Local anatomical abnormalities vary in congenital hip disease patients. Authors often present early to mid-term total hip arthroplasty clinical outcomes using different techniques and implants randomly on patients with different types of the disease, making same conclusions difficult.

We report long term outcomes (13 to 23 years) of the treatment of low and high dislocation cases (separately) with total hip arthroplasty using TM technology acetabular cups (Implex initially and then Zimmer) and short fluted conical (Zimmer) femoral stems.

From 2000 to 2010, 418 congenital hip disease hip joints were treated in our department with total hip arthroplasty. According to Hartofilakidis et al's classification, 230 hips had dysplasia, 101 low dislocation, (group A) and 87 high dislocation (group B). Pre-operative and post-operative values, at regular intervals, of HHS, SF-12, WOMAC, OHS and HOOS were available for all patients. Patient, surgeon and implant related failures and complications were recorded for all patients.

In all cases an attempt was made to restore hip center of rotation. In group A the average lengthening was 2.8 cm (range: 1 to 4.2) and in group B 5.7 cm (range: 4.2 to 11). In both groups, no hips were revised due to aseptic loosening of either the acetabular cup or the femoral stem. In group A, a cumulative success rate of 95.6% (95% confidence interval, 92.7% – 97.4%) and in group B a cumulative success rate of 94.8% (95% confidence interval, 92.6%–96.9%) was recorded, at 20 years, with revision for any reason as an end point. No s.s. differences were found between groups when mean values of HHS, SF-12, WOMAC and OKS were compared.

Satisfactory long-term clinical outcomes can be achieved in treating different types of congenital hip disease when appropriate surgical techniques combined with “game changing” implants are used.

The aim of this study is the comparative assessment of long term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA.

122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford hip score (OHS), Short form-12 health survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, timed up and go test (TUG), Parker mobility, Lower extremity function score (LEFS) and UCLA scores.

At a mean follow up of 14.4 years (10 to 20) a cumulative success rate of 96% (95% CI 96 to 99%) in Group A and 98% (95% CI 97 to 99%) in Group B with operation for any reason as an end point was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U test, p= 0.014), OHS (Mann-Whitney U test, p= 0.020) and physical component of SF-12 scores (Mann-Whitney U test, p= 0.029) only. In Group A, in multiple regression analysis, patients’ cognition (p=0.001), BMI (p=0.007) and pain (p=0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p=0.03) was found to influence quality of life (EQ-5D-5).

In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes.

There are numerous studies in the current literature that have demonstrated altered levels of various biomarkers in the serum of patients with implant loosening. Despite increasing interest in the biology of implant incorporation there are no studies investigating the changes in biological marker (of either osteoblastic or osteoclastic activity) levels during the integration of the bone-implant interface. Such a study would provide data about the biological profile of normal integration and would be helpful for future monitoring of implant prosthetic performance (either normal or abnormal).

We present data from a study performed on 100 osteoarthritic patients, who underwent cementless THA (Synergy, Reflexion Interfit, Smith & Nephew) and 100 non arthritic volunteers. Serial measurements of serum biochemical markers (bone formation and resorption), of cytokines and of other biological mediators and growth factors were evaluated at regular intervals over the course of six years. Curves of per cent changes from baseline and marker variability curves have been created for each marker which are indicative of the incorporation process.

Evaluating markers of osteoblastic activity, a first response, with average values below baseline, was observed at the level of the seventh day (perhaps as a response to local trauma). A second osteo-productive response was observed between the third week and 9 months (peak average values at the level of the 6^th month). At the 1st year time interval, average values reached baseline and remained at this level up to the 6th postoperative year. Evaluating markers of osteoclastic activity, a first response, with average values above baseline, was observed at the level of the seventh day (perhaps as a response to local trauma). A second osteoclastic response was observed between the third week and 3 months (perhaps a coupling response to enhanced osteoblastic activity). At 6 months, average values reached baseline and remained at this level up to the 6th postoperative year.

