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Volume 91-B, Issue SUPP_I March 2009

K.E. Gill J. Edge

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite(HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape.

All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. The surgery was undertaken by one surgeon, in one centre, in matched patients and using the same well-tried CSF acetabular cup and bearings.

335 patients had been entered into the trial, 228 females and 126 males.

191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%).

The number of perioperative fractures in the Furlong group was 13(6.8%)and in the Anca sample 22 (15.3%).

The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The possible reasons for this difference are discussed.


J. Boldt J. Cartillier A. Machenaud J. Vidalain

We present a prospective study focused on radiographic long-term outcomes and bone remodeling at a mean of 17.0 years (range: 15 to 20) in 208 cementless fully HA-coated femoral stems (Corail®, DePuy, Johnson & Johnson). Total hip replacements in this study were performed by three members of the surgeon design team (Artro Group) in France between 1986 and 1991. Radiographic evaluation focused on periprosthetic osteolysis, bone remodeling, osseous integration, subsidence, metaphyseal or diaphyseal load transfer, and femoral stress shielding. The radiographs were digitized and examined with contrast enhancing software (DICOM Anonymizer 1.1.2) for analysis of the trabecular architecture. Radiographic signs of aseptic stem loosening were visible in two cases (1%). Three stems (1.4%) showed metaphyseal periprosthetic osteolysis in two of seven Gruen zones associated with eccentric polyethylene wear awaiting metaphyseal bone grafting and cup liner exchange. One stem (0.5%) was revised due to infection. No stem altered in varus or valgus alignment more than two degrees and mean subsidence was 0.1 mm (range: 0 to 2) after a mean of 17.0 years. Five stems (2.4%) required or are awaiting revision surgery. Trabecular orientation and micro-anatomy suggested proximal load-transfer patterns in all except three cases (98.6%). Combined metaphyseal and diaphyseal osseo-integration and bone remodeling were visible in one hundred stems (48%). Diaphyseal stress shielding and cortical thickening were observed in three stems (1.4%). Other radiographic features are discussed in depth. This long-term study of 208 fully HA-coated Corail stems showed highly satisfactory osseo-integration and fixation in 97.6% after a mean of 17.0 years follow-up.


N. Botan B. Fourie S. Scott N. Shaw

The JRI cemented total hip replacement consisted of an acetabulum with a gamma irradiated UHMW polyethylene cup encased in a titanium metal shell, a 32 mm titanium head, and forged titanium alloy stem. Revision of this implant for failure, in particular that of the acetabulum, and the lack of published survivorship prompted a retrospective review of the local series. Data was compiled from theatre log books, patient records and X-rays.

During the period 1989–1997 a single surgeon performed 304 total hip replacements using this JRI prosthesis through an anterior lateral approach. The average age was 70 (48–96), with 186 (61%) female and 85% performed for osteoarthritis. Complete data was available in 236 cases to allow further analysis. The average follow up was 9.3 (1–17) years. During this period 37 hips had to be revised: 28 for a loose acetabulum, both components were loose in 5, and 3 had revision for infection. The mean time to revision was 7.4 (1–17) years.

This data provides a revision rate of at least 16% at ten years. This data does not take potential earlier radiographic failure nor patient function into account. This prosthesis therefore fails to comply with modern benchmarks for survivorship of implants. Furthermore this study highlights the importance of ongoing review of patients who have undergone joint replacement, in particular those with implants that have problems with design, as has been demonstrated in other metal backed components.


J. VIDALAIN A. MACHENAUD J. CARTILLIER

Bio-active fixation has increasingly gained acceptance over the last two decades. However extent of the coating is still a subject of debate. We introduced in 1986, the concept of total osteointegration of a tapered stem with the hope that we could achieve durable biological fixation while preserving a normal periprosthetic bone trophicity. Patients from our first clinical series using this stem are now eligible for 18-year follow up. Between July of 1986 and December of 1990 we performed 615 total hip arthroplasties using the Corail stem (DePuy). It is a straight tapered stem totally coated with a 150 μ thick layer of HA following an atmospheric plasma-spray process. The mean age at surgery was 64.5 (range 16 to 95 years) 242 patients are now deceased (39%), 62 (10%) patients are lost to follow-up. The mean follow-up for 243 living patients on file is 17.7years. 89 THAs required component revisions. 72 cup revisions were associated with wear and osteolysis. 8 cups and 4 stems have been revised for aseptic loosening. Owing to the high incidence of wear-related revision, Kaplan-Meïer survivorship at 18-year follow-up, using component revision for any reason as an endpoint, was 80.7±3.3 (95% confidence intervals). In contrast, Corail stem survivorship, using stem removal for any reason as an endpoint, was 95.0%±3.0 at 18-year follow-up, and considering aseptic loosening only, the survival probability of the stem is 98.9%±1.1 at 18 years. Therefore, despite wear and proximal osteolysis the fixation achieved with this totally HA-coated stem remained durable through 18-year follow-up. Regarding the periprosthetic remodelling during this period, modifications of the bone pattern have been strictly limited: slight resorption at the calcar level, absence of cortical hypertrophy, anecdotic significant stress-shielding. The radiological silence is one of the paramount facts demonstrated by this prospective study.


E. Garcia-Rey T. Muñoz J. Montejo J. Martinez

Introduction: Modular metaphyseal-diaphyseal femoral stems are infrequent in primary total hip arthroplasty. We analyse the results of a proximally hydroxyapatite coated anatomic two-piece modular femoral stem over a minimum five years follow-up.

Material and Methods. 94 ESOP (Fournitures Hospitalieres, France) stems are analysed. The mean follow–up was 70.45 + 8.6 months. Patients’ mean age was 65.8 + 9.6 years. Proximal osteopenia and radiographic stem fixation are assessed according to Engh et al.

Results: There were 2 aseptic femoral stem loosenings. There were no cases with thigh pain. Three stems presented subsidence. Mean femoral canal filling was 89% and was related to stem subsidence (p< 0.05). Stable bone fixation was obtained in 83 hips and was related to fluted femora (p< 0.0001). The cumulative probability of not having radiographic loosening was 97.8% (94.8% to 100%). The cumulative probability of not having proximal femoral osteolysis was 86.0% (78.9% to 93.1%), cortical widening 88.1% (81.5% to 94.7%), and proximal osteopenia 94.5% (89.8% to 99.2%).

Conclusions: A cementless two-piece modular hydroxyapatite coated femoral stem provides good clinical results with an absence of pain and excellent radiographic results when there is good adaptation between the metaphyseal part of the stem and the femoral anatomy. This design is an option in femora with good bone quality and especially in tunnel-shaped cases. Femoral osteopenia and cortical widening were infrequent in this series. The modular metaphyseal-diaphyseal junction is not an in vivo problem, contrary to previous reports. A longer follow-up is needed to assess the results of this design.


R. Raman V. Eswaramoorthy D. Dickson P. Angus

Aim: To report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic (HAC) coated femoral and acetabular components

Methods: We reviewed 586 consecutive cementless primary THA using HAC coated components in 542 patients, with a minimum 12-year follow-up to 18 years, performed at one institution between 1986 and 1994. Twenty eight (32 THA) were lost prior to 12-year follow-up, leaving 514 patients (554 THA) available for study. Threaded cups were used in 64% and press-fit cups with screws in the rest. Fully HAC coated stems were used in all patients. The clinical outcome was measured using Harris, Charnley and Oxford hip scores. Anterior thigh pain was quantified on a visual analogue scale (VAS) and quality of life using EuroQol EQ-5D. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis and stress shielding. Polythene wear was digitally measured. The radiographic stability of the femoral component was determined by Enghs criteria

Results: The mean age was 75.2 yrs. Dislocation occurred in 12 patients (3 recurrent). Re operations were performed in 11 patients (1.9%). Four acetabular and one stem revisions were performed for aseptic loosening. Other re-operations were for infection (2), periprosthetic fractures (2), cup malposition (1), revision of worn liner (2). The mean Harris and Oxford scores were 89 (79–96) and 18.4 (12–32) respectively. The Charnley score was 5.7 (5–6) for pain, 5.3 (4–6) for movement and 5.4 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Stable stem by bony ingrowth was identified in all hips excluding one femoral revision case. Mean stem subsidence was 2.2mm (0.30–3.4mm). Radiolucencies were present around 37 (6.6%) stems. Mean EQ- 5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1% for acetabular and 98.3% for femoral components. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 97.2%.

Conclusion: The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period.


A.J. Tonino B. Grimm B.C. van der Wal I.C. Heyligers

Introduction: Investigating the correlations between bone ongrowth and HA resorption on coated implants is important to understand the contribution of resorbable coatings on implant fixation and periprosthetic bone remodelling. It is only possible histomorphometrically and this study measured bone apposition and residual HA on hip stems of one single design.

Methods: Post-mortem retrievals of 13 ABG-I (Stryker) hip stems from 13 patients (10f, 3m, age: 58–86yrs, uneventful THA, death unrelated to hip diseases). The time from implantation (stem in-vivo) ranged between 3.3 to 11.2yrs.

Three cross sections were cut from the metaphyseal femur and surrounding bone proximal to Gruen zones 2 and 6 (regions with HA coating). The three sections were A (proximal), B (mid-part) and C (distal). Sections were prepared using the Donath technique and then paragon stained for quantitative histomorphometry using an Axioskop microscope (Carl Zeiss, Germany) with image analysing (SAMBA, France).

For each segment the total implant perimeter, percentage of implant perimeter covered by bone and the total percentage of residual HA coating were measured. Bone implant contact was defined as direct ongrowth of bone to the coating or the titanium surface.

Results: HA resorption increased significantly with the time in-vivo as measured by the residual HA (e.g. < 6yrs: Avg.=36.7%, > 6yrs: Avg.=10.1%, p=0.02). This correlation was true for all sections A, B and C (p=0.02–0.03). Beyond 8yrs HA was almost gone.

Bone ongrowth ranged between 18%–56% and was independent of the time in-vivo. Bone ongrowth was most strongly correlated to patient age with younger patients having significantly higher bone ongrowth (p=0.001). Bone ongrowth was correlated with HA-resorption only in the most proximal zone A (p=0.001) with lower ongrowth associated with lower levels of residual HA. However, HA resorption was not significantly correlated with patient age.

HA resorption was significantly higher most proximally with less residual HA (13.0%) than mid-stem (22.6%, p=0.05) and distal (28.1%, p=0.05). Metaphyseal stem level and bone ongrowth were not significantly correlated in this manner.

Discussion: HA resorption increased with implantation time and was nearly completed at 8yrs. As bone ongrowth was independent of time in-vivo and independent of HA resorption on the mid-part and distal coated stem sections there is evidence that long term implant fixation is not diminished while the HA coating is being resorbed.

Bone ongrowth but not HA resorption was strongly correlated to patient age indicating that the bone remodelling process is more affected by individual bone health than it can be stimulated by HA coating.

HA resorption increased significantly from the distal to mid-stem and the most proximal coating level in the same way as stress shielding and thus osteoclastic stimulation goes up.


D.C. HARDY

Osteointegration of HA coated devices is well demonstrated. An abundant experimental material exists, allowing to describe the various properties of HA (early osteointegration, sealing effect, gap healing effect, etc…). Various side-effects have been described (third body wear of HA debris, delamination of the proximal coating etc…). Thus controversy still exists, despite a more and more convincing clinical experience. The role of human retrievals is therefore crucial to determine the exact role of all these parameters in the natural life of the implant throughout the years.

49 human well-functioning explants have been retrieved during systemic autopsies in elderly patients previously operated for a displaced fracture of the neck with a Corail® implant. Delays of implantation vary from 5 days to 10 years. All these specimens have been processed for optical microscopy, electronic microscopy with backscattering. This constitutes the longest report on one single implant and the retrievals are evenly distributed over this ten-year period. Several histomorphometric parameters were measured in the different Gruen’s zones: cortical bone density, cortical bone thickness, density of endosteal bone

3 steps are recognized:

Bone formation around the implant appears early after surgery. Multiple units of bone formation go to coalescence as soon as 6 weeks and develop thereafter, leading to osteointegration.

Bone remodelling reorganizes the architecture of connecting trabeculae according to the mechanical stresses resulting from the presence of the implant. Compression areas are generally the seat of broad and interconnected trabeculae, whereas tensile stresses areas display the presence of long, thin, unconnected and often parallel trabeculae. Very broad and short trabeculae are often seen at the level of the corners.

Coating resorption is seen in every specimen beyond one year of implantation, predominantly in the areas with less bone coverage.

Release of HA particles in the joint cavities was never encountered. Some metallic particles, originating from the femoral ball are commonly seen in the polyethylene. HA particles (presumably scratched off the prosthesis during insertion?...) have never been identified in the heterotopic ossifications.

We conclude that the osteointegration of the Corail stems is a reliable phenomenon with a reproducible sequence of events. It lasts even after the disappearance of the coating in a 5–10 years period. The presence of the stem provokes a remodelling of the cortices but the presence of a total coating and its longer duration at the level of the tip does not induce a disappearance of the proximal bone or a loose of the proximal fixation.


B.J. de Kramer B.C. van der Wal B. Grimm I.C. Heyligers A.J. Tonino

Introduction: In uncemented total hip arthroplasty (THA) stem sizing and stem insertion affect the fit and fill of the prosthesis in the medullary canal. This study investigates how tightness of the stem fit influences bone remodelling and if there is a correlation between radiological and clinical Results: Methods: In a retrospective study a consecutive series of 64 patients following uncemented THA with a proximally coated anatomic stem (ABG-II, Stryker) was followed-up for 5 years using the Merle d’Aubigne (MdA) clinical score. Radiographic analysis of bone remodelling features per Gruen zone (R1 to R7) was performed on AP and lateral x-rays at 5 years. Femoral fit was measured at three levels (proximal, mid-stem, distal) on the direct postop x-ray using the femoral fit ratio (f) of Kim and Kim (tight femoral fit: f≥0.8, non-tight: f< 0.8). The medullary canals were categorised according to Noble (normal, stove pipe, champagne flute). Bone remodelling was compared to literature values of the ABG-I stem and correlated to clinical findings.

Results: The MdA improved from 9.6 pre-op to 17.1 at 5 years with no difference between tight and non-tight implants. Lateral thigh pain (LTP) occurred in 10/64 cases (3 requiring medication). Patients with LTP had significantly lower proximal (0.75 vs 0.80) and distal fit & fill (0.72 vs 0.79. LTP was equally frequent with a normal or varus position.

Proximal bone resorption occurred in 27% (R1) or 34% (R7) which is lower than the values reported for the ABG-I stem (R1: 48%, R7: 45%). Bone resorption was significantly higher with tight than non-tight mid-stem fit (69% vs 27%, p=0.04). The same trend was true for tight distal fit (56% vs 37%).

Cancellous densifications were frequent at mid-stem level (R2: 83%, R6:88%) but much less distally (R3: 44%, R5:25%). No influence of fit & fill was measured.

Cortical densifications were noted in 16% (ABG-I 15%) overall with a higher proportion measured for tight distal fit (25%) than loose distal fit (6%, p=0.07). A similar observation was made for cortical thickening (11% overall, tight:non-tight=16%:6%). Pedestal formation (17% overall) was more likely with a non-tight proximal fit (23% vs 12%) and mid-stem fit (20% vs 8%)

A proximal tight fit was achieved more frequently with normal (55%) and stovepipe femora (50%) than champagne flute femora which had the highest proportion of tight distal fit (85%).

Discussion: At 5 years femoral implant fit influenced bone remodelling reactions which are in agreement with the design philosophy of proximally press-fitting anatomic stems. However, implant fit could not be correlated to clinical outcome yet. This may require a longer follow-up.

As LTP occurred with non-tight fit it seems that elastic mismatch is not the main cause.

Less proximal bone resorption and less distal densifications confirm the design changes from ABG-I to ABG-II.


H. Behensky N. Walochnik C. Bach R. Rosiek P. Winter M. Liebensteiner M. Krismer

Study Design/Objective: Prospective two-leg cohort study on anterior cervical fusion versus cervical arthroplasty with emphasis on clinical outcome measures.

Patients and Methods: Between August 2003 and May 2005 21 consecutive patients underwent anterior cervical fusion with or without anterior decompression with 26 levels fused. Between December 2004 and August 2006 24 patients had cervical arthroplasty with 30 levels replaced. The mean age at operation of the fusion group was 52 years and 5 months (46–69) and for the arthroplasty group 51 years and 2 months (42–62). To establish fusion the Cervios® cage (Synthes) with or without anterior plating was used. In the arthroplasty group the Prodisc C® disc prothesis (Synthes) was used. Contraindication for arthroplasty were osteoporosis, osteopathies, spinal canal stenosis, hypertrophic spondylarthrosis, spondylolisthesis, tumors and privious infection. Both groups were comparable with respect to age and gender, diagnosis, level distribution and preoperative clinical outcome measures (VAS for nack pain and arm pain, neck disability index and SF-36–sub-scores pain, function, vitality).

Results: Postoperatively all of the clinical outcome measures significantly improved in both groups. After three months postoperatively no significant further improvement was evident.

VAS neck pain: Fusion group/arthroplasty group: Preoperatively 6.2/5.9 n.s., 6 weeks 3.5/3.1 n.s., 12 weeks 2.1/1.9 n.s, 1 year 2/2.1 n.s.

VAS arm pain: Fusion group/arthroplasty group: Preoperatively 5.5/5.3 n.s., 6 weeks 2.6/2.4 n.s., 12 weeks 1.7/1.8 n.s, 1 year 2/1.9 n.s.

Neck disability index: Fusion group/arthroplasty group: Preoperatively 43/40 n.s., 6 weeks 28/23 p< 0.05., 12 weeks 18/14 p< 0.05, 1 year 20/15 p< 0.05.

SF-36 subscore pain: Fusion group/arthroplasty group: Preoperatively 36/37 n.s., 6 weeks 42/44 n.s., 12 weeks 52/58 p< 0.05, 1 year 52/60 p< 0.05.

SF-36 subscore function: Fusion group/arthroplasty group: Preoperatively 52/54 n.s., 6 weeks 57/59 n.s., 12 weeks 60/62 n.s, 1 year 64/67 n.s.

SF-36 subscore vitality: Fusion group/arthroplasty group: Preoperatively 42/44 n.s., 6 weeks 45/46 n.s., 12 weeks 50/52 n.s, 1 year 54/56 n.s.

In the fusion group we had 1 recurrent radiculopathy and 1 non union without the need of further intervention. In the arthroplasty group we faced 1 recurrent laryngeus recurrens nerve palsy and 3 spontaneus fusions within 1 year postoperatively, which might not be classified as complication.

Conclusion: Short term outcome after both procedures is excellent in terms of pain relief and function. 10% spontaneus fusion after disc replacement within the first year was evident. In our series we found better results after 3 months to 1 year postoperatively with respect to the neck disability index and SF-36 subscore pain within the arthroplasty group.


R. Kakkar A. Siva Raman A. Bhadra P. Sirigiri A. Rai A. Casey R. Crawford

Introduction: Although there are several accepted methods of surgical treatment for single level cervical radiculopathy, the choice depends on the surgeon’s preference. The techniques may vary in perioperative morbidity, short and long term outcome, but no study so far has analysed their cost-effectiveness. To compare the outcome and cost-effectiveness of four techniques commonly used for degenerative cervical disc pathology.

Methods: We conducted a observational cohort study from two spinal units. Between 1999 and 2004, 60 patients underwent surgery for single level anterior cervical disc pathology. Out of this 30 patients underwent their surgery in centre A the other 30 in centre B. Centre A used two ACDF techniques-group 1- plate and tricortical graft, group 2- plate, cage and bone substitute (BCP granules). Centre B used two other techniques- group 3- cage alone with autologous locally harvested graft, group 4- disc arthroplasty. We had 15 patients in each of the above four groups. Operating time, blood loss, duration of stay, donor site morbidity, analgesia requirements, and total cost incurred per patient were recorded. All patients were followed up at 6 weeks, 3 months, 6 months, 1 year and 2 years. The clinical outcome and pain assessment were done using the SF12 and VAS.

Results: The three Fusion groups had a similar radiological outcome. With appropriate statistical analysis, there were no differences in physical and mental domains of the SF12 or pain scores between the groups. The average operative time in the group 1 was 160 minutes, group 2 was 100 minutes, group 3 was 90 minutes and group 4 was 105 minutes. Average blood loss was minimal in all groups. The average hospital stay was of 5, 2.7, 2.5, 2 days for groups 1–4 respectively. The average total cost per patient in the group 1 (surgery+stay+plate) was £2790, group 2 (surgery+stay+plate+cage+BCP) was £2400, group 3 (surgery+stay+cage) was £1900, and group 4(surgery+stay+disc implant) was £2350.

Conclusion: All the techniques gave similarly satisfactory clinical outcomes but using cages alone could be more cost-effective than using iliac crest auto-graft for fusion. The disc arthroplasty was comparable to cage with bone substitute and plate in terms of outcome and may giev the surgeon an alternative choice in patients who are not keen on/ unfit for fusion.


D. Daentzer S. Asamoto D. Böker

Introduction: Many different techniques exist for cervical interbody fusion after discectomy for soft and hard disc prolapses. The six years clinical and radiological results and the complications with a hydroxy-apatite ceramic (hac)-titanium implant are presented.

Methods: Between 1/1995 and 12/2000 a titanium implant coated with hydroxy-apatite ceramic (hac) has been used for ventral cervical interbody fusion after discectomy in 596 patients with soft and hard disc prolapses who were operated in 670 levels. There were 333 male and 263 female patients. The mean age was 48.2 years. Clinical and radiological follow-up studies were performed direct after operation and 6 weeks, 6 months and 1 year later with an average follow-up of 14 months. The functional outcome was assessed according to Odom’s score, and the neurological outcome according to Kadoya’s score.

Results: 93.2 % of the patients had a good to excellent result according to Odom’s score at follow-up whereas the neurological findings showed improvement in 71.2 % and no change in 27.9 %. After 6 months a good bony fusion could be seen around 91.2 % of the implants, and after 12 months around 95.7 %. 1,7 % of the operated patients developed a recurrent laryngeal nerve injury. Three implants broke into the adjacent vertebral endplate. Six patients had a second operation because of a dislocated cage. An adjacent segment pathology occured in 25 patients (4.2 %), of whom 15 patients had a second operation.

Conclusions: With the use of this hydroxy-apatite ceramic (hac)-titanium implant we get an immediate postoperative stability of the cervical spine without the need of any orthosis. Harvesting of bone grafts is unnecessary which reduces operation time and eliminates donor site complications. The clinical and radiological are good and comparable to other fusion techniques in the cervical spine and the complication rate is low. If the number of adjacent segment pathology can be reduced with total disc arthroplasty has to be clarified in further comparable studies.


S. BHAGAT J. Modi D. Pillai H. Bhalodiya

Background: Smaller versions of threaded lumbar cages were developed for cervical spine to obviate the need for allograft, iliac autograft use and to provide initial stability before fusion. Clinical trials of threaded cervical fusion cages have shown higher fusion rates and lower rates of graft-donor site complications.

Study design/Aims: Prospective. Radiological and clinical outcomes of an age, sex and diagnosis matched patient population who underwent cervical fusion with (A) BAK/C cages filled with autograft reamings (Center-pulse Spine-tech Inc., Minneapolis, MN) (N=50) were compared with (B) Anterior cervical decompression and fusion (ACDF, N=50).

Methods: Patients with symptomatic cervical discogenic radiculopathy were treated with either anterior cervical discectomy with uninstrumented bone-only fusion (ACDF) or BAK/C fusion cage(s). Independent radiographic assessment of fusion was made and patient-based outcome was assessed by a Short Form (SF)-36 Health Status Questionnaire. All patients had minimum follow up of at least 2 years.

Results: Similar outcomes were noted for duration of surgery, hospital stay, improvements in neck pain and radicular pain in the affected limb, improvements in the SF-36 Physical Component subscale and Mental Component subscale, and the patients’ perception of overall surgical outcome. Symptom improvements were maintained at 2 years. Iliac crest harvesting was carried out as a standard procedure in all cases of ACDF whereas only 2 cases in BAK/C group required the same. Average operative time of 115 minutes and 145 minutes, blood loss of 110ml and 175ml and hospital stay of 1.5 and 3.5 days were noted for BAK/C and ACDF groups respectively. Successful fusion was achieved in 49 cases in BAK/C and 46 patients in ACDF group. None of the patients in the BAK/C group had reappearance of symptoms while 3 patients in ACDF group had developed symptomatic adjacent level disc disease. The complication rate for the ACDF group was 9% compared with an overall complication rate of 3% with BAK/C. Complications that necessitated a second operative procedure included

Graft dislodgement (N=3) and

Cage subsidence, both requiring re-operation in the form of ACDF with plate supplementation.

Conclusions: These results demonstrate that outcomes after a cervical fusion procedure with a threaded cage are the same as those of a conventional uninstrumented bone-only anterior discectomy and fusion with a low risk of complications, less operative time and rare need for autogenous bone graft harvest.


M. Elbel C. Dehner L. Kinzl M. Kramer

Introduction: After whiplash injuries the majority of patients complain of pain, muscular dysfunctions and restricted movement of the cervical spine, however, the cause of these symptoms cannot be diagnosed.

Against this background, the hypothesis is formulated that functional disturbances in the form of pathological activities of the neck muscles occur as a result of a whiplash injury of the cervical spine. These pathological muscle activities can be demonstrated electromyographically and differ from the patterns of activity of healthy subjects.

Study Objective: Thus, the aim of this study was to establish an electromyographical method for the diagnosis of functional disturbances of the neck muscles after whiplash injuries of the cervical spine.

Material/Method: Primarily, an intramuscular recording of the electromyographical activity of the semispinalis capitis muscle was performed during flexion/extension and axial rotation in 46 patients with chronic symptoms after a whiplash injury of the cervical spine (QTF grade II) and 29 healthy subjects. The movement was controlled with techniques of virtual reality. The subject is immersed into a virtual outer space environment with a head-mounted display (HMD). In this virtual scene, the patient follows paths of motion of a signal (globe) with his/her gaze.

A subsequent study was conducted to validate the results that had been obtained. For this purpose, the electromyographical activity of the semispinalis capitis muscle was recorded in another subject group (n=20) and patients with acute symptoms as a result of a whiplash injury of the cervical spine (QTF grade II) (n=35).

Results: Compared to the physiological muscle activities that were established in the first subject group, changes could be observed in the chronic patient group.

Subjects in our study, for instance, show a decrease in electrical activity during flexion and the resulting stretching of the semispinalis capitis muscle, while the same movement causes an increase in activity in patients. On the basis of these differences, 93 % of subjects (specificity) and 83 % of patients (sensitivity) could be classified correctly with a discriminance analysis.

In the second study, the specificity was 88 % while a sensitivity of 86 % was determined in the acute patient population.

Conclusion: The results of these investigations enable a highly specific and sensitive diagnosis of muscular dysfunctions on the basis of the intramuscular recordings of the electromyographical patterns of activity of the semispinalis capitis muscle.


B.J. Lankester H.L. Cottam V. Pinskerova J.D. Eldridge M.A. Freeman

Introduction: The medial tibial plateau is composed of two relatively flat facets. An anterior upward sloping “extension facet” (EF) articulates with the medial femoral condyle from 0 to 20–the stance phase of gait (in Man but not in other mammals). Anatomical variation in this area might be responsible for antero-medial osteoarthritis (AMOA).

This paper reports the angle between the EF and the horizontal (the extension facet angle- EFA) in normal knees and in knees with early AMOA.

Method: MRI reports were searched to identify patients with acute rupture of the ACL on the assumption that they had anatomically normal tibiae (46 males and 18 females) and patients with MRI evidence of early AMOA without bone loss (11 males and 9 females).

A sagittal image at the midpoint of the femoral condyle was used to determine the EFA.

Results: The EFA in normal tibiae is 14 +/− 5 (range 3–25). The angle is unrelated to age. The EFA in individuals with early AMOA is 19 +/− 4 (range 13–26). The difference is significant (p< 0.001).

Discussion: There is a wide variation in the EFA in normal knees which is unrelated to age.

There is an association between an increased EFA (ie a steeper EF) and MRI evidence of AMOA. Although a causal link is not proven, we speculate that a steeper angle increases the duration of loading on the EF in stance and tibio-femoral interface shear. This may initiate cartilage breakdown.


A.K. bhadra A.S. Raman A. Rai A.T. Casey R.J. Crawford

AIM: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

METHODS: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

RESULTS & CONCLUSION: There was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.


M. Kramer C. Dehner M. Elbel L. Kinzl

Background: In a car-to-car collision, an adequate force has to be exerted to produce an injury of the cervical spine. This force is often described with the parameter delta-V. Limits for delta-V were defined for rear-end, frontal and side collisions on the basis of dummy experiments and volunteer crash tests under laboratory conditions, and then transformed for the road accident situation. According to this definition, an injury in a rear-end or side collision is unlikely at delta-V< 10km/h and probable at delta-V> 15km/h. For frontal collisions, the values are 20 km/h and 30km/h. To this day, there is no data to confirm these limits in the actual road accident situation.

Objective: Our objective was to compare clinical data and data from accident analyses of individuals after actual car-to-car collisions in a prospective study. We intended to check the validity of the delta-V limits on the basis of this data.

Methods: 57 individuals (25 males/32 females) were included in the study. The delta-V was calculated by a technical expert on the basis of photographs of the two cars involved. The individuals who had been in an accident were evaluated with regard to their history. Those reporting symptoms underwent a radiological and clinical examination.

Results: Rear-end collisions (n=21): The median delta-V for rear-end collisions is 13 km/h (min=3 km/h; max=58 km/h). 7 individuals reported symptoms. Both patients had delta-V values< 9km/h. Delta–V 10km/h.

Frontal collisions (n=13): The median delta-V for frontal collisions is 24 km/h (min=8 km/h; max=50 km/h). 4 individuals reported symptoms. Under delta-V 20, one individual had a fractured cervical vertebra (QTF IV).

Side collisions (n=19): The median delta-V for side collisions is 12 km/h (min=4 km/h; max=59,3 km/h). 9 individuals reported symptoms. Under delta-V 10 km/h, two patients had symptoms (QTF II and QTF IV (fracture).

Conclusions: The existing limits for delta-V cannot be transferred without reservation from the laboratory test situation to the actual road accident situation. Injuries and even fractures of the cervical spine can occur at a delta-V < 10km/h, particularly with side collisions. At the same time, delta-V values > 15km/h do not necessarily result in an injury of the cervical spine.


A.F. Mavrogenis P. Liantis P. Kontovazenitis P.J. Papagelopoulos D.S. Korres

The purpose of this study was to propose a new classification based on the structural, anatomical and biomechanical properties of the odontoid process, to evaluate the outcome and to suggest the adequate treatment in relation to the specific fracture type.

The files of 97 patients with odontoid process fractures admitted to our institution were reviewed. The external and internal anatomy of the axis has been studied. The fractures were classified according to the proposed new classification. The method was tested for reliability and validity. Mean follow-up was 14 years.

Intraobserver and interobserver agreement was excellent with intraclass correlation coefficients at levels of 0.98 and 0.85 respectively. Four types of odontoid process fractures are distinguished; type A fractures are avulsion fractures involving the tip of the odontoid; type B fractures are fractures of the neck between the lower edge of the transverse ligament and the line connecting the medial corners of the upper articular facets of the axis; type C fractures involve the area between the previously mentioned line and the base of the odontoid process (type C1) or extend to the body of the axis (type C2); type D fractures are complex fractures involving more than one level of the odontoid process.

Classification of odontoid process fractures has to be reconsidered as novel imaging technology has shown new patterns of fractures. Computed tomography scan with image reconstruction is mandatory. The analysis of the imaging data in the present study justifies the new classification.


M. Akbar G. Balean T.M. Seyler H.J. Gerner M. Loew

Introduction: Musculoskeletal injuries of the shoulder in paraplegic patients can result from overuse and/or incorrect use of wheelchairs. With improved long-term survival of these patients who exclusively depend on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion, they are particularly susceptible for shoulder pathologies. The purpose of this study was to compare the functional and structural changes in weight-bearing shoulders of paraplegic patients who are wheelchair dependent for more than 30 years with able-bodied volunteers.

Methods: This was a randomized study with 80 (160 shoulders) patients who had been paraplegic and wheelchair dependent for a mean of 33 years. These patients were matched for gender, age, occupation, and hobbies to a group of 80 (160 shoulders) able-bodied volunteers. The mean age for the paraplegic patients was 54 years and 51 years for the matched volunteers. Shoulders from both groups were prospectively evaluated using MRI. All films were analyzed by two board-certified radiologists who were blinded to the study. Prospectively collected outcome measures included a standardized clinical examination protocol, the Constant score, and visual analog scale (VAS) pain scores.

Results: The shoulder function according to the Constant score was significantly worse in paraplegic patients compared to able-bodied volunteers (p< 0.001). Similarly, the VAS scores were significant greater in the paraplegic patients (three-fold higher pain intensity, p< 0.001). Comparison of the MRI films of the paraplegic patients and the volunteers revealed the following significant differences: rotator cuff tears 67% (108/160) vs 5.6% (9/160); tendonitis 50% (80/160) vs 23% (37/160); tendonitis of the long head of the biceps 25% (40/160) vs 3.7% (6/160); rupture of the long head of the biceps 10% (16/160) vs 2.5% (4/160); subacromial subdeltoid bursitis 71% (113/160) vs 34% (55/160); acromioclavicular osteoarthritis 33% (53/160) vs 15% (24/160); and glenohumeral osteoarthritis 15% (24/160) vs 8% (13/160).

Conclusion: This is the first study comparing the long-term effect on shoulder pathologies of paraplegic wheelchair users to a cohort of able-bodied volunteers. The complications of weight-bearing activities in these patients require appropriate prevention including wheelchair and/or home modification, physical therapy, pharmacological pain management, surgical intervention, and patient education.


T. Mumme R. Marx R. Mueller-Rath S. Andereya D. Wirtz

Introduction: Aseptic loosening of cemented total knee arthroplasties is still an unsolved problem. In this regard the adhesion strength of the metal-bone cement interface is of major interest.

Material und Methods: Cemented tibial components coated with a silica/silane interlayer system (n=8) were dynamically loaded within a knee-simulator (DIN ISO 14243). After loading, the components were cut by “high pressure water jet technique” (Fraunhofer Institute for Production Technology, Aachen, Germany) into 10 slices (thickness 5 mm each) parallel to the shaft axis according to a standardised protocol. To evaluate the metal-bone cement interface with regard to gaps and cement failure, the tibial slices were analysed by light and fluorescent microscopy. These data were matched with uncoated components (n=8).

Results: The coated tibial components yielded a significant reduction of gaps in the metal-bone cement interface (p < 0.05) as well as a highly significant reduction of cement mantle failure (p < 0.001).

Conclusion: With the help of the silica/silane coating, gaps in the metal-bone cement interface with consecutive early cement mantle failure due to mechanical overstressing can be significantly reduced.


A. Martin M. Prenn O. Wohlgenannt A. von Strempel

Introduction: The benefits of postoperative wound drainage in patients with total knee arthroplasty (TKA) with regards to mobilisation and wound healing were studied. We wanted to determine the efficacy of an autologous blood retransfusion system.

Materials and Methods: 150 patients with TKA were divided into three groups of 50 patients:

A) Three wound drainages with an autotransfusion system and suction;

B) no wound drainage;

C) one intraarticular wound drainage without suction.

Haemoglobin values, blood transfusion requirements, blood loss, postoperative range of motion, knee society score and rate of complications were observed and recorded. All patients were operated without tourniques for lower blood loss during total knee replacement.

Results: In the group of patients with wound drainage and a retransfusion system the requirement of postoperative additional blood transfusion was not significantly less than in the group without wound drainage. Group A had the most blood loss of all. The group without wound drainage had more haematoma and wound healing complications. Best results were observed within the group with one intraarticular drainage without suction. The rate of complications was not increased and the blood transfusion requirements were the lowest.

Conclusion: This study shows that total knee replacement involving one intraarticular wound drainage without suction attains the best results. During the last four years we used this wound drainage technique in 787 TKAs and can confirm all findings of this study.


V.J. Luque J.C. Roa M.T. Porcel M. Quiles

Total knee arthroplasty had been reported to present similar amount of blood loss in external and hidden form. We studied whether lateral patellar release made any differences on both forms of blood loss.

Material and methods: We studied 91 patients (83 women an 8 men) undergoing primary unilateral total knee arthroplasty cemented posterior stabilised with patellar substitution, in 40 lateral patellar release were performed. Surgery is performed under tourniquet. The blood drain was recorded. We assumed that blood volume on the fourth postoperative day was the same as before surgery. Blood volume was estimated taking sex, body mass and height into account. Haemoglobin was recorded on preoperative and four days postoperative.

Results: We found more external blood loss in patients without lateral patellar release (p< 0,05) but no statistical differences in total and hidden blood loss. The amount of hidden blood in both groups were more than twice (975 mL) the external blood loss (443 mL). No relationship was found between body mass and any type of blood loss.

Conclusions: Lateral patellar release made no difference in the amount of total blood loss. In total knee arthroplasty hidden blood loss doubled external blood loss.


N. Moreno M. De la Torre R. Luis

Introduction: Obesity is a risk factor to develope knee OA. Patients who are obese often consider their disabling joint disease as a cause for their increased weight. The purpose of this study is to evaluate the changes of weigth and BMI in obese patients after TKA

Methods: 102 obese patients who underwent TKA between January 2002 and December 2003 were evaluated. They were followed for a mean duration of 35 months. Data about age, height, weight, BMI, hypertension, diabetes, NSAIDs and crutches were collected preoperative and at the end of follow-up. Statystical analysis was done using SPSSv11.5.

Results: Mean age was 69.8 y.o.. The average height was 157 cm. 24 were men and 78 women. Mean preoperative weight was 86.7 Kgs and at the end of follow-up was 87.3. BMI rose from 35.1 to 35.3. 90% recognized a better quality of life. 12.2% have a better control of their hypertension.30% needs NSAIDs and 4% uses crutches.

Conclusions: Obesity leads to an important number of Total Joint Replacement, specially TKA. Apparently it haven’t a worse outcome. Patients doesn’t loose weight after TKA, someones gain it. Knee OA can’t be considered as a cause of overweight.Obesity should be treated as an independent disease.


F. Thorey C. Stukenborg-Colsman G. von Lewinski C. Wirth H. Windhagen

Introduction: Besides other techniques to reduce blood loss, the use of pneumatic tourniquet is commonly accepted in total knee arthroplasty (TKA). Furthermore it is used to maintain a clean and dry operative field to improve visualization, to use a better cementing technique, and to reduce operating time. The time of tourniquet release is discussed controversially in literature. However, there are only a few prospective randomised studies that compared the effect of timing of tourniquet release in cementless or cemented TKA. To our knowledge, this is the first study that investigated the influence of tourniquet release on blood loss in a randomized prospective study in simultaneous bilateral cemented TKA.

Methods: 20 patients (40 knees) underwent simultaneous bilateral cemented TKA with the cemented Triathlon Knee System (Stryker) between February and May 2006. The mean age of the patients was 67 years (67+/−11 years). 7 males and 13 females were treated with TKA (mean tourniquet pressure: 282.5+/−33.5 mm Hg). In 20 patients one knee was operated with tourniquet release and hemostasis before wound closure (“Technique A”), and the other knee with tourniquet release after wound closure and pressure dressing (“Technique B”). To determine the order of tourniquet release technique in simultaneous bilateral TKA, the patients were randomized in two groups: “Group A” (20 knees) first knee with tourniquet release and hemostasis before wound closure, and “Group B” (20 knees) second knee with tourniquet release and hemostasis before wound closure. The patients were given low molecular weight heparin and a leg dressing to prevent deep vein thrombosis. The blood loss was monitored two days after surgery till removal of the wound drains.

Results: We found no significant difference in total blood loss between “Technique A” (753+/−390 ml) and “Technique B” (760+/−343 ml) (p=.930). Furthermore there was no significant difference in total blood loss between both techniques after randomizing in “Group A” (“Technique A” 653+/−398 ml; “Technique B” 686+/−267 ml; p=.751) and “Group B” (“Technique A” 854+/−374 ml; “Technique B” 834+/−406 ml; p=.861). However, the operating time showed a significant difference between “Technique A” (58+/−18 minutes) and “Technique B” (51+/−17 minutes) (p=.035).

Discussion: In this study we compared the effect of timing of tourniquet release on perioperative blood loss in a randomized prospective study in simultaneous bilateral cemented TKA. Our results showed no significant difference of blood loss but a significant difference of operation time. Therefore, we recommend a tourniquet release after wound closure to reduce operating time and to minimize the risk of peri- and postoperative complications at approximately similarly blood loss between both techniques.


G.A. Medalla P. Moonot U. Okonkwo Y. Kalairajah R.E. Field

INTRODUCTION: The American Knee Society score (AKSS) and the Oxford Knee score (OKS) are widely used health outcome measures for total knee replacements. The AKSS is a surgeon-assessed, variable weighted knee score. The OKS is a patient assessed equally weighted score. Our aim was to evaluate whether patient self assessment is a viable alternative to clinical review and whether it can provide enough information to identify which patient would require a clinic visit.

As there had been no previous studies correlating the two scoring systems, we investigated whether a correlation exists between the two scores at 2, 5 and 10 year periods. A correlation would allow us to determine what OKS value would achieve 90% sensitivity in identifying patients requiring clinical review at the above time points. This strategy would reduce the number of clinical visits required and its associated cost.

METHODS: We reviewed the data gathered prospectively from January 2000 to April 2006. All patients were part of an ongoing multi-surgeon single institution Knee Arthroplasty Outcome Programme. Preoperative, 2, 5 and 10 year post-operative OKS and AKSS were gathered from different cohorts. This method of comparison has been validated by previous publications. The scores were then analyzed using the Pearson correlation and linear regression. Different OKS values were analyzed for sensitivity and specificity.

RESULTS: 175 patients completed both the OKS and AKSS questionnaires preoperatively. 312 completed both scores at 2 years; 124 at 5 years and 57 patients at 10 years. The mean OKS, and the two AKSS components, the Knee score and Functional score improved significantly 2 years postoperatively when compared to their preoperative values. The Functional score deteriorated significantly from 5 to 10 years (p< 0.0001). There was good correlation between the OKS and the Knee score and Functional score at 2 years and a moderate correlation at 5 to 10 years. OKS > 24 showed more than 90 % sensitivity in identifying poor Knee scores in the 2, 5 and 10 year periods.

CONCLUSION: In this study, the good correlation of OKS and AKSS at 2-years suggests that postal Oxford questionnaire is sufficient in following up patients in the short term after total knee replacement. However, the moderate correlation at 5 and 10 years suggests that clinical evaluation is necessary.

We recommend that at 2 years, all patients complete an OKS questionnaire and if this is above 24, a clinical evaluation maybe required. Using this OKS value as a screening technique would allow a reduction of up to 50% in clinic visits and outpatient costs at the 2 year follow-up. This reduction is not as great at the 5 and 10 year periods. At these time periods, we recommend a clinical follow-up.


R. Trappler E. Smith G. Goldberg J. Parvizi W.J. Hozack

INTRODUCTION: Range of motion following TKA is a commonly assessed and important outcome parameter. The reported knee ROM is often measured using manual goniometers. The accuracy of goniometer in measuring ROM of the knee is not known. We compared the knee ROM measured with a manual goniometer and compared that to measurements obtained from computer assisted navigation system.

METHODS: This prospective ongoing study has so far recruited 60 patients (71 knees) undergoing TKA by a single surgeon. Measurements of the ROM were performed intraoperatively using a 14 inch 360° Nexgen Baseline® goniometer, validated by physical therapists, and the Stryker knee navigation system. Consistent anatomical landmarks were used to obtain flexion and extension measurements. Each goniometer and navigation measurement was performed twice by the same reader.

RESULTS: Goniometer was more inaccurate in measuring the knee ROM than the navigation. There was a 5.07° difference between two measurements obtained with the goniometer compared to a mean discrepancy of 1.15° using the navigation system. Further, the ROM measured by navigation was on average 13.9° larger than that measured by the goniometer. BMI affected the ROM recording obtained by both the goniometer and the navigation system.

DISCUSSION AND CONCLUSION: This study indicates that goniometer is not an accurate tool for measurements of knee ROM as there is a marked discrepancy between two goniometer readings. The navigation system seemed to produce more consistent, but markedly higher, readings than a manual goniometer. Reported results on knee ROM in the literature need to be interpreted with caution and scrutinized for potential inaccuracy of the measuring tool.


P. Hamilton M. Edwards Q. Bismil S. Bendall D. Ricketts

Introduction: Since the first meeting in 1875, and the subsequent introduction of the concept of evidence based medicine in the 1990s, the journal club has become an integral part of keeping abreast with current literature.

There is no study assessing orthopaedic journal clubs amongst training programs across the UK. This study had two aims: the first was to determine whether journal clubs still play an important part in orthopaedic training programs, the second was to evaluate the frequency, format and goals of journal clubs conducted in orthopaedic training programs in the UK.

Method: We surveyed fifty seven hospitals across the UK. This included hospitals from all the orthopaedic teaching regions of which twelve were teaching hospitals and forty five district general hospitals.

Results: A total of 57 hospitals were surveyed. Of these hospitals 28/57(49%) had a journal club programme in place. On average journals clubs were undertaken once a month and lasted about 1 hour. Most occurred during the working day and were chaired by a consultant. Specialist registrars presented the vast majority of papers (average of 1.9 each per session), with the JBJS Br being the most widely used journal (100% of journal clubs).

Of the twelve teaching hospitals questioned, five (42%) had journal clubs, and twenty three of the forty five (51%) district general hospitals had journal clubs. The average number of articles critically appraised by trainees who attended journal clubs was 5 (0–15) compared to 3 (0–18) in those not attending a journal club.

When asked whether there was any alternative way in which a trainee might otherwise learn how to critically appraise an article, fourteen suggested online journal forums and eighteen suggested self-directed learning or personal study.

Although only 49% of hospital had journal clubs, 88% of trainees believed that it formed a valuable part of training and 56% thought it should be compulsory.

Discussion: This study shows that journal clubs occur in around half of the orthopaedic departments surveyed across the country. This is despite the importance trainees’ associate with journal clubs being part of their training.

In contrast, studies from North America show that a regular journal club occurs in 99% of residency programs.

It may therefore be suggested that for those trainees who do not attend a journal club, an alternative method to learning the skills of critical appraisement may have to be sort. One suggested modality is through on-line journal clubs or forums within regions which trainees may be encouraged to undertake from their regional directors.


L. de Palma M. marinelli M. pavan A. orazi

Introduction: Pathological conditions, which determine human atrophy, are numerouses and heterogeneous.

Experimental studies prove that these different pathological conditions use common enzymatic pathways leading muscle atrophy. In every catabolic conditions where there is proteolyses’s increase, this one happens in association with up-regulation of two specific genes of skeletal muscle atrophy. These genes, MuRf1 (muscle ring finger-1) and MAFbx (muscle atrophy F-box), encode ubiquitin ligases. These ligases bind and mediate ubiquitination of myofibrillar proteins for subsequent degradation during muscle atrophy.

The aim of our study is to obtain a better understanding of human muscle physiopathology in atrophy by use of histochemistry and immunolocalisation of MuRF-1 and MAFbx.

Patients and Methods: 15 patients, amputated at third distal or proximal leg because of different acute or chronic pathology, were divided in two group. Group A: 12 elderly patients (mean age 72 years) amputated for vascular diseases (8) and complication of a diabetic foot (4). Group B: 3 young patients involved in car accident (mean age 25) amputated for limb’s acute arterial insufficiency. Gastrocnemius muscle biopsy specimens were obtained for all the patients, after that the informed consent was obtain, for histochemical (haematossilineosin), and immunohistochemical (anti- MuRf1, anti- MAFbx) analysis.

Results: Histochemistry: Group A: skeletal muscle showed a decrease in fiber size in cross-sectional area and fiber length with adipose tissue. Group B: light skeletal muscle structural alteration. Immuno-histochemistry: in group A, in muscular drawings, polyclonal antibodies direct against MuRf1 and MAFbx had stained muscle biopsy specimens. Muscle fiber cells showed MuRf1 and MAFbx subsarcolemmatic immunoreactivity and weakly immunoreactivity of the extracellular matrix. We noticed no positivity to anti- MuRf1 and anti- MAFbx less in sections from group B muscle biopsy specimens and in sections in which were present tissue muscle degeneration with replacement of adipose tissue.

Conclusion: The pathological results supported the concept that MuRf1 and MAFbx appeared to be regulatory peptide in cellular pathology that conduce to muscular atrophy. Our data support the hypothesis that different pathological conditions use common enzymatic pathways leading muscle atrophy.

The demonstration that the muscle-specific proteins MAFbx and MuRF1 are upregulated in multiple pathological conditions of skeletal muscle atrophy it is critical to continue studying the cellular pathways to discover promising targets for the development of effective new treatments for skeletal muscle disease.


A. Khurana S. Kadambande R. Kulkarni

Introduction: Complex fractures and singular acute orthopaedic admissions in an individual hospital form only a small proportion of admissions. An average orthopaedic surgeon does not gain and maintain enough experience to provide proficient care. Referral with in the department to a sub-specialist for that anatomical region is forming a norm. We studied the practice in our department to assess how much specialist care we provide.

Materials & Methods: Prospective study over four month’s period with specialist referrals reported by teams and Trauma Fellow. We observed the time spent before making the referrals and that taken by specialists in carrying out management. The spectrum of investigations by various specialist teams was also noted. Number of referrals made to each sub speciality was observed.

Results: Of a total of 836 acute admissions in the department over this four months period, 98 (11.7%) were referred to sub-specialists. Referrals were made on an average of 1.8 days after admission and were seen by the specialist after another 2.1 days. Average time to surgery was 4.7 days after referral. Special Imaging investigations were performed in 84 (86%) patients of whom 31 had been organised before the referral was made. 81 (82%) patients were operated by the specialist teams while rest underwent conservative treatment.

Discussion: With the changing structure and decreasing duration of higher specialist training, expertise in complex trauma is expected to be limited to the anatomical region of surgeons’ interest. Specialist management provides better patient care with improved satisfaction.

Conclusion: In the modern orthopaedic practice with intensive but limited expertise, specialist referrals are the acceptable solution both to the patient and the provider. This should be encouraged. Specialists should provide appropriate investigation and referral protocols.


D. Nicoll H. Mahayni D. Rowley

This study was carried out to evaluate the impact of Socio-Economic Status (SES) and the influence of geographic access to health services on the possible outcomes of total knee replacement (TKR).

Data on 345 patients with one year follow-up were collected from the database of the orthopaedic department. TKR outcomes were assessed according to Knee Society Score (KSS). A postcode was assigned to each patient depending on the residential area and data from the last census was used to calculate Scottish Index of Multiple Deprivation Score (SIMD) and its rating score for geographic access to health services.

The results show that the SES and the geographic access to medical services have significant impact on Function Scores but do not influence Knee Scores.

Patients living in the least deprived regions had a better post-operative Function Scores compared to those living in more deprived regions with differences of up to 13 points between groups (p< 0.001). Similarly the improvement in Function Scores was dependant on deprivation score. (p=0.015). Pre-operative Knee Score, post-operative Knee Score and improvement in Knee Scores were not influenced by deprivation score.

Patients living in rural regions had better post-operative Function Scores and greater improvements in Function Score compared to urban dweller patients (p≤0.011) with differences of up to 17 points. The Knee Score was not influenced by these variables.

These results suggest that SES and the region of residence should be considered when assessing the outcomes of TKR.


S. Bahari B. Lenehan J. McElwain

Introduction: This study was performed to review the changing patterns of trauma admissions in Ireland over 5 years (1999–2005).

Materials and Methods: A review of prospectively collected admission data of trauma patients admitted to the Adelaide & Meath Hospital (AMNCH). Dublin, Ireland, during 2005. Data obtained from Hospital In Patient Enquiry (HIPE) system. A comparison is made similar data from 1999. Demographic data, mode of presentations, type of injuries, time of injury and place of injury were recorded. Injury severity was defined using the Injury Severity Score (ISS).

Results: 23% increase in number of admission in 5 years period. Mean age of admission reduced from 35 (1999) to 32 (2005). 67% of admission occurred outside normal office hours (9am–5pm). Commonest mode of injury was road traffic accident (RTA) in 1999 and sports related injury in 2005. Work related trauma increases by 40% and assault increases by 35% from 1999 to 2005. High energy trauma cases reduce by 50% but open fracture cases double in 5 years. Mean overall ISS score was 56. 7(1999) decreased to 45.9 (2006).

Conclusion: These changes cause significant impact on the health system. Increase in facilities for management of trauma is essential as this trend is more likely to continue.


S. Juenemann C. Hasler R. Brunner

Purpose: X-Rays are presented on CD’s in a digital format with increasing frequency. The impression is that this technique requires more time to present a given x-ray compared to conventional pictures.

Methods: Time was measured for 6 orthopaedic residents presenting the most recent ap-view out of a given set. Ten sets of 6 x-rays for each case were saved in the conventional and digital format each. The order was randomised. As a precondition the computer was on and the same viewer software was used for all digital sets. The results were compared using a non linked student’s t-test (significance level p=0,05).

Results: Presentation of conventional x-rays required 21 sec (+− 7,46), of digital x-rays 90 sec (+− 27,56) respectively (p< 0,001).

Conclusions: In spite of ideal conditions digital x-rays on CD need significant more time in the orthopaedic clinic. In major centres patients present with different software and software in other languages which increase the required time even furhter. This latter problem will be assessed in another study.

Significance: This increase of preparation time used by a highly qualified staff member has implications on economics and logistics.


A. Martin O. Caglar M. Müller V. Senner M.B. Sheinkop M.A. Wimmer

Aim: Cycling is a common activity after TKA and it has been shown that up to 50 % of the TKA patients are riding a bike and 25 % think that cycling has an important place in their life. The specific contact mechanics of tibiofemoral joint is well known during walking, however, there is little data during cycling for TKA patients. The purpose of this study was to determine the tibiofemoral contact mechanics during cycling for TKA patients.

Methods: We recruited 10 patients implanted with a mobile bearing and 10 patients with a fixed bearing posterior stabilized prosthesis. An age-matched, asymptomatic control group consisted of 10 subjects. The patients were physically examined, and WOMAC index and knee society score were taken. Motion analysis was performed using a retroreflective marker based technique called “PCT”. Forces and moments during cycling were recorded with load cells at the crank shafts of the bike. Motion and load data were synchronized.

Results: Resultant pedal forces showed no significant differences between study groups but the generated impulse was higher in the mobile bearing group. Patients with contra-lateral osteoarthritis showed higher forces and impulse at the operated leg. The motion analysis showed the following mean values ±SD for TKA patients/Normals: maximum flexion angle 132.5° ±16.0°/131.5° ±18.3°, minimum flexion angle 41.4° ±12.0°/40.3° ±15.7°, range of rotation in transversal plane 12.6° ±4.7°/9.9° ±3.6° and range of anterior-posterior translation 5.3 mm ±5.1 mm/2.7 mm ±0.4 mm. There were no significant differences between study groups.

Discussion: In this study, force and impulse of TKA patients with contemporary prostheses were comparable to healthy subjects indicating functional restoration of the joint. Contralateral osteoarthritis may cause higher forces at the operated leg and thus, relatively higher stresses at the artificial articulation.

As expected, the generated forces at the bike pedal were low (20–25% body-weight) calling for little muscle activity and low compressive joint forces. However, with a mean maximum flexion angle of 131.5°, the observed motion ranges were higher than expected. Prostheses not designed for high flexion activities could lose tibio-femoral contact during cycling with detrimental effects on wear. Still, the measured range of rotation in the transverse plane indicates that despite its posterior-stabilized design rotation is taking place with approximately the same amount as it occurs in normal subjects. This may have detrimental effects on the post at the tibial plateau and could explain the previously observed rotational damage patterns on retrieved posterior stabilized TKA specimens.

Data are suggesting that leisure activities should be considered to determine the appropriate TKA design. This study will provide useful data for future design and wear testing scenarios.


R.S. Ahluwalia S. Matthews R.N. Slater

We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme.

We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery.

From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively.

Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period).

The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma.

This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre.


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A. Khurana H. Tanaka

Introduction: Trauma surgery creates enormous mental stress for operating surgeons, especially in trainees. This is responsible for sympathetic hyperactivity which can be measured by various cardio vascular variables. Air Traffic control is recognised as one of the most stressful occupations with accepted risks and incorporated remedies. We compared the stress during surgery with that experienced by air traffic controllers.

Materials & Methods: The study included 40 trainee doctors. We obtained multiple readings of heart rate, diastolic and systolic Blood Pressure with ambulatory monitoring methods when they operated. This was compared to their resting measurements obtained at home. Similar measurements were performed for Air Traffic controllers, while at work and at home.

Results: The heart rate and blood pressure were increased at the beginning and during surgery. Student t test was applied to compare the mean values obtained intra-operatively and in resting conditions. This suggested the increase to be statistically significant. This increase in autonomic function variables was compared with the values similarly obtained for Air Traffic Controllers. Operating surgeons manifested significant increase in comparison to the other group.

Discussion: Stress can not be eliminated but can be over come with experience. Recurrent sympathetic hyperactivity may contribute to various stress related ailments. As in Air Traffic controllers, stress should be accepted as integral part of occupation. Stress relieving manoeuvres should form an important part of surgeons’ occupational health and medical school/ foundation years curriculum.

Conclusions: Surgeons experience more emotional and mental stress than occupations accepted to be most stressful.


E. Betti M. Vitale M. Vaglini

The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability.

Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before.

NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time.

We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute Norian:

56 fractures were unicondylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3).

The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen. X-rays. The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%).

We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cutdown the functional recovery time. Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness.


D. Katsenis A. Kouris N. Schoinochoritis N. Savas K. Pogiatzis

Purpose: To assess the function of the knee joint and the development of knee arthrosis, at seven years postoperatively, in patients in whom a high energy tibial plateau fracture had been treated with minimal internal fixation augmented by small wire external fixation frames.

Material and Methods: Between October 1989 and November 1999, one hundred twenty nine high energy tibial plateau fractures were treated with hybrid fixation including small wire circular or hybrid frames, minimum internal fixation and occasionally provisional extension of the external fixation to the distal femur. The average patient age was 39 years. There were 69 (53%) C1 fractures, 19 (15%) C2 and 41 (32%) C3 fractures and 49 (38%) fractures were open. Complex injury according to Tscherne-Lobenhoffer classification was recorded in 87 (67%) patients. Clinical, subjective, objective and radiographic results were evaluated after an average follow up of 84 months.

Results: Results were assessed according to the criteria of Honkonen–Jarvinen. Excellent or good functional result was recorded in 98 (76%) patients. However, only 74 (57.5%) patients retained an excellent or good radiographic result at the final follow up. Compared with the radiographic appearance of the post-traumatic arthritis after an average of 48 months, there was found no statistically significant deterioration of the knee arthrosis (p< 0,05). No reconstruction operations were performed after the completion of the index procedure.

Conclusion: A high percentage of radiographic post-traumatic arthritis should be expected, after high energy tibial plateau fractures had been treated with minimal internal fixation augmented by small wire external fixation frames. However, because all the objectives of the fracture treatment can be obtained, the functional results remain satisfactory over time.


M. Ricci E. Vecchini A. Costa A. Sgarbossa P. Bartolozzi

PURPOSE OF THE STUDY: Arthroscopic assisted treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery, but bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical Results:

MATERIAL AND METHODS: seventy patients (mean age 47 years, range 18 to 72 years, 43 men, 27 women) were arthroscopically assisted treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 20 type I, 27 type II, 18 type III and 5 type IV. The fixation device was: Kirchner wire in Schatzker I, percutaneous cannulated screw in Schatzker II,III,IV, and bone cement filing of the fracture site in 1 case. In 32 cases, where bone loss was significant. we use autologous bone graft, in 18 cases SRS. There were 15 meniscal injuries: 3 underwent arthroscopic suture, 8 had partial meniscectomy and 4 sub subtotal meniscectomy. We also diagnosticated 7 lesions of the medial pivot 6 ACL, 1 PCL : all were left in place. Al patients in the first post-operatory day start passive rehabilitation with kinetech All cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Hospital for Special Surgery) and radiographical examination were done with an average follow-up of 46.7 months.

RESULTS: There were no complications except two immediate compartimental syndromes that stopped the arthroscopic treatment. Passive motion of the knee started at 1 day postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 93 for Schatker I, 91 for Schatker II, 87 for Schatker III, 86 for Schatker IV. In eight cases we found early signs of osteoarthritis. There were no secondary bony depression or significant valgus deformity on X-rays.

CONCLUSION: Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with open surgical technique for the types of fracture that we have treated (type III and IV). A minimal, percutaneous osteosynthesis which was the only possibility under arthroscopic control, did not modify the anatomical Results:


R. Bansal N. Bouwman S.J. Hardy

BACKGROUND: One of the prime concerns when managing patients in plaster casts is loss of reduction. There have been studies showing that proper moulding of plaster cast is critical in maintaining reduction. Recent studies have negated concerns that fibreglass (FG) casts do not allow swelling, when compared to plaster of Paris (POP) casts. However, their potential in maintenance of reduction has not been investigated.

MATERIALS AND METHODS: We compared the three-point bending properties of FG casts with POP casts over the first 48 hours. The effect of splitting the casts, at one hour and 24 hours, was studied. Also, the tolerance to handling was assessed by moving the hinge joint while the casts were setting.

Three identical jigs with hinged metal rods were designed to simulate Colle’s fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 8 groups and 42 tests).

RESULTS: Most deformation occurred within 1 hour for FG casts and 24 hours for POP casts. The total deformation in FG cast (mean 3.4 mm) was significantly less than in POP casts (mean 6.2 mm) (p > 0.05).

Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p > 0.05). No significant difference was noticed if the casts were split at 24 hours.

CONCLUSION: Three-point moulding with FG casts can provide better constant loading at the fracture site than the POP casts. Early setting of FG cast allows earlier splitting. We recommend clinical trials to ascertain the safety and efficacy of split FG casts.


D. Rouleau B. Benoit Y.G. Laflamme L. Yahia

Purpose: Restoration and maintenance of the plateau surface are the key points in the treatment of tibial plateau fractures. Any deformity of the articular surface jeopardizes the future of the knee by causing osteoarthritis and axis deviation. The purpose of this study is to evaluate the effect of trabecular metal (porous tantalum metal) on stability and strength of fracture repair in the central depression tibial plateau fracture.

Method: Six matched pairs of fresh frozen human cadaveric tibias were fractured and randomly assigned to be treated with either the standard of treatment (impacted cancellous bone graft stabilized by two 4.5mm screws under the comminuted articular surface) or the experimental method (the same screws supporting a 2 cm diameter Trabecular Metal (TM) disc placed under the comminuted articular surface). Each tibia was tested on a MTS machine simulating immediate postoperative load transmission with 500 Newton for 10000 cycles and then loaded to failure to determine the ultimate strength of the construct. Results: The trabecular metal construct showed 40% less caudad displacement of the articular surface (1, 32 ±0.1 mm vs. 0, 80 ±0.1 mm) in cyclic loading (p< 0.05). Its mechanical failure occurred at a mean of 3275 N compared to 2650 N for the standard of care construct (p< 0, 05).

Conclusion: The current study shows the biomechanical superiority of the trabecular metal construct compared to the current standard of treatment with regards to both its resistance to caudad displacement of the articular surface in cyclic loading and its strength at load to failure.


P. Lakshmanan A. Sharma J.P. Peehal H. David

Introduction: Avulsion fractures of the anterior tibial spine are not so common. The best form of treatment for displaced fractures is still debatable.

Aims: We aimed to analyze the results of different forms of internal fixation for avulsion fractures of the anterior tibial spine.

Material and Methods: Twenty-five patients with avulsion fractures of the anterior tibial spine had open reduction and internal fixation with different implants (AO screw, Herbert screw, stainless steel wire loop and absorbable stitch) and techniques. The mean follow up period was 3.66 years. They were evaluated clinically and radiologically, using KT 1000 arthrometer for ACL laxity and goniometer for range of movements. The outcome was measured using Lysholm Knee Score.

Results: Significant residual anterior laxity despite adequate fracture union was a common finding. Maximum ACL laxity was seen in adults in whom absorbable stitches had been used and they had a corresponding lower Lysholm score. Significant migration of the Herbert screws was noted in two of five patients in which it was used. Five of the eight patients with higher Lysholm score had AO screw fixation. Three patients with steel wire loop for stabilization of the fracture also had better results comparatively. Three individuals who had their knee immobilised in 25°–50° of flexion developed fixed flexion deformities, which took 12–18 months to recover.

Conclusions: The use of absorbable stitches as the primary method of fixation for avulsion fractures of the tibial spine should be avoided in adults. Herbert screw in this situation has a tendency to migrate. AO screws and non-absorbable loop yields better functional outcome. Immobilization of the knee in excessive flexion leads to prolonged fixed flexion deformity. Early range of movements can be achieved by replacing cast with a brace allowing flexion up to 90 degrees.


G. Erturan S.D. Deo R.A. Brooks

BACKGROUND: Complex tibial peri-articular fractures are known to be challenging with high complication rates. Techniques are evolving to assist the management of these injuries and this study looks at a Trauma unit’s experience to help evaluate indications, short and mid-term outcomes and complications.

METHOD: 4 year retrospective analysis of prospectively enrolled patients diagnosed with complex peri-articular fractures. Definitive treatment with Less Invasive Stabilisation System (LISS), low contact peri-articular plates and locking condylar plates, using minimally invasive percutaneous osteosynthesis (MIPO), irrespective of initial operative management were included. Follow up:until discharge from clinic with union and full weight bearing. Outcome: peri- and post-operative complications, loss of fixation, radiographic union, and range of motion.

RESULTS: 25 (15 proximal,10 distal tibial) operations by senior authors (RAB, SDD) over 4 years with a 16–88 year age (mean 44). Poly-trauma:7 (28%) of cases and 6 (24%) of the entire group were open fractures. Ten patients (40%): preceding damage-limitation procedure prior to definitive treatment (MIPO) and found to be over twice as likely to experience a complication compared to patients who did not. 3 (12%) of 10 had failed those alternative modalities. Overall infection rate was 24% (6 patients:2 deep wound infections; 4 open fracture wound infections). Infection was successfully managed with the use of debridement, flaps and antibiotics in 2 patients (8%); antibiotics alone on one (4%); in 3 patients with the delayed plate removal (12%), usually after union (1 revised with an intramedullary nail). Six plates (24%) were removed: 3 (12%) for infection; 2 (8%) for pain; 1 (4%) for plate fracture (revised). Other complications:2 (8%) significant wound breakdowns, one of whom required local flap cover. No mal-alignment issues; 1 patient developed common peroneal nerve neuropraxia. Patients who were operated after a week or more from injury were half (33%) as likely to suffer from a complication than those operated within a week (57%); P < 0.05 Chi-Square.

All progressed to union with 5 patients (20%) having metal work out at that end point and 8 (32%) healing without complication, further surgery or irritation. There were 18 re-operations in total in 9 (36%) of the patients.

CONCLUSION: Complex peri-articular fractures of the tibia continue to have a high re-operation rate with significant infection risk especially in open injury. Such techniques do provide a lower morbidity and short-term complication profile when compared with frames/hybrids and formal open fixation. The timing of minimal approach surgery is crucial and has yet to be fully defined. Within a department this type of fixation should be restricted to those with a specific interest, experience and training.


S. Rajkumar K. Nagarajah M. Moiz

OBJECTIVES: To review the short-term functional results of the surgical treatment of tibial plateau fractures using low profile peri-articular plates.

METHODS: Forty-nine displaced fractures of the tibial plateau in forty-nine patients were treated with open reduction and buttress plate fixation using low profile plate between 2002–2006. All aspects of their care, including tibial plateau fracture type, operative management and associated injuries, were documented. Preoperative and postoperative follow-up radiographs were analyzed for fracture classification and adequacy of reduction. All patients were followed up with clinical assessment and given Iowa knee functional outcome questionnaires. Data were also collected regarding return to work and sporting activities. The average age of the patients was thirty-eight years and the mean follow-up was 25 months, with a range of 12 to 52 months.. Of the forty-nine fractures studied, twenty-six were classified as Schatzker types I, II, or III, and the remaining twenty-three were types IV, V, or VI. Forty-six patients had closed injury while three had open fractures.

RESULTS: 48 of the fractures healed without additional surgical intervention or bone grafting except for one bicondylar fracture which needed amputation because of deep infection and soft tissue problem. Thirty eight patients had follow-up of greater than 1 year. The average time to radiographic callus was 6.2 weeks, and the average time to complete union was 16 weeks. The articular step-off average was 0.8 mm, with a range of 0 to 5 mm. The range of motion of the knee averaged 3° of extension to 120° flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 88 points (range, 72 to 100 points). The postoperative alignment demonstrated 1 patient with a malalignment of 4 degrees procurvatum and 1 patient with 3 degrees of valgus. There were two superficial wound infections and one case of deep infection.

CONCLUSIONS: Open reduction and internal fixation is a satisfactory technique for the treatment of displaced fractures of the tibial plateau, particularly for patients younger than fifty years. The use of low profile tibial plates appears to stabilize complex fractures of the tibial plateau with a low incidence of complications. The low profile plate functioned well in maintaining alignment and obtaining union in these high-energy fractures.


C. Kayali H. Agus A. Turgut

Objectives: The comminuted supracondylar femur fractures are resulted from high energy trauma. Infection and union problems are common complications. LISS is a new generation implant leading to decrease these complications. The aim of this prospective study is to compare the outcomes of distal femoral fractures treated by LISS (Less Invasive Stabilization System) of the multiple injured and isolated fractured cases.

Patients and Methods: This prospective study comprised of twentysix patients, sixteen men and ten women, who had 27 distal femoral fractures. Patients were divided as having multiple injury (group I) or isolated femur distal fractures (group II). There were fourteen supracondylar (AO type A) and thirteen intercondylar (AO type C) fractures. The average Injury Severity Scores (ISS) of group I and II were 26.7 and 9 respectively. Operations were performed according to biological fixation principles by means of submuscular manner. No grafting was performed to enhance the healing. The cases were evaluated based on the criteria of Schatzker–Lambert and modified Hospital for Special Surgery (HSS) scoring system.

Results: The mean hospitalization time was 16 days (range 13–46) in GI mainly depended on the presence of concomitant injuries and 8 days (range 6–12) in GII. The mean age of the patients was 49 years (range 26–80) (51.6 in GI and 45.6 in GII). The mean follow up period was 25.8 months. Union was achieved in all cases. Two cases required debridement procedures due to deep infection in group I. One of them healed completely but the other not resulted in chronic ostemyelitis. Revision surgery was carried out in one case due to screw pull out at second weeks postoperatively.

The average range of knee motion of the group I and II at the last control were 112.8°, 121.8 respectively. The mean modified HSSs were 73.9 and 79.9 respectively. There was no significant difference for HSS scores and range of knee motion (p> 0.05). Based on the criteria described by Schatzker and Lambert, the outcomes were assessed as excellent in 3 cases, good in 8, fair in 3, and poor in 2 in GI and as excellent in 3, good in 7 and fair in 1 in GII. Poor results of GI were because of osteomyelitis in one case and 15° varus deformity in another. The full weight bearing time was longer in group II depending on the concomitant injuries.

Conclusion: We concluded that LISS is effective method to yield satisfactory results for comminuted supracondylar fractures with multi trauma, even if their final results seem to be lower in comparison to isolated femur fractures.


A. Carfagni F. d’imperio M. rendine M. razzano

Proximal tibial fractures often are caused from trauma with high energy forces with associated soft tissue lesions. The authors report their experience with 45 cases of proximal tibial fractures treated with less invasive system plates (LISS) with good clinical and radiographic results after 5 years follow-up. There is evidence of good stabilisation of the fractures with this conservative soft tissue method combined with early rehabilitation.


M.T. Hirschmann T. Rychen L.G. Lorez N.F. Friederich

Background: Traumatic dislocations of the knee are uncommon (< 1% of all dislocations), but they account to the most serious ligament and soft tissue injuries of the knee. Diagnosis and treatment of the dislocated knee present a major challenge to the orthopaedic surgeon. The purpose of our retrospective study was to critically analyze the clinical outcome of all traumatic knee dislocations treated operatively between 1996 and 2006 in our institution.

Methods: Retrospective clinical case series study of all patients treated for traumatic knee dislocation (m: w=12:4; mean age 31 yrs, range 17–63 yrs) from 1998–2006.

The mechanism of injury was a traffic accident (n=7), a sport trauma (n=8) and slip and fall (n=1). The charts of all patients were analyzed.

The clinical outcome was assessed by personal telephone interview by a modified SSK questionnaire by Insall. Surgery was performed by one team of surgeons 2–89 days after trauma.

Mean and range were reported for continuous variables and relative and absolute frequencies vor categorial variables. Data were analyzed using Stata version 8. The level of significance was defined as p< 0.05.

Results: The injury pattern is reported below:

15 anterior cruciate ligament (ACL) lesions (11x ACL reconstruction), 15 posterior cruciate ligament (PCL) lesions (9x refixation, 3x reconstruction), 13 medial collateral ligament (MCL) lesions (8x reconstruction), 6 medial posterior collateral ligament (MPCL) lesions (4x reconstruction), 4 lateral collateral ligament (LCL) lesions (1x reconstruction), 3 popliteal muscle injuries (2x reconstruction), 5 medial meniscal lesions, 10 lateral meniscal lesions (9x suture, 1x partial meniscectomy), 3 femoral fractures, 1 proximal tibial fracture.

One angiography was performed. No vascular lesion was observed.

The follow up rate was 93% complete. The mean follow up time was 58 months (range 35–156).

83% of patients were able to return to work without any impairment. 62% of patients returned to the same level of sport activity. 54% of patients were absolutely painfree.

Based on a modified SSK score by Insall a mean of 182 points (range 129–200) on a scale with maximum 200 points could be noted.

Conclusions: Even though in a orthopaedic clinic specialized in the treatment of knee injuries traumatic knee dislocations remain a demanding therapeutic challenge. A highly specialized, customized and sophisticated treatment strategy of a experienced team of surgeons, nurses and physiotherapists is mandatory for acheivement of optimal functional and subjective outcome.


S. Ahmad H. Jahraja D. Sunderamoorthy K. Barnes L. Sanz M. Waseem

We are presenting a prospective study of 25 patients with clavicle fracture treated with Rockwood Intramedullary pin fixation. Operative management is required for open fractures, neurovascular injury or compromise, displaced fractures with impending skin compromise and displaced middle third fractures with 20mm or more shortening. Plate osteosynthesis or intramedullary fixation devices are used for operative management.

Patients and Methods: 25 patients with clavicle fractures underwent fixation of clavicle fractures with threaded intramedullary Rockwood pin. The indications for internal fixation were persistent wide separation of fracture with interposition of soft tissue in 12, symptomatic non-union in 3, associated multiple injuries in 3,one of them had a floating shoulder, impending open fracture with tented skin in 4 and associated acromioclavicular joint injury in 3 and one of whom had bilateral fracture clavicle.. All patients underwent open reduction through an incision centred over the fracture site along the Langer line. Intramedullary pin was inserted in a retrograde manner. Autologous bone grafting from iliac crest was done in all patients with nonunion. Radiographic and functional assessment conducted using DASH scores.

Results: There were 21 male and 4 female patients with a mean age of 34 yrs (range 17 to 64 yrs). Mean follow up was 12 months (range 5 months to 30 months). Radiographic union occurred in all patients within 4 months. In our study the commonest indication for Rockwood pin fixation was displaced middle third clavicle fracture followed by impending open fractures. Commonest complication was skin irritation at the distal end of the pin with formation of a tender bursa occurring in 9 patients, 3 of whom had skin breakdown. Fracture union occurred in all these patients with no further intervention and wounds healed completely after removal of the pin. One patient developed non-union and was later treated with ORIF with DCP and bone-graft. There were no deep infections, pin breakage or migration or re-fractures after pin removal. At the time of last follow up the average DASH score was 25 with a range of 18 to 52.

Conclusion: Open reduction and intramedullary fixation of clavicle fractures with Rockwood pin is a safe and effective method of treatment when surgical fixation of displaced or non-union of middle third clavicle fracture is indicated. This technique has an advantage of minimal soft tissue dissection, compression at the fracture site, less risk of migration and ease of removal, along with early return to daily and sports activities.


R. Attal M. Müller M. Hansen H. Bail M. Kirjavainen T. Hammer M. Blauth D. Höntzsch P. Rommens

Introduction: The Expert Tibia Nail was designed to address proximal, shaft, segmental and distal tibia fractures in one implant. Multiple locking options in various directions provide more stability and reduce the risk of secondary malalignment. Angle stable cancellous bone locking screws in the tibia head also improve fixation.

We evaluated this new implant in our series in a prospective, multicenter setting.

Methods: 190 patients were treated in 10 participating centers using the Expert Tibia Nail (Synthes). 127 patients suffered polytrauma, 58 presented as open fractures. Within the framework of the study 5 cases were proximal tibia fractures, 108 shaft fractures, 56 distal fractures, and 21 segmental fractures. These were followed-up postoperatively, after 3 months and one year and evaluated radiologically and clinically with regard to malalignment, union rate and complications.

Results: Non union occurred in 9 cases after one year of follow up (n=150). 20 patients showed delayed union. The rate of open and complex fractures was high in this group. Dynamisation was performed in 10 cases. Valgus/varus and recurvatum/antecurvatum malalignment of more than 5 degrees occurred in 13 cases. Stable reduction was achieved in 144 cases. In 4 complex fractures, initial reduction went into malalignment. 2 patients developed a deep infection after 3rd degree open fractures. 34 patients suffered from pain in the operated area. 6 screws broke during the follow-up.

Discussion: The Expert Tibia Nail proved to be an excellent tool to treat tibia fractures. Not only shaft fractures but also complex fractures in the proximal and distal metaphyseal area can be successfully stabilized due to advanced locking options and design of the nail. The rate of malalignment, non-union and complications was low.


A. Athanasopoulou V. Psychoyios G. Galani H. Dinopoulos M. Domazou A. Tsamatropoulos

Aim: The aim of this study is to evaluate the efficacy of the multidetector CT scan in shoulder fractures and to correlate these findings with those of plain x-rays.

Material and Method: A 105 patients with shoulder fracture were examined with a multidetector CT scanner after the acute injury. There were 64 male and 41 female with an average age of 52 yrs (range 16–95 yrs). The examination was performed with a CT PHILIPS BRILLIANCE, and six groups of detectors were used, with thin slices (1.6–2 mm). MPR and three dimensional reconstructions were performed.

Results: The mechanism of injury was fall during walk in 66 patients, fall from a height in 11 patients, and road traffic accident in 28 patients. They were detected 210 fractures at the shoulder region. A 135 fractures were located at the proxd imal end of the humerus, 75 at the scapula, in 95 out of 105 patients. In 10 patients with a comminuted fracture of the upper end of the humerus, the exact number of fragments as well as the precise location of them was not accurately assessed with plain xrays. MDCT control with multilevel anasynthesis and three dimensional reconstruction improved the understanding of the anatomic orientation in complex fractures and fractures–dislocations and in detection of subluxation of the fragments of the shoulder headin four part fractures in two patients.

Conclusion: Our results would orient us for using the MDCT scan in patients with acute shoulder injury, especially in cases with comminuted fractures, because it is better assessed the place, the orientation and the displacement of fragments, which are not easily identified in plain xrays. Furthermore, these reconstructions improve the preoperative planning in those patients


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B. Speigner T. Gosens

Background: Body fractures of the scapula are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaires and objective range of motion and muscle-strength testing to evaluate a series of patients who had received nonoperative care for a fracture of the body of the scapula.

Methods: We identified twenty-three patients (seventeen men and four women with a mean age of forty-four yours) who had sustained an isolated fracture of the body of the scapula. All patients were treated non-operatively. At a mean of sixty months, and a minimum of thirty months, outcomes were measured with the Constant shoulder score, the DASH (Disabilities of the Arm, Shoulder and Hand) and the RAND 36 (Rand 36 item Health Survey) patient questionnaires. Additionally we …

Results: On all scores a good to excellent result was obtained in those patients with an isolated scapular fracture. In those cases in which the scapular fracture was a part of a multi-trauma, the amount of accompanying injuries correlated with the inferior result.

Conclusions: Overall outcome of scapular fractures is good but the final result is dictated by the severity of accompanying injuries.


J. Vastmans T. Poetzel S. Hauck V. Buehren

Due to the fact that the treatment of distal femoral fractures is a therapeutic challenge, new specific implants were continuously developed. The techniques should guarantee a reliable bone healing for two different groups. For young patients with high energy trauma and more or less severe collateral injury and for old patients with osteopenic bone, weal soft tissue and a high rate of co-morbidity. Present widespread techniques are reduction and fixation with LISS plate or retrograde nails. In this clinical study from 2003 to 2006 we compared our supracondylar nail (SCN, Stryker) with the LISS plate. We were looking at a series of 77 patients (55 SCN and 23 LISS) with A (36) and C (41) fractures of the distal femur. 43 (78%) of the SCN group healed without complications, 1 malrotation, 1 case of infection, 2 pseudarthrosis and 5 problems with the distal locking screws were observed. In the LISS group only 23 (56%) healed primarily, whereas the complications occured more frequent. Beside radiographic control and clinical examination the success of operation was assessed with a standardised questionare (KOOS). The SCN group showed again a higher rate of satisfaction compared to LISS.

Conclusion: The SCN is working in A and also in complex C fractures. Furthermore we saw less rate of complications and more satisfied patients with the SCN.


R. Chidambaram C. Kachramanoglou D. Mok

Aim: To evaluate the radiographs of proximal humeral fractures in an attempt to define a diagnostic sign as a predictor of four-part fracture.

Diagnostic sign: The normal humeral head articular surface points towards the glenoid. We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proved otherwise.

Materials and Methods: Between 2002 and 2006, 80 consecutive patients underwent open reduction and internal fixation of their proximal humeral fractures in our Shoulder unit. We reviewed their preoperative radiographs and operative notes retrospectively. 79 patients were included in the study as one patient’s pre-operative radiograph was not available.

The AP radiograph was evaluated independently by three observers who were blinded to the identity of the patients and their operative diagnosis. The presence of ‘sunset’ sign was recorded. There was 90% inter-observer agreement. In the remaining 10%, a consensus review was performed as to the presence of sign for evaluation purpose. The findings were then correlated with the operative findings to confirm whether they were four-part fractures or not. With 95% confidence interval we calculated the sensitivity, specificity, and positive and negative predictive values for our diagnostic sign.

Results: 30 out of 79 patients displayed ‘sunset’sign in their preoperative radiograph. Of these 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign in diagnosis the four-part fracture was 93%. The specificity and sensitivity were 95% and 78% respectively. The sensitivity was affected by 8 patients with four part fractures with displaced articular head fragment which had dropped either medially or posteriorly.

Conclusion: Our results suggest that in patients with proximal humeral fractures, the presence of ‘sunset’sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.


T. De Baere T. Lequint

We present the results of surgical treatment of proximal humeral fractures in a group of 40 patients. The fractures were treated with the angular stable Lockin Proximal Humeral Plate, which is based on the LCP-principle (Locking Compression Plate). The upper part of the plate contains small suture holes for fixation of the tuberosities.

Between january 2002 and december 2005, 40 patients were operated using this technique. There were 24 women and 16 men and the mean age of our population was 56.5 years. Clinical and radiological evolution was followed until fracture fracture healing and functional recovery and a Constant-score was taken on a retrospective basis with a mean follow-up of 23.6 months. During follow-up 2 patients died of unrelated causes with their fractures healed and 2 patients were lost because they were living abroad.

Fracture healing was uncomplicated in 34 patients (89 %). In 4 patients there was secondary displacement of the fracture: varus displacement in 3 cases and complete loosening of the osteosynthesis in a patient who fell again a few weeks after the first intervention. In this patient a new osteosynthesis with the same device was realised and the fracture healed correctly. In the other 3 cases the fracture healed with some varus alignment and in 1 of these the hardware had to be removed because of intra-articular positioning of some screws after varisation of the humeral head. No secondary displacement of the tuberosities was seen. In one case we had an aseptic necrosis of the humeral head 6 months after the osteosynthesis and this patient needed a shoulder arthroplasty. Another patient had severe chondral lesions of the humeral head but symptoms respond well to medical treatment.

Hardware removal was necessary in 8 patients because of subacromial impingement or local tenderness. Reflex sympathetic dystrophy occured in 4 cases. The mean Constant-score was 57.6; when correction was made for age and gender the mean score was 73.0.

Conclusion: The LPHP plate is a reliable implant for proximal humeral fractures but attention should be paid to the possibility of subacromial impingment and the plate should not be placed too high. Although the LCP-system allows for rigid fixation, some loosening of the humeral head screws in osteoporotic bone remains possible, leading to varus displacement of the humeral head. In these cases early mobilisation should be avoided. Secure fixation of the tuberosities through the proximal suture holes is also mandatory if early mobilisation is foreseen.


We report the short-term results of an alternative treatment for acromioclavicular (AC) dislocation.

36 patients, aged 20 to 58 (mean 36), with Tossy types IV (16) or V (20) AC-injuries were operated on within 1 week after trauma. The majority of patients had sport-related injuries. All patients were engaged in overhead activities, either professionally or for sports. The surgical technique consisted of a double fixation. A processed tendon-graft, either fascia lata or tibialis anterior, was looped around the coracoid process and the distal clavicle in a figure-of-eight and sutured onto itself after reduction of the dislocation. The AC discus was removed if damaged. No attempt at repair of the ligaments was made. The graft was protected for 6 weeks with 2 percutaneously placed acromioclavicular K-wires. In this period pendulum exercises and up to 45° abduction were allowed.

21 patients had an excellent result with painfree function, including full range of motion and strength, at only 3 month postop; another 5 needed 6 months to reach an excellent result. These patients could fully return to their work or sports activities at 3 months postop. 5 developed frozen shoulder syndrome and had a poor result at 3 month postop. These patients recovered well and all had good or excellent results at 8 month postop. 3 patients refused follow up after removal of their K-wires and 2 refused follow up beyond 3 months, at which time their result was good (1/5) or fair (4/5).

Although a good to perfect reduction was obtained perop, X-rays showed perfectly maintained reduction in only 12 shoulders. 15 patients had minimal loss of reduction (< 5mm), 7 had < 100% ascension of the clavicle and 2 had > 100% ascension.

Complications were rare, with 3 patients having early pin migration or removal due to infection which led to loss of reduction. 3 other patients had minor AC wound problems and another 2 pintract infection; all without further consequences.

The use of a processed tendon-graft to reconstruct the coracoclavicular ligaments, protected by 6 weeks of K-wires, appears to be a valuable treatment option for Tossy grades IV and V AC injuries. This technique allows rapid recuperation of full function as well as return to work and sports in the majority of patients.


R. russo M. Ciccarelli L. Vernaglia Lombardi G. Giudice M. Gallo F. Cautiero

Aim: To describe a new surgical technique for the reconstruction of complex fractures of the proximal humerus that can be used in both young and elderly patients. It consists in the anatomical reconstruction of fragments as puzzle with used of bone block and small fragment bone between the methaepiphiseal and head before a minimal osteosinthesis with K.-wire and or cannulated screws and or surure bone.

The goal of this technique is to restore normal anatomy of proximal humerus around a bone bridge inside the head and the metaphysis.

Methods: From 2003 to 2005 we treated 25 patients (17 males and 8 females), average 49.6, with a 3- or 4-part fractures and fracture\dislocations. The surgical technique requires a medial reconstruction with bone block insert and osteosyntesis with minimal encumbrance(k-wire and cannulated srews). In eleven cases we used autologus platelet growth factor

Results: All cases were submitted X-ray at 3months 6 months and 1 years. ten cases, also had TC scan. The functional results were evaluated according to the Constant score. With a mean follow-up of 24 months (range from 12 to 36 months), the results were excellent or good in 24 patients; the mean active forward elevation was 160 degrees. In one case we found a sintomatic avascular necrosis that was resolved with a hemiarthroplasty.

Discussion: Surgical management of acute complex proximal fracture of the humerus is still a challenge to the surgeons, both in young and in elderly patients.

The Authors report the goal of this technique is to restore normal anatomy of proximal humerus around a triangle-shaped bone block positioned inside between the head and the metaphyseal. The fragments are then stabilized with a minimal osteosynthesis by K- wires, screws or bone sutures.

The results of our study show that the technique we propose has good clinical and functional outcomes, with a low percentage of complications.


G. Roederer F. Gebhard L. Kinzl

Purpose: Early results of MI treatment of proximal humeral fractures in mainly osteoporotic bone stock using the NCB®-PH plate showed promising results reaching 62 points (86% of age related normal value) in Constant Score 6 months postoperatively (Roederer et al., submitted, 2006). The purpose of this study was to analyze the long-term results focusing on functional outcome and complications.

Methods: So far out of a total number of 90 cases we have gained the data of 35 patients (24 women, 11 men; age 68 in the mean) who sustained fractures of the proximal humerus treated MI with the NCB-PH® plate (Zimmer Company, Winterthur, Switzerland). In 16 cases (46%) osteoporosis has been diagnosed pre-operatively. Radiological follow-up in two planes and functional outcome is assessed clinically (ROM) and using visual analogue scale (VAS) for pain and function, Constant Score and a modified adl score (activities of daily living).

Results: Average ROM (in degree) for anteversion was 101, glenohumeral abduction 87, external rotation 31 and internal rotation 81. Average VAS for pain was 1, 9 points (10 = worst) and for function 6, 4 points (10 = best). Average Constant Score was 65 points, average adl score was 16 points (30 = best). Between 6 and 12 months postoperatively one case (2, 9%) of sintering of the humeral head and one case (2, 9%) of avascular necrosis was detected. In 3 cases (9%) of reversed impingement we performed total removal of hardware. Four younger patients (11%; age 60 in the average) underwent the same procedure demanding it though not suffering of limited ROM or pain.

Conclusion and Significance: In the early results NCB-PH® proved to be an effective MI method of treatment of fractures of the humeral head in the elderly patient with mainly osteoporotic bone stock. The 1 year follow up data show further functional improvement (approx. 5% of Constant Score). The complication rate remains low (5/35 = 14%).

Especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. The latter we believe is due to the MI procedure and the early functional treatment due to high primary stability of the NCB-PH® plate. Despite good functional outcome, younger patients with higher levels of activity compared to the average patient sustaining proximal humeral fractures tend to feel subjective problems with the plate in situ demanding surgical removal of hardware. The long-term results also prove the NCB-PH® plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. Removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients’ subjective outcome


T. Taneja D. Zaher A. Koukakis C. Apostolou S. Owen-Johnstone T. Bucknill A. Amini D. Goodier P. Achan

The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital.

Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy.

The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.


F. Brunner C. Sommer C. Bahrs R. Heuwinkel C. Häfner P. Rillmann G. Kohut M. Müller R. Babst

OBJECTIVES: In recent years the incidence of proximal humerus fractures increased strongly. The optimal treatment of displaced, unstable fractures is still controversial. One of the major problem seen in previous treatment options was implant failure with secondary dislocation, pseudarthrosis and AVN. New angular stable implants promise a stronger anchorage and allow early functional aftertreatment, especially in osteopenic bone. Aim of this prospective case-series was to assess complication risks and functional outcome after ORIF with an angular stable form plate

DESIGN: Prospective case-series

SETTING: Multicenter study in 8 European Trauma Units

PATIENTS: 157 patients were treated for 158 displaced proximal humerus fractures

INTERVENTION: ORIF with a PHILOS plate.

RESULTS: According to the AO/ASIF classification 25%, 61% and 37% were classified as type A, B and C, respectively. One year follow-up rate was 84%, whereupon 6 patients had died in the mean time and 18 were lost to follow-up. Overall 71 complications were observed in 53 patients and led to 39 unplanned re-operations, whereupon most frequent were primary screw perforations (n=22), secondary screw perforations (n=13)–mostly with secondary impaction (n=11), and AVN (n=8). Increasing age and severity of fractures influenced the occurrence of complications, since the risk to obtain a complication was doubled in patients over 60 years compared to younger (Relative Risk 1.9; Fischer’s Exact, p=0.022) as well as in AO/ASIF B- and C-fractures compared to A-fractures (Relative Risk=1.8; Fischer’s Exact, p=0.05). Risks for complications related to the implant, surgical technique or fracture and bone were 9%, 20% and 13%, respectively. Within one year all fractures healed and 5 secondary dislocations were observed. The mean (SD) Constant score of the injured shoulder improved during follow-up period to 72 points (15.2) at 12 months follow-up, when 87% (16.6%) of the contralateral shoulder was reached. Across all follow-up examinations the Constant score in relation to the contralateral shoulder impaired with increasing severity of the fracture (ANOVA, p=0.006). The mean (SD) DASH score after one year was with 16 points (21.1) worser (T-test, p< 0.001) than before the accident [5.2 (11.4)].

CONCLUSIONS: Fixation with a Philos plate provides high stability to preserve achieved reduction, which benefits the good functional outcome. However surgical technique related complication risks are high, particularly due to screw perforations into the joint. Augmented awareness and improvement of surgical technique should reduce these risks. Complex fracture types and higher age increases the risk to sustain complications, where as only severity of fractures impairs the functional outcome.


J. Blum M. Hansen M. Müller P.M. Rommens H. Matuschka A. Olmeda

Introduction: There is an increasing tendency for internal fixation of proximal metaphyseal fractures. Intra-medullary nailing only recently has been considered to be a valuable option in these cases. Through the development of new reliable implant types, nailing finds increasing acceptance.

Questions: Is intramedually nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures and is it combined with a good outcome?

Material and methods: A prospective international mul-ticenter study with standardized study control focused on the “Proximal Humeral Nail (PHN–Synthes Inc.), possible complications and clinical outcome. 151 fractures had been treated in 11 hospitals, where 72 were A-type, 67 B-type and 12 C-type (AO). There were 37 male, 114 female patients, median age 66 years ranging from 16 to 97 years. The outcome had been measured through Constant-Morley scores and DASH scores. 108 patients could be followed up until 1 year postoperatively.

Results: Important complications were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), dislocation of fragments (n=2), non union (n=2), humeral head necrosis (n=3) and wound infection (n=1). The Constant-Morley score shows in total mean values one year postoperatively 75.3 in the injured and 89.9 in the non-injured side. The DASH score pre-operatively was in total 5.9 and 9.3 one year postoperatively, where the best results could achieve 0 points, the worst 100 points.

Discussion: Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related the technical failure in performing nailing. Here or the nail has not been introduced profoundly enough or the length for the spiral blade was not determined exactly and probably not controlled intraoperatively. This is due to the individual accuracy of the surgeon. The development of non-union (2/108) shows a ratio equal or even better to what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments n the other side, show the limit of this procedure, where in multifragmentary fracture type one spiral blade will not be able to fix a fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach. Constant score and Dash-score results perform similar to plate osteosynthesis, where clearly C-type-fractures present the worst prognosis.

Conclusion: Proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures. Even in many B-type fractures it is still a good alternative with limited incision to the plate osteosynthesis.

In C-type fractures it is not advisable as a standard routine, only for experienced surgeons it might be a possible solution in selected cases.


S.N. maripuri D. Lewis R. Evans C. Dent R. Williams

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures.

Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate.

Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted.

Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing.


L. Obert P. Clappaz D. Gallinet P. Garbuio

Introduction: The three or four-part fracture of the proximal humerus remains a challenging fracture in the case of elderly patient. In this continuing prospective study we compared the outcome after implantation of a shoulder hemiprosthesis of the anatomical generation and a reversed prosthesis.

Material and methods: 34 shoulder prosthesis were implanted in patients older than 70 between june 1996 and june 2004. All patients were evaluated by a surgeon not involved in treatment concerning activities of daily living (DASH scoring), clinical outcome (Constant-Murley Score), radiological results, and a summary of complications.

Group 1: anatomical prosthesis (Tornier): At an average follow-up of 16,5 (range 6–55) months, 13/17 patients with an average age of 78,6 years (70–95), were evaluated.

Group 2: reversed prosthesis (Depuy): At an average follow-up of 12,6 (range 6–18) months, 13/17 patients with an average age of 77,1 years (70–84), were evaluated. In this group functional treatment was started immediately after surgery.

Results: concerning age, follow up and dash scoring there were no difference between two groups. In reversed group : the outcome was better (Constant-Murley: 79,5 (57,8–100) vs 57,1 (21–85) p=0.005), the average active elevation was better by 30° (p< 0.001) and the average active abduction was better by 53° (p< 0.001). 7/13 cases of glenoid notching stage 2 or 3 were noted. In anatomical group : the average active external rotation was better by 10° (p=0.01). Tubercle fixations failed in 6/13 cases.

Discussion: No comparative study has still been published between the two sort of implant in elderly patients. Our results of shoulder arthroplasty in acute injury to the proximal humerus with reversed prosthesis are in agreement with the preliminary results reported by Sirveau. At short follow up, reversed prosthesis allow to reach early mobilisation with best functional results. Rotation remains the key point : with a significant gain in active abduction and elevation the reversed prosthesis group do not reach a better dash scoring. Attachment fixation of the posterior rotator cuff must probably be discussed in reversed prosthesis in acute fracture.


R. Russo L. Vernaglia Lombardi M. Ciccarelli G. Giudice F. Cautiero

Aim: The authors report a new ostheosinthesis device(Prysmatic Threeangular System P.T.S.) designed for the treatment of complex fractures of the proximal part of the humerus.

Methods: From May 2005 to February 2006 we treated ten patients, four patients were female and six male. The average age was 45.1 years (max. 69, min. 27). Cases included nine fresh fractures and a malunion of three-part fracture treated three months after the trauma. All patients had closed fractures; one was worsened by a partial and temporary lesion of the brachial plexus. All patients underwent a standard X-ray and a Ct scan. In all patients, some homologous spongy bone was inserted in the titanium structure; moreover, in five cases (the youngest patients) autologous blood-derived growth factors were added. All patients were kept immobilized by means of a brace with internal rotation for 4 weeks.

Results: In 6 cases the follow-up period ranged from 3 months to a 10 months in 6 cases. In these cases the CT scan allowed as to determine that the integration of the bank bone with the receiver took place after 3–4 months, while the check performed at 6 months did not show any peri-metallic lysis and showed that the P.T.S. had perfectly integrated with the metaepiphysis. No cases of nervous or vascular secondary lesions were detected. No infections, either superficial or deep, were noticed even after a long period.

Discussion: The best surgical treatment of three- or four-part, dislocation and unclassifiable complex fractures of the humerus is still debated, the results achieved with other system or a shoulder prosthesis are not constant. The Authors report a new system consisting of a prismatic threeangular titanium structure which, allows to modulate the reduction of the parts and open a window from the fracture rim through which the surgeon can directly observe the lesion and the relevant parts.


K. Lunsjö A. Tadros J. Czechowski F. Abu-Zidan

Background: We aimed to study the relationship between the number of fractured scapular regions, and the severity and distribution of associated injuries in blunt trauma patients.

Methods: 107 consecutive patients with fractured scapulae (100 males) with a mean age of 35 (8–65) years were prospectively studied between January 2003 and December 2005. Mechanism of injury, associated injuries, injury severity scale (ISS) and the number of anatomical scapular regions involved in each fracture were studied. Patients were divided into single-region, two-region fracture, and more than two-region fracture groups. Computer tomography was used for fracture classification in 99 patients and plain X-rays in the remaining 8.

Results: Road traffic collisions were the most common cause of scapular fracture. 95 patients (89%) sustained associated injuries. The most frequent was chest injury (68 (64%)). The median ISS was 9 (4–57) for the single-region fracture group (n 55), 20 (4–59) for the two-region fracture group (n 30), and 22.5 (4–54) for more than two-region fracture group (n 22) (p=0.02, Kruskal Wallis test). The median values of abbreviated injury scale (AIS) for chest injuries for the three groups were 1 (0–4), 3 (0–5) and 3 (0–5), respectively (p=0.001, Kruskal Wallis test). The single-region fracture group had significantly less posterior structure injury (9/55) compared with the multiple-region fracture group (46/52) (p=0, Fisher’s exact test).

Conclusion: Associated injuries are common in patients having scapular fractures. ISS and AIS for chest injuries are higher and posterior structure injuries more frequent in patients with fractures involving multiple scapular regions.


A. Akiki Y. Arlettaz

Proximal humerus fracture treatment remains controversial. If the conservative treatment is widely accepted for Neer I and Neer II fractures, the attitude is not very clear concerning Neer III and Neer IV fractures.

Several methods are proposed in the literature varying from suturing, pinning or plating the proximal humerus. Hemiarthroplasty are even considered.

In our study we present our results of an internal fixation procedure for 3 part or 4 part fractures of the upper part of the humerus.

Material and Methods: Antegrade nailing with self stabilizing screws, by T2 nail, is used in 13 patients treated between January 2004 and December 2005. Average age is 81 years old. The medial insertion technique is used because of the greater tuberosity fracture. Clinical and radiological data were available for the 13 patients with a mean follow up of 19 months. Functional outcome is assessed using the Visual Analog Scale (VAS) and the Constant Score.

Results: At last follow up, most of the patients are satisfied with their operation with a mean VAS of 2.46 and a mean Constant Score of 64.7. Mean antepulsion was 148° while mean abduction was 136°. No infection was reported. There are 4 cases of greater tuberosity necrosis without influence on the rotator cuff muscles. One case of head necrosis is signaled.

Discussion: Complex fractures of the proximal humerus remain a challenge for the orthopedic surgeons. To date, there is non agreement on the most appropriate osteosynthesis method and the results of shoulder arthroplasty or proximal plating remain controversial. The T2 nail appears to be a simple and reproducible method of achieving reduction, stability and early mobilization. It is an attractive alternative to shoulder prosthesis or proximal plating in trauma victims with complex displaced fractures.


S. Cerciello F. Visci F. Pezzillo G. Maccauro F. Di Gregorio T. Nizegorodcew

Introduction: Antegrade intramedullary locked nailing is a reliable method for the treatment of humeral shaft fractures. There is a still debate on the functional effect due to a possible damage during surgical approach of the rotator cuff, but in the Literature few paper deal with the analysis of tendons in these patients. Ultrasonography is still considered a reliable method in evaluating rotator cuff tendons. The aim of this study is to evaluate if antegrade intramedullary nailing may induce a possible damage on rotator cuff.

Methods: Between May 2002 to December 2005 42 patient suffering of humeral shaft fractures were surgically treated with Unreamed Humeral Nail. Of them 21 (13 males and 8 female) were followed (average follow-up 22,9 months). All the fractures were traumatic except 1 due to bone metastasis of carcinoma. Follow up was clinical with Constant Score, radiographic in 3 projection (neutral, internal and external), and ultrasonographic, evaluating tendon of m. Sovraspinosus.

Results: Healing of fractures was obtained after 2 month from surgery in all cases; Constant Score’s average was 77,0. Three cases of impingement syndrome due to excessive length of nail were observed, healed after the nail removal. Ultrasonography showed that in 13 cases rotator cuff was normal. In 5 cases we have found a signicative hyperecogen area, related to the scarf. We have never had a damage of tendon in all its tickness.

Conclusion: Our study confirms that antegrade intra-medullary nail is a reliable method for the treatment humeral shaft fractures, not adversely influenced shoulder tendons. Damage of rotator cuff observed in few cases is not related to surgical technique, but depends on surgical pitfall with an excessively long nail and then impingement syndrome.


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M. Fox S. Lambert R. Birch

To review the outcome of compound injury to the shoulder in which traumatic anterior dislocation is associated with concomitant rotator cuff tear and injury to the brachial plexus.

22 patients initially treated at the Peripheral Nerve Injury Unit since 1994 were reviewed from notes, telephone and clinically (n=13) where possible. 19 men and 3 women of average age 53 years were treated with a minimum 3-year follow up. All patients underwent exploration of the brachial plexus and nerve repair where required (graft n=5). Patients had either proven large cuff tear (n=13) or avulsion fracture of greater tuberosity with cuff injury (n=9). 7 of 13 cuff injuries and 7 of 9 tuberosity fractures had been repaired. Nerve injury at exploration was to circumflex (n=20), supra-scapular (n=12), musculocutaneous (n=6), or at the cord level (Posterior n=10, Lateral n=7 Medial n=8). Outcome measures were Berman pain score, sensation, muscle power (MRC grade), abduction, functional scores (Mallett and DASH) and return to work. Statistical analysis used tests for non-parametric data.

22 patients had exploration of the plexus. Most patients did not have an isolated nerve lesion (n=4). Increased depth of nerve lesion correlated with poorer functional outcome. E.g. for circumflex nerve injury (n=18), conduction block (n=8) vs. axonotmesis or neurotmesis (n =10) functional range of movement as assessed by Mallett score was significantly different; Mann Whitney U test p=0.043. Late exploration of nerve tended to correlate with poor outcome, as did late repair of rotator cuff, but not to statistical significance.

Our explorations have shown the nerve injury sustained in these patients to be more widespread than expected. We believe early exploration is vital to give an accurate diagnosis and predict outcome for the nerve lesion. This is particularly important in the presence of associated cuff injury where early repair confers favourable outcome.


I.M. Majid T. Ibrahim M. Clarke C.J. Kershaw

Aims: To investigate the effect of age and occupation on the outcome of carpal tunnel decompression.

Patients and Methods: A total of 271 patients undergoing primary carpal tunnel decompression by a single surgeon were studied. Patients with inflammatory joint disease, thyroid disease and diabetes mellitus were excluded. Outcome was assessed using the Levine-Katz carpal tunnel questionnaire at two weeks preoperatively and six months postoperatively. Cases were divided into six age groups (less than 40 years of age, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and over 80 years of age) and 12 occupational groups according to the International Standard Classification of Occupations (ISCO-88). Statistical analysis was performed using one-way analysis of variance (ANOVA) and post ad-hoc analyses.

Results: Overall there was an improvement in total Levine scores in 269 (99.3%) patients (mean change 33.1, 95%CI: 31.5 to 34.7). This change was greatest in those over 80 years of age (mean 35.8, 95%CI: 29.0 to 42.6) and in those who were service or sales workers (mean 39.6, 95%CI: 34.9 to 44.2), and least in the 70–79 age group (mean 30.7, 95%CI 25.7 to 35.8) and craft and trade workers (mean 29.8, 95%CI: 21.8 to 37.9). Patients reported a greater improvement in symptoms (mean score change 21.4, 95%CI: 20.2 to 22.2), than function (mean 12, 95%CI: 11.1 to 12.7). We found no significant difference in the total, functional or symptomatic Levine score changes between the six age groups (p=0.05) and the 12 occupation groups (p=0.05) following carpal tunnel decompression.

Conclusion: Almost all patients improved after carpal tunnel decompression. However, we found no influence of age and occupation on the outcome of carpal tunnel decompression in our series of patients.


T.A. SYED Y.R. SHAH R. CHENNAGIRI M.H. WETHERILL

INTRODUCTION: Median Nerve has small vessel on the volar aspect of the nerve which is filled with blood and results in so called ‘ BLUSHING’ of the nerve once it has been decompressed. It was thought that the nerve which didnot blush meant an inadequate decompression was carried out.

PURPOSE: To evaluate whether ‘Blushing’ of the Median Nerve is correlated with adequate decompression and level of recovery in Carpal Tunnel Syndrome through Mini Palmar Incision.

METHODS & MATERIALS: Retrospective analysis of a Single Surgeon practise where it was documented in operation notes whether the nerve was seen to ‘Blushed’ at the time of surgery.They were assessed postoperatively from notes for complete resolution of symptoms and whether there was any recurrence of symptoms.

RESULTS: n=330 Carpal Tunnel Decompressions were reviewed. It was noted that those who had complete resolution of symptoms had ‘Blushing’ noted at the time of surgery compared to those who had partial or incomplete resolution of symptoms wher ‘No BUSHING’ was noticed. Average time of follow up = 6 weeks. Blushing Noted at the time of decompression 192, Recovery/ improvement of symptoms 189, Blushing not noted at the time of surgery 38, NO documentation about Blushing in 100

CONCLUSION: Blushing of Median Nerve intraoperatively is a reliable sign for complete decompression of the nerve and is correalted with good final outcome.


R.S. Gaheer A. Ratnam

Carpal tunnel syndrome is a common condition with a prevalence of 2.7% based on symptoms, clinical signs, and neurophysiology. The procedure to cure these patients, whether it is open or endoscopic, is usually successful in returning sensation, abolishing numbness and paraesthesiae, and improving manual dexterity. However, as many as 14%–32% of patients may have persistent symptoms

The general treatment of patients with recurrent carpal tunnel syndrome is re-exploration of the median nerve and neurolysis. Various procedures have been described to cover the median nerve with muscle or fat tissue. These include–external neurolysis, local muscle flaps, fat grafts and flaps, vein wrapping and synovial flaps. The outcome of secondary carpal tunnel surgery is only fair and many procedures are possible.

In 19 patients presenting with recurrent carpal tunnel syndrome over a period of five years, silicone sheath was used to cover the median nerve following neurolysis. All of these 19 cases were performed by the senior author (ASR).

We audited the results of this procedure using the carpal tunnel outcome instrument (Levine et al., 1993) for subjective assessment and grip strength, thumb key pinch force and two point discrimination sensation for Objective assessment. 17 patients were followed up for the purpose of this study. 2 were lost to follow up. Twelve patients were satisfied with their outcomes and were prepared to undergo the surgery again or recommend it to others (more than 70%). However, two were dissatisfied and three were uncertain of their feelings.


T. Taneja N. Ellahee R. Patel B. Ollivere D. Nairn J. MahaluxmiVala P. Achan S. Curry D. Goodier

Carpal Tunnel Syndrome is the most common entrapment neuropathy encountered in clinical practice. Previous studies have suggested that the disease has a higher prevalence in the elderly(Stevens JC etal, Neurology 1988;) and that this sub group also tends to have a higher prevalence of severe CTS.(Seror P, Ann Hand Surg 1991; Bland etal, J Neurol Neurosurg Psychiatry). Surgical decompression of the median nerve is the treatment of choice with a reported success rate of between 53 and 97 %.(Katz et al, J Hand Surg 1998).

There has been some controversy regarding the effectiveness of surgery in elderly patients. The aim of our study was to evaluate the results of carpal tunnel release in patients over the age of 75 years at the time of surgery. A literature search revealed few studies carried out in elderly patients–Weber etal-(mean age 75 years), Porter etal (mean age 59.8 years) and Leit et al (mean age 79 years). The average age of our patient group (80.4 years) is the highest reported in literature so far.

We posted questionnaires to all patients who were over 75 years at the time of their surgery. There were a total of 49 patients (65 hands) operated over the last 10 years who belonged to this age group. We used the Brigham And Women’s Hospital Questionnaire devised by Levine et al. (1993). In addition, we added some questions to assess patient satisfaction with the procedure. 65% of the patients were females. The average age was 80.4 years.

The completed questionnaires were used to calculate the Pre and Post operative scores. The mean pre operative score was found to be 3.18, which improved post operatively to 1.8. (Scale of 1 to 5, with 1 being the best and 5 the worst). Importantly, although all symptoms improved, some such as pain and numbness showed a much greater improvement than grasping power. On the Visual Analogue Scale, pain scores improved from 6.4 to 2.3 post surgery. 82 % of patients had no scar tenderness, 12 % had mild to moderate tenderness, while 6 % reported severe scar tenderness. Overall 79% of patients showed improvement, 15 % felt that the surgery had made no difference, while 6% reported worsening of their symptoms after surgery.

Our study showed that 8 out of 10 elderly patients will improve after carpal tunnel release, though all symptoms are unlikely to improve. The symptom least likely to improve is weakness of the hand. The results of this study are important to counsel this sub group of elderly patients, so that they may take an informed decision on whether to proceed with the surgery.


A. Kapoor I. Rafiq P. Harvey R. Murali

INTRODUCTION: CTS is the most common nerve entrapment syndrome. Repeated flexion and extension activities of the wrist coupled with certain finger flexion causes oedema and compression of the median nerve within the carpal tunnel of the wrist. Several treatment options, both conservative and surgical are available to relieve the pressure on the median nerve. Although studies support the efficacy of splinting for CTS the length of splinting, type of splints, day or night use and the effects on other variables are still less agreed.

MATERIALS AND METHODS: A Randomised control trial with subjects randomised to a splint and a control group. 44 patients(60 hands) evaluated at recruitment, 2,8 and 12 weeks. Difference in Levine’s symptom and functional severity scores, between the two groups, used as the primary outcome measure.

STATISTICAL METHODS: Repeated measure analysis(ANOVA) and paired t test used for statistical analysis between the two groups.

RESULTS: There was no difference between the two groups at baseline. Improvement in symptom severity score in the splinted group at the end of 12 weeks(p< 0.05). No difference in functional severity between the two groups.

CONCLUSION: Splintage helps to improve symptoms related to carpal tunnel syndrome in a short term period. This is the duration that the patients referred by GP’s have to wait before seeing a hand specialist. Hence they can be treated with splints during this period to give them symptomatic relief.


V. Psychoyios F. Villanueva-Lopez K. Dakis P. Kinnas

Aim: To retrospectively review the results of the use of adductor digiti quinti flap in failed cases of primary carpal tunnel tunnel release. The concept under this procedure is to provide a highly vascularised bed for axonal regeneration.

Material: Twenty cases of failed carpal tunnel release included in the study. The average age of patients was 43 years. There were thirteen female and five male patients. In two cases, one male and one female the procedure performed bilaterally.

All patients had a repeat of release ading a neurolysis of the median nerve. The adducor digiti quinti flap was dissected up to its neurovascular bundle and flipped over..

Results: In thirteen cases the procedure was successful as this was detected objectively and subjectively. In four cases the situation was unchanged and in three a revision surgery required for decompression of the nerve. Complex regional pain syndrome developed in three cases.

Conclusion: Although postoperative healing and rehabilitation time is lengthy due to more extensile dissection, pain relief, motor and sensory improvement, and hand dexterity justify the procedure.


P. Haentjens D. Verheughe

Background: A recent change in the Belgian law lead to the obligation of evaluating the musculoskeletal system among employees using visual display terminal (VDT) during the routine annual visit. We conducted a cross-sectional study to determine prevalence of and risk factors for musculoskeletal symptoms (MSS) and disorders (MSD) in general, and carpal tunnel syndrome (CTS) in particular.

Methods: During the routine annual visit all VDT employees of different kinds of companies and occupations were asked about upper extremity MSS by their occupational physician. Participants who met the criteria for MSS within the last month were physically examined in search of a MSD in general, and CTS in particular. Prevalences were calculated, and key risk factors for MSS and CTS were determined using logistic regression analyses.

Results: The total prevalence of any upper extremity MSS among 1087 VDT-employees was 31.3%. Neck symptoms (21.6%) were the most frequently reported, followed by shoulder (21.6%), elbow/forearms (4.1%), hands/wrists (7.3%), and finger (5.2%) symptoms. The prevalence of CTS depended on the diagnostic criteria used: 1.8% for symptom-specific CTS (typical anatomical distribution of numbness and paresthesias), 1.2% for examination-confirmed CTS (at least one positive provocative test, Tinel’s nerve percussion test or Phalen’s wrist flexion test), and 0.2% for electrophysiologically-confirmed CTS (abnormal nerve conduction tests). Logistic regression analyses identified increasing age, female gender, the duration of professional VDT use per day, a history of thyroid diseases, and a history of rheumatoid arthritis as significant and independent factors associated with MSS. Adaptation of the work-place was associated with a lower likelihood of MSS. Only increasing age and female gender were identified as significant and independent factors associated with CTS (symptom-specific and examination-confirmed CTS). Job-related factors were not significantly associated with an increased risk for CTS.

Conclusions: Our study confirms the high prevalence of MSS among Belgian visual display terminal users (more than 30%). Two work-related factors were clearly associated with MSS: the duration of professional VDT use per day (increased risk) and prior adaptation of the workplace according to advice given by the occupational physician (decreased risk). By contrast, the prevalence of CTS was low (less than 2%), and no job-related risk factors for CTS could be identified among VDT users.


A. Mallick M. Clarke C.J. Kershaw

The purpose of the study was to evaluate if 2 week Levine score can provide an adequately responsive outcome measure in Carpal Tunnel Decompression by comparing it with 6 month score.

The treatment outcome of 300 patients with Carpal Tunnel Decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 55 years and 6 months, 71.3% (214) were female with 55.33% (167) operations being performed on right hand. All patients were scored through Levine questionnaire pre operatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated.

Although statistical significance was found between the pre operative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months post surgery. Multiple regression analysis with the 2 week–6 month score difference as the dependable variable shows a predictable outcome at 2 weeks.

We conclude that the Levine score at 2 weeks is a reliable, responsive and practical instrument for outcome measure in Carpal Tunnel Surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium term results in a high percentage of treated patients.


S. Joshy S.C. Deshmukh B. Thomas

Aim: Osteoarthritis of the wrist is a well recognised cause of secondary carpal tunnel syndrome. The aim of the study is to compare the outcome following carpal tunnel decompression with regard to patient satisfaction. We compared the outcome of carpal tunnel decompression between patients with and with out osteoarthritis of the wrist.

Patients and Methods: The study was done retrospectively. Clinical notes of all the patients who underwent carpal tunnel decompression over a period of 8 years were verified. Twenty four patients who underwent surgical decompression for carpal tunnel syndrome secondary to osteoarthritis were identified by reviewing the notes and the radiographs. Control group consisted of 24 patients who under went carpal tunnel decompression but without osteoarthritis of the wrist. The control group was matched for age, sex, side, and neuro-physiological severity of the nerve compression. Clinical notes were verified to find whether the patients were satisfied with the symptom relief at the first post-operative follow up visit.

Results: There were 24 patients in the group with osteoarthritis of the wrist. The mean age of the patients was 71 years (range 33–89 years). There were 19 females and five males. The right hand was involved in 17 patients and the left was involved in 7 patients. The control group with out osteoarthritis also had similar distribution regarding age sex side, and neuro-physiological severity of nerve conduction. In the group with osteoarthritis of the wrist 17(71%) patients reported the their symptom relief as satisfactory and the rest seven(29%) reported the results as unsatisfactory. In the control group 23(96%) patients reported their symptom relief as satisfactory and one (4%) reported their results as unsatisfactory (P= 0.0325).

Conclusions: Patient satisfaction following surgical decompression in patients with secondary carpal tunnel syndrome due to osteoarthritis is significantly lower compared to patients with out osteoarthritis of the wrist. Patients with osteoarthritis of the wrist should be warned about the higher incidence of poor outcome prior to decompression.


M. Costa U. Prakash P. Forguet

Background: Hip resurfacing preserves bone stock on the femoral head. Some authors believe that this is at the expense of sacrificing more bone on the acetabulum and they point out two main reasons for this. Since resurfacing tends to be used in younger and more active individuals a larger head to neck ratio seems desirable in order to provide a better range of movement before impingement. In addition, the acetabular component has to be a minimum of 5 mm thick to prevent deformation on implantation and the subsequent compromise in the congruency of the bearings.

Method: We report the average size of the acetabular components of 220 Cormet resurfacings and 199 Pinnacle cups implanted in our department over a period of 18 months. From these sizes we estimated the mean acetabular bone loss for each procedure.

Results: The mean cup size was 53.7 mm for Cormet and 54.1 mm for Pinnacle i.e. the acetabular component of the resurfacing was smaller than the equivalent uncemented total hip replacement.

Conclusions: These figures show that resurfacing arthroplasty does not necessarily lead to greater acetabular bone loss than a total hip replacement. In our practice, we concentrate upon preserving acetabular bone rather than establishing a large head to neck ratio. In spite of this approach, the occurrence of impingement and dislocation among our patients seems to be as rare as in other comparable series.


R. Steffen K.S. O’Rourke J.P. Urban H.S. Gill D.J. Beard P. McLardy-Smith D.W. Murray

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. We compared the changes in femoral head oxygenation resulting from the anterolateral approach to those resulting from the posterior approach.

Methods: In 22 patients undergoing hip resurfacing surgery, a calibrated gas-sensitive electrode was inserted supero-laterally in the femoral head via the femoral neck following division of the fascia lata. Inter-operative X-ray confirmed correct electrode placement. Baseline oxygen concentration levels were recorded immediately after electrode insertion. All results were expressed relative to this baseline, which was considered as 100% relative oxygen concentration. Oxygen levels were monitored continuously throughout the operation. 10 patients underwent surgery through the posterior approach, 12 patients through the antero-lateral approach.

Results: During the operation patterns were similar for both groups, except following joint relocation and soft tissue reconstruction; oxygen concentration recovered significantly in the anterolateral group only. The posterior approach resulted in significantly lower (p< 0.01) oxygen concentration at the end of the procedure (22%, SD 31) than the antero-lateral approach (123%, SD 99).

Discussion and Conclusion: The anterolateral approach disrupts the femoral head blood supply significantly less than the posterior approach in patients undergoing resurfacing. The incidence of complications related to avascular necrosis might be decreased by adopting blood supply conserving surgical approaches.


E.T. Davis M. Olsen R. Zdero M. Papini J. Waddell E. Schemitsch

Introduction: We aimed to examine the effect of neck notching during hip resurfacing on the strength of the proximal femur.

Methods: Third generation composite femurs that have been shown to replicate the biomechanical properties of human bone were utilised. Imageless computer navigation was used to position the initial guide wire during head preparation. Six specimens were prepared without a superior notch being made in the neck of the femur, six were prepared in an inferiorly translated position to cause a 2mm notch in the superior femoral neck and six were prepared with a 5mm notch. All specimens had radiographs taken to ensure that the stem shaft angle was kept constant. The specimens were then loaded to failure in the axial direction with an Instron mechanical tester.

A three dimensional femoral finite element model was constructed and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. The model was created with a superior femoral neck notch of increasing depths.

Results: The 2mm notched group (mean load to failure 4034N) were significantly weaker than the un-notched group (mean load to failure 5302N) when tested to failure (p=0.017). The 5mm notched group (mean load to failure 3121N) were also significantly weaker than the un-notched group (p=0.0003) and the 2mm notched group (p=0.046). All fractures initiated at the superior aspect of the neck, at the component bone interface. The finite element model revealed increasing Von Mises stresses with increasing notch depth.

Discussion: A superior notch of 2mm in the femoral neck weakens the proximal femur by 24% and a 5mm notch weakens it by 41%. This study provides biomechanical evidence that notching of the femoral neck may lead to an increased risk of femoral neck fracture following hip resurfacing due to increasing stresses in the region of the notch.


R.M. Gillies M. Hogg S.M. Donohoo L. Kohan

Introduction: The process of impacting cemented hip resurfacing components may, in part, be associated with femoral neck fracture. The impaction process may introduce fractures due to the impact shock wave passing through the bone during the setting of the implant and achieving a completely seated position. The aim of this study was to measure the impaction loads during hip resurfacing surgery and correlate the measured loads to theoretical calculations.

Methods: Following ethical approval 3 patients have been enrolled out of 24 patients in a pilot study. A surgical mallet was manufactured and instrumented with a calibrated impact load cell. During the impaction procedure the impact loads are recorded to a laptop using Labview software. An Excel spreadsheet has been written using the finite difference method to calculate the impact loads based on a mass (hammer, impactor and implant) and spring system (compression only) defining each part of the surgical instrumentation used to impact the resurfacing component onto the femoral head.

Results: Clinically, upto 19 impacts are used to seat the resurfacing implant onto the femoral head. Loads upto 24kN were recorded. The finite difference model was calibrated to the clinical measurements. The Pearson’s R correlation coefficient for the net force on the mallet was 0.91 and for the impulse was 0.98

Discussion: This study has investigated the clinical impaction loads imparted onto an implant during resurfacing surgery and developed a finite difference model of the process. The finite difference approach can be used to better understand the loads applied to not only the implant, but the underlying bone. This may, in part, give the surgeon a better understanding as to whether the bone has been predisposed to fracture following the high impact loads and thereby affecting the long-term integrity of the joint replacement.


The purpose of this study was to evaluate early results of a new, as yet undescribed, minimally invasive, gluteus maximus splitting posterior approach for metal on metal (MOM) hip resurfacing. Surgical approach is described, backed with a video of the procedure. Results of the first 100 cases are presented.

A new, minimally invasive, gluteus maximus splitting approach is described. The single incision approach allowed MOM hip resurfacing to be carried out through an incision ranging 8.25 ± 2.25cm. Release of gluteus maximus insertion to femur is not necessary. Intra-operative fluoroscopy is not necessary. Special acetabular reamer handle and acetabular impactor had to be used for accurate acetabular component placement. Femoral neck targeting device, suitable for minimally invasive surgery was used for accurate placement of femoral neck centring pin. This allowed for accurate placement of femoral component

Results of 100 patients who had undergone MOM hip resurfacing are presented: Average review was 2 years, range 22–46 months. Average age of patient was 57 years; range 55 ± 22 years. Average BMI was 27; range 29.95 ± 11.85. Average blood loss was 270ml; range 450 ± 350ml. Average incision was 8cm; range 8.25 ± 2.25cm. Operation time was no longer than conventional open posterior approach. Early discharge at day 3, post-op was possible and patients were able to walk without aids at 3 weeks, post-op. There were no cases of infection, nerve damage, dislocation or malposition of implant. There was no case of hypertrophic bone formation. There was one fracture neck of femur at 6 weeks post-op.

Minimally invasive hip resurfacing can be carried out successfully using a new gluteus maximus splitting approach with excellent early results and no complications apart from 1% risk of fracture neck of femur.


R.M. Gillies M. Hogg L. Kohan

Introduction: Cemented hip resurfacing component orientation may, in part, be associated with femoral neck fracture. Orientation offset may be introduced due to the cement setting prior to achieving a completely seated component. Varus/valgus orientation error may occur due to surgical error or poor instrumentation design. We modeled a number of different orientations and investigated bone mineral density change using the finite element method.

Methods: CT scans were used to reconstruct the femoral geometry and create a finite element model. The boundary conditions applied were hip muscle forces at the 45% position of the gait cycle. Two models were created, a preoperative (reference) and a postoperative (reconstructed) model. The post operative model was reconstructed using the Birmingham Hip Replacement (BHR). Implant offsets and varus/valgus orientations were analysed. The bone mineral density (BMD) changes at nine positions along the superior and inferior aspects of the alignment stem were analyzed.

Results: Results suggest bone loss decreases with increasing offset distances. Femoral offset distance is defined as the perpendicular distance from the center line of the femoral shaft to the center of the femoral head. Greater femoral stem offsets increases the abductor moment arm and this decreases the abductor force need for walking as well as the overall articulating reactive force at the articulating surface. As the BHR orientation deviates away from the an extreme valgus to a more varus position, the volume of bone that will decrease in BMD increases.

Discussion: There is minimal difference between the 1mm and 3mm offsets and their respective bone remodeling volumes. The 5mm offset has a larger bone volume where the BMD will increase; this is due to the larger moment applied to the proximal femur and is not an advisable surgical position as there may be a large density gradient at the mouth of the resurfacing component and could predispose the femoral neck to fracture. There is also not a lot of difference in bone remodeling volume between the extreme valgus, 5° and 10° cases. However, the extreme valgus case does present a “notching” risk. The objective of this study was to implement a consistent theoretical adaptive bone remodelling rule that may, in part, give an understanding as to how a femoral resurfacing component’s orientation would influence and simulate BMD changes in the proximal femur.


C. Heisel D. Schneider M. Menge J. Kretzer

Introduction: Aim of the study was to give an overview about the main macro- and microstructure differences of commercially available resurfacing hip implants. The effect of the manufacturing process and the subsequent heat treatment leads to variable microstructures of implant materials. It is undisputable that a low surface roughness and high sphericity improves the wear behaviour. But the radial clearance, the manufacturing process and heat treatment are discussed controversially.

Methods: Resurfacing hip implants with a 46mm head diameter and corresponding cups were analyzed. Commercially available hip resurfacing implants from 10 different manufacturers were included in this investigation. The heads and cups were measured in a coordinate measuring machine (Mahr Multisensor MS 222). A best fit sphere was created from the point clouds and evaluated using analysing software (Imageware 12.1, UGS Corp.). Head and cup radial clearances were measured and sphericity deviation calculated and graphically plotted. Measurements on surface roughness were carried out three times per implant (Mahr Pertometer M2). The microstructures of the heads and cups were inspected by SEM (LEO 440). Surface images were taken using the scanning electron mode. The back scatter electron mode was used to get element weighted images.

Element analysis was performed by EDX (Oxford D. 7060) to identify carbides and the alloy composition. Element distribution maps were taken to separate the single elements.

Results: The mean radial clearance was found to be 85.53μm. The range was from 49.47μm to 120.93μm. We classified all implants into three groups (low, midrange and high clearance). The low clearance group ranged from < 50μm to 75μm, midrange from 75μm to 100μm and high clearance from 100μm to > 125μm.

All implants showed a sphericity deviation less than 10μm. On average the heads tended to have a higher spherical deviation of 4.1μm (SD: 2.3μm) compared to the cups 2.7μm (SD: 1.4μm). Based on the SEM and EDX inspection the manufacturing process, heat treatment and carbide distribution could be clarified.

Discussion: This study gives an overview about the main macro- and microstructure differences of commercial available resurfacing hip implants.

The characteristically unspheric formations of the heads may be due to the cooling process after manufacturing the implant and there is also a relation between the wall thickness of the implant and the unspheric formations. With decreasing wall thickness the implant cools faster locally. Additionally a cup with a thin wall may deform under loading condition and a very tight clearance could be detrimental.

This study will help to understand clinical observations. It still has to be proven that these biomechanical factors influence the clinical performance of hip resurfacing implants.


M. Costa H. Amarasekera U. Prakash P. Forguet S. Krikler D. Griffin

Introduction: Two major complications of hip resurfacing arthroplasty are avascular necrosis of the femoral head and femoral neck fracture. Both are thought to be precipitated by disruption of the blood supply to the femoral head and neck during the approach to the hip joint. Ganz et al have described their technique of approaching the hip joint using a “trochanteric flip” osteotomy. This has the theoretical advantage of preserving the medial femoral circumflex artery to the femoral head. The aim of this study was to compare the intra-operative femoral head blood flow during the Ganz flip osteotomy to the blood flow during a posterior approach for resurfacing arthroplasty of the hip.

Methods: The intra-operative measurements of blood flow were performed using a DRT laser Doppler flow-meter with a 20 mW laser and a fibreoptic probe. The probe was introduced into the lateral femoral cortex and threaded into the femoral head under image intensifier control. Measurements were recorded before the approach to the hip was performed, after the approach was performed but before the head was dislocated, and after the head was dislocated.

Results: Our initial results indicate that there is on average a 50% drop in the blood flow to the femoral head after a posterior approach to the hip joint. In contrast, the trochanteric flip osteotomy produces a much smaller fall of around 18%. We have used these results to inform a sample size calculation, and are currently recruiting further patients to achieve a total of 42 in order to confirm a statistically significant effect.

Conclusion: The Ganz trochanteric flip osteotomy appears to produce less damage to the blood supply to the femoral head during resurfacing arthroplasty than the posterior approach. This study will inform surgeons in deciding on their preference for a routine approach for hip resurfacing.


H.C. Amstutz M.J. Le Duff F.J. Dorey

Introduction: The purpose of the present study was to assess the clinical results of metal-on-metal hip resurfacing for the treatment of hip arthrosis in patients with a BMI of 30 or more.

Materials and Methods: From a consecutive series of over 1000 Conserve® Plus metal-on metal hybrid resurfacings, 148 hips were resurfaced in 138 patients with a BMI of 30 or more at the time of surgery. Average age was 49.4 years (range, 18 to 72) with 88% male. The average weight was 104.6 kg (range 74 to 164) and average BMI 33.4 (30.0 to 46.4). “Idiopathic” OA was the dominant etiology with 80.0%. The femoral metaphyseal stem was cemented in 43 hips and press-fit in the remaining 105. All acetabular components were press-fit.

Results: Average follow-up was 6.2 years (range, 2.0 to 10.2). UCLA hip scores improved significantly (pain: 3.5 to 9.4; walking: 5.9 to 9.5; function: 5.4 to 9.2; activity: 4.3 to 7.1). There were no cases of acetabular or femoral component loosening. 2 hips (1.4%) were revised, 1 for femoral neck fracture and one for acetabular cup protrusio the day after surgery in a bilateral patient with poor bone quality. 3 hips (2.0%) have radiolucencies about the femoral stem. All are asymptomatic and none have progressed for an average of 5.2 years (range 4.5 to 6.8). There were no revisions for any reason and no radiolucencies observed in patients with a BMI of 35 or more (n=27).

Conclusions: Metal-on-metal resurfacing arthroplasty of the hip is performing extremely well in patients with high BMI, in contrast with the results of conventional THR. These results are in agreement with our previous finding that weight is protective of prosthesis durability with resurfacing. This could be explained by a greater fixation area on the femoral side, a greater bone mineral density, and a slightly reduced (but still high) activity level in this patient population compared to patients with a BMI less than 30 (7.1 vs 7.6, p=0.002).


C. McBryde K. Dhene A. Pearson P. Pynsent R. Treacy

Metal-on-metal hip resurfacing is increasingly common. Patients suitable for hip resurfacing are often young, more active, may be in employment and may have bilateral disease. One-stage bilateral total hip replacement has been demonstrated to be as safe as a two-stage procedure and more cost effective. The aim of this study was to compare the in-patient events, outcome and survival in patients undergoing one-stage resurfacing with a two-stage procedure less than one-year apart.

Methods. Between July 1994 and August 2006 a consecutive series of 93 patients underwent bilateral hip resurfacing within a year. 34 patients in the one-stage group. 44 patients in the two-stage group. The age, gender, diagnosis, ASA grade, total operative time, blood transfusion requirements, medical complication, surgical complications, length of stay, duration of treatment, revision and Oxford hip scores were recorded.

Results. There were no significant differences in age, gender, ASA grade between the one-stage and the two-stage. There were 4 minor complications in the one stage group and 5 in the two-stage group. All patients that suffered a complication made a full recovery. There was no significant difference in the blood transfusion requirements. The mean anaesthetic time was 136 minutes in the one stage group and 92 minutes in the two-stage group with a significant mean difference of 44 minutes(95% c.i. 31–52). The mean total length of hospital stay was 11 days in the one-stage group and 16 days in the two-stage group with a significant mean difference of 5 days(95\% c.i. 4.0–6.9). The mean difference in length of treatment time of 6.5 months was significant(95\% c.i. 4.0–9.0).

No patients have undergone a revision procedure during the study period and no patient is awaiting revision surgery.

Conclusions. This study demonstrates no detrimental effects when performing a one-stage bilateral metal-on-metal hip resurfacing in comparison to a two-stage procedure. There are advantages of a one-stage procedure over a two-stage procedure for bilateral disease. Total hospital stay is reduced by 31.3% and the mean length of treatment is reduced by 50.0%. These benefits do not appear to come at the cost of increase complications. The complication rate in both groups was very low and all of the complications were short-term and are unlikely to have any bearing on the longevity of the prosthesis.


E.T. Davis P. Gallie K. Macgroarty J. Waddell E. Schemitsch

Alignment of the femoral component during hip resurfacing has been implicated in the early failure of this device. Techniques to facilitate a more accurate placement of the femoral component may help prevent these early failures. We aim to establish whether the use of imageless computer navigation can improve the accuracy in alignment of the femoral component during hip resurfacing.

6 pairs of cadaveric limbs were randomized to the use of computer navigation or standard instrumentation. All hips had radiographs taken prior to the procedure to facilitate accurate templating. All femoral components were planned to be implanted with a stem shaft angle of 135 degrees. The initial guide wire was placed using either the standard jig with a pin placed in the lateral cortex or with the use of an imageless computer navigation system. The femoral head was then prepared in the same fashion for both groups. Following the procedure radiographs were taken to assess the alignment of the femoral component.

The mean stem shaft angle in the computer navigation group was 133.3 degrees compared to 127.7 degrees in the standard instrumentation group (p=0.03). The standard instrumentation group had a range of error of 15 degrees with a standard deviation of 4.2 degrees. The computer navigated group had a range of error of only 8 degrees with a standard deviation of 2.9 degrees.

Our results demonstrated that the use of standard alignment instrumentation consistently placed the femoral component in a more varus position when compared to the computer navigation group. The computer navigation was also more consistent in its placement of the femoral component when compared to standard instrumentation. We suggest that imageless computer navigation appears to improve the accuracy of alignment of the femoral component during hip resurfacing.


H.S. Gill P.A. Campbell A. Sabokbar D.W. Murray K.A. De Smet

Introduction: A major concern with cemented hip resurfacing arthroplasty (HRA) femoral components is the thermal damage to femoral head during cement curing; this maybe linked to fracture (reported incidence ~2%) and early failure. We investigated the effect of a modifid surgical technique using pulse lavage, lesser trochanter suction and early reduction on the maximum temperature recorded in the femoral head during HRA, compared to manual lavage and reduction after cement curing.

Methods: Patients undergoing total hip replacement (THR) were given a dummy HRA procedure, during which a temperature probe was inserted into the femoral head and the measuring tip placed close to the reamed surface; the position of the probe was confirmed by inter-operative xray. Four subjects received a dummy HRA femoral component using manual lavage and Simplex cement. The implanted femur was kept dislocated until the cement cured. The implanted heads were then removed and sectioned to locate the temperature probes, the THR surgery was then performed. Five patients receiving a definitive HRA were also measured; for these subjects suction on the lesser trochanter was used, pulse lavage given for 30 seconds prior to cementing with Simplex, and pulse lavage of the femoral head for 2 minutes, applied 1 minute after cementing the femoral component. The implanted joint was then immediately reduced and a further two minutes of pulse lavage applied to the reduced joint. Temperatures were recorded until the cement finally cured. In every case the cement was hand mixed for 1 minute and the component implanted at 2 minutes 30 seconds after mixing began.

Results: Sectioning showed that probe tips were < 0.5mm from cement mantle. The maximum temperature recorded in the femoral head was significantly (p=0.014) greater for the manual technique, median value of 47.2°C (37.0 to 67.9°C), than for the pulse lavage technique, median value of 32.7°C (31.7 to 35.6°C).

Discussion: The results show that excessive bone temperatures can occur during hip resurfacing. Temperatures above 45°C kill bone cells, the manual technique may lead to substantial thermal necrosis. Technique modification, with the use of suction on the lesser trochanter, generous use of pulse-lavage and joint reduction prior to cement curing, significantly reduced the temperatures recorded. With the modified technique, the maximum temperatures were well below the threshold of thermal damage. This modified technique is recommended as the potential for thermal bone necrosis is significantly reduced.


R.W. Poolman L.C. Keijser M.C. de Waal Malefijt L. Blankevoort F. Farrokhyar M. Bhandari

Background: The selection of presentations at orthopedic meetings is an important process. If the peer reviewers do not consistently agree on the quality score, the review process is arbitrary and open to bias. The aim of this study was:

1) To describe the inter reviewer agreement of a previously designed scoring scheme to rate abstracts submitted for presentation at the Dutch Orthopedic Association.

2) To test if quality of reporting of submitted abstracts increased in the years after the introduction of the scoring scheme.

3) To examine if a review process with a larger workload had lower inter rater agreement.

Methods: We calculated intraclass correlation coefficients (ICC) to measure the level of agreement among reviewers using the International Society of the Knee (ISK) abstract quality of reporting system. Acceptance rate and quality of the abstracts are described.

Results: Of 419 abstracts 229 (55%) were accepted. Inter-reviewer agreement to rate abstracts was substantial 0.68 (95%CI 0.47, 0.83) to almost perfect 0.95 (95%CI 0.92, 0.97) and did not change over the eligible time period. Less abstracts were accepted after 2004 (p = 0.039). The mean ISK abstract score, maximally 100 points, for accepted abstracts ranged from 60.4 (95%CI 57.7, 63.0) to 63.8 (95% CI 62.0, 65.7). The mean ISK abstract score for rejected abstracts varied from 45.8 (95%CI 40.3, 51.2) to 50.6 (95% CI 46.5, 54.8). Both scores for accepted and rejected abstracts did not change over time. Workload of the reviewers did not influence their level of agreement (p=0.167).

Interpretation: The ISK abstract rating system has an excellent inter observer agreement. Other scientific orthopedic meetings could adopt this ISK rating system for further evaluation in local or international setting.


J. Dettori D. Norvell B. Hanson B. Kopjar

Objectives: An evidence-based trauma database that rated the level-of-evidence for the majority of orthopedic trauma literature would be useful to orthopedic trauma surgeons and researchers. Currently, the development of a database using evidence ratings for such a large body of literature is a time-consuming and expensive endeavor. However, if an accurate rating could be obtained from an abstract without reading the full text, such an endeavor would be feasible. Thus, the purpose of this study is to determine if a reviewer can successfully ascertain the level-of-evidence from the article’s abstract without reading the full text article.

Methods: We compared the level-of-evidence rating obtained from reading an article’s full text with the rating obtained from reading the abstract alone. We reviewed 162 clinical articles published from January 2000 through April 2004 in five orthopedic trauma journals. To establish a full text rating, two reviewers independently rated the full text of each article for study type (therapeutic, prognostic or diagnostic) and level-of-evidence (I through V). The ratings from the two reviewers were compared and disagreements were reconciled through discussion to form a final full text rating. A third reviewer rated the abstracts of each article without access to the full text or full text rating.

Results: Of the 162 articles, 118 (73%) were therapeutic, 40 (25%) were prognostic and 4 (3%) were diagnostic. Most studies represented level IV evidence (65%), with only 15% representing the highest level-of-evidence, level I. Kappa values for agreement between the two reviewers rating the full text were 0.81 for study type and 0.79 for level-of-evidence, and the kappa values for agreement between the final full text rating and the abstract rating were 0.68 for study type and 0.75 for level-of-evidence, respectively. Thirteen of the discordant abstracts (8% of the entire set) lacked sufficient or correct evidence compared with the full text to render an accurate rating.

Conclusion: Accurate study type and level-of-evidence rating in trauma articles can be obtained in most orthopedic trauma articles from reading an article’s abstract alone. Thus, developing an evidence-based trauma database that uses abstracts to rate the level-of-evidence of the orthopedic trauma literature appears feasible and appropriate.

This research was supported by a grant from the AO Foundation, Clinical Investigation and Documentation, Clavadelerstrasse, 7270 Davos Platz, Switzerland


E. Tsiridis Z. Ali A. Bhalla Z. Gamie M. Heliotis N. Gurav S. Deb L. DiSilvio

Impaction allografting is a bone tissue engineering technique currently used in lower limb reconstruction orthopaedic surgery. Our hypothesis was that biological optimisation can be achieved by demineralisation and addition of osteogenic protein-1(OP-1) to the allograft. The objective of our in vitro study was to evaluate human mesenchymal stem cell (MSC) proliferation (Alamar Blue assay, titrated thymidine assay, total DNA Hoechst 33258 and scanning electron microscopy) and osteogenic differentiation (alkaline phosphatase assay) in two types of impacted carrier, namely demineralised bone matrix (DBM) and insoluble collagenous bone matrix (ICBM), with or without OP-1. The objective in vivo was to compare the osteogenic potential of impacted DBM with or without OP-1, with that of impacted fresh frozen allograft (FFA), again with or without OP-1. DBM+OP-1 optimized osteoinduction and significantly improved (p< 0.05) proliferation and differentiation in comparison to the majority of all other graft preparation in vitro. In addition DBM+OP-1 was significantly superior, with regard to osteogenesis, compared to the impacted FFA alone (p< 0.001), FFA+OP-1 (p=0.01) and DBM alone (p=0.02) in vivo. We propose that partial demineralisation and addition of OP-1 provides a good method for improving the osteoinductive properties of fresh allograft currently used in the impaction grafting technique.


R.W. Poolman P.A. Struijs R. Krips I.N. Sierevelt K.H. Lutz M. Zlowodzki M. Bhandari

Background: The Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals.

Methods: Two assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the four highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score.

Results: We found that only the Journal of Bone and Joint Surgery–American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p> 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC=0.80, 95%CI:0.60 to 0.90).

Conclusions: Our findings suggest that readers should not assume that

1) studies labelled as Level I have high reporting quality and

2) Level I studies have better reporting quality than Level II studies.

One should address methodological safeguards individually.


N. Maffulli G. Walley S. Bridgman D. Clement D. Griffiths G. Mackenzie

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.


R.W. Poolman P.A. Struijs R. Krips I.N. Sierevelt R.K. Marti F. Farrokhyar M. Zlowodzki M. Bhandari

Background: While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold:

1) to examine the reporting of outcome measures in orthopaedic trials,

2) to determine the feasibility of blinding in published orthopaedic trials and

3) to examine the association between the magnitude of treatment differences and methodological safeguards such as blinding.

Specifically, we focused on an association between blinding of outcome assessment and the size of the reported treatment effect; in other words: does blinding of outcome assessors matter?

Methods: We reviewed 32 identified RCTs published in the Journal of Bone and Joint Surgery (American Volume), in 2003 and 2004 for the appropriate use of outcome measures. These RCTs represented 3.4% (32/938) of all studies published during that time period. All RCTs were reviewed by two of us for:

1) the outcome measures used and

2) the use of a methodological safeguard: blinding.

We calculated the magnitude of treatment effect of blinded compared to un-blinded outcome assessors.

Results: The methodological validation and clinical usefulness of the clinician-based, patient-based, and generic outcome instruments varied. Ten of the 32 RCTs (31%) used a modified outcome instrument. Of these 10 trials, 4 (40%) failed to describe how the outcome instrument was modified. Nine (90%) of the 10 articles did not describe how their modified instrument was validated and retested. Sixteen (50%) of the 32 RCTs did not report blinding of outcome assessors where blinding would have been possible. Among those studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects (standardized mean difference 0.76 versus 0.25, p=0.01). Similarly, in those studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects (Odds ratio 0.13 versus 0.42, unblinded versus blinded, p< 0.001). The ratio of odds ratios (unblinded to blinded) was 0.31 suggesting that unblinded outcomes assessment was associated with an exaggeration of the benefit of a treatment’s effectiveness in our cohort of studies.

Conclusion: Reported outcomes in RCTs are often modified and rarely validated. Half of the RCTs did not blind outcome assessors even though blinding of outcome assessors would have been feasible in each case. Treatment effects may be exaggerated if outcome assessors are unblinded. Emphasis should be placed on detailed reporting of outcome measures to facilitate generalization. Outcome assessors should be blinded where possible to prevent bias.


V.D. Shetty S.L. Vowler R.N. Villar

Introduction: There are a number of publications in the literature on managing post-operative pain and early rehabilitation after primary total hip replacement (THR). However, there has been very little work in the literature to study the influence of the anaesthetic technique used on the post-operative length of hospital stay following primary THR. We, therefore, wished to particularly study the influence of anaesthetic technique and the anaesthetist concerned on the length of hospital stay, as well as the effect of age and body mass index (BMI).

Methods: We studied 121 consecutive THRs in 109 patients. All procedures in our study were performed by the same surgeon using the same posterolateral approach, the same prosthetic design and the same physiotherapy protocol for all patients. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. The mean age at the time of operation was 66.5 years (33 to 88). The influence of anaesthetist, anaesthetic technique, age of the patient and BMI on length of stay after primary THR was assessed separately.

Results: Our analysis showed that the length of hospital stay was greatly influenced by the anaesthetic technique used, those patients who received a lumbar plexus block having a shorter median length of hospital stay (3 days) than those who received general anaesthesia alone (5 days; p < 0.0001). The age of the patient was also critical (p = 0.003) as was the anaesthetist concerned (p = 0.01). BMI was unimportant.

Conclusions: For those surgeons who believe that a reduction in the length of hospital stay after primary THR is a worthwhile objective, we have one over-riding observation–the anaesthetic technique used is critical.


N. Maffulli S. Bridgman P. Richards G. Walley D. Clement G. MacKenzie Y. Al-tawarah D. Griffiths

Statement of Purpose: We tested the null hypothesis of no significant difference in arthroscopy rates for patients on a waiting list for arthroscopy in patients in which surgeons had a knee magnetic resonance imaging scan report prior to surgery, compared to those who did not have a report.

Methods and Results: This is a single-centre randomised controlled trial. 252 eligible patients consented and randomised. The two groups were similar with respect to a range of baseline factors. Very few arthroscopies were not performed–4.8% in the intervention arm and 5.5% in the control arm (χ2=0.06, df=1, p> 0.05). A longitudinal analysis of the secondary outcomes showed that there were no significant differences between the intervention and the control arms of the study.

Conclusion: Magnetic resonance imaging, prior to knee arthroscopy, does not lead to a reduction in the number of arthroscopies undertaken in the intervention group nor improve patient outcome in a range of secondary measures.


P.K. Schraeder U. Grouven R. Bender

Aim of the study: To calculate minimum-provider-volumes in total knee replacement by means of German routine data for the first time.

Materials and methods: In patients with primary total knee replacement (TKR) the correlation between hospital volume per year and risk of “insufficient mobility” (primary quality indicator) and “wound infection” (secondary quality indicator) was calculated by means of logistic regression models based on the data of 110.349 primary total knee replacements operated in 1.016 German hospitals in 2004.

Results: For both indicators a statistically significant relationship between hospital volume and outcome could be proven. Other risk factors such as age and ASA-status also had a significant influence, but did not appear as important confounders. The risk for the secondary quality indicator “infection” decreased constantly by increasing hospital volume, thus the curve was very flat. This supports the hypothesis that high volume hospitals show up to have a higher quality level than low-volume hospitals. A threshold value of 116 TKR per year (95% CI 90–141) could be calculated. However, the explanation value of the hospital volume was too low to derive a threshold level that clearly discriminates between good and bad quality of care. The relationship between the primary quality indicator “insufficient mobility” and the hospital volume unexpectedly showed a U-shaped distribution. This questions the concept of a minimum provider volume regulation for primary total knee replacement regarding the risk factor “insufficient mobility”. Therefore, in this case no quantitative threshold values were calculated.

Conclusion: This analysis supports the hypothesis of a volume-outcome-relationship in primary total knee replacement. However, a minimum provider volume that clearly discriminates between good and bad quality of care could not be calculated on basis of German quality assurance data.


N. Rosencher F.J. Singelyn C.C. Verheyen F. Piovella H.K. Van Aken

Continuous neuraxial or deep peripheral nerve blockade used to provide postoperative analgesia after major orthopaedic surgery is associated with a risk of spinal or perineural haematoma, especially in patients concomitantly receiving anticoagulants. Limited data on the use of fondaparinux in surgical patients in whom this procedure is performed are available. The EXPERT trial was an observational international study in patients undergoing major orthopaedic surgery designed to evaluate the overall efficacy and safety of once-daily 2.5 mg fondaparinux initiated 6 to 12 hours post-operatively and administered for 4±1 weeks after surgery. A 48-hour “therapeutic window” was applied in patients in whom a neuraxial/deep peripheral indwelling catheter was placed: one of the planned doses of fondaparinux was omitted, the catheter was removed 36 hours after the previous fondaparinux dose, and the next fondaparinux dose administered 12 hours after catheter removal. The primary endpoints were symptomatic venous thromboembolism (VTE) and major bleeding 5±1 weeks after surgery. These events were validated by an independent adjudication committee. Overall, 5704 patients (mean age ± SD: 66 ± 12 years) were recruited between July 2003 and October 2004. They underwent surgery for total hip replacement (52%, n=2941), knee replacement (40%, n=2263), hip fracture (6%, n=353), or other indications (3%, n=148). Fondaparinux was given for a median of 35 (range: 1–105) days. Many operations (62%) were performed under regional anaesthesia only. A neuraxial or deep peripheral nerve block catheter was placed in 29% (n=1630) of patients. It was removed between one and two days after surgery in 43% (706/1626), and between three and six days after surgery in 57% (920/1626). Overall, the rate of symptomatic VTE was 1.0% (54/5387); it was 0.8% (13/1535) in patients with catheter and 1.1% (41/3852) in patients without catheter, giving an odds ratio of 0.79 (95% CI: 0.42 to 1.49) in favour of patients with a catheter. The upper limit of the 95% CI being below the predetermined non-inferiority margin of 1.75, the efficacy of fondaparinux in patients with a catheter was therefore not inferior to that observed in patients without a catheter. The rate of major bleeding was 0.8% (42/5382) overall, 0.5% (7/1532) in patients with catheter and 0.9% (35/3850) in patients without catheter. No spinal or perineural hematomas or nerve damage were reported. At 5±1 weeks, 23 (0.4%) patients had died. In conclusion, 2.5 mg fondaparinux given daily for 4±1 weeks after major orthopaedic surgery was both effective and safe in routine practice. This benefit-risk ratio was similar in 1630 patients with a neuraxial/ deep peripheral indwelling catheter in whom a 48-hour “therapeutic window” was applied.


G.J. Rainey S. Khan I. Brenkel

Loss of blood is inevitable during knee replacement surgery, sometimes requiring transfusion. Allogenic blood leads to a risk of disease transmission and immunological reaction. There are various practices used. There is still a risk of bacterial transmission with stored blood and haemolytic transfusion reactions can still occur. Data was collected between 1998 and 2006. There was data on transfusion in 1532 patients undergoing primary knee replacements. There were 1375 unilateral TKRs and 157 bilateral TKRs. After reducing the bilateral cases to one record per patient, it was agreed to restrict the main analysis to 1532 patients. Data was collected prospectively at a pre-admission clinic 3 weeks prior to surgery. Haemoglobin was checked and body demographics including BMI were obtained. Each patient also had a knee score assessed. All patients received a LMWH pre-op until discharge. A tourniquet was used in each case and all patients had a medial para-patellar approach. No drains were used and operation details such as a lateral release were recorded. As per unit protocol, patients with a post-op haemoglobin less than 8.5g/dl were transfused as were symptomatic patients with haemoglobin between 8.5g/dl and 10g/dl. Each of the possible predictive factors was tested for significant association with transfusion using chi-squared or t-tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another. Results show that transfusion was more likely if the patient was older, female, short, light or thin. Among peri-operative factors, the chance of a transfusion was increased for bilateral patients, those with low knee scores and those with high ASA scores. Also patients undergoing a lateral release, those with low pre-op haemoglobin and those with a large post-op drop were more likely to be transfused. All the significant variables were entered into a forward stepwise multiple logistic regression. Transfusion was significantly more likely in those undergoing a bilateral procedure, with a low BMI, low pre-op haemoglobin and those with a large post-op drop (> 3g/dl). Allogenic transfusion is associated with immune-related reactions, from pyrexia to urticaria to haemolytic transfusion reactions, which can be life threatening. There is also the risk of viral pathogen transmission. Women were shown to be almost twice as likely to need transfusion. This has been shown in previous studies and is thought to be due to women having a lower weight and pre-op haemoglobin, both of which were shown to be significant independent factors in increasing the risk of transfusion. A pre-operative haemoglobin of less than 13g/dl, a BMI less than 25, and undergoing a bilateral procedure were shown to have an increased risk of transfusion. For patients falling into these categories, measures can be planned to try and reduce this risk.


Z.A. Matejovsky Z. Matejovsky I. Kofránek Z. Krystlik

The authors offer their personal experience with long term results on 71 patients (72 allografts) operated between 1961 and 1990. 23 were large osteoarticular grafts, 28 intercalary grafts and 20 fibular grafts. We used one composite hip endoprosthesis in 1988 after 16cm proximal femur resection due to Ewing sarcoma in a 10 year old girl. From the 23 osteoarticular grafts 14 (60%) are long term survivals including one after fracture salvage. Six had to be removed due to infection. From the 28 intercalary grafts 16 (57%) are surviving over 15 years. Infection occurred in 6 patients with chemotherapy. Two of them had intra-arterial CDDP and one additional radiation. All of the proximal humerus allograft had complete resorption of the proximal head within 3 years. The diaphyseal reconstructions with additional cancellous autografts incorporated within 3 years. The patient with the composite stem had two cup revisions, but the stem is doing well and we observed only a mild osteolysis at the proximal part of the graft between the 2nd and 5th year that remains stable. Fractures of the graft can be salvaged in most cases.

Infection leads to the removal of the graft in almost all cases. Factors influencing the survival, remodeling and complications of the grafts are discussed. The regime of cryopreservation, fixation and loading of the graft influence these factors together with the use of autologous bone chips around the allograft-host junction as well as the application of chemotherapy or radiation. Fracture of the graft can be salvaged in most cases in contrary to infection that remains the most severe complication that can occur at any time period. Even with the improvement of tumor endoprostheses the use of allografts remains an optional solution especially in young patients.


M.C. Kokkinakis K. Kafchitsas A. Rajeev J. Mortier M. Engelhardt

The osteochondral defect in the knee and ankle joint is a difficult and common problem in young population. The bone-cartilage autologous grafting represents a recently introduced treatment option for osteochondral lesions of the weight bearing articular surfaces of femoral condyles and talus.

The aim of our study was to evaluate the MRI findings, and in particular to find out about the fate and the time needed for the graft incorporation, to assess the continuity, homogeneity and smoothness of the cartilage layer of the transplant compare to the remaining cartilage, to estimate the viability of the graft and to determine the correlation between the MRI findings and the functional outcome.

We performed a prospective study and followed up 33 patients, who underwent osteochondral autografting for defects in both medial and lateral femoral condyles as well as in the talus. The grafts were harvested from the anterolateral region of the ipsilateral knee using an insider rinsing diamond bone-cutting instrument (DBCS). The grafts were implanted using press fit technique.

16(48%) women and 17 men were included in our followup with an average age of 38.4 years (age range-16to58 yrs). There were 20(60%) osteochondral defects in the femoral condyles and 13 in the talus. 13(40%) patients gave a history of trauma. All the patients were followed up with MRI scans between 1 to 4 years postoperatively.

The MRI study illustrated a cartilage contour interruption by 16(48%) patients and 19(58%) had uneven joint surface. 9(27%) of the patients were shown to have homogeneity between the graft and the surrounding bone and cartilage tissues. A subchondral oedema was observed in 2(6%) of the cases. Only 1 patient had a subchondral bone-oedema in the graft-donor site. All the autologous grafts were incorporated by 4 years as proven by MRI scans

The MRI evaluation revealed regular incorporation of the osseous part of the graft in the subchondral bone. On the contrary, cartilage layer integration was less common. The MRI findings did not show any correlation to the clinical outcome. Hangody (2003) reports all grafts to incorporate into the recipient bed and most articular surfaces to have congruency and similar appearance to the surrounding articular cartilage and bone in 6 years.

Despite using very accurate harvested autologous osteochondral cylinders, which fit exactly the defects, match precisely the corresponding chondral and osseous layers and cause no immune reactions, it was shown in this short term MRI followup that the height and the shape of the original articular surface cannot be fully restored. However the relief of symptoms and improved functional outcome are promising findings and define bone cartilage autografting as a currently efficient treatment of osteochondral lesions of knee and talus.


L.A. Aponte-Tinao G. Farfalli B. Politi E. Abalo M. Ayerza D. Muscolo

Introduction: Osteoarticular allograft represents a reliable option for distal femur reconstruction. The purpose of this study was to describe the technical details and results of distal femur tumor resection and reconstruction with an osteoarticular allograft.

Material and Methods: One hundred and twenty-two patients who received an osteoarticular allograft after distal femur resection were reviewed, with a mean follow-up of 7 years. Key points for successful fixation are allograft selection, absolute stability and satisfactory soft-tissue reconstruction at the time of surgery that allows aggressive rehabilitation. Survival of the allograft was estimated with the Kaplan-Meier method. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up.

Results: Three patients were lost to follow and twenty-three patients died for tumor related reasons without allograft failure. In the remaining 96 allografts, eighteen allografts failed due to 7 infections, 7 local recurrences, 1 massive resorption and 3 fractures. Overall allograft survival was 82% +/− 7.6% (+/− 2 SE) at five and ten years. Those patients who preserved the original allograft had an average functional score of 27 points and a mean radiographic score of 89%, which represents a good and excellent functional and radiographic result.

Discussion and conclusion: Osteoarticular allograft is a successful procedure for reconstruction of the distal femur. Adequate preoperative planning, careful surgical technique and aggressive rehabilitation lead to excellent function and low complication rate.


M.A. Ayerza G. Farfalli E. Abalo L. Aponte-Tinao D.L. Muscolo

Introduction: Unicompartmental osteoarticular defects of the knee are challenging due to demands of stability and function of this weight-bearing joint. Prostheses reconstruction often requires sacrificing the uninvolved compartment. Osteoarticular allograft reconstruction can restore the anatomy, and allows reattaching soft tissue structures such as meniscus and ligaments from the host. The purpose of this study was to perform a survival analysis of unicompartimental osteoarticular allografts of the knee and evaluate their complications.

Material and Methods: Forty unicompartmental osteo-articular allograft of the knee performed in 38 patients during the period 1962–2001, were followed for a mean of 11 years. In 36 patients, the bone defect was created by the resection of a tumor (33 giant cell tumors, 1 osteogenic sarcoma, 1 chondrosarcoma and 1 malignant fibrous histiocytoma) and in the remaining two by an open fracture. Twenty nine transplants were located at the femur that includes 11 medial and 18 lateral condyles. Eleven transplants were located at the tibia, including 4 medial and 7 lateral tibial plateaus. According to the reconstructed compartment, host meniscus and ligaments were reattached to the graft. Rigid internal fixation with plates and screws were used in each patient. Allografts survival from the date of implantation to the date of revision or the time of the latest follow-up was determined with the use of the Kaplan-Meier method. Complications as local recurrence, fracture, articular collapse and infection were analyzed.

Results: The global rate of allograft survival was 85% at five years. There were 8 complications in 6 patients: 2 local recurrences, 2 infections, 1 fracture, 1 massive resorption and 2 articular collapses. In 6 patients the allograft was removed and they were considered as failures. All these patients required a second allograft that included 2 unicompartmental and 4 bicompartimental reconstructions. The two patients with articular collapses required a regular total knee resurfacing prosthesis.

Discussion: Although the incidence of reoperations due to allograft complications may be high, the allograft survivor rate at five years was 85%. Unicondylar allografts, appear to be an alternative in those situations in which the massive osteoarticular bone loss to be reconstructed, is limited to one knee compartment.


M. Jakob W. Dick M. Heberer I. Martin

A major challenge to be faced in order to introduce cell-based therapies for bone repair into wide-spread surgical practice is to translate a research-scale production model into a manufacturing design that is reproducible, clinically effective, and economically viable. One possible means by which to achieve this goal is via a bioreactor system capable of controlling, automating, and streamlining all of the individual phases of the bone-tissue engineering process. In a first step to meeting this challenge, in this work we aimed at developing and validating a closed bioreactor system for

the efficient seeding of cells into 3-dimensional scaffolds and

the generation of osteoinductive constructs starting from human bone marrow-derived cells.

Our patented bioreactor technology essentially consists of scaffolds arranged in a circular plate, which is moved in alternating directions by a linear drive unit through a cell suspension/culture medium, thus resulting in the perfusion of the cell suspension/culture medium directly through the pores of the scaffolds in alternate directions. The cultivation chamber is fully isolated from the external environment, with liquid/gas exchange achieved through aseptic interfaces.

Human bone marrow nucleated cells from 3 donors were perfused through porous ceramic discs (8 mm diameter, 4 mm thick), resulting in adhesion of the osteoprogenitor cell fraction in the ceramic scaffolds. Efficiency of cell seeding was consistently greater than 80%. Cell seeded constructs were further cultivated under perfusion for a total of 20 days, resulting in the expansion of the osteoprogenitor cells directly within the scaffold pores and maintenance of greater than 90% cell viability. Ectopic implantation of the cultivated constructs yielded abundant and reproducible formation of bone tissue, distributed throughout the scaffold pores.

The developed bioreactor provides a simple and efficient approach

to establish and maintain 3D cultures of cells into scaffolds under perfusion, and

to generate osteoinductive grafts starting from minimally processed bone marrow aspirates and bypassing typical cell expansion in monolayers.

Incorporating the bioreactor unit into a system for automated medium change and monitoring/control of culture parameters is likely to lead to the development of a closed system for the standardized production of autologous cell-based bone substitutes.


S.A. Khan

Introduction: Extent of fibular resection dramatically alters limb function. Aim of our study was to evaluate the functional outcome following resections for 23 malignant tumors of fibula.

Methods: 23 biopsy proven malignant tumors of fibula were included in the study. There were 11 cases of Ewings sarcoma (PNET), 8 osteosarcomas, 2 malignant fibrous histiocytoma and 1 each of synovial sarcoma and chondrosarcoma. Following chemotherapy (wherever indicated) limb salvage surgery was done in all cases. There were 9 proximal, 6 middle and 9 cases of distal third of fibula. Type I resection was done in all proximal and 4 tumors of middle third fibula. Type II fibular resection with reconstruction of ankle joint was done in 10 cases. Reversal of contralateral fibula to reconstruct the ankle was done in 7 cases. Allograft was used in 3 patients.

Results: Average follow up was for 4.5 years (2 to 7 years). 17 patients (68%) were alive after 4 years of surgery. Local recurrence was seen in 3 cases and these were treated by above knee amputation. 3 patients died within 1 year of surgery. 82% of survivors had a good to excellent functional outcome according to the MSTS functional evaluation criteria and 65% were able to bear full weight and had unlimited activity. Recurrence was commonest in patients with PNET. All patients undergoing reversed fibular grafting showed good functional outcome.

Discussion and Conclusion: Results of limb salvage in malignant fibular lesions is infrequently reported. Site of fibular lesion is critical in salvage surgery and need for further reconstruction. Good results are obtained with reversed contralateral fibular reconstruction of the ankle.


E. Abalo G. Farfalli B. Politi L. Aponte-Tinao M. Ayerza D.L. Muscolo

Pupose: The purpose of this study was to analyze the outcome of proximal tibia osteoarticular allografts after tumor resections.

Material amd Methods: We performed a retrospective study over 58 patients in which a proximal tibia allograft reconstruction was undertaken. All patients were followed for a minimum of 5 years and allografts survival from the date of implantation to the date of revision or the time of the latest follow-up was determined with the use of the Kaplan-Meier method. In all patients, the patellar tendon from the host was reattached by suturing to overlapped donor flaps. Patients were clinically evaluated with the MSTS score system.

Results: The global rate of allograft survival was 65% +/− 12% (+/− 2 SE) at five and ten years, with no significant difference between patients who received chemotherapy and those who did not. Allografts needed to be removed in twenty patients due to 12 infection, 4 local recurrences and 4 fractures. Active knee extension was restored in all patients with an average functional score of 26.3 points.

Discussion: Survival analysis showed that 65% of proximal tibia osteoarticular allograft reconstructions remain stable at five and ten years. Patellar tendon reconstruction with allogeneic tissue in proximal tibia allograft restores active knee extension with an excellent functional result. Despite the incidence of complications, proximal tibia osteoarticular allografts continue to be a very valuable reconstructive procedure for large defects after resection of bone tumors.


G. Lob V. Heppert R. Laun T. Lob L. Rabenseifner

Introduction: Improved treatment of primary tumors leads to an increased life expectancy and thus to an increasing number of patients with bone metastases. Techniques like auto- or allogenic bone grafts, vascularised bone transfer and distraction osteogenesis often require multistage surgical procedures and inhibit full early limb function. Diaphyseal replacement using nails, plates and bone cement do not guarantee long term bone stability. Due to this experiences a new diaphyseal replacement device for humerus, femur and tibia has been developed.

Materials and Methods: The diaphyseal replacement implant OSTEOBRIDGE consists of two semi-circular cylindrical shells. The spacer is clamped around two nails via eight screws. Different sizes of spacers and nails can be used to bridge the bone loss correctly.

The outer diameter of the spacer ranges from 20–25–30 mm and the length from 40 to 70 mm. Two or three spacers can be combined via a special connector. Nails in the length 60 to 200 mm and the Ø 7 to 18 mm with the possibility of static or dynamic interlocking complete the modular system entirely made from Ti-6Al-4V.

Biomechanical Testing: Static compression tests to determine the maximum longitudinal forces of the clamp connection spacer/nail were performed, 4-point bending tests with the complete system to investigate the fatigue resistance were undertaken and torsional test to evaluate the rotational stability.

Prospectiv clinical evaluation: In between 2004 and 2006 35 patients were treated with the OSTEO-BRIDGE system.

The indication: Tumor: Humerus 8, Femur 16, Tibia 2, Postinfectious: Tibia 4, Posttramatic Femur 4, Tibia 2.

Results:

Biomechanical testing: the clamp connection spacer/ nail can neutralize axial loads which can not be expected in human beings. The clamp connection spacer/nail Ø 10 mm resisted an average axial load of 8,5 kN. This can be compared to a force of 850 kN (equivalent to 10 multiples of 85 kg body weight). The bending test with a nail Ø 10 mm shows that the spacer can resist long term loads from an occurring stress of 400 N/mm2 in the nail.

Clinical evaluation: All spacers are still in place and all are full functioning, except 2; one spacer in the femur had to be replaced by a second spacer due to bone cement incorporated during first operation.

One spacer was removed during amputation for recurrency of osteosarcoma. No infection, no loosing were reported.

Discussion: The OSTEOBRIDGE spacer system allows to replace lost daiphyseal bone over long distances with proved biomechanical stability. An advantage seems to be the early bony bridging over the spacer within the first 9 months. There might be another advantage in using the spacer as a container for antitumor, bactericidal or bone growth stimulating drugs.


D.A. Campanacci G. Scoccianti M. Mugnaini G. Beltrami L. Ciampalini P. De Biase R. Capanna

Ankle arthrodesis is considered a valid reconstructive option after bone tumor resection of the distal tibia, distal fibula and of the talus. The purpose of the present study was the review of author’s experience in ankle arthrodesis for bone tumors with the employ of bone grafts.

Over the last 15 years, 17 ankle arthrodesis were performed in author’s Institution for oncological pathologies. Average age at the time of surgery was 41 years (4–75). Twelve patients had a malignant tumor (3 osteosarcoma, 2 fibrosarcomas, 1 Ewing sarcoma, 1 emangioendotelioma, 1 condrosarcoma, 1 pleomorphic sarcoma, 1 adamantinoma and 2 metastases from renal carcinoma) and 5 patients had a benign tumor (4 giant cell tumors, 1 condroblastoma). In 13 cases the tumor involved the distal tibia, in 2 cases the distal fibula and in 2 cases the talus. In 15 patients we performed a tibiotalar arthrodesis and in 2 patients (tumors of the talus) a tibiocalcaneal arthrodesis.

The bone defect after resection was reconstructed with: cortical structural autografts from controlateral tibia and autologous bone chips from iliac crest in 5 patients; cortical structural autografts from controlateral tibia + cortical structural allografts + autologous bone chips from iliac crest in 2 patients; cortical structural allografts + autologous bone chips from iliac crest in 2 patients; structural autografts in 4 patients; autogenous vascolarized fibula in 4 patient with cortical allograft in 3 cases and autograft in 1 case. Stabilization was obtained by intramedullary anterograde nailing in 8 patients, plate in 2, two or multiple screws in 7 (including two tibiocalcaneal arthrodesis).

Three patients died before this review (1, 1.5, 7 years after surgery: 1 Ewing sarcoma, 2 patients with metastases from kidney cancer). Follow-up for alive patients ranged from 14 to 146 months (average 53). Two local recurrences were observed, in a Ewing sarcoma in 1 case and in a giant cell tumor in 1 case. One patient is alive with lung metastases but no signs of local recurrence. In all patients but one the arthrodesis healed successfully. In one case a deep infection occurred (with wound dehiscence) and the arthrodesis did not heal. Complications included 1 deep infection, 1 superficial infection of the donor site (controlateral leg) and 1 fracture of the controlateral tibia (donor site of cortical autograft) treated with plaster cast. Three patients underwent a secondary surgical procedure: two partial hardware removals and one myocutaneous sural flap.

The low rate of local recurrence (1/5 in benign tumors and 1/12 in malignant tumors) and the high percentage of bone union (16 out of 17) together with the satisfactory functional outcome showed that ankle arthrodesis with bone grafts can be an oncologically safe and a meccanically successful procedure in bone tumor surgery.


I. van der Geest M. de Valk H. Schreuder R. Veth

Introduction: Both enchondromas and chondrosarcomas are mesenchymal neoplasms which originate from cartilage cells, and they occur mainly in the extremities. Both these tumours are resistant to chemotherapy and radiotherapy, and surgery is the only treatment option. In the last few years limb saving procedures have become the treatment of choice. Intra-operative cryosurgery has been introduced as a local adjuvant therapy for skeletal benign and low-grade malignant tumours. It is applied after curettage of the lesion to destroy any remaining tumour cells, and to enlarge the oncological margin of resection. Since the introduction of cryosurgery as an adjuvans, oncological and functional results of this extremity sparing surgery are significantly enhanced.

Patients and Methods: A retrospective study was conducted to evaluate the oncological and functional results, and the complications of cryosurgical treatment.

Data were prospectively collected from the tumour register and patient records. Functional scores of the affected limbs were assessed according to the Musculo-Skeletal Tumour Society scoring system.

Results: Between 1994 and 2003 123 patients (47 men, 76 women, average age 49 years; range 13–83 yrs) were treated with curettage and cryosurgery for an Enneking stage 3 enchondroma (75 patients) or a low-grade chondrosarcoma (55 patients).

The minimal follow up was two years, and the average follow up 50 months (range 24–119 months).

At follow up three recurrences had occurred in patients treated for enchondroma. One residual tumour was diagnosed in a patient with chondrosarcoma grade Ib. All patients were treated again with curettage and cryosurgery and disease free at the latest follow-up.

Of the 37 complications the most common were a fracture at the surgical site (18), fracture of osteosynthesis (6), 3 wound infection (3), delayed soft tissue healing (3), and transient nerve palsy (3).

Functional MSTS scores increased in time to an average of 28 points (94%) at two year follow up. No significant difference in scores were found regarding to localisation of the lesion, age or gender. A significant discrepancy in functional scores was observed between patients who did suffer from one or more complications and patients who did not.

Conclusion: We believe that the use of cryosurgery is an excellent adjuvant therapy after curettage to achieve local control of aggressive enchondromas and low grade chondrosarcomas. It avoids the need for segmental resection, making reconstruction of the bony defect easier and therefore results in excellent functional outcome. Due to the initial high fracture rate osteosynthesis at the surgical site is used more often, and weight baring mobilisation is postponed until full consolidation is reached.


A. Krueger M. Tannast S. Kohl M. Beck K. Siebenrock

Introduction: In the treatment of polytraumatised patients acetabular fractures are challenging because of the necessity of perfect open reduction of the articular surface over an anatomy respecting approach. Luxation of the femoral head with accompanying Pikin fracture, interponated fragments and labral lesions are relevant additional injuries compromising a good result after correct operative treatment. The choice of the approach is a limiting factor for the visualization of the hip joint and is of capital importance for adequate internal fixation. A modified Kocher-Langenbeck- approach with osteotomy of the grater trochanter allows an anatomic reduction under perfect visualization with protection of the soft tissue.

Patients and Methods: This prospective study was accomplished from 1995–2003 including 60 patients (16 female, 16–80years) with an actabulary fracture (posterior wall-, T-type-, and transverse fracture) treated over a modified Kocher-Langenbeck-appraoch with osteotomy of the grater tro-chanter. The included patients had a minimum follow-up of 2 years with clinical and radiological examination. The outcome was assessed with the Merle d’Aubigné-score and degenerative changes with the Tönnis classification.

Results: Within 57 patients an anatomic reduction was achieved. In 3 patients the reduction was not anatomical but satisfactory (1–3mm). Arthrotic changes in the minimujm follow-up of 2 years were observed in 14 patients (8 Ps grade I, 3 Ps grade II, 3 Ps grade III). In 3 patients posttraumatic arthritis had to be treated with THR (1, 3, 8 years postoperatively). A avascular necrosis was not objected.

Conclusion: The treatment of suitable acetabular fractures over a modified Kocher-Langenbeck-approach with a osteotomy of the greater trochanter and dislocation of the femoral head is a safe method for anatomic reduction and internal fixation


K.å. Jansson P. Svedmark E. Buskens M. Larsson P. Blomqvist J. Adami

Introduction: Spinal fractures are associated with pain, disability, neurological dysfunction and mortality. Osteoporosis and risky leisure time activities are increasing in the population. New treatment options have been introduced. However, only a few international studies have reported its descriptive epidemiology. There are no clear consensuses regarding the choice of operative interventions versus non-operative treatment in patients with thoracolumbar fractures. Treatment is often based on local traditions, skills and experiences. The aim of this nationwide study is to analyse the incidence, the characteristics of the patients, the subsequent development, surgical incidence and mortality rate among hospitalized patients with thoracolumbar fractures in Sweden.

Methods: All discharges between 1997 and 2000 with diagnoses of thoracic or lumbar vertebrae fracture according to ICD 10 classification were selected from the National Inpatient Register. Surgery in these patients was categorised by procedure codes indicating spine operations. In order to calculate the risk of patients dying, linkage was performed to the Swedish Death Register using the unique personal identification number.

Results: We identified 13, 496 admissions during the study period. This corresponds to an incidence rate of 30 per 100, 000 person-years and the occurrence was stable during 1997 and 2001 for patients younger than 50 years but decreased for patients above 50 years. The incidence of spine surgery among all patients was 1.9 per 100, 000 person-years, ranging from 1.6 per 100, 000 inhabitants per year to 2.6 per 100, 000 in the different region of Sweden. The most common causes of the fracture were falls (53 %) followed by vehicle accidents (37%). Almost two thirds of the patients operated on were men (63 %) and two thirds had lumbar vertebral fractures (66 %). The median age of the patients operated on was 42 years. The median length of stay was eight days. Among those who was operated the 30 days case fatality rate was 0.7 %. Median age for death was 64 years. Operations were less common in women (OR 0.79). The number of patients operated on during the last study year 2001 was significantly increased (OR 1.29). The probability of being operated on was highest in the more urban and densely populated regions of Stockholm and southern Sweden.

Discussion: This national study based study showed a stable cumulative incidence of thoracolumbar fractures over the year 1997–2000. However, the two last year of this study an increased incidence of operation was observed. A possible explanation of this finding could be the new percutaneus technique for verterbroplasty. We find it of most importance to further investigate the reasons behind the gender differences in surgical incidence in patients with vertebral fractures


G. TAMBURELLA A. ARE

The authors present their experience of acetabular fractures, as examined according to Harris’ recent (2004) CT based classification into four separate groups and relative sub-groups.

Each group is here represented as a completely documented clinical case, with pre and post-op roent-grams as well as axial and volume rendering CT imagery.

The Harris classification differs from the classic and 40 year old Letournel classification, basically ignoring the fracture complexity and focusing on the pattern of the fracture itself, with respect to column walls and extension beyond the acetabulum. It’s also possible to include some commonly seen fractures otherwise not classified by Letournel. Fracture comminution therefore is not a defining characteristic.

This topographic approach is easier for the surgeon to comprehend and memorize, thus facilitating pre-operative planning and the possibility of interdepartmental assessment of the fracture types.

Obviously, computerized tomography is the defining technique of this classification. The axial CT display of acetabular fracture patterns within the pelvis is furthermore confirmed by the 3D reformatted images.

This classification is loosely based on that of Tile and Helfet ; with the advantage of further simplifying the sub-groups from 27 to 16.

The Harris classification is simple and unambiguous, providing clear indications for both diagnosis and surgical treatment planning of this most complex chapter of Traumatology.


J. Mutimer M. Ockendon T. Chesser W. Anthony

Introduction: Posterior wall acetabular fractures are potentially difficult fractures to treat due to difficulties associated with the types of approach, reduction and fixation required. Spring plates are a method of maintaining such fractures reduced.

Aims: To assess the clinical and radiological outcome with spring plate fixation of posterior wall fractures.

Materials and Methods: From July 1993 to August 2004, 91 patients with 92 displaced posterior wall fractures underwent posterior wall fixation with one or more spring plates.

All patients were assessed postoperatively with a CT scan and annually for up to 5 years for a clinical and radiological assessment. Clinically patients were graded according to the Epstein modification of Merle D’Aubigne/ Postel Hip Score. The radiographs were graded using the Roentographic Grade criteria used by Matta.

Results: Patients were reviewed at a mean 44 month follow up.

At the time of operation 40% of fractures were reduced anatomically. There were 12 post operative complications.

Clinically excellent or good results were seen in 70% and radiologically in 68%. There were 11 revisions for osteonecrosis, infection and osteoarthritis.

There was a high correlation between the accuracy of the reduction and the subsequent prognosis.

Conclusion: Posterior wall fractures can be treated successfully by the use of spring plates. Clinical results correspond closely with radiological appearance. The accuracy of reduction correlates highly with the subsequent prognosis and we recommend routine postoperative CT scanning to identify misplaced metalwork and the accuracy of reduction to help predict prognosis.


A. Pizzoli N. Rossi

Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard approach provides open reduction and internal fixation (O.R.I.F.) through a variety of surgical approaches which have been associated with relatively high complications rate such as haematomas, deep infection, and neuro-vascular lesions. These procedures need long operative times with significant blood loss.

Many authors have demonstrated the feasibility of closed reduction and percutaneous fixation (C.R.P.F.) for minimally or non displaced acetabular fractures; this technique can be considered a valid alternative to O.RI. F. in order to decrease the morbidity related to surgical approaches.

Between 2001 and 2006 we performed C.R.P.F. for acetabular fractures in 15 patients; the reduction has been controlled with fluoroscopy during the operation and with CT scan after the operative procedure. The osteosinthesis has been performed with cannulated screws and In more complex cases the reduction has been achieved and maintained with ileo-femoral external fixation (ligamentotaxis technique).

Fractures were classified according to AO classification. Clinical and functional results have been evaluated according to Harris Hip Score on the base of post-operative CT scan and on x-ray films at last follow-up.

According to our experience the use of external fixation in the treatment of acetabular fractures must be reserved for very selected cases in which for general or local condition the joint the distraction associated with minimal internal fixation can guarantee good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. The best reduction can be achieved when the treatment is carried out early while the best stability is achieved with the association of percutaneous cannulated screws. The use of external fixation has never compromised the range of movement of the hip.


S. Darmanis J. LECKENBY A. MANSOOR A. LEWIS M. BIRCHER

Purpose: The authors would like to report the outcome following evaluation of surgical treatment for acetabular fractures with more than 10 years follow-up.

Materials and methods: 133 consecutive patients were evaluated with 10–16 years post surgery follow-up (mean 12 years). Mean age was 34 years (17 to 70 range) and male: female were 2:1. 90% of our cases were tertiary referrals. The follow-up assessments included AP pelvis and Judet view radiographs and clinical evaluation was performed with the Harris hip score, Modified Merle d’Aubigne score and the SF 36v2 health survey.

Results: Fracture reduction was anatomical in 69% of the patients and in 31% it was non-anatomical. The reduction of the acetabular fractures was considered anatomical when all five lines on post-operative radiographs were corrected and the hip was congruent. Among our patients, 19% had excellent clinical results according to the modified Merle d’Aubigne Score and 58% according to the Harris Hip Score. A poor clinical outcome was identified in 18% of our patients according to the modified Merle d’Aubigne Score and 23% according to the Harris Hip Score. Radiographic evidence of osteoarthritis was in 35,8% of our patients (all grades of arthritis). 6 of our patients had neurological complications (sciatic nerve palsy) (3 pre-operatively, 2 post- operatively and in one patient there was a delayed sciatic nerve palsy secondary to haematoma). In 7 patients (8.6%) there was heterotopic ossification but in only three that was clinically a problem. Two patients developed intraoperatively pulmonary embolism. We had no post-operative deep vein thrombosis or pulmonary embolism.

Conclusions: Our results compare favourably with those of previous published studies with shorter follow-up period. Anatomical fracture reduction is mandatory and improves the clinical outcome. Infection and avascular necrosis are associated with poor clinical outcome. Early surgical intervention for displaced acetabular fractures can improve the final outcome.


H.L. Soberg A. Finset E. Bautz-Holter L. Sandvik O. Roise

Background: The assessment of factors associated with return to work (RTW/NRTW) after multiple trauma is important in trauma research. Goals in rehabilitation should comprise RTW. The purpose of this study was to examine the RTW rate and which factors that predicted RTW for patients with severe multiple injuries using a prospective cohort design.

Methods: 100 patients with a New Injury Severity Score (NISS) > 15, age 18–67 admitted to a Level I trauma center were included starting January 2002 through June 2003. Outcomes were assessed 6 weeks after discharge, 1 and 2 years post-injury. Instruments were the Brief Approach/Avoidance Coping Questionnaire, Multi-dimensional Health Locus of Control, SF-36, the WHODAS II and the COG for cognitive functioning.

Results: Mean age was 34.5 years (SD 13.5), 83% were male. Mean NISS was 35.1 (SD 12.7). 66% were blue-collar workers. At 1 year 29% achieved complete RTW, 43% at 2 years. Mean time back to work was 12.8 months (SD 5.9). Differences between the RTW/ NRTW groups concerned personal and demographic variables, and physical and psychosocial functioning. Survival analysis showed that risk factors for NRTW were lower education, length of stay in hospital/rehabilitation > 20 weeks and low social functioning shortly after the return home.

Conclusions: The majority of the patients had not completely returned to work 2 years post-injury. Demographic and injury related factors and social functioning were significant predictors of RTW status.


A. Athanasopoulou V. Psychoyios G. Galani H. Dinopoulos O. Paisios

Aim: The aim of the study was to investigate the efficacy of the multidetector CT scan in the diagnosis and classification of pelvic and acetabular fractures.

Material and Method: 41 patients, 13 women and 28 men suspect for acetabular or pelvic fracture were examined. Patient’s ranged from 15 to 72 years. Fracture classification was based in that of Letournel and Judet. Examination was performed with a Multidetector CT scanner (Phillips-Brilliance), withnmultiple detectors and thin slices of 2 mm Multilevel and three dimensional reconstructions were performed.

Results: in 15 patients suspects for pelvic or acetabular fracture in plain xray, the CT scan was negative for revealing a fracture. In the rest 26 patients, there were 19 fractures of the anterior column, 4 fractures of the posterior column, 11 acetabular fractures and 7 sacral fractures. All the fractures were detected at the horizontal plane. MPR views were offered additional information for the sacral and acetabular fractures. In 7 patients the fractures diagnosed only after the CT scan was performed. In these patient plain x-rays were negative for fracture. In 6 patients the treatment algorithm was modified, based on CT scans findings

Conclusion: We believe that MDCT is an appropriate as well as an essential method in patients suspects for pelvic or acetabular injuries. MPR and three dimensional reconstructions are very helpful in revealing the personality of the fracture element very important for classification purposes as well as for planning treatment.


G.H. Kelalis K. Zahariou L. Kollintzas A. Kalampokis A. Morakis

PURPOSE: To record our experience in surgical treatment of thoracic spine fractures with posterior stabilization, decompression and ligamentotaxis.

MATERIALS AND METHODS: From January 2000 until July 2006, 67 patients (48 males and 19 females), aged 16 to 85 years old (average 41,2 y.o) were surgically treated in our department due to thoracic spine fractures. Preoperative X-Ray and CT scan were used in all cases while in most of the cases we performed MRI to further evaluate the damage. In all cases we performed decompression and posterior stabilization using four different hardware types and whenever possible ligamentotaxis. Continuous electrophysiological monitoring was alo ued in all operations. We recorded the pre- and postoperative neurological status, the vertebral height loss, the kyphotic angle and spinal canal occupation. Moreover we recorded the average hospitalization time, the transfusion needs as well as major and minor complications. At the follow-up we measured the loss of correction at 3, 6 and 12 months postoperatively. The follow up ranged from 4 to 48 months.

RESULTS: Neurological damage was recorded in 43 % of the patients. The average preoperative kyphotic angle was 38.2° while the average spinal canal occupation was 29.8 %. The immediate postoperative correction was 16.7 °. During the follow-up we observed small, insignificant loss of correction. There were no major complications.

CONCLUSION: In cases of thoracic spine fractures the surgical treatment with posterior stabilization and ligamentotaxis is offering significant stability and adequate long term results.


B. Anand A. Anand J. Sutcliffe M. Akmal

Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified.

METHODS: Analysis of 1500 trauma patients admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) over 6 years was undertaken. 265 patients of these patients had spinal cord injuries (SCI). Data was obtained from the HEMS trauma registry, patient records and interviews with patients.

RESULTS: 265 patients sustained SCI (mean age: 38 25% female). The most common mechanisms of injury were motor vehicle accidents (46%) and falls (29%) Attempted suicide was a common cause of SCI in our study group (mean age 32. M:F ratio 2:1) The most common associated injuries were limb and head trauma. C-spine injuries were the most common spinal injury and were associated with the highest mortality rates (37%). C-injuries presented with a bimodal age distribution, 84% had head trauma and 30% had significant chest injuries. In patients who sustained thoracic spinal injuries 71% had severe chest injuries and 34% had head injuries. The most common associated injury in lumbar spine trauma was injuries to the limbs or pelvis (68%). Injuries to the lumbar spine occurred more frequently in the 20–40 year old age groups.

Discussion: Mortality rate in our study was 26%. Mortality rates were highest in patients with cervical spine injuries (37%). The causes of mortality were from suicide attempts, falls and RTA. The mortality rates in these groups were 20%, 22% and 32% respectfully. Our review highlights significantly higher mortality in the over 60-age group. Our population had high numbers of suicide attempts. We highlight suicide attempts as a significant aetiology for SCI. All the deaths in the suicide group were as a result of jumping from high buildings. In patients over 60, c-spine injuries are by far the common level of SCI. Subdural haematomas occurred in almost 10% of patients with c- spine injuries. Any injury to the cervical spine should therefore prompt investigation for intracranial trauma. The GCS should be closely monitored and a low threshold for performing a CT scan is advisable. Thoracic spine injuries are strongly associated with severe chest injuries. Lumbar spine and sacral injuries are strongly associated with severe pelvic and lower limb injuries. Understanding the demographics and etiology is essential to allow effective planning for spinal services. Appreciating the injuries associated with SCI should ensure better care for patients, by recognizing problems earlier and using a multidisciplinary approach to optimize treatment and reduce morbidity and mortality.


K. Lunsjö A. Tadros A. Hauggaard R. Blomgren F. Abu-Zidan

Background: Whether pelvic fracture instability is correlated to mortality in blunt multi-trauma patients is debatable. This is the first prospective study on patients with pelvic fractures aiming at finding whether pelvic fracture type affects mortality.

Methods: 100 consecutive patients (77 males, mean age of 31 (3–73) years) were studied between September 2003 and October 2004. Data were collected regarding mechanism of injury, associated injuries, injury severity score (ISS), blood transfusions and mortality. The fractures were classified according to instability where type O is stable, type R rotationally unstable and type RV both rotationally and vertically unstable. Since a pure acetabular fracture is a single break in the pelvic ring, we classified it as type O. Computer tomography was used for fracture classification in 73 patients and plain X-rays in 27 patients.

Results: 77 fractures were caused by road traffic collisions. Type O fractures (n 63) had lower median ISS (13(4–48)) than type R (n 19) (18(9–75)) and type RV (n 18) (18(6–66)) (p=0.019, Kruskal Wallis). There was no significant in ISS between type R and RV fractures. A logistic regression model has shown that ISS was the only significant factor that predicts mortality.

Conclusion: ISS is the most importnt predictor in defining mortality in patients with pelvic fracture and not the type of pelvic instability.


B. Sokòlski A. Caban A. Zawadzki I. Francuz D. Szydłowski K. Wojnarski

The aim of the study: The authors are going to compare three treatment methods of ring pelvic fractures: operative, non-operative and with the use of an external fixator.

Material and methods: Between 1995 and 2005, 395 patients with pelvic ring fractures were treated at our department. 131 patients took part in this study. There were 84 (64,1%) males and 47 (35,9%) females. The common reason of the injury were car accidents 98 patients (74,8%), the second were falls 23 (17,5%), crush 7 (5,4%) and others 3 (2,3%). All patients were initially evaluated with use of three standard plain radiographs (anterioposterior radiograph, inlet and outlet projection according Penal & Tile) and computerized tomography scans and three-dimensional reconstructions of the scans. These studies were used to classify the fractures according to the classification of Young-Burgess. There were LC I 24, LC II 30, LC III 2, APC I 8, APC II 22, APC III 8, VS 10, CMI 27 fractures. 39 patients (29,8%) were treated no operatively, 48 patients (36,6%) were treated with use of the external fixator, 18 (13,7%) patients were treated by combination of open reduction and fixation with additional external fixation, and the rest of patients (26, 19,9%) were treated by open reduction and fixation.

Results: The clinical results were evaluated according to the Majeed scale. Long term clinical results were for individual type of fractures: LC I- 14 excellent, 6 good, 4 fair, 0 poor;

LC II- 11 excellent, 6 good, 8 fair, 5 poor; LC III- 0 excellent, 2 good, 0 fair, 0 poor;

APC I- 5 excellent, 2 good, 1 fair, 0 poor; APC II- 14 excellent, 5 good, 3 fair, 0 poor;

APC III- 3 excellent, 0 good, 4 fair, 1 poor; VS- 5 excellent, 2 good, 3 fair, 0 poor;

CMI- 9 excellent, 7 good, 7 satisfactory, 4 poor,

Conclusion: A comparison of the non-operative and operative methods showed that anatomical open reduction and fixation gave the shortest time of treatment and better clinical results. The anatomical reduction and fixation the posterior parts of the pelvic is the key to good long term clinical result of treatment.


A. Tötterman J.E. Madsen N.O. Skaga O. Röise

Objective: To assess the impact of EPP on physiological parameters in hemodynamically unstable patients with blunt pelvic trauma.

Methods: Of 661 patients treated for pelvic trauma, 18 consecutive patients in shock underwent EPP with the intent to control massive pelvic bleeding. These patients constituted the study population. Data collected from the medical records and the Ullev̊l Trauma Registry included: demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiological parameters and outcome. An association between continuous variables was calculated using the Spearman correlation coefficient. A comparison between means was calculated using the t-test.

Results: Mean patient age was 44 years (range 16–80). ISS 47 (9–66). 39 % had non-measurable blood pressure at admission. Survival rate within 30 days was 72% (13/18) and correlated inversely to the age of the patient (p=0.038). Only one non-survivor died of exsanguination from multiple bleeding foci. A significant increase in systolic blood pressure (p=0.002) and hemoglobin count (p=0.012) was observed immediately after EPP. Arterial injury was observed in 80% of patients who underwent angiography after EPP.

Conclusions: 30-day survival rate after EPP was 72 %. A significant increase in systolic blood pressure and hemoglobin count was observed immediately after EPP, indicating that EPP as part of a multi-interventional resuscitation protocol may be life-saving in patients with exsanguinating pelvic injury. However, the high rate of arterial injuries seen after EPP indicates that the procedure should be supplemented with angiography once the patient is stabilized for transfer to the angiography suite.


A.Y. Milukov

From the appearing of the first works of R. Judet, E. Letournel, M. Tile up to this day, the methods of pelvic surgery changed cardinally. These operations are technically complicated and accompanied by blood loss. That’s why the low-invasive surgical methods including endoscopic approach are perspective.

The endoscopic methods of reposition and osteosynthesis offer advantages which are expressed in increasing of injury visualization, reduction of surgical incisions and fast postoperative restoration. A surgeon using the method of osteosynthesis needs endoscopic skills and thorough knowledge of standard surgical approaches.

We have the experience of the treatment of 12 patients. We consider that the indications for these operations are not only a type of pelvic injury, but also anatomico-technical moment: an opportunity of creating of workspace.

We have 2 techniques:

endoscopic osteosynthesis with using of pelvioscope;

optical endoscopic osteosynthesis.

In any case, it is necessary to create the workspace from a small incision above the injury region by the method of tissue pneumotization. Fracture reposition is realized using a fracture table and reducing attachments. Osteosynthesis is immediately carried out with both standard and original steel constructions using the special tools that we developed and produced (ports, drill, screwdrivers etc.). The intraoperative blood loss was not more than 150 ml in all cases and in the postoperative period in drains–not more than 100 ml. The promotion of the patients was realized by the standard methods. There were no complications. The good functional result was in all cases.

We think that further development of such techniques will allow to activate pelvic surgery on the new qualitative level.


A.Y. Milukov A.A. Pronskih V.V. Agadzhanyan

Materials and methods: We treated 415 patients with pelvic fractures. According to the classification of M. Tile, the fractures were allocated in the following manner: A-40%, B-31%, C-29%. 46% of these patients were admitted with different rates of severity of the shock state. Osteosynthesis was carried out in 51% cases: 27%- the external fixation only, 10%–internal constructions only and 14%–combined synthesis. The treatment of pelvic fractures must correspond to the requirements of anti-shock measures and to the treatment of intra-articular lesions. The most informative method of the radial diagnosis is CT examination with three-dimensional pelvic reconstruction. We oriented toward the severity of pelvic lesion (A, B, C) for the determination of the terms, the volume and the order of surgical interventions. We carried out the total volume of surgical interventions in the consideration of the severity of pelvic lesions in the shock of I and II rates. We used the internal or combined osteosynthesis in the partial or total loss of pelvic stability (B and C types). Internal osteosynthesis of the pelvis is biomechanically substantiated, because it regains the circular form, consequently, the pelvic stability too, it decreases the hemorrhage from the fractures regions, removes the pain more rapidly. Hemorrahage compensation was realized by intraoperative autohemotransfusion. In case of another dominant lesion, we operated by means of two brigades. In the shock of III and IV rates we carried out the pelvic stabilization only by the external fixation apparatus for the improvement of common state of the patient. The closed reposition and the osteosynthesis by external fixation apparatus with anterior frame do not ensure completely in the fractures of type C, but it is the most rapid method to obtain and to maintain of reposition in the future.

Results: Functional results were appreciated at the moment of discharge and after 12 months according to Majeed S.A. scale (1989) and according to data of computerized optic topography to appreciate the postural balance. Good and excellent results (70–100 points for the workers and 55–80 points for non-workers) were in 49% patients at the moment of discharge and in 82% patients after 12 months. Lethality value was 5,3%. Invalidism value was 6,9%. The mean terms of hospital stay were 32 days and the mean terms of resuscitation department stay were 1,5 days.

Conclusion:

The treatment of the patients with severe injuries of pelvis in polytrauma must be realized in special clinics, with necessary equipment and specially prepared nursing.

Treatment tactics depends on the severity of common state and on the severity of pelvic injuries.


F.D. WADIA M.R. Smith M. Vrahas G. Velmahos H. Alam M. Demoya

Introduction: Patients with complex pelvic fractures with uncontrollable haemorrhage have a very mortality from pelvic haemorrhage and associated injuries. Management remains controversial and includes an number of techniques including pelvic stabilisation, angiography and direct surgical control of haemorrhage. Packing the pelvic cavity is a technique used rarely in this situation but is popular to control haemorrhage from other sources in similar situations. We have reviewed our experience of pelvic packing for uncontrollable haemorrhage to assess the effectiveness of this technique.

Materials & Methods: From a prospectively gathered database of 132 patients with significant pelvic fractures admitted between April 2002 and December 2005, 8 patients (5 males and 3 females) with an average age of 52.9 yrs were identified who underwent pelvic stabilisation and packing as an emergent life saving procedure for uncontrolled haemorrhage associated with pelvic fracture. Basic data including their presenting vital signs, pelvic fracture pattern and associated injuries were recorded. All were subject to pelvic stabilisation packing and their subsequent clinical course including their transfusion requirements and additional management was also assessed

Results: 6 out of these 8 patients died, 5 within the first 24 hrs after injury and one after 14 days from sepsis & MOF/MODS. The exact source of bleed could not be identified in any of these patients and was assumed to be venous and from large fractured bony surfaces. 4 patients had angiography and embolisation in addition and 2 of these survived.

Conclusion: The mortality of haemodynamically unstable pelvic fractures remains high and all modalities of treatment should be used to control bleeding. Pelvic packing may form an important part in the armamentarium of haemostatic measures; its role, however, needs to be better defined by larger multi-centre studies. Although difficult to conclude, the pelvic packing may have been responsible for reducing the mortality in this subgroup from a 100% to 75%.


W. Witzleb U. Hanisch J. Ziegler K. Guenther C. Rieker

Aim: The purpose of this study was to analyze the in-vivo wear rates of Birmingham Hip Resurfacing (BHR, Midland Medical Technologies Ltd., Birmingham, U.K.) explants and to contrast the results to the wear rates of conventional 28 mm metal-on-metal bearings (Metasul, Zimmer GmbH, Winterthur, Switzerland).

Methods: The wear rates, measured by a coordinate measuring machine (CMM5, SIP, Geneva, Switzerland), of 6 femoral components and two complete pairings of the BHR retrieved from 8 hips were contrasted to 43 28 mm heads from second generation metal-on-metal bearings (Metasul, Sulzer Orthopaedics Ltd., Winterthur, Switzerland).

Results: After 13 months (7 to 24) the BHR femoral heads showed a median volumetric wear rate of 2.9 mm3 (interquartile range: 0.8 to 7.1), slightly, but not significantly higher than the investigated 43 28mm Metasul heads (0.8 mm3/year, p = 0.067, 14 months [7 to 24] in-situ). One BHR case with a cup abduction angle of 70° showed a significant higher wear rate of 17.8 mm3. All BHR cases showed only small amounts of metallic particle histological and correspondingly, a mild histiocytic tissue response without foreign body granuloma formation.

Discussion: During the first two years after surgery the investigated BHR components showed wear rates substantially lower than conventional polyethylene bearings, comparable to Metasul bearings, implanted with very successful clinical results. But whether the wear rates will drop down after the so called running-in period comparable to conventional metal-on-metal bearings and provide young and active patients with a biologically acceptable particle volume over a long time period, still remains to be seen.


E. Kheir E. Tsiridis S. Mehta P. Giannoudis

Background: Acetabular or pelvic ring injuries are invariably associated with high-energy trauma that could lead to a significant degree of disability. The purpose of this study was to investigate whether patients who had surgical treatment of isolated acetabular or pelvic injuries were able to return to their previous sporting activities.

Patients and Methods: Between Jan 2001 to Jan 2002, 68 consecutive patients were treated in our institution with isolated pelvic (PF) or acetabular fractures (AF). Demographics, fracture classification, rehabilitation, outcome and complications were documented prospectively. Frequency, level of activity and sports participation before and after surgery, as well as EuroQol (EQ-5D) was also recorded.

Results: There were 58 male and 10 female patients, with a mean age of 42 years (16–80) and mean follow-up 30 months (24–36). 43 out of 53 (81%) patients in AF group and 13 out 15 patients in PF group (83%) returned to a variable level of sports activity. Significant reduction in the level of activity was observed in those who sustained both column (BC) (p< 0.04) and posterior wall (PW) (p< 0.0009) fractures in the AF group. Significant reduction in frequency of sports practice also found in PW subgroup (p< 0.0001). Patients < 25 and > 40 years of age in PF group and < 40 or > 65 in AF group had significant reduction in EQ-5D scores in comparison to normal UK population.

Conclusion: The majority of patients returned back to sports activities following surgery. The worst prognosis lies with BC and PW acetabular fractures. Middle age patients do better comparing to younger or elderly patients in both groups.


S. Glyn-Jones D.J. Beard D.W. Murray H.S. Gill

Introduction: Interest in hip resurfacing has recently been renewed by the introduction of metal-on-metal designs; it is being increasingly used for young patients, with over 30,000 implanted worldwide. The 5 year clinical results appear promising, but there are no long term data available. Radiostereometry (RSA) measures of implant migration have been able to predict implant failure; specifically large and continuous migration predicts aseptic loosening. We present the results of a five year RSA study examining the migration of the Birmingham Hip Resurfacing (BHR).

Methods: Twenty-four subjects with primary OA were implanted with the BHR device and with bone markers for RSA. RSA measurements were taken at 3, 6, 12, 24 and 60 months. The migration of the head and the tip of femoral component were measured in 3D.

Results: Preliminary analysis showed that the total 3D migration of the head and tip over five years was 0.32mm and 0.23mm respectively.

Discussion: A distal migration of more than 0.4mm over 2 years increases the likelihood of failure in conventional stems. The total migration of the BHR was approximately 0.3mm over a five year period, significantly less than cemented THR devices. The device is stable and this is promising for long-term survival.


E. Tsiridis M. George D. Hamilton-Baillie Z. Gamie N. Upadhyay P. Giannoudis

Without thromboprophalaxis, the recorded incidence of deep venous thrombosis (DVT) in pelvic fracture varies between 35% and 61%. The incidence of pulmonary embolism (PE) is reported to be 2–10% and death subsequently occurs in 0.5–4% of patients. With preventative measures the incidence of clinically significant DVT has been reported as low as 0.5%. The primary aim of this study is to look into the efficacy of Enoxaparin in preventing clinically significant DVT and PE in patients with pelvic and acetabular fracture. The secondary aim is to investigate the effect of prolonged pre-operative exposure to Enoxaparin on operative and post-operative bleeding. Sixty-four patients with pelvic and acetabular fractures were reviewed retrospectively between 2000–2005. Patients with coagulopathies were excluded. 40mg Enoxaparin was administered daily following haemodynamic evaluation and continued thereafter until discharge. Blood loss was measured using 3 indicators: volume of blood transfused, difference in pre and post operative Hb, and amount of blood collected in surgical drains. The incidence of clinically significant DVT was 2.9% (2 cases). There was no confirmed incidence of PE. 47% of patients were operated on within a week of admission (Group A), 40% within 1–2 weeks (Group B) and 13% in over 2 weeks (Group C). The group with the most prolonged pre-operative exposure to Enoxaparin: Group C, required the least transfused blood (A: 4.8units, B: 2.0units C: 1.3units), bled the least into drains (A:310ml, B:253ml and C:212ml) and had the smallest post-operative fall in Hb (A:2.2, B:2.0, C:1.9). The low incidence of clinically detectable DVT in the study confirms that Enoxaparin is an effective method for reducing the incidence of significant thrombotic events. Prolonged pre-operative administration of Enoxaparin does not pre-dispose patients to an increased risk of operative and post-operative bleeding.


R. Spencer M. Bishay P. Foguet D. Griffin S. Krikler R. Nelson M. Norton U. Prakash D. Pring

Introduction: Hip resurfacing has become re-established in recent years as a viable option in younger, active individuals. The results of a multi-centre evaluation of the Cormet resurfacing device are presented.

Materials and Methods: Data has been entered from 1997 onwards from 5 centres, patients being selected as suitable by 8 individual surgeons. Pre and intraoperative details recorded including indications, patient details, implant used, Harris Hip Score (HHS) and surgical approach.

Results: A total of 781 procedures in 676 patients have been recorded (54% posterior approach, 40% antero-lateral, 6% Ganz approach). The mean follow-up is 2.5 years (0.1–9.7 yrs) and the mean postoperative HHS is 85.9 (range 25–100). The mean age at surgery was 54.2 years. 60% of implantations were on male patients. The principal diagnosis was; OA 87%, RA 5%, AVN, post-traumatic OA and DDH 2% each, Perthes 1% and the remainder 1%. It is thought likely that many cases of OA had many of the above-named pathologies as a precursor. The mean maximum flexion postoperatively was 98.6 degrees. Uncemented heads (a recent innovation) were used in 7%. Kaplan-Meier survivorship is 93% at 9 years. In the OA subgroup 3.3% have been revised, approximately equal numbers for femoral head collapse, dislocation and cup loosening, but the vast majority due to femoral neck fracture, which in turn was generally associated with the posterior approach.

Conclusions: The results of this cohort (which includes the learning period of the contributing surgeons) indicate highly satisfactory outcomes in terms of HHS and implant longevity. Sub-classification of cases into those presenting abnormal anatomy and those with ‘ordinary’ OA indicates better survivorship still in the latter group. The surgical challenge varies more with hip resurfacing than with standard hip arthroplasty and this should be considered when results of surgery are reviewed. The revision options are generally much simpler than after standard THR.


D.G. Allan J.C. Milbrandt M.B. Naughton

Introduction: Metal-on-metal (MOM) hip resurfacing is becoming a more accepted and available option to consider when treating increasingly younger and more active patients. Advantages include preservation of bone stock and a larger femoral head which increases range of motion without risk of dislocation. We report here the effects of gender on revision rates in patients receiving the Cormet 2000 MOM Hip Resurfacing System.

Methods: 1058 hips were implanted in a multicenter, prospective study. All patients received a cementless, press-fit Cobalt Chrome acetabular shell with plasma sprayed titanium and HA coating and cemented Cobalt Chrome femoral head. Patients were evaluated pre-operatively through 2 years using standardized questionnaires, physical examinations, and radiographic evaluations.

Results: There were 754 males (71%) and 304 (29%) females implanted with the device. Thirty-eight (3.6%) revisions were required; 19 females (6.3%) and 19 (2.5%) males. Males had risk factors significant for revision including increased age in 10-year increments and smaller implant size. Trending but not significant (p=0.08) was lower preoperative HHS.

Discussion and Conclusion: There was a difference in revision rates between males and females, likely due to a difference in bone mass and stability. Based on these findings, the optimal patient seemed to be a larger, younger, more active male. This population has previously been identified to be at most risk after THA and utilization of a resurfacing device may be a good alternative. In addition, future studies designed to optimally select females for MOM hip resurfacing may reduce the revision rate in that population.


D.G. Allan B.K. Parsley B.W. Dyrstad R.A. Trammell J.C. Milbrandt

Introduction: Metal-on-metal (MOM) hip resurfacing releases ions locally and into the systemic circulation, raising concern for potential long term complications of elevated trace metals. This study was designed to monitor serum cobalt (Co) and chromium (Cr) levels in patients after MOM resurfacing hip arthroplasty with the Cormet 2000 prosthesis and to compare detected levels with those previously reported for hip resurfacing prostheses.

Methods: We prospectively followed patients receiving the Cormet 2000 device. Serum samples were collected at 6 months, 1, 2, and 3 years following surgery. Pre-operative controls were obtained from subjects without implants. Serum Co/Cr levels were determined using high-resolution inductively coupled plasma mass spectrometry. ANOVA was used to compare ion levels in each group. Statistical significance was set at p< 0.05.

Results: 40 subjects (25 male) were followed. Average age was 51 years (33.7–66.1). Median preoperative Co/ Cr levels were 0.27 microg/L (0.087–0.601) and 0.19 (0.014–0.576), respectively. Co/Cr levels were significantly increased at all time points when compared to preoperative levels (p< 0.001). Peak Co and Cr levels were observed at 1 year (3.26 and 4.42, respectively). At three years, the median Co and Cr levels had dropped to 2.08 and 3.55, respectively, but this was not statistically significant.

Conclusion: Elevated serum Co/Cr levels were observed at all time points following implantation. Continued elevations at three years were observed; however, the levels appear to be trending down suggestive of a “wear-in” period. Long term elevations of Co/Cr levels are concerning and will require additional studies to assess long term health risks of these levels in this population.


O. Hersche U. Munzinger

Introduction: Resurfacing arthroplasty is rapidly gaining popularity, the patients are in many cases very satisfied with the result. However some patients continue to complain about persistent groin pain, which is not clearly understood and attruibuted to different causes.

We identified femoro-acetabular impingement as a source of pain, which promptly disappeared after surgical off-set restoration.

Method: Since 2002 we implanted 390 hip resurfacing systems. At a one-year follow-up 16 patients complained about groin pain, especially when starting to walk.

In 6 patients the clinical examination and the rx could demonstrate femoro-acetabular impingement. In four cases this was due to anterior osteophytes of the femoral neck, in two cases it was due to retroversion of the femoral implant. These 6 patients were revised.

Results: During surgery femoro-acetabular impingement between these osteophytes on the femoral neck and the acetabular rim or the implant could be demonstrated. The head-neck off-set was restored with a high-speed burr. Interestingly rapid bleeding of the femoral neck was noted in all cases confirming the presence of vital bone. After surgery five of the six patients were painfree after 6–12 weeks. One patient did not experience a difference until now. There were no femoral neck fractures seen after this procedure.

Conclusion: Femoro-acetabular impingement seems to be a common source of persistent groin pain after hip resurfacing. Care has to be taken to restore the head-neck offset during implantation.


P.A. Vendittoli R. Boddu Siva Rama A.G. Roy M. Lavigne

Introduction: Heterotopic ossification (HO) occurs commonly after total hip arthroplasty (THA). Its severe form can result in impaired range of motion with reduced functional outcome. The rate and severity of HO after hip surface replacement arthroplasty (SRA) have never been well studied.

Methods: Two hundred and ten hips (194 patients) were randomized to receive uncemented metal-on-metal THA (103) or metal-on-metal SRA (107). Standard antero-posterior radiographs of the pelvis were assessed for HO by 2 reviewers at the latest follow-up (minimum of 6 months), using Brooker severity grading and Kjaersgaard-Andersen regional classification.

Results: Pre-operative and post-operative data were similar for both groups. The incidence of HO was 38.5% in the SRA group compared to 32.6% in the THA group (p=0.5). However, there was a significant difference in severity grades for the 2 groups (chi square, p=0.02). According to Brooker_s classification, nearly half of HO was of grade 2 in SRA and of grade 1 in THA. SRA was associated with significantly higher rates of severe HO (grades 3 and 4) than THA (12.5% vs. 2.2%; p=0.009). Inter-rater agreement for Brooker grading was excellent (Cohen_s kappa, 0.88; p< 0.01). HO in SRA involved both the central and lateral regions in 26% of cases, whereas only 3% of HO in THA showed such a pattern (p=0.025). Risk factors, such as male gender, osteoarthritis, bilateral predilection, and previous history of HO, were observed in both groups. Patients with HO had reduced internal hip rotation (16.4° vs. 22.2°; p=0.02) and a higher incidence of postoperative hip pain (52% vs. 30%; p=0.04), but comparable functional outcome scores.

Discussion: The incidence of HO after hip arthroplasty seems to be determined by patient-related factors. However, HO severity appears to be associated with local surgical factors and thereby SRA may result in more severe HO than THA. An extensive surgical approach, additional soft tissue release and the blunt damage occurring in gluteal muscles with SRA may signal the induction of more severe HO. Peri-operative deposition of bone debris derived from femoral head preparation may also play a role by transplanting osteoprogenitor cells. Surgeons must be aware of this risk of severe HO when offering SRA as an alternative treatment to younger patients. Routine prophylaxis with NSAIDs needs to be considered in these patients. A meticulous surgical technique to reduce muscle damage, pulsed lavage to clear bone debris, and debridement of necrotic tissue, may help to decrease the risk of severe HO in SRA.


K. Sisak R. Villar

Introduction: A common criticism of the modern hip resurfacing arthroplasty is its high early complication rate, in particular femoral neck fracture, displacement of the acetabular component and avascular necrosis. The overall complication rate varies widely in different published series. The sometimes alarmingly high rate of complications, as much as 22% for femoral neck fractures alone (Mont et al. 2005), has deterred many surgeons from using resurfacing implants. As a specialist elective hip practice we wished to specifically determine the early complication rate of hip resurfacing arthroplasty using the metal-on-metal Cormet 2000 implants. We defined an early complication as any resurfacing procedure which required inpatient readmission and/or further intervention within 12 months of the primary operation.

Material and methods: We assessed 253 consecutive hip resurfacing procedures (226 patients). All procedures were performed by the same surgical team using the same surgical approach (posterolateral). Operations were performed between 2001–2005. The mean operating time for was 51.8 minutes. The mean age of patients was 50 years (27 to76) at the time of surgery. 141 patients (62.4%) were male and 85 (37.6%) were female. The preoperative diagnosis was osteoarthritis for the majority of patients 246 (97.2%), the remainder having avascular necrosis (4 cases, 1.6%), chondrolysis (2 cases, 0.8%) or large osteochondral defects (1 case, 0.4%).

Results: In this series there were two infections (one superficial and one deep), one intraoperative femoral neck fracture (converted to THR), no episodes of avascular necrosis, one revision because of acetabular component loosening and one readmission because of a postoperative haematoma 10 days after surgery. All together two patients needed a further operation within one year of the primary operation (one two-stage revision because of deep infection, one revision to THR because of acetabular component shift). The haematoma was treated conservatively. There was one deep vein thrombosis (DVT), one case of iliopsoas tendonitis, one case of trochanteric bursitis and one patient wore an abduction brace for 6 weeks because of slight instability although there was no dislocation. The patient with DVT was readmitted as an inpatient. The overall complication rate (readmission as an inpatient) was 1.6% (4 patients) with the Cormet 2000 implant. Reoperation rate was 1.2% (3 patients) (including the intraoperative conversion to THR).

Discussion: The Cormet 2000 is a fully uncemented hydroxy-apatite coated hip resurfacing implant. In our series we found a low early reoperation and infection rate. All the reoperations were performed for cases were the primary operation was carried out in the first 6 months of this series. There were no complications associated with the uncemented femoral component of the Cormet 2000 implant.


L. Marega M. Morlock G. Baroncelli M. Hahn G. Delling

The idea of resurfacing the femoral head instead of removing it has been attractive for a long time.

Unfortunately the results have been invariably poor if compared with contemporary available conventional hip prosthesis. In the last decade metal on metal technology with very accurate manufacturing made hip resurfacing a viable option. The main complication of this operation is early failure due to femoral neck fracture. This event is still incompletely understood and probably multi-factorial. Accurate placement of the femoral component to avoid notching the femoral neck, cementing technique to avoid over-penetration of the cement, small implantation forces and careful soft tissue handling to minimize the damage to the bone vascularity are thought to be the main issues. The ideal candidates for this operation are young and active patients because they have good bone quality and will take advantage of the improved performances that hip resurfacing can offer.

Unfortunately young men are also the group of patients at higher risk for the formation of heterotopic ossifications.). To prevent this complication radiotherapy was administered in a single dose of 6 Gy with two opposite fields of 18 MV generally the first post operative day. When we started to perform hip resurfacing we did not consider changing our protocol. Between March 2004 and May 2005, 55 hip resurfacings were performed using the ASR implant (DePuy) by a single surgeon (LM). Most males under the age of 60 received radiotherapy. There were 4 femoral neck fractures in the 23 male patients who received radiotherapy (17.3 %) and 1 fracture in the 32 patients who did not receive radiotherapy (3.1 %, Chi-square test: p= 0.07). All the fractures occurred between the 90th and the 120th postoperative day. No fractures were reported in the 12 women included in this study. What arouse our attention was the unacceptably high number of femoral neck fractures. The learning curve alone could not explain what was happening. At first the radiotherapy was not considered at all as factor but errors in the surgical technique were looked for. The clue came from the observation that there were no women in the fracture group in spite of the fact that the surgical technique was the same and also in spite of the fact that women should be at higher risk due to poorer bone quality as shown in the literature. This led us to check the incidence of fractures in the radiotherapy and in the non radiotherapy group. At this stage things became quite clear. Subsequently the histology of the specimen was re-examined with regard to this factor. Bone necrosis of the femoral head in the patients who underwent radiotherapy was much more pronounced then in other failures which show different degrees of necrosis. In conclusion there are strong indications that radiotherapy of the femoral head should not be performed in combination with hip resurfacing.


C. Lautridou B. Lebel G. Burdin S. Leclercq C. Vielpeau

Background: Early or later dislocation is a frequent complication associated with total hip arthroplasty. The Bousquet’s acetabular component, an original concept of dual mobility socket has been used, for increase stability and mobility. The first mobility is between the femoral head and the polyethylene insert, and the second mobility between the polyethylene and the metal cup socket. The cup, covered with alumina was impacted without cement. The purpose of this study was to evaluate the long-term results of a retrospective series of primary arthroplasty with this cup and a cemented Charnley type femoral component.

Materiel and methods: This study included 437 hip replacements performed between 1984 and 1990, in 389 patients with osteoarthritis (62.5%), dysplasia (11.4%), necrosis (8%), rheumatoid arthritis (5%), post-traumatic and others (13.1%). The average age of the patients at the time of the index procedure was 61 years. The patients were followed at routine intervals for clinical and radiographic review. The clinical results were appreciated with Postel–Merle d’Aubigne score (PMA). Osteolysis was noted according to Gruen zones.

Results: The outcome is known for 345 hips (79%): 164 alive without revision at a mean of 16,5 years follow-up, 137 died without revision, and 44 failures. 92 (21%) were lost at follow up. Revision, for aseptic loosening of femoral or acetabular component, was performed in 30 hips(6.8%). 5 dislocation occurred and were revised: 2 early regarding to technical errors and 3 after 10 years or more of follow up. 7 hips were revised for deep infection, and 2 for unaccountable pain.

At more than 15 years follow-up, the mean PMA hip functional score was 17.1. 66% of the hips was A, 4% were B and 30% were C according to the Charnley’s score. Of the 164 hips in the patients who had survived at least 15 years, 28 had femoral osteolysis in zone 7, and 31 had femoral osteolysis in one (or more) of the other 13 zones. 6 hips had an impingement sign on the neck of the femoral component, without aseptic loosening.

According to Kaplan-Meier analysis, the fifteen year survival rate, was 84.36% with revision for any reason (infection, dislocation, osteolysis…) for end point. The young age of the patients at the time of the index surgery is correlated with loosening.

Conclusion: The long term results of the press fit, double mobility socket with cemented Charnley type femoral stem are good. The prevalence of revision for dislocation is very low in our series. But this concept do not avoid wear, osteolysis and aseptic loosening, specially in young active patients. We can recommand this type of prosthesis for patients over 70 years, and/or with high risk of dislocation.


A. DAMBREVILLE M. PHILIPPE M. AMEIL

The topic of this study was to research the survival rate of ATLAS hip prosthesis (acetabular cup) performed by one operating surgeon only and with a minimum of 10 years follow up.

Material and method: The ATLAS cup was hemispheric, in titanium alloy TA6V4, with a thin layer (2.5mm). It had a large central orifice as well as a radial slot allowing a certain elasticity enabling a pressfit impaction. Between January 1989 and December 1995, 297 ATLAS were implanted in the Clinique Saint André of Reims, 171 ATLAS II non hydroxyapatite coated and 126 ATLAS III hydroxyapatite coated. There were 176 women (59,2%) and 121 men (40,8%). The average age was 66 (20 to 94).

Each patient was contacted by phone to find out if the prosthesis was still in place or whether a new operation had been performed. For the deceased patients, the family or the usual doctor were contacted by phone to answer the question with a maximum of details.

The non-parametric survival rates were performed using the actuarial method according to Kaplan-Meier. The results were given with a reliability rate of 95%. The PRISM program was used.

RESULTS: On the 1st of January 2006, out of the 297 patients present at the start, 38 patients (12,8%) could not be contacted, 70 patients (23,5%) had died, 35 were reviewed and 120 answered the phone inquiry.

32 patients had undergone a revision: 23 due to the cup: there were 15 cases of wear of the polyethylene, 4 osteolysis, 3 cases of recurring dislocation and a secondary tilt of the cup, 5 cases of acetabular and femoral revision for 4 femoral loosening (change of cup by principal) and 4 cases of revision of the femoral components only.

The survival rate of the global series of 297 ATLAS (coated and non coated with hydroxyapatite) taking into consideration only the revisions due to the acetabular cup (wear of polyethylene, wrong position) was evaluated at 90% after 10 years and 85,5% after 15 years.

The results were better for the ATLAS III coated in hydroxyapatite: 92,3% after 10 years and 88,4% after 14 years, which confirms the advantages of this surface treatment. In this series, the revision rate for wear of the polyethylene was less important (3%)

With a maximum of 17 years follow up no mobilisation of the insert in the cup had been observed and no metallosis.

Conclusion: The survival rate of the global series of 297 ATLAS (coated and non coated with hydroxyapatite), taking into consideration only the revisions due to the cup (wear of the polyethylene, wrong position) was of 90% after 10 years and 85,5% after 15 years.

The rate was higher for the ATLAS III coated with hydroxyapatite: 92,3% after 10 years and 88,4 % after 14 years, which confirmed the advantages of this surface treatment.


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G. von Foerster

The short stem titanium prothesis preserves the femoral neck. No reamer and no rasp is used for the implantation. Two times compression of the bone with a compressor and with the prothesis it self continues the principle of bone retention.

Preserving the femoral neck and compression of the bone lead to an high anchorage and the best primary stability. This is mandatory for safe osseo integration.

Except metal on metal all combinations are suitable. Deltaceramic-Deltaceramic is the most modern possibility.

The high anchored short-stemp leaves enough virgin-bone for any standard prothesis in case of later revision. In 1999 implantation of CFP Prothesis was started in the Endoklinik-Hamburg. Until 2005 2500 prothesis were implanted. A five year follow up of the first hundert cases does not show system corellated failures. An overview of 2400 implants shows a revision rate of 1%. Total exchange procedure was necessary in 8 cases because of deep infection (0,33%). Only very few none fixed stems and cups had to be reviced.

Minimal invasive surgery is well suitable. In our clinic we prefer the posterior aproach.

With six sizes left and right nearly all tipe of bone shape is covered.

Extreme varus or valgus hips are not indicated as well as severe deformaties.

The CFP Prothesis is an good alternative to the CUP Prothesis especially for the young patients with femoral head necrosis which we see in about 10%.

A five year follow up is only really interessting if it has bad results, with goog results it gives us confidence to wait for the ten year results.


K. Zweymüller M. Steindl U. Schwarzinger M. Brenner

Intruduction: Cementless cup anchorage for total hip replacement is among the techniques widely accepted today. Attention focuses on hemispheric cups mimicking the anatomical shape of the bony acetabulum. However, the first-generation cementless hemispheric cups had a number of design flaws, which have meanwhile been attended to. We therefore never really turned away from threaded cups and began to implant a cone-shaped version of commercially pure titanium in January 1985. Introduced in January 1993, the redesigned version was unlike any other implant described in the literature in terms of its outer shape, the locking mechanism for the polyethylene liner, the cutting strength of its teeth and the thin wall of the cup shell. We wanted to know whether this implant was generally applicable for all primary THRs irrespective of the underlying anatomy, i.e. whether the exclusive consecutive use of this implant was justified.

Method: Between 1/1/1993 and 30/4/1994, 332 patients underwent primary surgery for osteoarthritis with threaded cups and titanium stems. These self-tapping double-cone cups made of pure titanium feature sharply cutting teeth for anchorage without screws. The PE liner locks into the titanium shell by a 4-level conical locking mechanism obviating the need for indentations for rotational adjustment of the liner. All cups and stems implanted during this period were uncemented. At 10 years plus, clinical and monitor-controlled radiologic follow-ups were conducted to evaluate changes in cup position, radiolucent lines, osseo-integration and revisions.

Results: 209 patients (63 males and 146 females; mean age at surgery: 62.6 years, range: 18.9 to 83.2 years) showed up for follow-up. 71 were dead, 36 without revisions were contacted by phone, 10 were lost to follow-up. The mean follow-up time was 10.2 years (range: 10.0 to 11.1 years). 2 patients had undergone cup revision, one for low-grade infection after 9.6 years and one for cup fracture after 5 years. With cup revision as the endpoint, the Kaplan-Meier survival rate was 99,2 % (CI: 96.6 to 99.8). Radiography showed altered cup inclination in two patients and radiolucent lines signalling absence of osseointegration in one patient. All other implants were stable clinically and radiologically. Gaps between the cup floor and the bone tended to be spontaneously obliterated by newly formed bone. Complete obliteration was observed even in cases with incomplete cranial implant coverage due to hip dysplasia.

Conclusion: The outcome of threaded double-cone cups at 10 years and more compares well with the best results achieved with other implants, particularly hemispheric cups. This documents that their unique design features have so far stood the test of time. It also shows that these cups have a place in all patients candidates for primary total hip arthroplasty.


P. Zenz H. Knechtel G. Titzer-hochmaier W. Schwägerl

Introduction: The Allofit cup is a hemispherical pressfit cup with a flattened pole for cementless implantation. Clinical use started in 1993 and we report our clinical and radiographic results of the first 100 cases. 75 hips of this group have been followed during the first 3 to 4 years using EBRA for migration analysis. These results also are presented.

Material: Out of 100 hips 81 have been followed mith a mean of 10,1 years (9,8–11). 6 patients died, 11 did not show for follow up an 1 patient had a revision for deep infection with two-stage exchange meanwhile.

The initial diagnosis was primary coxarthrosis in 63, rheumatoid arthritis in 10, congenital dislocation of the hip in 5 and necrosis of the femoral hed in 3.

In all cases the cementless Alloclassic stem was used, as bearing material metasul was implanted in 73 and ceramic-polyethylene in 8 cases.

Complications: For prolonged exsudation from the wound one soft tissue revision was necessary. 2 luxations were treated conservative. One early deep infection healed after synovectomy and irrigation, one late deep infection was cured by a two stage reimplantation.

Results: The EBRA migration analysis after 3,6 years (2,3–4,2) showed cranial migration of 0,35 mm (0,2–0,6 mm), medial migration of 0,25 mm (0,10–0,40 mm) and a calculated total migration as a combination of both of 0,45 mm (0,22–0,72). Therefore at this time there was no evidence of early loosening or migration indicating later loosening.

The preoperative Harris hip score was 53,13 pts (23–73), the postoperative score after 10 years 96,5 (78–100).

Radiographic evaluation after 10 years showed no lucencies in 78 of 81 jpints. 3 hips had a lucent line of 1mm in zone III. We detected no signs of osteolysis, loosening or migration.

No reoperations for any reason exept 2 septic cases have been performed yet.

Summary: After 10 years the clinical and radiological results of this implant are very satisfying. These results confirm the early observations of a migration analysis performed 6 to 8 years before.


P. Mertl J. Vernois E. Havet A. Gabrion

Introduction: Modular necks used during primary or revision total hip arthroplasties permit to restor the ideal femoral offset and arm of abductors muscles, to ajust leg length and to reduce impingment between the neck and the socket with good hip balancing.

Material and methods: Modular necks are titanium implants manufactured with a double Morse taper: one cylindrical for the junction with the head, and one flat for the junction with the stem. They are avalaible in 2 lengths (short and long) with 6 different geometries: straight (CCD:135°), antevreted of 8° or 15°, 8° and 15° of varus (CCD: 127° and 120°), and a combination of anteverted and varus neck.

362 revision and 920 primary THA were performed with a minimal of 5 years follow-up in the Orthopaedic Department of Amiens University Hospital with modular necks.

Results: 23 patients died and 11 were lost of follow-up. None rupture was deplored. Femoral offset was restored in 97% of these cases even in the revision surgery, end equalization of leg length was obtained in 98% of the patients. Residual Trendelemburg sign was noted in 37 patients, always after revision. The rate of dislocation was low with 2% because of the absence of impingment.

Discussion: Because proximal femoral geometry is different for each patient and femoral offset independent from the IM canal diameter, modular neck is one easy solution to restor independent parameters. In addition, the per-operative trials permit to choose the best implant to avoid any impingment, reducing the risk of dislocation and increasing the range of motion. It’s ideal now for the use of hard bearings. Laboratory analysis have demonstrated very good resistance in assembly-distraction, deep flexion and rupture tests. No corrosion was noted and retrieved weight loss was minimal.


L. Zagra M. Corbella R. Giacometti Ceroni

Background: Acetabular dysplasia is a congenital deformity that leads to hip osteoarthritis. The reason is the abnormal load transfer on the head which causes the cartilage damage and the progressive lateralization of the rotation centre of the head. The reorientation spherical periacetabular osteotomy, introduced by H. Wagner in 1976, has the aim to normalize the acetabular parameters increasing the coverage of the femoral head. The original indication of the author was the correction of the insufficient acetabulum in young adult patients, just after the closure of the triradiate cartilage, in which it is possible a functional adaptation of the osteotomized hip.

Materials and Results: This surgical procedure has been performed in the First Division of Galeazzi Orthopedic Institute of Milan Italy, since 1979 (180 cases up today).

The hips operated before 1985 were 14. The patients were 10, in 4 cases the operation was bilateral. There were 9 females and 1 male. The average age of the patients at the time of the operation was 19.3 years. All the patients had a DDH without X-ray signs of osteoarthritis and had a mild or absent pain. In 9 cases the isolated periacetabular osteotomy was performed and in 5 cases a femoral varus osteotomy was associated at the same time. The osteotomies were Wagner type I in 12 cases and Wagner type III in 2 cases.

We always used a Smith-Petersen approach. The periacetabular osteotomy was made by special spherical chisels of different diameter under X-rays control. The fixation of the osteotomy was made in 8 cases according to the original technique with a special double horn plate fixed by screws to the ileum and in 6 cases only with the help of Kirsches wires, as actually we prefer.

10 cases with a clinical and X-ray follow-up longer than 20 years have been controlled. 4 cases are lost to follow-up. Occurrence and type of pain, walking, limp, range of motion were evaluated. Wiberg CE angle, signs of osteoarthritis and centre of rotation of the head are observed on the X-rays.

Discussion: Evaluating the results, natural history of DDH must be considered. The revision of long term results (follow-up longer than 20 years) shows that it is possible to obtain good clinical outcome in the prevention of arthritis and on patients’ symptoms. The indication must be strictly followed: full indication is maintained in dysplasia of the adolescent, indication in the young adult only if some symptoms are present, very rare indication in patients with signs of arthritis and only in very mild cases. As a matter of fact in a group of patients with a shorter follow-up that is not part of this study, in which the indication was extended to Tonnis 1–2 arthritis we had much more bad results and complication. We observed generally worst results with obese patients.


M. Tannast S. Mistry S. Steppacher F. Langlotz G. Zheng K.A. Siebenrock

Introduction: It could be shown that an ample number of classical hip parameters for radiographic quantification of hip morphology on anteroposterior (AP) pelvic radiographs vary significantly with individual pelvic tilt and rotation. This could be proven not only for classical hip parameters (e.g. the lateral centre edge angle) but also for more recently described radiographic features such as acetabular retroversion. The resulting misdiagnosis and misinterpretation can potentially impair a correct therapy for the patient.

We developed fast and easy-to-use computer software to perform three-dimensional (3D) analysis of the individual hip joint morphology using two-dimensional (2D) AP pelvic radiographs. Landmarks extracted from the radiograph were combined with a cone beam x-ray projection model and a strong lateral pelvic radiograph to reconstruct 3D hip joints. Twenty-five parameters including quantification of femoral head coverage can be calculated for a neutral orientation. The aim of the study was to evaluate the validity of this method for tilt and rotation correction of the acetabular rim and associated radiographic parameters.

Methods: The validation comprised three steps:

External validation;

internal validation; and

intra-/interobserver analysis.

A series of x-rays of 30 cadaver pelves mounted on a flexible holding device were available for step 1 and 2. External validation comprised the comparison of radiographical parameters of the cadaver hips when determined with our software in comparison with CT-based measurements or actual radiographs in a neutral pelvic orientation as gold standard. Internal validation evaluated the consistency of the parameters when each single pelvis was calculated back from different random orientations to the same neutral pelvic position. The intra-/interobserver analysis investigated the reliability and reproducibility of all parameters with the help of 100 randomized, blinded AP pelvic radiographs of a consecutive patient series.

Results:

All but one parameter (acetabular index) showed a substantial to almost perfect correlation with the CT-measurements.

Internal validity was substantial to almost perfect for all parameters.

There was a substantial to almost perfect reliability and reproducibility of all parameters except the acetabular index.

Conclusion: The software could be shown to be an accurate, reliable and reproducible method for correction of AP pelvic radiographs. This computer-assisted method allows standardized evaluation of all relevant radiographic parameters for detection of anatomic morphologic differences. It will be used to study the influence of pelvic malorientation on the radiographic appearance of each individual parameter. In addition, it allows evaluating the clinical significance of standardizing pelvic parameters.


B.M. Devitt J.S. Butler J. Street D. McCormack J. O’Byrne

Aims: A retrospective review of all periacetabular osteotomies (PAO) performed at a general elective orthopaedic Hospital over a 7-year period. To assess the clinical, functional and radiographic outcome associated with PAO when introduced as a new procedure to a non-super-specialised regional centre.

Methods: A retrospective review of 85 PAOs performed on 79 patients at Cappagh Hospital between 1/4/1998 and 1/4/2005. The medical records and radiographic images of all patients were reviewed. Clinical follow-up evaluations were also performed.

Results: 85 PAOs were performed on 79 patients. Mean age at time of surgery was 22.9 years (range, 14–41 years) with an increased preponderance of females (F:M=10:1) and right sided hip involvement (R:L=1.1:1). The mean Merle D’Aubigne and Postel hip score increased from 12.4 (range 9–14) preoperatively to 16 (range 11–18) postoperatively (P< 0.0001). The average lateral center edge angle increased from 5° preoperatively to 26° postoperatively (P< 0.0001). The anterior center edge angle averaged 6.6° preoperatively and improved to 34.4° postoperatively (P < 0.0001). The acetabular index angle decreased from an average of 24.8° preoperatively to 8.4° postoperatively (P< 0.0001). At clinical follow-up, 77% of patients had no/mild pain, 30% of patients had a limp and 64% of patients were unlimited in physical activity.

Conclusions: The short term results in this group of patients treated with PAO show reliable radiographic correction of deformity and improved clinical scores. We suggest that PAO may safely be carried out at a non-super-specialized institution provided the surgeons have sufficient experience and patients are selected appropriately.


M. Tannast S. Mistry S. Steppacher G. Zheng F. Langlotz K.A. Siebenrock

Introduction: Recently, the correct interpretation of anteroposterior (AP) pelvic radiographs has regained increased attention, particularly in the field of joint preserving hip surgery. The diagnosis of acetabular retroversion associated with femoroacetabular impingement or hip dysplasia is made regardless the individual pelvic orientation due to the lack of a method of correction. Furthermore, it is known that a substantial number of the most common radiographical hip parameters can vary with the individual pelvic orientation. The goal of the study was to evaluate which parameter can be measured accurately on an AP radiograph.

Methods: Digital AP pelvic radiographs of 100 consecutive hips were used for evaluation. The blinded and randomized x-rays were examined by two independent observers with special software that has been validated previously. The software is able to correct the projected acetabular rim and the associated parameters for pelvic malpositioning. The following parameters were investigated: femoral head coverage in craniocaudal and anteroposterior direction (in total and for each single quadrant of the femoral head), the lateral center edge angle, the acetabular index, the ACM-angle, the extrusion index, the cross-over sign, the retroversion index, and the posterior wall sign. All parameters were first measured regardless to the individual tilt and rotation. These non-standardized values were then compared to the standardized values for a neutral pelvic orientation. This was defined with a pelvic inclination of 60 degrees which was detected with one single strong lateral pelvic radiograph.

Results: There were no differences in evaluation of the radiographs between the two observers concerning the significance of standardized and non-standardized values for the measured features. All but three parameters were significantly different when measured to the anatomically reference neutral orientation. The only parameters that did not change after standardization were the total femoral coverage, the acetabular index and the ACM.

Discussion: Except from the ACM and the acetabular index, basically all parameters change when standardized to a neutral orientation. Although from a statistical point of view, the total craniocaudal femoral coverage did not change, it is likely that this is due to an inverse effect of the anterior and posterior part of the acetabulum. We conclude that the most common hip parameters can not be reliably measured without standardization. It remains to be proven that the standardization of the parameters correlates with the clinical symptoms.


J.B. Czubak M. Tyrakowski S. Pietrzak

Improvement in coverage achieved by double or triple osteotomies is limited by the size of the acetabular fragment and the ligaments connected with the sacrum. Correction is achieved with the notable asymmetry of the pelvis. In periacetabular Ganz osteotomy (PAO) the acetabular fragment has no connection with the sacrum, which creates enormous possibilities for correction, leaving the pelvic ring untouched.

The aim of the study is to present our experience and early results of using PAO in the treatment of hip dysplasia in adolescents and young adults who were previously treated operatively in childhood, and to find the technical and clinical impact of previous operations on our Results: In the years 1998–2005 262 periacetaubular osteotomies were performed in our hospital. All the patients were operated by one surgeon (JC). From this group 41 patients (43 hips) had previously been operated in childhood for the treatment of hip dysplasia. The previous treatment consisted of: open reduction in 10 hips, DVO in 14 hips, pelvic osteotomy (Salter, Dega, Chiari) in 8 hips, combined: open reduction+DVO+pelvic osteotomy in 10 hips, greater trochanter transfer in 3 hips, bone lengthening in 4 hips, acetabular cyst removal in 1 hip. The age at the primary operation ranged from 1–20.. The follow-up period ranged from 1–7,5 ys av. 2 ys.

In 31 hips the Smith-Petersen, and in 12 hips ilioinguinal approach were performed.

Methods. In clinical pre-op, and post-op examination the following factors were considered: pain, limping, Trendelenburg sign, range of motion, length discrepancy. Radiographic pre-op and post-op examination consisted of: AP view of the pelvis, false profile and AP view with the leg in abduction. Classic and anterior CE angle were measured. During the last examination Harris Hip Score was used.

Results. Flexion slightly decreased from pre-op. 90–140° (av. 118°) to 80–130° (av. 104°) post-op. abduction remained unchanged 15–60° (av. 40°) and 15–60° (av. 40°) respectively, adduction slightly increased 15–40° (av. 31) and 20–50° (av. 33°). The range of rotation did not change after the operation. The sign of Trendelenburg was found in 27 hips before operation and in 8 hips post-op. Pain (acetabular rim syndrome) was found in 40 hips before operation and in 4 hips after the surgery. Either classic or anterior CE angle increased after the surgery in all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. But in cases previously operated and in males we strongly recommend Smith-Petersen approach extended into the frontal part of the hip for a better exposure in the scarred and hardened tissues.

We find the technique of PAO as a safe, and effective tool for treating hip joint pathology increasing treatment possibilities for hip joint preservation.


I. Mechlenburg S. Kold L. Romer K. Soballe

Background and purpose. At the Ganz periacetabular osteotomy the osteotomized acetabular fragment is reoriented in an adducted, extended and rotated position. Two screws fixate the acetabular fragment and the patients are allowed 30 kg weight bearing immediately after surgery. We were interested in examining the stability of the reoriented acetabulum after the Ganz osteotomy and accordingly the migration of the acetabular fragment was assessed by radiostereometry.

Methods. Thirty two dysplastic patients (thirty two hips), twenty seven females and five males were included in the study. Median age was 39 (20–57) years. Radio-stereometric examinations were done at one week, four weeks, 8 weeks and six months. Data are presented as mean with 95% CI.

Results. Six months postoperatively, the acetabular fragment had migrated 0.7mm (0.4–1.0mm) medially, and 0.7mm (0.5–0.9 mm) cranially. Mean rotation in valgus direction was 0.5° (−0.1–1.0°). In other directions, migration was below 0.4. There was no statistical difference between migration 8 weeks and 24 weeks postoperative in translation or rotation.

Interpretation. This is the first paper dealing with radio-stereometric analysis in Ganz osteotomy. Due to the very limited migration, we find our postoperative partial weight-bearing regime safe.


R. Biedermann L. Donnan A. Gabriel R. Wachter M. Krismer H. Behensky

Periacetabular osteotomy (PAO) is a well established method to treat hip dysplasia in the adult. There are, however, a number of complications associated with this procedure as well as a time related deterioration in the grade of osteoarthritis that can influence the long term result. It is essential that patients are fully informed as to the effectiveness of PAO, the likelihood of complications and their influence on the subjective outcome prior to giving consent for surgery. Generic outcome measures offer the opportunity to determine treatment efficacy and the influence on the outcome by complications.

60 PAOs on 50 patients were investigated retrospectively after a mean follow up of 7.4 years. The patients’ self reported assessment of health and function was evaluated by the SF-36 and the WOMAC questionnaires at last follow-up. 40 healthy persons served as a control group.

The centre-edge angle improved from a mean of 8.7° to 31.5°. The weight bearing surface improved from a mean lateral opening of 8.7° to 4.2°. The degree of osteoarthritis improved in one case, remained unchanged in 20 and deteriorated in 17. There was a tendency of higher CE-angles towards a higher rate of deterioration, indicating that overcorrection may increase osteo-arthritic degeneration. 13 of the 60 interventions had no complications. Minor complications occurred in 25 (41%) interventions and in 22 (37%) at least one major complication occurred. SF-36 summary measure was 76.4 for PAO patients and 90.3 for the control group. Mean WOMAC score was 25.1. The severity of ectopic bone formation, incidence of postoperative peroneal nerve dysfunction and delayed wound closure did not influence the subjective result. Patients with major complications had a similar subjective outcome as patients with minor or no complications, but persistent dysesthesia due to lateral femoral cutaneous nerve dysfunction led to a worse subjective function as assessed with the WOMAC score.


P. Bernstein F. Thielemann K. Günther

For the prevention of premature osteoarthritis of the hip, the periacetabular osteotomy (PAO) of Ganz has become a common procedure. Though being a powerful method for obtaining large correction angles its drawback is the need for a broad exposure, resulting in more or less disfiguring scars. We modified the surgical approach to PAO by using two small skin incisions and reduced the extent of deep exposure by leaving the rectus femoris tendon in place and avoiding larger peri-articular deep soft tissue release.

The aim of this study is, to compare the early clinical and radiographic results of this less invasive approach with the conventional Smith-Peterson approach.

Patients and Methods: Between 01/04 and 05/05 22 consecutive PAO were performed through a conventional Smith-Peterson approach (group A). After introducing the less invasive technique 22 PAO were performed between 09/04 and 11/05 (group B). All patients were operated by the same experienced surgeon. Patients age ranged from 14 years to 46 years (mean age 26 years). Clinical (i.e. Harris-Hip-Score, Vancouver Scar Scale) and radiographic examinations (i.e. CE-angle) were performed preoperatively and postoperatively at an average follow-up of 16 months (range 6–29 months).

Results: Mean CE-angle correction in group A was 17° and in group B 23°. Functional improvement, as rated by the preoperative to postoperative Harris-Hip-Score-difference, was 15 points in group A and 22 points in group B. After the less-invasive approach, scars were considerable smaller and better-rated by the Vancouver Scar Scale (3 versus 4 after conventional surgery). The number of transient lateral cutaneous femoral nerve lesions was the same in both groups. The average time of surgery was 135 min. in group A and 153 min. in group B.

Conclusion: A smaller skin incision and limited soft tissue exposure improves cosmetic results after PAO without influencing the extent of acetabular correction negatively. The early and mid-term postoperative functional results, however, could not be significantly improved by the less invasive approach.


A. Troelsen B. Elmengaard K. Søballe

Introduction: Minimal invasive surgery (MIS) seems to be part of future orthopaedic solutions. Currently, most approaches for the Bernese periacetabular osteotomy (PAO) are characterized by relatively extensive incisions, dissection and detachment of muscles. We have developed a new MIS approach for the Bernese PAO. The purposes were to reduce patient morbidity and to improve the cosmetic result following surgery without negatively influencing the achieved reorientation of the acetabular articular surface. In this study we present the surgical technique, results and compare them to the ilioinguinal (II) approach.

Methods: The new MIS technique is a trans-sartorial approach using a three inch skin incision. Previously the II approach was used. From 1999–2006 a total of 215 patients with acetabular dysplasia were operated by the same surgeon in two successive time periods with the II (97) and the trans-sartorial (118) approaches. No supplemental surgery was performed. The two approaches are retrospectively compared regarding perioperative measures, transfusion requirements, complications and the achieved reorientation of the acetabular articular surface. Data are compared by Kruskal-Wallis Test and are presented as median and interquartile range.

Results: The trans-sartorial approach significantly reduced days of admission (8 days (7–9) vs. 10 days (8–13), p< 0.0001), duration of surgery (70 min (60–75) vs. 100 min (82.5–120), p< 0.0001), perioperative blood loss (200ml (150–350) vs. 450ml (325–700), p< 0.0001) and the percentage of patients receiving blood transfusion (18.6 % vs. 3.4%). Of severe neurovascular, infectious and technical complications none occurred in the trans-sartorial group and 3 cases of arterial thrombosis were seen in the II group. The achieved reorientation measured by the CE-angle postoperatively had median values of 31° (25–36) in the II group and 33° (29–36) in the trans-sartorial group, p=0.016. The postoperative AI-angles were 10° (2–14) and 3° (0–7) in the II and trans-sartorial groups respectively, p< 0.0001.

Discussion: Our shift to the trans-sartorial approach was rewarding as the duration of surgery, perioperative blood loss and transfusion requirements were reduced. The new MIS technique is safe and improves the cosmetic result without negative influence on the achieved reorientation of the acetabular articular surface.


R.M. Gillies M. Hogg S.M. Donohoo W. Schmidt J. Racanelli

Introduction: Bone resorption at the bone-implant interface is still a problem, leading to pain, poor function and the possibility of bone fracture. This loss of supporting bone tissue is due to resorption and impaired bone formation. Loosening of an implant is often not clinically or radiographically apparent for 8–10 years. It would be beneficial if these potential failures could be identified early so that revision surgery can be avoided. The aim of this study was to investigate the influence of implant material property changes and its influence on the trabecular loading patterns of the underlying supporting bone structure.

Methods: An intact and reconstructed 3D finite element (FE) model of a human femur was developed. The model was generated using PATRAN and CT scans. This was used to determine the stress, strain and interface sliding of a knee implant at heel-strike and stair climbing phases of gait. FE analysis of the model was performed using ABAQUS software. The materials properties of the bone were extracted from the CT data and applied using FORTRAN subroutines. Implant-bone interfaces were simulated using cementless fixation concepts. Sliding contact conditions were applied to simulate the immediate post-operative period.

Results: Three material property cases were analysed, with respect to the intact bone, at 100%, 25% and 2.5% of cobalt chrome’s (CoCr) Youngs modulus. At heel-strike, for the 100% case, higher stress was found at anterior flange while lower stress dominated around the pegs and intercondylar notch. For the 25% case, lower stresses were found in the intercondylar notch and higher stresses above the pegs. For the 2.5% case, stresses resembled that of intact bone, higher stresses were found above the pegs and lower stress in the intercondylar notch. In stair-climbing, for the 100% case, lower stresses were found around the pegs and in the intercondylar notch. For the 25% case, lower stresses were found in the intercondylar notch and higher stresses in areas above the pegs. For the 2.5% case, higher stresses were found at the distal condyles and lower stresses were observed in the intercondylar notch.

Discussion: The analysis presented changes in the trabecular loading and subsequently resulted in stress shielding. The general trend showed that the majority of stress shielding is occurring at the posterior flange and medial condyle while increased trabecular loading occurred at the anterior flange and lateral condyle regions. As the stiffness of the implant decreases from 100% to 25%, the differences in trabecular loading are extremely small. Both these implant material properties are very stiff in comparison to the underlying trabecular bone. However, as CoCr stiffness is decreased to 2.5% this yields a more homogenous stress distribution at the contact interfaces.


H. Gray A. Zavatsky L. Cristofolini D. Murray H.S. Gill

Finite element (FE) analysis is widely used to calculate stresses and strains within human bone in order to improve implant designs. Although validated FE models of the human femur have been created (Lengsfeld et al., 1998), no equivalent yet exists for the tibia. The aim of this study was to create such an FE model, both with and without the tibial component of a knee replacement, and to validate it against experimental Results: A set of reference axes was marked on a cleaned, fresh frozen cadaveric human tibia. Seventeen triaxial stacked strain rosettes were attached along the bone, which was then subjected to nine axial loading conditions, two four-point bending loading conditions, and a torsional loading condition using a materials testing machine (MTS 858). Deflections and strain readings were recorded. Axial loading was repeated after implantation of a knee replacement (medial tibial component, Biomet Oxford Unicompartmental Phase 3). The intact tibia was CT scanned (GE HiSpeed CT/i) and the images used to create a 3D FE mesh. The CT data was also used to map 600 transversely isotropic material properties (Rho, 1996) to individual elements. All experiments were simulated on the FE model. Measured principal strains and displacements were compared to their corresponding FE values using regression analysis.

Experimental results were repeatable (mean coefficients of variation for intact and implanted tibia, 5.3% and 3.9%). They correlated well with those of the FE analysis (R squared = 0.98, 0.97, 0.97, and 0.99 for axial (intact), axial (implanted), bending, torsional loading). For each of the load cases the intersects of the regression lines were small in comparison to the maximum measured strains (< 1.5%). While the model was more rigid than the bone under torsional loading (slope =0.92), the opposite was true for axial (slope = 1.14 (intact) 1.24 (implanted)) and bending (slope = 1.06) loads. This is probably due to a discrepancy in the material properties of the model.


S. Ostermeier C. Stukenborg-Colsman C. Hurschler H. Windhagen

INTRODUCTION The ability to evaluate the alignment of total knee arthroplasty using postoperative radiographs might be confounded by limb rotation. The aim of the presented study was therefore to measure the effect of limb rotation on postoperative radiographic assessment and to introduce a mathematical correction to calculate the true axial alignment in cases of a confounded radiograph.

METHODS A synthetic lower left extremity (Sawbones®, Inc,Vashon Island, WA) was used to create a total knee arthroplasty of the Interax I.S.A.® knee prosthesis system (Stryker, Limerick, Ireland). Laser guided measurement of the tibia showed a femoral valgus angle of 6.5° postoperatively. The model was fixed in an upright stand which positioned the limb in varying degrees of rotation. Four series of 10 antero-posterior (AP) radiographs were taken with the knee in full extension, with femoral limb rotation ranging from 20° external rotation to 20° internal rotation in respect to the x-ray beam, in 5° increments. After digitizing each radiograph, four observer independently measured the femoral valgus angle for each series of the long leg radiographs using a digital measurement software (MEDICAD®, Hectec, Altfraunhofen, Germany). Each observer was instructed to determine the femoral valgus angle following the software’s guidelines. In addition each observer measured the geometrical distances of the femoral component figured on the radiographic film. Using a student t-test, the effect of femoral limb rotation on the measured femoral valgus angle and a correlation between femoral rotation and femoral valgus angle was established. Then for each limb rotation the distances ratio was determined to calculate the limb rotation.

RESULTS Without an application of femoral rotation the femoral valgus angle was measured radiographically to be 6.5° (SD 0.4°). With external femoral rotation the measured femoral valgus angle linearly decreased to a minimum of 4.5° (SD 0.2°) at 20° femoral rotation. The linear regression (R2=0.94) calculated a 0.09° change of radiographically measured femoral valgus angle per femoral rotation angle. With the femoral rotation the radiographically measured ratio decreased linearly (R2=0.98) with further internal rotation.

DISCUSSION The results of the presented study suggest a significant influence of femoral rotation during radiographic evaluation of limb alignment after total knee arthroplasty. With further external femoral rotation the radiographically apparent femoral valgus angle decreases. As the apparent femoral valgus angle changes linearly, a calculation of the distances of the particular femoral component could be used to determine the real femoral valgus angle in cases of femoral limb rotation.


D. Nicoll D. Rowley

The aim of this study is to identify the incidence of mal-rotation of TKR components in a group of patients with unexplained knee pain identified from the University of Dundee joint replacement database and compare that group with a group of painless TKRs

38 of 45 NexGen LPS Total Knee Replacements identified with unexplained pain at a minimum of 1 year following surgery underwent CT scanning to determine rotational alignment. All patients had a Knee Society Pain score of 20 points or less and a mean Visual Analogue Pain Score of greater than 4.0. This group was compared with a control group of 26 TKRs all of which had never reported pain from 1 year post surgery.

In the painful group mean femoral component rotation was 2.2° of internal rotation (range 8.8°IR to 3.9°ER, sd 3.6, SEm 0.59) compared to 0.9°IR (range 6.9°IR to 6.8°ER, sd 3.39, SEm 0.67) in the painless group (p= 0.15). In the painful group 21.6% of femoral components were more than 6° internally rotated compared with 7.7% in the painless group however this was not statistically significant (p=0.18). No femoral components in either group were in excessive (over 8 degrees) ER.

Tibial component rotation was much more variable than femoral component rotation in both groups particularly in the painful group. Mean tibial component rotation was 4.1°IR (range 37.9°IR to 31.1°ER, sd 14.6, SEm 2.4) in the painful group compared to 2.2°ER (range 8.5°IR to 18.2°ER, sd 6.95, SEm 1.36) in the painless group (p=0.024). 15 tibial components (39.5%) were greater than 10° internally rotated in the painful group whilst no tibial components were more than 10° internally rotated in the pain free group (p< 0.001). In the painful group 7 tibial components (18.4%) were more than 10° externally rotated whilst 4 (15.4%) were in more than 10° ER in the painless group (p=1.00). Overall 22 tibial components (57.9%) were in more than 10° of malrotation in the painful group compared with 4 (15.4%) in the pain free group (p=0.05).

Mean rotational mismatch between femoral and tibial components was 1.9° tibial IR (range 39.7° tibial IR to 35.1° tibial ER, sd 16.1, SEm 2.7) in the painful group whilst in the painless group mean rotational mismatch was 3.1 degrees tibial ER (range 10.3° tibial IR to 22.1° tibial ER, sd 8.4, SEm 1.65). This difference was not significant (p=0.12). 16 TKRs (55.3%) had rotational mismatch of more than 10° in the painful group compared to 7 (26.9%) in the control group (p=0.02).

We conclude that rotational malalignment is frequent in painful total knee replacements and may be a major cause of pain after TKR. In particular tibial internal rotation is the most frequent alignment error in the painful TKR and appears to play a major role in the aetiology of pain after TKR.


R. Shariff M. Manickham M. McNicholas

Background: Osteoarthritic patients needing a TKA give pain as the major reason for being unable to exercise to lose weight. Weight gain in turn worsens the process of osteoarthritis, this feeds into the vicious cycle. Following a TKA, patients should ideally be able to exercise more and hence lose weight. We assessed this hypothesis in our prospective study by calculating BMI. BMI has been proven in previous studies to be a good reflection of body fat.

Materials and Methods: We prospectively followed up 94 patients in the knee arthroplasty clinic. Height, pre operative weight and post operative weight at 12 months were measured. All the peri-operative factors in all the patients were constant. We then calculated the pre and post operative BMI.

Results: Most of our patients at the 12 month follow up showed to have an increase in BMI. This difference was however not found to be statistically significant.

Conclusion: The result obtained in our study was contrary to previous studies which have shown significant change. We conclude that pre-operative pain alone is not a limiting factor in patient BMI changes peri-operatively.


T.G. Ryan B. Ohlson R. Adams

Introduction: Postoperative rehabilitation protocols following total knee replacement vary considerably among surgeons. Previous reports have shown the usefulness of music exercise videos for cardiovascular rehabilitation and general fitness. The authors created a music exercise video for use in the postoperative period following total knee replacement.

Methods: A prospective study was done whereby 45 patients undergoing 51 primary total knee replacements were randomized to a control (25) or video (26) group. All procedures were done by the senior author. All patients were evaluated at postoperative week 1,2,4,6, and 8 by a blinded examiner who generated Knee Society scores. Patients also completed a satisfaction questionnaire and the 8 week cost of rehabilitation was documented.

Results: Significant improvements were noted in patient’s assessment of understanding, confidence, and overall satisfaction when using the video (p< 0.05). Average return to usual activities was 34 days in the control and 14 days in the video group (p< 0.0001). Knee Society knee and function scores were improved for the video group and were statistically significant for the 6 and 8 week scores (p< 0.05). The combined Knee Society score at 6 weeks was 141 for the control group and 167 for the video group (p< 0.05). The therapy costs averaged US$2,602.00 in the control and US$287.00 in the video (p< 0.0001). No complications were reported while using the video.

Discussion: Use of the music video as a supplement to the rehabilitation program in the early postoperative period following total knee replacement is recommended due to improved patient satisfaction, earlier return to activities, and improved 6 and 8 week knee scores. These are achieved at a substantial cost savings which benefits both patients and society.


S. Tarabichi A. Tarabichi

Introduction: Morbidity and mortality are major concerns after simultaneous bilateral TKA. This paper reviews the results of patients who had simultaneous bilateral TKA (558 patients) and compares it to the results of single TKA (485 patients) carried out by the same surgeon in the same institution using same intra operative and post operative protocols.

Material and methods: 558 patients underwent simultaneous bilateral TKA while 485 underwent single TKA carried out by the same surgeon. The pre-op medical evaluation was carried out by a special multidisciplinary medical team. The decision to proceed with simultaneous TKA was made based on the clinical findings pre operatively. There were no additional special cares for the simultaneous group (central or arterial line) during surgery. Post op protocols were the same for both groups

Results: Blood transfusion was higher in the simultaneous knee surgeries (71%) as compared to (34 %) in a single knee group. We had 8 unscheduled ICU admission in the simultaneous group compared to 2 in the individual. Surprisingly DVT was less common in the simultaneous group. We had one death in the simultaneous group. The average knee score and average range of motion were the same in both groups.

Discussion and conclusion: Simultaneous bilateral TKA is safe. It is more economical and convenient, especially for patients who travel for the surgery. A special multidisciplinary task force is recommended to make the simultaneous knee surgery safe.


D.M. Rose W. Rahman H. Chan A.J. Trompeter S.H. Palmer

Purpose of study: To determine whether positioning the operated limb in flexion on a CPM machine reduces blood loss following uncemented total knee replacement. We also sought to determine whether limb arterial pressure, represented by ankle-brachial pressure index (ABPI), is affected by position of the limb.

Methods: We compared two groups of age and sex matched patients undergoing uncemented total knee replacement. The control group were treated in the postoperative period with the leg positioned flat in extension (48 patients). The CPM group were placed on a CPM machine at 90° of knee flexion for twelve hours immediately post-operatively (46 patients). Haemoglobin and haematocrit levels, blood transfusion requirement, length of hospital stay, range of motion and complications were compared.

In addition, we measured ankle and brachial pressures in a separate group of 39 patients with the limb in three different positions: flat with the knee in extension (ABPI 1), raised with the knee in extension (ABPI 2), and finally with the knee flexed to 90° (ABPI 3).

Results: The CPM group demonstrated a smaller drop in haemoglobin level (2.5 vs 3.1, p=0.013) and a reduced blood transfusion requirement (3 patients vs 14 patients, p < 0.05) in the post-operative period when compared to the control group. There was no significant difference in haematocrit drop, discharge range of motion, complications or length of hospital stay between the two groups.

ABPI measurements were calculated in the standard fashion, the mean ABPI in each limb position being 1.17 (ABPI 1), 0.87 (ABPI 2) and 0.83 (ABPI 3) respectively.

Conclusions: Short-term use of a CPM machine in the post-operative period reduces blood loss and appears safe following uncemented total knee replacement. We found limb arterial pressure to be reduced to the greatest extent with the limb in a position of 90° flexion at the knee, which may account for the reduction in blood loss seen in the CPM group.


S. Bridgman G. Walley D. Clement D. Griffiths G. Mackenzie N. Maffulli

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay.

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.


Y. ISHII H. Noguchi Y. Matsuda

In this prospectively randomized study, we compared the changes in the range of motion (ROM) in posterior cruciate ligament-retaining (PCLR) (n=50) and -sacrificing (PCLS) (n=50) total knee arthroplasties during the perioperative period. The median ROM in PCLR prostheses was 122.5° preoperatively, 120.0° intraoperatively, and 100.0° at discharge, and 115.0°, 120.0°, and 95.0°, respectively, in PCLS. The designs did not differ statistically in each period (p> 0.05). Both designs showed significant correlations between the preoperative and intraoperative ROM, and between the preoperative and discharge ROM. Only the PCLS showed a significant correlation between the intraoperative and discharge ROM. Since the PCL tenses with flexion, the degree of preoperative degeneration, intraoperative recession, and postoperative tension of the PCL may have played a major role in the results. The PCLS design has an advantage in rehabilitation planning because of the predictable changes in the ROM during the perioperative period, although the acquired average ROM at discharge did not differ statistically.


M. Hildebrand N. Gutteck D. Wohlrab W. Hein

Introduction: The aim of the study is to evaluate different operation techniques after total knee arthroplasty (TKA). Functional outcome as well as objective results in activity (activity monitor) after minimal invasive TKA was compared with functional outcomes after a standard midvastus approach.

Purpose: The primary purpose of the present study was to determine the difference between two approaches in surgery of total knee arthroplasty. Is there a difference in outcome between a standard and a minimal invasive surgery because of less muscle damage and soft tissue stress?

Material and methods: The study includes two groups with 20 patients each (MIS group versus standard group) The patients are investigated at six different times: 1 day preoperatively as well as on 1., 3., 7. day postoperatively as well as 6 and 12 weeks after surgery. We used the AMP 331 (Dynastream Innovations, Inc., Cochrane, AB) a new ankle-mounted activity monitor. Step count, distance travelled, walking speed, step length, cadence and energy expenditure were measured. 1, 6 and 12 weeks postoperatively patients got the device for 5 days.

Results: The average age in the standard group was 66.4 years and for the MIS group, 66,8. The MIS group has been shown a sig. higher KSS Score versus standard group in all follow up visits. Standard group has shown a slight higher blood loss and higher values of muscle specific lab parameter (Creatininkinase and Myoglobin). The Activity Score was better in the MIS group in comparison to the standard group. These results also mirrored the data from the activity monitor (AMP 331, Dynastream Innovations, Inc., Cochrane, AB). The average walking speed at 1, 6 and 12 weeks was sig. (p< 0.05) better than in the standard group. Same trend we have seen in cadence, step length and steps per day.

Conclusion: This study shows that patient who underwent minimal invasive surgery in knee arthroplasty have an better early outcome after surgery in activity and function because of saving muscle structure and minimise soft tissue stress.


J.R. Murray M. Sherlock N. Hogan C. Servant S. Palmer E. Parish M.J. Cross

Background: The purpose of this study was to assess the anterior femoral cortical line (AFCL) as an additional anatomical landmark for determining intraoperative femoral component rotation in total knee arthroplasty. The AFCL was compared with the Epicondylar axis, the anteroposterior (AP) axis (Whiteside’s line), and the posterior condylar axis. Dry bone, cadaver, MRI and intra-operative measurements were compared.

Methods: Fifty dry bone femora, and 16 wet cadaveric specimens were assessed to identify the AFCL and this was compared against the 3 reference axes discussed above. Photographs were taken of the specimens with K-wires/marker pins secured to the reference axes and then a digital on-screen goniometer was used to determine the mean angular variations with respect to the Epipcondylar axis.

In the clinical trial, 58 consecutive patients undergoing total knee arthroplasty were included. After a routine exposure the AP axis was marked on each distal femur. The AFCL was then identified and the anterior femoral cortical cut was made parallel to this line. The angle between this cortical cut and the perpendicular to the AP axis was measured using a sterile goniometer.

In the MRI study, 50 axial knee images were assessed and the most appropriate slice/s determined in order to identify the AFCL and the other 3 reference axes and then their relationship was measured by an on-screen goniometer.

Results: In the cadaveric study the AFCL was a mean 1° externally rotated to the epicondylar axis (SD = 5°), White-side’s line was 1° externally rotated (SD = 4°) and the posterior condylar axis was 1° internally rotated (SD = 2°)

By MRI and with respect to the epicondylar axis, the AFCL was a mean 5° externally rotated (SD= 3), White-side’s Line was 1° externally rotated (SD = 2) and the posterior condylar axis was 3° internally rotated (SD = 2).

In the clinical study in 8 patients it was impossible to draw the AP axis because of dysplasia or destruction of the trochlea by osteoarthrosis. In the remainder the mean difference between the anterior femoral cortical line and Whiteside’s AP axis was 4.1 degrees internally rotated (SD = 3.8°). The lateral release rate for this cohort was 4%.

Conclusion: The anterior femoral cortical line provides an additional reference point, completing the ‘compass points’ around the knee. It has been shown in this study to be reliable in the laboratory, on MRI and in a clinical setting for assessing rotation of the femoral component. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma.


J. DILLON J. CLARKE A. MENNEESSIER L. HERIN F. PICARD

Introduction: A successful total knee replacement (TKR) relies upon effective soft tissue management. Historically, soft tissue balancing has been difficult to assess and quantify intraoperatively. Computer navigation permits us to accurately assess kinematics during surgery. In a previous study we performed a series of varus and valgus stress measurements in extension to devise an algorithm for soft tissue management. In this study we evaluate the effectiveness of this algorithm.

Methods: This prospective study used the Orthopilot® CT-free navigation system during TKR for 57 patients with end-stage arthritis. We collected intraoperative kinematic data for 42 varus knees. Pre- and post-operatively, a varus and valgus stress was applied at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. The following medial releases were performed based upon the kinematics and the algorithm below:

No release–MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°.

Moderate release–MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°.

Proximal release–MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°.

Results: Pre-operatively, the mean MFT angle was −9.6°varus (−3° to −22°) with varus stress and −0.8°varus (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.5° varus (0° to −5°) with varus stress, and 2.1° valgus (4° to −1°) with valgus stress.

Using regressional analysis, there was a strong linear correlation between both varus (r=0.871, p< 0.0001) and valgus (r=0.894, p< 0.0001) stresses and the MFT angle.

Post-operatively, the mean MFT angle was maintained within a narrow range (0° to −5° with varus stress, 4° to −1° with valgus stress), with no outliers. There were no extension deficits.

Conclusions: Using computer navigation a quantifiable soft tissue management system was introduced. We evaluated this algorithm, and obtained reproducible results within a narrow range and no outliers. This algorithm may provide an effective soft tissue management plan in TKR.


D. Howcroft M. Fehily C. Peck A. Fox B. Dillon D. Johnson

Templating of preoperative radiographs is routinely recommended prior to knee arthroplasty. We performed this study to assess the reproducibility and accuracy of the templates for three commonly used knee implants (PFC, Kinemax, Scorpio). Six lower limb surgeons templated 10 patients for each of the three designs. The inter and intra-observer reliability and accuracy was calculated. There was marked variation in the reliability of the templating with the tibial insert scoring better than the femoral and the Kinemax being the most reproducible of the three. In general, the intra-observer scores (κ= 0.57–0.81) were better than the inter-observer ones (κ= 0.21–0.60). The Scorpio was the most accurately templated of the three implants, with the percentage correlating with what was actually implanted ranging from 55–62% for the femur and 72–75% for the tibia, with no templated sizes more than 1 size different from the actual implant. The other implants ranged from 38–42% for the femur and 53–58% for the tibia with both having up to 3% more than 1 size difference from the actual implant. We believe that the use of templating in total knee arthroplasty should be interpreted with caution and we urge the development of more accurate prosthesis sizing techniques.


A.J. Schuster A. von Roll T. Wyss

Aims : This prospective study investigated outcomes from TKA using the ligament balancing technique to implant a PCL-retaining knee prosthesis (balanSys knee system). In addition we wanted to know if we can achieve stability in these knees and if there is a difference between mobile and fixed bearing prosthesis designs?

Methods: Between March 2001 and Mai 2005 143 patients (17 bilateral; n=160) with osteoarthritis received the balanSys knee system with either a fixed or mobile polyethylene bearing. Objective assessments of the implant used Knee Society score (KSS) with the knee and functional score. Anterior-posterior translation was measured with the Rolimeter (Aircast) in 25° (Lachman) (mean of 3) and 90° of knee flexion (mean of 3), intraoperatively under anaesthesia and at follow up time. Subjective assessments used Visual Analogue Scale (VAS) data for pain, and patient satisfaction.

Results: The study population at follow up time (mean 4 years) contained 112 patients (31 males; 81 females) with 126 knee implants out of 160. Of these 126, 93 had fixed and 33 mobile bearings. Mean age at surgery was 70.6 years. The Rolimeter measurements for ap-translation showed an increase of stability from 8.3 preop to 4.6 mm at FU in 25° of flexion and 6.3 to 4.9 in 90° of flexion. The increase of stability for mobile bearings (7.8 to 5.8/6.1 to 6.0) is smaller than for fixed bearings (8.4 to 5.8/6.9 to 4.5). The t-test shows a clear cut significance Pr > [t] = 0.0038, the difference of the paired difference amounts to 1.4 mm. The t-test shows significant differences for both angles (25°/90°) Pr > [t] < 0.001. Mobile bearings have a higher laxity in ap direction compared to fixed bearings. ROM was similar for both genders (mean 118°). According to VAS, mean scores for pain and satisfaction were 1.5 (best 0) and 8.5 (best 10), respectively. The KSS (mean score 168; SD 31.1) was similar for both, fixed and mobile bearings. In 25° of flexion the subgroup of ‘tight’ knees (1–3.5 mm ap translation) and in 90° the subgroup of ‘loose’ knees (< 5.5 mm) performed best, with highest knee scores.

Conclusions: The TKA’s performed with a PCL-retaining prosthesis and a soft tissue oriented, ligament balancing, surgical technique were associated with good outcome (KSS mean score 168), a good range of motion (118°), good stability and with no significant differences between mobile bearing or fixed bearing implants at follow up (4 years). In addition patients reported little pain (1.5) and were very satisfied (8.5) with the outcome. Interesting was the fact that in 25° of flexion the subgroup of tight knees (1–3.5mm) and in 90° the subgroup of loose knees (< 5.5 mm) performed best, with highest knee scores.


A. Martin M.B. Sheinkop A. von Strempel

Aims: Because of the limitation of exposure inherent in minimally invasive surgical techniques for total knee replacement surgery, there is a significant risk of malalignment, malrotation, femoral notching and failure of soft tissue balance.

Methods: In this randomized study 50 patients with osteoarthritis of the knee, underwent TKR through a minimally invasive exposure using a navigation system; while a control group of 50 patients underwent the same surgery without navigation.

A subvastus approach was used with a less than 10 cm incision. Femoral component alignment is established with an intramedullary, and the tibial component, with an extramedullary alignment guide. The navigation system was used for fine adjustment and verification of cutting block position. The navigation system used for the study was the VectorVision® CT-Free Knee 1.5.1.

Results: The accuracy of prosthetic components positioning was significantly higher in the navigation group. The navigation system offered an objective analysis of medial and lateral ligament tension in full extension and 90 ° of flexion. In 8 cases navigation avoided femoral notching. No navigation related complications were registered. The additional surgery time for computer-assisted TKR was a mean 21 minutes. The nonnavigated implantation technique reached perfect component positioning in 62 % of the TKR.

Conclusion: Computer-assisted TKR results in predictable and accurate alignment, avoidance of femoral notching, avoidance of malrotation and appropriate balance of the soft tissue. Performing minimally invasive TKR without navigation has a higher risk of increased rate of unsatisfactory outcomes with shorter prosthetic survivorship when compared to the use of navigation.


S. yousufuddin D. chesney M. van der linden R. nutton

Objective: To evaluate the impact of soft tissue release on range of movement following total knee replacement.

Methods: Sixty four patients underwent PFC sigma total knee replacement through a medial arthrotomy. Range of active movement was measured preoperatively, and maximal flexion was measured after implantation, using the drop test while the patient was under anaesthetic. Soft tissue release was graded from 1 to 5, depending on the structures released.

Range of movement was correlated with extent of soft tissue release, to see if release had any impact on increase in range of movement.

Results: All patients had an improvement in range of movement following surgery. Post operative range of movement correlated strongly with preoperative ROM.

Patients requiring extensive releases tended to have less preoperative ROM, but the gain was independent of medial release. Those requiring extensive posterior release had poorer preoperative movement, and significantly less improvement.

In those requiring an extensive medial release, a posterior release improved gain in ROM.

Conclusion: Postoperative ROM following TKR is independent of extent of medial release. In patients requiring extensive medial release, a posterior release improves gain in movement.


S.A. Banks K.H. Mitchell M.K. Harman C.J. Leslie W.A. Hodge

There is interest to provide total knee arthroplasty (TKA) patients large ranges of functional knee flexion. Factors contributing to flexion include a posterior femoral position on the tibia, posterior condylar offset, and posterior tibial slope. These factors can be incorporated into implant designs and surgical techniques. It is useful to assess the robustness of the resulting design, that is, the consistency of kinematic or functional results when patient and surgical factors vary widely. This study evaluates in vivo flexion performance of a single implant design in patients whose posterior cruciate ligament (PCL) was either retained or sacrificed.

28 knees in 20 patients were imaged using fluoroscopy during maximum flexion kneeling and lunge activities. 20 knees (12 patients) received TKA with the PCL retained by a bone block (PCL+ group). Eight knees (7 patients) received TKA with complete PCL resection (PCL- group). All knees received a fixed-bearing TKA (3D Knee, Encore Medical, Austin, TX) with an asymmetric tibial bearing having a sagittally curved medial compartment and a lateral compartment fully congruous with the lateral condyle in extension (approximating anterior cruciate ligament substitution). Three-dimensional knee kinematics were determined using model-based shape registration techniques.

For the kneeling activity, mean implant flexion was 124°±11° for PCL+ knees and 121°±17° for PCL- knees (p> 0.05), mean tibial internal rotation was 10°±4° for PCL+ knees and 9°±3° for PCL- knees (p> 0.05) and tibial valgus was −1°±1° for PCL+ knees and 2°±4° for PCL- knees (p=0.003). Medial contact location averaged −2±4mm and for PCL+ knees and −1±2mm for PCL- knees (p> 0.05). Lateral contact location averaged −10±4mm for PCL+ knees and −7±1mm for PCL- knees (p> 0.05). For the lunge activity, mean implant flexion was 120°±11° for PCL+ knees and 121°±21° for PCL- knees (p> 0.05), mean tibial internal rotation was 11°±4° for PCL+ knees and 8°±3° for PCL- knees (p> 0.05) and tibial valgus was −1°±1° for PCL+ knees and 2°±2° for PCL- knees (p=0.0002). Medial contact location averaged 0±4mm for PCL+ knees and −4±3mm for PCL- knees (p=0.04). Lateral contact location averaged −8±4mm for PCL+ knees and −9±4mm for PCL- knees (p> 0.05).

There was no difference in implant flexion between PCL retaining and sacrificing TKA. Both groups had knees with more than 145° implant flexion (~155° skeletal flexion). There were no significant differences in tibial rotation or lateral condylar contact locations. There were differences in tibial valgus for both activities. PCL- knees exhibited a tendency for the medial compartment to ‘book open’ with flexion beyond 130°, consistent with loss of PCL function. Based on this small cohort comparison, it appears that robust flexion performance and knee kinematics can be obtained with a fixed-bearing TKA design.


S. Hakkalamani A. Acharya R. Finley N.J. Donnachie

Introduction: Restoring normal mechanical axis is one of the key goals of the total knee arthroplasty (TKA). The majority of the surgeons resect the tibia perpendicular to its axis in the coronal plane, then use an intra-medullary jig inserted through the centre of the knee or slightly medial to centre of the knee to resect the distal femur at a 6 or 7degree valgus angle. The aim was to establish the safety of using a predetermined valgus angle (VA) and entry point (EP) in the primary TKA. We also studied the relationship between the VA and EP to the height, weight and BMI of the patient.

Materials and Methods: We studied 125 long leg radiographs of 125 patients who underwent TKA under the care of senior author. All the radiographs were taken in the preoperative clinic with knee in full extension and patella facing forward. The radiographs were used to measure the valgus angle and entry point of the femur. The patients with VA between 6–7 degrees and EP at the centre were defined as normal group and rest were defined as outliers.

Results: The VA ranged from 4 to 9.5 degrees (with a mean of 6.8 and SD 1.11). Only 66 (53%) knees had the VA between 6 and 7 degrees. The EP ranged from 30mm medial to 18mm lateral to the centre of the knee with a mean of 7.7mm medial to the centre of the knee (SD 6.1). The EP was at the centre of the knee in 31 (24.8%) knees and lateral to the centre in 19 (15.2%) knees. Only 14 (11.2%) knees were in the normal group. Overall there was no significant relationship between the EP and VA to the height, weight or BMI of the patient at p-value > 0.001.

Conclusions: The resection of distal femur using the predetermined valgus angle, the predetermined entry point is not a safe practice in TKA. The long leg radiographs of the knee should be studied to identify the outliers. In future computer-assisted surgery and digitalisation of the images may obviate the need for this. However, it may be prudent though to use pre-operative templating of long leg radiographs during the learning curve of computer assisted surgery as well.


A. Baldini P. Zampetti L. De luca A. Trinci

Femoral intramedullary canal referencing is utilized by most of the total knee arthroplasty (TKA) systems. Violation of the canal is performed in order to engage rod instruments in the femoral diaphysis and to refer of the anatomical axis of the femur. Fat embolism, activation of the coagulation cascade, and bleeding may occur from the reamed femoral canal. The purpose of our study was to validate a new set of _minimally-invasive friendly_ instruments which allow to prepare the femur without violating the intramedullary canal. Twenty-five consecutive patients undergoing primary TKA through a mini-subvastus approach were enrolled in the study after informed consent had been obtained. Results of this cohort (group 1) were compared to another contemporary group (group 2) of 25 TKAs operated by the same surgeon using intramedullary instruments. The two groups were matched for gender, deformity, degree of arthritis, and surgical approach. Reliability of the new extramedullary set of instruments was first tested in ten cadaveric limbs. Preoperative long weight-bearing AP and lateral view of the knee were obtained taking care of neutral limb positioning. Template of the mechanical and anatomical axis were performed. Distal femoral resection was planned according to the template, and considering a bone cut perpendicular to the mechanical axis of the femur. Measurement from the template were reproduced on the distal femoral cutting jig. Flexion-extension control of the distal femoral resection was obtained using the anterior meta-diaphyseal cortex reference. Depth of resection, and varus-valgus angulation were selected according to the previous measurements and referring over the most prominent distal femoral condyle. A double check was performed using an extra-medullary rod referring two and a half finger-breaths medially to the antero-superior iliac spine. Postoperative blood loss, pain, swelling, functional recovery, and complications were recorded. Radiographic alignment was measured with long film. Mechanical axis was within 0±2° in 88% of group 1 and 84% of group 2 (p> 0.05). There were no difference between the two groups regarding the operative time. In group 1, postoperative blood loss (740 vs 820 mL) was reduced but this difference did not reach the statistical significance (p=0.07). No difference was found in terms of postoperative pain, knee swelling, and functional recovery. Extramedullary reference with careful preoperative templating can be safely utilized during total knee arthroplasty. Avoiding the violation of the femoral canal may enhance the benefits of a less invasive approach.


P. Thornton-Bott L. Unitt D.J. Johnstone A. Sambatakakis

Introduction: Patella baja is the distal positioning of the patella in relation to the femoral condyles in the sagittal plane. True patella baja is due to shortening of the patella tendon (PT), as measured by the Insall-Salvati method, and narrowing of the distance between the patella and the proximal tibia. Pseudo-patella baja describes narrowing of the distance between the patella and the proximal tibia without shortening of the PT and occurs following Total Knee Arthroplasty (TKA), where the tibial prosthesis plus insert are thicker than the resected tibia. Both may cause patella pathology, pain and a reduced range of motion. Pseudo-patella baja can be detected using the Caton-Deschamps method.

Soft tissue balancing is an important factor in the success outcome of TKA, but if extensive can necessitate the use of thicker tibial inserts. This may alter the position of the patella in relation to the tibia and increases the risk of creating a pseudo-patella baja.

Hypothesis: Patients who undergo extensive soft tissue releases during TKA, with the resultant use of thicker tibial inserts will develop a pseudo-patella baja, and will have a poorer outcome and reduced range of motion.

Method: In this prospective study, 506 patients aged 40–90 years underwent 526 Kinemax TKAs, performed by 7 surgeons in 5 centers between October 1999 and December 2002. The extent of soft tissue releases and the size of tibial inserts were recorded. Independent observers used the Caton-Deshamps method to assess patella position measured Pre and post-operative lateral radiographs. The patients were also assessed using the Oxford Knee Score and the American Knee Society Clinical Rating System, with a minimum follow-up of 12 months.

Results:

TKA surgery creates a Pseudo-Patella Baja. Excluding patients with a pre-operative patella baja, pseudo patella baja was introduced into 25.6% of patients. (p=0.00).

Extensive soft tissue releases during TKA are associated with a 100% increased in the incidence of pseudo patella baja compared to more moderate soft tissue releases. (p=0.002).

The use of large tibial inserts is associated with a significant increase in the incidence of pseudo-patella-baja, compared to smaller inserts. Three groups were identified: Small Inserts 8 mm, Medium inserts 10–12mm, and Large inserts 15, 18 & 22 mm. (p=0.042).

There was no correlation between the incidence of a pseudo-patella baja and changes in clinical or functional outcome, including range of motion, as measured using the OKS and AKSCRS.

Conclusion: Pseudo patella baja occurs in 25% of all patients following TKA, and in over 40% of patients in whom extensive soft tissue releases have been performed and/or large tibial inserts have been used. At 12 months, no detrimental outcomes were attributable to the incidence of pseudo patella baja.


F.G. Attar U. Saleem N. Yousuf R. Deshmukh

Aim of study (background): Probability of survival (Ps) is calculated presently by using the TRISS methodology for trauma patients. This utilises physiological scoring parameters, injury scoring system and the patient age. The physiological parameters need to be recorded for determining the RTS, but this data is often missed. The aim of our study was to assess how the essential variables correlate with the Ps and if any other variables contribute significantly to the Ps. Depending on the correlation of any new variables, is it time to change the formula for calculating Ps?

Material and methods: A retrospective study was carried out involving 678 trauma patients. The ISS and RTS scores were calculated from the trauma charts. The relationship between ISS, RTS, age and GCS with Ps was assessed using the correlation and regression analysis and then the affect of gender on Ps was assessed using a T test.

Results: ISS of trauma victims had a mean of 10.22. The results showed a strong negative correlation between ISS and Ps with an r value of −0.633 (p< 0.005). GCS correlated strongly with Ps, with an r value of 0.733 (p< 0.005). In the regression analysis; ISS and GCS showed a strong correlation with Ps. RTS made the weakest contribution to Ps, followed by age. GCS made the strongest unique contribution. There also no significant difference in the mean scores of Ps for males and females (p< 0.005).

Conclusion: The results indicated significantly strong correlations between ISS and GCS with Ps. There was a poor correlation between RTS and Ps. This is helpful for the patients in whom RTS scores cannot be calculated, as GCS can be used in place of RTS. There may be a need for a new system to calculate Ps using GCS and gender.


T. Clare J. Newman C. Ackroyd R. Evans

Since 1996 over 400 isolated patellofemoral replacements using the Avon prosthesis have been undertaken in Bristol. As a result of the usually gratifying outcomes seen in patients over 55 years old, the indications for this surgery were soon extended to include the many younger patients who have severely disabling patellofemoral disease. We present results from a prospective cohort study of patients under 55 years of age at the time of surgery.

110 knees in 86 patients (median age 47 years, range 24–54) have been treated with Avon patellofemoral replacement (88 in females and 22 in males). Diagnoses included lateral facet OA (59 knees), patella dislocation (25 knees), trochlear dysplasia (41 knees) and post patellectomy instability (7 knees). 79 knees had undergone previous surgery. 17 knees required additional intra-operative procedures including 11 lateral releases and 2 patella realignments. All patients were assessed pre-operatively and at regular intervals using the Oxford, Bristol and WOMAC scores.

All knees were scored preoperative and only one knee has been lost to follow-up due to the patient’s death, which was unrelated to surgery. Post-operative Oxford knee scores have been obtained for 106 knees with follow-up between 8 months and 8 years (mean follow-up 24 months). The mean Oxford score improved from 18 preoperatively to 31 at latest review. Bristol and WOMAC scores showed similar improvements. 16 knees required post-operative additional procedures including 6 lateral releases, 3 patella realignments and 11 revisions. Of the revisions 5 were for progression of tibiofemoral OA but none of these were knees with trochlear dysplasia. Equally good mean scores were seen when comparing patients with the 3 main underlying pathologies (trochlear dysplasia, patellar dislocation and lateral facet OA). At least 37% of the patients studied had pre-existing trochlear dysplasia and the majority of these patients report onset of symptoms, often patellar dislocation, in the first three decades of life. More than 90% of patients were overweight or obese according to their BMI at the time of surgery.

Many of this type of patient, with disabling symptoms, wish to “live now”. The short-term improvements are frequently dramatic. As yet there is no suggestion of prosthetic failure. Revision presents little difficulty since minimal bone is resected in the primary proceedure. Radiological deterioration of the tibio femoral joint is seen in some cases of primary OA but not with trochlear dysplasia.


M. Flören J. Davis R. Laskin

Background: Acquired patella baja occurs after both trauma and surgery of the knee including TKA, with prevalences between 30%–60%. The inferior position of the patella leads to alterations in the joint mechanics, reduction of range of motion, anterior knee pain, and can cause increased wear of the tibial and patellar polyethylene. Our aim was to evaluate the prevalence of patella baja after TKA and to assess the clinical effects of patella tendon torsion and twisting during surgical exposure of the knee.

Methods: Postoperative changes in patella height were measured on serial radiographs of 74 TKA implanted without patella eversion (group 1) and 57 TKA implanted with patella eversion (group 2). Pre- and postoperative Knee Society Scores, operative data, and complications were compared.

Results: With a cut-off level of 5% shortening, the prevalence was 12% (9 cases) in group 1 and 37% (21 cases) in group 2 (p=0.001). With the 10% cut-off level the prevalences were 5% (4 cases/group 1) and 14% (8 cases/group2) (p=0.1). The presence of patella baja was related to reduced flexion and increased pain 1 year after TKA.

Conclusion: Our study has shown that tension and twisting of the patellar tendon leads to shortening which was associated with reduced flexion and increased pain after TKA. By avoiding patella eversion the prevalence of acquired patella baja was reduced significantly.


W.L. van Hemert B. Grimm R.R. Senden I.C. Heyligers

INTRODUCTION: In total knee arthroplasty (TKA) it still remains undecided whether the patella should be resurfaced or not. This study used two accelerometer based motion analysis systems to study if functional tests are able to detect a difference in patients with or without a resurfaced patella.

METHOD: Retrospective study of a cohort of 53 unilateral TKA patients (Stryker Scorpio). With one surgeon always resurfacing and the other one routinely retaining the patella, patients were divided into a resurfaced group (RS, n=31) and a non-resurfaced group (NR, n=22).

Patients were clinically assessed for 2 years using the Knee Society Score (KSS). At final follow-up patients were assessed once using two accelerometer based motion tests (Dynaport Knee Test and Minimod Gait Test; McRoberts, Netherlands). The knee score is composed of four sub scores (Locomotion, Rise & Descend, Transfers, Lift & Move). The gait test records walking parameters such as step frequency, length and speed plus various parameters of step asymmetry, irregularity and efficiency. Statistical analysis was performed using the van Elteren’s test (KSS data) and a stratified regression analysis (Dynaport and Minimod data)

RESULTS: The mean pre-op KSS was not different between the groups (RS=42.7+/−16.5, NS=50.5+/−13.8, p=0.08). Differences remained non-significant post-op at three months (RS=42.7+/−16.5, NS=50.5+/−13.8, p=0.08), at final follow-up (RS=42.7+/−16.5, NS=50.5+/−13.8, p=0.08) and regarding total improvement (RS=8.7, NS=5.1, p=0.29).

The Dynaport knee test showed a significant functional advantage for patella resurfacing (RS=44.1+/−12.1, NR=39.7+/−19.2, p=0.04). The sub score Rise & Descend showed the largest advantage for patella resurfacing (RS=44.7, NR=39.7, p=0.04). The other sub scores also favored resurfacing but were not significant. The Minimod Gait test favoured RS in most parameters but at non-significant levels.

DISCUSSION: Using the KSS it was not possible to identify resurfacing or retaining the patella as the superior choice in TKA. However, using performance based tests it was possible to measure significant differences in favour of patella resurfacing but only when the motion tasks were most demanding and depending on patella-femoral function such as during Rise & Descend (stair climbing, slope walking, stepping onto blocks). This indicates a relevant functional benefit of patella resurfacing for the patient. Functional parameters derived from less demanding tasks such as normal gait (Mini-mod) could not verify this benefit.

The advantage of patella resurfacing may be less due to pain relief but due to a functional benefit during demanding motion tasks for which standard clinical scores and low demanding tests do not account for sufficiently and objectively enough. We recommend complementing the classic evaluation tools with demanding functional tests.


D. Tarity R. Norton J.J. Purtill J. Parvizi R.H. Rothman

Introduction: A small, yet not uncommon, problem following total joint arthroplasty (TJA) is post-operative ileus (POI). The purpose of this study was two-fold. First the study sought to determine the incidence of POI after TJA in a consecutive series of patients receiving regional anesthesia and an aggressive postoperative rehabilitation protocol. Second, the influence of narcotic medications, including intrathecal medications, in the incidence of POI was examined.

Methods: 5,262 patients underwent total joint replacements, including primary and revision surgery, at our institution from 2004 to 2005. All surgeries were performed at a university-affiliated institution where complications, if any, are prospectively recorded in a comprehensive database. Demographic, clinical, surgical, and radiographic details were obtained and examined.

Results: 26 (0.5%) patients developed ileus. There were 17 males and 9 female patients, who had a mean age of 67.7 years (range, 52.7 to 91.2 years). The mean BMI was 30.2 kg/m2. The index procedures included 15 primary hip, 4 primary knee, 4 revision hip, and 3 revision knee procedures. Of the patients who developed ileus, intrathecal narcotics were administered in 16 patients (62%).

Discussion: There is a very low incidence of postoperative ileus and gastrointenstinal hypomobility following joint arthroplasty. Early patient ambulation, a reduction in the use of postoperative narcotics, supplementation of analgesia with non-narcotic drugs, and reduced length of hospital stay may all have an important role in reducing this complication. Based on our findings, it seems unlikely that intrathecal narcotics have an adverse effect on gastrointestinal motility.


S. Lie N. Pratt L. Engesæter L. Havelin P. Ryan S. Graves O. Furnes

There is an increased early postoperative mortality (operation risk) after joint replacement surgery. This mortality is normally associated with cardiovascular events, such as deep venous thrombosis, pulmonary embolism, and ischemic heart diseases.

Our objective was to quantify the magnitude of the increased mortality and how long the mortality after an operation persists.

We focused on the early postoperative mortality after surgery for total knee and total hip replacements from the national registries in Australia and Norway, which cover more than 95% of all operations in the two nations. Only osteoarthritis patients between 50 and 80 years of age were included. A total of 244.275 patients remained for analyses.

Smoothed intensity curves were calculated for the early postoperative period. Effects of risk factors were studied using a non-parametric proportional hazards model.

The mortality was highest immediately after the operation (~1 deaths per 10.000 patients per day), and it decreased until the 3rd postoperative week. The mortality was virtually the same for both nations and both joints. Mortality increased with age and was higher for males than for females.

A possible reduction of early postoperative mortality is plausible for the immediate postoperative period, and no longer than the 3rd postoperative week.


L. Pulido J. Parvizi J.J. Purtill P.F. Sharkey W.J. Hozack R.H. Rothman

Background: Total joint arthroplasty (TJA) is a successful procedure. With the demographic tendency towards an elderly society and a relatively high prevalence of arthritis, the number of joint replacement in the US will increase dramatically in the upcoming years. The orthopaedic surgeons need to be aware of the various types of complications in the early hospital setting associated with elective TJA.

Methods: This prospective study reviewed the systemic and local early complications occurring after 13133 TJA which included 7,438 hip arthroplasties (6,010 primary and 1,428 revisions) and 5,695 knee replacements (4,944 primary and 751 revisions). A standardized and detailed form intended to capture all medical and orthopedic complications was devised, plus a full-time research fellow was dedicated to this study. The hospital course of every patient was followed on a daily basis closely. The circumstances leading to the complications and the details of the therapeutic intervention for each complication were recorded.

Results: In general the incidences of complications were higher following TKA compared to THA. There was 26(0.19%) deaths in the cohort that occurred within 10 days after surgery. 329 major (life threatening) complications occurred in the cohort that included myocardial infarction (36), hypotensive crisis (11), pulmonary embolus (145), tachyarrhythmia (93), pulmonary edema (10), acute renal failure (24), stroke (6), bowel obstruction or perforation (3), and pneumothroax (1). There were 37 major local complications. 301 (91%) of these complications occurred within 4 days of index surgery. There were 453 minor systemic complications, mostly related to anemia, and 99 minor local complications in this cohort.

Conclusions: Total joint arthroplasty despite its success can be associated with serious and life threatening complications. The introduction of MIS surgery and the potential for very early discharge of patients undergoing arthroplasty needs to be scrutinized in light of these findings.


J. Jerosch M. Morsi

Purpose: The purpose of the study was to evaluate the clinical and radiological results of Copeland cementless surface replacement arthroplasty (CSRA) applied in patients with two main indications.

Patients and Methods: The study was conducted on fifty shoulders in fifty patients between 2003 and 2005; 17 patients suffered from rotator cuff pathology. The patients were prospectively followed up clinically and radiologically for a mean of 12.7 months (range, 6–30 months). There were 30 female and 20 male shoulders. The mean age was 66.63 years (range, 21–85). The mean operative time was 44.6 minutes (range, 29–62 minutes). The clinical assessment was performed with the Constant score

Results: The constant score significantly improved from a mean of 15.52 points preoperatively to 57.02 points postoperatively. Of the patients, 96% considered the shoulder to be much better or better as a result of the operation. The Constant-Score improved in the group with degenerative arthritis from 16.32 point pre- to 62.25 postoperatively. In rotator cuff arthropathy the score improved from 14.19 to 53.06.

Radiologically, the humeral offset, the lateral gleno-humeral offset (coracoid base to the greater tuberosity) as well as the acromiohumeral distance were significantly increased. No intra-or postoperative complications encountered.

Conclusion: We conclude that the shoulder surface replacement arthroplasty allows good conservation of the bone stock and avoiding the complications encountered with the stemmed prostheses. In patients with rotator cuff arthropathy there are two main indications:

- patients below the age of 70, in order to avoid complications of the reverse prosthesis

- patients with still a goof active range of motion


L. Pulido J. Parvizi J.J. Purtill P.F. Sharkey W.J. Hozack R.H. Rothman

Background: Vascular injuries associated with total joint arthroplasty are the most feared complication. The arterial and venous injury can occur due to direct or indirect trauma. A high index of suspicion, recognition of the injury and prompt treatment, with the immediate availability of a vascular surgeon is vital for good outcome.

Methods: Using prospectively collected data on 13624 patients undergoing total joint arthroplasty at our institution, all incidences of vascular injury were identified. Detailed data regarding the mode of presentation, the type and the outcome of intervention delivered, and the eventual functional outcome of the total joint arthroplasty were determined.

Results: There were a total of 17 vascular injuries (0.1%). Majority (16/17) of these vascular injuries were detected in the postoperative recovery area. 9 injuries occurred after TKA and 8 occurred after THA. Indirect injury was the mechanism in TKA patients with popliteal artery thrombosis being the mechanism. In contrast direct injury was the mechanism in THA patients. Fasciotomy was performed in all TKA patients and none were needed in the THA patients. One patient died of complications related to vascular injury. 12 of 17 patients (70%) had launched a legal suit against the operating surgeon.

Conclusions: After more than 80 years of accumulated experience and more than 35000 joint replacements performed by 5 surgeons in our center, the vascular complication still continues to occur. Patient awareness regarding this real problem may play a role in defraying the extremely high likelihood of legal suits associated with this complication.


S. Kurtz E. Lau L. Havelin E. Dybvik K. Ong H. Malchau

Starting in the 1970s, long-term survivorship of total hip and knee arthroplasty has been under investigation for the Scandinavian population with the aid of implants registries. In the United States, no national arthroplasty registry currently exists. Nationwide inpatient discharge databases in the United States have proven useful when comparing the revision burden in the United States and Scandinavia. For this study, we compared the implant survivorship in the Medicare population with contemporaneous registry-based data from well-established and validated Scandinavian arthroplasty registries. The 5% systematic sample of Medicare claims from 1997 to 2004 were examined for primary and revision THA and TKA claims. The Medicare beneficiary ID was used to follow patients longitudinally between primary and revision surgery. De-identified data from the Norwegian and Swedish national hip and knee registry were also obtained for the same time period. During the 8-year study period, 30,583 and 62,878 elective primary total hip or knee replacements, respectively, were extracted from the Medicare data. In the same time period, 41,823 and 15,927 primary total hips or knees replacements were identified from the Norwegian registry. 82,037 primary total hips were identified from the Swedish registry. Survivorship was assessed by the Kaplan-Meier method, and Cox regression was used to evaluate the effect of patient attributes and cross-country comparisons. The K-M estimate showed that 8 years post-primary surgery, 93.6% of THA and 96.2% of TKA remained revision-free among the elderly Medicare population. By comparison, among Norwegians aged 65 and above, 96.0% of THA and 93.6% of TKA remained revision-free. In the US, men had a significantly higher risk of knee revision than women, but no significant gender difference among hip revision. In Norway, men had a significantly higher risk of hip revision, but no differences in knee revisions. In Sweden, men had a significantly higher risk of hip revision (5.4% vs. 3.3%). Older patients had a reduced risk of revision as compared with younger patients, in both the US and in Norway. The survival of THA is significantly better in Norway than in the US with a hazard ratio of 1.64 (p< 0.05). On the other hand, TKA had a better survival experience in the US than in Norway, with a hazard ratio of 0.55 (p< 0.05). This is the first study to evaluate the utility of Medicare as a source of THA and TKA survivorship data and to compare prosthesis outcomes in Medicare with those from Scandinavian arthroplasty registries. Unlike the Norwegian and Swedish registry data, the reasons for revision (e.g., femoral loosening) are not captured and thus greatly limited the value of the Medicare data as a tool to understand the need for revision, thereby helping to improve implant longevity and to reduce the associated cost and burden to the patient and care provider.


A. Pillai G. Nimon C. Dreghorn

Background: After Jules-Emile Pean and Neer, unconstrained prosthetic arthroplasty of the shoulder is widely used for glenohumeral osteoarthritis (OA), rheumatoid arthritis (RA) and trauma. While the debate continues over whether humeral head replacement (HHR) or total shoulder arthroplasty (TSR) is better for OA and RA, hemiarthroplasty is preferred in the trauma situation.

Aims: A retrospective review (1993–2000) of 54 patients with the DePuy Global second generation modular shoulder hemiarthroplasty is presented. We highlight the various complications encountered in the longer term and attempt to use our experience to rationalize treatment choice.

Methods: 49 shoulders in 41 patients were available for review. Case records and radiographs were reviewed and clinical assessment carried out. Functional assessment was done using the Constant (CM) and the American Shoulder and Elbow Society systems (ASES). Patients were also asked to complete a shoulder self assessment questionnaire (Insalata, Hospital for Special Surgery).

Results: The pre-op diagnosis was 20 RA, 12 OA, 11 trauma. The mean age was 63.4Yrs. The mean follow up was 6.8Yrs (4–11 Yrs). The mean Constant scores for the 3 groups were 48.1 RA, 46.3 OA, and 56.6 trauma. The mean ASES functional scores were 39.6 RA, 37.5 OA and 32.9 trauma. Active elevation in the RA group was a mean of 83.5°, and 69.5° for OA and 79° for the trauma group. 65% of the RA group was completely pain free compared to 50% and 54% in the OA and trauma groups respectively. Patient satisfaction was high in the RA and OA groups but poor in the trauma group. 90% of RA patients had evidence of superior migration of the prosthesis (ASM), with the majority of them developing cuff dysfunction. 36% of trauma patients had tuberosity escape/nonunion. 100% of OA patients developed late glenoid erosion. Presence of secondary glenoid arthrosis and ASM co-related with poor function (r =0.5, p< 0.05).

Discussion. Second generation prosthesis can prejudice the shoulder biomechanics. Over-tensioning the joint can lead to both glenoid wear and cuff rupture.

In OA patients, satisfaction was highest, but function was poor. Patients with out cuff tear pre-operatively did not develop it later. They may thus benefit from a TSR compared to HHR. RA patients had the least pain, best function and high satisfaction. Most had evidence of either primary or secondary cuff dysfunction. In them patients HHR may be the preferred option. Trauma patients did poorly in all respects. More anatomical reconstruction and greater emphasis on salvage of the humeral head is required in this group.


M.F. Pietschmann V. Froehlich A. Ficklscherer V. Jansson P.E. Mueller

Aim: Retears after rotator cuff surgery occur frequently and may compromise the functional results. Failure of bone anchors and sutures may influence the results to a great part. The goals of this in vitro investigation were to determine the mechanical strength and stiffness of different bone anchors frequently used in arthroscopic rotator cuff surgery. Focus was put a material and design of the anchors.

Material und Methods: Four bone anchors were tested, each standing for a specific group of bone anchor. The metallic Super Revo screw 5.0 (Linvatec), the absorbable screw Spiralok 5.0 (Mitek), the absorbable press-fit anchor Bioknotless RC (Mitek) and the absorbable Ultra-sorb RC (Linvatec). The anchors were tested on 12 pairs of fresh-frozen human shoulders. The mean age at the time of death was fifty-seven years (range 27–93 yrs.).

Cyclic loading was performed, as it was considered the best way to simulate the postoperative conditions. The maximum tensile strength, the failure mode, and the displacement of the fixation device (system displacement) under load at the first cycle of 75 N and at the maximum tensile strength were recorded.

Results: As reported before the most frequent failure mode for the titan anchor Super Revo 5 mm was a rupture of the threads at the eyelet.

The absorbable Spiralok 5 mm screw anchor showed the highest failure load with a mean of 223 N. The failure loads of the remaining anchors were similar and ranged from a mean of 169 N for the Super Revo 5 mm, over a mean of 173 N for the Ultrasorb RC anchor to a mean of 188 N for the Bioknotless anchor. Among these anchors the differences were not significant. Only the Spiralok 5 mm screw showed a significantly higher failure load when compared with the Super Revo 5 mm screw.

The displacement of the various systems showed significant differences. The displacement of the Bioknotless anchor showed after the cycle with a tensile strength of 75 N a mean displacement of 13.8 mm, which was significant when compared with the remaining anchors.

Discussion: Our study shows that there is no advantage in using titan anchors with regards to primary stability in arthroscopic rotator cuff repair. We could even detect a significantly higher failure load for the absorbable Spiralok 5 mm screw anchor compared to the Super Revo 5 mm titan screw. Stability and system displacement depend not only on the anchor material but on the design of the anchor. We found that the absorbable Bioknotless RC anchor showed a significantly higher system displacement during the first cyclic loading (75 N) while all other anchors tested had a similar system displacement.


R. Chidambaram D. Mok

Introduction: Symptomatic neglected and displaced three and four-part proximal humeral fractures are often difficult to reconstruct. Replacements has been reported to give poor functional outcome and hence not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system.

Material and Methods: Between 2003 and 2005, 15 healthy active patients with displaced three to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months.

Surgical technique: In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by gradual mobilisation program.

Results: All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 preoperatively to 14 at follow up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient.

Conclusion: Successful reconstruction of three and four part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome.


C. Torrens G. Gonzalez M. Corrales J. Cebamanos E. Caceres

Introduction: Concern remains in loosening of glenoid component reversed prostheses. This study is to analyze glenoid location of stem and 4 screws of glenoid component.

Material and method: 34 reversed prostheses included. Mean age 74,10, 33 females/1 male. Preoperative CT study : glenoid version; measure of anterior-posterior osteophytes. Postoperative CT study: central stem location and superior, inferior, anterior, posterior screws location. Study of influence of glenoid version and presence of osteophytes in location of glenoid implant.

Results: 27 retroverted glenoids (mean 6,5°); 7 ante-verted (mean 5,3°). 17 cases with anterior osteophyte and 12 of posterior. In 52% the central stem was centered inside glenoid, 33% anterior end was outside glenoid and 14% the posterior end. When central stem was anteriorly outside 85% presented retroverted glenoid (mean 8,33°). When the central stem was posteriorly outside 66% presented anteverted glenoid (mean 9,5°). Inferior screw was fully in place in 38%, ¾ part inside in 19%, 2/4 part in 23%, ¼ part in 19%. Superior screw was fully in place in 47%, ¾ part inside in 23%, 2/4 part in 19%, ¼ part in 9%. Anterior screw was fully in place in 66%, ¾ part in 23% and 2/4 part in 9%. Posterior screw was fully in place in 38%, ¾ part in 42%, 2/4 part in 14%, ¼ part in 4%. The correct positioning of superior screw correlates with less coverture of inferior screw. Anterior and posterior osteophytes did not correlated with stem nor screw positioning.

Conclusions: Positoning of central stem correlates with glenoid version. Anteriorly extruded stems correlate with higher retroverted glenoids and posteriorly extruded stems correlate with higher anteversion.

Positioning the inferior screw fully inside the lateral border of the scapula correlates with lower bony coverture of superior screw.


P. Stavlas H.V. Johannsen

Introduction. Posterior superior glenoid impingement as a cause of partial rotator cuff lesions and posterior superior labral tears in overhead athletes was first described in the early 90’s by Walch and Jobe.

Material and methods. From January 1994 to January 2002, 71 patients were treated (48 men and 23 women). The majority were overhead athletes: handball (39), ketcher sports (12), volleyball (8), others (12). Indications for surgery were shoulder pain with athletic activity and a failed trial of conservative treatment. Mean age was 26 (range, 17–41) years. Mean duration of symptoms was 31 (range, 7–120) months. Following diagnostic arthroscopy–excluding anterior inferior ligament lesions and other significant intaarticular pathology–the partial rotator cuff lesions and posterior superior labral tears were debrided arthroscopically. During postoperative rehabilitation emphasis was placed on strengthening rotator cuff muscles, restoring normal scapulohumeral rhythm and avoiding stretching of the anterior static glenohumeral stabilizers.

Results. In 97% of cases a partial rotator cuff were found, and 90% had significant posterior–superior labral lesions. There were also 6 SLAP type II lesions that were repaired. Sixty four out of 71 patients were available for a follow up of minimum 2 years: 61% were able to return to preinjury activity level without any shoulder symptoms and 22% were not able to return to their desired sport. Overall satisfaction rate was 84%. The average time for return to sports participation was 9 (range, 4–12) months. Thirty six out of 46 patients had a telephone interview in a second minimum 5 years follow up. Fifty two percent (52%) were still active overhead athletes and 48% had stopped athletic activity (half of them because of shoulder problems). Six patients had secondary operations: 4 a capsular shift procedure and 2 a subacromial decompression.

Conclusion. In patients with symptomatic posterior superior impingement arthroscopic debridement followed by careful rehabilitation is an acceptable treatment. There is some tendency for the symptoms to recur over time.


A.a. Nazir S. Roy K. Mathur S. Alazzawi

Background: goal of our study was to predict the size of intramedullary nail using forearm as reference. Intra-medullary nailing has become favoured treatment for femoral shaft fractures. An implant of the correct size is needed to achieve the desired results. Preoperative templating is useful and well established for trauma and elective surgery to ensure availablity of a suitable implant of correct size preoperatively. Various ways have been described to estimate the nail length. Most commonly used is to x-ray the other limb or directly measure the reamer under x-ray. However these methods involve use of x-rays and information is not well-timed. We describe a simple technique, which can be used to predict the length of femur and therefore have the intra medullary nail of appropriate length available.

METHOD: measurements were taken on 100 volunteers from the tip of olecranon to the tip of little finger and tip of greater trochanter to palpable joint line on the lateral side of the knee. Two observers took the measurements on both sides. We used an ordinary plastic tape measure for ease of use and reproducibility.

RESULTS: statistical analysis revealed a very strong correlation (with pearson correlation factor of 1) between the two lengths. Difference between the two means was 0.16 Mm.

CONCLUSION: forearm reference represents maximum nail length required. It provides a useful method of estimation of femoral length. It can be easily applied in clinical practice with a tape measure alone without resort to x-rays and other expensive and possibly harmful means.


E.J. Karadimas G. Papadimitriou I. Galanopoulos A. Lakoumendas G. Theodoratos

Purpose: The intramedullary nailing is the treatment of choice for the femoral shaft fractures, giving advantages of early mobilization and weight bearing.

The purpose of this study is to present our experience with numerous reamed femoral nails and to report the results and the complications.

Material and Method: From 1993 to 2004, 415 femoral shaft fractures (413 patients) were treated in our hospital. There were 312 males 101 females with mean age was 27.8 yrs (17–84 yrs). The 87 % of fractures were caused by high-energy injuries (traffic accidents). Pathologic fractures were not included.

The 415 fractures according to AO classification were divided as follows: Type A: 105 (25.4%), Type B: 179 (43.1 %), Type C: 131 (31.5 %) There were 341closed fractures and 74 open. Those 74 were classified according Gustilo to 33 Grade I, 24 Grade II, 14 Grade III A, 2 Grade III B and 1 Grade III C.

The fractures were treated with 308 AIM titanium nails and 107 Gross-Kempf nails. Dynamic stabilization was performed in the majority of the type A fractures, and static to those classified as B and C. We encourage our patients to walk with partial weight bearing, from the second post op day, except those with type C fractures who started their weight bearing after a month.

The patients were evaluated 3,6,12,36 weeks and 1 years post surgery clinically and with standing X-Rays.

Results: After a mean follow-up time of 1.5 years, our union rate was 97.8%. Type A fractures were united in an mean time of 16 weeks, type B in 20 weeks and type C in 23 weeks.

Our complications were: 9 non unions (aseptic pseudarthrosis) (2.2%), 14 delayed unions (3.4 %), torsional malunion (more of 5°) in 4 patients (0.96 %). In 6 patients (1.44 %) we had limb shortening of 15 mm. Neurological complications were observed postoperatively in 30 patients, 25 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 5 with paresis of peroneal nerve which were recovered in 3 months. There was found 28 broken screws but no broken nail. We had 3 pulmonary and 2 fat embolisms, but none of them was fatal. In 4 patients was observed clinically vein thrombosis below knee. Also we noticed one superficial and one deep infection, but we didn’t have a case of compartment syndrome.

Patients returned to their previous activities in a mean time of 10 months.

Conclusion: Our results confirmed that the antegrade intramedullary nailing technique had optimal results and high union rate regarding the treatment of the femoral shaft fractures. Some of the complications could be related with the surgeon’s skills-experience and could be avoided. We prefer the use of titanium nails because their modulus elasticity is closer to bones.


S. Syggelos E. Lambiris G. Skouteris E. Athanaselis A. Giannakopoulos E. Sourgiadaki E. Panagiotopoulos

INTRODUCTION: Cases of aseptic non-unions in patients with a femoral shaft fracture, who have initially been subjected to internal fixation by plating, are not rare. The aim of this retrospective, polycentric study was to evaluate intramedullary nailing as method of treatment of these patients.

MATERIALS AND METHODS: Thirty patients with aseptic femoral shaft non-union, after plating, were treated by reamed intramedullary nailing (IMN). The type of nailing was chosen according to the type of non-union. The mean follow-up time was 30 months and for statistical analysis, the student’s t-test was used.

RESULTS: All non-unions were healed in a mean time of 7.8 months (5–18) after nailing. The mean healing time after fracture was about 18.6 months (9–54). The healing times were irrelevant to whether the fracture was open or closed, the type non-union (atrophic or hypertrophic) and the type of fracture, according the AO classification. On the contrary, the delay from the initial plating to definitive treatment (IMN) affected the healing time and the final outcome, in a statistically significant way. Healing time was increased by 34.45% when the definitive operation was performed after between 8 and 16 months compared to the ones before the 8th month and by 72.28% if the IMN was delayed to between 16 and 24 months.

DISCUSSION: In conclusion IMN can be an ideal and cost effective method in treating patients with aseptic femoral non-union, after plating failure. This definitive operation should be performed as soon as the non-union is diagnosed in order to avoid unnecessary delay in fracture healing.


T. Taneja D. Mandal L. Sood J. MahaluxmiVala C. Natali P. Achan D. Goodier S. Curry A. Watson

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.


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H. AL-KHATEEB K. Willett

Introduction: Although a relationship between long-bone fractures and patient morbidity and mortality has been previously identified, the cause and effect of bilateral femoral fractures remain obscure.

Aim of Study: This study was designed to determine whether patients with bilateral femoral fractures with associated injuries die more frequently than patients with isolated bilateral femoral fractures, and the contribution of the associated injuries to patient mortality.

Materials and Methods: Retrospective analysis using the UK trauma Audit & Research Network (TARN) registry data from 1989 to 2005 on isolated bilateral femoral fractures ‘Group I’ (92) or with associated injuries ‘Group II’ (380). Univariate data analysis was performed to compare the groups’ ages, Injury Severity Scores, Glasgow Coma Scales, mortality, physiological parameters, the time to arrive to scene and the time to arrive to hospital. Logistic regression data analysis was performed to determine variables statistically associated with mortality.

Results: Patients in Group II had a significantly higher Injury Severity Score (23 vs 9), lower Glasgow Coma Scales value (12 vs 15), higher mortality rate (31.6 vs 9.8%) and lower mean systolic pressures (116 vs 135) than patients in Group I. Associated injuries included; head, thoracic, abdominal, spinal, and limb injuries. Regression analysis of variables on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and.

Conclusion: From the results of this study, we conclude that patients sustaining bilateral femoral fractures with associated injuries are at a greater risk of than patients with isolated bilateral femoral fractures.


G. Petsatodis B. Chalidis P. Papadopoulos J. Karikis M. Parziali J. Pournaras

Purpose: The evaluation of the results of the interlocking intramedullary nailing in the treatment of open and closed femoral and tibial fractures.

Material-Methods: During the decade 1996–2005, 408 patients with 429 femoral and tibial shaft fractures were treated with interlocking intramedullary nailing. All the nails inserted after reaming. From the 182 femoral fractures, there were 155 closed,

10 open, 9 pathological fractures and 8 non-unions. Accordingly, from a total of 247 tibial fractures, 190 were closed, 27 were open and there were also 30 non-unions. The average age was 37 years. The patients were assessed clinically and radiologically according to a specific protocol. Follow-up 1–9 years (average of 4, 4 years).

Results: There were 291 men (71%) and 117 women (29%). The mechanism of injury was a car or motor-vehicle accident in 210 cases, fall from a height in 134, direct force injury in 73 and labor accident in 12 cases. The average period of hospitalization was 5, 2 days. The average time to union was 3, 3 months and it was longer in open than the closed fractures. The percentage of union in all the cases was 96%.

Conclusion: Reamed interlocking intramedullary nails have been associated with higher union rates and lower union time without increasing complications in either closed or open fractures These advantages support their application in the treatment of all the closed and most of the open femoral and tibial shaft fractures.


I. Szabò F. BUSCAYRET B.T. EDWARDS P. BOILEAU C. NEMOZ G. WALCH

INTRODUCTION: Assessment of radiolucent lines (RLL) is the main component of the radiographic analysis of the glenoid component. The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies.

MATERIEL AND METHODS: The series consists of seventy-two shoulder arthroplasties with primary osteoarthritis. Shoulders were divided into two groups based on glenoid preparation technique:

Group 1: Thirty-seven shoulders operated on between 1991 and 1995 with flat back, polyethylene glenoid implants cemented after “curettage” of the keel slot.

Group 2: Thirty-five shoulders operated on between 1997 and 1999 with flat back, polyethylene glenoid implants cemented after cancellous bone compaction of the keel slot.

At least three of the following four fluoroscopically positioned, postoperative AP radiographs were analyzed: immediate postoperative, between the 3rd and 6th postoperative months, at one year postoperative and at two years postoperative. The immediate and the two year radiograph were required for study inclusion. The radiolucent line score (RLLS) was calculated using the technique of Molé, involving the summation of radiolucencies in each of six specified zones. The RLLS was compared between the two groups.

RESULTS: On the immediate postoperative radiographs the average of the total RLL score of the 9 analyzes was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). There was no significant difference in radiolucency behind the faceplate between the two groups (Group 1: 1.54 and Group 2: 1.41; p=0.394). On the 2-year postoperative radiographs the average RLL score of the 9 analyzes were 6.44 in the Group1 (4.05 under the tray, and 2.39 around the keel), and 4.19 in Group2 (p=0.0005) (2.86 under the tray, and 1.33 around the keel). The radiolucency around the keel and behind the faceplate (p=0.0005) was significantly more important (p=0.001) in the “curettage” glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the faceplate (p=0.001) was observed in the “curettage” glenoid preparation group.

DISCUSSION/CONCLUSION: Preparation of the glenoid component keel slot with cancellous bone compaction is radiographically superior to the “curettage” technique with regard to periglenoid radiolucen-cies. Although new techniques of glenoid preparation may help to decrease the rate of RLL, this study shows that even with better technique, the RLL are evolutive and may appear after few years in initially perfectly implanted glenoid.


M. Fuerst W. Rüther

Introduction: Rheumatoid arthritis often leads to severe destruction of the glenohumeral joint including synovitis and inflammation induced alterations of the rotator cuff. Cup arthroplasty, or surface replacement of the shoulder was introduced in the 1980s. The aim of this study was to confirm or withdraw the very promising results of the DUROM-Cup surface replacement for patients with rheumatoid arthritis.

Patients an Methods: From 1997 to 2000 a cohort of 42 DUROM-Cup hemiprotheses were implanted in 35 patients. The patients were evaluated preoperatively and after 3,12 and more than 60 month postoperatively. 7 patients were lost to follow up. A total of 35 DUROM-Cups (29 patients) could be examined prospectively after an average follow up period of 73.1 (+/− 12.1) month (Average age 61.4y, female n=21, male n=68). Rotator cuff defects were classified intraoperatively.

Results: Three revisions occured: One due to a too large implant, one due to glenoid erosion and one due to loosening of the implant. The constant score increased from preoperatively 20.8 points to 64.3 points at a mean follow up of 73.1 month. No differences were seen in patients with massive cuff tears. In these cases the cup was implanted in a more valgic position, so that articulation with the acromion could be achieved. The radiographic results did not show any changing of the parameters for the position of the cup. No further endo-prosthetic loosening was observed. The proximal migration increased in 66% and the glenoid depht increased in 37% of the cups.

Discussion: The results of the cemented DUROM-Cup surface replacement for patients with advanced rheumatoid arthritis of the shoulder are very encouraging, especially in patients with massive tearing of the rotator cuff. The advantages of cup arthroplasty are to be found in the reduced level of invasive surgery and the simpler technique with bone saving fixation. In the event of failure of the implant good further treatment options for salvage procedures remain.


C. Torrens S. Martinez-Diaz R. Abad P. Gelber E. Caceres

Introduction: Prostheses radiolucent lines are currently used to evaluate the components fixation. The objective of this study is to determine concordance and reproducibility of humeral stem radiolucent lines evaluation.

Material and method: Five observers evaluated 64 x-ray belonging to 32 pairs (1 antero-posterior view and 1 outlet view) obtained from 16 shoulder prostheses. 16 x-ray pairs were obtained immediately after surgery and 16 one year after surgery. Evaluation in four degrees of radiolucent width for each of the 7 zones that the humeral component was divided for. Evaluation of the component-cement interface and the cement-bone interface. Each observer made two evaluations of the 64 x-ray separated in 6 weeks. Statistics : index kappa with quadratic weighting.

Results: Intra-observer results: mean kappa index for component-cement interface: 0,3274. mean kappa index for cement-bone interface: 0,5269. Inter-observer results: mean kappa index for component-cement interface: 0,1242. mean kappa index for cement-bone interface: 0,2478. Evaluation of 2 pairs of x-ray of the each prostheses taken in a period of 1 year: component-cement interface: mean of 91,67% of plausible results, cement-bone interface: mean of 80,2% of plausible Results:

Conclusions:

- low kappa index of reproducibility (0,3274–0,5269) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface.

- low kappa index of concordance (0,1242–0,2478) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface.

- High number of plausible observations when the same prostheses was evaluated immediately after surgery and at 1 year follow-up.


A. CHATZISYMEON J. Christoforides P. Papadopoulos J. Pournaras

The use of a Shoulder Hemiarthroplasty for the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) is the subject of this study.

71 patients with 71 Proximal Humerus Fractures were treated with this method. Four were exluded from the study (they did not match the follow-up criteria). From the remaining 67, 60 were women and 7 men, aging from 38 to 96 years (average 67.13 year, S.D. 14,769s). Of these patients 22 were Neer 3 (1 with a dislocation) and 45 were Neer 4 (17 with a dislocation). There were 4 cases of a failed ORIF and in 8 cases the operation followed failed conservative treatment (2 non-unions and 6 AVN). Time between fracture and surgery ranged from 1 to 5 days in 54 cases, while in the rest it exceeded 8 weeks. The fracture classification was performed with the use of 3 plain X-rays (AP, Lateral and Axillary views) and the results were evaluated using the Constant Score. The mean follow-up was 55.75 months (range 36 to 105). The average Constant Score was 67.4 (S.D. 14.3). There were no significant statistical differences regarding sex and age in respect to the Constant Score (t 65 =.243, p =.81), range of motion (t 65 =.048, p =.96), strength (t 65 =.741, p =.46), activities of daily living (t 65 =.030, p =.97) and pain relief (χ2 [1] =.001, p =.98). On the other hand the group of patients with the higher pain relief scores presented higher Constant Score values and better shoulder joint function in respect to the group which presented lower pain relief scores.

In conclusion the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) with the use of a Shoulder Hemiarthroplasty is a good treatment method offering substantial pain relief, functional improvement of the joint leading to a faster rehabilitation in the majority of patients, regardless age and sex.


J.D. Bastian R. Hertel

Background: The purpose of the presented study was to evaluate the longterm outcome of surgically treated complex fractures of the proximal humerus including fractures with initial humeral head ischemia. The study was focused on the assessment of the functional outcome as well as on the occurence of avascular necrosis.

Methods: 100 shoulders (98 patients/60y/21–88) with intracapsular fractures of the proximal humerus were included in a prospective surgical evaluation protocol (Binary [LEGO] description system: 48/100 4-, 46/100 3-, 6/100 2-fragment fractures). Humeral head perfusion was assessed intraoperatively by means of laser-Doppler flowmetry and borehole judgement. 51/100 fractures were treated with osteosynthesis (group A). 49/100 were treated with hemiarthroplasty (group B). In group A 41/51 heads were perfused at the index procedure (A1) and 10/51 were ischemic (A2). The patients were re-evaluated at a mean follow-up of 5.0 years (3.3–7.3) using the Constant-Murley-Score (CMS), the Subjective Shoulder Value (SSV) and conventional x-ray imaging.

Results: The median total CMS was 76 (37–98) in group A, 70 (39–84) (group B) (p=0.02). The median SSV was 92 (40–100) (group A) and 90 (40–100) in group B (p=0.93). In group A1 6/30 heads were structurally alterated but not collapsed; 4/30 were collapsed. In group A2 6/10 were structurally alterated but not collapsed; 3/10 were collapsed. The median CMS for patients without structural alterations was 80 (37–98), for those with structural alterations 84 (53–93) and for those with collapsed heads 63 (48–74). The median SSV was 95 (50–100), 92 (50–100) and 60 (40–80), respectively.

Conclusions: Revascularization of the humeral head after initial ischemia is possible and occured in 7/10 patients. Their functional results were comparable to those of patients with initially perfused heads. When feasible, osteosynthesis is a viable option even for ischemic heads. The indication for osteosynthesis should be weighed against the fact that Osteosynthesis and Arthroplasty showed comparable long-term results.


A. Sukthankar E. Lingenfelter C. Gerber

INTRODUCTION: In irreparable rotator cuff tear associated with pseudoparalysis, inverse prostheses have shown to be able to restore overhead elevation and strength. If the rotator cuff disease involves the teres minor muscle, pseudoparalysis in external rotation can adversely affect function and functional outcome of inverse arthroplasty. The goal of our study was to evaluate the outcome of inverse total shoulder arthroplasty combined with latissimus dorsi transfer for combined pseudoparalysis in elevation and external rotation.

MATERIAL AND METHODS: From 1998 till 2005, we retrospectively analyzed 11 shoulders in 10 patients with at a mean follow up of 20 months. All 11 shoulders had a massive rotator cuff tear with fatty degeneration of the posterosuperior cuff including teres minor exceeding stage 2 according to Goutallier and an average osteoarthritis grade 2 according to Samilson and Prieto Data assessment included pre- and postoperative clinical examination and Constant Score as well as standard radiographs.

RESULTS At follow up, subjective shoulder value increased from 27% to 68%, Constant Score improved significantly from 48% to 94%, flexion from 106° to 141°, abduction from 95° to 150° and strength from 0.2 to 4.9 (p< 0.05). Although no gain was seen in active external rotation in adduction, a significant loss of external lag was noted from 47° to 9° (p< 0.05). All patients were able to perform overhead activities with increase in functional use of the arm (p< 0.05). Complication requiring revision included postoperative infection in one and hematoma in another case.

CONCLUSION: Irreparable rupture of the posterosuperior rotator cuff involving with pseudoparalysis of elevation and external rotation,, the implantation of an inverse prosthesis combined with latissimus dorsi transfer can increase active range of motion and substantially improve functional external rotation, as opposed to the published results of the inverse prosthesis alone, which do not improve active external rotation.


M.A. Zumstein R.W. Simovitch E. Lohri N. Helmy C. Gerber

INTRODUCTION: The reverse DELTA III shoulder prosthesis can successfully relieve pain and restore function in cuff tear arthropathy. The most frequently reported complication is inferior scapular notching. The purpose of this study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence.

STUDY PROTOCOL: Seventy-seven consecutive shoulders of 76 patients of an average age of 71 years with an irreparable rotator cuff deficiency were treated with a reverse DELTA III shoulder arthroplasty and followed clinically and radiographically under fluoroscopic control for a minimum of 24 months (mean: 44, range: 24 to 96). The effect of glenoid cranial caudal component positioning and of the prosthesis–scapular neck angle on the development of inferior scapular notching and clinical outcome was assessed.

RESULTS: All shoulders which developed notching did so in the first fourteen months. Forty-four percent of the shoulders had inferior scapular notching, 30% had posterior notching and anterior notching (8%) was rare. Osteophytes along the inferior scapula occurred in 27% of the shoulders. The angle between the glénosphère and the scapular neck (r=+0.677)) as well as the craniocaudal position of the glénosphère (r=+0.654) were highly correlated with inferior notching (p< 0.001). A notching index (notching index = height of prosthesis + (prosthesis scapular neck angle x 0.13) was calculated using the height of implantation of the glénosphère and the postoperative prosthesis scapular neck angle: This allowed a prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%. The height of implantation of the glenosphere had a greater influence on inferior notching than the prosthesis scapular neck angle by a factor of approximately 1:8. Inferior scapular notching was associated with a significantly poorer clinical outcome than absence of inferior notching: At final follow-up, the respective average subjective shoulder values were 62% and 71% (p=0.032), relative Constant scores were 72% and 83% (p=0.028), abduction strength was 4.3 versus 8.7 kilograms (p< 0.001), active abduction was 102° versus 118° (p=0.033) and flexion averaged 110° versus 127° (p=0.004).

DISCUSSION: Inferior scapular notching after reverse total shoulder arthroplasty adversely affects midterm clinical outcome. It can be prevented by optimal positioning of the glenoid component.


F. Reuther D. Wahl S. Müller

This prospective follow-up study investigates the correlation between healing of the tuberosities and the functional outcome after arthroplasty with a trauma shoulder prosthesis in elderly patients with non-reconstructable humeral head fractures.

Surgery was performed on 65 patients (66 cases). Patients underwent clinical and radiological evaluation.

A total of 56 patients (57 cases) were examined after a mean time to follow-up of 16 months (range 4–62 months). Mean Constant Score was 50 and the age- and gender-corrected value was 73%.

The Constant Score was significantly higher (62 points, p=0.015) if the tuberosities healed. Mean ASES index was 68 and correlated significantly to the Constant Score (r=0.77).

Healing of the tuberosities is crucial to achieve good functionality in patients treated with a humeral head prosthesis. For elderly patients, the main objectives are to recover the ability to perform activities of daily living, to become pain free, and to reach a high level of satisfaction. All these criteria are largely achieved by the procedure described in this paper.


T. BUFQUIN L. HUBERT P. MASSIN

Introduction. The treatment of complex fractures of the proximal humerus still raises controversy, particularly in those 3 or 4 part fragments fractures, which are at risk for osteosynthesis (poor fixation in poor bone) or for secondary avascular necrosis. Conventional hemi-arthroplasty has currently remained the most common surgical treatment, but the recovery of active mobility remains incomplete and disappointing.

Inverted shoulder arthroplasty has been initially proposed for the treatment of omarthrosis secondary to deficient rotatory cuffs, however its use in acute traumatology has not been yet investigated.

Material and Medthod. We hereby present the results obtained in 43 consecutive patients (41 women and 2 men) which were retrospectively reviewed with a mean follow-up of 21 months (5–58). The mean age was 78 years-old (64–97). There were 5 three-part fractures, 26 four-part fractures and 12 four-part fracture dislocations. All patients were clinically and radiologically assessed, except two, who deceased with incomplete follow-up data.

Results. The clinical outcome was satisfactory with a mean active forward elevation of 97° and a mean active external rotation in abduction (ER 2) of 30°. The mean Constant score was 44 points (16–69). The mean ponderate score was 66% (25–97%). The mean pain score was 12.5/15, the mean activity score was 10.9/20, the mobility score was 17.6/40 and the strength score was 3.6/25. The mean ponderate score of the controlateral shoulder was 105 %(80–130).

The mean ASES score was 9 points (0–19) out of 24. The mean DASH score was 44 points (0–92) out of 100.

Post-operative complications included 3 reflex sympathetic dystrophies, 5 regressive neurological complications, 1 loosening of the deltoid suture, 1 anterior dislocation and 1 acromion fracture. There was no infection.

Radiographs at last follow-up showed peri-prosthetic calcifications in 36 cases, displacements of the tuberosities in 19 cases and scapular notches in 10 cases (1 type III, 3 type II and 6 type I notches). No migration of the prosthetic components was observed.

Discussion. Satisfactory mobility scores can be obtained in the treatment of complex shoulder fractures in the elderly, despite frequent deficiencies of the rotator cuff, whatever their causes, degenerative or traumatic (secondary displacement).

Conclusion. Inverted shoulder arthroplasty might constitute an interesting alternative in the treatment of displaced 3 or 4 part fragment fractures in the elderly over 70. Long term results are required before extending the indications to younger patients or to other types of fracture.


P. Baker G. Akra W. Eardley J. Candal-Couto R. Liow A. Rangan

Introduction: The surgical management of proximal humeral fractures continues to be an unsolved problem for the orthopaedic surgeon. Disagreement remains over how best to fix the more challenging complex fractures in younger patients where the ultimate goals of treatment are restoration of a painless shoulder, adequate function, and preservation of humeral head viability.

The PHILOS plate attempts to improve on previously designed implants by preserving the biological integrity of the humeral head articular fragment. The minimally invasive technique minimises soft tissue damage whilst at the same time securing the reduction using multiple locking screws with angular stability, thus allowing early mobilisation.

Methods: Retrospective review of the notes and x-ray images of 54 fractures treated with the PHILOS plate between Jan 2000 and Aug 2005. Data including baseline demographics, the presence of any complications and the need for reoperation were collected. In addition 43 (81%) patients were contacted and Oxford (OSS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were calculated to assess functional recovery. All patients were contacted at a minimum of 6 months following fixation with an average follow up of 18 months (Range 6–41 months)

We also present a cost analysis relating to the use of the PHILOS plate in practice.

Results: 54 fractures in 53 patients (25F:28M). Average age 54.4. There were 26 2-part, 15 3-part and 13 4-part fractures. A total of 11 (20%) patients had complications of which 7 (13%) required reoperation. These complications included deep infection (3 cases), AVN (4), Non Union (3) and plate impingement (1).

Mean OSS and DASH at follow up were 24.8 (S.D 11.6) and 28.0 (S.D 26.9) respectively. Worse scores were seen in those patients who had complications (OSS 39.4 Vs 22.6, DASH 58.2 Vs 23.4) although this difference was not statistically significant. There was also a trend for poorer scores with increasing fracture complexity and better scores in those patients operated upon by surgeons with a specific interest in the upper limb and in patients whose surgeon had performed more than 5 fixations.

Conclusion: Our series reports a much higher complication rate (20%) than that previously published. Whilst those patients who do not suffer complications reported good functional outcomes the presence of postoperative complications was associated with poorer results. Outcomes following surgery were affected by patient, implant and surgeon related factors. Given the high rate of serious complications and their detrimental affect on outcome surgeons should give serious consideration to the appropriateness of using such implants. To clarify these issues, further prospective randomised trials are needed.


P. Biberthaler V. Braunstein C. Kirchhoff M. Kroetz M. Kettler W. Mutschler

Background: Fractures of the humeral head are a relevant problem in orthopedic surgery and the optimal therapeutic strategy of displaced fractures remains debated controversially in literature. In this respect, a special locking-plate was designed recently for the humerus to improve fixation of open reduction. However, analysis of larger series are still missing. Hence, the aim of this study was to analyze prospectively all patients suffering from humeral head fractures which were stabilized by the internal fixation system PHILOS (Synthes).

Patients and Methods: From 01/2002 until 08/2005 225 displaced humeral head fractures were treated by PHILOS plates. The fractures were classified according to the classification of Neer. Mean observation period was 9 months postoperative. For clinical evaluation the constant score was calculated after a mean observation period of 9 months. Moreover, an X-ray was performed in two plains to judge the implant position. From the total collective of 225 patients, an amount of 176 patients were enclosed into the clinical evaluation. The others were either deceased, or could not be contacted for other reasons.

Results: Out of the enrolled 176 patients into the follow-up study, 35% were Neer III, 43% were Neer type IV/V-3, and Neer type IV/V-4 were found in 12% beside 10% others. After 9 months, the mean constant score was absolute 75 ± 17 points. In direct postoperative X-ray of the 225 patients, a correct reduction and adequate axis between head and shaft was found in 92% of the patients. However, in 14% incorrect implant position was present in terms of intraarticular screws (11%) and elevated plate position in 6 cases. Moreover, after 9 months 8 patients demonstrated secondary implant dislocation, 3 of the head and 5 of the shaft and 14% suffered from secondary screw perforation into the joint due to humeral head sintering. Complete necrosis of the humeral head was present in 5 cases whereas partial necrosis was proven in 9 patients. Since sometimes, several complications were present in a single patient, the total amount of complication cases was 29 and these patients required secondary surgery.

Conclusion: The PHILOS locking plate system allows for an reliable internal fixation of humeral head fractures presenting a reasonable low complication rate. However, surgical pearls comprise mandatory cerclages of both tubercula framed onto the plate and correct axis of humeral head reposition. Typical pitfalls are intraarticular screws, secondary sintering and mislead anticipation of the stronghold of screw fixation in the bone by the locking mechanism. An randomized prospective study is currently on the way to further illuminate the quality of locking plate systems in the humeral head.


M.J. Kääb S. Greiner S. Eschenbach S. Zandi N. Haas

Introduction: Regarding operative treatment of proximal humeral fractures no current treatment guidelines have been established so far. Angular stable implant for stabilisation of proximal humerus fractures find increased spreading. Aim of the study was the evaluation of pain, function subjective contentment and especial the surgical complications after stabilization with the Proximal Humerus Plate.

Methods: 214 patients were treated with PHP from 8/2001 to 2/2005 and documented prospectively. The humeral head fragment was fixated with four angular stable self locking screws. Neer–Classification showed 102 2-part, 71 3-part and 41 4-part fractures. Follow up (x-ray, VAS, Constant Score) was performed after 6 and 12 months respectively.

Results: Until now 154 (72%) Patients were available for follow up. Complications were seen in 31 cases (20%). Leading were perforation of self locking screws of the humeral head (10), followed by secondary dislocation (7, 3 of them with re-trauma), secondary humeral head necrosis (6), implant failure (3), malposition (varus) (3), and infection (2). In 18 cases (12%) re-operation was necessary: removal of screws (7), re-osteosynthesis (6), hemiarthroplasty (5). The constant score (compared to uninjured side) was 6 months postoperatively 61 (71%) and after 12 months 73 (82%).

Conclusion: The problems of osteosynthesis of proximal humeral fractures using an internal fixator are shown by the complications. Especially rigid self locking head screws show a high risk to perforate the humeral articular surface. On the other hand results showed good primary and secondary stability in comparison with the literature.


A. Farron A. Cikes S. Brenn M. Wettstein F. Chevalley

Introduction: Locking plates and screws have been developed to increase stability of internal fixation in osteoporotic bone. The anatomic design should also facilitate the fracture’s reduction in complex cases.

The aim of this study was analyse the results of locking plates used for fractures of the proximal humerus and to look for specific complications.

Method: Forty four patients (mean age 60; 28 males and 16 females) were treated with a locking plate (Philos, Synthes-Sratec Medical, Switzerland) for trauma of the proximal humerus. There were fourteen 2-part (32%), ten 3-part (23%), ten valgus impacted 4-part (23%), 3 classical 4-part (7%) fractures and 7 non-unions (15%). Five patients presented an associated gleno-humeral dislocation. Patients were reviewed clinically and radiologically at a mean follow-up of 21 months (6–42). A particular attention was paid to the occurrence of specific complications.

Results: A deep infection occurred in two patients (4,5%); two others lost the reduction (4,5%), and one broke his plate (2,3%). We observed 9 cases (20,5%) of avascular necrosis. Six patients (13,6%) had an impaction of the fracture with secondary intraarticular protrusion of the locked screws, which induced a secondary glenoid wear. The impaction sometimes occurred even without any evidence of AVN. Protrusion of screws were more frequent in elderly patients or in cases of non-union. Revision surgery (18 operations) was performed in 16 patients (36%) : 9 isolated material removal; 3 revisions for loss of reduction and malposition of the plate; 2 debridement including implantation of a cement spacer with antibiotics; 4 arthroplasties (2 hemi and 2 total shoulder prostheses).

Conclusions: Proximal humerus locking plates and screws, designed to improve stability in osteoporotic bone, may have specific complications. They do not prevent fracture’s impaction, resulting in an intraarticular protrusion of the locked screws, which may induce a severe secondary wear of the glenoid. This phenomenon could be due to the direction of the forces and stresses applied on the humeral head, which is mainly parallel to the screws and not perpendicular to them. Accordingly, patients operated on with proximal humerus locking plates should be regularly controlled. In case of progressive humeral head impaction, the material should be removed before it damages the glenoid.


R. Shahid R. Reddy M. Maqsood

Aim: To assess the clinical and functional outcome of proximal humeral fractures (2,3 and 4 parts) fixation with PHILOS (Proximal Humeral interlocked Osteosynthesis) plate using Oxford and DASH scoring system.

Methods: Forty-eight consecutive patients were treated with PHILOS plate from the complex proximal humeral fractures. One senior surgeon, using PHILOS plates, operated all patients. The patients were regularly assessed clinically, and plain radiographic evaluation was performed for fracture healing, avascular necrosis, and implant failure. Clinical outcome was measured using Oxford shoulder scores and DASH (Disability of the arm, shoulder, and hand) scores. Patients, who died, lost the follow up or the follow up was less than 3 months were excluded from the study.

Results: There were nine male patients (Age: 29–89 yrs) and twenty-nine female patients (Age: 35–93 yrs). Average age: 65 yrs. 74% were two part and three part fractures. Five patients died and four were lost in follow-up. These patients were excluded from the study. Mean follow-up time: 21.7 months (range: 6–44 months). Mean oxford shoulder scores: 41.8 (range: 14–60), Mean DASH scores: 30.2 (range: 0–83.3). There were no cases of non-union. Two plates were removed after fracture healing for complications of impingement and screw cutout.

Discussion & conclusion: Proximal humeral fractures constitute 5–7% of all fractures and 26% of humeral fractures.13–16% of proximal humeral fractures are 3 & 4 parts. Proximal humeral fractures have been a challenge to acquire stable fixation. Difficulties have been multifactorial, including osteoporotic bone, angular instability and non-availability of the low-profile implant to avoid impingements. PHILOS plate having locking screws provides angular stability and better hold in osteoporotic bone. It is low profile, which avoids subacromial impingement. Multiple holes in the proximal part of plate for suture anchors helps for soft tissue augmentation. PHILOS plate can provide an excellent stable construct even in multifragmented Osteoporotic proximal humeral fractures.

Our study has shown that PHILOS plates are reliable implants for internal fixation of proximal humerus fractures. An inverse correlation was seen between oxford shoulder scores and DASH scores. Patients with higher oxford scores indicating a good outcome had lesser disability scores. Comminuted fractures (four part fractures) had less than satisfactory shoulder scores and higher disability scores. In general, younger patients did better than older patients. This study demonstrates that PHILOS plates provide stable internal fixation for proximal humerus fractures. Age and fracture configuration play a significant role in the clinical outcome of these fractures after internal fixation.


S. BATRA A. GUL M. HOSSAIN A. McMurtrie S. KALE

The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an “adequate” or “acceptable“ reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A& E) in UK. A nation wide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination, and ulnar variance, there being a significant difference between orthopaedic n=16(64%) and A& E staff n=24(32%); p=0.031; c2 = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff n=12 (48%) being more aware than A& E staff, n=6 (8%); p=0.002; c2 = 6.38. Only 19% formally measure the key parameters before decision making [52% Orthopaedic versus 8% A& E staff; p=0.018; c2 = 7.31]. Only 14% of respondents from hospitals equipped with picture archive navigation system (PACS) stated that they used the angle measurement function.

A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasize the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A& E setting with significant economic implications.


J.M. Costa Martins

The humerus neck fractures (HNF) are a frequent pathology in the 6th decade of life. Until now the manipulation and the most of the traditional surgeries (including prosthesis) haven’t shoed satisfactory results. By using the TGF system, a minimal invasive technique, we have the advantage of immediate mobility of the articulation. The TGF system is a mixed fixator that creats a new concept in osteotaxis. This new concept, using tension-guides, allows us to look at HNF as a non invasive and effective way of treatment.

We use the Neer classification, accepted worldwide in HNF. We have operated successfully 5 HNF Neer II, 16 HNF Neer III and 9 HNF Neer IV, between 26 years and 83 years old in 6 males and 24 females. The cinetical lesion’s energy was divided in: Hight energy–4 cases, Medial energy–5 cases, Low energy–21 cases.

Because of the complexity of this type of fractures, the conservative or the osteosynthesis have a low rate of sucess. With TGF system the results are good, with 100% of consolidation and a good final alignement. The funcional results are: Very good, with 100% of mobilization and no pain–4 cases; Good, with 80% to 100% of mobilization and some times pain–23 cases; Regular, with 80% to 50% of mobilization and pain with effort–3 cases; Bad, with less than 50% of mobilization and constant pain–0 cases. As complications we reported 4 pin superficial infection.

The TGF system has proved, as we can show, attending it’s safety ness and efficacy, to be the best method for the treatment of HNF.


A.G. Baltov N.N. Tzachev A.M. Iotov E.T. Takov

Introduction: For a period of 7 years were treated in Emergency Hospital Pirogov 205 patients with humeral shaft fracture (HSF)–125 with interlocking nailing (ILN), 80 with AO plates, these include 55 delayed unions (DU) and nonunions (NU).

Material and methods: We treated 15 DU (2–4 months), 19 NU after conservative treatment (4–12 months), 15 NU after operative treatment and 6 recalcitrant NU. 23 of the cases were men at the average age of 43.9 (18–74) and 32–women, at the average age of 64.7 (43–88). NU according to Weber-Cech were–2 hypertrophic, 18 olygotrophic and 20 atrophic, as 7 of them were infected. The initial trauma in 14 cases was high energy. The most common predisposing factors at DU are: poor bone contact–distraction 11 cases, soft tissue interposition 8 cases. At NU after conservative treatment: soft tissue interposition 13 cases and inadequate vascularity–severe injury 6 cases, and at NU after operative treatment: mechanical instability–inadequate fixation 18 cases and excessive soft tissue striping 11 cases. The usual contributing factors are: metabolic bone disease 23 cases; obesity 18 cases; poor functional level 14 cases; smoking 14 cases; advanced age 11 cases. Osteosynthesis with AO plate were 23 cases and the remaining 32–interlocking nails. Bone grafting was done in 23 cases, decortications in 12 cases, and channel reaming–in 20 cases.

Results: All the cases that were treated with AO plates consolidated for the average period of 103 days (70–150) and the cases with interlocking nails (with the exception of 3–9%) for the average period of 108 days (160–240). As post-operative complications we had 6 (26%) cases of iatrogenic neurological injury with plate ostheosynthesis, 3 (10%) cases of shoulder impingements with ILN, one case of shaft fracture and infection in both methods. The patients were followed for minimum 12 months after bone union–clinical and X-ray examinations (12–60) months. We rated the final functional result according to Rommens score: excellent–29, very good–13, good–8, satisfactory–2, bad–3.

Conclusion: We think that DU are more appropriate for interlocking nailing. The cases that NU are a result of unsuccessful conservative treatment, because intramedullary channel was obstructed, is better to be treated by ostheosynthesis with plate. And the contrary–it is suitable to replace ostheosynthesis with AO plate with interlocking nails after extraction of the implants in addition to bone grafting.


J.C. Feroussis A. Papaspiliopoulos M. Maris A. Kiriakos D. Varvitsiotis E. Kitsios

AIM: The diagnosis of the posterior dislocation can be missed. Chronic missed locked posterior fracture dislocations of the shoulder raise a difficult problem for treatment especially in young patients. The options for the treatment depend on the size of the humeral defect, the age of the patients and the time from injury to diagnosis.

METHOD: Eleven patients with missed locked posterior fracture dislocation of the glenohumeral joint, 25 to 52 years of age were treated with open reduction and transfer of the subscapularis tendon to the defect (modified Mc Laughlin technique). The interval from the injury to diagnosis ranged from 6 weeks to 6 months. Significant pain, prominence of the acromion, posterior bulging and complete loss of external rotation of the shoulder led to the diagnosis that was confirmed by an axillary radiograph and C.T. scan. The humeral head defect was from 20 to 40 per cent of the articular surface. Four patients also had a minimally displaced fracture of the upper humerus.

