Introduction: Ideal treatment of osteochondral lesions of the talus (OLT) is still controversial.

Aim of this study is to review the 10 years follow-up clinical and MRI results of open field Autologous Chondrocytes Implantation in the treatment of OLT.

Methods: From December 1997 to November 1999, 10 patients, age 25.8 +/−6.4 years, affected by OLT, received open field Autologous Chondrocytes Implantation. The mean size of the lesions was 3.1 cm² (2.2 – 4.3).

All patients were evaluated clinically (AOFAS score), radiographically and by MRI pre-operatively and at established intervals up to a mean follow-up of 119+/−6.5 months. At the final follow-up MRI T2 mapping evaluation was performed. A bioptic sample was harvested in 5 cases during hardware removal 12 months after implantation.

Results: Before surgery the mean score was 37.9 +/−17.8 points, at 24 months it was 93.9 +/−8.5, while at final follow-up it was 92.7 +/−9.9 (p< 0.0005).

Bioptic samples showed cartilaginous features at various degrees of remodelling, positivity for collagen type II and for proteoglycans expression. No degenerative changes of the joint at follow-up were found radiographically.

MRI showed well-modelled restoration of the articular surface. The regenerated cartilage showed a mean T2 mapping value of 46 msec with no significant difference compared to that of normal hyaline cartilage.

Conclusions: The clinical and histological results have confirmed the validity of the technique utilized with a durability of the results over time. T2 mapping was adequate in detecting the quality of the regenerated tissue coherently with the bioptic results.

Metal-polycarbonate urethane (MPU) bearing is a cutting-edge new bearing technology for hip reconstruction. It consists of a 3mm-thick pliable acetabular cup which biomechanically mimics human cartilage and can be coupled with large diameter metal heads. In pristine sockets, no acetabular bone reaming is required to insert the cup. No cement is needed and the cup is simply snapped by hand into a groove made with a special tool. In deformed sockets, the standard reaming technique must be used. The cup acts as a liner inserted into an uncemented metal shell.

MPU bearing has been analysed in comparative in vitro studies. Clinical and radiographic results have been recorded at a minimum follow-up of 2 years in 202 femoral neck fracture patients.

Polycarbonate-urethane elasticity is 20MPa (70 times less than UMHWPE, 10,500 times less than CoCr, p < 0.001). The number of particles generated per step is 1000 with MPU, 1,000,000 with ceramic-ceramic and metal-metal (MOM) (p< 0.001). Fluid film thickness is 0.25microns with MPU, 0.02 with MOM (p< 0.001). At a minimum follow-up of 2 years, X-rays showed good implant stability. In sockets where the buffer alone was implanted an improvement of the supraacetabular bone density was observed over time. Mean Harris hip score after 1 month was 58 points, increasing to 80 points at 2 years (p < 0.05). One patient was revised, due to non-implant-related pain.

The in vitro and clinical data support the use of this novel bearing technology which has the potential to revolutionize hip arthroplasty.

Metal-on-metal hip resurfacing (MOMHR) is a good surgical indication for young active patients. However, it cannot be used in patients with severe CDH and in particular a too short head/neck. To address these cases, a new surgical technique consisting of augmentation of the femoral head with impacted morcellized bone grafts has been developed.

32 osteoarthritis patients following severe congenital insufficiency of the femoral head/neck were treated with MOMHR combined with femoral head augmentation. The required amount of augmentation was calculated on preoperative X-rays and confirmed during surgery. Using special instrumentation, bone chips produced while reaming the socket and trimming the head were impacted on the head to achieve the desired reconstruction and lengthening. Finally, the femoral component was cemented.

Mean patient age was 49+ 9 years (18–66). Median head lengthening was 12+ 2 mm. Mean follow up is 4.2 years (3–6). Mean preoperative Harris hip score (HHS) was 58 and at follow-up 95 (p < 0.05). Mean leg lengthening was 2.2 cm (p = 0.001). In all Gruen zones, bone mineral density (BMD) decreased during the first 3 months. At 2 years in zone 1 mean BMD increased to 96.8% (p = 0.009) and in zone 7 to 102.1% (p = 0.05). A correlation was found between valgus positioning of the femoral components and increased BMD (p = 0.005).

