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: Displaced comminuted intra-articular calcaneal fractures (DCCF) need anatomic reduction to avoid painful subtalar joint, deformities, tendon or nerve impingment. Open reduction and internal fixation has been extensively reported, but all series reported considerable rate of skin complications, infections and need of additional plastic procedure. The aim of this study is to review a series of DCCF operated by minimally invasive technique.

MATERIAL AND METHODS: 66 DCCF type Sanders II-III were selected in 63 patients aged 18–57 years. X-ray and CT scan were performed. Surgery consisted of percutaneous traction-reduction of the calcaneal body by bone forceps and fixation by K-wires under image intensifier. Then, a lateral 3 cm skin incision was performed to reduce subtalar joint and to fix it by 1 or 2 screws. In case of involvement of the calcano-cuboid joint, the incision was distally extended and a 4-hole plate was applied. K-wires were removed 5 weeks after surgery and weight bearing was permitted 12–16 weeks after surgery. Patients were evaluated clinically by AOFAS score and radiographically at 4 years follow-up (3–7).

RESULTS: No skin complications or infections were encountered in the series. All fractures healed. Mean postoperative Bohler angle was 29±5°. AOFAS score was 89±11. 31 cases were excellent, 22 good, 9 fair and 4 poor. 25 cases presented radiographic signs of subtalar joint arthritis, painful only in 4.

DISCUSSION AND CONCLUSION: Minimally invasive surgical treatment resulted adequate for treating DCCF, in fact if soft tissues are preserved by surgical trauma, dangerous complications like infections and skin problems can be avoided.

Patellar maltracking after total knee arthroplasy (TKA) introduces complications such as anterior knee pain and patellar subluxation, generally due to prosthetic component malallignment in both tibiofemoral (TF) and patellofemoral joints. It is still debated if it is necessary to resurface the patella, which would better adapt the patellar articular surface to the prosthetic femoral troclea with a prosthesis, but also result in possible bone fractures. In this study, an in-vitro analysis is presented in order to identify differences between intact and TKA patellar tracking with and without patellar resurfacing and to show how much the latter is similar to intact knee patellar tracking.

Three fresh-frozen amputated legs with knees free from anatomical defects and with intact joint capsule, collaterals and quadriceps tendon were analyzed using the Stryker knee navigation system (Kalamazoo, MI-USA). Landmark digitations were used to define anatomical frames for femur, tibia and patella. Manually driven TF flexions, from 0 to 140, were performed under conditions of no load and of 10 kg on the quadriceps, with intact knee and TKA with patella resurfaced and not. TF flex/extension, intra/extra rotation, ad/abduction were calculated according to a standard convention. Patellar flex/extension, medial/lateral tilt, rotation and shift were calculated according to a recently proposed articular convention.

Since more repeatable, results relative to trials under 10 kg are reported. Intact knee: 4 abduction; considerable intra rotation (from 16 to 4), followed by continuous extra rotation starting at 30 TF flexion; linear increase in patellar flexion (from 20 to 110); initial medial patellar rotation (from 12 to 8), followed by medial rotation starting at 60 TF flexion; initial lateral patellar tilt (from 4 lateral to 4 medial), followed by medial tilt starting at 70 TF flexion; initial 6 mm lateral patellar shifts from 0 to 80 TF flexion, followed by 4 mm medial shift. TKA knee: small differences in ad/abduction between intact and TKA knees, both with and without resurfaced patella; slight initial extra rotation, followed by continuous intra rotation starting at 20 TF flexion; linear increase in the flexion of the patella, both resurfaced and not, close to the that of the intact knee; patellar rotation more lateral than in the intact knee; patellar tilt without resurfaced patella closer to the intact knee one; 6 mm lateral patellar shift, likely accounted for the surgical technique.

Slightly more than TKA with resurfaced patella, TKA with non resurfaced patella flexes nearly like the intact knee. The closeness in values of patellar flexion and tilt represents a proof of the closeness in behavior of not resurfaced patella in TKA to the patella in the intact knee.

