Total Hip Arthroplasty (THA) is one of the most important procedures in the fields of Reconstructive Orthopaedics. This study aims to present the preliminary results of the clinical and radiological evaluation of patients who have undergone THA with metal bearings, modular necks and big femoral heads and to correlate them with the results of the Finite Element Analysis. In the period from 1/1/2006 until today 90 patients (33 men and 57 women) with mean age 62,4 years have undergone primary THA. The patients were clinically and radiographically evaluated preoperatively, as well as postoperatively, in regular time intervals (1st, 3rd, 6th, 12th month and every year afterwards). The clinical assessment was based on two scales, Harris Hip Score (HHS) and Merle d’ Aubigne (MDA) score, whereas the radiographic on Engh criteria. The mean follow up was 16 months. The mean preoperative HHS and MDA score were 45 and 10,3 respectively, whereas 89 and 16,74 at the last evaluation. The mean Engh score was 16,12. No incidence of dislocation, infection and cup or stem adverse effect occurred. We demonstrate extensively, with respect to the used combination of neck and femoral head, the radiographic findings in the zones of Grün and Charnley, in the areas of the tip of the stem and the calcar, as well as the resulting clinical manifestations. The early clinical and radiological data are in line with the increase in the stresses and strains on the upper part of the femur, which are revealed through the Finite Element Analysis.

Total hip arthroplasty is nowadays a common treatment for a large number of pathological cases regarding the hip joint and is considered as the most successful orthopedic operation. With the mean age of patients constantly decreasing and the more intense way of life, the need for versatile implant designs has arisen. Currently modular hip implant systems are used extensively in order to compensate for difficult occasions, where offset and version correction are required. In addition to this femoral heads of bigger diameter have been introduced to deal with issues such as dislocation and impingement, although their influence on the mechanical behavior on the bone – implant assembly is not widely documented. Towards this direction a finite element model was generated. Computed tomographies of a cadaveric femur were used as raw data and processed, a Profemur-E system with variable heads was digitized, thus leading to a complete assembly consisting of the femur, the stem, the necks and the femoral heads in the commercial CAD software Solidworks. For typical loading scenarios – the stance phase of the gait cycle – the finite element analysis was performed in ANSYS Workbench. The results showed that the implementation of BFH and the neck version produced an increase in strains and stresses with respect to a normal head of 28mm and a straight neck in areas of clinical interest such as the calcar, the greater trochanter area and the stem tip region, considered responsible for thigh pain.

Purpose: The relationship between pain, quality of life (QOL) anxiety and depression in patients with chronic pain is complex. The aim of this study was focused in osteoid osteomas which treated with Radiofrequency thermal ablation (RFTA).

Patients and Methods: We determine the pain characteristics severity, duration, meaning of pain, (MINESOTA score), psychological distress (HADS), physical functioning, social functioning and quality of life (SF −36) and determine which of these variables improved after Radiofrequency thermal ablation in osteoid osteomas. A total of 26 patients with osteoid osteoma which proceed in RFTA and completed the questionnaires, evaluated pain, quality of life, anxiety, depression, physical functioning, and social functioning before and after the procedure in a mean follow up of 17 months. Pearson correlation coefficients were calculated to examine the relationships among the study variables. A multiple regression analysis was performed to determine which variables were the most important predictors.

Results: Pain was significantly correlated with all the other variables, in particular depression and anxiety. Pain QuoL and Depression improved dramatically after kyphoplasties in a follow up of 17 months period.

Conclusion: The clinical results indicate a 100% success rate with complete remission of symptoms and no relapses having been reported at the time of those patients who have arrived at the one year follow up. CT-guided RF ablation is a safe, simple and effective method of treatment for osteoid osteoma. and improve quality of life, anxiety and depression in these patients.

INTRODUCTION: Osteonecrosis of the femoral head usually affects young patients and is caused by disturbance of the femoral head’s blood supply. Bone subchondral necrosis eventually leads to articular incongruity and secondary arthritis of the hip joint.