It seems that bone implant interface in cementless total hip arthroplasty remains active up to the 9^th postoperative month. Possible future deviation from such ‘individual normal’ curves will be indicative of the initiation of the osteolysis process and loss of fixation.

The evaluation of the middle term behaviour of the Wagner-type stems in dysplastic femurs and the presentation of the technical and surgical differences with the implantation of a Wagner stem.

Between 1997 and 2008 we implanted 64 Wagner stems in 58 patients. Average age at the time of implantation was 64 years. 52 patients was operated because of DDH, and 12 had had previous osteotomy. All patients were prospectively evaluated radiographically and clinically at annual intervals. Functional outcome was assessed with Harris Hip Score and Oxford Score.

Mean follow-up of these series was 4 years (11-1)One stem was revised because of fracture of the lesser trochander and two more patients were re-operated for open reduction. With the re-operation as end-point and 95% Confidence Interval survivorship rate was 98, 5%. There were no progressive radiolucent lines. Stem migration was at an average 2mm (1–6) during the first two years and remained stable thereafter. There was no deep infection in these series. After the second year a dense zone is evident in all Gruen zones at the implant –bone interface with a width of 2–3 mm.

Dysplasia of the proximal femur may pose significant technical problems during THA due to the distortion of the geometry and the narrowing of the femoral canal. The sort, conical Wagner type stems can offer a very good alternative is such patients. They allow control of the anteversion and they are able get a good press-fit despite the metaphyseal/diaphyseal mismatch and the femoral bowing.

Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs.

Percutaneous fixation with iliosacral screws has been shown to be a safe and reproducible method for the management of certain posterior pelvic injuries. However, the method is contraindicated in patients with sacral anatomical variations and dysmorphism. The incidence and the pattern of S1 anatomical variations were evaluated in 61 volunteers (35 women and 26 men) using MRI scans of the sacrum. S1 dimensions (12 parameters) in both the transverse and coronal planes were recorded and evaluated. Individuals were divided in four groups based on the S1 body size and the asymmetry of dimensions on the transverse and coronal planes. In 48 (78.6%) patients, dimensions in both planes were symmetrical despite the varying size of the S1 body. In 9 (14.8%) patients, coronal plane dimensions were disproportionally smaller compared to those of the transverse plane with a varying size of S1 body making effective iliosacral screw insertion a difficult task. In 2 (3.3%) patients there was a combination of large transverse plane and small coronal plane dimensions, with large S1 body size. A preoperative imaging study of S1 body size and coronal plane dimensions and an intraoperative fluoroscopic control of S1 dimensions on the coronal plane are suggested for safe iliosacral screw fixation

Advance medial pivot total knee replacement has been designed to reflect contemporary data regarding knee kinematics. We report the clinical outcome of 284 replacements in 225 consecutive patients. All patients were prospectively followed for a mean of 7.6 years (5 to 9) using validated rating systems, both objective and subjective.

All patients showed a statistically significant improvement (p~0.01) on the Knee Society clinical rating system, WOMAC questionnaire, SF-12 questionnaire, and Oxford knee score. The majority of patients (92%) were able to perform age appropriate activities with a mean knee flexion of 117° (85 to 135). Survival analysis showed a cumulative success rate of 99.1% (95% CI, 86.6 to 100) at five years and 97.5% (95% CI, 65.6 to 100) at seven years. Two (0.7%) replacements were revised due to aseptic loosening, one (0.35%) due to infection and one (0.35%) due to a traumatic dislocation. In only two (0.7%) replacements, progressive radiological lucent lines (combined with beta angle of 85°) were observed

Aim: The evaluation of the middle term behaviour of the Wagner-type stems in dysplastic femurs and the presentation of the technical and surgical differences with the implantation of a Wagner stem.

Materials and Methods: Between 1997 and 2008 we implanted 64 Wagner stems in 58 patients. Average age at the time of implantation was 64 years. 52 patients was operated because of DDH, and 12 had had previous osteotomy. All patients were prospectively evaluated radiographically and clinically at annual intervals. Functional outcome was assessed with Harris Hip Score and Oxford Score.

