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Volume 84-B, Issue SUPP_II July 2002

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R. Brunner

The neurogenic clubfoot is composed of several deformities – such as cavus and equinus, hind foot varus, supination and adduction of the forefoot – which develop due to the neurological disease leading to muscle imbalance. Whereas over-activity and spasticity occur after damage of the central nervous system, flaccid paralysis is the result of damage of the spinal motor neuron or the nerve itself. Local overload at the lateral border of the foot, poor stability and small supporting area may interfere with function and hence require treatment of the deformity. The primary aim is a functioning foot. Treatment options are conservative means or surgical procedures.

Insoles are applied to correct the foot position: a lateral support forces the foot into valgus and pronation being effective only when loaded and worn in reinforced shoes. They can also be used to distribute pressure in case of local overload and sores. An individually manufactured foot orthosis provides more stability. If the forces are still overly big, the lever arm of an ankle foot orthosis is required.

Surgical procedures may be carried out in addition to or instead of conservative means. Skeletal surgery should not be performed early because the neurological disease persists despite the local correction and increases the risk for recurrences. Stiffening of the foot needs to be avoided in order to preserve function. Stiffness due to cavus is reduced by a Steindler release of the plantar fascia. Equinus should not be overstressed. If necessary, it is corrected by heel cord lengthening resulting in a persistent loss of force, or by aponeurotomy maintaining force but being less efficient to gain length. To balance supination, split or complete transfer corrects the pull of hyperactive anterior or posterior tibial muscles. Lacking skeletal deformation is a prerequisite for these soft tissue procedures. Thus their presence requires bony correction alone or in addition to soft tissue surgery. The varus of the os calcis is best corrected by an original or modified Dwyer valgus osteotomy. Cavus, supination and adduction deformity can all be corrected at the midfoot. These procedures preserve mobility and hence function of the foot. Severely contracted feet, however, may need corrective fusions. Nevertheless, stiffness is badly tolerated. An alternative is application of an external fixater of the Ilizarov type to correct the skeletal deformity and followed by an additional corrective osteotomy.

Botulinum toxin A paralysing a muscle for three months can be used to switch off overactive anterior or posterior tibial muscles in order to delay surgery or to prevent pull out after transfer. Application of casts to stretch overly short muscles can help to keep the deformity under control, but they need to be followed by splints in order to avoid early recurrence.


J. Chomiak P. Dungl

We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors.

Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus.

Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment.

Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation.

Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release.

Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction.

Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V.

This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing.


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B. Bartoníèek

Diaphyseal fractures can be divided into three groups comprising the basic types of fractures: fractures of both bones (radius and ulna), fracture dislocations, i.e., fractures of one of the bones accompanied by dislocation of the head of the other bone in the respective radioulnar joint, the Galeazzi fracture or the Monteggia fracture, and isolated fractures of one of the two bones – the radius or the ulna.

Photographs are decisive for diagnosis of the anteroposterior and lateral projections. Each must simultaneously visualize the elbow and wrist joints in order not to neglect potential injuries located there.

The basic aim is full restoration of the function of the forearm with emphasis on supination-pronation movement. This requires anatomical union particularly in regard to the ulna, which has a critical importance for the function of the forearm. In fracture dislocations, it is also necessary to restore stability in the respective radioulnar joint.

For the above-mentioned reasons, almost all diaphyseal fractures (except for non-dislocated or minimally dislocated fractures of the ulna) are indicated for surgery. Our procedure depends on the condition of the fracture and the general condition of the patient.

Plate fixation represents the gold standard for closed fractures – open fractures of Degrees I and II and some Degree III fractures classified according to Tscherne. More extensive defects of soft tissues require cooperation with a plastic surgeon.

The standard implants are dynamic compression plates (3, 5 DCP) with holes for 3.5 mm cortical screws. The surgical approach to the ulna is relatively simple. In fractures of the proximal half of the radius, we prefer the Henry approach in fractures of the proximal half of the radius because, unlike the Thompson approach, it allows safe dissection up to the radial head without damaging the deep branch of the radial nerve. The main principle is a 3 + 3 fixation, meaning that the plate must be fixed to each of the two main fragments, minimally by three screws. An exception can be made in the vicinity of the joint when the fragment is too short to accommodate three screws.


A. Biasibetti D. Aloj P. Gallinaro

The choice of treatment for open fractures is conditioned by the care of bone and soft tissue. Grade I open fractures can be treated as closed fractures, according to the centre’s protocol. In Grade II open fractures skin wounds must be left open, and the suture should be delayed for at least a week. Most authors perform fixation by means of intramedullary nails.

In our opinion, external fixation is the best choice in these cases. The skin cannot be closed in Grade III open fractures, and the basic point of treatment is adequate surgical debridement. The fixation must be done by external fixation. To achieve the treatment in an emergency situation, the device to be used must be quick and simple like a monolateral device that can be changed into a more complex one, such as an Ilizarov.

The Ilizarov technique uses distractional osteogenesis that can fill bone and soft tissue loss without further bone or soft tissue grafting.

Following these general guidelines, each district has its own particular approach to treating open fractures. Internal fixation by DCP plates is always indicated for forearm fractures. For a humerus fracture, simple direct shortening and external fixation can fill bone loss. Patients with fractures of the femur usually have multiple injuries. The problem is to provide a quick fixation in order to allow for easier intensive care. External fixation is the most indicated technique.


F. Delepine G. Delepine N. Delepine E. Guikov S. Alkallaf B. Markowska

A “hands-on” composite gives a similar functional result as a custom-made prosthesis and has a much better function than alternative techniques. Less expensive and more flexible than custom-made prostheses, it can be used even when no part of the iliac wing remains. The use of cement permits the adjunction of antibiotics needed for these complicated cases.

After peri-acetabular resection for bone sarcoma, a reconstructive procedure is necessary to stabilize the hip, avoid limb discrepancy, and permit full weight bearing. This procedure needs to be easy to perform because resection of the area is time and blood consuming. This leads to the use of a “hands-on” composite prosthesis.

Our reconstructive procedure uses a titanium cup with a long screw that is fixed in the remaining bone (sacrum or spine). When the cup is firmly fixed to the bone, the gap between the cup and bone is filled with cement loaded with antibiotics, and the polyethylene component is cemented on the innominate prosthesis. The femoral component of a usual hip total prosthesis is then implanted.

Since 1990 we have used this reconstructive procedure in 50 patients, 27 with bone sarcomas involving the acetabulum (11 chondrosarcomas, 9 Ewing’s sarcomas and 7 other sarcomas) and 23 for metastatic disease. Thirty of these patients were already metastatic when operated. The average duration of the reconstructive procedure was 45 minutes. Walking started from the fourth to tenth day after operation, but full weight bearing was usually authorised after six weeks.

Postoperative complications were frequent. Seven deep infections occurred, four required ablation of the prosthesis, and one would benefit from a saddle prosthesis. 33% of the patients had postoperative dislocation of the hip prosthesis and 13 patients had to be reoperated. Only two loosenings have been observed – one after deep infection and one after local recurrence in the sacral bone. Oncologic results: With a mean follow-up of five years, 28 patients died of disease and one from an unrelated disease. Four others with disease are still living. Seven local recurrences were observed (four in chondrosarcomas with a contaminated resection). The difficulty in obtaining wide margins explains the high rate of local recurrence (14 %). For patients with localised disease, the five-year overall survival rate is 75% and the five-year disease-free survival rate is 60%.

According to the Society for Musculoskeletal Oncology criteria, orthopaedic results were excellent in 7 patients, good in 30, fair in 6, and bad in 6. The mean functional score of 46 patients who still have their prostheses is 83% with usually no pain, excellent acceptance, length discrepancy of less than 1 cm, average flexion of 100 degrees, and unlimited walking without support.

We conclude that the rapidity and flexibility of this procedure are the positive aspects of this reconstructive technique. However, perfect positioning of the prosthesis remains difficult in a very large peri-acetabular resection. A computed guide is of great help to specify safe margins and prosthesis positioning. Longer follow-up is needed to ensure that the rate of late loosening will not be too high.


N. Delepine G. Delepine F. Delepine E. Guikov

Nowadays 80% of patients with bone sarcomas can benefit from limb salvage. Their disease-free life expectancy is not jeopardised by conservative surgery as long as safe margins are obtained. For this reason, the oncological result relies on the accuracy of pre-operative and per-operative surgical measurements. Pre-operative evaluation of tumours is now quite accurate with digital margins (computed tomography, MNR, digital angiography). However, surgeons are still using centimeters or conventional radiographs with their own technical limitations for per-operative evaluation. A more accurate technique is needed.

The system is composed of three components: 1) a color, graphic computer workstation with software to calculate and present the location of the surgical instrument on a three-dimensional, reconstructed bone image, 2) a complete set of hand-held instruments containing infrared emitters, 3) an infrared receiver linked to the work station. This measuring system enables determination of the position and incidence of a surgical instrument in real time during surgery, with an accuracy of less than one mm.

The system requires four steps: 1) recording data with C.T., N.M.R. or angiography, 2) creating a three-dimensional image displayed on the computer screen for preoperative simulation of a virtual operation, 3) recording the very important anatomical points of the patient and optimal incidences of the surgical instruments, 4) preoperative location of surgical instruments and control of their location on bone.

This system is very useful for resection of bone tumours when the conventional location is uncertain (innonimate bone, rib), when very sharp accuracy is needed to preserve the growth plate of the distal femur in young children, and to avoid medullary damage in a spinal tumour.

The frameless stereotactic device is also very accurate in the reconstructive phase of limb salvage. After an internal hemipelvectomy, the device permits localisation of the acetabular prosthesis in the precise location before resection.

In our practice, the accuracy of the video guiding system is always within two mm as compared to conventional measurements usually between one or two cm for long bones and three to five cm for innominate bone.

The use of a video guidance system is very beneficial for limb salvage surgery for pelvic bone tumours.


J. Correl W. Scharl

In the most severe clubfeet, especially in relapse, traditional operations are not helpful any longer. In these cases the Ilizarov method (IM) can correct even the worst deformities by gradual correction. Up to the age of about eight years, traditional operations can be performed in most cases of relapsed clubfoot. A disadvantage of the traditional operation is the shortening of the foot if a wedge is resected. With the IM the patient need not be immobilised postoperatively for a long period, which is important especially for those children with neurological diseases. We report on our 18 years experience with the IM.

We have operated 99 clubfeet with the IM. The first 91 consecutive cases in 79 patients are included in this retrospective study. The mean age of our patients was 14.2 years. The mean follow-up was two years, five months. The etiology was 28 congenital, 51 neurological, five rheumatological and seven with posttraumatic clubfeet. The mean number of operations per patient before presenting to us was 1.6 (range 0 to 8). The mean healing time – the number of days from application of the external fixator until its removal – was 115 days. Using the classification of Dimeglio we found 12 type 3 feet and 79 type 4 feet (stiff-stiff).

In 37 feet we observed a superficial infection, in seven a deep infection, and an ostitis in one. At the end of a seven-year follow-up period, clinical, radiological and laboratory tests of the patient with ostitis showed no signs of infection. In the beginning we had some torn wires, but this was a problem that could be solved with increasing experience.

We classify the patients into three groups. Feet that have a normal or almost normal shape and permit weight bearing and walking without pain are rated as good. Radiologically the foot is well corrected. A residual deformity without skin damage or complaints is rated as fair. A relapse, overcorrection or severely restricted walking capacity is rated as bad.

In our study we found 52 good, 33 fair and 6 bad results. All feet with a preoperative infection due to long lasting skin breakdown and ostitis healed well during treatment with an external fixator.

The IM is a safe procedure even in the most severe cases and allows correction if traditional methods can no longer be used. The results show that many good and at least fair results can be achieved. Normal function cannot be expected in these severely deformed feet, but the aim is to allow weight bearing and walking even in severe cases. The IM is especially helpful in neurologically relapsed clubfeet. The IM is an efficient tool in the hands of an experienced orthopaedic paediatric surgeon.


G. Delepine N. Delepine F. Delepine E. Guikov B. Markowska S. Alkallaf

The purpose of this study was to investigate the importance of the timing of surgery for disease-free survival (DFS). The increasing efficacy of neo-adjuvant chemotherapy in Ewing’s sarcoma modifies the prognostic factors. In a recent monocentric study the classical prognostic value of size and location of the primary disappeared (Delepine G, Alkallaf S. J. Chem.1997;9:352–63.). This study confirmed the value of histologic response and pointed out the importance of dose intensity of VCR and ACTD. However, the role of local treatment could not be significantly demonstrated because the number of patients was too small.

Seventy-five patients with an average age of 19 years (range 4 to 40) years with Ewing’s sarcoma of bone fulfilled the inclusion criteria for this study: localised tumour at first screening (CT of lungs + bone scan) and location of the tumour in resectional bones (limb, scapula, innominate, rib, maxilla, skull). Metastatic patients and vertebral locations were excluded. The patients received multi-drug chemotherapy and were treated by surgery and radiotherapy in cases of bad responders and/or marginal surgery. The histologic response was evaluated according to Picci’s criteria (Picci, A. J Clin Oncol.1993;11:1793–99). The duration of local treatment was calculated from biopsy to surgery in weeks.

After a mean follow-up of 54 months, 41 patients were in first complete remission. Patients operated before the tenth week had a higher chance (68%) of first complete remission than patients operated later (DFS: 43%). The difference is significant (p< 0.03). Further analysis shows that the difference is due to late local control, which causes a dismal prognosis for bad responders.

Local treatment must be performed early, especially when histologic response is incomplete or uncertain. Preoperative chemotherapy that is too long increases the risk of metastases in bad responders. These factors must be taken into account when analysing multicentre protocols.


E. Gautier A.J. Shuster S. Thomann R.P. Jakob

Minimally invasive plate osteosynthesis is a technically feasible surgical alternative to treat displaced diaphyseal fractures of the tibia. In recent years, this technique has evolved in response to the poor results following tibial fracture stabilization using the traditional open method of plate fixation. Devascularisation with periosteal stripping of bone fragments using open reduction and internal fixation to ensure adequate fracture visualisation led to a substantial percentage of complications including deep infection, delayed union or non union, and refractures after plate removal. Using the technique of minimally invasive plate osteosynthesis, fracture management is achieved with closed reduction followed by stabilisation using a subcutaneous epiperiosteal LC-DC-plate.

Twenty-four patients with 25 tibial fractures were treated by minimally invasive plate osteosynthesis at the Kantonsspital, Fribourg, Switzerland, between 1997 and 1999. These cases were retrospectively reviewed.

There were 11 male and 13 female patients with a mean age of 41 years (range 16 -64). Nineteen tibial diaphyseal fractures (7 type A, 11 type B, and 1 type C) and six tibial epiphyseal-metaphyseal fractures (4 type A, 1 type B, and 1 type C) were surgically treated. Three fractures were open (grade I). Twenty-four fractures were treated using a 4.5 mm titanium LC-DC-plate, and in one fracture a 4.5 mm stainless steel DC-plate was used for tibial fixation. Open reduction and internal fixation of the fibula was necessary in eleven fractures, nine of which were stabilized with a one-third tubular plate and two with a 3.5 mm LC-DC-plate. The postoperative regimen included partial weight bearing for eight weeks followed by progressive and protected weight bearing until fracture union was achieved. Fracture union was confirmed with radiographs obtained at six to eight weeks, twelve to sixteen weeks, and at final follow-up. The mean time to final follow-up was eighteen months.

All fractures had solidly united within four months postoperatively. Radiographically, healing was characterised by callus formation located on the lateral and posterior aspects of the tibial diaphysis, and was similar to that which is usually seen after stabilisation of tibial fractures using an intramedullary rod. Both ankle and knee range of motion were similar to the uninjured side by final follow-up. There were eight cases of residual valgus malalignment of less than five degrees, and were associated with distal third tibial diaphyseal fractures with concomitant fibula fractures which were not rigidly stabilised. Postoperative complications included two deep wound infections and one postoperative compartment syndrome.

Overall good results were obtained by using minimally invasive plate osteosynthesis of diaphyseal fractures of the tibia. Although this technique is more technically demanding than standard open reduction and internal fixation of tibial diaphyseal fractures, preservation of the soft tissue envelope and periosteal blood supply is beneficial for fracture healing. Surgical indications for minimally invasive plate osteosynthesis of the tibial diaphysis include a narrow tibial medullary canal as well as distal and proximal metaphyseal fractures not suitable for intramedullary rodding, and associated intra-articular tibial fractures. Minimally invasive plate osteosynthesis should be considered as a surgical alternative for the treatment of displaced diaphyseal fractures of the tibia.


P. Dungl

Postdysplastic ischaemic necrosis of the proximal femoral epiphysis has its origin in the vascular crisis during conservative or operative treatment of DDH and in the majority of cases has an iatrogenic origin. The severity of the symptoms and functional disability is dependent on the anatomic changes of the proximal femur and the whole hip joint respectively, which were caused by previous conservative or operative treatment, including repeated surgery. The symptoms such as limping from leg length discrepancy and abductor insufficiency, pain and restricted ROM are less apparent in small children, but become more conspicuous with the approach of the end of growth. For the classification of the patterns of ischemic necrosis of the femoral head, the classification according to Bucholz and Ogden was used.

Four principal types of this deformity are recognised. There are three main problems which are to be solved by surgical treatment. 1. The acetabular dysplasia with a pelvic osteotomy 2. Improving the bio-mechanics by distalisation of the greater trochanter and by the lengthening of the femoral neck with or without valgisation 3. Lengthening of the shorter extremity.

The decision on the type of surgery to be performed depends on the age of the patient and the severity of the anatomic deformity, as well as the functional disability. A very useful method for treatment was found to be a double intertrochanteric osteotomy with a trochanteric advancement, and almost invariably in combination with a triple or Salter pelvic osteotomy. The lengthening osteotomy of the femoral neck follows the principles of Müller and Wagner. A similar technique was also proposed later by Morscher.

My own contribution has been to modify the operation by an oblique execution of the osteotomy, and a method of fixation of the greater trochanter by means of an angle plate – providing a lengthening of the limb by up to 3 cm. In the case of acetabular dysplasia, a pelvic osteotomy should be performed as a first procedure in order to obtain better stability of the hip joint. A femoral osteotomy can follow at a minimal interval of three months. If the femoral osteotomy is performed as a first step without enlargement of the actabulum, there is the risk of further deterioration of the covering of the femoral head, even in a dislocation. This philosophy of treatment of sequel of postdysplastic necrosis has been used since 1979.

Up to 1984, we operated on 48 hip joints in 46 patients, 39 girls and 7 boys aged 4 to 21, with a follow- up of at least 15 years. In 12 cases, 10 girls and 2 boys aged 4 to 8, a Salter and valgus osteotomy was performed. Thirty-four patients (29 girls and 5 boys) had a triple pelvic osteotomy, with 2 girls being operated bilaterally. In 22 hips, a lengthening osteotomy of the femoral neck was added as a second stage procedure. Five parameters were used for clinical evaluation: pain, limping, range of motion, Trendelenburg sign, and leg length discrepancy. For radiological assessment, we used an AP X-ray of the entire pelvis taken before and after osteotomy, and also during follow-up. CE angle, Sharp’s angle, ACM angle, and lateralisation were recorded. Hip score was measured on all hips, but we found that CE, Sharp and lateralisation were of greater value. In a group of 12 cases operated on up to the age of 8 by combining Salter and valgus osteotomy, a cementless THR was necessary for a young woman of 25. The remaining 11 patients are up to the present time without any major problems. In a group of 14 patients operated for sequel of postdysplastic necrosis Type II deformity (all with triple pelvic osteotomies and five in combination with femoral neck lengthening osteotomy), all have a normal quality of life, including having natural childbirths. From 22 Type III hip joints in 20 patients operated for sequel of postdysplastic necrosis, a cementless THR was implanted in three cases 14, 17 and 18 years after original surgery. Fourteen patients (15 hip joints − 67%) can be considered as good results without needing to have any therapy. Three patients (4 hips) suffer from degenerative arthritis and are candidates for THR.


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W. Friedl

Proximal femur fractures are usually low-energy injuries of elderly patients, but they can also occur after highenergy trauma in young adults and children. The proximal femur shows very special biomechanical (high load) and biological (blood supply) characteristics. These factors, the patient’s age, and the implant characteristics (weight bearing capacity and cut out risk) are determinants for the surgical management of proximal femur fractures.

There are two main fracture groups that require a different approach because of the difference in blood supply: 1) medial femoral neck fractures and 2) lateral femoral neck, trochanteric, and subtrochanteric fractures.

Medial femoral neck fractures occur in about 90% of dislocated adduction fractures. Because of the high risk of pseudarthrosis and head necrosis (~30 %) in older patients, a hip joint prosthesis should be used. A total hip prosthesis is used (mainly cementless) for patients in good biological condition; in elderly patients (> 80 Y.) a hemiarthroplasty is performed. Because prospective studies have not shown any benefit for bipolar hemiarthroplasty, we use a unipolar hemiarthroplasty.

In non-dislocated fractures of the elderly and in all medial femoral neck fractures in younger patients, a joint-preserving osteosynthesis is used. The most used therapy is three canulated screws. Because of implantrelated complications (dislocation, cut out) particularly in steep fracture lines, comminution zones, and noncompliant patients, a stabler fixation with an intramedullary device should be used. We prefer the gliding nail because of the rotation stability and minimal cut out risk of the I-beam profile femoral neck component.

Lateral femoral neck, trochanteric, and subtrochanteric fractures have a minimal risk of femoral head necrosis. Intramedullary locked nail systems such as the gliding nail and gamma nail have a much lower bending movement and therefore allow full weight bearing in all types of fractures. The gliding nail also gives rotation stability to the head and neck fragment in unstable fractures because of the I-beam-profile of the femoral neck component, and has an over 50% reduced cut out risk as compared to screw profiles.

Extramedullary implants like the DHS do not allow full weight bearing in unstable trochanteric fractures and are unsatisfactory in subtrochanteric fractures. They can be safely used only in stable fractures. Prostheses should not be used in primary management of trochanteric fractures because of the very low re-operation rate in modern intramedullary implants (< 4 %). The operation time, possible late complication, blood loss, and costs are higher for a hip prosthesis.


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F. Grill

Clubfoot is medically defined as luxatio pedis sub talo. The process of dislocation mostly caused by muscular imbalance results in bony deformities and soft tissue contractures, which in the majority of cases – even after meticulous conservative treatment – have to be corrected by surgery. In children before school age, surgical corrections should always address the main pathology. To achieve normal alignment of the fore and hindfoot, a complete reduction of the talus within the acetabulum pedis has to be done by soft tissue release.

Analysing the pathomorphology, a clubfoot is characterised by equinus, varus, forefoot adduction, and horizontal subtalar medial rotation. Regarding bony deformation, the medial side of the talus is narrowed by the navicular, the medial malleolus, and the fibrocartilage between. Growth expansion is limited on the medial side and there is more growth expansion on the lateral convex side, leading to external rotation of its body (~ 10-25°) and internal inclination of the neck (~30-50°). The calcaneus is internally rotated 20-30°.

Regarding joint dislocation, there is a displacement of the navicular medially and plantarward towards the medial malleolus. The cuboid bone usually follows the position of the navicular and dislocates gradually to the medial side.

Soft tissue contractures are located medially (Lacinate Lig., M. Add. hallucis, Spring Lig., talo navicular Lig., Master knot of Henry) and posterior (lat. fibulo calc. Lig, post. capsule of the ankle joint). There is also a shortening of muscles e.g. short plantar flexors, M. tib. post., M. flex. hall. longus., M. flex. digit. comm., M. tib. ant.

The method of treatment depends on the severity of a clubfoot, the preoperatively achieved results of conservative treatment, and how extensive a subtalar release has to be performed. If the navicular can be reduced conservatively, a posterolateral surgical approach is indicated.

A transversal incision is performed starting laterally at the calcaneal cuboid joint and ending medially below the medial malleolus. A dorso lateral release of the subtalar joint, Tendo Achilles lengthening, and dorsal release of the ankle joint is performed.

At the age of three to six months, it is possible to correct subtalar malalignment to move the calcaneus away from the fib. Malleolus by external rotation in relation to the talus (Mini Cincinnati technique). If the talonavicular and the calcaneo-cuboid joint are dislocated, a complete subtalar release has to be done in order to reduce the talo-navicular, calcaneo-cuboid and talo-calcaneal joint. To avoid overcorrection, the talo calcaneal interosseous lig. should be kept intact whenever possible (Mc Kay-Simons procedure). This type of surgery should not be performed before the age of six months.

The subtalar release technique described by McKay was introduced in our hospital in 1983. Since then, 362 clubfeet have been treated by the above-mentioned techniques: 249 by the Mini Cincinnati (Group 1) and 113 by the McKay-Simons procedure (Group 2). Age at the time of surgery ranged from 2 to 12 months in Group 1 and 5 to 52 months in Group 2.

In Group 1, the results were excellent in 42%, and good (residual forefoot adduction) in 49%. A second surgical intervention had to be done in only 9%. Regarding shape and appearance of the foot in Group 2, results were excellent in 46%, good in 38% and insufficient in 16% (overcorrection 3%, relapse 13 %). Concerning functional outcome, the feet of Group 2 presented much more stiffness than those of Group 1, which was also found pre-operatively.

The treatment of clubfoot is still a matter of controversy because of different severity of deformity and different treatment philosophies.

According to our experience, the McKay-Simons procedure has proved to be ideal for simultaneous correction of various components of the deformity from one single approach. In particular, correction of subtalar horizontal rotational deformity in the subtalar joint can be easily performed.

Based on the survey, the danger of damaging nerves, blood vessels, tendons and joint cartilages can be kept to a minimum by using the Cincinnati approach. In the majority of cases, the foot appears normal, moves without pain, and is flexible enough to enable the child to walk on his toes or heels and to participate in sportactivities.

Limitation of mobility is nevertheless the main problem of all extensive soft tissue procedures in clubfoot surgery, and it is not known at this time if this will cause subtalar osteoarthritis in early adulthood.

Complete subtalar release develops less osteonecrosis, fewer changes in the navicular, and less cavus and adductus than the use of other surgical techniques.

Overcorrection and poor functional results were seen in patients less than six months old at the time of surgery. We recommend that a complete subtalar release be delayed until the child is aged 6 to 12 months. Treatment should ideally be completed by the time the child is ready to walk.


G. Hartofilakidis

For better communication, treatment planning and evaluation of results, a generally accepted classification is needed for determining the different types of congenital hip disease (usually referred to as developmental dysplasia of the hip) in adults. We have proposed the use of the following classification: Dysplasia, Low Dislocation, and High Dislocation. Knowledge of the local anatomical abnormalities in these three types of the disease is mandatory.

Total hip arthroplasty in all three types (especially in high dislocation) is a demanding operation and should be decided when there is an absolute indication. The acetabular component must be placed at the site of the true acetabulum, mainly for mechanical reasons. After the reaming process, if the remaining osseous cavity cannot accommodate a small cementless cup with at least 80% coverage of the implant, the cotyloplasty technique is recommended. This technique involves medial advancement of the acetabular floor by the creation of a controlled comminuted fracture, autogenous bone grafting, and the implantation of a small acetabular component with cement, usually the offset-bore acetabular cup of Charnley.

In order to facilitate reduction of the components and to avoid neurovascular complications, the femur is shortened at the level of the femoral neck, along with release of the psoas tendon and the small external rotators.

We believe that this operative technique of total hip arthroplasty is effective for the treatment of difficult conditions of highly dislocated hips.


K.P. Günther

Appropriate clinical studies that address the efficacy and effectiveness of orthotic treatment in general are difficult to identify, particularly in postoperative treatment of congenital clubfeet. Clinical experience, however, seems to necessitate casting and splinting for a certain time after surgical correction to prevent relapses.

Although treatment recommendations range from three months to two years after surgery, duration and intensity of orthotic therapy may depend on the severity of the clubfoot deformity, underlying disorders and the surgeon’s experience.

Knee-ankle-foot orthoses with a knee flexion of 90 are most commonly prescribed after the removal of postoperative casts. They allow appropriate abduction of the foot, and daily stretching exercises that can be performed by the parents in combination with physical therapy. Most splints are made of polyethylene or polypropylene, and current designs include static or rigid ankle and forefeet.

Some authors also recommend significantly smaller orthoses that are used in metatarsus varus treatment: Denis-Browne bars and orthoses with locking or elastic swivel joints that allow the hindfoot and forefoot components to be adjusted in relation to each other. However, since they do not have a moulded heal, they tend to slip off and cannot prevent recurrence of the equinus. Their application is also restricted to pre-walking infants unless considered for use at night.

Outflare shoes (anti-varus shoes) also keep the forefoot in the “corrected position”. To obtain a necessary 3-point correction, however, certain construction principles are mandatory. The hindfoot must be kept in high heel cup and the first metatarsal is pushed laterally against the counter-pressure that is exerted on the cuboid by the most distal and lateral part of the heel cup.

After introduction of continuous passive motion (CPM) into the treatment of congenital clubfeet, some groups have published encouraging results. Although the advocates of this treatment state that the duration of plaster cast immobilisation can be shortened after surgery, further evaluation of outcome and cost-effectiveness of this approach is necessary.


G. Hansson Y. Aurell

The value of ultrasonography (US) was assessed for studying the position of the navicular and the cuboid in children with clubfeet (CF). In most studies on the management of CF, more than 50% of the patients have required surgical treatment for correcting foot deformities. In addition, repeat surgery is commonly needed for correction of residual foot deformities, especially persistent forefoot adduction usually due to medial displacement of the navicular and sometimes also the cuboid. These conditions have often been overlooked at the initial surgery.

The authors examined 50 CF and 100 normal feet by US in children during the first year of life. With the transducer, the position of the navicular was studied along the medial border of the foot, and the position of the cuboid along the lateral border of the foot.

The results indicated that 1) Severe medial displacement of the navicular towards the medial malleolus, which might not be possible to reveal by clinical examination, was commonly seen in children with CF and 2) severe medial displacement of the cuboid was seen considerably less frequently.

Ultrasonography, using the most recent type of equipment, is a helpful tool when deciding if the navicular and the cuboid need to be re-aligned by open reduction in children with CF during the first year of life.


C. Hasler

Modern concepts in paediatric fracture respect individual, social and economic needs:

the patient’s demand for early mobility and capability to play

the requirement to achieve an optimal end result (no posttraumatic deformity, full range of motion, no leg length discrepancy) with a minimum of total expenditure and costs: primary treatment should be the definitive treatment. Thus, redo-procedures, unnecessary irradiation, and long hospital stays are prevented.

the spontaneous remodelling capacity should be anticipated for each specific fracture and be part of the treatment algorithm of fractures of the upper extremity. In the lower extremities a long lasting remodelling period leads to stimulation of the adjacent physis and thus to posttraumatic leg length differences.

The decision between conservative and operative treatment is based on the radiological assessment of fracture stability. Fractures with fragments in contact and at most with some angulation but no shortening may be termed stable. Conservative treatment on an outpatient basis is adequate: plaster immobilization and wedging of the plaster in case of a primary or secondary angulation. Fully displaced fractures or long oblique fractures with a strong tendency for shortening as well as comminuted fractures are unstable. Stable fixation with a child-adapted implant is required: closed reduction, minimal approach, satisfying scars, early full weight bearing, short hospital stay, and a minimal procedure for metal removal are achieved either by external fixation or elastic intramedullary nailing dependent on the fracture pattern and the surgeon’s preferences.

Humeral shaft fractures are the domain of non-operative treatment: immobilization e.g., with a U-plaster followed by functional bracing (Sarmiento) is efficient and more comfortable than a heavy hanging cast. Retrograde intramedullary nailing is indicated in open fractures, multiple injury patients, arterial injuries and compartment syndromes, or if conservative treatment does not lead to a satisfactory alignment. Concomittant radial nerve palsies: since natural history is excellent, observation instead of primary exploration is recommendable. Forearm: in case of complete fractures, closed reduction and plaster immobilisation is only justified if one of both bones is stable. If not, primary elastic intramedullary nailing prevents posttraumatic deformities and loss of function. Femur: Non-displaced fractures (less than 10° angulation in the sagital plane, no varus or valgus deformity, no malrotation) as well as displaced fractures in children younger than four years can be treated with a hip spica. In older children closed reduction followed by external fixation or elastic intramedullary nailing provides early stability and a quick return to play and school. Shortening and angulations with a subsequent high remodelling activity should be avoided in order to prevent femoral overgrowth. Lower leg: Most isolated tibial fractures (intact fibula) are managed conservatively in a long leg plaster. Radiological monitoring is recommended to detect secondary varus deformites which can be easily reduced by wedging of the plaster after 8 to 10 days. Fully displaced transverse tibia fractures and unstable fractures of the tibia and fibula – oblique fractures with shortening or fully displaced fractures – are either stabilised by external fixation or elastic intramedullary nailing.


L. Jani H. Schroeder-Boersch

Only someone with good common sense paired with a grain of fortune-telling might be able to foresee further improvements of THR implants adequately. After carefully reviewing the studies of the past, we have evolved our personal belief of what future improvements could look like. A new, improved stem should be made of titanium alloy, have a sandblasted surface structure with a tapered proximal fit stem design. Further advantages would be to allow a certain amount of bony restitution in the metaphyseal region and minimise the stress shielding effects on the femur. As an example of the often-difficult way from the idea on the drawing board to a commercially exploitable implant, we demonstrate the development of our newly designed “hollow-stem” prosthesis.

In an animal study a tapered cementless hollow-stem prosthesis was implanted in 10 foxhounds and subsequently analysed after 12 and 24 weeks. As a result, mineralisation occurred between the titanium stays of the prosthesis, as well as in the central hollow area as early as two to four weeks after implantation. After 12 weeks, density of cancellous bone between the titanium stays and in the hollow centre was considerably higher than on the contralateral untreated side. Load bearing within the centre of the stem was obvious due to the regular orientation of the trabecular bone.

After these positive results we began the conversion to a production line human stem prosthesis. With the help of a finite-element analysis, the stem was then modified in critical areas, resulting in an improved prototype which was subjected to a fatigue test according to ISO 7206-3 of 10.000.000 cycles without any damage. After careful deliberation with our ethics committee, we were finally able to commence with our pilot study consisting of the implantation of 20 hollow-stems and 20 Spotorno stems as a matched pairs study design.

The clinical and radiological evaluation after a minimum 12-month follow-up shows comparably good clinical results in both groups. Radiologically, some degree of subsidence was seen in three hollow stems compared to two Spotorno stems without being clinically relevant. The next step will be a larger randomized study using the hollow-stem as well as a solid stem of the same design. We will consider a more widespread utilisation of the hollow-stem only if this randomised study proves the hollow-stem to be superior.


R. Krauspe P. Raab

The goal of clubfoot management, regardless of the method applied, is still to improve function and form as close as possible to normal values. Since the final outcome of any therapy will only become evident at the end of growth, long-term follow-up studies are necessary to evaluate the results and methods. The aim of this study was to evaluate long-term results of corrective surgery for clubfoot deformity in a selected group of patients. Other congenital or acquired abnormalities like neuromuscular disease, arthrogryposis or others were excluded in order to identify the factors associated with the success or failure of the treatment.

A retrospective clinical and radiological study of 64 patients with 104 treated feet with a follow-up of 8 to 35 years (mean: 19.2 years) is presented. All of the patients were operated on by Scheel′s technique. In this technique the Achilles tendon was lengthened and combined with a dorsal arthrolysis. In some cases medial structures such as the tibialis posterior, long-toe flexors tendon sheaths and the medial ligaments of the talonavicular joint were released. A calcaneal traction was applied for four weeks and a plaster cast for six weeks.

