Avascular necrosis (AVN) is a disorder leading to femoral head (FH) destruction, while BMPs are known for their osteogenic ability. In this study we analyzed BMP-2, BMP-4, BMP-6 and BMP-7 expression at the RNA and protein level in the normal and necrotic sites of the FHs.

Quantitative RT-PCR for BMP-2,-4,-6,-7 genes was performed in samples from the normal and necrotic sites of 52 FHs with AVN. Protein levels of BMP-2,-4,-6 were estimated by Western Blot analysis. Statistical analysis was performed using the t-test (p< 0.05).

BMP-2 and BMP-6 mRNA levels were higher in the normal than the necrotic site (BMP-2 and BMP-6, normal vs necrotic: 16.8 vs 7.5 and 2 vs 1.66, respectively). On the contrary, BMP-4 mRNA levels were higher in the necrotic (1.2) than the normal site (0.97), while BMP-7 mRNA levels were low in both sites. At the protein level, BMP-2 expressed higher in the normal (0.63) than the necrotic region (0.58), while BMP-4 and BMP-6 detected at higher levels in the necrotic site (BMP-4 and BMP-6, normal vs necrotic: 0.51 vs 0.61 and 0.52 vs 0.57, respectively).

Different mRNA levels between the normal and necrotic site, as well as discrepancies between the gene and protein BMPs expression levels suggest a different regulation mechanism between the two regions. Better understanding of the expression pattern of BMPs could lead to a more successful use of these molecules in the prevention and treatment of AVN

Periosteum is a specialized connective tissue that surrounds bone, containing progenitor cells that develop into osteoblasts. The osteo-progenitor cells along with growth factors, such as BMPs, play critical role in development, reconstruction and bone formation. Aim: to evaluate the expression of BMPs in human periosteum and in different subrgroups, including different donor sites, gender, and smoking habits.

Gene expression of BMPs 2,4,6,7 was performed in 60 periosteal samples using quantitative RT-PCR. Samples were obtained from 32 men/28 women, 22 smokers/38 non-smokers, 29 lower/31 upper extremities.

BMP2 gene expression was significantly higher (median: 12.02, p< 0.05) than the mRNA levels of BMPs 4,6,7 (median: 1.36, 2.55, 0.04) in all samples. BMP2 mRNA levels were higher in large compared to small bones (median: 13.4 vs 9.48), while BMPs 4,6,7 gene expression was similar (1.3 vs 1.4, 2.7 vs 2.1, 0.04 vs 0.03, respectively). In lower extremities, BMPs mRNA levels were higher than in the upper; the same was detected in non-smokers versus smokers group (BMPs2,4,6,7: 13.9 vs 1.5, 3.1 vs 0.048, 8.7 vs 1.06, 1.6 vs 0.026, respectively). mRNA transcripts of BMP2 were higher in men than women (median: 13.1 vs 10.8).

In our study, BMP2 expression is characteristically higher than that of BMP4, BMP6 and BMP7, highlighting the critical role that BMP2 plays in bone homeostasis. Furthermore, the elevated expression of BMP2 in men towards women, and of all BMPs of the lower extremity samples indicate the effect of hormones and mechanical factors in periosteal BMPs gene regulation; while the effect of smoking is reflected in the reduction of BMPs expression in smokers.

We evaluated the contribution of specific gene polymorphisms of IL-1a/IL-1R/IL-1RA/IL-4Ra/IL-1b/IL-12/γIFN/TGF-b/TNF-a/IL-2/IL-4/IL-6/IL-10 cytokines in patients with AVN.

DNA was extracted from 112 patients and 238 healthy Greek individuals. DNA analysis was performed by the PCR-SSP method and the use of the Protrans kit. Statistical analysis was performed by χ2 test.

In the patients, the TC frequency of the IL-1a (nt-889) was 52% while in normal was 40%. The C/G allele frequency of TGF-b codon 25 in patients was 9% C and 91% G vs 13% C and 87% G in normal. At position −238 of TNFa, 11% of the patients had the GA genotype in contrast to 1% of the controls. The GG/GG haplotype of TNFa gene promoter (nt. −308 and −238) was more frequent in both groups, while the GG/GA haplotype detected in 9% and 1% of the patients and controls, respectively. At the −1082 position of the IL-10 gene, the GG genotype was detected in 15% of the controls and 7% of the patients. Also, the GCC/GCC haplotype in IL-10 (positions -1082/-819/-592) was higher in the controls (15%) than the patients (7%).

The genotypes TC (nt-889) of IL-1a, GC (codon 25) of TGF-b, GC (nt-1082) of IL-10 and GA (nt −238) of TNFa, are more prevalent in the patients than the healthy individuals (p< 0.05). Based on our results, the presence of one of the above mentioned polymorphisms or the simultaneous carriage of more than one may contribute to the risk for osteonecrosis

Introduction: Osteoporosis is a common skeletal disease characterized by a combination of low bone mass and altered bone microarchitecture with a consequent increase of fragility. The human CER1 is a novel candidate gene for osteoporosis that can bind directly to bone morphogenetic proteins and inhibit their activity. In this study we evaluated the contribution of five novel gene single-nucleotide polymorphisms (SNPs) of CER1 in blood samples from osteoporotic and control groups.

Materials and Methods: Peripheral blood samples from 100 postmenopausal women with osteoporosis and 50 healthy Greek women, between 45 and 85 years of age, were collected and DNA was extracted. CER1 polymorphisms genotyping was carried out by PCR and sequencing of the whole gene. Bone mineral density (BMD) was examined by DXA. Statistical analysis was performed using Pearson χ2 or Fisher’s exact test in order to compare allelic frequency distribution.

Results: Genetic analysis of the CER1 gene revealed five SNPs at the positions 239C> G (rs3747532), 1058G> T (rs1494360), 2160A> G, 2355A> G (rs17289263), and 2749T> C of the CER1 gene. The above genotypes were distributed differently among osteoporotic and controls. In osteoporotic patients, the SNPs frequencies were: 78.6% heterozygotes and 3.6% homozygotes for 239C> G SNP, 66.7% and 4.3% heterozygotes and homozygotes, respectively, with T allele at the position 1058, 52.4% heterozygotes and 9.5% homozygotes for the polymorphic site A> G nt.2160, 51.2% heterozygotes and 2.4% homozygotes for the G allele at 2355 position of the CER1 gene, whereas only heterozygotes (38.9%) for the 2749T> C polymorphic site were determined (P< 0.001). However, in the control group the polymorphisms were detected only in heterozygosity and the overall distributions of the polymorphisms 239C> G, 1058G> T, 2160A> G, 2355A-> G, and 2749T> C, were 38.9%, 31.3%, 15.6%, 9.4%, 6.9% (P< 0.001), respectively.

Discussion: All the above polymorphisms, except the SNP rs3747532, are correlated with osteoporotic patients for the first time. Allele frequencies of the control group are significantly lower than those of osteoporotic for any of the five polymorphisms. These data provide the first evidence of an association (and most possible significant cumulative contribution) between the aforementioned genotypes in CER1 gene and the risk for osteoporosis in postmenopausal women.

Introduction: The aim of this study is to present the effect of various local anaesthetics, in particular solution concentrations, in peri- and post-operative analgesia in patients with carpal tunnel syndrome (CTS).

Material and Method: 105 patients with CTS (81 female, 24 male, ages 27–79) underwent carpal tunnel release under local anaesthesia. The patients were divided into 5 groups (xylocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, chirocaine 0.25%). A tablet of Gabapentin (Neurontin) 400mg was administered to some patients of each group (41 pts of the 105pts) 12 hours prior to surgery. All patients were evaluated immediately after surgery, in 2 weeks and 2 months postoperatively according to VAS pain score, grip strength, finger active motion and two point discrimination. Postoperative complications were also reported.

Results: Anesthesia was immediate after the local injection. All patients improved postoperativelly regarding relief from pain and paresthesias. There was no statistically significant difference in grip strength before and after surgery. Only 10 patients used paracetamol immediately after surgery, without any statistically significant correlation to any group of patients. 1 patient developed complex regional pain syndrome 2 months after surgery.

Conclusion: The use of local anaesthesia in carpal tunnel release surgery is beneficial in providing immediate intraoperative effect and recovery and mobilization after surgery. Rehabilitation seems to be irrelevant of the type of local anaesthetic that was used during the procedure. Small solution concentrations of local anaesthetics (ropivacaine 0.375%, chirocaine 0.25%) provide adequate analgesia during surgery and provide a normal postoperative course.

Introduction: The value of arthroscopy, fluoroscopy, and e-learning courses (focusing on minimally invasive surgical techniques) for the treatment of intra-articular distal radius fractures (I-ADRF), remains controversial. This study compares the outcomes after fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures, with or without concomitant arthroscopic evaluation.

Materials and Methods: Forty-seven patients with I-ADRF underwent FA external fixation and percutaneous pinning. Among them 23 had additional arthroscopic evaluation of their wrist. For teaching purposes procedures with the use of fluoroscopy and arthroscopy were recorded and adapted as a course for the On-line Performance Support Environment for Minimally Invasive Orthopaedic Surgery (“OnLineOrtho” EU- sponsored project). The context of these courses was incorporated in an intelligent medical performance support environment. The duration of the procedure, the surgical findings and the outcomes were recorded.

Results: The follow-up period ranged from 24 to 62 months and the patients were evaluated at 3, 6, 12 and 24 months. The addition of arthroscopy prolonged the procedure by 25 minutes but diminished the number of images obtained by the image intensifier by 5. After arthroscopic evaluation the placement of subchon-dral pins was changed, because of step-off, in 11 of 23 patients. Also tears of the TFCC (14 of 23 patients), perilunate ligaments (16) were depicted. Patients who underwent additional arthroscopic evaluation had significantly better supination, extension and flexion at all time points than those who had only fluoroscopically assisted surgery. The value added by e-courses and the online performance support system is highlighted through the recognition of the systems effectiveness in e-training.

Discussion: During reduction and fixation of I-ADRF, arthroscopy is a very useful tool for the inspection of the articular surface, the ligaments and the TFCC. Long-term evaluation revealed that patients with additional arthroscopy returned to their previous activities in shorter periods and had better supination, flexion, and extension than patients with FA procedures. Fluoroscopy is essential for the minimally invasive surgical treatment of intra-articular distal radius fractures, whereas arthroscopy is an additional valuable tool that improves the outcome, and e-courses are useful adjuncts for teaching purposes.

Introduction: Avascular necrosis (AVN) of the femoral head (FH) is a painful disorder of the hip that leads to hip collapse. The pathology of AVN involves ischemic events leading to the death of bone. Several biological substances participate in the balance between osteoclasts and osteoblasts, like osteoprotegerin, RANK and RANKL. The expression of these genes affects the maturation and function of osteoblasts and osteoclasts and determines the rate of bone remodeling. In this study, we investigate the expression of OPG, RANK and RANKL in osteonecrotic FHs derived from 44 patients with AVN.

Methods and Materials: RNA and proteins were isolated from both necrotic and normal site of FHs of 44 patients diagnosed with AVN.

Quantitative RT-PCR was performed for OPG, RANKL and RANK molecules by using the Light Cycler FastStart DNA Master Hybridization Probes kit (Roche).

Western Blotting: 22 bone tissues were run on 4–12% NuPAGE gel (Invitrogen). Anti-OPG, anti-RANKL and anti-actin antibodies were used and membranes were immersed in ECL.

Results: Quantitative RT-PCR: The mRNA levels of OPG were higher in the necrotic (median: 5.25) than the normal site (median: 4.19) of the FHs and their difference was statistically significant (p< 0.05). The expression of RANK and RANKL was significantly lower than that of OPG following a similar pattern between the necrotic and normal site. The mRNA values of RANK and RANKL were higher in the necrotic sites [necrotic median: 1.0/normal median: 0.85, necrotic median: 0.8, normal median: 0.3, respectively] than the normal, although they were not statistically significant.

Western Blotting analysis: Normal sites from all FHs showed comparable OPG protein levels (median: 0.57) which were similar to those of normal (median: 0.63). Similar pattern to that of OPG was observed also for RANKL protein expression, where the median value for RANKL/F-actin ratio was 0.49 and 0.5 in normal and necrotic sites of FHs, respectively.

Discussion: OPG, RANK and RANKL are key genes for maintaining the balance between osteoblasts and osteoclasts. Our results show marked differences in the expression of OPG between the necrotic and the normal sites of the FHs; however, mRNA levels of RANKL varied insignificantly between normal and necrotic part of FH while mRNA levels of RANK gene remain similar in both sides of FHs. In contrast, the production of OPG and RANKL at the protein level showed no remarkable divergence. This indicates that the expression and production pattern of RANK may play the key role in the maintenance of the balance between osteoblasts and osteoclasts in AVN.

Introduction: Periosteum is a tissue with pluripotential mesenchymal cells (MSCs). During fracture repair several growth factors are released from periosteum, including bone morphogenetic proteins (BMPs), which induce the differentiation of bone marrow stromal cells towards the osteoblastic lineage, therefore increasing the pool of mature bone forming cells and enhance the differentiated function of osteoblasts.

The purpose of our study is to evaluate the expression of periosteal BMPs mRNA from fracture samples, collected within 24 hours of fracture and to compare it with BMPs expression from periosteal samples of normal (non-fractured) bones.

