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Volume 88-B, Issue SUPP_I March 2006 7th Congress of the European Federation of National Associations of Orthopaedics and Traumatology, Lisbon - 4-7 June, 2005

PM Rozing

The pathology of the RAshoulder differs from that of the OA shoulder. In addition to replacement of the glenohumeral joint, procedures have to be performed to deal with disorders specific for the RA shoulder, such as bone deficiency of the glenoid, thinning or rupture of the rotator cuff, and severe internal rotation defomity. Timing of shoulder arthroplasty in the rheumatoid patient is stilla controversial issue. Clinical symptoms are more important than the radiographic destruction for timing of surgery. The status of the rotator cuff and the glenoid will predict the functional result.

Controversial issues ar whether the synovitis of the AC-joint and the subacromial area should be treated arthroscopically early to prevent destruction of the cuff, whether repair of the rotator cuff or tendon transfers effect the end result, and whether replacement of the glenoid is beneficial.

The surgical management of advanced destruction of the rheumatoid elbow differs from one center to the next, as controversy exists regarding the success of synovectomy. Total elbow arthroplasty in patients with advanced joint destruction has gained popularity. Controversial issues and new developments will be discussed.

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U Rydholm

Modern pharmaceutical treatment of RA seems to result in less need of prophylactic surgery but the burden of secondary osteoarthrosis of the the large joints in the lower extremity will be present for a foreseeable future. The results of hip an knee arthroplasty are well known from the Swedish Arthroplasty Registers. Severe deformities of the hip and knee are nowadays very seldom seen, but the same does not hold true for the ankle and foot. As more RA patients are offered hip and knee replacement they will start loading their feet to an extent which the feet are not always able to withstand. Effetcive pain-killing pharmaceuticals also means a possibility to put weight even on an arthritic deformed foot. Thus, severe foot and ankle deformities are still rather frequently seen. Improved surgical methods for correction have evolved and in most cases reconstructive ankle and foot surgery will restore the weightbearing capacity of the RA foot.

A Nilsdotter

There is a lack of uniform systems for assessing outcomes after surgery in patients with RA.

Factors known to affect outcome are disease activity, pharmacological treatment, comorbidities, desires and motivation.

The consequences of disease influence to a high degree the patients’ quality of life, their ADL, working ability and recreational activities. That makes it important to measure the result from the patient’s perspective as well as reporting demographic data, disease activity, co-morbidities, functional status and surgical data.

We have found that patients with RA assigned for orthopaedic surgery seem to be most concerned about pain relief. The SF-36 scores also indicate that the patients’ physical function, pain and general health were more deteriorated than their social function and mental health. By following patients prospectively we will have the opportunity to find out whether expectations and perception of health influence the outcome after surgery.

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P Kopylov

Wrist fusion, ulna head resection and fusion of the MP or PIP joints are not anymore the only operations that can be offered to patients with RA. The modern medical treatment has changed the course of the disease and we are not anymore in front of patients with major joint destruction, very bad hand function and low demands. Young ladies with well controlled disease expect surgery to result in restitution of function which allows a life close to normal in terms of work and leisure time activities. If pain relief remains the main indication it has to be associated with reconstruction of function, preserving mobility and increasing grip strength. For these reasons it appears necessary to limit fusions and increase the use of joint implants. Accurate evaluation of the patients’ need and expectations will help in the choice of the appropriate surgical procedure to achieve the treatment goal.

CT Currie JD Hutchison Ann Yellowlees

The Scottish Hip Fracture Audit (1) was founded on Rikshoft, the Swedish hip fracture register (2), and since 1993 has documented case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care were updated by a multidisciplinary group in 2002(3). And hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004 (4).

Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A& E care, pre-operative delay, multidisciplinary care and audit participation are met.

Three national-level initiatives on hip fracture care have delivered: reliable and largescale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance and quality assurance, with methods for casemix-adjusted outcome assessment for hip fracture care also now developed.

Nicolai Bang Foss Henrik Kehlet

The incidence of hip fractures is rising, and at the same time the patients are getting increasingly frail and elderly. Patients in Europe have a median hospitalization time of as much as 28 days, and the peri-operative morbidity and mortality is high1. Most interventional studies have been unimodal with very heterogeneous results and at present, limited data are available from multimodal intervention according to the established principles of fast-track care2. This study has very positive results with a reduction in hospitalization from 21 till 11 days. Anaesthesiological intervention in a fast track regimen must be peri-operative in such a high-risk group of patients. Early operation is probably preferable3. Pre-operative regional analgesia potentially reduces cardiovascular morbidity, if instituted immediately after arrival4. The effect of regional anaesthesia and postoperative regional analgesia on morbidity and mortality in hip fracture patients may be advantageous5.

Postoperative epidural analgesia can be provided without restrictions on patient mobility and rehabilitation, provides superior dynamic pain relief and reducing the influence of pain as a restricting factor on physiotherapy6. A potential effect of intra-operative volume optimization has been shown, although the effect on morbidity and mortality is unclear7. No information exists for postoperative fluid therapy regimens, but fluid excess is probably important to avoid8. Hip fracture patients often suffer from malnutrition at the time of admission and protein and energy supplementation potentially reduces mortality and morbidity9. Therefore a short perioperative fasting period combined with aggressive peri-operative oral nutrition and anaesthesia and analgesia techniques, that minimizes catabolism and PONV seems rational. Since mortality and morbidity is so high these patients should be treated in close cooperation between surgeons and anaesthesiologists both in the pre and postoperative phase10, as established practice in other high risk patients. Mortality is not the optimal parameter the for success of intervention in this population, as effects are extremely difficult to document, since as much as 50–75 % of the perioperative mortality may be unrelated to the treatment regimen11.

The cumulated evidence for the peri-operative care of this patient group is scarce and fast-track rehabilitation regimens should look to other operational procedures for available evidence12. Future research should focus on broadening the evidence for relevant pre-operative optimization, the influence of regional analgesia on rehabilitation potential and optimized peri-operative fluid therapy, transfusion and nutrition regimens.

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Renato Laforgia

The new S.I.C.O. (Italian Society for Surgery of Osteoporosis) is trying to establish a register for osteoporotic complications, namely for Hip fractures, in fact at the moment only limited epidemiological data are available about the incidence of hip fractures in Italy. These data vary widely across the Italian Regions.

In the last five years E.S.O.P.O. study allowed us to have epidemiological data about osteoporosis in Italy, and from then a group of Orthopedic Units, distributed along all the country, are collecting data to better understand the epidemiological relevance of Hip Fractures.

84.188 Hip fractures were registered in 2001 from the Italian Ministry of health, which meant 1.48 fracture every 1.000 citizen, 25% of which were males.

From some areas through relating fractures and age was possible to establish that there were 3.7 fractures every 1.000 people over 50 years of age, 4.5 fractures every 1.000 females over 50 years of age, 1.9 every 1.000 males over 50.

From the Units working at the project few significant data were obtained: mean time between hospital arrival and surgery was 3.9 days, considered very high, the mean time of Hospital stay was 9.5 days for all patients, but 14.5 days for patients that underwent to an operation.

55% were lateral fractures for which a new “Italian” undersized titanium nail was introduced in February 2003, which rapidly was adopted in many hospital for its simplicity and low cost.

Controversial among Orthopedic surgeons arose because some of them are treating lateral fractures with total or partial hip replacement.

Because of different health organization between Regions of North, Center and South of Italy the patients are discharged to rehabilitation Unit mainly in North of Italy, less in Southern part where for a lack of Rehabilitation Units, most of the patients go back home, supported from public health operators at their family place.

Karl-Göran Thorngren

Introduction: The treatment of hip fracture patients differs widely throughout Europe. In the SAHFE project (Standardised Audit of Hip Fractures in Europe) it was found that both waiting time to operation and mean hospitalisation time for operated patients was considerably higher in certain Mediterranean countries compared to the Northern parts of Europe. Local tradition influences both the choice of operation method and the routines for rehabilitation. Background factors were rather similar with mean age around 80 years and a predominance of female patients, 75% were women. Experiences from good examples of treatment throughout Europe are important to optimise the overall hip fracture treatment of benefits both for the individual patient and for the society in form of resources needed. The costs for hip fracture treatment are already considerable and with an ageing population the resources for treatment of these patients need to be optimised throughout the world. With more elderly in the populations, the total number of hip fracture patients is prognosticated to increase 5 times in the next 50 years. This symposium deals with means to improve the treatment results by focusing on the patient to make possible the best rehabilitation results after different operative procedures. Examples will be given from centres who have worked on the whole treatment chain for these elderly resource consuming patients.

Dawn Skelton Chris Todd

ProFaNE, Prevention of Falls Network Europe, is a four year project, funded by the European Community Framework 5. It is a thematic network, coordinated by the University of Manchester, UK, with 25 partners across Europe. There are also Network Associates from a number of EU and non-EU countries who give their advice and experience at meetings, seminarsand conferences.

The aim is to bring together workers from around Europe to focus on a series of tasks aimed at developing multi-factorial prevention programmes to reduce the incidence of falls and fractures amongst elderly people. The work of ProFaNE is practical, both in terms of developing the evidence base for implementation of effective interventions and encouraging best practice across Europe. The task of each work package is to convene workshops, undertake personnel exchanges and set up collaborative studies, data sharing in order to develop evidence based protocols and publications which can be used to implement change.

Work Package 1 - Fall prevention trials - Taxonomy of interventions and agreed set of outcomes. An agreed and standardised set of outcome definitions and measures is important to improve the robustness of data from intervention studies, will enable comparison across studies, good quality measurement in multi-centre trials, and facilitate meta-analysis of trial results. A taxonomy of interventions will facilitate comparisons between studies, help to determine the most effective components or sub-components of interventions, and aid the decision making process of policy makers and health insurance plans. A Consensus taxonomy and outcome measures statement, Trial design statement, Meta - analysis protocol and Self help materials will be produced.

Work Package 2 - Clinical Assessment and Outcomes. Aims to gain an understanding of the current issues surrounding falls prevention across Europe and to embrace at national and international level, the different political and health service agendas in each country such that recommendations can ultimately be translated into working models of practice. They will establish a robust network of key members across Europe to facilitate the effective and efficient promulgation of evidence likely to influence service developments at national and local level and derive a consensus approach to assessment and management of older people at risk of falling in a variety of clinical settings using the existing evidence base as well as inviting expert opinions in the field.

Work Package 3 - Assessment of balance function and prediction of falls. Measurement tools are needed that predict the risk of falling and give objective assessment of balance function needed for daily life performance. The ultimate goal of the activities within this work package is to combine the expertise of different disciplines for the development of balance assessment tools that meet the requirements for large-scale intervention studies and routine-use in clinical settings. The knowledge needed to develop these instruments and measures is scattered over a wide range of disciplines (ranging from physiology to electrical engineering).

Work Package 4 - Psychological aspects of falling. We need to understand the psychosocial factors which affect the benefit of falling prevention programmes for older people. These include attitudes to falling (such as fear) and factors that promote or reduce uptake of and adherence to a range of falling-related interventions, including exercise. Understanding of attitudes and behaviour will inform guidelines for the design of interventions, and development of measures to assess relevant attitudes. We also co-ordinate development of self-test indices that older people can use to evaluate their own risk of falling, together with guidance as to the actions they should take to prevent falling.

Gunn-Britt Jarnlo* Jacqueline Close**


To gain an understanding of the current issues surrounding falls prevention across Europe and to embrace at national and international level, the different political and health service agendas in each country such that recommendations can ultimately be translated into working models of practice in each country.

To establish a robust network of key members across Europe to facilitate the effective and efficient promulgation of evidence likely to influence service developments at national and local level.

To derive a consensus approach to assessment and management of older people at risk of falling in a variety of clinical settings using the existing evidence base as well as experts in the field

To ultimately facilitate a pan-European approach to assessment and management of falls whilst minimising impact on clinical autonomy and paving the way for further research activity within member states.

Description of work: This work package focuses on the development of a consensus approach to the assessment and management of falls in older people across Europe. Fundamental to this process is the development of a clear understanding of how services across Europe are currently configured and what the national and international drivers for change might be over the next 5–10yrs. The ultimate aim is to be able to facilitate the development of a set of comparable assessment and outcome measures to be used in a large randomised controlled trial with fracture as the primary outcome measure. Year 1. Whilst undertaking the networking exercise in year 1, members had the opportunity to visit key individuals in European countries and anticipate the potential opportunities and constraints of developing and delivering falls services in a co-ordinated and comprehensive fashion. Year 2 focuses on the development of assessment tools, which can be tailored so as to be applied in a variety of clinical settings from community based assessment to the highly specialised investigation units. The work package links closely with other work packages on balance and gait and psychology to ensure consensus in recommendations. In addition to the recommendations for clinical assessment and management, the work package also provides advice and guidance on evaluation and audit of services and as such links closely with the taxonomy work. Recommendations are to be peer reviewed. Year 3 entails the collation of agreed assessment and evaluation methods and the translation of the recommendations into a format for dissemination including written documentation translated into a number of different languages and an interactive website with links to relevant organisation across Europe and the rest of the world. Year 4. During the final year, members of the work package take responsibility for the dissemination of the work to clinical colleagues.

Wiebren Zijlstra

Objectives: The development of effective fall prevention programs requires understanding of underlying causes of falls. Measurement tools are needed that predict the risk of falling and give objective assessment of balance function needed for daily life performance. The ultimate goal of the activities within this work package is to combine the expertise of different disciplines for the development of balance assessment tools that meet the requirements for large-scale intervention studies and routine-use in clinical settings. The knowledge needed to develop these instruments and measures is scattered over a wide range of disciplines (ranging from physiology to electrical engineering). The objectives of this work package are to combine expertise from different disciplines to transfer knowledge between disciplines, to co-operate in designing research and provide an intellectual environment for interdisciplinary projects and dissemination of knowledge into disciplines working in the clinical field.

Description of work: Recent technological developments allow for the measurement of human movement under real-life conditions by means of lightweight ambulatory equipment. This novel approach to the analysis of human movement can potentially fill the need for objective field instruments. However, suitable methods for balance assessment need to be developed. Activities of this work package are aimed at co-ordinating the development of methods that can be used in the clinical field for assessment of posture and gait. The work encompasses the organization of workshops, the co-ordination of research, and dissemination of knowledge through publications, teaching and training. Members co-ordinate their individual research efforts in such a way that the different research lines support and reinforce each other. The coordination of research will involve joint experiments and the definition of assessment protocols that can be used in the individual studies of all participating groups. The work focuses on the analysis of kinematic patterns during walking and standing in a natural environment by means of ambulatory equipment. Appropriate methods for signal acquisition and analysis are being developed. Protocols are being designed which specifically address different aspects of balance control (i.e. mental load, sensory dependence, and effects of mechanical manipulations). Laboratory tasks, which have proven to be sensitive for balance dysfunction, will be translated into valid, reliable and easy-to-use procedures for field use. These field instruments are based upon a sound theoretical framework against which the results can be understood and interpreted. In order to address the validity and predictive value of field instruments, longitudinal studies need to be performed that are in accordance with the work in other work packages. Apart from balance assessment procedures, activity levels, history of falls, and future falls need to be assessed. We expect this novel approach to give insight in the relation between objective measures of balance function, activity level and number of falls. Thus, the occurrence of falls can be related to (changes in) activity level.

Sallie Lamb Clemens Becker

Introduction: Randomised Controlled Trials (RCTs) of interventions to reduce the incidence of falls have used a variety of methods to define and measure outcomes. A standardised approach to defining and measuring outcomes, and a shared taxonomy of interventions is a prerequisite to interpret and disseminate the findings of studies.

Method: We agreed to focus on five areas: falls, injuries, psychological consequences, physical activity and quality of life. A systematic literature review has been performed to identify outcome definitions currently used in RCTs and is focusing on the quality of outcome measures in terms of reliability, validity and acceptability. A consensus building process is being performed using a modified nominal group technique to define a core set of outcome definitions and measures, which can then be piloted in a number of sites across Europe. Where consensus cannot be achieved, suggestions are made for future research to develop and/or appraise new methods of measurement and these will feed into future revisions of the recommendations. The taxonomy of interventions is being developed in parallel with this process.

Results: The presentation will demonstrate how varying methods of defining falls can lead to a different interpretation of trial results and suggest a range of definitions than might be included in future trials. We consider the number of falls, number of fallers, time to first fall, and fractures per fall ratios as examples.

Conclusions: An agreed and standardised set of outcome definitions and measures is important to improve the robustness of data from intervention studies, will enable comparison across studies, good quality measurement in multi-centre trials, and facilitate meta-analysis of trial results. A taxonomy of interventions facilitates comparisons between studies, helps to determine the most effective components or sub-components of interventions, and aids the decision making process of policy makers and health insurance plans.

Yizhar Floman

During the last 2 decades it has been recognized that scoliosis may start de novo during adult life as a result of advanced degenerative disc disease, osteoporosis or both. In some the degenerative process is superimposed on a previous adolescent curve. Aside from the disfigurement caused by the spinal deformity, pain and disability are usually the major clinical problem.

The prevalence of adult scoliosis rises with age: from 4% before age 45, 6% at age 59 to 15% in-patients older than 60 years. More than two thirds of the patients are females and the prevalence of right lumber curves is higher than in comparable series of patients with adolescent scoliosis.

Adult scoliosis is characterized by vertebral structural changes with translatory shifts i.e. lateral olisthesis accompanied by degenerative disc and facet joint arthrosis.

Although the magnitude of these curves is usually mild (20–30 degrees) lateral spondylolisthesis is observed frequently. It is also common to observe degenerative spondylolisthesis in patients with degenerative lumbar scoliosis. The annual rate of curve progression ranges from 0.3 to 3%.

Patients present with a history of a spinal deformity accompanied by loss of lumbar lordosis, trunk imbalance and significant mechanical back pain. Pain may arise not only from degenerative disc disease and facet arthritis leading to symptoms of spinal stenosis, but also from muscle fatigue due to the altered biomechanics secondary to a deformity in the coronal and sagittal planes. Root entrapment is common and occurs more often on the concavity of the curve. Symptoms of neurogenic claudication are also common in adults with lumbar scoliosis.

Non-operative care includes exercises, swimming, NSAIDs, and occasional epidural injections. Brace treatment can be tried as well. Curve progression as well as axial or radicular pain not responding to non-operative care are indications for surgical intervention.

Surgery may include decompression alone or in conjunction with curve correction and stabilization. Posterior instrumentation may be supplemented with interbody cages. Fusion is usually carried down to L5 but occasional instrumentation to the sacropelvis is mandatory. Problems with a high pseudoarthrosis rate are common with sacral fixation. Even in the best of hands a long recovery period (6–12 month) and moderate pain relief should be expected. As summarized by Dr. Bradford “despite recent advancements evaluation and successful management of patients with adult spinal deformity remains a significant challenge”

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T. David

Isthmic spondylolisthesis with pars interarticularis defect is a “ fatigue” fracture. In most cases there is no instability and moderate pain, with no need for treatment. Twenty per cent of the patients have severe back pain, and some also radicular pain, while some young patients have progressive lumbosacral kyphosis and instability with high grade spondylolisthesis. The sacral deformity and kyphosis result from the fracture and could be avoided by healinfg of the defect. Histological studies have shown that the pars defect can be a source of pain.

Patients with severe back pain and some with radicular pain or increasing deformity are candidate to surgery. Since many years, the only treatment was fusion with or without instrumentation and with or without correction of the deformity, by anterior or posterior approach. Fusion was mandatory in case of associated disc degeneration, including all the pathological discs into the fusion area. Isthmic repair has been done since many years using several techniques, but only in the absence of olisthesis and disc degeneration. However, it is known that many adult or senile subjects have degenerated discs and no back pain. Thus, what is the rationale to perform fusion in all patients with spondylolisthesis? The problem is to know the source of pain and to treat patients rather than x-rays. This can be achieved by anaesthetic injection of the lytic zone, MRI and discography, which can be helpful to differentiate patients who need fusio from those who do not need it. Initially we used, for isthmic repair, the Morscher hook-screw instrumentation, but in the last ten years we are using DOS instrumentation, which is stiffer. The indications and surgical technique, as well as the results of a comparative study between fusion (91 patients with 40-month follow-up) and repair (95 patients with 30-month followup), wil be presented in terms of duration of surgery, hospital stay, complication rate, number of revisions and return to previous activities.

This study shows less postoperative complications and higher rate of return to work or sports for pars repair versus lumbar fusion in a rather similar population. Therefore, isthmic repair seems to be the first surgical option for mild isthmic spondylolisthesis even in the presence of degenerated discs.

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Franco Postacchini

Degenerative spondylolisthesis is consistently responsible for narrowing of the spinal canal, but only in a part of the cases it causes lateral or central stenosis. The presence, type and severity of stenosis is related to several factors, such as the constitutional dimensions of the spinal canal, the orientation and severity of degenerative changes of the facet joints, and the amount of vertebral slipping. The type of stenosis, that is whether stenosis is central or lateral, depends on the orientation of the articular processes, and the length of the pedicles. Usually stenosis is lateral initially and central in later stages. Instability, that is hypermobility on flexion-extension adiographs is one of the main characteristics of degenerative spondylolisthesis. However, in many cases there is no appreciable hypermobility of the slipped vertebra. We consider the latter condition as a potential instability, which can become a manifest instability as a result of surgery, or when destabilizing factors unable to destabilize a normal vertebra intervene, such as disc degeneration or severe degenerative changes of the facet joints.

There is no indication for surgery in patients with no significant symptoms. In patients with an unstable motion segment who have only back pain it is usually sufficient to perform a fusion alone if stenosis is mild and asymptomatic. Neural decompression should be performed if stenosis is severe. Bilateral laminotomy, or even total laminectomy, may be carried out with no concomitant fusion in patients with mild olisthesis, no vertebral hypermobility on functional radiographs, mild central stenosis or any degree of isolated lateral stenosis, and mild or no back pain. The indications for monolateral laminotomy with no fusion are: moderate central stenosis in elderly patients with unilateral symptoms; lateral stenosis only on one side; and unilateral additional pathology, such as a synovial cyst. Patients with moderate or severe olisthesis, vertebral hypermobility even of mild degree, and/or severe central stenosis and chronic back pain should undergo decompression and fusion. The association of an arthrodesis allows decompression of the neural structures as widely as necessary.

Posterolateral instrumented fusion, using pedicle screw fixation, is the most common procedure, that can be done at multiple level when olisthesis is present at more than one level. In both cases it requires no, or a short, postoperative immobilization Posterolateral fusion may be replaced by PLIF. This procedure, associated with pedicle screw instrumentation, gives excellent results and a high rate of solid fusion. The devices inserted in the disc space are normally represented by cages filled with bone chips. An alternative are the use of blocks of porous tantalum (hedrocel), the stiffness of which is very similar to that of subchondral bone. We are using blocks of hedrocel since 3 years with excellent results in terms of intersomatic fusion. In 20 cases followed for at least 2 years we never observed mobilization of the implant or loosening of the pedicle screws, and we almost consistently found a tight union between the implant and the adjacent vertebrae.

Chris Todd* Lucy Yardley**

Background: ProFaNE is an EC-funded network supporting collaboration between researchers in the field of falls injury prevention. One component of ProFaNE concerns psychosocial aspects of falls prevention, which include assessment of fear of falling and attitudes to falls prevention programmes. Findings from members’ collaborative qualitative research on attitudes to falls prevention will be presented.

Methods: We conducted interviews with older people, assessing their beliefs and attitudes regarding falls prevention programmes. Interviews were structured around the Theory of Planned Behaviour, were carried out in the UK, the Netherlands, Germany, Switzerland, Norway, Greece and Italy. The thematic analysis reported here compares the beliefs of those who had taken part in a falls prevention programme and those who had not been offered this option.

Findings: Whilst many may reject the notion that falls are anything to do with them, participants reported being motivated to take part in programmes that are designed to improve strength and balance chiefly by a desire for, and experiences of, immediate benefits (including improved functioning and mobility, enjoyment and increased self-confidence) rather than by fear of falling. The main reported barriers to participation included lack of familiarity with such programmes, concern about exertion, transport and financial obstacles, and lack of motivation.

Conclusions: Falls prevention has negative connotations for many older people. Participation in falls prevention programmes may be enhanced by maximising and promoting their immediate benefits rather than their potential for reducing falls, by removing practical barriers, and by providing opportunities to sample programmes in order to demonstrate their immediate benefits. A focus on exercise as promoting health, fitness and independence may have wider acceptability.

L. Engebretsen S Johansen TC Ludvigsen

As a level I trauma hospital, OOU receives an increasing number of knee dislocations. This study evaluates acute knee dislocations seen at OOU from May 1. 1996 through Dec 2004.

Patients and methods: 136 patients with 137 dislocated knees were admitted in the periode. All patients were students or working prior to the injury and all had a high functional level. 50% of the dislocations occured in conjunction with major traffic accidents- the majority of which were motorbikecyklists, while the remaining injuries were sustained during sports. 4 patients had a complete injury of the peroneal nerve on admittance, while an additional 4 had decreased motor strength and \or sensory dysfunction.

In addition one patient had a ruptur of the patellar tendon and one a patella dislocation. Two of the patients in this group had a vascular injury. On admittance the patients underwent a diagnostic exam in the emergency room.. All the patients then had a MRI. The patients were the placed in a brace and on a CPM 2 hours 2 times a day for 7 days, and the vascular status was monitored closely. After 7–10 days the patients underwent surgery including arthroscopic reconstruction of the ACL and PCL with auto or preferably, if available allograft. Results for patient with a followup for more than 6 months are presented including IKDS, Cincinatti, Tegner and a clinical exam with KT1000.

Results:. No serious complication occurred in conjuntion with surgery or the hospital stay. One infection with staf occurred successfully treated. Two patients underwent secondary arthroscopic debridement for arthrofibrosis All the patients have returned to work, but the majority have had to reduce or change their sports activities.

Conclusion:. We have designed a treatment protocol for this difficult patient group. So far the complication frequency has been low.

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Jan Lindahl Harri Hietaranta

Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) disruptions are uncommon orthopaedic injuries. They are usually caused by high- or low-velocity knee dislocations. Because knee dislocations might spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee. Both of the cruciate ligaments are usually disrupted, and they are often combined with a third ligamentous disruption (medial collateral ligament or lateral collateral ligament and/or posterior lateral complex). Associated neurovascular, meniscal, and osteochondral injuries are often present and complicate treatment.

Classification Knee dislocations are classified by relating the position of the displaced tibia on the femur; anterior, posterior, medial, lateral, or rotational. Both cruciate ligaments might be disrupted in all these injuries. A rotatory knee dislocation occurs around one of the collateral ligaments (LCL) leading to a combined ACL and PCL injury and a tear of the remaining collateral ligament. Knee dislocations that spontaneously reduce are classified according to the direction of instability. Knee dislocations are classified as acute (< 3 weeks) or chronic (> 3 weeks).

Initial management The vascular status of the limb must be determined quickly. The knee should be reduced immediately through gentle traction-countertraction with the patient under anesthesia. After reduction, repeat vascular examination. If the limb remains ischemic, emergent surgical exploration and revascularisation is required. If the initial vascular examination is normal, postreduction a formal angiogram should be done especially if the patient has a high velocity injury, is polytraumatized or have altered mental status. Compartment syndrome, open injury, and irreducible dislocation are other indications for emergent surgery.

Definitive management Many authors have noted superior results of surgical treatment of bicruciate injuries when compared to nonsurgical treatment. In most cases early ligament surgery (at the second or third week) seems to produce better results compared to late reconstructions. Still the management of knee dislocations remains controversial. Controversies persist regarding surgical timing, technique, graft selection, and rehabilitation. The goal of operative treatment is to retain knee stability, motion, and function.

The most common injury patterns include both cruciate ligaments and either medial collateral ligament (MCL) or lateral collateral ligament (LCL) and/or posterolateral structures. Less commonly both collateral ligaments are disrupted. Our policy has been early (from 7 to 21 days) simultaneous reconstruction of both cruciate ligaments and repairing of grade III LCL and posterolateral structures. Most acute grade III MCL tears are successfully treated with brace treatment when ACL and PCL are reconstructed early.

Most cruciate ligament injuries are midsubstance tears that need to be reconstructed with autografts or allografts. Repairs can be done in cases of bony avulsion of cruciate ligaments or grade III collateral ligament or capsular injuries. Bone-patellar tendon-bone (BPTB) autograft has mainly used in our clinics to reconstruct the ACL. In some cases BTPB allograft or hamstring tendon autografts has been used. For PCL reconstruction, BPTB allograft (11 mm in diameter) or Achilles tendon allograft has been used.

Intrasubstance grade III tears of the LCL can be repaired (in early state) but may need to be augmented with tendon allograft. The LCL and/or the popliteofibular ligament are reconstructed either with an Achilles tendon allograft, hamstring tendon autograft/allograft, tibialis anterior tendon allograft, or the BPTB allograft.

Both cruciate ligaments are reconstructed arthroscopically. The ACL tunnels are placed in the center of its anatomic insertion in tibia and in its isometric or anatomic insertion in femur. A transtibial tunnel technique for PCL reconstruction is used. The PCL tibial tunnel is drilled first under arthroscopic guidance using the PCL guide. The ACL tibial guide is drilled at least 2 cm proximal to the PCL tunnel to ensure that wide enough bone bridge remains between these tunnels. Fluoroscopy is used to ensure the right guidewire placement.

Sequence of bicruciate ligament reconstruction with BPTB grafts

Drill PCL tibial tunnel first, then ACL tibial tunnel

Drill ACL femoral tunnel, then PCL femoral tunnel

Pass PCL graft through tibial tunnel and fix in femoral tunnel

Pass ACL graft through tibial tunnel and fix in femoral tunnel

Fix PCL graft on tibia at 90° of flexion with anteromedial step off

Fix ACL graft on tibia at extension

Rehabilitation Our protocol after bicruciate ligament reconstruction with MPTB grafts has been very active. Progressive range of motion is started early after the operation with an unlocked functional brace. If simultaneous suturation of a meniscus tear has been performed, motion is limited to 60° of flexion during the first 4 weeks. Progression from partial to full weight bearing is done over the first 6 weeks. Quadriceps exercises are progressed to open-chain knee extension exercises early as well as closed-chain hamstring exercises. Brace is discontinued after 12 weeks.

Steinar Johansen

Anatomy & Biomechanics

Lateral Collateral Ligament (LCL)

Primary stabilizer to varus opening

Femoral attachment – proximal/posterior to lateral epicondyle

Fibular attachment – midway along lateral fibular head

Popliteus Complex

Important stabilizer to posterolateral rotation

Stabilizer to varus opening

Popliteus attachment on femur

18mm anterior/distal to LCL

anterior fifth of popliteal sulcus

Popliteofibular ligament (PFL)

originates at musculo-tendinous junction of popliteus

attaches at medial aspect of fibular styloid

Mid-Third Lateral Capsular Ligament

Secondary stabilizer to varus opening

Thickening of lateral midline capsule

Meniscotibial portion often injured. Segond injury

Biceps Femoris Complex

Short head of biceps

Long head of biceps

Lateral Meniscus

Injury Mechanism

Rarely isolated injury

Usually as a combined ligamentous injury



Knee Dislocation


Varus blow

Noncontact twisting

Importance of injury

Grade III injuries do not heal

Lead to instability and osteoarthritis

Compromise cruciate ligament reconstructions

Diagnosis of LCL/PLC injury


Usually due to varus/hyperextension injuries

15 % have a peroneal nerve injury

Usually combined ligamentous injury

Clinical exam

Varus stress test

External rotation recurvatum test

Posterolateral drawer test

Dial test

Reverse pivot shift test

Varus thrust gait



Arthroscopic evaluation

Treatment for acute posterolateral knee injuries

Acute grade I and II injuries

Brace 6 weeks

Full ROM

Partial weight bearing

Acute grade III injuries

Repair/reconstruct within 2 weeks after injury

Attempt anatomic repair

Each structure repaired individually

Consider augmentation in midsubstance tears

Anatomic reconstruction

Treatment For Chronic Grade III Injuries

Assess for varus alignment

Proximal tibial opening wedge osteotomy

Reassess after 6 months for need for soft tissue reconstruction

Anatomic reconsruction of posterolateral structures

Two tailed reconstruction of LCL, PFLand popliteus tendon

Biomechanically restores function of native ligaments

Vielpeau Rosencher Emmerich Fagnani Chibedi Samama

Introduction Recent changes in the management of hip fracture surgery patients may have resulted in changes in the epidemiology of venous thromboembolism (VTE). We aimed to determine the incidence of and predictive risk factors for symptomatic VTE and mortality, and the use of VTE prophylaxis, in hip fracture surgery patients.

Methods Hip fracture surgery patients were enrolled in 525 hospitals in France between October 1 and November 30, 2002 in this prospective, multicenter, epidemiological study. VTE was assessed by a critical events committee at 3 months. Risk factors were identified using logistic regression.

Results Data were from 6860 (97%) of 7019 enrolled patients. Median age was 82 years and 76% were women. 47% were femoral neck and 53% trochanteric or subtrochanteric fractures. All were operated on (osteosynthesis 57%, half prosthesis 35% and THR 8%).

Prophylaxis with a low-molecular-weight heparin (LMWH) was administered perioperatively in 97.6% and for at least four weeks in 69.5% (median prophylaxis duration: 6 weeks). The rate of symptomatic VTE at 3 months was 1.34% (95% CI: 1.04– 1.64). There were 16 PE (rate 0.25%) and 3 were fatal. The rate of major bleeding was 1.2%. At 6 months, 1006 patients (14.7%) were dead. Significant risk factors for symptomatic VTE were: history of VTE (OR 2.9), induction of anesthesia until arrival in the recovery room > 2 hrs (OR 2.5), and varicose veins/post-thrombotic syndrome (OR 2.2). LMWH prophylaxis significantly reduced the risk of symptomatic VTE (OR 0.2).

Significant predictive factors for mortality were: cancer (OR 2.3), surgical complications requiring re-intervention (OR 1.8), confusion before fracture (OR 1.8), ASA score ≥3 (OR 1.7), BMI ≤18 kg/m2 (OR 1.6), congestive heart failure (OR 1.6), atrial fibrillation (OR 1.6) and age > 80 years (OR 1.1).

Conclusions Extended LMWH prophylaxis is applied widely after hip fracture surgery in France. The current rate of postoperative VTE is low. However, a major change in the care of these patients is needed because of the high mortality rate.

Lars C. Borris

According to the 2004 ACCP guidelines on antithrombotic and thrombolytic therapy general extended prophylaxis with low molecular weight heparins, vitamin K antagonists, or fondaparinux is recommended after major orthopedic surgery. This recommendation is based on a number of placebo controlled, clinical studies using venographic screening for deep vein thrombosis (DVT), as a surrogate end-point for pulmonary embolism (PE), other vascular thrombotic events were not considered. In a recent meta-analysis on these studies the overall event rate of symptomatic venous thromboembolism 30–42 days after a joint arthroplasty was 2.7% DVT and 0.6 % PE in patients having short-term prophylaxis and it was significantly reduced by extended prophylaxis. Bleeding episodes were seen in 4% of cases having extension. Taking into consideration the risk benefit for the individual patient do these findings justify that extended prophylaxis is used on a general basis? To answer this question also compliance, adverse event profile, and cost of the prophylactic regimens have to be addressed. It would be very attractive to be able to individualize the duration of the prophylactic period by assessing the thrombotic potential of every patient in order to balance the risks and benefits of continued prophylaxis.