RESULTS: The average length of follow up was 3,5 years. Stability was restored and maintained in all cases. Six patients reported little or no pain. They had almost full range of motion and no functional restriction in the ADL. The remaining five patients had mild pain and slight restriction of movements mainly in external rotation in abduction (elevation 150°, external rotation 25°, internal rotation to L5). These patients had mild functional dysfunction in the ADL. All patients had normal muscle strength and constant score from 60–82.

CONCLUSION: Once the diagnosis is established, open reduction and subscapularis tendon transfer reliably decreased patients pain level and significally improved the range of motion and the level of function, restoring stability of the joint. The alternative for older patients or patients with humeral head defect greater than 40% is the use of shoulder prosthesis.


M. Ashraf N. Nugent K. O’Sullivan J. O’Beirne T. O’Sullivan G. McCoy

Introduction: We performed a clinical and radiological study to determine the functional outcome in terms of union and shoulder function and other related complications associated with treatment of humeral diaphyseal fractures with Intramedullary nailing.

Methods and Patients: A review of 100 consecutive humeral nailing over a period of four years performed solely for diaphyseal fractures using Russell Taylor nails.

51 male and 49 female.

Average age of 48.0 (25.3–63.8IQR)

45 Simple, 46 comminuted and 9 pathological fractures.

70 were isolated and 10 were part of multiple trauma fractures.

91 closed and 9 open fractures.

52 fractures due to simple falls, 30 road traffic accident,9 pathological fracture,8 work related and 1 unknow cause.

Out of 100 nails, 90 were statically locked while 9 were locked proximally and 1 was locked only distally.

The outcomes were assessed clinically, radiologically and using the Disability of Arm Shoulder and Hand (DASH) function scoring system.

Statistically Cronbach’s alphas were calculated for the three scales of the DASH instrument. These scales were the function/symptom scale consisting of 30 items, sports/music module containing 4 items, and work module comprising 4 items.

Medians (interquartile ranges) and ranges are presented for numerical variables.

Mann-Whitney U tests (two-tailed) and Univariate and multivariate regression analysis were used.

Results: 90% fractures united initially and 4% had delayed union, giving cumulative union rate of 94%. Six non unions required a second procedure.

The DASH function scale scores was categorised into good 71 patients 85.5% (Score 0-< 25),

Medium 4 patients 4.8% (Score 25-< 40) and Poor 8 patients 9.6% (Score 40+).

Univariate and multivariate regression analysis showed, Increasing age (adjusted OR=0.96,95%CI 0.93–0.99,P< 0.01) and communited compared to simple fractures (adjusted OR=0.12,95%CI 0.03–0.45,P< 0.01) were associated with reduced likelihood of attaining full range of motion.

Male patients (unadjusted OR=2.37,95%CI 0.90–6.25,P=0.08) and patients involved in RTA compared to falls (unadjusted OR=4.5,95%CI 0.96–21.07,P=0.06) were associated with higher likelihood of attaining full range of motion.

85 % had no complication, while 15 % had complications.

One nerve palsy and one case of infection.

Seven patients required nail removal and 3 required removal of proximal locking screw.

Conclusion: To date, we have the largest series in the literature of antegrade nailing for diaphyseal fractures. In our series the vast majority of patients achieved desired functional outcome and union, hence we recommend the use of intramedullary nailing for humeral diaphyseal fractures. By eliminating surgical technique errors, complications can be reduced further and even higher union rates can be achieved.


A.D. Delgado-Martinez P. Fernandez-Bisbal S. Reyes-Sanchez D. Obrero

Introduction and objectives: The most commonly used treatment for extraarticular fractures of distal radius is closed reduction and maintenance of reduction in a cast. Two types of casts are used: plaster splint for 7–10 days and later exchanged to a circular cast and the use of circular cast immediately. The objective of this work is to compare both types of treatment in terms of ability to achieve reduction and to maintain it during healing.

Methods: A prospective, randomized and blinded study was designed. To date, 21 patients enrolled the study. Informed consent was given. The inclusion criteria were: older than 35 years, extraarticular distal radius fracture sustained less than 24 hours before and not previously treated. Exclusion criteria included previous injury in the same wrist, open fracture, and not compliance with the protocol. After intrafocal anesthesia with mepivacaine 1%, fracture was reduced under traction and immobilized in a dorsal short plaster splint (splint group) or a circular short plaster cast (circular group) randomly. After 10 days of immobilization, the plaster splint was changed to a circular short plaster cast. AP and lateral X-Rays were taken before reduction, after reduction, after 10 days (before changing cast), and at 21 days. Volar inclination of lunate fossa on the lateral X-Ray was obtained. On the AP proyection, the radial inclination and radial length was measured. Complications were recorded. Data was analysed through ANOVA between groups.

Results: When comparing X-rays before and after reduction, the volar inclination of the lunate fossa on lateral projection changed from −21,4° to 8,60° (30° change) after reduction in splint group and from −15,22° to 1,78° (17° change) in circular group (p< 0.05). The other comparisons were N.S. When comparing after reduction and 10 days later, the radial inclination changed from 20,20° to 18,80° (1,40° change) in the splint group and from 20,89° to 20,44 (0,44° change) in the circular group (p< 0.05). Other comparisons were N.S. No differences were found between 10 days and 21 days in any X-Ray parameter. No complications were found.

Conclusions: A better reduction was achieved with the plaster splint method in the immediate X-Ray control. Nevertheless, reduction was better maintained during the first 10 days with the circular plaster cast method.


C.J. Chambers T.M. Barton E. Lane G.C. Bannister

Introduction: Displaced Colles’ fractures are usually managed by closed reduction and cast immobilisation. They are reduced initially but frequently lose position because cast immobilisation is an inefficient means of stabilisation. This results in malunion. If position is lost after reduction and cast immobilisation or the fracture is unstable, closed reduction and cast immobilisation is often supplemented by longitudinal k-wire fixation. There is a paucity of literature examining the incidence of unacceptable malunion after closed reduction and k-wire stabilisation.

Aim: The aim of this study was to determine whether closed reduction, longitudinal k-wire fixation and cast immobilisation of displaced fractures of the distal radius avoids unacceptable malunion. A secondary aim was to define the type of fracture best treated by this method.

Methods: 53 patients underwent closed reduction and longitudinal k-wiring of displaced Colles’ fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation.

Results: Manipulation significantly improved fracture position (p< 0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. 73% of fractures manipulated for radial shortening > 2mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. The mean shortening between reduction and fracture union was 1.6mm. This did not correlate with Frykman Class or radial shortening at injury.

Discussion: Closed Reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures not reduced to allow for this later loss of radial length are more likely to malunite. This may compromise functional outcome.


C. Restrepo G. Goldberg T. Dietrich T.A. Einhorn J. Parvizi

Introduction: The safety of simultaneous bilateral knee replacement (BTKA) remains controversial. Some studies have proposed a higher incidence of serious complications, even death, following BTKA whilst others refute the latter. The objective of this meta-analysis was to evaluate the safety of BTKA.

Methods: A computerized literature search was conducted to identify all citations, between 1966 to 2005, concerning BTKA. All the English-language abstracts were obtained. A multistage assessment was then used to identify articles fulfilling the inclusion criteria for the study. All randomized, prospective studies reporting the outcome of BTKA were included. Details of any reported data were extracted and extensive analysis of relevant variables carried out.

Results: 150 published articles pertaining to BTKA were identified of which 18 papers on 27,807 patients (44,684 knees) were included in the meta-analysis.10,734 cases were unilateral TKA, 16,378 were simultaneous BTKA and 458 were staged bilateral TKA with at least 3 months time duration between the surgical procedures. The complications analyzed were DVT, PE, cardiac events and mortality. The incidence of PE (OR=1.8), cardiac complications (OR=2.4), and mortality (OR=2.24) were higher after simultaneous BTKA. The incidence of DVT was LOWER in the group with simultaneous BTKA.

Discussion: Based on the findings of this meta-analysis, simultanous BTKA seems to carry a higher risk of serious cardiac complications, pulmonary complications, and mortality. This procedure should be reserved for the healthy and young patients.


H.B. MEHTA V. Eguru S. johnson

Distal radius fractures are commonest injury managed by junior doctors in accident and emergency department. Technique of manipulation is very well described and doctors are prepared from the days of medical school. Though manipulation is done in good position at initial management many patients require re-manipulation and surgical stabilisation due to loss of position on subsequent examination. Many Senior surgeon thinks this is due to inadequate plastering and moulding technique.

Material and methods: We retrospectively, randomly selected 50 patients from 210 manipulations done in one year at District General Hospital. All these patients x-rays were reviewed and data collected for classification of fracture (Frykmann’s classification), radial height, ulnar varience, radial angulation, and Radial inclination measurements. Three Senior Orthopaedic Surgeons reviewed pre and post manipulation x-rays and asked for acceptability of initial reduction, plaster position and moulding signs on x-rays and asked to predict those requiring re-manipulation or loss of position.

Results: 70% of the fractures were frykmann I or II as intra articular fractures Prediction of senior surgeon was right for more than 60 percent of the cases. Average radial angulation was 14 degree on post manipulation films. Radial height and inclination was average 6 mm and 18 degrees respectively.

Discussion: Post manipulation is very important factor for maintaining reduction and poor moulding can lead to loss of position and require unnecessary additional operative procedure for initially well reduced fracture. Teaching of Plastering and moulding technique is very important skill development for junior doctors to improve outcome of these simple injuries


S. Sidhom L. Audige M. Muller C. Hilty C. Booth P. de Boer

Fractures of the distal radius are common skeletal injuries. In most practices patients are discharged within few weeks to few months. The aim of this study is to investigate whether there is a difference in outcome between 6 months and 1 year with different treatment methods with special focus on conservative management.

A one-year prospective cohort study of patients with fractures of the distal radius was set in York Hospital. From 204 patients included, 200 (98%), 182 (89%) and 164 (82%) patients were evaluated at 6 weeks, 6 months and 1 year, respectively. Two patients had bilateral fractures. In total 162 fractures were treated conservatively, and 8 fractures were treated operatively following failure of conservative immobilization.

Outcome assessment included Gartland and Werley, DASH and SF-36 scoring systems. Between 6 months and 1 year there was statistically significant improvement in the over-all Gartland and Werley score (p< 0.001) and most of its components such as the subjective evaluation, grip strength, arthritis change, finger function, and the range of motion. There was no significant improvement in pain and deformity.

In the conservatively treated patients a good or excellent result was found after 6 months in 77%, after 1 year in 92%. In the failed conservative group it was 61% (5/7) and 83 % (5/6).

Conclusion: This study has shown that functional improvement occurs up to 1 year following distal radius fractures, therefore a final say in the outcome may not be determined before that time should the need arise for reconstructive surgery or medico legal advice.


K. Vishwanathan H.G. Gandhi R.N. Daveshwar P.P. Golwala

Purpose of study: Aim was to evaluate the functional outcome of External fixation supplemented by K-wire fixation in communited fractures of lower end radius and compare the outcome in closed and open fractures treated by this method.

Methods: External fixation along with K-wire fixation was done in 25 consecutive patients (mean age-41.9 years; range-20 to 72 years). According to Frykman’s classification, there were 3 Type VII fractures and 22 Type VIII fractures. 15 fractures were closed type, 4 were Open grade I, 4 were Open grade II and 2 were Open grade III according to Gustilo and Anderson classification. The mean follow-up period was 14.1 months (range- 6 to 25 months).

Results: The mean union time was 7 weeks (range-5 to 8 weeks). Mean dorsiflexion was 37.6 degrees, mean palmar flexion was 44.4 degrees, mean ulnar deviation was 16.2 degrees, mean radial deviation was 14.2 degrees, mean supination was 73 degrees and mean pronation was 79 degrees. Comparison of union time, dorsiflexion, palmarflexion, ulnar deviation, radial deviation, supination and pronation between closed, Open grade I, Open grade II and Open grade III fractures revealed no significant difference. Significant radial shortening was observed in patients with open fractures (P=0.004). 1 patient developed schanz pin tract infection and late distal radioulnar joint subluxation was seen in 4 patients.

Conclusion: Supplementation of External fixator with K-wires is an effective method for treating both closed and open fractures of distal end radius however; radial shortening is seen in some cases with open fractures.


J.E. Tomlinson E. Hannon S. Sturdee N. London

Introduction: The use of simultaneous bilateral knee replacement surgery remains controversial–several studies have reported increased rates of complications, and the use of the technique remains in question. However, many of these procedures are not truly simultaneous, meaning it is difficult to draw accurate conclusions on the safety of this technique from the published literature.

Method: A retrospective notes based review of all those patients undergoing bilateral knee replacement surgery between 2000 and 2005 at Harrogate District Hospital was performed. Patients undergoing both unicompartmental (UNI) and total knee replacement (TKR) were included. Procedures were performed by a consultant orthopaedic surgeon and his knee fellow with one scrub team. The post operative morbidity and mortality was assessed both 30 days post operatively and also at six month follow up.

Results: A total of 112 procedures were performed over the five year period. There were no deaths reported within the study group. Within the group there were 3 DVT’s, 2 superficial wound infections and one case of aseptic loosening at six months. Average tourniquet time was 76 minutes for the TKR group and 82 minutes for the UNI group. Average length of stay over the five year period was 8.6 nights (TKR) and 6.6 nights (UNI).

Conclusion: Bilateral truly simultaneous knee replacement surgery is a safe technique with favourable rates of complications. It offers the benefit of improved efficiency with regard to both theatre time and length of hospital stay, which is valuable in the modern climate of economic strain within health services worldwide. It also offers an excellent opportunity to the trainee to operate independently within a controlled environment, and is favoured by patients–offering a single admission and rehabilitation period.


L.C. Biant W.J. Bruce P. Walker S. Herrmann W. Walsh

Intro: Total knee replacement (TKR) manufacturers offer the option of high flexion tibial tray inserts. The polyethylene is narrower posteriorly than the standard insert and comes with the theoretical risk of reduced longevity due to thinner implant. This trial studied both the intra-operative and post-operative difference in knee flexion.

Method: 100 consecutive patients undergoing posterior stabilized Genesis II TKR with Brainlab navigation were studied. The flexion of each knee was assessed per-operatively using the Brainlab navigation system for both the high flex and standard tibial insert trials. Patients were then randomized to receive either a high flex or standard definitive implant and the knee flexion measured clinically with a goniometer six months post op.

Results: Intra-operatively the high flexion insert trial flexed more than the standard flex option by 3.2 degrees. Clinically at six months post op there was no difference in knee flexion between the two groups.

Conclusion: There is no clinical difference in knee flex-ion at six months post-op in patients with a high flex or standard tibial insert. However, we believe that in certain technical circumstances the high flex option is a valuable option for the surgeon to have available.


A.A. Amin A.P. Sanghrajka N. Kang G. Scott

In order to eliminate the “conflict” that can occur with physiological roll back of the femur on the tibia, most modern knee arthroplasty prostheses are designed to have little conformity between the femoral and tibial surfaces. However, a consequence of this design is paradoxical anterior sliding of the femur on tibia, which can result in clinically significant gait abnormalities. Recent studies show that during movement of the knee, the medial side remains very nearly stable like a ball-in-socket joint, whilst the lateral side moves front to back, rotating around the centre of the medial side. A total knee joint prosthesis designed with these same kinematics may therefore be advantageous. The objective of this study was to investigate the hypothesis that the increased constraint of a medial pivot knee promotes earlier loosening of the prosthesis.

METHODS: This was a retrospective radiographic cohort study. Using our unit’s knee arthroplasty database, all patients with a Freeman-Samuelson 1000 knee arthroplasty (medial pivot design) or a Freeman-Samuelson Modular knee arthroplasty with a minimum follow-up of 2 years were identified, and matched as closely as possible for age, length of follow-up and pre-operative diagnosis (Osteoarthritis, Rheumatoid arthritis or Post-traumatic arthritis). This was a single surgeon series using a standard surgical approach with a posterior cruciate sacrificing technique. Standardised anteroposterior and lateral radiographs taken postoperatively, at 6 months, 1 year and then at yearly intervals, were examined systematically and independently of the senior surgeon (GS). Component migration and radiolucent line scores were allocated as recommended by the Knee Society.

RESULTS: Group 1 (n=55),–Freeman Samuelson Modular design, mean age–70.3 years, mean length of follow-up–4.5 years. Group 2 (n=48),–Freeman Samuelson 1000 design (Medial pivot), mean age–70.4 years, mean length of follow-up–4.3 years. There were no failures in group 1. There was one failure requiring revision of the femoral component in group 2. Radiolucent lines were more prominent and frequent in the tibia, particularly under the medial and lateral plateau’s (KSS zone 1 and 6). There was no significant difference in the overall radiolucent line scores between the two groups (p=0.39, Mann Whitney U test). Similarly we found no difference between radiolucent line progression in the specific tibial zones (1–6 KSS system). Radiolucent lines in the femur were infrequent and insignificant.

CONCLUSION: We found no statistically significant difference between the two designs of knee prosthesis in terms of either total radiolucent line score or rate of radiolucent line progression. The increased constraint of the medial pivot knee prosthesis does not appear to result in an increased incidence of radiographic loosening.


E.T. Davis E. Lingard E. Schemitsch J. Waddell

We aimed to identify whether patients in lower socioeconomic groups had worse function prior to total knee arthroplasty and to establish whether these patients had worse post-operative outcome following total knee arthroplasty. Data was obtained from the Kinemax outcome study, this was a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in thirteen centers, four in the United States, six in the United Kingdom, two in Australia and one in Canada. Pre-operative data was collected within six weeks of surgery and patients were followed for two years post-operatively. Pre-operative details of the patient’s demographics, socioeconomic status (education and income), height, weight and co-morbid conditions were obtained. The WOMAC and SF-36 scores were also obtained. Multivariate regression was utilised to analyse the association between socioeconomic status and the patient’s pre-operative scores and post-operative outcome. During the analysis, we were able to control for variables that have previously been shown to effect pre-operative scores and post-operative outcome. Patients with a lower income had a significantly worse pre-operative WOMAC pain (p=0.021) and function score (p=0.039) than those with higher incomes. However, income did not have a significant impact on outcome except for WOMAC Pain at 12-months (p=0.014). At all the other post-operative assessment times, there was no correlation between income and WOMAC Pain and WOMAC Function. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. This study demonstrates that across all four countries, patients with lower incomes appear to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to effect the final outcome following total knee arthroplasty. Patients with lower incomes appear able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively.


S. Tarabichi

Introduction: Literature fails clearly to indicate an advantage of a mobile bearing over the fixed bearing implant. The purpose of this study is to compare result of mobile bearing verses fixed bearing Total Knee replacement done by single surgeon and to see if there is any advantage for the mobile bearing.

Material and Methods: Eight hundred sixty two cases of a mobile bearing LPS Flex implant was compared to four hundred twenty six cases of fix bearing LPS implant done from January of 2001 to January 2006, both group was performed by the same surgeon and the same postoperative cause was done in both group. Documentation for complication and knee score were done in both groups and statistics and analyses were curried out for this result. Also three kinematics evaluation was curried on for ten patients of each group to asset the tibia femoral movement in both groups in deep flexions.

Result: We had three Knee dislocations in the mobile bearing group none in the fixed bearing group the rest of the complication were similar in both group.

Average range of motion was the same in both groups.

Knee score was similar in both groups.

Canamathic assessment confirmed in both group excessive exteneraltation of the femur over the tibia and in fixed bearing group it confirms the spelling of the lateral femoral condoral from the tibial Plato which wrist concern about the safety Fix bearing in deep flexion.

Discussion and Conclusion: There was no clear advantage of Mobil bearing over fixed bearing implant, mobile bearing requires a better sophistical balance to reduce rate of Knee dislocation postoperatively. The mobile bearing knee seems to be more accommodating to deep flexion over Hundred & Fifty degrees and concern should be raised about the fixed bearing in deep flexion activity.


T. Lind-Hansen P.T. Nielsen J. Petruskevicius B. Endelt K.B. Nielsen I. Hvid M.C. Lind

INTRODUCTION: Medial open-wedge HTO is an alternative in the treatment of medial knee OA for the young and active patient. However this technique leaves an open gap that requires stable fixation to achieve bony healing. As a bone substitute injectable calcium-phosphate-cements could be an alternative to autograft.

MATERIAL AND METHODS: Biomechanical testings were performed on open wedge HTO to investigate load to failure and displacement after cyclic loading (viscous and/or damaged material response). A medial 10 mm open-wedge osteotomy was performed on 7 pairs of composite (Sawbone) left tibiaes, and 8 pairs of preserved cadaver tibiaes. Osteosynthesis where performed with the Dynafix system. In half of the bones the gap was filled with 15 g of Calcibon®. The composite tibiaes were loaded at a ramp speed of 20 mm/min and failures of the constructs were recorded visually. On the cadaver tibiaes, cyclical loading were performed with a maximum load of 2250 N.

RESULTS: Filling of the gap with Calcibon® resulted in significant different load-to-failure patterns with failure at 10.2 kN compared to 2.7 kN in the group without Calcibon®. Displacement at the end of cyclical loading was 1.2 mm in the group with Calcibon® and 2.7 mm in the group without Calcibon®. This difference also was significant.

CONCLUSION: The injectable calcium-phosphate-cement Calcibon® enhances primary stability during load to failure and during cyclical loading in open wedge osteotomies on proximal tibia. Clinical studies are performed to investigate whether Calcibon® has any clinical advantage on wedge healing and stability.


M. Maier U. Schreiber V. Martinek A.B. Imhoff

The objective of the study was to verify a positive effect of an additional oblique cancellous screw on the primary rotational stability of complete and incomplete high tibial closed-wedge osteotomies (8°) in ovine tibiae. Of 51 specimen 48 were employed for final results. The osteotomy site was stabilized with L-shaped plates (Allopro, Sulzer Orthopedics GmbH, Freiburg, Germany). The specimen were subdivided in 4 groups: complete (1/2) and incomplete (4/5 of the mediolateral tibial diameter in height of the horizontal sawing-jig) (3/4) osteotomies each with (1/3)) and without (2/4) an additional oblique cancellous screw. Constant axial load of 200 Newton and rotational velocity of 0,496°/sec. was applied during testing. 8 ovine specimen were tested without osteotomy or rigid fixation as a control group (5). Statistical significance (p< 0,05) was determined via the nonparametric Mann-Whitney U-test. The results were charted with SPSS (version 11.0). Correlation between objective measurement parameters and primary rotational stability of the specimen was displayed according to Pearson. The primary rotational stabilty in group 1 (intact medial cortical bone, incomplete osteotomy with additional oblique cancellous screw) was significantly higher than in groups 2, 3 and 4. In this group the resulting torsional moments in the initial part of the charted graphs were even higher than in the control group. Group 2 (incomplete osteotomy without a oblique cancellous screw) showed a significantly higher primary rotational stability compared to the groups with complete osteotomy (group 3/4). Between the groups with complete osteotomy (3/4) no significant differences in rotational stability occured. No significant correlation could be found between the objective measurement parameters of the specimen (length, weight, maximal width of the tibial plateau) and the primary rotational stability of the rigidly fixated ovine tibiae. This biomechanical in-vitro assessment showed that an intact medial cortical bone bridge has a statistically significant impact on the primary rotational stability of lateral closed-wedge osteotomies in proximal tibiae. An oblique cancellous screw through the osteotomy gap has an additional effect concerning rotational stability. In case of complete osteotomy of the proximal tibiae or due to inadequate operative technique the stabilizing effect of the medial cortical bone bridge gets lost. This results in a deterioration of rotational stability at the osteotomy site and in a sufficicantly rigid fixation is no longer guaranteed. In this case an additionally inserted oblique cancellous bone screw leads to higher resistance against rotational forces. A rigid osteosynthetic stabilization of corrective osteotomies in proximal tibiae seems a condition precedent to obtain the desired correction angle.


T. Gunes C. Sen B. Bostan M. Erdem A. Kalaycioglu S. Sahin

Introduction: Medial laxity is an important problem in knees with mono-compartmental gonarthrosis. Medial laxity can cause the progression of the gonarthrosis if it is left uncorrected. Therefore, managing of medial laxity during high tibial osteotomy is very important. In this study, the effect of openning focal-dome type osteotomy on the medial laxity was investigated.

Materials-Methods: Four knees of two cadavers (74-year-old male and 52-year-old female) were used in this study. For the creating pseudo-medial laxity in the knee, while total medial menisectomy was performed in two knees of male cadaver, 5 mm osteochondral resection of both joint surfaces of the medial femoral condyle and medial tibial plateau was performed in two knees of female cadaver.

Results: After creation of the pseudo-medial laxity, opening focal-dome type osteotomy extending to proximal to the insertion of superficial medial collateral ligament was applied with circular fixator in all knees and 15° valgus effect was applied on the osteotomy line by motor unit of the circular fixator. By applying 15° valgus effect on the osteotomy, average reduction of medial laxity was measured as 70% in all knees.

Conclusions: Opening focal-dome type osteotomy decreases medial laxity effectively by tightening the superficial medial collateral ligament.


A. Baldini E. Baldi A. Trinci

Opening wedge high tibial osteotomy (HTO) for varus knee osteoarthritis has shown several advantages over the classic closing wedge technique. The aim of the current prospective study was to evaluate mid-term clinical and radiographic results, as well as complications, of medial opening wedge osteotomy using the hemicallotasis technique. Forty-nine high tibial oste-otomies were performed for unilateral varus primary osteoarthritis from 1999 to 2002. A medial incomplete osteotomy was performed after elevating the superficial collateral ligament. Four pins were inserted, two hydroxyapatite-coated in the metaphyseal bone, and two standard conical pins in the diaphyseal bone. The correction started 4–5 days postoperatively. The patient managed the correction by adjusting half of a turn twice each day. When the desired correction was achieved, the device was locked. Eight-to-nine weeks after surgery, the radiographic healing was evaluated, and if adequate, the device was removed on a outpatient basis. The mean age of the patients was 57 years (range, 32–70 years). The mean follow-up was 5 years (range, 4–7 years). The mean hip-knee-ankle angle (HKA) was 167 (range 164–171) deg preoperatively and 182 (range, 176–186) deg at follow up. We did not observe any early or late collapse of the new bone wedge. Union was achieved in all patients, and the mean time to fixation was 69 (range 60–85) days. Knee Society score improved from 52 points preoperatively to 93 at follow up. Eighty-five percent of the patients showed excellent-to-good clinical outcome. None of the knees had required revision surgery at follow-up. No meta-diaphyseal mismatch was noted on both the sagittal and coronal plain at radiographic analysis. Patellar height (IS ratio) reduced, on average, from 1.1 (±0.4) to 0.9 (±0.4), but no patella was found to be baja. Complications included a number of superficial infection uneventfully healed such as two cellulitis with erysipelas-like rushes, and five minor (grade I-II) pin tract infections. There were two technical problems. One obese patient developed an undisplaced inter-condylar fracture of the proximal tibial osteotomized fragment, which subsequently healed and the patient achieved a good clinical outcome. In another patient the anterior pin on the metaphyseal fragment was positioned too anteriorly, and was thereafter repositioned. There were no neurologic or vascular complications. Using the hemicallotasis technique for HTO the authors obtained a precise correction with a relatively low complication rate. The use of an external fixator allowed quick surgery, early weight-bearing, immediate knee motion, avoiding permanent hardware on bone. Conversion to a total knee arthroplasty seems to be easy when this technique has been employed, but the influence of pin tract infection on possible septic failures remains to be determined.


S.K. Rengasamy O.N. Nagi

Background: Long-term studies indicate that the clinical success of high tibial osteotomy deteriorates with time. The purpose of this study was to evaluate the long-term results of a combined lateral closing and medial opening wedge technique for high tibial osteotomy with a minimum 15 years follow-up.

Materials and Methods: From January 1981 to June 1990, ninety-two patients underwent ninety-four high tibial valgus osteotomies. The average preoperative varus deformity was 13.50. The surgical technique consisted of a proximal lateral closing wedge osteotomy and grafting of the lateral wedge to the medial side of osteotomy. No internal fixation was used. A knee brace was used to maintain the 80 to 100 of valgus overcorrection. Seventy patients (72 high tibial osteotomies) with at least fifteen years follow-up were evaluated. Clinical evaluation was done with the Hospital for Special Surgery knee rating scale. Radiologically, femorotibial alignment, posterior tibial slope and the Insall-Salvati ratio were measured.

Results: The mean initial postoperative correction for all knees was to 8.3 ± 2.7 degrees of valgus. Survivorship was 83%, 60% and 45% at fifteen, twenty and twentyfive years after surgery with conversion to a total knee arthroplasty as endpoint of failure. This was 76%, 45% and 32% during the same time interval when a Hospital for Special Surgery knee score of less than 70 points was also considered as end-point. Twenty-six high tibial osteotomies required subsequent arthroplasty at an average of 15.6 years after the index procedure. At the time of the most recent follow-up, the average preoperative knee score of 67 points had improved to 82 points for the knees that had not undergone an arthroplasty. There were two superficial wound infections and one delayed union.

Conclusions: We believe that our technique of a combined lateral closing, medial opening wedge high tibial osteotomy resulted in good long-term outcome due to the off-loading of the diseased medial compartment with minimal complications.


C. Stukenborg-Colsman S. Ostermeier N. Krackow C. Schlomach

Introduction: Recent knee prosthesis designs postulate to allow more flexion of the knee without increasing the contact stress on the polyethylene inlay. The study’s purpose was to compare the tibiofemoral contact stress of four different inlay types of a new “high flexion knee prosthesis system under dynamic, physiologic loading conditions in an in vitro test. Thereby, the cruciate retaining and posterior stabilizing designs were compared.

Material and Methods: The TriathlonTM system was implanted into 5 knees of fresh frozen human specimens. The prosthesis system is available with a mobile bearing (MCR) or fixed bearing inlay (FCR). In addition, the posterior stabilized design was although tested in the same manner (MPS=mobile bearing and FPS=fixed bearing inlay). After implantation, specimens were mounted for biomechanical testing in a knee simulator. The test mimicked both the speed and resulting moment exerted during a lower limb isokinetic extension test in a range of tibial motion from 120 degrees flexion to full knee extension. The quadriceps force cylinder was force-controlled provided a constant torque on the lower limb of 31 Nm whereby forces of up to 1500 N were recorded. Inlay motion was measured using an ultrasonic tracking system (CMS 100TM, Zebris GmbH; Isny, Germany). The tibiofemoral peak contact stress was measured using resistive ink, 0.1-mm-thin pressure sensors (Tekscan, Boston), measuring 572 points per compartment at 10 Hz.

Results: Average maximum peak contact stress was 18.8 (+/−6.6 MPa) at 11.5° flexion for the medial inlay (MCR) and 23 MPa (+/−11.7 MPa) at 119.5 deg for the lateral inlay (MCR). For the FCR we measured 23 MPa (+/−9,6 MPa, medial) at 67.5° and 19.7 MPa (+/−8.2 MPa, lateral) at 119.9° knee flexion. The average maximum contact stress on the MPS inlay was 19 MPa (+/− 12.6 MPa, medial) at 7.5° and 20 MPa (+/− 13.4 MPa) at 120°. For the FPS we measured 20.8 MPa (+/−13.1 MPa, medial) at 40.6° and 19 MPa (+/−11.6 MPa, lateral) at 120° knee flexion.

The maximal rotation recorded for the inlay centers was 1.6 ± 1.2 mm at 1.2° knee flexion and 4.3 ± 3.3 mm at 1.3° for the MPS design.

Discussion: This in vitro study characterizes the movement of the mobile bearing inlays of the TriathlonTM system on the tibial baseplate under simulated physiologic loading. With the dynamic ultrasonic tracking device the range of motion and internal/external rotation movement can be accurately determined. The results of this study correlated qualitatively to radiographic measurements. Contact pressures seem not to exceed the maximum contact stress of UHMWPE significantly even at high flexion angles up to 120°. The posterior stabilized design showed no significant lower maximum contact stresses than the cruciate retaining design.


L.A. Poultsides S. Varitimidis Z. Dailiana A. Klitsaki E. Theodorou G. Stamatiou K.N. Malizos

Introduction: TKA is usually performed under general or spinal anaesthesia (SA). Most of the patients who undergo this procedure are old and their postoperative rehabilitation could be compromised due to the adverse effects of the relevant anaesthesia. Lumbar Plexus and Sciatic nerve Block (LPSB) have been increasingly applied for intraoperative and postoperative analgesia. The aim of this study is to compare the time required for the performance of the anaesthesia technique, the quality of intraoperative anaesthesia and postoperative analgesia, the incidence of intraoperative or postoperative complications, the blood loss at the recovery room and the required intraoperative intravenous (IV) administration of fluid volume.

Material & Methods: Fifty (50) patients, mean age 70± 5years, ASA I-III were randomly divided into two groups to receive spinal anaesthesia (group A) or LPSB (group B). Patients in group A (n=25) received hyperbaric Bupi-vacaine 0.5% plus 15mcq Fentanyl through atraumatic 25g needle. Lumbar plexus and sciatic nerve block were performed with a 15cm insulated needle (Brown) and nerves were identified by a peripheral electric nerve stimulator. 30 and 15 ml of Ropivacaine (0.5%) were used for each block respectively. All patients received 0.2mg/ Kg of Midazolam and 50μg of Fentanyl IV. The success of the technique was defined as a complete sensory and motor block. All patients received postoperatively Patient-Controlled Anaesthesia (PCA) with morphine intravenously. Time to perform blockade, sensory and complete motor block, hemodynamic parameters, blood loss, IV fluid volume, postoperative analgesic requirements and satisfaction score were recorded. Results were analyzed with Chi Square test and Student’s t-test (level of significance: p< 0.05).

Results: Demographic data, operating time and hemo-dynamic parameters were similar in both groups. Three patients (group B) had insufficient blocks and were converted to general anaesthesia. Although SA is performed and accomplishes complete motor and sensory blockade faster (p< 0,05), LPSB leaded to decreased necessity of intraoperative fluid loading and blood loss at the recovery room (p< 0,05). Overall patient’s satisfaction till leaving the recovery room, Visual Analogue Score (VAS) intraoperatively, 4 and 8hours postoperatively and analgesic counts (recorded through the PCA) in the first 24hours were statistically significant between two groups, in favor of patients with LPSB.

Conclusion: PLSB is an effective alternative to spinal anesthesia taking into account basic clinical and anaesthesiological parameters intraoperatively and immediate postoperatively. Concerning postoperative pain and required administration of analgesics during the first 24hours, LPSB is more efficient compared to SA, underlining the importance of overall patient’s satisfaction during the first postoperative day.


D. Biau R. Nizard S. Katsahian M. Resche-Rigon R. Porcher

Background: Quality control has found an important application in assessing learning curves of trainees and controlling innovative technologies as they are initiated.

Objective: To develop a quantitative and individualized statistical tool that may help trainees and tutors to define when a procedure is adequately learned and supervision may be safely stopped.

Methods: A series of 78 consecutive computer assisted-based navigation total knee replacements in patients with osteoarthritis or rheumatoid arthritis was monitored to control surgical performance. The primary outcome was limb alignment in the frontal plane. The target for alignment was 180° and the standard deviation for limb alignment for this series was 2.35°. Knees implanted with a deviation of more than 3 degrees from the target value were considered as failures. A new statistical tool, the CUSUM for Learning Curve (LC-CUSUM) was used to monitor surgical performance. The LC-CUSUM was developed to test whether a process has reached a predefined level of performance. Therefore, the LC-CUSUM presumes the process is not controlled (not learned) at the start of monitoring and the test will signal when the process can be considered as in-control (learned). For continuous data, two LC-CUSUMs are drawn simultaneously.

Results: The first 20 prostheses were more often implanted in varus alignment. Subsequently, the surgeon tried to correct this problem but tended to implant the prostheses more in valgus alignment (overcorrection). After a few more procedures the surgeon found a balance, and the implants were positioned around the target value with no apparent tendency to favour one side or the other. The positive LC-CUSUM signalled first at the fifth procedure; however, the negative LC-CUSUM had not crossed the lower limit and the surgeon could not be deemed as having achieved the required level of performance. It is not until the 25th procedures that the negative LC-CUSUM crossed the lower boundary. At this point, enough evidence had accumulated to state that the surgeon had reached proficiency. A standard CUSUM was initiated to monitor the process to the end and ensure it would not deviate from the required performance. After the seventy-eighth procedure, monitoring was discontinued.

Conclusion: The LC-CUSUM is an innovative tool that allows quantitative monitoring of individual surgical performance during learning process. It allows stating when a predefined acceptable level of performance is reached.


S.H. Weeden R.H. Schmidt G. Isabell

INTRODUCTION: Patients undergoing total knee arthroplasty may experience significant blood loss and are at risk of receiving blood transfusions. A bipolar sealing device designed to reduce intraoperative and postoperative blood loss, was compared to conventional electrocautery to determine its efficacy in maintaining hemoglobin levels and reducing transfusions in minimally invasive unilateral total knee arthroplasty.

METHODS: A retrospective, matched control review of one hundred patients undergoing primary total knee arthroplasty by a single surgeon. Conventional electrocautery was used for hemostasis in 50 patients and bipolar sealing technology used in another 50 patients.

RESULTS: Patients in the bipolar sealing group had a significantly lower mean decline in hemoglobin compared to the control group (3.3 ± 1.1 g/dL vs. 3.9 ± 1.2 g/dL; p = 0.0085). The prevalence of autologous transfusion was significantly lower for the bipolar sealing group (16%) compared to the controls (44%) (p < 0.001). The prevalence of allogeneic transfusion was also significantly lower for the bipolar sealing group (8%) compared to control group (22%) (p < 0.001). The prevalence of transfusion as a whole was significantly reduced by 64 percent (p < 0.001). While not statistically significant the break through allogeneic transfusion rate was reduced by 75 percent (4 controls compared to 1 treatment).

DISCUSSION/CONCLUSION: The use of bipolar sealing technology in patients undergoing minimally invasive primary unilateral total knee arthroplasty is associated with a significant reduction in blood loss and transfusion rates compared to the use of conventional electrocautery.

No funds were received in support of this study.


H.L. GEORGE G. KUMAR P.K. MEREDDY R.A. HARVEY

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome.

Aim: To analyse the out come of 200 knee arthroscopies with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications.

Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and was done by same surgeon as day case. Same arthroscopic kit with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks.

Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding.

Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.


P.K. Mereddy V. Roberts S. Hakkalamani P. Evans N. Donnachie

Introduction: The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mechanism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO). The termination of VMO is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that quadriceps sparing approach may not be possible in all the patients undergoing total knee arthroplasty. We examined MRI scans of the knee joint to assess the variation in VMO muscle insertion in relation to the patella and variation of VMO muscle insertion in relation to the age.

Material and Methods: Between Jan 2005 and Dec 2005, 262 MRI scans of the knee joint were performed at our institute. We studied MRI scans of the patients aged 16 years and over. The scans with neoplasm or those without complete set of films were excluded from the study. There were 198 scans available for analysis. Our cohort consisted of 106 female patients and 92 male patients with an average age of 43 years (range 16–86 years). One hundred and thirty four patients were aged less than 50 years and 64 patients were 50 years or older.

We measured patellar height, VMO length on the axial views of the scans. The VMO insertion was calculated from the data and we divided the patients into proximal and distal groups in relation to the VMO termination on the patella. The proximal group included patients with VMO termination proximal to the mid-point of the patella and distal group included patients with VMO termination at or distal to the mid-point of the patella.

Results: The median height of the patella in female patients was 32mm (range 24–44mm) and in male patients was 36mm (range 28–48mm). The VMO length from the apex of the patella was 13.5mm (range 4–28mm) in female patients and 16mm (range 8–32mm) in male patients. Overall there were 119 (60%) patients in the proximal group and 79 (40%) in the distal group. In 20% of patients aged more than 50 years, VMO terminated in the distal half of the patella. In patients less than 50 years old, 50% had the VMO termination in the distal half of patella. A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient (p-value > 0.001, Chi-square test). There was no statistically significant relation between the level of insertion of VMO and the sex of the patient, in either age group (p-value 0.339).

Conclusion: Younger patients are statistically more likely to have a VMO which terminated at or more distal to the mid-point of patella. Therefore, the quadriceps sparing approach may not be possible in these subjects, however it is possible in majority of older patients.


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F. Iranpour J.P. Cobb A.A. Amis

Introduction: The normal relationships of the patellofemoral joint provide a basis for the evaluation of patients with patellofemoral abnormalities. Previous studies have often described the patellofemoral joint using X-rays which are encumbered with projectional inaccuracies. We have used CT to describe the geometry of this joint and its relationship to the tibiofemoral joint in terms of angles and distances.

Materials and method: 33 patients had a CT scan prior to medial unicompartmental knee replacement. These patients have minimum patellofemoral joint disease. Special software was used to convert the scans to 3D and measure the distances and angles. The flexion axis of the tibiofemoral joint was found as the line connecting the centres of the spheres fitted to posterior femoral condyles. These two centres and femoral head centre form a frame of reference for reproducible femoral alignment. The trochlear geometry was defined by fitting circles and spheres to slices and surfaces, then constructing an axis through their centres. The geometry of the patella was established by fitting two planes to the proximal and anterior extra-articular surfaces of the patella. The relationships between these planes and the rest of the patella were explored.

Results: The deepest points on the trochlear groove can be fitted to a circle with radius of 23mm (stdev 4mm) and an rms of 0.3mm. This centre is offset by 21mm (stdev 3mm) at an angle of 68° (stdev 8°) from the line connecting the midpoint between the centres of the femoral condyles and a point in the piriform fossa.

On either end of this line, the articular surface of the trochlea can be fitted to spheres of radius 30mm (stdev 6mm) laterally and 27mm (stdev 5mm) and an rms of 0.4mm medially. The centres of the circle and the two spheres fall on a line with an rms of 1.1mm.

The anterior and proximal patellar planes could be described as flat surfaces (rms of 0.4 and 0.3mm). The median ridge could be described as a straight line (rms of 0.2mm). The angle between planes was 112° (stdev 5°); the average angle between the proximal plane and the line on the medial ridge was 62° (stdev4°).

The functional centre of the patella was defined as a point in the centre of 2 planes orthogonal to the sagital plane from the midpoint between the most proximal and most distal points on the median ridge. The length, width and thickness of the patellae were measured at 22mm +/−4mm, 47mm +/− 3mm and 24 mm+/− 2 mm.

Discussion: This investigation has allowed us to characterise the patello-femoral joint geometry. The knowledge of the shapes of the surfaces of this joint and their relationships may help identify and explain the aetiology of patello-femoral dyplasia and other pathologies. It may also be of use in planning and performing joint reconstruction and may have implications for the design of patello-femoral replacements and the rules governing their position.


S. Ostermeier C. Stukenborg-Colsman C. Hurschler M. Bohnsack C. Wirth

INTRODUCTION: The techniques to stabilize the patella can be divided into two groups: the first group seeks to change the direction of the extensor mechanism in order to medialize the extending force vector of the quadriceps muscle, e.g. by a distal medialization of the tibial tuberosity or a proximal realignment; the second seeks to reconstruct the medial patellofemoral ligament (MPFL). The goal of this study was therefore to measure changes in patellofemoral kinematics in the intact, MPFL deficient knee, after medial transfer of the tibial tuberosity, after proximal realignment as well as after reconstruction of the MPFL.

METHODS: Eight fresh frozen right knee specimens were mounted in a knee simulator in which isokinetic flexion-extension motions were simulated. Extension cycles were simulated from 120° flexion to full knee extension with an extension moment of 31 Nm. Movement of the patella relative to the femur was measured using an ultrasound based 3D motion analysis system (Zebris, Isny, Germany). During the first test cycles, patellar movement under intact knee conditions were measured, while a constant 100 N laterally oriented force was applied by means of a steel cable attached to the patella. Subsequently, patellar movement was again measured after: transecting the MPL (deficient knee), performing a medialization of the tibial tuberosity, after reconstruction of the transected MPL using a semitendinosus autograft and after proximal realignment.

RESULTS: The patella of the intact knee moved along a medial path with a maximum attained position of 8.8 mm at 25° of knee flexion. The patella of the deficient knee moved up to 4.6 mm (p=0.04) in the medial direction at maximal extension at 30° of knee flexion. After medial transfer of the tibial tuberosity patellar movement reached a maximum medial position of 12.8 mm (p=0.04) at 22° of knee flexion with the laterally oriented force. With a reconstructed MPL, the patella attained a maximum medial position 14.8 mm (p=0.04) at 24.0° of knee flexion. Following proximal realignment, the patella moved on a medial, but significant (p=0.03) different path up to 13.8 mm medially at 30° of knee flexion. In addition, following medialization of the tibial tuberosity and proximal realignment, the center of the patella was significantly (p=0.03) more internally rotated (tilted) than the physiologic patella.

DISCUSSION: The shape of the movement curves after the stabilizating procedures resulted in a medialization relative to intact and deficient conditions. With the reconstructed medial patellofemoral ligament, the patella moved along the most medially oriented path with physiologic tilting. The results suggest that a semi-tendinous autograft can provide sufficient stabilization to prevent lateral displacement or subluxation with physiologic patellar tilt.


B.J. Lankester A.J. Barnett J.D. Eldridge C.J. Wakeley

Introduction: Patello-femoral instability (PFI) and pain may be caused by anatomical abnormality. Many radiographic measurements have been used to describe the shape and position of the patella and femoral trochlea. Some are difficult to apply when dysplasia is present.

This paper describes a simple new MRI measurement of the axial patellar tendon angle (APTA), and compares this angle in patients with and without patello-femoral instability.

Method: Axial MRI images of the knee of 20 patients with PFI and 20 normal knees (isolated acute ACL rupture) were used for measurement. The angle between the patellar tendon and the posterior femoral condylar line was assessed at three levels from the proximal tendon to its insertion.

Results: In normal knees, the APTA is 11 degrees of lateral tilt at all levels from the proximal tendon to its distal insertion. In PFI knees, the APTA is 32 degrees at the proximal tendon, 27 degrees at the joint line and 22 degrees at the distal insertion. The difference is significant (p< 0.001) at all levels.

Discussion: Measurement of the APTA is reproducible and is easier than many other indices of patello-femoral anatomy. In PFI, the APTA is increased by 21 degrees at the proximal tendon and by 11 degrees at its distal insertion.

In PFI, the patella is commonly tilted laterally. This is matched by the orientation of the patellar tendon. The increased tilt of the tendon is only partially corrected at its distal insertion with an abnormal angle of tibial attachment. When performing distal realignment procedures, angular correction as well as displacement may be appropriate.


K.J. Patel S. Gujral R. Mohan

Aims of study: The aim of this study was to analyze the results of oxford unicompartmental knee replacement in a distrct general hospital in UK.

Methods of study: A prospective study of 50 patients undergoing minimally invasive oxford unicompartmental knee replacement for osteoarthritis was conducted between 2001 and 2005. All patients were operated by the senior author of the study. Oxford Phase III medial unicompartmental (meniscal bearing) instrumentation and implants used in all cases.

Pre-op oxford knee score was recorded in all the patients. Post-op scores were recorded annually and at final follow up. X-rays were analyzed for implant positioning and loosening. Data were analyzed using SPSS version 12.

Results: Mean age of patients in our group was 65 years (range 44–78 years). There were 32 females and 18 males in the study. There were no intra-operative complications in any of the patients. Average duration of follow up was 16 months (range 6 months–4 years). Significant improvement in Oxford Knee score was noted after the surgery (43.7 vs. 20.8) (p< 0.05). Average duration of hospital stay was 4 days (range 3–6 days).

Conclusion: Oxford unicompartmental knee replacement gives excellent results, given careful patient selection, meticulous surgical technique and post-operative rehabilitation.


B.H. van Duren H. Pandit J. Gallagher D. Beard C. Dodd H.S. Gill D. Murray

Introduction: Treatment options for the young active patient with isolated symptomatic medial compartment osteoarthritis and pre-existing anterior cruciate ligament (ACL) deficiency are limited. Implant longevity and activity levels may preclude total knee arthroplasty (TKA), whilst high tibial osteotomy HTO and unicompartmental arthroplasty (UKA) are unreliable due to ligamentous instability. UKA’s tend to fail because of wear or tibial loosening resulting from eccentric loading. Combined UKA and ACL reconstruction may therefore be a solution.

Method: Fifteen patients with combined ACL reconstruction and Oxford UKA (ACLR group), were matched (age, gender and follow-up period) with 15 patients with Oxford UKA with intact ACL (ACLI group). Prospectively collected clinical and x-ray data from the last follow-up (minimum 3 years, range: 3–5) were compared. Ten patients from each group also underwent in-vivo kinematic assessment using a standardised protocol.

Results: At the last follow-up, the clinical outcome for the two groups were similar (ACLR: OKS 46, KSS (objective): 99, ACLI: OKS 43, KSS (objective): 94). One ACLR patient needed revision due to infection. Radiological assessment did not show any significant difference between relative component positions and none of the patients had pathological radiolucencies suggestive of component loosening. Kinematic assessment showed posterior placement of the femur on tibia in extension for the ACLR group, which corrected with further flexion.

Conclusions: The short-term clinical results of combined ACL reconstruction and UKA are excellent. Lack of pathological radiolucencies and near normal knee kinematics suggest that early tibial loosening due to eccentric loading is unlikely. Similarly, wear is unlikely to be a problem because of the wear resistance of mobile bearing devices.


B.H. van Duren J. Gallagher H. Pandit D. Beard C. Dodd H.S. Gill D. Murray

Introduction: The Oxford unicompartmental knee replacement (UKR) use in the lateral compartment has been associated with a reduced flexion range and increased medial compartment pain than seen with its medial counterpart due to, in part, the inadequacy of a flat tibial tray replacing the domed anatomy of the lateral tibia. A new design incorporating a domed tibial component and a biconcave meniscal bearing has been developed to overcome these problems.

This study reports a clinical comparison of new and old establishing whether this modified implant has maintained the established normal kinematic profile of the Oxford UKR.

Method: Patients undergoing lateral UKR for OA were recruited for the study. Fifty one patients who underwent UKR with the domed design were compared to 60 patients who had lateral UKR with a flat inferior bearing surface. Kinematic evaluation was performed on 3 equal subgroups (n = 20); Group 1-Normal volunteer knees, Group 2-Flat Oxford Lateral UKR’s and Group 3-Domed Oxford Lateral UKR’s. The sagittal plane kinematics of each knee was assessed using videofluoroscopic analysis whilst performing a step up and deep knee bend activity. The fluoroscopic images were recorded digitally, corrected for distortion using a global correction method and analysed using specially developed software to identify the anatomical landmarks needed to determine the Patella Tendon Angle (PTA) (the angle the patella tendon and the tibial axis).

Knee kinematics were assessed by analysing the movement of the femur relative to the tibia using the PTA.

Results: PTA/KFA values, for both devices, from extension to flexion did not show any significant difference in PTA values in comparison to the normals as measured by a 3-way ANOVA. The Domed implant achieved higher maximal active flexion during the lunge exercise than those with a flat implant. Only 33% of the flat UKR’s achieved KFA of 130° or more under load whilst performing a lunge, compared with 75% of domed UKR’s and 90% of normal knees. No flat UKR achieved a KFA of 140° or more, yet 50% of all domed UKR’s did, as did 60% of all normal knees.

Conclusions: There was no significant difference in sagittal plane kinematics of the domed and flat Oxford UKR’s. Both designs had favorable kinematic profiles closely resembling that of the normal knee, suggesting normal function of the cruciate mechanism. The domed knees had a greater range of motion under load compared to the flats, approaching levels seen with the normal knee, suggesting that limited flexion for the flat plateau results from over tightening in high flexion and that this is corrected with the domed plateau. Problems with the second generation of lateral Oxford UKA have been rectified by a new bi-concave bearing without losing bearing stability and normal kinematics.


M. Benedetti F. Catani L. Berti G. Mariani S. Giannini

Functional outcome in Total Knee Arthroplasty (TKA), as measured by means of gait analysis for kinematics, kinetics, and muscular activity around the knee shows abnormalities even in patients with excellent clinical outcome. Knee flexion during loading response phase is reduced, accompanied by co-contraction of knee extensors and flexors. Such subtle failure in knee performance during loading absorption was claimed to depend on several factors: quadriceps weakness, prosthetic design, pre-surgical pattern, proprioception disruption. It was supposed to damage the implant in time. The lack of the anterior cruciate legament seems to play a major role in the loss of control of the roll back pattern of the condyles on the tibial plateau in TKA patients. Previous works on unicondylar knee artrhoplasty (UKA) demonstrated better gait performance when anterior cruciate ligament was preserved allowing the patients to maintain normal quadriceps mechanics. The aim of the present work is to evaluate UKA patients knee function during gait compared to TKA with the hypothesis that UKA ensures more physiological knee loading response pattern of movement and a more phasic muscular activation, thus reducing the risk of failure. Twenty patients with Oxford/Exactech UKA (mean age 70 (SD 7.9), mean follow-up 2 years) were evaluated by means of a Vicon 612-8 cameras system, two Kistler forceplates and Telemg respectively for knee 3D kinematics, kinetics and muscular activity. Data of UKA were compared to those of a control population of ten healthy subjects and ten patients with TKA matched for age and follow up. Mean UKA-IKS score at the time of gait analysis was 90. Time-distance parameters evidenced a slight slow gait with reduced stride length and cadence and a symmetric longer stance phase with respect to TKA and controls. Knee kinematics on the sagittal plane showed knee flex-ion during loading response very close to controls and a reduced but phasic pattern of joint moments on the sagittal plane. Adduction moment at the knee was normal. EMG showed controversy results as some patients had a regular pattern of activation of rectus femoris and hamstrings without co-contraction whereas other patients had co-contraction. These preliminary results indicate that UKA allows in most patients a quite normal knee kinematics and kinetics, although some abnormalities persist in quadriceps activation. Further research is required to understand these findings assessing other factors which could influence quadriceps activity such as age, proprioception, and muscular strength.


P.R. Aldinger C. Hauck M. Clarius

Radiolucent lines (RL) are a common radiographic finding following Oxford Uni knee arthroplastv. These RL are commonly seen at the bone-cement interface under the tibial tray and can only be evaluated using screened radiographs. These lines occur during the first year, are well defined and remain constant for years. The clinical relevance of this phenomenon is unclear. Pulse lavage has the potential to thoroughly clean the trabecular bone by clearing the bone from bone marrow and debris and can thereby facilitate cement penetration and interdigitation into trabecular bone.

Pulse lavage can reduce the occurrence of radiolucent lines under the tibial tray by improving cement penetration and interdigitation.

Since 2001 we routinely use pulse lavage before cementing the Oxford uni implants at the Orthopä-dische Universitätsklinik Heidelberg (group A). At Nuffield Orthopeadic Center, Oxford conventional irrigation has been used before cementing (group B). At a minimum follow-up of 1 year 56 screened AP radiographs of the knee after Oxford UCA have been blinded and evaluated for radiolucency and cement penetration by an independent observer. For standardized evaluation the cement bone interface has been devided into 4 zones and a specific algorithm for evaluation of the radiographs has been developed.

Complete radiolucencies were detected in 2 cases (4%) in group A and in 13 cases (23%) in group B (p=0,001). Partial radiolucent lines were seen in 32 knees of group A (57%) and in 40 knees (71%) in group B. In zone 1 RLs were found in 31 tibias (55%) in group A, in 32 tibias (57%) in group B. In zone 2 17 (30%) group A, 29 (52%) group B. In Zone 3 4 (7%) in Gruppe A, 20 (36%) in group B. In Zone 4 6 (11%) group A, 30 (54%) group B. The differences between group A and B were significant (P=0.001) in zones 2, 3 and 4.

In group A in 14 cases (25%) RL were limited to one zone, in group B in 5 cases (9%), respectively. In 12 cases (21%) 2 zones were affected in group A (12 cases (21%) group B). RLs in 3 zones were found in 4 cases (7%) in group A and in 10 cases (18%) in group B.

Mean cement penetration (mm) was 2,3mm in group A and in 1,4mm in group B. The use of pulsed lavage led to an increase in cement penetration by a factor of 1,6 (cement penetration in group A/B zone 1: 1,4mm/0,8mm; zone 2: 2,4mm/1,5mm; zone 3: 1,4mm/0,7mm; zone 4: 4,0mm/2,4mm).

The use of pulsed lavage significantly decreases the appearance of RLs at a minimum of 1 year follow-up by increasing cement penetration into cancellous bone. Even though the clinical relevance of tibial RLs in unclear we recommend the use of pulse lavage to improve cement penetration and interdigitation with cancellous bone. Unnecessary revisions due to misinterpretation of RLs may be prevented.


S. Koëter M. Diks P. Anderson A. Wymenga

Lateralisation of the tuberosity tibia causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking patella (LTP), resulting in anterior knee pain, or objective patellar instability (OPI), resulting in recurrent luxations. For a precise preoperative diagnosis the tuberositas tibia (TT) trochlear groove (TG) distance was measured on a CT scan. A distance of more than 15 mm was considered to be pathological.

In a prospective study, the clinical results of a subtle, CT-guided medial tuberosity transfer for LTP and OPI were evaluated. 30 Consecutive patients with LTP and 30 patients with OPI and an increased TT TG were included. Outcomes were documented at 3, 12 and 24 months follow-up using the Lysholm scale, the Kujala score, and a visual analogue pain score. Postoperatively all but one patient reported good improvement in stability (no persistent subluxations or luxations). All patients had a marked improvement in pain and functional scores at follow up. Complications seem to be related to the peroperative technique. CT-guided TT transfer appears to be satisfactory and safe method for treating patients with an increased TT TG leading to either LTP or OPI.


S. Schmitt M.K. Harman S. Roessing W.A. Hodge

Survivorship of unicondylar knee replacement (UKR) exceeds 85% at 10 years. During long term follow-up, progressive osteoarthritis (OA) and loosening are typical of UKR failure. The decision to revise UKR is complex as radiographic findings are not always consistent with clinical symptoms. This study of revised UKR compares intraoperative assessment of component fixation and progressive OA with prerevision radiographic evaluations.

Twenty-seven UKR were retrieved from 22 female and 5 male patients. Patient age and time in situ averaged 76 (68–87) years and 79 (25–156) months, respectively. At index arthroplasty, all knees received a fixed-bearing medial UKR with cement fixation. Prior to revision, radiolucent lines and component alignment were assessed on radiographs according to Knee Society guidelines. Suspected revision reasons based on clinical and radiographic evaluation included aseptic loosening (63%), progressive OA (22%), and wear (15%). During revision surgery, component fixation was manually assessed and graded as well-fixed or loose, and progressive OA was graded using Outerbridge classification. Intraoperative and radiographic assessments were completed independently.

Average Knee Society Scores declined > 30 points to 53+18 (pain) and 43+11 (function) before revision. During revision surgery, femoral and tibial component fixation were graded as loose in 19 (70%) and 9 (33%) knees, respectively. There was Grade III or IV progressive OA in the lateral or patellofemoral compartment of 15 (56%) and 16 (59%) knees, respectively. Radiolucent lines were evident in 8 of 19 loose femoral components and 5 of 9 loose tibial components. In contrast, 3 of 8 well-fixed femoral components and 6 of 18 well-fixed tibial components had radiolucent lines. There were 11 loose femoral components and 4 loose tibial components without radiolucent lines. Radiographic limb alignment averaged 3°+3° valgus immediately after index UKR. Change in limb alignment ranged from 0° to 17° at revision. Tibial or femoral component alignment changed 5° to 9° in 12 (44%) knees and > 10° in 5 (19%) knees. Eight of these 17 knees (47%) had malaligned components graded as loose.

The prevalence of progressive OA at revision UKR was more than double occurrence suspected from radiographs. Interpreting radiographic indications for loosening was difficult. Radiolucent lines predicted loosening in 46% (13/28) of the components graded as loose and falsely predicted loosening in 35% (9/26) of the components graded as well-fixed. Radiolucent lines were absent in 15/28 (54%) of the loose components and changes in component alignment > 5° were associated with component loosening in < 50% of the knees. Rigorous attention to clinical symptoms and careful interpretation of radiographic phenomena are needed to determine indications for revision in UKR patients.


R.L. Bray R. Steele J.H. Newman S. Hutabarat C.E. Ackroyd

Purpose of Study: Fixed bearing unicompartmental knee replacement (UKR) has become popular since several series have now shown good 10 year survivorship and excellent function. However little is known about survival during the second decade.

Method: From the Bristol database of over 4000 knee replacements 203 St. Georg Sled UKR’s which had already survived 10 years were identified. The mean age at surgery was 67 years (48–85), with 64% being female. This cohort has been further reviewed at an average of 14.8 years (10–30) from surgery to determine survivorship and function.

Results: Survivorship during the second decade was 87.5%. 58 patients (69 knees) had died with implant in situ and only 2 after revision. A further 15 UKR’s have been revised at an average of 13 years post op; 7 for progression of disease in the opposite compartment, 4 for tibial loosening, 3 for polyethylene wear, 2 for femoral component fracture and 2 for infection.

99 knees were followed for 15 years, 21 knees for 20 years and four for 25 or more years. The average Bristol knee score of the surviving knees fell from 86 to 79 during the second decade, largely as a result of aging.

A previous study of the St Georg. Fixed bearing UKR showed an 89% 10 year survivorship and this is now extended to 82% at 15 years and 76.5% at 20 years.

Conclusion: Satisfactory survival of fixed bearing UKR can be achieved in the second decade suggesting that the indications for mobile bearings require careful definition since there is a higher incidence of complications in many people’s hands.


F. Dettoni G. Maistrelli P. Rossi F. Castoldi D. Stojimirovic M. Girardo R. Rossi

Introduction: This paper presents the short term results of 56 (28 males and 28 females) consecutive Unicompartimental Knee Arthroplasties (UKAs) and 54 (29 males and 25 females) High Tibial Opening Wedge Osteotomies (HTOs), performed in two centres (Toronto-Canada and Torino-Italy), between 2001 and 2004.

The aim of this prospective study was to compare UKAs to HTOs, in terms of clinical and functional Results: Materials and Methods:

In all UKAs we implanted an Accuris prosthesis (Smith& Nephew, Memphis TN), in all HTOs we performed a medial opening wedge osteotomy, according to the surgical technique and syntesized with a Puddu Plate (Arthrex, Naples FL).

We evaluated all patients preoperatively and at 6 months postoperatively, at 1 year, 2 years and at the last follow-up visit (mean 3,5 years for UKAs and 2,5 years for HTOs), using the Knee Society Score (KSS) and the WOMAC (Western Ontario and McMaster Universities) Score.

Results: The mean age at operation was 55 years for the HTO group and 65 years for the UKA group.

Postoperative program for the HTO group was: 4 weeks of CPM (continuous passive movement), partial weight-bearing al 4 weeks (30–50% of body weight) and then full weight-bearing at 8 weeks postoperatively.

In the UKA group, full weight bearing was allowed immediately after operation.

We observed only one significant complication postoperatively: an early infection in an HTO patient. We thought this complication was not related to the treatment chosen, but to external factors, so we decided to exclude this patient from our study.

In the HTOs group, the KSS knee score (KS) and function score (FS) improved from respectively 38 and 55 preopertively to 76 and 91 at the final follow-up evaluation, while in the UKA group KS increased from 43 to 93 and FS increased from 50 to 84.

The WOMAC Score improved from respectively 48 (HTO Group) and 45 (UKA Group) preoperatively to 15 (HTO Group) and 14 (UKA Group) at the final follow-up evaluation.

Discussion and conclusion: According to both scores (Womac and KSS), the two groups did not differ significantly at 1 year, 2 year and last followup evaluation, considering the different ages of the patients (55 years of the HTO Group versus 64 years of the UKA group).

Comparison of study groups shows good outcome at early and mid-term follow-up. All patients had scores rated good to excellent (both KSS and WOMAC).

However, we found a little difference in KSS between the two groups: UKAs have a higher Knee Score (better knee assessment), while HTOs have a significantly higher Functional Score (better performances, maybe due to a more “anatomic saving” procedure).

This data suggests that the UKAs have better knee assessment, meanwhile the HTOs have better function. Given that, both treatments lead to a good to excellent outcome at early followup.


M.C. Forster A.J. Bauze G. Keene

Between 29th May 2001 and 15th May 2003, 233 consecutive Preservation unicompartmental knee replacements (UKR) were performed. Of these, 30 were lateral UKRs (13%) performed in 12 men and 16 women (2 bilateral cases) with a mean age of 67 years (range 36 to 93 years). A metal-backed mobile bearing tibial component was used in 13 knees and an all-polyethylene fixed bearing tibial component in 17 knees. The patients were reviewed prospectively at 1 and 2 years. The 2 year results show no difference in range of motion or function between the mobile and fixed bearing versions of the Preservation knee when used on the lateral side. This is similar to the reported results on the medial side. There were 3 early revisions, all in the mobile bearing group. The incidence of revision has been reduced by the introduction of an improved cementing technique.


J. Roxo Neves M. Sarmento P.S. Carvalho S. Silvério A. Hillis

In cementless Total Hip Arthroplasty (THA), some discussion persist in different continents, weather straight double tapered stems providing proximal metaphyseal fixation are preferable to more diaphyseal cylindrical fixation designs.

With the objective of studying the grade of loosening of a straight double tapered stem and its survival rate, the authors analysed 257 THA with implanted Spotorno stems, followed up for a maximum of over 18 years (221 months), with an average of 110±57 months. The age of patients was 62±10 years in average, ranging from 18 to 86. Demographic data is analysed including, sex, height, weight and BMI.

Main diagnosis was Primary Degenerative Osteoarthritis in 56% and Avascular Necrosis in 13% of all patients. Other diagnosis occurrence is presented, as well as the affected side, type of cup, head and stem size distributions.

Clinical and functional evaluation of the THA showed Very Good and Good patient satisfaction grading in 78% of the cases and the average Harris Hip Score was 87, ranging from 49 to 98. In the Radiological evaluation, stem positioning, migration, osteolysis and distribution of radiolucent lines are quantified and described.

79 patients included in this study with 84 THA, died or were lost after a minimum of five years of complete clinical and radiological follow up. The most significant early and late complications of THA are presented and commented. THA requiring revision of the cup or stem for any cause, were 1 severe deep infection (0.4%), 4 cups loosened and migrated but not requiring revision of the stems (1.6%), 1 femoral osteolysis and loosening (0.4%) and 2 late traumatic femoral fractures (0.8%). From these, considering stem survival alone, a total of four stems (1.6%) underwent femoral revision as previously described, one due to infection, one due to loosening and two due to femoral fractures. Kaplan-Meyer cumulative survival analyses of the THA show a Spotorno stem survival rate of 98.4% at 18 years, with a confidence interval of 95%.

In the experience of the authors, the Spotorno double tapered straight stem provides excellent clinical results, with high survival rate at longterm evaluation. The design of the stem allows for immediate progressive weight bearing without significant migration or thigh pain. Femoral proximal osteolysis or radiolucent lines are almost always associated with wear or loosening of the cup, that very often allow for revision of the cup without the need for revision of the stem.


T.E. Nowak R. Schmidt P.M. Rommens R. Forst L.A. Mueller

Introduction: The aim of this study was to analyze the periprosthetic bone remodeling of the femoral component after implantation of an uncemented taper-design stem using CT-assisted osteodensitometry. This method allows accurate three-dimensional evaluation of cortical and cancellous bone with high resolution.

Material and methods: We followed 21 consecutive Patients with osteoarthritis who received primary total hip replacement using 21 uncemented three-dimensionally shaped taper stems (TiAl6V4-Cerafit, Ceraver, France). CT-evaluation was performed 2 weeks, 1 and 6 years post-op. Bone mineral density (BMD) [mg/ml] was determined separately for both cortical and cancellous bone using a special software.

Results: Mean decrease of cortical BMD in the proximal (metaphyseal) area 6 years post-op was −25%, (1 year post-op −15%). Only slight changes of BMD were observed in the distal (diaphyseal) area. Cancellous BMD decreased progressively from −26% 1 year post-op to −49% 6 years after index operation in the proximal area. Cortical bone density loss was lower and non-progressive at the diaphysis (Ø −7% 1 year, −9% 6 years post-OP) and the distal region (Ø −6% 1 year, −4% 6 years post-OP) of the stem. All stems showed no signs of loosening on plain radiography and good clinical results according to the Harris hip score.

Conclusion: Computertomography assisted osteoden-sitometry is the only method which allows discrimination between periprosthetic cortical and cancellous bone density changes in vivo. The analyzed uncemented stem is anchored at the diaphysis and distal region. Due to the changed biomechanical loading after stem implantation, progressive proximal cancellous bone density loss was measured for the first time in vivo. Its role in the pathogenesis of implant loosening is still unknown and needs to be further elucidated.


K. Zweymüller M. Steindl U. Schwarzinger

Introduction: Cementless tapered straight stems of the first generation were introduced in 1979, those of the second generation in 1986. For further perfection SL-PLUS stems were introduced in early 1993. These were redesigned proximally and featured slimmer necks for a larger range of motion, a central trochanteric pull-out thread and a larger surface area in the proximal stem third.

Method: Between 01/01/1993 and 31/03/1994 339 patients were implanted with these cementless new-generation stems. In the period under review no stems other than these, e.g. cemented implants or other implant systems, were used in primary THAs.

Of the 339 patients, 218 were available for follow-up, 72 had died, 38 without revision surgery were contacted by phone and 11 were lost to follow-up.

The underlying pathology was idiopathic degenerative joint disease (153 pts.), dysplastic OA (37 pts.), femoral head necrosis (12 pts.), posttraumatic OA (6 pts.) and OA of other origins (5 pts.). To evaluate changes in stem position, radiolucent lines, osseointegration and revision, clinical and monitor-controlled radiographic follow-ups were conducted at 10 years plus.

Results: 5 patients were revised within the follow-up time because of: one aseptic loosening, one low-grade infection, two periprosthetic fractures, one traumatic subsidence.

At the 10 year follow-ups (10,0 to 11,1, mean 10,2 years) the stem position was unchanged in all of the 213 patients. The stems had been implanted in proper anatomical alignment in 196 patients, in varus in 16 and in valgus in one patient. 93 patients showed no changes of the peri-implant bone. In 96 peri-implant bone apposition was recorded in one or more zones (Gruen). 20 patients presented with radiologic evidence of both peri-implant bone apposition and some atrophy. None of these patients showed abnormalities clinically (HHS: 95.2; 76–100). At the 10-year follow-ups 2 stems had worked loose. Another 2 patients presented with intertrochan-teric osteolyses with definite progression versus the 5-year follow-up. On analysis, radiolucent lines (RLs) were seen in zone 1 in 28.6% of cases, in zones 2 and 6 in 3.3%, in zones 3, 4 and 5 in 0.5% and in zone 7 in 22.1%.

The Kaplan-Meier survival rate was 98.2% (CI 95.3 to 99.2) with revision of the stem for any reason as the end point (N = 339).

Conclusion: The outcome of this quality control study showed the stem to be universally applicable in all primary THAs so that its continued use in the indications listed is well justified.


N. Aslam J. Saito K. Tokunaga E. Schemitsch J. Waddell

Purpose: To determine the differences in bone remodelling between a metaphyseal and a diaphyseal fixed stem in uncemented total hip arthroplasty.

Methods: Twenty-three patients undergoing uncemented total hip arthroplasty (28 hips) utilizing a metaphyseal fit stem were matched to 27 patients (32 hips) undergoing uncemented total hip arthroplasty utilizing a diaphyseal fit stem. Patients were matched for age, gender and follow-up. All patients were assessed by clinical and radiographic examination at 6 weeks, 3 months, 6 months and yearly thereafter. Radiographs were assessed for periprosthetic bone remodelling, canal fill, canal shape and bone quality using the cortical index and the Singh index. At latest follow-up all radiographs were assessed for frequency and time of appearance of spot welds, cortical hypertrophy and development of pedestal formation. All patients were assessed clinically utilizing the modified Harris hip score.

Results: At one year there was no difference in the clinical results between the two groups of patients utilizing the modified Harris hip score 90.6 + 1.5 in metaphyseal fit stems versus 91.7 + 1.7 for diaphyseal fit stems (p> 0.05). There was no statistical difference between the two groups in either femoral canal shape or bone quality–canal-to-calcar ratio 0.49 versus 0.45 (p> 0.05); cortical index 0.45 versus 0.44 (p> 0.05); Singh index 3.44 versus 3.70 (p> 0.05). In assessing canal fill proximal canal fill was statistically greater in metaphyseal fit stems and distal canal fill was significantly greater in diaphyseal fit stems (p< 0.01). There was a statistically significant increase in the frequency and timing of spot welds in metaphyseal stems at 3 months and 6 months (p< 0.05) but no difference in the frequency of spot welds at 1 year and 2 years. Cortical hypertrophy was significantly increased at 6 months, 1 year and 2 years in metaphyseal fit stems as compared to diaphyseal fit stems (p< 0.05). There was no difference in pedestal formation at 1 year or 2 years between the two stem groups (p> 0.05).

Conclusions: After one year the only significant difference between these two groups of patients is increased cortical hypertrophy in those patients undergoing metaphyseal versus diaphyseal stem insertion. Both stem designs demonstrated bone remodelling with no differences in spot welds or pedestal formation. At two years there was no functional difference between these two patient groups.


V. Kannan J. Cobb R. Richards A. Nakhla

INTRODUCTION: Periprosthetic bone remodeling after uncemented hip replacement has always been a matter of research and debate. DEXA analysis of BMD was studied by previous groups but not the cross sectional cortical volume. We report a validated CT based algorithm for accurate measurement of cortical volume in these group of patients.

METHODS: Twenty two patients (34 hips) who have undergone Uncemented Furlong total hip replacement agreed to undergo CT scan of their hips for our study. The mean age was 74.6 yrs. The mean follow up was 5.4 yrs. 12 patients had bilateral replacement.

Using software adapted for the specific purpose, femoral cortical volume was measured at three different levels at a fixed distance from the lower border of the lesser trochanter on both sides: 6mm distal to the tip of the prosthesis (z), At the top of the cylindrical portion(x) Midway between x and z (y).

Accuracy and precision of the of the method was also assessed.

RESULTS: The mean cortical volume in the proximal cylindrical portion (x), midpoint(y) and the portion of bone distal to the prosthesis (z) were 458 mm3, 466 mm3, 504 mm3 respectively. The corresponding cortical volumes in the contralateral native femur in unilateral hip replacements were 530 mm3(x), 511 mm3(y), 522 mm3 (z) giving a ratios of 0.86(x), 0.91(y) and 0.97(z). The mean cortical volumes on the left side of bilateral hips were 490 mm3(x), 499 mm3(y) and 528 mm3 (z). The mean cortical volumes on the right side were 456 mm3(x), 463 mm3 (y) and 516 mm3 (z).

No significant trend was noted with change of volume of bone with time.

In the three cases who had cemented hips on their other side, the cemented hips exhibited substantially more stress shielding than their cementless controls (ratios of 0.82, 0.74 and 0.85).

A high correlation between the test and standard measurements was noted. The interobserver agreement between two observers was also good.

DISCUSSION & CONCLUSION: In a fully coated uncemented femoral component, with documented long term results, it is to be expected that load will be shed steadily along the length of the prosthesis. In this study we have confirmed this supposition, with volumetric data, by showing that an almost normal bone just below the tip of the stem (97% volume) reduces to a bone volume of 91% by the middle of the stem and then 86% by the shoulder of the prosthesis. This decrease in the volume of cortical bone effectively normal at the tip of the prosthesis while not optimal appears to stabilize early with no trend of continued reduction over a decade. The effect of cementation on stress shielding was only examined incidentally in this study but appears to contribute to more marked bone loss.


M. Pospischill K. Knahr

Aims: The aim of this study is to present clinical and radiographic long-term results including a survival analysis of the cementless Alloclassic total hip arthroplasty system.

Matarial and Methods: 103 consecutive primary hip arthroplasties using a threaded conical titanium cup (Alloclassic CSF) and a rectangular titanium pressfit stem (Alloclassic SL) were evaluated clinically and radiographically with an average follow-up period of 14.4 years (range 10.2 to 17.1 years). In all cases a 32 mm alumina ceramic head and a UHMW polyethylene inlay were used. Clinical results were evaluated according to the Harris Hip Score, the SF-36 and WOMAC score. Radiographic results were analysed on antero-posterior x-rays. A statistical survivorship analysis was calculated using Kaplan-Meier curves.

Results: The average Harris Hip Score at the last follow-up was 89.2. The mean pain score was 41.6, the mean functional score 47.6. Radiographic results showed a continuous radiolucency around the cup in three cases. Radiolucent lines around the stem were observed only in the proximal zone 1 in 52 and in zone 7 in 26 cases. Cortical hyperthrophy occurred in the distal zone 3 in 33 cases and in zone 5 in 72 cases. Fifteen hips were revised, eleven of them because of increased polyethylene wear after a minimum follow-up of 10 years. One patient needed revision due to a late deep infection after 7.4 years. There were three cases of aseptic loosening without signs of progressive polyethylene wear that led to a cup exchange. The cumulative survivorship with revision due to aseptic component loosening as endpoint was 95.6 % for the cup and 100 % for the stem after 15 years.

Conclusion: Our data suggest that excellent long-term results can be achieved with the cementless Alloclassic system. The main limiting factor for implant survival was found in increased polyethylene wear. We therefore recommend early exchange of the inlay to avoid component loosening and the use of modern wear couples such as ceramic-on-ceramic, metal-on-metal or crosslinked polyethylene.


V. Kannan J.D. Witt

Introduction: The benefits of total hip replacement in patients with juvenile idiopathic arthritis are well documented. However only few results of uncemented total replacement with subsequent problems of loosening and revision surgery have been published. We report a minimum 2 year follow-up of uncemented total hip replacement in this group of patients

Material s& Methods: Between 1995 and 2003, 56 patients under the age of 29 years underwent 81 uncemented total hip replacements. 41 were females and 15 were males.1 patient died and 1 lost for follow -up. The average length of follow up was 6 years (range 2 to 10 yrs). In 67% of the patients the follow up period was 5 yrs or longer. The average age of onset of the disease was 5 yrs (range 1 to 19 yrs). The mean age at surgery was 18 yrs (range 11 to 29 yrs). Both hips were involved in 25 patients of which 18 were women and 7 were men. The mean interval between the onset of arthritis and surgery was 11 yrs. The mean interval between symptoms of hip involvement and hip replacement was 4.7 yrs. In 49% of patients the onset of arthritis was systemic, 22.6% polyarticular, 15.09% pauciarticular and 13.21% seronegative. Prior soft tissue release was performed in 6 hips(4).2 patients had previous supra-condylar femoral osteotomy for deformity correction.2 patients had total knee replacements(bilateral 1, unilateral 1). Usually a posterior approach was employed. A variety of prosthesis were used, Furlong HAC stem in 40 patients, SROM in 23 patients and CAD CAM in 17 patients. On the acetabular side, Furlong CSFHDP in 31 patients, Furlong ceramic in 15 patients, SROM cup in 21 patients, Duraloc cup in 9 patients and Muller support ring in 4 patients. The hips were graded before surgery and at follow-up using the scoring system of the Hospital for Special Surgery (Salvati and Wilson 1973)

Results: The mean improvement of HSS score for pain, ROM, mobility and function are 6.3, 3.1, 3.5 and 4.1 respectively. There was a mean improvement of 17.0 in the total HSS score. One patient had subsidence of both the CAD CAM stems at present waiting for revision. Radiolucent zones around the proximal sleeve SROM stem was noted in one patient requiring stem revision. Stress shielding of calcar was noted in 3 patients (CAD CAM 2, Furlong 1) and osteolysis around the cup in 1 patient. All patients with Furlong stem had very good osseointegration and there was no need of any revision. All patients with SROM stems also had very good osseointegration except one for which stem revision was done.

Conclusion: This study shows a lower revision rate and better radiographic appearance compared to previous reports with similar follow up of THA in Juvenile Idiopathic Arthritis.


R.L. Plaster

BACKGROUND: Historically results of cementless THA with a variety of porous material and design has been sporadic with 5–20% thigh pain. A simple straight tapered stem with anatomic features for proximal load transfer and excellent initial stability was developed in the early 90’s.

METHODS: 196 cementless collared Natural hip stems (Sulzer/ Zimmer) were implanted by a single surgeon using a posterior approach. They were entered into a database prospectively from 1992–95 and followed until 2006. Data was collected preoperatively and at intervals with last follow-up of 10–14 years. Physical exams, SF-36’s, hip assessments, patient satisfaction surveys and radiographs were performed. X-rays were analyzed for radiolucent zones and bone condensation/ remodeling.

RESULTS: 106 have 10 year data with 34 dead and 9 having moved out of state. One femoral component was removed for deep infection. Eight have had liner exchanges for polyethylene wear, 1 acetabulum was revised for recurrent dislocations.

There have been no femoral revisions for loosening and no complete radiolucencies involving the cancellous structured titanium (CSTi). 85% of x-rays show proximal bone condensation with maintenance of a strong calcar. Distal radiodense lines (halo) are present in 20% around the split smooth tip, with 30% showing an asymptomatic midstem cortical buildup.

Average Harris Hip scores at 10 years (including all Charnley classes) was 85. 90% of patients reported either no pain (65%) or slight (requiring no medication). 100% were satisfied with their outcomes. Anterior thigh pain was conspicuously absent occurring in one patient but disappearing the first year.

CONCLUSIONS: The design of the conical tapered stem which includes an anterior buildup proximal, proximal Cancellous Structured Titanium (CSTi), midstem anti-rotational flutes and a split/spread distal tip transmits force to the femur in a graduated load transfer keeping the proximal femur healthy without stress shielding. The split distal stem and decreasing radius provides a long zone of transition for stiffness and prevents thigh pain. The CSTi provides dependable bone ingrowth and seals the canal preventing osteolysis even in cases where there has been acetabular poly wear. X-rays, SF 36’s and clinical results document the success. As a straight stem ream/broach technique, excellent clinical results can be obtained by general community orthopedists using techniques they are comfortable with.


G. Flivik K.L. Hermann L. Ryd

Introduction: Progressive retroversion of the stem within the femur has been suggested to be an important initial mode of hip prosthesis failure. We have assessed the relationship between postoperative stem anteversion angle, measured with CT, and the rotational stability as measured with repeated radiostereometric analysis (RSA) with 5 years follow up.

Patients and methods: 57 patients were operated on with THA using a cemented, matt and collared stem. The achieved stem anteversion angles were measured postoperatively with 3-D CT-examinations. The patients were divided into three groups depending on their ante-version angle: ≤10°, 11°–25° and ≥25°. They were followed with repeated RSA examinations for 5 years to determine the stem migration pattern.

Results: The mean postoperative anteversion angle was 20.5° (range 1°–43°). At 5 years, all except one stem had rotated into retroversion. There was a strong correlation between the postoperative anteversion angle and later rotation into retroversion (p=0.007). The group with ≤10° of stem anteversion rotated significantly more into retroversion, seen as early as 3 months (p=0.02), but more obvious at 5 years (p=0.002) with a mean of 9.9° of retroversion compared to 3.8° in the 11°–25° group and 2.4 ° in the ≥25° group. The distal stem migration results were accordant with more migration at 5 years (p=0.008) for the ≤10° anteversion group (1.6 mm subsidence compared to 0.5 and 0.3 mm respectively). Two stems have been revised because of aseptic loosening, both with a low initial anteversion angle (7° and 1°) and large retroversion at 5 years (7 ° and 31° respectively).

Conclusion: Measured by RSA, rotation into retroversion of the femoral stem was a regular finding in this study using a conventional prosthesis design. We propose that such rotation is a common finding in hip arthroplasty, but the degree may be design sensitive. Our results strongly suggest that the initial rotational position of the femoral component during surgery is decisive for the degree of later retroversion and probably prosthetic longevity; the less anteverted position the more the stem will migrate into a more retroverted position after the operation. This rotational migratory pattern is correlated to subsidence and eventual loosening. Hence, meticulous attention should be paid to the rotational position of the femoral stem during surgery, with less than 10° of anteversion appearing deleterious. However, too much anteversion will risk impingement and possibly other unwanted biomechanical effects, and an upper limit still remains to be established.


P.R. Aldinger C. Volz A. Jung V. Ewerbeck D. Parsch

Aim: Stress-shielding is a common problem after uncemented THA that may lead to proximal femoral atrophy and consecutive aseptic loosening.

Methods: In 143 patients with 154 uncemented CLS-stems periprosthetic bone mineral density (BMD) was measured using DXA after a mean of 12 years (10–15) postoperatively (T1). Five years later the same group of patients was examined at a mean of 17 years (range: 15–20) (T2) using the identical protocol.

Results: We obtained a complete prospective set of data of two consecutive DXA measurements in 76 cases (32 men, 44 women). In all cases regular bone ongrowth did occur and there were no signs of radiographic loosening (T1 and T2). On radiographic evaluation there was no significant change in periprosthetic bone formation in all Gruen zones between T1 and T2. There was no significant change in activity and BMD. In male patients we found no significant changes in periprosthetic BMD (netavg T1–T2: −1,19%, p< 0,01), in female patients there was no significant difference either (netavg T1–T2: −1,32%,p< 0,01). We analyzed the differences in BMD in all Gruen zones (zone 1–7) comparing T1 and T2 and found no significant differences in any zone (p< 0,01).

Conclusion: This study showed that there is no significant change in periprosthetic bone mineral density in the long term using the uncemented CLS stem. There was not a single case of stress shielding in the long term. Once osseous integration has occurred the periprostethic BMD changes remain minimal in the long term.


M. Clauss R. Lusser M. Lüem P.E. Ochsner T. Ilchmann

Introduction: Since its introduction in 1977 the Müller straight stem and its various copies have become one of the most often used cemented stems worldwide (about 1.1 million stems, figure quoted by manufacturer). Though, there is still a lack of long-term follow-up data.

Material/Methods: A consecutive series of 165 primary hip replacements (161 patients) with the original forged Müller straight stem (CoNiCr) was operated between July 1984 and June 1987 and followed prospectively. Mean age at operation was 68.9 years (25.6 to 86.3 years). 70 stems were implanted in female patients. Operation was done in supine position through a transgluteal approach with no trochanteric osteotomy. All stems were cemented with a second-generation technique (distal plug, cement syringe). The head diameter was 32 mm diameter, 134 heads were out of metal, 31 out of ceramic. 151 hips had a cemented polyethylene cup (52 with armament screws). 13 were combined with an acetabular reinforcement ring (Müller ring) and one with an anti-protrusion cage (Burch-Schneider).

Clinical and radiological follow-up was planned at 4 months 1, 2, 5, 10, 15 and 20 years. Clinical follow-up included a standardised examination and the completion of an IDES form. Cumulative survival rates were calculated by Kaplan-Meier analysis. Radiographs were analysed for osteolysis according to Gruen et al. (zones 1–7) and radiolucent lines.

Results: 3 patients (3 stems) were lost to follow-up (two postoperative and one after 16.8 years), 103 patients (with 106 hips) had died without revision and 55 patients (56 hips) remained for follow-up. 15 stems were revised, 11 for aseptic loosening (9 in combination with the cup), two for infection and two for other reasons. 13 further patients had isolated cup revision. Survival with aseptic loosening of the stem as endpoint was 86% (95%-CI: 82 to 90%) at 20 years.

The median HHS at the last follow-up was 80 points (range 30–98 points).

31% of the non-revised 41 stems showed osteolysis, most of them in zone 7 (21.9%). Two stems with isolated cup revision had a continuous radiolucent line. Incomplete radiolucent lines appeared most frequently in zone 1. Cup revision was associated with increased radiological changes on the femoral side (p=0.094, Mann-Whitney U-test).

Conclusion: The Müller straight stem shows excellent clinical and radiological results in the long-term, comparable to those achieved with other well established cemented and non-cemented stems. From our data further clinical use of the Muller straight stem can highly be recommended.


J.A. Skinner J. Donaldson T. Abuzakuk Y. Shenava S. Kumar P.K. Jaiswal R. Pollock R. Carrington T. Briggs

We aimed to determine whether proximal femoral bone remodelling, as measured by DEXA scan for each Gruen Zone, differed for 3 different femoral stem designs. These were:

Group 1 – Triple taper polished (C-stem J& J DePuy)

Group 2 – Double taper polished (TPS J& J DePuy)

Group 3 – Collared satin finish stem (Stanmore Biomet)

Ethical Committee approval was obtained and all patients gave informed consent. All operations were performed by 3 surgeons using a standard lateral approach, third generation cementing technique and a standard post-operative regime.

Seventy-five patients were randomised prospectively using a stratified randomisation programme for known risk factors in bone density. The randomisation was stratified by age, sex, Charnley Group (A or B), BMI and femoral neck bone mineral density. There were 25 patients in each Group, 5 patients did not have complete data sets and were therefore withdrawn from evaluation.

The Groups were similar with regard to age, sex, BMI, BMD and Charnley Group. Patients were followed up at 3, 6, 12 and 24 months by Nurse Practitioners for clinical and radiological evaluation and DEXA scan at each time of follow-up. There were no catastrophic failures of sepsis or dislocation. All patients functioned well at 24 months by Harris Hip Score.

The bone remodelling pattern will be described for each stem design. Findings are summarised thus. In the lateral Gruen Zones the triple taper and collared stem design faired better and both behaved differently to the double taper design. In Gruen Zone 7, all stems demonstrated reduced bone density as compared to pre-operative scans but this was less with the triple taper design.


G. Grappiolo G. Burastero G. Moraca A. Camera G. Santoro T. Gruen L. Spotorno

Background: This report presents the long term (over 20 years) experience with the use of a grit-blasted, press-fit femoral prosthesis.

Methods: The first 300 consecutive primary THA procedures using a collarless, three-dimensional tapered, straight, titanium alloy stem with a grit-blasted surface (performed in 299 patients) were evaluated up to twentytwo years. A cementless all-polyethylene socket in 80 percent of the cases, were used. Radiographic evaluation, performed by an independent observer using a zonal analysis method, included assessment of component migration, Engh’s implant-bone femoral fixation score, implant-bone demarcations, and periprosthetic osteolysis. The average duration of long-term radiographic follow-up was 12.6 years (range; 10 to 16 years).

Results: At last examination only five hips were lost to follow-up and 84 patients were deceased. The femoral revision rate was 7 percent (two hips for aseptic loosening, five hips for septic loosening, and twelve hips with osseointegrated stems for severe progressive femoral osteolysis) and the acetabular revision rate was 28% (revised for either socket migration or progressive peri-acetabular osteolysis or both). Survivorship, based on any revision (femoral or acetabular) was 89% at ten years and 65% at twenty years; survivorship of the femoral component was 95% at ten years and 89% at twenty years. The incidence of femoral periprosthetic osteolysis, was 47%, with 5% of distal endosteal osteolysis. Radiographic femoral implant-bone fixation was stable, bone-ongrowth in 97%; stable, fibrous-fixation in 1%.

Conclusions: The grit-blasted, press-fit, collarless, tapered femoral component continued to perform well clinically and radiographically up to twenty years of follow-up despite the challenging environment of peri-prosthetic osteolysis associated with the acetabular component design. This implant is still in use virtually without design modifications. This study demonstrates the durability of the results of the grit-blasted femoral component and indicates that such an implant offers a viable alternative for fixation without bone cement.


P.R. Aldinger A. Jung V. Ewerbeck D. Parsch

Introduction: THA in young and active patients remains a major challenge. Uncemented femoral components have been advocated in young patients, but there are only few reports with more than 10 years follow-up.

Materials and Methods: We followed the first 153 consecutive implantations of an uncemented, straight femoral stem (CLS, Zimmer Inc, Warsaw, USA) in 141 patients. Mean time of follow-up evaluation was 17 years (range, 15 – 20 years), mean age at surgery was 47 years (23–55).

Results: At follow-up, 20 patients (20 hips) had died, and 7 (7 hips) were lost to follow-up. 10 patients (10 hips) underwent femoral revision- 1 for infection, 4 for periprosthetic fracture, and 5 for aseptic loosening of the stem. Overall survival was 91% at 17 years (95%-confidence limits, 88%–94%), survival with femoral revision for aseptic loosening as an end point was 95% (95%-confidence limits, 93% – 98%). The mean Harris-Hip-Score at follow-up evaluation was 84 points. 116 hips were available for radiolographic evaluation. Radiolucent lines (< 2mm) in Gruen zones 1 and 7 were present in 12,9% (15 hips) and 13,8% (16 hips), respectively. Radiolucencies in zones 2 – 6 were found in 0,9% (1 hip) – 2,6% (3 hips) on ap x-rays. Only one case of distal osteolysis was found after a previous Wagner resurfacing. No case of severe femoral osteolysis was found at follow-up.

Conclusions: The long-term results with this type of uncemented femoral component are encouraging and compare favorably with those achieved in primary cemented total hip arthroplasty in this group of young and active patients.


A. Suckel F. Geiger M. Garbrecht

Background: The long-term results for uncemented hip arthroplasty have not yet been sufficiently documented for a period of more than 15 years.

Methods: A clinical, phone, and radiological check-up with a mean follow-up of 15 (15–17) years analyzes the clinical results, the rate of aseptic loosening, the survival rate of the prosthesis, and the necessary re-interventions for a group of 320 consecutive total hip surgeries using Zweymüller screw cups and Zweymüller-SL stems in 303 patients from the years 1988 and 1989. The surgery was performed on 183 hips in women and 137 hips in men; 17 patients were operated on both sides. The mean age at the time of operation was 67 (29–99) years. All patients were permitted to put full stress on the leg immediately after the operation, and the prosthesis system was used as universal implant, no matter what the bone quality and the patient’s age. 164 (51.3%) of the hip patients had died at the time of the follow-up examination. Clinical and radiological examinations were available for 97 (30.3%) of the hips, phone interviews and radiological examinations for 4 (1.3%) of the hips, and phone follow-ups for only 49 (15.3%) of the hips. 6 (1.9%) of the hips were assessed as lost to follow-up.

Results: The Harris hip score results in a mean value of 88. The rate of aseptic loosening is 2% for the acetabular component and 1% for the femoral component. The stem and the cup had a survival rate of 98% in the surviving patients each. In 97.8% of the implanted prostheses, no exchange of a prosthesis component became necessary; in 95.2% of the patients, no operative revision of any kind was required.

Conclusions: With the Zweymüller hip endoprosthesis, excellent long-term results can be achieved both from a clinical perspective and regarding the rate of aseptic loosening and the survival rate. The system can be fully stressed immediately after the operation; age and poor bone quality are not contraindications for an implantation.


C. Plaass M. Lüem P.E. Ochsner T. Ilchmann

Introduction: The Acetabular Reinforcement Ring (ARR) (ME Müller®) was introduced in 1977 as successor of the Endler ring, especially to allow total hip replacement (THR) in patients with congenital hip dislocation, serious dysplasia and revision of loose cups. The Polyethylen (PE)-inlay can be freely oriented in the fixed ARR. It is the first implant with screws having angular stability as the screw-heads are blocked when cementing the inlay in the ring.

Patients and Methods: Out of 2251 primary THR performed between 1984 and 2005 at our hospital the ARR was used in 399 hips (363 patients). The indication for a THR with ARR was mainly a deficient acetabular bone stock as judged by the operating surgeon. 51 % of the patients had osteoarthritis, 22% dysplasia, 7% fractures, 6,5% osteonecrosis, 5% protrusion acetabuli, 4% rheumatoid arthritis and 4,5% other diagnosis. The mean age at operation was 66.4 years, 64% were females.

Intraoperatively, the ARR was placed with its medial border adjacent to the tear drop figure. The weight bearing area was fixed with 3–4 cancellous screws in the acetabular bone stock. Regular clinical and radiological follow-up 3months, 1, 2, 5, 10,15 and 20 years was planned. The radiographs were assessed for osteolysis, radiolucent lines and screw breakage after 15 years. Survival for revision due to aseptic loosening was calculated by Kaplan Meier.

Results: The overall survival regarding aseptic loosening of the cup was 100% after 10 years, 97,2% after 15 and 93,2% after 20 years.

Of the 96 patients (104 rings) operated at least 15 years ago, one was lost for follow-up. Three rings were revised due to aseptic loosening (11, 12, 16 years after implantation) and one was removed due to infection (1,8 years after implantation). 54 patients (with 56 rings) died before they reached the 15 years control. None of them was revised for aseptic loosening of the ring. 37 patients (43 hips) remained for 15-years control, six of them refused to come and were contacted by questionnaire or phone. Two cups were radiologically loose with broken screws but not symptomatic. The mean HHS after 15 years was 80.1.

Conclusion: The ARR shows a very good long term survival even in patients with difficult acetabular situations such as deficient bone stock. The design allows an application in a variety of positions. Even at a teaching hospital good long term results could be reached with this implant.


K. Bargiotas L. Papatheodorou M. Hantes T. Karachalios K. Malizos

Aim: We present the surgical technique and early functional and radiological results of cementless acetabular reconstruction with Monoblock Trabecular Metal (MTM) (Zimmer Warsaw, Indiana) cups in patients with Developmental Dysplasia of the Hip (DDH).

Materials and Methods: From 1997 to 2004, 70 hips (57 patients) with DDH were received an MTM acetabular component. There where 7 men and 49 women. Average age was 50 years (range 35 to 77). According to the classification of Hartofilakidis et al there where 14 hips with high dislocation, 15 with low type I, 16 with low type II, 8 with low type III dislocation and 17 with hip dysplasia. In all patients a MTM cup was implanted in the true acetabulum through a standard posterior approach. Morselized graft was used in 6 cases and a structural graft only in one. Diameter of the cup was ranging from 42 to 56 mm with 54 out of 70 cups being smaller than 50 mm. Screws where used in 12 out of 70 cases A femoral shortening osteotomy was utilized in only two high dislocation cases.

All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).

Results: Average follow up was 50 months (range 103 to 24). There were no revisions for aseptic loosening, radiologic loosening or cup migration during last evaluation. Two patients developed non-progressive radiolucencies in zone one.

There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.

Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.

Conclusion: MTM acetabular component achieved adequate initial stability in this demanding group of patients and they have excellent radiological and clinical results. Posterior approach without femoral osteotomy provided adequate exposure in almost all cases.


K. Zweymüller M. Brenner M. Steindl

Introduction: Stable cup anchorage in dysplastic hips is a key problem of THA. The pupose of this study was to evaluate the usefulness of a cementless cup without acetabuloplasty based on medium term Results: Method 53 patients, 47 females and 6 males aged 20 to 76 (mean 49) years at surgery were followed-up after 4.9 to 11.4 (mean 8.8) years. Crowe’s dysplasia classification showed 30 hips to be grade I, 23 grade II and 1 grade III pre-operatively. All patients were implanted with threaded pure-titanium double-cone cups. Acetabuloplasty was omitted and care was taken to achieve primary stability in the bone stock available. Pre-operative leg length discrepancy versus contralateral was 0 to 7 (mean 3.9) cm.

Results: On postoperative radiography 45 cups were completely covered by bone in position I. Of 6 cups 3 quarters were covered, of 1 cup 2 thirds and of another one ½ of the cranial circumference. All of the incompletely covered cups were stable at follow-up. Altogether 51 cups had maintained their position by radiographic evidence and were firmly anchored in bone. Cup loosening in Crowe grade I and II necessitated 2 revisions. Leg length was equalized in 39 patients with mean lengthening by 3.4 (1.2 to 4.5) cm.

Conclusion: In the management of dysplastic hips the system used provides stable anchorage in the bone stock without additional acetabuloplasty. Even pronounced soft tissue tension on substantial leg lengthening does not impair implant stability.

Summary: Primary stable implantation of a cementless titanium cup in hip dysplastia cases without additional acetabuloplasty is achieving good medium term results.


K. DIALETIS N. CHRISTODOULOU C. SDRENIAS G. SALAGIANNIS A. STAVRIANOU T. GEORGAS P. PSYLLAKIS

AIM OF STUDY: The mid and long-term clinical and radiological evaluation of patients with degenerative arthritis secondary to congenital hip diseases with placement of the cup proximal to the true acetabulum.

MATERIAL AND METHODS: We operated on a total of 99 hips (90 patients) with arthritis due to CHD from 1996 to 2006. In 48 of these hips (mean age 55.8 yrs), the cup was inserted high.

The procedure was always performed with the patient in lateral position through a lateral transgluteal approach. We did not perform osteotomies of the greater trochanter or femur shortening osteotomies and the cup was placed where there was sufficient bone stock. The major determining factor in cup stability was the presence of sufficient anterior and posterior column. We also tried to insert the cup as medial as possible although in about half the group (25 out of 48), cup placement was superior and lateral. The limb length discrepancy was corrected by varying the neck length of the implant. A special stem was used in 5 cases.

The mean intraoperative time was 65 mins with minimal soft tissue disruption as compared with the classic methods. The patients were mobilized postoperatively in a couple of days.

RESULTS: Despite the higher rates described in literature, cup loosening occurred in only two hips and there was no incidence of stem loosening. There were no neurological complications. There were three complications in total: one DVT and two dislocations due to cup loosening as a result of mal-positioning.

CONCLUSIONS: The extremely low rate of cup loosening, improvement of Harris Hip Score and back pain, decreased intraoperative time are significant advantages of managing congenital hip diseases with the above technique using the uncemented Zweymüller implants. The long period of follow up (8 to 11 years for 31% of the patients) in this study is significant.


J.F. Quinlan J. Dillon E. Walker T.J. O’Sullivan

Patients with DDH are known to be at risk of early degenerative changes to their hips. To date, no consensus exists as to the most appropriate management of this group, with many surgical options being associated with specific complications such as dislocation and early wear. In addition, modern resurfacing methods are considered by many to be contra-indicated in patients with DDH due to the technical difficulty of the procedure.

This prospective study analyses a single surgeon series of known DDH hips that underwent metal on metal resurfacing from November 1999 to July 2004 inclusive.

There were 31 resurfacings carried out on 28 patients (11 males, 17 females). The mean age of the study group at the time of surgery was 43.9+/−9.1 years. No patient was lost to follow up. Pre-operatively, 23 hips were classified as Crowe I (n=9), II (n=5), III (n=5) and IV (n=4). Patients were followed up to a mean of 46.4+/−18.1 months. The mean Harris Hip scores were 54.9+/−9.3 pre-operatively and 98.1+/−4.9 post-operatively (p< 0.001, Student’s t-test). Using the UCLA activity profile, the mean scores were 3.2+/−1.0 pre-operatively and 6.4+/−1.8 post-operatively (p< 0.001, Student’s t-test).

Although the management of young patients with early degenerative changes secondary to DDH remains controversial, the results of this study suggest that not only is resurfacing technically possible even in advanced cases, it also offers excellent functional outcomes and should be considered in appropriate cases.


D. Regis A. Sandri E. Citriniti P. Bartolozzi

Introduction: The management of periprosthetic osteolysis is a challenging problem in revision hip arthroplasty. Filling acetabular bone defects with structural allografts resulted in early failure due to resorption of the graft. The application in combination with reinforcement rings should promote bone incorporation as a result of reduced mechanical stresses. This study evaluates the long-term results in the treatment of acetabular deficiencies using bulk allografts supported with a Burch-Schneider Anti-Protrusio Cage (APC).

Materials and Methods: From January 1992 to December 1995, 69 consecutive patients underwent revision surgery following periprosthetic osteolysis and aseptic loosening of the cup. Acetabular bone loss included IIIA and IIIB types according to Paproski classification. 12 patients died for unrelated causes with a well-functioning total hip arthroplasty in situ. 3 cases were lost at follow-up. The study group consisted of 56 hips in 54 patients. There were 11 males and 43 females, aged from 33 to 84 years (medium 65). Average follow-up was 11.7 years, ranging from 10 to 14.4. Surgical procedure included filling acetabular bone defects with bulk allografts supported with a Burch-Schneider APC which was fixed with screws to the iliac bone. A poly-ethylene cup was finally cemented into the metal cage. Deambulation was allowed one week after surgery, but weightbearing was delayed two months. Clinical evaluation was determined using Harris hip score (HHS). The stability of the acetabular implant was assessed according to Gill criteria. The progression of the bone graft was evaluated using Gross grading.

Results: 2 patients developed deep infection that was treated by resection-arthroplasty. Aseptic loosening of acetabular cage following an extensive resorption of bone graft was observed in 6 cases and 3 of them underwent rerevision. X-ray signs of graft incorporation occurred in 48 hips. Average HHS values of 30 (range, 11 to 81) and 75 (range, 28 to 100) points were assessed respectively in the preoperative time and at follow-up.

Discussion and Conclusions: In severe acetabular bone deficiencies the application of reinforcement rings in combination with massive allografts has been advocated in order to prevent bone graft resorption and cup loosening. Burch-Schneider Anti-Protrusio Cage is able to protect the graft spanning bone defects and promoting augmentation of periprosthetic bone stock. With an aseptic failure rate of 8.9% and a total survival rate of 85.7% at an average of 11.7 years, the use of APC and structural allograft proved out to be an effective procedure in the long-term reconstructive treatment of extensive loss of acetabular bone stock.


G. Grappiolo L. Spotorno G. Burastero M. Gramazio

Introduction: The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur.

Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required.

Purpose of the study is to analize surgical procedure and then reconstruction options on severe hip dysplasia.

Materials and methods: From 1984 till today 2308 cases of arthroplasty were performed in dysplastic hip, 565 cases have a previous femoral osteotomy; out of these 2308 cases 128 cases need treatment for corrections of femural side deformity.

64 cases were subjected to a greater trochanteric osteotomy. In 12 cases proximal femural shortening was associated. In 9 cases rotational abnormality and shortening were controlled with a distal femur osteotomy.

55 cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only uncemented stems were used and in the majority of cases a specific device for displastic hip (Wagner Conus produced by Zimmer).

Discussion: Long-term results in these patients are steadily inferior to that in the general population (70% survival at 15 yrs). On femural side early failures are the reflection of learning curve and are due to insufficient fixation of the osteotomy.

Despite this, the more promising outcomes are concerning shortening subtrochanteric osteotomy with uncemented stem but only early and mid-term data are available.


C. Röder B. Bach S. Eggli M. Melloh A. Busato

Introduction: Studies about the influence of patient characteristics on mechanical socket failure in THA apply different methodologies and reveal inconclusive results. In addition the fixation mode has rarely been in the focus of investigation.

Methods: We conducted a two-arm matched pairs case-control study assessing the influence of patient characteristics sex, age, weight, BMI, diagnosis, and activity level (Charnley classification) on the odds for mechanical socket loosening. The cemented and uncemented fixation mode was analyzed separately.

Results: 299 cases and 986 controls were included in the cemented study arm and 510 cases and 3000 controls in the uncemented arm. Women had reduced loosening odds for the cemented (OR=0.59, p=0.0024) and uncemented (OR=0.63, p=0.0001) fixation compared to men (OR=1). Each additional year the intervention was postponed reduced the loosening odds by about 2 % for cemented (OR=0.98, p=0.017) and uncemented (OR=0.98, p=0.0002) sockets. In cemented sockets the weight group of 73–82 kg had lower loosening odds (OR=0.63, p=0.017) than the lighter (OR> 0.92) and heavier (OR> 1.1) weight groups. There were no significant effects of weight in the uncemented group. In contrast, obese patients (BMI> 30) with uncemented sockets displayed elevated loosening odds (OR=1.41, p=0.034) compared to an insignificant effect in the cemented arm. Osteonecrosis was the only main pathology revealing elevated loosening odds (OR=1.27, p=0.049) but only in cemented sockets. The Charnley classification as an indirect proxy of activity revealed changing and insignificant effects.

Conclusions: Female sex and a delayed intervention have similarly protective effects on the odds for cemented and uncemented socket loosening. Whilst a certain body weight range has a significantly protective effect in cemented sockets the more important finding is the significantly increased risk for uncemented socket loosening in obese patients. Patients with osteonecrosis are the only etiologic group at a significantly increase risk for socket loosening, but only with a cemented fixation. The Charnley classification as a surrogate for activity level had no influence on loosening risks in either socket fixation mode. Level of Evidence: Level III (case-control study)


M. Ribas E. Domínguez O. Marín I. Ginebreda J.M. Vilarrubias

Introduction: today there is still no consense in reconstruction of severe acetabular defects in hip revision. Since 1988 we use size matched impacted acetabulum allografts. We evaluate how they behave in the mid- and longterm.

Material and method: we present our first 44 transplants with a mean follow-up of 11,2 years (range 6 to 17). The mean age of the patients was 58,6 years (range 19 to 83). According to Gross Classification 26 cases presented an acetabular defect type III while 18 presented type IV. Evaluation included Merle D’Aubigne Score and radiological assessment of allograft and cup according to Engh Criteria (JBJS, 1994).

Results: homogenization of the radiological trabecular pattern was observed in 42 from 44 cases (95,4 %). There were 3 infections and 7 cases of aseptic loosening (15,9 %), that were revised with new cup implantation. Up to now none of these 7 cases have shown further signs of loosening. According to the Kaplan-Meier’s curves the overall predictive survival rate was 76.4 % at 15 years. In cases of pelvic discontinuity (type IV) survivorship was significantly higher (85,7%, p=0,018). There was a highly marked improvement in Merle D’Aubigne Score in Gait (2,2 preoperative – 4,9 at follow-up, p=0,021) and Pain (2,5 preoperative 5,4 at follow-up, p=0,032).

Conclusions: despite published reports with high incidence of failures in the midterm with structural allografts this serie shows clearly that a size matched impacted acetabulum allograft can be successfull in severe defficiencies if proper donor selection and excellent fixation technique is undertaken.


G. Bailie J. Howell M. Hubble J. Timperley G. Gie

Introduction: Recurrent dislocation is a significant problem after total hip replacement. Aetiology is multifactorial and treatment should address the reason for dislocation. The use of a constrained tripolar liner is an option in the surgical treatment of dislocation.

Methods: A retrospective review was carried out of patients who have undergone revision hip surgery and had a constrained liner cemented into the acetabulum. Patients were identified from a computer database. All patients had a constrained liner cemented onto a satisfactory pre-existing cement mantle, cemented into a reconstruction ring, or cemented into a well fixed cementless shell. The Osteonics Tripolar Liner was used in all cases and the outer aspect of the tripolar liner was prepared with a burr to create grooves and thus improve cement interlock. Data collected included demographics, reason for revision, components used, re-revision rate, outcome and survival.

Results: There were 58 cases identified where a cemented constrained liner was inserted at revision hip surgery. Average age at time of surgery was 77years (range 40–94). Reason for use of a constrained liner was recurrent dislocation in over 95% of cases. There were 9 patients who died with less than 2 years follow-up; they were excluded, leaving a study group of 49 cases. Average duration of follow-up was 46months (range 24–76).

There have been 4 infections, one of which required removal of prostheses and 2 stage revision. There was one case of fall post-operatively and fracture of the contra-lateral femoral neck. There have been 3 implant failures requiring re-revision. All failures were due to disarticulation of the liner, 2 of which occurred in the same patient on separate occasions. There have been no revisions for loosening, and there have been no cases of failure at the bone-cement interface or at the cement-cement interface with the cement-in-cement technique. Overall survival of the cemented constrained liner was 91.8% at average 3.8years.

Conclusion: This study demonstrates that a cemented constrained tripolar liner is a viable option in revision hip surgery, particularly in the treatment of recurrent dislocation.


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

In acetabular revision press-fit cups usually are used in smaller defects and contact to the host bone should be more than 50 %. Due to the thin wall thickness and the surface design the cementless press-fit cup Allofit S has a specific characteristic during implantation. Therefore this cup was used for revision with greater acetabular defects and analysed in a prospective study. The press-fit in these cases was 4 mm and additional 2 or 3 screws into the Os ilium were used.

64 cups were were followed prospectively for 38.3 months with a minimum of 24 months and examined clinically (Harris-Hip-Score) and radiographically for migration (Method of Nunn et al.) and loosening (Method of Delee and Charnley). Corresponding to Nunn et al. and Blum et al., cup migration was defined to be a change of position greater than 3 mm or referring to Cordero-Ampuero et al. and Dickob et al. a change of inclination greater than 5 degrees. There were 25 revisions of the cup and 39 complete exchanges of the prosthesis due to 54 aseptic and 10 septic loosenings (two-step revision with spacer and cementless reimplantation). There were acetabular defects of type Paprosky 2A in 12 cases, of type 2B in 15 cases, type 2C in 19 cases, type 3A in 16 cases and type 3 B in 2 cases. The average age of the patients was 70.9 ± 8.9 years.

The Harris-Hip-Score increased from 45.4 ± 14.9 points preoperatively to 81.8 ± 17.5 points one year and 82.3 ± 17.1 points two years postoperative. There was no loosing or significant migration of the cups.

The Allofit S press-fit cup shows good result in cup revisions with greater acetabular defects when using a press-fit of 4 mm and additional 2 or 3 screws. In these cases it seems to be a good and cheeper alternative to specific implants like trabecular metal cups.


D.A. Campanacci G. Beltrami M. Mela A. Franchi D. Podda H. Rudiger R. Capanna

Liposarcomas (LPS) are the most common soft tissue malignant tumor with a reported annual incidence of 2.5 per million people. The latest histopathologic classification of liposarcomas identifies three main groups: well-differentiated LPS; myxoid-round cell LPS; pleomorphic LPS. Dedifferentiated LPS is considered as a subgroup of well-differentiated LPS where there is an area of transition from a low grade to a high grade non lipogenic lesion (typically MFH or fibrosarcoma). The purpose of the present study was a retrospective review of the data of 146 consecutive patients affected by liposarcoma, with the aim to correlate the outcome of patients with treatment modalities and prognostic factors.

There were 89 males and 57 females with an average age of 54 years (range 16–92). The tumor grading following Broders criteria showed a low grade lesion in 48% of cases and a high grade lesion in 52% of cases. The histologic pattern showed a well differentiated liposarcoma in 25 patients (17%). The most frequent histologic finding was a myxoid liposarcoma in 55 cases (38%) while a round cell component of variable rate was seen in 22 cases (15%). A pleomorphic LPS was observed in 32 cases (22%). Dedifferentiated liposarcoma occurred only in 3 cases (2%). Surgery alone was performed in 31% of cases while chemotherapy (adriamycin and ifosfamide) and/or radiationtherapy were associated in 69% of cases. Brachytherapy was performed in 50 cases. Surgical margins resulted radical in 4 (2.5%) of cases, wide in 89 (61%), marginal in 45 (31%) and intralesional in 8 (5.5%) of cases.

In 10 cases (6.8%) a local recurrence occurred and in 33 cases (22.6%) a metastatic lesion was observed. Local recurrence were treated with surgical excision in 7 cases and with amputation in 3 cases. At an average follow up of 55 months, 68.5% of patients were continuosly disease free, 6.8% were disease free after local recurrence or metastasis excision or both, 4.8% were alive with disease, 14.4% were dead of the disease, 5.5% were dead of other cause. Eleven patients (7%) underwent an amputation, in 5 cases as first surgical procedure, in 3 cases after a local recurrence and in 3 cases for complications of the radiationtherapy. Local control was significantly correlated with the type of surgery at presentation and with surgical margins. Overall survival was significantly correlated with surgical margins, with grading and with the histotype of the tumor.

In the present series of soft tissue liposarcoma the combined treatment allowed limb salvage in 93% of cases (7% of amputations). Virgin lesions at presentation and free surgical margins resulted positive prognostic factors for local control. The histotype of the tumor, grading, and surgical margins resulted significative prognostic factors in survival, with round-cell and pleomorphic and high grade lesions showing the worse prognosis.


F. Gruber R. Zettl P. Ritschl

Introduction: Loosening of the acetabular Implant after Total Hip Replacement (THR) is often associated with massive bone loss. Many different solutions to this problem have been reported. The implant we used in our series is a cementless cup that consists of two different modular components: the outer shell, with a caudal hook and 3 iliac wings, and the inner module that can be placed in 20° angulation, where the liner is inserted. Non-structural bone graft was used.

Materials and Methods: From April 2002 to October 2004 24 patients were treated with this implant (age 70,7 years, 48–88). They had had zero to six prior surgeries. Indications were: Aseptic loosening (20), septic loosening (2), repetitive luxations(1), intraoperative acetabular fracture (1). Acetabular bone loss was intraoperatively graded using the DGOT classification. Paprosky Classification was used for preoperative radiological grading.

Harris Hip Score (HHS) was used for clinical evaluation (preoperative scores were retrospectively ascertained from patients’ charts). For radiological follow up plain X-rays of the pelvis a.p. and targeted views of the cup were used. Radiolucency, osteolysis (around cup, caudal hook, screws), migration (medial, cranial) and dumping was noted and the results divided into 3 groups: stable (no migration) at risk (cranial or medial migr.), loosened (cranial and medial migr.).

Results:18 Patients with implants in situ could be examined at an average follow up time of 18,3 months (3–30). (1died, 1 could not be reached, 2 did not want to come to fu, 2 explantations after infection). Average stay in hospital: 26 days, non weight bearing for av.: 9,8 weeks. Complications: 1 transient common peroneal nerve palsy, 1 luxation after 4 months (treated conservatively).

HHS improved from 36,4 to 69,3 points (max. 100). Pain: 15,5 to 36,8 pts (max. 44). Activity of daily living:14,3 to 36,8pts (max. 47). Walking distance 3,6–5,8 pts (max.11).

Radiological results (n=19, patient who died included in rad. FU): Radiolucency and osteolysis: Cup 5, hook 12, screws 10. Migration: medial:7 (all of those had medial bone defects), cranial:4, angulation > 4°:4 Outcome: stable: 11, at risk: 3, loosened 5 (1 died, 1 explanted, 3 control every 3 months)

Conclusion: In our series the SPH Bicomponente does not provide sufficient postoperative stability to facilitate good ingrowth of bone graft. Loosening occurs especially in cases with medial bone defects where the cup has too little contact to pelvic bone. In these cases cemented cups or structural grafts might give better stability. ‘At risk’ patients show better clinical performance than one would expect from the radiological findings.

A second follow up is starting recently with an average FU time of about 36 months.


R. Fernandez-Fernandez D. Duran E. Garcia-Rey E. Gil-Garay

Introduction: Bone stock in revision total hip arthroplasty is one of the most important issues for the orthopaedic surgeon. Different options have been described to manage acetabular bone defects. We reviewed the clinical and radiological results of two different uncemented oblong cups

Material and methods: 18 LOR (Sulzer) and 21 BOFOR (EndoPlus) uncemented cups were evaluated. Morsellized cancellous bone graft was used in all cases but 3. Mean follow-up was 31.6 months. Mean patient age was 72.3 years (32 to 91). Bone defects were classified according to Paprosky’s criteria. Clinical and radiological results were recorded.

Results: There have been no infections and no re-revisions in this series, although one patient is awaiting evaluation for re-revision. Clinical results improved according to the Harris Hip Score from 44 to 75 points. 34 cups were considered stable and 5 showed migration. All unstable cups were implanted in patients with type IIIA or IIIB bone defects. We observed the appearance of non-progressive radiolucent lines of less than 2 mm in 7 hips, sclerosis lines in 1 and acetabular osteolysis in 2.

Conclusions: Uncemented oblong cups are a valid option in revision total hip arthroplasty. The results were worse in patients with major acetabular bone defects. A longer follow-up is needed to evaluate these cups and confirm our findings.


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H. Miettinen J. Kettunen S. Miettinen M. Hämäläinen H. Kröger

Preliminary results using Trabecular Metal (TM) acetabular component (made of tantalum) in primary and in revision total hip arthroplasty are encouraging in few published papers in the literature.

Patients and Methods: The outcome and survivorship of a TM revision uncemented acetabular cup were assessed in 85 consecutive patients (Male 48, Female 37, mean age 70,9 years, range 54–92) undergoing revision THA in the time period from 13.5.2004 to 8.6.2006. Years from previous operation to revision arthroplasty was in average of 10,0 years (range 1–23). Acetabular bone defects were assessed using Paprosky grading system. Monoblock TM cup was used in 26 operations(Paprosky grade I=13; grade IIa=1; Grade IIb=6 and Grade IIc=6). Modular revision TM cup was used in 59 operations (Paprosky grade I=7; Grade IIa=5; Grade Ibis=15;Grade IIc=24; Grade IIIa=5 and Grade IIIb=3). 55 allografts (femoral heads) were used to fill bone defects in 39 acetabulums. TM augment was needed in 4 operations. In 17 operations also the femoral component was revised. Seven of these operations were re-revision operations. Full weight-bearing was allowed after 44 operations, partial weight-bearing after 37 operations and no weight-bearing after 4 operations. In four operations, where TM cup was initially tried to use, the fixation was found to be insufficient. Consequently, the method of revision was changed either to plating and TM-cup (Paprosky grade IIIB, n=2) or protection cup-system (Paprosky grade IIc, n=2).

Results: Subjectively, the patients were satisfied with this operation at the follow-up (mean 14 months, range 3–26). 58 (68%) patients were painless and 72 (85%) patients walked without any support. X-ray studies showed good TM-cup fixation into acetabular host bone and bone defect filling in 84 out of 85 cases in this short follow-up.

Complications: 7 dislocations, 1 deep infection and 1 sciatic nerve injury. These complications were concentrated to alcoholic and patients with many other health problems.

Conclusion: TM implant has very good primary fixation properties in host bone. The cup shows reliable ingrowths and defect filling with host bone. Our good short-term results with TM-cup are similar to the few previously published papers. Further clinical investigation is needed to show the durability and functionality of this new prosthetic material.


G. Beltrami G. Scoccianti M.M. Mela A. Franchi L. Livi D.A. Campanacci R. Capanna

Neoadjuvant therapy in soft-tissue sarcomas is still a controversial issues regarding indications, patients selection and treatment protocols. In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. Among these patients, 49 received preoperative chemotherapy (epirubicin plus ifosfamide, according to Italian Sarcoma Group protocol), associated to preoperative conventional external beam radiationtherapy in 36 cases (73.5%). The histologic types were liposarcoma (30,6%), synovial sarcoma (20,4%), fibrosarcoma (16,3%), pleomorphic sarcoma or malignant fibrous histiocitoma (12,1%), leiomyosarcoma (8,2%), other histotypes (12,1%). Tumor size was 10 cm or larger in 21 cases, 6 to 9 cm in 23 patients and 5 cm or smaller in 5 cases. Neoplasms were high-grade (Broders grade 3 or 4) in all cases but five.

After neoadjuvant treatment we performed a limb-sparing surgical excision of the tumor in 47 patients (96%), while a primary amputation of the limb was necessary in only two cases (4.1%). A vascularized miocutaneous flap was used in 8 cases, and adequate surgical margins were achieved in more than 70% of the cases.

Postoperative chemotherapy was given in 26 cases (53%), postoperative radiotherapy just in 5 (10%). We report the outcome data on these 49 cases, regarding overall survival, local or distant relapse, local and systemic complications, early and long-term limb salvage rate.

According to histologic examination of the resection specimen, average percent of necrosis after neoadjuvant treatment was 70.6% (range 30 – 99%). Wound dehiscence occurred in 6 patients but ultimately healed succesfully in all of them.

At an average follow-up of 23 months (range 3 – 82), 37 patients were continuously disease free (76%), two patients had local recurrence (one amputated), four patients were alive with metastatic disease, five patients had died with disseminated disease (at 4, 19, 28, 37 and 61 months after surgery), one patient had died of unrelated disease.

Due to the inconstant tumor response, neoadjuvant treatment in soft tissue tumors is still a controversial issue. On the basis of data presently available, we think that it can be a useful treatment in high-risk tumors (larger than 5 cm; high grade). In these cases, at a low and acceptable rate of local complications, the conjoined use of preoperative chemotherapy and radiotherapy can help to make a limb-salvage surgery possible and at the same time can maybe reduce the risk of distant metastasis.


G. Scoccianti G. Beltrami M.M. Mela A. Franchi L. Livi D.A. Campanacci R. Capanna

In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. We investigated the outcome and risk factors in a homogeneous group of 112 patients, affected by high-grade soft tissue sarcomas of the limbs (not metastatic at presentation) and treated with limb-sparing surgery, brachytherapy and conventional postoperative radiation therapy. Postoperative chemotherapy was added in one fourth of the cases.

The histologic types were liposarcoma (21.4%), leiomyosarcoma (19.6%), synovial sarcoma (17.9%), pleomorphic sarcoma or malignant fibrous histiocitoma (14.3%), fibrosarcoma (9.8%), other histotypes (17%).

All the tumors were high-grade (Broders grade 3 or 4). Size of the neoplasm was 10 cm or larger in 8 cases, 6 to 9 cm in 60 patients and 5 cm or smaller in 44 cases.

A limb-sparing surgical excision was performed in all the cases; histologically adequate margins were achieved in 96 cases (85.7 %). In 28 cases a myocutaneous or fasciocutaneous flap was necessary for local reconstruction.

At an average follow-up of six years, 67 patients (59.8%) were continuously disease-free; 8 patients (7.1%) had presented metastatic disease (in one case combined with local relapse) but were alive with no evidence of disease at last follow-up; 3 patients (2.7%) were alive with metastatic disease; 28 patients (25%) had died with disseminated disease; 6 (5.4%) had died of unrelated causes.

Local recurrence occurred in 10 patients (8.9%) requiring an amputation in 2; metastatic disease occurred in 39 patients (34.8%).

Four more patients required an amputation for complications different from recurrence: one early amputation for surgery-related complications and three late amputations for radiation-related complications (two not-healing fractures, one unresolvable wound sloughing).

Wound sloughing occurred in 12 patients (5 surgery-related and 7 radiation-related).

Local control rate, disease-free survival, overall survival and limb salvage rate were examined at 5 and 10 years, aiming also to identify tumor or treatment characteristics with prognostic value for the outcome.

The use of brachytherapy is an important option for achieving a significant boost in radiation within the surgical bed. Combined treatment with limb sparing surgery plus brachytherapy and external beam radiation therapy seems to offer satisfactory results in terms of local control and limb salvage survival. The use of myocutaneous or fasciocutaneous flaps is often useful in this kind of surgery, making possible a limb-sparing procedure with adequate oncological margins. New protocols and randomized studies on chemotherapy need to be introduced to improve systemic control and overall survival.


P.J. Papagelopoulos A.F. Mavrogenis J. Vrouvas C. Vlastou P.N. Soucacos

The management of localized soft tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumor bed during surgery.

Ten patients over a 4-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was done postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60–65 Gy.

After a median follow-up period of 30 months, the 4-year local disease-free survival rate was 80%. The 4-year actuarial survival rate was 85%. There were no failures within the high-dose region of the implant. No patients had locoregional failures. One patient developed distant metastases. No serious side effects were noticed. Pro-phylactic intramedullary nailing was done in 1 patient. Pathological fractures occurred in 2 patients. All patients had good cosmetic and functional outcomes.

Intra-operative implantation of the tumor bed in combination with tumor resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.


N. Fabbri C. Errani A. Toscano A. Longhi D. Donati M. Manfrini E. Barbieri M. Mercuri F. Bertoni

Introduction: The role of surgery for local control in the multimodal management of Ewing’s sarcoma has substantially increased during the past 20 years. However, selection bias due to location (extremities vs axial skeleton) and relatively non-homogeneous treatment received by patients in multi-institutional trials may limit objective evaluation and comparison of the relative role of surgery and radiation therapy in this setting. Purpose of this study was to review a large series of patients homogeneously treated at a single institution.

Methods: 268 patients with non-metastatic Ewing’s sarcoma of the extremities treated by contemporary multimodal management were reviewed. Chemotherapy was administered according to 4 sequential protocols of adjuvant (1) and neoadjuvant (3) treatment. Local control consisted of surgery in 136 patients, surgery and radiation therapy in 70 patients, and radiation therapy in 60 patients. Two patients underwent only chemotherapy.

Results: The 5-year event-free survival (EFS) and overall survival (OS) were 62 and 69 per cent respectively. The rates of 5-year EFS and local control were significantly lower in patients treated with radiation therapy compared to patients treated by surgery or surgery and radiation therapy (48 vs 66 per cent, p=0.002; 80 vs 94 per cent, p= 0,0001). In group 3 (Radiation Therapy only) there were also 6 secondary malignancies.

Conclusion: Surgery was associated with better survival and local control in this series. In our opinion, surgery should always be considered in the local treatment of Ewing’s sarcoma of the extremities. Postoperative Radiation Therapy must be added in cases of inadequate surgical margins.


S. Cherix

Introduction: Isolated limb perfusion (ILP) is the local infusion of high doses of TNF and Melphalan, a potent chemotherapeutic agent, under controlled hyperthermia (< 40°). ILP may be used as an exclusive limb salvage procedure or as a neo-adjuvant treatment.

Material & method: Retrospective study in a tertiary centre with a multidisciplinary approach.

Results: Since 1992, 51 patients (mean age 54,8) 27 women, 24 men, with an non-resectable soft tissue sarcoma of an extremity (44 lower limb, 7 upper limb), have been treated by ILP, followed by surgical resection in 34 (65%). 6 patients had a 2nd ILP after local recurrence or ongrowing unresected tumor.

They have been evaluated after a mean follow-up of 3,6 years (13 months–15 years).

Five patients had grade I sarcoma, 17 grade II, 28 grade III and 1 unstated (FNCLCC classification). All but 5 presented a localised disease at the time of diagnosis. The reason for ILP was extracompartimental location in 10, contiguity to nervous or vascular structures in 10, the size of the lesion alone for 10 (up to 28 cm), and local spread of the tumor at presentation or by former surgical procedures 21. Thirteen patients presented major or longlasting post-operative complications, mostly cutaneous and neurological. Twenty-five percent of patients had a complete response to treatment, 44% a partial response, 17% no change and the remaining 14% a progressive disease. Ten radical (R0), 20 marginal (R1) and 4 intralesional (R2) resections have been performed 5,3 months (1,5–42) after ILP. Seven patients had a primary amputation (14%) and 10 had no operation or refused it. A reconstructive surgery was performed in 32% of the patients, and 27% had a complmentary radio- and/or chemotherapy. With a mean follow-up of 3,6 years (13 months–15 years), 33% patients were free of recurrence, 13% had local recurrence only, 27% distant only, and 27% both local and distant. From the 19 patients (40%) with local recurrence, 12 needed at least one new operation, with 5 more amputations.

Overall time to distant recurrence is 27,9 months (2–43), and to local recurrence is 22,3 months (2–78) respectively. Two and 5 years survival are 60,3% and 43,5% respectively.

Conclusion: As 24% of the patients were finally amputated, a 76% limb salvage was observed for tumours that were initially non-resectable.


H.R. Dürr

Introduction: Soft tissue sarcomas represent a rare malignancy showing 2–3 new cases/100.000/year. Based on that and other factors the therapeutic approach is not standardized. In the last years the most radical procedures as compartment resections hade been no longer adviced but there is still no common recommondation which surgical approach seems to be the best in respect to oncological and functional outcome. Radiation theray is part of the multimodal concept is unquestionable but there is still a discussion regarding timing and inclusion of patients. There are many ongoing studies to evaluate the effect of systemic chemotherapies with or without local procedures as hyperthermia or perfusion of the extremities. Aim of this review is therefore to give an overview about facts and speculations in this subject.

Methods: All relevant studies regarding the prognostic impact of resection margin, timing of radiation therapy, chemotherapy and local combined treatment modalities of the last 20 years had been reviewed. The foccus had only been the non-metastazised patient.

Results: Regrading the influence of resection margins an advantage of radical compartment resections could not been shown. There are conflicting datas showing prognostic disadvantages with resectionmargins of millimrters but also demonstrating no benefit with margins of serveral centimeters. The benficial effect of radiation in respect to local reccurencies is well accepted. By applying radiation before surgery the treated volumes are smaller, posttherapeutic complications hence reduced. But the risk of local complications regarding surgery seems to be enhanced. The systemic advantage is unclear. The position of intraoperative radiation therapy is also conflicting. Regarding systemic chemotherapy the results are also conflicting. One has to be aware that only 20% to 30% of the patients will have a regression of the tumour whereas a prolongation of survival still is debated. Local combined therapies show a sometimes dramatic effect to the tumour but seem not to alter prognosis.

Conclusions: Radical compartment resections seem no longer to be justified in comparision to wide resections. The local benefical effect of radiation therapy is well accepted, timing depended on local factors. Systemic chemotherapy shows conflicting results. Local combined therapies may influence the tumour but seem not to influence the prognosis of the patient.


R.U. Ashford S.W. McCarthy R.A. Scolyer S.F. Bonar R.Z. Karim P.D. Stalley

Introduction: The most appropriate protocol for biopsying musculoskeletal tumours is controversial. Some authors advocate the use of CT-guided core biopsy. At the Royal Prince Alfred Hospital, Sydney, Australia, initial biopsies of most musculoskeletal tumours involve a surgeon-led operative core biopsy technique with frozen section evaluation. The latter is used to determine whether diagnostic tissue has been obtained and, if possible, to establish a definitive diagnosis.

Aims: To determine the accuracy and cost effectiveness of a surgeon-led biopsy protocol for biopsying musculoskeletal tumours.

Methods: A retrospective audit of biopsies of musculoskeletal tumours performed in the bone and soft tissue sarcoma unit at the Royal Prince Alfred Hospital over a two year period was performed.

Results: One hundred and four patients had biopsies performed under the protocol. There were no non-diagnostic biopsies and one minor error resulting in no change in the patient’s management. There was no requirement to re-biopsy any of the patients. A surgeon-led operative core biopsy with frozen section evaluation was 38% more costly than a CT-guided core biopsy (AU$1804 versus AU$1308).

Conclusions: Surgeon-led biopsy with intra-operative frozen section evaluation is effective and accurate and, despite being labour intensive, the reduction in the need for repeat biopsies justifies its use. Whilst the technique is approximately 38% more costly, there is no requirement for re-biopsy and anxiety associated with the need for this is allayed.


P. Diehl F. Dörfler F. Gradinger R. Gradinger H. Rechl

Goal: Evaluation of prognostic factors on the long term survival of soft tissue sarcomas after resection.

Methods: Between 1991–2003

a) 29 synovial sarcomas males:femals 15:14 (mean age 36),

b) 15 leiomyosarcomas m:f 8:7 (mean age 62) and between 1997–2004

c) 26 malignant fibrous histiocytoma MFH m:f 11:15 (mean age 69) cases were treated individually with multimodal therapy regimen (irradiation/chemotherapy).

R0 resection was archived by 71% of the synovialsarcomas, 60% of leiomyosarcomas and 73% of MFHs’. The histological garding of synovialsarcomas was: G1: 0%, G2:21%, G3:73% and Gx: 6%. The histological garding of leiomyosarcomas was: G1:7%, G2:20%, G3:73% with 11 primary recurrences and the grading of the MFHs’ was G1: 7,7%, G2: 15,4%, G3: 69,2% und Gx: 7,7%.

Results:

Synovial sarcomas:

After a follow-up of 8 (2–14) years the overall survival was 57%, after R0-resection 65% and after R1 resection 0%. The survival of G2 und G3 was 67% and 53% respectively. The survival of T1 and T2-tumors was 100% and 39% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 50% und 28%. 55% of the patients developed local recurrence.

Leiomyosarcomas

After a follow-up of 8 (2–14) years the overall survival was 33%, after R0-resection 44% and after R1 resection 17%. The survival of G2 und G3 was 33% and 27% respectively. The survival of T1 and T2-tumors was 50% and 33% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 73% und 32%. 80% of the patients developed local recurrence.

MFHs’

After a follow-up of 4,5 (1–8) years the overall survival was 73%, after R0-resection 90% and after R1 resection 50%. The survival of G1, G2 und G3 was 50%, 75% and 83% respectively. The survival of T1 and T2-tumors was 100% and 75% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 20% und 0%. 19% of the patients developed local recurrence.

Scores for function and quality of life after treatment were 79% (37%–100%) for synovial- and 76% (53%–93%) for leiomyosarcomas and 76% (44%–100%) for MFHs

Conclusions: The investigated soft tissue sarcomas are highly malignant tumors. Bad prognostic factors for reduced long term survival are T2-tumors and G3-tumors (except MFHs’), local recurrence, metastases at the time of diagnosis and tumors after R1-resection, requiring aggressive multimodal treatment with chemotherapy, radiation and wide or even radical surgery.


V. Engell F. Damborg M. Andersen K. Kyvik K. Thomsen

Introduction: Clubfoot – Congenital talipes equinovarus (CTEV) – is one of the most common congenital conditions requiring orthopaedic surgery. However little is known about the impact on health-related quality of life in these patients. A score on physical- and mental-health is used for this purpose.

The aim of the present study was to compare health-related quality of life in CTEV to a background population.

Materials and Methods: The Odense based Danish Twin Registry (DTR) is unique as it contains data on all 73,000 twin pairs born in Denmark over the last 130 years. All 46,418 twins born from 1931 through 1982 received an Omnibus questionnaire in the spring of 2002. The incidence of CTEV was self-reported. Included in the questionnaire were questions for The Medical Outcome Study Short Form-12 (SF-12). We calculated SF-12 Physical Component Summary scale (SF-12 PCS) and SF-12 Mental Component Summary scale (SF-12 MCS) using the SF Health Outcomes Scoring Software.

80 reported to have CTEV and the remaining 29,516 were used as controls.

Results: 46,418 twins received and 34,944 (75%) returned the questionnaire. 34,485 (99% of the responders) answered the question ‘Were you born with club-foot?’ The sex distribution in these was 15,731 (46%) males and 18,754 (54%) females.

The self-reported prevalence of CTEV was 0.0027 (95% confidence interval 0.0022–0.0034).

80 reported to have CTEV and the remaining 29,516 were used as controls.

In the CTEV group SF-12 PCSmean was 50.18 (SD 11.19) vs 53.09 (SD 8.11) in the controls.

p< 0.0007.

In the CTEV group SF-12 MCSmean was 50.58 (SD 10.52) vs 51.78 (SD 8.47) in the controls.

NS.

Conclusion: The impact of congenital clubfoot on health-related quality of life was significant only on the physical scale. The clubfoot patients scoring lower than the controls. There was no difference in the mental scale between the two groups.


J. Alonso N. Davis R. Harris

Introduction: Children with clubfoot treated by the Ponseti method of clubfoot management require anterior tibialis tendon transfer if there is persistent varus and supination deformity. However the size of bone is a determining factor in whether this transfer can be carried out. We have assesses the difference in the age at which the lateral cuneiform ossifies in normal feet compare with clubfeet

Methods: Foot x-rays of children less than 4 years old (AP view) carried out between 2003 and 2005 were obtained from the Radiology department Booth Hall Children’s Hospital. A total of 341 radiographs were analyzed. Exclusion criteria included: any condition affecting foot anatomy or weight bearing or any previous surgery (including surgery for clubfoot). The lateral cuneiform was measured with 1mm accuracy in the longest diameter.

Results: We analysed the size of the lateral cuneiform in patients with and without clubfoot in relation to age. In children without clubfoot there was a R2 value of 0.517, showing a positive correlation between age and size of the bone. In children with clubfoot, R2 value was 0.207 showing no correlation between age and ossification rate of the lateral cuneiform. In addition, we compare the size of the lateral cuneiform between patients with and without clubfoot at different ages. There was a significance difference in the level of ossification of the lateral cuneiform in all age groups. In addition, a greater number of patients with no ossification of the lateral cuneiform were found amongst the clubfoot group in all age groups up to the age of 36 months.

Conclusions: We have identified a delayed ossification in the lateral cuneiform in children with clubfoot when compared with normal feet. This delayed ossification should be taken into account when considering anterior tibialis tendon transfer for correction of clubfoot


R. Shariff J. Sampath A. Bass

Introduction: Majority of children with cerebral palsy patients suffer from fixed flexion contractures of their knees. Procedures commonly used to correct knee flexion deformities include hamstring release, anterior femoral hemiepiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are not very popular because of a theoretical risk of permanent physeal closure. We present our initial experience in correction of knee flexion deformity by using the 8-plate technique. This uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Materials and Methods: We analysed the case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate techinique between April of 2005 and August 2006. A total of 18 limbs in 12 patients underwent this procedure. Preoperative and post operative flexion deformity was measured using a goniometer. All measurements were made by the senior surgeon.

Results: The mean age of the patients was 12.8 years (range between 9–16)

Mean follow up time for the patients after they had undergone the procedure was 8.5 months (range 3 – 15). The Mean correction achieved – 16.15 degrees (range 5 – 40)

Conclusion: We conclude that this is a simple technique with few complications to date. The learning curve for this procedure is 1 case. All patients in our series have shown promising results, with sustained gradual correction to date. We also present technical tips in the 8-plate anterior femoral hemi-epiphyseodesis procedure.


C. GIGANTE E. TALENTI

A less invasive surgical treatment of clubfoot is increasingly considered, it aims to limit extensive exposure, to improve the functional and cosmetic outcome and to lower the risk of stiffness and recurrence of the deformity. The Ponseti method consists in an original casting technique followed, only in the most resistant clubfeet, by a percutaneous Achilles tenotomy. Critical decision is the selection of the clubfeet which needs tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision.

MATERIAL AND Methods: 98 newborns with 122 congenital clubfeet were treated by the Ponseti casting technique from mid-2000 to June 2006. According to Manes classification, there were 20 mild, 47 moderate and 55 severe clubfeet. After 3 to 8 weeks of casting, clubfeet candidate to surgery underwent sonographic assessment according to the original technique previously published by the authors. On the sagittal posterior plane the R.O.M. of the ankle and subtalar joints was stated both in neutral position and under manipulation. No surgery was performed in clubfeet with normal sonographic dorsiflexion, percutaneous tenotomy was done in clubfeet with mild limited sonographic dorsiflexion and more extensive posterior release (tendon Z-lengthening and posterior cut of ankle and subtalar joint) was performed in clubfeet with most evident sonographic persistent equinus and anterior dislodgment of the talus in the ankle mortise. The R.O.M. was checked again by ultrasound at the end of treatment. According to Ponseti method a Denis Browne bar, with clubfoot 60° externally rotated, was worn full time until the walking age.

Results: 35/122 clubfeet (28,6%) were treated conservatively (all the 20 mild and 15/47 of moderate deformities), 87/122 (71,4%) surgically (32/47 of moderate deformities and all the 55 severe deformities). On the basis of the dynamic ultrasound evaluation 38 clubfeet underwent simple tenotomy and 49 ones underwent extensive posterior release. At the end of the casting normal dorsiflexion was documented by ultrasound in 72 (82,7%) of the operated feet.

Conclusions: The need of surgery in the Ponseti casting technique shows a great variability in Literature. These controversial data are probably due not only to the different confidence in the Ponseti method, but also to the different criteria used in evaluating the correction obtained by casting. Ultrasound assessment of the deformity gives objective qualitative and quantitative information about the restoration of the physiological dorsiflexion and articular biomechanics. On the basis of this simple, non invasive and widely available procedure the surgeon can evaluate the effectiveness of the serial casting and may be able to establish and graduate the need of corrective surgery.


F. Monsell D. Eastwood S. Hoey L. Kangesu J. Harper N. Sebire

Background: Proteus Syndrome is a rare, sporadic overgrowth disorder for which the underlying genetic defect remains unknown. Although the clinical course is well-described, there is no systematic histopathological description of the lesional pathology.

Objective: To describe the histopathological features encountered in a series of patients with Proteus syndrome from a single centre.

Patients/Methods: Patients with Proteus syndrome who had undergone therapeutic surgical resection or biopsy were identified from a database and the histopathological findings were reviewed, with particular reference to descriptive features of the underlying tissue abnormality.

Results: There were 18 surgical specimens from nine patients, median age 4 (range 1–9) years, including four main categories; soft tissue swellings (lipomatous lesions), vascular anomalies (vascular malformation and haeman-gioma), macrodactyly (hamartomatous overgrowth) and others (sebaceous naevus and non-specific features). In all cases the clinical features of overgrowth were due to increased amounts of disorganised tissue, indicating a hamartomatous-type defect in which normal tissue constituents were present but with an abnormal distribution and architecture. Vascular malformations represented a prominent category of lesions, accounting for 50% of the specimens, predominantly comprising lymphatic and lymphovascular malformations. No malignancy or cytological atypia was identified in any case.

Conclusions: The histopathological features of lesions resected from children with Proteus syndrome predominantly include hamartomatous mixed connective tissue lesions, benign neoplasms such as lipomata and lymphatic-rich vascular malformations.


F. Monsell S. Pollock A. Caterrall F. Franceschi D. Eastwood

Background: The Ilizarov external fixator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity where scarred tissue planes, abnormal anatomy and impairment of local blood supply are common.

Objective: To assess the outcome of treatment of recurrent club-foot deformity using this device.

Patients/Methods: The study evaluated Ilizarov external fixator correction of 40 feet in 31 patients. Deformity was idiopathic in 29 patients, associated with constriction bands in 6 patients and was syndromic or associated with a defined neuromuscular disorder in 6 patients.

Patients were reviewed clinically and completed questionnaires documenting pain, function and satisfaction before and after treatment at a mean follow-up of 44 months (range 14–131). All patient’s notes and radiographs were examined.

Results: Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%, correlating with improved pain and function scores. Pain and function scores were not significantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%, and was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%). Feet with recurrent deformity had been treated with the Ilizarov fixator at a younger mean age (7.8 years) than those feet which did not recur (mean age 12.6 years). 71% of recurrences experienced significant pain post treatment, compared with only 36% of those feet where deformity did not recur. Functional ability was, however, similar in the two groups. Further surgical treatment has been necessary in 6 patients, including 4 further Ilizarov frames.

Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap.

Conclusions: Treatment of relapsed clubfoot with the Ilizarov fixator can improve the appearance of the foot, correlating with improvement in pain, function and patient satisfaction. This must be balanced however against a high recurrence rate, particularly in young idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and the risk of complications inherent in the technique.


S.M. Blake P. Cox

It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage.

32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus/heel varus) and midfoot (adduction/derotation) components were specifically studied.

During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction/derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction/derotation score > = 3) predicted the need for a combined plantarme-dial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting.

Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.


G. Ayana R. Thomas D. Sinclair A. Ray H. Read

Aims: Evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia resulting from meningococcal septicaemia and to assess the benefit of fasciotomies within this group.

Introduction: There have been only two published series on the orthopaedic management of meningococcal septicaemia in children. We carried out a retrospective review of all patients who had undergone this intervention in RHSC.

Methods: Between 1994 and 2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, subsequent operative intervention and eventual outcomes.

All presented with vague viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 children were admitted from A& E and 4 were transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had some form of surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died from overwhelming sepsis had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In our study 2 of our 7 patients who underwent fasciotomy the demarcation level receded distally post decompression leading to more distal amputation levels.


D. Garcia-German J. Parra García A. Bueno Sánchez A. Fernández Fernández-Arroyo

Introduction: Treatment of choice in osteogenesis imperfecta (O.I.) patients presenting severe deformities of lower limbs is endomedular nailing with previous corrective osteotomy. Fassier-Duval telescopic rod permits anterograde nailing without the need of distal arthrotomy and thus, joint damage.

MATERIAL AND Methods: We retrospectively revised the first 14 rods implanted in 9 patients at our service, 6 males and 3 females. Average age of 6.14 years. Sillence type III: 5, type IV: 4. Six right femurs, 7 left femurs and one tibia were nailed. In 5 of the 14 cases surgery was performed on acute fractures on previous deformities, in 9 cases because of progressive deformities. Corrective osteotomies were performed in all cases. Seven of 9 patients were receiving treatment with palmidronate prior to surgery. Improvement in quality of life with Bleck scale was assessed.

Results: Six of 14 operations were salvage procedures because of failure of other implants. Complications included a transient sciatic palsy, lack of telescoping in one case, one acute fracture with implant failure and one delay in consolidation. Two reoperations were needed. Global Bleck score improved from 7.37 to 12.75 (p=0.024), walking score improved from 1.25 to 2.87 (p=0.038).

DISCUSSION AND Conclusions: Fassier-Duval telescopic rod is a safe and useful implant for the treatment of deformities in the lower limbs in patients with O.I. There was a significant improvement in both global quality of life score and walking score.


F. De Maio P. Farsetti V. Potenza F. Forconi E. Ippolito

Fibrous dysplasia is a genetic not hereditary disease of the skeleton, most frequently located at the femoral bone. The extension and the radiographic morphology of the femoral lesion are variable, and the prognosis is unpredictable. The purpose of this study is to propose a radiographic classification of the femoral lesion, related to the prognosis and the natural history of the disease.

The authors reviewed the radiographic examinations of 25 patients affected by fibrous dysplasia of bone with femoral involvement, who were followed-up at least two years after diagnosis. Eleven patients had bilateral localization of the disease, for a total of 36 affected femurs. A radiographic classification of the femoral lesion was proposed based on the localization, the extension and the type of the lesion.

The authors classify the femoral lesions as lytic, lytic with surrounding sclerosis, lytic and sclerotic, sclerotic and complex. They observed a prevalence of the lytic lesions and involvement of the proximal part of the femur. Many lesions (40%) expanded with age, and the sclerotic component also increased. The lytic lesions worsened with age, causing severe deformity of the femur. However the mostly sclerotic lesions turned out to be stable at follow-up. The worsening of the lesion was not related to the sex of the subjects; 77% of the worsened lesions were observed in patients younger than 20 years of age, while 66% of the stable lesions were found in patients older than 20 years.

In conclusion, this study demonstrated that the prognosis of the femoral lesion in fibrous dysplasia is related to the type of lesion, as per the radiographic classification here in described. Prognosis is also related to the age of the patient and the presence of a sclerotic component, which suggested a greater stability of the lesion.


H.L. GEORGE B.R. Arumelli L.A. James N. Garg C.E. Bruce

Purpose of Study: To discuss on Clinical presentations, Investigations, Histopathology, Differential diagnosis and Treatment options based on a series of six Lipoblastomas that we encountered in our paediatric orthopaedic practice.

Materials and Methods: This series consists of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006. Mean age 17 months. Mean follow up was 26 months. The youngest was a six month old infant with a swelling on his right instep. The second patient was a three year old girl who presented with a limp and swelling in her foot, the third patient was an 18 month old boy with a swelling on the dorsum of his left forearm, fourth patient had a swelling of his left thigh and two patients had swellings in their back. They were investigated appropriately with MRI, CT or USG and surgical excision planned accordingly.

Results: Male to female ratio was 5:1. Age groups; 2 patients were of less than 12 months of age, another two of them was between 12 to 24 months and the last two were under 36 months at the time of diagnosis. Anatomically three patients had swellings in the lower limb, 2 had swellings over dorsum of their trunk one patient had a forearm swelling.

Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up.

Discussion: Lipoblastomas are uncommon, benign tumour of embryonal mesenchymal cells. It is a rare tumour but occurs mostly during infancy and early childhood. It most often presents on the extremities, back, head and neck.

Histology: cellular neoplasm composed of lipoblasts in different stages of maturation and fine vascular network, with well defined septa.

Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading.

These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported.

Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

Conclusion: All patients were originally thought to have simple lipomas or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour and is rarely encountered in orthopaedic training. It is important that we orthopaedic surgeons be aware that lipoblastoma is in fact the most likely diagnosis of a fatty lump in a child of less than two years of age. Lipoblastomas needs through imaging and if possible cytogenetic evaluation for accurate diagnosis before surgery because complete surgical resection is mandatory to prevent a likely local recurrence.


A. Pascarella P. Guida N. de Sanctis G. Iannella N. Buompane R. Cavallo

Purpose: Many surgical techniques have been described for the treatment of pathological fractures due to aggressive unicameral bone cysts in order to varying rates of success and incomplete healing or recurrence. Many Authors suggested curettage and bone grafting as effective treatment in case of active lesion in children 8 – 12 years old, adjacent to the physis with width of the lesion exceeds that of the adjacent physis and recurrence or persistence. Due to invasive nature of operation this method non is preferred by several Authors : we preferred minimally invasive treatment consisting closed reduction and flexible with titanium rod (Nancy)intramedullary fixation for low operative morbidity whether for the fracture or for the cyst; in case of recurrence of the cyst the closed curettage of the cyst with arthroscopic technique can be applied successful.

Methods: Between 2002–2004 40 aggressive unicameral cysts were observed as pathologic fractures in patients between 5–15 years old in these cases there was a significant loss of bone stock. The site of involvement was in 33 patients the metadiaphysis of humerus, in 7 the femur; radiograms reveal expanding lesion in metaphyseal-diaphyseal site with cortex tinned from its inner surface and erosion with infraction with displacement. The parents were informed about contextual presence of two lesions: the fracture and cyst. The proposed internal fixation with Nancy titanium rods heals the first and might heal the second lesion ; in case of failure this method do not exclude another possibility of treatment as arthroscopic curettage. The Nancy flexible intramedullary fixation was performed with retrograde access 3 0 4 mm. diameter. Two nails with “ Eiffel Tower” construction were inserted by two miniportals 1 centimetres far from the physis. Follow up of treated lesion was made with periodic x rays performed every 45 days.

Results: In 36 patients after a 2-year period of observation the cyst has completely or incompletely healed but with a sufficient bone stock in the remainder four cases the arthroscopic procedure was performed. Curettage of cystic wall by trimmer blade and multiple miniportals 4,5 millimetres is the best way to treat all the cyst. In all the cases we used the standard optical cannula 30°.

Conclusions: In conclusion minimally invasive treatment by Nancy rods and artrhoscopy can be effective because assure high incidence of favourable results by decompression-scaffolding of the lesions, the patient quickly recover natural life and school attendance.


S. thambiraj R. Vadivelu R. Asirvatham I. Hyde C. Hogg K. Abrams

Background and Aim: Developmental dysplasia of the hips covers a wide spectrum of hips scenario ranging from mild subluxation to frank dislocation. Sonographic examination has been a widely accepted method of screening and monitoring treatment. Graf IIa+ hips are believed to indicate physiological immaturity with alpha angles appropriate for age and are expected to develop normally without any treatment. The aim of this study was to assess the final outcome of sonographically proven Graf IIa+ hips and to identify any factors which may influence the progression of dysplasia in this group of children.

Materials and methods: Over a six year period, 19,170 new born babies were assessed for DDH. 393 infants with high risk factors and clinical abnormality of the hips underwent ultrasound examination. The scans were performed and reported according to Graf Technique. Pavlik harness treatment was instituted as indicated. Seventy four hips in 44 children were classified as Graf IIa+. Patients who had the hips scans before four weeks and those with incomplete medical records were excluded. All children had regular follow-up with a pelvic x-ray. Acetabular Index (AI), Reimers Index (RI) and Centre edge (CE) angle was measured. All children were followed up until their hips were clinically or radiologically satisfactory. The results were analysed using SPSS software.

Results: Thirty six children with 60 Graf IIa+ hips were eligible for this study. There were 28 girls with 46 hips and eight boys with 14 hips (Girls: Boys = 3.5:1). 29 Left hip and 31 right hip were involved. At a mean follow up of 13 months (range 6 – 41months), the AI was normal in 62%, mildly dysplastic in 30% and severly dysplastic in 8% of the hips. The Reimers Index was normal in 73%, sub-optimal in 24% and subluxated in 3% of the hips. The CE angle was normal in 65%, mildly pathological in 23% and moderately pathological in 12% of the hips. Limitation of abduction after 48hrs of birth appeared to have a direct effect on the development of dysplasia (p=0.02)

Conclusion: From our study, we believe that hips with Graf IIa+ scans are not as benign as they were thought to be. When associated with limited abduction after 48 hours of birth, a high index of suspicion and a long term follow up may be prudent.


D.M. Mueller F. Grill

Background: Screening modalities in early detection of DDH remain controversial worldwide despite of universal accessibility to ultrasound and despite of encouraging preliminary results reported about the Austrian and German general ultrasound screening programs. The goal of our investigations was to provide a long time survey on effects following the introduction of the ultrasound exam in prevention of DDH and to proof its beneficial medical and economic effects as well as to analyze possible adverse effects, when utilized by a general screening.

Method: Nationwide data about ultrasound screening exams, sonographic follow up exams, frequencies of functional abductive treatment measures as well as hospitalizations due to DDH were requested by different Austrian health care providers. Through a representative recall over a time frame ranging partially back to 1980 a surveillance analysis is provided. The medical effectiveness of the screening was mainly assessed by the annual appearance of early late cases, representing open reductions (O.R.) upon the first two years of life. Other variables as the disease related incidence of age matched annual hospitalizations and the disease prevalence measured by non age matched hospitalizations in relation to the year specific population were analyzed. A cost benefit analysis was performed by comparing the treatment and diagnostic costs in the year before program start (1991) to the last year of surveillance (2004).

Results: Since 1980 the functional treatment rate has continuously been reduced from approximately 12 percent to 3.23 percent in 2004. Early late cases (O.R.) due to DDH have been also diminished to an international competitive rate of 0.13 per 1000 newborns, while other age specific early surgical interventions could be almost eradicated. Current additional investments of the program figure only 16.94 € per newborn and embody approximately 1370 € per detection of one affected newborn. Control exams are contributing to roughly 25% of the calculated costs.

Interpretation: By founding a nationwide program Austria has introduced a medically efficient screening modality to reduce early late cases and to limit treatment of DDH exposed children to less invasive measures by early diagnosis. In contrary to suspicions of possible adverse effects of such screening, overtreatment has been abandoned while the functional treatment rate has sunken to an acceptable level. Costs saving effects have been already realized on the treatment side. Further savings shall be realized by limiting an unacceptable rate of control exams.


G. Sohár N. Kopasz A. Pocsik T. Mészáros K. Tòth

Early detection and management of developmental dysplasia of the hip (DDH) yields simpler and more effective the treatment. Diagnosis by ultrasound has changed the clinical view of the disease. However, the need and the way of ultrasound screening is still controversial. Diagnosis by ultrasound has shown that morphological abnormalities may not be associated with clinical signs.

In Hungary all newborns are screened clinically within the first and also the third week of life, and controlled at the age of four month. Clinical examination is performed by an Ortopaedic specialist. Ultrasound screening is first performed for children with clinical signs and for children at risk at three weeks of age. Radiological examination, when necessary, is first performed at the age of four month.

In the five year timeline (2001–2005) that was re-evaluated 7339 children presented 9706 times for screening for DDH at the University of Szeged (Hungary) Department of Orthopaedics. Out of these cases 6991 (95.2%) children were found to be healthy and 348 (4.8%) were diagnosed for DDH. Children with dysplasia presented 896 times for treatment and follow-up. Patient compliance in the DDH group was average 2.5 visits, while for the healthy group it was only average 1.2 visits. Because of clinical signs or risk factors 1569 (21%) children had ultrasound examination, all-together 2169 times. 84% of the initial ultrasound examination showed Graf stage Ia hip. Out of the diagnosed 348 DDH cases 31 patients (Graf IIa-IIc) were administered with Pavlik harness, and 314 (Graf Ib-IIa) were treated with splinting. Remaining 3 cases were diagnosed late, where no ultrasound examination was performed. In the DDH cases 832 ultrsonographic examination was performed during the treatment (average 2.4 examination/case).

Radiographic control of all treated children excluded avascular necrosis in all cases. For this population 14 first operative procedure was needed so far. In our experience clinical screening and selective ultrasound examination is effective in the screening and early detection of developmental dyspalsia of the hip. In our practice, we promptly treated all patients with detected morphological changes as a deficiency in hip development. This way selective screening has helped us in the management of developmental dyspalsia of the hip. Hopefully, with the selective indication the number of false positive cases was reduced, while the „silent” clinical instabilities were given a chance for better long term development.


A. Pillai D. Bramley

Background: DDH represents a spectrum of anatomical abnormalities in which the femoral head and the acetabulum are either in improper alignment or grow abnormally. Although screening leads to earlier identification, 60–80% of abnormal hips of newborns identified by physical examination resolve spontaneously by 2–8 weeks and 90% of the hips of newborns with mild dysplasia identified by ultrasound resolve spontaneously between 6 weeks and 6 months.

Aims: To assesses accuracy of ultrasound screening of neonatal hip by the static technique of Graf. We attempt to answer the question whether routine radiological follow up of these children are indicated.

Methods: Since 2001, we have performed selective ultrasound screening of over 600 neonates (1200 hips). The reasons for referral included, breech presentation, clicky hip, unstable hip, dislocation, foot deformity and family history of DDH. Clinical examination, followed by serial ultrasound examinations at presentation, 6 weeks and 3 months of age were carried out. A radiological examination and measurement of the acetabular index was performed at 6 months of age. Hips were classified according to the 4 Graf types. We compared the ultrasound findings with the acetabular index (AI) for individual patients.

Results: All children were followed up prospectively from presentation to discharge. For neonates without any family history of DDH and normal clinical examination (symmetrical skin creases, equal limb lengths, unrestricted abduction and no instability demonstrated on the Ortolani and Barlow manoeuvres) the ultrasound classification according to Graf co-related with the acetabular index on 6 month radiographs. 100% of hips with normal scan (Graf I) both at 6 weeks and at 3 months of age had a normal AI.

Discussion: The static technique of Graf is an accurate and reliable method of assessment of neonatal hips. In children with normal clinical examination, and no family history of dysplasia, scan findings are a good predictor of the AI. Routine radiological follow up in such patients is not necessary.


G.G. Verma B. Mehta R. Massey

Purpose: The aim of the study was to assess the usefulness of ultrasound in the management of Irritable hips in children’s.

Materials and Methods: Retrospective analysis was performed for 168 patients with irritable hip from January 2004 to December 2005. The right hip was affected in 86 patients and the left hip was affected in 85 patients. Bilateral hip affection was seen in 3 patients. All the patients presented with pain in the hip joint. Most had pain on internal rotation. Majority had limp lasting 0 – 3 days. All patients were older than 1 year. White Blood Cell count (WBC), C-Reactive Protein (CRP) and Ultrasound of the hip was performed on all the patients as per the Irritable hip protocol. Temperature and associated medical condition were also recorded. Patients were divided into two groups, Group A who could weight bear involved 146 patients and Group B who could not weight bear had 22 patients.

Results: Ultrasound examination showed no effusion in 77 patients in Group A and 11 patients in Group B. Remainder of patients in both the groups had hip joint effusion ranging from 2mm – 7mm. All the patients were treated conservatively. None needed aspirations of the effusion in the hip joint or secondary operative procedure.

In group A (Weight bearing patients), 30 patients had mild temperature and 1 had moderate temperature. All of these 31 patients had normal WBC, CRP and their ultrasound showed effusion from 0 – 7mm. 12/31 patients had URTI.

In group B (Non weight bearing patients), 5 patients had mild temperature with normal WBC, CRP and their ultrasound showed effusion from 0 – 6 mm. 1/5 patient had URTI.

All the remaining 115 patients in group A and 17 patients in group B had normal WBC and CRP values.

No associated medical problems were found in 102 patients in group A and 12 patients in group B. Upper respiratory tract infection was noted in 40 patients in group A and 9 patients in group B. Gastroenteritis was noted in 4 patients in group A and 1 patient in group B.

Conclusion: Questions are raised with regards to the role of ultrasound in management of Irritable hips. Ultrasound for irritable hips in weight bearing patients with normal WBC and CRP is of no help. Ultrasound may be considered for non-weight bearing patients despite normal parameters.

Significance: Ultrasound is not of much help in management of irritable hip with normal WBC and CRP. Ultrasound is of definite value to surgeon before any operative procedure for the hip joint.


P.C. Gutiérrez P.F. Domenech D. Bustamante J.V. Roca

Purpose: To study the development of the hip and the relationship of radiological angles between acetabulum and proximal femur in children 0–3 years and thus the influence of walking and weight bearing on hip development.

Material and Methods: A study mesuring radiological angles in antero-posterior X-rays of pelvis in 334 children between 0 a 3 years of age (1997–2005), including acetabular index (AI) and physeal proximal angle (PPA (Alsberg’ angle) with goniometer (error ± 1°). Patients with pelvis or femur fractures or inflammatory diseases were excluded. Age distribution was of 1 (69.2%), 2 (22.2%) and 3 years (8.7%). 36.8% were males and 63.2% females. Descriptive statistics, T- test, Spearman correlation and ANOVA were used. Level of significance p< 0.05.

Results: The mean AI was 20.2°, 19.9° and 17.3°, in 1, 2 and 3 years. The AI angle diminishes significatively in children older than 2 years of age (p = 0.002). The mean PPA was 79.5°, 74.9° and 74.2°, in 1,2 y 3 years respectively. The Alberg’s angle reduced significatively at 1 year of age (p = 0.0005). AI and PPA was higher in females after 1 year of age (p = 0.02 and p = 0.04). There are not significative correlation between AI and Alsberg’ angle in different groups of children (r = 0.03). The age was important factor in both angles changes (p = 0.0005), but female patients (p = 0.002) and left side (p = 0.02) influenced only in AI.

Conclusions: AI and PPA angles reduced with age specially in 2 and 1 year, respectively, suggesting the effect of weight bearing and walking on hip shape. There was not relation between both angles in different groups of age.


M. Burton E. Whitby A. Rigby M. Bell

Background: Information on embryological hip development has been obtained from post mortem examination

. There is less information on normal foetal hip

. Magnetic resonance imaging (MRI) allows development to be followed in the healthy baby.

AIM: To assess the value of MRI of the foetus and neonate to provide information on normal and abnormal hip development.

To establish normal patterns of hip development.

To obtain charts that could be used to detect abnormality earlier.

There are three aspects to this study:

Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies.

Measurements will be gained for foetus in utero

Similarly for pre and term babies.

PATIENT SELECTION: 30 patients for each aspect of this pilot study, 90 in total (3).

For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.

Method: MR images in axial and coronal planes were obtained using a high resolution T2 weighted sequences (4).

Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius & diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.

Results: The babies ranged in gestation from 17 – 42 weeks

With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs = 0.98) for all but depth (ICCs = 0.86). The measurements for all dimensions were in line with previous post mortem studies.

CONCLUSION: MRI is a valid and acceptable alternative to post mortem in the assessment of hip development eventually allowing early detection of abnormal hip development.


R. Mohammed S. Pendyala M.A. Shaheen

Objectives: Injury is a major cause of morbidity in children, but can be prevented if at-risk groups are identified and proper precautions taken. Our study aims to identify the patterns of paediatric fractures in terms of at-risk bone, age, type of fracture, seasonal variations and attempts to look at the role of prevention.

Methods: Retrospective study of the children with fractures presented to A& E and admitted to the paediatric ward at the University Hospital of Hartlepool during August 2004 to August 2005. As used elsewhere we categorised data into injury types.

Results: From the total of 1067 children reviewed,564 were boys and 503, girls. Age incidence-highest in the group of 10–14 years (462), with highest presentation in April, May, June months. Of all orthopaedic injuries, 918 were closed fractures, 38 – open fractures, 40 – dislocations, 71- joint injuries. Upper limb (797) were much common than lower limb fractures (270), with wrist being the commonest site (209). Amongst the 198 admissions, 153 had upper limb and 45 lower limb fractures, with forearm being commonest (117) of whom 51 required surgery. In-patient bed-days occupied were 336.

Discussion: Information about the patterns of injuries in children is important in planning injury prevention. Incidence of paediatric injuries can be reduced with public education, implementation of safety strategies and government legislation. Orthopaedists can be instrumental in reducing incidence of paediatric injuries by participating in patient education, research, and programs that promote safe play.


J.R. Fountain A. Anderson M. Flowers M. Bell

Introduction: This study examined the cohort of patients selectively screened over a 5 year period with ultrasonography according to our risk factors (positive Ortolani or Barlow manoeuvre, breech presentation, first degree affected relative and talipes equinovarus) for developmental hip dysplasia (DDH). The aims were to evaluate the success of those managed in a Pavlik harness and identify predictive factors for those that failed treatment.

Methods: 1181 patients were selectively screened between 1999 and 2004. Of those, 128 patients (189 hips) were identified as having hip instability. Failure was defined as inability to achieve or maintain hip reduction in a Pavlik harness. A proforma was designed to document patients’ risk factors and ultrasound findings at time of initial dynamic ultrasound scan where the senior radiographer and treating consultant were present. Each hip was classified according to Graf type. Acetabular indices were recorded prior to discharge.

Results: All 128 patients with hip instability were managed in a Pavlik harness. This was abandoned for surgical treatment in 9 patients (10 hips) giving a failure rate of 5.3 % (0.17 per 1000 live births). All those successfully managed had an acetabular index of less than 30 degrees at follow up (6 – 48 months). 7 hips in the series were classified as Graf type IV, of these, 6 went on to fail management in a Pavlik harness. 67% of those that failed were also breech presentation compared to 22% of those managed successfully. There were no complications associated with management in a Pavlik harness. 16 patients born within our region presented after 12 weeks of age with DDH resulting in a late presentation rate of 0.3 per 1000 live births.

Discussion: Our overall rate of selective screening is 14 per 1000 live births with a subsequent treatment rate of 2.3 per 1000 is comparable with other centres. Our rate of failure for DDH in a Pavlik harness 0.17 per 1000 live births is an improvement on any previously published results. Irreducible hips, Graf type IV hips and breech presentation correlated with a high likelihood of treatment failure.


A. ABRAHAM G. Marwah J. McVie R. Montgomery

Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus.

Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8).

Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)

Results:

AVN scores

Closed Reduction (n=34) : Grade 1 : 5.

Open Reduction (n= 11) : Grade 1: 2, Grade 2: 1, Grade 3: 1.

Open, with shortening (n=24): Grade 1: 5, Grade 2: 1. Severin Scores:

Closed I: 22 II:3 III:8 IV:0

Open I:6 II:1 III:2 IV:2

Shortening I: 8 II:8 III:3 IV:2

Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results.

Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued.


Y.B. AL-ARABI V. Mandalia D.M. Williamson

Aims:

1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

2) To determine the effect of cast quality as reflected in the skin cast distance (distance between the cast and the skin in the plane of major displacement or angulation) and the cast index (the inside diameter of the cast in the sagittal plane divided by the inside diameter in the coronal plane) on re-displacement rates in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.

Methods: This is a prospective study of 57 children aged 4 to 15 with metaphyseal and Salter-Harris II wrist fractures treated with simple manipulation. Under fluoroscopic imaging, a simple stability test involving moving the hand at the wrist in the dorsopalmar, and radioulnar planes was performed following reduction, and x-ray images were saved. We recorded and compared the displacement and angulation on the initial x-rays, during the test, and at one-and 6-week follow-up. We also recorded the skin-cast distance (SCD), and the cast index (CI).

Results: 38 patients had isolated radius fractures and 19 had radius and ulna fractures. Four patients needed remanipulation with K-wire fixation. Multiple regression analysis revealed significant correlation between percentage loss of reduction on testing and subsequent re-displacement (relationship between the two sets of values r = 0.6167, (p< 0.001)). This indicates that instability on testing (seen as a significant percentage loss of reduction) is likely to be associated with some loss of reduction on follow-up. There was a significant relationship between the skin cast distance and the cast index, and loss of reduction on one week follow-up. (p=0.006). Isolated radius fractures had a higher risk of re-displacement than radius and ulna fractures (3.9% and 0.9% respectively; p< 0.05%)

Conclusion: Stable reduction on stability testing in wrist fractures in children immobilised in a good cast (reflected in a low SCD, and CI) is associated with a good outcome. Isolated radius and ulna fractures are more likely to re-displace than radius and ulna fractures. There is a relationship between instability and loss of position at the 1-week follow-up. Potentially unstable fractures can be prevented from slipping by a good cast. A stable fracture on our stability test rarely slips. We therefore feel that stability test is a useful adjunct in decision-making.


S. Srinivas N. Prasad

Aim: To evaluate the outcome of displaced distal radius fracture in children & review our practice.

Methods: A retrospective review of case notes and radiographs of all children requiring orthopaedic intervention under general anaesthetic for displaced distal radius in our hospital over a period of 18 months (January 2005 to June 2006) was carried out. We had treated 72 fractures of the distal radius in same number of children. All but 3 cases were treated by primary closed manipulation & plaster immobilisation. Average age was 11.7 years (range 5 to 16 years).

We looked at the re-displacement rate amongst these children that required a second procedure. We also sought predictive factors for redisplacement if any.

Results: There were 22 female & 50 male patients. All the fractures were closed injuries with no distal neuro-vascular deficit. Of the 72 cases, 16 cases showed more than 50% initial displacement and 6 were completely displaced (off-ended). 9 cases had volar angulation.

Redisplacement of fracture after initial satisfactory reduction was seen in 9 cases (12.7%) & required a second procedure. The secondary procedure involved closed reduction and percutaneous K wire fixation in 4 patients and open reduction in 2 cases. 3 cases had closed remanipulation & change of plaster.

We reviewed the factors responsible for re-displacement after a closed reduction such as initial displacement, angulation, adequacy of initial reduction, associated ulna fracture, type of plaster, and initial post-operative images.

Average age has been 12.7 years. 3 out of 5 (60 %) completely displaced fractures treated by closed reduction and manipulation required a second procedure. Only 1 in 16 cases of incompletely displaced fracture required a second procedure.

Volar angulated fractures tend to redisplace after closed reduction, 3 out of 7cases (42 %) required a second procedure. Associated ulna fracture (22.7%) increased the risks of redisplacement.

5 out of 24 epiphyseal injuries redisplaced but these were either severely displacement or had volar angulation. 3 out of 4 cases (75 %)that were severely displaced had inadequate primary closed reduction & underwent a second procedure.

Conclusion: We would like to conclude that despite achieving a very good initial reduction, offended distal radius fractures & those with volar displacement have high risk of re-displacement. Inadequate primary reduction has invariably resulted in requiring a second procedure. It is advisable to treat such cases by primary open reduction and K wire fixation in order to prevent redisplacement.

In management of paediatric distal radius fractures, primary reduction with percutaneous Kirschner wire has better outcome and lower incidence of redisplacement in selected cases with features of complete displacement and volar angulation especially in the older age group (> 11 years).


A. ABRAHAM

Background: The epidemiology of fracture in children has been reported in detail by other authors. The most common mechanism in their study was a fall in or around the house onto an outstretched hand causing a fracture of the distal radius and ulna. These injuries accounted for 35.8% of all fractures in this age group and the annual incidence was estimated to be 16 per 1000 children in the UK.

The controversial issues in the management of distal radius fracture involve what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time, indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone, details of the position of the arm during immobilisation in a cast, and whether the cast should immobilise the wrist alone or both, the wrist and the elbow. The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents’ discretion.

We performed a systematic review of all areas of the management of distal radius metaphyseal fractures in children. Growth plate injuries were not included for analysis.

Methods: Any randomised or quasi-randomised controlled trials which compared types of immobilisation and the use of wire fixation for distal radius fractures in children were included.

Types of outcome measures:

Radiological deformity

Effect of cast index

Complications of k-wiring

Remanipulation rates

Compliance with splintage

Cost of various forms of splintage

Effect of intact ulna

Upper limb function while immobilised

Wrist and elbow ROM

10 studies complied with the inclusion criteria and were analysed using Review Manager software provided by the Cochrane Collaboration

Summary of Results:

Regarding displaced metaphyseal fractures:

K wire fixation reduces redisplacement

There is no proven increase in complications with k wires

Intact ulna favours redisplacement

Long casts do not reduce displacement

Short casts allow better early function

Regarding stable compression fractures:

Removable splints are not associated with displacement

Patients prefer removable splints for buckle fractures

Removable splints cause less discomfort and allow better early function


M. Resende Sousa D. Tavares F. Sant’Anna M. Cassiano Neves

Introduction: The distal forearm is the most common fracture site in children. The stresses from a fall on the outstretched hand are prone to result on a physeal or metaphyseal fracture of the distal radius. Fortunately subsequent growth disturbance is unusual. Our aim is to report the advantages or disadvantages of the Kapandji method compared with the crossed pin fixation.