This impaction bone grafting technique expands the use of MOMHR to patients with severe congenital hip dysplasia leading to a more anatomical reconstruction with a full recovery of function and BMD.

A linkage-based mathematical model was used to design a ligament-compatible prosthesis to keep certain ligament fibres isometric during passive motion. The sagittal plane talar component radius is about 50% longer than that of the normal talus, the tibial component is spherically convex. A fully conforming meniscal bearing is interposed between them. Experiments in cadaver specimens confirmed the mathematical prediction that the bearing moves forwards on both metal components during dorsi-flexion and backwards during plantar flexion.

Between July 2003 and July 2008, the prosthesis was implanted into 250 patients at nine hospitals in Northern Italy. By November 2007, 158 in 156 patients were seen at least six months post-operatively. Mean age was 60.5 years. The diagnosis was post-traumatic osteoarthritis in 127, primary osteoarthritis in 17, rheumatoid arthritis in 10.

The mean follow-up was 32.5 months. The pre-operative AOFAS score of 36.2 rose to 75.9, 79.3, 77.9, and 79.0 respectively at 12, 24, 36, 48 months. Dorsi-flexion increased from 0.1° to 9.7°, plantarflexion from 15.1° to 24.6°. In 30 patients at one hospital, the range of postoperative motion, 14° – 53°, was significantly correlated to the range of bearing movement on the tibial component, 2mm–11mm, measured radiologically, (r2 = 0.37, p < 0.0005).

By December 2007, 2 revision operations had been performed at 24 months, one for unexplained pain not relieved by a successful arthrodesis, one in a patient with Charcot-Marie-Tooth disease. There were no device-related revisions (loosening, fracture, dislocation). The Kaplan-Meier survival rate (component-removal as end-point) at 4 years was 96% (Confidence interval 90–100%).

Early clinical results have demonstrated safety and efficacy. The survival rate at four years compares well with multi-centre 5-year rates published by the Swedish (531 cases, survival 78%), Norwegian (257, 89%) and New Zealand (202, 86%) registries.

Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB).

Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB.

Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years.

Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up.

Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained.

Anterior bony impingement of the ankle is a common cause of chronic ankle pain, and it represents an important indication to arthroscopic treatment.

The purpose of the study was to analyze the factors affecting the clinical outcome of surgical treatment and to describe a new classification based upon the arthroscopic assessment, considering prognostic factors and rationale for treatment.

84 consecutive patients with a mean age of 32.6 years were treated between 2000 and 2005. The impinging lesions were divided into localized (antero-medial, antero-lateral and syndesmotic) or diffuse. The status of the chondral layer (A – Normal; B – Focal ICRS grade I–II; C - Focal ICRS grade III–IV; D – Diffuse ICRS grade I–II; E – Diffuse ICRS grade III–IV) was documented, as well as the presence of altered foot morphology (cavus or flat) or ligament lesions. Previous traumas or surgery were considered. Patients were evaluated after a 24–87 months follow-up, following the AOFAS scale.

The pre-operative AOFAS score was 39.4, while at follow-up it scored 80.1(p< 0.05). Patients with diffuse anterior impingement obtained the best result in terms of improvement. Patients with normal cartilage had a better outcome but among cartilage lesions the better improvement was obtained in patients with diffuse severe cartilage damage. Associated regenerative treatment for focal chondral grade III–IV lesions provided the better results. Patients with associated surgically repaired ligament lesions had the better clinical outcome with respect to intact ligaments.

On the basis of the results we purpose a new classification, based upon the prognostic factors, into 2 types: I – Localized; II - Diffuse. Further classification was made into subtypes A to E according to the associated chondral lesions. Finally the presence of associated conditions such as ligament lesions, previous sprains or surgery was considered, being relevant as prognostic factors.