Results: Mean follow-up of these series was 4 years (11-1)One stem was revised because of fracture of the lesser trochander and two more patients were re-operated for open reduction. With the re-operation as end-point and 95% Confidence Interval survivorship rate was 98, 5%. There were no progressive radiolucent lines. Stem migration was at an average 2mm (1–6) during the first two years and remained stable thereafter. There was no deep infection in these series. After the second year a dense zone is evident in all Gruen zones at the implant –bone interface with a width of 2–3 mm.

Discussion: Dysplasia of the proximal femur may pose significant technical problems during THA due to the distortion of the geometry and the narrowing of the femoral canal. The sort, conical Wagner type stems can offer a very good alternative is such patients. They allow control of the anteversion and they are able get a good press-fit despite the metaphyseal/diaphyseal mismatch and the femoral bowing.

Conclusions: Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs

Distal tibia and ankle sepsis can threaten the viability of the limb. We present the management protocol and results in 37 patients with chronic infection of the distal tibia and ankle, followed up for a mean of 4 years.

The mean age was 45.6 years. Host type A were 21 patients, type B were 9, and type C were 7 patients. Treatment included radical debridement, multiple cultures sampling and local antibiotic application. Twenty seven patients required bone stabilisation, whereas 3 host C patients were amputated. Soft tissue coverage included 5 free muscle flaps, 3 soleus flaps and 5 pedicle fasciocutaneous local flaps. Bone defects of a mean of 6.3 cm (3–13cm) in 20 cases were treated with distraction histogenesis (13 cases) or the free fibula vascularised graft (7 cases).

Mean hospitalisation time was 26.2 days (host-A: 19.6 vs. host B/C: 32.2, p=0.036). Host-A patients required 2.3 operative procedures whereas host-B/C 3.9 (p=0.01). Union occurred in 26/27 (96%) of cases requiring fixation (one ankle arthrodesis revision/host-B patient). External fixation frames were kept in situ for a mean of 31.7 weeks (12–85). Mean leg length discrepancy was 0.6 cm. Ankle arthrodesis was performed in 7 patients (5% among host-A patients vs. 38% among B/C). Independent ambulation was achieved in (35/37) 95%. All patients were satisfied with the result. Bacteriology revealed Staph. aureus in 71%, whereas 38% were polymicrobial (7% in host-A vs. 88% in B/C patients, p< 0.001). Infection recurrence occurred in 5.4% (none in host-A vs. 13% in B/C patients, p=0.03), whereas the overall complication rate was 43% (24% in host-A vs. 75% in B/C patients, p=0.02).

Functional limb salvage without leg length discrepancy was possible in 92% of cases. Systemically compromised patients required longer hospitalisation, more operative procedures, had frequently polymicrobial infections and more complications.

Two-staged revision TKA is a common strategy for the management of infected TKA (i-TKA) in properly selected patients. However, there is considerable variation in the parameters (e.g. the duration of intravenous administration of antibiotics and of the time interval between the stages, the intraoperative use of frozen sections, the use of knee aspiration etc.) of the treatment protocol among Orthopaedic Centres making the comparative evaluation of results difficult. The aim of this study is to present a standardised two-staged revision protocol with satisfactory mid-term clinical outcome.

Thirty-four consecutive cases of infected primary TKAs were treated in our department between 2000 and 2006. For 24 of them the postoperative follow-up is greater than 2 years. All patients underwent the same treatment protocol: knee aspiration prior to implant removal and surgical debridement, more than 5 specimens for frozen sections and cultures (aerobic, anaerobic and fungi) during the first stage, custom antibiodic impregnated cement spacers, intravenous administration of antibiotics for 3 weeks followed by 3 weeks of per os administration based on culture and antibiogram, a 6-week interval free from antibiotics, second aspiration and second stage with repetition of frozen sections and cultures. In the case of positive frozen section specimens during the second stage the implantation of a new prosthesis was cancelled and a different management strategy was introduced. Preoperative and postoperative data were collected in the form of Total Knee Society Score (knee score and functional score), Oxford-12 Score, laboratory parameters and radiographs at regular intervals.