Materials and Methods: We reviewed 29 children brought to the operating room for reduction and percutaneous fixation of distal forearm fractures during the last 18 months. There were 23 boys and 6 girls aging between 4 and 15 years old. Fractures were classified in four general types: physeal, torus, greenstick and complete. Sixteen fractures were fixed using the Kapandji technique and 13 were fixed with crossed pins.

Results: All patients recovered full range of motion. None of the fractures required open reduction. Pinning using the Kapandji technique was easier and took about 50% less of the operating time. Nevertheless we found that there was no leading criteria to decide which were the fractures that would need pinning after reduction. There was an incidence of 10% of superficial infections that subsided after removal of the wires with no further complications in both methods.

Conclusions and Discussion: Radial collapse, loss of wrist motion, and distal radioulnar joint dysfunction, all common problems associated with distal radius fractures in the adult, are rarely seen after children’s distal radial fractures. Closed reduction is usually easy. Although the final results were the same comparing crossed pin fixation and the Kapandji method, the later proved to be easier and less time consuming in the operating room. For this reason we favour this type of fixation for the distal forearm fractures in children.


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P.K. Inaparthy N. Shah M. Wijerathna K.W. Tuson

Aim: To determine whether operator’s experience and time of operation (MUA) affects the outcome of fractures in paediatric age group as measured by re-MUA rate.

Method: Retrospective analysis of 918 children with fractures requiring MUA over a period of eight years was carried out.

Results: Re-MUA rate for those 910 children was 9.8%(90). There was a significant difference in these fractures requiring re-MUA depending upon the operator’s experience and time. Amongst all (90) who required re-MUA 7(7.7%) had index surgery by consultants and 83(93.3%) had MUA by trainee surgeons. 23(17.4%) patients were operated between 9 to 1700 hours and rest of them had MUA after 1700 hours (82.6%). At repeat procedure 4(4.4%) required some sort of fixation. (K wiring or ORIF)

Conclusion: The current overall re-MUA rate is higher than data published from the specialised centres and surgeons, but is probably more representative of norm, when performed in a general setting. Exact fracture personality should be evaluated carefully to reduce re-MUA rate. Re-MUA rate for trainee needs to be improved.


A. DONAMARDI GORVA J. METCALFE M. FLOWERS J. FERNANDES S. JONES

Introduction: Ankle fractures accounts for 25% to 38% of all physeal fractures. An accurate diagnosis is the key to the appropriate management of these fractures. Traditionally the management decisions have been based on x-ray findings. We have used computed tomograpy (CT) scans in additon to x-rays in the management of these fractures.

Objective: To determine the usefulness of computed tomograpy (CT) scans in the management of ankle fractures in children.

Materials and Methods: Between 2001 to 2005, 53 patients with ankle fractures who were managed in our unit had CT scans in addition to plain radiographs. The mean age was 12.3 years (+/− 2.1). The radiographs were reviewed by senior paediatric orthopaedic surgeon who classified the fractures and formulated treatment plans (operative/non-operative). The CT scans were then reviewed by the respective surgeon and a similar exercise undertaken. A Radiologist confirmed that the fractures were classified accurately.

Results: In 47% (25 fractures) the x-ray diagnosis/classification tallied with the CT scans whilst in 53% (28 fractures) the CT scans showed the fractures were more extensive/serious than noticed on the x-rays. The management was changed in 34% after reviewing the CT scans, In 9 from operative to non-operative treatment and in the other 9 from non-operative to operative treatment.

Conclusion: We have found CT scans to be more useful than plain radiographs in making an accurate diagnosis of ankle fractures in children and thus planning appropriate management.


G. Christodoulou G. Tagaris G. Sdougkos A. Vlachos A. Vris

Introduction: This study examines the proximal tibial metaphyseal fractures in children and specifically the valgus deformity and leg overgrowth of the tibia.

Methods: We examined 27 children with proximal tibial metaphyseal fractures. Among them, 11 presented with greenstick fractures, 6 with complete, 5 with hairline, 3 with torus and 2 with stress fractures. The mean age was 7 years old (1–14). The average follow up period was 9.5 years. Fifteen children were below the age of 7 while 12 were between 8–14 years old. Twenty five patients were treated conservatively and 2 surgically.

Results: Valgus deformity occurred during the follow up period in 73% of the children aged below 7 y.o. and 17% of the older children. The higher values of valgus deformity ranged between 8–18 degrees and were observed at 10–18 months post-traumatically, especially in younger ages and after inadequate reductions. At the time of the final follow up examination, satisfactory spontaneous correction of the deformity, inversely proportional to age was observed in all cases. The degree of final valgus deformity ranged between 1–9 degrees. Overgrowth of the affected extremity was observed in 74% of the cases and ranged between 0, 4 and 1, 5 cm. Tibial overgrowth is not dependent to skeletal age. None of torus and stress fractures developed valgus deformity or longitudinal overgrowth. Compartment syndrome occurred in one case.

Conclusion: A high tendency to valgus deformity, especially in younger ages, was observed in proximal tibial metaphyseal fractures, even among undisplaced or surgically treated ones. Approximately two years post-traumatically, the beginning of a progressive spontaneous satisfactory correction of the deformity – inversely proportional to age – was noticed. It is worth mentioning that valgus deformity up to 10 degrees and tibial overgrowth up to 1, 5 cm cause no functional or cosmetic problems. The above observations prevent us from unnecessary surgical correction. Conservative treatment is preferred for the proximal tibial metaphyseal fractures. Operative treatment is indicated after inadequate reduction, especially in older children and after open fractures.


A. Norrish C. Lewis W.J. Harrison

Distal femoral growth plate (DFGP) fractures were originally described as the ‘wagon wheel’ fractures, because they were noted to occur in the young boys who ran alongside wagons passing at speed and got their leg caught between the spokes. The resultant high energy injury was a forceful hyperextension and twisting of the knee. There was a significant incidence of severe complications with these injuries. In our setting, in a developing country, we noted that DFGP injuries appeared more common and tended to occur with a lower energy mechanism of injury.

To investigate if this were a real phenomena, we designed a prospective study looking at DFGP injuries with the primary outcome measure being the mechanism of injury and the secondary outcome measures including method of fixation and functional outcome.

The inclusion criteria for the study were all patients that presented with a DFGP fracture over a period of one year. There were no exclusion criteria. All data was collected prospectively on a standard proforma. Patients were treated according to a standard treatment regimen: where the fracture could be reduced closed and was stable, plaster cast only. Where a fracture could be reduced closed and was unstable, percutaneous pin fixation, where a fracture could not be reduced closed, open reduction and internal fixation.

Forty-three patients were included in the study. 39/43 (91%) of the patients were boys, and the average age was 15.5 years (standard deviation, SD, 3.2 years). Thirty-three (77%) of the injuries resulted from low energy trauma, with the majority (28/33) resulting from sporting injuries, predominately football, with others having simple falls (3/33) or falling off bicycles (2/33). The 10 high energy injuries resulted from pedestrians (3/10) or cyclists (1/10) hit by cars and falling from a height (6/10). Some significant differences were seen in the mean ages of the high and low energy groups. The low energy group were significantly older, with a mean age of 16.3 years (SD 2.8 years) compared to 13.1 years (SD 3.1 years) for the higher energy group (Student’s t-test, p=0.004). When comparing the type of fracture, according to the Salter Harris classification, significantly more Salter Harris IV and V fractures were seen in the high energy group (Chi Squared test, p=0.039) compared to the low. Open fractures were 1/10 (10%) of the high energy group, but there were no open fractures in the low energy group. Complications including infection and amputation, only occurred in the high energy group.

This is the first study to show, that in some countries, the DFGP injury may be more commonly due to a low energy mechanism of injury. The reasons for this may include delayed physeal closure, that has been previously shown in this group.


U. Bergström L. Uddst̊hl U. Pettersson O. Svensson

A prior fragility fracture is one of the strongest predictors for a subsequent one, and this should be a target for secondary fracture prevention. All injured patients admitted to the emergency floor, Ume̊ University Hospital, Sweden, were registered. Between 1993–2004, there were 113,668 injury events, including 29,190 fracture events (one or more fractures at the same time), of whom 12,635 patients were _ 50 years. 1,994 of them had at least two fracture events; 500 had 3; 131 had 4; 35 had 5; and 11 had _ 6 fracture events. Mean age at the baseline fracture was 72.2 years and 75.5 at the second one. Thus, over 50 years of age, not less than 37% of all fractures were serial fractures, and 20% of the patients are serial fracturers.

Hip and radius fracture were the most common ones, but 20% were fractures not traditionally labelled as fragility fractures. However, since more than 78% were caused by falls in the same level, most presumably have a fragility component.

The interval between the two first fractures was longer than reported in several previous studies, mostly on patients participating in clinical trials. However, our material is population-based and unselected, since there is just one trauma facility in the area, and the general population is healthier than in-hospital or trial patients. On the other hand, there is a cut-off bias, so the interval is likely to be even longer.

Interestingly, the difficult-to-treat hip fracture was the second common baseline fracture, the most common subsequent one, and hip-hip fractures were the most common combination, not less than 8.5% of the serial fractures. It is therefore clinically important to use the information provided by the fracture event, a fragility fracture may actually be regarded as a biomechanical test or a natural experiment. Trauma units, therefore, have an onus to screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients, but alas this is rarely done. A similar neglect of secondary prophylaxis and treatment after cardiovascular disorders would be an outrage! Secondary prevention is especially important since serial fractures are so common, often preventable, having a high impact on health-related quality of life


K. Papavasiliou J.M. Kirkos M.E. Potoupnis I.K. Sarris F.E. Sayegh C. Dimitriou G.A. Kapetanos

Introduction. This prospective cohort study aimed at the assessment of the incidence of indolent SH among otherwise ‘healthy’ and symptoms’ free postmenopausal women suffering from primary KOA.

Methods. During a period of 23 months (November 2004 – Sepetember 2006), two hundred and forty-two postmenopausal women suffering from primary KOA were enrolled. None of them had suffered any osteoporotic fracture, received any anti-osteoporosis treatment or suffered from any disease interfering with their bone mass/quality. The serum levels of Intact-Parathyroid Hormone (I-PTH), Calcium and Phosphorus were evaluated and Creatinine Clearance was calculated. The latter was performed in order to determine a possible relation between the patients’ renal function and the I-PTH level.

Results. The patients’ mean age was 70,20 years (range: 49–81). The years that had passed since their menopause ranged from 7 to 31 (mean of 18,7 years). The patients were divided into three groups according to their age: Group A (n=41) age < 64 years, Group B (n=140) age 65–74 years and Group C (n=61) age > 75. The overall incidence of SY in all three groups was 35,95% (87 out of 242 patients). Group C patients were most likely to suffer from SY (25 out of 61 patients or 40,98%). The I-PTH values of Group A patients were normal in 27 out of 41 patients (68,85%) and of Group B in 92 out of 140 patients (65,71%). One group B patient suffered from Primary Hyperparathyroidism. No statistically significant relation between the patient’s renal function and the I-PTH level was found.

Discussion/Conclusion. SH appears to be a ‘silent’ epidemic among elderly postmenopausal women. According to our results, women 75 years-old and older are most likely to suffer from SY. One of the main reasons for that seems to be the insufficient calcium and/or vitamin D intake. It is our belief that anti-osteoporosis diagnosis and treatment modalities should be focused on this group of patients.


U. Bergström A. Agrell O. Svensson

Even in patients with pronounced osteoporosis, fragility is rarely a sufficient or necessary cause of fracture. Almost always a trauma involved. Exposure to injuries varies with eg sociologic and climatologic. Since 1993 all injuries admitted to Ume̊ University hospital, Sweden, up to 58 parameters have been registered, eg mechanism, environment, involved products and diagnoses. The 12-year population-based injury register now comprises113,668 injuries (29,190 fractures).

The absolute number of fractures is important from a practical clinical point of view. Most fractures occur in the extremities of life, perhaps due to both a weaker skeleton in growth and senescence and to exposure to injury. The earlier fracture peak in girls is caused by their earlier growth spurt. The higher and broader fracture peak in boys also reflects behavioural factors. Men continue to have more fractures until around 50, showing the effect of menopause.

Radius fracture incidence in Ume̊ was about 15% higher than in Malmö, Sweden. But surprisingly hip fracture incidences were in the same order of magnitude in Malmö and Ume̊, which is remarkable considering the 8o latitude difference. But this may be explained by the different injury mechanisms in the two fractures

Low energy-trauma (fall in the same level) was most common in the extremities of life. However, most of the other mechanisms also involved low-moderate trauma, and high-energy trauma was rare. In this sub arctic register, outdoor slips was a common cause of fracture in middle age but as in other materials such injuries became less common with age.

A further detailed analysis of the mechanisms causing fractures and soft tissue injuries could be a useful tool in prevention of fall injuries. Is it possible to identify frequent fallers or other accident prone people, before an incapacitating injury? This would indeed be a major public health challenge


C. Ojeda-Thies A. Torrijos-Eslava O. Macho-Perez C. Bohorquez-Heras E. Gil-Garay

Introduction: The main symptom of osteoporosis is fractures. Osteoporostic hip fractures are and increasing problem due to their morbid-mortality and health cost. The necessity of recommending treatment for osteoporosis upon discharge after hip fractures is generally accepted. The object of this study is to evaluate secondary prevention upon discharge and at 6 months after a hip fracture

MATERIAL AND Methods: Prospective observational study analyzing all osteoporòtica hip fractures among patients older than 50 treated during 2004, with telephonic follow-up.

RESULTS: We attended 563 fractures in 556 patients, with a mean age of 82,96 years (50 – 105) and a female: male ratio of 2,9:1. Mortality was 7,8% in-hospital and 20,2% at 6 months. Though 52,1% had suffered a previous osteoporotic fracture an 13,7% a previous hip fracture, only 16,3% had at some time been treated for osteoporosis.

Pharmacological treatment for osteoporosis (%, Upon discharge vs. at 6 months): Global (38,1 vs. 31%), Calcium +/− vitamin D (8,2 vs. 18%), Ca-VitD + biphosphonate (28,1 vs. 10,8%), Biphosphonate only (3,4 vs. 1,7%). The patients that had received treatment upon discharge were morle likely to receive it at 6 months (RR 2,2, CI95% 1,5 – 3,2). Women, patients that had been sent to a temporary nursing home and patients that had a better functional status were more likely to receive treatment (p< 0,05). There was no significant correlation with patient age or previous fractures.

CONCLUSIONS: Our study’s patients are similar to other studies published. Treatment compliance with biphosphonate falls at 6 month after discharge. It is important to recommend treatment for osteoporosis upon discharge.


F.A. Kalberer R.J. Sierra S.S. Madan D.C. Meyer R. Ganz M. Leunig

Background: Femoroacetabular Impingement is now considered a prearthritic hip mechanism. It frequently occurs in patients with subtle anatomic abnormalities of the acetabulum, “acetabular retroversion”, which is often difficult to detect on standart xrays. Early diagnosis is of utmost importance as surgical intervention in early stages can most likely halt progression of disease. The objective of this study was to assess wether an easily visible anatomic landmark on an anteroposterior (AP) pelvic xray can be used to screen patients with acetabular retroversion.

Methods: The AP pelvic xrays of 1010 patients who were seen at the autors’ institution for a painful hip were reviewed over a 16 year period. Those xrays that did not meet standardized criteria were excluded leaving 149 AP radiographs (298 hips) for analysis. The ‘crossover sign’ (COS), indicative of acetabular retroversion, was recorded for each hip. An easily visible landmark, the prominence of ischial spine (PRIS) into the true pelvis was also recorded and measured. Interobserver and intraobserver variability was assessed.

Results: The presence of the PRIS as diagnostic of acetabular retroversion showed a sensitivity of 91% (95%CI 0.85 to 0.95), a specifity of 98% (95% CI 0.94 to 1.00), a positive predictive value of 98% (95%CI 0.94 to 1.00), a negativ predictive value of 92% (95% CI 0.87 to 0.96). There was good and very good intraobserver and interobserver reliability for measurements of the COS and PRIS, respectively.

Conclusion: There was excellent sensitivity and positive predictive value of the PRIS as a radiographic marker of acetabular retroversion. The rims of the anterior and posterior walls are sometimes not clearly visible, and even if they are, their translation into a reliable interpretation of acetabular retroversion is difficult. The PRIS sign appears as a good visible prominence on the AP radiographs which can’t be easily confused.


E. Nordell G. Jarnlo K. Thorngren

PURPOSE: Patients who sustain fall-related distal forearm fractures are at risk to sustain new fractures later in life. Risk factors for falls such as low physical activity, impaired gait and neuromuscular function, and comorbidity are well known, as well as risk factors for fractures such as female gender, old age, low body mass index (BMI) and low mobility. Fracture prevention is often directed toward bone mass density treatment, but there is evidence that high level of physical activity reduces falls and therefore also reduces fractures. Health related quality of life (HRQoL) has become an important additional measure. The aims of this study were to evaluate the HRQoL, reported with EQ-5D and SF-12, in women who had sustained fall-related distal forearm fracture one year earlier and compare with Swedish normative data, and to physical performance and self-reported comorbidity.

PARTICIPANTS: Sixty women with a fall-related distal forearm fracture were invited to examine health-related quality of life and physical performance at a mean time of 13 months after they had sustained their fracture (S.D. 1.6, range 10–17). The inclusion criteria were that they should be able to perform the physical tests and to understand verbal and written Swedish. Forty three women (72%), mean age 68 (SD 8.4, range 50–84), agreed to participate.

METHODS: The women filled in two generic HRQoL-questionnaires; EQ-5D and SF-12. They self-rated their physical activity and reported ailments, which were regularly examined by a doctor, and intake of prescribed medication. They reported problems or difficulties from the locomotor system and depressive symptoms during the three last months. All women underwent physical performance tests; handgrip strength, one leg standing (OLS) and walking speed. Fisher’s exact test, Mann Whitney U test and Spearman’s rank correlation coefficient were used in the statistical analyses.

RESULTS: In the younger women (age 50–59) the HRQoL was lower compared to Swedish normative data. The EQ-5D index and VAS scores correlated moderately to the physical component summary (PCS-12) of the SF-12 (rs=0.73 and rs=0.69, respectively). The correlation to the mental component summary (MCS-12) of the SF-12 was lower (rs=0.32 and rs=0.22, respectively). Women who reported comorbidity and low physical activity scored lower in the corresponding items of health in both questionnaires.

CONCLUSIONS: Low results in HRQoL questionnaires in apparently healthy older women with fall-related distal forearm fracture may indicate underlying comorbidity, not captured by physical performance tests. We suggest that HRQoL questionnaires should be used in additional to physical outcome measures for this patient group. The use of HRQoL questionnaires to find patients for preventive measures of falls and fractures should be further explored.


T.A. SYED Y.R. SHAH M.H. WETHERILL

Introduction: Distal Radius Fractures (DRF) and Hip Fractures are considered as fragility fractures. The purpose of this study was to assess whether DRF precedes hip fracture or not. This retrospective analysis was carried out in a group of patients who sustained bilateral non contemporary hip fractures.

Materials and Methods: Retrospective analysis of radiographs and notes of all the patients requiring surgery for bilateral neck of femur fractures, from January 1994 to June 2005 at a district general hospital. Data included ages at the first and second fractures, mechanisms of injury, types of fracture and implants used. Time interval between the two fractures was also noted.

These were analyzed for presence of any Distal Radius Fractures (DRF) prior to first admission for hip fracture and time period between first and second admission. It was also analyzed whether a DRF was sustained between these two episodes.

Results: Ninety five patients had bilateral neck of femur fractures during the study period with an average age of 76 years at the first fracture. There were eighty-three females and twelve males. The time interval between bilateral non contemporary hip fracture was 2.5 years.

Out of these ninety five patients a small minority of patients had a DRF preceding their first hip fracture. Those sustaining DRF prior to their second hip fracture was also studied and statistical methods were employed to predict the presence of DRF prior to hip fractures

Conclusion: This study shows that there is no correlation between sustaining two fragility fractures i.e DRF & Hip Fracture and DRF may not necessarily precede a Hip Fracture.


A. Krueger S. Kohl M. Leunig K. Siebenrock M. Beck

Purpose: The purpose of this study was to examine the arthroscopy findings in the hips of patient with persistent pain after surgical hip dislocation for femoroacetabular impingement syndrome.

Type of study: Retrospective, consecutive series of patients

Patients and Methods: Sixteen consecutive patients (6 male/10 female; average age 33,5 years 19–60y) with persistent pain after surgical hip dislocation for the treatment of femoroacetabular impingement were included. At the index surgery, all patients had an osteo-chondroplasty of the head neck junction and a resection of the acetabular rim with reattachment of the labrum in 9 cases. All patients had a preoperative arthro-MRI and were treated with arthroscopy of the hip.

Results: At arthroscopy all reattached labra were stable. In the cases without preservation of the labrum, the joint capsule was attached level with the acetabular rim and had important synovitis. All patients had adhesions between the neck of the femur and joint capsule or between labrum and capsule. In 3 patients the arthroscopic procedure was technically limited by massive thickening of the capsule. Overall 75% (12 of 16) patients showed less pain or were pain free. MDA improved from preoperatively 13 to 16 points at last follow up.

Conclusions: Persistent pain after surgical dislocation of the hip could result from intraarticular adhesions that can be shown in the MRI. Hip arthroscopy after previous surgery can be demanding due to scarring. If the adhesions can be released good results can be achieved. Hip arthroscopy is a save therapeutical tool to treat patients with intraarticulary adhesions after surgical dislocation of the hip for femoroacetabular impingement.


A. Moroni M. Romagnoli M. Cadossi F. Pegreffi S. Giannini

INTRODUCTION Metal-on-metal hip resurfacing (MOMHR) has recently been reintroduced as a viable treatment option for young active patients. A short femoral neck and insufficient head are common deformities following CDH, Perthes disease and SFCE. Therefore, severity of these deformities is a contraindication for MOMHR, as contact between the femoral resurfacing component and the femoral head would be inadequate and off-set insufficient.

METHODS 32 patients with severe deformity of the hip were treated with Birmingham hip resurfacing and head lengthening. We used a standard acetabular component in 18 patients and a CDH acetabular component and supplementary screw fixation in 14. Bone chips produced while reaming the acetabulum were impacted on the femoral head to achieve the desired length, as evaluated on pre-op x-rays. Rehabilitation included no weight-bearing for 1 month and partial weight-bearing for another month.

RESULTS Median patient age was 44 years. Median head lengthening was 1.2 cm. Minimum follow-up was 3.1 years, maximum 5.2. Mean Harris Hip Score was 98. At follow-up 82% of the patients were involved in heavy or moderately heavy work. 34% of the patients practiced sports. Co and Cr serum concentrations at 25 months were respectively ng/ml 1.76, and 0.75. DXA analysis of the proximal femur showed complete recovery of BMD in Gruen zone 1 and increased in zone 7 (p= 0.05). There were no major complications.

DISCUSSION AND CONCLUSIONS The absence of major complications and the quality of our results support this technique in young active patients with severe deformity of the hip.


M. Leunig K. Mladenov A.A. Jamali D.C. Meyer A. Martinez M. Beck R. Ganz

Background: Acetabular retroversion has been proposed to contribute to the development of osteoarthritis of the hip. For the diagnosis of this condition, conventional AP pelvic radiographs may represent a reliable, easily available diagnostic modality as they can be obtained with a reproducible technique allowing the anterior and posterior acetabular rims to be visible for assessment. This study was designed to

establish a method to directly quantify anatomic acetabular version on AP pelvic radiographs and to

determine the validity of the radiographic “cross-over-sign” to detect acetabular retroversion.

Methods: Using 43 desiccated pelves (86 acetabuli) the anatomic acetabular versions were measured at three different transverse planes (cranially, centrally and caudally). From these pelves, standardized AP pelvic radiographs were obtained. To directly measure central acetabular version (AV), a modified radiographic method is introduced for the use of AP pelvic radiographs. Moreover, the validity of the radiographic “cross-over-sign” to detect cranial acetabular retroversion was determined.

Results: The mean central and caudal anatomic AV were approximately 20°, the mean cranial AV was 8°. Cranial retroversion (AV < 0°) was present in 19 of 86 hips (22%). A linear correlation was found between the central and cranial AV. Below 10° of central AV, all acetabuli were cranially retroverted. Between 10° and 20°, 30% of the acetabuli were cranially retroverted and above 20°, only one of 45 acetabuli was cranially retroverted. The radiographic measurement of the central AV (20.3° ± 6.5) correlated strongly with the anatomic AV (20.1° ± 6.4). The sensitivity of the ‘cross-over-sign’ to detect an cranial acetabular anteversion of less than 4° was 96%, its specificity 95%, and the positive predictive and negative predictive values 90% and 98%, respectively.

Conclusions: The cranial AV is on average 12° lower than the central AV, with the latter directly measurable from AP pelvic radiographs. A central AV of less than 10° was associated with cranial retroversion. The presence of a positive ‘cross-over-sign’ is a highly reliable indicator of cranial AV of < 4°.


C.R. Fraitzl W. Käfer M. Nelitz H. Reichel

Introduction: There is rather broad consent that mildly slipped capital femoral epiphyses (SCFE) should be treated by in situ fixation with wires or dynamic screws. There is recent evidence, however, that even mild slips lead to early damage of the acetabular labrum and cartilage by abutment of a prominent femoral metaphysis. It is therefore proposed that treatment of mildly slipped capital femoral epiphyses should not only prevent further slipping of the epiphysis, but also address potential femoro-acetabular impingement (FAI) by restoring the anatomy of the proximal femur. To find proof for this newly proposed therapeutical approach, we reviewed all patients treated in our department ten to twenty years ago for unilateral slipped capital femoral epiphysis by in situ fixation without restoration of the anatomy of the proximal femur.

Methods: From forty-four patients treated between October 1984 and December 1995, twenty-eight could be contacted and eighteen reviewed. Development of FAI was documented by clinical examination (range of motion, “impingement provocation test”) and radiological evaluation (AP radiographs of the pelvis and lateral cross-table radiographs of both hips). Statistical analysis was performed with paired t test and Wilcoxon matched-pairs signed-ranks test in case of numerical data, and Fisher’s Exact Test and Chi-squared Test for Independence in case of ordinal data. The level of significance was set at p < 0.05.

Results: Comparing involved to non-involved hips, mean internal rotation and abduction differed significantly (15° ± 7.9° vs. 21° ± 7.9° (p < 0.01) and 37° ± 7.7° vs. 42° ± 6.7° (p < 0.01), respectively), but the “impingement provocation test” was found positive in only four vs. six hips (p = 0.71). Radiological examination showed significantly difference with respect to waisting of the femoral neck (p < 0.01) and bony appositions at the femoral head neck junction (p < 0.01). No regular waisting was found in all involved hips, whereas it was present in nine non-involved hips. A distinctly reduced or absent waisting was seen in twelve of the involved hips but in only four of the non-involved hips. Bony appositions were found in fourteen of the involved hips, but in only four of the non-involved hips. Furthermore the angle α according to Nötzli et al. (2002) showed a significant difference in its mean on AP radiographs (84° ± 10° vs. 60° ± 15°, p < 0.01), not so, however, in lateral cross-table radiographs (50° ± 8° vs. 48° ± 11°, p = 0.3).

Conclusion: From a clinical point of view, in situ fixation may be sufficient in treating mildly SCFE, whereas radiological data suggest that restoration of the anatomy of the head-neck junction of the proximal femur might be sensible to prevent or delay FAI and thus development of osteoarthritis of the respective hip joint.


W. Dandachli V. Kanaan R. Richards V. Sauret M. Hall-Craggs J. Witt

INTRODUCTION Assessing femoral head coverage is a crucial element in acetabular surgery for hip dysplasia. CT has proven to be more accurate, practical and informative than plain radiography at analysing hip geometry. Klaue et al first used a computer-assisted model to indirectly derive representations of femoral head coverage. Jansen et al then described a CT-based method for measuring centre edge angle of Wiberg at 10 rotational increments. Haddad et al used that method to look at dysplastic hips pre- and post-acetabular osteotomy. We present a novel CT-based method that automatically gives an image of the head with the covered area precisely represented. We used this technique to accurately measure femoral head coverage (FHC) in normal hips and in a prospective study of patients with hip dysplasia undergoing peri-acetabular osteotomy. The impact of surgery on acetabular anteversion and inclination was also assessed.

METHODS Using a custom software programme, anatomical landmarks for 25 normal and 26 dysplastic hips were acquired on the 3D reconstructed CT image and used to define the frame of reference. Points were then assigned on the femoral head surface and the superior half of the acetabular rim after aligning the pelvis in the anterior pelvic plane. The programme then automatically produced an image representing the femoral head and its covered part along with the calculated femoral head coverage. To do so, the software represents the femoral head by a best-fit sphere, and the sphere and the acetabular contour are then projected onto a plane in order to calculate the load bearing fraction and area.

RESULTS In the normal hips FHC averaged 73% (SD 4), whereas anteversion and inclination averaged 16° (SD 7°) and 44° (SD 4°) respectively. In the dysplastic group the mean FHC was 50% (SD 6), with a mean anteversion of 19° (SD 10°) and mean inclination of 53° (SD 5°). Peri-acetabular osteotomy has been performed on 16 hips so far, and the FHC for those averaged 66% (SD 5), a mean improvement of 32%. The respective anteversion and inclination post-operatively were 18° (SD 12°) and 40° (SD 8°).

DISCUSSION This is the first study to our knowledge that has used a reliable and practical measurement technique to give an indication of the percent coverage of the femoral head by the acetabulum in normal hips. When this is applied to assessing coverage in surgery to address hip dysplasia it gives a clearer understanding of where the corrected hip stands in relation to a normal hip, and this should allow for better determination of the likely outcome of this type of surgery. The versatility of the method gives it significant attraction for acetabular surgeons and makes it useful not only for studying dysplastic hips but also other hip problems such as acetabular retroversion.


E. Garcia-Rey E. Garcia-Cimbrelo J. Ortega-Chamarro A. Cruz-Pardos J.M. Sanchez

Introdution. Gamma sterilisation in air produces free radicals in the polyethylene (PE) with the result of degrading its mechanical properties, increasing wear and debris, and producing osteolysis and loosening. PE sterilized in the absence of air and high cross-linked polyethylene (HXLPE) have been used to avoid osteolysis and loosening. This prospective randomized study has assessed results in a series using two different poly-ethylenes associated with the same prosthetic design.

Methods: We assessed 45 Allofit cups with Sulene-PE liner (sterilized with nitrogen) and 45 Allofit cups with Durasul-PE liner (HXLPE), both associated with an Alloclassic stem (28-mm femoral head) (Zimmer). The minimum follow-up is 5 years and the mean follow-up 66.3 months. The linear femoral head penetration was estimated at 6 weeks, at 6 and 12 months and annually thereafter, using a software package employing the Dorr method, given the nonspherical cup shape.

Results All assessed hips had good clinical and radiographic results. There was no loosening of any prosthetic component. There were no radiolucent lines or osteolysis. Femoral head penetration in the early postoperative radiographs was 47.4% less in the Durasul group (0.09+0.03 mm) than the Selene-PE group (0.19+0.06 mm)(p< 0.0001). The mean yearly linear femoral head penetration was 20% lower in the Durasul group (0.008+0.008) than the Sulene-PE group (0.04+0.02)(p< 0.0001). Differences increase after the third year. Mean linear femoral head penetration at 5 years was 39.1% less in the Durasul group (p< 0.0001).

Conclusions: Although the digitized method used is not totally accurate and is used only for a general estimate, there is a significant reduction in yearly linear femoral head penetration with Durasul-PE. Longer-term results are needed to confirm that this polyethylene generates less osteolysis.


C. Olyslaegers K. Defoort J. Simon L. Vandenberghe

Highly cross-linked polyethylene (XLPE) has been introduced in total hip arthroplasty in an effort to reduce polyethylene wear and the associated periprohetic osteolysis. Cross-linking is a procedure in which irradiation and subsequent heating stabilize the internal structure of PE. Most of the conventional PE’s used, are gamma irradiated in air or an inert environment with a dose level of no more than 25 to 50 kGy. By irradiating PE at a higher dose, optimally around 95–100 kGy, a definite reduction in wear rate has been achieved. History already provided us some mixed in vivo results regarding altered PE. Therefore, present time surgeons are cautious when it comes down to using a new PE.

Some short follow up in vivo studies already suggested reduced wear rates with XLPE in comparison to conventional PE. Our aim was to demonstrate these reduced wear rates in a 2-dimensional head penetration model using the DICOMeasure™ computerized edge detection method (GreyStone, France) and to perform a clinical comparison of both groups using the Harris Hip Score and SF-36 questionnaire.

Sixty hips with a Trilogy XLPE liner (Zimmer Co.) were age and BMI matched with a control group of twenty conventional Trilogy PE liners (Zimmer Co.).

No differences in clinical performance were seen, but a statistically significant reduction of 67% in steady state wear rate was observed in the XLPE group.

It is clear that, due to the reduction and stabilization of free radicals in polyethylene, a reduction in annual wear can be achieved.


B. Grimm A.J. Tonino I.C. Heyligers

Introduction: Simulator wear studies of crosslinked polyethylene (PE) show promising results but long-term clinical investigations addressing concerns about in-vivo aging, PE deterioration, late wear and osteolysis are scarce. This study reports the longest published follow-up comparing conventional to crosslinked PE.

Methods: Crosslinked PE (Stryker Duration: 3MRad gamma irradiation in N2, post-irradiation annealed) was compared to conventional PE (3MRad gamma irradiation in air) in a MTS hip simulator and a prospective randomized clinical study involving 48 THA patients (Stryker ABG-II stem and cup, 28mm ball diameter) with a mean follow-up of 8 (7–9) years. Patients were followed-up annually using the HHS, radiographs and wear measurements applying a digital Livermore method.

Results: Forty patients (23 conventional, 17 Duration) were left for analysis (five premature deaths, 3 loss to follow-up). Both groups were statistically non-different (p> 0.1) regarding age (63.9 years), gender, BMI, stem size, cup size, cup inclination and liner thickness leaving the insert material as the only variable. Pre-op HHS (39.7) and post-op HHS (93.7) were also not different.

At 8-years the wear rate was significantly (p< 0.01) lower for Duration [0.088 ± 0.03 mm/yr (0.02–0.14)] than conventional PE [0.142 ± 0.07 mm/yr (0.05–0.31)]. This reduction (−38%) compared well to the simulator (−45%) and did not change over time (−33% at 5-years). Radiolucencies and signs of osteolysis were also less in the Duration group (n.s.).

Discussion: In-vivo wear reduction by crosslinked PE is similar as predicted by the simulator and does not seem to deteriorate over time. Concerns over higher levels of residual free radicals after annealing instead of remelting do not seem justified. The lower wear correlated with reduced radiographic signs of osteolysis which may result in superior survival at longer follow-up.


C. Geerdink B. Grimm W. Vencken A.J. Tonino I.C. Heyligers

Introduction: Wear of the polyethylene (PE) acetabular component is widely regarded as the primary factor limiting the longevity of total hip arthroplasties (THA). To compare wear patterns of different polyethylene inserts computer assisted measurement techniques for in vivo polyethylene wear were developed. This study was performed to investigate which software out of four programs is most precise and easy to use in daily clinical practice.

Materials and Methods: 24 anteroposterior digital radiographs of patients with a THA (Stryker ABG-II with N2Vac and Duration PE inserts in metal backed cups) with an average of 8.0 years follow-up were measured twice by a blinded single observer for linear wear (head penetration) in a single image analysis. Four computer assisted wear measurement methods were compared, the commercially available Martell Hip Analysis suite 7.14 and Rogan Hyperview, a not yet available Rogan beta-version called View Pro-X and Roman v1.70, freely available software to download from the internet. While both Rogan software can read the DICOM format from the hospital image server, images had to be converted for Martell (greyscale TIFF only) and Roman (any format).

The annual wear rates were compared and intra-observer variability was calculated as the difference between both measurements (precision). The average time it takes to measure one image (without format conversions) was documented and practicality of daily clinical use was evaluated.

Results: The annual wear rates measured were (mean +/− SD): Martell=0.09+/−0.21,, Hyperview=0.14 +/−0.10, Pro-X=0.12+/−0.07 Roman=0.12 +/−0.06. Martell was the only method measured negative wear (7/24 cases).

The precision was (mean +/− SD): Martell = 1.74+/−1.53, Hyperview = 0.36 +/−0.92, Pro-X = 0.10+/−0.11 Roman = 0.08 +/−0.08.

The average measuring time per image was: Martell = 94s, Hyperview = 94s, Pro-X = 92s Roman = 158s.

Discussion: The Roman method is the most precise and easiest to use in daily practice, but takes the longest time to measure. The Rogan View Pro-X software is nearly as precise and easy to use but not on the market yet. It is an improvement over the Hyperview which looses precision by using a elliptical interpolation necessary for non-metal backed cups instead of circular interpolation which is more precise for metal backed cups. The Mar-tell method produced the intolerable low precision and in some cases “negative wear”. Only on large patient groups it may produce realistic average wear rates. We found out that the Martell edge detection method, originally developed for scanned analogue x-rays, functions inferiorly with digital images, the coming hospital standard. Image processing (smoothening) of the digital x-rays did increase accuracy and precision. We recommend the Roman software, a digital version of the Livermore method, for precision, ease of use and cost.


S. Tarasevicius O. Robertsson U. Kesteris R.J. Kalesinskas H. Wingstrand

Background: The role of polyethylene (PE) wear in relation to synovitis and elevated hydrostatic pressure in the loosening process after THA has gained increased attention. The aim of our study was to investigate the correlation between prosthetic head size, PE wear and sonographic capsular distention, reflecting the degree of intracapsular synovitis/synovia/hydrostatic pressure.

Patients and methods: In 2005 we analyzed 60 randomly selected and unrevised OA patients 10 years after surgery with 32 or 28mm femoral heads. We evaluated radiographic signs of loosening, linear and volumetric PE wear. Sonographic examination was performed to measure the “capsular distance”, i.e. the capsular distension, defined as the distance between the metallic echo from the anterior surface of the prosthetic femoral neck, and the echo from the anterior surface of the anterior capsule.

Results: The linear wear was 0.2 mm per year and 0.1 mm per year in the 32 mm and 28 mm head size group respectively (p< 0.001), the volumetric wear was 139 mm3/year and 48 mm3/year (p< 0.001), and the capsular distention was 17 mm and 13 mm respectively (p< 0.001). There was also a significant positive correlation between PE volumetric wear and capsular distension (r=0.63, p< 0.001).

Interpretation: We conclude that 32 mm femoral heads were associated with almost three times higher volumetric wear as compared to 28 mm heads, and increased “capsular distension”, reflecting increased synovitis/synovia/hydrostatic pressure in prosthetic hip.


P. TRICLOT

Introduction: The purpose of this prospective randomized study was to compare the minimum 4-year follow-up penetration of polyethylene inserts of identical desing in two configurations in a consecutive series of hybrid total hip arthroplasty.

Method: Between August 2000 and december 2001, 102 patients (102 hips) with a mean age of 69.2 years were randomized to receive either highly cross-linked (Durasul, 49 hips) or contemporary (Sulene, 53 hips) polyethylene inserts. Other parameters, including the 28 mm cobalt-chrome femoral head, the cementless cup (Fitmore, Zimmer) and cemented stem (Emeraude, Zimmer), were identical in both groups. The primary criterion for evaluation was head penetration measurement, using the Martell System.

Results: At a minimum 4-year follow-up evaluation, 34 hips in the durasul group and 30 hips in the Sulene group had complete radiologic data available for analysis (median follow-up of 4.8 and 4.9 years in the Durasul and Sulene group, respectively). The median femoral head penetration rate was 0.029 mm/year in the Durasul group versus 0.123 mm/year in the Sulene group (Mann and Whitney test, p=0.0027). The median volumetric penetration rate was 7.99 mm3/year in the Durasul group versus 41.93 mm3/year in the Sulene group. The yearly volumetric penetration rate was 80% lower in the Durasul group (Mann and Whitney test, p=0.0034).

Discussion and Conclusion: This study demonstrate a signifiant reduction of the yearly linear and volumetric femoral head penetration in highly cross-linked poly-ethylene. Longer-term results ae needed to warrant that these early data generate less occurence of osteolysis.


R.M. Gillies J.H. Gan G.M. Hawdon S.J. McMahon

Introduction: Prevalence of femoral neck fracture in resurfacing hip arthroplasty continues to question if failure is technique-related or due to the inherent bone quality. This study aimed to correlate cement penetration profile during resurfacing hip with inherent bone density. The hypothesis is that osteoporotic bone is unable to support the prosthesis leading to fatigue failure.

Methods: Fifteen patients scheduled for total hip replacement (THR) were recruited to undergo resurfacing arthroplasty prior to THR. Each patient was implanted with a resurfacing femoral component (BHR, Smith & Nephew, Memphis, TN). Antibiotic simplex cement was inserted one minute after mixing at 18°C to fill 10% of the femoral component volume. The femoral head-implant section was removed and kept in buffered formalin. The patients then proceeded with standard THR. The femoral head-cement-prosthesis section was separated using electrical discharge (ED) machining technique and CT-scanned. The depth and volume of cement penetration were measured from the CT scans and correlated with femoral neck bone densities.

Results: Cement penetration was compared for three groups of bone density: normal, osteopenic, osteoporotic. Average cement thickness were found to be 0.36 ± 0.16mm (proximal), 0.28 ± 0.11 mm (centre) and 0.12 ± 0.05 mm. During hip resurfacing, cement is forced into the porous structure, e.g. the trabeculae and airspaces when the femoral component is fixed onto the head of the femur. In normal bone, the trabeculae is dense and air spaces occupy a small volume of the bone. Greater cement penetration was expected in osteopenic and osteoporotic bones. However, no significant difference was found between cement thickness and volume against inherent patient bone density (p> 0.05). High viscosity of the cement may have prevented more cement to penetrate the bone. While the exterior cortex of the femoral head is strengthened by a cement layer, the interior structure of the femoral neck is still susceptible to fracture at high loads. In addition, increased bone necrosis due to the exothermic reaction during cement fixation may predispose patients to fracture.

Discussion: Resurfacing hip replacement is a viable technique if the fracture risk can be reduced by gaining the best possible cement penetration. This would provide continuous cement stiffness with the bone.


A. Mahmood M.S. Zafar I. Majid N. Maffulli

Objectives: Minimally invasive hip arthroplasty (MIHA) has become a trend in last few years. The orthopaedic literature is deficient in well designed scientific studies to support the idea that MIHA provides superior outcomes compared with Total Hip Arthroplasty(THA) performed through standard incisions. We have attempted a comprehensive quantitative review of the published literature to assess the methodology of those studies and reported surgical outcomes.

Methods: We conducted a comprehensive literature search of different online databases. All relevant articles in peer-reviewed journals were retrieved except those not mentioning outcomes, case reports, review of literature and letters to editors. Two independent authors analyzed these articles for year of publication, type of study, patient numbers, surgical method, follow-up, complications and patient satisfaction. Each article was also graded using a validated methodology score; Coleman’s Ten Criteria to assess the quality of study.

Results: 38 studies met our inclusion criteria which contained a total of 6434 hip arthroplasties.78.5% (4031) of these were MIHAs. There was significantly less intra-operative blood loss with MIS technique. However no significant difference was noted between the two groups with respect to operating time, the mean length of hospital stay, pain score, dislocation and revision rates, neurological injury and incidence of peri-operative fracture. In addition the patient characteristics and surgeon experience had a significant effect on outcome. Scores were predominantly low for quality of the studies with patient numbers, follow up time and validated outcome measures being the weakest areas.

Conclusion: Minimally invasive hip arthroplasty is clearly in its infancy and continually evolving with new techniques and instruments being developed to treat a broader range of patients. At the present time there is still a lack of quality evidence to advocate its expansion. The better designed studies in fact suggest that it should perhaps be limited further to recognised expert centres. The complication rates and learning curve may be altered by changes in training and adapting surgical techniques. We emphasize the need for meticulous design in future studies comparing the outcomes of these two procedures.


C. D’Arrigo A. Speranza R. Iorio A. Ferretti

Introduction: In the last few years minimally invasive surgery in hip replacement is becoming more popular among orthopaedic surgeons because of less morbidity and faster rehabilitation. However several complications have been reported expecially in the so called “learning curve” (first twenty cases). The purpose of this study is to evaluate the learning curve of three different minimally invasive approaches.

Methods and Materials: In this study three different surgical approaches of THA were evaluated: lateral mini incision (GroupA), minimally invasive anterior approach (GroupB) and minimally invasive antero lateral approach (GroupC). The first twenty cases of each surgical approach were selected and compared with a control group (GroupD) of 149 total hip replacement operated using a lateral standard approach (> 12 cm) in the same period by the same experienced surgeon.

In all cases a specialized dedicated surgical instrumentation was used. Inclusion criteria to enter the study group (A-B-C Groups) were:BMI< 30, diagnosis of primary osteoarthritis, age< 75 years.

Following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional outcomes (HHS, WOMAC) at six weeks.

Results: No dislocations, infections and early aseptic loosening were detected in groups A, B and C. No significant differences were detected regarding the length of hospital stay in all groups. In group B the time of surgery was significantly higher than in group D. The total blood loss of group A, B and C was statistically lower than group D. Clinical outcomes at six weeks in groups B and C were significantly better that in group A and D. The following complications were detected:

Group A: two sciatic nerve palsy (one transient and one permanent), one greater trochanter fracture, one femoral stem malposition.

Group B: one greater trochanter fracture, one proximal femoral fracture, one rupture of tensor fasciae latae, two haematomas.

Group C: no complications were detected.

In control group D (149 patients) the following complications were observed: one proximal femoral fracture, one case of cup malposition and one infection.

Conclusions: The main advantages of all MIS approaches seem to be the reduced total blood loss, even in the learning curve. However during learning curve the minimally invasive approaches seem to have a higher rate of complications than the standard procedures even in selected patients. In muscle sparing approaches (anterior and antero lateral) the early functional outcomes are better than other approaches (standard and mini incision). Among the evaluated minimally invasive procedures, the antero lateral approach seems to be safer and less demanding than others.


E. Sendtner D. Boluki J. Grifka

AIM: Total hip replacement is the most successful procedure since 3 decades. In the last years a lot of new helpful implants were introduced to the market, minimal invasive procedures are presented in increasing numbers and the technique of navigation is introduced. On the other hand there is no scientific proof of the benefit of these procedures. The objective of this study was to collect data about the different procedures and the common used implants.

METHOD: In a countrywide anonymous survey, 250 German trauma surgery and orthopaedic surgery departments were asked about their MIS procedures and their treatment strategies.(August 2006)

RESULTS: 112 of the questionnaires have been returned so far. We found 82% of the surgeons doing minimal invasive THR, 18% are doing more than 50% of all procedures in MIS technique, while 45% of the colleagues report, that the patients never ask for the procedure. Most of the surgeons (58%) define “minimal invasive” as the preservation of muscle, tendons and soft tissue, 1% as the preservation of bone and 41% as the length of skin incision (6–12cm). The most common MIS approach is the lateral (45%), followed by the anterior approach (25%) and the modified Watson-Jones approach (21%) and the MIS dorsal approach (19%) (Some use more than 1 approach). For standard procedure (not minimal invasive) there is most used the Kocher approach (51%), followed by Bauer approach (29%) and Smith-Petersen/Watson-Jones (19%). 23% use navigation and 51% are convinced, there is no sense in that.

66% do not use articular resurfacing, 33% are using short implants.

49% are using cellsaver regular, 99% are using wounddrains.

CONCLUSION: While the technique of MIS in THR is whidespread in Germany, an exact definition is still missing. Patients don’t expect MIS as much as surgeons perform it. Out of the variety of approaches a standard still has to be defined.

For minimal invasive procedure there is most used a lateral approach, for standard procedure the Kocher approach. New implants are used by every third surgeon, navigation by every fourth surgeon.


A. Eslampour J. Parvizi P.F. Sharkey W.J. Hozack R.H. Rothman

Introduction: The potential benefits of Minimally invasive total hip arthroplasty (MIS THA) continues to be heavily debated. We hypothesized that the potential benefits of MIS THA may relate to factors such as patient selection, patient preconditioning, improvements in anesthesia technique, pain management, and not the incision size. This randomized, prospective study was designed to investigate the role of these confounding factors in general and aggressive rehabilitation in particular on the outcome of THA.

Methods: 100 patients undergoing THA at our institution were randomized into one of four groups. Group A was patients who had standard THA (incision length> 10 cm) and received standard preoperative and postoperative care. Group B patients had THA using small incision (< 10 cm) and standard protocols. Group C patients had regular incision THA, but received aggressive rehabilitation and pain control regimen. Group D patients had THA through small incision and received aggressive regimen.

Results: The demographic distribution amongst all the groups was similar. There was a significant improvement in function as measured by Harris Hip Score, LASA (validated rehabilitation score), SF-36, and lower extremity function test in all groups. The extent of functional improvement, home discharge, patient satisfaction, and analgesia requirement was better in patients who received aggressive preoperative and postoperative care regimen regardless of the size of their incision. There was no difference in estimated blood loss, mean operative time, transfusion needs, and complications between the groups.

Discussion: This study highlights the importance of family education, patient conditioning, pre-emptive analgesia, and aggressive preoperative and postoperative rehabilitation in influencing the outcome of THA. The aforementioned factors, and perhaps not the surgical technique per se, may play a major role in imparting advantageous outcome to MIS THA that is reported by various investigators.


K. Scheuerer R. Kipping

Different approaches for minimally invasive implantation of hip TEPs are currently the subject of lively discussion. The technique presented here is a tissue-saving procedure, independent of the implants used, and considerably accelerates early patient rehabilitation. The paper describes the double incision version of the Yale method with its special anatomical features, in particular contrast to Berger’s technique (Chicago). It is possible to work under accurate visual guidance in the acetabular and shaft areas without an X-ray intensifier. The structures of the pelvic and trochanteric muscle origins as well as the iliotibial band remain completely intact.

The results of the first implantations (n = 251) show shorter hospitalisation times, the possibility of muscle-compensated pelvic stabilisation on the first postoperative day, complete weight-bearing without crutches, reduced blood loss and the required EC substitution. The Merle d’Aubigne score both immediately after surgery and on completion of the follow-up rehabilitation shows higher values than conventional techniques. Analysis of the VAS shows considerably less postoperative pain than with conventional techniques.

The peri- and postoperative complications are discussed.

In summary, the Yale technique is a tissue-saving approach to the implantation of hip endoprostheses with pronounced advantages in early rehabilitation for the patient in the sense of immediate postoperative weight-bearing and muscular stabilisation of the pelvis and less pain.


S. Junk-Jantsch G. Pflueger V. Schoell

In fall 2004 we started with minimal invasive hip surgery at our clinic. Our requirements: Use of our standard implant system (Bicon threaded cup and Zweymüller stem), fast realization of the minimal invasive procedure through the continuation of the used, anterolateral Watson-Jones approach, modified for this technique, retaining the supine position with unchanged orientation concerning the positioning of the implant parts. Our expectations: Reduction in operative trauma through lower blood loss with less post-operative pain, less limping especially during the first weeks, less trochanter pain through the preservation of the gluteal muscle tendons, fewer posterior dislocations by preservation of the dorsal capsule, and a better cosmetic result.

The patient is placed in supine position on the standard OR table with the option of tilting the legs down. The contralateral leg lies on a leg holder in extended position, flexed by approx. 20 degrees. This allows to bring the leg in hyperextension (without hyperlordosis of the lumbar spine), adduction and external rotation during broaching the femur. The main criterion of the minimal invasivness is the preservation of the gluteal tendons and not primarily the reduction of the length of the skin incision. An extensive capsular release with partial dissection of the rectus tendon for exposure of the acetabulum is necessary. For the stem implantation a notching of the piriformis can be necessary in addition to this. During the stem preparation the soft tissues should not influence the axial entrance of the rasps into the femoral canal otherwise there is a danger of a dorsolateral perforation. Right-left-lateral-double-offset rasps and the use of manipulation rasps as trial prostheses have worked satisfactorily. Retrospective analyses of numerous peri- and post-operative data were accomplished, as well as radiological evaluations regarding the optimal position of the implanted joints, and compared with a conventional control group.

After a learning curve the OP duration was the same in both groups. The development of the haemoglobin and hematocrit levels were identical, 1/3 of the patients needed blood subsitution (autologous or stored blood). 90% of the analysed postoperative x-rays in standing position showed equal bilateral leg length corresponding to the preoperative planning, the planned offset was achieved in 93%. Deviations of the remaining were without clinical relevance. The complication rate was 2,5%.

Conclusions: The anterolaterale approach in supine position is standardised for the minimal invasive THR. The compliance with the developed implantation technique is a requirement for the optimal positioning of the prosthesis and to avoid complications. The subjective patient assessments, especially of those who experienced both methods, are impressive.


G. Puskas F. Kalberer C. Dora

The fear of high complication rates, repeated surgery and component mal positioning, especially early in the surgeon’s experience, can be an obstacle for starting a new technique like minimally invasive THR.

The aim of the present investigation was to report on our learning curve of the first 100 consecutive minimally invasive total hip replacements through an anterior approach and to focus on intraoperative and postoperative complications as well as on the quality of implant positioning.

In order to have a comparison, the last 100 THR performed through our previously used direct lateral approach were retrospectively evaluated. In both groups, complex acetabular and femoral reconstructions were excluded as they were performed though a digastric trochanteric osteotomy. Every change of the initial surgical plan was considered an intraoperative, every change in the rehabilitation plan considered a postoperative complication. The quality of implant positioning was evaluated in a standardized anteroposterior pelvic x-ray and a cross table lateral view at the 3 month follow-up visit and included the positioning of the cup and the stem in both views and the amount of leg-length discrepancy.

In terms of age, gender, BMI, ASA-score and origin of osteoarthritis both groups differed not from each other. Intraoperative and postoperative complications were more frequent in the MIS-Group (17 versus 7) and occurred within the first 30 cases. 12 were solved during the same anesthesia and 2 during the same day without manifest disadvantage at the 3 month follow-up visit. In one case a dislocation occurred. In two patients neuralgia of the lateral cutaneous femoral nerve was successfully treated conservatively. Implant positioning and leg-length discrepancy did not differ between the two groups.

Overall, starting a minimally invasive technique was associated with more frequent complications; however, if recognized and appropriately managed nearly none of them resulted in disadvantages for the patient at the 3 months follow-up visit.


F. Rachbauer R. Rosiek M. Nogler E. Mayr M. Krismer

Introduction: Minimally invasive total hip arthroplasty has evoked substantial controversy with regard to whether it provides superior outcomes compared with conventional total hip arthroplasty. The objective of this study was to compare the results of a minimal invasive direct anterior approach (MIDA) with those of a conventional lateral transgluteal approach (CLT).

Methods: 120 patients (120 hips) admitted for unilateral total hip arthroplasty were randomized to undergo surgery via minimal invasive direct anterior or conventional lateral transgluteal approach. Patients with a body mass index of more than 35, previous hip surgery, preoperative neurological deficits and with an age of more than 80 years were excluded. Two surgeons performed all procedures. To estimate muscle damage serum creatinkinase was assessed. Blood loss was calculated according to Rosencher by comparing preoperative to postoperative hematocrit. Postoperative pain and the ability to perform the activities of daily living were recorded in a dairy via modified WOMAC first on a daily basis, then on each second day and finally once a week for a total of 12 weeks. WOMAC questionnaire and SF-36 were administered at 6 weeks and 3 months follow-up.

Results: The groups were similar demographically. Patients in MIDA group had significantly less total blood loss (p = 0.006), postoperative blood levels of creatinine kinase were significantly lower (p = 0.001). Operative time was similar in both groups, we found no difference in component placement. Physical component summary of SF-36 at 12 weeks follow-up showed a significant benefit for the MIDA group. Averaged modified WOMAC scores and their pain and function subscores demonstrated a clear advantage on every recorded day during the first 12 weeks for MIDA. Median WOMAC sum score and respective pain as well as function subscores were better in the MIDA group at 6 and 12 weeks follow up.

Conclusions: A minimally invasive direct anterior approach is superior to a conventional lateral transgluteal approach with regard to blood loss and muscle trauma, resulting in better health related quality of life in the first three months after operation.


S. Pneumaticos V. Nikolaou C. Savvidou P. Tsiolis

Purpose: The objective of this study was to compare the results of a single mini-incision posterior approach with those of a standard posterior incision total hip arthroplasty.

Patients & methods: During the year 2005 52 patients were randomized to undergo total hip arthroplasty (THA) surgery through a short incision of 10 cm (or less) or a standard incision of 16 cm. 27 pts (20 females – 7 males) underwent THA through a posterior standard approach whereas 25 pts (19 females – 6 males) underwent THA through a posterior minimal invasive technique. Surgical indication was primary degenerative osteoarthritis in all patients. A single experienced surgeon performed all operations. In all patients the same cementless acetabulum and femoral component was used. The anaesthetic, analgesic, and postoperative physiotherapy protocols were standardized in both groups. The patients were compared with respect to the preoperative ASA score, incision length, hospital stay, intraoperative blood loss, postoperative blood transfusion, early mobilisation and satisfaction evaluated by the Harris Hip Score(HHS) and the visual analoque scale (VAS) for pain.

Results: The two groups were matched for age, grade according to the system of the American Society of Anesthesiologists and the preoperative Harris Hip Score. No significant difference was detected with respect to average surgical time, postoperative hematocrit, blood transfusion requirements, pain scores, or analgesic use. Additionally, we found no difference in early walking ability or length of hospital stay and no difference in component placement or functional outcome scores at the latest follow-up 6 – 12 months (mean 8 months) after surgery.

Conclusions: In arthroplasty the term ‘minimal invasive’ not only refers to the length of the skin incision but more so to its soft tissue protecting features and thereby to a better outcome. There was no evidence that the mini-incision technique resulted in less bleeding or less trauma to the soft tissues of the hip. Even more, it offers no significant benefit in the early postoperative or late period compared with a standard incision of 16 cm.


I.A. Karnezis C. Pasapula

Aim of study: ‘Dark discs’ (intervertebral discs with normal shape and height but low signal intensity on T2-weighted MRI) are believed by some authors to represent an early stage in the degenerative process although other authors have suggested that they are simply an appearance of the normal aging process. This study addresses the above question by investigating the correlation between disc morphology on MRI of the lumbar spine (‘dark disc’ or obviously degenerative signs such as annular tear, loss of disc height and shape and end plate changes) and the distribution of lower back pain.

Background: It is generally accepted that spinal levels appearing degenerate on MRI may act as ‘pain generators’ either directly or indirectly (by affecting adjacent structures or levels). Furthermore, histopathologic and discographic studies have shown transmition of specific patterns of somatic pain from degenerate spinal levels.

Methods: 231 consecutive patients (mean age: 45 years, SD:15.9) presenting with mechanical lower back pain of more than six months duration completed topographic graphs of the distribution of their back pain (categorised for this study as upper-, mid-, low-lumbar and sacroiliac area pain) and underwent an MRI of the lumbar spine. Chi-square test was used to investigate the association between presence of abnormalities at any spinal level and pain at any of the considered body areas. Two sets of analyses were performed: one including ‘dark discs’ in the ‘pain generators’ group and the other excluding the ‘dark discs’ from this group.

Results: When the ‘dark discs’ were not considered as ‘pain generators’ the only association to reach statistical significance was that between L5/S1 abnormalities and mid-lumbar pain (P=0.02). However, inclusion of the ‘dark discs’ in the ‘pain generators’ group increased the strength of the association between L5/S1 abnormalities and mid-lumbar pain (P< 0.01) and also resulted in the associations between L3/4 and L4/5 level abnormalities and sacroiliac area pain reaching statistical significance (P=0.02 and P< 0.01 respectively).

Conclusion: The significant statistical effect of considering ‘dark discs’ as ‘pain generators’ on the association between specific spinal level abnormalities and presence of back pain in well-defined areas suggests that the MRI appearance of a ‘dark disc’ should be considered an early stage in the degenerative process and not simply an effect of normal aging.


T. Ibrahim I. Tleyjeh O. Gabbar

Background: Chronic low back pain is the most common complaint of the working age population. Controversy exists regarding the benefit of surgical fusion of the spine for the treatment of chronic low back pain. We performed a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention.

Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index and Cochrane registry of clinical trials) were searched from 1966 to October 2005. Two authors independently extracted data on study characteristics and methodological quality and the number of patients with early complications from surgery. The random-effect meta-analysis comparison was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up of patients undergoing surgical versus non-surgical treatment. Between-study heterogeneity was analyzed by means of I2.

Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondy-lolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved posterolateral fusion with or without instrumentation or flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The pooled mean difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I2=21.4%). Surgical treatment was associated with a 13% pooled rate of early complication (95% confidence interval: 6–20%, I2=66.9%).

Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention. This difference in ODI is of minimal clinical importance. Furthermore, surgery was associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain.


J. Laffosse P. Chiron F. Molinier H. Bensafi J. Puget

Introduction: The minimally invasive posterior approach has become a standard for total hip replacement (THR) but the interest for the other minimally invasive approaches has not waned in any way. We carried out a prospective and comparative study in order to analyse the interest of the anterolateral minimal invasive (ALMI) approach in comparaison to a minimally invasive posterior (MIP) approach for THR.

Material and method: We carried out a prospective and comparative study. A group of 35 primaries THR with large head using the ALMI approach, as described by Bertin and Röttinger, was compared to a group of 43 primaries THR performed through the MIP approach. The groups were not significantly different with respect to age, sex, bony mass index, ASA score, Charnley class, diagnoses and preoperative Womac index and PMA score. The preoperative Harris hip score was significantly lower in ALMI group. Early functional results have been evaluated thanks to Womac index and modified Harris hip score at 6 weeks, 3 and 6 months. A p value < 0.05 has been considered as significant.

Results: The duration of surgical procedure was longer and the calculated blood loss more important in ALMI group (respectively p=0.045 and p=0.07). The preoperative complications were significantly more frequent in this group with 4 greater trochanter fractures, 3 false routes, 1 calcar fracture, and 2 metal back bascules versus one femoral fracture in MIP group. Other postoperative data (implant positioning, morphine consumption, length of hospital stay, type of discharge) were comparable. The early functional results at 6 weeks, 3 and 6 months were also comparable. No other complication has been noted during the first 6 months in the two groups.

Discussion and Conclusion: The ALMI approach uses the intermuscular interval between the tensor fascia lata and the gluteus medius. It leaves intact the abductors muscles and the posterior capsule and short external rotators. The early clinical results are excellent despite of the initial complications related to the initial learning curve for this approach and the use of the large head with metal-on-metal bearing. The stability of the arthroplasty and the absence of muscular damage should permit to accelerate the postoperative rehabilitation in parallel with less preoperative complications after the initial learning curve.


K. oinuma H. shiratsuchi Y. saito K. michinaga

Objectives: The direct anterior approach (DAA) is a distal portion of Smith-Peterson approach to the hip joint. Independent from the length of skin incision, no muscular dissection has to be done for total hip arthroplasty (THA). We have developed minimally invasive THA using DAA on the standard surgical table. The purpose of this study is to present the clinical results of 162 THAs with this approach and to know whether DAA can be safely performed on a standard surgical table.

Patients and Methods: Between August in 2004 and June in 2006, 189 primary THAs in 167 patients were performed through DAA in our hospital. We excluded patients with severe developmental dysplasia (12 hips) and with previous hip surgery (7 hips). The severity of dysplasia was graded according to the Crowe classification. We excluded Crowe type 3 or 4 osteoarthritis which requires a modified procedure to cope with the difficult anatomic situation and a different rehabilitation protocol, although it was possible to perform THA with DAA. In order to assess the recovery rate and safety of a rapid rehabilitation protocol after surgery, we also excluded patients with walking disability of uninvolved lower limb (8 hips). Thus, the results included 162 hips in 149 patients (125 women and 24 men). They were followed for at least 3 months postoperatively. The mean age was 62.6 years. The mean BMI was 23.1. The preoperative diagnosis was osteoarthritis in 142 hips, avascular necrosis of the femoral head in 11 hips, femoral neck fracture in 7 hips and rapid destructive cox-arthrosis in 2 hips. In patients with osteoarthritis, 136 hips (95.7%) are secondary to developmental dysplasia (Crowe 1: 112 hips, Crowe 2: 24 hips). Only 5 hips (5.4%) were primary osteoarthritis. The Bicontact total hip stem was used in 135 hips, the CentPilar system in 21 hips and others in 6 hips.

Results: Mean surgical time was 70.1 (range: 45 to 150) minutes. Mean operative blood loss was 368 (range: 73 to 1053) ml. Patients were able to walk over 50 meters with T-cane an average of 4.7 (1~30) days after surgery. Complications included one cup migration, one traumatic dislocation, one transient femoral nerve palsy, one heterotopic ossification and one asymptomatic stem subsidence (4 mm) in the early period postoperatively. The cup migration occurred 1 month after surgery and required re-surgery through the same incision. The radiographic analysis showed a mean cup inclination of 42.1 ± 7.1 degrees and a mean anteversion angle of 16.9 ± 4.3 degrees. The femoral component coronal alignment was within 3 degrees of neutral position in 159 hips. Varus alignment of more than 3 degrees was found in 3 hips.

Conclusion: We confirmed that the direct anterior approach was a safe and reproducible technique on the standard surgical table and allowed the prosthesis to implant correctly with no muscular dissection and no risk of denervation.


F.E. Sayegh M.A. Potoupnis E.I. Kenanidis G. Kapetanos

Background: Caudal extradural steroid injection is an alternative method of treating patients with chronic low back pain and sciatica.

Aim: The purpose of our study is determining the effectiveness of the caudal extradural steroid injection in patients with severe chronic low back pain and sciatica.

Patients – Methods: A total of 158 patients with severe and chronic low back pain and sciatica participated in the study, aged 23–78 years old. 86 patients were men and 72 women.

Patients were divided into two groups according to the injected drug. Group 1 or the injected group (n=91) received a caudal extradural injection (CEI) that consists of 12 to 15 ml of 2% xylocaine together with 1 ml of Betamethasone Dipropionate and Betamethasone phosphate. Group 2 or the placebo group (n=52), received a caudal extradural injection that consists of 6–8 ml of 2% xylocaine mixed with 6–8 ml of water for injection. The mean duration of symptoms was comparable between the two groups.

In order to estimate the degree of recovery from symptoms, all patients answered a specific questionnaire. The Oswestry Disability Index Questionnaire (ODI) was answered by all patients on the first day of clinical examination, and on different follow-up periods after caudal injection.

The straight leg-raising test was evaluated in all patients at the same follow – up periods.

Results: Recovery from symptoms and a decrease in the O.D.I score after the CEI was observed in both groups. However the mean ODI score of the injected group was statistically significant lower than this of control group for a period until one month after the injection (p < 0,001, Wilkoxon Signed Ranks test). Also the mean improvement time of positive SLR test in the injected group was statistically significant lower than this of control group (log rank test, p = 0,019)

Conclusions: The caudal extradural steroid injection is a reasonable non-surgical therapeutic option among patients with severe chronic low back pain and sciatica. It offers pain relief to patients who do not respond to prolonged conservative therapy, or who refuse surgery. It can easily be performed in the outpatient clinic.


L. Kandel T. Sahar I. Lev M. Brezis V. Ne’eman D.O. Odebiyi A. Lahad

Introduction. Back pain is one of the most common health problems in the industrialized world. Although using insoles appears to be common clinical practice, there is no hard data to support its effectiveness in prevention of low back pain. As a part of a Cochrane review, we conducted a literature search to determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Materials and methods. We identified relevant clinical trials by searching The Cochrane Back Group Specialized Registry, The Cochrane Central Register, MED-LINE, EMBASE and CINAHL. All retrieved abstracts were blinded and were assessed by two independent investigators who decided on their inclusion. All these were again assessed by two different independent investigators, using the eleven items reflecting internal validity recommended by the Cochrane Back Review Group. A trial was considered to be of high quality if six or more out of eleven criteria were met.

Results. Our search found a total of 324 references. 8 papers, meeting the predetermined inclusion criteria, were retrieved of which six were found suitable for final evaluation. The clinical trials described in the papers included more than 2400 patients who used insoles for 3–5 months. Two articles with 199 patients demonstrated improvement in low back pain, while three larger studies found no difference between using insoles or no using insoles.

Discussion. There is no evidence for recommending the use of insoles for prevention of back pain. Additional high quality trials must be done to determine if they are effective in the treatment of low-back pain.


S. Bahari M. El-Dahab M. Cleary J. Sparkes

Introduction: This study is performed to investigate the efficacy of steroid, local anaesthesia (LA) or combination of both in reducing post operative pain in lumbar discectomy.

Materials and Methods: The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups of 1ml of steroid and 1ml of LA, 1ml of steroid and 1ml of saline, 1ml of LA and 1ml of saline and 2mls of saline as control. 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine were used. Combinations of above were applied topically over the nerve root prior to closure. Preoperative, day 1 and eight weeks post operative visual analogue pain score were recorded. 10cm visual analogue pain score chart was used. 24 hours post operative opiate analgesia requirements and duration of inpatient stay were recorded. Data was analysed using Student t-test and Fisher exact t-test.

Results: No significant differences seen in the mean pre operative pain score between all groups. Mean Day 1 post operative pain and analgesia requirement in steroid and LA, steroid only, LA only and control group were 0.9, 2.5, 2.1 and 3.3 respectively. Mean opiate analgesia requirement 24 hours post operatively were 32.4mg, 54mg, 32.4mg and 56.8mg respectively. Mean inpatient stay were 2.2day, 3.91day, 4.62day and 3.63day respectively. At 8 weeks post operatively, no significant differences in the pain score in all groups.

Conclusions: Significant post operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p< 0.05). The results are reflected as well in significant reduction in the post operative analgesia requirement (p< 0.05) and the significant reduction in inpatient stay. (p< 0.05) We recommended the use of perioperative steroid and LA infiltration in lumbar discectomy. Improved post operative pain control reduces post operative opiate analgesia requirement and reduced inpatient stay.


A. Zeh M. Planert W. Hein

Introduction: Veldhuizen (2002) developed a new flexible Scoliosis-Brace for effective curve correction in Idiopathic Scoliosis. This new Brace is characterised by a improved cosmetic appearance and wearing comfort compared to conventional ortheses (Cheneau, Boston).

We investigated the effectiveness of the TriaC™-Brace regarding the primary curve correction in Idiopathic Scoliosis (IS).

Materials and Method: Following the guidelines given by Veldhuizen (2002) we have treated 20 patients (15 girls, 5 boys, average age: 12,43) with diagnosis of IS (King I:6, King II:4, King III:8, King IV:1, lumbar:1) with the TriaC™-Brace from 2002–2004.

At the beginning of the therapy with the new orthesis the Risser sign was 2,68 at an average.

The daily wearing time was instructed with 22–23 hours.

Lumbar curves showed an average cobb angle of 26,1 degrees (standard deviation=8,6) and thoracic curves of 24,4 degrees (standard deviation=6,5).

The radiological assessment of primary curve correction (cobb-angle) was performed 6,2 weeks after the beginning of the therapy (anterior posterior radiograph of the spine in standing position with orthesis).

Further radiological controls were performed every six months. We evaluated the wearing time, comfort and leisure activity with a valid scoring system (Quality of Life Profile for Spine Deformities).

The overall mean wearing time of the Triac™-Brace was 14,7 months.

Results: For lumbar curves (n=12) we measured a primary correction of 9,9 degrees (40%; statistically significant, t-test, p=0,01) and for thoracic curves (n=20) of 2,2 degrees (8,4%; not statistically significant, t-test, p=0,42).

A insufficient primary curve correction (defined as < 30% of the initial cobb-angle) was observed in 16 thoracic curves (89%) and in 4 lumbar curves (30%).

An increasing correction during the therapy as reported by Veldhuizen (2002) could not be observed.

There was a curve progression of at least 5 degrees of the cobb-angle in 4 cases.

The evaluation by the scoring system (response in 85%) resulted in a high score for cosmetics (4,2/5) and mobility of the back (4,6/5). The wearing time was reported by 90% of the patients with 22–23h.

Conclusion: We do not recommend the conservative therapy of thoracic or double curves (King III, King I and II) with the TriaC™-Brace.

Larger studies are necessary to investigate the effectiveness of the orthesis in lumbar curves. The improved wearing comfort and cosmetics are a potential advantages of this new orthesis.


S.C. Budithi R. Pollock T. Friesem

Study Design: Prospective analysis of a cohort of patients who underwent a Spinal Fitness Exercise Program in a nurse led spinal assessment clinic in a University Hospital.

Objective: To determine if psychological status affects the outcome of a spinal fitness exercise program in patients with low back pain.

Background: Evidence for the effectiveness of exercise programs in the treatment of chronic mechanical low back pain is well documented. In this study, the effect of psychological status on the outcome of a self-help spinal fitness exercise programme was studied.

Methods: Patients who were referred by their primary care physicians to the nurse led spinal assessment clinic and met the inclusion criteria were given a spinal exercise booklet, which describes with the aid of diagrams how to perform a series of lumbar core stability exercises for them to practise at home. Back pain related disability was assessed before and 3 months after the exercise program using the Oswestry Disability Index (ODI). Psychological status was measured using the Distress and Risk Assessment Method (DRAM). This classifies patients into 4 groups based on the combination of scores from the Modified Somatic Perception Questionnaire (MSPQ, 13 questions, scored 0–13) and Modified Zung Questionnaire (23 questions scored 0–69): normal, at risk, distressed somatic and distressed depressive.

Results: Forty one patients were enrolled into the study (19 male, 22 female, mean age at treatment 45.8 years, age range 22–78 years). The DRAM scores showed that 9 had no psychological disturbance (normal), 17 were at risk, 4 were distressed somatic and 11 distressed depressive. Even though there was a statistically significant improvement in the mean ODI after the exercise program for all DRAM groups, the improvement in the ODI was not significantly different between the four groups (ANOVA, p = 0.596).

Conclusions: Our study suggests that the outcome of a spinal fitness exercise programme is not affected by the psychological status of the patient. We conclude that patients should not be excluded from spinal fitness exercise programs on the basis of psychological status.


O.R. Richards M. DeMatas C. Bruce J. Dorgan M. Cunliffe

Aprotinin has been shown to reduce blood loss in a number of surgical specialities. Patients with Duchenne Muscular Dystrophy (DMD) bleed more during surgical procedures than patients without this condition. The aim of this study was to evaluate the effect of aprotinin in reducing blood loss in scoliosis correction surgery in patients with DMD.

A retrospective analysis of case notes was performed. Thirty two patients diagnosed with DMD who underwent surgical correction for scoliosis over the last 25 years were included. All patients underwent posterior spinal fusion and instrumentation, between the levels T3 and L3. All procedures were carried out by the same lead surgeon. Patient age, body weight, length of procedure, and estimated blood loss were recorded. Blood loss as a percentage of total circulating volume was calculated and compared between patients who had not received aprotinin (seven patients), and those who did (25 patients). Blood loss as a percentage of total circulating volume in the group of patients with aprotinin (range 37% – 107% mean 67%) was significantly lower (P< 0.05) than the group without aprotinin (range 67% – 157% mean 111%). There was found to be no statistically significant relationship between blood loss and length of procedure. There was no statistically significant difference in the duration of the procedure between the two groups of patients. Despite the small number of patients this study shows a beneficial effect for aprotinin in reducing blood loss during scoliosis correction surgery in patients with DMD.


S.G. Pneumaticos S.N. Chatziioannou C. Savvidou V. Nikolaos P. Zoumboulis E. Lambiris

Introduction: Minimally invasive augmentation techniques of vertebral bodies have been widely used in the treatment of painful osteoporotic vertebral compression fractures (VBCFs). Kyphoplasty seems to achieve pain relief and improvement in quality of life. However, the effect of kyphoplasty on the height and the kyphotic deformity of the vertebrae is now yet clear. The present study reports our experience in kyphoplasty procedures for osteoporotic VBCF’s.

Materials and Methods: A total of 105 VBCF (45 thoracic and 60 lumbar vertebrae) in 56 patients (16 male, 40 female; mean age: 69 years, range 32–87 years) were treated with kyphoplasty between 2002–2005. All patients were preoperatively evaluated with radiographs, MRI and bone scintigraphy, and postoperatively immediately following the procedure and 6 months later with radiographs. Eight patients were treated within a week from their injury (new fractures). All patients completed the Oswestry Disability Index Questionnaire pre- and immediately post-operatively and at 6 months. The height of the treated vertebrae and the kyphotic deformity were measured before, after the kyphoplasty and at 6 months. All procedures were performed under general anaesthesia and fluoroscopy guidance.

Results: 54 patients were included in the study; 2 patients expired from causes unrelated to the procedure. All patients experienced pain relief following the procedure and the average Oswestry Disability Index score decreased from 76% preoperatively to 12.4% postoperatively (P< 0.001) and to 18.5% (P< 0.001) at 6 months. The observed mean height restoration at 6 months was 3mm (range 0–15mm) (P=NS) and the kyphotic deformity correction was 3.70 (0–120) (P=NS). In the new fractures the height restoration was 7.1mm and the kyphotic correction 7.80 (P=0.01). There were no cases of pulmonary embolism nor were any significant cement leakages noted.

Conclusion: The treatment of painful osteoporotic VBCFs with kyphoplasty is safe and reduces pain and disability. However, it does not lead to restoration of the vertebral height nor to correction of the kyphotic deformity, except in new fractures.


A. Hempfing L. Ferraris F. Geiger C. Carstens P. Metz-Stavenhagen

Introduction: With the advent of thoracoscopy, anterior release procedures in adolescent idiopathic scoliosis (AIS) have come into more frequent use, however, the indication criteria for an anterior release in thoracic AIS are still controversial in the literature. The aim is to achieve a better coronal correction but the benefit as compared to a single posterior approach is not yet clarified.

Material and Methods: Two groups of 15 patients each were matched for sex, age and cobb angle. Patients of group 1 were operated with a staged procedure of an anterior release followed by posterior instrumentation (anterior-posterior spinal fusion, APSF) and patients of group 2 were operated by a single posterior spinal fusion (PSF) with performance of concave sided rib osteotomies (concave thoracoplasty, CTP).

Results: Mean age: 16.2 y (APSF), 17.6 y (PSF). Mean preop curve: 81.7° ± 10.1° (APSF), 84.2° ± 14.1° (PSF). Mean postop curve: 34.9° ± 15.5° (APSF), 34.3° ± 12.2° (PSF) (p=0,49).

Conclusion: The single posterior approach gave the same coronal correction rate as compared to patients operated with a two stage procedure with preceding anterior release. A posterior release with CTP is more effective in increasing spinal flexibility than disc excision. According to our clinical experience, an anterior release prior to posterior instrumentation in AIS should only be considered in hyperkyphosis, coronal imbalance or massive curves.


S. Sonne-Holm S. Jacobsen T. Jensen L. Hyldstrup H. Rovsing H. Rovsing

Background: The epidemiology of Schmorl nodes is based on post-mortem investigations. The proposed pathogenesis of the focal nodes is a bulging of the disc into the vertebral body depending of the degree of osteoporosis. Secondar peripheral osteophytes are formed at the annular insertion.

Study design: A cross sectional epidemiological study of 4151 participants of the Copenhagen Osteoarthritis Study in 1993 with a 13 years follow with the Roland-Morris (R-MQ) back pain questionnaire.

In 1993 standardized, lateral radiographs of the lumbar spine were recorded and the bone mineral density (BMD) was estimated by digital x-ray radiogrammetry of standardised hand x-rays.

Methods: Statistical correlations were made between Schmorl nodes and low back pain in 1993, the R-MQ score, BMD and the presence of osteophytes, disc degeneration and endplate sclerosis.

Results: There were 2610 women and 1538 men. At follow up 1190 women and 674 responded. In 196 cases one or more Schmorl nodes in the lumbar spine were found (women 3.7 %, men 6.5 %). A decreasing prevalence of Schmorl nodes by ages was found in both genders (p< 0.000). At the time of the radiographic examination participants with Schmorl nodes clamed of low back pain (p=0.003). The presence of nodes was without relation to osteophytosis, intervertebral disc degeneration or sclerosis of endplates (p> 0.14) in 1993. Neither was the R-MQ score at follow-up related to Schmorls nodes(p> 0.26). The presence of nodes was associated with higher BMD (mean 0.50 (SD 0.079) versus 0.53 (SD 0.081)(p=0.000), however the difference disappeared taking into account age at examination.

Conclusion: This large scaled epidemiological study cannot confirm the hitherto hold opinion of the implication of the Schmorls nodes. The nodes are not associated with radiological degeneration and osteoporosis neither are they a predictor of lower back pain later in life.


F. Damborg V. Engell M. Andersen K. Kyvik K. Thomsen

In the litterature patients suffering Mb. Scheuermann (MS) have been reported to experience more back pain and other back related constrains compared to subjects matched for age and sex. We have been unable to find publications on health-related quality of life by SF-12 or SF-36 in MS. The aim of the present study was to compare health-related quality of life status in MS to the background population.

Materials and Methods: The present cohorts are derived from The Danish Twin Registry and consist of all Danish twins born from 1931 through 1982. This twin cohort has been shown to very closely resemble the general Danish population. A total of 46,418 twins received and 75% returned a questionnaire of which 34,007(97.3 %) answered the question ‘Have you been diagnosed with Scheuermann’s disease?’ Included in the questionnaire were the standardised questions for The Medical Outcome Study Short Form-12 (SF-12), from which we calculated the SF-12 Physical Component Summary scale (SF-12 PCS) and the SF-12 Mental Component Summary scale (SF-12 MCS) using the SF Health Outcomes Scoring Software. Nine-hundred-and-forty-three reported to have MS and the remaining 33,064 responders were used as controls.

Results: The mean(SD) age in the MS group was 43.7(11.9) years compared to 44.4(13.7) in the control group (NS). The overall self-reported prevalence of MS was 2.8% (95% c.i.l. 2.6–3.0), male : female prevalence was 3.6% (95% c.i.l. 3.2–4.1) : 2.1% (95% c.i.l. 1.9–2.3). In the controls male : female prevalence was 45.2% (n=14,953) : 54.8% (n=18,111).

Conclusion: The perceived health status from SF-12 PCS in self-reported MS was moderately though highly significantly worse than in controls in a big cohort of Danish twins. There was no difference in SF-12 MCS between the two groups.


S. Muthian E.B. Ahmed

Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater than 5° of anterior wedging in 3 consecutive vertebrae. We describe a new technique for the surgical treatment of thoracic kyphosis due to Scheuermann’s disease. Eleven patients were treated in our series.

Results: The average preoperative kyphotic angle was 83.3 degrees (58 – 94 degrees). Multiple posterior closing wedge osteotomy was performed and four rods (two proximal and two distal) were contoured and fixed to pedicle screws and the deformity reduced by the cantilever technique.

The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level.

Conclusion: We find this technique simple and effective in reducing curves of high magnitude and the reduction was maintained in the long term. Our complication rate was comparable to that quoted in literature.


D. Nicoll D. Rowley

Pre- and post-operative Knee Society Scores for 2105 Total Knee Replacements (TKRs) with minimum three year follow-up were evaluated. The effect of gender, age at operation and BMI at operation on Knee Society Data at pre-operative review, at one year post-operatively and at three years after TKR was analysed.

Total Knee Score pre-operatively, and at both one year and three year review was found to be independent of gender, age and BMI. There was no effect of the three demographic variables on the component scores for pain, range of motion, stability, alignment, extensor lag and flexion contracture.

Lower Function Scores were associated with female gender (p< 0.001), age greater than 70 at time of operation (p≤0.004) and obesity (p< 0.001). Median Function Scores were consistently higher in males than females by 5 points pre- and post-operatively (p< 0.001). At three years post-operatively, the median Function Score in the 80 and over age group was lower than all other age groups (p< 0.001), by between 15 and 20 points. Whilst the normal and overweight groups had similar Function Scores the class I obese and class II obese groups consistently had lower median Function Scores by 5 (p< 0.001) and 10 points (p< 0.001) respectively.

We conclude that whilst the Knee Score and its component scores are independent of gender, age and BMI, all three of these demographic variables can be associated with significant differences in Function Score.


R. Sinigaglia U. Nena D. Fabris Monterumici

Object. Our purpose is to evaluate early benefits and complications of pedicle subtraction osteotomy (PSO) for patients with fixed thoracolumbar kyphotic deformities.

Background. The fixed sagittal imbalance is a syndrome in which the patient is only able to stand with the weight-bearing line in front of the sacrum [1]. Its etiology could be very different, but usually it is due to idiopathic scoliosis or degenerative sagittal imbalance [2]. Different techniques are reported in the literature for its correction [3]. In particular, in the last few years, the PSO is affirming as a good technique in correcting the fixed thoracolumbar sagittal deformity, with its three column osteotomy [13].

Materials and Methods. From December 2005 to July 2006 the first 10 PSOs for patients with fixed symptomatic thoracolumbar sagittal deformity were performed in our Spine Center. All 10 were female (100%). Mean age was 63.8±5.3 (55–71). The diagnosis was idiopathic scoliosis in 7 cases (70%), degenerative sagittal imbalance in 3 (30%). Patients had undergone a mean of 1.5±0.97 (0–3) operative procedures prior to the PSO.

Results. A pedicle subtraction was always performed between the level L1 and L4. An average of 10±2.9 (7–16) vertebral levels were included in the spinal fusion. Intraoperative estimated blood loss was 1300±305 (800–1800) mL, operative time was 298.5±37.5 (250–360) minutes. An average increase in lumbar lordosis of 28.3±12.1 (8–51) degree was established with this technique: the transpedicular wedge resection contributed 73.5%±25.4% (19.4±6.1 degree) of this correction; the remaining correction came from multilevel facetectomy. The average improvement in the sagittal plumb line was 4.3±5.1 (from −5 to +15) cm. There were 8 (80%) perioperative complications: 4 major (1 subdural hematoma; 1 pulmonary embolism; 1 fracture of the upper end vertebrae; 1 pemanent neurologic deficit); 4 minor (1 transient neurologic deficit; 3 wound dehiscences). Most patients reported improvement in terms of pain and self image as well as overall satisfaction with the procedure.

Conclusions. Pedicle subtraction osteotomy is a useful procedure in correcting fixed sagittal thoracolumbar imbalance. Often it is well-tolerated, but certainly this is a technically demanding procedure with high perioperative complication rates.


C.O. Tibesku V. Vieth A. Skwara V. Stückmann W. Heindl S. Fuchs-Winkelmann

Introduction: Mobile bearing total knee arthroplasty (TKA) has been developed to theoretically provide a better, more physiological function of the knee and produce less polyethylene (PE) wear. The theoretical superiority of mobile bearing TKA’s over fixed bearing devices has not yet been proven in clinical studies.

The objective of the present study was to analyze in vivo the knee joint kinematics in the sagittal plane in a patient population that had received either a fixed or a mobile TKA in a prospective, randomized, patient- and observer-blinded, clinical study.

Methods: 31 patients were evaluated by means of fluoroscopy during unloaded flexion and extension against gravity, as well as during step-up and step-down with full weight bearing. In these 31 patients, 22 fixed bearing TKAs, 16 mobile-bearing TKAs and 19 natural knee joints were included.

All patients had been operated in a prospective, randomized, patient- and observer-blinded, clinical study, and had received either fixed or a mobile bearing, cruciate retaining Genesis II TKA for primary osteoarthritis.

Fluoroscopic radiographs were evaluated by measuring the „patella tendon angle” as a measure of antero-posterior translation as well as the “kinematic index” as a measure of reproducibility.

Results: During unloaded movement, fluoroscopic analysis did not show a significant difference between both types of prosthesis designs and the natural knee. In the weight-bearing movement, both types of TKA designs did not show the typically arched but a more linear patellar tendon angle curve, with a greater angle in extension and in flexion than the natural knees. This means that the femur glides anteriorly under load near extension and does not show the natural roll-back in flexion. In the mobile-bearing group, inter-individual deviations from the mean during weight-bearing movements were significantly less than in the fixed-bearing group.

Conclusions: In the present study, no functional advantage of mobile bearing TKA over fixed bearing devices could be found. Both TKA designs showed the typical kinematics of an anterior instability. Long-term follow-ups are necessary to elucidate the possible influence of lower PE wear on the incidence of aseptic loosenings.


V. Wylde I. Learmonth

Introduction: Chronic joint pain is the primary reason for individuals electing to undergo TKR and therefore pain relief is an extremely important outcome after surgery. Although the literature suggests that TKR produces excellent pain relief, the prevalence of chronic pain after TKR is often masked in the reporting of mean pain scores. The aim of this study was to explore the prevalence, impact and onset of pain at 1-year after TKR.

Methods: 243 patients (251 knees) were recruited into a multi-centre randomised controlled trial comparing the outcomes of the Kinemax Plus fixed-bearing and mobile-bearing implant. Patients were assessed pre-operatively and then 3 months, 1-year and 2-years post-operatively. At each assessment time patients completed the WOMAC, KOOS quality of life scale, SF-12, American Knee Society Score, Satisfaction Scale for Joint Replacement Arthroplasty and a clinical examination. As part of the clinical assessment patients were asked to rate the pain in their knee as none, mild, occasionally moderate, continually moderate or severe.

Results: To date, 240 knees have reached their 1-year follow-up. Complete data regarding pain ratings was available for 198 patients. The mean age of patients was 68 years (range 40–81) and 52% were male. At 1-year after TKR, 13% of patients had occasionally moderate pain, 6% had continually moderate pain and 6% of patients had severe pain. In total, 25% patients reported moderate-severe pain at 1-year after TKR. 60% patients with pain at 1-year post-operative also experienced moderate-severe pain at 3 months post-operative. Using a Mann-Whitney U test, patients with moderate-severe pain at 1-year after TKR had significantly worse physical function (p< 0.001), knee-related quality of life (p< 0.001) and mental health scores (p< 0.05) than those patients with no-mild pain.

Conclusion: This study suggests the prevalence of pain after TKR is high, with 25% of patients reporting moderate-severe pain at 1-year after TKR. Pain experienced at 1-year post-operative was most frequently preceded by pain at 3-months post-operative, suggesting that for many patients a pain-free period after surgery is not experienced. The pain present at 1-year after TKR affected several domains of life, including functional ability, quality of life and mental health. Future research will focus on developing a pre-operative screening protocol to identify patients at risk of chronic pain after TKR.

This research was supported by funding from Stryker UK.


K. Peters H. Bolder R. Tetteroo

Introduction: The short-term functional recovery after a total knee arthroplasty (TKA) is largely dependent on initial wound healing. Haematoma formation may lead to prolonged wound drainage and tissue necrosis, which can have a negative effect on early range of motion, post-operative pain and infection rate.

To decrease haematoma formation, primary soft tissue homeostasis and adequate tissue repair are essential. Growth factors, especially PDGF (platelet derived growth factor) and TGF-β (transforming growth factor-beta), play a crucial role in the biochemical cascade at the site of repair. These growth factors are mostly derived from platelets.

The objective of this study was to evaluate the effect of autologous platelet concentrate on blood loss (postoperative decrease of haemoglobin concentration), wound healing complications, range of motion, pain reduction and outcome scores when used in total knee arthroplasty.

Method: 96 patients undergoing primary total knee arthroplasty were included and randomized in two groups. In the study group, autologous platelet concentrate was applied at wound closure. Treatment with autologous platelet concentrate involves direct application of concentrated platelets, growth factors and fibrin in the operation wound. A small volume (55–110 ml) of the patient’s own blood is taken to derive a platelet rich gel which can be sprayed directly into the wound.

The peri-operative haemoglobin concentration, peri-operative range of motion, haematoma formation, number of days of wound drainage and complications were collected. The pain score (VAS), IKSS, 12 questionaire score and SF-36 score were recorded at regular intervals.

Results: There was no significant difference between the groups in post-operative haemoglobin decrease, range of motion, haematoma formation, wound drainage or pain scores. In the study group there were 3 deep infections. In the control group we had no infections.

Conclusion: We found no benefit in the use of autologous platelet concentrate in total knee arthroplasty. Furthermore, it is of concern that we had three deep infections with use of the autologous platelet concentrate.


M HASSABALLA A PORTEOUS J H Newman

Introduction: There is an impression among Orthopaedic surgeons that mobile bearing knee replacement has a better functional outcome than fixed bearing knee replacement. Since kneeling demands a high level of function after knee replacement this study was undertaken to see if mobile bearings in either total or unicompartmental replacement conferred an advantage.

Methods: A prospective randomised study of 207 TKR patients receiving the same prosthesis (Rotaglid, Corin, UK) was performed. Patients were randomised into a mobile bearing group (102 patients with a mean age of 53 years) and a fixed bearing group (105 patients with a mean age of 55 years). Data was also prospectively collected on 215 UKR patients who received the same unicompartmental implant (AMC, Uniglide, Corin, UK). 136 patients (Mean age: 62 yrs) had a mobile insert and 79 (mean age: 65 yrs) a fixed insert.

All patients completed the Oxford Knee Questionnaire preoperatively as well as at 1 and 2 years postoperatively. Their stated kneeling ability and total scores were analysed with a perfect score for kneeling ability being 4, and 48 the maximum total score.

Results: In all groups both the kneeling ability and the total scores improved markedly from their preoperative state. At two years the total score for the fixed bearing devices was marginally better than for the mobile (Rotaglide 36;31 and Uniglide 37;33)

There was a more striking difference with respect to kneeling ability with the fixed bearing variants performing better, (Rotaglide 1.4; 0.9 and Uniglide 1.9; 1.4), However, the greatest difference was between the UKR and TKR groups (UKR 1.7; TKR 1.2). Pre-operatively less than 2% of TKR patients (7% of the UKR patients) could kneel. Post-operatively, the patients’ kneeling ability improved with 21% for the mobile bearing, 32% of fixed bearing UKR patients. The TKR patients kneeling ability was 13% of the mobile, 26% of fixed bearing patients were able to kneel with little or no difficulty. In all groups the stated kneeling ability was poor with less than 50% of any group being able to kneel with ease or only minor difficulty.

Conclusion: Those undergoing UKR appeared to perform better than those with a TKR. None of the forms of knee replacement used resulted in good kneeling ability, though this function was improved by arthroplasty in all groups. Mobile bearing inserts


S. Datir M. Sayana A. Rahamatalla G. Walley I. Dos-remedios C. Wynn-Jones N. Maffulli

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty on joint proprioception and range of motion.

Methods: 47 patients were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score, EuroQol), range of motion and proprioception were assessed prior to and at 3,6, and 12 months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak that detected positions of sensors placed on the test limb. Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. There was statistically significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but there was no difference between the groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05).

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.


Introduction: Unicompartmental kneearthroplasty became applicated in the past decade also in younger more active patients. Therefore the durability of the bone anchorage and polyethylene wear are at increased risk for failure. Provides the cementless implantation of the AMC-Uniglide prosthesis a reliable fixation? Are the clinical and functional results comparable to the cemented version of this prosthesis?

Methods: The AMC-Uniglide ensures congruent area contact with physiological kinematics resulting from imitation of the healthy morphology of the femoral condyle and unrestricted movement of the polyethylene bearing. This also secures a low intrinsic stability, which relieves the implant-bone fixation. There is a cemented and cementless version of this prosthesis. From 1991 to 12/2003 we performed 477 implantations with cement and 137 cementless. The follow up is (3–14) mean 8 years and seized 96% of the cases. They were assessed according to the Knee Society Rating System and analyzed radiologically (F. C. Ewald).

Results: Knee Score cemented 35/94, cementless 36/94 (pre/post). Function Score cemented 52/90, cementless 54/92 (pre/post). Rang of movement improved from flexion/extension 109/5/0 to 124/2/0. Patient assessment was (cemented/cementless) excellent 72%/75%, good 20%/18%, fair 5%/5%, poor 3%/2%.

Loosenings needing revision: 10 times (2%) in the cemented group, 2 times (1,5%) in then cementless cases.

The radiological investigation showed less radiolucent lines in the cementless cases.

Conclusion: The cementless implantation of the AMC-Uniglide gives excellent results comparable to the cemented version. The loosening rate is even lower. A stable interface at 1 year never deteriorated! The cementless fixation is attractive for younger patients (less 70 years) and is preeminent for the mini-invasive implantation technique.


I. Rafiq S.H. ZAKI A. KAPOOR M.L. PORTER A.K. GAMBHIR V. RAUT A.O. BROWNE

Aim: PFC Sigma total knee was introduced in 1997 incorporating a number of design changes. We report our medium-term results of a consecutive series of PFC sigma knees performed between Nov 1997 and Dec 1998.

Method: Between November 1997 and December 1998 a consecutive series of 166 TKAs (156 patients)were carried out using the PFC Sigma total knee replacement system at Wrightington Hospital. Out of the 156 patients 9 were lost to follow-up. This left 147 patients (156 knees) with a mean follow-up of 90 months (range 84 – 96 months). 137 patients (88%) had primary osteoarthritis, 14(9%) had R.A and 5(3%) had post-traumatic arthritis. The mean age was 70 yrs (53 – 88 yrs).85 were female and 62 male. All patients were followed at 3 months, 6 months,1 year and then yearly. Clinical evaluation was done by American Knee Society and Oxford knee scores. Knee society score was used to assess the postoperative radiographs.

Results: The mean Knee society score improved from the preoperative mean of 45 (range 30 – 65) to postoperative mean of 84 points(range 45 – 92). The mean preoperative functional score was 38(range 25 –5) and mean postoperative functional score was 73 points(range 50–95). According to the final scoring 90 % of the knees were rated excellent, 4% good, 4 % fair and 2 % poor. The mean preoperative Oxford knee score was 43 (range 33–52) and mean postoperative score was 17 (14–29). Range of motion improved from a mean of 90(range 50–125) to 105(range 65–130). There was no significant difference (p = 0.03) in the American Knee Society score and Oxford knee score when comparing patients with and without resurfacing of the patella and PCL-retaining with PCL-substituting implants.1 knee (0.6%) was revised within 18 months due to aseptic loosening.1 knee(0.6%) had superficial wound infection which cleared with oral antibiotics.2 patients(2 knees) developed deep infection out of which one resolved following early debridement, the other developed chronic infection requiring long term suppressive antibiotics. 3 patients had proven below knee deep venous thrombosis; one of them developed a non-fatal pulmonary embolism. Radiological review using radiological knee society scoring showed radiolucent lines under 35 % of the tibial components(56 knees)and 11 % of Femoral components(18 knees). For survivorship analysis, the actuarial life- table method was used with calculation of the numbers at risk and the survival rates at annual intervals. The 95% confidence limits were calculated by the method of Rothman. The survivorship at the end of eight year follow-up was 99.40. None of the patellar components failed.

Conclusion: Our study shows excellent clinical results of PFC Sigma Total knee replacement after almost eight years follow-up. We plan to continue monitoring this cohort of patients for long-term results.


S.M. Hussain J.A. Savin L. Cochrane B.R. Singer

The merit of staging bilateral total knee arthroplasties (separate procedures) versus replacing both joints at the same anaesthetic (sequential) is a topic debated in literature. The aim of this study was to evaluate & compare the clinical outcome in patients who had undergone either bilateral staged or sequential total knee arthroplasties (TKAs).

METHODS: Computerized database and medical records of patients who had had bilateral TKAs in the Tayside region between 1984 and 2003 were retrospectively evaluated. Outcome was assessed using Knee Society Score, Pain Score, Function Score and Range of Movement.

RESULTS: 438 sequential and 526 staged procedures were evaluated. The sequential group had better function score at 1 and 3 years (P< 0.001). There was no other statistically significant difference in the outcome measures.

The mean ages of the sequential and staged study groups were 70.67 and 69.19 years, respectively (P=0.011).

CONCLUSION: Sequential TKA appears to confer a functional advantage over staged procedures in the short and medium term.


A. Cohen I. Brenkel J. Skinner D. Warwick

Introduction: Pharmacological and mechanical methods are recommended to prevent venous thromboembolism (VTE) following hip replacement (THR). However, data on mechanical methods such as graduated compressive stockings (GCS) are limited. This study examined the efficacy and safety of GCS when added to fondaparinux.

Methods: The randomised treatments were 2.5 mg fondaparinux for 5–9 days starting postoperatively alone or with GCS for 42±7 days. The primary efficacy outcome was VTE or sudden death prior to Day 42±7. All patients were to have duplex USS at day 42 + 7. VTE was defined by verified symptomatic VTE or asymptomatic proximal DVT. The main safety outcomes were major and minor bleeding and VTE death.

Results: 856 patients were randomised, of which 799 were THR patients. Of these 756 (95%) were evaluable, 377 in the fondaparinux and 379 in the fondaparinux plus GCS groups. Risk factors for thrombosis were recorded (age > 75 in 20%, history of obesity in 21%, cancer in 6% and VTE in 3%). Compliance with GCS was high, with 85% wearing them continuously. The primary efficacy outcome of VTE or sudden death in THR patients was similar in each treatment group, the results were 5.5% in the fondaparinux only group and 5.3% in the fondaparinux with GCS group; odds ratio was 0.96, 95% confidence interval 0.50–1.83, p=0.91. Outcomes were not different for long-length and short-length stockings. Major bleeding occurred in one patient (< 1%), minor bleeding in 6.7%. No VTE deaths were reported.

Discussion: The addition of GCS to fondaparinux showed no benefit in thromboprophylaxis over fondaparinux alone in this large study of THR patients. Therefore GCS may not be indicated in patients receiving fondaparinux. Graduated compression stockings are time consuming to measure and fit, inconvenient and expensive; therefore we recommend a reconsideration of this current and commonly used practice in THR.


K.A. Gustke M. Mahfouz

Frequently surgeons performing total knee replacements are faced with the dilemma of whether to notch the anterior cortex or overhang the medial and/or lateral cortices when implanting the femoral component. This is almost always seen in female patients. There is also a higher incidence of patellar alignment problems in female patients post total knee replacement. A unique 3D to 3D matching study of 202 cadaveric femurs has demonstrated a significant difference in the average comparable shapes of male versus female distal femoral anatomy. For the same AP dimension, female distal femurs are more than 5mm narrower. Also the angle formed between the anterior condyles and the posterior condyles are significantly different with the female being more trapezoidal in shape.

Most existing total knee femoral component designs follow the ratio similar to that found in the average male distal femur. Options for management of this gender variability have been either utilizing instrumentation that references the anterior cortex to avoid notching or placing additional flexion on the distal femoral cut to allow downsizing. Both techniques are potentially problematic. Total knee implants systems are now utilizing this anthropomorphic data to redesign for separate male and female femoral components taking into consideration the relatively narrower female distal condylar width, lower medial anterior femoral condyle, and greater patellofemoral Q-angle.


A. Martin M. Gamal El Amir M. Prenn C. Oelsch A. von Strempel

Introduction: Existing data in the literature is supporting either patellar retention or patellar resurfacing during primary TKA. There is no clear answer for the question in which cases the patella should be retained or resurfaced during primary TKA.

Materials and Methods: In this prospective study 2 groups of patients with a mean follow up of 34 months after TKA were compared. 83 patients (98 TKA) were implanted with a TKA with patellar retention (group 1) while 93 TKA (86 patients) were done including a patellar resurfacing (group 2). The patients were randomized according to the year of birth. The NexGen® MBK and the LPS were implanted. A dome shaped patellar prosthesis with 3 pegs was used for patellar resurfacing. Clinical Outcomes were based on the knee society score parameters, anterior knee pain, patient satisfaction, feeling of instability, step test while component position and limb alignment were measured by standard radiographs.

Results: No statistical differences between both groups with regard to post-operative anterior knee pain and knee society score were found. We found no pre-operative predictor factors for the development of post-operative anterior knee pain for each group and both together. Patellar maltracking was worse in group 1 than in the resurfaced group (3 cases with patellar subluxation in group 1 versus 2 cases in group 2).

Conclusion: According to the not significant differences for the clinical outcomes between group 1 and 2 we routinely retain the patella. Patellar resurfacing is done only in selective cases.


V.D. Shetty S.K. Krishnamurthy S.L. Vowler A.E. Halliday

Background: Pathological medial plica is known to cause anteromedial knee pain. However, clinical diagnosis of pathological medial plica is poorly defined in the literature and therefore, arthroscopic diagnosis remains gold standard. We report a system of clinical diagnosis based on the criteria set by us for these painful conditions of the knee.

Methods: We prospectively studied forty-eight symptomatic patients (sixty-six knees) with clinical suspicion of pathological medial plica based on five “essential” and four “desirable” criteria set by us. All patients were subjected to arthroscopic examination, to confirm or disprove our clinical diagnosis and, for treatment.

Results: Arthroscopic examination confirmed our clinical diagnosis of medial plicae in forty-four (sixty-two knees) of these patients showing a diagnostic accuracy of 91.7% (95% confidence interval: 80.0%, 97.7%), sensitivity of 100% (95% CI: 92.0%, 100.0%) with our method. Those with pathological medial plicae at arthroscopy (forty-four patients; sixty-two knees), were treated by arthroscopic resection. Thirty-nine patients (fifty-five knees) showed satisfactory outcome (95% CI: 75.4%, 96.2%) after arthroscopy.

Conclusions: We believe that our method of clinical diagnosis of pathological medial plica is simple, non-invasive, economic and reliable. Symptomatic medial plica can be successfully treated by arthroscopy. This study has changed our clinical practice and also allowed us to decrease substantially the cost of diagnostic imaging.


J. Parvizi E. Smith S. Grossman L. Pulido R.H. Rothman

Introduction: Pulmonary embolism (PE) is a potentially fatal complication of total joint arthroplasty (TJA). Therefore, reliable means for diagnosis and evaluation of severity is essential. This study evaluates the reliability of common clinical signs and symptoms in the diagnosis of PE. In addition, clinical presentation is correlated with size and location of emboli within the pulmonary vasculature (segmental, lobar, or main).

Methods: The clinical and imaging records of all patients with confirmed diagnosis of PE following TJA performed between 2000 and 2004 were reviewed in detail. The mode of presentation and the subsequent imaging findings were noted.

Results: A total of 132 confirmed PE cases were studied. Clinical presentation included dyspnea (19.7%), chest pain (7.6%), change of mental status (6.8%0, hypotension (6.1%), and diaphoresis (3.8%). Mean room air pulse-oximetry was 85.5%. Arterial sampling showed mean O2 saturation of 88.1% and pO2 of 58.7. There was not a direct correlation between the size of the PE and the clinical presentation. However, there was a correlation between the severity of oxygen desaturation and the size and location of the embolus.

Conclusions: The presentation of PE can be non-specific and highly variable ranging from mild dyspnea to catastrophic hemodynamic collapse. Common clinical signs have a low sensitivity for diagnosis and do not correlate with severity of disease. The only correlation seemed to be measured arterial O2 saturation and pressure. Thresholds for the diagnosis of clinically significant pulmonary embolisms need to be established to improve management of this important condition.


F.G. Harrison F. Orozco J. Parvizi J.J. Purtill R.H. Rothman

Introduction: The use of coumadin for prophylaxis against thromboembolism (TE) following total joint arthroplasty is the standard of care. In light of recent publication of the American College of Chest Physicians (ACCP), we altered our anticoagulation protocol to be compliant with the recommendations. This study evaluates the incidence of TE and bleeding complications following TJA when low dose coumadin vs. regular dose coumadin was administered.

Methods: 987 consecutive patients undergoing total joint arthroplasty by a single surgeon between the years of 2004–2005 were included. 446 patients operated on during the 2004 received low dose coumadin (intended INR 1.5–1.7) whilst 541 patients undergoing TJA during 2005 were given regular dose coumadin (intended INR 2–2.5).

Results: The mean INR for patients operated during the year 2005 was significantly higher than the INR for patients receiving TJA in 2004. There were more complications in 2005. There were 13 PE, 44 wound drainage, 4 DVT, and 11 hematoma formation (requiring surgical evacuation) during the year 2005 compared to 10 PE, 26 wound drainage, 6 DVT, and 5 hematoma formation in 2004. The difference for all complications except DVT was significant.

Conclusion: This study confirms the commonly held belief that aggressive anticoagulation does carry a higher incidence of complications such as wound drainage and bleeding. It appears that administering higher dose coumadin increased the bleeding complications without conferring additional protection against thromboembolic disease.


K.S. Anagnostidis G. Ioannidis I.K. Sarris A. Giannakou A. Pavlitou G.A. Kapetanos

Introduction: The use of polymethylmethacrylate (PMMA) bone cement loaded with antibiotics has become increasingly common in the treatment of infected knee and hip arthroplasties and also as prophylaxis in primary joint replacement. However bacterial resistance in antibiotics is an increasing and emerging problem. PMMA bone cements containing different antibiotics, such as gentamicin plus vancomycin may be effective in prevention and treatment of infections (particularly from MRSA and MRSE). The purpose of this study was to determine the in vitro elution characteristics of gentamicin and van-comycin when combined in acrylic cement.

Material and methods: Three groups of six cement disks were prepared. Group I (control group) contained 0.5g of gentamicin sulphate per 40-g packet of Palacos-R+G powder. Group II contained 0.5g of gentamicin sulphate and 1g of finely powdered vancomycin and Group III contained 0.5g of gentamicin sulphate and aqueous solution of vancomycin (containing 2mL water for injection and 1g vancomycin). All discs were prepared using vacuum mixing technique. Each cement disc (25mm diameter × 20mm thick) was fully immersed in a 50-mL bath of normal saline at 37o C temperature in a covered beaker. At specific sampling intervals (1, 3, 7, 15, 30, 60, 90, 120, 150, 180 days) the discs were removed and placed in fresh 50 ml bath for 24 hours. Then a 2 mL sample of each solution was taken. Samples were frozen at −60° C until they were analyzed. Gentamicin and vancomycin concentrations were measured using fluorescence polarization immunoassay.

Results: With regards to gentamicin release, high but rapidly decreasing antibiotic levels were detected within the first week, resulting in an almost steadily low concentration by the end of the first month. Cement samples eluted significantly more gentamicin (120%-20% during the first month) when powdered vancomycin (Group II) was added. The influence on the gentamicin release was significant but minor when aqueous solution of vancomycin (Group III) was added (40%-20% during the same period).

With regards to vancomycin release, high antibiotic levels were detected within the first 3 days and low concentrations after the first week. Cement samples from Group II eluted significantly more antibiotic (80%–100%) in comparison with samples from Group III during the first days.

Gentamicin and vancomycin are detectable in measurements at 150 and 180 days samples.

Conclusions: Bone cements loaded with combinations of gentamicin and vancomycin are more effective in releasing gentamicin than bone cements with gentamicin as a single drug. The presence of powdered vancomycin in cement samples has major influence on the total gen-tamicin release in comparison with cements containing aqueous solution of vancomycin.


G. Shah S. shah G. Singer O. Ghazanfar

Introduction: Serum inflammatory markers are routinely used as pre assessment investigation before the revision hip surgery. Various investigations are used to aid in diagnosis of infection in the revision prosthetic hip replacement including aspiration, broad range PCR, bone scan and serum interleukin- 6.

Materials and Methods: 256 consecutive revision total hip replacements were assessed for the value of pre operative ESR and c-reactive proteins (CRP) in predicting the deep infections.

All patients were evaluated prior to surgery. The patients with coexisting inflammatory disease or peri-prosthetic fracture were also evaluated.

A hip was diagnosed as infected on the basis of positive intra operative microbiology samples three or more out of five and or histological evidence.

Results: Using the values of ESR > 35 mm/1st hour and CRP> 10mg/l, the positive predictive value (either/or) was 56% and the negative predictive value was 96%.

14 patients had an underlying inflammatory arthritis and 5 were peri prosthetic fractures. The inflammatory markers tended to be elevated in these patients. Excluding these 19 patients and using the same criteria, the positive predictive value was 65% and the negative predictive value was 97%

Discussion: We conclude that a CRP< 10 mg/l and ESR < 35 mm/1st hour are very useful in excluding infection(negative predictive value of 97%, excluding peri-prosthetic fractures and inflammatory joint disease). But raised inflammatory markers are less accurate in predicting infection.


A.A. Kurth O.E. Dahl C.N. van Dijk B.I. Eriksson S.P. Frostick N. Rosencher J. Schnee A.V. Christiansen H.R. Büller

BACKGROUND: Oral DVT prophylaxis not requiring monitoring is an advantage in orthopaedic patients. Dabigatran etexilate is an oral direct thrombin inhibitor undergoing evaluation for the prevention of venous thromboembolic events (VTE) following orthopaedic surgery.

METHODS: In a phase III, multicenter, non-inferiority, double-blind study, patients undergoing total knee replacement were randomized to 3 treatments. The patients received 8±2 days of oral dabigatran etexilate, 150 or 220 mg once daily starting with a half dose (i.e.75 or 110 mg) 1–4 hours after surgery, or subcutaneous enoxaparin 40 mg once daily starting 12 hours prior to surgery. The primary efficacy outcome was the composite of total VTE and all causes of mortality during the treatment period. All efficacy and safety outcome events were adjudicated by blinded independent committees.

RESULTS: Efficacy could be evaluated for 1541 (75%) treated and operated patients. Total VTE and death occurred in 40.5%, 36.4% and 37.7% of patients assigned to dabigatran etexilate 150 or 220mg once daily or enoxaparin, respectively. Proximal DVT and/ or PE occurred in 3.8%, 2.6% and 3.5% of patients receiving dabigatran 150 or 220mg or enoxaparin, respectively. Three deaths occurred during the treatment period, one in each of the treatment groups. Safety was evaluated for all 2076 patients receiving study treatment. The rate of major bleeding was 1.3%, 1.5% and 1.3% of patients receiving dabigatran 150 or 220mg or enoxaparin. Elevated LFTs (ALT > 3xULN) occurred in 3.7%, 2.8% and 4.0% of the patients treated with 150 and 220 mg dabigatran or enoxaparin during the study. A temporary rise in LFTs was observed during the follow-up period in 0.5% of the patients who had received dabigatran and in 0.4% of the patients who had received enoxaparin.

CONCLUSIONS: Non-inferiority for the primary efficacy endpoint was met for both doses of dabigatran etexilate compared to enoxaparin. There was no difference in bleeding rates between the treatment groups. Oral administration of dabigatran etexilate once daily, given early in the postoperative period, was effective and safe for the prevention of total VTE in patients undergoing total knee replacement surgery.


S. THOMAS M. VAN KAMPEN

Aim: This study was undertaken to assess the incidents of Deep Vein Thrombosis (DVT) and/or Pulmonary Embolus (PE) in orthopaedics outpatients who were immobilised in lower limb casts.

Materials and Methods: We retrospectively analysed the incidents of DVT/PE in a district general hospital over a one year period in orthopaedic outpatients who had their lower limb immobilised. Only patients who were no already on anti-coagulants were included and patients with co-morbidity associated with a higher risk of thrombosis were excluded. The diagnosis of DVT was made by ultrasound scan and PE confirmed with a CT pulmonary angiogram. The details of patients who were found to have a clot were cross checked with the outpatient plaster room register. The relevant case notes were then studied.

Results: There were three hundred and eighty patients who had lower limb casts, six of whom developed a blood clot during the period of immobilisation. All patients were male -and four patients presented with a DVT and two patients presented with a pulmonary embolism, all patients survived.

There were two smokers and one patient was very overweight.

Discussion: Incidents of DVT among patients with lower limb casts are low. At present there is no guideline on the use of DVT prophylaxis in orthopaedic outpatients. Our results show that even though the number of proven DVTs is low, the potential of developing a fatal pulmonary embolus in these patients is present.

Conclusion: DVT prophylaxis could be considered for orthopaedic outpatients who are treated with lower limb casts and who have additional risk factors. A larger prospective survey is required before guidelines regarding prophylaxis can be drawn up.


A. Rafee C. Rajasekhar Z. Saeed A. Jalgaoankar S. Shah A. Paul

Background: The standard diagnostic approach in patients suspected of having pulmonary embolism starts with D-dimer and perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography will perform.

Aims: This study evaluates the effectiveness of D-dimer as a screening tool for Pulmonary Embolism (PE) and to determine the accuracy and potential clinical utility of VQ scan in the diagnosis of pulmonary embolism in orthopaedic trauma patient.

Methods: We retrospectively reviewed 757 consecutive trauma admissions involving lower extremity and spinal injuries over 12 months and identified 20 patients with symptoms mimicking PE, without typical clinical symptoms, which underwent rotten investigations for PE (ABG, Blood test, D dimer, Chest X-ray and VQ scan).

Plasma D-dimer levels were measured as a prerequisite test in all patients before undergoing VQ scan to confirm the absence of PE. All patients had either mechanical, such as foot pumps, or chemical DVT prophylaxis.

Results: The mean age was 65 (ranging from 45–88) years, there were 11 female and 9 male. D-dimer levels in the postoperative or post traumatic period were elevated. Mean value was 3.63 (sd=2.72, range 0.60–14.34), Comparing D-dimer levels between those treated operatively (14 patients) and those treated conservatively (6 patients) we found that both groups displayed the same trend; however levels were higher following surgery.

The classical triad of dyspnoea, pleuritic chest pain and haemoptysis occurred in only 2 patients. Signs of DVT were present in 3 patients. The electrocardiographs were normal in only 4 patients, though changes particularly suggestive of PE (S1Q3T3, Right bundle branch block or right heart strains) were absent in all of the patients. Chest X-ray changes were of limited value. None showed any of the supposedly characteristic changes.

All of the patients had a VQ scan were started on chemical treatment for PE and non of them had definite PE, 12 the patients had probable PE Those patient with probable scan were not subsequently given anticoagulants owing to their medical conditions

Conclusion: The D-dimer level is never normal (< 0.5mg/l), following total trauma, and so cannot exclude a DVT or PE. The level it raises to is indistinguishable form that seen in the population with a PE and so cannot identify those patients in whom further investigation is warranted. VQ scan is not a definitive diagnosis we should rely more and more on a CT Angiography scan for the diagnosis of PE in this group of patients. This should be organised by medical team, especially with shortening of training time, to avoid wasting of resources and time which are of paramount. Requesting a D-dimer test in this population wastes time and resources and is of no benefit


K.S. Anagnostidis N. Michailidis G. Mesomeris J.M. Kirkos K.D. Bouzakis G.A. Kapetanos

Introduction: Infections with multiresistant bacteria have become a serious problem in joint arthroplasty. Vancomycin and teicoplanin showed high effectiveness against multiresistant bacteria as methicillin-resistant S.epidermidis (MRSE) and methicillin-resistant S.aureus (MRSA).

Objective: The purpose of the present study was to determine the mechanical properties of Palacos R+G cement (containing gentamicin) mixed with:

i) powdered vancomycin or teicoplanin,

ii) aqueous solution of vancomycin or teicoplanin.

Material and methods: Five groups of ten cements specimens were prepared. Group I (control group) consisting of Palacos-R+G cement samples (contained 0.5g of gentamicin sulphate). Group II consisting of Palacos-R+G cement mixed with 1g of finely powdered vancomycin. Group III contained 400mg powdered teicoplanin. Group IV cement samples contained aqueous solution of vancomycin (2mL water for injection plus 1g vancomycin) and Group V contained aqueous solution of teicoplanin (2mL water for injection plus 400mg teicoplanin). All cement specimens were prepared using vacuum mixing technique. In order to examine the mechanical properties of the specimens (25mm diameter × 20mm height), impact and compression tests were applied. The impact test is a well-established method for the characterization of materials’ fatigue properties, as well as of creep behavior determination in case of porous materials. The size of the produced impression after a certain number of impacts reveals the material strength. Furthermore, the compression resistance, i.e. the Young’s modulus and the yield strength are properties that can be calculated by the compression tests.

Results: The compression tests showed that the specimens from Group III (containing 400mg of teicoplanin) had overall better mechanical properties, having approximately 10% higher Young’s modulus in comparison with specimens from Group II (containing van-comycin) and specimens from Group III (control group). Yield strength had no significant difference between the three groups. The impact test revealed a corresponding tendency, with the specimens containing 400mg of teicoplanin having the smaller impression (increased fatigue strength) when compared with specimens from the other groups.

With regards to samples from Groups IV and V (aqueous solutions of antibiotics) mechanical properties were significant deteriorated in comparison with cement samples from the other groups.

Conclusions: The experimental data showed that the addition of 400mg teicoplanin in Palacos R+G bone cement had better mechanical properties compared with addition of 1g vancomycin or than Palacos R+G cement with gentamicin as a single drug.

Aqueous solutions of antibiotics must not be added to the bone cement because they dramatically impair mechanical properties of the cement.


K. Anagnostakos P. Hitzler D. Pape D. Kohn J. Kelm

Implantation of antibiotic-loaded beads is accepted as an efficient option for local antibiotic therapy in orthopedic-related infections. However, recent reports have emphasized the bacteria growth persistence on antibiotic-impregnated bone cement. Hence, the aim of this study was to elaborate if bacterial adherence and growth could be determined on explanted gentamicin- and gentamicin-vancomycin-loaded beads after infection eradication. 18 chains of antibiotic-loaded beads (11 gentamicin-, 7 gentamicin-vancomycin-loaded) were examined. Indications for primary beads implantation included postoperative infections after total hip or knee arthroplasty, rotator cuff reconstruction, chronic foot osteomyelitis, anterior cruciate ligament reconstruction and dorsal spondylodesis. Among the isolated organisms, Staphylococcus epidermidis, Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent ones. In 4 cases (3 × S. epidermidis, 1 × MRSA) bacteria growth persistence could be determined on the beads. S. epidermidis-strains persisted only on gentamicin-loaded beads, MRSA could grow on gentamicin-vancomycin-impregnated cement. In one case, the emergence of a gentamicin-resistant S. epidermidis-strain could be observed despite preoperative susceptibility. Bacteria growth persistence on bone cement is a hazardous problem in the orthopedic surgery and should therefore be born in mind. Adherence to cement can lead to emergence of bacteria resistance despite preoperative antibiotic susceptibility and might result in clinical recurrence of infection.


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S. Al-Nammari N. Bejjanki J.D. Lucas K.S. Lam

Introduction: MRSA spondylodiscitis is an increasingly common phenomenon. Despite this there is very little reported on it.

Objectives: Our objective was to present relevant demographics, clinical presentations and outcomes for this condition from our institution.

Methods: We performed a retrospective review of patients presenting over a six year period from 2000 to 2005.

Results: 13 cases were identified. The mean age was 65 years (range 36–92), 85% were male. All cases presented with back pain, spinal tenderness and systemic upset. Neurological deficit was present initially in 38% and a further 8% developed neurological deterioration during treatment. The thoracic spine (53%) was most commonly affected followed by the lumbar (33%), thoracolumbar junction (7%) and cervical spine (7%); 16% of cases were multilevel. The WCC, ESR and CRP were elevated in all cases with means of 17.3 ×10-9/L, 102 mm/hr and 236 mg/L respectively. In cases cured of infection, the WCC, ESR and CRP normalised at a mean of 10 weeks, 14 weeks and 19 weeks respectively. Radiological diagnosis was established with MRI in all cases. The most common risk factors were diabetes mellitus (62%), mal-nourishment (54%), cirrhosis (31%), end stage renal failure (15%) and intravenous drug use (15%). Multiple risk factors were present in 76% of cases and 15% had no identifiable risk factors. The main sources of sepsis were intravenous catheters (23%), urinary tract (15%) and intravenous drug use (15%). In cases cured of infection treatment consisted of intravenous vancomycin mono-therapy for a mean period of four weeks followed by oral combination or monotherapy antimicrobials for a mean period of 8 weeks. Operative intervention was required in 38% of cases. At six months 54% of cases were clinically free of infection, 38% had died and 8% required ongoing treatment. Neurological deficit was present in 50% of survivors. At one year 29% of survivors suffered from MRSA bacteraemia and spondylodiscitis recurrence.

Conclusion: This is a devastating condition. Clinical suspicion should remain high and prompt diagnosis and treatment is essential.


A.K. bhadra S.P. Krishnan S. Young N. Chaya R.W. Carrington D. Goldhill T.W. Briggs J.A. Skinner

Introduction: Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. We performed two separate studies:

1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion

2) prospective study to analyse the influence of perioperative haemoglobin concentration (Hb) on post-operative fatigue, hand grip strength, duration of in-patient physiotherapy and post-operative morbidity score (POMS) and also the prognostic factors to predict functional recovery.

Method: 500 orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty.

200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.

Results: In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below Hb of 8g/dL. Mean transfusion threshold in surgeons was 8.3g/dL compared to 7.9g/dL for anaesthetists (p< 0.01). 97% of surgeons transfused two or more units compared to 78% anaesthetists (p< 0.01). This threshold Hb increased if patient was symptomatic (surgeons 9.3g/dL, anaesthetists 8.8g/dL, p< 0.05), or if known to have pre-existing ischaemic heart disease (surgeons 9.0g/dL, anaesthetists 9.2g/dL, p< 0.05).

A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).

A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20).

A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).

Conclusion: Haemoglobin level below 9g/dL is the most common ‘trigger’ for blood transfusion. Surgeons tend to be more aggressive in their attitude to transfusion. A fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty.


D. Varoga S. Lippross C. Wruck R. Mentlein T. Pufe

Introduction: Osteomyelitis often causes functional impairment due to tissue destruction and the incidence of this condition appears to be increasing. Antimicrobial peptides (AP) are effectors of the innate defence system and play a key role in host protection at cellular surfaces. Human beta-defensins (HBD) represent a major subclass of antimicrobial peptides and act as a first line defence through their broad spectrum of potent antimicrobial activity (1). The aim of the present in vitro and in vivo investigations was to study the expression and regulation of HBD-2 and -3 in the case of bacterial bone infection and to analyze the effects of immunosuppressive drugs on bone-derived AP-expression.

Methods: Samples of healthy human bone, osteomyelitic bone and cultured osteoblasts (primary-, hFOB- and SAOS-2 cells) were assessed for the expression of HBD-2/-3 by RT-PCR, immunohistochemistry or ELISA. Regulation of HBD-2/-3 was studied after exposure to Staphylococcus aureus (SAS) or Pseudomonas aeruginosa (PAS), proinflammatory cytokines (IL-1, 10ng/ml) and immunosuppressive drugs (glucocorticoids, methotrexate) and was assayed by ELISA. An osteomyelitis mouse model was performed to demonstrate the regulation of the murine homologues of HBD-2/-3 by real time RT-PCR and immunohistochemistry.

Results: ELISA experiments demonstrated, that samples of infected bone produce higher levels of endogenous antibiotics such as HBD-2 when compared with samples of healthy bone. After exposure of osteoblasts to bacteria or proinflammatory cytokines a clear HBD-2/-3 induction was observed. Additional treatment with glucocorticoids or methotrexate prevented bacteria mediated HBD-2 induction in cultured osteoblasts. The osteomyelitis mouse model demonstrated transcriptional up-regulation of the murine HBD-homologues in bone after intra-osseous contamination of the tibia.

Discussion: Our study firstly demonstrate that osteoblasts are able to produce anti-inflammatory peptides such as HBD-2 in vitro and in an animal model of staphylococcal osteomyelitis. We provide evidence for a new role of osteoblasts during infection of bone tissues, namely, the ability to produce antimicrobial peptides and modulating immune responses in inflammatory bone diseases.

Immunosuppressive drugs such as glucocorticoids or methotrexate may increase the susceptibility to bone infection by decreasing AP-expression levels in case of microbial challenge. Novel approaches to management are required particularly in the era of multi-resistant bacterial strains. Current investigation will focus on the regulation of human β-Defensins in bone and may allow artificial amplification for prevention of bacterial bone infection in the future.


H.J. van der Heide P.R. van der Kraan W.J. Rijnberg P. Buma W. Schreurs

Introduction : The reason why heterotopic ossification develops after total hip arthroplasty is still not known, but it is assumed that inflammatory reaction is the major driving force. In literature little is known about the cytokine levels at the site of surgery, most measurements are done in serum. This study was conducted to investigate if the levels of different pro- en anti-inflammatory cytokines are measurable in drainage fluid and, when measurable, whether we can find a difference in cytokine concentration between one and six hours postoperatively.

Materials and methods: Samples from the drainage system in 30 consecutive patients undergoing primairy total hip replacement were collected at one and six hours after closure of the wound. GM-CSF, G-CSF, IFN-γ, TNF, MCP-1, IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13 and MIP-1beta levels were measured in the drainage fluids.

Results: Measurable levels of all cytokines studied were found, except for IL-17. A significant elevation of almost all cytokines was observed between the sample after one hour and six hours postoperatively. The elevation was significant for all cytokines except IL-10 and MIP-1b. We found a strong correlation between the different pro-inflammatory cytokines. Levels are much higher than previously shown levels in serum. When computing the IL-6 to IL-10 ratio, this ratio increased from 304 (SD 256) to 12357 (SD 6788) (p< 0,000), which shows an increased predominance of the pro-inflammatory interleukines when comparing the measurements after one and six hours respectively.

Conclusion: Detectable levels of numerous cytokines can be measured in drainage fluid post-operatively. The levels of most cytokines in drainage fluid are higher in samples taken six hours after surgery as compared to samples taken after one hour. Further studies are needed to detect the relation between these cytokine concentrations and the heterotopic bone formation.


O.E. Dahl B.I. Eriksson M. Homering L. Borris W.D. Fisher A.K. Kakkar L.M. Kwong A.G. Turpie

Rivaroxaban is an oral, direct Factor Xa inhibitor in clinical development for the prevention of VTE after major orthopaedic surgery. Data from three phase II trials of twice-daily (bid) rivaroxaban in patients undergoing elective, total hip or knee replacement were pooled to determine whether age, gender or weight affected the efficacy or safety of rivaroxaban, and thus whether dose adjustment would be necessary. Patients received 5–9 days of oral rivaroxaban (2.5–30 mg bid, post-operatively), or s.c. enoxaparin. A logistic regression model using total daily dose of rivaroxaban as a covariate, and adjusted for differences between dose groups with respect to study, age and gender, was used to estimate rates of the primary efficacy endpoint (DVT, PE or all-cause mortality; n=1380 intention-to-treat patients) and clinically relevant bleeding (major and non-major clinically relevant bleeding; safety population, n=1854). Rivaroxaban at total daily doses of 5–20 mg had similar efficacy and safety to enoxaparin. Overall, logistic regression showed a positive dose–response relationship with rivaroxaban for clinically relevant bleeding (p< 0.001), and a flat relationship for the primary efficacy endpoint (p=0.115). The risk of VTE increased with age – the efficacy endpoint was estimated to occur in 17.3–9.4%, 18.7–17.3% and 26.6–20.2% of patients aged < 60 yrs, 60–70 yrs and > 70 yrs receiving rivaroxaban (total daily dose 5–60 mg), respectively, in separate regression models. Age was also prognostic for clinically relevant bleeding with rates of 1.4–12.0% (< 60 yrs), 2.7–15.4% (60–70 yrs) and 5.7–15.4% (> 70 yrs). The rates are for a population distributed equally across the studies and genders. Incidences of the efficacy endpoint were higher in females (25.8–20.5%) than males (16.6–10.7%), while clinically relevant bleeding occurred more frequently in males (5.4–16.3%) than in females (1.7–11.6%), after adjustment for age. Weight was not prognostic for the efficacy endpoint or clinically relevant bleeding (p=0.87 and p=0.48, respectively, after adjustment for age, gender and study), nor did it modify the dose–response relationships with rivaroxaban. Incidences of the efficacy endpoint for a population of equal study and gender distribution and of mean patient age were 23.4–15.7% and 19.1–14.6% in patients weighing < 65 kg and ≥90 kg, respectively, with corresponding bleeding rates of 3.3–16.5% and 3.2–17.5%. This analysis indicates that age, gender or weight did not affect the dose–response relationships (or lack thereof) between rivaroxaban and the primary efficacy endpoint or clinically relevant bleeding. As expected, age was prognostic for VTE and bleeding. These findings suggest that rivaroxaban may not require dose adjustment for age, gender or weight in orthopaedic patients.


C. Ryge M.R. Lassen S. Solgaard S. Sonne-Holm

Background: Data on thromboembolic complications (TEC) following major orthopaedic surgery are generally obtained retrospectively from registries or prospectively from large industry-sponsored international multicentre trials. However, the results may differ from those observed in unselected patients in routine operations performed by orthopaedic surgeons. The purpose of the ESMOS study was to describe the number and time of onset of serious symptomatic arterial and venous TEC within 90 days after surgery in an unselected population of patients undergoing total hip replacement (THR).

Patients and methods: A total of 500 (430 primary THR and 70 revision THR) consecutive patients were included in the study performed between January 2004 and May 2005 in Frederiksborg County (Denmark). They were to be followed for 90 days after surgery. Patients were interviewed before surgery for medical history and on days 5 (while in hospital) and 90 (by telephone call) for signs and symptoms of acute myocardial infarction (AMI), pulmonary embolism (PE), deep-vein thrombosis (DVT), transitory cerebral ischemia (TCI)/stroke and retinal vein thrombosis (RVT). The validity of the events was confirmed using files from hospital, general practitioner and international criteria.

Results: Overall, 498 patients were followed-up for 90 days, 2 patients having withdrawn consent. In-hospital pharmacological thromboprophylaxis was performed in 499 patients. Twenty-four patients (4.8%) experienced at least one serious TEC up to day 90: 2 (0.4%) patients died from surgical-related complications (no autopsy was performed); 1 (0.2%) patient experienced AMI, 5 (1.0%) had PE, 10 (2.0%) DVT, 4 (0.8%) TCI, and 2 (0.4%) RVT. Moreover, 2 patients experienced two TEC: AMI followed by TCI in a first patient, PE and TCI in a second patient. The first event occurred up to day 5 in 9 patients (38%) and after day 5 in 15 patients (62%). Five patients (1%) had clinically relevant bleeding complications: 3 patients had a single, minor, upper gastrointestinal bleeding episode while in hospital, one patient developed a huge expanding haematoma at the operation site treated with hip spica and another patient a peritoneal haematoma leading to re-operation.

Conclusion: This study performed in an unselected population clearly shows that THR still results in serious TEC in spite of a wide use of modern anaesthesia techniques, thrombosis prophylaxis and early mobilisation. In the future, we need to better identify at-risk patients in order to optimise their management, in particular post-discharge care, and reduce the risk of serious TEC.


S.W. Young R. Pitto

Recently, the International Consensus Statement Group reported that mechanical prophylaxis with foot-pumps should be considered “Grade A” recommendation for prevention of deep-vein thrombosis after total hip replacement. Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent duplex ultrasound studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance.

846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novame-dix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone.

Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05).

In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance.


J.R. Eyre R. Jeavons T. Branfoot M. Dennison S. Royston S. Britten

Aims: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: Between 2000 and 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected – ex-fix type, whether revision was necessary, reasons for revision.

Results:

97 grade III open fractures in 95 patients

64 required temporary spanning ex-fix: 23 applied at trauma centre/41 at DGH

14/64 ex-fixes required revision (prior to definitive Ilizarov): poor plastics access(6)/instability(2)/both(6)

All 14 revised had been applied in a DGH, i.e. 14/41 DGH ex-fix needed revision (34%)

Ex fixes revised after application at trauma centre vs. DGH = 0/23 vs. 14/41, p< 0.01 ×2

Revision of Hoffman hybrid vs. monolateral ex fix = 4/4 vs. 10/60 p< 0.001 ×2

Non modular system (Orthofix) vs. modular systems (Hoffman II/AO) = 7/17 vs. 0/39 p< 0.001

Discussion: Recently Naique and Pearse showed a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems such as Hoffman II and AO required no revision, irrespective of whether they were applied at trauma centre or DGH.

All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.

Conclusion: We recommend modular external fixation systems such as Hoffman II or AO if problems of temporary external fixation of open tibial fractures are to be avoided. Hybrid temporary external fixation should be abandoned as temporary fixation in such an injury


R. Abad S. Bermejo S. Sanchez J. Garcia P. Hinarejos L. Puig

Background and goal of study: Although a great percentage of the total postoperative bleeding corresponds to a hidden blood loss in the tissues and joint, visible blood from the drainage is considered the gold standard for monitoring blood loss after a knee arthroplasty. Only one study was not able to find a consistent relationship between the total blood loss and postoperative drained blood. The aim of our study was to assess the usefulness of a postoperative drainage as a monitor of bleeding following a knee arthroplasty.

Material and methods: Fifty patients undergoing unilateral arthroplasty from March to November 2004, were prospectively followed until the fourth postoperative day. Drained red blood cells(RBC) loss was assessed by multiplying the drained blood volume by an haematocrit (Hct) of 30% from a pilot study. Total RBC loss and hidden RBC loss from each patient were calculated. Regression analysis was performed to assess the relationship between the total RBC loss and drained RBC loss.

Results and discussions: The average age of the fifty ASA 2 patients was 72 +− 7 years. Nearly all the procedures were performed under intradural anaesthesia. Cemented technique and tourniquet were used in all cases. The mean total RBC loss was 615 +−197ml. The mean drained RBC loss was 206+− 113ml, and mean hidden RBC loss was 414 +−194ml. Thus the hidden loss was 67% of the total blood loss. Regression analysis shown a poor correlation coefficient between the total RBC loss and drained RBC loss (r= 0.31, p< 0.03).


F. Yao M. Zheng A. Farrugia C. Seed M. Benkovich L. Ireland V. Winship J. Winter D. Wood

Introduction: There are no current estimates of the risk of transmission of HIV, HBV, HCV, or HTLV by musculoskeletal tissue transplantation. Such accurate data would be helpful to determine the effectiveness of current and proposed screening and processing procedures, and contribute to increased confidence in the use of musculoskeletal tissue products.

Methods: The prevalence rates of HIV, HBV, HCV, and HTLV were determined from 12.245 musculoskeletal tissue donors from three bone tissue banks across Australia from the period 1993 to 2004. The incidence rates among tissue donors were estimated by comparing the data with age-specific incidence rates of first-time blood donors. We estimated the probability of a tissue donor was within the window period when infection was undetected by serological screening procedures by the modified incidence-window period model. Further we calculated the projected probability of viremia with the addition of nucleic-acid amplification testing (NAT).

Results: The prevalence (per 100,000 persons) of confirmed positive tests among musculoskeletal tissue donors was 169.15 for HIV, 427.68 for HBV, 534.63 for HCV, and 121.66 for HTLV. This is greater than the prevalence among first-time blood donors during the same period (6.47 for HIV, 136.00 for HBV, 215.29 for HCV, and 3.46 for HTLV). The incidence rate among musculoskeletal donors were estimated to be 15.81, 0.68, 3.53, and 4.85 per 100,000 person-years, respectively. The estimated probability of viremia (per 100,000 persons) at the time of donation was 1.38 for HIV, 0.46 for HBV, 1.82 for HCV, and 0.85 for HTLV. These estimations would be even lower with the addition of NAT – 0.57, 0.23, and 0.20 respectively.

Conclusions: The prevalence and incidence of HIV, HBV, HCV, and HTLV among musculoskeletal tissue donors, although low are significantly higher than those of first-time blood donors. Current screening and processing measures are effective, though the probability of viremia can be reduced further by nucleic-acid amplification testing.


H.D. Bhansali D. Hughes B. Purbach P. Kay

Introduction: There is an increasing trend for autologous blood transfusion in hip and knee replacement and we therefore felt the need to properties of the fluid reinfused.

Objectives of the study: The study objective was to determine the volume and Haemoglobin content of the reinfused blood.

Materials and methods: We prospectively studied 108 patients with primary Hip and knee arthroplasty. The drained blood was reinfused within 6 hours as recommended by the manufacturer. The volume of the drained and reinfused fluid was measured in millilitres.. The Haemoglobin (Hb.) of the patient was measured preoperatively and postoperatively in recovery. The Hb. of the drained blood and reinfused blood were also measured.

Results : The mean volume of the drained blood in the hip replacement group was 180.6 ml. while that of the reinfused blood was 132.7 ml. The mean volume of the drained blood in the knee group was 372.78 ml. while that of the reinfused blood was 362.76 ml.

The mean Haemoglobin of the reinfused blood in the hip group was 6.9 gm/dl significantly lower (p< 0.05) than the drained blood Hb. of 10.9. Similarly the Haemoglobin of the blood reinfused in knee replacements was significantly lower at 6.8 gm/dl. (p< 0.001). This was less than half of the average Hb. content of homologous blood transfusion.

Conclusion: The Haemoglobin content of the reinfused blood in Hip and knee replacement was quite low to be considered as a replacement for homologous blood transfusion and further studies may be required to confirm the efficacy of reinfusion drainage compared to homologous blood transfusion.


A. Mourikis E. Tsiridis P. Baltopoulos N. Papaioannou

Tourniquet induced ischemia-reperfusion syndrome (IRS) may trigger systemic inflammatory response following a total knee arthroplasty. The IRS will be studied in a prospective randomized controlled study in humans undergoing total knee arthroplasty, by measuring blood inflammatory mediators and blood gases.

Materials and Methods: Forty four (n=44) patients (female/male: 35/9 male) with a mean age of 72 years, undergoing primary total knee arthroplasty for osteoarthritis, were prospectively randomized in two groups. 22 patients operated with tourniquet [tourniquet group (TG)] and 22 patients operated without a tourniquet [non-tourniquet group (NTG)]. The mean overall ischemia time was 90 minutes. Arterial and venous blood samples were collected preoperatively, and at 1, 2, 3, 6, 24, 48 hours postoperatively. The pro-inflammatory (IL-1b, IL-6) and anti-inflammatory cytokines (IL-10) as well as the adhesion molecules (ICAM, VCAM), the CRP and blood counts were measured and correlated with the blood gases.

Results: Patients in TG had higher cytokine and inflammatory mediators values, compared to the NTG group especially during the sixth postoperative hour and the first postoperative day. The most abrupt changes were evident in the patients with the highest preoperative levels of cytokines and inflammatory mediators especially when the ischemia time was more than 90 minutes. Male patients demonstrated the most significant changes.

Discussion: The use of the tourniquet triggers the systemic inflammatory response. The most remarkable changes in inflammatory mediators are evident during the sixth postoperative hour and the first posoperative day. Tourniquet may be used for Total knee Replacement but care should be taken to decrease the ischemia time to the absolutely necessary specifically in males.


K. Kaspar G. Matziolis G. Kasper H.J. Bail G.N. Duda

Introduction: Currently used small animal models of a critical size defect do not sufficiently simulate the biologically unreactive situation in an atrophic non-union. Furthermore, models using intramedullary nails are of little, and poorly standardised, biomechanical stability. This is a characteristic known to promote callus formation though, rather leading to a hypertrophic non-union.

The aim of this study was to establish an atrophic non-union model in the rat femur under well defined biomechanical conditions and with minimised interactions between the processes in the healing zone and the implant by using external fixation.

MATERIALS AND METHODS: 80 male Sprague Dawley rats were randomly divided into two groups (non-union vs. control). All animals received an osteotomy (app. 0.5 mm gap) of the left femur, stabilised with a custom made external fixator. In the non-union group the periosteum was cauterised 2mm distal and proximal of the osteotomy, and the bone marrow was removed. X-rays were performed once weekly. Animals were sacrificed at 14 or 56 days post-operation. At both time points the femurs of 16 animals of each group underwent histological/histomorphometrical and immunhis-tochemical analyses (PMMA or paraffin embedding). Additionally at 56 days 8 animals of each group were tested biomechanically. The maximum torsional failure moment and the torsional stiffness were determined in relation to the intact femur. Post-mortem x-rays were evaluated in a descriptive manner.

RESULTS: At 14 days the histology and radiology showed considerable mineralised periosteal callus in the control group, while the non-union group only showed very little periosteal callus, distant to the osteotomy. At 56 days the control group was completely, or at least partially, bridged by mineralised callus. The non-union group did not show a bridging of the osteotomy gap in any of the animals, moreover the bone ends were resorbed and the gap widened. The relative mean torsional stiffness was significantly larger (p< 0.001) in the control group compared to the non-union group (136.2±34.5% vs. 2.3±1.2%). In the non-union group no maximal torsional failure moment could be detected for the osteotomised femurs. In the control group it was 134.2±79.1%, relative to the intact femur.

DISCUSSION: The cauterisation of the periosteum and the removal of the bone marrow, in combination with a high stiffness of the external fixator may create an atrophic non-union under well defined biomechanical conditions and with minimised interactions between the healing zone and the implant. This model will allow better standardised investigations on the subject of atrophic non-unions.


B. Magnan E. Samaila P. Bartolozzi

Introduction: A minimally invasive procedure including percutaneous reduction and external fixation can be performed for Sanders’ type II, III and IV heel fractures in order to obtain a tridimensional reconstruction of the os calcis with a reduced risk of local complications, allowing for early motion.

Methods: 54 consecutive closed articular displaced cal-canear fractures in 52 patients were treated with the Orthofix Heel Mini-Fixator. Patients were followed for an average of 49 months (range, 27 to 94 months) and assessed clinically with the Maryland Foot Score and radiographically with X-rays and CT scans.

Results: Clinical results at follow-up scored excellent or good in 49/54 cases (90.7%), fair in 2 cases (3.7%) and bad in 3 cases (5.6%). Mean preoperative Böehler’s angle was 6.98° ± 12.93 (range, − 5.95–19.86), while after surgery the average value was 21.94° ± 9.36 (range, 12.58–31.30) (p < 0.01). C.T. scans were evaluated according to the S.A.VE. score, showing excellent results in 24 cases (44.4%), good results in 25 cases (46.3%), fair results in 3 cases (5.6%) and bad results in 2 cases (3.7%). Mean preoperative S.A.VE. score was 17.58 ± 4.98 (range, 12.60 – 22.56) while the postoperative score was 25.66 ± 2.44 (range, 23.22 – 28.1) (p< 0.01).

Sudeck’s atrophy was observed in 10 patients (18.6%) that healed within four months. Three pin tract superficial infections (5.6%) were resolved without removal of the device. Three patients (5.6%) showed thalamic displacement following early weight-bearing but did not require further surgery.

Conclusions: Percutaneous reduction and external fixation proved to be a reliable technique in order for obtaining stable reduction of os calcis fractures. The clinical results appear to be comparable to those obtainable with the open reduction and internal fixation, with the added advantages of being minimally invasive procedure, having substantially shorter operating times and reducing risk of complications related to surgical exposure.


A. Mahmood O. Ennis R. Maheswari I. Moorcroft P. Thomas

Single centre prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation.

Methods: Surgical management of all patients followed protocol of senior author (PBMT), with regard to technique and fracture reduction.

Operations performed by several different surgeons including senior author.

Definitive fixator used as a reduction tool in 34 cases, fracture reduction device used in 162 patients – ST.O.R.M

Followed up in a dedicated external fixator clinic by the senior author until one year post fracture healing.

Fracture healing was determined by fracture stiffness measurements.

Results: 196 tibial fractures in 196 patients, average age 29 (range 12–80).

111 right sided and 85 left sided.

166 male and 30 female.

116 fractures due to low energy and 80 due to high energy.

Mechanism of injury: football 75, fall 52, RTA 49, direct blow 7, assault 4, rugby 3, crush 2, dancing 2, bowling 1, roller skating 1.

33 patients had an additional 74 injuries: 35 fractures (3 open), 7 compartment syndromes, 3 dislocations, 7 head injuries, 16 chest injuries, 9 soft tissue injuries.

According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3.

Time to # healing was 19 weeks on average (range 9–87)

X ray data: 15 patients had deformity > 5 degrees in the coronal plane and 1 of these also had deformity > 10 degrees in the saggital plane.

One patient underwent osteotomy for correction of malunion.

85 patients had a total of 279 pin site infections requiring Abx (6 with 14 pin infections requiring iv abx), and 33 pins were removed due to persistent infection. 15 patients had 32 ring sequestra which settled with debridement under GA.

7 fixators removed early due to pin site infection.

1 established osteomyelitis-lautenbach.

7 refractures, all healed(5 with pop, 2 with further fixator)

Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation.

Malunion: 1

Conclusion: Our results show that external fixation of closed tibial fractures is a viable alternative to other treatment methods with regard to healing time and angular deformity.

Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining healing on clinical or radiological grounds which is known to be unreliable. This is the first time this highly repeatable methodology has been used for such fractures.


M. BELTSIOS O. SAVVIDOU N. GIANNAKAKIS G. KOUFOPOULOS J. KOUVARAS S. DAGAS T. GRIVAS

PURPOSE: There is an argument in the literature regarding the use of intramedullary nail or the external fixation followed by intramedullary nail in tibial fractures with severe damage of soft tissues, threatened compartment syndrome, open type IIIA fractures and in polytrauma patients. The purpose of this retrospective study was to evaluate the results of non-jointed external fixators as a definite treatment for these type of tibial shaft fractures.

MATERIAL AND METHOD: 86 patients (91 tibial shaft fractures) were treated at the authors’ institute with a non-jointed external fixator. The mean patient age was 35 years (range, 15–80). There were 70 male and 16 female patients. The average time of surgery from the accident was 10 hours. The indications for application an external fixator was: severe damage of the soft tissues in 11 fractures, an incipient compartment syndrome in 12 fractures, open type III Gustilo fractures in 57, and 11 tibia fractures in polytrauma patients. According to AO classification 46 fractures were type A, 32 type B and 13 type C.

RESULTS: The average follow up was 2.9 years (ranged, 1–5 years). The average operative time was 50 min. Complications included: 3 non-unions, 5 delayed unions, 1 malunions, 1 tibia shortening, 3 superficial infections of soft tissues in open fractures, 26 pin infections and 1 osteomyelitis in open fractures. In 2 patients fat embolism was diagnosed while pulmonary embolism was a complication in 2 patients. Deep venous thrombosis (DVT) developed in 5 patients. A re-operation was performed in 11 out of 91 fractures. Change of the method was necessary in 2 out of 91 fractures. The primary callus in 10 out of 91 fractures was due to the stiffness of the unilateral non-jointed external fixators and did not influence the final results. Mean time of fracture union for the open fractures that did not require change of the method nor bone graft was 25 weeks, while for the closed fractures was 18 weeks. The dynamization of the system and partial weight bearing was started at 6 weeks and all the patients had full weight bearing by the 12th week.

CONCLUSION: The unilateral external fixators were the definite treatment in 88 out of 91 fractures. The unilateral external fixators can be used as a definite treatment for tibial shaft fractures in the majority of the cases. Re-operation or change of the method is unusual and must be performed only when there is a delay in callus formation.


R. Gudena J. Mehta R. Morgan-Jones

Introduction: Sequential staged distraction with fixed rate and rhythm, alternative compression and distraction is well described in the literature to treat non-unions. However we looked the union in established non-unions of tibia using one stage distraction without further manipulation at the fracture site maintaining the stability.

Materials and Methods: 12 patients with established tibial non-unions were referred during the period of 2001–2005. 2 cases were infected non unions. All patients were symptomatic and exhibited deformity at the non-union site. Ten males, two females were in the study group with a mean age of 39.2 years. The location of non-union was distal 1/3 of tibia in 8 cases and 2 cases of proximal and middle 1/3. External fixation was used to acutely distract the fracture (one stage) and tension the soft tissues to attain fracture stability. Infection at the fracture site required further operative debridement. Regular followup with radiographs to assess the union.

Results: Osseous union was achieved in all the cases at an average time period of 17.2 weeks. There was no recurrence of osteomyelitis in the infected cases following secondary debridement. All the patients were pain free and fully mobile without aid at review.

Conclusion: We concluded that acute distraction osteogenesis produces fracture union in selected established cases of non union. This method can be used to obtain impressive gains in the lengths of the long bones. Bone is uniformly produced regardless of the location of the non union. This is more patient compliant, effective and relatively easy to perform.


S.P. Kelley M. Rogers B. Morgan M. Jackson

INTRODUCTION – Tuberosity fractures of the calcaneum are rare injuries. The traditional operative treatment involves open reduction and internal fixation with a tension band wire construct. We have developed a new technique of fixing these fractures with internal fixation using cannulated screws and a figure of eight wire. This paper describes the new technique outlining its advantages and compares the 2 methods of fixation biomechanically to determine their properties with respect to fracture fixation.

METHOD – 20 sections of bovine bone were taken to act as an experimental model for the calcaneum. They were osteotomised to create the posterior process fracture model. 10 were fixed using a traditional tension band wire construct and 10 were fixed using the cannulated screw and wire construct. Each construct was subjected to biomechanical testing to identify the stiffness, energy to failure and load to failure.

RESULTS – During loading the cannulated screw and wire constructs showed a significant increase in stiffness and energy to failure compared to the tension band wire constructs

CONCLUSION – The increased stability of the cannulated screw construct demonstrated by the testing offers biomechanical benefit over the traditional tension band wire construct. This, as well as the improved technical aspects of the cannulated screw fixation, may be beneficial for clinical use.


E. Tsiridis Z. Gamie

Pin placement into the medial calcaneus places a number of structures at risk of damage. Research evidence suggests that the greatest risk of posterior pin placement is to the medial calcaneal branch of the tibial nerve. By using palpable anatomical landmarks, we attempted to redefine the safe zone taking into account possible variations. The medial heel region of twenty-four cadavers was dissected to find the major structures at risk. The inferior tip of the medial malleolus (point A), insertion point of tendo calcaneus (point B), navicular tuberosity (point C) and the medial process of the calcaneal tuberosity (point D) were all selected as anatomic landmarks from which to measure the identified structures using digital electronic calipers. The commonest variation in origins of medial calcaneal nerves was found to be one arising before the bifurcation of the tibial nerve along with one arising from the medial plantar nerve (10/24). The safest zone for percutaneous pin placement has been calculated as beyond two-thirds of the distances AB, CD, AD and CB. More posterior pin placement reduces the risk of damage to the medial calcaneal nerve and its branches, although the risk remains and blunt dissection before pin placement is recommended.


A.E. Badila R.A. Radulescu C.F. Cirstoiu O. Nutiu R. Manolescu C. Nita D.N. Popescu A. Dinu

Aim: To compare 2 methods of osteosynthesis (pinning and plate and screws) in displaced intraarticular fractures of the calcaneus

Material and method: Between 2001 and 2005, 82 displaced intraarticular fractures of the calcaneus were surgically treated in our department. Fractures were classified according to Bohler’s classification: 18 Bohler type II and 64 Bohler type III fractures.

Open reduction and reconstruction with osseous grafts (autologous grafts in 22 cases and heterologous grafts in 52 cases) were used in 74 cases. In 8 cases (all of Bohler II type) grafts weren’t used. Osteosynthesis with plate and screws was performed in 26 cases and with pins in 56. The 2 groups were similar in what concerns age, sex ratio, BMI, degree of comminution. The surgical procedure was delayed in both groups (average − 6 days). Pins were removed at 6 weeks and the plates at 12 months.

Results: A number of clinical parameters (pain evolution, moment of partial and full weight bearing, achievement of clinical and radiological union, ankle and forefoot mobility, etc.) were similar in both groups. Skin complications were more frequent in the plate group even if similar lateral surgical approaches were used. Pain along peroneal tendons was much more frequent in the plate group.

Conclusions: Even if theoretically osteosynthesis with plate and screws assures a better fixation, in practice it has similar clinical results with the pinning. The number of complications is higher after plate osteosynthesis. The pins can be extracted with local anesthesia, while plate extraction requires lumbar or general anesthesia and a full extent surgical procedure.


E. LAMGLAIT P. CRONIER A. TALHA P. MASSIN

MATERIAL AND METHODS. From 1986 to 2002, among 195 fractures treated with this plate, 181 were evaluated. A first series of 116 cases analysed in 1997 (follow up 22 months) was enlarged by a recent series of 65 cases (follow up 29 months). According to Duparc, there were 5(2.7%) type II, 69(36.9%) type III, 103(55.1%) type IV, 10(5.3%) type V. According to Sanders there were 67(37%) type 2, 65(36.9%) type 3, 49(27.1%) type 4. The protocol was as follows: fractures were investigated with standard views (including Broden’s views) and CT scans. The average delay before surgery was 5.5 days. Blisters were not a contraindication to surgery, if not obviously infected.

Reduction was performed by an extended lateral approach, and checked under fluoroscopy. Joint reduction was fixed by screws. The reconstruction plate, bent in a standard way, was then placed laterally, from above the tuberosity towards the inferolateral part of the anterior process. All but one or two posterior screws ideally converge to the sustentaculum tali (ST), building a strong support below the posterior facet. Postoperatively partial weight bearing below the threshold of pain was allowed in the majority of cases. Clinical results were assessed using the French Orthopaedic Society (SOFCOT) functional score for both series, and AOFAS (American Foot and Ankle Society) score, and Mary-land Foot Score (MFS) for the recent series.

RESULTS. According to the SOFCOT, there were 74% good and excellent results. The average MFS was 87/100, the average AOFAS score, 82/100. The average beginning of walking without crutches was 10 weeks. In the second series of 65 cases, 78.4% of active patients went back to their previous job at the same level.

Reduction was assessed anatomic on the postoperative Broden view in 90.5% of cases. The average Böhler’s angle remained stable. Secondary fusion of the subtalar joint was required only in 4 cases (2.1%). Wound healing was delayed in 19.7%, but generally, it was spontaneously obtained in a few weeks. Three deep late infections (1.6%) healed after plate removal.

DISCUSSION. ORIF of displaced articular calcaneal fractures using a contoured lateral plate has yet become a routine in our institution. The concept of screws converging from the plate to the ST, which is the strongest part of the broken bone, provides both optimal fixation of the primary fracture line (separation fracture), and a solid support below the reduced posterior facet. In most of cases early partial weight bearing did not jeopardize articular reduction, except the 4 (2.2%) significant secondary displacements. Therefore, in very comminuted fractures involving the tuberosity, we rather use of the new AO locked Plate.

Conclusion: Because the reconstruction plate was always modelled in the same standardized shape, we developed a specific precontoured thinner plate.


S. Giannini C. FALDINI F. VANNINI R. BEVONI C. BIAGINI G. GRANDI

INTRODUCTION: Displaced comminuted intra-articular calcaneal fractures (DCCF) need anatomic reduction to avoid painful subtalar joint, deformities, tendon or nerve impingment. Open reduction and internal fixation has been extensively reported, but all series reported considerable rate of skin complications, infections and need of additional plastic procedure. The aim of this study is to review a series of DCCF operated by minimally invasive technique.

MATERIAL AND METHODS: 66 DCCF type Sanders II-III were selected in 63 patients aged 18–57 years. X-ray and CT scan were performed. Surgery consisted of percutaneous traction-reduction of the calcaneal body by bone forceps and fixation by K-wires under image intensifier. Then, a lateral 3 cm skin incision was performed to reduce subtalar joint and to fix it by 1 or 2 screws. In case of involvement of the calcano-cuboid joint, the incision was distally extended and a 4-hole plate was applied. K-wires were removed 5 weeks after surgery and weight bearing was permitted 12–16 weeks after surgery. Patients were evaluated clinically by AOFAS score and radiographically at 4 years follow-up (3–7).

RESULTS: No skin complications or infections were encountered in the series. All fractures healed. Mean postoperative Bohler angle was 29±5°. AOFAS score was 89±11. 31 cases were excellent, 22 good, 9 fair and 4 poor. 25 cases presented radiographic signs of subtalar joint arthritis, painful only in 4.

DISCUSSION AND CONCLUSION: Minimally invasive surgical treatment resulted adequate for treating DCCF, in fact if soft tissues are preserved by surgical trauma, dangerous complications like infections and skin problems can be avoided.


G. Vashista N. Rashid M. Khan

Opinions is divided among surgeons whether to operatively fix displaced calcaneal fractures in elderly patients and heavy smokers. In a long term follow-up of operatively treated calcaneal fractures, we considered several factors that could affect outcomes and complication rates.

Method: 59 calcaneal fractures in 54 patients that underwent operative fixation for displaced intra-articular fractures from April 1995 to January 2006 were reviewed. There were 18 Tongue type and 41 Joint depression fractures on X-rays. Of 38 available CT scans, 25 were Sanders Type II and 13 were Types III and IV fractures.

Average interval to surgery was 6 days. Postoperative mobilisation regime was passive range of motion immediately following surgery with non weight bearing for 6 weeks. Weight bearing was started at 6–8 weeks. On follow-up, patients were assessed with clinical and radiological exam, completed Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and Visual Analogue Scale (VAS) scores.

Results: The duration of follow-up was between 6 months to 11.2 years (6.4 years). The pre and post operative Bohler angles were 8° ± 11° and 29° ± 6° respectively. There was significant limitation of subtalar movement on the operated side irrespective of the presence of arthritis. The average AOFAS, SF-36 and VAS scores were 79, 58 and 3 respectively. Good results were associated with age < 50 years, ASA grade I, pre-op Bohler angle of < 5° and Sanders < IIC. 89% of patients returned to their previous level of activity after an average of 6.5 months.

Smoking was not associated with early or late complication rates and did not affect outcome.

Conclusions: We think that advanced age and smoking are not contraindications for operative fixation of displaced calcaneal fractures.


A.V. Corotti Sasareanu J.R. Almoguera Sanchez J.J. Beltran Bengoechea J.J. De Miguel

Between 2000 and 2004 we used subtalar arthrodesis to treat 44 patients for continued pain after intra-articular calcaneal fracture. All the fractures were due to laboral accidents.

Average time to union was 3 month(2 to 4 months). Complications were minor in 12 patients and major in 10 patients.

Lenght of follow-up was 23 months.

Hindfoot scores (clinical rating system of the American Orthopaedic Foot and Ankle Society)improved from 35,11 to 67,22.

The results were excelent in 7 patients, good in 24, fair in 7 and bad in 6 patients. Return to previous activities was possible in 26 pacients.

We concludes that subtalar arthrodesis represents a rather effective treatment of the subtalar arthritis due to inta-articular calcaneal fractures.

The majority of patients can have improvement with surgical reconstruction but pain relief is usually not complete.


N.T. Roidis S. Papadakis A.K. Chong S. Vaishnav C. Zalavras J.M. Itamura

Aim of the study: To define the dimensions of the radial head, as well as the radiocapitellar and proximal radio-ulnar joints. The most congruent portions of the radial head articulations were determined.

Materials & Methods: Computed tomography scans of twenty-two cadaveric adult elbows were obtained in three forearm positions – supination, neutral, pronation. The radial head dimensions, the radiocapitellar joints, and the proximal radioulnar joints were also measured. Multivariate analysis of variance was used to determine which portions of each articulation were the most congruent.

Results: At the level of the radial trough, the maximum diameter was 22.3 mm, the minimum diameter was 20.9 mm, and the diameter difference was 1.4 mm. This difference represented only 6.3% of the overall maximum diameter. The depth of curvature of the radial head trough was 2.3 mm, the radial head length was 9.8 mm, and the radial neck length was 10.7 mm. At the isthmus of medullary canal, the maximum diameter was 9.7 mm, the minimum diameter was 8.2 mm, and the diameter difference was 1.5 mm. This difference represented 15.6% of the maximum diameter. The average radiocapitellar distance at the radial lip was 4.0 mm, the trough 2.4 mm, and the ulnar lip 2.2 mm. Thus, the radial head tended to become uncovered at the radial lip (p < 0.0001). The radiocapitellar joint was tighter in pronation than in supination (p = 0.0008). The proximal radioulnar joint was most congruent at the MPRUJ (middle proximal radioulnar joint), at the midportion and posterior aspects, rather than the anterior aspect (p < 0.0001). The PRUJ coverage was between 69.0 and 79.2 degrees.

Conclusions: Prosthesis trial sizing should be judged by the articulations providing the most congruency –

1) the ulnar lip or trough of the radiocapitellar joint in pronation and

2) the posterior or midportion of the MRPUJ.


L. Sanz R. Dias C. Heras-Palou

Background: An important sign in the assessment of distal radioulnar joint instability is the ballottement test were passive movement of the affected joint is compared to the contralateral normal side. The subjective appreciation of increased laxity renders the test positive.

In cases in which the contralateral side can not be tested or is known to be abnormal the relevance of the ballottement test is compromised.

Based on the observation that distal radioulnar joint passive mobility decreases in normal subjects when the wrist is radially deviated we propose a modification of the ballottement test in which mobility of the DRUJ is tested both in radial and ulnar wrist deviation.

Objectives: We aim to verify the observed decreased range of motion of the DRUJ in normal individuals when assessed in radial deviation compared to ulnar deviation and report the intraoperative findings of a series of patients who demonstrated an abnormal modified ballottement test in the abscense of bony deformity in the DRUJ.

Method: A group of 38 healthy volunteers (76 wrists) with no history of significant wrist injuries were assessed and the amount of DRUJ mobility given a subjective score of between 1 and 3. All wrists were assessed in ulnar and radial deviation as well as in neutral. The average age of the participants was 32.4 years. There were 22 female and 16 male subjects.

Our clinical case series reports the review of clinic notes and operative records of 32 patients (age gender) (32 wrists) who demonstrated an abnormal modified ballottement test and whose degree of instability granted surgical intervention.

Results: Out of the 76 normal wrists, 72 demonstrated decreased range of movement of the DRUJ in wrist radial deviation compared to examination in neutral or ulnar deviation. In the remaining 4 no difference was perceived but examination in neutral was considered “stiff” (less than average on the examiners experience).

All patients in the case series were found to have an ulnar detachment of the dorsal aspect of the TFCC (Palmer 1B) for which they underwent open repair.

Conclusion: DRUJ mobility in normal wrists decreases in radial deviation compared to neutral.

The observed decreased mobility of the DRUJ is likely to be due to tightening of the ulno-carpal ligaments.

An abnormal modified ballottement test was an indicator of severity as those with a positive result required surgical intervention and also correlated with the anatomical lesion found at surgery (Palmer 1B TFCC tear)

We believe the proposed modification enhances the diagnostic value of the DRUJ ballottement test and also allows to detect abnormalities in those cases in which the contralateral side can not be examined.


W. Yoon A.K. Das S. Ilyas S. Gadikoppula S. Raza

Our study investigated a consecutive series of 53 cal-caneal fractures treated at Southend General Hospital during a 4 year period. In total 75% were intrarticular and 25% extrarticular. Overall 51.92% of patients underwent operative intervention 66.67% of these being intrarticular. All patients underwent AOFAS scoring. The minimum followup period was 6 months and the average was 18 months.

In the non-operative group (Undisplaced intra/extrarticular with Bohler’s angle 20–40 degrees) the < 50 year old group had an average AOFAS score of 86.3 versus 63.64 in the > 50 year old group.

In the operative group the AOFAS score was heavily dependent upon restoration of Bohler’s angle. This study shows that if Bohler’s angle is < 20 degrees the average AOFAS score after followup was 51.00 but if the angle has been restored to > 20 degrees the average score is 69.53. This result is reinforced by the fact that 75% of patients returned to work in the > 20 degree Bohler’s angle group wheras only 33.34% returned to work in the < 20 degree group.

This study shows that surgical restoration of Bohler’s angle to > 20 degrees gives a better outcome than for conservative treatment.


M. Waseem K. Saldanha S. Chaudhry H. Jharaja

Aim: Aim of this study is to determine if cubital tunnel view radiograph of the elbow is useful in the investigation and treatment of Ulnar nerve entrapment at the elbow.

Patients and Methods: 28 patients presenting with symptoms suggestive of ulnar nerve entrapment at the elbow were prospectively studied. Detailed history and clinical examination was elicited in each patient and classified according to McGowan’s classification. Diagnosis of ulnar nerve entrapment at the elbow was confirmed by nerve conduction studies. Cubital tunnel view radiographs were taken and evaluated for any evidence of bony encroachment of the ulnar nerve bed in the cubital tunnel. Those patients with normal cubital tunnel view radiograph underwent simple ulnar nerve decompression where as those with significant bony encroachment of ulnar nerve bed underwent anterior transposition of the ulnar nerve. The results of surgery were assessed at follow up using the Wilson and Krout criteria. The difference in results in two groups was statistically analyzed by applying student ‘t’ test.

Results: There were 20 patients (male=14, female 6) in the simple ulnar nerve decompression group with a mean age of 52 yrs (range 32 to 61 yrs) and 8 patients (male=6, female=2) in anterior transposition group with a mean age 59 yrs (range 45 to 69 yrs). Mean follow up was 25months (range 9 months to 32 months). According to McGowan’s classification there were 5 grade I, 9 grade II and 6 grade III patients in simple decompression group where as there were none grade I, 3 grade II and 5 grade III in anterior transposition group. All patients had neurophysiological evidence of ulnar nerve entrapment in pre-operative nerve conduction study. Wilson and Krout grading at final follow up showed 15 good, 4 fair and 1 poor result in simple decompression group and 5 good, 2 fair and 1 poor result anterior transposition group. There was no statistically significant difference between the two groups (p value < 0.001).

Conclusion: Cubical tunnel view radiographs are valuable in the management of ulnar nerve entrapment at the elbow. Patients with normal radiograph can be treated by simple nerve decompression


T. Ibrahim M. Rowsell W. Rennie A. Brown G. Taylor P. Gregg

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.

The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.

The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.


J. Sluimer T. Gosens

OBJECTIVE: The purpose of this study is to examine the effect of a single percutaneous injection of platelet-rich-plasma compared to an injection of corticosteroids in patients with chronic lateral epicondylitis.

BACKGROUND: Lateral epicondylitis is a common problem that usually resolves with nonoperative treatments. Platelet Rich Plasma (PRP) is a component of whole blood that contains concentrated amounts of powerful growth factors. PRP has been used for a variety of orthopedic applications including tendinopathy, wound healing and spinal fusion with varying degrees of success. Buffered PRP has also been used to enhance cell proliferation in-vitro.

HYPOTHESIS: Treatment of chronic severe lateral epicondylitis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem.

METHODS: One hundred patients with persistent lateral epicondylar pain were evaluated in this study. All these patients were initially given a variety of nonoperative treatments. These patients had significant persistent pain for at least 3 months despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (experimental group, n = 50) or corticosteroids (control group, n = 50).

RESULTS: PRP has a significant better effect on lateral epicondylitis than corticosteroid injections.

CONCLUSION: This in-vivo data suggest that tendon healing is occurring in lateral epicondylitis using PRP.


M. Gulcek V.S. UNAL F. OKEN O. YILDIRIM S.Y. GULCEK A. COMERT A. UCANER

Aim: The literal knowledge about the configuration of the radial bone is rare. Radial bone is investigated anatomically by computerized tomographic methods in this study.

Patients and Methods: Twenty-one cleaned and dried cadaveric bones were used for this investigation. The measurements were done on the diaphyseal, proximal and distal metaphyseal CT sections of the bone. A tortional angle was defined. The repetetive measurements were done by two different researchers on the same sections in different times. The interclass and intraclass correlation coefficients were analysed.

Results: The mean measurement of the radial tortional angle was 73 degrees [between 59° to 86°]. The ICC value between the initial measurements of the observers was, 9990 and considered torsion to be significant. (p< 0.001)

The ICC value between the secondary measurements of the observers was,9980 and considered torsion to be significant. (p< 0.0001)

The ICC value between the both measurements of the first observer was,9975 and the found torsion to be significant. (p< 0.0001)

The ICC value between the both measurements of the second observer was,9956 and the found torsion to be significant. (p< 0.0001)

Conclusion: This method is useful for evaluating the rotational alignment of the radial bone and rotational motion restruction of the forearm after fracture healing. It can also be used to predict the potential of remodelling of the radial bone in pediatric forearm fractures.


N.A. Darlis R.A. Kaufmann F. Giannoulis D.G. Sotereanos

The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Some authors suggest that contracture release in this age group is less predictable and results less favorable than in adults. A retrospective review of the senior author’s patients produced 16 patients under the age of 21 that had post-traumatic elbow contracture releases. Three patients with arthroscopic releases and one patient lost to follow up were excluded from this study.

Twelve adolescent patients (mean age 16.7 years, range 13–21) had open release of post-traumatic elbow contractures. All releases were initiated through a lateral approach with anterior capsular release and were supplemented by posterior release (in 4 patients) through the same incision. Medial-sided pathology was addressed through a separate medial incision in 3 patients. In three patients the radial head was excised. Muscle lengthening was used in only one patient.

The mean follow-up was 18.9 months (range 10–42 months). Preoperative flexion was increased from 113 to 129deg (p< 0.01), extension from −51 to −15deg (p< 0.001) for a mean total gain of 54deg in the flexion-extension arc (p< 0.001). Pronation was improved from 58 to 77deg and supination from 56 to 62deg, but these improvements did not reach statistical significance. At the final follow-up the patients maintained 93% of the motion that was achieved intraoperatively. All patients achieved a functional ROM of at least 100deg in the flexion-extension arc. No patient lost motion. One patient had a superficial infection that was treated conservatively

Our experience with post-traumatic contracture release in adolescent patients has been rewarding; all patients reached a functional range of motion. The advantage of the lateral approach used in these patients is that it allows simple and safe access to the anterior capsule, which is often adequate to regain full extension. Through the same approach the posterior structures can also be addressed without violating the lateral collateral ligament. The medial approach is more demanding and was reserved only for patients with medial sided pathology. Fractional musculotendinous lengthening was rarely necessary in post-traumatic contractures. Open release in adolescent patients with congruent stiff elbows has yielded satisfactory results in our hands.


F.S. GIANNOULIS N.A. DARLIS R. WEISER D.G. SOTEREANOS

PURPOSE: We describe the results of 64 patients who underwent treatment for acute distal biceps tendon rupture using a single incision and suture anchors. The purpose of the study is to evaluate if this method is reliable and if it can reduse the risk of ectopic bone formation or synostosis.

Methods: 64 patients underwent surgical repair for acute rupture of the distal biceps tendon, using suture anchors and a single incision. All performed by 1 surgeon. We had 63 male and 1 female with a mean age of 48 years (range 30–59). Our operative technique consisted of an “S”-shaped anterior incision centered over the antecubital fossa. After identification and protection of the lateral antebrachial cutaneous nerve, we exposed and mobilized the ruptured biceps tendon. The distal portion of the tendon was debrided and the radial tuberosity gently decorticated. A 4 stranded suture was then inserted into the tuberosity. The tendon was advanced to bone and the sutures were tied using the modification of Kessler’s technique, holding the elbow in 90° of flexion. The post-op protocol was a posterior splint for 10 days (in 90° of flexion and 20° of supination), a dynamic hinged-extension block brace in 45° for 3 weeks and progressive advancement to full extension in 3 more weeks. Strengthening exercises were permitted after 3 months.