The aim of this study is to present guidelines for treatment of acquired adult flat foot (AAFF) and review the results of a series of patients consecutively treated. 180 patients (215 feet), mean age 54? 12 years affected by AAFF were evaluated clinically, radiographically and by MRI to chose the adequate surgical strategy. Tibialis posterior dysfunctions grade 1 were treated by tenolysis and tendon repair (48 cases), grade 2 by removal of degenerated tissue and tendon augmentation (41 cases), grade 3 by flexor digitorum longus tendon transfer (23 cases); in these cases subtalar pronation without arthritis was corrected by addictional procedures consisting of either calcaneal osteotomy (66 cases), subtalar athroereisis (25 cases) or Evans procedure (21 cases) in case of severe midfoot abduction. Subtalar arthrodesis (82 cases) or triple arthrodesis (21 cases) were performed in case of subtalar arthritis isolated or associated with midtarsal arthritis respectively. Postoperatively plastercast without weight-bearing for 4 weeks followed by walking boot for 4 weeks was advised. All patients were followed up to 5 years. Before surgery the mean AOFAS score was 48+\−11, while it was 89+\−10 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+\−5° preoperatively and 8°+\−4° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 165°+\−12° preoperatively and 175°+\6 at follow-up. Surgical strategy in AAFF should include adequate treatment of tibialis posterior disfunction and osteotomies for correction of the skeletal deformities if joints are arthritis free; arthrodesis should be considered in case of severe joint degeneration

Objective: Different

Methods: have been proposed to date to achieve the regeneration of hyaline cartilage in osteochondral lesions of the talus (OLT). The aim of this study was to present a new one-step arthroscopic procedure with the use of mesenchimal stem cells (MSC) supported on a collagen scaffold and Platelet Rich Fibrin (PRF).

Methods: 14 patients with a diagnosis of OLT underwent this procedure. The MSC were harvested from the posterior iliac crest and concentrated directly in the operating room. An ankle arthroscopy was performed with lesion detection and curettage. The cell concentrate was mixed with a collagen paste as scaffold and with PRF as a pool of growth factors in order to have a final composite to fill the lesion site. Partial weight bearing for 2 months and early ROM was advised postoperatively.

Results: According to the American Orthopaedic Foot and Ankle Score (AOFAS) system the patients had a preoperative score of 65.1 (range 35–79), a postoperative of 69.4 (range 61–97) at 6 months and of 83.6 (range 65–100) at 12 months follow up. MRI control at 6 and 12 months showed a progression of the reparative process in the osteochondral lesions. Histological and immuno-hystochemical analysis on a sample biopsed during a control arthroscopy at 12 months confirmed the hyaline quality of the regenerated cartilage.

Conclusions: This one-step technique demonstrated to be capable to regenerate hyaline cartilage, with the advantages of a reduced surgical time, lower costs and lower patient’s morbidity.

Knowing patient bone density is important to select the proper fixation technique and for secondary osteoporosis medical treatment. However few studies addressing hip fractures provided data regarding patient bone mineral density.

Materials and Methods: Four hundred and thirty three consecutive female patients were included in our study. Inclusion criteria were: AO/OTA fracture type A1, A2 or B, age ? 80 years and minor trauma. BMD values of the lumbar spine (L2–L4) and right proximal femur (neck, trochanter, Ward’s triangle) were measured by dual-energy x-ray absorptiometry. Patients were divided into three groups: Group A had trochanteric fractures (n = 79, average age 85 ? 5), Group B had femoral neck fractures (n = 67, age 84 ? 4) and Group C had no fractures (n = 287, age 82 ? 2). Data was assessed statistically using Analysis of Variance (ANOVA) and receiver operating characteristic (ROC) analysis.

Results: Group A ROC curve had higher values when compared to Group B ROC curve in all corresponding BMD tested sites. Total number of patients with femoral neck fracture and a T-score higher then −2.5 SD were 14 (20.9%), 25 (37.3%) and 16 (23.9%) at the femoral neck, trochanter and at the Ward’s triangle respectively. Patients with a trochanteric fracture and a T-score higher than −2.5 SD were 8 (10.1%), 15 (19.0%) and 12 (15.2%) at the femoral neck, trochanter and Ward’s triangle respectively. BMD values at the trochanteric measurement site demonstrated that the incident rate between the two patient groups differed significantly depending on the diagnosis of osteoporosis (Chi square test: X² = 6.12, p = 0.013).