E de Brie L Lapidus S Cannerberg T Mohr B Cars S Ponzer

Background. Thrombosis is a rare complication for the single orthopaedic surgeon. The objective for this study was to determine the incidence of thromboembolism after orthopaedic surgery at Söder Hospital.

Methods. All patients operated on during 1997–2000 (n= 25284) were given a short questionnaire regarding postoperative complications. The patients were asked to return the form at 6 weeks. About 50% of the forms were returned spontaneously. A research nurse contacted the rest of the patients. The questionnaires were compared with patient’s charts. An orthopaedic surgeon judged if the complication was related to surgery.

Results. 99.5% of the surveys were returned. 0.78% deep vein thrombosis (DVT) and 0.20% pulmonary emboli (PE) were radiographically diagnosed. DVT mean age was 59.6 and PE 74.7 years. Median DVT detection time was 18.0 and PE 20.6 days. DVT and PE incidence was higher in lower extremity compared to upper extremity surgery. DVT incidence in Achilles tendon ruptures (9.5%), knee replacement (5.8%), pelvic fractures (4.8%) was high.

Conclusions. Thromboembolism incidence in orthopaedic surgery was low. However, some surgical procedures had a high DVT incidence. The results of this study imply the need for adjusting thromboprophylaxis according to the surgical procedure.

Ola E. Dahl

Major bone surgery causes damage to the bone marrow cells and destruction of blood vessels. This induces a tremendous local and systemic thrombin generation. This may trigger vascular instability during surgery that in seldom cases may be fatal in susceptible patients in particular if bone cement is implanted. The overall mortality following elective hip replacement is low since the patients are selected for the procedure and medically optimized. Following emergency hip fracture surgery the patients are substantially older, many have co-morbid conditions and the mortality is markedly higher. Vascular events dominate. Pulmonary embolism, and myocardial infarction are prominent together with pneumonia (a condition that trigger the coagulation system).

Postoperatively, thrombin continues to be generated for a long time after surgery as a part of the inflammatory healing process. Vascular complications dominate and epidemiological studies have shown a general complication risk period lasting for nearly 3 months and significantly longer in subgroups. Although, mortality has decreased in recent years, morbidity continues to play an important and less focused role although with substantial health economic implications.

A.B. Wymenga

The supporting structures on the medial side of the knee consist of:

- Layer I, the superficial fascia.

- Layer II, the superficial Medial Collateral Ligament (sMCL) with parallel fibers running from the femoral epicondyle to the anteromedial tibial crest 5–7 cm below the joint line.

- Layer III, the deep capsular layer.

The pes tendons are situated between Layer I and II–III. Beneath the sMCL Layer III thickens and forms the deep MCL (dMCL) from femur condyle to meniscus and from meniscus to tibia.

More dorsally Layer II and III fuse and form the Postero Medial Capsule (PMC) which is connected to the meniscus and tibia. The PMC is augmented by the semimembranosus tendon.

The sMCL is the primary restraint against valgus and transsection causes 2–5 degrees laxity in flexion or approximately 3–5 mm joint opening. Additional cutting of the PMC gives additional laxity of 7–8 degrees up to 10 degrees. An isolated sMCL lesion causes more laxity in flexion and a combination of sMCL with a PMC lesion causes also laxity in extension. The dMCL does provide some stability in 45 dg. of flexion but is not very strong.

The goal of MCL-PMC reconstruction should be functional anatomical repair of the pathology and retention of the meniscus. After treating the pathology the medial side of the knee should be stable in extension (by repair PMC) and in flexion (by repair sMCL).

The PMC – meniscus – semimembranosus complex should be refixated at the posteromedial tibia corner if it is loose.

Bony avulsions should be fixed with washer and screw or anchors. Ligamentous avulsions can be fixed at the anatomical insertion site with trans-osseous non-resorbable sutures or bone anchors or screws with toothed washers. A distalisation of a ligament insertion (sMCL) with its bony attachment is also an elegant solution in chronic cases. If the surgeon wants to tension the SMCL at the femoral side, the bony insertion with the ligament attached to it can be recessed at its original position. Allografts and double stranded hamstring autografts can be used when native tissue is lacking.

Simon P Frostick

Patients who suffer a fracture of the proximal femur are high risk for developing venous thromboembolism. They require effective anti-thrombotic prophylaxis. In an audit of 11,900 patients a mortality of 17% occurred 3 months after the injury. Although post mortem examination was rare, it was estimated that nearly 50% of 753 deaths were thrombosis related, 6.9% specifically attributed to pulmonary embolus. It is likely that many of the other deaths, attributed to various respiratory problems were also at least in part due to PE. Comparing the data with actuarial tables demonstrated an excess mortality in both gender and in nearly all age groups. In a second audit, although many patients were receiving some form of prophylaxis, many were given ineffective agents and probably using an ineffective regime. In many patients a fracture of the proximal femur is regarded as a terminal event. However, the data from these 2 audits would suggest that many of these patients are dying unnecessarily and that effective prophylaxis would reduce the risk of death. Chemical prophylaxis commenced immediately after surgery and continued for 5 weeks would be appropriate.

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J Fisher

Wear and wear debris induced osteolysis is recognised as a major cause of long term failure in hip prostheses. Historically ultra high molecular weight polyethylene acetabular cups produced micron and submicron wear particles which accumulated in peri prosthetic tissues, and stimulated macrophages to generate wear debris induced osteolysis. Acceleration of wear and osteolysis was caused in historical materials by oxidative degradation of the polyethylene following gamma irradiation in air, and by third body damage and scratching of metallic femoral heads. Current conventional ultra high molecular weight polyethylene cups are irradiated in an inert atmosphere to reduce oxidative degradation and are articulated against ceramic femoral heads to reduce third body wear. More recently modified highly cross linked polyethylene has been developed, and while these materials produce a four to five fold reduction in wear volume the wear particles have been found to be more reactive, resulting in only a two fold reduction in functional osteolytic potential. The question remains as to whether this performance is adequate for high demand patients, particularly if larger diameter femoral heads are to be used.

Recent interest in improved function, stability and reducing dislocations has generated interest in using larger diameter heads and hard on hard bearings.

Alumina ceramic on ceramic bearings have shown a one hundred fold decrease in wear compared to highly cross linked polyethylene materials, and cell culture studies have shown the wear particles to be more bio-compatible and less osteolytic potential.

Metal on metal bearings also produced very low wear rates compared to polyethylene. The wear particles are very small, 10 to 50 nanometers in size, some concern remains about the systematic release of metallic ions. These are lubrication sensitive bearings, and they unlike polyethylene wear decreases as the head size increases due to improved lubrication. Size 36 mm metal bearings are now commonplace for total joint replacements with even larger head sizes being used for surface replacement solutions.

The demand for increased function and improved stability is leading to increased use of hard on hard bearings with larger diameter heads.

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T. A. Papaioannou

Osteolysis and periprosthetic bone loss have been a concern since Charnley’s original reports of metal on Teflon. Willart and Semlitch were the first investigators to propose a biologic mechanism for osteolysis associated with particulate wear debris. Harris in 1976 and Goldring 1983 describe the presence of macrophages and giant cells in the synovial membrane at the bone cement interface in loose THR. Initially it was associated with cement and it was called cement disease. Reports of resorption around cementless implants led to the realization that PE alone was good enough to create bone loss.

Aetiology: Submicron wear particles are phagocytosed by macrophages resulting in release of various cellular mediators from these activated cells.

Cellular mediators playing significant role in osteolysis are IL-1, IL-6, TNF-a, PGE2. These mediators lead to stimulation and differentiation of osteoclasts and inhibition of osteoblasts.

These factors together assist in the dissolution of bone at the interface allowing for micromotion of the prosthesis that leads to further generation of wear debris.

On top of the above there is release of collagenase, stromelysin, gelatinase which further destroy the bone. Another active area of research involves roles at Rank, Rank and osteoprotegerin. Recently there is extensive work done as far as it concerns the role of endotoxin in osteolysis and periprosthetic bone loss. It still remains a controversial issue.

Other researchers have studied the effects of elevated periarticular hydrostatic pressure and fluid access in the development of osteolysis (effective joint space).

Particles bioreactivity: It has been shown that the major determinants of particle bioreactivity are particle size, composition, shape, and concentration. Particles of submicron size are more stimulatory and there is a dose dependent response. Concerning the composition it has been found that UHMWPE, CoCr and stainless steel particles induce more severe reactions than Titanium and alumina ceramic. It also has been found that Al2O3 particles were more easily phagocytosed than UHMWPE at the same size and concentration but TNF-a release was higher with than UHMWPE with Al2O3. Concerning the metal to metal particles it has been found that the volumetric wear is less than M/P with smaller particles and less intensive tissue reaction but Shanbhag reported that bioreactivity of metal wear debris is a function of the total surface area and not the volume of wear debris and casts doubts at the theory that metal to metal wear particles produce a less intense biological response. Concerning the highly crosslinked PE it has been found that wear debris from gamma crossed –linked remelted PE contains very few fibrils after a dose of 5 Mrads and virtually none after 9.5 Mrads.

Clinical Manifestations: The majority of patients with osteolysis are asymptomatic. Pain is caused mainly from a fracture.Ultimately periprosthetic bone loss results in aseptic loosening. Furthermore if the component becomes loose bone loss often progress more rapidly resulting in large bone defects that can lead to catastrophic failure or fracture.

Radiographic manifestations: Characteristic radiographic patterns of osteolysis have been described on both the femoral and acetabular side with cemented and cementless components. Recent studies have suggested that plain radiographs often underestimate the extent of osteolysis and CT or MRI may be necessary to assess the true extent of the bone loss.

Anthony D Woolf

Rheumatoid arthritis is the most common inflammatory disease of the joints affecting about 0.5% of adults, women more often than men with a peak age of onset of 35–45 years. It is usually progressive affecting further joints and the destructive disease process causes irreversible bony erosions and the joints become structurally deformed, with long-term pain and disability. It has an early and significant impact on the person’s ability to work and socio-economic status with work capacity restricted in a third within a year and within 3 years almost half 40 may be registered work disabled.

The aims of management of rheumatoid arthritis are to reduce pain an inflammation; reduce disability; prevent joint damage and progression; and to reduce the comorbidities that are associated with the disease. As joint damage is irreversible it is important to diagnose the disease and institute disease modifying anti-rheumatic therapy as soon as possible. There is as yet no way of preventing the disease.

Lifestyle interventions of avoiding obesity, maintaining physical activity and avoiding smoking may improve outcome. Symptoms can be effectively controlled with analgesics and NSAIDs and joint damage can be reduced with disease modifying antirheumatic therapy with consequent benefits to quality of life. Biological therapies, such as anti TNF, are the latest advance that is dramatically improving the outlook for those developing RA. Rehabilitation interventions can improve and maintain function, including dynamic training. Surgery also has an important role, predominantly arthroplasty when pharmacological therapies have not adequately prevented joint damage.

Effective management of rheumatoid arthritis requires early diagnosis and treatment by recognising those with early inflammatory arthritis and for expert assessment within 6 weeks to decide about disease modifying anti-rheumatic therapy. This should be in addition to symptomatic therapy, rehabilitation and education to improve understanding of their chronic disease and to encourage self management. Such management should be provided through a multiprofessional and multidisciplinary group. People with RA need regular monitoring to ensure optimal disease management. This will reduce the risk of longterm joint damage and disability and will lessen indirect costs of RA. This approach requires systems for early diagnosis and for referral to experts, which includes education of primary care physicians to enable them to recognise synovitis. Public education is also needed to ensure early presentation to the primary care physician at the onset of symptoms.

K. Knahr

Osteoarthritis is a slowly progressive musculoskeletal disorder that can occur in any joint and is characterised by symptoms of pain, stiffness or loss of function. Studies showed that the work related disability rate with osteoarthritis varied from 30 to 50%, it is also a frequent cause of early retirement.

Age is the strongest predictor of the development and progression of radiographic osteoarthritis. Further risk factors are physical activity, injuries, high bone mass index and intensive sport activities.

Targets that are most important in the prevention or management of osteoarthritis are to reduce pain, disability and to prevent radiological progression.

There are various life style factors that increase the risk of developing osteoarthritis, increase its rate of progression and may increase pain and functional limitation. Preventable or modifyable risk factors are obesity and mechanical aspects of the joint f.e. joint laxity or malalignment. Tears of menisci or ligaments may lead to at normal loading of articular cartilage and result in the increased deveopment of osteoarthritis. Further risk factors are certain occupations (f.e. farmers for hip- and knee osteoarthritis), intensive sport participation, muscle weakness and nutritional factors.

Pharmacological interventions are mainly to treat the symptom of pain and have nearly no effect on tissue damage. Nevertheless activity and participation is improved as well as using simple analgesics, antiinflammatory drugs, disease modifying therapies, hyaluronic acid and intraarticular steroids. There is no evidence that pharmacological interventions can prevent osteoarthritis as defined by radiological changes.

Biomechanic deficiencies may lead to joint damage and result in pain and disability. Therefore surgical correction of these abnormalities can relief pain and improve function. Further surgical interventions to reduce the impact of osteoarthritis include cartilage repair and joint preserving surgeries. For severely damaged joints, partial or total replacement of the joint is now possible for all those joints that are commonly affected by osteoarthritis.

Osteoarthritis is commonly associated with limited function that can be improved with a wide variety of rehabilitative interventions. Symptoms of pain may be reduced by joint specific exercises, transient immobilisation, heat or cold packings and braces or other devices. Further attention can be put on modifiying the environment as adaptions at home and at work, support services or other social interventions. Eduction and self managements play an important role as well in early as in late stages of the disease.

Kristina åkesson

The number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system is increasing in Europe and worldwide. It is therefore essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.

Most musculoskeletal conditions occur in the elderly and as the elderly population will reach above 20% within the next 20 years this will further augment the problem within Europe, particularly as these conditions also increase with advancing age. It must be recognized that at most levels within the health care systems or within society, the impact of these conditions today and for the future is underestimated, both regarding number and regarding consequences; disability, handicap, social implications and costs. The major challenge is, however, not to make recommendations for preventive strategies but to implement them in order to secure a change, leading to improved care and improved quality of life for patient, regardless of age.

The first step in order to make a change is to define the size of the problem – the burden of musculoskeletal conditions. With respect to the incidence and prevalence the size of the problem is relatively well known. The size of the problem when it comes to the impact on the individual is less well known, as is the burden in terms of economic and societal costs. For many conditions the risk factors are identified and common to many conditions.

The second step involves evidence – evidence for the effectiveness of the interventions available today. When evaluating evidence it is useful to define population in terms of the normal or healthy population, those at risk, those at early or moderate stage and those at late stage of the condition since this will translate into preventive strategies appropriate for each level.

The final step is implementation and this is the major challenge at all levels, from policies trying to influence the entire population to adopt a healthier life style, to change the management of the individual patient in the doctor’s office. Based on knowledge of size and evidence, it is possible to transform recommendations into an actual action plan at national, regional and local levels. The principles for successful implementations are to a large extent similar for all levels.

The tools for success need to be identified and they may include financial or economic mechanisms, regulatory mechanisms, and educational or organisational mechanisms. It is particularly important to identify barriers and facilitators that will influence the outcome of the proposed strategy.

Musculoskeletal conditions have many risk factors and interventions in common with other conditions that affect public health, such as diabetes and cardiovascular conditions. In primary prevention it is therefore key to collaborate not only within the musculoskeletal field but also with other fields in order to improve also musculoskeletal health.

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Georgios Digas

Traditional polyethylene oxidizes, wears and generates particles over time, which most probably contributes to increased risk of periprosthetic osteolysis. Even contemporary sterilization methods such as radiation and package in oxygen reduced or oxygen substituted environment do not eliminate oxidation over time. Thus, there is a need for alternative bearing in total hip replacement surgery and especially in patients with high activity and long life expectancy.

All three major alternate bearings, ceramic-on-ceramic, metal-on-metal and highly crosslinked polyethylene produce major reductions in volumetric wear. The electron beam, melted highly cross-linked polyethylene has an in vivo penetration rate after the bedding in period, which is less than 8 microns per year. This is not substantially different from ceramic on ceramic or metal on metal. Therefore, the inherent risk of periprosthetic osteolysis with these alternate bearings is probably smaller than observed with conventional polyethylene.

In the competition between different articulations highly cross-linked polyethylene has some advantages. The polyethylene is more adaptable than the hard bearing surfaces. This means that extended lip liners, offset liners, constrained liners and further special designs may be used. These options are not possible with any of the hard bearings. Another advantage with polyethylene is forgiveness. Impingement in hard-on-hard bearings may lead to serious complications such as chipping of the ceramics or metallosis in a metal on metal articulation.

Impingement should also be avoided with use of polyethylene, but if it occurs, the consequences are often more benign at least in the short term perspective. Micro-separation results in less material damage with use of polyethylene than with the 2 other types of articulations. A few degrees of additional abduction above the geometrical limits for a particular socket is far less harmful if it is made of polyethylene compared to the situation in ceramic-on-ceramic or metal-on-metal bearings. Polyethylene is also more familiar to the majority of orthopaedic surgeons. In the operating room the cross-linked polyethylene is identical to those types of polyethylene, which have been used fore 3 to 4 decades. Finally the cost is a major factor (Harris 2004). The hard-on-hard bearings are substantially more expensive. The fracture incidence of ceramics components has decreased with improved manufacturing technology, but the risk of polyethylene fracture appears to be still smaller.

On the other hand using highly cross-link polyethylene carries some risks. Particles generated from this new material are smaller with higher inflammatory response. Compared with joints including conventionally sterilised polyethylene the total particle production is, however, reduced with more than 85%, which has implications for the magnitude of the inflammatory response.

The significance and importance of the irradiation and melting induced changes of the mechanical properties of the polyethylene is not known. Long term follow-up is needed to evaluate this issue.

Charnley preferred small head sizes in total hip replacement because they resulted in transmittance of low frictional torque to the acetabular implant. Mueller advocated larger head sizes with improved joint stability and lower contact pressure. Large heads do, however, imply increased volumetric wear. Therefore, 32 mm heads were abandoned in the early 90ties in favour of 28 mm heads. Another consequence of using larger heads is that polyethylene liners are relatively thin. The highly cross-link polyethylene and the hard bearings can be used with bigger femoral heads, which increases the range of motion and the hip joint stability.

Amorphous diamond coatings has been studied as an alternative bearing surface in the laboratory (Santavirta 2003). Such coatings may provide wear rates 104 to 105 times lower than conventional THR articulations, because of their extremely hard surface and low coefficient of friction without any corrosion paths (Santavirta et al. 1999 Lappalainen et al. 2003).

Oxidized Zirconium (OxZr) is another material, which has similar advantages. Oxinium materials are the results of a process that allows thermally–driven oxygen to diffuse and transform the metallic zirconium alloy surface into a durable low-friction oxide. The Oxinium material is harder than commonly used cobalt chrome, and with only the surface changing during the manufacturing process, the rest of the implant remains metal to maintain its overall strength. OxZr provides superior abrasion resistance without the risk of brittle fracture, thereby combining the benefits of metal and ceramics. Knee simulator tests have shown that OxZr can reduce polyethylene wear substantially (Ries et al. 2002). Although promising, these two coatings still lack clinical documentation.

During the last decade it has become evident that many designs of total hip arthroplasty can in patients with normal bone quality be fixed to the bone with a high degree of reproducibility. This has had the effect that younger patients have been operated on in increasing numbers. Wear and periprosthetic bone loss have remained a serious and comparatively frequent complications. The introduction of more wear resistant articulations has the potential to solve these problems making the procedure safer also among these patients. So far there is no or very scarce evidence that these articulations can be used safely during decades without complications causing progressive and often silent bone destruction resulting in difficult revisions with high morbidity. In the case of metal on metal articulations release and accumulation of ions remains a long term concern and especially if the patients will suffer from a temporary or permanent disease associated with impaired renal function.

Because evidence of long term superiority of these new articulations is lacking it is of utmost importance that these new implants and materials are introduced into clinical practice in a controlled way. Careful surveillance of preclinical and gradually enlarged randomised studies followed by multicenter trials is necessary to avoid disastrous mistakes so common in the past.

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D.A.J. Verettas

Joint replacement implants, especially in their modular forms, are subjected to wear and corrosion at various sites in their articulation, such as the bearing surfaces, the undersurface of the insert, the femoral head-neck junction and the implant or polymethylmethacrylate-bone interface. Movement of the bearing surfaces is not the only cause, as faulty implant positioning can initiate wear through impingement between two parts of the articulation.

These wear products of polyethelene or metal, in particulate form, are influential to the ultimate fate of the prostheses through the initiation of local and systemic immune reactions.

These debris are phagocytised by macrophages and phagocytised proteins are partly degraded in intracellular vesicles, where they become associated with the major histocompatability complex molecule HLA-DR. This molecule when transported to the cell membrane, interacts with CD4+ lymphocytes to activate an immune response and initiate the production of interleukin1b, interleukin 6 and tumor necrosing factor a. These cytokines mediate the inflammatory response and activate osteoclasts causing periprosthetic osteolysis.

Polyethelene and metal wear particles, in addition to their local effects, can be disseminated beyond the periprosthetic tissues and reach distant organs and regional lymphnodes. The concentrations of certain elements of metallic implants, such as iron, cobalt, chromium or titanium have been detected in lymphnodes, the liver and the spleen in levels a lot higher than normal, especially in patients with loose prostheses and, less so, in patients with stable prostheses.

The reported values of metal ions in published series vary. Thus certain investigators (Brodner et al) have reported continuous systemic cobalt release during a five year follow-up period and in levels slightly above detection values, while others (Clarke et al, Lohtka et al) have reported consistently high levels of cobalt and chromium ions in metal on metal articulations. The diameter of the femoral head appears to be a significant factor. In surface hip replacements with large diameter heads the amount of detected metal ions was significantly higher compared with total hip replacements with use of 28mm diameter femoral heads. In that type of replacement the levels of cobalt was 50 times higher than normal and of chromium 100 times higher.

Polyethelene particles, similarily have been detected in paraaortic lymphnodes in percentages similar to metal ions. However the detection of PE particles in the liver or the spleen was less, compared to metal ions, possibly due to the difficulty of modern methods to detect PE particles of submicrometre size. The relevance of the dissemination of metal ions and of PE wear debris in organs distal to the operated joint need to be carefully evaluated since certain of these elements are known carcinogens. Two studies have reported slight increase of haemopoeitic cancers in patients with cobalt alloy implants and in patients with metal on metal devices, while others have documented the development of malignant tumours in the vicinity of total hip replacements.

Since prostheses with metal on metal bearing surfaces are used more and more frequently in younger patients, these patients require careful monitoring for longer periods.

C. Dora

Interest on acetabular version arose from unstable developmental dysplastic hips. Initial studies and clinical observations described the dysplastic hip as being excessively anteverted.

The advent of computed tomography allowed further detailed analysis of the acetabulum in the axial plane, yet these studies failed to determine conclusively whether or not the dysplastic acetabulum is abnormally anteverted. Much controversy evolved from different methods of measuring and from the fact that a more anteriorly located acetabular deficiency results in excessive anteversion while a more posteriorly located deficiency in retroversion. It remains inconclusive to what extent acetabular dysplasia is due to a mal-orientation of an otherwise normal configured acetabulum or to a deficient acetabulum which is otherwise normally orientated. Furthermore, the acetabular opening spirals gradually from mild anteversion proximally to increasing anteversion distal to it and therefore render its measurement dependent from pelvic inclination and from the level of the transverse CT scan slice.

On an orthograde pelvic X-ray, both, pelvic inclination and rotation can be controlled. Therefore, acetabular version is best estimated from the relationship of the anterior and posterior acetabular rim to each other on an orthograde pelvic X-ray.

The main hip pathologies, acetabular rim overload and anterior femoro-acetabular impingement, both occur in the superior part of the acetabulum, the acetabular dome, and that’s where version is best measured. We called this version of the acetabular dome.

Interest on retroversion of the acetabular dome arose from analysis of complications such as persistent posterior subluxation after acetabular reorienting procedures. They resulted in the hypothesis that the site of acetabular deficiency may vary and be more posteriorly located in some cases resulting in a rather retroverted than anteverted acetabular dome.

In fact, retroversion of the acetabular dome was found to be a characteristic feature of specific hip disorders. A review of ten patients with posttraumatic premature closure of the triradiate cartilage before age 5 showed beside a bowed hemipelvis with lateralized and caudalized acetabulum a mean retroversion of the acetabular dome of 27°. A review of 14 patients suffering from proximal femoral focal deficiency with a functional hip joint revealed a mean retroversion of the acetabular dome of 24°. Typically this was accompanied by femoral retrotorsion and coxa vara.

Finally, bladder exstrophy, when treated without pelvic osteotomy, typically end up with externally rotated or retroverted acetabula (Sponseller, 1995) Even in DDH, retroversion of the acetabular dome has been shown to be a significant variation as 40 of 232 such acetabula showed to have a retroverted dome (Li, 2003).

Furthermore retroversion typically can result from pelvic osteotomy in childhood as 26 from 97 subjects, who underwent either Salter or Le Coeur osteotomy in childhood ended up with retroverted acetabular domes after closure of the pelvic bone growth plates. In the context of neuromuscular or genetic disorders, dysplastic hips also may have retroverted acetabular domes and may additionally be influenced from fixed spine deformities. Finally, retroverted acetabular domes may be found in otherwise non dysplastic hips.

The relevance of acetabular retroversion is both technical and clinical: First, it calls for a more individual approach to acetabular dysplasia because presence of retroversion will affect the manner in which corrective osteotomy will be done. Salter-like reorientation maneuvers will result in worsening the pre-existing posterior deficiency or acetabular rim overload and risk continued posterior subluxation or dislocation of a previously reduced hip (Lee, 1991). Second, anterior overcorrection of a primarily retroverted acetabula may necessitate a further intervention to remove bone from the anterior aspect of the acetabulum or anterior part of the femoral head-neck junction due to limited hip flexion (Crockarell 1999, Myers 1999). Third, evidence that the long-term effect of retroversion of the acetabular dome is harmful is increasing: An association between decreased acetabular anteversion and osteoarthritis was found as soon as 1991 (Menke, 1991) and the prevalence of retroversion among patients with idiopathic hip osteoarthritis has been found to be 20% versus 5% among the general population (Giori, 2003). Furthermore, decreased acetabular and femoral anteversion was found to be a major cause of altered rotation, hip pain and osteoarthritis (Tönnis, 1999). A positive impingement test was the key clinical finding (Reynolds,1999). This anterior impingement of the femoral head-neck junction against the border of the prominent anterior acetabular wall which over a long period of time may lead to fatiguing and destruction of the acetabular labrum and the adjacent cartilage is thought to initiate groin pain and early osteoarthritis. Finally, even for total hip replacement, severe retroversion of the acetabular dome will make surgery more difficult.

Michael Leunig Reinhold Ganz

Lesions of the acetabular rim have been implicated as a cause of hip pain in various pathologic conditions and are considered to predispose the hip to development of accelerated degenerative disease. In developmental dysplasia of the hip (DDH) and anterior femoroacetabular impingement (FAI), intrinsically normal intraarticular soft tissue structures are exposed to joint loading forces that physically exceed their tolerance level posing these pathomorphologies as precursors of osteoarthritis. In DDH, the deficient acetabular coverage of the femoral head has been related to osteoarthrosis, while the orientation of the femoral head is considered to play a less important role. The resulting instability and anterolateral migration tendency of the femoral head leads to chronic shear stresses at the acetabular margin. In FAI, repetitive peak contact pressures occur when the femoral head-neck junction abuts against the acetabular rim during joint flexion. Predisposing morphologies are femoral abnormalities such as an insufficient femoral head-neck offset seen in head tilt or pistol grip deformities, slipped capital femoral epiphysis, or malunited femoral neck fractures with the orientation and shape of the acetabulum contributing to this pathology. In classical DDH and FAI, diagnosis is primarily based on clinical signs and symptoms and conventional radiography. However, in cases of clinical and radiographic borderline disease establishment of the correct diagnosis is sometimes difficult. This presentation reports how the MRarthrographic appearance of acetabular rim pathologies can be used to differentiate both conditions. In DDH and FAI, labral pathologies localize identically with a predilection to the anterosuperior quadrant of the acetabulum. Labral tears are found in 64% in both groups. The volume of the labrum is increased in 86% DDH hips but in none of the FAI hips. Ganglion formation in the periacetabular area is seen in 71% DDH and 21% FAI hips. These findings provide evidence that the anterosuperior acetabular rim represents the initial fatiguing site of the hip under both DDH and FAI. The capability of MR-arthrography to depict differences in labral pathologies suggests this method as a helpful diagnostic tool to define the most appropriate treatment strategy specifically in borderline cases.

S. Puloski M. Leunig R. Ganz

Background: Numerous radiographic indices have been described to help define the degree of acetabular deficiency in adult patients with developmental dysplasia. The lateral centre-edge angle (LCE) of Wiberg and the anterior centre-edge (ACE) angle of Lequesne are two of the commonly measured indices that are reported in the evaluation of procedures that are used to correct acetabular deformity. Unfortunately much of the reported literature that tries to define abnormal indices has been extrapolated from the evaluation of “normal” pelvi or those with osteoarthritis. The purpose of this study was to evaluate the application and limitations of the LCE and ACE angles in a group of patients with developmental dysplasia treated with periacetabular osteotomy.

Methods: 50 cases were randomly selected from a larger cohort of over 500 patients with acetabular dysplasia treated at our institution with periacetabular osteotomy. The preoperative and post osteotomy false profile and anteroposterior plain radiographs were reviewed. Cases were first grouped into one of three categories based on a general estimation of the location of acetabular deficiency as determined from the AP radiograph.

A number of radiographic indices were measured and compared including the VCE angle, LCE angle, and acetabular angles of Tönnis and Sharp. Variation in both the VCE and LCE angle was evaluated by measuring the index using two different reference points. This included (1) the traditional mark of the furthest point along the sclerotic density of the weight bearing zone and (2) an alternate point representing the furthest extent of lateral or anterior bony coverage. Additional sources of measurement error were determined. The relationships between the centre-edge angles and other radiographic indices were determined. An evaluation of the indices and correction on post osteotomy radiographs was also performed.

Results: Fifty cases in 45 patients were reviewed. There were 31 female and 19 males. The mean age was 30 years (range, 17–45). A general review of all preoperative AP radiographs revealed that all hips displayed some degree of lateral deficiency.

Nineteen of these cases displayed a “classic” lateral and anterior deficiency. However, 19 cases displayed a more uniform deficiency and 12 cases were in fact retroverted.

Evaluation of the radiographic indices revealed:

A mean VCE angle of 2.3 degrees (SD±12.7) and LCE angle of 3.4 degrees (SD±9.3). These were corrected to 25.8 degrees (SD±11.6) and 28.6 degrees (SD±8.7) following osteotomy.

The VCE and LCE angles did not appear to be correlated (r=0.35). This is contrary to previous studies evaluating non-dysplastic pelvi (Chosa et al., 1997). The LCE angle showed no significant correlation to other lateral coverage indices (Tönnis, Sharp).

No correlation was seen either in the post osteotomy values, or in the absolute degree of correction.

The alternate VCE (aVCE), using the most anterior aspect of the acetabular margin as the reference point was consistently larger (p< 0.001) with a mean difference of 27.1 degrees (SD±10.0). There was however a positive correlation between these two methods of measurements (r=0.77).

A similar variation was seen when comparing the LCE angle and the alternate LCE (aLCE). The mean difference between measurements was 7.3 degrees (SD±8.7)(p< 0.001).

The mean VCE in hips with primarily anterior and lateral deficiency (−6.7°±12.5) was significantly lower (p< 0.01) than those with uniform deficiency (5.1°±8.3) or those with retroverted acetabuli (8.9°±13.3)

Dysplastic hips with a decreased LCE angle but relatively normal Tönnis angle should be treated carefully as osteotomy may result in excessive angular correction in the coronal plane, thus creating a negative Tönnis angle. This can ultimately lead to problems with lateral and/or anterolateral impingement.

Potential sources of error in measurement that were identified include:

Deformity of the acetabulum and occasional abnormalities of the femoral head limit the ability to identify the center of the rotation necessary to measure the centre-edge angles. Subluxation of the femoral head also creates a degree of error. These difficulties were observed in over 20% of cases.

Alteration in pelvic tilt and rotation theoretically decreases the accuracy of measurement. Practically over 30% of radiographs were seen as less than ideal.

The absolute reference point for VCE and LCE angles as the end of the sclerotic line in the weight bearing area can be (1) difficult to define (2) does not always represent the most anterior or lateral extent of the acetabular margin. This discrepancy appears to increases in dysplastic hips. This has been suggested previously (Fabeck et al.,1999) and is now supported by our findings.

Conclusion: Centre-edge indices can be useful parameters in defining acetabular morphology. However, these parameters should not be used in isolation and the absolute values do little to define the overall location and degree of deficiency in hips with acetabular dysplasia. A number of significant sources of measurement error limit their accuracy especially in patients with hip dysplasia. Currently, it is our feeling that no single radiographic parameter fully defines the specific morphology in each individual case nor reflects the success of correction when treating patients with periacetabular osteotomy.

M Beck A Martinez S Li R. Ganz

Radiodense structures resembling ossicles at the acetabular rim have received multiple names including “Os acetabuli, Os supertilii, Os marginale superius acetabuli, and Os coxae quartum”.

Various theories regarding their origin have been postulated. These structures commonly are observed in dysplastic hips and hips suffering from femoro-acetabular impingement and represent fractures of the acetabular rim. In our series we observed acetabular rim fragments in 4.9% of the dysplastic hips and in 6.4% of the hips with femoro-acetabular impingement.

Two different pathomechanics are responsible for the occurrence of these rim fragments. In dysplasia the short acetabular roof reduces the amount of available loading surface which leads to an overload on the lateral margin of the acetabulum, propagating the development of a fatigue fracture. However, as in all hips additional cysts were visible, it must be postulated, that cysts have to be present additionally and act as stress risers through which the rim bone eventually will fail. In hips with femoro-acetabular impingement the mode of failure is different. The relative anterior overcover in retroverted hips is subjected to stress during flexion of the hip, which is further increased by the frequent presence of an non-spheric extension of the femoral head as seen in cam impingement. The nonspheric femoral head-neck junction is jammed into the rim area. By repetitive traumatization the anterior rim eventually will fracture.

The clinical importance of acetabular rim fractures in the dysplastic hip is readily understood even by an unexperienced observer. However, it has to be considered as a sign that the hip has decompensated and it usually goes with significant articular cartilage damage. Because the radiographic appearance of the hip with femoro-acetabular impingement seems normal at first sight, the mechanism leading to anterior rim fracture may be overlooked. However, recognition and adequate treatment is important to prevent further degeneration of the hip.

R. Ganz

Alignment, coverage and congruency are traditional keywords for the morphological interpretation of the hip joint. Most of the collected information come from ill-defined radiographs and are mainly used to characterize the capacity of a hip for load transmission. Accordingly threshold values for undercoverage are more precise than the definition of overcoverage.

