Introduction. To determine the advantages and risks of plating after lengthening (PAL) of tibia in children and adolescents. Materials and Methods. 35 consecutive tibial lengthenings were done for limb length discrepancy (LLD) in 26 patients. Gradual lengthening by an external fixator from a tibial (usually diaphyseal) osteotomy was followed by internal fixation with a lateral tibial submuscular plate. The mean age at the time of the lengthening was 10.3 years (4.8 – 16.8 years). The aetiology for LLD was congenital in 21, acquired in 3, and developmental in 2 patients. The mean follow-up was 4.3 years (8 months – 9.9 years). Results. The mean lengthening was 5cm (3–8.6cm) or 19.1% (10.8 – 35.2%) of the initial length of tibia. It took 78.8 days to reach the target length at a lengthening rate of 0.75mm/day. The mean time to plate substitution after cessation of lengthening was 24.7days/109 days after osteotomy. This led to an average external fixation index (EFI) of 23.1days/cm. Optimisation of this technique by judicious estimation of timing of plate substitution would reduce the EFI. Consolidation was recorded at 192 days after osteotomy. Bone healing index (BHI) was 39.8days/cm and was age dependent: <12 year olds = 37.5 days/cm; 12 years = 44.7 days/cm. Using the estimated consolidation time if treatment was solely by external fixator, calculated by tripling the time taken to reach target length after osteotomy, the BHI in this series would have been 52.9 days/cm (p < 0.001). Knee flexion recovery to > 90 degrees was noted at 153.5 days after plating. One greenstick fracture occurred 116 days after plate insertion, 1 tibial shaft fracture occurred 315 days post removal of plate - both following injury and were treated conservatively. Six episodes of sepsis, 5 superficial and 1 deep were treated with antibiotic suppression. The plates were removed from 28 tibiae, 437.4 days after insertion. Conclusions. Plating after lengthening not only reduces the fixator time but appears to achieve consolidation faster than if treatment was by external fixation alone. This facilitates early recovery of joint motion and limb function

Segmental bone transport (SBT) using an external fixator is currently a standard treatment for large-diameter bone defects at the donor site with low morbidity. However, long-term application of the device is needed for bone healing. In addition, patients who received SBT treatment sometimes fail to show bone repair and union at the docking site, and require secondary surgery. The objective of this study was to investigate whether a single injection of recombinant human bone morphogenetic protein 2 (rhBMP-2)-loaded artificial collagen-like peptide gel (rhBMP-2/ACG) accelerates consolidation and bone union at the docking site in a mouse SBT model. Six-month-old C57BL/6J mice were reconstructed by SBT with external fixator that has transport unit, and a 2.0-mm bone defect was created in the right femur. Mice were divided randomly into four treatment groups with eight mice in each group, Group CONT (immobile control), Group 0.2mm/d, Group 1.0mm/d, and Group BMP-2. Mice in Group 0.2mm/d and 1.0mm/d, bone segment was moved 0.2 mm per day for 10 days and 1.0 mm per day for 2 days, respectively. Mice in Group BMP-2 received an injection of 2.0 μg of rhBMP-2 dissolved in ACG into the bone defect site immediately after the defect-creating surgery and the bone segment was moved 1.0 mm/day for 2 days. All animals were sacrificed at eight weeks after surgery. Consolidation at bone defect site and bone union at docking site were evaluated radiologically and histologically. At the bone defect site, seven of eight mice in Group 0.2mm/d and two of eight mice in Group 1.0mm/d showed bone union. In contrast, all mice in Group CONT showed non-union at the bone defect site. At the docking site, four of eight mice in Group 0.2 mm/d and three of eight mice in Group 1.0 mm/d showed non-union. Meanwhile, all mice in Group BMP-2 showed bone union at the bone defect and docking sites. Bone volume and bone mineral content were significantly higher in Group 0.2mm/d and Group BMP-2 than in Group CONT. HE staining of tissue from Group 0.2mm/d and Group BMP-2 showed large amounts of longitudinal trabecular bone and regenerative new bone at eight weeks after surgery at the bone defect site. Meanwhile, in Group CONT and Group 1.0mm/d, maturation of regenerative bone at the bone defect site was poor. Differences between groups were analyzed using one-way ANOVA and a subsequent Bonferroni's post-hoc comparisons test. P < 0.05 was considered significant. rhBMP-2/ACG combined with SBT may be effective for enhancing bone healing in large bone defects without the need for secondary procedures

It is common belief that consolidated intramedullary nailed trochanteric femur fractures can result in secondary midshaft or supracondylar fractures, involving the distal screws, when short or long nails are used, respectively. In addition, limited data exists in the literature to indicate when short or long nails should be selected for treatment. The aim of this biomechanical cadaveric study was to investigate short versus long Trochanteric Femoral Nail Advanced (TFNA) fixation in terms of construct stability and generation of secondary fracture pattern following trochanteric fracture consolidation.

Eight intact human cadaveric femur pairs were assigned to 2 groups of 8 specimens each for nailing using either short or long TFNA with blade as head element. Each specimen was first biomechanically preloaded at 1 Hz over 2000 cycles in superimposed synchronous axial compression to 1800 N and internal rotation to 11.5 Nm. Following, internal rotation to failure was applied over an arc of 90° within 1 second under 700 N axial load. Torsional stiffness, torque at failure, angle at failure and energy at failure were evaluated. Fracture patterns were analyzed.

Outcomes in the groups with short and long nails were 9.7±2.4 Nm/° and 10.2±2.9 Nm/° for torsional stiffness, 119.8±37.2 Nm and 128.5±46.7 Nm for torque at failure, 13.5±3.5° and 13.4±2.6° for angle at failure, and 887.5±416.9 Nm° and 928.3±461.0 Nm° for energy at failure, respectively, with no significant differences between them, P≥0.167. Fractures through the distal locking screw occurred in 5 and 6 femora instrumented with short and long nails, respectively. Fractures through the lateral entry site of the head element were detected in 3 specimens within each group. For short nails, fractures through the distal shaft region, not interfacing with the implant, were detected in 3 specimens.

From biomechanical perspective, the risk of secondary peri-implant fracture after intramedullary nailed trochanteric fracture consolidation is similar when using short or long TFNA. Moreover, for both nail versions the fracture pattern does not unexceptionally involve the distal locking screw.

Introduction and Objectives: The disadvantages attributed to unreamed intramedullary nails in fractures of the femoral diaphysis include delayed fracture consolidation and fatigue of the material. The aim of our study is to describe the low incidence of these complications.

Materials and Methods: We present a series of 25 patients treated by means of 26 unreamed femoral nails (Synthes) and static locking in all cases and follow up until the time of bone healing (6 months). Mean age of the patients was 43 years (range 18–86 years). The most common cause of injury was automobile accident. All treated fractures were located in the diaphysis (32-A in 9 cases, 32-B in 15 cases, and 32-C in 2 cases) and were closed fractures, except in 4 cases (2 Gustillo type II and 2 of type IIIa). In only 6 patients was the femoral fracture the sole lesion. In the rest of the patients, it was accompanied by other skeletal (multiple fractures) or visceral (polytraumatic) lesions.

Results: We were able to achieve fracture consolidation within a period ranging from 2 to 6 months (mean 4.2 months). We did not experience any problems with material fatigue in any of the cases. In one case it was necessary to remove the static lock to allow for bone healing due to diastasis of the fracture site.

Discussion and Conclusions: Unreamed intramedullary nails allow for consolidation of fractures of the femoral diaphysis in a period of time of about 4 months, which we consider to be accurate. Furthermore, the absence of reaming is associated with a less severe local reaction, which we consider to be preferable.

Purposes of the Study

To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator.

Introduction: There is a need for new non-invasive, predictable and quantifiable techniques to assess the process of fracture healing and remodelling in bone. There are several methods to monitor the bone healing in-vivo. But these methods either fail as quantitative predictors of the healing process (X-ray) or exhibit complicated and expensive measurement principles. Some known in-vivo stiffness measurement methods have several disadvantages including the risk of bone malalignment. Therefore we compared ex-vivo torsional strength of bone with in-vivo torsional stiffness under minimal load in two animal model of distraction osteogenesis. Additionally the device was tested in an ex-vivo model.

Methods: An external fixator was combined with a rotating double half-ring. The measurement device was fixed to the half-ring during measurements. It was equipped with a linear variable differential transducer, a load cell, and a stepper motor. During measurements the two parts of the half-ring were rotated against each other and the load and displacement were recorded. The slope coefficient after performing a linear regression between data points of moment and displacement curve was defined as stiffness. Afterwards all models were tested in a material testing system as gold standard. This was tested in an in-vivo animal study of tibial distraction (minipigs time of consolidation 10 days/sheeps time of consolidation 50 days).