Materials and Methods: Periosteum samples were collected from 25 patients with recent fracture (during the past 24 hours) (age: 12–80) and 25 individuals without fracture (age: 10–73). BMPs (BMP2, BMP4, BMP6) mRNA levels were analysed by Real Time RT-PCR by using the Light Cycler machine and PBGD as a housekeeping gene.

Results: BMP2 mRNA levels were significantly higher (p< 0.05) in normal samples (median:12.15) than in fracture (median:4.39). BMP6 and BMP4 mRNA expression followed similar pattern to that of BMP2 but in significant lower levels. In normal samples, BMP4 mRNA median levels were 1.99, while in fracture samples the levels were significantly lower (median:0.35), (p< 0.05). BMP6 mRNA levels were also higher in normal samples (median:2.21) than in fractures (median:1.87) (p> 0.05). Furthermore, the decrease of BMPs mRNA levels in fracture samples was higher for BMP4 followed by BMP2 and BMP6.

Discussion: Our results indicate high BMP2 mRNA levels expressed from periosteal cells. In recent fractures there is a significant reduction of BMP2 compared to normal samples; however, the expression of BMP2 remains more elevated in comparison to the other BMPs highlighting the potential role of BMP2 at the initiation of healing process of fractures. BMP6 and BMP4 expression was similar among normal periosteal cells while levels of BMP6 were higher than BMP4 in fracture periosteal cells. The suppression of BMP6 expression was minimum and less significant than BMP2 and BMP4 suppression indicating the potential role of BMP6 at the early stages of MSCs differentiation in periosteum. On the other hand, BMP4 remains in low levels in any confrontation and seems that plays a minor role in early healing process of fracture. BMPs are considered to play central role in fracture response and bone remodelling but further investigation has to be done as much in their correlation and toward other growth factors as in their expression levels during bone fracture repair process.

Aim: According to the literature, mortality rate after hip fracture (HF) approaches 20% per year. Morbidity, mortality and rehabilitation after HF are the objectives of this study.

Material: We followed 192 patients (72 men −120 women, age: 78.6 years), who suffered from HF: intertrochanteric (64%), subcapital (30%) or subtrochanteric (6%). Before the injury 70% of the elderly lived with relatives, yet self-assisted, 17% with relatives but were unabled, 10% completely independent and 3% unabled and alone or instituted. Gait before injury was independent in 50%, while 48% used a walking aid and 2% were in bed.

Results: In a minimum postoperative 12-month follow-up, 75% of the patients were questioned. Mortality rate was 21,8% (men 37,5% - women 12,5%): 7% deceased while in hospital, 57% during the 1st trimester and 36% in the next 9 months. Mean average hospital stay: 8,3 days and the mean interval from injury to operation: 2,7 days (0–13). Direct postoperative complications were recorded in 26,5%. Rehabilitation was continued for 32% of patients in specialized centers and for 7% at home and 35% of patients regained their pre-injury functional level, whereas 37% needed a walking frame. Family members modified their activities in 40% of cases.

Conclusions: Mortality and morbidity in elderly patients with HF overcome 21% and 26% respectively, whereas only 35% of patients regained their pre-injury functional level. Despite the beneficial effect of family support, the lack of organized rehabilitation program and the delay of operation are potential negative factors for the patients outcome.

Aims: Previous work at this institution has demonstrated that perfusion beneath circumferential negative pressure wound therapy (NPWT) is decreased, which conflicts with most studies on NPWT and perfusion. This study investigates perfusion beneath non-circumferential NPWT in humans and also discusses the potential methodology flaw common to all previous research in this field.

Methods: Tests were conducted on both lower limbs of six volunteers (N=12). Volunteers were sequentially randomised into two groups, which would receive different suction pressures (−400 mmHg and −125 mmHg). A doughnut shaped NPWT dressing was placed over the shin of each leg. The central hole allowed for measurement of the transcutaneous partial pressure of oxygen (tcpO2), an indirect measure of perfusion. Readings were taken every five minutes throughout the experiment. After acquiring readings for 15 minutes to establish a baseline, suction was switched on and readings were taken for another 15 minutes. Suction was then disconnected and readings were taken for 15 minutes. Suction was then reapplied and the sequence was repeated. Data were analysed using the Wilcoxon and Mann-Whitney tests.

Results: On applying suction pressures of −400 mmHg, there was a significant reduction of the tcpO2 (mean reduction 7.35 mmHg, SD 7.4, p< 0.0005). At −125 mmHg, there was also a significant reduction of the tcpO2 (mean reduction 5.10 mmHg, SD 7.4, p< 0.0005). Although there was a tendency for greater reductions in the −400 mmHg group this was not significantly different to the −125 mmHg group (p=0.07).