Introduction: The main goal of surgical correction of hallux valgus is the morphological and functional rebalance of the first ray and correcting all the characteristics of the deformity. Historically, distal metatarsal osteotomies and SCARF have been indicated in cases of mild or moderate deformity with inter-metatarsal angles up to 20° and are procedures widely used for correction of hallux valgus. The aim of this study is to compare a distal metatarsal osteotomy recently described (SERI) with SCARF osteotomy in a clinical prospective randomised study.

Methods: 20 patients with bilateral hallux valgus similar on both sides regarding clinical and radiographic assessment were included. Clinical evaluation using American Orthopaedic Foot and Ankle Score (AOFAS) and radiographic assessment were considered before surgery up to 2 years follow-up. All patients were operated bilaterally in the same surgical sitting, and received at random SCARF osteotomy on one side, and on the other a SERI osteotomy performed through a 1 cm skin incision under tdirect view control and fixed with one Kirschner wire. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bandage and weight bearing with talus shoes for 30 days.

Results: No statistical differences were observed in preoperative HVA, IMA, DMAA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in SERI (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed uneventfully. At 2 year follow up, no statistical differences were observed in HVA, IMA, DMAA comparing SCARF with SERI. Average AOFAS score was 87±12 in SCARF and 89±10 in SERI (p=0.07).

Conclusions: Both SCARF and SERI techniques proved effective in the correction of hallux valgus, however SERI, performed with a shorter skin incision, in less surgical time, fixed with a cheaper device (one Kirschner wire), resulted in a better clinical outcome.

Introduction: Facioscapulohumeral muscular dystrophy (FSHD) is the third most common hereditary disease of the muscle after Duchenne and myotonic dystrophy. FSHD consists in an atrophic myopathy with predominant involvement of the face, upper arms, and shoulder muscles. FSHD compromises the muscles of the scapu-lothoracic joint, and usually spares muscles of the scapu-lohumeral joint. Consequently, when the patient tries to abduct or foreword flex the shoulder, the contraction of the relatively preserved scapulo-humeral muscles produces an abnormal rotation of the scapula, that is not hold to the chest wall because of the insufficiency of the scapulo-thoracic muscles, resulting in a winged scapula and in a limited arm motion. The aim of this study is to describe an original scapulopexy and report the long term results obtained in 9 patients affected by FSHD.

Material and methods: Nine patients (4 male and 5 female) affected by winged scapula in FSHD were observed and selected. Average age at surgery was 25 years (range 13–39). Surgery consisted in scapulopexy of both sides in the same surgical time. Through a skin incision on its medial border the scapula was exposed and positioned over the chest. The 5th to the 8th ribs were exposed in the part below the scapula. The position of the scapula over the chest was fixed by 4 doubled metal wires to the 5th, 6th, 7th and 8th rib. Each wire was passed anteriorly to the rib, and into a hole performed 1.5 cm from the medial border of the scapula. By tightening the wires, the scapula was fixed firmly over the chest. A figure of eight dressing that holds the shoulders back was applied immediately after surgery and maintained for six weeks.

Results: The average surgical time was 65 minute for each single procedure. One patient experienced an unilateral pneumothorax the day after operation, which resolved spontaneously in 48 hours. Average follow up was 11 years (range 3–15). All patients experienced a complete resolution of the winged scapula and an improvement of range of motion of the shoulder compared to the pre operative conditions. Average pre-operative abduction was 68 and post-operative was 85. Average pre-operative flexion was 78 and post-operative 112.

Discussion: This technique is easy and quick to perform, does not require grafts, reduces post surgical complications such as pneumothorax or haemothorax, and ensures good results even at considerable follow-up.

Purpose: Four external fixation pin types differing in coating, design and implantation technique were tested in an animal study.

Methods: Forty tapered pins were divided into 4 Groups according to pin design type: Group A consisted of 10 standard self-tapping pins (ø5–6mm, pitch 1.75mm), Group B 10 hydroxyapatite (HA)-coated self-tapping (ø5–6mm, pitch 1.75mm), Group C 10 standard, self-drilling, self-tapping (ø5–6mm, pitch 1.25mm) and Group D 10 HA-coated, self-drilling, self-tapping (ø5–6mm, pitch 1.25mm). Four pins were randomly implanted into the femoral diaphysis of 10 sheep. The pins were implanted at 2-cm intervals apart. Pre-drilling was used for Groups A and B but not for Groups C and D. Sheep were euthanized 6 weeks after surgery.

