Total hip arthroplasty (THA) in neglected congenital dislocation of the hip (CDH) constitutes a challenging procedure, with surgical difficulties and complications. The purpose of this study was to analyse the complications of THAs in CDH.

Between June 1983 and September 2002, 418 THAs-were performed in 356 patients with CDH, with a mean follow-up 108 (7–237)months. The mean age at surgery was 53.3 (24–79) years with 325 females and31 males. 83 patients had CDH in high position. 307 arthroplasties were cementless, 39 cemented and 72 hybrids. 40 stems were custom made. The cup always was positioned at the true acetabulum. 24 shortening osteotomies of the femur, 8 corrective supracondylar and 6 trochanteric osteotomies were performed.

Preoperatively the average Merle d’Aubigne-Postel hip score was 1.1 for pain, 4.8 for range of motion and 3.1 for walking ability. Postoperatively the average hip score was 5.2, 4.7 and 5.3 respectively. The average length discrepancy was 8 cm (3–12) preoperatively and 1.5 cm remained in 8 patients. Complications included 7 intraoperative fractures of the femur, 12 dislocations, 4 peroneal nerve palsies that recovered, 25heterotopic ossifications, 7 deep vein thromboses, 3 pulmonary embolisms, early mechanical loosening in 4 cemented and 10 cementless cups and 3infections.

Complications were diminished dramatically last years due to improved surgical technique, new available implants and preoperative evaluation of the hip with CT and CAD-CAM-CAE study that allowed better surgical planning with trial stem implantation from a series of stem designs and custom made femoral components manufacturing

Purpose: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to deþne the risk of vascular complications after proximal locking in intramedullary tibial nailing. Methods: Seven fresh cadaver legs were obtained from the University Hospital of Ioannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization. Results: MRI sections combined with CT and 3D-CT have been used to illustrate the þndings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these þndings highlighted the surgical risks associated with this type of proximal locking and its direction. Conclusions: Proximal anteriorposterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended as an alternative procedure to eliminate the potential for iatrogenic lesions.

This study of surgically treated distal tibia fractures was undertaken to compare the internal fixation with the two external fixation methods.

There were 40 patients with 41 pilon fractures. The mean age was 51.2 years (18–76). 17 of the 40 patients-14 from vehicular accident, 3 from fall – were treated with an ankle-spanning half-pin external fixator (11C, 6B, 11 Weber B- 5 C, 1IIIa, 5I, 6II). 11 patients-10 from vehicular accident, 1 from fall- were treated with a single-ring hybrid ankle-spanning external fixator (9C, 2 B, 6 Weber B-4 C, 5I, 2II). 13 patients-10 from vehicular accident and 1 from fall- were treated with an epiunion plate (1A, 8B, 4C, 5I, 3II, 10 Weber B- 1C). The mean follow-up was 4.2years (1–8). Fracture union was defined as having three cortices bridging on the plain radiographs for a patient who was able to bear full weight. Non union was defined as a fracture that did not heal within a year.

Fracture union was achieved for 36 of the 41 fractures. Three patients with external fixator, one with hybrid and one with plate had septic pseudarthrosis. Fractures in the external fixator and hybrid groups had a tendency to lose the reduction. Four patients with external fixator had delayed union and have lost range of motion in the ankle. Five patients in the external fixator group are candidates for ankle arthrodesis due to arthritis.

The ORIF and hybrid fixator were equally efficacious in achieving bony union and not to lose range of motion in the ankle. Fractures in the external fixator with the ankle – spanning had higher rate of delayed union and loss of motion in ankle. The choice of the external fixator is dependent on the surgeon and the type of the fracture. However the patient must be followed up for the stability of the system.

We present the results of custom made cementless implants for treatment of osteoarthritis due to congenital disease of hip and osteonecrosis due to other diseases, where the normal anatomy was severely modified and it was impossible to insert the smallest available implant.

There were 43 patients with 52 hips, 6 males – 46 females. The mean age was 48years (22–61). The mean follow-up was 24 months (1–48). There were 32 patients with low dislocation, 14 with high dislocation, 1 with infantile septic arthritis, 1 with Hodgkin disease, 1 with dysplasia, 1 with ankylosing spondylitis, 1 with congenital varus hip and 1 with Perthes disease. Our protocol was consisted of plain radiographs and CT of the acetabulum, femur, knee condylars and foot in order to be evaluated the bone stock of acetabulum and the femur anteversion.

All the patients were evaluated – according to the Merle D’ Aubigne score – two, three and every six months after the operation. There was one complication with a proximal femur fracture in a high dislocated hip during the operation and two complications postoperatively. Both of them were high dislocated hips, and the one had paresis of sciatic nerve, that it recovered. The other had septic loosening and was undertaken revision in two stages. All the patients improved in pain, in walking ability and in range of motion.

The impossibility of using the smallest available implant due to the high deformity and the young age led us to use custom made implant. Although a long follow-up is required for these procedures the first results are very encouraging according to the recovery of the patients which were related to the restoration of hip biomechanics provided by the three dimensional neck orientation.

Total hip arthroplasty (THA) in neglected congenital dislocation of the hip (CDH) constitutes a challenging procedure, with surgical difficulties and complications. The purpose of this study was to analyse the complications of THAs in CDH.

Between June 1983 and September 2002, 418 THAs were performed in 356 patients with CDH, with a mean follow-up 108 (7–237) months. The mean age at surgery was 53.3 (24–79) years with 325 females and 31 males. 83 patients had CDH in high position. 307 arthroplasties were cementless, 39 cemented and 72 hybrids. 40 stems were custom made. The cup always was positioned at the true acetabulum. 24 shortening osteotomies of the femur, 8 corrective supracondylar and 6 trochanteric osteotomies were performed.

Preoperatively the average Merle d’Aubigne-Postel hip score was 1.1 for pain, 4.8 for range of motion and 3.1 for walking ability. Postoperatively the average hip score was 5.2, 4.7 and 5.3 respectively. The average length discrepancy was 8 cm (3–12) preoperatively and 1.5 cm remained in 8 patients.

Complications included 7 intraoperative fractures of the femur, 12 dislocations, 4 peroneal nerve palsies that recovered, 25 heterotopic ossifications, 7 deep vein thromboses, 3 pulmonary embolisms, early mechanical loosening in 4 cemented and 10 cementless cups and 3 infections. Complications were diminished dramatically last years due to improved surgical technique, new available implants and preoperative evaluation of the hip with CT and CAD-CAM-CAE study that allowed better surgical planning with trial stem implantation from a series of stem designs and custom made femoral components manufacturing.

Aim: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to define the risk of vascular complications after proximal locking in intramedullary tibial nailing.

Material and Methods: Seven fresh cadaver legs were obtained from the University Hospital of loannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization.

Results: MRI sections combined with CT and 3D-CT have been used to illustrate the findings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these findings highlighted the surgical risks associated with this type of proximal locking and its direction.

Conclusions: Proximal anterior-posterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended.