Non-invasive sampling of tumor-derived genetic material in circulation through liquid biopsy may be very beneficial for an accurate diagnosis and evaluation of response to treatment in patients with malignant and benign soft tissue tumors. We previously showed that tumor-derived genomic aberrations can be detected in plasma of patients with leiomyosarcoma (LMS) and leiomyoma (LM). In LMS patients, we also showed that the levels of circulating tumor DNA (ctDNA) correspond with response to treatment. We developed an approach tailored to genomic profile of LMS (characterized by intermediate levels of point mutations and copy number alterations, CNAs). Based on TCGA data, we designed a panel of 89 most frequently mutated genes in LMS, which we profiled in plasma DNA by deep sequencing. In parallel, plasma samples were analyzed by shallow whole genome sequencing for detection of CNAs. With this approach, we detected ctDNA in 71% (20/28) of samples from 6/7 patients with advanced disease with >98% specificity. The combination approach for orthogonal profiling of point mutations and CNAs proved to increase the sensitivity of ctDNA detection. Currently, we seek to further improve the sensitivity of ctDNA detection by refining our capture panel and tracking LMS-specific DNA methylation markers in circulation, in addition to point mutations and CNAs. The ultimate goals of our ctDNA studies are 1) to develop a highly sensitive assay for evaluation of response to therapy and long-term surveillance for patients with LMS, and 2) to develop a blood-based test for accurate pre-operative distinction between LMS and LM.

To identify LMS-specific DNA methylation markers, we analyzed a test cohort of 76 LM, 35 uterine LMS and 31 extra-uterine LMS by Illumina Infinium EPIC arrays. We identified differentially methylated CpGs between LM and uterine LMS, and between LM and all LMS using a newly developed custom pipeline in R. The results of this analysis are currently being validated in a new dataset of 41 LM and 153 LMS generated by our group. Recently published (PMID: 34301934) genomic data from new 53 LMS samples are used to refine the panel of the most frequently mutated genes that we identified previously in the LMS TCGA data.

Our preliminary analysis of test cohort revealed >270 differentially methylated CpGs between LM and uterine LMS, and >1000 differentially methylated CpGs between LM and all LMS. The preliminary analysis of genomic data shows that the initial panel of 89 frequently mutated genes could be substantially narrowed down to cover only selected tumor suppressor genes. Once validated, these results will be used to refine the ctDNA assay for LMS and LM.

Our results point to multiple epigenetic markers that could be used for ctDNA profiling, in addition to point mutations or CNAs. Further validation will allow us to select the most reliable LMS- and LM-specific DNA methylation markers and the most frequently mutated regions across independent datasets, and these markers will be incorporated into our new ctDNA test for a concurrent detection of point mutations, CNAs and DNA methylation markers in circulation.

Aims

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Abstract

Abstract

Aims

The aim of this meta-analysis is to assess the association between exchange of modular parts in debridement, antibiotics, and implant retention (DAIR) procedure and outcomes for hip and knee periprosthetic joint infection (PJI).

Infections are among the main complications connected to implantation of biomedical devices, having high incidence rate and severe outcome. Since their treatment is challenging, prevention must be preferred. For this reason, solutions capable of exerting suitable efficacy while not causing toxicity and/or development of resistant bacterial strains are needed. To address infection, inorganic antibacterial coatings, and in particular silver coatings, have been extensively studied and used in the clinical practice, but some drawbacks have been evidenced, such as scarce adhesion to the substrate, delamination, or scarce control over silver release.

Here, antibacterial nanostructured silver-based thin films are proposed, obtained by a novel plasma-assisted technique, Ionized Jet Deposition (IJD). Coatings are obtained by deposition of metallic silver targets. Films thickness is selected based on previous results aimed at measuring extent and duration of silver release and at evaluating toxicity to host cells (fibroblasts). Here, composition (grazing incidence XRD) and morphology (SEM) of the obtained coatings are characterized for deposition onto different substrates, both metallic and polymeric. For heat sensitive substrates, possible alterations caused by coatings deposition in terms of morphology (SEM) and composition (FT-IR) is assessed. Then, a proof-of-concept study of the capability of these films to inhibit microbial biofilm formation is performed by using two different supports i.e., the Calgary Biofilm Device and the microplates. To the best of the Authors knowledge, this is the first study describing the application of specific anti-biofilm analyses to nanostructured coatings. In particular, anti-biofilm activities are tested against the following pathogenic strains: Escherichia (E.) coli NCTC12923, Staphylococcus (S.) aureus ATCC29213 and S. aureus 86. Among these, the strain 86 is not only pathogen but it also possesses several antibiotic resistance genes, allowing the evaluation of the utilization of nanostructured coatings as an alternative anti-microbial system to face the global threat of antibiotic resistance.

Results indicate that films deposited from silver targets are composed of nanosized aggregates of metallic silver, indicating a perfect transfer of composition from the deposition target to the coatings.

Results obtained here indicate that the films have significant antibacterial and antibiofilm activity. In addition, they prove that the system can be successfully applied for evaluation of coatings antibacterial efficacy for biomedical applications.

Patients with cancer and bone metastases can have an increased risk of fracturing their femur. Treatment is based on the impending fracture risk: patients with a high fracture risk are considered for prophylactic surgery, whereas low fracture risk patients are treated conservatively with radiotherapy to decrease pain. Current clinical guidelines suggest to determine fracture risk based on axial cortical involvement of the lesion on conventional radiographs, but that appears to be difficult. Therefore, we developed a patient-specific finite element (FE) computer model that has shown to be able to predict fracture risk in an experimental setting and in patients. The goal of this study was to determine whether patient-specific finite element (FE) computer models are better at predicting fracture risk for femoral bone metastases compared to clinical assessments based on axial cortical involvement on conventional radiographs, as described in current clinical guidelines.

45 patients (50 affected femurs) affected with predominantly lytic bone metastases who were treated with palliative radiotherapy for pain were included. CT scans were made and patients were followed for six months to determine whether or not they fractured their femur. Non-linear isotropic FE models were created with the patient-specific geometry and bone density obtained from the CT scans. Subsequently, an axial load was simulated on the models mimicking stance. Failure loads normalized for bodyweight (BW) were calculated for each femur. High and low fracture risks were determined using a failure load of 7.5 × BW as a threshold. Experienced assessors measured axial cortical involvement on conventional radiographs. Following clinical guidelines, patients with lesions larger than 30 mm were identified as having a high fracture risk. FE predictions were compared to clinical assessments by means of diagnostic accuracy values (sensitivity, specificity and positive (PPV) and negative predictive values (NPV)).

Seven femurs (14%) fractured during follow-up. Median time to fracture was 8 weeks. FE models were better at predicting fracture risk in comparison to clinical assessments based on axial cortical involvement (sensitivity 100% vs. 86%, specificity 74% vs. 42%, PPV 39% vs. 19%, and NPV 100% vs. 95%, for the FE computer model vs. axial cortical involvement, respectively). We concluded that patient-specific FE computer models improve fracture risk predictions of femoral bone metastases in advanced cancer patients compared to clinical assessments based on axial cortical involvement, which is currently used in clinical guidelines. Therefore, we are initiating a pilot for clinical implementation of the FE model.

Calcium phosphates-based coatings have been widely studied to favour a firm bonding between orthopaedic implants and the host bone. To this aim, thin films (thickness below 1 μm) having high adhesion to the substrate and a nanostructured surface texture are desired, capable of boosting platelet, proteins and cells adhesion. In addition, a tunable composition is required to resemble as closely as possible the composition of mineralized tissues and/or to intentionally substitute ions having possible therapeutic functions. The authors demonstrated nanostructured films having high surface roughness and a composition perfectly resembling the deposition target one can be achieved by Ionized Jet Deposition (IJD). Highly adhesive nanostructured coatings were obtained by depositing bone-apatite like thin films by ablation of deproteinized bovine bone, capable of promoting host cells attachment, proliferation and differentiation. Here, biomimetic films are deposited by IJD, using biogenic and synthetic apatite targets. Since IJD deposition can be carried out without heating the substrate, application on heat sensitive polymeric substrate, i.e. 3D printed porous scaffolds, is investigated.

Biogenic apatite coatings are obtained by deposition of deproteinized bone (bovine, ovine, equine, porcine) and compared to ones of stoichiometry hydroxyapatite (HAp). Coatings composition (FT-IR-ATR, FT-IR microscopy, XRD, EDS) and morphology (SEM, AFM) are tested for deposition onto metallic and 3D-printed polymeric substrates (polyurethane (PU)). Different post-treatment annealing procedures for metallic substrates are compared (350–425°C), to optimize crystallinity. Then, uniformity of substrate coverage and possible damage caused to the polymeric substrate are studied by SEM, DSC and FT-IR microscopy.

Biogenic coatings are composed by carbonated HAp (XRD, FT-IR). Trace ions Na⁺ and Mg²⁺ are transferred from deposition target to coating. All coatings are nanostructured, composed by nano-sized globular aggregates, of which morphology and dimensions depend on the target characteristics. As-deposited coatings are amorphous, but crystallinity can be tuned by post-treatment annealing. A bone-like crystallinity can be achieved for heating at ≥400°C, also depending on duration. When deposited on 3D-printed PU scaffolds, coatings, owing to sub-micrometric thickness, coat them entirely, without altering their fibre shape and porosity.

Obtained biomimetic bone apatite coatings can be deposited onto a variety of metallic and polymeric biomedical devices, thus finding several perspective applications in biomedical field.

Abstract

Aims

The aim of this study was to report the results of three forms of reconstruction for patients with a ditsl tibial bone tumour: an intercalary resection and reconstruction, an osteoarticular reconstruction, and arthrodesis of the ankle.

Introduction

In the United States, cementless femoral fixation remains the dominant mode of fixation for femoral neck fractures, despite strong worldwide registry data that supports cemented fixation. The reason for this discrepancy remains unknown, controversial and often difficult to compare due to multiple variables. The purpose of this study was to evaluate a matched cohort of patients undergoing arthroplasty for femoral neck fractures and assess outcomes of revisions, periprosthetic fractures and mortality.

Introduction

Reverse total shoulder arthroplasty (RTSA) is rapidly being adopted as the standard procedure for a growing number of shoulder arthropathies. Though short-term outcomes are promising, mid- and long-term follow-ups present a number of complications – among them, humeral stem and glenosphere component loosening. Though not the primary complication, previously reported aseptic loosening required revision in 100% of cases. As the number of patients undergoing RTSA increases, especially in the younger population, it is important for surgeons to identify and utilize prostheses with stable long-term fixation. It has previously been shown in the hip and knee literature that implant migration in the first two years following surgery is predictive of later failure due to loosening in the 5=10-year postoperative window. The purpose of this study is to, for the first time, evaluate the pattern and total magnitude of implant migration in reverse shoulder arthroplasty using the gold standard imaging technique radiostereometric analysis (RSA).

Introduction

Reverse total shoulder arthroplasty (RTSA) is a semi-constrained joint replacement with an articulating cobalt-chromium glenosphere and ultra-high molecular weight polyethylene (PE). Because of its limited load bearing, surgeons and implant manufacturers have not elicited the use of highly cross-linked PE in the shoulder, and to date have not considered excessive PE wear in the reverse shoulder a primary concern. As the number of shoulder procedures is expected to grow exponentially in the next decade, however, it is important to evaluate how new designs and bearing materials interact and to have an understanding of what is normal in well-functioning joint replacements. Currently, no in vivo investigation into RTSA PE wear has been conducted, with limited retrieval and simulation studies. In vitro and in silico studies demonstrate a large range in expected wear rates, from 14.3 mm³/million cycles (MC) to 126 mm³/MC, with no obvious relationship between wear rate and polyethylene diameter. The purpose of this study is to evaluate, for the first time, both volumetric and linear wear rates in reverse shoulder patients, with a minimum six-year follow-up using stereo radiographic techniques.

Purpose of the study and background

A 2011 Cochrane review concluded that spinal manipulative therapy (SMT) is no better than other interventions for reducing pain and improving function in chronic low back pain (CLBP). Using individual participant data (IPD) from trials has advantages, among others: a more precise estimate of the effect and the potential to identify moderators. Our objective was to assess the effect of SMT in adults with CLBP and to identify relevant moderators.

Introduction

Total shoulder arthroplasty is the fastest growing joint replacement in recent years, with projected compound annual growth rates of 10% for 2016 through 2021 – higher than those of both the hip and knee combined. Reverse total shoulder arthroplasty (RTSA) has gained particular interest as a solution for patients with irreparable massive rotator cuff tears and failed conventional shoulder replacement, for whom no satisfactory intervention previously existed. As the number of indications for RTSA continues to grow, so do implant designs, configurations, and fixation techniques. It has previously been shown that continuous implant migration within the first two years postoperatively is predictive of later loosening and failure in the hip and knee, with aseptic loosening of implant components a guaranteed cause for revision in the reverse shoulder. By identifying implants with a tendency to migrate, they can be eliminated from clinical practice prior to widespread use. The purpose of this study is to, for the first time, evaluate the pattern and magnitude of implant component migration in RTSA using the gold standard imaging technique radiostereometric analysis (RSA).

Aim

There is a theoretical advantage for immediate postoperative start of rifampicin after debridement, antibiotics and implant retention (DAIR). Anti-biofilm treatment may be mostly needed during the first postoperative days in order to prevent new biofilm formation. However, there are concerns with regard to development of rifampicin resistance if rifampicin is started too early. Rifampicin monotherapy will rapidly result in rifampicin resistance, but this may not occur when prescribed as part of combination antimicrobial therapy and after thorough surgical debridement. We hypothesized that in this setting the probability of development of rifampicin resistance is very low. We evaluated the frequency of development of rifampicin resistance in patients with acute staphylococcal PJI who were treated with DAIR followed by immediate postoperative start of rifampicin in combination with a betalactam or glycopeptide.

Aim

Early discharge of patients after joint arthroplasty leaves patients responsible for monitoring their postoperative wound by themselves. This might result in a delayed presentation of postoperative complications. The use of a mobile woundcare app by patients after arthroplasty might result in (1) earlier report of complications, (2) an increase in patient satisfaction and (3) insight in the incidence and duration of postoperative wound leakage. Therefore, the ease of use and perceived usefulness of using a postoperative mobile woundcare app in patients after joint arthroplasty was investigated.

Osteoarthritis (OA) is a leading cause of joint deformity and functional limitation. An imbalance of anabolic and catabolic activity results in destruction of the extracellular matrix of articular cartilage. There is evidence to support the role of DNA methylation in the pathogenesis of OA, but the effect of other epigenetic modifiers is yet to be described. This study looks at the effect of novel epigenetic modulators, PFI-1, a bromodomain inhibitor, and SGC707, a histone methytransferase inhibitor, and their effects on gene expression in the pathogenesis of OA. Chondrocytes were extracted from OA femoral heads (n=6), cultured and incubated. Samples were treated with media alone (control), interleukin 1-beta (IL-1β) plus oncostatin M (OSM) alone, or in combination with increasing concentrations of PFI-1 or SGC707. Levels of expression of iNOS, COX2, IL8, IL1B, matrix metalloproteinase-13 (MMP13), RUNX2 and COL9A1 were measured using qRT-PCR, and expressed relative to GAPDH. PFI-1 (0.5 and 5µM) suppressed expression of catabolic genes in OA chondrocytes, at basal levels and when co-stimulated with IL-1β+OSM. Catabolic gene expression decreased (iNOS, COX2, IL-8, IL-1β and MMP), and RUNX2 expression was also supressed. There was no effect on expression of the anabolic gene COL9A1. SGC707 (0.1 and 1µM) did not induce a reduction in expression of all the catabolic genes. This study has demonstrated that PFI-1 has a potent protective effect against cartilage degradation, by modulating the expression of catabolic genes in OA chondrocytes. This further validates the role of epigenetics in OA, with implications for therapeutic interventions in the future.

INTRODUCTION

The goal of the study was to perform quality control with a commercially available navigation system when introducing PST technique at our academic department. The learning curve was assessed by the Cumulative Sum (CUSUM) test. We hypothesized that the PST process for TKA was immediately under control after its introduction when analyzed with the CUSUM technique.

INTRODUCTION

The patient-specific templates (PST) for total knee arthroplasty (TKA) have been developed to improve accuracy of implantation, decrease operating time and decrease costs. There remains controversy about the accuracy of PST in comparison with either navigated or conventional instruments. Furthermore, the learning curve after introducing PST has not been well defined. The goal of the present study was to perform quality control with a commercially available navigation system and the CUCUM test when introducing PST technique at our academic department.

Introduction

An appropriate positioning of a total knee replacement (TKR) is a prerequisite for a good functional outcome and a prolonged survival. Navigation systems may facilitate this proper positioning. Patient specific templates have been developed to achieve at least the same accuracy than conventional instruments at a lower cost. We hypothesised that there was no learning curve at our academic department when using patient specific templates for TKR instead of the routinely used navigation system.

High-dose antibiotic-loaded acrylic cement (ALAC) is used for managing periprosthetic joint infections (PJIs). The marked increase in resistant high-virulence bacteria is drawing the attention of physicians towards alternative antimicrobial formulations to the routinely used antibiotics. To date, few studies simultaneously investigated the elution properties of a broad range of antibiotics. The aim of thepresent in-vitrostudy was to determine the elution kinetics of 14 different high-dose ALACs.

All the ALAC samples showed a burst release of antibiotics in the first hour, progressively decreasing overtime, and elution curves strictly adhered to a non-linear regression analysis formula. Among aminoglycosides, commonly addressed as the most appropriate antibiotics to be loaded into the bone cement, the highest elution rate was that of tobramycin. Among the glycopeptides, commonly used to treat PJIs because of the prevalence of aminoglycoside resistance, vancomycin showed better elution in comparison with teicoplanin. Clindamycin, that can be associated with aminoglycosides to prepare ALACsshowed the highest absolute and relative elutions among all the tested formulations. A noticeable elution was also detected for colistin, an antibiotic of last resort for treating multi-drug resistant bacteria.

The current study demonstrates theoretical advantages in the preparation of ALAC for some antibiotics notroutinely used in the clinical setting for PJIs. The use of these antibiotics based on the infecting bacteria sensitivity may represent an useful option for physicians to eradicate PJIs. In vivo testing should be considered in the future to confirm the results of this study.

Background:

With the increase in the average age of the population, the incidence of symptomatic rotator cuff tears will also increase. Combined with more access to information via the internet etc., the patient population is more informed of the treatment modalities available and is expecting good reproducible results of their surgeries.

Background

Combined physical and psychological (CPP) programmes are widely recommended for Chronic Low Back Pain (CLBP) patients, but not often implemented. Patients with longstanding CLBP participating in a two-week CPP programme improve in functional status and quality of life and this is maintained at two-year follow up. One-year follow-up data is available of 955 participants.

Purpose:

The objective of this study was to determine the tensile strength of the different components of the rotator cuff tendons and their relationship to rotator cuff tears.

Purpose:

To determine the insertion of the different layers of the rotator cuff and apply it to rotator cuff tears. Anatomical insertion of the rotator cuff holds the key to a proper anatomical repair.

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age.

The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery.

Background

Giant cell tumours of bone (GCT) are benign bone tumours with a locally aggressive character. Local recurrence is considered the main complication of surgical treatment and is described in up to 50% of patients. Intralesional curettage with the use of adjuvants like phenol or polymethylmetacrylate (PMMA) is recommended as initial treatment, significantly decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for local therapy remains controversial.

INTRODUCTION

Many studies have looked at the effects of titanium tibial baseplates compared to cobalt chrome baseplates on backside wear. However, the surface finish of the materials is usually different (polished/unpolished) [1,2]. Backside wear may be a function not only of tray material but also of the locking mechanism. The purpose of this study was to evaluate the wear performance of conventional polyethylene inserts when mated with titanium tibial trays or cobalt chrome tibial trays that both have non-polished topside surfaces.

Introduction

Local recurrence of Giant cell tumours of bone (GCT) is considered the main complication of surgical treatment (50%). Intra-lesional curettage with adjuvants like phenol or polymethylmethacrylate (PMMA) is recommended as initial treatment, decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for treatment remains controversial.

Aim of this study is identification of risk factors for recurrence in GCT, specifically after intra-lesional curettage with or without adjuvants.

Purpose

The treatment of C2 fractures with collar, halo or surgery can all be justified depending on the patient. In our unit, primary treatment is with a halo: in a previous study presented at BASS we found an 85% fusion rate. In a follow on study, we wished to assess the outcome in those patients who underwent surgical treatment.

BACKGROUND

Although osteoarthritis (OA) is not an inflammatory arthritis, a characteristic feature of OA is increased production of pro-inflammatory cytokines, such as interleukin 1beta (IL-1b), by articular chondrocytes. In fact, the degree of articular inflammation is often associated with disease progression; indicating that this process probably contributes to articular damage. Suppressor of cytokine signalling (SOCS) proteins are, as the name suggests, inhibitors of cytokine signalling that function via the JAK/STAT pathway (Janus kinase/signal transducers and activators of transcription). Eight SOCS proteins, SOCS1-SOCS7 and CIS-1 (cytokine-inducible SH2-domain-1 with similar structure to the other SOCS proteins) have been identified, of which, SOCS1-3 and CIS-1 are the best characterised. Reduced expression of SOCS proteins would be predicted to result in increased cytokine responsiveness and thereby could contribute to OA pathology.

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus in adult patients after trans-articular tumour resection.

To review the accuracy of our systematic process in preventing wrong level lumbar microdiscectomy.

X-ray is used to identify the correct level for the skin incision to be made, x-ray is again used if the surgeon is in doubt prior performing the flavotomy. Following a lumbar microdiscectomy a Watson Chane is inserted into the empty disc space and an intra-operative x-ray is taken to confirm the level the discectomy has occurred. Observers A and B independently reviewed intra-operative x-ray in patients undergoing lumbar microdiscectomies and correlated the accuracy of the x-ray in determining correct level surgery against the pre-operative MRI scan and the preposed level of surgery.

123 patients, 66 males and 57 females underwent 127 lumbar microdiscectomy procedures between 2007 and 2009. The levels where surgery occurred are;- L2/3 -1 patient, L3/4–8 patients, L4/5–53 patients and L5/S1-65 patients.

Kappa coefficient was used to determine inter-observer and Pearson Correlation coefficient was used to determine the X-ray and MRI relationship

Percentage of patients who required a pre-flavotomy x-ray level check are:- L2/3–100%, L3/4-63%, L4/5–45%, and L5/S1–40%. Pearson's correlation in confirming the level lumbar microdiscectomy was performed using final x-ray and the pre-operative MRI scan was 1. Kappa coefficient between observer A and B was 1.

This process of using intra-operative x-ray in determining the exact level where lumbar microdiscectomy was performed is 100% accurate. This is our standard process in preventing wrong level surgery for lumbar microdiscectomy.

The Royal Liverpool and Broadgreen University Hospital, Liverpool, UK

Plasmacytoma is the localised form of multiple myeloma, which can affect any part of the body including the axial skeleton (Kelly et al, 2006; Ampil et al, 1995). These myelomas/plasmacytomas arise from one malignant clone of cells, which secrete the same type of immunoglobulin. Where the clone of cells remains localised, it is known as plasmacytoma, but when there is spread of the malignancy to multiple bones and marrow, it is known as multiple myeloma (Boccadoro and Pileri, 1995).

We present a case of solitary sacral bone plasmacytoma (SBP), in a seventy year old man which presented as low back pain, following a fall. He was neurologically intact, and had no sphincteric incontinence, but MRI revealed a large expansile lesion in S1, which caused severe spinal stenosis, involving the left L5 exiting foramen, with an irregular area of low signal posteriorly. Bone scan showed increased tracer uptake in L5 and a mixed hot/photopaenic appearance in the mid-sacral region indicating tumor involvement. Myeloma screen confirmed that the serum IgA was high, with positive kappa monoclonal band, positive Bence Jones Protein (BJP), normal IgM and IgG, and normal calcium profile. CT-guided biopsy revealed sheets of mature plasma cells, consistent with the diagnosis. Fine needle aspiration biopsy of an enlarged groin lymph node revealed neoplastic infiltration, consistent with myeloma. Skeletal survey and CT chest/abdomen/pelvis (CAP) were not contributory. The patient had six courses of radiotherapy and improved remarkably, and is being considered for chemotherapy as well as follow up in the out-patients' department.

Alumina–alumina bearings are among the most resistant to wear in total hip replacement. Examination of their surfaces is one way of comparing damage caused by wear of hip joints simulated in vitro to that seen in explanted bearings. The aim of this study was to determine whether second-generation ceramic bearings exhibited a better pattern of wear than those reported in the literature for first-generation bearings. We considered both macro- and microscopic findings.

We found that long-term alumina wear in association with a loose acetabular component could be categorised into three groups. Of 20 specimens, four had ‘low wear’, eight ‘crescent wear’ and eight ‘severe wear’, which was characterised by a change in the physical shape of the bearing and a loss of volume. This suggests that the wear in alumina–alumina bearings in association with a loose acetabular component may be variable in pattern, and may explain, in part, why the wear of a ceramic head in vivo may be greater than that seen after in vitro testing.

Purpose of the study: Dementia in the elderly subject aged over 75 years is currently an important public health problem. An important part of the activity in orthopaedic surgery involves this age group. In 2007, 16,812 elderly persons aged over 75 years were hospitalised in our University Hospital (769 in orthopaedic surgery): 1380 patients were considered demented (40 in orthopaedic surgery). The purpose of this work was to evaluate the cognitive function of this population in a teaching hospital unit of orthopaedic and traumatology surgery where the prevalence of dementia appears to be underestimated.

Material and methods: Data were collected over a period of four years. This study concerned 113 patient, including 83 women, mean age 81.8 years (range 75–92). The reason for hospitalisation was predominantly fracture of the proximal femur (73%); thirty patients had hip, knee or shoulder arthroplasty and 24 other situations. The Mini Mental State Examination (MMSE) was performed.

Results: The MMSE could be interpreted for 100 patients: < 24 for 33, 24 to 26 for 29 and > 27 for 38. Among the 24 patients with no cognitive disorder known before hospitalization (nine patients known to be demented were removed from the analysis) and for whom the MMSE was completed entirely, the most frequent alterations were noted for attention, calculation, and recall-memory items.

Discussion: Finally, one-third of the subjects aged over 75 years and hospitalized in our unit presented signs of altered cognitive function according to the MMSE(< 24). This score is one of the criteria for frailness of the elderly subject. This population has an unstable precarious medicosocial status with defective adaptation to stress and change in environment. These persons are exposed to a high risk of morbidity, mortality, dependence, longer hospital stay and institutionalization. The purpose of this screening is to improve management for these patients by proposing more specifically adapted care.

Conclusion: It is thus indispensable to screen for cognitive disorders systematically in patients aged over 75 years hospitalized in a surgery unit. The MMSE score can be used for this purpose. This work is in favour of a physician or better a geriatrician within the unit who could be financed directly by his-her own sector of activity.

Purpose of the study: Conventional techniques for implantation of a TKA allow a neutral mechanical axis (HKA 180±3) in 70 to 86% of patients. The purpose of this work was to evaluate the contribution of intraoperative radiologic assistance for this objective.

Material and methods: We conducted a prospective randomised study in a single-operator consecutive series of cemented TKA, model TC-SB, excluding revisions and frontal deviations > 25. The series included 65 women and 39 men, mean age 73 years. All operations were performed on a radiolucent table. An extramedullary guide was used for the tibial cut and an intramedullary guide for the femoral cup. Patient randomisation was done after the cuts. According to the randomisation, the orientation of the cuts in the frontal plane was measured radiographically using a fluoroscope and an aiming plate situated on the hip, then the ankle. Secondary cuts were made if the angular deviation was greater than 1°. The position of the TKA assisted by the fluoroscope (group R+, n=52) and that of the non-assisted TKA (group R-, n=52) was assessed on the digitalised goniometry.

Results: Mean operative time was 70 minutes in group R+ and 59 minutes in group R-. In group R+, the mean mechanical alignment was 3.9 varus preoperatively and 0.13 valgus postoperatively (5 valgus to 3 varus) with 91% in the ±3 range. In group R-, the mean mechanical alignment was 6.7 varus preoperatively and 0.06 varus postoperatively (6 varus to 5 valgus) with 80% of the cases in the ±3 range. The standard deviation was 2 in group R+ and 2.7 in group R-, with no significant difference.

Discussion: The accuracy of the implantation obtained with the conventional instrumentation for the TC-SB prosthesis is among the best reported in the literature. Intraoperative radiological assistance enabled a tighter spread of the results around the mechanical alignment. The technique was simple to use and precise. The mean duration of exposure to the fluoroscope was 3 s (PDS 3 – 35 gray cm²).

Conclusion: We reserve this assistance in priority for patients with major bone deformities or medullary obstacles.

Purpose of the study: Restrained implants with intrinsic stability guaranteed by a large central stem have been developed for revision knee arthroplasty, irrespective of the underlying cause. Successful restraint implies excellent fixation of the prosthetic implants which can be obtained using press-fit centromedullary stems. The purpose of this work was to assess the long-term results of this mode of fixation in this indication and to search for clinical correlations with potential radiological images around the stems.

Material and methods: We report 46 cases of Sigma^®PFC TC3 revision total knee prostheses reviewed retrospectively at two years with a mean follow-up of eight years. Mean age at surgery was 68 years. Revision was indicated for aseptic loosening (n=24) and septic loosening (n=22). The knee society criteria were used for the clinical evaluation. Radiographic measurements were made semiautomatically with the Imagika^® software.

Results: The mean clinical score improved from 42 points preoperatively to 84.7 at two years and 83.7 at last follow-up. Outcome was excellent (n=30), good (n=7), fair (n=1) and poor (n=1). The mean function score improved from 34.3 preoperatively to 69.1 at two years and 64.2 at last follow-up. Radiographic alignment was correct in all cases. The press-fit effect was observed for 63% of the femoral implants and 76% for the tibial implants. Around the stems, 57% of the implants exhibited condensation lines and 23% lucent lines measuring less than 2 mm. There was no relation between radiological findings and the clinical or functional scores. There were two failures, one for frontal instability at six years and the other for aseptic loosening at eight years. Excepting these two cases, there was one case of femoral implant migration with no clinical expression. For all other patients, the radiographic image remained unchanged between the two year check-up and the final follow-up.

Discussion: Thee presence of lucent lines or condensation lines is well known for this type of implant with long centromedullary stems. Nevertheless, this is the first clinical series evaluating the clinical impact of these radiographic images. In our opinion, these images are related to the relative mobility of these implants which should be checked regularly, although no long-term clinical expression occurs. For us, this type of implant enables good function and long-term stability.

Purpose: Recognition of the glenoid version is important for evaluation of different pathologies. There is no consensus on method to use to evaluate version. The purpose of this study was to compare different measurement strategies in one hundred-sixteen (116) patients with shoulder CT-scans.

Method: Scapula CT-scan axial images were revised and the cut below the base of the coracoid was selected. The glenoid version was measured according to the Friedman method (FM) and the “scapula body” methods (BM). In case of B2 glenoid three different reference lines have been measure: the neo-glenoid NG (posterior erosion surface), paleo-glenoid PG (original glenoid surface) and the intermediate-glenoid IG (line from anterior and posterior edge). Three orthopaedic surgeons independently examined the images two times and intra/inter-observer reliability was calculated using Intra-Class Correlation (ICC). The objective of this paper is to define which method shows best reliability.

Results: Group 1 (B2 excluded n=53): The average glenoid version was significantly different between two measurement techniques for all three observers, with an average of – 7.29° for BM technique and – 10.43° for FM. Intra-observer reliability was excellent for both methods (ICC: 0.958–0.979 for FM; 0.940–0.970 for BM). Inter-observer reliability was excellent for both methods (FM: ICC= 0.977; BM: ICC= 0.962). The light superiority of the first method was not significant. For group 2 – B2 glenoid (n=63): six different measures of version were taken resulting by two scapula reference line (FM and BM) and three glenoid reference line (PG, IG, NG). The average glenoid versions were significantly different (p0.82). The inter-observer reliability were also very-good or excellent for all methods (ICC > 0.79). The most reliable method for measurement of B2 glenoid version was the association of the Friedman line for the scapula axis and the intermediate glenoid line with excellent intra observer reliability (ICC > 0.957) and inter-observer reliability (ICC=0.954).

Conclusion: Measurement of glenoid version on axial cut of a Ct-scan is highly reliable. Significant differences exist between measures depending which method is used, underlying the importance of a consensus for research and clinical purpose. Despite very good performance of all methods, authors recommend the use of the Friedman method for the scapula axis reference and an intermediate glenoid line in case of B2 glenoid.

Purpose: The long term effects of treatment in a cohort of patients with chronic low back pain (CLBP) participating in an intensive pain management program.

Background: Cognitive behavioral treatments produce clinically relevant benefits for patients with CLBP.

Methods: The program provided by RealHealth-Netherlands is based on cognitive behavioral principles and executed in collaboration with orthopedic surgeons. Primary outcomes were daily functioning and self-efficacy. Measurements were at baseline, last day of residential program and at 1 and 12 months follow-up. A GLM procedure with repeated measures was applied to examine changes over time and to explore possible unwanted side effects. Effect sizes are analyzed using cohen’s d. Clinical relevance was examined using minimal clinical important differences (MCID) estimates for primary outcomes and quality of life. To compare results with literature Standardized Morbidity Ratios (SMR) were determined.

Results: 107 patients with CLBP participated. Mean scores on primary and secondary outcomes showed a similar pattern: improvement immediately after following the program and maintenance of results over time. Effect sizes were 0.9 for functioning and 0.8 for self-efficacy. Clinical relevancy: 79% reached MCID on functioning, 53% on self-efficacy and 80% on quality of life. Found study results were 36% better and 2% worse when related to previous research on respectively rehabilitation programs and spinal surgery for similar conditions (SMR 136% and 98%respectively).

Conclusion: The participants of this evidence based program learned to manage CLBP, improved in daily functioning and quality of life. The study results are comparable with results of spinal surgery and even better than results from less intensive rehabilitation programs.

Conflict of Interest: None

Sources of Funding: None

Purpose: The glenoid status is a crucial aspect of planning for shoulder replacements. This study revisits the classification proposed by Walch et al and discusses its value to orthopedic surgeons in terms of reproducibility and reliability.

Method: Three evaluators viewed one hundred-sixteen (116) shoulder CT-scans with primary glenohumeral arthritis and classified glenoid wear according to Walch classification two times. The validation study was done for three sets of data: Set I: the complete classification: A1, A2, B1, B2, C. Set II: regrouping with main categories: A,B,C. Set III: regrouping categories according to glenoid facet morphology; Normal concavity: A1, A2, B1; Biconcave glenoid: B2; Retroverted glenoid: C.

Results: Intra-observer Kappa values for Observer 1, 2, and 3 averaged 0.866 (0.899, 0.927, 0.773) for Set I; for Set II, the values averaged 0.915 (0.955, 0.975, 0.814); and for Set III, the values averaged 0.874 (0.897, 0.948, 0.777), all excellent values. Inter-observer reliability values for Set I averaged 0.621 (0.776, 0.512, 0.574), indicating good agreement; for Set II, the values averaged 0.759 (0.880, 0.713, 0.685), indicating excellent inter-observer agreement; and for Set III, the average was 0.642 (0.825, 0.519, 0.581), indicating good inter-observer agreement.

Conclusion: A clarification of the Walch et al classification of the osteoarthritic glenoid was necessary, especially with regards to the wordings of categories B2 and C. When used properly, it is a reliable and valuable tool for orthopedic surgeons of all levels of experience in the evaluation of the osteoarthritic glenohumeral joint.

Purpose of the study: The risk of homologous blood transfusion for primary total knee arthroplasty (TKA) varies between centres from 4 to 72%. Measurement of mean blood loss for patients undergoing primary total hip or knee arthroplasty led us to adopt a global blood-sparing protocol.

Material and methods: This was a prospective observational study involving 90 TKA (TC-SB) implanted by one surgeon in 56 women and 33 men, mean age 74 years, ASA 3 for 29%, mean BMI=31. Programmed autologous transfusion and blood recovery were not applied. Alpha epoeitine (EPO was administered in the preoperative period in accordance with the predicted serum haemoglobin at discharge. Tranexamic acid (TA) was injected intravenously during the operation.

Results: The mean operative time was 63 minutes, mean tourniquet time 51 minutes. During the perioperatively period, the mean 7-day blood loss was 566±254 ml red cells and 1560±643 total blood. Mean serum haemoglobin at discharge was 1.0 g/dl. Fourteen percent of patients had a postoperative serum haemoglobin less than 10 g/dl (lowest level 8.4 g/dl). One patient had a transfusion; this was a man in his nineties who was operated on without a tourniquet and without TA because of a poor arterial system. Nearly 86% of patients received TA with a significant (p< 0.05) decrease in bleeding compared with those who did not receive TA (365 ml total blood). EPO was delivered for 22% of patients (2.8 injections on average) to reached 14.2 g/dl the day before the operation.

Discussion: This overall strategy for blood sparing enabled us to reduce the risk of transfusion and limit costs. In this series, the prescription of EPO was not targeted to reach a set level preoperatively but was based on the predicted serum haemoglobin level at discharge. Thus seven patients with a preoperative haematocrit below 39 did not receive EPO. None of these patients were transfused. Their discharge haemoglobin was between 10.7 and 12.4g/dl. Use of TA should be included in the calculation of the predicted discharge haemoglobin level in order to better determine candidates for EPO injections.

Introduction: Primary bones sarcomas account for 5% of childhood cancers; however the introduction of neo-adjuvant chemotherapy and the development of surgical techniques have resulted in reduced mortality and a longer length of survival. Consequently improving post operative functional outcomes has become an important focus of research. The aim of this study was to investigate and compare differences in the complications and functional outcomes of EPR and rotationplasty in skeletally immature patients.

Methods: This is a retrospective case control study of twenty-four patients, of whom twelve received rotation-plasty and twelve received EPR. Patients were selected at random and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively.

Results: Five patients (42%) treated with endoprosthe-ses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty. However this difference was not found to be statistically significant. The average MSTS score in the EPR cohort was 22.7 and 18.9 in rotation-plasty patients. Mann Whitney U testing confirmed this difference to be statistically significant (p=0.05).

Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR.

The theoretical benefit historically attributed to rota-tionplasty lies in the provision of a functional and durable hinge joint, however these results suggest that this advantage has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology.

Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty.

Introduction: Since January 2008 a large set of parameters of each hip fracture patient admitted to the RdGG hospital, were documented prospectively. This documentation was repeated by a written survey 3 months and 1 year after the fracture.

