Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected nonunion and bone defect 5cm of ulna which was managed with the induced membrane formation.

A 33-years old male presented to outpatient department, 2 months after internal fixation on both left bone forearm fractures (Gustillo I). There was pus discharge from the operative site of ulna. Culture results: MRSA, C-Reactive Protein (CRP): 2,58 (0–5), Erythrocyte Sedimentation Rate (ESR): 42 (0–20). Intravenous (iv) Teicoplanin and Rifampicin were administrated and after one month no topic symptoms and CRP- ESR were normal. One month later he had again actively draining sinus (CRP: 1,47 ESR:22). The implant (ulna) was removed and a gap 5 cm was created at the fracture site (necrotic-infected bone debrided), which was filled by cemented spacer (Tobramycin and vancomycin). An external fixator was applied to ulna. Radius was not involved. Post op. iv the same antibiotics for 4 weeks. At the end of 8 weeks, the spacer was removed and the gap was filled with autologous cancellous bone graft (iliac crest).

After 5 months the patient was reviewed. No any clinical and functional problems. Radiographics and CT-images were showed osseous consolidation.

This technique (called as ‘Masquelet’) gives promising result in the management of infected long bone defects in upper extremity.

Purpose of this study is to compare the reduction of discogenic pain associated with disk herniation in two groups. Group A (31 patients) with lumbago, with/ without sciatica, with no neurologic deficit followed consernative treatment (antiflammatory drugs, physiotherapies) and the group B (31 patients) with the same symptoms submitted in percutaneous disc decompression after six weeks consernative treatment with poor results. Follow up had a period of six months, one year and two years in two groups. All patients in both groups evaluated clinically and the symptoms registrated in special protocol that included pain distribution, sensation, muscle strength and reflections (ahilleus and patellar). All of them submitted in X-ray and MRI so that the two groups have the presuppositions for percutaneous decompression of disc (absense of a free, non-contained or sequestered fragment, remained disc height > 50%, no neurologic deficit, no arthritis in facets). An AVS scale on a questionnaire adapted to Greek population helped assessing pain relief degree, life quality and mobility improvement. The method that we used is t-test for small independent patterns.

We found a statisticasignificant decrease on terms of pain relief, mobility and life improvement during the one and two years follow-up in group B which submitted in percutaneus decompression of intervertebral disks comparetively with A

Background and Objectives: It has been extensively discussed that there is a lowering effect of Replacement Therapy on lipids and lipoproteins. Recent hypotheses relate the lipids and osteoporosis. Thus, there is a possibility that hormone therapy improves osteoporosis not only via direct effect of estrogens on bone tissue, but also via lowering the lipids that may have detrimental effect on bone tissue. The aim of this study was to assess the effect of various regimens of hormone therapy on lipids and osteoporosis and the correlation between lipids and osteoporosis under given hormone treatment.

Methods: Three hundred and thirty five women (n=335) participated in this open study and were assigned to receive orally (a) CEE (n=29), (b) Tibolone (n=75), (c) CEE/MPA (n=57), (d) E2/NETA (n=72), (e) raloxifene (n=64) and (f) no therapy (control) (n=68) for at least 12 months. At baseline and 12 months blood samples were taken and analyzed for lipids and lipoproteins (total cholesterol, triglycerides, HDL, LDL, Lipoprotein (a), Apolipoprotein-A1, Apolipoprotein–B). At baseline and 12 months DEXA was also performed for the measurement of BMD of the lumbar spine.

Results: In the unopposed estrogen group (CEE) most of the variables were negatively connected with osteoporosis and BMD, but none of them were statistically significant. In the raloxifene group similar features were observed, but only LDL reached statistical significance (p=0.0031). In the tibolone group almost all variables were negatively correlated with osteoporosis and BMD, but again only LDL reached statistical significance (p=0.038). In the E2/NETA group most variables were negatively correlated with osteoporosis and BMD, but none reached statistical significance. In the CEE/MPA group all of the variables were negatively correlated with BMD and osteoporosis, but statistical significance was reached by total cholesterol, LDL and Lp(a) (p=0.008, 0.007, 0.047 respectively).

Conclusion: In this study it has been observed that there is a trend in almost every medication group towards an inverse correlation between lipids and BMD. The effect is more prominent in the tibolone, raloxifene and, mainly, in the CEE/MPA group. The greater effect was observed from the point of the lipids, in the LDL variable group. It is very important to clarify whether these findings could be extrapolated at orthopaedic trauma research providing thus a novel explanation for the aetiology of atrophic non unions in patients with compromised vascular function either locally or systematically.

