Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy.

Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data.

Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis.

Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus.

Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy.

Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data.

Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis.

Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus.

We carried out a prospective study of 71 patients who had undergone reconstruction of the anterior cruciate ligament with the ABC scaffold. Their mean age was 28 years (18 to 50). All had either sub-acute or chronic traumatic deficiency of the ligament. The mean period of follow-up was five years (four to seven). Assessment included the use of the International Knee Documentation Committee score, the modified Lysholm score, the Tegner Activity score, the Knee Injury and Osteoarthritis Outcome score and measurement with the KT-1000 arthrometer. Two patients had mild recurrent synovitis. There were no infections and no failures of the ligament. During the period of study, two patients sustained a traumatic fracture of a femoral condyle. The implants retained their integrity in both cases. All patients returned to their previous or enhanced levels of daily activity by three months after operation and 56 (79%) achieved their pre-injury level of sporting activity by six months. The patients who were competing in National level sports returned to play at one level less after operation than before. The Lysholm score showed that 58% of the patients (41) were excellent, 34% (24) good, and 8% (6) fair, with a mean post-operative score of 93. According to the International Knee Documentation Committee score, 35% of knees (25) were ‘normal’, 52% (37) ‘nearly normal’ and 13% (9) ‘abnormal’. Complete satisfaction was noted in 90% of patients (64). The development of osteoarthritis and the management of anterior cruciate deficiency associated with laxity of the medial collateral ligament remains uncertain. Our results indicate that in the medium-term, the ABC ligament scaffold is suitable and effective when early and safe return to unrestricted activities is demanded. We acknowledge the current general hostility towards reconstruction of the anterior cruciate ligament with artificial materials following reports of early failure and chronic synovitis associatiated with the production of particulate debris. We did not encounter these problems.

Aims: We decided to investigate the efþcacy of postoperative Epoetin Alfa in decreasing allogenic transfusion exposure in patient who had an mediummajor orthopaedic intervention who could conduct in major loss of blood. Material-Method: Between July 2000-Mars 2002 in our department a trial was conducted comparing the safety and efþcacy of a weekly epoetin alfa dosing regimen (40000⋄4) with a daily regimen (10000⋄15) in patients with hemoglobin levels 9g/dl< Hb< 11g/dl in the 2nd postoperative day after a major orthopaedic procedure. The average age was 28–85y. Results: In the þrst group (24p) there was a increase of the Ht 6units and in the 2nd group 4units. In the þrst group we had a death in the 13een postoperative day from diffuse intravascular coagulation. In both groups the rehabilitation and discharge of the patients were quicker and there was no postoperative transfusion. In 9 cases of the þrst group and only in 2 of the second we observed a enormous augmentation of the platelets (600000–1000000) but without any signs of thrombosis. This point needs more investigation. Conclusion: These data showed the weekly Epoetin Alfa regimen to be at least as efþcacious and more convenient as the daily regimen in the treatmen of the postoperative anaemic patients. More investigation is needed for possible complications.

Surgeon who used the uncemented cup must choose between two kids of cups: the porous coated (press fit) and the threaded. Many authors present several discouraging results. Nevertheless satisfactory results have also been obtained using threaded cups and the explanation lays in the design the alloy and the surface characteristics of the acetabular component.

We describe the clinical and radiological outcome of 93 THA in 81 patients using a screw-in cup (Link- type) performed between 1994–2000. Our follow-up time was and the average age of the patients was 68y,all were primary THA(78 OIA,15 sub-capital fractures).Clinical evaluation was perfomed using the Merle d’ Aubigne hip score.

Results: We had good results in 90,3%. Migtation of 2mm of the treaded ring was present in 9 (nine) THA. Although only one has been revised up to now the future of the others remain uncertain. There was no revision of the femoral stem but we had one septic loosening.

Conclusion: Our findings suggest that long-term fixation of a treaded cup in primary T’HA was satisfactory if there aren’t present any migration factors like osteoporosis whatever the etiology (in these cases we must put an over-size cup) and a wrong primary position. We believe also that the design of the Link-type treaded cup with this depth-extension space of the treads and the absence of the bottom hole is related with our good results.

Introduction: Primary fixation of displaced sub-capital fractures with low morbidity and low mortality offers an approach to a very common problem. The vast majority of patients receiving this form of treatment will not require further surgery. When confronting with the problem of primary arthroplasty which includes a higher morbidity and higher mortality, a higher infection rate and the possibility of prosthetic loosening especially in young patients, the choice seems clear.