AIM: To study the adequacy and outcome of tantalum rods implantation in patients with avascular necrosis of the femoral head (up to grade III, according to Ficat’s classification)

PATIENTS AND METHOD: 25 patients with 30 affected hips (5 with bilateral lesions) have been treated, the last 5 years, by tantalum rod implantation. The mean age was 37 years and the mean time of follow up 20 months (6–48), for 24 patients. In four hips we had type III lesions and in the rest type II.

RESULTS: The postoperative evaluation included radiological and clinical (Harris Hip Score – HHS) examination. All patients with type II osteonecrosis had a statistically significant increased HHS score, 6 months and 1 year after tantalum implanting. One patient, with a type III lesion, was subjected in total hip replacement because of disease’s progression, 1 year later. The two others had serious pain relief and improved range of hip motion.

DISCUSSION: Implantation of tantalum rods can be a method of choice in treatment of early stages of AVN of the femoral head. The implant achieves decompression, supports the subchondral plate of the necrotic areas and probably induces bone re-generation. Studies in more patients and with extended follow up time will be helpful for method’s evaluation.

Purpose: The purpose of this prospective investigation is to determine if soft tissue and intra-articular local anaesthetic injection with bupivacaine and adrenaline have beneficial post-operative effects in patients who had total knee replacement (TKR) for osteoarthritis.

Material and Methods: 97 patients were divided randomly into 2 groups. The mean age was 74.7 years. In control group I there were 17 men and 33 women with a mean age of 73.5 years, in group II 16 men and 31 women of mean age of 74.9 years. The patients who were allocated to control group I (n =50) had no intraarticular treatment. We used general anaesthesia in all these patients. The study group II of 47 patients had received intraoperative injection of 0.25% bupivacaine(8ml) with epinephrine (1ml – 1mg) with 2/3 injected into the soft tissues and 1/3 injected into the joint. Clinical parameters evaluated included pain, blood use and bleeding index (calculated by preoperative haemoglobin minus postoperative hemoglobin plus the number of units of packed red blood cells transfused) and range of motion (ROM) at discharge.

Results: Flexion at discharge was improved from 70 (60–90)° in the control group to 90 (80–120)° in study group II (p = 0.005), the difference between the two groups receiving different amounts of analgesics were statistically significant. Number of days until 90 degrees of flexion and until discharge was reduced in group II compared with the control group I (p = 0.003 and 0.002). Also and the blood loss decreased.

Conclusion: This simple method is effective in improving all the postoperative course of primary TKR and should be considered as a part of a perioperative patient treatment program.

Aims: This experiment study was undertaken to evaluate the differences, in bone response to various grafts.

Methods: Ninety, 3.5 months New Zeland white rabbits, weighing 4kg, were divided randomly in 6 groups of 15 animals. Under anesthesia, a 4.5mm hole was drilled in the 2 posteriors femoral condyles of each rabbit, in totaling 180 condyles. Holes were filled with various grafts as follow: Group I-autograft, Group II-xenograft (Lubboc®), Group III-allograft DBM (Grafton®), Group IV-substitute calcium sulfate (Osteoset®), Group V-substitute calcium phosphate hydroxyapatite (Ceraform®), Group VI- was used control. After the implantation, the animals were sacrificed at 1, 3 and 6 months intervals tissue samples from the implanted areas were processed for histological evaluation.

Results: Group I: At 1 month, autologous grafts were lined with activated osteoblasts and osteoclasts. Lamellar bone and cartilage were evident. Neoangiogenesis was prominent. At 3, 6 months defects were filled with mature bone. Group II: Lubboc® displayed moderate (1 month) to intense (3 months) remodeling activity and pronounced neoangiogenesis. At 3 months, endochondral osteogenesis and lamellar bone production were more prominent. At 6 months graft material was significantly restricted and lamellar had considerably replaced woven bone. Group III: Grafton® putty was present at 1, 3 months. There were few osteoblasts and numerous multinuclaeated cells rimming implant surfaces. Endochondral ossification foci, new bone formation and neovascularisation were observed (1, 3 months). At 6 months DBM fibers were absent. Lamellar and woven bone was evident. Group IV: At 1 month new bone (mostly woven) was present, lined with activated osteoblast and few osteoclasts. Endochondral ossification and angiogenesis were evident. At 3, 6 months bone remodeling was augmented, and Osteoset® graft was diminished. Complete closure of defects was observed, at 6 months. Group V: Ceraform® exhibited almost the same properties as Osteoset®. However, endochondral osteopoiesis and bone remodeling were less intense. Additionally, after 6 months, Ceraform® was still evident. Group VI: The defect areas were clearly observed at 1, 3 months.

Conclusion: Autografts are the most effective graft materials. Although Lubboc® is not totally resorbed, it seems to induce lamellar bone synthesis stronger than Grafton®. Bone substitutes are inferior to allografts.

Aims: To investigate the potential of biological þxation of cementless total hip prosthesis in patients over 75 years old, with diagnosed osteoporosis. Methods: Between 1994Ð2000, 30 patients (mean age 77.3 years) underwent total hip arthroplasty (THA). Twenty-two (22) patients, 10 male and 12 female, were found at the last follow-up, which ranged from 1.5–7 years (mean follow-up, 3 years). THA was performed due to primary osteoarthritis (n=16), subcapital fracture (n=4), or dysplastic hip (n=2). Eight (8) smooth, tapered design (CLS) and 14 proximally porous coated prostheses were implanted. Singh index was used for the evaluation of osteoporosis and modiþed Harris Hip Score was used for the clinical evaluation of each patient. Modiþed Wixon score was used for the evaluation of stability probability of the tapered stem. Engh score was calculated for the evaluation of osseointe-gration of the porous coated implants. Results: Pre and post-operative mean Singh index was grade 4. Mean modiþed Harris Hip Score at the last follow-up was 88.6. For the CLS-Spotorno stem a stable þxation probability was calculated at 74.8%, while possible instability was calculated at 48.17%. Porous coated stems provided +13.45 mean Engh score, implying satisfactory þxation of the implant. Post-operative systematic complications are not reported, in contrast to 3 dislocations in the þrst post-operative period, which were treated by closed reduction. Conclusions: In patients over 75 years old, with possible cardiopulmonary disease, cementless total hip arthroplasty offers a reliable treatment, regardless the presence of osteoporosis. Satisfactory osseointegration and absence of systematic complications is compromised by the high cost of titanium implants.

Aims: To evaluate the value of 99mTc-labeled mono-clonal Fab antibodies (Leukoscan) in the diagnosis of septic loosening of total hip arthroplasty (THA). Methods: 16 patients (mean age 63.2 years) with hip arthroplasty (5 hemi,9 cementless,2 cemented THAs) were investigated for deep infection with the use of Leukoscan. Patient selection was based on a “high-risk protocol”. All patients were clinically evaluated using modified HHS and each patient’s workout included x-rays, WBC, ESR, CRP, dynamic bone scan 99mTc-MDP and Leukoscan. Two (2) patients were treated by wide debridement and continuous lavage,6 with revision surgery and 8 with Girdlestone. Histologic samples and cultures were received and their results were compared with Leukoscan’s findings. Results: Preoperative evaluation of the patients revealed as major risk factors:pathologic blood tests (16), previous surgical interventions (13), implant loosening (8), wound infection (7). Mean mHHS was 58 (28–80), mean ESR 51 (23–87 mm/h), mean CRP 4,1 (0,9–18 mg/dl). Bone scans were evaluated as 15 positive and 1 negative and they were matched with 15 positive and 1 negative Leukoscan respectively. Twelve (12) positive histopathologic results and 2 positive tissue cultures were matched with 14 positive Leukoscans, while 1 positive Leukoscan was not verified by positive histopathologic findings of chronic infection. Bacteriae identified were: S.epidermidis 5x, S.aureus 2x, Escherichia Coli 1x, S.saprophyticus 1x, Klebsiella pneumoniae 1x. Conclusions: Leukoscan seems to offer a reliable diagnostic tool for investigation of septic bone infection in presence of hip arthroplasty, presenting a senstitivity of 100% and spesitivity of 93,75%. Proper patient selection, based on diagnostic criteria and risk factors is essential.