Results: There were no major complications. Mean pin insertion torque was 3100 ± 915 Nmm in Group A, 2808 ± 852 Nmm in Group B, 2589 ± 852 Nmm in Group C and 2180 ± 652 Nmm in Group D. Mean pin extraction torque was 1570 ± 504 Nmm in Group A, 2128 ± 1159 Nmm in Group B, 1599 ± 809 Nmm in Group C and 2200 ± 914 Nmm in Group D. Insertion torque of the coated groups was lower than insertion torque of the standard groups (p < 0.05). However, extraction torque of Groups B and D was higher than Groups A and C (p < 0.05). No differences in pin fixation were found between the two coated pin groups (Group B and D). Morphologic analysis showed extensive bone to pin contact without fibrous tissue interposition in the coated pin groups and fibrous tissue interposition in the uncoated pin groups.

Conclusion/Significance: This study demonstrated that coating pins with hydroxyapatite is effective regardless of the pin design and the implantation technique.

Tibial component loosening continues to be the most common mode of TKA failure. A debate persists on the dependence of mobilisation of this component on the equilibrium between mechanical load transfer and counterbalancing bone resistance. The aim of the present work is to study the in-vivo kinematics of TKA and to relate it with the degree of posterior slope with which the tibial component was implanted for two prosthesis designs with congruent polyethylene insert.

Twenty-three patients with osteoarthritis of the knee had TKA using a cemented prosthesis (OPTETRAK, Exactech). A cruciate retaining (CR, 10 knees) or a posterior stabilized (PS, 13 knees) implant was randomly assigned at operation. Standard pre- and post-operative antero-posterior and lateral roentgenograms of the knee were taken. Fluoroscopic analysis was performed after at least 18 and 7 months after surgery for the CR and the PS group, respectively. Patients performed stair ascending, chair rising-sitting and step up-down motor tasks. Articular contacts were assumed as the two points on the medial and lateral femoral prosthetic condyles closest to the tibial component base-plate. The spine-cam distance was calculated as the minimum distance between corresponding surfaces.

Only small differences in the position of the contacts over knee flexion angles were found among the motor tasks and between the two TKA designs. An overall posterior location of the tibio-femoral contact points was found at the medial and lateral compartments over all motor tasks, a little more pronounced for the PS patients. Statistically significant correlation over the three motor tasks analysed was found between posterior position of the tibio-femoral medial contact in maximum knee flexion and the post-operative tibial posterior slope. This is true for the PS and for the aggregated groups. Although no statistically significant, a general trend is observed of higher degree of flexion at which the cam contacts the spine as the post-operative posterior slopes increases: a 35 higher knee flexion angle for a tibial component implanted with a 5 of posterior slope. Generally, even when the correlations were statistically significant the correlation coefficients were always lower than 0.4.

The present work reports combined measurements of post-operative posterior slope and full in-vivo relative motion of the components in both CR and PS TKAs. General trends were found between posterior slope of the tibial component and positions of the tibio-femoral contacts, but a statistically significant correlation was found only for the tibio-femoral medial contact in maximum knee flexion in the PS and in the aggregated. General trends were found between posterior slope of the tibial component and degree of flexion at which the cam starts to be in contact with the spine. The nearly standard antero-posterior translation of the tibio-femoral contacts can be bigger in flatter polyethylene inserts.

Introduction: Neck hyperextension (NH) is defined as a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, which ultimately results in an inability to approximate the chin to the sternum. NH may occur in relation to several myopathies. It is characterized by a general weakness and contractures of the axial muscles which produces a progressive increase of lordosis associated with a limitation in flexion of the cervical spine, that forces the patient to assume awkward compensatory postures to maintain balance and level vision. This study reports on operative complications, the degree of correction, the achievement of a solid arthrodesis, the maintenance of the correction and the clinical assessment of 7 patients.

