Introduction and purpose: Fatigue leads to various disruptions in the musculoskeletal system. Specifically, it has been observed that fatigue disturbs perception of the position of the limbs and the spine as well as posture balancing control and gait kinematics. The purpose of this study is to determine whether orientation of the pelvis undergoes changes after a period of extreme work-related fatigue.

Materials and methods: Orthopaedic Surgery residents in our hospital often work 24-hour shifts in the emergency department, which is considered a tiring activity which constitutes an appropriate model for professional burnout. In order to assess the position of the pelvis, we used pelvis tilt on the sagittal plane which is defined as the inclination of the plane which runs through all four anterosuperior and posterosuperior iliac spines with respect to the horizontal. The pelvic tilt of 19 resident doctors was measured at the beginning of their shifts, 16 hours into their shifts and on completing their 24-hour shift. An analysis was made of the differences between the values obtained and the influence of gender, weight and body mass index.

Results: Fatigue caused by 16 and 24 hour shifts in the emergency department led to a mean decrease in pelvic tilt of 1.1° (significant p=0,014) and 1.6° (significant p=0,003) respectively.

Conclusions: The fatigue caused to resident doctors by their shifts in the emergency department leads to significant pelvic retroversion.

The common factor in all (mechanical) prosthetic failure mechanisms is the induction of osteolysis around the endoprosthesis with subsequent prosthetic migration and finally loosening of the prosthesis. Both initial prosthesis-bone fixation and long-term prosthesis survival depend on the quality of the peri-prosthetic bone mass. The effects of treatment of RA patients with prednison are inhibition of osteoblastic activity and inhibition of calcium resorption from the intestines. The bone mass loss during the first six months of prednison treatment is substantial and will seldom be regained. Bisphosphonates are known to decrease osteoclastic activity and may therefore stop osteolysis at the bone-prosthesis interface.

The aim of the study was to evaluate a possible association of bisphosphonates with reduced migration of total knee prostheses (Interax, Howmedica Osteonics, Rutherfort, USA) in a high-risk group. Roentgen Stereophotogrammetric Analysis (RSA-CMS, Medis, The Netherlands) was used to measure the micromotion.

Retrospectively a group of nine RA patients treated with prednison (non-bisphosphonates group) and a group of fourteen RA patients (bisphosphonates group) treated with prednison in combination with bisphosphonates (Etidronate) were included from a prospective randomized study of 82 patients (Nelissen et al., 1998).

At the two-year follow-up evaluation, functional scores and knee scores did not differ significantly among the two groups. At the two-year follow-up evaluation, the non-bisphosphonates group subsided −0.47 ± 0.8 mm, and the bisphosphonates components subsided 0.07 ± 2.9 mm. In the analysis of variance with repeated measurements, with correction for follow-up time, sedimentation rate, and prosthesis fixation type, the bisphosphonates group migrated 1.20 mm less in the total migration (95% c.i.: 1.07–1.30 mm) compared to the non-bisphosphonates group.

In this study, bisphosphonates medication in addition to corticosteroid medication was associated with reduced migration of knee prostheses compared to corticosteroid medication alone.

Aims: Purpose of this study was to obtain long term follow-up in patients with Osteofibrous Dysplasia (OFD), in order to investigate natural history of the disease, late results of treatment, and potential risk of Adaman-tinoma development in this setting. Methods: A retrospective study of 48 patients with histologically proven OFD observed at our Institution between 1900 and 1997 was undertaken. Clinico-pathologic features of all cases were reviewed and found consistent with OFD. A clinical status update and current radiographs were obtained in all patients. A subgroup of 21 patients with minimum follow-up of 20 years (21 to 44 years, average 27) was analysed for functional result and adamantinoma development. Functional result according to MTS-ISOLS score correlated with surgical aggressiveness. Results: Best results were observed in patients that received a single biopsy or curettage; worse results were seen after multiple resections or osteotomies and associated with complications as infection or compartment syndrome. No patients had current symptoms or significant symptoms changes nor physical findings, radiographic clues or subsequent radiographic changes suggesting adamantinoma development. Conclusions: OFD is a benign condition; the natural history of the disease has minimal consequences in the adult life. Surgical treatment is usually not necessary and may actually worsen the result because of the potential for severe complications.

The relationship with adamantinoma remains unclear, follow-up is suggested.

Purpose: Posterior instability of the shoulder requires surgical treatment in involuntary forms and after failure of functional treatment. As for anterior instability, a bone block can be fashioned from an iliac graft or a pediculated graft harvested from the acromion. This retrospective analysis concerned the results obtained in eighteen consecutive cases.

Material and methods: This series included ten men and eight women, mean age 26 years (15–42) at time of surgery. Fourteen (77%) practised sports activities including four at competition level. Symptoms had persisted for four years on the average. For three patients (16%) posterior instability was expressed by recurrent luxation subluxation. For nine patients (50%) posterior subluxation was a common involuntary event. Six patients suffered from painful shoulders due to an unrecognised posterior instability accident. Diagnosis of posterior instability was establised by arthroscopy in seven patients (39%). For nine shoulders the intervention consisted in a screwed posterior iliac block associated with a tension procedure on the capsule (group 1). For the other nine shoulders the block was harvested from the acromion and pediculated on the deltoid (group 2).

