Revision after failed femoral components may be technically demanding due to loss of peri-prosthetic bone. This retrospective study evaluated the long-term results of femoral revision using the cementless Wagner Self-Locking stem. Between 1992 and 1998, 68 consecutive hips in 66 patients underwent femoral revision using this implant. A total of 25 patients died from unrelated causes without further revision; the remaining 41 hips in 41 patients (12 men and 29 women) with a mean age of 61 years (29 to 80) were reviewed at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral approach was used in 32 hips. A total of five stems required further revision because of infection in two, progressive subsidence in two and recurrent dislocation in one. Four hips had dislocated and eight stems had subsided ≥ 10 mm. The mean Harris hip score improved from 33 points pre-operatively to 75 points at final follow-up (p < 0.001). In all, 33 stems (91.7%) showed radiological signs of stable bone fixation. The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%) and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship with revision and ≥ 10 mm migration of the stem as the endpoint was 83.6% (95% CI 76.6% to 91.4%).

This study shows quite good survival and moderate clinical outcome when using a monoblock tapered titanium stem for supporting the regeneration of bone in complex revision hip surgery.

Introduction: A minimally invasive procedure including percutaneous reduction and external fixation can be performed for Sanders’ type II, III and IV heel fractures in order to obtain a tridimensional reconstruction of the os calcis with a reduced risk of local complications, allowing for early motion.

Methods: 54 consecutive closed articular displaced calcanear fractures in 52 patients were treated with the Orthofix Heel Mini-Fixator. Patients were followed for an average of 49 months (range, 27 to 94 months) and assessed clinically with the Maryland Foot Score and radiographically with X-rays and CT scans.

Results: Clinical results at follow-up scored excellent or good in 49/54 cases (90.7%), fair in 2 cases (3.7%) and bad in 3 cases (5.6%). Mean preoperative Böehler’s angle was 6.98° ± 12.93 (range, – 5.95–19.86), while after surgery the average value was 21.94° ± 9.36 (range, 12.58–31.30) (p < 0.01). C.T. scans were evaluated according to the S.A.VE. score, showing excellent results in 24 cases (44.4%), good results in 25 cases (46.3%), fair results in 3 cases (5.6%) and bad results in 2 cases (3.7%). Mean preoperative S.A.VE. score was 17.58 ± 4.98 (range, 12.60 – 22.56) while the postoperative score was 25.66 ± 2.44 (range, 23.22 – 28.1) (p< 0.01).

Complications: Sudeck’s atrophy (10), pin tract superficial infections (3), thalamic displacement following early weight-bearing(3).

Conclusions: Percutaneous reduction and external fixation proved to be a reliable technique in order for obtaining stable reduction of os calcis fractures. The clinical results appear to be comparable to those obtainable with the open reduction and internal fixation, with the added advantages of being minimally invasive procedure, having substantially shorter operating times and reducing risk of complications related to surgical exposure.

Introduction: Symptomatic treatment of Civinini-Morton syndrome (interdigital neuritis: IDN) may be performed directly on the involved nervous branch using orthotics, local drug injections or surgery.

Alcoholization with phenol by a percutaneous approach has the aim to induce a permanent chemical neurolysis, obtaining remission of the neuritic painful symptoms.

Methods: 71 patients were treated by percutaneous alcoholization of the interdigital nerve using a needle-electrode connected to an electrostimulator by a dorsal approach to the intermetatarsal space. Once the nerve is localized by induction of paresthesia up to the toes, 2,5 ml of phenol 5% in water solution are injected, immediately followed by local anesthetic for a post-procedure analgesia. The patients were evaluated by visual analogue scale for pain (VAS).

Results: Mean follow-up was 36±8 months. Percutaneous alcoholization of the common interdigital nerve by phenol injection proved to be effective (VAS < 30) in 80.3% of cases (57/71).

Conclusions: Treatment of Civinini-Morton syndrome by alcoholization with phenol by a percutaneous approach showed considerable better results when compared with those reported in the literature with conservative treatment or local steroid injection, and even comparable with those obtained with surgical nevrectomy in absence of complications related to surgical approach.

Introduction: In two-stage revision of an infected total hip replacement a preformed temporary antibiotic-loaded polymethylmethacrylate spacer may be required in order to allow weightbearing and joint motion while ensuring antibiotic local release.

Methods: 29 patients with infected hips were treated by a two-stage procedure including removal of prosthesis and implantation of a spacer. The device comprised a stem with 3 available head sizes pre-coated by bone cement supplemented with gentamicin (2.5% w/w) and vancomycin (2.5% w/w). Joint motion and weight-bearing were allowed when the bone stock ensured an adequate stability to the spacer. Systemic antibiotics were administered for 8 weeks. The spacer remained in situ for an average of 155 (range 70–272) days. Reimplantation was performed when recovery of clinical and serological signs of infection was obtained. Patients’ evaluation included clinical assessment (HHS), standard x-ray and laboratory parameters.

Results: mean follow-up was 52 months (range 36–100). Healing of the infection was obtained in 27/29 cases (93.1%). 5 patients required resection-arthroplasty (2 persistent infections, 2 inadequate bone stock, 1 recurrent infection). In 4 cases the spacer dislocated, being treated by non-surgical reduction. The reimplanted patients (24) showed no clinical or laboratory signs of infection recurrence, with a mean HHS score of 79 (range 53 to 100); no radiographic signs of loosening were observed.

Discussion: the use of a preformed antibiotic-loaded spacer in two-stage revisions, allowing a local antibiotic release together with some degree of joint motion, appears to enhance infection’s treatment improving patients’ quality of life and functional recovery.

Introduction: A minimally invasive procedure including percutaneous reduction and external fixation can be performed for Sanders’ type II, III and IV heel fractures in order to obtain a tridimensional reconstruction of the os calcis with a reduced risk of local complications, allowing for early motion.

Methods: 54 consecutive closed articular displaced cal-canear fractures in 52 patients were treated with the Orthofix Heel Mini-Fixator. Patients were followed for an average of 49 months (range, 27 to 94 months) and assessed clinically with the Maryland Foot Score and radiographically with X-rays and CT scans.

Results: Clinical results at follow-up scored excellent or good in 49/54 cases (90.7%), fair in 2 cases (3.7%) and bad in 3 cases (5.6%). Mean preoperative Böehler’s angle was 6.98° ± 12.93 (range, − 5.95–19.86), while after surgery the average value was 21.94° ± 9.36 (range, 12.58–31.30) (p < 0.01). C.T. scans were evaluated according to the S.A.VE. score, showing excellent results in 24 cases (44.4%), good results in 25 cases (46.3%), fair results in 3 cases (5.6%) and bad results in 2 cases (3.7%). Mean preoperative S.A.VE. score was 17.58 ± 4.98 (range, 12.60 – 22.56) while the postoperative score was 25.66 ± 2.44 (range, 23.22 – 28.1) (p< 0.01).

Sudeck’s atrophy was observed in 10 patients (18.6%) that healed within four months. Three pin tract superficial infections (5.6%) were resolved without removal of the device. Three patients (5.6%) showed thalamic displacement following early weight-bearing but did not require further surgery.

Conclusions: Percutaneous reduction and external fixation proved to be a reliable technique in order for obtaining stable reduction of os calcis fractures. The clinical results appear to be comparable to those obtainable with the open reduction and internal fixation, with the added advantages of being minimally invasive procedure, having substantially shorter operating times and reducing risk of complications related to surgical exposure.

Implantation of metatarso-phalangeal prostheses or spacers has been widely indicated for the replacement of the articular surfaces in severe hallux rigidus.

A reabsorbable device in poly(D-L-lactic acid) (PDLLA) which is dome-shaped with a stem for implantation into the first metatarsal, avoiding any resection of the base of the proximal phalanx, is proposed.

The rationale of the reabsorbable spacer is to maintain the distance between the articular surfaces and provide a sliding surface suitable for articulation. It is then reabsorbed and replaced by fibrous tissue, which allows motion and removes pain.

37 reabsorbable spacers have been inserted for severe hallux rigidus in 33 patients aged from 26 and 76 years (average 58). Patients were reviewed with a follow-up ranging between 36 and 96 months (average 59.5).

The results were assessed using the American Orthopaedic Foot and Ankle Society (A.O.F.A.S), hallux-metatatarsophalangeal-interphalangeal scale.

Anteroposterior and lateral weight-bearing X-rays were made preoperatively and at follow-up, evaluating the dimensions of the articular space and the length of the first metatarsal.

The chronology of device reabsorption was studied in 10 patients with M.R.I., assessing complete reabsorption within 4 months of the operation.

Excellent and good results were obtained in 91% of patients. The A.O.F.A.S. score was 43.7+/−20.6 pre-operatively and 82+/10.3 post-operatively.

The reabsorbable spacer confirmed the expectations of its protagonists. This procedure would appear to be an alternative to arthrodesis of the first metatarso-phalangeal joint or traditional permanent implants, and represents an intermediate technique between an implant and resection arthroplasty.

PURPOSE OF THE STUDY: Arthroscopic assisted treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery, but bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical Results:

MATERIAL AND METHODS: seventy patients (mean age 47 years, range 18 to 72 years, 43 men, 27 women) were arthroscopically assisted treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 20 type I, 27 type II, 18 type III and 5 type IV. The fixation device was: Kirchner wire in Schatzker I, percutaneous cannulated screw in Schatzker II,III,IV, and bone cement filing of the fracture site in 1 case. In 32 cases, where bone loss was significant. we use autologous bone graft, in 18 cases SRS. There were 15 meniscal injuries: 3 underwent arthroscopic suture, 8 had partial meniscectomy and 4 sub subtotal meniscectomy. We also diagnosticated 7 lesions of the medial pivot 6 ACL, 1 PCL : all were left in place. Al patients in the first post-operatory day start passive rehabilitation with kinetech All cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Hospital for Special Surgery) and radiographical examination were done with an average follow-up of 46.7 months.

RESULTS: There were no complications except two immediate compartimental syndromes that stopped the arthroscopic treatment. Passive motion of the knee started at 1 day postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 93 for Schatker I, 91 for Schatker II, 87 for Schatker III, 86 for Schatker IV. In eight cases we found early signs of osteoarthritis. There were no secondary bony depression or significant valgus deformity on X-rays.

CONCLUSION: Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with open surgical technique for the types of fracture that we have treated (type III and IV). A minimal, percutaneous osteosynthesis which was the only possibility under arthroscopic control, did not modify the anatomical Results:

Introduction: The management of periprosthetic osteolysis is a challenging problem in revision hip arthroplasty. Filling acetabular bone defects with structural allografts resulted in early failure due to resorption of the graft. The application in combination with reinforcement rings should promote bone incorporation as a result of reduced mechanical stresses. This study evaluates the long-term results in the treatment of acetabular deficiencies using bulk allografts supported with a Burch-Schneider Anti-Protrusio Cage (APC).

Materials and Methods: From January 1992 to December 1995, 69 consecutive patients underwent revision surgery following periprosthetic osteolysis and aseptic loosening of the cup. Acetabular bone loss included IIIA and IIIB types according to Paproski classification. 12 patients died for unrelated causes with a well-functioning total hip arthroplasty in situ. 3 cases were lost at follow-up. The study group consisted of 56 hips in 54 patients. There were 11 males and 43 females, aged from 33 to 84 years (medium 65). Average follow-up was 11.7 years, ranging from 10 to 14.4. Surgical procedure included filling acetabular bone defects with bulk allografts supported with a Burch-Schneider APC which was fixed with screws to the iliac bone. A poly-ethylene cup was finally cemented into the metal cage. Deambulation was allowed one week after surgery, but weightbearing was delayed two months. Clinical evaluation was determined using Harris hip score (HHS). The stability of the acetabular implant was assessed according to Gill criteria. The progression of the bone graft was evaluated using Gross grading.

Results: 2 patients developed deep infection that was treated by resection-arthroplasty. Aseptic loosening of acetabular cage following an extensive resorption of bone graft was observed in 6 cases and 3 of them underwent rerevision. X-ray signs of graft incorporation occurred in 48 hips. Average HHS values of 30 (range, 11 to 81) and 75 (range, 28 to 100) points were assessed respectively in the preoperative time and at follow-up.

Discussion and Conclusions: In severe acetabular bone deficiencies the application of reinforcement rings in combination with massive allografts has been advocated in order to prevent bone graft resorption and cup loosening. Burch-Schneider Anti-Protrusio Cage is able to protect the graft spanning bone defects and promoting augmentation of periprosthetic bone stock. With an aseptic failure rate of 8.9% and a total survival rate of 85.7% at an average of 11.7 years, the use of APC and structural allograft proved out to be an effective procedure in the long-term reconstructive treatment of extensive loss of acetabular bone stock.

Introduction: Distal osteotomy of the first metatarsal is indicated in the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal using a percutaneous technique.

Methods: From 1996 to 2001 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 82 patients for the treatment of painful mild-to-moderate hallux valgus. Patients were assessed at a mean follow-up of 35.9 months employing a clinical and radiographic protocol. The American Orthopedic Foot and Ankle Society’s hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment.

Results: in 107 of the 118 cases (90.7%), patients were satisfied with the procedure. The mean score obtained in the clinical assessment using the AOFAS scale was 88.2 ± 12.9. The radiographic assessment showed significant changes (P< 0.05) in the values of the hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle and the sesamoid position at the postoperative assessment compared to preoperative values. Recurrence of the valgus deformity was observed in 3 cases (2.5%), non-painful stiffness of the first metatarsophalangeal joint in 7 (5.9%) and a deep infection resolved by antibiotic therapy in 1 (0.8%).

Conclusions: The percutaneous procedure proved to be a reliable technique for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable to those obtainable with the traditional open techniques, with the additional advantages of a minimally invasive procedure, substantially shorter operating times and a reduced risk of complications related to surgical exposure.

Study Design. A retrospective clinical study was conducted.

Objectives. To evaluate the clinical and radiologic outcomes of one-stage posterior decompression-stabilization after partial reduction and trans-sacral interbody fusion with a titanium cage for severe L5–S1 spondylolisthesis.

Summary of the Background Data. Trans-sacral inter-body fusion for the management of severe L5–S1 spondylolisthesis with or without partial reduction and pedicular fixation has been previously described. The use of a transsacral titanium cage has not been previously reported.

Methods. Thirty-two patients with severe L5–S1 spondylolisthesis were treated consecutively with posterior decompression, partial reduction, pedicular fixation, and posterior lumbar interbody fusion using a trans-sacral titanium cage. The mean age at the time of surgery was 24.6 years (range, 11–55 years). The mean follow-up period was 48.3 months (range, 12–102 months). Twenty-three patients had severe back pain and twenty-five patients radicular pain. Nine patients had a partial unilateral L5 motor deficit and twenty-one an L5 sensory deficit. Twelve patients had extremely tight hamstrings. The mean preoperative percentage of slipping was 71.7% (range, 52–91%). Patients were evaluated for complications and fusions, and outcomes were collected using the modified Scoliosis Research Society Outcomes Instrument.

Results. At follow-up, all patients, except one with major vascular complications, were extremely or reasonably satisfied with the surgery. All patients showed improvements in radiologic indexes and stable fusion at the final follow-up examination.

Conclusions. Posterior decompression and partial reduction followed by circumferential stabilization performed in one stage combining pedicle fixation with trans-sacral titanium cage interbody fusion is an effective and safe technique for the management of severe spondylolisthesis.

A minimally-invasive procedure using percutaneous reduction and external fixation can be carried out for Sanders’ type II, III and IV fractures of the os calcis. We have treated 54 consecutive closed displaced fractures of the calcaneum involving the articular surface in 52 patients with the Orthofix Calcaneal Mini-Fixator. Patients were followed up for a mean of 49 months (27 to 94) and assessed clinically with the Maryland Foot Score and radiologically with radiographs and CT scans, evaluated according to the Score Analysis of Verona. The clinical results at follow-up were excellent or good in 49 cases (90.7%), fair in two (3.7%) and poor in three (5.6%). The mean pre-operative Böhler’s angle was 6.98° (5.95° to 19.86°), whereas after surgery the mean value was 21.94° (12.58° to 31.30°) (p < 0.01). Excellent results on CT scanning were demonstrated in 24 cases (44.4%), good in 25 (46.3%), fair in three (5.6%) and poor in two (3.7%). Transient local osteoporosis was observed in ten patients (18.5%), superficial pin track infection in three (5.6%), and three patients (5.6%) showed thalamic displacement following unadvised early weight-bearing.

The clinical results appear to be comparable with those obtainable with open reduction and internal fixation, with the advantages of reduced risk using a minimally-invasive technique.

Objective of study: Two-stage revision procedure of infected total hip replacements usually involves the application of a temporary antibiotic-loaded poly-methylmethacrylate spacer. A preformed spacer which allows weightbearing and joint motion while ensuring a sustained antibiotic release was evaluated.

Material and Methods: 26 consecutive patients affected with an infected total hip arthroplasty were treated by the insertion of an industrially preformed temporary spacer (Spacer-G). This device comprises a cylindrical stainless-steel rod coated with bone cement supplemented with gentamicin (1.8% w/w) and vancomycin (2.5% w/w). Joint mobilization and assisted weight-bearing were permitted when bone stock allowed an adequate mechanical stability of the spacer. Reimplantation was performed when normalization of serological parameters was obtained. Patients’ evaluation included clinical assessment, standard x-ray and laboratory parameters.

Results: The spacer remained in situ for an average of 155 (70-272) days allowing healing of the infection in 24 cases. 5 patients required resection-arthroplasty (2 persistent infections, 2 inadequate local bone conditions, 1 acute recurrence of infection). In 4 cases the spacer dislocated, because the head diameter was too small. The successfully-reimplanted patients (21) were assessed with a mean 48 (17–83) months follow-up showing no clinical or biohumoral signs of infection recurrence. Functional outcome was satisfactory (mean value of Harris Hip Score: 79) and no radiographic aspects of loosening were observed.

Conclusions: The Spacer-G used in the two-stage revision of infected total hip replacements permitted an effective local antibiotic release together with some range of joint motion, which improved the quality of life of the patients during treatment of infection and accelerated recovery of function after reimplantation.

A clinical retrospective study was conducted. Results of isolated decompression for degenerative lumbar stenosis was compared with the outcome in patients who underwent decompression-stabilisation.

From January 1992 to December 2002, 127 patients (average age 65.5) with lumbar degenerative stenosis surgically treated were studied. In all patients the Roy-Camille technique was used for decompression; in 41 patients decompression and posterior stabilisation procedures were carried out. Average follow-up was 6 years (range 2–11 years).

The outcomes, evaluated according to Lassale classification, were satisfactory in 81% of the decompressed group while improved to 88% in the stabilised–decompressed group. Three patients of the first group required stabilisation for intractable low back pain (one patient) and lumboradicular symptoms (two patients), while problems related to the device (one hardware failure) and two instances of adjacent segmental instability were seen in the second group.

Decompression alone is associated with an increased rate of residual low back pain (one patient in this cohort required fusion). The decompression–stabilisation procedure reduces the incidence of low back pain but is associated with other complications such as significant blood loss, possible wound infections, urinary tract infections (due to increased surgical time), device failures, root impingement and late adjacent segmental pathologies.

The Roy Camille technique is effective for achieving adequate decompression. The surgeon should always be aware of patients who might require fusion. The instrumented stabilisation should be reserved for patients with chronic low back pain and evident instability, degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis.

Standard external fixators have always caused difficulties in visualising fracture fragments radiologically in both planes; for this reason multiple shots are often required, exposing patients and surgeons to high X-ray levels. Radiolucent external fixator X-calibre is composed of a new thermoplastic material reinforced by carbon fibres (PEEK-CA 30). The aim of this study is to evaluate the first 30 tibial fractures treated with this device.

Thirty external fixators X-calibre were used to treat 30 patients with tibial fractures with an average age of 40.4 years (range 21–60). According to the AO classification we have treated nine type A, 13 type B, and eight C fractures. Five were open fractures. The average follow-up was of 18 months. The time of healing was the same as seen using the standard fixator and the average time was 115 days (range 85 to 190). One tibial plafond fracture healed with 8° valgus deformity and persistence of pain during walking. There was loss of reduction on the third day after surgery due to erroneous evaluation of the fracture, which presented a butterfly fragment.

This new radiolucent fixator showed the following advantages: single use, sterile package, radiolucency, less X-ray exposure for patients and surgeons, deal mechanical performance for each use, reduced storage and sterilisation costs, less instrumentation, less weight and increased comfort for the patient, average healing time and results comparable to the existing radio-opaque system.

Different methods of filling bone defects are reported: shortening followed by lengthening or bone transplant. In both cases the resection and docking bone site (immediately or after transplant) has a high risk of delayed consolidation or non-union. The aim of this study was to evaluate the strategies to avoid this risk.

We studied 19 patients treated from 1997 to 2002: 11 (group 1) were treated with immediate shortening and proximal callotasis. In eight patients (group 2) we performed monofocal proximal-distal bone transplant. In seven patients of group 1 we performed only decortication of the docking site (group 1A); in four cases (group 1B) decortication was associated with an autologous bone graft. The docking site was checked radiologically and considered healed when we allowed full weight-bearing after fixator removal.

In two patients (28.5%) in group 1A, three (75%) in group 1B and two (25%) in group 2 healing was achieved without any other operations. Docking site refracture or pseudoarthrosis was treated in all patients by new decortication and autologous bone graft with an average healing time of 90 days.

We suggest performing acute bone loss shortening in combination with decortication and autologous bone graft when local conditions permit. After bone transplant it is not necessary to wait for spontaneous consolidation, but better to plan from the beginning another operation before the two the docking site fragments are in contact.

Now we are using AGF and BMP-7 (OP-1) for treatment of the docking site but the study is still underway.

Distal osteotomy of the first metatarsal can be performed by a percutaneous minimally invasive procedure when indicated for the surgical treatment of hallux valgus. The intermediate-term results of percutaneous distal uniplanar osteotomy of the first metatarsal were assessed in 118 feet in 82 patients (36 bilaterally) to determine the effectiveness of the percutaneous procedure.

A modified Lamprecht – Kramer – Boesh technique was performed under distal nerve trunk anaesthesia (ankle block) without a tourniquet, using a K-wire for stabilisation of the osteotomy. No surgical approaches and no soft-tissue procedures were required. Post-operatively adhesive tape was applied and immediate weight-bearing allowed.

The patients were followed for an average of 36 months (range 24 to 78 months). Clinical assessment was based on the American Orthopaedic Foot and Ankle Society, hallux-metatarsal-phalangeal-interphalangeal (AOFAS) scale. Anteroposterior and lateral weight-bearing radiographs were performed pre- and post-operatively, and the hallux valgus angle, the first intermetatarsal angle, the distal metatarsal articular angle (DMAA) and the position of the sesamoid were recorded. The average score according to the AOFAS scale was 86.6±12.9. Patients were satisfied with the result of the procedure in 90.7% of cases. The results confirm the effectiveness of the percutaneous procedure to achieve a satisfactory distal osteotomy of the first metatarsal without the need for soft-tissue procedures in the surgical management of symptomatic hallux valgus.

Preoperative autologous blood donation (PABD) is widely practised in elective orthopaedic surgery, but few data are available as regards recombinant human erythropoietin (rHuEpo) support during a PABD programme in children.

In January 1999 we introduced a PABD protocol with erythropoietin (10000 U s.c. twice weekly during the 3 weeks preceding surgery) in children who were scheduled for corrective surgery of scoliosis. Between January 1999 and November 2003, 23 consecutive patients (five males and 18 females, median age 15.1 years) were enrolled. Preoperative haemoglobin (Hb) levels, the numbers of collected and of autologous and allogeneic blood transfused units were determined. The results were compared with a historical group of 28 consecutive patients (seven males and 21 females, median age 15.4 years) who underwent spinal surgery between January 1994 and December 1998 and who differed from the first group only by the absence of concomitant erythropoietin therapy.

Administration of rHuEpo allowed all patients to complete the PABD programme, whereas 36% of patients in the non-treated group had to stop predeposit because they developed anaemia. Furthermore, significantly higher numbers of collected blood units and haemoglobin levels were measured. A significantly lower requirement for allogeneic blood was observed in the rHuEpo-treated group: 1/23 vs. 9/28 patients (4.3%–32.1%, p < 0.001).

The present study documents the efficacy of presurgical rHuEpo in facilitating autologous blood collection, thus reducing exposure to allogeneic blood, in paediatric patients undergoing corrective spinal surgery.

The management of infected total hip replacements is a challenging problem in orthopaedic surgery. Two-stage revision procedures usually involve the application of a temporary antibiotic-loaded polymethylmethacrylate spacer. A preformed spacer which allows weight-bearing and joint motion while ensuring a sustained antibiotic release was evaluated.

From September 1996 to March 2002, 26 consecutive patients with an infected total hip arthroplasty were treated by the insertion of an industrially preformed temporary spacer (Spacer-G®). This device comprises a cylindrical stainless-steel rod coated with bone cement supplemented with gentamicin (1.9% w/w) and vancomycin (2.5% w/w). The spacer is currently available in three sizes of head diameter, each size with two stem lengths. Joint mobilisation and assisted weight-bearing were permitted when the bone stock provided adequate mechanical stability of the spacer. Patients’ evaluation included clinical assessment and standard X-ray and laboratory parameters. Reimplantation was performed when serological parameters had normalised.