Our research goal was to determine the percentage of patients returning to their living situation prior to their fracture.

Methods: From 1-1-2008 to 1-3-2009, 339 hip fracture patients were treated, 244 female, 95 male. Average age was 78.1 (21–101). ASA distribution showed 240 ASA I/ II patients and 99 ASA III/IV patients. Conservative treatment was chosen in 7 patients, 213 were treated with an osteosynthesis and 117 with a (hemi)-arthroplasty. All patients received a survey regarding their living situation 3 and 12 months after their hip fracture.

Results: 327 patients could be analyzed as the pre fracture living situation of 12 patients was unknown; 71% lived independently, 21% in a care home and 9% in a nursing home. The follow-up (FU) of the living situation of the first two groups was analyzed.

Patients living independently: 45% was discharged directly to their own home, 24% to a nursing home and 3% to a care home. A special rehabilitation unit within our hospital, the “Herstel Unit”, received 28% of patients for further recovery. Patients could rehabilitate here for a maximum of 4 weeks before going home. After 3 months 84% of the patients had returned to their independent living situation, 11% lived in a nursing home and 5% in a care home. This analysis is done in 184 patients as 12 had died and 35 were lost to FU. After 12 months 38 (84%) of 45 still lived independently, 4 went to a nursing home, 3 to a care home, 21 died and 4 were lost to FU.

Care home patients: 47% was discharged directly to their care home, 15% to the “Herstel Unit” and 37% to a nursing home. At 3 months 69% of the patients had returned to their care home, 31% lived in a nursing home. Analysis is done in 45 patients as 15 had died and 8 were lost to FU. 12 months FU is accomplished in 27 patients of whom 19 died, none lost to FU; 88% lived in a care home, 12% in a nursing home.

Conclusions: More than 80% of the pre operative independently living patients have returned to their own independent living situation within 3 months. At 1 year FU this percentage is steady. 52% of this population stayed briefly on an alternative location for further recovery. The patients living in a care home have stayed longer on an alternative location, but more than 90% of them have returned to their pre fracture living situation at 12 months FU.

Our results challenge the prejudice that hip fracture patients live or end up living in a nursing home. These data can be used to calculate the amount of specific discharge locations needed in the near future.

Press-fit cups have given excellent clinico-radiographical results. This is a retrospective clinico-radiographical study about the long term performance of pure Titanium cementless modular press-fit cups (FitekTM) having, on the outer surface, an oriented multilayer titanium mesh (SulmeshTM) with 65% porosity (average pore size=400–640 micron). The cup was implanted after underreaming the acetabulum by 2 mm. In the cup’s equatorial area there are two “fins” originary designed to improve rotational stability but actually representing two excellent primary mechanical stabilizers.

We have evaluated the first 100 consecutive cups implanted in 92 patients with an average FU of 9,7 years (range 9–11 years). All operations have ben performed by the two Senior Authors (PGM and RB). Regarding etiology, we had 43 Primary Arthritis, 37 Dysplastic Arthritis, 12 Osteonecrosis and 8 Post-traumatic Arthritis. results were evaluated with the Harris score. Radiographic evaluation was performed using AP and lateral x-rays pre-op. post-op and at the last follow-up.

We had 86 Excellent, 10 Good, 2 Fair and 2 Poor. The 2 Poor results were 2 aseptic loosenings of the stem

The Mann-Whitney nonparametric U test and the Kruskal-Wallis test showed that the survival rate of the 100 analyzed cups, after a mean follow-up of 9.7 years, was 100% (end point: revision for any cause)

Etiology was not statistically correlated with post-op score.

Nevertheless, dysplastic patients showed inferior results compared to arthritic patients in different parameters, as pain, limp, Range Of Motion (p < 0.05), putting socks and shoes (p < 0.05).

Our cups were intentionally implanted and radiographically appear in a fairly horizontal position (36.5° on average).

In 6 cases we could calculate an eccentricity of the metal heads proving bidimensional linear wear of the liner (average 0.265 mm / year). At the last follow-up we had 3 femoral osteolysis, while in the acetabular side radiolucent lines were present in 14 % of the cases, never progressive.

In no case we found a change of position of the cup.

FitekTM cementless cups gave excellent results at 10 years with complete stability and osteo-integration. Excellent primary mechanical stability was given by the rough surface (SulmeshTM) and by the two “fins” in the equatorial area.

Reconstruction following internal hemipelvectomy for bone tumors remains a major surgical challenge. Most of the cases are considered not suitable for reconstruction because of high complication occurrence. Allografts coupled with standard prosthesis is a reliable method of reconstruction.

26 patients received a McMinn stemmed cup (Link, Germany) after periacetabular tumor resection from February 1999 to 2006. In 18 patients the reconstruction followed resection of the acetabular area while in other 8 an extrarticular resection of the proximal femur was performed. In 21 cases a stemmed acetabular cup were associated with massive bone allograft. There were 13 female and 13 male with a mean age of 41 years (13 to 70). Average follow-up was 45 months (7 to 105).

Six patients were affected by local recurrence of the tumour and five underwent hindquarter amputation. In 4 of them the index surgery followed a previous recurrence of the tumour. Finally 6 patients died for related causes within 2 years. All the other 20 have been followed clinically and radiographically for a minimum of 24 months.

Deep infection occurred in one case, there were no cases of dislocation. Radiolucency at the prosthesis-bone interface was observed in 3 cases, 2 patients had proximal migration < of 20 mm. Only one patient was treated for aseptic loosening because of incorrect initial position of the implant. The iliac osteotomy was consolidated in all cases, while a delayed union was frequently observed in the pubic osteotomy, however without compromise the stability of implant. Functional result were evaluated according to the MSTS system and this showed 65% of excellent or good clinical results.

The procedure requires appropriate patient selection, accurate preoperative planning, meticulous selection and preparation of allograft. Usually artificial ligaments are applied to reduce hip instability, however, this type of reconstruction do not require complex fixation, thus reducing surgical time and early complications.

Synovial sarcoma (SS) is rare but increasingly diagnosed and associated with poor prognosis. Primary surgical resection with wide margins and adjuvant radiation-therapy is considered gold standard in treatment of primary SS. Although (Neo)adjuvant chemo- and radiationtherapy are used in the primary treatment of SS, they are not advocated outside a clinical trial setting. In patients with primary SS and pulmonary metastases, (neo)adjuvant chemotherapy is often added to the treatment protocol but it’s effect on overall survival seems limited.

Between 1985 and 2004 33 patients with primary SS were treated in our clinic. Seventeen patients were diagnosed with pulmonary metastases at presentation (9) or during postoperative follow-up (8). Wide resection or focally marginal resection followed by radiotherapy was used as primary treatment for all patients. All primary metastasized patients were treated with adjuvant multi-agent chemotherapy including Isofosfamide. Average survival in this group was 32 months (5 year OS 50%), compared to 60 months in the late metastasized patient-group (2 and 5 year OS 50 and 11%). Wide resection was not related to improved overall survival when compared to marginal margins and additional radiation therapy. In the early metastasized group combined chemo-radiaton therapy provided no significant improvement in overall survival over adjuvant chemotherapy or radiation therapy alone. However additional chemotherapy in the late metastasized group was slightly associated with increased overall survival (5 year OS 0% vs 66%).

Treatment of early pulmonary metastasized SS remains highly dependent of the individual preference of patient and physician. In contrast to the reported prolonged disease free/overall survival of Enneking stage IIA and IIB SS patients, aggressive surgical and chemo-radiation therapy has not yet been associated with improvement of disease free/overall survival in stage III disease. Patients presenting with late pulmonary metastasis might benefit from adjuvant multi-agent chemotherapy treatment.

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery.

Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization.

Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively.

Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.

Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery.

Ethics approval: None Audit

Interest Statement: None

Detection of local recurrence after sarcoma resection can be impaired by metal implants locally, or by the patient ‘s general condition. Metal implants cause severe distortion and scattering of either MRI or CT data acquisition. Therefore the detection of local recurrences in proximity of heavy metal implants such as prostheses or osteosynthesis material can be difficult. Patient related conditions, e.g. renal insufficiency, allergy, claustrophobia, may completely prohibit the use of contrast media or even a scan itself.

Ultrasound provides several advantages, and can be used for different indications in sarcoma patients. Patient related conditions prove no obstacle for this technique. Currently our indications are local follow-up after soft-tissue sarcoma resection and evaluation of regional lymph nodes, detection of local recurrence of bone sarcoma in proximity of metal implants, and amputation stump evaluation.

We describe a patient study population of 103 patients. Seventeen had only diagnostic and staging ultrasound, four had an evaluation of their amputation stump, 24 were followed after resection of a soft-tissue sarcoma, and 58 were followed by this method after sarcoma resection and implantation of metallic implants. Evaluation modalities are described according to the indications.

Results: We have detected nine local recurrences, and four patients with suspect lymph nodes had a biopsy of which half showed malignant tumour cells. Infection and inflammation around metallic implants can be evaluated, the technique also allowing placement of drains in infected seromas in irradiated regions. It should be emphasised that reliable results can only be achieved if a baseline ultrasound is performed, followed by subsequent studies at regular intervals.

Little is published about the use of cementless conical stems in primary hip arthroplasty for congenital hip disease. A conical stem was designed in the 80’s by Prof. Wagner. The stem is made of a rough blasted titanium alloy with a cone angle of 5° and 8 sharp longitudinal “ribs” that cut into the inner cortex, designed to achieve rotational stability: The ribs depth of penetration ranges between 0.1 and 0.5 mm and is also very important to achieve osteo-integration. The CCD angle is 135°. The stem is straight and can be implanted in any degree of version thus being very useful for dysplastic arthritis with significant femoral neck anteversion.

Between 1993 and 1998 the senior author (RB) implanted 92 conical stems in 88 consecutive patients with dysplastic arthritis. The acetabular component was cementless and titanium with tridimensional porosity. The articulating surface was a second generation Metal-on-Metal.with a femoral head of 28 mm. According to the Hartofilakidis classification 63 patients had type A, 18 type B and 11 type C.

The average follow-up was 11.2 years (range 10.1–14.8)

Using the Harris Hip Scoring system we had 82 (89%) satisfactory results, with excellent correction of pre-op pain (42/44 Harris) and no case of anterior thigh pain; 88% of patients had no or slight limp at follow-up. No patient required revision of the stem, but one cup required revision for loosening (Type C class). We had one dislocation (1%) that was treated conservatively

Radiographically, all stems were osteo-integrated, 17% showed some resorption in femoral zone 1 and 7. In the same zones we observed 4 cases of real osteolysis without loosening. No radiolucent line was observed in other femoral zones. In the acetabular side we had 13 cases (14%) of radiolucency, but in only 1 case (1%) was it progressive.

A straight conical titanium femoral stem gave very satisfactory clinico-radiographical results in dysplastic arthritis at a mean of 11.2 years of follow-up.

Multi-ligament knee injuries require complex surgery. Hinged external fixators propose to control the tibio-femoral relationship, protect reconstructions and allow early mobilisation. However, a uniaxial hinge may be too simplistic for such a complex joint. We investigated the influence of an external fixation device on ligament strains and joint contact forces.

Six fresh frozen cadaveric lower limbs (41–56 years old) were obtained. Displacement transducers (Microstrain, USA) were attached to mid-substance lateral (LCL) and medial collateral (MCL) ligaments, and the anterior and posterior cruciate (PCL) ligaments through minimal soft tissue incisions. Joint pressures were measured by transducers (Tekscan) introduced in the medial and lateral compartments through small sub-meniscal arthrotomies. Flouroscopic imaging was used to construct the hinged fixator centred over the epicondylar axis. Ligament tensile strains and joint contact forces were determined through a passive arc of 20 to 110 degrees of flexion and extension, with and without the external fixator (ExFix^™, EBI Biomet Australia).

The application of the external fixation device resulted in minimal change in the mean peak percentage strain of the PCL, MCL and ACL ligaments, while the LCL peak percentage strain decreased. Generally the peak percentage strain for each ligament occurred at or near the same flexion angle in both the un-instrumented and instrumented case within each limb, but the peak percentage strain flexion angles varied significantly across limbs. Peak joint contact forces increased significantly (p < 0.05) in the lateral compartment after attachment of the external fixation device. There was no difference seen in the medial compartment joint contact forces.

This study shows that a uniaxial hinged external fixator can be used in a multi-ligament reconstructed knee to maintain joint congruence and allow early postoperative rang of motion without compromising the results of reconstructions or repairs.

Introduction: Both enchondromas and chondrosarcomas are mesenchymal neoplasms which originate from cartilage cells, and they occur mainly in the extremities. Both these tumours are resistant to chemotherapy and radiotherapy, and surgery is the only treatment option. In the last few years limb saving procedures have become the treatment of choice. Intra-operative cryosurgery has been introduced as a local adjuvant therapy for skeletal benign and low-grade malignant tumours. It is applied after curettage of the lesion to destroy any remaining tumour cells, and to enlarge the oncological margin of resection. Since the introduction of cryosurgery as an adjuvans, oncological and functional results of this extremity sparing surgery are significantly enhanced.

Patients and Methods: A retrospective study was conducted to evaluate the oncological and functional results, and the complications of cryosurgical treatment.

Data were prospectively collected from the tumour register and patient records. Functional scores of the affected limbs were assessed according to the Musculo-Skeletal Tumour Society scoring system.

Results: Between 1994 and 2003 123 patients (47 men, 76 women, average age 49 years; range 13–83 yrs) were treated with curettage and cryosurgery for an Enneking stage 3 enchondroma (75 patients) or a low-grade chondrosarcoma (55 patients).

The minimal follow up was two years, and the average follow up 50 months (range 24–119 months).

At follow up three recurrences had occurred in patients treated for enchondroma. One residual tumour was diagnosed in a patient with chondrosarcoma grade Ib. All patients were treated again with curettage and cryosurgery and disease free at the latest follow-up.

Of the 37 complications the most common were a fracture at the surgical site (18), fracture of osteosynthesis (6), 3 wound infection (3), delayed soft tissue healing (3), and transient nerve palsy (3).

Functional MSTS scores increased in time to an average of 28 points (94%) at two year follow up. No significant difference in scores were found regarding to localisation of the lesion, age or gender. A significant discrepancy in functional scores was observed between patients who did suffer from one or more complications and patients who did not.

Conclusion: We believe that the use of cryosurgery is an excellent adjuvant therapy after curettage to achieve local control of aggressive enchondromas and low grade chondrosarcomas. It avoids the need for segmental resection, making reconstruction of the bony defect easier and therefore results in excellent functional outcome. Due to the initial high fracture rate osteosynthesis at the surgical site is used more often, and weight baring mobilisation is postponed until full consolidation is reached.

Long-term clinical study to explore the curative effect and mechanism of the treatment of adult chronic osteomyelitis by implant Osteoset T.

The study object were 65 case adult chronic osteomyelitis patient from November 1977 to April 2003 in a University-based hospital. Age ranged from 18 to 69 years old. 40 cases were treated by general debridement (Method I); 25 cases were treated by general debridement and implant Osteoset T in dead space (Methods II). Stage IA(The UTMB Staging System) osteomyelitis 39 cases; The Organism was Staphylococcus Aureus 28 cases. In all cases (group A), 40 cases were treated with Method I (group AI), 25 cases were treated with Method II (group AII). The majority of the patients, 39 resulted as Stage IA (group B); 22 were treated with Method I (group BI) and 17 cases were treated with Method II (groupBII). Finally, 28 patients were chronic Staph Aureus osteomyelitis (Group C); 13 were treated with Method I (group CI) and 15 cases with Method II (group CII); Followed from 36 to 334 months, mean 75.0 months. Then respectively evaluate and analysis analyze the success rate of different method with standard.

The success rate of group BI was 59.09%, group BII was 94.12%, contrast the success rate there was significant difference (p< 0.05). The success rate of group AI was 60.00%, group AII was 80.00%. The success rate of group CI was 46.15%, group CII was 80.00%.

The use of Osteoset T has demostrated better healing rate than left the empty cavity there after debridement and irrigation. Osteoset T can local delivery antibiotic, filler of the dead space, It can be mixed with different antibiotics, reduces the hospitalization time, reduces the number of operation. Unfortunately, Osteoset dos not help with the bone growth.

Background: Surgical treatment of spinal deformities is complex and is performed by a limited number of spine surgeons. To obtain adequate radiological and clinical correction, a large amount of clinical experience is required when planning corrective surgery because of the enormous amount of patient related variables, and the many surgical techniques (e.g. rod rotation vs translation, pedicle screws vs hooks, anterior vs posterior).

The widely used classification systems (King and Lenke) are useful for documentation of the deformities. Unfortunately explicit guidelines for surgery are not clear. A multi-centre database with pre and postoperative patient data including photographic images and x-rays will be very useful in decision making. It will allow surgeons to find similar cases in the database that will help them in their decision making for surgical planning and execution. Furthermore it will provide extensive data to perform outcome studies, and to develop general treatment guidelines. Surgery for spinal deformities will become more evidence based and less dependent on the individual surgeons judgement.

Methods: A modern web-based database system, Scolisoft was developed for documenting patient data and curve characteristics. The system contains patient data (demographics etc), radiological data (AP, Lat, bending films), classification of curve patterns according to the often-used classification systems and information about the surgical procedure. It includes pre and postoperative radiological data and clinical photographs.

The patient data can also be stored and printed as a PDF-file, so that it can be used as a patient chart and for patient information purposes.

Scolisoft allows the user to select patients based on all the individual characteristics, e.g. curve classification. For pre-operative planning of a specific deformity, a cohort of patients with the same deformity (patient demographics, curve pattern, bending films etc) can be selected and the postoperative results viewed.

With the same selection tool, cohorts of patients can be selected for outcome studies.

Furthermore Scolisoft provides the possibility of discussing difficult cases with other spine surgeons using the system.

Finally, complications are registered according to the existing Scoliosis Research Society complication registry system.

Experiences: Data of more than 200 patients have been entered into the former PC application system. The current web based system has 60 cases that have been entered during its trial phase. Most cases have been adolescent or adult idiopathic scoliosis. Forty two surgeons have used the software and eight surgeons have participated in entering cases. The web-based version has shown to be very user friendly. Submitting the radiological and clinical images is easy (but takes some time). All data input is possible by a simple click of the mouse. Therefore it is relatively easy to learn.

The system already has the possibility for documenting other spine pathology such as sagittal plane deformities, fractures and spondylolisthesis.

Conclusion: Scolisoft is a powerful, user-friendly web-based registry for spinal deformities. It is a very useful tool in planning spinal deformity surgery and research. In this time of evidence-based medicine, it is time to take the planning of scoliosis surgery out of the realm of myth, and this database is a strong step in that direction.

Purpose of the study: Osteosynthesis procedures proposed for fractures of the proximal humerus have evolved greatly since the development of anterograde nailing systems with the objective of providing a conservative surgical solution for sometimes complex fractures. We analyzed retrospectively the results obtained in a consecutive series of 30 patients treated in our unit with a Telegraph® nail.

Material and methods: Between March 2001 and August 2003, 39 patients presenting fractures of the proximal humerus were treated with a Telegraph® nail. Accorrding to the Duparc classification, the fractures were: 17, 11 ST+T, 4 CT II, and 7 CT III. Five patients died before the review presented here. Four CT III fractures presented material disassembly early and required revision with a hemiarthroplasty. For the 30 patients reviewed here, we noted the Constant score and the results of the Matsen test as well as radiographic findings.

Results: Mean follow-up for the 30 patients was 16 months (range 6–33). Mean age at trauma was 58.7 years (range 19–91). The mean Constant score was 57.4 (range 16–84) with 72% after weighting. The Matsen test was positive for 59%. Subjectively, 69% of patients were satisfied or very satisfied. There were several complications: secondary intraoperative shaft fracture treated orthopedically, four nonunions of the surgical neck, four tuberosity migrations, three cases of head necrosis, two subacromial impingements (one with rotator cuff tear). Nonunion was generally observed with static locking and in one case with an oversized nail. We were unable to identify any factor predictive of head necrosis due to the small number of cephalotuberosity fractures. Disassembly was generally observed in patients with an initially displaced fracture with periosteal rupture, osteoporosis and old age.

Discussion and conclusion: Our results are less satisfactory than others published in the literature for series using this material and it is difficult to compare with results for series using other types of material because the study criteria were highly variable. Although all fractures in this series, including the most complex, appear to benefit from this nailing system, we did note that complications were not exceptional even though certain compliations observed were related to our learning curve. Surgeons should be aware that the planned option can be changed intraoperatively. Arthroplasty may be necessary in certain cases if the conditions are not adequate for stable osteosynthesis.

Purpose of the study: Resection of the lateral quarter of the clavicle is an effective treatment for painful acromio-clavicular arthropathy. An open procedure can create a disgraceful or painful scar or be associated with secondary instability and muscle weakness. Arthroscopic resection would avoid these complications.

Material and methods: Between 1992 and 2002, 35 patients were treated arthroscopically for isolated painful acromioclavicular arthropathy after failure of medical treatment. Twenty-seven patients (mean age 44 years) were reviewed clinically (Constant score, subjective outcome, stability) and radiographically (quality of resection, coraco-clavicular space, ossification) at more than two years follow-up. Acromioplasty was performed in all cases to improve exposure in 14 or because of an aggressive acromion (n=7). A scarf orthesis was worn to prevent pain. Self-controlled rehabilitation exercises were proposed.

Results: There were no postoperative complications excepting one case of retractile capsulitis in the context of an occupational accident. Excluding this case, mean sick-leave was five weeks (range 3–20). At mean follow-up of seven years, all scars were pain free and minimally visible. There was no problem with frontal or sagittal instability. The Constant score improved 24 points on average compared with the preoperative score with a significant gain for pain (+9 points). Two patients were disappointed: one retained a sequellar capsulitis and one persistent pain after insufficient resection. On average, the resection measured 10 mm (range 6–20 mm). Three patients had an insufficient posterosuperior resection. The coracoclavicular interval remained unchanged in all cases and four patients presented secondary ossification of the resection zone. Two patients were sensitive to acromioclavicular palpation with a positive cross arm test (one had an insufficient resection and the other ossifications at last follow-up).

Discussion and conclusion: Arthroscopic acromio-clavicular resection reduced operative morbidity. The operation does not destabilize the joint. The total joint surface area can be resected to avoid a residual pos-terosuperior impingement which would be a source of persistent pain. The presence of secondary ossifications in the zone of resection has led us to propose NSAID treatment although the prophylactic effect remains to be demonstrated.

Purpose of the study: The revision modular femoral prosthesis (PFM-R) (Centerpulse) uses a cone-shaped straight femoral stem with winglets for press-fit revision fixation in the femoral shaft. The risk of secondary migration further into the shaft is well known. The purpose of this paper was to assess the degree of PFM-R stem migration and to search for predictive factors in order to better ascertain the limits of this type of revision anchorage in the femoral shaft.

Material and methods: Fifty-three files (48 patients) were reviewed retrospectively at minimum none months follow-up. Mean patient age was 56.6 years. Revision was required for loosening (SOFCOT classification): grade 1 (n=5), grade 2 (n=8), grade 3 (n=17), grade 4 (n=10). For 13 hips, the implant to be replaced was not cemented (monobloc stem, infection), or a first-intention PFM-R.

Results: Mean migration was 4.1 mm (0–17 mm), less than 5 mm in 73.5% of cases. There was no correlation between migration and SOFCOT grade. Conversely, there was a significant difference in migration between the grade 1 and grade 3B and between Paprosky grade 1 and 4 (p=0.05). The degree of migration was correlated with the length of the persistent isthma (p< 0.0001), with the morphology of the isthma [conic/inverted conic (p< 0.01), conic/cylindric (p< 0.051)], with the cortical index (p=0.06), the length of the anchor wings (p=0.051), but not with the length of the femorotomy bridge. The length of the wing anchorage was correlated with the length of the persistent isthma (p=0.002) and with the morphology of the isthma [(conic/inverted conic p=0.02), cylindric/inverted conic (p=0.02)], but did not increase significantly with bridging length. There was a trend towards migration in osteoporotic bone (p=0.07).

Discussion and conclusion: Use of a straight stem for anchorage in the femur is associated with secondary migration which depends on the quality of the bone in the anchorage zone and the extent of the press-fit. The persistence of a cone-shaped or cylindrical isthma measuring greater than 4 cm associated with a cortical index greater than 45% and a long wing anchorage can provide excellent primary stability. It would be useless to use long stems since they do not increase the quality of anchorage. The absence of an isthma and the presence of osteoporosis are limitations for this concept.

Purpose of the study: The aim of this work was to compare the long-term clinical, ultrasonographic and iso-kinetic results obtained with two approaches to repair of the torn Achilles tendon.

Material and methods: The patients were reviewed at mean six years follow-up (range 2–12 years) and served as their own control. The series was composed of two groups of ten patients. The first group underwent open suture (OS) (mean age 48 years, age range 38–64 years) and the second was treated percutaneously with Tenolig® (PCS) (mean age 43 years, age range 25–68 years). The Mann, McComis and Kitaoka scores were noted as was the distance from the heal to the ground in one leg stance (comparison with opposite side). Cybex® was used to measure the isokinetic force and an ultrasound control was performed (tendon structure, dimensions).

Results: The calf of the operated side displayed amyot-rophy compared with the healthy side in all cases of PCS (mean 2 cm, range 0.5–6 cm). The heal-ground distance was often smaller compared with the healthy side in PCS. The Mann scores were equivalent for OS and PCS. The Kitaoka and McComis scores were, on average 86 (80–100) and 94 (60–95) respectively for OS versus 82 (85–100) and 91 (60–95) for PCS. Mean caliber of the operated Achilles tendon increased compared with the healthy side for both suture techniques. Isokinetic force was 3–6% greater with OS for peak force, average force, and total work.

Discussion and conclusion: Both techniques have specific complications: recurrent tears and sural nerve injury for PCS, risk for the skin and adherences for OS. The long-term outcome after PCS of the Achilles tendon is comparable with that of OS in terms of healing quality. Recorded values are however slightly higher with OS. Our results are in line with data in the literature. OS can be reserved for particularly active patients who wish to recover maximum function.

Hydroxylapatite (HA) is widely employed as coating of cementless hip stems. Nevertheless there is a deficiency of long-term follow-up studies, and none, to our knowledge, with a ceramic on ceramic coupling, that it is important to avoid the effect of polyethylene wear on stem survival.

Between June 1990 and December 1991, 151 prostheses with an anatomic fully HA-coated cobalt-chrome stem, alumina bearing surfaces, and a threaded Ti-6Al-4V cup, were implanted in 147 consecutive patients (57 males, 90 females, average age 58 years). All were primary surgeries, there were no specific exclusions. Ten died for unrelated causes to the surgery, one died from postoperative complications; thirty nine of the surviving patients were lost to follow-up. The Merle D’Aubigné and Postel score was recorded before and after surgery at each review. An anteroposterior view and a frog-lateral view of the involved hip were taken at each follow-up review. The results were analysed by the Kaplan-Meier method to estimate the cumulative probability of revision.

In two cases, the prosthesis was completely removed with Gilderstone’s procedure because of septic loosening. Among the others, 10 cups required revision surgery for aseptic loosening, and 6 stems were revised for thigh pain. The mean Merle D’Aubigné rating improved from 10 before operation to 16.4. Bone stability was recorded in all cases but three in which there was a painfree fibrous stability. The Kaplan-Meier analysis at 12 years predicted asurvival rate for the prosthesis of 86% (95% CI 79 to 92), and for the stem of 93.8% (95% CI 89.7 to 98).

At 12 years the HA-coated stem has shown an overall good outcome while the threaded non HA-coated cup employed had a bad survival that had influenced the survival of the prosthesis. In conclusion we are confident to consider HA a viable and effective coating.

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.

Introduction: The Kudo total elbow prosthesis (TEP) is a well established implant, with good mid-term results. In the last decades this implant underwent several modifications. The last modification (type 5) has overcome the problems of stem breakage of the humeral component by modifications of the stem. The ulnar component can be placed with or without cement; the humeral component is always placed without cement.

Aims of this study: To examine the mid-term results of the Kudo type 5 TEP and to compare the results of the uncemented Kudo total elbow prosthesis (TEP), with the hybrid Kudo TEP (uncemented humeral component and cemented ulnar component).

Material and methods: Between 1994 and 2004 89 Kudo type 5 TEPs were placed for joint destruction due to rheumatoid arthritis (RA). The mean age of the patients was 55 years (range 21–84 years). Twenty-two prostheses were placed in males, 66 in females. Forty-nine TEPs (group 1) were fully uncemented and 40 TEPs (group 2) were hybrid (humeral component uncemented, ulnar component cemented). The groups were comparable as related to age, sex and indication for surgery. After implantation of the prosthesis a radiograph was made every two years or sooner when indicated.

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.

Results: In group 1, seven ulnar components had to be revised due to aseptic loosening after a mean follow-up of 4 years (range 1.5–6.3 years). Three of these ulnar components were short-stemmed, four were long stemmed uncemented.

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.

Conclusion: In this group of patients with RA the survival of the Kudo type 5 TEP with cemented ulnar component is better as compared to the uncemented ulnar component.

Background: To assess the accuracy of pedicle instrumentation placement using an image guidance system ( Medi Vision) in a pig cadaveric model.

Methods: A 4mm diameter (10cm long) screw was inserted transversely into the spinous process of a pig cadaver percutaneously using fluoroscopic guidance. The dynamic reference base (DRB) of the image guidance system was then attached to the screw. Using the navigation system both pedicles at each level were identified and 3.2mm guide wires inserted percutaneously. This process was performed for each level from D7 to L4. Actual wire placement was recorded using standard anteroposterior and lateral fluoroscopic images. Virtual trajectories generated by the image guidance system were recorded on the guidance system database. Accuracy of wire placement was then evaluated in an automated way by linear correlation between corresponding images.

Results: 20 pedicles were instrumented at 10 levels from D7 to L4. Mean estimate of accuracy for dorsal levels AP and lateral (mm). Mean = 1.452mm, standard deviation 1.57mm. Mean for lumber levels= 1.047mm, standard deviation 1.187mm

Conclusion: Lumbar pedicle instrumentation showed more accuracy when compared to dorsal pedicle instrumentation. The error of navigation that was accommodated by the image guidance system was 2mm.

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.

Introduction: Allograft-Prosthesis Composite represents a reliable option for proximal femur replacement after resection for bone tumor. It provides advantages over megaprostheses because of better soft tissue repair and superior abduction strength, quality of gait, hip stability, and load transfer by healed bone rather than prosthetic stem, with potential impact on implant survival. Purpose of this paper was to review details of the surgical technique and results.

Methods: A retrospective study of 62 patients who had resection of the proximal femur because of a bone tumor and reconstruction with an Allograft-Prosthesis Composite was undertaken. The basic surgical technique consisted of an uncemented tapered long stem prosthesis (i.e. Wagner or Wagner-type stem) cemented in the allograft and press-fitted in the host bone, achieving bone-bone contact through a transverse osteotomy. Details of the surgical technique included: 1) accurate preoperative planning, canal sizing and implant selection; 2) under-reaming of the proximal 5–10 mm of the host medullary canal, depending upon bone quality and diameter of the selected stem; 3) allograft preparation and prosthesis cementation in the allograft; 4) introduction of the composite implant, pressfitted in host medullary canal, until bone-bone contact is achieved; 5) careful repair of abductors and iliopsoas to corresponding allograft tendon insertions.

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.

Results: There were 2 septic failures. Two patients developed asymptomatic nonunion. There were no dislocations. Most common complication was fracture of the allograft greater trochanter (30%), which required surgery in only 1 case and never substantially affected function. The incidence of trochanteric fracture decreased from 63% in the first 27 patients to 5% in the following 35 patients by switching implant design from a valgus 145° neck angle to 135° neck angle, improving offset and abductors function. Bone grafting of the allograft-host union was required in 10% of the cases.

According to MSTS, results were satisfactory in 90% of the patients, with average score 91% (75%–96%).

Discussion and Conclusion: Allograft-Prosthesis Composite is a successful procedure for reconstruction of the proximal femur. Careful surgical technique is the key to excellent function and low complication rate.

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.

Introduction: Fondaparinux, a selective inhibitor of activated factor X, has been shown to reduce further the risk of venous thromboembolism (VTE) in major orthopaedic surgery compared to the low molecular weight heparin enoxaparin, when both were applied for 7 days after surgery.

Aims: To compare the expected costs and clinical outcomes of fondaparinux with enoxaparin applied for 7 days after surgery, we conducted a cost-consequence analysis in patients undergoing major orthopaedic surgery, i.e. total hip replacement, total knee replacement and hip fracture repair.

Methods: Our decision model included endpoints relevant in routine clinical practice and the natural history of VTE over a long term period of 5 years. Costs for prevention, diagnosis and treatment of VTE and its complications were estimated from the Belgian health care payer perspective. Analyses were conducted for different time horizons and for the three indications, separately, and then combined.

Results: Overall, our results indicated that the initial investment in fondaparinux (cost per day: 10.39 Euros versus 3.74 Euros for enoxaparin) was soon compensated by savings due to avoided VTE events, with cost neutrality being achieved after 90 days and further savings being incurred over longer time periods mainly due to avoided post-thrombotic syndromes. These findings were most pronounced in patients undergoing hip fracture repair. Sensitivity analyses showed these findings to be robust for the three indications separately, and combined.

Conclusions: We conclude that our analysis of health and economic consequences over a long term period, demonstrates the value for money of fondaparinux versus enoxaparin for the prevention of VTE events after total hip replacement, total knee replacement and hip fracture repair.

Introduction: Primary and revision total hip surgery in the face of poor neuromuscular function, cognitive impairment or recurrent dislocation are fraught with complications. A useful option for such cases is the constrained acetabular component, or “captive cup”. We present the largest series reported to date, and use radiostereometric analysis (RSA) to assess cup migration.

Method: Between February 1999 and September 2003 126 patients were identified as high risk of dislocation and were treated with a constrained acetabular component. One hundred and sixteen cases were revision arthroplasties and 10 were primary replacements. Patients were assessed pre-operatively (WOMAC, Harris Hip Scores and SF-36). Defects were reconstructed with allograft (massive, morsellised or strut) where required. All components were inserted into uncemented metal cups. Radiostereometric beads were inserted. Post-operatively patients were followed up regularly and clinical scores repeated. Radiostereometric analysis (RSA) was performed at 6 months, and then annually to assess prosthesis migration.

Results: Mean follow-up was 3.1 years (range 1 – 5.6 years). At last review 8 patients had died, and 2 were lost to follow-up. There were 7 revisions: 3 for infection, 2 for periprosthetic fractures, and 2 for aseptic loosening. There was one case of cup disassociation successfully treated with open reduction. There have been no further dislocations. There was a statistically significant improvement in WOMAC and Harris Hip scores. RSA confirmed cup migration was greater than for non-captive cups, but was nevertheless acceptable: 0.16mm medially, 0.47mm proximally, 0.16mm posteriorly. Interestingly there was no statistically significant difference at 6, 12 and 24 months suggesting most migration occurs early on.

Conclusion: Our results suggest the “captive cup” is an effective and safe option for the treatment of primary and revision arthroplasty in those at high risk of dislocation. RSA analysis confirms minimal prosthesis migration.

Introduction: Tibial pilon acquired deformities are often a combination of axial deviation, translation, rotational defects and leg length discrepancy. Correction of deformity pattern with a percutaneous rectilinear supramalleolar osteotomy and an external fixation by Ilizarov apparatus aims to reduce misalignment progressively, simultaneously and mini-invasively.

Method: From 1994 to 2004, 29 patients have been treated for pilon tri-planar deformity of the leg. The mean age was 26 years (range 16 to 49 years), 15 were males and 14 females. Type and level of the deformity were determined by preoperational X-ray pictures. Two rings of Ilizarov apparatus are positioned in the segment of the limb proximal to the osteotomy: one at the level of the proximal tibial metaphysis and the other 3–4 cm further the osteotomy. A third ring is positioned at the level of the tibial pilon, parallel to the articular edge of the ankle. In order to maintain stability of the ankle, a half ring or horseshoe-shaped component should be placed on the calcaneus and metatarsals with opposing olive wires. The positions of the mobile joints between the rings will depend on the location of the correction axis. The closed metaphiseal osteotomy is performed in order to correct triplanar deformities in a progressive way, through angulations and translation in an oblique plane. The half ring on the foot allows maintaining the ankle distracted, which is necessary to reduce articular compression and to avoid soft tissue damages and muscular contractures in this region. Correction of translational deformities, axial deviation, and rotational deformities we performed in two stages. The axial deviation and translational deformity should be corrected in the first stage, and the rotational deformity is corrected during the second stage.

Results: In all cases we achieved correction of the angular or rotational deformities. Bleeding was never over 100 ml. We have not observed any soft tissue damages. Controlled weight-bearing was practiced in first day postoperatively, and the mean hospitalization time was 4 days. Time required to reach the correction was in a range of 3–6 weeks. In 20 patients the entire of the leg discrepancy was in a range of 1,5–6 cm. We reported no case of infection or non union. The devices have been removed after a mean time of 11 weeks (range 8–15 weeks).

Conclusion: Corrections of triplanar deformity of the pilon by the Ilizarov apparatus are progressive and mini–invasive. Also, it allows treating misalignment and lengthening by a single operation. The apparatus layout combining foot fixation and ankle distraction permits to correct soft tissues, secondary deformities, and finally a rapid weight bearing recovery.

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.

Introduction and Aims: Reinfusion drains have been used to decrease the need for blood transfusion following total knee replacement. The aim of this study was to evaluate the degree of activation of platelets and leucocytes in both the blood that has been salvaged after total knee arthroplasty and the patients’ blood following reinfusion.

Method: A prospective series of 24 consecutive patients undergoing a primary total knee replacement in a case-control study were investigated. Post-operatively 12 patients received salvaged blood reinfusion and as a control, 12 patients underwent TKA with a standard drain. The reinfusion was initiated four hours after the operation. Blood samples were taken from all patients at three and five and a half to six hours post-operatively. A third sample was acquired in the treatment group from salvaged blood after reinfusion. Platelet, platelet-leucocyte and leucocyte activation markers were studied in both the drainage blood and the patients’ blood following reinfusion.

Results: Comparison between platelet, platelet-leucocyte and leucocyte activation markers in patients’ circulation prior to reinfusion compared to salvaged blood showed that almost all markers were significantly increased in salvaged blood. For example the platelet activation markers P-selectin (p< 0.01), Factor V (p< 0.01), CD40L (p< 0.01) and platelet derived microparticles (p< 0.01) were all significantly increased in the drainage blood. All studied platelet-leukocyte and leucocyte activation particles were also significantly increased. Following re-infusion of autologous salvaged blood there was no statistically measurable effect on activation markers of patients’ circulating platelets and leucocytes, but there was a slight drop in platelet count in the reinfused group compared to the control group. Levels of prothrombin fragment F 1+2 increased in the reinfused group compared to control indicating either activation of coagulation or simply the effect of addition of the high levels present in the salvage blood.

Conclusion: Blood from reinfusion drains showed a significant increase in activation of platelets and leukocytes indicating activation of coagulation. The reinfused blood did not lead to a difference in platelet and leukocyte activation but a decrease in platelets and an increase in fragment F1+2 suggests the possibility of activation of coagulation.

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated.

Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old).

Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients)

Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents.

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.

Introduction: In the two-stage revision procedure for infected total hip arthroplasty (THA), healing of the infection can be enhanced by using an antibiotic-loaded acrylic cement (ALAC) spacer. The spacer also acts as a temporary implant, preserving the gap between bone segments and a certain degree of joint motion.

Materials and methods: Between 1995 and 2003, 19 infected THAs were surgically treated by two-stage revision procedures, using gentamicin-loaded spacers. The infections were sustained by Staph. aureus in 7 cases, Staph. aureus + Enterococcus faecalis in 1 case, Staph. epidermidis in 4 cases, Strept, agalactiae in 1 case and Strept, β-haemoliticus in 1 case. In 5 hips presenting with secreting fistulae, no causative microrganisms were isolated.

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.

Results: Seventeen patients were evaluated at an average follow up of 42.3 months (range, 6 to 92 months).

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).

Conclusions: The low incidence and the pathophysiologic heterogeneity of THA infections do not allow to identify standardised protocols for their treatment. Two-stage revision is one available option and several authors demonstrated higher rates of success when compared to one-stage revision. The use of ALAC spacers increases the efficacy of the procedure and in our experience positively influenced the clinical-functional outcome.

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.

From 1990 to 2003 the Ilizarov technique was used to treat 41 patients affected by the following congenital or acquired deformities : post-poliodeformity (n=8), hemimelia (n=6), pseudoachondroplasia (n=5), idiopathic genu valgum/varum (n=5), hypoplasia (n=3), osteomyelitis with growth arrest (n=3), DDH (n=2), rickets (n=2), Blount disease (n=2), Ollier disease (n=1), Perthes disease (n=1), arthrogryposis (n=1), hypochondroplasia (n=1) and congenital genu flexum (n=1). Post-traumatic deformities and simple leg-length discrepancies were excluded. The majority of the patients (26/41) presented with multi-planar deformities with the following average degrees: varus 22°, valgus 21°, internal rotation 36°, external rotation 42°, antecurvatum 20° and recurvatum 15°. The average leg-length discrepancy was 6 cm (range 2–10 cm). In total, 66 segments (30 femurs and 36 tibias) in 50 limbs were treated. The rotational corrections were performed at a rate of 4 mm/day; the angular corrections at the rate of 1.5 mm/day on the concave side and 0.75 mm/day on the convex side. The rotational correction occurred on the regenerate. The average correction time was 44 days, the healing time 86 days.The results were: excellent (correct mechanical axis, normal ROM and no limping) in 14 cases, good (correct mechanical axis, limping and reduced ROM) in 24 cases, fair (residual deformity, limping and joint contracture) in three cases, poor (residual deformity, limping and rigid joints) in none. The complications were: five pin tract infections and three fractures.

Purpose: We report a series of 78 total hip arthroplasty revisions using a locked femoral stem, Ultime.

Material and methods: These patients presented aseptic loosening (88%) and septic loosening (12%). Fracture was associated in 17%. The preoperative Postel Merle d’Aubligné (PMA) score was 10.2 points. Using the Vives-SOFCOT classification, 29% of the loosenings were stage I, 37% stage II, 24% stage III, and 10% stage IV. All fractures were associated with lossening. We used a femoral window in 57% and trochanterotomy in 14 cases. The first eight patients in this series had an allograft (impacted piecemeal). Most of the patients resumed weight bearing the first week. The PMA score was used to assess outcome. AP and lateral views were used to evaluate stem-bone contact and cortical thickness at three levels.

Results: Early complications were phlebitis (n=1) and superficial haematoma (n=5). Late complications were dislocation (n=6), stem fracture (n=2), deep infection (n=3). At last follow-up, 81% of the aseptic loosenings, 77% of the septic loosenings, and 70% of the fractures on stem had a good or excellent PMA score with a mean gain of 4, 5, and 1 points respectively. Bone reconstruction showed an increase in internal cortical (2 to 4.4 mm) and stem-bone contact increased in the lower two-thirds of the stem. Allografts did not improve results. Furthermore, 28% of the patients had hip pain which could not be related to clinical findings or implant characteristics. Half of the patients were reoperated.

Conclusion: In this series, functional improvement was similar to that in published series. The femoral window facilitated the procedure and decreased intraoperative complications. The Ultime prosthesis met the objectives set by the manufacturer, i.e. primary stability and bone reconstruction authorising subsequent revision.

Purpose: Deep infections of the operative bed are rare but serious complications of first-intention total hip arthroplasty. Data from French series are scarce. We present a study of incidence, characteristic features and potential risk factors using a consecutive series of 790 implants performed during first-intention procedures in the same university hospital.

Material and methods: All patients who underwent first-intention surgery from November 1995 to May 1999 were included. We collected demographic, clinical, and therapeutic data. Deep infection was defined as bacteriological demonstration of the infectious agent from at least two intra-operative specimens during the revision procedure. Patient follow-up ranged from one month to four years. Univariate analysis was used to search for potential risk factors. The chi-square and Fischer exact tests were applied.

Results: Overall incidence was 1.77 deep infections for 100 operations (95%IC 0.84–2.7). Mean time to development ranged from 14 days to 32 months. Eleven infections were recognised within the first year and three after one year. Two risk factors were identified: absence of systemic antibiotic prophylaxis (relative risk = 4.74, p=0.03), and drainage discharge after 48 hr (relative risk = 3.62, p=0.02). Other variables associated with infection with a relative risk greater than 2 were obesity, corticosteroid therapy, and haematoma or postoperative wound healing problem.

Conclusion: The incidence found in this series is slightly higher than generally described in other countries. This study has incited us to revisit our protocols for preoperative skin preparation and to establish a systemic antibiotic prophylaxis.

The authors present their experience using osteogenic protein 1 (OP-1; “Osigraft”) in the treatment of recalcitrant atrophic pseudoarthrosis (PA) of the limbs in patients in whom osteosynthesis surgery failed at least two to four, and more, times. All patients with PA who were treated showed a preoperative radiographic pattern of severe bone atrophy surrounding the peri-fracture zone, without evident signs of reparative activity. All osteosynthesis hardware showed clear evidence of mechanical failure (rupture or mobilisation) so they were changed in all patients during the surgery. From January 2003 to February 2004 we used Osigraft to treat 10 patients with an atrophic PA at the following level: two femurs, three humera, one forearm, three tibiae (1/4 distal) and one tibia (1/3 medium). Osigraft was associated in seven patients with an autograft and in three patients with an allograft plus platelet growth factors (one distal femur, one distal tibia and one humerus). Mean age of patients was 38 years (range: 22–54) and mean duration of disease from the initial trauma was 36 months (range 26–40).

The radiological aspect of the newly formed bone, both endostal and periostal, was very similar to that observed in primary healing, with an inter-fragmentary callus as observed in similar cases treated since the beginning with the most appropriate therapy and that healed after the first operation. In all cases we observed healing of the PA focus in a time period of 6–11 months (mean 8.5) with a satisfactory functional recovery in eight cases; in two cases residual articular stiffness, one knee and one ankle, will require arthroscopic surgery.

Because of the limited number of patients treated with this new method, we can only draw preliminary conclusions. However, compared with our previous experience, we can confirm that Osigraft (OP-1) significantly contributes to bone healing whenever biological reparative potential is strongly compromised because of the type of original trauma, the long time elapsed since then and the many preceding surgeries. Healing times, even if they appear to be quite long, are actually short considering the severity of our cases, usually requiring further surgery for PA not healing after the third intervention (more than 30 %) and cured, if reached, in 12–18 months.

Purpose: In 1988, the conclusions of the SOFCOT symposium appear to condemn use of cemented implants for revision of loosened femoral elements. Eleven years later, at the 1999 Symposium, Vidalain demonstrated that cementing remains a reasonable alternative. The purpose of this retrospective analysis was to estimate long-term results of revisions using a long cemented stem without bone stock reconstruction.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent revision surgery with this technique. We retained for analysis 95 hips (15 lost to follow-up 25 deceased patients) in 66 women and 29 men, mean age 70 years at revision (42–86). The preoperative Postel Merle d’Aubigné (PMA) function score was 8/18. Femoral implants in place had been cemented in 80% of the hips. Using the SOFCOT criteria, 65% of the loosenings were stage II, 29.5% stage III. All were aseptic loosenings and the same revision technique was used in all cases: removal-replacement of both prosthetic elements, use of a long cemented stem without associated grafting.

Results: Mean follow-up was eight years (60–157). Thirty nine percent of the patients had early postoperative complications. The mean function score at last follow-up was 14.8/18 with 62.4% of the outcomes considered good or very good. Age, restitution of the rotation centre, quality of cementing, and stem/femur fit influenced the result significantly. Radiographic analysis showed a progressive lucent line in 32% of the hips, only 36% of the femoral stems were totally free of lucent lines. Cumulative actuarial survival was 87% at 14 years and fell to 65.5% considering certain radiographic loosening as the endpoint.

Conclusion: Use of a long cemented femoral stem for revision total hip arthroplasty provides acceptable long-term functional outcome. Results are significantly affected by imperfect technique. This type of implant, which destroys any hop for restoration of bone stock, should be reserved of elderly subject where a more “ambitious” procedure were be too risky.

Introduction and purpose: Fatigue leads to various disruptions in the musculoskeletal system. Specifically, it has been observed that fatigue disturbs perception of the position of the limbs and the spine as well as posture balancing control and gait kinematics. The purpose of this study is to determine whether orientation of the pelvis undergoes changes after a period of extreme work-related fatigue.

Materials and methods: Orthopaedic Surgery residents in our hospital often work 24-hour shifts in the emergency department, which is considered a tiring activity which constitutes an appropriate model for professional burnout. In order to assess the position of the pelvis, we used pelvis tilt on the sagittal plane which is defined as the inclination of the plane which runs through all four anterosuperior and posterosuperior iliac spines with respect to the horizontal. The pelvic tilt of 19 resident doctors was measured at the beginning of their shifts, 16 hours into their shifts and on completing their 24-hour shift. An analysis was made of the differences between the values obtained and the influence of gender, weight and body mass index.

Results: Fatigue caused by 16 and 24 hour shifts in the emergency department led to a mean decrease in pelvic tilt of 1.1° (significant p=0,014) and 1.6° (significant p=0,003) respectively.

Conclusions: The fatigue caused to resident doctors by their shifts in the emergency department leads to significant pelvic retroversion.

The common factor in all (mechanical) prosthetic failure mechanisms is the induction of osteolysis around the endoprosthesis with subsequent prosthetic migration and finally loosening of the prosthesis. Both initial prosthesis-bone fixation and long-term prosthesis survival depend on the quality of the peri-prosthetic bone mass. The effects of treatment of RA patients with prednison are inhibition of osteoblastic activity and inhibition of calcium resorption from the intestines. The bone mass loss during the first six months of prednison treatment is substantial and will seldom be regained. Bisphosphonates are known to decrease osteoclastic activity and may therefore stop osteolysis at the bone-prosthesis interface.

The aim of the study was to evaluate a possible association of bisphosphonates with reduced migration of total knee prostheses (Interax, Howmedica Osteonics, Rutherfort, USA) in a high-risk group. Roentgen Stereophotogrammetric Analysis (RSA-CMS, Medis, The Netherlands) was used to measure the micromotion.

Retrospectively a group of nine RA patients treated with prednison (non-bisphosphonates group) and a group of fourteen RA patients (bisphosphonates group) treated with prednison in combination with bisphosphonates (Etidronate) were included from a prospective randomized study of 82 patients (Nelissen et al., 1998).

At the two-year follow-up evaluation, functional scores and knee scores did not differ significantly among the two groups. At the two-year follow-up evaluation, the non-bisphosphonates group subsided −0.47 ± 0.8 mm, and the bisphosphonates components subsided 0.07 ± 2.9 mm. In the analysis of variance with repeated measurements, with correction for follow-up time, sedimentation rate, and prosthesis fixation type, the bisphosphonates group migrated 1.20 mm less in the total migration (95% c.i.: 1.07–1.30 mm) compared to the non-bisphosphonates group.

In this study, bisphosphonates medication in addition to corticosteroid medication was associated with reduced migration of knee prostheses compared to corticosteroid medication alone.

