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Volume 86-B, Issue SUPP_III March 2004

G. Biette R. Nizard P. Bizot L. Sedel

From 1979 to 2002, 131 total hip replacement were performed consecutively in patients less than 30 years of age (13 to 30,7 mean 24;2) in 75 patients (44 in males and 31 in females. Seventy six in 57 patients could have more than 2 years follow-up and will presented hereby. Regarding the type of prosthesis, 59 stem were cemented and 16 cementless. Five different socket were implanted: 6 screw-in metal back: 8 bulky cemented, 23 bulky cementless, 13 metalback press fit with titanium mesh and 26 HA covered.

Underlying diseases were Avascular necrosis in 46, 8 inflammatory disease, 6 after infected articulation, epiphysiolysis in 4 and acetabular fracture in 3.

48 were done primarily, 28 were a revision procedure and 10 had some past history of infection.

Mean follow up was 7,84 years (range 1,13-22,9). One patient (two hips deceased at 1,1 year. One hips was lost to follow-up. 73 had complete clinical and radiological evaluation.

Nine hips were revised from 2,97-18,64 years after the index procedure (mean 8,53). In 7 only the socket was revised, in two both components. Two of these were infected (secondary infection in one). Of the remaining: 45 had no pain, 18 slight uncommon pain, 10 were classified 5 and 8 had some limp.

Radiological evaluation: 56 had no lucent lines nor subsidence, 4 had some radiolucent line none progressive and 1 had a complete lucent line: and is considered as impending failure. In no case osteosysis was documented.

With the exception of socket loosening due to non optimal design of the initial system (bulky alumina cemented or cementless) the overall results are in favor of theis material in young and active patients.

Ofer Levy

Thermal capsular shrinkage presents the prospect of reducing redundant capsule, and therefore may be a suitable method of treating capsular-type instability. A prospective study of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. The mean Rowe score improved from 33.1 to 74.1 points at followup of up to 48 months. Twenty of the fifty-eight shoulders had recurrence instability. Recurrent instability was related to the type of instability: 76.9% for voluntary instability, 30.3% for involuntary instability and none of 12 shoulders for instability/impingement pain. Recurrence was related as well to previous instability surgery (70%). The outcome was not related to the direction of instability, type of radiofrequency probe used, age of patient or ligamentous laxity. Twenty-two (57.9%) of thirty-eight patients returned to their pre-instability level of sporting activity. By using repeated RF treatments for the failed thermal shrinkage cases the failure rate was reduced from (20/58) 34.5% to (13/58) 22.4% and cumulative changes were seen on electron microscopy. These results are comparable to some of the results for open inferior capsular shift for patients with multidirectional instability with substantial less morbidity. The application of the minimal effective energy is controlled according to the tissue response without any charring or burning effect to the tissue. No scar was seen in repeated arthroscopies, or in electron microscopy studies. Thermal shrinkage does not negatively affect a later open stabilisation, but rather may provide better conditions for secure open surgery. We have found significant improvement in proprioception following thermal shrinkage treatment. We believe that by re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and that there is a greater dynamic muscular contribution to shoulder stability. When using the correct technique for the right indications, Radiofrequency thermal shrinkage is a viable alternative to open inferior capsular shift in patients with capsular type of instability.

M. Demirhan

In the last decade many changes happened in arthroscopic shoulder instability treratment. As all arthroscopic procedures cause less pain and early rehabilitation. Stabilisation techniques began with very demanding transglenoid suture techniques. After innovation and developments of suture anchors, arthroscopic stabilisation becam safe and reliable operation. Bankart repair with anchors and arthroscopic knot is a well-accepted method in anterior instability. The stronger the repair is, patient can return daily and sports activities earlier and safer. Treatment of capsular laxity is still controversial. Shrinkage with radio-frequency was presented in last years for tretment of laxity in unidirectional and multidirectional instabilities. Despite its easy application, treatment principles are not clear and the long-term results are unknown yet. New capsular plication with arthroscopic suture might be alternative and more reliable method but it needs great experience in arthroscopic shoulder surgery. Some lesions such as SLAP may diagnosed and treted arthroscopically easily. Further more arthroscopic labrum repair after first traumatic dislocation is getting widely accepted in younger patients because of high recurrence rate. An overview of thermal shrinkage, multidirectional instability, associated lesions and treatment of first traumatic dislocation will be discussed in this symposium.

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Michel Onimus

Modern oncologic treatments have resulted in an increase of the duration of life of patients with cancer; however the onset of a vertebral metastasis results in a decrease of the quality of life. The aim of surgery is to increase or restore the quality, but not the duration of life. The decision for surgery depends mainly on the functional impairment, and more incidentally on the primitive tumor, the metastatic diffusion, and the general status of the patient. Decision for operative technique depends on the anatomical patterns of the metastasis, considered with reference to the three columns classification of Denis.

The anterior column initial involvement results in instability with mechanical pain, increased by standing and coughing, decreased by supine position, similar to pain experienced with traumatic instability. The middle column involvement results in foraminal extension with radicular pain. The initial posterior column involvement is unfrequent and diagnosis is usually late as standard X-Rays are negative.

At a later stage, invasion of both anterior and middle column result in vertebral collapse with severe mechanical pain and cord compression. This is best treated by anterior approach, allowing a better tumoral resection and a better vertebral reconstruction using bone cement than by posterior approach. Middle and posterior column invasion result in canal invasion and cord compression, without vertebral collapse. Posterior column involvement requires a posterior approach, giving an easy access from C1 down to S1. In selected cases, a combined approach should be recommended because allowing a more complete resection, with less local recurrence rate.

Lastly diffuse lesions or multisegmental instability may require a posterior approach and an extensive stabilisation.

G. Zanoli

Among the many ‘revolutions’ in contemporary medicine and science, the idea behind Evidence-Based Medicine (EBM) is possibly the most remarkable one. People should receive only those interventions that work (i.e. those that are most likely to do more good than harm) and physicians should try to adopt those behaviours that are most consistent with the best available scientific information.

The burden of musculoskeletal conditions is growing in most developed and third world countries. The importance of the problems we study has been recognized by the United Nations by declaring the decade 2000–2010 the ‘Bone and Joint Decade’.

Despite the many great achievements in the last century, clinical research in the field of muscoloskeletal disorders has not always been flawless: this has been already pointed out by many methodologists in the past decades, even before the outburst of systematic reviews. However, and not surprisingly, the mission statement of the Decade could have been taken from an EBM textbook: This symposium will present different aspects of EBM applied to musculoskeletal disorders. Hopefully it will serve as a source of knowledge but, even more, as a source of inspiration to continuous research in the field and, most of all, as an invitation to join the rapidly growing EBM movement.

After a first international meeting in Ferrara in April 2001 ( e_Musk1) we are setting up an e_Musk Coordinating Centre at the University of Teesside in Middles-brough, UK. It is becoming a forum for like minded people to network and interact, whose long-term goal are patient-centeredness and bringing down the professional barriers. We are organizing a 2nd e_Musk meeting for June 18th–19th 2003.

Karoly Fekete Peter Cserhati J. Manninger T. Laczko

Aims and Methods: Hungary, 60% (3500 cases annually) of all fresh intracapsular femoral neck fractures are traditionally treated by osteosynthesis. Since 1990 nailing has been replaced: from 01.11.1990 to 31.08.2002 the authors performed 3092 procedures using percutaneous double cannulated screw fixation combined with a special tension band plate. The authors based the development of their In technique on results from research done by Woodhouse and Rösing. They proved by animal experiment that total femoral head ischaemia will already lead to irreversible necroses after just 6 hours. Results: The rate of late femoral head collapse at 3–6 years follow-up assessment is significantly lower if osteosynthesis is performed within 6 hours after the accident, i.e. in the phase of reversible ischaemia (p< 0,001). Followup assessment after 3–4 years was possible within the frame of international collaborations (SAHFE) with the same initial results for two groups treated by cannulated screw in 1993–94 and 1997–98 respectively. Emergency treatment also has a favourable somatomental effect on elderly patients. Conclusions: In a work-up of the 3 year follow-up results of 486 femoral neck fracture patients operated over a 2 year period, it was found that reposition and osteosynthesis done within 6 hours significantly decreased the ratio of the development of late femoral head necrosis and non-union. In addition to surgery performed within a short period of time, we consider that the exact anatomical repositioning and the correct placing of the osteosynthesis materials, that is, a good surgical technique is very important.

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M.D. Imhoff

The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. The preferred techniques are easy implantable suture anchors made of titanium (Fastak). Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. From 4/96 to 10/00 we performed a prospective analysis of 242 shoulders, who underwent arthroscopic shoulder stabilization with FASTak-(n = 159) Panalok-(n = 26) and Sure-tac suture anchors (n = 57) in our clinic. The patients were re-examined with a follow-up of at least 12 months. The best results were in the FASTak-group. After 2 years 4.7% suffered a redislocation. 28.6% (2 patients) needed a revision, but none of the shoulders required a second open stabilization. The reason for redislocation or sub-luxation were traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. The Rowe score was 83.1 ± 20.9 points. There was a high satisfaction of the patients with the operative result and 60.9% could go back to their pre-op sports level. At 24-months follow-up this study demonstrates good results of arthroscopic shoulder stabilisation with FASTak suture anchors. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected.

P. Jalovaara J. Partanen T. Heikkinen H. Wingstrand K.-G. Thorngren

Aims: To find out if osteosynthesis (OS) or hemiarthroplasty (HA) is better in terms of functional outcome. Patients and methods: In 1989–1996, all displaced cervical hip fractures were prospectively, using the same forms, registered at the University Hospitals of Oulu in Finland and Lund in Sweden. Cross-matchings was performed for age, sex, preoperative residence, and ambulatory capacity. Results: The first study comprised 357 pairs (OS with two hook pins and cementless Austin-Moore HA): OS was associated with a better functional outcome and lower mortality, but a higher re-operation rate than hemiarthroplasty. The second study had 446 pairs (OS two hook pins and cemntless HA): OS was associated with better function and lower mortality than HA, especially in younger patients, and it is recommended as the primary treatment for cervical non-pathological hip fractures in patients younger than 80 years and with good ambulatory capacity, whereas the oldest patients can also be safely treated by HA. The third study comprised 82 pairs (OS with three screws and cementless HA): Functional recovery is slightly better after OS with three screws than after uncemented HA, although no significant differences were seen in a sample of this size. On the other hand, OS is associated with a higher re-operation rate. Conclusion: OS seemed somewhat better in terms of functional outcome.

J. Tidermark

Fracture healing complications and reoperations after internal fixation (IF) of displaced femoral neck fractures are common in spite of an improved surgical technique. The complication rate in prospective studies with a two-year follow-up is 35–50%. The long-term outcome after a unipolar hip arthroplasty seems to be suboptimal for active patients and the outcome after a bipolar arthroplasty is insufficiently reported.

In a prospective study the fracture healing complications rate at two years in patients with displaced femoral neck fractures treated with IF was 36% compared with 7% in patients with undisplaced fractures. The quality of life (EQ-5D) of patients with uneventfully healed fractures at two years was lower in patients with primary displaced fractures than in patients with primary undisplaced fractures.

In a prospective randomised trial, patients with displaced femoral neck fractures were randomised to IF or total hip replacement (THR). IF resulted in more complications than THR, 36% versus 4%, and necessitated more reoperations, 42% versus 4%. Hip function and quality of life (EQ-5D) were generally better in the THR group.

The future treatment algorithms for elderly patients with displaced femoral neck fractures would benefit from being patient-related rather than diagnosisrelated. For an elderly, relatively healthy, lucid patient with a displaced femoral neck fracture THR yielded a better outcome than IF. The indications for unipolar- and bipolar arthroplasties need to be further evaluated in randomised trials with sufficient follow-up time.

S1091 PAINFUL FOOT Pages 207 - 208
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L.B. Engesæter

Foot pain in children is common. The reason for the pain can usually be determined from history and physical examination, but often a radiogram is necessary. The causes for painful foot can be divided into following categories:

• Trauma (Fractures, sprains, soft tissue injuries, puncture wounds, overuse syndromes)

• Infections (Osteomyelitis, septic arthritis, ingrown toe-nail)

• Arthritis (Degenerative, juvenile rheumatoid)

• Osteochondroses (Köhler, Freiberg, Sever) • Deformities (Bunions, tarsal coalitions)

• Tumors

• Others The specific treatment depends on the diagnosis and occasionally on the age of the child.

R. Gradinger R. Burgkart L. Gerdesmeyer W. Mittelmeier

We have to deal with an increasing number of patients who are suffering from a femoral neck fracture. In Ger-many in 1996 135.000 patients with this kind of fracture were treated. These fractures are usually found in old people and have a high complication rate:

Osteonecrosis of the femoral head: 12–43% (Kyle 1994)

Pseudarthrosis: 16–28% (Rogmark 2002)

The indications for a total hip replacement are:

– age > 65years

– presence of osteoporosis (also under 65)

– daily activity possible (otherwise hemialloarthroplasty)

– comorbidity such as osteoarthritis

We have to consider several aspects:

The mortality rate is lower if we use a hip replacement (THR ~6%, osteosynthesis ~10%) The complication rate is lower if we use hip replacement (THR ~2%, osteosynthesis ~5%) In 30% of cases we have to change from osteosynthesis to a total hip replacement due to secondary complications of osteosynthesis in mobile patients If we look at this data, we must conclude that total hip replacement is the goldstandard in the treatment of femoral neck fractures (with Garden III and IV) in the population older than 65 years. Hemialloarthroplasty is only indicated for patients who are more or less immobilized.

Dietrich Schlenzka

Stereotactic principles used primarily for brain surgery have been developed further and introduced into spine surgery at the beginning of the 1990’s. The system solutions available consist of three components: the surgical object (vertebra), the virtual object (CT-image data of the vertebra), and the navigatorallowing the surgeon to localise the position of the instrument inside the surgical object in real-time. Optoelectronic systems using infrared light emitting diodes and magnetic field based navigators are in use.

Lumbar pedicle screw insertion was the first clinical application for this technique. Screws can be positioned safely following a preplanned optimal trajectory or according to the anatomic situation utilising the real-time module intraoperatively.

The effectiveness of this new technique has been shown in prospective studies (Schwarzenbach et al 1997, Laine et al 1997, 1999).

In a a prospective randomised clinical trial one-hundred consecutive patients were randomly allocated for either conventional (Group 1) or computer assisted (Group 2) pedicle screw insertion. From the computer assisted group nine patients were dropped out. There was no statistical difference between the groups. CT-based optoelectronic navigation was used for screw insertion in Group 2. The screw position in the pedicle was assessed postoperatively by an independent observer with CT.

The pedicle perforation rate was 13.4% (37/277 screws) in the conventional group and 4.6% (10/219 screws) in the computer assisted group (P=0.006). The majority of perforations was less than 4 mm. A pedicle perforation of 4 to 6 mm was found in 1.4% (4/277) of the screws in Group 1, and none in Group 2. Intraoperatively, eleven screws were repositioned in Group 1 and none in Group 2. There were no postoperative complications related to screw placement.

We conclude that higher accuracy of pedicle screw insertion with computer assisted navigation than with conventional methods could be demonstrated under clinical conditions in a randomised controlled clinical trial.

At present CAOS Systems are used also for localisation of intraosseous pathologic processes during biopsies in spine and pelvis, sacroiliac screw fixation and vertebral osteotomies.

Refinement of the method for use in minimal invasive and percutaneous procedures is in progress.

J.W. Thomas Byrd

For the hip, published literature reports approximately 50% successful outcome of operative arthroscopy in the presence of arthritis. These results are not very promising but some patients respond remarkably well. Careful patient selection is paramount to a potentially successful outcome. General parameters include: younger patients; mechanical joint symptoms; partial joint space preservation; adequate rotational motion; reasonable expectations; and failure of conservative treatment.

Arthroscopy has helped to understand the pathological process associated with various forms of osteoarthritis. We are now capable of recognizing these at earlier stages in the disease. However, it remains to be seen whether we can change the natural history of the disease process. Despite increasingly sophisticated technology with MRI, MRA, etc., radiographs remain the most important tool in assessing arthritic changes. Radiographs have traditionally been poor at detecting early degenerative disease, but with the information from arthroscopy, we are now more capable of recognizing the clinical importance associated with subtle radiographic findings.

S1093 CAVUS FOOT Pages 208 - 208
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Romanus Bertil

Introduction: Cavus deformity of the foot is defined as equinus (plantar flexion) of the forefoot in relation to the hind foot. In 1/2–3/4 of the children an underlying disease could be diagnosed, usually neuromuscular in origin. Pathomechanism. Gradual developing deformity caused by muscular imbalance, the intrinsic muscles of the foot being weaker as well as the foot dorsiflexors. Main deformities are: claw toes, flexion of the first metatarsal, heel varus and equinus. The deformities will become more rigid with increasing growth and/or progression of the underlying disease. Symptoms are: shoefitting problems, pain, callosities under the forefoot and lateral border, clumsiness during gait and running, tripping. Predominant ages are 8 – 12. Diagnosis: The primary goal is to establish or role out an underlying disease before adequate treatment can be applied. The examination should focus on detailed muscle function and joint mobility. Standardised standing X-ray examination and EMG is often needed for diagnosis and to evaluate muscles to be transferred. Treatment: Moulded insoles, shoe modifications and AFOs are symptomatic. Preventing progression is important. In flexible feet tendon transfers is often sufficient. In rigid deformities various osteotomies is helpful. In the older teenager and adults triple arthrodesis combined with tendon transfers is often needed. Summary: Cavus foot is a common cause for foot problem in the growing child. Neuromuscular dysfunction has to be diagnosed. Surgical procedures are often needed.

Roger Lemaire

Over the past 100 years, experimental and clinical studies have tried to accelerate fracture healing and to bring ununited fractures to union . Besides advances in surgical management, non-surgical means have been investigated. Mechanical enhancement of fracture healing using controlled micromotion has been used with some success but does not seem to have been applied to nonunions. Electrical stimulation has been found effective in hypertrophic nonunions, but less so in atrophic nonunions and in the presence of a gap; the various devices available have never gained wide acceptance for various reasons. Low-intensity pulsed ultrasound has been found effective to heal non-unions, especially hypertrophic, with a success rate around 85 % . High-energy extracorporeal shock wave therapy (ESWT) has also been found effective in non-union management, but this is still controversial and there is a need for prospective controlled studies. Biological action has also been attempted for a long time. All attempts to stimulate fracture healing using systemic drugs, diet supplementations, vitamins or hormones have been essentially unsuccessful unless when correcting a pre-existing deficiency . More recently, several molecules have demonstrated an osteoinductive capacity in animal studies; human recombinant BMP-2 is currently under investigation in clinical trials. Percutaneous injection of bone marrow into a non-union has also proved of interest, particularly following centrifugation to increase the number of osteoprogenitor cells; current research aims at selecting these cells prior to injection.

To conclude, a number of non-surgical means are currently available which may be of interest to accelerate fracture healing or to heal nonunions. Some are totally non-invasive, others are minimally invasive; early results have been encouraging for several of them, but there is still a need for clinical validation using prospective controlled studies. Some of those methods may well turn into alternate solutions to surgery in the future . Cost is currently a limiting factor, as long as it is not reimbursed by national health systems in most countries.

P.A. Noffe

Aims: Low-intensity pulsed ultrasound has shown acceleration of bone healing in fresh fractures. The goal of this study is to assess the effect of low-intensity ultrasound on bone healing in established nonunion cases and following osteotomy. Methods: A non randomized trial on 29 cases, located in the tibia, femur, radius/ulna, scaphoid, humerus, metatarsal and clavicle, met the criteria for established nonunions. On average, the post-fracture period prior to the start of ultrasound treatment was 61 weeks. Daily, twenty-minute applications of low-intensity ultrasound at the site of the non-union were performed by the patients at home. In a placebo-controlled, randomized clinical trial double-blinded trial, 97 adults, who had undergone an osteotomy of the lower extremity were randomly allocated an active- or placebo ultrasound device. Every two weeks the patients were examined both clinical and radiological. Results: Twenty-five of the twenty-nine non-union cases (86%) healed in an average treatment time of 22 weeks. Forty-six patients (75 bones) were treated with an active ultrasound device and 44 patients (78 bones) with a placebo device were eligible for analysis. An overall reduction of time to consolidation of 32% was established. A nonunion, which had to be treated operatively, occurred in four cases in the placebo group and in none in the active group. No other prognostic variables were found. Conclusions: Low-intensity ultrasound can stimulate bone healing in osteotomies and nonunions. In patients with a fracture or osteotomy, who are at high risk of developing nonunion, low-intensity ultrasound can be valuable as additional therapy.

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Philippe Hernigou

Tissue engineering can be defined as any effort to create or induce the formation of a specific tissue in a specific location through the selection and manipulation of cells, matrices, and biologic stimuli. The biologic concepts and the biochemical and biophysical principles on which these efforts are based have become a rapidly evolving field of biomedical research. More importantly, tissue engineering is becoming a clinical reality in the practice of orthopaedic surgery, providing patients and physicians with an expanding set of practical tools for effective therapy. The efficacy of all current clinical tools depends entirely on the cells in the grafted site, particularly the small subset of stem cells and progenitor cells that are capable of generating new tissue. The current author reviews a series of key biologic concepts related to the rational design and selection of cells in contemporary bone grafting and tissue engineering efforts. The functional paradigms of stem cell biology are reviewed and sources for autogenous stem cells for connective tissues are discussed. Finally a technique to obtain stem cells for the treatment of non unions is described.

We included 48 patients: 38 cases of posttraumatic non union (12 of them with infection); 4 non unions following arthrodesis (3 knees, 1 tibiotarsal); 4 cases with Illizarov technique; 2 patients with congenital abnormalities. The source of bone marrow was the iliac crest.

The marrow was reduced in volume (50 ml) in order to increase the concentration in stem cells by elimination of erythrocytes and polynuclear cells. The number of nucleated cells was counted in the marrow transplanted and the fibroblast colony forming cells (CFU-F) and the osteoblast colony forming cells (CFU-Ost) were cloned to appreciate the number and the activity of progenitor in the marrow transplanted.

V. Antolic

On the first to second day after birth, equinus, varus, forefoot adduction, calcaneopedal block derotation degree, reducibility characteristics, creases, cavus and muscle condition are evaluated using the clubfoot severity scale, and a long-leg cast is applied. Casting is preceded by the Ponseti treatment: the first ray is dorsiflexed while maintaining finger pressure on the talar neck just in front of the lateral maleolus in the external rotation and abductus. Immobilization is interrupted by redressive manipulation therapy depending on the clubfoot appearance and parents’ participation. Redressive manual and casting therapies typically provide good correction of the foot; yet the equinus persists in the majority of cases. The undercorrected equinus is the major reason for one-stage surgery, consisting of postero-medial-lateral release, capsulotomies and à-la-carte tendon elongation through the modified Cincinnati incision, done at the age of 7 to 9 months. As a rule forefoot derotation and heel fixation are not necessary. There are no skin problems or oedema, and the child usually stays in hospital only for one day after surgery. The outcome, however, is unpredictable even in a fully corrected foot. After surgery, the foot is regularly checked for a potential adductus, lack of dorsiflexion and cavus, and redressive therapy is promptly instituted. Any residual deformation resistant to conservative measures is treated surgically. In the long term, children should as a rule wear ordinary shoes. A typical reoperation – medial release with sectioning of the plantar fascia – is required in approx.10% of cases. Derotation below the knee and transposition of the tibialis anterior tendon are less frequent. At this Department, complete re-correction is required in less than 1% of cases.

M. Krismer R. Biedermann

Aims: A review of the existing literature is presented and compared with the results of a cohort study. These data are compared with the natural course of fracture healing. Methods: In a prospective cohort study 56 patients with nonunions and 14 patients with delayed unions after fracture or osteotomy were treated with shock wave therapy and followed for 2 years or to consolidation. These results and the previous data were assembled and were compared with the results of three studies on the natural course of fracture healing. Results: Consolidation was seen in 56% of patients with nonunions after a mean of 5.2 months, and in 93% of patients with delayed unions. The success rate of shock wave therapy was strongly associated with the time between primary diagnosis and shock wave therapy. Discussion: The success rate in the own cohort was quite similar to the results reported in the literature, after 3 months 52%, 41%, 19%, 40% or 25%, and 41%, 67%, 61% or 38% after 6 months respectively. At 12 months, healing occurred in up to 80%. The fractures were usually immobilised until union was assessed. It is not likely that a single intervention of shock wave therapy causes effects that last for several months. The results were compared with the natural course of fracture healing, also showing a time dependend healing rate. Conclusion: A considerable part of the effect of shock wave therapy may be attributed to the natural course of fracture healing, where healing is seen even after 6 or 12 months. Only a randomised study will be able to show whether shock wave therapy has any effect on fracture healing.

J.H. Kuiper C. Rao N. Graham P. Gregson R. Spencer-Jones J.B. Richardson

Introduction: Impaction grafting has become a popular technique to revise implants. The Norwegian Arthroplasty Registry reports its use for a third of all revisions. Yet, the technique is seen as demanding. A particular challenge is to achieve sufficient mechanical stability of the construction. This work tests two hypotheses: (1) Graft compaction is an important determinant of mechanical stability, and (2) Graft compaction depends on compaction effort and graft properties. Methods: Impaction grafting surgery was simulated in laboratory experiments using artificial bones with realistic elastic properties (Sawbones, Malmö, Sweden). Bone stock was restored with compacted morsellised graft, and the joint reconstructed with a cemented implant. The implant was loaded cyclically and its migration relative to bone measured. In a second study, morsellised bone of various particle sizes and bone densities, with or without added ceramic bone substitutes, was compacted into a cylindrical mould by impaction of a plunger by a dropping weight. Plunger displacement was measured continuously. Results: Initial mechanical stability of the prostheses correlated most strongly with degree of graft compaction achieved. Graft compaction to similar strength was achieved with less energy for morsellised bone with larger particles, higher density, or bone mixed with ceramic substitutes. Conclusion: Initial mechanical stability of impaction-grafted joint reconstructions depends largely on degree of graft compaction achieved by the surgeon. Compaction depends partly on the vigour of impaction, and partly on graft quality. Higher bone density, larger particle size and mixing with ceramic particles all help to facilitate graft compaction, giving a stronger compacted mass with less effort.

E. Ornstein

Aim: To investigate the migration and rotation patterns of the socket in hip revisions with impacted morselized allograft bone and cement. Methods: 17 Exeter socket revisions were followed by radiostereometry (RSA) and radiography for 5 years. The surgical procedure described by the Nijmegen group in Netherlands was used. The allograft bone chips were prepared in a bone mill and had an approximate size of 3 mm. Results: All but 1 socket migrated proximally (accuracy 0.2 mm).

Five socket revisions with a radiolucent line > 2 mm in at least 1 zone had a migration and a rotation rate 2–5 times larger (broken lines) than 12 socket revisions (unbroken lines) without a radiolucent line > 2 mm. Allograft resorption in at least 2 zones was observed in all these 5 revisions but in 4 of them no progression of the radiolucent line was seen after the 2 years and there was no clinical deterioration or threat to bone stock.

In 8 of the revisions radiographic signs of trabecular incorporation or remodeling of the graft were observed. No rerevision was performed. Conclusions: Further follow-up is needed for evaluation of the clinical relevance of radiolucent lines in impaction grafting. As a consequence of these findings a RSA study using larger bone chips has been started.

B.W. Schreurs

Aims: To reconstruct acetabular bone stock loss in revision hip surgery, from 1979 on we have used a biologic reconstruction method with tightly impacted cancellous allografts in combination with a cemented polyethylene cup. Methods: This studies presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients at a mean of 16.5 years (15–20 years) followup. The Kaplan-Meier survivorship for the cup with end-point revisions for any reason was 79% at fifteen years followup (95% C.I.: 67–91%). Results: Excluding two revisions for septic loosening at 3 and 6 years, the survivorship with end point aseptic loosening was 84% at fifteen years years (95% C.I.: 73–95%). At review there were no additional radiological loosenings, although 7 acetabular reconstructions showed radiolucent lines in one or two zones. Conslusions: This acetabular bone impaction technique using large morselized bone chips (range 0.7–1.0 cm) and a cemented cup is a reliable reconstruction technique, even after a 15–20 years followup.

V. Vécsei

Per definition we distinguish between shaft fractures of the tibia and fibula (lower leg), proximal tibial fractures, distal tibial fractures and isolated tibial shaft fractures. There are different criteria to classify a tibial fracture: 1. age, 2. soft tissue damage. Not only the terms, “open” and, “closed” but also coexistent neurovascular damage and the presence of a compartment syndrome have to be mentioned. 3. Furthermore there are well known anatomical classifications of tibial fractures (AO, OTA). Special conditions, as osteoporosis, osteopenia, pathological fractures and osteogenesis imperfecta have to be recognized.

The optimal treatment concept depends on the correct diagnosis, the manifestation of priorities, calculation of risks, management of complications and rehabilitation.

The treatment options of severe tibial fractures are: The interlocking nail in reamed or unreamed technique, the external fixator and in very rare cases plating or screw fixation.

The following principles in the treatment of severe tibial fractures should be mentioned:

The method of choice in closed and I° open tibial fractures is the reamed intramedullary nailing. If there is a coexistent fibular fracture at the same level as the tibial fracture, plating of the fibula should be performed.

The preferred method in closed tibial fractures with moderate soft tissue damage and in II° open tibial fractures is the unreamed interlocking nailing.

The closed tibial fracture with severe soft tissue damage as well as the III° open fracture are preferable treated by external fixation. The changing to intamedullary stabilization should be included in the therapeutic plan, primarily, or should be indicated later on.

Plating (ORIF) of severe tibial fractures has become a very rare performed procedure and is presently done just in some special exemptions. A complementary osteo-synthesis, including nailing and plating, is not included in our therapeutic concept. Proximal and distal tibial fractures involving the joint surface are not included in this consideration.

The indication for fasciotomy must not be too restrictive. A compartment syndrome should not prevent intramedullary nailing and a standardized protocol for second look procedures to protect bone and soft tissue has to be made.

In children the method of choice in severe tibial fractures is the external fixation The own experiences, during a three year period (1999–2001), including 208 tibial/ fibular shaft fractures are presented. We had 77% closed and 23% open fractures. Overall 90% were treated by intramedullary nailing. In the open fractures, we fixed all I° open fractures by nailing and 56% of the II° open fractures. 67% of III°a fractures, 90% of III°b and all III°c fractures were initially stabilized by external fixation.

E. Tukiainen

Bone defects can be reconstructed by shortening, conventional cancellous bone grafting, bone transport or microvascular bone grafts. Each method has special indications, advantages and disadvantages.

Microvascular bone grafts provide living, solid bone to fill or bridge bone defects. They also promote bone healing and resist infection. However, microvascular bone grafting entail increased duration of the operation, a two team approach and it bears the risks of donor site morbidity. Therefore only extensive defects or poor prospect of healing warrant this method.

Iliac crest flap is mainly used to reconstruct metaphyseal or articular defects. It offers a large piece of corticocancellous bone, with an option to make an arthrodesis, if indicated.

Microvascular fibula is used to bridge long diaphyseal defects (traumatic, congenital) or to reconstruct avascular bone necrosis.

Osteomuscular latissimus dorsi flap (including the lateral part of scapula) offers a solution for bone and soft tissue defects, especially in open comminuted fractures, infected nonunion fractures or post-operative deep bone infections.

P. Buma

A large series of animal experiments in goats was performed in relatevely simple bone chamber models and in very realistic loaded pre-clinical models. In this paper the focuss is on two experiments. In exp 1 we analysed the effect of rinsing of allograft bone on bone ingrowth into the bone induction chamber. We found that rinsing improves the ingrowth capacity to a level that is comparable to that of autologous bone. In experiment 2 we analysed the effect of two different reconstruction methods, e.g., a mesh or a strut graft, on the revascularization of impacted allograft bone in a femoral reconstruction. We found that new vessels can enter the impacted bone through the mesh and that this promotes an early revascularization of the bone graft.

In patients we analysed 24 biopsies of 20 patients and quantitated the amount of non-incorporated graft (remnants of original material), graft in the process of incorporation, incorporated graft (=new bone) and fibrous tissue. With increasng follow up peripods after the revision operation the amount of normal bone increased upto ca 90%. The remaining 10% consists of non-incorpated bone and fibrous tissue.

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D.W. Murray

Unicompartmental knee replacement (UKR) is an established and effective treatment for early unicondylar osteoarthritis of the knee. However good results will only be achieved with a UKR if appropriate implants, indications and surgical techniques are used.

There are now many UKR available. The majority have been introduced recently and have no published clinical results, as a result it is not clear how well they will function. Wear is a potential problem with UKR because of thin polyethylene and small contact areas. To minimise wear we use a device with a fully congruous unconstrained mobile bearing, the Oxford UKR.

The indications for UKR are confusing. The Oxford UKR is recommended for medial compartment osteoarthritis with full thickness cartilage loss and a functionally intact Anterior Cruciate Ligament. The Varus deformity should be correctable and there should be full thickness cartilage in the lateral compartment. It is appropriate for about one in four osteoarthritic knees needing replacement. With fixed bearing devices, because of problems with wear, the indications are narrower and contraindica–tions include young patients and damage to the Patello-femoral joint. These devices can however be used in the lateral compartment. There is currently a vogue to consider UKR as a pre-TKR. Under these circumstances the indications are relaxed and worse results are achieved.

UKR are now routinely implanted through a minimally invasive approach, which decreases morbidity and aids recovery. There is concern that the small incision will compromise implantation. The techniques used range from free hand with a burr to sophisticated instrumentation. We use a mill to precisely restore ligament balance and function to normal and have shown that, with this instrumentation, the device can be implanted as precisely through a short incision as through a standard one.

If appropriate implants, indications and surgical techniques are used then UKR achieve better short term functional results than both HTO and TKR, and they can achieve a long term survival that is similar to TKR and better than HTO.

Under these circumstances we believe that UKR is the treatment of choice.

S2033 HIGH TIBIAL OSTEOTOMY Pages 210 - 210
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P. Hernigou

Tibial osteotomy is a time-honored procedure in the treatment of medial femorotibial osteoarthritis. However new points need to be discussed in a modern approach of this technique.

What factors have a bearing on the decision and the technique ? During this symposium will be discussed: the advantages of the tibial opening versus closing wedge; the possibility to avoid bone grafts by using bone ceramics for opening wedge osteotomies; the importance of reliable fixation technique; the importance of decreasing the posterior slope of the tibia if the osteotomy is done on a knee with an anterior cruciate deficiency.

How long is tibial osteotomy effective and what are the outcome of postosteotomy procedures after failure of the osteotomy: most of the data indicate that tibial osteotomy is very often effective and, that achieving a moderate degree of valgus is a decisive factor in the long term osteotomy survival. However since the patients are young at the tissue of the osteotomy and since the results deteriorate over the time, the subsequent procedures should be discussed. Can a second osteotomy be done after failure of the first osteotomy ? Is it possible to perform a unicompartmental arthroplasty after a high tibial osteotomy ? What are the technical problems of a total knee arthroplasty after a high tibial osteotomy ?

S2053 HA COATING Pages 210 - 210
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K. Soballe

Introduction: The present series of studies were performed in order to investigate the effect of hydroxyapatite coating on bone ingrowth into cementless implants when subjected to pathological and mechanical conditions mimicking the clinical situation.

Material & methods and results: Hydroxyapatite (HA) and titanium alloy (Ti) coated implants were inserted into the femoral condyles in mature dogs. The observation period ranged between 4 and 16 weeks and the results were evaluated by mechanical push-out test and histomorphometric analysis.

The HA coating yielded superior effect on bone ingrowth compared to Ti when surrounded by a gap-whereas no effect was found in the press fit situation.

Allogeneic bone graft packed around the implant enhanced the anchorage of Ti implants, but HA coating alone without bone graft offered almost the same improvement in anchorage in 2 mm defects. Only minor improvement was obtained when bone graft was used together with hydroxyapatite.

Another interesting study showed that HA coating was able to prevent polyethylene particles to migrate around the implant by creating a seal of bony ingrowth.

HA coating on a porous surface resulted in significantly stronger fixation compared with HA coating on a grit blasted surface.

A clinical study (using roentgen stereophotogrammetric analysis, RSA) on total hip arthroplasty showed that HA coated femoral components were stable 3 months after surgery whereas migration of Ti coated components continued resulting in significantly less migration of HA coated components at 60 months.

P. Messmer T. Gross P. Regazzoni A.L. Jacob

Introduction: Open reduction and internal fixation (ORIF) is considered the treatment of choice in dislocated unstable pelvic fractures. However ORIF has several drawbacks, such as considerable soft tissue trauma, a substantial intraoperative blood loss and up to 25% infectious complications. To overcome these problems mini-invasive osteosynthesis techniques have been developed.

Methods: Analysis of the problem revealed necessary changes on the level of intraoperative imaging, surgical approach, reduction devices and technology integration. Intraoperative imaging with computertomography gives all the time an appropriate representation of the real position of bony fragments of the pelvis. A new type of axial reduction clamps allows fracture reduction through small incisions. Preshaped plates can be pushed underneath the soft tissue. Computer navigation helps to place screws in a save manner percutaneously.

Results: We present the setting of a new multifunctional image guided therapy suite, which is an optimal platform for mini-invasive treatment of fresh dislocated anterior and posterior pelvic ring fractures, as well as for percutaneous treatment of pelvic non unions. The technique of reduction and fixation of an anterior pelvic ring fracture through two small incisions instead of a full ilio-inguinal approach is shown. A case of percutaneous bone grafting of a delayed union of the sacrum is presented.

Conclusions: Mini-invasive osteosynthesis techniques require appropriate imaging tools, new reduction devices and most notably special skills. However all together may reduce severe side effects of conventional pelvic surgery.

Eero Hirvensalo Jan Lindahl

Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws.

Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear.

Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant.

P. Thomas

Apart from the inflammatory reaction upon surgery itself, the immunological biocompatibility of a given material varies with factors like the site of implantation, the immunogenicity of implant constituents and the individual reactivity of the patient. Most investigations have focused on cytotoxic, osteolytic or proinflammatory effects of wear debris and corrosion products. In some patients specific immune response, e.g. allergic reactions, to the implant components may develop and lead to localized or generalized eczema, local swelling, recurrent urticaria or even implant loosening. However the number of these patients seems to be much lower than the sensitisation rates to cobalt, chromium or nickel ranging between 2–10% in the general population. To identify implant associated allergic reactions the diagnostic approach should encompass both epicutaneous patch testing and in vitro methods, e.g. analysis of T-cell reactivity in peripheral blood and perimplantar tissue. Several patients with allergy-mediated implant intolerance under the picture of eczema, swelling, seroma formation or implant loosening will be presented. Based on these cases, a new panel of patch test substances (developed by the German Contact Dermatitis Group), immunohistology and molecular biology approach to characterize the periimplantar immune response will be exemplified. As the author is actually establishing a nationwide register for implant-associated allergic reactions, more information about incidence and clinical picture of these reactions will be available in the future. Certainly, these patients profit from an interdisciplinary problem solving approach.

Christine B. Chung

Compressive and entrapment neuropathies are common disorders often caused by mechanical or dynamic compression of a segment of nerve. These nerve abnormalities often occur as the nerve passes adjacent to osseous prominences, through fibro-osseous tunnels or openings in fibrous or muscular tissues.

The clinical diagnosis of nerve injury requires a detailed level of nerve anatomy, innervation patterns and an accurate neurological examination. Electromyography, motor and sensory nerve conduction and velocity studies can be utilized for the diagnosis of nerve injury in select cases, although false negative rates have been reported in as many as 30% of cases. MR imaging, with its excellent soft tissue contrast and multiplanar imaging capabilities, is the diagnostic imaging method of choice for compressive or entrapment neuropathies. It allows visualization of the nerve at the level of clinical abnormality, as well as identification of the compressive lesion. Moreover, MR imaging can also be utilized to assess the end-organ (muscle innervated) for resultant changes from nerve compression.

The purpose of the discussion will be to review the MR imaging findings of a variety of classic compressive neuropathies.

Björn Falck

Entrapment neuropathies are chronic local nerve lesions caused compression of anatomical structures around the nerves. The entrapment neuropathies are localized to regions where the nerves pass through anatomically narrow tunnels. The best example is carpal tunnel syndrome, which is also the most common entrapment. In literature more than 60 different entrapments have been described. Only a small number of the suggested entrapments have been reported according to standards required by evidence based medicine. Examples of these doubtful syndromes are the pronator and piriformis syndromes.

The diagnosis of entrapments is based on the subjective symptoms, clinical findings and an electrodiagnostic consultation, consisting of EMG and neurography.

Needle EMG can be used to demonstrate axonal lesions of motor axons. It is quite useful in moderate or severe lesions of mixed nerves. However, in purely neurapraxic lesions needle EMG is normal. Neurography across the site of entrapment is the most sensitive method. Surface electrodes can be used in the diagnosis of carpal tunnel syndrome and ulnar nerve lesions at the elbow. The nerve lesion can be localized very accurately using short segment studies. In deeply located nerves or small nerve branches, neurography must be done using needle electrodes (Morton’s metatarsalgia and meralgia paresthetica). The sensitivity and specificity of modern neurophysiological methods are high. The syndromes with consistently normal neurophysiological findings cannot be accepted as neuropathic, other etio-logic causes must be considered in these cases.

Bernd J. Krause Sven N. Reske

Accurate differentiation between loosening and infection is very important in the optimal treatment of patients with painful lower-limb arthroplasty. The distinction is very difficult, time consuming and expensive. FDG-PET has shown to be a powerful tool in the diagnosis of infection and inflammation. FDG-PET is particularly valuable in the evaluation of chronic osteomyelitis, sarcoidosis, fever of unknown origin, the acquired immunodeficiency syndrome and infected prostheses and also holds promise to monitor disease activity and response to therapy.

FDG-PET is an effective modality in the diagnosis of infection associated with lower-limb arthroplasty. Overall sensitivities range from 90% to 100% and specificities of 81% to 89% have been reported. In contrast to conventional nuclear medicine and radiologic techniques (Particularly MRI), PET is not affected by metal implants used for orthopedic procedures. Bone marrow uptake is minimal in these patients who usually are elderly. Furthermore, better spatial resolution of PET compared with conventional nuclear medicine modalities allows the detection of small and subtle lesions that can go unnoticed with other tecniques. When PET imaging is used to diagnose periprosthetic infection, certain cautions should be taken into account when interpreting the scans. The criteria to be used to distinguish infection from aseptic loosening should be clearly defined. Increased FDG uptake must be present along the interface between prostheses and bone to suggest infection. Often a significantly increased FDG uptake is found around the neck and/or head portion of the prosthesis following arthroplasty. Nevertheless, without increased FDG uptake along the interface between bone and prosthesis, a diagnosis of infection can not be made with confidence. For knee prostheses this diagnostic criterion is not as optimal as in the hip prostheses resulting in more false-positive results. Surgical intervention usually results in increased FDG uptake for up to 6 months. However, nonspecific increased FDG uptake caused by uncomplicated arthroplasty persists for an extended period of time.

As a metabolic modality, FDG-PET is superior to anatomic imaging techniques in the diagnosis and treatment of patients with prosthetic infections and inflammations that rely on the presence of hyperemia and increased perfusion. Novel PET tracers are being tested that may further enhance the role of this technique.

J. Fenollosa

Even when the bone fusion has been successful, the pain may continue to ruin the life of the patient. Two mechanisms have been identified as origin of the pain, one extra and one intradural.

The compressive extradural lesions are caused mainly by the action of progressive stenoses or by the disruption of the pedicular wall by badly placed screws.

As for defective screw’s trajectory, the most dangerous points are mainly the pedicle’s medial or inferior corticals. In the intraforaminal trajectory the dural sleeve of the lumbar root may be mangled too, suffering a mixed mechanicalbiological mismanagement. Even without laceration a burst cortical or the metal contact can be the origin of root irritation or even palsies. These lesions are present in most series in between 1 and 10% of the screws, depending of the surgical experience. The use of navigational devices finds in this technique his principal indication.

The CAT usually diagnoses the misplaced screws. The artefacts caused by stainless steel are the reason of banning this metal for spinal devices. When doubt the pain origin can be proved by electromyographical analysis. The electrical stimulus of the screw with a 0.2 millisecond pulse of 5 – 10 mA DC signals a violated pedicle wall. The treatment of these lesions is always the removal of compressive hardware. When a non-union compounds the root compression a TLIF with cage plus posterolateral fusion with posterior instrumentation, allows the liberation of the root without entering the compromised canal.

The compression of the dural sac by recurrent stenosis was frequent in posterior fusions. The lamina thickens by the transmission of charges through this bony continuum. Nowadays it can be yet seen with lamina decortication and bone grafts stocked between the rods and the base of the spinous process. The CT myelogram shows the lesion. The extraction of the hardware and resection of the redundant bone inside the canal, can resolve the compression. The most fearful lesions are the peridural and the intradural fibrosis caused by the operative mishandling of the dural sac or by septic epidural episodes. The neurologic lesions are often irreversible. The treatment is the most difficult and the outcomes the gloomiest of the spinal surgery. The best treatment is the prevention by delicate handling of the dural sac. Suture with titanium micro-clips must be done in all the dural wounds. Disc resection adjoining articular fusion in the treatment of stenotic canals must be avoided, to prevent a cicatricial circle. Abstention of foreign bodies inside the canal, use of bipolar cautery and soluble haemostatic substances to stop the intra-canalar bleeding, are the means of preventing the peridural fibrosis. Corticoids locally or covering the dura with a thin layer of anti-adhesive gel is a good prevention of adherences. The wounds of the dura can produce too a leakage of CSF leading to a compressive myelomeningocele if intracanalar. Wear titanium particles can be found in defective constructs. The motion between rod and screws can produce them. If the particles enter the canal they can produce both compression and fibrosis.

In the case intradural adherences blocking the roots in bundles, little can be done. Once secured the immobilisation of the level by a good extracanalar bone-fusion, the use of electrical interference electrodes in contact with the affected roots is the only solution. Some aid can be expected with the use of antiproliferative cytokines as interferon gamma or reverse-transcriptase inhibitors as Suramin, administered after a surgical cleaning of the fibrosis. With all the inconveniences of these treatments yet they allow a modicum of hope.

J. Harms

The analysis of failed spinal fusion usually always proves that either biomechanical or biological basic principles have not been observed. We find this in both fractures and tumors, but particularly also in degenerative changes within the region of the lumbar spine.

One must be aware of the fact that lumbar fusion which includes the lumbosacral hinge can have considerable impact on the entire sagittal profile of the spine. In particular in fusion over several in multisegmental fusion within the lumbar region this must be considered as in the case of an unfavorable position of the lumbosacral hinge and in fusion over several segments, no possibility remains for compensation of the malposition within the region of the lumbar spine.

It is obvious that an unfavorable sagittal profile with displacement of the gravity line anteriorly (lumbar kyphosis) results in an unfavorable distribution of the forces at the lumbosacral hinge so that a fusion is always jeopardized by the occurrence of higher bending moments and shearing forces.

Under this aspect, the restoration of an optimal sagittal profile with proper position of the sacrum above the hip joint should be given special attention. We know that the pseudarthrosis rate is significantly lower in correct position of the sagittal profile as in cases of potentially existing flattening of the lumbar spine in terms of a lumbar kyphosis.

There is a close link between the biomechanics and the biology of a fusion.

Particularly in older patients, these two parameters must be given considerable attention if fusion of the lumbar spine is intended, particularly if the lumbosacral hinge is included.

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Ivan Bojanic

Acute trauma and repetitive nicrotrauma connected with certain athletic activities are oftenmentioned when describing the etiology of nerve entrapment syndromes. According to the literature it is obvious that nerve entrapment syndromes in athletes are not as rare as they were once considered to be. Certain sports or physical activities have been mentioned that lead to specific nerve entrapment syndromes – for example, cyclist’s palsy and bowler’s thumb. Unlike nerve entrapment syndromes, vascular and neurovascular syndromes in athletes seem to be more common and have been described in greater detail, while nerve entrapment syndromes in athletes have been reported only recently. To support this contention, I present currently available information about nerve entrapment syndromes in athletes. For each syndrome possible cause of compression, clinical symptoms and signs, and the most effective treatment is presented. On the upper extremity are described: spinal accessory nerve, thoracic outlet syndrome, brachial plexus, long thoracic nerve, suprascapular nerve, axillary nerve, musculocutaneous nerve, lateral ante-brachial cutaneous nerve, radial nerve above the elbow, radial tunnel syndrome, Wartenberg’s disease, distal posterior interosseous nerve, ulnar nerve at the elbow and in Guyon’s canal, median nerve at the elbow and in carpal canal, anterior interosseous nerve and digital nerves. The syndromes described on the lower extremity are: groin pain, piriformis muscle syndrome, pudendus nerve, meralgia paresthetica, sural nerve, common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, tarsal tunnel syndrome, the first branch of the lateral plantar nerve, medial plantar nerve (jogger’s foot) and interdigital neuromas (metatrsalgia.

In conclusion I stress that nerve entrapment syndromes must be considered in the diferential diagnosis of pain in athletes.

Jy. Lazennec G. Saillant

Introduction Infection of posterior instrumentation supposes a severe failure in long arthrodeses with a demineralized skeleton.

Materials and methods From 1998 to 2002, ten patients of 19 to 76 years (mean 56 years) have been grafted with anterior Peek cages filled with autograft.

Four cases of scoliosis were operated as an average 5 times by posterior approach (3 – 9 times), all of them suffered fistulised non-unions recidivating after every one of the previous operations. 4 times the germ xas a Staph. Aureus Met. resist (1 associated with a streptococcus and 2 of them with an enterococcus). Three patients presented severe radicular pain.

Six posttraumatic cases underwent a surgical extraction of the posterior instrumentation. All of them presented a non-union with total loss of the initial angular correction. In one case the septic destabilisation affected the level proximal to the fixation. The germ responsible was every time a Staph. Aureus Met. Res. with an enterococcus associated in one of the cases.

Two inveterate fistulae were operated before. The grafts were performed on 1 to 4 levels without a new posterior fixation but in one case (5 thoracolumar approaches, 5 on lumbosacral fusions, external support by a 3 points corset between 4–6 months). The postoperative antibiotherapy has been maintained for 4 months in average (3–12 mos). The fusion was appreciated by the graft aspect on CT scan with a mean follow-up of 22 months (12 months minimum).

Results: No anterior infection has been observed, but in one post-traumatic case with a violation of the discal space by a screw. (Flare-up of the infection without anterior collection, treated by a new posterior approach with definitive kyphotic fusion as a result). All the nine others fused with clinical improvement (sevrance of the rigid corset and decreasing analgesic doses in a mean time of six months) and without significant correction loss. Three cases of radicular pain improved too. As a complication, one female patient previously operated three times by an anterior approach, was operated a new by a minimal left approach without incidents. She suffered in the postoperative period an ureteral necrosis needing a secondary nephrectomy.

Conclusion This strategy of intersomatic graft is a recovering solution in the mechanical failures of severe and reccurrent infections, often germs association. With these severe deformities on aged patients this technique is more difficult. The positive culture of disc material is a bad prognostic factor. In case of previous anterior approach, it is a good procedure the catheterisation of the ureteral duct to prevent a possible necrosis. The intersomatic cage has been a safe procedure assuring a primary and late stability in those patients with a deficient bone-stock. The cages did not induced any additionnal septic problems.

L. Peterson

Autologous chondrocyte transplantation is a two-stage procedure for treating full-thickness chondral and osteochondral joint lesions. It has been used in more than 1200 patients in Sweden and 8000 outside of Sweden.

No serious general complications have been seen, no deep infections, no deep thrombosis.

Relevant serious complications are graft delaminations, especially in partial or total loss of attatchment. These can be a result of inadequate surgical technique, too aggressive rehabilitation or too early return to competitive highimpact sports. They often occur 6–12 months postop. Marginal delaminations can be handled by debridement and microfracture. Partial and total graft delaminations need retransplantation. This can be performed with good result. More common complications are periosteal delamination and hypertrophy of the periosteal flap causing catching, pain and swelling. If symptoms does not disappear with a change in rehabilitation an arthroscopic debridement is necessary.

Arthrofibrosis with limited R.O.M. is treated with intensified physical therapy. If that fails arthroscopic debridement is needed. Other relevant complications like infection and thrombosis could usually be prevented.

Anders Lindahl

Autologous chondrocytes transplantation (ACT) was first used in humans in 1987 and is based on a surgical technique where cells are injected under a periosteal flap. Due to the sometimes tricky surgical isolation and suture of the periosteum and complications with hypertrophy of periosteal tissue (5 – 10% of the cases) that in some cases requires a second arthroscopic trimming ‘easier’ transplantation techniques based on cells cultured on scaffolds and membranes have been suggested. However, the standard ACT technique creates a unique in vivo bioreactor where chondrocytes and periosteum form a unique local environment. If live periosteum and chondrocytes are transplanted to a defect in the rabbit patellae a cartilage repair tissue is formed in contrast to treatment with ‘dead’ periosteum and live chondrocytes were no repair tissue is demonstrated. The unique environment formed by the periosteum and chondrocytes might be responsible for the unique in vivo induction of early embryological development patterns seen in limb formation in the foetus: We have found that the transplanted chondrocytes are expressing early developmental genes e.g Sox 9 and wnt14 and fibroblast growth factor 3 receptors (FGFR3), a marker of chondrocytes progenitor cells. Furthermore, we have found that the articular chondrocytes are able to demonstrate a phenotypic expressivity with an additional ability of bone and adipose tissue formation. Changes to the transplantation procedure must address these unique features of the ACT technology in order to maintain the long term clinical outcome.

Th. Slongo

The fractures of the humerus shaft and of the proximal humerus in childhood turn off less than 1% of all fractures. Healing is unproblematic, according the literature the non operative treatment is the treatment of choice.

Under the influence of the ESIN (Elastic Stable Intramedullary Nailing) the readiness to operate children’s fractures has changed completely. The reasons for it are multiple. According to this trend, also is to recognize a change in the treatment of the humeral fractures in childhood obviously.

The presentation on hand shall show the reasons of this paradigm change more nearly. The classic indications for the operative therapy of humeral fractures were: 3∞ open fractures, comminuted fractures, secondary complications.

We have asked whether, today, this concept is still valid in Europe. The tendency towards more operative treatment becomes apparent in the documentation of children’s fractures that has started by the international working group for children’s trauma in collaboration with the AO – Doc in 1991.

We think every unstable humerus fracture should be stabilized today. We posit in the rest, that if a general anaesthesia for reduction of humeral fracture is indicated, we aim at a definitive, stable and save fixation, i.e. potentially unstable fractures should be reduced in the OR. In our hands and relying on our experience we prefer to stabilize humeral fractures with ESIN.

P.P. Schmittenbecher

For a long time treatment of all forarm fractures was coservatively in principle. Retrospective analysis of more than 1000 fractures showed that 97,8% were treated orthopedically, 22% finished consolidation with an axial malalignment of more than 10∞ and 6,9% showed bad functional results 3–13 years later. Most bad results were found in shaft fractures of both bones on the same level or in oblique fractures with convergent displacement.

The introduction of elastic stable intramedullary nailing (ESIN) gave the opportunity to stabilize instable diaphy-seal fractures with less [Aufwand], with an implant adequate for children and with the possibility of immediate postoperative movement. Within three years, 161 diaphy-seal forearm fractures were managed by cast (27%), reduction (32%) or osteosynthesis (41%). In 14 cases (8,7%), secondary osteosynthesis took place because of secondary or re-displacement during orthopedic treatment. The functional results following ESIN are very good.

In radial neck fractures with severe displacement of more than 60° an open reduction and fixation by K-wires was the preferred method for a long time. After open reduction, radial head necrosis was the result in a significant part of cases independent of the quality of reduction. Closed reduction with the tip of the nail without touching the fracture region improved the results extremely. Seldom a transcapsular reduction manoever is necessary.

In a multicentric study of proximal radius fractures including 67 cases, 27 fractures with a relevant displacement were managed surgically (24 ESIN, 3 K-wire). 3 [Verplumpung] of the radial head, two of them combined with premature closure of epiphyseal plate, and one radial head necrosis took place, but only in one case with ESIN, whereas all cases with open reduction and K-wire use showed problems during the healing course.

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S. Boriani G. Barbanti Bròdano F. Giardina A. Marinelli

Despite progress in surgical methods, the clinical results of spine fusion are still not satisfactory, although success rate is certainly higher than in the past, some patients require multiple surgeries to treat a spinal disorder.

There are many reasons for which a revision surgery may be necessary: for failure of spinal previous fusion, as pseudarthrosis, for junctional failure or for decompensation of previous fusion.

This is a review of 54 patients who underwent revision spine fusion between ’96 and 2000: they were 20 males (37%) and 34 females (53%), in 9 (17%) cases was interested cervical segment, in 9 (17%) thoracic, in 10 (18%) thoracolumbar, in 26 (48%) lumbar; in 29 (54%) patients, previous fusion was performed for a fracture, in 23 (42%) for degenerative pathology (in 17 (31%) was made a postero-lateral fusion, in 4 (7%) cases postero-lumbar interbody fusion and in 2 (3%) cases anterior fusion), in 1 (2%) case for degenerative scoliosis and in 1 (2%) case for a tumour excision. Revision surgery had to be performed in 28 (52%) patients for a mechanical complication, in 14 (26%) for instability of device, in 7 (13%) for wound infection and in 5 (9%) for pseudoarthrosis. Revision procedures were in 37 (68%) cases a new spinal fusion (17 (31%) postero-lateral, 7 (13%) postero-lumbar interbody, 7 (13%) anterior fusion and in 6 (11%) cases both anterior in 7 (13%) removal of mechanical devices, in 7 (13%) cleaning of wound and in 3 (5%) elongation of devices.

We have performed a clinical and radiological evaluation with al least 2 years of follow-up. From our analysis of results of the present study, it appears that the rates of improvement after a second operation is lower than that after an initial operation and the rates of complication are significantly higher. This is probably relates to the greater complexity of revision surgery, the more invasive nature of procedure and the longer duration. and posterior fusion).

F. Schuind F. Burny

A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion.

H. Hedin S. Larsson K. Hjorth S. Nilsson

Aims: To evaluate one of the surgical options for treating femoral fractures in children.

Methods: In a consecutive and prospective study during the period 1993–2000, 96 children aged 3–15 years with 98 displaced fractures femoral fractures were treated with external fixation and early mobilization.

Results: All fractures healed. Minor complications included pin tract infections (18%) and clinical insignificant malunions. Major complications (6%) included 2 refractures after significant trauma and three plastic deformations after premature fixator removal. Malunions remodelled almost completely, overgrowth was far less than expected. Isokinetic muscle strength was tested for both hamstrings and quadriceps and showed no residual weakness.

Conclusions: External fixation of displaced femoral fractures can be used as surgical alternative in children aged 3–15 years. The treatment provides satisfactory results with a low rate of major complications. Early mobilization seems to prevent residual muscle weakness. The treatment reduces the number of days in hospital for the child and the number of days of sick leave for the parents.

P. Reynders

Fractures of the shaft of the humerus are usually easy to treat, irrespective of the personality of the fracture.

The blood supply is abundant that union is rapid. There is no tendency to over-riding; on the contrary, the only danger is that the fragments may be allowed to distract by the weight of the limb and cause delayed union. The middle third is the most vulnerable in relation to delayed or non-union. This is because the main nutrient artery enters the bone very constantly at the junction of the middle and lower thirds or in the lower part of the middle third. The radial nerve is another structure at risk from fractures or operations on the humerus. It does not travel along the spiral groove of the humerus next to the bone as is commonly described; instead along most of its course it is separated from the humerus by a variable layer of muscle, and lies close to the inferior lip of the spiral groove.

In general treatment of the fractured shaft of the humerus is not usually difficult. The fractured ends can be readily aligned with the patient sitting, when the weight of the forearm on the distal fragment will usually achieve an acceptable position. Support of the wrist a collar and cuff or narrow sling, allowing the elbow to lie free and unsupported may be all that is required. In the early stages when there is considerable pain a well padded plaster of Paris U-slab passing from the region of the acromion down to the olecranon and up the inner side of the arm to the axilla and bandaged in place is very effective in relieving discomfort. After two weeks the collar and cuff bandage can be replaced by a functional orthosis type Sarmiento for another four to six weeks. A “ hanging cast” popularized by Caldwell is no longer recommended because it may distract the fracture and produce delayed union.

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P.M. Rommens J. Blum

Objective: to study the clinical performance of a new intramedullary nail, which is introduced in a retrograde way, for the treatment of humeral shaft fractures.

Design: prospective, non-randomized multicentrical clinical study.

Setting: Level I trauma centers in 4 European countries.

Patients: In a two year period, 102 humeral shaft fractures in 102 patients were nailed. Seventy-three fresh fractures, 12 pseudarthroses, 3 refractures and 14 pathological fractures were involved. Decision for nailing was taken by each surgeon individually. The diaphysis was defined as the part of the humerus between two centimetres below the surgical neck and five centimetres above the olecranon fossa. Sixty-six fractures were closed: 62 grade I and 4 closed grade II and III. There were also 7 open fractures, 4 grade I, 2 grade II and one grade III.

Intervention: all fractures were stabilized with the new unreamed humeral nail (UHN), which was introduced in a retrograde way.

Main outcome measurements: 42,5% of operations were performed in less than one hour, 82,4% in less than 90 minutes (skin to skin). In four patients (3,9%), additional fissures or fractures occurred on the entry portal, in one patient (1%) an additional diaphyseal fracture occurred during nail insertion. There were 4 (3,9%) secondary radial nerve palsies. Seventy-five fractures could be followed up until fracture healing, 58 fresh fractures, 9 pseudarthroses, 2 refractures and 6 pathological fractures. Five fractures needed more than 8 months for fracture healing, in all these patients (5/75 = 6,7%) secondary surgery was necessary. In three patients, inter-fragmentary compression was used with the UHN, once cancellous bone grafting was performed and in one patient changement of procedure to plate and screw osteosynthesis was considered necessary. Sixty-seven patients (89,4%) showed an excellent shoulder function and 7 (9,3%) an acceptable one, 66 (88,0%) an excellent elbow function and 7 (9,3%) an acceptable one at the time of fracture healing.

Conclusions: The unreamed humeral nail (UHN) is a very elegant device for intramedullary stabilization of fresh and pathological fractures and pseudarthroses. The retrograde approach is safe when the nail is introduced carefully through an appropriate entry portal. In case of good fragment adaptation and sufficient stability, an unproblematic fracture healing can be expected.

Rainer Kotz Florian Mittermayer Petra Krepler Martin Dominkus Eva Schwameis Maria Sluga

Ten year results of 100 primary lower limb reconstruction prostheses implanted between 1982 and 1989 were analysed. In a Kaplan-Meier estimate there was a 85% three years, a 79% five years and 71% ten years survival rate. Most common reason for implant failure was aseptic loosening in 27% of patients (11 patients; range 10–121 months) after initial operation. Other reasons for revision surgery were implant failure (4) and infection (4). Early repair of prostheses-related minor complications, was polyethylene bushings destruction. After a median followup of 127.5 months after the initial surgery, 51 patients had died and eight patients were lost to followup. Forty-one patients were evaluated clinically and radiologically using the MTS score and the radiologic implant evaluation system of the International Symposium on Limb Salvage. 41 patients had a mean of 80% (range, 40%–100%) of the normal functional capability.

M. Innocenti L. Delcroix D. Campanacci G. Beltrami R. Capanna

Aims:Vascularized fibula has been widely used in limb salvage surgery to reconstruct large bone defects. Aim of this study is the analysis of the complications related both to the donor and the recipient site in a series of patients affected by bone tumors. Material and methods: In the period from 1988 to 2002, 114 patients ranging in age between 4 and 64 years underwent bone reconstruction by mean of a vascularized fibula graft. There were 64 men and 50 women and all them were affected by malignant neoplasm. The upper limb was involved in 25 cases and the lower extremity in 89 cases. The length of resection ranged between 7 and 28 cm, the follow up between 6 and 166 months. Results: Several complications have been noted either at the donor or at the recipient site. The most common complications affecting the donor leg, have been the retraction of flexor tendons (6), the valgus deformity of the ankle (3) the retraction of extensor hallucis longus (1) and a transient palsy of the peroneal nerve (1). The most frequent complications observed at the recipient site has been a fracture of the graft (15) followed by non union (12), infection (5 cases), failure of plate (5), skin necrosis (4), transient palsy of the peroneal nerve (3) and joint stiffness. Because of complications, a total failure of the procedure occurred in 4 cases. Conclusions: Although the vascularized fibula graft is the recommended procedure in dealing with challenging reconstruction of large diaphyseal defects, this option is not free of complications. However, in our experience, when conservative treatment of complications was not successful, further surgery was able to lead to recovery in the majority of cases.

S3001 THE RHEUMATOID WRIST Pages 215 - 216
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Daniel B. Herren Beat R. Simmen

The wrist is one of the main targets of rheumatoid arthritis. The classic pattern of deformity and destruction shows involvement of the radio-carpal and the radio-ulnar joint with destabilization of the carpus, resulting in a ulnar sliding of the wrist. With ongoing disease a radial tilting and a carpal supination is observed. Although considered as a uniform systemic disease of immunogenetical background the patients show various courses of this disease. The recognition of the pattern of progression may have implications on the management and also on the surgical treatment of the patients. Most currently used classifications of wrist deformity include mainly the actual destruction of the carpal joints but do not include the different possible pattern of progression. For optimal surgical treatment of rheumatoid wrists it seems mandatory to recognize the type of destruction if possible already at early stages of the disease. Based on radiological long-term analysis, Simmen et al. proposed a new classification of rheumatoid wrist involvement considering the type of destruction and possible future development with direct consequences for surgical decisions. Three pattern of destruction are distinguished, based on the morphology of destruction and the course over the duration of the disease. Serial radiographs allow the classification in either type I, II or III wrists. Type I rheumatoid wrists show a spontaneous tendency for ankylosis type II wrists remain stable and show a destruction pattern which resembles osteoarthritic changes and type III wrists show a disintegration with progressive destruction and loss of alignment. Type II is further subtyped in III a with more ligamentous destabilization and type III b shows bony destruction with finally complete loss of the wrist architecture. The classification into the different types of the natural course of the disease at wrist level is based on serial radiographs and measurement of carpal height ratio and ulnar translation. A change in the carpal height ratio of more than 0.015 and/or an increase of ulnar translation of more than 1.5 mm per year classifies a wrist in the type III category. Type I and II wrists have a low probability undergoing radiocarpal dislocation.

Therefore surgical treatment including wrist and tendon synovectomy and usually ulnar head resection, gives satisfactory results also in the long-term. In contrast type III wrists, because of ligamentous and/or bony destruction, require a procedure which provides realignment and stability.

J. Bellemans

Performing a total knee arthroplasty in a patient with a flexion contracture or recurvatum deformity requires from the surgeon an adequate knowledge of the principles of flexion – extension space balancing.

In the standard TKA procedure, adequate balancing between the flexion and extension space is usually easily achieved, leading to an equal and symmetrical space both in flexion and extension, which results in a stable knee and maximal range of motion after implantation of the prosthetic components. The situation is different in the knee with a flexion contracture or recurvatum, where the extension space is relatively smaller (flexion contracture) or greater (recurvatum) than the flexion space. In both of these situations, the flexion and extension space should be balanced by the surgeon in order to avoid an important deficit in range of motion or an instability problem. Several surgical techniques are available for this.

In the knee with a flexion contracture, the extension space is relatively too small. Adequate removal of posterior osteophytes will increase the extension space, and this should be the first step in the flexion – extension space procedure (1). Next, the collateral structures should be balanced, with release of the tight structures that are effective in extension only (2).

These are predominantly the iliotibial band in the valgus knee, and the posterior oblique ligament in the varus knee. If these 2 steps are not sufficient, proximalisation of the femoral component by 2 to 3mm may be required (step 3), or a formal release of the posterior capsule from the posterior femoral condyles (4). When an anterior reference system is used, the surgeon can also decide to use a slightly larger femoral component with a slightly increased tibial resection to equalise the gaps (5).

In the knee with a recurvatum deformity, the extension space is relatively too large. In this situation, distalisation of the femoral component by removing 2 mm less distal femoral bone, will decrease only the extension space without altering the flexion space (1). In case of anterior referencing, the use of a slightly undersized femoral component will further equalise the gaps (2). Just using a thicker tibial insert to fill up the extension space, while increasing the flexion space by resecting the PCL or increasing the tibial slope, may be another option in the modest recurvatum knee (3).

R. Capanna D.A. Campanacci P. De Biase A. Astone

Aims: Massive allografts have been widely employed to replace skeletal defects after bone tumour resection. They have major advantages but the major concern is the long term behaviour of the implant. The aim of the present study was to evaluate the incidence of complications in allograft reconstruction and to describe the new techniques to decrease their rate. Methods: The present series includes 68 patients with 70 massive allografts operated from 1996 to 2002. 35 were males and 35 females with an average age of 31 years (4–79). The massive allograft was used as osteoarticular reconstruction in 28 cases, composite in 28, intercalary in 10, knee arthrodesis reconstruction in 3 and scapular replacement in one case. In 7 cases a vascularized fibula was associated. The femur was involved in 23 cases, the humerus in 16 and the tibia in 17, the pelvis in 7, the radius in 3, the scapula in 2 and patella and a finger in 1 case. Results: Infection rate on 68 cases was 6% (4 cases). All infections healed after surgical revision. Two patients were lost at fu and 10 patients have less than 12 months of fu. The 58 patients left have an average fu of 34 months (12–71). Among these patients 45% had one or more complications treated surgically and 2/3 of the cases healed. Non union rate was 12% and fracture rate 5%. Conclusion: Allograft reconstruction showed a high rate of complications. Almost half of the patients (45%) presented one or more complications which required surgery in 40% of cases. Aggressive antibiotic perioperative regimen and adequate soft tissue coverage of the graft may reduce the risk of infections. Biologic augmentation with vascularized grafts, bone marrow and/or growth factors may reduce non union rate. Cement filling of the graft and composite implant (with prosthesis association) have been introduced in order to decrease the risk of diaphyseal and articular fractures.

Olle Svensson

The computer and telecommunications revolution has barely begun, although it has already profoundly changed our daily lives. But health care is still regrettably unplugged compared with other industries. Why? There are several obvious answers. For one thing, modern medicine is both complex and fragmented. And the medical profession has a long tradition and a strong ethos, not easily influenced by IT nerds. Also, security and patient integrity as well as other legal aspects put limits on what is feasible and desirable. The collapse of the dot.com business and the numerous accounting scandals have certainly not increased the profession’s confidence of internet.

Yet, documentation in today’s health care is obsolete: at the same time redundant and insufficient. Access time for paper documents are often measured in days or weeks rather than in milliseconds. This slow communication technology is bad for our patientsòat a time when the sheer magnitude of information necessary for medical decision-making is increasing exponentially. Another aspect is research and quality control. No manager of a manufacturing industry would keep his/her job without keeping the board happy with hard data on the quality of what is produced. How about medicine?

This symposium aims at giving a smorgasbord of IT applications in orthopaedic care, quality control and research. We will also discuss perhaps the most important question: what do we want the new technology to do for our patients and for orthopaedic surgery? Complications of limb salvage

S3002 MP JOINT DEFORMITIES Pages 216 - 216
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Philippe Kopylov

The MP joint is the key joint for function of the fingers. Rheumatoid arthritis involvement of this joint is frequent (1/3 of patients), and results in severe painful deformity and functional loss. The factors leading to the classic ulnar drift and volar luxation are multiple but the permanent pathophysiological element is synovitis of the joint. No deformation will occur in the MP joint without synovitis.

Etiopathogenesis: The causes of MP joint deformity in Rheumatoid arthritis are anatomical, pathological and indirect.

The asymmetry of the metacarpal heads with a slight ulnar tilt induce the deformation in this direction. The weakness and the length of the radial collateral ligaments compared to the ulnar collateral ligament makes the laxity to occur on the radial side of the joint. The obliquity of the extensor tendons pull the fingers ulnarly with a tendency of dislocation over the MP joints.

Synovitis is at the origin of elongation, rupture or destruction of the ligaments, attrition of the cartilage and bone resorption. The distention of the extensor hood predominate radially and accentuate the extensor tendon obliquity. The destruction of the A1 pulley of the flexor tendon participate to the volar luxation of the joints. The ulnar sliding and radial tilt of the carpus, the tension of Abductor Digiti Minimi and the contracture of the intrinsic muscle participate indirectly or aggravate the deformation. The thumb force in pinch grip and the ulnar deviation of the finger in heavy prehension participate also to the deformation.

Classification: Without prognostic factor the following classification gives information on the stage of the deformation and the treatment that can be proposed.

synovitis without deformation, normal radiographs

synovitis with ulnar deviation, normal radiographs

synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with almost normal cartilage

ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and more or less bone erosion on radiographs

Synovectomi with stabilization and realignment procedures can only be used in stage 1 and 2. In stage 3 and 4 arthroplasty is more appropriate.

Treatment: Indication are pain, loss of function and cosmesis.

Synovectomy. The prophylactic effect of synovectomy is still subject to debate. The almost impossible total synovectomy, the difficulties to control the effect of the procedure and the different stage in disease of each patient make the synovectomy unpredictable as a real prophylactic procedure.

Stabilization and realignment procedures has always to be part of a synovectomy. If the destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed. For this purpose different techniques can be used. Suture of the extensor hood on the radial side enables reorientation of the extensor tendons. The radial collateral ligaments can be strengthened or their attachments reinserted, the Abductor Digiti Minimi or the intrinsic tendons can be divided. Some tendon transfers (intrinsic, Extensor Indicis Proprius) can also be proposed.

Arthroplasty. The choice of the procedure depends most of the surgeon preferences. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand with very good results on the aspect of the hand and on pain. The mobility of the MP joints is variable and depends of the mobility of the finger joints. The bone erosion and the rupture of these devices are in favor of autologous interposition arthroplasties which, on the other hand, gives lesser mobility and stability. For these reasons silicon and interposition arthroplasties are often indicated late in the MP joint destruction process. More recently, new non constrained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function. If the preliminary results are confirmed in the long term, these non constrained devices will have a good indication as early MP joint replacement in the active young rheumatoid patient.

Conclusion: MP joint deformity in rheumatoid arthritis is complex. The Etiopathogenesis will guide the treatment most appropriate in each patient. However some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure. The ulnar deviation can be reduced and corrected by ligaments and tendon procedures. The volar subluxation/luxation indicates an advanced deformity of the MP joint that requires arthroplasty.

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John Stanley

Aetiology and pathogenesis: The pathogenesis of boutonnière deformity, in the rheumatoid patient is usually quite clear, and is due to either a central slip failure or volar subluxation of the middle phalanx. This subluxation is seen more commonly in the patients with psoriatic arthropathy. The most common cause is a chronic synovitis of the proximal interphalangeal joint leading to attenuation of the sagital fibres between the central slip and the lateral bands and at a later stage disruption or attenuation of the central slip itself.

Synovitis of the pip joint with separation of the lateral bands from the central slip allows the lateral bands to sublux forwards to lie anterior to the axis of rotation thus the intrinsics which extend the proximal and distal joints of the finger come to act as flexors of the proximal joint and continue to act as extensors to the distal joint. The patient will use the intrinsic muscles and they now have a flexion force upon the PIP joint and hyperextension force on the DIP joint, causing a boutonnière deformity. Volar subluxation of the middle phalanx draws forwards the lateral bands and defunctions the central slip creating the same imbalance. Scarring of the volar plate as is seen in volar plate injuries with the production of a pseudo-boutonnière deformity is sometimes seen in psoriatic arthropathy.

In a boutonnière deformity the PIP joint is flexed and the DIP joint is extended. With the joints in this position, the origin and insertion of the intrinsic muscles are closer together, and as a consequence, with the passing of time, the muscles fibres will remodel in a shortened position, creating a lateral band tightness.

Classification: Boutonnière deformity can be classified into four stages.

Type I. The deformity is totally correctable passively, and there is full flexion of the DIP joint when the PIP joint is fully extended.

The patient has a passively correctable flexion deformity of the PIP joint, and can actively flex the distal interphalangeal joint.

The anatomical alterations are the following: elongation of the sagital fibres and volar displacement of the lateral bands but no secondary shortening of musculo-tendinous system.

Type II. Flexion of the DIP joint is limited when the PIP joint is passively corrected.

The patient cannot actively or passively flex the distal interphalangeal joint, when the PIP joint is passively corrected. Secondary shortening of the intrinsic/lateral band system because the intrinsics have remodelled in a shortened position.

Type III. Stiffness of the PIP joint without joint destruction.

There is no passive correction of the deformity but the joint surfaces are sound. The patient can not passively extend the PIP joint nor flex the DIP joint.

Type IV. Stiffness of the PIP joint with joint destruction.

In these cases, stiffness of the PIP joint is not only due to soft tissue remodelling but mainly to joint destruction.

In this type, destruction of the joint cartilage should be added to the previously described anatomical deformities. X-ray examination is needed to confirm the diagnosis.

Treatment: Boutonnière deformities, are both aesthetically and functionally less disabling than swan neck deformities because there is usually little loss of active PIP joint flexion. Some therapeutic options exist, and choosing the most appropriate surgical procedure will depend on the severity of the anatomical deformities which need to be corrected.

Correction of PIP joint flexion. Mobilisation of the lateral bands and transposition of the lateral bands posterior to the axis of rotation of the PIP joint. Release of the volar plate of the PIP joint is often necessary because of secondary contracture.

Improving active DIP joint flexion. The only way to restore loss of active DIP joint flexion is by performing a Dolphin tenotomy or formal lengthening of the conjoined lateral bands over the middle phalanx.

Improving passive PIP joint extension. Passive extension of the PIP joint can usually be obtained by gentle manipulation and serial application of plaster of paris casts, as well as the use of a Capner (or armchair splint)the dorsal structures are usually quite thin and lax. If the joint can not be passively extended, a surgical release of the lateral bands is indicated,. Y-V plasty shortening of the central slip and extensor mechanism is usually necessary. A longitudinal incision at both sides of the central slip, allowing the lateral bands to displace dorsally during PIP joint extension with reefing of the lateral bands to the remnants of the central slip is needed in most cases.

PIP joint arthroplasty. A PIP joint arthroplasty should be considered when the joint is destroyed. A radiological examination is essential in making the diagnosis, as many stiff PIP joints in flexion do not have their joint surfaces preserved because boutonnière deformities are often secondary to PIP joint synovitis. A full soft tissue procedure must be performed at the same time.

DIP joint arthrodesis. Arthrodesis is only indicated for the treatment of uncorrectable deformity of the DIP joint with or without joint destruction, confirmed by radiological examination. The functional results of an arthroplasty are far superior for the treatment of a swan neck than a boutonnière deformity, because of the integrity of the extensor apparatus in the former, allowing for immediate postoperative motion.

7. PIP joint arthrodesis will be the treatment of choice if the finger presents a gross deformity with deteriorating function or failed surgery.

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K.-G. Thorngren

Hip fractures have increased in most western countries during the end of the last century. This increase will continue mainly because of an increasing number of elderly persons and also due to an increase in the risk of hip fractures in the oldest. This constitutes a threat to resources for medical care. Practise differs concerning choice of operation method and principles for rehabilitation throughout the world. A national registration of the outcome after hip fractures in the elderly started in 1988 in Sweden to compare different methods of surgery, mobilization and rehabilitation. This project has attracted great international interest and several centres have participated with prospective registration. With support from the European Commission a project was started in 1995 called Standardised Audit of Hip Fracture in Europe (SAHFE). The project aims to encourage centres in Europe to participate in a hip fracture audit with a defined data set consisting of a core of 34 questions which includes outcome measures at 4 months from operation. Printed forms are distributed to the participants as well as a computer program designed for the project. In addition there is a large number of optional questions. Each participating centres collects its own data and registers for own analysis. The data are then sent to the project centre in Lund. Hospitals wishing to participate in these international comparisons are welcome. The SAHFE project will promote comparisons of demographic features, surgical technique and rehabilitation methods to facilitate the dissemination of the best practise of hip fracture surgery and rehabilitation throughout Europe. Further international participation will widen the spectrum and facilitate improvements of the hip fracture treatment of benefit both to the patients and the society which has to provide health care to the increasing number of elderly.

P. Herberts H. Malchau

Aims: In 1979 a national observation study of total hip arthroplasties was started in Sweden. The Swedish Hip Register describes the epidemiology of primary and revision surgery and identifies risk factors for failure. Every unit reports details concerning implants, surgical and cementing technique and revision procedures online via the Internet home page (www.jru.orthop.gu.se). Methods: Currently the register contains 203 625 primary total hip arthroplasties performed during 1979–2001 and 18 067 revision procedures. Revision is the failure endpoint definition and modified Kaplan-Meier statistics and Poisson models are used for survival analysis. Each hospital receive their results annually providing a system for continuous improvement. Results: The results show that serious complications have declined significantly despite an increasing number of patients at risk. The revision burden for cemented THR (94% of the implants are cemented) is only 7.5%, which is much lower than in other countries. Over the 22 year period revision for aseptic loosening has been reduced to one quarter. Demographics are important since male gender and young age significantly increase the risk for revision. Cementless implants have in general had a worse outcome than expected but improved during the last decade. Conclusion: Problem areas are the young population and revision surgery which must be improved. The revision burden is about two times higher in all other countries. This finding implies that the register is extremely cost-effective and the reduction in direct costs for the health care service in Sweden corresponds to approximately USD 140 millions over the last ten years.

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C. Delloye

Along with prosthetic components, a bone allograft is a major option to be considered in reconstructing a segmental bone loss after a primary malignant bone tumor resection.

In most cases of primary bone tumor surgery, segments of long bone will be used as allografts. These are sterilely procured in operating theatre after an organ procurement. To facilitate the reconstruction, the periarticular soft tissues along with the cartilage are also dissected free during the harvest.

Bone or osteochondral allografts can be implanted alone with osteosynthetic material or combined with a prosthesis. The allograft can be used as an osteoarticular end, an intercalary construct with or without arthrodesis or be implanted with a prosthesis.

The main indication for using bone allograft in 2003 are the intercalary bone loss, an osteoarticular defect at the upper limb, at the proximal tibia and femur if tendon insertions are to be resected and at an anatomical location where no reliable prosthetic material exists such as the scapula or distal fibula.

A risk of disease transmission and a high rate of fracture and nonunion are the main disadvantages of this material.

An anatomical reconstruction of the skeleton, the possibility to reinsert tendon insertion, the biologic anchorage of the graft with a bony callus, the absence of bone reaction to wear particles and the possibility to recreate a stable joint are among the advantages of using this bone grafting materials. With a bone allograft, virtually any segmental bone loss can be reconstructed.

Bone allografts remain a sound material to work with when dealing with a bone tumor. The surgeon must however anticipate the potential complications by performing an appropriate reconstruction.

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O. Robertsson

Aims: Realizing the problems of choosing the optimal treatment at the time of rapid development of knee implants and surgery complicated with low individual volume and long follow-up time the orthopaedic profession initiated the Swedish Knee Arthroplasty Register in 1975. Methods: All centres performing knee arthroplasty in Sweden participate in the project and the unique ID number provided to all Swedish citizens allows for tracking of the vast majority of patients. Survival statistics using revision as an end-point have been used to estimate the cumulative revision rate (CRR) of different implants and methods and postal inquiries to gather information on patient satisfaction and health. Results: The register has proved beneficial in a number of ways: Research: It is a base of information that can provide data for direct analyses or be used to facilitate separate studies. Quality:Surgeons have been warned of inferior implants, technically demanding implants, diseases not to be treated with certain methods and specifics methods of treatment. Control and comparison helps decision-making and increases the probability for appropriate choices. Guidance: Surgeons can be guided regarding preferred techniques, implant- and patient-selection and patients can be guided regarding what to expect (risk evaluation), why specific methods are to be preferred and when to wait or proceed with surgery. Political/economical benefits:Purchasers of medical treatment, are more willing to provide financial means when; effects of previous financing can be shown, the results can be documented, improvement in quality can be demonstrated and future trends can be predicted. Conclusions: The register has helped improve quality, guide surgeons and patients and benefited the orthopaedic profession as well as the nation as a whole.

K.-G. Thorngren

In Scandinavia registers of locomotor system disease and trauma were developed in the mid 1970’s. In Sweden since then there exists registers of hip and knee arthroplasties and some years later similar registers were developed in Norway, Finland and Denmark. In 1988 a register on the treatment and rehabilitation of hip fractures started in Sweden and also since 1993 a spine register has been in use. The arthroplasty registers contain parameters concerning age, sex, diagnosis and technical factors for the operation. The outcome parameter is survival of the prosthesis e.g. if it has been revised or not. The real need to perform a revision arthroplasty has been considered a sufficiently well defined parameter to register. The hip fracture registration contains also background parameters as well as rehabilitation outcome including functional outcome parameters above all walking capacity and place of living. Functional outcome and patient rated quality of life are also included in the spine register. The arthroplasty registers have been very useful to separate better from not so well performing models as well as showing the importance of good cementing technique, type of cement as well as the influence of age, sex and diagnosis in a more rapid and reliable way because of the large-scale magnitude of the study. The hip fracture register has shown the importance of optimised operation and rehabilitation, which saves considerable resources in this increasing group of elderly patients. The symposium will exemplify performance, spread and results of orthopedic registers, which is an efficient way to evaluate on a large-scale everyday orthopedic practise. This way of registration has attracted great interest and is now spreading internationally. For hip fractures a European project has started called SAHFE (Standardised Audit of Hip Fractures in Europe).

B.-D. Katthagen L. Leue

Aims: The purpose of this study is to answer the question, whether local femoral head bone banks are still suitable and how to manage and make them safe. Methods: Surgical donors (THR) are selected by medical history, clinical examination and internationally standardized serological testing. Femoral heads are prucured during THR under OR-sterile conditions. Two different viral and bacterial inactivation methods are performed regularly. Either heads are devided into halves and then autoclaved in an open sterile hot and cold resistant box (121°C,20min,1,4 bar) or entirely processed in a closed sterile box in a water bath (80°C,100min-Marburger bone bank system) and stored in a refrigerator (−80°C). Validation of inactivation has been performed using measurement of the temperature in the center of the bones. Results: 867 bone allografts processed in the described method have been transplanted between 1993 and 2001 in our hospital. Autoclaved grafts have been used in limited bone defects with good surrounding bone stock quality. Water bath treated entire femoral heads have been used in total joint revision surgery. Temperature measurement in autoclaved bones confirmed the biological validation performed by Ph. Chiron (EAMST 1993). Water bath treatment has previously been validated. These grafts proved to be safe, effective and affordable and avoid the higher infection risks of bones procured from organ donors. By the described method we are able to meet a big part of the bone allograft demand in our institution. Conclusions: Using the described method local femoral head bone banks can procure safe and reasonable bone allografts from living surgical donors (THR). Allografts from organ donors cause higher risks and should be used where structural grafts are needed.

Martti Hirn

The growing amount of tissues transplanted every year challenges the bookkeeping of tissue banks to guarantee prompt and reliable traceability. The task is even harder when the tissues are procured, stored and transplanted in diffenrent hospitals. The problems faced us during the years led us to seek a solution from the new electronic possibilities.

The Tampere University Tissue Bank is collecting tissues and data from 9 different units. The tissues have been transplanted mostly in Tampere University Hospital but delivered also to 10 other hospitals for transplantation. A Microsoft Access based program was used for bookkeeping. We had to do double work when bringing the data from papers to tha Access database. To ease the work we started to develop a Web-based program, which could discuss between the different units.

An up-to date Web-based program has been created and it has been testdriven from the beginning of September 2002. The tissue-harvesting and tissue-transplanting units can fill the electronic forms ready in Web. The central bank sees the up-to-date information in the central registry in the Web. For the sake of patient security the forms are planned so that every box in the form has to be filled or otherwise the program does not progress and you are not able to continue. We have managed to minimize the mistakes of tissue bookkeeping caused by human errors. We have also managed to speed-up and standardize the whole bookkeeping process of tissue-harvesting and tissue-transplanting dramatically. It is also very easy to generate different kind of research reports by thisWeb-based system. The security of the data is guaranteed by encrypted connections and fault-tolerant server clusters situated in high-security hosting centres.

We have been able to remove the overlapping paper work. There are no more missing or wrongly filled data. The several paper-vision files of tissue on different stages during the laboratory checking is now replaced only with one final file, which is printed for archive when the tissue has been used and also the data or recipient has been filled. The forms and the whole program are easy to modify and all users can utilize the new up-to-dated versions immediately. It makes the database very flexible and every user has the possibility to improve the program. Because of these improvements the safety and the possibility for quick traceability have been increased.

S.B.W. Vehmeijer

In the past decades the use of allografts has increased rapidly in the field of orthopaedic surgery. In particular in revision hip arthroplasty allografts are frequently employed. Several reports in the past decades on the transmission of HIV and hepatitis have, however, raised concerns on the safety of allografts. These reports have led to a revision of the standards for tissue banks. The screening of donors’ medical and social history was improved and rigorous testing methods were implemented. Processing methods introduced by tissue banks have further reduced the risk of transmission.

Despite these precautions, however, a recent report of the CDC has again caused for concern regarding the safety of allografts. After receiving allografts from a common source one patient died and another developed a serious infectious complication. These cases make it clear that the use of allografts is still not without risks. Orthopaedics should be aware of these risks but should also be familiar with the measures taken by tissue banks to reduce these. Only then can the surgeon decide whether he should use an allograft for a specific indication and more important which graft he should select.

This presentation will provide an overview of measures that may be taken by tissue banks to reduce the risk of disease transmission. Also, suggestions are made for orthopaedic surgeons for the selection of an appropriate graft from a safety point of view.

E. Czerwinski P. Dzialak J. Osieleniec

Osteoporosis is one of the most common diseases. It occurs in 11% of population and in 31% of women above the age of 50. Familial occurrence, aging, menopause, low calcium diet and smoking are the predominate risk factors of osteoporosis occurrence. Due to prevalence of bone resorption over osteogenetic processes, bone mineral density (BMD) decreases and deterioration of bone microarchitecture follows. Whether BMD loss will reach fracture threshold depends from the primary peak bone mass ( achievable at the age of 25 yrs) but it is determined by genes.

Bone fractures consist of great meaning of osteoporosis in clinical practice. Life risk of any fracture in 50-year-old women is 39.7%. Spinal fractures affect 21% of women at that age and 80% at the age of 70. Proximal femur fractures (PFF) are the most difficult and problematic. 20% of women will die during the first year after fracture and 50% of those surviving will become disabled. There were 1.700.000 PFF worldwide in 1990. Population aging will lead to more then 3 fold increase in 2050 giving 6.300.000 PFF fractures.

Fracture prevention is based on early diagnosis and treatment. DXA measurement of spine and hip BMD are the golden standard for diagnosis. According to WHO criteria osteoporosis is ascertained at level of −2.5 T-score. Treatment of osteoporosis should combine pharmacoterapy and fall prevention programme.

Jaroslaw Czubak

The term of hip dysplasia means an abnormality of shape, size or spatial configuration of the acetabulum. It also concerns the femoral head, with mutual relationships, proportions and alignment between the femoral head and the acetabulum the most crucial factors. The reason of any symptoms in hip dysplasia is the dysplastic acetabulum and its disproportion in relation to the femoral head. Dysplasia of the acetabulum appearing at puberty has been attributed to secondary “absorption” of bony acetabulum. The presence of fatigue fractures at a later age has been considered as resulting from trauma. However, the fragments of the acetabular rim should be ascribed to overloading of the rim in dysplastic hips, causing fracture and separation of its segment. They are sometimes associated with cysts in the acetabular roof. Limbus tears with or without an associated bony fragment are known to occur after traumatic dislocation of the hip but also without any history of injury. There is no explanation of their cause or their relation to acetabular dysplasia. Limbus tears have been diagnosed by arthroscopy, arthrography and CT scans.

Clinical signs. No hip dysplasia in adults is really symptom-free. A casual examination applied between the painful episodes may appear so normal, that the articular origin of the pain may be doubted. In most cases pain is elicited by passive movement of the thigh into full flexion, adduction and internal rotation. This combination of movements brings the proximal and anterior parts of the femoral neck into the contact with the rim of the acetabulum, exactly at the point where the labrum is likely to be damaged.

Preop imaging. An anteroposterior radiograph, or “faux profil” view of Lequesne de Seze may demonstrate a congruent but short acetabular roof (Type II) or an incongruent hip with a shallow acetabulum and a more vertical than normal acetabular roof (Type I). Type I hip is potentially or really unstable. The femoral head has migrated laterally or anteriorly or in both directions, distorting the spherical shape of actebular inlet into an oval. A simple 3-dimensional classification is recommended by myself using conventional X-ray and CT scan on equatorial level. The CE angle and sectors angle acc. Anda are used to describe the anterior, lateral and posterior coverage. To check the possibilities of reduction, the anteroposterior radiograph is made in max. abduction of the hip. To simulate the correction movement of the acetabular part we use our own “Super pelvis” software.

Intra-op control. For intraoperative correction control we use a C-arm, which also controls step by step all stages of the periacetabular osteotomy. To check the final correction the X-ray of both hips is absolutely obligatory. What we should check is: the displacement of the acetabular fragment (to avoid lateralization, if necessary to make medialisation) and the positions of the anterior and posterior acetabular rim. If this is impossible with the normal a-p X-ray, the C-arm is used for achieving the “faux profil”. The computer assisted orthopaedic surgery system appears the most accurate intra-op control.

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H. Kröger

Vertebral fracture (VF) is a common complication of osteoporosis. Patients with osteoporotic VFs are often without symptoms and many of these fractures are detected by chance. Only one third of VFs is clinically diagnosed. However, osteoporotic VFs may also be very painful and cause severe discomfort during several weeks. In both genders low bone mineral density (BMD), prevalent VF and increasing age are strong predictors of VF. About one fifth of the patients with a VF suffer a new VF during the following year.

Clinical consequences of VF include acute and chronic back pain, decreased quality of life and increased mortality. The care of patients with VF includes proper pain management and early rehabilitation. The use of elastic lumbosacral brace reduces pain when mobilising patient after VF. Calcitonin has been shown to have an analgetic effect. Sometimes the vertebral fracture causes a diagnostic problem and reasons other than osteoporosis should be ruled out (e.g. myeloma, lymphoma, metastases, other malign diseases). If feasible, the diagnosis of osteoporosis should be confirmed by BMD measurement. Osteoporotic VFs are seldom unstable requiring operative treatment. In case of neurological complications operative decompression and stabilisation should be considered. Impaired bone quality causes problems in pedicle screw fixation. Cement augmentation and special anchorage screws may provide increase in holding power in osteoporotic bone. Percutaneous vertebroplasty and balloon kyphoplasty are mini-invasive procedures that provide immediate and long lasting pain relief in VF patients. These techniques are technically demanding and require careful patient selection. Recent, prospective, randomized studies have shown that antiresorptive drugs can prevent new fractures in patients who had experienced previous fractures.

Jerzy Jablecki

Microsurgical techniques have become useful in reconstructive surgeryn of the hand. Toe-to-hand transplantation is currently the procedure of choice for thumb loss reconstruction, as well traumatical as congenital. For a successful outcome meticulous planning is imperative and presumes a thorough knowledge of pertinent anatomy and surgical technique

The method of thumb reconstruction must be individualized and is dependent on the patient’s functional needs, age, and the level of the amputation. Postoperatvely, diligent nursing care is essential in assuring a positive outcome.

From Nov. 1979 to Dec. 2001 53 second toe-to-hand transfers were performed at Center of Replantation of Limbs in Trzebnica/Poland. Mean age was 27 years. Males (79%) and manual workers (91%) dominated the series

The rate of failure was 5,5%. The transfer gave functionally acceptable thumb with 8–12 mm two poin discrimination, on average 55% of strength in pinching (compared with unaffected side), 35 degrees of range flexion (but with flexion contracture)and poor cosmesis. Second toe transfers are preferable in cases with proximal thumb amputations, and in children. Their main advantage is the minimal morbidity of the donor site.

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Olle Svensson

Radius fracture is the earliest and one of the most common symptoms of osteoporosisò1/6 of fractures seen in the emergency roomòand many patients with distal radius fractures would benefit from osteoporosis treatment to prevent future fractures. Nearly 80% are women, most frequent between 60–70 years of age; men have a more flattened incidence curve.

As to classification, distal radius fractures span a wide spectrum, but the sheer bulk of them calls for a simple and robust classification with a low interobserver error. Older’s classification gives an indication of the risk for redislocation, and perhaps the presence/localisation of comminution in the distal/metaphyseal areas are more prognostic than the dislocation per se in unstable fractures.

Despite improved surgical treatment, most series still report dissatisfaction rates around 20% with significant complications. One reason is that the population of patients with fragility fractures is so heterogeneous in terms of autonomy, cognitive function, and functional demands. Although anatomy does correlate with function, a stratification in background factors seems to be reasonable. The chronological age of the patient and the radiological classification grade of the fracture are often not the most important factors in terms of functional outcome, health-related quality of life and patient satisfaction in the long run.

The indications for reduction and external/internal fixations are still unclear, but there has been clear trend towards a more active approach, and a combination of different surgical techniques. But since it is still unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes, there is a need for evidence for the management of these fractures in terms of efficacy (clinical trials) and effectiveness (general practice).

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Jan Skowronski

Introduction Wrap-around procedure was introduced by Morrison and now it has full acceptation as a technique of thumb reconstruction associated with preservation of MP joint. Author presents: indications for this procedure, determination of flap diameters, bone graft and selection of dominant vessel leading to the great toe by arteriography. Aim of the study The end functional results of hand and foot after wrap-around flap procedure. Material and method 15 cases were analysed (follow-up 2–5 years) to present the functional outcomes.

Hand – the stability and MP motion in 14 case were satisfied. The sensibility, except one case, in 2 points discrimination test was between 14 mm – 20 mm. Pinch and grasp reached 40–60% of hand’s opposite site. Remodelling processes were satisfactory except one case of limited bone graft resorption which required supporting by cancellous bone.

Foot – function of the foot was outlined by podoscope and pedobarography (before and after operation). Podograms in all cases revealed limited deficits in loading pulp of toe. Pedobarograms in 6 cases revealed lateralised trajectory of loading. In these cases there were no chance to weight-bear of forefoot. In the rest cases only deficits in loading surface of the toe’s tip were presented on pedobarograms. The notices to vascular complications like twisting pedicle, constriction by tight skin closure or kinking pedicle were mentioned too. Conclusions The wrap-around procedure is good and sure method in reconstructions of adult’s thumb deficits.

H. Deramond

Aim: To describe technique, indications and results of percutaneous vertebroplasty (PV). Method: PV is accomplished by injecting cement into a vertebral body via a percutaneously placed cannula under imaging guidance. Results: In patients with osteoporotic compression fractures the treatment has to be done as early as a few weeks after the acute onset of the pain that requires parenteral narcotics. Late treatment can be successful in relieving pain particularly in patients with osteonecrosis on the site of the vertebral collapse.

PV is also indicated in patients complaining with severe back pain related to metastatic lesions or myeloma involving vertebral bodies if the lesion is not associated with neurological signs or epidural involvement. PV can be performed before radiation therapy or reserved for patients who have already received maximal dose radiation. PV induced complications are more frequent in these indications and that treatment should be considered after a multidisciplinary discussion.

PV is the treatment of choice in painful and or aggressive vertebral hemangiomas. Association with injection of absolute ethanol is suggested in aggressive forms of that pathology. Conclusion: PV is a standard of care for the treatment of pain resulting from spinal compression fractures and vertebral Hemangiomas.

A. Renner I. Zimmermann

Aims: Department of Hand Surgery in the National Institute of Traumatology and Oxyology – before 2001: National Institute of Traumatology – was established in 1959 as the first independent hand surgery department in Hungary. Our Institute was the centre of operations for thumb reconstruction nearly in 2 decades in Hungary. Methods: The techniques for thumb reconstruction, selected after considering many factors, will be presented in my lecture. All the treatment options we applied in our practice for thumb reconstruction will be summarized in the form of a table. In the first period we performed 3 stage thumb reconstructions (31 cases). This period was followed by the method of elongation acquired from professor Ivan Matev, mainly in young growing patients, but also performed in adults by extending the indications (36 cases). Phalangization proved to be an excellent technique in many patients when the major part of the first phalanx was preserved after the injury (47 cases). Results: Indications, surgical technique and results achieved with all these three methods will be highlighted in my presentation.

M. Ceruso G. Checcucci S. Pfanner

Author’s experience in surgical treatment of aplasia of the thumb according to the Buck-Gramcko procedure introduced by this author in 1971 is reported.

Inidcation of the pollicization of the index finger according to Buck-Gramcko is aplasia of the thumb in the 3rd, 4th and 5th stages (Blauth’s classification).

The surgical technique is particulary complex because of knowledge of microsurgery and soft-tissue reconstruction necessary. The different surgical phases may be schematically divided into a cutaneous stage which calls for the reconstruction of the web space, a vacular stage, a skeletal stage in which the reduction of the trapezium radial I metacarpal is reduced and a miotendinous stage.

Surgery is carried out on patients of at least one year of age as it is necessary their cardial-pulmonary system be adequately mature, development of the endostal circle, thicker vascular walls and a suitably developed bimanual grasp, as well.

The revision of these cases treated is especially significant because an average follow-up of the 17 years puts in good light the functionality of the hand, both from the points of view of strength and movement (Percival’s classification).

After a revision of the case studies with a long term f.-u. we may affirm that the pollicization of the index finger according Buck-Gramcko, to achieve the development of the first finger in opposition, is the best-choice surgery in the reconstruction of the aplasial thumb and owes its effectiveness to the association of microsurgical techniques for preparing an island pedicle composite-tissue flap to the cardinal principles of articular reconstruction and of tendon transfers.

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Eero Hirvensalo

The Act for Patient Injuries came into force on May 1987 in Finland. This Act covers all medical treatment, both public and private care in Finland including examination, surgical and non-operative treatment, physiotherapy, rehabilitation as well as patient transportation. The Finnish Patient Insurance Centre handles all claims in Finland, about 6.000 cases yearly, of which about 1.700 will give compensation to the patients. So far, operative treatment in orthopaedics and traumatology has produced most injuries. The Centre is supervised by an independent Patient Injury Board stated by the Ministry of Health. The injuries are divided into three subgroups: 1. treatment injuries, 2. injuries caused by infection and 3. true traumatic accidents. In addition, there is a special pool for medicine induced side effects or injuries which is organized in cooperation with pharmaceutical companies selling drugs in Finland.

All evaluation of each individual case is based on probability. If there is more than 50% probability between the suspected treatment phase and injury the precondition for compensation is present.

Moreover, the evaluation is concentrated to the case itself and the personnel involved will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has guaranteed that most of the injuries have been reached and evaluated by the Patient Insurance Centre. All the 18 hospital districts in Finland covering both common health services and hospital care have their own policyholder status. Total expenses, both compensation and administrative, will be charged from the districts with a non-profit principle. Private hospitals and smaller units have their own contracts with insurance companies, and medical and dental unions have contracts of their own for individually working physicians and dentists.

The prerequisite for compensation is that there has to be an objectively recognised and measurable harm to the patient due to a diagnostic or treatment procedure. In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means e.g., that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare. These are for example all injuries caused by broken medical equipment, falling of the patient during examination or treatment etc. However, it does not cover falling of the patients if this occurs during the hospital stay while no medical treatment is given.

The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.

J.G. Grohs

Aim: Stabilisation of vertebral bodies by injection of bone cement after osteoporotic fracture is well known for reduction of pain. During the last years the balloon kyphoplasty was introduced for reduction of kyphosis and increase of vertebral height. We investigated the used of this method in vertebral bodies even months after osteoporotic fractures with delayed ossification or unstable non-unions within the vertebral bodies. Methods: These fractures had a median age of 17 weeks. In the magnetic resonance imaging no signs of ongoing bone remodelling were found within the horizontal fracture gaps. In functional x-rays the instability within the vertebral body was proven. During surgery the needle was introduced via a transpedicular or extrapedicular approach and passed straight through the gap of the non-union. In very flat bones this procedure can be more tricky. The balloon was inserted and inflated to decrease the local kyphosis. After removal of the balloon bone cement (PMMA) was filled into the hole to fixate the fragments and stabilize the vertebral body. Results: The Patients had a distinct decrease in pain by preventing the movements within the vertebral body. Life quality measured with the Oswestry disability questionnaire showed a distinct and long lasting increase. Conclusion: In selected cases the balloon kyphoplasty is sufficient to reduce and stabilize vertebral bodies despite of a long period after the fracture.

S3071 TOPIC OPEN Pages 220 - 220
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Paolo Gallinaro

Negative outcomes, accidents and complications are unavoidable. In surgery as in aviation a major role is played by human factors contributing to 30 to 90 per cent of accidents. However in aviation accidents and near-accidents are investigated and all errors are reported.

Surgical errors and near-accidents are never reported nor investigated and no lesson can be learned.

U. Berlemann T. Franz S.J. Ferguson P.F. Heini

Minimal-invasive augmentation techniques have been advocated to treat osteoporotic vertebral body fractures (VBFs). Kyphoplasty is designed to address both fracture-related pain as well as the kyphotic deformity usually associated with the fracture. Previous studies have indicated the potential of the technique for immediate pain relief and reduction of vertebral height, but whether this is a lasting effect, has not been well investigated. The current prospective study reports on our experience and the one-year results in 27 kyphoplasty procedures in 24 patients with PMMA for osteoporotic VBFs.

Pain was assessed on a 0–10 VAS. Deformity and reduction of the vertebral body was measured as the angulation between the two endplates on standing lateral radiographs. All parameters were taken pre-op, one day and two months post-operatively and after one year. Multiple regression analysis was conducted to determine the importance of independent factors as predictors of the achieved fracture reduction.

All but one patient experienced pain relief directly following the procedure with a lasting effect after 2 months and also one year in 25 cases. An average vertebral kyphosis reduction of 47.7% was achieved with no loss of reduction after one year. Pain relief was not related to the amount of reduction. The potential for reduction was related to pre-op kyphosis, level treated, and fracture age, but not to the age of the patient.

In this series, kyphoplasty was an effective treatment of VBFs in terms of pain relief and durable reduction of deformity. However, whether spinal realignment results in an improved long-term clinical outcome remains to be investigated.

Roger Lemaire

Every surgical act could be considered a criminal offence, were it not for the patient’s consent. The latter formerly used to be considered implicit but it now has to be made explicit, which may include signing an informed consent document. In case of litigation, the surgeon may be required to provide evidence that the patient received full information and was in a position to give informed consent. Every adult individual is supposedly able to understand and to recall technical information on any specific operation; we know how unrealistic this is. The information should be complete, including on complications least likely to occur; it should also be made understandable to the patient. Assuming this would be possible, the surgeon may be requested later on to provide evidence that such information was provided. How to prove this remains an unsolved problem. A stereotyped informed consent document will be no obstacle to a determined lawyer. Unless every patient receives a customised information booklet written with assistance from a lawyer, the surgeon will always have difficulties in providing evidence that the patient was fully informed. Litigation will often end up with patient and surgeon presenting two irreconcilable versions. One of the reasons is poor retention of information by the patient. A number of studies all showed that retention of basic information is poor and falls down to 50 % after one week and 18 % after 6 months; besides, any “unpleasant” information will be selectively forgotten. In countries that do not have a no-fault compensation system, the only way for some patients to obtain compensation for a disability or financial harm following surgery is to sue the surgeon for malpractice. Lawyers have found out that it was easier to plead the absence of informed consent. We have no real possibility to prevent this, and the quest for absolute security would be hopeless and would result in a paranoid behaviour on the part of the surgeons. Judiciary insecurity has become part of our everyday life and we must cope with it; no-fault compensation systems may improve this but only to some extent. It is best to treat only patients with whom a confident relationship appears possible, as we know that they will usually not quite understand what is going on and will anyway forget most of the information provided.

H. Deramond

Aim: To show the place of percutaneous vertebroplasty (PV) in the treatment of painful osteoporotic vertebral compression fractures (VCF). VCF is a common and often debilitating complication of osteoporosis. Although most fractures heal within a few weeks or months, a minority of patients continues to suffer with pain that does not respond to conservative therapy. Methods: PV is accomplished by percutaneous injection of cement into the fractured vertebral body. Reinforcing and stabilizing the fracture provides pain relief. Injection of cement is accomplished under real time using a bilateral transpedicular approach or a unilateral transpedicular or parapedicular route. Results: PV is indicated in patients with severe, persistent and often incapacitating focal back pain not responding to a standard medical therapy of 4 to 12 weeks duration and related to one or more collapsed vertebral bodies. PV should be used earlier in patients at risk of immobilization complications and requiring narcotics. The success rate exceeds 90% and the complication rate is lower than 1%. Most of the complications are transient and should be avoided using good technique. Conclusion: PV should be always considered as a good alternative treatment compared to medical therapy in painful patients with osteoporotic compression fractures.

K.A. åkesson

With the increasing number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system, it is essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.

The Bone and Joint Decade initiative was developed around the core issue of improving the health related quality of life for those afflicted with a musculoskeletal condition. It was recognised that at most levels within the health care system or within society, the impact of these conditions today and for the future were underestimated both regarding number and regarding consequences; disability, handicap, societal implications or costs. The increasing population of elderly, reaching above 20% within the next 20 year, will further augment the problem within Europe, as these conditions also increase with advancing age.

In order to make a change, strategies needs to be developed addressing a number of issues: what is the incidence and prevalence of these conditions today, what is burden in terms of economic and societal costs, what is the impact on the individual and what is the outcome for the individual with optimal care but also with sub-optimal care. From systematic reviews of evidence-based interventions and collation of guidelines, recommendations for strategies including multiprofessional approaches have been developed. The evidence for interventions is identified in terms of effectiveness in dealing with symptoms, tissue damage, activities and participation. Policies can than be based on what is achievable and what is needed after local adaptation.

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Ian McDermott

The menisci function within the knee as load distributors, shock absorbers and secondary stabilisers. The medial meniscus has been shown to carry as much as 50% of the load across the medial compartment, and the lateral meniscus 70% of its compartmental load. After total meniscectomy, joint contact areas decrease by approximately 75%, and peak local contact stresses increase by as much as 235%. Meniscectomy may lead to a 14 times increase in the risk of arthritis at 20 years.

Axial load across the knee is converted into hoop stresses along the circumferential collagen fibres within the meniscus. Strong and stiff attachment of both meniscal horns, via the insertional ligaments, to the tibia is essential. Disruption of the circumferential fibre arrangement will defunction the meniscus. Preservation of meniscal tissue, where possible and appropriate, is now accepted practice.

Most techniques for meniscal repair have been validated in vitro by testing radial pull-out strengths. However, meniscal tissue is highly anisotropic, with little strength in the radial direction, perpendicular to the circumferential collagen fibres. Physiological forces in the radial direction, across the menisci, are probably only very small. Therefore, mechanical evaluation of radial pull-out strengths is probably of little clinical significance.

The role of different repair techniques, and the significance of gapping across repair sites under cyclical loading will be discussed.

Dieter Kohn

Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side.

There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use.

René Verdonk

The critical role that the meniscus plays in the knee along with the advantages of preserving as much of the meniscus as possible have both been well documented. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears.

Despite the benefits associated with successful meniscal repair there is a potential risk of complications.

The nature of arthroscopic repair does carry a certain risk.

Meniscus refixation with bioabsorbable arrows is considered reliable but shows other complications that must be kept in mind.

Despite the numerous complications discussed in the literature, virtually all of these have resolved spontaneously or had satisfactory outcomes after appropriate treatment.

Several precautions should be included in the surgical technique to minimize the likelihood of complications.

Ph. Beaufils

Meniscus repair is now an accepted procedure, but many questions remain, regarding the results, indications versus meniscal resection. How to assess the results of meniscal repair?

Clinical results doesn’t allow to assess the healing rate. Some failure of healing can be asymptomatic. There is thus a need for an objective assessment of the healing process: by arthroscopy (but it is invasive); by MRI but the hypersignal in the meniscus area is difficult to interpret. The best way seems to be arthro CT, even if it is a quite invasive technique.

Indications: Indications mainly depend on two factors: location of the lesion stability of the knee

1. Location of the lesion.

In case of lesions in the red-red zone or red-white zone: the healing potential is good ameniscectomy would be total and would lead to secondary degenerative changes. it is thus the best indications for meniscal repair

In case of lesions in the white-white zone: the healing potential is poor the meniscectomy would be partial with usual good long term results.

Indications for meniscal repair should be very selective in this occurrence

2. Etiology

2.1. ACL Tears Meniscectomy is the key of degenerative process after ACL rupture. ACL reconstruction is able to preserve meniscal status

We must thus preserve the menisci as much as possible: by doing a meniscal repair in case of unstable extended lesions by abstention if he meniscal is table.

In all the cases, ACL should be reconstructed.

Results of meniscal repair in this context are good both in terms of clinical results and healing rate

Isolated meniscal repair should be only considered in presence of 4 criteria: symptomatic meniscal lesion, no functional instability, non repairable meniscal lesion, low demanding patient

2.2. Stable Knees

Meniscectomy remains the most frequent procedute in this condition with good functional results. But, according to the long term FU results (> 10year) (multi-centre study of the SFA 1996), the rate of asymptomatic knees is only 60% on the medial side, and 50% on the lateral side. The rate of joint line narrowing is 28% on the MM and 40% on the lateral side. The recovery after lateral meniscectomy is often long with a high rate of rearthroscopy (14%). There is a specific complication on the lateral side: rapid chondrolysis by young patients.

Meniscal repair should be thus proposed as often as possible

The best indcation is a peripheral vertical lesion by a young patient.

The rate of secondary meniscectomy is about 10% but the rate of complete healing is only 50 to 60% according to the literature.

Prognostic factors are: time to surgery: recent lesions have a better prognosis (12 weeks ?) extension of the lesion side of the lesion: lateral lesion is better than medial one.

Intrameniscal horizontal cleavage grade 2 lesion by young patients is a specific indication which gives good results and avoids a total meniscectomy.

Conclusion: Meniscectomy and meniscal repair are not opposite techniques but complementaries technique.

Meniscal repair should be recommended for red-red or red-white zone to preserve the meniscus and thus the cartilage, specially on ACL unstable knees, lateral side, young patients (children+++).

But many questions remain: which strength do we need ? what about shear forces is there any secondary degenerative changes of the meniscal tissue with an increasing risk of iterative tear which long term results with the new devices ?

J. Poul

Juvenile hip instability is associated with many conditions. Most of them belong to the group of neuromuscular diseases. Generally following categories can be enumerated: 1. Cerebral palsy, 2. Myelomeningocele, 3. Spinal cord injury, 4. Paraplegia following spine surgery, 5. Poliomyelitis, 6. Inflammatory hip disease, 7. Idiopathic instability, 8. Recurrent post-traumatic hip instability. In the groups 1–5 a chronic muscle imbalance is the reason of the displacement of the femoral head. Inflammatory joint disease produces displacement through cartilage and bone destruction and increased intra-articular pressure. Very rare idiopathic instability is usually associated with generalised hypermobility. For the early diagnosis a careful clinical examination is necessary involving range of motion, testing of the hip stability by the Palmén’s test in the same way like in new-borns. Routine x-ray screening at least once per year is mandatory. For the groups 1–5 a muscle imbalance has to be corrected first. Elimination of muscles contractures or muscles transfers respectively, showed a high efficiency if these surgical corrections were performed early. Femoral osteotomy alone does not provide reliable results. Any form of pelvic osteotomy is necessary to correct acetabular insufficiency. For the inflammatory hip disease early active surgical treatment is best prevention of displacement. Idiopathic hip instability has to be differentiated from common snapping hip. No treatment is necesary. Recurrent hip dislocation can be cured by a posterior capsulorrhaphy.

B.W. Schreurs S.B.T. Bolder P. Buma N. Verdonschot

Bone impaction grafting of the femur is associated with more complications when segmental defects are present. The effect of segmental defect repair on initial stem stability was studied in an in vitro study with fresh frozen goat femora. A standardized medial segmental defect was reconstructed using a cortical strut or a metal mesh. As controls we used intact femora and femora with a non-reconstructed defect. In all four groups impacted bone grafting was performed in combination with a cemented Exeter stem. Each group contained five femora. Reconstructions were dynamically loaded up to 1500N. Migration was measured with Roentgen Stereo-photogrammetric Analysis. All cases with a non-reconstructed segmental defect failed into excessive varus rotation. None of the femora with a reconstructed defect failed. Cortical struts and metal meshes were equally effective in creating a stable stem construction (varus rotation 2.89±2.27 and 2.27±0.57, respectively). Reconstructions with a metal mesh were more reproducible, although the obtained stability was significantly lower (p< 0.01) when compared to impaction grafting in an intact femur (varus rotation 0.58±0.36).

Besides, structural grafts may negatively influence the revascularization of the underlying impacted grafts in contrast to an open wire mesh. So, an in vivo study of 12 goats was done. A standardized medial wall defect was reconstructed with a strut or a mesh in six goats per group. In all femora impaction grafting was performed in combination with a cemented Exeter stem. After six weeks the femora were harvested. A high rate of peri-prosthetic fractures was found (43% and 29% for the strut and mesh groups, respectively). Histological and micro-radiological examination showed different revascularization patterns for both reconstruction techniques. In the strut group revascularized graft was found at the edges of the defect. In the mesh group fibrous tissue and blood vessels penetrated through the mesh and a superficial zone of revascularized grafts was found. Segmental defect reconstruction with a strut reduced the amount of revascularized grafts medially behind the strut (p=0.004). This may interfere with the stability of the stem in the first period after surgery and the incorporation of the impacted grafts on the long-term.

We would recommend segmental defect reconstruction with a mesh. A regime of unloading and long-stem prostheses should be used, irrespective of the reconstruction technique

W.M. Strobl

Aims: Instability and dislocation of the hip is one of the most striking problems for children and young people with neuromuscular disorders. The purpose of this study was to find out pathomechanical risk factors relating to specific neuromuscular disorders. We compared our findings with literature and questioned if there is any impact on current screening and treatment principles. Methods: In a prospective long-term-study 2500 patients with neuromuscular disorders regularly underwent analysis of both muscular dysfunction and structural deformities by clinical examination and native radiographs. Walking patients had additional slow motion video-analysis and in the case of surgical intervention pre- and postoperative 3D-gait analysis. The vast majority of patients with the TBI-type of cerebral palsy had unstable hips. 66 severely subluxated or dislocated hip joints underwent 3D-CT-scan examinations prior to surgical reconstruction, soft tissue releases and muscle transfers. Conclusions: Developmental biological studies presume that a complex systemic network of both genetical determining factors and external biomechanical influences affect physiological growth and maturing of the juvenile hip joint. Under clinical condiions it may be possible to discover and analyse some of the most important factors. Primary, compensating and secundary functional disorders have to be differentiated by clinical examination, radiographs, and motion analysis. Increased or spastic and decreased or paretic muscular activity may cause different degrees of muscular imbalance. Together with additional compensating movements they form specific pathological motor patterns which occur typically related to specific neuromuscular diseases.

J. Poul

Aims: Several authors reported better results after combined tenotomy of hip flexors and adductors in cerebral palsied (CP) children than by isolated tenotomy of adductors. Prospective study involving 45 children (90 hips) was performed in this research project. Methods: 45 children with spastic form of CP in the age range of 2–13 years (preoperative Reimer’s index in 25 hips 0–24%, in 38 hips 25–39%, in 18 hips 40–59%, in 9 hips over 60%) were submitted to combined adductor and flexor release. All patients were postoperatively immobilised in broomstick POP cast for 6 weeks and cured by night splinting for at least 6 months postoperatively. Routine x-rays were taken before operation, after removal of POP cast and 3–5 years after operation, all in strictly neutral position. Results: Mean Reimer’s index correction was 16%, maximally 49% in 76 out from 90 affected hip joints. CE angle correction ranged from 3 to 48 degrees. Postoperative changes of both parameters were statistically siginificant. Using Vojta kinesiologic grading 41 children (91%) became improved. The proportion of walkers/non walkers changed from 9/36 to 27/18. Conclusions: In this cohort the correction of Reimer’s index under 39% was achieved in 96% of all treated patients. Many patients benefited from the operation becoming walkers. Adequate soft tisue procedure offers a very good possibility how to reduce the rate of osteotomies in CP patients.

K. Dreinhöfer

Aims: The purpose of this presentation is to discuss what population interventions are effective, what the evidence for the different interventions for the different conditions is and how one can identify those who will benefit most. Methods: Evidence of effective interventions for primary, secondary and tertiary prevention of the individual conditions has been identified from systematic reviews and guidelines through literature review. From this and expert opinion, recommendations have been developed which follow a template to enable common themes appropriate to the different musculoskeletal conditions to emerge. Results: Common factors with an effect on the population level on different musculoskeletal conditions include exercise, body weight, diet, smoking, alcohol and occupational factors. One specific factor is injury prevention including falls to prevent osteoporotic fractures. One recommendation supported by evidence that applies to all conditions considered is the need for early appropriate intervention for those at highest risk or with early features of the condition. Evidence for the different interventions for the conditions will be presented Conclusions: Prevention of musculoskeletal conditions on a population level is possible. If risk factors for the different conditions are identified, development of effective interventions is necessary.

K. Dreinhöfer

Aims: The purpose of this presentation is to discuss what population interventions are effective, what the evidence for the different interventions for the different conditions is and how one can identify those who will benefit most. Methods: Evidence of effective interventions for primary, secondary and tertiary prevention of the individual conditions has been identified from systematic reviews and guidelines through literature review. From this and expert opinion, recommendations have been developed which follow a template to enable common themes appropriate to the different musculo-skeletal conditions to emerge. Results: Common factors with an effect on the population level on different musculoskeletal conditions include exercise, body weight, diet, smoking, alcohol and occupational factors. One specific factor is injury prevention including falls to prevent osteoporotic fractures. One recommendation supported by evidence that applies to all conditions considered is the need for early appropriate intervention for those at highest risk or with early features of the condition. Evidence for the different interventions for the conditions will be presented Conclusions: Prevention of musculoskeletal conditions on a population level is possible. If risk factors for the different conditions are identified, development of effective interventions is necessary.

Anna K. Hell Reinald Brunner

Neurological problems such as cerebral palsy, myelomeningocele and others may lead to unstable hips in children and juvenile patients. Major problems may arise due to the inability to treat the underlying condition. Patients may suffer from spasticity, reduced muscular tone, bone loss or bony deformity. Despite these problems several tactics are used to gain long-term reduction of unstable hips.

Femoral osteotomies are done alone or in combination with pelvic osteotomies, and/or muscular procedures. The indication of the femoral osteotomy alone is the unstable hip with a normal pelvic anatomy shown in the three-dimensional computed tomography (CT). Long-term follow up (11 to 18 years) of patients with intertrochanteric femoral osteotomy alone resulted in hip centration if patients were younger than four years of age at the time of surgery. In older patients hip centration always improved but femoral osteotomies alone did not result in sufficient coverage of subluxated or dislocated hips. Therefore in these patients with pelvic deformity we perform an intertrochanteric varusderotation and shortening osteotomy to correct the femur deformity in combination with a Pemberton type peri-acetabular pelvic osteotomy, an open reduction of the hip joint and a capsuloraphy.

E. Ornstein

Aim: To find out when, at which interface, and to what extent migration of the Exeter stem after revision with morselized allograft bone and cement takes place and to evaluate if restricted weight bearing had any influence on the migration pattern. Methods: 40 stem revisions were followed by radiostereometry (RSA). The surgical procedure described by the Exeter group in England (Gie et al 1993) was used. Results: Most migration occurs within the first weeks after surgery. The Exeter stem migrates “within” the cement mantle and the stem-cement beam also migrates relative to femur.

All stems migrated distally and most of them also migrated medially or laterally and posteriorly. Migration was still observed in one third of stems between 1.5 and 2-year follow-ups. At 2 years stem subsidence averaged 2.5 mm, medial or lateral migration averaged 1.2 mm and posterior migration averaged 2.9 mm. No correlation to the preoperative bone stock deficiency was observed. Between 2 and 5 years only marginal migration occurred in 11 of the 15 stems followed for 5 years.

No differences in the migration pattern were detected when free weight bearing was allowed immediately after revision in hips without intraoperative skeletal complications as compared to when restricted weight bearing was practiced. No rerevision was performed. Conclusions: Most migration occurs early. Subsidence occurs of the stem within the cement mantle and of the stem-cement beam. Many stems migrate marginally even after 2 years but this does not deteriorate the results during the first five years. Restricted weight bearing postoperatively in uncomplicated cases might not be needed.

Ullmark Gösta

The clinical success of revision THA combined with impaction morcelised bone graft is completely dependent on healing of the bone graft. Both the platelets inside a fibrin clot contained in the graft bed, and the row bone surfaces of bone graft pieces leak bone morpogenetic proteins essential for healing.

Pre operatively in the state of aseptically loosening when osteolysis is the predominant metabolism, there are also a bone healing activity present in the endosteum, as could be visualised studying Flouride-uptake in a Positron Emission Tomography scan.

One day after revision THA using a Lubinus SP II stem with impacted morcelised fresh frozen and fat reduced allografts, no bone healing activity could be detected using PET.

8 days after the same kind of surgery an intense bone healing activity detected as an elevated Flouride-PET uptake was seen.

3 weeks after the same kind of surgery, histological analyses of human biopsies from the graft beds surrounding femoral stems revealed an intense state of healing. A fibrin clot, invaded by inflammatory cells, predominantly granulocytes, was surrounded the necrotic graft pieces. Fibroblasts creating a granulation tissue with newly formed capillaries were also seen in the graft bed. This is the healing scenario normally seen at periostal callus formation. Occasionally bone formation with osteoide was seen in the periphery of the graft beds at this early stage.

3–4 months after surgery histological analyses showed the fibrous healing to have reached 3–5 mm inside the graft beds. Bone healing was somewhat slower; it had reached 2–4 mm.

At this stage a continuously high bone healing activity could be confirmed using PET.

6 months post operatively the fibrous and bone healing had advanced further 2–3 mm.

10 months after surgery, the superficial 3-mm of the graft beds were mainly bone healed as seen by histology. Also the deeper layers of the graft beds were now in an intense state of bone healing. The secondary stage of bone healing, creating new Haversian canals and trabeculares in the direction of load, visible in plain radiographs, is not yet present at this time.

1 year compared to 1 week after surgery PET scans revealed the maximal bone forming activity to have advanced from the surface of the graft beds (which is in the interface to the endosteum) to the deep graft area close to the cement mantle surrounding the stem.

1 1/2 year after surgery is the earliest stage, to my knowledge, when new trabecular formation inside the graft bed can be detected at plain radiographs. Predominantly first visible in the most loaded Gruen zones. If new trabecular formation is not detected after 3 years it is unlikely to become present at al. Cortical repair however may be detected after half a year.

The course of healing described here is to my knowledge predominant. Less good healing scenarios do however occur. Whole or parts of the graft bed may remain necrotic, as has been described in the literature. In case of non-healing, the stem and the cement mantle is bound to a slow but continuos subsidence. Pain is not likely to occur until the tip of such a stem is in contact with the cortex.

Christopher Curwen I. Karnezis

Aims: Given that all previous reports on the increased-crystalinity, increased modulus of elasticity, yield strength and density Hylamer polyethylene have been based on observations on uncemented metal-backed acetabular cups, the aim of the present study is to investigate the rate of wear of a cemented Hylamer UHMWPE acetabular cup. Methods: 36 consecutive cases of THA (mean age: 54.7 years) using a cemented Hylamer UHMWPE acetabular cup and a cemented femoral stem were prospectively followed-up with yearly radiographs for an average period of 54.4 months. Two-dimensional femoral head penetration was determined from AP pelvic radiographs, using computeraided uniradiographic methodology. Multiple regression analysis was used to identify all predictor variables that may account for increased average linear and calculated volumetric wear (Kabo’s formula), as well as for increased total area of peri-prosthetic osteolysis on the femoral and acetabular sides. Results: The average linear wear rate was 0.35 mm/year (SD 0.12) with a significantly high average linear wear rate during the initial (‘wear-in’) period (approximately 12–18 months). The average total volumetric wear was calculated to 764.4 mm3 and the average volumetric wear rate to 169.8 mm3/year. Significant osteolysis was seen in an average of 1.5 (range: 0 to 7) out of the 7 Gruen zones on the femoral side and an average of 1 (range: 0 to 3) out of the 3 Charnley-Delee zones on the acetabular side. Conclusions: Increased rate of linear wear and a high rate of peri-prosthetic osteolysis have been observed in the early results of our series of cemented Hylamer UHMWPE acetabular cups.

Hamadouche Moussa F. Madi L. Kerboull J.P. Courpied M. Kerboull

Aims: The aim of this open prospective study was to evaluate the minimum 2-year follow-up outcome of a consecutive series of low friction total hip arthroplasties combining zirconia on polyethylene. Methods: Between January 1997 and June 1999 fifty-five total hip arthroplasties were performed in 51 patients. The mean age was 52.2 ± 12 years. The 22.2-mm femoral head made of zirconia ceramic was secured to the femoral component through a Morse taper that had an angle of 11°25 for 27 hips and 5°40 for 33 hips. All prostheses were of Charnley-Kerboull design. Clinical results were evaluated according to the Merle d’Aubigné hip score. Wear of the acetabular component and periprosthetic osteolysis was measured on serial radiographs of the pelvis. Results: The mean follow-up of the series was 32 months (24 to 48 months). No patient was lost to follow-up. The mean functional hip score significantly increased from 12.2 ± 2.6 preoperatively to 17.8 ± 0.2 at the latest follow-up (paired Student’s t test, p < 0.0001). None of the acetabular or femoral component had migrated. Wear of the socket was always undetectable on plain radiographs. However, lytic endosteal lesions of the calcar were observed in 19 of the 55 arthroplasties (34.5%). These lytic lesions appeared between the first and second postoperative year. Conclusions: Early calcar osteolysis observed in this study can be related to either run-in wear or to preliminary severe wear. The authors do not recommend further use of zirconia ceramic until long-term follow-up studies are available.

O. Hersche U. Munzinger

Aims: The aim of the study was a ten-year survivorship analysis of the cemented Weber stem. This cemented, collared stem is successfully implanted since 1968, but exact data were lacking until now. Methods: Between 1984 and 1990 1374 Weber stems have been implanted at our institution in 687 male and 687 female patients with an average age of 62 (63 resp.) years. After surgery and at regular intervals thereafter the patients are clinically and radiographically controlled. Those patients with incomplete data were contacted by telephone or by letter. Results: The Weber stem was combined in 623 cases with an Endler cup, which is an uncemented threaded polyethylen cup and in 612 cases with a Zwey-müller cup, a threaded titanium shell with a polyethylen inlay. In the other cases different cups in small numbers were used. The rate of intraoperative complications was 5% and the rate of postoperative complications was 6%.

310 patients (23%) had to be revised after an average duration of eight years. In 233 cases only the cup was revised, in 35 cases both components were revised and in 14 cases only the stem was revised.

In 222 of the 233 cup revisions (95%) the Endler cup had failed. In the 35 cases with revision of both components the Endler cup had failed in 28 cases. In the 14 stem revisions only in two cases an Endler cup was involved. The Endler cup resulted in a significant increase of stem revisions. The ten-year survivorship of all hips was only 82% due to the high failure rate of the Endler cup. If only the stem was analysed the ten-year survivorship increased to 96%. Conclusion: This high survival rate confirms the clinical impression of the excellent performance of the Weber stem.

M.R. Norton R. Yarlagadda G.H. Anderson

Aim: To report the early results of the Elite Hylamer hip with Zirconium femoral heads in patients younger than 60 years. Methods: 29 hips were implanted in 26 patients by a single surgeon with a specialist interest in hip arthroplasty. Third generation cementing techniques were used for all implants. All patients have been followed up. There has been one death. Results have been analysed using the life table method using the Peto method for 95% confidence intervals. Results: Mean age 49.2 years (range 31–57). 12 Females and 17 Males.15 of 29 hips (53.3%) have been revised or are currently on the waiting list for revision surgery. These failures have occurred in 7 Females and 8 Males. Mean time to failure 35.4 months (range 18 to 68 months). All failures have been as a result of aseptic loosening. Survivorship analysis reveals a 32.42% survival at 5 to 6 years (6.9% standard error). Conclusions: At the time of its introduction, Hylamer was thought to represent a significant step forward in the reduction of the problem of osteolysis. This however has not been our experience. In the light of the catastrophic failure rate in this series of patients, all postoperative X-rays were critically reviewed. We were unable to observe any dramatic technical errors by way of implant malpositioning and cement mantle deficiencies to account for the observed failures. We have also seen that statistically there is no difference in the hip scores for the patients whose hips have failed and those who have not yet met the criteria for failure. In view of this it is imperative that patients with this implant should be reviewed both clinically and radiologically. We feel that these results should be published earlier rather than later to ensure that others remain vigilant in the follow up of their patients

Christof Rader T. Barthel C. Hendrich M. Bockholt J. Eulert

Aims: The purpose of the study was to obtain long-term results after total hip arthroplasty (THA) with cemented titanium stems typ Mueller-Geradschaft. Methods: 91 patients with a total of 110 THA were clinically and radiologically examined after an average follow-up of 9,5 years (9 to 11). The recruitment was 84%. The Harris score was determined clinically. Radiologically the directly postoperative radiographs were compared to the control radiographs according to the recommendations of Gruen et al. and Johnston et al. Results: In 1 cases (1%) a septical complication appeared after two years which was treated in two-stage surgery. Revisions after aseptic loosening have been carried out in 4 cases (4%). No other cases showed evident signs of loosening and applied revision surgery. Clinically, in all of those 4 cases of aseptic loosening the Harris score remained above 75 points. Altogether in 36 cases more than one RLL was ascertained which were only be observed in zones 1, 7, 8, 14. The body weight was significantly higher (82 kg; d=2.4) in the 4 revisions than in cases without RLL, especially the ratio body weight to surface of the stem was clearly different (1.5 kg/cm2 versus 1 kg/cm2; p< 0.005) in the two patients groups. This did not apply to sex, activity, size or kind of stem, Harris-score, ectopic ossification or body-weight index. Conclusions: Cemented titanium stem protheses showed good long-term results. The biggest possible stem should be implanted. Periodically, radiological controls of THA are necessary because the subjective findings of patients does not correlate to the state of prosthesis loosening

M.A. Hafez A.P. Wright J. Smith P. Venugopal P.D. Angus

Introduction: There are more than 60 different hip prostheses currently available for total hip replacement (THR). Cemented prostheses make up about 90 to 95% of current total UK market. The cost of THR prosthesis varies widely with some prostheses cost 5 times more than others. Furlong Stainless steel cemented is a low-cost prosthesis that has been used in few hospitals in UK and Europe. There is no published data to report its survival and performance. Aim: To evaluate the outcome of a low-cost THR prosthesis (Furlong stainless steel) that has been in use in our hospital since 1993. Patients and Methods: we retrospectively reviewed 142 THR performed between 1993 and 2001. The average age was 72 and osteoarthritis was the primary pathology in 92%. Operations were performed by different grades of surgeons. 25 patients were dead at the time of the study. Results: 4 cases underwent revision (2.8%) with survival rate of 97.2%. 6 cases of dislocation, 17 cases of heterotopic calcifications, 5 cases of DVT and one neurological injury. 88% reported no pain and 79.6% were satisfied. Conclusions: The results of this study compare favourably with Furlong Titanium cemented prosthesis and other popular THR prostheses (e.g. Charnley). It is rational to continue using this prosthesis, which appears to be cost effective.

S.I.M. Umarji M. Beer R.S. Twyman A.G. Cobb

Aims: A prospective study of the long term fixation of an all- polyethylene acetabular component with a 2mm rim for cement pressurisation, and methylmethac-rylate spacer beads for optimal cement mantle thickness. Methods: A consecutive series of 1348 hip arthroplasty patients aged between 23 and 94 (average 68 years) has been prospectively studied between 1993 and 2002. The cemented Ultima (De Puy) stem and cup were used via an anterolateral approach by 6 surgeons in a District General Hospital. Clinical and radiological assessment was at 0, 2, 5, 6, 7 and 8 years. Detailed assessment of the cup has been carried out to determine cases of clinical or radiological failure, quality of cement fixation to bone, and the profile of the cement mantle. Results: 875 patients have been followed up for a minimum of 2 years, 52 for a minimum of 8 years. The cumulative survival rate of the cup using revision for aseptic loosening as an endpoint at 8 years was 98% and using radiological evidence of loosening as an endpoint was 96%. There were no cases with less than 2 mm of cement mantle thickness and good quality bone cement interface was seen in all on the initial postoperative films indicating adequate pressurisation. Conclusions: The design of the Ultima polyethylene cup has been successful in achieving good cement pressurisation during implantation, an even cement mantle thickness, and clinical success rates which compare favourably with other cemented acetabular components.

J. Fischer M. Waseem K. Barnes

Aims: This study reports a retrospective review of notes and x-rays of 45 patients who underwent fixation of inter- and subtrochanteric fractures of the femur with the Intramedullary Hip Screw. Methods: 45 consecutive patients who underwent IMHS fixation between 1998 and 2001. Diagnoses: 24 intertrochanteric- and 15 subtrochanteric fractures, 2 prophylactic nailings for metastases, 4 reoperations for previously failed DHS/DCS. Data collected from patient notes included the intra-operative use of skeletal- vs. ski-boot traction, intra- and postoperative complications. X-ray review included classification of the fractures, grading of osteoporosis, measurement of neck-shaft angle, screw position in the femoral head, and distance from the screw to the nearest cortex. Results: The rate of intraoperative complications was 8,8%, post-operative complications occurred in 13,3% of the patients. The mortality rate within the first 3 months was 15,5%. Re-operations were necessary in 4,4% of the patients. The sliding screw was positioned in the middle sector of the femoral head in the coronal plane in 17 patients and in the sagittal plane in 14. Superior position occurred in 18 cases, inferior in 4, anterior in 4 and posterior in 16 patients. Conclusions: The main complication in our series was screw cut-out from the femoral head. This occurred in 4 patients, 2 of whom were previously failed DHS/DCS fixations. There was no single factor predicting implant failure. The results for primary fixations are comparable to most reported series in the literature and show that the outome is dictated by the original fracture pattern. There is a high failure rate if the implant is used for revision procedures.

S.I.M. Umarji B.J.A. Lankester G.C. Bannister

Aim: To compare extracapsular and intracapsular proximal femoral fractures in terms of pain scores, morbidity, mortality and total stay in hospital. Method: A prospective study over a 8 month period at a regional trauma centre. 170 patients over 60 years of age were included and their mean age was 82.6 years. Pain scores were recorded daily using a visual analogue scale. Results: Extracapsular fractures are more painful (p< 0.01 Mann-Whitney), associated with greater morbidity (p< 0.05 Chi-square, Fishers Exact) and are slower to recover (p< 0.01 Mann-Whitney) compared to intracapsular proximal femoral fractures. There was less mortality associated with undisplaced intracapsular fractures compared to all others (p< 0.01 Mann-Whitney). Conclusions: trochanteric proximal femoral fractures are more problematic medically and as such require more medical, nursing and resource input compared to intracapsular fractures. This knowledge can be used by the clinician to anticipate greater morbidity and as such treat more promptly.

Antonio Moroni C. Faldini F. Pegreffi S. Giannini

Aims: We compared treatment with external fixation (EF) vs DHS in osteoporotic trochanteric fractures. Methods: 40 patients were randomized to receive either 135° 4-hole DHS (Group A) or an Orthofix trochanteric external fixator with 4 hydroxyapatite-coated Osteotite pins (Group B). Inclusion criteria were: female, age ≥65 years, AO fracture type A1-2 and BMD lower than -2.5T score. Fixators were removed at 3 months. Results: There were no differences in patient age, fracture type, BMD, ASA, hospital stay, or quality of reduction. Operative time was 64±6 minutes in Group A and 34±5 minutes in Group B (p< 0.005). Average number of blood transfusions was 2±0.1 in Group A, and none in Group B (p< 0.0001). Fracture varization at 6 months was 6±8° in Group A and 2±1° in Group B (p=0.002). Harris Hip Score was 62±20 in Group A and 63±17 in Group B (ns). In Group B, no pin-track infections occurred. Pin fixation was maintained over time, as shown by no differences between pin extraction and insertion torque. Conclusions: We consider EF a viable treatment option for this patient population. Operative time is short, postoperative complications are minimized, and fixation is improved.

N.H. Shah N. Walton T. Sudhahar S.T. Donell

Aims: To compare the results between intramedullary hip screw (IMHS) and dynamic hip screw (DHS) regarding operative time and radiation exposure time Methods:We reviewed radiation exposure times obtained during the fixation of 281 extracapsular proximal femoral fractures. Dynamic hip screw was used in 148, and intramedullary hip screw was used in 133. Results: The results showed that there was no statistical difference in ionising radiation exposure in closed reduction of these fractures regardless of fracture configuration or surgical experience of the surgeon, but there was a statistical difference in implant insertion time and radiation exposure (p= < 0.05). Conclusions: We conclude that intramed-ullary implant takes more radiation exposure because they take more time for insertion, which is irrespective of surgical experience and complexity of fracture.

V.K. Peter A. Mohsen M. Bielby R. Philips K. Sherman W. Viant

Aims: Dynamic hip screw for intertrochanteric fractures is one of the most common procedures performed by orthopaedic surgeons. The prerequisite for proper placement of the implant is accurate insertion of the guide wire. The Computer Assisted Orthopaedic Surgical System [CAOSS] is designed to assist the surgeon by planning the trajectory based on one intra-operative AP and Lateral image from a C-Arm. Methodology: After closed reduction on the fracture table, two near orthogonal x-ray images containing the proximal femur with the registration phantom are obtained using a standard C-Arm and then processed after distortion correction. The phantom is supported by an end effector, which is continuously tracked in 3D space. Features of interest are extracted and the image registered in space through the evaluation of the phantom’s projection in the x-ray image. The versatility of the CAOSS is increased by the provision allowing the adjustment of the planned trajectory to the surgeon’s satisfaction. Once the trajectory is accepted, the surgeon implements the plan by moving a passive manipulator arm, while receiving visual positional cues from the computer in the form of a targeting screen. When the targeting is complete; the arm is locked in position and the trajectory implemented. Results: We present the results of the pilot clinical study involving 10 patients using this device. The results obtained were compared with an equal number of patients randomly selected from the complete neck of femur database, who had undergone a conventional DHS placement, during the last one-year. Accuracy of placement of the implant was assessed by an independent observer and by a previously validated computer program that assesses the accuracy from scanned post operative X-rays. The average targeting time was 6 minutes and overall there was no significant difference between the two groups.

Elyazid Mouhsine R. Garofalo M. Hofer F. Chevalley

Background: Extracapsular fractures of proximal femur are known to have a significatively high morbidity and mortality rate at one year, and this rate is higher in case of non operative treatment. The standard gamma nail (SGN) was originally designed to provide a stable implant which allows early mobilisation and weight bearing of the elderly patients. The design of SGN however, appeared to be associated with intraoperative or postoperative femoral shaft fractures in up to 17%, requiring further surgery and compromising the outcome in these elderly patients. The trochanteric nail (TGN) was developed to overcome the problems encountered with the use of the SGN.

We report our experience in the use of the TGN in the treatment of extracapsular fractures of proximal femur. Methods: Between December 1999 and January 2001, eighty-seven consecutive patients with an extra-capsular fracture of the femur (in one case bilateral) and one patient with a proximal femoral metastasis were treated with a TGN. Nine patients died within four months of the operation and 3 were lost at follow-up. Seventy-five patients, for a total of 76 fractures were followed clinically and radiographically until the end of treatment, for a mean follow-up period of 10 months. Results: In none of 88 cases did an intraoperative shaft femur fracture occur, nor was this complication observed in the 76 femurs evaluated at follow-up. Postoperative infection was never found and union was achieved in every case. Two cases of cutting-out were reported and both were caused by incorrect placement of implant. Only nine patients (12%) required two crutches or walker at the last follow-up. Conclusion: The TGN is a promising alternative for the treatment of extracapsular fractures of the proximal femur. This implant enables the surgeon to treat most of intertrochanteric and high subtrochanteric fractures with a less invasive technique, and permits early mobilisation and unprotected weight-bearing, without the complications observed with the use of the SGN.

M. Ramakrishnan S.S. Prasad J.C. Kaye

Aim: To report our experience with a newly devised Long Proximal Femoral Nail [Long PFN] for treating complex subtrochanteric femoral fractures. The nail has the advantage of providing rotational as well as axial stability in the proximal femur with its hip pin in addition to the strong hip screw and easy operation technique. Methods: Twenty-four consecutive patients with twenty-four displaced subtrochanteric femoral fractures were treated with long PFN. The fractures were classified according to the Seinsheimer’s criteria. In 9 patients, the proximal femur had posteromedial wall comminution with displacement. The average age of the patients was 68.7 years. Closed reduction of the fracture was attempted in all cases and when it failed to achieve satisfactory reduction, a limited open reduction and cerclage cabling of the fracture was performed prior to the nailing with a particular emphasis on the postero-medial wall reconstruction. Result: The average follow up period was 49.7 weeks. All fractures in our series achieved bony union with an average time to union of 24.5 weeks. No patients had implant failure and no deep infection noted in the patients who had limited open reduction. Two patients had chest infection and one had non-fatal pulmonary embolism. Conclusion: Long PFN is a reliable implant in the treatment of complex subtro-chanteric fractures. Posteromedial wall reconstruction of the proximal femur is mandatory when treating sub-trochanteric fractures with Long PFN to avoid mechanical failure and non-union.

C. Faldini G. Calvosa F. Calderazzi S. Crimaldi A. Faldini S. Giannini

Aims: The pourpose of this study is to review a series of A2 intertrochanteric fractures in old, obese osteoporotic patients treated by total hip arthroplasty. Methods: 52 patients with A2 intertrochanteric fracture aged ≥ 75 years, mentally healthy, with BMD lower than 2.5 T score and Body Mass Index ≥30 were selected. They were 40 female and 12 males, aged 82±5 years with Body Mass Index of 32±2. Through a Hardinge approach to the hip, the femoral head was removed and a cemented cup and stem were implanted. Then the greater trochanter fragments were fixed by cerclage. The lesser trochanter fragment was not fixed. Medius gluteus muscle fibers were sutured to the greater trochanter and to the vastus lateralis muscle. All patients were allowed weight bearing as soon as possible after surgery. Results: No surgical complications were observed. Average Harris Hip Score at 1 month was 63±9 at 3 months 77±6 and at 1 year 78±7, at 5 years follow up 76±14 in the 24 patients still alive. None of the other died for causes related to the interthrocanteric fracture. Average return to normal daily activity time was 27±5 days. Conclusions: Total hip arthroplasty is a safe procedure for treatment of old, obese osteoporotic patients affected by A2 intertro-chanteric fractures. In fact, no failure occurred in any of the patients allowed unrestricted weight bearing from the first day after surgery. Moreover, they could return to normal daily activity in less than 5 weeks.

Daniel Hernandez-Vaquero A. Suarez-Vazquez M.A. Garcia-Sandoval J.M. Fernandez-Carreira D. Perez-Hernandez

Aims: To study the utility of a computer assisted orthopaedic surgery (CAOS) wireless system (navigator) in Total Knee Arthroplasty (TKA). Methods: Randomised prospective study. A sample of 40 TKA patients was randomised in two groups: CAOS was used in 20 of them. In the other group standard technique with manual alignment was performed. Femoral angle (formed between the femoral mechanical axis and the femoral component), tibial angle (formed between the tibial mechanical axis and the tibial platform) and femorotibial angle (formed between femoral and tibial mechanical axes) were measured from Computed Tomography Surviews taken in the immediate postoperative period. Results: In the standard group (without navigator) the femoral angle mean was 91.7° (ranged 90 to 94°). Tibial angle mean was 90.2° (87°–95°) and femorotibial angle mean was 175.9° (172°–180°) showing a slight prevalence of varus deviation of the extremity mechanical axis. In the group with navigator the femoral angle mean was 90.2∞ (87–93°), tibial angle mean 89.6°(85°–93°) and femorotibial angle mean 179.2° (177°–182°). There were statistically significant differences between groups for the femoral angle (p=0.001), and the femorotibial angle (p < 0.001). An ideal femorotibial angle (180±3°) was achieved for all the patients of the CAOS group but only 9 patients of the standard technique group reached this objective (p< 0.001). Conclusions: The use of CAOS for TKA favors the implant placement in a position nearer to the ideal mechanical axis.

M. Sparmann B. Wolke M. Lautenbach

Aims: The purpose of this study was to find out if navigation devices can improve the alignement of knee arthroplasties even in experience surgeons. Methods: An external group of investigators – members of the Department of Epidemiology of the German Research Institute of Rheumatology – designed a prospective randomized study for the anlayzes of the alignement of knee implants with and without the support of a navigation device. Long standing X-rays before and after surgery were performed. The analyzes of X-rays was done in an external department of radiology. The analyzing radiologers didn’t know to which group the X-rays belonged. In total 120 patients with and 120 patients without the use of the Stryker navigation device were analyzed. The results were compared with the Qui square test. Results: There was a significant difference between the group of non navigated and navigated total knee arthroplasties. In the group without navigation system between 3 and 6% of the implants were positioned in mal-alignement of more than 3°. In the navigated group there was no case which differed to far from the ideal mechanical line. Conclusions: Even in the hands of very experienced surgeons the use of a navigation device can improve the alignment of implants. This study could prove it in concern of varus/valgus-position of the femoral and tibial component but also in the flexion/extension-position of the femoral component and the slope of the tibia component. The positioning was much more accurate in the navigated group. There was no case in the navigated group with wrong alignement.

J. Victor D. Hoste

Aims: The aim of the study was to determine the accuracy of the kinematical determination of the centre of rotation of the hip and to compare the outcome of the Computer assisted surgery (CAS) group versus a control group of patients with conventionally instrumented TKA, in a prospective randomized way. Methods: A prospective, randomized and controlled trial was undertaken with an image based CAS system (ION®), using specific knee software for the GENESIS II®total knee system. Randomization was performed on a consecutive group of 50 primary TKA’s, without exclusion criteria. All computed kinematical centres of rotation of the hip were compared to the anatomic fluoroscopic images. The difference between the kinematical centre of rotation and the anatomic centre of the femoral head was measured in the frontal plane. Coronal alignment was measured on full leg standing films. Validation of the full leg standing films was carried out in comparing the pre-operative measured angle and the computed deformity angle at the beginning of the surgery. Outcome of the CAS group was compared to the conventional group on the following items: tourniquet time, operative time, blood loss, patellar alignment, tibial slope, coronal alignment, range of motion and complications. Results: ACCURACY: The correlation index between pre-op full legs and CAS measured values was excellent: r2=0.997. Difference between kinematical centre of rotation and anatomic centre of the hip: mean deviation between the two points was 1.2 mm (0–4mm), stdv 1.2 mm. This corresponds with a mean angular deviation of 0.17° (0–0.57°). OUTCOME: Tourniquet time: conventional 56 min., CAS 72 min. p=0.002. Operative time: conventional 70 min., CAS 93 min. p< 0.001. Blood loss: conventional 3.3 g/dl, CAS 4 g/dl. Patellar alignment: no tilt > 5°, no subluxation > 3 mm, both groups. Tibial slope: conventional 3.5°, CAS 3°. Post-operative mechanical alignment was between 0 and 2° of deformity for 16 conventional knees, and between 3–4° for 5 conventional knees. In the CAS group, all 21 knees scored between 0° and 2° of mechanical alignment. ROM at 6 weeks: flexion conventional 106°, CAS 105°. Fixed flexion contracture: conventional 2.9, CAS 2.1. Complications: delayed wound healing: conventional 2, CAS 1. Conclusions: Computer assisted kinematical determination of the centre of the hip can be highly accurate. Post-operative coronal alignment in CAS group is excellent, however not significantly better than conventional instrumentation.

Reinhard Fuiko B. Kotten R. Zettl P. Ritschl

Aims: Kinematic and pointing procedures, are used for non-image based navigated implantation of TKA. Pointing procedures require exact knowledge about the landmarks. In this anatomical study, landmarks are defined and repeatedly referenced. The precision and the reproducibility are evaluated, by means of inter- and intra- observer study. Using the landmarks, the axes of the femur and tibia are calculated. Methods: The specific landmarks of 30 femur and 27 tibia specimens, were palpated by 3 surgeons and digitised by means of a photogrammetric system, as used intra-operatively. The recorded data are evaluated. Results: The specific landmarks can be referenced with great precision. The vectors that influence the implant position, show femoral a mean inter-observer deviation of 0,9mm and 1,0mm tibial. The repeating accuracy of every single observer was 1,5mm femoral and 1,0mm tibial. The calculated long axes at the femur and tibia, thus reach a precision of 0.1° (min-max:0°–0,9°) at the femur and 0,2° (min-max:0°–1,1°) at the tibia. The short axes at the distal femur and at the proximal tibia, exhibit an average deviation of 0,7° to 1,9° (min-max: 0°–11,3°). Conclusion: Long axes (mechanical axes) can be determined exactly, the precision of the short axes (rotational axes) is unsatisfactory, although palpation of landmarks were accurate. Therefore, palpation of more than one rotational axis at the femur and the tibia, is mandatory and should be visualized on the monitor during the operation.

Sandeep R Konduru F.A. Khaweri D.F. Finlayson

Introduction: Revision hip surgery with impaction allografting is an attractive operation because of its potential to restore lost bone stock. Several authors have reported variable results, some disastrous, with massive subsidence of the stem.

Aim: To study the radiographic and clinical results of impaction allografting for revision hip surgery done in our department.

Materials and methods: 49 patients (50 hips) underwent revision hip surgery using the impaction allografting technique and the Exeter stem between the years 1993 to 1997. The average follow up was 6 years (range 4 – 9 years).

Results: There were 7 dislocations. One patient had early painful subsidence of the stem requiring revision. 44 (90%) hips had subsidence of stem equal to or less than 5 mm at last follow up. 5 (10%) had subsidence ranging from 6 to 7 mm. Hip function was uniformly good and patients were extremely satisfied.

Conclusion: Revision hip surgery with impaction allografting is an effective operation. With meticulous attention to this technique, revision hip surgery need not necessarily be associated with inferior outcomes compared to primary hip surgery.

G.B. Flugsrud B. Espehaug L.I. Havelin L. Nordsletten H.E. Meyer

Aims: We wanted to investigate the association between risk factors recorded prospectively before primary hip replacement, and the risk for later revision hip surgery. Methods: During the years 1977–83 The National Health Screening Service in Norway conducted an investigation of risk factors for cardiovascular disease. 56,818 persons born 1925–42 were invited, and 92% participated. We matched these screening data with data from the Norwegian Arthroplasty Register concerning primary and revision hip arthroplasty. Results: We identified 504 men and 834 women who had received a primary total hip replacement after the screening. Of these 75 and 94 were revised during follow-up. Mean age at screening was 49 years; mean age at primary hip replacement was 62 years. Mean age at censoring was 68 years. Men vs women had a relative risk of 1.9 of undergoing hip revision during follow-up (95% CI 1.3–2.8). For each years increase in age at primary hip arthroplasty, the risk of revision surgery during follow-up decreased with 14% for men and 17% for women. Men who at screening had the highest level of physical activity during leisure had 5.5 times the risk of later revision, relative to those with the lowest level of physical activity (95% CI 1.0–31.9). Conclusions: Men have a higher risk for revision hip surgery. There is less risk of revision the older the patient is at primary hip arthroplasty. Men with intense physical activity at middle age are at increased risk of undergoing revision hip surgery before they are 70 years old.

E.R. Gardner N.A. Shah D.B. Allan

Aim: To assess the radiological appearance and subsequent behaviour of impacted allograft in revision hip surgery using the Charnley femoral prosthesis. Method: A prospective radiological study of hip arthroplasty revised for aseptic loosening with femoral bone loss was performed. Preoperative bone loss was assessed using the Endo Klinik grading. Impaction grafting with fresh frozen femoral head allograft and the Charnley stem was used in all cases. Postoperative X-rays and annual review films were examined for graft distribution, cortical repair and stem subsidence. Graft consolidation and cortical repair was assessed. Results: Twenty cases were followed up for 6 to 8 years. Fourteen cases had even distribution of graft and 6 had deficiency in one Gruen zone. Graft consolidation was identified in all cases at one year. Cortical repair was noted in 14 out of 15 Endo Klinik III cases. One patient died after 2 years and 9 months. Two stems have subsided by more than 5 mm and are asymptomatic. Two cases with subsidence have been revised. All cases with subsidence were associated with graft deficiency in Gruen zone II or III on the postoperative X-ray. Conclusions: Good initial graft distribution on the postoperative X-ray is associated with graft consolidation, cortical repair and minimal stem subsidence. Initial deficiency in graft distribution is associated with stem subsidence and revision. These findings highlight the importance of a surgical technique, which ensures even graft distribution.

U. Clemens R.K. Miehlke

Aims: The latest software 3.0 and 4.0 of the OrthoPilot knee navigation system use a new mathematical algorithm to reconstruct mechanical axis. The purpose of the study is to evaluate the alignment of prosthetic components with this software and compare it with the results from older software as well as with manual technique. Method: Thirty navigated SEARCH knees with software 3.0 of an uninterrupted series were evaluated versus thirty navigated knees with older software and a similar series of conventionally instrumented knees of a different type. Results: The results, concerning the five parameters mechanical axis a.p., femoral axis a.p., femoral axis lateral, tibial axis a.p. and tibial axis lateral, are clearly superior to the old navigation group and the manual group. For example, the number of cases with a good mechanical axis, 0,1or 2° of deviation from optimum, was reached in 17 of the manual, 19 of the old navigation and 27 of the new navigation cases. The additional time for operation is 8.7 minutes. No specific complications occurred. Conclusions: The OrthoPilot-Software 3.0 and 4.0 are clearly superior to the old generations. More features, as for example resection-height of the distal femur and the orientation of the femoral component are solved in a convincing manor. The numbers of outliers is again diminished. Navigation in knee arthroplasty with the OrthoPilot has become more sure and intelligent.

O. Schwartz R.A. Imberg D.G. Mendes M. Said

Aims: The purpose of this study is to evaluate the efficacy of radiographic and computed tomography pre-operative planning and postoperative results of total knee arthroplasty. Material and methods: 124 procedures of Corin MTK total knee arthroplasty were pre-formed since July1998.A strict radiological and CT evaluation was done prior to and following the surgery and accompanied the clinical evaluation and follow up. A cohort of 32 patients is presented in details regarding the imaging pre-operative planning and the post-operative results. The radiological data included: 1. Angle of frontal deformity, 2. Angle of instability, 3. Fi-Fc – distance from the tip of the fibular head to the distal part of the lateral femoral condyle, 4. Frontal inclination angle of tibial component, 5. Frontal inclination angle of femoral component, 6. Sagital posterior inclination of tibial component, 7. Sagital posterior inclination angle of the femoral component, 8. The distance from the patella to the knee center of motion. The computed tomography data included: 1. The actual dimensions of the patella, tibia and femur, 2. The preoperative angle between the posterior condylar line and anterior condylar line, 3. The angle between the posterior condylar line and the transepicondylar line, 4. The Angle of external rotation of the femoral component, 5. The Angle of external rotation of the tibial component, 6. The distance of lateralization of the femoral and tibial components. Results: The desired value of external rotation of the femoral component was 6–80. Measuring the pre operative angle between the posterior condylar line and the transepi-condylar line helped to determine the degree of external rotation intraoperatively. The mean external rotation of the femoral component in our cohort was 6.73.

Measuring the the angle of external rotation of the tibial component preop helped to determine the extent of external rotation of the tibial component intraoperatively.

A significant decrease of the postop Q angle was noticed in all patients. Conclusion: Radiographic and computed tomography postoperative data reflects the value of the preoperative planning of total knee arthroplasty.

F. Haddad C. Stossel S. Sexton

Background: Revision total hip replacement is challenging when there is severe proximal bone loss. The Kent hip femoral prosthesis – a distally locked femoral stem – was designed to overcome this difficulty, however no study to date has assessed its durability. Methods: We independently reviewed the results of 105 Kent Hip Prostheses used at one hospital between 1987 and 2000. The indication for revision was aseptic loosening in 64, periprosthetic fracture in 19, septic loosening in 4, and severe bony deformity in 14. In the remaining 4 cases, a Kent hip prosthesis was inserted in the presence of metastatic tumour in the proximal femur to enable mobilisation. A functional evaluation of these patients using the Oxford Hip Score and a survival analysis of the stems was performed. Results: The mean duration of follow-up was 5.3 years (range 20 months to 15 years). The mean time to full weight bearing following surgery was 4 days and mean hospital stay was 13 days. Almost all patients experienced substantial improvement in hip related pain and disability (as measured by the Oxford Hip Score). 12 stems required further revision. Taking removal of the stem for any cause as the end point, cumulative survival at 15 years was 88%. Conclusions: Cumulative survival rates for the Kent hip femoral prosthesis compare favourably with other revision stems used where there is severe proximal bone loss. It enables early full weight bearing and hospital discharge, resulting in a low post-operative medical complication rate. However the need for continuing follow-up remains, since the rate of complications such as locking screw fracture, aseptic loosening, and periprosthetic fracture, may increase in the future.

I. Szabò F. Buscayret G. Walch P. Boileau T.B. Edwards

Aims: The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies. Methods: Seventy-two shoulder arthroplasties with primary osteoarthritis were divided into two groups based on glenoid preparation technique: thirtyseven shoulders with “curettage” of the keel slot, and thirty-five shoulders with cancellous bone compaction. The radiolucent lines were analyzed on fluoroscopically positioned, postoperative AP radiographs. The RLL Score (RLLS) was calculated using the technique of Molé. The RLLS was compared between the two groups. Results: On the immediate postoperative radiographs the average of the total RLL score was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). On the 2-year postoperative radiographs the average RLL score was 6.44 in the Group1, and 4.19 in Group 2 (p=0.0005). The radiolucency around the keel and behind the face-plate (p=0.0005) was significantly greater (p=0.001) in the “curettage” glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the face-plate (p=0.001) was observed in the “curettage” glenoid preparation group. Conclusions: Preparation of the keel slot with cancellous bone compaction is radiographically superior to the “curettage” technique.

C. Friesecke J. Plutat A. Block

Aims: The aim of this study was to investigate the functional results and complications of the total femur prosthesis Endo-Model?. Material and methods:100 total femurs implanted between 3/89 and 9/97 during aseptic revision arthroplasty, all consecutive cases, were included in the study. 87% were female, 13% male. The mean age was 68 years, ranging from 40 to 94. The mean follow-up was 5 years, ranging from one to 12 years. 77% had suffered a complication following implantation of a total hip replacement, 4% of a total knee and 19% following a complication affecting the diaphysis, in most cases a fracture between total hip and total knee prosthesis. From all 100 patients 41% had sustained a periprosthetic fracture preoperatively. Results: As a total femur is a limb saving prosthesis the functional result of hip and knee was assessed according to the Enneking scheme in separate pre- and postoperative evaluations. Preoperative the mean score for hip function was fair, it improved to good postoperatively. For the knee the preoperative score was fair to good, postoperatively better than good. 65% had no complications, deep infection 12%, dislocations 6%, technical faults 3%, patella pain 2%, nerve palsy 1%, secondary wound healing 1%, haematoma 2%, perioperative mortality 3%, not located 5%. Conclusion: The total femur prosthesis Endo-Model? is a valuable limb-saving implant in desolate cases of revision arthroplasty. Meticulous preoperative planning is compulsory. The functional results are surprisingly good. The complication rate is acceptable. To reduce the infection rate we now introduced a perioperative antibiotic prophylaxis.

R. Elke B. Berli

Aims: The outcome analysis of different revision techniques should provide guidelines for future stem revisions. Methods: Between 1989 and 2000 revisions of 478 femoral stems were performed. 252 of them with cemented components and 226 without cement. In 86 cases a Wagner revision stem was used. The mean observation time was 6.4 years. Success and failures were analysed and classified. Results: Four types of defects and remaining bone stock patterns could be distinguished: Type I with normal diaphyseal bone and minor lesions at themetaphyseal side, type II with a regular isthmus but defects, mostly contained ones, of the proximal femur, type III a wide isthmus with a thin and cylindrical cortical wall, type IV with destructions of the proximal femur which need structural allografting to provide sufficient initial stability. Type I revisions can be performed with regular components as used in primary cases, type II revisions need a slightly longer revision stem with either conical or cylindrical diaphyseal part, type III should be treated with components, that allow for axial load transmission proximally and can take rotational loads distally (the “load sharing concept”). Type IV needs a long revision stem in combination with an appropriate choice of structural allografts. Conclusions: If the type and length of the revision stem is chosen according to this classification, the failure rate of stem revisions can be reduced and the us of expensive allografts can be limited.

I. Escriba R. Sancho X. Crusi M. Valera

Aims: The bone – conductive proparties of hydroxyapatite (HA) coatings are attractive in revision surgery with bone loss. The purpose of this study is to analyse the clinical and radiological results of 55 cases of revision hip arthroplasty using hydroxyapatite femoral stems. Methods: Between May 1995 and October 2000 we performed 55 patients total hip replacements in 50 patients (5 bilateral) using hydroxyapatite (HA) – coated femoral stem. The average age of the patients at the time of the index revision was 67 years (range 44–84). Clinical evaluation was by a Merle d’Aubigne Score (preoperative 6.54 points). Radiological evaluation used the AAOS system for preoperative films and scaring system after Engh for the postoperative films. Bone grafts was required in 35 cases. Results: Postoperative Merle d’Aubigne score was 17.25 points. Complications: 3 dislocations, one transitory nerve palsy and 14 associated intraoperative fractures. All grafts consolidated. None of the femoral stem components required revision because of aseptic loosening. No radiologically progressive lucency or signs indicating a loose implant were visible in anycases. There were no cases of femoral stem migration. Conclusions: We conclude that the hydroxyapatite femoral stem is suitable for implantation at revision hip arthroplasty and can give good results in the short to medium term, because the clinical and radilogical results are excellent, with a early consolidate fractures.

D.C. Wirtz A. Schuh C. Rader F. Gohlke H.D. Carl G. Zeiler R. Forst

Aims: Prospective multi-center study to evaluate the mid-term results of 280 uncemented femoral stem revisions using the modular MRP-Titan system. Methods: 273 patients with 280 MRP-Titan systems, follow-up for a mean time of 3 years (1 to 8 years). Harris hip score for clinical evaluation, bony defect classification according to Paprosky [163 cases (58%) with type 2B, 2C and 3]. Results: Three aseptic loosenings (1%), three septic loosenings (1%), one additional re-revision because of periprosthetic fracture. Postoperative dislocations occurred in 23 cases (8%), 17 of these (6%) were managed by closed or open reposition without changing the implant. In 6 cases (2%) the antetorsion angle of the modular prosthesis neck was altered. Harris hip score: 38 points preoperatively, 85 points at the last follow-up postoperatively. In 18 cases (6.4%) radiolucient lines were seen, but with no progression and no migration of the stems. The overall survival-rate after 8 years of follow-up was 92%. Conclusions: The modular MRP-Titan system has proven to be valuable in quite problematic cases of hip revision arthroplasty with extensive femoral defects. The system allows intraoperative adaptation of implant length and antetorsion angle to the actual situation, a feature not provided by non-modular femoral revision implants.

I. Szabò F. Buscayret G. Walch P. Boileau T.B. Edwards

Aims: The purpose of this study is to compare the radiographic results of two different glenoid component designs by analyzing the radiolucent lines (RLL).

Methods: Sixty-three shoulder arthroplasties with primary osteoarthritis were divided into two groups based on glenoid component type: thirty-five shoulders with flat back, and thirty-one shoulders with convex back, polyethylene glenoid implants. The radiolucenct lines were analyzed on fluoroscopically positioned, postoperative AP radiographs. The RLL Score (RLLS) was calculated using the technique of Molé. The RLLS was compared between the two groups.

Results: On the immediate postoperative radiographs the average of total RLL score was 1.67 in Group 1 and 0.98 in Group 2 (p< 0.0005). There was a statistically significant association between the type of implant and the incidence of radiolucency behind the faceplate as well (p< 0.0005). On the 2-year postoperative radiographs the average RLL score was 4.19 in the Group1 (2.86 under the tray, and 1.33 around the keel), and 3.23 in Group2 (p=0.02) (2.09 under the tray, and 1.14 around the keel). The radiolucency behind the face-plate (p< 0.0005) was significantly greater in the flat back group, but not around the keel (p=0.427). There was no significant difference between the two groups regarding the degree of RLL score progression.

Conclusions: The initial and mid-term RLLS is better with convex than fl at back glenoid component.

A. Carroll Fintan D. Brown B. Bolton-Maggs

Aims: The purpose of this study was to quantify the functional outcome of the Aequalis shoulder system. Methods: Pre-operatively, 85 patients were scored using the constant scoring system to assess pain, activity, mobility and strength and adjusted (for age) and modified (excluding strength) scores were calculated. Range of movement (ROM) was assessed using a nominal scale. All patients were regularly followed up and were assessed functionally, using the constant scores and ROM, using a nominal scale Results: Pre-operatively, modified constant score range was 4 – 76 with mean 30.3. ROM was variable but poor overall. Abduction was < 600 in 69% and internal rotation was < ‘hand to buttock’ in 77%. At follow up (range 6 – 60 months, mean 24 months), modified constant score range was 29–126 with mean 74.6. Abduction was > 600 in 76% and internal rotation was > ‘hand to sacrum’ in 77%. No implant has been revised. There have been 2 periprosthetic fractures and 2 implants appear radiologically to be loose. Subjectively, only 6 patients are disappointed with the clinical outcome. Conclusion: The Aequalis shoulder system has been demonstrated to be a reliable implant with up to 5 year follow up. It has a good functional outcome with demonstrable improvement with pain, activity and mobility.

C. Garreau de Loubresse M.R. Norton P. Piriou G. Walch

Aims: To review the early results of shoulder arthroplasty in the weight bearing shoulder of long term pareplegic patients. We have been unable to find previously published results of this subgroup of shoulder arthroplasty patients in the litterature. Method: The case notes and X-rays of 5 female patients who had undergone shoulder arthroplasty were analysed. These patients all had longstanding paraplegia and were wheelchair bound. All patients has been prospectively scored with the American Shoulder and Elbow Surgeon’s (ASES) function score and the Constant score. Results: The patients had a mean age of 70 yrs (61–88) at the time of surgery. Three of the 5 shoulders and rotator cuff tears at the time of surgery, 2 of which were repaired. The results are summarised in the table. There was no radiological evidence of failure apart from the migration of the single cemented glenoid component. Conclusion: In view of the satisfactory improvement in pain in particular following these procedures, we feel that it is reasonable to continue to offer this procedure in this subgroup of patients. We will however remain vigilant with regard to any further complications arising because of the increased loading in these prostheses at the medium and long term.

Ph. Valenti D. Katz

Aims:The purpose of this study was to evaluate the results obtained with a reversed shoulder prosthesis in cuff tear arthropathy. Materiels and methods: 37 inverted Delta 3 prosthesis were performed on 35 patients between 1995 and 1999. The average age was 74 years old (64–87). Majority were female. A pre-operative standard x-rays and CT scan assessed bone stock of the glenoid and trophicity of the deltoid.we performed a preacromial approach to obtain an excellent exposition of the glenoid. Rotator cuff were founded non reconstructable (34 cases) and in 3 cases non functionnal with fatty muscle degeneration. Results: Functionnal results were assessed using Constant score. The mean follow up was 32 months (18–70). Constant score was improved from 21,65 (8–45) in pre operative to 62,09 (35–75) in post operative. Forward flexion increased from 33 degrees (0–80) to mean 120 degrees (60–150). The operative mean value for pain was 2 and it was reduced to a mean value of 13,9 (15 = painless). 90% of the patients were satisfied and returned to their daily activities. Complications occurred 5 times: one post operative dislocation, one neuroalgodystrophy, one loosening of the glenoid component and 2 infections. Conclusion: Inverted Delta 3 prosthesis represents a successful choice for cases of irreparable rotator cuff and gleno-humeral arthritis with an excellent deltoid and a good glenoid bone stock. But it is also a salvage procedure after a failure of a non constrained prosthesis which restored stability and improved function in all patients.

Sigbjørn Dimmen P. Siewers J.E. Madsen

Aims: The complications and functional long time results after glenohumeral arthrodesis are described. Methods: 22 patients (9 men, 13 women) with a median age of 64 (19 – 75) years were operated with a glenohumoral arthrodesis between 1982 and 2000. The indications for surgery were fracture sequelae (11), severe osteoarthritis (4), deltoid dysfunction (3), failed revision arthroplasty (1), chronic posterior dislocation (1), tuberculosis (1) and gunshot wound (1). Standard AO surgical technique with stable plating was used. 6 patients are dead and 1 refused examination. The remaining 15 patients were examined retrospectively after a mean of 7.8 years. The American Shoulder and Elbow Surgeons (ASES) score and Oxford score were registered and radiographs taken. Results: 8 patients had intermittent or continuous pain with a mean pain score (VAS) of 1.5 (0–8). 1 patient was reoperated after 4 months due to excessive pain and one was operated due to a humeral shaft fracture after 8 months. The implants had been removed in 5 patients and 1 had a lateral clavicle resection after 3 years. No patients had infections, but 1 had reflex sympathetic dystrophy. Radiologically all but two arthrodesis fused, the remaining 2 were painfree. Mean Oxford score was 33 (20 – 49), mean ASES score was 59 (15 – 95). Conclusions: The functional results after glenohumeral arthrodesis are comparable with results reported after shoulder arthroplasty. The he arthrodesis has a wide range of indications and the long time complications related to shoulder prosthesis may be avoided.

Mark Frankle A. Kumar J. Hamelin M. Vasey

Aims: The modes of failure of bipolar arthroplasty and outcomes following revision surgery have not been described. Methods: 7 patients (2f, 5m) who previously underwent bipolar arthroplasty were treated with revision surgery. Patient self-assessment was obtained pre- and postoperatively with a satisfaction survey, SF-36, SST, ASES scores, and preoperative/postoperative x-rays. Results: Modes of failure included rotator cuff failure 6/7, superior arch deficiency (4/7) and glenoid erosion (3/7). Revision surgery was performed to reconstruct instability, resurface eroded bone and repair available rotator cuff tissue. Anterior superior arch deficiencies were all revised to a semiconstrained reverse prosthesis. Other patients (3/7) were revised to unconstrained TSA. In this group, additionally soft tissue reconstructions were performed. ASES scores improved from 33 preoperatively to 55.5 postoperatively (P < 0.05). The mean SF 36 domains for PHC improved from 33.9 to 38.4 (P < 0.05). The mean VAS score for pain improved from 5.9 to 2.9 (p< 0.05). Mean active elevation increased from 60° to 78°. External rotation improved from 45° to 60°. 80% reported excellent/good, 20% reported satisfactory and none reported unsatisfactory outcome. Complications included 2 patients with recurrent instability. Conclusion: Revision shoulder arthroplasty following failure of a bipolar prosthesis requires reconstructive options of a semiconstrained prosthesis and conventional TSA with complex soft tissue reconstructions. Soft tissue problems such as superior arch deficiency and rotator cuff tears are the most common mode of failure. Patients may be improved from pain but limited improvement of shoulder function is to be expected

K. Laiho I. Soini H. Kautiainen M. Kauppi

Aims: To examine whether functional radiography and functional magnetic resonance imaging (MRI) are equal to detect the extent of unstabile anterior atlantoaxial subluxation (aAAS) in rheumatic patients. Methods: The series consisted of 23 patients with unstable aAAS (diagnosed by functional radiography) examined by functional MRI because of a neck symptom. Twenty-two patients had rheumatoid arthritis and one had juvenile idiopathic arthritis. aAAS was diagnosed if the anterior atlanto-axial diameter (AAD) was > 3 mm and was considered unstable if the AAD differed > 2 mm between flexion and extension radiographs. The AAD was measured from radiographs (flexion and extension) and MRI images (flexion and neutral). Results: The extent of aAAS during flexion measured by radiography was greater than that found by MRI in all our 23 cases [the mean difference was 3 mm (95% CI: 2 to 4)]. In 4 patients (17%) MRI could not find aAAS. The difference between the AAD measurements during flexion by these two methods was substantial (i.e. , ≥ 4 mm) in 9 cases (39%). Severe aAAS (≥ 9 mm) was seen in 15 patients (65%) by functional radiography and in 4 (17%) by functional MRI. Conclusions: The magnitude of aAAS was often substantially smaller in functional MRI than in functional radiography. Thus one cannot rely on functional MRI alone; functional radiographs are needed to show the size of unstable aAAS.

M. Caniggia M. Franci O. Capria G. Cecchi

Aims: The purpose of this study was to evaluate the efficacy of the inverted Delta 3 prosthesis in nonreconstructable massive rotator cuff tear. Methods: 31 inverted Delta 3 prostheses were performed between October 1999 and February 2002. The average age was 72.8 years old (65–84) and the average follow-up was 17.8 months (3–36). A deltopectoral approach was performed in all cases. Rotator cuffs were found to be nonreconstructable in all 31 cases. Results: Functional results were assessed using the Constant score. Constant score was improved from 32.1 preoperatively to 59 postoperatively. Forward flexion increased from 52 degrees to 135 mean degrees. 85% of the patients were satisfied. Two complications occurred: a stupor of the radial nerve and a ditching of the cementless humeral component. Conclusions: Inverted Delta 3 prosthesis represents a successful choice for cases of irreparable rotator cuff and gleno-humeral lesions in old patients with an excellent deltoid and a good glenoid bone stock. It reduces pain and improved function in all patients. The loosening of glenoid component is not frequent with a short-term follow-up.

P. Suchomel R. Lukas T. Soukup J. Stulik M. Sames L. Hrabalek

Aims: The optimal treatment of Type II odontoid fractures remains controversial. Our retrospective multicentric study of 114 odontoid process fractures documents experience with management of these fractures and discuss a new classification subtype II T and its surgical treatment. Methods: Fractures were defined using plain radiographs and CT reconstructions as per the Anderson- D’Alonzo classification. We have surgically treated 114 consecutive patients suffering from C2 odontoid fracture. 104 fractures were classified as Type II and 10 as Type III. Two cases of atypical, horizontal, mid-shaft odontoid process fractures were reported. In 55% an anterior two-screw fixation technique was chosen, remaining 45% underwent single-screw fixation. Results: One year follow-up data were available in 86.8% of cases and no major complications were found. Fusion rate calculated 6 months following surgery was 93%. We encountered cases, where the fracture line passes transversally through the middle of the shaft of odontoid process, below the level of transverse atlantal ligament, and we suggest to classify these cases as Type II T fractures. Also we analysed series of 75 surgically treated C1-2 instabilities and out of 11 pseudoarthrosis of the odontoid process 7 unrecognised Type II T fractures were found. Conclusions: Reported atypical fractures, newly classified as Type II T, are highly unstable (especially in rotations). In the authors’ opinion, two- screw technique should be the treatment of choice when internal fixation indicated.

S. Fuerderer S. Delank P. Eysel

Aims: In this study, the subsidence of different interbody fusion devices was investigated. Hereby, the influence of different designs as well as of the preparation technique was evaluated. Methods: 3 common cervical interbody fusion devices (BAK, Novus and WING) underwent axial compression testing with 4000 cycles in a bovine spine model. The vertebral bodies were prepared in 3 different ways, taking away 0, 1 and 2 mm of the end-plate. So each fusion device was tested in each preparation group in 5 vertebrae. Every 1000 cycles, the subsidance was measured. Results: Taking away 1 and 2 mm of the endplate resulted in a strong increase of the subsidance compared to the situation with intact end-plate. In addition, the design of the interbody device had an influence onto subsidance: In case of intact endplates, the cages with rectangular supporting areas resisted better to axial compression than the cylindrical implant. When the cortical bone of the endplate was taken away, all three implants showed similar subsidance curves. Conclusions: Implants with plane supports seem to provide better stability against subsidance than cylindrical implants. During preparation, the cortical structure of the endplate should be taken care of, especially in the zone, where the implant has its bearing areas

M.H. Neva A. Kotaniemi K. Kaarela J.T. Lehtinen E.A. Belt M. Kauppi

Aims: To evaluate whether the atlantoaxial disorders (anterior atlantoaxial subluxation and atlantoaxial impaction) associate with destruction of shoulder or peripheral joints, and bone mineral density (BMD) in patients with long-term rheumatoid arthritis (RA). Methods: An inception cohort 67 patients with seropositive and erosive RA were followed up for 20 years. Cervical spine, shoulder, hand and foot radiographs, and the BMD of the lumbar spine and femoral neck were evaluated. Results: A positive relationship was detected between the occurrence of atlantoaxial disorders and the destruction of both shoulder (p < 0.001) and peripheral (p = 0.001) joints. In addition, the severity of atlantoaxial disorders positively correlated with the grade of destruction in the evaluated joints. Furthermore, a positive relationship was found between the occurrence of the atlantoaxial disorders and a decrease in BMD of the femoral neck (p = 0.019). Conclusions: Patients with severe RA and osteoporosis have an increased risk for atlantoaxial disorders, therefore the cervical spine radiographs of these patients should be analysed before major surgery and also at regular intervals. The co-existence of shoulder and cervical spine disorders makes the differential diagnosis of shoulder and neck pain challenging.

P. Lis A. Rud P. Kowalczyk A. Marchel

Aims: Presentation of modified anterior cervical discectomy by Smith- Robinson method with stabilisation by Cornerstone Carbon Cage (CCS). Methods: Since November 2001, we have been performing unique anterior intervertebral stabilisation procedures with use of carbon implants. Cornerstone Carbon Cage is an artificial intervertebral graft with empty space inside to be filled by bone chips. Cages are from 5 to 7millimetres high, with a higher anterior edge for restoration of physiological lordosis. During the operation we use typical right-side approach to vertebral column. Using intervertebral retractor we perform very wide discectomy until obtaining complete decompression of lateral recesses with exposition of joints of Luschka, which are anatomical lateral limits of the disc space. Afterwards, the wedge-shaped resection of posterior edges of the upper and lower vertebral body which are formed by osteophytes, is performed. Then, we fill the cage by bone chips and osteophytes, and using intervertebral retractor we wedge it into intervertebral space. Results: The procedure allows us to obtain the restoration of lordosis, good stabilisation of vertebral column, and additionally, through a minor distraction, procures decompression of spinal roots in intervertebral foramina. Conclusions: Through a wide intra-operational view, after discectomy and wedge-shaped resection of the vertebral body, it is possible to entirely decompress spine and nerve roots. The above modification of Smith-Robinson method creates ideal conditions for use of CCS.

C. Viamonte N. Alegrete J. Vilarinho

Aims: It is believed that arthrodesis of spinal segments leads to excessive stress at unfused adjacent levels. The incidence, prevalence and radiographic progression of symptomatic adjacent-segment disease were studied. Methods: A series of 85 patients who had an anterior cervical arthrodesis for the treatment of cervical spondylosis with radiculopathy or mielopathy were reviewed with a minimum of 7 months and a maximum of ten year follow-up. The annual incidence of adjacent-segment disease was defined as the percentage of patients who had been disease-free at the start of a given year of follow-up in whom new disease developed during that year. The prevalence was defined as the percentage of all patients in whom symptomatic adjacent-segment disease developed within a given period of follow-up. The hypothesis that new disease at an adjacent level is more likely to develop following multilevel arthrodesis was also tested. Results: Symptomatic adjacent-level disease occurred at an incidence of 5,3% per year, with an 18,2% maximum at the third year of follow-up and a final prevalence of 34,1%. The greatest risk of new disease was at the interspaces of the sixth and seventh cervical vertebrae. Patients with a multilevel arthodesis were significantly more likely to have symptomatic adjacent-level disease. Conclusions: Symptomatic adjacent-segment disease may affect more than one-third of all patients within ten years after an anterior cervical arthrodesis. A multilevel arthrodesis and the interspaces between the sixth and seventh cervical vertebrae appear to be the greatest risk factors for new disease...

P. Lis A. Rud P. Kowalczyk A. Marchel

Aims: Presentation and evaluation of clinical outcomes of patients with cervical degenerative disc disease treated by Smith – Robinson method with interbody fusion by Cornerstone Carbon Cage (CCS) in own clinical experience. Methods: We operated 37 patients by anterior cervical discectomy with interbody stabilisation by CCS in the last 11 months. 31 patients were operated for the first time. In 6 cases, patients were reoperated after surgical treatment in other hospitals. The Smith – Robinson cervical discectomy with anterior interbody fusion by CCS was performed in all patients. Additionally, in 12 patients titan cervical plates were used. Follow-up examinations were performed in 2 and 6 months after the treatment. Results: All treated patients experienced total pain termination. In patients with posttraumatical discopathy and heavy cervical spondylosis with ligamental instability (33% all patients) additional internal stabilisation by cervical plate was performed. Neurological or local long-term postoperative complications were not observed. Conclusions: Patients who underwent treatment by anterior cervical discectomy met. S-R with interbody stabilisation by CCS benefited from the treatment and present good clinical outcome with pain termination and gradual disappearance of neurological disabilities. Using of cornerstone carbon cage allows to obtain good stabilisation without the necessity of allogenic bone graft insertion. This kind of stabilisation is sufficient without external collar stabilisation.

R.V. Patel J. Stygall J. Harrington S. Newman F.S. Haddad

Aims: To compare the intraoperative cerebral microemboli load between primary total hip (THA) and knee arthroplsty (TKA) using transcranial Doppler ultrasound and to investigate whether a patent foramen ovale influences cerebral embolic load in general. The timing of the microemboli will be related to certain surgical activities to determine if a specific relationship exists. Methods: Patients undergoing primary TKA or THA, with no history of stroke, TIA, ongoing CNS disease or alcoholism included. All operations carried out under a standardised general anaesthetic and performed by two consultant orthopaedic surgeons. Microemboli load recorded, using transcranial Doppler ultrasound (TCD), onto VHS tape for subsequent playback and analysis. Patent foramen ovale detection performed using bolus intravenous injection of agitated saline followed by valsalva manoeuvre technique and TCD. Timing of specific surgical steps recorded for each operation and emboli load calculated for that period. Results: 20 THA and 20 TKA patients were studied. Cerebral microembolisation occurred in 50% of THA and 40% of TKA patients. Total microembolic load for THA patients was 137 (range=0–83) and 50 (range=0–21) for TKA patients. Prevalence of PFO in the THA group was 35%, and 20% in the TKA group. 57.1% of PFO positive THA patients and 75% of PFO positive TKA patients displayed microemboli. Insertion of the femoral component in THA and release of the tourniquet in TKA were associated with higher cerebral microemboli load. Conclusion: Intraoperative cerebral microembolisation occurs in almost half of patients during hip and knee arthroplasty. Patients who have a PFO appear more likely to be associated with cerebral embolisation. Specific surgical activities are associated with larger embolic loads.

G.V. Kuropatkin S.A. Litvinov

Aims: The purpose of this study is to estimate prospects of application Taurolin for treatment of the vertebral osteitis and purulent discitis. Methods: In the period from 1998 to 2001 16 patients with vertebral osteitis and purulent discitis were treated with the use of Taurolin-Gel 4%. The average age was 33,5. One-stage surgical procedure was always performed – careful surgical cleaning of a suppurative focus with total intravertebral disc and partial vertebral body resection, filling it with Taurolin-Gel 4% followed by drainage with obligatory transpedicular screw-rod fixation. In 9 cases Staph. Aureus was found, in 2 cases – Staph. Hemolyticus, in 1 case – Staph. Intermed and Klebs. Pneum were found. Adequate drainage of the wound and regular sampling of the effluent fluid were very important. When tests show the absence of bacteria, the drains can be removed, otherwise Taurolin may be used as a further instillation. The radioisotope scanning of a spine was applied to have additional control of inflammatory process. Results: In 13 of these cases local and general signs of infection disappeared after one implantation of Taurolin-Gel 4%. In 3 cases a second implantation was necessary. Neurological reactions to introduction of Taurolin-Gel 4% were not observed. In all patients a good medium-term result was obtained. After 1 year the X-ray control, CT-scan and radioisotope scanning showed good fusion in site of infection and absence of inflammatory reaction in all cases. Allergic or similar incompatibilities were not revealed. Conclusions: Taurollin-Gel 4% is a good local drug for treatment and prophylaxis of infections in spine surgery. The advantage is that it can be introduced into surgically cleaned cavities and does not require removal. If it is necessary to use bone graftings, Taurolin-Gel can be easily mixed with corticospongious bone chips or different artificial bone materials.

M.R. Lassen K.A. Bauer B.I. Eriksson A.G.G. Turpie

Aims: Whether the use of elastic stockings (ES) on top of pharmacological thromboprophylaxis is beneficial remains debated. In a worldwide phase III program including 7344 patients in major orthopaedic surgery, fondaparinux, the first synthetic selective factor Xa inhibitor, demonstrated a substantial benefit over enoxaparin in preventing venous thromboembolism (VTE); risk reduction > 50% without increasing clinically relevant bleeding. The aim of this study was to evaluate the influence of ES on this superior efficacy of fondaparinux. Methods: In all four randomized, double-blind trials, comparing a once daily 2.5 mg s.c. injection of fondaparinux to enoxaparin, the primary efficacy outcome was VTE up to day 11, defined as deep-vein thrombosis (DVT) detected by mandatory bilateral venography, or documented symptomatic DVT or pulmonary embolism. A post-hoc analysis on primary efficacy was performed according to the use of ES. Results: The table shows VTE incidences by day 11 without and with ES. Conclusions: In major orthopaedic surgery, fondaparinux showed a similar superior efficacy over enoxaparin in patients with and without ES, indicating that ES did not influenced the major benefit of this new agent. An additive effect of ES in enoxaparin-treated patients cannot be excluded but the effect is insufficient compared with fondaparinux alone.

B.I. Eriksson K.A. Bauer M.R. Lassen A.G.G. Turpie

Aims: The fondaparinux thromboprophylaxis phase III studies database including 7344 patients in orthopaedic surgery provides information regarding patient management according to country specificities. Methods: 4 randomized double-blind trials were conducted in 376 centers in 23 countries comparing fondaparinux to enoxaparin – 1 in major knee surgery (MKS) in North America (NA); 2 in total hip replacement (THR) in NA and in Europe, respectively; and 1 in hip-fracture (HF) surgery worldwide except in NA. The use of regional anesthesia or cement during surgery, use of stockings during hospitalization, or prolonged prophylaxis (PP) after discharge were left to the investigators. Results: In all studies the majority of patients were women, particularly in HF. The median age was 67 years for THR, 69 years for MKS, and 79 years for HF. In THR studies, regional anesthesia was used more frequently in Europe (59%) than in NA (24.4%). The table summarizes investigators’ practice. Conclusions: There are important differences in the management of orthopedic surgery patients according to country specificities and type of surgery. However, fondaparinux is more effective than enoxaparin for thromboprophylaxis irrespective of patient or surgery characteristics.

Bengt I. Eriksson G. Agnelli A.T. Cohen O.E. Dahl M.R. Lassen P. Mouret N. Rosencher

Aims: To investigate the efficacy and safety of a new dosage regimen of the oral direct thrombin inhibitor ximelagatran, and its subcutaneous (sc) form melagatran, started in close proximity to surgery. Methods: In a randomised, double-blind, parallel-group study, duration 8–11 days, patients undergoing total hip or knee replacement (THR, n= 1856; TKR, n= 908) received either sc melagatran 2 mg immediately before surgery followed by sc 3 mg in the evening after surgery, and then by oral ximelagatran 24 mg bid as a fixed dose (the ximelagatran group), or sc enoxaparin 40 mg od, started the evening before surgery. Bilateral venography was performed on the final day of treatment. Results: The rate of proximal deep vein thrombosis plus pulmonary embolism was 2.3% in the ximelagatran group vs. 6.3% in the enoxaparin group (p< 0.000002; RRR 63.2%). The total rates of venous thromboembolism (VTE) were 20.3% vs. 26.6%, respectively (p< 0.0003; RRR 23.6%). Cases with symptomatic VTE were rare: 8 in the ximelagatran group and 12 in the enoxaparin group. Bleeding events were more common in the ximelagatran group compared with the enoxaparin group (3.3% vs. 1.2%) as were the transfusion rates (66.8% vs. 61.7%). Importantly, there were no differences in fatal bleeding, critical organ bleeding or bleeding requiring re-operation. Conclusion: Pre-operatively initiated sc melagatran followed by oral ximelagatran was superior in efficacy to enoxaparin in preventing VTE in patients undergoing THR or TKR.

M.R. Lassen K.A. Bauer B.I. Eriksson A.G.G. Turpie

Aims: To assess whether there was a relationship between the timing of the first administration of fondaparinux and its efficacy and safety in preventing venous thromboembolism (VTE) in orthopaedic surgery. Methods: Overall, 3616 patients received fondaparinux in 4 randomized, double-blind studies in this setting. We performed a post-hoc analysis of the effect of this timing on VTE up to day 11 (primary efficacy) and bleeding with a bleeding index (BI) ≥2, using logistic regression. These 2 parameters were also analyzed according to whether fondaparinux started before 6 hours or at 6 hours or later postoperation. Results: Logistic regression showed that the efficacy of fondaparinux was not affected by the timing of its first administration (p=0.67). However, there was a statistically significant relationship between this timing and bleeding with a BI ≥2 (p=0.008). The table gives the incidence of VTE and bleeding with a BI ≥2 according to the interval between skin closure and the first fondaparinux injection. Conclusions: The efficacy of fondaparinux in preventing VTE in orthopaedic surgery was not related to the timing of its first administration. In addition, a significant reduction in the incidence of bleeding with a BI ≥2 was observed when the first fondaparinux injection took place between 6 and 9 hours after skin closure.

A.J. Brooksbank S. Sckhtivel P.K. Rickhuss

Aims: Following hip fracture, a delay to surgery of greater than 24 hours is associated with a higher morbidity and mortality. In our unit, one of the common perceived delays is patients admitted on warfarin. The elective perioperative management of patients on warfarin is well documented. We aimed to define the incidence and delay of patients admitted with hip fractures on warfarin, and how its reversal was managed. Methods: Data was collected prospectively from 14 hospitals who contribute to the Scottish Hip Fracture Database. In addition to the data recorded on the Standardised Audit of Hip fractures in Europe form (SAHFE), specific questions relating to warfarin and its reversal were asked. Results: During 1.8.01–31.12.01, 1641 patients were admitted with a hip fracture, 42 patients (2.6%) were taking warfarin with the commonest indication being atrial fibrillation (40.5%). Mean INR on admission was 2.83 (range 1.2–8.2), and at surgery was 1.43 (range 1.0–2.0). Active reversal occurred in 19 patients. A delay to theatre of > 48 hours occurred in 72.7% of the warfarin group versus 19.0% in the non-warfarin group. There were wound complications in 5 patients taking warfarin. Conclusions: The number of patients admitted on warfarin was lower than we had anticipated. Delay to theatre was significantly higher in the warfarin group. The approach to the perioperative management of patients taking warfarin was varied.

I. Benareau R. Tests J.-L. Lerat B. Moyen

Aims: Functional results of anterior cruciate ligament (ACL) is closely related to the anatomical position of the graft. Femoral or tibial miss placements are associated with increase laxity, decrease range of motion. Based on anatomical dissections we developed a triangle method able to be used as fluoroscopic intra-operative landmark to increase the reproductibility of the placements. Methods: A lateral X ray of normal knee is mandatory before the surgical procedure. During the ACL reconstruction using patellar tendon a pin is placed to determine the tibial tunnel, and a small screw is inserted at the femoral ACL location. Under imagine intensifier, a lateral X ray of the operated knee is realised. The picture is exported and analysed on a PC computer. The surgical placement is compared with the ACL center position according to the triangle method. 35 knees have been operated and compared with 35-paired knees operated with the same technique and operator. Results: The mean distance between the ACL center and the surgically chosen femoral position is 7.5 ± 1.9 mm for the standard surgery and 4.9 ± 1.3 mm for the fluoroscopy based surgical navigation. The Wilcoxon test for small-paired series indicates a statistical significance (p=0.001). The mean extra operative time is 15 ± 7mn. Conclusion: This technique is simple, easy and rather fast. It gives to the surgery a significative improvement for positioning the ACL graft on the femoral side. It has to be confirmed for larger and by long term clinical results.

J.T. Nurmi P. Kannus H. Sievänen T. Järvelä M. Järvinen T.L.N. Järvinen

Aims: Serial dilation of the walls of the bone tunnel has been advocated to provide more dense bone-tunnel walls and optimal conditions for rigid fixation in anterior cruciate ligament (ACL) reconstruction with soft tissue grafts. The aim of this study was to compare the initial fixation strength obtained using serial dilation versus conventional extraction drilling in ACL reconstruction. Methods: Initial strength of doubled anterior tibialis tendon grafts fixed with bioabsorbable interference screw was assessed in 21 pairs of human cadaver tibiae. Bone tunnels were created with either serial dilation or conventional extraction drilling (cannulated drill bits). The specimens were subjected to a cyclic-loading test (1500 loading cycles between 50 and 200 N at 0.5 Hz frequency). The specimens surviving the cyclic-loading test were loaded to failure at a rate of 1.0 m/min (single-cycle load-to-failure test). Results: During the cyclic-loading test, no significant stiffness or displacement differences were observed between the two bone-tunnel techniques. Three specimens failed in the serial-dilation group, while there were six failures in the extraction-drilling group. In the subsequent single-cycle load-to-failure test, the average yield load was 473 ± 110 N for the serial-dilation group and 480 ± 115 N for the extraction-drilling group (P=0.97). No significant difference between the two bone-tunnel techniques was found with regard to stiffness nor mode of failure. Conclusions: Serial dilation of the bone-tunnel walls does not increase the initial fixation strength of soft tissue grafts in ACL reconstruction.

B.I. Eriksson K.A. Bauer M.R. Lassen A.G.G. Turpie

Aims: In major orthopedic surgery, fondaparinux provided a major benefit over enoxaparin, with an overall venous thromboembolsim (VTE) risk reduction of > 50% and similar safety profile regarding clinically relevant bleeding (leading to death or reoperation, or occurring in critical organ). The aim of the present study was to analyze this superior efficacy according to patients and surgery characteristics. Methods: In four phase III trials, the primary efficacy outcome was the VTE incidence up to day 11, defined as deep-vein thrombosis (DVT) detected by mandatory bilateral venography or documented symptomatic DVT or pulmonary embolism. Primary efficacy was further analyzed according to predefined categorical covariates using a logistic regression model. Results: Fondaparinux was more effective than enoxaparin irrespective of age, gender, obesity, the use of cement or surgery duration (odds reduction from −46.9% to −59.7% in favor of fondaparinux. Clinically relevant bleeding did not differ between the two groups according to predefine covariates. Conclusions: For VTE prevention in major orthopaedic surgery, the superiority of fondaparinux over enoxaparin was consistent irrespective of patient or surgery characteristics.

B.I. Eriksson K.A. Bauer M.R. Lassen A.G.G. Turpie

Aims: In orthopedic surgery, the optimal duration of thromboprophylaxis is debated, and very few data are available in hip fracture. We addressed these issues in 5 randomized double-blind clinical trials of fondaparinux. Methods: In four studies in 7344 orthopedic surgery patients, fondaparinux was administered up to 11 days and compared to approved enoxaparin regimens. In the PENTHIFRA-Plus study in 656 hip fracture surgery patients, after an initial treatment with fondaparinux for 7±1 days, patients were randomized to fondaparinux or placebo for additional 21±2 days. In all trials, primary efficacy was venous thromboembolism (VTE), at the end of the treatment period. Results: In the four 11-day prophylaxis studies, fondaparinux reduced the incidence of VTE from 13.7% with enoxaparin to 6.8% (risk reduction [RR]: 55.2%; P< 0.001). Fondaparinux efficacy was significantly influenced by treatment duration (P< 0.001): for instance, the incidence of VTE was lower in patients treated for 9 to11 days (5.2%) than in patients treated for ≤5 days (8.7%, P= 0.038). In the PENTHIFRA-Plus study, the incidence of VTE up to 4 weeks was reduced to 1.4% compared with 35.0% with placebo (relative RR: 95.9%, P< 0.001). The incidence of symptomatic VTE was also significantly lower with fondaparinux (0.3%) than with placebo (2.7%, relative RR: 88.8%, P=0.021). Conclusions: Fondaparinux efficacy in preventing VTE in orthopedic surgery increased significantly with a longer duration of treatment. Hip fracture surgery patients are at high risk of VTE up to 4 weeks after surgery and treatment with fondaparinux for 4 weeks postoperatively provides greater benefit than active treatment for only 1 week.

P. Haentjens K. De Groote L. Annemans

Aims: We conducted an cost-utility analysis to compare standard (in-hospital) with prolonged (out-of-hospital) enoxaparin prophylaxis after elective total hip and knee replacement. Methods: The perspective was that of a societal healthcare payer, taking Belgium as a case country. The main outcome measure was the incremental cost-utility ratio, reported as the incremental cost per quality-adjusted life year gained (Euro/QALY). Costs for diagnosis and treatment of proximal and distal deep vein thrombosis, pulmonary embolism, postphlebitic syndrome, and major bleeding were obtained from a Delphi panel (orthopaedic surgeons) and the official reimbursement rates (Federal Ministery of Health). QALYs for these health states were based on utility scores as reported in the literature. Results: In the base-case analysis, incremental costs of prolonged prophylaxis amounted 58 Euro and 114 Euro per patient, with an additional gain in QALY of 0.0083 and 0.0018 after total hip and knee replacement, respectively. Thus, a strategy of prolonged enoxaparin prophylaxis was associated with a cost-utility ratio of 6,964 Euro/QALY and 64,907 Euro/QALY after total hip and knee replacement, respectively. Applying a societal willingness-to-pay threshold value of 20,000 Euro/QALY, prolonged enoxaparin prophylaxis is cost-effective after elective total hip replacement. Sensitivity analyses confirmed the general robustness of these findings. Conclusions: After elective total hip or knee replacement, prolonged enoxaparin prophylaxis leads to increased effectiveness at increased cost. Nevertheless, given the additional costs healthcare decision makers in Europe are usually prepared to pay for a gain in effectiveness, prolonged prophylaxis with enoxaparin is cost-effective after total hip replacement

J. Sourlas G. Papachristou E.A. Magnissalis N. Efstathopoulos S. Plessas

Aims: The topographical measurement and representation of the ACL insertion on the tibial plateau, based on a greek population sample. Methods: Fourty eight tibial plateaus were explanted during TKA surgery in 33 female and 15 male patients (average age of 71.2 yrs) suffering from osteoarthritis and rheumatoid arthritis. By means of a calliper, measurements were conducted in order to determine the dimensions shown. Data were used for a topographical representation.

Conclusions: To the authors’ best knowledge, this is the first such anthropometric study on a greek population and its results provide a confirmation on the relatively wide base of ACL insertion on the tibial plateau. The biomechanical performance of this natural configuration for a full range of motion, is possibly not sufficiently reproduced by conventional ACL reconstruction techniques using just one bundle.

M.W.J. Morris J.L. Williams A.J. Thake J.N. Brown L. Yang

Aims: To investigate the optimal dimension interference screw for fixation of a tendon graft in a bone tunnel. Methods: A porcine model was developed to represent ACL reconstruction in the distal femur. A standard 8mm size pig flexor tendon graft was inserted into a standard 8mm bone tunnel. The screw dimensions were varied. The tendon was loaded with a constant force using a Universal Testing Machine. The construct was tested to failure at a rate of 50mm/minute. Load, deformation data and mechanism of construct failure were recorded. The screw diameters of 7, 8 and 9mm and lengths of 20, 25 and 30mm were tested in 80 individual reconstructions. Results: The mean pull out force was similar between the 7mm (191N) and 8mm screws (188N), but significantly different for the 9mm screw (109N) (p< 0.05) The 30mm screw (231N) was marginally better than the 20mm screw (215N) (p> 0.05). The mechanism of failure however, was significantly different between the groups. All grafts fixed with a 9mm screw failed at the tunnel opening (100%), whereas those fixed with a 7mm screw failed by slippage of the graft along the length of the tunnel (83%). The screw length did not affect the mechanism of graft failure. Conclusion: Our results suggest that a screw size equal to or 1mm less than the diameter of the tunnel gives the optimum initial interference screw fixation of tendon in a bone tunnel.

F. Adam D. Pape K. Schiel S. Rupp D. Kohn

Aims: The purpose was to evaluate the biomechanical properties of Hamstring graft fixation methods with ability for circumferential graft ingrowth in a standardized experiment with high precision Radiostereometric Analysis (RSA). Methods: We used 30 porcine specimens for the study. A fourstranded graft was sutured with a baseball stitch. Ten trials were performed in each group. The sutured end of the graft was fixed with a Washer-Lock (WL) or two resorbable Cross-Pins (CP). In the Suture-Disc (SD) group 8 polyester sutures (Ethibond 5USP) were knotted over a titanium button. The tibial bone and the tendon-graft were marked with tantalum beads. The grafts were loaded axially under RSA control increasing the force in steps of 50N to load of failure. Micromotion between tendon graft and tibial bone was measured with RSA. Results: Load at failure was significantly higher for the WL and CP fixation (722±173N; 647±129N) compared to SD fixation (445±37N). Stiffness of fixation was significantly higher for WL and CP fixation 492N/mm; 416N/mm) compared to SD fixation 111N/mm). Graft displacement started at low loads for SD fixation (47N) compared to WL and CP (344N; 250N). Graft motion at 200N load was significantly higher in the SD group (1.85mm) than for the WL (0.33mm) and CP (0.3mm) fixation. Bungee cord effect at 200N for the SD was measured 1.32mm, for the CP 0.50mm and for the WL 0.22mm in average. Conclusions: Direct fixation of a quadrupled tendon graft with WL or CP is preferable to SD fixation. Low linear stiffness of SD fixation with linkage suture material allows for a high amount of elastic deformation.

S.R. Annapureddy A.N. Murty John Ireland

Aim: This investigation compares the tibial tunnel appearances at 1 year and again at 8 years post-operatively in 49 patients and reports on the clinical significance of these appearances. Materials and Methods:49 consecutive patients who underwent isolated central anterior cruciate ligament reconstruction using a four stranded hamstring tendon technique comprised the study group. The patients were reviewed clinically and with weight bearing AP and Lateral radiographs at one year and eight years (range 5–9years) from reconstruction. Two blinded observers measured the tunnel diameters using a digital caliper on the 1year and 8 year radiographs. Tunnel enlargement was calculated from the known drill size with correction for magnification. The findings were correlated with clinical outcome and various associations were studied. Results: At one year postoperatively tunnels had increased in diameter by a mean of 26% at the proximal end, and by 19% at the distal end. By 8 years both measurements had reduced to 20% and to 13% respectively and this decrease in tunnel enlargement was significant (p< 0.05). Tunnel enlargement was significantly greater in those knees with persistent effusion at one year. (P< 0.05). 10 patients (26%) had distal tibial tunnel diameters which were less than the original drill size and of these ten patients only one had a positive Lachman (side to side difference> 3mm) compared to 9 in the rest. (P< 0.05). Conclusion: Tunnel enlargement that occurs at 1yr reduces by 8 years from reconstruction. Decrease in tunnel enlargement at the distal end is associated with an improved and lasting stability.

R.K. Goddard H. Wynn Jones B.I. Singh J.C. Shelton M.A.S. Mowbray

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of four methods of fixation of hamstring anterior cruciate ligament (ACL) grafts. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent biomechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts. Method: Twenty stifle joints were obtained from 10 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon graft was then introduced into the tibial tunnel and secured with either a titanium round headed cannulated interference (RCI) screw, a bioabsorbable RCI screw, an Endobutton or an expansile Bollard. Five of each method of fixation were tested mechanically to ultimate failure and under cyclical loading. Results: The mean ultimate tensile loads (UTL) were: titanium RCI screw = 444 N, bioabsorbable RCI screw = 668 N, Endobutton = 999 N and Bollard = 1153 N. Under cyclic loading conditions the titanium and bioabsorbable RCI screws rapidly failed after several hundred 5 to 150 N cycles due to tendon damage and slippage. Both the Bollards and Endobuttons survived 1500 cycles at 50-450N, with less tendon slippage. Conclusion: Titanium and bioabsorbale RCI screws provide poor initial fixation of tendon grafts and fail rapidly under cyclic loading. Both Bollards and Endobuttons provide sufficiently high UTL’s and survive cyclic loading to allow early postoperative rehabilitation.

H. Paessler J. Rossis D. Mastrokalos I. Kotsovolos

Aim: To evaluate whether a guiding pin for a femoral tunnel could be positioned through the tibial tunnel into the center of the anatomical ACL attachment. Methods: 77 knees underwented arthroscopic ACL reconstruction with hamstrings. The femoral tunnel was drilled through an anteromedial portal at the center of the anatomic insertion at about 10.00 resp.14.00 position. Tibial tunnel (mean diameter 7.55 ± 0.54 mm) was drilled using a guide inserted at 90 degrees of knee flexion. Then, through the tibial tunnel, a 4mm offset femoral drill guide was positioned as close as possible to the femoral tunnel and a 2.5 mm guide wire was drilled. The position of the guide wire was photographed arthroscopically and the deviation was measured as the distance between the center of the femoral tunnel and the guide wire. Results: The mean deviation was 4.50 ± 1.54 mm (p = 0.00000004) In 74 knees (96.1%) the guidewire did not reach the femoral tunnel. Only in 3 knees it reached the superomedial edge of the femoral tunnel. No statistical relationship was found between deviation and tibial tunnel inclination angles or tibial tunnel diameter. Conclusions: Transtibial femoral tunnel drilling does not reach the anatomic site of the ACL insertion, even with larger tibial tunnels (for hamstring grafts up to 8.5 mm). Transtibial tunnel drilling should be replaced by drilling through the anteromedial portal at least for tunnels with diameters < 9 mm.

T. Järvelä T. Paakkala M. Järvinen

Aims: To evaluate the morphologic changes in the patellar tendon 10 years after harvesting its central third for reconstruction of the anterior cruciate ligament, and examine the association between the morphologic changes and the occurrence of anterior knee pain of the patients. Methods: Thirty-one patients who had undergone an anterior cruciate ligament reconstruction using central-third bone-patellar tendon-bone autograft with a closure of the patellar tendon defect were included in this study. An ultrasonographic and Power Doppler examination was performed at a mean follow-up of 10 years. Results: Ultrasonography of the harvested patellar tendon showed intratendinous calcification in 9 patients, hypoechoic lesion in 20 patients, hyperechoic lesion in one patient, and peritendinous changes in one patient. No abnormality was visible in the contralateral (normal) patellar tendons of the 31 patients. The harvested patellar tendon was significantly thicker than the contralateral patellar tendon both at the proximal third (p=0.017) and at the distal third (p=0.020) of the tendon. Patellar osteophytes were more common in patients with anterior knee pain than without it (p=0.05). Conclusions: Sonographic morphologic changes of the patellar tendon were common 10 years after the harvesting procedure. Also, the harvested patellar tendon was significantly thicker than the normal patellar tendon.

I. Siev-Ner I. Dudkiewicz M. Warshavski M. Azarias M. Heim

Introduction: Since James Syme described his amputation at the ankle joint (1842), there were progonists and opponents to it. Most authors agreed that Syme’s Amputation should not be considered for patients with Diabetic Vascular Disease (DVD). Patients and Methods: We describe the results of 70 patients who underwent Syme’s Amputation between the years 1980–2000 in our department. Fifty-one of the patients had Syme’s Amputation due to Diabetic Vascular Disease. The other 19 patients had their Syme’s Amputation due to other reasons (i.e. trauma, malignancy, congenital). Results: The 19 patients of the non-DVD group had success rate of 94.7% (18/19). The overall success rate of the DVD patients was 49% (25/51). When we analysed the DVD group by age, the cut point was 65 years old. Patients under the age of 65 (including) had success rate of 68.2% (15/22) and over the age of 65 30.8% (8/26). The cause (disease) is the leading factor in predicting the success. If the patient has DVD, there is 18.5 fold (odd ratio) to fail a Syme’s Amputation. The age is the second in significance for success in Syme’s Amputation. For each decade aging, there is 1.96, (odd ratio) fold chance to fail a Syme’s Amputation. Conclusions: Patients sustaining DVD should be considered as good candidates for Syme’s Amputation if they are younger than 65 years old.

Heinrich Frenkel C. Melzer

Aims: Only gangrene of the entire foot and life-threatening sepsis with severe infection require a high amputation. Method: Between 1984 and 1999, 188 amputations in the area of the lower extremity were carried out at Bad Düben specialist hospital for orthopaedics. In 31 cases, partial amputation (so-called amputation of border zones) was required in the area of the foot owing to diabetic foot syndrome. The medical records were analysed and the patients who were still living underwent a follow-up examination; 8 patients had died. Results: Of the 31 patients, 20 were men and 11 were women. From 1982 to 1987 there were 4 partial amputations of the foot, from 1988 to 1993 there were 12 and from 1994 to 1999 there were 11. The average age was 69.1 years. In 11 cases, amputation of the lower leg as a subsequent operation was necessary. Here the average age was 71,8 years. It was noted that from 1994 to 2001 subsequent amputation of the lower leg had only been required twice (eight times from 1984 to 1993). The patients who underwent a follow-up examination were satisfied after partial amputation of the foot. Conclusions: For diabetic feet with neuropathy and infection, partial amputation of the foot can be regarded as the treatment of choice. Prompt referral to hospital is necessary to ensure optimum glucose adjustment and any treatment required for accompanying diseases. With interdisciplinary management between the physician, vascular surgeon and orthopaedist, and with treatment in a team with the orthopaedic shoemaker, in addition to surgical measures, we the necessary local can prevent gangrene of the entire foot and life-threatening sepsis from leading to a high amputation.

A. Andrade C. Lemos J. Sá P. Canela J. Neves

Diabetic foot is a disease with social, familiarly and economic charge.

Usually the patients with neuropathic diabetic foot have a compromise in large vessels of the calf that invalids most of the techniques of Plastic Surgery for reconstruction for skin losses of the foot.

The authors describe the utilization of little fragments of skin (proximally 4 mm diameter) draw under local anaesthesia in the tight. The receptor area due not have infection and clean of necrotic tissue. Tendons have also due excised or recovered of granulation tissue With this technique they have treated 4 patients; 3 have total recuperation of the lesion and in one, with a scar in the hallux, all the skin has lost. The largest area of the lesion treated has 8 x 6 cm, and time o healing has 12 weeks.

The reconstitution of the donor area is complete at 4 weeks with no scars.

The authors conclude that this technique is valid for dorsal loss of skin due to neuropathic diabetic foot.

H.H. Wetz A. Koller U. Hafkemeyer

Aims: Minor foot amputations in diabetic subjects aim at the preservation of limb length and thus in keeping subject’s ability to walk. Different surgical techniques will be described and clinical 5-years outcome will be presented. Methods: The study comprises subjects with diabetic-neuropathic osteoarthropathy (DNOAP) who underwent minor amputations or resections of the foot between 1996–2001. In all patients post-treatment examination has been performed. Focus was on wound healing, duration of rehabilitation process, walking ability and the use of mobility aids. Results: In 86 diabetic subjects 121 minor amputations of the foot have been carried out. The frequency of reamputations was 56% in the mean with a distinct accumulation in the area of forefoot amputations. For post-surgery treatment in case of forefoot amputations orthopaedic shoes have been prescribed; in case of hindfoot amputations orthopaedic devices were used. The activity pattern according to the criteria of Hoffer revealed walking ability in 92% of the patients. Conclusions: Amputations and resections of the foot have a long lasting tradition and they deserve particular attention. Although a relatively high frequency of reamputations must be admitted, they allow for the preservation of limb length. However, as an essential prerequisite a high standard in the fabrication of orthopaedic shoes and orthopaedic devices must be secured.

J. Berka K. Fink U. Dorn

Introduction: Pressure relief is essential in treating plantar neuropathic ulcers in the diabetic foot. This can be achieved in an excellent way by total contact casting, therefore especially the longstanding, problematic ulcer-nonresponding to common methods (such as insoles, special shoeware etc,) is adressed by this method.A second indication for total contact casting is presented by the acute stage of neuroosteoarthropathy (Charcot’s foot) with or without ulceration. Methods: 19 patients with diabetes type II were treated by total contact casting. The mean age was 55 (46–75) years. Only 4 out of 19 patients were women We found plantar ulcers 12 of the 19 cases, 7 cases had no ulcer, but a Charcot’s foot stage I was present. Most ulcerations were classified as Wagner stage II and III without any sign of infection. The mean duration of casting was 8 (1–22) weeks. All patients were treated in an outpatient-clinc, no admission to the hospital was needed. The method of casting is exactly presented. Results: Complications were seen in only one of the cases due to skin problems.8 of the 12 ulcers healed completely under casting, 4 healed by a mean of 4 weeks later due to further treatment after casting. All the cases of osteoathropathy could be treated until reaching stage II without any progression of the foot-deformity. Conclusions: The total contact cast gives us the possibility to treat patients with plantar neuropathic ulceration and/or Charcot’s foot stage I with the advantage of good plantar pressure reduction and upkeeping the patient’s full mobility at the same time.

G. Volpin Y. Zalizniak R. Shachar H. Shtarker J. Solero A. Kaushanski M. Daniel

Aims: Foot and leg infections and osteomyelitis are common findings in diabetic patients. The primary goal at present is limb salvage. This study reviews our experience with this pathology. Methods: This is a study of 2–6 years of 458 consecutive diabetic patients with foot or leg infections. 29% of them had IDDM (Type I) and 71% had NIDDM (Type II). Initial treatment consisted of a meticulous surgical eradication of the infection combined with antibiotic treatment (26%-plantar incision, 14%-amputation of a single or more toes, 32%-amputation of a single or more metatarsals, 19%-below knee amputation and 9%-an above knee amputation. Follow-up consists of 410 Pts. The remaining 48 Pts died prior to the end of the study. Results: 357 patients (87%) had a complete healing of the infection following a single surgical intervention. 17 Pts had also reconstructive vascular procedures. 53 Pts (13%) had 2 or more surgical interventions, during one or more hospitalizations, mainly of “a proximal amputation” The percentage of successful foot salvage following initial foot surgery was 90% (267/296). The remaining 10% patients with initial foot infection, had a secondary below knee or above knee amputations. Conclusions: Based on this study it is suggested that meticulous debridement of the source of infection by “minor” amputations, combined with I.V antibiotics, have yielded a relatively high percentage of success of limb salvage and reduced the necessity for initial above or below knee amputation. It is further suggested that the NIDDM patients are more prone to leg and foot infections than the IDDM patients; hence, they should be observed regularly.

H.H. Wetz A. Koller U. Hafkemeyer B. Drerup

Aims: Foot deformities following diabetic-neuropathic osteoarthropathy are often responsible for major amputations at the lower limbs. To preserve foot and lower limb length salvage procedures have to be introduced. Methods: In 59 patients with severe deformities of the foot (Sanders II-IV) surgical reposition and resection of necrotic bony substance has resulted in an axial correction of foot-malposition. Stabilization was effected using a fixateur externe device (Hoffmann II) over a period of 6 weeks. After removal of the fixateur externe stabilization of the lower leg was performed for another 6 weeks by means of orthotic devices. Results: Surgical reposition and stabilization in a total of 59 feet has resulted in 57 cases to conservation of the foot, in 2 cases later amputation was necessary. Immobilization in the fixateur externe resulted in a fast detumenescence of accompanying oedemas and in wound healing without special problems. Post-treatment examination after two years on the average revealed in all patients a stable pseudarthrosis without bony connection. 43 from 57 patients after about 6 months were provided with orthopaedic footwear. Conclusions: Surgical procedures which refrain from the use of implants and which do not increase arthropathic activities are capable to correct severe malpositioning of the foot without increasing the activity of arthropathy and result in superior long-term results in diabetic patients. They should therefore be applied with preference.

Ch. Beckmann B. Drerup H.H. Wetz

Aims: Better understanding of the influence of body mass to plantar peak pressure as a main biomechanical risk factor for ulcerations in the diabetic foot. To predict the effect of weight change on peak pressure. Methods: In-shoe peak pressure measurement (PEDAR, Novel) are performed in 5 patients with diabetic neuropathy and 5 controls: all wearing the same kind of ready made shoes with ready made standard fitting insoles of cork. Each subject is measured in 3 modes of weight simulation: normal weight, 20 kg weight increase (waistcoat with weight pieces) and 20 kg weight release by a movable overhead suspension covering a 6m walkway. Pace is selected individually after some pre-test walking to be comfortable in all 3 weight modes. For data analysis the plantar area of the foot is divided into 6 regions, particularly metatarsal region and heel. Results: No significant difference between diabetics and controls is found. In the most threatened regions (metatarsals and heel) peak pressure increases and decreases linearly with weight: A simulated weight change ± 20 kg increases/ decreases metatarsal peak pressure by ± 6.4 N/cm2. The corresponding figure for the heel region is ± 2.6 N/cm2. Conclusions: Weight increase or weight loss in the individual patient has at least in the metatarsal and heel region a significant effect to the plantar peak pressure. The linear relationship allows for a simple method of predicting the effect of weight change to peak pressure

K.A.N. Saldanha M.J. Bell J.A. Fernandes M. Saleh

Aims: To review the results of limb lengthening and deformity correction in fibular hemimelia. Methods: Fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achterman and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had significant femoral deficiency. Lengthening of tibia and in significant cases femur was done using either De Bastiani, Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. Results: The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Conclusion: Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb.

V. De la Varga E. Guerado G. García-Herrera Y. Serrano

Aims: The purpose of this study was to describe the histologic adaptation of the femoral artery wall to the strechtening derived from femoral lengthening by callus distraction. Methods: In 32 New Zealand white rabbits a left femoral bone lengthening was carried out with a total distraction of 30% of initial length. The study was divided into eight progressives stages and at the end of each stage both femoral arteries were excised and prepared for light microscopy and ultrastructural analysis. Results: Light microscopy: Changes in the media layer architecture were observed since lengthening of the 15% of the initial length, reaching its maximum by lengthening of 30% of initial length. Six month after the end of the distraction, the media layer still showed morphologic changes compared to the unlengthened group. U.E.: During the greatest distraction period and one month thereafter the Smooth Muscle cells of the media lost its contractile characteristics and greatly increased their syntesis organelles, and mytosis and isolated binuclear cells are observed representing and accelerated cell proliferation. Six months after the end of the distraction the muscular cells returned almost completely to the normal contractile state. Conclusions: The response of the arterial wall against the strechtening is more a regenerative response due to the muscle cells than a reparative response of the connective tissue. This study suggest that with the greatest distraction, and one month later, the muscle cells change from the original contractile phenotype to a synthetic phenotype, that is a prerequisite for cellular proliferation. The return to the original characteristics six months thereafter could support the reversibility of the cellular phenotype opposite to the progressive elongation.

V. Consoli D. Palla G. Bonamici S. Marchetti S. Maccarrone M. Maltinti

Introduction: the prevalence of diabetics in the old population, and the enhancement of medications actually cause an enormous augmentation of the incidence of diabetic foot. Aim: aim of the study is to report authors’ experience about the transmetatarsal amputation. Patients were enrolled according to skin conditions, arteriography and life expectation. However, based on personal experiance arteriography has not been one of the main criteria in selecting the level of amputation. Methods: Since jenuary 1997 up to december 2002 thertyfour patients were treated. 26 were male, 8 females, the mean age was 69 years. The total amount of transmetatarsal amputation has been 36 surgical procedures. Those were performed after a peripheral anesthesia, the surgeon always avoided the use of torniquette. A short leg cast was made in order to let the wound heal and to avoid equinus deformity untill the weightbearing gait was allowed. Results: At a mean follow-up of 48 months 28 patients were able to walk using one or without crutches, two patients needed two crutches full time, four patients underwent to a further procedure of resection at a more proximal level. Conclusion: the outcome showed to be dependent by many variables, however middle term results are encouraging, patients can walk and attend again their own daily activities fairly soon. Although it is well understood that the long term result will be worst, we suggest to try whenever it is possible to perform a transmetatarsal amputation expecially in old people who can not easily ricover from a leg resection.

S.D. Kaufman J.A. Fernandes M. Saleh J. Pagdin

Aims: To review the presentation, progression, treatment, and outcome of congenital posteromedial bow of tibia. Methods: Seventeen patients were studied using radiographs and medical records retrospectively. The time period was from 1989 to 2002. Data was collected with special reference to deformity correction and lengthening. Complications were analysed. Results: Eight of the patients were male and nine female; eleven of them had deformity correction and lengthening, whereas two are awaiting surgery, two underwent contralateral epiphysiodeses and one, periosteal stripping. Twelve were treated with the Ilizarov device, seven with LRS. The range of discrepancy pre – operatively was from 3 to 8.8 cm. Mean length gained was 3.7 cm with residual discrepancy within 0.6 cm. Complications noted were minor grades of infection and 3 patients required further corrective surgery. The bone-healing index was 62 days per cm. There was some decrease in ankle movement noted, this was unchanged or improved post-operatively. Conclusion: Successful simultaneous deformity correction and lengthening for this condition is possible. The Ilizarov frame provided more benefits in reducing complications. This is the largest series of lengthening and correction of this deformity published and the residual deformity and initial length discrepancy is greater than previously stated.

G. Aphendras A.V. Korompilias K.N. Malizos A.E. Beris Xenakis Th P. Soucacos

Aims: The purpose of this study is to to assess the surgical results, complications, and long-term results of vascularized fibula in the treatment of congenital pseudarthrosis of the tibia. Methods: Seven patients who had congenital pseudarthrosis of the tibia were treated consecutively at our clinic between 1992 and 2000 with free vascularized fibular graft. There were four females and three males. The mean age at the time of operation averaged 6.5 years (range 1–12 years). Four left tibias and 3 right tibias were involved. Stability was maintained with internal fixation in four patients, external fixation in two patients and intramedullary pin in one patient. Results: The average follow-up was 2.6 years (range 6 months to 8 years). In five patients, both ends of the graft healed primarily within 2.7 months (range 1.5 to 3 months), and hypertrophy of the fibular graft occurred rapidly with a well-formed medullary canal. In one patient the distal junction did not unite and although required three subsequent operations still not healed. Stress fracture occurred in one patient underwent four additional operations before union achieved. Conclusions: Despiting the continuing problems and the relatively high complication rate, the ultimate results with free vascularized fibula transplant are generally good specially as compared with published series in whom conventional grafting techniques had failed. However, even achieving union of pseudarthrosis is not enough for the resolution of this disease and is only half of the problem; the other half is to maintaining

P. Gutiérrez Carbonell J.J. Verdú Verdú S. Soler Martinez R. Sanchis

Aims: Study our experience and short term results using a mix of osteoconductive (HA) and osteoinductive (AGF) materials. Methods: From October 2001 until June 2002, we have treated bone defects in 9 patients. Seven male and 2 female. Mean age 10.4 years (range 4–18 years). Mean follow-up: 5.6 months (range 3–9 months). AGF was obtained after autologous blood centrifugation according to blood volume, knowing the patient height and weight (Nadler Score). AGF was obtained through previous concentrate of platelets and red cells, with a further concentration, reducing its volume to 1/3. 10 c.c. of thrombin (500 UI) and HA (500R) were added, just before applying it to the patient. Total surgery time for preparation AGF was 20–30 minutes. Clinical cases treated were: varus osteotomy in Perthes (1 case- 11%); curettage in osteomyelitis (2 cases- 22%); essential cyst, after conventional corticoid treatment failure (2 cases- 22%); forearm pseudoarthrosis (2 cases- 23%) and triple arthodesis by valgus pronated spastic foot (2 cases- 22%). We never use autologous iliac graft with AGF- HA. Results: We have obtained radiological and clinical consolidation in all bone defects after 3–4 months. Radiological success is not clear after 4 months in one of the osteomyelitis cases (12’5%). Conclusions: 1. The iliac graft harvest morbility is about 9.4%- 49%. 2. A 2nd approach is avoided in children and adolescents. 3. With the use of AGF- HA we avoid morbility, diseases transmission, reduced surgery time and offer an alternative to autologous grafting.

K.A.N. Saldanha M. Saleh M.J. Bell J.A. Fernandes

Aims: To review the hip subluxations or dislocations occurring during femoral lengthening in patients with congenital longitudinal lower limb deficiencies. Methods: Sixty-three patients with congenital longitudinal lower limb deficiencies underwent femoral lengthening using either De Bastiani, Villarubias or Ilizarov technique. Acetabular index, medial joint space, CE angle of Wiberg, acetabular angle of Sharp and neck-shaft angle were measured on anteroposterior radiographs of hip before, during and after lengthening. Acetabulum was considered dysplastic when the Sharp angle was more than 45 degrees. Hip was considered to be subluxed when the medial joint space increased during lengthening. Results: During femoral lengthening, eleven hips subluxed as measured by the increase in medial joint space and one hip dislocated. All these hips had a pre-operative acetabular index more than 25 degrees, CE angle less than 20 degrees and Sharp angle more than 45 degrees. The average neck-shaft angle was 75 degrees. Following subluxation, lengthening was stopped and the hips were reduced in hip spica after adductor and sartorius tenotomies. In one patient femoral shortening and acetabuloplasty had to be done to reduce the sub-luxation. No case of avascular necrosis or chondrolysis was noted. Conclusions: Hip subluxation during femoral lengthening of congenital longitudinal lower limb deficiencies tends to occur when there is associated ace-tabular dyplasia and femoral coxa vara. Careful preoperative assessment, if need be hip reconstruction prior to lengthening and close monitoring during lengthening is recommended.

J.A. Fernandes K.A.N. Saldanha M. Saleh M.J. Bell

Aims: To review the results of reconstruction of pseudoarthrosis and/or significant varus with retroversion of proximal femur in congenital longitudinal lower limb deficiencies. Methods: 23 of 95 patients had proximal femoral reconstruction. 7 had pseudoarthrosis of the neck of femur and the remaining had significant coxa vara with retroversion of femur. 3 patients with pseudoarthroses were treated with valgus derotation osteotomy and cancellous bone grafting, 2 with fibular strut grafts, 1 King’s procedure and 1 with excision of fibrous tissue and valgus derotation osteotomy. Remaining patients underwent valgus derotation osteotomies. A variety of internal fixation devices and external fixators were used. Results: All patients with pseudoarthroses underwent multiple procedures to achieve union. 3 with cancellous bone grafting underwent repeat osteotomies to correct residual varus and 2 had grafting repeated twice. 2 patients achieved union after fibular strut grafting. One patient, who underwent excision of pseudoarthrosis, achieved union but had to undergo further valgus osteotomy. The remaining 17 patients with coxa vara and retroversion of femur also had valgus osteotomies repeated more than once (average 2.3) for recurrence of varus deformity. There were significant numbers of implant failures. Average initial neck-shaft angle of 72 degrees improved to 115 degrees after reconstruction. Conclusion: Achieving union of pseudoarthrosis and early axis correction using valgus derotation osteotomy with a view to later lengthening is important in limb reconstruction. Recurrence may require repeated osteotomies and pseudoarthrosis may need more aggressive surgery to achieve union. Muscle slides and soft tissue releases decrease the stress on implant and maintain correction.

Piotr Wojciechowski D. Kusz S. Dudko

Aims: Lengthening of bones with Ilizarov method is acknowledged method as well very inconvenient. First inconvenience is long lasting of immobilization in external stabilizer, responsible for joints contracture and muscles atrophy. Use of interlocking nail makes possible removal of stabilizer immediately after finishing of lengthening without risk of deformity of fresh bone callus. Methods: From 1999 to 2001 we used this method in the treatment of 11 patients age 13–23 years [~16,9], with shortening of femur 3–8 cm [~4,9]. Etiology of shortening was: congenital [8], aseptic necrosis of femoral head [2] and comminuted fracture of femoral shaft [1]. During surgery we cut cortex of femur, than interlocking nail and finally external stabilizer were applied. After we reached planned lengthening nail was locked and stabilizer was removed. For complications we used Paley classification. Results: We received planned length of femur in 10 cases. Average time of applying of external stabilizer was 14 days/1cm of lengthening. Problems: fracture of femoral shaft without displacement during driving of the nail [1], pin site infection of soft tissues and transient restriction of movements of knee in all cases. Obstacles: wedging of the nail [2], fracture of femur after removal of the nail [1] and deep infections along the nail [1]. Complications: shortening of femur about 0,6 cm because of premature rebuilding of bone callus [1]. Conclusions: Advantage of this method is decrease of complications thanks to shortening of time of immobilization in external stabilizer, inconveniences are: more extensive surgery, risk of wedging of the nail and fracture after removal of the nail because of weak bone callus.

A.W. Davidson H.S. Hosalkar R.A. Hill

Abstract: Dealing with peri-articular pathology in the skeletally immature is challenging. Where the process is benign the emphasis rests on preservation of the joint while minimising the risk of recurrence. However when dealing with lesions of the femoral head this may lead to avascular necrosis (AVN), negating the effects of conservative surgery, and potentially subjecting a child to a prolonged period of fruitless treatment, increased hospital stay, reduced mobility and significant time out of education and social interaction. Case & Method: A 13 year-old Caucasian female presented with a six-month history of pain in her right hip, initially in the groin, and a limp necessitating the use of crutches. Radiographs revealed a lytic lesion in the femoral head with a thinned but intact articular surface. This was biopsied, and a diagnosis of chondroblastoma reached. The operative alternatives of arthrodesis and arthroplasty were discarded in preference for hip salvage. An anterior approach to the hip, with dislocation of the femoral head allowed identification of the fragile cortical margin of the chondroblastoma. This was opened with a scalpel and curetted. Corticocancellous strips of bone graft were placed into the defect as struts around cancellous graft. An autogenous fascia lata graft was sutured over the articular defect in the femoral head. The capsule was repaired. Results: One year post-operatively she is pain free and has returned to normal activities. Radiographs show good incorporation of the bone graft. Conclusion: Femoral head preservation is effective with benefits outweighing the risk of AVN.

A.K. Malik A.A. Shetty J.P. Compson

Aims: For the scaphoid, several views are needed to visualise the whole bone. These sets of views are routinely called “scaphoid views”. However certain views are better than others for imaging particular parts of the scaphoid. The authors believe that asking for scaphoid views from the radiology department often leads to a wide variety and number of radiographic views being taken, even when a protocol is in place. Methods: 50 radiographers from 4 London teaching hospitals were asked which and how many views of the scaphoid they would take, at initial presentation and in the outpatient setting. They were also asked to describe and demonstrate exactly how they would take the view(s) chosen. Results: We found a wide variation in the descriptive terms used by radiographers for particular views. There was also little agreement on how many and which views to take despite protocols being in place. Conclusion: Not only is their complete lack of agreement on what “scaphoid views” should be, it was also discovered that there was little agreement on the nomenclature of the individual views themselves. This can lead to loss of information from the wrong views being taken as well as unnecessary radiation exposure. The lack of nomenclature also leads to confusion between radiologists, radiographers and surgeons.

N. Dastgir F. Khan B. Quinn J. O’Beirne

Material and Methods: In our study the results of a consecutive series of symptomatic non unions of scaphoid fractures treated with Herbert screw and bone graft during period between July 1996 and June 2000 are studied. Out of a total of 66 patients (one bilateral), 61(91.04%) cases who had symptomatic non unions (type D) were treated with Herbert Screw plus iliac crest bone graft while 6(8.95%) cases were treated for acute unstable fractures (type B)with Herbert screw only (these are excluded from the study). The time interval between injury and surgery was 12.2 months (range 2–72 months) Patients were followed up for radiological evidence of union and clinically for range of movement of wrist, grip strength and outcome score. Results:Total No 61, Union 47 (77.1%), Persistent non-union 14 (22.9%). The site of fracture (p=.044), type (p=.028), screw placement (p=.019) were found to be significant factors infl uencing outcome. No statistically significant influence on outcome was found with patient’s age (p=0.983) and also with time interval to non union surgery (p=0.749). Using the scaphoid outcome score, an assessment scale based on pain, occupation, wrist motion, strength and patient satisfaction, functional results were graded as excellent in 19 cases, good in 12 cases, fair in 10 cases and poor in 5 cases. Conclusion: We recommend axial placement of Herbert screw with bone grafting via Russe approach and for difficult proximal pole non unions dorsal approach is recommended.

Neil Ashwood G. Bain

Intraosseous ganglia are typically found in the epiphyses of long bones with the two most common locations being the femoral head and medial malleolus. Almost a fifth of cases reported are found in the carpal bones where the ganglion may be an infrequent cause of chronic wrist pain. Persistence and severity of symptoms rather than radiological findings determine the need for further management. Curettage and bone grafting has been performed for patients with constant symptoms that have severely restricted occupational or recreational activities. Clinically the patients improve but in up to forty percent symptoms persist affecting function.

The authors describe an arthroscopic assisted technique of debridement and bone graft used to treat eight patients with intraosseous ganglions of the lunate. All patients returned to work within four months with significant improvement in function and substantial reductions in pain scores. The modified Green scores increased 33.8 points from 51.2 to 85.0 points (p=0.03) by one year postoperatively. Radiographic analysis showed trabeculation within the lunate at an average of 13.8 months following surgery.

The technique is safe, with minimal morbidity and no re-operations.

B.Y. Ng A.N. Misra P.F. Hales

Aims: To evaluate the role of Blatt’s capsulodesis and scapholunate ligament repair in patients with chronic scapholunate instability. Methods: Nineteen (15 males, 4 females) patients with chronic scapholunate instability underwent surgical repair and dorsal capsulodesis. At a mean follow-up of 28 months, all patients were assessed to identify any improvement in analogue pain scores, grip strength, range of movement of wrist and overall result of surgery. Results: Pre-operative arthroscopic findings revealed a scapholunate gap of > 2mm and ease at visualising the capitate by passing the scope through the scapholunate interval confirming the diagnosis. Surgery consisted of repair of torn ligament and supplementary dorsal capsulodesis (Blatt’s technique). 12 patients (63%) had returned to normal working activities at pre-injury level. There was a marked improvement in level of pain (mean pain level= 8.7 pre-operative vs. 2.3 postoperative, p=0.003). Seventeen patients (89.5%) would recommend this operation to others with similar problems. Only one patient (5%) rated the results as worse off following surgical intervention. Statistically significant pain improvement and grip strength were noted. ROM of wrist did not improve in most patients. Conclusion: Treatment of the chronic scapholunate instability remains contentious. It is suggested early surgical intervention will benefit majority of the patients. Our result concluded that Blatt’s capsulodesis has a role in chronic scapholunate instability.

N. Misra Amit B.Y.N.G. Aaron P.F. Hales

Aim: To evaluate the functional and radiographic results of dorsal capsulodesis in predynamic and dynamic scapholunate instability. Methods: Nineteen patients underwent a scapholunate interosseous ligament repair combined with a dorsal capsulodesis as described by Blatt, in as many wrists for scapholunate instability between 1994 and 1999. The diagnosis was based on a clinical, radiographic and arthroscopic assessment. Mean follow up was 22 months (8 months – 5 years). 15 patients were available for follow up. Most (13 of 15) of the patients presented with predynamic or dynamic instability. Results were analysed clinically and radiologically. Results: Thirteen patients showed a good or excellent clinical result. There was a statistically significant improvement in pain relief (VAS scores) and grip strength (58% of the opposite side). Mean extension and ulnar deviation was significantly better (62% and 53% of the opposite side respectively) and there was a significant reduction in wrist flexion (49% of the opposite side). 13 patients returned to their original level of activity. There was no significant change in the mean SL gap and angle after surgery. Thirteen patients would recommend this operation. Conclusions: We thus believe that this procedure can produce encouraging results in cases of pre dynamic and dynamic instability in a patient population with low demand wrists. Larger case loads and more complete follow ups would be desirable to derive strong evidence based conclusions.

Mikko Haara H. Kröger J. Arokoski P. Manninen M. Heliövaara

Aims: Prevalence and risk factors of osteoarthritis in the carpometacarpal joint of the thumb have been amply explored in previous studies. However, no study has focused on CMC OA as a predictor of disability and mortality. We investigated CMC OA for its associations with risk factors, disability and with life expectancy in a extensive health survey. Methods: In 1978–80, a representative population sample of 8,000 Finns aged 30 or over were invited to participate in a comprehensive health examination; 90% complied. Hand radiographs were taken from 3,595 subjects and the clinical status was completed for 3,434 subjects. By the end of 1994, 897 subjects with hand radiographs had died. Results: The age adjusted prevalence rate of CMC OA of Kellgren’s grade 2 to 4 was 7% for men and 15% for women. Adjusted for alleged risk determinants, body mass index was directly proportional to the prevalence of CMC OA in both sexes, OR =1.29 (95% confidence interval 1.15–1.43) per each increase of 5 kg/m2 in body mass index. Smoking seemed to carry a protection against CMC OA in men but not in women. No significant association was found between history of workload and CMC OA. Restricted mobility, tenderness and swelling were frequently found in the presence of radiological CMC OA, but no significant increase occurred in the prevalence of disability. In men CMC OA of Kellgren’s grade 3 to 4 significantly predicted total mortality (adjusted relative risk 1.32, 95% confidence interval 1.03–1.69). Conclusion: In line with previous studies, body mass index strongly determines the prevalence of CMC OA. CMC OA is highly prevalent, but its impact on disability in the general population is scanty.

Nickolaos A. Darlis V.Th. Chouliaras G.D. Afendras A.N. Mavrodondidis G.I. Mitsionis A.E. Beris

Aim: To study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes. Method: The preoperative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were digitized and measured using CAD methodology. Patients’ mean age was 31,3 years and mean time from fracture 50,4 months. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The Herbert and Fisher classification was used and two subgroups concerning the absence (14) or presence (21) of early arthritic changes were created. Results: 62,5% of the patients (including patients without radiologicaly obvious arthritis) were presented with increased radial height and radial inclination, 28% with an affected carpal height, 17% with ulnar translocation of the wrist and up to 48% (varying according to the method of measurement) with a DISI pattern of instability. No statistically significant differences could be established between the morphological groups or between the two subgroups concerning early arthritis. Conclusions: Carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and thus treating non-union with early arthritis with osteosynthesis and bone grafting seems justified. In view of our findings it seems appropriate to supplement this procedure with distal radial osteotomy or with temporary lunate stabilization in selected patients.

A. Evans F. Hussain O. Oni

Aims: To compare objective and subjective methods of assessment of outcome following total knee replacement. Methods: A retrospective review of 560 consecutive total knee replacements, performed under the care of a single surgeon, between January 1990 and January 2000, on 456 patients, was carried out. Minimum follow-up was two years. The patients were assessed using two postal questionnaires, a clinical interview and examination and a radiological investigation. The results from each assessment were entered into a database and evaluated. Results: The results from the postal and direct questionnaires were comparable. These results correlated well with clinical and radiographic evaluation. A simply worded questionnaire was found to be more user- friendly than a complex questionnaire. Questions about specific daily activities were less user-friendly than questions about general function. Conclusions: A simple postal questionnaire provides an accurate reflection of outcome after total knee arthroplasty. This has significant implications with regard to cost and clinical time when planning follow-up after knee replacement.

A. Butler-Manuel H. Apthorp A. Rogers

Aims: The 98% 10 year survivorship of the cemented AGC TKR is regarded as gold standard.(1) The authors attributed their excellent results to the flat on flat design and the compression moulded polyethylene rather than the cement. The aim of this trial is to determine if the type of fixation also influences outcome. Method: Participants were randomly allocated to either a cemented or cementless hydroxyapatite coated AGC prosthesis. All patients were assessed with the Hospital for Special Surgery Score (HSS) and radiographs pre-operatively and then post-operatively at six weeks, six months, one year and annually. Results: 223 knees were studied with a mean follow up of 39 months (max 8 years) Both groups were well matched for age and sex. There were no significant differences between the two groups in post-operative HSS scores or in improvement of HSS scores. There has been no observable migration in either group. There were 15 radiolucenies (< 2mm) in the cemented and 1 in the HA group. A common finding in the HAC group was a radiodense line around the uncoated stem of the tibial prosthesis which is of no clinical significance. There has been 1 case requiring revision, which was from the HAC group. In addition 2 patella buttons were revised following traumatic separation. Conclusion: The early results are equally good for both groups with no significant difference in outcome or complication rate between cemented and HA coated fixation.

H. Migaud E. Becquet C. Chantelot T. Ala Eddine F. Gougeon A. Duquennoy

Aims: Henri Dejour promoted a mechanism involving a third femoral condyle to achieve Posterior Stabilization (PS) in total knee arthroplasty (TKA) introducing the HLS II prosthesis. This retrospective study was conducted to assess the behavior of such PS mechanism. Methods: Between 1992 and 1993, 105 HLS II prostheses (94 patients) were consecutively inserted (78% arthrosis, 19% rheumatoid arthritis). No patient was lost for follow-up but 14 had died, 6 were unable to walk (severe neurological disorder), 4 were contacted by phone. Consequently, 70 patients (77 TKA) mean aged 66 years (22–79) were assessed after a mean follow-up of 7 years (6–8). All the components were fixed with cement and patellar resurfacing was always performed. Results: The knee IKS score increased from de 27 points [0–63] before surgery to 81 [21–100] at follow-up and functional IKS from 35 points [0–75] to 64 [0–100] (p< 0,0001). Similarly range of motion improved from 114° [60°–140°] to 116° [80°–135°] (NS). At follow-up, 86% of the patients were able to practice stairs (13% without support and 28% in alternative manner) against 52% before surgery (1% without support and 1% in alternative manner) (p=0,001). Tibial bone-cement radiolucencies were observed without loosening in 30% (all < 1 mm and non- progressive) mainly related to severe preoperative varus deformation (p = 0.01). One late infection required reoperation. Ninety months survival was 97% ± 1.3% with reoperation related to infection or mechanical disorder as end-point. Conclusion: The posterior stabilization, by means of a third condyle, allowed a satisfactory range of flexion and improved ability to practice stairs. Mid-term follow-up did not identified adverse effects of this PS mechanism on component fixation or knee stability.

Y. Masse R. Nizard J. Witvoet J.Y. Nordin

Aims: Mid and long term results of a continuous series, including learning curve, of 500 TKR cruciate sparing implanted between September 1992 and February 1995 by different surgeons of GUEPAR (staff members and residents) Material: Patients average age70.3 years (26–93). Etiology: Primary OA 74%, post traumatic 6%, RA 6%, associated aetiology in 14% (osteonecrosis, microcristalline arthropathy...). No previous surgery in 325 knees. 175 knees operated before (tibial osteotomy: 37, femoral osteotomy: 4, patella:13, other knee surgery: 74% knee arthroplasty mainly unicompartmental: 19.) Operation procedureby medial approach, except 16 lateral (3.2%) and 6 tibial osteotomy (1.2%). Lateral retinacular release in 19.6% aligned patella and 29.2% subluxed or luxed patella. Per operative complications: PCL weakness (24), tibial plateau fissure (16), condylar fracture (1), patellar fracture (3) without consequence on weight bearing. Although anatomic shape of Wallaby 1 trochl, 86.5% inlay and 11.1% resurfacing patellar component have been done. Very few patella (2%) are not resurfaced at the beginning of our experience. Postoperative complications: No specific earliest complications related to the prosthesis. Latest compliations are: 2 infections in the first month treated by lavage debridement with total recovery and 6 latest infections (> 5th month) with prosthesis removed. 1 bipolar aseptic loosening, 1 patellar loosening without fracture and only 2 of 21 patellar fractures have been fixed by wires. 3 reoperations for persistent pain: 2 patella resurfacing and 1 patellar lateral retinacular release, 3 periprosthetic femoral fractures, 2 fixed by plate, 1 treated by conservative treatment with good results.1 medial collateral ligament rupture after trauma revised with another prosthesis. 5 Sudeck syndrome. Results: Femoro tibial alignment is good (between 3° valgus and 2° varus) in 71.1% and reach 90% if between 5° valgus and 5° varus in%. 38 patients (38 knees: 7.6%) are deceased or lost for follow-up before 1 year (without any revision); 462 knees (92.4%) are follow-up between 1 to 5 years and 381 (76.%) more then 5 years. According to International Knee Score results on these 381 knees are: 104∞ of average flexion (pre op. 109∞), 90.6% had any or mild pain. IKS Knee score 90,6 (45–100) (pre op. 25) IKS function score: 59,7 (0–100) (pre op. 28,5) Survival rates at 8 years: 98.2%(confidence interval of 95%: 99.4–96.9) for removed prosthesis whatever the reasons, and 99.2% (confidence interval of 95% 100–98.4)for revision for mechanical failure only. Conclusions: Encouraging results with a true condylar divergent device encourage us to continue Alignment has to be improved, perhaps with navigation tools.

C.G. Dimitriou P. Papadopoulos D. Karataglis Ch. Karatzetzos J. Pournaras

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

P. Keblish J. Boldt J.-L. Briard

Aims: Fixed valgus requires lateral releases for stable patellar tracking and gap balancing. Adequate extension space must be achieved without weakening the lateral sleeve. This complication can occur with sub-periosteal femoral LCL/popliteus releases. Distal LCL lengthening and/or lateral epicondylectomy with advancement maintaining soft tissue strength/stability. Methods: 174 valgus TKAs with 5- to 15-year follow-up were reviewed. Demographics included 93% females, 13% rheumatoid, mean age 69. Prostheses utilized were LCS meniscal (30%) and rotating (70%). Fixation was cementless in 86%. The direct lateral approach was used in all cases. Results: Good/excellent results were 91% (HSS scores 54 to 84). Deformity correction mean > 15° to < 5° valgus. Of the failures, 5 were meniscal PCL-retaining (1 malposition, 2 subluxations, 2 wear). Four meniscal and one rotating bearing spin-out were related to inadequate (over/under) concave side balancing, all in early cases with standard femoral sub-periosteal releases. Conclusion: Release of contracted concave side soft tissues, without compromising strength/integrity of the LCL/popliteus complex, is required to achieve stable flexion-extension gap balance and correction of the biomechanical axis in fixed valgus TKA. Improved techniques of lateral side releases that maintain ligament attachments and allow more precise lateral extension gap adjustment have eliminated failures related to soft-tissue imbalance with non-constrained implants. Key technique points of the lateral approach, with emphasis on the deep releases, will be illustrated.