Three cases of patients affected with massive bone defects are reported, in which over 50% of the segments are involved. The treatment options considered were original and not yet described in literature. The patients were affected with: partial agenesia of the tibia, congenital hypoplasia and pseudoarthrosis of the femur, and massive post-traumatic bone defect. In all these cases the Ilizarov’s method was applied. In the first case, instead of carrying out an osteotomy and callotasis of the residual bone tissue, an osteotomy was performed close to the tibiofibular syndesmosis and a distraction at this level was executed. In the second case of pseudoarthrosis with antecurvatum of the proximal femur of 135°, varus of 100°, length discrepancy of 63%, a multiplanar gradual correction of the proximal deformity of the femur was carried out followed by a distal lengthening. The third case concerning the pluri-fragmented exposed diaphyseal fracture of the tibia and fibula, with massive bone loss, was treated by restoring all the small fragments, even those without periosteal connections, to increase the proximal and distal bone mass. Once the fusion of the fragments occurred, a proximal osteotomy and callotasis was performed to rejoin the fracture’s segments.
Dysplasia epiphysealis hemimelica is a rare congenital abnormality of enchondral ossification of one or more epiphyses, thus determining an asymmetrical growth in that bone district. We are here considering 2 cases. The first case regards a 4-month-old female baby with an irreducible flexion of the right knee. The X-rays highlighted an area of different density with irregular contours and multiple ossifications; the MRI showed a bone lesion with osteocartilaginous structure in contiguity with the medial condyle; during the operation a osteocartilaginous formation partially fused with the medial condyle was observed. The second case regards a 10-month-old male baby, with a medial malleolus swelling. The X-ray highlighted an area of different density with irregular contours and multiple ossifications, medial to the epiphyseal nucleus of the talus; the MRI showed an osteocartilaginous lesion in contiguity with the talus; during the operation an osteo-cartilaginous formation fused with the talus was observed. The histological findings confirmed in both cases the presence of cartilaginous and bone tissue in absence of pathological lesions. Being a lesion of malformative origin, the early removal of the abnormal ossification nuclei will permit to avoid the secondary lesions described in literature, like asymmetrical growth of the limb and functional limitation.
We treated 34 patients with recurrent dislocation of the hip with a constrained acetabular component. Roentgen stereophotogrammetric analysis was performed to assess migration of the prosthesis. The mean clinical follow-up was 3.0 years (2.2 to 4.8) and the radiological follow-up was 2.7 years (2.0 to 4.8). At the latest review six patients had died and none was lost to follow-up. There were four acetabular revisions, three for aseptic loosening and one for deep infection. Another acetabular component was radiologically loose with progressive radiolucent lines in all Gruen zones and was awaiting revision. The overall rate of aseptic loosening was 11.8% (4 of 34). Roentgen stereophotogrammetric analysis in the non-revised components confirmed migration of up to 1.06 mm of translation and 2.32° of rotation at 24 months. There was one case of dislocation and dissociation of the component in the same patient. Of the 34 patients, 33 (97.1%) had no further episodes of dislocation. The constrained acetabular component reported in our study was effective in all but one patient with instability of the hip, but the rate of aseptic loosening was higher than has been reported previously and requires further investigation.
Evaluation took place after an average of 5.3 years of follow up (range 1.7–10.6 years) and consisted of a questionnaire, elbow function assessment and anteroposterior and lateral radiographs in a standard way. Pre- and postoperative range of motion was analysed with the paired T-test. Pain scores and EFAS scores postoperatively were analysed using the independent sample T-test. The survival of the prosthesis was calculated from the time of implant to the time of revision or occurrence of radiolucencies.
In group 2 five patients died of an unrelated course and no revisions have taken place, one TEP is loose on X-ray (after two years) with a suspicion of septic loosening The EFAS scores (87 in group 1 and 91 in group 2) and range of motion (84 degrees in group 1 and 90 degrees in group 2) were the same in both groups.
There was correlation between fluoroscopic copies and virtual trajectories. This image guidance system may not only aid in the placement of pedicle instrumentation but also assist the senior surgeon in trainee supervision.