Results: All acute tears (< 3 weeks) were repaired anatomically. The follow-up period was 39 months (range 18m – 11years). Objective data consisted of ROM (range of motion) of the elbow, flexion and supination strength were measured by a BTE Work Stimulator. The ROM was normal in 54 patients, 10 patients lacked 10° of extension. 51 patients returned to their pre-injury level of activity and within 6 months returned to work. All patients reported pain relief and good recovery of strength and were completely satisfied of the outcome. There were no implant failures, nerve palsies or heterotopic bone formation.

Conclusions: Use of a single incision repair with bone suture anchors provides secure fixation of distal biceps tendon to the radius with minimal volar dissection wich is associated with a minimum risk of synostosis and posterior interosseous nerve injuries. This method is reliable for acute ruptures. Return to normal strength and range of motion can be expected if tendon repair is performed before 3 weeks. The advantages of this method are less dissection for re-attachment of the tendon, less nerve injuries and no ectopic bone formation or synostosis.


V. Psychoyios K. Dakis F. Villanueva-Lopez A. Kefalas

Aim: Postraumatic elbow stiffness is a common condition after elbow trauma. Sometimes it is a quite disabling symptom not responding to conservative measures. We present the surgical treatment of such cases of posttraumatic elbow stiffness.

Material: Twenty three patients, fourteen male and nine female with an average age of 34 yrs, underwent a surgical treatment of their stiff elbow. The average preoperative range of motion regarding elbow flexion-extension was 65° and the average rotational movement was 123°. All patients had received a resection of the anterior capsule, release or resection of posterior elements, removal of loose bodies and resection of osseous beaks if it was necessary. Two patients received a triceps lengthening. The results evaluated with the Mayo Elbow Performance Score.

Results: The average follow up was twenty nine months. All the patients were available for clinical assessment. There was an improvement of the average ROM to 115°, regarding flexion extension and to 164° regarding supination pronn. Postoperatively a dynamic elbow splint was used in twenty patients and a hinged external fixator in the remaining patients. Revision elbow release was performed in three patients and in one patient the elbow stiffness was deteriorated. Sixteen patients had an excellent or good result, and seven had a fair or poor one.

Conclusion: Elbow stiffness is an extremely disabling condition causing a functional impairment. Surgical elbow release is quite reliable, and relatively safe procedure given the fact that the patient follows strictly the rehabilitation protocol.


J. MARMORAT P. Culpan F. Kelberine F. Bonnomet T. Judet

Objective: This study compares the results obtained from arthrolysis of the elbow performed arthroscopically with those done open.

Material and Methods: 139 patients from 3 hospitals, who had undergone an arthrolysis of their elbow, were studied retrospectively. 58 had an arthroscopic arthrolysis and 81 were open. The patients included were aged between 18 and 65, had a loss of passive range of motion, due to either osteoarthritis or post trauma. Patients with previous extra articular osteotomy, septic or inflammatory synovitis were excluded. The clinical evaluation comprised measuring their: range of motion, pain, level of activities, presence of effusion or locking. The images obtained were standard radiographs, CT scan and bone scans to allow us to accurately determine the presence of loose bodies, fibrous tissue in the fossae, the presence of osteophytes or arthritis. All data was recorded in preoperative, postoperative and final assessment.

This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).

Results: The two groups were similar on all points with the exception of their aetiologies. There was no clinical difference preoperatively. The arthroscopy was performed through 4 portals in 94% of cases; in the open cases the most common approach was lateral (53%). Intra operatively the significant differences were the removal of posterior osteophytes and capsular releases (p< 0.001) were performed more frequently in the open procedure. At the end of the procedure, the flexion and the gain in flexion-extension range was greater in the arthrotomy group; however the arthroscopic group lost less motion from end of procedure to the final result (8 versus 17 degrees). At the last review, the gain in range of motion remained greater in the group with the open arthrotomy. The number of complications in the 2 groups was identical, though the location of any nerve injury was different. The method of rehabilitation was the same; however this was continued for longer in the arthroscopic group. Final radiographic assessment showed that a less extensive debridement of bone was achieved arthroscopically.

Conclusion: A more extensive release and an easier intra operative evaluation resulting in a better improvement in range of motion at the end of procedure are achieved with arthrotomy. The subsequent loss of motion is more significant in this group however the final outcome showed the gain in range of motion remained greater. It was noted however, that even with less improvement in mobility, with either technique, the patients were equally satisfied.


A.M. Manunta M.M. ML Manunta M.D. M. Dattena E.S. E. Sanna Passino

Introduction: Recently, tissue engineering based on stem cells has emerged as a new discipline that amalgamates aspects from biology, engineering, material science and surgery and that has as goal the fabrication of functional new tissue to replace damage tissue. The aim of our study was to verify if the pluripotent cells derived from inner mass cell (ICM, Inner Cell Mass) of embryos at the first stages of development (blastocysts), seeded on Tissucol., maintaining them properties, and grow and form cartilage in chondral defects, when used for repair the lesion.

Methods: An osteochondral full thickness lesion was produced in the medial femoral condyles of twelve sheeps. The pluripotent cells were then isolated from feeder layer and seeded on fibrin glue before the transfer. We proceded with aspiration of ES cells in fibrinogen and successively addition of trombin at time to transplantation. The creation of full-thickness defects was performed in such a manner as to render it impermeable to blood-borne cells and signaling substances emanating from the subchondral bone-tissue spaces. After this, into the left knee 170 μl of Tissucol were inserted whether on right knee170 μl of Tissucol with 120.000 ES cells into the hole. The number of stems cells obtained initially correspond to the maximum quantity avalaible before the last differentiation of them.

The new tissue obtained was tested using the ICRS classification, and analysed biomechanically by the Artscan 200 series. We performed besides immunohistochemical evaluation of cartilage to check collagen type I.

Results: The compressive stiffness of the reparative tissue was higher in the treated group (Es cells + Tissucol) mean = 1.02 N than in the control group (Tissucol) mean = 0.68 N).

Four weeks after transplantation immunohistological analysis show in the treatment group cartilaginous tissue; The cells in the repair cartilage were round and arranged in numerous small clumps; the matrix showed strong metacromasia, indicating that this was hyaline cartilage. eight weeks after transplantation, the cells were largely distributed on the area and the repair tissue still resembled hyaline cartilage. After eight weeks the repair tissue implanted was fibrous with prevalence in extracellular matrix of Type II collagen.

Conclusion: Passage in fibrinogen and the addition of thrombin doesn’t alter the properties of the cells; Tissucol mimics embryonic environment and appears to be quite suitable and appropriately flexible delivery vehicle. This repair tissue manifests neither a arcade-like organization of its fibers nor a well-define zonal stratification of its chondrocytes but detection of Type I collagen rendering the pluripotent-cells-fibrin glue complex a possible candidate for the repair of cartilage lesions.


X. Mir J.S. Font A.A. Monegal F.P. Santana J.B. Doreste

Introduction. Prospective study based on professional sportsmen who affected from Chronicle Compartmental Syndrome in forearm and its treatment.

Material and methods. 32 Chronicle Compartmental Syndrome in forearm were studied in 24 patients. Our selection was composed by 16 men and 8 women. In 8 of our cases both forearms were operated. The age range was from 17 to 33 years of age. Their sportive activity included: 20 professional motorcyclists, 2 wind-surfers and 2 mountainbikers.

To demonstrate evidence of Chronicle Compartmental Syndrome we performed a diagnostic test based on the measure of the intracompartmental pressure after stimulating their usual sportive activity. We considered a positive test when the measured an IMP> 15 mmHg after effort. We also performed a dynamometric of their grip and strength of the thumb-index forceps before and after surgery.

Results. All 24 patients presented clinical and tests compatible with Chronicle Compartmental Syndrome in forearm during effort activities which reached severe range due to loss of sensibility and propioception.

- From 15 to 20 mmHg of IMP after effort, 8 cases.

- From 20 to 30 mmHg of IMP after effort, 11 cases.

- Over 30 mmHg of IMP after effort, 13 cases.

Minimal invasive surgery based on fasciotomy was performed to release compartmental pressure in flexor and extensor compartments of the forearm.

Conclusions. We can conclude that after fasciotomy most of our patients improve either clinically and diagnostic tests results, without strength loss, and are able to return to their usual activity completely recovered in a short period of time


C. Pascual Garrido A. Makino S. Bosio J. Astoul-Bonorino L. Aponte-Tinao M. Isola M. Ielpi M.A. Ayerza L.D. Muscolo

Introduction: Autologous chondrocyte implantation (ACI) has been developed in order to repair cartilage successfully. Experimental models are based on osteochondral defects with potentially triphasic chondrogenic system: periosteal flaps, bone marrow cells and transplanted chondrogenic cells. All these three have chondrogenic activity so it is difficult to determinate the role of the implanted cells unless appropriate control is set up.

The purpose of this study is to determinate if the inoculation of chondrocytes under periosteal flaps does improve the chondrogenic potential of periosteal flaps.

MATERIALS AND Methods: 10 New Zealand rabbits, 8 months old were used. Right knees served as study group (ACI Group; N5: Chondrocytes + Periosteal Flap) – (Fibroblast Group: N5 Fibroblast + Periosteal Flap) and left knees as control group (N: 10: osteochondral defect alone). During the first procedure dermal fibroblast cells were isolated from skin biopsy and chondrocytes were isolated from the medial femoral condyle as a full thickness of the right and left knee were done. Chondrocytes and dermal fibroblasts cells were incubated for 4 weeks. Then they were implanted under periostel flap according to study group.

Chondrocyte and Fibroblast Implantation:

A parapatellar incision was performed on both knees. Defect was cleaned and on study group the periosteum taken from the tibia was sutured leaving one edge free to inoculate the chondrocytes or fibroblast according to group using a needle Then the defect was closed using fibrin glue. The animals were euthanatized 8 months postoperative.

Analysis: Specimens were evaluated using Hematoxylin and Eosin. Safranine and inmunohistochemistry for Collagen Type 2 using the ICRS score system.

Statistical Analysis: T student, Fisher and confidence interval were used. A p value < 0,05 was considered significant.

Results: Control non treated group presented a histological score grade mean IV (95% CI: 44–97)

The ACI group showed a tissue type means II (ICRS) (95% CI: 28–99%) Collagen type 2 was evident only in the deep layers. The fibroblast group did show a reparative tissue, tissue type mean II (95% CI: 28–99%) Collagen type 2 was evident in deep layers

DISCUSSION: According to this study the inoculation of chondrocytes under periosteal flaps does not improve significally the chondrogenic potential of periosteal flaps.(p: 0,77). Comparing the same procedure with chondrogenic and non chondrogenic cell lines could determinate the role of different chondrogenic components (periosteum and chondrocytes). Probably the chondrogenic capacity of the periosteum is sufficient to stimulate a reparative tissue. However none of these procedures could establish an adult normal cartilage hyaline tissue.


S. Giannini C. Faldini S. Pagkrati G. Grandi D. Leonetti M. Nanni

INTRODUCTION: Diaphyseal aseptic nonunions are challenging complications in forearm fractures, as length imbalance of radius and ulna impairs severely its function. The aim of this study is to report the results of a series of patients operated on by an original technique.

MATERIAL AND METHODS: 60 patients aged 17–72 years (mean 35) were treated between 1980 and 2000. Ten patients presented radius nonunion, 37 ulna non-union, and 13 nonunion of both bones. Nonunions occurred after conservative treatment in 8 cases, after one surgical procedure of plating or nailing in 47 cases and after 2 or more surgical procedures in 5 cases. Surgical treatment occurred at mean 36 months after the fracture and consisted of freshening the bone and applying a plate and an opposite cortical bone allograft; in 17 cases omologous intercalary bone graft was applied to restore length, axial and rotational alignment. Postoperative treatment consisted of functional bracing associated with intensive rehabilitation of the elbow and wrist beyond clinical and radiographic union. Average follow up was 15±7 years.

RESULTS:. One implant failed due to infection, requiring additional surgery. Mean elbow ROM was 122°±18. Compared with the contralateral arm, mean loss of wrist ROM was 20°±17. Mean loss of forearm rotation was 25°±15. Average healing time was 14±4 weeks X-ray analysis showed bone healing and good osteointegration of the graft in all cases.

DISCUSSION AND CONCLUSION: Combining a plate and an opposite massive cortical bone graft resulted to be a very effective technique for surgical treatment of forearm nonunions.


F.S. GIANNOULIS J. GREENBERG N.A. DARLIS R. WEISER D.G. SOTEREANOS

PURPOSE: We describe a new technique for the treatment of painful instability of the distal ulna after Darrach procedure using an allograft as a mechanical interposition. The purpose of the study is to evaluate the results of this technique.

Methods: In this study we report on 17 patients who underwent revision of their Darrach procedure using an allograft (human Achilles tendon allograft). The average age of the patients was 47 years (range 39–68) and the average time after the original procedure was 15 months. The indication for the revision surgery in all patients was incapacitating pain over the distal stump of the ulna which increased during pronation or supination and with active grip. Pain was assessed using a VAS (Visual Analog Scale). Grip strength was measured using a dynamometer. All patients had instability of the distal ulna, and crepitus or palpable “clicking” during forearm rotation. Radiographs of all patients demonstrated erosion of the medial cortex of the radius, indicating impingment.

Technique: 2 or 3 suture anchors were placed into the medial cortex of the radius, proximal to the sigmoid notch where the impingment occurred. An adequate amount of the allograft was then sutured into an anchovy. The size of the allograft was determined by pronating and supinating the involved forearm with pressure applied to the ulnar aspect of the ulna to assess crepitus. Sutures were placed through the allograft, creating a pillow-shaped spacer. Two or three drill holes were then placed into the distal ulna for fixation of the allograft to the ulna. With final allograft placement there should be significant padding between the radius and the ulna to prevent any palpable crepitus during forearm rotation under compression.

Results: After an average follow-up time of 34 months all patients were re-evaluated by subjective assessment, range of motion, grip strength, pain relief and radiographs. We report 16 patients with good and excellent results and 1 patient with persistent complaints (our first patient). There were no radiographic changes noted.

Conclusions: The use of an allograft as a mechanical interposition between the radius and the ulna has not been described previously. With this technique there is no need for a metallic prosthesis and as much bulk graft as necessary is obtainable. We believe that this technique is an excellent alternative to metal arthroplasty for reconstruction of difficult cases of failed distal ulna resection.


S. Krishnan J. Jaggiello A. Flanagan T. Briggs

Aim: To report the clinical and histological outcome of autologous chondrocyte implantation (ACI) using two techniques -collagen covered ACI or ACI-C and matrix carried ACI or MACI- over eight year period.

Patients and methods: One hundred and seventy one patients (61 ACI-C and 110 MACI) who underwent ACI were followed-up prospectively using both objective and patient reported clinical outcome measures. Biopsy of the repair tissue was performed in 115 patients.

The mean clinical follow-up was 39.4 months (13mths to 8 years) and the mean timing of biopsy was 14.8 months. The mean age at the time of surgery was 32 years (15 to 55 years). The site of defect was as follows: medial femoral condyle-95, lateral femoral condyle-25, trochlea-7, patella 27 and multiple sites- 12. The mean proportion of viable cells available for implantation was 96.3 % (range: 86 to 100) and the mean number of multiplication of cells during culture was 90 (range: 9 to 667).

Results: 79 % of patients had an improvement in clinical outcome, 5 % of patients had no difference and 16 % had deterioration in clinical outcome. Short Form 36 (SF-36) health survey assessments demonstrated significant improvements in both mental and physical component scores (p< 0.001). The number of patients who demonstrated hyaline-like, mixture of hyaline-like and fibrocartilage, fibrocartilagenous and fibrous tissue histology were 32, 22, 59 and 2 respectively.

The most favourable sites were lateral femoral condyle and trochlea where as the least favourable site was patella. There was no correlation between the mental score of patients and the final clinical result. Improvement in functional score was significantly higher among those who had a higher pre-operative function (p< 0.001). There were 7 patients who had previously failed micro-fracture and all of them obtained significant improvements in pain and function. Those who had a higher proportion of viable cells after cell culture demonstrated a tendency towards better outcome, but failed to reach statistical significance (p=0.14). There was no correlation between the number of cell multiplications at the time of cell culture and final clinical outcome (p=0.65). There was no significant difference in clinical outcome between the ACI- C and MACI techniques of ACI (p> 0.05).

Conclusion: Autologous chondrocyte implantation is a useful procedure for patients with symptomatic chondral defects of the knee and produces significant improvement in both objective and patient reported clinical outcome scores in up to 79 % of patients.


P. Valis M. Repko R. Chaloupka

Purpose of the study: Solid chondrograft in the treatment of the osteochondral defects seems like rutine method in present time. In our prospective study we focused to the evaluation of the chondrograft quality and its incorporation to the implanting place.

Material and Methods. We have been using the technique of the solid autologous chondrograft implantation since 2000. We have been evaluating the patients regulary by magnetic resonance (3,12 and 24 month postoperatively), by second look arthroscopy and clinically with evaluation of the Lysholm and Weber scores. Also we are using the evaluation of the chondrograft quality by electronmicroscopy and by imunohistochemic methods on the samples taken by second look arthroscopy from the border of implanting places.

Our set contains of 51 patients (28 men and 23 women) with the chondrograft implantation (39 knees and 12 ankles). An average age of patients was 27 years and 3 month with average follow up 3 years and 7 month.

Results: The full incorporation of the chondrograft have been observing in 49 patients (94%) using the second look arthroscopy and magnetic resonance imaging. There were no marks of subchondral edema. We took the samples from implanting places in 11 patients. There were hyalin chondral tissue evaluated by electronmicroscopy imaging in 10 samples and mixed hyalin-fibrous tissue in one sample. There were colagen No.2 in all samples examined by imunohistochemy with coloring by hematoxilineosin.

Lysholm score in knee operations were before surgery 37,5, one year after the surgery 81,4 and after two years 83,1. Weber score in ankle operations were before surgery 17,3, one year postoperatively 4,6 and after two years 4,5.

Conclusion: The examination of our set of patients argumentative very good clinical, imaging, as well as histological results of implanted chondrografts incorporation.


S. Anders O. Wiech J. Schaumburger J. Grifka

Introduction: Bone-marrow stimulating techniques like microfracturing for focal chondral defects of the knee joint are widespread utilizing mesenchymal stem cells (MSC) for an autogenous reparation process. Microfracturing shows good results for smaller defects up to 2cm2 while larger defects tend to an early secondary degeneration. Autologous Matrix Induced Chondrogenesis (AMIC®) combines microfracturing with application of a porcine collagen type-I/III bilayer matrix to host the MSC and to stabilize the blood clot.

Methods: 32 patients (25m, 7f, mean age 37.4y (18–52y)) with 35 focal chondral defects of the knee joint (ICRS III–IV°) of the condyle, trochlea and/or patella were treated by standardized microfracturing and application of a collagen matrix (Geistlich Biomaterials, Wolhusen, Switzerland). The outcome was evaluated prospectively by clinical scores and MRI with a follow-up of 6 to 24 months. The mean defect size was 3.86 cm2 (1.0 – 6.8 cm2). 22 patients (68%) had at least one operation (1–8) on the knee before. 9 defects were caused by trauma. All 7 patients with osteochondritis dissecans had an autologous bone grafting. In 5 patients an ACL stabilization was performed simultaneously.

Results: All patients considered their knee as abnormal (ICRS III° (70%)) or severely abnormal (ICRS IV° (30%)) preoperatively according to the ICRS functional status. The Cincinnati-Score improved from 52.9 to 81.1 points while the Lysholm-Score rose from 60.4 to 85.9 points (each p< 0.001). Pain decreased significantly from 6.1 to 2.2 (10=max.) on the visual analogue scale. 4 biopsies (4–21 months) revealed reasonable results with regard to surface formation, filling and integration in the Brittberg score (∅10.25 pts., 12 pts.=max.) The MRI follow-ups showed an adequate filling of the defect, no prolonged effusion occured.

Conclusion: Microfracturing in combination with a collagen matrix (AMIC®) is a minimal invasive, effective technique for the repair of focal cartilage defects of the knee joint. Not using cultured chondrocytes it can be performed cost-effectively as a single-step procedure. Both primary and secondary treatments are possible. The first results concerning clinical functional improvement, pain reduction and patients’ satisfaction as well as defect filling in MRI are promising.


S. Balasubramanian B. Komarasamy R. Vadivelu S. Tandon T. Green M. Newey

Introduction: Microfracture is found to be effective for isolated chondral defect of knee in young adults however controversy exists over the relevance of microfracture treatment in degenerative knee. The purpose of the study is to assess the outcome and patient satisfaction with the arthroscopic microfracture of osteoarthritic knee.

Materials: We collected the demographic details of the patient, weight, procedure and follow up details from June 2000 to Dec 2002. We reviewed the case notes retrospectively and assessed the patient satisfaction with Oxford knee score and Lysholm score.

Results: There were total of 194 patients but only 76 patients returned the questionnaire. The average patient age was 57 years (range: 27–87 years) with majority of the patients being male patients (43 patients). The average weight of the patient was 82 kg (44–119) and the mean duration of operation was 28 minutes. The patients were evaluated at an average follow-up of 51 months (range: 36–66 months). The average Lysholm score was 49 (4–100) with mean oxford score of 32.5(13–56).

21 patients required knee replacement at an average of 24 months (range: 6–48 months) from the initial microfracture. 17 out of 21 patients had kissing lesion and all showed grade 4 degenerative changes

Discussion: Age and weight does not appear to have any effect on microfracture treatment however more number of female patients seem to have more kissing lesion and poor result. With shorter duration of operation and proper explanation to patient give short term symptomatic relief before replacement surgery. It is worth considering this treatment for isolated grade 4 lesion or less than grade 4 degenerative chondral lesions in appropriately selected patients.


P.K. Jaiswal D.H. Park J. Jagiello R.W. Carrington J.A. Skinner T. Briggs G. Bentley

Introduction: Smoking is associated with impaired wound healing, delayed bony union following fractures and an adverse effect on the immune system. Furthermore, smoking is an important risk factor for the development pulmonary complications following major surgical procedures, as well as wound complications. We determined whether smoking had a deleterious effect on outcome after autologous chondrocyte implantation (ACI) in the treatment of ostechondral defects of the knee.

Methods: We identified 103 (54 females and 49 males) patients with a mean age of 34.2 (range 18 to 49) who had undergone ACI between January 2001 and August 2004 who also had their smoking status recorded. The patients were divided into 3 groups according to their smoking status. The Visual Analogue Score, Bentley Functional Rating Score and Modified Cincinatti Scores were used to assess function pre-operatively, 6 months and then yearly thereafter.

Results: Group 1 consisted of 31 smokers (mean pack years of 13.4), group 2 consisted of 63 non-smokers and group 3 contained 9 ex-smokers. In Group 1, the Modified Cincinatti Score pre-operatively, 6 months, 1 year and 2 years following surgery were 34.1, 42.6, 43.5 and 46.7 respectively. In group 2 the scores were 47.4, 59.6, 59.1, 65.3, and in group 3 the scores were 39.8, 50, 53.3, 51.8. At the 1 year check arthroscopy, the graft failure rate in group 1 was 12% and biopsies revealed mixed hyaline and fibrocartilage in only 25% (there were no patients with hyaline cartilage). There were no graft failures in group 2 and 43.8% of the biopsies performed were either hyaline (12.5%) or mixed hyaline and fibrocartilage (31.3%). The wound complication rate was 24% in group 1 and 8% in group 2.

Conclusions: The results of this study suggest that people who smoke have a worse functional outcome and a higher complication rate following chondrocyte implantation. This association has not been previously described and should be included in the pre-operative counselling of patients undergoing the procedure.


P.K. Jaiswal D.H. Park J. Jagiello R.W. Carrington J.A. Skinner T.W. Briggs G. Bentley

Introduction: Several studies have implicated excessive weight as a negative predictor of success of total knee arthroplasty. In addition, obese patients are known to have increased risk of wound complications after orthopaedic and general surgery. The purpose of this study was to compare the clinical and functional outcomes of autologous chondrocyte implantation for treatment of osteochondral defects of the knee performed in obese patients with those performed in non-obese patients.

Methods: We analysed the data on all our patients that have been followed up for a minimum of 2 years and had their height and weight recorded initially in our database. Functional assessment consisted of Bentley Functional Rating Score, Visual Analogue Score, and the Modified Cincinatti Scores (collected prospectively at 6 months, 1 year, 2 years and 3 years following surgery). Patients were placed into 3 groups according to their body mass index (BMI). Group A consisted of patients with BMI of 20 to 24.9, group B patients with BMI of 25 to 29.9 and Group C are patients with BMI of 30 to 39.9.

Results: There were 80 patients (41 males and 39 females) with a mean age of 35.4 (range 18 to 49). The mean BMI for the entire group was 26.6. The pre-operative, 6 month, 1 year, 2 year, and 3 year Modified Cincinatti Score in Group A (32 patients) was 54.4, 80.3, 82.7, 74.7 and 72.6. Similarly in Group B, the scores were 53, 41, 54, 56, 49.5 and in Group C the scores were 36.3, 36.3, 49.6, 36, and 35.7. The wound infection rate in Group A was 6.25%, in Group B was 17.6% and Group C was 14.3%.

Conclusions: Initial results from this study suggest that BMI is an important predictor of outcome after chondrocyte implantation. The group of patients that would gain most benefit from ACI are patients that are not overweight (defined by BMI in the range of 20 to 24.9). Further work is being carried out to support the hypothesis that surgeons should strongly consider not operating on patients unless the BMI is less than 25.


P.K. Jaiswal D.H. Park R.W. Carrington J.A. Skinner T.W. Briggs A.M. Flanagan G. Bentley

Introduction: ACI is used widely as a treatment for symptomatic chondral and osteochondral defects of the knee. Variations of the original periosteum-cover technique include the use of porcine-derived type I/type III collagen as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) using a collagen bilayer seeded with chondrocytes. We report the minimum 2 year follow-up results of 192 patients randomised to autologous chondrocyte implantation (ACI) using porcine-derived collagen membrane as a cover (ACI-C) and matrix-induced autlogous chondrocyte implantation (MACI) for the treatment of osteochondral decfects of the knee.

Methods: 192 patients (mean age 34.2) were randomised to have either ACI (86 patients) or MACI (106 patients). 1 year following surgery patients underwent check arthroscopy (with or without biopsy) to assess the graft. Functional assessment was performed yearly by using the modified Cincinatti knee score, the Bentley functional rating score and the visual analogue score.

Results: 24 patients were excluded from the study as they underwent additional procedures (e.g. high tibial osteotomy). In the ACI group the modified Cincinatti score increased from 42.5 pre-operatively to 56.7, 54.1, and 60.4 at 1 year, 2 years and 3 years respectively. In the MACI group the Cincinatti scores increased from 46.0 pre-operatively to 59.9, 58.9, and 58.4. Arthroscopic assessment showed a good to excellent International Cartilage Repair Society score in 90.7% of ACI-C grafts and 68.4% of MACI grafts. Hyaline-like cartilage or hyaline-like with fibrocartilage was found in biopsies of 51.9% of ACI-C grafts and 25.9% of MACI grafts.

Conclusions: ACI grafts are more likely to produce hyaline-like or mixed hyaline-like cartilage and fibro-cartilage with better ICRS grades than MACI grafts. However, this does not translate to better a clinical functional outcome. More importantly, ACI and MACI had similar results that were maintained at 3 years.


E. Monaco L. Labianca A. De Carli F. Conteduca A. Vadalà A. Ferretti

Cadeveric studies showed that single bundle ACL reconstructions were successful in limiting anterior tibial translation but were insufficient to control a combined rotatory load of internal and valgus torque. One possible cause of these condition could be that current single bundle procedures cannot realistically reproduce the complex anatomy of the ACL, especially the different function of its anteromedial(AM)and posterolateral(PL)bundle. The hypothesis of our study is that the addition of the PL bundle to the AM bundle, in an “in vivo” double bundle computer assisted ACL reconstruction, is actually able to reduce the internal rotation of the tibia at 30° degrees of knee flexion. Computer assisted ACL reconstruction has been used because it could be very effective in evaluating the global performance of the reconstructed knee.

Ten consecutive doble bundle ACL reconstructions were performed in our Hospital using hamstrings graft and the 2.0OrthoPilot-B. Braun-Aesculap ACLnavigation system. The average age of patients was 27.8 years.

The double-looped semitendinosus tendon replicating the AM bundle was fixed first at 60° of knee flexion. Than the gracilis tendon replicating the PL bundle was fixed at 15° of knee flexion. Maximum manual A–P displacement at 30° of flexion, maximum internal and external rotation of the knee were evaluated using the navigation system before surgery and after single(A–M)and double (AM+PL)bundle reconstruction. Statystical anlisys was done using paired T-test.

Before ACL reconstruction mean manual maximum AP displacement was 17.2mm;mean manual maximum internal rotation was 19.8mm and mean manual maximum external rotation was 16.8mm. After AM bundle reconstruction mean manual maximum AP displacement was 6.1mm;mean manual maximum internal rotation was 17.0mm and mean manual maximum external rotation was 16.3mm. After AM+PL bundles reconstruction mean manual maximum AP displacement was 5.3mm;mean manual maximum internal rotation was 16.2mm and mean manual maximum external rotation was 14.6mm. There was no statistically significant difference in the tibial internal rotation at 30° after single bundle(AM)and double bundle(AM+PL)reconstruction.

In this study the effectiveness of the PL bundle in controlling the internal rotation of the tibia, responsible of rotational instability of the knee, was evaluated in “in vivo” ACL reconstruction. The navigator system allowed us to obtain “in vivo” the real and correct value of AP displacement and internal and external rotation of the tibia before and after reconstruction.

Our hypothesis that the addition of the PL bundle to the AM bundle is actually able to reduce the internal rotation of the tibia at 30° degrees of knee flexion, minimizing the pivot shift phenomenon, on the basis of our study has not been confirmed.


M. Goddard A.J. Rees

Purpose: To quantify the amount of agreement among UK orthopaedic surgeons regarding the natural history and treatment including surgery and rehabilitation of the ACL deficient knee.

Methods: Following from Marx et al (Arthroscopy. 2003 Sep;19(7):762–70) a surgeon mail survey was performed to 360 members of the British Association for Surgery of the Knee. Surgeons who had treated ACL deficient patients in the last year were asked to complete the survey. Thirty questions were included to determine the surgeons’ opinions regarding the natural history of the ACL deficient knee, indications for surgery and patient selection, surgical treatment and rehabilitation. Clinical agreement was present when 80% or more agreed on the same response option.

Results: 150 surgeons in total responded to the survey; 121 had treated ACL deficient patients in the past year. The mean age was 48.9 years and 83% considered their practice to be a subspecialty in knee surgery. The mean number of ACL reconstructions performed in the past year was 41 (range 1–210). Clinical agreement was present for 12 (40%) of the 30 questions; surgeons disagreed on 18 (60%) of the questions.

Conclusions: Similar significant variation regarding the management of ACL injuries is seen among members of BASK as among members of the American Academy of Orthopaedic Surgeons (AAOS). Clinical disagreement included whether ACL deficient patients can participate in all recreational sporting activities, that ACL reconstruction reduces the rate of arthrosis in the ACL deficient knee, and the use of bracing in non-surgically treated ACL deficient knees. Surgeons also disagreed about age, open growth plates, radiographic evidence of osteoarthrosis, pain, and, repairable and unrepairable meniscal tears in ACL deficient patients.


A. Marx R. Siebold A. Ellermann

Introduction: Looking at the controversial discussion about indication, transplant choice and fixation techniques in active ACL-injured patients with open physes we recommend even in childhood an ACL reconstruction using a quadruple hamstring graft.

Material and Methods: ACL-replacement was performed with a four strand hamstring graft using an Endobutton and a suture washer or staple for extracortical fixation. The drilled tunnels were positioned transepiphyseal in the anatomic position. A standardized examination was performed. IKDC, Tegner, Lysholm and Cincinatti Knee Score were raised. With the KT-1000 the functional stability was tested. Variation in leg length and leg deformity were analyzed.

Results: 54 patients (22 female/32 male) operated at an age between 8 to 16 years (mean 13.3) were examined at mean f/u of 32 months (range 12–90) postoperatively. Measured with the Cincinatti and Lysholm Score 94% were classified as normal or nearly normal. Mean Tegner Score difference before trauma and postoperatively was 0.29 (range 0–3). Four patients developed instability due to an adequate trauma. Clinical and radiological examinations did not show growth disturbances in any patient. The results did not correlate to gender.

Conclusion: Presuming a bad progression in conservatively treated ACL-injured young patients and performing a careful operative treatment (small tunnel diameters, ligamentous graft, extracortical fixation, etc.) the above mentioned technique shows satisfying results and should be considered as a standard treatment in this special group.


L.K. PAPATHEODOROU L.A. POULTSIDES M.E. HANTES K. GRAFANAKI C. STATHOPOULOS K.N. MALIZOS

INTRODUCTION: The process of ligamentization includes the histological and structural remodelling of the tendons graft to ligamentous tissue. There is little information documenting the mechanism of ligamentization process in molecular level. A number of essential genes are involved in this process and their expression can be regulated through complex biochemical pathways. Animal studies have shown that transcutaneous application of low intensity pulsed ultrasound (LiUS) accelerate the tendon and ligament healing process and recent reports have proven the efficacy of the transosseous application of LiUS for both enhancement and monitoring of the bone healing. The purpose of this study is to investigate the effect of transosseous low-intensity pulsed ultrasound (LiUS) during lingamentization process on the healing at tendon graft-bone interface in rabbits, by examining the expression levels of TGF-β1, biglycan and collagen I using semi-quantitive RT-PCR.

MATERIALS AND METHODS: Twenty-eight New Zealand rabbits were used in this study. The anterior cruciate ligament was excised and replaced with the long digital extensor. Custom-made ultrasound transducers were implanted onto the bone fragment and along the surface of the bone tunnel at the right knees of the rabbits (study group). The LiUS-treated animals received 200-μsec bursts of 1 MHz sine waves with pulse repetition rates of 1 KHz and average intensity of 30 mW/cm2, for 20 minutes daily, while the left knee received no LiUS (control group). Semi-quantitative RT-PCR was performed from RNA samples representing both study and control groups at 1, 2, 3, 5, 7, 8, 9, 12, 14 and 21 days, using specific primers.

RESULTS: Analysis of the RT-PCR products showed that there is significant up-regulation of biglycan and collagen-encoding genes in the study group compared to the control group. In addition, TGFb1-encoding gene exhibits a bimodal profile. In the study group, it represses its mRNA levels from day 1 until day 9 and then the initial expression levels are restored. The control group showed no essential alteration of expression levels for TGFb1.

DISCUSSION: Transosseous LiUS treatment affects the expression levels of significant genes like TGF-β1, big-lycan and collagen type I. All the above studied genes mediate important biochemical pathways in lingamentization process and possibly enhance the healing rate of the tendon graft-bone interface in a bone tunnel in rabbits. The present report is supportive of the hypothesis that transosseous application of LiUS enhances tendon graft healing to bone through effects on molecular level. These present findings suggest that indeed ultrasound treatment after joint ligament reconstruction may facilitate earlier rehabilitation.


F. Giron P. Aglietti P. Cuomo M. Losco N. Mondanelli

Introduction : The purpose of the study is to compare in a randomised clinical double blind trial two methods of hamstring ACL reconstruction, the SIngle Bundle (SB) and the Double Bundle (DB).

Materials and methods: Seventy patients, with a chronic ACL insufficiency, were randomized to receive a unilateral single or double bundle ACL reconstruction. All the operations were performed by the same surgeon using the same two incision outside-in technique. The tibial guide wire was introduced with a 65 degrees Howell guide in extension to avoid impingment. To introduce the second tibial wire (posterolateral wire) a prototype guide that lets you place the wire with a fixed angulation and a fixed distance (9 mm) from the first was used. On the femoral side we used a modified Rear Entry guide. In a SB reconstruction the 10.00 o’clock position (right knee), intermediate between the two anatomic bundles, was used. In a DB reconstruction the first wire was placed in the anteromedial insertion area, close to the “over the top” position on the lateral wall and for the second wire the same prototype guide that gives you the correct angulation and distance with the first (10 mm) was used. The direction was chosen in order to exit 5 mm close to the posterior cartilage. The graft was prepared and pretensioned as to have two arms of the same diameter. It was fixed on the cortex of the tibia by means of a titanium ring bridge when doing a SB and looped around a cortical bony bridge when doing a DB. Tensioning and femoral fixation of the SB was done at 20 degrees, while in the DB tensioning and fixation of the PL bundle was achieved first after cycling at 10–15 degrees and of the AM bundle at 40–45 degrees. Femoral fixation was obtained via RCI titanium interference screws and one additional cortical titanium staple. The same moderately aggressive rehabilitation was utilized in both groups. Outcome assessment was performed by an indipendent observer, blinded to the involved leg and type of reconstruction, using the new IKDC form, the KOOS score, the KT-1000 arthrometer.

Results: All patients reached a minimum follow-up of one year. No difference was found in terms of overall KOOS and IKDC subjective scores. A significant difference was found (p< .001) in KT data and in IKDC final ojective scores (Excellent-A-result: 73% SB and 95% DB). he DB group showed a tred to less pivot shift (glide).

Conclusion: In the short period the DB reconstruction offered better knee stability and better objective results than the 10.00 o’clock SB. Longer follow up and accurate instrumented in vivo rotational stability assessment is probably needed to further disclose small but important differences.


T. Jarvela M. Jarvinen

Introduction: Anatomical observation and biomechanical studies have shown that the anterior cruciate ligament (ACL) mainly consists of two distinct bundles, the anteromedial (AM) bundle and posterolateral (PL) bundle. Conventional single-bundle ACL reconstruction techniques have focused on the restoration of the AM bundle while giving limited attention to the PL bundle. The purpose of this prospective, randomize clinical study is to compare the outcomes of ACL reconstruction when using either double-bundle or single-bundle technique and bioabsorbable interference screw fixation, and similar rehabilitation, with both techniques.

Methods: Sixty-five patients were randomized into either double-bundle (n = 35) or single-bundle (n=30) ACL reconstruction with hamstring tendons and bio-absorbable screw (Hexalon, Inion Company, Finland) fixation in both group. The evaluation methods were clinical examination, KT-1000 arthrometer measurements, radiographic evaluation, as well as International Knee Documentation Committee (IKDC), and Lysholm knee scores. There were no differences between the study groups preoperatively. For an average of 14 months of follow-up (range, 12 to 20 months), 30 patients of the double-bundle group and 29 patients of the single-bundle group were available (91%).

Results: At the follow-up, the rotational stability, as evaluated by pivot shift test, was significantly better in the double-bundle group than in the single-bundle group. Also, the early anterior stability tended to be better with double-bundle technique, although at the 14-month follow-up, no significant difference between the groups was found anymore. In addition, none of the patients in the double-bundle group had graft failure, while four patients in the single-bundle group had. However, knee scores were equal at the follow-up, and all the results were significantly better at the follow-up than preoperatively, in both groups.

Conclusions: Rotational stability and early anterior stability were better with double-bundle technique than with single-bundle technique in ACL reconstruction with hamstring autografts and bioabsorbable screw fixation. However, both fixation techniques improved patients’ performance.


J. Walawski K. Gaweda R. Weglowski

Aims: The purpose of the paper is to compare results of reconstruction of ACL with quadrupled ST and GR tendons via arthrotomy in the study group and arthroscopy in the control group.

Methods: Treatment results of the consecutive cohort of 26 patients in the study group treated by arthrotomy were compared to the results of the consecutive cohort of 22 patients in the control group treated by arthroscopy operated between September 2002 and December 2003 by the same operating team. The patient’s age varied from 17 to 46 years (mean 24,5y) in the study group and 18 to 48 years (mean 23,7y) in the control group, with minimum follow-ups longer than 30 months. For the evaluation clinical examination, Lysholm& Gillquist and Marshall scales and KT-1000 assessment were used. For the proximal fixation endo-button plate and for the distal screw-post fixation were applied. There were no differences in graft harvesting, graft preparation and rehabilitation protocol in both groups.

Results: There were 3 traumatic graft failures in the study group. Mean gained Lysholm& Gillquist score in the study group was 31,42(+−4,68SD) and mean gained Marshall score was 12,18(+−2,27SD). 57.69% of the patients in the study group returned to the sport and work without any limitation on the preoperative level, additional 30.76% has only minor limitation in sport or work. There was 1 case of superficial infection and 1 deep infection in the study group. Both infections resolved without sequels. MM lesions in 10 cases (38,46%) and no LM lesions were found intraoperatively.

There were 2 traumatic and 1 unclear graft failures in the control group. Mean gained Lysholm& Gillquist score was 34,35(+−8,86SD) and mean gained Marshall score was 12,33(+−2,88SD). 45,46% of the patients in the control group returned to the unlimited sport and work on the preoperative level, additional 36,37% has minor limitation in sport or work and 1 patient despite stable knee was unable to return to the work. There was 1 case of deep vein thrombosis of the operated leg and 1 neuroma in the arthroscopy portal area in the control group. MM lesions in 12 cases (54,5%) and LM lesions in 5 cases (22,7%) were found intraoperatively.

The average KT-1000 side-to-side difference in the study group was 2,88 mm and in the control group 2,73 mm.

Conclusions: Mid-time follow-up reveals good to very good clinical outcome in both groups with no statistically significant differences. It looks interesting why the better average return to sport ratio was gained in the study group. 2 cases of infection discourage this approach except necessity additional cartilage repair. Differences in meniscal injuries rate might also advocate for arthroscopy as more capable in diagnose and treatment.


A. Karim J. Thomas A. Edwards G. Puddu N.P. Thomas A.A. Amis

Background: Several approaches to the ACL attachment and drilling methods exist, with little evidence of which method is the best.

Hypothesis: The “Retrodrill” or an “inside-out” drilling technique result in uniform intra-articular tunnel mouths compared with standard “outside-in” conventional ACL drill bits.

Study Design: Controlled laboratory study.

Methods: Sixteen cadaveric knees were divided into Anterograde (A) and retrograde “Retrodrill” (R) groups and ACL tunnels drilled. The femoral tunnel mouths were moulded using PMMA, then Nylon rods of identical diameter containing 1mm diameter K-wires were inserted into the tunnels and AP and lateral X-rays taken. Matching laboratory experiments utilised 10 pig femurs and synthetic bone.

Results: In group A, the mean difference between tunnels and their mouths was 1.6±0.5mm, compared with 0.3±0.2mm for Group R (p < 0.001). The mean femoral tunnel angulation in the sagittal plane for Group A was 45±10 degrees and 78±14 degrees for Group R (p< 0.001); and 30±12 degrees, and 71±12 degrees (p< 0.001) in the coronal plane respectively. There were similar ACL attachment hit rates from the groups. In porcine bone, tunnel mouth widening in the anterograde tibial group was 0.7±0.4mm, 0.04mm±0.1mm for the anterograde femoral group, and 0.06±0.1mm for the retrograde group (p< 0.001). In synthetic bone, the difference between the tunnels and their mouths was 0.8±0.8mm, 0.2±0.1mm and 0.1±0.1mm (p< 0.001) respectively.

Conclusions: The “Retrodrill”, or an inside out antero-grade drilling technique, produced a more uniform tunnel with no difference in ACL attachment hits.


M.Z. Farook A. Marsh A. Khaleel

Introduction: Though Cutaneous nerve injury following ACL reconstruction is a recognized complication, we identified an undescribed pattern of numbness involving the entire shin from the knee to the ankle.

Methods: A review of 143 Hamstrings ACL reconstructions performed between 1999 and 2004 was done. Mean age was 34.8 years (17–57) and the follow-up was 40.2 months (9–80).

Results: The patterns of numbness were classified into non-scar related and scar related. 76 patients (53 %) had non-scar related numbness. Among this 7 (5%) had numbness of the entire shin from the knee to the ankle. This pattern of numbness is significant considering the large area involved. 38 patients (27%) had scar related numbness.

Non-scar related numbness corresponded to the innervation of the branches of the Saphenous nerve. Only 39% of patients with non-scar related numbness and 47% with scar related numbness recovered completely. None of the patients who had numbness of the entire shin recovered. Interestingly only 3 patients reported that this numbness bothered them.

Conclusion: Anatomical studies have shown that it is difficult to identify a safe zone for tendon harvest. Efforts should be made to minimize the risk of such nerve damage, by making the incision more horizontal and keeping the knee in flexion while harvesting the graft. Patients should be warned of this complication while taking consent.


P. Di Benedetto V. Madonna A. Causero C. Zorzi E. Campailla

The chioce of the graft and its fixation in LCA reconstruction is basic for the outcome of the surgical procedure. Several solutions have been proposed; each of them had advantages and disavantages. The choice of the graft and the surgical technique is often due to surgeon’s opinion.

The goal of the fixation is stability which allowes incorporation of the graft in the bone tunnels. Bone-patellar tendon-bone graf has the advantage of bone to bone fixation which is impossible using tendon grafts. Femoral fixation techniques for hamstrings can be classified in: compression tecniques, expansion tecniques and suspension tecniques (cortical or canellous).

TTS (Top Traction System) is a new tecnique for femoral fixation using hamstrings. The fixation is achieved by a retrograde screw that allowes fixation to the antero-lateral cortex of the femur. A ring is fixed to the screw to allow tendons passing. The screw is sefl-threading, its lenght is 28 millimeters and its diameter is 6,5 millimeter; its pull-out strenght is 1350 N. The screw is built in titanium alloy and only one size.

Surgical technique is simple an reproducible and the instruments are easy to use. The positioning of the screw is fully guided by instruments that minimize errors.

This fixation device allowes further graft traction after tibial fixation without twisting hamstrings. Results after 5 years are good but we need long term follow-up for final opinion.


A. Marmotti G. Collo R. Rossi M. Germano F. Castoldi P. Rossi

The purpose of this study is to identify the optimal amount of knee flexion required to drill the femoral tunnel in ACL reconstruction using the transtibial technique in order to ensure the correct alignment between the femoral tunnel and the interference screw.

Methods: Twenty (10 × 2) fresh-frozen cadaveric knees were used. The native ACL was resected and its tibial attachment was identified. The angle of the tibial tunnel was set at 55° using an Arthrex tibial guide. The extra-articular tibial tunnel entry point was located at the anterior border of the superficial MCL. The intra-articular exit point of the guide wire was digitized with a digital camera and referenced to anatomical landmarks (the anterior border of the PCL, the lateral aspect of the medial spine and the anterior horn of the lateral meniscus). The femoral tunnels were made using the transtibial technique and a 5mm femoral guide to insert guidewires at 70, 80, and 90 degrees of knee flexion (groups a, b, c respectively). The angles of divergence between the longitudinal axis of the femoral tunnel and the interference screw (placed through an anteromedial portal at 120° of knee flexion) were then measured.

Results: The degrees of divergence were: 5° ± 2° for group a, 12° ± 4 for group b, and 15° ± 3° for group c.

Conclusions: Optimal femoral tunnel and interference screw alignment is achieved using the transtibial technique when the femoral tunnel is drilled with the knee in 70 degrees of flexion and the screw is inserted at 120 degrees of knee flexion.

This study identifies a mathematical formula for the optimal amount of knee flexion required to drill the femoral tunnel in ACL reconstruction using the transtibial technique in order to ensure the correct alignement between the femoral tunnel and the interference screw.


P. Smitham D. Michaels F. Vizesi R. Oliver W. Bruce Y. Yu N. Cotton W.R. Walsh

Introduction: The use of bioabsorbable devices in sports medicine surgery in the shoulder and knee continues to evolve as new designs, devices and materials become available. Concerns over potential problems associated with metal artifacts and permanent metal devices continue to motivate the development and use of polymeric based devices. Calaxo interference screws (Smith & Nephew Endoscopy, Andover, MA) are composed of a novel bioabsorbable material blend of poly DL- lactide – co – glycolide 85:15 (65%) and calcium carbonate (35%). These screws have been shown to be osteoconductive when placed in the centre of a 4 stranded tendon graft in an ovine ACL reconstruction [1]. The screws are fully resorbed at 26 weeks with new bone formation in the tunnel. In general, osteoconductive materials are often more effective when placed adjacent to a bony bed. This study investigated whether positioning the Calaxo screw adjacent to the bone tunnel was superior to screw placement within the tendon as in our previous study [1].

Materials and Methods: An intra-articular anterior cruciate ligament (ACL) reconstruction model using 2 doubled over tendon autografts whip stitched and inserted into the right hind limb of 8 sheep were used. Animals were culled at 26 or 52 weeks following surgery (n=4 per time point) and data was compared using the same surgical model but with screws placed in the center of the 4 stranded graft (Walsh et al., 2006). The tibias were CT scanned and processed for paraffin histology along the axis of the bone tunnel. Three dimensional models using the DICOM data obtained from the CT where made using MIMICS (Materialise, Belgium).

Result & Discussion: Results showed excellent biocompatibility of the screws with no adverse reactions at 26 and 52 weeks as in our previous study [1]. The screws were fully resorbed by 26 weeks with new bone replacing the PLC material. Similarly, the screws were not detectable at 52 weeks with new bone formation where the screw had previously resided. The intra-articular portion of the graft, articular cartilage and synovium was normal at 26 and 52 weeks as previously reported [1]. Tendon – bone healing proximal to the screw progressed in a normal fashion. No calcification of the intraarticular portion of the graft was noted. Computed tomography, 3D models and histology revealed an osteoconductive response to the PLC material with new bone formation as the material degraded in vivo.

Placement of the screw adjacent to the tendon graft and thus against the bone tunnel appears to provide superior results compared to screw placement in the middle of the graft sleeve device. This effect may be due to direct contact of the osteoconductive material to the adjacent bone bed.

[1] Walsh et al., Arthroscopy 2006, in press.


H. Palm S. Jacobsen S. Sonne-Holm M. Krasheninnikoff P. Gebuhr

Introduction: Re-operations after intertrochanteric fractures (ITF) are often caused by fracture displacement following postoperative mobilisation. The biomechanical complexity of the fracture, implant position, and the patient’s characteristics are known to influence postoperative outcome significantly. We investigated the importance of an intact lateral femoral wall (LFW) for the postoperative displacement after fixation by a sliding compression hip screw (SHS).

Methods: Two hundred and fourteen consecutive patients with ITF fixated by 135° SHS mounted on four hole lateral plates were included between 2002 and 2004. The fractures were preoperatively classified according to the AO/OTA classification system. The status of the greater and lesser trochanter, the integrity of the LFW and implant positioning were assessed postoperatively. Re-operations due to technical failure were recorded for six months.

Results: Only three percent of patients (5/168) with postoperatively intact LFW’s were re-operated within six months, while twenty-two percent (10/46) of patients with fractured LFW’s had been re-operated (p < 0.001). In multivariate logistic regression analyses combining demographic and biomechanical parameters, a compromised LFW was a significant predictor for reoperation (p = 0.010). Seventy-four percent (34/46) of the LFW fractures occurred during the operative procedure itself. Peri-operative LFW fractures only occurred in three percent (3/103) of the AO/OTA type 31A1–A2.1 ITF fractures, compared to thirty-one percent (31/99) of the AO/OTA type 31A2.2–A2.3 fractures (p < 0.001).

Conclusions: A postoperative fractured LFW was found to be the main predictor for reoperation after ITF. Consequently we conclude that patients with pre- or potential postoperative LFW fractures are not treated adequately by SHS. ITF should therefore be classified according to the integrity of the LFW, especially in regard to randomized trials comparing fracture implants.


C. Corradini D. Schipani M. Zanotta C. Verdoia

Despite several anatomical and neurophysiological studies have demonstrated the sensory role of anterior cruciate ligament (ACL), it is still unclear how significant the absence of the ACL will affect knee proprioception. Also because some mechanoreceptors has been discovered in the injured bundle commonly resected during ACL reconstruction.

In fact recently it has been observed that subjects with long standing ACL deficiency have not a knee joint pro-prioceptive deficit as measured by threshold of passive movement detenction and the ability to reproduce flex-ion angles, commonly accepted methods.

The aim of this study was to investigate the possibility to recognize a sensorial and behavior impairment in ACL deficient knee.

Through a computerized device the kinaesthetic data were collected from 120 sportsmen between 20–49 years (mean 32,4) affected by unilateral isolated ACL injury diagnosed with MRI and verified arthroscopically. The protocol consisted in four exercises, two bipodal on static and dynamic stance and two monopodal on healthy and injured lower limb. The balance index was divided in four areas on two dimensional plane for a qualitative assessment.

The mathematical and statistical elaboration revealed on bipodal static test a significant and costant displacement on the left side indipendently by the injured side and age. The kinaesthetic awarness was confirmed also by a significant increase of balance index in all exercises. Further studies are necessary to a better knowledge as a possible new tool.

In conclusion, this is the first report of a typical sensorial and behavior impairment in ACL deficient knee with intriguing clinical significance.


D.J. Biau C. Tournoux S. Katsahian P. Schranz R. Nizard

Background From individual randomized studies it is unclear which of patellar (PT) tendon or hamstring (HS) tendon grafts yields the best functional results after ACL reconstruction. Therefore, we performed a meta-analysis to provide quantitative data to compare PT (control group) to HS (treatment group) grafts after ACL reconstruction with regards to knee function.

Methods We searched computerized databases for randomized controlled trials reporting one of the following outcome related to function: final overall International Knee Documentation Committee (IKDC) score and return to pre-injury level of activity. Studies were abstracted independently by two reviewers. Random effect models were used to pool the data.

Results Fourteen trials (1263 patients) met the inclusion criteria. There was no difference in final overall IKDC and in the number of patients returning to full activity after PT and HS graft reconstruction. Relative risk was 0.90 for final overall IKDC score class A in favor of PT grafts (not significant, P=0.13), and 0.94 for return to pre-injury level of activity in favor of PT grafts (not significant, P=0.28). Quantitative interaction tests on the effect of treatment based on study quality, randomization status, number of strands used, and length of follow-up were not significant. At last follow-up, only 41% and 33% of PT and HS graft reconstructed patients were respectively reported as normal using the final overall IKDC.

Conclusion There was no difference in the final overall IKDC and in the number of patients returning to full activity after HS tendon graft and PT graft reconstructions. It should be emphasized that more than 60% of the patients will not make full recovery after their reconstruction and patients should be informed accordingly.


R. Mansingh . Jarvis J. Web S. O’Brien

Hip fractures are a major challenge and impose high demand on orthopaedic services.

DHS has been proved to be a gold standard method of treatment in uncomplicated extracapsular fractures. The introduction of Intramedullary devices has provided us with a wider choice of construct. Since there was conflicting literature evidence comparing the outcomes of DHS and IMHS, we set out to analyse the same in our practice.

Forty patients in each group operated in the year 2000, comparable in fracture pattern, age and sex distribution were studied. The operating time, fluoroscopic exposure, blood loss, complications (Intra-op, Post-op and Deaths), duration of hospital stay and the discharge destinations were studied from the clinical notes and Hospital information system. Statistical analysis was carried out using SPSS for all the available data.

Statistically, the DHS has a lesser duration of surgery, lower fluoroscopic exposure and lesser duration of hospital stay. However, clinically it appears that the IMHS is fraught with more complications.


G. Lòpez A. Maestro M. Leyes F. Forriol J.L Lopis L. Fernandez

Introduction: Loss of the meniscus frequently leads to progressive arthritic changes in the involved compartment. Replacement of the lost meniscus with a resorbable collagen scaffold has been proved to allow regeneration of meniscal tissue.

MATERIAL AND Methods: Between June 2001 and September 2004, 42 patients, 38 male and 4 female, underwent arthroscopic placement of a collagen meniscus implant (CMI) to reconstruct the damaged medial meniscus. Their age ranged between 22 and 50 years. All patients had an associated ACL insufficiency, 39 secondary to acute ACL tear and 3 ACL graft failures. ACL reconstruction with hamstrings grafts (39) and ACL revision with allograft (3) was performed at the time of CMI implantation. The interval between ACL injury and surgery ranged between 3 weeks and 6 months. Ten patients also had a lateral meniscus tear. All patients were followed with clinical, weight-bearing radiographs, KT-1000 and magnetic resonance examinations for at least 18 months (range, 18– 84 months). The IKDC form was used to record and evaluate the Results:

Results: The length of the implanted CMI ranged between 3 and 5.5 cm and required 4 to 8 stiches.

The IKDC subjective evaluation was normal in 18 patients, nearly normal in 18, abnormal in 5 and severely abnormal in 1. Range of motion was normal in 28 patients and nearly normal in 14. KT 1000 examination was normal in 32 patients, nearly normal in 7, abnormal in 1 and severely abnormal in 2.

The X ray findings were normal in 28 patients, nearly normal in 6 and abnormal in 8.

Complications included 2 saphenous nerve neuritis, 1 ACL graft tear with CMI implant breakage and 2 knee stiffness that required mobilization.

40 patients returned to work. The average time to resume work was 5.5 months

Conclusion: Simultaneous ACL reconstruction and collagen meniscal implantation is a viable and effective option in young active patients with ACL insufficiency and associated meniscal injuries.


A. Suckel

The comparability of studies of extra-articular proximal femur fractures is compromised by the lack of a widely accepted, simple classification system with clinical and prognostic relevance. The aim of the study is to define the complication profile as well as differences relating to age, gender and survival rate of simple trochanteric fractures (typ 1), intertrochanteric comminute (typ 2) and subtrochanteric fractures (typ 3).

The records of 335 consecutive patients were analysed prospectively. Patients had a mean follow-up of 10 (0–56) months, and were treated operatively with three intramedullary nailing systems.

Simple trochanteric fractures (n=67) show only wound healing problems (1.5%). Median age is m/f 76.4(45–98) years/82.7(39–101), and the two-year survival rate is m/f 50.3%/84.9%. Intertrochanteric comminute fractures (n=204) demonstrate the highest complication rates (25%) with 9.7% femur head perforations, 3.5% other hardware related problems and 11.8% wound healing problems. Median age is m/f 72.5(41–94) years/83.6(54–100), survival rate is m/f 92.7%/66.5%. We observe a complication rate of 17.0% in subtrochanteric fractures (n=64), no femur head perforation but 9.1 % other hardware problems and 7.8% wound healing problems. Median age is m/f 61.1(24–91) years/81.6(38–99), surviving rate is m/f 92.3%/67.9%. The overall complication rate is nearly twice as high in females compared to males (19% versus 10%).

The 3 types of proximal extraarticular femur fractures show diferrences in epidemiological data such as median age and surviving rates. Furthermore intramedullary nail osteosynthesis of extraarticular proximal femur fractures lead to different complication patterns in simple trochanteric fractures, in comparison to inter-trochanteric comminuted fractures and subtrochanteric fractures. The recommended surgical treatment in Type 1 fractures leads to a low complication rate. Type 3 fractures exhibit an acceptable complication level; pseudarthrosis and intraoperative shaft fissures as well as wound healings problems are the main complications. Type 2 fractures represent fractures whose treatment is problematic, with the highest complication rate of hardware-related problems (13.2%), including femoral head perforation (9.7%), and the highest number of wound healing complications (11.8%), more than a third of which are infections.


S. Mitchell J. Sinker D. Sochart

Many studies exist that assess intramedullary and extra-medullary fixation of these fractures, but few exist that compare the two. We performed a retrospective cohort study to compare the above implants in the management of subtrochanteric femoral fractures. 100 fractures in 95 patients were studied, with 47 in the recon nail group and 53 in the DCS group, with 33 male and 62 females, average age 68 years (16–98 years). Data was obtained by review of case notes and x-rays of all cases. The following information was obtained :- age, sex, energy/mechanism of injury, fracture classification (AO & Russell-Taylor, single observer), grade of surgeon, duration of surgery, ASA grading, co-morbidity (using Covinsky score), pre-operative mobility, postoperative mobility (using D’Aubigne & Postel score), mortality, intra-operative complications, post-operative complications, revision surgery/implant failure, follow-up and radiological assessment of reduction/implant position(single observer). Statistical analysis of the data was performed using chi-squared, Fisher’s, Mann-Whitney U and unpaired t-tests. Results showed no significant differences in co-morbidity, complications, mortality, duration of surgery, hospital stay, sex, surgical grade or pre-operative mobility. There were significant differences in age, fracture classification, radiological assessment of reduction/implant position, mechanism of injury and post-operative mobility. Overall 28-day mortality was 8%, post-op complications were seen in 54% and 19 cases required further surgery (detailed breakdown to be presented). Certain areas of bias were identified, in that the DCS had a higher number of complex fracture patterns, thus affecting post-op mobility, whereas the recon nail group had a higher proportion of pathological fractues.


E. Garcia-Cimbrelo A. Murcia-Mazon A. Blanco-Pozo E. Marti

Introduction. Alternative bearing surfaces to polyethylene have been introduced to avoid the appearance of osteolysis in THR. The aim of this study has been to perform prospective analysis of the data from a multi-center clinical trial for assessing the incidence of early alumina-specific-complications.

Material and Methods. We analysed 310 Cerafit cups associated with a Multicone-HA stem using alumina-on-alumina bearings implanted in four institutions from 1999 to 2003, with a mean follow-up of 4.7 years. Patients’ mean age was 52.8+13.4 years. Linear femoral head penetration was analysed using a software package.

Results. There were 4 revisions: 2 revisions due to dislocations resulting poor surgical technique (1 cup and 1 stem) and 2 revisions after a trauma (1cup and 1 stem). There was 1 alumina liner fracture 36 months after implant in a hip with a horizontal acetabular angle (35°) and a thin alumina liner (size 50/32). The other cases showed good clinical and radiographic results at the end of follow-up. The radiographic difference between the femoral head and cup centres at 6 weeks postsurgery was 2.48+0.60 mm, without changes in the course of the follow-up. The mean linear femoral head penetration was unreliable (0.00186+0.0032 mm/year) because it was below the mean error for the measurement system.

Conclusions. These data demonstrate that Cerafit Alumina-on-Alumina prostheses show excellent results after 5 years. Liner fractures are uncommon. Despite the blurred alumina images, the digitized method, although not totally accurate and used only for a general estimate, allows us to measure the approximate distance between the centre of the cup and the centre of the femoral head. Changes in linear femoral head penetration were not seen in any hip. Continued follow-up should determine if reduction in wear among the alumina-on alumina bearings results in less osteolysis.


F. Geiger M. Zimmermann-Stenzel B. Lehner C. Heisel

The aim of the study was to compare mortalitiy and complication rate after operative treatment of pertrochanteric fractures with primary cemented arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN).

283 patients, which were treated betwen 1992 and 2005 for pertrochanteric femoral fractures, except pathologic fractures and a minimum age of sixty years were included. 132 of these 283 patients were treated by primary arthroplasty.

Up to the end of 1999 all unstable fractures were treated by primary total hip replacement. In the year 2000 the PFN was introduced and only patients with severe osteoarthritis and osteoporosis received primary arthroplasty. I possible, more stable fractures were treated with a DHS.

One year mortality was chosen as main indicator as it depends on the surgical trauma as well as the rapid return to preinjury activity and further complications. A one year period was chosen as the mortality ratio approaches that of an age matched reference population after this interval. Influencing cofactors were eliminated by stepwise logistic regression analysis.

It was shown that restoration of the preoperative ambulatory level correlated with survival rate after one year. As elderly patients are often unable to cooperate with partial weight bearing, the primary stability of the device is crucial to allow early mobilisation

Mortality was significantly influenced by age, gender and comorbidities but not by fracture classification. One-year mortality was significantly higher for primary total hip replacement (34.2 %) than for internal fixation (DHS: 18.4 %; PFN 21.4 %) and hemiarthroplasty (13.3 %). Since the PFN and hemiarthroplasty were introduced the over all mortality was reduced from 29 % to 18 %.

Conclusion: For stable fractures a Dynamic Hip Screw (DHS) and for unstable fractures a short proximal femoral nail (PFN) can be recommended. Primary cemented hemiarthroplasty is a viable option for treatment of intertrochanteric fractures if osteoporosis prevents from full weight bearing or if osteoarthritis makes further operations likely. Primary total hip replacement should be avoided, due to the fact that dislocation and mortality were significantly higher than in the other groups.


W. Walter S. Kurtz M. Tuke W. Hozack K. Holley D. Campbell G. Hooper J. Garino T. Spriggins

Squeaking is a rare complication of hard-on-hard hip bearings. Occasionally the noise is troublesome enough to warrant revision surgery. The purpose of this study is to contribute to the understanding of the mechanism(s) underlying squeaking.

We analyzed 10 alumina ceramic-on-ceramic bearings from squeaking hips collected at revision surgery. The reason for revision was given as squeaking (6 cases) or squeaking and pain (4 cases). Six of the 10 patients were male, average patient age was 48. Bearings were retrieved after an average of 23 months in service (11 to 61 months). There were 4 different designs of acetabular component from 2 different manufacturers. Nine have an elevated metal rim which is proud of the ceramic and one does not. Two bearings were 36mm in diameter, 6 were 32mm and 2 were 28mm.

All 10 bearings showed evidence of edge loading wear. Mean dimensions of the wear patch were 37mm by 12mm on the acetabular component and 32mm by 13mm on the femoral heads. Wear dimension was not related to bearing diameter. Seven of the 10 implants also had evidence of impingement of the femoral neck against the elevated metallic rim or the ceramic insert or both. There was no chipping or fracture of any of the ceramic components.

Squeaking is a recently recognized complication of hard on hard bearing surface. This retrieval study is the first of its kind, to our knowledge attempting to unravel the mechanism of this undesirable complication. Although impingement seems to be present in majority of cases, the latter does not seem to be necessary. Edge loading wear was the common factor in all cases and this may prove to be a critical mechanism.


I. Rafiq S. Ahmed A. Kapoor S. Shafique H. Quyyum S.H. Zaki M. Pervaiz

AIM: Operative treatment is the choice of management for unstable sub-trochanteric fractures because it allows early mobilisation thus preventing serious and fatal complications. This study was conducted to compare the results, advantages and disadvantages of using dynamic condylar screw and interlocking nail for treatment of subtrochanteric fractures.

METHOD: A prospective randomised controlled study was carried in our centre. The study included 64 patients presenting to our Trauma and Orthopaedic unit between July 2000 to November 2003. The criterias for inclusion were an age of less than 70 years, a non-pathalogical sub-trochtanteric fracture less than 4 weeks with no previous history of surgery and a femoral anatomy that allowed osteosynthesis with intramedullary nail or a dynamic condylar screw. The patients were randomly divided in 2 groups which was accomplished with use of computer generated random numbers. The group1 treated with DCS and group 2 was treated with interlocking nail. Both groups were comparable with regard to age, gender, body mass index, medical history according to index of Fitts et al and system of American Society of Aneasthesiologists, mental status and mobility score. The pre-injury functional status of the patients was recorded using Sikor-ski and Barrington pain and mobility scale and parker and palmer mobility score. The estimated intraoperative blood loss, operative time and intraoperative complications were recorded. Follow-up was done at 4th, 12th and 24th week and then 1 year. Patients were assessed for range of hip movements, muscle strength while functional recovery was assessed with Sikorski and Barrington pain and mobility scale. The radiograph at 1 year was used to assess the neck shaft angle.

RESULTS: The mean age of the patients was 49 (range 30–65). There were 38 males and 26 females. The intra-operative blood loss, average hospital stay and operative time was more in case of patients undergoing DCS fixation(p< 0.05). The time fracture union and full weight bearing mobilisation was better in patients who had intra-medullary fixation.1 patient in group1 had screw cut out from femoral shaft, this was treated by change of side plate to longer one with bone graft augmentation.1 patient in group 2 had non-union which was treated by removal of interlocking nail and refixation of fracture with DCS along with bone graft. There was no infection, DVT or mal-union in any group.1 pateint from each group was lost to follow-up. All other patients were evaluated with Sikorski and Barrington’s pain and mobility score. The difference was not significant between the goups(p< 0.05).

CONCLUSION: The results of our study support the use of interlocking nail especially in communited fractures of subtrochanteric region.


J.M. Buchanan

Aims Osteolysis from polythene debris contributes to loosening of total hip components. Will ceramic/ceramic bearings in conjunction with Hydroxyapatite Ceramic Coated Hips (HAC) survive any better?

Material. Hydroxyapatite Ceramic Coated Hips were first used in Sunderland, U.K. in May 1988. More than 2400 HAC hips have been inserted.

There are 521 hips in 441 patients with ceramic/ceramic bearings. I am reporting this consecutive series.

These hips are generally inserted into patients with a 20+ year life expectancy. This ranges from 18 to 74. Mean age is 52.4 years. These young patients are mostly active and many are working.

Amongst the indications were osteoarthritis 297, hip dysplasia 76, and ankylosing spondylitis 18. Thirty eight had had previous childhood hip disorders, and 19 had rheumatoid arthritis. The series also includes 43 with AVN and 7 revisions from cemented hip replacement

All the patients are assessed using the Harris Hip Score before and after surgery. They are assessed annually. Post operative scores show 22 patients with Harris Hip Scores of less than 80, but only 9 patients have problems attributable to HAC hip surgery. These include 2 patients with infection, 3 fractured ceramic acetabular liners, two broken heads and 2 patients with loose cups, one from aseptic loosening. Apart from this one case, aseptic loosening has not been a problem.

Discussion. The results have been rewarding. There are 2400+ HAC hips in the whole series. This sub group of 521 ceramic/ceramic HAC hips is small with a maximum follow up of 14 years. However, there have been few failures which could be attributed to the HA coated device. The broken ceramic components are a concern. It is probable that third body inclusions between the modular components led to stress concentrations. It is also possible that acetabular impingement was a problem and the hips may have been subluxing a few microns with every step and not just gliding with every step. This might overload the alumina implants leading to their failure. All the earlier prostheses are alumina/alumina but 55 hips inserted since august, 2005 have an alumina/zirconia compound head (Biolox Delta®). There have been no cases of periprosthetic osteolysis.

Conclusions. Hydroxy Apatite bony bonding secures the implants. No cement or polyethylene is used which can contribute to osteolysis.

Wear in ceramic bearings will be negligible. Third body inclusions must be avoided to prevent wear or fracture.

The femoral spigot must not impinge on the acetabular margin causing subluxation which may lead to fracture.

The ceramic material has to be supported to prevent fracture.

The outcome of the patients in this sub-group has been rewarding. Alumina/alumina hip arthroplasty should be considered where life expectancy is substantial.


L.I. Havelin G. Hallan E. Dybvik

There has been no general agreement about the use of uncemented hip prostheses in patients with rheumatoid arthritis (RA). In the present study we compared the results for the cemented and uncemented stem that most commonly had been used in RA patients in the Norwegian Arthroplasty Register.

MATERIAL AND Methods: All hospitals in the country participate and report their primary and revision operations of RA patients to the register. This group constitutes 3.5% of the patients in the register. For the present study we included primary prosthesis operations in RA patients during 1987–2005, where either the Corail or the Charnley stem, the most commonly used uncemented and cemented stems, had been used. We calculated survival by the Kaplan-Meier method and by Cox multiple regression with adjustment for age and gender.

Results: The 10 years survival of the total hip prostheses were 81 % in the uncemented group and 89 % in the cemented group. However, the revisions of the uncemented prostheses were mainly performed due to cup problems. With revision of stem for any reason as end-point, the 10-year survival was 98% for the fully HA-coated uncemented Corail stem and 91% for the cemented Charnley stem. In the Cox regression, the risk for revision of the Charnley stem was 3.4 times increased compared to the Corail (95% CI: 1.43–8.06. P< 0.006). Also revision due to aseptic stem loosening was statistically significant increased for the Charnley stem, whereas there was no significant difference concerning revision due to dislocation or periprosthetic fracture.

Conclusions: Both stems had a 10-years survival better than 90%, and the uncemented stem had excellent results in RA patients. However, the uncemented total hip prostheses had inferior results compared to the cemented total hip prostheses due to problems with the uncemented cups that had been used in association with this uncemented stem.


L.R. McGrath

Particulate debris has been demonstrated to have a major role in the aseptic loosening of artificial joints. Biological activity is stimulated by particles of size 0.1 to 10 microns with maximum affect being seen in particles of approximately 0.5 microns. This study investigated the particle size of wear debris produced at the stem/cement interface in cemented artificial hips comparing different materials and surface finishes of the stem.

Materials and Methods: The stem surfaces of three cemented femoral prostheses with different surfaces were used as templates, one smooth (Exeter, How-medica), one slightly rough (Elite, DePuy) and one very rough (Capital, 3M). Three commonly used implant materials were compared, cobalt chrome, stainless steel and titanium alloy.

Test plates were manufactured in each material and with each of the three surface finishes.

The plates were opposed to cement pins in a sliding wear tester. The debris produced was collected, filtered and examined under an electron microscope. Representative samples of particles produced by each test series were measured and aspect ratios calculated.

Plates were also measured pre and post test to ensure no significant change in surface roughness during testing.

Results: Each of the materials demonstrated an increase in mean particle size with increasing roughness of the test surfaces. This was more marked for titanium alloy than for cobalt chrome.

For any given surface roughness the size of particles produced was smallest for the hardest material (cobalt chrome) and largest for the softest material (titanium alloy).

Conclusion: The majority of particles produced were within the biologically active range. Particle size of debris was related to surface roughness with rougher surfaces producing larger particles. Harder materials produced smaller particles than softer materials and more particles in the biologically active range.


G.H. Isaac J. Fleming P. Kay L. Nordsletten M. Stone

Hip arthroplasty has its true genesis in 1962 when the Charnley Total Hip was first implanted. The system comprised a stainless steel femoral stem with fixed 22,225mm head articulating against an all polyethylene acetabular cup. Both components were fixed in position with acrylic bone cement. There have been a number of changes in design, materials and surgical technique but the essential concept remains the same. The system was widely used by both senior and junior surgeons. Numerically implantations peaked at ~45,000 per annum in the late1980’s and is still at around ~25,000 per annum in the mid 2000’s. Geographically the system was used in all five continents. Patients varied widely both in age, activity, and diagnosis. It would therefore seem an appropriate vehicle to examine the variations in results of total hip replacement by patient profile, geography, and era of implantation.

A search was carried out on the US NCBI website for publications reporting on results with the Charnley system up to the end of 2002, and which comprised a follow-up of more than 10 years, and gave survivorship data. This resulted in 28 papers with 14 countries of origin available for review. For all studies basic data such as age and diagnosis, range implantation dates, likely specific design of prosthesis, origin of study and number in study was either reported or could be deduced. A ten year survivorship was reported in 16 studies for stem and cup and 7 for stem only. If the longest follow-up was considered for each study then 18 reported on stem and cup (9392 hips, implanted 1962–92) and 15 on stem only (4243 hips, implanted 1966–91). A total of 11 studies had four of more points on a survivorship curve, seven with stem and cup, four with stem only.

There are a number of points of interest in this data. The first is that with one exception the performance is remarkably consistent as shown by the survivorship curves. There is no significant difference in the survival rates from different centres, countries, and with implantation dates ranging from 1962 through to 1992. Secondly, there appears to have been little or no change in the average age of patients with implant date. There is some evidence to indicate from the 10 year data that failure rate per year is lower in older patients but does not seem to be affected by implantation date. The latter despite the fact that both surgical technique and component design changed over the 30 year implantation period. A further observation is that the failure rate per year is lower in studies with greater numbers of patients.

The general conclusion from this review is that the Charnley Total Hip is remarkably consistent in its performance both over time and location of implantation. Its performance also seems to have been affected very little by changes in technique or design.


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R.M. Gillies S.M. Donohoo W.L. Walter

Introduction: Squeaking is reported ceramic-on-ceramic hip bearings in association with acetabular component malposition – particularly too much or too little anteversion. Acoustic analysis of squeaking hips with modular ceramic-titanium acetabular components suggests that there may be dynamic uncoupling of the ceramic insert from the titanium shell with edge loading of the ceramic. The aim of this study was to investigate edge loading of a modular ceramic-titanium acetabular component during gait at different positions of anteversion using the finite element (FE) method.

Methods: An intact and reconstructed 3D FE model of a human pelvis was generated using PATRAN. Bone properties extracted from the CT data were applied using FORTRAN subroutines. A generic acetabular titanium shell and ceramic liner were modelled and placed in the pelvis in two different positions: ideal anteversion and 18 degree excess anteversion. The contact conditions simulated a fully osseointegrated acetabular shell and a matched taper junction with a friction coefficient of 0.2. We ran FE analysis with ABAQUS software to determine the stress distribution and surface separation of shell and liner at toe-off.

Results: The separation distance between the ceramic liner and the acetabular shell for the anteverted component (40mm) was an order of magnitude greater than that for the ideally positioned component (4mm). There was “tilting” of the ceramic liner out of the acetabular shell in both cases.

Discussion: Based on clinical observations, the toe-of phase of gait is a common position for squeaking to occur. Clinical retrievals also show evidence of edge loading wear and contralateral taper interface separation with the “tilting” of the liner out of the acetabular shell. It is envisaged that the “tilting” of the liner in the acetabular shell may allow forced vibrations associated with the squeaking phenomena, possibly in combination with edge loading.


S. Darmanis J. Timperley G. Gie M. Hubble J. Howell

Purpose: The authors would like to report a technical innovation in cemented hip arthroplasty. The new device, a “rim cutter” (patent pending) was designed in Exeter and aims at improving the surgical technique of insertion of cemented sockets. The principle aim of this innovation is to cut a rim around the periphery of the acetabulum to a set depth so that the flange of the socket seats into this rim and thus by sealing the space underneath the flange, there is a sustained rise in cement injection pressure behind the socket during implantation. This, improves cement macro and micro interlock, creates a congruent cement mantle with no radioluciencies, especially in the highly predictive DeLee-Charnley Zone I.

Materials and methods: A retrospective clinical study was performed in order to assess the radiological result of the use of the rim cutter. Two groups of patients with 30 in each group (consecutive cases) were enrolled in the present study. In group A, the rim cutter device was used while in group B, the acetabulum was prepared without the use of the rim cutter. In all cases an Exeter contemporary cup and stem were used. All cases were evaluated with postoperative radiographs which were analysed to record the anatomic measurements with regard to:

i) centre of rotation of the socket (COR),

ii) height of the centre of rotation from the teardrop,

iii) lateralisation of the centre of rotation from the teardrop, and iv) the width of the cement mantle in the three acetabular zones.

These values were compared with the equivalent measurements made for a normal contralateral hip. In addition to these measurements, any radiolucent line in any zone was recorded. The post-operative film was templated using Orthoview (TM, Southampton, Hampshire) software, which is a digital X ray templating system.

Results: The group where the rim cutter was used showed significantly improved radiological parameters. In this group (group A) the socket was placed closer to the normal centre of rotation (COR) compared to the other group (group B) where the rim cutter was not used. This difference was statistically significant (p< 0.0001). Two cases in the non rim cutter group showed radioluciencies in Zone I. Similarly, with regard to the lateralisation of the COR, the implants in the rim cutter group were closer to the COR of the contralateral normal hip The cement mantle was found to be more concentric in the rim cutter group (in group A, more patients had the same width of cement mantle in all Zones) than the non rim cutter group. This difference between the two groups was statistically significant (p< 0.0001).

Conclusions: The introduction of the new “rim cutter” represents a progression in the technique for the preparation of the acetabulum in cemented hip arthroplasty. It indicates a further step, following the introduction of flanged sockets.


O. Furnes S. Lie L. Engesæter L. Havelin

Background: During the 1990s a change in operative technique for primary hip replacement took place in Norway. This study was designed to measure the revision rate in different time periods in cemented Charnley total hip replacements reported to the Norwegian Arthroplasty Register.

Patients and methods: 26 873 primary cemented Charnley total hip replacements reported to the Norwegian Arthroplasty Register in the time periods 1987–91, 92–96, 97–01 and 2002–05 were studied. Only hips with Palacos and Simplex cements with and without antibiotic were studied. To compare the time periods Kaplan Meier analysis was used. To adjust for differences in approach to the hip, age, sex and use of systemic antibiotic prophylaxis Cox regression was used.

Results: There was 28 % less risk of revision due to all causes in the time period 1997–01 compared to 1987–91 (RR=0.72 (95% CI 0.60–0.86), p< 0,001). There was inferior result in the time period 1992–96 compared to 1987–91, but from 1997 there has been an improvement of results due to fewer aseptic loosenings of the femoral component (RR 0.44 (95% CI 0.35–0.56), p< 0.001). There was however more luxations in the later period, and there was no improvement in revisions due to aseptic loosening of the acetabular component.

Conclusion: There has been an improvement in revision rate of the cemented Charnley prosthesis the last two time periods, due to fewer aseptic loosenings of the femoral component. The reason is probably better technique of component placement and better cementation technique. In the future prevention of luxation and better cementation technique of the acetabulum should also be emphasised.


F. Damborg N. Nissen B. Abrahamsen K. Brixen H.R. Jørgensen

Introduction: Implantation of a THA changes the strain distribution pattern in the proximal femur, with a massive loss of stress in the proximal part of the femur and an increase in stress at the distal part of the femoral component.

Aim: The purpose of this study was to quantify the changes in BMD during long-term follow-up, i.e. five years, after insertion of the collarless, two-side conical, cemented Exeter stem.

Material & Methods: Eighteen patients (all women), aged 55 to 80 years, undergoing THA were included in the study after informed consent. BMD was measured in 7 regions of interest according to Gruen et al., using Dual Energy X-ray Absorptiometry postoperatively, after 18 and 60 months of follow-up. At the same time, the contra lateral hip and spine were scanned. Results were tested using Wilcoxon matched-pairs signed-rank test. P values below 0.05 were considered significant.

Results: During the first 18 months, a significant decrease in BMD was present in Gruen zones 2, 3, 6, and 7. No significant changes were seen in BMD of the zones 4, and 5 in the contra lateral hip, nor at the spine. In zone 1 there was a small but significant rise in BMD.

From 18 to 60 months of follow up we observed a significant rise in BMD in all Gruen zones but zone 4 and 7. Despite this the total periprostetic BMD decreased during the study periode. There was no significant decrease in BMD in the contra lateral hip. In the spine, we observed a significant rise in BMD.

Conclusion: During short-term follow-up (i.e. 18 months) after THA, BMD decreased in Gruen zones 2, 3, 6 and 7. The bone loss is similar to findings in other implants and seems to be related to the changes in stress pattern within the proximal femur. During long-term follow-up (i.e. 5 years) BMD increased again in these zones, however, BMD remained lower than baseline.


S. GAJJAR M.L. Porter

Introduction: We previously reported our results of 98 Charnley Low-Friction Arthroplasty in 76 patients with Paget’s disease of the hip at an average follow-up of 10.4 years. The current report presents the outcome of this procedure at 15 to 30 years.

Methods: A total of 98 Charnley low-friction arthroplasties were performed on 76 patients, 27 men (37 hips) and 49 women (61 hips) with an average age of 67.4 years (range 51–79 years). All operations were performed by the trans-trochanteric or antero-lateral approach.

Results: When component revision was used as the endpoint, the survivorship of the acetabular component was 93% at 15 years (CI, 81% to 98%), 83% at 20 years (CI, 59% to 93%), 72% at 25 years (CI, 41% to 89%) and 36% at 30 years (CI, 2% to 78%). The survival of the femoral component was 91% at 15 years (CI, 80% to 96%), 84% at 20 years (CI, 60% to 94%), 84% at 25 years (CI, 60% to 94%) and 72% at 30 years (CI, 38% to 89%). The survival of both components was 89% at 15 years (CI, 76% to 95%), 81% at 20 years (CI, 56% to 92%), 81% at 25 years (CI, 56% to 92%) and 81% at 30 years (CI, 56% to 92%).

When component failure was used as the endpoint, the survivorship of the acetabular component was 78% at 15 years (CI, 64% to 87%), 66% at 20 years (CI, 48% to 80%), 43% at 25 years (CI, 21% to 62%) and 12% at 30 years (CI, 2% to 32%). The survival of the femoral component was 76% at 15 years (CI, 62% to 85%), 67% at 20 years (CI, 48% to 80%), 47% at 25 years (CI, 25% to 67%) and 7% at 30 years (CI, 1% to 26%). The survival of both components was 74% at 15 years (CI, 59% to 83%), 64% at 20 years (CI, 44% to 78%), 43% at 25 years (CI, 20% to 64%) and 7% at 30 years (CI, 1% to 27%).

Discussion and Conclusion: Long term results using Charnley’s Low Friction Arthroplasty achieved in this patient group are comparable to general arthroplasty population.

(Previous report: Charnley low-friction arthroplasty for Paget’s disease of the hip.

J Arthroplasty. 2000 Feb;15(2):210–9).


L. Müller C. Ehrmann T. Nowak R.P. Pitto R. Forst R. Schmidt

Introduction: This study was initiated to evaluate cortical and cancellous bone density (BD) changes of the acetabulum after cemented and uncemented total hip arthroplasty (THA) using computer tomography (CT)-assisted osteodensitometry in-vivo.

Materials and Methods: 15 cemented ZCA Pfannen cups (Zimmer, USA) (age 78 years) and 21 press-fit Trilogy cups (Zimmer, USA) (age 72 years) were implanted by one surgeon. All hips were investigated by a standardized CT-mode (slice thickness 2 mm, table feed 5 mm, extended CT-scale). 6 CT-scans at the level of the cup and 4 scans above the dome of the cup were analyzed 2 weeks and 2 years after surgery. Cancellous and cortical bone mineral density (BMD) (CaHA mg/ml) were elaborated with a special software tool (CAPPA postOP, CAS Innovations AG, Erlangen).

Results: 2 years after index operation cemented cups showed mild cancellous BD loss (−8% to −20%) and no significant cortical BD changes cranial, significant cortical (−4% to −20%) and cancellous (−16% to −44%) BD loss ventral and no significant BD changes dorsal to the cup.

For press-fit cups we observed highly significant (p< 0,01) cancellous BD loss in all sectors (−17% to −53%), cortical BD loss ventral and dorsal to the cup (−12% to −23%) and very limited BD loss cranial (−4% to −13%) to the cup.

Conclusions CT-assisted osteodensitometry allows a thorough assessment of the actabular bone in-vivo. Different patterns of stress shielding were observed for cemented and press-fit cups. For the press-fit cup high BD loss for both cortical and cancellous bone was observed in all areas adjacent to the pelvic implant, except for cortical BD at the acetabular dome, suggesting fixation of the cup in the cranial cortical bone. Comparetively less BD loss was seen for cemented cups in all sectors, especially for cancellous bone, suggesting a more physiological stress transfer to both cortical and cancellous pelvic bone.


A. Acharya A.J. Timperley C. Lee

Vast amount of literature is available on mechanical properties of PMMA, but not about the composite specimens of old and new cement. This is important, as in cement revision has become established technique with good clinical results. Originally Greenwald and later Li described properties of such specimens. However in these studies the old samples were only few days old, unlike clinical situation, where the old cement is a few years old.

We therefore decided to test short-term mechanical properties of composite specimens and compare these with new uniform specimens. We choose specimens of cement 3–17 years old (median 11.8) for the manufacturing of the composite specimens.

Material and Methods: Uniform and composite specimens were fabricated and were tested for bending, tensile and shear strength. Beam shaped specimens were fabricated for bending and tensile tests, cylindrical for shear. Seventeen beams and eight cylindrical specimens fabricated earlier (1988–2002) using the same moulds were available to form composite specimens. Old specimens were placed into the moulds and new cement was injected next to these. Specimens were allowed to polymerize at room temperature for 30 minutes and stored in saline at 37 °C for 6 weeks before testing. Specimens were tested in Lloyds EZ 20 machine with customized jig so that the junction was subjected to bending, tensile or shear force.

Results: Bending tests: The load and bending stress for new specimen was 80N and 47MPa as compared with 72N and 38MPa for composite specimens. 4 composite specimens failed though old cement, 3 through the junction and 1 through the new cement. There was no statistical difference in maximum load between uniform and composite specimens (p=.29). However there was a difference in the stress between uniform and composite specimens.

Tensile tests: The load and tensile stress for new specimen was 916N and 29MPa as compared with 795N and 24MPa for composite specimens. 7 composites failed through old cement, 1 through new cement and 1 at junction. There was difference in the load and stress of uniform specimens as compared with composite specimens.

Shear tests: The load and shear stress for new specimen was 2718N and 35MPa as compared with 2055N and 26MPa for composite specimens. There was significant difference in load as well as stress in uniform specimens as compared with composite specimens.

Discussion: This study demonstrates that composite specimens fail at 89.6% of bending load, 77.2% of tensile and 74.6% of shear load as compared with uniform new cement specimens. They have 81.4% of bending stress, 74.9% of tensile stress and 73.3% of shear stress at failure as compared with uniform specimens. Of more importance is the fact that only four of these composite specimens (23.5%) failed at the junction and the rest thirteen failed either through old cement (64.7%) or through new cement (11.8%).


B. Purbach P. Kay M. Wroblewski P. Siney P. Fleming

The Triple-tapered cemented polished C-Stem has evolved from the study of long-term results of the Charnley low-frictional torque arthroplasty when the first fractured stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process- the lack or loss of proximal stem support.

The concept, design and the surgical technique cater for a limited slip of the C-stem within the cement mantle transferring the load more proximally. With a follow-up past 12 years and 4063 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.

We have reviewed 1008 primary C-Stem hip arthroplasties performed by 23 surgeons with a minimum of 5 years clinical and radiological follow-up. The mean follow-up was 7 years (range, 5 – 12) and the mean age at surgery was 57 years (range (15 – 85). In 58% the underlying pathology was primary osteoarthritis, 20% congenital dysplasia, 10% quadrantic head necrosis, 5% rheumatoid arthritis, 5% slipped upper femoral epiphysis and 4% protrusio acetabulae.

The concept of the triple tapered stem is validated radiologically with an improved proximal femoral bone stock in over 20% of cases and a maintained bone stock in 60%.

There were no post-operative complications within 1 year in 87% and no late complications (after 1 year) in 91%. The main late complications were 3.9% aseptic cup loosening, 1% infection and 0.8% dislocation. There were no aseptic loose stems.

Twenty-eight hips have been revised (2.8%), 3 for infection, 2 for dislocation and 23 for aseptic cup loosening. There were no revisions for aseptic stem loosening.

The results support the concept but place a demand on the understanding of the technique and its execution at surgery.


P. Vandenbussche T. Scheerlinck

Background: Interfacial gaps between cement and femoral hip implants are a potential source of stem debounding and loosening. We used a CT-scan technique to measure the characteristics of these gaps for two different implant types and two different implantation protocols.

Methods: Using a third generation cementing technique, 22 plastic replicas of straight Charnley-Kerboul stems (Stratec) and 18 replicas of anatomic Lubinus SPII stems (Waldemar-Link) were implanted in 20 pairs of embalmed cadaver femora. In each pair of femora, the same stem type was used. However, at one side a stem with the same size as the broach was used (line-to-line), while at the other, we cemented a stem that was one size smaller (undersized). Based on a validated CT-scan measurement tool[1], we quantified the extent of interfacial gaps, determined their location and measured the cement thickness in areas with and without gaps. Differences in interfacial gaps between both implant types and both implantation techniques were analysed with a general linear model (GLM).

Results: In total 10308 connective CT-images were segmented and analysed. Interfacial gaps were found in every specimen (average: 6.43% of the stem surface), but their extent varied widely between specimens (SD: 8.99%; 0.15% – 31.69%). According to a GLM, the quantity of interfacial gaps did not vary significantly between implant types (Kerboul: 7.92±10.69%; Lubinus: 4.61±6.14%, p=0.246) and between implantation techniques (line-to-line: 7.73±10.24%; undersized: 5.13±7.57%, p=0.416). Irrespective of the implant type and the implantation protocol, flat regions of the stem surface showed significantly more interfacial gaps than corner regions (flat: 6.02%; corner: 4.36%; Chi-square: p< 0.001). Overall, more gaps were found at the anterior surface of the implant (anterior: 7.61%; medial: 4.99%; lateral: 4.46%; posterior: 4.43%; Chi-square: p< 0.001). For Kerboul and line-to-line stems, the extent of interfacial gaps increased consistently from the distal to the proximal stem region. This was not true for Lubinus and undersized stems. The thickness of the cement mantle showed no significant differences in areas with and without interfacial gaps (cement thickness: 3.50 mm in gap regions and 3.45 mm in regions without gaps, paired t-test: p=0.823).

Conclusions: Interfacial gaps between a femoral hip implant and cement are common and were found in all specimens. As these gaps can be extensive (up to 30 % of the stem surface), they could influence implant stability and survival. The interfacial gaps described here were probably due to air that was introduced along the implant during stem insertion. Further studies are needed to confirm that theory, to determine the consequences of these gaps and to search for methods to prevent them.


S.M. GAJJAR M. Anderton D. Campbell

Aim: The dorsal flange stem was introduced following reports of stem fracture using the Charnley “flat-back” stem. This retrospective study reports the outcome using the Flanged Charnley stem in total hip replacement.

Materials and methods: Between January 1983 to December 1996, 1170 cemented total hip replacements (915 patients) were performed using the flanged Charnley stem. The main indications were osteoarthritis, rheumatoid arthritis and avascular necrosis. There were 532 females and 383 males aged 32 to 83 years (average 70.2 years). 612 patients were alive at an average follow-up of 16.6 years (9 to 22 years). All operations were performed by the trans-trochanteric or antero-lateral approach. Patients were evaluated using the Charnley’s modification of Merle d’Aubigne system.

Results: All patients had an improvement in function following the operation. Aseptic loosening of the stem was noted in 32 patients. Survivorship to revision of the femoral stem was 94% at 10 years (95% CI, 89%–99%) and 90% (95% CI, 81%–99%) at 15 years. The common complications included dislocation, wire breakage and trochanteric non-union. Femoral stem fracture resulted in 1 patient requiring stem revision.

Conclusion: The use of the Flanged Charnley stem in total hip replacement gives good long term outcome.


T. Scheerlinck D. Janssen J. van Aken N. Verdonschot

Introduction: It is generally accepted that the cement mantle surrounding femoral hip implants should be at least 2–3 mm thick. To achieve that goal, manufactures or surgeons often undersize the stem compared to the broach. However, some implants, such as the Charnley-Kerboul stem, are typically cemented line-to-line i.e. with a broach and stem of the same size. Despite their “minimal” cement mantle, these stems are very successful. This apparent contradiction is known as the “French Paradox”[1]. We used a finite element analysis (FEA) model to investigate the effect of these different cementation philosophies on cement crack propagation and rotational stem stability.

Material and Methods: Based on a CT-scan image of a Charnley-Kerboul plastic stem replica[2], twelve FEA models were created. By decreasing the stem size (4 stems), the average cement mantle thickness increased (1.71–3.77mm). However, the incidence of cement mantle defects (< 1mm) and areas of thin cement (< 2mm) decreased (defects: 34.7–0.0%; thin cement: 40.7–0.0%). The amount of cortical bone support was varied (3 times) between 18.4 and 72.2%. All models were alternately loaded with a cyclic torque load (25.8Nm) and a transversal load (400N) in a ratio of 9:1 for two million cycles. The model predicted fatigue crack formation within the cement and rotational stem stability.

Results: Overall, increasing implant size and increasing the amount of cortical bone support to the cement, improved resistance to accumulated cement damage and rotational stem stability. In both models with undersized stems, more cement cracks and full thickness (FT) cement fractures appeared after less loading cycles than in both models with canal-filling stems. Worst results were obtained with a severely undersized implant surrounded by a thick cement mantle that was poorly supported by cortical bone (first FT crack after < 100 000 cycles, > 220 initiated cracks and 0.6° of implant rotation after 2 million cycles). Best results were obtained with the maximal canal-filling stem surrounded by a thin and deficient cement mantle that was well supported by cortical bone (no FT cracks, < 10 initiated cracks and 0.3° of implant rotation after 2 million cycles).

Conclusion: This study emphasizes the importance of an adequate cementation technique that aims at pressurizing cement up to the cortical bone. This protects the cement mantle against fatigue fracture and stabilises the implant especially if the stem is undersized. From a mechanical point of view, canal-filling stems make sense. They limited the formation of cement cracks and improved rotational stability to the implant. This could explain the excellent results obtained by implants that are cemented line-to-line.


D.H. sochart N. Chaudhary

We present the results of the polished triple tapered C-stem femoral component.

Prospective data was collected on a consecutive single surgeon series of 326 hip replacements in 293 patients performed between 2000 and 2005. All operations were performed via the posterior approach with a cemented all polyethylene acetabular component and third generation cementing of the femoral component.

There were 169 (58%) female patients and 124 (42%) males. There were 111 (34%) left sided procedures, 149 (46%) right sided and 33 bilateral (10%). Average age at time of surgery was 66.3yrs (25 – 89), with an average duration of follow-up of 50 months (12 – 78). The majority of the replacements were for osteoarthritis (271 hips 83%).

Nine patients (10 hips) died during the follow-up period at an average of 36 months (18 – 52), but outcome data was available on all patients and none were lost to follow-up. There was 1 temporary femoral nerve palsy, 2 non-fatal pulmonary emboli and 3 undisplaced trochanteric fractures. There were no dislocations, fatal pulmonary emboli, deep infections or revisions for any reason.

The stem was neutral in 90%, varus in 8% and valgus in 2%. There were no progressive radiolucencies in any Gruen zones and no distal femoral cortical hypertrophy. The average subsidence was 0.83mm, with none in 21%, < 0.5mm in 28%, 0.5 – 1mm in 41%, 1 – 2mm in 8% and 2 – 4mm in 2%.

There were no revisions and no stems demonstrated any features suggestive of current or future loosening. The study and prospective data collection is ongoing.


G.J. Myers R.J. Grimer S.R. Carter R.M. Tillman S. Abudu

We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.

A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 33% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 35% at ten years but appears to have been abolished by the use of a the rotating hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.

Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery but infection remains a serious problem for all patients. We believe that a cemented, rotating hinge prosthesis with a hydroxyapatite collar offers the best chance of long term prosthesis survival.


P. Ruggieri G. Bosco L. Campanacci M. Mercuri

Purpose of this study is to report the preliminary results of the clinical experience of the Rizzoli with a new modular reconstructive tumor prosthesis for the lower limb (GMRS-Stryker).

Material and methods: based on the clinical experience and the review of 842 cases of modular tumor prosthesis for the lower limb, a new prosthetic design was introduced derived from the previous. It is a modular system with a rotating hinge mechanism for the knee and several possible options for the stems, including titanium and chromium-cobalt-molybdenum stems, cemented and uncemented, curved and straight-fluted, with or without hydroxyapatite coating. Moreover adaptors were available to revise older HMRS implants with GMRS components.

Between October 2003 and march 2006 this system was implanted at the Rizzoli in 85 cases. This series included 42 males and 43 females, ranging in age from 8 to 76 years. The sites of prosthetic reconstruction were distal femur in 60 cases, proximal femur in 7, total femur in 1, proximal tibia in 17 cases.

There were 79 oncologic and 6 non oncologic diagnoses. The histological diagnoses of the oncologic cases included 11 giant cell tumors and 68 malignant tumor: 52 osteosarcomas, 7 spindle cells sarcomas, 6 Ewing’s sarcoma, 3 chondrosarcomas. Of the 79 oncologic cases 55 were primary reconstructions with GMRS prosthesis and 24 secondary reconstructions for failure of a previous reconstruction.

In 16 cases HMRS/GMRS hybrid implants were used in reconstruction or revision, using adaptors.

All patients are periodically checked in the outpatient clinic of the Rizzoli.

Complications were reported and analyzed, x-rays were reviewed and pertinent information achieved for each patient. Functional results were assessed according to the MSTS system.

Results: at a short follow up (min 5 months, max 30 months) showed 76 patients NED (11 benign and 65 malignant), 1 NED1 after treatment of local recurrence, 4 NED1 after treatment of metastases.

There was 1 case of infection, treated with removal of the implant and spacer with antibiotics. There were 3 disruptions of the knee extensor apparatus, 1 patellar instability treated by revision of the prosthesis.

Functional result were evaluable in 59 cases and showed a function of 26% to 50% in 14% of pts, of 51% to 75% in 19%, over 76% in 67%. Results were considered good or excellent in 86% of the evaluated patients.

Conclusions: Although the results have been evaluated at a short term follow up, this prosthetic system is promising and it can also be used in some non oncological settings, such as challenging revisions of prosthetic failures with massive bone loss or some post-radiation non unions or allografts failures.


A. Bank P.P. Varga

Aims: Chordoma is an uncommon malignant tumour with developing the remnants of notochord and usually manifesting itself in patients in their forties and fifties, aggressive local tumour in some cases resulting metastatic progression and might its histological picture show malignancy in long-lived patients. The objective are the presentation of the surgical technique of wide resection in the sacrococcygeal region, discuss the technical aspects of body wall reconstruction and presentation the long-term results of the surgical treatment of sacrococcygeal chordoma in our department.

Methods: Although we have treated 48 patients surgically between 1992 and 2005, this lecture includes 37 patients with at least 2 years follow-up. We applied wide resection in all cases and if it was necessary, reconstruction of the body wall was performed by insertingmetal wire frame and artificial fascia layer.

Results: We performed 48 wide resections, in 28 cases combined with reconstruction. Most of the patients have had local pain and 26 patients have had preoperative neurological symptoms. It was attained significant local pain relief in 90 percent of the patients and in 77 percent of the patients improvement of the neurological symptoms. Due to radiologically proved local recurrence of the tumour in twelve cases we had to perform second, and in two cases third surgery.

Conclusion: The wide resection of sacrococcygeal chordoma following with reconstruction of the body wall is a well designed and safe surgical procedure which results long survival in combining in certain cases with radiotherapy.


M. HIZ T. Aksu M.C. Unlu S. Ustundag Y. Tenekecioglu

Proximal humerus is the common site for primary bone malignancies that surgical treatment consists of wide excision of the tumor and reconstruction with tumor resection prosthesis or allograft. The ultimate function of the shoulder depends on the degree of sacrification of adjacent structures. Thirty-two patients with primary malignancies have been treated by wide excision and endoprosthetic replacement by senior author between 1989–2005 12 patients were female, 20 patients were male, mean age was 26,6 years (range 7–69 years). Histological diagnosis was 14 osteosarcoma, 4 Ewing’s sarcoma, 4 chondrosarcoma, 3 parosteal sarcoma, 4 giant cell tumor, 1 aneurysmal bone cyst, 2 synovial sarcoma. Synovial sarcoma, osteosarcoma and Ewing’s sarcoma patients received neoadjuvant chemotherapy prior to excision. Mean follow-up was 50,4 months (range 6–153 months). Oncologic results were 20 patients NED (no evidence of disease), 2 patients AWD (alive with disease), 10 patients DOD (died of disease). Functional outcome was scored according to Musculo-Skeletal System Tumor Society (MSTS) rating scale, 7 patients were excellent, 22 patients were good and 3 patients were poor. Regarding complications 2 patients developed local recurrence, 2 patients had superficial infection. Infected cases were treated by systemic antibiotic treatment. All patients had dexterity of the hand and elbow. Regarding shoulder abduction and forward flexion, 7 patients whose deltoid muscle and axillary nerve could be spared got nearly normal shoulder function but even the patients with loss of deltoid had limited abduction owing to elevation of scapula by shrugging. Elongation of the newly formed shoulder capsule was seen in patients that artificial mesh augmentation was not used. Prolene mesh was used to create a new substitute instead of resected shoulder joint capsule. These patients did not show any elongation at long-term follow-up. All arthroplasties was hemi-type without glenoid reconstruction. Hemiarthroplasty by a modular tumor resection prosthesis system after wide excision of proximal humerus seems to be an effective method of treatment after shoulder malignancies. The main determinant of the function is the status of deltoid axillary nerve and rotator cuff but the patients deprived of structures had a functional upper limb with a good command of the elbow and the hand.


G. Bianchi D. Donati C. Di Bella M. Colangeli S. Colangeli M. Mercuri

Introduction: The use of allograft prosthetic composite (APC) of the proximal tibia offers advantages over prosthetic replacement or osteoarticular graft with a better functional outcome since the possibility of a careful soft tissue reconstruction;

Materials and Methods: From 1994 to 2002, 62 APC of the proximal tibia were performed in our department after bone tumor resection (56 malignant bone tumors, 4 cases of previously failed knee implant and 2 stage 3 benign tumors). The patients median age was 18 yrs (range: 11–77 yrs) and the mean resected length was 13.2 cm (range: 8.5–28 cm). The median follow up was 59 months (range: 13–137 months)

Results: In three patients (4,8%) a recurrence was reported at 22, 33 an 40 months and amputation was performed.

Infection was reported in 15 patients (24.2%): 2 early infections (healed with surgical debridment), 1 femoral stem septic loosening (treated with early revision with cemented stem); in 8 cases removal of the infected APC was required followed by implant of a new prosthetic device after cement spacer; two infections did not healed and patient underwent amputation; in two cases a good functional result was achieved removing the infected graft and covering the proximal tibia with cement and no other surgery was required.

Non union of the graft was observed in 8 patients (12.9%): in 4 patients autologous bone grafting was necessary to heal the osteotomy line. In other 3 cases non union was associated with graft fracture. In one case non union was associated with tibial stem loosening and revision of the whole implant was done.

Polyethylene wear was assessed in 5 patients (8%) and revision of the polyethylene components was always required.

Nine patellar tendon rupture (14.5%) were assessed and repaired was performed in seven cases.

The functional outcome of 42 patients with more than two years of follow up was excellent in 25 cases, good in 13, fair in 2 and poor in 2.

Discussion: APC of the proximal tibia is an effective alternative to osteoarticular graft and modular prosthesis because it allows good to excellent results in most of the patients (90.4%). The major concern is infection rate (24.2%) that usually lead to amputation (80%). Non union does not usually represent a problem because it’s tendency to spontaneous or bone grafting induced healing. Aseptic loosening of the tibial or femoral stem is rare. Patellar tendon rupture rate (14.5%) is similar to modular prosthetis rate and can be lowered using a femoral component with patellar groove.


A.F. Mavrogenis C.K. Kyriakopoulos J. Andreou P.J. Papagelopoulos

Intraarticular osteoid osteomas account for approximately 13% of osteoid osteomas. The hip is the commonest location of intraarticular osteoid osteomas.

We present 16 patients with intra-articular osteoid osteomas of the hip treated with RFA. These were 13 men and 3 women, with a mean age of 27 years (range, 16–48 years). Eight osteoid osteomas were located in the femoral head, 6 in the femoral neck, and 2 in the acetabulum.

The approximate mean duration of the procedure was 82 min (range, 50–125 min). The mean hospitalization time was 8.7 h (range, 6–12 h). All patients had pain improvement within the first 24 h. Five patients had pain relief within the first 3 days, 9 patients within the first week, and 2 patients within 2 weeks post-procedural. Twelve patients continued to have some restriction of their physical activities up to one month after the operation. All patients returned to their previous status of physical activity within the first 2 to 3 months post-procedural. At the latest follow-up, there were no residual or recurrent symptoms. Five patients complained for mild pain, which was probably due to hip synovitis that resolved within a week. One patient experienced transient paresthesias and pain in the buttock at the site of the trocar and electrode insertion.

Intra-articular osteoid osteomas have clinical and imaging features significantly different from those seen in extra-articular lesions. CT-guided percutaneous RFA is a simple minimally invasive, safe and effective method for most intra-articular osteoid osteomas.


M. Ballester J. Sanchez R. Garcia M. Font I. Vilalta J. Auleda R. Tibau

Introduction: Scaphoid fractures are the most common carpal fractures, mainly affects young man.

The fixation of the displaced fractures is well accepted, but more controversy is seen with the fixation of nondisplaced fractures.

Surgery offers less cast time, and faster return to daily and sports activities.

MATERIAL AND Methods: We present 20 patiens (17 man- 3 woman), mean age 31 years old, that sustained a nondisplaced scaphoid fracture.

Surgical treatment was performed with a volar percutaneous fixation with a Herbert canulated screw. Patients were casted for 1–2 weeks and then rehabilitation was started.

Results: 60% of the fractures were produced after low energy trauma.

Functional evaluation 2 months postoperative were flexion 60°, extension 55°, radial deviation 21, ulnar deviation 18°.

Patients returned to sports activities at 11 weeks and at 13 weeks to their previous work.

Time to bone union was 9 weeks

In 5 cases pain in the place of the surgical scar were present, we had one case of sensitive branch lesion.

Conclusions: The percutaneous fixation of the nondisplaced scaphoid fractures with a Herbert screw allowed a fast functional recovery, good union rate and few complications.


G. Fraschini F. Camnasio C. Scotti

The purpose of this study was to analyse the long-term results of prosthetic joint replacement in patients suffering from metastatic bone disease. The treatment was performed in order to prevent or treat pathological fractures, to control the pain and improve the functionality of the lower limb.

120 patients suffering from metastatic disease of the lower extremities were treated with prosthetic replacement between 1992 and 2004

The patients, 80 females and 40 males, having an age at the time of surgery ranging from 32 to 83 years, were treated by the same equipe in the San Raffaele Hospital in Milan.

The primary tumor included breast carcinoma (66), lung carcinoma (19), kidney tumor (17), prostatic tumor (7), plasmocytoma (5), non identified tumor (5), melanoma (1). The metastasis was located in the proximal femur in 112 cases, in the distal femur in 3, in proximal tibia in 5. In 8 out of 120 patients, the metastatic lesion was the first sign of carcinoma, 25 patients had a pathological fracture and the bone metastases were detected from 6 mounth to 13 years after the diagnosis of the primary tumor.

Knee: in our casuistry 8 patients with a metastasis in proximal tibia or distal femur were operated with modular prostheses: in 1 case of this group (single lesion of kidney tumor), we have implanted an allograft-prosthesis-composite.

Proximal femur: for the treatment of this site, we have included also those patients having a life expectancy inferior to 1 month. In 30 cases the lesion was located in the epiphysis and neck and we have implanted 5 endoprosthesis, 5 total hip prostheses and 20 bipolar prostheses. In 82 patients with a metastasis located in the metaphysis we used a modular prosthesis with a femoral resection up to 16 cm.

69 patients are alive with a follow-up ranging from 6months to 12 years. 5 patients died in early post surgical period. 13 patients developed local recurrence. These latest have suffered from a pathological fracture, which had occurred before the first surgical treatment. Pain relief was achieved in all patients after surgery with acceptable functionality of the operated limb.

We considered the risk of pathological fractures more important than life expectancy. Moreover, we believe that the surgery to these patients should be definitive. In fact, the use of prostheses allow for a wide resection of the lesion. This condition represents also an advantage in those cases where radio- or chemiotherapy can not be performed. Moreover, the prostheses permit an immediate weight bearing, a good functional recovery and also, in patients with critical general condition, a more easy assistance. In conclusion, for patients with metastatic bone disease, we consider a correct approach the radical excision of the lesion and the implant of a prosthesis.


P. Tunn D. Pink P. Reichardt S. Fehlberg

Frequent imaging after a completed multimodal therapy of osteosarcoma is recommended by therapy optimization studies to detect local or systemic tumor recurrence. Considering the low rates of local recurrence, regular local imaging has to be questioned.

150 patients with osteosarcoma were treated in our department between 1991 and 2005. The median age of patients with osteosarcoma was 17 years with a range of 4 – 79 years and a female:male ratio of 1:1.1. The primary tumors of 147 patients were treated surgically, while 3 patients refused to be operated. After a wide resection, a tumor endoprosthesis was implanted in 103 (70.1%) of the 147 patients, 16 (10.9%) patients underwent a Borggreve rotationplasty, a resection and biological reconstruction was implemented in 10 (6.8%) patients, while further 18 (12.2%) patients were amputated. The median follow up was 95 months.

Local recurrences appeared in 2 (1.4%) patients which had been treated with a hemipelvectomy. After implantation of a tumor endoprosthesis, local recurrences were not observed. Postoperative complications observed after the implantation of a tumor endoprosthesis included infections (n=14; 13.6%), loosening, fractures and wearing of endoprotheses (n=7; 4.8%), luxation (n=1; 0.7%) as well as traumatic shaft fractures of involved bones (n=5; 3.4%). All complications included specific symptoms and were diagnosed outside the routine follow up.

In conclusion, local radiological imaging after resection of an osteosarcoma and reconstruction with a tumor endoprosthesis as a routine examination should be questioned, however it is definitely indicated in patients with specific symptoms.


P. De Biase P. Caldora M.M. Somigli D.A. Campanacci G. Beltrami

Radiofrequency ablation (RFA) is a relatively new technique to produce cell death by radiowaves (460– 480 kHz) caused by an alternating current emitted from the tip of a needle electrode and causing local ions vibration producing heat. In orthopaedic fields RFA has been proposed for the treatment of osteoid osteoma and painful metastases.

Methods: 121 patients with a clinical and radiographic accerted osteoid osteoma have been treated with percutaneous radiofrequency ablation at our institutions from 1998 till December 2005. Average age of the patients was 23 years. Preoperative symptoms lasted 10 months on average. The osteoid osteoma was localized at the limbs in 111 cases, at the pelvis in 4 cases and at the spine in 6 cases.

Results: At follow up we had 3 cases of recurrences and 2 fair results with a total of 5 unsuccessful cases. The fair results were due to a mistake of radiological indication and one case of ineffectively ablation. We observed 3 cases of skin burns in tibia with superficial infections: 2 cases resolved without treatment while the latter case showed initial bone infection and needed surgical revision.

Conclusion: Percutaneous RFA of osteoid osteoma proved to be a successful treatment in more than 95% of the cases with a low complication rate.


M. Rongieres J. Ayel A. Gaston P. Mansat M. Mansat

Treatment of advanced Kienbock’s disease is challenging, and controversial. Palliative procedures should be chosen.

The goal of this study was to analyse the results of scaphocapitate arthrodesis with lunarectomy in advanced cases. Fourteen consecutive wrists in 13 patients were re-examined at a ranged follow-up of 31,7 months (range 3 to 103). Preoperative radiographs showed Lichtman stage 3a disease in 4 patients, stage 3b in 9 patients, and stage 4 in the last patient. Eight patients were women, and the involved wrist was the dominant in 8 cases. The age at operation averaged 36,6 years (range 24 to 55). Symptoms consisted in pain or pain with stiffness. Operative techniques consisted through a dorsal approach in excision of the dorsal interosseus nerve, lunarectomy, and scaphocapitate arthrodesis. Autologous bone graft was used in 8 cases, and osteosynthesis used K wires or staples. The wrists were immobilized in arm cast during 6 weeks, and rehabilitation was started. Postoperatively, one patient developed a complex regional pain syndrome.

At longest follow-up, patients were very satisfied in 8 cases, satisfied in 4, and poorly or not satisfied in 2 cases. Three wrists were painless, and only one wrist had no improvement. One wrist had no improvement. All the employed patients returned to their original work. Mean wrist motion increased slightly. Flexion increased from 33.3 to 33.9°, extension from 39.6 to 39.3°, ulnar deviation from 20 to 23.7°, and radial deviation from 18.8 to 17°. The arc of motion was useful (Flexion- Extension: 73.7° range, Pronation-Supination: 172.7°) Grip strength increased and reached 64.5% of the controlateral wrist. The mean gain was 5.6 Kg (+199%). The improvement was slow and very progressive over one year. On radiographs the arthrodeseses were consolidated in all cases, but the union seemed partial but asymptomatic in two wrists. Correction of scaphoid in flexion was difficult to obtain. No arthritis or degenerative changes were observed, but the distal radial epiphysis seemed to be reshuffled to the new joint and articular surfaces, with progressive disappearance of the radial lunar notch

Scaphocapitate arthrodesis associated with lunarectomy allows getting a painful and functional wrist. This simple procedure theoretically decreases load across the radiolunate joint, prevents further carpal collapse, and stabilizes the midcarpal joint.


P.J. Delgado J.M. Abad A. Fuentes F. Forriol F. Lopez-Oliva

AIM: We present the results of scaphoid non-unions treated with open reduction, bone grafting and internal fixation with biodegradable implants on active heavy labour workers.

MATERIAL AND METHODS: Between 2002 to 2004, 20 patients with scaphoid non-unions were treated by open reduction, bone grafting and internal fixation using self-reinforced poly-L-lactic acid screws. The mean prospective follow-up was 24 months (range, 12–38 months). The mean age was 28 years (range, 18–42 years). All patients were male and heavy-labour workers.

The patients were assessed clinically (modified Mayo wrist score) and radiograhically. The grip and pinch strength were also studied.

RESULTS: We find 13 excellent results, good in 5 cases and poor in 2 cases. A Matti-Russe group patient was revised 6 months after the first intervention. Any fragment displacement, implant loosening or adverse reaction was found. Most of the patients (90%) return to the same work and the same level without complications.

CONCLUSION: Both groups are a good alternative for the scaphoid non-unions treatment. However, biodegradable implants disappears in the time, the removal are no necessary, facilitate the revision surgery, if necessary, and permitted MRI studies to evaluated the graft viability.


K. Owers P. Scougall D. Dabirrahmani G. Wernecke A. Jhamb W. Walsh

Negative ulnar variance, lunate shape and increased load transmission are associated with Kienbock’s disease. This may reflect trabecular alignment being more susceptible to shear forces along “fault planes” in Type 1 lunates, causing microfractures and avascular necrosis. The aim of this study was to assess the relationship between lunate bone structure, density and ulnar variance.

Standard 90/90 radiographs of 22 cadaveric wrists were taken for ulnar variance and lunate shape. The lunates were harvested and routine CT scans (1mm) were taken in 22/22 in the coronal, sagittal and transverse planes. DICOM files were analysed using Mimics (Materialise, Belgium) to measure Hounsfield units. MicroCT scans (SkyScan, Belgium) (40 μm) were taken in 10/22 in the coronal plane and measured for trabecular angle at the proximal and distal joint surfaces and the ‘tilting angle’ (between scaphoid and radius joint surfaces). Data was anlaysed using one-way ANOVA tests using SPSS for Windows.

Negative ulnar variance was noted in 7/22, neutral 10/22 and positive 5/22. Lunate shape according to Zapico was 0/22 Type 1, 18/22 Type 2 and 4/22 Type 3.

Lunate bone density was significantly lower in the ulnar positive specimens compared to ulnar negative and neutral (p< 0.001) (fig. 1).

The average trabecular angle measured 84.7° (+/− 4.5°) at the proximal and 90.3° (+/− 2.6°) at the distal joint surfaces and tilting angle was 115.7° (+/− 12.0°) (fig. 2). The 50% slice on the microCT correlated best with xray measurements of this angle.

This study quantifies the previous finding that load transmission through the lunate and hence lunate bone density is related to ulnar variance and that this is higher in ulnar negative wrists. MicroCT is a useful modality to assess trabecular structure and supports the ‘fault plane’ hypothesis of Kienbock’s Disease.


N. Darlis F. Giannoulis R.W. Weiser D.G. Sotereanos

Arthroscopic debridement and pinning is not considered to be effective in dynamic scapholunate (SL) instability treated more than three months post injury; open procedures (capsulodesis, tenondesis, SL ligament reconstruction, intercarpal fusions) are preferred for these patients. The best procedure for this problem is yet to be determined. A restrospective review of the senior author’s records produced thirteen patients with late presenting dynamic SL instability who were unwilling to undergo an open procedure and were treated initially with aggressive arthroscopic debridement and pinning. The mid-term results of this approach are presented.

Eleven of the initial thirteen patients were available for follow-up. Their mean age was 36 years (range 23–50) and the mean time elapsed from injury was 7 months (range 4.5–10). The diagnosis of dynamic SL instability was based on a positive Watson’s test, SL gapping on grip view radiographs and arthroscopic findings of a Geissler type III (in 5 patients) or type IV (in 6 patients) SL tear. The SL angle was under 550 in all patients. The procedure included aggressive arthroscopic debridement of the torn portion of the SL ligament to bleeding bone in an effort to induce scar formation in the SL interval. The SL interval was subsequently reduced and pinned (with 2 pins through the SL and one pin in the scaphocapitate joint) under fluoroscopy. The pins were removed at a mean of 9.6 weeks (range 8–14).

The mean follow-up was 36 months (range 12–76). Three patients were re-operated at 9, 10 and 11 months after the initial procedure. Re-operations included a dorsal capsulodesis, a four-corner fusion and a wrist arthrodesis. The eight remaining patients achieved two excellent, four good, one fair and one poor result with the Mayo wrist score. Patients diagnosed with Geissler III tears were found to be younger and achieved better final wrist score (mean 86 points versus 76 points in patients with Geissler IV tears). Two pin track infections were treated conservatively.

Late (more than three months post injury) arthroscopic debridement and pinning was found to be only moderately successful for dynamic SL instability (6 out of 11 patients achieved a good or excellent result without re-operation). This approach, however, does not preclude subsequent open surgery. It is best suited for patients with Geissler type III tears (not a gross drive through sign) who are unwilling to undergo an extensive open procedure provided they understand the risks and benefits of this approach.


M. Citak R. Gaulke D. Kendoff I. Hamwi C. Krettek T. Hüfner

Introduction: Image based navigation is able to increase precision and reduce intraoperative radiation time in drilling procedures in orthopeadic trauma indications. Due to specific anatomic conditions and necessary adequate fluoroscopic visualizing, specific indications need intraoperative 3-D fluoroscopy based navigation modalities. This kind of navigation has already been successfully used in several orthopaedic interventions. The complex anatomic structure of the scaphoid, the suggested minimal invasiveness and misplacement rates of the screws make 2-D based fluoroscopic navigation impossible. Missing options for a stable reference marker fixation at the scaphoid or carpus did not allow an intraoperative registration for the navigation. We report about the development of an adequate non invasive fixation technique of the reference marker for navigated interventions and the first implementation of 3-D fluoroscopy based scaphoid screws.

Materials and method: Fixation of the reference marker was achieved by immobilisation of the complete hand and forearm in maximum dorsal extension of the wrist. We used a completely new developed radiolucent hand fixation device (HFD) fixed nonivasively to the carpus and a conventional navigation system (Brainlab, Germany) in combination with 3-D fluoroscopic imaging (Iso-C, Siemens, Germany).

Tests were done on 10 intact specimen and the process included the initial drilling and final placement of an osteosynthetic screw. Postoperative placement was controlled with a 3-D scan. Results concerning a defined optimal screw positioning and drill failures attempts were done by another independent surgeon.

Results: All 3-D scans were done without complications. The multiplanar reconstructions allowed a proper visualisation of the scaphoid in all cases. No additional movement of the fixed extremity occurred during the operation. No registration failures were detected. An optimally defined screw placement in the scaphoid was achieved in 9 cases. Two repeated drill attempts were necessary in one case, another case needed three drill attempts. The scaphoid was never perforated.

Discussion: Our development of a new immobilizing device for the complete hand and forearm allows proper use of 3-D fluoroscopy based navigation at the scaphoid including a placement of an osteosynthetic screw. Further movements of the hand or fingers are intraoperatively only possible after the definite drill placement has been performed.

The 3-D imaging modality allows a direct control of the reduction and screw placement intraoperatively. Our tests did not include simulated fracture conditions, a general use of our new technique can now only be implemented to non displaced fracture types, while clinical and further laboratory tests have to improve our findings for all types of scaphoid fractures.


M. Broadbent M. Shakeel O.S. Bach

Aims: Chronic wrist pain has always been a diagnostic challenge. With the introduction of wrist arthroscopy and MRI, previously used techniques such as arthrography and cineradiography were made redundant. However the gold standard of wrist arthroscopy can still fail to diagnose the problem in some patients with chronic wrist pain. The aim of this study was to demonstrate that the combination of arthroscopy with arthrography gives more information, therefore permitting a clearer diagnosis in these patients.

Methods: A retrospective cohort study of 40 consecutive patients who underwent wrist arthroscopy for chronic wrist pain, between November 2003 and October 2005. All patients had their investigation and management by a single upper limb consultant orthopaedic surgeon. All had plain x-rays, 42.5% had MRI prior to surgery, and all but one had an intra-operative arthrogram, performed under the same anaesthetic as for the wrist arthroscopy. All demographic data was collected along with history of the patient’s wrist pain, examination, investigations and management.

Results: The results showed a ratio of patients 21M: 19F with mean age of 38 years in males and 40 years in females. On examination 15% demonstrated pain with carpal instability. 55% showed pathological findings on their X-rays. 82% of those who had an MRI, had a pathological finding. 97.5% had wrist arthrograms intra-operatively. 56% of these showed pathological findings on wrist arthrogram. In 18%, it altered the differential diagnosis prior to performing the arthroscopy and 38% it reinforced our diagnosis.

The final diagnoses after wrist arthrogram and arthroscopy were 42.5% with TFCC injuries, 20% with SNAC pathology, 20% with synovitis with no other pathology, 10% with carpal ligamentous pathology and 7.5% with radiocarpal osteoarthritis.

Conclusions: Performing an arthrogram initially provided more information, thereby allowing the surgeon to undertake the arthroscopy with increased accuracy. It also permitted the diagnosis of more subtle findings.

Therefore, the arthrogram is another tool in the diagnosis of wrist pathology, and should not be forgotten. It is especially useful in patients with chronic wrist pain, where the diagnosis may be more complicated.


M. Hexel M. Chochole M. Wlk C. Krasny F. Landsiedl

Introduction: Ulnocarpale Impaction Syndrom is defined as a degenerative disease on the basis of a relative mis-proportion in lenghth ratio between ulnar and radius, caused either by posttraumatic degeneration or idiopathic history. This causes an unusual high load bearing in the ulnar carpale joint as well as in the distal radio – ulnar joint. All these factors lead to a degeneration of the triangular discus, secondary lunotriqutral instability and chondromalazia of ulna, lunate bone and the triquetral bone.

Ulnocarpale Impaction Syndrom is diagnosed by clinical evaluation as well as typical radiologic findings. If non operative treatment leads to unsatisfactory results few operative options can be considered. Ulnar shortening osteotomy is one of them.

Material and Methods: From 2003 until 2006, 10 Patients were treated. 3 female patients and 7 male patients, with an average age of 46 years and/or 42,7 years were operated on. We evaluated forearm rotation, power, DASH Score, Numeral Analogue scale and radiologic findings considering ulnar lenghth and bone consolidation.

Results: Painfree forearm rotation increased significantly postoperatively. An increase in power was seen as well as a reduction of the DASH score of 51,6 points. Also the numeral analogue scale showed a reduction of 5 points. Postoperatively the ratio of ulnar to radial lenghth was nearly equal (average of ulnar -1mm) and all osteotomies showed normal bony healing.

Conclussion: Surgical therapy of painful ulnar impaction syndrom using ulnar shortening osteotomy seems to be a very feasible and practical procedure. In comparison to resection arthroplasty and the wafer procedure, ulnar shortening osteotomy shows no significant increase of pressure in the sigmoid fossa. Therefor it is the treatment of joice in our departement.


J.A. Webb J. Stothard

Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments.

Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre.

Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded.

Costings of theatre time and out-patient time were obtained from the hospital management.

Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation.

Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum.

Discussion: We conclude that outpatient interventions for dupuytrens disease, ganglions and trigger digits results in significant cost savings over formal surgical treatment.


J. Font A. Monegal F. Santana J. Doreste X. Mir

Introduction. Prospective comparative study to evaluate the efficacy of the ultrasound diagnosis vs MRI in rupture of the Triangular fibrocartilage with arthroscopic confirmation.

Material and methods. 55 patients presenting clinical wrist pain were studied from January’2004 untill september 2006. Our patient selection was composed by 30 men and 25 women, and the age range was 17 to 70 years old. 40 were Right-handed and 15 Left-Handed. Patients presented wrist pain related to several disorders. Our protocol included Sonography with a 11–MHz linear array probe using real-time compound spatial imaging and 1T-MRI studies. Wrist arthroscopy was performed in all of them.

Results. 67 % of our patients presented Triangular fibrocartilage rupture at arthroscopy. The distribution of our patients related to the complementary tests was:

- Arthroscopy (+) 37 cases out of 50 (64%)

- Ultrasound (+) 21 out of 37 (+ Art))

- MRI (+) 22 out of 37 (+ Art)

According to this results we can easily calculate the sensibility/specificity and PPV/PNV of both tests:

- Ultrasound Sensibility/Specificity: 58,3 %/36,8 %

- MRI Sensibility/Specificity: 61 %/47 %

- Ultrasound PPV/PNV: 58 %/31,8 %

- MRI PPV/PNV: 68 %/37 %

Conclusions. Due to the results we obtained in our study, we can consider ultrasound as sensible and specific as MRI at diagnosis for the rupture of the Triangular fibrocartilage. In our opinion we conclude that neither MRI nor ultrasound results should be considered satisfactory for a proper diagnosis. This could be sorted out by the use of more resolutive MRI and ultrasound equipments.


N.A. Darlis F. Giannoulis R.A. Kaufmann D.G. Sotereanos

Despite the widespread use of demineralized bone matrix (DBM) allografts there are few clinical studies comparing DBM to iliac crest bone grafting (ICBG). A comparison of DBM to ICBG is presented in patients who underwent four corner fusions of the wrist by one surgeon using identical operating technique.

The senior author’s first fourteen consecutive patients in which DBM was used for four corner fusion were compared with fourteen patients selected from a total of 48 patients in which ICBG was used. The ICBG group was matched for age, indication and healing impairing co-morbidities (mainly smoking). Patient radiographs from the 8th, 12th and 24th postoperative week follow up were digitized and blinded. Three orthopaedic surgeons, not involved in the patients care, rated the degree of bony union in a scale of 0 (no evidence of healing) to 3 (solid bony healing). The operating technique and fixation was identical in all patients. K-wires were removed at a mean of 8.2 weeks for DBM and 7.7 weeks for the ICBG group.

All patients had a minimum follow-up of one year. All fusions healed both radiographically and clinically without complications. Review of the radiographs revealed significantly less visible healing at 8 weeks in the DBM group (mean score 1.50 versus 1.74 of the ICBG group, p< .05). Lower scores were also obtained for the DBM group at 12 and 24 weeks but they did not reach statistical significance.

In this study both DBM and ICBG were equally effective in achieving solid bone union for intercarpal fusions. However, the statistical power of this series is not adequate to conclude that healing rates are equal between the two graft materials. The radiographic appearance of bridging bone lagged behind in the DBM group. The biological significance of this finding is not clear; it could indicate delayed mineralization at the fusion site. Such a delay may be significant in graft choice for patients with healing impairment.


G. Heers J. Grifka N. Borisch

Abstract: Although the unconstrained pyrocarbon prosthesis (Ascension®) has been presented as a new alternative in the treatment of idiopathic arthritis of the proximal interphalangeal joint of the hand a few years ago, there is still a lack of studies analyzing the results of this implant.

In this study 10 patients (13 implants), that were tretated with this type of prosthesis between february 2002 and january 2005 were studied. All but one patient were satisfied with the postoperative situation and would agree to another operation.

A significant pain reduction was observed. The average ROM was 58degrees. Five patients demonstrated a free extension, two patients had a swan neck defomity, which could be actively compensated for, and the remaining six patients had an extension deficit of 30–45degrees. The average flexion was 76° (+/−12°).

X-ray examination was unremarkable in eight patients with a regular position of the endoprosthesis. However, in five patients significant radiolucent lines (> = 1mm) were observed. So far, a luxation of the prosthesis has not occurred and all implants are still in-situ. However, a dorsal tenoarthrolysis had to be performed in 3 patients.

The results of this study show a high rate of patient satisfaction with a significant pain reduction. The radiological results have to be closely monitored in the future.

Long-term results with a higher number of patients are necessary. A central registry for finger implants is recommended.


T. Kasai Y. Ogawa S. Ishii T. Chikenji Y. Hamada M. Miyamoto

OBJECTIVE: The purpose of this study were to present a new surgical classification, based on types of injuries, and to evaluate significance of our post-operative protocol for fingertip replantation, especially crush-avulsion cases.

METHODS:Twenty fingertip amputations in 20 consecutive patients were replanted at our institute for recent 5 years. There were 17 male patients and 3 female patients, ranging in age from 19 to 62 years(mean,45.3years). All cases were classified as crush and avulsion according to Yamano. There were 13 amputations in Zone I and 7 in Zone II according to Tamai’s classification for the level of amputation. Also, we classified our cases based on the type of injury. [New Classification] Type IA: Distal transverse palm arterial arch (DTPA) is remained in the proximal part Type IB: DTPA is remained in the amputated part Type II : Loss of DTPA There were 4 cases in Type IA, 4 in Type IB, and 12 in Type II. Postoperatively, 12000–24000U of urokinase and 500 ml of low molecular-weight dextran were given intravenously for 7 consecutive days. In very severe crush/avulsion cases, 10000–15000 U of heparin were given intravenously for 5 days additionally.

RESULTS: The overall survival rate of the 20 replantations was 90.0% (zone I:83.3%, Zone II:100%). The survival rate was 100% in type IA, 100% in type IB, and 83.3% in type II. For arterial repair, vein grafts were necessary in 1 of 4 type IA(25%), 1 of 4 type IB(25%), and 11 of 12 type II(91.7%). In 3 of 4 type IA, end to end anastomosis were possible by the technique of transpositioning DTPA. In 3 of 4 type IB, proper digital artery was anastomosed to central artery of the pulp. Regarding functional outcomes with a follow-up period greater than 6mons, excellent cases were 87.0% (according to Tamai’s functional classification). The mean range of motion of the distal interphalangeal joint was 40 degrees. All patients achieved protective sensation of replanted fingertips. Other complications were cold intolerance(22.2%), nail deformity(66.6%), and pulp atrophy (33.3%). Blood transfusions were not necessary in all cases.

CONCLUSIONS: Our new classification of fingertip amputation based on DTPA was available for strategy of arterial repair, because if DTPA is lost, most cases (91.7%) need vein grafts. Also, in crush/avulsion fingertip amputation, our clinical protocol was very useful and raised success rate of fingertip replantation (90.0%) for crush-avulsion cases.


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E. Prause D. Power M. Khalid S. Tan

Introduction: In 1979 Linburg and Comstock described anomalous tendon slips between flexor pollicus longus and the flexor digitorum profundus in 31% of individuals (Linburg, Comstock; J Hand surg 1997, Jan). The purpose of this study is to find out the incidence of Linburg-Comstock Syndrome in the British population.

Methods: A clinical examination of the hands of healthy volunteers, including office workers and medical professionals was carried out. It was determined if flexion of the thumb causes concomitant flexion of index or/and middle finger. Additionally, pain on passive extension of the fingers was also documented.

Summary of Results: 70 volunteers were included, the test for Linburg-Comstock syndrome was positive in 55% of people who had concomitant flexion of the fingers with the thumb and pain in the wrist with passive extension. In 70% of people just concomitant finger flexion was seen. In 10 cadaveric dissections no connecting tendon slips were found but one fibrinous connection between FPL and FDP was noted.

Conclusion: Our study shows that the incidence of Linburg –Comstock Syndrome is much higher than previously thought based on the clinical examination. However cadaveric dissections did not confirm a distinct structural connection except in one case where there was a fibrinous connection. It is likely that at least in some cases it is a acquired anomaly in response to repeated use/overuse of thumb and index fingers.


M. Ashraf R. Thakral T. McCarthy P. Lundon K. O’Sullivan J. MacElwain

Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate the validity or otherwise of this standard sign.

Material and Methods: Metal pointers were attached to the dorsum of the fingers, flexed at MCP and PIP joints. These pointers represented the mid longitudinal axis of the phalanges. Standardised AP radiographs of the closed fist were taken in all cases with the wrist placed in neutral position, in a custom made jig. The radiographs were assessed by two different observers using Picture Archiving and Communication System, software version VA42B, to determine the convergence of the metal pointers towards the scaphoid tubercle, as described in the cascade sign and Lister method..

Statistics: Power of the study was determined with an assumption of a type-2 error of 0.05 and a two sided test. Descriptive statistics and confidence limits were calculated using SPSS 11 software.

Results: We observed that the metal pointers did not equivocally converge towards the scaphoid tubercle. The persistent pattern of convergence was within a 2–3cm radius of the scaphoid tubercle. The statistical analysis, two tailed paired t-test of this pattern showed strong association with this latter finding. (p< 0.003).

Conclusion: Our study suggests that the cascade sign is sensitive but not specific to access the rotational deformity of the fingers. Radiological there is significant scatter about the scaphoid tubercle.


T. APARD Y. SAINT CAST

Introduction: The surgical gold standart treatment of the thumb osteoarthritis is the trapeziectomy with tendon interposition and ligament reconstruction. The trapeziometacarpal prosthesis is an option badly estimated in the literature.

Between 1994 and 2001, 43 non-cimented trapeziometacarpal prosthesis ARPE® (Biomet) was implanted by the same operator for isolated trapezio-metacarpal degenerative osteoarthritis. The minimal follow-up is 5 years.

The aim of this study is to evaluate the fonction of the thumb with a 5 year-old or more trapeziometacarpal prosthesis. The technique is described and the revisions are analysed.

Material and methods: 33 women and 2 men, mean age 59,4-years, were operated after failure of the conservative treatment. There are 7 lost sight (9 prosthesis) and 2 deaths (2 prosthesis). 27 other patients (32 prostheses) were examined by the author with an original revision questionnary associated to the score of DASH. The average follow up for the 25 prosthesis always implanted is 86 months.

7 revisions (16%) were necessary on average after 34 months (1 month in 10 years) : 5 for loosenning, 1 for premature dismantling and 1 for recurrent partial dislocation. 6 were treated by trapeziectomy with tendinous interposition of palmaris longus according to the technique of F.E. Jones.

Results: The mobility is perfect for all patients but one. There is no tendancy for the cup or steem to sink into the bone but there is often some medial calcifications around the trapezium. Average DASH score is 27.4/100. There is no infection and only one dislocation at 1 months (reduction by closed procedure). The survival of the prosthesis is 85% in 5 years.

In the first 13 months, 4 revisions is necessary. The ablation of the cup is easy but the extraction of de metacarpal still is often difficult. The scaphometacarpal height is constantly lowered (34,5 % on average). Aesthetically, 2 patients are disappointed and preferred their thumb with prosthesis.

Discussion and conclusion: The prosthesis ARPE ® is an effective option in this series for the treatment of the degenerative trapeziometacarpal osteoarthritis but its radioclinic control is necessary for the first year.


M.S. Zafar V. Rajaratnam M. Craigen

PURPOSE: The success of treatment for mucous cysts of the distal interphalangeal joints of the fingers has been widely variable. The aim of this study was to evaluate the results of surgical treatment of these cysts at our hand unit.

METHODS: Eighty one cysts were treated, with a mean follow up of 18 months(6–24 months). Thirty-one patients (25%) had nail ridging or deformity at presentation. All patients had surgical excision and joint debridement through a dorsal approach.

RESULTS: All patients who underwent surgery had evidence of osteoarthritis with osteophytosis at the time of surgery. No recurrences were noted. Nail ridging resolved after surgery in 55 (67%) digits; the remaining digits had partial improvement or persistent ridging. Five (6%) infections occurred and were treated successfully with antibiotics(4 cases) or debridement,(1 case).6 patients had increased stiffness of the joint and occasional pain or swelling noted in 8 (9.8%) cases.

CONCLUSIONS: Contrary to the published literature, the recurrence rate following excision and joint debridement is very low. Although some patients have decreased range of motion, pain is usually relieved. Some residual sypmtoms might be related to the underlying arthritic process rather than a complication of treatment.


G. Gradl M. Wendt P. Gierer M. Beck T. Mittlmeier

Objective: Osteoporotic fractures of the distal forearm are demanding in terms of operative therapy and implants used. Volar fixed angle plating has become a standard procedure for these fractures. Recently intra-medullary nailing was introduced in clinical practice for the use in distal radial fractures. This randomized multi-center study compares both fixation techniques in terms of clinical and radiological outcome as well as quality of life score.

Material and Methods: Up to now a total of 85 patients with extra- and intraarticular unstable fractures of the distal radius were included. 53 patients (Targon DR®, B. Braun-Aesculap: n=24; 2.4 mm plate, Synthes: n=29) completed the 6 months follow-up. Follow up examinations included an osteodensitometry using pQCT, X-ray analysis and a detailed clinical function examination. In addition the SF36 questionaire for quality of life assessment was carried out.

Results: The operation time for volar plating was significantly longer than for intramedullary nailing (50.3±20.2 min versus 40.2±13.4 min), as was the time in hospital (5.4±1.8 days versus 2.2±0.6 days) (MW±SD; p< 0.05; Student-t-Test, post hoc: Bonferonni). The Gartland an Werley function score averaged 2.7±1.1 versus 1.9±0.8 for volar plating in comparision to treatment with the Targon DR® nail and thus just failed to reach statistical significance (p = 0.052). Radiological Evaluation revealed bony healing in all patients of both groups. Radial length was maintained in all but one patient (96%) in the nailing group and all but 2 patients (93%) in the plating group. A loss of volar tilt −5°was seen in 1 patient in the nailing group (4%) and 3 patients in the plating group (10%). Of interest radiological signs of bony healing developed much faster after intramedullary nailing. The Quality of life as measured by the SF36 was minimaly diminished in both groups (body/social function: Targon DR®: 56.3±25.1/63.4±21.2 points − 2.4 mm plate: 52.8±23.3/60.5±23.3 points). Osteoporotic bone loss was detected in a total of 72% of patients. Osteoporosis had no adverse effects on bony healing or functional parameters. We encountered two complications. One mild CRPS (volar plating) and in one case paraesthesia of the R. superficialis n. radialis (intramedullary nailing).

Conclusion: Both intramedullary nailing with the Targon DR® nail and volar plating using a 2.4 mm volar fixed angle plate allows stable fixation of osteoporotic distal forearm fractures. Lower operation time and minimally invasive operative procedure of intramedullary nailing is accompanied by faster mobilization.


A. Moroni C. Faldini A. Hoang-Kim F. Pegreffi F. Tesei S. Giannini

Introduction: Screw loosening is a common complication of osteoporotic fracture fixation leading to implant loosening, fracture malunion and non-union. Because recent animal studies have shown that bisphosphonates improve implant fixation we wanted to assess whether alendronate (ALN) improves screw fixation in a clinical setting of osteoporotic fractures.

Methods: Sixteen consecutive patients with AO/OTA A1 pertrochanteric fractures were selected. Inclusion criteria were: female over the age of 65, BMD T-score less than −2.5 SD. Fractures were fixed with a pertrochanteric fixator and 4 hydroxyapatite (HA)-coated screws. Two screws were implanted in the femoral head (screw positions 1 and 2) and two in the femoral diaphysis (screw positions 3 and 4). Patients were randomized to either postoperative systemic administration of ALN, 70 mg per week for 3 months (Group A) or no ALN. Fixators were removed at 3 months post-op in all patients.

Results: All the fractures healed. No differences in screw insertion torque between the two groups were found. No pin loosening or infection occurred. The combined mean extraction torque of the screws implanted at positions 1 and 2 (cancellous bone) was 3181 ± 1385 N/mm in Group A and 1890 ± 813 N/mm in Group B (p < 0.001). The combined mean extraction torque of the screws implanted at positions 3 and 4 (cortical bone) was 4327 ± 1720 N/mm in Group A and 3785 ± 1181 N/mm in Group B (ns).

Discussion and Conclusion: This is the first study to demonstrate in a clinical setting improved screw fixation following post-operative ALN treatment. We observed a two-fold fixation increase in the screws implanted in cancellous bone. With cortical bone, the difference in screw fixation was less marked. Besides its bone preserving ALN should be recommended as an effective solution to improve fixation in osteoporotic bone.


D.N. Pafilas M. Vekris D. Gartzonikas A.V. Korompilias A. Beris

Introduction: Digital nerve lesions with nerve gaps require reconstruction with the use of some form of graft or guide. Neurotube, a bioabsorbable polyglycolic acid (PGA) conduit, has been proposed as an effective solution for this kind of defect in emergency and planned surgery.

Methods: Nineteen posttraumatic lesions of common (5 cases) or proper (14 cases) palmar digital nerves were repaired by means of Neurotube from January 2003 till January 2006. The nerve gap size averaged 22 mm (range 15–35 mm). Thirteen lesions had associated vascular, tendon or osseous injury.

Results: Nerve regeneration was evaluated at a mean of 17 months postoperative interval. Positive results in recovery of sensibility were noticed in 73 % of the cases; static and moving two point discrimination was excellent (less than 6mm and 4mm respectively) in 9 cases and fair in 5 (7–15mm and 5–7mm respectively). Dysesthesia was present in 6 patients, cold intolerance in two, delayed wound healing in one and one patient complained for painful scar. There was no infection, conduit extrusion or allergic reaction.

Discussion and Conclusion: Bioabsorbable polyglycolic acid conduit presents an attractive and useful alternative for the reconstruction of digital nerve lesions with a small nerve gap, especially when a direct anastomosis of the two stumps is not possible, or when the suture appears to be in tension. Its use is simple, safe and also eliminates the donorsite morbidity associated with nerve-graft harvesting.


M. Egermann K. Ito W. Hofstetter P. Richards

Introduction: Osteoporosis, a major public health burden, is associated with increased fracture risk. Fracture healing in osteoporosis is altered with reduced callus formation and impaired biomechanical properties of newly formed bone leading to high risk of fixation failure. Experimental data have shown decreased healing potential in aged animals and in animal models of post-menopausal bone loss. It is unclear whether fracture healing is similarly impaired in senile osteoporosis. The objective of this study is to investigate fracture healing in a small animal model of senile osteoporosis, senescence-accelerated mouse prone 6 (SAMP6).

Materials & Methods: A mid-femur osteotomy was created in SAMP6-mice (n=24) and senescence-resistant inbred strains (SAMR1) (n=24) were used as controls. The osteotomy was rigidly fixed using a newly developed screw-plate-implant (MouseFix). Fracture healing was evaluated at 7, 14, 28 and 42 days after surgery using micro-CT and histomorphometry. Biochemical marker for bone formation (osteocalcin) and bone resorption (TRAP5b) were evaluated from serum samples. MSC were extracted from the femurs of mice and cultured in vitro and differentiated into either osteoblasts or adipocytes using standard induction media.

Results: Studies carried out in vitro confirmed that MSC isolated from the bone marrow of SAMP6 mice had a reduced tendency to differentiate toward the osteoblast cell lineage as previously reported in human osteoporotic patients. Although osteoblastogenesis was clearly impaired, the formation of new bone in SAMP6 mice was comparable to that observed in SAMR1 mice. Similar results were found for histomorphometry data analyzing the degree of bone mineralisation. Interestingly, osteocalcin levels were significantly increased in serum samples from osteoporotic mice at day 7 and 14 following fracture.

Discussion: The data presented here indicates that fracture healing proceeds normally in a mouse model for senile osteoporosis. This finding supports the clinical observation that although fracture fixation is difficult in osteoporosis, healing potential seems to be unchanged. MSC from osteoporotic patients as wells as from SAMP6-mice show reduced proliferation rate together with adipogenic rather than osteogenic differentiation pattern. However, decreased cell dynamics seems not to influence diaphyseal fracture healing. Other sources of MSC other than bone marrow-derived MSC may therefore be pivotal in determining the outcome of intramembranous bone repair in both normal and osteoporotic bone.


A. MEROLLI M. Santin L. Ambrosio L. Nicolais

INTRODUCTION. A new class of soybean-based bio-materials has been presented to the scientific community (patent PCT/GB01/03464) which shows good mechanical properties and an intrinsic anti-inflammatory potential, probably related to the phyto-hormone Genistein. This plant isoflavone is also reported to inhibit osteo-clastic activity.

MATERIALS AND METHODS. De-fatted soybean curd was prepared into granules which were subsequently implanted in a cylindrical cavity drilled into the femural canal of New Zealand White rabbits. Retrieved femurs were embedded in poly-methyl-meta-acrylate and samples were analyzed by back-scattered electron microscopy (BSEM).

RESULTS. Retrieved operated femurs showed a macroscopic appearance similar to the non-operated controls. BSEM showed that granules were still present at the site of implantation after 8 weeks, but a clear progressive degradation took place from the periphery to the centre of the femural canal already after 3 weeks. The degradation of the granule was accompanied by the production of new trabeculae apposed to the surface of the material.

CONCLUSIONS. It can be hyothesised that the released Genistein shifts the metabolic balance towards bone production by inhibiting the macrophagic and osteo-clastic activities and that the material degrading surface supports the apposition and mineralization of the newly-formed bone.


T.A. SYED M.Z. SADIQ Y.R. SHAH D.A. WALLACE

Introduction: Management of acute rupture of the Achilles tendon is controversial. Conservative treatment has a higher re-rupture rate while surgery has complications like infection and wound breakdown. We devised a protocol in our hospital to decide between the surgical or non-surgical options

At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’.

PURPOSE: The purpose of this study was to compare the incidence of Re-rupture in those treated by cast immobilization where the ends were approximating at ultrasound examination at our institution.

METHODS: This study Prospectively assessed the results in 50 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our regimen depending on the findings of the ultrasound examination, between 2003 and 2006. All ruptured Tendoachilles had ultrasound done in Full Equinus position to assess whether the ends are approximating or not. If ends were approximating they were treated in an equinus cast. Patients were evaluated on the basis of the subjective results and functional outcome measure, along with validated visual analogue scores. Re-rupture rates were measured at 06 months after injury. There were 35 Male and 13 females. This was followed by a final questionnaire to assess their return to pre-injury activities. Two patients were lost to follow-up as they moved out of the area.

RESULTS: All the 48 re-ruptures available for analysis had their ultrasound done on initial presentation. 25 were treated non-operatively and 23 underwent surgery. The overall complication rate for Non Operative was minimal, with NO re-rupture or documented deep vein thromboses. In operative group there were 2 re-ruptures, 5 postoperative infection and discharge.

CONCLUSION: The results of our non-operative treatment were better overall than published results of non operative & operative repair of acute Achilles tendon rupture. In this study the ends are approximating, confirmed on ultrasound before being assigned to Cast Immobilization.

SIGNIFICANCE: The previous studies have not assigned patients into operative or non-operative groups based on whether the ends are approximating in full equines position. By assigning only those in whom the ends are approximating, to cast immobilization, re-rupture rates are less, thus resulting in better and stronger healing of TAs’ and avoiding risks of surgery.


J.D. Calder M. Ismail A. Karim

Introduction: Open Repair of the Achilles tendon is associated with problems of wound breakdown and infection. Percutaneous methods have been associated with sural nerve injury. The Achillon system avoids these problems. However no studies have assessed the strength of this repair and whether it allows early active rehabilitation.

Materials/Methods: Simulated Achilles tendon ruptures in sheep Achilles tendons were repaired using either the Achillon method or a two strand Kessler technique with a No.2 Ticron Suture. The tendon diameter was measured in all cases, and was matched for both groups (mean 9mm, range 8–10mm). Specimens were loaded to failure using an Instron tensile testing machine.

Results: Mean load to failure for the Achillon method was 153.13N ±59.64 (range 65–270), and the mean load to failure for the Kessler Repair was 123.13N ±24.19 (range 75–150). This difference was not statistically significant p=0.209. A Pearson’s correlation coefficient was carried out for each group to see if mean load to failure was related to tendon diameter. There were statistically significant higher mean loads to failure for wider tendon repaired by the Achillon method p=0.047, however this was not the case with Kessler repairs p=0.231.

Discussion: The Achillon repair had a similar load to failure as the 2 strand Kessler repair. These results support the use of early active rehabilitation following the Achillon repair and we could not demonstrate stretching at the repair site. As this method is minimally invasive and does not grasp the tendon it may also have less effect on disruption of tendon blood supply and allow faster healing.

Conclusion: The Achillon repair has comparable tensile strength to Kessler Repair, and is a biomechanically sound method of repair of the acutely rupture Achilles tendon in suitable Patients.


S. Herrmann B. Datta N. Mafulli M. Neil W. Walsh

Treatment of chronic Achilles tendon ruptures can be technically demanding due to tendon retraction, atrophy and short distal stumps. Although rare, re-rupture following surgical treatment is a major late complication.

Biomechanical studies on the strength of reconstructed Achilles tendon using autologous tendon grafts have not been well documented.

This study examined the time zero in vitro mechanical properties of a reconstructed Achilles tendon (TA) using the peroneus brevis (PB) or the flexor hallucis longus (FHL) tendons in a human cadaver model (n=17).

The TA was reconstructed using the same technique for all specimens. Biomechanical testing was performed using an MTS 858 Bionix testing machine and structural properties (failure load, stiffness and mode of failure) were determined.

Average failure load was significantly higher in the PB-group (p=0.0116) (PB: 343.82 N (+/− 124.90 N, FHL: 241.54 N (+/− 82.17 N)). There was no significant difference in stiffness (p=0.212), (PB: 16.53 N/mm (+/− 6.25 N/mm), FHL: 14.00 N/mm (+/− 3.84 N/mm)) or energy (p=0.075).

Mode of failure was the same for all specimens, with the tendon graft cutting through either the distal or proximal TA-stump. Reinforcement of these stumps could lead to increased failure loads. Based on the biomechanical data, the present study supports the use of either FHL or PB to reconstruction chronic TA tendon ruptures. The greater failures loads for PB may not be clinically relevant considering the peak loads. The addition of the suturing pattern, whilst is does reconstruct the tendon, does not provide a similar ability to resist the load.


M. Majewski A. Gösele J. Benthien W. Dick

We examined 52 patients with acute Achilles tendon rupture (ATR), 43 men and 9 women, with a median age of 43 (28–68) years after percutaneous Achilles tendon repair with early functional therapy. 11 patients were treated in a cast (C) and 41 had a specially designed shoed (S). The mean follow-up was 56 (36–95) months. Patients suffering from health problems, which could affect their gait and balance (e.g. OA, spinal stenosis,…), as well as patients suffering from complications postoperatively, were excluded from the study. The mean Hannover Achilles Tendon Score was 81 (50 – 95) points (C = 81, S = 81).

Their calf muscle function studied three to eight years after treatment were found to have a significantly impaired dynamic muscle function of the calf muscles when tested in a specially constructed heel-raise test device. The Wilcoxon matched-pairs signed-ranks test showed a two-tailed P value of < 0,0001.

The average calf size was 38 (31–46,5) cm on the uninjured side and 36 (32–44,5) cm on the injured side. Only two patients had an equal calf size. Comparing the uninjured and injured side the two-tailed P value was found to be extremely significant < 0,0001.

The correlation between the maximum force and functional heel raise testing to the calf size on the injured side was weak with a Spearman correlation coefficient (r) = 0,33–38. There was no difference found between the patients treated in a cast and the patients treated in a shoe with percutaneous Achilles tendon repair and early functional therapy.

The principle finding in the present study was that the impact of an ATR is of great importance for the functional outcome than the treatment that is given. The difference in flexion strength and endurance between the injured and the uninjured side remained even after a 56 months follow-up. Therefore, calf size and functional muscle testing is a good tool to test functional outcome after Achilles tendon rupture. However, there was only a weak correlation between the size of atrophy and the amount of force reduction.


P. Haentjens D. Vanderschueren P. Lips S. Boonen

Objectives: A recent meta-analysis (JAMA. 2005;293:2257–2264) reported that supplementation with oral vitamin D 700–800 IU/day reduces the risk of hip or any nonvertebral fracture in elderly individuals by approximately 25%. However, this metaanalysis was unable to define the role of additional calcium supplementation. The aim of the current study was to assess the need for calcium supplementation in individuals receiving vitamin D for the prevention of hip and nonvertebral fractures.

Methods: MEDLINE (search terms: ‘vitamin D’ AND ‘hip fracture’), bibliographies of articles retrieved, and the authors’ reference files were used to identify randomized controlled trials (RCTs) of oral vitamin D supplementation with or without calcium supplementation vs placebo/no treatment in postmenopausal women and/or older men (over 50 years) specifically reporting hip fracture risk. Data extraction was independent by

Results: All pooled analyses are based on random-effects models. Based on 4 RCTs (9083 subjects), the pooled relative risk (RR) of hip fracture for vitamin D supplementation alone was 1.10 (95% confidence intervals [CI], 0.89 to 1.36). No between-trial heterogeneity was observed. For the 5 RCTs (9227 subjects) of vitamin D supplementation with calcium supplementation, the pooled RR for hip fracture was 0.79 (95% CI, 0.64 to 0.97). There was no heterogeneity between trials. The RRs for all nonvertebral fracture were 0.98 (0.83 to 0.16) for vitamin D alone and 0.84 (0.73 to 0.96) for vitamin D with calcium, with moderate heterogeneity between trials. In an adjusted indirect comparison of the summary RRs from the 2 meta-analyses, the RR for hip fracture for vitamin D with calcium vs vitamin D alone was 0.72 (95% CI, 0.53 to 0.96) and the RR for all non-vertebral fractures was 0.77 (95% CI, 0.60 to 0.99).

Conclusions: Oral vitamin D supplementation appears to reduce the risk of hip and any nonvertebral fractures only when calcium supplementation is added. Our findings suggest that to optimize clinical efficacy, vitamin D supplementation should be complemented with calcium supplements.


E. Caceres M. Bustamante X. Nogues R. Elosua L. Perez-Edo S. Balcells A. Diez-Perez D. Grinberg

Introduction and Hypothesis: Genetic studies of osteoporosis have analysed single polymorphisms in individual genes with inconclusive results. An alternative approach may involve haplotypes and gene-gene interactions. The aim of the study was to test the association between COLlAl, ESRl, VDR and TGFBl polymorphisms or haplotypes and BMD in Spanish postmeno-pausal women.

Methods: Sixteen polymorphisms were analysed in 719 postmenopausal women. ANOV A, ANCOV A and Xi2 tests were used to perform the statistical analysis.

Results: COLlAl -1997G> T (p=0.04) and TGFBl Leu10Pro (p=0.02) were found to be associated with adjusted lumbar spine BMD (LS BMD). Interactions were observed between: the C0LlAl -1997 Grr and Sp1 polymorphisms (p< 0.0l for LS BMD); and the COLlAl 1663 indelT and VDR ApaI polymorphisms (p< 0.0l for FN BMD). The COLlAl GDs and ESRl LPX haplotypes were associated with FN BMD (p=0.03 and p=0.03).

Conclusion: Polymorphisms at COLlAl and TGFBl and haplotypes at COLlAl and ESRl were associated with BMD in a cohort of postmenopausal Spanish women. Moreover, COLlAl polymorphisms showed significant interactions among them and with the VDR 3’ pol ymorphisms.


V. Psychoyios K. Dakis P. Annis A. Athanasopoulou P. Kinnas

Backround: To present the results in a series of patients with complex distal radius fractures featuring comminution of the articular surface and the metaphysis in whom we used a volar as well as a dorsal approach in order to control the axial alignment and reconstitute the articular surface.

Material: There were sixteen patients with an average age of 26 years. All the fractures were classified as C3 according to AO Universal Classification. All the patients underwent an open reduction and internal fixation through a dorsal as well as a volar approach. Secondary operations were necessary for five patients.

Results: The average extension was 56, the average flexion was 51, pronation 70 and supination 76. The grip strength was 75% of the contralateral hand. The average ulnar inclination was 20°, 3 dorsal inclination, 0.9 mm ulnar variance and 1 mm articular incongruity. Three patients had radiological signs of radiocarpal arthritis. Excellent or good results achieved in the 40% of the patients according to the system of Green and O’Brien

Conclusion: The combination of dorsal and volar approach it is necessary for the carpus to be well aligned in order to achieve stability and give the opportunity for early mobilization. Sometimes additional operations are necessary.


D. Giannikas S. Sigelos A. Karbasi C. Matzaroglou M. Tyllianakis

Aim of the study: The evaluation of denervation efficiency in the treatment of the arthritis of the base of the thumb.

Material and method. Between 2001– 2004, 15 patients were surgically treated for arthritis of the basis of the thumb. There were all females of an average age of 53 years. In all patients the procedure was done ambulatory under local anesthesia. After completing a protocol form, regarding pain motion and power of the thumb, an incision was made at the level of the wrist crease extended from the level of FCR to the level of the 2nd extensor compartment. Through this incision the articular branches which conform the studies of Wilhem and Fusche supply the 1st CMC joint were divided.

A supplementary incision for the first intermetacarpal space was made. The patients were free to return to their activities the third postoperative day and they were reviewed after 3, 6, 12, 24 months by an independent doctor. Their data were also recorded conform the protocol

Results: Twelve patients out of 15 had excellent improvement of their strength. Pinch and grip power was doubled. Mobility of the thumb according to Kapanji scale was improved in all cases. Pain was reduced in 65% average. The patients were satisfied from the operation. There was one patient with poor improvement and two patients who never shown up at the follow-up. As the last were at the beginning of our learning curve we think that could have a less satisfactory result.

Discussion: The method is simple with minimal impact to the patient activity or life. It gives good results in 65% –75% and leaves further operative procedures possible. Although there not enough data yet for this procedure and our number of cases is small with short follow-up we believe that it is a nice procedure, it satisfies both the patient and the surgeon regarding the overall improvement of mobility and pain.


M. Tarello M. Favuto A. Casella B. Panero A. Masse’

BACKGROUND and AIM: There is no consensus on the best treatment for acute Achilles tendon ruptures. There is no single, uniformly accepted surgical technique, and the surgical options include open repair with or without augmentation and percutaneous techniques. A retrospective analysis was conducted to compare different surgical procedures for the treatment of the rupture of the achilles tendon.

PATIENTS and METHODS: from october 2002 to september 2006, 176 patients (male 155 and female 21) underwent surgical procedures: 105 open repair (Kessler, Barbed wire) and 71 percutaneous repair (Ma Griffith, Tenolig, Bio-tex).132 patients were evaluated, including criteria was a minimal follow-up of six months;; all patients were interwieved, 81 were assesed with physical examination using Kitaoka rating score and 44 also with isokinetic dynamometer test (Kintrex) measuring strenght, power and endurance.

RESULTS: The mean surgical time was 53.5 minutes with the open repair and 28,6 minutes in closed procedure. All the closed procedures were performed in regional anesthesia and did not required hospitalization. Objective and functional assessement and the isokinetic test showed no statistically significant difference between the two groups (p< 0.05). All patients return to pre-injury working and recreational sport activities. At the physical examination 47 patients showed an important (more than 2 cm) reduction of calf circumference. In the open group there were no rerupture, one deep infection, 10 painful or ipertrophic scars. Complication in the percutaneous repair included 3 reruptures (2 patients fell few days after surgery), no wound infections, 3 disturbances in sensitivity of the sural nerve.

CONCLUSION: On the basis of these results, the percutaneous repair as suitable alternative to open techniques may be recommended. This is a simple and safe surgical procedure which allows to achieve an high rate of excellent functional outcomes with minimal morbidity. Furthermore the time for surgery is shorther and the procedure can be performed without hospitalization.


A. pace T. davis

Carpometacarpal arthritis of the thumb is a common source of morbidity particularly in post-menopausal women. It is commonly and successfully treated by trapeziectomy with or without ligament reconstruction and tendon interposition. This randomised prospective study compared the results of trapeziectomy alone or combined with tendon interposition and ligament reconstruction in 125 patients. Each patient had subjective and objective assessment of thumb pain, stiffness and strength and were scored using the D.A.S.H. and P.E.M. scoring systems. Patients were assessed pre-operatively and at 3 months and 1 year after surgery. The results of the two procedures revealed statistically improved pain levels but there was no statistically significant difference between the two in terms of pain relief, stiffness, weakness, grip strength, keypinch and thumb key pinch as well as in the D.A.S.H. and P.E.M. scores. The study shows that in the short term soft tissue reconstruction in addition to a simple trapeziectomy provides no improved benefit to the patient.


K. Rajasekar A. Faraj

The factors affecting patient satisfaction with the outcome following treatment of Tendo-Achilles rupture were assessed. 35 patients were reviewed. 14 were treated non-operatively and 21 by open surgical repair.

Mean follow up was 2 years (range 9 months- 4 years). Evaluation consisted of questionnaire and information from medical records. Mechanism of injury, type and time of injury, co-morbidity and follow-up were noted from the medical records. From the questionnaire, pre injury activities, occupation, post-injury activities and overall satisfaction with their function were collected. The overall satisfaction level was quoted by the patients themselves by grading 10 for excellent recovery and 1 for the poor recovery.

Seventy percent were very satisfied with the outcome of treatment with a mean visual analogue score of 8.4 (7–10). The age, gender and occupation did not have any significant influence on the satisfaction level. The main determinant in the unsatisfied group was reduced post injury leisure activities. This was statistically significant between the two groups at p=0.003. Delay in initiation of treatment had a significant influence, with the group that presented late for treatment being less satisfied with p=0.015. Regression analysis showed that physiotherapy following treatment increased post injury activity and the level of satisfaction with p=0.034.

Reduced post injury leisure activity, delay in initiation of treatment and post treatment physiotherapy had a significant influence on patient satisfaction with outcome. There was no significant difference in the overall outcome between the operative and non-operative group.


S.G. Haidar S. Joshy R. Charity S. Ghosh A. Tillu S. Deshmukh

Purpose: Management of unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation applying the principle of a volarulnar tension band platting. An attempt to introduce a new radiological classification for the accuracy of reduction is made. The classification includes 10 criteria.

Materials and Method: We reviewed clinically and radiologically 99 patients (101 fractures); 60 were type C and 41 were type A. The average follow up was 37 months (24 – 57). The average age was 46 years (19 – 81). Sarmiento’s modification of Gartland and Werley and Cooney’s modification of Green and O’Brien were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9°, radial inclination of 22°, radial height of 11mm and palmer cortical angle of 32°. The mean dorsiflexion was 61°, palmer flexion was 59°, pronation was 80° and supination was 76°. Grip strength was 86% of the opposite side. The average DASH score was 13.6. There was 13 poor results, 6 of them had a significant loss the initial reduction. There was significant correlation between our classification outcome and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides a strong fixation that maintains reduction and allows early mobilisation.


M.C. Glanzmann R. Sanhueza-Hernandez

Fusion of the subtalar joint is an accepted method for numerous hindfoot pathologies. Various open techniques have been reported with similar good to excellent results. We designed this prospective analysis to evaluate the efficacy of arthroscopic subtalar fusion to compare the outcome with standard open techniques.

Method: 51 adults with a mean age of 42 years (range 21–75) were operated due to persistant pain and impaired function of the hindfoot unresponsive to symptomatic treatment. Patients were excluded if a significant deformity was present. Scoring was done according to the AOFAS ankle-hindfoot scale preoperatively and at each follow-up exam. A summery of the surgical technique is further given.

Results: 53 arthroscopic subtalar fusions were performed in 51 patients. At final follow-up (minimum 2 years) the AOFAS score improved from 52 preoperatively to 88 points. Non-unions were not observed. Clinical outcome was good and excellent in over 95% of all cases. Progression of degeneration in adjacent joints was minimal. Through the arthroscopic approach intraoperative visualization and preparation of the fusion site is superior to the open technique. Furthermore the clinical outcome supports the use of the endoscopic technique for the treatment of painful osteoarthritis of the hindfoot.


N. ZAGOREOS B. MILLER T. TRUMBLE

Stronger flexor tendon repair techniques achieving excellent zero time biomechanics are considered the cornerstone of the early active motion rehabilitation protocols in digital flexor tendon surgery. Stronger suture materials are being introduced constantly without being tested biomechanically. The purpose of this study was to identify the role of the suture material on the flexor tendon repair techniques.

Seventy two tendon segments from thirty six cadaveric flexor tendons were lacerated and repaired with 2 different repair techniques and 3 different suture materials. The repair techniques involved an easier form of the popular Strickland technique and the stronger Modified Becker technique. Ethilon, Ethibond and the newer Fiberwire sutures were used, creating a wide range of materials with diverse biomechanical properties. The repair constructs were tested in an in vitro linear load to failure model where the ultimate strength, the 2 mm gap load and the mode of failure were recorded. Furthermore, a similar test was performed using only suture materials tied in a loop in order to compare the materials without any tendon or repair technique interaction.

The Modified Becker repairs demonstrated higher loads to failure than the Modified Strickland repairs irrespective of the suture material. Stronger suture materials increased significantly the strength of the modified Becker repair. The biomechanical characteristics of the modified Strickland technique were not influenced by the different suture materials. The 2 mm gap loads were not influenced by the suture material with either technique. The mode of failure was by suture breakage in the case of the Modified Becker repair and mostly by suture pullout in the case of the modified Strickland technique. The superior strength characteristics of the Fiberwire over the rest of the suture materials were also observed in the suture material study.

Suture materials do not have a significant effect on the biomechanical characteristics of every flexor tendon repair technique. Techniques most likely to benefit are those that grasp the tendon substance tightly and are limited only by the breaking strength of the suture material itself.


M. Whitehouse B.J. Lankester I.G. Winson S. Hepple

Introduction: Fresh autogenous cancellous bone graft is the material of choice in reconstruction and fusion procedures in foot and ankle surgery. There are many potential donor sites for graft harvest, all with recognised minor and major complications. The proximal tibia is one such potential site, and is particularly suited to foot and ankle surgery being within the operative field and under tourniquet control.

Purpose: To assess pain, morbidity and ability to weight bear in a large group of patients undergoing foot and ankle surgery utilising cancellous bone graft from the proximal tibia.

Method: A retrospective audit was undertaken of 148 procedures performed over a period of five years. Minimum follow-up was 3 months. Data were obtained from operation notes and patient interview.

Results: Most patients had no pain (78%) or very mild pain (20%) at the site of graft harvest immediately following surgery. At review, 96% had no pain; 4% had very mild pain with certain activities such as kneeling. There were no major complications. 4 patients (2.7%) had persisting areas of parasthaesia at review, but none were troubled by it. One patient had a superficial wound problem that resolved. The ability to bear weight was dictated by the primary procedure. Usually this was from 2–3 weeks. There were no complications related to early weight bearing in this series.

Conclusion: The proximal tibia is a suitable and safe site for bone graft harvest for foot and ankle surgery. There is no need for additional restriction in weight bearing following this procedure.


D. Kumar R. Cheppali J. Herman-Kuiper

Introduction: Flexor tendon repair in zone 2 has a high re-rupture rate. Various pulleyplasties were described to reduce gliding resistance. In an experimental study on pig trotters, we performed pulleyplasty by meshing alike split skin graft and determined its effect on breaking strength and gliding resistance of repaired tendon.

Method: Phase 1: Two pairs of middle pulley of the same pig were pulled apart from bone on Universal testing machine. One of each pair were meshed (10 rows of 1mm slits 2 mms apart longitudinally).

Phase 2: The two ends of two repaired flexor tendons were attached to a tension load cell each. The proximal end load cell was connected to Universal testing machine. Gliding resistance was measured under saline before and after meshing.

Phase 3: The test was repeated on 4 specimens using a digital load scale. Ten observations of peak resistance were obtained each with normal pulley, meshed pulley, after edge tying of the pulley.

Results: Breaking strengths were 162 and 59 N in one pair and 89 and 50 N in another. The pulleys became 1.5 – 4 times stretchable.

Meshing increased the gliding resistance by approximately 20% and 30% in phase 2 and 3 respectively. Edge tying decreased the gliding resistance by 27% below that of normal pulley

Discussion and Conclusion: Meshing weakens significantly but breaking strength stayed above 50 N, which is more than average breaking strength of a tendon repair (30N, Norris et al). Meshed pulley were dragged farther and preventing it by edge tying decreased the gliding resistance.

No animal was killed for the study.


H. Migaud J. Girard T. Trichard F. Remy M. Soenen F. Bachour A. Duquennoy

Purpose of the study: Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from consecutive analysis of the same cohort is lacking. The purpose of this study was to evaluate the same cohort of patients who underwent ankle fusion.

Material and Methods: The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (2–22 years) of follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up, 20 had died and one had undergone leg amputation. The second analysis thus included 25 patients (18 men and 7 women), mean age 62±12.6 years (40–94) at the 2000 assessment performed 23±4.5 years (19–36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale.

Results: The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8±22.6 (19–92) in 1984 and 64.7±18.3 (34–90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1–21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range −1 to −24). Ten of these thirteen patients developed severe intercurrent conditions explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed early osteoarthrtic degradation with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four sub-talar fusions which were painful at mobilization). The mediotarsal joints degradation was later and less severe than for the subtalar joint with a majority of moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15° without pain.

Discussion: This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated late degradation of function expected after ankle fusion. It did show however the presence of radiographic degradation of the subtalar joint but with little clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up.


A. Suckel O. Mueller P. Langenstein N. Wuelker

The standard treatment of arthrosis of the ankle joint is arthrodesis while new prosthesis leed to good clinical results. Currently there is much controversial discussion, and knowledge of the fundamentals of biomechanics is becoming ever more important.

Ten macroscopically and roentgenographically normal foot specimens were tested comparing tibio-talar arthodesis vs. nativ situation on a kinematic gait simulator. The stance- phase of normal walking gait was simulated from heel-contact to toe-off. Ground reaction forces were simulated by a tilting angle- and force-controlled translation stage upon which a pressure measuring platform was mounted. Force was applied to the tendons of the foot flexor and extensor muscle groups by cables attached to an additional set of six force-controlled hydraulic cylinders. Tibial rotation was produced by an electrical servo motor.

The change after arthrodesis was a varying degree of relocation of average force and maximum pressure from the lateral onto the medial column of the foot; the increase force on talonavicular joint and decrease on calcaneocuboid joint is statistically significant. The average force increased from native 66.7N to 80.8N upon arthrodesis in the talonavicular joint and decreased in the calcaneocuboid joint from 71.9N to 58.5N. Peak pressure increased from 3728kPa to 4552kPa in talonavicular joint and decreased in calcaneocuboid joint from 3809kPa to 3627kPa. After arthrodesis, we measured inconsistent changes in Chopart joint. On some feet, the changes in stress were slight, but on majority, relocation of force and peak pressure was significant. The result was a change in the function of Chopart joint with increased extension load on talonavicular joint at time of highest joint load during push-off.

These in vitro observations explain the clinical observations that have followed ankle arthrodesis. For one, there are reports on tibiotalar arthrodesis patients who are largely mobile and free of complaints, which correlates with the observation that not all preparations indicate a clear relocation of force and intraarticular peak pressure onto the talonavicular joint. In these cases, the ability of strong muscular plantar flexion could explain a good functional result. In contrast, and in addition to subtalar joint degeneration, arthroses in the talonavicular joint have been frequently observed following tibiotalar arthrodeses. The relocation of both force and intraarticular peak pressure onto the medial column of the foot in the majority of preparations explain the degeneration on the extensor side of the joint with osteophyte formation impressively.


R.J. Weiss E. Broström A. Stark P. Wretenberg

Objectives. To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip.

Methods. In this prospective follow-up study 14 RA patients scheduled for ankle/hindfoot arthrodesis were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- versus post-operative conditions, Wilcoxon’s matched pairs test and Friedman ANOVA by rank test were used.

Results. At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up.

Conclusions. Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.


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S. Giannini R. Buda F. Vannini R. Bevoni F. Di Caprio

INTRODUCTION: Post-traumatic arthritis of the ankle in the young active patient represents a reconstructive challenge. Fresh total shell osteochondral allografts are an increasingly popular option in the reconstruction of various amounts of cartilage defects, although concerns for bipolar allografting are reported. The purpose of this study is to describe the preliminary results of a series of 18 bipolar shell ankle allografts performed by using a specifically designed instrumentation.

