Introduction: There is a controversy regarding conservative or surgical treatment of calcaneal fracture. We report our experience in surgical treatment of calcaneal fractures.

Materials and Methods: Between March 1998 and May 2004, 30 patients with 32 calcaneal fractures were treated surgically in our departments. Twenty four fractures were caused after a fall from height, 4 fractures were consequence of a road accident, 2 fractures after a blast injury and one after a football injury. There were 4 females and 26 males. Two cases were bi-lateral fractures. Age range 20–66 (mean 33). Follow-up time 7 to 72 months (mean 24 months). The fractures were classified according to Sanders classification: there were 22 patients with Sanders III, 8 patients with Sanders IV and one patient with Sanders II. All patients were operated with the same procedure and the same surgeon. The surgical procedure was delayed from 10 to 14 days post trauma, until swelling subsided. Open Reduction Internal Fixation was performed using lateral approach, “L” shape with subperiosteal dissection of lateral wall, and using a calcaneal reconstruction plate.

Results: The functional outcome was evaluated according to Rowe Score. The clinical results were excellent in 3 patients (10%), good in 22 patients (70%), fair in 4 patients (14%) and poor in 2 patients (6%). The Boehler angle was reconstructed in 29 of 32 calcaneus. 3 patients returned to their previous level of activity, 9 patients returned to work, 14 patients mentioned some pain in the site of the operation. Two patients were treated successfully with oral antibiotics for superficial wound infection. Six patients suffered from peripheral nerve damage. One patient experienced subtalar pain, and underwent a subtalar arthrodesis, furthermore the patient developed Complex Regional Pain Syndrome (CRPS), finally he underwent below knee amputation (BKA). One patient had a flap necrosis and underwent sural flap coverage with excellent results. All the patients were recognized in a process to be recognized as disabled by the social security.

Conclusion: Our results were good in majority of patients according to the known classification systems. However, the recovery period from calcaneal fractures is long and the majority of patients do not achieve their previous functional level. The secondary gain might bias the results.

Purpose: The purpose of this paper is to evaluate the results of One or Two-Stage revision surgery, in the treatment of infected Total Knee Arthroplasty.

Materials and Methods: Between 1978 and 2003, 43 cases of infected TKA were operated. Forty-one cases were followed more than one year. Twenty two patients were males and 19 females. Average follow-up (F-U) time was 8 years (range 1–25). Nine were diagnosed during the first six months postop and 32 cases were late infections. All patients were given intravenous antibiotics for 6 weeks according to culture.

One stage procedure was performed in 20 patients with a painful knee without purulent discharge. Of them, 9 patients were infected with Staph Aureus (45%), 2 Enterococcus, 1 Strep Viridans, 1 Brucella. Seven were clinically infected without positive cultures (35%). Average age at revision was 75.6Y, with 1.9 co-morbidities. Average time interval between primary and revision was 45.6 months. Gallium bone scan was positive in 40%, WBC was above 11000 in 20%, increased ESR in 25% and CRP values above 3 mg/L in 80%. Intra-operative loosening was found in 60% of femoral and tibial components.

Two stage procedure was performed in 21 patients, when pus was present during the operation. Interposed cement impregnated with antibiotics was left between bone ends and at least six weeks of IV antibiotics were given. Average age at revision was 68Y,with 2 co-morbidities. Average time interval between primary and revision was 20 months. Positive Gallium bone scan was in 100%, WBC above 11000 in 80%, increased ESR in 80% and CRP values above 3 in 63%. Twelve patients were infected with Staph Aureus (60%), 4 Enterococcus, 1 Strep Haemolyticus, 1 Candida and 3 clinically infected cases without positive cultures (14%). Intraoperative loosening was found in 43% and 79% of femoral and tibial components, respectively.

Objective result was graded according to HSS score. The differences between ‘one-stage’ and ‘two stage’ groups were checked by t-test of variance.

Results: Twenty four patients out of 41 (60%) were available for F-U, 11 among One Stage group and 13 among Two Stage group. Eleven patients died and 6 were lost for F-U. Subjective satisfaction was reported by 80% of patients. Overall, HSS score increased from 48.3 preoperatively to 80 postoperatively, with 30% excellent result, 48% good, 13% fair and 9% poor.

For One Stage group, postoperative subjective satisfaction was reported by 78% of patients and HSS increased from 49.9 to 81.4. Average arc of motion was 93°. There were 4 patients with recurrent infection (20%), 2 of them were treated with antibiotics and 2 needed second revision (10%).

For Two Stage group, postoperative subjective satisfaction was reported by 82% of patients and HSS increased from 47.3 to 78.6. Average arc of motion was 85°. No re-infection was recorded in this group.

No significant difference between the two groups was found in relation to postoperative HSS score and arc of motion. However, remarkable difference is reported regarding reinfection rate.

Discussion and Conclusion: In this series with an average of 8 years follow-up, HSS score in revision of infected TKR is lower (30% excellent and 48% good) than expected result in primary TKR. The ‘Two-Stage’ procedure was more effective in our hands than ‘One-Stage’ as for eradication of infection in Total Knee Arthroplasty.

The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose a metal-on-metal prosthesis with improved tribology was developed. Our early results of using this system are presented.

Materials and Methods: From 1997 till present 68 Meta-sul hip arthroplasties were performed on 64 patients. 16 cases performed during 2001 were not included in the study due to short follow-up period. Of the remaining 52 cases, 39 were fully followed up (18 male and 21 female) and five were telephonically contacted. Six were lost to follow up and two died for reason not related to the THR. The average age at operation was 57y (27–77y), average height 163cm and average weight 79kg (50–180kg). 18 cases were left and 21 right sides.

4 patients had bilateral THR. There were 3 revision cases due to loosening of cemented cup and 3 post surgical hip procedures. The etiology of the hip pathology was OA in 23, AVN in 10, CDH in 3, two post surgical procedures and one Paget’s disease. The THR prosthesis system consisted of a Wagner type uncemented cup with a factory-assembled Metasul inlay. An uncemented collarless hydroxypaptite coated, Spotorno stem, with a modular 28mm head was used. Long stem was used in 3 cases and reinforcement cage in one. Additional screws (average of 3,4) were used for primary cup fixation. The anterolateral approach, laying either supine or on the side was performed. Average hospitalization time was 12 days. Full weight bearing was allowed as tolerated.

Results: The average follow-up was 30 months. Average Harris Hip Score pre-operatively was 45 (15-74) and post-operatively 75 (15–99). Subjectively, 87% of the primary cases with various etiologies were satisfied with the outcome. The majority of patients had pain-free range of motion and returned to improved daily function. One technical intra-operative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring due to a femoral crack. Immediate post-operative complications included 2 cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intra-operative culture was treated successfully with 6 weeks of intravenous antibiotic therapy. Late complications included one case of cup loosening and one of a painful hip with suspected infection that required revision with a cemented prosthesis. Radiographic examination included measuring of radiolucent lines around the femoral stem according to the zones described by Gruen et al. and acetabulum as described by DeLee and Charnley. No femoral radiolucent lines were found. Seven cases revealed partial ace-tabular radiolucent lines.

Discussion: The Metasul metal-on-metal THR system was used so far with relatively satisfactory results in the early follow-up period despite the leaning curve. It is early to draw conclusions as to the superiority of this system over conventional metal-polyethylene bearing prosthesis. Long term follow-up studies are needed.

The purpose of this study is to evaluate the results of revision surgery in the treatment failed TKR with the TCP III like prosthesis.

Materials & Methods: Between 1985 till May 2001, 116 failed knees were managed. 91 underwent complete revision, 18 were arthrodesed, 6 underwent patella revision only and 1 arthrolysis. Among the complete revisions: 45 were due to mechanical failure (loosening, wear or instability) 29 for infection and 17 for painful or stiff knee.

In 81 of them the implanted prosthesis was TCP III or CCK and were evaluated in this study. 33 were males and 58 females. The average age at revision was 72 years. Most of the cases were performed by the senior author. All cases were osteoarthritic except one which was rheumatoid. The distribution of TCP III like prosthesis was as follows: 47 were TCP III, 33 were CCK and 2 dual. The infected cases were treated whether by one stage or two stage surgery. Patella was not resurfaced but reshaped if patella bone stock was not adequate.

Results: Nine patients died and 14 patients could not be traced in the last follow-up. The average follow up was around 6 years (range of 6 months to 16 years). As compared to preoperative situation almost all of the patients were on the overall subjectively satisfied. The preop HSS score was poor for all the patients. The average postop HSS score was 82 for mechanical failure, 76 for infection and 77 for painful knee. One infected knee got reinfected after 3 years. Three cases had to be revised for the second time to a rotating hinge prosthesis: 2 due to instability and one due to loosening.

Discussion: The TCP III like prosthesis proved in our hands to be a relatively successful implant in revision knee surgery. The new modular CCK design is quite an improvement over the TCP III design and is more versatile in allowing restoration of previous anatomy and joint line. The obvious advantage of this implant are its immediate inherent stability combined with a reproducible normal valgus alignment. The results were best in the treatment of failed knee due to mechanical failure.