The patients were grouped according to the duration of follow-up (< 10, 10–20 and > 20 years) and the results were compared. Clinical evaluation followed the criteria according to the McKay Score, a score of 180 from which points for sequela (either morphologic or functional) are subtracted.

There was an inverse relationship between the functional rating score and the length of follow-up. Acceptable results decrease over time as the patient approaches skeletal maturity. In the group with a follow-up of > 20 years, only 5% were rated as good, 34% as satisfactory, 28% as poor and 33 % as failure.

Radiographic evaluation of the last group showed marked deformities of the talus and navicular bones, as well as advanced osteoarthritis. The degree of bone deformity of the talus (flat-top-talus) and navicular seems to depend on the degree of persistent residual joint subluxation after surgery and contribute to the development of secondary osteoarthritis of the ankle and subtalar joint over time. Considering the goal of treatment is to restore form and function, assessment and approach of all the components of the individual deformity is required.

A complete subtalar release to realign the calcaneus to an externally rotated position is followed by a reduction of the talonavicular joint. To achieve full reduction, release of the calcaneocuboid joint is necessary because it is linked with the talonavicular joint.

Preliminary results of 89 congenital clubfeet treated with a complete subtalar release with an average follow- up of five years show 12.4% excellent, 41.6% good and 39.3% satisfactory according to the McKay-Score. The results of this series underlines the importance of careful and complete derotation and anatomic realignment of the talocalcaneonavicular joint complex in order to have a lifelong functional foot with the least amount of deformity and disability. The results of any treatment for clubfoot deformity should be judged after skeletal maturity, making a follow-up of at least 20 years necessary.


M. Kerboull

Eighty-nine patients (8 males, 81 females) with an average age of 52 years had 119 high dislocations (Crowe IV, 30 bilateral and 59 unilateral). The patients underwent 118 total hip arthroplasties between 1970 and 1986 using original or modified Charnley prostheses. Only 39 patients had not had a previous operation. Pain in the hip associated with stiffness and limitation in activity was the main indication for surgery. Back or knee pain was the chief complaint of 11 patients. Pre-operatively and post-operatively, a thorough assessment of the patients was made including hips, pelvis lumbosacral spine, knee, leg length discrepancy and static body balance.

The operation was performed through a transtrochanteric approach. A small socket was always inserted and cemented into the true acetabulum augmented by an autogenous graft, and a straight femoral component implanted at the level of the lesser trochanter. Muscle releases and tenotomies were not performed. Twenty-nine patients (35 hips) had died or were lost to follow-up. Sixty patients were still alive at the last examination in 1996, and regularly seen with a mean follow-up of 16 years. The mean follow-up of the whole series was 12.8 years.

At the last examination, clinical results according to the d’Aubigne rating system were classified as excellent 59.3%, very good 15.2%, good 15.2%, fair 5.1%, and poor 5%. Only 10 patients had a persistent waddling gait and a positive Trendelenburg sign. The results were slightly less good when a major femoral angulation needed an alignment osteotomy.

One femoral and seven acetabular loosenings were revised. In addition, five hips were revised for severe polyethylene wear and osteolysis before definite loosening, and two hips for heterotopic ossifications. The rate of revision was 12.7%. At twenty years, the survival rate was 99% for the femoral component and 87% for the socket, cemented fixation as end point, whereas the cumulative survival rate of the prosthesis was 78%, revision as end point.

The leg shortening, mean 4.84 cm (range 3-8 cm), was accurately corrected 63 times and within 1 cm 42 times. The lengthening was an average of 3.80 cm (2 to 7 cm). Leg length discrepancy was, on the whole, reduced as much as possible (mean 2.6 cm pre-operatively, 0.4 cm post-operatively). Of the 18 pre-operative painful knees, 10 were greatly improved, but four of these needed an operation.

Lateral pelvic tilt was corrected in more than 50%, pelvic frontal asymmetry was substantially reduced, as well as lordosis and lateral curve of the lumbar spine. As a result, low back pain has been relieved in 40 patients, but two required a laminectomy for a lumbar canal stenosis.

Total hip arthroplasty on high riding hips may be a wonderful operation, but this operation is full of pitfalls, technically demanding, and may represent a serious risk of complication. A successful result depends on a complete pre-operative assessment of the patient, a perfectly performed surgical procedure, and a reasonable selection of its indications.


E. Morscher

The longevity of the fixation of implants in a formerly dysplastic hip is compromised by several risk factors:

Young age.

Severity of the dislocation.

Previous surgery. Hip arthroplasty after a previous intertrochanteric osteotomy is technically more demanding but not necessarily associated with a higher rate of complications.

Distortion of the acetabulum. Fixation of the socket in a dysplastic hip joint acetabulum (one of the main aims of a THR) is compromised both by using a small implant and an insufficient containment of the socket in the bony acetabulum.

Small cups (small implant/bone contact area, thin polyethylene wall). Small cups are especially used in cases where the implant must be positioned higher up in the iliac bone.

High hip center and lateral placement of the cup. A high hip center is not to be considered as a risk factor as long as there is no simultaneous lateralisation of the cup. Upward displacement of the center of rotation must be compensated for by changing muscle length and the arms of the abductors with a longer neck in order to preserve muscle power. The acetabular component, i.e., the center of rotation of the hip articulation should be positioned as medially as possible.

Insufficient containment of the acetabular socket. As a rule, the positioning of the socket into the original acetabulum creates normal mechanics of the hip and provides the best bone stock for fixation of the cup, especially in complete dislocations. However, placement of the cup into the original acetabulum of a subluxated femoral head in an angle that is not too vertical leaves a supero-lateral void. Enlargement, i.e., reinforcement of the roof of the acetabulum with screws and bone cement has not proven to be adequate. Acetabuloplasty, i.e., grafting with an autologous cortico-cancellous graft taken from the resected femoral head or using an acetabular reinforcement ring (ARR) is indicated if 20 and more degrees of the weight-bearing surface of the cup would otherwise remain uncovered.

Massive cortico-cancellous bone grafts. The use of bulky autologous or homologous cortico-cancellous grafts which would be loaded over 50% or more of the weight-bearing surface of the cup is not recommended.

Excessive anteversion, narrow medullary cavity, and capsular contractures on the femoral side. The most typical deformity of the proximal end of the femur in hip dysplasia is an excessive anteversion angle of the neck of the femur. Anteversion angles of 45 degrees and more are corrected by a derotational osteotomy of the femur. To avoid overlength of the leg by positioning the cup into the original acetabulum, a subtrochanteric shortening osteotomy may be indicated.

Preoperative planning is mandatory. Procedure, choice of method, and availability of appropriate equipment and endoprosthetic implants must be ensured. Computerised tomography with 3-D reconstruction is recommended for more complex anatomical situations.


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J.P. Metaizeau

The treatment of fractures in children is essentially conservative because young bone heals rapidly and growth remodels many malunions. In addition, we do not have implants which respect the biomechanics of the growing bone. The techniques perfected for the adult skeleton have adverse effects in children and their disadvantages still outweigh their advantages.

Fixation which is too rigid encourages cortical union but inhibits the formation of periosteal callus which is of prime importance in the child. This approach evacuates the fracture haematoma, damages the periosteum, increases local devascularisation, and encourages infection and secondary hypertrophy. The rigidity of a plate also produces a rapid thinning of cortices in young bone, adding the risk of recurrent fractures.

However, conservative treatment does not always give perfect results. Some injuries are liable to sequellae which are not corrected by growth. Children with polytrauma, severe brain injuries, osteogenesis imperfecta, and neurological problems cannot always be treated orthopaedically and require surgery.

Stable intramedullary nailing (SIMP) seems to be particularly adaptable to growing bone. SIMP is carried out with two pre-bent pins that allow stabilisation of nearly all diaphyseal and metaphyseal fractures and also respects the healing process and the unique biomechanical properties of young bone. This technique presents many advantages and few disadvantages but it is not designed to supplant conservative treatment. The aim is primarily to treat fractures that cannot be treated conservatively without adding iatrogenic complications.

Pre-bent pins are placed in the medullary canal of the bone. Each pin gives a three- point fixation and the three points press on the bone. Two extremities of the pin press on metaphyseal cancellous bone, and the apex of the curve presses on the inner aspect of the cortex.

The principal feature of this osteosynthesis is its elasticity. If one deforms the pin, it resists by developing a force which opposes the deformation. This force returns the pin to it’s original form upon removal of the deforming force. Because the pinning is performed without opening the fracture site, the hematoma and the periosteum are preserved, which is essential for bone consolidation. The elasticity of the pinning allows slight movements in compression and distraction which are particularly favourable for consolidation.

A child is discharged from hospital after two days for fractures of the humerus, forearm or tibia and after five days for femoral shaft fractures. Cast immobilisation is not necessary. Function is recovered rapidly, with a minimal absence from school. If complications occur, they are infrequent and rarely severe.


M. Napiontek

The assortment of primary operative techniques starts with posterior release and ends with the most sophisticated ones such as complete subtalar release. The proper selection of one of them is a key to success and has to be done on the basis of clinical and radiographic parameters.

Posterior release: The indication for this procedure is determined by persistent equinus. On AP and lateral radiographs the normal talocalcaneal angle is visible AP greater than 20; lateral greater than 35 degrees). On the lateral radiograph in corrected equinus or standing, the angle between the calcaneus and tibia should be smaller than 80 degrees. A physical examination con- firms equinus position more precisely. Attention should be paid to the possibility of iatrogenic rocker bottom deformity. In such cases posterior release should be combined with dorsal release of the calcaneocuboid and talonavicular joint.

Posteromedial release: Clinical indications for this procedure are hindfoot equinus and varus and passively corrected medial spin measured with a bimalleolar angle less than 85 degrees. This angle should be checked during surgery when the posteromedial release is completed. If overcorrection is not achieved, the procedure has to be extended in sequence to lateral release or complete subtalar release. Radiographic indications are as follows: diminished talocalcaneal angle on AP (less than 20 degrees) and/or on lateral radiographs (less than 35 degrees), as well as partial overlap of the talus and calcaneus on AP radiographs.

Posteromedial-lateral, posterolateral-medial and partial subtalar release: Indications for these techniques are the same as for posteromedial release. The difference concerns the not corrigible medial spin. The decision about which technique should be used is made before surgery, but its conversion during surgery to another one is possible and depends on obstacles appearing during release. Intraoperative radiographs may help in making the decision.

Complete subtalar release: The clinical indication for this technique is primarily stiff varus and medial spin. The selection of this procedure may be the result of the primary decision or incomplete correction after less extensive procedures. To overcome the obstacles, the talocalcaneal interosseous ligament must be completely cut. Radiographic indications are the same as for posteromedial- lateral or partial subtalar release. Complete overlapping of the talus and calcaneus on AP radiograph inclines the surgeon to choose this method.

All techniques mentioned can be extended to the correction of forefoot adduction. A metatarsal first ray angle lower than 70 degrees is indicated for correction. For small children, the opening of the cuneonavicular and first cuneometatarsal joint with a slight transposition of the tibialis anterior is preferred. In older children, open wedge osteotomy of the medial cuneiform is done. For correction of calcaneocuboid displacement, no open reduction is performed even if a +2 displacement of the cuboid is seen on AP radiograph, because self-existent reduction occurred. However, closed stabilisation of this joint by K-wire is performed. A stable subtalar complex can be rotated as a block during partial or complete subtalar release.


F. Langlais J.C. Lambotte L. Montron

For unstable fractures of the femoral shaft, the current interlocking nails are the most reliable fixation. However, these procedures require the use of an image amplifier for targeting the distal screws, and are expensive, ancillary instrumentation and an extensive stock of numerous nail sizes with various diameters, sides, and lengths is necessary.

We report a consecutive series of 60 unstable femoral fractures treated with the Endolock nail. This closed 11 mm diameter nail is introduced after little or no reaming. Distal fixation is achieved by means of a spur that unfolds from the nail and fixes into the posterior metaphysis. Radiological control during the procedure is recommended but not mandatory.

Fusion was achieved in all cases but three (5%). Two were aseptic in the same patient who presented two upper limb non-unions, and one with infection (little or no reaming was used in the nine open fractures). Eight moderate mal-unions were observed (angulation < 10°, external rotation < 20°, shortening < 20 mm) but did not require re-operation. All of these were the consequence of insufficient reduction of the fractures. No secondary displacement occurred between operation and fusion. No complications related to spur penetration or removal were observed.

The Endolock nail allows satisfactory interlocking without the mandatory use of an image amplifier, with little or no reaming, and at a low cost.


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M. Leunig K. Siebenrock R. Ganz

Acetabular dysplasia is the most common cause of secondary osteoarthritis of the hip joint resulting in many young adults requiring total hip replacement (THR). Although THR has a predictably good functional result, the longevity of prosthetic replacement in this young cohort of patients has been notably inconsistent. Therefore, there has been an increasing interest in better methods for treating acetabular dysplasia in young adults with the emphasis shifting from the femoral to the acetabular side during the last 10 years.

For reorientation of the acetabular fragment to improve coverage, various pelvic and periacetabular osteotomies have been proposed. Most necessitate more than one incision and change of patient position. The Bernese periacetabular osteotomy (PAO) combines complete and incomplete osteotomies, as well as a controlled fracture requiring only one approach. This is beneficial for the vascular supply of the acetabular fragment and allows an additional anterior capsulotomy without restrictions.

The osteotomies of the PAO are close to the joint and therefore allow a pronounced acetabular reorientation similar to juxta-articular triple osteotomies. Moreover, anteversion and medialization/lateralization of the center of rotation can be corrected with only minimal changes of the pelvic geometry. This enables a normal delivery in young females. The partially remaining posterior column protects the sciatic nerve from iatrogenic damage. The polygonal shape of the osteotomy and avoidance of soft tissue stripping (abductors) are advantageous for the stabilization of the reoriented fragment, thus facilitating early mobilization and rehabilitation.

Seventy-five dysplastic hips with a minimal follow-up of 10 years after PAO were evaluated. There were good to excellent result in 73% of these patients. The mean lateral center edge angle increased from 6° to 34° and the mean anterior center edge angle improved from 4° to 28°. The post-osteotomy index angle was successfully reduced from an average of 26° to 6°. Lateralisation of the femoral head was reduced from an average 16° to 10° compared to 11° on the contralateral side. Femoral head cranialisation also normalized from 9° to 4° compared to 5° on the opposite hip. Poor results were correlated with older patients, pre-existing arthritis, labral pathology, and mal-correction. Treatment of labral lesions was performed only as a supplementary measure if the labrum was unstable and included either refixation or resection.

The PAO is a technically demanding procedure, and is unforgiving of seemingly minor imprecision. With the fact that 85% of our major complications occurred within the first fifty osteotomies, it is obvious that a learning curve exists for this procedure. It is imperative that surgeons undertaking this procedure do so with a full understanding of each stage and have the necessary patience, attention to detail and adequate cadaveric experience with the technique.


V. Stìdry P. Dungl

We examined a group of 26 patients (28 hip joints) with postdysplastic osteoarthritis who were operated in 1995 and 1996.

The Zweymüller Bicon prosthesis was used in all cases. Only patients with dysplasia Type B and C according to Eftekhar were included. By the method of Ranawat and Pagnana, the true acetabular region and the approximate femoral head centre were determined on preoperative and postoperative radiographs. The patients were controlled in 1999 with HHS. Antero-posterior radiographs of the pelvis and lateral radiographs of the acetabulum according to Zweymüller were made in all hips.

In most of the operated hip joints the true center of the rotation differed from the ideal centre, with the maximal difference being 18 mm cranially. Cranial placement of the cup occurred more frequently in Type C. No patient was reoperated, and as determined by radiographs, there were no indications of loosening in the acetabular and femoral components.

The Zweymüller Bicon total hip joint endoprosthesis is suitable in most cases of postdysplastic osteoarhritis of the hip. No special or individual implant was necessary in 1995 and 1996. Good primary stability and a good result was achieved in all cases. We consider this type of hip implant as especially useful in CDH osteoarthritis.


K. Zweymüller

Patients with hip dysplasia that are to be managed with total hip replacement constitute a special group of arthroplasty candidates. Each patient will need to be treated according to his or her anatomical pattern. The important point to remember is that dysplasia in itself is not a contraindication to cementless hip replacement. However, there are certain points that need to be taken into account in the management of this special patient population.

The surgical technique must be appropriate; in particular, cup medialisation is an important feature. The implant system used should be modular so as to permit a large number of combinations, and it also should provide cups for hard bone and cups for soft (osteoporotic) bone, as well as anti-dislocation inserts. Such a system will also allow limb length to be corrected, usually without reference to the centre of rotation of the hip joint. The primary objective is the positioning of the cup in the native bone stock at a site that will ensure optimum primary stability. If an adjunctive shelf procedure is considered necessary, any buttressing done will have to be performed after the cup itself has been stably implanted.

In our centre between 1993 and 1995, 122 were patients with dysplastic hips. One hundred and eleven of these hips were clinically and radiologically followed-up by the author. Mean follow-up was 4.1 years (range 2.1 to 6.1 years). Typically, there were more women than men: 88 cups were implanted in female patients and 23 in male patients. The average age at surgery was 53 years. The youngest patient in the series was 19 years of age and the oldest was 77. Coxa vara osteochondritica (25 cases) was treated as a separate diagnostic and management group. In 17 cases previous acetabuloplasties had been done, usually a Chiari osteotomy. In terms of severity of the dysplasia, 67 hips were Grade I, 36 were Grade II, and eight were Grade III according to Randelli.

All patients were managed with our biconical threaded cup made of commercially pure titanium. In 91 cases the Standard version, designed for use in normal or in hard bone, was employed. The Porosis type of cup, with a 46% greater thread surface area, was chosen in 20 cases. Antidislocation inserts were used in two cases. Conical cups are inserted with prestress and do not therefore require additional fixation with screws or lugs. The most important instrument for the achievement of optimum implant positioning is the medialising reamer with an aggressive front-cutting action. The use of this instrument allows sufficient bony coverage to be obtained to allow fixation of the titanium cup in the host bone with a good primary stability.

The following standard radiographs were used in the analysis: (1) AP view of the operated hip and the contralateral hip; (2) AP and axial views of the operated femur; (3) monitor-controlled AP view of the cup. In 110 cases the position of the cup had not changed during the follow-up period and cranial migration was seen in one case. This case and an additional one were judged to be “at risk” since the patients were pain-free and the position of the implants had remained unchanged for the past two years. These two patients also had more than 2 mm Zone III lucencies. In both cases a superior (Zone I) sclerotic area was found to have developed postoperatively. This pattern differed from the one observed in patients with stable implants, in whom the extent of preoperative sclerosis was significantly reduced following arthroplasty. This regression of sclerosis around a stable implant suggests that the implantation of the titanium cup results in an improvement of the periacetabular stress pattern. In 84 cases there was evidence of increasing integration of the implant; in 22 cases no bony response could be detected, i.e., there was neither apposition of new bone nor loss of existing bone stock. In one case part of the rim of the titanium cup was found to have broken off superiorly. This patient has been recently revised with an exchange of the cup. At revision the cup was found to be so soundly osseointegrated to the extent that it could be removed only after being cut up with a diamond tool. None of the other patients have required revision to date, and none are scheduled for revision as a result of follow-up.


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M. Porter

The clinical results of cemented hip arthroplasty in patients with DDH are excellent in terms of pain relief and implant longevity. The survivorship of the femoral stem in young patients less than 40 years of age is 97% at ten years and falls to 89% at 25 years. In comparison, survivorship of the acetabular component is 97% at ten years but falls to 58% at 25 years. The excellent survivorship of the femoral stem can be explained by a favourable canal flair index, competent cancellous bone, and secure fixation with acrylic cement. The inferior results of the acetabular component are explained by the distorted pelvic anatomy and lack of bone support for the acetabular component. We continue to recommend cemented hip arthroplasty in this cohort of patients. Our current practice is to use fourth generation cementing techniques and to employ autografting of the acetabulum to address some of the anatomical deficiencies of the original anatomy.


V. Vécsei M. Greitbauer

Classification systems for open fractures help the surgeon to follow guidelines for treatment, to predict the prognosis, and to allow comparison of results. The systems of Gustilo and Anderson and of Oestern and Tscherne are most widely used. Although both systems have undergone several revisions, the crucial factors have not changed. They deal with the size of the wound, level of contamination, extent of soft tissue injury, and comminution of bone.

In recent years additional classification systems have been created to classify severe open fractures (type III), mainly of the lower extremity. The Mangled Extremity Severity Score (MESS) became the most practicable score for establishing a dividing line between possible functional limb salvage and the need for primary amputation.

Management: The principle of surgical debridement of all necrotic tissues has to be followed. Nowadays, soft tissue coverage and restoration of lost bone can be achieved secondarily by different means. However, the method of primary skeletal stabilization has a high impact on the final outcome after open diaphyseal fractures.

Upper extremity: Most open fractures of the humerus and forearm can be stabilized sufficiently with plates. Because of the good soft tissue coverage of the humerus and proximal forearm and the good blood supply of this region, coverage of implants can usually be achieved in cases with vast soft tissue destruction and severe bone comminution. External fixation with the option of primary shortening and secondary bone transport is a good alternative in cases of humeral fracture. Indications for intramedullary nailing are limited to minor open fractures that do not require radial nerve exploration. At the distal forearm, the thin soft tissue layer and the necessity of two approaches often make coverage of plates impossible. External fixation is the method of choice in these cases.

Lower extremity: Femoral fractures are a domain for intramedullary nailing. The indications for nailing are restricted more by systemic factors rather than by the extent of soft tissue injury. The advantages of intramedullary nailing are based on the closed surgical procedure that leaves the actual fracture site untouched. Static interlocking ensures axial and rotational stability and warrants early functional treatment and weight-bearing mobilisation. External fixation is indicated as emergency treatment, and plating should be restricted to condylar and supracondylar fractures.

Tibial fractures leaving 7 cm intact bone proximally and 5 cm distally can be sufficiently stabilized by intramedullary locking nails. In cases of open fractures, small diameter nails can be inserted in the unreamed technique without deterioration of the endosteal vascular supply. This method has better reported results concerning time to union, axial alignment, joint function, and infection rates in comparison with the use of external fixation devices. However, external fixation is an adequate method, especially in cases with extreme proximal and distal fractures. If insufficient stabilization or delayed union with the use of unreamed nails or external fixators occurs, reamed nailing can be performed in a second step with good results. Plating should be restricted to tibial head and pylon fractures.


K. Bachfischer L. Gerdesmeyer W. Mittelmeier R. Gradinger

The cranial cup is now a standardised implant in acetabular revision surgery. In order to illustrate the positive results of a standardised implant in acetabular revision surgery in comparison to other possibilities of reconstruction, we analysed results of all data in our study group.

Aseptic loosening of implants often causes segmental and cavitary acetabular deficiency. Experiences gained in radical tumour surgery with reconstruction by custommade endoprostheses induced the development of the cranial cup for revision total hip arthroplasty. This new cementless revision cup has an oval shape and a special cranial flap, as well as an intramedullary rod if necessary.

This type of cranial cup has been used since 1993. From 9/97 to 1/99, we implanted 30 cranial cups in revision hip surgery and collected all data of these patients prospectively. Clinical and x-ray follow-up was documented on a regular basis.

Acetabular deficiency occurred twice in type 1, five times in type 2, twenty-two times in type 3 and once in type 4. The AAOS D’Antonio score was used. Cranial cups were implanted without cranial flap in 10 cases, with cranial flap in 20 cases and once using the intramedullary rod additionally. Only 28 patients were included in our last examination because one patient had died and one was bedridden because of a reason other than the hip. The Harris hip score increased from an average of 32 points preoperatively to 63 points postoperatively. Twenty-one patients are satisfied or very satisfied with their surgery. Radiograph examinations showed an average inclination angle of 42.5° in all cranial cups.

Up to now there have been complications in four patients who suffered luxations, but only one required a change of inlay. One intraoperative injury of the urinary bladder had to be revised later. Three implants showed a change of position in x-ray. One was the patient with the urinary bladder injury and possible septic loosening, the second was a patient with extreme osteoporosis, and the third was a patient who did not receive an intramedullary rod for a type 4 lesions. Currently, these three patients do not have any complaints.

We have always achieved primary stability. Morselised bone autografts or bone substitute materials were used to fill remaining defects. An intramedullary rod should be used in pelvis discontinuity and is obligatory to achieve the necessary stability. Developed from the experiences of custom-made tumour endoprostheses, the cranial cup with all possible variations is an appropriate intraoperative variable implant in revision acetabular surgery.


R. Ascherl M. Tauber H. Albersdorfer G. Werding

We report our clinical experience with the first 54 cases of long bone fractures treated with the Fixion IM Nail. This innovative nailing system eliminates the need for interlocking screws and reaming of the medullary canal when the nailing of a long bone fracture is needed, offers a minimally invasive procedure for intramedullary nailing, and significantly reduces fluoroscopy exposure. Biomechanically, the nail assumes the hourglass shape of the medullary canal by its abutment to the medullary walls. The formation of a supporting forces entity, that could be defined as “the bone-nail supporting forces system entity,” becomes practically an integral part of the medullary walls at the points of attachment.

In order to avoid using interlocking screws and reaming of the medullary canal when the nailing of a long bone fracture is required, the “FIXION IMN” system was proposed.

Since March 1999 we have implanted 54 Fixion Intramedullary Nails for traumatic and pathological fractures in 50 patients with a mean age of 52 years (18 to 85). Among these patients, 33 had humeral fractures, 13 had tibial fractures, and 8 had femoral fractures; the pathological fracture cases consisted of 4 humeral cases and 1 femoral case. The Fixion IM Nail system consists essentially of four longitudinal bars connected radially by four thin membranes. The nail is sealed proximally with a unidirectional valve. During insertion, the nail is connected to a driver handle which assists with insertion and serves as a conduit for the saline during the expansion process. Inflation of the nail is by means of a pump that connects to the driver handle. Once in position, the nail is expanded by inflation under controlled pressure with saline. The expansion causes abutment of the longitudinal bars to the inner surface of the canal along the entire length, resulting in fixation of the fracture. The procedure is monitored fluoroscopically and clinically to ensure accurate reduction of the fracture.

The surgeries were uneventful. Postoperative complications were not reported in any of the cases. The nail was inserted easily and good fixation was achieved. The patients made a complete recovery with early pain-free mobilisation and full range of motion.


O. Adamec P. Dungl R. Hart

The outcomes of the Berman-Gartland osteotomy in 26 feet (20 children) from 1995 to 1999 were evaluated. Average age at time of operation: 8 years, 3 months (range 37 to 194 months). Average age at follow-up: 2 years, 5 months (range 2 to 70 months).

The osteotomy is performed in tourniquet from three lengthwise incisions and fixed by Kirschner wires and plaster of Paris for six weeks. Only patients with idiopathic PEC were included in this study. Average age at time of primary operation was ten months. For analysis, the type and percentage of preceding operations were: pantalar release (40%), posterior release (12%), and tendo calcaneus elongation (8%). Eight feet (30%) were not primarily surgically treated. Indicated for metatarsal osteotomy were: footwear difficulty (92%), gait instability (65%), and muscle spasm (56%). Average adduction deformity of the forefoot was clinically assessed as 30 degrees (20 to 45 degrees). Forefoot rigidity was evaluated according to Black as grade II (14 feet) and grade III (12 feet).

Radiograph assessment was made by the use of T-I.MTT and C-V.MTT angle changes in the dorsoplantar weight-bearing view. We succeeded in correcting the average values of T-I.MTT angle from 28 degrees (range 20 to 43 degrees) preoperatively to 4 degrees (range 2 to 15 degrees) postoperatively, and C-V.MTT angle from 16 degrees (range 8 to 24 degrees) to 2 degrees (range -5 to 7 degrees). Isolated metatarsal varus deformity was found in 12 feet, in combination with talo-navicalar joint hypercorrection in nine feet, and in combination with residual talo-navicular joint subluxation in five feet.

Calcaneocuboid joint displacement was classified as grade I and II in 16 and 3 feet respectively. Preoperative residual displacement was not found in seven feet.

Complications were noted in three metatarsal nonunions (2% of 130 osteotomized metatarses), four pin migrations, one superficial infection, and one persistent forefoot swelling.

At final follow-up, clinical findings and outcomes were assessed as excellent in 16 feet (62%) and good in 10 feet (38%). We recorded no inferior result. An apparent relationship was not found between the type and timing of preceding operations and varus forefoot deformity persistence. In 19 feet (73%), residual grade I and grade II tibial subluxation of the cuboid bone was found.


M. Ambroziak M. Zgoda D. Chmielewski R. Gòrski

The purpose of our study was to estimate the influence of previous fractures and operative procedures around the hip, the follow-up period from the arthroplasty, and effect of the age of patients at the time of surgery on the results of total hip replacement in patients with a history of fracture of the hip.

Forty-six patients were analysed after a mean follow-up of 6 years after arthroplasty. There were 34 females and 12 males. Mean age at the time of operation was 65 years (range 32 to 82). The reasons for arthroplasty were displaced subcapital femoral neck fracture in 23 patients (50%), failure of internal fixation for femoral neck fracture in nine patients (20%), and posttraumatic osteoarthritis of the hip in 14 patients (30%) that included six patients with a history of fracture of the acetabulum. Results were assessed with the Merle d’Aubigne Postel scale (evaluation of gait, range of motion, pain). Radiographic findings were classified according to the Moreland Grouen scale. Quality of life after arthroplasty and subjective assessment of patients was recorded.

Results were: 33 (71%) satisfactory, 14 (30%) excellent, and 19 (41%) good. Thirteen (29%) were classified as unsatisfactory: 9 (20%) fair and 4 (9%) poor. Patients with acute fracture or non-union of the femoral neck showed the best results: 11 excellent and 8 good. The poorest results were in the group of patients with osteoarthritis following acetabular fracture treated by total hip replacement: 3 were classified as fair and 3 as poor. Twelve cases of internal fixation of the femoral neck before arthroplasty had no influence on the final outcome. Although none of the patients returned to their previous occupation, subjective assessment showed 27 (59%) and 14 (30%) with excellent and good results, respectively. There was no significant relationship between age of patient and the final outcome of total hip arthroplasty.

Total hip arthroplasty following hip injury provided satisfactory long-term results. Previous history of internal fixation had no influence on final outcome. The poorest results were achieved in patients with a history of acetabular fracture. Patients’ subjective assessment was satisfactory in most cases despite radiological evidence of loosening of the prosthesis in a statistically insignificant number of patients.


L. Bálint Á. Bellyei T. Illés Z. Koòs

The goal of the present study was to evaluate the results of a one-stage operation performed on dislocated hips in children with infantile cerebral palsy. Our data indicate that the one-stage operation is a quite useful method to treat hip dislocation in children with infantile cerebral palsy. Based on our experience we emphasize the use of an individual operation plan in every instance. In selected cases it seems to be justified to ignore an element of the method.

We used the radiological findings for evaluation by comparing the geometric parameters in the affected hips before and after surgery.

During the last ten years, 21 dislocated hips in 13 patients were operated on by the one-stage surgical technique used at the Department of Orthopaedic Surgery of University Medical School of Pécs. The technique consists of the following steps: open reduction, iliopsoas tendon transfer, and femoral varus derotational osteotomy with shortening, modified Tönnis acetabuloplasty, and open adductor tenotomy. Spastic diplegia occurred in eight children and hemiplegia in five. During this period, eight girls and five boys were operated, with 12 procedures on the right hip and 9 on the left. Mean age was 11.4 years. The average age of the children at the time of operations was 6.5 years. In eight hips of five children, all elements of the surgery were carried out in one sitting; in six hips of four children the surgery was performed without acetabuloplasty. In nine hips of seven children there was no need for open reduction, and in six hips of five children we used deep frozen allograft to perform acetabuloplasty. A varus derotational femoral osteotomy with shortening was a part of the surgical approach in all cases.

We evaluated Hilgenreiner (H), Wieberg (CE) and collodiaphyseal (CCD) angle preoperatively and postoperatively. The average preoperative H angle decreased from 39.7 to 24 degrees postoperatively. The average preoperative CE angle increased from minus 18.6 to 31.9 degrees postoperatively. The minus means that all of the patients had dislocation in their hips. The average preoperative CCD angle decreased from 165.2 to 131.4 degrees postoperatively. The results were evaluated by the modified Severin classification based on age and anatomical changes of hips: 17 cases were evaluated as excellent, 2 as good, and 2 as acceptable.

We did not see any complications such as avascular necrosis of the femoral head, absolute revalgisation (compared to the opposite side), subluxation, re-dislocation, or disturbed development of the acetabulum.


L. Bálint J. Kránicz M. Czipri

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients.

A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured.

In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%.

After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care.


L. Bálint J. Kránicz M. Czipri

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients.

A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured.

In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%.

After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care.


H. Behensky J. Landauer M. Krismer

This study was performed to evaluate whether derotation and/or translation are the correct mechanisms of bracing with the Chenau brace in treatment of adolescent idiopathic scoliosis. Bracing in the treatment of adolescent idiopathic scoliosis is an accepted procedure. Variable types of braces with different correction principles are in use. The Boston and the Milwaukee brace correction mechanisms seem to be clear, but not for the Chenau brace which is said to be an inspiration/ derotation device.

Curves were measured according to Cobb and rotation of the apex vertebra was determined according to Perdriooe. Translation of the apex vertebra perpendicular to the centre sacral line was measured according to Mason and Carango. Measurements were performed on standing radiographs AP and were taken immediately before starting therapy, six months afterwards to ascertain initial correction, and at least one year after treatment. Compliance was judged as follows: regular and frequent control examinations, an obviously used brace, and visible skin signs. Two groups were formed (Group A: good compliance, n=33, Group B: bad compliance, n=22).

In Group A, continuous curve correction of 6° Cobb angle was evident. Patients in Group B showed a mean curve progression of 4° (t=test, p=0.003). After six months of therapy, both groups demonstrated signifi- cant apex translation (Group A: p=0.0001, Group B: p=0.0003). The difference between the groups was not significant, but no significant derotation of the apex vertebrae.

At follow-up patients with good compliance showed almost the same apex distance as before therapy, whereas deterioration was evident in Group B (p=0.01). The difference of p=0.04 between the two groups was significant. Apex rotation was significantly increased in both groups (Group A: p=0.02, Group B: p=0.03) and the difference between the two groups was not significant.

Curve correction in idiopathic scoliosis with the Chenau brace is a translation process and can be determined as a shift of the apex vertebra to the centre sacral line. Therefore, the Chenau brace is not a derotation device.


H. Behensky S. Doering M. Krismer G. Rumpold B. Roessier B. Hofstötter G. Luz-Kuehbacher

The aim of our study was to determine whether preoperative preparation by means of a video film could influence postoperative hip motion. The video shows a patient undergoing total hip replacement surgery covering the time period from admission to discharge, and keeping strictly to the patient’s perspective.

In 1958 Janis opened up the field of research on preoperative psychological states and postoperative recovery. Since then, numerous studies have been performed and a variety of variables were demonstrated to influence postoperative outcome. Our study takes into consideration the results of previous research and provides a new combination of methods for psychological preparation prior to surgery.

One hundred patients scheduled for elective total hip replacement surgery for osteoarthritis of the hip joint were randomly assigned to a control group (n=54) and a preparation group (n=46). The preparation group was shown the videotape on the evening before surgery. The video gives the pre-surgical patient the opportunity to identify with a patient who had successfully undergone surgery before. Physical examination, including motion analysis of the hip, was performed. Range of hip motion was documented in degrees with reference to neutral joint position.