Discussion: There are notable differences in bone mass density. Femoral neck BMD proved to be the best diagnostic site using DXA, with 15.07% of hip fracture patients having a normal age-related bone mass. Higher non-osteoporotic bone densities were found in women with hip fractures: BMD values were (27.40%) at the trochanter and (17.81%) at the Ward’s triangle.

Conclusions: There was a significant difference between non-osteoporotic related fractures in Group A and Group B. There were more non-osteoporotic related fractures in Group B. A lower BMD was found in patients with trochanteric fractures than in patients with femoral neck fractures. Assessment of bone quality in these patients is of paramount importance in choosing the correct surgical treatment. In patients with poor bone quality, fixation augmentation techniques can be used. We recommend routine DXA scans of the affected fractured hip in all elderly hip fracture patients prior to surgery.

Aims: This work analyzed the effects of storage by fresh-freezing at −80°C on the histological, structural and biomechanical properties of the human posterior tibial tendon (PTT), used for ACL reconstruction.

Methods: Twenty-two PTTs were harvested from eleven donors. For each donor one tendon was frozen at −80°C and thawed in physiologic solution at 37°C, and the other was tested without freezing (control). Transmission electron microscopy (TEM), differential scanning calorimetry (DSC) and biomechanical analysis were performed.

Results: We found the following mean changes in frozen-thawed tendons compared to controls: TEM showed an increase in the mean diameter of collagen fibrils and in fibril non-occupation mean ratio, while the mean number of fibrils decreased; DSC showed a decrease in mean denaturation temperature and denaturation enthalpy. Biomechanical analysis showed a decrease in ultimate load and ultimate stress, an increase in stiffness and a decrease in ultimate strain of tendons.

Conclusions: Fresh-freezing brings about significant changes in the biomechanical and structural properties of the human PTT. A high variability exists in the biophysical properties of tendons among individuals and in the effects of storage on tendons. Particular care is required when choosing an allograft tendon and further studies are required to clarify the role of donors’ age and sex, and other factors, in determining the suitability of an allogenic tendon. The future directions could be:

(a) To choose the tendon grafts considering the donors’ characters;

INTRODUCTION: Post-traumatic arthritis of the ankle in the young active patient represents a reconstructive challenge. Fresh total shell osteochondral allografts are an increasingly popular option in the reconstruction of various amounts of cartilage defects, although concerns for bipolar allografting are reported. The purpose of this study is to describe the preliminary results of a series of 18 bipolar shell ankle allografts performed by using a specifically designed instrumentation.

METHODS: 18 patients, 13 males and 5 females (mean age 31±10 years) affected by post traumatic arthritis of the unilateral ankle joint grade III received bipolar shell allograft of the ankle. The mean follow-up was 12 months (range 24–8). The ideal patient to allograft match was permitted through CT scan and x-rays. Two steps surgery, one for allograft preparing and one for the recipient site, were performed by using specifically designed jigs. Patients evaluation was carried out clinically by AOFAS and radiographically by X-Rays, CT scans, MRI.

RESULTS: No intraoperative, complications occurred. All the patients demonstrated good consolidation rates of the allograft at X-Rays, CT scan and MRI controls performed at 4, 6, 8, and 12 months. At 8 months follow-up, all the patients were allowed complete weight bearing. Normal ROM of the ankle and regular gait with no pain and no need of support was resumed in 13 patients. In 2 patients a fracture of the fibula was reported. In one case, cause of the fracture was patient non compliance to the weight-bearing restriction. In the other case the fracture occurred distal to the osteotomy site, possibly due to a trauma. Both the cases required revision of the graft which appeared damaged in the lateral site. In the first case an ankle arthrodesis was performed. A bioptic harvest of the transplanted cartilage in 5 patients at 1 year follow up demonstrated chondrocytes vitality > 90%.