The spacer remained in situ for an average of 155 (70–272) days, allowing healing of the infection in 24 cases. Five patients required resection arthroplasty (two persistent infections, two inadequate local bone conditions and one acute recurrence of infection). A second spacer was implanted after 4 months in one subject. In four cases the spacer dislocated, because the head diameter was too small or because of a rotational instability of the stem in the femur. The successfully-reimplanted patients (21) were assessed with a mean 53 (22–88) months of follow-up, showing no clinical or bio-humoral signs of infection recurrence. Functional outcome was satisfactory with a mean value of Harris Hip Score of 79 (53–100), and no radiographic aspects of loosening were observed.

The Spacer-G® used in the two-stage revision of infected total hip replacements permitted an effective local antibiotic release together with some range of joint motion, which improved the quality of life of the patients during treatment of infection and accelerated recovery of function after reimplantation.

Implantation of metatarso-phalangeal prostheses or spacers has been widely indicated for the replacement of the articular surfaces in severe hallux rigidus. Giannini proposed a reabsorbable device in poly(D-L-lactic acid) (PDLLA) which is dome-shaped with a stem for implantation into the first metatarsal, avoiding any resection of the base of the proximal phalanx.

The rationale for the reabsorbable spacer is to maintain the distance between the articular surfaces for a predictable time and to provide a sliding surface suitable for articulation with the proximal phalanx. It is then reabsorbed by fragmentation and replaced by fibrous tissue, which maintains the articular space, allows motion and relieves pain.

Twenty-three reabsorbable spacers have been inserted for severe hallux rigidus in 20 patients aged from 26 to 76 years (average 58). Patients were reviewed with a follow-up ranging between 24 and 50 months (average 36). The results were assessed using the American Orthopaedic Foot and Ankle Society (A.O.F.A.S), hallux-metata-tarsophalangeal-interphalangeal scale. Anteroposterior and lateral weight-bearing X-rays were made preoperatively and at follow-up, evaluating the dimensions of the articular space and the length of the first metatarsal. The chronology of device reabsorption was studied in 10 patients with M.R.I., assessing complete reabsorption within 4 months of the operation.

Excellent and good results were obtained in 91% of patients. The A.O.F.A.S. score was 43.7±20.6 pre-operatively and 82±10.3 post-operatively. The reabsorbable spacer confirmed the expectations of its supporters. This procedure would appear to be an alternative to arthrodesis of the first metatarso-phalangeal joint or traditional permanent implants and represents an intermediate technique between an implant and resection arthroplasty.

Elbow dislocations are difficult to treat because of the high incidence of short- (vascular and neurological lesions) and long-term (decreased range of motion and instability) complications. We report the results obtained in 20 elbow dislocations treated with hinged cast tutorisation or hinged external fixator.

We treated 20 patients with an average age of 45 years (range 16– 62 years). The average follow-up was 7 months (range 5–18 months). We divided the patients into two groups: patients treated by a hinged tutor for 4 weeks (group A), patients treated by hinged external fixator, removed after 5 weeks (group B). All the patients were evaluated clinically using the “Mayo elbow performance score” after 3 weeks, 1 month and 1 year.

Results were excellent in six elbows and good in 14; none of the patients had an insufficient or poor score. We observed deficit in prono-supination in three patients and deficit in flexion and extension in six patients; three patients complained of epicondylar pain when carrying something. At the end of the treatment none of the patients complained of instability.

According to our data normal function can be restored after early mobilisation. Our experience suggests that the most important aspect in the choice of treatment is the evaluation of joint stability after reduction. The results obtained with the external fixator are very good in terms of restoring function; the incidence of complications is very low and was equally distributed between the two groups.

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length.

The treatment of bone cysts by topical injection of methylprednisolone acetate was initiated at the end of 1973, and the late results are reported in this paper. In seventy-two cases followed up for one to three years favourable results have been obtained in about 90 per cent. The technique of local injection and the surgical equipment employed, in the case of focal recurrences, are considered. With this method, surgical treatment of bone cysts in youth is seldom necessary.