METHODS: 18 patients, 13 males and 5 females (mean age 31±10 years) affected by post traumatic arthritis of the unilateral ankle joint grade III received bipolar shell allograft of the ankle. The mean follow-up was 12 months (range 24–8). The ideal patient to allograft match was permitted through CT scan and x-rays. Two steps surgery, one for allograft preparing and one for the recipient site, were performed by using specifically designed jigs. Patients evaluation was carried out clinically by AOFAS and radiographically by X-Rays, CT scans, MRI.

RESULTS: No intraoperative, complications occurred. All the patients demonstrated good consolidation rates of the allograft at X-Rays, CT scan and MRI controls performed at 4, 6, 8, and 12 months. At 8 months follow-up, all the patients were allowed complete weight bearing. Normal ROM of the ankle and regular gait with no pain and no need of support was resumed in 13 patients. In 2 patients a fracture of the fibula was reported. In one case, cause of the fracture was patient non compliance to the weight-bearing restriction. In the other case the fracture occurred distal to the osteotomy site, possibly due to a trauma. Both the cases required revision of the graft which appeared damaged in the lateral site. In the first case an ankle arthrodesis was performed. A bioptic harvest of the transplanted cartilage in 5 patients at 1 year follow up demonstrated chondrocytes vitality > 90%.

DISCUSSION: Accurate preoperative planning, sizing, and the use of specifically designed jigs makes viable and reproducible the bipolar shell allograft in the ankle joint in selected cases. Although preliminary results are encouraging, longer follow-up is required in order to confirm longer term cartilage viability and the validity of the technique.


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P.J. Felicíssimo L. Pires

Aims: Numerous techniques for subtalar arthrodesis have been described, with intraarticular and extraarticular methods. The purpose of this paper is to show our results with subtalar arthrodesis with arthroscopic technique.

Methods: We reviewed 30 subtalar fusions and followed 26 patients (20 females and 6 males, average age 56,3 years) for an average of 48 months.

The preoperative diagnosis was primary arthrosis in 19 cases, arthrosis secondary to trauma in 7 cases and subtalar instability secondary to neuropathic conditions in 4 cases. Patients are placed in a prone position. All arthroscopic procedures were done with non-invasive distraction, thigh tourniquet. Two portals, one each side of Achilles tendon, 2,5-3,0 cm above the junction of posterosuperior surface of the calcaneus and the Achilles tendon. A 4,0 mm 30 degree oblique arthroscope and a rotatory 4mm burr were used. Fixation was done with dynamic cannulated screw from calcaneus into talus.

Results: Fusion occurred in all cases. Using the American Orthopaedic Foot and Ankle Society (AOFAS) scored system the patients averaged is 92,7. Twenty four patients (92,3%) were satisfied and two are not satisfied (7,7). No Complications were reported. All patients wore normal shoes.

Conclusions: Arthroscopic subtalar arthrodesis and open arthrodesis have similar results, with less morbidity in first one. It can be the chirurgical technique of choice for subtalar arthrodesis in all cases without hind-foot malalignment requiring correction.


A. Leardini D. Sarti F. Catani M. Romagnoli S. Giannini

A new design of total ankle replacement was developed. According to extensive prior research, the design features a spherical convex tibial component, a talar component with radius of curvature in the sagittal plane longer than that of the natural talus, and a meniscal component fully conforming to these two. The shapes of the tibial and talar components are compatible with a physiologic ankle mobility and with the natural role of the ligaments.

Within an eight-centre clinical trial, 114 patients were implanted in the period July 2003 – September 2006, with mean age 62.2 years (range 29 – 82). The AOFAS clinical score systems and standard radiographic assessment were used to assess patient outcome, here reported only for those 75 patients with follow-up longer than 6 months.

Intra-operatively, the components maintained complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, associated to a considerable anterior motion in dorsiflexion and posterior motion in plantarflexion of the meniscal-bearing, as predicted by the previous mathematical models. Mean 10.0 and 23.5 degrees respectively of dorsi- and plantar-flexion were measured immediately after implantation, for a mean additional range of motion of 19.2, which was maintained at follow-ups. Radiographs showed good alignment and no signs of evolutive radiolucency or loosening. The mean AOFAS score went from 40.8 pre-op to 66.2, 74.6 and 77.2 respectively at 3, 6 and 12 month follow-ups. One revision only was performed successfully three days after implantation because of a technical error.

In the score system utilized, Function and RoM sections scored better than any average previous total ankle result, Pain scored similarly. The satisfactory though preliminary observations from this novel design encourage continuation of the implantation, which is now extended over a few European countries. Instrumented gait and three-dimensional fluoroscopic analyses are in progress to quantify functional progresses.


G.A. Higgins M.S. ali M. mokhemer mohamed

We present the functional and radiological results after implantation of thirty four uncemented Buechel Pappas total ankle replacements. The average follow-up period was 5 years. All consecutive uncemented Buechel Pappas total ankle replacements were performed by the senior author (MSA) between 1990 and 2005, at Corbett District General Hospital, Dudley. Thirty four ankle replacements were performed. One patient died before follow-up. All ankle replacements were performed for osteoarthritis. The patients were assessed clinically and radiologically.

Thirty four ankle replacements were performed on thirty three patients. There were eight female and twenty five male patients. One patient had died 2 years after her ankle replacement. The average age of the patients was 69(58–84). All ankle replacements were performed for osteo-arthritis. 59% had post traumatic osteoarthritis.

The average body mass index was 30 (22–37). One hundred percent of patients were happy with their ankle replacement. Fifty nine percent of patients were completely pain-free, or had occasional twinges. All patients were mobile, forty seven percent of patients required no walking aids and only six percent required 2 walking aids. One patient complained of occasional instability. One patient sustained a medial malleolar fracture intra-operatively which was fixed with two partially threaded cancellous screws. The patients were placed in a back-slab post-operatively and were non-weight bearing for a period of 6 weeks. No revision operations were performed to date.

Clinical examination revealed forty two (5–57) degrees of movement in the ankle replacement at follow-up. Radiological examination revealed forty five (0–57) degrees of movement in the ankle joint. Pearson Correlation coefficient was 0.956, p< 0.001. There was excellant correlation between clinical and radiological assessment of range of movement.

Examination of the radiographs demonstrated no evidence of gross subsidence, or lucency. One implant had a poorly positioned talar component, but so far this has been assymptomatic.

The American Foot and Ankle Society Scores were 34.6(20–56) pre-operatively compared with 76(54–100) at follow-up. This was significant improvement p< 0.001. Average scores for pain, function and alignment were 30(20–40),40(29–50) and 9(5–10).

There was one intra-operative fractured medial malleolus and two superficial wound infections (with negative swabs) treated with antibiotics.

We compare our results with others published and feel the Buechel Pappas Uncemented Total Ankle replacement performs well and is a good alternative to ankle arthrodesis preserving ankle movement and biomechanics. The results are comparable to other uncemented total ankle replacements.


M. Kapella A. Reinert R. Kreusch-Brinker

To evaluate whether endoprosthetic ankle replacement is an adequate treatment option. the following studies involving total ankle replacement (TAR).

From June 1997 to December 2004 a total of 68 TARs were performed in 66 patients, of whom 22 received cemented implants, 40 cement-free implants, and 4 hybrid implants. The indications for TAR included post-traumatic joint destruction in 54 patients, rheumatoid arthritis in 6 patients, and idiopathic osteoarthritis in 8 patients. Bilateral TAR was performed in two patients with rheumatoid arthritis, one of whom developed surgical site infection six months after the first implantation, thus requiring arthrodesis through external fixation; follow-up of this patient revealed no abnormality, and extension/flexion was 15-0-25°. Upon follow-up visits conducted 10 to 72 months following TAR patients were grouped according to ankle score, visual analog scale, subjective symptoms, and walking distance. The average preoperative ankle score did not exceed 70 points (17–67). Thirty-nine out of 66 patients displayed a balanced gait with only minor walk abnormality as well as ranges of movement between 30° and 55° including extension above neutral (excellent and positve outcome). Fifteen out of 66 patients complained of persisting discomfort located in the medial, lateral and anterior sides of the upper ankle joint and showed extension deficits of 5 to 15° (adequate outcome). Twelve patients had a poor outcome.

A total of 34 wound revisions were required in 25 patients, including: osteosynthetic treatment of malleolar fractures in 7 patients, wound revision in 4 patients, exostosis removal in 4 patients, and extension of the Achilles tendon in 3 patients. Three arthroscopies were performed due to persisting discomfort.

Implant loosening occurred in 13 cases and was treated as follows: tibial plateau replacement (6 cases), inlay replacement (4 cases), total implant replacement (2 cases), and arthrodesis (5 cases).

Out of 66 patients, the treatment outcome was excellent in 8 patients, positive in 31 patients, and adequate in 15 patients; in 12 patients no significant therapeutic benefit in terms of upper ankle joint function and symptoms was obtained. In view of the short observation time no long-term results are available so far. In the short and medium term TAR appears to improve the range of movement of the ankle joint in two-thirds of patients who fulfil the indications for TAR, which include a satisfactory range of movement (minimum 40°) and lateral ligament stability.


T. Saussez T. Saussez O. Cornu B. Devos Bevernage P. Maldague T. Leemrijse

Discussion: Total ankle replacement shows continuous progress. Many implants are proposed to the surgeon. The purpose of this study is to evaluate the matching between the components and the anatomy on different levels of tibial cut.

Methods: 18 cadaveric distal tibias were cut at a distance of 0, 3, 6 and 9 mm from the joint space. The mediolateral and anteroposteriror length were measured; and the surface as well. These same measurements were performed to the tibial components of 5 different prosthesis (AES®, Hintegra®, Mobility®, Salto®, Star®). For each tibial cut, we selected tibial components that matched the mediolateral length. Then, these components were classified in function of their anterioposterior matching for the different levels of cut.

Results: We showed that some components are more universal than the others because of a maximal contact surface and an anteroposterior cortical support.

Conclusion: The longevity of the TAA depends on the stress forces, the matching surface, the components coating and the bone quality. This is a preliminary study wich certainly needs to take into consideration with others factors like occurrence or absence of stabilizing keel and differents methods of component fixation.


M. Stenger O. Ovesen S. Overgaard

Introduction: Periacetabular osteotomy (PAO) is a major orthopaedic surgical procedure which may be associated with a significant blood loss and complications. We have compared the perioperative blood loss and complications using two different approaches – The modified iliofemoral (MI) and ilioinguinal (II) for PAO.

MATERIALS AND Methods: 92 PAO’s in 80 patients (54 females; 26 males), with dysplastic hip joints, operated at Odense University Hospital with the Bernese method, between 2003 and Feb. 2006, using the MI or the II were included. The MI include no release of the tensor fascia lata, sartorius or rectus femoris.

The procedures were reviewed with primary focus on perioperative blood loss, length of surgery and neurovascular complications. Patients who underwent combined surgery of acetabulum and femur were excluded.

Data are presented as mean with 95% confidence interval (CI) in brackets.

Results: The MI approach was used in 65 and the II in 27 PAO’s. Average time for surgery in the MI group was 88 min (95% CI: 83–94) and in the II group 106 min (95% CI: 97–114), (P=0.0007). The intraoperative blood loss in the MI group was 571 ml (95% CI: 489–654) compared with 518 ml (95% CI: 387–649) in the II group (P=0.49). However, postoperatively, the hemoglobin concentration was 7.1 (95% CI: 6.9–7.3) in the MI group compared with 6.6 (95% CI: 6.1–6.8) in the II group (P=0.002).

The MI group had 1 case of major arterial bleeding, however no blood transfusion. The II group had 2 cases of arterial thrombosis and one transient sciatic nerve palsy. One patient received blood transfusion.

CONCLUSION: In this study, the MI approach was proved to be significantly faster than the II, however no significant difference was found in intraoperative blood loss, but the hemoglobin fell significantly less in the MI compared with the II group. The II approach was associated with 3 major complication compared with one in the MI.


D. Williams L. Smith V.G. Langkamer

The rate of homologous blood transfusion (HBT) following primary total hip replacement (THR) can be as high as 30–40% and is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR.

The aim of this randomized prospective study was, therefore, to determine if the use of post-operative salvage affects post-operative haemoglobin and haematocrit values and reduces the rate of homologous blood transfusion. Secondary outcome measures included length of hospital stay and patient satisfaction. A cost analysis was also conducted on the basis of the results obtained.

The patients were randomized during the operation (at the point of reduction of the primary THR) to receive either two Medinorm vacuum drains or the autologous retransfusion system. A power calculation estimated that 72 patients would be required in each group to detect a significant difference of 0.7 gdL-1 in post operative haemoglobin level (at 80% power with an value of 0.05). This assumed a standard deviation of 1.5 gdL-1 obtained from a previous retrospective study.

There were 82 patients in the Medinorm vacuum drain group and 76 patients in the autologous retransfusion group. In the group with the autologous system, 76% of the patients were retransfused with a mean of 252mls. There was no significant difference between the groups when comparing haemoglobin and haematocrit values. However, significantly fewer patients in the group with the autologous system had a postoperative haemoglobin value less than 9.0 gdL-1 (8% vs. 20%, p = 0.035). Furthermore, significantly fewer patients with the autologous retransfusion system required a transfusion of homologous blood (8% vs. 21%, p = 0.022). There was a small overall cost saving in this group.

This study has shown that use of an autologous retransfusion system for primary THR reduces the necessity for HBT and is cost effective. POS also results in significantly fewer patients dropping their post-operative haemoglobin level below 9.0 gdL-1. As a result our unit routinely uses the autologous retransfusion system for primary THR.


H.C. Doets D. Vergouw H.E. Veeger H. Houdijk

The purpose of this study was to investigate the energy cost of walking after total ankle arthroplasty (TAA), and to investigate if possible differences could be attributed to changes in external mechanical work required for the step-to-step transition.

Eleven patients, 6 months to 4 years after successful unilateral TAA, and 11 healthy controls walked on a treadmill at a self-selected speed (SWS) and a fixed walking speed (FWS, 1.25 m/s). Ground reaction forces and oxygen uptake were measured. External mechanical work was analyzed using the double inverted pendulum model.

At SWS, velocity in the TAA group was reduced (v=1.29 vs 1.42 m/s, p=0.05) but metabolic energy cost was not different (E=2.50 vs 2.24 J/kg/m, p=0.32). At FWS, metabolic energy cost in the TAA patients was significantly higher (E=2.58 vs 1.96 J/kg/m, p=0.003). The difference in metabolic energy cost at FWS coincided with an increased negative work in the leading leg and reduced positive work in the trailing leg with TAA during double support. Although this indicates that the mechanical work for the step-to-step transition increases, the total external mechanical work over a complete stride was not different between the TAA and the control group.

TAA patients walk at a higher metabolic energy cost. This cannot be explained by differences in external mechanical work. Other factors, such as changes in muscle function, should be taken into account.


B.I. Eriksson L. Borris O.E. Dahl W.D. Fisher S. Haas A.K. Kakkar L.M. Kwong F. Misselwitz A.G. Turpie

Routine prophylaxis is recommended to prevent venous thromboembolism (VTE) – manifesting as deep vein thrombosis (DVT) and/or pulmonary embolism (PE) – in patients undergoing major orthopaedic surgery. Rivaroxaban (BAY 59-7939) is a novel, oral, direct Factor Xa inhibitor in development for the prevention and treatment of VTE. The efficacy and safety of 5–9 days’ prophylaxis with rivaroxaban were investigated in three randomized, double-blind, phase IIb trials in patients undergoing elective, total hip or knee replacement (THR or TKR), relative to subcutaneous enoxaparin.

Two trials (one in patients undergoing THR, N=722; and one in patients undergoing TKR, N=621) investigated twice-daily (bid) rivaroxaban (at total daily doses of 5–60 mg); the third (in patients undergoing THR, N=873) investigated once-daily (od) rivaroxaban (at doses of 5, 10, 20, 30 or 40 mg od).

Rivaroxaban – at all doses tested – had similar efficacy to enoxaparin in the bid trials. This promising finding was strengthened by the od trial, in which the observed incidences of the primary efficacy endpoint (DVT, non-fatal PE or all-cause mortality) were lower in patients receiving rivaroxaban 5, 10, 20, 30 and 40 mg od (14.9%, 10.6%, 8.5%, 13.5% and 6.4%, respectively) than enoxaparin (25.2%). Although there was no significant dose–response relationship between rivaroxaban and the primary efficacy endpoint in these trials, there was with major VTE (proximal DVT, PE or VTE-related death; p=0.0072) in the od trial (incidences were 8.5%, 2.7%, 0.9%, 1.9% and 1.1% with rivaroxaban 5, 10, 20, 30 and 40 mg od, respectively, vs 2.8% with enoxaparin).

Significant dose–response relationships between rivaroxaban and major bleeding were observed in all three trials. In the bid trials, major bleeding rates with rivaroxaban were similar to those with enoxaparin at total daily doses of 5–20 mg. In the od trial, major bleeding occurred in 2.3%, 0.7%, 4.3%, 4.9% and 5.1% of patients receiving rivaroxaban 5, 10, 20, 30 and 40 mg od, respectively, and in 1.9% of those receiving enoxaparin.

Rivaroxaban was generally well tolerated in the bid and od trials, and the incidence of nausea and vomiting with early post-operative oral rivaroxaban administration was low for all doses tested.

The bid trials suggest that oral rivaroxaban at total daily doses of 5–20 mg may be a safe and effective alternative to enoxaparin for the prevention of VTE after major orthopaedic surgery. The od trial suggests that the more-convenient od regimen is feasible and that 10 mg od, a dose within the range identified by the bid trials, should be investigated further. As a result, oral rivaroxaban 10 mg od is currently being investigated in four phase III trials for the prevention of VTE after major orthopaedic surgery (the RECORD trials).


F. Astore L. Spotorno F. Traverso A. Dagnino D. Ricci N. Ursino M. Scardino

The aim of this study is to evaluate techniques which may reduce intra and Post-Operative (PO) bleeding in hip surgery.

Methods: In this prospective study, from 9/2005 to 6/2006, we evaluated Blood Loss (BL) after primary total hip arthroplasty. Exclusion criteria were anti-coagulant drugs not discontinued 10 days before surgery and patients whose condition precluded weight bearing PO. We included total hip arthroplasty with posterior surgical approach, spinal anaesthesia, hypotensive surgery and peri-operative blood salvage (Ortho PAS, Euroset). When appropriate, the Mini-Invasive Approach (MIA) was used. In a different sub-set of patients, including some of the minimally invasive patients, a new bipolar Radio-Frequency sealer (TissueLink) was used. The PO program had pain control, LMWH for prevention of DVT, exercise from the day of surgery and walking on crutches from the next day. We analysed: blood loss after surgery and for 3 days; haemoglobin values (g/dL) before surgery and for 5 days PO; thigh circumference pre-op and at 5 days and adverse events such as transfusions and luxation. For the statistical evaluation the paired “t-test” was used, with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant.

Results: 324 patients (mean age 68; range 23 to 89; 179 F & 145 M) were admitted to the study. Mean BL was 305ml intraoperative, 501ml at 6 hours PO, 304ml at 1day PO, 132ml at 2 days PO and trace at 3 days. Rather than simple unit measures, we analyzed the Percent Change in Hb from preoperative levels (%CHb). The patients had a mean %CHb of 23,09% at 1day PO, 26,67% at 2 days PO, 28,13% at 3 days and 29,07% at 5 days. Transfusion rates (TR; trigger set at Hb< 8g/dL) were related to the preoperative Hb and age. Overall TR was 15% (51/324), the prevalence of homologous transfusion was 7% (24/324). The TR for each Hb value: 21% (15/69) for Hb=12–13, 20% (20/98) for Hb=13–14, 17% (15/88) for Hb=14–15 and 5% (1/29) for Hb=15–16. The mean value of pain during rehabilitation was 3,11(VAS). MIA (53/324) was associated with reduced BL (mean %CHb at 1st day PO 19.12; TR 9%), but with high variability. The use of bipolar sealer (58/324) was associated with a significant reduction in overall BL (mean %CHb at 1st day PO 15.83; TR 5%) as well as a reduction of thigh swelling (37%) and of mean rehabilitation pain (30%; VAS=2.15).

Discussion: Reduced blood loss, reduced post-operative pain and a faster functional resumption are obtained with both the minimally invasive approach and the TissueLink sealer approach. In addition, MIA provides muscle preservation and the use of the TissueLink sealer provides reduced post-operative swelling.

Conclusion: This study shows that both the minimally invasive surgical approach and the use of an irrigated RF bipolar sealer can lead to reduced blood loss and faster functional resumption following hip surgery.


C.W. Colwell C.E. Jacques D.G. Stevens T.J. O’Keefe R.I. Hall J. Parvizi A. Nadel J.M. Murkin

This phase III, multicenter, double-blind placebo controlled study evaluated safety and efficacy of aprotinin in reducing blood transfusion in subjects undergoing THA.

Subjects were stratified by preoperative autologous blood donation and randomized to receive aprotinin (1 mL test dose; load, 2 million KIU and 0.5 million KIU/hour) or placebo. Subjects were assessed at baseline, postoperative days 1, 2, 3, 7 (or discharge) and 6±2 weeks. Primary efficacy variable was percentage of subjects requiring blood transfusion through day 7 or discharge. Safety was based on adverse event (AE).

Of 359 randomized subjects, 175 in each group completed the study. Demographics of the groups were similar. Aprotinin reduced by 46% the requirement for any transfusion (17% vs 32% of subjects, p=0.0009). Aprotinin reduced allogeneic blood transfusion in subjects regardless of predonation status (11% vs 22%, p=0.0063), who made no predonation (13% vs 24%, p=0.0216), and who predonated (32% vs 62%, nd). The aprotinin group had a reduction of the number of any (48 vs 109 units; p=0.0003) and allogeneic (30 vs 72 units; p=0.0041) units transfused and total fluid loss (709 vs 957 ml; p=0.0002) compared with placebo.

One patient died in the placebo group. AEs were reported in 83% of aprotinin-treated and 86% of placebo subjects, with 10% and 11%, respectively, described as serious AEs. No clinically important differences between aprotinin and placebo AEs were observed. Hypersensitivity to aprotinin was not reported.

In this study, full-dose aprotinin was safe and effective in decreasing blood transfusion in subjects undergoing THA.


B. Rogers A. Cowie C. Alcock J. Rosson

Introduction: The correction of anaemia prior to total hip arthroplasty reduces surgical risk, hospital stay and cost. This study considers the benefits of implementing a protocol of identifying and treating pre-operative anaemia whilst the patient is on the waiting list for surgery.

Methods: From a prospective series of 301 patients undergoing elective total hip arthroplasty (THA), patients identified as anaemic (Hb< 12 g/dl) when initially placed upon the waiting list were appropriately investigated and treated. Pre- and post- operative haemoglobin (Hb), need for transfusion, and length of hospital stay were collated for the entire patient cohort.

Result: 7.6% of patients were anaemic when initially placed upon the waiting list for THA and had a higher transfusion rate (25% to 4%, p< 0.05) and longer hospital stay (7.5 to 6.6 days, p< 0.05). Over 40% of these patients responded to investigation and treatment whilst on the waiting list, showing a significant improvement in Hb level (10.1 to 12.7 g/dl) and improved transfusion rate.

Discussion: Quantifying the haemoglobin level of patients when initially placed on the waiting list helps highlight those at risk of requiring a post-operative blood transfusion. Further, the early identification of anaemia allows for the utilization of the waiting list time to investigate and treat these patients. For patients who respond to treatment there is a significant reduction in the need for blood transfusion with its inherent hazards.


M. Gaston A. Amin R. Clayton I. Brenkel

Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives.

We also had data on preoperative age, sex and body mass index (BMI).

There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001).

Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.

The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.

This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.


I. Majid H. Rahbi T. Ibrahim M. Slibi

Aim: To evaluate the morbidity and mortality in the perioperative period of patients with aortic stenosis following fractures of the proximal femur.

Patients and Methods: A retrospective review was undertaken of medical notes of all patients (n=20) admitted to our trauma unit over an 18 month period with fractures of the proximal femur and concomitant aortic stenosis confirmed by transthoracic echocardiography. Assessment was made of perioperative factors thought to be important in influencing outcomes in such patients as highlighted in the 2001 Report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) “Changing the way we operate”. These included previous history of angina or ischaemic heart disease, preoperative optimisation by an anaesthetist or physician, maximum pressure gradient across the aortic valve and ventricular ejection fraction on transthoracic echocardiography, seniority of anaesthetist and surgeon performing the procedure, intraoperative invasive monitoring, postoperative high dependency care and complications and outcomes.

Results: Prior to surgery three patients (15%) were seen by a physician and nine patients (45%) by an anaesthetist for medical optimisation. The mean maximum pressure gradient across the aortic valve on transthoracic echocardiography was 38.6 mmHg (range: 12 to 111 mmHg), and five patients (25%) were confirmed as having severe aortic stenosis. Anaesthesia was performed by consultant anaesthetists in 85% of cases with the remaining 15% carried out by trainees. No patients had intraoperative central venous pressure (CVP) monitoring, and only three of the 20 (15%) patients had intra-arterial blood pressure (IABP) monitoring. Only two patients spent one day in the High Dependency Unit postoperatively. The remainder of the patients were discharged back to the general ward where the mean length of stay was 28 days (range: 0 to 135). Postoperatively two patients (10%) developed arrhythmias, three (15%) experienced an episode of acute left ventricular failure and four (20%) developed hypotension. There were two deaths (10%).

Conclusion: It is evident that patients with proximal femoral fracture and concomitant aortic stenosis are still not benefiting from the recommendations of the NCEPOD report in the perioperative period. The authors suggest the introduction of a dedicated multidisciplinary team for the management of patients with proximal femoral fractures and concomitant aortic stenosis.


S.A. Pickering S. Whitehouse R. Crawford W. Donnelly

Introduction/Aims: Early results of a prospective randomised control trial suggested improved position of components implanted during primary hip replacement. The aim of this study is to definitively show the benefit of computer aided navigation in hip arthroplasty with regard to acetabular component position, stem position and leg length.

Method: Eighty consecutive patients were prospectively recruited. Patients were quasi-randomised, on an alternating basis, to undergo hip arthroplasty conventionally or with imageless computer navigation. Postoperatively, a CT scan was performed of the pelvis and lower limb. Using a dynamic CT planning software package, the cup and stem position was measured and compared to the position expected by the three operating surgeons in control cases and the position given by the navigation unit in the study group. Change in leg length was measured clinically and compared with the navigation predicted leg length change. Statistical analysis was performed by a statistician.

Results: Thirty nine navigated hips (29 female, 10 male) and forty one control hips (26 female, 15 male) were recruited. In the navigated group, the mean age was 65.7 and mean BMI was 29.1. In the control group, the mean age was 64.7 and the mean BMI was 29.4 in the control group. Uncemented, securfit/trident hips were used in 18 navigated cases and 20 control cases, with all other cases being cemented Exeter stems and contemporary cups. None of these differences were significant using the Mann-Whitney test. The mean operating time was 128 minutes for navigated hips and 84 minutes for controls, the difference significant at p< 0.005 using t-test.

There was no significant correlation between clinical leg length change, measured in the operating theatre and the leg length change predicted by navigation. Accuracy of cup and stem placement was assessed by comparison of the homogeneity of variances, the Levene statistic, in the navigated and control groups. The range of cup inclination, cup version and stem version was significantly narrowed in the navigation group (p< 0.05).

Conclusion: Computer navigation improves the accuracy of component placement in hip arthroplasty with respect to cup version, cup inclination and stem version with either cemented or uncemented hips.


L. Borris M. Lassen M. Breindahl C. Ryge

To target postoperative patients in need for prolonged pharmacologic thromboprophylaxis due to persistent coagulation activation, we developed and evaluated a qualitative test method, which detects the urinary excretion of prothrombin fragment 1+2 (uF1+2). The test was developed as a dip-stick device consisting of a one step rapid lateral flow immunoassay with visual readout on one test line and one control line. The assay time was between 5 and 10 minutes.

Spot urine samples were collected in 113 patients undergoing elective hip arthroplasty preoperatively and on day 5 after operation. Specimens were frozen immediately and stored until batch analysis. Pharmacologic thromboprophylaxis was administered according to national guidelines until day 7±2 after the operation. The results of the new dip-stick device were compared with the results of a laboratory based enzyme-linked-immunosorbent-assay (ELISA) method and a predetermined cut-off value. Patients were followed for development of vascular thrombotic complications/unexpected death until day 90 after the operation.

10 (8.8%) patients experienced an event during the study: 2 (1.8%) died unexpectedly and 8 (7.1%) had a vascular thrombotic event. All patients with clinical events had significantly raised postoperative levels of uF1+2. The clinical accuracy of the dip-stick test was acceptable with a sensitivity of 100% and a negative predictive value of 100%. Compared to the standard ELISA method the dip-stick test had a sensitivity of 93% and a specificity of 48%.

Laboratory ELISA analysis of urinary excretion of uF1+2 is neither feasible nor applicable in postoperative patients. Bed-side testing of persistent coagulation activation, however, could help to determine the need for prolonged thromboprophylaxis. The new dip-stick urine test was very easy to use, had a high negative predictive value and sensitivity and thus appears to be safe. However, the number of false positive test results prompts a fine-tuning of the test device. In terms of clinical applicability the test was acceptable. The study showed that about one third of the patients could be excluded from further extension of thromboprophylaxis beyond the first week.


H. Kiefer

In THA navigation systems mostly the anterior pelvic plane (APP) is used as reference for cup orientation. For the femoral torsion the sagittal plane of the leg in 90° knee flexion is used as reference. The common procedure is associated with a pointer based palpation of anatomical landmarks. But sometimes it shows difficulties especially in obese patients. The purpose of the current prospective study was to evaluate the THA navigation based on palpation of the APP and the femoral sagittal plane using a novel intra-operative ultrasound device in comparison to standard palpation technique.

Methods: In 2006 the data of 50 patients with navigated THA were analyzed. An image free computer-assisted navigation system (OrthoPilot, B. Braun Aesculap, Germany) was used together with an integrated ultrasound device (probe: 80mm, 5–8 MHz, Telemed, Latvia). First, the registration of bony landmarks, i.e. anterior iliac spines and symphysis for APP as well as patella and tibial pylon for the femoral sagittal axis was performed using the conventional pointer method (PO). Then registration was repeated using the ultrasound device (US). The landmarks of the APP and the dorsal condylar line to define the femoral torsion alignment were recorded. The intra-operative cup orientation and the resulting range of motion was monitored. After cup placement in the “safe zone” described by Lewinnek the femoral stem was rasped monitoring the predicted final ROM, leg length and offset. The navigation software provides simultaneously data for for both, pointer and ultrasound palpation. Cup anteversion, inclination, the antetorsion angle of the rasp as well as the predicted amount of impingement free internal (IR) and external rotation (ER) of the leg are shown. At the end of operation ROM was checked clinically. Plain standardized post-operative X-rays were evaluated for inclination and anteversion angles according to Pradhan.

Results: The calculated mean difference between US registration and PO palpation was 2,2° (range -1,7 – 5.9°) for the cup inclination and 8,7° (range 1,5° – 16°) for anteversion. The impingement free total ROM of the femur as predicted by the Orthopilot, i.e. 109° for PO and 103° for US registration matched well with the clinical data. The clinical findings confirmed the US registration based ratio of mean external (ER 62°) to internal rotation (IR 41°). However, the predicted mean IR as calculated for PO palpation, i.e. 31°, was reduced by a mean of 9° in favor of 13° of more ER (76°).

Conclusion: The results show a higher coincidence of US based registration with the clinical findings. The difference is due to a registration at the bone surface with the US method, while PO palpation cannot overcome a undefined thickness of soft tissue layer, especially in front of the symphysis in obese patients.


Y. PINOIT O. MAY J. GIRARD T. ALA EDDINE P. LAFFARGUE H. MIGAUD

Introduction: The anterior pelvic plane (APP), described by Lewinnek, is defined by the following points : anterior iliac spines, pubic symphysis. This plan is mostly considered as vertical in weight bearing and is currently used as the reference to guide cup insertion by means of imageless computer assistance (CAS). However, to our knowledge, there is no data that strongly confirm APP is vertical in weight bearing and how much his orientation is modified with regards operative position, or THA insertion. This study assessed these data by means of a radiological analysis.

Material and Methods: The orientation of the APP was measured with regards to the vertical plane on weight-bearing profile X-rays of the pelvis in 106 subjects including:

1) 82 patients with THA (40 who had at least one dislocation, and 42 matched patients without instability randomly selected, 19 of these 42 underwent a profile X-ray of the pelvis before and after THA insertion)

2) and 24 standard subjects who underwent lying and weight-bearing profile X-rays of the pelvis to assess the modifications of orientation of the pelvis between these two positions.

Results: Thirty-eight percent of the subjects in weight-bearing had an orientation of the APP different of more than ± 5° from vertical plane and 13% were out of the interval ±10°. The orientation of the APP was not significantly different between the groups (standard and THA) nor between the groups who had stable or unstable THA. The orientation of the APP was significantly modified between lying and weight-bearing posture, from a mean of 1,2° lying to −2,25° upright. Under these conditions, 12 subjects presented a variation of more than 7°. Insertion of a THA did not significantly modify the orientation of the APP in weight-bearing among the 19 subjects (variations were small (−1° ± 7° [from – 21° to 8°]), but were more than 5° for 7 of the 19 subjects).

Discussion and Conclusion: Most of the surgeons use the APP as a reference to guide navigation for cup insertion, considering it is vertical in weight-bearing. However, it is not true for 38% with a margin of 10°, which is equivalent to approximately half of the anatomical anteversion of the acetabulum. Standing up produced a significant variation of the orientation of the APP with regards to lying position. These errors that are not integrated by most of the CAS without preoperative CT scans, may produce cam effect or dislocation when the patient is moving to sited position. The variations of APP orientation with regards to vertical plane suggest it is not adequate to guide the CAS insertion of the cup. There is no reliable reference, easily identifiable during surgery that integrates the variations of position of the pelvis. This leads us to promote a new CAS for THA insertion free of reference plane, based on kinematics.


L. Perlick H. Bathis C. Luring T. Kalteis M. Tingart F. Kock J. Beckmann

Background: During the past decade, there has been a resurgence of interest in hip resurfacing as a mode of treatment for the younger patient with hip disease since major disadvantages of previous resurfacing systems have been overcome. The purpose of the presented study was to clarify if an imageless navigation system will allow precise placement of the femoral component.

Methods: Between September 2004 and May 2006, 50 metal-on-metal surface arthroplasties each were performed either using an imageless navigation system or the conventional technique. The inclination and the axial alignment of the femoral component were determined by two independend examiners and compared to the values presented by the navigation system.

Results: In the preoperative x-rays a mean CCD-Angle of 129.2 degrees (Control group: 127.5°) was measured. The mean femoral shaft angle was 137.5 degrees (Control group 133°) postoperatively with a mean deviation of 2.1 degrees compared to the values shown by the system. In the computer assisted group the mean deviation from the ideal placement in the axial plane was 2.9 degrees compared to 4.8° when using the conventional technique.

Conclusion: The use of a navigation system was associated with only an average time loss of 7 minutes for surface data acquisition und mounting of the reference base. The computer assisted technique appears to be helpful to avoid notching during the femoral bone preparation and improve implant positioning which might improve durability.


C. Dora C. Pfirrmann H. Nötzli J. Hodler M. Zanetti

After THR, trochanteric soft tissue abnormalities may be associated with residual trochanteric pain and limping. However, normal MR appearance of the trochanteric region after THR is not known. The aim was to evaluate MR imagings in asymptomatic and symptomatic patients after THR through a transgluteal approach.

Triplanar MR images of 25 asymptomatic (14 men, mean age 60.4 years, 11 women, mean age 60.2) and 49 symptomatic patients (19 men, mean age 62.7 years, 20 women, mean age 64.3) at least 1 year after THR were analyzed by two blinded radiologists. In 14 symptomatic patients MR imaging was correlated to surgical findings.

Tendon defects were uncommon in asymptomatic and significantly more frequent in symptomatic patients (gluteus minimus 8% vs. 56%, p< 0.001; lateral gluteus medius 16% vs 62%, p< 0.001; posterior gluteus medius 0% vs18%, p< 0.025). Signal changes within tendons were very frequent in both groups except for the posterior gluteus medius tendon which demonstrated this finding more frequently in symptomatic patients (20% vs 59%, p=0.002). Changes in tendon diameter were very frequent in both groups but significantly (p=0.001–009) more frequent in symptomatic patients. Fatty atrophy was evident in the anterior two thirds of the gluteus minimus muscle in both asymptomatic and symptomatic patients. In the posterior superior third of the gluteus minimus muscle differences of fatty degeneration were significant. Fatty atrophy of the gluteus medius muscle was only present in symptomatic patients. Bursal fluid collections were more frequent in asymptomatic (32% vs 62%, p=0.021). MR diagnosis was confirmed in all 14 patients undergoing revision surgery.

Although more frequent in symptomatic patients many MR findings are frequently found in asymptomatic patients. However, defects of the abductor tendons and fatty atrophy of the gluteus medius and the posterior part of the gluteus minimus muscle are rare in asymptomatic patients.


M. Dodd F.S. Haddad F. Rayanmarakkar

The incidence of post-operative peri-prosthetic fractures is increasing. This is a consequence of the larger number of revision cases being undertaken, the increase in the use of cementless implants and a number of patients who develop undetected osteolysis as a result of poor follow up. The Vancouver classification has been shown previously, in North America, to be a valid and reliable method for determining the configuration of a periprosthetic fracture. This is essential in directing the fractures further management appropriately and the classification system has been adopted by surgeons throughout the world.

The reliability of any classification system depends on the reproducibility between the clinicians who are making the management decisions. We have revalidated this classification system, independently from the original authors, at a centre in Europe. The radiographs from 30 patients with peri-prosthetic fractures were reviewed by 6 expert consultant surgeons, 6 non-experts at registrar level and 6 medical students, who had received no specialist teaching in this area, in order to assess intra and inter-observer reliability and reproducibility. Each observer read the radiographs on 2 separate occasions and classified the fracture according to its type (A, B1, B2, B3, and C). The results were subjected to weighted kappa analysis and were: 0.76 (substantial agreement) for experts; 0.68 (substantial agreement) for non-experts; and 0.61 (substantial agreement) for medical students.

Our results confirm the reliability and reproducibility of this classification system. In addition we have shown that substantial agreement can even be found between individuals with no specialist training. This is a classification system that can be reliably used by non-experts, between centres and across continents.


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M. Salcedo S. Martínez J. Cordero Á. Hernández I. Viñuales

Objective: Descriptive retrospective analysis of hip peri-prosthetic fractures treated surgically from 2000 to 2005 analysing risk factors and Results:

Material and Methods: 31 patients with a mean age of 77 years (56–94) were operated of a periprosthetic fracture which happened 73 months (0–300) after the index arthroplasty

Fractures were classified following the Vancouver system: 1 patient presented a type Al(3%), 4 a B1(13%), 23 suffered a B2(74%), 1 a B3(3%) and 2 patients presented a type C(6%)

The risk factors described in the literature were evaluated, as well as the different types of treatment with their clinical and radiological results.

Risk factors:

Personal: 21(68%) patients were women

Previous condition of arthroplasty: 22(71%) non cemented, 23(74%) total prosthesis, 3(10%) revision surgery; 13(54%) presented osteointegration, 2(8%) stable fibrous fixation and 9 (38%) were unstable; in (7%) there was subsidence

Surgical technique: 11(52%) patients had insufficient size of the implant and 15 stems were in varus (54%)

Bone status: 5 femur (20%) presented stress risers and 29(97%) diffuse osteopenia

Polyethylene wear: 10(50%) of THA

Osteolysis was observed in 21 patients (70%): 19(90%) in zone 1, 4(19%) in zone 2, 3(14%) in zone 3, 2(10%) in zone 4, 2(10%) in zone 5, 4(19%) in zone 6 and 15(71%) in zone 7. 5(24%) patients presented osteolysis in one zone, 9(43%) in two zones, 4(19%) in three zones, 2(10%) in four zones and 1(5%) in six zones

Type of treatment: 19(61%) patients were treated with open reduction and internal fixation (ORIF) without revision of the prosthesis, 11(35%) with revision surgery plus ORIF and 1(3%) with a resection arthroplasty. Bone graft was used in only 1(3%) patient

Type of osteosynthesis: 16(52%) only cables, 1(3%) cables and plates, 2(6%) plates and screws, 11(35%) plates and cables and screws, 1(3%) intramedullary nail

Clinical results:

There were 0(0%) infections and 0(0%) exitus but 7(23%) patients suffered postoperative medical complications

The mean time for allow weight-bearing was 3 months (2–6)

For the 25 patients that achieved the complete follow up, maximum recovery was recorded after 9 months (3–13); 24(89%) patients recovered their previous status and 15(60%) had no pain. 15 patients maintained the instrumental level before the fracture and 10(66%) recovered it

Radiological results:

The mean time for fracture union was 6 months (3–18). At the end of follow-up 1(4%) patient presented non-union

0(0%) patients presented mal-union, 2(8%) a refracture, and 6(24%) evolved to implant loosening

Conclusions:

Patients with periprosthetic fractures present a high number of previous local risk factors

Surgical treatment achieves a very low mortality rate and a good/excellent clinical result

Overuse of ORIF without prosthesis revision obtains consolidation in most cases but with a high risk of loosening


M. Nogler E. Mayr M. Thaler A. Williams J. Moctezuma de la Barrera M. Krismer

Background and purpose: Implantation of the femoral component at 10 to 15 degrees of anteversion is recommended in total hip arthroplasty. Surgical guidelines suggest that the lower leg be positioned horizontally or vertically with the knee flexed to 90° (figure of four). By constructing a perpendicular axis (a “figure-of-four” axis) to the lower leg, anteversion of the stem is approximated. This study was performed to validate the figure-of-four axis as a reliable intraoperative tool to approximate the retrocondylar line as reference for stem version.

Method: In 21 cadavers placed supine on an operating table, the lower legs were aligned to the horizontal plane. Using a box column drill, Steinmann nails were inserted perpendicular to the lower leg into the medial epicondyles. The Steinmann nails were replaced by cannulated titanium screws, representing the figure-of-four axis. The femoral neck axes, retrocondylar lines and the figure-of-four axes were determined using CT images of the specimen.

Results: The median version of the femoral neck axis was anteversion of 9.8° (IQR 4.5°–15.1°). The median figure-of-four axis showed a deviation of 0.5° (IQR −2.1°−2°) in relation to the retrocondylar line, whereas the median difference of the axis in relation to the femoral neck axis was 9.5° (IQR −13.6° – −2.1°).

Interpretation: The figure-of-four axis, being nearly parallel to the retrocondylar line, is a valid indirect method to determine stem version intraoperatively in patients without varus/valgus deviations of the knee.


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D. Lazovic F. Dunai N. Kaib

Malposition of cups and stems in THA leads to a higher rate of dislocation and wear, to leg length discrepancies and to a higher revision rate. Surgical navigation of the implant components should lead to a more accurate position of THA.

1481 consecutive THA were evaluated from November 2001 to June 2006. In a first series until December 2002 127 THA with navigated cups were compared with 110 manually implanted THA. In a second series all following 766 THA with navigated cups were compared to 384 THA with both navigated cup and stem. Navigated surgery was done as a routine procedure by all surgeons, from residents to consultants.

Evaluation was done for radiographs, clinical results, the navigation system data for cup anteversion and inclination, centre of rotation, leg lengthening, offset and antetorsion of the stem, technical exclusions and intra- and postoperative complications as dislocation, seroma, thrombosis and duration of surgery.

The results showed a better alignment in inclination and anteversion of navigated cups compared to non navigated cups and additional improvement when cup and stem were navigated. In stem navigation a good control of the leg lengthening and a reliable prediction of the safe range of motion could be seen. The overall dislocation rate was 0.3% in the navigated groups after December 2002. Thrombosis, seroma and infection were seen in a very low rate in all groups.


J. Conroy S. Whitehouse L. Ingerson S. Graves D. Davison R. Crawford

Introduction: Dislocation remains one of the most common orthopaedic complications of hip replacement. Surgical technique, implant design and patient factors have been suggested as risk factors. The 2005 AOA Joint Registry recorded data on 101, 952 hip procedures between 1999 and 2004. We analyzed risk factors for early revision in this group of patients.

Methods: Ethics approval was obtained then a formal application was made to the Australian Joint Registry to release the required data. All primary hip replacements between 1/09/1999 – 31/12/2004 were studied. Statistical analyses of traditional risk factors including initial diagnosis, sex, age and head size were performed. We also studied the effect of fixation method on revision for dislocation.

Results: A total of 65,992 primary hip replacements across all diagnoses groups recorded were investigated with regard to diagnosis. The only initial diagnoses with significantly increased relative risk (RR) of revision for dislocation compared to osteoarthritis was fractured neck of femur (RR 2.25, p< 0.0001) and rheumatoid arthritis (RR 1.9, p< 0.01).

58,109 primary hip replacements for osteoarthritis were investigated for effect of age group, sex and fixation method. Age group and sex were not significant risk factors in revision for dislocation. Studying fixation method, cementless acetabular components were implanted more frequently (49,027, 84%) than cemented (9,082, 15.6%). In total, there were 428 (0.7%) revisions for dislocation, 369(0.8%) with a cementless acetabulum and 59 (0.6%) with cemented. Relative risk (cementless v cemented acetabulum adjusted for age group, sex and head size) of 1.59 (CI 1.19 to 2.12, p< 0.01). Head sizes of > 30mm, 28mm, 26mm and 22mm had significantly increasing relative risk (p< 0.001).

Discussion: The results from this large database indicate rheumatoid patients and those after fractured neck of femur have increased risk of revision for dislocation compared to osteoarthritis. Many of the traditional groups thought to be at higher risk of dislocation were not associated with an increased risk of revision for dislocation. These included age group, sex, avascular necrosis, developmental dysplasia and failed internal fixation. Cementless acetabuli have a higher rate of revision for dislocation. This has not been previously reported. Further investigation is needed to identify the cause of this finding.


H. Lindahl H. Malchau G. Garellick P. Herberts

INTRODUCTION: The postoperative periprosthetic femoral fracture is a severe complication after total hip surgery. It has become the third most common reason for revision. Three-hundred and twenty one fractures operated during 1999–2000, were followed in a prospective nationwide study. The study focused on the failure rate, patient satisfaction, treatment and radiographic evaluation.

PATIENTS AND METHODS: During 1999–2000, 230 fractures after a primary THR and 91 after a revision THR were reported to the Swedish National Hip Arthroplasty Register. All hospital records were collected. At follow-up the Harris hip score, a health-related quality of life measure (EQ-5D) and patient satisfaction were used as outcome measurement. A radiologist performed the radiographic evaluation.

RESULTS: A high number of patients had a loose implant at fracture time (66% in the primary group and 51% in the revision group). Eighty-eight percent of the fractures were classified as Vancouver type B fractures. A major finding was the association between the type of implant and the risk of a periprosthetic fracture. The Charnley and the Exeter prostheses were significantly over represented among patients with fractures and the Lubinus prosthesis significantly under represented. The surgeons grading of the Vancouver type B1 fracture was not in agreement with the study radiologist in more than 34% of the cases. Patient’s satisfaction concerning mobility, self-care, normal activities, pain and anxiety compared to an age matched population with a THR were poor. There was a high failure rate and by December 31, 2004, 22% had been reoperated.

DISCUSSION: A recommendation is to follow all THR patients with regularly radiographic monitoring and to intervene before the fracture. Implant related factors have to be considered when choosing implant for routine use. Difficulty in evaluating the x-rays concerning the stability of the prostheses might lead to sub optimal treatment. We recommend exploration of the implant for all patients with a Vancouver type B fracture if there is any doubt about the fixation status.


J. Charity E. Tsiridis M. Hubble G. Gie J. Howell T. John

Objectives: Retrospective case control study of management and outcome of periprosthetic femoral fractures, from the lower limb reconstruction unit in Exeter.

Material and Methods: 144 fractures over a period of 20 years were reviewed. The Vancouver classification system wasd used to clasify the fractures. The prosthesis length was measured pre and post-peratively. The use of impaction grafting technique for inadequate bone quality of the surrounding bone was assessed (type B3 fractures). The use of Dall/Miles, DCP and Mennen plates was also assessed. Healing was defined using radiological and clinical criteria and where available the Harris Hip Score. Chi-square test with p< 0.05 was used for the statistical analysis of the Results:

Results: When the Vancouver system was applied 2.85% of the fractures were classified as type A, 87.2% as type B and 10% as type C. Within the type B group 13.2% were subtype B1, 12% subtype B2 and 62% subtype B3. 1 out of 6 Mennen, 4 out of 16 Dall/Miles and 2 out of 20 DCP plates failed. Overall 68% healing, 5% non-union, 4% infection, 23% re-fracture rate at 12 months follow-up. Better healing was achieved when impaction grafting was used for B3 fractures (p=0.001). Better healing was achieved when the revision stem was bypassing the most distal fracture line by at least 2 ipsilateral femoral diameters and impaction grafting was used for B3 fractuires (p=0.01).

Conclusion: Impaction Grafting can compensate for the inadequate bone in type B3 fractures and appears to promote union. Revision stem should bypass the most distal fracture line by at least 2 cortical diameters to achieve healing.


A. Toom A. Märtson A. Arend T. Haviko

Heterotopic ossification (HO) is a frequent pathological phenomenon after total hip arthroplasty. Incidence of HO after the total hip arthroplasty is in average 43%. Most often classification from Brooker and co-authors has been used to assess the HO. Overall 47% of all studies published until the 1999 have used Brooker’s system, but there has been reported a “fair” reproducibility (Cohen’s kappa 0.5) of this system.

The aim of the present study was to estimate the influence of used classification system to the evidence of HO, to assess the reliability of the more often used classification systems, to determine the sources of errors in the assessment-process of HO and, to compose a new classification system with higher reliability.

Four investigators assessed HO in 111 patients applying most often used classification systems and the new system. Six investigators measured dimensionality of HO in 28 patients applying method of digital planimetry. Kappa statistics of all the compared classification systems were calculated. Main sources of errors were detected by dispersion model.

Average evidence of HO differed up to 1.4 times if the different systems were applied to assess HO. Therefore, using literature data, always the criteria of a system used should be taken into consideration.

Most important source of errors in the HO assessment was the error of diagnosing process. This source consisted of two components: inter-observer variation that formed 25.5% (+/−8.0%; p=0.0015) of total error and intra-observer variation that formed 60.9% (+/−7.3%; p< 0.0001). Technical performing error had less contribution in total error, namely 8,0% (+/−0.6%; p< 0.0001) and subspecialisation of the investigators did not cause any systematic bias having a proportion of 5.7% (+/−4.9%; p=0.2457).

Reliability of the Brooker’s system was lowest among the compared systems. Combining the Della Valle’s system which had high reliability with the Brooker’s system, we composed a new classification preserving high reliability. The results obtained using the new classification allow comparison with the results obtained using each of the parent classifications.


J. Walsh J. Quinlan K. Butt M. Towers A. Devitt

Introduction: The position of the L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is used frequently as a pre-operative guide for incision placement, in patients undergoing spinal surgery.

Aim: To investigate whether a line drawn between the two highest points on the iliac crests corresponds to the L4/5 disc inter-space, in varying patient age groups.

Patients and Methods: We reviewed 450 AP and lateral lumbar spine radiographs in patients ranging in age from 20 – 90 years. Patients with an obvious deformity or previous spinal surgery were excluded from the study. In the AP films, a line was drawn between the two highest points on the iliac crests. From this line, the distance to the midpoint of the L4/5 disc was measured.

Results: In all age groups measured, the true L4/5 disc inter-space lay below the line between the iliac crests, at an average of 4.33mm below the supracristal plane. The plane intersected the spine at the L4/5 interspace in only 31.9% of cases and was found to lie at the lower half of the L4 body or above in 49.3% of cases.

Conclusions: These results show that, using a line drawn between the two highest points on the iliac crests as a guide to the position of the L4/5 disc interspace may lead to unintentionally cranial positioning of an incision or cannulation in this area. Therefore, it is advisable to perform a pre-operative AP and lateral radiograph of the lumbar spine, to enable accurate incision placement when performing spinal surgery in this area.


E. Fawzy H. Dashti N. Oxborrow J. Williamson

Aim: To measure the quality of five major scientific meetings by assessing the publication rate of papers presented and recording their citation index.

Material and Methods: Abstracts of podium presentations at the meetings of the Scoliosis Research Society, International Society for the Study of the Lumbar Spine, British Scoliosis Society, BritSpine and Eurospine were included. We performed a Medline search to identify publications from the abstract. We calculated the time from meeting to publication and recorded the citation rate of the articles.

Results: Of 396 abstracts, 182 were published in peer-review journals – a publication rate of 46%. The publication rates of the five meetings (SRS, BSS, ISSLS, Eurospine, Britspine) were 69%, 53%, 51%, 38%, 24% respectively. Most publications were in “Spine” (55%), then European Spine Journal (11%). The median citation rate of the papers from the SRS, ISSLS, BSS, Eurospine, Britspine meetings was 3, 3, 3, 2, and 1 respectively. The average time to publication was 16 months.

Discussion & Conclusions: Podium presentation is a valuable means for the dissemination of research findings. However, a paper in a peer-reviewed journal is subjected to greater scrutiny, and is perhaps a better indicator of the work’s merit. The average rate of publication in medicine following presentation is 45%1. Spinal meetings are within this range. Although the quality of the scientific work is not the only factor to determine publication, and nor is the quality of the presentations the only factor to assess in evaluating a meeting, the rate of publication and citation rate provide an indicator of the quality and scientific level of meetings.


J.P. Cashman W.F. Cashman

Introduction. Total hip arthroplasty is one of the most successful operations performed by an orthopaedic surgeon. There are three surgical approaches in use since Charnley popularised the trans-trochanteric approach. Opinion has been divided as to which approach is superior.

Aim. This study was designed to examine the difference in morbidity between the classical Charnley trans-tro-chanteric approach and the antero-lateral trans-gluteal (Hardinge) approach in primary hip arthroplasty.

Methods. Information on 891 patients, who underwent primary total hip arthroplasty performed by a single surgeon, was collected prospectively between 1998–2003 using a modified SF-36 form, pre-operatively, intra-operatively, and at three months. Information collected includes patient demographics, diagnosis, intra-operative blood-loss, and post-operative satisfaction and range of motion. Information was collected on the Excel database and analysed using Minitab statistical package.

Results. The two groups were statistically similar for gender and side of pathology. There was no statistical difference in blood-loss between the groups. There was higher morbidity in the TT group. More patients were doubtful or dissatisfied with the THR in the TT group. There was a greater range of motion in the Hardinge group.

Conclusion. In this study population, the trans-trochanteric approach was associated with higher morbidity, a lower patient satisfaction rating and a lower range of motion.


P.K. Inaparthy R. Chana G. Andrew P.W. Skinner K.W. Tuson G. EPOS

Introduction: Various surgical approaches have been described for the hip joint but the optimal surgical approach for total hip replacement remains controversial. The lateral approach & the posterior approach are the most commonly used approaches.

Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS.

AIM: To find out the affect of surgical approach on oxford hip score.

Methods: Exeter Primary Outcomes Study was a prospective non-randomised multicentre study involving six centres across the UK. Ethical committee approval was taken and the study was conducted over a period of five years. 1610 patients were included in the study. All the patients underwent primary hip replacement with Exeter stem AND were followed up in the clinics for pre-operative assessment and then at three months, year one, year two and year five post-operatively. Oxford hip score was noted at pre-operative assessment and postoperatively at three months, year one, two, three, four and five, either in the clinics or by post. All data was analysed in conjunction with a statistician using SPSS.

Results: We had 1587 patients with regular follow-up. Lateral approach was the most common surgical approach (n=1143) compared to posterior approach (n=436). Sex ratio for each surgical approach was comparable. Oxford hip scores significantly improved postoperatively (P < 0.05) up to four years, with both the surgical approaches. The posterior approach gave a better improvement in OHS compared to the lateral approach for all the four years. The absolute oxford hip scores improved significantly with the posterior approach for the first 12 months post-operatively.

CONCLUSION: Posterior approach gives greater patient perceived clinical benefit in the first year after surgery which could help in early rehabilitation compared to lateral approach. This should be considered when assessing the best approach for the patients.


A. Ibrahim H. Crockard S. Boriani C. Bunger A. Gasbarrini J. Harms C. Mazel R. Melcher K. Tomita

Introduction An international six-centre prospective observational cohort study.

Objective. To assess the feasibility of radical surgical excisional treatment of spinal metastasis

Materials and methods. Patients with histologically confirmed spinal metastasis originating from epithelial primary site mostly treated with instrumented surgery were studied. Surgical strategies were either radical excisional (enbloc and debulking) or palliative decompressive surgery. Outcomes assessed were measures of quality of life including pain, mobility, sphincter and neurological functions.

Results. A total of 223 patients with a mean age of 61 years and equal number of males and females were studied. Breast, renal, lung and prostate accounted for three quarters of tumours and 60% had metastasis that extended beyond one vertebra. Most patients presented with pain (92%), paraparesis (24%) and abnormal urinary sphincter 22% (5% were incontinent). Seventy four percent of patients underwent radical surgery, 92% of all patients had instrumented fixation. 73% of the radical group had improved pain control (63% for palliative group), 72% regained ability to walk (45% for palliative group), 92% maintained a functional neurological function of Frankel E/D (64% for palliative) and 55% had improved sphincter control (21% for palliative group).

Overall of all petients who underwent surgery, 71% had improved pain control, 53% regained mobility, 64% improved by at least one Frankel grade or maintained normal neurology and 39% regained normal urinary sphincter function. While 18% were bed bound preoperatively, only 5% were still in bed postoperatively. Perioperative mortality rate was 5.8% and morbidity was 21%. The median survival for the cohort was 352 days (11.7 months). The radical surgery group had a median survival of 438 days and the palliative group 112 days (P = 0.003).

Conclusion. Surgical treatment of spinal metastatic tumour is feasible with low mortality, an acceptably low morbidity and affords patients better quality of remaining life. Radical surgical excision has better outcome than palliative surgery in pain control and in neurological function rescue including regaining mobility and improvement in sphincter control.


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R. Sinigaglia U. Nena D. Fabris Monterumici

Object. Our purpose is to describe a new surgical technique, the transoral kyphoplasty, that we performed in 3 cases of tumors in C2.

Materials and Methods. From February 2004 to January 2006 3 cases of C2 tumoral localizations did not show healing after 6 months of conservative treatments. To reduce pain and avoid both C2 collapse and prolonged immobilization transoral kyphoplasties were performed.

Results. There were no complications and/or complaints related to the procedure. There were no C2 related symptoms or neurological problems. The first patient died 8 months after surgery due to unrelated causes. The second and the third are alive and, follow ups of 2 years and 8 months respectively, reveal good and pain-free cervical motion, with no findings regarding pathologic mobility/instability on X-ray and CT.

Discussion. The management of tumors of the C2 body is still controversial. In cancer patients non-operative treatment could fail. In these cases the literature recommends internal fixation (anterior or posterior), percutaneous vertebroplasty, or transoral vertebroplasty [14]. Anatomically, the transoral route is the most straightforward percutaneous access to the C2 body [4]. In our cases, after conservative treatment failure, we performed the transoral kyphoplasty to avoid major surgical procedures, and considering kyphoplasty an improvement of the vertebroplasty. While maintaining the normal cervical spine anatomy, and avoiding arthrodesis or fixation that reduce the cervical spine range of motion, in the thoracolumbar spine kyphoplasty versus vertebroplasty is correlated with a reduction in the complication rate [5].

Conclusions. Transoral kyphoplasty could be considered a safe, quick and effective treatment in reducing pain and avoiding vertebral collapse in patients with tumors in C2, not responding to non-operative treatment.


S. Schaeren I. Broger B. Jeanneret

In spinal stenosis with degenerative spondylolisthesis, decompression and fusion is widely recommended. However, the main drawback of fusion remains pain at the bone donor site. A novel dynamic transpedicular system (Dynesys™) was introduced to stabilize the spine without adding bone graft for fusion. Two years results reported earlier were excellent.

Objective: To test whether dynamic stabilization in situ can maintain enough stability to prevent progression of spondylolisthesis in long term follow-up.

Methods: 26 consecutive patients (mean age 71 years) with lumbar spinal stenosis and degenerative spondylolisthesis underwent interlaminar decompression and stabilization with Dynesys™. Patients were re-evaluated clinically and with plain and functional radiographs after a minimum follow-up time of 4 years.

Results: A total of 20 patients could be evaluated. Pain on VAS as well as walking distance improved significantly (p< 0.01) at 2 years and remained unchanged at 4 years follow-up. Radiographically spondylolisthesis did not progress and the motion segments remained stable. Implant failure in terms of screw- loosening (3 patients) or breakage (1 patient) seen after 2 years did not increase. Progressive degeneration at an adjacent level was seen in 35% of the patients at 2 years and in 39% at 4 years. Overall, patient satisfaction remained high as 95% would undergo the same procedure again.

Conclusions: In elderly patients with spinal stenosis and degenerative spondylolisthesis, decompression and dynamic stabilization leads to sustained excellent clinical and radiological results. It maintains enough stability to prevent progression of spondylolisthesis. Since no bone grafting is necessary, donor site morbidity is eliminated. The degenerative disease however is progressive and degeneration at adjacent motion segments remains a problem.


M. Tzermiadianos A. Hadjipavlou S. Renner R. Havey M. Voronov M. Zindrick A. Patwardhan

Residual kyphotic deformity is considered the main factor for the increased risk of new fractures after an osteoporotic vertebral fracture. We hypothesized that even in the absence of kyphotic deformity, the altered pressure profile of the disc after a fracture will increase the risk for subsequent fractures.

Materials and Methods: Six fresh-frozen, human thoracolumbar specimens, consisting of 5 adjacent vertebrae, were used. A void was randomly created under the upper (n=3) or the lower (n=3) endplate of the middle vertebra. The specimen was then compressed in flexion until a selective fracture of the weakened endplate was observed. Vertebral kyphosis was reduced with extension. After cementation of the fracture, the rest of the trabecular content was evacuated and was filled with cement. Specimens were tested in flexion-extension (±6Nm) under 400N preload before and after the index fracture. Pressure was recorded at the discs above and below the fractured VB and strain at the anterior wall of the adjacent VBs. Finally, the specimen was loaded in flexion until a subsequent fracture was observed on fluoroscopy.

Results: In the intact specimens, nucleus pressure increased by 26.4±13.9% in full flexion compared to neutral posture. After the index fracture, the pressure in full flexion increased by 15.2±11 % in the discs with unfractured endplates, but decreased by 19±26.7% in the discs with the fractured endplate (p< 0.05). Anterior wall strain at the VB adjacent to the fractured endplate increased by 94.2%±22.8% (p=0.02), compared to an 18.2%±7.1% (p=0.98) increase at the VB adjacent to the unfractured endplate. Subsequent loading of the specimens after cementation of the index fracture resulted in a fracture of the adjacent VB close to the fractured endplate of the middle vertebra in 4 specimens and at the upper potted VB in one specimen. Maximum load applied with the actuators failed to create a fracture in one specimen.

Discussion: The effects of the fractured endplate were isolated by eliminating other known parameters. Vertebral kyphosis was reduced and cement was similarly distributed under both endplates.

In the intact specimens, nucleus pressure gradually increased during flexion. This can more evenly distribute the load during flexion to the entire surface of the endplate and avoid excessive load concentration to the anterior portion. After an endplate fracture, the nucleus pressure gradually decreased during flexion, meaning that the anterior annulus was forced to bear more load. This uneven load transfer to the anterior part of the VB resulted in doubling the strain at the VB adjacent to the fractured end plate. All adjacent factures were observed at the vertebra next to the damaged endplate. The altered mechanical behavior of the nucleus can be ascribed to the increased available space after the endplate depression.


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J.M. Tulha R. Pinto R. Matos N. Neves A. Trigo Cabral

Our objective is to perform a prospective study on the efficiency and durability of pain reduction through percutaneous PMMA vertebroplasty in patients with vertebral osteoporotic fractures.

We started in March 2002, and up to January 2005 we have performed this technique in 43 patients, 42 female and 1 male, with osteoporotic vertebral fractures. We performed a total of 56 vertebroplasties, 36 lumbar and 20 thoracic. The majority is for the thoracolumbar junction. Patient age went from 56 to 85, with an average of 70,7 years.

Cryteria for inclusion in this study have been the following:patients with osteoporosis, preferably with one or two collapsed vertebral bodies, with intractable pain for over 3 months. Exclusion cryteria have been: infection, blood coagulation deficits and mieloradicular compression. Relative exclusion criteria are Fractures over 70% body collapse, Posterior wall fragmentation and Young patient fracture with no prior disease.

We perform our PV under local anesthaesia with sedation and in a lateral decubitus position. We preferably use a parapedicular approach for both thoracic and lumbar fractured vertebrae.

The material we prefer are the LP2 system or the LCO and we chose Exolent spine for PMMA.

We follow a protocol that consists in:bed rest for 2 hours, allowing the patient to sit and have small walks afterwards;Dismissal the following day, with a mild analgesic for the effects of the skin incision;Maintain drug treatment for osteoporosis;Revision on the 2nd and 7th day;New revision at 3, 6 and 12 months.

Evaluation of the results was made by defining a pain score: Score 1 corresponds to minor or no improvement in pain.

Score 2 corresponds to a medium improvement in pain, with 25 to 50% less drugs required.

Score 3 corresponds to a better improvement in pain, with 75 % less drugs required.

Score 4 corresponds to complete relief of pain. In our revision, we had a minimum follow-up of 12 months, maximum of 44, and an average of 28 months. We have observed the following results:

- 2 patients with score 1

- 4 patients with score 2

- 32 patients with score 3

- 5 patients with score 4

We can resume this by stating that 90 % of the patients had a relief in pain, and a good result was observed in 75 %.

We have had some complications, which consisted in:

- PMMA leakage into the disc in 1 case

- Transitory radicular pain in 1 case

- Hiperthermia in 1 case

- Cannula breakage in 1 case, which was resolved through a small incision. None of these has altered the final result.

- Venous leakage in 1 case, which we have considered as the only serious complication..

In conclusion, and up to now, we have obtained pain reduction in 90% of the cases; we have prevented collapse of the treated vertebrae, and we have not had collapse of any adjacent vertebrae.

It is a technique that may have complications, but results depend on a correct selection of patients.


A. Ramieri P. Cellocco V. Barci G. Costanzo

Introduction: Currently, percutaneous vertebroplasty and kyphoplasty are commonly used for the treatment of vertebral osteoporotic compression fractures (Phillips et al., 2003). Even without fractures, an osteoporotic vertebral body may develop some structural modifications with dystrophic features, defined as “intravertebral clefts” and “intravertebral vacuum” (Missori et al, 2005). These conditions may be painful and the MRI is the imaging technique of choice for their evaluation.

Materials and methods: A prospective consecutive series of 21 elderly patients with pain in the thoracolumbar or lumbar spine were evaluated. MRI findings showed modifications of the vertebral body consistent with algodystrophy. Lesions were treated by means of percutaneous augmentation with PMAA, using a single pedicle approach. The outcomes of such procedure were evaluated with a visual analogue scale for pain (Chen et al, 2005).

Results and conclusions: Percutaneous augmentation has not determined any complications neither early nor late. Outcomes have showed to be good or excellent, except for a patient with insufficient amount of injected PMMA. Augmentation of the vertebral body showed to be effective in reducing or solving pain, in spite of the biomechanical alterations due to algodystrophic phenomena. During kyphoplasty, particularly when performed for painful Schmorl nodes, balloon inflation creates a positive pressure room inside the vertebral body opposed to the negative pressure caused by abnormality of the discovertebral junction. This phenomenon makes it possible to fill the vacuum with PMMA without the risk of cement leakage.


H. Mhaidli A. Montesdeoca J. Lorenzo T. Fernandez

INTRODUCTION AND OBJECTIVE: To compare the clinical and radiological results of the unilateral posterolateral approach with the bilateral transpedicular approach in the treatment of osteoporotic fractures with percutaneous vertebroplasty (PV).

MATERIAL AND METHODS: 75 patients with 113 symptomatic osteoporotic vertebral fractures treated with PV were studied: 53 females and 22 males. Average age 70.5 years (41 – 91), average follow-up 24 months (12 – 50). A unilateral posterolateral approach was used in 84 vertebrae and a bilateral transpedicular approach in 29 vertebrae. The most frequently treated vertebrae were L1 (30 vertebrae), L2 (27), L3 (19) and D12 (14). A posterolateral approach was used in 63 vertebrae (80.8%) and a transpedicular bilateral approach in 15 (19.2%). X-ray and MRI at pre-op, post-op, three months, six months and annually; post-op C-T of all patients. The Visual Analogical Scale (VAS), and the Oswestry Disability Index (ODI)were used at pre-op and six month follow-up.

RESULTS: There were 72 cement leakages in 54 vertebrae (47.8%). In the posterolateral approach there were 33 cement leakages (39.3%), and there were 21 vertebrae with cement leaks (72.4%) in the bilateral transpedicular approach group. This difference is statistically significant (p=0.004). The cement leakages were classified in six anatomic groups. For the whole series cement leakages were more frequent to the proximal disk with 22 cases (19.5%), 11 leaks to the distal disk (9.7%), 9 to the external-vertebral venous plexus (8%), 10 paraparavertebral leaks (8.8%), 8 spinal canal leaks (7.1%), others 4 cases (3.5%) The most frequent cement leakage in both approaches is to the proximal disk. In the posterolateral approach the pre-op and post-op VAS were 7.76 and 2.66 as well as a pre-op and post-op ODI of 72 and 32.73. In the transpedicular approach the pre-op and post-op VAS were 7.71 and 2.21, and ODI of 66.3 and 28.04 respectively. No statistically significant differences were found in the clinical results between both groups.

CONCLUSION: The clinical outcomes for both approaches were similar, however the incidence of cement leakages is significantly higher in the transpedicular approach. We recommend the unilateral posterolateral approach in the treatment of osteoporotic vertebral fractures with PV to reduce the risk of cement leakage.


T. Repantis P. Korovessis S. Zacharatos

Background. Balloon kyphoplasty has been established as an effective minimal invasive method to treat vertebral fractures of osteoporotic and pathologic etiology.

Objectives. Comparative analysis of the clinical and radiographic outcomes of balloon kyphoplasty for treatment of osteoporotic and pathologic vertebral fractures.

Study design. Prospective comparative study.

Materials-Methods. Twenty five patients (14 women and 11 men) aged (average + SD) 73 + 8 years (range 52–83 years) with vertebral fracture were treated with kyphoplasty and were sampled into three groups: 14 patients (Group A) suffered from osteoporotic fractures and underwent percutaneous kyphoplasty, 5 patients (Group B) suffered from fractures caused from malignancy were treated with percutaneous kyphoplasty, and 6 patients (Group C, hybrid) who underwent combined operation (open kyphoplasty plus instrumented fusion). These patients underwent 25 operations to treat 38 vertebral fractures located between T11 and L5. Preoperative and postoperative radiographs were compared to calculate the changes of vertebral body height ratio (AVBHr, PVBHr) and Gardner kyphotic deformity angle. Sagittal spine alignment was analyzed on whole spine standing radiographs. The VAS, the Oswestry Disability Index (ODI) and the SF-36 surveys were used to evaluate the clinical results. The average time of follow-up was 31.5 + 7 months (range 25–40 months). The average preoperatively SF-36 score (Domain Bodily pain) was 8+ 16, The VAS was 9+1.3 while the ODI was 28+ 17.

Results. The average SF-36 (Bodily Pain) score did not significantly differ among the groups and was improved postoperatively to (average, SD) 40+14. VAS improved postoperatively in an similar way in all three groups to 4+1.4 and the ODI was improved in all three groups to 49+ 17, without significant differences among groups. The AVBHr improved significantly only in group A (p=0.01), while there was no change in PVBHr in any group. The Gardner angle improved significantly in groups A (p=0.006) and C (p=0.05) respectively.

Discussion. The inflatable bone tamp placed percutaneous or open in combination with spinal instrumentation was efficacious in the treatment of osteoporotic and pathologic vertebral fractures. Kyphoplasty alone or as hybrid was associated with early clinical improvement of pain and function in the treatment of painful pathologic compression fractures, as well as with reduction of Gardner angle.


A. Hadjipavlou M. Tzermiadianos P. Katonis I. Gaitanis D. Paskou K. Kakavelakis A. Patwardhan

The circulatory effects of multilevel balloon kyphoplasty (BK) are not adequately addressed, neither the effectiveness of egg shell cementoplasty in preventing anticipated cement leakage in difficult cases. The purpose of this study was to evaluate

the effect of multilevel BK to blood pressure and arterial blood gasses;

the incidence of methylmethacrylate cement leakage using routine postoperative computer tomography scan and

the effectiveness of egg shell cementoplasty to prevent cement leaks.

Materials and methods: This is a prospective study of 89 patients (215 vertebral bodies-VBs) with osteoporotic compressive fractures (OCF), and 27 with osteolytic tumors (OT) (88 VBs). The mean age was 67.6 years. 27 patients with OCF were treated at one level, 26 at two, 21 at three, 7 at four, 6 at five, and 2 at six levels at the same sitting. Three patients with OT were treated at one level, 6 at two, 9 at three, 3 at four, 4 at five, and 2 at seven. Egg shell balloon cementoplasty to prevent cement leakage was performed in 10 patients with severe endplate fracture or vertebral wall lytic destruction. Arterial blood pressure and oxygen saturation were monitored during surgery. Arterial blood gases were measured before and 3 min after cement injection. Cement leakage was assessed by the postoperative x rays and computer tomography scans.

Results: A drop in blood pressure of more than 25mmHg during cement injection was observed in 6 patients, and was not associated with the number of VB treated. Blood pressure was dropped more than 40mm in 2 patients and the procedure was aborted after completing 1 level in the first and 2 levels in the second. Drop in arterial O2 saturation was noted in 4 patients. One patient treated for 5 levels developed fever and tachepnoea for 24 hours after surgery. Arterial O2 and chest x-rays were normal. Cement leakage was found in 9.7% (21/215) of VBs treated for OCF. Its incidence per location was: epidural, 0.9% (2 VBs); intraforaminal, 0.5% (1 VB); intradiscal, 3.2% (7 VBs); and through anterior or lateral walls, 5.1% (11 VBs). In the OT group cement leakage was found in 10.2% (9/88) of the treated VBs. Its location included 8 (9%) through the anterior or lateral walls and one (1.1%) intradiscal. Cement leakage had no clinical consequences. No cement leakage was observed in cases treated with egg shell balloon cementoplasty.

Conclusions: BK is a safe procedure when applied for multiple levels in the same sitting, and its rare circulatory effects are not related to the number of levels treated. The incidence of cement leakage in this study was 10%, which is far less than that reported with vertebroplasty using routine postoperative CT scan. Egg shell balloon cementoplasty can effectively minimize cement leakage in cases with fractured endplate or lytic destruction of VB walls.


T. Barz M. Melloh H. Merk L. Staub F. Knöfler

Background context: Surgical treatment of lumbar spinal stenosis is one of the most frequent procedures in spinal surgery. Nevertheless, the predictive quality of instruments like treadmill test and MRI has not yet been clearly defined for the lumbar spinal stenosis.

Purpose: Objective of this study was to verify correlations between treadmill test and MRI findings in the narrowest spinal segment.

Methods: In a prospective study (EBM-level 3) 25 patients with inpatient treatment for lumbar spinal stenosis were investigated between 01/2005 and 06/2005. Exclusion criteria were a reduced walking capacity for other reasons (e.g. gonarthrosis). Treadmill tests were performed following the protocol by Deen. Patients estimated their maximum walking distance before performing the tests. Area of the dural sac, area of the neuroforamina and disc height at the dorsal margin were examined by MRI for the narrowest spinal segment. VAS and ODI were used as clinical assessment instruments.

Outcome Measures: The median age of patients was 67 yrs (IQR 58–73 yrs) with 44 % females. The median distance reached in the treadmill test was 70 m (IQR 30–135 m), the median estimated maximum walking distance 200 m (IQR 100–300 m). In the narrowest spinal segment the median area of the dural sac was 91 mm2 (IQR 65–143 mm2), the median area of the neuroforamina 43 mm2 (IQR 36–51 mm2) and the median disc height 1,4 mm (IQR 0,9–2,5 mm). The median VAS was 7 (IQR 6,5–8) and the median ODI 33 (IQR 32–37).

Results: The distance reached in the treadmill test correlated with the maximum walking distance estimated by the patients (Spearman’s rho=0,62, p=0,001), area of the dural sac (rho=0,54, p=0,006) and disc height (rho=0,45, p=0,03), but not with area of the neuroforamina and VAS. VAS correlated with the disc height (rho=−0,6, p=0,002), but with no other MRI findings.

Conclusions: The distance reached in the treadmill test and MRI findings in the narrowest spinal segment predict the level of clinical symptoms. Possible reasons for the slightly limited predictive quality of MRI findings are that this study did not regard the time of development of the stenosis, that effects of multilevel stenosis were not considered, and that MRI findings in lying position without lordosis might differ from findings in standing position. However, the treadmill test is a valid and highly practicable pre-surgery diagnostic instrument in lumbar spinal stenosis.


K.å. Jansson F. Granath G. Németh B. Jönsson P. Blomqvist

Introduction: Although decompressive surgery of spinal stenosis is a common procedure in spine surgery, there are no studies assessing patients’ perceived health related quality of life (HRQOL) by EQ-5D. An objective was to describe status overall and by analyzing pre- and one year postoperative health related quality of life (HRQOL) by the EQ-5D instrument in patients operated on for lumbar spinal stenosis. This cohort was compared to a Swedish population EQ-5D survey.

Methods: Data were obtained from the National Swed-ish Registry for lumbar spine operations 2001–2002. On 230 patients (mean age 66 years, 53% females) operated on for lumbar spinal stenosis the primary outcome measures were pre- and postoperative EQ-5D data. In addition, patient and disease characteristics (pain and walking ability) were reported. Analysis of variance (ANOVA) was performed and the relative differences pre-and postoperatively compared to a Swedish population survey were calculated.

Results: The majority of patients experienced an improved and their EQ-5D score increased from 0.36 to 0.64 one year after operation. However, they did not reach the level reported by an age- and gender matched population sample (mean difference 0.18). Woman had lower pre- and postoperatively EQ-5D scores than men. Preoperative severe pain was a significant predictor for a lower postoperative EQ-5D score. Four out of ten reported considerable improvement while a similar portion of patients (41%) with high preoperative scores were slightly improved. A third group (14%) were unchanged with low EQ-5D scores, and a few (4%) perceived a decline in their HRQOL. The mean VAS rating of leg- and back pain improved one year after operation by 28 and 29 %, respectively. The proportion of patients able to walk longer than 500 m increased from 25 % preoperatively to 65 % postoperatively.

Conclusions: Our national Swedish representatively cohort of disc herniation patients has a remarkable low EQ-5D scores preoperatively. However their HRQOL improved considerably in 80 % of the patients one year after surgery. The health related quality of life improves after surgery for lumbar spinal stenosis, approaching the population reference level. It is of most importance to further investigate the risk factors behind the less favourable outcomes in health related quality of live (EQ-5D score) in women.


P. Parisini M. Di Silvestre F. Lolli G. Bakaloudis

Study design. A retrospective study design

Objective. To comprehensively compare the 2-year clinical outcome of lumbar laminectomy alone versus lumbar laminetomy supplemented with dynamic stabilization (Dynesys system) in degenerative lumbar stenosis in elderly patients.

Material and Methods. A total of 60 elderly patients with an average age of 65.1 years (range, 50 to 78 yrs) affected by lumbar stenosis that underwent lumbar laminectomy alone (30 cases) or lumbar laminectomy with supplementary Dynesys system (30 cases) at our Department were sorted and matched according to three criteria : similar patient age, similar degenerative lumbar desease, and identical operative methods (i.e. levels of laminectomy). Patients were compared according to Oswestry Disability Index (ODI), Roland Morris, SF-36 and VAS outcomes scores.

Results. The two cohorts were well matched at 2-years follow-up. Patients treated with lumbar laminectomy alone presented reduced operative time and intraoperative blood loss and reduced postoperative complications, with better clinical outcome compared with patients that received laminectomy with supplementary Dynesys system, for ODI score (28.9 vs 31), Roland Morris (8.25 vs 9.1) and VAS scores (leg pain 36 vs 44.3; back pain 31 vs 38.7), while SF-36 scores resulted similar in both groups of patients.

Conclusions. In degenerative lumbar stenosis, supplementary dynamic stabilization in addition to decompressive laminectomy did not presented significant advantages, with respect to functional outcome, in comparison to lumbar laminectomy alone.


J. Schwickal-Melot G. Godde P. Krause D. Werner P. Mark P. Simons C. Huyer

Introduction: Lumbar spinal stenosis (LSS) is a condition involving the narrowing of either the spinal canal or neural foramina and may lead to intermittent neurogenic claudication (INC). Traditionally LSS is been treated by conservative therapy followed by decompression and, if required, stabilizing of the lumbar spine for non-responders. Current results indicate that decompression may lead to increase of biomechanical stresses at levels adjacent to the operated level causing degenerative disorders.

In the last years dynamic devices represent an alternative for the more invasive decompression surgery.

Currently a registry is maintained to collect data on patients implanted with the X STOP.

Methods: Patients who were diagnosed with LSS and planned for an implantation of the X STOP were included in the study. Diagnosis was confirmed by CT or MRI scans. Outcome was measured by the Zurich Claudication Questionnaire measuring symptom severity (SS), physical function (PF), and patient satisfaction (PS). An analysis was performed for the patient who completed the pre-operative and either the 1-year follow-up or 2-year follow-up assessment.

Results: 283 patients participated in the study by completing either the questionnaires by the patient or data forms by the specialist. From these 89 patients completed the pre-operative and 1-year assessment and 20 completed the pre-operative and 2-year assessment.

The results showed a clinical significant change for the domains SS and PF for both 1-year follow-up and 2-year follow-up. For the domain PS the mean score is 1.81 (very satisfied = 1, somewhat satisfied = 2).

The clinically significant success rate based on clinically improvement in 2 of the 3 domains is 71.9% and 65.0 % after respectively 1-year and 2-year follow-up.

Discussion: Our results suggest that intermediate term clinical outcomes of X STOP IPD surgery are stable over time although it may indicate that over time a decrease in clinical significant improvement may be observed. As INC caused by LSS is an ongoing degenerative disease, this may be explained by the ongoing degenerative process.


M. MATAS M. UBIERNA M. LLABRES E. CASSART J. RUIZ M. IBORRA J. CAVANILLES

Study design: Long-term retrospective study of the low grade isthmic Spondylolisthesis treated by means of instrumented posterolateral fixation in adults.

Objective: To evaluate clinical and functional survival of surgical treatment of the espondylolisthesis after minimum 10 years of follow-up. To study the radiologic behaviour of the fused and the adjacent level.

Summary of background: It’s been suggested in many different series that posterolateral instrumented fusion is not always capable to improve the lumbar pain neither to stabilize a vertebral segment if the anterior column is not supported. The need to perform and interbody fusion in the surgical treatment of isthmic spondilolysthesis is still unknown.

Material and method: From a total of 42 patients operated by low grade isthmic espondylolisthesis, it’s been obtained a clinic and radiological follow up in 31 patients, 19 females and 12 males. The average age at the moment of surgery was 34.9 years and in the last review was 46.5 years. The average follow up has been 11.8 years. Pain and functional disability was quantified by a visual analogical Scale (VAS) and the Oswestry Disability Index (ODI). Quality of life was assessed by the SF-36. The preoperative and postoperative percentage of slip and lumbosacral kyphosis was evaluated in serial radiographs at the fused level. The intervertebral disc height and dynamic behaviour was evaluated at the adjacent level.

Results: Spondylolisthesis was present at L5 in 24 patients, L4 in 6 patients and at L3 in 1 patient. In the 87% of cases the fusion was one level and the 3% was two levels. The mean (range) anterior slip at postoperative was 21.9%, and 23.1% at the final follow up. The average angle for the lumbosacral kyphosis was 19.4° in the postoperative and 19.5° in the follow up. The Oswestry Disability Index scores average at follow up was 13,6. 75.8% of patients were considered with a minimum disability and 17.2% with a moderate disability. The 67.7% of the patients develop rewarded activities, the 25.6% develop domestic tasks and the 6.45% are in a disability situation. There was no statistically significant difference between the study population SF-36 scores and those of the general population, same age and gender, in any of the eight domains.

Conclusions: Long-term clinical and radiographic outcomes after “in situ” posterolateral instrumented fusion of adult low-grade Spondylolisthesis were satisfactory. This study further confirms that such surgery is appropriate for these selected patients.


T.H. Hansson O. Ogikubo P. Wessberg L. Forsberg

Introduction: It is likely that the incidence of spinal stenosis will increase with ageing populations. The outcome after surgery in central spinal stenosis has been satisfying in quite many studies. The appropriateness of the indications for surgery has been found to be only around 60% however.

Recently we reported that the degree of cauda equina constriction at the most constricted level in the lumbar spine directly was related to typical preoperative symptoms like walking distance, radiating pain but also quality of life. The aim of this study was to relate the degree of preoperative constriction to the results one year postoperatively.

MATERIAL AND Methods: 35 men and 47 women, mean age 64 years with preoperative imaging of the lumbar spine, completed preoperative questionnaires and operated for central stenosis between June 2002 and May 2004 were followed up one year postop. The self administered pre- and postoperative questionnaires asked for pain intensity in the back or leg(s) (VAS), walking distance before neurogenic claudication, health related quality of life (EQ5D) etc.. In all the subjects the preoperative cross sectional area (CSA) of the most stenotic (constricted) vertebral level was determined from magnified CT or MR examinations and related to the one year postoperative

Results: Results: The average CSA for the most constricted lumbar level was 58.0 SD 23 mm2. For those with a CSA < 68 mm2 parameters like walking ability, pain intensity in the leg and back, health related QoL was improved in a statistically significant way. For those with a preoperative CSA > 68 mm2 no signifcant improvement was found one year postoperatively.

Conclusion: Subjects operated for central spinal stenosis having a pronounced cauda equina constriction (CSA) also had the best outcome one year postoperatively.


D. Garcia-German F. Sánchez-Mariscal Díaz L. Zúñiga Gòmez J. Pizones Arce P. Alvarez González E. Izquierdo Núñez

Introduction: The need for reduction of high grade spondyloisthesis continues to be a source of debate. Recent papers report on better outcomes with “in situ” fusion.

MATERIAL AND Methods: We retrospectively revised 17 patients treated for high grade spondylolisthesis. Average age 16.3 years, average follow-up 76.4 months. Average slip was 78.47%. Posterior approach in 14, double approach in 3. L4-S1 fusion in 16. In 3 patients posterior fusion with double fibular graft and screws was performed. Reduction was performed in 14 cases. Radiographic, clinical data and complications were assessed.

Results: Slip improved from 75.07% to 41.3% (44% correction, p=0.001) and slip angle measured in the superior end plate of L5 from 17.7% to 8.3% (53.1% correction, p=0.05) in the reduction group. There were no permanent neurological complications and no dural tears. Global SRS-22 scores were 4.28 in the reduction group and 4.03 in the non reduction group (p=0.14), satisfaction with the treatment was 4.4. Two patients had to be reoperated because of implant failure and progression. Two asymptomatic screw breaks were noted.

DISCUSSION AND Conclusions: We believe that partial reduction of high grade spondylolisthesis can be safely obtained with a correct surgical technique, rendering slightly better results than “in situ” fusion with no increase in complications.


P. Bartolozzi D. Pasquetto M.A. Marino

Study Design. A retrospective clinical study was conducted.

Objectives. To evaluate the clinical and radiologic outcomes of one-stage posterior decompression-stabilization after partial reduction and trans-sacral interbody fusion with a titanium cage for severe L5–S1 spondylolisthesis.

Summary of the Background Data. Trans-sacral inter-body fusion for the management of severe L5–S1 spondylolisthesis with or without partial reduction and pedicular fixation has been previously described. The use of a transsacral titanium cage has not been previously reported.

Methods. Thirty-two patients with severe L5–S1 spondylolisthesis were treated consecutively with posterior decompression, partial reduction, pedicular fixation, and posterior lumbar interbody fusion using a trans-sacral titanium cage. The mean age at the time of surgery was 24.6 years (range, 11–55 years). The mean follow-up period was 48.3 months (range, 12–102 months). Twenty-three patients had severe back pain and twenty-five patients radicular pain. Nine patients had a partial unilateral L5 motor deficit and twenty-one an L5 sensory deficit. Twelve patients had extremely tight hamstrings. The mean preoperative percentage of slipping was 71.7% (range, 52–91%). Patients were evaluated for complications and fusions, and outcomes were collected using the modified Scoliosis Research Society Outcomes Instrument.

Results. At follow-up, all patients, except one with major vascular complications, were extremely or reasonably satisfied with the surgery. All patients showed improvements in radiologic indexes and stable fusion at the final follow-up examination.

Conclusions. Posterior decompression and partial reduction followed by circumferential stabilization performed in one stage combining pedicle fixation with trans-sacral titanium cage interbody fusion is an effective and safe technique for the management of severe spondylolisthesis.


P. Zencica R. Chaloupka M. Krbec J. Cienciala L. Tichy

Introduction. The influence of lumbar and lumbosacral fusion on adjacent moving segments has been the subject of a number of studies, which have shown the origin and progress of degenerative changes and instability brought about by alterations of kinematics and elasticity of the fused segment. Back pains which emerge later in the postoperative period may be the consequence of degeneration and instability in the adjacent segment to the said fusion. The fusion shifts the centre of rotation to the level adjacent to the fusion, which increases the pressure and pull on both the disk and joints. It can be supposed that the pull and attendant pains are in direct proportion to the rigidity of the spondylodesis that is more pronounced after anterior intersomatic fusion and less so after posterior. The development of hyperlordosis or kyphosis in the lumbar region is also a risk factor for adjacent segment failure.

Material and methods. The authors performed a retrospective analysis on a group of 91 patients with spondylolisthesis who had undergone PLIF technique with transpedicular fixation surgery and PLF.

A total of 10 (11%) of 91 patients developed symptomatic next segment desease at a previously asymptomatic level. Date were obtained in patients with next – segment failure based on X-rays studies, neurological assessment and sequential follow-up examinations. The aforementioned patients had a mean age of 42.8 years and the mean follow up period was 8.7 years after surgery. 7 cases were isthmic, 2 degenerative and 1 dysplastic spondylolisthesis.

Fusion in every case entailed the use of autologinous bone grafts, and with the PLIF technique cages, in 3 cases, dowels, in 6 cases, and autofibula in 1 case were used. The mean follow-up period between original surgery and next-segment failure was 3.8 years.

Results. In ten cases from the group there was evidence of instability or degeneration, instability in 3 cases (all above fusion) and degeneration in 7 cases (4 above and 3 below fusion) respectively.

All patients with instability in cranial adjacent segment underwent successfully additional surgery by using 360° fusion with instrumentation (ALIF).

Discussion. In X-rays conducted prior to surgery, signs of hypermobility were present in the cranial adjacent segment in one case. This hypermobility affected the rigidity of the fusion in the caudal segment, which accelerated the progress of instability and caused further surgery to be necessary.

The cause of instability could also be overloading of the spine, damage to the stability of ligament and bone structures sustained during the operation, or a combination of the above.


R.W. Poolman I.N. Sierevelt F. Farrokhyar J.A. Mazel L. Blankevoort M. Zlowodzki M. Bhandari

Background: The Journal of Bone and Joint Surgery, American Edition (the Journal) recently initiated a section called “Evidence-Based Orthopaedics”. Furthermore, a Levels of Evidence rating is now used in the Journal to help readers in clinical decision-making. Little is known if this recent emphasis of Evidence-based Medicine (EBM) influenced surgeons’ perceptions about and competence in evidence-based medicine. Therefore, we examined perceptions and competence in evidence-based medicine among Dutch orthopaedic surgeons.

Methods: Members of the Dutch Orthopaedic Association were surveyed to examine surgeons’ attitudes towards evidence-based medicine and competence in evidence-based medicine. We evaluated perceptions using a newly developed instrument tailored to surgical practice. Univariate analysis, and a multivariable analysis using Generalized Estimating Equations were performed to model the competence instrument.

Results: 367 Surgeons responded (60%). Orthopaedic surgeons welcomed evidence-based medicine. Practical evidence-based medicine resources were perceived as the best methods to move from eminence-based to evidence-based practice. Four variables were significantly and positively associated with the competence instrument:

1) younger age, particularly age between 36 and 45 years,

2) experience of less than 10 years,

3) having a PhD degree, and

4) working in an academic or teaching setting.

The majority of the respondents (65%) were aware of the Journal’s evidence-based medicine section, and 20% used the Journal’s evidence-based medicine abstracts in clinical decision-making. This increased awareness in evidence-based medicine was also reflected in a frequent use of Cochrane reviews in clinical decision-making (27%). Surgeons who used the Journal’s evidence-based medicine abstracts and Cochrane reviews had significantly higher competence scores.

Conclusions: Evidence-based medicine is welcomed by Dutch orthopaedic surgeons. Recent emphasis of evidence-based medicine is reflected in an increased awareness about the Journal’s evidence-based medicine section, Levels of Evidence, and the largest evidence-based medicine resource: Cochrane reviews. Younger orthopaedic surgeons had better knowledge about evidence-based medicine. Development and use of evidence-based resources as well as pre-appraised summaries like the Journal’s evidence-based medicine abstracts and Cochrane reviews were perceived as the best way to move from eminence based- to evidence-based orthopaedic practice.


A. Atrey P.A. Gibb J. Carvell C. Gupte M.F. Edmondson

Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen.

While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall.

We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient.

The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost.

With support from the British Orthopaedic Association (BOA), the BOA medico-legal committee, the specialist societies and consultant users (via the website) we hope that the project will continue to evolve with a greater selection of procedural consent forms becoming available.

It is believed, from the evidence available, that this approach should decrease the incidence of patient misunderstanding, and the potential risk of successful litigation, while encouraging better communication between patients and surgeons.


B. Fevang S. Lie L. Havelin L. Engesæter O. Furnes

Objective: To study the incidence of joint replacement procedure, arthrodesis, and synovectomy among patients with chronic inflammatory joint disease during the period 1994 to 2004.

Methods: Data from the Norwegian Arthroplasty Register was used to find the number of joint replacement procedures performed in Norway 1994 – 2004. The incidences of arthrodeses and synovectomies were obtained from the Norwegian Patient Register. Incidence rates were calculated based on age, year, and gender specific population rates for the Norwegian population, obtained from Statistics Norway.

Results: There were 8268 primary joint replacements, 3554 arthrodeses, and 5012 synovectomies performed in patients with inflammatory arthritis (IA) during the study period. A reduction in joint replacement procedures and synovectomies took place during the period 1994 to 2004, in patients with IA. For the oldest patients (80 years and older), no such trend was found. During the same time period, the incidence of joint replacements due to osteoarthritis increased. A significant reduction in the incidence of arthrodesis procedures was also found for the total study group, but not for the different subgroups.

Conclusion: The incidence of joint replacements and synovectomies among patients with chronic inflammatory joint disease decreased from 1994 to 2004. This may be the result of improved medical treatment of these patients.


B. Batuwitage S. Kirmani K. Draviaraj F. Ali M. Babu

Aim: Inability to lose weight is often attributed to restriction of mobility due to painful arthritic joints. We hypothesise that removing the pain by total hip replacement or knee replacement will improve patients exercise tolerance thereby helping them lose weight.

Method: A prospective study of obese patients (BMI > 30) undergoing consecutive primary total hip or knee replacement. BMI was measured pre operatively and 1 year post operatively. Patients with medical conditions or complications of surgery that would limit mobility were excluded. A questionnaire detailing pre and postoperative activity levels, walking distance/aids and diet was completed.

Results: 37 patients were included in the study. All patients had symptomatic osteoarthritis. There were 21 female and 16 male patients with an average age of 70 (range 51 – 85). 23 patients had total knee replacements and 14 had total hip replacement. The average follow up was 11.4 months (range 8 – 12 months).

The International classification of adult weight according to BMI was used to categorise patients. Obesity is defined as a BMI greater than 30 and is graded in severity. Class I is a BMI of 30.0 – 34.9, Class II is 35.0 – 39.9 and Class III is greater than 40.0

There were 14 patients in obese class I. 5 patients increased their BMI, 4 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.36. 13 patients had an improvement in walking distance and in 1 patient it remained unchanged.

There were 16 patients in obese class II. 6 patients increased their BMI, 5 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.62. 14 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There were 7 patients in obese class III. 1 patient increased their BMI, 1 patient remained the same and 5 patients decreased their BMI. There was an average decrease in BMI of 1.3. 5 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There was an average increase of BMI of 0.19 in all patients. All patients reported an improvement in activity levels and a reduction in the use of walking aids.

Conclusion: Overall there was an increase in the BMI of obese patients undergoing total knee or hip replacement. This study suggests that total knee or hip replacement in obese patients for osteoarthritis despite improved activity levels does not result in a reduction in BMI. This is either as the improvement in mobility is not sufficient to confer a significant loss of weight or that pre-operative obesity is unrelated to inactivity due to osteoarthritis. Interestingly, the weight loss in obese class III patients (BMI > 40) who undergo total hip or knee replacement suggests that they benefit more from surgery than other classes of obesity.


C. Ojeda-Thies I. Moracia-Ochagavia J. Rubio-Suarez J. Alonso-Biarge E. Garcia-Cimbrelo

Introduction: There are protocols on the management of polytrauma in obstetric patients. However, there is little information about osteo-articular injuries sustained in these patients. The object of this study is to review the management of these patients and to suggest a guideline.

Material and method: Inclusion criteria: Pregnant patients treated during the last 6 years, treated as inpatients in our center during pregnancy due to osteo-articular injuries.

Variables studied: Gestational age, mechanism of injury, fracture type, management, termination of pregnancy and sequelae.

Results: We treated 13 patients with 21 fractures in our center, with an incidenc of 2,13 fractures/10.000 births. The mechanism of injury was low degree trauma in 6 cases (60% 3rd trimester) and high-degree in 7 (83% 1st and 2nd trimester). There was a predominance of lower extremity fractures, especially tibia and fibula (7 cases) and pelvis (3 cases).

Gestational age was 1st trimester (3 cases), 2nd trimester (5 cases), 3rd trimester (5 cases). 10 women were treated surgically, 8 before finishing gestation. Gestation ended as and induced abortion (3 cases, 1 due to fetal death and 2 due to teratogenic risk), and birth (10 cases, all alive, 50% eutocic). Only 3 babies needed type II or type III neonatal reanimation.

CONCLUSIONS: Pregnant women can get injured by low-energy trauma, especially during the third trimester. Pregnancy does not necessarily compromise surgical management of fractures. We review diagnostic and therapeutic management strategies for these patients.


P. Hamilton M. Lemon R. Field

Aim: Our aim was to determine the in-hospital costs of total hip replacement (THR) and total knee replacement (TKR), and compare them to their reimbursement under the national tariff system and to our North American colleagues.

Methods: In 2004 an elective orthopaedic centre was set up in South West London which performs mainly primary lower limb arthroplasty. We used a retrospective analysis of financial statements from September 2004- December 2005 inclusive to establish operative costs (including implant), perioperative costs and post operative costs until discharge.

Results: A consecutive series of 1538 primary TKR patients (mean age = 72.2) and 1118 primary THR patients (mean age = 70.8) was studied from September 2004 to December 2005 accounting for 88% of the workload. Average post operative stay was 6.5 days for TKRs and 5.7 for THRs and 66% of the patients were ASA grade III or over. The cost including implant of a THR was £6054, and for a TKR it was £6499. After adjustment to allow direct comparison to tariff, our THR cost is 2.3% less than and 1.0% more than the 2004/5 and 2005/6 tariffs respectively. Our adjusted TKR cost is 5.0 % and 4.2% less than the 2004/5 and 2005/6 tariffs respectively. Our cemented and uncemented THR costs are 8.0% less than and 6.6% more than their respective tariffs introduced for the first time in 2005/6. Overall there is no large discrepancy between our THR/TKR costs and tariff reimbursements.

Discussion: Although in our unit our costs are similar to the re-imbursements used in the UK, we question the ability of general NHS hospitals in the UK to perform at these levels and prices for three reasons. Firstly, our high volume of joint replacement activity has enabled us to negotiate the most favourable implant prices in the UK. Secondly, length of stay in our unit is approximately 60% of national average. Thirdly, our unit is run without many of the infrastructure costs of a general hospital as well as the cost incurred by training junior staff and research and development. Costs were also found to be favourable compared with our American colleagues and similar to our Canadian colleagues.

Conclusion: Our elective only orthopaedic centre provides a cost effect way of performing primary arthroplasty surgery while maintaining high standards of care and twenty-four hour intensive care cover. We believe this cost effectiveness may be unachievable in general NHS hospitals in the UK.


D. Sunderamoorthy P. Kanakanalu P. Sherry

Aim: To assess satisfaction of patients seen in the fracture clinic in our DGH. The results from the audit were compared with the National Average to assess the efficiency and patient satisfaction.

Methods: We did a questionnaire survey of patient satisfaction attending the fracture clinic in our DGH. The above audit was done for a period of 4 weeks on patients attending one orthopaedic surgeon fracture clinic during the month of March 2006. 130 patients completed the questionnaire, 20 of which were incomplete. This left us with 110 questionnaires for assessment.

Results: The M:F was 11:7. 88% of them felt access to the clinic was easy. 12% of the patients were disabled of which only 15% felt the access was easy. 28% were seen on time and 65% were seen within 15 minutes of the stated appointment time. 82% of them felt that were not informed of the waiting time. 87% of them felt that were able to discuss their problem with the doctor. 95% of them felt the doctor explained the diagnosis and the reasons for their action in an understandable way. 94% felt the staffs were courteous. 91% were satisfied with the fracture clinic service, 60% felt the clinic was organised well, 88% felt their dignity was respected and 88% rated the care they received to be excellent to good.

Conclusion: The above audit showed that majority of the patients seen in the fracture clinic were satisfied and level of service was comparable to the national average.


T. Sudhahar J. Velupla M. Madhusudan L. Sanz M. Waseem

We present a retrospective study of comparision between two types of aritifical boen graft substitues. There is an overwhelming marketting drive on part of companies to sell alternative bone grafts/BMP. We in this study compae two such producsts and their cost effectiveness

This is an interventional, retrospective, non consecutive, non randamised case series study of 27 patients. Type I bone graft is Mini MIIG which is surgical grade calciun sulphate which is osteoconductive. Type II bone graft is Allomatrix which conatins bone marrow aspirate, bone morphogenic protein, concellous bone chips and surgical grade calciun sulphate which is osteogenic, osteoinductive and osteoconductive. In this study 14 cases were treated with Mini MIIG and 18 with Allomatrix. There were 24 primary fractures with bone defect, 2 non union and 1 delayed union. Complete bony union were seen in all 27 patients. Average time to heal since bone grafting is 3 months. Complications are extrubent callus formation, bone formatiom in soft tissue, but no patient required secondary procedure to trim the bone. Cost for Allomatrix is £ 356.00 and Mini MIIG is £348.00. Use of such artificial bone grafting avoids the complication of autografting which includes bone graft side morbidity like pain, bleeding and neurvascular damage. For fresh fractures useage of such artificial bone grafts doesnt shorten the healing time, doesnt prevent collapse at fracture site and it is not cost effective. For non union and delyaed unions it avoids the cost for artifical bone grafting. But autograft also incurs the cost of removing, theatre timing. human resources cost and hospital inpatient costs. There is no difference between one type of bone graft over the other and for fresh fracture both of them has no advantage over using no bone grafts.

Our study concludes artifical bone graft is of no advantage for fresh fractures and for non union and delayed unions it is too small a number to come to any conclusion.


S. Phillips G. MacPherson M. Gaston B. Noble H. Simpson

Fracture repair is a wound healing process that in young healthy patients usually proceeds to uncomplicated union. However, the healing cascade is delayed with increasing age, medication and certain diseases such as rheumatoid arthritis.

Recently the important role of the immune system in fracture repair has become apparent within the emerging subject of Osteoimmunology. Patients with rheumatoid arthritis have an altered immune system and therefore we have investigated the hypothesis that patients with rheumatoid arthritis have a higher incidence of non-union after a fracture compared to patients without rheumatoid arthritis.

Method: The Edinburgh Royal Infirmary computer database was searched over a 10 year period (May 1996- May 2006) to identify all patients with non-union out of the total number of patients presenting with fractures. These patients groups were then subdivided into patients that had and did not have rheumatoid arthritis. Patients were excluded if they were lost to follow up, or if the fracture either occurred before the May 1996 or management continued passed May 2006. In this study non-union was defined as failure to heal within expected timescale and lack of progression at serial x-rays (all non-union were diagnosed at least 3 months from fracture).

Results: From May 1996 through to May 2006, 8,456 patients with fracture were defined. 71 of these patients with fractures had rheumatoid arthritis. Of these patients 63 had union of their fractures whilst 8 patients developed non-union of their fracture (11.3%). In a total of 8385 non rheumatoid arthritis patients 164 developed non-union of their fracture compared to 8221 patients who had union of their fractures (2%). Comparison between these two patient groups suggests rheumatoid arthritis patients are more likely to develop non-union of traumatic fractures (Chi squared test, p value < 0.001).

Patients with rheumatoid arthritis who progressed to non-union were on the following medication, Gold (1), Indomethacin (1), Non steroidal anti-inflammatories (4), Combination analgesia (2), Antihypertensives (2), Omeprazole (1) and Thyroxine (1).

Discussion: The results from this study suggest that patients with rheumatoid arthritis have a greater incidence of non-union after a fracture compared to patients without rheumatoid arthritis. This maybe due to the abnormal immune system in rheumatoid arthritis patients. However rheumatoid arthritis patients are often on a number of medications and these drugs rather than the innate alteration of the immune system may be responsible for the altered healthy response. However whether as a result of the rheumatoid arthritis itself or the medication, our study demonstrates a higher non-union rate in the rheumatoid arthritis patients and this needs to be taken into account when treating rheumatoid arthritis patients with fractures.


M. Lavigne V. Massé P. Vendittoli A. Roy

PURPOSE: The purpose of this study was to compare the level of post operative sport activity in a randomized study of SRA and THA.

INTRODUCTION: Return to high activity level has been proposed has an advantage of hip resurfacing (SRA) compared to THA. However, patient selection for SRA favours higher demand individuals, thus leading to a biased comparison of both techniques.

MATERIALS AND METHODS: Patients were randomized to THA or SRA. At minimum one year follow-up, the patients were asked about the activities they have resumed, the level of satisfaction regarding return to sports and the factors limiting full return to intense activities. 80 THA and 85 SRA with a mean follow-up of 16 months were analyzed.

RESULTS: The postoperative UCLA activity score was significantly higher in the SRA group (6.3 versus 7.1, p< 0.05). 77% of the SRA patients returned to high or moderate activity level vs 39% in the THA group (p=0.007). In the THA group, the activity level was mostly restricted due to concern about instability. However, some THA patients were still able to perform high demand activities.

DISCUSSION AND CONCLUSION: This study suggests that SRA allows return to higher activity level when compared to THA. This may be due in part to the larger diameter head of SRA which improves stability and suction-fit (reducing micro separation of the bearing during activities). Enhanced proprioception due to the retained femoral neck may also be involved in the bias towards SRA. Further follow-up is will determine if higher activity level is detrimental to implant survivorship


G.F. Dall P.M. Simpson S. McKenzie S.J. Breusch

Background: Several factors can alter a cements viscosity and hence it’s handling characteristics. An in vitro study was performed to ascertain whether anecdotal observations of differences in handling between batches of the same cement brand existed.

Methods: 3 batches of Simplex P Tobramycin (SPT), Refobacin Bone Cement (RBC), SmartSet GHV (SSG) and Palacos R+G (PRG) were tested. 6 replicates of each batch were vacuum mixed and their viscosity in relation to time was measured in laboratory conditions (50 ±5% humidity and 23 ±1°C) using a rheometer. 6 replicates of each batch had their handling characteristics examined after they were hand mixed in theatre conditions.

Results: Inter and intra-batch variability was seen in the viscosity of all brands of cements tested. Inter-batch calculations were influenced by high intra-batch viscosity variability. The viscosity of RBC cement was very similar to SSG, but significantly different to PRG (p = 0.01 at 5N and p = 0.009 at 40 N).

Interpretation: Our results suggest that in clinical practice extrinsic factors such as preparation conditions and methods probably play a more important role than the cements intrinsic variability. However, variability in handling and viscosity will exist in all brands of cement prepared in theatre conditions and the surgeon needs to be aware why they may act differently.


A. MEROLLI A. Cacchioli P. Tranquilli Leali C. Gabbi

Introduction. Radio-opaque additives for Orthopaedic Bone Cement, like BaSO4 or ZrO2, are now routinely used because of the valuable help in identifying cement location around an implant on the x-ray films. A new bone cement formulation was devised with the aim to improve the reparative response of bone tissue surrounding a cemented implant, soon after the operation: a 6% NaF 6% BaSO4 preparation “Fluoride Bone Cement©” (Tecres, I) was tested in-vivo versus a 9% BaSO4 preparation “CemexRX©” (Tecres, I). NaF stimulating action towards bone repair is prompt by the formation of fluoroapatite and the stimulation of osteoblast differentiation. NaF-added cement acts like a “drug-release device” for fluoride ions.

Materials & Methods. Eighteen outbred male New Zealand White rabbits of approximately 3,2 kg of weight have been used. They were divided into six groups of three units. Gropus A1, A2, A3 were implanted with cement without fluoride “CemexRX©” while groups B1, B2, B3 had “Fluoride Bone Cement©”. Retrieval occurred after 17 days (A1, B1); 33 days (A2, B2); 60 days (A3, B3). The surgical implantation site selected was the distal femural canal (meta-epiphyseal region). The canal in the right femur was filled with cement while the canal in the left femur was used as a surgical control (“sham” operation). Sections of 100 micron of thickness were taken by a rotating diamond-saw microtome (Leitz Wetzlar) and analyzed by polarized light and ultra-violet fluorescence microscopy (Nikon Miscroscope). One hundred and twenty sections were obtained for each femur.

Results. Calcein green fluorescent labelling showed that no real endosteal osteogenic response was evidenced the day after surgery, for both cement preparations, while periosteal response was normal. This was the consequence of the biological insult of the intramedullary polymerization of the cement. Xylenol orange showed that all the contra-lateral femurs (“sham”) had a normal endosteal and periosteal osteogenesis at all times. Both cement preparations continued to show a limited end-osteal response after 17 days and a slow recovery after 33 days, with better pictures in favour of NaF cement. After 60 days recovery in endosteal osteogenesis was adequate but, again, NaF cement showed the highst number of good pictures.

Conclusions. Adding NaF promoted the better recovery in endosteal osteogenic response observed in comparison with NaF-free cement. To differentiate the biological response it was essential to compare a high number of sections (120) in comparable locations, in a contralateral “sham” operated control in the very same animal. This procedure, costly and demanding, seems to be a right methodological approach.


A. Lilikakis M. Sutcliffe

Introduction: There is extensive literature on the effect of vancomycin on the compression strength of plain cements, none however on antibiotic-loaded cements. The addition of vancomycin to antibiotic-loaded bone cement is common practice in revision joint replacement surgery for infection. The scope of this study was to record the effect of vancomycin addition on the compression strength of antibiotic-loaded bone cement and to compare the results with the international standard (ISO 5833–2) in order to evaluate safety in clinical use.

Materials & Methods: The formulations used were Palamed G, containing 0.55g of gentamicin; and Copal, containing 1g of gentamicin and 1g of clindamicin. Vancomycin concentrations of 2.5%, 5% and 10% per powder weight were added. The ISO requirements for the testing procedures were followed. Samples of Palamed G with 5% vancomycin and non-standardised mixing procedures were also tested, as well as samples of both bone cements without vancomycin, as controls.

Results: The mean compression strength of plain Palamed G was 91.08 MPa. With the addition of 2.5%, 5% and 10% vancomycin, the mean compression strengths were 79.82, 82.3 and 74.56 MPa respectively, a reduction of 12.36%, 9.64% and 18.13%. The mean strength of the Palamed G specimens with 5% vancomycin and non-standardised mixing was 72.88 MPa, a 19.9% reduction. The mean compression strength of the plain Copal was 86.27 MPa. With the addition of 2.5%, 5% and 10% vancomycin, the mean compression strengths were 76.59, 78.92 and 71.19 MPa respectively, a reduction of 11.22%, 8.52% and 17.48%. Copal with 10% and Palamed G with 5% vancomycin and non-standardised mixing, were the only cements with compression strengths not significantly exceeding the ISO standard of 70 MPa.

Conclusion: The addition of up to 5% vancomycin per powder weight to the antibiotic-loaded Copal and 10% to Palamed G bone cements can be considered safe. Care should be given to the mixing procedure of the cement, as it significantly affects its compression strength.


G. Szczęsny A. Gòrecki W.L. Olszewski

Satisfactory healing of soft tissue wounds and bone fracture requires activation and response of the immune system. Our previously reported laboratory observations revealed that proper healing of the long bone fractures corresponds with an increased mass of lymph nodes (LNs) draining the site of injury when compared with contralateral limb, whereas delayed fracture healing is characterized by decreased mass of the regional LNs. Aim of the study was to investigate whether an image of LNs may be an indicator of the kinetics of fracture healing.

Patients & Methods. Observations were carried out in two groups of adult patients with closed not infected fractures of lower extremities healing uneventfully (n=15) and fractures with delay healing (n=17, diagnosed clinically and with X-ray and CT scans). Patients with venous thromboses were excluded. Morphologic structures of the lymphatic system of lower extremities were visualized on lymphoscintigraphies with 99mTc-Nanocol. Lymphoscintigrams were scanned and evaluated quantitatively. The surface of iliac lymph nodes of the fractured and contralateral limb served to calculate of LNs size index. Differences between groups were evaluated using Student-T-test.

Results. The surfaces of inguinal LNs of the fractured limb in patients with uneventful healing fractures were larger than in contralateral limbs (index=1.67±0.57), whereas in patients with non-union the inguinal LNs surface was smaller (index=0.49±0.45, p=0,00000031).

Conclusions. Lymphoscintigraphic pictures of the lymph nodes draining the site of injury reflect to a certain extent regenerative processes. Speculatively, observed changes depend upon molecular mediators drained with the lymph from fracture gap. The method can be used for non-invasive monitoring of the fracture repair process.


W.M. Glinkowski J. Zylkowski A. Wojciechowski A. Gòrecki

The quantitative measurement is required for fracture healing evaluation in clinical studies approaching toward Evidence Based Medicine. Early detection of fracture healing impairment is demanded to introduce as early as possible the optimal treatment leading to recovery. Clinically validated and tested methods usually utilize X-ray and CT data. The aim of this study was to improve assessment of fracture healing progress or impairment examined with X-ray and computed tomography (CT) and to determine the usefulness of quantitative methods based on newly developed 3D image analyzing software. An original software “3D Reconstructor” was developed. The application operates on medical image data stored in DICOM format. 3D Reconstructor v.2.0 allows 2D reconstruction in custom surface directs through data block and 3D reconstruction as well. The usefulness of the application was evaluated for long bone fracture healing with three-dimensional presentation of fracture callus. Twenty otherwise healthy fracture patients (average age 43 years) with fractures of the tibial shaft, humerus, forearm, and clavicle were enrolled and underwent chronological series X-ray imaging and spiral CT scanning when it was clinically justified and necessary. Patients were preselected for CT study because of healing impairment suspicion. Computer Tomography examination was performed 14 to 56 weeks after injury (GE Pro Speed SX, slice 2–3 mm, image reconstruction 1 – 1,5 mm, 120 kV, 100 mAs). Qualitative assessment included fracture line/margins, fracture gap, external callus appearance, callus-to-cortex ratio, bridging, and radiologic union. Quantitative assessment of CT density changes (Hounsfield units [HU]) in the fracture gap was performed in patients using 3D Reconstructor multimodality image analysis software. Regions of interest (ROI) were analyzed in details by quantitative and qualitative assessment. Complete bone union was confirmed in 2 cases, delayed union in 8 cases and nonunions in 10 cases. The use of 3D Reconstructor enhanced quantitative evaluation of fracture callus in all evaluated cases. Low union rate observed in computed tomography derives from patient’s preselection based on clinical observations. Reliable fracture healing assessment can be enhanced with computed tomography and Computer Aided Diagnostic methods that supplement quantitative analysis of CT images. CAD quantitative assessment of the fracture gap and callus was successfully performed using 3D Reconstructor software in clinical cases. Higher accuracy of pseudoarthrosis and delayed union diagnosis was achieved. The reliable diagnosis in fracture cases may be supported with Computer Aided Diagnostic Methods. Still ongoing project, “3D Reconstructor” seems to be more accurate over not “armed” evaluation of original CT DICOM files of fracture healing in selected cases.


H.C. Amstutz S.T. Ball M.J. Le Duff

Introduction: ‘Revisability’ has been touted as one of the major advantages of resurfacing arthroplasty of the hip. However, this theoretical advantage has never been clearly demonstrated. The objective of the present study was to test the hypothesis that a failed, modern generation metal-on-metal resurfacing arthroplasty (MMRA) can be converted to a total hip (THA) as easily and with comparable results as a primary (THA).

Methods: Twenty-two failed MMRA’s in 21 patients with an average age of 49.5 years (23 – 72 years) were converted to a THA. In 18 hips, the acetabular component was retained, and in 4 hips both components were revised. The control group of primary THA’s, implanted during the same time period by the same surgeon, consisted of 64 patients with an average age of 50.8 years (27 – 64 years).

Results: There was no significant difference in operative time, blood loss and complication rates between the conversions and the controls. The average follow-up was 47 months (12 – 113 months) for the conversions and 57 months (24 – 105 months) for the controls. Clinical outcomes measures were comparable with average Harris Hip Scores of 92.7 and 90.3 for the MMRA conversions and primary THA’s, respectively. The UCLA activity scores were 6.6 and 6.4 in the conversion group and THA group, respectively. There have been no cases of aseptic loosening of the femoral or acetabular components in either group, and there have been no dislocations after MMRA conversion.

Conclusion: Conversion of failed MMRA to a THA appears to be as safe and effective as a primary THA.


D. Kendoff M. Citak J. Geerling T. Stübig A. Pearle C. Krettek T. Hüfner

Introduction: Intraoperative visualisation of anatomic joint line reduction and hardware placement is techniqually demanding, twodimensional c-arm imaging do not always allow acute decision making about remaining articular steps and hardware misplacement. Postoperatively identification of these failures may need extensive revison surgery and is costly. The new mobile Iso-C3D imaging device provides intraoperative multiplanar reconstructions, consequently immediate decision making becomes possible.

Materials and Methods: 250 different joint fractures were intraoperatively scanned with the Iso-C3D (ankle fractures; forefoot, calcaneus; pilon tibiale; tibia plateaus; wrists; spine; pelvic fractures). Multiplanar reconstructions were obtained from 100 fluoroscopic images the Iso-C-3D provides during one automatic scan protocol. Decisions about remaining articular steps and implant misplacements were compared with the knowledge of conventional c-arm images which were done before. If necessary directly intraoperative corrections were performed.

Results: In 43 clinical cases (17%) a direct intraoperative correction resulted in implant change (8%) or correction of reduction (9%), caused by articular steps > 2mm, screw or k-wire misplacement. In all those cases conventional c-arm images did not reveal the significant step or misplacement, correction decision were all based on the Iso-C3D imaging in those cases. In other (9%) significant steps or misplacements were identified in c-arm images and confirmed with the Iso-C3D images.

Discussion: With the new intraoperative three dimensional imaging device a direct introperative idenfication of remaining intraarticular steps and implant misplacements becomes possible. Missed steps and misplacements can be avoided and reduction of operative revison rates might result.


S.P. White M. Lee I. Learmonth

Background : A composite femoral stem was introduced with a structural stiffness similar to that of the native femur to promote proximal load transfer. This consisted of a cobalt-chromium alloy core surrounded by an injection-moulded layer of polyaryletherketone covered with a porous titanium mesh.

Material and Methods: 31 consecutive primary total hip replacement stems were implanted in 26 patients with an average age of 37 years (range 17–57) using the Epoch stem (Zimmer, Warsaw, IN) as part of a prospective multi-centre trial. A cementless Harris-Galante I acetabular component with a 28mm polyethylene insert (Zimmer) was used in 29 cases, a Plasmacup with 28mm polyethylene insert (Aesculap, Tuttlingen, Germany) in 1 case and a bipolar head in 1 case. Annual follow-up with Harris Hip Scores and radiographic evaluation was performed for a mean of 10.1 years.

Results : Harris Hip Scores improved from a mean of 52 points preoperatively to 90 at the time of last follow-up. Radiographs showed no stem migration or loosening. 4 cases with polyethylene wear showed trochanteric osteolysis. Specific radiographic features noted were a sclerotic halo in Gruen zones 1 in 8 cases, calcar rounding in 10 cases and improvement in calcar appearance with squaring of the calcar in 4 cases. Calcar resorption was seen in 1 case associated with polyethylene wear. There have been 8 instances of revision of the head or acetabular component- 3 liner exchanges for polyethylene wear, 3 acetabular component revisions for liner dissociation with associated cup damage, 1 acetabular component revision for infection and 1 bipolar head revised to unipolar head with cementless acetabular component for pain. No stem has required or requires revision.

Conclusion : The Epoch stem resulted in an excellent clinical outcome with evidence of radiographic stability and proximal bone preservation, and no cases of stem revision in a cohort of young patients with long-term follow-up.


L. Kandel K. Romas R. Stalnikowicz M. Brezis

Introduction. Ankle and midfoot injuries are one of the most common orthopaedic complaints, both in the general medicine and the orthopedic practice. The percentage of fractures among these is small, however many of them will undergo an xray. Ottawa ankle rules are clinical guidelines developed for the use of radiography in these cases. This aim of this prospective study was to examine these rules’ implementation in the Israeli emergency medicine department and our ability both to predict a fracture and to reduce the amount of unnecessary xrays.

Materials and methods. 92 consecutive patients with ankle injuries attending our emergency medicine department were divided in two groups. Study group included 32 patients who arrived during the morning shift and were examined by an internal medicine specialist according to the Ottawa ankle rules. Patients discharged without an xray were followed in the clinic or by telephone communication. Control group included 60 patients who were examined during the evening and night shifts by orthopedic residents unaware of the study.

The mean age in the study group was 24 years and in the control group – 26 years. There was good acceptance of the study in patients of the study group. Only 2 of them insisted on the xrays and were excluded from the study. Rest 30 patients were followed as described.

Results. 9 patients (30%) in the study group underwent an xray as opposed to 55 patients (92%) in the control group (p< 0.001). There was one fracture diagnosed in each group. In the study group, no fractures were found later in patients discharged without an xray. The mean time spent in the emergency department was 58 minutes in the study group and 98 minutes in the control group (p< 0.002).

Discussion. The Ottawa ankle rules were developed as a simple “yes/no” decision tool as to whether to xray the ankle. In our emergency department, these rules were proved both accurate and safe. They can be effectively used by professionals not trained in trauma. It can save radiation and patient waiting time without jeopardizing the treatment.


A. Saithna Y. Feras W. Moody I. Sargeant

Background: The timing of surgery for closed ankle fracture is controversial. Conventional teaching recommends either immediate surgery or a delay of 5–7 days in order to minimise soft tissue complications. However, there have been no large studies to produce clear guidelines and the literature is conflicting. Some authors suggest that delayed surgery results in increased risk of wound complications, less satisfactory rate of anatomical reduction, increased hospital stay and health service cost.

Objective: We aimed to determine whether surgery can be safely performed in an intermediate time frame with respect to soft tissues complications.

Method: We performed retrospective analysis of case notes and plain radiographs of 85 patients undergoing open reduction and internal fixation for closed ankle fractures at our unit in 2004. Data was analysed using the StatView statistical analysis program. Continuous variables were assessed for association with wound complication by means of an unpaired t-test. Nominal variables were assessed using Fisher’s exact test.

Results: The overall rate of infection in our population of 85 patients was 9.4%. This comprised 7 superficial wound infections and one deep infection. Patients were classified into early (within 1 day), intermediate (between 2–6 days) and delayed (after 6 days) groups according to the time delay prior to surgery. Only 1 patient in the intermediate surgery group developed infection compared to 6 in the delayed group and this was statistically significant (p = 0.046).

Conclusion: We suggest that with experience, meticulous soft tissue handling and good operative technique, delaying surgery until swelling has subsided is unnecessary in the majority of patients and is associated with a higher risk of wound complication.


A. Athanasopoulou V. Psychoyios H. Dinopoulos G. Galani S. Loti

Aim: The aim of the study is to evaluate the usefulness of the MDCT scan in the diagnosis of calcaneal fractures and its use in the surgical treatment

Material. 112 calcaneal fractures were examined with a MDCT scan (slices one to two mm, pitch 1.5) with multilevel reconstruction as well as three dimensional reconstruction. The fractures were classified according to Munich classification system. Findings that were evaluated were the involvement of the subtalar joint, the number of fragments of the posterior facet and the extent of displacement.

Results: There were 85 intraartiular fractures and 27 extraarticular. 32 fractures were of type I according to Munich classification system (extraarticular without displacement). 15 fractures were of type II (extraarticular with some displacement). 2 fractures were of type III (intraarticular without displacement). 27 were of type IV (two fragments). 19 were of type V (with free fragments in the joint and 17 were type VI (more than four fragments).

Conclusion: The above mentioned radiological method of evaluating calcaneal fractures offers a quick diagnosis since it can depict the fragments and its displacement very accurately. Furthermore this method permits a very precise preoperative planning for the surgical treatment of these injuries


G.J. McLauchlan R. van Mierlo G. Perkins

In patients with an ankle fracture initial delay to operation because of time constraints is often prolonged because swelling precludes surgery for some days. We made use of a year long prospective audit of 2000 trauma patients to analyse the effect of delay to surgery on length of stay in ankle fracture patients.

One hundred and fifty patients were admitted with an ankle fracture. One hundred and twenty nine were operated on. The median (inter quartile range) time to surgery was 3 (2–5) days. Twenty six patients got to theatre within 24 hours. For those who didn’t get to theatre within 24 hours the median time to surgery was 4 days.

For the group as a whole there was a poor correlation between wait for surgery and length of stay (Pearson = 0.6). For the 98 patients under the age of 60 there was a significant relationship (Pearson co-efficient = 0.85). Fifty per cent of those under 60 were discharged within 48 hours of their surgery. The number of co-morbidities was different between the under and over 60s. The over 60s had a median (inter quartile range) of 2 (1–5) co-morbidities, compared to 0 (0–1) in those under 60.

Patients under 60 with an ankle fracture are generally medically fit. If 90% of such patients had their fractures fixed within 24 hours the median post operative length of stay for all ankle fractures in this population would fall from 7 to 3 days and the number of bed days saved would be 400 a year. The length of stay in patients over the age of 60 is more related to their associated co-morbidities than their time to surgery.


A. Ahrberg T. Engel C. Josten

Objective: 15 patients (male:female= 9:6, mean age 39,5 years) with ankle fractures treated with osteosynthesis including a syndesmotic screw were enrolled in this prospective study. Instability of the distal syndesmosis was proven intraoperatively and then a tricortical syndesmotic screw was placed.

Patients were mobilized with an AirCast®e brace and cranes for six weeks, then the syndesmotic screw was removed and patients started full weight bearing. Follow-Up was 21.7 weeks mean after removal of the syndesmotic screw.

Using the x-rays of the ankle after and the CT of both ankles before removal of the syndesmotic screw we evaluated the radiologic results: the syndesmotic interval in the fontal and axial cuts, the Espace claire de Chaput (total clear space, TCS) und the medial clear space (MCS). The functional results were evaluated by the scores of Phillips, Olerud/Molander and Weber.

Results: The mean frontal interval difference was 0,3 mm und the mean axial interval difference was 0,5 mm, in one case Fall (6,7%) there was a axial interval difference of 2 mm and in one case the interval had been over corrected. There was no subluxation of the talus in any patient. In 3 patients (20%) the syndesmotic screw had been placed in a second operation, after there was suspection of syndesmotic insufficiency in the x-rays which had been verified by CT. After implantation of the screw the CT scan showed regular syndesmotic intervals. Average TCS was 5.3 (range 3.40 – 7,40), mean MCS was 2.2 (range 1.0 – 4.5).

Average functional scores were: Phillips 118.53 (range 53 – 135), Olerud/Molander 93 (range 60 – 100) and Weber 2.33 (range 0 – 12).

Conclusions: Only with CT, the correct placement of the syndesmotic screw can be verified, the syndesmotic interval in the axial cuts can be evaluated and the position of the fibula in the Incisura fibularis can be assesed, therefore CT should be postoperative standard after syndesmotic screw placment. If an ankle fracture has not been treated with a syndesmotic screw, postoperative CT of both ankles should be done in any radiological or clinical suspicion of syndesmotic insufficiency.


S. BATRA A. GUL

Plain radiographs remain important diagnostic tools in the initial assessment of patients with suspected fractures or dislocations of the foot. Analysis of foot radiograph is a difficult task even in the hands of experts, which is misinterpreted in 2.1% cases. Human visual system is more sensitive to horizontal and vertical stimuli & cardinal orientations (Vertical and Horizontal) perceived more accurately than others. Any absolute judgement task is subject to two types of error: Systematic error and random error. Hence a system of assessment with very high random error of measurement is unlikely to be a reliable assessment method. We tried to find out the influence of experience and orientation on interpretation of foot radiograph.

AP and lateral radiograph from 25 patients who had some form of foot injury were included in this study. The radiographs were first analysed by an experienced foot surgeons for fractures with clinical details to facilitate the identification of the fracture & then presented in two different orientations (vertical and horizontal) to 38 orthopaedics surgeons of different grades and blinded about the nature of the study. We used Kappa analysis & logistic regression to find out the influence of orientation and experience on interpretation skills.

Overall agreement between the foot surgeon and other observers was 0.4. Overall agreement between the observers and the foot surgeon, in the vertical orientation, was.43 and in the horizontal orientation was.32. When experience was taken into consideration agreement between orthopaedics surgeons and the foot surgeon was.416 and agreement between registrar and foot surgeon was.367 and the SHO and foot surgeon was.369. We found that the regression coefficient for horizontal orientation was −.302 and the regression coefficient for the experience was 0.067. Hence horizontal orientation increases the chance of misinterpreting a foot radiograph by 30.2% and with increasing experience the chance of correctly identifying the fracture increases by 6.7%. From this study it is evident with all the other variables like experience, quality and adequacy of radiographs optimised, orientation of the foot radiograph alone can significantly affect the interpretation skills of the observer.


S. Patil A. Hui

Introduction: Several institutes in continental Europe and the US now prescribe low molecular weight heparin for patients with ankle fractures being treated in a below knee plaster cast. Jorgensen et al reported an incidence of deep venous thrombosis (DVT) of up to 20% in patients treated in a cast. However, their study included patients with variable diagnoses, ranging from tendon ruptures to fractures. The aim of our study was to assess the incidence of DVT in patients with ankle fractures that have been treated conservatively in a below knee cast.

Method: We performed an ultrasound scan on patients with conservatively ankle fractures at the time of removal of the cast. The same ultrasound technician performed all the scans. The local regional ethics committee had approved this study.

Results: So far we have performed an ultrasound scan on 98 patients with ankle fractures. We are likely to complete the study in November 2006 (120 patients). We have encountered only 2 below knee DVTs (2.04 %). None of them involved the popliteal vein. Both patients were completely asymptomatic and were full weight bearing in the cast. A repeat scan showed no evidence of progression. None of the patients had an above knee DVT or a pulmonary embolism.

Discussion: The risk of deep venous thrombosis is said to be higher in patients with a plaster cast because of the decreased ability of the calf muscles to pump the venous blood back to the heart. Though some studies have indicated an incidence of up to 20%, the incidence in our population was only about 2%Thus, DVT is a rare event in patients with ankle fractures. Though it is a serious event, its rarity does not justify a blanket prophylaxis regimen for all patients with ankle fractures.


R. Thakral M. Ashraf K. Kaar W. Brennan P. McHugh

Background/Aim: A preliminary biomechanical study conducted on cadaver fibulae, was observed to have a significant (p< 0.001) difference between two different methods of interfragmentary screw fixation for oblique fractures.

A further study was undertaken to verify the results on composite material with biomechanical properties similar to human bone.

Material and Methods: Forty, custom designed composite fibular specimens were used for the biomechanical testing. The specimens were divided into two groups of 20 each. Group I comprised of specimens with biomechanical properties similar to young healthy bone and group II comprised of osteoporotic bone quality. The fibular specimens were osteotomised to resemble a short oblique fracture of the lateral malleolus. The fractures were fixed with interfragmentary cortical lag screws placed in antero-posterior and postero anterior directions, 10 samples in each group.

Results: In both groups, the mean force required to disrupt the fracture fixation was observed to be 0.45 kN higher in samples fixed with screws placed in postero anterior direction.

Conclusion: This study further confirms the screw placement in postero- anterior direction provides a stronger biomechanical construct for short oblique fracture of the lateral malleolus.


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C.F. Cirstoiu A.E. Badila D.N. Popescu R. Ene R.A. Radulescu

Introduction: Talus fractures are rare, but because of its peculiar anatomy the complications rate is high. Its arterial vascularisation can be compromised by trauma in displaced fractures or by the surgical approaches.

Material and methods: Between 2001 and 2005, 30 patients with talus fractures were surgically treated in the Department of Orthopedics and Traumatology of Bucharest University Hospital. Sex ratio was 3 men/27 men. 27 fractures were closed. The mean age was 37 years (extremes: 17 – 54 years). Fractures were classified according to Hawkins classification: type I – 9 cases, type II – 13 cases, type III – 8 cases. All patients underwent clinical and radiological examinations at 3, 6 and 12 months and every year after this interval.

Results: Hawkins type I fractures were treated by cast immobilization without weight bearing for 6 to 8 weeks. Orthopedic reduction was performed in emergency in order to avoid vascular and cutaneous complications. Hawkins type II and III fractures were surgically treated. Anterior or transmaleolar internal surgical approaches were used. After reduction, osteosynthesis with 2 or 3 compression screws was performed. Avascular necrosis of talus was observed in 6 cases (5 type III fractures, 1 type II case). Cutaneous complications were observed more frequently in type II and III fractures and in the neglected ones. Sepsis occurred in one case. 80% of cases with avascular necrosis developed osteoarthritic changes. Radiological union was observed in average at 6 months.

Conclusions: The prognosis of fracture-dislocation of talus is reserved, because of the high rate of avascular necrosis and osteoarthritis. The most important factors associated with good results are short time interval between trauma and surgical treatment and a perfect reduction. The surgical approach must avoid extensive devascularization of talus neck. Prolonged cast immobilization and long time avoidance of weight bearing favourably influenced fracture union. The most important complication is avascular necrosis.


P. Determe O. Laffenetre C. Cermolacce

Introduction: This document is our report on the prospective follow-up of 38 patients operated between May 1998 and May 2005. If the technique in itself hardly poses any difficulty, our experience of talo-crural and sub-talar arthroscopy has proved to be a major asset.

Materials and method: This involved 38 patients (23 men and 16 women) mean age 55y who received a double or triple talar arthrodesis by means of retrograde nailing. 4 patients had a septic history, and 7 an anterior sub-talar arthrodesis. In 19 cases, sub-talar refreshing was carried out in accordance with our arthroscopic principles. Whenever possible, the same procedure was followed at the talo-crural stage, despite an anterior or anterolateral approach (cartilaginous refreshing as regards the geometry of the surfaces, and careful refreshing of the splints and trans-osseous perforations).

In one case, the technique was purely bifocal arthroscopy, 26 patients had bone grafts (25 autografts, 1 allograft). Indications therefore were 7 failed talar arthroplasties, 6 ankle pseudarthrodesis with side-effects in the sub-talar joint, 5 primitive bifocal arthosis, 5 complex traumatisms in the hinde foot, 4 neurological varus equinus feet, 3 side-effects of talar laxity, 1 diabetic osteo-arthropathy and one pseudarthrosis of the leg with subjacent talo-crural arthrosis. The average follow-up is of 38 months (12–90).

Results: Complete weight bearing has always been possible, except for a paraplegic patient. 2 non-fusions (one at each level) are noted in two patients who were succesfully treated with a change of method. All of the other set within an average period of 2.6 months. We note one resolvent aseptic discharge in a looking screw, one algodystrophy, one sepsis of the iliac site, and one of a locking screw. The patients were evaluated by the AFCP, SFMCP talar score, whose average value rose from 20.7 to 66/100. 19 patients were very satisfied, 15 satisfied, 2 disappointed and 2 dissatisfied.

Discussion: This osteosynthesis, very reliable biomechanically, enabled a number of delicate situations to be recovered, using a graft, however, in 68%of cases. Applying the principle of endoscopic refreshing resulted in a fusion rate of 97.5%. In our experience, a septic history doesn’t contra-indicate nailing.

Conclusion: This technique, often reserced for difficulty cases, has proved to be extremely reliable, with an excellent fusion rate.


C. Jensen A.S. Bajwa F. Yousaf M.S. Siddique

Background: Ankle fractures are the second commonest lower limb fractures after hip fractures and as opposed to the latter occur commonly in younger population of working age. Due to a host of different factors including the state of soft tissues and delayed presentation, there is often a delay of several days between fracture and operation, resulting in longer admissions. It is hypothesised that early intervention may shorten hospital stay and hence save on hospital resources.

Aims: To ascertain the impact of timing of ankle fracture surgery on length of post operative and total hospital stay and its implication on resources.

Methodology: Consecutive ankle fractures that underwent open reduction and internal fixation at Newcastle General Hospital over a 4-year period were studied as a retrospective cohort. Data collection from Theatre records, PAS system, case notes and radiographs was undertaken and entered in SPSS database.

Results: 431 cases of ankle fracture open reduction and internal fixation were included in the study. 41% were female and 59% were male patients, with a mean age of 39.1 years (SD±17.8), with age range from 16 to 89 years.

298 patients were operated within 48 hours of admission (early surgery group), and 136 patients after 48 hours (delayed surgery group). The mean hospital stay in the early operation group was mean 5.3 days (SD±4.9) and in the delayed surgery group it was 12.2 days (SD±8.4). The patients who were operated early had shorter total hospital stay (p< 0.001) and also had shorter post-operative stay (p< 0.05). Increasing age and female gender appeared to predispose to longer hospital stay but this was not statistically significant. Mean age, gender and ASA grade, fracture class and operating surgeon’s grade distribution were not significantly different in the early and late surgery groups.

Each patient in delayed surgery group spent an extra 6.9 days in hospital stay compared to the early surgery group, translating into an extra 937 hospital bed days. The average extra cost of hospital stay per case in the delayed surgery group (£1414) exceeds the average expense of surgery per case in that group. The delayed surgery group resulted in added expenditure of £192085 to the trauma division solely for extra hospital stay.

Conclusion: Timing of surgery in ankle fracture appears to be the most significant determinant affecting the hospital stay. This has a significant resource implication, financially and in freeing up of hospital resources, as well as impacting on the lives of this large group of patients.


A. Spoor J. de Waal Malefijt

Introduction: The incidence of early osteoarthritis after the modified Bristow procedure for recurrent anterior shoulder dislocation has been the subject of several articles during the last decade. Recurrent dislocation, recurrent subluxation after surgery or the procedure itself have been suggested as the main causes of degenerative changes.

Materials and Methods: Thirty-four patients with recurrent anterior dislocation of the shoulder were treated by the same surgeon between May 1989 and April1999. Nineteen patients were allocated for long term follow-up assessment. Patients filled in a questionnaire in which they scored mobility, strength, stability and satisfaction. A Rowe score was established in each patient and radiographs in two directions (AP and axial) were taken.

Results: Twenty shoulders (6 women and 13 men) with an average follow-up of 7.7 years were seen. Seventeen patients had an history of more than 3 dislocations. The mean interval between the first dislocation and surgery was 6.8 years. In all patients a substantial improvement of stability was recorded after surgery. Redislocation occurred in only one patient. The overall satisfaction rate was 6.2. The mean Rowe score at follow-up was 92. There was no limitation in abduction while external rotation was slightly limited in 7 patients. Three patients showed arthritic changes (2 mild, 1 moderate), which, surprisingly, were also seen in the opposite shoulder.

Conclusion: The occurrence of arthropathic changes in a shoulder after surgical stabilisation is based on multiple factors. The recurrent dislocation that has taken place before any surgical procedure plays a predominant role.


A.M. Noorani A.A. Malone A. jaggi S.M. Lambert J.I. Bayley

This study identifies variations in presentation and demographics between structural and non-structural (muscle patterning) shoulder instability.

We analysed 1020 unstable shoulders (855 patients) from our institution database. Demographic details, direction and aetiology were obtained from medical records. Anterior dislocations comprised 67%, posterior 31% and inferior 2% of all directions of instability and 75 shoulders had multidirectional instability.

Structural causes were dominant in anterior instability (traumatic 39% and atraumatic 38%) and muscle patterning in posterior (81%) and inferior (90%) instability. Males accounted for 64% of all patients (73% of all structural patients and 53% of muscle patterning patients. Mean age at presentation was 25 years old (structural patients 28 years and muscle patterning patients 21 years old). There were 690 unilaterally unstable shoulders (57% right- and 43% left-sided); the dominant arm was affected in 58% overall, in 42% of all left-handers and only 33% of left-handers with muscle patterning. Bilateral shoulder instability occurred in 19% of all patients (12% of patients with structural instability and 28% of those with muscle patterning instability). For muscle patterning, the mean age at onset of symptoms was 14 years, and mean length of symptoms before presentation was 8 years. There was a trimodal distribution of age at onset of symptoms corresponding to peaks at 6, 14 and 20 years. In the group with onset of muscle patterning under 10 years old, there was a higher proportion of females (71% vs 47%), laxity (63% vs 29%) and bilaterality (54% vs 42%), and fewer presenting with pain (17% vs 50%).

Muscle patterning instability is associated with a demographic and presentation profile which may help distinguish it from structural forms of instability. As age at presentation increased, pain increased and joint laxity decreased. Bilaterality did not appear to be associated with gender, the presence of laxity or pain.


J. Luetzner F. Krummenauer J. Luebke M. Bottesi

Purpose: Although arthroscopic Bankart repair is yet an established procedure in the treatment of traumatic anterior shoulder instability, it is still not known whether it reproduces the good results of the open repair procedure. Aim of this investigation was to compare the functional and subjective outcome between open and arthroscopic Bankart repair.

Material and methods: A retrospective cross sectional study design on the comparison of open and arthoscopic Bankart treatments between 1995 and 2004 was implemented at the Dresden Orthopedic Surgery Department. In this period a total of 223 patients underwent surgery due to anterior shoulder instability, among which 212 patients had posttraumatic instability. A diagnostic arthroscopy was performed in all patients, but only 40 patients with intact capsulolabral complex and without capsular laxity were treated arthroscopically, the remaining 183 patients underwent an open Bankart procedure.

A total of 186 patients with posttraumatic anterior instability could be clinically re-examined within 1 to 5 years after initial surgery, among which 147 patients underwent an open and 39 patients an arthroscopic Bankart procedure. The median age of this sample was 27 years (interquartile range 21 – 37 years) at initial surgery, 21% of these patients were female.

Results: After open surgery 11 of 147 patients (8%) and 6 of 39 (15%) after arthroscopic surgery reported one or more re-dislocation after initial treatment, which occurred after a mean dislocation free time of 62 versus 40 months, respectively (95% confidence intervals 59 – 65 versus 36 – 44 months). Both a univariate analysis (Logrank test p=0.012) and a multivariate Cox regression analysis (Likelihood Ratio p=0.023) confirmed a statistically significant difference in the time between initial surgery to first reluxation. 4 of the 11 re-dislocations after open and 1 of 6 after arthroscopic surgery occurred after a new accident. That makes a re-dislocation rate without new adequate trauma of 5% after open and 13% after arthroscopic treatment.

ROM showed no difference between open and arthroscopic Bankart procedure for abduction and a mild difference for external rotation. 21 of 115 (18%) patients had an external rotation lag of 20° or more after open surgery versus 1 of 34 (3%) after arthroscopic treatment (Fisher p=0,027). The Rowe score demonstrated “good” or “excellent” functional results in 102 of 117 (87%) patients versus 28 of 35 (80%) patients after open versus arthroscopic treatment (Fisher p=0,285).

Conclusion: In this sample arthroscopic Bankart repair demonstrated more frequently and significantly earlier re-dislocation after initial surgery than did the open treatment alternative. External rotation lags of at least 20° occured more frequently after the open procedure.


F. Weitz H. Weitz T. Järvelä Hajo Weitz Timo Järvelä Frederick Weitz

We will present the results of our different studies from 1979 till now. Between 1979 and 1984 we tested 1120 consecutive patients with distorsion trauma by stress x-rays, taking only the anterior drawer sign. 237 patients (21, 2 %) were treated operatively because of pathological instability. The correlation: operative findings/positive anterior drawer sign was 85 %. Because of our prospective study in 19 84: arthrography versus x-ray in 52 patients we abandoned the invasive arthrography because it did not give better information about the instability of the ankle. After an investigation of 42 patients with instable ankle joints in our and in the university hospital of Kuopio treated by Evans operation in 1983 with the outcome 42% anteriorly instable, 26% pain at the insertion point at metatarsus V, we looked for a better reconstruction method.

We chose our own method, anatomical reinsertion of FTA and FC, and augmentation of FTA with half of syndesmosis anterior.20 patients, who were treated with this anatomical reconstruction technique(group A), and 20 patients, who underwent primary repair (group B), were controlled 2–4 years after operation. We reviewed 15 patients from group A and 17 from group B. Functional scores were good in both groups without significant difference and no difference in the mean talar translation between the two groups. In a second investigation -92–93 with 43 primary ligament repairs and 31 reconstructions, 89% were active athletes. The outcome after 2–4years was 2, 3% of primary repaired ankles were still painful vs. 22,6 of ankles in delayed reconstruction group. Improvement of anterior stress radiography 3,9mm of those with ligament repair and 1,5 mm of those with reconstructive procedures. This difference between these two groups was significant.

Should we operate primarily or treat the patients adequately-air cast, active rehabilitation and only persisting instability by operation with an anatomic reconstruction??


M. Regauer S. Hinterwimmer D. Bürklein K. Kanz W. Mutschler

Introduction: Scapular manipulation is one of the most successful techniques for reducing anterior shoulder dislocations. However, as there is evidence in the literature that elbow flexion can avoid tendon interposition and muscular compression forces on the glenohumeral joint are at a minimum in the overhead position, we created a modification of the original technique with the principle of scapular manipulation in overhead position and traction on the upper arm with the elbow flexed. The aim of this study was to assess the effectiveness of this new method.

Methods: 62 patients with acute anterior shoulder dislocation who were treated with this new method were evaluated prospectively with regard to primary success rate and reduction time as main outcome parameters. Results were compared to the published data on the original method. Statistics was conducted using the chi-square test and the ANOVA post hoc test with Bonferroni-Dunn-transformation.

Results: 59 of the 62 dislocations (61% first time dislocations, 21% with associated fractures) were reduced successfully by use of the new method by 21 different physicians indicating a primary success rate of 95.2%. The mean reduction time was 3.13 minutes. Primary success rates of the original method reported in 5 studies range from 78.4 to 96.0% (mean 87.1%). In 2 out of 5 single test and global level comparisons our new modification revealed a statistically significant better primary success rate compared to the original method (p< 0.05). There were no iatrogenic complications in our study, and the method was easy to perform even without any experience in reducing shoulder dislocations.

Conclusion: Modification by overhead position and elbow flexion can even improve the high primary success rate of the original scapular manipulation technique. Therefore, the method is strongly recommended as a first choice technique for reducing anterior shoulder dislocations.


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R. Bozic D. Hudetz A. Aljinovic N. Cicak

Aims of the study: The purpose of this paper was to evaluate the long term results of the open Bankart procedure for an anterior shoulder instability in heterogenic non selected patients.

Material and Methods: Hundred and seventy seven patients were operated on at our instutution using open Bankart technique without using suture anchors, between 1993 and 2002. Hundred and sixty nine patients were evaluated. Average follow up was nine years and seven months (4–13 years). Average age at the time of operation was 27 (15 – 67). 89 % of shoulders had more than 3 dislocations, 60 % had more than 10 and 37 % more than 20 dislocations. American Shoulder and Elbow Society Scoring System and Constant Scoring System were used for assessment.

Results: 155 patients (92 %) had Bankart lesion and 150 patients (89%) had Hill-Sachs lesion. Five patients (2.9%) had redislocation of the operated shoulder caused by new trauma, two of them underwent reoperation. 164 patients were satisfied and very satisfied with the results. None of patients needed a shoulder arthroplasty because of symptomatic osteoarthritis. Average Constant score was 92 and American Shoulder and Elbow Society Scoring System was 90. Average loss of external rotation in adduction was 6 degrees and loss of external rotation in 90 degrees abduction was 3 degrees comparing to contra lateral shoulder.

Discussion/Conclusion: The Bankart procedure for anterior shoulder instability gives reliable long-term results.


R. Russo G. Giudice M. Ciccarelli L. Vernaglia Lombardi F. Cautiero

Aim: In this work we report mild term clinical results of a consecutive series of 104 arthroscopic stabilizations for traumatic or non traumatic anterior-inferior shoulder instability treated using for the stabilization always poly- L-lactic acid Bioknotless anchors (Mitek, Nor-wood, Mass., USA) and surgical technique described by Thal, and the clinical results of 74 patients reviwed

Methods: From 2000 to 2005, 104 consecutive patients underwent arthroscopic capsuloplasty repair using bio-knotless anchors.14 cases were performed SLAP II by original reconstruction with bioknotless anchors. All the patient underwent preoperative a clinical examination and valued Constant and Rowe score, and subjected a X-Ray study and MRI o TC\ arthroTC scan. All patients were operated by same surgical team. 74 patients (55 male, 19 female) were reviewed with at least 20 months follow-up (20 – 60 months). Average age was 25 (18–45).

Results: Recurrence rate for instability was 6,7% (5/74). All recurrence, was associated with a large Hill-Sachs lesion and poor quality of capsular tissue. Overall, the results were good or excellent in 91,5% using the Rowe score. At X-ray study 28 cases have not show Samilson’s arthrosis, in 4 (14,7%) cases we observed geoid on glenoid side.

Conclusion: The improvement in the results, to use absorbable anchor, obtained could be related to the development of materials and in particular at use of PLLA (poly-L- lactic polymer) and PGACP (polygluconate co-polimer), at surgical techniques carried out, to the different fixation methods and not least to the different inclusion criteria used for the selection of patients.

Arthroscopic capsulolabral stabilization for the treatment of recurrent anterior shoulder instability repair using absorbable Knotless offers reliable results with respect to failure rate, range of motion, and shoulder function also at 4 years follow-up.

The percentage of rate for instability is 6,7% and is in accord with the International Literature on non resorbable anchors.


G. Tytherleigh-Strong R. Carey Smith A. Getgood

Aim: To characterise the reasons for failure following primary surgical stabilisation, the indications and the results of surgery in a subgroup of patients undergoing revision arthroscopic shoulder stabilisation.

Methods: All patients who underwent revision shoulder stabilisation over a 3 year period were included in the study. Information about the index procedure, imaging and the findings at arthroscopy were used to characterise the mechanism of failure. Patients were assessed clinically and WOSI scored at 6 and 12 months and then annually.

Results: Thirty-six patients were reviewed. Twenty underwent an arthroscopic (AR) and 15 underwent an open (OR) revision procedure. The AR index procedures were 15 arthroscopic (4 suture-anchor, 10 thermal shrinkage, 1 unknown) and 5 open (3 Bankart, 2 Putti-Platt). The OR index procedures were arthroscopic 10 (4 suture-anchor, 3 transglenoid, 2 thermal shrinkage) and 6 open (4 Bankart, 2 Putti-Platt). Soft-tissue failure was the primary mechanism in all AR cases (4 further trauma, 7 inappropriate primary procedure, 3 missed pathology, 6 technical error). The OR primary mechanism of failure was bone loss 12 (4 epileptic) and soft-tissue failure 3. At AR follow-up of 25.8 months (10–45) there had been 1 re-dislocation and 1 subluxation, mean WOSI 298 (68–517). There had been no OR re-dislocations at 22.5 months (10–42) follow-up, mean WOSI 313 (76–621).

Conclusion: Recurrent instability following surgical stabilisation maybe due to bone loss or soft-tissue failure (further trauma, inappropriate primary procedure, missed pathology, technical error). Revision arthroscopic surgery maybe indicated in soft tissue failure cases and can produce acceptable medium term results.


E. Apergis C. Thanasas X. Xaralabidis G. Papadimitriou G. Arealis G. Theodoratos

Fracture of the volar rim of the distal radius could be an isolated fracture or part of a complex type of fracture. Frequently it is displaced and rotated because of the attachment of the volar radio-carpal ligaments. Fixation of this fragment is mandatory to preserve integrity of radio-carpal and distal radio-ulnar joints. Given the difficulty of manipulation of this osteochondral fragment we studied the efficiency of a wire-loop as a method of fixation of this fragment.

Eleven patients were examined (8 male, 3 female) mean age 42,6 years (21–72 years) who had various type of fractures of the distal radius but had in common the presence of an osteochondral fracture of the volar radial rim in the ulnar side (7 patients), in the radial side (3 patients) or on both sides (1 patient). Distal radius fracture was type B3.1 (1 patient), B3.3 (4 patients), C3.1 (3 patients), C1.3 (1 patient) and radiocarpal fracture-dislocation in 2 cases. All patients were treated operatively. Eight of them had early (1 – 10 days post-injury) and three had delayed treatment (1 month post-injury). The rim fragment was found displaced in all patients and rotated 45°-180° in 5 patients. Different types of fixation of the distal radius fractures were used, while in all patients the rim fragment was fixed using a wire loop.

Results were estimated after a mean follow-up of 1 year (6 months- 4 years) using clinical (pain, function, range of motion, grip strength) (Cooney 1987) and radiological (articular congruence, arthritis) criteria. Results were evaluated as excellent (4 patients), good (5 patients) fair (1 patient) and poor (1 patient), while in two cases there was loss of fragment reduction.

In conclusion, although intraarticular fractures are often associated with injury of the interosseous ligaments, probably they have no effect on the integrity of the volar radiocarpal ligaments, the origins of which could influence the volar rim fracture displacement. Wire loop is a valid method for fixation of osteochondral fracture of the volar radial rim, giving stability and avoiding comminution and necrosis of the fragment.


D.R. Cohen O. Olivier H.A. Jahraja G. Kemp J. Hunter M. Waseem

Introduction: We present a double blinded prospective randomized controlled trial between viscoseal and intraarticular diamorphine injection in shoulder arthroscopy.

Materials & Methods: Twenty adult patients undergoing arthroscopic subacromial decompression were randomised into two groups. The Viscoseal group received 10ml of Viscoseal and 10ml of 0.5% bupivacaine injected into the subacromial bursa at completion of the procedure (n=10). The matched control group received 10mg diamorphine and 10mls of 0.5% bupivacaine (n=10). All procedures were performed by the senior author. The patients were blinded to the injections given. Post-operative regimes were standardised and all patients were assessed by visual analogue pain scores at recovery and 1, 2, 6, 12 & 24 hours post-operative. The presence or absence of nausea and time to discharge were also noted.

Results: The mean age of the Viscoseal group was 53 (range 34–70) years and in the control group 59 (32–85) years. In the Viscoseal group 40% of patients were discharged on the same day, while there were no early discharges in the diamorphine group this difference did not reach statistical significance (P=0.054 by Fisher’s exact test). There were no significant differences in post-operative pain score or the fraction pain-free between the two groups or in supplementary analgesic drug doses given (all P> 0.08). Only 10% of the Viscoseal group were nauseous post-operatively compared to 60% of the control group (P=0.03 by Fisher’s exact test).

Discussion: Arthroscopic surgery has never been more popular. Patients like smaller scars, early discharge and quick return to daily life and work; for surgeons arthroscopic surgery is skilful, satisfying and digitally recordable; and the NHS benefits from reduced hospital stay and post-operative complications.

Review of the literature involving the use of viscoseal in shoulder surgery revealed no direct comparison with diamorphine, but only to bupivacaine alone.

Many methods of post-arthroscopic pain relief are available. In our hospital diamorphine with bupivacaine is standard, at £2.57 per treatment. In the present study nausea was significantly lower in the Vicoseal group, but no significant intervention was required and oral anti-emetics sufficed. Pain was not significantly different, and there were no significant differences in supplementary analgesia or in early discharge. In our opinion, the significant improvement in nausea alone is not enough to justify the high price of £52.88 per Vicoseal treatment. We believe that the benefits for routine use have not been demonstrated.


D.N. Adla S. Shukla R. Pandey

Introduction: Arthroscopic stabilisation of shoulder joint for instability following a traumatic dislocation is gaining popularity. It has various advantages like being minimally invasive, causes minimal damage to the shoulder muscles, quicker rehabilitation, minimal loss of external rotation, and addresses the pathology. This can be performed using non-absorbable suture anchors to repair the Bankart’s lesion, which involves arthroscopic knot tying. Recently, devices, which avoid tying knots, and are absorbable, have been developed for arthroscopic shoulder stabilisation.

Aim: To evaluate the clinical results of arthroscopic Bankart’s repair using knotless, bio-absorbable suture anchor device.

Methods: A total of 32 patients with recurrent anterior dislocation of shoulder of traumatic origin underwent arthroscopic stabilisation using absorbable knotless suture anchors (Mitek U.K.). Average follow up was 2.4 years. Oxford shoulder instability score were used to evaluate clinical outcomes.

Results: The average age of patients at surgery was 24 (18–28). The average number of dislocations per patient were three. The average hospital stay was 1.1 days. The mean operating time was 70 minutes. 90.6 % (29 out of 32) had no further instability or dislocation. The recurrence rate was 9.4% (3 out of 32). The two redislocations required open repair and one patient has a residual instability. The average Oxford instability score was 22. All the patients returned to their pre-operative occupation. Of the 7 keen sportsmen, 5 returned to their contact sports at pre-injury level and 2 returned to their contact sports at a slightly lower level. In two cases we had breakage of anchor loop intraoperatively. Two patients had initial stiffness, which eventually resolved. No other complication was noted.

Conclusion: The clinical outcome of arthroscopic stabilisation of shoulder using knotless bio-absorbable suture anchors are good and are comparable to other methods of arthroscopic Bankart’s repair. The advantages are that the anchors are absorbable and there is no knot tying involved.


P.J. Delgado M. Miranda J.M. Abad F. Forriol F. Lopez-Oliva

Introduction: Intraarticular fractures of distal radius are associated with high energy mechanisms, are severe and difficult to obtain a surgical reduction. The aim of our paper is to compare the clinical, radiographically and activity results in workers treated with surgical and conservative procedures.

MATERIAL AND METHODS: A prospective study was organized in 43 heavy-labour workers (34 male and 9 female) with unstable fractures of distal radius, treated between 2003 and 2005. The minimal follow-up was of one year. The mean age were 40 years (22–65 years) and dominant limb was involved in 40% of the cases. To treatment groups were established. Group 1, conservative treated with indirect reduction and cast immobilization (n=20) and Group 2 surgically treated with indirect reduction and percutaneous fixation with K-wires and cast immobilization (n=24).

Pain, mobility and radiograhs were evaluated and also strength (isokinetics), functionality (DASH score) and, finally, the return to work at 3, 6 and 12 months.

RESULTS: Fracture healing was obtained at 7 weeks but the time to return to work were 14 weeks after surgery. Pain score, at 12 months, were 2,3 points for conservative treatment and 2,9 points for the surgically group. The flexion – extension mobility loss, in relation to the contralateral wrist, was lesser in the conservative group at 3 and 6 month but similar (11°) at 12 months in both groups. Radiographs corrections were anatomically in 38% of the cases of group 1 and in 80% of group 2. Functional and strength results were similar in both groups. All the patients return to the same work activity.

CONCLUSIONS: Percutaneous fixation of unstable intraarticular distal radius fracture is comparable to the conservative treatment but the percentage of anatomical reductions was higher. It would be of importance in the evolution of the patients.


L. Obert G. leclerc L. daniel Y. tropet P. garbuio

PURPOSE: To compare the functionnal and radiological results concerning the “same” distal radius fracture of 3 different and consecutive procedure : dorsal plate, pins and palmar plate.

MATERIAL AND METHOD: Sixty two patients with a dorsally displaced extra-articular fracture of the distal radius were treated by dorsal plating [group 1, 20 patients, mean age 59,9 yo (25–87)], pinning [group 2, (22 patients, mean age 55,6 yo (17–83)] and volar plating [group 3, 20 patients mean age 57,1 yo (17–78)]. Patients were evaluated by a surgeon not involved in the treatment. Posttreatment evaluations consisted of measurements of range of motion, grip strength, radiographic evaluations between post operative time and last follow up, and evaluation by Herzberg scoring, associated with Gartland and Werley rating system and completion of Disability of Arm, Shoulder, and Hand questionnaires. Comparaison of three groups was performed with Kruskall-Wallis or ANOVA test (quantitatives variables) and Khi-2 (qualitatives variables) (p-value < 0.05).

RESULTS : Operative time was same for plate groups but two times more than pin groups. In Group 1 most complications and fair functionnal results were reported (32%) in spite highest follow up. Group 3 showed best results in flexion-extension, with DASH scoring, ulnar variance conservation, and most excellent and good results with Gartland and werley rating system. In group 2 and 3 same percentage of complications were pointed: 5%. Indenpendtly of tretament best results were reported in men, less than 30 yo.

DISCUSSION : If dorsal plate remains logical, such a fixation is challenging with high percentage of complications. In such extrarticular distal radius fracture palmar plate as pinning reach good and reliable functionnal results. Reduction of the palmar cortex remains probably the technical point. If the palmar plate is sufficiently rigid it can offer adequate stability for the treatment of the distal radius fracture in which the anterior and/or posterior metaphyseal cortex is frequently comminuted severely.


A. Abramo P. Kopylov M. Tagil

Background: Distal radius fractures are among the most common fractures, consisting of about 1/6 of all fractures shoving up at the ER. Many times surgical treatment is indicated. However which type of operation to chose is not known. The standard operative treatment has been external fixation but more modern techniques for internal fixation have become increasingly popular. Our aim was to evaluate if internal fixation is beneficial for the patients. To do this we did this randomized study.

Material and methods: Between May 2002 and March 2005 a randomized study between closed reduction and external fixation versus open reduction and internal fixation with the TriMed® system was performed in 42 consecutive patients. 29 were women and 13 were men in the ages between 20 and 63 with a mean age of 48 years. 20 were randomized to closed treatment and 22 to open treatment. Patients were followed with clinical examination, radiographs, examination of range of movement and grip strength and outcome measured by DASH for one year.

Results: DASH-scores showed no statistical significant differences between the groups neither early at seven weeks (32 in the open group an 29 in the closed) nor late at one year (9 vs. 13) postoperatively. Range of movement in flexion and extension was better in the internal fixation group at 5 weeks (45 degrees vs. 67) degrees postoperatively but this difference disappeared at one year (121d egrees in both groups). Grip strength was significantly better for the TriMed group at 5 weeks (32% of the opposite side vs. 8% in the external fixation group) and 7 weeks (47% vs. 34%) and at one year (78% vs. 90%) postop. Range of movement in forearm rotation was significantly better in the open group during the whole follow up (126deg. vs. 101deg. at seven weeks and 149 vs. 133 at one year). There were three cases of redislocation in the external fixation group. They were all later treated with osteotomy. However there were 15 cases of minor complications in the open group compared to 9 cases in the closed group. The minor complications were mainly consisting of transient tingling of the radial nerve in the open group and skin adherences in the closed group.

Conclusion: Open reduction and internal fixation for distal radial fractures give better result regarding motion and grip strength than External fixation but there is no difference in subjective outcome. Complications are common in both groups but these are often minor non lasting complications. However malunion is more common with external fixation.


C. ANGRISANI S. Del Prete

Conservative treatment is not always possibile because it needs anatomic reduction of the fractures and to prevent the functional difficulties. There’s inherent tendency loss of reduction after non-operative treatment. According to criteria of instability of Cooney et al. as dorsal angulation > 20° degrees, loss radial length> 10 mm, intraarticular extension, etc. or if we had fractures A3, B, C of A.O. classification, open, bilateral fractures in polytrauma, will be useful to operate with internal or external fixation. We need to respect the morphology of three columns. We compare two different types of devices usually used in the last ten years in our hospital as the external fixation with Pennig and the plates and screws in internal fixation, underlining the advantages and the disadvantages. Between January 1997 and December 2006 215 patients with comminuted and unstable fractures complicated with different clinical aspects of exposure or vasculopathy or neurological acute entrapment or lesion, of severe displacement were treated by external fixator of Pennig. They were evaluated according to Gartland e Werley system, Sarmiento modified. Pain, disability and functional disease of articulation, radiological criteria of instability. To follow up average 12,4 months (range 5 to 24 months) the patients were distinguished as excellent, good, in 76% and fair good and bad in 24%. Complications of treatment were 3 osteitis and trombosis. In the same period we applied 142 plates the most in the volar side as DCP, LCP in association when it needs with graft, pinning and platelet gel after centrifugation of blood of the patient useful to bone healing. These patients were evaluated regarding to anatomy and function after reduction as strength of punch by Jamar dynamometer, pain, range of motion. After three months the patients operated with plates showed a ROM and a strength of punch better than those operated by external fixator. On the contrary after six months, more and more after twelve months the clinical and radiological results that is anatomical and functional outcomes were the same. At one year the Dash score was the same in the both of groups and there was not a difference between them. So we are authorized to use the external fixator of Pennig in unstable fracture A3 of wrist after failure of closed reduction, higher energy fractures and dislocations, unstable articular methaepiphiseal and comminuted fractures, exposed fractures, bilateral and complicated in politrauma. We applied volar plate and screws when there are extraarticular displaced fractures (A3.3), articular displaced fracture (B, C), corrected osteotomies, particularly in fracture type B (internal osteosintesis with plate + eventual volar graft), type C (internal osteosintesis volar plate associated with dorsal approach and pinning) + possible graft.


A.S. DESAI A.K. CHOUDHARY K.B. SHAHI

Aim of the study: to assess the early complication rate following k-wiring of distal radial fractures and their final clinical outcome.

Materials & methods: a prospective study. 48 Patients with 50 distal radial fractures (26 male,22 female) with mean age 34 years(range 4–88) were treated by closed k-wiring during the period jan 2005-june 2005.

They were assessed in terms of early complications following mua and k-wiring and their final clinical outcome.

Results: 12 patients(24%)had discharge, pin tract granulation, loosening out of which 4 required antibiotics. Out of 12 only 2(4%) had positive swab culture requiring i.V. Antibiotics

.3(6%)Had symptoms suggesting superficial radial nerve damage of which 2 recovered completely after pin removal. One had residual symptom which got better before planned exploration.

9 Patients (18%)had stiffness of which only 3(6%)had residual stiffness at the end of 6 months. Crps was noted in 1 patient(2%)who recovered after good physio.

There wer nocases of deep infection, osteomyelitis, tendon rupture, pin migration or significant loss of position.

Conclusion: our data suggests that though early complication rate of k-wiring is alarming, it doesnot affect the final clinical outcome of fracture management and this complication can be avoided by proper technique and care.

There is no rationale in giving antibiotic coverage for all the pintract discharges unless swab positive.


F. rayan D. shukla S. bhonsle C. mukundan

MRI scan for the knee joint has often been regarded to be the non invasive alternative to a diagnostic arthroscopy. MRI scan is routinely used to support the diagnosis for meniscal or ACL injuries prior to recommending arthroscopic examination and surgery. Identification of meniscal tears can be difficult to interpret and can be observer dependent as well as dependent upon the sensitivity of the scanner. Similar difficulties may exists in clinical examination as well.

Our aim was to compare and correlate clinical, MRI and arthroscopic findings in the diagnosis of meniscal and Anterior Cruciate Ligament (ACL) Injuries.

This was an observational study of 131 patients over 36 months who had both MRI and arthroscopic surgery.

Our study showed clinical examination had better sensitivity (0.86 vs 0.76)and specificity(0.73 v/s 0.52) in comparing to MRI in diagnosis of medial menisceal injuries. similarly +predictive value and −predictive value were higher for clinical examination. whereas for lateral menisceal and ACL injuries there were marginal differences in sensitivity, specificity and predictive values

We conclude that carefully performed clinically examination can give equally or better diagnosis of meniscal and ACL injuries in comparison to MRI scan.

MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has much better negative predictive value than positive predictive value in both meniscal and ACL injuries diagnosis. When clinical signs and symptoms are inconclusive, performing MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery.

When clinical diagnosis is in favour of either meniscal or ACL injuries, performing MRI scan prior to Arthroscopic examination is unlikely to be of significance. MRI scan should not be used as a primary diagnostic tool in meniscal and ACL injuries


P.E. Gelber J.C. Monllau A. Torres J. Lloreta F. Alameda E. Cáceres

INTRODUCTION: Shrinkage is one of the complications observed after allograft meniscal transplantation. Subtle immune rejection and alterations in meniscal permeability leading to nutritional deficit have been suggested as causes of shrinkage. The purpose of this study was to ascertain how freezing, one of the most common procedures used to preserve allografts, alters the collagen’s architecture.

METHODS: 26 fresh human external menisci were harvested in sterile conditions during TKR procedures. 13 of them were immediately frozen to −80° C while the rest were used as controls. All the menisci were cut, processed and preserved in a 2.0% glutaraldehyde and then analyzed with transmission electron microscopy. Four hundred collagen fibrils were recorded and measured in longitudinal and transversal sections in each meniscus. According to the collagen’s periodicity and degree of disruption, loss of banding, degree of collagen packing, fibril size variability and its intrafibrilar oedema, each meniscus was pointed from 0 to 7. Subsequently they were classified in grades ranging from a normal state (grade I; 0 to 2 points) to severe disarray (grade III; 5 to 7 points).

RESULTS: The fibril collagen diameters of those menisci that had been previously frozen showed an average size in the longitudinal section of 14.256 nm, whereas 17.279 nm were seen in the menisci used as controls (p=0.019). In the transverse section, the frozen menisci averaged 13.145 nm and 16.935 nm the controls (p=0.003).

Samples of the 13 previously frozen menisci were classified as grade III in 8 cases (61,54 %), and grade II in 5 cases (38.46 %). They averaged 4.846 points. The control groups were classified as grade I in 6 cases (46.154%) and grade II in 7 cases (53.85 %). The frozen menisci averaged 4.85 points whereas the control group did so 2.46 (p< 0.001)

CONCLUSIONS: The fibril diameters in frozen menisci showed a thinner diameter and had a higher degree of disarray. Therefore, the results suggest that the freezing process alters the menisci’s collagen net. This could partially explain the pathological changes found in shrunken menisci. This is the first work that quantified and qualified methodologically the collagen meniscal architecture and its potential changes.


M. Hoberg W.K. Aicher M. Rudert

The meniscus of the human knee joint has an outstanding function for stability, shock absorption and power transmission of the thigh on the shank. After a meniscus trauma so far often only the partial or complete removal of the meniscus has to be performed. Only with injuries in the outside third a primary suture of a tear leads to the healing due to the existing vascularisation in a high number of cases in younger patients. After partial or total meniscektomie cartilage degeneration and resulting osteoarthrosis of the knee joint often is the consequence.

A goal of our investigations was the establishment of meniscus cell cultures as well as their characterisation regarding the expression of different growth factors, cytokines and proteins and the influence by adding different recombinant growth factors. We are able to cultivate human fibrochondrocytes, which originate from menisci of the knee from patient undergoing total knee replacement. Investigations were performed by immune-histochemistry and RT PCR. We could show the expression of collagen I, II, III and VI, the matrix-metalloproteinases 1, -2, -3 and -8 in the human meniscus. In Addition the expression of TGFβ1, BMP II, AS.02, Thy 1, TGFβ1, iNOS and interleukin (IL) -1, -6 and -18, ECGF and VEGF was proved. PDGF-1 and collagen X could not be found in the meniscus investigated. Same expression analysis was performed in same patients’ synovial cells and chondrocytes from knee joint. Differences were found in the collagen expression. Synovial cells do not synthesise collagen II but collagen I. Investigated chon-drocytes show a high level of collagen I an II expression, but fibrochondrocytes a low level of collagen II and high of collagen I, too. After stimulation of meniscus cells with IL-1, TGFβ1 and TNF-α no difference was found in the expression of TGFβ1, BMP II and IL-18, but a total inhibition of IL-6. TGFβ1 suppressed IL-1 expression totally compared to not stimulated fibrochondrocytes.

We were able to cultivate, characterize and stimulate human fibrochondrocytes from meniscus of the knee. We could show that meniscus cells express a huge amount of different growth factors, cytokines and proteins and can be distinguished from synovial cells and joint chondrocytes by the low level expression of collagen II. We also investigated first time the reaction of human meniscus cells after stimulation by recombinant growth factors. These results are a basis for the tissue engineering of meniscus tissue.


W. Rodkey K.K. Briggs

INTRODUCTION: Absence of meniscus tissue leads to decreased clinical function and activity levels. In a previous study, we reported significant correlation between actual measured amounts of meniscus tissue removed at meniscectomy and symptoms, function and activity 2 years after surgery. In particular, it was noteworthy that patients with > 50% remaining meniscus tissue were significantly better in all categories measured than patients with < 50% total meniscus tissue remaining. The purpose of the present study was to determine, prospectively, changes in Tegner activity levels from preoperative to 2 years postoperative in patients who received Collagen Meniscus Implants (CMI) and were documented to have > 50% total meniscus tissue at 1-year relook arthroscopy.

METHODS: In a randomized controlled investigational device clinical trial (Level of Evidence I), 138 patients 18 to 60 years old underwent partial medial meniscectomy and placement of a CMI to fill the meniscus defect. There were 64 acute (no prior meniscus surgery) and 74 chronic (1 to 3 prior partial meniscectomies on the involved meniscus) patients. At index surgery, meniscus defect size was measured with specially designed instruments, and the percent of meniscus loss was calculated based on these actual measurements. Relook arthroscopy was performed at 1 year on 124 patients (90% surgical follow-up), and percent total meniscus tissue (remnant + new tissue) was determined by making these same measurements and calculations. Patients were followed clinically for a minimum of 2 years after CMI placement. At each follow-up, all patients completed questionnaires, including a Tegner score to assess activity. We then determined changes in Tegner score from the index surgery to 2 years status post CMI in these patients.

