Percutaneous fixation with iliosacral screws has been shown to be a safe and reproducible method for the management of certain posterior pelvic injuries. However, the method is contraindicated in patients with sacral anatomical variations and dysmorphism. The incidence and the pattern of S1 anatomical variations were evaluated in 61 volunteers (35 women and 26 men) using MRI scans of the sacrum. S1 dimensions (12 parameters) in both the transverse and coronal planes were recorded and evaluated. Individuals were divided in four groups based on the S1 body size and the asymmetry of dimensions on the transverse and coronal planes. In 48 (78.6%) patients, dimensions in both planes were symmetrical despite the varying size of the S1 body. In 9 (14.8%) patients, coronal plane dimensions were disproportionally smaller compared to those of the transverse plane with a varying size of S1 body making effective iliosacral screw insertion a difficult task. In 2 (3.3%) patients there was a combination of large transverse plane and small coronal plane dimensions, with large S1 body size. A preoperative imaging study of S1 body size and coronal plane dimensions and an intraoperative fluoroscopic control of S1 dimensions on the coronal plane are suggested for safe iliosacral screw fixation

Purpose: To evaluate the differencies in graft orientation between transtibial and anteromedial portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction.

Materials and Methods: Fifty one patients who undergoing arthroscopically ACL reconstruction underwent MRI of their reconstructed knee. Thirty patients had ACL reconstruction using the transtibial technique (group A) while in the rest 21 the anteromedial technique (group B) was used. In the femoral part graft orientation was evaluated using the femoral graft angle (FGA). The FGA was depicted at the coronal views by two axes: the anatomical axis of the femur and the axis of the femoral tunnel. In the tibial part graft orientation was evaluated using the tibial graft angle (TGA). The TGA was specified as the angle between the axis of the graft and a line parallel to the tibial plateau at the sagittal view.

Results: The mean FGA for group A was 12.52° while for the group B was 27.06°. This difference was statistically significant (p< 0.001 paired t-test). The mean TGA for group A was 64.24° while for the group B was 63.11° but this was not statistically significant.

Conclusions: Using the anteromedial portal technique the ACL graft is placed in a more oblique direction in comparison with the transtibial technique in the femoral part. This may have an impact in rotatory knee stability. However, there are no differencies between the two techniques in graft orientation in the tibial part.

Background: Clinical tests used for the detection of knee meniscal tears do not present acceptable diagnostic sensitivity and specificity values. Diagnostic accuracy is improved by arthroscopic evaluation or performing magnetic resonance imaging (MRI) tests. The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination test for the detection of meniscal tears.

Methods: Two hundred and thirteen symptomatic patients with recent knee injuries who all were clinically examined, had MRI tests and underwent arthroscopic surgery and 197 asymptomatic volunteers who all were clinically examined and had MRI tests of their normal knees were included in this study. For clinical examination the medial and lateral joint line tenderness test, McMurray test, Apley compression and distraction test, Thessaly test at 5° and Thessaly test at 20° of flexion were used. For al clinical tests sensitivity, specificity, negative predictive value and diagnostic accuracy rates were calculated against arthroscopic and magnetic resonance imaging data.

Results: Thessaly test at 20° of flexion showed a high diagnostic accuracy rate at the level of 94% and a low number of false negative recordings in detecting tears of both the medial and lateral meniscus. Other traditional clinical examination tests, with the exception of joint line tenderness which presented a diagnostic accuracy rate of 88% in detecting lateral meniscal tears, showed inferior rates.

Conclusions: Thessaly test at 20° of flexion can be safely used as a first line screening clinical test for the detection of meniscal tears reducing the need and the cost of modern magnetic resonance imaging methods.

Introduction: To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts (VBG) for treating scaphoid nonunions (SN).

Methods: VBG from the distal radius were used to treat 52 SN. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of radiographs obtained in all cases, 19 patients were also assessed postoperatively with MRI at 3 months (15 of 19 were assessed preoperatively with MRI) and 15 had serial MRI evaluations (6–12 months). The clinical follow-up time of this subgroup of 19 patients ranged from 6 to 27 months.

Results: All patients showed clinical signs of union within 12 weeks from the procedure. 3-months MRI showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 14 patients; plain MRI showed union in 13 patients but contrast-enhanced MRI revealed union in all cases. Eight patients were considered to have osteonecrosis of the proximal pole intraoperatively: 4 showed proximal pole necrosis with postoperative plain radiographs and 5 of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all 8 scaphoids. Serial MRI at 6 and 12 months, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases.