DISCUSSION: Accurate preoperative planning, sizing, and the use of specifically designed jigs makes viable and reproducible the bipolar shell allograft in the ankle joint in selected cases. Although preliminary results are encouraging, longer follow-up is required in order to confirm longer term cartilage viability and the validity of the technique.

INTRODUCTION: Diaphyseal aseptic nonunions are challenging complications in forearm fractures, as length imbalance of radius and ulna impairs severely its function. The aim of this study is to report the results of a series of patients operated on by an original technique.

MATERIAL AND METHODS: 60 patients aged 17–72 years (mean 35) were treated between 1980 and 2000. Ten patients presented radius nonunion, 37 ulna non-union, and 13 nonunion of both bones. Nonunions occurred after conservative treatment in 8 cases, after one surgical procedure of plating or nailing in 47 cases and after 2 or more surgical procedures in 5 cases. Surgical treatment occurred at mean 36 months after the fracture and consisted of freshening the bone and applying a plate and an opposite cortical bone allograft; in 17 cases omologous intercalary bone graft was applied to restore length, axial and rotational alignment. Postoperative treatment consisted of functional bracing associated with intensive rehabilitation of the elbow and wrist beyond clinical and radiographic union. Average follow up was 15±7 years.

RESULTS:. One implant failed due to infection, requiring additional surgery. Mean elbow ROM was 122°±18. Compared with the contralateral arm, mean loss of wrist ROM was 20°±17. Mean loss of forearm rotation was 25°±15. Average healing time was 14±4 weeks X-ray analysis showed bone healing and good osteointegration of the graft in all cases.

DISCUSSION AND CONCLUSION: Combining a plate and an opposite massive cortical bone graft resulted to be a very effective technique for surgical treatment of forearm nonunions.

Purpose: To evaluate the safety and efficacy of hylan G-F 20 viscosupplementation in patients with symptomatic osteoarthritis (OA) of the ankle.

Methods: Prospective, multi-center, open study in patients with primary or secondary grade II talocrural OA confirmed by X-ray. At baseline, patients had to score between 50–90 mm on the Patient-completed Ankle OA Pain VAS (0–100 mm). Patients received one intra-articular injection of 2 ml of hylan G-F 20 and were given an option of a second and final 2 ml injection if their pain remained between 50-90 mm on the VAS after 1, 2 or 3 months. Intraarticular injections were placed in the anteromedial portal of the ankle joint as described for ankle arthroscopy. Patients were followed for 6 months after the final injection. As rescue medication, patients could only take paracetamol up to 4 g per day, except on the day of or the day before a study visit.

All treatment emergent adverse events (AEs) were recorded. The primary efficacy endpoint was change from baseline (at final injection) in the Ankle OA Pain VAS at 3 months after the final injection. Secondary endpoints were Ankle OA Pain VAS scores at all other time-points, total Ankle OA Scale, Patient and Physician Global OA Assessment (VAS), and health-related quality of life (SF-36).

Results: Fifty-five patients (33 M; 22 F) were enrolled and received a first injection of hylan G-F 20. Twenty-four patients (44%) received a second injection. The mean age was 41 years (range 19–70). Overall, treatment with hylan G-F 20 was well tolerated. Seventeen patients (31%) had a treatment related AE of the target ankle. All were of mild or moderate intensity, the majority consisting of arthralgia and injection site pain. There was a statistically significant decrease in Ankle OA Pain VAS score from 68.0 mm at Baseline to 33.8 mm at Month 3 (p< 0.001, paired t-test), which was maintained at 6 months follow-up. The decrease was statistically significant at all time points. Patients who received only 1 injection demonstrated a greater decrease at 3 months (−42.5 mm) than patients with 2 injections (−23.5 mm). The secondary efficacy endpoints showed similar results. Of the total study population, 29 patients (53%) were responders (i.e. at least a 50% decrease in ankle OA pain) after 3 months. 64% of patients receiving 1 injection were responders after 3 months. The SF-36 questionnaire showed statistically significant improvements for both the physical and mental component scores at 3 and 6 months follow-up.