Flexion/extension, abduction/adduction, and external/ internal rotation in 90° hip flexion were investigated. For range of motion analysis, sum scores were calculated.

Motion analysis revealed no preoperative difference between the groups. Three months after surgery, the increase of joint mobility (preoperative versus postoperative) in prepared patients was significantly better for internal rotation (32%, p=0.005), rotational range of motion (21%, p=0.03) and abduction (22%, p=0.04). Heterotopic ossifications were identified on plain AP radiographs and were judged according to the score of Brooker, et al. Incidence did not differ between groups. Twelve months postoperatively, the increase (preoperative versus follow-up) of rotational range of motion (24%, p=0.01) remained unchanged in prepared patients, whereas an increase of abduction could no longer be revealed. Flexion/extension and sagittal range of motion did not show any differences three and twelve months postoperatively.

Our videotape preparation led to an increase of motion after total hip replacement. Regarding rotational range of motion, this effect still remained twelve months after surgery.


L.C. Biant R.W.J Carrington J.C.S. Tsui N.I. Garlick

This study examined the reliability of pre-operative templating of the femur in total hip replacement (THR), and the accuracy of the templates provided by leading arthroplasty manufacturers. Templates are provided by arthroplasty manufacturers to be used with pre-operative radiographs as an aid to selecting the appropriate size of prosthesis that will allow an optimal cement mantle in THR. These templates vary in magnification from 10-20% (Mode 15%).

A retrospective review of the pre- and post-operative AP pelvis radiographs of 50 randomly selected patients who underwent THR in 1998 was performed. The radiographs were taken using the uniform standard technique. The magnification of the post-op radiograph was calculated by measuring the femoral head size. This was compared to the magnification of the pre-op radiographs using the ratio of the inter-teardrop distance. The post-operative radiographs were templated using a 15% template and compared to the size of prosthesis inserted.

The mean radiograph magnification was 22.5% (range 10.7 to 32.6%), with the majority (74%) between 20–25%. The 15% template oversized the prosthesis in 68% of cases. A 10% template would have been inaccurate in 96% of our sample group.

In a standard AP pelvis radiograph, the only variable that affects magnification is the extent to which the patient’s soft tissues raise the bony structures away from the plate. This variation in magnification renders preoperative templating of the femur in THR unreliable. Accuracy could be improved by using templates with a magnification of 22.5%.


S.D. Burtt M. Pater G. Scott

This report concerns an operative technique using inexpensive pre-polymerised cement discs as a means of addressing the bone loss from the posterior femoral condyles found during revision total knee replacement.

Bone lost from the posterior condyles in the loosened femoral component of a total knee replacement enlarges the flexion gap at revision. Downsizing the femoral component to fit the remaining bone requires a thicker tibial insert and a proximalised new femoral component to maintain balanced gaps in flexion and extension. Patella infera results from this proximalisation of the joint line and interferes with the extensor apparatus.

Some knee systems offer customised components with thickened posterior femoral condyles or provide the surgeon with the option of adding metal augments to the femoral component to manage the posterior femoral bone loss.

This technique has been applied to ten cases (follow- up ranging from 15 to 46 months) in which inexpensive pre-polymerised cement spacers were incorporated into the posterior femoral cement mass. This allowed the use of primary stemmed components with preservation of the original joint line position.

No case has resulted in loosening although two cases have required further revision due to recurrence of their original infection. At revision of these cases the cement discs remained firmly incorporated in the cement mass.

We conclude that this technique is reliable, inexpensive and could be applied to other prosthetic varieties.


A. Biasibetti D. Aloj P. Gallinaro

The choice of treatment for open fractures is conditioned by the care of bone and soft tissue. Grade I open fractures can be treated as closed fractures, according to the centre’s protocol. In Grade II open fractures skin wounds must be left open, and the suture should be delayed for at least a week. Most authors perform fixation by means of intramedullary nails.

In our opinion, external fixation is the best choice in these cases. The skin cannot be closed in Grade III open fractures, and the basic point of treatment is adequate surgical debridement. The fixation must be done by external fixation. To achieve the treatment in an emergency situation, the device to be used must be quick and simple like a monolateral device that can be changed into a more complex one, such as an Ilizarov.

The Ilizarov technique uses distractional osteogenesis that can fill bone and soft tissue loss without further bone or soft tissue grafting.

Following these general guidelines, each district has its own particular approach to treating open fractures. Internal fixation by DCP plates is always indicated for forearm fractures. For a humerus fracture, simple direct shortening and external fixation can fill bone loss. Patients with fractures of the femur usually have multiple injuries. The problem is to provide a quick fixation in order to allow for easier intensive care. External fixation is the most indicated technique.


R. Brown K. McHugh V. Novelli D. Jones

The aim of the study was to review the role of Magnetic Resonance Imaging of the spine in discitis in the toddler age group (one to three years).

Discitis presents differently in different age groups of children. It is most difficult to diagnose in the uncommunicative non-compliant toddler. The clinical features are often non-specific and laboratory and microbiological tests can be unhelpful. A highly sensitive test is required to aid in making the diagnosis. Although MR Imaging has been used in discitis for several years, we reviewed its actual effectiveness in this specific difficult age group.

At a mean of 21 months at follow-up (range 10 to 40), MR imaging of the disc was variable, with partial recovery after 15 months and complete recovery after 34 months. Routine follow-up MR imaging was not recommended.

We reviewed the role of Magnetic Resonance Imaging in eleven consecutive cases, both at presentation and at a follow-up clinic.

MR imaging was diagnostic in all cases, reduced the diagnostic delay, and often avoided a disc biopsy. It demonstrated any paravertebral inflammatory collection, which helped in determining the duration of the oral therapy given after the initial intravenous antibiotics.


R. R. Brown T. Bull

Objective scoring techniques for back pain are increasingly being used both in the pre-operative selection of patients and as a post-operative outcome measure. Our aim was to determine the strength of correlation between three main scoring techniques used to quantify the severity of the back or leg pain on presentation to a chronic back pain clinic.

The Oswestry Disability Index (ODI), the Medical Outcomes Study 36 item Short Form Health Survey (SF36), and the Visual Analogue Scale (VAS) were competed by 130 patients between July and December 1999. There were 65 males and 65 females with the mean age of 49 years. The patients were divided into three groups: with back pain only, sciatic leg pain only, and those with both. The correlation was analysed using the Pearson correlation test.

There was a good correlation between the Oswestry Disability Index and Visual Analogue Scale for patients with back pain (r=0.641, p< 0.001) and with sciatic leg pain (r=0.469, p< .001). The physical component of the SF36 strongly correlates with the VAS in back pain (r=0.364) and sciatic leg pain (r=1). However there is a poor correlation between the ODI and VAS and all other components of the SF36.


P. Chobanov M. Todorov

The purpose of our study was to compare the mechanical nature of nails with different cross-sections in order to optimise the elasticity-stability ratio. There is no doubt that elastic intramedullary osteosynthesis is a successful choice for treating femoral shaft fractures in children. However, misalignment is a potential problem connected with stability of the fixation.

The mechanics of two types of nails with the same type of surface, but with different kind of cross sections – a circle (Ender) and an ellipse – was examined using the “finite elements” method.

The standard configuration of the two nails was put under four kinds of deforming forces: bending in the frontal plane and the sagital plane, torsion, and axial compression. Strength coefficient and stiffness were calculated in each particular situation.

In respect to angular stability (frontal plane) and axial compression, the mechanical characteristics of the two types of nails are similar. The stability of the elliptical nail is higher in bending in the sagital plane and in torsion. The elliptical implant has better intramedullary cohesion because the large half-axis is perpendicular to the sagital plane.

Nails with an elliptical cross section provide the opportunity for redistribution of stiffness. As a result, better mechanical properties are achieved. The elliptical cross section assures better intramedullary cohesion.


A. Croce P.F. Bottiglia Amici-Grossi C Balbino R. Milani

The various surgical prosthetic solutions in coxarthrosis on a dysplastic basis were evaluated in a critical way.

In our institute more than 3,750 hip prostheses were implanted from 1994 to 1999, and 366 (9.76%) were used for dysplastic coxarthrosis. This high percentage can be explained by the particular geographical position of our institute that has patients coming from the Lombardia region area where CDH is endemic.

Our evaluations consider the highest number of possible parameters in order to realize which is the most modern and reliable surgical solution. Of course, each case is individual and our advantage is to have a prosthesis that is the most suitable for each patient.

The number and type of prostheses used were: 27 ABG, 35 CONUS, 25 CUSTOM MADE, 7 HN, 5 MALLORY, 35 OMNIFLEX, 3 PARHOFER PLASMAPORE, 4 PERSONALISED CUSTOM MADE, 3 RIPPEN, 18 RMHS, 45 SAMO PG, 130 ZWEYMULLER, 18 P507, 6 OMNIFIT, and 5 GYPSE.

From our unique perspective we can consider that in the last several years the use of a cemented prosthesis is progressively disappearing (less than 13%). The use of a cementless prosthesis in young patients (age range 20 to 65) preserves bone stock during implantation, placement and replacement when necessary. If the patient’s age and general conditions allow, we generally operate both dysplastic hips in one stage.

All cases were evaluated with DEXA, which provides qualitative and quantitative data about the periprosthetic bone stock. Various parameters were studied, including restoration of normal biomechanics, centre of rotation, equalisation of limb-length, the Trendelenburg sign, and nerve complications.


F. Delepine G. Delepine N. Delepine E. Guikov S. Alkallaf B. Markowska

A “hands-on” composite gives a similar functional result as a custom-made prosthesis and has a much better function than alternative techniques. Less expensive and more flexible than custom-made prostheses, it can be used even when no part of the iliac wing remains. The use of cement permits the adjunction of antibiotics needed for these complicated cases.

After periacetabular resection for bone sarcoma, a reconstructive procedure is necessary to stabilize the hip, avoid limb discrepancy, and permit full weight bearing. This procedure needs to be easy to perform because resection of the area is time and blood consuming. This leads to the use of a “hands-on” composite prosthesis.

Our reconstructive procedure uses a titanium cup with a long screw that is fixed in the remaining bone (sacrum or spine). When the cup is firmly fixed to the bone, the gap between the cup and bone is filled with cement loaded with antibiotics, and the polyethylene component is cemented on the innominate prosthesis. The femoral component of a usual hip total prosthesis is then implanted.

Since 1990 we have used this reconstructive procedure in 50 patients, 27 with bone sarcomas involving the acetabulum (11 chondrosarcomas, 9 Ewing’s sarcomas and 7 other sarcomas) and 23 for metastatic disease. Thirty of these patients were already metastatic when operated. The average duration of the reconstructive procedure was 45 minutes. Walking started from the fourth to tenth day after operation, but full weight bearing was usually authorised after six weeks.

Postoperative complications were frequent. Seven deep infections occurred, four required ablation of the prosthesis, and one would benefit from a saddle prosthesis. 33% of the patients had postoperative dislocation of the hip prosthesis and 13 patients had to be reoperated. Only two loosenings have been observed – one after deep infection and one after local recurrence in the sacral bone. Oncologic results: With a mean follow-up of five years, 28 patients died of disease and one from an unrelated disease. Four others with disease are still living. Seven local recurrences were observed (four in chondrosarcomas with a contaminated resection). The difficulty in obtaining wide margins explains the high rate of local recurrence (14 %). For patients with localised disease, the five-year overall survival rate is 75% and the five-year disease-free survival rate is 60%.

According to the Society for Musculoskeletal Oncology criteria, orthopaedic results were excellent in 7 patients, good in 30, fair in 6, and bad in 6. The mean functional score of 46 patients who still have their prostheses is 83% with usually no pain, excellent acceptance, length discrepancy of less than 1 cm, average flexion of 100 degrees, and unlimited walking without support.

We conclude that the rapidity and flexibility of this procedure are the positive aspects of this reconstructive technique. However, perfect positioning of the prosthesis remains difficult in a very large periacetabular resection. A computed guide is of great help to specify safe margins and prosthesis positioning. Longer follow-up is needed to ensure that the rate of late loosening will not be too high.


N. Djordjevic-Marusic Z. Vukasinovic S. Slavkovic

We compared the clinical and radiological effects of the Salter and the Chiari pelvic osteotomy on congruent dysplastic adolescent hips with mild symptoms and free of degenerative changes.

The Salter innominate osteotomy has a significant role in the surgery of paediatric hips with significant elasticity of triradiate cartilage, while the Chiari procedure is reserved for incongruent dysplasia with mild or moderate arthrosis in adolescents or young adults. Neither of these operative procedures is an ideal indication for congruent dysplastic adolescent hips free of arthrosis. Hypothetically, the residual remodelling potentials of immature congruent dysplastic adolescent hips can be sufficient to overcome the disadvantages of the Salter and the Chiari osteotomy and give good, long-lasting results. The effects of these quite different procedures in two homologous groups were compared.

There were 30 hips treated with Chiari and 25 hips corrected by Salter osteotomy. All hips were congruently dysplastic according to the distance between the centres of the femoral head and the acetabulum (Klaue et al., classification). Groups were homologous considering mean age (14.5 years), follow-up period (8.5 years), presence of preoperative pain, Trendelenburg sign, and degenerative changes. Assessment for pain and Trendelenburg sign was made at follow-up. Radiological measurement was made of the central-edge angle of Wiberg (CE), acetabular angle of Sharp (AAS), and the femoral head coverage index of Heyman and Herndon (FHC). Progression of degenerative changes was analysed according to the criteria of Kellgren and Lawrence.

At follow-up in the Chiari group, presence of pain was reduced from 54% to 6.6%, and from 35% to 12% in the Salter group. The presence of Trendelenburg sign was reduced 3% in the Chiari group and remained the same in the Salter group. At control, mean values of radiological parameters were normal in both groups (Salter: CE-27.8°, AIS-36.8°, ING-82.8%; Chiari: CE-36.8°; AIS-39.7°; ING-90.8%). Individual analysis showed 16% of dysplastic hips in the Salter group, and none in the Chiari group. Only one hip (4%) had grade 1 arthrosis after Salter osteotomy. There were five grade 1 hips (17%) in the Chiari group and one (3%) grade 2 arthrotic hip.

At follow-up (mean 8.5 years) greater reduction of pain was found in the Chiari group than in the Salter group, but the presence of Trendelenburg sign remained almost unchanged in both groups. There was normalisation of the mean values of radiological parameters in both groups, but the Salter osteotomy was unable to correct dysplasia in 16% of the adolescent hips. Progression of degenerative changes was more rapid in the Chiari group.


N. Delepine G. Delepine F. Delepine E. Guikov

Nowadays 80% of patients with bone sarcomas can benefit from limb salvage. Their disease-free life expectancy is not jeopardised by conservative surgery as long as safe margins are obtained. For this reason, the oncological result relies on the accuracy of pre-operative and per-operative surgical measurements. Pre-operative evaluation of tumours is now quite accurate with digital margins (computed tomography, MNR, digital angiography). However, surgeons are still using centimeters or conventional radiographs with their own technical limitations for per-operative evaluation. A more accurate technique is needed.

The system is composed of three components: 1) a color, graphic computer workstation with software to calculate and present the location of the surgical instrument on a three-dimensional, reconstructed bone image, 2) a complete set of hand-held instruments containing infrared emitters, 3) an infrared receiver linked to the work station. This measuring system enables determination of the position and incidence of a surgical instrument in real time during surgery, with an accuracy of less than one mm.

The system requires four steps: 1) recording data with C.T., N.M.R. or angiography, 2) creating a three-dimensional image displayed on the computer screen for preoperative simulation of a virtual operation, 3) recording the very important anatomical points of the patient and optimal incidences of the surgical instruments, 4) preoperative location of surgical instruments and control of their location on bone.

This system is very useful for resection of bone tumours when the conventional location is uncertain (innonimate bone, rib), when very sharp accuracy is needed to preserve the growth plate of the distal femur in young children, and to avoid medullary damage in a spinal tumour.

The frameless stereotactic device is also very accurate in the reconstructive phase of limb salvage. After an internal hemipelvectomy, the device permits localisation of the acetabular prosthesis in the precise location before resection.

In our practice, the accuracy of the video guiding system is always within two mm as compared to conventional measurements usually between one or two cm for long bones and three to five cm for innominate bone.

The use of a video guidance system is very beneficial for limb salvage surgery for pelvic bone tumours.


G. Delepine N. Delepine F. Delepine E. Guikov B. Markowska S. Alkallaf

The purpose of this study was to investigate the importance of the timing of surgery for disease-free survival (DFS). The increasing efficacy of neo-adjuvant chemotherapy in Ewing’s sarcoma modifies the prognostic factors. In a recent monocentric study the classical prognostic value of size and location of the primary disappeared (Delepine G, Alkallaf S. J. Chem.1997;9:352–63.). This study confirmed the value of histologic response and pointed out the importance of dose intensity of VCR and ACTD. However, the role of local treatment could not be significantly demonstrated because the number of patients was too small.

Seventy-five patients with an average age of 19 years (range 4 to 40) years with Ewing’s sarcoma of bone fulfilled the inclusion criteria for this study: localised tumour at first screening (CT of lungs + bone scan) and location of the tumour in resectional bones (limb, scapula, innominate, rib, maxilla, skull). Metastatic patients and vertebral locations were excluded. The patients received multi-drug chemotherapy and were treated by surgery and radiotherapy in cases of bad responders and/or marginal surgery. The histologic response was evaluated according to Picci’s criteria (Picci, A. J Clin Oncol.1993;11:1793–99). The duration of local treatment was calculated from biopsy to surgery in weeks.

After a mean follow-up of 54 months, 41 patients were in first complete remission. Patients operated before the tenth week had a higher chance (68%) of first complete remission than patients operated later (DFS: 43%). The difference is significant (p< 0.03). Further analysis shows that the difference is due to late local control, which causes a dismal prognosis for bad responders.

Local treatment must be performed early, especially when histologic response is incomplete or uncertain. Preoperative chemotherapy that is too long increases the risk of metastases in bad responders. These factors must be taken into account when analysing multicentre protocols.


A. Davidson G. Bentley

We clinically and radiologically reviewed 79 uncemented PFC acetabular components inserted by our unit during a seven-year period, June 1991 to June 1998. Of these, 50 (63.3%) were primary and 29 (26.7%) were revision arthroplasties. The mean follow-up was five years (60 months), with a range of 12 to 95 months. Sixteen (20%) were excluded from the study, leaving 63 (26.7%) for review. Three (4.7%) cases were deemed to have failed (at 63, 69, 79 months), all of which were primary arthroplasties. One of them was found to be loose at revision and the other two cups had 2 mm of periacetabular radiolucency in only one zone, but had no definite evidence of loosening.

The remaining 60 (95.3%) cases showed no radiological evidence of migration of any cups, and no hip had a radiolucent line in all three zones of the acetabulum. Clinical review gave a mean Harris hip score of 96.5. Fifty (79.4%) reported no pain from the hip. One case (1.6%) had undergone recent revision of the stem, at which time the cup was found to be stable. Three (4.7%) reported slight, occasional pain. Another three (4.7%) described mild pain that did not compromise their average activities and was relieved by simple analgesia. Two cases (3.2%) complained of moderate pain that placed some limitations on their activities and required regular analgesia, and one elderly patient who had an ankylosed contralateral hip and ipsilateral sciatic nerve palsy described marked pain (1.6%), and these were considered poor outcomes. In all of these cases the cups were clinically and radiologically stable.

In conclusion, 81% of outcomes were excellent, painfree THRs. A further 4.75% had good and 4.75% fair results. 4.75% had poor outcomes and 4.75% of cases failed. We conclude that the PFC cup merits continued use and follow-up, and together with other uncemented cup designs, may produce benefits in the form of quality and longevity of results in total hip arthroplasty.


J. Fabula F. Greksa P. Kellermann T. Mészáros

The aim of the study was to determine the mid-term clinical result of the patient operated by Chiari pelvic osteotomy.

A mid-term evaluation of the Chiari pelvic osteotomy performed on 65 hips in 58 patients is presented. Indications were: 1) congenital hip dysplasia in cases where conservative or other surgical treatment had failed, 2) deformed, laterally uncovered femoral head due to Legg-Calvé-Perthes disease, 3) age between 10–40 years, 4) no signs of advanced osteoarthritis.

Patients were classified according to pain, limp, Trendelenburg sign, range of motion, abductor muscle strength, and radiographic appearance (Wiberg and Idelberger angles). A mean follow-up of five years revealed relief of pain and an increase of hip motion in many cases. However, limping and a positive Trendelenburg sign frequently persisted. The radiographic appearance showed that the Wiberg angle had increased from the preoperative average of 6 degrees to 30 degrees postoperatively. The Idelberger angle decreased from the preoperative average of 72 degrees to an average of 60 degrees postoperatively.

The Chiari osteotomy is a technically exacting procedure which provides adequate femoral head coverage. This coverage facilitates pain relief and increased function. However, the results were less consistent in the cases of Perthes disease.

Considering the indications and contra-indications, the Chiari pelvic osteotomy has good clinical results in the reduction of painful standing and walking of young adult patients with DDH.


B. Fink M. Protzen W. Rüther

The aim of this study was to analyse the long-term results of a cementless conical threaded cup with elevated inlay-rim, without bone grafting in joint replacement of dysplastic compared to non-dysplastic hips, and concerning the survival rate and the rate of cup migration.

Most techniques of joint replacement of dysplastic hips contain bone grafting with more or less large-scale procedures. Without bone grafting, medialisation of the cup is often necessary. The conical threaded Link-V cup has the opportunity of stabilising the joint by using a polyethylene inlay with an elevated rim so that implantation in high angles of flexion and anteversion is possible. This is a technically easy procedure in dysplastic hips, but higher rates of loosening and cup migration are possible.

A cementless conical threaded cup (Link V) with elevated inlay-rim was followed in 36 dysplastic hips (DH) and 167 non-dysplastic osteoarthritic hips (OA) over a minimum follow-up of five years. Mean follow-up in DH-hips was 8.4 2.3 years and in OA-patients 8.6 3.2 years. Survival analysis was performed and cup migration was radiographically analysed using the method of Nunn et al.

The 10-year survival rate of the cup was 87% in DHhips compared to 92% in OA-hips. Luxation occurred in three OA-joints and none in DH-hips. Radiological cup migration was seen in 75% of DH-hips and in 70% of OA-joints. A change of the angle of flexion (mostly decrease) of more than two degrees was found in 50% of DH-hips and in 72% of OA-joints. There was vertical migration of more than 2 mm in 75% of DH-hips and in 70% of OA-hips, and a horizontal migration of more than 2 mm in 45% of DH-joints and in 40% of OA-hips. A radiolucent line of minimum 2 mm was seen in one case of each group.

Using a cementless threaded cup with elevated inlayrim is a practicable and technically easy procedure for treatment of destroyed dysplastic hips. Although cup migration is frequent in dysplastic and non-dysplastic hips, failure-rate is still acceptable but tends to be higher in dysplastic than in non-dysplastic hips.


A. Eren A. Faik A. Evren U. Ender

The purpose of our study was to evaluate the necessity of blood transfusions in operations for neglected DDH. It is generally known that blood transfusion is necessary in neglected DDH operations. Because of transfusion complications, Erythropoetin and autologous blood donation are proposed for blood replacement. However, these two methods are expensive and not useful in children.

We evaluated Hb-Hct levels in 48 children (52hips) operated on from 1992 to 1997. Mean age was 5.7 years (range 1.5 to14). Open reduction and pelvic osteotomy was performed in 40 hips, and open reduction, femoral shortening, and pelvic osteotomy in 12 hips.

The authors performed all of the operations. We approached the surgical technique and haemostasis carefully by using a curved ostetom instead of a gigly saw and left the medial apophisis and periosteum intact until the roof surgery. Dissection of the posterior-superior part of the ischiadic notch was avoided, and without using a drain. Oral supplemental ferrum (5 mg/kg) was prescribed to all patients until the Hb value increased to 12mg/dl. There was close clinical status follow-up of the patients for ten days after surgery and Hb–Hct levels were recorded periodically.

In the open reduction and modified Salter osteotomy group there were 4/40 hips respectively (10%). In the combined surgery group (open reduction, femoral shortening, pelvic osteotomy) there were 16 hips (33%) that required transfusion. We preferred packed red blood cell transfusion for blood substitution. Transfusions were made within one to five days. Mean loss of Hb was 4.7g/dl. Up to 7g/dl Hb level was well-tolerated by the patients. Digitalisation was required for one patient. There were no mortalities or infections in our patients up to the time of follow-up.

The process requires experienced surgeons, a meticulous surgical technique, a shortened operation time by modification of the pelvic osteotomy, and without using a drain. This is one of the most effective and less expensive ways to perform an operation for neglected DDH with a minimal loss of blood.


C. Gaebler U. Berger P. Schandelmaier M. Greitbauer H.H. Schauwecker B. Applegate G. Zych5 V. Vécsei

A multicentre trial of four Level One trauma centres retrospectively analysed complications and odds for complications in complex open and closed tibial fractures stabilised by unreamed, small diameter nails.

467 tibial fractures were included in the study. There were 52 proximal fractures (11.1%), 219 mid-shaft fractures (46.9%), and 196 distal fractures (42%). Breakdown into different AO/OTA groups revealed 135 type A fractures (28.9%), 216 type B fractures (46.3%), and 116 type C fractures (24.8%). 265 were closed fractures (56.7%) and 202 were open fractures (48 Gustilo grade I (10.3%), 80 grade II (17.1%), and 74 grade III (15.9%).

Analysis revealed five (1.1%) deep infections (with a 5.4% rate of deep infections in Gustilo grade III open fractures), 43 delayed unions (9.2%), and twelve (2.6%) non-unions. Compartment syndromes occurred in 62 cases (13.3%), screw fatigue in 47 cases (10%), and fatigue failure of the tibial nail in three cases (0.6%). Fracture distraction of more than 3 mm should not be tolerated when stabilizing tibial fractures with unreamed, small diameter nails as this increases the odds to acquire delayed union by twelve times (p < 0.001), and the odds to acquire non union by four times (p = 0.057).

There was a significant increase of complications in the group of grade III open fractures (p < 0.001), AO/OTA type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low compared to other methods of stabilisation in these severe fractures.


E. Fernandez M. Juanto

The authors call attention to the fact that puncture wounds of the foot are often considered simple, but can have potentially serious complications and sequelae.

In the majority of the cases, osteomyelitis in children is a haematogenous infection and the microorganism involved is a gram-positive coccus. The role of the puncture wound in osteomyelitis has been overlooked in the past. We present our experience with six cases of osteomyelitis following deep puncture wounds of the foot.

We reviewed six cases (1990–1999) of pseudomonas osteomyelitis in children. At the time of the injuries, five cases were boys younger than the age of seven and one was 12 years old. The sites affected were: metatarsal (2), phalanx (2) and calcaneous (2). The cause of injury was tree splinter (2), fork (1), needle (2) and nail (1). At the time of injury, all of the wounds contained foreign matter that was not initially completely removed and osteomyelitis developed as a result. The time interval until definitive diagnosis ranged from 5 to 730 days.

There is a similar history in all of the cases. For two or three days following the injury, the symptoms showed improvement and the injured site became swollen, tender, and painful afterwards. Treatment in all cases was hospitalisation, debridement and parenteral antibiotics for 18 to 22 days. After hospitalisation, an oral antibiotic (ciprofloxacin) was taken in two cases for three months and in four cases for four months.

After treatment, mean follow-up was 60 months (range 8 to 98 months). We have had no sequelae, recurrences or early growth arrest, and we consider the results to be good in all of the cases.

Puncture wounds of the foot should not be considered as “simple” injuries. Proper initial treatment is critical for the prevention of subsequent and potentially serious complications.


J. Gil-Albarova J. Bregante-Baquero I. Monton A. Herrera

The records of 82 patients (129 feet) with resistant clubfoot deformity treated surgically by means of different releases were retrospectively reviewed. There are many treatment regimes for clubfoot. Some authors recommend manipulation with minimal multi-stage surgery, whereas others recommend neonatal corrective surgery. However, objective comparison of different treatment programs is not easy because different criteria are used to evaluate the results.

Teratologic or neuromuscular clubfeet were not included in this revision. Between 1982 and 1998, 82 patients (27 girls, 55 boys) with 129 clubfeet underwent surgical treatment. All feet were initially treated with a serial long-leg cast for a minimum of four months. Mean age at the time of first surgery was 5.5 months (range 3.5 to 24). Minimum follow-up was two years.

Primary posterior release was performed on 105 feet. Subsequent medial release was performed on 16 feet, posteromedial release on three, and a subtalar (Cincinnati) release on three. Primary isolated posteromedial release was performed on 14 feet, and two of these required a subsequent subtalar (Cincinnati) release. Primary isolated medial release was performed on seven feet.

Primary isolated lateral release was performed on one foot and primary isolated subtalar (Cincinnati) release was performed on two feet. Subsequent derotative tibial osteotomy was performed in seven cases, wedge tarsectomy on four feet, triple arthrodesis on five, and calcaneocuboid fusion on one foot.

Residual varus was present in seven feet. Calcaneal gait caused by overlengthening of the Achilles tendon occurred in one foot, and residual equinus in two feet. Residual valgus heel was observed in three feet.

The surgeon must assess each foot and plan the surgery accordingly. A total release is not required for every foot.


T. Gautheron K. Zouaou N. Benammar

In order to define the operative indications, we compared the post-operative complications, time of consolidation, incidence of compartment syndrome, and fat embolism in centro medullary nails made from two different metals.

This study includes approximately 234 centro medullary nails (TARGON System) used for treatment of diaphysal fractures of the leg or femur after a skiing injury. Steel nails were used before 1998 and titanium nails after 1998.

The time of consolidation was the same for steel nails and titanium reamed nails. We remain faithful to limited reaming which avoids destruction of bone, and cortical and exothermic damage, but enables easier insertion of the titanium nail for leg fractures and bone grafts in sitù.

The incidence of compartment syndrome with use of a titanium nail is reduced threefold. Regarding femoral fracture, the insertion of the nail without wire is more complicated and the operative stage is extended by 25%. The time of consolidation is the same for titanium or steel nails, and there were no failures with either type.

However, we advise using titanium reamed nails for leg fractures and steel reamed nails for femoral fractures. If there is a suspicion of fat embolism, it is better to use femoral titanium nails.


T. Gosens E.J. van Langelaan

The purpose of the study was to analyse the clinical and radiological results of cementless HAP-coated Mallory- Head hip replacement in dysplastic hips. The collective included 20 males and 30 females (64 hips), with a mean age of 52.6 (range 20–68) years at operation. We also included two patients (4 hips) with spondyloepiphy-seal dysplasia (dwarfism). All patients were operated by one surgeon (EvL) during the period 1991–1997. A majority had “champaign flute” type femur. A minority had a normal or “stove pipe” type femur (Dörr). Most patients had acetabular dysplasia classified as A or B (Eftekar); some were classified as C and one as D (after Schanz osteotomy). Previous operations included: derotating varous osteotomy (11), acetabular shelf plasty (9), Salter or Chiari pelvic osteotomy (4) and tenotomy of the hip adductors (2).

After a mean follow-up of 57 (range 32 to 97) months, a clinical and radiological analysis was performed by an independent investigator (TG). Postoperatively no or only mild pain was reported by 89% of all patients. The VAS for pain (0–10) was excellent: 1.70 (0–7). Limping was reported in 23% and 75% used no support when walking. The HHS increased from 42 to 90 points.

Complications were marginal and there were no infections. One patient developed habitual dislocation and a revision of the cup was perfomed. We saw two periprosthetic fractures of the femur: once during surgery (treated conservatively) and once after a fall (treated by plating). We saw one case of temporary ischiadical nerve palsy after leg lenghtening of 5 cm. There were two cases in which we had used 32mm heads, and PE-wear necessitated revision of the cup after seven and eight years follow-up, respectively.

Cortical hypertrophy indicating stress transfer was found in 28% and located mostly on the borders of Gruen-zones 2, 3 and 5, 6. This cortical hypertrophy (“ballooning”) started to appear after 0.5 to 1 year and did not disappear after a longer follow up. Endosteal spotwelds were infrequently seen (9%) and in 13% of all patients we saw some form of halo- or shelf-formation at the distal stem. The criteria of Enghs fixation scale are not signs of loosening in the Mallory-Head HAP-coated femoral prosthesis.

No radiolucent or radiodense lines were seen around the acetabular cup. In all cases but one (Schanz osteotomy) the anatomical centre of rotation could be restored.

We conclude that the cementless Mallory-Head HAPcoated femoral prosthesis has shown, up to present time, excellent clinical and radiological results in hip dysplasia.


T. Gosens G.J. Harsevoort

Today more and more papers are published about the operative treatment of femoral fractures in children and even uncomplicated and isolated fractures are treated by using elastic nails, plates or an external fixator. Advantages are said to be a shorter stay in the hospital, easier handling by parents and nurses, less costs and better control of rotational disorders, and without complications from anaesthesia or an operation. We summarised our results in treating conservatively 50 femoral fractures in 49 children treated between 1992 and 1997.

The mean age was 6.2 years; male/female ratio was 30/19. We included five children with minor polytraumatisation (including one girl with a bilateral femoral fracture) and two children with complicated fractures (grade I). Children younger than three years of age were treated by Bryant-traction (18), and children older than three years were treated by Weber-traction (23). In both groups the callus was palpable after 2 to 3 weeks and a “one-legged” hipspica-plaster-cast was applied. Full weight bearing was permitted. Children needing surgery (major polytraumas, brain damage, etc.) were excluded. Seven cases had a fracture without dislocation and were treated by early casting. One boy was treated by Russell-traction.

An unacceptable dislocation of the fracture still existed in two cases after one week with Weber-traction. Peroperatively, interposition of the soft tissues appeared to be the reason. There were no problems of alignment and rotation, but differences in leg length or problems in consolidation were seen in the group treated with Bryant- traction. In the Weber-traction group, the girl with the bilateral femoral fracture developed a mild endorotation in the left leg, but we saw no further complications.

We think that these results in treating femoral fractures conservatively are satisfying and there is still a place for conservative treatment of femoral fractures in children. In our hospital we try to advance this type of conservative treatment by selecting cases that are appropriate for home traction, which is better for children and their parents and also less expensive for the Health Care System.


J. M. Gutiérrez Carrera T. Ruiz Valdivieso E. Imaz Corres

Nineteen periprosthetic fractures above 835 total knee arthroplasties (748 primary and 87 revision) in an eight-year period (1992–1999) were studied retrospectively. In six cases the fracture was situated in the proximal metaphysis of the tibia, 11 cases in the femur and two cases in the patella. Fourteen fractures were intraoperative (9 fractures during primary implantation and 5 fractures during revision arthroplasty). Some intraoperative fractures were not observed either by the surgeon or in postoperative radiograph control. There was trauma in three cases (1 tibia, 1 femur, 1 patella). Two cases were secondary to osteolysis (1 patella, 1 femoral condyle). Non-operative treatment was performed in eight fractures (traction and/or cast bracing). Operative treatment was performed in 11 fractures (3 plate osteosynthesis, 1 external fixation, 7 internal fixation with screws).

The results of this study show that the greater part of the fractures occur intraoperatively in relation to revision arthroplasty and technical mistakes during the osteotomy, the component test, and aggressive impaction. Undetected fractures occur in radiograph control because of low quality or insufficient view of the bone around the prosthesis.


A.R. Harvey M.G. Uglow N.M.P. Clarke

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery was comprised of a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications.

Pre-operatively, feet were prospectively categorised into one of four grades according to a system reported by Dimeglio. Children were reviewed on two subsequent occasions. At review, feet were again graded. In addition, appearance and functional outcome was analysed and included an assessment of gait, activity and functional limitation.