Conclusions: Contrast-enhanced MRI is able to assess the viability of the proximal pole and to demonstrate the early union after treatment of SN with VBG allowing thus earlier mobilisation.

Purpose: The aim of this study was to document donor site problems one year after anterior cruciate ligament (ACL) reconstruction and to compare the differencies between hamstring and patellar tendon autografts.

Materilas and Methods: Sixty-four patients undergoing primary arthroscopically ACL reconstruction were randomized to have a central third bone patellar tendon bone (PT) autograft (30 patients) or a doubled semiten-dinosus/doubled gracilis (HS) autograft (34 patients). The postoperative rehabilitation regimen was identical for both groups. All patients were examined one year postoperatively. Objective parameters evaluated included pre and postoperative IKDC and Lysholm score, side-to-side KT-1000 maximum-manual arthrometer differences. The Shelbourne score was used to evaluate anterior knee symptoms. Loss of sensitivity in the anterior knee region postoperatively as well as scar sensitivity were also recorded.

Results: Three patients (10%) in the PT group had anterior knee symptoms while only one (3%) in the HS group. The mean Shelbourne score was 98 for the HS group and 93 for the PT group but this was not statistically significant. However, 8 pateints (23%) had disturbed sensitivity in the anterior knee region in the HS group, but none in the PT group and this was statistically significant (p< 0.005). Scar sensitivity was present in 3 patients (10%) in the PT group and in one (3%) in the HS group. No differencies were found postoperatively between the groups regarding IKDC, Lysholm score and side-to-side KT-1000 measurements.

Conclusions: Although,notstatisticallysignificantpatients in the PT group had more anterior knee symptoms and scar sensitivity, one year postoperatively. In contrast, harvesting of hamstring tendons produces significantly more sensory nerve complications in the anterior knee region than harvesting the middle third of patellar tendon. Both grafts seem to improve equally patients’ performance.

Purpose: To assess þbular graft viability and the evolution of the subsequent bone healing into the hosting tunnel. Methods and Materials: Eight patients (10 grafts) with femoral head AVN were examined with 4 consecutive MRI examinations at 2w, 6w, 3m, and 6m postoperatively using a 1T scanner. A dynamic 3D-T1-w TFE sequence (9 sections every 8s) was applied for estimating the perfusion in the graft (SI curve). Multiplanar imaging in the axis of the graft was used for a delayed fat-suppressed T1-w Spin Echo sequence (acquisition matrix 512, slice thickness 3mm). The following parameters were evaluated: a) more or less than 50% increased SI in the graft, b) maximum SI close to the graft, c) maximum width of the medullary enhancement close to the graft, d) width of osteonecrotic area. The þnal MRI examination together with plain x-ray þlms and clinical examination were used to assess outcome. Results: The decrease of% enhancement area in the graft medulla, the gradual decrease of the enhancement in and around the graft, correlated well with the clinical þndings. The dynamic study and the parameter c, showed no correlation with the clinical status. In 2 cases, enhancement close to the upper end of the graft and in the necrotic zone, suggested expanding inversion of the process. Conclusion: High resolution enhanced MRI, may offer an additional means for assessment of the healing process of vascularized peroneal grafts in patients with femoral head necrosis.

Aims: To assess morbidity and the long term sequellae following multiple compartment syndrome of the tibia. Methods: We prospectively followed 21 referred patients (pts). Syndromeñs etiology, the socioeconomic consequences and the way the condition affects the quality of patientsñ lives were evaluated. Patientsñ morbidity, the number and the severity of the reconstructive operations were assessed. A subjective SF-36 evaluation was also performed. Results: The aetiology of the syndromes was RTA in 13 pts, accident at work in 7 and in 1 patient the result of an osteotomy and external þxation. Late release of the compartments was performed in 9 pts. In the remaining 2 pts release was performed at onset. The consequences were drop-foot in 14 pts, club foot in 2, cavus foot in 8, clawing of toes in 14, ankle stiffness in 7, plantar numbness and anesthesia in 13, plantar callosities in 5 and chronic infection in 8. Effective management involved 1–10 subsequent reconstructive procedures in the following 1 to 5 years with hospitalization ranging from 35 to 360 days. One patient was amputated. Two pts were able to perform an easy job and only those 2 in whom the compartments were released in time returned to previous occupations. The remaining are currently unemployed. Conclusions: Established compartment syndromeñs effects on soft tissue and bone seriously affect limb function, permanently impair quality of the patientñs life and deprive them from working effectively. These þndings emphasize the importance of early diagnosis and prompt release.

