The use of a Shoulder Hemiarthroplasty for the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) is the subject of this study.

71 patients with 71 Proximal Humerus Fractures were treated with this method. Four were exluded from the study (they did not match the follow-up criteria). From the remaining 67, 60 were women and 7 men, aging from 38 to 96 years (average 67.13 year, S.D. 14,769s). Of these patients 22 were Neer 3 (1 with a dislocation) and 45 were Neer 4 (17 with a dislocation). There were 4 cases of a failed ORIF and in 8 cases the operation followed failed conservative treatment (2 non-unions and 6 AVN). Time between fracture and surgery ranged from 1 to 5 days in 54 cases, while in the rest it exceeded 8 weeks. The fracture classification was performed with the use of 3 plain X-rays (AP, Lateral and Axillary views) and the results were evaluated using the Constant Score. The mean follow-up was 55.75 months (range 36 to 105). The average Constant Score was 67.4 (S.D. 14.3). There were no significant statistical differences regarding sex and age in respect to the Constant Score (t 65 =.243, p =.81), range of motion (t 65 =.048, p =.96), strength (t 65 =.741, p =.46), activities of daily living (t 65 =.030, p =.97) and pain relief (χ2 [1] =.001, p =.98). On the other hand the group of patients with the higher pain relief scores presented higher Constant Score values and better shoulder joint function in respect to the group which presented lower pain relief scores.

In conclusion the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) with the use of a Shoulder Hemiarthroplasty is a good treatment method offering substantial pain relief, functional improvement of the joint leading to a faster rehabilitation in the majority of patients, regardless age and sex.

Purpose: The evaluation of the results of the interlocking intramedullary nailing in the treatment of open and closed femoral and tibial fractures.

Material-Methods: During the decade 1996–2005, 408 patients with 429 femoral and tibial shaft fractures were treated with interlocking intramedullary nailing. All the nails inserted after reaming. From the 182 femoral fractures, there were 155 closed,

10 open, 9 pathological fractures and 8 non-unions. Accordingly, from a total of 247 tibial fractures, 190 were closed, 27 were open and there were also 30 non-unions. The average age was 37 years. The patients were assessed clinically and radiologically according to a specific protocol. Follow-up 1–9 years (average of 4, 4 years).

Results: There were 291 men (71%) and 117 women (29%). The mechanism of injury was a car or motor-vehicle accident in 210 cases, fall from a height in 134, direct force injury in 73 and labor accident in 12 cases. The average period of hospitalization was 5, 2 days. The average time to union was 3, 3 months and it was longer in open than the closed fractures. The percentage of union in all the cases was 96%.

Conclusion: Reamed interlocking intramedullary nails have been associated with higher union rates and lower union time without increasing complications in either closed or open fractures These advantages support their application in the treatment of all the closed and most of the open femoral and tibial shaft fractures.

We present a rare case of multifocal Proteus mirabilis osteomyelitis in an HIV-positive patient. Despite the patient’s good immune status as assessed by her CD4 cell count and the aggressive treatment, she eventually underwent bilateral above-knee amputations to eradicate the infection. Multifocal Proteus mirabilis osteomyelitis can have an unpredictable clinical course with a severe outcome in HIV-positive patients.

The aim of this biomechanical study was to investigate the role of the dorsal vertebral cortex in transpedicular screw fixation. Moss transpedicular screws were introduced into both pedicles of each vertebra in 25 human cadaver vertebrae. The dorsal vertebral cortex and subcortical bone corresponding to the entrance site of the screw were removed on one side and preserved on the other. Biomechanical testing showed that the mean peak pull-out strength for the inserted screws, following removal of the dorsal cortex, was 956.16 N. If the dorsal cortex was preserved, the mean peak pullout strength was 1295.64 N. The mean increase was 339.48 N (26.13%; p = 0.033). The bone mineral density correlated positively with peak pull-out strength.