Aims: Purpose of this study was to obtain long term follow-up in patients with Osteofibrous Dysplasia (OFD), in order to investigate natural history of the disease, late results of treatment, and potential risk of Adaman-tinoma development in this setting. Methods: A retrospective study of 48 patients with histologically proven OFD observed at our Institution between 1900 and 1997 was undertaken. Clinico-pathologic features of all cases were reviewed and found consistent with OFD. A clinical status update and current radiographs were obtained in all patients. A subgroup of 21 patients with minimum follow-up of 20 years (21 to 44 years, average 27) was analysed for functional result and adamantinoma development. Functional result according to MTS-ISOLS score correlated with surgical aggressiveness. Results: Best results were observed in patients that received a single biopsy or curettage; worse results were seen after multiple resections or osteotomies and associated with complications as infection or compartment syndrome. No patients had current symptoms or significant symptoms changes nor physical findings, radiographic clues or subsequent radiographic changes suggesting adamantinoma development. Conclusions: OFD is a benign condition; the natural history of the disease has minimal consequences in the adult life. Surgical treatment is usually not necessary and may actually worsen the result because of the potential for severe complications.

The relationship with adamantinoma remains unclear, follow-up is suggested.

Purpose: Posterior instability of the shoulder requires surgical treatment in involuntary forms and after failure of functional treatment. As for anterior instability, a bone block can be fashioned from an iliac graft or a pediculated graft harvested from the acromion. This retrospective analysis concerned the results obtained in eighteen consecutive cases.

Material and methods: This series included ten men and eight women, mean age 26 years (15–42) at time of surgery. Fourteen (77%) practised sports activities including four at competition level. Symptoms had persisted for four years on the average. For three patients (16%) posterior instability was expressed by recurrent luxation subluxation. For nine patients (50%) posterior subluxation was a common involuntary event. Six patients suffered from painful shoulders due to an unrecognised posterior instability accident. Diagnosis of posterior instability was establised by arthroscopy in seven patients (39%). For nine shoulders the intervention consisted in a screwed posterior iliac block associated with a tension procedure on the capsule (group 1). For the other nine shoulders the block was harvested from the acromion and pediculated on the deltoid (group 2).

Results: Mean follow-up for all patients was eight years. The Duplay score was 75 points at last follow-up. Twelve patients (85% of the athletes) were able to resume their sports activities, half at the same level. Nine patients were pain free. Six patients (33%) had persistent apprehension but did not present true recurrence at physical examination. The Duplay score was 69.4 points in group 1 (follow-up 12 years) and 82.2 points in group 2 (follow-up three years). Thirteen patients (77%) did not have any sign of joint degeneration at last follow-up. One patient had advanced stage IV degeneration related to an intra-articular screw. All patients felt their shoulder had been improved by surgery and one third were disappointed with the results.

Discussion: Use of a posterior block is an effective treatent for posterior instability giving results comparable with those obtained with anterior blocks in terms of shoulder stability, pain, recovery of motion, and subjective outcome. This procedure favours joint degeneration less than anterior stabilisation. Results obtained with pediculated acromial blocks are encouraging.

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis.

Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis.

Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection).

Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple.

Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability.

Objective: Starting from results of studies made in the last ten years about the presence of myofibroblasts as the main cells involved into fibro-contractile disease, we investigated if this cells were also involved into pathogenesis of club foot deformities.

Methods: Specimens removed surgically from five patients affected by congenital club foot were investigated. Each specimen was cut in three parts: the first, was fixed for optical microscopy in formalin; the second was fixed for trasmission electron microscopy (TEM) in glutaraldehyde and postfixed in osmium tetroxide; the third was immediately placed in cold (4°C) tissue culture medium. We have stained the first part of each specimen with: haematoxylineosin, Pasini, Masson, Congo red, Van Gieson, Martius scarlet blue and immunostaining for a-smooth muscle actin (a-SM actin). The third part of each specimen, dissected into 2mm. cubes, was place in standard medium and cultured at 37°C. On the cultured cells, we have valued metalloproteinases and a-SM actin expressions. Moreover, a part of culture cells, when reached confluence, were detached with trypsin-EDTA and centrifuged for 10 min. at 2000 rpm. to obtain a pellet, subsequently fixed for TEM.

Results: Optical and electron microscopy have showed, only in one of our cases, the presence of myofibroblast’s clusters in the Henry’s nodule and in the medial and lateral fibrous nodules, that are characteristic nodule of congenital club foot.

Conclusions: Starting from the results of our studies, we would like to study in detail the role of myofibroblast in the pathogenesis of club foot.

We report on six men and two women (mean age 42.5 years) who had sustained posterior dislocation of the shoulder in motor vehicle accidents (three), falls (two), equestrian accidents (two), cycling accidents (one) and in a fainting spell (one). In four patients, the dislocation was the only injury, but two had humeral shaft fractures, one a humeral neck fracture and the fourth a glenoid and humeral shaft fracture. The mean delay to diagnosis was 14 weeks (2 to 21).

In three patients a medical officer, a general practitioner and a radiologist missed the dislocations, but in five orthopaedic surgeons missed them. Four patients had only anteroposterior radiographs of their shoulder taken, one had anteroposterior and lateral scapular views, and three had anteroposterior and lateral radiographs of the humerus.

Four patients underwent hemi-arthroplasties and the other four open reduction and McLaughlin procedures.

Though rare, posterior dislocations are often missed. Careful examination, especially in the absence of external rotation, can eliminate this. In the presence of a fracture, a dislocation or injury to the joint above and below must be excluded. Anteroposterior and lateral scapular views alone are inadequate in trauma cases and an axillary or modified axillary view should be done. If there is any doubt, CT should be performed.

Purpose: We reviewed 30 cases of osteochondrial lesions of the astragalus dome treated surgically.

Material and methods: Among the 30 patients, 17 practised sports and 24 had a history of trauma. Delay to surgery was ten months. All patients were treated by curettage using perforations according to Pridie. There were 11 direct approaches, 13 malleolar osteotomies and six arthroscopies. Cancellous grafts completed the treatment in six cases.

Results: Mean follow-up was three years seven months (minimum two years). All the patients had an arthroscan at last follow-up. The postoperative results were assessed according to clinical and arthroscan criteria.

Discusion: We emphasise the importance of the Fracture Osteonecrosis Geode (FOG) classification system and the subsequent pathophyisiological and prognostic conclusions. The Berndt and Harty classifications should be abandoned. Only symptomatic lesions should be treated. Surgical treatment (arthroscopy or direct access with cancellous graft) is required for efficacy at this stage. Surgical treatments provides very good results in 75% of the cases with pain relief and improved walking distance. We advocate arthroscopic perforation curettage for localised necrosis. In case of major substance loss, cancellous grfat requires a direct access.

Purpose of the study: We reviewed 30 cases of osteochondral lesions of the astragalar vault treated surgically.

Material and methods: Among the 30 patients, 17 participated in sports activities and 24 had a history of trauma. Mean delay to surgery was 10 months. Treatment included osteochonritis curettage and Pridie perforations. Direct access was used in 11 cases, malleolar osteotomy in 13 and arthroscopy in 6. Cancellous bone grafts were used in 6 cases.

Results: Mean follow-up was 3 years 7 months (minimum 2 years). All patients had an arthroscan at last follow-up. Evaluation of post-operative outcome was based on clinical assessment and arthroscan findings. Surgical treatment provided very good results in 75 p. 100 of cases with pain relief and improved walking distance.

Discussion: Our cases pointed out the important contribution of the FOG (Fracture Osteonecrosis Geode) classification to pathogenic and prognostic analysis. The Berndt and Harty classifications were not found to be useful.

Conclusion: In case of localized necrosis, we propose arthroscopic perforation curettage. In case of bone loss, a direct cancellous graft may be used.

We evaluated the effectiveness of arthroscopic repair in patients with shoulder instability owing to a bony fragment as part of the Bankart lesion, using spiked Suretacs, sutures and anchors.

Over a two-year period, we followed up 23 of 25 consecutive cases, all with a bony fragment as part of the Bankart lesion. The mean age of patients, all of whom were male, was 21 years (17 to 35). Almost all injuries were sustained playing sports. Patients were clinically evaluated at six weeks and 20 weeks postoperatively and interviewed telephonically.

Full arthroscopic examination was performed in a lateral decubitus position. The affected capsular structures and labrum, with its attached bony fragment, were fully mobilised. The bony fragment was always attached to the capsular structures, with labral ring intact. We used a spiked Suretac anchor to reattach the bony fragment to its original anatomical position, and Mitek anchors and no. 1 Ticron sutures for individual reattachment of the capsule and ligaments. Postoperatively patients were immobilised in a shoulder sling for six weeks. Early restricted active and passive movements were advised. Patients routinely received postoperative physical and biokinetic rehabilitation. The mean follow up period was 16 months (5 to 29). There was no redislocation or subjective instability.

This technique yields excellent results, but because it is technically difficult should be used only by experienced shoulder arthroscopists with thorough knowledge of pathological shoulder anatomy.

Purpose: Is prevention of postoperative venous thrombosis using low-molecular-weight heparin (LMWH) sufficient in orthopaedic and traumatology units?

Material and methods: Between 1995 and 2000, all patients undergoing orthopaedic or traumatology procedures involving the lower limb underwent a venous control the sixth day after surgery: RPO with phlebography if positive until September 1996 then duplex Doppler of the lower limbs. In all 755 patients, mean age 68 years (34–90), undergoing planned orthopaedic procedures (341 THA, 135 TKA, 111 tibial osteotomies, 66 single compartment prostheses, cruciate surgery) or procedures for trauma (56 femoral neck, trochanter, bimalleolar, etc.) were included.

Results: A total of 118 cases of deep vein thrombosis were discovered giving an incidence of 16%. The deep vein thrombosis was in the sural territory in 95 cases (posterior tibial, fibular, vastus and/or anterior tibial) but there were also 13 cases of proximal thrombosis in the iliofemoral or femoral localisations. The large majority of the cases were homolateral to the surgical side, eight were found in the other limb. In this series, the venous risk differed from one surgical procedure to another (for the same operator): 11% for THA, 22% for TKA (without tourniquet) and 17 to 12.5% for tibial osteotomies with tourniquet (valgisation and transposition of the anterior tuberosity), 13.5 % for single compartment prostheses with tourniquet. Our oldest patient was 90 years old and was treated by intermediary arthroplasty for a cervical fracture. The youngest were 34 years old for anterior cruciate ligament surgery or valgisation osteotomy and 38 and 39 years for THA subsequent to advanced necrosis. Finally, there was no statistical difference by sex.

Conclusion: Systematic use of duplex Doppler examination of both limbs postoperatively revealed a large number of deep vein thrombosis patients despite systematic use of LMWH which certainly modified their clinical presentation. These patients were then given adapted treatment which led to regression of the complications: postphlebitis syndrome and pulmonary embolism with the risk of medicolegal complications.

In shoulder arthroplasty the glenoid component remains a problem. Hemi-arthroplasty requires less theatre time and gives rise to fewer complications. The question is whether the results of hemi-arthroplasty are inferior to those of total shoulder arthroplasty.

We assessed 189 patients who since July 1994 had undergone hemi-arthroplasty or total shoulder arthroplasty, excluding patients who suffered fractures, malunion or nonunion. In 77 patients (41%) the glenoid was replaced. The mean age of patients was 62 years. All humeral and glenoid components were cemented. Preoperative and postoperative assessments included pain (visual analogue scale), muscle strength, range of motion, functional activities and Constant shoulder scores.

At this early stage, total shoulder arthroplasty appears to give slightly better functional results than hemi-arthroplasty. However, there were five (6.5%) complications associated with the glenoid components, including glenoid component fracture, loosening and migration. Hemi-arthroplasty eliminates concerns about glenoid wear and glenoid complications, and we believe total shoulder arthroplasty should be reserved for specific problems.

We report a patient with a subperiosteal ganglion cyst of the tibia which was imaged by radiography, arthrography, CT and MRI. The images were correlated with the arthroscopic surgical and histological findings. Spiculated formation of periosteal new bone on plain radiographs led to the initial suspicion of a malignant tumour. Demonstration of the cystic nature of the tumour using cross-sectional imaging was important for the precise diagnosis. Communication between the ganglion cyst and the knee was shown by a delayed arthrographic technique, and the presence of this communication was confirmed at arthroscopy and surgically.

Reorientation of the acetabulum may be required in adolescents and young adults with developmental dysplasia of the hip. We have carried out a retrospective review of 51 hips after triple osteotomy with an average follow-up of ten years (8 to 15). Forty-eight hips (94%) were available for review and of these 39 (81%) were improved compared with before operation, 29 (60%) scoring good or excellent. Radiographic assessment showed improvement of the average centre-edge angle by 19°, the acetabular index by 12° and the anterior centre-edge angle by 26°. The degree of osteoarthritis progressed by one grade in ten hips (21%) over a period of ten years.

The satisfactory long-term clinical and radiographic results have encouraged us to continue this treatment for symptomatic acetabular dysplasia in these patients.