Results: Mean follow-up for all patients was eight years. The Duplay score was 75 points at last follow-up. Twelve patients (85% of the athletes) were able to resume their sports activities, half at the same level. Nine patients were pain free. Six patients (33%) had persistent apprehension but did not present true recurrence at physical examination. The Duplay score was 69.4 points in group 1 (follow-up 12 years) and 82.2 points in group 2 (follow-up three years). Thirteen patients (77%) did not have any sign of joint degeneration at last follow-up. One patient had advanced stage IV degeneration related to an intra-articular screw. All patients felt their shoulder had been improved by surgery and one third were disappointed with the results.

Discussion: Use of a posterior block is an effective treatent for posterior instability giving results comparable with those obtained with anterior blocks in terms of shoulder stability, pain, recovery of motion, and subjective outcome. This procedure favours joint degeneration less than anterior stabilisation. Results obtained with pediculated acromial blocks are encouraging.

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis.

Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis.

Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection).

Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple.

Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability.

Objective: Starting from results of studies made in the last ten years about the presence of myofibroblasts as the main cells involved into fibro-contractile disease, we investigated if this cells were also involved into pathogenesis of club foot deformities.

Methods: Specimens removed surgically from five patients affected by congenital club foot were investigated. Each specimen was cut in three parts: the first, was fixed for optical microscopy in formalin; the second was fixed for trasmission electron microscopy (TEM) in glutaraldehyde and postfixed in osmium tetroxide; the third was immediately placed in cold (4°C) tissue culture medium. We have stained the first part of each specimen with: haematoxylineosin, Pasini, Masson, Congo red, Van Gieson, Martius scarlet blue and immunostaining for a-smooth muscle actin (a-SM actin). The third part of each specimen, dissected into 2mm. cubes, was place in standard medium and cultured at 37°C. On the cultured cells, we have valued metalloproteinases and a-SM actin expressions. Moreover, a part of culture cells, when reached confluence, were detached with trypsin-EDTA and centrifuged for 10 min. at 2000 rpm. to obtain a pellet, subsequently fixed for TEM.

Results: Optical and electron microscopy have showed, only in one of our cases, the presence of myofibroblast’s clusters in the Henry’s nodule and in the medial and lateral fibrous nodules, that are characteristic nodule of congenital club foot.

Conclusions: Starting from the results of our studies, we would like to study in detail the role of myofibroblast in the pathogenesis of club foot.

We report on six men and two women (mean age 42.5 years) who had sustained posterior dislocation of the shoulder in motor vehicle accidents (three), falls (two), equestrian accidents (two), cycling accidents (one) and in a fainting spell (one). In four patients, the dislocation was the only injury, but two had humeral shaft fractures, one a humeral neck fracture and the fourth a glenoid and humeral shaft fracture. The mean delay to diagnosis was 14 weeks (2 to 21).

In three patients a medical officer, a general practitioner and a radiologist missed the dislocations, but in five orthopaedic surgeons missed them. Four patients had only anteroposterior radiographs of their shoulder taken, one had anteroposterior and lateral scapular views, and three had anteroposterior and lateral radiographs of the humerus.

Four patients underwent hemi-arthroplasties and the other four open reduction and McLaughlin procedures.

Though rare, posterior dislocations are often missed. Careful examination, especially in the absence of external rotation, can eliminate this. In the presence of a fracture, a dislocation or injury to the joint above and below must be excluded. Anteroposterior and lateral scapular views alone are inadequate in trauma cases and an axillary or modified axillary view should be done. If there is any doubt, CT should be performed.

Purpose: We reviewed 30 cases of osteochondrial lesions of the astragalus dome treated surgically.

Material and methods: Among the 30 patients, 17 practised sports and 24 had a history of trauma. Delay to surgery was ten months. All patients were treated by curettage using perforations according to Pridie. There were 11 direct approaches, 13 malleolar osteotomies and six arthroscopies. Cancellous grafts completed the treatment in six cases.

Results: Mean follow-up was three years seven months (minimum two years). All the patients had an arthroscan at last follow-up. The postoperative results were assessed according to clinical and arthroscan criteria.

Discusion: We emphasise the importance of the Fracture Osteonecrosis Geode (FOG) classification system and the subsequent pathophyisiological and prognostic conclusions. The Berndt and Harty classifications should be abandoned. Only symptomatic lesions should be treated. Surgical treatment (arthroscopy or direct access with cancellous graft) is required for efficacy at this stage. Surgical treatments provides very good results in 75% of the cases with pain relief and improved walking distance. We advocate arthroscopic perforation curettage for localised necrosis. In case of major substance loss, cancellous grfat requires a direct access.

Purpose of the study: We reviewed 30 cases of osteochondral lesions of the astragalar vault treated surgically.