Preservation of the dorsal vertebral cortex at the site of insertion of the screw offers a significant increase in peak pull-out strength. This may result from engagement by the final screw threads in the denser bone of the dorsal cortex and the underlying subcortical area. Every effort should be made to preserve the dorsal vertebral cortex during insertion of transpedicular screws.

A rare case of radiocarpal dislocation is presented. The lunate and proximal pole of the scaphoid were displaced in a volar and proximal direction. The injury was missed initially and the patient was subsequently operated on six weeks later. Open reduction and internal fixation of the scaphoid was performed and this was followed by an uneventful postoperative period, with a satisfactory functional outcome at the eight-year follow-up, despite carpal instability non-dissociative-dorsal intercalated segmental instability configuration of the carpus.

We believe that although open reduction in neglected cases carries the potential risks of avascular necrosis and nonunion of the affected carpal bones, an attempt should be made to restore the anatomy of the carpus.

Aim: Evaluation of health-related quality of life in scoliotic patients as compared to age matched general population individuals. Correlation with the curve degree and the method of treatment.

Material – method: Ninety patients with idiopathic scoliosis were interviewed. The assessment included: a) the SF-36 questionnaire, evaluating general health status, b) Specific Quality of Life Instrument, designed and validated for adolescents with spinal deformities, c) Postoperative Patients Satisfaction Score, for patients operated on for scoliosis. Patients were subdivided to three groups according to the curve degree and method of treatment: Group A, patients with curves < 20o, treated with observation and regular follow up. Group B, curves between 20o and 40o, treated with a Boston brace. Group C, curve > 40o, operative treatment.

Results: SF – 36 physical health summaries were not significantly different among the three groups, nor between the scoliotic patients and normal individuals. Mental health summaries and quality of life scores were lower in Group B and C patients.

Conclusion: Patients treated for idiopathic scoliosis were found to have approximately the same quality of life as the general population. Quality of life deterioration in scoliotic patients is mainly related to psychological rather than physical factors.

Purpose: To evaluate the functional outcome following internal fixation of bicondylar distal humerus fractures (AO type C) using the ACUMED modified titanium plates.

Material-Methods: Fourteen patients (9 male, 5 female) aging 18 to 78 years (av. 54 y.) with bicondylar distal humerus fractures, between September 2002 and May 2004, were included in our study. All of them underwent open reduction and internal fixation. The articular surface was reduced through a transolecranic approach using one or two compression screws and the fractures was then fixated using the modified titanium ACUMED plates.

Results: Postoperative follow-up ranged from 6 to 24 months (av. 12 m.). The results were evaluated using the Mayo Clinic Score. The mean range of elbow flexion-extension was 115o. Nine patients had an excellent/good result, 3 had affair and 2 a poor result. One patient underwent a second procedure for symptomatic metalwork. In one case there was soft tissue infection that resolved successfully with antibiotic administration.

Conclusion: The internal fixation of bicondylar AO (type C) distal humerus fractures with the ACUMED plates through a transolecranic approach is an extensive but atraumatic operation that offers excellent reduction and a stable osteosynthesis leading to a good functional outcome.

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.

Purpose: We evaluate the results of treatment of A.O. type C distal femoral fractures with 3 methods of internal fixation (condylar plate, 95° condylar blade plate, D.C.S.).

Material-Methods: From 1988–2003, 108 patients (59 male, 49 female), aging 19 to 84 years (aver. 46 years), with 116 fractures A.O. /C were treated. 108 were closed and 8 open, Gustillo type II. We used condylar plate in 38 patients (group A), 95° condylar blade plate in 24 (group B) and D.C.S. in 54 (group C).

Results: Postoperative follow-up ranged from 1 to 15 years. An early mobilization programme was initiated. The results were evaluated using the Schatzker-Lambert criteria. Pseudarthrosis was found in 4 cases in group A, 6 in B and 3 in C. Varous deformity was present in 10 cases in group A, 6 in B and 2 in C. Severe knee stiffness was present in 2 patients of group A, 2 of B and none of group C.

Conclusion: The Dynamic Condylar Screw – D.C.S. seems to have an advantage compared to the other 2 methods of internal fixation regarding the treatment of A.O. /C distal femoral fractures offering stability, anatomical reduction, and early mobilization with a good functional outcome.

Aim: Although several surgical procedures have been proposed for advancedstage Kienböck’s disease, it still remains a difficult therapeutic problem. This study documents the clinical, radiographic and MRI outcomes of ten patients, who underwent lateral closing wedge osteotomy of the distal radius by the same surgeon, after MRI confirmation of advanced Kienböck’s disease. Methods: Ten patients (6 men and 4 women) with a mean age of 28,7 years (range 21–66) were included in this study. Seven had Lichtman stage III-B and three stage IV disease. The lateral closing wedge osteotomy was performed at the distal metaphysis of the radius through a palmar approach and was fixed with a 3,5mm titanium T-plate. The average follow up period was 52 months (range 36–60 months). Results: Substantial pain relief, increase in grip strength and range of wrist flexion and extension were achieved. Clinical results were excellent in two patients, good in five, fair in two patients and poor in one patient according to Nakamura’s postoperative scoring system. Gadolinium enhanced MRI at the latest follow up revealed signs of revascularization of the lunate in 6 cases. Conclusions: Lateral closing osteotomy decreases radial inclination and pressure at the radiolunate joint, thus improving lunate coverage. It is a reliable extra-articular procedure for advanced Kienbock’s disease that provides pain relief while there is evidence that it may improve lunate vascularization.

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.

Aims: The purpose of our study is to evaluate the results of the treatment of unstable upper humerus fractures with the implantation of the Plant-Tan Plate which is a combination of an internal fixator with a neutralization plate. Methods: In a period of 17 months (January2001–May2002), 10 fractures in 10 patients (7female – 3 male) were treated. Their ages ranged from 45 to 75 years (mean 67.8 years). Patients with unstable fractures (two to four according to Neer’s classification are include in the study. The Plant-Tan Plate was used. Two head screws were placed in all fractures. The follow-up ranged from 4 to 21 months (mean 14.5months). The ASES scoring system was used to evaluate the results. Results: All our patients achieved clinical and radiological union of the fractures in a period of 4 months. The average cumulative score of activities of daily living of ASES Scoring System was 23 out of 30 (76.66%). One superficial wound infection occurred which was resolved with the administration of antibiotics. Conclusions: The Plant-Tan Plate rapresents a new, promising method of internal fixation for fractures of the proximal humerus, which offers anatomical reduction and a stable osteosynthesis (provding angular and rotational stability), so that an early rehabilitation program can be instituted.

Aims: This study was designed to evaluate the postural effects on nystagmus response, during caloric vestibular stimulation. Methods: 43 female patients with right thoracic idiopathic scoliosis (mean age =13.5, scoliotic curves:20û– 40û) and 31 non-scoliotic healthy subjects (mean age=13.1) entered the study. In all patients was performed an electronystagmographic study of labyrinthine function with caloric stimulation. We evaluated: the frequency, the amplitude, the slow phase velocity of nystagmus. The differences in labyrinthine sensitivity were evaluated with the use of unilateral weakness parameter, while differences in left- and right- beating nystagmus evaluated by estimating the directional preponderance parameter. Results: 19 patients from the study group (44.2%), revealed unilateral weakness of the left labyrinth, while 24 patients from the study group (55.8%) had normal caloric responses. On contrary, only one patient of the control group (3.2%) revealed unilateral weakness of the left labyrinth (> 20%). These differences were statistical signiþcant (p< 0.05, Chi-Square test).17 patients from the study group (39.5%) revealed directional preponderance of the right-beating nystagmus. All these patients had also left unilateral weakness. Conclusions: From the above results we can conclude that in 17 patients from the study group the right labyrinth was preponderant, while in other 2 patients there was signiþcant evidence for this. The results are discussed with special reference to aetiology in idiopathic scoliosis.