RESULTS: Of 124 relooks, 111 patients (90%) had > 50% total meniscus tissue. In these patients, average Tegner activity scores improved by two levels from 3 to 5 from preoperative to 2 years status post CMI. This increased change in activity levels significantly correlated with total meniscus tissue > 50% (r=0.21, p=0.02). These findings mirrored those we previously reported for partial meniscectomy patients in which > 50% of the meniscus was maintained.

CONCLUSIONS: There is a significant correlation between change (increase) in Tegner activity levels over 2 years and percent total meniscus tissue in patients who receive the CMI as treatment for meniscus loss and have > 50% total meniscus tissue. This study confirms the importance of preserving as much meniscus tissue as possible at the time of repair or meniscectomy. It clearly supports the potential positive benefits of regrowing or regenerating lost meniscus tissue to assist patients in regaining their activity.


P. Wilmes R. Seil D. Pape D. Kohn

Introduction: The purpose of our investigation was to determine if tibial lateral meniscus insertions (anterior and posterior horn) can precisely and reproducibly be determined on preoperative radiographs. Bony landmarks and their topographic relations to the meniscus insertions were described, measured and statistically evaluated. We concentrated on the lateral meniscus because there are many reasons to restrict the indications for meniscus replacement on the lateral compartment.

Methods: We prepared the lateral meniscus insertions in 22 tibial plateaus from 11 body donors. Insertion site outline was performed on anterior and posterior horns with radio opaque 1.6 mm steal balls. Anteroposterior and lateral radiographs were performed. On these radiographs, different landmarks of the tibial head were defined and their distances measured (width, depth, distance from lateral tibia border to meniscus midpoint, distance from lateral tibia border to lateral tibial spine). These measures were statistically evaluated and percent values for meniscus insertion midpoint position were determined.

Results: On anteroposterior radiographs, from lateral to medial, the anterior meniscus midpoint was located on 45.1 % ± 1.3 % of the tibial width, the posterior meniscus midpoint on 49.8 % ± 1.9 % of the tibial width. On lateral radiographs, from anterior to posterior, the anterior meniscus midpoint was located on 41.9 % ± 3.2 % of the tibial depth, the posterior meniscus midpoint on 72.1 % ± 2.3 % of the tibial depth. With linear regression analysis, we could show that the lateral meniscus insertions have constant relations, as well to the dimensions of the tibia plateau as to the lateral tibial spine.

Conclusions: We think that it is possible to determine precisely and reproducibly on preoperative anteroposterior and lateral radiographs the insertions of the lateral meniscus. Our results and the method to determine preoperatively meniscus insertions might bring decisive advantages considering the optimal fixation of meniscus transplants, enhancing biomechanical conditions and possibly improving postoperative results.


G. von Lewinski T. Pressel C. Hurschler F. Witte

Introduction: The goal of meniscal transplantation is to prevent progressive joint degeneration that predictably follows meniscectomy. The meniscal transplant’s ability to transfer load effectively depends on its ability to bear circumferential loading. Purpose of this study was thus to investigate the influence of intraoperative pre-tensioning on the chondroprotective of meniscal transplants in a sheep model.

Methods: Thirty-six sheep were divided into 6 groups (n = 6), subjected to a sham operation (group A), a meniscectomy (group B), or a meniscal autograft using tag sutures with different levels of pre-tensioning (group C, 0 N; group D, 20 N; group E, 40 N; group F, 60 N). Macroscopic (International Cartilage Repair Society score) and histological evaluation (Mankin score) of the articular cartilage was performed after 6 months.

Results: Higher suture pretension (40 N, 60 N) resulted in less cartilage degeneration than in meniscectomized (P =.047; P =.036) and non-pre-tensioned (P =.028; P =.015) knees, with International Cartilage Repair Society scores of 1.63 +/− 0.57 and 1.66 +/− 0.51 in groups E and F, respectively, and scores of 2.40 +/− 0.27 and 2.68 +/− 0.46 observed after meniscectomy and meniscal transplantation with no pre-tensioning, respectively. Group F had a significantly better Mankin score of 6.66 +/− 2.15 (P =.05) compared with group D. Regarding criterion cells, trends toward less degeneration compared with meniscectomized and non-pretensioned knees (P =.054 and P =.055) were found. The coefficient of variation of the Mankin scores was greater than that of the International Cartilage Repair Society score. Group A had significantly better cartilage than all other groups.

Conclusion: Adequate intraoperative pre-tensioning has an influence on the chondroprotective effect of meniscal transplants but did not prevent the development of articular cartilage degeneration.

Clinical Relevance: The results suggest that intraoperative pre-tensioning could improve the chondroprotective effect of meniscal transplantation.


W.G. Rodkey K.K. Briggs J.R. Steadman

INTRODUCTION: Loss of meniscus tissue leads to decreased clinical function and activity levels. However, no report has quantified the amount of meniscus tissue removed at meniscectomy and correlated meniscus tissue loss with clinical symptoms, function, and activity. We determined, prospectively, the amount of tissue loss at time of partial medial meniscectomy and then correlate extent of meniscus loss with clinical symptoms, function, and activity levels 2 years following the index meniscectomy.

METHODS: In a randomized controlled investigational device clinical trial (Level of Evidence I), 149 patients 18 to 60 years old underwent partial medial meniscectomy and served as controls. There were 81 acute (no prior meniscus surgery) and 68 chronic (1 to 3 prior partial meniscectomies on the involved meniscus) patients. At index surgery, size of the meniscus defect was measured using specially designed instruments, and percent of meniscus loss was calculated based on actual measurements. Patients were followed clinically for a minimum of 2 years after meniscectomy. At each follow-up, every patient completed questionnaires including Lysholm and Tegner scores to assess function and activity. Amount of meniscus tissue at index surgery was correlated with the individual domains of the Lysholm scale. Tegner index was calculated to determine the amount of lost activity regained 2 years after surgical intervention.

RESULTS: Two-year data were available for 127 patients (85% follow-up). There was a significant correlation between the amount of meniscus tissue remaining following the index meniscectomy and 2-year Lysholm domains of squatting (r=0.281, p=0.001), stair-climbing (r=0.251, p=0.004), and swelling (r=0.261, p=0.003). In particular, it is noteworthy that patients who had > 50% of their meniscus remaining had significantly better function than patients who had < 50% meniscus remaining. Patients who had worse or no improvement in pain symptoms at 2 years averaged 42% meniscus remaining, while patients who had improved pain scores had on average 51% meniscus remaining. Tegner index for patients with < 50% meniscus remaining averaged 24%, and for patients with > 50% meniscus remaining averaged 52% (p=0.017); hence, a greater amount of meniscus tissue remaining allowed patients to regain significantly more of their lost activity.

CONCLUSIONS: There is a significant correlation between the amount of meniscus tissue removed at men-iscectomy and clinical symptoms, function, and activity 2 years after surgery. This study confirms the importance of preserving as much meniscus tissue as possible at the time of meniscus repair or meniscectomy as well as the potential positive benefits of regrowing or replacing lost meniscus tissue in order to minimize clinical symptoms that may be suggestive of early degenerative changes.


S. Karthikeyan H. Kwong P. Upadhyay S. Drew S. Turner M. Costa D. Griffin

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.

The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.

The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.

Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.

58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)

In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.


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C. Chiari E. Kon U. Koller M. Delcogliano D. Salter L. Ambrosio R. Plasenzotti M. Marcacci S. Nehrer

Objective: Meniscus regeneration is limited, moreover, loss of meniscal tissue leads to osteoarthritis. A new biomaterial, consisting of hyaluronic acid and polycaprolactone was applied as a meniscus substitute device in a study in sheep.

Methods: 24 sheep received a total medial meniscal replacement. Group SCF (n=12) was treated with a cell free scaffold, Group SCS (n=12) with a scaffold seeded with autologous chondrocytes harvested from the contralateral joints, which served as sham controls (n=12). Further 12 non-operated and 2 menisectomy controls were included in the study.

The animals were sacrificed after 4 months. The implants and joint surfaces were evaluated on a macroscopic (Implant Gross Assessment Score; Gross Assessment of Joints Score) and histological level.

Results: There was no significant difference of the Implant Gross Assessment score between the SCF and SCS groups. All implants showed excellent capsular ingrowth at the periphery. Dislocation, extrusion and tears occurred in part of the specimen due to biomechanical problems caused by soft tissue quality. The mean Gross Assessment of Joint Changes Score of the groups SCF and SCS was not statistically different. Cartilage damage was significantly more severe in joints with implants than in non-operated joints and sham controls, but less pronounced than in menisectomy controls. Histological evaluation showed residual scaffold with an associated foreign body response in all implants. Fibrous tissue was present in all implants, in contrast small foci of cartilaginous differentiation were more common in the cell-seeded constructs.

Discussion: At 4 months regenerative meniscal tissue was present but immature. The present study showed that strong biomechanical scaffold properties are a required to allow guided tissue regeneration and maturation under loading conditions. Cell seeding of the scaffold encourages cartilaginous differentiation. Modification of the scaffold and the cell-seeding technique will be investigated in further studies.


N. Aslam J. Cameron

BACKGROUND: The purpose of this study was to evaluate the long term results of meniscal transplantation in a consecutive series of younger patients treated for pain in the tibiofemoral compartment following a previous meniscectomy.

METHODS: One hundred and thirty eight (138) menisci were implanted into one hundred and thirty-five (135) patients over a sixteen year period.

Seventy five (75) knees also had an associated osteotomy, and eleven (11) had a ligament reconstruction. The clinical outcome using pain and functional knee scores and failure rate of all transplants was evaluated at a mean 10.2 years (2–16 years) postoperatively.

RESULTS: One hundred and twenty (120) patients with one hundred and twenty three (123) meniscal grafts were available for final follow up. Fifteen (15) patients were lost to follow up. Seventy five percent (75%) of patients had an improvement in pain knee score and seventy one percent (71 %) of patients had an improvement in functional knee score.

Twenty patients (16.6%) underwent a total knee replacement at a mean interval of 9.3 years after the meniscal transplant.

Patients with isolated meniscal transplantation had the most improved clinical outcome.

Patients with concomitant knee osteotomy and knee ligament reconstruction procedures also had improved knee function without an increase the rate of complications.

CONCLUSIONS: The long-term results of meniscal transplantation are encouraging in terms of reducing knee pain and increasing function at a mean follow up of 10.2 years. Patients with isolated meniscal transplantation have improved outcomes.


M.A. Zumstein D.C. Meyer E. Frey B. von Rechenberg H. Hoppeler B. Jost C. Gerber

INTRODUCTION: Chronic experimental rotator cuff tears are associated with muscle retraction, atrophy, fatty infiltration, a pronounced change in the pennation angle of the muscle and consequent shortening of muscle fibres. It was the purpose of this investigation to study whether slow, continuous elongation of the musculotendinous unit can revert the pennation angle and elongate the shortened muscle fibres.

MATERIAL AND METHODS: The infraspinatus tendons of twelve sheep were released. After retraction of the tenotomised musculotendinous unit, the infra-spinatus was elongated one mm per day using a new elongation-apparatus. After restoring the approximate original length, the tendon was repaired back. Muscular architecture (retraction and pennation angle), fatty infiltration (in Hounsfield units=HU) and muscular cross sectional area (in % of the mean control side) were analyzed at start, at the time before elongation, at the time of repair and six and eighteen weeks thereafter.

RESULTS: In four sheep the elongation failed technically. In the other eight sheep, elongation could be achieved as planned. After retraction of 29mm ± 6 mm after 16 weeks (14% of original length, p=0.008), the mean traction time was 24 days ± 6 days with a mean traction distance of 19 mm ± 4 mm. At sacrifice the mean pennation angle increased in the failed sheep from 30° ± 6° up to 55° ± 14° (p=0.035). In those sheep in which traction was applied, the mean pennation angle was not different to the control side (29.8° ± 7.5° vs. 30° ± 6°, p=0.575). Compared to preoperative, there was a significant increase in fatty infiltration (36 HU, p=0.0001) and decrease of the muscular cross sectional area of 43 % (range 21% to 67%, p=0.0001) at 4 months. In the sheep in which traction could be achieved, fatty infiltration remain unchanged (36 HU ± 6 HU vs 38 HU ± 4 HU, p=0.438) and atrophy decreased by 22% (range 10% to 33%) after 6 weeks of continuous traction (p=0.008).

CONCLUSION: Continuous experimental elongation of a retracted musculotendinous unit is technically feasible and might lead to recovery of the muscle architecture, partial reversibility of atrophy and, arrest of progression of fatty infiltration.


M.V. Wlk A. Abdelkafy S. Kotsaris F. Landsiedl

Background: Recent studies of arthroscopic rotator cuff repairs have shown high failure. The different suture configurations were mostly tested in non degenerative animal tendon specimen. We used instead fresh-frozen degenerative human cadaver rotator cuffs. The goal of this study was to determine the biomechanical properties of commonly used arthroscopic stitches in ruptured human cuffs in comparison to intact rotator cuffs.

Method: 36 human rotator cuff tendons were harvested, documented according to size, thickness and location of rupture, and divided into a ruptured and non ruptured specimen group. We found 12 ruptured and 24 intact cuffs. Three stitch configurations (simple, horizontal, and massive cuff stitch) with a Fiber Wire 2 (Arthrex) were randomized and biomechanically tested in each set of tendon specimen. The specimen were mounted on a uniaxial load machine (ZM200, Fa Shokoohi) and loaded to failure under displacement control at a rate of 0.6 mm/sec. Ultimate tensile load, and type of failure were recorded.

Results: Ultimate tensile load was significantly higher (p < 0.05) for the massive cuff stitch (186 ± 12 N) than it was for either the simple stitch (102 ± 9 N) or the horizontal stitch (138 ± 10 N) in the intact cuff cohort. In the ruptured cuff group ultimate tensile load was significantly lower (p < 0.05) for the massive cuff stitch (115 ± 12 N), the simple stitch (77 ± 9 N), and the horizontal stitch (103 ± 10 N) in comparison to the intact cuff group. The simple and horizontal stitches failed by tissue pull-out in both groups, whereas the massive cuff failed by pull-out and once by suture breakage in the group of intact cuffs.

Conclusion: Ruptured rotator cuffs showed significant less biomechanical strength concerning all three stitches in comparison to the intact cuff group. Overall the massive cuff stitch showed superior ultimate tensile load.


P.E. Müller M.F. Pietschmann V. Froehlich A. Ficklscherer V. Jansson

Aim: The aim of the study was to investigate the influence of bone density of the greater tuberosity on mechanical strength of different bone anchors for rotator cuff surgery. Especially in osteopenic bone the metal bone anchors and transosseus sutures are still the “gold-standard” in rotator cuff surgery.

Material and Methods: Four bone anchors, each standing for a specific group of bone anchor, and two suture materials were tested. One of them was the metallic Super Revo screw 5.0 (Linvatec), the absorbable screw Spiralok 5.0 (Mitek), the absorbable press-fit anchor Bioknotless RC (Mitek) and the absorbable Ultrasorb RC (Linvatec). The suture materials tested was the well known V-37 (Ethicon) and the new Orthocord (Mitek) both USP 2. All fixations systems were tested on a) 6 pairs of fresh-frozen human shoulders from young adults (range 20–50 yrs.) and b) 6 pairs of fresh frozen human shoulders from elderly (range 60–93 yrs.). Cyclic loading was performed, as it was considered the best way to simulate the postoperative conditions in a manner similar to those used in prior studies until the system failed. The maximum tensile strength, the failure mode, and the displacement of the fixation device (system displacement) under load at the first cycle at 75 N and at the maximum tensile strength were recorded.

Results: The absorbable Spiralok 5 mm screw anchor showed the highest failure load with a mean of 171 N in osteopenic bone. The suture material Orthocord and V-37 had the lowest mechanical strength in osteopenic bone with a mean of 125 N resp. 114 N. The remaining anchors had an almost identical failure load with means of 150 N (Super Revo 5 mm and Bioknotless RC) and 151 N (Ultrasorb RC). No statistical significance was found though. Comparing the mechanical strength of each fixation system in healthy and osteopenic bone no statistical significant difference was found except for the V-37 suture. In healthy bone the failure load of V-37 suture had a mean of 204 N and in osteopenic bone of 114 N.

Discussion: The absorbable Spiralok 5 mm screw showed a good performance in healthy and osteopenic bone when compared with standard bone anchor like the titan Super Revo 5 mm screw or transosseous sutures. Absorbable anchors have certain advantages, besides that usually they are more expensive. They can easily be overdrilled in case of rupture of the suture material, and they do not interfere during later revision surgery or for imaging studies such as magnetic resonance imaging.


S. Jarvela T. Jarvela H. Aho I. Kiviranta

Introduction: Shoulder pain, caused by subacromial impingement or rotator cuff tear, is common for the middle-aged and elderly people. It can cause diminished ability to work and prolonged sick-leaves. The purpose of this study was to evaluate the effect of the operative treatment of this pain (arthroscopic subacromial decompression, rotator cuff repair) when the patients returned home the same day (outpatient) from the day-surgery unit or stayed 1–3 nights at the ward (hospitalized).

Methods: Ninety-three patients were included in this prospective, comparative study. The inclusion criteria were:

1) shoulder pain more than 6 months with no response for conservative treatment,

2) no previous shoulder surgery of the same shoulder or surgery of the contralateral shoulder,

3) clinically and radiologically diagnosed subacromial impingement or rotator cuff tear.

The minimum of the follow-up was 2 years (range 24 to 32 months), and 76 patients (82%) participated to the evaluation at this point. In the outpatient group were 37 patients (24 subacromial impingements, 13 rotator cuff tears), and in the hospitalized group 39 patients (23 subacromial impingements, 16 rotator cuff tears). Evaluation methods were clinical examination, radiographic evaluation, isometric elevation strength measurements, as well as the University of California Los Angeles (UCLA) and Constant shoulder scores. All operations were done by one experienced orthopaedic surgeon, and all evaluations at the follow-up by one independent examiner.

Results: At the follow-up, both shoulder scores (UCLA, Constant) were significantly better than the preoperative scores in every patient group (p< 0.001). In the patients with subacromial impingement, muscle strengths of the operated shoulders improved to the level of non-operated, contralateral shoulders, while in the patients with rotator cuff tear, the strength was still diminished (the mean difference in elevation strengths when comparing to the contralateral side was 1.8 kg). However, no significant differences in the shoulder scores or muscle strengths were found when the outpatient group and hospitalized group were compared.

Conclusions: Operative treatment of subacromial impingement and rotator cuff tear after failed conservative treatment led to good results at 2-year follow-up. The patients in the outpatient-group had similar results than the patients in the hospitalized patient-group. However, because the hospitalization is more expensive, the outpatient surgery is recommended.


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A. IOSSIFIDIS Z. SHAH I. GILL

The aim of this prospective study was to report the mid-term results of arthroscopic repair of full thickness rotator cuff tears.

One hundred and four shoulders in 102 consecutive patients were operated within a two-year period. There were 52 female and 50 male patients with a mean age of 64 years (range 41 to 79). Standard arthroscopic techniques of cuff repair were used, under regional inter-scalene block and balanced anaesthesia. The mean size of the cuff tear was 3 cm (range 1 to 6 cm). Patients were discharged within 24 hours and followed a specific rehabilitation protocol. An assessment was performed pre-operatively and at a mean follow-up of 7 months (range 3 to 24 months). Outcome measures included pain, activities of daily living, shoulder power and function and level of patient satisfaction.

Satisfactory pain relief was achieved in 98 patients (94%) with significant pain relief in 87 patients (83.6 %) and good in 12 patients (11.5 %). Ninety -six patients (92.3%) reported a satisfactory improvement in activities of daily living, with significant improvement in 89 (85.6%) and good in 7 (6.7%). Shoulder power was markedly improved in 95 patients (93%). High levels of patient satisfaction were noted in 93 patients. Seven patients were moderately satisfied and two patients were not satisfied.

The mean shoulder score improved from 29 pre-op to 82 post-op, and the shoulder function score from 32 pre-op to 84 post–op. Similar results were found when the subgroup of 65 patients over the age of sixty was compared to the group of 37 patients under the age of sixty. No difference in outcome was also noted in relation to the size of the tear, length of follow –up or sex of the patient.

We believe that this study has shown that the arthroscopic repair of the rotator cuff can consistently achieve a satisfactory outcome. It may therefore be considered as an alternative to the traditional open techniques.


P. MASSIN J. HEIZMANN S. PROVE A. PONTHIEUX

Introduction. Using conventional tests, manual computer-assisted methods offer a satisfactory reproducibility and accuracy in wear evaluation in knee arthroplasty. However, repeatability may be underestimated. Various calibration methods were proposed but not tested. Accuracy may decrease with fluoroscopic images.

Method. We recalculated intra- and interobserver variability based on 132 fluoroscopic images of 3 unimplanted specimens, using specific analyses like the Brand and Altman test or the repeatability coefficient. Calibration was tested in comparison to a reference method (based on a circular shape of known diameter). The influence of a radiological marker embedded into the central part of the polyethylene to control the incidence of fluoroscopic guided images was tested. Accuracy was compared between fluoroscopic and digitized plain radiographs.

Results. The coefficient of repeatability indicated a variation of 0.4 mm in repeated measurements by the same observer. Although a high interobserver reproducibility (r=0.99), the Brand-Altman test showed inconsistent values in about 30% of cases with both observers. The method of calibration influenced the results significantly. Under ideal conditions of radiographic incidence, the accuracy was better with a digitized x-ray (0.10 mm) than with fluoroscopic images (0.25 mm), and compared favourably with fully automatized methods. If small variations of radiographic incidence occured, the accuracy droped to 1 mm. A comparison of successive radiographs of the same implant showed that 1° tilting induced an average reduction of 0.36 mm in the apparent thickness of the polyethylene.

Discussion. When comparing wear measurements in TKA using manual, computer-assisted methods, examination by a single observer should be preferred. The difference between the measurements of the thickness of the polyethylene insert on two images taken with exactly the same incidence should be considered significant if it is greater than twice the precision of the method, i.e. greater than 0.20 mm on digitized X-ray images, or greater than 0.50 mm on fluoroscopic images. In the absence of a strict control of the radiographic incidence, it appears that the difference between the measurements of the thickness of the polyethylene on two images should be considered significant only if it is greater than 2 mm. Given the estimated wear rate of conventional TKR, 10 years of use of the prosthesis would be needed before such systems can detect wear with certainty.

Conclusion. A metallic marker of known dimension embedded in the central part of the polyethylene insert appears mandatory to control calibration as well as the angle of incidence of fluoroscopically guided radiographs. This would improve the performance of radiographic measurements enough to offer clinical relevance.


P. Ciampi C. Scotti M. Vitali G. Fraschini

The aim of the study is to evaluate the results obtained in patients older than 70 years who were treated with open surgical repair for massive ruptures of the rotator cuff and the functional outcome.

This is a retrospective analysis of a consecutive series of 280 patients who underwent open repair of a massive rotator cuff tear between 1999 and 2003. The inclusion criteria were: age 65 or over, symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size > = 5 cm, minimum follow-up of 2 y since surgery. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views) and nmr of the shoulder. Patients were assessed with the Costant score, Simple Shoulder test, UCLA score before and after surgery. Pain was assessed by use of a visual analog scale. The mean age of patients was 75b years (range 65–91). There were 41 men and 28 women. The mean duration of symptoms before repair was 18 months (range 1–58). The dominant arm was affected in 54 patients (78%). The change in UCLA scores, SST, Costant score and their subcomponents were analyzed with the paired Student’s test, assuming a normal distribution of the total score. In an exploratory analysis trying to identify preoperative variables that could be associated with a good surgical outcome, a multivariate logistic regression analysis was performed including the following variables: age equal or more than 80 years, sex history, shoulder different affected, UCLA score, SST, costant score and use of formal physical therapy. Satisfactory results were achieved in 250 patients: the mean preoperative UCLA score was 9.3, Costant score 45, and the mean score after surgery was 16.9 and 65 rispectively. The mean preoperative function score was 2.4, after surgery was 8.1. The UCLA preoperative score for active forward flexion averaged 1.3 (30°–90°), and postoperative rating increased to 4.5 points (p=0,0001)corresponding to an active forward flexion between 120° and 150°.


B. Jost A. von Roll C.W. Pfirrmann C. Gerber

Background: It is commonly believed that rotator cuff tears do progress in size over time. Recent reports suggest that tear progression may not be necessarily true. It was the purpose of this study to review non-operatively treated isolated supraspinatus tears especially in terms of tear size progression.

Methods: Inclusion criteria were non-operatively treated isolated full-thickness tears of the supraspinatus, MRI at time of diagnosis available, and patients willing to undergo an additional MRI after more than 2 years after diagnosis. Twenty-four patients (20 men, 4 women) with an average at time diagnosis of 51 years identified and reviewed with MRI and clinically based on the Constant score.

Results: The average follow-up was 46 (27–87) months. The Constant score (not available at time of diagnosis) at follow-up averaged 75 points (relative Constant score 86%). Overall the average tear size did not change significantly over time (366mm2 at follow-up versus 393mm2 at time of diagnosis, p > 0.05). In 2 patients the tear was not detectable any longer on MRI suggesting that it was healed, in 7 patients the tear was smaller, in 10 patients it did not change over time and only in 5 patients it progressed.

Discussion and Conclusion: Non-operatively treated isolated supraspinatus tears were unchanged, smaller or even healed in 79% of the patients after a follow-up period of more than 4 years. This suggests that supra-spinatus tears do not necessarily progress over time and even have a potential to heal.


A. Sukthankar C.M. Werner P. Brucker R.W. Nyffeler C. Gerber

INTRODUCTION: Full thickness rotator cuff tears have been associated with changes of the anterior acromion. In a previous study we also documented differences in lateral extension of the acromion in rotator cuff tears compared with shoulders with intact cuffs. It was the purpose of this study to verify in a prospective examination, whether presence or absence of rotator cuff tearing in a precisely defined population is quantitatively related to the degree of lateral extension of the acromion.

MATERIAL AND METHODS: 59 consecutive patients between 60 and 70 years and hospitalized for reasons other than shoulder pathologies were entered into a prospective study. All 110 shoulders without previous operations, major trauma or rheumatoid arthritis were examined radiographically and with ultrasonography by two independent examiners.

RESULTS: 67 cuffs were intact, 28 showed a cuff tendinopathy, 17 a full thickness tearing. The acromion index for shoulder with rotator cuff tear was 0.75, for tendinopathy 0.68 and for normal cuffs 0.65. The differences between rotator cuff tears and the other two groups was significant (p< 0.05). The acromion index was not related to gender or osteoarthritis. An acromion index of < 0.77 had a positive predictive value of > 70%. An acromion index of < 0.7 predicted an absence of rotator cuff tearing with an accuracy of 97%. Interobserver agreement of the assessment was excellent with 88%.

CONCLUSION: The relationship between rotator cuff tears and a large extension of the acromion can be used to predict the presence of rotator cuff tears in shoulders between ages 60 and 70. A cause-effect relation is probable and will be studied further.


G. Matziolis D. Krocker S. Tohtz C. Perka

While significant component malalignment in the frontal and sagittal plane may lead to early loosening and pain, even small errors in the rotational component alignment are not tolerated due to its complex impact on knee joint kinematics and especially the patella tracking. It is accepted that navigated implantation of total knee arthroplasties improves accuracy in the frontal plane but it is yet unclear weather navigation leads to a more precise rotational component alignment. The study evaluated the influence of navigated implantation on femoral and tibial component alignment.

In a prospective randomized study 32 navigated and 28 conventionally implanted total knee arthroplasties were evaluated through a postoperative CT scan. In all cases the femoral component was referenced to the surgical epicondylar axis and the tibial component was referenced to the medial third of the tibial tuberosity. The angles between these bone landmarks and the components were measured on the CT scans and compared between both study groups.

The rotational malalignment of the femoral component in the conventional operating technique was 0.1° ± 2.2° (range 3.3° of internal rotation and 5.0° of external rotation). Navigated implanted femoral components showed a malalignment of 0.3° ± 1.4° (range 4.7° of internal rotation and 2.2° of external rotation), the difference was not significant. The rotational malalignment of the tibial component in the conventional technique was 7.5° ± 6.0° (range 27.1° of internal rotation and 15° of external rotation). Navigated implanted tibial components showed a malalignment of 6.9° ± 4.7° (range 21.2° internal rotation and 11.0° external rotation), the difference was not significant.

In conclusion the use of a navigation system did not improve the rotational alignment of the tibial or femoral component if only one bone landmark was used. Taking the relatively small errors of a navigation machine into account the error is attributable to the surgeon, who seems to be unable to precisely define bone landmarks. More than one landmark (e.g. additionally Whiteside’s line, posterior condyles, flexion gap for the femur and ankle joint for the tibia) should be used to define the component rotations. Consideration of different rotational landmarks is best done with a navigation system that, in contrast to the manual technique, has the possibility to show the degree of deviation of the components from each landmark.


F. Catani A. Ensini A. Leardini L. Bianchi S. Giannini

Navigation-assisted surgery in total knee arthroplasty (TKA) is aimed at improving the accuracy with which prosthesis components are implanted in the bones, according to anatomical plane orientations. Traditional surgical techniques based on the identification of transepicondylar and intramedullary axes are replaced with those based on segmental anatomical frame definitions following anatomical landmark identification. These frames are offered on the screen to the surgeon to target in real time the alignment goal by adjusting position and orientation of the bone saw guides. However, immediately after sawing, final bone, and in case cement, preparation and component implantation is necessarily a series of actions performed manually by the surgeon. In the current study, we wanted to compare intra-operatively the final component alignments with the corresponding at the original resection planes.

In this series, 50 Scorpio PS TKAs were analyzed. The navigation system used was the Stryker Knee Navigation System (Stryker-Navigation, Kalamazoo, USA). An ‘anatomical survey’ defined anatomical frames for the femur and tibia, based on relevant anatomical landmark identification, and provided target orientations for all the relevant bone cuts. These references were targeted in all three anatomical planes, and bone cuts were made accordingly. Corresponding alignments of the bone resection planes in the frontal, sagittal and transverse planes for the femur and in the frontal and sagittal planes for the tibia were recorded, with a 0.5° resolution. Then, component implantation was performed and alignments were measured again by means of an instrumented probe. Because of the shape of the prosthesis components, only the alignments in the frontal plane for the femur and in the frontal and sagittal planes for the tibia were recorded.

The difference between the alignment of the bone cuts and the alignment of the prosthesis components, in the frontal plane of the femur, and in the frontal and sagittal planes of the tibia was larger than 2° respectively in 8%, 6%, 10% of the patients.

The present study offers a figure for the different alignment between resection planes and final implanted components, necessarily the effect of the manual procedures implied in TKA for the final implantation of the components. Considering that 1° is the claimed achievable accuracy of the navigation systems, and that the correct alignment goal was achieved at the resection planes, these figures reveal that in up to 10% of the patients the benefit obtained by navigation can be lost by the manual procedures implied in component implantation. These differences in alignment put also concerns in the postoperative statistical comparison between conventional and navigated TKAs.


F. Lampe K. Bohlen S. Dries E. Hille

Introduction: There is an ongoing discussion about potential risks and benefits of minimally invasive approaches (MIS) in total joint replacement. The aim of this study was to evaluate, whether a higher incidence of malalignments could be observed after minimally invasive navigated TKA and wether the results in the early postoperative period were better compared to standard approaches.

Methods: A total of 50 patients were treated with a navigated (OrthoPilot 4.2) Columbus knee prosthesis (BBraun Aesculap, Germany). In 25 patients either a standard or a minimally invasive (mini-mid-vastus) approach was carried out. In both groups the same exclusion criteria for MIS were adopted. Initially during surgery (Nav1a) and finally after implantation of the original components (Nav1b) the mechanical leg axis, passive range of motion and stability were measured by navigation according to the common workflow of the system. After restarting the software the same parameters were evaluated once more in a second procedure (Nav2) by reacquisition of joint centers both kinematically and by anatomical landmark palpation with the original prosthesis already implanted. Nav2 was conducted independantly from the initial surgical procedure. To validate the intraoperative measurements additional pre- and postoperative long-leg-standing radiographs were made. During the the first 10 days postoperatively daily range of motion (ROM) and pain (VAS) were measured. Perioperative blood loss and complications were documented. Results were analyzed by student’s t-test.

Results: Both groups were comparable with regard to preoperative demografic, radiologic and intraoperative data (Nav1a). There were no significant differences between the groups concerning intraoperative measurements of mechanical leg axis, passive range of motion and stability by Nav1b and Nav2. Additionally no differences were found for the alignment in the postoperative radiographs. The length of the skin incisions were significantly shorter in the minimally invasive group. Postoperative ROM was significantly higher and pain was significantly less intensive in the MIS group. Blood loss and complication rates were comparable.

Discussion: If the exclusion criteria for MIS were accepted no differences regarding the quality of alignment, passive range of motion and ligament stability could be demonstrated between conventional and MIS navigated TKA. Patients with MIS navigated TKA performed superior in terms of early p.o. function and pain. From the authors point of view the technically demanding minimally invasive implantation of knee prostheses should be exclusively performed with support of navigation.


A. Martin M.B. Sheinkop M. Prenn D. Moosmann A. von Strempel

Introduction: Optimal component position in all planes and well balanced soft tissues lead to a good clinical outcome and long-term survival after total knee arthroplasty. We investigated the implantation accuracy of navigated total knee arthroplasty at 3 months followup and the influence on the clinical outcome at 2 years followup.

Patients and Methods: Forty-four patients (44 procedures) were enrolled in our prospective study. One half of the surgeries were performed using a computed tomography based navigation system, and one half of the surgeries were performed without computed tomography navigation. Outcomes were based on the Insall knee score parameters, anterior knee pain, patient satisfaction, feeling of instability, and step test. The radiographic parameters were the mechanical axis, tibial slope, lateral distal femoral angle, and medial proximal tibial angle.

Results: The radiographic measurements showed no differences between both groups (patients within ± 3° inaccuracy range in computed tomography based/computed tomography free groups; mechanical axis 86%/81%, tibial slope 95%/91%, lateral distal femoral angle 95%/91%, medial proximal tibial angle 91%/95%). The cumulative error of alignment showed no difference between the study groups. Seventeen of 21 (81%) patients fulfilled four criteria in the CT based group, and 15 of 21 (71.4%) patients fulfilled four criteria in the comparison group. Nineteen of 21 (90.5%) patients in both groups achieved three criteria in an optimal manner. An increased (p < 0.001) Insall knee score was found for changes over time in both study groups; however, there were no differences between the CT based or CT free patient groups. The postoperative ROM in both groups showed no difference at the 3-month and 2-year followup examinations. Both groups had an increase (p ≤ 0.002) in ROM between the 3-month and 2-year followup examinations. The examination of ligament balancing in full extension showed a higher rate of a stable soft tissue situation in the CT free navigation group but the difference was not significant. In 30° of flexion we detected a better (p = 0.004) ligament situation medially and laterally in the CT free group. The anterior drawer test showed a better (p = 0.035) stability in the CT free navigation group.

Discussion: The computed tomography free system provided equal radiographic results, but we found improved ligament balancing in the computed tomography free group. The computed tomography based module has an optimal preoperative planning procedure, but is more expensive and time consuming.


J. CLARKE J. DILLON A. MENNESSIER L. HERIN F. PICARD

Introduction: Computer navigation systems allow real time evaluation of knee behaviour intraoperatively. Measurements made by navigation reflect soft tissue balance throughout surgery. We studied three different populations of patients undergoing total knee replacement (TKR) with a CT-free navigation system where the goal was to achieve normal alignment. We compared the initial pathological kinematics in each group with the resultant kinematics after correction.

Method: The Orthopilot® was used during TKR for three groups of patients A (n=71), B(n=60) and C(n=43) all with endstage osteoarthritis. Patients in groups A and B had TKR performed by surgeon 1, and group C by surgeon 2.

Results: Pre-operatively, the mean mechanical femoral axis and the mean mechanical femoro-tibial (MFT) angle were calculated. The mean mechanical femoral axis for group A was −0.5° varus (−6° to 9°), group B was −0.68° varus(−6° to 6°), and for group C was 2.67° valgus (−12° to 10°). P< 0.0001, using Kruskal-Wallis test. Pre-operatively, the mean MFT angle for group A was −3.75° varus(−15° to 17°), group B was −2.98° varus(−17° to 13°), and for group C was 0.16° valgus(−17° to 25°). P=0.003 using Kruskal-Wallis test. These results show that the initial preoperative kinematics are different for the three different populations.

Post-operatively we measured the mean MFT angle in groups A, B and C. In group A, the mean MFT angle was −0.38° varus (−4° to 2°), group B was −0.41° varus(−5° to 2°), and group C was −0.02° varus(−3° to 5°). P=0.7 using the Kruskal-Wallis test. These results show that the post-operative kinematics are similar between the three different populations.

Discussion: Populations A and B preoperatively exhibited a mean varus MFT angle (−0.5° and −0.68° respectively), compared with a mean valgus MFT angle for group C(2.67°), which were statistically significantly different. Although different surgeons operated on the 3 groups (surgeon 1 operated on groups A and B, and surgeon 2 operated on group C), post-operative kinematics were within a narrow range (−0.02° to −0.41°) and not statistically different (p=0.7).

Conclusion: The Orthopilot® results showed that these populations had different initial pathological kinematics. Despite this, and using different operators we obtained similar post-op results within a narrow range. Computer navigation produces reliable, reproducible results independent of population or operator variables.


N.N. Biasca T. schneider F. catani

Introduction: Computer navigation in total knee arthroplasty (TKA) may assist the surgeon with precise information about ligament tension and varus/valgus alignment throughout the complete range of motion, but there is only little information about how much ligament laxity is needed and how much laxity is too much. In the current study we measured the mechanical axis and opening of the joint at different time points, in different degrees of knee flexion and with varus and valgus stress during the procedure of computer navigated TKA.

Methods: Forty-nine consecutive patients underwent a MIS computer navigated TKA. With the Stryker Knee Navigation System varus/valgus alignment and distraction/compression was measured in 0°, 45° and 90° of knee flexion immediate after digitalization of the knee and after fascial closure. Values were noted in a neutral position and with maximal varus and maximal valgus stress applied. Patients with posterior stabilized implants were compared to those with cruciate retaining implants. Patients with preoperative varus malalignment or valgus malalignment were compared to patients with straight preoperative mechanical axes.

Results: At the beginning of the operative procedure the mean mechanical alignment was 1.9° varus at 0° knee flexion, 1.5° varus at 45° knee flexion and 1.5° varus at 90° knee flexion. Patients showed a mean mediolateral joint opening of 6.1° at 0° knee flexion, 5.9° at 45° knee flexion and 4.5° at 90° knee flexion. After implantation of the knee prosthesis and fascial closure mechanical alignment was 0.3° varus at 0° knee flexion, 0° varus at 45° knee flexion and 0.2° varus at 90° knee flexion. Mean joint laxity was 3.4° at 0° knee flexion, 3.1° at 45° knee flexion and 2.3° at 90° knee flexion. There was more lateral than medial joint opening postoperatively in 45° and 90° knee flexion regardless of the prosthesis type implanted. Preoperative varus and valgus malalignment could be reduced to values identical with those patients with straight preoperative mechanical axes.

Discussion: Mean varus/valgus laxity after implantation of a MIS computer navigated TKA was lower than prior to prosthesis implantation. Varus/valgus laxity of an approximate total range of 1.5°–2° can be achieved at all measured degrees of knee flexion and seems to be the ideal laxity for TKA. Computer navigation in TKA can consistently reduce preoperative varus/valgus malalignment to a level comparable to patients with preoperatively normal mechanical axes. More lateral joint opening is found before as well as after implantation of the prosthesis in 45° and 90° of knee flexion. The type of prosthesis implanted seems not to effect postoperative joint laxity.


N.N. Biasca T. Schneider F. Catani

Introduction: One of the four pillars of successful total knee arthroplasty (TKA) is restoration of the joint line. In conventional TKA the surgeon does not have a tool to control the accuracy of joint line restoration intraoperatively. The present study investigates if the preoperative joint line can be restored using an optical navigation system for TKA.

Materials and methods: Patients from two Orthopedic Centers (Istituto Orthopedico Rizzoli Bologna, 51 patients; Orthopädie Samedan, 42 patients) received computer assisted TKA (Stryker Scorpio) using the Stryker Knee navigation system. Using the software delivered with the navigation system depth of femoral and tibial medial and lateral osteotomies were recorded. After definite prosthesis implantation medial and lateral femoral condyle height as well as tibial length including polyethylene inlay were also recorded. Varus/valgus alignment was additionally recorded before and after prosthesis implantation.

Results: After femoral osteotomie varus/valgus alignment was 0 degrees (Stdv. 0.6 degrees). Lateral and medial osteotomies were performed with a depth of 8.2 and 8.8 mm respectively. Tibial osteotomie was performed with 0 degrees of varus/valgus (stdv. 0.7 degrees). Lateral and medial tibial osteotomies were performed with a depth of 7.5 and 4.8 mm respectively. After definite prosthesis implantation femoral and tibial varus/valgus alignment was 0.2 degrees of varus (stdv. 0.8 degrees) and 0.1 degrees of varus (stdv. 0.8 degrees) respectively. The femur was lengthened by 0.2 mm (stdy. 3 mm) medially and 1.1 mm (stdy. 3.1 mm) laterally. The tibia was shortened after component implantation by 1.5 mm (stdy. 3.4 mm) medially and 1.1 mm (stdv 3.1 mm) laterally.

Discussion: With the use of the Stryker Knee Navigation System, we can reconstruct the preoperative joint line with reproducible accuracy after a TKA. When prosthesis component and polyethylene inlay thickness are known, osteotomies may be performed and corrected intraoperatively to restore the joint line.


S.A. Sexton Y. Kamat C. Pearce A. Adhikari

Introduction: Computer assisted knee arthroplasty (CAKA) has been shown in a number of studies to result in improved post-operative alignment of prostheses. However prosthetic alignment is only one part of total knee arthroplasty surgery and outcome is likely to depend on other factors such as soft tissue balancing.

Our study compared the functional outcome following knee arthroplasty using CAKA or conventional instrumentation, and investigated whether the theoretical advantage of improved prosthesis alignment with CAKA resulted in improved functional outcome.

Materials and Methods: Data on 299 patients have been recorded to date. 139 patients have a minimum one year follow up. No patients were lost to follow up. All patients were operated on by a single surgeon at a dedicated arthroplasty centre and were allocated to one of two groups: Computer assisted navigation using a robot assisted technique (PiGalilieo, Plus Orthopaedics, Rotkreuz, Switzerland), or using conventional instrumentation. In both groups the prosthesis used was the TC-Plus Self-aligning bearing (Plus Orthopaedics).

Functional outcome was measured using the Oxford Knee Score (OKS).

A power analysis was performed with alpha of 0.05 and power of 80%. In order to detect a difference of 4 points in the OKS, 126 patients were required. This number was exceeded in our study at one year.

Results: The mean OKS at one year follow up was 24.9 (range 12 – 54, s.d. 9.8) for the CAKA group and 25.3 (range 12–49, s.d. 9.7) for the control group. There was no significant difference in functional outcome at one year between the two groups (p = 0.41).

At two years follow up the mean OKS was 25.39 (range 13 – 53, s.d. 10.3) for the CAKA group and 24.14 (range 12–43, s.d. 9.1) for the control group (p = 0.33). The results for the two year follow up group should be treated with caution as further patient numbers are awaited to obtain adequate power.

Conclusions: Although several studies show that use of CAKA results in improved prosthesis alignment, our study indicates that CAKA does not result in improved functional outcome as assessed by the patient at short term follow up. Improved prosthesis alignment is thought to result in improved long term outcome, however long term studies are necessary to show whether the known advantages of CAKA in improved prosthesis alignment results in improved patient satisfaction and increased implant survival. These further studies are important in order to justify the increased costs associated with CAKA.


N.N. Biasca T. Schneider

Introduction: Computer-assisted minimal invasive total knee arthroplasty (MIS-TKA) provides the patient with the advantages of computer navigated total knee arthroplasty (CN-TKA) and early mobilization and progressive rehabilitation because of minor soft tissue injury. Since conventional landmarks are not visible for the surgeon throughout the operation, he must rely on the data displayed by the computer navigation system. This study was designed to assure that MIS-TKA reveals identical mechanical accuracy as conventional computer navigated TKA while reducing rehabilitation time.

Materials and methods: The Stryker knee navigation system was used intraoperatively. There were forty patients included in this study: 20 consecutive patients received computer navigated TKA (Scorpio) and 20 consecutive patients received MIS-TKA (Stryker-MIS Scorpio). Preoperatively and 6 months after the operation all patients received orthoradiograms and a CT-scan of the knee to determine mechanical and rotational alignment. Intraoperatively data shown by the navigation system was recorded. The HSS knee score was recorded preoperatively and 6 months postoperatively. Length of skin incision, length of hospital stay and postoperative range of motion were also determined.

Results: Analysis showed that the mechanical axis improved in both groups to less than 1° of varus. Rotational alignment of the femoral component showed reproducible values of less than 2° of rotation without significant differences between the two groups. Also, ligament laxity was almost identical preoperatively and postoperatively in 0°, 45° and 90° of knee flexion. Length of skin incision was significantly shorter in MIS-TKA. HSS knee score improved from a mean of 76 points (range 57–96) preoperatively to a mean of 92 points (range 64–100) 6 months postoperatively for both groups. Patients from the MIS-TKA group revealed a quicker recovery time than patients from the CN-TKA group. ROM improved sooner after the operation in the MIS-TKA group, however after 6 months both systems reached the same ROM. The length of hospital stay was significantly reduced by the MIS-TKA group.

Discussion: The Stryker knee navigation system aids the surgeon to precisely optimize mechanical and rotational alignment and to avoid malrotation and axial malalignment not only in CN-TKA but also in MIS-TKA. We have found no significant differences in preoperative and postoperative ligament laxity between the two groups. The advantages of minimal soft tissue damage in MIS-TKA can be achieved without loss of accuracy and with a great benefit for the patient.


C. Lüring F. Oczipka E. Tamm J. Grifka M. Tingart L. Perlick

Soft tissue management is a critical factor in total knee arthroplasty especially in valgus knees. The stepwise release has been based upon surgeon’s experience until now. Computer assisted surgery gained increasing scientific interest in recent times and allows the intraoperative measurement of leg axis and gap size in extension and flexion.

We therefore aimed to analyse the effect of the sequential lateral soft tissue release and the resulting change in the a.p. limb axis on the one hand and the tibiofemoral gaps on the other hand as well in extension as in flexion in 8 cadaveric knees. Measurements were obtained using a CT-free navigation system.

In extension the highest increase compared to the previous release step was found for the first (iliotibial band, p=0.002), second (popliteus muscle, p=0.0003), third (LCL, 0.007) and the sixth (entire PCL, p=0.001) release step. In 90° flexion all differences of the lateral release steps were statistically significant (p< 0.004). Massive progression of the lateral gap in flexion was found after the second (popliteus muscle, p=0.004) and third (LCL, 0.007) release step.

Computer assisted surgery allows to measure the effect of each release step of the sequential lateral release sequence and helps the surgeon to asses the result better.


J. McConnell J. Dillon A. Kinninmonth M. Sarungi F. Picard

Introduction: Computer navigated total knee replacement does not require the use of intramedullary alignment rods, and is thus less invasive than traditional methods.

One previous study has suggested that the computer-assisted technique may reduce blood loss in comparison to traditional methods. This study (Kalairajah et al, 2005) used blood volume loss from drainage bottles as a primary outcome measure (n=60). Hidden (internal) blood losses were not accounted for.

Our study uses a more accurate method of assessing blood loss, and the sample size is larger (n=136; 68 standard TKR versus 68 computer assisted TKR).

Methods: 136 TKR patients were included, of which 68 had standard TKR and 68 computer assisted. Patients were matched such that in each group half had BMI in the range 20–30, and half had BMI between 30–40. Patients were also matched for gender. All patients had Tranexamic acid at the start of the procedure.

Total body blood volume was calculated using the formula of Nadler, Hidalgo & Bloch (1962). This was then used, together with haematocrit and volume re-infused or transfused, to calculate true blood loss, as described by Sehat, Evans, and Newman (2004). This method is considered to be more reliable than measuring drain output, as it takes account of “hidden” losses. The navigated and non-navigated groups were compared using Student’s t-test.

Results: The average blood loss was 583ml in the standard TKR group, and 442ml in the computer assisted TKR group. This difference was statistically significant (p=0.003).

Conclusions: A previous study found reduced blood loss when performing total knee replacement using computer navigation, compared with traditional methods. Our study confirmed this finding, using a larger sample size, and a more reliable method of assessing blood loss.

Our study found that overall blood loss was less for both groups, when compared to the findings of Kalairajah Y et al. We suspect that this difference was due to our departmental policy that all patients receive tranexamic acid at the start of joint replacement procedure.


T.P. Murphy K.J. Mulhall K.J. Saleh

Introduction: A critical technical and economic challenge in total knee arthroplasty revision (TKAR) is bone loss management. Easily applied, valid pre-operative measurements of bone loss are essential to allow accurate planning and meaningful comparisons between series. We compared 2 radiographic measurement ment systems with actual intra-operative bone loss in order to determine their validity.

Methods: A prospective IRB approved cohort study of 290 consecutive TKAR patients was utilized to assess the Anderson Orthopaedic Research Institute (AORI) system and the University of Pennsylvania (UPenn) assessment system. These preoperative measures were performed on standardized antero-posterior and lateral knee radiographs by 31 orthopaedic surgeons trained in their use. The validity and reproducibility of both systems was determined versus the gold standard measure of actual intra-operative bone loss.

Results: 215 patients (74.1 percent) were assessed to have bone loss pre-operatively versus 222 (76.4 percent) intra-operatively. Using the AORI classification system agreement between preoperative and intraoperative classification was moderate for the femur (K = 0.50) and good for the tibia (K = 0.63). The UPenn system gave resultant mean scores of 0.137 for femur and tibia versus intraoperative findings of resultant mean scores of 0.14 and 0.143 for the femur and tibia, respectively. These differences were not statistically significant (p < 0.02).

Discussion: This study demonstrates a high incidence of bone loss among TKAR patients, emphasizing the importance of effective measurement tools. Both the AORI and UPenn systems are valid tools for pre-operative estimation of actual bone loss facilitating planning and clinically successful, cost effective management of bone loss in TKAR.


C. Lüring J. Grifka J. Wolfsteiner L. Perlick H. Bäthis M. Tingart

Introduction: Restoration of neutral alignment of the leg is an important factor affecting the long-term results of total knee arthroplasty (TKA). Recent developments in computer-assisted surgery have focused on systems for improving TKA. To verify that computer assistance improves the leg alignment and the component orientation, we present a single center study with 1000 patients.

Materials and Methods: In a prospective study two groups of 500 patients each undergoing TKA had operations using either a computer-assisted image free navigation system or a conventional technique. Alignment of the leg and the orientation of components were determined on post-operative long-leg coronal and lateral films.

Results: The mechanical axis of the leg was significantly better in the computer-assisted group (97%, within ±3° varus/valgus) compared with the conventional group (78,5%, within ±3° varus/valgus). The coronal alignment of the femoral component was also more accurate in the computer-assisted group.

Discussion: Computer-assisted TKA gives a better correction of alignment of the leg and orientation of the components compared with the conventional technique. Potential benefits in the long-term outcome and functional improvement require further investigation.


J. DILLON J. CLARKE A. MENNESSIER L. HERIN F. PICARD

Introduction: Accurate soft tissue balancing is an essential part of total knee replacement (TKR), but has been difficult to quantify using traditional instrumentation methods. Computer navigation systems allow us to accurately assess intra-operative kinematics, which are affected by soft tissue management. The aims of this study were to evaluate the role of varus and valgus stress measurements and subsequently devise an algorithm for soft tissue management during TKR.

Methods: We used the Orthopilot® CT-free navigation system during TKR for patients with primary end-stage arthritis. This was a prospective study with 71 patients collecting intra-operative kinematic data. 57 knees were varus, 13 valgus, and 1 well aligned.

Pre- and post-operatively, the surgeon applied a varus and valgus stress at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. We compared the kinematics of each varus knee. Based upon the kinematics and the surgeon’s experience the following medial releases were performed as usual and divided into three categories:

No release (limited medial approach).

Moderate release (postero-medial release including the semimembranosis).

Proximal (extensive) release.

Results: Pre-operatively, the mean MFT angle was −9.6° (−3° to −22°) with varus stress and −0.8° (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.7° (−1° to −7°) with varus stress, and 1.1° (4° to −3°) with valgus stress. Using regressional analysis, there was a strong linear correlation between both varus (r=0.742, p< 0.0001) and valgus (r=0.771, p< 0.0001) stresses and the MFT angle.

With the following medial releases, these kinematics were found:

No release – MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°.

Moderate release – MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°.

Proximal release – MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°.

The results show that post-operatively, the mean MFT angle is maintained within a narrow range (−1° to −7° with varus stress, 4° to −3° with valgus stress). 5/57(9%) patients had a mean MFT angle of 6.4°(0° to 7°) with valgus stress, and were considered to have been over-corrected. There were no extension deficits.

Conclusions: Navigation allows us to quantify soft tissue balancing based upon the initial kinematics with varus and valgus stress testing. From these measurements, an algorithm was developed, which showed that an appropriate release was made in 52/57 (91%) patients, but this may require some adjustment to reduce the number of outlying results.


D. Kendoff S. Hankemeier M. Citak G. Wang G. Zheng T. Hüfner C. Krettek

Introduction: The main purpose of this study was to analyze the accuracy of conventional versus navigated open wedge corrective osteotomies of the proximal tibia. Furthermore, the intraoperative radiation dosage and the time of the operative procedure of both groups were compared.

Methods: 20 legs of 11 fresh cadaver (9 male, 2 female, age 35–71 years) were randomly assigned to conventional open wedge high tibial osteotomy (HTO) (n=10) or navigated open wedge HTO (n=10). Two legs had to be excluded because of pre-existing knee injuries. The aim of all corrective operations was to align the mechanical axis to pass through 80% of the tibial plateau (80% Fujisawa line), regardless of the preexisting alignment. The intraoperative mechanical axis was evaluated either by the cable technique for conventional HTO, or by a navigation module for navigated HTO (Medivision, Oberdorf/Switzerland). An angle fixed implant with interlocking screws (Tomofix, Mathys, Bettlach/Switzerland) was used to minimize postoperative loss of correction. Postoperatively, CT-scans were performed and the Fujisawaline and MPTA measured with a computer software for deformity analysis (Med-iCAD) The main outcome parameter was the accuracy of the correction, which was measured by the Fujisawa line. Secondary outcome parameters were the intraoperative radiation measured by the dose area product and the time of the operative procedure. For statistical analysis the standard deviation (S.D.) was calculated and the paired t-test applied.

Results: After conventional HTO, the mechanical axis was intersecting the Fujisawa line at 72.1% of the tibial plateau (range 60.4–82.4%, S.D. 7.2%). In contrast, after navigated HTO the tibia plateau was passed through 79.7% (range 75.5–85.8%, S.D. 3.3%). Thus, the accuracy of the correction was significantly higher after navigated HTO (p=0.020). In addition, the standard deviation of the corrections was significantly lower after navigated HTO (p=0.012). The medial proximal tibia angle (MPTA) increased 7.9° (range: 4.7–12.1°) after conventional HTO and 9.1° (range: 4.6–12.6°) after navigated HTO. The average dose area products of the conventional HTO (49.5 cGy/cm2, range 36.0–81.2 cGy/cm2) and navigated HTO (42.8 cGy/cm2, range 28.3–58.1 cGy/cm2) were comparable (p=0.231). However, navigated HTO elongated the operation time significantly (navigated HTO: 82 min, range 55–98 min; conventional HTO: 59 min, range 47–73 min) (p< 0.001).

Conclusion: Continuous three-dimensional imaging of the axis and of intraoperative tools with the a navigation module significantly improves the accuracy of open wedge osteotomies of the proximal tibia. Prospective clinical studies will show whether the results of this cadaver study can be transferred to the regular clinical use.


A. Toepfer G. Ludger

Increasing age and a higher level of mobility lead to an increasing incidence in revision arthroplasty after total knee replacement and tumor surgery. So far, the reconstruction of large defects in bony and soft tissue environments can be accomplished by the modern modular components of revision implants. The consecutive reconstruction of the extensor mechanism in extended revision has its own drawbacks and is often associated with significant functional limitations for the patient. Specially designed implants and methods are required to generate good functional

Results: The modular knee revision system MML provides specific modifications of the tibial component for reconstruction of the extensor mechanism. Combined with artificial strips, an excellent functional outcome could be achieved. In this study, 70 patients were operated with the MML endoprosthesis in knee revision or tumor surgery. An excellent functional outcome could be determined. At 7 years after surgery, an average of 32±13 points was achieved on the Oxford Knee Score. The outcome measurement using the functional scoring system of the American Knee Society (AKS score) showed similarly good results with 71±25 points out of 100. A minor deficit of only 2° in active extension could be observed after reconstruction of the extensor mechanism. In conclusion, we have demonstrated that the MML modular revision system is appropriate for reconstruction of segmental bone defects.


M. Pullagura S. Sengupta N. Shankar

Fresh frozen allograft bone was used to fill defects during revision total knee replacements in 21 patients (21 knees) using radial impaction grafting technique. Radial Impaction grafting technique produces a very rigid bone cement construct to allow for immediate weight bearing without any reinforcements. The strength of the graft substitute with stems allowed us to avoid metal augments in both type II and type III defects in majority of cases. At a minimum of 12 months follow up (12 to 60 months follow up, average 28 months), 19 of the knees showed radiological incorporation of the graft and no evidence of lysis of bone graft. Radiological incorporation of the graft was seen as early as six months and remodelling was continuing at three years. There were no cases of non-union. There were no cases of collapse of the graft or migration of the implant. There was one cases of osteolysis due to deep infection, which needed re-operation. There was one case of traumatic peri-prosthetic fracture, which was treated conservatively.

Oxford knee scores improved from an average of 45 (35 to 53) to 17.4 (12 to 22) at an average follow up of 27.4 months. American Knee Society scores improved from an average of 39.8 (31 to 53) to 87.8 (30 to 70). Knee Society Function scores improved from an average of 45 (30 to 70) to 85 (65 to 100) at last follow-up.

We recommend use of radial impaction grafting technique to fill defects of type II and type III in Tibias during revision knee arthroplasty.


C. Restrepo E. Ghanem J. Parvizi W.J. Hozack J.J. Purtill P.F. Sharkey

Introduction: Management of bone loss during revision total knee arthroplasty (TKA) can be challenging. The degree and location of bone loss often dictates the type of prosthesis that can be utilized during revision surgery. The aim of this prospective study was to determine if plain radiographs are adequate in assessing the degree of bone loss around TKA and identify the limitations of plain radiographs for this purpose, if any.

Methods: 205 patients undergoing revision TKA at our institution were included. The indication for revision was aseptic failure in 120 patients and septic failure in the remaining patients. The plain radiographs were evaluated by a research fellow and the attending surgeon. The degree and the location of bone loss around the TKA was determined using the UPenn Bone Loss chart. The degree of real bone loss was then determined intraoperatively.

Results: The predicted amount of bone loss for the tibia based on the AP (p=0.136) and lateral (p=0.702) radiographs correlated well with the intraoperative findings. However, plain radio-graphs underestimated the degree of bone loss around femur, particularly the condyles (p=0.005).

Discussion: Reconstructive surgeons performing revision TKA need to be aware of the limitations of routine radiographs in assessing the degree of bone loss around the femoral component. Hence, patients undergoing revision TKA with suspected bone loss may need to be evaluated by additional imaging techniques and/or alternative reconstructive options need to be available to deal with greater than expected degree of bone loss intraoperatively.


M. Pietsch J. Rachl O. Djahani S. Hofmann

Purpose: There is a growing demand on revision surgery in the last decade. 60 – 80% of these revisions are performed for early failure within the first three years. We are a referral center for painful and failed TKAs and have performed more then 400 revision surgeries between 2000 and 2005. In this paper we have analysed the cause(s) of failure(s) in patients with painful or failed TKAs.

Material and Methods: 100 consecutive revision surgeries were analysed using a standardized diagnostic algorithm. This included extended history, clinical evaluation with special tests and laboratory examinations. Radiographic analysis included standard x-rays, full leg standing weight bearing x-rays and special fluoroscopic views. Patients with suspicion of implant malrotation received a special computer tomography and stress x-rays. In patients with suspicion of infection aspiration of the joint and if negative a dynamic technetium and leucocyte bone scan was performed. The suspected cause(s) of failure(s) was analysed during revision surgery in all cases.

Results: In 48% malalignment (> 4°) caused overloading, pain and/or PE-wear. In 26% malrotation (> 3°) of the tibia and/or femoral component caused either patella malttracking, stiffness or flexion gap instability. In 23% pain was caused by instability either in extension, midflexion and/or full flexion. In 19% the cause of pain was infection. In 24 % several other rare causes could be identified. Only in 9% there was aseptic loosing over the time without any implantation failure. 78% of all revisions were performed within 3 years after the primary surgery.

Conclusions: Aseptic loosing, PE-wear and instability had been described as the main failure mechanisms in TKA. In this study it could be shown, that these are only secondary phenomena’s for the three main implantation failures of malalignment, malrotation and mismatch of the flexion/extension gaps. In most of the early failures within 3 years after primary implantation these revision surgeries might be prevented by a more precise primary implantation.


F. von Knoch M. Zanetti F. Naal S. Preiss J. Hodler M. von Knoch U. Munzinger T. Drobny

Introduction: Stiffness after primary total knee arthroplasty (TKA) is a severe complication that has been associated with excessive internal rotation of the femoral component.

Methods: Between 2001 and 2004, 18 patients with 18 well-fixed, aseptic primary TKA underwent revision TKA at a single high-volume joint replacement center for stiffness in the presence of femoral component mal-rotation. Stiffness was defined as ROM with less than 90° of maximum flexion or a flexion contracture greater than 10°. Femoral component malrotation was defined as a condylar twist angle of more than 4° of internal rotation using CT scans. Following IRB approval, 17 out of 18 patients (median age at time of the index surgery 62.7 years, range 45 to 78; female, n=11; male, n=6) were available for retrospective outcome assessment. The mean time between primary and revision TKA was 3.2 years (range, 9–79 months). At a mean follow-up of 3.3 years (range, 2 to 6), all patients were evaluated clinically using the Knee Society objective and functional scores, and by CT measurement of femoral component rotation. Patients without additional procedures between primary and index revision TKA (group A, n=9) were compared using Student t-testing with those which had undergone additional interventions (group B, n=8).

Results: Five patients had required additional procedures after the index revision TKA including closed manipulation under anesthesia in one case, patellar resurfacing in one case, metal removal after tubercle osteotomy and open debridement in another case, and tibial component revision followed by revision TKA in one case. CT scans after revision TKA revealed correction of femoral component rotation in all but one case from each group. After revision TKA, the mean objective score was overall 73 points, in group A 82 points compared to 63 points in group B (p< 0.001). In group A there were 78% excellent or good results compared to 13% in group B. The mean function score was overall 74 points, 78 points in group A compared to 69 points in group B. There were 67% good or excellent results in group A compared to 12% in group B. Mean flex-ion increased overall from 71 to 92 degrees (p< 0.01), in group A from 61 to 96 degrees (p< 0.01) and in group B from 82 to 89 degrees. Mean flexion contracture was reduced overall from 7 to 4 degrees, in group A from 6 to 3 degrees, and in group B from 8 to 5 degrees. Stiffness persisted in four cases (24%) (group A, n=1; group B, n=3). Satisfaction (VAS 0–100; 100=completely satis-fied) scored overall a mean of 52 points, in group A 57 points and in group B 44 points.

Conclusion: Overall, revision TKA for knee stiffness associated with femoral component internal malrotation resulted in significantly improved knee motion. However, outcome was less predictable in those patients with additional procedures between primary and revision TKA.


D. Dornacher K. Dreinhoefer J. Frey H. Schirrmeister H. Reichel

The non-invasive diagnosis of musculoskeletal infections remains a challenge. Recent studies have indicated that fluorine-18 fluorodeoxyglucosepositron emission tomography (FDG-PET) is a highly accurate imaging technique in selected patient groups with infected total hip replacement. The present study analyses the diagnostic accuracy in a consecutive series of patients with suspected musculoskeletal infections.

METHODS: 163 consecutive patients with suspected periprosthetic infections (40 THR, 46 TKR), discitis (22) or a suspected infection involving the peripheral skeleton (55) were studied with FDG-PET. In this retrospective study two independent nuclear medicine physicians interpreted the images solely based on the information provide at the time of investigation. The final diagnosis was based on histopathological studies or microbiological culture or on clinical findings after at least twelve months of follow-up.

Results: Based on the final composite assessment, 21/40 patients with THR, 15/46 with TKR, 22/55 with suspected infection in the peripheral skeleton and 10/22 with suspected discitis had infection. FDG-PET identified correctly 68/76 infections (sensitivity 89.5%) and demonstrated a negative predictive value of 81/87 (specificity 93.1%). FDG-PET was of different diagnostic value at different sites with sensitivity and specificity for suspected infections of THR (100/81.3), TKR (81.8/85.7) infections of the peripheral skeleton (90.9/100) and discitis (100/100).

DISCUSSION AND Conclusions: FDG-PET is highly accurate for the evaluation of musculoskeletal infections. While it correctly identified all patients with suspected discitis, it seems also be reliable to rule out infected THR. However, the specificity in suspected infections of THR and TKR is lower due to granulomatous tissue caused by wear-induced polyethylene particles in aseptic loosening.


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E. Ashby M.J. Davies A.P. Wilson F.S. Haddad

Aims: To determine the rate of orthopaedic wound infection using ASEPSIS and compare this to the rate of infection as defined by the US Centres for Disease Control (CDC) and the UK Surgical Site Infection Surveillance Service (SSISS).

Background: It is a common misconception that reported rates of orthopaedic wound infection are accurate, reliable and reproducible. Most definitions of infection, including CDC and SSISS, are subjective and depend on the interpretation of the surgeon. ASEPSIS1 is a method of wound scoring which grades wounds as uninfected, disturbed healing, minor infection, moderate infection and severe infection. ASEPSIS scoring has been proven to be both objective and repeatable2.

Method: Over 4 years, 1113 orthopaedic wounds were prospectively evaluated using the CDC definition for surgical site infections, the SSISS definition and the ASEPSIS scoring method. Patients were seen pre-operatively and at 3 and 5 days post-operatively. They also completed a wound surveillance questionnaire at 2 months post-discharge.

Results: The overall infection rates were 8% as defined by CDC, 4% as defined by SSISS and 3% as defined by ASEPSIS. Further classification of the wounds as defined by ASEPSIS revealed that 91% of wounds showed no evidence of infection (score < 10), 6.6% showed a disturbance of healing (score 11–20), 2.3% had a minor infection (score 21–30), 0.4% had a moderate infection (score 31–40) and 0.3% had severe infection (score > 40).

Conclusion: This study illustrates that accurate wound surveillance is not simple. Different wound infection definitions give very different rates of infection and make comparisons between surgeons and hospitals impossible.

We propose that ASEPSIS provides the most accurate and reproducible results and also provides more information with the grading of wound infection. The overall rate of orthopaedic wound infection using the ASEPSIS method is 3%. If all hospitals used this scoring method, more accurate comparisons of infection rates could be made.


L.A. Poultsides E. Petinaki K.N. Malizos

Introduction The aim of this study was firstly to investigate the prevalence of icaABCD-operon which codes the production of the polysaccharide intracellular adhesin(PIA), responsible for biofilm production, in a collection of clinically significant staphylococci isolated from orthopaedic infections and secondly to assess the relationship between biofilm production and the presence or not of ica-operon.

First Step – Material & Methods Between 1/2003 and 12/2005 200 CoNS were isolated from orthopaedic patients associated with soft tissue and bone infections(group I) and 200 CoNS from blood cultures of hospitalized patients from different wards of the same Hospital(group II). Identification was carried out by Gram-stain, catalase and coagulase tests and the API Staph System. Detection of icaADBC genes was performed by PCR. Production of biofilm was tested by the method of Christensen.

Results In group I, 62(31.37%) carried the entire ica-operon; from these isolates biofilm formation was detected in 35(17.5%). 5 isolates, despite biofilm production, did not carry any gene of ica-operon. In group II, 70(35.5%) carried entire the ica-operon; biofilm formation was detected in 37(18.5%) of these isolates. 3 S. capitis, 1 S. epidermidis and 1 S. hominis carried only the icaADB, icaA and icaB genes respectively.

Second Step – Material & Methods Based on the observation of PIA-production only in (50%) of ica(+) CoNS, 20 S. epidermidis isolates recovered from clinical specimens (pus) of orthopaedic patients and belonging to distinct PFGE clones, were selected on the basis of the presence of the entire ica operon. Nevertheless, only 10 of them produced biofilm. Nucleotide sequence analysis of ica-operon was carried out in all isolates; expression of icaADBC genes was also tested by RT-PCR.

Results Sequencing analysis revealed that all isolates carried an intact ica-operon, without point mutations. Concerning icaADBC mRNA production, all genes of ica-operon were expressed in biofilm-producing isolates, whereas in the no-biofilm producing strains the icaA and icaC genes were not expressed, while a faint expression was observed for the icaB and icaD genes.

Discussion Biofilm-forming capacities of CoNS from orthopaedic infections was not significantly greater than those from other infections (p> 0,05). The capacity of ica-operon(+) staphylococcal isolates to form biofilm seems to be dependent on the expression of ica-genes, specifically of icaA and icaC. The inability of ica(+) isolates to produce biofilm emphasizes that some unknown mechanisms influence icaADBC expression. Finally, the recognition of biofilm-producing CoNS without carrying any gene of ica operon underlined the existence of unidentified also mechanisms controlling biofilm production, apart from icaADBC expression.


F. Boettner M. Erren A. Wegner K. Becker W. Winkelmann C. Goetze

78 patients (41 male and 37 female) with a revision total knee or hip arthroplasty were enrolled in this prospective study to evaluate the role of new laboratory markers in the diagnostic of deep implant infection.

The average age at the time of surgery was 64 years. Based on intraoperative cultures, 21 patients had a septic and 57 patients had an aseptic revision total joint arthroplasty. White blood cell counts, erythrocyte sedimentation rate, C-reactive protein levels, interleukin-6, procalcito-nin and TNF-alpha were measured in preoperative blood samples. Diagnostic cut of values were determined by Receiver Operating Characteristic curve analysis.

If patients with rheumatoid arthritis and other concomitant infections are excluded the C-reactive protein (> 3.2md/dl) and interleukin 6 (> 12 pg/ml) have the highest sensitivity (0.95). Interleukin 6 is less specific than the C-reactive protein (0.87 versus 0.96). Combining C-reactive protein and interleukin identifies all patients with deep implant infection. Procalcitonin (> 0.3 ng/ml) and TNF-alpha (> 40 ng/ml) are very specific (0.98 versus 0.94)) but have a low sensitivity (0.33 versus 0.43).

The combination of C-reactive protein and interleu-kin 6 is an excellent screening tests for deep implant infection. Highly specific marker like procalcitoninn as well as preoperative joint aspiration might be useful to identify patients with true positive CRP and/or interleu-kin 6 levels.


C. Dora M. Altwegg C. Gerber E. Böttger R. Zbinden

A significant portion of prosthetic joint infections with biofilm-embedded bacteria may not be adequately sampled by standard periprosthetic tissue collection techniques. The aim of the present study was to combine ultrasonication sampling procedures with standard in-traoperative sampling and cultural techniques.

A total of 69 patients with implants to be removed were included in this study; a prosthetic joint infection was diagnosed or rejected according to a standardized clinical score. Intra-operative tissue specimens were cultured using standard techniques; implants were subjected to ultrasonication and sonicates used for inoculation of cultures and broad-range eubacterial PCR.

According to the clinical score, a prosthetic joint infection was present in 14 of the 69 patients. 11/14 had positive cultures for tissue samples, 13/14 had positive cultures when considering in addition the results from sonicate cultures. Sonicate PCR was positive in 12/13, and negative in 1/13 (excluding one infection due to Candida albicans). Ultrasonication improved sensitivity of culture from 78.6% to 92.9%; sensitivity and specificity of PCR from sonicates was 92,3% and 100%, respectively.

Combined with serially sampled periprosthetic tissue, ultrasonication of implants may help to increase the sensitivity of laboratory investigations based on cultural procedures. PCR analyses did not improve sensitivity although implementation of PCR may aid in improving the specificity of cultural detection.


C. critchley T. Taneja V. White J. Moore-Gillon A. Sivaraman C. Natali

Introduction: Tuberculosis (TB) continues to cause a sig-nificant burden of disease in the United Kingdom (UK). The incidence of TB in London is four times greater than the national average, with almost half of the 7000 cases/year seen nationwide being found in the capital. Although the majority of cases are pulmonary, extra-pulmonary infection is not uncommon.

Methods: We reviewed 107 patients treated for spinal TB in East London, UK, between 1997–2006. 59 were male and 48 were female. Their mean age was 39.9 (6–89). 69 patients were Asian, 26 African, 10 UK-born Caucasian, 1 other European and 1 Middle Eastern. Rates of HIV co-infection are inexact as many declined to be tested.

All patients presented with symptomatic back pain, with or without neurological compromise.

All patients had appropriate pre and post treatment imaging. 100 had microbiological and/or histological confirmation of TB. The disease was predominantly in the thoraco-lumbar spine, although cervical involvement was seen in 5%. All patients presented with anterior column involvement, with psoas abscesses in 30%.

Combination chemotherapy, according to British Thoracic Society guidelines, was the main modality of treatment. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 15% of the 107 patients treated required surgical intervention.

Results: There were no deaths related to TB or our intervention. Most patients had full neurological recovery, but a small percent had permanent neurological compromise. There was a high incidence of persistent chronic back pain for which patients continued to seek medical advice.

Conclusion: Medical management is the mainstay of treatment for spinal TB, but there are certain circumstances where surgical intervention will be required. Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients, 2 years ago we set up what we believe to be the only dedicated multidisciplinary spinal TB clinic in the UK. Patients are managed jointly by the respiratory and orthopaedic teams.


C. Koh K. Hassan D. Karunaratne

PURPOSE: Methicillin Resistant Staphylococcus Aureus (MRSA) is a bacterium we all encounter at some point in our lives. Recently, it has received significant amount of press coverage and has been a clinical and political concern. It has no predilection and affects both young and old alike. Control of MRSA spread is multi-factorial and current selective screening has become less useful. Hence, our orthopaedic department in a district general hospital setting has carried out an audit to find cost-effective ways to control the spread of MRSA.

METHOD: 686 patients were screened over a period of 3 months in 2005. Nasal and perineum swabs were taken within 24 hours of admission. Patients who developed MRSA infection in wounds were identified from hospital records. All hospital events (hardware) recorded were costed.

RESULTS : Of the 686 patients screened, 27 developed MRSA wound infections. 14 were new cases identified through screening. The costing for the period of 3 months for 10 patients (medical notes of 4 patients were not located) is £96 000. The total cost from MRSA infection when extrapolated is £384 000 per year. These figures are grossly underestimated as some surgical equipments were not costed.

DISCUSSION: We recommend 8 additional auxillary staff to cover 2 wards. This will enable nurse cohorting and cost £120 000 per year. Our department should have a positive pressure dressing room which cost £20 000 to build. This will ensure wounds are inspected in a clean controlled environment. A PCR rapid MRSA detection device plus staffing and culture media cost £149 000 per year. This should be used on emergency admissions. A cheaper detection kit can be used on elective patients which cost £12 000 per year. Hence total running cost will be £301 000 a year and subsequent years will cost £261 000. Compare that to £384 000 bearing in mind it was extrapolated from 3 months study on 14 newly identified MRSA positive orthopaedic patients who developed wound infection. Apart from that, we also recommend a holding bay for suspected cases whilst awaiting PCR results. Colonisers should be treated with Aquacept or Bactroban. At induction, teicoplanin and gentamicin iv should be used. MRSA patients should be nursed in side rooms. Beds should also be ring fenced.

CONCLUSION: It is much more cost-effective for a hospital trust to implement our recommendations to combat the spread of MRSA than to continue with the current practice.


N. Efstathopoulos E.J. Giamarellos Bourboulis J. Lazarettos V. Nikolaou T. Tsaganos P. Koutoukas A. Papalois P. Tsiolis F. Xypnitos

AIM: Chronic osteomyelitis is a difficult to treat infection requiring prolonged antimicrobial therapy and involving systems of local antimicrobial delivery. Linezolid is a new antimicrobial agent with well documented in vitro activity against gram positive cocci when resistance to other antistaphylococcal agents is present. Few data are present regarding its embedding in local antimicrobial delivery systems and subsequent elution. The elution of linezolid by a polylactic acid (PLA) system was studied.

METHODS: Linezolid was dry-mixed with PLA at a ratio of 1:9, ie 50mg of linezolid were mixed with 450mg PLA. The mixture was diluted with 0,5mL of methanol and placed at the bottom of a cylindrical vial. Two replicas were created and one mL of Mueller-Hinton broth was added over the free solid surface of each mixture. Vials were transferred to a 37°C incubator and broth was replaced every 48h for 11 days. Concentration of linezolid was determined by an HPLC method using a Zorbax Eclipse XDB-C8 column and UV detection.

RESULTS: Mean linezolid concentration at days 1, 3, 5, 7, 9 and 11 was 2778.54 mg/L, 2456.22 mg/L, 668.63 mg/L, 324.86 mg/L, 390.10 mg/L, and 155.28 mg/L respectively.

CONCLUSION: Elution of linezolid by a PLA local delivery system remains very high throughout the period studied. The results are promising for the therapy of staphylococcal chronic osteomyelitis with the use of a PLA local antimicrobial delivery system employing linezolid.


E.J. Karadimas K. Høy E.S. Hansen P. Helming R. Holm B. Niedermann L. Haisheng C. Bunger

Introduction: Spondylodiscitis is a rare but serious disease due to delay in diagnoses and inadequate treatment. The outcome mainly related to the early diagnosis.

The purpose of our study is to analyze retrospectively our patients, who had received conservative treatment or either posterior or combined approach.

Material and Method: Between 1992 and 2000, 163 patients were hospitalized due to spondylodiscitis; 62 were females and 101 males. The mean age was 56 years (1–83yrs).

The diagnosed was based on clinical examination, cultures, bone histology, X-rays, bone scan and MRI with gadolinium. The location of the infection was in 13 (8%) patients the cervical spine, in 62 (38%) the thorachic, in 10 (6%) the thoracolumbar junction and in 78 (48%) the lumbo-sacral spine. In 95 cases, concomitant diseases were present.

In 67 (41%) patients was not able to detect any microorganism. From the remaining patients, 53 (33%) were infected by staph.aureus and 22 (13%) by mycob tuberculosis.

The patients according to the treatment provided, were divided in three groups:

Group A: 70 patients, which had conservative treatment with antibiotics and bracing.

Group B: 56 patients, which, sustained posterior decompression alone

Group C: 37 patients, which had anterior debridemant and posterior decompression and stabilizations or anterior stabilization.

Results: The 12 months follow up reveals that 8 patients (11.4%) of group-A were operated. On the other hand 24 (42.9%) of the group-B were revised, as well as 6 (16.2%) patients from the group C.

The group A patients had not neurological symptoms. In group B, 11 had altered neurology and the operation was beneficial for 5 of them (45.5%), 4 remained unchanged and in 2 was deteriorate. In group C, 11 patients had altered neurology, from which 9 (81.8%) were improved and 2 remained unchanged.

The in-hospital complications were: 2 pulmonary embolism, 2 post operative haematomas, 1 persistent anaimia, 1 diafragm paralysis, 2 atelectasia and 1 cerebral thrombosis. In addition 3 patients had residual psoas abscess, 2 pancreas abscess, 1 cerebelum abscess and 3 lung infection.

The in-hospital mortality was 3 patients, other 17 patients died during the follow up

Conclusion: Spondylodiscitis is a valid diagnose for persisting back pain. Bacterial isolation is still difficult no matter the improved techniques, but in the majority of the cases is Staph.Aureus.

The conservative management in selected patients is effective up to 89%. From the operations performed the decompression alone had unacceptable high re-operation rate and also, it wasn’t so beneficial regarding the neurological improvement. If it is combined with anterior reconstruction and posterior stabilization provides better results.


C.P. Horn H. Gollwitzer L. Gerdesmeyer

Introduction: The extracorporeal shock wave therapy (ESWT) has a wide spectrum of indication in orthopaedics. However, infection in the application area is regarded as a contraindication. Therefore, in this study, the effect of of ESW on bacteria and their interaction with antibiotics is tested.

Methods: Standardized suspensions of S. aureus (ATCC25923) were exposed to different energy flux densities (EFD 0,38–0,96 mJ/mm2) and different impulse quantities (1000–12000 impulses) of a focussed ESWT. The surviving bacteria were quantified and compared to an untreated control group. The permeability of the cell wall of treated bacteria was analysed with a fluorescence assay and the DNA examined qualitatively for defects.

The influence of ESW on the effectiveness of antibiotics was examined using Gentamicin whose stability under influence of ESW was proven infrared-spectrometrically earlier.

S. aureus in specific broth (CAMHB) was treated with 4000 impulses at 0.59 mJ/mm2. Then the MIC against Gentamicin was compared with the MIC of an untreated control group.

For the examination of synergistic effects between antibiotics and ESW, bacteria were treated with ESW (4000 impulses, 0.59 mJ/mm2) in a solution of CAMHB and varying Gentamicin concentrations (0.25 – 4 μ g/ml).

The vital bacteria were quantified and compared to the control group which was exposed to either ESW or Gentamicin. Bacterium colonies were quantified according to the guidelines of the NCCLS, the statistical evaluation was done with the Man-Whitney-U- test.

Results: The ESW showed a significant germicidal effect (P < 0.01) after application of either a high EFD (> 0.60 mJ/mm2, 4000 impulses) or a high impulse quantitiy at low EFD (up to 12,000 impulses, < 0.60 mJ/mm2). The amount of CFU could be reduced by up to 99.9%.

Despite the germicidal effect of the ESWT neither a change of the bacterium cell permeability nor a damage to the DNA could be proved. Synergistic effects between Gentamicin and ESW were not found. No loss of effectivity of the Gentamicins at a simultaneous application of the ESW (P > 0.05) could be seen either.

Conclusion: The ESWT has a significant germicidal effect on bacteria after exceeding a certain threshold energy.

It could be shown that the applied total energy is responsible for the germicidal effect rather than single paramters as EFD and impulse quantity. A synergistic effect of antibiotics applied in addition to the ESW could not be proved. When ESW was carried out in presence of Gentamicin, the antibacterial effect of Gentamicin was influenced neither positively nore negatively.

The simultaneous application of ESW and systemically or locally applied antibiotics could represent a new therapy approach against tissue and bone infections. To prove this, further in-vivo studies are needed.


A. Malik B. Purushothaman P. Aparajit P. Dixon A. Berrington

Objective: To identify institution specific risk factors for developing MRSA surgical site infection (SSI) and develop an objective mechanism to estimate the probability of MRSA infection in a given patient admitted to the orthopaedic unit.

Design: A cohort study was performed to identify risk factors in all patients who had MRSA infection during admission on the orthopaedic unit between January 2002 and December 2004. Logistic regression was used to model the likelihood of MRSA. A stepwise approach was employed to derive a model. The MRSA prediction tool was developed from the final model.

Results: Of the 11 characteristics included in the logistic regression, the features that strongly predicted a MRSA infection were ASA grade, patient’s residence and reason for admission.

110 had MRSA infection in their surgical wound. 83 of 110 (75.5%) patients were non-elective admissions, of which 49 (60%) were proximal femur fractures. 20% of proximal femur fractures admitted from nursing home and 7.8% from their own homes developed SSI with MRSA. This cohort of SSI with MRSA had an average of 5.7(1–18) previous admissions. 25 (23%) had been previously colonised with MRSA. Majority of them (76%) were between 70–90 years old and were ASA grade 3–4.

Conclusion: Through multivariate modelling technique we were able to identify the most important determinants of patients developing SSI with MRSA in our institute and develop a tool to predict the probability of MRSA in a given patient. This knowledge can be used to guide the use of appropriate prophylactic antibiotic and to take other required measures to avoid the SSI with MRSA.


D. Donati M. De Paolis G. Bianchi M. Colangeli S. Colangeli C. Di Bella

Long-term clinical study to explore the curative effect and mechanism of the treatment of adult chronic osteomyelitis by implant Osteoset T.

The study object were 65 case adult chronic osteomyelitis patient from November 1977 to April 2003 in a University-based hospital. Age ranged from 18 to 69 years old. 40 cases were treated by general debridement (Method I); 25 cases were treated by general debridement and implant Osteoset T in dead space (Methods II). Stage IA(The UTMB Staging System) osteomyelitis 39 cases; The Organism was Staphylococcus Aureus 28 cases. In all cases (group A), 40 cases were treated with Method I (group AI), 25 cases were treated with Method II (group AII). The majority of the patients, 39 resulted as Stage IA (group B); 22 were treated with Method I (group BI) and 17 cases were treated with Method II (groupBII). Finally, 28 patients were chronic Staph Aureus osteomyelitis (Group C); 13 were treated with Method I (group CI) and 15 cases with Method II (group CII); Followed from 36 to 334 months, mean 75.0 months. Then respectively evaluate and analysis analyze the success rate of different method with standard.

The success rate of group BI was 59.09%, group BII was 94.12%, contrast the success rate there was significant difference (p< 0.05). The success rate of group AI was 60.00%, group AII was 80.00%. The success rate of group CI was 46.15%, group CII was 80.00%.

The use of Osteoset T has demostrated better healing rate than left the empty cavity there after debridement and irrigation. Osteoset T can local delivery antibiotic, filler of the dead space, It can be mixed with different antibiotics, reduces the hospitalization time, reduces the number of operation. Unfortunately, Osteoset dos not help with the bone growth.


N.E. GOUGOULIAS D. PARIDIS K. BARGIOTAS T. MORAITIS Z.H. DAILIANA K.N. MALIZOS

Introduction: Management strategies and results in 30 cases of foot osteomyelitis are presented.

Patients-Methods: From 1/2003 – 1/2006, 30 patients (15 men, 15 women, mean age 47.7 years, range 1.5–82) presenting with foot osteomyelitis were treated. Mean hospital stay was 12.6 days (range 1–45) and 1.3 hospital admissions were recorded (range 1–4). The follow-up period averaged 15.7 months (range 3–56). Bone infection involved the toes in 3 cases, the metatarsals in 9, the head of the hallux in 2, the midfoot in 3, the calcaneus in 9, whereas 3 cases presented as generalized charcot’s osteomyelitis. Eleven patients were classified as host-type A, 10 as B and 9 as C. Nine patients were diabetic, one rheumatoid, four had vascular insufficiency, two had insensate feet. An open calacaneal fracture was the cause in two cases, whereas ORIF of a closed calacaneal fracture in one, ORIF of metatarsal fractures in one and hallux valgus corrective surgery in two. One paediatric patient with calcaneal osteomyelitis developed subtalar arthritis. A draining sinus/wound was present in 24 cases. Each patient underwent an average of 2.3 surgical procedures (range 1–7). The treatment protocol included surgical debridement, use of the bead-pouch technique for local antibiotic administration and closure primarily (n=23), or by secondary healing (n=3), skin graft (n=2), local fasciocutaneous (n=1), or free vascularized muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Amputation was undertaken if salvaging or reconstructive procedures could not be undertaken.

Results: Infection control (salvageable cases) was achieved in 23 cases (76.7%), whereas amputations were performed in 7 cases (23.3%). Four amputees were classified as host C (57.1%), whereas a significantly lower rate of patients successfully treated (21.7%) were host-C (p=0.0008). A below knee amputation was undertaken in two host-type C patients with generalized osteomyelitis of the foot. One 1st ray and two 1st and 2nd ray amputations were performed for not salvageable diabetic feet infections. Finally in 3 cases of posttraumatic chronic toe osteomyelitis in host-type A patients, a distal phalanx amputation was the definite solution. One patient developed a septic TKR in the contralateral leg and one diabetic patient developed osteomyelitis at a different location in the earlier affected foot.

Conclusions: The treatment strategy of radical debridement, local antibiotic delivery by the bead-pouch technique and use of flaps if needed, successfully treated salvageable feet. Amputation was the solution in neglected cases and in immunocompromised patients.


A. Norrish J. Bates W.J. Harrison

A number of series report limb length discrepancy in long bone chronic osteomyelitis, however in most cases, it is shortening of the affected bone. This is thought to be due to damage in the affected growth plate leading to early growth arrest. However, it is known that the inflammatory state of chronic osteomyelitis results in an increased blood supply and, as in other conditions such as rheumatoid arthritis, the increased blood supply results in overgrowth of the affected bone.

In order to study the effect of long bone chronic osteomyelitis on limb length, we designed a prospective trial of 42 consecutive patients presenting to our unit with chronic osteomyelitis of a long bone. The inclusion criteria were all patients presenting with a long bone osteomyelitis. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms of 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. On examination, 3 (7%) patients had shortening of the long bone compared to the unaffected side (of an average of 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The most common bone affected was the tibia (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%).

All patients underwent radiographic analysis, and the average percentage of long bone affected was 59%. 8/42 (12%) of patients had at least one physis affected (2 of these patients had undergrowth and 1 had overgrowth).

This large prospective series of patients is the first in the world literature to show the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. We suggest that the mechanism for this is related to the duration of symptoms. In areas of the world where there is poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make limb length discrepancy is more likely to be due to overgrowth rather than undergrowth.


F.N. Kwong R.M. Porter D.R. Griffin C.H. Evans

Background: High doses of local antibiotics are used to treat infected acute fractures or chronic osteomyelitis. In the U.S.A., tobramycin is one of the most commonly used antibiotics in trauma surgery. It is an aminoglycoside antibiotic with a broad spectrum of action. However, its effect on the osteogenic potential of bone marrow derived mesenchymal stem cells (MSC’s) is unknown. We hypothesised that high concentrations of tobramycin would be detrimental to the osteogenic potential of multipotent stem cells derived from the bone marrow.

Methods: MSC’s were derived in vitro from reamings obtained in patients undergoing hip hemiarthroplasties. Following subculture, these cells were exposed to various concentrations of tobramycin for 15 days, with a change of media every other day.

The amount of bone formed under each condition was assessed by solubilising the mineral content in hydrochloric acid overnight and then measuring the change in colour induced by Calcium exposed to a commercial reagent. The amount of calcium detected was then determined using a standard curve.

This experiment was repeated in cells from 3 patients.

Results: The amount of calcium formed was as follows Tobramycin concentration of 0 microg/ml

There was a statistically significant impairment in osteogenesis at a concentration of tobramycin of 400 microg/ml and above.

Conclusion: A high local dose of tobramycin affects negatively the osteogenic potential of stem cells derived from the bone marrow.


D.R. van der Jagt A. Schepers

The search for the ideal bearing surfaces to be used in Total Hip Replacement continues. The current “best” materials are felt to be various combinations of metal, ceramics and cross-linked polyethylene. Laboratory studies suggest that ceramic-on-metal articulations may provide distinct advantages. This study aims to identify the best combination with the lowest side effect profile.

In February 2004 a prospective randomised trial on different bearing surfaces was started. The combinations selected were ceramic-on-cross-linked polyethylene, ceramic-on-ceramic, metal-on-metal and ceramic-on-metal. Institutional ethics clearance was obtained. In all patients uncemented femoral stems are used, with an uncemented porocoated acetabular shell. A uniform 28mm femoral head size was selected. Blood samples have been taken to measure the metal ion concentrations in all patients. These are measured pre operatively, and repeated at follow up visits at 3 months and 1 year, with further follow up at 3,5 and 10 years post operatively. Whole blood ion levels are measured using a graphite furnace atomic absorption spectrometer.

Between February 2004 and April 2006 one hundred and ten hips have undergone total hip replacement. There are 105 patients (5 bilateral). 40% are males and 60% female. The average age at operation is 52 years (17 to 72). 49% hips are left and 51% right. Follow up includes blood samples and the Harris Hip Score. Complications to date have been surgeon related, with three femoral components needing early revision for technical reasons. This has not affected the bearing surfaces. Radiological and clinical assessment shows no difference between the different bearing surface groups.

Post operative whole blood metal ion levels are compared to the patient’s pre operative level. To date there is no increase in the metal ion levels for the ceramic-on-cross linked polyethylene and ceramic-on-ceramic articulations. The ceramic-on-metal group is providing moderately raised metal ion levels, and the highest metal ion levels are in the metal-on-metal articulation group. At one year, the ceramic-on-metal group demonstrates a drop to close to pre-operative levels and these are still significantly lower than the metal-on-metal group. This confirms laboratory studies on the ceramic-on-metal articulation, which demonstrate significantly lower wear than comparable metal-on-metal articulations. The high level of metal ions in the latter groups has always been of concern.

This study demonstrates a lower blood level of metal ions in the ceramic-on-metal group. If the in vivo wear rate in this group continues to replicate the laboratory wear studies, this articulation becomes a very attractive bearing surface in younger active patients, and may well become a bearing surface of choice in the future.


L. Karamat K. Knahr

Patients and methods: We obtained postoperative blood concentrations of Co, Cr, Mo, Ti, Al, Ni and Nb in 75 patients undergoing primary THA at our institution between January 1998 and December 2000. All patients were treated with the same prosthetic device (VARI-ALLTM, Zimmer, Winterthur, Switzerland) using three types of articulations: metal-on-metal (METASULTM), ceramic-on-ceramic (CERASULTM) and metal-on-cross linked polyethylene (DURASULTM). 25 patients out of each articulation-group were evaluated by blood analysis 24–38 months after surgery. The patients were submitted to strict criteria of inclusion.

Results: The Al-, Ti-, Ni- and Nb-blood levels were all below their detection limit. The median Co blood concentration in the ceramic group was 0.19 ng/ml, 0.69 ng/ml in the metal group and 0.19 ng/ml in the cross-linked PE group. The difference between the metal and ceramic group and between the metal and polyethylene group is statistically significant (p=0.001 in both comparisons). The median blood concentration of Cr was 0.19 ng/ml in the ceramic and in the cross-linked PE group, and 0.47 ng/ml in the metal group, the difference being statistically significant (p=0.003 and p=0.0002). Regarding the median blood concentrations of Mo, we found no statistically significant differences comparing the three articulations (p> 0.05). Comparing the three articulation-groups there were no significant differences in the categories age, follow up time and preoperative blood level of creatinine.

Conclusion: Although the blood concentrations of Co and Cr were significantly higher in patients with a metal-on-metal THA they were far from reaching toxic levels. Comparing our results using direct-conical metallic cup inserts with those of total hip devices with metallic sandwich-inlays blood concentrations of Co and Cr appear to be similarly elevated (Lhotka et al, J Orthop Res 2003).


T. Bielecki T.S. Gazdzik

Introduction: Platelets play a central role in hemostasis and healing processes. Upon their activation, platelet alfa-granules release over 30 cytokines including platelet-derived growth factor (PDGF), transforming growth factor-alfa (TGF-alfa), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), epidermal growth factor (EGF) and also active substances like serotonin, catecholamines, von Willebrand factor, proaccelerin, osteonectin and antimicrobial proteins. By concentrating platelets, platelet-rich plasma (PRP) with higher levels of growth factors might be reached, which could stimulate the healing processes. The activator for PRP is a mixture of thrombin and calcium chloride. After connecting these substances platelet-rich gel (PRG) is formed.

Aims: In present study, we investigated in vitro antimicrobial activity of PRG after antibiotic administration.

Material and Methods: 30 minutes after iv Amoxillin/ clavulanic acid administration 54 ml of whole blood was collected from each of 10 donors. PRPs were prepared with using GPS system from Biomet. In vitro laboratory susceptibility to PRG was determined by the Kirby-Bauer disc diffusion method on Mueller-Hinton agar (Becton Dickinson). Baseline antimicrobial activity was assessed by measuring the zones of inhibition. Agar plates were coated with one of the following strain: Staphylococcus aureus ATCC 43300 (MRSA), Staphylococcus aureus ATCC 25923 (MSSA), Klebsiella pneumoniae ATCC 700603 (ESBL), Escherichia coli ATCC 35218 (ESBL), Escherichia coli ATCC 25922, Enterococcus faecalis ATCC 29212 and Pseudomonas aeruginosa ATCC 27853.

Results: We tested 10 samples of PRG. Zones of inhibition produced by PRG ranged between 6 – 23 mm in diameter. PRG inhibited the growth of Staphylococcus aureus. PG also was active against Escherichia coli, Enterococcus faecalis. No activity against Klebsiella pneumoniae and Pseudomonas aeruginosa was detected.

Conclusions: Our previous study showed PRG no activity against Enterococcus faecalis without antibiotic administration. In this investigation we observed PRG strong activity against this bacteria after iv Amoxicillin-clavulanic acid administration. In infections during antibiotic treatment, PRG antimicrobial properties are enhanced by antibiotics that are concentrated in plasma.


A. Aprato S. Garazzino A. Biasibetti D. Aloj G. Di Perri A. Masse’

Antibiotic concentration in infected bone is a major determinant of clinical response. As glycopeptides and fluoroquinolones are widely used for the treatment of bone infections, aim of our study was to assess their diffusion in infected human bone. Patients with a posttraumatic septic pseudoarthrosis undergoing debridement of infected tissue, who received a glycopeptide or a fluoroquinolone for > 1 week, were studied. Plasma and bone specimens were collected intraoperatively for phamacokinetic and microbiologic assays at a mean of 4.1h after antibiotic administration. Bone samples were crushed and concentrations were measured by HPLC-UV method. Overall plasma exposure was also determined with daily sampling. 16 patients were studied. 6 patients received iv vancomycin 1 g bid over a 1-hr infusion Bone cultures grew E. faecalis, MRSA and MRSE (MIC < 2 mg/L). Mean plasma concentration of vancomycin at time of osteotomy was 19.8 mg/L. Mean bone concentrations were 2.4 mg/L in cortical and 7.1 mg/L in cancellous bone, with a mean bone extraction of 12 % and 36 %, respectively. 4 patients were treated with iv teicoplanin 10/mg/Kg for MRSA infection (MIC < 2 mg/L). Mean bone concentrations were 8.9 mg/L and 37 mg/l respectively for cortical and cancellous bone, respectively corresponding to 6% and 25% of plasma levels. Six patients were treated with a fluoroquinolone. 3 patients received iv ciprofloxacin 400mg bid and E. coli grew from bone samples(MIC = 0.5 mg/L). Mean Plasma concentration of ciprofloxacin at the time of osteotomy was 3.6 mcg/mL. Mean bone concentrations were 1.7 mg/L in cortical bone and 30.2 mg/L in cancellous and newly formed bone, with respective bone/ plasma ratios of 0.5 and 8.4. 3 patients were administered iv levofloxacin 500mg qd and Enterobacter spp. were isolated (MIC = 1 mg/L). Mean plasma concentration at the time of surgery was 2.5 mcg/mL. Mean bone concentrations were 0.3 and 2.69 mcg/mL in cortical and cancellous bone, respectively. To our knowledge this is the first study that compares different antibiotic’s concentration in infected bone with the same dosing procedure. Both vancomycin and teicoplanin provided mean bone concentrations exceeding the susceptibility breakpoint of the infecting agents. Higher and constant glycopeptides plasma levels may be required for preventing recurrencies in bone infections. Only ciprofloxacin provided cortical bone concentrations higher than the susceptibility breakpoint of the infecting agent, and similar to those reported in non-infected bone. Ciprofloxacin concentration in cancellous bone and in bony callus were far higher than those detected in plasma, which may be related to an augmented vascularization and/or selective accumulation of fluoroquinolones into regenerating bone, as observed in children’s cartilage growth plate. Ciprofloxacin may be therefore preferred to levofloxacin.


A. Hart P. Tarassoli C. Patel J. Powell N. Fersht S. Muirhead-Allwood J. Skinner

Introduction and aim: We have previously shown an association between whole blood metal ions and reduced CD8+ T cells in patients with unilateral metal on metal (MOM) hip resurfacings. Our aim was to substantiate this controversial finding with a follow up cohort of larger numbers of patients before further immunological investigation.

Method: We measured lymphocyte subset counts and whole blood Cobalt and Chromium in 2 groups of patients: a Birmingham hip resurfacing group (n=100); and a metal on polyethylene MOP hip arthroplasty group (n=34). Metal ions were measured using inductively-coupled mass spectrometry (ICP-MS) with a Dynamic Reaction Cell (DRC). The detection limit was 10 parts per trillion. All hip components were well fixed, clinically and radiologically.

Results: Cobalt and chromium levels were significantly elevated in the MOM resurfacing group compared to the MOP group (p< 0.0001). There was a statistically significant decrease in the MOM resurfacing groups’ level of CD8+cells (T cytotoxic) (p=0.005) when analysed by a Mann-Whitney U test. There was no significant difference between levels of CD4+ (T helper cells), CD19+ (B cells) and CD16/56+ (Natural Killer cells). A threshold level of blood cobalt and chromium ions for depression of total numbers CD8+ T cells was observed.

Conclusions: This follow up cohort of 100 MOM hip resurfacing patients has replicated the association of reduced CD8+ T cells and raised metal ion levels observed in our founder cohort. This was specific to CD8+ T cells. We are now more certain that this association needs further detailed immunological investigation.


N. Hailer H. Dahlstrand A. Stark

INTRODUCTION: Metal-on-metal alloarthroplasty of the hip is gaining popularity in order to avoid complications associated with polyethylene wear. On the other hand, metal-on-metal articulations release metal ions, the biological effects of which remain unclear. Genetic and immunological changes have been associated with increased metal ion levels in arthroplasty patients. We intended to study the outcome after metal-on-metal arthroplasty of the hip with a focus on the toxicologically and immunologically relevant metal ions chromium, cobalt, nickel, and manganese.

PATIENTS AND METHODS: A prospective, randomised study was designed where all patients received a cemented arthroplasty of the hip, either with a metal-on-metal bearing (Metasul ®; 28 patients) or with a metal-on-polyethylene bearing (Protasul ®, 26 patients). Only patients with primary osteoarthritis of the hip and without other metallic implants were included (mean age 65 years, range 45–74). Follow-up was performed after a minimum of two years. Clinical outcome was measured by the Harris hip score and the SF36, and radiographic analysis was undertaken by plain radiography. Metal ion concentrations in patient serum were analysed by high-resolution plasma mass spectrometry.

RESULTS: It was found that the clinical outcome was almost identical in both groups with respect to Harris hip score and SF36, and radiographic signs of osteolyses or loosening did not occur in any group. In the metal-on-metal group, chromium concentrations increased 4.1 fold and cobalt concentrations increased 7.6 fold when compared to preoperative values (p< 0.05; Wilcoxon Mann Whitney Test), whereas nickel and manganese concentrations did not change significantly. In the metal-on-polyethylene group, no significant increase in the concentration of any ion occurred.

DISCUSSION: In conclusion, metal-on-metal and metal-on-polyethylene arthroplasties of the hip provide equal clinical and radiographic outcomes in the medium term, but the concentrations of chromium and cobalt increase considerably after metal-on-metal arthroplasty. Importantly, the allergogenic and previously not assessed ions nickel and manganese show no significant changes in the medium term after any type of hip alloarthroplasty. To our knowledge, this is the first study that addresses manganese and nickel concentrations in a prospective, randomized setting, and our patients will be followed further with respect to possible immunological and genetic changes.


A. Hart P. Tarrassoli C. Patel P. Buddhdev T. Hester S. Muirhead-Allwood J. Skinner

Introduction: We have previously shown an association between whole blood metal particles from unilateral metal on metal (MOM) hip resurfacing and reduced CD8+ T cells (JBJS Br April 2006). There are no reported clinical effects of these findings. Certain patients maybe at high risk of developing clinical effects; one such group is patients with bilateral hip resurfacings. There are no published studies of bilateral hip resurfacings. Our aim was to investigate the association between whole blood metal ions and reduced CD8+ T cells in a follow up cohort of bilateral MOM hip resurfacings.

Method : Peripheral blood samples were analysed from patients with bilateral MOM hip resurfacings (n=25), unilateral hip resurfacings (n=34) and metal on polyethylene (MOP) hip arthroplasty (n=34). Samples were analysed for: lymphocyte subsets (FACS analysis); whole blood cobalt and chromium ion levels (using inductively-coupled mass spectrometry). Xrays revealed all hip components were well fixed.

Results : When compared to patients with standard MOP hip replacements there was a 30% reduction in both the bilateral and unilateral resurfacing groups’ level of CD8+ cells (T cytotoxic) (p=0.010). All other lymphocyte subgroups were not significantly different. There was evidence of a threshold effect of raised metal ions and reduced CD8+ T cells but no evidence of a dose-response relationship.

Conclusions : Bilateral MOM hip resurfacing is associated with a reduced CD8+ T cell count when compared to MOP hip arthroplasty. This association is not significantly different from the levels seen after unilateral MOM hip resurfacing.


T. REPANTIS P. KOROVESSIS G. PETSINIS M. REPANTI

Background: Recent studies have reported early periprosthetic osteolysis in patients who have been treated with a contemporary metal-on-metal total hip arthroplasty and suggested that metal hypersensitivity associated with an immunologic response to metal may be of etiologic importance. We evaluated the results and histologic findings in patients who underwent revision surgery for a failed contemporary metal-on-metal total hip arthroplasty.

Material and Methods: Two hundred and seventeen total hip arthroplasties (SL-Plus stem and Bicon-Plus cup) with a Sikomet metal-on-metal articulation were implanted in one hundred and ninety four consecutive patients and retrospectively reviewed at mean of 77 months postoperatively. Clinical follow up was performed with the Harris hip score and plain radiographic evaluation was performed. Histologic analysis was performed on the periprosthetic tissues of 14 hips that underwent revision arthroplasty.

Results: The mean Harris hip score improved from 45 preoperatively to 96 at final evaluation. Fourteen (6.4%) hips were revised: 9 for aseptic loosening, 2 for technical failure and three for septic failure. Histologic examination of the retrieved periprosthetic tissues from the eleven patients who underwent revision for aseptic loosening or technical failure showed microscopic metallosis and extensive lymphocytic and plasma cell infiltration around the metal debris. With an endpoint of removal of a component with aseptic loosening, endpoint survivorship was 93% for the stem and 98% for the cup respectively.

Conclusions: Our findings are in agreement with recent publications and support the possibility that periprosthetic osteolysis and aseptic loosening in hips with metal-on-metal articulation are possibly associated with hypersensitivity to metal debris. Prospective, comparative randomized long-term studies are necessary to determine the cause(s) of loosening of this particular articulation.


C.H. Lohmann D. Laupichler S. Junk-Jantsch M. Fiedler G. Pflüger

Introduction: Metal/metal total hip arthroplasties (THA) with improved qualities of the alloys and encouraging midterm clinical results are widely used. Hyperergic reactions have been observed in revision tissues in a series of failures. This study examined synovial fluids of patients with aseptic loosening of THA from metal/metal and ceramic/polyethylene endoprostheses or arthritis of the hip by analysis of various released cytokines.

Materials and Methods: The aspirations of synovial fluids from 11 patients with arthritis of the hip, 6 THA revisions with ceramic polyethylene articulations, and 22 metal/metal articulations were retrieved. 15 of the 22 cases showed lymphocytic infiltration in the histologies.

The aspirates were examined with a commercially available assay using a Multiplex Reader. The interleukins Il-1 beta, -2, -5, -6, -10, -12, -13, -15,-17 and IL-1 receptor antagonist (Il-1ra) were measured. Further G-CSF, GM-CSF, IFN gamma, MIP 1 beta, MIP alpha, MCP 1, and TNF alpha were assayed.

Results: Samples from patients with aseptic loosenings showed increased Il-10 and MCP compared to osteoarthritis. TNF alpha, MIP alpha, and Il-1β were increased in metal/metal THA. Il-5, Il-12, Il-13 and Il-17 were only increased in patients with lymphocytic reactions, but not in ceramic/polyethylene articulations. GM-CSF, G-CSF, IFN gamma, Il-1ra Il-2, and Il-6 were only elevated in THA with lymphocytic reactions compared to metal/metal cases without.

Diskussion: Aspirates from aseptic loosened THA are important diagnostic tools. The data showed a distinctly different cytokine profile joint fluids in aseptic loosenings of metal/metal THA vs. ceramic-UHMWPE articulations and fluids from osteoarthritis patients. The data may contribute to establish a cytokine profile to determine failures due to lymphocytic infiltrations before revision of metal/metal articulations.


P.A. Vendittoli S. Mottard A.G. Roy M. Lavigne

INTRODUCTION: Improved factors influencing component wear with regards to bearing surfaces, metallurgy, tribology, and manufacturing technology allowed reintroduction of metal-on-metal (MOM) articulation in total hip arthroplasty (THA) and surface replacement arthroplasty (SRA).

MATERIALS AND METHODS: Sixty three patients were implanted with a forged, high carbon content, chrome-cobalt, MOM SRA component (Durom, Zimmer, USA). Samples of whole blood and serum were collected pre-operatively and, post-operatively at three months, six months one year and two years. Chromium and cobalt concentrations were measured using a a high-resolution, sector-field, inductively-coupled plasma mass spectrophotometer (HR-SF-ICP-MS).

RESULTS: At two years, whole blood levels were Cr 1.25 umol/L (SD 0.55), Co 0.62 umol/L (SD 0.26). In comparison to the pre-operative levels, the levels increased significantly for both elements Cr 1.3X, Co 5.0 X. Component size was inversely proportional to the chromium and cobalt ion levels at one year post operatively (ANOVA regression analysis, p = 0.0404, for Co and p = 0.0156 for Cr). Other factors such as age and activity level did not correlate with the metal ions levels.

DISCUSSION AND CONCLUSION: Chromium and cobalt metal ions measured in patients following implantation of the high carbon content, forged, metal on metal SRA implants used in this study are very low in comparison to other published results with different SRA implants. We believe that these encouraging results found with the SRA components used are resultant of favourable manufacturing and tribologic factors such as low surface roughness, high carbon content, forged chromium and cobalt material, component clearance, and optimum component sphericity. The results of this study are also in accordance with the concepts of reduced wear with larger diameter MOM articulations.


B. Ogunwale J. Brewer R.D. Meek

Background: Increased use of metal on metal (MOM) hip replacements has stimulated interest in immunological effects of chronic CoCr elevation. Unlike metal-on-polyethelylene, MOM implants are associated with a perivascular infiltrate of lymphocytes & plasma cells. This may be the mode of failure of MOM implants. A reduction in CD8+ T lymphocyte counts associated with MOM implants has previously been described. CoCr therefore seems to affect the adaptive immune response even though it is not a proteinous antigen.

We therefore analyzed the effects of CoCr particles on T cells & B cells. We also analyzed it effects on dendritic cells, which are the key antigen presenting cells to T helper cells.

Methods: CoCr nano particles were produced by repetitive short spark discharges between electrodes of prosthetic CoCr alloy. Electron micrography & BET both confirmed nanoparticle size.

Dendritic cells (DCs) were harvested from mouse bone marrow & cultured in medium supplemented with GM-CSF for 6 days, generating DCs typically 80–90% CD11c+. These were incubated with CoCr in concentrations of 25, 10 & 2.5 μg/ml, for 24 hours, or lipopolysaccharide 1 μg/ml as a positive control. Following incubation, activation status of CD11c+ DCs was characterized by MHC Class II, CD40, CD80 & CD86 expression by FACS analysis.

T-Lymphocytes were harvested from mouse lymph nodes & cultured in medium without phenol red. These were incubated at 5 ×105 cells/well with either CoCr, conA (positive control) or CoCr + conA & repeated using 2.5 ×105 cells/well. Other positive controls (CD3 & CD 28) were studied in repeating the experiment. At 48 hours Almar Blue was added & further incubation for 24 hrs. Light absorbance at 570nm & 600nm was then used to determine T cell proliferation

B-Lymphocytes were harvested from the lymph nodes of mice which were only able to mount a B-cell reaction to Hen egg Lysozyme (HEL). These were incubated with medium with CoCr, HEL (positive control) or CoCr+ HEL. The concentration of the CoCr was varied between 25, 10 & 2.5 μg/ml. FACS analysis for markers of B cell regulation was performed after 48 hours incubation..

Results: CoCr did not significantly increase CD 40 expression on DCs, although such expression was increased significantly by lipopolysaccaride CoCr did not significantly up or down regulate B cells as compared to the effects of HEL. CoCr did inhibit proliferation of T-cells & this was more pronounced where the ratio of CoCr/cell density was higher.

Conclusion: Both dendritic & B cells are unaffected by CoCr in vitro. However, CoCr inhibited T cell proliferation. This demonstrates the observed reduction in CD + T cells are probably due to a direct effect of CoCr, & not mediated through another cell type. The perivascular response to MOM implants on the other hand probably requires cell interaction in an in vivo environment.


A. Hart L. Pele N. Fersht T. Hester J. Skinner J. Powell

Introduction and aim: We have previously shown suppressed levels of CD8+ T lymphocytes in patients with metal-on-metal (MOM) hip resurfacing compared to patients with metal on polyethylene hip replacements. Functional assessment of T lymphocytes may help to determine the importance of this CD8+ reduction following hip resurfacing.

Method: We isolated peripheral blood mononuclear cells (PBMC) from patients with unilateral MOM hip resurfacing (n=7) and healthy controls without hip replacement (n=8). Patients with hip resurfacing had excellent Harris Hip scores (mean 90) and well fixed components on radiographs. Whole blood and serum levels of Cobalt (Co) and Chromium (Cr) ions were measured with Inductively-Coupled Mass Spectrometry. T cell function was assessed by

cell proliferation assays (3H-thymidine incorporation) and

cytokines secretion (ELISA) following exposure to antigen challenge using Tetanus Toxoid and polyclonal mitogen phytohaemoagglutinin (PHA).

Results: Co and Cr ion levels were significantly elevated in the MOM hip resurfacing group compared to the control group (p< 0.001). Proliferation rates of T cells were comparable between the two groups over one week, but interferon-gamma (IFN-γ) production in the MOM hip resurfacing group was significantly decreased (p < 0.05), when compared to the control group.

Conclusion: IFN-γ is normally produced by CD8+ (T cytotoxic cells) and CD4+ (T helper 1 cells) in response to viral infection and high levels of IFN-γ is associated with autoimmune disease. Raised levels of metal ions from hip resurfacing reduces the production of IFN-γ following stimulation with PHA. This finding has been patented for potential therapeutic use through MRC technology.


L. Rabenseifner H. Willert I. Lang

Introduction: Hip simulator tests, analyses of retrieved components as well as radiostereometric measurements revealed that cups made of highly linked polyethylene show a much better wear performance than cups of conventional polyethylene. However, to the best of our knowledge, histomorphological studies of tissues from the surrounding of highly cross – linked polyethylene components have not been reported yet. The aim of this study was to examine such tissues for particles, released from highly cross – linked polyethylene cups and to compare the findings with those of conventional polyethylene.

Material and methods: So far, periprosthetic tissues retrieved at revisions of 11 total hip endoprostheses with highly cross – linked polyethylene cups could be analysed. The revisions became necessary 3 to 50 months after implantation because of cup loosening (4), stem loosening (1), infection (3), periprosthetic fracture of the femur (1), multiple dislocations (1) and periarticular ossification (1). The findings were compared with those of 5 artificial joints (2 ABG, 2 Müller Cup older design, 1 Metalback pressfit) with conventional polyethylene cups and 54 to 231 months of function. 5 μm sections were made from the tissues and conventionally stained with HE and van Gieson. Morphometric measurements were done using objectives 10 and 40 of an Olympus microscope and the ‘Analysis’ program of Soft Ware Imaging GmbH. In the Durasul TM – cases, the total amount and the total area of particles were ascertained while in the cases used for comparison only random CX 40 samples could be measured because of the much higher content of particles.

Results: The DurasulTM cases showed in contrast to the cases with conventional polyethylene cups, no distinct foreign body reaction. In four of the DurasulTM cases no particles could be detected at all and in the remaining seven particles could be found only in a few areas. Their number per section was between 6 and 1208, their total area per mm2 section ranged between 0,03 and 6,99 × 10 5.mm2 In the conventional polyethylene cases the number of particles per section was between 2832 and 71447, their total area per mm2 section ranged between 1,06 and 25,91 × 10 3mm2! The average size of the DurasulTM particles was clearly bigger than the size of the conventional Polyethylene.

Discussion: The measurements in tissues of early revisions show that DurasulTM releases much less particles into the surrounding than PE and cause rather no foreign body reaction. Accordingly, the burden of the tissue with polyethylene debris is much lower while the particle size is bigger with DurasulTM than with PE.


P.K. Schraeder

Aim: To assess the volume-outcome relationship of total hip replacement means of a Health Technology Assessment and to assess the effects of a minimum provider volume regulation on medical care in Germany

Methods: Electronic bibliographic databases, the reference lists of relevant articles and various health services research-related resources were searched and selected studies were assessed using defined quality criteria. Additionally, the implementation of these results and its consequences – excluding hospitals and/or surgeons that do not perform a defined number of operations a year from medical care – for the German Health System were calculated on routine data basis of the German Health insurance. Several different cut-off points (20 operations per year/50 operations per year) and the respective consequences on medical care were calculated.

Results: 26 publications, that comprise in a narrower sense with the volume-outcome-relationship of total hip replacement, were assessed. The results in literature concerning defined outcome parameters are inconsistent, but a general correlation between high volume and low complication rate could be identified. In contrast a cut-off point, that is able to discriminate “good” from “bad” health care could not be deduced from the results in the literature. Methodological aspects of the performed studies concerning volume-outcome relationship are to be considered, too, i.e. study design, statistics, endpoint definition. In Germany 1264 hospitals performed 150.000 total hip replacements in 2005. Implementing a regulation based on minimum provider volumes of 20/50 total hip replacements/year would lead to an exclusion of 216 (17%)/483 (38%)hospitals respectively from medical care. This would result in a reallocation of 2214 (1.4%)/11.478 (7,4%) patients/ year respectively.

Conclusion: Importance of HTA reports and expected consequences on health care will even increase in Germany especially regarding recent legal context. A correlation between high volume and low complication rate in total hip replacement could be identified by means of HTA. Keeping these results in mind and knowing that in consequence hospitals/surgeons that do not perform a defined number of operations a year will be excluded from medical care, the application of a minimum provider volume regulation in the German health care system must be performed very sensitve, because significant effects are to be expected.


D.R. Neumann J. Berka U. Dorn

Aims: A polyethylene free, metal on metal acetabular system (Hofer-Imhof cup; Lubrimet metal on metal articulation made of CoCr-forge alloy) was designed in an effort to improve total hip arthroplasty longevity. This study was undertaken to review the clinical performance of this implant and to determine if acetabular loosening or revision and wear and osteolysis were prevalent.

The long term results (mean follow up period 110 months) are presented in this study.

Methods: In this prospective, randomized study a minimum of 90 months follow up results involving the first 100 implanted metal liner total hip arthroplasties are presented. The mean follow up was 110 months. Between April 1995 and November 1996 ninety-eight patients (100 hips) had a total hip replacement consisting of a titanium cementless self reaming, parabolic cup, a cementless titanium stem and the Lubrimet® metal on metal articulation.

Two acetabular and one femoral component had to be revised due to aseptic loosening without showing macroscopic evidence of metallosis and no histological evidence of excessive metal wear. One patient hat to be revised by a complete change of the total hip (acetabular component and stem) showing histologic evidence of a metal induced hyperergic immunologic reaction. One patient presented with a broken neck of the stem and had to be revised by stem exchange.

As a none device related orthopedic complication one acetabular component required revision surgery due to a periprosthetic fracture.

Conclusions: The long term results of the Hofer-Imhof Lubrimet®Metal-on-metal articulation are satisfying and so the system represented a viable alternative for total hip arthroplasty in younger higher demand patients in the past. Due to the possible development of a hyperergic immunologic reaction to the metal on metal articulation and the availibility of a ceramic on ceramic articulation we do not implant this liner anymore.


G.C. Georgiou S.M. Provelengios N.T. Vergados E.N. Voskaridou E.I. Valentis E.E. Dounis

We reviewed retrospectively the results of total hip arthroplasties that were performed at one institution in young patients who had different types of sickle-cell Haemoglobinopathies to ascertain whether this form of therapy for Osteonecrosis of the hip was appropriate.

MATERIAL-METHOD. Between 1991–2005, 40 patients (24 females-16 males) who have sickle-cell anaemia (12 pts) and microdrepanocytic disease (28 pts), underwent a THR (4 pts bilaterally).The average age at the time of the primary operation was 42.5 yrs (range 18–57 yrs). Cemented, hybrid or uncemented prostheses were used in all cases.

Usually 4–5 blood units are needed perioperatively. Prophylatic antibiotic therapy and anticoagulation treatment always is used.

RESULTS. At the follow-up one patient had died because of haematological complications while was in the hospital. Three others have died of unknown to us reasons. The mean follow-up was 6 yrs-7 mo.

Thirty-six hips re-evaluated and according the Harris Hip Score in 17 the result was excellent, in 15 good and in 4 fair.

The main problem, during the operation, was the difficulty to open the femoral canal, which was very narrow and in some cases completely closed and the bone cortex very dense.

One patient had a revision procedure in two stages for septic loosening seven years after the primary THR. Four patients had a revision procedure for aseptic loosening between one and ten years after the primary operation.

The more serious complications during the surgical intervention were fracture of the greater trochanter in four cases and fracture of the diaphysis of the femur in four, also, cases.

CONCLUSIONS. In this cohort of patients with the multiple medical problems and the frequent admissions, total hip arthroplasty offers a satisfactory solution to the hip problem. However accurate patient selection and carefull multidisciplinary pre-, intra-and post-operative approache is mandatory, including detailed pre-operative examination, close collaboration with the haematologist, pre-operative red blood cell exchange, perioperative use of antibiotics, intra-operative care for preventions of crises of sickling and finaly antibiotic therapy in cases of dental interventions or catheterisms


P. Hoekman I. Garba G. Djimraou D.B. Halidou

Hip arthrodesis is still a major option for the painful arthritic hip in the third world, where total hip prostheses are seldom available or too expensive for the patient. Various procedures for hip fusion have been described in the literature; they are often complex, frequently need a long period of post-operative immobilisation and are coupled with a considerable failure rate.

A new simple technique for hip arthrodesis is described without dislocating the hip preoperatively in order to maintain the oxygen concentration in the femoral head, using a self devised plate and requiring no post-operative immobilisation.

During a three year period the procedure was performed in 22 patients by the same surgeon. In all cases the indication for hip fusion was hip osteo-arthritis. The cause of osteo-arthritis was in 46% hip destruction by tuberculosis, in 23% aseptic osteonecrosis of the femoral head, mostly linked to sickle cell anaemia, in 8% complications of trauma of the hip, in 8% slipped upper femoral epiphysis and in 15% primary arthritis. Two had concurrent femoral osteotomy for correcting malposition of the limb and one had during the same procedure a femoral diaphysis osteotomy with placement of a Wagner elongating device in order to proceed with a callotasis. Mean follow up was 15.4 months. All hips, except one, achieved a solid fusion by radiographic and clinical criteria between 6 and 12 months after surgery. The failure of fusion was in the oldest patient (63 years) who presented loosening of plate and screws due to an advanced degree of osteoporosis. One superficial infection occurred that resolved under antibiotics.


A. Eslampour G. Goldberg A.S. Hilibrand R.H. Rothman J. Parvizi

Introduction: Many patients with DJD of the hip may have co-existent spinal arthritis. This prospective study sought to determine: how hip arthritis commonly presents, the incidence of low back pain- as identified by patients- before and after THA and the correlation between LBP and hip arthritis.

Methods: 344 consecutive patients undergoing THA were recruited prospectively at a single institution. A detailed questionnaire containing diagrams on which the patient could draw out the site of their pain was administered to all patients preoperatively and postoperatively. Detailed clinical, radiographic, and cross sectional imaging of all the patients were reviewed in detail by a hip surgeon, a spine surgeon, and a neurologist.

Results: 170 patients (49.4%) had true LBP which resolved in 63 patients (37%). Of the remaining 107 patients the back pain was of the same intensity following THA in 33 patients (30%) and had decreased in 74 (70%) patients. 22 of the 33 patients with continued LBP were known to have spine pathology. 35 patients developed LBP after THA.18 patients in the latter group were investigated further and 12 were found to have severe previously unrecognized spine pathology.

Discussion: Hip and spine arthritis often co-exist. Majority of patients with ‘back’ pain experience a complete resolution of their pain following THA so long as prior spine pathology did not exist. THA seems to be beneficial in reducing the symptoms even for those with a pre-existent LBP and spine pathology. A number of patients may develop LBP following THA that may relate to unidentified spine pathology. Patients with true LBP may benefit form evaluation of their spine prior to THA.


N. Aslam J. pan E. Schemitsch J. Waddell

Purpose: The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of posttraumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture.

Method: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25–78 years). The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow up. Thirty patients (32 hips) were available for latest follow up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment.

Results: Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p> 0.05).

Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05).

Conclusions: Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear.


J. George Malal A. Pillai G.A. Nimon

Background: Hip fracture is a serious injury mainly affecting the elderly population. The injury has a high mortality of 30% at 1 year and also has a major impact on the quality of life of the survivors. The Scottish Hip Fracture Audit has identified significant difference in the level of care provided in hip fractures between different hospitals and regions. The study aims to assess the impact of the experience of the operating surgeon on the long term outcome of hip fractures taking a cemented bipolar hip arthroplasty as an index procedure.

Materials and Methods: All patients who had the index procedure carried out over an eight year period at the Dumfries and Galloway Royal Infirmary were included in the study. Their preoperative mobility and health status along with the experience of the surgeon performing the procedure were determined. The outcome assessment was carried out using a modified Harris hip score.

Results: 46 patients were followed up at a mean of 45 months (range 16 to 109). One patient required a revision for aseptic loosening. Of the remaining, 18 procedures were carried out by consultant surgeons and 27 by trainees unsupervised. There was no statistical difference in the age, sex, ASA grade, preoperative mobility level or duration of follow up between the two groups of patients. The mean hip score at the time of follow up for the consultant group was 67.2 and 52.6 for the trainee group. This was statistically significant with a P value < 0.05.

Conclusion: The proportion of hip fracture surgeries done by, or under the direct supervision of a consultant orthopaedic surgeon vary widely between various Scottish hospitals (20% to 90%). The significant difference in long term out come of the procedure based on the surgeon’s experience calls for greater supervision and training of juniors.


J. cowie L.A. Khan J.A. Ballantyne I.J. Brenkel

Aim: To study the effect of smoking on the rate of complications and functional outcome after Total Hip Replacement (THR).

Methods: Data was prospectively collected for all patients undergoing a unilateral, primary THR in one hospital during the period 1998 to 2006 Data was collected at pre-operative assessment, in the peri-operative period and at 6 months, 18 months, 3 years and 5 years. Patients were placed in one of three groups; smokers, ex-smokers and those who had never smoked.

Outcome measures included rate of complications: infection, DVT, PE, length of hospital stay and Harris Hip Score (HHS).

Statistical analysis was undertaken to determine any correlation between smoking and these outcome measures using chi-squared tests, t-tests and multiple regression adjusting for confounding factors.

Results: 1765 patients underwent THR during the study period, of whom 635 were males and 1130 females, with a mean age at operation of 69.

268 patients (15%) were smokers, 582 patients (33%) were ex-smokers and 917 patients (52%) had never smoked. As there was little data available on when the ex-smokers had stopped smoking we studied current smokers compared to patients that had never smoked

There were no significant differences in complications such as DVT, PE, Deep infection and Superficial infection, these were all rare events. Neither was there any significant difference in hospital stay times. After adjusting for pre-operative HHS, age, sex and ASA status current smokers had significantly lower HHS at 6 months (p< 0.001, 95% confidence interval for effect size 1.6 to 5.3), and also showed a lower HHS at 18 months, 3 years and 5 years although not significantly so.

Conclusion: Current smokers have a significantly lower HHS post-operatively in comparison to non-smokers. In a health system where more and more patients wish to know the risk associated with potential operative interventions, we can now say that patients who smoke will have a poorer outcome post Total Hip Replacement. This may also allow us to discourage some patients wishing to have THR whom are poor operative candidates.

We plan to further analysis the data to try and ascertain why this is the case.


J. Cashman J. Larkin C. Collins G. Casey M. Whelan M. Tangney G. O’Sullivan

Background; We investigated, as a neoadjuvant to surgical therapy, the effect of a gene therapy of the primary tumour on the progression of minimal residual disease to overt liver metastases. The gene construct coding for the immunostimulatory molecules GM-CSF and B7-1 was delivered to the growing tumour by electroporation in Balb/C mice.

Methods; JBS fibrosarcomas were induced subcutaneously and were randomised at 80mm3 to control and treatment groups. One day prior to treatment, the portal circulation was seeded with tumour cells. Gene delivery was assessed by in vivo imaging, cytokine measurement and anti–tumour cytotoxicity (in vitro and in vivo). Responses were determined by liver examination.

Results; Gene expression and cytokine production was evident in treated tumours. Development of liver metastases was inhibited by neoadjuvant therapy in all 8 animals, in comparison to none of the control animals (n = 6) (average liver weight=0.99 g vs. 1.748 g. p< 0.03.) Metastases were confirmed histologically. Cytotoxicity studies and rechallenge confirmed development of specific T cell antitumour responses after gene therapy.

Conclusions; Immunogene therapy of the primary tumour induces effective anti–tumoural responses and inhibits the development of liver metastases. This strategy could be developed for neoadjuvant therapy of some human cancers.


N. Fabbri S. Schuster A. Toscano C. Errani M. Mercuri G. Bacci

Introduction: Secondary sarcomas of bone are a rare group of usually high-grade malignant tumors developing over different pre-existing bone conditions, historically associated with worse prognosis than their primary counterpart. Purpose of this study was to investigate the factors affecting the outcome, with emphasis modern multi-modal management.

Methods: From approximately 30000 bone tumor cases filed at our Institution, 87 patients with secondary sarcoma were identified. Secondary chondrosarcomas were not included and all the patients had an high-grade lesion. Patients were divided in 3 groups: radiation induced sarcomas (29), sarcomas in Paget’s disease (34), and sarcomas in benign lesions (24). Of these patients, 67 were admitted for treatment while 20 were consultations; of the 67 patients admitted, 44 had stage II while 23 had stage III disease. There were 57 males and 30 females, average age was 52. Most common histotype was osteosarcoma (81). Treatment varied from none to combined multimodal management including chemotherapy and surgery.

Results: Cumulative survival is 37% at 10 years. Survival was affected by stage of disease (II=54%, III=0%; p< 0.00005), site (extremities 44%, pelvis-spine 0%; p< 0.00005), inclusion of surgery in the treatment plan (yes 51%, no 0%; p< 0.00005), and type of treatment (combined chemotherapy and surgery 56%, surgery 39%; p=0.07). No differences were noted between the 3 main etiologic groups.

Conclusions: Secondary sarcomas are a rare group malignant tumors with heterogeneous clinical features. While stage and site are still the most relevant prognostic factors, modern multimodal management including neoadjuvant chemotherapy and surgery seems to favourably affect the outcome.


S. Syggelos P. Megas G. Kasimatis A. Kouzelis E. Lambiris

INTRODUCTION: Osteonecrosis of the femoral head usually affects young patients and is caused by disturbance of the femoral head’s blood supply. Bone subchondral necrosis eventually leads to articular incongruity and secondary arthritis of the hip joint.

AIM: To study the adequacy and outcome of tantalum rods implantation in patients with avascular necrosis of the femoral head (up to grade III, according to Ficat’s classification)

PATIENTS AND METHOD: 25 patients with 30 affected hips (5 with bilateral lesions) have been treated, the last 5 years, by tantalum rod implantation. The mean age was 37 years and the mean time of follow up 20 months (6–48), for 24 patients. In four hips we had type III lesions and in the rest type II.

RESULTS: The postoperative evaluation included radiological and clinical (Harris Hip Score – HHS) examination. All patients with type II osteonecrosis had a statistically significant increased HHS score, 6 months and 1 year after tantalum implanting. One patient, with a type III lesion, was subjected in total hip replacement because of disease’s progression, 1 year later. The two others had serious pain relief and improved range of hip motion.

DISCUSSION: Implantation of tantalum rods can be a method of choice in treatment of early stages of AVN of the femoral head. The implant achieves decompression, supports the subchondral plate of the necrotic areas and probably induces bone re-generation. Studies in more patients and with extended follow up time will be helpful for method’s evaluation.


P.M. Negrão Ramos M. Vieira da Silva R. Coelho R. Lemos J. Costa e Castro

Femoral head osteonecrosis is a progressive disease that affects patients in the third to the fifth decades. It is probably a multifactorial disease since many patients that have the known risk factors never develop it and others develop the disease without any risk factors.

There isn’t any totally effective treatment that can stop the disease and prevents bone collapse, but it is known that operative treatment gives better results than conservative treatment in Ficat stages I and II.

The authors began in October of 2003 the surgical treatment of pre-collapse patients (Ficat stage I and II) with the tantalum hip screw hopping that it could prevent progression to collapse.

The tantalum is an innovating new metal with an excellent bio-integration and with mechanic properties very close to normal bone. The tantalum hip screw gives structural support to the necrotic bone segment, permits immediate charging of the affected hip and pretends to be a substitute to peroneal graft.

There isn’t any published clinical result of the use of the tantalum hip screw in the literature to date.

Between the October of 2003 and November of 2004 we made 10 such procedures in 8 patients with mean age of 44 years. The patients were Ficat grade I and II and we could identify that most of the patients had been taking corticosteroid medication. There was one hip with less than 15% of extension and 9 with a severe extension (more than 30% of the femoral head from the University of Pennsylvania system of classification and staging).

There was rapid radiographic progression of the disease in all patients but one with bilateral involvement. There was progression for femoral head collapse in 70% of the patients despite the femoral hip screw. In 3 patients the collapse led to screw protrusion on the acetabulum and needed hip arthroplasty, on average, 12 months after screw implantation.

The harris hip score of the 5 patients (7 hips) than weren’t submitted to hip arthroplasty gave a good result in 1 patient and a fair result in 3 patients (4 hips). There was a poor result in the other patient.

The tantalum hip screw made it more difficult to do a hip arthroplasty but it didn’t make it impossible.

This study shows that the tantalum hip screw didn’t prevent the progression of the femoral neck osteonecrosis in all but one patient with an initial Ficat grade IIa.

The fact that 9 in 10 patients had a severe extension of the disease (> 30% of the femoral head diameter) could have prevented the success of the tantalum hip screw because the area of sustention of the screw was limited and the disease continued to progress around the screw.


D. Cumming A. Vince R. Benson

To assess the referral system, clinical notes and radiographs of patients presenting with metastatic disease of long bones in a regional oncology unit.

Thirty questionnaires were sent to oncologists asking about reasons for referral to orthopaedics and use of scoring system to assess risk of pathological fracture.

Ninety three percent of oncologists did not use a reliable scoring system to assess risk of pathological fracture. The majority referred in respect to pain on mobilising and the presence of a lytic lesion. Sixty percent felt an improvement in communication between the departments was required.

The notes and radiographs were reviewed of thirty-seven patients presenting with femoral metastatic lesions to the oncology department.

Sixteen patients had a Mirels score of greater than eight. Four patients were referred for an Orthopaedic opinion. All patients underwent prophylactic fixation. Twelve patients with a score of greater than eight were not referred. Seven of theses patients suffered a pathological fracture within three months.

Five patients had a Mirels score of 8. One patient had prophylactic fixation. No fractures occurred.

Sixteen patients had a Mirels score of less than 8. None of these patients were referred for an orthopaedic opinion. None of these patients had a pathological fracture within three months.

In conclusion, we presently do not offer a multidisciplinary approach to metastatic disease affecting the appendicular skeleton.

The majority of patients’ who score eight or above in the Mirels scoring system are at risk of fracture and do require prophylactic surgery.

In keeping with the BOA guidelines, “Metastatic Bone Disease: A Guide to Good Practice”, we would recommend that the introduction of a multidisciplinary approach and the use of a recognised scoring system is essential to improve patient care.


H.R. Dürr S. Seitz C. Weis C. Von Schulze Pellengahr V. Jansson

Introduction: Due to an increase in survival skeletal metastasis becomes a significant factor on life quality in carcinoma patients. Also shown in publications of the last years the surgical approach and the expected prognosis are very much based on the primary. Especially patients with breast carcinoma show very long survival times, which must be considered in choosing the adequate surgical approach. Aim of this study was to proof that on a large collective of consecutively treated patients.

Methods: Between 1980 and 2005 115 patients with metastatic disease to the bone due to breast carcinoma had been surgically treated. In 112 female and 3 male the mean age at surgery was 58 years (17–84 years). Retrospectively location and extension of the disease, symptoms, surgical approaches, complications, recurrencies and survival time had been evaluated.

Results: The most often peformed procedure was a decompression with or without stabilisation of the spine in 42 cases. Four vertebroplasties had been additionally performed. The proximal femur had to be reconstructed with an endoprotsthetic device in 24 cases, an endoprostehtic reconstruction of the humerus was necessary in 2 patients, of the pelvis in one case. One diaphyseal prothesis was implanted. Two resctions/amputation without any reconstruction had to be performed. In 20 cases a compound osteosynthesis, in 19 cases a biopsy only was done. In most of the cases postsurgical radiation was administered in some cases preoperative radiation had been applied. Follow-up was done 1 to 26 years after surgery (average 11.7 years).

Many pateints showed an extented survival despite disseminated disease with a high and quality of life. Radical resection as tried in a few patients did not proof to be beneficial regarding the prognsotic effect.

Conclusions: Patients with skeletal manifestations of breast carcinoma showed long survival times despite extented disease. The intralesional surgical approach including radiation therapy showed a better functional outcome in comparison to radical procedures with no disadvantage in survival time or local recurrencies.


S.P. Kelley R. Ashford A. Rao R. Dickson

INTRODUCTION. We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the spine since establishment in 1958 until year 2000.

AIM. To analyze the incidence of primary tumours of the spine and to record the site of occurrence, sex distribution, survival and pathology of these tumours.

Summary of the Background Data. Primary tumours of the spine are particularly rare, accounting for between 4% and 13% of published series of primary bone tumours.

METHOD. The Leeds Bone Tumour Registry was reviewed and a total of 2750 cases of bone tumours and tumour-like cases were analyzed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry.

RESULTS. Primary bone tumours of the osseous spine constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was multiple myeloma and plasmacytoma. Osteosarcoma ranked third. The mean age of presentation was 42 years and pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis,

CONCLUSIONS. The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.


K.C. kose O. Cebesoy B. Akan L. Altinel D. Dinçer T. Yazar

Introduction: This is a retrospective study to determine the effects of vertebroplasty and kyphoplasty on quality of life in multiple myeloma patients with spinal compression fractures.

Material and Methods: Thirty-four patients with primary multiple myeloma were treated for symptomatic compression fractures between June 2003 and June 2005. Kyphoplasty was applied to 22 levels in 18 and vertebroplasty to 28 levels in 16 patients.

The pain-related disability was evaluated for every single daily living activity using visual analog scale (VAS) over 10 points. (pain at rest, walking, sitting–standing, taking a shower and wearing clothes). (This evaluation is performed to every patient with degenerative disorders of the spine upon admission to our clinic.) Overall VAS scores were evaluated over 50 points (0 minimum, 50 maximum) preoperatively, at postoperative six weeks, six months and at one year prior to taking analgesics.

The amount of analgesic use was recorded. Data was analyzed statistically using variance analysis, Friedman’s multiple comparison test and Student’s t test.

Results: The mean overall pain score in the kyphoplasty group decreased from a preoperative value of 36 to 12.13 at the sixth postoperative week, to 8.63 at the sixth month and to 9.72 at one year. (p< 0.001).

The mean overall pain score in the vertebroplasty group decreased from a preoperative value of 37.83 to 15.33 at the sixth postoperative week, to 12.17 at sixth months and to 13.47 at one year. (p< 0.001).

Student’s t test was used to analyze the percentage of differences in overall pain score. Difference between groups was not statistically significant at the sixth week (p=0.106) but was statistically significant both at the sixth month (p=0.024) and at one year (p=0.027) in favor of kyphoplasty group.

No secondary collapse was observed in adjacent levels in both groups. There were no intrapostoperative neurologic/pulmonary complications in both groups. Analgesics usage significantly decreased in both groups.

Conclusion: In multiple myeloma, when pathological spinal compression fractures cause intractable pain and are unresponsive to conservative treatment, both vertebroplasty and kyphoplasty are effective in increasing quality of life and decreasing pain.


N. Fabbri G. Farfalli G. Gamberi S. Benassi A. Briccoli M. Mercuri

Introduction: Giant Cell Tumor (GCT) is rarely associated with lung metastases (1–4%). No prognostic factors have been reliably associated with the occurrence of lung metastases.

Since high levels of urokinase-type plasminogen activation system have been associated with cancer metastasis, purpose of this study was to investigate its expression in patients with giant cell tumor and the relationship with outcome.

Materials and Methods: Expression of urokinase-type plasminogen activation system was evaluated by immunohistochemistry in the primary lesion of 65 patients with GCT. This included urokinase-type plasminogen activator (u-PA), plasminogen activator inhibitor type 1 (PAI-1), and u-PA receptor (u-PAR). Patient population consisted of 12 cases that developed lung metastases and 53 cases that did not show metastases at last follow-up. Clinical outcome of the 2 groups was retrospectively reviewed and correlated with u-PA, PAI-1 and u-PAR expression levels.

Results: Overexpression of u-PA, PAI-1 and u-PAR was more frequent in the metastatic (92%) than non-metastatic (21%) group (p< 0.0005). Incidence of local recurrence was higher in the metastatic (67%) than non-metastatic (30%) group (p=0,024). Risk of re-recurrence after 1st local recurrence was more than 4 times higher in the metastatic than non-metastatic group (p=0.05). No differences were observed in the 2 groups with respect to age, sex, site, stage, treatment, follow-up and mortality.

Conclusions: Overexpression of urokinase-type plasminogen activation system in this study associated with an increased risk of lung metastases, local recurrence and local re-recurrence. Evaluation of urokinase-type plasminogen activation system expression levels may identify a subgroup of patients with increased risk of relapse


S. Bhatnagar H. Murata A. Abudu R. Grimer S. Carter

We reviewed the treatment and clinical outcome of 32 consecutive patients with Ewing’s sarcoma who presented with or developed pathological fracture after biopsy between 1984 and 2004. The minimum follow-up was 18 months. The mean age at diagnosis was 20 years (5 – 51). There were 18 males and 14 females. All patients were newly diagnosed and had localized disease at the time of diagnosis. 21 patients presented with pathological fracture while 11 patients developed fracture during the course of chemotherapy. The femur was the most common location in 15 patients.

All the patients had chemotherapy according to the protocol current at the time of treatment. 6 patients had radiotherapy alone while 26 patients underwent surgical excision and reconstruction. Of the patients who had surgery, 7 patients had adjuvant radiotherapy. Fracture healing was the norm after pre-operative chemotherapy. Surgical margins were wide in 17 patients, marginal in 4 and intralesional in 3 patients.

Local recurrence developed in one patient (3%). Metastases occurred in 12 patients (37%). At the time of review 16 patients were free of disease, 3 were alive with disease and 13 patients had died of disease. The cumulative 5 year metastases free and overall survival in all the patients was 58% and 61 % respectively and similar to patients with Ewing’s sarcoma without fracture treated at our centre. The prognosis of patients who presented with fracture was exactly similar to those who developed fracture in the course of treatment.

We conclude that limb preserving surgery is perfectly safe in patients with Ewing’s sarcoma who have associated pathological fracture and survival is not in any way compromised. Survival of patients who present with fracture is similar to those who develop fracture in the course of treatment. The exact role of adjuvant radiotherapy in these patients needs to be clarified.


V. Potenza P. Farsetti R. Caterini C. Tudisco F. De Maio F. Mancini E. Ippolito

Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1.

At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected.

The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open.

At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age.

Conclusions: An association of distal radial wedge-closing osteotomy and either distal ulnar hand resection or shortening distal ulnar osteotomy to correct Madelung’s deformity gave very good results in line with other reports. The limited number of our cases may be compensated by the very lengthy long-term follow-up of our series that showed how the results of these corrective operations do not deteriorate in time; moreover no radiographic osteoarthritis was present even almost 50 years after the operation.


Objective: To evaluate per-operative and postoperative complications following surgical correction of neuromuscular scoliosis and assess the amount of radiological correction of Cobb’s angle and pelvic obliquity angle.

Design: Retrospective study of 25 consecutive patients with neuromuscular scoliosis (10 Duchenne Muscular Dystrophy, 8 Cerebral palsy, 2 Neurofibromatosis, and 1 each of Spinal Muscular Atrophy, Friedrich’s Ataxia, Spina Bifida, Rett’s Syndrome and incarcerated hemi-vertibrae) who had surgical correction for their spinal disorders between 1999 and 2002.

Background: Aims of surgical correction in neuromuscular scoliosis include improving sitting ability, cardio-respiratory function and cosmesis. Patients studied underwent a combination of anterior release, posterior spinal fusion and pelvic fixation. Due to the length and complexity of procedures many of these patients need two stage surgical procedures on two separate occasions to achieve this goal. However our practice is performing these two stage procedures in one sitting with post operative ITU support.

Results: Patients were aged between 4 and 16 years of age with mean preoperative Cobb angles of 75.9° and pelvic obliquity of 18°. A mean correction of 55.8° of Cobb angle and 12° of Pelvic obliquity were achieved. We had mean operating time of 413 minutes with a mean blood loss of 50.2 ml/ Kg body weight. All patients were admitted to ITU post operatively with a mean stay in ITU of 5.8 days. All patients achieved clinical and radiological spinal fusion. Instrumentation had to be removed from one patient after fusion because of persistent infection.

Conclusion: Surgery for Neuromuscular Scoliosis is time consuming and complicated. With anticipation of blood loss, complications and ITU support, we can successfully perform the two-stage procedure in one sitting.


M. Ramachandran A. Schindeler C. Godfrey M. McDonald D. Little

Background: Recombinant bone morphogenic proteins (BMPs) are potent bone anabolic agents suggested for the treatment of orthopaedic complications associated with neurofibromatosis type 1 (NF1), in particular, congenital pseudarthrosis of the tibia. We have explored the effect of Nf1 haploinsufficiency on ex vivo and in vivo models of BMP-induced bone formation in Nf1+/− mice.

Methods: Using an Nf1+/− knockout mouse model, we expanded primary cell cultures from calvarial and long bone osteoblasts and measured osteogenic markers, such as alkaline phosphatase and mineralization using Alizarin Red staining, and the responses of these markers to BMP-2 treatment. We also developed an in vivo muscle pouch heterotopic ossification model to assess the ability of BMP-2 to form bone.

Results: Primary osteoblast cultures from Nf1+/− mice showed reduced ALP staining, ALP activity and mineralization, denoting an anabolic deficiency. Nf1+/− osteoblasts responded to BMP-2 treatment, although osteogenic markers were reduced compared to BMP-2 treated Nf1+/+osteoblasts. Heterotopic bone was induced in both genotypes by surgically implanting BMP-2, however less bone was formed in Nf1+/− mice than Nf1+/+ controls.

Conclusion: These data indicate that BMP therapies have potential utility in treating orthopaedic defects in children with NF1, but that dosing may need to be optimized for this patient subgroup or that catabolism may need to be also controlled.


R.A. rajan J. Pagdin S. Jones J. Fernandes

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index.

Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers.

Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences.

Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing.


KYPHOPLASTY IN BONE TUMOURS Pages 137 - 137
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S.W. Becker J. Meissner A. Chavanne A. Tuschel M. Ogon

Kyphoplasty is an efficient tool in the treatment of primary tumours (plasmocytoma) and osteolytic metastasis. Especially in plasmocytoma the current chemotherapy has increased life expectancy significantly. Therefore minimal-invasive stabilisation is not only a palliative treatment but really increases quality of life in those cases.

Kyphoplasty offers several special tools and techniques to lower the leakage rate which is especially high with other cementoplasty techniques in the osteolytic spine.

Materials and Methods: Prospective study of all vertebral tumours compared to osteoporotic fractures treated with kyphoplasty in 2004. 6 months follow up with VAS, SF36 and Oswestry score.

Results: In 2004 we performed 67 Kyphoplasties. 12 kyphoplasties were performed in tumour cases (5 plasmocytoma and 7 metastasis). No complications occurred during surgery and during hospital stay. Follow-up included 11 tumours (1 death during F/U) and 46 osteoporotic fractures. 1 patient was treated with combined decompression/kyphoplasty. The pain level (VAS) was significantly reduced in all cases within 2 days (osteoporotic group 2,2 – tumour group 5,4) and reached nearly the same result after 6 weeks which persisted for 6 months (osteoporotic group 1,6, tumour group 2,1). The SF 36/Oswestry Score improved accordingly in both groups. At 6 weeks and 6 months F/U no statistical difference in the scores was seen.

Conclusion: Kyphoplasty is a safe treatment method for osteolytic vertebral tumours with vertebral collapse. Clinically the results don’t differ from conventional cases. In cases with canal compromise, a combination with open techniques is possible. Special kyphoplasty techniques allow a reconstruction of the lytic wall and minimise leakage and cement dislocation. Significant improvement of life quality can be achieved offering the spine surgeon a valuable tool in the treatment of spinal metastasis.


K.L. Devalia P. Moras S. Jones J. Pagdin J. McMullan J.A. Fernandes

Aim: Spinal stenosis is a known entity in achondroplasia and a need for screening for the symptomatic children was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether clinical and radiological imaging would identify the at risk group.

Materials and methods: 205 achondroplastic children were treated at our service in the last 20 years. A prospective clinical screening programme for spinal stenosis which also included the MRI imaging of entire spine was however introduced only in 1996. 26 patients were available for this study. Case notes were reviewed for clinical symptoms and neurological signs. MR images were assessed for stenosis especially at Cervico medullary junction and lumbar level. Canal diameters were measured at all spinal levels from CMJ to lumbo-sacral junction. Neurosurgical interventions were recorded. An attempt was made to identify high risk factors that required surgical intervention.

Results: Delayed milestones were observed in 7 patients. Positive history of back pain or radicular pain was obtained in 10 whereas 10 patients had symptoms of neurogenic claudication. Brisk reflexes and clonus were consistent findings. Severe foramen magnum narrowing was observed in 23 patients and 13 showed ‘kinking’ or ‘pinching’, suggesting severe compression. Of the 17 patients seen by neurosurgeons 6 required single or multiple surgical decompressions. Ventriculo-peritoneal shunt was inserted in 4. 5 children required CMJ decompression and one required lumbar canal decompression. There was a 7 mm difference in AP diameter measured on MRI at CMJ between the two non operated and operated groups. Female patients with delayed milestones and CMJ narrowing to less than 25 mm were identified as high risk.

Conclusion: The cause of increased morbidity and mortality in young achondroplasts is attributable to severe CM compression. Sudden death can occur by acute or gradual progressive encroachment of respiratory centre at medulla oblongata. We were able to identify symptomatic patients early before developing myelomalacia and cord changes by screening all symptomatic children with achondroplasia. We propose that female gender, especially with delayed milestones as another high risk factor. We stress upon the importance of developing a nationalised selective screening programme with guidelines in specialist orthopaedic and joint multi-disciplinary Skeletal Dysplasia clinics.


P. Baker R. Nanda P. Proctor B. Hanusch W. Eardley J. Hovenden I. Mcmurtry

Background: In recent years an increased trend in MRSA infection has been seen in hospitals and the community, with colonisation rates of between 4 – 17% reported in these patient groups. There is also an association between carriage of Staph. Aureus and staphylococcal surgical wound infection.

In our institution there has been concern regarding MRSA surgical site infection and possible cross contamination of elective and emergency patients. There would be implications for implant related infections if this were to occur. This had prompted the unit to consider adopting a screening programme to identify and treat MRSA carriers. This would aim to minimise risk of post operative infection and cross infection. As little was actually known about the MRSA colonisation rates of admissions to our hospital we undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.

Aim: To ascertain the incidence of colonisation with MRSA, rate of wound infection and the associated risk factors in patients admitted to the trauma ward with a fractured neck of femur.

Method: A prospective, blinded case series of 100 consecutive patients admitted to the trauma ward with a fractured neck of femur. Three swabs (axilla, nasal and perineum) were taken within 24 hours of admission. Data from each patient was collected to ascertain the presence of risk factors linked to MRSA colonisation and each patient was followed until discharged to assess for surgical site infection.

Results: 304 swabs were taken from 100 patients. Age range 60–97. 26% admitted from institutionalised care and 74% admitted from their own home. Four patients were colonised with MRSA on admission (2 nasal, 2 perineal). An association was seen between patients colonised on admission and long term or recent residence in institutionalised care. One of these patients went on to develop colonisation of the surgical wound however this did not lead to surgical site infection and the patient was successfully treated with MRSA eradication therapy only. In these 4 patients all wounds healed satisfactorily with no evidence of infection.

There were three superficial surgical site infections postoperatively, all in individuals who were clear on their admission screening. Of these two were due to MRSA and one was due to MSSA. There were no cases of deep infection requiring further surgery.

Conclusion:While MRSA continues to be a growing concern we found that, in our hospital, rates of MRSA colonisation and subsequent infection were not high. There were no documented cases of MRSA wound infection in colonised individuals. Given the cost involved in swabbing all patients to detect these low levels of colonisation we do not feel that an expensive screening regimen would be cost effective or justified in our institution.


F.J. Teixeira P. Coutinho E. Rodrigues N. Tavares F. Coelho

Introduction: Treatment of supracondylar and intercondylar fractures of the distal femur is a challenge for most orthopaedic surgeons and has been changing for the last few years with the introduction of retrograde nailing.

Methods: The authors review all type A and C fractures submitted to surgical treatment, in our department, in the period between 1995 and 2005.

Of the 120 fractures (in 117 patients), 16 were excluded from our study (10 patients were followed in other institutions and 6 died of non-related causes).

From the total of 104 fractures reviewed 77% had been submitted to rigid internal fixation with extramedular devices (95 Blade plates, DCS, Condylar plates, etc) although in the last few years (since 2000) the use of intramedular retrograde nailing has became the standard form of treatment (16 type A and 8 type C, including 2 C3).

Results: Despite the gap in follow-up (96,5 months in the extramedular group and 39,6 months in the intramedular) significant differences were observed regarding: inicial and late complications, time to fracture healing, non and mal-unions, need for re-operation, final clinical results and patient satisfaction.

Conclusions: Retrograde nailing of the femur is a simple technique which allows early mobilization of the knee while maintaining excellent stabilization of the fracture. It’s a more biological fixation, it offers greater soft tissue preservation and lesser need for bone grafting.

In our experience the application of retrograde nails in type A fractures and the combination of multiple screws fixation and retrograde nails in type C fractures provide the best results.


W.G. Rodkey K.K. Briggs

Introduction: Meniscus loss increases the rate of knee degeneration, leading to additional surgeries or even knee replacement. We determined if replacement of lost meniscus tissue with the Collagen Meniscus Implant (CMI) decreased the need for additional surgeries in multi-operated chronic knees by performing a statistical “survivorship” analysis.

Methods: Patients 18 to 60 years old who had undergone one to three prior partial medial meniscectomies and currently had clinical symptoms of meniscus pathology were prospectively randomized (Level of Evidence I) either to receive the CMI or have an additional partial meniscectomy and serve as controls. Seventy-seven CMIs were implanted, but 5 were removed within 6 months for technical reasons. Those five patients were excluded from this analysis. The remaining 72 CMIs were compared to 66 meniscectomy only controls over 4 years to determine survivorship. “Survivorship” was defined as not having a second surgery on the study knee.

Results: Four CMI (6%) and 12 control patients (18%) required reoperation through 4 years. Survivorship at one year was 89% for control and 97% for CMI patients, 87% for control and 95% for CMI patients at 2 years, 83% and 94% respectively at 3 years, and 79% for control and 94% for CMI patients at 4 years. CMI patients had a significantly higher survivorship than controls (p=0.02). Confidence interval (CI) analysis revealed that meniscectomy only control patients were 3.8 times [CI 95%: 1.2 to 12.4] more likely to require repeat surgery than CMI patients who retained the implant.

Conclusion: In those patients who retained the implant, the CMI decreased the need for additional surgery for chronic knee injuries in multi-operated patients. The additional tissue regeneration supported by the CMI may decrease or minimize progression of degenerative changes and reduce the necessity for additional surgeries.


I. Ohnishi T. Matsumoto J. Matsuyama M. Bessho S. Ohashi W. Sato H. Okazaki K. Nakamura

Ring frames have the advantage of allowing progressive correction. However, the available frames for complex deformities are heavy and bulky leading to poor compliance by patients. Also, the mounting procedure requires considerable expertise and skill. On the other hand, a unilateral external fixator has the advantages of less bulk and a lighter weight. Thus, it causes less disability and can achieve better patient compliance even with bilateral application. However, previous unilateral fixators have had various limitations with respect to deformity correction, such as restricted placement of hinges, restricted correction planes, and a limited range of correction angles. In addition, it was impossible to achieve progressive correction while fixation was maintained. To overcome these disadvantages of existing unilateral fixators, we developed a new fixator for gradual correction of multi-plane deformities including translational and rotation deformities. This unilateral external fixator is equipped with a universal bar link system. The link is constructed from three dials and two splines that are connecting the dials. The pin clamps are able to vary the direction of a pin cluster in the three dimensional planes. The system allows us to correct angulation, translation, rotation, and the combination of the above. In addition, open or closed hinge technique is available because the correction hinge can be placed right on the center of rotational angulation (CORA), or at any desired location, by adjusting the length of the link spline. By increasing the spline length, the virtual hinge can also be set far from the fixator. Gradual correction can be performed by rotating the three dials using a worm gear goniometer that is temporarily attached. A 3D reconstructed image of the bone is generated preoperatively. Preoperative planning can be done using this image. Mounting parameters are determined by postoperative AP and lateral computed radiography images. These postoperative images are matched with the pre-operative 3D CT image by 2D and 3D image registration. Then, the fixator can be virtually fixed to the bone. By performing virtual correction, it is possible to plan the correction procedure. The fixator is manipulated by rotating each of the three dials to the predetermined angles calculated by the software. Static load testing disclosed that the fixator could bear a load of 1700 N. No breakage or deformation of the fixator itself was recognized. Mechanical testing demonstrated that this new fixator has sufficient strength for full weight bearing, as well as sufficient fatigue resistance for repeated or prolonged use. The results of clinical application in patients with multi-plane femoral deformities were excellent, and correction with very small residual deformity was achieved in each plane.


A.S. rajeev M. pullagura J. pooley

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humero-ulnar (medial) compartment remains remarkably well preserved. The significance of this post-mortem findings,in an elderly population, with unknown elbow symptom logy, who died from diverse causes, is unknown. There has been no clinically based,in vivo,study of this subject. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought.

We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment.

The findings presented in this work are in full agreement with previous work on the articular wear and biomechanics of the elbow joint. Previous studies which have been on cadaveric specimens, with findings of uncertain symptomatic relevance. To our knowledge, this finding has not previously been demonstrated in a symptomatic, young population. Unicompartmental lateral degeneration of the elbow is therefore a real clinical entity rather than a interesting post mortem finding. As such, it demands consideration in terms of investigation, diagnosis and treatment. It is likely that in the past, many patients have been misdiagnosed as having chronic lateral epicondylitis.

We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treatment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes.


D. Lazzara G. Di Muria M. Marcucci A. Trombetta

We will report the clinical and radiographical results of a comparison between conservative and surgical treatment of Perthes disease after an average period of 25 years. All the children were observed at Orthopaedic and Traumatologic Center (CTO) of Florence between 1962 and 1989.

Patients and Methods: Nineteen patients (20 hips) treated surgically using femoral and/or pelvic osteotomies and twenty patients (21 hips) treated conservatively with pelvi-podalic casts and no weight bearig were clinically (Harris Hip Score) and radiographically (Mose, Sharp, Stulberg criteria) evaluated after an average period of 25 years (16 to 43 years), by usig an A-P hip and pelvic view and a frog-leg view of both hips. All the children were radiographically evaluated using Catterall’s and Herring’s criteria. In the “surgical group” there were 10% of cases in the I, 30% in the II, 25% in the III and 35% in the IV group of Catterall classification. In the “conservative group” these percentages were 28%, 19%, 34% and 19% respectively.

Results: In the surgical group 13 patients had an eccellent clinical result (100 to 90 points), 4 good (89 to 80), 1 fair (79 to 70) and 2 poor (< 70 points), with an average Harris Hip Score of 89,8 (57 to 100). In the conservative group there were 16 eccellent, 2 good, and 3 poor results, with an average Harris Hip Score of 98,5 (55 to 100). Using Stulberg’s criteria we had good results (I and II class) in 86% of the cases in the “conservative group” and 70% in the “surgical group”.

Discussion: We correlated clinical and radiographical signs to find out if any of these sign can be predictive and we found that the most important factor was the age of symptom’s beginning. When symptoms started before 5 years old, 95% of the hips were in I and II class of Stulberg. After 5 years this percentage was only 64%. However we will report even the other clinical-radiographical correlations.


N. Ihme S. Schroeder S. Dernbach

A slipped capital femoral epiphysis (SCFE) can be fixed in-situ with K-wires or screws. For the latter is said that one disadvantage is the lack of femoral neck growth. Assumed reasons for this is despite an injury of the physis by the often too long thread the missing lubrication of the screw in the bone.

The following study evaluates the amount of remaining bony growth and method-depending complications in screw fixation of SCFE.

Method: All children with titanium screw fixed SCFE and completed growth were evaluated retrospectively. For percutaneously fixation a cannulated titanium screw (Fa. Firma Königsee) was used. With help of the postoperative X-ray follow-up in two dimensions the remaining bony growth was assessed. Further parameters were possible complications like AVN, misplaced screws, problems in removal of the screws and duration of surgery.

Result: 40 patients with 49 SCFEs were treated bilaterally with cannulated screws in the time period 1999 to 2005, 4 got an additional closed reduction. In 6 cases a correction osteotomy was performed. The contralateral hips off these patients were enclosed in the study. The average growth of the femoral neck was 6 mm both at the healthy and SCFE-hip (Range 0–19mm) and depended not on the degree of dislocation. None had a premature closure of physis. In 2 cases screws were changed due to excessive growth despite a growth reserve in screw length of 1 cm. 1 acute and 4 of 7 acute-on-chronic slips developed a clinically relevant AVN.

In 20 patients we tried to remove the screws after completed growth. This was possible in 30% minimal invasively and in 30% with open surgery. In 40% parts of the screws or even the whole screw remained in situ. Time of surgery for bilateral screw pinning was 51 minutes, for removal 91 minutes in average (34–278).

Discussion: The percutaneously fixation of SCFE with cannulated screws is a save and easy procedure that allows further bony growth of the femoral neck and remodelling but is more than difficult to remove the titanium screws due to bony integration. One screw is sufficient for fixation, secondary dislocation does not happen. We recommend the use of cannulated steal-screws with a backward incisive thread. Titanium screws should be used only in cases of a high risk of AVN to allow the early control of femoral head blood flow with MRI.


U. Schütz W. Puhl

Introduction: The new anatomical adapted stem system OptanTM (Zimmer) is presented, showing the first mid-term-results for cemented and cementless fixation. Its cross-section in the proximal area corresponds with its antetorsion, anteversion and helitorsion, to the 3D-morphology of the proximal femur.

Material and Methods: 313 Optan stems (175 cemented, 148 cementless) were implanted in 306 patients (mean age 62.1 y. (20–74 y.), m/f-ratio 0,8). The clinical and radiological parameters for calculation of Harris Hip Score (HHS), Merle d’Aubigné (MD), WOMAC and periprosthetic bone reaction (Gruen et al.) were recorded. An implant migration analysis using two different biplanar radiographic digital measurement systems (DMA, UMA) was done also.

Results: The clinical results for latest follow up examination (5 and more y.p.o.) for cementless (cemented) Optan are: HHS mean (m) 97.6, standard deviation (SD) 7.32 (m 95.1, SD 9.85), MD m 17.6, SD 1.04 (m 17.1, SD 1.48), WOMAC m 1.44, SD 1.56 (m 1.75, SD 1.62). Cemented implantation shows a stable radiographic follow up regarding full cement mantle without any periprosthetic bone adaptations. The SD for the varus-valgus angle rises proportional to the thickness of the cement layer. Only little flattening of the calcar cortical bone (Z7b) could be seen in both, cemented and cementless Optan 2–3 years p.o.. No stem migration was evident in both fixation principles. No relevant osteolyses and cortical bone hypertrophies could be seen. 12 dislocations (closed reposition), 2 femoral fissures (all while cementless fixation), 2 septic loosenings and 1 aseptic loosening were documented till now. Radiographic results of cementless stem show a low rate (29,1%) of secondary endostal reactive line formation in the distal part of the stem (Z3,4,5) beginning 6–12 month postoperative, especially when drilling of femoral bone canal was done. When the distal part of the stem (Z3,5) was fixed directly to cortical bone little hypertrophy of the cortical bone gets relevant 4–5 years p.o. in a few cases.

Conclusions: Compared with other anatomical stems the cementless Optan shows excellent midterm results. The clinical results of the cemented fixation are not quite so good, this may be related to the older mean age of the patients with cemented stem fixation. Among other things, the development of the Optan-stem had the aim, to make an interoperative change of fixation technique easier. Using the same stem design the decision about the fixation type can be made intraoperatively in the last second.


I. STEFANOVSKA

The aim of the study is to evaluate the prognostic value of Herring’s classification for treatment planning of Perthes Disease and predicting the final outcome of the disease.

We analysed 45 patients treated in our department in the period of 1992 – 2005. The analysis consisted of determining the lateral pillar collapse in fragmentation stage and the containment of the femoral head in the residual stage. We did retrospective analysis of the x-rays in fragmentation stage and classified the patients according to Herring’s classification. Group A included 10 patients, group B – 20 patients and group C included 15 patients. We used Hayman – Herndon Acetabulum – Head Index (AHI) to analyse the x- rays in the residual stage. The statistical analysis of the results included the analysis of the differences between the lateral pillar collapse among the groups and the differences between affected hip and the contralateral control hip. Correlation between the degree of lateral pillar collapse and the AHI in the residual stage was also analyzed. Correlation between the age of onset of the disease and AHI was determined for each group, too.

The results show significant differences between the lateral pillar collapse in Herring groups, and among the affected and control hips. Differences of AHI values were also significant between the groups. Correlation between the AHI and lateral pillar collapse for each group shows moderate connection just as the one between AHI and age.

Herring’s classification is reliable in classifying patients with Perthes disease. It enables good prediction of the natural course of the disease and thus influences the treatment decision-making


B.M. Jolles H. Dejnabadi E. Martin C. Voracek C. Pichonnaz P.F. Leyvraz K. Aminian

Introduction: Coordination is a strategy chosen by the central nervous system to control the movements and maintain stability during gait. Coordinated multi-joint movements require a complex interaction between nervous outputs, biomechanical constraints, and pro-prioception. Quantitatively understanding and modeling gait coordination still remain a challenge. Surgeons lack a way to model and appreciate the coordination of patients before and after surgery of the lower limbs. Patients alter their gait patterns and their kinematic synergies when they walk faster or slower than normal speed to maintain their stability and minimize the energy cost of locomotion. The goal of this study was to provide a dynamical system approach to quantitatively describe human gait coordination and apply it to patients before and after total knee arthroplasty.

Methods: A new method of quantitative analysis of interjoint coordination during gait was designed, providing a general model to capture the whole dynamics and showing the kinematic synergies at various walking speeds. The proposed model imposed a relationship among lower limb joint angles (hips and knees) to parameterize the dynamics of locomotion of each individual. An integration of different analysis tools such as Harmonic analysis, Principal Component Analysis, and Artificial Neural Network helped overcome high-dimensionality, temporal dependence, and non-linear relationships of the gait patterns.

Ten patients were studied using an ambulatory gait device (Physilog®). Each participant was asked to perform two walking trials of 30m long at 3 different speeds and to complete an EQ-5D questionnaire, a WOMAC and Knee Society Score. Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. The outcomes of the eight patients undergoing total knee arthroplasty, recorded pre-operatively and post-operatively at 6 weeks, 3 months, 6 months and 1 year were compared to 2 age-matched healthy subjects.

Results: The new method provided coordination scores at various walking speeds, ranged between 0 and 10. It determined the overall coordination of the lower limbs as well as the contribution of each joint to the total coordination. The difference between the pre-operative and post-operative coordination values were correlated with the improvements of the subjective outcome scores. Although the study group was small, the results showed a new way to objectively quantify gait coordination of patients undergoing total knee arthroplasty, using only portable body-fixed sensors.

Conclusion: A new method for objective gait coordination analysis has been developed with very encouraging results regarding the objective outcome of lower limb surgery.


A. Nisar A. Salama J. Freeman A.G. Davies

Aim:This study was carried out to assess various factors responsible for the development of avascular necrosis and the effect of treatment on clinical outcome.

Methods: We studied the clinical notes and radiographs of patients presenting with SCFE during the period between 1994 and 2003.

Results: Seventy three patients (n=73) with ninety two (n=92) hips were included in the study. There were 16 acute, 43 acute-on-chronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slips were classified as stable and 15 as unstable slips. Fifty three slips (57.6%) were mild, 34 (37%) were moderate and five (5.4%) were severe slips. Despite no deliberate attempts to reduce the slip at the time of surgery eighteen hips (n=18) showed a median decrease in slip angle of 8 degrees (range 2–36) in acute and acute-on-chronic slips. The mean preoperative slip angle was 32 degrees (range 9–76) compared to postoperative slip angle of 29.9 degrees (range 10–75) (p=0.004). Four patients developed avascular necrosis (AVN). Intraoperative reduction of the slip was significantly related to development of AVN (p< 0.001). According to the criteria of Heyman and Herndon eight patients had functional deficit at the time of final follow up and clinical outcome was fair, poor or failure. All of these patients had a reduction in the angle of slip at the postoperative radiographs compared to their preoperative radiographs.

Conclusion: Reduction of slipped capital femoral epiphysis is responsible for poor outcome and also related to the development of avascular necrosis. We recommend single in situ pinning for these cases regardless of severity of slip.


N. Lynen U. Maus N. Ihme A. Kochs F. Niethard

Introduction: Previous investigation showed that joint distraction (arthrodiastasis) is able to reduce intraarticular pressure and to have a positive effect on the regeneration of bone and cartilage on both sides of the joint. Many reports have been published about the results of arthrodiastasis in the treatment of femoral head necrosis in young children, pointing out good reconfiguration of the femoral head and improved range of motion. In contrast to that, -to our knowledge- there is so far no study showing the effect of hip joint distraction in older children with femoral head avascular necrosis.

Question: In the present study the outcome of the treatment of femoral head avascular necrosis in older children by hip joint distraction was investigated.

Methods: The hip joint distraction method was performed in three patients with necrosis of the femoral head. The causes of avascular necrosis were: Late onset Perthes’ disease in two patients and slipped capital femoral epiphysis (ECF) in one patient. The average age of the patients was 13.4 years. They all suffered from persistent severe pain and mostly limited range of motion of the hip joint. The plain radiographs revealed a Catterall IV, Herring C stade in both patients with late onset Perthes’disease. In the radiograph of the ECF patient a severe deformity of the femoral head was visible. After intraoperative soft tissue release, joint distraction was performed with an Ilizarov-ring fixation and immediately distracted 4–5 mm under image control. Distraction was continued 1 mm per day until the Shenton line was overcorrected. At this time the fixator was changed so that flexion-extension exercises were encouraged with the fixator in place. The patients were kept non-weight bearing. After 4 weeks the fixator was changed, so that in addition abduction up to 30° was possible. In total fixator duration time was 3.5 months. (In one case due to a fracture, the fixator was left for further 3 months) During distraction period with the fixator two patients suffered a femoral fracture without a causal adequate trauma.

Due to these major complications further investigations on additional patients have been stopped.

Results: The outcomes after 2.5 years showed in two patients an ankylosis of the hip joint with adductionflexion contracture and radiographical no reshaping of the femoral head. The third patient had a poor range of motion while radiographic findings showed a good reconfiguration of the femoral head. Nevertheless even in this patient advanced arthrosis was evident.

Conclusion: In conclusion, due to the major complications and the unsatisfactory “middle-term”-results, arthrodiastasis as a therapy of avascular necrosis of the femoral head in older children has failed in our study. In our opinion fracture was as a result of immobilisation osteopenie.


M. Ramachandran M. Fox C. Munns C. Cowell R. Brown D. Little

Background: Traumatic femoral head osteonecrosis in adolescents has a poor prognosis due to collapse and subsequent degenerative change. There are currently no satisfactory treatments available for this condition. Bisphosphonate therapy has improved outcome in animal models of osteonecrosis. We have evaluated bisphosphonate therapy as a novel strategy for adolescent traumatic osteonecrosis.

Methods: We established a protocol of identification of adolescents with osteonecrosis utilizing bone scans immediately after surgical treatment for hips at risk of osteonecrosis after trauma. Of a consecutive group of twenty-eight patients with either unstable slipped capital femoral epiphyses (SCFE) (22), femoral neck fracture (4) or hip dislocation (2), seventeen patients with osteonecrosis were identified. These patients (13 boys and 4 girls, mean age 12.6 years) and their families consented for treatment with intravenous bisphosphonates based on animal experimental evidence. Of the patients with osteonecrosis, twelve had presented with unstable SCFE, four with femoral neck fractures and one following traumatic hip dislocation. The average length of bisphosphonate treatment was 20.3 months (range 7 to 39). All patients were followed for at least 2 years.

Results: At mean follow-up of 38.7 months, fourteen patients (82%) were pain free. Clinically, all patients had a good to excellent outcome. The mean Harris Hip Score was 91.1, the Iowa Hip Rating was 92.1 and the Global PODCI score was 91.5. On radiographs, nine patients (53%) were rated as Stulberg I–II, six (35%) as Stulberg III, and two (12%) as Stulberg V.

Conclusion: Bisphosphonates therapy may play an adjunctive role in the treatment of adolescents with traumatic osteonecrosis.


Z.S. Vukasinovic

When surgical treatment of dysplastic hip and hip joint incongruence in adolescence is necessary, triple pelvic osteotomy is preferable to other types of pelvic osteotomies (even when they are associated with femoral ones). We evaluated our ten years long experience with the mentioned method.