Purpose:In this study we investigated the MRI þndings of healing process after arthroscopic meniscal repair. Methods and Materials: 15 patients with buckethandle medial meniscal tears were operated arthroscopically within 3 weeks after injury. All had accurately diagnosed meniscal tear with preoperative MRI. Six patients had an additional anterior cruciate ligament tear, also primarily reconstructed with the meniscal repair. The MR examination was perfrormed with a 1 T scanner, applying the following pulse sequences: T1-w Spin Echo (SE), PD-w Turbo Spin Echo (TSE) with fat suppression, T2-w TSE and T1-w SE in coronal and axial plane after iv administration of paramagnetic contrast agent. The postoperative MRI examinations were performed in 3 weeks intervals starting at the 6th postop and till the 18th , and 6 weeks thereafter. All patients were asymptomatic postoperatively. Results:Grade III and IV signal alterations were present on all MRI scans. Contrast enhanced images showed in addition: a) signal alterations extending through the path of suture out of the meniscus, b) enhancement of the medial collateral ligament simulating injury and c) synovitis in all patients. In one patient examined sequentially, the contrast-enhanced images demonstrated that a and b decreased after 3 months and synovitis was no more evident. Conclusion:Contrast enhanced MRI is the method of choice for demonstrating the normal healing process of the arthroscopic meniscal repair in bucket-handle tears. A gradually disappearing of the abnormal enhancement is related to scar tissue rather than to meniscal retear.

Introduction: Amputation of the fingertip with loss of the finger pulp, exposed bone and nail bed injury is a common problem, not infrequently neglected. Fingertip reconstruction requires new pulp glabrous skin coverage with sensitivity, buttressed by the nail. The aim of this study is the analysis of our experience from the use of a homodigital, island flap for the reconstruction of amputated fingertips Materials and Methods: The homodigital island flap was applied in 46 patients (57 fingers), at every level of finger amputation with special indication on fingertip coverage. For the index and the middle fingers, use of the ulnar bundle is preferred. For the thumb, ring and little finger use of the radial neurovascular bundle is preferable. The neurovascular bundle is well dissected from the flap to the base of the finger. After suturing of the flap the donor area is covered with split thickness skin graft from the hypothenar. The finger is mobilized one week after the procedure. Results: Postoperatively, ROM was normal in 45 fingers, 6 fingers had 100 loss of extension at the DIP and 6 fingers had loss of motion between 100–200 . TPD was 4mm (3–10mm). Three patients had cold intolerance for 8 months. There was no neuroma or sensitive scar formation and no need for a second operation. According to patients cosmesis was acceptable in all fingers. Conclusions: The use of homodigital island flap provides excellent functional reconstruction of the fingertips after a complex tissue loss in Allen III and IV amputations It is a straightforward operation carried out under wrist block with excellent cosmetic results.

Purpose: To review the MRI findings in transient osteoporosis of the hip (TOH) and to investigate the pattern of perfusion in dynamic studies.

Material and Methods: Twenty-seven patients (29 hips), 23–66 years old, were referred for hip pain without history of trauma. In all patients the diagnosis of TOH based on x-rays (decrease bone density of the femoral head) and MRI (bone marrow edema-BME) was confirmed after complete resolution of symptoms and MRI findings after 6–18 months. MRI studies included T1-w SE, T2-w-SPIR-TSE and contrast enhanced T1-w TFE in dynamic mode and delayed SE. Imaging assessment included joint effusion, location and extent of BME (types A–D), sparing of the femoral head, subchondral linear lesions, and collapse.

Results: Joint effusion was observed in 28 of 29 hips. The extent of BME in the femoral head was type A in 5/29 hips, B in 2/29, C in 16/29, D in 6/29. Associated BME of the acetabulum was depicted in 6/29 hips. In 12/29 hips the bone marrow edema was sparing the subchondral area. Subchondral line was only found in 2/29 hips. On dynamic T1–w images all hips presented with a delayed pattern of perfusion up to 40 sec.

Conclusion: MRI findings are useful in diagnosing TOH and differentiating this entity from early AVN.

Purpose: We present the results of subacromial decompression and repair of the rotator cuff through a minimal deltoid-on approach.