Three children were lost to follow-up, leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23–82). The mean time from surgery to first and second reviews was 35 and 56 months, respectively.

There was a significant improvement in grading at first review compared to pre-operative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared to the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared to first review.

There was no significant change in function between the two post-operative reviews (Chi-square tests), with the majority of children experiencing little functional limitation. There were no wound complications.

Relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable.


R. Hart P. Dungl O. Adamec J. Chomiak

The authors reviewed a group of 24 patients (26 hips) who had been managed with open reduction through an anterolateral approach from 1981 to 1985. Eight patients with an inadequate clinical (6) or roentgenographic (2) follow-up were excluded from the study. The purpose was to evaluate 18-year results of nine hips operated in pre-walking age up to 12 months and nine hips operated later. All patients were operated by the senior doctor. The goals of management are concentric reduction and its maintenance in order to provide the optimum environment for development of the hip joint.

The average age of the children at the time of operation was seven months (range 3–10 months) in the first group and 32 months (range 15–60 months) in the second group. Open reduction was performed if a stable reduction could not be achieved with traction as demonstrated with arthrography.

Evaluation of the first group: marginal dislocation was found in one hip (11.1%) and in the rest of cases the head was highly dislocated. A simultaneous derotational femoral osteotomy was added in the course of four reductions (44.4%) and in three of these cases a subsequent Salter osteotomy was performed. Five hips (55.6%) were reduced without additional femoral osteotomy and in three of these cases, a subsequent combination of Salter and derotational varisation osteotomy was performed. Average age at the time of the subsequent operation was 31 months (range 19–44 months).

In the second group, only high dislocations were found and each procedure was accompanied with simultaneous and subsequent interventions. At the final follow-up of the first group, the clinical findings were evaluated as Severin class A in eight hips (88.9%) and class B in one hip (11.1%). Three hips (33.3%) were Severin roentgenographic class I, and six hips (66.7%) were class II. Six hips (66.7%) showed avascular necrosis classified as Ogden-Bucholz Type I (3) and Type II (3). No significant degenerative changes were found. In the second group, the results were worse – two patients had already had THAs implanted.

The results are excellent or good in children operated in the pre-walking age. The results in patients operated later are worse. We consider this method to be useful for the treatment of congenital dislocation of the hip.


C.B. Howard A. Simkin Y. Tiran S. Porat D. Segal Y. Mattan O. Elishuv

We tested the hypothesis that it is possible to accelerate fracture healing by changing the mechanical environment used in current methods i.e., from initial rigidity or micromovement followed by dynamisation to initial macromovement followed by rigidity (micro-movement).

It is accepted that callus formation requires movement at the fracture site and this callus response is limited to the first few weeks after fracture. Logically, early macromovement at the fracture site would be beneficial for callus formation. Additional callus is not produced by further movement. Indeed, it may be counter-productive, just as continuing movement around two ends of a wooden stick bonded with glue will retard and even prevent “union”. We postulate that continuing movement at the fracture site after the callus response has ceased will also delay union. As a result, rigidity rather than dynamisation is required in the later stage of fracture healing.

After testing an animal model, we built an external fixator which allowed 5 mm of axial movement without “self-locking” and could be compressed at a later date in order to prevent further movement.

A trial containing 15 patients with unilateral tibial shaft fractures (closed or grade 1 open) was undertaken after permission was obtained from the Helsinki Ethical Committee.

So far, 13 patients have been entered into the trial. They have completed therapy and are at least one year post-fracture (12 months to 22 months). Age range is from 20 to 49. The group is composed of nine males and one female.

Under general anaesthetic, an external fixator was applied and the fracture reduced. The patients started ankle exercises (active and passive) the following day, with as much weight-bearing on the fractured leg as possible on the day after. The patients were seen every two weeks and AP and lateral radiographs were taken. The fracture was compressed two to six weeks later. The percentage of body weight that the patient was able to tolerate through the fractured limb was measured by using the scales of Meggit’s step test. The fixators were removed when there was radiographic union and the patient could take at least 80% of body weight through the fractured limb. Mean time duration up to removal of the fixator was 10.8 weeks (range 7 to 15.4 weeks).

We conclude that it is possible to increase the speed of bone healing by changing the mechanical environment to initial macromovement followed by elimination of movement.


H. Huber

Little is known about the risk of later development of osteoarthritis after operative clubfoot correction. There are only a few long-term reports of 30 years and more after operative correction with a standard technique.

Slight deformity after correction of an idiopathic clubfoot may be well tolerated by children and young adults. However, if these slight deformities become symptomatic with advancing age remains unsettled. To answer this question, a long-term follow-up of more than 30 years is needed. Functional and radiological correlation is poor in the adult foot with a slight under-corrected clubfoot deformity. A computer-assisted foot scan will provide the exact static and dynamic measurement of the pressure under each part of the foot at every moment of gait. This instrument allows better analysis of residual clubfoot.

Between 1962 and 1966 we operated 15 children with the standard operative technique of Phelps-Codivilla. In all cases there was a persistent deformity after continuous casting since birth. In two cases a heal cord lengthening procedure had been previously performed. Mean age at operation of the four girls and 11 boys was four (1 to 8) years. Six had unilateral involvement, whereas the remaining nine patients required bilateral surgery. In four cases there was a second medial release for relapse. A Steindler procedure was used in two cases and in two cases correction of clawtoes was necessary. Operative technique: Two separate incisions were made. One was longitudinal posterior that enabled lengthening of the heel cord, the tendon of the tibialis posterior and long flexors, as well as release of the posterior capsule. A second incision was made on the medial aspect of the foot in order to release the talonavicular and navicularcuneiform joints. The reduced navicular was fixed with a K-wire.

Twelve patients were examined clinically, radiologically and by functional testing after a mean follow-up of 33.5 (34 to 38) years. Eight patients had no pain and were not disturbed. There was a slight malreduction of the subtalar joint, but without any signs of joint degeneration. The foot pressure showed overpressure of the lateral forefoot. Four patients had pain and functional limitation. Their complaints had begun only two to four years earlier, and had been asymptomatic until then. All patients developed osteoarthritis of the subtalar joint, and their foot scans were abnormal.

Definitive assessment of the successful treatment of idiopathic clubfoot deformity is only possible with a long-term follow-up study. A slight undercorrection can be functionally well tolerated for a long period of time. The first occurrence of pain is still possible at the age of 35 years and older. A computer-assisted assessment of foot pressure by using a foot scan is a sensitive diagnostic tool.


M. Halici H. Örgü S. Kabak S. Karaoglu V. Sahin

The purpose of this study was to evaluate the role of locked intramedullary nailing without reaming for the treatment of open tibial and femoral shaft fractures that has recently been widely used all over the world, and recently evaluated.

Seventy open femoral and tibial shaft fractures were treated by meticulous wound excision and early inter-locking nailing without reaming between 1996 and 1999 in our department. The average follow-up of the patients was 20.2 (12–36) months. Thirty-six were fractures of the tibia, and 34 of the femur. Ten (14.3%) were classified as Grade I., 32 (45.7%) as Grade II, and 28 (40%) as grade III according to Gustilo-Anderson. Most of the fractures were the result of high-energy trauma.

In patients fixed with locked intramedullary nails due to no immobilisation, rehabilitation began just after the operation. Hip, knee and ankle functions were regained rapidly. All fractures were united in an average of 17.1 (10.1–36.6) weeks. There were six (8.6%) delayed unions and four superficial infections (5.7%). One patient developed deep infection (1.4%) and required further surgical treatment. Locking screws broke in one tibia (1.4%) and two femurs (2.8%), but the breakage did not result in loss of reduction. Although there was no nail breakage observed, two (2.9%) had between eight and twelve degrees external rotation, four (8.5%) shortening of 1.1 to 2.5 cm., and three (4.3%) valgus seven to ten degrees. Of the seventy fractures, 52 (74.2%) were classified according to Folleras as excellent, 8 (11.4%) as good, 6 (8.5%) as fair and 4 (5.7%) as poor.

Early unreamed intramedullary interlocking nailing is a very effective and safe treatment method for open tibial and femoral shaft fractures.


J. Jochymek J. Skotáková

Clubfoot (CF) is a congenital deformity of the foot with a multi-factorial etiology. The question of the best therapy is still open. The aim of our study was to compare the formerly used limited posteromedial release (PMR) with the recent extensive complete subtalar release (CSR).

From 1989 to 1997, 473 children were treated surgically. Our cohort contained 101 patients (129 affected feet) with CF confirmed by radiographs and physical findings. Forty-eight patients (59 feet) were operated with PMR, and 53 (70 feet) with the method of CSR after McKay. Both groups were comparable to Dimeglio’s classification concerning this type of deformity. All feet were operated on primarily with either no preceding therapy or with some conservative therapy. Average age at the time of surgery was 9.3 months.

The radiographic parameters (Kite’s angle, lateral TC angle, TC index, T-I.MTT angle, lateral tibiotalar angle) were evaluated according to Simons. The physical parameters (heel position, forefoot adduction, range of motion in the tibiotalar joint, range of motion in the subtalar joint, the process of taking off, the general shape of the foot, assessment of wearing shoes, and plantogram) were also evaluated. Assessment of the radiographs and the physical parameters showed substantially better results in the group with complete subtalar release.

A three-grade evaluation was used for assessment of the combined physical and radiographic assessment: good, fair, and poor. In the group with PMR, 54% were classified as good, 31% as fair and 15% as poor. In the CSR group, good results were achieved in 72%, fair in 17%, and poor in 11%.

The lower occurrence of re-operation in the group with subtalar release was apparent. With suitable timing, excellent results can be achieved with this operation. We conclude that extensive complete subtalar release is one of the best methods to correct this type of clubfoot. Subtalar release as described by McKay produces significantly better long-term statistical results than posteromedial release, in both clinical evaluation and radiograph assessment.


P. Janicek S. Ondrusek Z. Rozkydal O. Jelinek

In the First Department of Orthopaedics of St. Anna University Hospital in Brno, Czech Republic, a total number of 9,393 total hip replacements (THR) were performed from 1964 to 2000. Since 1986, the cementless technique has been used primarily for young patients suffering from late DDH. Within the last ten years we have implanted 5,574 THRs, including 440 cementless systems and 2,122 hybrid THRs.

We focused on cases of patients with late DDH where dysplastic acetabulum was found and where the smallest available cementless CLS acetabular cup was implanted through the anterolateral approach.

We present five to seven years follow-up of 41 hips with dysplastic acetabulum that was evaluated by coxometry and where the expansion acetabular cup of diameter 46 mm was implanted together with different types of femoral stems.

After five to seven years no significant aseptic loosening has been found. None of the Harris grafts of the superior acetabulum used in 10 (24.4%) implantations have failed. We have had good medium-term results with this type of cementless acetabular cup. A few case reports from our earlier history include acetabular components under 40 mm in diameter, or intercalar shortening osteotomy of the proximal femur due to the high post-dysplastic dislocation of the hip combined with implantation of a THR.


D. Jahoda A. Sosna L. Landor

The aim of this paper is to present a new solution in treating osteoarthritis after congenital dysplasia. In the First Orthopaedic Clinic in Prague, we have obtained, by using oval-shaped cups, excellent results in the treatment of acetabular deficiency occurring in THA loosening. These positive results have also encouraged us to use the implants in THA for secondary coxarthrosis.

In severe acetabular defects, an endoprothesis is very difficult to implant. A whole range of methods has been described for fixing the acetabular component. We prefer not to use cemented implants with middle-aged patients. Methods using bulk bone grafts are being scaled down. Cup implantation to the neoacetabulum is disadvantageous because forces inherent to the hip joint are considerably higher in the superior lateral position. Cotyloplasty and controlled fracture impair the medial wall with the enhanced risk of implant protrusion to the pelvis. The implementation of an oval cup eliminates the above-mentioned disadvantages.

During the period of 1994 to 1998, we applied the LOR cup in treating secondary coxarthrosis eight times in six women (mean age: 54 years). 83% had already been operated for congenital hip dislocation. The stage of the dysplasia was classified as Crowe II in two hip joints, Crowe III in four, and Crowe IV in two. An average of four screws were used for a 52x64 cup. Mean follow-up was 4.8 years.

The mean Harris hip score at follow-up was 92 points. There were no infections, luxations, implant migrations, or screw failures. The radiograph evaluations revealed just one case of a translucent line 1 mm wide in the b,c zone. Osteointegration was perfect with the other implants.

Using the oval-shaped cup does not usually require implementation of bulk bone grafts. Implant shape and the option of implementing an eccentric inlay enables preservation of the rotational centre, which is advantageous in terms of biomechanics. Implantation of the cup is easy and fast. Because of the good results, we suggest introducing the oval-shaped cup as a standard method of THA primo-implantation with patients who have acetabular dysplasia. The LOR cup was designed as a revision implant, but a disadvantage is the insufficient size scale and the 32 insert. For widespread application, it is therefore necessary to design a smaller size 28 inlay cup. We are currently developing our own acetabular component with a more suitable size scale and a plasma-sprayed hydroxyapatite ceramic coating.


S. Kabak M. Halici F. Balka B. Ergun

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups.

The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded.

Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B.

Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union.

We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment.


S. Kabak M. Halic F. Balka B. Ergun

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups.

The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded.

Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B.

Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union.

We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment.


G.A. Macheras K. Tsiamtsouris A. Kostakos N. Poullis

The capacity of the lumbar spine canal has direct relation to space-compromising conditions. Primary narrowing of the canal may produce no symptoms, but a slight reduction in capacity as a result of degenerative lesions, age, or disc bulging may result in symptomatic spinal canal stenosis. We studied the dimensions in the adult Greek population in order to find the variability factor in the capacity of the lumbar spinal canal.

The dimensions of the lumbar spinal canal were measured in 27 adult men and 42 adult women, all under the age of 50. MRI was used to measure four levels of the spine (L2 through L5). The AP and transverse diameters, as well as the cross section area, were measured at each level. Mean age (sd) of females was 34.8 (6.8) years. Mean age for males was 35.2 (7.3) and was comparable to women (P0.8). Mean age of a third group of 11 males over the age of 50 was 54.5 (2.6). All individuals included in the study were healthy and without any apparent degenerative changes in the lumbar spine or any symptoms related to it. Hotelling’s tests (Anderson, 1958), in terms of multivariate measurements of the spinal canal, were used to compare both genders and the two age levels. Tests for trends in the lumbar levels L2 through L5 were based on the exact binomial distribution for the number of cases exhibiting a complete trend from L2 to L5. The reported significance levels are adjusted for multiplicity of tests.

The relation of spinal width to lumbar levels is shown separately for the groups of males and females women under the age of 50 and for the group of males under over the age of 50. In all four lumbar levels, the group of men over 50 years old had a narrower spinal canal compared with men under 50 years old (2=0.005). This was particularly evident in levels L2 and L5 where the spinal canal for older men was narrower by factors of 15.5% and 13.1%, respectively. In the two gender groups of comparable age, spinal width was found to differ between men and women (2< 0.0001). In particular, the females had a wider spinal canal than males in levels L2, L3 and L4 and a narrower canal in level L5. Spinal width was found to exhibit a decreasing trend in lumbar levels L2 through L5. The evidence for this trend was strong for all three groups: females under the age of 50 (P< 0.0001), men under 50 (2< 0.005), and the older men (P< 0.0001). A similar trend was present for the anteroposterior diameter, as well as for the Transverse diameter. A numerical summary (mean, sd) of all spinal measurements is reported.

We believe this study to be an important one that provides useful information regarding the capacity of the lumbar spinal canal, thus helping the surgeon to properly evaluate the stenotic patient.


I.. Kaftandziev I. Todorov S. Stojmenski B. Gavrilovski

The purpose of this study was to compare intramedullary nailing and plate fixation in the operative treatment of acute humeral shaft fractures.

The operation time, amount of blood transfusion, time to union, complications, and functional outcome were compared. At the Traumatology Clinic, Medical Faculty Skopje from 1995 to June 1999, 46 patients with acute humeral shaft fractures were operatively treated. The patients were divided into two groups: Group A – 24 patients treated with open reduction and internal fixation with dynamic compression plate, and Group B – 22 patients treated with closed reduction and intramedullary nailing (most of them with the Marchetti-Vicenci intramedullary nail). All of the fractures were classified according AO classification. The follow-up period was 6 to 12 months.

Intramedullary nailing of acute humeral shaft fractures offered a less invasive surgical procedure with less complications than open reduction and internal fixation. The results showed that the intramedullary nailing surgical procedure had a shorter operating time and less blood transfusion. There was no significant difference between the two groups regarding time to union. In Group A there was one patient with delayed union, two with deep infection and two with postoperative radial palsy. In Group B there were two patients with delayed union. Functional outcome for uncomplicated fractures was the same in both groups.


L. Kolodziej M. Kolban S. Radomski W. Lach

The aim of the work was to evaluate long-term results of posteromedial release in the treatment of congenital clubfoot. The posteromedial release – which includes capsuloligamentothomy of the tibiotalar and tibio-calcaneal joints from the posterior and medial aspects and “Z” lengthening of the Achilles and posterior tibial muscle tendons with Steindler procedure – has been the basic treatment of choice for many years in cases of congenital clubfoot in the Child Orthopaedic Clinic of the Pomeranian Medical Academy. In some cases transfer of the anterior tibial muscle tendon was also included in that procedure.

Between 1979 and 1990, a total of 135 children were treated with posteromadial release at the author’s institution. Thirty-five patients were excluded from the study because of incomplete medical documentation or because of a possible different origin of the deformity, i.e., subtle spastic cerebral palsy or arthrogryphosis, etc. The study group consisted of 100 patients with 135 clubfeet. At the final follow-up, 46 patients were evaluated with 61 clubfeet. Mean age at the time of surgery was 12.3 months (5–48). All patients had been treated conservatively at the author’s clinic before operative treatment started. Average age of the beginning of the manipulative treatment (followed by cast application in weekly intervals) was 4.3 weeks (1 to 48). Mean follow-up period was 15.7 years (range 20.4–10.1). The patients’ age at the last follow-up ranged from 11 to 21 years old.

The final evaluation based on the criteria of Magone, et. al., gave us the following results: Excellent: 17 feet (28%); Good: 17 feet (28%); Fair: 11 feet (18%); Poor: 16 feet (26%).

Posteromedial release with the Steindler procedure added gives us more than 50% excellent and good results when applied early and with proper pre- and post-operative conservative treatment.


Z. Koòs J. Kránicz L. Bálint

Conservative management of talipes equinovarus has a good effect on adductus deformity of the forefoot, whereas equinus deformity cannot usually be treated well conservatively. However, adductus is the most common recurrent deformity after operations. The aim of the study was to use radiological analysis to explore the reasons that lead to recurrent adductus.

In 86.7% of the cases, either a correction was evaluated as radiologically inadequate but seemed to be good physically, or compensation for an operative over-correction resulted in recurrent adductus some years later. In spite of adequate correction from both a physical and radiological view, recurrent adductus developed in 13.3% of the cases. In our opinion, these recurrences were due to persistent muscle imbalance.

In our department, 458 children were operated on for clubfoot from 1982 to 1997. The patients involved in this study were those managed by medial and posterior soft tissue release after an ineffective six to nine month period of conservative treatment that was started when they were one to two weeks old. Children treated previously in another hospital were excluded from the study. We controlled 228 feet and 42 cases of recurrent adductus were found 2 to 16 years (mean 6.8) after the operations. The radiographs were examined at the end of ineffective conservative treatment, during the early postoperative days, and finally at the follow-up. The anteroposterior talocalcaneal (ATC) angle, the talometatarsal (TM) angle and the naviculometatarsal (NM) angle were measured in all of the radiographs. Based on the measured angles, three main groups of patients were formed.

Recurrent adductus in 24 feet (Group A) was caused by inadequate operative corrections, including inappropriate correction of either the hind foot (reduced ATC angle) or the forefoot (reduced NM angle), or both. Although the talocalcaneal and talometatarsal positions were normal in early postoperative radiographs, adductus developed again two to five years later in seven cases (Group B). In these cases, we think that persistent muscle imbalance was responsible for the recurrent deformity.

In 11 feet the ATC angles were in normal range or increased (Group C). These adductus deformities were caused by either an overcorrected talocalcaneal position resulting in compensatory metatarsal varus or medial subluxation of the talonavicular joint, which had been only partially compensated by the lateral deviation of the 1st ray.


K. Koudela J. Ferda

In cases of severe postdysplastic coxarthosis, it seems to be impossible to recognize acetabular geometry and the real femoral position on a plain X-ray because the real diameters and angles can be disfigured when projected. Computed tomography (CT) provides important information to the surgeon about the concavity, shape and stereotomy of the acetabulum.

It is quite difficult to correctly evaluate severely changed hips. CT displays more precise acetabular diameters and angles than a plain radiograph. Because of the high density of bony tissue, the CT makes it easy to produce a three-dimensional display of the hip.

From September 1995 to December 1998, 224 patients (148 female, 76 male) underwent arthroplasty using a non-cemented prosthesis according to Zweymüller. A total of 236 hip joints were operated and classified as Crowe Group I (76 hips), Crowe Group II (149 hips), and Crowe Group III (11 hips). There were no Crowe Group IV hips.

A total of 96 patients were examined by 3D CT in preoperative planning. Based on CT results, four joints were not recommended for an operative solution.

CT protocol: scanner Elscint TWIN II, slice 2.5 mm, 120 kV, 285 mAs, matrix 3402,

No. of slices: 40–50, incremental dual acquisition. Postprocessing: axial images, multiplanar reconstructions, 3D SSD.

Acetabular stereometry: superoinferior diameter, anteroposterior diam., depth, bottom thickness, femoral neck anteversion angle and subtrochanteric marrow diameter.

A three-dimensional CT of the hip is a very effective tool for preoperative assessment.


G. Kovacs D. Fleega

In 1990, after many years of experience with 150 repairs, an arthroscopic transhumeral rotator cuff reconstruction technique was developed and used by the authors to treat all sizes of rotator cuff tears. This technique allowed the same type of repair to be performed as with the open procedure, thus providing the possibility to achieve the same success rate as an open repair with the advantages of minimally invasive surgery.

We reviewed a total of 307 arthroscopic rotator cuff repair procedures performed on 304 patients between December 1990 and March 1994. There were 150 cases with arthroscopic transhumeral fixation and 157 with tendon end-to-end. Of the 150 transhumeral repair cases studied, 18 cases were traumatic, 124 were Impingement III tears, and eight were defects after calcium removal. The tears were classified as 42 – small, 66 – medium, and 42 – large. Average age was 56 years.

An anterior acromioplasty and an arthroscopic tendon to bone repair using the bone cutting giant needle was performed in all of the cases. An AC joint plasty was done in 20 cases and a tendon transposition in five cases. Postoperatively, the patients started full passive motion a day after surgery and active motion six weeks later.

Of the 150 cases with arthroscopic transhumeral repair cases, it was possible to evaluate 132 patients having 133 procedures. Mean follow-up was five years. The results were evaluated according to the classification of Neer. There were 64% classified as excellent, 34% as satisfactory, and 2% as unsatisfactory. The UCLA average score improved from 15.8 preoperatively to 31.5 postoperatively. Full reconstruction was done in all cases except three.

Arthroscopic transhumeral reconstruction of rotator cuff tear reduces morbidity without having to perform open surgery. This procedure can be performed in an outpatient setting. After the learning curve, repairs are easier than the open method and have fewer complications.


G.A. Macheras K. Tsiamtsouris A. Kostakos N. Poullis

We present our experience with HA-coated total hip prosthesis in a minimum follow-up of eight years.

From 1989 to 1991 we performed 92 THRs in 83 patients. The mean age was 62 years (range 32–75). The preoperative diagnosis was: O.A. 68, AVN 12, CDH 8, and post-traumatic arthropathy 4. Pre-operative mean was HHS 43.

A posterior approach was used. The ARC 2F Cup, an HA coated spherical cup with thread around the equator, was used. Initial stabilisation is achieved by screwing the cup into the acetabulum. If necessary, a secondary fixation is enhanced by one or two bone screws to the ilium. The Omnifit stem is HA-coated in the proximal third and gives good immediate metaphysical fixation and optimal filling of the metaphysis. Three doses of Cefuroxime for prophylaxis and low molecular weight heparine were used in all cases. All patients had non-weight-bearing on the second postoperative day, partial weight-bearing in six weeks and full weight-bearing in 12 weeks.

Four patients were lost to follow-up. Mean H.H.S. was 91 in the first six months, 93 in the first year, and 95 in the second and third year. In the fifth year 97.93% were symptom-free in the first six months and 97% from the third to the fifth post-operative year. 3.7% of the patients complained of mild or moderate activity related to hip pain.

No patients suffered marked or disabling pain. Four patients complained of thigh pain six and eight months post-operatively. There were no major complications except for two superficial and two symptomatic deep vein thromboses. All patients returned to their prior activities within four to six months post-operatively. Radiographic evaluation of acetabular components revealed bone condensation in all three Charnley zones. We had no component migration or screw breakage. Calcar resorption was detected on the femoral side in seven patients. During the first post-operative year, AP radiographs of eleven patients indicated cortical hypertrophy in zones 3 and 5. There was no subsidence of the femoral stem.

We believe our results are encouraging although the follow-up period is short. We have had no revisions and the functional results are quite good. All patients are asymptomatic and satisfied with the result.


W. Morgenstern

In order to overcome high intra-observer and inter-observer reliability, there is a new classification system for Adolescent Idiopathic Scoliosis (AIS). The type C (King II) of this system describes pronounced lumbar curves in which the center sacral vertical line (CSVL) lies outside the lumbar apical vertebra on the concavity of the curve. It has been proposed that selective anterior thoracic fusion (ATF) is not possible in these cases because of insufficient spontaneous correction of the lumbar curve or postoperative lumbar progression. This retrospective study analyses the results of a group of patients who received selective ATF for type C curves. The purpose of the study was to analyze the ability of the new classification system to predict the outcome of anterior thoracic fusion in the combined AIS type Lenke C, and to define predictive parameters revealed in the study.

From 1989 to 1994, 407 patients underwent anterior fusion for scoliotic deformities of different etiologies. There were 174 patients with anterior thoracic fusion. Twenty-one patients (< 19 years old) had combined AIS with a Risser sign < 5 with the criteria of a Lenke type C curve. Fourteen patients had a minimum follow-up of two years. The parameter analysis included coronal and sagittal corrections. Horizontalisation of lumbar and thoracic endvertbrae and correction of both curves were measured on pre-op bending and Cotrel traction films.

Fourteen female patients with a mean age of 15.4 years were followed for an average time period of 3.3 years. Mean correction of the lumbar curve and the thoracic curve was 46.0% (±18.5) and 54.7% (±16.4) respectively. Patients with preoperative horizontalisation on Cotrel traction films of the lumbar endvertebra of less than 6° had an average correction of the lumbar curve of 60.1% (±8.1) and an average loss of correction of 3.6% (±14.6); those with more than 5° had 27.2% (±9.7) and 19.4%(±11.5) respectively. Horizontalisation of the thoracic endvertebra of less than 10° on preoperative Cotrel traction films had an average correction of the lumbar curve of 62.7% (±8.7) and −2.8% (±10.4) loss of correction; those with more than 9° had 44.6%(±13) and 12.8%(±13.6) respectively. Preoperative correction of more than 50% of the thoracic curve on Cotrel traction films had an average correction of the lumbar curve of 53.1% (±18.3); loss of lumbar correction was −1.9% (±8.9); less than 50% had 38.9% (±15.7) and 22 % (±10.7) respectively.

Patients with combined AIS and pronounced lumbar curves (type C) can be treated with selective anterior thoracic fusion. Horizontalisation of the thoracic and lumbar endvertebrae and correction of the thoracic curve on preoperative Cotrel traction films have an important predictive value for the unfused lumbar curve and are superior to bending films in this context.


N. Maruthainar D. Graham F.M. Surace G. Bentley

The issue of preservation or sacrifice of the posterior cruciate ligament in total knee arthroplasty remains unresolved.

We report the results of 200 consecutive total knee arthroplasties performed at our hospital under the direction of the senior author. Pre-operatively, patients were randomly chosen to receive either a Kinemax (posterior cruciate retaining) or a Press-Fit-Condylar (posterior cruciate sacrificing) prosthesis. We implanted 97 Kinemax and 103 Press-Fit-Condylar prostheses which were prospectively followed-up by clinical and radiographic assessment. Review at mean follow-up of 2.7 years showed a satisfactory clinical result in both groups [Surace, et al., 1994].

We present the results of our further review, with maximum follow-up of over nine years (mean: 5.9 years). Revision of the implant has been performed in five knees (three Kinemax and two Press-Fit-Condylar). The polythene spacer had to be replaced in one patient with a Press-Fit-Condylar implant.

Patients were assessed with the Hospital for Special Surgery Knee Score and radiologically assessed with the Knee Society Roentgenographic Evaluation and Scoring System. Pre-operative demographics and disease states of the patients were similar, with an average Hospital for Special Surgery Knee Score of 63. At the latest assessment the average knee score was good (85). Remarkably, the mean knee score for the posterior cruciate sacrifice and the PCL groups remains similar (mean: 85). Radiographic evaluation demonstrated that the prosthetic components of both groups were in comparable alignment. The posterior cruciate ligament retained (Kinemax) patient group showed a mean 5.9 degrees of the valgus angle at the knee. The angle in the posterior cruciate ligament sacrifice (PFC implant) group was 6.2 degrees. Evaluation of the radiolucent depths below the femoral, tibial and any patella component showed a mean total depth of 1.5 mm (pcl retaining) and 1.7 mm (pcl sacrificing).

Our study presents a quantitative perspective of the results of total knee replacement with proven implant systems and performed in a general orthopaedic unit by both consultants and surgeons in training. The Kinemax (Howmedica) and Press-Fit-Condylar (DePuy Johnson and Johnson) implant systems have both previously demonstrated good results and continue to be available with little subsequent modification.

To our knowledge, there have been no other large prospectively randomised studies of posterior cruciate ligament preservation or sacrifice in total knee replacement.


A. Moroni G. Magy J. Heikkila C. Faldin S. Giannini

We compared thirty-eight patients from three orthopaedic centres who had external fixation of the femur or the tibia. Patients were randomised to receive standard (tapered 5/6 millimeter) pins (Group A) or OsteoTite (hydroxyapatite coated tapered 5/6 mm) pins (Group B).

In Group A there were 18 patients who received 71 pins. Average age of the patients was 49±12 years. Three patients had external fixation in the femur and 15 in the tibia. External fixation was used in three types of treatment: fracture fixation (4), knee osteotomy (12), and bone-transport (2). Two different fixator frames were used: a unilateral fixator was mounted in 15 patients and a circular fixator in three patients. In Group B, 20 patients (average age: ± 48 years) received 86 pins. Four patients had external fixation in the femur and 16 in the tibia. External fixation was used in three types of treatments: fracture fixation in three patients, knee osteotomy in 13 patients, and bone-transport in four patients. Two different fixator frames were used: a unilateral fixator was mounted in 16 patients and a circular fixator in four patients.

No significant difference regarding sex, age, external fixation treatment type, external fixation frame, and length of treatment were observed between the two groups. Mean final pin insertion torque was 477 ± 214 Newton cm in Group A and 339 ± 184 in Group B (p< 0.01). Mean pin extraction torque was 205 ± 169 Newton cm in Group A and 532 ± 211 in Group B (p< 0.01). Pin extraction torque was significantly lower compared to the corresponding insertion torque in Group A (p< 0.01). Pin extraction torque was significantly higher compared to the corresponding insertion torque in Group B (p< 0.01). Pin tract infection rate was lower in Group B compared to Group A (p< 0.01).

This study shows that hydroxyapatite coating was clinically effective in the improvement of the bone pin interface strength of tapered pins. By using these pins, deterioration of the bone pin interface strength can be avoided and external fixation complications minimised.


K. Mulhall P. Kelly W.A. Curtin H.F. Given

The authors wished to determine if macrophage activation and the release of osteolytic cytokines in response to orthopaedic wear debris could be suppressed pharmacologically with the use of anti-inflammatory and anti-oxidant agents.

The current long-term results of total joint arthroplasty are limited by mechanical wear of the implants with an associated immune mediated bone lysis with subsequent loosening and eventual failure. It has been demonstrated that the osteolysis seen in cases of aseptic loosening is mediated by the immune system both directly and indirectly by activated macrophages. Macrophages indirectly cause osteolysis through release of the osteoclast activating cytokines TNFα, IL-1 and PGE2. They also directly resorb bone in small amounts when activated by wear particles.

We utilised established cell culture models of both peripherally derived monocyte/macrophages and lymphocyte enriched co-cultures and examined the effects of polymethylmethacrylate particles alone on the cells in culture. The effect of anti-inflammatory and anti-oxidant agents (dexamethasone, diclofenac and n-acetyl cysteine) in varying concentrations was then examined using ELISA of cytokine release and electron microscopy to examine ultra structural responses.

Cell viability was also measured in cultures over 24 hour periods (at 6, 12 and 24 hours) using Trypan blue exclusion and Coulter counter, while cell type and morphology were determined cytologically, including-naphthyl acetate esterase cytochemical identification and electron microscopy.

The use of N-acetyl cysteine was associated with very significant suppression of TNF, IL-1 and PGE2 in both macrophage and lymphocyte enriched co-culture with no effect on cell viability. While diclofenac was also associated with significant decreases in cytokine expression, it was associated with a decrease in cell viability that approached significance. Dexamethasone did not have a reliable effect on these cytokines. Ultra-structural electron microscopic examination of the cells also demonstrated signs of definite down-regulation of cytoplasmic and nuclear activation.

Novel anti-oxidant therapies and possibly other immune modulating drugs can eliminate the activation of macrophages in response to periprosthetic wear particles without any associated decrease in cell viability and thus may provide a means of reducing the incidence of loosening and failure of total joint arthroplasty.


M. Muschik D. Schlenzka C. Kupferschmidt

The goal of the present study is to investigate if one of the two dorsal operative procedures (rod-rotation versus translation technique) leads to a better radiographic correction of idiopathic adolescent thoracic scoliosis after operative treatment.

The operative technique in scoliosis surgery introduced by Cotrel and Dubousset attempts to achieve an improvement of the sagittal profile and a derotation of the vertebrae, in addition to a correction of the main curvature of the scoliotic spine by rotation of the convex-side rod (rod-rotation). The technique of segmental correction was described by Luque. Correction of the scoliosis is performed after fixation of each vertebral body with wire cerclages, followed by segmental correction of the deformed spine. The Universal Spinal System was introduced and an operating technique was developed to take advantage of the principle of segmental correction of scoliosis (translation technique).

The radiographic outcomes in two groups comprising a total of 69 adolescent patients treated for idiopathic thoracic scoliosis with dorsal instrumentation by the use of a unified implantation system (Universal Spinal System) were compared retrospectively by an independent observer. In 30 patients an intraoperative correction of the scoliosis was performed by translation technique (translation group) and in 39 patients the correction was achieved by Cotrel-Dubousset instrumentation (rod-rotation group). The mean follow-up interval was 40 months with a minimum of 12 months. The preoperative radiographic measurements of the scoliotic spines showed no significant differences between the two groups.

In both patient groups, the thoracic primary curve, lumbar secondary curve, and apical rotation of the thoracic curve were improved by the operation. The thoracic primary curve was corrected from 50 6° to 24 7° (p< 0.01) in the translation group and from 54 11° to 22 11° (p< 0.01) in the rod-rotation group. The extent of the correction of the thoracic curve was significantly greater in the rod-rotation group than in the translation group (59% versus 52% correction; p< 0.01). Thoracic apical rotation was corrected from 21 ± 9° to 16 ± 10° (p< 0.01) in the rod-rotation group and from 19 ± 9° to 17 ± 7° (p< 0.05) in the translation group. Lumbar apical rotation and the sagittal profile were unchanged in both groups.

Based on the results of this study with a small number of patients, the ability of the translation technique to correct the thoracic major curvature seems to be less than that of the rod-rotation technique. No differences are to be expected in the correction of the lumbar minor curvature or of the rotation of the thoracic apex. Neither procedure is expected to influence the sagittal profile or lumbar rotation.


T. Noshpal J. Kamnar

We wanted to solve the problem of acetabular dysplasia with a cementless total hip endoprothesis by using a smaller acetabular cup in order to fit the size of the dysplastic acetabulum without using any additional bone transplantation for superstructure of the acetabulum.

By using this type of acetabular reconstruction we can preliminarily conclude that the bone superstructure of the acetabulum can be avoided and that problems may occur if remodelation of the bone transplant has failed. Irregular biomechanical bending in the supraacetabular region can also be avoided.

Uncured developmental dysplasia of the hip joint (DDH) is a huge problem to solve in elderly patients. DDH can be expressed in several forms according to stage, i.e., in young and elderly patients we can find different consequences, from slight to moderate supraacetabular dysplasia combined with anterior dysplasia, valgus and anteversion of the proximal femur, to high hip luxation.

In efforts to find a better way to solve slight and moderate supraacetabular dysplasia (in some cases combined with high luxation), we have tried to use a smaller acetabular cup that will fit the dysplastic acetabulum, combined with a higher hip centre, dysplastic polyethylene, and a longer femoral neck to avoid leg length discrepancy and weakness of the gluteal musculature.

From January 1999 to January 2000 we performed the above-mentioned type of operation in 33 patients (25 females, 8 males) with dysplastic coxarthrosis of the hip. Age range was from 32 to 63 years. In all cases we performed the application of a Zimmer or Biomet smaller acetabular cementless cup after reaming the acetabulum near the internal lamina of the iliac bone. Good primary fixation of the acetabulum was achieved in all of the cases. Supraacetabular reconstruction was not used. In some cases where the dysplasia was very expressive, we left the acetabular cup uncovered for about 0.5 cm. In the postoperative period we advised the patient to load the operated leg over two crutches without full weight bearing for approximately six weeks. After that time period and according to clinical and radiographic findings, we prescribed walking with one crutch, and walking without crutches four months later.

The follow-up period is short but preliminary results of our study are satisfactory. There were no early postoperative complications. Incorporation of bone was good in the acetabular cups measured with radiographs and in some cases with Tc99m. In some cases where we left part of the cup uncovered, there was supraacetabular formation of new bone after six months.


L. Nevsímal P. Míka M. Skoták

Until recently, diaphyseal fractures in children aged 4–12 years were treated conservatively. Although Prof. Havránek recommended oblique bilateral skin traction in his monograph entitled Split Russell Traction, he is currently inclined to use skeletal traction through the proximal tibia (Goteborg traction). The author himself stresses that this therapy requires great expertise from the medical staff. In addition, patients are immobilised for several weeks in hospital.

The Pediatric Traumatology School in Nancy, France prepared a method of intramedullar elastic ostheosynthesis according to Métaizeau and Prévote.

After our experience with intramedullary fixation using Prévote’s nails in diaphyseal fractures of adults and diaphyseal forearm fractures, we also decided to use this ostheosynthesis in diaphyseal femoral fractures of children.

Our group includes four patients (2 boys, 2 girls) with a mean age of 4.2 years (range 4–11). Average time from injury to operation was eight hours.

The patient is in a supine position and given a general anaesthesia. After repositioning, two or more Prévot nails are inserted above the distal physis from the medial and lateral side towards the femoral diaphysis. The nails cross distally and proximally to the fracture line and are anchored in the intertrochanteric area. The operative procedure usually lasts approximately thirty minutes.

The patient is hospitalised from two to five days. The child walks with crutches after discharge, and trains the operated lower extremity. According to the parents, these children began to load the extremity spontaneously after two weeks. After four weeks we perform a radiographic check and permit full loading. The bars are removed in eight weeks in children up to the age of seven years, and 12 weeks in older children.

All of the children recovered without any problems. The schedule for follow-up is from nine to twelve months. The extremities do not appear to have a tendency to overgrow.

The method of mini-invasive osteosynthesis of diaphyseal femoral fractures in children aged from four to twelve years is a modern alternative to conservative treatment. It is more comfortable for the patients, avoids the skin complications of traction therapy, and significantly shortens the time of treatment. This method will also be particularly useful in treating polytraumatised patients.


T. Pavelka M. Linhart J. Zeman

The incidence of non-union in the long bones varies with each bone and with the methods of treating acute fractures. Several factors have been implicated as the cause of non-union, most of which are inherent in the nature of the fracture. High-velocity open fractures with skin or bone loss, distraction at the fracture site, and an inadequate external or internal fixation increase the incidence of non-union in fractures.

Weber and Cech classify non-unions as two types – hypervascular and avascular. Hypervascular non-unions can be treated by stable fixation of the fragments alone, whereas the avascular type requires decortication and bone grafting for healing. Reamed intramedulary nailing is an effective technique for management of the tibial shaft aseptic non-union for both types.

Twenty tibial non-unions were treated with a reamed intramedullary nail. The initial fracture management consisted of a cast in seven patients (35%), external fixation in four (20%), plate osteosynthesis in four (20%), and unreamed nailing in five (25%). The time from injury to nailing averaged 32 weeks. Patients were followed for an average of 16 months.

All non-unions united uneventfully and functional results were excellent. Contraindications are a history of prior acute infection or excessive shortening due to bone loss.

Reamed intramedullary nailing is an effective, relatively low-risk technique for the management of non-union of the tibia. The closed technique should be used when possible. When necessary, open alignment should be executed with minimal dissection. Osteotomy of the fibula is a necessary component of this technique and bone grafting is indicated in cases of avascular non-union.


J. Ostrowski J. Karski M. Okoñski M. Dugosz

The outcome of surgical treatment for congenital clubfoot depends, among other things, on obtaining correct repositioning of the tarsus in relation to the talus, i.e., peritarsal correction. This correction includes successfully repositioning the navicular, which is dislocated medially in relation to the head of the talus.

Evaluation of talonavicular repositioning is possible in older children when it is possible to observe the navicular bone on a radiograph. In radiographs of younger children between the ages of three and five, the navicular bone cannot be seen. USG examination may be helpful in the evaluation of talonavicular positioning, enabling better planning of the surgical procedure and its range.

In the Paediatric Orthopaedic Department of Medical Academy in Lublin from 1995 to 1999, 225 children (256 feet) were surgically treated. The peritarsal correction method (Turco) was used to manage 221 feet, and 31 feet by the subtalar release method according to Crawford by the incision of Cincinnati. Fifty-two feet were re-operated because of recurrent deformation.

USG examinations revealed incorrect positioning of the navicular bone. There was medial displacement in 24 feet (recurrent deformations), and wedge-shaped navicular bone in 18 feet and connected with dorsal displacement (overcorrection).

Medial displacements were observed in residual adductus deformation, whereas dorsal displacements were observed in feet with cavus or calcaneal deformity, which is connected with excessive lengthening of the calcaneal tendon (overcorrection).

USG examination in recurrent clubfoot enables the evaluation of talonavicular repositioning (not possible on radiographs) in younger children two to five years old, and is helpful to better plan the range of the operation.


F. Picek

The purpose of our study was to evaluate several specific methods of skeletal stabilisation and soft-tissue treatment of open fractures in the orthopaedic department in a district hospital.

After stabilisation of the patient and diagnosis of concomitant injuries, the basic initial evaluation of the fracture type, soft-tissue laceration, and neurovascular status is made. Deformities of the legs are realigned promptly. Sterile wound dressing and early intravenous administration of antibiotics are applied. Prophylaxis against tetanus is considered.

Radiograph diagnostics are made and the Tscherne, Gustilo and Anderson classifications of open fractures are used. All devitalised tissue is removed in the operating theatre. The following methods of bone stabilisation are used: immobilisation in a cast, external fixation, and intramedullary nailing. Repeated debridement of soft-tissue is carried out. Postoperatively, time duration for bone-healing and deep infections were analysed.

During the past five years, 159 patients with a tibial shaft fracture were treated. Twenty-six were open fractures Type I (8), Type II (9), Type IIIA (7), and Type IIIB (2). Methods of stabilisation were cast (5), external fixation (7) and intramedullary rod (14).

Deep infection in Type III fractures was reported in two cases and a non-union in one case. Bone grafting was performed in two cases. Nailing followed short-term use of an external fixator in three cases. No amputations were necessary. The average time (in months) for union was 5 (Type I), 5.8 (Type II), and 8 (Type III).

Our experience agrees with the principle that the method of choice is intramedullary nailing that may follow the short-term use of an external fixation. Open fractures of the tibial shaft represent a limb-threatening and potentially life-threatening emergency. Optimum treatment involves appropriate initial evaluation, the administration of antibiotics, urgent operative debridements, skeletal stabilisation, and early soft-tissue closure or flap-coverage.

The type of treatment depends on the individual characteristics of the fracture and the concomitant soft-tissue injury. Fractures with a higher degree of comminution and soft-tissue laceration have more complications.


D. Pokorny A. Sosna

We present the results of treatment of complicated comminutive fractures and fracture dislocations of the proximal humerus at the First Orthopedic Clinic of Prague in the last ten years. We also compare the results using two different methods of treatment: shoulder arthroplasty and non-anatomical shoulder reconstruction.

Treatment of complicated fractures of the proximal humerus is difficult. The results are not always good because the moving apparatus of the shoulder is often destroyed. The common method of treatment is shoulder arthroplasty with reconstruction of the rotator cuff. In our clinic we use (especially in young patients) the so-called non-anatomical reconstruction of the shoulder that enables us to save the humeral head. This reconstruction is suitable when three-fourths of the joint surface is preserved with the technical possibility of further fixation to the distal fragment.

From 1990 to 1999 we operated on 42 acute fractures not suitable for anatomical reconstruction or conservative treatment. Shoulder arthroplasty was performed in 22 patients and non-anatomical reconstruction in 20 patients. It was possible to maintain partial blood supply of the humeral head in seven patients. Evaluation of functional results was made by the method according to Constant and radiographs were also evaluated. In non-anatomical reconstruction we paid particular attention to the observation of the onset of necro-biotic rebuilding of the humeral head.

In the 22 patients who underwent shoulder arthroplasty, we recorded results of three excellent, fourteen good, four satisfactory and one unsatisfactory. In patients who had non-anatomical shoulder reconstruction, the results were four excellent, eleven good, four satisfactory and one unsatisfactory. Out of this group there were three excellent and four good results in patients with a partially saved blood supply to the humeral head. There are signs of necro-biotic changes of the humeral head in four patients, but its presence clearly has no direct effect on the final shoulder function.

There are significantly worse results from arthroplasty in trauma cases than in other diagnoses such as osteoarthritis and rheumatoid arthritis. According to our own method, non-anatomical reconstruction of the shoulder has comparable results. In addition, this procedure enables saving the humeral head. There is also the advantage of no problems that are associated with arthroplasty (infection, migration of components, etc.). We have achieved remarkably good results in non-anatomical reconstruction with partial saving of the blood supply of the humeral head. The development of necro-biotic rebuilding of the head has no direct influence on the functionality of the shoulder.


T. Paavilainen

There are some special features involving replacement surgery of totally dislocated or severely dysplastic hips (Eftekhar Stage C and D). To achieve abduction strength strong enough to balance the pelvis and reliable fixation of the acetabular component, the cup must be seated near the anatomic level or even lower. Therefore, the femoral component in most cases is to be mounted below the intertrochanteric level in order to get the prosthesis reduced and the greater trochanter with intact attachment of the gluteus medius muscle distally advanced. At these levels the femoral diaphysis is straight and requires a straight stem. We started these techniques over 15 years ago with Lord’s madreporic prosthesis, but the stem – especially the calcar part – was too curved. A totally straight cementless, collared stem was designed with Biomet Inc. and has been used since 1988.

For this stem the femur was prepared with broaches, but it was far too easy to get a proximal split when rasping the cortical bone or inserting the stem. For this reason a new stem with a tapered, oval proximal part was designed in 1993. The femur is prepared with reamers and no broaches are needed. Because the stem is collarless, vertical/rotational stability is achieved by the oval wedge shape of the proximal stem, and not by the collar. Therefore, rotational instability and loosening of the stem are avoided.

We present the operative methods. The collarless stem has been used since 1993 in 58 hips of 43 patients. Mean age of the patients was 54 years (range: 21 to 71). Only six of the patients were men. The most common cause of hip deformity was DDH (47 hips). Five hips had congenital coxa vara, two cases had tuberculosis of the hip, and two patients had diastrophic dysplasia. There was one arthrogryphosis multiplex patient and one congenital proximal femoral deficiency. Schanz osteotomy had been performed in 11 of the DDH cases. Forty-four of the 47 DDH hips were high dislocations (Eftekhar C or D).

Complications: There were three dislocations, three late fractures of the greater trochanter fixed with a hookplate, two splits of the proximal diaphysis fixed with a cable, and one late fracture dislocation revised with a collared stem. Deep infection occurred in one case and removal of the prosthesis was necessary. In two cases the stem migrated 3 to 7 mm but stabilised spontaneously with osteointegration. In one case the stem migrated 15 mm. Fibrous union remained, but it is painless.

The final outcome was good in all other cases, but the patient with deep infection is waiting for a rearthroplasty, and the case with fibrous union is likely to be revised when it becomes symptomatic. Pain relief and the functional results including improvement of gait and abduction strength were generally good. Most of the patients were highly satisfied.


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K. Saniukas D. Galvydiene D. Rugienyte S. Bernotas

The authors provide an analysis of the results of surgery for clubfoot at the Vilnius University Children’s Hospital in Lithuania from 1979 to 1999.

We operated 565 clubfeet in 464 patients. Average age of the patients was 4.1 years. From 1979 to 1993, 172 feet were operated. Most patients had the so-called Zacepin procedure for clubfoot release that contains a multi-stage release of different clubfoot components, but without attention to bony alignment restoration. At that time most patients were operated from 1.5 to 4 years of age. In that group 45% of the patients had a recurrence of the deformity and an additional operation was necessary.

From 1993 to 1999, 393 clubfeet were operated. Mean age of the patients was 2.7 years (range 6 months to 7.4 years.). A more extensive release was introduced using the Cincinnati approach and restoration of normal talocalcaneal and talonavicular alignment following adequate soft tissue release. In this group 14% of the patients had a recurrence.

The main goal of the clubfoot surgery was an exact reposition and fixation of the talocalcaneal and talonavicular alignment with adequate soft tissue release. The Cincinnati approach was the most effective and safe for correcting all of the components of the deformity. The best results were found in the patients who were operated at the age of six to eight months. In order to get a better functional outcome, at three to four years of age a number of our operated patients required an additional procedure such as a split tibialis anterior tendon transfer, a lateral column shortening, or a medial column lengthening. An excessive reposition of the talus produces a strange and severe foot deformity that is difficult to manage.


V. Saraph E. B. Zwick G. Steinwender

The results of the Baumann procedure (intramuscular lengthening of the gastrocnemius and soleus in the proximal part of the muscle) for correction of fixed gastrosoleus contracture in diplegic children are presented.

Eleven ambulatory children with diplegic type of cerebral palsy (mean age: 10 years) were operated for correction of fixed gastrosoleus contracture by the Baumann procedure as part of a multi-level, single-session surgery for gait improvement. Evaluation included clinical examination and gait analysis. Mean follow-up after surgery was 2.7 years.

Clinical examination demonstrated significant improvements in active and passive ankle dorsal flexion with maintenance of ankle plantar flexor power. Ankle kinematics showed an increase in the dorsal flexion at initial contact, an average angle in single limb support, and maximum dorsal flexion in swing. Although there was an increase in dorsal flexion at the beginning of push-off, the total range of motion during push-off was not affected. Ankle movement demonstrated better loading in stance, manifested by significant improvement in maximum flexor movement in the second half of single stance. Post-operatively there was a change from abnormal generation of energy to normal energy absorption in mid-stance. Positive action during pushoff was significantly increased.

It is known that the growth of muscle occurs at its musculo-tendinous junction. Anatomic and simulation studies have demonstrated differences in the muscle fasicle length and pennation angles. With the Baumann procedure, an intramuscular lengthening gives the best chance for functional adaptation in the muscle. When needed, the soleus can also be lengthened. Multiple incisions permit stretching of the muscle fibres even in severe deformities.


A. Raimann C. Saavedra G. de la Fuente M. Díaz J. Garrido

We evaluated long-term follow-up clinically and radiologically of patients with developmental dysplasia of the hip operated between 1956 and 1971 with adductor tenotomy and open reduction of the hip.

Ninety-six patients with developmental dysplasia of the hip were operated between 1956 and 1971. Their ages were from 10 months to 44 months. Eighty-eight patients (88.5%) were girls and 11(11.5%) were boys. There were 58 unilateral cases and 38 bilateral cases for a total of 134 operated hips. The cases with bilateral involvement were operated simultaneously. For all patients, the surgical team used the same technique consisting of open reduction through a Smith Petersen incision together with an adductor tenotomy and lengthening or tenotomy of the Psoas muscle. Postoperative immobilization was a pelvic-toe cast for one month followed by two plaster casts with abduction rod for three to five months. Postoperative follow-up was from 15 years to 44 years, 4 months (mean: 24 years, 4 months).

The clinical outcome evaluated pain, range of motion, limp, muscle strength, and leg length discrepancy. Radiological evaluation included Mose index, acetabular head index, Wiberg’s CE angle, medial articular space, Sharp’s angle, acetabular index of the weight-bearing zone, acetabular depth, radial quotient in unilateral cases, width and shape of teardrop, collodiaphyseal angle, Shenton line, and degenerative changes of the hip.

The results of clinical evaluation were: Excellent – 60 (44.7%), Good – 35 (26.1%), Fair – 26 (19.4%), Poor – 13 (9.7%). Radiological results according to a modified Severin classification were: Class I – 60 (44.7%), Class II – 33 (24.6%), Class III – 31 (23.1%), Class IV – 9 (6.7%), Class V – 1 (0.7%), Class VI – 0 (0%).

Complications were: infections in six hips (4.4%), three (2.2%) being deep ones. Avascular necrosis according to Bucholz and Odgen occurred in 38 hips (28.3%). Four hips (3%) were Type I, 31 hips (23.1%) were Type II, three hips (2.2%) were Type III. Degenerative changes occurred in 29 hips (21.6%) of which seven hips (5.22%) were Grade I, 12 hips (8.95%) were Grade II, and 10 hips (7.46%) were Grade III.

Our conclusions were: 1.) Open reduction of developmental dysplasia of the hip is a valid method in late treatment or failure of orthopaedic treatment. 2.) Clinical results are better than radiological results. 3.) The rate of degeneratives changes increases with long-term follow-up. 4.) The best radiological results are achieved in patients who are younger than one and half year of age at the time of surgery. 5.) There was a significant rate (23.1%) of avascular necrosis Type II according to the Bucholz and Odgen classification, but this can only be realized with long-term follow-up.


M.A. Rauschmann N. Hailer K.D. Thomann

This study presents an historical review of the treatment of talipes equino-varus during the last centuries. The aim of the study was to show how knowledge about the pathogenesis and the progress of new techniques in orthopaedic surgery (plaster of Paris, anaesthesiology, asepsis, antisepsis) have influenced the treatment of this disease during the centuries.

This investigation is based on a study of the library of the German Orthopaedic and Science Museum that has more than 3000 historical books and theses from the middle of the 19th century to the present time.

In the 18th and 19th century there were different theories about the pathogenesis of clubfoot. For example, Paré was of the opinion that secondary forces were responsible for the deformity. Camper and Wolff were convinced that intrauterine pressure on the extremities was the reason for pes equinovarus. Little, Stromeyer and Delpech believed that shortening of the muscles was the origin. The pathogenesis of the clubfoot is still obscure.

The concept of therapy with redression and retention during the first month has not changed since Hippocrates. However, the techniques of redression and retention have changed during the decades. Machines and rural instruments were used for redression until the end of the 19th century (Lorenz, Thomas). Retention was improved by the development of new splints (Arceo, Venel, Scarpa). The introduction of plaster of Paris (Mathysen) in the treatment of the clubfoot led to a further improvement of retention in early treatment.

A new era began with asepsis and anaesthesia. These techniques allowed progress in the operative therapy of the tendons. The open and subcutaneous tenotomy was developed by Delpech, Dieffenbach, and Stromeyer.

In spite of the operative possibilities, we conclude that conservative treatment still has a major role in the concept of treatment for equinovarus.


I.T. Sharpe N.J. Talbot P.J. Schranz

We present a retrospective clinical and radiological review to assess the use of the AO unreamed femoral nail and spiral blade in the treatment of subtrochanteric fractures. Treatment of the subtrochanteric fracture remains a challenge. A combination of high stress concentration, poor cortical bone quality and comminution leads to a high incidence of problems. The abovementioned implant has been recommended for use in such fractures. However, several authors have reported mechanical failure and spiral blade migration. We have used the unreamed femoral nail since 1996 in 65 femoral fractures, and of these 32 were subtrochanteric fractures. A retrospective clinical and radiological study was undertaken to assess the use of the implant.

Clinical notes and radiographs were obtained for patients with subtrochanteric fractures treated with the AO unreamed femoral nail from November 1996 to November 1999. Fracture pattern was classified according to Seinsheimer. Assessments were made of callus formation and fracture healing. Any complication or implant failure was noted.

Thirty-two patients required an unreamed femoral nail. There were 20 females and 12 males, with an average age of 75 years. There were 16 fractures due to a fall, 15 pathological fractures, and one due to a car accident. Classification was: Type I: 6; Type II: 13; Type III: 6; Type IV: 3; Type V: 1. Mean follow-up was five months (range 3 to 18). Eight deaths occurred within one month. There were two pain-free non-unions, one revision with bone graft for non-union, and one spiral blade back out. No breakage of implants occurred.

We found that this implant provides stable fixation in these difficult fractures if adequate reduction is obtained. We have not experienced the implant failures reported in other series. We recommend the use of the implant, especially in those patients who are elderly or have pathological fractures.


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M. Repko

This contribution presents the analysis of a group of 14 patients with a serious form of meningomyelocele associated with equinovarosity of the foot. The severity of the condition depends on the neurosegmental level of the lesion as well as the seriousness of the essential malady.

The primary treatment of these patients is aimed at early surgical management of meningomyelocele. It is fundamental that the patient should undergo a thorough neurological examination in which the prognosis of the illness and the expected degree of immobility of the patient should be determined. If full immobility is expected, radical correction of the foot deformity should be deferred. If, at any age, a tendency to verticalise occurs, immediate correction of the foot deformity is required in order to prevent decubitus and provide for posture stability.

The treatment of paralytic clubfoot is above all adversely affected by skin hypaesthesia which tends to cause decubitus and aggravate healing of the wound after the surgery.

Our group consists of 14 patients who were operated for a serious form of lumbar meningomyelocele associated with L2-S2 areflexia soon after birth. The current mean age of the group is 14 years (range 6 to 20). Four patients aged from two to six years were operated. Serious complications of wound healing after surgery occurred in one patient. All four patients are able to walk with a stagger and clumsily with the help of crutches. The remaining ten patients have been left immobile without hope of stable standing.

The treatment of paralytic clubfoot demands intensive cooperation of neurologists and neurosurgeons. It is necessary to carefully think about all aspects of a patient’s prognosis before radical surgical treatment of the foot is considered.


P. Sponer K. Karpas

The aim of this study was to compare the results of resection arthroplasty with two-stage re-implantation procedure performed for peri-prosthetic infection of the hip. Patients who have had a resection arthroplasty can expect to have less pain, but their functional recovery is inferior to that which can be obtained after a two-stage re-implantation. Resection arthroplasty is usually unacceptable as a definitive solution for relatively young and active patients.

Possible options for the operative treatment of a periprosthetic infection include debridement with retention of the prosthesis, immediate one-stage exchange arthroplasty, and excision arthroplasty – either as a definitive procedure or as the first of a two-stage reconstructive procedure. The choice of a particular treatment is influenced by a number of factors.

At the Department of Orthopaedic Surgery in Hradec Králové we performed resection arthoplasty of the hip in 67 patients between 1984 and 1998. Mean age was 67 years (range 44–91). We were able to follow-up 33 of these patients in 1999. At follow-up, replacement of the total hip prosthesis in two stages had been carried out in 10 of the 33 patients. In 23 patients (11 male, 12 female) the resection arthroplasty had been present for an average of five years. In the remaining ten patients (3 male, 7 female) a total hip reimplantation had been performed after an average of 17 months (range 3 to 63). Mean follow-up after reimplantation was four years. The Harris hip score was calculated for the individual patients during follow-up.

The Harris hip score was 66 in the re-implantation group compared to 57.5 in the patients with resection arthroplasty. Personal satisfaction and hip function were better after the two-stage re-implantation procedure.


P. Sponer K. Karpas

The aim of this study is to compare the results of resection arthroplasty with two-stage re-implantation procedure performed for peri-prosthetic infection of the hip. Patients who have had a resection arthroplasty can expect to have less pain, but their functional recovery is inferior to that which can be obtained after a two-stage re-implantation. Resection arthroplasty is usually unacceptable as a definitive solution for relatively young and active patients.

Possible options for the operative treatment of a periprosthetic infection include debridement with retention of the prosthesis, immediate one-stage exchange arthroplasty, and excision arthroplasty – either as a definitive procedure or as the first of a two-stage reconstructive procedure. The choice of a particular treatment is influenced by a number of factors.

At the Department of Orthopaedic Surgery in Hradec Králové we performed resection arthoplasty of the hip in 67 patients between 1984 and 1998. Mean age was 67 years (range 44–91). We were able to follow-up 33 of these patients in 1999. At follow-up, replacement of the total hip prosthesis in two stages had been carried out in 10 of the 33 patients. In 23 patients (11male, 12 female) the resection arthroplasty had been present for an average of five years. In the remaining ten patients (3 male, 7 female) a total hip reimplantation had been performed after an average of 17 months (range 3 to 63). Mean follow-up after reimplantation was four years. The Harris hip score was calculated for the individual patients during follow-up.

The Harris hip score was 66 in the re-implantation group compared to 57.5 in the patients with resection arthroplasty. Personal satisfaction and hip function were better after the two-stage re-implantation procedure.


G. Szõke S-H. Lee J. Lakatos AHRW. Simpson

It has been shown that the bone, nerve, tendon, and muscle can generate new tissue when a leg is lengthened. In this study we have examined the muscles to see whether the proliferative response occurs uniformly along the fibres or whether it is a disproportionate occurrence, and also to see whether the muscles of animals of different age responded differently.

In five adult (more than 25 weeks) and five young (8 to 9 weeks) New Zealand White rabbits, a mid-diaphyseal tibial osteotomy was created and stabilised with an Orthofix (M-100) external fixator. After seven days, lengthening was carried out at a rate of 1.6 mm/day until a 20% increase in the tibial length had occurred. One hour prior to sacrifice, all of the animals were injected with bromodeoxyridine (BrdUrd, 40mg/kg).

Proliferative response of muscle tissue was assessed by measuring the positive staining index (PSI) of BrdUrd in a two-step indirect immunohistochemistry using the monoclonal antibody Bu20a. We accomplished this staining in transverse sections (between the proximal and middle third, and between the middle and distal third of the muscle belly) and in longitudinal sections along the proximal, middle and distal third of the myotendinous junction (MTJ) of the lengthened flexor digitorum longus muscle belly. The opposite limb was used as a control for each animal.

All of the muscles showed a proliferative response that was significantly higher on the experimental side. There was no difference between the PSI of the proximal transverse sections and the distal transverse sections. The young animals demonstrated significantly increased PSI in all sections compared with the adult animals (immature distal transverse section PSI: 4.91%; mature distal transverse section PSI: 1.67%). The PSI of the longitudinal sections of MTJ showed significantly higher values than in the muscle belly (PSI at the MTJ in adults: 5.23%; PSI at the MTJ in the young: 13.2 %). The PSI result was increased at the distal third of the MTJ in mature and immature rabbits (p0.05).

The muscles show a proliferative response to elongation forming new muscle tissue. The proliferative reaction to lengthening is far greater in the muscles of growing animals compared to adults. The myotendinous junction demonstrates much more intensive proliferative activity than the muscle belly. The distal third of the myotendinous junction shows the highest PSI results. The results of this study help to interpret the results of the animal model for clinical studies and also indicate an advantage in carrying out lengthening on young individuals.


I. Shpilevsky G. Brodko

The aim of this research was to elaborate indications for application of some methods of surgical treatment of DDH in teenagers.

There are some significant problems with surgical treatment of DDH in teenagers. The most serious one is that the results of routine reconstructive methods usually satisfy neither the patients nor the orthopaedists. In addition, in most of the cases it is too early for total hip arthroplasty.

From 1985 to 1996, we operated twenty teenagers with late stages of DDH. Group A was eight patients (12 to 14 years old) with marginal hip luxation (acetabulum angle was more than 40°). Group B was seven patients (10 to12 years old) with iliac hip dislocation (acetabulum angle was more than 50°) and Group C was five patients (11 to 14 years old) with iliac hip dislocation (plane acetabulum).

In Group A we performed our first two-stage method of surgical treatment. For the first stage we performed corrective transtrochanteric femur osteotomy (AO plate fixation) and partial acetabuloplasty, and corrected not more than half of the acetabulum angle deficiency. The second stage was performed four to six months later. We removed the femur AO plate and again performed a partial acetabuloplasty. A spherical acetabulum with normal angle and stable hip joint were the results of this method.

In Group B we performed our second two-stage method of surgical treatment. For the first stage we performed a corrective and shortening (2 to 3 cm) transtrochanteric femur osteotomy (AO plate fixation), open reduction of the hip and partial acetabuloplasty and corrected not more than half of acetabulum angle deficiency. The second stage was performed 4 to 6 months later and we removed the femur AO plate and performed a Salter osteotomy. A spherical acetabulum with normal angle and a stable hip joint were also the results of the application of this method.

In Group C we performed the well-known Ilizarov technique of femur reconstruction (modification of Schanz osteotomy with correction of femur shortening). Normalisation of gait and reduction of the Trendelenburg sign were the results of the application of this method.

The results of these methods were studied 3 to 10 years after the end of postoperative rehabilitation. Good results were obtained in 16 cases, satisfactory in four (one in Group A, two in Group B and one in Group C).


K. Siebenrock W. Morgenstern R. Ganz

The study reviews 24 patients with 27 total hip arthroplasties in which an acetabular reinforcement ring with hook was used for primary total hip arthroplasty (THA) due to underlying hip dysplasia.

There were 19 female and 5 male patients with a mean age of 50.6 years (31 to 70) at the time of surgery. A bulk autograft for acetabular reconstruction was used in four cases with Crowe Type III and IV dysplasia. In eight cases cancellous bone alone was used to fill the gap between the reinforcement ring and the acetabulum. All patients had a polyethylene cup cemented into the ring and 22 cases had a straight Müller CDH stem cemented into the shaft.

Mean follow-up was 10.7 years (range: 8.1 to 12.7). No clinical or radiographic signs of loosening of the reinforcement ring were found in 24 (88.9 %) of the 27 THAs. Two revisions (7.4%) were performed for aseptic loosening and one acetabular component had radiographic signs of loosening. The Merle D`Aubigné score had increased from 7 to 15 points.

The acetabular reinforcement ring continues to have favourable results in this specific patient group and may also prevent graft resorption and cup migration.


K. Siebenrock W. Morgenstern R. Ganz

The study reviews 24 patients with 27 total hip arthroplasties in which an acetabular reinforcement ring with hook was used for primary total hip arthroplasty (THA) due to underlying hip dysplasia.

There were 19 female and 5 male patients with a mean age of 50.6 years (31 to 70) at the time of surgery. A bulk autograft for acetabular reconstruction was used in four cases with Crowe Type III and IV dysplasia. In eight cases cancellous bone alone was used to fill the gap between the reinforcement ring and the acetabulum. All patients had a polyethylene cup cemented into the ring and 22 cases had a straight Müller CDH stem cemented into the shaft.

Mean follow-up was 10.7 years (range: 8.1 to 12.7). No clinical or radiographic signs of loosening of the reinforcement ring were found in 24 (88.9 %) of the 27 THAs. Two revisions (7.4%) were performed for aseptic loosening and one acetabular component had radiographic signs of loosening. The Merle D`Aubigné score had increased from 7 to 15 points.

The acetabular reinforcement ring continues to have favourable results in this specific patient group and may also prevent graft resorption and cup migration.


P. Závitkovsky T. Malkus M. Trnovsky

The purpose is to present our experiences with the conversion of external fixation to an intramedullary nail in the treatment of open fractures and fractures in polytraumatised patients. These are traumatological cases where primary use of an intramedullary nail is difficult or impossible.

References in the world literature to the two-stage treatment of the fractures of the tibial shaft are more than 2O years old and are considered as unsuccessful. However, later papers presented conversion as an advantageous procedure. A higher stability of the fracture and better comfort of the patient are acquired by the use of conversion.

From 1995 to 1999 in the Orthopedic Clinic Bulovka in Prague, Czech Republic, ten patients (8 male, 2 female) were treated by the method of conversion of external fixation to an intramedullary nail. The group of patients was composed of eight open fractures: one Gustillo-Anderson 1, two Gustillo-Anderson 2, three Gustillo-Anderson 3A, two Gustillo-Anderson 3B, one closed fracture Tscherne CIII, and one closed fracture Tscherne CII in a polytraumatised patient. Conversion was performed from 6 to 48 days after primary stabilisation by external fixation (mean 21.2 days). We currently use the UNI-fix clamp external fixator. Conversion by standard procedure is performed up to the 21st day to the 28th day after primary stabilisation. Injury of soft tissues and skin covering must be solved at the time of conversion.

Analysis of the results in the ten cases was made from three months to 4.5 years. All of the cases were subjectively classified as excellent or very good. There were no deep infections. In three cases there was prolonged secretion from the screw holes of the external fixator. For one patient, bone grafting into a fracture bone defect was necessary after six months. ROM of the knee and ankle joint was without reduction of function. When the period of follow-up was more than one year, all patients had perfect healing of the fractures.

This method gives very satisfactory therapeutic results with a minimum of complications, and covers the spectrum of the treatment of complicated fractures of the tibial shaft. However, the indications are very strict. If conversion is not able to be performed before the 21st to the 28th day after primary stabilisation, it is more advantageous to continue with treatment by external fixation because of the risk of deep infection. After the 28th day following primary stabilisation, conversion to an intramedullary nail is not indicated.


T.D. Tennent P. Calder R. Salisbury P. Allen D. Eastwood

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres.

It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided.

Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days.

All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis.

In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection.


L. Zahradníèek

The following report is focused on the principles and results of management of proximal femoral fractures in the Orthopaedics and Traumatology Department of Kladno Hospital. The observed file includes patients treated from 1998 to 1999.

Proximal femoral fracture is the most frequent diagnosis in traumatology hospitalisation. Correct management is very important from a medical point-of-view not only because of the frequency, but also with regard to economics.