Material and methods: Seven patients affected by various myophaties and NH were included. The mean age was 16.5 years (10–28 years). All underwent surgery, in which the paravertebral muscles were detached from the spinous processes and then transversally sectioned in order to bilaterally expose the laminas of vertebrae C2 to C7. The space between C1–C2 appeared mobile, while the spinous processes from C2 to C7 were close together and thus allowed only a very limited motion in between them. Ligamenti interspinosus and nuchae were detached and the facet joints from C2 to C7 were enlarged by capsulotomy. With a spreader rongeur, the interspinous spaces at each level were gently opened. Cortical cancellous autologue graft were shaped into wedges. After careful opening of each interspinous space, the bone wedges were driven between the spinous processes to maintain the achieved correction. The average follow-up time was 10.4 years (2.4–16.5 years).

Results: No major surgical complications occurred. At follow-up, the average angle between C2–C7 in neutral position had decreased (p = 0.016) from 50.7 (40–70) to 21.4 (2–50). The range of motion in the C1–C2 joint remained unaffected, while it decreased in C2–C7 (p = 0.016) from 33.5 (15–64) to 1.8 (0–8). In all cases, a solid arthrodesis was achieved.

Discussion and conclusion: The follow-up showed significant clinical improvement of posture in all patients. Our study has shown surgical treatment of NH to be an effective method within the whole series of seven patients, achieving both good immediate and good long-term results.

Introduction Osteochondral lesions of the talus are a common occurrence especially in sports injuries. The biomechanical nature of the ankle joint makes it susceptible to sprains which can cause damage not only to the capsulo-ligamentous structures, but also to the joint cartilage and subchondral bone. As it is known, joint cartilage is a highly specialized and multitask tissue. Because joint cartilage has poor reparative capability, damage may be irreversible and as a consequence, can also lead to osteoarthritis. The purpose of this study is to review the results of a series of patients treated with autologous chondrocytes implantation (A.C.I.) and to describe the evolution in surgical technique that we have been implemented in the last 8 years.

Methods Thirty-nine patients with a mean age of 27 8 years affected by osteochondral lesions of the talus > 1.5 cm2, were treated by autologous chondrocyte implantation. All patients were checked clinically and by MRI up to 4 years follow-up. The first 9 patients received the ACI by open technique and the remaining 30, arthroscopically. In the last 10 patients the cartilage harvested from the detached osteochondral fragment was used for the colture. All patients were checked clinically (AOFAS score), radiographically and by MRI, before surgery, at 12 months and at follow-up. Eleven patients underwent a second arthroscopy with a bioptic cartilage harvest at 1 year follow-up. Samples were stained with Safranin-O and Alcian Blue. Immunohistochemical analysis for collagen type II was also performed

Results Before surgery the mean score was 48.4 17 points, at 12 months 90.9 12 (p< 0.0005), while at follow up was 93.8 8 (p< 0.0005) demonstrating an improvement over time. The histological and immunohistological analyses performed on the cartilage samples using Safranin-O, Alcian Blue staining and anti-human collagen type II antibody respectively showed a typical cartilage morphology, were positive for collagen type II and for proteoglycans expression.

Conclusions The clinical and histological results have confirmed the validity of the technique utilized, with laboratory data confirming the newly formed cartilage was of hyaline type for all the cases evaluated.

Introduction: Deterioration of bone-pin interface, causing pin loosening and infection, is a major cause of postoperative complications following external fixation. This paper presents the results obtained using hydroxyapatite (HA)-coated pins in various bone types, such as osteoporotic bone.

Materials And Methods; In an animal study comparing HA-coated and standard pins, pin insertion and extraction torque were measured. Subsequently, a clinical study compared insertion, extraction torque and pin-tract infection rate of standard and HA-coated pins implanted in healthy and osteoporotic bone.

Results: hi the animal study, mean final insertion torque was 4360±1050Nmm in the standard group and 3420 ± 676 Nmm in the HA-coated group. Mean extraction torque was 253 ± 175 Nmm in the standard group and 3360 ± 1260 Nmm in the HA-coated group (p = 0.002). In the clinical study on healthy bone, the mean insertion torque was 4130 ± 2160 Nmm in the standard group and 3440 ± 1930 Nmm in the HA-coated group (p = 0.03). The mean extraction torque was 1470 ± 1700 Nmm in the standard group and 5130 ± 2300 Nmm in the HA-coated group (p < 0.001). There were 33 pin-tract infections in the standard group and 20 pin-tract infections in the HA-coated group (p < 0.05, power 0.9). The standard pin group had a mean extraction torque of 730 (0–5500) Nmm in the infected pin-tracks and 2110 (0–7000) Nmm in the uninfected pin-tracts (p < 0.0001). The HA-coated group had a mean extraction torque of 5310 (1000–8000) Nmm in the infected pin-tracts and 5080 (0–8000) Nmm in the uninfected pin tracts (NS). In the clinical study on osteoporotic bone, mean final insertion torque was 461 ± 254 Nmm in the standard group and 331 ± 175Nmm in the HA-coated group (p = 0.01). Mean extraction torque was 191 ± 154 Nmm in the standard group and 600 ± 214 Nmm in the HA-coated group (p < 0.0005). Pin infection rate was greater in the standard group (p < 0.05).