At the final follow-up 22 out of 24 patients were free of infection. In four patients (2 Host C and 1 Host B) the 2nd stage was repeated (2–6 times) due to polymicrobial infection and positive intraoperative frozen sections. In one of them a knee arthrodesis was finally performed. The diagnostic accuracy of knee aspiration before the 1st stage was low. Total Knee Society Score rose from a preoperative average of 64 (50 to 95) to a postoperative average of 145 (130 to 180). The Oxford 12 score also rose from a preoperative average of 52 (44 to 58) to a postoperative average of 30 (23 to 38). At the final follow-up no radiological signs of implant loosening were observed.

The above standardised protocol of two-staged revision in i-TKA, when indicated, can provide satisfactory mid-term clinical results.

Deep infection following total knee arthroplasty (TKA) is a devastating complication for the patient and a costly one for patients, surgeons, hospitals and payers. The aim of this study is to compare revision TKA for infection, revision TKA for aseptic loosening and primary TKA with respect to their impact on hospital and surgeon resource utilisation. The evaluation of hospital cost was carried out on a microeconomic basis in order to best evaluate the true cost.

Demographic, clinical and economic data were obtained for 25 consecutive patients with an infection after TKA who underwent a two-stage revision arthroplasty (Group 1), 25 consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and 25 consecutive patients who underwent a primary TKA (Group 3), all of which where admitted at our institution between January 2000 and December 2005. The economic evaluation included both surgical treatment and hospitalisation cost. Because fixed charges do not depict accurately real resource consumption, total cost was calculated through direct cost analysis. All direct health sector costs such as medical supplies, drugs, implants, laboratory and radiology tests, salaries and wages and overhead expenses, including equipment and plant depreciation were calculated. All patients were followed up for a twelve-month period.

Revision procedures for infection were associated with longer operative time, more blood loss and a higher total number of operations compared with both revisions for aseptic loosening and primary TKA. Furthermore, revisions for infection compared to revisions due to aseptic loosening and primary TKAs were associated with twofold and 2.6 times higher total number of hospitalisations, 2.5 and 5.6 times higher total number of inpatient days, 10.2 and 53.8 times higher cost of inpatient drugs and 1.2 and 2.37 times higher cost of implants, respectively. The costing evaluation of the three operative techniques is still on progress.

Patients’ treatment with an infection after TKA is associated with significantly greater hospital and physician resource utilisation compared with that used for patients with a revision due to aseptic loosening or a primary TKA.

In order to evaluate the short- and long-term clinical and radiological results of MIS in TKA, a prospective randomized trial was designed in our department. All patients admitted to the department under the care of one surgeon specializing in Joint Replacement surgery were assigned to participate in the study, signed a concern form, and randomly allocated into two groups. For patients of group A, a TKA was performed using the mini mid-vastus approach; for patients of group B the surgery was performed using a conventional medial parapatellar incision. The Genesis II prosthesis and MIS instrumentation were used for all patients.

Pre and postoperative clinical and radiological data were collected for all patients at regular time intervals (pre, 1st d, 3rd d, 6th d, 3rd w, 6th w, 3rd m, 6th m, 9th m, 1st y, and every year thereafter). Early postoperative pain was also evaluated using a VAS scale and the ability of early SLR was also recorded.

Until now 80 patients (40 MIS, 40 Controls) have entered the study with a follow-up of more than 6 months. In 5 patients (12.5%) of group A the MIS surgery was abandoned in favor of conventional surgery due to technical problems.

Patients in MIS group A had knees with greater range of motion at 3 w, 6 w and 3 months, better function at 3 and 6 months, and less blood loss. In contrast, the same patients experienced greater pain during the first 3 postoperative days. Surgery lasted 16 minutes more on average for the MIS group A. On radiological evaluation technical errors were observed in 5 patients of MIS group A.

Aim: We present the surgical technique and early functional and radiological results of cementless acetabular reconstruction with Monoblock Trabecular Metal (MTM) (Zimmer Warsaw, Indiana) cups in patients with Developmental Dysplasia of the Hip (DDH).

Materials and Methods: From 1997 to 2004, 70 hips (57 patients) with DDH were received an MTM acetabular component. There where 7 men and 49 women. Average age was 50 years (range 35 to 77). According to the classification of Hartofilakidis et al there where 14 hips with high dislocation, 15 with low type I, 16 with low type II, 8 with low type III dislocation and 17 with hip dysplasia. In all patients a MTM cup was implanted in the true acetabulum through a standard posterior approach. Morselized graft was used in 6 cases and a structural graft only in one. Diameter of the cup was ranging from 42 to 56 mm with 54 out of 70 cups being smaller than 50 mm. Screws where used in 12 out of 70 cases A femoral shortening osteotomy was utilized in only two high dislocation cases.

All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).

Results: Average follow up was 50 months (range 103 to 24). There were no revisions for aseptic loosening, radiologic loosening or cup migration during last evaluation. Two patients developed non-progressive radiolucencies in zone one.

There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.

Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.

Conclusion: MTM acetabular component achieved adequate initial stability in this demanding group of patients and they have excellent radiological and clinical results. Posterior approach without femoral osteotomy provided adequate exposure in almost all cases.

Background: Clinical tests used for the detection of knee meniscal tears do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or performing magnetic resonance imaging (MRI) tests. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears.

Methods: Two hundred and thirteen symptomatic patients with recent knee injuries who all were clinically examined, had MRI tests and underwent arthroscopic surgery and 197 asymptomatic volunteers who all were clinically examined and had MRI tests of their normal knees were included in this study. For clinical examination the medial and lateral joint line tenderness test, McMurray test, Apley compression and distraction test, Thessaly test at 5° and Thessaly test at 20° of flexion were used. For al clinical tests sensitivity, specificity, negative predictive value and diagnostic accuracy rates were calculated against arthroscopic and magnetic resonance imaging data.

Results: Thessaly test at 20° of flexion showed a high diagnostic accuracy rate at the level of 94% and a low number of false negative recordings in detecting tears of both the medial and lateral meniscus. Other traditional clinical examination tests, with the exception of joint line tenderness which presented a diagnostic accuracy rate of 88% in detecting lateral meniscal tears, showed inferior rates.

Conclusions: Thessaly test at 20° of flexion can be safely used as a first line screening clinical test for the detection of meniscal tears reducing the need and the cost of modern magnetic resonance imaging methods.

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.

Introduction: Suppurative conditions in closed cavities/tunnels require surgical drainage and irrigation for elimination of infection. The purpose of this study is to evaluate the pattern of extension of infections in hand compartments and the necessity for intraoperative and continuous postoperative catheter irrigation.

Material and Methods: Compartmental infections of the hand and wrist (CIHW) were diagnosed in 42 consecutive patients involving the flexor tendon sheaths (pyogenic flexor tenosynovitis) (28); the tip (3); the carpal tunnel (2); or extended to multiple compartments including the above mentioned and the thenar, midpalmar, web and Parona’s (9). Three patients had diabetes mellitus, 2 suffered from bites, 15 had penetrating injuries and 7 were working with animals or meat products. Fifteen were previously treated in other centers. After meticulous clinical evaluation to define all the involved compartments, all patients were treated with drainage of the respective compartments, sheath irrigation and appropriate antibiotics, whereas continuous postoperative catheter irrigation was used in 24. Hand therapy started the third postoperative day.

Results: Mean follow-up time was 20 months. The most common pathogen was S. aureus (14 patients) whereas cultures were negative in 15. Three patients received additional fungal treatment. Results were excellent or very good in 25 hands and good in 12 regaining full or near full ROM. Recurrence of infection in 4 (that were initially treated inadequately in other centers or had intraoperative sheath irrigation without postoperative continuous irrigation) necessitated a revision of the procedure with extensive debridement and continuous postoperative irrigation. Finally, 1 patient developed complex regional pain syndrome.