Conclusion: NPWT reduces tissue perfusion, with higher suction pressure resulting in greater reductions in perfusion. Studies on perfusion using laser Doppler, which report findings contrary to these, may be flawed due to the measuring technique of this device. The compressive forces of NPWT are likely to result in false increased readings on application of suction when using the laser Doppler.

This represents a paradigm shift in our understanding of NWPT and that these dressings should be used with caution on tissues with compromised perfusion.

Foot osteomyelitis is a common problem for which management is variable and few guidelines exist.

To present our treatment protocol and the results in 36 patients (20 men, 16 women, mean age: 49.5 years) with osteomyelitis distal to the ankle, followed up for 17.6 months (range: 3–64).

Bone infection involved toes (n=4), lesser metatarsals (n=11), hallux (n=3), midfoot (n=4), calcaneus (n=9), whereas 4 cases presented as generalised osteomyelitis. Postoperative infection was the cause in 10 cases. Eleven patients were classified as host-type A, 14 as B and 11 as C. A draining sinus was present in 28 cases. The treatment protocol included surgical debridement, the bead-pouch technique for local antibiotic administration and closure primarily (n=27), or by secondary healing (n=5), skin graft (n=2), local fasciocutaneous (n=1), or free vascularised muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Generalized Charcot osteomyelitis was an indication for amputation.

Mean hospital stay was 13.8 days (range 1–34) and 2.7 (range 1–7) surgical procedures per patient were recorded. Infection control was achieved in 26 cases (72.2%), whereas amputations were performed in 10 cases (27.8%). Below-knee amputation was undertaken in 4 host-type C patients with Charcot osteomyelitis of the foot. Ray amputations were performed in 4 diabetic feet. Six amputees were classified as host-C and 3 as host-B. One host-type A patient with recurrent post-traumatic toe osteomyelitis, underwent a distal phalanx amputation as definitive solution. Amputation rates were 55% among host-C, 22% among host-B and 9% among host-A patients (p< 0.001).

Diffuse foot osteomyelitis in systemically compromised patients resulted in high amputation rates. Better results were obtained in non-compromised hosts and focal osteomyelitis.

Flaps constitute an integral part of the treatment of soft tissue and skeletal infections of the extremities, focusing on the coverage and augmentation of the local biology.

In a 6-year period, a total of 33 septic defects of the upper (6) and lower (27) extremities were treated with 4 free and 29 pedicled flaps, after extensive surgical debridement of the septic site. In the lower extremity, treatment included 3 free (2 latissimus dorsi and 1 serratus anterior), and 24 pedicled flaps (5 heads of gastrocnemius, 7 soleus, 1 abductor hallucis, 9 reverse fasciocutaneous, 1 combined medial head of gastrocnemius and soleus and 1 extensor longus hallucis) for 3 cases of soft tissue sepsis and 24 septic defects of the skeleton. In the upper extremity, 1 free vascularised fibular graft (combined with muscle-skin) and 5 pedicled flaps (2 homodigital, 1 heterodigital, 1 cross-finger, 1 periosteal) were used for 3 soft tissue and 3 skeletal septic defects. All but one flaps of the lower extremities were covered with split thickness skin (simultaneously or within 7 days), whereas flaps of the upper extremity included skin in all cases.

Three flaps (2 reverse fasciocutaneous and one soleus) were revised (with latissimus dorsi, serratus anterior and extensor longus hallucis flaps respectively) in a mean period of 4 months due to persistent infection and 4 skin grafts were revised due to superficial infection. In a minimum follow-up period of 9 months (9–60 months) full coverage of the defect and treatment of infection was accomplished in all patients, resulting in a good functional and aesthetic outcome. Except for 2 patients, all were able to walk and use their extremity and returned to previous activities.

The use of flaps in the treatment of septic skeletal or soft tissue defects leads to a functional upper or lower extremity and successfully prevents amputation.

Introduction: TKA is usually performed under general or spinal anaesthesia (SA). Most of the patients who undergo this procedure are old and their postoperative rehabilitation could be compromised due to the adverse effects of the relevant anaesthesia. Lumbar Plexus and Sciatic nerve Block (LPSB) have been increasingly applied for intraoperative and postoperative analgesia. The aim of this study is to compare the time required for the performance of the anaesthesia technique, the quality of intraoperative anaesthesia and postoperative analgesia, the incidence of intraoperative or postoperative complications, the blood loss at the recovery room and the required intraoperative intravenous (IV) administration of fluid volume.

Material & Methods: Fifty (50) patients, mean age 70± 5years, ASA I-III were randomly divided into two groups to receive spinal anaesthesia (group A) or LPSB (group B). Patients in group A (n=25) received hyperbaric Bupi-vacaine 0.5% plus 15mcq Fentanyl through atraumatic 25g needle. Lumbar plexus and sciatic nerve block were performed with a 15cm insulated needle (Brown) and nerves were identified by a peripheral electric nerve stimulator. 30 and 15 ml of Ropivacaine (0.5%) were used for each block respectively. All patients received 0.2mg/ Kg of Midazolam and 50μg of Fentanyl IV. The success of the technique was defined as a complete sensory and motor block. All patients received postoperatively Patient-Controlled Anaesthesia (PCA) with morphine intravenously. Time to perform blockade, sensory and complete motor block, hemodynamic parameters, blood loss, IV fluid volume, postoperative analgesic requirements and satisfaction score were recorded. Results were analyzed with Chi Square test and Student’s t-test (level of significance: p< 0.05).

Results: Demographic data, operating time and hemo-dynamic parameters were similar in both groups. Three patients (group B) had insufficient blocks and were converted to general anaesthesia. Although SA is performed and accomplishes complete motor and sensory blockade faster (p< 0,05), LPSB leaded to decreased necessity of intraoperative fluid loading and blood loss at the recovery room (p< 0,05). Overall patient’s satisfaction till leaving the recovery room, Visual Analogue Score (VAS) intraoperatively, 4 and 8hours postoperatively and analgesic counts (recorded through the PCA) in the first 24hours were statistically significant between two groups, in favor of patients with LPSB.

Conclusion: PLSB is an effective alternative to spinal anesthesia taking into account basic clinical and anaesthesiological parameters intraoperatively and immediate postoperatively. Concerning postoperative pain and required administration of analgesics during the first 24hours, LPSB is more efficient compared to SA, underlining the importance of overall patient’s satisfaction during the first postoperative day.

Introduction: Management strategies and results in 30 cases of foot osteomyelitis are presented.

Patients-Methods: From 1/2003 – 1/2006, 30 patients (15 men, 15 women, mean age 47.7 years, range 1.5–82) presenting with foot osteomyelitis were treated. Mean hospital stay was 12.6 days (range 1–45) and 1.3 hospital admissions were recorded (range 1–4). The follow-up period averaged 15.7 months (range 3–56). Bone infection involved the toes in 3 cases, the metatarsals in 9, the head of the hallux in 2, the midfoot in 3, the calcaneus in 9, whereas 3 cases presented as generalized charcot’s osteomyelitis. Eleven patients were classified as host-type A, 10 as B and 9 as C. Nine patients were diabetic, one rheumatoid, four had vascular insufficiency, two had insensate feet. An open calacaneal fracture was the cause in two cases, whereas ORIF of a closed calacaneal fracture in one, ORIF of metatarsal fractures in one and hallux valgus corrective surgery in two. One paediatric patient with calcaneal osteomyelitis developed subtalar arthritis. A draining sinus/wound was present in 24 cases. Each patient underwent an average of 2.3 surgical procedures (range 1–7). The treatment protocol included surgical debridement, use of the bead-pouch technique for local antibiotic administration and closure primarily (n=23), or by secondary healing (n=3), skin graft (n=2), local fasciocutaneous (n=1), or free vascularized muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Amputation was undertaken if salvaging or reconstructive procedures could not be undertaken.

Results: Infection control (salvageable cases) was achieved in 23 cases (76.7%), whereas amputations were performed in 7 cases (23.3%). Four amputees were classified as host C (57.1%), whereas a significantly lower rate of patients successfully treated (21.7%) were host-C (p=0.0008). A below knee amputation was undertaken in two host-type C patients with generalized osteomyelitis of the foot. One 1st ray and two 1st and 2nd ray amputations were performed for not salvageable diabetic feet infections. Finally in 3 cases of posttraumatic chronic toe osteomyelitis in host-type A patients, a distal phalanx amputation was the definite solution. One patient developed a septic TKR in the contralateral leg and one diabetic patient developed osteomyelitis at a different location in the earlier affected foot.

Conclusions: The treatment strategy of radical debridement, local antibiotic delivery by the bead-pouch technique and use of flaps if needed, successfully treated salvageable feet. Amputation was the solution in neglected cases and in immunocompromised patients.

Purpose: To evaluate the differencies in graft orientation between transtibial and anteromedial portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction.