Aims: The underlying cause of Idiopathic Scoliosis (IS) remains enigmatic. Recently, an increasing number of studies disclosed Central Nervous System (CNS) abnormalities and asymmetries sometimes involving the corticospinal tracts. The present study was designed to investigate the motor system of scoliotic patients with transcranial magnetic stimulation. Methods:21 female patients with right IS (mean age=12.7, scoliotic curves:20û–40û) and 20 normal subjects (mean age=13.8) entered the study. Recordings were made with surface electrodes from 1st dorsal interosseous and abductor hallucis muscles. Corticomotor threshold (LT, UT, MT) was deþned at rest in 1% steps using the method of Mills & Nithi. Central motor conduction time (CMCT) was calculated using the F-wave method. Silent period (SP) measurements were done using a standardized protocol at 130% MT stimulus intensity. Other parameters included cortex to muscle latencies, F- and M-wave latencies, UT-LT range, amplitude and area of MEPs. Electrophysiological data were correlated with several clinical characteristics including handedness, degrees of the scoliotic curve and the Pedriolet and Nash indexes. Normality of data distribution was tested using the Kolmogorov-Smirnov test and thereafter appropriate statistical tests were used. Results: In 14 patients lower limbs were also tested and it was found that asymmetry of facilitated Cx-M was 1.4±0.75ms in IS (vs 0.71±0.47 in controls, p=0.059). It correlated signiþcantly with Nash & Moe and Perdriole indexes (Spearmanñs r=0,554 and 0.575 respectively, p< 0.05) and showed a trend towards signiþcance with degrees of scoliotic curve (Pearsonñs r=0.531, p=0.062). Conclusions: There are no signiþcant asymmetries or pathological alterations in the motor system of patients with IS. However, an increased asymmetry of facilitated

Purpose: We present the results of the management of muskoloskeletal lesions accompanied by rupture of a main arterial vessel, foccusing on the priorities in salvaging the affected limp.

Materials – methods: In a period of 3 years and 6 months (Sep.1999–Mar 2003), 21 patients having sustained multiple injuries were admitted with signs of poor vascularization distally to the lesion. 16 were male and 5 female, their ages ranging from 16 to 49 years (average 27 years). The musculoskeletal injuries were: open III C humeral fracture in 2 patients, open III C femoral fractures 5, open III C tibial shaft fractures 10, knee joint dislocations 4 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: Follow-up ranged from 6 to 48 months (mean 27 mon.). Amputation was performed in 3 patients due to failure of the revascularization procedure 2 weeks postoperatively. External fixation was maintained as a final method of treatment in 5 cases, while in 9 cases we exchanged it to intramedullary nailing. In the 4 cases of knee dislocation, ligament reconstruction was imperative. Eventually 18 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.

Aims. The assessment of the potential pathological influence of Growth Hormone (hGH), Testosterone, Estradiol, Follicle Stimulating Hormone (FSH) and Luteinizing Hormone in the development of SCFE and the re-evaluation of the Harris theory (increased quotient of hGH/sex hormones in patients suffering from SCFE).

Methods. Nineteen patients in total were included in the study. Fourteen patients (7 boys, 7 girls, 16 hips) suffering from SCFE during the proceeding of this study, formed group ‘A’. Another 5 patients (4 boys, 1 girl), that had been treated for SCFE a few years before the study, formed group ‘B’. We measured serum hGH, FSH, LH, Testosterone and Estradiol levels. Furthermore we checked all necessary anthropometrical and clinical characteristics (age, height & weight, sexual maturation, grade of slipping).

Results. Thirty six out of 95 in total measurements (37,9%) revealed pathological values. The majority of group A patients had pathological values (43% of measurements). The Harris theory seems to be true in 7 out of 19 in total patients: 5 group A patients (2 boys and 3 girls) and 2 group B patients (1 boy and 1 girl).

Conclusions. We believe that a temporary (?) disorder or imbalance of hGH and sexhormones, under the possible influence of FSH and LH (along with other etiologic factors) during the early years of adolescence, may play a potentially significant role in the development of SCFE.

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.