The purpose of this study was to investigate the outcome after surgical therapy of patients suffering from HO of the hip after treatment in ICU.

We retrospectively examined 39 patients with heterotopic ossification of the hip (18 bilateral and 21 unilateral). All patients have had history of ICU treatment for several reasons, such as craniocerebral injury (35 patients-90%), 2 patients with Guillain-Barre syndrome (5%), 1 patient with pulmonary druse (2.5%), and 1 patient with inflammatory bowel disease (2.5%). They all underwent surgical removal of HO and postoperative irradiation therapy. On the basis of plain radiographic findings, we evaluated the recurrent ossification after an 18-month follow-up period.

The evaluation of the average 18-months follow-up period showed relief of pain and clear improvement of range of motion in most of our patients. Specifically, improvement in the range of movement was observed in 41 hip joints (71.93%) in contrast to 16 hip joints (28.07%) that did not show any alteration post-operatively. No lesion re-occurrence was observed. There was only one complication of peroneal nerve paresis following HO excision.

The majority of our patients that were treated with surgical excision of the ectopic bone around the hip joint significantly improved their range of joint movement and were relieved from pain. Surgical excision seems to provide a superior quality of life in these patients, as they have a high risk for major complications due to their poor level of mobility.

This study compares the endoscopic carpal tunnel release with the conventional open technique with respect to short and long-term improvements of functional and clinical outcomes.

We assessed 72 outpatients diagnosed with carpal tunnel syndrome. Thirty-seven patients underwent the endoscopic method according to Chow and 35 were assigned to the open method. Improvement in symptoms, severity and functionality were evaluated shortly preoperatively (at two days, one week and two weeks) and one year after using the Symptom Severity Scale, Symptom Severity Status and DASH questionnaire. Changes in clinical outcomes (grip strength, key pinch and two-point discrimination test) were evaluated one year postoperatively. Complications were also assessed.

Both groups showed similar improvement in all but one outcome one year after the release; increase in grip strength was significantly higher for the endoscopic group. The endoscopic method was also associated with a significantly faster short-term improvement. Separate analysis of the questionnaire components referring to pain reveals that the delay of improvement in the open group is due to the persistence of pain for a longer period. Paresthesias and numbness decrease shortly after the operation with comparable rates for both groups.

Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point.

A sample population of 22 cadaveric femurs was used. Computed-tomography sections every 0.5 mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools.

In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5±1.5 mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R2=0.7310) and the projected femoral neck-shaft angle (R2=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing.

The clinical relevance of the results is that in varus hips (neck-shaft angle • 120o) the correct entry point should be positioned over the trochanter tip and the use stiff nails is advised. In cases of hips with neck-shaft angle between 120o and 130o, the optimal entry point lies just medially to the trochanter tip (at the piriformis fossa) and the use of stiff implants is safe. In hips with neck-shaft angle over 130o the anatomical axis of the canal is medially to the base of the neck, in a “restricted area”. In these cases the entry point should be located at the insertion of the piriformis muscle and the application of more malleable implants that could easily follow the medullary canal should be considered.

Antigranulocyte scintigraphy with the use of monoclonal antibodies or antibody fragments (leukoscan) is a promising diagnostic tool that has been used widely during the recent years for the establishment of prosthesis infection after total hip or knee arthroplasty.

In the present study we report the Ioannina University Hospital experience in the diagnostic efficacy of leukoscan for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty.

We considered all patients with suspected total hip or knee arthroplasty infection that had undergone a leukoscan examination for the diagnosis of this infection in our department during the year 2004. All patients underwent a 3-phase bone scan and a subsequent leukoscan. For the whole group of patients the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated by comparison of the results of three-phase bone scan or leukoscan with the results obtained from cultures of synovial fluid obtained from articular puncture or cultures of intraoperative sampling from those patients that had undergone a revision surgery.

A total of 19 patients with total joint arthroplasty (12 THA and 7 TKA) and suspected prosthesis infection were included in the study. The mean age of patients was 67 years. Twelve patients had verification of prosthesis infection in cultures. The overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the three-phase bone scan were 54%, 83%, 88%, 45% and 63% respectively. On the contrary, the overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for leukoscan were 75%, 86%, 90%, 66% and 79%, respectively.

Antigranulocyte scintigraphy with the use of monoclonal antibody fragment sulesomab (leukoscan) had good but not perfect diagnostic performance for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty.

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

We present our experience from use of acetabular reinforcement rings in revision total hip arthroplasty when bone defects are present. From 1987 to 2000, acetabular reinforcement rings were utilized in 59 revisions, in 52 patients with a mean age of 60 years (31–81). In 48 hips, Ganz rings were used and in 11 hips, Burch-Sch-neider rings. For the existing defects of the acetabulum, morsellized bone allograft was used. The patients were evaluated clinically with the modified Merle d’ Aubigne-Postel scale and radiologically with the criteria of Gill-Sledge-Muller. Acetabular reconstruction was successful in 51 of 59 hips (86.5%) after a mean follow-up period of 7 years (2–15). One of the 11 Burch-Schneider rings failed (9.1%) and 7 of the 48 Ganz, raising the failure rate of this ring up to 14.6%. Complications included dislocation in 5 cases, deep vein thrombosis in 2, superficial infection in 1 and pubis rami fracture in 2 cases.

Reinforcement rings in our opinion could be of valuable help in reconstruction of the bone deficient acetabulum. Although in this study, it is not possible for these two rings to be directly compared, Burch-Schneider one appears to have a more clear role and lower failure rate. However, in order to evaluate in a more reliable way the true fate of the acetabular reinforcement rings, especially in the presence of the limited role of biological fixation, longer follow-up time is needed.

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.

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.

Introduction: The treatment of “congenital hip disease” by total hip arthroplasty is now well established, but the indications for this type of surgery, the preoperative planning, the selection of the stem and the technique to be followed are still open to debate.

Aim of the study: The purpose of this study is to analyse the long-term follow up after use of the cementless-system (CLS) femoral component designed by Spotorno in dysplastic or congenitally dislocated hips.

Material and Methods: Our study includes 70 hips in 59 patients, 49 females and 10 males, 36 left hips and 34 right hips that treated with total hip arthroplasty from 1987 to 2000. The mean age of the patients was 48.5 years (range 34–74 years). Forty-one hips were congenitally dislocated and twenty-nine were severe dysplastic. Preoperative planning with CT and CAD-CAE system were used for selection of the stem. 11 patients had bilateral total hip arthroplasties with Spotorno CLS stem. Many different cups were used.

Results: The mean follow up was 8.1 years (range 2–14 years). No patients were lost during the follow-up period. Patients were evaluated clinically with Merle d’ Aubigne and Postel hip score. There was a significant postoperative clinical improvement of the mean pain score by 3.7 points, of walking ability by 2.2 points and of motion by 2, 6 points. Thigh pain was not reported. There were no deep infections or mechanical loosening that required revision of the femoral component.

Conclusions: Although, the femoral component Spotorno CLS is used to every kind of hip diseases, had excellent long-term clinical results in adults, with dysplasia or congenital hip dislocation. Spotorno CLS uncemented femoral component represents an attractive option for adults with “congenital hip disease”.

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.

INTRODUCTION: The treatment of “congenital hip disease” by total hip arthroplasty is now well established, but the indications for this type of surgery, the preoperative planning, the selection of the stem and the technique to be followed are still open to debate.

AIM OF THE STUDY: The purpose of this study is to analyse the long-term follow up after use of the cementless-system (CLS) femoral component designed by Spotorno in dysplastic or congenitally dislocated hips.

MATERIAL AND METHODS: Our study includes 70 hips in 59 patients, 49 females and 10 males, 36 left hips and 34 right hips that treated with total hip arthroplasty from 1987 to 2000. The mean age of the patients was 48.5 years (range 34–74 years). Forty-one hips were congenitally dislocated and twenty-nine were severe dysplastic. Preoperative planning with CT and CAD-CAE system were used for selection of the stem. 11 patients had bilateral total hip arthroplasties with Spotorno CLS stem.

RESULTS: The mean follow up was 8.1 years (range 2–14 years). No patients were lost during the follow-up period. Patients were evaluated clinically with Merle d’ Aubigne and Postel hip score. There was a significant postoperative clinical improvement of the mean pain score by 3.7 points, of walking ability by 2.2 points and of motion by 2,6 points. Thigh pain was not reported. There were no deep infections or mechanical loosenings that required revision of the femoral component.

CONCLUSIONS: Although, the femoral component Spotorno CLS is used to every kind of hip diseases, had excellent long-term clinical results in adults, with dysplasia or congenital hip dislocation. Spotorno CLS uncemented femoral component represents an attractive option for adults with “congenital hip disease”.