Results: Between in-vivo initial torsional stiffness and torsional strength in minipigs we found a highly significant (p=0.001) coefficient of determination of 0.82, but we found only a poor correlation (p> 0.05) in sheeps. However, the results of the ex-vivo model showed a high precision and accuracy.

Discussion: The results of this study suggest that the bone regenerate strength of healing bones can be assessed in-vivo by the presented inital stiffness measurement method in the beginning of an early stage of healing as shown in minipigs. But at the end of the healing period the correlation of strength and stiffness leveled off. There is a similar model showing an excellent correlation, that agree with our data. They explained the weakening of the correlation at the end of healing by a transformation of early bone to lamellar bone after a 2/3 consolidation. In summary, the presented device could be a reliable future tool to monitor the healing progress in patients with bone malalignement or fractures in the beginning of the healing period.

Introduction and Objectives: In 2000 Bösch published the results of a laterally displaced percutaneous sub-capital osteotomy of the first metatarsal, without medial exostosis resection and without soft tissue surgery. There is no data on the characteristics of the bone consolidation in relation to the level and displacement of the osteotomy. We present data on these variables.

Materials and Methods: This is a prospective clinical study of: 30 trans-epiphyseal osteotomies, 30 metaphyseal osteotomies, 30 diaphyseal osteotomies and 10 completely displaced and dislocated osteotomies of the first intermatatarsal space. There was a minimum 1 year clinical and radiological follow-up. All the osteotomies were fixated by means of a 2 mm diameter Kirschner nail.

Results: The epiphyseal osteotomies consolidated without any apparent periosteal callus, there was osteolysis and fragment impaction in 19 cases; 1 non-union and 3 delays in consolidation. The metaphyseal osteotomies consolidated with variable degrees of periosteal callus; in 9 cases there was osteolysis and fragment impaction, in 1 case there was non-union but this had consolidated spontaneously after 2 years. Diaphyseal osteotomies consolidated with abundant medullar-periosteal callus; in 5 cases there was fragment impaction. Diaphyseal osteotomies with head dislocation consolidates with abundant medullar-periosteal callus; in 7 cases there was metatarsal shortening (3mm–7mm).

Discussion and Conclusions: We found that 97% of the osteotomies healed perfectly in 2–3 months. The type of consolidation and whether there was or not metatarsal shortening depended on the bone tissue at the point of contact of the fragments: Cancellous-cancellous bone (epiphyseal osteotomies), cancellous-cancellous or cancellous-cortical bone (metaphyseal osteotomies, cortical-cortical bone (diaphyseal ostetomies).

The thrombin-related peptide, TP508, a synthetic 23 amino acid peptide, has been shown to promote soft tissue, cartilage and fracture repair. We have previously demonstrated that two injections of TP508 have signifi-cantly enhanced bone consolidation in a rabbit model of distraction osteogenesis. This study was to test if a single injection of TP508 in a slow-releasing preparation will have the similar effects.

Unilateral tibial osteoectomies were stabilized with M100 Orthofix lengtheners in 17 male adult NZW rabbits. After 7 days, lengthening was initiated at a rate of 1.4 mm/day for 6 days. The following treatments were given: Group 1: TP508 in saline (300ug/300ul, n=6) was injected into the osteotomy gap at day of surgery and into the lengthening gap at end of lengthening. Group 2 (Control): Dextran gel (300ul, n=6) and Group 3: 300ul Dextran gel mixed with microspheres containing 300ug TP508 (n=5), was injected into the lengthening gap at end of lengthening. All animals were terminated 2 weeks after lengthening. Bone formation was assessed by weekly radiography and the specimens were subject to pQCT, microCT and histology examinations.

On radiographies there was more bone formation in the TP508 treated groups than that of the control group at 1st week post-lengthening and complete union was seen in 50% rabbits in Group 1, 33% in Group 2, and 60% in Group 3 at termination. The mean BMD of the regenerates was significantly higher in the TP508 treated groups than that of the control group (p< 0.05). MicroCT analysis demonstrated advanced bone formation in the TP508 treated animals. For histology, the regenerates were mainly consisted of woven bone of neocortilization and callus remodelling in Groups 1 and 3, whereas in Group 2, focal defects with cartilaginous tissues were frequently seen.