Materials and Methods: Fifty one patients who undergoing arthroscopically ACL reconstruction underwent MRI of their reconstructed knee. Thirty patients had ACL reconstruction using the transtibial technique (group A) while in the rest 21 the anteromedial technique (group B) was used. In the femoral part graft orientation was evaluated using the femoral graft angle (FGA). The FGA was depicted at the coronal views by two axes: the anatomical axis of the femur and the axis of the femoral tunnel. In the tibial part graft orientation was evaluated using the tibial graft angle (TGA). The TGA was specified as the angle between the axis of the graft and a line parallel to the tibial plateau at the sagittal view.

Results: The mean FGA for group A was 12.52° while for the group B was 27.06°. This difference was statistically significant (p< 0.001 paired t-test). The mean TGA for group A was 64.24° while for the group B was 63.11° but this was not statistically significant.

Conclusions: Using the anteromedial portal technique the ACL graft is placed in a more oblique direction in comparison with the transtibial technique in the femoral part. This may have an impact in rotatory knee stability. However, there are no differencies between the two techniques in graft orientation in the tibial part.

Introduction: To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts (VBG) for treating scaphoid nonunions (SN).

Methods: VBG from the distal radius were used to treat 52 SN. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of radiographs obtained in all cases, 19 patients were also assessed postoperatively with MRI at 3 months (15 of 19 were assessed preoperatively with MRI) and 15 had serial MRI evaluations (6–12 months). The clinical follow-up time of this subgroup of 19 patients ranged from 6 to 27 months.

Results: All patients showed clinical signs of union within 12 weeks from the procedure. 3-months MRI showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 14 patients; plain MRI showed union in 13 patients but contrast-enhanced MRI revealed union in all cases. Eight patients were considered to have osteonecrosis of the proximal pole intraoperatively: 4 showed proximal pole necrosis with postoperative plain radiographs and 5 of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all 8 scaphoids. Serial MRI at 6 and 12 months, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases.

Conclusions: Contrast-enhanced MRI is able to assess the viability of the proximal pole and to demonstrate the early union after treatment of SN with VBG allowing thus earlier mobilisation.

Introduction: Surgery in the foot and ankle is usually performed under general or spinal anaesthesia. Peripheral nerve blocking is gaining the preference of both surgeons and patients. The aim of this study is to evaluate the adequacy of anaesthesia with the method of triple nerve blocking at the region of the knee.

Materials and methods: One hundred and forty-four patients (79 men and 65 women) that were diagnosed with ankle and foot injuries or diseases underwent surgery using triple nerve blocking at the knee region as a method of anaesthesia. Surgical procedures included bone and soft tissue procedures and especially fracture fixation, osteotomies, tendon repairs, neuroma and tumor excisions, nerve decompressions and arthrodeses. The common peroneal, tibial and saphenous nerves were blocked with injection of 8 ml ropivacaine 2% for each nerve. The injection was performed by an Orthopaedic surgeon with the use of a neurostimulator. An anesthesiologist was available when necessary.

Results: Ninety-four patients tolerated the procedure without the need of additional injection of anaesthesia or analgesia. In 45 patients additional injection of local anesthetic was necessary. Five patients needed intravenous injection of analgesia in order to complete the procedure. Patients were mobilized the day of surgery, reducing in that way hospital stay. Hospitalization ranged from 0 to 1 days with 58 patients discharged the day of the operation. No complication related to the injection of the anestheric was observed.

Conclusion: Triple nerve blocking at the knee, as a method of anaesthesia, is proposed for certain procedures in the foot and ankle; it allows early mobilization of patients and reduces length of hospital stay. If the neurostimulator is used appropriately, the rate of patients that needs additional analgesia intraoperatively is diminished and no adverse effects of the local anestheric are observed. Complications observed with the practice of spinal or general anesthesia are avoided.

Purpose: Arthroscopy offers a view of intra-articular pathology, but its use in the treatment of intra-articular distal radius fractures remains controversial. This study compares functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation (EF) of distal radius fractures.

Type of study: double randomised prospective, comparison of 2 different procedures.

Methods: Between January 2000 and December 2003, 20 patients with comminuted intra-articular distal radius fractures underwent AA EF and percutaneous pinning and 20 patients underwent and FA EF reduction and pinning.