The understanding of what is a normal hip anatomy is changing rapidly; other parameters have to be included as well. The impingement concept introducing motion as an important initiator of osteoarthritis is based on relatively minor morphological abnormalities of the hip which were of little interest until now. With high quality MRI we recently learned that a hip joint may have substantial cartilage damages although it looks radiographically normal.

This Symposium is a first attempt to update on our standards Puloski et al. point to weak radiographic parameters. Dora discusses hitherto barely noticed indicators like the acetabular version which has a high potential for morbidity. Beck et al explain the acetabular rim fragment, a structure which can be seen in dysplastic as well as in impinging hips. Finally Leunig et al. use the MRI-morphology of the labrum to distinguish between dysplasia and hip impingement in borderline hips.

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Olle Svensson

Fracture is the only clinically relevant aspect of osteoporosis—a major public health problem in many countries. The strongest predictor for a new fragility fracture is a previous one. For instance, a patient with one osteoporotic vertebral compression fracture has about a seven-fold increased hip fracture risk; a patient with two compression fractures a 14-fold hip fracture risk. Today, we have evidence based and efficient osteoporosis drugs as well as non-pharmacologic methods for fracture prophylaxis. In risk group patients it often is possible to halve the fracture risk.

The orthopaedic surgeon is the first and sometimes the only doctor a fracture patien sees. Therefore, as orthopaedic surgeons, we have a great opportunity—and indeed an onus—to identify patients with increased fracture risk, and to do something about it.

Imagine patients with myocardial infarction or stroke discharged from hospital without blood pressure control or having a biochemical profile taken? Such negligence is, alas, not uncommon for patients with fragility fractures. We must think in terms of absolute fracture risk, and implement today’s evidence based knowledge.

Secondary prophylaxis should be an integrated part in fracture treatment. And this calls for a multidisciplinary and multiprofessional teamwork including surgeons, geriatricians, endocrinologists and general practitioners, as well as nurses, physiotherapists and a wide range of other paramedical specialists. Such “fracture chains” will reduce the number of unnecessary and preventable injuries and will have a great impact in terms of cost and suffering. This symposium will give an overveiw of fracture-preventing strategies.

Karl-Göran Thorngren

In the trend to operate hip fractures with less invasive procedures it is important to realise that the semi-percutaneous approach to make osteosynthesis with two screws or hook pins for femoral neck fractures, actually is a mini invasive procedure. It is well proven since decades.

The major question is to select the right patients for osteosynthesis versus arthroplasty (unipolar hemi, bipolar hemi or total hip arthroplasty). It is depending on the damage to the blood supply of the femoral head. There is at the moment no methods for this in routine use, but with the development of MRI techniques it might be possible. The goal is to select the right patients for osteosynthesis to minimise the healing complications and the need for secondary hip arthroplasties.

The hook pin procedure has been extensively used in Sweden through decades. Since the last 5 years there is an increasing trend for the most displaced fractures in older patients to be operated with a hemi arthroplasty. Previously a primary osteosynthesis was the first choice in all patients. The results of 10 years use of this procedure in Lund 1988–1997 shows that for the total of femoral neck (cervical) hip fractures the need for a secondary arthroplasty within 2 years was 20%. Previously published need for secondary arthroplasty was 13% when only well trained surgeons operated. There is thus no need to behead all displaces femoral neck fractures because some fail. In Norway the principles of primary osteosynthesis still mostly prevail. In a randomised comparison between hook pins and screws it was found that the rates of early failure of fixation, non-union and need for reoperation did not differ significantly between the two osteosynthesis methods. The use of hook pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6) and a lower incidence of necrosis of the femoral head (odds ratio 3.5). The technique of performance was of significant importance. There was a highly significant relationship between poor reduction and poor fixation of the fracture and subsequent reoperation. Likewise per-operative drill penetration of the femoral head was associated with a greater risk of reoperation. In total 22% of these patients needed a major reoperation (usually hemi arthroplasty). In 7% of the cases the fixation device needed to be removed after a healed fracture. In another randomised study between hook pins and three screws 57% of the patients were operated within 6 hours from admission to hospital and 92% within 24 hours. The mean (median) time for operation was 36 (30) minutes for the hook pins and 40 (35) minutes for the AO screws. After 2 years 77% of the hook pin patients had not needed any reoperation compared to 73% in the AO screw group. In total a secondary hemiarthroplasty had been performed in 7% and a total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. Again, healing was much higher if the reposition and positioning of the osteosynthesis material was optimised.

Osteosynthesis is a mini invasive procedure. It is indicated for all undisplaced cervical fractures and for less displaced fractures, particularly in younger patients. Attention to the reposition and positioning of the osteosynthesis material is necessary. An image intensifier with large field of view and good resolution facilitates this, preferably a biplanar. The future goal is to select the patients better for the different procedures osteosynthesis or arthroplasty.

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E Czerwinski M. Czerwinska

The risk of further fractures increases 2–10 times after the first fracture. Actual fracture risk for the given person (absolute fracture risk) can be calculated from data collected in 10-year prospective studies (NHANES or Kanis 2001). To calculate absolute fracture risk one has to multiply age-related risk factor ascertained in above studies by the coefficient estimated for particular factors influencing possible fracture (relative fracture risk). The most commonly used factors are: age (RR 2.0 for each 5 yrs over 65), low BMD (RR/SD 1.4–2.6), low-energy fracture after the age of 40 (RR 4.0), proximal femur fracture in mother (*RR 1.9), body mass lower than 58 kg (*RR 1.9), early menopause – before the age of 45, smoking (RR 1.2), susceptibility to falls (*RR 3.5), corticosteroids intake.

Absolute fracture risk in 60-year-old woman whose foreseen 10-year probability of femoral neck fracture is 2.3% with normal BMD but burden by factors marked by asterisks would be: 2.3% x 1.9 x 1.9 x 3.5 = 29%. As 76% of fractures occur in women with normal BMD absolute fracture risk is the most objective information. In case of proximal femoral fracture 10-year probability of 10% or more fracture risk provides a cost effective threshold for women in Sweden.

We can increase bone mineral density by pharmacological intervention. Every patient should be given calcium and vit. D supplementation and a specific medication, which should be adjusted to: age, sex and presence of hot flashes and fractures. HRT is preferred in women aged 50–60 yrs suffering from hot flashes. HRT decreases the risk of spine (50%) and proximal femur fracture (40%). However some risk of breast and uterine cancer has to be taken into consideration. Selective estrogen modulators (SERM; raloxifene) act as estrogen agonists on bone and cardiovascular system but as antagonists on breast tissue. Decrease of spinal fracture (45%) and breast cancer incidence (70%) is proven but no positive action on proximal femur is reported.

In women who underwent osteoporotic fracture one can apply bisphosphonates, strontium ranelate or PTH. Alendronate reduces spine fractures (47%) and proximal femur fractures (51%). Similar effects are documented for risedronate (spine – 60% and proximal femur 40–56%). Strontium ranelate not only inhibits bone resorption but also stimulates bone formation. Decrease of spine and proximal femur fractures occurrence has been proven (41%). PTH injected sc. in daily doses is the most powerful compound which rebuilds bone trabeculae in severe cases and reduces incidence of peripheral fractures (53%). Calcitonin is effective in spine fractures but not in proximal femur.

Fall prevention program should be implemented in all patients with osteoporosis independently from pharmacological intervention.

Charles S B Galasko

The incidence of reported cases of whiplash has risen dramatically in many Western Countries.There was an initial increase, in the United Kingdom, following the compulsory wearing of seatbelts for drivers and front seat passengers but since then the incidence has increased even more. This pattern has been reported in other regions.

Many factors have been proposed to account for this increased incidence, including changes in car design, increased traffic density, psychosocial aspects and increased litigation.

Although whiplash injury is defined as a “minor” injury it may be associated with prolonged morbidity. The factors causing chronicity are not well understood but do include the severity of the initial injury (WAD 3 injuries doing significantly worse than WAD 1 and 2 injuries), the development of psychological symptoms, age and bio-social factors. Prolonged litigation and prolonged inappropriate treatment also lead to chronicity.

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Antoni Moroni

Because of the decreased holding power of the screws, fixation of osteoporotic fractures has a high failure rate (10%–25%). It should also be reported that even if fixation does not fail, several osteoporotic patients with fractures have unsatisfactory functional results due to bony malunion.

Elderly patients with osteoporosis demand better fixation techniques. Treatment goals in this particular patient population include: proper fracture alignment, stable fixation and early rehabilitation. A surgeon should adopt a minimally-invasive technique in order to relieve the patient of physiological stress and allow for full-weight bearing of the fractured limb. Several fixation augmentation techniques have been proposed such as the use of PMMA, calcium phosphate cement, oblique screw insertion and cannulated ported screws.

Our studies indicated that osteoporotic bone fixation can be greatly improved by using implants coated with calcium phosphates such as hydroxyapatite. Hip fractures are the most severe form of fracture in patients with osteoporosis. Cut-out of the load-bearing implant is seen more frequently compared to patients with good bone quality often leading to revision surgery. We compared dynamic hip screw (DHS) fixation with hydroxyapatite(HA)-coated AO/ASIF screws to DHS fixation with standard AO/ASIF screws in osteoporotic trochanteric fractures. One-hundred-andtwenty patients were divided into two groups and randomized to receive 135° 4-hole DHS with either standard lag and cortical AO/ASIF screws (Group A) or HA-coated lag and cortical AO/ASIF screws (Group B). Inclusion criteria were: female, age > 65 years, AO/OTA fracture type A1 or A2 and a bone mass density (BMD) T-score lower than −2.5. Exclusion criteria included lag screw extension into the proximal third of the femoral head. Between the two groups, there were no differences in patient age, BMD, screw position in the femoral head, tip apex distance, quality of reduction and fracture impaction at the 6-month follow-up. In Group A, femoral neck shaft angle (FNSA) reduced over time (134 ± 5° postoperative vs. 126 ± 12° at 6 months, p = 0.003), whereas in Group B, no reduction occurred over time, as indicated by the lack of difference between the FNSA post-operative (134 ± 7°) and at 6 months (133 ± 7°). Lag screw cut-out occurred in four Group A cases but not in Group B (p < 0.05, = 0.8). Three patients with cases of cut-out underwent revision with bipolar prostheses. At 6 months, the Harris hip score was 60 ± 25 (Group A) and 71 ± 18 (Group B) (p= 0.007).

External fixation could be a viable treatment option in elderly trochanteric fracture patients since it typically involves a low energy trauma. However post-operative complications associated with inadequate pin fixation have limited its use. Because of the development of HA-coated screws, we compared external fixation with HA-coated screws (H-CP) to DHS with AO/ASIF stainless-steel screws in osteoporotic trochanteric fractures. Forty patients were divided into two groups and randomized for treatment with either 135° 4-hole DHS (Group A) or external fixation with 4 H-CP (Group B). Inclusion criteria were: female, age > 65 years, AO/OTA fracture type A1–2 and a BMD T-score lower than −2.5. All fixators were removed at 3 months. There were no differences in patient age, fracture type, BMD, ASA, hospital stay and quality of reduction. Average number of blood transfusions was 2 ± 0.1 in Group A, whereas no blood transfusions were required in Group B (p < 0.005). Post-operative FNSA was 134 ± 6 ° in Group A and 132 ± 4° in Group B (ns). In Group A, the varus collapse of the fracture at 6 months was 6 ± 8° and in Group B 2 ± 1° (p = 0.002). The Harris hip score was 62 ± 20 in Group A and 63 ± 17 in Group B (ns). In Group B, no screw infection occurred.

Conclusion: A valuable strategy that will benefit the elderly osteoporotic patient and provide for early mobilization is the use of a minimally-invasive technique, a well-restored anatomy of the fractured limb, no blood transfusion requirements and early rehabilitation. These should also be beneficial for maintaining the overall well-being of the patient. Our results demonstrate that enhanced screw osteointegration and fracture fixation will have a positive impact on the quality of life in the elderly osteoporotic patient.

David Marsh

Several studies document what we all know – that, in the vast majority of patients treated in fracture units for low-trauma fractures, there is no attempt to identify and treat factors predisposing to further fractures. We treat this fracture, send ‘em home and wait for the next. How mindless is that?

Equally, it is completely unrealistic to expect orthopaedic surgeons, focused on surgically treating a tide of challenging osteoporotic fractures, to assess the risk in each patient of further falls and the degree to which bone strength is compromised, and be responsible for prescribing treatments which will reduce risk in a cost-effective way. Yet the fracture unit is absolutely the best (and most cost-effective) place to identify the group of patients who will benefit most from preventive measures.

The answer is to work in a system, which connects up the right people to give each patient what they need. Surgeons to heal the current fracture (together with rehabilitationists to restore function and confidence) and physicians to assess and treat falls risk and osteoporosis.

Making this happen in practice requires answers to questions only you can answer:

who are the best physicians for our fracture unit to work with?

what is the best mechanism for selecting the appropriate patients to refer?

how do we persuade the commissioners to pay for it?

This is an issue in which it is worth us investing a lot of effort: we will ourselves soon be old and we must get this right in time for when we need it!

Philip Sell

Whiplash associated Disorder is a clinical entity that is well recognised by doctors patients and the legal profession. It is however a clinical syndrome that has few of the characteristics that are normally associated with the epidemiology and pathology of injury.

The dilemma of Whiplash is the absence of hard evidence of any pathological process that would normally be considered evidence of a disease process.

Epidemiology exposes some of the gaps in the current models of whiplash. There are unexplained cultural variations. The different legal mechanisms of claim should not influence a physical traumatic disorder.

There is normally a clear relationship between the kinetic energy involved in injury and the tissue disruption that occurs. Experimental models using crash tests produce conflicting results. Studies of polytrauma reveal a very low incidence of post traumatic neck pain.

A range of opinions are available in the literature on pathology and biomechanical factors. Systematic analysis reveals the level of evidence for the establishment of the disease of whiplash in the 1960’s to be level two or three, while the evidence for discarding whiplash as a physical disease in the modern literature is level one or two. It is much harder for physicians to discard a cultural fixed belief in a disease that may never have existed rather than to accept the verifiable logic of modern models of disease.

Various historical arguments that have been used to support a physical basis for whiplash associated disorder have a flawed logic. The current best evidence would suggest that the acute phase of a whiplash disorder may be the result of a minor soft tissue injury, the natural history of which is recovery. There is little or no evidence to support a physical basis for chronic symptoms, which on the balance of probability are due to psychosocial factors. Whiplash is a ‘convenient’ model of illness which results in ‘gain’ for all those involved in its manifestations. It is a convenient disease.

Aris Seferiadis

Victims of motor vehicle accidents often seek health care following whiplash injuries. Their complaints (whiplash associated disorders, WAD) are classified on a 1–4 scale developed by the Quebec task force (QTF) in 19951. A number of victims will not recover, developing chronic symptoms instead2. The pathophysiology of the complaints following a whiplash injury is largely unknown. Several different treatments are currently employed by health professionals to treat victims of whiplash injuries in the acute and chronic phase of the disorder.

Responding to the acute symptoms with activity (act-as-usual and exercise) results in improved outcome3. There is evidence that sick-leave may be reduced by high-dose methylprednisolone given within 8 hours of injury in patients with QTF grade 3 WAD3.

Approximately 50 % of patients with chronic WAD suffer from zygapophyseal joint pain that will be relieved for a period of several months if treated with percutaneous radiofrequency neurotomy3. Moderate evidence supports multimodal rehabilitation programs for increasing levels of function3 and coordination exercise to reduce pain in chronic WAD3.

State-of-the-art treatment for acute WAD is available and needs to be implemented.

Further research on the treatment of chronic WAD should focus on the patients’ cognitions and movement behavior.

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Martin Gargan

The cost of claims for personal injury after whiplash injury costs the economy of the United Kingdom some £3 billion per year. The majority of vehicle occupants subjected to rear-end shunt either suffer no effects or make a complete recovery however a minority suffer adverse psychological and social consequences which may be largely unrelated to the severity of the initial physical insult.

The early psychological reactions include feelings of being shocked, frightened and angry which are related to the victim’s subjective perception of accident severity. During the days after many victims continue to experience anxiety and distress manifest in physical, emotional, cognitive and social complaints – which may be severe enough to constitute the diagnosis of acute stress disorder which has a high risk of subsequent PTSD (Post – Traumatic Stress Disorder)

Ongoing apparently disproportionate disability can take a number of forms but is usually an unconscious process resulting from the interaction of physical, psychological and social variables.

The risk factors for a poor psychological outcome include pre-accident characteristics, the nature of the accident, beliefs favouring chronicity, quality of care along with independent post-accident events and in many cases the effect of litigation.

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J.C. Le Huec S Aunoble

Surgical treatment of degenerative disc disease (DDD) has been widely modified in the last decade. The clinical evaluation of back pain has been improved by the use of functional scores and VAS. The discography is an adjunct for decision-making, but CT scan and MRI are the keys to evaluate the aging process.

The conservative treatment with physiotherapy and exercise programs is always the first and very useful treatment. Percutaneous therapy like facets injection, laser, IDET, radiofrequency in the disc can be a solution in some specific cases. Their efficacy has been evaluated in different studies and is sometimes controversial but there aren’t contraindications for further treatment and their complication rate is low. Dynamic posterior stabilization devices using pedicular screws and ligament tension band are proposed to try to put the disc in rest and some histological analyzes confirmed this hypothesis. Interspinous devices have been evaluated since many years but there indications need to be established as the literature available doesn’t provide clear indication criteria. Partial disc replacement is a new challenge for DDD. Many devices have in clinical evaluation but only few have prospective studies demonstrating their efficacy. The PDN was the pioneer and as the other in the evaluation process it has to solve the problem of the stability of the device. The last products on the market are promising. The total disc replacement is the last solution before fusion. Many studies including prospective and randomized have demonstrated the efficacy of total disc replacement. The indication is the key point of success. The training to perform the approach safely is mandated. Finally the fusion: anterior, posterior or combined is the ultimate solution to treat DDD. This was the gold standard and is still the most widely used treatment. As a dead end fusion is used only if other solutions cannot be proposed or used. DDD therapy has to be considered with the help of an algorithm including all motion preservation treatment before fusion.

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João Cannas J. Mineiro

The multiplicity of factors that influence the clinical evolution of discopathies, determine a great diversity in its presentation.

The barely known genetic predisposition, the individual morphological aspects, the age and sex, the associated co-morbidities as well as the patient environment define in its all an individual context that influences decisively the treatment for each patient.

On the other hand, the identification in each case of the different stages of the multilevel DDD, causes doubts regarding the involvement of each segment in the respective clinical condition.

To singly identify all sources of pain, and not only each painful level, is the main challenge poised to the spine surgeon when defining the treatment strategy.

The diagnosis aggressiveness must be proportional to its doubts, and the discography, the disco-scanner and the facet blocks are fundamental when the conventional clinical investigation is inconclusive.

The use of minimal invasive techniques such as IDET or Coblation can be considerate as alternatives, especially in the early stages of single-level DDD.

The nucleoplasthy – nuclear prosthesis- is an interesting alternative in the intermediate stages of the discogenic pain DDD, as well as in the predominant facet pain or in the foraminal dynamic stenosis is the dynamic stabilization. Those are techniques with controversial results and which liability in some cases is yet to be proven.

Last, the use of different techniques in different levels in the context of multi-level DDD – ex: fusion + disc replacement; disc replacement + dynamic stabilization with or without decompression procedures in the spinal canal- must be rigorously considered according to the specific dysfunction of each segment and considering the anatomical and functional reconstruction of the spine.

Ian Leslie

The incidence of major hand injuries has fortunately declined in Europe in recent years owing to the enforcement of Health and Safety Regulations and the automation of many manual tasks. As the numbers of major injuries decline so too does the surgical skill and experience of the surgeon. Yet, major injuries will still occur and patient expectation will always be driven higher as media encompasses dramatic results from around the world. This symposium draws together experts from Europe and especially from Turkey and India where experience with these injuries is so much greater nowadays than in Western Europe.

Classification is difficult but necessary if outcome comparisons are to be made. A brief outline of available classifications will be given. The speakers will then cover the topic on an anatomical basis including the priorities in the acute management.

João Cannas

Fusion has been the surgical reference for treating degenerative disc disease, nevertheless in the last two decades the recognition of it’s inconvenients, such as the degenerescence of the adjacent level, the growing demand for a better life quality by the patients and the evolution of the knowledge regarding the biomechanics of the spine and of the intervetebral disc itself, have stimulated the development of new technologies for the treatment of DDD among which the Disc Replacement.

In this symposium will be analysed the biomechanics of the disc and disc replacement, enhancing the already known benefits of the movement preservation, by discussing the different philosophies of the available systems: non-constraint; semi-constraint; and constraint.

The analysis of the overview results in the literature of fusion in comparison with disc replacement will also proportionate a fundamental actualization when deciding over the current perspectives in the treatment of DDD, considering the treatment alternatives developed in the meanwhile.

The disc replacement is an actual challenge with believers all over the world as an important step forward towards better life quality of patients with incapacitant low back pain. But with indications and limits that must be well known. Besides that it’s a demanding technique with potential risks associated and that demands specialization in this domain for its practice.

Always considering the different phases of evolution of the DDD, which can occur simultaneously in the same patient, different therapeutics solutions are considerate and which application deserves a profound reflexion according to the diagnosis characteristics, its staging, the ponderation of risks and benefits and as well its socioeconomics consequences.

João Mota da Costa

Most of the major acute injuries of the hand will involved the tendons, either flexor or tendon lesions or both.

In programming the repair of tendons we have to evaluate all the others structures affected that need to be repair and remember that we should provide a good coverage of these structures.

In some situations it will be possible to suture the tendons directly, but in others we might need tendon grafts or to transfer some motor units for reconstruction of others, including the use of tendons of amputated parts. In other situations with grate tissue destruction and loss of pulleys of the flexor tendons it might be reasonable to do the reconstruction at a later procedure and to utilize silicone rods to maintain the space for a later reconstruction.

Tendon adhesions, joint stiffness, boutonniere and swan neck deformities are some of the complications that we might expect to have, even with a good rehabilitation program, and to solve at a later surgical procedure.

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Roger Lemaire

An informed consent document signed by a patient before surgery is supposed to provide evidence that he effectively received adequate information to be able to give informed consent. In fact, it only provides limited legal protection to the surgeon. Although the situation may vary from one country to another and, within each country, from one court to another, a standard consent form is usually considered inadequate, and a procedure-specific consent form appears as a minimal requirement. Even this will provide limited protection if a patient has presented a complication not listed. When confronted to a determined lawyer who pleads the absence of informed consent, a surgeon will most often not be able to give evidence for disclosure of some specific items to the patient.

This raises a number of questions:

- How extensive should the information be? Should compliance with a legal obligation always prevail over common sense?

- How much information can the average patient understand, store up and recall? How make sure that information has transformed into knowledge?

- Is it fair to require a surgeon to decide himself that his patients have been adequately informed, without being suspected to have faced a conflict of interest? Or should an independent authority be responsible for attesting, after an examination interview, that patients have received adequate information and are eligible for surgery?

- Should disclosure of all complications be forced on a patient who does not wish to know about them? Common sense and legal obligations may diverge on this point.

- Should preoperative consultations be (video) taped so as to procure objective evidence to serve in case of subsequent litigation?

In litigation cases, the burden of proof used to bear on the patient but has now more or less overtly been transferred to the surgeon, while he is not offered the possibility to face such demands in the current organisation of health care in most countries. Even though paternalistic medicine is no longer politically accepted, many patients still expect counselling rather than just information; law makers and lawyers have decided that these patients are wrong, but it is difficult for physicians who have been trained in the spirit of Hippocrates’ oath to behave merely as informers and technical care providers.

Medical activity takes place nowadays under ambiguous conditions. There is a politically accepted vision of medicine in which choices and decisions are made by the patients, as it is supposedly possible to bring all of them to a level of knowledge and understanding which makes this possible; when going in the field, things are different, and most patients are still looking for expert counselling in addition to or in lieu of information. As compared to the situation which prevailed a few decades ago, patients are much less ignorant about medicine in general, but the problem is that medicine has progressed far more rapidly than the layman’s medical knowledge.

Besides, a number of studies have shown that retention of information by patients decreases rapidly over time and is fragmentary, with potential benefits from surgery being recalled much better than possible complications. Patients have also been shown to ingenuously deny receiving information despite documented evidence; ingenuous fabrication, i.e. affirmation of an untruth, is also a classical observation

We know all too well that a number of our patients come to surgery without a proper comprehension of their pathology and therapy, and we have to pretend that we are not aware of it, otherwise we would have to deny those patients the benefit of surgery. To change this would require a major involvement not only of the medical profession but also of the almighty health care administrations and of the funds providers

Paolo Gallinaro

Commercial aviation has recognized since long time that the so called “human factor” is the main responsible for the majority of accidents or near-accidents, which are always reported in aviation but almost never in medicine. Therefore I strongly support the idea that we could much learn from aviation in order to cope with the major cause of our accidents. Like airmen, pilots, air traffic controllers and so on, we also make errors. The first step to reduce the burden of our errors is to be able to admit them in order to analyse their causes, which up to now we are unable to do. Only one medical journal, the Lancet, has started to publish our errors. But beware not to make confusion between, complication, negative outcome and medical error.

The “human factor” must not be understood as human error; on the contrary the human factor is related to the majority of accidents, where the human error is only a minor and final cause.

To understand how “human factors” can play a role in determining the “accident”, we must first distinguish between active and latent failures. Active failures are unsafe acts committed by those at the sharp end of the system: the pilot, air traffic controller, anaesthetist, surgeon.

Latent failures arise from fallible decisions, usually taken within the higher levels of the organization or within society at large. A clear example is the crash of the SAS aircraft in Milano Linate with a small aircraft of the general aviation on the same runaway. No ground radar was available and the fog made the rest. But only the “sharp end” of the system, i.e. the traffic controllers paid for their error, not those responsible for not buying the ground radar.

We must develop a new culture of error but this will remain difficult until our legal systems do not change their approach towards negative outcomes. This vicious circle needs to be cut for the benefit of all, patients and doctors.

SKIN COVER Pages 13 - 13
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S Raja Sabapathy

Most major Upper limb injuries are invariably associated with significant skin and soft tissue loss. With the recent technical advances, it is possible to cover most defects. This allows salvage of limbs which were being amputated before. Primary reconstruction of composite defects is also possible thereby shortening the reconstructive process. The ten key points are

Debridement is the key to success. The quality of the bed determines the infection rate and the ultimate functional outcome. Good debridement is essential irrespective of the type of skin cover provided. You make it or miss it at this stage.

Cover the wound as early as possible, preferably within 48 hours and certainly before infection sets in. Tendons and bones do not tolerate exposure. Dried and dead bones and tendons must be excised before providing skin cover.

While providing skin cover, make the complete plan and not decide for the day. The cover provided should facilitate the next stage of reconstruction (bone or tendon graft or transfers)

Good skeletal stability is a must before providing skin cover. In the upper limb stable internal fixation is preferable. Loose fixation is the beginning of the end.

If secondary procedures are to be done, skin flaps provide better access than fascial flaps covered with graft.

Composite defects need not always be reconstructed with composite flaps.

One need not try every known flap. Do what you are good at. Repetition is the mother of skill.

Having said that one must also recognize the inherent limitation of any technique. Be willing to change or try alternate plans when faced with problems.

Don’t forget donor site morbidity. Initial patient satisfaction is dependent on wound healing. Long term satisfaction is dependent upon donor site morbidity.

Do not give up reconstruction of a major hand injury for fear of inability to cover the wound. Never hesitate to seek help. A well healed reconstructed hand is functionally far better than the best available prosthesis.

Eero Hirvensalo

Patients seek more and more actively compensation for treatment injuries, accidents, infections, and even because of unsatisfied results. Injuries or mistreatment are quite frequently seen in orthopaedic surgery, because operations are increasing and unsatisfactory results can be easily recognised from radiographic documentation.

Compensation can be theoretically sought by three main routes: directly from the orthopaedic surgeon or his insurance company, secondly, from the institution where he is working (or its insurance company) and thirdly, from a statutory system if there is one available. The first two direct compensation mechanisms are based on direct link between the patient and the physician involved. A statutory system can be universal and act more as a no fault compensation system.

Statutory patient insurance was introduced in1987 in Finland (Patient Insurance Act). This act covers all medical treatment, both public and private care in Finland including examination, surgical and nonoperative treatment, inpatient ward treatment, physiotherapy, rehabilitation as well as patient transportation.

All hospitals and companies dealing with medical care need to be insured. The institutions or companies responsible of the medical work owe the policyholder status. Therefore workers in the medical field need not to make their own insurance agreements nor pay any insurance fees to the companies.

The Finnish Patient Insurance Centre handles all claims in Finland, about 7.000 cases yearly, of which about 2.000 will give compensation to the patients. An independent Patient Injury Board stated by the Ministry of Health supervises the Centre.

So far, orthopaedics and traumatology has been the leading speciality in producing injuries. The injuries are divided into six subgroups: 1) treatment injury, 2) infection, 3) equipment-related injury, 4) accident related injury, 5) wrong delivery of pharmaceuticals and 6) unreasonable injury (severe complication with permanent disability after accurate treatment).

The evaluation of patient injury is concentrated on the case itself. The personnel involved to the treatment will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has been adopted well in Finland.

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 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 and do not lead to compensation 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 as well as breakage of medical equipment and error of delivery of pharmaceuticals in pharmacies. Unreasonable injuries are seen a few yearly.

The prerequisite for compensation is that there has to be an objectively recognised harm to the patient due to a diagnostic or treatment procedure. Patient insurance covers the following costs: 1) medical treatment expenses, 2) other necessary expenses caused by the injury, 3) loss of income on maintenance, 4) pain and suffering, 5) permanent functional defect, and 6) permanent cosmetic injuries.

In 2004 the total costs of compensation paid was 24.2 million e (public health care 88% and private health care12%).

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.

Patients owe still the possibility to sue the hospital or doctors involved. However, these cases will be normally handled by the Patient Insurance Centre and not by the medical personnel individually. In fact, the amount of trials against medical units or personnel has diminished dramatically after adoption of the Patient Insurance Act in Finland.

Marianne Arner

Pediatric hand surgery in general requires special considerations and this is even more true when planning surgery in children with CP. It is important for the surgeon to realize that the functional problems these children exhibit have their cause in a brain damage which is not amenable to hand surgical treatment. Therefore it is crucial to carefully analyze each child’s impairment including the voluntary motor control and the child’s specific needs before endeavoring into surgery. Associated impairments, such as mental retardation, nutritional problems, epilepsy, dystonia or severe sensory deficits may influence decision-making, but the crucial factor is often the child’s own wish for an improved function. A child that completely neglects his or her extremity is usually not helped by surgery, at least not in an attempt to get a better hand function.

Hand surgery in CP mainly comes down to three techniques: 1. Reducing strength in spastic muscles by release operation, either at the origin of the muscle, at the insertion or as a fractional lengthening at the musculo-tendinous junction, 2. Increasing strength in weak antagonists by tendon transfer or 3. Stabilizing joints through an arthrodesis or a tenodesis. Most often a combination of these techniques is used. Almost all hand surgeons in this field have acquired their personal choice of procedures and scientific support for the benefits of the different techniques is scarce. My personal arsenal will be described in the panel but includes biceps-brachialis muscle release at the elbow, pronator teres rerouting, flexor carpi ulnaris to extensor carpi radialis brevis (Green’s) transfer and adductor pollicis muscle release in the palm combined with extensor pollicis longus rerouting for the thumb-in-palm deformity. In my mind, it is not most important which tendon transfer that is selected, but the choice of which child to operate and at what age. It is also important to tension the tendon transfers exactly right and to plan the postoperative treatment properly. The surgeon should, of course, also make sure that the child’s and the parent’s expectations on the results are realistic.

Botulinum toxin A has now been used for several years in the treatment of children with cerebral palsy and the drug has been shown to be safe and effective in reducing muscle tone both in the lower and the upper extremities. It has been more difficult to show effects on hand function especially in the long-term perspective. I will present our treatment protocol for botulinum toxin injections.

In 1994, a population-based health care program for children with CP was started in Lund in southern Sweden. All children in our region with a diagnosis of CP, born after Jan 1st 1990 are invited to follow the program which includes regular measurements of range of motion in extremity joints, standardized radiographic examinations of the hip joints and registration of surgery and spasticity treatments. The program, called CPUP has been very successful in the prevention of spastic hip dislocation, wind swept position and contractures. Some early results from the upper extremity part of CPUP will be presented. We believe that the program in time will give us valuable information on the natural course of joint motion and impairment of hand function in children with CP.

Richard Wallensten

In Sweden 99 % of all complaints against doctors are handled by a public authority, The Medical Responsibility Board (HSAN). This way it is very rare fore a medical complaint to reach the judicial courts in Sweden. HSAN is a national authority that assesses medical negligence. If health care staff is at fault, the Board can take disciplinary action against them.

The Board is made up of nine members. The chairman is a lawyer with judicial experience and the other members have experience from various sectors of the health services. Anyone who is or has been a patient can file a complaint to HSAN. The National Board of Health and Welfare, the Parliamentary Ombudsman and the Chancellor of Justice can also file complaints to HSAN. The complaint must contain details of the actual examination, care or treatment referred to, when and where it took place and, if possible, who was at fault and what the fault is considered to be. HSAN must be informed of the subject of complaint within two years of the incident’s occurrence. If this is not the case, disciplinary responsibility will have lapsed.

HSAN’s decisions are always public. A case is prepared by getting the opinion of the accused doctor and a copy of the patient records.

When a case has been prepared medical experts with links to HSAN review it. HSAN subsequently examines the case and arrives at a decision. The chairman alone examines certain cases following a review by medical experts. Copies of the decision are sent both to the person who filed the complaint and those to the person(s) cited.

If the person filing the complaint is not happy with the decision, it may be appealed. The appeal must be lodged within three weeks from the date the decision is made public. The court of appeal is the county administrative court.

HSAN does not handle requests for economical compensation. If the plaintiff wants money he/she has to go to court. This happens extremely seldom.

HSAN handles about 3000 cases a year and in less that 6–10 % a decision against the accused is made. 70 % of the cases concern doctors and 30 % dentists, nurses and others. The number of orthopaedics cases is about 300 per year and a ruling against the surgeon happens in less than 10 %. The complaints in orthopaedics concern clinical examination, faulty diagnostics (usually that x-rays were not taken), faulty treatment and misconduct. Most of the cases in orthopaedics originate in the emergency department.

César Silva

Congenital Hand Deformities are probably the most frequent cause of non-traumatic complaint in consultations on paediatric hand surgery.

The incidence of occurrence is about 1 in 500 live births. Some of these abnormalities are minor and do not interfere with function. Many, however, have a significant functional and/or cosmetic deformity.

Only a few congenital malformations have a regular single gene mode of transmission, most have an irregular and unpredictable pattern of inheritance; sometimes occurs as part of a malformation syndrome or skeletal dysplasia, or in a sporadic way.

In fact, the cause for 40 to 50% of these anomalies is “unknown”.

Themes like handling the patient and parents and the psychological effects of the anomaly, the general principles of treatment, timing of surgery and the principles of reconstructive surgery are discussed.

The classification proposed by A.B. Swanson and revised with the assistance of the Congenital Anomalies Committee of the International Federation of Societies fo Surgery of the Hand will be used to propose the general guides of treatment.

The most common anomalies will be approached in more detail and the option of treatment is discussed in base of experience of the author.

M. Arner

Hand surgery is rarely indicated in children with arthritis, but presents specific problems. The initial diagnosis can be difficult due to discrete clinical symptoms and limited radiological signs. A decreased wrist extension or finger joint stiffness can be early signs of arthritis in a child. Destruction of joint surfaces are difficult to evaluate since many skeletal parts in the hand, e.g. the carpal bones, are still not ossified in young children. Accelerated skeletal maturation can often be the only radiological sign of an active synovitis in the joint. The hands and wrists are often involved at an early stage of juvenile arthritis and different growth disturbances may occur, the most commonly seen is a shortening of the distal ulna. Surgery itself may also affect growth. When performing soft tissue surgery, like synovectomies or arthrolyses on the juvenile arthritic hand, a significant risk of postoperative joint stiffness has to be considered. Surgical treatment of arthritic hands in children are often delayed until adolescence, and doing any kind of surgery in a teenager is a difficult task which requires special attention and finesse. Personal experience from the Children’s Hospital in Lund, Sweden will be presented.

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Mr Sunil Dhar

Traditional surgical treatment of hallux valgus is based around distal soft tissue realignment and distal metatarsal osteotomies. Over the decades several osteotomies have been practiced, but currently the Scarf osteotomy is gaining popularity.

This presentation will discuss the various procedures for proximal correction of the hallux valgus, the scope of the Scarf osteotomy, its pitfalls and published results. Our own experience of the Scarf osteotomy runs to several hundred patients and the overall satisfaction rate from realignment of hallux valgus is over 80%.

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Julian Chell

The management of adolescent hallux valgus presents a considerable challenge for the orthopaedic foot surgeon. Those presenting fall into two groups, idiopathic and neuromuscular. The management of the symptomatic hallux in neuromuscular cases is more clearly defined with arthrodeses of the first metatarsal-phalangeal joint being the treatment of choice. This affords the most consistent long-term results and the greatest degree of correction.

In the idiopathic symptomatic hallux valgus the treatment is more variable depending on the severity of the deformity and the underlying pathological changes. The demographics of adolescent hallux valgus and its associated abnormalities are discussed. There is a higher incidence of an increase in the distal metatarsal articular angle in severe cases where combined surgical intervention in the form of double and triple osteotomies may be required to achieve long-term correction and a treatment algorithm is presented. Since approximately half of symptomatic patients will be under 10 years of age with significant residual growth early surgical intervention has a higher recurrence than in the mature foot.

H. Reichel

The current concepts of proximal femoral fixation in hip arthroplasty can be divided into three groups: the surface replacement concept, the femoral neck prostheses, and the short stems prostheses.

Between 1999–2004 more than 500 short stems prostheses (Mayoä) were implanted at the Orthopaedic department of the Martin-Luther-University, Halle, Germany.

To investigate the early functional results, a prospective randomized study was performed comparing 40 cementless short stem prostheses (Mayoä 1) with 40 cementless anatomical standard stem prostheses (ABGä 2) implanted in patients with unilateral hip osteoarthritis.

Age, gender, diagnoses, and body mass index showed no significant difference between both groups. In all patients, an uncemented acetabular press-fit cup was used. The implantations were performed by 4 orthopaedic consultants. A standardized anterolateral approach to the hip was used in all cases. In the short stem group, the femoral neck was preserved to achieve a multi-point fixation of the double-tapered stem in the intertrochanteric region.

The patients were followed clinically and radiographically at 3, 6, and 12 months postoperatively. Differences between both groups were tested using Student’s t-test. No specific complications occurred neither during surgery nor during the follow-up (FU). No patient was lost for FU. The radiograhic FU showed a correct implant position in all cases.

Concerning the Harris hip score (HHS), a statistically significant difference (< 0.01) was found at 3 months: the HHS for the short stem group averaged 93.87 points (range, 60–100 points), for the ABG group 87.02 points (range, 60–100 points). Preoperatively, at 6, and at 12 months, no statistically significant difference could be found between both groups.

In this study, patients having a short stem prosthesis returned faster to work and normal daily activities. We attribute this to the femoral neck approach without involvement of the greater trochanter and the abductor muscles. With its good functional results and its bone-saving concept, the short stem is an attractive design particularly for young patients.

Derek McMinn Joseph Daniel Chandra Pradhan Paul Pynsent Hena Ziaee Tim Band Roger Ashton

Hip Resurfacing has always been an attractive concept for the treatment of hip arthritis in younger patients. Introduction of modern metal-on-metal hip resurfacing in 1991 in Birmingham, UK made this concept a reality.

In the early years, resurfacings were used only by a few experienced surgeons. From 1997, Birmingham Hip Resurfacings (BHRs) are being widely used in younger and more active patients. A breakdown of the ages at operation in the regional NHS hospital in Birmingham during the period April 1999 to March 2004 show that the mean age of metal-metal resurfacings is 51 years and the mean age of total hip replacements is 70 years.

At a 3.7 to 10.8 year follow-up (mean follow-up 5.8 years), the cumulative survival rate of metal-metal resurfacing in young active patients with osteoarthritis is 99.8%. In the long term, none of these patients were constrained to change their occupational or leisure activities as a result of the procedure. The overall revision rate of BHRs in all ages and all diagnoses is also very low (19 out of 2167 [0.88%] with a maximum follow-up of 7.5 years).

Improvements in instrumentation and a minimally invasive approach developed by the senior author have made this successful device even more attractive. Although objective evidence does not support the fact that the longer approach was any more invasive than the minimal route, patient feedback shows that it is very popular with them. While minimal approach is indeed appealing, it has a steep learning curve. In the early phase of this curve, care should be taken to avoid the potential risk of suboptimal component placement which can adversely affect long-term outcome.

It is true that metal-metal bearings are associated with elevated metal ion levels. In vitro studies of BHRs show that they have a period of early run-in wear. This is not sustained in the longer term. These findings are found to hold true in vivo as well, in our studies of 24- hour cobalt output and whole blood metal ion levels. Epidemiological studies show that historic metal-metal bearings are not associated with carcinogenic effects in the long-term.

Metal ion levels in patients with BHRs are in the same range as the levels found in those with historic metal-metal total hip replacements.

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Andrew Taylor

The concept of a congruent and incongruent joint will be introduced and the results of various distal osteotomies will be presented. The differential diagnosis of pain around the 1st metatarsophalangeal joint will also be discussed.

Although not exclusively a complication of distal osteotomies, the correction of acquired hallux varus will also be presented.

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K.P. Günther

In addition to “conventional” total hip replacement with cemented or cementless stems more recently different implant designs have been proposed by Orthopaedic Surgeons in Europe and US. Especially surface replacement and short stem prosthesis are believed to overcome the disadvantages of conventional THR in younger patients.

The symposium “MINIMAL DEVICE OR REPLACEMENT FOR THE HIP” is trying to summarize current implant philosophies and to review critically the available data of functional as well as radiographic outcome.

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K.P. Günther

With the advent of new hip implants (resurfacing and short stem prosthese) current treatment recommendations have to be reevaluated. The indication for surgical treatment in hip osteoarthritis as well as the choice of implants is mainly based on personal experience of the surgeoun (internal evidence) and clinical data (external evidence). Experimental studies can support the information from clinical trials and are necessary to evaluate the mechanical properties of an implant. They do not replace the clinical evaluation, however.

The level of evidence depends on type, quality and quantity of available data from published investigations. Recent innovations like surface replacement and short stem prostheses have mainly been investigated in single center observational studies with a relatively short followup.

Wider introduction of new implants, however, needs continuous evaluation of clinical and radiographic performance. Examples are given, how this monitoring should be performed in a clinical setting.

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Christian Mazel

Incoming of a spine metastasis remains a major bad prognosis factor in cancer evolution. Consensus over the years is now well accepted in most of European teams dealing with spinal metastasis. Two major opportunities exist in the treatment of spine metastasis:

Conservative treatment with an association of radio and or chemotherapy and or hormonotherapy. Efficiency of such treatments is well documented and must not be considered as a patient abandon.

Surgical treatment is based on two major options. The first one is palliative with the aim of decompression and stabilization. Aim is to cure pain and neurological involvement. The second one is curative with total or partial vertebrectomy in the aim to cure the cancer.

In all cases decision must be made considering age- general condition histo – pathology – neurological status

Considering surgical indications through out this symposium we would like to address three controversial points.

The first topic to be addressed will be: “Total vertebrectomy: when?” presented successively Doctor MARTIN BENLLOCH and Professor BORIANI. The goal of this presentation is to determine the indications of total vertebrectomy more than the surgical technique. These indications appearing essential within the framework of the metastatic patients, while insisting not only on the natural history, but also on the tumoral extension which determines the feasibility of the vertebrectomy. Professor POINTILLART and Professor BORIANI will then discuss about the strategy to adopt when confronted with multi-metastatic patients “Multi-metastatic patients: what strategy?”. This topic will focus primarily on the problem of multi level spinal metastatic lesions: the strategies to be adopted with respect to the patients presenting other metastatic lesions, as well as on a functional forecast (fragility of the long bone), or on the other hand, on metastasis without immediate functional incidence. We also would like to discuss the treatment of the primitive tumour, i.e. if it is the metastasis which is revealing cancer, is it necessary to first treat the primitive tumour, than proceed to the treatment of the metastatic lesions? The third topic of this session will be “When Not to Operate on Metastatic Patients?”, presented by Professor POINTILLART. The goal of this discussion is to be able to give a progress report on the surgical indications within the framework of a spinal metastatic patient. In a certain number of cases surgery is questionable with the discovery of lesions, because of their extended character, or the extreme malignity of the primitive tumour. In other situations, too many lesions will make surgery disputable. Last case scenario is a recurring tumor, because of its extension, its development, even its neurological complications, will make surgery challenging. All these points in our opinion should be openly discussed. Each session will be followed by a 10 minute discussion

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Vincent Pointillart

Strategy means coordination of techniques and technicians facing a problem in which the solution is unclear and uncertain.

The only secured point is that there is no hope for curing the patient, and thus, his own opinion will have to be included in the decision making process.

Situations in which that question arises are extremely different from one case to the other and we will be able only to give our own guidelines.

In emergency, if a neurologic deficit occurs and increases, the goal is to decompress and limit the surgery to the most limited aggression and then to return to a more comfortable situation to take the proper decisions.

Elements to be taken in account

The vertebrae:

Situation is different according to the type of scattering.

Regional scattering accessible by a single approach ( similar if this scattering is associated to a second localization treatable by an isolated radiotherapy plus vertebroplasty if necessary) which is a situation closed to a single level metastasis, or general diffusion leading to a whole spine metastasis where radiotherapy plus general treatment if any are the only solutions. The schedule for these will be decided according to the risks of fracture or neurologic compression and the pain

The other localizations:

The whole question is about the potential risks induced by these. Bone fracture, brain oedema, hypoxemia, increased bleeding linked to liver incapacity.

The time to obtain a complete map of localizations is usually too long in these situations and therefore clinical situation should guide complementary exams to remain reasonable. When looking at the scoring of the patient with Tokuashi score When having no clinical significance, others metastases should be underscored and compared to the potential risk benefit comparison of surgery. One should not refuse surgery just because of a low Tokuashi grading since some surgeries like a two level cervical corpectomy through an anterior approach induces a minimal “cost” for the patient.

The cancer

Sometimes, the cancer is already known and the strategy has to be decided according to the treatments already done locally and in general (hormonotherapy, chemotherapy…). The primary response to these treatments is usually a good predictive key for the future. Depending on the expectable response to the other therapies, surgery could be the only technique that could help the patient or on the contrary only a second line technique if you may hope a good result from others.

In other cases, the metastases reveal the cancer. If no primary tumor can be easily found, the lesions should be treated first to ensure the best quality of life since it is known that the risk for a short life expectancy is high (same in case of a large lung cancer).

Conclusion In that goal multidisciplinary decision making process is the only way of offering these tools and finding the right order of use.

Participation of the patient in this decision is mandatory.

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Vincent Pointillart

The first part of the answer to this question is easy: when the risk benefit balance is negative !

How to determine elements to be taken in account and what is their specific weight is another question which is unsolved yet.

A first group is easy to determine: those whose problem can be solved with non surgical techniques, i.e. metastases responsive to radiotherapy and if too fragile accessible to vertebroplasty. This group underlines the interest of an early diagnosis through a wide use of MRI. By that mean, diagnosis of metastases is possible at the stage of cell penetration in the cancellous bone, before any kind of destruction. This would not be the case by the use of CT scan, where destruction only can be seen, bone scintigraphy where bone reconstruction is shown or even worse plain X rays where a wide range of destruction can only be shown.

On the contrary, MRI T1 hyposignal and even better STIR sequences allow a secured early diagnosis, opening all ways of treatment before surgery is indicated.

If the primary tumor is known as radio/chemo therapy resistant, surgery will done in better conditions than in emergency facing all major complications.

A second group is also easy to determine: those who won’t get any benefit from surgery. These have a complete thoracic paraplegia, lasting for one day with almost no pain. Hope for neurologic recovery is almost zero, risk for infection, skin problems major and the post op pain will be greater than the preop.

If the pain is important and resists to WHO grade 3 pain killers, fixation can be proposed, risks clearly explained.

For the others, the discussion between all members of the team is the only way to find the most suitable answer, knowing here again that nobody knows clearly what should be done “case by case”.

Each member of the team must give his techniques, risks and benefits and association of methods gives the lowest “price” accessible to the patient.

Oncologist: chemo, radio sensitivity, general situation of the patient, foreseeable life expectancy, other metastases with and without clinical significance,

- Radiotherapist: area having already received radiation (classical situation in breast cancer), spinal cord acceptance for more, risk of increased weakness of the vertebrae just after the radiation.

- Radiologist: completion of check up, risk for bleeding and possibilities of embolization, vertebroplasty possibilities, on which vertebrae and timing of these compared with surgery and radiotherapy.

- General practitioner: he knows ( or should) the patient and his family and will be in charge of the immediate follow up

- Anesthetist: responsible for the pain care of the patient and the anesthetical contraindications.

- Spine surgeon: he knows the possibilities and risks.

Till now, no score exists to balance the Tokuashi score which is rather a score to foresee life expectancy. We need a score of the “cost” of surgery because a simple anterior cervical corpectomy is possible for any kind of patient and this is of course not the case for a long posterior instrumentation.

To us also, the level of denutrition is a good indicator of risk of complications and the value of surgery in these cases.

Conclusion No never, no always, just a discussion in which patient and family have to be included. It may happen that giving up surgery means acceptance of death. If serenity is achieved, it might be the best help we can offer rather than sending the patient for definitive intubation and no words.

Göran Benoni

Introduction. Haemostasis is a vital, complicated process. Many standard orthopaedic operations strain the limits of this process, leading to blood transfusions. The former view is that haemostasis occurs cascade-wise in discrete steps, primary haemostasis followed by coagulation, followed by fibrinolysis. This view has been modified to the insight that although there is a temporal succession of these steps, there is also multiple ante- and retrograde interactions between the various reactions.

The complexity of the haemostatic system also implies individual variance of the effectiveness of haemostasis. Minor haemostatic defects such as mild cases of von Willebrand disease probably occur in several per cent of the population. Furthermore many orthopaedic patients are on medication with ASA, NSAIDs, clopidogrel, antidepressants, warfarin and LMWH, all common drugs which affect haemostasis.

Methods to reduce blood loss. Basal measures include avoidance of hypothermia, appropriate positioning of the patient, appropriate anesthesiological and surgical techniques and if possible discontinuation of unsuitable drugs.

In patients with known haemostatic disorders, substitution of the deficient coagulation factors may improve haemostasis. The same holds true for patients on warfarin medication where substitution with vitamin K, with factors of the vitamin-K dependant complex or with plasma normalizes haemostasis.

Desmopressin stimulates the release of factor VIII and the von Willebrand factor and thus improves platelet function in some subgroups of von Willebrand disease and in platelet dysfunction due to ASA or dextran use. However, the blood-saving effect in patients without these disorders has not been conclusively shown.

In recent years the role of factor VII as a main initiator of coagulation has been stressed. Case reports of effective haemostasis in severe trauma using recombinant factor VII have been published but the experience of its use in orthopaedic surgery is so far limited and the cost is prohibitive for routine use.

During surgery and trauma, the fibrinolytic system is activated with particularly high levels of fibrinolytic markers in the wound. The effect of tranexamic acid, a synthetic fibrinolysis inhibitor has been studied in 17 randomised control trials in knee and hip arthroplasty. The drug significantly reduced blood loss and/or blood transfusion in the majority of these studies. The same findings were reported in 2 studies in spinal surgery.

To exert full effect, tranexamic should be given prophylactically, before the beginning of surgery. In studies at our department, the use of tranexamic acid was highly costeffective as it is significantly cheaper than blood transfusions.

Aprotinin, a protease inhibitor decreasing fibrinolysis has been extensively used in cardiac surgery. It has also been shown to reduce blood loss and blood transfusion in 4 out of 5 RCT:s in major orthopaedic surgery. Neither aprotinin nor tranexamic acid were reported to increase the frequency of postoperative venous thromboembolism.

Fibrin sealant, sprayed onto the wound has also been reported to reduce bleeding in spinal surgery as well as in arthroplasties.

Conclusion It is important to reduce blood loss and the burden of transfusion in orthopaedic surgery. This can be achieved by some simple basal methods as well as by the aid of various drugs to ameliorate haemostasis. At present, tranexamic acid seems to be the most costefficient drug for routine use.

Etienne Pitsaer

The management of autologous blood aims at reducing the need for allogenic transfusion. Blood requirement (autologous and/or allogenic) will depend on the pre-operative red blood cell stock and on the perioperative blood loss. The red cell stock is related to body weight and preoperative haemoglobin (haematocrit) level; it can be calculated accurately, whereas the perioperative blood loss (external and occult) is variable and unpredictable.

Preoperative donation of autologous blood, as well as intraoperative and/or postoperative recuperation and reinfusion of shed blood decrease the risk for allogenic transfusion in total hip replacement (THR) and total knee replacement (TKR) surgery. However, their efficiency and cost effectiveness are not optimal when applied to unselected patients.

Up to 50% of the predonated units of autologous blood are wasted after THR and THK surgery if patients have not been specifically selected to predonate blood.

In hip surgery the volume reinfused after intraoperative blood recuperation obviously depends on intraoperative bleeding; it averages 500 ml in a hip revision operation.

In TKR (with a tourniquet) the volume reinfused after postoperative recuperation depends on the amount of blood drained in the immediate postoperative period, which reflects both the amount of bleeding and the efficiency of the drainage. On average, 500 ml of shed blood with a haematocrit of 35% is reinfused, which increases the haemoglobin level by 1.0 gr/dl on average. The efficiency of this technique is unpredictable, with a wide dispersion of individual values (standard deviation: 208 ml) for the volumes reinfused. However, in patients with a body weight of 70 kg or less, the increase in haemoglobin level was more predictable and averaged 1.23 gr/dl.

In order to improve the efficiency of these two techniques (preoperative autologous blood donation and recuperation/reinfusion of shed blood), patients need to be targeted, taking into account:

- the calculated preoperative (day before surgery) red blood cell stock and the number of units of predonated blood,

- the lowest postoperative haemoglobin and haematocrit level clinically tolerable for that specific patient,

- the expected perioperative blood loss, which depends on such factors as duration of surgery, anticoagulant administration, use of a tourniquet,etc)

As a general rule, a haemoglobin level < 13 gr/dl, age > 65 years and weight < 70 kg all increase the risk to require autologous or allogenic blood transfusion, and would justify planning predonation of blood and/or recuperation/reinfusion of shed blood.

M. Pons F. Alvarez J. Solana R. Viladot

Objective: The objective of this retrospective study is to evaluate our results with proximal closing-wedge osteotomy of first metatarsal for the treatment of hallux valgus with severe intermetatarsal (IM) angle and normal proximal articular set angle (PASA).

Material and methods: We reviewed 110 patients (141 feet) who had been treated by proximal closing-wedge osteotomy of first metatarsal between March-97 and February-04. 87% were women and the mean age was 47.8 years. A single cannulated screw was used for osteotomy fixation in 82% of patients. Additional procedures as phalangeal osteotomy or Keller resection were done when necessary.

Results: With a mean follow-up of 42.3 months, correction of the deformity was good or excellent in 80.5% of cases and fair in 15.4%. Pain due to bunion disappeared in 94.3% of feet. Mean preop IM (angle) was 17.3 and postop was 7.9. Metatarsal-phalangeal angle improved from 42.4 to 15.9. Fusion was achieved in 6.8 weeks (average). Complications were: hypercorrection in 13 feet (2 required reoperation); recurrence of deformity in 10 feet (1 reoperation); central metatarsalgia in 8 feet. Neither infection nor nonunions were observed. Patient satisfaction was excellent or good in 92.7% of patients.

Conclusion: Proximal closing-wedge osteotomy of first metatarsal is a good technique for the treatment of hallux valgus with severe IM angle and normal PASA. It is an easy and reproducible technique with good results, low number of complications and a high rate of patient satisfaction

A. von Campe P. Vienne

Background: Distal metatarsal osteotomy is indicated for correction of mild to low-moderate symptomatic hallux valgus deformity and has shown good to excellent functional and cosmetic results. Original chevron osteotomy and its modifications are the most used distal metatarsal osteotomies. These techniques have limitations for correction of greater deformities.

Objective: To describe a new reversed L-shaped (ReveL) distal metatarsal osteotomy through minimal invasive technique to treat mild to severe hallux valgus deformities and to analyze the functional and cosmetic results of this procedure after at least two years follow-up.

Methods: Between November 2002 and March 2004, a ReveL osteotomy through single medial short approach was performed by 95 patients (120 feet) of an average age of 53 years (range 16 to 79). Overall complications, hallux valgus and I–II intermetatarsal angle corrections were analysed. 28 patients (36 feet) were clinically and radiologically reviewed with a mean follow-up of 33 months (range 25 to 42).

Results: 89% of the patients were satisfied or very satisfied with the cosmetic result. The average AOFAS score increased from 56 points preoperatively to 91 points at mean follow-up. There were no nonunion or avascular necrosis. The mean correction of the hallux valgus angle was 11° and 5 ° for the I–II intermetatarsal angle. There was no significant loss of correction of hallux valgus angle and I–II intermetatarsal angle between first postoperative assessment and follow-up. At least two years after the procedure, the force developped at the forefoot at push-off was still decreased compared to a normal population, particularly on the first metatarsal and on the big toe.

Conclusions: Good and very good functional and cosmetic results were obtained after Revel osteotomy for correction of symptomatic hallux valgus up to 60° of deformity in our series. There was no significant loss of correction after two years follow-up. The reduced forces on the first metatarsal head and on the first toe had no negative influence on the final subjective and objective result.

V. Dhukaram M.G. Hullin

Introduction: A retrospective review was conducted on individuals who have undergone Mitchell osteotomy for mild to moderate hallux valgus deformity. Hallux valgus leads to altered load bearing function of the foot and correction of deformity might result in shortening of the first metatarsal. Transfer metatarsalgia is one of the common postoperative complication. This study aims to look at the restoration of load bearing function of the foot post deformity correction.

Methods: Patients with preoperative intermetatarsal angle of less than 14 degrees were included. Clinical records and radiographs were reviewed. Clinical evaluation done with AOFAS scores and plantar pressures recorded using musgrave system. The foot was divided into 7 regions: first metatarsal head, 2nd & 3rd metatarsal heads, 4th & 5th metatarsal heads, midfoot, heel, hallux and lesser toes. Average pressure, peak pressure distribution and contact time of all seven regions were analysed. A control group of 15 individuals with twenty normal feet were included for comparison. Statistical analysis was done with analysis of variance of the means and Pearson correlation tests.

Results: Seventeen mitchell osteotomy was performed on 13 patients with follow up ranging from 14 to 66 months, a mean of 34 months. Most of our study group were females with an age range of 25 to 71 years, a mean of 53 years. The mean postoperative AOFAS scores were 87 and a median of 90 out of 100. Pedobarograph findings: Statistically significant reduced average pressure, peak pressure and contact time were noted under hallux when compared to the normal control group. The peak pressures were reduced at all forefoot regions but statistically insignificant. Otherwise, the pressure distribution, contact time and center of pressure progression were similar to the normal feet. On analysis of correlation between the parameters observed, reduced pressure distribution under first metatarsal head lead to increased pressures under 4th, 5th metatarsal heads and lesser toes. Significant correlation found between the pressure distribution under hallux and the AOFAS scores, which reveals the outcome of procedure, depends on the load bearing characteristics of hallux and not the first MT head.

Conclusion: Mitchell osteotomy restores the load bearing function of the feet to near normal except hallux, which may affect the outcome of the procedure.

S. Giannini F. Ceccarelli C. Faldini F. Vannini R. Bevoni

Introduction: The main goal of surgical correction of hallux valgus is the morphological and functional rebalance of the first ray and correcting all the characteristics of the deformity. Historically, distal metatarsal osteotomies and SCARF have been indicated in cases of mild or moderate deformity with inter-metatarsal angles up to 20° and are procedures widely used for correction of hallux valgus. The aim of this study is to compare a distal metatarsal osteotomy recently described (SERI) with SCARF osteotomy in a clinical prospective randomised study.

Methods: 20 patients with bilateral hallux valgus similar on both sides regarding clinical and radiographic assessment were included. Clinical evaluation using American Orthopaedic Foot and Ankle Score (AOFAS) and radiographic assessment were considered before surgery up to 2 years follow-up. All patients were operated bilaterally in the same surgical sitting, and received at random SCARF osteotomy on one side, and on the other a SERI osteotomy performed through a 1 cm skin incision under tdirect view control and fixed with one Kirschner wire. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bandage and weight bearing with talus shoes for 30 days.

Results: No statistical differences were observed in preoperative HVA, IMA, DMAA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in SERI (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed uneventfully. At 2 year follow up, no statistical differences were observed in HVA, IMA, DMAA comparing SCARF with SERI. Average AOFAS score was 87±12 in SCARF and 89±10 in SERI (p=0.07).

Conclusions: Both SCARF and SERI techniques proved effective in the correction of hallux valgus, however SERI, performed with a shorter skin incision, in less surgical time, fixed with a cheaper device (one Kirschner wire), resulted in a better clinical outcome.

C. Matzaroglou E. Panagiotopoulos M. Chanos M. Papoutsakis E. Lambiris

Purpose: The evaluation of midterm results of a proposed surgical technique for the correction of hallux valgus deformity.

Material-Methods: Fifty-one female patients with sixty-two hallux valgus deformities were operatively treated between 1997–2002. The average age was 54.9 years and the mean follow up period was 32.7 months. A modified – 90 degrees angled – chevron osteotomy fixed with a Hebert screw was performed in all patients. Concomitant lesser toes abnormalities were managed at the same time. Preoperative, postoperative and last follow up radiographic intermetatarsal (IMA) and hallux valgus (HVA) angles, were measured and compared. Subjective analysis consisting of the AOFAS hallux scale was performed.

Results: The averaged preoperative HVA was 34.1 (range 22–56) and the averaged IMA 15.5 (range 10–29). The corresponding postoperative angles were 14.2 (range 0–28) and 8.1 (range 6–22). The mean AOFAS score was 94.3 (65–100). All the osteotomies were fused and there was not any case of non-union or loosening. Two patients showed late recurrence of the deformity but refused any further treatment.

Conclusions: Hebert screw is a reliable fixation method of the chevron osteotomy for the treatment of hallux valgus. The osteotomy site is firmly secured, avoiding early displacement of the lateral fragment.

S.N. Anjum F. Denolf

In moderate and severe Hallux Valgus metatarsus varus and incongruency of the joints are often important features. Basal osteotomy and distal soft tissue release can often achieve adequate correction of intermetatarsal angle (IMA) and joint alignment.. We retrospectively evaluated the results of Basal Osteotomy in 26 feet in 20 patients between January 1999 and December 2003. American Orthopaedics Foot & Ankle Society Score (AOFAS) was used for assessment. A subjective grading system was used to check patient’s satisfaction. The surgical technique consisted of crescentic basal osteotomy, lateral distal soft tissue release and medial capsular plication according to Roger Mann. Fourteen osteotomies were fixed with K wires that needed second operation to remove them. Barouk Screw was used to fix the osteotomy in 12 feet. Patients were mobilised in High heeled shoe postoperatively. Average age was 55.2 years and average follow-up was 25.8 months. The average preoperative Hallux Valgus Angle (HVA) and IMA were 37.38° and 17.27° respectively. At follow-up the HVA and IMA averaged 13.3° and 6.4° respectively. Sixteen feet had incongruent joint preoperatively that became congruent after surgery. In 25 feet sesamoid position improved after surgery. Average AOFAS score was 88.8. 94% patients were highly satisfied and graded their results as good to excellent. One patient had AOFAS score of < 50 due to her generalised poly-arthralgia and osteoporosis. K wire was broken across the TMT joint in one case and needed removal under GA. This lead to change of our practice as we started using Barouk screw to fix the osteotomy. Other complications consisted of decreased sensations over medial side of toe in three and mild metatarsalgia in one foot. Basal osteotomies with distal soft tissue release in the treatment of Hallux valgus give good correction of the deformity and high patient satisfaction. Barouk screw provides stable fixation.

R. Radl A. Leithner M. Zacherl U. Lackner J. Egger R. Windhager

We conducted a prospective clinical study to determine the influence of personality traits on the subjective outcome of operative hallux valgus correction. The surgical technique used in all patients was the chevron osteotomy. Preoperatively, personality traits were evaluated by means of the Freiburg Personality Inventory (FPI-R). 42 patients (38 female, 4 male) could be enrolled in the analysis. The mean age of the patients at the time of operation was 48.3 years (20 to 70). Three months postoperatively 37 patients were satisfied, and 5 patients were not satisfied with the operative procedure. The comparison of the two groups (satisfied and dissatisfied patients) revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angles were 12.2° ± 7.8 and 13.4° ± 8.3 (p=0.74), and the first-second intermetatarsal angles were 7.4° ± 2.5 and 7.6° ± 4 (p=0.89) in the two groups. The results of the current study suggest that the patient’s subjective result after the operative hallux valgus correction is influenced by some individual personality profiles.

R. Kolundzic M. Madjarevic I. Smigovec D. Matek T. Cuti

Aims: The aim of the study is to present early results in the treatment of hallux valgus with a new 3D subcapital metatarsal osteotomy, based on a original Wilson osteotomy. 3D subcapital metatarsal osteotomy is a simple and fast procedure where we shift capitis of metatarsal bone to lateral and plantar, and fix with K-wire.

Materials and methods: In the period from 1997 to 2003, 25 patients (all females) and 34 feet were operated. The patients were followed up from 1 to 7 years. The age of the patients varied from 33 up to 60 years (median value – 45 years of age). Indications for the corrective metatarsal osteotomy were the angle of hallux valgus more than 20 degrees, intermetatarsal angle more than 20 degrees as well as pain due to shoe pressure over the medial side of metatarsophalangeal joint, and aesthetic reasons. In this study all feet were evaluated (radiological, clinical and subjective evaluation).

Results: The angle of hallux valgus was 20 to 50 degrees (mean value – 32.3 degrees) preoperatively, and dropped to 2 to 35 (mean value – 12.47 degrees) postoperatively. Intermetatarsal angle was 10 to 22 (mean value – 15 degrees) before operation, and 3 to 15 degrees (mean value 5 degrees) after operation. The DMA angle was 0 to 30 (mean value – 15 degrees) before operation, and 0 to 20 degrees (mean value – 20 degrees) afterwards. Shortening of first metatarsal bone was 1 to 8 mm (mean – 3 mm). We did not have any complications.

Conclusion: Early results of this study show that new 3D subcapital metatarsal osteotomy in treatment of hallux valgus is a good method. It is necessary to follow strict and precise criteria in the indication of operative procedure in treating hallux valgus. The procedure itself is simple and fast.

M. Madjarevic R. Kolundzic D. Matek I. Smigovec T. Cuti

Aims: The aim of the study is to present later results in the treatment of hallux valgus with Austin corrective metatarsal osteotomy.

Materials and methods: In the period from 1982 to 1991, 238 patients (230 females and 8 males) and 380 feet were operated. The patients were followed up from 11 to 20 years. The age of the patients varied from 40 up to 60 years (the median value of around 46 years of age). Indications for the Austin corrective metatarsal osteotomy were the angle of hallux valgus more than 20 degrees, intermetatarsal angle more than 10 degrees as well as pain due to shoe pressure over the medial side of metatarsophalangeal joint and aesthetic reasons. In this study, 130 patients and 230 feet were evaluated (radiological, clinical and subjective evaluation).

Results: The angle of hallux valgus was 20 to 52 degrees (mean value – 34.5 degrees) before operation, and 8 to 36 degrees after operation (mean value – 16.1 degrees). Intermetatarsal angle was 10 to 25 (mean value – 15 degrees) before operation and 7 to 22 degrees (mean value – 8 degrees) after operation. Shortening of first metatarsal bone was 2 to 6 mm (mean value – 3 mm)

Conclusion: The study shows that Austin corrective metatarsal osteotomy in treatment of hallux valgus is a good method if strict and precise criteria are closely followed in the indication of operative procedure in treating hallux valgus, especially with middle-aged patients.

G. Cakmak C. Gokhan K. Ulunay K. Baris Y. Haluk B. Selcuk

Aim: The PASA (proximal articular surface angle) is a very useful measurement of the hallux metatarsal articular orientation for the preoperative evaluation and the selection of the surgical procedure. The measurement of PASA is found to be dependent mostly to the evaluator. The spatial orientation of the hallux can affect the measurement of PASA. In this study we try to evaluate the effect of pronation and the inclination of the first metatarsal on the measurement of PASA in 10 cadaver first metatarsals.

Material and Methods: The study is made on 10 cadaver first metatarsals. The metatarsals are fixed to a device. The metatarsal inclination and pronation of the metatarsal can be changed by this device. 15-30-45 degrees inclination and 0-10-20 degrees pronation are applied to the metatarsals. After applying radio opaque putty to the medial and lateral articular edges; metatarsal dorsal diaphysial ridge, the x-ray and digital images are taken at different degrees of inclination and pronation. The measurement of PASA is done by graphic software on computer. The statistical analysis is performed by paired sample T-test.

Results: We found that changing the inclination has no effect on PASA (p> 0.1). The pronation of first metatarsal has found to have a positive effect on PASA (p< 0.005). As the degree of pronation increases, the degree of PASA is found to be increased also. No difference was found between the measurements of x-ray and digital photography images.

Discussion: Inclination of the first metatarsal can change depending on the height of the medial longitudinal arch. By this experimental study we tried to simulate the pes cavus and pes planus deformity on the radiologic measurement of the hallux by modifying the inclination and pronation of the first metatarsal. According to the current study, inclination has no effect on measurement of PASA. Pronation of the first metatarsal accompanies some hallux deformities. As pronation influences the measurement of PASA, the current data suggests that the measurement of PASA is not suitable for making clinical and surgical decisions.

D. Mittal S. Rajá J.V. Mehta

Aims Pedobarography has improved the understanding of load transmission in hallux valgus. The aim of this study is to evaluate Pedobarography in Modified McBride procedure which transfers the deforming of adductor hallucis into a correcting force on the first metatarsal neck. Material and Methods Nineteen patients with 27 feet in total who underwent this procedure were included in this study. Average age was 49 yrs (range 28 – 73). Average follow up was 7 months (range 6–14 months). Pedobarography was performed before and after the operation using EMED SFX 6 system to record the contact area, total force, peak pressures and contact time for total foot, great toe and areas of foot medial to gait line. Results Pedobarographic measurements showed a statistically significant improvement in the contact area of the great toe 7.4 cm preoperatively to 8.7 cm postoperatively (17.5%, p < 0.001) and reduction in peak pressures of the great toe from 67.5 N/cm to 48 N/cm (29%, p < 0.001) and the total foot from 89 N/cm to 82 N/cm (8% p < 0.05). Conclusion We conclude that Pedobarography demonstrates the normalisation of forces in the foot following Modified McBride Procedure.

S.E. Varitimidis L.A. Poultsides Z. Dailiana A. Passias E. Kitsiopoulou K.N. Malizos

Introduction: Surgery in the foot and ankle is usually performed under general or spinal anaesthesia. Peripheral nerve blocking is gaining the preference of both surgeons and patients. The aim of this study is to evaluate the adequacy of anaesthesia with the method of triple nerve blocking at the region of the knee.

Materials and methods: One hundred and forty-four patients (79 men and 65 women) that were diagnosed with ankle and foot injuries or diseases underwent surgery using triple nerve blocking at the knee region as a method of anaesthesia. Surgical procedures included bone and soft tissue procedures and especially fracture fixation, osteotomies, tendon repairs, neuroma and tumor excisions, nerve decompressions and arthrodeses. The common peroneal, tibial and saphenous nerves were blocked with injection of 8 ml ropivacaine 2% for each nerve. The injection was performed by an Orthopaedic surgeon with the use of a neurostimulator. An anesthesiologist was available when necessary.

Results: Ninety-four patients tolerated the procedure without the need of additional injection of anaesthesia or analgesia. In 45 patients additional injection of local anesthetic was necessary. Five patients needed intravenous injection of analgesia in order to complete the procedure. Patients were mobilized the day of surgery, reducing in that way hospital stay. Hospitalization ranged from 0 to 1 days with 58 patients discharged the day of the operation. No complication related to the injection of the anestheric was observed.

Conclusion: Triple nerve blocking at the knee, as a method of anaesthesia, is proposed for certain procedures in the foot and ankle; it allows early mobilization of patients and reduces length of hospital stay. If the neurostimulator is used appropriately, the rate of patients that needs additional analgesia intraoperatively is diminished and no adverse effects of the local anestheric are observed. Complications observed with the practice of spinal or general anesthesia are avoided.

M. Knupp O. Magerkurth H. Ledermann B. Hintermann

Introduction: Realigning the foot and good ligament balancing have been recognized to be the mainstay for successful reconstruction of complex hindfoot disorders and deformities. This is particularly true for posttraumatic conditions, where deformities and scarring might be the underlying cause of foot dysfunction. For surgical reconstruction, i.e. osteotomies, arthrodeses and total ankle replacement, references are needed for restoration of the anatomy and the function. Most surprisingly to date no data is available regarding dimensions on standard X-rays of the hindfoot. The purpose of this prospective study therefore was 1) to define relevant and reproducible measures on lateral hindfoot X-rays and 2) to assess their reliability.

Methods: 100 lateral view X-rays were taken. Dimensions assessed were the talar area covered by the tibia, the angle of the distal tibial joint plane to the tibial axis (tilt), the width of the tibia on the joint level, the height of the talus, the joint radius of the ankle joint and the offset of the centre of rotation from the tibial axis.

Results: The tibial coverage of the talus was 88.1 degrees (SD = 0.36), the angle of the distal tibial joint plane to the tibial axis (tilt) was 83 degrees (SD 3.6), the width of the distal tibia 33.6 mm (SD = 2.4), the radius of the ankle joint 18.6 mm (SD = 4.0) with an anterior offset of the centre of rotation of 1.7 mm and the height of the talus was 28.2 mm (SD = 2.1).

Conclusions: In case of symptomatic deformity any reconstruction, i.e. correcting osteotomies, ligament reconstruction, arthrodeses or arthroplasty, should aim to correct the foot in a physiological way; respecting the original dimensions of the hindfoot to achieve maximal benefit. Anterior-posterior translation of the talus may be a source of pain, restriction of motion and a cause of degenerative joint disease because of eccentric joint loading. This is also true for the height of the talus, which may have a significant impact on the hindfoot physiology. To achieve good biomechanical function, the positioning of the talus in relation to the tibia needs to be planned carefully prior to surgery. Poor coverage of the talus by the tibia and too much tilt of the distal tibia lead to higher joint forces and may be the cause of instability. Surgical procedures may fail if this is not recognized preoperatively. Several easily accessible measures on X-rays were found to be reliable to describe the hind-foot, as only small variation was found on the evaluated X-rays. If reconstruction of the hindfoot is required, care should be taken to identify the physiological joint geometry.

S. Rohit A. Kolita A. Zubairy

Background: Postoperative pain following forefoot surgery can be difficult to control with oral analgesia so regional analgesic methods have become more prominent in foot and ankle surgery. The effects of ankle and popliteal blocks performed separately have been well described in the literature but we have not found any study that looks at the combined effects of the two procedures. It is the aim of this study to evaluate the efficacy of a combination of these blocks and decide if they provide significantly better postoperative analgesia than ankle block alone in forefoot surgery.

Methods: This is an ongoing prospective, randomised, controlled and single blind study. Proposed end-point should be reached in 3 months. The total number of patients to be included will be 60, with 30 in ankle block only group (control) and 30 in ankle and popliteal blocks group. All patients are to undergo forefoot surgery. Postoperative pain is evaluated in the form of a visual analogue scale and verbal response form. Evaluations take place four times for each patient: in the recovery room, 6 hours postoperatively, 24 hours postoperatively and on discharge. The pain assessor, who helps the patient complete the pain evaluation forms, is blinded to the number of blocks used. The amount of opiate analgesia required whilst as an inpatient will also be recorded. On discharge the patient is asked to rate their satisfaction with the pain experienced during their hospital stay. Results will be analysed using paired Students t test.

Results: Early results are showing that combined ankle and popliteal blocks provide better analgesic effect than ankle block alone. This is shown both in the patient response forms and also in reduced amounts of opiate analgesia required. Further discussion of the results and conclusions will be drawn once the study has been completed.

L. Gerdesmeyer M. Henne J. Vesters

Purpose: To determine the effectiveness of rESWT for chronic plantar heel pain.

Materials and methods: 70 patients were enrolled and randomly assigned to either active or placebo treatment. 2000 shock waves per session and 3 sessions were applied, interval of 2 weeks. The primary efficacy criteria were subjective outcome on Visual Analogue Scale (VAS) and Roles- and Maudsley-Score. The primary study endpoint was 12 weeks. Nonparametric procedures have been used for teststatistical analyses. In addition to P-values, results have been presented by means of Mann-Whitney estimators as nonparametric effect sizes and their one-sided 97.5% confidence intervals as required by the ICH E9 Guideline ( Exact Wilcoxon-Mann-Whitney test, ï ¡ = 0.025 one-sided)

Results: 62 patients could be examined 12 weeks after rESWT. Drop out rate 12%. Significant decrease in pain sensation could be found in the active group (p< 0, 001). The VAS decreased from 7.1 (+/− 1,6) to 3.6 (+/− 2,3). Placebo group showed slight improvement from 6.7 (+/−1,8) to 5.9 (+/− 2,2). The effect size (Mann-Whitney) denotes a large superiority of the rESWT group (MW = 0.72). The lower bound of the asymptotic one-sided 97.5% confidence interval denotes superiority of the test group (LB-CI = 0.58). The results scored on Roles- and Maudsley-Score showed similar improvement. Only minor side effects as petechial bleeding and swelling were detected.

Conclusion: The radial shock wave therapy is effective and save in treatment of chronic heel pain.

R. Simpson A. Zarugh N.M. Shaath

Introduction: We present the results of a prospective randomized trial of Zadik’s procedure V. chemical ablation by sodium hydroxide for the treatment of ingrowing toenails.

Materials and Methods: Thirty eight patients had Zadik’s procedure, 45 patients had chemical ablation by sodium hydroxide. Mean average follow-up was 12.45 months for Zadik’s group and 11.69 months for the chemical group.

Results: We have studied 5 end points: 1/return to normal shoe wear. In Zadik’s group, the average return to normal shoe wear was 2.13 weeks and 3.73 weeks in the chemical group. 2/average return to normal activity was 2.18 weeks for Zadik’s group and 3.89 for the chemical group. 3/the median numbers of dressings were 3 and 8 for Zadik’s and chemical ablation patients respectively. 4/the pain score, using the visual analogue, were not statistically significant between the two groups. 5/the recurrence rate, 23 recurrences in Zadik’s group (60.5%) and seven recurrences in chemical ablation group (15.6%). However, only 13 patients had symptomatic recurrence (34.2%) in the Zadik group and two patients had recurrence in the chemical ablation group (4.4%).

Conclusion: The use of chemical ablation by sodium hydroxide in the treatment of ingrowing toenails shows statistically significant reduction in the recurrence rate of ingrowing toenails compared to Zadik’s procedure (P< 0.05). Key words: Ingrowing toe nails, Zadik’s, Chemical ablation.

T. Mulier G. Dereymaeker

Introduction: In spite of the common occurrence of hallux valgus deformity and the multiple corrective procedures that have been proposed, only few studies have been published about the anatomy of this joint. None of these studies mention the existence of a meniscal structure in the first MTP joint. The fact that this structure is often seen during bunion surgery evoked this study.

Material and methods: A hunderd and two human cadaveric feet were dissected primarly to study the anatomy of the first metatarsophalangeal (MTP) joint. The anatomical findings on the specimens were correlated with clinical findings on 100 consecutive hallux valgus procedures. Particular attention was paid to the localization and histology of this meniscal structure. Based on this study, possible associations between the presence of this structure and the pathophysiology of the hallux valgus deformity and chondral lesions are proposed.

Results: A meniscal structure was present in 19 percent of the cadavers. A striking negative correlation is found between the presence of a meniscus and the extent of chondral lesions (P < 0.05). The presence of the meniscus was higher in cadavers with hallux valgus deformity (33%), however no significant correlation is found between the occurrence of hallux valgus deformity and the presence of this meniscus (P = 0.2). In our clinical study this meniscus was seen in 40% and was particularly high in younger patients with mild -painful-bunions.

Conclusions: The presence of this meniscal structure seems to stabilize the MTP joint, preventing hallux valgus (or rotational ) deformities. Once the rotational deformity increases the meniscus tears becomes painful and slips into the joint. In the more advanced hallux valgus deformity this meniscus plays little function and seems to disappear, leading to arthrosis.

H.-J. Kock M. Serly C. Jacobs Ch. Niewoehner St. von Gumppeneberg

To reduce both operative trauma and wound length in plate osteosynthesis of dislocated WEBER type B fractures of the distal fibula we started using 3 hole one-third tubular „anti-glide“ AO plates in 1996 instead of longer implants.

From 1996 to 2001 a total of 72 patients with isolated WEBER type B fractures were treated operatively by using 3 hole one-third „anti-glide“ AO plates. A clinical and radiographic follow-up examination was performed after 38.6 [18–63] months using the original WEBER score. The statistical method to compare our results with previous investigations was Chi-Square-Test according to Pearson (p=0.05).

67 (93.1%) of all patients were without complaints while 3 (4.2%) complained about exercise induced pain and 2 (2.7) reported rest pain. 69 (95.8%) patients showed identical ranges of ankle joint movement, whereas 3 (4.2%) patients had minimal loss of joint function. Radiographically perfect joint configurations were seen in 69 patients while 3 (4.2%)showed grade 1 arthrosis according to BARGON. A total of 68 (94.4%) patients showed very good (n=50) or good (n=18) results according to Weber. In 4 cases the result was not satisfying. This was not significantly different from other investigations with longer implants, but scar length was reduced and duration of after-treatment was signifcantly faster than treatment with longer implants (p< 0.05).

It is concluded that operative stabilisation of isolated Weber type B ankle fractures with 3 hole dorsal „anti-glide“ AO plates can be recommended as a safe, convenient, cost-effective and simple alternative to the use of longer implants.

G. Kuropatkin V.G. Drjagin B.S. Minasov

Aim: The pylon tibial fractures are a challenge for the orthopaedic surgeons. The purpose of this study was comparative analysis of different surgical methods of the pylon fractures.

Methods: From 1994 to 2003 143 pylon fractures were treated. There were 87 men and 56 women from 15 to 74 years old. In 45 cases we used only external fixation (Ilizarov apparatus), in 29 open reduction and screw fixation was combined with external fixations. Sixty eight fractures were treated by ORIF according AO principles. In 51 cases “clover leaf” and 1/3 tubular plates were used, in 18 cases stable fixation was realized by LCP-plates. Follow-up results were analyzed through 9 and 12 months.

Results: The good and excellent results (no pain, deformities and good function) were received in 72,7% patients, the satisfactory results – at 23,8 % cases. In 9 patients the superficial and in 4 the deep wound infection took place. The best results are received in cases of Locking Compression Plate (LCP) application.

Conclusions: Full restoration of axis and articular surface (with or without bone grafting), stable fixation and early mobilization of the joint is essential in successful treatment of pylon fractures. Indirect reduction and external fixation can be applied only in A and B1-type of fractures. At types B2,3 and C good results can be received only at use of a stable internal osteosynthesis.

G. Matricali P. Coeman G. Dereymaeker

Objective: to investigate the long-term clinical and radiological outcome of talar avascular necrosis after treatment by a patellar-tendon bearing brace (PTB), and if parameters predictive for a positive or negative outcome could be identified.

Patients and methods: 21 patients were reviewed retrospectively, 10 had a non-traumatic origin and 11 a traumatic one (groups comparable to gender and age). Mean follow-up was 5,5 and 6,3 years, respectively; mean use of the PTB was 17,2 and 14,8 months. Clinical outcome was assessed by the Mazur scale and the Kitaoka score for function, and a VAS for pain and subjective satisfaction; radiological outcome by the Ficat & Arlet classification and by the Kellgren scale. Clinical parameters were analysed for their positive or negative predictive value on outcome.

Results: A very early pain control was achieved in both groups (2.1 versus 1.9 weeks). On both the Mazur scale and the Kitaoka score the non-traumatic group scored lower as the posttraumatic group (66,3 versus 77,6 and 76.1 versus 78.1). Both VAS were similar in both groups: 3,1 and 3,6 for pain and 6,8 and 7,1 for satisfaction. The need for analgesic medication was slightly higher in the non-traumatic group: 4 versus 3 patients. Radiologically both groups showed a similar outcome with both evaluation systems. Older age, delay in treatment, corticosteroids, alcohol, hyperlipidaemia and female gender were identified as negative predictive parameters.

Conclusions: A PTB is an efficient treatment for talar avascular necrosis of both non-traumatic and traumatic origin. Clinical outcome is better in the posttraumatic group, although radiological outcome is comparable. Only negative predictive parameters could be identified.

S Giannini R. Buda F. Vannini B. Grigolo M.V. Filippi

Introduction Osteochondral lesions of the talus are a common occurrence especially in sports injuries. The biomechanical nature of the ankle joint makes it susceptible to sprains which can cause damage not only to the capsulo-ligamentous structures, but also to the joint cartilage and subchondral bone. As it is known, joint cartilage is a highly specialized and multitask tissue. Because joint cartilage has poor reparative capability, damage may be irreversible and as a consequence, can also lead to osteoarthritis. The purpose of this study is to review the results of a series of patients treated with autologous chondrocytes implantation (A.C.I.) and to describe the evolution in surgical technique that we have been implemented in the last 8 years.

Methods Thirty-nine patients with a mean age of 27 8 years affected by osteochondral lesions of the talus > 1.5 cm2, were treated by autologous chondrocyte implantation. All patients were checked clinically and by MRI up to 4 years follow-up. The first 9 patients received the ACI by open technique and the remaining 30, arthroscopically. In the last 10 patients the cartilage harvested from the detached osteochondral fragment was used for the colture. All patients were checked clinically (AOFAS score), radiographically and by MRI, before surgery, at 12 months and at follow-up. Eleven patients underwent a second arthroscopy with a bioptic cartilage harvest at 1 year follow-up. Samples were stained with Safranin-O and Alcian Blue. Immunohistochemical analysis for collagen type II was also performed

Results Before surgery the mean score was 48.4 17 points, at 12 months 90.9 12 (p< 0.0005), while at follow up was 93.8 8 (p< 0.0005) demonstrating an improvement over time. The histological and immunohistological analyses performed on the cartilage samples using Safranin-O, Alcian Blue staining and anti-human collagen type II antibody respectively showed a typical cartilage morphology, were positive for collagen type II and for proteoglycans expression.

Conclusions The clinical and histological results have confirmed the validity of the technique utilized, with laboratory data confirming the newly formed cartilage was of hyaline type for all the cases evaluated.

B.Y. Ng V.K.Y. Soong B. Sankar I. Siddique M.P. Maguire R. Mohil A.A. Henderson

Purpose: To evaluate the objective outcomes in patients who had undergone hardware removal after ORIF of calcaneus fractures.

Materials and Methods: Between 1994 and 2002, 31 cases of hardware removal was performed in 30 patients (25 male, 5 female) with an average age at operation of 47 years (31 to 65 years) were reviewed. Patients’ demographic details were recorded including smoking habit. Fracture patterns were graded according to the Sanders’ classification with preoperative CT scans. The clinical result was assessed using Bristol hind foot scoring system. Serial radiographs assessments were also recorded.

Results: Average follow-up was 4.5 years. Average delay from time of injury to surgery was 12.4 days (range 5 to 24 days). 7 (23%)fractures were Sanders’ type 2A, 8 (26%)fractures were type 2B, 6 (19%)fractures were type 2C, 2 (6%) fractures were type 3AB and 8 (26%) fractures were type 3AC. Average time from surgery to hardware removal was 27 months (range 11 to 45 months). There were 16 smokers and 14 non-smokers. There were 5 deep infections and 3 superficial wound infections after ORIF of calcaneus fractures. 84% of the patients shown objective improvement following hardware removal at the latest follow-up. 2 patients had unsuccessful hardware removal due to dense scarring. No wound infections were recorded. Smoking habit had no significant bearing on the objective outcome improvement following hardware removal (p= 0.891), time from surgery to hardware removal (p=0.53) and wound morbidity (p= 0.4882). Objective improvement showed a statistically significant improvement in the Sanders’ type 2 compared with Sanders’ type 3 (p=0.015).

Conclusion: Removal of hardware is justified in symptomatic patients following ORIF calcaneus fractures. It results in an improved objective outcome and has a low complication rate. Hardware removal may be considered in cases of Sanders’ type 2 calcaneus fractures which are refractory to improvement.

R. Thakral K. Kaar P. McHugh W. Brennan S. Lalor

Abstract: A study on cadaver ankles was performed; two methods of ‘Danis-Weber type B’ lateral malleolar fracture fixation were compared.

Materials and Method: Ten ankles from five female cadavers were used. The distal fibulae were osteotomised at the level of the syndesmosis with a saw and the fracture fixations were divided into two groups. In Group I, the fractures were fixed with traditional antero-posterior cortical screws and in Group II, the contra lateral fractures from the same cadaver were fixed with postero-anterior cortical screws. The distal fibulae in both groups were subjected to biomechanical compression and torsion forces and the force at which the fixation gave way was recorded.

Results: In the former group the breaking force was significantly lower than that required in the latter group by a mean of 0.4 kN.

In conclusion, the fixation done in Group II was found to be biomechanically more stable.

E. Vasiliadis V.D. Polyzois K. Gatos S. Dangas G. Koufopoulos D. Polyzois

Aim: To evaluate the results of management of Char-cot foot and ankle deformities by the use of the Ilizarov apparatus.

Material-Method: This is a retrospective study of 11 cases (9 patients) aged from 39 to 60 years old (mean 44 years), all suffering from Charcot foot neuroarthropathy. All cases showed established midfoot breakdown. In four cases hindfoot deformity coexisted. Three feet were ulcerated. In six cases the Iizarov frame was applied using complex hinges and closed compression fusions were performed, utilizing the bent wire technique. In five cases the correction of the deformities was performed acutely with the use of percutaneous cannulated screws. In the later cases the Ilizarov frame neutralized the former osteosynthesis method. The Ilizarov device remained attached for 8 weeks, regardless the presence of other osteosynthesis hardware. The Maryland Foot score (MFS) was utilized for objective assessment by the physician and the SF-36 questionaire for subjective assessment by the patient.

Results: A statistically significant improvement in MFS and SF-36 score was recorded. In all cases the aim for a stable and painless extremity was achieved. All patients returned to their previous activities and kept using normal shoe wear.

Conclusions: A lot of references are found in the literature describing failure in the treatment of Charcot foot deformity with the use of internal fixation. This is justified by the poor bone quality and decreased bone density of the diabetic and alcoholic patients. The use of tensioned wires in multiple levels provides adequate fixation in cases where a frame is used solely and safe neutralization where a frame is combined with internal fixation.

A.D. Mendonca T.D.A. Cosker N.K. Makwana

Aims: The aims of this study were to 1) determine if vacuum assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, 2) if it helps debride wounds and 3) if it prevents the need for further surgery

Materials and Methods: 15 patients were reviewed, average age 49.3yrs at an average of 6.3 months (1–18months). Ten patients had diabetes (8 IDDM) with 5 patients having grade 3 ulcers (Wagner-Meggitt). All wounds were surgically debrided prior to the application of the VAC therapy. The VAC therapy was applied according to the manufacturers instrucrtions. The main outcome measures were 1) time to satisfactory wound closure 2) change in the wound surface area and 3) need for further surgery

Results: Satisfactory healing was achieved in 11 patients (73.3%). 10 were diabetic, 5 patients had peripheral vascular disease and 5 patients had both. The time to satisfactory healing was 2.5 months, average 1–6 months. The average size of the wound ulcer was 7.41cm2 (2–10cm2) prior to treatment and 1.58cm2 (0–2cm2) following treatment in an average of 2.5 months. VAC therapy helped debride all non healing wounds following surgical debridement. In 10 patients, the need for further radical surgery, namely amputation, was avoided.

Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes with or without periphearl vascular disease. Its use in foot and ankle surgery leads to a quick wound closure and in some cases avoids the need for further surgery with a potential for limb salvage.

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

Aims: Neuregenic osteoarthropathy often results in a deformity of the foot needing surgical intervention. Indications for surgery are reulcerations, deep infections and decompensation of the static structure of the foot architecture. External fixation is a promising technique for correction.

Methods: Between 1997 and 2003, 65 feet which could be examined retrospectively, were operated for neuroarthropathy in 21 women and 43 men. A diabetic polyneuropathy was present in 56 patients. In 59 cases, an external fixation was used while in nine cases Steinmann pins were used. Follow-up treatment consisted of mobilisation in a ankle-foot-orthosis (AFO) for up to a year.

Results: For diabetics, the mean duration of the disease was 24.8 years (Type 1) and 13.7 years (Type 2). All feet were at a stage 3 or 4 according to Levin and were classified as types II–V according to Sanders. In five cases there was luxation alone was observed, another nine cases exhibited a combination of luxation and osseous changes. Surgical revision was necessary in seven cases, sometimes repeatedly. As the illness progressed additional operations were necessary in 13 times. It became necessary in six cases due to loss of correction. The fitting of a prosthesis was necessary in two patients (three feet) following amputation. The mean duration was 752 days. Pin infections and disturbances in wound healing were commonly observed but could be treated successfully by conservative means. The occurrence of this complication was independent of previous ulcerations or infections. Within the first year after operation, 13.9% of the feet developed an ulcer. All of the patients could be mobilised with the help of an orthosis (47 cases) or orthopedic shoes (15 cases)

Conclusions: External fixation is a suitable and variable method for correcting malalignment of the foot in cases of neuroarthropathy. It has a low complication rate and can be used for rapidly developing as well as non-progressing osteoarthropathies. In general, a fibrous ankylosis is the result of treatment, which allows pain free mobilisation under full whight bearing. In suitable cases, with a good alignment of the foot and good patient cooperation, the use of the AFO can be changed to orthopedic shoes after about 12 months.

S. Atesalp D. Bek B. Demiralp B Kilic

The purpose of this paper is to report on the use of a tendon transfer (anterior tibial to midfoot) to correct dynamic foot and ankle varus deformity. Anterior tibial tendon transfer to mid-foot is useful to consider in planning treatment where there is a need to rebalance a foot in which the unopposed or weakly opposed anterior tibial causes the abnormal varus position of the foot and ankle. 12 patients, 22 feet had anterior tibial tendon transfers performed. 10 were bilateral. 10 patients had neuromuscular disease as the underlying cause for the foot imbalance, 1 patient had idiopathic clubfoot with residual, recalcitrant varus after earlier posteromedial release and 1 patient was hemiplegic secondary to stroke caused by encephalopathy. Age of the patients at the time of their initial procedure(s) ranged from 2 to 34. There was at least 1 year follow-up after each procedure for the patient to be entered into this study. A 1-grade functional loss was encountered following tendon transfer of anterior tibial muscles grading between 4–5. (4=good, 5=being normal). The transferred muscles allowed the dynamic varus deformity to be removed and the foot to become plantigrade. In its transferred position, it functioned to actively contract and contributed to give support of the ankle. After an initial period of cast use post-operatively and bracing for 6 months to support the transfer, continued use of AFO was no longer necessary. Anterior tibial tendon transfer to mid-foot, originally described by Garceau continues to be an useful method for rebalancing a foot in which the abnormal pull of the normal or almost normal functioning anterior tibial muscle. This muscle is unopposed or weakly opposed because of the underlying neuromuscular disorder or previous surgery. Thus, it causes the foot and ankle to turn into varus. The technique used is straightforward and simple. It is a useful procedure to consider when rebalancing a foot may be needed.

M. Galli L. Mancini D. Pitocco V. Ruotolo M. Vasso G. Ghirlanda

Aim: Evaluation of multifactorial treatment of Charcot foot disease in diabetic patients

Materials and Method: We followed 25 diabetic patients with Charcot foot in acute phase (Eichenholtz Stage I) from 2001 to 2003 (mean follow-up 22 months) admitted to the Day Hospital of Diabetology of the Catholic University of Rome. All patients presented a good vascularization (ABI > 0.9) and osteomielytis was excluded by means of 111Indium labelled leukocyte scintigraphy.

Six patients presented a structural derangement localized to the forefoot (Pattern I according to Sanders and Frykberg Classification), one to the ankle (Pattern IV) and 18 to the mid-foot region (Pattern II and III). At first clinical evaluation, 13 patients presented a plantar monolateral ulcer. Their treatment was multifactorial. An offloading regimen was adopted, with the use of a total contact cast and crutches, in order to avoid weight-bearing on the affected foot for the first two months. Patients responsive to the treatment were successively treated with a pneumatic cast (Air cast) and partial weight-bearing for another four months. Four unresponsive patients underwent surgical treatment. 10 patients were also treated with alendronate (70 mg per os once a week). Three patients died during treatment and one during the follow-up, three of them for cardiovascular disease, one for bronchopneumopathy.

Results: All patients reached the quiescent or chronic phase (Eichenholtz Stage III) at an average of six months from the onset of the treatment (range 3 to 9 months). No major or minor amputation was performed. Multifactorial treatment prevented the development ulcers in all patients that started the treatment without this complication (12 patients). 7 out of 13 ulcerated patients developed a recalcitrant ulcer (unresponsive to medical and orthotic treatment). 4 patients underwent surgical treatment: midfoot arthrodesis with Ilizarov external fixation (2 patients), rockerbottom deformity resection (one patient), Lelievre realignment (one patient). 3 patients healed after surgical treatment. Thus an overall amount of 9 out of 13 ulcerated patients healed after multifactorial treatment.

Conclusions: Multifactorial treatment demonstrated effective in the management of Charcot foot in diabetic patients. Medical and orthotic treatment alone is effective in preventing complication throughout the natural history of the disease. Medical and orthotic treatment alone is frequently unsuccessful in treating plantar ulcers when major deformities has already developed. Medical and orthotic treatment combined with surgical treatment demonstrated an increased percentage of success.

O. Frank M. Horisberger B. Hintermann

Introduction: Posttraumatic osteoarthritis of the ankle joint usually occurs secondary to an intraarticular fracture of the weight bearing ankle joint. The question whether also recurrent ankle sprain and /or chronic instability alone can cause this entity, is, however, still a question to debate. The aim of this retrospective study was, therefore, to analyse the history and findings of a consecutive series of patients that were treated for post-traumatic end-stage osteoarthrosis of the ankle.

Methods: The complete database (including physical exam, standard radiographs, patient questionnaire and AOFAS hindfoot score) of all patients was analysed.

Results: Out of 268 patients (females, 135 patients; males, 133) 221 (82.5%) had had a fracture (Fx) and 47 (17.5%) suffered from chronic ankle instability with recurrent sprains (but did not have a fracture). The latter group could be subdivided into 29 (10.8%) patients with recurrent sprains (RS) and 10 (6.7%) patients with only a single sprain (SS). The mean (range) delay between primary trauma and surgical treatment for endstage osteoarthritis was 21.1 (1–58) months for Fx, 37.07 (1–61) months for RS and 22.5 (5–48) months for SS.

Conclusion: Obviously, not only fractures, but also severe sprains and /or chronic instability play an important role as a cause of end stage osteaorthrosis of the ankle joint. The obtained results suggest that a single severe sprain (dislocation) can cause similar articular damages to an intraarticular fracture, as the time to develop osteoarthrosis does not differ. This is in contrast to the current opinion that ankle sprain, in most instances, does not result in symptomatic articular degeneration.

A. Basile L. Pisano M. StopponI A.U. MinnitI

We present the results of a multicentre retrospective study of closed fracture dislocations of the Lisfranc joint treated by closed reduction and percutaneous screw fixation (follow-up: almost 5 years).

Forty-two patients that presented between 1994 and 1999 to the authors™ institutions were selected for this study (follow-up AOFAS score 81.0 ± 13.5).

A review of the literature shows that opinions differ as to the most appropriate method of treatment, be it closed or open reduction, screws or K-wires fixation, but most of the authors agree that it is imperative to achieve anatomical reduction.

In our study, no statistically significant differences could be detected when outcome scores of patients with anatomical reduction were compared with outcome scores of patients with nearly anatomical reduction, in both the combined fracture dislocation and pure dislocation subgroups. The conclusion is that even a nearly anatomical reduction is considered acceptable and predictive of a satisfactory outcome.

Furthermore, we found a statistically significant difference in the AOFAS score between patients with combined fracture dislocations and pure dislocations, with the latter having a worse AOFAS score. This suggests that the ligament bone interface cannot heal with sufficient strength to regain stable long-term function.

Y. Tourne F. Jourdel D. Saragaglia

Introduction The aims of this paper was to check the main clinical features of the posterior ankle impingment syndrom and to evaluate the results of the surgical treatment according to a retrospective study. Material and Methods 21 patients (17 males,4 females),(mean age of 33 years)were operated on between 1991 and 1999. 71 % had sporting activities. Plantar flexion were painful in 94 % of cases with various radiological changings of the posterior process of the talus and soft tissues surrounded (XRays, radionucleid imaging, CTscan and MRI). A posterior approach were performed with bone resection and peritalar joints debridment. Results All the patients were clinically and radiologically reviewed using AOFAS score. The mean follow-up was of 5 years(range 3 to 10 years). No septic evolution were reported. The overall functional results were excellent with a mean AOFAS score of 90/100 points with no degenerative changings in the peritalar joints. The patients were satisfied in 90 % of the cases Discussion-Conclusion Surgical managment is a successful and reliable procedure to treat the posterior ankle impingment syndrom, very frequent in sporting population and nowadays well documented by conventional Xrays and uptodate radiological examinations.

P. Vorlat W. Achtergael P. Haentjens

Aims: To explore potential predictors of functional outcome after conservative treatment of acute fractures of the base of the fifth metatarsal. These fractures are the most frequent fracture of the foot. The factors that influence final clinical outcome are rarely investigated. Regression analysis regarding this problem was never performed.

Methods: The study design was observational and retrospective. Adults, conservatively treated for an acute fracture of the base of the fifth metatarsal included. All patients were given a plaster cast at the emergency department and were instructed not to bare weight (NWB) on the affected limb for at least one week. The further modalities of treatment were decided by individual surgeons according to their current clinical practice. A validated scoring system was used. Additional questions were asked about residual cosmetic and shoe problems and also about intensity of pain and the general feeling of comfort. The respective influences of factors on clinical outcome were examined using multiple linear and logistic regression modeling.

Results: 38 patients (11 men, 27 women) were analysed. The mean age was 48 years. 6 had a Jones fracture, while 32 had a tuberosity avulsion fracture. The mean non-weight bearing period was 2 weeks and 4 days (range 1 to 5 weeks) while the cast was worn for a mean of 5 weeks and 3 days (range 1 to 10 weeks). Three Jones fractures and all the avulsion fractures were healed at the end of treatment. The mean follow-up time was 298 days, ranging from 51 to 603 days. The mean result of the ankle score at follow-up was 77.5 (range 20 to 100). Thirteen of the 38 patients reported problems in wearing shoes. Only 8 patients experienced cosmetic problems. The mean linear analogue score for pain was 2.34, that for general comfort was 8.11. Overall, the most significant predictors of poor functional outcome at final follow-up evaluation were increasing duration of NWB and longer follow-up time. Longer NWB was importantly associated with worse global score, pain, comfort and reported stiffness. Neither gender nor fracture type had any significant influence on the overall clinical outcome.

Conclusions: The most important variable linked to final clinical outcome is the duration of the non-weight bearing period. Neither gender, age, length of casting nor even fracture type, had any significant influence on the overall clinical outcome. Therefore NWB should be kept to a minimum for acute avulsions.

G. Kakarala D.A. Elias

Introduction: The unique architecture of the tarsometa-tarsal joints gives rise to a complex articulation between the midfoot and forefoot. The Lisfranc injury has a classic pattern leaving its telltale signs in an arch pattern starting at the medial cuneiform, continuing through the second, third and fourth tarsometatarsal regions and finally may end as a fracture of the cuboid. However, various other patterns and classifications of Lisfranc fracture dislocation have been recorded in medical literature.

Aim: To highlight the hitherto undescribed arch patterns of Lisfranc injuries.

Methodology: 8 patients with atypical Lisfranc injuries were studied prospectively.

Arch patterns: In 2 patients the arch started at the medial aspect of the ankle with injury to the medial malleolus or the deltoid ligament, passed through the tarsometatarsal region and ended at the cuboid. In one patient the arch started at the tarsometatarsal joints and ended at the lateral malleolus and in another patient the lateral end point resulted in tear of the calcaneofibular ligament. One patient had the medial starting point at the Lisfranc ligament but the arch of injuries went through the forefoot fracturing the midshaft of the 2nd, 3rd and 4th metatarsal shafts without injuring the tarsometatarsal region, thus forming an arch pattern much more distal than usual. Six of the 8 patients had operative management. On follow up, in terms of activities of daily living, 75% had excellent function of the foot. It is not the aim of this paper to highlight the management of these injuries.

Conclusion: In the process of listing the telltale signs of a Lisfranc injury it is mandatory to bear in mind that the arch of injuries may extend to as proximal as the ankle joint or as distal as the forefoot and this will enable us to define the entire spectrum of the Lisfranc injury, however atypical it may be.

A. Qureshi S. Zafar D.J. McBride

Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. We reviewed the cases undertaken in our department, complications, which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12 years period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range [18 to 66]). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. In conclusion this study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although, the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed.

N Khan D. Fick T. Brammar J. Crawford M.J. Parker

Introduction: Treatment for ruptured Achilles tendon can be classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing); post-operative splintage can be with a rigid cast or functional brace. The aim was to identify and summarise the evidence from randomised trials of the effectiveness of different interventions.

Methods: We searched the Cochrane specialised register, MEDLINE, reference lists of articles and contacted trialists directly for all randomised and quasiran-domised trials comparing different treatment regimes for acute Achilles tendon ruptures.

Results: Fourteen trials involving 891 patients were included.

Open operative treatment compared with non-operative treatment was associated with a lower risk of re-rupture (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.1–0.6, p=0.003) but a higher risk of other complications including infection, adhesions and disturbed sensibility (OR = 14.1, 95%CI = 6.3–31.7, p< 0.00001).

Open versus percutaneous operative surgical repair was associated with a longer operation duration and higher risk of infection (OR = 12.9, 95%CI = 1.6–105.6, p=0.02).

Patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work, quicker return to sporting activities and fewer reported complications (p=0.0003).

Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques and different non-operative regimes.

Conclusions: Open operative treatment significantly reduces the risk of re-rupture but has the drawback of a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay and time off work and sports.

R.M. Christ F.W. Hagena

Introduction and aim: In a prospective comparative study we were interested in the question, wether the total ankle arthroplasty in the midterm FU, especially in patients with RA, is a successful and correctly indicated surgical procedure. We compared our clinical and radiological results with a cohort of patients with OA. Furthermore we analysed especially the rheuma patients for their known periarticular osteopenia and the cementless fixation as a possible contraindication for the ankle arthroplasty.

Material and methods: With a mean FU of 4,4 years and a total number of 153 total ankle arthroplasties from 07/1997 to 12/2003 we assessed 92 patients with 94 S.T.A.R total ankle arthroplasties. Indication for this surgical procedure was the rheumatoid arthritis in 26 patients (27.7%) and an idiopathic osteoarthritis of the upper ankle joint in 29 cases (30.8%), furthermore a posttraumatic osteoarthritis in 39 patients (41.5%)

Results: The functional increase in their range of motion (ROM) and the significant decrease of pain are the most important and impressing facts for the patients.

The increase of ROM in all patients is 17.9 (RA: 18.7 /OA: 16.6). Significant pain relief is described by 92.4% of patients, here all the groups showed no significant differences. An increase in the clinical outcome measured by the Kofoeds Ankle Score is seen from < 70 pts. preoperatively (100% of patients) to > 75 pts. postoperatively (82.3% of patients). The most frequent complication especially in patients with RA is a delayed wound healing (19%), but the revision rate is higher in patients with traumatic and idiopathic osteoarthritis (17% OA /13% RA). A secondary arthrodesis has to be performed only in 2 OA cases.

Conclusion: Rheumatoid arthritis in the LDE stage IV and V is the adequate indication for the S.T.A.R. prosthesis. The functional benefit and the clinical outcome is satisfying, the results for the rheumatoid arthritis patients are comparable to other indications. Periarticular osteopenia is not considered as a contraindication.

B. Komarasamy A. Best R.A. Power V. Leninbabu

Purpose: To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN).

Methods and results: We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, four patients died of unrelated causes and two patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the AOFAS hindfoot score and three independent observers reviewing radiographs.

Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again.

Conclusion: Despite a high rate of ankle and subtalar non-union most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and sub-talar joint arthritis, patients should be warned of the potential for non-union and high complication rates.

N. Aslam K. Nagarajah B. Sharp M. McNally

Introduction: Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. Ilizarov method provides stability with remote fixation and allows weight bearing.

Patients and Methods: Fourteen consecutive patients were studied. The mean age at onset of disease was 50 years(range 4–70). 13 of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months(range 8–372). Aetiology included traumatic arthritis in 5, failed fusion in 6, septic arthritis in 1, infected ankle fracture nonunion in 1 and avascular necrosis of talus in 1. There were 10 males and 4 females. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotics treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. Below knee cast was applied for 4 weeks.

Results: 13 of 14 patients had complete ankle fusion at a mean period of 5 months. 1 patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site.

Conclusion: The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems.

S. Mueller S. Wolf F. Braatz P. Armbrust L. Doederlein

Introduction: Arthrodesis is considered the primary treatment in case of non-response to conservative therapy of ankle arthritis[1]. Reports on long-term gait results after arthrodesis have been made indicating a decrease in motion concerning the hindfoot and an increase in the forefoot [2]. The aim of this study is to evaluate the gait of patients who had undergone ankle arthrodesis using a new foot model.

Material/methods: 17 subjects (10 males, 7 females) who had undergone unilateral arthrodesis returned for clinical examination and gait analysis. The median age at time of operation was 56 years, the follow-up time was 49 months (median). Operative procedures were performed as internal (n=15) and external fixations (n=2). Patients were instrumented with a set of 17 reflective markers. For data acquisition we used a Vicon system with 9 cameras. The person was asked to walk a 7m walk way. For the evaluation of foot kinematics a multi-segment foot model was used [3]. Kinematic data were also collected from the healthy side. Differences between means for the ankle arthrodesis and healthy side were tested using paired T-tests (p< 0.01).

Results: The ankle angle is the generally accepted parameter to describe motion between the shank and the foot regarded as a rigid segment (a). In our model it was defined exclusively by the angular position of the hindfoot relative to the tibia (b). The loss of motion in the ankle joint is shown by the significant decrease of ROM in the arthodesis side. Also significant is the decrease in hind- and forefoot ROM in frontal plane movement (d, e). Furthermore the results show a decrease of ROM of the medial arch (c).

Sag. Ankle Angle ROM (standard): 14,31 4,72 *(OP); 28,39 4,96(healthy)

Sag. Ankle Angle ROM (footmodel): 9,36 2,62 *(OP); 18,68 4,33

Sag. Med Arch ROM: 12,85 4,85 * (OP); 20,11 4,71

Front. Subtalar Inversion ROM: 4,59 1,44 *(OP); 7,56 1,96

Front. Forefoot Ankle Supination ROM: 10,23 3,71 *(OP); 13,91 3,82

(Mean standard deviation; * statistical significance from healthy side p< 0.01)

Discussion/conclusion: The operative fusion of the ankle joint limits the sagittal plane motion of the tibial to hindfoot segment due to the lack of tibiotalar motion. Since the talus can not be marked for 3D-measurements, other hind-, mid- and forefoot markers were used to determine ankle motion. The remaining motion which is found in these clinical cases must be addressed to subtalar movement. In contrast to the common clinical opinion of a higher mobility of the fore- and midfoot joints, we find a significant reduced ROM of the corresponding parameters (a, b, c, d, e) with our model.

M. Monteagudo N. Martinez T. Muñoz S. Martos M.J. Rodea

In order to regain preinjury activities following an Achilles tendon rupture while reducing the potential complications of open surgery and non-operative treatment, we developed a new protocol that involved the use of a modified local anaesthetic technique, percutaneous repair and early function.

We prospectively treated 32 patients with acute Achilles tendon ruptures according to our protocol with a 12 month minimal follow-up. Surgery was performed on an outpatient basis and within 48 hours from rupture for all cases. Our local anaesthetic technique allowed us to have a comprehensive control over sural nerve location by the definition of a “safe area” (video will be shown) and has proved to be effective to avoid sural nerve damage during surgery. The 28 male and 4 female patients had a mean age of 35 years (range, 26 to 47 years). The percutaneous repair was performed with a #2 nonabsorbable monofilament. Patients began range-of-motion exercise at 48 hours, used a posterior splint for 2 weeks, and then began ambulation with crutches and a 2 cm heel wedge incorporated on sport shoes or alternatively country boots. At 5 weeks, the wedge shoe was discontinued, full weight-bearing was allowed, and progressive resistive exercises were initiated.

There were no reruptures, wound infections, sural nerve damage, recurrent pain, or skin necrosis in our group of patients. One patient (with an hemathological disorder) developed a deep venous thrombosis that resolved uneventfully.

Mean AOFAS score was 80 at 6 months and reached 98 at 12 months. High-demand patients (police officer, firemen, athletes, professional soccer player) returned to their activities by 5–6 months. Patients were very satisfied with the procedure and subjetive evaluation turned to be very good or excellent for all cases.

Achilles tendon management using our protocol is an efficacious method demonstrating a low morbidity rate together with a return to preinjury level by 6 months. In addition, this protocol is cost effective (saves on hospital admission, anaesthesia, complications) and athletes in our group were able to obtain their athletics goals with minimal or no deficits.

C. Perka H. Katterle T. Drahn G. Matziolis

Introduction: The objective of the study was to test the hypothesis that revision total hip arthoplasty in cases with extensive acetabular bone defects performed with a newly developed, conical, titanium, ribbed shaft socket designed for cementless press-fit into the dorsocranial ilium would not demonstrate inferior outcomes using literature controls.

Methods: 38 consecutive hips had an acetabular revision with a pedestal cup. All of the patients had a type IIIa or IIIb defect according the Paprosky-classification. There was an average follow-up of 4.2 years, with a range of 3 to 6 years. Two patients died, one patient was lost to follow-up. All patients were evaluated radiographically, by CT-Scan and clinically.

Results: At the time of follow-up, 32 (91.4%) cups were stable. Aseptic loosenings occured in one case, septic loosenings occured in 2 cases. The average Harris Hip Score improved from 43 points (range: 16–78 points) preoperatively to 82 points (range 56–98 points) postoperatively. Complications included four dislocations without recurrency. The guide instrument facilitates correct anchorage in the dorsal ilium in all cases.

Conclusion: The presented findings show the short-term efficancy of the procedure with respect to implant fixation and clinical results in large acetabular defects, but longer follow-ups and a larger number of patients are needed before the durability of this reconstructive technique can be assessed. The implant allows restoration of the correct centre of rotation, equalization of leg length and optimization of the strength of the hip abductors. Our results should be considered encouraging.

A. Malviya N. Makwana P. Laing

Aims: Lateral ligament complex injuries are a common cause of chronic ankle instability. It has been found that functional and mechanical instability of the ankle joint can respond to arthroscopic debridement of the ankle alone and that not all structurally unstable joints require stabilisation. The aim of this study was to find out the role of EUA & Arthroscopy in the management of these problems.

Methods: We retrospectively studied 43 patients with chronic lateral ankle instability who had failed to respond to a functional rehabilitation programme. All patients underwent an examination under anaesthesia with stress views to determine instability proceeded by arthroscopic examination of the ankle.

Results: Intra-articular bony lesion was seen in 41.8% of cases. 79.1% had fibrosis in the anterolateral gutter, 27.9% had osteochondral defect, 30.2% had osteophytes causing impingement and 9.3% had loose bodies. Structural instability was confirmed in 53.4% and functional instability in 46.6%. Arthroscopy demonstrated attenuation of the Anterior Talofibular ligament in 14%. Following arthroscopic debridement lateral reconstruction was required in only 14(32.5%). 23 patients (53.4%) went on to improve after arthroscopy alone and did not need lateral reconstruction.

Conclusion: Arthroscopic assessment and treatment of intraarticular lesion in patients with chronic ankle instability can result in a stable ankle that does not necessitate a lateral ligament complex reconstruction.

S. Garg N. Singh T. Abed

Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged.

We reviewed 96 patients who had an acute percutaneous repair done by a single surgeon at district general hospital between January 1998 to April 2004. The mean follow up was 27 months. The repair is carried out using six stab incisions over the posterolateral aspect of the tendon. The procedure can be carried out under local anaesthesia. All patients were put in a below knee cast after the operation. Cast was changed at 4 weeks keeping the foot in plantigrade position. The mean period of immobilization was 8 weeks.

They returned to work at 12 weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were 2 injuries to the sural nerve. There were no late reruptures. This technique is simple to undertake and has a low rate of complications. We present one of the largest series reported in literature.

A.M. Perera A. Qureshi K.M. Porter

The importance of correctly identifying and treating ankle syndesmosis injuries is paramount to achieving a good functional result. Although it is clear that anatomical correction is essential the practical aspects remain disputed. Controversial issues include diagnosing and determining which injuries need treating, the number and size of screws for fixation, the number of cortices engaged, a screw removal strategy and the use of biodegradable screws or other forms of fixation. We report the results of a survey of 440 orthopaedic surgeons to determine current UK practice, this is then compared to best practice as determined by literature review.

When analysis was performed for the group and by sub-speciality (foot and ankle, trauma and general orthopaedics) we found large differences in practice. Furthermore it appeared that some aspects of treatment varied considerably from published evidence, for instance four out of five screws were removed much earlier than clinical studies have recommended.

N. Usami S. Inokuchi E. Hiraishi A. Waseda C. Shimamura H. Ikezawa

Reconstruction of the lateral ligaments of the ankle has been performed for many years, but few reports are available regarding the outcome after 10 years or longer, and there are no such reports on reconstruction with the more recently developed artificial ligaments. I report the clinical outcome and radiological findings.

Materials and results: The subjects are 62 feet in 57 patients (male 28 feet, female 34 feet). All patients were followed up by direct examination and stress roentgenography for 10 years or longer. Mean follow-up period is 11 years and 9 months.

On stress X-ray taken at the final examination, TTA improved preoperatively 19 degrees to 4 degrees postoperatively, and ADT improved from 12 to 5 mm. There was no marked development or progression of arthropathic changes. No allergic reaction to the artificial ligament material occurred in any patient. postoperatively and no patient had instability that became severe enough for reoperation to be required. As for arthropathic changes, in 3 patients with a TTA of 10 degrees or more postoperatively, progression of mild osteoarthritic changes was observed.

Discussion: There have been few studies involving long-term follow-up for 10 years or more. This procedure is not happened OA changes and ADL limitation because reconstruction at anatomical position of ATFL and CFL. It has not been happened pathological rupture of artificial ligament because lateral ligaments are not intra-articular ligament but periarticular ligament.

Conclusion: Reconstruction with artificial ligament is anatomical procedure and can be expected the prolonged effectiveness.

M. Costa A.H. Robinson S.T. Donell V. Curry G.P. Riley

Aims: 1 To assess the histological changes in patients with Achilles tendinopathy. 2 To map the distribution of nerves and nerve endings within the Achilles tendon

Methods: Tendon biopsy specimens were taken from patients with spontaneous (ie previously painless) Achilles rupture patients and chronic painful tendinopathy patients. ‘Normal’ cadaveric /lacerated tendon biopsies were used for comparison. Sections were stained with H& E for basic histology. Immunolocalisation of nerve tissue was performed with 2 anti-neurofilament antibodies. Non-specific immunoglobulin was used as a negative control.

Results: The number of nerves and nerve endings found within the normal tendons and both groups of degenerate tendons was very low

Only 30% of the normal tendon sections showed any positive staining at all

Compared to 36% of ruptured tendon and 43% of the painful tendinopathy sections.

Conclusions: Tendon rupture and chronic painful tendinopathy biopsies ALL show widespread degenerative changes

There is a paucity of nerve tissue within these tendons, which may have implications for the neurogenic hypothesis of tendon degeneration

There appear be more nerve fibres in vascular areas of the painful tendinopathy biopsies

There may be more nerve fibres in the peritendinous tissue

F.C.N.K. Kwong R.A. Power

Implantation of allograft bone continues to be an integral part of revision hip surgery. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing bone in order to reduce that risk. One part of that processing can be carried out immediately prior to implantation using pulsed irrigation.

We report the incidence of deep bacterial infection in a series of 138 patients undergoing 144 revision hip arthroplasty procedures who had undergone allograft bone implantation. The allograft bone used was fresh-frozen non-irradiated. Allograft femoral heads were milled following removal of any residual soft tissue and sclerotic subchondral bone. The bone chips were then placed in a standard metal sieve and irrigated with Normal Saline (pre-warmed to 60 degrees Centigrade) delivered as pulsed lavage at 7 bar pressure. No antibiotics were used in the irrigation solution. The bone chips were washed until all visible blood and marrow products had been removed.

The deep infection rate at a minimum one year follow-up was 0.6%. This method of secondary processing appears to be consistent with a very low risk of allograft related bacterial infection.

M. Hubble A. Patten W. Duncan J. Howell A.J. Timperley G. Gie

Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing “cement in cement” revisions, and this technique is not in widespread use.

Since 1989, we have performed a cement within cement femoral stem revision on 354 occasions. The indications for in cement revision included facilitating acetabular revision, replacement of a monoblock stem with a damaged or incompatible head, revision of hemiarthroplasty to THA, component malposition and broken stem. Cement in cement revision was only performed in the presence of well fixed cement with an intact bone-cement interface. An Exeter polished tapered stem was cemented into the existing cement mantle on each occasion.

Follow up of 5 years or longer is available for 175 cases, and over 8 years in 41. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. Advantages include preservation of bone stock, reduced operating time, improved acetabular exposure and early post operative full weight bearing mobilisation. This technique has not been used for 1 stage revision of infection.

This experience has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral component or hemi-arthroplasty, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis.

P. Wojciechowski D. Kusz L. Cielinsk A. Drozhevsky

Early reports on revision total hip arthroplasty (RTHA) suggested that outcomes of this procedure are as good as those of primary total hip arthroplasty (THA). However, RTHA is associated with longer surgery time, greater blood loss and increased risk of complications (thromboembolism, nerve injury, periprosthetic fractures, recurrent hip dislocations and infections). Aseptic loosening after RTHA was reported in 36% of patients aged over 55 years within 4 years after revision. Infections were reported in 32% and complications during surgery in 23% of patients respectively. Unsatisfactory results of RTHA stimulate the search for alternative procedures. Girdlestone excision arthroplasty (GA) seems to be a good solution for older patients with high risk of complications related to a poor general condition.

Material and method Between 2000 and 2003 we operated 39 patients, 10 for septic (26%) and 29 aseptic (74%) loosening of their THA. All patients complained of painful limb aggravated by weight bearing and the severity of pain was the main indication for the surgery. Average survival time of previous THA was 9 year (range: 1 to 20). We assessed pain, walking distance and the need to use walking aids. The outcomes were measured according to the Harris Hip Scale. The patients had the GA performed. The procedure involved removing implant and bone cement and placing the major trochanter into bone acetabulum. If an infection was present, an antibiotic irrigation system was introduced. No cast or braces were used and walking was started 2–7 days after surgery, depending on patients general condition.

Results Good pain control was reported by 33 (85%) patients. The average Harris Hip Score changed from 25 points preoperatively to 53 at latest follow-up. Average limb shortening was 4 centimetres (range: 2 to 8). Walking aids (one or two crutches) were required by all patients. Eighteen (46%) patients walked more than 500 m, 12 (31%) patients walked 200–500 m and 9 (23%) patients walked less than 200 m, of whom one patient was wheelchair bound.

Infection ceased in 9 cases, 1 patient died because of complications related to chronic infection.

Discussion GA yields satisfactory results in patients who have to have their prostheses removed. It provides a mobile, painless joint. The disadvantages of GA are: limb shortening and unstable gait which requires the use of crutches. This procedure should be indicated for patients with high risk of complications due to poor general health, infection and/or massive loss of bone stock which render more invasive procedures impossible. GA is also advisable in patients with weak hip abductor muscles, when RTHA is associated with a high risk of recurrent hip dislocation. The Girdlestone arthroplasty is a satisfactory salvage procedure in most cases of failed THA, when the choice of reimplantation exposes the patient to a high risk of further failure.

B. Fink J. Singer M. Fuerst S. Schubring A. Grossmann

Aim: The aim of this prospective study was to analyse the rate of sinking and the clinical results of the new cementless modular revision stem Revitan curved concerning the length of fixation of the implant and the technique of implantation (endofemoral compared with transfemoral).

Material and Methods: 51 cementless modular curved revision stems (Revitan curved) were implanted 17 times endofemoral and 34 times transfemoral. All operations were performed by the first author with 24 times a total exchange of the hip implants and 27 times an exchange of the stem. Patients were followed every 3 months in the first postoperative year and then every 6 months. Because sinking of a cementless implant occurs during the first postoperative year the minimum follow-up was 12 months (average follow-up was 22.5 + −12.6 months). Patients were evaluated clinically using the Harris Hip-Score and length of fixation of the implant as well as implant sinking was evaluated radiographically.

Results: The Harris Hip-Score increased from 45.7 preoperatively to 86.7 twelve months postoperative in endofemoral implanted stems and from 41.6 preoperatively to 81.2 twelve months postoperative in transfemoral implanted stems. The patients with transfemoral implanted stems had a significant higher amount of limping and positive Trendelenburg sign after the operation. With time the percentage decreased and reached nearly the same level as in patients with endofemoral implanted stems. 2 endofemoral and 1 transfemoral (with a fixation length of less than 3 cm) implanted stems showed a sinking of 5 mm. 2 transfemoral implanted stems had to be revised because of aseptic loosening. In both stems the fixation length was less than 3 cm in the first revision due to operative technical reasons.

Conclusion: The curved cementless revision stem Revitan shows encouraging results using the endofemoral and transfemoral technique. In transfemoral implantation a secure fixation can be reached with a fixation length of more than 3 cm (which is less than the usually recommended fixation length of 4 to 6 cm for cementless revision stems). Transfemoral implanted stems need a longer time of rehabilitation than endofemoral implanted stems

R. Nagai V.R. Raut P.R. Kay B.M. Wroblewski

Introduction. Preoperative bone stock and cement-bone interface in revision total hip replacement (THR) for deep infection have never been investigated while they are both well known to be important for mechanical outcome after revision THR for aseptic loosening.

Purpose. The purpose of this study was to assess pre-operative bone stock and immediate postoperative cement-bone interface as factors affecting infection control after one stage revision THR for deep infection.

Material and methods. This study included 115 cases which satisfied following conditions; a) One stage revision THRs for deep infection were carried out by a single surgeon. b) Follow-up of more than five years was done. Preoperative bone stock was classified into four grades (Grade 0: No bone loss, Grade 1: Demarcation, Grade 2: Localized cavitation, Grade 3: Extensive bone loss). Immediate postoperative cement-bone interface was also graded into four categories (Grade A: White-out, obscure interface, Grade B: Clear line, no measurable gap, Grade C: Gap within 1mm, Grade D: Gap more than 1mm). These two factors were analyzed in view of infection control after surgery.

Results. Preoperative bone stock did not show significant influence on infection control. Immediate postoperative cement-bone interface was an affecting factor for cure of infection.

Conclusion. There was a good chance of cure of infection even in cases with significant bone loss. Good cement fixation appeared to be important in view of infection control. The results suggested the importance of shielding of medullary space with antibiotic-loaded cement from infected joint space in revision THR for infection.

D.W. Elson I.J. Brenkel

Introduction: Pain is one of the most important outcome measures that contributes to patient dissatisfaction following total knee arthroplasty (TKA) and unexplained pain poses a difficult problem to manage. This paper focuses on a group of patients with unexplained knee pain post arthroplasty to identify any predictors of a poor pain outcome.

Methods: A prospective study of 622 primary TKAs performed on 512 patients using cemented press fit condylar prosthesis was the basis to examine a group of patients that reported moderate or severe pain at 5 years. Demographic and operative variables as well as American Knee Society Scores were collected prospectively. Data was available for 462 knees at 5 years. After exclusion of patients with mild pain, two groups were generated; 374 with no pain and 28 with moderate or severe unexplained pain. Univariate linear analysis was performed to identify possible predictors of poor outcome and this was further refined using multiple regression analysis to remove the effect of confounding factors.

Results: Comparison of the pain and no pain group found the following to be significant predictors of poor outcome: Staged approach to bilateral disease when compared to simultaneous bilateral surgery (13% vs 2%, P< 0.01), age below 60 (17% vs 7%, P< 0.01) and performing lateral release (13% vs 5%, P< 0.01). Other factors which had no predictive effect were gender, body mass index, operating surgeon, patella component, instability and range of motion.

Conclusions: Avoiding surgery in patients aged below 60 and performing simultaneous bilateral TKA instead of a staged approach to bilateral disease, should aid selection of patients for improved outcome in terms of pain. Good surgical technique to avoid lateral release is also recommended to improve outcome.

K. O Shea E. Bale P. Murray

Introduction: The majority of patients with osteoarthritis of the knee suffer from femorotibial pain with a smaller proportion suffering predominantly patellofemoral symptoms. No clear consensus exists as to the need for patellar resurfacing when performing total knee replacement for patients with symptomatic femorotibial osteoarthritis but without prominent patellofemoral symptomatic and radiographic disease.

Aims: To identify the advantages and disadvantages of both resurfacing and non-resurfacing of the patella during cemented total knee replacement performed for osteoarthritis predominantly of the femorotibial joint. To objectively clarify the rationale for the use of either procedure in clinical practice.

Methods: Prospective randomised double blinded clinical trial. Patients with osteoarthritis of the knee and principally femorotibial symptoms were included. Patients with rheumatoid arthritis, gross deformity of the knee and gross radiological or clinical patellofemoral arthritis were excluded. The implant used was a cemented posterior stabilised AMK (DePuy, Leeds UK) prosthesis. Preoperative American Knee Society Score, SF-36 questionnaire and WOMAC scores were calculated for each patient. These instruments were repeated and combined with clinical and radiological follow up at 3 months, 6 months and 1 year.

Results: 58 patients were recruited into the study, 53 of whom completed follow up and were in included in the analysis. Baseline characteristics were similar in each group. Operating room time was less in the non-resurfaced group (p< 0.05). At 2 years, 3 patients in the non resurfaced group had undergone a revision procedure. There was no difference between the resurfaced and non-resurfaced groups in terms of global functional outcome as measured by SF36 and WOMAC scores at 1 and 2 years post-operatively. The American Knee Society score showed no difference between the two groups (p=0.86) at 1 year post surgery.

Conclusion: There is no significant difference in clinical outcome at 1 and 2 years following surgery vis-à-vis those who did and did not have patellar resurfacing performed during knee replacement for predominantly femorotibial symptomatic osteoarthritis. There was a higher revision rate in the non-resurfaced group. In TKR using a PS AMK prosthesis routine resurfacing of the patella should be performed.

F. Catani A. Leardini C. Belvedere A. Ensini S. Giannini

Patellar maltracking after total knee arthroplasy (TKA) introduces complications such as anterior knee pain and patellar subluxation, generally due to prosthetic component malallignment in both tibiofemoral (TF) and patellofemoral joints. It is still debated if it is necessary to resurface the patella, which would better adapt the patellar articular surface to the prosthetic femoral troclea with a prosthesis, but also result in possible bone fractures. In this study, an in-vitro analysis is presented in order to identify differences between intact and TKA patellar tracking with and without patellar resurfacing and to show how much the latter is similar to intact knee patellar tracking.

Three fresh-frozen amputated legs with knees free from anatomical defects and with intact joint capsule, collaterals and quadriceps tendon were analyzed using the Stryker knee navigation system (Kalamazoo, MI-USA). Landmark digitations were used to define anatomical frames for femur, tibia and patella. Manually driven TF flexions, from 0 to 140, were performed under conditions of no load and of 10 kg on the quadriceps, with intact knee and TKA with patella resurfaced and not. TF flex/extension, intra/extra rotation, ad/abduction were calculated according to a standard convention. Patellar flex/extension, medial/lateral tilt, rotation and shift were calculated according to a recently proposed articular convention.

Since more repeatable, results relative to trials under 10 kg are reported. Intact knee: 4 abduction; considerable intra rotation (from 16 to 4), followed by continuous extra rotation starting at 30 TF flexion; linear increase in patellar flexion (from 20 to 110); initial medial patellar rotation (from 12 to 8), followed by medial rotation starting at 60 TF flexion; initial lateral patellar tilt (from 4 lateral to 4 medial), followed by medial tilt starting at 70 TF flexion; initial 6 mm lateral patellar shifts from 0 to 80 TF flexion, followed by 4 mm medial shift. TKA knee: small differences in ad/abduction between intact and TKA knees, both with and without resurfaced patella; slight initial extra rotation, followed by continuous intra rotation starting at 20 TF flexion; linear increase in the flexion of the patella, both resurfaced and not, close to the that of the intact knee; patellar rotation more lateral than in the intact knee; patellar tilt without resurfaced patella closer to the intact knee one; 6 mm lateral patellar shift, likely accounted for the surgical technique.

Slightly more than TKA with resurfaced patella, TKA with non resurfaced patella flexes nearly like the intact knee. The closeness in values of patellar flexion and tilt represents a proof of the closeness in behavior of not resurfaced patella in TKA to the patella in the intact knee.

J.C. Theis J. Pennington A. Bayan T. Doyle R. Hill

Purpose: There are numerous papers from specialist arthroplasty centres outlining results of total knee arthroplasties but little information from outside these major centres. We carried out a review of a fixed bearing total condylar knee replacement used in Dunedin by a variety of surgeons for over 10 years.

Method: All patients who received a Duracon/PCA fixed bearing total knee replacement between 1992 and 1996 were assessed clinically, fluoroscopically and completed an SF12, WOMAC and IKSS questionnaire.

Results: At a mean 9.7 (8–12) years follow up, 126 (69.6%) patients were available for review and 46 (25%) were deceased. The average age was 72 years (52–88) and the primary diagnosis was osteoarthritis in 95% of the cases. There were 34% Charnley Grade A, 37% Grade B and 29% Grade C respectively.

The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.

There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.

Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.

Conclusion: These results suggest that knee replacements carried out outside specialist arthroplasty centres perform very well with a survival rate of the implant of 95% at 10 years.

S. Tarabichi A. Saleh S. Larsen

Introduction: In living normal knee the lateral femoral condyle rolls posteriorly more than the medial side to the extent that in deep flexion the lateral femoral condyle sublux from the tibial surface(Nakagawa et al). The purpose of this presentation is to study the tibiofemoral movement in patients who had full flexion after total knee replacements and to compare it with that of normal knee.

Materials and Methods: 23 knees were scanned using SIEMENS SIREMOBILE Iso-C with 3D Extension C-arm. The system is able reconstruct 3D images that can be viewed from deferent angle and precise measurements of distances between the deferent components of the implant can be made. The knee was scanned while the patient is sitting in kneeling position with the calf touching the thigh (flexion of over 150degree).

Results: All the cases studied showed a variable roll back between the medial and lateral femoral condyle. In all cases the lateral roll back was much more than the medial. In 14 cases we confirmed lateral condyle subluxation similar to what is seen in normal knee. The position of the foot (internal or external rotation) during scanning did not affect the lateral femoral condyle role back.

Discussion: Although previous studies have shown paradoxical types of tibiofemoral movement in patients who have total knee replacements throughout the range of movement, the knees in patients who had full flexion after TKA tend to have the same tibiofemoral movement as the normal knee in deep flexion. The lateral femoral condyles spin off or subluxation could adversely affect the implant components especially if the design does not accommodate this movement.

Conclusion: The lateral femoral condyle may sublux from the tibia during kneeling in patients who have full flexion after TKA. These findings should call for changes in the implant design to accommodate the lateral condyle roll back.

M. Pleser O. Woersdoerfer

Aims: Does CT-less navigation using the NAVITRACK-System improve post-operative rotational alignment of prosthesis compared to not-navigated implantation technique?

Methods: A total number of 250 patients was enrolled into a randomized mono-centre-study. Ninety patients received computer-aided-surgery (CAS), 160 patients received not-navigated implantation technique. Mechanical leg-/femur-/tibia-axes were identified using complete-leg-CT-scans. Rotational alignment was calculated measuring the angles formed between condylary and epicondylary axes (femoral), transverse tibia plateau axis and tibial tuberosity (tibial) respectively, by the use of coronar CT-scans. Knee Society – and SF-36-Scores were collected pre- and post-operatively at 6 weeks /6 months. Statistical analysis was performed by the chi-square-test.

Results: (All values in mean +− SEM (range)) A mechanical-axis-range of 180 +− 3 was achieved in 97,9% of navigated, and in 76,8% of the not-navigated patients. The tibial component was placed in a 2,1 +− 1,3 -varus-position in navigated patients. In the conventional patient group varus position was 1,8 +− 1,4. A 0,8 +− 1,5 femoral-valgus-position was found in navigated patients, respectively a 0,3 +− 2,7 varus-position in the not-navigated. The internal rotation (relative to epicondylar axis) of the femoral component was 2.8 +− 1,0 (0,7–3,8) in the CAS-group and 2.1 +− 1,5 (0–5,9) in the non-navigated. On the tibial side, the internal rotation of the plateau relative to tibial tuberosity was 20.5 +− 2.5 (16,8–24,8) in CAS- and 22.2 +− 7.5 (9,3–43,2) in the conventionally treated patients.

Conclusions: CT-less navigation using NAVITRACK was suitable to a.) reconstruct mechanical axis within the limits of 180° +− 3° and b.) reduce rotational malalign-ment especially on the tibia. The system may improve the survivorship of TKR as well as the functional outcome after implantation.

C.O. Tibesku T. Dierkes A. Skwara D. Rosenbaum S. Fuchs

Introduction: Mobile bearing total knee arthroplasty (TKA) has been developed to theoretically provide better, more physiological function of the knee and produce less PE wear. The theoretical superiority of mobile bearing TKAs over fixed bearing devices has not yet been proven in clinical studies. The objective of the present study was to prospectively analyze clinical and functional outcomes of randomized fixed and mobile bearing total knee arthroplasty patients by means of gait analysis, electromyography and established clinical scores.

Methods: In a prospective, randomized, patient- and observer-blinded, clinical study, 33 patients (mean age 63 years) received a cruciate retaining Genesis II TKA for primary osteoarthritis. 16 patients received a mobile bearing and 17 patients a fixed bearing device. The day before surgery and 24 months postoperatively, established clinical (KSS, HSS, WOMAC, UCLA, VAS) and quality of life (SF-36) scores were used to compare both patient groups. Electromyography of standardized locations was measured with the MyoSystem 2000 and analyzed with Myoresearch software. Gait analysis was performed with a six camera motion analysis system and force platforms.

Results: Both groups showed significant improvements between pre- and postoperative evaluation in gait analysis and electromyography, but gait analysis results as well electromyography did not show any difference between both groups at follow-up. Clinical and quality of life results significantly improved from pre- to postoperative evaluation, but only the Knee Society Score showed a significant superiority of the mobile bearing group (mean 159.0; SD 27.7; range, 105–196) over the fixed bearing group (mean 134.4; SD 41; range, 56–198) (p=0.0022).

Conclusions: In the present study, no functional advantage of mobile bearing TKA over fixed bearing devices could be found, although the mobile bearing group had better clinical results. Thus, long-term clinical results and in-vivo wear analyses have to be followed, and more subtle functional analyses (e.g. fluoroscopy) have to be employed to finally judge over the theoretical advantage of mobile bearing TKAs.

C.A. Busch B.J. Shore R. Bhandari S.J. MacDonald C.H. Rorabeck R.B. Bourne R.W. McCalden

Introduction: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. Locally administered pre-emptive analgesia is effective, reduces central hyper-sensitisation and avoids systemic drug related side-effects and may be of benefit in minimally invasive joint replacement.

Materials and methods: 64 patients undergoing total knee replacement were randomised to receive a peri-articular intra-operative injection containing ropiva-caine, ketorolac, epimorphine and epinephrine. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured.

Results: PCA use over 24 hours post surgery was significantly less in patients receiving the injection (P=0.013). Patient satisfaction at 4 hrs post operation was greater (P=0.003). VAS for pain during activity at 4 hrs and 24 hours were significantly less (P=0.001) in the injected group. The average ROM at 6 weeks was no different. Overall hospital stay and the incidence of wound complications was not different between the 2 groups.

Discussion: Peri-articular intra-operative multimodal analgesia significantly reduces post-operative analgesia requirement. Patient satisfaction is greater in the injection group. No cardio and central nervous system toxicity was observed.

K.J. Mulhall H.M. Ghomrawi B. Bershadsky K.J. Saleh

Although conventional thinking and teaching have implicated weight and body mass index (BMI) in premature failure of total knee arthroplasty (TKA) there is scant evidence based confirmation of this belief. Furthermore, there is little knowledge regarding the precise effect of BMI on functional outcomes following TKA. We performed this study to assess the effect of weight on the longevity of TKA and on outcomes following TKA revision (TKAR).

186 consecutive subjects undergoing TKAR in a 17-center prospective cohort study, had data collected on weight (pounds), BMI and time elapsed between primary and revision surgery (T). The Physical Component Score (PCS) of the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, and the Knee Society Score (KSS) were also collected preoperatively and at 6-month follow-up. Univariate, bivariate and multivariate statistical methods were used in the analysis.

The mean BMI and weight were 31.8 (54% of subjects had a BMI > 30) and 200 pounds (range 107–350) respectively. The distribution of both measures of excessive weight was close to normal. Average time between primary and revision procedures (T) was 7.3 years (range 6 months to 27 years). Using linear regression, T significantly decreased as weight (BMI) increased. Mean SF-36 PCS, WOMAC and KSS-Function scores were significantly improved 6 months after revision surgery. However, BMI and, in particular, weight were predictive of worse physical functional outcomes.

This study demonstrates the deleterious effect of weight on both the longevity of primary TKA as assessed at the time of revision and on functional outcomes following TKAR. Although further prospective data regarding this population is indicated, the current findings direct us towards better outcomes prediction for overweight patients and more effective counselling and appropriate management of these patients.

T. Floerkemeier C. Hurschler F. Witte M. Wellmann F. Thorey U. Halbritter H. Windhagen

Introduction Non-invasive prediction of load bearing capacity is an important issue in the advanced clinical treatment of distraction osteogenesis in order to define the appropriate point of time for the removal of the external fixateur. Therefore, non-invasive stiffness measurements were recommended as a promising tool due to the high correlation between strength and various kinds of stiffness: Torsional, bending and compressive.

However, previous experiments only analysed the relationship between a single type of stiffness. This approach neglects the multi-dimensional characteristics of bone loading in compression, bending and torsion.

This study investigates how compressive, bending (ap and ml) and torsional stiffness are related to the torsional load bearing capacity of healing callus tissue using a common set of bone regenerate samples of sheep treated with distraction osteogenesis. In addition, this study compares the evolution of the various kinds of stiffness.

This study provides insight into how the various stiffness modes are suited to predict the load bearing capacity by in-vivo stiffness measurement.

Material and Methods Mid-diaphyseal osteotomies were performed in 26 right tibiae of mature, female domestic sheep. Tibiae were then stabilized using an external half-ring Ilizarov fixator. After a 4-day latency period the tibiae were distracted at a rate of 1.25 mm per day in two increments for 20 days. As a result of a parallel study, the callus was treated with different combinations of growth factors and carrier material resulting in four treatment groups plus a contralateral control group. The sheep were sacrificed and the tibiae were harvested on the 74th day.

The ends of the tibiae were embedded in PMMA and mounted to a sequence of special custom made jigs for compressive testing, 4-point-bending and torsion in a material testing machine.

Stiffness was calculated by regression of the initial linear part of the load-displacement curves.

In a final experiment, the specimens were loaded in torsion until failure to record the ultimate torsional moment.

Results Torsional stiffness exhibits the highest correlation with the ultimate torsional moment (r2 = 0.77), while the ones for compressive (r2 = 0.60) and bending (ap (r2 = 0.70); ml (r2 = 0.66)) are only slightly lower.

Discussion This ex-vivo study in sheep shows that torsional, bending (ap and ml) and compressive stiffness measurements are all suitable means to predict the load bearing capacity of healing callus tissue. Our results show that torsional stiffness measurements perform slightly better than compressive and bending stiffness measurements. However, further studies are necessary to underline the superior performance of torsional stiffness measurements, since the sheep-tibiae were failed by applying torsional stress.

M. Jung J. Tuischer C. Sergi H.G. Simank

This study evaluated the effect of a collagen type I /hyaluronate (c/h) implant combined with recombinant human growth and differentiation factor-5 (rhGDF-5) in osteochondral cartilage defects of Göttinger minipigs.

In 20 Göttinger minipigs, critical size defects (6.2mm wide and 10mm deep) were created in the medial condyle of both femora. Defects were treated on one side either with the c/h implant alone (n=10) or the c/h implant + rhGDF-5 (n=10), whereas the other side was left empty as an intra-individual control. After 3 and 12 months, 5 animals from each treatment group were killed. The evaluation included macroscopic investigation, biomechanical exploration by relaxation test and semi-quantitative histological scoring using the O’Driscoll score.

No macroscopic differences were found between the two treatment groups, neither could any differences be found in semi-quantitative histological scoring. Biomechanical measurement after 12 months showed a significant increase in peak stress in the c/h group compared to empty defects, however, rhGDF-5 supplementation was not found to influence the biomechanical properties compared to controls. Bony cysts were seen throughout the three treatment groups, indicating insufficient bone regeneration. In two animals treated with rhGDF-5, pronounced ossifications within the joint capsule were observed. In contrast, no ossifications were detected in the knees with empty defects or single treatment with c/h implant.

In conclusion, the combination of a c/h implant plus rhGDF-5 did not result in better defect regeneration compared to c/h implants alone or even to empty defects in our minipig model.

One major problem seems to be the incomplete regeneration of the bony defect when using this device. In further studies, bilayer matrices should be used to address this problem. Due to the small number of specimens in this study, it cannot be resolved whether the ossifications seen in two knees were due to the usage of rhGDF-5 or can be regarded as an independent event. Further data about growth factor interaction should be acquired in animal studies before clinical introduction can be considered.

A. Moroni F. Pegreffi A. Frizziero A. Hoang-Kim S. Giannini

Purpose: Four external fixation pin types differing in coating, design and implantation technique were tested in an animal study.

Methods: Forty tapered pins were divided into 4 Groups according to pin design type: Group A consisted of 10 standard self-tapping pins (ø5–6mm, pitch 1.75mm), Group B 10 hydroxyapatite (HA)-coated self-tapping (ø5–6mm, pitch 1.75mm), Group C 10 standard, self-drilling, self-tapping (ø5–6mm, pitch 1.25mm) and Group D 10 HA-coated, self-drilling, self-tapping (ø5–6mm, pitch 1.25mm). Four pins were randomly implanted into the femoral diaphysis of 10 sheep. The pins were implanted at 2-cm intervals apart. Pre-drilling was used for Groups A and B but not for Groups C and D. Sheep were euthanized 6 weeks after surgery.

Results: There were no major complications. Mean pin insertion torque was 3100 ± 915 Nmm in Group A, 2808 ± 852 Nmm in Group B, 2589 ± 852 Nmm in Group C and 2180 ± 652 Nmm in Group D. Mean pin extraction torque was 1570 ± 504 Nmm in Group A, 2128 ± 1159 Nmm in Group B, 1599 ± 809 Nmm in Group C and 2200 ± 914 Nmm in Group D. Insertion torque of the coated groups was lower than insertion torque of the standard groups (p < 0.05). However, extraction torque of Groups B and D was higher than Groups A and C (p < 0.05). No differences in pin fixation were found between the two coated pin groups (Group B and D). Morphologic analysis showed extensive bone to pin contact without fibrous tissue interposition in the coated pin groups and fibrous tissue interposition in the uncoated pin groups.

Conclusion/Significance: This study demonstrated that coating pins with hydroxyapatite is effective regardless of the pin design and the implantation technique.

I. Rubel E. Fornari B. Miller W. Hayes

Introduction: The use of self-tapping screws has become increasingly popular since it allows for a rapid screw placement avoiding the tapping step during ORIF of fractures.. While sharing the same basic principle of cutting flutes and partial threads at the tip, at least four types of screw design is currently available, varying in the number and shape of cutting flutes. The purpose of this biomechanical study was to research for any significant difference between the various self-tapping screws

Material and Methods: Three different designs of 4.5-mm self-tapping screws and one standard 4.5 screw serving as control were compared for pull-out strength after insertion into an adult human non-embalmed cadaveric humeri. All specimens were machined to a 5 mm uniform cortical thickness. Four equidistant 3.2 mm holes were drilled into each specimen by an MTS mounted drill. All screws were inserted randomly in one of the four positions using a hand screwdriver. The cortical bone specimen was secured between two metal plates to the base of a MTS machine while a uniaxial tensile force was applied to the jig for screw removal at a rate of 0.833 mm/sec until holding power had decreased to 25 % of the maximum. Load displacement curves were recorded. Resulting data was analyzed using paired student-t tests. P values of less then 0.05 were considered statistically significant.

Results: The mean load-to-failure was 97.4167N (S.D. 13.29924) for the Synthes control screw, 69.2333N (S.D. 4.48360) for the Synthes self-tapping screw, 67.15 (S.D. 11.23864) for the Stryker self-tapping screw, and 55.0667 (S.D. 8.59271) for the ODI self-tapping screw. A significant difference was found between the mean pull-out strength of the Synthes control screw when compared to each of the three self-tapping screws (Pairs 1–3, P < 0.05). Furthermore, the mean pull-out strength of the ODI self-tapping screw was found to be significantly less than Stryker self-tapping screw (Pair 6, P < 0.05). There was no significant difference between Synthes self-tapping screws and Stryker self-tapping screws (Pair 5, P < 0.05).

Discussion and conclusion: Self tapping screws with three short cutting flutes performed better than those with two long cutting flutes. Despite of the different designs and length of the cutting flutes in self-tapping screws, they all have less pull out strength than regular screws

J.J De Poorter T.W.J Huizinga J Ellis A Mountain R.C. Hoeben R.G.H.H. Nelissen

Elderly patients with a high mortality risk for revision surgery are severely handicapped by a loosened hip prosthesis. Loosening is mainly caused by particle-induced osteolysis leading to the formation of a synovium-like interface tissue. As an alternative to revision surgery we have investigated the possibility of removing the tissue using a gene therapy approach and thereafter stabilizing the prosthesis with percutaneous cement injection.

First we demonstrated that transduction of interface cells with a gene coding for E.coli nitroreductase (NTR) resulted in a 60-fold increase in sensitivity to the prodrug CB1954 that is converted to a toxic metabolite by NTR. Given these in-vitro data, we explored if intra-articular administration of this adenoviral vector encoding NTR followed by the prodrug was able to kill sufficient tissue in-vivo to allow refixation of the prosthesis by cement.

We report the first three patients from a phase 1 study of 12 patients with a loosened hip who are experiencing debilitating pain and have significant comorbidity. On day 1 the vector is injected into the hip joint and on day 3 the prodrug is injected. On day 10 three holes are drilled in the femur and one in the acetabulum. Biopsies are taken from the periprosthetic space and low viscosity cement (Osteopal, Biomet Merck, Sjöbo, Sweden) is injected under fluoroscopic guidance.

The first three patients have been included in the study and five more are planned for treatment before June 2005. The patients are females of 86, 72, and 79 years old. There were no adverse effects from vector injection (3x10 exp 9 particles). Six hours after prodrug injection the patients experienced nausea, (WHO grade 1) a commonly reported reaction to this prodrug. There was vomiting in two patients. Hip pain increased, but this was anticipated as this therapy will increase prosthesis loosening. 16 ml of cement was subsequently injected into the periprosthetic space in the first patient and 18 ml in the second. The patients were ambulated the day after surgery.

The first two patients have a follow-up of twelve and six weeks. There was no pain in the hip. The maximum walking distance had increased from 5 to 30 meters in the first patient.

The current study is the first to use in vivo intra-articular adenoviral mediated gene transfer in a clinical setting. Our preliminary results suggest that gene therapy and cement injection for hip prosthesis refixation is clinically feasible.

H.A. Anetzberger E. Thein S. Vogt A. Imhoff

The fluorescent microsphere (FM) method is considered the best technique to determine regional bone blood flow (RBBF) in acute experiments. In this study we verified the accuracy and validitiy of this technique for measurement of RBBF in a long-term experiment and examined RBBF after meniscectomy. 24 anesthetized female New Zealand rabbits (3 groups, each n=8) received consecutive left ventricular injections of FM in defined time intervals after meniscectomy. Group 1 from preoperatively to 3 wks postoperatively, group 2 from 3 wks to 7 wks, and group 3 from 7 wks to 11 wks postoperatively. To test the precision of the FM-method in long-term experiments two FM-species were injected simultaneously at the first and last measurement. After the experiment both humeri, femora, and tibiae and reference organs (kidney, lung, brain) were removed and dissected according to standardized protocol. Fluorescence was determined in each reference blood and tissue sample and blood flow values were calculated. Blood flow in kidney, lung, and brain revealed no significant difference between right and left side and remained unchanged during the observation period excluding errors due to shunting and dislodging of spheres in our experiments. Comparison of relative bone blood flow values obtained by simultaneously injected FM showed an excellent correlation at the first and last injection indicating valid RBBF measurements in long-term experiment. We found a significant increase of RBBF 3 wks after meniscectomy in the right tibial condyles compared to the non-operated left side. Similar changes were found in the femoral condyles. RBBF in other regions of tibia, femur, and humerus revealed no significant difference between right and left bone samples of the same region. Our results demonstrate that the FM method is also valid for measuring regional bone blood flow in long-term experiments. In addition we could demonstrate that meniscectomy leads to an increase of RBBF in the tibial condyles very early. This increase might be caused by stress-induced alterations of the subchondral bone.

J.C. Theis N. Aebli G. Davis J. Krebs D. Schwenke

Purpose: To investigate the effect of pressurizing vertebral bodies during vertebroplasty using different materials in the development of fat embolism (FE) and any associated cardiovascular changes.

Polymethylmethacrylate (PMMA) is the material of choice for vertebroplasty (VP). However, PMMA has several disadvantages such as exothermic curing, uncertain long-term biomechanical effects and biocompatibility. As a result alternative materials are being developed to overcome these problems.

In order to determine the role of PMMA in the generation of cardiovascular changes following vertebroplasty we compared injection of cement with wax in an animal model.

Method: In twenty sheep, four vertebral bodies were augmented either with PMMA or bone wax. Heart rate, arterial, central venous and pulmonary artery pressure, cardiac output and blood gas values were recorded. At postmortem the lungs were subjected to histological evaluation.

Results: The consecutive augmentation of four vertebral bodies with PMMA induced cumulative fat embolism causing significant deterioration of baseline mean arterial blood pressure (MABP) and blood gas values. Injection of bone wax resulted in similar cardiovascular changes and amount of intravascular fat in the lungs.

Conclusion: In this animal model cardiovascular complications during multiple VP happen regardless of the augmentation material used. The deteriorating baseline MABP during VP is associated with the pressurization and displacement of bone marrow/fat into the circulation rather than caused by polymethylmethacrylate.

J.P. Dillon A.J. Laing J.R.S. Chandler C.J. Shields J.H. Wang A.J. McGuinness H.P. Redmond

Aims: Pharmacological modulation of skeletal muscle reperfusion injury after trauma associated ischaemia may improve limb salvage rates and prevent the associated systemic sequelae. Resuscitation with hypertonic saline restores the circulating volume and has favourable effects on tissue perfusion and blood pressure. The purpose of our study was to evaluate the effects of hypertonic saline on skeletal muscle ischaemia reperfusion (I/R) injury and the associated endorgan injury.

Methods: Adult male Sprague Dawley rats (n=24) were randomised into three groups: control group, I/R group treated with normal saline and I/R group treated with hypertonic saline. Bilateral hind-limb ischaemia was induced by rubber band application proximal to the level of the greater trochanters for 2.5 hours. Treatment groups received either normal saline or hypertonic saline prior to tourniquet release. Following twelve hours reperfusion, the tibialis anterior muscle was dissected and muscle function assessed electrophysiologically by electrical field stimulation. The animals were then sacrificed and skeletal muscle harvested for evaluation. Lung tissue was also harvested for measurement of wet-to-dry ratio, myeloperoxidase content and histological analysis.

Results: Hypertonic saline significantly attenuated skeletal muscle reperfusion injury as shown by reduced twitch and tetanic contractions of the skeletal muscle (Table). There was also a significant reduction in lung injury as demonstrated by differences in wet-to-dry ratio, myeloperoxidase content and histological analysis.

Conclusion: Resuscitation with hypertonic saline may have a protective role in attenuating skeletal muscle ischaemia reperfusion injury and its associated systemic sequelae.

V. Athanasiou D.J. Papachristou A. Saridis C.D. Scopa E. Lambiris P. Megas

Aims: This experiment study was undertaken to evaluate the differences, in bone response to various grafts.

Methods: Ninety, 3.5 months New Zeland white rabbits, weighing 4kg, were divided randomly in 6 groups of 15 animals. Under anesthesia, a 4.5mm hole was drilled in the 2 posteriors femoral condyles of each rabbit, in totaling 180 condyles. Holes were filled with various grafts as follow: Group I-autograft, Group II-xenograft (Lubboc®), Group III-allograft DBM (Grafton®), Group IV-substitute calcium sulfate (Osteoset®), Group V-substitute calcium phosphate hydroxyapatite (Ceraform®), Group VI- was used control. After the implantation, the animals were sacrificed at 1, 3 and 6 months intervals tissue samples from the implanted areas were processed for histological evaluation.

Results: Group I: At 1 month, autologous grafts were lined with activated osteoblasts and osteoclasts. Lamellar bone and cartilage were evident. Neoangiogenesis was prominent. At 3, 6 months defects were filled with mature bone. Group II: Lubboc® displayed moderate (1 month) to intense (3 months) remodeling activity and pronounced neoangiogenesis. At 3 months, endochondral osteogenesis and lamellar bone production were more prominent. At 6 months graft material was significantly restricted and lamellar had considerably replaced woven bone. Group III: Grafton® putty was present at 1, 3 months. There were few osteoblasts and numerous multinuclaeated cells rimming implant surfaces. Endochondral ossification foci, new bone formation and neovascularisation were observed (1, 3 months). At 6 months DBM fibers were absent. Lamellar and woven bone was evident. Group IV: At 1 month new bone (mostly woven) was present, lined with activated osteoblast and few osteoclasts. Endochondral ossification and angiogenesis were evident. At 3, 6 months bone remodeling was augmented, and Osteoset® graft was diminished. Complete closure of defects was observed, at 6 months. Group V: Ceraform® exhibited almost the same properties as Osteoset®. However, endochondral osteopoiesis and bone remodeling were less intense. Additionally, after 6 months, Ceraform® was still evident. Group VI: The defect areas were clearly observed at 1, 3 months.

Conclusion: Autografts are the most effective graft materials. Although Lubboc® is not totally resorbed, it seems to induce lamellar bone synthesis stronger than Grafton®. Bone substitutes are inferior to allografts.

R. Skripitz A. Werner W. Ruther P. Aspenberg

The aim of our study was to evaluate if PTH is able to increase the trabecular density of osteoporotic bone at the site of an implant and whether the anabolic effect of PTH at this side is stronger then the effect of an osteoclast inhibitor like alendronate.

48 cement rod was inserted in the tibia of 48 female rats, of which 36 had been ovariectomized. The cement rods, which served as implants, were made of Palacos R bone cement. After implantation, the 36 ovariectomized rats were divided in 3 groups. One was injected subcutaneusly with PTH (1–34) at a dose of 60 g/kg BW. The second was injected with alendronate at a dose of 205 g/kg BW. The third with vehicle only. The remaining 12 sham operated rats were also injected with vehicle only. All injections were given three times a week and the rats were killed 2 weeks after implantation.

The tibial segments around the hole of the rods were prepared histologically. Thus the surfaces which had been in contact with the rod appeared as straight lines and could be analyzed histomorphometricly. The trabecular density of the bone closest to the implant was measured. One femur of all animals was used for measurement by DEXA.

There was a substantial increase in the trabecular density close to the rods with PTH treatment (Anova p=0.002). PTH lead to a trabecular density of 89%, where as the ovariectomized animals revealed a trabecular density of 58% and the sham operated control of 68%. No significant increase of implant related trabecular density could be found in the alendronate treated group. In this group a density of 72% was established. DEXA showed the expected differences in bone mineral content (Anova p=0.001).

In this study, intermittent PTH treatment increased implant-related trabecular density in osteoporotic bone after 2 weeks. No such positive effect could be found with alendronate treatment at such a short period of time. We think the reason for this phenomenon could be the early onset of the anabolic PTH effect on regenerating bone, whereas alendronate is thought to only inhibit bone resorption, which might lead to a later effect.

The early onset of PTH effects even in osteoporotic bone suggests that intermittent PTH treatment might lead to an increased micro-interlock between implant and bone and might therefore be considered as a possible drug to enhance incorporation of orthopedic implants.

T. Gunes B. Saygi M. Erdem R.D. Koseoglu N. Kilic C. Sen

Objectives: Hyaluronic acid (HA) is used in osteoarthritis especially for the control of pain. In this animal study, we investigated the effects of HA on the early stage of osteoarthritis.

Methods: The experimental osteoarthritis model was constituted on 10 rabbits by the way of anterior cruciate ligament transection. In HA group, HA was injected 0.6 ml (15mg/ml) dosage per week for 3 weeks in right knees of ten rabbits and in SF group, saline was injected 0.6 ml dosage per week for 3 weeks in left knees of rabbits. Because three rabbits died in experimental period, fourteen knees of seven rabbits were taken into account for the study. The knees of rabbits, which were sacrified at 12th weeks after index operation, were measured according to cartilage area and Mankin scale.

Results: The mean cartilage area of HA and SF groups were measured 1.097 mm2 and 0.477 mm2, respectively. The difference of mean cartilage area between HA and SF groups was statistically significant (p< 0.05). According to Mankin scale, the mean total point of scale was measured 3.57 in HA group and 11.14 in SF group and the difference between mean total points of groups was significant (p< 0.05). Although, there is no significant difference in cellular abnormality, matrix staining, and tidemark continuity criteries of scale, we found the significant difference between total point and structure of cartilage criteria of scale.

Conclusions: HA has a retarder effect on progression of cartilage injury in early stage osteoarthritis.

M. Foeren H. Koepp W. Puhl

Introduction: Filling of bone defects is a significant challenge in Orthopaedic Surgery. Human fresh-frozen allograft is still the most effective bone graft substitution material («gold standard»), guaranteeing all essential biological and physiochemical demands (osteogenic, osteoinductive, and osteoconductive) when the necessary amount of autologous bone is not available. Using donor screening recommendations, more than 50 % of potential donors have to be excluded. With increasing incidence for revision hip surgery and especially acetabular reconstructions, a hospital associated bone bank has difficulties meeting demand. The aim of this study is to evaluate the balance and resource utilisation of a hospital associated bone bank for fresh-frozen allografts and the correlation to commercial alternatives regarding cost effectiveness.

Method: For evaluation of resource utilisation and cost effectiveness of a hospital associated bone bank, all donation processes and the details of allograft use were analysed and summarized within a period of 30 months. Given the increasing disproportion of demand and availability, the reasons for exclusion, especially for exclusion during the preservation period, were carefully scrutinized. The costs of installation and maintenance of the bone bank, as well as all costs in the screening process were balanced to calculate the «per head»-price. The results were compared to commercial alternatives.

Results: Within the period of evaluation 632 femoral heads were available for donation. Through the screening process 359 femoral heads (56.8%) met at least one criterion for exclusion. At the end of the observation period of six months and after HIV retesting, 246 allografts met all criteria for use. The mean period between inclusion in the bone bank and release was 10.9 5.0 months (range 6.0–30.8).

50.8% of released allografts (125 heads) were used in revision arthroplasty. In spine surgery 83 allografts (33.7%) were implanted in spinal fusions and for cage filling during vertebral body replacement. Thirty-two grafts (13.0%) were used in miscellaneous surgeries with minor bone demand.

The costs per donation were 92, with personnel costs the price per head was 140. The price range for commercial alternatives starts at 100 for 1 cm.

Conclusion: A hospital associated bone bank for fresh-frozen allografts is still an effective and cost effective method to maintain material for bone defect filling. To meet demand, information and communication to donors has to be increased to get the HIV-retests. Additionally, division of donations into smaller portions helps to decrease waste in surgeries where less bone is required.

E. Tsiridis M. Kain M. Song J. Bancroft J. Rene S. Kakar E. Morgan L.. Gerstenfeld P. Tornetta T. Einhorn

Background: Metaphyseal fracture healing presents special biomechanical challenges in orthopaedic surgery. The void typically created by damage to the metaphyseal cancellous bone must usually be filled in order to recover the biomechanical integrity of the bone. While autologous bone grafting is a standard treatment for these fractures, bone graft substitutes delivered with or without pharmacologic agents may augment healing.

Hypothesis: Tricalcium phosphate (TCP) is a known osteoconductive bone filler and OP-1 an osteoinductive bone morphogenetic protein; both have been used in the past in diaphyseal fractures with success. PTH (parathyroid hormone) has been recently shown to enhance osteoblastic activity, to have a net anabolic effect on bone mass, and to enhance healing of diaphyseal fractures. Each of these agents may also enhance healing of metaphyseal fractures.

Objective: The potential of all above factors to accelerate metaphyseal fracture healing has been evaluated in a new metaphyseal fracture model developed in our laboratory in a rabbit model.

Material and Methods: A metaphyseal wedge osteotomy was created in the distal tibia of 16-week-old female New Zealand White rabbits (n=20). The osteotomy was bridged with a custom-made external fixator. The osteotomy gap was filled with TCP containing OP-1 (n=4), TCP alone with daily subcutaneous injections of 10μg/Kgr BW PTH (n=4), or TCP alone with daily subcutaneous administration of 40μg/Krg BW PTH (n=4). Two control groups, TCP alone (n=4) and normal healing (n=4), were also included. Assessment methods included biomechanical testing in both compression and torsion, radiographic examination, and QCT scans.

Results: Healing was observed in both PTH treated groups as well as in the OP-1 group at 4 weeks post-surgery. PTH appeared to have a systemic effect on bone formation, whereas the effect of OP-1 was local to the osteotomy site. In comparison, healing was delayed in the normal healing and TCP alone groups.

Conclusion: PTH and OP-1 both enhance metaphyseal fracture healing. The different systemic vs. local effects of these two agents, suggest that PTH and OP-1 may have potential synergism in accelerating healing of metaphyseal fractures.

F. Thorey F. Witte J. Nellesen N. Griep-Raming H. Menzel G. Gross A. Hoffmann H. Windhagen

Introduction: Despite advances in endoprosthesis fixation by implant surface alteration, the problem of aseptic implant loosening still exists. Especially in patients with revisions osseointegration and filling of gaps at the bone-implant interface is mandatory for implant survival. Simple BMP-2 immersion has been introduced previously to act as an osteoinductive coating for advanced osseointegration. However, because of the uncontrolled release kinetics and subsequent molecular action and activity of BMP-2, purely osteoinductive actions are hard to differentiate from osteoclastic BMP-actions leading to bone remodelling, which could counteract the implant fixation process and might be the reason for failed attempts to use BMP-2 for implant fixation. In this study we investigated the osteoinductive potency of BMP-2 bound to titanium surfaces by a highly controlled molecular coupling with specifically designed polymers, allowing a slow controlles release kinetics. We present the first results of two different polymers that were implanted in the tibia and femora of New Zealand White Rabbits.

Methods: In this study we designed cylindrical titanium-implants with an inner thread (Ti6-Alï·& #8220;4V, 3 mm hight x 3 mm diameter) and an electropolished outer surface that were coated with different polymers. The polymers were fixed to the surface using the photochemical method of grafting. The implants were implanted in the proximal tibia and distal femora of New Zealand White Rabbits. The anatomical locations of the implants were alternated to test their osseointegration in different quality of bone (cancellous vs. cortical bone). After 4 weeks the animals were sacrificed and DEXA-scans (Dual-energy X-ray absorptiometry), micro-CT and histological analysis were performed. ANOVA and t-test were used for statistic analysis.

Results: In high-resolution DEXA-scans we found a difference in bone mineral density (BMD) between PVBP and a control implant in the distal femora (PVBP 0,720 g/cm², control 0,661 g/cm²) and in the proximal tibia (PVBP 0,633 g/cm², control 0,431 g/cm²) with an increase of bone mineral density. In the histological investigation we found an increase of osteoblasts around the implants coated with PVBP and PVBP-Co-Acryloxysuccimid. Furthermore, the micro-CT scans showed an increase of BV/TV (bone volume/total volume) for both polymers.

Discussion: In this study we present the first results of the investigation of polymer-coated titanium-implants implanted in the proximal tibia and distal femora of New Zealand White Rabbits. The results of DEXA-scans, micro-CT and histological analysis showed an increase of osseointegration. We suggest that controlled release kinetics after coupling of these polymers with BMP-2 can additionally increase osseointegration. To get a closer look on the polymers, their characteristics in-vivo, and coupling with BMP-2 further investigations are conducted.

A.J. Laing J.P. Dillon J.H. Wang H.P. Redmond A. McGuinness

Background: Periprosthetic osteolysis precipitates aseptic component loosening, increases periprosthetic fracture risk and through massive bone loss, complicates revision surgery.

Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation. Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia and cardiovascular disease. The antiinflammatory properties of HMG-CoA reductase inhihitors or the statin family are well recognised. We investigated the effects of ceriv-astatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.

Methods: Polymethylmethacrylate-particle-stimulated human macrophages were cultured in vitro with cerivastatin at 75 and 150micromols/litre. TNF- alpha (tumour necrosis factor alpha) and MCP-1 (monocyte chemotactic protein) expression were determined using ELISA. UO126, a Raf/MEK/ERK intracellular transduction pathway inhibitor, was utilised to identify the mitogen activated protein kinase (MAP- Kinase) pathway involved and western blotting was used to demonstrate the effect of cerivastatin on this pathway.

Results Human monocyte/macrophage cultures were activated by PMMA particles evidenced by TNF- alpha and MCP-1 expression(p< 0.05). This activation was consistently attenuated by cerivastatin therapy. Similarily, PMMA activation was attenuated by the Raf/MEK/ERK inhibitor, UO126.

Western blotting confirmed Raf/MEK/ERK down-regulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.

Conclusion We have demonstrated in vitro, that statins can abrogate particle induced inflammatory responses in a dose dependent manner and this is mediated intra-cellularily through its effect on the Raf/MEK/ERK transduction pathway. We propose that by attenuating this inflammatory response, the associated subsequent osteoclast activation and osteolysis is attenuated. Statins therefore may have role in promoting implant longevity

G. Cakmak S. Bolukbasi U. Kanatli A. Dursun O. Erdem G. Yilmaz

Aim: Bone grafts and bone graft substitutes are often used at radical surgical procedures such as; trauma, congenital anomalies, tumor surgery, bone infections, revision arthroplasty surgery, spinal surgery. However autograft and allograft bone are frequently used, they have some limitations. ABM/P-15 (Pepgen P-15) is a combination of anorganic bovine derived hydroxyapa-tite matrix coupled with a synthetic-cell binding peptide (P-15). This tissue engineered particulate bone replacement graft has been established for the treatment of periodontal osseous defects. The aim of this study is to determine the effect of ABM/P-15 on the healing of a critical sized segmental defect in rat radius.

Methods: 36 Wistar rats were used at this study. A critical sized segmental defect was created in each rat radius. 13 defects were filled with ABM/P-15 Flow (putty form), 12 defects were filled with ABM/P-15, and 11 defects were used as a control group. The rats were killed at 10 weeks. The healing of defects was evaluated with radiographic and histological studies.

Results: The use of ABM/P-15 and ABM/P-15 Flow were demonstrated improved healing of segmental bone defects in rat radius on radiographic and histological studies compared with control group. Statistical evaluation showed that there were significant differences between control sites, and sites treated with P-15 and P-15 Flow (p< 0.005). The highest radiological and histological grades were achieved by P-15. Osteogenic proliferation was seen at the P-15 group more than P-15 flow.

Conclusion: Segmental cortical bone defects may be treated with ABM/P-15 instead of bone allografts, and autografts. According to the radiologic and histological parameters measured in this study, the implantation of ABM/P-15 resulted in optimum healing of the segmental cortical bone defects.

H.H. Muratli L. Celebi O. Hapa A. Bicimoglu

Because endothelins (ET) have effects on functions of both osteoblasts and osteoclasts, it is thought that these peptides may be one of the mediators of coupling phenomena that maintain the connection and regulation between bone formation and resorption process in osteogenesis. Along with their demonstrated effects on osteogenic cells they have dual activity on both mineralization and resorption process. So it is also thought that they may have a major role in bone turnover and remodeling processes. We aimed to investigate if ET had a role in the pathophysiology of osteoporosis. Therefore we looked for a difference in ET plasma levels between osteoporotic and normal people.

86 patients (16 men and 70 women) with a mean age of 62.6 (ranges: 51–90) years were included in this study. All patients were examined by dual energy X-ray absorbsiometry evaluation at first. Patients were divided into 3 groups regarding reported T scores. T-scores less than −2.5 on either total lumbar spine or total hip were accepted as osteoporosis, while scores between −1 and −2.5 were accepted as osteopenia and scores above −1 were accepted as normal according to the suggestions of World Health Organization. According to these criteria 19 patients were normal, 43 were osteopenic and 24 were osteoporotic. Then total plasma level of ET was measured in all patients with monoclonal antibody based sandwich immunoassay (EIA) method.

One-way analysis of variance test was used to compare endothelin values between normals, osteopenics and osteoporotics regardless of gender and for each gender. A value of p< 0.05 was considered as significant.

Endothelin total plasma level in patients with osteoporosis was a mean of 98.3663.96 pg/ml, a mean of 100.9247.2 pg/ml in osteopenic group and a mean of 99.5656.6 pg/ml in normal group. The difference between groups was not significant (p> 0.05). In men with osteoporosis endothelin level was a mean of 185.7017.2 pg/ml and this was significantly higher than osteopenic men (124.8059.6 pg/ml) (p< 0.05) and normal men (93.0050.1pg/ml) (p< 0.05). In women there was not any significant difference between groups (normal:102.0060.7pg/ml, osteopenics: 94.7042.7pg/ml, osteoporotics: 79.9053.8pg/ml) (p> 0.05).

We found out that plasma ET levels of osteoporotic men were significantly higher than normal men. But comparison regardless of gender among osteoporotics, osteopenics and normals and comparison of female osteoporotics, osteopenics and normals yielded no significant differences. We think that the reason for differences in our results regarding gender may be the higher estrogen level of the females even if they were in the postmenopausal period and thus estrogens’ possible effect of down regulation in ET-1. Considering these results we think that ET may have a role in the pathophysiology of the men osteoporosis and it can be used as a marker for diagnosis and treatment follow-up of osteoporosis.

J.T. Street B.J. Lenehan J.H. Wang Q.D. Wu H.P. Redmond

Background Apoptosis of osteoblasts and osteoclasts regulates bone homeostasis. Skeletal injury in humans results in angiogenic responses primarily mediated by vascular endothelial growth factor(VEGF), a protein essential for bone repair in animal models. Osteoblasts release VEGF in response to a number of stimuli and express receptors for VEGF in a differentiation dependent manner. This study investigates the putative role of VEGF in regulating the lifespan of primary human osteoblasts(PHOB) in vitro.

Methods PHOB were examined for VEGF receptors. Cultures were supplemented with VEGF(0–50ng/mL), a neutralising antibody to VEGF, mAB VEGF(0.3ug/mL) and Placental Growth Factor (PlGF), an Flt-1 receptor-specific VEGF ligand(0–100 ng/mL) to examine their effects on mineralised nodule assay, alkaline phosphatase assay and apoptosis.. The role of the VEGF specific antiapoptotic gene target BCl2 in apoptosis was determined.

Results PHOB expressed functional VEGF receptors. VEGF 10 and 25 ng/mL increased nodule formation 2.3- and 3.16-fold and alkaline phosphatase release 2.6 and 4.1-fold respectively while 0.3ug/mL of mAB VEGF resulted in approx 40% reductions in both. PlGF 50ng/mL had greater effects on alkaline phosphatase release (103% increase) than on nodule formation (57% increase). 10ng/mL of VEGF inhibited spontaneous and pathological apoptosis by 83.6% and 71% respectively, while PlGF had no significant effect. Pretreatment with mAB VEGF, in the absence of exogenous VEGF resulted in a significant increase in apoptosis (14 vs 3%). BCl2 transfection gave a 0.9% apoptotic rate. VEGF 10 ng/mL increased BCl2 expression 4 fold while mAB VEGF decreased it by over 50%.

Conclusions VEGF is a potent regulator of osteoblast lifespan in vitro. This autocrine feedback regulates survival of these cells, mediated via the KDR receptor and expression of BCl2 antiapoptotic gene.

J.C. Theis N. Aebli J. Krebs H. Stich P. Schawalder

Current research efforts aim at enhancing osseointegration of cementless implants to improve early bone fixation.

Purpose: The aim of the present study was to investigate whether bone morphogenic protein (BMP) 2 had a positive effect on the osseointegration of hydroxyapatite coated implants.

Method: Hydroxyapatite (HA) implants were coated with BMP-2 and hyaluronic acid (HY) as the carrier or with HY alone. Uncoated HA-implants served as controls. The osseointegration of the implants was evaluated either by light microscopy or by pullout tests after 1, 2 and 4 weeks of unloaded implantation in the cancellous bone of 18 sheep.

Results: The BMP-2 coating significantly increased bone growth into the perforations of HA-implants. The proportion of bone-ingrowth at 4 weeks was 32% for the BMP-implants compared to 12% for HA implants. However, BMP-2 did not enhance the percentage of bone implant contact and interface shear strength values.

Conclusion: This study indicates that BMP-2 may help to increase bone growth across gaps of cementless implants in the early stages of bone healing improving fixation and decreasing the risk of loosening.

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G. Burastero G. Grappiolo M. Podestà F. Frassoni S. Castello N. Sessarego L. Spotorno

Introduction In our experimental design we evaluated the osteogenic potential of h-bone marrow (hBM), h-mesenchymal stem cells (hMSC), bone morphogenetic protein (BMP-7) and the combination hMSC plus BMP-7. The aim of the study was to define the capacity to elicit bone formation of expanded hMSC alone and associated with BMP-7

Material and methods A rat femoral segmental defect model was used in this study. 12 male athymic rats were used. The institutional Animal Ethics Committee approved the study. Athymic rats test graft groups consisted of: G1-autoclaved bone and h-BM; G2-bone and h-MSC; G3-bone with BMP-7; G4-bone and h-MSC with BMP-7. h-BM aspirates were harvested from iliac crests of patients undergoing to THA. A plate has been fixed on the femurs with four cerclage wires before a femoral gap of 6mm has been realized in the diaphysis. Gap was filled with different graft. Defect was evaluated at 2, 4, 8, 12 weeks after implantation with radiographs. Evaluation of bone graft has been done using a Cook classification. Histological study with toluidine blue and safranine O at 12 weeks has been performed in each group.

Results At 8–12 weeks after surgery G1 shown non visible new bone formation, G2 minimal new disorganized bone and G3 disorganized new bone bridging graft to host at both ends. The G4 group show significant new bone and graft remodelling. Histological analysis confirmed the rx results.

Conclusion The association hMSC plus BMP-7 determines a significant activation of the osteogenic activity at 8 weeks that may have a remarkable impact on the future orthopedic surgery strategies.

C.O. Tibesku T.S.A. Szuwart S.A. Ocken A. Skwara S. Fuchs

Aim: Investigations on human hyaline cartilage of late stage degenerative arthritis showed that the vascular derived endothelian growth factor (VEGF) seems to play a role in the development of degenerative arthritis. The current study was designed to evaluate the expression of VEGF on chondrocytes of hyaline cartilage in the time course of degenerative arthritis.

Methods: In twelve white new-zealand-rabbits the anterior cruciate ligament was resected to create an anterior instability of the knee. In twelve control rabbits only a sham operation without resection of the ACL was done. Another four animals have not been operated at all (0 weeks). Four animals of each group were sacrificed at three, six and twelve weeks each. After opening of the knee joint, the degenerative arthritis was macroscopically graded and the hyaline cartilage of the load bearing area was evaluated histologically according to Mankin and by immunostaining for VEGF.

Results: The macroscopic and histological grade of degenerative arthritis according to Mankin showed a positive linear correlation to the time after surgery. The scores of the control group were constant in the time course. In the cartilage of the untreated animals (0 weeks) an average of 12 percent (SD 2.6) VEGF-positive chondrocytes were found. After 3 weeks the trial group (17.6%; SD 5.7) as well as the control group showed a significant increase (16.2%; SD 4.7). After 6 weeks the value in the control group dropped to normal (11.5%; SD 5.9) and remained constant after 12 weeks (11.6%; SD 3.3). In the trial group the percentage of VEGF positive chondrocytes rose steadily (19.4%; SD 4.6 after 6 weeks; 21.3%; SD 5.4 after 12 weeks). There was a positive linear correlation between the percentage of VEGF positive cells and the Mankin score (r=0.767; p< 0.01) and the macroscopic score (r=0.518; p=0.02).

Conclusion: The current study shows for the first time an in-vivo increase of VEGF expression on chondrocytes in the time course of osteoarthritis, which is dependent on macroscopic and histological grades. Further studies are needed to evaluate whether this pattern applies to human beings and whether new treatment approaches could evolve from this knowledge.

M Wellmann F. Witte J. Nellesen H.-A. Crostack T. Floerkemeyer H. Windhagen

Introduction: The long consolidation phase of patients undergoing distraction osteogenesis (DO) causes a high risk of side effects and contributes to high costs. Thus, the development and evaluation of treatments that accelerate the bone consolidation process is of great interest. Evidence suggests that recombinant human bone morphogenetic protein 2 (rhBMP-2) increases the mechanical integrity of the callus. However, the potential benefits of rhBMP-2 on trabecular microarchitecture during DO have not been investigated up to date. In this study the regenerate microarchitecture was assessed using 3D micro-computed tomography (CT).

Methods: Mid-diaphyseal osteotomies were created in the right limb of twenty-four skeletally mature sheep, which were stabilized with an external fixator. After a latency period of 4 days, the tibiae were distracted at a rate of 1.25 mm daily over a period of 20 days. The operated limbs were randomly assigned to three treatment groups and one control group: (A) triple injection of rhBMP-2/NaCl, (B) single injection of rhBMP-2/Hydroxylapatite, and (C) single injection of buffer/Hydroxylapatit, (D) no injection. Groups A and C were injected at day 27. Group B was injected on days 3, 10 and 17. The animals were sacrificed after 74 days. The tibiae were analyzed by CT and for bone volume/total volume (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th.), trabecular separation (Tb.Sp.) and Connectivity. The BV/TV was maesured for the total volume of the distraction zone (BV/TVtotal) respectively in a subvolume with emphasize on the cortical bone region (BV/TVcortical). All other microarchitecture parameters were measured in the cortical weighted subvolume.

Results: The stereologic evaluation revealed a significant higher BV/TVcortical, Tb.N and Connectivity in the triple rhBMP-2 injected group A than in the control (D). Furthermore, the Tb.Sp. in group A was significant lower than in group D. The single injections of rhBMP-2/carrier in group B showed a significant higher BV/TVcortical, Tb.N and Connectivity than the control (D). Although the BV/TVcortical was increased in group A and B, there was no significant difference in BV/TV total between the rhBMP-2 treated groups (A, B) and the control (D).

Discussion: In this DO model a triple injection of rhBMP-2 has been demonstrated to induce significant changes in trabecular microarchitecture. RhBMP-2 does not increase the total amount of newly formed bone, but it enhances the formation of the corticalis. The microstructural changes in the cortical volume: increase of Tb.N and Connectivity, decrease of Tb.Sp., are discussed to be biomechanically highly relevant. This study suggests that rhBMP-2 optimizes the trabecular microarchitecture, which might explain the advanced mechanical integrity of newly formed bone under rhBMP-2 treatment.

M. Brewster D.M. Power S.R Carter

Aims Soft tissue sarcomas (STS) of the foot and ankle are rare tumours. The aims of this study were to examine the presenting features and highlight those associated with a delay in diagnosis.

Methods Patients presenting during a 10-year period were identified using a computerised database within the Orthopaedic Oncology Unit at the Royal Orthopaedic Hospital, Birmingham, UK. Additional information was obtained from a systematic case note review.

Results 1519 patients were treated for STS of which 87 (8.2%) had tumours sited in the foot and ankle. Of these, 75 (86.2%) had presented with a discrete lump (56% of them having an inadvertent whoops excision biopsy), 3 (3.4%) with ulceration and the remaining 9 (10.3%) with symptoms more commonly associated with other benign foot and ankle pathology. The 9 had previously been treated as plantar fasciitis (3), tarsal tunnel (2), Morton’s neuroma (1) and none specific hind foot pain (3). Median delay from onset of symptoms to diagnosis as STS was 26 months for this group (mean 50; range 6–180 months) compared to 12 months (mean 32; range 3–240) for the “whoops biopsy group and 10 months (mean16; range 2–60 months) for the unbiopsied discrete lump group.

Conclusion Soft tissue sarcoma in the foot and ankle may present insidiously and with symptoms of other benign pathologies. Failure to respond to initial treatment of suspected common benign pathology should be promptly investigated further with an MRI scan.

C.O. Tibesku T. Szuwart S.A. Ocken A. A. Skwara S. Fuchs

Aim: Previous investigations have shown the vital role of chondrocyte CD44 in cartilage homeostasis and matrix attachment and indicated a participation of CD44v5 in the development of osteoarthritis. However, all reports dealt with late stage human osteoarthritis, as human specimens are only available at the time of surgery. Thus, little is known about the expression of CD44v5 in the time course of osteoarthritis. The current study was designed to evaluate the expression of CD44v5 on chondrocytes of hyaline cartilage in the time course of osteoarthritis.

Methods: In twelve white new-zealand-rabbits the anterior cruciate ligament was resected to create an anterior instability of the knee. In twelve control rabbits only a sham operation without resection of the ACL was done. Four animals of each group were sacrificed at three, six and twelve weeks each. After opening of the knee joint, osteoarthritis was macroscopically graded and hyaline cartilage of the load bearing area was evaluated histologically according to Mankin and by immunostaining for CD44v5.

Results: In the trial group, macroscopic and histological grades of OA showed a positive linear correlation to the time after surgery. Immunostaining showed an increased expression of CD44v5 in the control group after 3 and 6 weeks, which dropped to normal after twelve weeks. There was no difference between control and trial groups after 3 and 6 weeks, but after 12 weeks. We found a significant positive correlation between CD44v5-expression and macroscopic (r=0.294) and histological (r=0.314) grades of OA.

Conclusion: The current study shows in-vivo an increase of expression of the hyaluronan receptor CD44v5 in the time course of osteoarthritis. Further studies are needed to evaluate whether this pattern applies to human beings and whether new treatment approaches could evolve from this knowledge.

S. Seitz G. G. Horvath H. Guelkan M. Regauer P. Neth W. Mutschler M. Schieker

In tissue engineering, scaffolds are vitalized by cells in vitro. Human mesenchymal stem cells (hMSC) are very interesting because of their ability to differentiate towards the osteogenic lineage and their self renewing capacity. Yet, it is important that implanted cells do not disseminate and exhibit unwanted cell growth outside the implantation site. Therefore the aim of this study was to detect migrated cells in organs of mice after implantation of a composite (cell-scaffold) substitute.

HMSC (Cambrex, USA) were inoculated on a clinically approved 3D scaffold (Tutobone(TM), Tutogen, Germany). One composite and one scaffold without cells were implanted subcutanously, left and right paravertebrally in athymic nude mice (nu/nu). After 2, 4, 8 and 12 weeks constructs were explanted and organs (liver, spleen, lungs, kidney, heart, testicles, brain and blood) were harvested. The entire organs were homogenized and genomic DNA was isolated for qualitative and quantitative PCR.

Human DNA was found in all explanted composites at all examined time points. No human DNA could be detected in control scaffolds. Moreover we did not detect human DNA in all explanted organs at any time point. As internal controls we could detect 1 single hMSC in a pool of 106 mouse cells.

In conclusion, we could proof that cells of implanted composite substitutes do not migrate to other organs. Furthermore, this study showed that implanted hMSC seeded on 3D scaffolds survive over time frames up to 12 weeks.

P.A. Rust G.W. Blunn S.R. Cannon T.W. Briggs

Introduction Tissue engineering aims to produce a cellular structure in an extracellular matrix, which when implanted heals tissue defects.

To tissue-engineer bone suitable cells need to be grown on a scaffold. In this study we grew human marrow cells as they can differentiate into osteoblasts, on porous hydroxyapatite (HA) scaffolds, as this is osteoconductive, allows cell penetration and in growth of capillaries after implantation.

Increased extravascular perfusion through bone increases new bone formation. So we reproduced these physiological conditions in our novel bioreactor by perfusing scaffolds at 6ml/hr.

Hypotheses 1. Culture in our bioreactor improved cell penetration through HA scaffolds compared to static conditions. 2. Human mesenchymal stem cells (MSCs) cultured in our bioreactor differentiated into osteo-blasts and produced bone extracellular matrix.

Method MSCs were isolated from 8 human bone marrow aspirates taken from patients following informed consent. For each experiment 16 scaffolds were seeded with MSCs and comparisons were made between the two conditions. After 7 days culture the scaffolds were sectioned longitudinally and the number of cells at increasing depths were counted. The scaffolds were observed under SEM & TEM. Osteoblastic markers ALP and type I pro-collagen (PICP) were measured.

Results Penetration of cells through the scaffolds was significantly greater when cultured in the bioreactor.

After 14 days in bioreactor culture the HA was covered with cuboidal cells, consistent with osteoblasts, however in static culture cells remained fibroblastic. TEM results showed that MSCs in the bioreactor produced organised collagen matrix after 21 days and osteoid by 28 days, but no collagen matrix was observed following static culture.

ALP and PICP were significantly greater over 15 days culture when in our bioreactor.

Conclusions These results show that when MSCs were cultured in our bioreactor they attached and penetrated through porous HA scaffolds, whereas in static conditions few cells penetrated below 2mm. Our bioreactor significantly improved 3-dimensional growth, resembling tissue.

Moreover, MSCs grown on HA in the bioreactor produced significantly more ALP and PICP indicating osteoblastic differentiation. Furthermore, bone osteoid was produced.

Therefore this culture method could be use to convert autologous MSCs from human marrow into tissue-engineered bone which could be used to heal defects after tumor excision.

J.F.S. Ritchie K. Venu KK. Pillai D.H. Yanni

Aims: We present a prospective study, with three-year follow-up, of the incidence, course and influence on surgical outcome of the abductor digiti minimi cord in Dupuytren’s contracture of the PIP joint of the little finger.

Methods: All patients presenting for surgery with primary Dupuytren’s contracture of the little finger over a six-month period were included in the study. Patterns of disease cords and joint involvement were noted. All fingers underwent fasciectomy of the central and pre-tendinous cords. If significant contracture remained the abductor cord was excised next, and the PIP joint itself released only if correction could still not be obtained. Contracture and range of movement of affected joints measured with goniometer pre-operatively, at each stage intra-operatively and at 3 months and 3 years post-op.

Results: The abductor cord was present in twleve of the nineteen fingers in the study, including all of those with ulnar-sided disease. The ulnar neurovascular bundle was found to be deep to the cord in nine fingers, encased by diseased tissue in two and displaced superficially in only one finger. Mean initial flexion deformity in these twelve fingers was 59, corrected to only 51 by resection of the central and pre-tendinous cords. Excision of the abductor cord further improved the contracture to 25 while PIP join release improved it to 6. Flexion deformity was 18 at three months and 21 at three years. For the seven fingers in which no abductor cord was found, mean initial flexion deformity was 42, improving to 24 following fasciectomy and 4 with joint release. It was 16 at three months and 18 at three years. No significant difference in outcome could be identified between the groups at three months or three years.

Conclusions: The abductor cord is present in roughly two-thirds of little fingers with contracture pf the PIP joint. The ulnar digital nerve usually lies deep to the abductor cord but in roughly one quarter of cases is either encased in or superficial to it. In affected fingers, resection of the cord accounts for more than half of the total correction obtained and three quarters of that obtained by fasciectomy. Presence of the ADM cord does not prejudice long-term outcome provided it is adequately resected.

H. Al Hussainy S. Jones F. Ali S. Club S Bostock

Arthroscopic procedures may be associated with considerable pain in the first 24 hours. Intra-articular bupi-vacaine provides good analgesia but is short lasting. Intra-articular morphine has been shown to prolong postoperative analgesia in knee and ankle arthroscopy. The aim of this study is to assess the safety and analgesic effect of intra-articular morphine following day case wrist arthroscopy.

Ethical approval was firstly obtained. 31 patients were randomly assigned to one of 2 groups in a double blind clinical study. Group 1 received 5ml of 0.5% bupi-vacaine intra-articularly with 5mg of morphine subcutaneously. Group 2 received 5ml of 0.5% bupivacaine and 5mg of morphine intra-articularly. There were 15 patients (mean age 41.2 years) in group 1, and 16 patients (mean age 38.9 years) in group 2. Postoperatively pain was assessed using a 100mm visual analogue pain scale (VAPS) at 1, 2, 6 and 24 hours. Analgesia requirements were recorded at these times post operatively. The presence of nausea, vomiting, other complications and patient satisfaction were recorded.

Visual analogue pain scores did not show any significant difference between the groups at 1, 2, 6 and 24 hours. Supplementary analgesic consumption over the 24 hour period was slightly greater in group 1 than in group 2. None of the patients who had intra-articular Morphine had vomiting nor any other complications and did not require anti-emetics. Most patients in either group were satisfied with the level of postoperative analgesia.

Intra-articular bupivacaine with or with out morphine provides adequate postoperative pain relief following wrist arthroscopy. There seems to be little difference between the two methods studied.

A Arya G Kakarala R Singh I Persaud R Kulshreshtha S Reddy J Compson

Disorders of the pisotriquetral joint can cause ulnar sided wrist pain. This joint is not usually seen during routine wrist arthrosopy because it often has a separate joint cavity. The senior author believes that it is more commonly seen from the 6R portal if looked for, than one would expect from the assumed anatomy.

This study assessed the frequency with which the pisotriquetral joint could be observed in 36 consecutive wrist arthroscopies. The connection between the radiocarpal and the pisotriquetral joint were found to vary from a complete membrane separating the two, to no membrane at all, with variations in between. The types of connections are described. The anatomy of the connections was also studied by dissecting the wrist joints of eight fresh frozen cadavers. The findings matched the arthroscopic observations.

In more than 50% of patients, the pisotriquetral joint could be clearly visualised by arthroscopy. The technique and findings have been recorded on video and form part of the presentation.

J. Salim A.P. Walker I. Sau K.H. Sharara

Aim: This study involved a postal questionnaire survey to know the attitude of consultant orthopaedic surgeons in U.K. with regards to their postoperative management of Dupuytren’s surgery patients.

Methods & Results: A questionnaire was sent to Orthopaedic surgeons practising in UK. 573 consultants replied to the questionnaire. 169 surgeons (29.49%) stated to have special interest in hand surgery. 357 surgeons (62.3%) stated having no interest in hand surgery. 43 surgeons did not reply to the questionnaire. 81 surgeons (14.13%) always used post operative splintage.109 surgeons (19.03) used splintage most of the time, 126 surgeons (21.98%) rarely used it and 89 surgeons (15.53%) stated never using any form of splintage.

Most of them used static splintage (45.20%) and only 5.23% used dynamic splintage.11 surgeons stated using both the types of splintage. 267 surgeons did not questionnaire. Majority of the surgeons applied a static splint (pop slab, thermoplastic splint) after the surgery while others applied it after reducing the dressing within 2 weeks of the operation. 264 (46.07%) surgeons did not reply to the question.

In majority of cases the splint was applied by the occupational therapist. The surgeon, physiotherapist, and orthotist in some cases also applied the splint. Individual comments from surgeons made an interesting reading. After an initial period of continuous splintage majority of the surgeons used night splintage only. 265 surgeons did not reply to the question. Mostly the splint-age was used for 4–6 weeks. Although the spectrum of splintage varied from 2 weeks to 24 weeks. Some of the surgeons stated their own clinical practice in their comments.

179 surgeons stated always referring their patient for postoperative physiotherapy.

13 surgeons (2.26%) never referred their patients for physiotherapy.

77 surgeons on very odd occasions had postoperative physiotherapy for their patients.

Majority of surgeons started the physiotherapy between 1 and 2 weeks, after the stitches have been removed. 107 surgeons favoured early commencement of hand exercises within first week of surgery. 224 surgeon did not reply to this question.

Most of the surgeons followed the patients for two to four months. Longer follow up was done for patients with recurrence, severe or bilateral disease. Also those patients, who had proximal interphalangeal joint contracture and other risk factors, were followed for a longer period. Some of the surgeons commented following them for life in their clinical practice.

Conclusion: This survey revealed interesting facts regarding the management of Dupuytren’s contracture surgery patients. The disparity in reply clearly indicates the need for further research with attention to long term funtional results.

G. Adamczyk A. Kostera-Pruszczyk P. Chomicki-Bindas

Introduction: Conventional nerve conduction studies localize the lesion of a nerve and can disclose the degree of focal conduction block or pinpoint the region of focal slowing, giving complementary information about the character of the lesion. In a group of active population transient disturbances during physical efforts are commonly observed.

Aim: To precise the evolution with time of EMG recordings of the median nerve in common sport-specific positions.

Material and methods: 20 healthy volunteers and 12 symptomatic patients (persons with a conduction block were excluded from the study). Conventional EMG of median nerve was performed, than a “reversed Phalen” position kept for 30 min, and consequent measurements in 5 min periods were performed.

Results: In 20% of asymptomatic patients a significant decrease of sensory nerve action potential was recorded after 20 min of observation, while 100% of symptomatic in daily living and negative in conventional EMG studies developed a severe decrease of conduction and blocks after 15 min. These symptoms recuperated after 5 min in functional wrist position. We proposed to these patients a neuromobilisation physiotherapy program, that clinically diminished their complaints.

Conclusions: EMG shows a 97–100% diagnostic specificity and sensitivity. It might be a functional test helping to distinguish a group of risk of development of carpal tunnel syndrome with exercises. This method is useful among patients with functional disturbances due to joint instability or repetitive motions in sports.

R. Bilic P. Simic M. Jelic R. Stern-Padovan S. Vukicevic M. Pecina

Background: Bone morphogenetic proteins (BMPs) induce new bone in patients with bone defects and at extraskeletal sites in animals. Standard treatment for symptomatic scaphoid non-unions is bone graft with or without internal fixation by a screw or wires. We tested the ability of human recombinant osteogenic protein-1 (OP-1, BMP-7) with compressed autologous or allogeneic bone graft to accelerate the healing of scaphoid non-union.

Study Design: Randomized and controlled pilot study in 17 patients with a scaphoid nonunion.

Methods: Patients were randomly assigned to one of three groups: (1) Autologous iliac graft (n=6), (2) Autologous iliac graft + OP-1 (n=6) and (3) Allogeneic iliac graft + OP-1 (n=5). Radiographic, scintigraphic and clinical outcomes were assessed throughout the follow-up period of 24 months.

Results: OP-1 improved the performance of both autologous and allogeneic bone implants. Three dimensional helical CT scans and scintigraphy showed that the pre-existing sclerotic bone within proximal scaphoid poles was mainly replaced in OP-1 treated patients with well vascularized new bone. Addition of OP-1 to allogeneic bone implant equalized the clinical outcome with the autologous graft procedure and enabled circumventing the second donor graft harvest procedure resulting in less blood loss, shorter anesthesia and no pain at the donor side.

Conclusion: This is the first evidence that a recombinant human BMP accelerates scaphoid bone non-union repair and resorption of sclerotic bone in this specific microenvironment.

Clinical Relevance: OP-1 might be successfully used in healing of scaphoid non-union.

A. Karantana M.J. Downs-Wheeler C.A. Pearce A. Johnson G.C. Bannister

The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study.

Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability.

We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design.

Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p< 0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests.

Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.

M.M. Eskandari C Yilmaz V. Oztuna Kuyurtar

Purpose: The aim of this study was to redefine the localization of the thenar motor branch (TMB) of the median nerve in relation to the surface landmarks which are in routine use.

Methods: The study was performed in 37 hands of 34 patients who underwent carpal tunnel release. All of the patients were women and the mean age was 50 (35–67). A radiological marking technique was used to determine the localization of the TMB, the middle finger radial side line and the Kaplan’s cardinal line. For marking TMB a circumscribing soft radioopaque yarn was used while the surface landmark lines were demonstrated by taping one K-wire for each. An image intensifier print image was obtained for each case and the distances between the markers of the TMB and the wires were measured.

Results: The TMB had a mean ulnar offset of 12.6 mm (4.0–19.7) from the middle finger radial side line and located 4.4 (0–9.5) mm proximal to the cardinal line.

Conclusion: During the carpal tunnel release operations one must pay more attention to the localization of the TMB of the median nerve because it was found to be 12.6 mm ulnar than that was described in classic literature.

C. Lamas C. L. Gomez A. Carrera M.C. Pulido M. Llusa I. Proubasta J. Itarte

Purpose: The purpose of this study is to investigate the external and internal vascular anatomy of the lunate bone. The genesis of lunatomalacia requires some combination of load, vascular risk and mechanical predisposition. The findings will be correlated with the major existing theories of the cause of lunatomalacia and the most frequent fractures associated with Kienbocks disease: transverse shear fracture and midcoronal fracture.

Material and methods: We studied 21 cadaver upper limbs using latex injection and Spalteholz technique. We investigated the extra- and intraosseous blood supply. In 17 wrists we evaluate the incidence and distribution of anatomic features, arthrosis, and soft tissue lesions.

Results: The lunate morphology was 5 Type I (29.4%), 11 Type II (64.7%) and 1 Type III (5.9%). The lunate was found to have a separate facet for the hamate in 47.1% (Size 3–6 mm). Most frequent arthrosis was identified in the radius (88.2%) and lunate (94.1%). The triangular fibrocartilage complex (TFCC) was found torn in 47%, the lunotriquetral interosseous ligament (LTIL) was torn in 23.5%, and the scapholunate interosseous ligament (SLIL) was torn in 53% of the wrists. Statistical analysis found a correlation between the presence of arthrosis at the proximal pole of the hamate and the presence of a lunate facet. There was also a correlation between the presence of a tear in the SLIL and the presence of cartilage erosion in the scaphoid (p= 0.002). Arthrosis on the lunate was found to have a correlation with an SLIL tear or TFCC tear. The nutrient vessels entered the lunate throught the dorsal and volar poles in all the specimens. Dorsal vessels enter the bone through one or two foramina in the proximal, ulnar, and nonarticular aspect of the bone. Two to six nutrient vessels were observed entering the volar pole throught a ligament insertion: radioscapholunate ligament of Testut-Kuentz, radio-lunate-triquetrum ligament and ulnar-lunate-triquetrum ligament.

Conclusions: The lunate had consistent dorsal and palmar arteries entering the bone in all the specimens. The supply blood and foramina number is more important in the volar pole of the lunate than the dorsal pole. The vascular patterns support a theory of compression fracture from repeated trauma, or anatomical predispositions as the most likely cause of Kienbocks disease.

R. Singh G. Kakarala I. Persaud M. Roberts S. Standring J. Compson

Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx.

We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy.

The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary.

M. Lautenbach M. Sparmann

There is an high incidence of failures of total wrist arthroplasties. We review our experiences in revising total wrist implant arthroplasties to arthrodeses. The most common mode of failure of the arthroplasties in our series was metacarpal loosening with dorsal perforation of the stem. Loosening of the proximal stem, progressive mal-position of the wrist and other causes appeared.

We used for the revision arthrodesis in all our cases tricortical iliac crest bone grafts and additional spongiosa transplants from this donor site region. In one case we used a vascularized iliac crest bone graft to bridge the bone defect because of a bad host quality of the recipient area. Fixation was achieved with plates and screws.

Our average follow-up period was 32 month. 40 patients with 41 failed wrist implants (3 different types) were treated with this technique. 40 wrist undergoing arthrodesis attained a solid painless fusion after a single operation. In one case a non-union with a loosening of the screws due to using a non-rigid plate was seen. In this case a revision was necessary to achieve a bone healing. All patients were satisfied, pain free and achieved an increased pinch and grip strength after bony fusion (measured with Yamar-Vigorimeter). A persisting loss of carpal height was seen in all cases.

Arthrodesis after failed total wrist arthroplasty is a satisfactory salvage procedure even in cases with a bad quality of the recipient area. We recommend a rigid fixation technique to prevent non-unions.

A. Guney C.Y. Turk M. Halici

Aim: To biomechanically achieve both the most ideal and the strongest core and periferal suture method by combining 2 and 4 strand core sutures with the simple running and a new locking periferal suture techniques.

Materials and Methods: Fourty flexor digitorum pro-fundus tendons from sheep hindlimbs were studied. The tendons were then repaired using 4 different repair techniques: Group 1 – control, Group 2 – 2 strand modified Kessler’s core suture and simple running periferal suture, Group 3 – 2 strand modified Kessler’s core suture and a new multilocking loop periferal suture, Group 4 – 4 strand modified Kessler’s core suture and simple running periferal suture, Group 5 – 4 strand modified Kessler’s core suture and a new multilocking loop periferal suture. After tenoraphy all fresh sheep cadavers tendons were tested to failure using a distraction rate of 20 mm/min. Maximal strength, 2 mm gap formation force, load to failure, stiffness, method of failure and rate of tendon resistance were assessed. After and before tenoraphy, front – back and side sizes were measured.

Results: Maximal strength was 496, 32, 94, 45 and 100 Newtons for Groups 1, 2, 3, 4 and 5 respectively. There was a significantly statistical difference between the groups (p< 0.0001). Load to 2 mm gap formation was 23, 63, 36 and 72 Newtons for Groups 2, 3, 4 and 5 respectively. There was a significantly statistical difference between the groups (p< 0.0001). Load to failure was 3,783 0,285 0,505 0,41 and 0,572 Joule for Groups 1, 2, 3, 4 and 5 respectively. There was a significantly statistical difference between the groups (p< 0.0001). Tendon stiffness was 42.6, 5.16, 11.2, 5.8 and 12.6 Newton/milimetre for Groups 1, 2, 3, 4 and 5 respectively. There was a significantly statistical difference between the groups (p< 0.0001). The rate of tendon resistance was 0.97, 0.8, 1.0 and 0.91 for Groups 2, 3, 4 and 5 respectively. There was no significantly statistical difference between these groups (p=0.747> 0.05). All the simple running repairs failed by suture pullout, while all the new multilocking loop periferal suture repairs failed by suture breakage.

Conclusion: The new multilocking loop periferal suture was the best performer overall, with greater ultimate strength, load to failure, 2 mm gap formation force and stiffness.

M. Lautenbach A. Eisenschenk M. Sparmann

From January 2000 to March 2004 16 thumbs after total avulsion-amputation were replanted in our hospitals. In 15 cases this was successful. In one case the thumb was lost 28 hours after replantation. Mostly the amputation was in the region of the first phalanx or the IP-joint of the thumb.

In all cases our operative procedure for this form of amputation was the reconstruction of the vessels with vein grafts after the osteosynthesis and the reconstruction of the tendons. The donorsite region for the grafts was in 12 cases the dorsal forefoot and in 4 cases the distal forearm. In none of these cases there was the possibility of reconstructing both arteries. Mostly only an anastomosis for one artery and one vein could be done. For none of these patients it was possible to reconstruct the nerves primarily. Until now transphers of neurovascular skinislands of longfingers, free nerve transplantations with coaptations to the proximal stump of the injured nerve, free nerve transplantations with coaptations to the trunk of the median nerve or in one case an end-to-side coaptation have been performed to achieve a resensibility of the thumbs. In one case a patient rejected an operative nervereconstruction, because a sprouting of the proximal stump of the injured nerve lead to a (reduced) sensibility of the thumb. In 4 cases a therapy to achieve a resensibility has so far not been carried out.

After replantations of injured thumbs necroses of the skin in different kinds were noticed. In 4 cases secondary skinreconstructions were necessary. All 15 successful replanted thumbs achieved very good results concerning function, strength and patient’s satisfaction.

Our results don’t agree with the mostly bad results after total avulsionamputations mentioned in literature. We think that the replantation after total avulsionamputation of the thumb has a high chance of being successful and can achieve very good longtime results.

E.T. Skyttä E.A. Belt J.T. Lehtinen H.M. Mäenpää

The purpose of the study was to evaluate the outcome of de la Caffinière prosthesis in the management of rheumatic destruction of the first carpometacarpal joint. By the end of 1998 the procedure was performed on 49 patients, 20 on the right hand and 29 on the left. All patients were addressed with a letter query and patient records and radiographs were assessed. Subjective contentment was measured with visual analog scale (VAS) and a questionnaire.

Thirty six of the patients had seropositive rheumatoid arthritis, 8 juvenile chronic arthritis and 5 other rheumatic variants. The mean follow-up was 8.6 (0.5–17) years. Subjective contentment was either excellent of good in 88% of the patients, and 75% were painfree.

Survival analysis with reoperation or significant loosening as end point was performed. Two cups loosened and one prosthesis was constantly dislocated, and these three were revised with tendon interposition technique. The survival rate was 96% (95% CI 84 to 99) at 5 years, and 92% (95% CI 77 to 97) at ten years.

Fairly good 10-year survival and encouraging subjective results have lead us to plan and start a clinical out-patient follow-up study to collect additional objective data on implant survival and function. Preliminary results of the new study yield superior range of motion compared to tendon interposition arthroplasty, which is the golden standard in our institute at the moment. However, we promote caution and emphasize the importance of patient selection since two additional revisions in our latter study may reveal a subgroup which is more prone to implant failure.