The fibrocartilaginous labrum acetabulare enlarges the acetabular socket and contributes to the stability of the femoral head. In DDH the labrum is everted and pushed upward by the femoral head. In the dislocated hip the labrum is often inverted into the acetabular cavity and obstructs anatomic reduction. In the past, excision of the labrum was performed to allow the reduction of the femoral head. The aim of this study was to evaluate the position of the labrum in early detected decentered hips and its role in the early treatment of DDH. During the eleven-year period from 1992–2002, 21,709 neonates (43,418 hips) were examined both by ultrasound and by Ortolanis test to establish the diagnosis of DDH. According to Grafs classification the following hips were present: 298 type D-hips, 252 type IIIa, 4 type IIIb and 20 type IV. Therefore 431 of the patients (356 females and 75 males) showed 574 sonographically unstable hips affected by DDH (1.32%). Due to its echogenic structure, the fibrocartilaginous labrum is clearly visible by ultrasound. In type D, type IIIa, and type IIIb it was always located cranially to the femoral head; in type IV it was located medially to the femoral head. The average age of the children at the time of the diagnosis was 42 33 days (mean value SD). Ortolanis test was positive in 61 hips (10.63%) and negative in the remainder of the hips (89.37%). 21.5 % of the cases were diagnosed within the second week of life, 52.9 % between the third and the eighth week, and 25.5 % after the eighth week. The labrum was not inverted in any of these cases, nor was an open reduction necessary in order to remove it as an obstacle to the closed reduction. Only the ultrasound examination allowed the early diagnosis of the unstable decentered hips. The importance of the labrum decreases when an early diagnosis can be made and an early treatment can be performed.
Key points for successful fixation are absolute rotational stability and satisfactory circumferential bone-bone contact at the time of surgery. Postoperative regimen consisted of hip, followed by progressive bracing and toe-touch weight-bearing for 6 weeks, weight-bearing.
According to MSTS, results were satisfactory in 90% of the patients, with average score 91% (75%–96%).
Loosening of the glenoid component after total shoulder arthroplasty is the most common indication for revision surgery and the reason for 40% of postoperative complications. Presupposing that implants would survive better in areas with higher bone mineral density (BMD), we aimed to determine BMD of the cancellous part of the glenoid and the dimensions of its cortical bone. Using spiral CT scans of the left and right shoulders of 45 men and 25 women with no shoulder pathology, we assessed the BMD of the anterior, middle and posterior subcortical planes of the cancellous part of the glenoid at the superior, middle and inferior levels. The cortical thickness was measured at corresponding sites. In both sexes, at all three levels we found the posterior plane had the highest BMD and cortical thickness. These findings indicate that BMD varies between planes and areas of cancellous bone in the glenoid. This may influence the engineering of future implants.
Lumbar disc replacement with a modern articulating disc prosthesis was first done in 1984, using the Charité SB I prosthesis. Since then other discs, easier to implant, have been developed (Prodisc, Maverick, Centurion). We present short-term (6 to 18 month) clinical results of implantation of 121 Centurion disc prostheses in 93 consecutive patients. This modular three-component titanium/polyethylene disc is inserted as one unit and suitable for minimal interventional approaches. The mean age of the patients was 43 years (23 to 63). The primary diagnosis was degenerative disc disease, with 16 patients having symptoms of spinal stenosis. Forty-four patients underwent single-level disc replacements and 28 double-level disc replacements. Nine patients had a fusion of another level at the time of the index procedure and 12 patients had disc replacement at a junctional level after previous fusion procedures. At 6-month follow-up of 50 patients, clinical outcome was excellent in 27 patients, good in 16, fair in four and poor in three. The Oswestry score improved from 51.2 ±16.0 preoperatively to 13.2 ± 17.8 (p <
0.01) at 6 months. One of the first 29 patients was lost to follow-up. In the other 28 there were 16 excellent, seven good, three fair and two poor outcomes. The Oswestry score improved from 49.7 ± 17.5 preoperatively to 13.0 ± 14.9 (p <
0.01) at 1 year. Good short-term clinical results were achieved in a heterogeneous patient group, largely with advanced disc degeneration and severe disc space narrowing. Using a new insertion mechanism, posterior placement within the disc space and disc space distraction could be reliably achieved even in preoperatively collapsed and immobile disc spaces.
Average interval between the two surgical stages was 5.5 months (range, 2 weeks to 13 months). Systemic antibiotics were administered to all patients for a minimum period of 6 weeks after removal of the infected implant. The revision stem was cemented in 5 patients and not cemented in 13 patients. All the acetabular components were uncemented. In one patient, the second stage procedure consisted exclusively in removal of the spacer and debridement, owing to persisting infection sustained by Staph. aureus + Staph. epidermidis.
Recurrence of infection (Staph. aureus) occurred in 1 patient and was treated by resection-arthroplasty. Aseptic loosening of the stem was observed in 1 patient, who was subsequently treated by stem revision. Average Harris Hip Score was 78 points (range, 65 to 90 points).
This paper introduces a new biological material for the treatment and augmentation of ligament and tendon deficiencies, and presents a variety of uses in orthopaedic conditions. The membrane was originally tested and used in cardiac valve replacement, where it is still in use. Manufactured from bovine pericardial tissue, the collagen biolink membrane is treated chemically by cross-linking with gluteraldehyde. Aldehydes are chemically capped to prevent inflammatory response. The result is a strong collagenous material that provides a non-stretch bio-integrate for ligament replacement/augmentation. The membrane is fashioned to meet the particular ligament/tendon requirement. This material is well suited for use in foot and ankle surgery, as well as in other situations, especially rotator cuff surgery. It may revolutionise ligament and tendon surgery.
The objective of this study was to determine the tensile strength of the different components of rotator cuff tendons. A test bench that performs tests at consistent rupture speed was used to do separate tensile tests on 10-mm strips of capsular and tendinous layers in four fresh frozen cadaveric shoulders. The layers were left attached only on the humeral side. The maximum force was comparable but the elongation of the outer part of the tendon was greater, indicating that the capsular part would tear first. On average, a 10-mm strip of capsular layer failed at 170N with elongation of 7 mm, while a 10-mm strip of tendinous layer failed at 230N with elongation of 10 mm. Using six fresh frozen cadaveric shoulders, we went on to determine the strength of the rotator hood, a thin layer of tendon extending beyond the tuberosity major and connecting the supraspinatus to the subscapularis via the bicipital tunnel. The rotator hood ruptured at a mean force of 70 N. We concluded that the two layers of the cuff contribute equally to the strength. It is therefore important to repair both layers. The difference in elongation of the tendinous and capsular layers makes the capsular layer more vulnerable to elongation stress. The rotator hood is a strong and important structure, and it is important to repair it.
After many patients, some of whom were unexpectedly young, had presented with medial migration of the hemi-prosthetic head and erosion of the glenoid, we decided 2 years ago to do preoperative DEXA on all shoulder replacement patients. The aim was first to determine normal bone mineral density (BMD) of the glenoid and secondly to predict which patients would be at risk. We used the same DEXA method as for the hip. The glenoid was divided into three areas, numbered R1, R2 and R3, and we determined BMD in each of them. Preliminary studies showed that patients fell into two groups. In one, BMD in the R2 and R3 areas was in the range 0.3 to 0.5. Most often the patients in this group were younger or had acute trauma and the contralateral shoulder was not pathological. BMD in the other group was in the range 0.9 to 1.3. Nearly all patients with OA of the shoulder fell into this group. In this ongoing study, patients are followed up annually with clinical examination and standard radiographs. Follow-up to date has only been 2 years. So far no medial migration of the hemi-prosthetic head has been noted in patients in the group with BMD between 0.9 to 1.3.
We report the long-term results of 51 pelvic osteotomies in 43 patients with a mean follow-up of 15 years (13 to 20). The mean age of the patients was 28 years (14 to 46). At review three patients were lost to follow-up, and six had received a total hip arthroplasty. Of 48 hips, 42 (88%) were preserved, with good to excellent clinical results in 27 (64%). Pre-operatively, 41 (80%) of the treated hips had shown no sign of osteoarthritis. Thirty-one (65%) hips showed no progression of osteoarthritis after follow-up for 15 years. Significant negative factors for good long-term results were the presence of osteoarthritic changes and a fair or poor clinical score pre-operatively. Pelvic reorientation osteotomy for symptomatic hip dysplasia can give satisfactory and reproducible long-term clinical results.
After gaining experience from 1990 to 2003 using the Cincinnati incision in the surgical treatment of congenital clubfoot, we were able to extend its use to the early surgical treatment of congenital vertical talus (CVT). Eight of the 172 feet were affected by CVT; four were idiopathic, three were associated with arthrogriposis and one with cerebral palsy. The average age of the six children at the time of the operation was 13.5 months (range 6–27 months). We performed a posterior, medial and lateral release of the subtalar joint and of the talona-vicular joint. The reduction of the talus was performed using a K-wire placed through the posterolateral aspect of the talus in its longitudinal axis. After the calcaneus was reduced from its everted position, a second K-wire was placed through the calcaneus and into the talus. The medial talonavicular joint capsule was opened and the redundant capsule reconstructed. Peroneal tendon lengthening was performed in five cases. The radiological evaluation, according to Hamanishi, showed preoperatively a talo-first metatarsal angle of 94° (NV: 3.3 ± 6.4 SD) and a calcaneal-first metatarsal angle of 54° (NV: −9 ± 4.5 SD); postoperatively the values were 24° and 7°, respectively. There were no wound complications or avascular necrosis of the talus. With the Cincinnati incision we were able to visualise the talo-calcaneal and talo-navicular dislocation in all three spatial planes. It also allowed us to correct the deformity in all three mentioned planes and in a single-step procedure.