We strive to operate on traumas indicated for operation as soon as possible, but we often treat them in the regular operation program the next day. For pertrochanteric fractures, the Dynamic Hip Screw is most often used. We use cervicocapital endoprostheses for cervical fractures of elderly patients, total endoprostheses for younger patients, and osteosyntheses for patients with the joint in good condition. Subtrochanteric fractures are treated by a reconstructional nail, or rarely by a Gamma nail because of its financial demands. As a preventive measure, patients are given antibiotics for 24 hours. Drains are extracted on the third postoperative day and patients are verticalized on crutches. The stitches are removed on the tenth to twelvth post-operative day and patients are transferred to out-patient treatment. It is worth mentioning that an attempt is made to stabilise subtrochanteric fractures by external fixation for a patient contraindicated for operation.

From 1998 to 1999, 283 patients (217 female, 66 male) with proximal femoral fracture were hospitalised. The types of fracture were: 137 cervical (11 were undislocated, wedged, and primarily indicated for conservative therapy), 104 pertrochanteric, and 31 subtrochanteric. There were also four false-joints, two periprosthetic fractures and three luxation of endoprostheses. We conservatively treated 11 patients with stable cervical fractures, with good results. There were 21 patients contraindicated for operation and only four of them are mobile. In the observed file there were seven deaths prior to operation, ten in the immediate postoperative period, and no mors in tabula.

There were 283 patients with proximal femoral fractures hospitalised in the studied period. From the total of 216 operations, 186 (86%) are independently mobile and satisfied with the result.


T.D. Tennent P. Calder R. Salisbury P. Allen D. Eastwood

The purpose of the study was to perform an independent assessment of the results of open reduction and internal fixation (ORIF) on a selected group of displaced intra-articular calcaneal fractures from two centres.

It still remains controversial whether to manage intraarticular calcaneal fractures conservatively or operatively with few long-term results. The identification of patients who may benefit from the procedure is still undecided.

Fifty fractures in 46 patients with a defined significant displacement of an intra-articular fracture of the calcaneum underwent ORIF by one of the two senior authors. Mean age at operation was 46 years and mean follow-up was 44 months. 88% of the injuries were due to a fall from a height. 30% of the patients had contralateral foot/ankle injuries, and 20% of the patients developed a superficial wound infection. The infection rate was significantly higher in patients whose surgery was delayed more than 14 days.

All patients were independently reviewed after a minimum two-year follow-up. A clinical, radiographic and subjective assessment of the outcome was made. The results were correlated to the original fracture type. The mean Atkins score was 88 (out of 100). Bilateral injuries fared worse. Heel pain at follow-up correlated with a poor score. Atkins scores over 90 occurred in 77% of Saunders Type II, 50% in Type III, and 43% in Type IV fractures. 94% returned to work at a mean of 10 months post-injury. Three patients have undergone a subtalar arthrodesis – two for persistent pain and one for a significant malunion. One patient required a flap but there have been no cases of chronic osteomyelitis.

In patients with significantly displaced fractures, ORIF is a worthwhile procedure with 90% of patients satisfied and 94% returning to work. Gross articular comminution does not preclude a good/excellent result if hindfoot alignment is restored. ORIF after fourteen days should be avoided due to the high risk of infection.


H. Zehetgruber A. Grübl C. Wurnig

The purpose of this study was to evaluate if there was a difference in the outcome of operative treatment for rotator cuff-tears in patients younger and older than the age of 60.

Thirty-eight patients (19 male, 19 female) underwent 40 procedures and were postoperatively evaluated 15 and 42 months after surgery. At the time of follow-up they had a physical examination that included the Constant score, radiograph in three planes and a questionnaire focused on the need for analgesics, nocturnal pain, and return to full activity (work and sports). Cuff tears were classified by the Harryman classification. Corresponding to the study design, patients were divided into two age groups: under the age of sixty years (51a, min. 44a, max. 58a, n=22) and patients sixty years of age and older (68,3a, min. 60a, max. 82a, n=16).

Active range of motion increased significantly in both age groups (p< 0.05) from 101° to 152° in abduction after the first 15 months after surgery and in anteversion from 117° to 155°. By the time of the second evaluation, abduction had decreased to 136° for abduction and 149° for anteversion. The results of functional assessment by the Constant score was 72 points after 16 months and after 42 months decreasing to 62 points in the group of patients under the age of 60, and from 71 to 66 points in the group of patients 60 years of age and older.

In both age groups there was a continuous increase in muscle force: from 4.35kp after 15 months to 4.5kp after 42 months in patients younger than 60, and from 2.24kp to 3.75kp in the older age group. Pain and the use of analgesic medication decreased significantly (p< 0.0001 and p=0.0003) in both age groups during the first 15 months after surgery and after 42 months had remained at the same low level. There was a correlation between extent of the cuff tear and results of functional assessment by the constant score. For patients with Harryman Type I cuff tears, mean score after 15 months was 78 points decreasing to a mean score of 65 points after 42 months. Harryman Type II cuff tears decreased from 74 to 70 points, with Type III cuff tears decreasing from 63 to 57 points.

Patients in the age group of 60 years and older had more similar benefits from operative treatment for rotator cuff-tears than the group under the age of 60. The best clinical result in both groups appeared during the first two years after surgery and decreased an average of 3.5 years postoperatively. The results of the Constant Score were influenced primarily by the size of the cuff tear.


H. Zehetgruber C. Wurnig

The aim of this study was to evaluate how three different scoring systems (Constant, Reichelt, and UCLA scores) perform in individuals with normal shoulder function.

Scoring systems to evaluate the outcome of surgical treatment around the shoulder are well established. A total of 201 individuals were enrolled in this study. They were divided in four age groups and divided by sex: Group 1: Under 50 years of age: 25 female, 21 male; Group II: From 50 to 59 years of age: 17 female, 21 male; Group III: From 60 to 69 years of age: 18 female, 12 male; Group IV: 70 years of age and older: 24 female, 15 male.

All underwent clinical examination, ultrasound examination for detection of cuff tears, and radiograph examination in three planes. In all cases the dominant arm was enrolled. Twelve patients were excluded from the study because ultrasound depicted cuff tear or radiograph showed more than mild osteoarthritis according to the criteria of Hawkins, et al. (1990).

The main factor influencing the over-all score was the age-dependent decrease of muscle force measured in forward arm flexion (max. 12.5kp). The score was also influenced by the limitation of internal rotation (Group I: 13%, Group II: 26%, Group III: 40%, Group IV: 41%). According to the Reichelt and UCLA scores, males in Groups I, II and III reached a 100% top score in the UCLA and Reichelt scoring systems. In Group IV composed of older male patients, 20% scored less that the top score because of loss in active motion and muscle force. Only females in Groups I and II scored maximum results. Females in Group III scored 11% and in Group IV composed of older female patients, 50% scored less than the top score because of loss in active motion and muscle force.

Due to the natural aging process, males and females in Group IV could not accomplish maximum scores. We recommend that the top scores for the oldest age group be adjusted in order to avoid drawing erroneous conclusions from the scores in this age group.


A Bayan J Matheson

Eighty-one patients treated surgically for non-insertional Achilles’ tendinopathy between 1987 and 1999 by one surgeon were reviewed by a comprehensive postal questionnaire. Fifty-six patients (73 tendons) returned a questionnaire at an average of 58.7 months after surgery. The duration of preoperative symptoms averaged 24.6 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Twenty (35.7%) of these patients were involved in competitive or serious recreational sport. There were 34 men and 22 women with a mean age of 42.5 years (range: 23 to 66). All patients who had insertional tendinopathy or retrocalcaneal bursitis were excluded from this study. The surgical procedure consisted of excision of the paratenon circumferentially and early mobilisation. All patients had the same post operative treatment. There were 77.5% excellent, 6.4% good, 6.4% fair and 6.4% poor results. Eleven percent developed complications post operatively. We concluded that surgical decompression of the Achilles’ tendon is a very effective treatment for patients with non-insertional Achilles’ tendinopathy who have failed conservative treatment.


R Atkins

Background: Fracture non-union remains a severe clinical problem. The methods of Ilizarov allow a new approach using a tensioned fine wire circular frame to construct cylinders around limb segments that are then manipulated with respect to each other with deformity correction using hinges. Ilizarov introduced the concept of bone formation in distraction. The use of fine wires and non-invasive techniques minimise bone and soft tissue damage.

Method: Two hundred consecutive non-unions treated by the use of an Ilizarov frame were studied prospectively. The first 100 cases to have finished treatment were analysed. The mean time from fracture was 22.8 months (range: six months to 37 years) and the mean number of surgical procedures was four (range: one to 122). Eighty-eight percent affected the tibia. Unifocal compression was also used where bone loss was not a problem.

Results: Ninety-three fractures united. There were two amputations for overwhelming infection, four refractures and one defaulter. Infection, present in 56 cases at presentation was eradicated in all successful cases. Time in the frame for unifocal distraction (n=6) was 6.0 months (2.5-13), for unifocal compression (n=36) was 8.4 months (2.8-20), for bifocal compression distraction (n=33) 10 months (2.9–17.4) and for bifocal excision distraction (n=24) 19 months (6.5–41). Comparing times in frame for tibial bifocal cases, compression/distraction was 9.1 months (2.9–17.4), excision with shortening and relengthening was 15.7 months (6.5–23.6) and excision/transport was 23.5 (12.6–41.5), indicating increasing time required for more radical treatments.

Conclusion: The Ilizarov method provided an excellent technique for the treatment of non-unions. The technique was initially difficult for the surgeon and the patient but, with increasing experience, treatment times were reduced and the frames became progressively more manageable and less painful. In our hands, the Ilizarov frame has become the treatment of choice for all but the simplest non-unions.


R Ratahi H Crawford M Barnes

Previous studies have documented a variation in the occurrence of musculo-skeletal conditions affecting the hip and foot in the New Zealand Maori and Pacific Island races compared with the European race in New Zealand. Similar data regarding scoliosis are lacking. A manual and computerised review of outpatient records of Starship Hospital (1989–2000) and Middlemore Hospital (1997–2000) revealed 363 patients less than 20 years of age with a diagnosis of scoliosis. Major aetiological diagnoses included adolescent idiopathic (63), syringomyelia (12), myelomeningocele (16), cerebral palsy (55) and congenital (55). Significant racial variations were noted in the idiopathic, syringomyelia and neuro-muscular groups compared with New Zealand census predictions. Idiopathic scoliosis was uncommon in Maori (9%) and rare in Pacific Islanders (1%). Conversely, these groups accounted for 66% of all scolioses and over 50% of Maori and Pacific Islanders were found to have a syrinx. MRI is indicated in Maori and Pacific Islanders with apparent adolescent idiopathic scoliosis. Maori accounted for 31% of patients with myelomeningocele and scoliosis. 40% of patients with cerebral palsy and scoliosis were Maori, reflecting the known inferior status of perinatal and other health parameters in this group of people.


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G Beadel G Hooper J Burn B Robinson S Fairbrother

Aim: In 1990 the Christchurch Hospital Sarcoma Clinic established management guidelines for patients with suspected sarcomas, recommending referral prior to investigation, biopsy and excision. The aim of this study was to determine whether these guidelines are being followed.

Method: A review of the case notes of all sarcomas referred to the Sarcoma Clinic between 1990 and 1999 was performed.

Results: There were 53 referrals, 34 (22%) from orthopaedic surgeons, 56 (37%) from general surgeons, 16 (10%) from general practice and 47 (31%) from other specialties. Only 83 (54%) of the referrals had followed the guidelines. Twenty-five (74%) of the orthopaedic referrals, 19 (34%) of the general surgical, 10 (63%) of the general practice and 29 (62%) of the other specialties had followed the guidelines. Seventy (46%) of the referrals had failed to follow the guidelines. Thirty-four (49%) of these had undergone excision inadequate for sarcoma prior to referral, of which eight had been re-excised. Twenty-four patients had not been staged prior to excision despite having a positive fine needle aspiration (FNA) in four cases. Eighteen patients (26%) had FNA or biopsy prior to imaging or referral.

Conclusion: Forty-six percent of sarcoma patients had not been treated according to the recommended guidelines. Forty-nine percent of these had inadequate primary sarcoma excision and this may have compromised their outcome. Orthopaedic surgeons had the best record for following the guidelines at 74% of referrals but this could be further improved. Doctors and especially surgeons need to be more aware of the principle of early referral of patients with suspected sarcomas.


G Beadel J McKee

Aim: To determine whether there is a difference in outcome between reamed and unreamed tibial nails.

Method: We performed a prospective, randomised trial comparing the results of reamed versus unreamed titanium tibial nails. Perioperative oxygen saturation and FIo2 were measured in each patient. Time to union was compared using survival analysis.

Results: There were 60 patients with 60 tibial shaft fractures including 10 (17%) compound fractures and three patients with thoracic trauma. There were 32 reamed and 28 unreamed nails. Fifty-seven nails were statically locked (95%). The average nail diameter in the reamed group was 9.7mm, significantly larger than that in the unreamed group (9.2mm), (p=0.02). There were no significant differences in average oxygen saturation and FIo2 between reamed and unreamed nails during insertion, immediately postoperatively or during the first two postoperative days. Forty-eight (80%) patients were followed until the fracture healed. Two patients died and 10 (17%) were lost to follow up. The mean time to union was 13.5 weeks in the reamed group versus 16 weeks in the unreamed group. This was not significant (p=0.2). There were 10 (17%) complications including one delayed union in each group, both united following ‘dynamization’. There were three compartment syndromes treated with fasciotomies. No nails broke and there were no deep infections.

Conclusion: We have shown no difference in the effects on pulmonary function between the two groups, but unfortunately we had insufficient patients to assess the effect of thoracic trauma.


G Brick S Mills

Aim: The S-ROM femoral component is a versatile modular prosthesis that can be adapted to the majority of complex hip revision situations. The purpose of this study is to review the results of this prosthesis with a minimum follow-up of two years.

Method: Fifty-six consecutive revision hip arthroplasties using the S-ROM femoral component were performed in 49 patients by the senior author. The patients with segmental femoral allografts were excluded. A retrospective chart review and radiographic analysis was performed and the pre-operative and post-operative modified Harris hip scores compared.

Results: Forty-nine patients with 56 hips were evaluated between two and seven years after revision surgery. There were 25 females and 24 males. The average age was 66.6 years (range: 44.8 to 94.6). Revision arthroplasties were performed for loose components in 36 hips, infected components in 10 hips, recurrent dislocation in three hips and for miscellaneous diagnoses in seven. The average number of previous surgical procedures on the affected hip was 2.4 (range: one to seven). The modified Harris hip score improved from a pre-operative average of 42 to a post-operative average of 73 at the most recent follow-up examination. Three patients had failed revisions at seven years (5%). One patient underwent a resection arthroplasty for infection, one patient underwent re-revision for recurrent dislocation and one patient dislocated, became infected and is on suppressive antibiotic therapy. Other complications included nine dislocations (16%), seven intra-operative fractures (13%), trochanteric irritation in five patients (9%), residual thigh pain in three patients (5%), heterotopic ossification in two patients (4%), one post-operative sciatic nerve palsy (2%) and early osteolysis in one patient (2%).

Conclusion: Short to intermediate term follow-up of the S-ROM femoral component in this group of revision patients has yielded excellent results. In terms of loosening and osteolysis these results are comparable to primary hip arthroplasty using the S-ROM prosthesis.


M J Brick

Aim: Total hip arthroplasty implant inventories are based on anatomic studies on populations with a different ethnic mix from New Zealand. The purpose of this study was to:

Compare the proximal femoral geometry with published data from the American population.

Compare the proximal femoral geometry with implant sizes currently being used in New Zealand.

Hypothesis: That New Zealanders have a significantly greater offset when compared with published American data.

Method: Fifty-seven femora were obtained from medical school cadavers. Using a standardised technique the femora (stripped of soft-tissue) were x-rayed and surface and endosteal measurements were taken. These measurements were compared with previously published data from an American population. The implants used in 200 consecutive primary total hip arthroplasties were measured to compare with them the New Zealand population.

Results: Twelve of the 14 measurements were significantly different when compared with the American population. In particular, femoral head offset averaged 46.7mm compared with 43mm in the American study. Femoral head diameter was also significantly larger (49.2mm vs 46.1mm).

Conclusion: If the goal of implant sizing is to reproduce the rotational axis and offset of the native hip joint, NZ Surgeons may be frequently under sizing implants with regard to offset.


M Clatworthy J U Bulow L Pinczewski S Howell P Fowler

Introduction: It has been proposed that tunnel widening in ACL reconstructions is due to excessive graft tunnel motion secondary to elastic fixation.

Aim: To determine whether techniques which fix the graft closer to the joint (interference screws), eliminate the bungy cord and are stiffer will decrease tunnel widening. The clinical significance of tunnel widening is examined.

Method: Two hundred and fifty nine patients were evaluated prospectively. Four fixation methods were evaluated. Sixty-nine were reconstructed using Endobuttons and staples (elastic fixation). Forty-eight were subjects reconstructed with a bone mulch screw and staples, 55 patients were reconstructed with metal interference screws and 87 with bioabsorbable interference screws. Patients underwent a clinical examination, IKDC, Cincinnati knee score and KT-1000 testing one year post-operatively. These factors were correlated with tunnel widening. Tunnel widening was determined using magnification adjusted AP and lateral radiographs using Scion Image software.

Results: Tunnel widening occurred with all the fixation methods. Mean tunnel area increased 122% for the Bioscrew, 89% for the metal interference screw, 76% for the bone mulch screw and 36% for the Endobutton (ANOVA p=< 0.0001). Tunnel widening did not correlate with increased laxity, poor IKDC or Cincinnati knee scores.

Conclusions: Tunnel widening occurred with both elastic and rigid fixation methods. Tunnel widening could not be avoided by fixing the graft closer to the joint or eliminating the ‘bungy cord’. Graft tunnel motion was not the sole cause of tunnel widening in ACL reconstruction. Tunnel widening did not correlate with poor outcome in the short term.


G Brick J Balance

Aim: The current trend in fixation of acetabular components is towards press-fit, no-hole components to reduce the wear debris production and its access to the bone prosthesis interface. The purpose of this study is to review the outcome of no holes or holes with or without adjuvant screw fixation in a porous expanded rim modular acetabular component of the same design with a minimum of two year follow up.

Method: This was a retrospective review of the charts and radiographs of 204 consecutive Osteonics PSL acetabular components inserted by the same surgeon. Radiographic analysis included assessments of radiolucencies in the three zones of Charnley & DeLee, as well as assessments of migration and wear using the technique of Livermore. Osteolytic cysts were recorded and any progression noted.

Results: The underlying diagnosis was similar in all groups with osteoarthritis comprising 57%. In the screw group one component has been revised for loosening secondary to impingement. Three had significant osteolysis, all of which have been revised. There was no significant difference for the 28 mm heads between the groups for radiolucencies or migration. The 22 mm heads had a higher rate of linear wear. Complications included seven dislocations, two with grade three heterotopic ossification and one late haematogenous infection.

Conclusion: Comparing acetabular components with and without screws and no-hole components there was no significant difference in radiolucencies, wear and migration. Osteolytic cysts occurred only in cups with holes and screws. Because of these findings the surgeon continues to use the no-hole cup wherever possible in primary and revision arthroplasty. Longer follow up will be required to confirm that this decreased osteolysis persists over time in the no-hole group.


H Blackely A Gross

Aim: Proximal femoral allografts are a rare but valuable option in severe femoral bone loss in revision hip arthroplasty. However, there are no long-term follow-up reports on their use. The purpose of this study was to review the average 11-year results of massive proximal femoral allografts used for severe bone loss in revision hip arthroplasty.

Method: Sixty-three total hip arthroplasties in 60 consecutive patients were revised with a proximal femoral allograft and a prosthesis. The mean length of the allograft was fifteen centimeters. All patients had undergone at least one previous total hip arthroplasty, with a mean of 3.8 operations. Each patient was assessed before operation and at follow-up with a modified Harris hip score and radiographs.

Results: At a mean follow-up of 11 years (range: nine to 15 years), 45 patients (75%) were alive, 14 patients (23 %) were deceased and one patient was lost to follow- up. The average preoperative Harris hip score was 30 points; at the latest follow-up the average score of those with the original graft in situ was 71. The deceased and lost patients represented 15 allografts (24%) with an average of five years and seven months follow-up. There were five failures for infection, four of which were successfully revised. Three hips failed with aseptic loosening at average 10 years and three months, two have been successfully re-revised and the third is awaiting revision. Success was defined as a postoperative increase in the Harris hip score of greater than twenty points, a stable implant, and no need for further surgery related to the allograft at the time of review. The success rate for all patients was 78% at an average of nine years follow-up. The success rate of those living was 77% at an average of 11 years follow-up.

Conclusion: At an average of 11-years following proximal femoral allografts the clinical and radiological results were encouraging.


W Bevan E J Jamieson

Aim: This study was performed to review the early results of the use of a semi-constrained acetabular component in the treatment of recurrent hip dislocation at Palmerston North Hospital.

Method: A retrospective case study of patients who underwent acetabular component revision with a semi-constrained cup for recurrent dislocation of the hip was performed.

Results: Between April 1999 and July 2000, 10 patients with an average age of 75 years underwent acetabulum revision with a semi-constrained cup. There was an average of four dislocations before revision surgery, per patient. At follow-up between three and 18 months after the revision, there had been no dislocations. Aggressive post-operative rehabilitation was permitted, allowing discharge at an average of seven days postoperatively.

Conclusion: The use of a semi-constrained acetabular cup was successful as a means of treatment for recurrent hip dislocation. This is an early review of the use of the implant. There are no published data on long term survival of this implant. The semi-constrained cup provides a simple yet effective option for dealing with the elderly recurrent hip dislocation


A S Don K D Karpic

Aim: To evaluate outcome with current treatment methods of patients with severe (AO Type C) fractures of the tibial plafond.

Method: All patients with AO Type C fractures of the tibial plafond were included in the study. Treatment was predominantly by way of temporary external fixation with staged open reduction and internal fixation once soft tissue swelling had receded. A clinical and radiological review was performed at an average of two years after initial presentation.

Results: Thirty-five Type C fractures were reviewed. All fractures united. There were no deep infections. Sic patients have required major subsequent surgery. Three have undergone arthrodeses for post-traumatic degenerative change. Three have had bone grafting and/or adjustment of fixation.

Conclusion: Temporary external fixation with staged internal fixation for AO Type C fractures of the tibial plafond produced reasonable results at medium term follow up.


J M Fielden J M Cumming G Horne P A Devane

Introduction: Long waits for total hip joint replacement (THJR) surgery affect quality of life and are likely to impose significant medical, personal and other costs on individuals and society.

Aim: To define the economic and health costs of waiting for THJR surgery.

Method: A prospective study of 130 patients requiring primary THJR is being undertaken. Data on health related quality of life (HRQL), using self completed EQ-5D and WOMAC questionnaires, are collected on enrolment, and every month before surgery and continuing for six months after surgery. Monthly cost diaries are used to record medical, personal and other costs. Inferential statistics and regression analyses will be used to test the strength of associations between costs and waiting times, and changes in HRQL before and after surgery.

Results: Preliminary results indicate that costs are greatest before surgery (mean=$70.41 per person, per month), remain high during the first month after surgery (mean=$53.24 pp pm), and drop significantly (p< 0.05) within six months after surgery (mean=$12 pp pm). WOMAC scores of pain, stiffness and physical function show significant improvements (p< 0.05) within three months after surgery. The EQ-5D also indicated significant (p< 0.05) positive changes.

Conclusions: The preliminary results suggested that patients had high dependency levels for the first month after surgery. Consequently, costs associated with recuperation after surgery may have shifted from the public hospitals onto the community and family. Significant improvements in HRQL by three months after surgery indicated that THJR is a successful intervention for osteoarthritis.


M Clatworthy R Chiu C Chiu T Minas

Introduction: We report one surgeon’s experience with autologous chondrocyte implantation (ACI) for the treatment of large chondral knee defects

Method: Over a five-year period, 295 chondral knee defects in 169 patients were treated with ACI. Most patients were complex having failed other treatments. Only 4% of patients had simple condylar lesions. Patients were followed prospectively. Patients were independently evaluated by an history, clinical examination, WOMAC score, Cincinnati Knee Score (CKS), IKDC, SF-36 and patient satisfaction scores administered pre-operatively and at 12, 24, 36 and 48 months post-operatively.

Results: Two hundred and sixty seven grafts (89%) were functioning well. The common causes for graft failure were poor graft incorporation and delamination, non-compliant rehabilitation and progressive osteoarthritis. Periosteal hypertrophy was present in 20% requiring arthroscopic debridement. All outcome measures improved significantly with time.

Conclusion: In a complex group of patients ACI showed encouraging results in the short term.


A Cromhout H Tobin

Aim: To examine the efficacy and ease of use of the scapular manipulation method in the reduction of anterior shoulder dislocations and the need for sedation/analgesia that usually requires prolonged observation of the patient after reduction.

Method: This was a prospective series over six months. All patients presenting to the Waikato Hospital Emergency Department with uncomplicated anterior shoulder dislocations were included in the study. Reduction was firstly attempted with the Scapular Manipulation Method without analgesia or sedation. Where this was unsuccessful, analgesia and/or sedation was given and their shoulders reduced by one of various methods. The patients who received sedation were then observed as required.

Results: Thirty-five patients with anterior shoulder dislocations were seen. In 30 cases the scapular manipulation method of reduction was used with a success rate of more than 80%. The need for sedation/analgesia that would usually lead to a period of observation was greatly reduced.

Conclusion: The scapular manipulation method of reduction of anterior shoulder dislocation is an easy and safe technique with a success rate, and it obviates the need for prolonged patient observation.


P Devane G Horne

Aim: The direct lateral approach, as described by Hardinge et al, may have the advantage of reducing the incidence of dislocation after total hip arthroplasty. The purpose of this paper is to describe a modification of the direct lateral approach used by the author on consecutive total hip arthroplasty for all patients; including primary arthritis, fractures and revisions over a period of five years. The incidence and causes of complications, specifically dislocation, is discussed.

Method: A modification of the direct lateral approach, where gluteus minimus is split anteriorly rather than being detached from the greater trochanter, is described. This approach allowed its primary repair during wound closure, reducing surgical dead-space and theoretically reducing the incidence of dislocation. The records of all patients in whom the author performed this approach for total hip arthroplasty between 1 February 1994 and 1 February 1999 were examined. Patients were routinely seen at one year after operation and any early complications of surgery recorded. Minimum follow-up for this series was one year.

Conclusion: This modification of the direct lateral approach which preserves the integrity of gluteus minimus while still allowing adequate exposure and is extensile, gave a very acceptable incidence of dislocation in total hip arthroplasty for degenerative disease, fracture, and revision cases.


J M Fielden G Purdie G Horne P A Devane

Introduction: Hip fractures in the elderly create an economic and social burden on individuals and society. Earlier predictions of the incidence of hip fractures in the older adult population showed that by the year 2011 the rate would rise to epidemic proportions.

Aim: To analyse the actual hip fracture rate from 1988 to 1999 and then to compare it with the hip fracture rate predicted by Rockwood, Horne and Cryer in 1990.

Method: Data on the number of patients admitted to New Zealand hospitals with a diagnosis of fractured neck of femur were obtained, and compared with Rockwood’s (1990) weighted regression and baseline predictions. Poisson regression was used to test for changes in hip fracture rates over time.

Results: The numbers of hip fractures for females, from 1988 to 1993, were similar to the numbers predicted, yet have been significantly lower than stated predictions since 1995 (all age bands, P < 0.002; in the 85+ group, p < 0.0001). For males, hip fracture numbers are closer to those predicted, and since 1995 are less than the weighted regressions predicted. The difference was not statistically significant.

Conclusions: Despite the absence of a nationally agreed and coordinated strategy aimed at osteoporosis prevention, it appears that the use of risk assessments, osteoporosis prevention strategies, in combination with improved retirement home and personal care interventions and treatments are likely to have contributed to this situation. The 4.6% drop in the age group most at risk of hip fracture (85+), may be a contributing factor.


J C Cullen

Despite changes in operating theatre conditions, antibiotic usage etc., infection rates following total hip arthroplasty remain remarkably constant. The management of infections may be either as one or two stage procedures, the evidence supports a two stage procedure as being the more reliable. A system of management for a two-stage procedure is discussed. This allows early weight bearing and the second stage can be carried out at any time when the results of the appropriate blood tests and aspiration deem this appropriate.


R G Gordon

Aim: To describe a novel; approach for total knee arthroplasty in the face of a chronic irreducible lateral dislocation of the patella.

Method: The patient was a 74 year old female with severe osteoarthritis of both knees and chronic irreducible lateral dislocation of the patellae. The degree of lateral dislocation was more severe on the left side. For the less severe knee, a standard medial approach was performed for the total knee arthroplasty and this was combined with an extensive lateral retinacular release and also with the use of a rotating platform on the tibial side. This approach failed to centralise the patella. On the side of the severe lateral dislocation of the patella, a lateral subvastus approach was performed. This was combined with a tibial tubercle osteotomy with medialisation and three degrees of external rotation of the femoral component.

Result: This approach centralised the patella and produced a very favorable clinical outcome with 0 to 105 degrees of flexion, much improved quadriceps strength, and excellent pain relief.

Conclusion: In the presence of osteoarthritis of the knee and a chronic irreducible later dislocation of the patella, the use of a lateral subvastus approach to the knee combined with medialisation of the tibial tubercle should be considered for the performance of a total knee arthroplasty


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G F Heynen

Aim: The purpose of this paper is to review clinically and radiographically the results of the first 100 total hip arthroplasties using the Thrust Plate femoral component both to give an early insight into its performance to date and whether this justifies the continued use of the implant.

Method: A prospective follow-up study was embarked upon in June 1998 using the Thrust Plate prosthesis in patients deemed suitable for the use of a cementless femoral component and who agreed to partake in the study using an ‘experimental implant’. Between June 1998 and March 2000, 100 hundred patients were entered into the study. There were 73 male and 27 female patients with an age range of 20 to 64 years. All patients have been followed by the author and were reviewed clinically and radiographically at regular intervals. No patients have been lost to follow-up.

Results: The average Harris Hip Score improved from 52 pre-op to 94 at last follow-up. There were no wound complications, infections, dislocations or clinically proven thrombo-embolic complications at the last follow-up appointment. There have been four revisions, all as a result of failure of fixation of the Thrust Plate. There is one patient with a radiographically loose implant, but clinically is still functioning well with a hip score of 90.

Conclusions: With a failure rate of 5% the author has some concerns about the ongoing use of the implant and is now applying more stringent selection criteria. The learning curve is significant. However, when technical considerations are taken into account, this failure rate can be explained. The overall incorporation of the implant when assessed radiologically in those cases that have not been revised has been satisfactory and longer-term follow-up is required to judge the implant’s performance over time.


T-K Ho

Aim: To investigate the efficacy and safety of a two-tunnel technique for the decompression of the carpal tunnel.

Method: The technique consists of making two small incisions, one at the distal wrist crease and a second one on the mid-palm, 2.5cm from the first incision. Through these two incisions, the proximal and distal extent of the transverse carpal ligament (TCL) was identified and two specifically designed dissector-retractors were introduced. One to isolate the deep surface of the TCL protecting the median nerve and the other to isolate the superior surface of the ligament. The TCL was then divided under direct vision.

Results: One hundred and seventy-nine cases were studied from 1996 to 1999 with a minimum follow-up of three months. The patients were assessed using the scoring system described by Levine et al 1993. The overall improvement of symptoms was 1.62 points. The average return to activities of daily living was 5.6 days and the average return to work was 4.2 weeks.

The complications included eight patients with pillar pain; one transient superficial palmar branch numbness; one transient digital branch paraesthesia; one retained suture and two superficial wound infections.

Conclusions: This new technique appears to have the potential benefits of small incision surgery such as endoscopic techniques. It uses simple and re-useable instruments, and has been shown to be safe.


G Hooper P Armour J Scott

Aim: To compare the function in two groups of high demand patients with a total knee arthroplasty (TKA) – one group using a posterior cruciate sacrificing (PCS) prosthesis and the other a posterior cruciate retaining (PCR) prosthesis of similar design.

Method: Patients were eligible for the study if they were greater than two years from surgery, less than 65 years of age and without other co-existing morbidity to significantly decrease their physical activities. Group A underwent surgery by one surgeon who routinely retained the posterior cruciate ligament whereas Group B underwent surgery by one surgeon who routinely sacrificed the PCL. A mobile bearing TKA of similar design was used in each group. All patients were selected and assessed by an independent assessor using a questionnaire developed specifically to assess higher levels of activity not usually assessed by other knee scores.

Results: Group A (28 TKA in 20 patients) were matched with Group B (25 TKA in 19 patients) for age, length of follow-up and range of motion. The gross activity score was 3.36 in Group A compared with 3.12 in Group B. The combined walking, running and stair climbing score was significantly better in Group A (7.68 compared to 6.64 in Group B). Group B perceived their TKA was closer to a normal knee (2.00 compared to 2.32) with decreased anterior knee pain.

Conclusions: Retaining the PCL in TKA results in better function without significant complications.


G H Horne M Gilbart P Devane J Fielden

Aim: To determine the incidence of periacetabular osteolysis in an uncemented, press-fit, one-piece, titanium plasma spray backed acetabular cup used in conjunction with a cemented or uncemented femoral component followed for 10 years.

Method: Patients undergoing primary total hip arthroplasty in 1989 were reviewed and new radiographs obtained. These were compared with the initial post-operative radiographs and the presence of osteolysis in the three zones of Delee and Charnley were recorded.

Results: Of 57 patients, 14 were deceased at the time of follow-up and nine were lost to follow-up. Ten patients had undergone revision for problems related to the femoral stem. There was only one possible case of periacetabular osteolysis seen in this series. In this case the lytic lesion was seen on the early post-operative radiograph and did not change in 10 years, and thus may not have been osteolysis.

Conclusions: The reported incidence of periacetabular osteolysis with two-piece cups varies between 30 and 50%. Thus, this cup has an extremely low possible osteolysis incidence. This study raises the wisdom of the continued use of two piece cups of any design.


S Hadlow

Introduction: Satisfactory ten-year survival statistics from the Swedish Arthroplasty Register, combined with new minimally-invasive surgical implantation techniques, have seen a resurgence in interest in unicompartmental knee arthroplasty (UKA).

Aim: To compare unicompartmental component positioning following minimally invasive and open implantation.

Methods: The radiographs of patients with UKAs implanted using a minimally invasive technique were retrospectively compared with a similar number of UKAs implanted using an open technique. Optimal component positioning and methods of determining this from radiographs will be presented.

Results: Twenty-three consecutive Ripicci UKAs (21 patients) were implanted using a minimally invasive technique. Radiographs were compared with an equivalent number of Marmor UKAs implanted using an open technique. All patients derived from a single surgeon’s practice. Preliminary results indicated that tibial tray positioning was satisfactory, and that variations in the femoral component positioning were due largely to the design modifications of the Ripicci UKA.


S L Hardy B Coleman

Aim: To study the complications of an extended lateral femoral osteotomy (after Paprosky) of the femur utilised for exposure in revision total hip replacement.

Method: A retrospective audit was performed of the senior author’s revision hip patients who had, at the time of surgery, an extended lateral femoral osteotomy for both deformity correction and to facilitate cement removal. No attempt was made to correlate the use of an osteotomy and operating time or overall results as no unbiased control group was available. The time to radiological union and complications of the procedure was reviewed to assess the safety of an osteotomy in one surgeon’s practice.

