Introduction: There is scant information on the trends of simultaneous bilateral total knee arthroplasties (BTKA). The safety of BTKR has been put into question because of a possible association with increased morbidity and mortality. We hypothesized that substantial changes in BTKA patients demographics, in-hospital complications and mortality have occurred over time in the United States.

Methods: We analyzed information collected for the National Hospital Discharge Survey (NHDS) from 1990 to 2004, to elucidate temporal changes in the utilization, demographics, comorbidity profiles, hospital stay, and in-hospital complications of patients undergoing BTKA in the United States. Three five-year periods were created (1990–1994, 1995–1999, 2000–2004) to facilitate temporal analysis. Temporal changes in patient and health care variables were analyzed.

Results: 153,259 discharges after BTKR were identified (20.18% performed between 1990 and 1994, 28.73% between 1995 and 1999 and 51.08% between 2000 and 2004). Utilization of BTKR more than doubled for the entire civilian population and almost tripled among females. All age groups experienced an increase in utilization of BTKR throughout the study period, except those 85 and older. Most recently a decline of approximately 50% was seen. The distribution of BTKR procedures among age groups changed significantly, with an increased proportion of patients between the ages of 45–64 receiving this procedure (32.83% in 1990–1994; 43.62% in 2000–2004). Comorbidity burden increased steadily over time for hypertension, diabetes mellitus, hypercholesteremia, obesity and renal disease, with half of all patients being affected by hypertension in the most recent time period. The prevalence of coronary artery disease and pulmonary disease decreased from the second to the third time period. Length of hospital stay decreased by half from 9.27 (range 2–53) days between 1990–1994 to 5.44 (range 1–44) days between 1995–1999 and to 4.68 (range 1–33) days between 2000–2004. Overall, procedure related complications rates decreased over time from 19.85% in the first time period to 8.89% in the most recent time period studied.

Discussion: We identified a number temporal changes associated with BTKR performed during the same hospitalization. While utilization in general increased over time, operations on patients above the age of 85 years and amongst those with cardiac and pulmonary disease decreased during the last decade. Overall, procedure related complication rates fell by approximately 50% over the study period.

Total hip arthroplasty (THA) in neglected congenital dislocation of the hip (CDH) constitutes a challenging procedure, with surgical difficulties and complications. The purpose of this study was to analyse the complications of THAs in CDH.

Between June 1983 and September 2002, 418 THAs-were performed in 356 patients with CDH, with a mean follow-up 108 (7–237)months. The mean age at surgery was 53.3 (24–79) years with 325 females and31 males. 83 patients had CDH in high position. 307 arthroplasties were cementless, 39 cemented and 72 hybrids. 40 stems were custom made. The cup always was positioned at the true acetabulum. 24 shortening osteotomies of the femur, 8 corrective supracondylar and 6 trochanteric osteotomies were performed.

Preoperatively the average Merle d’Aubigne-Postel hip score was 1.1 for pain, 4.8 for range of motion and 3.1 for walking ability. Postoperatively the average hip score was 5.2, 4.7 and 5.3 respectively. The average length discrepancy was 8 cm (3–12) preoperatively and 1.5 cm remained in 8 patients. Complications included 7 intraoperative fractures of the femur, 12 dislocations, 4 peroneal nerve palsies that recovered, 25heterotopic ossifications, 7 deep vein thromboses, 3 pulmonary embolisms, early mechanical loosening in 4 cemented and 10 cementless cups and 3infections.

Complications were diminished dramatically last years due to improved surgical technique, new available implants and preoperative evaluation of the hip with CT and CAD-CAM-CAE study that allowed better surgical planning with trial stem implantation from a series of stem designs and custom made femoral components manufacturing

Purpose: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to deþne the risk of vascular complications after proximal locking in intramedullary tibial nailing. Methods: Seven fresh cadaver legs were obtained from the University Hospital of Ioannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization. Results: MRI sections combined with CT and 3D-CT have been used to illustrate the þndings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these þndings highlighted the surgical risks associated with this type of proximal locking and its direction. Conclusions: Proximal anteriorposterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended as an alternative procedure to eliminate the potential for iatrogenic lesions.

This study of surgically treated distal tibia fractures was undertaken to compare the internal fixation with the two external fixation methods.

There were 40 patients with 41 pilon fractures. The mean age was 51.2 years (18–76). 17 of the 40 patients-14 from vehicular accident, 3 from fall – were treated with an ankle-spanning half-pin external fixator (11C, 6B, 11 Weber B- 5 C, 1IIIa, 5I, 6II). 11 patients-10 from vehicular accident, 1 from fall- were treated with a single-ring hybrid ankle-spanning external fixator (9C, 2 B, 6 Weber B-4 C, 5I, 2II). 13 patients-10 from vehicular accident and 1 from fall- were treated with an epiunion plate (1A, 8B, 4C, 5I, 3II, 10 Weber B- 1C). The mean follow-up was 4.2years (1–8). Fracture union was defined as having three cortices bridging on the plain radiographs for a patient who was able to bear full weight. Non union was defined as a fracture that did not heal within a year.

Fracture union was achieved for 36 of the 41 fractures. Three patients with external fixator, one with hybrid and one with plate had septic pseudarthrosis. Fractures in the external fixator and hybrid groups had a tendency to lose the reduction. Four patients with external fixator had delayed union and have lost range of motion in the ankle. Five patients in the external fixator group are candidates for ankle arthrodesis due to arthritis.

The ORIF and hybrid fixator were equally efficacious in achieving bony union and not to lose range of motion in the ankle. Fractures in the external fixator with the ankle – spanning had higher rate of delayed union and loss of motion in ankle. The choice of the external fixator is dependent on the surgeon and the type of the fracture. However the patient must be followed up for the stability of the system.

This study describes the clinical features and treatment of the 53 patients with primary tumors of the hand. A review of primary tumors of the small bones of the hand during a 9 year period (1991–2001) was done. There were 14 enchondromas, 1 malignant fibrous histiocytoma, 15 ganglions, 5 haemangiomas, 1 haemangioma of median nerve, 4 giant cell tumors of tendon sheath, 4 osteoid osteomas, 1 lymphangioma, 1 exostosis, 1 dermatofibrosarcoma, 1 neurilemoma, 2 neurinomas, 1 glomus tumor, 1 benign fibrous histiocytomas and 1 papillary endothelial hyperplasia. There were 34 males and 19 females with an average age 37.7 years. The mean follow-up was 6y (1–8y). There were 33 lesions in the fingers, 3 in the metacarpals, 13 in the carpus and 4 in the palm. Swelling and localized tenderness were the most common presenting complaints. One patient died of metastatic disease. 3 patients were seen initially with locally reccurent lesion. All the patients were treated surgically. The material was analyzed in terms of diagnosis, localization, surgical management and post-operative complications. Primary tumors of the hand are rare. The cases in these series are similar to that of other reports. As in other musculoskeletal neoplasms, a treatment plan must be formulated based on the location, size and biologic behaviour of the lesion.

We present the results of custom made cementless implants for treatment of osteoarthritis due to congenital disease of hip and osteonecrosis due to other diseases, where the normal anatomy was severely modified and it was impossible to insert the smallest available implant.

There were 43 patients with 52 hips, 6 males – 46 females. The mean age was 48years (22–61). The mean follow-up was 24 months (1–48). There were 32 patients with low dislocation, 14 with high dislocation, 1 with infantile septic arthritis, 1 with Hodgkin disease, 1 with dysplasia, 1 with ankylosing spondylitis, 1 with congenital varus hip and 1 with Perthes disease. Our protocol was consisted of plain radiographs and CT of the acetabulum, femur, knee condylars and foot in order to be evaluated the bone stock of acetabulum and the femur anteversion.

All the patients were evaluated – according to the Merle D’ Aubigne score – two, three and every six months after the operation. There was one complication with a proximal femur fracture in a high dislocated hip during the operation and two complications postoperatively. Both of them were high dislocated hips, and the one had paresis of sciatic nerve, that it recovered. The other had septic loosening and was undertaken revision in two stages. All the patients improved in pain, in walking ability and in range of motion.

The impossibility of using the smallest available implant due to the high deformity and the young age led us to use custom made implant. Although a long follow-up is required for these procedures the first results are very encouraging according to the recovery of the patients which were related to the restoration of hip biomechanics provided by the three dimensional neck orientation.

Total hip arthroplasty (THA) in neglected congenital dislocation of the hip (CDH) constitutes a challenging procedure, with surgical difficulties and complications. The purpose of this study was to analyse the complications of THAs in CDH.

Between June 1983 and September 2002, 418 THAs were performed in 356 patients with CDH, with a mean follow-up 108 (7–237) months. The mean age at surgery was 53.3 (24–79) years with 325 females and 31 males. 83 patients had CDH in high position. 307 arthroplasties were cementless, 39 cemented and 72 hybrids. 40 stems were custom made. The cup always was positioned at the true acetabulum. 24 shortening osteotomies of the femur, 8 corrective supracondylar and 6 trochanteric osteotomies were performed.

Preoperatively the average Merle d’Aubigne-Postel hip score was 1.1 for pain, 4.8 for range of motion and 3.1 for walking ability. Postoperatively the average hip score was 5.2, 4.7 and 5.3 respectively. The average length discrepancy was 8 cm (3–12) preoperatively and 1.5 cm remained in 8 patients.

Complications included 7 intraoperative fractures of the femur, 12 dislocations, 4 peroneal nerve palsies that recovered, 25 heterotopic ossifications, 7 deep vein thromboses, 3 pulmonary embolisms, early mechanical loosening in 4 cemented and 10 cementless cups and 3 infections. Complications were diminished dramatically last years due to improved surgical technique, new available implants and preoperative evaluation of the hip with CT and CAD-CAM-CAE study that allowed better surgical planning with trial stem implantation from a series of stem designs and custom made femoral components manufacturing.