Conclusion: There was no deterioration of the bone-pin interface strength (measured by torque resistance at the time of pin extraction) with HA-coated pins. The improved strength of fixation of the HA-coated pins was associated with a lower incidence of pin-tract infection.

Aims: Prior research has demonstrated that currently available total ankle implants fail to restore physiologic joint mobility. Most of the modern mobile-bearing designs that feature a flat tibial component and a talar component with anatomic curvature in the sagittal plane function non physiologically with the natural ligament apparatus. The aims of this investigation were a) to elucidate the natural relationship between ligaments and articular surfaces at the intact human ankle joint and b) to develop a new design of total ankle replacement able to replicate this relationship between the retained ligaments and the implanted prosthetic components.

Methods: Motion during passive flexion was analyzed in ten skeleto-ligamentous lower leg preparations including tibia, fibula, talus, calcaneus and intact ligaments. Geometry of ligament fiber arrangement and articular surface shapes was obtained with a 3D digitizer (FARO Technologies, Inc.). A sagittal four-bar linkage model was formulated as formed by the tibia/fibula and talus/ calcaneus rigid segments and by the calcaneofibular and tibiocalcaneal ligaments. To test the ability of possible new prostheses to reproduce the compatible mutual function between the articulating surfaces and the ligaments retained, non-conforming two-component and fully-conforming three-component designs were analyzed. A new total ankle replacement has been designed, prototypes manufactured and implanted in seven skeleto-ligamentous lower leg preparations, and motion was observed. A corresponding new prosthesis has been produced (Finsbury, UK), and implanted in four patients.

Results: The articular surfaces and the ligaments alone prescribed joint motion into a preferred single path of multiaxial rotation (one degree of unresisted freedom). Fibers within the calcaneofibular and tibiocalcaneal ligaments remained most isometric throughout the passive range. The four-bar linkage model well predicted the sagittal plane kinematics observed in corresponding experiments. A ligament-compatible, convex-tibia, fully-congruent, three-component prosthesis design showed the best features: complete congruence over the entire range of flexion together with an acceptable degree of entrapment of the meniscal bearing. Restoration of natural joint kinematics and ligament recruitment was observed in all replaced ankles.

Conclusions: The overall investigation is demonstrating that a profound knowledge of the changing geometry of the joint passive structures throughout the range of passive flexion (mobility) is mandatory for a successful design of joint replacements.

Aims:Understanding total knee replacement mechanics and their influence on patient mobility requires accurate analysis of both operated joint accurate kinematics and full body kinematics and kinetics. The main aim of this study is to perform these two analyses conjointly, as never been reported previously. An innovative graphic-based interface is also pursued aimed at supporting quantitative functional assessment of these patients during the execution of daily living motor tasks in a single synchronized view.

Methods: Three-dimensional fluoroscopic and gait analysis were carried out on eleven patients with PCL-retaining mobile bearing (Interax ISA, Stryker / How-medica / Ostetonics) and on ten posterior stabilized fixed bearing (Optetrak PS, Exactech) knee prostheses. Patients performed three trials of stair ascent twice on the same day: first in the radiology department for fluoroscopy acquisition and later in the Movement Analysis Laboratory, utilizing an identical staircase. Three-dimensional fluoroscopic analysis entails reconstruction of absolute and relative positions and orientations of the two metal components in space by analyzing series of fluoroscopic images of the operated knee and utilizing knowledge of the 3D cad models of these components. Conventional stereophotogrammetry and dynamometry were used to calculate kinematics and kinetics of the trunk, pelvis and of the major joints of the lower limb. An advanced computer-based interface was developed (MULTIMOD, EU-funded project: IST-2000-28377) to show together a) original video of the patient tasks, b) 3D graphical representation of bony segment motion, c) original fluoroscopic images, d) 3D reconstruction of prosthesis component relative motion, and e) graphical transverse plane representation of the contact areas at the base-plate of the replaced knee. All these were registered in space and synchronized in time.

