Cartilage chips were rehydrated and mixed with the cell/fibrinogen solution and with thrombin, in order to form a fibrin glue gel composite with cells and chips (group A). Control composites were made from lyophilised cartilage chips assembled with fibrin glue, but not containing chondrocytes (group B). Other control groups included fibrin glue/chondrocyte specimens without cartilage chips (group C) and specimens made of the fibrin glue alone (group D). All samples were weighed and implanted into subcutaneous pouches of nude mice. Animals were sacrificed at 2 and 9 weeks. Samples were evaluated grossly and the final/initial mass ratio was calculated. Samples were evaluated histologically, biomechanically, and biochemically.
Upon retrieval, only the samples in experimental group A retained their original pre-implantation mass. Histological analysis showed newly formed cartilage matrix in the specimens from group A and C. Biomechanical analysis showed significantly higher modulus in experimental samples, with respect to the other groups at the latest time point. Analysis of hydraulic permeability showed significantly decreasing values for all groups throughout the experimental times and lowest values for the experimental samples of group A in the latest time point, although there was no statistically significant difference among the groups. Biochemical analysis demonstrated higher values in the latest time point for samples prepared with cells for water and GAG content, whereas highest values for hydroxyproline were recorded for samples assembled with cartilage chips. DNA analysis showed higher values of samples prepared with chondrocytes and fibrin glue and also an important increase in values of the samples made of fibrin glue only, indicating a possible host fibroblast growth inside the samples over time. This tissue-engineered composite presents cartilaginous appearance and biomechanical integrity after 9 weeks in vivo.
The Authors report the early results of endoscopic curettage with bone grafting to treat aneurysmal bone cysts. Four patients with aneurysmal bone cysts (one located in the femur and three in the humerus) received curettage with homologous bank bone grafting by endoscopy. In one case we used homologous bank bone in chips with osteoconductive properties and in three cases we used homologous bank bone in paste with osteo-inductive properties. The follow-up showed complete improvement in pain, new bone formation and remodelling at 2 years. Even if we do not yet have final results about recurrence, these early data encourage us to continue this study so that a longer follow-up will confirm the benefits of this procedure.
The authors report the results of the use of autologous growth factors in a patient affected by systemic sclerodermia. Two total hip prostheses were implanted in this woman. Because of the delayed wound healing in this patient, either because of the long-term corticosteroid therapy or the basic connective dissease, she decided not to have surgery. Some time later the patient decided positively for surgery, as her condition was becoming serious. Therefore, as part of a pre-operative protocol, she discontinued corticosteroids for 8 months beforehand and increased pharmacological therapy to improve blood perfusion in soft tissues. During surgery, we injected in the periprosthetic zone and in both sides of the surgical wound. Our patient had a normal period of healing and after 2 weeks the result was so good that we were able to remove the skin suture easily.
The purpose of this review is to evaluatei the clinical and surgical aspects of lumbar disc herniation in paediatric and adolescent patients. Between 1975 and 1991, a total of 5,160 lumbar disc operations were performed at the Rizzoli Orthopaedic Institutes. We included in this study only 129 patients (2.5%), aged from 9 to 18 years, with a mean age of 16.2 years (S.D. 1.7). Almost half of the patients (66 cases) ranged from 17 to 18 years of age and 49% (63 cases) from 9 to 16. Only three subjects were aged 9, 11 and 12 years.
This group consisted of 84 boys and 45 girls. Eleven had noted the onset of symptoms after a trauma and 15 during athletic activities or after lifting heavy objects. Almost all of the patients (106 cases, 82%) had low-back pain with radiculopathy, 13% (17 cases) complained of lumbar pain alone, 5% (six cases) had sciatica and 16% (21 cases) presented with a radicular neurological deficit.
Posterior discectomy by conventional procedure without fusion was performed in all patients, except for three cases with associated spondylolisthesis, treated by a posterolateral artrodesis, supplemented in two cases by pedicle screw fusion. Patients were followed in a short-term assessment using medical records. Long-term follow-up was conducted by a mailed, self-report questionnaire that quantified leg and back pain and scored the ability to return to normal activities and satisfaction.
Short-term results were excellent for 120 patients (93%) and postoperative complications included one superficial wound infection and one discitis. A total of 98 (76%) long-term responses were obtained with a mean follow-up time of 12.4 years (range, 6-19.4 years). Mean age at long-term follow-up was 28.7 years whereas the functional outcomes were excellent in 56%, good 30% and poor 14%. Eight patients (6.2%) required additional surgical treatment at a mean interval from the first surgery of 9 years (range 2 to 16). Three of them had a re-exploration for a herniated disc at the same level, five at a different level.
Our results have confirmed, as in adult patients, a negative trend between the short-term and long-term functional outcomes in young patients treated by discectomy. Furthermore, they have suggested that young individuals with lumbar Scheuermann-type changes are at great risk of experiencing herniation of intervertebral discs (10% in our series).
The cause of intermetatarsal neuromas is unclear even if there is a mechanically induced degenerative neuropathy of the intermetatarsal nerve. Treatment of Morton’s neuroma includes conservative methods such as steroid or local anaesthetic injection, orthotic devices and surgical therapy. Surgical therapy has a reported failure rate of between 7% and 24%, depending on the case histories. Dockery in 1999 and Masala et al. in 2001 presented their results on alcoholisation of Morton’s neuroma. The aim of this study is to prove the reproducibility of the aforementioned procedure and its results.
Between December 2001 and March 2004, 30 patients with Morton’s neuroma were examined with US and treated with alcohol injections under US guidance by the same operator. Among these 23 were women and seven men with age ranging between 37 and 70 years. Fifteen patients presented with more than one neuroma in the same foot or in both feet. The standard US was followed by a 3D US in order to extend the diagnosis in treated patients. Alcohol-sclerosing intralesional treatment was performed in 45 neuromas. The treatment consists of an injection cycle (minimum 1, maximum 4), composed of 50% ethyl alcohol (95%) and 50% of a 2% aqueous solution of carbocaine. A total of 90 injections were performed, with an average of two for each neuroma. The patients were examined after the treatment by both authors. On 31 (69%) neuromas, the alcohol-sclerosing intralesional treatment was successful; 14 (31%) neuromas had only a partial improvement and therefore the patients underwent a surgical excision. No procedure-related complications were observed.
The results of this study indicate that, even considering the failure rate, compared to surgery the alcoholisation treatment of neuroma under US guidance is a valuable conservative procedure because of its low morbidity and cost-effectiveness. Alcoholisation under US guidance thus could be a useful tool for orthopaedic surgeons in order to determine whether surgical excision is really necessary.
The purpose of this work was to create an in vitro model of tissue-engineered cartilage structure produced by isolated swine articular chondrocytes, expanded in culture and seeded onto a biological scaffold.
Swine articular chondrocytes were enzymatically isolated from pig joints and expanded in monolayer culture. When confluence was reached, cells were resuspended and seeded in vitro onto biological collagen scaffolds for 3, 4 and 6 weeks. Samples were retrieved from the culture and analysed macroscopically and biomechanically by compressive test. Gross evaluation was performed by simple probing, sizing and weighing the samples at all time periods. A baseline of the values was also recorded at time 0. Then, samples were biomechanically tested by unconfined compression and shear tests. Finally, the samples were fixed in 4% paraformaldehyde and processed for histological evaluation. Some samples were stained with Safranin-o, and some others subjected to immunostaining analysis for type II collagen.
Upon retrieval, samples showed dimensional enlargement and mass increase over time and gross mechanic integrity by simple probing. A biomechanical test demonstrated an initial reduction in the values of compressive and shear parameters, followed by a consistent increase throughout the tested time points. Histology showed cartilage-like tissue maturing over time within the biological scaffold.
The results from this study demonstrate that isolated chondrocytes could be seeded onto a biological collagen scaffold, producing cartilage-like matrix with tissue-specific morphology and biomechanical integrity. This tissue-engineered cartilage structure is easily reproducible and it could represent a valuable model for studying the behaviour of different variables on the newly formed cartilage.
There is more than one option for proximal humerus reconstruction after oncological resection but we believe osteochondral allografts provide a good biological solution for these defects. We report three cases with different histological diagnoses and different results following such reconstruction. The aim is to highlight the advantages and disadvantages of this surgical procedure.
The first case report concerns a 15-year-old boy (M.P.) with Ewing’s sarcoma of the proximal humerus. The gleno-humeral articulation and most of the rotator cuff were not involved by the disease. An allograft was used for the reconstruction after satisfactory resection. This allowed good restoration of the function quickly. At 12 months there was a fatigue fracture in the allograft, which required revision with a modular prosthesis. In another patient, a young woman (E.C.), a proximal humeral defect was reconstructed following resection of a benign lesion, fibrous dysplasia. She does not have complete restoration of function but there are no complications at 3 year follow up. The last case is a 49-year-old woman (M.M.), who had osteochondral allograft reconstruction of the proximal humerus after resection of a completely destroyed head by a giant cell tumour. She had good initial results but required revision surgery with Kuntscher nail and vancomycin was added to the cement due to infection.
The biological articular reconstruction after oncological wide resection allows good functional results when rotator cuff tendons are available and allografts permit a good and fitting reinsertion. The reported early restoration of function in the young boy (case 1) has to be considered in the stress-fracture genesis. The authors consider that the lack of motion in case 2 was due to a non-aggressive and careful rehabilitation: a quite poor functional result to avoid complications. The case 3 failure is due to an infection, one of most frequent complications in allograft implants. The choice of using an osteochondral allograft must be considered as a useful alternative with prosthetic replacements.
Autogenous bone grafting is widely used. In particular cancellous bone is osteoconductive, but the morbidity at donor sites is a reason to use bone substitutes.
In 5 years we have treated 64 patients affected by orthopaedic (arthrodesis of the ankle or the foot, THP revision) or traumatologic problems (acute fractures of tibial plateau, non-union or malconsolidation) with mineral bone substitutes (Pyrost or Osteoplantl). In a prospective clinical study, these substitutes were implanted as follows: the bone defect was filled by bone substitute (usually 5 ml)and we evaluated regeneration of bone defect by X-ray, MR and histological evaluation of osteogenic cells (at removal of osteosynthesis). In 85% of cases the regeneration of the bone defects was complete; in the other cases a partial or insufficient regeneration was found.
In different animal investigations Pyrost has been shown to have osteoconductive and osteostimulative effects: these substitutes have no antigenic propriety. In conditions of low osteogenetic potency, the combination of bone substitutes and autogenic bone marrow affects bone formation. In disadvantageous bone bed, bone substitutes must be augmented with bone marrow and in large segmental defects combination with autogenic bone grafts is recommended. A prerequisite for the application of bone substitutes in large defects is a sufficient primary stability of the bone bed. The application in infected tissue is not favourable.
Non-union of the radius and/or ulna is comparatively common in the treatment of forearm fractures. Bone graft from the iliac crest secured by rigid plate fixation under compression is indicated in non-unions with a bone defect longer than 2 cm. The aim of the study is to compare the results with the current literature.
Thirteen patients (female: 1; males: 12), mean age 44 years (23–75 years), were treated in our department between 1993 and 2003. In 10 patients the original injury involved both radius and ulna; in the remaining three only the ulna was affected. All the fractures had been internally fixed, except for a radius fracture. Non-unions involved the ulna in eight cases, the radius in one case and both radius and ulna in four cases. A cortico-cancellous graft was used to fill a defect of the ulna in 11 cases and of the radius in two cases. In the non-unions of both bones only one bone was operated (one radius and three ulna); a different treatment was performed in the other bone. The mean time between the original injury and the indexed procedure was 7 months (3–14 months). The mean bone defect was 4 cm (2–6 cm). A T-shaped cortico-cancellous graft was always used. All the patients were evaluated clinically and radiographically with a mean follow-up of 4 years (1–10 years).
Bony union was achieved in all the patients at an average time of 4 months (3–6 months). At the follow-up the mean elbow flexion was 130°, the mean extension lag 4°, the mean pronation 71° and the mean supination 61°. The mean grip strength was 38 kg, 81% of the contralateral side.
Cortico-cancellous bone graft from the iliac crest is an effective technique to fill a bone defect of between 2 and 6 cm. Up to this length the mechanical properties of the graft are optimal for a rigid plate fixation under compression; moreover, biological conditions allow ready integration of the graft. Rigid fixation with cortico-cancellous bone graft from the iliac crest is a useful technique for forearm non-unions with a bone defect of between 2 and 6 cm.
This study was conducted to evaluate the clinical and radiographic results on titanium stems that were similar in design but differed with regard to proximal grit-blasted surface texture with and without a hydroxy-apatite (HA) coating. We evaluated 40 patients who had undergone primary total hip replacement by a postero-lateral approach. The stems, all made of titanium alloy, tapered, grit-blasted, collarless, with anterior-posterior fins, did present some differences: in a group of 20 stems a proximal hydroxyapatite coating (thickness: 50 μm) was implanted; in another group of 20 stems the proximal surface was without HA coating. Clinical and radiographic evaluations were performed pre-operatively at 3, 6 and 12 mounths during the first year; than once for the following years.The mean duration of follow-up was 6 years.
At the final follow-up examination the Harris hip scores in the HA-coated group (mean, 96 points) and non-HA coated group (mean, 94 points) were similar. Bone-remodelling patterns were similar in the groups and the fast bone integration of the HA coated group. In both groups only two cases of aseptic loosening of the stems were found.
After 6 years of follow-up, the clinical and radiographic results among grit-blasted titanium tapered stems with or without Ha coating were perfectly similar. The optimum final bone integration was due just to the singular shape of femur (type B Dorr’s) with an excellent proximal bone stock. The micromotion of implants reduced the bony-anchored stems in two cases.
Benefits for the patients and for the Health Care System could rise from the adoption of a global clinical approach (“disease management approach”) for osteoporosis and its fracture complications vs the current “component-based approach”. Disease management is a kind of method aimed to manage (from a clinical and managerial perspective) highly prevalent and expensive diseases from the prevention to treatment and rehabilitation in order to improve patient outcome and to lower costs in general.
Osteoporosis and its fracture complications in the Italian population meet the criteria of being highly prevalent and expensive. Four million women and 800,000 men in Italy suffer from osteoporosis. Furthermore, incidence and costs of hip fractures in the elderly Italian population (> 65 years old) are comparable to those of acute myocardial infarction in people aged > 45. Accordingly, we built a simulation model to evaluate potential benefits of a disease management approach.
Incidence and costs (including drug-related costs) of hip fractures registered in Italy in 2001 were compared to those predictable in the hypothesis of treating all individuals who have at least one vertebral fracture with bisphosphonates. Almost 1.5 million people in Italy are supposed to have a vertebral fracture and consequently an increased risk of hip fracture. We considered a NTT value of 40 (“Number To Treat”: number of patients to treat in order to prevent one hip fracture), according to the FIT study (Fracture Intervention Trial, involving 6,500 patients).
Only 6.4% of subjects with a vertebral fracture is currently receiving treatment with bisphosphonates. In this simulation, the extension of this anti-resorptive therapy to all individuals with vertebral fractures would produce a 48% reduction in the incidence of hip fractures (NTT=40) among people aged > 65 and increase global costs to an acceptable 21% rate.
The number of hospitalisations for hip fractures in the elderly would be reduced from 78,350 (2001) to 40,850 (simulation); direct costs for hospitalisation and surgery would pass from 438 million (2001) to 236 million Euros (simulation); general costs for rehabilitation from 416 million (2001) to 224 million Euros (simulation); indirect costs from 171 to 93 million Euros; drug-related costs would rise from 46 million (0.29% of the national pharmaceutical expenses) to 750 million Euros (4.4% of the national expenses). This study seems to confirm the benefits (with regards to health and cost of illness) of a disease management approach for osteoporosis and its fracture complications.
Lim mineralisation protein (LMP) is a new positive regulator of the osteoblast differentiation programme. In humans three “splice variants” of LMP have been identified: LMP-1, LMP-2 and LMP-3. Recent studies demostrated that LMP-1 gene acts as a transcriptional factor inside the cells and is able to induce expression of specific bone genes, like the bone morphogenetic proteins (BMPs), to improve bone formation in vitro and ectopic bone formation in vivo and seems to induce spinal fusion in several animal models.
In order to evaluate the osteoinductive properties of the shorter variant of LMP, plasmidic and adeno-viral vectors expressing the optimised sequence of human LMP-3 have been generated. The osteogenic activity of LMP-3 was evaluated in vitro with experiments of transfection and infection of mesenchymal stem cells, fibroblasts and pre-osteoblasts; in vivo we investigated whether direct gene transfer of LMP-3 in the triceps muscles of immunocompetent mice was able to induce ectopic bone formation. All the animals were studied by histology and X-rays at different time points. In all the experiments BMP-2 was used as positive control.
These experiments demonstrated that the “gene transfer” of LMP-3 in fibroblasts and pre-osteoblasts stimulates production of specific bone proteins, such as osteocalcin, osteopontin and bone sialoprotein, and induces bone mineralisation in vitro. It was also demonstrated that LMP-3 is able to induce, in a dose-dependent manner, bone mineralisation and expression of specific bone genes (BMP-2, OSX, RunX2, alkaline phosphatase) in mesenchymal stem cells. Finally, the experiments showed that direct gene transfer of LMP-3 in the triceps muscle of mice induces ectopic bone formation in all the animals treated more efficiently than BMP-2.
These data demonstrate that gene transfer of LMP-3 could be used, more efficiently than BMP-2, in inducing bone formation in several cell lines and in vivo, establishing the osteoinductive ability of LMP-3. Thus, LMP-3 could represent, in the near future, a therapeutic alternative in several clinical conditions.
Stimulation of bone healing and bone formation through local application of growth factors may improve the clinical outcome in high tibial osteotomy in varus knee. The goal of the present study is to evaluate the effectiveness of autologous growth factors asscociated with or without granular coralline hydroxyapatite used to fill open wedge defects after tibial osteotomy for valgisation in 13 patients with medial femorotibial degeneration.
The integration of the coralline hydroxyapatite was complete in every case; we did not encounter any general or local problems, nor were there any intra-operative, peri-operative or post-operative complications. We conclude that local application of autologous growth factors associated with coralline hydroxyapatite is a good solution to stimulate callus formation and ossification in the early phase of bone healing and can substitute bone graft to fill bone defects.
Bone loss, either due to a septic process or to surgical débridements, is frequently associated with bone infections. Bone loss may be present in septic non-unions, osteomyelitis or septic joint prosthesis. In each of these conditions the use of bone or bone substitutes may be indicated. However, the risk of septic recurrence makes the choice of the right implant in these patients particularly difficult.
Clinical cases are presented to show the different choices available. Attention is focussed on: (1) when, in the presence of bone loss, a bone graft can be avoided and with which suitable procedures good results can be obtained; (2) when and how autologous bone grafts should be used; (3) when homologous bone grafts or bone substitutes are indicated; (4) how bone grafts should be protected against bacterial adesion and proliferation; and (5) the role of new technologies, such as bone growth factors. In this regard the clinical results are presented of the use of platelet-rich plasma (PRP) added to autologous or homologous bone after bone débridement in six patients treated with two-stage non-cemented revision of septic hip prosthesis and in two patients with septic non-union of the femur. At a minimum follow-up of 6 months (max. 1 year), we did not observe any infection recurrence, while bone remodelling and clinical outcome were favourable.
The use of bone growth factors such as PRP possibly added to autologous or homologous bone appears to be a promising technique to achieve bone reconstruction in débrided bone infections. However, with the limited numbers of patients and the short-term follow-up conclusions cannot be drawn and the use of growth factors with this indication should be limited to selected cases: patients with wide bone loss and with no signs of active infections.
No international guidelines are available concerning bone reconstruction in infections. Clinical experience shows that different surgical procedures are effective and the choice should take into considerations the type and site of bone defect, the host type and the pathogenesis of the bone loss. Growth factors may be a useful tool in these conditions and further studies are indicated.
We prospectively evaluate clinical results and MRI findings on a series of 47 patients, with an average age of 31.7 years, treated by matrix-induced autologous chondrocyte implantation (MACI) for knee and ankle chondral defects.
As isolated lesions, the joints affected were 37 knees and five ankles. As combined lesions, there were four knees and one kissing lesion in the ankle. The average size of the defects was 3.5 cm2. Clinical-functional evaluation was carried out according to ICRS, modified Cincinnati knee, Lysholm II and Tegner scales. The AOFAS score was used for the evaluation of the ankle. MRIs were taken before the operation as well as at 6, 12 and 24 months postoperatively. Among 10 second arthroscopic studies (four knees, six ankles), two biopsies were carried out after 2 years, from the medial femoral condyle and the patella, respectively. These specimens were evaluated by light microscopy, immunohistochemistry (type I and II collagen), SEM and TEM analysis.
Follow-up averaged 25.6 months. At the latest follow-up, knee scores improved after surgery. AOFAS did not improve in the patient with the kissing lesion. MRIs showed hyaline-like cartilage at the site of implantation in all treated joints with exception of the kissing lesion; four knees showed recurrence of subchondral bone oedema 1 year after surgery. Histological analysis on the biopsies revealed good definition of the tidemark and presence of type II collagen.
Clinical results and MRI findings support the efficacy of the MACI technique. Morphological findings are indicative for hyaline-like tissue formation in the implant site.