Material and Method: Eighty-seven patients with longstanding shoulder pain were evaluated in two years (1999–2000) in our department. In sixty -eight of them symptoms were due to impigment syndrome. Eight patients with follow up time less than six months were excluded from this study, twenty were treated conservatively and the remaining forty (22 female, 18 male, mean age 50.3) underwent surgery. Three x-ray views were obtained in all patients, i.e. standard AP, true AP, and subacromial space projection. MRI was also obtained in all patients. MRI revealed calcific tendinitis in fifteen patients, osteophytes of the acromioclavicular joint in thirteen, a hooked (type III) acromion in ten and partial tear of the supraspinatus tendon in nineteen. In five of them there was also a partial tear of the infraspinatus. Finally, seven patients were suffering of a full thickness tear of the supraspinatus tendon. All patients were operated through a minimal deltoid-on approach. Acromioplasty and coracoacromial ligament dissection was performed in all. In patients with osteoarthritis of the acromioclavicular joint, osteophytes were carefully removed. Calcific deposits were also removed in all patients. In eighteen patients tears of the rotator cuff were detected and repaired using bone anchors.

Results: All patients were examined six months postoperatively. Results were evaluated with CONSTANT SCORE and with a questionnaire for patient’s satisfaction. Thirty-seven patients were very satisfied with the result and three were satisfied. As for Constant score, pain improved at an average of 7.8 points, daily activities by 5.4, and range of movement by 4.2 points. Results were evaluated by the examiner as excellent in thirty-six patients (90%) and very good in four patients.

Conclusion: Deltoid-on approach, in patients with impingement syndrome of the shoulder provides adequate exposure for the surgical repair with minimal trauma and a very low rate of complications.

Purpose: We assessed the consequences of the permanent lesions after multiple compartment syndrome of the tibia. We also assessed the socioeconomic consequences during the period of secondary operations and rehabilitation.

Material and Methods: We followed 20 prospective patients (pts) who were referred to our department after multiple compartment syndrome of the tibia. We present the patiens’ causes, the socioeconomic consequences and the way the condition affects the quality of patiens’ lives. We also assessed the morbidity of the patients and we present the number and the severity of the reconstructive operations which were needed.

The cause was RTA in 13 pts, accident at work in six and in one patient the result of a reconstruction osteotomy and external fixation. The opening of the compartments was done in nine pts but in two of them we caught the condition at an early stage on time. The consequences were a dropped foot in 13 pts, a club foot in two pts, cavus foot in eight pts, clawing of toes in 13 pts, ankle stiffness in six pts, plantar numbness anaesthesia in 12 pts, plantar callosities in five pts and chronic infections in eight pts. The number of reconstructive operations was from one to ten with a hospitalization duration from one month to five years. Only two pts were able to work an easy job and two pts went back to their previous job, those in whom we had opened the compartments in time. In one pts an amputation below the knee was done. The rest of the pts are unemployed or work as assistant.

Conclusion: The permanent lesions after a multiple compartment syndrome of the tibia are very serious for the functioning of the limb, the quality of the pts’s live life and their work. It is very important to prevent this condition by opening all compartments in time (or at a very early stage).

We evaluated the clinical outcome of IM nailing for the treatment of femoral shaft pseudarthrosis in patients who had multiple failed plate osteosyntheses. From January 2000 untill April 2001, 20 (19 male-1 female, mean age 28) patients were treated because of femoral shaft non-union in our institution. All patients had two or more failed plate osteosyntheses. There were no septic non-unions in this group. Eight patients had an established non-union on an average of nine months post-op and the remaining eleven had radiological and clinical evidence of implant failure. There was no segmental bone loss, hi all patients the implants were removed and nailing was performed. Extensive periosteal stripping, bone necrosis and soft-tissue scaring were constant findings in all patients. Twelve patients received interlocking nails. Eight femurs were grafted with iliac crest bone graft. All patients were followed by serial x-rays until union.

There were no postoperative complications. All pseudarthroses were healed within an average of 9.7 months (8–12). Non-unions which received bone graft (eight out of twenty) in day one, were healed faster than those which didn’t. There were no re-operations among these patients. Among the remaining ten patients five were grafted five to six months postoperatively and three had had nail dynamization.

IM nailing for femoral shaft non-unions after multiple failed plate osteosyntheses is a safe and effective method of treatment. Autologous bone graft reduces healing time and re-operation rate.