Conclusions: Treatment of OA of the ankle with intraarticular hylan G-F 20 injections is well tolerated. Treatment with hylan G-F 20 significantly decreases pain which is maintained for up to 6 months.

OBJECTIVE OF THE STUDY: Metatarsal osteotomies are common procedures for correction of hallux valgus. The aim of this study is to compare linear distal metatarsal osteotomy (LDMO) with SCARF osteotomy a clinical prospective randomised study.

METHODS: Forty patients affected by bilateral hallux valgus similar in both sides regarding clinical and radiographic assessment were included. X-rays, AOFAS, Maryland Foot Score (MFS) were considered before surgery up to 4 years follow-up. All patients were operated bilaterally, and received SCARF osteotomy in one side, and in the other LDMO performed through a 1 cm skin incision under the direct view control. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bondage and weight bearing with talus shoes for 4 weeks.

RESULTS: No statistical differences were observed in preoperative HVA, IMA, PASA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in LDMO (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed. At 4 year follow up, no statistical differences were observed in HVA, IMA, PASA comparing SCARF with LDMO. Average AOFAS score was 87±12 in SCARF and 89±10 in LDMO (p=0.07), and MFS was 86±7 in SCARF and 90±3 in SERI (p=0.08).

CONCLUSION: Both SCARF and LDMO techniques resulted effective in the correction of hallux valgus, however SERI, a minimally invasive technique, performed with a shorter skin incision, more rapid surgical time, fixed with a less expensive device (one kirshner wire), resulted in a better clinical outcome.

A new design of total ankle replacement was developed. According to extensive prior research, the design features a spherical convex tibial component, a talar component with radius of curvature in the sagittal plane longer than that of the natural talus, and a meniscal component fully conforming to these two. The shapes of the tibial and talar components are compatible with a physiologic ankle mobility and with the natural role of the ligaments.

Within an eight-centre clinical trial, 114 patients were implanted in the period July 2003 – September 2006, with mean age 62.2 years (range 29 – 82). The AOFAS clinical score systems and standard radiographic assessment were used to assess patient outcome, here reported only for those 75 patients with follow-up longer than 6 months.

Intra-operatively, the components maintained complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, associated to a considerable anterior motion in dorsiflexion and posterior motion in plantarflexion of the meniscal-bearing, as predicted by the previous mathematical models. Mean 10.0 and 23.5 degrees respectively of dorsi- and plantar-flexion were measured immediately after implantation, for a mean additional range of motion of 19.2, which was maintained at follow-ups. Radiographs showed good alignment and no signs of evolutive radiolucency or loosening. The mean AOFAS score went from 40.8 pre-op to 66.2, 74.6 and 77.2 respectively at 3, 6 and 12 month follow-ups. One revision only was performed successfully three days after implantation because of a technical error.

In the score system utilized, Function and RoM sections scored better than any average previous total ankle result, Pain scored similarly. The satisfactory though preliminary observations from this novel design encourage continuation of the implantation, which is now extended over a few European countries. Instrumented gait and three-dimensional fluoroscopic analyses are in progress to quantify functional progresses.

INTRODUCTION Metal-on-metal hip resurfacing (MOMHR) has recently been reintroduced as a viable treatment option for young active patients. A short femoral neck and insufficient head are common deformities following CDH, Perthes disease and SFCE. Therefore, severity of these deformities is a contraindication for MOMHR, as contact between the femoral resurfacing component and the femoral head would be inadequate and off-set insufficient.

METHODS 32 patients with severe deformity of the hip were treated with Birmingham hip resurfacing and head lengthening. We used a standard acetabular component in 18 patients and a CDH acetabular component and supplementary screw fixation in 14. Bone chips produced while reaming the acetabulum were impacted on the femoral head to achieve the desired length, as evaluated on pre-op x-rays. Rehabilitation included no weight-bearing for 1 month and partial weight-bearing for another month.

RESULTS Median patient age was 44 years. Median head lengthening was 1.2 cm. Minimum follow-up was 3.1 years, maximum 5.2. Mean Harris Hip Score was 98. At follow-up 82% of the patients were involved in heavy or moderately heavy work. 34% of the patients practiced sports. Co and Cr serum concentrations at 25 months were respectively ng/ml 1.76, and 0.75. DXA analysis of the proximal femur showed complete recovery of BMD in Gruen zone 1 and increased in zone 7 (p= 0.05). There were no major complications.

DISCUSSION AND CONCLUSIONS The absence of major complications and the quality of our results support this technique in young active patients with severe deformity of the hip.

Navigation-assisted surgery in total knee arthroplasty (TKA) is aimed at improving the accuracy with which prosthesis components are implanted in the bones, according to anatomical plane orientations. Traditional surgical techniques based on the identification of transepicondylar and intramedullary axes are replaced with those based on segmental anatomical frame definitions following anatomical landmark identification. These frames are offered on the screen to the surgeon to target in real time the alignment goal by adjusting position and orientation of the bone saw guides. However, immediately after sawing, final bone, and in case cement, preparation and component implantation is necessarily a series of actions performed manually by the surgeon. In the current study, we wanted to compare intra-operatively the final component alignments with the corresponding at the original resection planes.

In this series, 50 Scorpio PS TKAs were analyzed. The navigation system used was the Stryker Knee Navigation System (Stryker-Navigation, Kalamazoo, USA). An ‘anatomical survey’ defined anatomical frames for the femur and tibia, based on relevant anatomical landmark identification, and provided target orientations for all the relevant bone cuts. These references were targeted in all three anatomical planes, and bone cuts were made accordingly. Corresponding alignments of the bone resection planes in the frontal, sagittal and transverse planes for the femur and in the frontal and sagittal planes for the tibia were recorded, with a 0.5° resolution. Then, component implantation was performed and alignments were measured again by means of an instrumented probe. Because of the shape of the prosthesis components, only the alignments in the frontal plane for the femur and in the frontal and sagittal planes for the tibia were recorded.

The difference between the alignment of the bone cuts and the alignment of the prosthesis components, in the frontal plane of the femur, and in the frontal and sagittal planes of the tibia was larger than 2° respectively in 8%, 6%, 10% of the patients.

The present study offers a figure for the different alignment between resection planes and final implanted components, necessarily the effect of the manual procedures implied in TKA for the final implantation of the components. Considering that 1° is the claimed achievable accuracy of the navigation systems, and that the correct alignment goal was achieved at the resection planes, these figures reveal that in up to 10% of the patients the benefit obtained by navigation can be lost by the manual procedures implied in component implantation. These differences in alignment put also concerns in the postoperative statistical comparison between conventional and navigated TKAs.

INTRODUCTION: Distal metatarsal osteotomies have been described for surgical treatment of hallux valgus with good results. The aim of this study is to review the results of our first 1000 consecutive hallux valgus cases treated by minimally invasive distal metatarsal osteotomy, SERI (Simple Effective Rapid Inexpensive).

MATERIAL AND METHODS: 1000 feet in 641 patients (359 bilateral), aged between 20 and 65 years (mean 49) affected by hallux valgus without arthritis were studied. Inclusion criteria were deformity less than 40° and intermetatarsal angle up to 18°. A 1-cm medial incision at the metatarsal neck, and a complete osteotomy were performed using an oscillating saw. With the naked eye all characteristics of the deformity were corrected by displacement of the metatarsal head (HVA, IMA, PASA, dorsal or plantar displacement). The osteotomy was stabilized by a 2-mm Kirschner wire. Immediate weight bearing was allowed with gauze bandage and talus shoes for 4 weeks. All patients were checked at an average follow-up of 37 months.

RESULTS: All osteotomies healed, delayed consolidation was observed in 25 feet. Slight stiffness was observed in 31 feet. Mean AOFAS score was 48+15 pre-op and 89+13 at follow up. The pre-op HVA was 32+8, while at follow-up it was 18+8 (p< 0.005), pre-op IMA was 14+3, while at follow-up it was 6+4 (p< 0.005), the pre-op PASA was 21+9, while at follow-up was 9+8(p< 0.005).