Material and methods: Among the 30 patients, 17 participated in sports activities and 24 had a history of trauma. Mean delay to surgery was 10 months. Treatment included osteochonritis curettage and Pridie perforations. Direct access was used in 11 cases, malleolar osteotomy in 13 and arthroscopy in 6. Cancellous bone grafts were used in 6 cases.

Results: Mean follow-up was 3 years 7 months (minimum 2 years). All patients had an arthroscan at last follow-up. Evaluation of post-operative outcome was based on clinical assessment and arthroscan findings. Surgical treatment provided very good results in 75 p. 100 of cases with pain relief and improved walking distance.

Discussion: Our cases pointed out the important contribution of the FOG (Fracture Osteonecrosis Geode) classification to pathogenic and prognostic analysis. The Berndt and Harty classifications were not found to be useful.

Conclusion: In case of localized necrosis, we propose arthroscopic perforation curettage. In case of bone loss, a direct cancellous graft may be used.

We evaluated the effectiveness of arthroscopic repair in patients with shoulder instability owing to a bony fragment as part of the Bankart lesion, using spiked Suretacs, sutures and anchors.

Over a two-year period, we followed up 23 of 25 consecutive cases, all with a bony fragment as part of the Bankart lesion. The mean age of patients, all of whom were male, was 21 years (17 to 35). Almost all injuries were sustained playing sports. Patients were clinically evaluated at six weeks and 20 weeks postoperatively and interviewed telephonically.

Full arthroscopic examination was performed in a lateral decubitus position. The affected capsular structures and labrum, with its attached bony fragment, were fully mobilised. The bony fragment was always attached to the capsular structures, with labral ring intact. We used a spiked Suretac anchor to reattach the bony fragment to its original anatomical position, and Mitek anchors and no. 1 Ticron sutures for individual reattachment of the capsule and ligaments. Postoperatively patients were immobilised in a shoulder sling for six weeks. Early restricted active and passive movements were advised. Patients routinely received postoperative physical and biokinetic rehabilitation. The mean follow up period was 16 months (5 to 29). There was no redislocation or subjective instability.

This technique yields excellent results, but because it is technically difficult should be used only by experienced shoulder arthroscopists with thorough knowledge of pathological shoulder anatomy.

Purpose: Is prevention of postoperative venous thrombosis using low-molecular-weight heparin (LMWH) sufficient in orthopaedic and traumatology units?

Material and methods: Between 1995 and 2000, all patients undergoing orthopaedic or traumatology procedures involving the lower limb underwent a venous control the sixth day after surgery: RPO with phlebography if positive until September 1996 then duplex Doppler of the lower limbs. In all 755 patients, mean age 68 years (34–90), undergoing planned orthopaedic procedures (341 THA, 135 TKA, 111 tibial osteotomies, 66 single compartment prostheses, cruciate surgery) or procedures for trauma (56 femoral neck, trochanter, bimalleolar, etc.) were included.

Results: A total of 118 cases of deep vein thrombosis were discovered giving an incidence of 16%. The deep vein thrombosis was in the sural territory in 95 cases (posterior tibial, fibular, vastus and/or anterior tibial) but there were also 13 cases of proximal thrombosis in the iliofemoral or femoral localisations. The large majority of the cases were homolateral to the surgical side, eight were found in the other limb. In this series, the venous risk differed from one surgical procedure to another (for the same operator): 11% for THA, 22% for TKA (without tourniquet) and 17 to 12.5% for tibial osteotomies with tourniquet (valgisation and transposition of the anterior tuberosity), 13.5 % for single compartment prostheses with tourniquet. Our oldest patient was 90 years old and was treated by intermediary arthroplasty for a cervical fracture. The youngest were 34 years old for anterior cruciate ligament surgery or valgisation osteotomy and 38 and 39 years for THA subsequent to advanced necrosis. Finally, there was no statistical difference by sex.

Conclusion: Systematic use of duplex Doppler examination of both limbs postoperatively revealed a large number of deep vein thrombosis patients despite systematic use of LMWH which certainly modified their clinical presentation. These patients were then given adapted treatment which led to regression of the complications: postphlebitis syndrome and pulmonary embolism with the risk of medicolegal complications.

In shoulder arthroplasty the glenoid component remains a problem. Hemi-arthroplasty requires less theatre time and gives rise to fewer complications. The question is whether the results of hemi-arthroplasty are inferior to those of total shoulder arthroplasty.

We assessed 189 patients who since July 1994 had undergone hemi-arthroplasty or total shoulder arthroplasty, excluding patients who suffered fractures, malunion or nonunion. In 77 patients (41%) the glenoid was replaced. The mean age of patients was 62 years. All humeral and glenoid components were cemented. Preoperative and postoperative assessments included pain (visual analogue scale), muscle strength, range of motion, functional activities and Constant shoulder scores.

At this early stage, total shoulder arthroplasty appears to give slightly better functional results than hemi-arthroplasty. However, there were five (6.5%) complications associated with the glenoid components, including glenoid component fracture, loosening and migration. Hemi-arthroplasty eliminates concerns about glenoid wear and glenoid complications, and we believe total shoulder arthroplasty should be reserved for specific problems.