Material and method: Between 1995 and 2000, a series of 21 patients (15f, 6m) were admitted for a displaced subcapital fracture (16 type Garden III, 5 type Garden IV) to our clinic. All the patients were operated 24 to 36 h after admission.

The mean age was 48y. The technique consists of:

Anatomic reduction (with a C-arm), which was the most crucial point of the technique.

Results: The mean follow-up was 34 m. We did not have any osteonecrosis of the head. No complications. The mobility of the hip was normal in all patients. There were two cases with delayed union and one case with non-union due to a distention at the site of the fracture after the reduction_

Conclusion: We believe that this technique, especially the combination of an anatomic reduction of the fracture and the use of a cancelocortical graft is a very prospective alternative to a prosthetic replacement in relatively young patients.

In modern surgery, one main goal is to reduce perioperative and postoperative transfusion need.

The haemostatic disorders, the patients’ gender and the type of the operation seems to predict the blood loss in orthopaedic surgery.

It has been reported recently, an association of the Factor V Leiden mutation and with a lower rate of intra-partum blood loss,

Purpose: The aim of our study was to evaluate if there is an association between blood loss and pro c global system in orthopaedic operations.

Pro C Global system is influenced by FRO C, PRO S, APC resistance (FV Leiden) and FV111.

Materials and methods: We studied 42 patients, 31 women and 11 men, between 22–86 years old, who were operated in our hospital.

19 with total knee arthroplasty, 11 with total hip arthroplasty, 11 with fractures and 1 patient with amputation of -the lower leg.

The blood loss for each patient was calculated according the Mercurialli formula: Total blood loss: total blood volume x (Ht preop-Ht day 5 postop)+ml of RBC transfused. The total blood loss was expressed in terms of percentage of total blood volume and defined as relative blood loss.

Patients were divided into two groups with high and low relative blood loss, according the median value of the relative blood loss.

Pro C global values was monitored in all patients pre-operatively on a BCT analyzer (Dade Behring). Values > 0.8 are considered normal.

Results: The median value of relative blood loss was 15,05%. 21 patients were below this level and considered to have low relative blood loss. 21 patients were above this level and considered to have high relative blood loss. 18 patients had pro C Global values < 0.8 and 24 patients had Pro C Global > 0.8. Patients with low relative blood loss tend to show lower Pro C Global values than patients with high relative blood loss. (0,87 versus 0.90, p= 0.7 NS) without statistical difference.

Conclusions: In this study the Pro C global system does not seems to predict perioperative blood loss in patients with orthopaedic surgery and so it is useless to be monitored preoperatively.

It is known that patients who are undergoing major orthopaedic operations of the lower legs (fractures, total hip and knee arthroplasty) belong to a high-risk group, for the development of thromboembolic events.

20–40% of the patients develop deep vein thrombosis (DVT) of the calf and 2–4% fatal pulmonary embolism.

These patients may have remarkable activation of the coagulation system, which is important for the development of deep vein thrombosis of the lower legs.

Purpose: The aim of the study is to evaluate the activation of selected blood coagulation parameters, during the preoperative and postoperative period, in patients undergoing high risk of orthopaedic operation of lower limbs.

The exact estimation of these factors is necessary, so that these patients receive the suitable prophylactic antithrombotic therapy,

Patients and methods: We studied 24 patients, 16 women and 8 men, between 23–84 years old, 12 with femur fracture, 8 with total knee replacement and 4 with total hip replacement surgery.

All patients had normal renal function, and the platelets, count, the PT and aPTT were in a normal range.

The patients were hospitalized for 7 days and then they were observed as outpatients for the possibility of developing deep vein thrombosis and for a 4 weeks period.

All patients received a combination of LMWH and graduated compression elastic stockings as a prophylaxis against DVT.

Plasma concentration of Di-dimers and Thrombin -Antithrombin complex (TAT) were measured preoperatively and the second, the fourth and the sixth day postoperatively.

Di-dimers plasma concentration were measured by automated analyzer (VidasBiomerieux) and TAT plasma concentration were measured by an enzyme-linked microimmunoabsorbent assay (microelisa Dade-Berhing)

Results: Preoperative TAT concentration in patients with femur fracture were high. Postoperatively decreased with the major decreasement on the second day (p< 0.039). Till the 6th postoperative day TAT concentration remained above normal range. Di-dimers plasma concentrations were high preoperatively and remained also high postoperatively, without significant statistical difference.

In patients with total hip and knee arthroplasty TAT plasma concentration increased significantly the 12nd postoperative, day, decreased the 4th postoperative day and then increased again (p< 0.01). Di-dimers plasma concentration increased significantly the 2nd postoperative day and then decreased (p< 0,03).

Until the 6th postoperative day Di-dimcrs concentration remained above normal range. Patients with fractures had higher TAT levels preoperatively than patients with total hip and knee arthroplasty. (p< 0.027)

Conclusions: All patients with major orthopaedic surgery of lower limbs have shown significant activation of the coagulation system postoperatively. Patients with fractures present significant activation of the coagulation system post and preoperatively. So it may be necessary in patients with fractures, to start anticoagulation prophylaxis against DVT preoperatively, and the last dose of LMWH must be given 12 hours before the operation.

Introduction: The acute rupture of Achilles tendon is injury with absolute indication for operation. Rupture of the Achilles tendon is only in rare instances due exclusively to an accident. Commonly, the site of rupture reveals marked fraying and degenerative lesions.

Therefore, the pathologic tissue must be excised and often a large defect is created. Different procedures have been described to repair this defect.

Methods: In our department, between June 1995–June 1997 we have use the operation described by Lange to bridge the defect in 15 acute rupture of Achilles tendon.

This procedure consists in turning down a fascia flap from the gastroknernius to bridge the gap and end-to-end suture. In 13 patients the plantaris tendon has been used as a reinforcing membrane. In 2 cases we didn’t found it. We didn’t have any postoperative complications. After care a long -leg cast is applied with sufficient equinus of the foot and flexion of the knee for 6 weeks. For 6 weeks more a short leg cast was applied with the foot in neutral position and weight hearing was slowly resumed.

Results: All the patients were reviewed between 6m and 2y. (F.U. 14m) and pain, range of motion, power, and functional level were evaluated.

We had 2 far results and 1 poor but -no rerupture. The gap that we were obliged to repair was between 3cm–8cm

Discussion: We believe that this procedure, described for neglected rupture, is a method that we can recommend for acute rupture of degenerative Achilles tendon.

100 randomized primary cementless THRs in 80 patients were reviewed retrospectively regarding the HA cover of the stem which was Waldemar Link’s, ribbed type, made of Titanium, with a collar and mostly applied without the trochanteric screw. The femoral neck was always retained high as possible. Full weight bearing on the operated leg started the 3rd postoperative day, while years earlier the 6th postoperative week. Two more or less, equal groups were formed: (A) without, (B) with HA covered stems and two subgroups: patients of 60 to70 years and 70 to 80 years. Gender was matched as possible and mean follow-up time was 8 years (range 7 to IO years). The Harris Hip Score was used for clinical evaluation and the method of “pencil and ruler” in plain X- Rays for radiographical one. Patients who died after the 8th postoperative year of evaluation were included.

Results

1, The postoperative hip score was at average for group (A) 92.1 points and for gr. (B) 92,4p.

2. In gr. (A) we found* at a rate 70% 2mm of symptom less, adaptive, slow early migration, while in gr. (B) this corresponded to 1 mm of same migration at a rate 60%. In both groups migration stopped by the second postoperative year.

3. “Alarming” stem migration was found in two cases: one in each group. The cause was that the stems applied, were undersized and the patients were women on menopausal osteoporosis. Both sterns were revised. Two more “alarming” stem migrations were found, one in each group, in patients suffering from collagenosis with the relevant bone quality. This migration was related to bone retreat primarily and irrelevant to stem’s loosening, gender or age of patients. Both stems have not been revised yet.

4. Similar and minimal-2% for gr. (A) vs 4% for gr. (B)- was the rate of symptomless, limited, non-sclerotic of less than 2mm wide demarcations gradually resolving, 5. Similar and minimal-2% for gr. (A) vs 5% for gr (B)- was the rate of stress shielding phenomenon resolving in 2 years time.

