The use of conventional stems in hip arthroplasty may be difficult in cases of dysplasia, coxa vara or coxa valga, after fracture or proximal femur osteotomy. In fact the morphologic alterations of the proximal femur might require prosthetic components characterised by small size and different neck angles to restore correct joint biomechanics. In these cases we are often compelled to compromise between the ideal implant aneiversion and fit and what we can really achieve. An alternative to conventional prostheses is represented by custom-made prostheses.

For 3 years we have been using the Modulus stem in the treatment of morphologic disorders of the hip. The conic shape of the stem easily fits the different morphologies of the proximal femur, whereas the modularity of the neck makes it possible to correct length, inclination and declination of the femural neck. We studied 59 patients by clinical and radiographic examination before surgery and 1, 3, 6 and 12 months postoperatively. We recorded a statistically significant improvement in the clinical score already at 1 month but this was even better at 6 months after surgery, with respect to the pre-operative examination.

With the use of this prosthesis, the recovery of correct joint biomechanics together with high tribologic standards could improve the implant survival, leading to cost reduction and patient satisfaction.

Secure tendon-to-bone fixation is essential for successful rotator cuff repair. Thus, the biomechanical properties of devices used in rotator cuff repair should be better understood. This controlled laboratory study was performed to evaluate response to incremental cyclic loading of six different anchor-wire complexes commonly used in rotator cuff repair.

Two absorbable anchors 5 and 6.5 mm in diameter and one metallic anchor, coupled with both ethibond or fibrewire (FW) were tested on five pairs of fresh-frozen human cadaveric shoulders. An incremental cyclic load was applied until failure using a Zwich-Roell Z010 electromechanical testing machine. The ultimate failure load and mode of failure were recorded. A t-test was used for statistical analysis.

The FW suture coupled both with absorbable and metallic anchors provides a statistically significant stronger fixation. However, while the metallic anchors in most cases fail due to the slippage of the anchor, absorbable anchors fail due to rupture of the loop. The FW seems to increase the strength of fixation devices under cyclic load both using absorbable or metallic anchors with relevant differences in failure mode (slippage of the metallic anchor and loop failure in absorbable ones). Using a FW suture, the risk of metallic anchor migration might increase.

The increase in knee arthroscopy performed on an out-patient basis, along with the need for cost reduction and a safe and rapid patient discharge, has underlined the importance of adequate anaesthesia techniques. We designed this study to compare efficacy, efficiency and surgeon’s satisfaction of total intravenous anaesthesia with propofol and remifentanil with those of spinal or peripheral nerve blocks for outpatient knee arthroscopy.

A total of 120 patients undergoing elective outpatient knee arthroscopy were randomly allocated to receive total intravenous anaesthesia with propofol and remifent-anil (n=40), combined sciatic-femoral nerve block (n=40) or spinal anaesthesia (n=40). Preparation times, surgeon’s satisfaction, discharge times and anaesthesia-related costs with the three anaesthesia techniques were analysed.

Preparation time was shorter with general anaesthesia (13 min) than with spinal anaesthesia or sciatic-femoral block (15 min; p=0.006). Surgeon’s satisfaction was similar in the three groups. Furthermore, 17 patients receiving peripheral nerve block (42%) and 12 receiving spinal anaesthesia (30%) by-passed the post-anaesthesia care unit after surgery as compared with only two general anaesthesia patients (5%; p=0.01). Discharge from the post-anaesthesia care unit was more rapid after peripheral block; however, stay in the Day Surgery Unit was shorter after general anaesthesia than peripheral or spinal blocks (p=0.026). Urinary retention was reported in three spinal anaesthesia patients only (8%; p=0.03).

Regional anaesthesia techniques reduce the rate of admission and the duration of stay in the post-anaesthesia care unit as compared with general anaesthesia. Peripheral rather than spinal nerve blocks should be preferred to minimise the risk of urinary retention.

Aims: To identify the incidence of neurological deþcit and functional outcome following displaced acetabular fractures. Methods: We carried out a prospective study of 136 patients who underwent skeletal stabilization of displaced acetabular fractures. Patients with sciatic nerve injuries were identiþed, assessed and followed up clinically. Routine EMG and nerve conduction studies were performed post-operatively on all cases with clinical proven neurological lesions to correlate the level, severity of the lesion and monitor progress of recovery. Results: 27 patients (19.8%) have neurological deþcit identiþed preoperatively. In 12 patients where the femoral heads were dislocated posteriorly. 20 were male and 7 were female. The mean age was 33.8 years (range 16–66). 15 patients had associated injuries but none of the patients had injury to the spinal cord. The mean ISS was 12.6 (range 9–34). The mean follow up was 3.4 years (range 1.5–6 years). 13 patients with complete drop foot at presentation. 9 patients had EMG proven double crush lesion. 3 patients had ipsilateral knee injury. 2 patients had intraopearative iatrogenic injury. All 9 patients with double crush syndrome have no improvement in function. Conclusions: Acetabular fractures associated with sciatic nerve injuries are devastating injuries with signiþcant long term morbidity. 50% patients showed improvement with time. Identiþcation of double crush lesion is vital as it is associated with poorer functional recovery as compared to single lesion.

Introduction and Objectives: This is a retrospective study on the treatment of lumbar degenerative disk disease (LDDD) using intervertebral arthroplasty. The lack of uniformity in the treatment of LDDD, persistence of pain even with solid fusion, and the possibility of changes over the fusion site have encouraged us to seek other solutions for this condition. Total intervertebral arthroplasty has been proposed as a possible alternative for selected cases of LDDD.

Materials and Methods: Between November 1999 and July 2002, 16 patients with LDDD were treated surgically using third-generation total intervertebral arthroplasty (Link SB Charité III) with a chromium-cobalt alloy and ultra-high molecular weight (UHMW) poly-ethylene. Average follow-up time was 14 months (6-36 months), and average age was 42 years (35–52). There were 11 females and 5 males. All patients underwent radi-olographic studies, CT scan, MRI, and discography (minimum 2 levels). Indications included LDDD of one to three segments, absence of root tension signs, absence of complete disc collapse, and iconography including concordant discography. LDDD was primary in 11 cases and post-discectomy in 5 cases. Surgery was indicated when at least 6 months of conservative treatment failed to yield results. Blood loss and length of hospital stay were compared to a similar group that underwent posterolateral arthrodesis. Pain, function, and degree of disability were evaluated before and after surgery using GEER (1999) instruments for the evaluation of degenerative lumbar pathology. Increase in height of the posterior intervertebral space and segmentary lordosis were also measured.

Results: Preoperative VAS: 7.8; postoperative VAS: 2.3. Disability index (Oswestry) was 41.3% preoperative and 10.8% postoperative. Average increase in height of posterior intervertebral space was 2.4mm, and mean segmental lordosis was 19.5°, which remained constant through the end of the follow-up period. Average hospital stay was 4.8 days (3–15) compared with 7.5 (5–18) for a group of patients who underwent suspended arthrodesis of L4–L5 with a much smaller quantity of blood loss. No infections were found. Complications: One patient developed an epidural haematoma, which was treated conservatively. Another developed a postoperative retroperitoneal haematoma, which was also treated conservatively. In neither case was there an adverse effect on the outcome of the procedure. One patient showed malpositioning of the prosthetic components on follow-up radiographs, with poor clinical progression at one year postoperative. The patient was treated with posterolateral fusion and right L5 foraminotomy. No infections were seen.

Discussion and Conclusions: Treatment of LDDD with intervertrebral arthroplasty was shown to be effective in the short term, if strict guidelines are followed. Aggressive surgical management is highly inferior to conventional arthrodesis. A longer follow-up period is needed to confirm the validity of this treatment. Technical error in malpositioning of the components in one case caused a poor result.

We undertook a prospective MRI study to measure the retroversion of the humeral head in 33 consecutive infants with a mean age of 1 year 10 months (3 months to 7 years 4 months) who had an obstetric brachial plexus lesion (OBPL). According to a standardised MRI protocol both shoulders and humeral condyles were examined and the shape of the glenoid and humeral retroversion determined.

The mean humeral retroversion of the affected shoulder was significantly increased compared with the normal contralateral side (−28.4 ± 12.5° v −21.5 ± 15.1°, p = 0.02). This increase was found only in the children over the age of 12 months. In this group humeral retroversion was −29.9 ± 12.9° compared with −19.6 ± 15.6° in the normal shoulder (p = 0.009), giving a mean difference of 10.3° (95% confidence interval 3.3 to 17.3). This finding is of importance when considering the operative treatment for subluxation of the shoulder in children with an OBPL.

We performed a prospective study using MRI in 16 consecutive infants with a mean age of 5.2 months (2.7 to 8.7) who had shown inadequate recovery from an obstetric lesion of the brachial plexus in the first three months of life, in order to identify early secondary deformities of the shoulder. Shoulders were analysed according to a standardised MRI protocol. Measurements were made of the appearance of the glenoid, glenoid version and the position of the humeral head.

The appearance of the glenoid on the affected side was normal in only seven shoulders. In the remainder it was convex in seven and bioconcave in three. The degree of subluxation of the humeral head was significantly greater (p = 0.01) in the affected shoulders than in normal shoulders (157° v 170°). The presence of an abnormal appearance of the glenoid, retroversion of the glenoid and subluxation of the humeral head increased with age. There was a statistical difference (p = 0.05) between infants younger than five months and those who were older.

Above-knee amputation has been the traditional treatment for osteosarcoma of the proximal tibia. Recent advances in chemotherapy have encouraged the development of limb-salvage techniques. Van Nes rotationplasty for malignant lesions of the distal femur has increased in popularity as a reconstructive technique, but no similar procedure has been described for lesions of the proximal tibia. We have developed a modified rotationplasty for this lesion and have performed it in four children. The surgical technique, postoperative management and results of the procedure are described. Two patients had delayed wound healing. No other complications have developed and our patients were disease-free at follow-up, while the appearance of the leg was well accepted by the patients and their parents. This procedure is a useful addition to the armamentarium of the tumour surgeon for the treatment of malignant lesions of the proximal tibia.

En-bloc resection, extracorporeal irradiation and re-implantation of the irradiated bone have been used to treat 15 patients suffering from primary malignant tumours of bone or cartilage and two with benign lesions. This treatment is an alternative to replacement by prosthesis or allograft bridging techniques. After a mean follow-up of over five years results are encouraging, despite some complications and the relatively long period before weight-bearing is allowed.