Purpose: Although transient osteoporosis of the hip was initially described in pregnant women, now most frequently identified in middle-age and older men. Has also been reported to occur in either hip and in both successively. This condition is referred as migratory transient osteoporosis of the hip. In this study the authors describe five cases of migratory hip osteoporosis and the differential diagnosis with osteonecrosis is also discussed.

Material and Methods: Thirty-four patients with transient osteoporosis were presented. Of the 34 patients five had a similar episode of severe pain in the contralateral hip 14 months mean time later. Early bone scans and MRI of the hips had been carried out in all of the patients. After the evaluation of these findings and thorough exclusion of other conditions diagnosis of migratory transient osteoporosis was demonstrated, and confirmed by the natural course of the disease.

Results: All cases were treated with nonsteroidal anti-inflammatory medications and protected weight-bearing. The course of the disease has not been appreciably altered by medical treatment, and the mean time interval from the onset of symptoms to clinical recovery was 4.6 months (range 3 to 6 months). Imaging findings on MR confirmed the diagnosis during both episodes and paralleled the reduction of pain.

Conclusions: Migratory transient osteoporosis of the hip is a rare self-limited condition of uncertain etiology and pathogenesis, which “migrate” from one hip to the other. Magnetic resonance imaging is highly sensitive in the early detection of this condition and moreover is helpful in the exclusion of other entities. Although the diagnosis is one of exclusion, it must be considered and contrasted with hip osteonecrosis.

Introduction: In cases of severe, rigid scoliotic curves, anterior or posterior fusion alone is inadequate and surgical treatment with a combined anterior and posterior) approach is required. The purpose of this study is to evaluate the effectiveness and the complications of these lengthy procedures.

Material and Methods: Between 1993 and 2002, 125 patients with scoliosis were surgically treated in our department. A total of 18 patients with scoliosis were treated with a combined anterior and posterior approach. The mean age of these patients was 19.6 years (range 5.5 – 60 years). Fourteen patients were subjected to a single-stage procedure, while 4 patients underwent a staged procedure. Thirteen patients underwent anterior release and posterior nstrumentation, while 5 patients underwent both anterior and posterior instrumentation. Additional thoracoplasty was performed in 3 cases. The mean duration of the operation was 12.1 hours (range 4.5 – 14 hours). All patients were monitored postoperatively in the Intensive Care Unit. The mean duration of follow-up was 4.5 years (0.6 – 9 years).

Results: Anterior release and posterior instrumentation achieved a mean 30% correction of curves that were corrected by only 15% with traction preoperatively. Combined anterior and posterior nstrumentation achieved a mean 44% correction of curves that were corrected by only 22% with traction preoperatively. One patient presented residual pneumothorax that was treated with chest tube. One patient with neuromuscular scoliosis presented wound dehiscence and early infection, which led to removal of the posterior instrumentation.

Conclusions: A combined anterior and posterior procedure is indicated in patients with severe, rigid curves. It achieves greater correction, and prevents the crankshaft phenomenon in immature patients. We recommend the single-stage procedure (if patient general condition permits), because: 1) total anesthesia time is reduced, 2) total intraoperative blood loss is reduced, 3) hospital stay is reduced, and 4) greater curve correction is achieved. Severe complications include respiratory dysfunction and diffuse intravascular coagulation in multiply transfused patients, especially with use of an intraoperative autotransfusion device.

Aim: This study describes the clinical features and treatment of 94 patients with skeletal osteochondroma during the last 20 years.

Materials-methods: A retrospective review of various size solitary osteochondroma was evaluated. There were 51 males and 44 females with mean age 21 years. The mean follow-up was 8 years (1–12). There were 40 lesions in the distal femur, 6 in the greater trochanter, 19 in the proximal tibia, 1 in the proximal fibula, 1 in the calcaneus, 3 in the lateral malleolus, 1 in the medial malleolus, 3 in the talus, 2 in the tarsus, 3 in the metatarsals, 3 in the scapula, 4 in the humerus, 1 in the elbow,1 in the radius, 6 in the fingers. The lesions were diagnosed by history and plain radiographs. In two patients with large lesions around the knee an angiography was done

Results: Pain and local tenderness were the main symptoms. The treatment was en bloc excision of the tumor. There were no recurrence. Two patients had wound infection which was dealt with antibiotic.

Conclusion: The site and the results of this study are similar with the literature. The radiologic image is pathognomic for the tumor. The treatment consisted of en bloc excision. There is high possibility of recurrence in case of insufficient excision.

Aim: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to define the risk of vascular complications after proximal locking in intramedullary tibial nailing.

Material and Methods: Seven fresh cadaver legs were obtained from the University Hospital of loannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization.

Results: MRI sections combined with CT and 3D-CT have been used to illustrate the findings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these findings highlighted the surgical risks associated with this type of proximal locking and its direction.

Conclusions: Proximal anterior-posterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended.