Aim

Gram negative bacteria (GNB) are emerging pathogens in chronic post-traumatic osteomyelitis. However, data on multi-drug (MDR) and extensively drug resistant (XDR) GNB are sparse.

Aim

Data on Prosthetic joint infection (PJI) caused by multi-drug resistant (MDR) or XDR (extensively drug resistant) Gram negative bacteria (GNB) are limited. Treatment options are also restricted. We conducted a multi-national, multi-center assessment of clinical data and factors of outcome for these infections.

Report of a case of migrating periprosthetic infection from a hip replacement to a contralateral knee joint undergoing a total knee replacement.

We present a 74-year old female patient who underwent a total hip arthroplasty of the left hip after a subcapital fracture of the femur. Four months after the index procedure the patient presented with signs and symptoms of infection of the operated joint. Staph aureus and Enterococcus faecalis were recognized as the infecting bacteria. The implants were removed, cement spacers were placed and a total hip arthroplasty was performed again after three months. Unfortunately, infection ensued again and the patient underwent three more procedures until the joint was considered clean and t he hip remained flail without implants. The patient elected to undergo a total knee arthroplasty due to severe osteoarthritis of right knee. Intraoperatively tissue samples were taken and sent for cultures which identified Enterococcus faecalis present in the knee joint. Enterococcus migrated from the infected hip to nonoperated knee joint. Intravenous antibiotics were administered for three weeks but the knee presented with infection of the arthroplasty ten months after its insertion. The implants were removed the joint was debrided and cement spacers were inserted.

The patient decided not to proceed with another procedure and she remains with the cement spacers in her knee.

Rare report of migrating periprosthetic infection. Nosocomial enterococci acquired resistance cannot be ruled out. Unique characteristics in enterococci antibiotic resistance and biofilm formation.

Two-stage revision procedure is the gold standard in management of periprosthetic infections. Cement spacers have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (thermal necrosis, random porosity, unspecified antibiotic delivery rate).

To present the concept of using PerOssal as a canal filling spacer and local antibiotic delivery system in two-stage revisions of hip and knee infected arthroplasty.

8 patients (6 females, 2 males) with infected arthroplasty (4 TKRs, 4 THRs) were managed with two-stage revision procedures during the years 2006–2008 (minimum FU: 12 months). Our protocol consisted of:

Preoperative determination of the causative organism

We had 7 cases with eradication of infection, 2 with delayed wound closure, and 1 late recurrence of disease.

We think that PerOssal can offer a very useful additional and genuine support in managing infected joint arthroplasties with so far good clinical results.

Introduction: Two-stage revision procedure is the gold standard in management of periprosthetic joint infections. Cement spacers have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (thermal necrosis, random porosity, unspecified antibiotic delivery rate).

Purpose: To present the concept of using PerOssal as a canal filling spacer and local antibiotic delivery system in two-stage revisions of hip and knee infected arthroplasty.

Material & Methods: 8 patients (6 females, 2 males) with infected arthroplasty (4 TKRs, 4 THRs) were managed with two-stage revision procedures during the years 2006–2008 (minimum FU: 12 months). Our protocol consisted of:

Preoperative determination of the causative organism its sensitivity to antibiotics

Results: We had 7 cases with eradication of infection, 2 with delayed wound closure, and 1 late recurrence of disease.

Conclusion: We think that PerOssal can offer a very useful additional and genuine support in managing infected joint arthroplasties with so far good clinical results with respect to infection control.

To compare usual practices against published guidelines of Perioperative Antimicrobial Prophylaxis (AP), which is an established method to reduce the risk of postoperative infection in TJR.

We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum.

The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B (2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR: 5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, therapeutic (group B) or prophylactic (group A), was comparable in both groups (p> 0.05).

Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic and therapeutic) in both groups.

Background: Perioperative Antimicrobial Prophylaxis (AP) is an established method to reduce the risk of intraoperative infection in TJR. Usual practices are not always compatible with published guidelines leading to excess morbidity, antibiotic overuse and emergence of resistance.

Methods: We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum.

Results: The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B(2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR:5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, prophylactic (group A) or therapeutic (group B), was comparable in both groups (p> 0.05).

Conclusions: Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic or therapeutic) in both groups.

The objective of the present study is to analyse the clinical, microbiological, and therapeutic features of patients with infective spondylodiscitis (ISD), who were followed up in our Outpatient Bone Infection Clinic.

We retrospectively studied the epidemiological and clinical characteristics of all patients diagnosed with ISD from January 1998 to December 2006. Data were extracted from an electronic data base registry and patients’ files.

Sixty patients either with spontaneous (n= 42, 70%) or postoperative (n= 18, 30%) ISD were evaluated. Population mean age was 56 years, 33 (55%) were male and 27 (45%) were female. The infection was localised in the lumbar (78%), thoracic (18%) or cervical (4%) spine. Predominate symptoms were pain (87%) and fever (50%). Fistula was observed exclusively in postoperative ISD (45%). In spontaneous ISD, the major causes were Brucella spp (33%), gram positive cocci (12%), gram negative bacteria (14%), Mycobacterium tuberculosis (7%), while in 33% of cases no pathogen was detected. In postoperative episodes of ISD the major causes were gram positive cocci (45%), gram negative bacteria (30%) and polymicrobial infection was documented in 22% of cases while in 25% of cases no pathogen was detected. Based on clinical, laboratory and imaging (especially MRI) data, treatment was individualised. Most patients (88%) received a combined antimicrobial treatment. Patients with spontaneous pyogenic/brucellosis or tuberculous/post-operative ISD received treatment for a median duration of 8/12/10 months and the response rate was 84%/81%/55.5%, respectively. Surgery was necessary in 40% of postoperative ISD cases for healing, while only one spontaneous case required a surgical intervention.

ISD is more frequently localised at the lumbar level. Long term combination antimicrobial treatment may be essential. Surgery may be required in iatrogenic cases in the presence of foreign bodies.

Purpose: Little has been written about the size of bone defect that could be restored with one-stage lengthening over a reamed intramedullary nail. The aim of this study was to investigate the mechanical properties of the callus created at gaps of various sizes in sheep tibiae treated with reamed intramedullary nailing.

Material-Methods: Sixteen adult female sheep were divided into four main groups: a simple osteotomy group (group I) and three segmental defect groups (1, 2, and 3 cm gap; groups I to III). One intact left tibia from each group was also used as the non-osteotomized intact-control group (group V). In all cases the osteotomy was fixed with an interlocked Universal Humeral Nail after 7 mm reaming. The osteotomized site was closed in layers including the periosteum without additional bone grafting and the limb was protected with long soft cast for 5 weeks postoperatively. Healing of the osteotomies was evaluated after 16 weeks by biomechanical testing. The examined parameters were torsional stiffness, shear stress and angle of torsion at the time of fracture.

Results: Samples with a simple osteotomy or 1 cm gap were fractured distally to the callus zone, whereas samples with 2 and 3 cm gaps were fractured at the callus zone or at distal metaphysis. The regenerate bone obvious in the x-rays in the group of 1 cm and 2 cm gap had considerable mechanical properties. Torsional stiffness in these two groups was nearly similar and its value was about 60% of the stiffness of the simple osteotomy group. A gradually decreased stiffness was observed as the osteotomy gap increased. There was a decrease in maximum shear stress from simple osteotomy to osteotomy with a fracture gap of 3 cm. No significant differences were found among the angles of torsion at fracture for the various osteotomies or the intact bone. Our results showed that the group of 1 cm gap had the 65% of the shear stress at failure of the simple osteotomy group.

Conclusion: We believe that there is evidence indicating that intramedullary nailing would be a reasonable option when one-stage lengthening of a long bone of 1 or 2 cm is contemplated.

Aim: End result study of closed intramedullary nailing of humerus fractures.

Materials & methods: Between 1995–2003, 42 patients with fracture of the humeral shaft, were selected to be treated by I.N. The average age was 48 years old (17years–82years) The Selection criteria were: α) loss of closed reduction (24 patients), b) pathological fractures (5 patients), c) non-union following external fixation (2 patients) and d) delay of union (7 patients). The intramedullary nail was inserted through a proximal entry point via a transdeltoid incision. In 25 cases the entry point was below the greater tuberosity to avoid rotator cuff injury and in 18 cases the entry point was intraarticular. All nails were locked either proximal (41) or distally (1). Open technique was required for 21 cases. Passive full range of motion of elbow and shoulder joint was encouraged after the second postoperative day. Active assisted exercises were initiated the second postoperative week. Bone healing was confirmed by clinical and radiological findings. Shoulder mobility was evaluated by the Constant-Murley scoring system.

Results: The average follow-up time was 21 months (9 months–8 years).All fractures were finally healed. The average healing time was 13 weeks (8weeks–13weeks). Patients with extraarticular entry point of the nail had full passive shoulder motion between the 2th and the 4th postoperative week, whereas patients with intraarticular nail application presented delayed passive shoulder motion with final limitation of the normal range of motion. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with neurapraxia of the radial nerve installed posttraumatic, who had full recovery 3 months later. There was one proximal migrated nail, which required revision. None of the patients required nail removal.

Conclusions: Intramedullary nailing of humeral shaft fractures seems to be a reliable method of treatment. Shoulder mobilization after anterograde insertion of the nail can be easily restored with proper choice of entry point and proper physiotherapy program. The advantages of this method include: shorter operative time, less blood loss, small incision with minimal soft tissue damage. Extraarticular nail insertion should be the entry point of choice as there is no trauma to the rotator cuff.

Aims: To evaluate the effectiveness of external fixation exchange by intramedullary nailing during consolidation phase following callus distraction phase. Methods: In 12 skeletally mature female sheep, equally divided in two groups (group A and group B), we performed tibial shaft osteotomy and 2cm gradual callus distraction using Ilizarov external fixator in a 0,5mm/12h rate. In group A, Ilizarov fixator was removed immediately after lengthening completion, and static unreamed intramedullary nail was inserted. In group B, Ilizarov device remained during consolidation phase. Formatted callus was studied, with radiographs, ultrasonograms, and triplex. All animals were sacrificed 70 days after osteotomy and bone specimens, were evaluated by DEXA and histopathologic examination. Results: In group A, all animals successfully tolerated intramedullary nailing and limb alignment was attained. All but one formatted mature callus and had started the remodeling phase retaining callus length, before being sacrificed. One animal had delayed callus maturation and 0,5cm loss of callus length, because of failed insertion of distal locking screw in the nail. In group B, all formatted mature callus too, but 2 had serious axis disorder, 3 persistent superficial pin-track infections and 1 deep infection in the same time. Conclusions: Replacement of Ilizarov device by static unreamed intramedullary nail during callus consolidation phase decreases the total duration of external fixation, limits joint stiffness, pin-track infections and axial deformities, and provides protection against refracture. Our results suggest that there is no considerable difference between callus maturation in the two groups.

Aims: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing þxation and early postoperative passive motion. Methods: 51 patients, 33 women and 18 men (average age 49,5 years) with displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus, were treated operatively in the last 10 years (1991–2001). Stable þxation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head, was achieved with non-absorbable (Ethibon No 5) sutures, avoiding any use of hard material. Early passive motion with pendulum exercises was applied to all patients at the 2nd postoperative day, followed by active assisted exercises after the 4th to 6th postoperative week, and þnal strengthening exercises after the 2nd to 3rd postoperative month. Results: Long term results (mean follow up period 5.6 years), were evaluated according to Constant-Murley Scoring System. 42 patients (82.3%) had very good result (Constant score > 80) without pain and satisfactory motion (160û forward elevation, 50û to 80û external rotation and internal rotation up to T12). The incidence of avascular necrosis was 3,9%. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossiþcations and 2 nonunions revised to hemi-arthroplasty and plate osteo-synthesis plus bone grafting. Conclusions: Advantages of this minimally invasive technique are: shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with tension band effect, and adequate rotator cuff repair, allowing for early joint motion.

Aim: To evaluate time of union and functional recovery of the shoulder joint in humeral shaft fractures treated with antegrade intramedullary nailing.

Methods: During 1998–2002, 29 patients (16 male and 13 female, mean age 43.7 years) with humeral shaft fractures underwent antegrade, proximal locked, intramedullary nailing. A modified extra-articular entry point, 1 cm below the greater tuberosity, was used to avoid rotator cuff damage. The nail, after accurate measurement of its length and proximal metaphysis enlargement up to 10 mm, was impacted into the narrow, cone-shaped, distal part of the humerus, without the necessity of distal screw interlocking. Passive motion of the shoulder joint was initiated from the 2nd postoperative day and active assisted exercises after the 2nd postoperative week.

Results: Mean follow up period was 27 months. Solid callus formation was noted in all fractures, between the 14th and 18th postoperative week. No cases of intra-operative fractures, nerve irritation, rotational instability, nail migration and loss of distal impaction were noted. Mean Constant-Murley score was 93 points at the 16th postoperative week.

Conclusion: Antegrade intramedullary nailing is a reliable and beneficial procedure for the treatment of humeral shaft fractures, regarding union and functional recovery of the arm. The extra-articular entry point should be preferred to avoid rotator cuff and articular surfaces damage whereas the accurate measurement of the nail length and the firm impaction of it at the olecranon fossa makes distally interlocking unnecessary, decreasing significantly the overall operative time and the associated complications.

Purpose: The assessment of long term results and complications rate using the GN and PFN nailing systems for the treatment of peritrochanteric fractures of the femur.

Material-Methods: Between 1991–2002, 195 patients (102 male, 93 female, average age 61.2 years) with a peritrochanteric fracture of the femur (80 A2, 86 A3, 12 pathological, and 17 combined) underwent intra-medullary nailing with the GN (134 patients) or the PFN (61 patients) system. Mean follow up period was 6.5 years. Outcome analysis included time of healing, delayed union or nonunion, infection, hip function (Salvati & Wilson scale), technical complications (cut out, Z effect, malrotation) and mechanical failures (bending fatigue, loosening, breakage of the implant or screws and fracture below the tip of the nail). Intraoperative difficulties in the application of the nails or screws were registered as well.

Results: Solid union of the fracture was achieved in 171 cases (87.6 %). 25 patients died from reasons unrelated to the implant. The overall complication rate was 20.51 % (10 infections, 3 nonunions, 5 implant breakages, 11 cut-out of the neck screws, 5 Z effects and 6 distal screws failures. The Salvati and Wilson score was > 30 in 121 patients (71.1%).

Conclusions: Use of the GN and PFN systems yielded good results in our study. Technical or mechanical complications were mostly related to the operative technique and the type and preoperative reduction of the fracture, rather than these systems themselves. Z effect is a specific complication of PFN in cases with a fracture reduction in varus, especially when comminution of the medial cortex is present.

Aim: A comparison of two different techniques of acro-mioclavicular joint reduction in complete AC disruption.

Methods: During 1992–2001, 59 patients (50 male; 9 female; average 32.3y), underwent surgical reconstruction for complete (Allman-Tossy III) AC dislocation. Fixation of the joint was achieved in all patients by double-banded coracoclavicular stabilization, using heavy nonabsorbable sutures in a double-banded ligamentous substitution manner. In 35 patients (group I) a temporary acromioclavicular fixation was done (with K-W, removable at 6th postoperative week), whereas in the rest 24 patients (group II) an additional fixation of the acromioclavicular disruption, with nonabsorbable sutures, without using K-W was performed.

Results: Mean follow-up period was 6.4 years. Our results according to Constant-Murley score were excellent or very good in 25 patients (71.4%) of group I and 21 (87.5%) patients of group II. Loss of reduction (3), calcification (5) and superficial pin infection (2) were noted with greater frequency in patients of group I. Three of them reoperated because of K-W migration or breakage. Complications of group II included 1 superficial infection, 1 calcification with restriction of joint motion and 1 case with slight loss of reduction.

Conclusions: Reduction of the acromioclavicular joint in association with adequate retention of the coracoclavicular joint are the cornerstones for a good surgical result. Double banded coracoclavicular fixation and acromio-clavicular repair with heavy nonabsorbable sutures and no use of K-W, seems to be the best surgical technique provided adequate stabilization of acromioclavicular joint, preservation of clavicular rotation, no risk of implant migration and no need of material removal.

Purpose: In this retrospective study we have analysed the effect of retears and muscle-malfunction on the results of the repair of 90 massive rotator cuff tears (MRCT) with a minimum follow-up of 2 years.

Materials: We reviewed 90 patients (15F,75M) with 90 massive rotator cuff tear repairs (66R, 24L). The age at surgery was 59 (45–75) years, follow-up 49 (24–134) months. 53 patients had a direct repair and transosseus fixation, 33 patients a local tendon transfer, and 4 a delta-flap. Beside clinical assessement, and evaluation of the Constant-Score, a standarised dynamic and static ultrasound examination of the rotator cuff, SSP and ISP with their kinematic contraction patterns, was performed.

Results: 51.1% rated their result as excellent, 28.9% as good, 11.1% as moderate, 5.6% as fair and 3.3% as poor. The unadapted Constant-score was 68.5 (contralateral 75.8). 61.1% had an ultrasonographically intact cuff reconstruction, 27.8% had a small retear and 12.2% had a retear > 2cm. The Constant-score of patients with an intact reconstruction was 71.6, with large retears 59.7 and with small retears 64.3. Patients with normal Type I contraction patterns of SSP and ISP had a Constant-score of 78.3 and 74.8, whereas those with a type III (little contraction) had 54.9 and 53.1.

Conclusions: 80% good and excellent subjective results show an appropriate treatment of MRCT’s. Because of the significant influence (p< 0,03) of muscle-malfunction, a preoperative ultrasonography of the rotator cuff muscles is performed to assess the muscle function and determine the indication for a muscle transfer.

Purpose: We present the midterm results of conservative treatment of upper (atlas and axis) cervical spine injuries and we propose a CT-based radiological follow-up study.

Material and Methods: In a 12 year period (1990–2001), 45 patients (33 male and 12 female) with a mean age 37.2 years (range 15–75) were presented with an acute injury of the upper cervical spine. There were 19 fractures of the atlas (8 Jefferson’s fractures, 6 isolated lateral mass fractures and 5 posterior arch fractures) and 26 axial fractures (12 odontoid fractures, types I–III according to Anderson’s classification and 14 traumatic spondylolisthesis, types I–II according to Effendi classification). Twenty (20) patients were immobilized using halo-vest and 25 Minerva orthosis. Two (2) patients presented with Brown-Sequard syndrome. All patients were retrospectively reviewed and had clinical and radiological follow-up study (plain films and CT spiral reconstruction films).

Mean follow-up was 6.2 years. Mean immobilization time was 3.8 months range.

Results: Patients with incomplete neurological lesion did not recover. One patient with an isolated atlas lateral mass fracture, developed a hemiparesis during his hospitalization, which was partially resolved. In the final follow-up study, all patients presented a stable upper cervical spine, on the dynamic flexion/extension plain films. In the final CT spiral reconstruction films, fracture line was evident in 12 patients (27%), while atlantoaxial joint incongruity was obvious in 5 patients. Seven (7) patients (16%) complained for residual neck pain and stiffness and presented reduced range of motion.

Conclusion: Conservative treatment of atlantoaxial injuries is effective and offers a stable upper cervical spine. Solid fracture union is not always present. CT spiral reconstruction is very helpful in detecting transverse ligament efficacy and atlantoaxial joint incongruity.

The purpose of this study is to determine the indications and effectiveness of hybrid external fixation in the treatment of tibial plateau fractures and to evaluate the patient’s functional recovery.