Aims: To investigate the effect of tibial reamed intramedullary nailing in treating tibial shaft aseptic nonunion. Method: Between 1990 to 2002, the intramedullary nailing was used in100 patients with aseptic tibial nonunion. Seventy-þve were men and 25 women with a mean age of 31 years (ranging from 18 to 76 years). Thirty-eight (38%) of the fractures were initially open (A:9, B:12, C:15) according to Gustilo-Anderson classiþcation. Sixty-seven (67%) cases were initially treated with external þxation, 13 (13%) with plate and screws, 6 (6%) with I.N., and 14 (14%)with plaster of Paris. The time that elapsed from injury to intramedullary nailing ranged from 6 months to 7 years (mean 15,6 months). Fibular osteotomy was performed in 76 cases through a separate incision. In 6 cases bone grafts from the iliac crest were used. Results: During a follow-up period of one to seven years (mean: 2 years), all of the cases achieved consolidation an average of 6 months after nailing. In 4 cases a late infection was observed which settled after nail removal. One patient developed impending compartment syndrome which was detected on the þrst post-operative day and was treated with a fasciotomy. Transient peroneal nerve palsy occurred in one patient and this recovered in 3 months. In nine patients a clinically acceptable deformity was noticed. Conclusions: Because of its high union rate and low complication rate, we believe that the reamed nailing technique should be considered preferentially for all aseptic tibial shaft nonunion cases.

Aims: To evaluate the results of our preliminary experience with the retrograde nailing for distal femoral fractures. Methods: During the period 1997 Ð 2000, 39 patients with 43 fractures of the distal femur, treated with retrograde intramedullary nail. There were 10 periprosthetic, 2 nonunions after previous failed þxation and 1 pathological fracture. 12 fractures were extra-articular, 18 had intra-articular extension and 2 fractures were open Type II according to Gustillo classiþcation. The mechanism of injury was road trafþc accident in 15 cases, with 9 of those being polytrauma patients, simple fall in and 1 spontaneous fracture. Results: Union was achieved in 11,3 weeks average time. There were 2 mal-unions and 1 nonunion needed reoperation. From the rest of the patients there were 4 with an excellent functional score, 19 good and 2 fair results. There were one superþcial infection, treated conservatively. In one patient the metalwork removal was necessary because he complained of pain from the distal interlocking screws. Conclusions: Retrograde intramedullary nailing, appears to be a reliable technique to treat fractures of the distal femur. It is accompanied by a high union rate and a low infection rate. It offers the advantage of little soft tissue impairment and adequate stability necessary for the fracture healing. Blood loss is usually small and therefore the method is suitable for fracture treatment in elderly and polytrauma patients. The accuracy of the reduction remains a question, because there is no precise method to test it intraoperatively.

Aim: To evaluate time of union and functional recovery of the shoulder joint in humeral shaft fractures treated with antegrade intramedullary nailing.

Methods: During 1998–2002, 29 patients (16 male and 13 female, mean age 43.7 years) with humeral shaft fractures underwent antegrade, proximal locked, intramedullary nailing. A modified extra-articular entry point, 1 cm below the greater tuberosity, was used to avoid rotator cuff damage. The nail, after accurate measurement of its length and proximal metaphysis enlargement up to 10 mm, was impacted into the narrow, cone-shaped, distal part of the humerus, without the necessity of distal screw interlocking. Passive motion of the shoulder joint was initiated from the 2nd postoperative day and active assisted exercises after the 2nd postoperative week.

Results: Mean follow up period was 27 months. Solid callus formation was noted in all fractures, between the 14th and 18th postoperative week. No cases of intra-operative fractures, nerve irritation, rotational instability, nail migration and loss of distal impaction were noted. Mean Constant-Murley score was 93 points at the 16th postoperative week.

Conclusion: Antegrade intramedullary nailing is a reliable and beneficial procedure for the treatment of humeral shaft fractures, regarding union and functional recovery of the arm. The extra-articular entry point should be preferred to avoid rotator cuff and articular surfaces damage whereas the accurate measurement of the nail length and the firm impaction of it at the olecranon fossa makes distally interlocking unnecessary, decreasing significantly the overall operative time and the associated complications.

