AIM

Retrospective study comparing the effectiveness of preoperative autologous blood donation versus intra-operative blood saver systems in minimizing the need for allogeneic blood transfusion in scoliosis surgery.

Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis.

Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest.

All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site.

CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area.

In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects

The SRS-22 is a valid instrument for the assessment of the health related quality of life of patients with Idiopathic scoliosis. The purpose of this study is to evaluate the reliability and validity of the adapted Greek version of the refined Scoliosis Research Society-22 Questionnaire.

Following the steps of cross – cultural the adapted Greek version of the SRS-22 questionnaire and a validated Greek version of the SF-36 questionnaire were mailed to 68 patients treated surgically for Idiopathic Scoliosis with a mean age at the time of operation 16.2 years and a mean age at the time of evaluation 21.2 years respectively. A 2nd set of questionnaires was mailed in 30 patients within 30 days from the 1st set. Reliability assessment was determined by estimating Cronbach’s a and intraclass correlation coefficient (ICC) respectively. Concurrent validity was evaluated by comparing SRS-22 domains with relevant domains in the SF-36 questionnaire using Pearson’s Correlation Coefficient (r).

The calculated Cronbach’s a of internal consistency for three of the corresponding domains (pain 0.85; mental health 0.87; self image 0.83) were very satisfactory and for two domains (function/activity 0.72 and satisfaction 0.67) were good. The ICC of all domains of SRS-22 questionnaire was high (ICC> 0.70). Considering concurrent validity all correlations demonstrated high correlation coefficient.

The adapted Greek version of the SRS-22 questionnaire is valid and reliable and can be used for the assessment of the outcome of the treatment of the Greek speaking patients with idiopathic scoliosis

Aim: We present a new trunk asymmetry index for topographic measurement of patients with thoracolumbar scoliosis, which does not require full 3-dimensional reconstruction of the back shape and can be performed with a digital camera and a laptop.

Material and methods: To date, 27 patients were assessed preoperatively, and 14 of these also had post operative assessments. The midline was identified between the two lateral edges of the trunk visible on a digital photograph. This was compared with a straight line. We derived an asymmetry index for each image and compared this with the cobb angle on x-rays pre- and postoperatively.

Results: The new asymmetry index correlated well with the cobb angle up to about 50°. Curves beyond this tended to have compensatory curves. This made interpretation more complex, however, if the compensatory cobb angle was subtracted from the major cobb angle, the asymmetry index fell at the expected points. It clearly distinguishes pre-operative and post-operative images. With POTSI, (posterior trunk symmetry index) there is a significant difference between the pre- and post-operative groups and significant overlap of the two distributions.

Conclusions: Surface topography of scoliotic patients is a useful tool to assess the progression of scoliosis without X-rays, reducing radiation exposure. The proposed new index is a promising measurement for monitoring the progress of a thoracolumbar curve with much better sensitivity and specificity than existing topographic indices, without requiring the capital outlay for surface topography equipment as it can be obtained from a simple digtal photograph and laptop.

Aim: We show the short term results of cementless THA in patients younger than fifty years old who were suffering from avascular necrosis of the femoral head.

Materials Methods: From 09/1997 to 04/2002 we have treated 21 young patients (7 males and 14 females), aged from 24 to 50 years (mean: 37 y) and 27 hip (6 bilateral and 15 unilateral) suffering from AN, with cementless THA. Preoperatively all patients were assessed clinically for their function with D Aubigne Postel scoring system and we also assessed joint destruction and femoral head subsideness with radiographs and MRI respectively. All hips were III or IV Ficat stage and probably there was severe pain and limitation of joint functionality. We used a porous coated component for the acetabulum (Duraloc) and a partially coated cementless femoral stem with distal fixation (AML).

Results: We had no early or late infections, no dislocations and no nerve palsies. 2 patients had persistent thigh pain who has subsided a year after operation. At last follow up (88 30 months, mean: 48 m) we evaluate clinically and radiologically all patients using DAubigne Postel score and radiographs. We had 25 hips (93%) with excellent or good results and 2 hips in two different cases of bilateral replacements with fair or poor result. No evidence of radiological looseness of the components was found. All patients were very satisfied with their function in regard to previous condition and most of them returned to their normal life.

Conclusion: Cementless total hip replacements show excellent short term results in young patients with final stage avascular necrosis thought we need longer follow-up to come in to definite conclusions.

Purpose: The results of surgical treatment of intertrochanteric hip fractures using a sliding hip screw-plate and Norian-SRS, as an adjuvant means of stabilization, are presented.

Material – Methods: 103 patients (27 male, 76 female) with intertrochanteric hip fractures, were treated with a sliding hip screw. Their age ranged from 56 to93 years (av. 68,9y) . In group A (50 patients) we only used a sliding hip screw -plate, while in group B ( 53 patients) we also used Norian-SRS above the upper surface of the sliding hip screw.

Results: Postoperative follow-up ranged from 5 to17 μnνϵς. Mobilization was initiated on the 2nd day with partial weight bearing. A group progressed to full weight bearing in 3 , while B group in 2 months. 8 patients in group A and 2 in group B developed varous deformity. Screw cut out developed in 5 patient of group A and none of group B. Backsliding of the screw ranged from 0 to 16 mm. (av. 4,95 mm.) in group A and from 0 to16mm. (av. 3,25mm.) in group B.

Conclusion: Norian-SRS augmentation of intertrochanteric hip fractures treated with a sliding hip screw-plate, increases the stability of the osteosynthesis, permitting earlier rehabilitation and mobilization of the patient and leading to better functional results.

Aim: Nanoindentation is a technique, developed over the last 15 years which is now widely used in the materials science for probing the mechanical properties of thin films. The properties most commonly measured are Young’s modulus (E), and Hardness (H). One of the great advantages of the technique is its ability to probe a surface and map its properties on a spatially – resolved basis, often with a resolution of better than 1μm.

Materials and methods: specimens from 5 lumbar vertebrae (L-4) were obtained from fresh, unembalmed human cadavers (2 males and 3 females), aged from 16 to 90 years. After carefully removing posterior elements and soft tissues, the vertebral bodies were cut to a thickness of 5mm and embedded in epoxy resin to provide support for the porous network. Then the samples were metallograpically polished to produce smooth testing surfaces and nanoindentation tests were conducted to measure Young’s modulus and hardness of individual trabeculae. Measurements were made in both longitudinal and transverse direction in relation to the longitudinal axes of the trabeculae. The indentation load – displacement data obtained in these tests were analyzed, using the method of Oliver and Pharr.

Results: a total of 719 nanoindentations were produced in this research. A mean of 7–8 indentations were made in 103 separate trabeculae both in longitudinal and transverse direction. The mean Young’s modulus was found to be 13.7(2.5) Gpa, which is higher than the one obtained by classic micromechanical tests. There were no significant differences of elastic moduli among the longitudinal and the transverse directions of the trabeculae (13.8. Gpa and 13.5 Gpa, respectively).

Conclusion: nanoindentation is a very promising technique for evaluating intrinsic mechanical properties of bone at sub-micro level of organization. It may have many applications and may contribute to the improvement of our knowledge concerning bone biomechanics, the effects of metabolic bone diseases on bone mechanical properties and the capabilities of surgical treatment

Aim: In this study we present the results of the management of muskoloskeletal injuries accompanied by rupture of a main arterial vessel, focusing on the priorities in salvaging the affected limp.

Material – methods: In a period of 5 years (Sep.1999– Sep 2004), 24 patients having sustained multiple injuries were admitted with signs of poor vascularization distally to the lesion. 19 were male and 5 female, their ages ranging from 16 to 49 years (av. 28 years). The musculoskeletal injuries were: open III C humeral fracture in 2 patients, open III C femoral fractures 4, open III C tibial shaft fractures 10, knee joint dislocations 8 patients. All patients had a preoperative angiography in order to assess the severity of the vascular lesion. Immediate stabilization of the fracture with an external fixation system was performed, followed by restoration of the vascular injury by means of a by-pass, end-to-end suture or interposition of a “stent”.

Results: Postoperative follow-up ranged from 6 to 54 months (mean 34 mon.). Amputation was performed in 4 patients due to failure of the revascularization procedure 2 weeks postoperatively. External fixation was maintained as a final method of treatment in 7 cases, while in 13 cases we exchanged it to intramedullary nailing. In the 8 cases of knee dislocation, ligament reconstruction was imperative. Eventually 20 limps were salvage with a satisfactory functional outcome.

Conclusion: In polytrauma patients with both musculoskeletal and vascular injuries the immediate application of an external fixator represents a precausative for a successful vascular operation. Exchanging the external fixation system to interlocking intramedullary nailing accelerates the healing process.

Aim: The results of operative treatment of acetabular fractures, as well as its role in the prevention of post-traumatic osteoarthritis are presented. Methods: From 1990 to 2000, þfty patients had an open reduction and internal þxation of an acetabular fracture. Thirty-two patients were male and eighteen were female, with an average age of 37,8 years (range: 18 to 71 years). The mechanism of injury was a motor vehicle accident in most cases (84%). 22 fractures were A-type, 24 B-type and 4 C-type according to the AO classiþcation, while according to the Letournel-Judet classiþcation 21 fractures were simple and 21 complex. Osteosynthesis was achieved with either lag screws alone or with a combination of lag screws and a buttress plate. Results: Follow-up ranged from 2–10 years (average: 5,8 years). Clinical evaluation according to the Dñ Aubigne-Postel scoring system gave 20 excellent (40%), 18 good (36%), 5 fair (10%) and 7 poor (14%) results. Early postoperative complications included 5 cases of common peroneal nerve palsy and 3 cases of wound infection. Late complications included 1 case of avascular necrosis of the femoral head, 12 cases of post-traumatic osteoarthritis (24%) and 5 cases of Brooker III heterotopic ossiþcation (10%). Conclusions: Operative treatment of ace-tabular fractures although demanding bears very good results. Post-traumatic arthritis remains a common complication, even if care is taken for the anatomic reduction of the fracture.

Objectives: We present the medium-term results of 453 primary, posterior cruciate retaining total knee replacements.

Methods: We used the Genesis I prosthesis to 453 knee-joints between 1993–2001. The patients included were 386 (67 bilateral) with age between 58–87 years (aver. 68,5 yrs). The diagnosis was osteoarthritis in 418 cases, rheumatoid arthritis in 21 cases, post-traumatic arthritis in 9 cases and osteoarhritis combined with rheumatoid disease in 5 cases. The knees flexion was ranged from 60° to 120° and the extension from 0° to 20°. In 423 cases a 5°–30° varus knee and in 31 cases a 5°–20° valgus knee was documented. The Genesis I knee prosthesis was used with cement, without patellar component implantation. The postoperative protocol included early weight bearing and follow up on the 3rd, 6th,12th month and every year.

Results: The follow up period was ranged from 2 to 10 years (aver. 5,2 yrs). Superficial infection was noted in 5 patients with a satisfactory outcome, pneumonic embolism in 3 (1 death) and deep venous thrombosis in 7 patients. The clinical and radiological assessment followed the Knee Society standards. Postoperatively the flexion was ranged from 80° to 130° with full extension of the knees. The preoperative varus & valgus deformity was totally corrected. No signs of mechanical loosening were documented. No revision surgery was needed. All the patients are happy with a good level of every day activity.

Conclusions: Our results eight years postoperatively are quite satisfactory (98%). All the prosthesis exhibit good behaviour and we believe that this type of prosthesis is a positive solution for the arthritis of the knee which needs surgical assessment.

Objectives: We present the level of biological fixation and the medium-term results of the hemispherical porous coated acetabular component.

Methods: A number of 299 acetabular components type Duraloc 100 were placed to equivalent primary hip arthroplasties. The patients were 273 (26 bilateral), 218 women and 55 men with age which ranged between 22–80 years (aver. 52 yrs). We performed a press-fit technique to stabilize the cup and an acetabulum under-reaming of 2 mm. The size of the components we used was ranged between 48–56 mm. 175 cups were combined with the Elite cemented stem (hybrid), whereas 124 cups with the AML cementless stem. In every case a 10° hooded polyethylene liner was required. The postoperative protocol included early partial weight bearing for six weeks, full weight bearing after three months and follow up on the 3rd, 6th, 12th month and every year. The clinical evaluation was performed with D’ Aubigne-Postel system while the radiological evaluation according to the AAOS standards. The follow up period was ranged from 2 to 9 years (aver. 5,2 years).

Results: During the last follow up no mechanical no radiological loosening was detected. The cup was definitely incorporated to the bone substrate.

Conclusions: Eight years postoperatively the results are perfect. We believe that the hemispherical porous coated, press-fit acetabular component exhibits a satisfactory biological behaviour in primary hip replacements.