Results: Follow-up period was 9–27 months. Evaluation was clinical (grip strength, range of motion) and radiographic (palmar tilt, radial shortening, stepoff). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the MAYO wrist score were used 3-9-12 months postoperatively. In 9/20 patients of AA group the subchodral pins were changed after artrhroscopic view because of stepoff. The following tears were found: TFCC (12 of 20 patients), SL (9/20), LT (4/20). Patients who underwent AA surgery had significantly better supination; wrist extension; and flexion compared with the FA surgery group (86 vs 75; 76 vs 65; and 76 vs 63 degrees respectively). Radial shortening and DASH scores were better for the AA group compared to the FA group (AA:12, FA:25) the 3rd and 6th postoperative month but the difference decreased after the 12th month.

Conclusions: A reduction and fixation of intra-articular distal radius fractures provides improved inspection of the ulnarsided components of the injury. Long term evaluation revealed that patients with AA procedures returned in decreased periods to their previous activities (based on DASH score) and had better of supination, flexion, and extension than patients with FA surgery.

Purpose: The aim of this study was to document donor site problems one year after anterior cruciate ligament (ACL) reconstruction and to compare the differencies between hamstring and patellar tendon autografts.

Materilas and Methods: Sixty-four patients undergoing primary arthroscopically ACL reconstruction were randomized to have a central third bone patellar tendon bone (PT) autograft (30 patients) or a doubled semiten-dinosus/doubled gracilis (HS) autograft (34 patients). The postoperative rehabilitation regimen was identical for both groups. All patients were examined one year postoperatively. Objective parameters evaluated included pre and postoperative IKDC and Lysholm score, side-to-side KT-1000 maximum-manual arthrometer differences. The Shelbourne score was used to evaluate anterior knee symptoms. Loss of sensitivity in the anterior knee region postoperatively as well as scar sensitivity were also recorded.

Results: Three patients (10%) in the PT group had anterior knee symptoms while only one (3%) in the HS group. The mean Shelbourne score was 98 for the HS group and 93 for the PT group but this was not statistically significant. However, 8 pateints (23%) had disturbed sensitivity in the anterior knee region in the HS group, but none in the PT group and this was statistically significant (p< 0.005). Scar sensitivity was present in 3 patients (10%) in the PT group and in one (3%) in the HS group. No differencies were found postoperatively between the groups regarding IKDC, Lysholm score and side-to-side KT-1000 measurements.

Conclusions: Although,notstatisticallysignificantpatients in the PT group had more anterior knee symptoms and scar sensitivity, one year postoperatively. In contrast, harvesting of hamstring tendons produces significantly more sensory nerve complications in the anterior knee region than harvesting the middle third of patellar tendon. Both grafts seem to improve equally patients’ performance.

Introduction: Osteomyelitis and septic arthritis (SA) below the elbow are severe conditions affecting the function and viability of the hand. Factors predisposing to these conditions and parameters affecting prognosis are emphasized.

Material and Methods: In a 4 years period, 16 patients with SA (4) or osteomyelitis (12) were treated in a University Orthopaedic Department providing care to a rural population of 1.000.000, Nine had history of trauma in unhygienic environment, 3 had immunodeficiency and in 4 osteomyelitis was iatrogenic [previous fixation of fractures (3) and vein catheterization (1)]. SA was located in the wrist (2) and thumb joints (2) and osteomyelitis involved the radius (3), ulna (1), metacarpals (3) and phalanges (5). Ten patients received oral antibiotics in other centers. The mean delay from onset of symptoms to referral to our center was 22 days. Apart of antibiotics administration, surgical treatment included debridement and irrigation for SA and excision of necrotic bone, stabilization (external fixators), use of antibiotic beads and secondary bridging with bone graft for osteomyelitis. Additional procedures (amputations, arthrodesis) were also required in some cases.

Results: Cultures were positive in 9 of 16 cases [Staph. aureus (5) and enterobacter cloacae (3)]. Patients underwent multiple procedures (mean: 3.8) and 4 underwent amputation of a digit (2) and hand (2) due to the rapid extension of infection threatening and finally taking the lives of 2 elderly and immunosuppressed patients. Mean follow-up period of the 12 surviving and non-amputated patients was 18 months. Union was accomplished in all cases. Functional results were excellent or very good in 10 of 12 patients and good in 2 patients. All patients were satisfied and returned to their previous occupations.

Conclusions: Osteomyelitis and SA below the elbow was frequent in population living in unhygienic environment or working with soil. All cases received medical treatment with delay. Immunosuppressing conditions favored the extension of infection and threatened patients lives. Delay in treatment in combination to immunosuppression resulted to significant morbidity. Early treatment including surgical drainage, thorough debridement and antibiotic administration is necessary for elimination of skeletal infection and salvage of the hand and patients life.