In conclusion we have demonstrated that a single injection of TP508 in the form of slow releasing micro-spheres has enhanced bone consolidation during distraction osteogenesis. TP508 may therefore be applied in the slow-releasing preparation for augmenting bone formation at reduced doses, costs and risks of infections through repeated injections.

We evaluate the effectiveness of external fixation exchange by intramedullary nailing during consolidation phase following callus distraction phase. In 12 skeletally mature female sheep, equally divided in two groups (group A and group B), we performed tibial shaft osteotomy and 2cm gradually callus distraction using Ilizarov external fixator in a 0.5mm/12h rate. In group A, immediately after lengthening completion, Ilizarov fixator was removed, and static unreamed intramedullary nail was inserted under fluoroscopic guidance. In group B (control group), Ilizarov frame remained (according to the usual technique) during consolidation phase. Callus maturity was studied in both groups, in specific time intervals, with plain x-rays, ultrasonograms, triplex and digital subscription angiograms. All animals were sacrificed 70 days after osteotomy and bone specimens including callus, were evaluated with MRI, DEXA and histopathologic examination.

In group A, all animals successfully tolerated intramedullary nailing, keeping limp alignment. All but one formatted a mature callus and kept callus length before being sacrificed. One sheep had a delayed formation of the callus and 0.5cm loss of callus length, because of failed insertion of distal locking screw in the nail. In group B, four of six formatted mature callus, two had axis disorder, three superficial pin-track infections and one deep infection in the same time.

We conclude that replacement of Ilizarov device by static unreamed intramedullary nail during callus consolidation phase decreases the total duration of external fixation, limits articular stiffness, pin-track infections and axial deformities, and provides protection against refracture. Our results suggest that there is no considerable difference between callus formations in the two groups.

Introduction and purpose: Primary instability and subsidence of hip implants is a very common problem. What is the load on a locking screw?

Materials and methods: Helios® modular prosthesis (IQL / Biomet España) with distal holes (static/dynamic). Fifty patients (46%) with locking, total n=109 (26 of 67 with FX of proximal femur, 14 of 25 aseptic loosening cases and 13 of 17 with periprosthetic fractures). Experimental study: stress on the distal locking screws. Loads applied in 9 cadavers with 3 types of simulated fractures: group I, femoral neck; group II, intertro-chanteric; and group III, subtrochanteric. Imitating slow, normal and fast walking, sitting down and standing up, going up an down stairs (Zwick Z010 and screw capacity meter).

Results: Follow-up 6–18 months. 50 with distal locking (20% dynamic, 80% static): 13 screws removed between 6 and 12 weeks (7 in revisions, 3 in FX, 3 others).

Subsidence: 80% 1–2 mm, 14% 3–5 mm, 6% 6 mm or more.

Experimental study: Weight-bearing: group I, 40.89% (max. 78.61%); group II, 43.15% (max 90.84%); group III, 64.49% (max. 136.74%). No torsional stress. Maximum stress when walking fast and climbing stairs.

Conclusions: When bone consolidation occurs in 6 to 12 weeks, distal locking ensures sufficient reinforcement and prevents movements of over 30 μm. If more time is needed for proximal bone integration, shaft fixation is preferable. The Helios® system provides both solutions satisfactorily.

Introduction. The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. Materials & Methods. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome. Results. The mean defect size after tumour resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale(MSTS) score of the evaluable 9 patients was 85% (57% to 100%)with good or excellent results in 7 patients. Conclusions. A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of com-plications requiring surgical intervention, even though most were not serious

Introduction. Acetabular revision surgery is challenging due to severe bone defects. Burch-Schneider anti-protrusion cages (BS cage: Zimmer-Biomet) is one of the options for acetabular revision, however higher dislocation rate was reported. A computed tomography (CT)-based navigation system indicates us the planned direction for implantation of a cemented acetabular cup during surgery. A large diameter femoral head is also expected to reduce the dislocation rate. The purpose of this study is to investigate short-term results of BS cage in acetabular revision surgery combined with the CT-based navigation system and the use of large diameter femoral head. Methods. Sixteen hips of fifteen patients who underwent revision THA using allografts and BS cage between September 2013 and December 2017 were included in this study with the follow-up of 2.7 (0.1–5.0) years. There were 12 women and three men with a mean age of 78.6 years (range, 59–61 years). The cause of acetabular revision was aseptic loosening in all hips. The failed acetabular cup was carefully removed, and acetabular bone defect was graded using the Paprosky classification. Structural allografts were morselized and packed for all medial or contained defects. In some cases, solid allograft was implanted for segmental defects. BS cage was molded to optimize stability and congruity to the acetabulum and fixed with 6.5 mm titanium screws to the iliac bone. The inferior flange was slotted into the ischium. The upside-down trial cup was attached to a straight handle cup positioner with instrumental tracker (Figure 1) and placed on the rim of the BS cage to confirm the direction of the target angle for cement cup implantation under the CT-based navigation system (Stryker). After removing the cement spacer around the X3 RimFit cup (Stryker) onto the BS cage for available maximum large femoral head, the cement cup was implanted with confirming the direction of targeting angle. Japanese Orthopedic Association score (JOA score) of the hip was used for clinical assessment. Implant position, loosening, and consolidation of allograft were assessed using anterior and lateral radiographies of the pelvis. Results. Fifteen hips had a Paprosky IIIB defect, and one hip had a pelvic discontinuity. JOA score significantly improved postoperatively. No radiolucent lines and no displacement of BS cage could be found in 9 of 15 hips. Consolidation of allografts above the protrusion cage was observed in these patients. Displacement of BS cage (>5mm) was observed in 6 hips and displacement was stopped with allograft consolidation in 5 of 6 hips. The other patient showed lateral displacement of BS cage and underwent revision surgery. Average cup inclination and anteversion angles were 37.7±5.0 degree and 24.6±7.2 degree, respectively. 12 of 16 patients were included in Lewinnek's safe zone. One patient with 32 mm diameter of the femoral head had dislocation at 17 days postoperatively. All patients who received ≥36mm diameter of femoral head showed no dislocation. Conclusions. CT-based navigation system and the use of large femoral head may influence the prevention of dislocation in the acetabular revision surgery with BS cage for severe acetabular bone defects

Introduction. The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator. Method. 9 patients underwent the ‘rail and nail’ technique for the management of femoral non-union. Distraction osteogenesis was commenced on the 6. th. post-operative day. Proximal locking of the nail and removal of the external fixator was performed approximately one month after length had been restored. Full weight bearing and joint rehabilitation was encouraged throughout. Consolidation was defined by the appearance of 3 from 4 cortices of regenerate on radiographs. Results. 7 males and 2 females of adult age underwent treatment between 2009 and 2016. The mean lengthening was 6.6cm (3–10cm). The external fixator was removed at a mean 123 days (57–220), with an external fixation index of 20 days/cm. The regenerate healing index was 28 days/cm. There were no deep infections. Significant complications were seen in 4 patients including knee stiffness, a foot drop, delayed union of the non-union osteotomy (requiring exchange nailing and bone grafting) and revision nailing due to a prominent proximal tip. Conclusion. The combined over-sized intramedullary nail and external fixator enables compression of the femoral osteotomy, alignment of the bone and controlled lengthening. Once the length has been restored, removal of the external fixator and proximal locking of the nail reduces the risk of complications associated with the fixator and stabilises the femur with the maximum working length of the nail. This small retrospective study demonstrates encouraging results for this complex clinical scenario

This study reviews the implantation of extracorporally irradiated autografts as a treatment modality and alternative for pelvic Ewing’s Sarcoma. We identified 13 cases between 1994 and 2004 (7 male, 6 female), with mean age 14 years (6.5–34.5). The disease free survival was 69% overall, (75% excluding one case initially treated elsewhere) with a mean follow-up of 6.1 years (3.1 – 8.2). Four patients died with distant metastases at a mean time of 17 months (13–23). Functional results showed a median MST-Score of 86% (IQR 68.5 to 91.5), a median TES-Score 85% (IQR78.5 to 93.5) and a median Harris Hip-Score 89% (IQR 82.5 to 96.5). Solid bony union was observed at all osteotomy sites. Consolidation was achieved after median 6 months (IQR 5 to 7). There were three complications (23%) which required operative intervention, one (8%) due to infection, which required removal of the autograft. Advantages with this technique include ideal fit in the defect and thus promotes healing through greater contact at osteotomy junctions. It avoids early and late loosening and/or breakage of a prosthesis. It acts as a biological bridge for creeping substitution and bony incorporation in the defect. It allows re-attachment of tendons and ligaments, and thus preserves anatomic relationships. There is no risk of disease transmission or immunological reactions. It is cost effective and convenient in any institution with radiotherapeutic equipment. We conclude this is an appropriate treatment option for localised and resectable pelvic Ewing Sarcoma