Matrix-induced autologous chondrocyte implantation (MACI) is a tissue engineering technique which requires the use of a collagen membrane on which the cultured chondrocytes are seeded. We report on the arthroscopic MACI technique for the treatment of chondral defects in the lateral tibial plate of the knee.
The implantation procedure was performed on two male patients affected by traumatic chondral lesions, 2.5 and 2 cm2 in size, respectively. The procedures were performed through traditional artrhoscopic portals and the seeded membrane was fixed with fibrin glue. Clinical-functional evaluation was performed according to ICRS score, modified Cincinnati knee score, IKDC, Lysholm II and Tegner scales. MRIs were taken 6, 12 and 24 months postoperatively.
After 2 years all the clinical scores were improved in both patients. MRI showed filling of the defects with hyaline-like tissue with reduction of subchondral bone oedema and restoration of a regular articular surface.
Even though the MACI technique is mostly performed with an open procedure, the site of these lesions could not be reached without sacrifying tendinous and ligamentous structures of the knee. With the arthroscopic approach an optimal view of the lesion could be achieved and appeared to be the best solution for these patients. The size of these defects was too large for bone marrow stimulation techniques and/or osteochondral grafts to be successful. By using fibrin glue for fixating the seeded membrane the procedure could be performed arthroscopically in a simple and safe way. No specifically designed instruments were used in these cases.
New magnetic resonance imaging (MRI) techniques for imaging cartilage have an ever-increasing role in the evaluation, diagnosis and monitoring of joint disorders. Relatively few studies have been undertaken to determine the long-term response of the cartilage to different treatments such as microfractures, osteochondral autograft, osteocondral mosaicplasty and autologous chondrocyte transplantation.
Intravenous administration of gadolinium diethylene-triamine-pentacetic acid (GdDTPA) on MR represents an exciting possility to explore and validate strategies for repairing cartilage. GdDTPA is an ionic contrast agent that is administered and is given time to penetrate cartilage where it is distributed according to the concentration of the charged molecules in cartilage matrix. The main macromolecular constituents of cartilage are glycosaminoglycans (GAG) and collagen. GAG have abundant negatively charged carboxyl and sulphate groups that by osmotic effect give the cartilage stiffness. GdDTPA enhances the cartilage that is depleted of GAG, then is distributed in an inverse relation to the concentration of the negatively charged GAG. In the normal articular cartilage tissue GAG has a lower concentration at the articular surface and a higher concentration in the deeper zone as histological and GdDTPA on MR studies have confirmed. Many problems we can consider to be the choice between i.v. contrast administration and intra-articular injection, which is an invasive route. Furthermore, the time course of penetration of Gd-DTPA into cartilage depends on the cartilage thickness. The time for maximum signal enhancement may vary from 45 min. for the thin ventral femoral condyle to about 4 h in patellar cartilage. Progress has also been made in evaluating the distribution of GAG in patients with osteoarthrits.
Our goal is to gain information regarding the state of the cartilage in follow-up of autologous condrocyte transplantation correlated with the clinical implications. The severity of the focal defect of cartilage in one negative result is estimated from the morphologic appearance of the hyperintense lesions on contrast-enhanced MR images. In agreement with Gillis et al. we could observe clear time-associated differences of GAG density in the patients who received autologous chondrocyte implants.
We report the clinical results and MRI findings observed in 50 patients who underwent collagen meniscus implant (CMI) between March 2001 and October 2003. Fifty patients affected by irreparable meniscal lesions or who had previously undergone partial medial meniscectomy were arthroscopically treated with CMI, a tissue engineering technique designed to promote meniscal regeneration. Average age at the time of surgery was 38.4 years. The average size of the lesion/defect was 4.3 cm. Additional procedures included 16 ACL reconstructions, eight high tibial osteotomies and two autologous chondrocyte implantations. All knees were evaluated according to the Lysholm II and Tegner activity scales. MRI was performed 6, 12 and 24 months postoperatively. Six arthroscopic examinations of the implant were performed at different times (6 to 16 months postoperatively).
Postoperative complications included saphenus neuroapraxia in three patients and CMI rupture in one patient who presented with persistent knee swelling. Follow-up averaged 16.5 months, with a minimum of 6 months. At the most recent evaluation, 46 patients showed an improvement in the clinical scores. A progressive, uniform signal was evident by MRI. At the second arthroscopic study, free fragments of the implant were observed in cases of CMI rupture. In another patient, partial resorption of CMI was observed at the posterior horn. The remaining four arthroscopic examinations demonstrated regeneration of meniscal-like tissue.
Clinical results achieved with CMI are promising. MRI proved to be an effective tool for monitoring the evolution of the implant and showed good correlation with clinical outcomes and arthroscopic findings at follow-up.
Collagen meniscus implant (CMI) is a tissue engineering technique for the management of irreparable meniscal lesions. In this study we evaluate morphological and biochemical changes occurring in CMI after implantation. Gene expression technique was also adopted to characterise the phenotype of the invading cells.
Light microscopy, immunohistochemistry (type I and II collagen), SEM and TEM analysis were performed on five biopsy specimens harvested from five different patients (range, 6 to 16 months after surgery). Fluorophore-assisted carbohydrate electrophoresis (FACE) and real-time PCR evaluation were carried out on two biopsy specimens harvested 6 and 16 months, respectively, after implantation. All these investigations were also applied on non-implanted scaffolds for comparison.
Scaffold sections appeared to be composed of parallel connective laminae, connected by smaller connective bundles surrounding elongated lacunae. In the biopsy specimens, the lacunae were filled by connective tissue with newly formed vessels and fibroblast-like cells. Immunohistochemistry revealed exclusively type I collagen in the scaffold, while type II collagen appeared in the biopsy specimens. FACE analysis carried out in the scaffold did not detect any GAG disaccharides. Conversely, disaccharides were detected in the implants. Real-time PCR showed a signal only for collagen type I. In the scaffolds no gene expression was recorded.
The morphological findings demonstrate that CMI is a biocompatible scaffold available for colonisation by connective cells and vessels. Biochemical data show a specific production of extracellular matrix after implantation. The absence of signal for type II collagen gene can be attributed to different maturation stages of the in-growing tissue.
Autologous chondrocyte implant (ACI) is a very effective technique in the treatment of chondral lesions in order to restore normal hyaline cartilage. This technique, reported for the first time by Peterson in 1994, is advised for young or middle-aged. active patients with a single painful chondral injury (3/4 grade of Outerbridge scale), starting from more than 2 cm². New tissue engineering techniques with the use of biomaterial derived from hyaluronic acid (HYAFF matrix) provide ideal support for the culture and proliferation of chondrocytes, allowing at the same time arthroscopic implant. There are many advantages of arthroscopic techniques: easy implant and less pain post-operatively; however, the indications for arthroscopic technique are still restricted: single chondral inury, 2–6 cm² in size and localisation at the femoral condyles.
At the Department of Orthopaedic Surgery of the University “ Federico II ” of Naples starting from January 1996 to the present, 29 patients were treated with ACI. Eight patients (six men and two women) had an arthroscopic implant. Median age was 18; in seven patients an OCD of the medial femoral condyle was present and just one patient had a post-traumatic injury of the medial femoral condyle. Hyalograft was used in all cases. All patients underwent CPM starting from the second post-operative day and full charge was allowed after 2 months. All patients were evaluated by clinical examination with IKDC score and functional score (Tegner) at 3, 6 and 12 months after surgery and with a MNR at 6 and 12 months after surgery and then every year.
Good results were found subjectively in 88% of the patients, with a complete lack of pain in 70% cases. Using the IKDC score good results were found in 85% of the cases (average score 90). With the Tegner score we reported an improvement in the level of activity in 60% of the cases.
The MNR images, performed with standard sequences, fat-suppressed and in the last cases with dGEMRIC, showed the presence of regeneration tissue inside the chondral defects, with a signal very similar to that of the cartilage tissue, sometimes slightly deeper.
Our experience shows that ACI is an effective way of treating chondral lesions with excellent results. We think that progress in the field of biomaterials will extend the indications for arthroscopic techniques, also allowing implants in larger lesions and at other sites.
Chondral injury has become one of the most difficult problems to solve in orthopaedics. This pathology is very common: Curl et al. founded an incidence of 63% of chondral lesions (2.7 lesions for knee in 31,156 knee arthroscopies) with a 20% rate of lesions of grade IV of Outerbridge.
During the past few decades many techniques were developed: with these techniques the lesion is just reparied with the formation of fibro-cartilage tissue with biochemical and bioelastic characteristics very different from the hyaline cartilage tissue.
Microfracture technique : This technique, proposed by Steadman et al., utilises hand-drills to create numerous perforations in the subchondral bone at 3–4 mm apart. Indications for this techniques are lesions from 0.5 to 2 cm2 with an outlined border in patients with low functional demand. Osteochondral autograft transplantation (OATS, mosaicplasty): Osteochondral autograft transplantation is indicated for isolated lesions from 1 to 3 cm2 or in OCD. Outerbridge et al., in a study of 10 patients with 6.5 years of follow-up, achieved good functional results in all pateints treated with this technique. Autologous chondrocyte implant: ACI, reported for the first time by Peterson and colleagues in 1994, is advised for young or middle-aged, active patients with a single painful chondral injury (3–4 grade of Outerbridge scale), starting from more than 2 cm2. They. reported good results in the treatment of chondral lesion with a long follow-up (2–10 years). New tissue engeneering techniques with the use of biomaterial derived from hyaluronic acid provides ideal support to the culture and proliferation of chondrocytes, allowing at the same time arthroscopic implant.
Today there are many options in the treatment of chondral lesions, but no one technique can be considered the gold standard. ACI in arthroscopy is a more promising technique in the treatment of the chondral lesions, but the indications are still too restricted.
Neglected rupture of quadriceps tendon is an infrequently occurring lesion resulting from sport, but it is very interesting as regards the physiological and functional repercussions. The lesion is common in football players. The pathogenesis is a flexion trauma of knee. Many authors point out the importance of a pre-existent degeneration due to exogenous and endogenous factors. Pain, inextensible knee, ecchymosis, axe hit are a common presentation in acute events, difficult knee extension and pain in chronic. X-ray study shows calcification at the tendon-bone junction.
The treatment of neglected rupture of quadriceps tendon is surgical. If a defect of 5 cm or more is present between the ends of tendon the fascia lata can be used to correct the gap. When the ends can be apposed an end-to-end repair is possible. We treated a neglected rupture of quadriceps femoris muscle tendon in a bodybuilder with a particular technique: we stripped and harvested the semitendinosus and gracilis tendon and sutured them together. Then we made a transverse hole in the mid-portion of the patella; the tendons were passed through the transverse hole in the patella and sutured with the lateral, medial and intermendial vastus, and with the rectum femoral. At 6-month follow-up the patient has no pain and stability is improved, a practical range of knee motion regained. Full forceful extension is not completely restored.
It is well known that tibial osteotomy of arthritic painful genu varum in patients younger than 70 years of age has advantages both for the mechanical effect of symmetrical distribution of joint loading and for the biological effect produced by the bone section on the local venous intraosseus pressure which reduces pain. Patients were selected according to pre-operative X-ray evaluation of the limbs taken with the patient bearing weight on one foot: varus deformity not greater than 25°, knee flexion not greater than 15°, joint movement not less than 90° and absence of femorotibial subluxation or other instabilities. Surgery consists in application of three proximal and two distal screws into the medial side of the tibia. An Orthofix Fixator with self-aligning body is applied and an oblique osteotomy performed medially through a 3-cm skin incision using a drill bit and an osteotome to keep the lateral cortex intact in order to avoid lateral translation of the distal segment.
The patient can correct progressively the deformity himself by distracting the compression-dsistraction unit with an allen wrench. Once the desired correction has been achieved (8°–10°), a control X-ray is taken and the central body locking nut of the fixator tightened. Patients can bear full weight with crutches 4–5 days after surgery.
We have treated a total of 163 patients (92 men, 71 women). Their average age was 60 yearsand average healing time 75 days. Results were excellent in 60%, good in 25%, fair in 10% and poor in 5%. The average post-operative valgus was 9%. The technique and the clinical results are discussed.
The authors present their experience with high tibial osteotomy for the correction of varus knee, performed wih an open wedge technique (Puddu). This technique allows correction of varus knee with a medial tibial osteotomy open wedge, using a special tibial plate; this plate is fixed with two cortical screws and two spongious screws and is formed by a tooth that prevents the correction from loosening. The aim of our work is the retrospective clinical and radiographic evaluation of 18 patients treated with Puddu technique at the University of Naples.
Indications for this technique are: constitutional varus knee, chondral damage after medial meniscectomy and medial gonarthrosis. From June 1999 to the present we treated 18 patients (13 women, five men), median age 54, with high tibial osteotomy with Puddu technique at the department of Orthopaedics and Traumatology of the University of Naples. Before the osteotomy we normally perform a knee arthroscopy to achieve a correct articular balance (evaluation of articular cartilage, menisci and ligaments) and to treat associated lesions. All patients were evaluated by clinical examination with IKDC score and X-rays. Median follow-up was 30 months.
Results are very good with an important improvement in pain and disability. Vascular and neurological complications were not found in any of the patients; all the osteotomies had a strong consolidation and showed good correction of the deformity.
High tibial osteotomy with Puddu technique in our opinion seems to be an effective technique in the treatment of medial knee arthritis and in the correction of femoral-tibial axis. It is an easy, reproducible and trusted technique and in our opinion recommended over the traditional tibial osteotomies (closed wedge osteotomy, dome osteotomy and osteotomy with external fixation, etc).
Adolescent idiopathic scoliosis is known to aggregate within families; however, the pattern of inherited susceptibility is unclear. A genomic screen and statistical linkage analysis of a genetic isolate including individuals with idiopathic scoliosis is being performed to identify variants responsible for this disease.
Scoliosis does not demonstrate a characteristic pattern of classical genetic (inherited) disorders. The severity of the disease within families can change and sometimes generations are skipped. However, the role of hereditary or genetic factors in the development of this condition is widely accepted. Numerous investigators are currently attempting to locate these genes. Studies based on a wide variety of populations have suggested an autosomal dominant mode of inheritance or sex-linked inheritance pattern. Other authors state that the “genetics link” may be complex, with an interaction of several genes rather than just one.
To identify chromosomal loci encoding genes involved in susceptibility to idiopathic scoliosis and the trasmission way of scoliosis we are studing a genetic isolate. We have generated a 10,600 individual pedigree of the village of Campora, in the Cilento area, starting from the beginning of the 17th century connecting all the 1200 living inhabitants. The actual population of Campora derives from a few founders; therefore, the living inhabitants are all related to each other. The population will undergo clinical and radiographic evaluation for the presence and degree of scoliosis. A genomic screen and statistical linkage analysis of the families with individuals having idiopathic scoliosis will be performed. With this approach we can identify variants responsible for this complex disease and genetic links of scoliosis.
Pes planus is a complex syndrome whose origin can be quite different. Knowledge of the causes is essential for optimal treatment. Clinical and radiographic examinations are the basis for a correct diagnosis. Arthroreisis of the sub-astragalic joint, extrasenotarsum, represents the gold standard for surgical correction of idiopathic pes planus in childhood. The rate of excellent and good results has been 98% in the authors’ experience. We conclude that the arthroreisis of the sub-astragalic joint is an easy, fast and efficacious operation in the management of idiopathic pes planus.
In the reconstruction of the anterior cruciate ligaments of the knee, early loading of the leg is usually desirable. Thus, it is of a great interest to evaluate the early stability of screws used for tibial fixation of the ligament, rather than long-term stability of such devices when the neoligament is certainly integrated. The purpose of this study (controlled laboratory study) was to investigate the early osteointegration and biodegradation of hydroxyapatite (HA)/poly(L-lactide)(PLLA) (HA/PLLA) composite screws compared with tricalcium-phosphate (TCP)/PLLA (TCP/PLLA) composite screws used for tibial fixation in the reconstruction of the anterior cruciate ligaments.
We used two types of resorbable screws: BioRCI (Smith& Nephew) composite screws (30% HA and 70% PLLA) and Biocryl (Mitek) composite screws (30% TCP and 70% PLLA) that were inserted into the distal femur of three skeletally mature sheep. Each animal received one HA/PLLA composite screw and one TCP/ PLLA composite screw. The three sheep were sacrificed 20, 40 and 60 days after surgery. Results were evaluated by radiological (RX, TC and RMN), histological and microradiographic analyses.
The amount of bone tissue osteointegrating the screw was higher for TCP/PLLA screws than for HA/PLLA screws. No sign of real biodegradation was observed in any of the specimens.
In conclusion, TCP/PLLA composite screws provide a favourable early osteointegration compared to HA/PLLA composite screws; this could provide an early loading of the leg, which is the primary goal of clinicians and patients in this case. In addition, this could provide a considerable reduction of medical expenses, due to the decrease in hospitalisation and rehabilitation time.
Enchondroma of the hand is a common benign tumour composed of mature cartilage; it is usually asymptomatic and found accidentally or after pathologic fractures. Malignant transformation may occur, though only very rarely. The age of the patients varies widely. The small bones of the hand are the most frequent anatomic site for this pathology.
Enchondromas are conventionally treated by curettage and the bone defect is then filled with morceellised autologous bone chips from the iliac crest or with an allograft. Recently, bone substitutes have also been used instead of autologous or allogenic bone graft.
Calcium phosphate cement is a promising injectable biomaterial able to increase the number of osteoblasts without inducing a marked de-differentiation, an effect that is useful when a high number of bone forming cells are required. This bone substitute has been used successfully for the treatment of distal radius fractures and or mal-unions, femoral neck fractures, tibial plate fractures, complex calcaneal fractures and enchondromas.
From 2001 we treated 12 patients who were diagnosed as having solitary enchondromas, nine in the hand (four metacarpal bones and five finger bones); 6 patients had an associated pathologic fracture that occurred as a result of simple trauma. A surgical treatment with a complete removal of the tumour and the injection of Norian SRS cement into the cavity and fluoroscopic control was performed as a standardised procedure in all cases. The patients allowed to perform complete range of motion 3 weeks after surgery. At follow-up they were evaluated by clinical examination, X-ray and the DASH questionnaire.
None of the patients had swelling or deformity or tendon injuries or wound infection. Four patients had a slight loss of flexion at the MF joint but none considered this a functional limitation; all the others regained a complete ROM. All the patients returned to their presurgical occupation. Five of them complained of a hypertrophic scar. The X-ray showed a complete fill of the bone gap. They were satisfied and the mean DASH score was 6.06.
Clinical results have been reported with simple curettage without bone grafting or bone substitutes, but these two elements minimise the volume of the bone defect, maintain bone strength and promote new bone formation. Autologous bone graft caused pain in the donor site. Reconstruction of the tumour cavity provides immediate mechanical stability and good functional outcome.
Patello-femoral tracking and polyethylene wear are strongly dependent on rotational alignment of the components in total knee arthroplasty. In the current literature four methods to obtain correct axial femoral alignment are reported: the transepicondylar axis method, Whiteside’s method, the tibial axis method and 3° external rotation of posterior condyles method. Because of its simplicity the last of these is the most popular method used at present. But it is also the most accurate? The purpose of this study was to investigate the accuracy of the 3° external rotation method, comparing it to the transepicondylar axis and the White-side’s A-P line.
We performed a CT scan examination of the hip and the knee of 40 patients scheduled to undergo a total knee arthroplasty. Seven cases of valgus deformity were excluded from the study, leaving 34 cases. The mean age was 72.4 and the left knee was involved in 23 cases. The mean height was 159 cm and the mean weight was 76.6 kg. The mean varus deformity was 14° (min 5° – max 30°). CT scan was conducted using a Picker PQCT machine. Two axial images were obtained in all the patients: one of the femoral neck and one of the knee with good visualisation of the posterior aspect of the condyles of the femur and epicondyles. We measured the following angles: the femoral anteversion angle (between the femoral neck line and the posterior condylar line), the posterior condylar angle (between the posterior condylar line and the transepicondylar axis) and the Whiteside’s angle (between the posterior condylar line and the perpendicular line to the White-side’s A-P line).
The mean femoral anteversion angle was 5.5°± 13.7° (min -24°; max 33°). The mean posterior condylar angle was 6.1°± 2.5° (min 1°; max 14°). In 20 cases (60.6%) the posterior condylar angle was greater than 5°. The mean Whiteside’s angle was 6°±3.5° (min 1°; max 16.5°). In 17 cases (51.5%) it was greater than 5°.
Both the posterior condylar angle and the White-side’s angle showed average values, which doubled the 3° proposed as standard for external rotational alignment of the femoral component, with maximum values of 14° and 16.5° respectively. More than 50% of the cases showed a posterior condylar angle grater than 5°. The two methods (transepicondylar and Whiteside’s line) are complementary. The posterior condylar axis and the Whiteside’s line were not altered by severe varus deformity or femoral neck retro- or anteversion. The 3° external rotation of the posterior condyle line is not recommended as a standard procedure to determine the degree of external rotation of the femoral component in total knee arthroplasty.
The frequent association of patellofemoral pain and malalignment of the extensor mechanism is well known. In our experience, lateral hypertorsion of the tibial metaphysis (enough to cause excessive compression on the external facet of the patella) is a common finding in patients with anterior knee pain, and is even observed with computed tomography (CT).
Many surgical procedures have been described, both for the realignment of the extensor apparatus and for the reduction of the excessive patellar compression. The technique of tibial tuberosity derotation consists of a distal realignment on the frontal plane with consequent reduction of the external patellofemoral pressure. This latter, based on studies on anatomic preparations, can achieve a reduction of about 50% if the tibial extra-torsion is reduced surgically. In our study, the results obtained with this surgical procedure in the medium term have been evaluated in a group of 26 patients with patellar maltracking. Our study concerned 10 men and 16 women, aged 17–42 years. These patients were affected by a painful patellar syndrome that had persisted for a period between 8 and 18 months. They underwent surgery during the period between September 1992 and June 1995. Preoperatively, each patient underwent a cycle of physiokinesiotherapy, for at least 6 months.
The pain disappeared in 15 patients; it developed after moderate activity in four patients and appeared only occasionally in five patients. In only two cases did the pain remain unchanged. Seven patients reported difficulty in assuming or maintaining a kneeling position. After surgery, the Lysholm score increased from 43 to 79. When questioned about the degree of satisfaction with the corrective surgery, 16 patients declared themselves to be very satisfied, six patients were fairly satisfied, and four patients were not satisfied.
We propose this procedure as a treatment for anterior knee pain resistant to conservative therapy, in young patients with external hypertorsion of the proximal tibial metaphysis and without significant chondro-pathology.
Although endomedullary nailing is a reliable and quick method of treating long bone fractures, permitting an early load, it presents some risks and some problems due to rotational, flexion and compressions forces on its structure. In prematurely permitted loading, an operated limb that is not fully healed may be incompetent in weight-bearing and thus entirely supported by the nail, causing it to bend or break. We encountered this in two patients treated with a Kuntscher nail for femoral fracture who fell on the affected limb while walking on crutches after about 40 days after surgery. They suffered violent pain and a significant deformity of the limb in the area of the fracture. One patient was a 42-year-old man and the other a 19-year-old woman. A closed manipulation to straighten the bent nails according to the Patterson and Ramser method was performed in order to remove them and a guide-wire was introduced in the cavity of the nails during extraction. A new Kuntscher nail was inserted along the wire, shortening the time of operation and reducing the risks of X-ray exposure. Since it can be difficult to find the exact path along the medullary cavity when inserting a new nail and in order not to disturb the fracture healing, we recommend using a guide-wire as illustrated and not to ream the cavity.
Unlike tri-compartmental arthroplasty, unicompartmental knee arthroplasties (UKAs) correct only osteochondral condylar defects and do not include any ligament balancing. Pre-operative deformities of more than 20° strongly suggest that UKA is not indicated. Best results are generally obtained by avoiding hypercorrection and not exceeding 5° of residual deformity post-operatively. Since 1997, 112 UKAs have been implanted. We performed tibial osteotomies with respect to tibial plateau inclination in the frontal plane (metaphyseal axis). Our patients were pre-operatively studied and then re-evaluated after a mean follow-up of 4 years. We used the GIUM (Gruppo Italiano Utilizzatori Monocompartimentali) scoring system. Pre-operative and post-operative radiograms from all patients were collected, and then we correlated the amount of correction of lower limb mechanical axis with GIUM score for each patient. Mean pre-operative mechanical axis of the lower limb showed a varus deformity of 7.43°, whereas post-operative values averaged 5.56° of varus deformity, with a minimal valgus correction of the deformity. Thus, correction of angular deformity was statistically negligible (p> 0.5). Mean pre-operative GIUM score was 20.3, whereas mean post-operative score was 71.6 (p< 0.001). Correlation between entity of correction and GIUM score was significant (r=0.76). The amount of angular correction of the mechanical axis of the lower limb was statistically significant in influencing functional outcomes (p< 0.05). The best results are obtained by correcting excessively valgus knees to a physiologic range, while varus knees have to be minimally corrected. The worst results are obtained with greatest modifications of the mechanical axis of the lower limb.
Pronatus syndromes of the hindfoot often represent a deformity in patients of developing age. They are characterised by internal valgus rotation and adduction of astragalus, calcaneous pronation and valgus tibial-calcaneous axis. During the walking phase, the astragalic leaning phase is increased with a consequence of wider pronation of the forefoot. This often creates a functional compensation of the joint and of the myotendinous structures of IMF and progressive valgus deviation of the hallux.
In the last few years, many different techniques to correct and to stabilise the altered alstagalus-calcaneous relation have been introduced. This altered relation represents the ‘primum movens’ of this deformity through the stimulation of the endotarsal proprioreceptors; this evokes some inputs that allows the capsular ligaments a retraction structure during the development.
In the period between April 2001 and December 2003, in the 1st Clinica Ortopedica of the Bari University, 30 patients (16 males and 14 females; age range between 7–12 years, median age 9.6 years) with pronatus syndrome were treated with surgical astragalus-calcaneous arthrorisis according to Pisani; 27 patients were operated bilaterally. All patients (57 feet) were evaluated at a median follow-up of 15.3 months (range 2–32 months). Clinical and radiological results have shown alignment of the hind-foot and normal plantar part of the foot.
These data confirms that the astragalus-calcaneous arthrorisis represents a valid technique in the pronatus syndrome.
Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques.
Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation.
Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation.
Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details.
As the digital venous system in foetus has received little attention by researchers, a morphological study regarding appearance, localisation and differentation in the foetal hand during the first 3-month period of pregnancy has been conducted. Eighteen fingers from six human embryonic hands of 6, 9 and 12 weeks of gestation, derived from voluntary abortions, were the object of this study. Transverse sections obtained from the tip of the third digit to the base and perpendicular to the digital axis were alternatively stained with haematoxylin-eosin or blue of toluidine. At the sixth week a widespread presence of venous capillary vessels is masked by the mesenchymal cells. At 9 weeks a widespread presence of capillary vessels persists both on the ventral and on the dorsal part of the digit; at this stage it is possible see lacunar areas dividing the finger into compartments. At 12 weeks the neurovascular bundles are perfectly differentiated; in the anterior part there is a widespread presence of capillary vessels and in the posterior part, close to the extensor apparatus, we still see a wide venous area semicircular in shape, going from the apex of the finger till its base.
At the end of the first 3 months of intrauterine life the digital venous system is in its basic pattern already perfectly differentiated. It is possible to describe in the anterior digital part the presence of the superficial and deep venous system. In contrast, in the dorsal part we still see a wide venous lacunar area close to the extensor tendons.
In the last few years the study of the biology of fracture repair processes has isolated chemical mediators that induce and modulate bone repair. In orthopaedic surgery and traumatology, in cases of unsuccessful fracture setting, loss of bone and in the treatment of bone cavities it is advisable to associate a biological substitute in order to restore bone continuity and to maintain the mechanical properties of the skeletal segment.
Platelets contain several growth factors (PDGF, TGFβ, EGF, IGF) capable of stimulating the proliferation of mesenchymal and mature cells such as fibroblasts and osteoblasts. The autologous platelet gel is obtained by separating and concentrating platelets from 450 ml of a patient’s blood. This procedure is simple, with a low risk of infections. It is free of immunogenic risk and it is comparatively cheap, considering the risk connected with a possible graft of homologous bone or with the use of allo- or xenograft.
From 2003 we applied autologous platelet gel in eight patients: two cases of humerus pseudoarthrosis for exposed and plurifragmentary fractures, one with vascular and nerve injury; one forearm infected pseudoar-throsis with loss of bone and soft tissues caused by local drug injections; one infected ulnar pseudoarthrosis for high energy exposed proximal forearm and elbow fracture; one distal radius non-union after sub-amputation of distal forearm; one distal radius resection for TGC and implant of allograft epiphysis; one massive osteomyelitis of entire forearm after exposed distal radius fracture; and one humerus fracture in re-implanted arm with elbow arthrodesis.
The patients were treated with surgical curettage of bone, iliac bone graft and autologous platelet gel; two received a vascularised fibular graft, all stabilised with internal fixation and six stabilised also with external fix-ation. They were immobilised for a mean of 3 months; then with a partial tutor they started physiotherapy. At the follow-up they were evaluated clinically and radiologically and with the DASH score.
None of the patients had local or general post-operative complications; X-ray showed the restoration of regular skeletal filling. Only in one case was bone reabsorption seen in the distal humerus. All patients were satisfied and four of them returned to their pre-surgical occupation.
The results of this application are difficult to standardise because of the complexity of each case. Imaging techniques are currently the only means to validate the remodelling process and to demonstrate its faster pace with platelet gel application. We are satisfied by the use of autologous platelet gel as a possible co-treatment in cases characterised by multiple surgical treatments with inactive pseudarthrosis and osteoepenia. The application is also simple, and the cost is relatively low with respect to the results obtained.
The autologous chondrocyte implantation (ACI) technique described by Peterson, which we adopted in 1997, is not suitable for an arthroscopic application. Since November 2000 we have been moving towards a system based on a solid collagenic scaffold (MACI®, Verigen) which allowed us to develop an entirely arthroscopic procedure applicable to all knee joint areas.
A total of 47 patients (mean age 31 years), accounting for a total of 52 focal, non-degenerative chondral defects with an average size of 4.7 cm2 (range: 3.2 – 6.2 cm2), have been treated arthroscopically. All were mobilised on the first and discharged on the second day after surgery. Partial weight-bearing was introduced after 4 weeks and increased to the full extent after 8 weeks. They were clinically evaluated by Modified Cincinnati, IKDC and Visual Analogue Scale (VAS). In two cases, after specific informed consent, an arthroscopic second look was performed1 year after surgery. The regeneration was assessed macroscopically (ICRS Cartilage Repair Assessment score) and histologically (histomorphometry and immunochemistry).
We re-assessed the first 30 knee joints with a mean follow-up of 23 months (min 12, max 36). Cincinnati Scores improved from 2.8±1.14 (baseline Clinician) to 9.4±0.73, and from 2.5±0.90 (baseline Patient) to 9.7±0.50 at 3 years, respectively. IKDC and VAS results paralleled the Cincinnati scores. The two second- lookprocedures performed showed a regenerated tissue assessed as normal according to ICRS, a finding also supported by the histological evaluation.
The arthroscopic technique can be considered an established approach for second-generation ACI application, even in case of multiple lesions, and mainly for medial femoral condyle localisations. Our approach, based on traditional arthroscopic tools and procedures, can be easily performed by other adequately trained surgeons, thanks to the optimal mechanical properties of the membrane, characterised by a high resistance to tears, also after prolonged exposure to the intra-articular perfusion fluids. From the surgical perspective, the procedure is easy and fast, also when compared to the open-ceiling techniques, and in particular for non-condylar localisations (patella, trochlea and tibial plate), with clinical and histological outcomes that seem comparable to those obtained with liquid-suspension systems.