Twenty-seven patients with 28 intra-articular fractures of the proximal tibia were surgically treated with hybrid external fixation in a two years period (1999–2001). There were 25 patients (19 men and 6 women) available for the last follow up evaluation. The mean age was 35 years (17–76). According to Schatzker classification, there were 6 fractures type V and 22 type VI. Three of them were open fractures. The method included, indirect reduction based on ligamentotaxis and compression of the fractured segments with olive pins, in most patients. Additional limited internal fixation with free screws was also performed in 5 cases. Open reduction was necessary in 6 patients. Mobilization of the injured articulation was started at the third postoperative day, while full weight bearing was allowed after three months. The fixator was removed in average 12th week. Final evaluation was done according subjective, functional, clinical and radiological criteria. Mean follow up period was 14 months.

All fractures except one united at an average time of 13, 5 weeks. Twenty-two patients (77.6%) graded as excellent and good, hi detail, subjective results were acceptable in 72%, functional in 84%, clinical in 70% and radiological in 80%. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and superficial pin path infections.

The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow quick mobilization and functional recovery of the knee joint. Moreover it is an application rather atraumatic because, only occasionally requires open reduction.

Purpose: The purpose of our study is to record the composition and the viability of the cells from reaming products during intramedullary nailing of tibia or femur.

Material and Methods: We studied 21 fractures (13 tibia and 8 femur). The patients had mean age 27 years {1 9–67) and they didn’t face any systemic disease. The operation was done during the first 3 days from the injury and there was pro-operative x-ray check for measuring the medullar cavity. For 16 fractures we used reamers with diameter smaller or equal to the medullar cavity and for the rest 5 for biomechanical reasons we used bigger reamer. We take the products in aseptic condition in the operating room and after the proper elaboration they were been analyzed histo logically. The patients were followed up until the complete healing of the fractures.

Results: Our first observation was that in the very small reamers, which didn’t “touch” the endosteum there were non-viable marrow cells. After that with reamers till 1mm less than the intramedullary diameter there was viable bone mass 35–70% more than the non-viable. When the reaming exceeded this border microscopic analysis showed pieces (1–1, 5mm) of bone mass with few viable elements in the center of them and more compressed dead cells in the perimeter. From the p.o. follow-up it was remarkable that the patients whose bone was reamed didn’t exceed the intramedullary diameter showed primary callus formation in x-rays after 4–5 weeks, but the others after 5–7 weeks.

Conclusions: In conclusion, although our sample is not big enough, we can say that there are sighs that the reaming products cells are more viable when the reaming does not exceed the intramedullary diameter. This fact seems to have positive influence in the callus formation procedure.

The purpose of this study is to evaluate the results of the treatment of displaced greater-tuberosity fractures by open reduction and stable fixation with heavy non absorbable sutures and early passive motion. Thirty-six patients, 21 male (average age 50 years) and 15 female (average age 62 years) underwent open reduction and internal fixation for a displaced greater-tuberosity fracture of the proximal humerus, between 1992–2000. Main indication for operative treatment was at least 1 cm displacement of the tuberosity. Reduction and stable fixation of the greater tuberosity with its rotator-cuff attachments, was performed by a lateral approach using heavy transosseous nonabsorbable sutures. Passive motion was started at the second postoperative day followed by active range of motion after the fifth postoperative week.

All patients were examined periodically using clinical and radiological criteria. All fractures were healed without any displacement within 3 months. Final assessment was performed according to Neer’s criteria for pain, motion, function, strength and patient’s satisfaction, in a mean follow-up period of 4 years. Twenty seven patients (75%) rated excellent, without pain, showing active forward elevation at 160 to 180°, external rotation at 60 to 80° and internal rotation up to tiq level. Nine patients (25%) rated very good, had only minor pain problems.

We conclude that, if displaced fractures of the greater tuberosity are not diagnosed and treated promptly, may result in limitation of motion and functional disability. To our experience open reduction and stable fixation with transosteal suturing, allowing early passive motion of the joint, gives excellent to very good final results.