Conclusions: A high index of suspicion and profound knowledge of the anatomy is essential for early diagnosis and prompt surgical treatment of CIHW. Initially «benign» infections often extend in multiple compartments of the hand as a result of inadequate initial treatment. Intraoperative irrigation is not always adequate for the resolution of infection, especially in neglected cases or cases with underlying conditions. Early surgical debridement of all the involved compartments in combination to continuous postoperative irrigation, administration of appropriate antibiotics and precocious onset of hand therapy is the treatment of choice for these potentially debilitating, infectious conditions of the hand.

Aim: To evaluate long term effects of stress shieldieng phenomenon after cementless total hip arthroplasty. Materials-Methods: 80 female pts with OA were randomly allocated in 4 groups according to the type of the cementless stem which was primarily implanted (A-Zwey-Muller,B-Corail,C- Optifix,DAutophor900S). BMD changes of the operated hip (in seven zones), of the operated, contralateral normal hip and of the Lumbar spine were measured pre-op, at 2, 8 and 12 months and every year thereafter. Results: At ten years, 72 pts were available for follow up, all with satisfactory clinical and radiological results with no evidence of polyethylene wear or endosteal lysis. In all groups, the greatest reduction of BMD (calcar atrophyzone 7) was observed at the 2nd post-op year (A:24%, B:8%, C:14.8%, D:18.5%). In all groups, the greatest increase (zone 4) of BMD was also observed at the 2nd post-op year (A7%, B2%, C2.5%, D6.3%). In all groups a similar pattern of slow but progressive recovery of bone mineral density changes after the 3rd year was observed in both zones, approaching baseline values at 10 years in all groups. Preoperative lumbar BMD (osteopenia), body weight, sex and height were not statisticaly correlated to calcar atrophy. Conclusions:We suggest that the clinical and theoretical relevance of stress shielding phenomenon in total hip replacement has been overestimated in the literature

Aims: To assess morbidity and the long term sequellae following multiple compartment syndrome of the tibia. Methods: We prospectively followed 21 referred patients (pts). Syndromeñs etiology, the socioeconomic consequences and the way the condition affects the quality of patientsñ lives were evaluated. Patientsñ morbidity, the number and the severity of the reconstructive operations were assessed. A subjective SF-36 evaluation was also performed. Results: The aetiology of the syndromes was RTA in 13 pts, accident at work in 7 and in 1 patient the result of an osteotomy and external þxation. Late release of the compartments was performed in 9 pts. In the remaining 2 pts release was performed at onset. The consequences were drop-foot in 14 pts, club foot in 2, cavus foot in 8, clawing of toes in 14, ankle stiffness in 7, plantar numbness and anesthesia in 13, plantar callosities in 5 and chronic infection in 8. Effective management involved 1–10 subsequent reconstructive procedures in the following 1 to 5 years with hospitalization ranging from 35 to 360 days. One patient was amputated. Two pts were able to perform an easy job and only those 2 in whom the compartments were released in time returned to previous occupations. The remaining are currently unemployed. Conclusions: Established compartment syndromeñs effects on soft tissue and bone seriously affect limb function, permanently impair quality of the patientñs life and deprive them from working effectively. These þndings emphasize the importance of early diagnosis and prompt release.

Aim: Evaluation of intermediate clinical and radiographic results of displaced intra-articular fractures of the calcaneus treated with ORIF. Materials- Methods: From 1994 to 2002, 167 displaced intra-articular fractures of the calcaneus were treated with ORIF. There were 145 male and 12 female patients. Mean age 34 years. Standard x-rays, Broden views and CT-scan images in coronal and transverse plane were obtained pre and post operatively. Fractures were classified as type III, IV, V according to Sanders. All fractures were approached through an extended lateral L-type approach. AO calcaneal plate was used. Average follow-up was 5 years. Results: In 143 Sanders type III and IV fractures KITA-OKA score was 91. Reduction failure rate was 5.5%(8 pts). 24 patients had Sanders type V fractures and KITAOKA score was 84 and reduction failure rate was 25% (6 pts). 29/167 patients complained of peroneal tendons tenderness which subsided after hardware removal. 79/167 patients had restriction of subtalar joint movements but no complains (SF_36) There were two superficial wound infections and five patients with delayed wound closure. In a group of 45 patients with similar fracture patterns who were treated conservatively, KITA-OKA score was 71, 41 fractures were malunited, 40 patients had moderate to severe pain and early OA sings. Conclutions: Displaced intra-articular fractures of the calcaneus should be treated as any other displaced intra-articular fracture, with open reduction and stable internal fixation