DISCUSSION AND CONCLUSION: SERI osteotomy was simple, effective, rapid and inexpensive in correcting hallux valgus deformity. Clinical and radiographical findings showed an adequate correction of the deformity.

Functional outcome in Total Knee Arthroplasty (TKA), as measured by means of gait analysis for kinematics, kinetics, and muscular activity around the knee shows abnormalities even in patients with excellent clinical outcome. Knee flexion during loading response phase is reduced, accompanied by co-contraction of knee extensors and flexors. Such subtle failure in knee performance during loading absorption was claimed to depend on several factors: quadriceps weakness, prosthetic design, pre-surgical pattern, proprioception disruption. It was supposed to damage the implant in time. The lack of the anterior cruciate legament seems to play a major role in the loss of control of the roll back pattern of the condyles on the tibial plateau in TKA patients. Previous works on unicondylar knee artrhoplasty (UKA) demonstrated better gait performance when anterior cruciate ligament was preserved allowing the patients to maintain normal quadriceps mechanics. The aim of the present work is to evaluate UKA patients knee function during gait compared to TKA with the hypothesis that UKA ensures more physiological knee loading response pattern of movement and a more phasic muscular activation, thus reducing the risk of failure. Twenty patients with Oxford/Exactech UKA (mean age 70 (SD 7.9), mean follow-up 2 years) were evaluated by means of a Vicon 612-8 cameras system, two Kistler forceplates and Telemg respectively for knee 3D kinematics, kinetics and muscular activity. Data of UKA were compared to those of a control population of ten healthy subjects and ten patients with TKA matched for age and follow up. Mean UKA-IKS score at the time of gait analysis was 90. Time-distance parameters evidenced a slight slow gait with reduced stride length and cadence and a symmetric longer stance phase with respect to TKA and controls. Knee kinematics on the sagittal plane showed knee flex-ion during loading response very close to controls and a reduced but phasic pattern of joint moments on the sagittal plane. Adduction moment at the knee was normal. EMG showed controversy results as some patients had a regular pattern of activation of rectus femoris and hamstrings without co-contraction whereas other patients had co-contraction. These preliminary results indicate that UKA allows in most patients a quite normal knee kinematics and kinetics, although some abnormalities persist in quadriceps activation. Further research is required to understand these findings assessing other factors which could influence quadriceps activity such as age, proprioception, and muscular strength.

Introduction: Screw loosening is a common complication of osteoporotic fracture fixation leading to implant loosening, fracture malunion and non-union. Because recent animal studies have shown that bisphosphonates improve implant fixation we wanted to assess whether alendronate (ALN) improves screw fixation in a clinical setting of osteoporotic fractures.

Methods: Sixteen consecutive patients with AO/OTA A1 pertrochanteric fractures were selected. Inclusion criteria were: female over the age of 65, BMD T-score less than −2.5 SD. Fractures were fixed with a pertrochanteric fixator and 4 hydroxyapatite (HA)-coated screws. Two screws were implanted in the femoral head (screw positions 1 and 2) and two in the femoral diaphysis (screw positions 3 and 4). Patients were randomized to either postoperative systemic administration of ALN, 70 mg per week for 3 months (Group A) or no ALN. Fixators were removed at 3 months post-op in all patients.

Results: All the fractures healed. No differences in screw insertion torque between the two groups were found. No pin loosening or infection occurred. The combined mean extraction torque of the screws implanted at positions 1 and 2 (cancellous bone) was 3181 ± 1385 N/mm in Group A and 1890 ± 813 N/mm in Group B (p < 0.001). The combined mean extraction torque of the screws implanted at positions 3 and 4 (cortical bone) was 4327 ± 1720 N/mm in Group A and 3785 ± 1181 N/mm in Group B (ns).

Discussion and Conclusion: This is the first study to demonstrate in a clinical setting improved screw fixation following post-operative ALN treatment. We observed a two-fold fixation increase in the screws implanted in cancellous bone. With cortical bone, the difference in screw fixation was less marked. Besides its bone preserving ALN should be recommended as an effective solution to improve fixation in osteoporotic bone.