PURPOSE

We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy.

Introduction

treatment of femoral neck fractures in the physically active elderly, is still an open question. The comparison of total replacement and partial hip replacement showed substantial superiority of the first approach than the latter. We can not disregard the problems that THR can lead in the elderly: more surgical time, greater blood loss, major sacrifice of bone in osteoporotic subjects. The Tribofit® acetabular system, has the objective to overcome these problems with the implantation of a single 3mm soft, pliable buffer made of polycarbonate-urethane between the large diameter metal femoral head and the subchondral bone, thus replacing the articular cartilage. The surgical technique includes the reaming of the cartilage layer, the creation of a circumferential groove and the snap-fit insertion of the buffer.

The purpose of the prospective study was to evaluate the effectiveness of this approach in the treatment of femoral neck fractures in the elderly.

The durable fixation of an uncemented cup is due to two major factors: the primary stability obtained by the design of the cup and the secondary fixation obtained by the features of the surface of the cup. The CSF (cancellous screws fixation) cup is an emispheric press-fit Hydroxyapatite coated cup that has 5 holes for screws. This permit to insert screws not only in the superior part of the acetabulum but also in the inferior and supero-medial. This theoretically guarantee, also in those cases in which a perfect press-fit was non achievable, a good primary fixation. This primary fixation permit the osteo-conductive function of the HA coating in order to gain secondary e more stable fixation.

From january 1999 to september 2003 we per-formed130 uncemented THR with the CSF cup and the Furlong stem. In the first 100we always insert three screws. In the next 30 only in case of a non perfect-press-fit (10). The mean age was 65 years (14–80). The follow-up varying from 5 years to 6 months. The study is retrospective.

At the last follow-up all implants resulted well integrated.. The formation of new trabecular bone bonding the cup was noted on the X-ray since the third month’s control. There was no complication due to the position of the screws. All patients regained full authonomy.

Primary stability is mandatory in order to obtain a good secondary fixation by osteointegration. The possibility to insert additional screws in a triaxial fashion permit to obtain good primary stability. in all the cases. The screws must be inserted carefully under X-ray in order to avoid complications. Hydroxyapatite, guiding the growth of new trabecular bone bonding the cup to the pelvic bone, guarantee a good secondary fixation.

The mean way to fill bone loss, to fix loss of continuity or to correct severe dysplasia in pelvis and in the femur during replacement or revision arthroplasty is the augmentation of the bone stock by mean of bulky or morcellized bone allograft. In order to treat these problems, limiting the possible complications connected to the use of massive bone allograft (bulky or morcellized), and to simplify the surgical procedure we thought to apply in selected cases the platelet’s derived autologous growth factors (AGF), alone or added to Granular Hydroxyapatite.

From january 2001 to june 2003 we have applied-autologous growth factors in 10 cases. The diagnosis was: 5 acetabula in primary THR, 2 acetabular and 1 femoral revision after THR, 1 femoral and 1tibial revision after TKR. We applied the pure AGF in 2 cases and AGF plus Granular Hydroxyapatite in 8 cases. We used emispherical, HA coated, uncemented acetabular cup plus screws (6 cases), uncemented revision cup plus screws (1 case), straight HA coated uncemented femoral stem (1 cases), semi-constrained cemented TKR prosthesis (1 cases). The mean age atoperation was 45 years (21–69). The mean follow-up time was 12,5 months (28–6).

At the last follow up in all the implants there were no signs of loosening; all the graft seems to be well osteo integrated except in 1 case in which we have had fracture and partial reabsorption of the granular HA, without failure of the implant. We haven’t had any inflammatory reaction or signs of intollerance to the graft.

The short term results of our experience seems to be encouraging. If these results will be confirmed in the future the application of AGF should reduce the utilization of massive bone allograft.

The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical.

Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed.

The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia.

We assessed peripheral nerve function during and after lower-limb lengthening by callotasis in 14 patients with short stature, using motor conduction studies.

Four patients with short stature of varying aetiology showed unilateral and one showed bilateral weakness of foot dorsiflexion. Both clinical and electrophysiological abnormalities consistent with involvement of the peroneal nerve were observed early after starting tibial callotasis. There was some progressive electro-physiological improvement despite continued bone distraction, but two patients with Turner’s syndrome had incomplete recovery. A greater percentage increase in tibial length did not correspond to a higher rate of peroneal nerve palsy. The function of the posterior leg muscles and the conduction velocity of the posterior tibial nerve were normal throughout the monitoring period.

The F-wave response showed a longer latency at the end of the bone distraction than in basal conditions; this is probably related to the slowing of conduction throughout the entire length of the nerve.

We have reviewed 16 patients treated by leg lengthening for various forms of Turner dwarfism with regard to the long period of healing and the complications. We consider that Turner dwarfism is a suitable indication for leg lengthening because of the moderate length deficit and the morphological appearance of the patients, and have introduced an improved programme of management to deal with the problems encountered.

A chart is presented to assist with the assessment and treatment of patients with growth-related deformities. It is based on anthropometric values from five published sources and relates sitting height to stature, limb length, the radiographic lengths of the leg bones and the lengths of the feet and hands. It has proved useful in the prediction of leg-length discrepancies, in the diagnosis of cases of short stature, and in the assessment of spinal shortening from scoliosis.

We report our experience of lengthening by over 30% a total of 117 lower limbs in achondroplastic patients. We have compared four methods: transverse osteotomy, oblique osteotomy, callotasis of the shaft and chondrodiatasis of the epiphysis. Chrondrodiatasis of the femur and callotasis of the tibia are the techniques which gave fewest complications.

We have compared, in rabbits, two techniques of limb lengthening by distraction of the epiphyseal plate using a unilateral external fixation frame. In all cases, 14 mm of symmetrical lengthening without deviation was achieved. With rapid distraction at rates of 1 mm per day (distractional epiphyseolysis) separation of the epiphysis from the metaphysis occurred by day 7, and by day 70 almost complete ossification of the cartilage and the elongated segment was evident. In contrast, slow distraction at 0.25 mm every 12 hours (chondrodiatasis) produced hyperplasia of growth cartilage without any evidence of detachment at 28 days, the end of the distraction period. By day 70 the epiphyseal plate had returned to normal thickness with normal cellular morphology, while the lengthened segment was occupied by ossified tissue. The significance of these findings is discussed.

We describe a technique for slow, progressive, symmetrical distraction of the growth plate using a lightweight dynamic axial fixation system. Results are given for the elongation of 40 bony segments in children with limb-length discrepancies and 60 segments in children with achondroplasia or hypochondroplasia. Increases in limb length of up to 36% were obtained in non-achondroplastic and up to 64.5% in achondroplastic patients. There were no nerve or vascular lesions or bony infections and no case required a bone graft. Pin-track complications occurred in only 1.5%.

The results obtained with a lightweight dynamic axial fixator in the treatment of fractures are reported. The apparatus comprises a single bar with articulating ends which clamp self-tapping screws and can be locked at an angle appropriate for axial alignment. A telescopic facility allows ready conversion from rigid to dynamic fixation once periosteal callus formation has commenced. Reduction and controlled distraction or compression are achieved by means of a detachable compressor unit. We treated 288 patients with fresh fractures and 50 with ununited fractures. The success rate for fresh fractures was 94%, with average healing times ranging from 3.4 to 6.5 months. In ununited fractures also, the success rate was 94% with average healing times ranging from 4.7 to 6.5 months. Complications were minimal. The device is versatile and can be applied in an average of 15 minutes. It permits ambulatory fracture care without sacrificing a sound anatomical result.