The authors comment on the treatment of patients suffering from spina bifida. The indications to surgical-orthopaedic approach for lower limb correction in patients with spina bifida are outlined. According to the authors’ experience, the therapeutic approach should be aimed at treating deformities of the lower extremities in order to apply orthotic devices, particularly for higher levels of medullary lesion, and to obtain standing and/or gait with support. In the natural history of spina bifida, this purpose has become more and more important, since reduced complications, longer average life, and improved clinical, therapeutic and technological knowledge have radically changed the life expectancy of these patients.
The analysis of a series of 71 patients with spina bifida, treated over 20 years, has enabled the authors to evaluate the main sites of deformities. They examined the surgical procedures carried out in relation to the levels of damage and observed the resulting functional autonomy. The foot was the site which offered the most frequent opportunities for treatment at all levels. Knee deformities were treated in a few cases. In particular, difficulties arose when treating L3-L4-L5 neurosegmental levels of the hip, with the result that today bone correction of this joint is performed in association with muscle transposition (external oblique abdominis m. pro medio gluteus m.) in order to ensure a dynamic correction.
The authors emphasise the need for a more cautious surgical approach, since lower limb alignment, often achieved using orthopaedic aids and splints, is more important from a functional point of view than the anatomic and radiographic correction of the deformities. From a functional point of view, apparently positive neurosegmental levels for functional recovery are damaged by the lack of early training using splints. Actually, even severe clinical conditions can acquire increased functional autonomy if splints are early introduced to aid walking. Moreover, there are increased indications for spinal surgery in patients suffering from severe paraplegia in order to improve cardio-respiratory function. A correct alignment and an adequate application of orthotic devices reduce the frequency of pelvic obliquity, which favours spine deformities.
In the correction of hallux valgus, there are many different treatments with the aim to resume angular values I MF (metatarsal-phalangeal), I IM (intermetatarsal), PASA (proximal articular set angle), sesamoid position, to improve transferring metatarsal pain and the aesthetics of the forefoot.
From November 2001 to November 2003, in the 1st Clinica Ortopedica at Bari University, 40 patients were treated for hallux valgus (nine males and 31 females). The age ranges from 17 to 82 years of age (median age: 50 years).
The correction technique is based on a distal metatarsal osteotomy (modified Chevron techniques) and fixation with ‘hallux splint’ interfragmentation dynamic and compression device (Waldemar Link GmbH & Co Hamburg, Germany). This technique give intra-operative stability of the osteotomy, giving free weight-bearing from the beginning in the post-operative phase and the complete resumption of daily activities in a short period of time.
At a median follow-up of 2 months, a significant improvement in the angular values is shown by radiological evaluation. Therefore, the result shows that this surgical technique is valid in the correcting hallux valgus.
Although various treatment options are available, which include shaving, microfractures, abrasion arthroplasty osteochondral allografts and autografts, chondrocyte grafts and unicondylar prostheses, symptomatic articular cartilage defects represent a therapeutic challenge.
Since November 2002, as a non-biological answer to the problem, we started using synthetic cartilage implants made of polyvinyl alcohol- hydrogel (PVA – H) (SaluCartilage). This is a transparent synthetic polymer with a molecular weight of 308,000 daltons and 20% of water content, available in cylindrical shape of various diameters. Following the second part of the OATS technique, under arthroscopic control and by mini-arthrotomy, or completely arthroscopically assisted, the cylindrical implant is inserted, using press-fit technique, into previously punched out and dilatated osteochondral defects.
Our patients, whose mean age was 56 years (range 48–68 years) have been post-operatively reviewed clinically and by serial MRI exams. Patients showed significant improvement over pre-operative values in the IKDC score, with an average increase of 20 points. Follow-up MRI images revealed a normal healing process, without signs of osteolysis or wear.
As complications we had one case of implant dislocation 1 year after surgery and one case of progressive loosening due to osteoarthritic disease, both of which have required a knee prosthesis.
Our experience has led us to emphasise the use of this type of treatment only in cases that fullfil precise indications: (a) Third and fourth degree chondral or osteochondral symptomatic defects; (b) focal unicompartmental defects with 15 mm maximum extent; (c) patient’s age limited from fourth to seventh decade of life; and (d) absence of angular deformities or articular instabilities.
The synthetic cartilage resurfacing technique has the advantages of no donor defect, one short-step surgical procedure, immediate weight-bearing and no extensive rehabilitation programme. Early results of first 15 patients are being presented, expecting a longer observation follow-up study.
After previous experience with hip screws and gamma nails, based on recent biomechanical studies, we started treating femoral neck fractures with PFN nail. The proximal femural nail is made of titanium, has two lengths, and a distal flexible component of various diameters with which the femoral neck area can be stabilised with an 11.5-mm cephalic screw and an anti-rotation 6.5-mm screw, both of variable lengths.
From January 2002 to January 2004, 80 of 100 trochanteric fractures were treated with PFN nail. Most fractures were of the 31.A2 and 31.A3 AO type. Mean surgery time was 40 min. Patients began ROM exercises on the first post-operative day and assisted weight-bearing on the fourth and were controlled at 1, 2, and 6 months and then yearly.
No important intra-operative complications and no post-operative fractures have been encountered. However, we do report one case of screw cut-out. About 80% of results were good-excellent.
We can state that the use of PFN nail is of particular value since its unique technical features seem to reduce post-operative complications and surgical stresses, due to less invasiveness, intra-operative complications, and, due to the enhanced stability granted by additional cephalic screws and reduced size and increased flexibility of the distal part of the nail. Finally, we emphasise some surgical tips for best results: respect of correct nail introduction point, minimal proximal reaming, gentle introduction of the nail and particular attention to cephalic screw position and length.
The purpose of this study is TO describe and illustrate a new method of reversible hemi-physeal tethering utilized for correcting various angular deformities of the extremities. Since hemi-physeal stapling was first introduced by Dr. Blount in 1950, this method has waxed and waned in popularity. Some associated problems include staple migration or breakage necessitating premature revision surgery. The author has devised a new construct comprising a two-hole plate and two screws to achieve gradual correction of deformities while averting the problems of hardware migration or breakage. In a pilot study, 25 children with 40 physeal deformities have been treated since 2001 utilizing the plate method. The children ranged in age from 19 months to 15 years and had a variety of underlying diagnoses. The plate is placed extraperiosteally and is removed upon attaining a neutral mechanical axis. No postoperative immobilization or limitation of weightbearing is required. In all cases short-term follow-up reveals improvement or resolution of deformity without need for osteotomy. Complications have included two early migration of short screws (< 16 mm) necessitating exchange for longer screws. There have been no premature or permanent physeal closures and no other significant peripoerative complications. Growth guidance employing a two hole plate and screws offers a secure and flexible means of redirecting the physis (es) in order to accomplish safe and gradual correction of angular deformities in children. Growth is reversible; the treatment is modular and may be repeated prn.
From Urist’s studies (1965) to the following observations by Sampath and Reddi (1981) on the role of BPM morphogenetic protein and, more particularly, BPMs/ Ops in the complex mechanism of bone regeneration to recent studies (Solheim, 1998) on the properties of the single elements belonging to the superfamily of AGF of platlet derivation to activate the specific receptors of stem cells, considerable progress has been made in research and clinical application. The non-specificity of the present evaluation methods of patient outcome prevent us from singling out which element has activated the osteogenetic process, and when and which one has affected the course favourably.
In order to answer all these questions, we have carried out a prospective study between autologous AGF and stem cell application in orthopaedics and the ex vivo evaluation in vitro of platelet activation of osteoblasts. From March 2002 to January 2004, we treated 21 cases of osteolysis (in mobilisations due to pros-thesis of hip and knee, necrosis of bone head femur, pseudoarthrosis of the humerus and ulna, and aneurysmal relapsing cyst). The procedure consisted in using stem cells+AGF+autologous bone graft (two cases) or bank bone graft (13 cases)-or hydroxyapatite (two cases)+autologous fibrin glue and at the same time, in vitro culture of the patient’s osteoblasts+AGF. Among the AGF, PDGF is an important mitogenous factor. Among the isoforms of PDGF, the PDGF-AA and PDGF-AB are stored in alpha –granules and released when platelets are activated. PDGF-AA is preferentially secreted by osteoblasts and fibroblasts. PDGF-AA and PDGF-AB were measured in supernatants of osteoblasts in culture media, activated platelet culture media, osteoblasts plus activated platelet culture media at day 0, day +4, after adding platelet and day +8. At the end a cytological test was performed. The study has proved that the PDGF-AA increases remarkably after adding platelet gel to the osteoblasts, more than in control cultures which are lacking in platelet gel, which might mean the platlets activate the osteoblast and activate the osteogenetic process.
The use of autologous fibrin glue enriched in AGF has demonstrated a better recovery of the tissue scar, as well as emathic save and better stop of grafts. The range of cases is not homogeneous and prevents us from drawing any statistical conclusions, but the quick bone recovery leads to great satisfaction both for patients and their physicians.
Surgical treatment of epicondylitis is still a topic of discussion mainly with regard to timing and type of therapy and to long-term results. Many surgical techniques have been suggested (and used by us, too), such as: tendon scarification, possibly in association with bone drilling, epicondylar muscle detachment and sensory deafferentation. Nevertheless, these techniques show some limits: general or peripheral anaesthesia, invasive approach, post-operative immobilisation (requiring rehabilitation), and a long time for recovery (2 months in our experience) with a delay in working activities.
For more than a year we have been using radiofrequency treatment: in day-surgery, with minimally invasive technique and local anaesthesia in case of failure of non-surgical and/or infiltrative treatments. Patients were selected after differential diagnosis with other diseases (fibromyalgia, polymyalgia rheumatica, and thoracic outlet syndrome). Even if our follow-up is quite short, the results of the evaluation of the 54 treated patients show: immediate disappearance of pain, fast functional recovery, return to working activities after 3 weeks, no short-term recurrence and absence of complications.
In primary total hip arthroplasty in patients affected by congenital dysplasia of the hip, stabilisation of the cup because of the altered shape of the acetabulum presents a problem. We have obviated this by creating a standard protocol with a press-fit classification that helps us to resolve such problems. In 269 cases (from 1994 to 2004) of patients affected by congenital dysplasia of the hip, we have always reconstructed the acetabulum using autologous bone grafts. After the right preparation of the acetabulum, when the cover of the metal back is complete and the stability is optimal (type I), bone grafts are not required (106 cases). After positioning of the cup, if we find defects that leave less than 30% of the external surface of the metal back uncovered but the stability is good (type II) (138 cases), we reconstruct such defects with small bone grafts (bone chips) captured by the femoral head of the patient. Greater bony defects that, after positioning of the metal back, do not allow an adequate stability and leave more than 30% of the cup (type III) uncovered (25 cases), we reconstruct the acetabulum with part of the femoral head fixed with screws. The follow-up at more than 5 years is between good and excellent (89–100) in all pateitns according to the Harris Hip Score.
Since 1985 an original cementless, stainless prosthesis for C3-C7 cervical vertebral body substitution has been in use, fixed to contiguous vertebral bodies with screws. The prosthesis was employed in 151 patients, who were mostly affected by cervical metastases involving intractable pain with signs of nerve-root and/or myelon compression, using a permanent collar.
The use of this kind of prosthesis allowed a easy and quick surgery with early post-surgical mobilisation of the patient without any external support. Cervical pain resolution was very evident in all patients. Cervical substitution did not affect the prognosis of tumour but allowed a better nursing and quality of life of these patients. At a follow-up of 2.5 years we have not observed any prosthesis mobilisation.
In the last year some modifications were added to the prosthesis. Overall the prothesis was made of titanium, produced in two fashions, closed and open, and different lengths. The closed prosthesis is employed according to the indications of the previous prosthesis (in cases of corporectomy in neoplasms). The second one, open and empty, is filled with bone chips (autologous or etherologous) to achieve fusion with sorrounding vertebral bodies. Indications for the last type was corporectomy for discoarthrosis at two contiguous levels in patients in whom the intermediate vertebra were removed to assure a complete and safe cord decompression. The open prosthesis could also be used in burst fractures, avoiding other systems that require an anterior plate. The implantation technique presents no difficulties and can be easily incorporated into the group of standard surgical procedures for anterior interbody fusion.
We have used the prosthesis in 11 cases. The new titanium prothesis was easy to handle and provided immediate stability in all cases. Clinical and radiological follow-up examinations were performed at the time of discharge from hospital, and 3 and 6 months postoperatively. The clinical outcome was good or excellent in all the cases performed. On X-rays there was no implant migration or dislocation at the last follow-up and, to date, in CT reconstruction no insufficient fusion or pseudarthrosis has been observed. We cannot report any local complication. Results were promising and encouraging at a short-term control. Follow-up will be continued.
We report our 4 years’ experience using of demineralized human bone matrix (DBM) in the treatment of complex pathology characterised by bone loss or less regenerating ability, such as congenital or secondary bone mal-union, osteomyelitis, aseptic prosthetic failure, complex bone loss fractures, etc.
Considering the known limitations of autologous transplants (limited quantity, infections and fractures of donor sites, operative and bleeding time increase, abdominal herniations, etc.), we have searched in the literature for alternative materials that would be as similar to the osteoconduction and osteoinduction ability of autologous transplant as possible, respecting bio- and immunocompatiblity.
Since May 2000 we have used DBM in 50 cases: the first 15 patients with mixed technique (DBM and autologous transplant) and then the other 35 only with DBM. We have controlled each patient clinically and by X-ray: average follow up 34 months.
With the same type of pathology and operative technique we have observed a similar recovery with both techniques (DBM with or without autologous transplant); in addition, in patients treated with rigid osteo-synthesis or in patients with osteoporosis we have noted early bone regeneration and no complications with respect to rejection or to osteolysis at the surgical site. In our opinion, this confirms the good osteoconduction and osteoinduction ability of DBM.
For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle.
We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed.
In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary.
In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs.
Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination).
Current therapies for intervertebral disc degeneration are aimed at treating the pathologic and disabling conditions arising from discopathy rather than directly treating the underlying problem of disc degeneration. Our group is exploring the potential of cell therapy to repopulate the disc and stop the progressive loss of proteoglycans. Stem cells appear to be excellent candidates for this purpose, based on their ability to differentiate along multiple connective tissue lineages. The purpose of this study is to investigate the interaction between stem cells and nucleus polposus cells to test the feasibility of stem cell therapy for the treatment of disc degeneration.
Human nucleus polposus cells (NPCs) were isolated from patients undergoing disc surgery and were co-cultured for 2 weeks with muscle-derived stem cells (MdSCs) from 3-week-old mdx mice in monolayer culture system at different ratio with or without added TGF-β1. Each well contained an admixture of cells with NPC-to-SC ratios of 0:100, 25:75, 50:50, 75:25, and 100:0. Proteoglycan synthesis and DNA content were measured.
Co-culturing of NPCs with MdSCs in the monolayer culture system resulted in vigorous increases in proteoglycans synthesis as compared with NPCs alone and MdSCs alone both with and without TGF-β1. The increases were on the 200% for an NPC-to-MDSC ratio of 75:25. Addition of TGF-β1 to the NPC and MDSC co-cultures resulted in further increases up to 400%. DNA content also increased with co-culture.
The data from this study show that there is a synergistic effect between stem cells and nNPC resulting in upregulated proteoglycan synthesis in vitro. The observed benefits of co-culture might be due either to stem cell plasticity, the stem cells trans-differentiation towards chondrocyte-like cells, or the stimulation of NPC by agents synthesised by stem cells or other mechanisms. Elucidation of the precise mechanisms of action may permit development of strategies to optimise the synergistic effects in vivo. These results support the feasibility of developing a stem cell therapy approach to treat and prevent intervertebral disc degeneration.
In cementless joint arthroplasty, the first goal is stabilisation of the prosthetic components, due to bone ingrowth. In the past, to achieve the best fixation, orthopaedic surgeons used osteoconductive materials (HA, TriCa-Ph). To accelerate the fixation process, we have developed an osteoinductive procedure with growth factors. A product created from cancellous bone (BMP’s), bone marrow (stem cells) and platelet-rich plasma (growth factors) is applied to the tri-dimensional fixation surface (spongiosametal) of the prosthesis. Since June 2003, we have treated 15 arthroplasties with this procedure (11 THA, four TKA). The average duration of clinical follow-up was 6 months (range from 2 to 9 months). In case of THA, the average Harris Hip Score was 96 (Range from 91 to 100). In case of TKA, the average of HSS scoring was 90 (range from 85 to 100). The radiographic examinations were good. DEXA and RSA evaluations are underway.
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.
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.
Reaming intramedullary nailing, possibly associated with autologous bone grafting, is an effective procedure for the treatment of uninfected non-union and limited post-traumatic segmental bony defects. The main purpose of the treatment is to remove the causes responsible for the pathological evolution of fracture healing and to create proper vascular and mechanical conditions in the lesion site.
Hypertrophic non-union, which is considered a biologically active pathological condition, can be effectively treated by reaming of the medullary canal and by introducing a new nail of a larger diameter locked in a dynamic configuration; the purpose of this procedure is to help osteogenic compressive forces at the non-union site. In contrast, for the treatment of atrophic non-union it is necessary to avoid all mechanical stresses on the non-union site and give a new proper biological input. Cancellous and cortical-cancellous autologous bone grafting has undoubtedly well-known osteoinduc-tive and osteoconductive properties as well as introducing new osteogenic bone marrow cells to the non-union site.
Non-union site exposure, essential to remove pathological tissues and to open medullary canal, must be performed by gently dissecting the soft tissues to lower the infection risk and to save the periosteal vascularisa-tion.
The authors report their experience using locked reamed intramedullary nailing combined with cancellous and/or cortical-cancellous autologous bone grafts for the treatment of uninfected non-union, non-biologically active delayed union and limited post-traumatic bony defects in 15 cases. Based on our experience, such a procedure is reliable and with excellent biological and mechanical properties, as all of the lesions healed at the end of the treatment without complications. In these “bone callus” diseases, which always provide clinical and psychological discomfort, this procedure has demonstrated good results and, because of this, in our series, has also been used for the treatment of delayed union.
Rotational defects of the lower limb are frequently encountered and often underestimated. In fact, many symptoms in the lower joint can be related to rotational alteration in the lower leg. These problems are often more visible in the knee joint because they reflect the rotational problems of proximal and distal femur and tibia, respectively. The extensor apparatus, due to the fact that it interacts with both bones, is the more affected joint. Many authors have demonstrated that femoral anteversion increases stress on the patello-femoral joint due to excessive lateralisation of the patella. In the same manner, distal femur internal rotation increases the stress due to altered tracking of the patella during ROM.
Valgus knee places stress on the patello-femoral joint, increasing the Q angle and determining a retraction of the lateral structure that causes stress on the lateral patellar face and altered patellar scratch during ROM. External tibial rotation also has been documented to increase the Q angle and patellar tilt, causing excessive stress on the patello-femoral joint. Valgus pronation of the foot, increasing the valgus stress on the knee, can contribute to patello-femoral symptoms, increasing the muscle imbalance at this level.
These documented alterations contribute together with other anatomical abnormalities, such as trochlear dysplasia or muscle hypoplasia, in creating the high variability of patello-femoral symptoms that are observed. Rotational deformity of the lower leg therefore represents a frequently encountered pathological condition that must be taken into account when treating patello-femoral symptoms.
The arthritic varus knee (AVK), charaterised by an overloaded medial compartment of the joint, shows different clinical patterns with corresponding distinctive pathological signs. The surgical approach with opening wedge high tibial osteotomy is indicated in less demanding cases. Transferring the stress in the cartilage and bone of lateral compartment it may represent a definitive solution for both the deformity and the mechanical axis.
Between 1995 and 2003 we treated 52 patients, 60 knees, with distractional osteogenesis using external fixators. The mean age was 51 years (range 45 to 68 years). Radiographic findings showed a third-degree condition according to the Ahlback classification, while pathologically the condition was considered second degree according to the Outerbridge classification. The mean initial varus angle was 8.2°. We analysed the clinical results using the Hospital for Special Surgery score scale and the radiographic result by standing standard X-rays and Rosemberg X-rays.
We followed 38 of 52 patients for 3, 6, 9 and 12 months and then conducted a yearly control with a mean follow up of 4.2 years. The clinical score was 78.5 versus 45.5 in the pre-operative evaluation. At the follow-up radiographic evaluation shows a valgus angle of 2.98° even if there was less of initial correction (mean angle at 6 month 3.53°).
The technique used, moving the weight to the normal compartment of the knee, gives a definitive solution to varus of the femoral-tibial joint, correcting both the deformity and the mechanical axis. The treatment showed several advantages for possible new correction in the late post-operative period and and a minimally invasive operation, even though patient compliance is not good. The best results were obtained thanks to rigorously following the indication for this treatment. In these patients we consider distractional osteogenesis using external fixators a definitive treatment for AVK and not only a way to gain time and to postpone total knee replacement, which is always possible after an osteotomy.
Valgus deformity of the knee in relation to femoral dysplasia and post-traumatic varus deformity in relation to supracondylar fracture often needs to be corrected with varus or valgus distal femoral osteotomy. This procedure must be very precise to avoid compartimental overstress. However, in valgus knee the deformity is very often not only bi-planar but also tri-planar. In fact, the rotational defect of the distal femur can play an important role in determining the clinical symptoms and in altering the pathway of patello-femoral joint.
Therefore, correcting only the valgus deformity does not solve the clinical symptoms related to incorrect rotation of distal femur. The same problem is often encountered in distal femoral deformity in relation to supracondylar fracture. The bad alignment of the healed fracture is very often on the three planes and this fact has always to be taken into account during the pre-operative planning.
The pre-operative planning is fundamental and CT of the knee joint with reference to hip and ankle must be performed to evaluate the degree of rotational deformity that must be corrected. During surgery after the correction of valgus or varus deformity is fundamental to re-check the femur rotation, because the osteotomy automatically changes also the rotation of the distal femur. However, this correction may be insufficient to correct the rotation that can maintain clinical symptoms in the patello-femoral joint. If this is the case, an additional correction in external rotation is usually necessary to achieve an overall correction of distal femoral deformity.
In our opinion, the difficulties and accuracy necessary to correct this type of pathology are often underestimated.
With the plasma–spray technique of applying a hydrox-ylapatite (HA) coating bone ingrowth can be enhanced and early migration of hip prostheses reduced. The significance of coating resorption is controversial. In this study the bone growth and the degradation of the HA coatings were evaluated and compared by SEM.
Premature loosening was identified in four cups with an Ha coating over a porous-coated surface 3 years post-operatively.The Ha coating has a thickness of up to 50 μm. The cup specimens were soaked in 6% sodium hypochlorite to render them anorganic, dehydrated, and sputter-coated with gold-palladium. Secondary electron images of all specimens were obtained by field emission SEM (Zeiss:DSM.962).
Ultrastructural analysis showed that all porous-coated Ha-coated cups had bridges of lamellar bone in direct contact with the implant surface (30% bone in-on growth). Different types of coating degradation were observed. Delamination between the coating and implant surface releases numerous particles or fragments; the resorption by osteoclasts of the amorphous phase was shown to expose the crystalline phase of the coating grains.
This study suggests that resorption disintegrates the Ha coating and reduces the bonding strength between implant and bone and the strength of the coating-implant interface, which might lead to implant loosening,coating delamination and acceleration of third-body wear processes.
Data were analysed using descriptive statistics. Subgroup comparisons were made using chi square tests.
The response rate was 50% (n= 504). 91% of the responding sample had a lifetime prevalence of LBP and also answered the modified FABQ questions. The mean of the activity fears scale was 4.18 (SD = 1.14) and the mean of the work fears was 4.91 (SD = 1.08), indicating that most respondents held very negative beliefs regarding LBP in relation to work and activities. Those who had experienced LBP reported more psychological problems on the GHQ.
Quantitative data were summarised using descriptive statistics. Qualitative data were transcribed, coded and analysed using the qualitative data analysis approach of
11/19 studies reported inconclusive results, 8/19 showed a statistical association between drawings and the psychological assessment tool. However the more clinically relevant, sensitivity data ranged from 24–93%, specificity 44–91%, positive predictive values 28–93%, and negative predictive values 35–92%. The range of this data is too wide to be acceptable clinically as predictive of psychological state.
Patients who consulted complementary practitioners were more likely to be female, to be psychologically distressed, to work, to have left school aged over 16 and to have severe pain (p< 0.05 in all cases). Working was independently associated with consulting a complementary practitioner (Exp (B) = 2.0, p=0.00)
1) beliefs and attitudes about LBP
2) reported practice (using a clinical vignette)
A total of 3602 questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1367) and physiotherapists (n=1624). Intervention packages were sent to consenting practitioners in March 2004, and the follow-up is planned for September 2004.
There is published evidence of the efficacy of DBM in animal spine models, but at present there is scanty evaluation of its use in the human spine in routine clinical practice.
The purpose of our pilot study has been to observe the radiological evidence of fusion rates in lumbar spine transverse process fusions, using DBM.
This findings of this study have led us to design a randomised prospective study which will compare using stringent experimental design the use of DBM with using the more traditional autologous graft.
At follow up significantly more females had urinary incontinence (p< 0.001) and bowel disturbance (p< 0.05), higher VAS scores (p< 0.05) and lower SF36 Pain and Energy scores (p< 0.05) than males. Urinary disturbance at presentation did not affect the outcomes. Bowel disturbance at presentation was associated with sexual problems (< 0.005) and abnormal rectal tone (p< 0.05) at follow up. Objective reduced perianal sensation at onset persisted in a significant number at follow up (21/32 patients; p< 0.05) as did leg weakness (14/23; p< 0.005). There was a weak association between delay to operation and bowel disturbance (p< 0.05) at follow up. Eight patients had faecal soiling and faecal incontinence at follow up and this was associated with sudden onset of symptoms, initial abnormal rectal tone and time to operation (p< 0.05). The SF36 scores at follow up were reduced compared to age matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5.
This study was carried out in order to document the indications, methods, complications and results of revision lumbar disc replacement surgery.
Out of a total series of 29 disc replacement operations carried out by the senior author 8 patients have required revision (10 operations). All of these patients have been followed prospectively since their initial operation and data was extracted from the case notes, theatre logs and radiographs.
The primary indications for revision were recurrence of, or failure to relieve back pain. Of the 8 patients requiring revision for their symptoms, 3 had prostheses that had clearly failed on CT. Four patients had the pros-thesis removed and were revised to a circumferential fusion using iliac crest autologous bone graft anteriorly and pedicle screws posteriorly. Three patients had a posterolateral fusion only using pedicle screw fixation with retention of the prosthesis. Two patients had a posterior procedure carried out which failed to resolve the situation satisfactorily, and subsequently had the prosthesis removed and interbody cage fusion. Out of the 6 anterior cases there were 2 injuries to the great veins requiring vascular repair. There were few complications with posterior surgery. Although numbers are small, the patients who had anterior surgery seemed to do better than those retaining their prosthesis with posterior surgery alone.
We conclude that a posterolateral fusion is a safe but symptomatically unsatisfactory revision strategy for failed disc replacement, and that anterior revision with conversion to inter-body fusion is a better option but has a higher rate of surgical morbidity.
This prospective study was carried out to document the efficacy of lumbar disc replacement using a viscoelastic prosthesis in the medium term.
Eleven patients were included in the pilot study of this prosthesis, with an average age at surgery of 41, and these have now reached 5 years follow-up. They have been followed up prospectively with clinical and radiological evaluation, and outcome assessment using the Oswestry Disability Index (ODI), Visual Analogue pain scales (VAS), and the Low Back Outcome Score (LBOS).
There have been 3 revision operations in patients who failed to get lasting symptomatic relief. Two patients have had their prosthesis removed with revision to an inter-body fusion supplemented with pedicle screw fixation, and one has been revised to a posterolateral fusion while retaining an apparently well functioning prosthesis.
In the 8 ‘survivors’ the improvement in the ODI, VAS and LBOS seen at the 2 year follow-up has been maintained in the longer term. Fine cut helical CT scan has shown that the prosthesis has undergone mechanical failure in 3 patients, without significant clinical problems. One patient (with a virtually perfect ODI and LBOS) appears to have undergone ‘autofusion’ with significant heterotopic ossification anterior to the disc prosthesis.
In conclusion, despite some successes, the rate of early failure of this prosthesis, both radiologically and clinically, is unacceptable, and its use has therefore been abandoned.
16 patients benefited greatly from the surgery and 6 benefited to some extent, giving an overall good result of 71%. 7 patients had no or little relief from surgery (29%).
Moderate to severe degenerate changes in SC and IC joints on histology were found in 59% of patients. 91.6 % of these patients did well with surgery. Only 60 % of those with mild changes did well.
Discography was possible in five out of six attempted cases. Two were positive and both did well from surgery. Three patients had negative discographies and two of them had a poor result and one had only some relief.
Of 97 post-contrast MRIs, 85 showed RDP (18 large-contained, 22 large-sequestrated, 26 moderate-contained,4 moderate-sequestrated,13 small-contained, and 2 small-sequestrated), 5 HES, and 7 lateral recess stenosis but no RDP or HES. From operation records, 31 of these 85 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 10 of 18 large-contained (55.6%), 19 of 22 large-sequestrated (86.4%), 8 of 26 moderate-contained (30.8%), 4 of 4 moderate-sequestrated (100%), 6 of 13 small-contained (46.2%) and 1 of 2 small-sequestrated (50%). Of the 7 which did not show RDP, 1 (14.3%) was found to have moderate-contained RDP during operation.
The satisfaction of patients at both sites was analysed using a number of factors- the care provided was 79% before the move and 82% afterwards, their understanding of a nurse led service was rated as 73% and 85% respectively. Evaluation of the quality of information demonstrated that their questions had been answered well 78% and 75% respectively and the confidence and trust in the person providing the care was 91% and 89%.
Failure by the IT department in delivering effective links to hospital computer system resulted in the LBOS data not being completed in the period following the move with logistical difficulties in clinic organisation.
Here we discuss the evaluation of two spinal devices: Dynesys, a spinal stabilisation system for back pain, and X STOP, an interspinous process distraction device for spinal stenosis.
For Dynesys, 30 patients with lower back pain were recruited. The first 20 patients have completed their 9 month scan, and the results show that the device reduces the range of movement at the operated segments, with a small increase in movement at adjacent segments and an overall reduction in the range of movement of the lumbar spine.
For X STOP, the first 10 of 45 have reached their second scan at 6 months post surgery. The scans demonstrate a net increase in the cross-section of the spinal canal of 21% when flexed to 35% whilst standing, and an increase in the surface area of the exit foramen of 23% flexed and 51% standing at operated levels.
25 (12.4%) patients who had dural tear had worse results.
There was no statistical improvement in the Brantigan cage group. Despite clinical improvement, five patients in the Stabilis group failed to unite and six demonstrated subsidence of the implant. The relationship between non-union and subsidence was statistically significant (p = 0.017). Furthermore, the change in ODI between patients who united and those who did not was both statistically significant (p=0.03) and the difference in mean ODI between the two groups was considerable (21%).
Decision to operate for lumbar nerve root compression is usually based on the clinical findings and MRI scan evidence of nerve root compression. Decision-making is difficult in the subset of patients with pain in the groin, buttock or thigh with L5 and S1 nerve root compression as evidenced by MRI scan. We retrospectively studied 125- diagnostic nerve root injections, of which there were 12 patients who had pain in the groin, thigh or buttock and their MRI scans were reported as nerve root (11 L5 & 1 S1) compression by the radiologist. All these 12 patients were subjected to injection of the affected nerve root with bupivacaine and methylprednisolone under the guidance of image intensifier. Of these 5 (42%) of them had temporary relief of the symptoms; and all of them underwent surgical decompression of the affected nerve root. They were followed for an average of 12 months with satisfactory results. This demonstrates the importance of nerve root injections as a diagnostic tool in patients with atypical symptoms with a positive MRI scan.