Purpose: Athrophic non unions constitute a major problem in orthopaedic trauma. The main probably cause of atrophic non union is damage of the vascular system and dysfunctional regeneration of the vasculature at the area of the fracture. The most important hormonal pathway controlling angiogenesis is VEGF (Vascular Endothelial Growth Factor). The use of VEGF for enhancing bone healing in atrophic non unions could be a very promising solution for the future. An interesting alternative to the use of VEGF is the use of Erythropoietin (Epo). VEGF has been also reported to interact with Endothelial Progenitor Cells (EPCs). Our scope is to identify a possible new role for Epo as a valid substitute for VEGF through the clarification of the molecular and cellular pathways of fracture healing.

Methods: A survey was conducted via internet (Med-line - Pubmed, Cochrane database, Scopus) and relevant textbooks.

Results: It has been reported that Epo could induce increased chemotaxis, migration of Mesenchymal Stem Cells (MSCs), but also activation of Metaloproteinase - 9 and production of pro-angiogenic factors. These effects on MSCs could explain the observation that Epo could be very useful in the treatment of wound healing and burn healing in animal studies. It has been that Epo could express receptors at the chondrocytes, but also induce better bio-mechanical strength, callus formation, histomophometric image and increased bone density at the treated with Epo animals when compared with control animals. It is also worthy to note that the Epo has been found to stimulate neo-vascularisation in vivo, differentiation of endothelial cell lines towards a vascular pathway and improvement of cardiac function through EPCs and VEGF, implying Epo also in the differentiation and chemotaxis of the circulating EPCs. We should not forget that the transformation of EPCs in mesenchymal cells (i. g. myoblasts) has already been demonstrated.

Conclusions: The consequences of these observations could be very interesting: EPCs have been reported to enhance neo-vascularisation and angiogenesis at the region of the fracture. All these imply a novel role for EPCs in combination (or even replacing the rare) MSCs under the influence of VEGF and Epo for the enhancement of fracture vascularisation and healing enhancement. Further studies should clarify this new field in basic orthopaedic, trauma and bone metabolism science.

One hundred and twenty-nine patients who had had 153 consecutive primary total knee replacements (twenty-four bilateral procedures) between February 1988 and February 1990, with insertion of medial pivot total knee system with cementless femoral and cementless tibial component without replacement of the patella, were enrolled in a prospective study. The average age of the patients at the time of surgery was 67.4 years, the average weight was 78 kg, and the most common diagnosis was osteoarthritis (prevalence, 92.9%). Twenty-six knees had a valgus deformity, ninrty-nine had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus Six patients had a previous high tibial osteotomy, twenty-one arthroscopic debridment and thirty-two total knee athroplasty at the other knee.

One hundred and ten patients (123 knees) were followed for an adequate interval (mean, 5.1 years; range, 3.8 to 6.8 years). Thirteen patients (fifteen knees) died, and twelve patients (fifteen knees) were lost to follow-up. The mean age of the patients at the time of the index arthroplasty was seventy years (range, twenty-nine to eighty-five years). The patients were evaluated clinically and radiographically, according to the scoring system of the Knee Society, and the results on a self-administered questionnaire were used to evaluate pain, function, satisfaction, and patellofemoral symptoms. A Kaplan-Meier survivorship analysis was performed with a revision operation as the end point. Failure was defined as aseptic loosening as evidenced by progressive radiolucent lines and/or revision due to aseptic loosening or collapse.

The mean functional and clinical scores, according to the system of the Knee Society, were 85 and 93 points, respectively, at the most recent follow-up examination. The result was excellent for 103 knees, good for thirteen, fair for three, and poor for six. One revision operation was necessary because of infection. The over-all rate of patellofemoral symptoms was 6 per cent (seven knees). Non-progressive radiolucent lines were present at the cement-bone interface in 39 per cent (thirty-nine) of the ninety-nine knees that had complete radiographic follow-up. No prosthesis had loosened by the time of the most recent follow-up examination. The rate of survival of the implant was 97 per cent at six years, and the standard error of the mean was 1.6 per cent.