Results: Thirty patients with 31 osteotomies were reviewed, all with long-stem fully porous coated femoral stems. It was the senior author’s anecdotal opinion that osteotomy facilitated cement removal without canal perforation and was necessary for varus deformity correction in many patients. All osteotomies united without further procedures after an average of 22 weeks (range: 12 to 38 weeks). There was one fatigue fracture of the osteotomised fragment, one non-union of the greater trochanter and two cable failures; all without significant sequelae. There was one fracture of the medial proximal femur that required a period of four weeks of bed-rest; otherwise all patients were mobilised full weight bearing as tolerated. One patient had deep infection and a loose femoral component. Two patients had instability of the hip in the post-operative period.

Conclusion: We have shown that the osteotomy reliably united and was safe even with early full weight bearing, with few complications. Extended femoral osteotomy for deformity correction and cement removal in revision hip replacement is a safe and easy technique that reliably facilitates revision.


J G Horne J Stoddart P Devane J Fielden

Aim: To ascertain whether there is a relationship between time to surgery and mortality in hip fracture patients.

Method: The records of 120 patients admitted with hip fractures were examined. The approximate time of injury, the time of admission to hospital, the time of surgery, the number of medical co-morbidities, the A.S.A. grade, age, and length of hospital stay, were recorded. Death statistics were obtained from the Registrar of Births Deaths and Marriages. An analysis was then performed to assess the presence of correlation between time from injury to surgery, time from admission to surgery and three and six-month mortality in patients who were A.S.A. grades two or three.

Results: Preliminary analysis of the data showed a strong correlation between time from injury and the time from admission, to surgery and subsequent death. When these times exceeded 24 hours the mortality increased.

Conclusion: This study suggested that every effort should be made to operate on patients with hip fractures within 24 hours of admission to minimise mortality resulting from this injury.


P Robertson S A Jackson

Introduction: Spinal fusion for the treatment of low back pain (LBP) remains controversial. Surgeons must evaluate outcomes to justify these procedures.

Aim: To examine the subjective and objective outcomes in patients undergoing posterolateral spinal fusion for degenerative spondylosis and LBP using pedicle screw instrumentation.

Method: A prospective, independent assessment of subjective (patient assessment of outcome, procedure worth, procedure repeatability, and pain scores) was carried out. Objective measures (Low Back Outcome Score (LBOS), Prolo Functional/Economic Score, medication requirements and employment status) were also assessed prospectively.

Results: Seventy-one percent of the patients rated their outcome successful and 86% rated it worthwhile and would repeat the experience. Pain scores were improved in 78.6%. The LBOS improved from 18 to 40 (p< 0.05), yet only 28.6% of patients reached good or excellent scores. The Prolo score improved from 4.2 to 6.4 with 46% good or excellent outcomes. Pain medication requirements reduced by 75%. Twenty-three patients were insured by the ACC and 16 of these were on earnings related compensation (ERC) before surgery. At the time of the follow-up 14 were working full-time, five were working part-time with an income top up from the ACC, and four remained on ERC. Return to work rates were inversely proportional to duration of time off work prior to surgery.

Conclusions: Patient satisfaction was acceptable for this form of surgery particularly considering the magnitude of preoperative disability. The improvement in functional scores was significant yet failed to reach good or excellent levels for the majority. Despite this return to work rates were high for this class of patient justifying careful use of fusion as an intervention in selected patients with intractable LBP.


H Rawlinson P Robertson A T Hadlow

Introduction: Titanium mesh cages (TMC) for the reconstruction of thoracolumbar vertebral body defects offer an alternative to structural iliac crest autograft or allograft. The stability and safety of these cages has not been addressed.

Aim: To assess the stability and safety of titanium mesh cages in the reconstruction of thoracolumbar vertebral body defects.

Method: Independent radiological review before and after surgery, and at follow-up was performed for 27 patients having implantation of TMCs. Measurements of thoracolumbar kyphosis, cage settling, translational deformities and any evidence of implant failure were recorded.

Results: Indications for reconstruction with TMC included burst fracture (13), post-traumatic kyphosis (8), primary tumour resection (3), debridement of infection (1) and stabilisation of severe kyphotic deformity in achondroplasia with spinal stenosis (2). Kyphoses were corrected by a mean of 12 degrees (61%, range: zero degrees to 38 degrees, 0% to 85%). No cage moved. One patient had a recurrence of the kyphosis of more than five degrees (12 degrees). Five patients demonstrated some settling of the cage within adjacent vertebral bodies (1% to 8%, mean = 3.4% of height loss over length). Translational malposition of three cages occurred. One of these cases demonstrated the maximum settling and another was associated with the only case of instrumentation failure. Spinal canal intrusion did not occur.

Conclusions: We found that the use of TMCs was safe when managing vertebral body reconstruction. Significant kyphosis or translational deformity did not occur, however minor cage settling within adjacent vertebra did. The fusion rate is unknown as the mesh cage obscured graft maturation. Construct failure only occurred after pre-operative translational malalignment could not be corrected. This demanding procedure offers a reconstructive option with superior structural stability and reduced bone grafting morbidity.


P A Robertson O R Nicholson

Introduction: Age related histological and radiological changes are widespread in the lumbar spine. The correlation with symptoms is poor and there is good evidence that in later decades the incidence of back symptoms decreases, despite the relentless progression of radiological abnormalities. Much confusion exists regarding Accident Compensation Corporation (ACC) insurance entitlement following injuries in the presence of asymptomatic but existing radiological ageing changes (spondylosis) and existing but asymptomatic spondylolysis/isthmic spondylolisthesis.

Aim: To review the relevant literature and ACC Acts to clarify the ACC Act definition of injury/accident and exclusion criteria and the natural history of spondylosis/spondylolysis/spondylolisthesis, in relation to patients sustaining new lumbar spine injuries in the presence of existing but asymptomatic radiological abnormalities.

Method: The relevant literature and legislation (1992 ARCI and 1998 AI Acts) were reviewed.

Results: Regarding spondylolysis and low grade isthmic spondylolisthesis the literature is conflicting in relation to the incidence of back symptoms. The ACC Acts do not discuss existing disorders or degenerative conditions, but focus on exclusion of cover for ‘personal injury caused wholly or substantially by the ageing process’.

Conclusions: As with clinical decision making medico-legal assessment requires a meticulous history as the primary focus. It is inappropriate to apportion undue weight to radiological abnormalities that correlate poorly with symptoms.


J G Horne W Bruce P Devane H Teoh

Aim: To examine the histology of the bone-cement interface in a canine total hip model comparing two different cementing techniques.

Method: Seven adult mongrel dogs underwent staged bilateral total hip replacement. On one side the cement was packed into the femur with a finger while on the opposite side the femoral canal was washed, brushed, distally plugged and injected with cement under pressure before inserting the femoral component. Sequential fluorochrome bone labelling was performed. The dogs were sacrificed up to six months after the surgery. Undecalcified sections of the femur were examined by fluorescent microscopy.

Results: Post-operative radiographs showed complete filling of the proximal femur with cement in the pressure injected group, and a relatively thin mantle in the finger-packed group. Histology of the finger-packed group showed minimal intrusion of cement into the cancellous bed, direct apposition of cement and bone with small areas of fibrous tissue interposition. In the pressure- injected group the cement extended to the endosteal cortex, there was no bone necrosis, and the intruded bone underwent remodelling similar to that at the margins.

Conclusions: This study suggested that ‘third generation’ cementing techniques result in greater contact between bone and cement, and may explain the claim that femoral stems in humans inserted using third generation techniques are more durable than those inserted using ‘first generation’ techniques.


A Roberts

Aim: To study of the results of the first 100 Miller-Galante, unicompartmental knee replacements performed by one surgeon over the period from May 1990 to November 1996, with particular reference to the failure mechanisms.

Method: A cohort of 100 patients has been followed up prospectively on a biennial basis. They have been assessed using the Nottingham Knee Proforma of Tew & Waugh. An up-dated review was carried out of the cases for the preparation of this presentation.

Results:

Alive, knee functioning satisfactorily – 57

Dead, knee functioning satisfactorily – 21

Lost to follow up – 10

Significant symptoms, not revised – 2

Infection – 1 case not requiring revision

Revised – 9

Due for revision – 1

Of the 32 patients over the age of 74 at the time of replacement none have required revision (18 still alive).

Reasons for revision:

6 developed degeneration in another compartment

2 had unexplained pain

1 developed loosening of the tibial component (19 components found to be well fixed to bone at revision)

1 developed significant wear and is due for revision

Conclusions: This prosthesis remains a surgical option for treatment of unicompartmental knee osteoarthrosis. As judged on survival it appears to be superior to high tibial osteotome (HTO) but it appears to be inferior to total knee replacement (TKR). It is easier to revise than failed HTO or TKR. Careful patient selection is obviously required.


A Shimmin

Aim: To review the efficacy of Osteogenic Protein-1 (OP-1; BMP-7) in treating non-unions of fractures of the long bones.

Method: Twenty-eight patients who had previously had non-unions of long bone fractures treated unsuccessfully by conventional methods were entered into the study. OP-1 was used with autograft in 22 cases (OP-1 Implant is composed of 3.5mg OP-1/1g bovine bone collagen). The author reviewed all x-rays and, with the assistance of the 21 treating surgeons, assessed the clinical outcomes.

Results: There had been an average of 3.1 (median = two, range: one to 12) previous procedures and 24.3 months (median = 22 months, range: five to 84 months) since the injury. Twenty of the non-unions were diaphyseal and eight were metaphyseal. Seventeen of the 28 patients had some alteration to internal fixation. Nine patients had significant concomitant conditions. On clinical examination, 20 fractures had united, three were unable to be assessed and five had failed. The average time to union was 5.6 months (range: three to 15 months). When the x-rays were reviewed 21 had united. Two were unable to be assessed and five had failed. There were no adverse events or complications that can be attributed to the use of OP-1.

Discussion: This is a follow up of 28 difficult cases which had failed to respond to the current gold standard for treating recalcitrant non-unions. The contribution made by alteration of fixation needs to be recognised. Irrespective of this fact, there had been an average of 3.1 previous bony procedures involving grafting and changes of fixation.

Conclusion: OP-1 initiates bone formation in humans, it appears to be safe and may potentiate the action of autograft. The results for this group of recalcitrant cases suggested that it had been useful in obtaining successful outcomes for these patients who had failed to unite their fractures after traditional techniques had been used.


M Sherwood P Devane G Horne

Introduction: Ultra high molecular weight polyethylene (UHMWPE) wear debris generated at the articulating interface of total hip arthroplasties continues to be the major cause of early failure of these implants.

Aim: To validate the accuracy and reproducibility of the three-dimensional technique (3D) of in vivo measurement of UHMWPE wear using PolyWare ™ when applied to digitised radiographs. The aim was to keep the cumulative errors below the accepted annual linear wear rate of 0.15 mm.

Method: Using precision phantoms with known cup and head sizes and known deviation simulating wear, series of x-rays were taken simulating a number of variables. These variables were grouped into: patient variables (centering, exposure, motion artefact, prosthesis orientation), image acquisition variables (film and cassette type, x-ray exposure, non-circularity of the projected image, magnification, image sharpness), digitisation variables (input resolution, sharpness), and errors inherent to the PolyWare™ software analytical process.

Results: Patient factors contributed the largest errors to the process – these were highly variable. Exposure and input resolution also contributed errors to a lesser extent. No significant error introduction was found with regard to any of the other above-mentioned factors, in particular the PolyWare™ analysis.

Conclusions: The three dimensional method (PolyWare™) is accurate and highly reproducible. Apart from patient factors, which directly and indirectly introduce errors, this method is a satisfactory means of estimating the in vivo wear of UHMWPE.


J V Schaumkel C J H Brown

Introduction: The literature gives ample evidence to discourage sub-optimal reductions of perilunate fracture/dislocations. These, inevitably, lead to poor long-term results.

Aim: To evaluate critically the results of open reduction, fracture stabilisation and ligament repair in a cohort of greater and lesser arc perilunate dislocations treated by one surgeon at a single institution.

Method: Ten patients who underwent reconstructive surgery for perilunate wrist injuries were reviewed at least 18 months following their surgery. The pathology included three pure perilunate dislocations (PD), three trans-scaphoid perilunate fracture-dislocations (TSPD), one TSPD with a lunate fracture, one trans-scaphoid PD, and two trans radial styloid PDs. Each patient was assessed at a single clinic visit. A clinical rating based on the modified Mayo Wrist Scoring Chart was applied noting pain, satisfaction, range of motion and grip strength. Radiographic analysis was also performed.

Results: Nine out of 10 patients had returned to their preoperative employment. Overall, 70% of the patients were satisfied with their wrist function and 50% had mild pain only on vigorous activities. There were five ‘fair’ results and five ‘poor’ results. The range of scores was 30 to 75 (average = 55). Average arc of motion was 78 degrees. Three patients showed evidence of wrist arthritis. One patient had a pin site infection. Two patients still had mild nerve symptoms – one ulnar and one median nerve. One patient needed a proximal row carpectomy.

Conclusions: Greater and lesser arc injuries of the wrist are associated with high energy trauma. These injuries result in significantly reduced wrist function, however they are treated. Open reduction and ligament repair with fracture stabilisation lead to a high degree of patient satisfaction and pain relief. In this study the clinical wrist score did not support this.


D I Simunic H Katoozian N D Broom P A Robertson

Aim: To investigate, quantify and model the influence of three biomechanical factors on the severity of mechanically induced nuclear disruption in healthy bovine, caudal, intervertebral discs.

Method: A preliminary study was conducted with a fully divided annular wall to investigate the cohesive nature of the isolated nucleus and its tendency to form clefts when loaded. A second more clinically relevant model using whole bovine discs was then conducted to investigate whether significant clefts could be induced in healthy discs by controlling flexion, hydration and rate of compressive loading.. A finite element model of the bovine caudal disc was constructed to predict the complex stress conditions that exist within the disc.

Results: We found that high degrees of flexion and hydration were significant risk factors in nuclear disruption (P < 0.005), while the rate of loading showed no significant effect (P = 0.37). The intact disc study also showed that flexion and hydration are significant risk factors (P < 0.002). In contrast with the preliminary study, the rate of loading was also shown to be mildly significant (P < 0.1). The finite element model predicted relatively high concentrations of stress and strain energy density within the nucleus. This is consistent with the experimental observations of cleft formation.

Conclusions: While it is well established that dehydration of the nucleus is a symptom of degeneration this study suggested that the healthy nucleus, when maximally hydrated, is more susceptible to nuclear disruption when loaded. This supports the hypothesis that the histologically abnormal and degenerate nuclear material removed at surgery, may well have attained this state as a result of biomechanical and biochemical changes occurring in the disc following rather than preceding a prolapse. This study further defined the rôle of trauma in disc injury and prolapse of the normal disc.


R Story

Aim: To study the results of a percutaneous suture technique for the management of acute ruptures of the Achilles’ tendon.

Method: Ten patients with acute Achilles’ tendon rupture were entered into the study. We utilised a percutaneous surgical technique and functional post-operative regime described in the current literature.

Results: All were recreational sports people with an average age of 42.9 years. At an average follow-up of six months there were no re-ruptures, no wound complications, no sural nerve injuries, and no episodes of deep vein thrombosis. No patient had any discomfort during normal walking. In comparison to the uninjured side, there was still a mild reduction in calf circumference but minimal deficits in endurance, strength or range of motion.

Conclusions: The technique was easily performed and overall the treatment appeared to have very high patient acceptance and low morbidity. The well described benefits of early mobilisation were evident.


P Sutton J Livesey K Speed T Bagga

Aim: To estimate the prevalence of iron deficiency in patients undergoing primary total hip (THR) or knee (TKR) replacement surgery and to test the clinical effectiveness of routinely prescribing iron supplements to all anæmic patients after THR and TKR.

Method: This was designed as a randomised, doubleblind, placebo-controlled trial. Serum ferritin was measured in 230 consecutive patients admitted for primary THR or TKR. Seventy-two patients were entered into the randomised arm of the trial, 35 were randomised to the treatment group, and 37 to the placebo group. Patients meeting the inclusion criteria after primary THR or TKR were randomised to receive six week’s treatment with either ferrous sulphate (200mg) or an identical gelatin placebo, three times daily. The serum ferritin level and the change in hæmoglobin were measured between five and seven days post-operatively and each patient attended for an out-patient review at six weeks after the surgery.

Results: The study achieved a statistical power of 80%. Serum ferritin was abnormally low in 15 of 230 patients (6.5%). Hæmoglobin in the group of patients receiving ferrous sulphate increased by a mean of 0.31 g/dL more than the group receiving the placebo (95% confidence interval −0.17 −0.79 g/dL). This difference was not statistically significant (p=0.18).

Conclusions: We found that iron deficiency was uncommon in patients who had undergone primary THR or TKR. The routine prescription of oral iron salts to all anæmic patients after these procedures had no clinical benefit.


Taylor C Rorobeck R Bourne K Inman

Introduction: While Total Knee Arthroplasty (TKA) has produced excellent results, there is concern about its durability in younger patients. It was our hypothesis that the results in younger patients would be inferior to those of older patients.

Aim: To review the results of TKA in patients aged 50 years or younger, with at least 5 years of follow-up.

Method: All TKA patients aged 50 years or less were identified. There were 71 arthroplasties in 52 patients. Two patients had died and two were unable to be contacted, leaving 67 arthroplasties in 48 patients. The surviving knees were assessed using the Knee Society Score.

Results: The mean age at arthroplasty was 44 years (range: 22 to 50 years) and the mean follow-up was 9.6 years (range: five to 20 years). Twelve of the TKAs (17.9%) had been revised. There was no statistically significant difference in rate of revision due to pre-operative diagnosis, the type of prostheses or the type or number of previous surgical procedures. The 10-year survival with TKA revision as the endpoint was 78% and 15 year was 71%. The mean knee score was 84% and function score 69%.

Conclusion: While TKA can produce excellent results, we found a high rate of revision among patients aged 50 years or younger. We recommend that TKA be used with caution in this group as our results were inferior to those in older patients.


M Toes R J Kyd

Introduction: Criticism has often been made regarding the functional outcome of amputations at the level of the knee joint with regard to the prostheses that are fitted.

Aim: To evaluate the quality of life of a group of amputees with regard to their artificial limb following through-knee or Gritti-Stokes amputation.

Method: The Waikato Limb Fitting Centre’s records were used to identify all through knee amputees fitted with a prosthesis since 1972. Patients were sent a previously validated Prosthesis Evaluation Questionnaire (PEQ). This consisted of 21 questions graded on a linear analogue scale (0 to100), regarding prosthesis function, mobility, psychosocial experience as well as general wellbeing.

Results: Forty-five amputees were identified as having been fitted with a prosthesis, however 13 were known to be deceased. Of the 24 postal returns (86% response), 19 were able to be included in the analysis. A PEQ score of > 50 was recorded in 68% of patients for prosthesis fit, comfort and appearance, and in 50% of patients for prosthetic noise. Although ability to walk was impaired to some degree in 58%, especially on slippery surfaces in 84%. More than 80% were able to transfer from a car independently. Less than 16% avoided specific activities (PEQ< 50) because of concern regarding a strangers’ reactions, and 90% recorded a positive response by family to their prosthesis (PEQ> 50). Seventy percent recorded a PEQ> 50 for their overall quality of life.

Conclusions: The majority of patients fitted with a through knee prosthesis had good functional and psychosocial outcomes. When a below knee amputation is not possible, amputation at the level of the knee joint offers a satisfactory quality of life.


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R Tregonning M Dagger

Aim: To assess patients’ progress early after ACL reconstruction and to identity factors favouring outpatient surgery.

Method: Eighty-three patients who had received a bone-patellar tendon-bone graft of whom 32 patients (38.5%) were treated as day-cases answered a telephone questionnaire. Information was gained on pain levels (scored from one to seven), medication received, complications and re-admission rates.

Results: On the night of discharge 28% of day-case patients suffered pain greater than level 4 but all stated that oral non-steroidal anti-inflammatory drugs and non-opiate analgesics were sufficient to control their pain. Over the first 2 weeks after operation outpatients experienced statistically higher pain levels than inpatients (P = 0.03). Most patients in the study experienced their peak pain levels on the first and second days after the surgery rather than on the night of the surgery. Eighty-one percent of outpatients had their surgery started before 9:30am compared with 29% of inpatients. Drowsiness (n = 18), nausea (n = 11), unsuitable home conditions (n = 9) and pain (n = 7) were the most common reasons for patients choosing in-patient treatment. Six patients (five in-patients and one out-patient) were treated for superficial infections including the one patient who required re-admission (for intravenous anti-biotics). There were no other significant complications.

Conclusion: Some patients may be treated safely as out-patients using oral pain relief with no significantly greater re-admission or complication rates than inpatients. An important factor in day-case treatment in this study was that having surgery early in the day allowed more time in hospital for recovery . Drowsiness and nausea after operation, and social factors at home were more important factors than pain.


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J-C Theis

Aim: To analyse the Dunedin residual orthopaedic waiting list based on a simple patient questionnaire and a quality of life assessment using EuroQol and SF12.

Method: All patients on the residual waiting list were sent a postal questionnaire enquiring about their need for surgery and their quality of life. Based on their answers, patients were entered into three action groups: 1. back to GP care 2. clinical review 3. booked for surgery. Those patients requiring a clinical review were seen in a special clinic and reassessed in relation to their need for surgery.

Results: Two hundred and sixty-one patients were surveyed. One hundred and fifty-eight had complete data available for analysis and of the remaining 103 patients, 88 were taken off the waiting list for various reasons. Fifteen did not reply. The average time on the waiting list was 19 months (range: < six months to eight years). Sixty percent of the patients felt that their condition had changed and 99% felt that they still required the surgery. The results of the EuroQol and DF12 questionnaire revealed three groups of patients. 1. normal (9 patients). 2. slight impairment (115 patients) 3. moderate impairment (34 patients). Most of these patients had stable conditions except the sub group with deteriorating osteoarthritis of the hip/knee. Group 1 patients were all referred back to their GP. Thirty percent of group 2 patients were referred back to their GP, 60% were booked for a review and 10% were booked for surgery. None of Group 3 patients were referred back to their GP. Seventy percent required a clinical review and 30% were booked for surgery. Our clinical review is continuing but it is anticipated that those who still require surgery and score above the financial threshold will probably be less than one third of the cases.

Conclusion: This paper describes a decision making rationale in relation to assessment of continuing need for surgery in patients on the residual orthopaedic waiting list. Eighty percent of patients had stable conditions, which were not interfering significantly with their activities of daily living and could be managed safely by the GP. Further work is required to identify those patients who are at risk of deteriorating and to work out a practical and cost effective monitoring programme.


M Wong Wan Nar

Introduction: Bone tendon junction (BTJ) healing has been found to be both histologically and biomechanically sub-optimal. Tendons heal to bone by fibrous scar formation without restoration of the normal transitional fibrocartilage zone. We postulated that chondrocytes might stimulate the healing process and restoration of a transitional fibrocartilage zone.

Aim: To study chondrocyte pellets cultured in vitro which were then used as interposition material in an animal BTJ healing model.

Method: Eighteen weeks old, New Zealand rabbits, each with a partial patellectomy followed by repair was used as the animal model for BTJ healing. Chondrocyte pellets cultured from cartilaginous ribs of a six weeks old rabbit were used as interposition material. No interposition material was used in control group. Samples were harvested at two, four, six, eight, 12 and 16 weeks for histological studies.

Results: Twenty-two samples were harvested. Each group had two and three samples for early and late time-points respectively. The samples taken at two weeks showed persistence of the chondrocyte pellets. Structural continuity was established at four weeks. Histological sections showed gradual cell migration. New bone formation was seen at the original BTJ at the 12th and 16th weeks, with disappearance of the chondrocyte pellet, and formation of a new BTJ. No BTJ formation was seen in the control group.

Conclusion: Our study indicated that cultured chondrocyte pellets had a stimulatory effect on BTJ healing. The mechanism of action requires further elucidation. This finding has a potential clinical application in improving BTJ healing.


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B Tietjens M Casey

Introduction: Patients with neglected patellar tendon ruptures present with weakness, instability, extensor lag and sometimes pain. Reports in the literature describe autograft and allograft reconstruction and sometimes quadricepsplasty. Post-operative splintage with a cast or brace is often recommended.

Aim: To describe a simple effective method of surgical treatment for neglected ruptures of the patellar tendon.

Method: Patients who were included all had neglected patellar tendon ruptures that were initially misdiagnosed or had failed other treatment. Through a midline incision scar tissue was excised and two or three strong cerclage wires were used to approximate the patella and ruptured tendon. The wires were passed from the quadriceps tendon to the absorbable sutures in the tibia. No quadricepsplasty was necessary. Following the surgery immediate mobilisation was initiated without the use of a brace. The wires were removed six months following surgery.

Results: Four patients were treated at an average of 29 months following the initial injury. The average follow- up was 26 months (range: 13 to 42 months). The average range of motion was 110 degrees. All patients had improved quadriceps strength, no extensor lag and had returned to work.

Conclusion: We have described a simple effective method of treatment without the use of autograft or allograft. The strong cerclage wires allowed immediate mobilisation.


S.R.S. Bibby J.C.T. Fairbank J.P.G. Urban

Introduction: Although the cell density of the intervertebral disc is low, cells perform a vital role, being responsible for maintaining and remodelling the extracellular matrix. In animal models of scoliosis, cell viability of epiphyseal chondrocytes was found to be adversely affected. Here we examine cell density and viability of surgical disc specimens.

Method: A total of 41 discs were removed from 13 consenting patients (3M, 9F, 5–40 yrs) during corrective surgery for scoliosis. Control samples were obtained from 3 non-scoliotic discs. These were further dissected to compare the outer annulus of the disc from the more concave and more convex sides of the quadrant removed at surgery. Cell density was measured using a modified Hoechst’s method. Cell viability was determined microscopically in sections using intracellular fluorescent probes.

Results: Cell density was found to be lowest in apical discs, independent of absolute disc level (p< 0.01, Student’s t test). A significantly lower percentage of live cells was found in samples taken from the convex side of the scoliotic curve (p< 0.01, Student’s t test). No significant differences in cell viability were found in either side of control discs.

Discussion: Cell viability was seen to be lower on the convex side of the scoliotic curve, suggesting that it is more difficult for cells to survive under the conditions on the convexity compared with the concavity. This may be due to differences in the mechanical conditions or the diffusion distances across the disc. Cell numbers were lowest in the apical disc, where stresses are thought to be maximal. Fewer viable cells may decrease production of matrix macromolecules, and thus compromise matrix integrity. A delicate balance exists between production and breakdown of matrix macromolecules, and any factor that interrupts this equilibrium state has the potential to affect the structure and function of the intervertebral disc.


M.A. Adams

Mechanical function and failure of intervertebral discs. In a healthy disc, the nucleus pulposus acts like a pressurised fluid which is restrained by tensile stress within the annulus. With increasing age, the nucleus becomes more fibrous, and biochemical changes cause the whole disc to become less elastic, and more yellow in colour. Mechanically, the hydrostatic nucleus shrinks with age, and concentrations of compressive stress appear in the posterior annulus. Experiments on cadaveric spines have shown that healthy discs can prolapse when loaded severely or repetitively in bending and compression, and that internal disruption of the disc probably follows damage to the vertebral endplates. However, mechanical loading is not necessarily harmful to living discs: on the contrary, moderate repetitive loading may lead to disc hypertrophy rather than injury.

Disc degeneration. Degeneration represents some mechanical or biological “insult” superimposed on normal ageing. A defining feature of “degeneration” should be structural failure of the annulus or endplate, because all degenerated discs exhibit structural failure whereas many old discs do not. Degeneration creates high stress concentrations within the annulus. Paradoxically, severe degeneration can lead to gross disc narrowing and reduced stresses in the annulus, presumably because it is “stress shielded” by the apophyseal joints. Animal experiments show that disc degeneration always follows mechanical disruption. In some cases, it may possibly precede it.

Disc degeneration and back pain. Pain-provocation studies have shown that severe and chronic back pain often originates in the posterior annulus fibrosus, and can be elicited by relatively moderate mechanical pressure. Anatomical studies indicate that the outer annulus is supplied with complex and free nerve endings from the mixed sinuvertebral nerve. MRI and discographic studies show that back pain is closely correlated with structural features of disc degeneration such as radial fissures and prolapse, although age-related changes in composition are clinically irrelevant. The stress-shielding of severely degenerated discs (see above) suggests that discogenic pain may be most closely associated with intermediate stages of degeneration. The localised stress concentrations found in degenerated cadaveric discs have been directly linked to low back pain in living people.

Medico-legal implications. The widely-held belief that a disc will not prolapse unless it is degenerated is no longer compatible with the scientific evidence. Severe loading, which in life usually arises from vigorous muscle contractions, can injure normal discs. On the contrary, it seems likely that severely degenerated discs are too fibrous to prolapse, and that many of the cell-mediated changes associated with disc prolapse occur after prolapse, rather than before. However, genetic inheritance is important in disc degeneration and prolapse, suggesting that some discs are more vulnerable than others to mechanical loading. The nature of this vulnerability is largely unknown, but is likely to involve genetic weaknesses in composition, and previous fatigue damage. It would be desirable to distinguish between these last two factors, but this is likely to prove difficult in practice.


P Pollintine P Dolan M A Adams

Introduction: Pathological changes in the elderly spine include intervertebral disc degeneration, apophyseal joint arthritis and osteoporotic fracture of the vertebral body. Such changes are likely to be inter-related through alterations in the sharing of load between the apophyseal joints and the intervertebral disc unit. We describe an accurate, non-destructive method for calculating the load sharing based on measurements of the distribution of stress within the intervertebral disc.

Materials and Methods: Twenty three motion segments, consisting of two vertebrae and the intervening disc and ligaments, were dissected from 17 human lumbar spines. A preliminary “creep” test was used to reduce disc height and water content by an amount equivalent to the diurnal variation seen in vivo. Then, a constant load was applied to each motion segment, using a computer-controlled hydraulic materials testing machine, for a period of 20s while a pressure-transducer, sensitive to spatial variations in compressive stress, was pulled through the disc along its mid-sagittal diameter. Profiles of vertically-acting compressive stress were obtained in each disc positioned in 2° of extension (appropriate for an erect standing posture). The total compressive force acting on the intervertebral disc was calculated by modelling the disc using approximately 20 elliptical rings of known cross-sectional area. The force acting on each ring was given by the product of area and the average compressive stress acting on it, which was obtained from the appropriate region of the stress profile. The total force acting through the disc was obtained by summing up the force contribution from each ring. The force acting on the apophyseal joints was calculated from the difference between applied (known) load and the calculated load acting on the disc. A correction factor was obtained separately for each disc to account for deviations in the cross-section from the elliptical, and variations in the sensitivity of the transducer in disc tissues of different ages. The correction factor was obtained by comparing the applied force with the force calculated from a stress profile measured before creep loading while the disc was in a neutral position, when the load passing through the apophyseal joints is negligible.

Results: The proportion of load passing through the apophyseal joints increased significantly with age (r2=0.48, p< 0.01), from 7% at age 27 yrs to 42% at 82yrs. Similarly, the proportion of load passing through the apophyseal joints increased with degree of disc degeneration (r2=0.5, p< 0.05 Pearson, Chi-square) from 8% in “grade 1” discs to 40% in “grade 4” discs.

Discussion: The compressive load passing through the apophyseal joints is higher than that predicted by previous, inaccurate, methods, or by experiments which failed to reduce the height and water content of the intervertebral disc. Increased load-bearing may be a contributing factor in apophyseal joint degeneration. Also, in lordotic postures, “stress shielding” by the apophyseal joints could contribute to bone loss in the vertebral body, leaving it vulnerable to osteoporotic fracture when the spine is loaded in flexion.


A.V. Nowicky A.H. McGregor .P Cariga N.J. Davey

Purpose & Background: The spinal muscles are increasingly being linked to spinal complaints. However, little is known regarding the corticospinal control of these muscles. Corticospinal pathways can be activated using transcranial magnetic stimulation (TMS) applied over the motor cortex. This study uses TMS to assess corticospinal input to the paraspinal muscles in the thoracic region.

Methods: Ten individuals (mean [± SD] age 33 ± 10 yrs; mean height 166 ± 10 cm; two left-handed; five male, five female) with no history of neurological disorder were recruited into this study and written informed consent obtained. Subjects lay prone in a relaxed position with the head unsupported. Surface electromyographic (EMG) recording electrodes were positioned bilaterally over the paraspinal muscles adjacent to thoracic spinal processes T1 and T2. TMS was applied using a MagStim 200 stimulator connected to a double cone coil with its cross-over positioned over the vertex so that the maximum induced current flowed in a posterior to anterior direction. The stimulus intensity was adjusted in steps of 5% of the maximum stimulator output (MSO), and ten stimuli were delivered at each strength. Threshold for a motor evoked potential (MEP) in each muscle was determined as the minimum intensity that would evoke MEPs to 50% of stimulus presentations. Latency of MEPs was determined by measuring the time between the stimulus and the start of the first deflection in the MEP. The procedure was repeated for the other pairs of thoracic segments between T3 and T12.

Results: In all subjects, it was possible to evoke MEPs in relaxed paraspinal muscles at all thoracic levels. Mean (±SEM) threshold for evoking a MEP on the left side increased from 47 ± 2.5 %MSO at level T1 to 55 ± 2.5 %MSO at T12 (Pearson correlation, P< 0.05) but remained more constant (P> 0.05) on the right side (T1, 55 ± 3.9 %MSO; T12, 57 ± 3.3 %MSO). Over all levels tested, mean threshold for MEPs was 3.9 ± 0.6 %MSO higher on the right than the left side (Student’s paired t-test, P< 0.05). Mean latency of MEPs on the left increased from 11.9 ± 0.7 ms at level T1 to 15.5 ± 0.6 ms at T12 and on the right from 12.3 ± 0.5 ms at level T1 to 16 ± 0.7 ms at T12 (Pearson correlation, P< 0.05). Throughout the thoracic region, latency of MEPs was 0.8 ± 0.2 ms longer on the right than the left side (Student’s paired t-test, P< 0.05).

Conclusion: The latency of MEPs increased as recordings were made from muscles innervated more caudally. Threshold for MEPs varied between subjects and at different spinal levels but our results indicate that it was higher at more caudal levels, perhaps suggesting weaker corticospinal innervation. Threshold was lower and latency shorter for muscles on the left side raising the interesting possibility that paraspinal muscles have some asymmetry in their corticospinal innervation. This study has provided us with baseline electrophysiological data allowing us to investigate the voluntary control pathways to muscles stabilising the thoracic spinal cord following trauma or disease.


S.N. Kumar J.R. Meakin R.C. Mulholland

Introduction: Despite a very high fusion rate (90%) achievable by present techniques, the clinical success rate for curing back pain is in the range of 50%. We hypothesise that disc degeneration gives rise to abnormal stress patterns in the bone. Although the cages integrate fully, load is taken by the cage producing abnormal stress patterns in the vertebrae. Unless a near normal stress pattern in the vertebrae is established, pain may continue.

Method: A simple finite element model of a disc and its adjacent vertebral bodies was developed using ANSYSS software. The dimensions of the model were based on the human lumbar disc. The normal disc was modelled as a fluid with a bulk modulus of 1720 MPa. The degenerate disc was modelled as having the same material properties for the nucleus and the annulus. Fusion of the disc was modelled by replacing the nucleus with commonly used cages. In all the models, the material properties of the cancellous bone (E=100 MPa; v=0.3) and the cortical bone (E=12000 MPa; v=0.3) remained the same. The model was loaded axially with 1.5 kN.

Results: The vertical and horizontal stress patterns around a loaded degenerate disc showed areas of increased loading in the endplate and the cancellous bone confirming the authors’ previous work using load transducers. The introduction of the cages in the model changed the stress distribution – they caused an increase in the compressive stresses in the cancellous bone, and a high concentration of tensile and compressive stresses at the point of contact with the cages.

Conclusion: This study has shown that fusion cages alter the pattern of stress distribution in the adjacent vertebral bodies similar to that of a degenerate disc. It supports the concept that abnormal weight transfer is a more significant cause of back pain as compared to abnormal mobility.


A.K.D. Goswami S. Rao

Introduction: Wide laminectomy has been the accepted treatment of choice for stenosis in the lumbar spine. Recently, bilateral laminotomy has been proposed as an alternative decompressive technique for spinal canal stenosis. There have been no biomechanical studies to determine the in vitro difference in stability between these techniques.

Objective: To determine the in vitro difference in stability in a functional spinal unit (FSU) following bilateral laminotomy, and compare it to the instability resulting from laminectomy.

Methods: Six fresh human cadaver lumbar spines were injured sequentially at the L4-5 level: bilateral laminotomy and laminectomy. The normal and injured spines were subjected to flexion, extension, lateral bending and torsional moments. The three-dimensional motion behaviour of each spine before and after the two injuries was recorded using a magnetic motion sensor. The data from all five spines was pooled for statistical analysis.

Results: With flexion and extension loading, bilateral laminotomy induced significantly less sagittal angulation and translation in the FSU than did laminectomy. Significant increases in coronal translation occurred with laminectomy in spines subjected to lateral bending loads. There were no significant differences between the two techniques in coronal plane angulation with lateral bending loads and torsional loads.

Discussion: Adequate exposure of the lateral recesses requires limited medial facetectomy with both laminotomy and laminectomy. With laminotomy, the lamina and posterior ligamentous structures are preserved. This is aimed at decreasing the potential late development of spinal instability associated with laminectomy. The increase in motion seen with laminectomy in sagittal angulation / translation, and coronal translation in this in vitro model, may represent clinical instability, and may be responsible for continued symptomatology in these patients. Preservation of the lamina, spinous processes, and the posterior ligamentous structures significantly enhances the biomechanical stability of the FSU.


K. Olmarker

Since the discovery of the relationship between the occurrence of sciatica and the epidural presence of herniated disc material in 1934, the predominating theory regarding the pathophysiology of sciatica has been based on the assumption that the disc material mechanically affects the adjacent nervous structures which subsequently leads to sciatica. The treatment of choice thus became surgical removal of the herniated disc material. However, a number of observations have indicated that this “mechanical theory” may not fully explain the radiating pain of sciatica. For instance, mechanical deformation of peripheral nerves is seldom painful, and invasive intra spinal tumours most often induce neurological dysfunction and not pain.

Under the assumption that the nucleus pulposus, which is the part that is herniating in the case of disc herniation, would comprise some component that independently from the mechanical deformation would induce nerve injury, an experiment was performed in 1993 in a newly developed model in the pig. This study showed, for the first time, that autologous nucleus pulposus per se induced structural injury and a marked reduction in nerve conduction velocity, and this opened a new research field. Since then, a large number of experimental studies have been performed by independent research groups mainly in Sweden, USA and Japan, on the nucleus pulposus effects. It has thereby been seen that nucleus pulposus may induce structural and functional changes in nerve roots in the absence of mechanical deformation. Nucleus pulposus is also “inflammatogenic” and also initiates pain behaviour changes by sensitising the nerve tissue.

Based on these data the proinflammatory cytokine TNF (tumour necrosis factor) has been defined as one essential substance for inducing both the nerve root sensitisation and the nerve injury. Preliminary clinical trials have been started in Gothenburg for evaluating if selective inhibition of TNF may prove useful in establishing an alternative pharmacological treatment modality for sciatica.


J.M. Sahlman M. Hyttinen R. Inkinen H.J. Helminen K.H. Puustjärvi

Introduction: The evidence of genetic background as an important causative factor in disc degeneration and osteoporosis is increasing. Defects in the COL2A1 gene coding for type II collagen are known to lead to disturbed chondrogenesis and ossification. Retardation of growth, abnormal shape of vertebral bodies and intervertebral discs and occult spina bifida have been described in young mice with the defect. How the gene defect is manifested later in life has not been described.

Purpose of the study: The purpose of this study was to describe, at the microscopic level, the structure of intervertebral discs of transgenic Del1 mice carrying a deletion mutation in the Col2a1 gene, and the effect of the gene defect on the structural properties of bone. In addition, we wanted to see how the gene defect manifests in disc tissue and skeletal bone later in life and if there were differences between sexes.

Materials and methods: The study material consisted of transgenic male (n=27) and female (n=21) mice and their age-matched littermate controls (n=22 and 21, respectively). The transgenic mice were offspring of the transgenic founder mouse Del1 harbouring six copies of a mouse type II collagen transgene with a 150-bp deletion. The mice were divided into two age groups, the younger group being 3 to 13 months and the older 15 to 21 months of age. The two major macromolecules of the intervertebral discs, proteoglycans (PGs) and collagen, were studied. The PG concentration of the intervertebral discs’ nucleus pulposus, annulus fibrosus, and the vertebral bodies and end plates was measured from Safranin-O-stained sections using digital densitometry. Collagen orientation of these structures was evaluated using quantitative polarised light microscopy. Bone mineral density (BMD) was measured with dual energy x ray absorptiometry (DXA), and the breaking force of the femoral bone with three point bending test only for nine 14-month-old females (four control mice and five with gene defect) and fourteen 14-month-old male mice (six control mice and eight with gene defect).

Results: In the young mice, there were no changes in the measured parameters in the intervertebral discs due to the gene defect. However, Safranin-O density and thus PG concentration of the vertebral trabecular bone was 47 % lower in the young transgenic female mice than in the controls (p< 0.001). Ageing had a significant effect on the measured parameters. The Safranin-O density in the nucleus pulposus of the old transgenic male mice was 35 % higher than in the age-matched controls (p< 0.05). In the females, however, Safranin-O density in the nucleus pulposus was 53 % (p< 0.01) and in the vertebral bone 68 % (p< 0.01) lower in the transgenic mice than in the controls. The Safranin-O density in the annulus fibrosus of the transgenic female mice was not changed as compared to the controls. The collagen orientation in the nucleus pulposus of old transgenic male mice was 27 % higher than in the age-matched controls (p< 0.05). In the old females there was no difference in the collagen orientation of the nucleus pulposus between the transgenic mice and controls but in the annulus fibrosus the orientation was 41 % (p< 0.01) and in the vertebral bone 70 % (p< 0.05) lower in the transgenic mice than in the controls. There was no difference in the BMD and the breaking force of the femurs of 14-month-old male mice as compared with the age-matched controls. However, in the old transgenic female mice, the femoral BMD was 14 % (p=0.05) and the breaking force 27 % (p=0.09) lower than in the controls.

Conclusions: The transgene of the Col2a1 gene caused a decrease in the nucleus pulposus PG concentration and in the annulus fibrosus collagen orientation in the old female mice. These features can compromise the structural and load-bearing properties of the discs and thus predispose to disc degeneration. Interestingly enough, the male mice seemed to benefit from the genetic defect in this respect. In addition, in the old transgenic female mice, the PG concentration and the collagen orientation of the vertebral trabecular bone were decreased which contributed to the loss of BMD and breaking force of bone seen in these mice. The fact, that these differences in the bone were not seen in the male mice suggests that this animal model could possibly be used in studies of postmenopausal osteoporosis.


A.T. Bucknill K. Coward C. Plumpton S. Tate C. Bountra R. Birch S.P.F. Hughes P. Anand

Study Design: To examine the innervation of the lumbar spine from patients with lower back pain, and spinal nerve roots from patients with traumatic brachial plexus injuries.

Objectives: To demonstrate the presence of nerve fibres in lumbar spine structures and spinal nerve roots, and determine whether they express the sensory neuronespecific sodium channels SNS/PN3 and NaN/SNS2.

Summary of background data: The anatomical and molecular basis of low back pain and sciatica is poorly understood. Previous studies have demonstrated sensory nerves in facet joint capsule and prolapsed intervertebral disc, but not in ligamentum flavum. The voltagegated sodium channels SNS/PN3 and NaN/SNS2 are expressed by sensory neurones which mediate pain, but their presence in the lumbar spine is unknown.

Methods: Tissue samples (ligamentum flavum n=32; facet joint capsule n=20; intervertebral disc n=15; spinal roots n=8) were immunostained with specific antibodies to protein gene product (PGP) 9.5, a pan-neuronal marker, SNS/PN3 and NaN/SNS2.

Results: PGP 9.5-immunoreactive nerve fibres were detected in 72% of ligamentum flavum and 70% of facet joint capsule but only 20% of intervertebral disc specimens. SNS/PN3-and NaN/SNS2-positive fibres were detected in 28% and 3% of ligamentum flavum and 25% and 15% of facet joint capsule specimens respectively. Numerous SNS/PN3 and NaN/SNS2-positive fibres were found in the acutely injured spinal roots, and some were still present in dorsal roots in the chronic state.

Conclusions: SNS/PN3 and NaN/SNS2-immunoreactivity is present in a subset of nerve fibres in lumbar spine structures, including ligamentum flavum and injured spinal roots. This is the first time that sensory nerve fibres have been demonstrated in the ligamentum flavum, and this raises the possibility that, contrary to the conclusions of previous studies, this unique ligament may be capable of nociception. Selective SNS/PN3 and NaN/ SNS2 blocking agents may provide new effective therapy for back pain and sciatica, with fewer side effects. Other novel ion channels are being studied in these tissues.


A.J. Freemont J.A. Hoyland A. Rajpura R.J. Byers C. Bartley M. Jeziorska M. Knight R. Ross J. O’Brien J. Sutcliffe C. LeMaitre A. Goswami

Purpose and Background: There is increasing evidence that events within the diseased intervertebral disc (IVD) are mediated by locally synthesised cytokines. A prominent histological, imaging and surgical feature of IVD disease is degradation of the cartilaginous discal matrix. Whilst the mechanism by which this is mediated is unknown, in other situations where connective tissues are degraded degradation is the result of production of matrix-degrading enzymes by local connective tissue cells stimulated by cytokines, particularly the beta isoform of interleukin-1 (IL-1β). Included amongst these disorders is osteoarthritis (OA) of diarthrodial joints. OA has many similarities to the discal “degeneration” seen in mechanical back pain syndromes. In the current study, we have used a combination of in-situ techniques to establish if IL-1β is responsible for stimulating matrix degradation in the IVD.

Methods: Using a combination of radioactive in-situ hybridisation (ISH) and competitive in situ zymography (ISZ) we have studied expression of IL-1β and IL-1R – its type 1 receptor (ISH) and matrix degradation (ISZ) in five diseased lumbar IVD taken at spinal fusion surgery and 10 cadaveric IVD (five normal and five diseased). The nucleus pulposus (NP) was separated from the annulus fibrosus and diced into 0.5cm cubes. Half the cubes (typically three) were fixed in formalin and processed into paraffin wax for ISH, and half were used for ISZ. For ISH, 5 μm sections of paraffin-embedded tissue were reacted with cDNA probes radiolabelled with 35S to 580 and 530 base segments of the IL-1β and IL-1R molecules. Hybridisation was disclosed using autoradiography. For ISZ, 50 μm vibratome sections were placed into wells on microscope slides precoated with gelatin. Sections were incubated for 10 days, half in culture medium and half in medium supplemented with human recombinant IL-1 receptor antagonist (IL-1Ra – an inhibitor of IL-1). Sections were photographed at daily intervals to detect evidence of gel degradation.

Results: Chondrocytes within patient and cadaveric diseased but not normal discs expressed mRNA for both IL-1β and IL-1R. By ISZ, the same cells degraded gelatin. Degradation was inhibited by recombinant IL-1Ra.

Conclusion: This study shows that chondrocytes of diseased discs express IL-1 and its receptor. The same cells produced matrix-degrading enzymes by a mechanism that can be inhibited by the IL-1 inhibitor IL-1Ra. IL-1 is a potential therapeutic target for the management of IV disc disease.


S. Roberts J. Melrose .S. Smith .C. Little .P. Ghosh J. Menage E. Evans S. Eisenstein

Background: The healthy, adult human disc is innervated but the nerves are restricted to the outer few millimetres of the annulus fibrosus. In degenerate discs with associated back pain, however, the nerves are more numerous and penetrate further in.

We have used a sheep model of intervertebral disc degeneration to monitor the presence and organisation of nerves in the disc as degeneration progresses. This model has been used to study morphological and bio-chemical changes of the disc as it degenerates, in addition to associated alterations in end-plate vascularity and vertebral bone remodelling. One aspect of this model which has not been studied to date is how the innervation of the disc may change with the onset of degeneration. This is the object of the present study.

Materials and Methods: Four-year old, skeletally mature Merino wether sheep (n=64) were divided randomly into lesion and control groups. A surgical incision was created in the anterolateral annulus in the L1–L2 and L3–L4 discs of the lesion group. The control group received the same retroperitoneal surgical approach but the annulus was not incised. Intact lumbar discs encompassed by adjacent vertebral bodies were removed at 3,6,12 and 26 months post operation. Specimens were fixed, decalcified and paraffin embedded before sectioning (7μ thick, vertical sagittal sections) and stained immunohistochemically with the neuronal marker, PGP9.5, together with standard histological stains.

Results: The incised region of the outer annulus underwent collagenous re-organisation, consistent with an active repair process as early as three months post-operatively. However, the inner annular lesion had a poor repair response and propagated with time, sometimes through to the nucleus. In contrast, remodelling of the outer annular lamellae occurred across the cut region. For example, in one sample at two years post injury there were up to six lamellae “bridging the gap”. Nerves were present in all samples but in the sham animals they were very few and confined to the very outer annulus or longitudinal ligament. In the operated animals, nerves were more extensive, occurring in the matrix adjacent to the fissure where there was often blood vessel ingrowth. The maximum number of nerves was seen at 12 months post-operatively, before diminishing in number at 24 months post-op. This paralleled the presence and extent of blood vessel penetration in this experimental model.

Conclusions: We have used an animal model to follow longitudinally the penetration of nerves into the ovine intervertebral disc in association with disc degeneration. Whilst we obviously cannot assess back pain in these animals, and not all nerves are nociceptive, nerves nevertheless are a pre-requisite for the perception of pain. Hence the greater numbers, size and penetration of nerves into degenerate discs demonstrated here has important implications not only for the aetiopathogenesis of degenerative disc disease but also for the treatment of its associated symptoms. Further characterisation of this innervation, i.e. whether autonomic or sensory, may provide an indication as to its nociceptive potential.


A.J. Freemont J.A. Hoyland R.J. Byers C. Bartley P. Baird M. Jeziorska M. Knight R. Ross J. O’Brien J. Sutcliffe C. LeMaitre A. Goswami

Purpose and Background: We have previously reported our investigations of nerve ingrowth into intervertebral discs (IVD) from patients with mechanical low back pain. We have shown that in discs that are painful on discography (pain level discs) nerves actively grow into the deep annulus fibrosus and nucleus pulposus. Nerve ingrowth accompanies blood vessel ingrowth and advances into the nucleus pulposus from the end plate. The morphology and neurochemistry of these nerves indicate them to be nociceptive.

The growth of non-myelinated pain fibres in other settings is regulated by the cytokine Nerve Growth Factor (NGF). In this study, we have investigated the production and distribution of NGF, or more particularly its active isoform – NGF-β, and its receptors, in diseased intervertebral discs in order to establish whether this cytokine might be responsible for the observed nerve ingrowth in this situation.

Methods: Tissue sections of 21 pain level, 15 non-pain level diseased and 12 normal intervertebral discs, taken at the time of spinal surgery, and from cadavers, were probed by radioactive in situ hybridisation (ISH) for expression of NGF-β, and by immunohistochemistry (IHC) for its high and low affinity receptors (trk-A and p75 respectively). In addition, either serial sections were stained with cell specific markers (CD31 – endothelial cell, PGP9.5 – neurones, GAP43 – actively growing nerves) or sections were doubled stained (two antibodies or both ISH and IHC).

Results: We have demonstrated that NGF-β is synthesised by the endothelial cells of blood vessels growing into the IVD from the end plate. The high affinity receptor is expressed by those small nerve fibres that accompany the vessels and in their offshoots in pain level discs that are growing from perivascular nerves into the disc. In addition to their expressing the nerve specific molecule PGP9.5, the trk-A positive cells also express the nerve growth associated protein GAP43.

Conclusion: The data indicate that nerve ingrowth into IVD is regulated by NGF-β. We have localised this production to the endothelial cells of ingrowing blood vessels. NGF-β is a potential therapeutic target for the management of back pain.


C.L. Le Maitre A. Rajpura W. Staley R.J. Byers M. Knight R. Ross A.J. Freemont J.A. Hoyland

Background: Low back pain (LBP) is a major cause of disability. However, current treatments are often empirical and few are directed at the underlying disorder, altered discal cell metabolism, which precipitates the problem. The use of gene therapy to manipulate discal metabolism to treat LBP is an interesting possibility. The Intervertebral disc (IVD) is a therapeutic target in LBP, and one approach to gene therapy would be to isolate IVD chondrocytes (IVDC) and transfer genes ex vivo into these cells. Subsequent reinjection of these genetically altered cells into the lumbar IVD, would permit the expression of the transgene in vivo, generating the therapeutic protein within the IVD.

Methods: To test the viability of this approach, we isolated human IVDC from patients undergoing surgery, grew them ex vivo and transfected them with the marker gene LacZ, using an adenovirus vector and the CMV promoter. Expression of the gene was then measured using X-gal staining for the gene product _-galactosidase. Post infection, some cells were treated with forskolin for 24 hours to assess whether expression of the transgene could be manipulated.

Results: IVDC infected with adenovirus/CMV-LacZ showed maximal LacZ expression 2 days post infection, with almost 50% of cells displaying X-gal positivity. Cells maintained a low level of expression for the remaining 12 days of the study. Control cultures showed no LacZ expression. Cells treated with forskolin after infection with adenovirus/CMV-LacZ exhibited 4 times the level of _-galactosidase activity seen in unstimulated cultures.

Conclusion: This study shows that human IVDC can be transfected with a foreign gene using the adenovirus vector. The gene transduction of a therapeutic gene into IVDC could provide a long lasting effect. In addition, the use of inducible promoters could allow for the autoregulation of gene expression.


L.C. Roberts P.S. Little E.G. Cantrell J.A. Chapman J.C. Langridge R. Pickering

Purpose of study: General practitioners (GPs) are often asked to recruit patients for research studies. However, a mismatch exists between the numbers of potential patients (estimated from pilot work and reported literature) and actual patients recruited. The purpose of this study was to establish GPs’ perceptions of the reasons for this mismatch.

Background: An OCPS survey reported that 16% of adults consulted their GP with back pain per year. Thus a GP, serving an average population of ~1900 patients, might expect to see around 300 patients with back pain every year, although this estimate includes all causes of back pain. Nevertheless, this represents a significant proportion of a GP’s workload.

In the ‘Back Home’ study, which was a randomised controlled trial of a patient information leaflet for people with acute low back pain (previously presented to this Society), recruitment of patients was problematic. A total of 28/97 GPs in the New Forest area agreed to recruit patients for the study, but in 22 weeks, only 8 patients emerged. Despite extending the catchment area of the study, and having 51 participating GPs, in 2_ years, only 64 patients were entered from 19 of these GPs. Therefore, we decided to investigate GPs’ perceptions of the reasons for such poor recruitment.

Methods: The challenge for this research was identifying how best to gain information from GPs about poor recruitment, recognising that requests for information about poor response rates may yield a limited response! The least intrusive means of accessing information was considered to be a brief questionnaire containing an open question that asked GPs to list any reasons that they thought may have contributed to the slow recruitment of patients into the study. GPs were then asked to rate 12 factors, identified by GPs who had withdrawn from the study. The factors were rated using a Likert scale from 1–4 (1=‘not at all’, 2=‘mildy’, 3=‘moderately’ and 4=‘very significantly’).

Results: Of the initial 51 participating GPs, 11 did not complete the study: 1 left the practice; 2 retired; 7 withdrew (3 of these due to pressure of work); and 1 was asked to leave the study by the research team due to issues of non-conformity with the study protocol.

Forty GPs were sent a questionnaire and 24 responded (60%). They gave 47 unprompted reasons for poor recruitment of patients – the most popular being: pressure of work (n=12); difficulty remembering (n=10); feeling ‘over-researched’ (n=4); and few patients fitted the inclusion criteria (n=4). When GPs rated the 12 listed factors, the maximum score for each item = 96 (24x4). According to the GPs, the top 4 factors were: pressure of work (score=60); forgetting to include suitable patients (52); time-consuming process of entering patients (39); GPs are ‘over-researched’ (31).

Conclusion: Research studies that necessitate GPs accessing patients from their routine surgeries are likely to experience difficulties with recruitment. It is vital that researchers and funding agencies address this issue if research within primary care is to survive.


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A.L. Faulkner W.B. Johnson S.M. Eisenstein X. Zhao B. White V. Franklin F. Lyndon B.J. Tighe S. Roberts

Introduction: Intervertebral disc degeneration occurs with ageing and is often associated with back pain. During such degeneration, gross morphological differences between the central nucleus pulposus (NP) and outer annulus fibrosus (AF) are lost and the disc loses hydration and height due to decreased proteoglycan content. The cartilage endplate may also become calcified and this blocks the passage of nutrients into the disc, causing cell death and further degeneration. A potential therapy of degeneration is “re-inflation” of the disc with the use of hydrogels seeded with autologous disc cells. In this study, we have assessed the ability of a variety of hydrogels to support intervertebral disc cell growth.

Method: Intervertebral disc cells were isolated enzymatically from bovine tails and cultured as a monolayer in 10% foetal calf serum in DMEM containing antibiotics and ascorbic acid. This stimulates the cells to proliferate and thereby produces increased cell numbers. The cells were then seeded onto various hydrogels including hyaluronic acid (HA), 2-hydroxyethyl methacrylate (HEMA), N’N’ dimethyl methacrylate (NNDMA) and polyacryloyl morpholine (AMO) before harvesting at set time points of 1, 3, 6 and 9 days for hyaluronic acid and 1, 7, 14, 21, and 28 days for the other hydrogels. Cell number, morphology, viability and adherence to or migration into the hydrogels were assessed. Cell proliferation was also determined by immunostaining for the Ki67 antigen.

Results: Disc cells became incorporated in the HA gel, adopted a spherical morphology and remained viable for up to nine days. However, after a few days, a large proportion of the cells began to migrate through the gel to form a monolayer on the bottom of the tissue culture well. These monolayered cells became fibroblastic and proliferated. NP cells appeared to proliferate to a greater extent than AF cells both in monolayer and in suspension. Ki67 antigen immunostaining confirmed cell proliferation. On the non-porous HEMA, NNDMA and AMO, both cell types adhered and adopted a fibroblast-like morphology. Cell adhesion was greatest to the HEMA. NNDMA and AMO had lower levels of cell adherence. Both cell types became incorporated into the porous materials and adopted a rounded morphology. Cell incorporation appeared to be greatest into porous HEMA.

Conclusion: These initial studies show that intervertebral disc cells will adhere to or migrate into a variety of hydrogels and remain viable. The morphology and proliferative capacity of cells derived from both the AF and NP were responsive to the structure of the hydrogel with which they were cultured. Thus, cells were able to become fibroblastic or chondrocytic. Further analyses will reveal whether matrix synthesis by disc cells is similarly responsive to the hydrogel format. The results of these experiments suggest that the hydrogels tested have potential as support matrices in intervertebral disc repair to provide relief from discogenic low-back pain.


T. Pincus A.K. Burton S. Vogel A.P. Field

Study design: A systematic review of prospective cohort studies in low back pain.

Objectives: To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain.

Summary of background: The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions. However, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed.

Methods: A systematic literature search was followed by the application of three sets of criteria to each study: methodological quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care, pain clinics and workplace-based studies.

Results: Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from depressive mood and, to a lesser extent, somatisation emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophising as a coping strategy.

Conclusions: Both depressive mood and somatisation are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors, there is a need to clarify their role in back-related disability through rigorous prospective studies.


M.A. Pinnington C.F. Dowrick E. Thornton

Purpose: To develop a qualitative health diary for patients with low back pain to record their LBP experience over a seven day period; to classify patients at two and six weeks by quantitative function and anxiety questionnaires; and to thematically analyse diary data for predictive validity on outcome. Background: The diary has been traditionally used as a tangible record of everyday process. In the medical setting, diaries have been used to help patients document symptoms and feelings, but usually in a peripheral role as a quantitative adjunct rather than a main study instrument. As a qualitative tool, the health diary exhibits many of the advantages of an in-depth interview in that it yields a personal and subjective account of illness far richer than can be gained by quantitative techniques. Health diaries may allow patients to reveal aspects of their individual illness experience, especially emotional distress, which may otherwise remain hidden. The importance of being able to predict the outcome of LBP in the early stages of an episode is well documented, given its prevalence and drain on healthcare resources. The condition lends itself well therefore to a diary study.

Method: All adults consulting their GP for a new episode of low back pain in three general practices were given a pack containing: a seven-day unstructured, free-text health diary, Roland & Morris Disability Questionnaire (RMDQ), Hospital Anxiety & Depression Questionnaire (HAD) and a General Information questionnaire. Patients were asked to complete the three questionnaires, invited to record their LBP experience over the ensuing 7 days in the diary, and return by post to the researcher. Patients were asked to complete a second and third RMDQ and HAD at two and six weeks following GP consultation. Data collected at the three different time points enabled patients to be categorised at six weeks into one of three groups; fully-recovered, partly-recovered, or not-recovered. Diary entries are being analysed thematically using well-established methods of qualitative thematic analysis to search for predictive validity of diary data.

Results: Preliminary coding of diary entries has so far identified the emergence of 11 primary themes; physical/pain, employment, reflection, emotional, functional, coping, temporality, expectations, social, role/ duties, medication. A number of secondary themes have also been noted from this data. To date, 35 completed diaries have been returned (89% completion rate). We aim to collect 100 data sets before an in-depth thematic and predictive validity analysis can be completed.

Conclusions: No conclusions can be made at this stage, but the emergence of such a rich set of primary themes from the unstructured diaries is encouraging. We hope that in-depth analysis of diary entries will identify themes common to those patients who have not recovered from their LBP at 6 weeks, and who may be at greatest risk of chronicity. The health diary may prove to be an easily-administered, cost-effective and valid predictor of outcome in the very early stages of an episode of LBP.


A.K.D. Goswami M.T.N. Knight A.J. Freemont

Introduction: Recent cadaveric studies have identified neovascularisation and neoneuralisation as probable mechanisms in the causation of discogenic pain. Calcium pyrophosphate deposits have been observed in discs in several studies. Their significance in the causation of discogenic pain is unclear. Direct correlation between the pain site and histological features can be verified by aware state endoscopic visualisation.

Aim and Objectives: The study aims to examine and correlate the presence of neovascularisation, crystalline pyrophosphate deposits in the disc, and discogenic pain by spinal probing and discography under endoscopic visualisation.

Material and Methods: Tissue removed from intervertebral discs of 224 patients during surgery was examined directly, and polarised microscopy was used to identify the presence of calcium pyrophosphate and neovascularisation. Their presence was correlated to diagnostic provocative findings of spinal probing and discography and intradiscal distortion during aware state endoscopy.

Results: Calcium Pyrophosphate: Twenty out of 224 patients (9%) demonstrated calcium pyrophosphate in the discs. Fourteen had pain reproduced on probing or discography. Thirteen out of 20 patients (65%) had either an annular collection or leak at the index level. 6 had an extradiscal cause of pain. One hundred percent of the patients with annular collections or leaks had pain on spinal probing or discography. Sixteen patients with pyrophosphate deposits did not have neovascularisation.

Neovascularisation: Thirty seven out of 224 patients (16.5%) showed neovascularisation in the disc. Four discs had crystalline pyrophosphate deposits. Thirty three out of 37 (90%) had pain on probing and/or discography. Out of four patients who had no pain on probing or discography, two had demonstrated tears during previous discographic procedures which were treated with laser annealing. These patients had disc bulges and compressive radiculopathy.

Conclusion: The presence of pyrophosphate in the disc without a tear or leak does not directly render them tender to provocation. The presence of pyrophosphate is not correlated to neovascularisation. Annular tears or leaks are not directly correlated to the presence of pyrophosphates. There is a high correlation between pain provocation and neovascularisation.


H.P. Taylor S.W. Richards N. Khan A.H. McGregor J. Alaghband-Zadeh S.P.F. Hughes

Aim of Study: The aim of the study was to investigate the effect of muscle retractors on intramuscular pressure in the posterior spinal muscles during posterior spinal surgery.

Methods: Twenty patients undergoing posterior spinal surgery were recruited into this study and recordings of intramuscular pressure during surgery were performed using a Stryker® compartment pressure monitoring system, prior to insertion of retractors, 5, 30 and 60 minutes into surgery and on removal of retractors. Prior to and following use of the retractors, muscle biopsies were taken from the erector spinae muscle for analysis.

Results: A significant increase in intramuscular pressure (p< 0.001) was observed during surgery, with pressure rising from 7.1±4.1 mmHg pre-operatively to 26.4±16.0 mmHg 30 minutes into the operation. On removal of retractors, this pressure returned to or near to the original value. Analysis of muscle biopsies using calcium-activated ATPase birefringence revealed a reduction in muscle function following prolonged use of self-retaining retractors.

Discussion: This study demonstrates a substantial rise in pressure in the erector spinae muscle during posterior spinal surgery. Following retraction, marked changes were noted in the function of the muscles. This could be an important factor in the generation of operative scar tissue and post-operative dysfunction of the spinal muscles, and therefore, may be a cause of persistent back pain frequently observed in post-operative patients. Currently, this work is being extended to investigate the relationship between loss of muscle function and duration of retraction, and to study the long term implications of loss of muscle function with respect to surgical outcome and chronic back pain.


D.A. Jones S.R.S. Bibby J.P.G. Urban

Introduction: The intervertebral disc is a significant contributor to back pain, and is thus a tissue that is often examined postmortem. Tissue preservation during storage is of importance both experimentally, for research and teaching purposes, and clinically, for possible use in transplantation. The biomechanical function of the disc after storage has been investigated. However, to our knowledge the biological and metabolic consequences of storage have not been studied. Here we have investigated the effects of storage in the intervertebral disc on glucose, lactate, and cell viability.

Method: A total of 53 discs from 14 bovine tails were obtained within 24 hours of slaughter. Discs were either removed immediately and wrapped in clingfilm or kept in situ, surrounded by muscle. Tissue was stored at 4_C, and samples were taken at 2 hours to 9 days. Disc tissue was analysed for lactate, glucose, and cell viability. Muscle was analysed for lactate. Statistical analysis of data was performed using Student’s t test.

Results: Lactate concentrations in discs stored in tails increased with time of storage, being significantly higher even after 24 hours (p< 0.01). In contrast, lactate levels in isolated discs remained constant. Glucose levels were undetectable in discs, irrespective of storage. Muscle lactate was always significantly higher than disc (p< 0.01). The percentage of live cells fell significantly with storage in situ (p< 0.01).

Discussion: The increase in lactate observed in discs remaining in situ appears to arise from lactate diffusing in from surrounding muscle, as no increase was noted in isolated discs. As would be expected, this high concentration of lactate and low glucose appears to affect cell viability adversely, possibly as a consequence of lowered pH. This change in metabolite concentration and hence cell viability is important to note when considering human postmortem tissue, as it may affect the biological function of the disc.


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M.M. Murray M. Holmes C.G. Greenough

Introduction: After a year in post, the waiting time to see the spinal surgeon in a large hospital had risen from 0–62 weeks. A nurse-led assessment clinic was inaugurated to triage patients, cut waiting times and accelerate treatment.

Methods: Referrals were taken directly from general practitioners, and patients triaged using proforma history and examination systems into five categories: mechanical back pain, nerve root entrapment, potentially serious pathology, unknown diagnosis and suitable manipulative therapy.

Audit based on direct patient entry with a light pen interface was integrated into the process. Seventy percent of patients were referred complaining of mechanical back pain, and an Educational Rehabilitation Programme was provided within the clinic.

Results: Following the inauguration of the spinal assessment clinic, waiting times in the consultant clinic fell from 62 weeks to 26 weeks; waiting times in the assessment clinic were between four and six weeks. Emergencies may be seen the same week.

The time from GP referral to surgery for routine nerve root compression fell from 92 weeks to 24 weeks (of which 12 weeks was waiting time for scanning).

Detailed audit of scanning requests in 127 patients demonstrated confirmation of clinical diagnosis in 80 percent of whom half went on to surgery. Of the 20 percent with negative scans, a fifth were subsequently found to have trochanteric bursitis.

An audit of 94 patients revealed reduced analgesic consumption, increased return to work and reduced consultation rates at one year. Five patients were referred to other clinics for further consultation. The satisfaction of the clinic amongst general practitioners was 94 percent. Referrals to the clinic have risen from 403 in 1993 to 1511 in 1999, necessitating the appointment of three further nurse practitioners. Prospective review of 104 patients revealed 95 percent satisfaction rate of the clinic and 67 percent satisfaction rate with rehabilitation. Average low back outcome score increased from 29 to 35 (p< 0.001).

A training programme for nurse practitioners has been established and, to date, ten of the clinics have been inaugurated nation-wide using this model.

Conclusions: A nurse-led clinic for triage of back pain patients has had major impact on waiting times, has produced measurable improvements in patients’ outcome and is associated with high satisfaction ratings in both patients and general practitioners.


A.H. McGregor P. Wragg W.M.W. Gedryoc

Purpose & Background: Posteroanterior mobilisation (PA) is a manual physiotherapy technique that is commonly used as an examination tool and a form of conservative treatment for spinal complaints. The efficacy of this technique is controversial and this may be in part due to a limited knowledge of the mechanical and physiological mechanisms underlying this technique. This study aims to evaluate the ability of interventional MRI to image the mechanics of mobilisation in terms of spinal movement and soft tissue deformation during a PA mobilisation.

Methods: 5 normal subjects (4 female, 1 male, mean age 29.6 ± 3.9 years) with no current or history of neck pain requiring intervention were recruited into this study, and written informed consent obtained. Subjects were scanned using a General Electric Signa SP10 Interventional MRI scanner (iMR). This is an open MRI scanner consisting of 2 connected but opposing ring “doughnut” magnets. The gap between these magnets is 56 cm generating a uniform field of 0.5Tesla. Subjects were scanned in the prone position with their necks in either a neutral or flexed position. In each position, subjects underwent a PA mobilisation to the 2nd and 6th cervical vertebrae. Sagittal and axial images of the spine were obtained prior to, during and following the mobilisation. Measurements of intervertebral rotation and translation were obtained from the sagittal images, and measures of soft tissue compression with respect to the spinous process were obtained from the axial images. Paired analysis of variance was used to investigate the impact of the mobilisations in each position.

Results: Clear images of vertebral position could be obtained if the mobilisation was sustained once the appropriate force had been delivered. From these images, it is possible to measure vertebral angulation, translation and soft tissue compression. From these measures, it became clear that intersegmental vertebral angulation and translation did not alter as a result of the force applied regardless of cervical position. However, marked and significant changes were seen in terms of soft tissue compression and in some instances overall angulation of the cervical spine.

Conclusion: This pilot work suggests that it is feasible to use iMR technology to study the mechanics of spinal mobilisation. Preliminary findings suggest that there is little or no displacement of the vertebral bodies as a result of an AP mobilisation, although there is considerable soft tissue compression.