Results: No significant statistical differences on clinical data were found between the two patient populations. Observations at the interface allowed distinct identification of the most critical phases of the task and of the most common compensatory mechanisms utilized by these patients. Statistically significant correlation was found between knee flexion at foot strike and the position of the mid-condylar contact points, and between maximum knee adduction moment and corresponding lateral trunk tilt.

Conclusions: A more complete and powerful assessment of the functional performances of different TKR designs is obtained by combining gait and fluoroscopic in-vivo analyses, which provide correlated and synergic quantitative information.

Although dynamic hip screw (DHS) is considered the treatment of choice for pertrochanteric fractures, we theorized that external fixation would produce clinical outcomes equal to, if not better than, outcomes obtained with conventional treatment. As external fixation is minimally-invasive, we expected a lower rate of morbidity and a reduced need for blood transfusions. We compared fixation with DHS vs. Orthofix pertrochanteric fixator (OPF) in elderly pertrochanteric fracture patients. Forty consecutive pertrochanteric fracture patients were randomized to receive either 135A1 4-hole DHS (Group A) or OPF with 4 HA-coated pins (Group B). Inclusion criteria were: female, age B3 65 years, AO type A1 or A2 and BMD less than −2.5 T score. There were no differences in patient age, fracture type, BMD, ASA, hospital stay or quality of reduction. Operative time was 64 B1 6 minutes in Group A and 34 B1 5 minutes in Group B (p < 0.005). Average number of post-operative blood transfusions was 2.0 B1 0.1 in Group A, and none in Group B (p < 0.0001). Pain was measured 5 days post-operatively and was lower in Group B (p < 0.005). Fracture varization at 6 months was 6 B1 8A1 in Group A and 2 B1 1A1 in Group B (p = 0.002). In Group B, no pin-tract infections occurred. Pin fixation improved over time, as shown by pin extraction torque (2770 B1 1710 N/mm) greater than insertion torque (1967 B1 1254 N/mm), (p= 0.001). Harris hip score at 2 years was 62 B1 20 in Group A and 63 B1 17 in Group B. This study shows that OPF with HA-coated pins is an effective treatment for this patient population. Operative time is brief, blood loss is minimal, fixation is adequate and the reduction is maintained over time.

The purpose of this study is to demonstrate the validity of the autologous chondrocytes transplantation (A.C.T.) technique implemented over the last 6 years in the treatment of osteochondral lesions of the talus.

Our case study included 22 patients (12 males and 10 females), with an average age of 27 years affected by osteochondral lesions of the talus surface. All lesions were > 1.5 cm2, monofocal, and post-traumatic in origin. The first 9 patients received ACT (Genzyme technique) and the remaining 13 patients received ACT with an arthroscopic technique. In 6 of the patients, the cartilage harvested from the detached osteochondral fragment was used for culturing, avoiding the first step arthroscopy in the knee. Before surgery, all patients were assessed clinically, radiographically, and using MRIs. For clinical evaluation patients were assessed using the American Foot & Ankle Society 100 point score. Before surgery the mean score was 48.4 points. 11 patients underwent second-look arthroscopy at one year during which a biopsy was harvested for histologic analysis of the reconstructed cartilage. Of these, 9 patients (Genzyme technique) also had hardware removed.

The mean follow-up of the 22 patients was 36 months. At follow-up, all patients but one were satisfied with their results. With regards to the clinical results evaluated using the American Foot and Ankle Society score, an average of 90.5 was obtained at 24 months, while at 36 months the average score (19 patients) was 94.0 (range 54–100). During follow-up arthroscopy, 4 patients had mild fibrosis and 1 patient required regularization of flap overgrowth causing pain.

The clinical and histological results have confirmed the validity of the surgical technique utilized with no subjective nor objective complications. An improvement of the symptoms and of articular function has also been observed: laboratory data confirmed the histological appearance of the newly formed hyaline cartilage in all cases evaluated. Immunohistochemistry showed a positive staining for collagen type II located in the extracellular matrix and in the chondrocytes in the healthy and transplanted cartilage biopsies. All the specimens studied were also positive for proteoglycans expression as was the Alcian blue reaction, which highlighted the presence of these fundamental components of a cartilaginous matrix.

Aims: The pourpose of this study is to review a series of A2 intertrochanteric fractures in old, obese osteoporotic patients treated by total hip arthroplasty. Methods: 52 patients with A2 intertrochanteric fracture aged ≥ 75 years, mentally healthy, with BMD lower than 2.5 T score and Body Mass Index ≥30 were selected. They were 40 female and 12 males, aged 82±5 years with Body Mass Index of 32±2. Through a Hardinge approach to the hip, the femoral head was removed and a cemented cup and stem were implanted. Then the greater trochanter fragments were fixed by cerclage. The lesser trochanter fragment was not fixed. Medius gluteus muscle fibers were sutured to the greater trochanter and to the vastus lateralis muscle. All patients were allowed weight bearing as soon as possible after surgery. Results: No surgical complications were observed. Average Harris Hip Score at 1 month was 63±9 at 3 months 77±6 and at 1 year 78±7, at 5 years follow up 76±14 in the 24 patients still alive. None of the other died for causes related to the interthrocanteric fracture. Average return to normal daily activity time was 27±5 days. Conclusions: Total hip arthroplasty is a safe procedure for treatment of old, obese osteoporotic patients affected by A2 intertro-chanteric fractures. In fact, no failure occurred in any of the patients allowed unrestricted weight bearing from the first day after surgery. Moreover, they could return to normal daily activity in less than 5 weeks.

Aims: The purpose of this paper is to review a series of ankle post-traumatic deformities treated by arthroplasty, þbula lengthening, bone graft and correction of the malunion. Methods: 30 cases, mean age 40 (±15), were operated 6–30 months after injury and followed up at 5 years. Clinical Maryland foot score (MFS) and X-ray evaluation were performed pre op and at follow up. After medial revision of bone and soft tissue structures, through a lateral transmalleolar approach, mal-union of the posterior malleolus or sinking of the lateral tibial plafond were corrected using autologous cortical cancellous bone graft covered by its periosteal ßap. Postoperative treatment consisted of immediate continual passive motion weightbearing allowed after an average of 8–12 weeks after surgery. Results: Pre op MFS was 64±8 and post-op it was 82±11. 11 patients had excellent results with normal range of motion, no pain, and no progression of the arthritis. The result in 9 cases was good with a normal range of motion, little pain after long walk, and no progression of arthritis. 7 cases were fair because of a decrease in the range of motion and progression of arthritis and moderate pain. 3 poor cases needed arthrodesis. Conclusions: Fibula lengthening, bone graft and correction of malunion were effective treatment of ankle post-traumatic valgus deformity in order to delay ankle fusion in young patients. The success of the procedure was correlated to the severity of arthritis and the joint congruity obtained by surgery.

Aims: Our purpose was to determine if DHS fixed with hydroxyapatite (HA)-coated AO/ASIF screws improves fixation and clinical outcomes in osteoporotic trochanteric fracture patients. Methods: 120 osteoporotic patients with trochanteric fractures were randomized to receive 135° 4-hole DHS fixed with either standard lag and cortical stainless-steel AO/ASIF screws (Group A) or HA-coated lag and cortical stainless-steel AO/ASIF screws (Group B). Inclusion criteria were: female; age ≥65 years; AO type A1 or A2; and BMD lower than -2.5 T score. Results: Tip Apex Distance (TAD) was 22±4mm in Group A and 23±5mm in Group B (ns). In Group A there were 4 cut-out cases and none in Group B (p< 0.05, β=0.8). Post-op (ns) and 6 month (p=0.008) femoral neck-shaft angle was 134±5° and 129±7° (Group A) and 134±7° and 133±7° (Group B). At 6 months, Harris Hip Score was 63±22 (Group A) and 71±18 (Group B) (p=0.02). Conclusions: HA-coated AO/ASIF screws prevent fracture varization and lag screw cutout, thus improving clinical outcomes in osteoporotic trochanteric fracture patients.