Aim: Tissue injury leads to platelets migration and release of growth factors (GF): Platelet-Derived GF (PDGF) and Transforming GF-beta (TGF-b) that are particularly important for the bone repair process. The purpose of our study is to evaluate the new bone formation with the use of AGF-bone graft combination and to estimate the concentrations of PDGF-AB and TGF-b2 during the procedure.

Methods: AGF-bone graft combination was used in 34 patients with long bone defects (24) and spinal fusion (10). TGF-b2 and PDGF-AB concentrations were assessed in samples from blood. Aliquots were taken at each stage of AGF preparation (whole blood, buffy coat, AGF, wound drain) and analyzed for TGF-b2, PDGF-AB concentration and platelet counts. ELISA was performed to quantify concentrations of active PDGF-AB and TGF-b2. Postoperative evaluation was clinical and radiological (radiographs, tomograms, QCT).

Results: Mean follow up time was 9 months. Signs of bone union were apparent in radiographs 3–6 months after the index procedure. Average platelet count increased from 212x106 cells/ml to 680x106 cells/ml (buffy coat) and to 1280x106 cells/ml (AGF concentrate), resulting in a 604% increase. A 480% increase of PDGF-AB levels and a 320% increase of TGF-b2 levels in AGF concentrate comparing to whole blood levels was determined. TGF-b2 and PDGF-AB levels were also detected in samples collected from the wound drains, in increased levels comparing to the AGF concentrates.

Conclusions: In all cases the clinical results were very encouraging with augmented osteogenesis, whereas the laboratory results (increased values of TGF-b2 and PDGF-AB in subsequent stages of the procedure) practically predicted the clinical success.

Purpose: We present the results of subacromial decompression and repair of the rotator cuff through a minimal deltoid-on approach.

Material and Method: Eighty-seven patients with longstanding shoulder pain were evaluated in two years (1999–2000) in our department. In sixty -eight of them symptoms were due to impigment syndrome. Eight patients with follow up time less than six months were excluded from this study, twenty were treated conservatively and the remaining forty (22 female, 18 male, mean age 50.3) underwent surgery. Three x-ray views were obtained in all patients, i.e. standard AP, true AP, and subacromial space projection. MRI was also obtained in all patients. MRI revealed calcific tendinitis in fifteen patients, osteophytes of the acromioclavicular joint in thirteen, a hooked (type III) acromion in ten and partial tear of the supraspinatus tendon in nineteen. In five of them there was also a partial tear of the infraspinatus. Finally, seven patients were suffering of a full thickness tear of the supraspinatus tendon. All patients were operated through a minimal deltoid-on approach. Acromioplasty and coracoacromial ligament dissection was performed in all. In patients with osteoarthritis of the acromioclavicular joint, osteophytes were carefully removed. Calcific deposits were also removed in all patients. In eighteen patients tears of the rotator cuff were detected and repaired using bone anchors.

Results: All patients were examined six months postoperatively. Results were evaluated with CONSTANT SCORE and with a questionnaire for patient’s satisfaction. Thirty-seven patients were very satisfied with the result and three were satisfied. As for Constant score, pain improved at an average of 7.8 points, daily activities by 5.4, and range of movement by 4.2 points. Results were evaluated by the examiner as excellent in thirty-six patients (90%) and very good in four patients.

Conclusion: Deltoid-on approach, in patients with impingement syndrome of the shoulder provides adequate exposure for the surgical repair with minimal trauma and a very low rate of complications.