AIM: The scaphoid resection with four-corner fusion is an effective procedure for treatment of postraumatic and degenerative wrist osteoarthritis. Few studies that evaluated the functional and workers compensation results are available in the literature. We presented the results of 4-corner fusion on active heavy labour workers. MATERIAL AND METHODS: A prospective study to evaluate 38 patients (37 male and 1 female) who underwent 4-corner fusion, between 2002 to 2005, with an average of 24 months of follow-up (range, 12–48 months) were made. The mean age of the patients were 32 years (range, 25–48 years). All patients were heavy-labour workers. The aethiology in 77% of the patients was SNAC wrist. Dominant limb was involved in 65% of the patients. All patients were immobilised in a cast for 4 weeks after surgery. Patients were assessed clinically and radiographically. Functional analysis of grip and pinch strenght were performed. RESULTS: Consolidation was obtained in all cases at 10 weeks. Pain evaluation score was 77 at pre-op and 19 on post-op time. The range of flexion – extension movement postoperative was 57°. Average lost of pinch strength was 25%. All patients return to work, 80% to the same activity level and 20% to a different work performing less strenuous activities. After surgery, the range time to return to work was 160 days. CONCLUSION: The four-corner fusion allows an effective stabilization, maintaining the bone stock and eliminate wrist pain. This technique permit a fast return to work with a great level of satisfaction and preserve a functional range of motion with a minimum lost of force in heavy labour workers

Aims: Several surgical methods to treat varus knee deformities in young patients are known. In the present study the surgical procedure and the medium and long term results of the treatment with opening wedge valgus high tibial osteotomy are analysed. Methods: 27 cases in 11 patients are analysed. Average age: 21 years. 5, ales and 4 females. 8.3 years of follow-up. Surgical procedure: ßuoroscopic control. References: femoral head, knee centre and ankle centre. Osteotomy: Opening wegde valgus high tibial osteotomy. Correction: alignement according tomechanical axis. Bone grafting: autogenous bone grafts and osteotoconduction material. Osteosynthesis with a plate. Knee dynamic orthoses until fusion is achieved. Results: No pre or post-operative complications. Consolidation before 2.5 months in all cases with early full weight-bearing. Results analysed according to the scoring scales: Excellent/Good: 24 cases, Fair: 3 cases, Poor: 0 cases. Conclusions: Opening wedge valgus high tibial osteotomy is an excellent method to correct varus knee deformities in young patients. It does not usually present complications and the correction achieved in the post- operative persists in time in all our cases

Purpose: We set four objectives: compare compression plate with locking screw, assess bone graft usefulness, assess utility of resection and compression of fracture site, and determine prognostic factors. Materials and methods: A multicentre study was carried out including Sant Pau, Valle de Hebròn and IMAS hospitals in Barcelona. 54 surgical cases treated from 1994 to 2003 were included for retrospective study. Three groups of factors were analysed: familial, factors associated with the initial trauma and those associated with the surgical procedure. We studied the statistical relation to consolidation, consolidation time and postoperative complications. Results: The following factors significantly enhanced consolidation (p< 0.05): treatment with nail in atrophic pseudoarthrosis and plate in hypertrophic. Consolidation time was significantly shortened (p< 0.05) if fractures were initially simple (type A) and for those initially treated conservatively. Postoperative complications were reduced (p< 0.05) in fractures that were initially simple (type A). Conclusions: There were no differences between the two implants studied in terms of consolidation, consolidation time and complications. However, cases of atrophic pseudoarthrosis had a better outcome with nails and the hypertrophic cases with plates. Bone grafts did not improve results. Compression of the fracture site was a determining factor in achieving consolidation; therefore, open intramedullary nailing should be performed to this end. Simple fractures and fractures initially receiving conservative treatment were good prognostic factors following pseudoarthrosis surgery

Introduction. Since 2005, we have performed implantation of bone marrow-derived mononuclear cells for osteonecrosis of the femoral head in order to improve vascularization and bone repair. This study focused on early bone repair of osteonecrosis of the femoral head after transplantation of bone marrow-derived mononuclear cells (BMMNC). Patients and Methods. Twenty-two patients (30 joints) who had bilateral osteonecrosis followed for more than 2 years after BMMNC implantation were evaluated. Eight women and 14 men were included. Their mean age at surgery was 41 years (range, 18 to 64 years) and the mean follow-up period was 31 months. Pre-operative stage according to the ARCO classification was Stage 2 in 25 joints and Stage 3 in 5 joints. The mean volume ratio of osteonecrosis was 21%. For preparing BMMNC, about 700ml of bone marrow was aspirated from the ilium and centrifuged using a Spectra cell separator (Gambro). The BMMNC were seeded to interconnected porous calcium hydroxyapatite (IP-CHA) and implanted to the osteonecrotic lesion. As a control, cell-free IP-CHA was implanted for 8 patients (9 joints). A woman and 7 men were included. The mean age at surgery was 49 years (range, 28 to 73 years) and the mean follow-up period was 37 months. Preoperative stage was stage 2 in all patients. The mean volume ratio of osteonecrosis was 22%. At post-operative evaluations; progression of collapse, consolidation at reactive zone, post-operative course of volume rate of osteonecrosis, and bone absorption at osteonecrosis was assessed. Results. Shrinkage of osteonecrosis has been observed subsequent to bone consolidation at the transitional zone which progressed from 3 to 6 months post-operatively in the BMMNC-seeded group. Progression of collapse more than 2 mm was detected in 4 joints (13%), and hip arthroplasty was performed in 1 joint (3%). Consolidation at the reactive zone was detected in 28 joints (93%) and the volume rate of osteonecrosis significantly decreased by 12 months after surgery. Bone resorption at the osteonecrotic lesion was observed in 14 joints (47%). Meanwhile, subtle bone consolidation was detected after 12 months post-operatively in the control group. Progression of collapse was observed in 6 joints (67%) and further surgical treatments were needed in 3 joints (33%). Conclusion. This study found that BMMNC was beneficial to osteonecrosis of the femoral head from the viewpoint of prevention of collapse

Aims: A review of the existing literature is presented and compared with the results of a cohort study. These data are compared with the natural course of fracture healing. Methods: In a prospective cohort study 56 patients with nonunions and 14 patients with delayed unions after fracture or osteotomy were treated with shock wave therapy and followed for 2 years or to consolidation. These results and the previous data were assembled and were compared with the results of three studies on the natural course of fracture healing. Results: Consolidation was seen in 56% of patients with nonunions after a mean of 5.2 months, and in 93% of patients with delayed unions. The success rate of shock wave therapy was strongly associated with the time between primary diagnosis and shock wave therapy. Discussion: The success rate in the own cohort was quite similar to the results reported in the literature, after 3 months 52%, 41%, 19%, 40% or 25%, and 41%, 67%, 61% or 38% after 6 months respectively. At 12 months, healing occurred in up to 80%. The fractures were usually immobilised until union was assessed. It is not likely that a single intervention of shock wave therapy causes effects that last for several months. The results were compared with the natural course of fracture healing, also showing a time dependend healing rate. Conclusion: A considerable part of the effect of shock wave therapy may be attributed to the natural course of fracture healing, where healing is seen even after 6 or 12 months. Only a randomised study will be able to show whether shock wave therapy has any effect on fracture healing

Aims: A biomechanical and clinical study was made to compare two nonunion fixation device: the AO dynamic compresiòn plate and a locked intramedullary nail. Methods: A retrospective review was made of all patients from three major hospitals in the Barcelona area with the diagnosis of aseptic non-union of the humeral shaft. After exclusion criteria series were limited to fifty-four patients, treated between 1992 and 2002. Of these, 35 were women and 19 were men with a median age of 55 (18–91) years. Operative treatment was with plate in 74.1% and locked nail in 25.9%. Statistical analysis was made to compare consolidation rate, consolidation time and complications in both devices and to looking for possible prognostic consolidation factors. We used the Finite element Method to compare the biomechanical behaviour between plate and nail. Results: The consolidation rate was 78.6% with nail and 70.3% in plate, but this rate has significantly improved (p< 0.05) when plate is used in hypertrophic non-union and nail in atrophic union. The median consolidation time was 5.73 months with nail and 4.92 months in plate. The complication rate was 21.4% with nail and 20.0% in plate. Focus deformation is lesser with nail than plate in anterior bending, axial charge and torsion but no in lateral bending. Six or more cortical screws beside focus with plate increase consolidation too (p< 0.05). The consolidation rate in graft group was 70.5% versus 85.7% in group without graft. Conclusions: Plating provides better results in hypertrophic nonunions and nailing in atrophic nonunions. Six or more cortical screws beside focus when plate is used improves consolidation rate. Consolidation not seems be modified by graft use