6. No further mechanical or biological loosening were noticed at mid-term results

7. Similar- 20% for gr (A) vs 15% for gr (B) was the rate of mild symptomless ectopic ossifications.

Conclusions: No significant differences were found at mid-term results between the two groups, the one without (A) and the other (B) with HA covered sterns. In case a stem happens to be undersized not securing primary fixation or in case the bone’s quality is not promising mechanical and biological fixation of the stem, then the presence of HA cover will not prevent the stem from “alarming” migration. Though we are still using successfully the cementless stem for patients over 70 years of age, when ever dealing with such quality of bone as with collagenosis then it would be wise to consider the use of the cement and even so reservations must exist.

Introduction: Mitchell’s operation is a double step-cut osteotomy through the neck of first metatarsal (MT) which displaces laterally and plantar flexes the metatarsal head and minimally shortens the first MT. In coexisted further forefoot abnormalities this osteotomy can be combined by additional corrective osteotomies of the rest metatarsals and straightening of toes.

Material and Methods: A prospective study was carried out in our Department, on 42 patients (51feet) operated with this osteotomy alone or combined.

The mean follow-up time was 10 years (range, 3–15 years). The average age of patients was 58 years. The average angle of HV deformity was 38 degrees (in nine feet this angle was more than 40 degrees). Mean inter-metatarsal (IM) angulation was 15 degrees.

The procedure was always followed by Y or V capsuloplasty of first metatarsophallangeal (MTP) joint. Moderate arthritis of first MTP joint was not considered by us as a contraindication for this operation. The osteotomy was secured by two crossed K-wires.

In 20 feet (15 patients) with coexisted forefoot abnormalities oblique osteotomies of the rest metatarsals, arthrodeses of proximal interphalangeal (PIP) joints and elongation of extensor tendons were carried out.

Results: In examination, we checked the correction of the deformities; we assessed pain and comfortability in wearing shoes and the joints motion, hi early postoperative examination the mean correction in HV angle was 18 degrees and in IM angle was 5 degrees, but in last examination there was a loss of 5 degrees in the HV angle correction. One hallux was overcorrected. 90% of the results were satisfactory including all feet with osteoarmritis of first MTP joint. 10% of the results considered as poor including all feet with preoperative HV deformity of more than 40 degrees. Ten feet (eight patients) suffered from metatarsalgia established because of fall of MT arch. We feel that Mitchell’s osteotomy is not suitable for HV deformity exceeding the 40 degrees.

Introduction: Moderate and major operation concerning trauma or selective procedures (like total ¥2) joint replacement) can lead to considerable amount of blood loss and postoperative anaemia. This loss affects negatively the patients’ postoperative course concerning mortality, morbidity as well as patients’ recovery. We decided to provide these patients with Epoetin Alpha in the early postoperative period to control anaemia.

Material and Methods: In our Department, from July 2000 until March 2002, we treated 42 patients with postoperative anaemia due to moderate or major operations (like hip and femoral fractures, total joint replacements). Patients’ age ranged from 28 to 85 years, hi this study we included all patients with 9g/dl < Hb < 1 Ig/dl on second postoperative day, without coexisted contraindications for administration of Epoetin Alpha. Patients having been transfused due to serious postoperative anaemia were not included in this study. Laboratory tests included full blood count check up to the end of treatment.

Patients were divided in two groups, hi the first group (18 patients) were provided 2 X 10000 units Epoetin Alpha daily for 15 days, hi the second group (after August 2001) we provided 40000 units X 4 every three days, hi all cases we provided Fe per os. One patient (in the second group) sustained diffuse intravascular coagulation (DIG) on the 13th postoperative day and finally she died. In the first group we noticed an increase of Ht by 4 units (mean rate) and in the second group by 6 units. Two cases in the first group presented a slight raise of the Ht (one unit), while the patient who presented DIG belonged to the second group. No patient was transfused postoperatively. Mobilization of patients especially the elderly was earlier than usual. An interesting notice was the raise of platelets (> 600000) in nine cases of the second group and in only two cases of first group, without complications. This raise was attributed to the stimulation of bone marrow due to the fast blood loss during the operation.

Conclusion: The effectiveness and safety of Epoetin Alpha has been proved in many studies concerning selective orthopaedic operations. Update results show that Epoetin Alpha has a significant effect in the treatment of postoperative anaemia. Of course further investigations (like double blind studies and control of potential complications from administration) are mandatory.