Introduction

Acute kidney injury is a recognised post-operative complication in primary joint replacement. Recently it has been demonstrated that antibiotic regimen can significantly impact on the proportion of patients who develop acute kidney impairment post-operatively. Within our unit an increased rate of acute kidney injury had been noted post-operatively over the last 5 years. This increase followed the introduction of a rapid recovery protocol for arthroplasty patients. Our aim was determine whether we could identify a causative factor or those who were at increased risk of post-operative renal impairment.

Introduction

In total knee arthroplasty (TKA), the correct positioning of the components is a key element to obtain good functionality and durability of the implant. The use of computer-assisted surgery (CAS) in TKA ensure excellent limb alignment, components orientation and ligament balancing; however, it is still unclear whether this translates to better mid- to long-term clinical and functional outcomes. We present our clinical, functional and radiological results in a case series of two hundred implants at a medium follow up of 2.5 years.

The problem of modular acetabular cups in total hip replacement (THR) links with its survival, unpredictable because of wear and fixation. In fact, while primary fixation is not a problem, the use of screws could generate bone resorption. A monoblock cup made by tantalum and polyethylene insert is available since some years. Tantalum is a metal element with an elasticity intermediate between cortical and trabecular bone, a three times higher porosity than titanium and a very high ductility. These features allow a very high primary and secondary stability eliminating movements between insert and metal.

From 2001 we started using the TMT cup and we performed 48 implants in 45 patients: 18 male and 30 female. The mean age was 64 years old.. 80% of the patients were affected of primary arthritis, 20% avascular head necrosis and fracture. In last 20 procedures we perform a minimal invasive approach (around 9 cm.). The mean follow up was 26 months. We reported no infections, no loosening and 1 traumatic dislocation. Follow up showed good stability on the acetabular side.

In conclusion we can affirm that, despite our preliminary results, the tantalum cup could open new perspectives in primary hip replacements.

Acetabular loosening is often dangerous because the patient is pain free for several years. The following bone loss may represent the biggest challenge in revision surgery.

Object of this study is to evaluate the use of an iliac stem cup (Link®) associated with impacted bone grafts in acetabular loosening and CDH.

We performed 25 implants in loosening (13 grade 2 and 12 grade 3 of Paprosky): average age was 68 years old in 16 female and 9 male. Mean follow up was 22 months.

We used bone grafts in 17 cases. In 1 case we cemented the Mcminn cup because of poor initial stability with no complication at 18 months.

We noted radiolucency lines < 2 mm. in 1 case and bone resorption in 2 cases. The complications were: malpositioning of the stem (1%), sacroiliac pain (4%), superficial infection (2%) and DVT (1%).

In conclusion, we can affirm that McMinn cup, despite a demanding surgical technique, represents a valid alternative to acetabular revision surgery because of the good initial stability, the respect of loading lines and besides it allows the use of pressurized bone chips.

Fractures of lower limb treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation using MIPO. From January 1998 to May 1999 we collected 32 cases of lower limb fractures treated with O.R.I.F (Group I). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional and new devices with angular stability that offer more mechanical stability (Group II 90 cases). In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had only 4 cases of varus deformity and 1 DVT.

The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability. MIPO is a demanding technique with undoubted advantages: it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients.

Fractures of distal femur and tibia treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation of closed fractures of the lower limb using MIPO in comparison with conventional O.R.I.F. procedure. From January 1998 to May 1999 we collected 32 cases of lower limb fractures (10 distal femur, 15 pilon, 7 distal tibia) treated with O.R.I.F procedure (Group I). The mean age was 47.6 years (range 23–76). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional devices (36 cases). From March 2001 we performed part of our minimal invasive surgery (54 cases) with new devices with angular stability (Less Invasive Stabilization System, Synthes) that offer more tools for subcutaneous osteosynthesis and more mechanical stability of the implants. Our 90 cases formed Group II. The mean age was 53.2 years (range 21–80). The mean follow up was 18 months. We used bone grafts in only 1 case of severe pilon fracture. In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had no infection, no delayed or non-union (a mean consolidation time of 8–10 weeks for pilon fractures, 6 weeks for distal tibia fractures, 10–12 for distal femoral and proximal tibia ones). 2 cases of varus deformity in 1 pilon fractures (1 MIPO); 1 DVT in distal tibial fracture; 2 cases of varus deformity of distal femoral fracture (1 DCS). Conventional O.R.I.F. surgery showed some limits: wide exposure, damage to vascular supply of soft tissues and bone, blood loss, high risk of infections, not indicated in polytrauma patient: international literature reported high rate of postoperative complications. The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability and facilitated this technique In conclusion, minimal invasive surgery is a demanding technique with undoubted advantages: it reduces surgical exposures and risk of infection; it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients.

Pes planus is a complex syndrome whose origin can be quite different. Knowledge of the causes is essential for optimal treatment. Clinical and radiographic examinations are the basis for a correct diagnosis. Arthroreisis of the sub-astragalic joint, extrasenotarsum, represents the gold standard for surgical correction of idiopathic pes planus in childhood. The rate of excellent and good results has been 98% in the authors’ experience. We conclude that the arthroreisis of the sub-astragalic joint is an easy, fast and efficacious operation in the management of idiopathic pes planus.

Unicompartmental knee prosthesis (UKP) has been used for 40 years but it is still controversial. Nevertheless, this procedure is positive and it can be a good alternative if it is correctly indicated.

From January 2001 we implanted 51 UKP in 47 patients. The diagnoses were: primary arthritis in 45 cases, post-traumatic degeneration in five and arthritis secondary to meniscectomy and ACL reconstruction in one. The mean age was 64.5 (range 49–81), 32 women and 15 men. Mean follow-up was 26 months (range 6–36). Post-operative recovery starts with physical rehabilitation, rarely with kinetics, and full weight-bearing walking the first day. DVT is prevented by treatment with low-molecular-weight heparin for 25 days and elastic stockings. From September 2002 we performed this procedure by minimally invasive surgery with an 8-cm incision and extramedullary intraoperative tools. We did not observe any infections or loosening: we performed just one revision of the femoral component because of a technical error. In four other cases a malpositioning of the femoral component was reported that was pain-free at follow-up.

Current studies are starting to show valid and encouraging results at mid- and long-term follow-up, too. The best candidates for UKP are patients over 60 years who are not overweight, with asymptomatic patellar degeneration and no anterior instability and who perform light sport activity. In comparison with high tibial osteotomy (HTO), UKP shows some advantages, such as faster recovery and better mid-term results. In comparison with total knee arthroplasty (TKA), UKP gives better range of motion, faster postoperative recovery and an easier operation in case of infection or loosening. Some features should be evaluated and the surgical technique should employ state-of-the-art hardware. We evaluate the advantages of this procedure with particular emphasis on the minimally invasive technique.

In conclusion, although our study is still in progress, correct patient selection, the surgical technique and the updated design of the new prosthesis can give satisfactory results and represent a valid alternative to HTO and TKA. In addition, compared to TKA, UKP shows a real economic advantage.

In acquired knee deformations the usefulness of arthroscopy is strictly correlated with the degree of axial defomation and cartilaginous degeneration. The authors comparatively consider two groups of patients (the first one Albach I and II and the second one Albach III and IV) treated with arthroscopic débridement (washing and curettage), in relation to the joint’s degeneration stage. A minimum 6-month follow-up, using KSKSS grading revealed satisfactory medium-term results.

Acetabular loosening is often dangerous because the patient is pain free for several years. The subsequent bone loss may represent the greatest challenge in revision surgery. The extension of the bone loss may be small or wide, but it could also be associated with several defects. Usually, the most affected district is the dome, especially because the cup leans to migrate proximally. The object of this study is to evaluate the use of an iliac stem cup (Link®) associated with impacted bone grafts in acetabular loosening and congenital hip dysplasia (CDH).

The surgical technique requires a posterolateral approach, dedicated cannulated hardware tools to improve iliac stem positioning, intraoperative C-arm and bone grafts to enhance primary stability. We performed 21 implants in 18 cases of acetabular loosening (10 grade 2 and 8 grade 3 according to Paprosky) and three CDH: average age was 68 years old in 14 women and seven men. Mean follow-up was 21 months. We used bone grafts in 17 cases. In one case we cemented the McMinn cup because of poor initial stability with no complications at 18 months. We noted radiolucency lines < 2 mm in one case and bone resorption in two cases. Mean Harris Hip Score (HHS) was 60 preoperatively and 88 postoperatively. The complications were: malpositioning of the stem (1%), sacroiliac pain (4%), superficial infection (2%) and DVT (1%).

The primary cementless stability is achieved by the aid of an iliac palpator checked by fluoroscopy: the palpator works as a guide for the iliac stem to avoid malpositiong or wrong inclination. In addition, the dedicated cup trials could also function as an impactor for chips bone grafts in the so-called “impaction grafting technique”. In conclusion, we confirm that the McMinn cup, despite a demanding surgical technique, represents a valid alternative to acetabular revision surgery because of the good initial stability and the respect of loading lines and it also allows the use of pressurised bone chips. Furthermore, the hip centre is restored in acetabular loosening and CDH.