Purpose: The assessment of long term results and complications rate using the GN and PFN nailing systems for the treatment of peritrochanteric fractures of the femur.

Material-Methods: Between 1991–2002, 195 patients (102 male, 93 female, average age 61.2 years) with a peritrochanteric fracture of the femur (80 A2, 86 A3, 12 pathological, and 17 combined) underwent intra-medullary nailing with the GN (134 patients) or the PFN (61 patients) system. Mean follow up period was 6.5 years. Outcome analysis included time of healing, delayed union or nonunion, infection, hip function (Salvati & Wilson scale), technical complications (cut out, Z effect, malrotation) and mechanical failures (bending fatigue, loosening, breakage of the implant or screws and fracture below the tip of the nail). Intraoperative difficulties in the application of the nails or screws were registered as well.

Results: Solid union of the fracture was achieved in 171 cases (87.6 %). 25 patients died from reasons unrelated to the implant. The overall complication rate was 20.51 % (10 infections, 3 nonunions, 5 implant breakages, 11 cut-out of the neck screws, 5 Z effects and 6 distal screws failures. The Salvati and Wilson score was > 30 in 121 patients (71.1%).

Conclusions: Use of the GN and PFN systems yielded good results in our study. Technical or mechanical complications were mostly related to the operative technique and the type and preoperative reduction of the fracture, rather than these systems themselves. Z effect is a specific complication of PFN in cases with a fracture reduction in varus, especially when comminution of the medial cortex is present.

Aim: To investigate the potential of biological fixation of cementless total hip arthroplasty (THA) in patients over 75 years old, with diagnosed osteoporosis.

Material-Methods: Between 1994–2000, 30 patients (mean age 77.3 years) underwent cementless THA.25 patients were found at the last follow-up, which ranged from 3–7 years (mean follow-up,4 years).THA was performed due to primary osteoarthritis (n=18), subcapital fracture (n=5), or dysplastic hip (n=2).7 Spotorno,9 Synergy and 9 Perfecta prostheses were implanted.Singh index was used for the evaluation of osteoporosis and Harris Hip Score (HHS) was used for the clinical evaluation of each patient.Modified Wixon score was used for the evaluation of stability probability of the tapered stem.Engh score was calculated for the evaluation of osseointegration of the porous coated implants.

Results: Pre and post-operative mean Singh index was grade 4.Mean HHS at the last follow-up was 88.6.For the Spotorno stem a stable fixation probability was calculated at 74.8%.Porous coated stems provided +13.45 mean Engh score,implying satisfactory fixation of the implant.Postoperative systematic complications are not reported.

Conclusions: In patients over 75 years old, with possible cardiopulmonary disease, cementless total hip arthroplasty offers a reliable treatment,regardless the presence of osteoporosis.Satisfactory osseointegration and absence of systematic complications is compromised by the high cost of titanium implants.

Aim:Evaluate the results of primary cemented/cementless THA for the treatment of displaced femoral neck fractures.

Material-Method:121 pts with femoral neck fractures underwent THA 2.1 days on average after their admission.The mean follow up period 4.1 y.112 pts had Garden III-IV fractures,9 pts had Garden II fractures.A cementless THA was applied in 75 pts (Group A,average age 61.4 y),46 pts were treated with cemented THA (Group B,72.4 y).Last follow up evaluation with Harris Hip Score (HHS) and radiological assessment with the Engh/Wixon scores was available in 92 pts.In 25 elderly pts a cementless THA was applied due to established impairment of their cardiopulmonary status.

Results:The mean HHS was 82,3.Radiological score for the cementless THA:+5,8 for the cup and +6,4 for the stem according to Engh scale (satisfactory integration for the prosthesis Perfecta,Synergy) and a 74,8% liability of integration according to Wixon scale (Spotorno).Complications:Early dislocation 3,loosening 5,heterotopic ossification 8,periprosthetic fracture 1,femoral nerve paresis 1,wound infection 1.No systematic complications were noted in the elderly patients with cardiopulmonary disorders,possible due to selection of a cementless THA.

Conclusions:THA (cemented/cementless) for the treatment of displaced femoral neck fractures give very good midterm results.Cementless THA is probably the choice of treatment in elderly pts with cardiopulmonary disorders.

To investigate the potential of biological fixation of cementless total hip prosthesis in patients over 75 years old, with diagnosed osteoporosis.

Between 1994–2000, 30 patients (mean age 77.3 years) underwent total hip arthroplasty (THA). Twenty-two (22) patients, 10 male and 12 female, were found at the last follow-up, which ranged from 1, 5–7 years (mean follow-up, 3 years). THA was performed due to primary osteoarthritis (n=16), subcapital fracture (n=4), or dysplastic hip (n=2). Eight (8) smooth, tapered design (CLS) and 14 proximally porous coated prostheses were implanted. Smgh index was used for the evaluation of osteoporosis and modified Harris Hip Score was used for the clinical evaluation of each patient. Modified Wixon score was used for the evaluation of stability probability of the tapered stem. Engh score was calculated for the evaluation of osseointegration of the porous coated implants.

Pre and post-operative mean Singh index was grade 4. Mean modified Harris Hip Score at the last follow-up was 88.6. For the CLS-Spotomo stem a stable fixation probability was calculated at 74.8%, while possible instability was calculated at 48.17%. Porous coated stems provided +13.45 mean. Engh score, implying satisfactory fixation of the implant. Post-operative systematic complications are not reported, in contrast to 3 dislocations in the first post-operative period, which were treated by closed reduction.

In patients over 75 years old, with possible cardiopulmonary disease, cementless total bip arthroplasty offers a reliable treatment, regardless the presence of osteoporosis. Satisfactory osseointegration and absence of systematic complications is compromised by the high cost of titanium implants.

Aim: To evaluate the midterm results of primary cemented or cementless total hip arthroplasty for the treatment of displaced femoral neck fractures.

Material and Methods: Between 1990–2000, 121 patients with displaced fractures of the femoral neck underwent primary prosthetic replacement 2.1 days on average after their admission. The mean age of the patients was 65,7 years (ranged 33–88) and the mean follow up period 4,1 years (mean 2–10 years), 112 patients had type III–IV femoral neck fractures according to Garden classification while the rest 9 patients had Garden II fractures but with associated osteoarthritis of the hip joint, A cement-less total hip arthroplasty was applied in 75 patients (Group A, average age 61,4 years) while the rest 46 patients were treated with cemented T.H.A (Group B, average age 72.4 years). Last follow up evaluation with the modified Harris Hip Score (HHS) and radiological assessment with the Engh and Wixon et al scores was available in 92 patients. 10,8% of the patients died from reasons unrelated to the implant, In 30 elderly patients (< 75 years old, 22 available in the last follow up) a cementless T.H.A. was applied due to established impairment of their cardiopulmonary status (coronary disease, chronic heart failure, COPD, positive history of myocardial infarction) or systematic diabetes mellitus.

Results: The mean HHS was 82, 3 degrees (52–97). Radiological score for the cementless T.H.A. was +5, 8 for the cup and +6,4 for the stem according to Engh scale (satisfactory integration for the proximal porous prosthesis-Perlecta, Synergy), and a 74,8% liability of integration according to Wixon scale (Sportono type of prosthesis). Complications were recorded in 19 patients: Early T.H.A, dislocation 3, 26% (3 Pi), loosening 5,4% (5 Pt), heterotopic ossification 8,6% (8 Ft), periprosthetic fracture 1,08 % (1 Pt) and femoral nerve paresis 1,08 % (1 Pt). One patient (1, 08%) had superficial wound infection treated with i.v. antibiotics, continuous irrigation and debridement. No systematic postoperative complications (acute renal failure, heart failure, coma) were noted in the elderly patients with cardiopulmonary disorders, possible due to selection of a cementless prosthesis and therefore to the lesser intraoperative time and the avoidance of toxic reactions from the cement.

Conclusion: Total cemented or cementless prosthetic replacement for the treatment of femoral neck fractures in selected cases give very good midterm results. Cementless T.H.A, is probably the choice of treatment in elderly patients with cardiopulrconary disorders, as the integration of the prosthesis is not affected from the degree of osteoporosis and the toxicity of cement is avoided.