In the present series, total knee arthroplasties with the medial pivot modular knee system resulted in excellent relief of pain, an excellent range of motion, and restoration of function. They were also associated with a low prevalence of patellofemoral problems.

We present our experience with HA-coated total hip prosthesis in a minimum follow-up of eight years.

From 1989 to 1991 we performed 92 THRs in 83 patients. The mean age was 62 years (range 32–75). The preoperative diagnosis was: O.A. 68, AVN 12, CDH 8, and post-traumatic arthropathy 4. Pre-operative mean was HHS 43.

A posterior approach was used. The ARC 2F Cup, an HA coated spherical cup with thread around the equator, was used. Initial stabilisation is achieved by screwing the cup into the acetabulum. If necessary, a secondary fixation is enhanced by one or two bone screws to the ilium. The Omnifit stem is HA-coated in the proximal third and gives good immediate metaphysical fixation and optimal filling of the metaphysis. Three doses of Cefuroxime for prophylaxis and low molecular weight heparine were used in all cases. All patients had non-weight-bearing on the second postoperative day, partial weight-bearing in six weeks and full weight-bearing in 12 weeks.

Four patients were lost to follow-up. Mean H.H.S. was 91 in the first six months, 93 in the first year, and 95 in the second and third year. In the fifth year 97.93% were symptom-free in the first six months and 97% from the third to the fifth post-operative year. 3.7% of the patients complained of mild or moderate activity related to hip pain.

No patients suffered marked or disabling pain. Four patients complained of thigh pain six and eight months post-operatively. There were no major complications except for two superficial and two symptomatic deep vein thromboses. All patients returned to their prior activities within four to six months post-operatively. Radiographic evaluation of acetabular components revealed bone condensation in all three Charnley zones. We had no component migration or screw breakage. Calcar resorption was detected on the femoral side in seven patients. During the first post-operative year, AP radiographs of eleven patients indicated cortical hypertrophy in zones 3 and 5. There was no subsidence of the femoral stem.

We believe our results are encouraging although the follow-up period is short. We have had no revisions and the functional results are quite good. All patients are asymptomatic and satisfied with the result.

The capacity of the lumbar spine canal has direct relation to space-compromising conditions. Primary narrowing of the canal may produce no symptoms, but a slight reduction in capacity as a result of degenerative lesions, age, or disc bulging may result in symptomatic spinal canal stenosis. We studied the dimensions in the adult Greek population in order to find the variability factor in the capacity of the lumbar spinal canal.

The dimensions of the lumbar spinal canal were measured in 27 adult men and 42 adult women, all under the age of 50. MRI was used to measure four levels of the spine (L2 through L5). The AP and transverse diameters, as well as the cross section area, were measured at each level. Mean age (sd) of females was 34.8 (6.8) years. Mean age for males was 35.2 (7.3) and was comparable to women (P0.8). Mean age of a third group of 11 males over the age of 50 was 54.5 (2.6). All individuals included in the study were healthy and without any apparent degenerative changes in the lumbar spine or any symptoms related to it. Hotelling’s tests (Anderson, 1958), in terms of multivariate measurements of the spinal canal, were used to compare both genders and the two age levels. Tests for trends in the lumbar levels L2 through L5 were based on the exact binomial distribution for the number of cases exhibiting a complete trend from L2 to L5. The reported significance levels are adjusted for multiplicity of tests.

The relation of spinal width to lumbar levels is shown separately for the groups of males and females women under the age of 50 and for the group of males under over the age of 50. In all four lumbar levels, the group of men over 50 years old had a narrower spinal canal compared with men under 50 years old (2=0.005). This was particularly evident in levels L2 and L5 where the spinal canal for older men was narrower by factors of 15.5% and 13.1%, respectively. In the two gender groups of comparable age, spinal width was found to differ between men and women (2< 0.0001). In particular, the females had a wider spinal canal than males in levels L2, L3 and L4 and a narrower canal in level L5. Spinal width was found to exhibit a decreasing trend in lumbar levels L2 through L5. The evidence for this trend was strong for all three groups: females under the age of 50 (P< 0.0001), men under 50 (2< 0.005), and the older men (P< 0.0001). A similar trend was present for the anteroposterior diameter, as well as for the Transverse diameter. A numerical summary (mean, sd) of all spinal measurements is reported.

We believe this study to be an important one that provides useful information regarding the capacity of the lumbar spinal canal, thus helping the surgeon to properly evaluate the stenotic patient.