Aims: We compared treatment with external fixation (EF) vs DHS in osteoporotic trochanteric fractures. Methods: 40 patients were randomized to receive either 135° 4-hole DHS (Group A) or an Orthofix trochanteric external fixator with 4 hydroxyapatite-coated Osteotite pins (Group B). Inclusion criteria were: female, age ≥65 years, AO fracture type A1-2 and BMD lower than -2.5T score. Fixators were removed at 3 months. Results: There were no differences in patient age, fracture type, BMD, ASA, hospital stay, or quality of reduction. Operative time was 64±6 minutes in Group A and 34±5 minutes in Group B (p< 0.005). Average number of blood transfusions was 2±0.1 in Group A, and none in Group B (p< 0.0001). Fracture varization at 6 months was 6±8° in Group A and 2±1° in Group B (p=0.002). Harris Hip Score was 62±20 in Group A and 63±17 in Group B (ns). In Group B, no pin-track infections occurred. Pin fixation was maintained over time, as shown by no differences between pin extraction and insertion torque. Conclusions: We consider EF a viable treatment option for this patient population. Operative time is short, postoperative complications are minimized, and fixation is improved.

Aims: The purpouse of the study is to review a series of hallux valgus treated by minimally invasive distal metatarsal osteotomy with a simple, effective, rapid, inexpensive (SERI) technique. Methods: 54 consecutive feet in 37 patients, aged 48 ± 23 years affected by hallux valgus deformity less than 40û with an intermetatarsal angle up to 20û were reviewed at 5 years follow up. Surgical technique consisted of a 1 cm medial incision at the metatarsal neck, then an osteotomy was performed using an oscillating saw. With a direct line of vision, all characteristics of the deformity (HVA, IMA, DMAA) were corrected by lateral displacement of the metatarsal head; contemporary plantar or dorsal displacement was performed according to insufþciency or overloading of the þrst ray. The osteotomy was stabilized by a 2 mm Kirschner wire. All patients were clinically (AOFAS score) and radiographically checked at an average follow up of 5 years. Results: The clinical score at follow up was (91±12). The pre-op hallux valgus angle was 32.5±9, while post-op it was 22±7 (p< 0.0001), pre-op inter-metatarsal angle was 13±3, while post op it was 9±3 (p< 0.0001), the pre-op distal metatarsal articular angle was 19±10, while post-op it was 9±7 (p< 0.0001). Conclusions: Clinical and radiographic þndings showed that SERI osteotomy permitted an adequate correction of all the pathologic characteristics of the deformity, and this factor is responsible for our satisfactory results.

Only recently has the mobility of the ankle joint been elucidated. Sliding/rolling of the articular surfaces and slackening/tightening of the ligaments have been explained in terms of a mechanism guided by the isometric rotation of fibres within the calcaneofibular and tibiocalcaneal ligaments. The purpose of this investigation was to design a novel ankle prosthesis able to reproduce this physiological mobility.

A four-bar linkage computer-based model was used to calculate the shapes of talar components compatible with concave, flat and convex tibial components and appropriate fully congruous meniscal bearings. Three-component designs were analysed, and full congruence of the articular surfaces, appropriate entrapment of the meniscal bearing and isometry of the two ligaments were required.

A convex tibial component with 5 cm arc radius gave a 2 mm entrapment together with a 9.8 mm amount of tibial bone cut, while maintaining ligament elongation within 0.03 % of the original length. The physiological patterns of joint motion and ligament tensioning were replicated. The talar component slid backwards while rolling forwards during dorsiflexion. These movements were accommodated by the forward displacement of the meniscal bearing on the tibial surface under the control of the ligaments. The complementary surfaces provide complete congruence over the entire range of flexion, such that a large contact area is achieved in all positions.

To restore the physiological mobility at the ankle joint, not only should the components be designed to be compatible with original ligament pattern of tensioning, but also these should be mounted in the appropriate position. A suitable surgical technique was devised and relevant instrumentation was manufactured. Five below-knee amputated specimens replaced with corresponding prototype components showed good agreement with the model predictions.

Current three-component designs using a flat tibial component and physiological talar shapes cannot be compatible with physiological ligament function.