We treated 78 hips (67 patients) with Tonnis-Vladimirov triple pelvic osteotomy between 1996 and 2005. Average age of our patients was 15 years and 6 months. The patients were followed for mean 39 (17–133) months. In 2 hips triple pelvic osteotomy was associated with femoral corective osteotomy, in one hip with femoral corective osteotomy and open reduction, and in 7 with the translocation of the greater trochanter.

Treatment results were evaluated, both anatomically and functionally. Anatomic improvement was detected by measuring CE angle of Wiberg. It improved from an average of 16,1 – to 43,1 degrees – the difference has proven to be statistically highly significant. Functional improvement (absence of waddling gate or limp; as well as better range of motion) was noticed in almost all the cases. The improvement was accompanied by spatial reorientation and correction. Major complications included asymptomatic pubic and/or ischial osteotomy nonunions in seven patients.

We found good radiographic correction of deformities and improvement of hip function with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of acetabular dysplasia and hip joint incongruence in patients older than 8–10 years. It may prevent and postpone the development of secondary osteoarthrosis.


M.J. BARAKAT T. WHILE J. PYMAN F. MONSELL M. GARGAN

The results of a functional, clinical and radiological study of 30 children (60 hips) with whole body cerebral palsy are presented with a mean follow-up of ten years.

Bilateral simultaneous combined soft-tissue and bony surgery was performed at a mean age of 7.7 years (3.1–12.2).

Evaluation involved interviews with patient/carers and clinical examination.

Plain radiographs of the pelvis assessed migration percentage and centre-edge angle.

Twenty two patients were recalled. Five had died of unrelated causes and three were lost to follow-up.

Pain was uncommon, present in 1 patient (4.5%). Improved handling was reported in 18 of 22 patients (82%). Carer handling problems were attributed to growth of the patients. All patients/carers considered the procedure worthwhile.

The range of hip movements improved, with a mean windsweep index of 36 (50 pre-operatively)

Radiological containment improved, with mean migration percentage of 20 degrees (50 preoperatively) and mean centre-edge angle of 29 degrees (−5 preoperatively) No statistical difference was noted between the three year and ten year follow-up results demonstrating maintained clinical and radiological outcome improvement.

In conclusion, we consider that bilateral simultaneous combined hip reconstruction in whole body cerebral palsy provides painless, mobile and anatomically competent hips in the long term.


F. rayan S. purushothamdas J. arora M. scott

The aim of the study is to compare the postoperative pain relief provided by continuous perfusion of wound by bupivacaine and fentanyl with that of patient controlled analgesia using morphine in elective shoulder surgery. This retrospective case control study included 76 consecutive patients who had elective shoulder surgery. 39 patients had patient controlled analgesic system (PCA) with morphine and 37 patients had a continuous wound perfusion(intra bursal) with bupivacaine and fentanyl via a disposable Silicone Balloon Infuser. Patients were also given additional oral NSAIDs or morphine if needed. The pain score measured postoperatively based on a 10 point Visual Analogue Scale (VAS) at 1, 2, 3 and 18 hours was noted. The use of antiemetics and additional painkillers was recorded. The complications of both methods were also noted.

We found that the analgesia provided by continuous perfusion of wound by bupivacaine and fentanyl was constant and comparable to that provided by the patient controlled analgesic system using morphine. PCA with morphine was associated with significantly high incidence of nausea and vomiting (p < 0.001).We conclude that continuous perfusion of the wound by bupivacaine and fentanyl appears to be a simple, effective and safe method of providing analgesia following elective shoulder surgery.


Y. Morar Y. Maharaj S. Day A. Hammer A. Agarwal

Introduction: The ideal regimen for safe and effective post operative pain relief inspinal surgery remains elusive. Numerous studies have been conducted comparing epidural with patient controlled analgesia with no firm conclusion as to which is best.

Aims: To determine the efficacy of acute pain relief between surgical placed epidural catheter and patient controlled analgesia for lumbar spinal surgery.

Method: A 42 month retrospective survey of 82 spinal surgery patients case notes and anaesthetic charts performed by a consultant spinal surgeon and his registrar from 2002 to 2005. There were 34 epidural and 48 PCA patients. Visual analogue Score (0–10) at 6 hourly intervals up to 36 hours, complications and age of patient were looked at. Exclusion criteria for epidural were dural tear, history of hypotension, unexplained neurological symptoms, and bleeding disorders and surgeon choice. Epidural infusion consisted of bupivacaine 0.1% with 5mls loading dose and 10mls/ hour infusion and PCA consisted of morphine sulphate 2mg/ml with a 1ml loading dose and 5 minute lockout interval.All patients were on standard analgesia which included oromorph 5mg four hourly orally and paracetamol 1gram six hourly as required orally. No radiographic evidence of epidural catheter placement was performed. Post-operative complications which included hypotension, nausea, vomiting, and drowsiness were monitored.

Results: The average age for the epidural group was 46.9 and PCA group 49.8. The most striking finding was that the average pain score at each six hourly interval waslower in the epidural group. This was significant in the first 18 hours post-operatively.However, 3 complications occurred in the epidural group which included hypotension. In addition, 3 epidural infusions were stopped and changed to PCA most likely due to improper placement of catheter. There were no complications with the PCA group.

Conclusion: This observational study demonstrates clinically and statistically that in the acute post-operative phase and up to 36 hours that epidural analgesia for lumbar spine surgery is more effective than PCA. From this survey, the risk of epidural was higher, although no serious complications occurred. Surgeon placement of catheter is also important in the effective delivery of epidural pain relief. The lower efficacy of the PCA may have been due to poor patient understanding of the concept of PCA and thereforeits


K.A. Lammin E. Burgess G.J. McLauchlan

Patients overestimate pain following hip and knee replacement.

Ninety two patients awaiting hip or knee replacement were asked at their pre-operative assessment to estimate the level of pain they expected following their surgery on a 10cm visual analogue scale. Note was made of their age, gender, previous surgeries, Amsterdam anxiety score as regards the anaesthetic and surgery and an information score relating to their anaesthetic and surgery. Seventy nine patients had pain scores collected on a daily basis post surgery.

Mean (std dev) age of the group was 68 (11) years and with a female to male ratio of 1.57. Females were significantly more anxious about the surgery than males (t-test, p< 0.007). Patients were more anxious about the anaesthetic and the surgery with hip replacement compared to knee replacement although this did not reach significance (t-test p=0.07). The mean (std dev) pain score pre-operatively was 7.5 (1.6). The mean (std dev) pain score expected was 7.0 (2.2) on the first post operative day and 4.3 (2.2) on the sixth post operative day. Forty four per cent of patients expected to have pain greater than their arthritis pain on the day following surgery.

The level of pain experienced post-operatively was significantly lower than expected. Mean (std dev) pain score was 5.1 (2.7) on day 1 post op and 3.3 (2.4) on day 6 (t-test, p< 0.05 for both). There was no correlation between age, gender, number of previous surgeries, anxiety or information scores and the expected level of pain.

The majority of patients, whatever their age, gender or level of anxiety over estimate their level of post-operative pain after joint replacement. Studies are needed to assess whether educating patients about pain post surgery will be of benefit, particularly in their early rehabilitation.


C. Matzaroglou E. Sourgiadaki E. Panagiotopoulos A. Saridis P. Megas A. Kouzelis K. Filos E. Lambiris

Purpose: The purpose of this prospective investigation is to determine if soft tissue and intra-articular local anaesthetic injection with bupivacaine and adrenaline have beneficial post-operative effects in patients who had total knee replacement (TKR) for osteoarthritis.

Material and Methods: 97 patients were divided randomly into 2 groups. The mean age was 74.7 years. In control group I there were 17 men and 33 women with a mean age of 73.5 years, in group II 16 men and 31 women of mean age of 74.9 years. The patients who were allocated to control group I (n =50) had no intraarticular treatment. We used general anaesthesia in all these patients. The study group II of 47 patients had received intraoperative injection of 0.25% bupivacaine(8ml) with epinephrine (1ml – 1mg) with 2/3 injected into the soft tissues and 1/3 injected into the joint. Clinical parameters evaluated included pain, blood use and bleeding index (calculated by preoperative haemoglobin minus postoperative hemoglobin plus the number of units of packed red blood cells transfused) and range of motion (ROM) at discharge.

Results: Flexion at discharge was improved from 70 (60–90)° in the control group to 90 (80–120)° in study group II (p = 0.005), the difference between the two groups receiving different amounts of analgesics were statistically significant. Number of days until 90 degrees of flexion and until discharge was reduced in group II compared with the control group I (p = 0.003 and 0.002). Also and the blood loss decreased.

Conclusion: This simple method is effective in improving all the postoperative course of primary TKR and should be considered as a part of a perioperative patient treatment program.


A. Perez-Caballer L. Alcocer F. Macule J. Vaquero A. Villamor

Objective: Exogenous hyaluronic acid (HA) acts as a lubricant and shock absorber, and is considered to have many other beneficial effects in the joint. Several studies have shown that HA is able to provide pain relief and promote the synthesis of endogenous HA and protect the cartilage and synovia by covering joint surfaces. The objective of this study is to investigate wheter an isotonic solution of hyaluronan reduces post-arthroscopic symptoms in the knee such as joint pain, swelling and impairment of function when injected into the joint following arthroscopic surgery.

Material and Methods: A total of 93 patients (66 men, 27 women) were assessed in a multicentre, controlled study conducted by several investigators from different orthopedic surgery departments in Spain. All investigators were highly skilled in arthroscopy. Patients were allocated into two groups, control group (45 patients) or treatment group (48 patients). The treatment group received an injection of 10ml of isotonyc solution of hyaluronan (ISH) 0.5% with a physiological pH value at the end of the knee arthroscopy after final lavage with normal irrigating solution. Untreated patients underwent standard arthroscopic surgery (meniscectomy or articular lavage) and did not receive any further treatment on completion of the procedure. Pain in patientes were assessed using a 100mm visual analog scale (VAS). Between-group comparative analyses were performed before surgery and 1 and 4 weeks after surgery using a Mann-Whitney U-test.

Results: One week after surgery, a significant reduction in pain (up to 17%) was observed for patientes treated versus control patients (p< 0.01). This improvement was maintained until week 4, although the difference between control group and treated group decreased over time. The area under the curve of VAS was 39% lower for treated patients versus untreated patients. On comparing both groups, there was a significant 8% difference in the reduction of other functional symptoms at 1 week after surgery but no difference at 4 weeks after surgery. No adverse events were reported.

Conclusions: The results show that there were was a significant decrease in pain in the first week after surgery, accompanied by a significant reduction in sum of symptom scores. These results suggest that ISH accelerates post-arthroscopy recovery during this important period by reducing pain and discomfort, and increasing the mobility of the affected knee.


S. Hakkalamani A.F. Carroll C. Ford R.W. Parkinson

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts after TKR. The use of peripheral nerve block has certainly reduced the use of opiates by 50%; however adding the sciatic nerve block to the femoral nerve block is controversial. The aim of this study was to compare femoral and femoral plus sciatic nerve blocks in postoperative pain management of patients undergoing TKR.

Materials and Methods: Total of 42 patients were studied. Twenty patients with an average of 75yrs (51–86yrs) received femoral nerve block alone. Twenty-two patients with an average age of 69yrs (53–83yrs) received femoral plus sciatic nerve block. 0.5% Chirocaine was used for nerve blocks. There was no significant difference between two groups in terms of pre-operative pain, pre-operative deformity, ROM and patella replaced. The primary outcome measures used were visual analogue scale (VAS) pain scores at 24 hours, 48 hours and 72 hours after the surgery. The amount of opiate consumption and PCA (patient controlled analgesia) used were also recorded. The secondary outcomes were postoperative nausea and vomiting, straight leg raise, neurological deficit, knee flexion, independent mobility and discharge from the hospital.

Results: The results showed significant decrease in the amount of pain in the femoral nerve block group than the combined nerve block patients. Patients who had combined nerve block complained of heaviness in the legs and were slow to mobilise. There was no significant difference in consumption of opiates, use of PCA, nausea and vomiting, independent mobility and the time of discharge from the hospital between the two groups.

Conclusion: The addition of sciatic nerve block to the femoral nerve block does not provide any additional benefits in TKR.


S.P. Muijs S.P. Dijkstra C.F. Bos

In the Leiden University Medical Center (LUMC), the non-augmented direct repair method as described by Duquennoy for treatment of chronic lateral ankle instability, is used since the early eighties. To our knowledge, this procedure has not been described in English literature before. We performed a retrospective study, to assess the long-term outcome of non-augmented anatomical direct repair procedures, as originally described by Duquennoy. The procedure reassures ankle stability by retightening and reinsertion of the original talofibular and calcaneofibular ligament, without dissecting the ligamental tissue. The purpose of this study is to determine the long-term effects of the procedure in terms of postoperative quality of life, joint function and development of osteoarthritis.

Twenty-three patients who were treated in our institution between 1985 and 2002 completed the Short Form-36 Health Survey (SF-36) for assessment of postoperative quality of life and the Olerud Molander Ankle Score (OMAS) for subjective symptom evaluation. Clinical reevaluation, including physical examination of the ankle and the completion of the Ankle Society ankle-hindfoot scale (AOFAS) questionnaire, was conducted for twenty-one patients after a mean follow-up of 13±7 (range 3–22.2 years) years. At final follow-up radiographs were taken to assess the development of osteoarthritis. The mean total postoperative SF-36 and OMAS scores were 79.6 (SD ±14.6) points and 81.7 points (N= 23 patients) respectively. The mean total postoperative AOFAS score was 89.7 points (N= 21 patients). We found a significant postoperative reduction in talar tilt and anterior drawer sign. According to the AOFAS, the long-term functional outcome of the procedure was excellent in 10 patients (48%), good in 7 patients (33%), fair in 4 patients (19%) and poor in none of the treated patients. The results in terms of ankle function and stability do not seem to deteriorate in time. The procedure is seldom causing restriction in range of motion, neither a higher chance of degenerative changes in the ankle joint on the long term. We conclude that the procedure as originally described by Duquennoy is simple and effective, with a very low complication rate and does not provoke restriction in range of motion of the ankle joint.


O. BiLGE M.N. Doral A.O. Atay A. Uzumcugil O. Tetik G. Leblebicioglu

Introduction: Osteochondral lesions of talus are rarely seen. The aim of our study is to report the early functional results of the treatment of the talus osteochondral lesions with Arthroscopic microfracture technique and of the intraarticular hyaluronan injection postoperatively.

Material and Methods: 15 patients (8 men, 7 women) are included in this is a prospective, randomized clinical study between the years January 2003 and February 2006. The mean age is 39 +/−11 SD. The patients had chronic ankle pain. 7 patient had right, 8 patient had left ankle pain. Their MRI revealed osteochondral lesion on the medial and central part of the talus. All the patients are treated with arthroscopic debridement and microfracture. The patients are mobilized non-weight bearing on postoperative first day and full-weight bearing on postoperative third week. As a second part of the study, 6 patients randomized by envelope are selected to apply intraarticular Hyaluronan (Adant) injection. The injection is performed half dose by starting from postoperative third week, weekly, for 3 weeks. The foot and ankle function index is used for the functional evaluation and the pain category of the Freiburg index is used for the pain evaluation of the patients. The surveys are filled by all the patients preoperatively and ninth week postoperatively. The follow-up period is 6 months.

Findings: 10 patients have previous history of ankle trauma. For the biostatistics evaluation of the data, paired t-test is used. The increase in the Freiburg pain index is observed in the evaluation preoperative and postoperative data (p< 0.05). The effect of intraarticular Hyaluronan injection is found insignificant statistically (p> 0.05). The Foot and Ankle Index scores revealed a significant clinical improvement only in the categories; walking 4 blocks and walking fast (p< 0.05). In the injection group, the only significant improvement is observed in the category of walking 4 blocks (p< 0.05).

Results and Discussion: There are different developing modalities in the treatment of talus osteochondral lesions. As a result of our study, arthroscopic debridement and microfracture is found to decrease the pain and to increase the functional performance. The effect of intraarticular Hyaluronan injection is found to be insignificant compared with the non-injection group. Our patient number is small and follow-up period is short. Multi-centered, prospective and randomized studies are needed for further evaluations.


V. Kumar A. Panagopoulos I. Triantafyllopoulos L. van Niekerk

Background: Stress radiography and more recently magnetic resonance imaging have been used to study the integrity of lateral ankle ligaments in chronic symptomatic instability after injury.

Aim: Our aim was to see if magnetic resonance imaging was as good as examination under anaesthesia and stress radiography, for diagnosing injury to the lateral ankle ligaments.

Study Design: Cross-over study.

Methods: Fifty eight patients, 47 men and 11 women, were included in the study. These were athletes or military personnel with symptomatic instability of the ankle after injury. This cohort of patients had MRI scans, stress radiographs and arthroscopic treatment of their ankle. Integrity of the calcaneo-fibular ligament (CFL) was recorded arthroscopically. The sensitivity, specificity, positive and negative predictive value of MRI and stress views, in assessing integrity of the CFL, were compared against the arthroscopic findings which was considered to be the gold standard.

Results: Stress radiography under anaesthesia and MRI has sensitivities of 94% and 47% and specificities of 98% and 83% for diagnosing injury to the CFL, respectively. Stress radiography has a higher accuracy in diagnosing CFL injuries as compared to MRI.

Conclusion: The results of this study casts doubt on the efficacy of MRI in the diagnosis of serious ankle ligament injuries.


J.P. Marchaland L. Matthieu Y. Nader C. Bures L. N’Guyen G. Versier

INTRODUCTION: The authors present the results of a surgical technique for lateral ankle chronic instability, derived from Castaing and Duquennoy procedures. It uses a half peroneus brevis with a tightening of the antero- lateral capsule. A Plasty with the extensorum digitorum brevis was used in the event of associated subtalar instability.

MATERIAL AND METHODS: Between 2001 and 2005, 38 cases of ligamentoplasties have been performed for chronic instability of the ankle. 32 (25 men and 7 women) of them have been reviewed with a mean delay of 26 months (extremes of 10 months to 5 years). They were middle-aged of 28,5 years. All the patients have been reviewed with stress X-Ray in varus of the both ankles (measure of tibio talar angle, arthritis) and had a strength measure in eversion by the same examiner. The functional evaluation was performed with Molander and Olerud ankle score.

RESULTS: There were 20% of complications, especially cutaneous cicatrisation problems and algodystrophy. After surgery, no patient had instability; only one, had apprehension of the ankle. 90 % retrieved the same sport with the same level. No body changed of job. 3 patients were disappointed because of pain in sports and stiffness. At revision, the functional score was 90 against 59 at the pre operative time. The difference of strength in eversion between the two ankles was about 7%. Laxity had a good correction seeing the average tibio talar angle between the both ankle is 0,5°.

DISCUSSION: The results of this procedure show a distinct improvement of stability, radiological laxity and functional activity. The arthrotomy performed in Duquennoy procedure, is useful for diagnosis and treatment. It shows the cartilage and allows the removal of impingement and foreign bodies. A plasty that uses the single evertor deprives the ankle of a part of active and proprioceptive control. However, the patients didn’t feel a difference or a discomfort. The patients who had the surgery on the jump foot side had no significative difference of strength in eversion between the both ankles.

CONCLUSION: This anatomical procedure gives 91% of satisfaction, for these active young people. The postoperative physiotherapy allows the complete recovery of activities from the sixth month after surgery.


S.A. Jain R.K. Kakwani A.L. Pimpalnerkar

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer.

METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series.

DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination.

CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability.


S. Giannini C. FALDINI F. VANNINI C. BIAGINI R. BEVONI M. ROMAGNOLI

INTRODUCTION: Distal metatarsal osteotomies have been described for surgical treatment of hallux valgus with good results. The aim of this study is to review the results of our first 1000 consecutive hallux valgus cases treated by minimally invasive distal metatarsal osteotomy, SERI (Simple Effective Rapid Inexpensive).

MATERIAL AND METHODS: 1000 feet in 641 patients (359 bilateral), aged between 20 and 65 years (mean 49) affected by hallux valgus without arthritis were studied. Inclusion criteria were deformity less than 40° and intermetatarsal angle up to 18°. A 1-cm medial incision at the metatarsal neck, and a complete osteotomy were performed using an oscillating saw. With the naked eye all characteristics of the deformity were corrected by displacement of the metatarsal head (HVA, IMA, PASA, dorsal or plantar displacement). The osteotomy was stabilized by a 2-mm Kirschner wire. Immediate weight bearing was allowed with gauze bandage and talus shoes for 4 weeks. All patients were checked at an average follow-up of 37 months.

RESULTS: All osteotomies healed, delayed consolidation was observed in 25 feet. Slight stiffness was observed in 31 feet. Mean AOFAS score was 48+15 pre-op and 89+13 at follow up. The pre-op HVA was 32+8, while at follow-up it was 18+8 (p< 0.005), pre-op IMA was 14+3, while at follow-up it was 6+4 (p< 0.005), the pre-op PASA was 21+9, while at follow-up was 9+8(p< 0.005).

DISCUSSION AND CONCLUSION: SERI osteotomy was simple, effective, rapid and inexpensive in correcting hallux valgus deformity. Clinical and radiographical findings showed an adequate correction of the deformity.


D. Koulalis W. Schultz D. Mastrokalos K. Zachos G. Karaliotas M. Menelaou I. Liberis

Aim of study: Comparison of clinical and radiological results of the applied methods.

Material and method: 20 patients with osteochondritis dissecans of the talus were treated. Autologous chondrocyte transplantation was applied to a group of 10 patients (Group A) and autologous osteochondral transplantation to the rest 10 patients (Group B).Group A: Average-age=30,8 years, -follow up time= 33,6 (12–48) months, -lesion size= 20×16,2 (35–15 × 25–15) mm and depth =7 (20–5) mmGroup B: Average –age =33, 7 years, follow up time =32,4 (12–48) months, – lesion size=16,5×15 (25–10 × 20–10) mm and depth=4 (5–3) mm.All patients underwent clinical und radiological investigation and the symptoms were classified in accordance with the Finsen classification. Group A was treated with autologous chondrocyte and Group B with autologous osteochondral transplantation. Osteotomy of the medial or lateral malleolus was necessary by 6 Group A – patients and 4 Group B – patients. Postoperative treatment : Non-weight bearing for 6 weeks, continuous passive motion of the joint, clinical and radiological follow up 3rd, 6th, 12th and yearly basis

Results: Postoperatively the average Finsen score showed for Group A an improvement from 3,5 (very bad) to 1,1 (excellent) and for Group B from 3,6 (very bad) to 1 (excellent). MRI follow up showed defect coverage by 7 patients of Group A and 9 patients of Group B after 12 months. Second look arthroscopy was performed by 4 patient of Group A and 3 patients of Group B showing full coverage of the defect site. Complications: persisting swelling for an average time of 2,7 months in Group A and 4,3 months in Group B. Additionally 10 degrees loss of joint extension in 4 patients of Group A and 3 patients of Group B.

Conclusion: Autologous chondrocyte transplantation as well as autologous osteochondral transplantation present very good clinical results. As methods of articular surface restoration they have their advantages and disadvantages playing an important role in chosing one of them, in combination always with the surgeons philosophy. The existence of these methods is important in influencing the course of the ankle joint towards a good prognosis, in cases of osteochondral lesion. Further investigation is necessary.


A. Rochwerger J.F. Gonzalez E. Demortière D. Louzan D. Ould-Ali V. Rosca . Curvale

Introduction: The scarf osteotomy is a reliable technique in bunion surgery. A so-called « self stable technique» was developed in our department since 1992. We report the results of retrospective study including two groups of patients which had a scarf osteotomy. In the first group they had an internal fixation and in the second one an ‘selfstable technique’ with no device.

Material and methods: One hundred and seventy one patients operated for hallux valgus were reviewed for this study. There were 105 feet operated with the so called ‘self stable techniqu’, using modified saw cuts and 103 had the conventional technique with an internal fixation. All patients had a clinical and radiological pre- and postoperative examination. The result was assessed according to the AOFAS Score.

Results: The follow-up was on average 6.3 years (ranging from 2 to 13 years). The result was considered satisfactory globally in 74% of the cases, 76% in the « selfstable group and 72% in the conventional group. All items were significantly improved in both groups and the good results remained with time: improvement in shoe wear, pain, angular corrections. The hallux valgus angle decreased from 34° to 16°, there was no difference between both groups. The first intermetatarsal angle changed from 15° to 10. No significant difference was found in term on bone healing and complications between both groups.

Discussion: These results are comparable with those of the literature. The « selfstable technique » is significantly identical to the conventional one. The patients have the same rate of complications. The corrections that this osteotomy is able to offer are not altered by the change of fixation of the osteotomy.

Conclusion: This modified scarf osteotomy of the first metatarsal provides equivalent long-term results in our experience.


P. Bock U. Lanz A. Engel

Introduction: There are more than 150 different methods of surgical correction of hallux valgus deformity. In our institution there is a long tradition of SCARF osteotomy. We hereby present the longterm results of the SCARF.

Material & Methods: During the years 1995 and 1996 111 patients with 128 feet were operated on for a hallux valgus deformity by the SCARF osteotomy. Of those, 81 patients with 95 feet could be seen for follow up. The mean age at time of surgery was 50.9 (21–78) years. A clinical and radiographic examination was done.

Results: After an average time of 121.9 (107–141) months 92% of the patients were very satisfied with the result of their surgery. The VAS for pain improved from an average of 6.5 to 0.34. The AOFAS score for the forefoot improved from a preoperative average of 54.4 to a postoperative average of 91.6. The radiographic evaluation gave the following results: the preoperative HVA of 31.7° improved to an average of 16.8°; the preoperative IMA of 14.8° improved to an average of 7.6°. The preoperative average dorsal extension of the MTPI did not change very much from 48.6° to 50.6°, the preoperative plantar flexion decreased from an average of 50.6° to 15°. Two patients had to be reoperated because of a recurrent hallux valgus deformity. Five other patients had a recurrent deformity, but did not need any further surgery. We could observe 3 patients with an overcorrection where one needed another surgery. No head necrosis was seen.

Conclusion: Overall the SCARF osteotomy gave good and predictable results with a good correction of the deformity and a low potential for recurrence if applied for the right patient group.


D. Matewski E. Szymkowiak J. Puchala J. Kruczynski

Approximately 40 to 50% of the civilized population may expect feet disorders, and in 90% localized in the forefoot. Hallux valgus (H.V.) deformity is not a single malformation, but a complex problem affecting the first ray of foot, frequently accompanied by deformities and symptoms of the lesser toes. Proximal osteotomy and soft tissue release of I metatarso-phalangeal joint (MTP) provides adequate correction of intermetatarsal angle and joint alignment.

Material and methods. 65 patients (59 women and 6 men) with 83 hallux valgus deformities treated by surgical corrections with cuneiform proximal osteotomy of the first metatarsal bone and soft tissue plasty of I MTP joint were evaluated. The average age of the patients was 52,8 years (±12,4) and the mean follow-up was 4,2 years (±1,0). Mann criteria were used to assess the radiological stage of the disease. Treatment results were assessed by means of two numerical scales: Mielke scale and AOFAS scale. On the basis of the sum of points obtained for each criteria, the treatment result was qualified as: excellent, good, fair or poor. In the radiological assessment the alteration of the valgus angle (HVA) and the intermetatarsal angle (IMA) of the hallux were evaluated.

Results. Exacerbation of hallux valgus deformity in radiological examination was moderate or severe in accordance to the Mann criteria. 21 feet accompanied by deformities of lesser toes had additionally surgical procedure for the treatment of them. According to Mielkie scale the mean score was 6,5pts. (±1,9), and the treatment result of 95% of patients was evaluated as excellent or good. The mean score in AOFAS scale was 91,2pts (±11,2) with percentage of 80,6% excellent and good results. Higher percentage of fair and poor results in AOFAS scale was due to restricted motion of first MTP joint in 8 patients, out of whom due to persistent pain ailments in 6. In case of 4 feet, cosmetic improvement was unsatisfactory, and 4 patients had problems with wearing commercial shoes. Average correction value of the hallux valgus angle was 21° (33,5° to 12,5°). Foot intermetatarsal angle correction was 9° (16,2° to 7,2°).

Conclusions. Proximal osteotomy of the first metatarsal bone with soft tissue release of I metatarso-phalangeal joint allows for good correction of the hallux valgus deformity with good functional results.


A. CAPRIO G. TEORI A. PICCINATO F. OLIVA F. TREIA

The hallux rigidus, first described by Nicoladoni in 1881 (1), is the painful and decreased motion, especially dorsiflexion at the metatarsophalangeal joint, of the great toe. The purposes of this report were to evaluate the mid-term results of the Sliding osteotomy technique(2,3,4).

Thirty nine (46 feet) consecutive patients (mean age 38 years) with hallux rigidus of I and II grade were followed over a five-year period.

All patients were evaluated clinically and radiographically preoperatively and post operatively.

At the time of final follow-up, the mean AOFAS score was significantly improved: excellent 26 (56,5%); good 12 (26%); fair 6 (13%); poor 2 (4,5%).

This clinical review suggest that this procedure as a safe, effective measure to treat in patients with hallux rigidus of I and II grade.


A. Rochwerger I. Farhat F. Azam B. Blondel G. Curvale

Introduction: The choice of a procedure for the treatment of hallux rigidus depends on the severity of the disease, patient activity level, and expectations about the surgery. For patients who have severe hallux rigidus, arthrodesis has shown good results. On the opposite the results of joint-preserving procedures are less frequently presented.

Material et Methods: The following study concerns 113 cases of hallux rigidus with a mean age of 58 years. Seventy seven percent of the patients underwent arthrodesis of the first metatarsophalangeal joint, 23 % of them had a joint preserving procedure : phalangeal osteotomy and cheilectomy and were reviewed at an average 69 months postoperatively.

Results: The patients were assessed according to the AOFAS score. In the group, which had an arthrodesis, the results were satisfactory in 85 % of the cases. In the joint preserving technique group, 80% of patients were completely satisfied, 15% were satisfied with reservation, and 5% were dissatisfied. One patient suffered continued metatarsophalangeal joint pain that led to an arthrodesis after 10 years.

Discussion: First metatarsal decompression osteotomy are known for increasing joint range of motion but the risk of complication and patient dissatisfaction is less after phalangeal osteotomy.The clinical results are frequently not correlated with the radiological data.

Conclusion: Cheilectomy is classically proposed with predictable success to treat Grade-1 and 2 and selected Grade-3 cases. Nevertheless, in our experience we proposed as an alternative to a joint preserving procedure always an arthrodesis which functional results seemed more reliable. These results encourage us in being less restrictive in the indication for a joint preserving procedure.


M. Pospischill A. Kranzl K. Knahr

Aims: Minimal invasive total hip replacement is supposed to allow a quicker rehabilitation in the immediate post-operative period due to reduced soft tissue damage. The aim of this study is to compare gait kinematics after total hip arthroplasty using a one incision minimal invasive approach to a traditional approach.

Matarial and Methods: 21 patients were available for a complete analysis. In 12 patients (MIS group) a minimal invasive, modified Watson-Jones approach was used, in 9 patients (Standard group) a transgluteal approach as described by Bauer was used. All operations were performed by a single surgeon with the patient in supine position. In all cases the same cementless implant (Alloclassic® VariallTM system) with standard instruments was used. 3D gait analysis was carried out pre-operatively, 10 days postoperatively and after 3 months. The variables analysed in this study were velocity, step length, range of hip extension, range of pelvic tilt, Trendelenburg’s sign and Duchenne limp, pelvic rotation and symmetry.

Results: There were no significant differences between the MIS and the Standard group in any of the evaluated variables. In both groups of the patients presented a decrease in the hip extension at the end of stance phase 10 days postoperatively. About half of these patients compensated with an increased sagital pelvic tilt during maximal hip extension. At the 3 months follow-up all patients in both groups had an increased hip extension compared to the preoperative values, reached normative values. The velocity was reduced in both groups at the 10 days follow-up, ¼ reached normative values after 3 months.

Conclusion: Our data show no significant improvement of gait kinematics in patients who underwent a total hip arthroplasty using a minimal invasive approach (modified Watson-Jones) compared to a standard approach (Bauer) during the early postoperative period.


B. Magnan E. Samaila P. Bartolozzi

Introduction: Distal osteotomy of the first metatarsal is indicated in the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal using a percutaneous technique.

Methods: From 1996 to 2001 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 82 patients for the treatment of painful mild-to-moderate hallux valgus. Patients were assessed at a mean follow-up of 35.9 months employing a clinical and radiographic protocol. The American Orthopedic Foot and Ankle Society’s hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment.

Results: in 107 of the 118 cases (90.7%), patients were satisfied with the procedure. The mean score obtained in the clinical assessment using the AOFAS scale was 88.2 ± 12.9. The radiographic assessment showed significant changes (P< 0.05) in the values of the hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle and the sesamoid position at the postoperative assessment compared to preoperative values. Recurrence of the valgus deformity was observed in 3 cases (2.5%), non-painful stiffness of the first metatarsophalangeal joint in 7 (5.9%) and a deep infection resolved by antibiotic therapy in 1 (0.8%).

Conclusions: The percutaneous procedure proved to be a reliable technique for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable to those obtainable with the traditional open techniques, with the additional advantages of a minimally invasive procedure, substantially shorter operating times and a reduced risk of complications related to surgical exposure.


B. Devos Bevernage P. Maldague T. Leemrijse

Background: Iatrogenic hallux varus is a very disappointing potential complication following hallux valgus surgery. Depending on its clinical and radiological form, a possible surgical technique is the reconstruction of the lateral components of the first metatarsophalangeal joint.

Methods: A new surgical technique of ligamentoplasty based upon the use of the abductor hallucis tendon is described. The new method was applied in 5 patients (6 feet) with a mean follow-up of 25.8 months. Four hallux varus deformities were operated by only the transplant of the abductor hallucis tendon and two were associated with the use of an osseous buttress.

Results: We found a radiographic correction of most of the factors considered as being at the origin of the iatrogenically induced deformity. All of our patients considered the result as very good and no complications were noticed.

Conclusion: This new technique is a reliable, anatomic reconstruction with the use of the tendon participating in the physiopathology of the hallux varus deformity. No other functional tendon is harvested.


B. Magnan E. Samaila P. Bartolozzi

Implantation of metatarso-phalangeal prostheses or spacers has been widely indicated for the replacement of the articular surfaces in severe hallux rigidus.

A reabsorbable device in poly(D-L-lactic acid) (PDLLA) which is dome-shaped with a stem for implantation into the first metatarsal, avoiding any resection of the base of the proximal phalanx, is proposed.

The rationale of the reabsorbable spacer is to maintain the distance between the articular surfaces and provide a sliding surface suitable for articulation. It is then reabsorbed and replaced by fibrous tissue, which allows motion and removes pain.

37 reabsorbable spacers have been inserted for severe hallux rigidus in 33 patients aged from 26 and 76 years (average 58). Patients were reviewed with a follow-up ranging between 36 and 96 months (average 59.5).

The results were assessed using the American Orthopaedic Foot and Ankle Society (A.O.F.A.S), hallux-metatatarsophalangeal-interphalangeal scale.

Anteroposterior and lateral weight-bearing X-rays were made preoperatively and at follow-up, evaluating the dimensions of the articular space and the length of the first metatarsal.

The chronology of device reabsorption was studied in 10 patients with M.R.I., assessing complete reabsorption within 4 months of the operation.

Excellent and good results were obtained in 91% of patients. The A.O.F.A.S. score was 43.7+/−20.6 pre-operatively and 82+/10.3 post-operatively.

The reabsorbable spacer confirmed the expectations of its protagonists. This procedure would appear to be an alternative to arthrodesis of the first metatarso-phalangeal joint or traditional permanent implants, and represents an intermediate technique between an implant and resection arthroplasty.


S. BHAGAT A. Phadnis C.J. Mann

Introduction: There is an increased risk of revision for aseptic loosening with a transgluteal approach as described in the Swedish Hip Register. Femoral component malpositioning is itself associated with a poor outcome. A cuff of posteriorly situated glutei during the direct lateral approach may result in levering the proximal stem anteriorly and the tip of the stem posteriorly and does not allow the entry point of the stem to be placed posteriorly at the level of neck resection resulting in possible malpositioning.

The purpose of this study was to determine whether there is a significant difference in femoral component alignment when the posterior and direct lateral approaches are compared.

Materials and methods: Forty patients underwent an direct lateral approach and forty a posterior approach (n = 80). Inclusion criteria included primary hip arthroplasty using a cemented Exeter femoral component. At 6 weeks a standard AP and a modified lateral radiograph were taken. Measurements were taken from digitized radiographs as follows:

1. AP radiograph

A Tip of stem to outer medial cortex.

B Tip of stem to outer lateral cortex.

2. Lateral radiograph

C Tip of stem to anterior outer cortex

D Tip of stem to posterior outer cortex.

Component alignment was defined as A – B and C – D.

Results: A–B was 0.71 for the modified direct lateral approach and 2.56 for the posterior approach. C–D was 1.47 for the direct lateral approach and 1.21 for the posterior approach. This difference was not statistically different using paired t tests as p > 0.05(P=0.69) for lateral views measurements.

Discussion: This study demonstrates that there is no significant difference between direct lateral and posterior approaches as far as femoral component alignment is concerned. The increased revision rate noted by the Swedish Hip Register when a transgluteal approach is likely to be multifactorial, but not likely to be due to femoral component malalignment.


S.C. Budithi R. Pollock A.V. Nargol

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction.

Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups.

Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated.

Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate.


J. Charity E. Tsiridis M. Hubble G. Gie J. Howell J. Timperley

Introduction: Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 DDH.

Objective: Prospective evaluation of SDTSO with Cemented Exeter Femoral Component.

Material and Methods: 15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years followed-up for a mean of 77 months (11 to 133). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient lost to follow up.

Results: 18 Crowe IV hips. Charnley-D’Aubigne-Postel score for pain, function and range of movement were improved from a mean of 2, 2,3 to 5,4,5 respectively. One osteotomy failed to unite at 14 months and revised successfully. Clinical healing was achieved at a mean of 6 month while radiological at a mean of 9 months. The mean length of the excised segment was 3cm and the mean true limb lengthening was 2cm. 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting performed in all cases. Mean subsidence was 1mm and no stem was found loose at the latest follow up. No sciatic nerve palsy observed and no dislocation.

Conclusion: Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with SDTSO. Transverse osteotomy is necessary to achieve derotation and reduction can be maintained with a DCP plate. Intramedulary autografting prevents cement interposition at the osteotomy site.


C. Perka

Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis.

In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient.

The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up.

In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising.


C.V. Albanese M. Lucidi M. Rendine N. Santori L. Pavan R. Passariello F.S. Santori

Introduction: Bone resorption in the proximal femur is commonly seen after cementless total hip arthroplasty (THA). One of the main determinants of bone remodeling seems to be prosthesis design. With DXA, the amount of bone mass after THA can be precisely determined. We evaluated the BMD behavior of two different ultra-short implants with proximal load transfer, in order to study how a design can affect femoral bone remodeling. The rationale behind these designs is the experimental evidence that loading the medial and the lateral flare effectively preserves in time metaphyseal bone stock. Moreover, biomechanical tests have confirmed that this kind of stress distribution allows to remove the diaphyseal portion of the stem.

Methods: A total of 33 patients operated with a cementless femoral implant were included in this study. Two slightly different designs were tested: Type 1 (Stanmore Orthopaedics), featuring an extremely short distal stem (n=10), and Type 2 (DePuy International Ltd), where distal stem was virtually absent (n=23). All implants were customized based on pre-operative CT data. The main features of these implants were the ultra-short stem and the large lateral flare. The rationale was to preserve bone stock and gain a more physiologic load transfer to the proximal femur thus preventing stress-shielding. DXA examination was performed on all patients 3 years after THA. Due to the peculiar design, a specific protocol of analysis with five regions of interest (ROI) was developed: ROI1 (greater trochanter), ROI2 and ROI4 (respectively lateral and medial of the ultra-short stem), ROI3 (below the tip) and ROI5 (calcar). The same protocol was applied to the non-operated contralateral femur and percentage contralateral BMD was calculated with the following formula: (BMD of operated hip/BMD of contralateral hip)×100. A standard DXA of contralateral hip and lumbar spine was also performed to evaluate the skeletal bone mineralization.

Results: No differences were found in the anthropometric data and sex between the two groups. Age was found lower (p=0.001) in Type 2. BMD of lumbar spine and contralateral femur from standard DXA were not different in the two groups. BMD was higher in Type 2 in ROI4 and ROI5 (p< 0.001). The calculated percentage contralateral BMD was higher in Type 2 in ROI2 (p=0.009), ROI4 (p< 0.001) and ROI5 (p=0.01).

Conclusions: This study confirms that progressive shortening of femoral stem produces a more proximal loading, which effectively preserves in time metaphyseal bone stock and increases periprosthetic BMD in the medial ROIs. The increased BMD in periprosthetic lateral and medial proximal regions in the operated hip respect to the contralateral femur seems to be due not only to the increased weight-bearing, but also to the specific ultra-short stem design.


F. Pipino

The neck is the firmer structure of the proximal femur designed to spread the stresses both in compression and tension towards the metadiaphisys and the greater trochanter. Therefore femural neck preserving in total hip arthroplasty allows an optimized stresses’ distribution to obtain both an optimal integration and a subsequent better bone remodelling. The solidity of the structure and the geometric architecture with a femural neck angle of 125° guarantee the maximum primary stability, especially torsional of the stem. At last femural neck retaining allows, when requested, the revision with a richer bone-stock. For the aforementioned reasons since 1979 I proposed the femural neck preservation making a short cementless stem named Biodinamica. From 1983 to 1996 I personally implanted 498 Biodinamica prostheses with very satisfactory results showing a long term survival of the 98% (f.up 13 to 17 years). In 1996 with Ing. Keller it has been created the C.F.P. stem with the T.O.P. acetabular cup as evolution of Biodinamica system. The improvements are critical: materials have changed (from Cr-Co-Mb to Ti alloy), coating and design too. We report clinical and radiographical results of 10 years of C.F.P. implants that showed a further improvement, not only about the prosthesis’ survival, but especially regarding their quality with a 91% excellent clinical outcome. In conclusion we report the 25 years experience retaining the femural neck in hip arthroplasty with Biodinamica (498) and after C.F.P. (445) of a complessive cases of 943 arthroplasty.


R. kennelly E.J. conroy A. laing A.R. poynton

Introduction: C1-2 polyaxial screw-rod fixation is a relatively new technique. While recognising the potential for inadvertent vertebral artery injury there have been few reports in the literature outlining all the possible complications.

Aim:To review all cases of C1 lateral mass screw insertion with emphasis on the evaluation of the potential structures at risk during the procedure.

Methods: We retrospectively reviewed all patients in our unit who has C1 lateral mass screw insertion over a 2 year period. The C1 lateral mass screw was inserted as part of an atlantoaxial stabilisation or incorporated into a modular occiput/subaxial construct. Outcome measures included clinical and radiological parameters. Clinical indicators included age, gender, neurologic status, surgical indication and the number of levels stabilised. Intraoperative complications including blood loss, vertebral artery injury or dural tears were recorded. Radiological indicators included post-operative plain radiographs to assess sagittal alignment and to check for screw malposition or construct failure.

Results: A total of 18 C1 lateral mass screws were implanted in 9 patients. There were 3 male and 6 female patients who had C1 lateral mass screws inserted in this tertiary referral centre. Two patients had atlantoaxial stabilisation of a C2 odontoid fracture. There were 4 patients with rheumatoid arthritis whose C1 lateral mass screws were inserted as part of an occipitocervical or subaxial cervical stabilisation. The other pathologies included trauma and spinal tumours.

There was no vertebral artery injury and no cerebrospinal fluid leak. Three patients developed post operative occipital neuralgia. This neuralgia was transient in one of the patients having settled at 6-week follow up. In the other 2 patients the neuralgia was unresolved at the time of latest follow up but was adequately controlled with appropriate pain management. Post operatively no patient had radiographic evidence of construct failure and all demostrated excellent sagittal alignment.

Conclusion: It has been reported that the absence of threads on the upper portion of the long shank screw may protect against neural irritation. However insertion of the C1 lateral mass screw necessitates careful caudal retraction of the C2 dorsal root ganglion. The insertion point for the C1 lateral mass screw is at the junction of the C1 posterior arch and the midpoint of the posterior inferior part of the C1 lateral mass. Two patients in our series suffered occipital neuralgia post insertion of the C1 lateral mass screws. This highlights the potential for C2 nerve root irritation during and after the insertion of the C1 lateral mass screw.


E.T. Davis C. Webber M. Olsen R. Zdero J. Waddell E. Schemitsch

We aimed to establish if radiological parameters, dual energy x-ray absorbtiometry (DEXA) and quantitative CT (qCT) could predict the risk of sustaining a femoral neck fracture following hip resurfacing. 21 unilateral fresh frozen femurs were used. Each femur had a plain AP radiograph, DEXA scan and quantitative CT scan. Femurs were then prepared for a Birmingham Hip Resurfacing femoral component with the stem shaft angle equal to the native neck shaft angle. The femoral component was then cemented onto the prepared femoral head. No notching of the femoral neck occurred in any specimens. A repeat radiograph was performed to confirm the stem shaft angle. The femurs were then potted in a position of single leg stance and tested in the axial direction to failure using an Instron mechanical tester. The load to failure was then analysed with the radiological, DEXA and qCT parameters using multiple regression. The strongest correlation with the load to failure values was the total mineral content of the femoral neck at the head/neck junction using qCT r= 0.74 (p< 0.001). This improved to r=0.76 (p< 0.001) when neck width was included in the analysis. The total bone mineral density measurement from the DEXA scan showed a correlation with the load to failure of r=0.69 (p< 0.001). Radiological parameters only moderately correlated with the load to failure values; neck width (r=0.55), head diameter (r= 0.49) and femoral off-set (r=0.3). This study suggests that a patient’s risk of femoral neck fracture following hip resurfacing is most strongly correlated with total mineral content at the head/neck junction and bone mineral density. This biomechanical data suggests that the risk of post-operative femoral neck fracture may be most accurately identified with a pre-operative quantitative CT scan through the head/neck junction combined with the femoral neck width.


S. Piltz O. Pieske H. Karin

Introduction: Bilateral and transverse fractures of the first two sacral vertebrae with intrapelvic intrusion of the lumbo-sacral spine are very rare injuries. In most cases the lesion occurs after a fall from great height in a kyphotic position when landing. Today’s CT-scans in these mostly polytraumatized patients enable a clear diagnosis. In contrast conventional radiographs have a high risk to ignore these fractures. Operative treatment requires proper reduction and secure fixation which so far is not unrestricted possible using recommended techniques. For reduction lumbo-sacral distraction followed by lordotic extension is essential but difficult to obtain. Therefore we modified the lumbo-pelvic instrumentation to facilitate these requirements.

Methods: In the last four years we treated three female patients (aged 27–68 years) as follows: Variable axis screws (VAS – Synthes®) were inserted in the L4 and L5 pedicles and connected with two connecting rods. An additional variable axis screw was inserted in each posterior iliac spine. These both screws were connected with a transverse connecting rod situated over the transverse fracture line. This rod was connected with the two upright rods using a rod-to-rod connector and forming a hinged joint. Due to the not tightened nut of the pedicle screws at that time it was possible to spread the lumbo-sacral fracture line. After tightening of the lumbar screws the upper part of the body was slightly elevated resulting in a lordotic extension in the hinged joint. Subsequently the hinged joint was locked (Video).

Results: Postoperative CT scans revealed anatomic reduction and properly inserted implants in all cases. Follow-up was uneventful but a heparin related thrombopenia in one patient. Two patients were mobilized under full weight bearing within 4 and 10 days, respectively. In one cases this was not possible because of relevant foot fractures. Neurological deficits completely resolved in one patient within fourteen days and markedly diminished in another patient within months (persistent neuralgia). In one patient no neurological deficit existed. In all cases a complete hardware removal was done in 8 to 11 months.

Conclusions: The presented procedure is suitable for the so-called jumper’s fractures and results in anatomic reduction of the displaced fractures and a secure stabilization. The described hinged joint offers effective lordotic extension which is the key point for reduction. Thus this configuration is a reduction as well a fixation device. Full weight bearing in an erect posture is immediately possible and clearly shorten the rehabilitation period.


P. GEORIS T. THIRION S. PETERS R. LEMAIRE P. GILLET

Radiographic evidence of migration of the femoral stem component after THA is the most important diagnostic sign of femoral implant loosening. Early detection of stem subsidence may help in deciding to perform revision surgery before severe bone destruction has occurred, at a moment when standard clinical and radiological follow-up may still be reassuring.

The aim of this study was to identify the most appropriate bone and prosthetic landmarks to study subsidence and to determine the accuracy of the Imagika® method as compared to the ‘gold standard’ EBRA-FCA® software.

256 THA in 242 patients (102 men, 140 women) with a median age of 63.8 years (range: 36–85) received 4 different cementless or cemented prosthetic stem designs. They were followed for 10.6 years (range: 6–16). CLS® stems were used in 56 patients, MS-30® in 76, Elite® in 50 and Osteal® in 74.

4 specific analysis models were created in the Imagika® software in order to evaluate several possible landmarks on the proximal femur and on the stem, and to evaluate the possibility of using a correction factor to improve the comparability of successive x-rays taken under non standardised conditions. The most accurate prosthetic landmarks were the prosthesis shoulder in CLS® and MS-30® stems and the lateral aspect of the collar in Elite® and Osteal® stems. The best bone landmark was the top of the greater trochanter in all cases.

For the whole series, the annual linear subsidence rates were 0.049+/−0.014 mm with EBRA-FCA® and 0.052+/−0.012 mm with Imagika® respectively (P = 9E-7). Migration values in the 4 different groups were respectively 0.06 +/− 0.01 mm/yr and 0.05 +/− 0.01 mm/yr in the CLS® group (P = 4.6E-6), 0.02 +/− 0.002 mm/yr and 0.06 +/− 0.09 mm/yr in the MS-30® group (P = 6.8E-4), 0.06 +/− 0.002 mm/yr and 0.04 +/− 0.003 mm/yr in the Elite® group (P = 4.2E-5), and 0.05 +/− 0.005 mm/yr and 0.06 +/− 0.004 mm/yr in the Osteal® group (P = 7.4E-7). The different prosthetic designs did not show significant differences concerning migration values when studied according both methods.

Thanks to a correction factor, the Imagika® method uses all the radiographs when EBRA-FCA® rejects incomparable radiographs.

The Imagika® method is more users friendly and provides excellent reliability thanks to an automatic edge detection device.

Since no significant difference was observed between EBRA-FCA® and Imagika® methods whatever the prosthetic stem design studied, our results authorise us to apply these analysis models within the Imagika® software to all THAs to follow their radiographic evolution and to possibly predict the clinical evolution.


M. Melloh L. Staub C. Roeder S. Sommer P. Rieger T. Barz

Introduction: Lumbar fusion is one of the most frequently recommended treatments in spinal surgery, whereas ALIF and PLF are discussed controversially. This prospective and consecutive study examined if complications and rehabilitation differed between patients with a degenerated lumbar spine, who had been treated with ALIF or PLF.

Methods: Between 04/2002 and 12/2005 clinical data of 39 patients, who were treated with ALIF, and of 296 patients, who received PLF, were submitted to the European Spine Register SSE Spine Tango. Complications and rehabilitation process were documented after a median follow-up time of 9 weeks (IQR 8–24 weeks). Analysis was performed with non-parametric tests. The study corresponds with an EBM-level 3.

Results: The median age of patients with ALIF was 56 years (IQR 37-66 yrs) vs. 64 yrs in the PLF group (IQR 54–72 yrs) with a male to female ratio 10:29 vs. 108:188.

Patients after ALIF and PLF had an even complication rate (5/39 vs. 26/296, p = 0,41). The types of complications in the ALIF group were less severe (sensory and motoric disturbance vs. implant failure and implant malposition). All five patients needing reintervention belonged to the PLF group. Three quarters of all patients underwent rehabilitation. The proportion of patients with outpatient rehabilitation was higher in the ALIF group (14/39 vs. 50/296 patients, p = 0,05).

Conclusions: Patients with degenerative lumbar spine disease have a less severe type of complications after ALIF than after PLF, whereas the complication rate is even. Concerning the higher proportion of patients with outpatient rehabilitation in the ALIF group, one has to consider their lower age compared with patients in the PLF group. Except for the severeness of complications and the proportion of outpatient rehabilitation one cannot conclude an advantage of either of the two surgical methods.


G. Cinotti G. Giannicola E. Ferrari F. Postacchini B. Sacchetti A. Corsi M. Riminucci P. Bianco

Posterolateral spinal fusion is considered one of the most challenging condition for bone graft substitutes since using autogenous bone graft pseudarthrosis have been reported in 30% of cases.

MATERIALS AND METHODS.We develop a model of posterolateral spinal fusion in the rabbit based on skeletal stem cells (SSCs) loaded into a coral-hydroxyapatite material (Pro-Osteon 500RTM). 15 rabbits received cell-material constructs, 15 rabbits were sham-operated (decortication of transverse apophyses), 15 rabbits received material alone. The animals were housed for 6 months and radiographically monitored. At sacrifice, the explanted spine was analyzed by conventional and high resolution (Faxitron) radiography, and the outcome judged, blind of histology results, by two orthopedic surgeons.

RESULTS: radiographic evaluation showed a fusion rate rate of 90% in animals treated with cell constructs or biomaterial alone, and no fusion in the sham controls. Histology revealed abundant new bone formation directly on the scaffold in the cell construct and biomaterial alone groups, but no evidence of bone formation in the midregion of the interapophyseal space, where poorly vascular, dense fibrous tissue was observed.

CONCLUSIONS: The study shows that:

1) the cell-biomaterial constructs which per se were highly efficient in previous animal studies, used in different absolute quantities but identical ratios were not efficient in the direct preclinical model.

2) Radiography alone is misleading.

3) Once efficient cell and material preparations are obtained, additional consideration must be given to specific circumstances of the pre-clinical and clinical application such as mobility of the graft and its component and vascularization of the graft bed.


P.M. Menchetti W. Bini G. Canero E. Mazza

A 980 nm Diode (Biolitec AG) Laser energy introduced via a 21G needle under C-arm or CT-Scan guidance and local anesthesia, vaporizes a small amount of nucleous polposus with a disc shrinkage and a relief of pressure on nerve root. The procedure in the disc herniation treatment over the years had several changes, not only related to the different types of lasers (Ho:YAG, Nd: YAG, Er:YAG), but also in the types of optical fibers employed and in the neuronavigation systems. In our department starting under C-arm, realized that the only way to visualize the nerve root and increase the total energy delivered in several points of disc herniation, was to use a CT-Scan guidance (Aquilion 64 Slices Toshiba).

Matherial and Method: A prospective study on 350 patients (470 cases) affected by contained and non contained disc herniation was performed. The patients had a PLDD (Percutaneous Laser Disc Decompression) under CT-Scan guidance. A control group of 200 patients (350 cases) affected both by contained and noncontained disc herniation had a PLDD under C-arm.

Results: The results showed a statistically significant difference (p< 0.05) in the effectiveness of the PLDD in Disc Herniation treatment. Non Contained disc herniation had a successful result in 88.5% of cases under Ct-Scan guidance vs 70% of cases under C-arm. No statistically significant (p > 0.05) difference was found in contained disc herniation group. The laser energy delivered under CT-Scan was on average 40% (S.D. 0.36) more than under C-arm, because the visualization of nerve root and the size of the disc herniation permits to apply laser energy on different points, in order to obtain a disc shrinkage over a bigger surface, without any damage on surrounding tissues.

In conclusion, CT-Scan guidance appear to be the best way to practice PLDD not only in terms of resolution, treating succesfully non contained disc herniation, but also because the visualization of the nerve root permits a safe application of the laser energy and the effectiveness of the procedure give a faster return to normal life.


V. Kosmopoulos N. Theumann C. Schizas

Introduction: Several studies have looked at accuracy of thoracic pedicle screw placement, both in vivo and on cadavers, using fluoroscopy, image guidance, and anatomical landmarks. To our knowledge the upper thoracic spine (T1-T6) has not been specifically studied in the context of screw insertion and placement accuracy without the use of either image guidance or fluoroscopy. Our objective was to study the accuracy of placement of upper thoracic screws without the use of fluoroscopy, and report on implant related complications.

Methods: A single surgeon inserted a total of 60 screws in 13 consecutive non-scoliotic spine patients. These 60 screws were the first to be placed in the high thoracic spine in our institution. All previous surgeries used only a hook or wire technique for the upper thoracic spine. The most common diagnosis in our patient population was trauma. All screws were inserted using a modified Roy-Camille technique. Post operative axial computed tomography (CT) images were obtained for each patient and analyzed by an independent senior radiologist for placement accuracy. Furthermore we reviewed the operative records of each patient to record any implant related complications.

Results: No pedicle screw misplacements were found in 61.5% of the patients. Fifty three out of the 60 screws were placed correctly within all the pedicle margins. The overall pedicle screw placement accuracy was 88.3% using our modified Roy-Camille technique. Five medial and 2 lateral violations were noted in the 7 misplaced screws. One of the 7 misplaced screws was considered to be a marginal violation. No implant related complications were noted. Furthermore, no learning curve effect was noted as far as misplacement pattern was concerned.

Conclusion: We found that inserting pedicle screws in the upper thoracic spine based solely on anatomical landmarks was safe with an accuracy comparable to that of published studies on image guided surgery at the thoracic level.


K. Trieb L. Pohl M. Nittinger

It is the aim of this study to investigate the influence of the age of vertebral fractures on the clinical and radiological outcome of balloon kyphoplasty. All data were recorded prospectively at each visit (admission, postoperatively, discharge) and no patient was lost. 92 Patients (27 male, 65 female, mean age 67,2 years, mean body mass index 26,4) with 102 vertebral fractures (84 patients had one fracture, six had two and two had three fractures) were included in this study. All fractures were type A of the AO-classification (29 were A1.1, 34 were A1.2, 36 were A1.3, 2 were A3.1 and one was A2.3). Radiologically verebral body height, kyphosis angle, kyphosis index, compression index and bone cement application were evaluated. Clinically pain intensity (VAS 0-10), pain medication consumption (WHO 1-3) and surgical specific data were documented. The age of the vertebral body fracture was less than one week in 23 patients, between 7 and 14 days in 22 patients and more than 14 days in 57 patients. The mean surgical time was 43 minutes with a mean cement volume of 3,3 ml. A significant reduction of the kyphosis angle and index and an increase of the verebral body height could be documented. Pain medication consumption was reduced from 1,8±0,9 preoperatively to 1,2±1,1 at discharge. A significat reduction of pain intensity was observed (8,2±1 preoperatively vs. 3,9±2,5 at discharge). The most intense pain reduction at discharge was seen in fresh fractures (ifracture age < 7 days 2,4±0,5, 7–14 days 4,0±0,6, > 14 days 4,4±0,3; p< 0,005). Balloon kyphoplasty is a reliable method to reduce vertebral body fractures. A pain reduction can be achieved in all cases, but pain is mot effectively reduced in fresh treated fractures.


A. Anand B. Anand M. Wiseman A. Goodship M. Akmal

Background: The cause of intervertebral disc degeneration (IVDD) is multifactorial. One proposed mechanism is that IVDD originates in the nucleus pulposus (NP) and progresses radially to the annulus fibrosis (AF). Failure of current treatment modalities in preventing and treating IVDD and thereby low back pain have led to a growing interest in tissue-engineered solutions where a biological repair is induced. By preventing the abnormality at the NP it may be possible to halt further progression of IVDD. Injection of NP cells into an early degenerative IVD, where the AF is still intact, may retard the degenerative process and is presently under investigation. Using a 3-dimensional scaffold that could be successfully introduced into the NP cavity through minimally invasive techniques would prevent the loss of chondrocytic phenotype of the cells and be an improvement over the existing technique by which cells are directly injected into the NP cavity.

Methods:

CaSO4 and CaCO3 3% alginate hydrogels were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel.

NP cells released from pooled bovine NP tissue were dispersed into the CaSO4 and CaCO3 alginate gels (10x106 cells.mL-1) with and without hylan (Synvisc®) and cultured for 21 days.

Results:

Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity.

NP DNA and ECM synthesis was significantly greater in the CaCO3 alginate gel than in the CaSO4 alginate gel (p< 0.05).

Synvisc® significantly increased sulphated GAG (p< 0.01) and collagen (p< 0.05) production. These effects were supported histologically and immunohistologically where cells in the CaCO3 and Synvisc® gels stained more intensely for proteoglycan and collagen type II.

Discussion: This study demonstrates that slowly polymerising CaCO3 and CaSO4 alginate gels are injectable and capable of sustaining NP cells in-vitro. Cells remain viable, maintain their phenotype, proliferate and produce ECM during the culture period. CaCO3 alginate gel provides a 3-dimensional matrix more favourable to NP cellular activity than the CaSO4 alginate gel. Synvisc® has a chondro-stimulatory effect on NP cells in-vitro. These effects are similar to those observed previously with hyaluronic acid, in that it binds to cell surface CD44 receptors, thereby affecting essential cellular functions and cytoskeleton structure. Synvisc® however has an advantage in that it is highly viscous and can reside longer within an alginate construct thereby having a sustained long-term stimulatory effect. This study demonstrates a successful tissue-engineered approach for replacing the NP and, subject to further studies, may be used for retarding mild-to-moderate IVDD, alleviating lower back pain and restoring a functional NP through a minimally invasive technique.


A. van Ooij S. Kurtz L. Van Rhijn T. de Bruin

We removed 23 Charité artificial discs in 19 patients due to severe back-and legpain and performed an anterior as well posterior fusion. Mean interval between insertion and retrieval is 8,4 years (3,0–16,0 years). The mean age at retrieval is 49,4 years (40–72 years). The cause of persistent or recurrent pain was one or more of several problems thought to be related to the pain: subsidence, migration, wear with or without breakage of the metal marker ring, facetjoint or adjacent degeneration. In all cases wear of the polyethylene core was seen in major or minor degree. The wear was related to posterior impingement possibly due to hyperlordosis and extension instability and was subsequently more pronounced in the peripheral rim than in the central dome. Also a relationship was noted to in vivo oxidation of the polyethylene, especially in the rim. In the periprosthetic tissue an inflammatory reaction was found, more in the severe wear cases. Polyethylene loaded macrophages were seen, also polyethylene particles lying freely in the tissue. The macrophages proved positive for Interleukin 6. The wear pattern and the inflammatory reaction resembles the pattern seen in total hips and knees. Probably a substantial number of patients will exhibit these wear changes some years after insertion. It is questionable whether changes in sterilization and packaging and better insertion and sizing techniques will prevent wear development in the future.


A. Zeh M. Planert P. Lattke G. Siegert J. Davis A. Held W. Hein

Study design: Cross-sectional study of 10 patients to measure the serum levels of cobalt and chromium after TDA.

Summary of Background Data: In total hip endoprosthetics and consequently for TDA (total disc arthroplasty), metal-on-metal combinations are used with the aim of reducing wear debris. In metal-on-metal TDA the release of metal ions has until now been secondary to the main discussion.

Objectives: To investigate the release of cobalt and chromium ions into the serum following implantation of the metal-on-metal MaverickTM type artificial lumbar disc.

Materials and methods: We investigated the serum cobalt and chromium concentration following implantation of 15 Maverick™ TDAs (monosegmental L5/S1 n=5; bisegmental L4/5 and L5/S1 n=5; average age = 36.5 years). 5 healthy subjects (no metal implants) acted as a control group. The measurements of the metals were carried out using the HITACHI Z-8200 AAS polarized Zeeman atomic absorption spectrometer after an average of 14,8months.

Results: The concentrations of cobalt and chromium ions in the serum amounted on average to 4.75μg/l (standard deviation 2,71) for cobalt and 1.10μg/l (standard deviation 1,24) for chromium. Compared to the control group, both the chromium and cobalt levels in the serum showed significant increases (Mann-Whitney Rank Sum Test, p=0.0120). At follow-up the Oswestry Disability Score was on average significantly decreased by 24.4 points (L5/S1) (t-test, p < 0.05) and by 26.8 points (L4-S1)(t-test, p < 0.05). The improved clinical situation is also represented by a significant decrease of the Visual Analog Pain Scale of 42,2points after the follow-up (t-test, p< 0,05).

Conclusion: Significant systemic release of Cr/Co was proven in the serum compared to the control group. The concentrations of Cr/Co measured in the serum are similar in terms of their level to the values measured in THA metal-on-metal combinations or exceed these values given in the literature. Long-term implication of this metal exposuere in unknown and should be studied further.


T.M. Grupp J.J. Yue R. Garcia P. Cocchi C. Schilling L. Cristofolini W. Blömer

Introduction: Degenerative disc desease is one of the most frequently encountered spinal disorders. The intervertebral disc is a complex anatomic and functional structure, which makes the development of an efficient artificial disc a challenge [1].

Based on the complexity of the anatomical structures and the nearly unknown loading conditions at the moment only contradictory knowledge exists about the kinematics after TDA and in particular the location of the center of rotation in the human lumbar spine [2].

The objective of our study was to evaluate the kinematics of the human lumbar spine and the ability of TDA to restore the native conditions in regard to range of motion (ROM), neutral zone (NZ) and center of rotation (COR).

Material and Methods: In-vitro flexibility testing on functional spinal units (FSU) out of 12 fresh frozen lumbar spines has been performed. The FSU (L2/L3 and L4/L5) were tested first in the native condition, followed by nucleotomy and partial annulus resection and also after TDA with activ L (lumbar artificial disc, Aesculap Germany).

Therefore a spinal simulator has been customized, applying pure moments for flexion/extension, lateral bending and axial rotation (+/−7.5Nm) and axial preload (FP=400N) with a defined velocity (1°/s). The instantaneous COR has been calculated based on the velocity pole method using a 3D ultrasonic motion analysis system, measuring the twelve components of motion.

Results: The TDA with activ L leads to a good restoration of ROM and NZ in all loading directions under in-vitro flexibility testing. The instantaneous COR is exemplary described for the native condition under flexion/ extension in the sagittal plane. For the native condition the COR is located in the center of the inferior vertebral endplate. After nucleotomy the COR shifts dorsally into the region of the spinal cord and a significant grade of instability has been measured.

After insertion of the lumbar artificial disc the instability can be reduced to the native grade of motion and the COR is located again in the main axis of the spinal column in the upper third of the inferior vertebra.

Conclusion: The instantaneous COR has been estimated in-vitro for the different loading situations in the human lumbar spine before and after TDA. Based on the newly introduced method further optimizations of TDA devices can be undergone in regard to the particular aspect of physiological kinematics.


S.G. Pneumaticos C. Savvidou A. Pilichou B. Psichas

Background: Misplaced pedicle screws are associated with significant complications during posterior spinal instrumentation.

Purpose: The purpose of this study is to evaluate the efficacy of triggered electromyographic stimulation in predicting the appropriate placement of pedicle screws.

Study Design: Prospective clinical trial.

Patient Sample: Fifteen consecutive patients (3 males; 12 females).

Outcome Measures: Not applicable.

Materials and Methods: All patients underwent posterior thoracolumbar spine fusion. Surgery was performed for spondylolisthesis, spinal stenosis, degenerative scoliosis and fractures. All patients received continuous electromyographic monitoring during surgery. During insertion of pedicle screws the integrity of the medial pedicle cortex was tested by stimulating each screw head with a monopolar pedicle probe stimulator and recording the compound muscle action potentials. A threshold of 7 mA and below was considered indicative of pedicle breach. Intraoperative screw placement was verified with the use of image intensifier. Finally, all patients following surgery underwent plain radiographs and CT scan of the operated region to evaluate the position of the pedicle screws.

Results: One hundred and fourteen pedicle screws were inserted from T7 to S1 in all patients. There were no myogenic responses at the threshold tested. No screw had to be repositioned intraoperatively. There were no new neurologic deficits recorded following surgery. Review of the radiographs and CT scans obtained following surgery revealed no medial pedicle cortex breach. There were two screws that violated the lateral pedicle cortex, without any subsequent complications for the patients.

Conclusions: Our study suggests that the absence of myogenic responses following stimulation at a threshold of 7 mA and below during pedicle screw placement, is a strong indicator that no medial pedicle cortex breach has occurred.


M. Pfeiffer F. Hassel H. Braeutigam U. Schorer

Between 11/2005, and 9/2006 a first series of patients has undergone transpedicular instrumentation with 3D robotic assistance in the lumbar spine at our Orthopaedic Department. This technology must not be confused with standard spine navigation and will be presented in detail.

16 patients (12m, 4f, avg. age 55 yrs.) were randomly selected from our clientele for lumbar fusion or dynamic stabilization via transpedicular instrumentation. After informed consent they obtained thin slice CT scans of the operating field prior to surgery.

The Mazor computer system then imported the scans, allowing 3-D planning of screw placement. A fixation device was then attached to the patient and the system was calibrated in connection with a standard fluoro-scope. On the device a robotic device with a working arm was mounted. Automatic matching algorithms then moved the robot, pointing its arm towards the designated pedicle screw portals. The screws could then be placed through the working arm, either cannulated (ICON) via K-wires, or solid (XIA) via standard awls. Percutaneous MIS insertion was also feasible. Instrumentation was then set forth after removal of the robot as usual. The CT accuracy of screw placement in all robot-assisted patients was scored according to Mattes et al. postoperatively.

1 patient had to be instrumented manually for reasons unrelated to the system. In 2 early obese patients the system denied robotic access due to insufficient imaging, thus enforcing standard manual technique. In the remaining patients a total of 58 screws had to be placed. No clinical complication related to the Mazor system occurred. A total of 6 screws could not be placed by the system due to steep lumbosacral angles. Additional time of surgery could be reduced to 40 minutes per case during the series.

None of the robotic screws was misplaced in the final CT. 1 of the 6 non-robotic screws was misplaced at the S1 level and needed replacement due to apparent nerve contact without palsy. The robotic screws reached an average Mattes score of 1.5 which can be considered superior to sole fluoroscopic techniques (2.5). Additional decompression did not impede the system which does not rely on surface matching. On the basis of the clinical application, additional features were developed, e.g. robot mounting wedges for hyperlordosis, and oblique fluoro view acquisition. The planning software also avoids “supercharging” of the pedicle due to screw oversize. In one case this inevitably would have happened in conventional technique.

This is the first report worldwide about the beginning of robotic assisted pedicle screw placement in Europe in daily routine. The Mazor System now has proven its usefulness and potential. Additional most recent data will be available at time of presentation as the system is further evolving and under continuous use.


M. Flören J. Davis R. Laskin

Background: Recently, less invasive techniques for total knee arthroplasty (TKA) were introduced and the early results suggest a more rapid return of flexion and functional activities, while requiring fewer analgesics after surgery. Despite these findings, there is concern over the possibility of a steep learning curve and the potential risks of implant misalignment or poor fixation that may compromise long-term results. The purpose of this study was to analyze the potential learning curve effect on clinical and radiographic Results: Methods: This retrospective review compares the first 30 (Group 1) to the latest 30 cases (Group 2) in one surgeon’s consecutive series of 152 mini-incision mid-vastus TKA. Pre- and postoperative Knee Society Scores were compared, implant alignment was measured, and flexion was evaluated during hospital stay, at 6 weeks and 3 months after surgery. Complications and operative data were collected.

Results: Flexion was significantly higher in group 2 during hospitalization and at all clinical follow-up evaluations. At last follow-up mean flexion was 111° ± 8 (95–125) in group 1 and 121° ± 11 (90–140) in group 2 (p= 0.001). The mean length of skin incision was 11.7 cm ± 1.5 (8–15) with a mean incision length of the vastus medialis oblique muscle of 3.2 cm ± 1.0 (1–5). A steady improvement of knee and function scores was found in the entire series which were significantly greater in group 2. There were no complications and the radiographic evaluation found no implant or limb misalignment, or signs of early loosening.

Conclusion: The introduction of a mini-incision technique is an evolutionary process. The clinical and functional results show continued improvement after more than 100 cases. There was no classical learning curve effect and no increased complication rate in the earlier series. Thus far, the benefits of the mini-incision mid-vastus approach outweigh the new technique related difficulties and possible new risks. There are no signs of compromise that will affect the long-term results of mini-incision TKA.


T. Karachalios D. Giotikas T. Moraitis G. Karidakis N. Roides K.N. Malizos

In order to evaluate the short- and long-term clinical and radiological results of MIS in TKA, a prospective randomized trial was designed in our department. All patients admitted to the department under the care of one surgeon specializing in Joint Replacement surgery were assigned to participate in the study, signed a concern form, and randomly allocated into two groups. For patients of group A, a TKA was performed using the mini mid-vastus approach; for patients of group B the surgery was performed using a conventional medial parapatellar incision. The Genesis II prosthesis and MIS instrumentation were used for all patients.

Pre and postoperative clinical and radiological data were collected for all patients at regular time intervals (pre, 1st d, 3rd d, 6th d, 3rd w, 6th w, 3rd m, 6th m, 9th m, 1st y, and every year thereafter). Early postoperative pain was also evaluated using a VAS scale and the ability of early SLR was also recorded.

Until now 80 patients (40 MIS, 40 Controls) have entered the study with a follow-up of more than 6 months. In 5 patients (12.5%) of group A the MIS surgery was abandoned in favor of conventional surgery due to technical problems.

Patients in MIS group A had knees with greater range of motion at 3 w, 6 w and 3 months, better function at 3 and 6 months, and less blood loss. In contrast, the same patients experienced greater pain during the first 3 postoperative days. Surgery lasted 16 minutes more on average for the MIS group A. On radiological evaluation technical errors were observed in 5 patients of MIS group A.


T. REPANTIS P. KOROVESSIS Z. PAPAZISIS

Background data. The clinical outcome of decompression and posterolateral spinal fusion for patients with degenerative lumbar spinal stenosis may be influenced by a variety of pathophysiologic factors. Among them, sagittal balance of the spine has gained new interest regarding its correlation with low back pain following lumbar spine surgery.

Objectives. To study the effect of sagittal spinal alignment on low back pain in patients operated for degenerative lumbar spinal stenosis.

Study design. Multifactorial analysis.

Materials and Methods. In this prospective randomized comparative study 45 consecutive patients were included, who underwent decompression for symptomatic degenerative lumbar spinal stenosis and two-, three- or four levels posterior transpedicular fixation with three instrumentations of different stiffness (dynamic, semirigid and rigid) plus posterolateral fusion. All patients were followed up for an average period of four-year radiologically and with SF-36 (domain Bodily pain) to investigate possible correlations between anthropometric parameters, stiffness and extension of instrumentation, roentgenographic sagittal balance, motion in adjacent free level and low back pain.

Results. Bodily pain scores improved with the time lapsed from index operation (P< 0.0001). As the distance of the apical lumbar vertebra from plumbline increased, bodily pain score improved significantly (P=0.0006). At the last observation following surgery patients had better Bodily pain score than that they had preoperatively (P=0.0001) and six months postoperatively (P< 0.0001) respectively. Patients, who received four levels instrumentation had higher Bodily pain score (P=0.0245) than their counterparts who received two levels instrumentation.

Discussion. Maintenance or even improvement of lumbar lordosis, instrumentation of three and four vertebrae, and time lapsed from index operation was associated with improvement of back pain. On contrary, patients’ age, gender, instrumentation stiffness, vertebral inclination, thoracic kyphosis and sagittal lumbar flexibility did not affect the surgical outcome regarding back pain in adult patients who underwent decompression and stabilization 2 to 4 levels for degenerative lumbar spinal stenosis.


S.D. Schoifet T. Depaulis K. Lehmann

Long term quadriceps strength defictis have been reported after a TKA performed with a quadriceps splitting approach. Will an MIS-TKA performed with a mini midvastus approach significantly improve long term quadriceps strength retention?

147 subjects were chosen in a retrospective manner for this study. 52 MIS-TKA, 48 quadriceps splitting TKA, and 47 controls with normal knees and no prior surgery. All groups were age and gender matched. All knees were tested more than 1 year after the index operation on a Cybex isokinetic dynamometer. All surgeries were performed by the author.

The average Knee Society knee score for the MIS-TKA group was 94.3 and the average age was 71. The quadriceps splitting group had an average knee score of 95.7 and an average age of 72. The control group had an average age of 70. All groups averaged 38% male and 62% female. At 30 degrees from full extension the MIS-TKA group retained 96.6% of the control group strength and the quadriceps splitting group 94.5%. At 15 degrees from full extension the MIS-TKA group improved to 99.7% while the quadriceps splitting group fell to 85% of the control group strength.

MIS TKA with a mini midvastus approach preserves terminal quadriceps strength better than a standard quadriceps splitting approach.


E. THIENPONT

Introduction: The aim of this study was to analyze the clinical importance of one single factor, the length of the skin incision in minimal invasive total knee arthroplasty.

Materials & methods: This was a prospective randomized single surgeon study. All patients were randomized for sex, age, diagnosis and BMI. In 40 consecutive knees, primary total knee arthroplasty was performed with minimal invasive instruments, through a 12 cm skin incision and a mini-midvastus approach. After cementation of the components and closure of the arthrotomie, half of the patients (20) were randomized (enveloppe technique) to have their skin incision extended from 12 to 20 cm.

The following data were assembled by a skin incision blinded study nurse: VAS, use of morphine pump, range of motion, straight leg raising, time to independent ambulation, time to discharge, wound problems and complications up to 6 weeks postoperative.

Results: For all these studied parameters there was no statistical significant difference between both study groups.

Conclusion: With this prospective randomized study we were able to analyze the functional effect of a larger skin incision in minimal invasive (MI) total knee arthroplasty and the placebo effect for the patient to see a smaller scar. We can conclude that the exact length of the skin incision is a non issue in MI total knee arthroplasty. Patients benefits are obtained by less soft tissue damage, the avoidance of patellofemoral and tibiofemoral dislocation and optimal patient management. We even believe that performing MI total knee arthroplasty through a comfortable incision could be advantageous. Shorter operating time, less skin bruising and avoidance of skin – implant contact can be obtained.


M. Rudert W.K. Aicher M. Hoberg

Introduction: The highest goal after meniscus damage is the preservation of the meniscus, which is often not possible due to the bad healing of meniscus lesions in the avascular zone. Therefore, the goal of our investigations was the analysis of expression of different angiogenic factors, growth hormones and cytokines in human meniscus cells (fibrochondrocytes). The mutual influence of the fibrochondrocytes by endothelial cell cocultures was analyzed, in order to examine the molecular bases of the healing of meniscus tears in vascularized zones more exactly. For this purpose, commercially available HUVEC [human umbilical vein endothelial cells] were used as well established and stable endothelial cell model.

Material and Methods: Meniscal fibrochondrocytes were expanded in DMEM medium enriched with antibiotics and 10 % FCS. Cocultures of mensical cells and HUVEC were incubated in transwells over four and twelve days, separated by a semipermeable membrane. The expression of Angiopoietin-1, Angiopoietin-2, End-ostatin, VEGF, SMAD-4, Thrombospondin-1, Aggrecan, Biglycan, Fibronectin, Vimentin, Connexin-43, IL-1β, iNOS, MMP-1, MMP-3, MMP-13, collagen-I, -II, -III, -VI, X, and -XVIII were examined by RT-PCR and immunhistochemistry in fibrochondrocytes in the comparison to cultures without endothelial coculture. A proliferation assay was used to investigate the mitotic activity in the coculture compared to the control culture after 4 and 12 days.

Results: In presence of HUVEC, meniscal fibrochon-drocytes expressed the following factors at rates comparable to cells w/o HUVECS: Angiopoietin-1, Angiopoietin-2, VEGF, SMAD-4, Aggrecan, Biglycan, Fibronectin, Vimentin, Connexin-43, iNOS, MMP-1, MMP-3, MMP-13, Thrombostatin-1, collagen-I, -II, -III, -VI, X, and -XVIII. In contrast, expression of end-ostatin (5.1-fold ± 1.2, p< 0.01) and IL-1β (10.3-fold ± 2.3, p< 0.003) were expressed significantly higher in the coculture when compared to the individual cell cultures. The proliferation rate of HUVEC was significantly decreased in coculture when compared to controls: 22 % after 7 days and 35 % after 14 days (p< 0.001).

Discussion/ Conclusion: We were able to cultivate and characterize human fibrochondrocytes from menisci of the knee joint. We could show that coculture of meniscus cells with endothelial cells revealed an increased expression of the anti-angiogenetic factor endostatin and the pro-inflammatory IL-1β. This suggests that meniscus cells are trying to inhibit proliferation of endothelial cells in their neigbourhood, which implicates huge problems in the research field of neoangiogenisis and tissue engineering in meniscus tissue for new healing methods after meniscus trauma.


R.L. Plaster

BACKGROUND: Clinical results at 10–14yrs of the NKI noncemented TKA(AAOS 2005, Plaster) showed no failure of ingrowth and no tibial osteolysis. A similar 10yr study of the NKII series indicated a higher revision rate based solely on tibial osteolysis at the tip of the medial screw, creating a 9% partial revision rate (poly-exchange and grafting of cyst) of NKII at 10yrs. There is no failure of the actual ingrowth bond.

METHODS: Between Dec 1995–01, 1410 pts were implanted with NKIIs (Zimmer). Prospective data was collected at preop, surgery & intervals up to 5–10yrs. Classification of osteolytic cysts is defined: Grade 1=cyst of 1cm; Grade 2=cyst > 1cm without cortial erosion; Grade 3A=cyst < 1cm with cortical erosion; Grade 3B=cyst 1cm with cortical erosion & Grade 4=stress fracture or perosteal reaction indicative of a stress fracture. Specimens from revisions have been evaluated by 2 independent labs. Inserts were replaced using a highly crosslinked poly.

RESULTS: 445 pts were seen for clinical and xray f/u, 65 expired. Osteolysis occurred in 36% most of which were early stages. Revision were required in 9%. Exams of the poly show wear with football shaped extrusions into the screw holes & abrasive scores consistent with micromotion. Microscopic analysis show macrophages with inclusions suggestive of poly debris but there is a paucity of actual poly seen.

DISCUSSION: Osteolytic cysts are occurring in the NKII & not in NKI. It is not known if these are design issues or poly “improvement” issues. One postulation is smaller particles but increasing numbers has led to a decrease in the bone tolerance. Early f/u of highly cross-linked poly shows marked improvement and no cysts.

Generation of the tibial cyst is multifactorial. Implantation techniques can increase poly imminence impingement by the femoral notch thus increasing forces on poly during gait. Lowering the notch on the NKII improves patella contact but can lead to impingement if the surgeon flexes the femur or places too much slope on the tibia. Hydraulic action is also postulated, joint fluid is being forced down the screw channel carrying with it small poly particles. The tight peripheral tolerances of the insert into the baseplate may create such a tight fit that the insert acts like a piston with each step. Lab testing is currently being done to test this hypothesis and evaluate micromotion and wear patterns. We are recommending polyexchanges for stg 3 & 4 pts to the highly crosslinked poly as well as curetting and grafting all cysts. Early results show cyst resolution. Stress fractures may require long stem revision baseplates. Stg 1 & 2 can be followed with serial xrays


F. Billi S. Aust E. Ebramzadeh

TKR backside wear studies have concluded that, compared to rough trays, polished trays decrease total amount of backside wear by 80% to 87%. However, size and volumetric concentration of sub-micron-sized polyethylene particles are critical factors for macrophage-mediated osteolysis. We assessed the size and morphology of polyethylene wear debris from TKR backside wear simulations comparing polyethylene fretting against polished and blasted metal surfaces. A 3-station fretting wear simulator reproduced loads and motions typical of the backside of fixed-bearing inserts of TKRs. 5-million cyclic experiments combined low (50μm) or high (200μm) linear motion with +3o rotational motion. Load profile was double-peak Paul curve (peak 10MPa). Eight 3-station experiments measured polyethylene wear against blasted or polished metal surfaces of Ti6Al4V or CoCr. Polyethylene particles were isolated from serum following gradient separation and filtration on 0.01μm polycarbonate filters. Using SEM analysis, average 200 particles per sample were characterized with Meta-morph™ image analysis software. Concentration of submicron particles in the debris from rough surfaces was 31–32% under 50μm motion, 28–30% under 200μm. Surprisingly, this concentration from polished surfaces was substantially greater: 69–78% (50μm), and 57–63% (200μm). However, total poly wear against rough surfaces was 0.45–1.63mm3/

Mcycles, and 0–0.35mm3/Mcycles against polished. Taking this into account, the volume of submicron particles from polished surfaces is less than 0.1mm3/ Mcycles and from rough surfaces between 0.1 and 0.45mm3/Mcycles.

In conclusion, although polished metal trays produce up to five times less wear than blasted surfaces, they may also lead to an increase in the osteolytic potential of the polyethylene debris.


M. Hoberg W.K. Aicher M. Rudert

Introduction: After a meniscus trauma, preservation of the meniscus is the most important surgical goal. The use of scaffolds colonized with meniscus cells (fibrochondrocytes) to reconstruct meniscal defects seem to be a promising way for the treatment of a meniscus trauma. The goal of our investigations was the analysis of expression of different anabolic and catabolic factors in human fibrochondrocytes after seeding these cells onto a collagen I scaffold to investigate the regenerative potential of such a construct for the treatment of meniscus tears.

Material and Methods: Human meniscus tissue was digested in collagenase and dispase and cells were characterized by immunohistochemistry. To test scaffolds, we used a commercially available bovine collagen I matrix approved for surgical purposes. The scaffold was colonized with human fibrochondrocytes in a density of 106 cells per cm2. Cells expanded at the same ínoculation density w/o scaffold served as mock-controls. After 14 and 28 days in culture, the cells were extracted from the scaffold by aid of collagenase (Sigma, Deisenhofen, FGR) and analyzed for the expression of different factors, including IL-1β, IL-6, TGF-β, TIMP-1, TIMP-3, MMP-1, and MMP-3 using a quantitative RT-PCR-technology.

Results: Bovine collagen I matrices could be colonized with human fibrochondrocytes. After 14 and 28 days of incubation on the scaffolds, the cells show the same mRNA expression levels of IL-1β, TIMP-1, TIMP-3, and TGF-β when compared to controls. In contrast, after 14 days IL-6 (12.7-fold ± 4.4, p< 0.001), MMP-1 (11.3-fold ± 2.4, p< 0.001), and MMP-3 (13.7-fold ± 6.8, p< 0.031) were upregulated on transcription levels in the scaffold when compared to controls after the same period of culture. After 28 days of culture in scaffold the expression of MMP-3 was upregulated 78.2-fold (± 7.4, p< 0.0001), MMP-1 (71.3-fold ± 5.9, p< 0.0001) and IL-6 was elevated 98.9-fold (± 9.1, p< 0.0001) compared to controls.

Discussion/Conclusion: We were able to cultivate and characterize human fibrochondrocytes from menisci of the knee joint colonized onto a bovine collagen I matrix. We could show that meniscus cells revealed a significantly increased expression of MMP-1 and MMP-3, and also a significant elevation of IL-6 mRNA after 14 and 28 days of culture. No changes were found in the expression levels of IL-1β, TGF-β, and the TIMPs. This suggests that the meniscus cells colonized onto a bovine collagen I scaffold produce a considerable amount of catabolic or inflammatory factors. This may lead to a destruction of the scaffold-matrix itself and the extracellular matrix of the meniscus. Secondly, IL-6 could induce a global inflammation around the scaffold by activating the IL-6 inflammation cascade.


P. Georis J.P. Huskin P. Gillet

The New Jersey Low Contact Stress prosthesis was introduced in 1977. LCS mobile bearing prostheses have been implanted in patients in the United States since 1985. The PCL-sacrificing rotating platform design of the LCS® prosthesis was designed to minimally constrain knee kinematics while minimising bone-cement-prosthesis interface stresses and polyethylene wear.

The purpose of the current study was to assess the in vivo rotating platform PE wear of the LCS-RP® and to check if the PE tray mobility is preserved over time.

We investigated 120 total knee replacements in 108 patients (38 men, 70 women) treated by the LCS-RP® prosthesis for osteoarthritis or rheumatoid arthritis. Average age of the patients was 70.4 years (range: 36–81). Average follow-up was 15.3 years (range: 10–18).

PE wear assessment was performed using a specific analysis model created in the Imagika® software on AP radiographs.

Rotating platform mobility was assessed thanks to another analysis model. We used prosthetic landmarks (tip of the prosthetic stem, tibial tray and tantalum markers embedded into the PE) visible on lateral radiographs.

Linear wear rates were 0.012+/−0.007 mm (tibial plate/ PE interface), 0.026+/−0.034 mm (PE/internal condyle interface) and 0.017+/−0.041 mm (PE/external condyle interface). There were no significant differences between wear values of both internal and external sides of the upper surface of the PE insert (P = 0.000054) and of tibial plate PE/external condyle PE interfaces (P = 0.0012), but a P value of 0.063 was observed between the tibial plate PE interface and the internal condyle PE interface.

The PE range of motion was 5.3 +/− 1.2° (range: −2.5 (external) to +3.2 (internal)) at last follow-up as compared to the first radiograph (3 months after operation). All trays preserved there mobility in rotation.

Annual PE wear rates were extremely low as well as at the lower and the upper surfaces of the mobile bearing. Our results suggest that the long term mobility conservation contributed to low PE wear rates despite a high anatomic congruency due to the prosthetic design.


J.F. Huber P. Schoenenberger J. Huesler G. Ruflin M. Zumstein

Introduction: Assessment of symptoms regarding quality, strength and localisation is a part of the medical consultation. After that these informations need to be documented in the medical files. This process can be substantially ameliorated with a patient questionnaire, which assessess the symptoms and disabilities in a structured way. We developed a simple graphic questionaire (pationnaire), clearly structured, easy to understand and simple to fill out. The aim of this study was to test the construct validity of the ‚pationnaire’ with personal interviews (the agreement of symptoms and disabilities), and the ability and time to fill it out without help.

Study design: Monocentric analytical study measuring the agreement.

Persons/patients and methods: The persons/patients were randomly selected by the interviewer. They signed an informed consent approved by the local ethical commitee. After a short introduction about the ‚pationnaire’ and its aims, people filled out one directly without help. The time to completion was measured. The person/patient was then personally interviewed about items within the ‚pationnaire’ to assess their correlation with their symptoms and disabilities, and uncover any sources of misunderstanding or misinterpretation.

At the end of the interview every person/patient was asked for a statement about their understanding, formulations, difficulties with the ‚pationnaire’, missing questions and general impression.

Results: 78 persons/patients (50 women, 28 men) were included. Their average age was 46.3 years (range 12–93 years). 97% (76) could fill out the ‚pationnaire’ without help, 2 needed help and further explanations. Average time for completion was 9.9 min (range 3–45 mins) – the longest time being taken by those who needed help. Complete agreement between the questionaire and the perceived symptoms/disabilities was found in 94% (n=73), it was partial in 3.8% (n=3), and„no agreement“ occurred in 2.2% (n=2, persons, both of whom needed support). The understanding was rated very good in 98% and difficult in 2% (both elderly persons > 80 years). The formulation ’my symptoms are’ was preferred by everybody compared to ’which symptoms do you have’. In general the overall rating was good or very good for all persons, although older people with co-morbidities needed help.


D. MAINARD L. GALOIS S. VALENTIN J. GASNIER C. EGROT J. DILIGENT

Introduction: A good cup positioning requires reliable anatomical landmarks expecially for navigation. The anterior pelvic plane (APP) seems to be a good reference for navigation because it is in relation with pelvic tilt which do affect the position of the cotyle and consequently the position of the cup. The value of this plane is not well known according to gender, age, weight… The aim of the study is to assess radiologically the APP in standing and supine position before and after total hip arthroplasty.

MATERIALS AND Methods: 92 Patients (32 males, 60 females, mean age 65 years) underwent strict lateral X-rays in standing and supine standardized position. Uninterpretable or unsatisfying X rays were withdrawn. 45 patients underwent a standing X-ray, 24 a supine X-ray, 21 a supine and standing X ray. Statistical analysis used a Student t-test.

Results: Non matched values showed a retroversion of the pelvis of 6.4° (+/− 6.9) in supine position, 0.3° (+/− 7.4) in standing position. Matches values showed an retroversion of the pelvic of 6.9° (+/− 5.3) in supine position, 0.3° (+/− 5.03) in standing position (significant difference). Extreme values varied from −15° to + 18° (3 patients showed no variation, 2 patients a retroversion from supine to standing position). There was no statistical difference between male and female but a statistical differences in females.

Discussion: The APP is easily assessable by X rays in standing as in supine position. Bony landmarks of the plane are also assessable by navigation tools and to can be a good plane as reference. Several authors showed the repercussion of the pelvic tilt on the cotyle position. The difference between standing and supine position is about 6°. But for some patients the difference is may be of 20°and that could explain some impigment and instability. A cup well positioned in supine position may be not so good in standing position because of the pelvic tilt.

Conclusion: The value of the APP is important to know before THA and seems to be a good plane as reference for navigation.


M. Norberg B. Danuser A. Klipstein T. Läubli C. Jeanrenaud

Work-related musculoskeletal disorders are a persistent and expensive health challenge in all industrial countries including Switzerland. A recent European survey indicates that, among the working population, the three most common work health problems reported are: back pain (30%, increasing), stress (28%), muscular pain in arms or in legs (25%). A relatively small group of patients causes relatively high health services costs and long absenteeism from work and furthermore show a high risk to loose workability.

Significant progresses have been made these last years in the understanding of the disorder occurrence and chronitisation. Despite of this, the management and successful rehabilitation of MSD suffering workers is still difficult. Recent reviews recommend an intervention strategy based on the bio-psycho-social model. Work hardening and work rehabilitation programs seek to achieve a balance between the physical and mental demands of the job and the individual’s abilities. In a pilot project, we developed and tested the needed instruments and protocols for a multi-disciplinary intervention strategy that takes both aspects into account. This involves the application of clinical and occupation medical skills (rheumatology, occupational medicine, work psychology, ergonomics).

Aim: The goal of this controlled, blind, case control study is to compare the effectiveness of the multidisciplinary intervention strategy versus the standard treatment. The two methods will be compared with regard to patients’ ability to return to work. The multidisciplinary intervention strategy consists of

work hardening, cognitive training, and psychosocial counseling directly related to the person’s real work conditions and demands, and

job analysis and, if necessary, modification of work conditions.

Patients were recruited for participation in the two groups (120 patients in the intervention group and 120 patients in the control group) in collaboration with companies that have a work absence management system. Two research teams – with members from two university centers (Orthopedic Hospital, Lausanne;University Hospital Zurich) and from the two Swiss institutes working in the area of work and health (Center for Organizational and Occupational Sciences (ZOA), Swiss Federal Institute of Technology; Institut universitaire romand de Santé au Travail (IST), University of Lausanne), will conduct the case control study jointly. In addition, a research team at the University of Neuchâtel will conduct a cost-benefit analysis of the multidisciplinary and the standard treatment.

Significance: The whole study would produce new strategies for the management of MSD and workplace rehabilitation as well as guidelines for both authorities and companies. Its potential impact in terms of risk and cost reduction for companies and the society is important.


B.M. Jolles F. Nicolas

Introduction: Registration of complications in a Department of Orthopaedic Surgery or Traumatology has always been the concern of surgeons as a simple feedback to improve the quality of care they provide to their patients. However, it has not been made through a systematic approach in Switzerland to date. The literature shows only one study which proposes to set up a database and software for general surgery complications.

The purpose of this study was to show the feasibility of setting up a computerized register of complications for a whole Department of Orthopaedic Surgery and Traumatology, based on a simple, user-friendly and upto-date scientific approach.

Methods: After a systematic literature review, the definitions, types and classification of complications were determined. A protocol for data registration was defined as well as the tasks for the people involved. A client-server software was chosen and further developped, in close collaboration with the Information Technology Department to benefit from an automatic download of patients’ administrative data.

Results: The classification of complications by de Waal Maletfijt was adapted and the coefficient of severity proposed by Clavien was used. A definition of each complication was communicated to all staff involved. A self-developed Microsoft Access application with a local database as back-end was developed. A new strategy to capture the complications efficiently was developed and used after staff approval. Data collection was done before surgery (prehospitalisation), on the day of surgery and after the operation until the end of the stay in hospital.

Conclusions: This systematic approach to record complications was found feasible, efficient and a useful tool for the assessment of quality of care.


M. Suarez-Suarez F. Ferrero-Manzanal A. Salas-Bustamante M. Alvarez-Rico J. deCos-Juez P. Garcia-Gonzalez A. Meana-Infiesta G. Acebal-Cortina A. Murcia-Mazon

INTRODUCTION: In guided tissue regeneration a membrane is used for defect isolation to protect it against invasion from surrounding tissues and to keep intrinsic healing factors ‘in situ’. This technique has been successfully used in maxillo-facial surgery, but short experience has been reported in long-bone defects, with synthetic membranes and with variable results. In the other hand, calcification and ossification inside the arterial wall have been described.

OBJECTIVE: The aim of the study was to evaluate the use of cryopreserved aorta allografts as membranes for guided tissue regeneration in comparison with expanded poly-tetra-fluoro-ethylene (e-PTFE) synthetic membranes.

MATERIAL & METHODS: Prospective, randomized, blinded study in 15 New-Zeland rabbits. 10 mm mid-diaphyseal defects were created in both radii: 10 defects were covered with a cryopreserved aortic allograft as a tube, 10 with an e-PTFE membrane and 10, with no barrier membrane, served as controls. Animals sacrifice at 6–12–24–30 months. Studies: X-rays, CT, MR, morpho-densitometric analysis, electronic and optical microscopy. Immuno-cytochemistry on tissues and arterial wall cells cultured.

RESULTS: None of the control defects healed. Nine defects covered with an artery completely reconstituted, but only six of those covered with e-PTFE, with a nearly normal cortical-medullar pattern and with progressive increasing in density and thickness of medullar and cortical to values similar to those of the normal bone. Histological studies showed no inflammatory response to the arterial graft, direct union between the artery and the regenerated bone and even mature bone between the elastic laminae of the arterial wall, suggesting superior biocompatibility properties. Immuno-cytochemistry and ultrastructural studies suggest that arterial allografts could act not only as membrane barriers, with additional osteoinductive properties due to trans-differentiation of viable arterial wall cells (endothelial, smooth muscle and/or tissue specific stem cells) towards osteoblastic cells, and also due to ossification secondary to changes in proteins of the arterial extracellular matrix. This could be the application of the process of arterial wall calcification and ossification (usually seen in arteriosclerosis, gender, diabetes or kidney failure) for regeneration of long-bone defects.

CONCLUSION: Cryopreserved aortic allografts can be used as membrane barriers for guided bone regeneration, with superior results to e-PTFE membranes.


R. Chidambaram A.G. Cobb

Introduction: Analysis of the ages at the time of surgery of all patients undergoing primary hip and knee replacement in a UK District General Hospital setting over a period of 13 years

Method: Retrospective study of all cases of primary hip and knee replacements performed at our institution between 1993 and 2005.

Results: A total of 4703 patients had primary total joint replacement in this period. This includes 2591 hip replacements and 2112 knee replacements. The ratio of females to males was 2:1

The average age of primary hip replacement patient was 70 years. (male patients 68 years and 71 years in females.) Over the 13 year period, the average age of male patients was noted to decline steadily from 71 in 1993 to 66 in 2003. But the average age of female patients remained constant at around 71 years.

The number of patients below age 60 years undergoing hip replacement procedures was analysed. Only 8% of patients were under 60 years of age in 1993 rising to 23% in 2005. Between 2000 and 2005 this figure was at or above 20%.

Surface hip replacement was started at our hospital in 1999. The number of patients treated with surface hip replacement as a proportion of all primary hip procedures has increased to 32% in 2005. The average age of these patients was 57 years. The sex difference was approximately 1:1 as compared to 1:2 in total hip replacement.

The average age of primary knee replacement patients was 73 years, 72 yrs for males and 73 yrs for females. No change in average age was noted over the period. The proportion of patients under age of 60 years varied between 4 and 9%

Conclusion: The average age of male patients having primary hip replacement in the UK is declining and the proportion of young males undergoing hip replacement is increasing. Unless there has been a change in the incidence of osteoarthritis, these observations may reflect either a change in surgical selection criteria possibly associated with the success of surface replacement or else patients’ demand for early intervention. No changes have been observed in the age of patients undergoing knee replacement.


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

Introduction: Non-invasive prediction of load bearing capacity during consolidation of distraction osteogenesis and fracture healing would represent a significant advance in the treatment of patients by defining the appropriate point of time for the removal of the fixator externe. Thereby the risk of refracture, malunion and infection could be reduced. Several methods have been proposed in the past to predict the load bearing capacity: dual-energy x-ray absorptiometry (DEXA), stiffness measurements, quantitative computed tomography, quantitative radiography and ultrasound. In this ex-vivo study stiffness- and DEXA-measurements were compared regarding their suitability to predict the load bearing capacity of bone regenerate.

In addition this study analysed how compressive, bending and torsional stiffness as suitable tools were related to the torsional load bearing capacity using a common set of bone regenerate samples of 26 sheep treated with distraction osteogenesis.

Material and Methods: After osteotomy the sheep tibiae were stabilized using an external half-ring Ilizarov fixator. Followed by a 4-day latency period the tibiae were distracted at a rate of 1.25 mm per day in two increments for 20 days. On the 74th day the sheep were sacrificed and tibiae were harvested. The ends of the specimens were embedded in PMMA for further biomechanical testing. Therefore, the specimens were mounted to a sequence of special costume made jigs for compressive testing, 4-point bending and torsional testing in a material testing machine. Stiffness was calculated by regression of the linear part of the load-displacement curves. The maximum torsional moment of the specimens was determined in a final experiment. In addition the bone mineral density (BMD) of the distracted bone tissue was measured using DEXA. The correlation between the maximum torsional moment and the various types of stiffness respectively BMD was analysed to gain information about the suitability predicting the load bearing capacity.

Results: Torsional stiffness exhibits the highest correlation with the maximum torsional moment (r2 = 0.77) followed by bending (ap (r2 = 0.70); ml (r2 = 0.66)) and compressive stiffness (r2 = 0.60). The correlation for BMD with the maximum torsional moment was smallest (r2 = 0.39).

Discussion: This ex-vivo study revealed that the stiffness measurements seem to be a helpful tool to predict the load bearing capacity of bone regenerate. The results of this study showed stiffness measurements as a more suitable mean to determine the load bearing capacity. Within the various types of stiffness measurements torsional stiffness measurements perform slightly better than bending and compressive stiffness measurements. Nevertheless, further studies are necessary to support the results of this study since the specimens failed applying torsional stress.


R.O. Sundaram S. Lipscombe S. Subramanian P. Chandran M. O’Malley I. Shackleford

Introduction: Radiation dose exposure to patients in a main X-ray department in a hospital is well documented and controlled. Few studies report the radiation exposure to patients undergoing spinal surgery received from an image intensifier. There are no recommended doses published when using the image intensifier

Methods: We reviewed the radiation doses and exposure times from computer and radiation log records of all the patients who underwent trauma & orthopaedic surgery which required an image intensifier between January and September 2005. The Dose-Area-Product (Gray/cm2) and screening time was recorded.

Results: More than 600 patients underwent trauma & orthopaedic surgery that required an image intensifier at the time of surgery. The mean screening Dose Area Product of the patients undergoing spinal surgery and other common procedures are shown (Gray/cm2):- Lumbar fusion – 23. Disc replacement – 10. Discogram – 4.9. Foraminal injection – 4.4. DHS – 1.86. IMHS – 1.33. ORIF Ankle – 0.89. MUA k-wire wrist – 0.04. The four surgical procedures which required the most radiation were spinal procedures. The maximum radiation is given to patients undergoing lumbar spinal fusion.

Conclusion: Patients undergoing spinal surgery can receive as much radiation exposure as those undergoing procedures such as barium swallow or standard lumbar spine films. Efforts should be made to reduce radiation exposure to orthopaedic patients, and operating surgeons especially those undergoing spinal surgery. By publishing our radiation exposure doses, we can begin to establish guidelines for recommended patient doses.


J. Matsuyama I. Ohnishi R. Sakai K. Miyasaka A. Harada M. Bessho S. Ohashi T. Matsumoto K. Nakamura

The most important issue in the assessment of fracture healing is to acquire information on the restoration of mechanical integrity of the bone. To measure bending stiffness at the healing fracture site, we focused on the use of echo tracking (ET) that was a technique measuring minute displacement of bone surface by detecting a wave pattern in a radiofrequency echo signal with an accuracy of 2.6 μ. The purpose of this study was to assure that the ET system could quantitatively assess the progress, retardation or arrest of healing by detecting bending stiffness at the fracture site.

With the ET system, eight tibial fractures in 7 patients with an average age of 37 years (range: 24–69) were measured. Two tibiae in 2 patients were treated conservatively with a cast, and 6 tibiae in 5 patients were treated with internal fixation (intramedullary nailing: 4, plating: 1, screw 1). Patients assumed supine position, and the affected lower leg was held horizontally with the antero-medial aspect faced upwards. The fibula head and the lateral malleolus were supported and held tight by a Vacufix ®. A 7.5 Hz ultrasound probe was placed on each antero-medial aspect of the proximal and distal fragments along its long axis. Each probe was equipped with a multi-ET system with 5 tracking points with each span of 10 mm. A load of 25 N was applied at a rate of 5 N/second using a force gauge parallel to the direction of the probe and these probes detected the bending angle between the proximal and distal fragments. An ET angle was defined as the sum of the inclinations of both fragments. In the patients treated with a cast, the contralateral side was also measured and served as a control. Fracture healing was assessed time sequentially with an interval of 2 or 3 weeks during the treatment.

None of the patients complained of pain, or no other complication related to this measurement occurred. In the patient (patient:M) treated with a cast, the ET angle exponentially decreased as time elapsed (y = 1.4035e-0.1053x, R = 0.9754) and the radiographic appearance showed normal healing. Including this case, in all patients with radiographic normal healing, the ET angle exponentially decreased. However, in patients with retarded healing (patient:N), the decrease of the angle was extremely slow(y = 0.2769e-0.0096x, R = 0.815). In patients with non union (patient:T), the angle stayed at the same level.

With this method, noninvasive assessment of bending stiffness at the healing site was achieved. Bending angle measured by ET diminished over time exponentially in patients with normal healing. On the contrary, in patients with healing arrest, no significant decrease of the bending angle was recognized. It was demonstrated that the echo tracking method could be applicable clinically to evaluate fracture healing as a versatile, quantitative and noninvasive technique.


T. Tischer S. Vogt S. Milz M. Maier

Shock wave treatment has been shown to induce new bone formation both under physiologic conditions and during fracture repair. Whereas various underlying molecular working mechanisms have been shown in recent studies, no study has assessed the influence of varying energy flux densities (EFD) on the amount of new bone formation in vivo. Therefore, the aim of this study was to investigate whether the effect of shock waves on bone is dependent on the applied EFD and if so, to identify the minimal dose necessary to induce new bone formation in vivo to avoid unwanted side effects of high-energy shock waves.

To this end, 30 New Zealand white rabbits were randomly divided in 5 groups and treated with extracorporeal shock waves at the distal femoral region (1,500 pulses at 1 Hz frequency each):

(a) control (sham treatment),

(b) EFD 0.35 mJ/mm2,

(c) EFD 0.5 mJ/mm2,

(d) EFD 0.9 mJ/mm2 and

(e) EFD 1.2 mJ/mm2.

To investigate new bone formation, animals were injected with oxytetracycline at the days 5 to 9 after shock wave application and sacrificed on day 10. Histological sections of treated and untreated femora of all animals were examined using broad-band epifluorescent illumination and contact microradiography. The amount of new periosteal and endosteal bone was measured and signs of periosteal detachment, cortical fractures, and fragmented trabecular bone with callus were recorded.

Application of shock waves showed new bone formation beginning with 0.5 mJ/mm2 EFD and increasing with 0.9 mJ/mm2 and 1.2 mJ/mm2. The latter EFD resulted in new bone formation also on the opposite cortical bone and cortical fractures and periosteal detachment occurred. EFD of 0.35 mJ/mm2 did not lead to any new bone formation. Here for the first time a threshold level is presented for new bone formation after applying shock waves to intact bone in vivo.

We conclude that the results presented here have significant impact on further clinical applications of shock waves on bone tissue. In the present study, it is clearly demonstrated that the amount of new bone formation is directly dependent on the applied EFD. If the applied EFD is to low, no significant new bone formation will occur. If it is too high, unwanted side effects, like the formation of bone spurs in the shoulder or nerve entrapment syndromes in the elbow or feet by bony overgrowth may result.


H.I. Bekler F. Okyar G. Bulut A. Gokce T. Beyzadeoglu

A conventional implant/bone construct typically involves a plate fixed to a fracture bone via set of screws aligned vertically to the plate/bone interface. In this study new configurations of plate/bone constructs with varied screw angulations were tested. The conventional screw configurations a parallel set of screws aligned vertical to interface were tested against two new configurations, called the divergent configuration and the convergent configuration. A total of four construct systems were prepared for tests. The samples used in the experiments are listed. Sample A, named conventional construct, used a set of parallel screws drilled vertical to the interface plane. Sample B, named convergent construct, used screw holes drilled such that their axes converged. Samples C and D, named divergent construct, used screw holes with diverging axes. The difference between Samples C and D is in the angle of alignment between their screw axes and the normal to the interfacial plane, the former drilled at 150 and the latter at 300. The load displacement curves for the four samples are shown. The failure loads, along with the mode of failure for each sample are read from the load-displacement curves. At a first glance, it is observed that the sample with highest pullout strength in terms of failure load is the conventional construct (A). This is followed by the divergent constructs (C and D), and the sample with the lowest strength is the convergent construct. It takes a more careful investigation, however, to note that similar results will not apply when one takes the average pullout stiffness as a criterion. Here, we define the average pullout stiffness of the structure as It is immediately noticed that samples producing the highest stiffness are those prepared as divergent constructs (C and D), followed by the convergent construct (B), and finally, Sample A produced the lowest stiffness. Also note that the initial portion of the load-displacement curve for Sample D (300 screws) is highly nonlinear, although the curve then assumes a linear shape. The stiffness obtained in the linear region of Sample D, and that of Sample C are quite close in comparison.

This initial deviation in the curve of 300 divergent screws may be explained by a self-aligning motion of the screws as the load is applied, during which the angle of alignment tends to decrease towards a smaller angle. As the angle gets closer to that of Sample C and the curve becomes linear, the stiffness produced by Sample D, approaches to that of Sample C.

As a result, we have found the divergent constructs to be a promising alternative to the conventional set of screws, used in treating fracture involving bones with osteoporosis. Moreover, research needs to be focused on determination of an optimal angle of alignment, the number of screws to be used and the optimal distance between each screw for the divergent construct.


S. Jacobsen T. Jensen P. Bach-Mortensen S. Sonne-Holm L. Hyldstrup

Background/Objective: Since estrogen receptors (ERα/ERβ) were identified in human chondrocytes, animal-and experimental studies have demonstrated the importance of continued estrogen production for the integrity of articular cartilage. However, human epidemiological support of the hypothesis has been inconclusive. The present study investigated the relationship between reduced bone mineral densities (BMD), as a surrogate parameter of endogenous estrogen status – assessed by digital x-ray radiogrammetry (DXR), and reduced minimum hip joint space width (JSW).

Methods: Standardised hand radiographs of the Copenhagen Osteoarthritis Study cohort of 3.913 adults (1.470M/2.443F) with a mean age of 60 years (range, 18–92), were analysed by the X-Posure digital software v. 2.0 (Sectra-Pronosco). The system is operator independent. From 1.200 individual measurements per radiograph mean BMD was calculated. Minimum hip joint JSW was assessed in standardized, pelvic radiographs.

Results: DXR-BMD decreased in both men and women after the age of 45 years, progressively more so in women. While minimum hip JSW in men remained relatively unaltered throughout life, a marked decline in female minimum hip JSW after 45 years was observed. We found moderate, but highly significant relationships between reduced BMD and reduced hip JSW in women (p < 0.001), adjusted for age and dysplastic joint incongruity.

Conclusion: We believe that the present study supports the hypothetical relationship between reduced estrogen levels and hip joint space width reduction in women.


J. Baas B. Elmengaard T.B. Jensen T. Jakobsen N.T. Andersen K. Soballe

Introduction: Bone grafts should be biocompatible, mechanically stable and be replaced with new bone over time. BMP’s are known to increase bone formation around allografted implants, but have also been associated with increased graft resorption and implant instability. Bone resorption can be inhibited by bisphosphonates.

We hypothesized that topical bisphosphonate (Pamidronate, Mayne Pharma) in combination with rhBMP2 (InductOs, Wyeth) would give increased mechanical implant fixation and increased new bone formation without excessive allograft resorption. We looked at both porous-coated Ti implants and HA-coated implants.

Methods: Four 2.5 mm gap implants were inserted into the proximal humeri of each of 16 dogs. The gap around each implant was filled with fresh frozen impacted allograft with or without intervention treatment. Half the dogs received Ti-implants, the other half HA-implants. The 4 treatment groups were:

allograft alone (control)

allograft + rhBMP2

allograft + pamidronate

allograft + rhBMP2 + pamidronate (combination)

The observation time was 4 weeks.

Results: For both the Ti and HA subgroup, the control-group had significantly better mechanical fixation than all other groups by push-out test. The fixation was twofold higher in the control group than the rhBMP2-group and more than 20-fold higher than the pamidronate group and combined group. The HA implants were twice as well fixed as the Ti implants with corresponding treatment.

The HA implants had less fibrous tissue and more new bone compared to the Ti implants. The fractions of allograft were the same.

The rhBMP2 group had more new bone and much less fibrous tissue than the mechanically superior control group. However, there was almost no allograft left in the rhBMP2 group due to extreme resorption.

The addition of pamidronate seemed to freeze bone metabolism around the implants. Neither in the pamidronate group nor in the combination group was there anything but minor new bone growth. The allograft was preserved. In the pamidronate group there was a dense, thick fibrous capsule around the implants. This was not the case in the combined rhBMP2-pamidronate group, and is most likely a positive effect of the rhBMP2.

Discussion: Topical pamidronate and rhBMP2 in combination and alone greatly weakened the mechanical fixation of the implants. The experiment confirms previous reports of mechanical instability of implants when BMPs are added to periimplanteric defects. Pamidronate alone had catastrophic effects on bone metabolism and implant fixation in this experiment.

The negative results with rhBMP2 may be due to over dosage, which warrants further preclinical testing. Despite the limitations of this animal study with non-loaded implants, the results encourage extreme caution in adjuvant therapies of arthroplastic surgery.


C. Dynybil C. Schmidt M. Backstroem K. Schlichting G. Duda C. Perka

Introduction: Selective COX-2 (Cyclooxygenase-2) inhibitors have been found to impede fracture healing. The effect of selective COX-2 inhibitors on tendon healing in a bone tunnel, however, is unknown.

Methods: The authors performed bilateral anterior cruciate ligament reconstructions in 32 rabbits and used peripheral quantitative computed tomography (pQCT) to compare tendon-to-bone healing between tunnel aperture and midtunnel regarding bone mineral density (BMD) and ingrowth of new bone. Each animal was assigned to one of four groups. Two groups received selective COX-2 inhibitors orally for 3 weeks (Cele-coxib; 10 mg/kg/d), the two other groups received no COX-2 inhibitors (controls). The animals were sacrificed 3 and 6 weeks after surgery. In biomechanical testing maximum load to failure and stiffness of the tendon grafts were calculated from the load displacement curve and failure modes were recorded. To assess indirectly the effect on local COX-2 activity the synovial content of Prostaglandin E2 (PGE2), the major metabolite of arachnidonic acid metabolism and catalyzed by COX-2, was measured by Enzyme-linked Immunosorbent Assay (ELISA).

Results: Animals treated with selective COX-2 inhibitors had significantly lower BMD at the tunnel aperture (P=.02). In all groups the BMD at the tunnel aperture was significantly higher in comparison with the midtunnel (P< .05). In the controls ingrowth of new bone was greater at the tunnel aperture at 3 weeks (P=.028). After 3 weeks of COX-2 inhibitor administration synovial fluid concentrations of PGE2 were significantly lowered (P=.018) and increased more than threefold by 6 weeks after surgery and 3 weeks after last drug administration (P=.022), while in the controls there was a decrease in PGE2 between week 3 and 6. At 6 weeks the controls exhibited a twofold increase in maximum load to failure (3 weeeks: 28.2±20.9 N; 6 weeks: 59.6±53.6 N; P=.394), whereas the COX-2 inhibitor treated specimens decreased 1.9fold (3 weeks: 69.3±50.5 N; 6 weeks: 37.4±16.8 N; P=.24). Maximum load to failure values correlated with PGE2 changes, but not statistically significant (r2= −0,502; p=0,056). Failure modes at 3 and 6 weeks were rupture and degloving, respectively, of the tendon graft.

Discussion: This study revealed decreased bone mineral density at the tunnel aperture at 3 weeks, an increase of the inflammatory mediator PGE2 and decreased graft stability with time after treatment with selective COX-2 inhibitors. Untreated controls appeared to have a more physiological healing course with a continuous decrease in PGE2 and an increase in graft stability. Our results suggest, that selective COX-2 inhibitors may delay tendon healing in a bone tunnel.


P.J. Delgado A. Garcia-Lopez J. De Felipe A. Fuentes F. Lopez-Oliva

AIM: The scaphoid resection with four-corner fusion is an effective procedure for treatment of postraumatic and degenerative wrist osteoarthritis. Few studies that evaluated the functional and workers compensation results are available in the literature. We presented the results of 4-corner fusion on active heavy labour workers.

MATERIAL AND METHODS: A prospective study to evaluate 38 patients (37 male and 1 female) who underwent 4-corner fusion, between 2002 to 2005, with an average of 24 months of follow-up (range, 12–48 months) were made. The mean age of the patients were 32 years (range, 25–48 years). All patients were heavy-labour workers. The aethiology in 77% of the patients was SNAC wrist. Dominant limb was involved in 65% of the patients. All patients were immobilised in a cast for 4 weeks after surgery. Patients were assessed clinically and radiographically. Functional analysis of grip and pinch strenght were performed.

RESULTS: Consolidation was obtained in all cases at 10 weeks. Pain evaluation score was 77 at pre-op and 19 on post-op time. The range of flexion – extension movement postoperative was 57°. Average lost of pinch strength was 25%. All patients return to work, 80% to the same activity level and 20% to a different work performing less strenuous activities. After surgery, the range time to return to work was 160 days.

CONCLUSION: The four-corner fusion allows an effective stabilization, maintaining the bone stock and eliminate wrist pain. This technique permit a fast return to work with a great level of satisfaction and preserve a functional range of motion with a minimum lost of force in heavy labour workers.


F.S. GIANNOULIS N.A. DARLIS R. WEISER D.G. SOTEREANOS

PURPOSE: Trapezial excision with ligament reconstruction combined with tendon interposition has proven to be a highly effective technique for the treatment of OA of the CMC joint. We believe the same procedure is possible with use of modern orthobiologics.

Methods: 35 patients underwent surgical treatment for CMC arthritis with a new technique using Graft Jacket (Wright Med.) instead of FCR. Graft Jacket is an acellular human collagen (dermis) allograft. It is rapidly revascularized, repopulated with host cells and has high tensile strength.

Technique: The Graft Jacket was rehydrated and cut to create a 15cm strip. It was then placed around or sutured to the FCR (the anchor) and passed into the intramedullary cavity of the metacarpal as in the standard LRTI procedure. The remaining Graft Jacket is sutured together as an anchovy to fill the former trapezium gap, so that both suspension and interposition occurred. The mean age of the patients was 56 years and the median follow-up period was 1 year. All patients had marked pain and radiographic evidence of severe arthritis before surgery. Pain, grip and pinch (tip and key) strength, stability and range of motion were measured pre- and post-operatively. Pain was assessed on a VAS (Visual Analog Scale). The ability to perform ADLs (Activities of Daily Living) requiring use of the thumb and to return to work were analyzed as well. Following surgery all thumbs were immobilized in a static splint for 10 days and then were placed into a removable orthoplast splint for 4–6 weeks. Radiographic examination was performed in all patients at the 10th post-op day, and also at 2 and 6 months after surgery.

Results: Significants improvements were seen with grip strength (average 25lb) and tip (average 3.5lb) and key (average 4.5lb) pinch strength as well as palmar and radial abduction (average 25o). Pain was significantly reduced with an average of 6.0 on the VAS. There were no foreign body reactions or other infections in our series.

Conclusions: This study showed that excellent results can be achieved in strength, pain reduction, range of motion and ADLs with this new technique in which Graft Jacket was utilized instead of FCR in ligament reconstruction and interposition arthroplasty of the CMC joint. Our results indicate less morbidity than with use of FCR (swelling, ecchymosis or weakness) with excellent final outcomes.


R. Jandhyala S. BHAGAT A. Greenbaum

Introduction: The centre provides hand services to remote hospitals which require patients to travel long distances at odd hours for assessment and consenting to their operation only to be done at a later date in day surgery unit unless otherwise indicated.

Aims: Compare video conferencing to patient and surgeon ‘face to face’ consultation in counselling of patients prior to surgery.

Methods: Four injuries (Nail bed, extensor tendon, nerve repair, wrist laceration) were identified for which operative management was clear. 10 plastic surgery SHOs were shown photographs of the patients injury and asked to ‘counsel’ the ‘patient’(played by consultant plastic surgeon) with regards to the intended benefits, risks and complications of surgery.

The assessment was done for all four scenarios both in person and over a video conference link (AHMS). The order of each case was varied to minimise ‘rehearsal’ of the consent. The consent process was scored on a number of points followed by rating. SHOs acted as their own controls removing bias of differing levels of knowledge.

Results: The mean counselling time was 6 minutes/session. Equipments functioned reliably with audio and speed rated as excellent. Quality of councelling sessions using telemedicine was considered by consultants as good (32/40) to satisfactory (8/40) and was found comparable to in person councelling in obtaining consent.

Conclusion: Telemedicine is as effective as specialist-on site counselling for non-controversial hand injuries and thereby reduces the movement of patients from remote A& E departments to plastic surgery units for consent and booking of their surgery.


S. BHAGAT M. Bansal R. Ranjan B. Shah

Introduction: Osteoarthritis of thumb CMC joint is a common pathology. Several non-prosthetic surgical options exist. There is abundant literature both in favour of and against combining trapeziectomy with ligament reconstruction and/or tendon interposition (LRTI). This study provides qualitative and quantitative outcomes assessment of a single surgeon series of consecutively operated 65 patients with trapezio-metacarpal joint arthritis using Trapeziectomy with LRTI.

Methods: 50 female and 15 male patients at an average age of 63 at the time of surgery were followed up for a mean of 3 years, 4 months. Radial half of flexor carpi radialis is dissected using a Carroll tendon retriever and passed through a transosseous hole in the thumb metacarpal base to exit on its dorsum. Patients were put in a full below elbow cast for a period of 4 weeks following which hand therapy was instituted. Patients were evaluated using quick DASH score and objective data like thumb opposition, radiographic scaphometacarpal mobility and gap, pinch and grasp strength. All operations were carried out by senior author.

Results: Good to excellent results were obtained in 59 cases with satisfactory opposition. Pinch strength was 4.3 Kg being 1 to 2 Kg less than reference range. Scoring with quick DASH did not decrease with the longevity of follow up. No complications were encountered. No correlation was found between variables like age, sex, dominance, occupation, primary diagnosis, reduced space on follow up radiographs, severity of arthritic changes and final outcome.

Discussion: Present study is one of the largest consecutive single surgeon series reported recently. All efforts were made to eliminate confounding factors like multi surgeons, modifications of technique, different patient populations etc. The study supports the concept of interposition arthroplasty in the treatment of basal joint arthritis of thumb provided strict attention to the details of surgical technique is observed.


T. Winkler P. von Roth M.R. Schumann K. Sieland M. Taupitz C. Perka G.N. Duda G. Matziolis

Background: Autologous mesenchymal stem cells (MSC) have been shown to improve the functional outcome after severe skeletal muscle trauma. The reasons for this improvement have yet not been revealed. Up to now insufficient techniques of cell labelling, which could only be used for histologic analysis ex vivo, have been a problem.

The development of iron oxide nanoparticles, which are taken up and endosomally stored by stem cells, allows the evaluation of cellular behaviour in the muscle with the use of magnetic resonance imaging (MRI). Previous work has shown that labelling does not affect the proliferation and neurogenic differentiation capacity of embryonic stem cells. In the present study we are currently investigating the in vivo distribution and migration of locally transplanted MSC after blunt muscle trauma in a rat model.

Methods: MSC cultures are derived from tibial biopsies of Sprague Dawley rats via plastic adherence. A standardized open crush injury of the left soleus muscle is performed in each animal. 24 hours before transplantation cells are labelled with very small superparamagnetic iron oxid particles (VSOP-C200, Ferropharm, Teltow, Germany) and Green Fluorescent Protein (GFP). One week after trauma different amounts of stem cells (5×105, 1×106 and 5×106) are transplanted into the soleus muscle by local injection. Distribution and migration of the cells are evaluated over time by the repeated performance of high resolution-MRI at 7 Tesla (Bruker, Rheinstetten, Germany). At the endpoint of the study, three and six weeks after transplantation, the muscles are harvested and histologically and immunohistochemically analysed.

Results: Cells could be visualised inside the soleus muscle in the MRI 24 hours after transplantation showing characteristic signal extinctions in T2*-weighed images. The hypointense signal could be followed over the longest investigated time of six weeks and could be easily discriminated from the structures of the injured muscle. Preliminary results show that the cell pool changed its shape over time with the loss of an initially depicted injection canal and an increase in the surface/volume ratio. First histologic Prussian Blue stained sections showed co-localisation of the respective MRI signal and nanoparticle labelled cells. Fusion events of marked cells with regenerating myofibers could be observed.

Conclusion: Magnetic labelling of MSC is a powerful tool to analyse the in vivo behaviour of the cells after transplantation into a severly injured skeletal muscle. For the first time the observation of an intraindividual time course of the distribution of the transplanted cells is possible. Our preliminary results are promising and the ongoing work will further characterise migration processes and the correlation of the MRI results with muscle function evaluated by contraction force measurements.


A. Panagopoulos M. Tyllianakis D. Deligianni M. Pappas E. Sourgiadaki D. Mavrilas A. Papadopoulos E. Lambiris

Purpose: Little has been written about the size of bone defect that could be restored with one-stage lengthening over a reamed intramedullary nail. The aim of this study was to investigate the mechanical properties of the callus created at gaps of various sizes in sheep tibiae treated with reamed intramedullary nailing.

Material-Methods: Sixteen adult female sheep were divided into four main groups: a simple osteotomy group (group I) and three segmental defect groups (1, 2, and 3 cm gap; groups I to III). One intact left tibia from each group was also used as the non-osteotomized intact-control group (group V). In all cases the osteotomy was fixed with an interlocked Universal Humeral Nail after 7 mm reaming. The osteotomized site was closed in layers including the periosteum without additional bone grafting and the limb was protected with long soft cast for 5 weeks postoperatively. Healing of the osteotomies was evaluated after 16 weeks by biomechanical testing. The examined parameters were torsional stiffness, shear stress and angle of torsion at the time of fracture.

Results: Samples with a simple osteotomy or 1 cm gap were fractured distally to the callus zone, whereas samples with 2 and 3 cm gaps were fractured at the callus zone or at distal metaphysis. The regenerate bone obvious in the x-rays in the group of 1 cm and 2 cm gap had considerable mechanical properties. Torsional stiffness in these two groups was nearly similar and its value was about 60% of the stiffness of the simple osteotomy group. A gradually decreased stiffness was observed as the osteotomy gap increased. There was a decrease in maximum shear stress from simple osteotomy to osteotomy with a fracture gap of 3 cm. No significant differences were found among the angles of torsion at fracture for the various osteotomies or the intact bone. Our results showed that the group of 1 cm gap had the 65% of the shear stress at failure of the simple osteotomy group.

Conclusion: We believe that there is evidence indicating that intramedullary nailing would be a reasonable option when one-stage lengthening of a long bone of 1 or 2 cm is contemplated.


R. Gudena P. Kempshall D. Shewring

Introduction: Dorsally angulated metaphyseal fractures of the proximal phalanges usually occur in the middle aged or elderly and are common. Reduction is difficult to maintain with non-operative treatment, due the action of the intrinsic muscles. Most techniques advocated in the literature suggest a transmetacarpal K-wire fixation.

We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface.

Methods: Over a three-year period, sixty patients with these fractures were treated in this way. A single wire is inserted through the rim of the proximal phalangeal base with MCPJ fully flexed, avoiding transfixion of the collateral ligament. The wire is passed up the medullary canal, across the fracture and up either to subchondral bone or to engage the opposite cortex. The metacar-pophalangeal joints were immobilised with a thermoplastic splint in full flexion and interphalangeal joints mobilised under supervision by the hand therapists. The wire was removed at three weeks.

Results: Most patients achieved a full range of movement at 6 weeks follow-up. There were no pin site infections.

Conclusion: Dorsally angulated metaphyseal fractures of the proximal phalanges fractures are difficult to treat by non-operative means. If the fracture heals in an angulated position the altered line of pull of the intrinsics will result in loss of flexion at the MCPJ and of power grip. This method is straightforward and gives satisfactory results. It avoids damage to the articular surface of the MCPJ, allows mobilisation of the entire digit and reliably controls the fracture.


V. Alt S.T. Donell A. Chhabra A. Eicher R. Schnettler

Introduction: The addition of recombinant human bone morphogenetic protein-2 (rhBMP-2) showed significant reduction of secondary intervention, fracture healing time and infection rates compared with intramedullary nailing alone in open tibia fractures. However, the upfront price of approx. 3000 € is a barrier to its regular use. The goal of the study was to determine potential cost savings and cost-effectiveness of rhBMP-2 in grade III open tibia fractures from the perspective of the UK National Health Service (NHS) and the German Health Care System and to derive conclusions for other European health care systems.

Materials and Methods: Clinical data from a previously published randomised controlled study with 450 patients (“BESTT study”) were used to generate total treatment costs for each patient for the control and the 1.5 mg/ml BMP-2 group based on the current German-DRG and the NHS for UK. The analysis was performed from a health care system and a societal perspective for a one year time horizon. Furthermore, assessment of the cost-effectiveness of BMP-2 was done by utility analysis.

Results: The use of BMP-2 for grade III open tibia fractures is leading to cost savings of 3183 € per case and, therefore, to net savings for the German health care system. The main driver for cost savings is faster fracture healing with faster resumption of work and reduced expenses for sickness leave payments. For the UK rhBMP-2 is a cost-effective strategy with a cost-effectiveness ratio of approx. £11,000/QALY which is well below the standard £30,000 benchmark for the NHS. From a societal perspective, rhBMP-2 is a cost-saving treatment.

Conclusions: BMP-2 leads to net savings in grade III open tibia fractures in Germany which can be expected for other European countries where sickness payments are provided by health care insurers. For countries like UK where sickness are provided by third parties BMP-2 is a cost-effective treatment strategy from a health care system perspective and a cost-saving treatment from a societal perspective.


M. Raghuvanshi A. Donamardi Gorva D. Rowland S. Madan J. Fernandes S. Jones

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail.

METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months.

RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications.

CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging.


A. Rios-Luna M. Villanueva-Martinez H. Fahandezh-Saddi J. Pereiro-del Amo P. Berenguel-Martinez F. Villanueva-Lòpez M. Del Cerro-Gutierrez J. Quero R. Jimenez-Garcia

We present in this work our experience with the sural fasciocutaneous flap to treat coverage defects following a lower limb posttraumatic lesion. This work is a review of the fasciocutaneous sural flaps carried out in different centres between 2000 and 2005. The series consist of 14 patients, 12 men and 2 women with an average age of 38 years (23–54) and with a medium follow-up time of 2 years (12–48 months). In all of the cases, aetiology was a lower limb injury being the most frequent the distal tibial fracture (eight patients), followed by sequelae from Achilles tendon reconstruction (two patients), fracture of the calcaneus (two patients) and osteomyelitis of the distal tibia (two patients) secondary to an open fracture. Associated risk factors in the patients for performing a fasciocutaneous flap were diabetes (1 case) and cigarette smoking (4 cases).

The technique is based on the use of a reverse-flow island sural flap with the superficial sural artery dependent on perforators of the peroneal arterial system. The anatomical structures which constitute the pedicle are the superficial and deep fascia, the sural nerve, external saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin.

The flap was viable in 13 of 14 patients. Only in one case, a diabetic patient, the graft failed. No patient showed signs of infection. Slight venous congestion of the flap occurred in two cases. No further surgical intervention of the donor site was required because of morbidity. In two cases partial necrosis of the skin edges occurred which resolved satisfactorily with conservative treatment.

The sural fasciocutaneous flap is useful for the treatment of complex injuries of the lower limbs. Its technical advantages are: easy dissection with preservation of more important vascular structures in the limb, complete coverage of the soft tissue defect in just one operation without the need of microsurgical anastomosis. All of that results in a well vascularised cutaneous islet and thus a reliable flap


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P. Hoekman S. Diallo B.S. Souna P. Casteleyn

A total absence of acute compartment syndrome (ACS) was noted in 966 tibial fractures in African patients of diverse ethnic groups, reviewed retrospectively at our institution. According to general incidences reported in the literature, we should have experienced between 22 and 86 cases of acute compartment syndrome. The purpose of this prospective study was to confirm these findings and at the same time to try to find an explanation for this phenomenon.

During a period of 1 year and 4 months, 257 tibial fractures were prospectively analyzed for clinical signs and late sequelae of acute compartment syndrome. In 156 of these patients, presenting 158 fractures of the tibia, the pressure in the anterior compartment was systematically measured. Not a single case, nor late sequel of ACS was diagnosed.

The hypothesis we forward for this total absence of ACS is the effect of chronic high temperature surroundings in preventing ACS by safeguarding the arteriovenous gradient and lowering the vascular resistance. We propose that further investigation should be carried out to study this hypothesis.


T. Winkler G. Matziolis M. Schumann G. Stoltenburg-Didinger G.N. Duda C. Perka

Background: Scientific investigation of muscle trauma and regeneration is in need of well standardised models. These should mimic the clinical situation and be thoroughly described histologically and functionally. Existing models of blunt muscle injury are either based on segmental muscle damage or in case of whole muscle injury also affect the innervating structures. In this study we present a modified model of open crush injury to the whole soleus muscle of rats sparing the region of the neuromuscular junctions.

Methods: The left soleus muscles of male Sprague-Dawley rats were crushed with the use of a curved artery forceps. Functional regeneration was evaluated 1, 4 and 8 weeks after trauma (n = 6 per group) via in vivo measurement of muscle contraction force after fast twitch and tetanic stimulation of the sciatic nerve. The intact right soleus muscle served as an internal control. H & E staining was used for descriptive analysis of the trauma. The amount of fibrosis was determined histomorphologically on Picro-Sirius Red stained sections at each point of time.

Results: Across the evaluated regeneration period a continuous increase in contraction force after fast twitch as well as after tetanic stimulation could be observed – describing the functional regeneration of the traumatized soleus muscle over time. Tetanic force amounted to 0.34 ± 0.14 N, which are 23 ± 4% of the control side one week after trauma, and recovered to 55 ± 23% after eight weeks. Fast twitch contraction was reduced to 49 ± 7% of the control side at one week after injury and recovered to 68 ± 19% during the study period. Fibrotic tissue occupied 40 ± 4% of the traumatized muscles after the first week, decreased to approximately 25% after four weeks and remained at this value at eight weeks.

Conclusion: The trauma model characterised morphologically and functionally in the presented study allows the investigation of muscle regeneration caused by highly standardized injury exclusively to muscle fibers.


A. Glynn R. Whitehead D. Murphy G. McHugh P. Keogh P. Kenny S. O’Flanagan

Introduction: It is standard procedure in our unit to use compartment pressure monitoring in all patients presenting with tibial fractures. A sustained difference of less than 30mmhg between the diastolic blood pressure and the compartment pressure (known as the delta pressure) is taken as an indication for fasciotomy.

Aim: To review the impact continuous compartment pressure monitoring has on the management of patients with tibial fractures.

Methods and materials: Between January 2004 and June 2006, 28 patients admitted to our unit following tibial fracture had a compartment pressure monitor inserted. The outer sheath from a 16G cannula connected to an arterial manometer was used in each case.

The records of these 28 patients were reviewed. Twenty three were male. Ages ranged from 19 to 83 years old. Eight patients had open fractures and 20 had closed fractures. Seven patients (25%) had difficulties with communication which could have impeded or delayed the diagnosis of a compartment syndrome.

Results: Average delta pressure ranged from nine to 69mmHg in our patient population. High energy injuries resulted in a significantly lower delta pressure (p=0.05). Open fractures were more likely to result from high energy, although this was not statistically significant (p=0.068). Two patients had fasciotomy performed based on clinical picture and a sustained decrease in delta pressure. No patient had a missed compartment syndrome.

Conclusion: Continuous compartment pressure monitoring is especially useful in patients who are most at risk for compartment syndrome i.e. those having sustained high energy injury or open fractures. It can also aid decision making when the clinical picture of compartment syndrome is equivocal, or when a patient’s ability to communicate pain is impaired.

However, due to the ease of use and the low cost involved, we recommend that all patients with tibial fracture should have continuous compartment pressure monitoring performed.


P. Tos L.G. Conforti B. Battiston

Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery.

Microsurgery surely is a good weapon when facing extensive tissue losses and infections.

From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb.

These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps).

In the last few years, the approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery.

Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis Flap in the coverage of an amputation stump and that of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated.

In 78.5% of the cases of osteomyelitis recovery was obtained after a single operation, and in only 12.3% of the cases the flaps had to be partially revised.

In 2 cases, after the bony resection and coverage by means of a Gracilis Muscle Flap, a homolateral fibular transfer with the Ilizarov technique was performed.

The length of bone resections treated by fibular flaps was 8–12 cm (mean 9).


E. Husebye . Lyberg J. Madsen M. Eriksen O. Røise

Background: Increased intramedullary pressure in the femoral cavity causes intravasation of bone marrow content to the circulation which may lead to occlusion of pulmonary vessels and cardiorespiratory dysfunction. A one-step reamer-irrigator-aspirator (RIA) technique has been developed to reduce the intramedullary pressure (IMP) during the reaming procedure.

Material and method: In a randomized study in 19 Nor-wegian landrace pigs reamed intramedullary nailing was performed with two different reamer devices. Nine animals were operated with a traditional reamer and ten animals with RIA. One animal in the RIA group was excluded due to a perioperative femoral fracture, and three animals in the traditional group due to a perforation of the distal medial femoral cortex. The intramedullary pressure was registrated with a transducer-tipped pressure monitoring catheter during reaming.

Results: The highest intramedullary pressure during reaming was mean 33 mm Hg in the RIA group and 188 mm Hg in the traditional reamer group. This difference was significant (P < 0.05). Intramedullary pressures recorded before surgery, at the opening of the femoral cavity with an awl, by insertion of a guide wire, at insertion of the intramedullary nail, and ten minutes after nail insertion showed no significant differences between the groups.

Conclusion: The use of a one-step reamer-irrigator-aspirator technique in the pig femur induced less intramedullary pressure increase than the use of a traditional reamer.


C. Moser A.W. Baltzer

Objective: In the absence of dependable and reproducible non-surgical treatment alternatives for osteoarthritis (OA), new approaches are needed. A new therapy, based on the intra-articular injection of autologous conditioned serum (ACS), is used in several European countries. ACS is generated by incubating venous blood with medical grade glass beads. Peripheral blood leukocytes produce elevated amounts of endogenous anti-inflammatory cytokines such as interleukin-1 receptor antagonist (IL-1Ra) that are recovered in the serum(1).

In the present study, the clinical efficacy and safety of intra-articular injections of ACS were compared to intra-articular hyaluronan (HA), and placebo (saline) in patients with confirmed knee OA.

Study Methods: In a prospective, randomized, patient- and observer-blind, placebo-controlled trial with three parallel groups, 399 patient knees with OA were included in an intention to treat (ITT-) analysis. Efficacy was assessed by patient-administered outcome instruments (WOMAC, VAS, SF-8, GPA) after 7, 13 and 26 weeks. The frequency and severity of adverse events were used as safety parameters.

Results: In all treatment groups, intra-articular injections produced a significant reduction in WOMAC-scores and weight-bearing pain (VAS), as well as improvement in health-related quality of life. However, responses to ACS were far stronger. The superiority of ACS and either HA or placebo was statistically significant for all outcome measures and all time points. The mean improvement for patients treated with HA and placebo was half that in the ACS-group (p< 0.001). No significant differences between HA treatment and placebo injections (p> 0,05, at all time points and all outcome measures) were recorded. Frequency of adverse advents (AE) was comparable in the ACS- and the placebo-group (p> 0,05), whereas there were significantly more AE in the HA-group (p< 0,05 for the comparison with ACS and placebo).

Conclusion: Patients with OA of the knee treated by intra-articular injection of ACS showed significantly better clinical improvement during 26 weeks observation compared to patients injected with HA or placebo. The results demonstrate that ACS is highly effective and well tolerated in the management of chronic, idiopathic OA of the knee.

So far, the efficacy of ACS is defined through improvement in clinical signs and symptoms, particularly pain. It remains to be determined whether there are disease-modifying, chondroprotective, or even chondroregenerative, sequelae.


J. Flechtenmacher A. Wagenitz K. Heil K. Lehnhardt K.U. Seiler M.M. Schoenharting

Introduction: Bradykinin (BK) exerts its effects directly via B2 receptors but also indirectly through release of factors such as prostaglandins, cytokines, or histamine. During in vitro and preclinical in vivo studies, the B2 receptor inhibitor icatibant (ITB) has been shown to be a potent inhibitor of BK effects. Recently it has been found that a single injection of 90 μg of ITB significantly reduced pain in patients with knee OA, and this effect lasted for about 1 week. The aim of the present study was to determine whether ITB, by multiple dosing, may exert long-lasting clinically relevant effects on OA pain.

Objectives:

To compare the onset, extent and duration of pain relief (pain during activity, at rest and at night) in the affected knee between 2 dose groups of ITB and placebo by using a visual analogue scale (VAS).

To compare ITB and placebo for safety and the efficacy variables: Western Ontario McMaster Universities OA index (WOMAC), and time until need of rescue medication.

Study design: Randomised, double-blind, placebo-controlled, 3-arm, parallel-group, 12-week multi-centre study to compare the effect of intra-articular injections of 2 doses of ITB (500 μg and 2000 μg) and placebo in patients with symptomatic unilateral knee OA. Subjects were treated 3 times in weekly intervals and then followed-up for 10 weeks. Assessments of pain and intake of rescue medication was followed with an electronic patient diary on a daily basis. Functional assessment of the affected knee joint was performed by answering the WOMAC questionnaire at several visits following the last injection.

Statistical analysis included the Chi-square test, differences in means, Wilcoxon-test, the trapezoid rule and Kaplan-Meier curves, using analysis of variance without and with covariates (ANOVA, ANCOVA).

Results: 340 subjects were screened, and 266 were randomised and treated: 90 with placebo, 86 with 500 μg and 90 with 2000 μg ITB. Treatment-emergent adverse events were experienced by 13 subjects treated with placebo, 8 with 500 μg and 17 treated with 2000 μg ITB.

After 3 injections, long-lasting reduction in pain up to 12 weeks after start of treatment could be observed in all treatment groups. Onset of pain relief by _ 10 units was fast and had been reported already 4 hours after start of injection. Both ITB groups consistently demonstrated greater effects on pain when compared to the placebo group; however, there was no difference between the 500 μg and 2000 μg dose groups.

Conclusion: The outcome of the present study demonstrates ITB as an analgesic with fast onset and long-lasting pain relief, which could be differentiated against placebo. Its extent of pain relief, together with its excellent safety profile, qualifies ITB as a promising alternative for intervention in acute and chronic pain.


D. Koulalis N. Efstathopoulos K. Papaparaskeva N. Pyrovolou A. Lenti V. Konstantinou G. Papachristou

Purpose of study: To investigate and compare the characteristics of the reconstructed articular surface microscopically and histologically after a time period of 6 weeks following the treatment of a focal defect of the right femoral head with subchondral drilling and autologous osteochondral transplantation in rabbits

Material and method: A 2,5 mm diameter and 3 mm depth iatrogenic osteochondral defect in the anterolateral weight bearing area of the right femoral head was created in 12 rabbits. In a group of 6 rabbits the lesion was treated with autologous osteochondral transplantation. The donor site for the transplant was the lateral condyle of the ipsilateral knee joint. The other group of 6 rabbits was treated with subchondral drilling. Both groups were sacrificed after a time period of 6 weeks and specimens were evaluated histologically under the classification system of the ICRS. For statistical analysis we used the Mann – Wittney test

Results: According to the ICRS score statistical significance was found for all variables between the 2 groups (subchondral drilling 6 weeks vs autologous osteochondral transplantation 6 weeks).: articular surface (p=0,049), matrix (p=0,003), cell distribution (p< 0,0005), subchondral bone (p=0,010), cartilage mineralization (p=0,0) except cell population viability.

Discussion: In comparison to subchondral drilling, autologous osteochondral transplantation provided better results concerning the smoothness and continuity of the articular surface, the consistency of the matrix with dominance of the hyaline and mixed hyaline – fibrocartilage type of tissue, the normality of subchondral bone and the columna r distribution of cells. The viability of the cell populations was the same for both methods. The incorporation of the osseous part of the graft was successful in all cases and the surgical procedure did not produce any necrosis of the femoral head.

Conclusion: In cases of focal osteochondral defect of the femoral head in rabbits, reconstruction of the articular surface through autologous osteochondral graft transplantation gives superior macroscopical and histological results in comparison to subchondral drilling


M. Schmitt-Sody P. Metz O. Gottschalk A. Klose V. Jansson

Objectives: Platelets are suggested to participate in the pathogenesis of rheumatoid arthritis. We showed for the first time in vivo an increase of platelet-endothelial cell interactions in mice with Antigen-induced-Arthritis (AiA). However, underlying mechanisms are not clear so far. Therefore, the aim of the present study was to investigate first the impact of P-selectin on AiA and second the influence of platelet P-Selectin on the endothelial damage and activation of leukocytes by means of intravital microscopy.

Methods: In the first part C57/Bl6 and P-selectin deficient mice were disposed in four groups (n=7; control/AiA per strain). In the second part ex-vivo labelled platelets were transferred between different strains in AiA. The extent of AiA was assessed by knee joint swelling and by histological scoring. Platelet- and leukocyte-endothelium interactions were investigated.

Results: In arthritic P-selectin deficient mice compared to arthritic C57/Bl6 mice, platelet interaction was significantly reduced and reached the level of both control groups without AiA. In addition interaction of leukocytes in P-selectin deficient arthritic animals was significantly decreased in comparison to arthritic C57/Bl6 animals. Swelling of the knee joint and histological score was reduced in arthritic P-selectin deficient mice compared to arthritic C57/Bl6 mice. In the second part a significant increase of leukocyte-endothelial cell interaction in P-selectin deficient arthritic recipients was shown if P-selectin sufficient platelets were donated. If P-selectin deficient platelets were donated, the number of adherent leukocytes was significantly reduced.

Conclusion: We demonstrated for the first time in vivo a significant decrease of the interaction of platelets and leukocytes with the endothelium in P-selectin deficient mice with AiA and a reduction of clinical and histological symptoms of arthritis. Furthermore we showed that platelets provide storage of P-selectin for the recruitment of leukocytes in P-selectin deficient animals and therefore platelets seem to play a critical role in leukocyte-endothelial cell interaction. These findings suggest that P-Selectin is involved in the development and maintenance of arthritis and it could be at least partly responsible for the leukocyte tissue damage in AiA. Therefore, a reduced presence of P-selectin due to inhibition of platelets could be a new option for treatment of rheumatoid arthritis.


G. Ayana J. St Mart G. Tait

Aims: To evaluate the outcome of open excision of the Acromio-Clavicular Joint (ACJ) in isolated Acromio-Clavicular Joint osteoarthritis and compare it with the published rates for arthroscopic intervention.

Introduction: Anectdotally this operation has been reported as very successful. There are no reviews of this particular operation in the literature. Arthroscopic excision has been advocated as being successful in > 90% of patients in repeated studies.

Methods: A two year period of theatre records produced a group of patients who had undergone this procedure. Case-notes were obtained and the patients with isolated ACJ were identified. Information on patient demographics, duration of symptoms, length of operation, operative complications and follow up were obtained. The patients were contacted and asked to fill out a DASH form. They were invited to a research clinic for clinical review.

Results: 31 patients with 32 isolated osteoarthritic ACJs were identified. Ratio of men to women was 22:9. Mean age at surgery was 48 years. Duration of symptoms before surgery was 105 weeks (mean). Mean time of surgery was 17 minutes. 80% were discharged from follow up by 4 months, mean follow up being 12 weeks. Complications were limited to 2 superficial wound infections. One patient did not have resolution of symptoms.

DASH score results were excellent in all bar one of those returned.

Conclusion: This simple operation has been shown to be effective in 96.9% of patients. The complication rate was 6.2%. Patient satisfaction is high.

These results are comparable to the best results of arthroscopic ACJ Excision.


S.J. kirmani S. pillai R.B. Madegowda S. Shahane

Background: The aim of this study was to analyse mid-shaft clavicle fractures in children and adults to find out the factors that would influence the healing time and the necessity of surgical intervention.

Methods: We identified all the midshaft clavicle fractures treated at Chesterfield Hospital between January 2003 and January 2006. We studied the case notes and radiographs of these patients. We grouped the midshaft fractures into those in children and those in adults. Each group was further subdivided into two part and three part fractures. It was also noted whether a vertical butterfly fragment was present in the three or more part fractures. The fractures were analysed for their incidence, presence of comminution, degree of displacement, type of treatment and the follow-up time before discharge.

Results: – Over the 3 year period, 242 middle 1/3 clavicle shaft fractures were treated. Among the mid shaft fractures there were one hundred and eight (44.6%) children and one hundred and thirty four (55.3%) adults.

There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures.

There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%).

The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment.

Conclusion: The incidence of clavicle fractures in children is nearly as high as in adults. In children the number of days for discharge is nearly double for three part fractures when compared to two part fractures.

The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment.


J.T. Melton M.R. Wyatt K. Yein L. Williamson

Background. Patients with severe osteoarthritis of the knee often have to endure many months of pain and limited function whilst waiting for surgery. Measures that can improve quality of life and knee function while on waiting lists are worth employing and may improve post-operative recovery. This study was designed to evaluate the effects of standardised western acupuncture and supervised exercise therapy on pain control and functional ability in patients with severe osteoarthritic knee pain awaiting knee arthroplasty.

Methods. A three arm, single blind, randomised controlled trial was devised and took place at the Great Western Hospital, Swindon, UK. 181 patients awaiting knee arthroplasty met eligibility criteria and were entered into the trial. Block computerized randomisation was used to allocate patients to one of three treatment groups using a blinded third party. The three treatment groups were acupuncture for six weeks; supervised exercise therapy for six weeks or standardised advice. Outcome measures were assessed at 7 and 12 weeks following the initiation of treatment. The main outcome measures used were the Oxford Knee Score questionnaire, a 50 meter timed walk and duration of hospital stay following knee arthroplasty. Statistical analysis was performed with one way variance (ANOVA) analysis by intention to treat. Bonferroni method was used for analysis of statistically significant group differences.

Results. There was no baseline difference between groups. At 7 weeks there was a 10% reduction in Oxford Knee Score in the acupuncture group and a significant difference between the acupuncture and the other two groups: mean (SD) acupuncture 36.8 (7.2); physiotherapy 39.2 (8.2); control 40.3 (8.48) (p=0.0497). The supervised exercise group had a lower mean 50 meter walking time (50.3 seconds SD 17.7) compared to the acupuncture group (54.9 seconds SD 17) and the control group (58.4 seconds SD 25.2). Both these effects were still present but diminished at twelve weeks. There was a trend (p=0.0984) towards a shorter inpatient stay of one day for the physiotherapy group (mean 6.5 days SD 2.0) compared to the acupuncture group (mean 7.77 days SD 3.96).

Conclusions. Acupuncture can provide short-lived pain relief and improvement in function in patients with severe knee osteoarthritis awaiting knee arthroplasty. Supervised exercises lead to improvement in mobility. This functional improvement may decrease duration of hospital stay. Both interventions can be delivered safely and effectively in an outpatient group setting in a district general hospital and appear to be worthwhile for patients on the waiting list for surgery. Further evaluation of the effects of both treatments delivered simultaneously is planned.


B. Halle D.M. Halle S. Overgaard T. Torfing

Background: We examined the role of the geometry of acetabulum in the development of osteoarthritis in young men. Contrary to previous studies we evaluated the significance of the anterior, posterior and total coverage of the femoral head, the influence of the femoral neck and the consequence of acetabular retroversion on standardized x-rays.

Material and Methods: Men (n=78) aged 26–55 years (case-group) were selected from the Danish Hip Arthroplasty Register. This group was compared to a control-group (n=78) selected from men of the same age group received as trauma patients. Anterior/posterior pelvic radiographs were evaluated taking into account the degree of pelvic rotation and tilt.

Results: Femoral head coverage, femoral head-neck ratio and centre edge angle were significantly smaller in the case-group, acetabular index angle and modified ACM-angle were significantly bigger. Anterior, posterior and total coverage of femoral head showed no difference. The frequency of acetabular retroversion was greater among cases.

Interpretation: Osteoarthritis of young men is associated with a small superior acetabular coverage, a steep acetabular roof, a small acetabular depth, a thickened femoral neck and acetabular retroversion.


E. CHRONOPOULOS H.B. Park A. Tasaki H. Gill E.G. McFarland

Aim: Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis.The overall complication rate for open, isolated DCE is higher than previously reported.

Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis. Isolated DCE., as an open procedure has been considered to be a safe procedure, and it is the gold standard for comparison for arthroscopic distal clavicle excision. This study attempts to define the incidence of complications after isolated, open DCE.

Materials & Methods: This prospective, non-randomized study included 702 patients who underwent arthroscopic surgery of the shoulder. 580 patients were included in the control group. All patients underwent a thorough preoperative evaluation and final diagnosis was given after arthroscopic evaluation. There were 42 patients with isolated A–C joint arthritis, which underwent an open D.C.E. Mean follow up was 16.7 months. There were 30 men and 12 women with a mean age of 42,6 (± 12,5) years. The dominant arm was involved in 30 patients. 16 patients participated in sports while 9 of them were competitive athletes. 38 (90%) patients had symptomatic arthritis, 2(5%) cases were of osteolysis and separation arthritis each.

Results: 22 (52%) of the 42 patients developed complications. There were 2 deep infections and 2 stitches abscesses. 4 (9.5%) patients developed a stiff shoulder and 1(2.4%) patient developed heterotopic ossification. 16 (38%) patients had tenderness in A–C joint for a period over 3 months while 6 (14%) patients had local tenderness at the last follow up. Painful scar was present in 2 (5%) patients over 3 months.

Conclusions: The overall complication rate for open, isolated DCE is higher than previously reported. Patients should be advised of these possibilities and this study serves as a baseline for comparison for future study.


R. Wirbel G. Tosounidis F. Bachelier C. Braun T. Pohlemann

The clinical results following open reduction and internal fixation via a modified dorsal two-portal-approach in dislocated scapular neck and glenoid fractures should be evaluated.

The approach with two dorsal portals to the glenoid, one cranially and one caudally of the infraspinatus muscle, is described.

From 1.7.1992 until 30.06.2006, 37 patients (27 men, 10 women, mean age 53 years), 31 patients with glenoid fractures and 6 patients with unstable scapular neck fractures were operated on via the two-portal-approach.

The reduction was controlled radiographically, the clinical results were analysed using the Constant-score.

The mean follow-up was 68 (6–168) months. In 22 out of the 31 glenoid fractures the reduction was anatomically. The mean Constant-score revealed 81,1 (35–100) points.

In one case an early postoperative wound infection could be cured by local revision and one patient developed an arthritis of the acromioclavicular joint after two years.

The dorsal two-portal-apporach allows a good visualisation to the dorsal scapular neck and the glenoid area fascilitating reduction and a safe internal fixation of dislocated scapular neck and glenoid farctures.


G. Gruber G.A. Bernhardt H. Clar C. Wurnig

Background: An acromiohumeral interval narrower than six millimeters has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study was conducted as an assessment of inter- and intraobserver variation in the radiographic measurement of the acromiohumeral interval and its critical value.

Material and Methods: Thirty blinded, standardized anteroposterior shoulder radiographs were independently reviewed by five board certified orthopedic shoulder surgeons. The acromiohumeral distance, from the inferior anterior acromial aspect to the humeral head was measured in millimeters. The five investigators classified each film a second time in random order.

Results: Finally the same 27 radiographs (90%) have been evaluated by five investigators at both examination time points. The results of three investigators showed significant intra-observer variation ranging from 4 to 11 millimeters for the same radiograph. Six investigator pairs showed significant inter-observer variation at both examination time points (p< 0.05). The maximum inter-observer difference for the same radiograph was 11 millimeters (ranging from 1 to 11, SD 0.3 – 4.2).

Conclusion: In view of our results the assessment of the acromiohumeral interval using anteroposterior x-rays does not seem to be a reproducible method of measurement. Further investigations in combination with CT or MRI are necessary to ensure our findings.


S. Kohl A. Krueger J. Gralla R. Hertel

Introduction: Glenoid version seems to play an important role in the loading and stability of the glenohumeral joint. Measurement of Glenoid version on standard x-rays has been shown to be inaccurate. The purpose of this study was to assess the accuracy of the glenoid version measured on standard CT scans.

Material and Methods: The version of the glenoid was assessed using a multislice CT. We analysed 60 scapulae in 47 Patients (32 male; 18 to 83 years; 17 osteoarthritis and 29 instability). The retroversion of the glenoid was measured in 2 planes. First on the standard axial plane and second in a corrected axial plane (multiplanar reconstruction of scapula in a “true” axial plane with respect to the three-dimensional adjustment of the scapula).

Results: In the standard axial plane the mean retroversion was 8° (range, −5° to 22°). In the correct axial plane the difference of the retroversion was averages 6° compared to the standard axial plane. The range of the error was form 0° to 15°.

Conclusion: Measurement of glenoid retroversion on standard axial ct scans was unreliable. The clinical relevance: The standard shoulder CT is not suited for the preoperative planning of the glenoid correction. Therefore we would advocate the assessing of the glenoid version a defined “true” axial plane obtainable trough multiplanar reconstruction.


C. Torrens M. Corrales G. Gonzalez A. Torres E. Caceres

Introduction: Reversed prostheses implantation requires screwing of the glenoid component with prefixed angles. This study is to determine anatomical angles of scapula that take part in reversed prostheses implantation.

Material and method: Seventy-three 3-dimensional computed tomography of the scapula and 108 scapular dry specimens were analyzed. Mean age of the CT-3D serie was of 52.59 years old (ranging from 16 to 84). There were 46 females and 27 males. The following measures were made on each patient: length of the neck of the inferior glenoid, angle between the glenoid surface and the upper posterior column of the scapula, angle between the major craneo-caudal glenoid axis and the base of the coracoid process and angle between the major craneo-caudal glenoid axis and the upper posterior column of the scapula. Measures were performed in the AP view as well as in the posterior view of the scapula.

Results: The length of the neck of the anterior glenoid was classified into two groups named ‘short-neck’ and ‘long-neck’ for both three-dimensional computed tomography and cadaveric scapulas with statistically significant differences between both groups (p< 0,001 for the three-dimensional computed tomography scapulas and p=0,034 for the cadaveric group). The angle between the glenoid surface and the upper posterior column of the scapula was also classified into two different types: type I (52° ranging from 48° to 57°) and type II (64° ranging from 60° to 70°) with statistically significant differences between both groups (p< 0,001 for the three-dimensional computed tomography scapulas and p< 0,001 for the cadaveric group). The angle between the major craneo-caudal glenoid axis and the center of the base of the coracoid process averaged 18,25° (ranging 13° from to 27°). The angle between the major craneo-caudal glenoid axis and the upper posterior column of the scapula averaged 8° (ranging 5° from to 18°).

Conclusions:

- scapulas can be classified into two groups regarding the angle between the glenoid surface and the upper posterior column of the scapula with significant differences between them.

- two different lengths of the neck of the inferior glenoid body have also been differentiated in the anterior as well as in the posterior faces of the scapula.

- the base of the coracoid process is not in line with the posterior column of the scapula.

- three-dimensional computed tomography of the scapula constitutes and important tool when planning reversed prostheses implantation.


E. CHRONOPOULOS H.B. Park H. Gill A. Tasaki E.G. McFarland

Aim: The diagnosis of partial biceps tears cannot be made reliably with existing physical exam tests. Diagnostic arthroscopy is recommended if this diagnosis is suspected.

The accuracy of the physical examination for biceps pathology remains controversial. The goal of this study was to investigate the validity and clinical usefulness of various physical tests used for diagnosing partial tears of the biceps tendon.

Materials & Methods: The study was a prospective blinded study of 847 consecutive patients who underwent arthroscopic procedures for a variety of shoulder conditions. Forty subjects were found at the time of arthroscopy to have partial biceps tears (24 men and 16 women) with an average age of 59 YO (range from 18 to 83 YO). A pre-operative physical examination using 9 different commonly used tests was performed for all the patients. Statistical analysis included sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and likelihood ratios (LR) for these tests.

Results: The prevalence rate of partial tears was 5 percent of all arthroscopic procedures. Associated conditions included rotator cuff tears (85 percent) and anterior instability (7.5 percent). The sensitivity, specificity, PPV, NPV and the LR for the Speed_s test were 50 percent, 67 percent, 8 percent and 96 percent and 1.51, respectively. None of the other tests was sensitive (less than 50 percent). The lift-off sign had a LR of 2.61 but had a sensitivity of only 28 percent.

Conclusion: The diagnosis of partial biceps tears cannot be made reliably with existing physical exam tests. Diagnostic arthroscopy is recommended if this diagnosis is suspected.


S.G. Haidar S. Joshy C. Kat F. Fatah S. Deshmukh

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment.

Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome.

Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.


F. Lam B. Mostofi D. Bhatia K. van Rooyen C. Vaughan J. de Beer

Introduction: A secure repair of the subscapularis represents an integral part of any surgery involving the anterior approach to the shoulder. Dysfunction of the subscapularis leads not only to poor functional results but also to anterior joint instability which is potentially untreatable. We have devised a new technique of double row fixation of the subscapularis using two suture anchors.

Aim: To evaluate the biomechanical strength of this double row technique against the established methods of simple suturing and transosseous repair techniques.

Method: Twenty matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of 10 shoulders repaired with the double row technique. This involved incising the subscapularis along the bicipital groove and a lesser tuberosity osteotomy carried out leaving the subscapularis attached to a thin island of bone. A suture anchor (Twinfix) was then inserted just medial to the osteotomy site and the tendon repaired to bone using two horizontal mattress sutures. A second anchor was inserted laterally to supplement the repair with two simple suture knots. The remaining 10 contralateral shoulders were allocated equally between groups 2 and 3. In group 2, the subscapularis was divided longitudinally 1cm medial to the bicipital groove and repaired with simple interrupted suture knots. In group 3, the subscapularis was incised at its insertion to lesser tuberosity and the tendon repaired to the osteotomy site by multiple transosseous sutures through drill holes in the anterior humeral cortex.

The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded.

Results: The load to failure was found to be significantly higher in the double row repair technique compared to simple suturing and transosseous methods. Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue.

Conclusion: This new double row technique is simple to perform and preliminary biomechanical testing has shown this to be superior in terms of fixational strength compared to established methods. Additional advantages of this technique which have not been taken into account in this in vitro study include non violation of the subscapularis tendon with bone to bone healing.


D.J. Bell T. Gothelf J. Goldberg W. Harper M. Pelletier Y. Yu W.R. Walsh

Introduction: A cosmetic deformity does not always occur after a biceps tenotomy. The anatomical restraints preventing distal excursion of the long head of biceps tendon following tenotomy have not previously been described. This study aims to evaluate the biceps sheath and its potential role as a restraint to distal excursion of the biceps following tenotomy.

Methods: Fifteen fresh cadaveric specimens were dissected free of overlying soft tissues to reveal the rotator cuff, biceps sheath and long head of biceps muscle belly and tendon. Eight specimens were used for gross anatomical analysis. Measurements of the length of the biceps sheath on the humeral (bone) side and tendon side were made using a digital caliper (Mitutoyo, Japan). The long head of biceps tendon was then released from the glenoid labrum and the excursion of the stump relative to the rim of the articular surface measured. The biceps sheaths of two specimens were used for histological analysis.

Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed.

Results: The biceps sheath surrounds the long head of biceps tendon and inserts into the bone of the proximal humerus. It is trapezoidal in cross-section, with a mean length of 75.1 mm on the bone side and 49.3 mm on the tendon side. The average excursion of the stump was to within 2.8 mm of the rim of the articular surface.

Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum.

The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N)

Discussion: The biceps sheath is a consistent structure intimately associated with the biceps tendon. It appears to contain blood vessels which provide nutrition to the tendon, similar to the vincula of flexor digitorum pro-fundus. Mechanical testing reveals that a substantial force is sometimes required to pull the biceps tendon from the sheath. This may explain why biceps tenotomy does not routinely result in a “Popeye” biceps.


S.G. Haidar J. Lloyd D. Cox S. Deshmukh

The purpose of this study was to investigate the effect of the degree of abduction on shoulder abduction strength.

Thirty healthy volunteers with no history of shoulder complaint participated in this study. A modified Nottingham Mecmesin Myometer was used. The modification allowed the Myometer to be attached to a clinic table at different angles in order to be at 90°to the arm in varying degrees of abduction. Abduction strength of both shoulders was measured on four occasions at two-week intervals. On each occasion, a different abduction position was adopted at 90°, 60°, 30°and 0°.

The results showed that shoulder abduction strength varies according to the degree of abduction. In comparison with that at 90° of abduction, shoulder abduction strength showed an increase by 12.5% and of 31.3% at 60° and 30° of abduction respectively. However, it was decreased by 18.8% at 0° of abduction. The Student’s T-test showed significant difference between shoulder abduction strength at 90° abduction and all other three abduction positions.


B.M. Jolles K. Aminian A. Bourgeois B. Coley P. Claude J.P. Bassin P.F. Leyvraz A. Farron

Introduction. Quantification of daily upper-limb activity is a key determinant in evaluation of shoulder surgery. For a number of shoulder diseases, problem in performing daily activities have been expressed in terms of upper-limb usage and non-usage. Many instruments measure upper-limb movement but do not focus on the differentiations between the use of left or right shoulder. Several methods have been used to measure it using only accelerometers, pressure sensors or video-based analysis. However, there is no standard or widely used objective measure for upper-limb movement. We report here on an objective method to measure the movement of upper-limb and we examined the use of 3D accelerometers and 3D gyroscopes for that purpose.

Methods. We studied 8 subjects with unilateral pathological shoulder (8 rotator cuff disease: 53 years old ± 8) and compared them to 18 control subjects (10 right handed, 8 left handed: 32 years old ± 8, younger than the patient group to be almost sure they don_t have any unrecognized shoulder pathology). The Simple Shoulder Test (SST) and Disabilities of the Arm and Shoulder Score (DASH) questionnaires were completed by each subject.

Two modules with 3 miniature capacitive gyroscopes and 3 miniature accelerometers were fixed by a patch on the dorsal side of the distal humerus, and one module with 3 gyroscopes and 3 accelerometers were fixed on the thorax. The subject wore the system during one day (8 hours), at home or wherever he/she went. We used a technique based on the 3D acceleration and the 3D angular velocities from the modules attached on the humerus.

Results. As expected, we observed that for the stand and sit postures the right side is more used than the left side for a healthy right-handed person(idem on the left side for a healthy left-handed person). Subjects used their dominant upper-limb 18% more than the non-dominant upper-limb. The measurements on patients in daily life have shown that the patient has used more his non affected and non dominant side during daily activity if the dominant side = affected shoulder. If the dominant side ≠ affected shoulder, the difference can be showed only during walking period.

Discussion-Conclusion. The technique developed and used allowed the quantification of the difference between dominant and non dominant side, affected and unaffected upper-limb activity. These results were encouraging for future evaluation of patients with shoulder injuries, before and after surgery. The feasibility and patient acceptability of the method using body fixed sensors for ambulatory evaluation of upper limbs kinematics was shown.


A. Farron A. Reist A. Terrier

Introduction. Arthritis of the glenohumeral joint is usually associated with erosion and flattening of the articular surfaces. The aim of this study was to evaluate the influence of the articular flattening on the joint reaction forces and the humeral head translations during abduction and rotation.

Method. Analysis was conducted with a 3D finite element model of the shoulder, including the scapula, the humerus and 6 muscles: middle, anterior and posterior deltoid, supraspinatus, subscapularis, and infraspinatus. Both the glenoid and humeral head were eroded to artificially reproduce the flattening of an arthritic joint. Two situations were studied:

1) an intact joint with a radius of curvature of 24mm for the humeral head and 26mm for the glenoid;

2) an eroded joint with a radius of curvature of 40mm for the humeral head and 42mm for the glenoid.

Movements of external rotation (0–45°) and abduction (0–150°) were performed by muscles’ activation. Contact forces caused by muscles wrapping on bony surfaces were accounted for. Joints forces, glenohumeral contact point locations and humeral head translations were calculated for the intact and eroded joint.

Results: For the eroded joint, articular forces were up to seven times higher during rotation and five times higher during abduction. For the intact joint, the glenohumeral contact point and humeral head remained centred. On the other hand, for the eroded joint, eccentric contact points with large antero-posterior and supero-inferior humeral head translations were observed. Animated views showed that this fact was clearly related to the rocking-horse effect.

Conclusions: This study showed that flattening of the glenohumeral joint due to osteoarthritis increases dramatically the articular forces and humeral head translations. This phenomenon is by itself responsible for progression of the joint’s erosion and flattening and acts as a vicious cycle. It also partly explains the reduced range of motion observed clinically. Accordingly, to limit the risks of rocking-horse effect after shoulder arthroplasty, the joint’s reconstruction should restore a natural articular radius of curvature, with a centre of rotation in the middle of the humeral head.


A. Witteveen S. Giannini G. Guido J. Jerosch H. Lohrer C.N. van Dijk

Purpose: To evaluate the safety and efficacy of hylan G-F 20 viscosupplementation in patients with symptomatic osteoarthritis (OA) of the ankle.

Methods: Prospective, multi-center, open study in patients with primary or secondary grade II talocrural OA confirmed by X-ray. At baseline, patients had to score between 50–90 mm on the Patient-completed Ankle OA Pain VAS (0–100 mm). Patients received one intra-articular injection of 2 ml of hylan G-F 20 and were given an option of a second and final 2 ml injection if their pain remained between 50-90 mm on the VAS after 1, 2 or 3 months. Intraarticular injections were placed in the anteromedial portal of the ankle joint as described for ankle arthroscopy. Patients were followed for 6 months after the final injection. As rescue medication, patients could only take paracetamol up to 4 g per day, except on the day of or the day before a study visit.

All treatment emergent adverse events (AEs) were recorded. The primary efficacy endpoint was change from baseline (at final injection) in the Ankle OA Pain VAS at 3 months after the final injection. Secondary endpoints were Ankle OA Pain VAS scores at all other time-points, total Ankle OA Scale, Patient and Physician Global OA Assessment (VAS), and health-related quality of life (SF-36).

Results: Fifty-five patients (33 M; 22 F) were enrolled and received a first injection of hylan G-F 20. Twenty-four patients (44%) received a second injection. The mean age was 41 years (range 19–70). Overall, treatment with hylan G-F 20 was well tolerated. Seventeen patients (31%) had a treatment related AE of the target ankle. All were of mild or moderate intensity, the majority consisting of arthralgia and injection site pain. There was a statistically significant decrease in Ankle OA Pain VAS score from 68.0 mm at Baseline to 33.8 mm at Month 3 (p< 0.001, paired t-test), which was maintained at 6 months follow-up. The decrease was statistically significant at all time points. Patients who received only 1 injection demonstrated a greater decrease at 3 months (−42.5 mm) than patients with 2 injections (−23.5 mm). The secondary efficacy endpoints showed similar results. Of the total study population, 29 patients (53%) were responders (i.e. at least a 50% decrease in ankle OA pain) after 3 months. 64% of patients receiving 1 injection were responders after 3 months. The SF-36 questionnaire showed statistically significant improvements for both the physical and mental component scores at 3 and 6 months follow-up.

Conclusions: Treatment of OA of the ankle with intraarticular hylan G-F 20 injections is well tolerated. Treatment with hylan G-F 20 significantly decreases pain which is maintained for up to 6 months.


M. Galli D. Pitocco V. Ruotolo L. Mancini M.C. Collina C. Chinni F. Visci S. Caputo G. Ghirlanda

Background: The pathogenesis of CN is still unknown. An increase of the bone blood supply seems to be one of the mechanisms involved. A feature of CN is a bone reabsorption. IGF-1 can influence the bone tissue by various mechanisms but its vasodilatory effects in others tissues are well-known. Alendronate have an inhibitory effect on bone reabsorption. Aim of this study is to evaluate the effect of alendronate on foot bone density in CN and above all if this effect can be mediated by a modification in IGF-1 levels.

Methods: Twenty patients with a diagnosis of acute CN of the foot were enrolled. According to the randomization, 11 patients were treated with 70 mg of alendronate per os once a week (TG) and 9 patients were followed as control group (CG). Markers of bone turnover [urinary hydroxyprolin, serum collagen carboxyl-terminal telopeptide of type 1 collagen (ICTP), serum bone alkaline phosphatase (B-ALP)], IGF-1 and BMD by dual energy X-ray absorptiometry (DEXA).

Results: ICTP didn’t show significant difference between the two groups (0,54±0,05 ng/ml vs 0,56±0,06 ng/ml p< 0,6) at the outset, after six months the treated group had a significant decrease of this parameter (0,54±0,05 ng/ml vs 0,30±0,03 ng/ml p< 0,05).

In TG hydroxyprolin followed the same trend showing a significant decrease after the six month treatment (18±3,2 mg/l vs 13±3,6 mg/l p< 0,05).

At the same time B-ALP reduction was almost significant (36±4,8% vs 23±3,9% p=0,06)

DEXA demonstrated an improvement in total foot mineralization in the TG(0,18±0,06 g/cm2 vs 0,24±0,08 g/cm2 p< 0,05) and in the distal phalanxes (0,194 g/cm2 vs 0,242 g/cm2 p< 0,01) (fig. 3). Only the TG showed a significant decrease of IGF-1 throughout the trial (142,8±24 vs 123,5±41 ng/ml p< 0,05).

Conclusions: The increase in bone blood flow could be linked to the vascular effects of IGF-1. Alendronate in acute phase helps to stop bone reabsorption and this effect could be mediated by the decrease of IGF-1 levels.


S.G. Haidar T. Fayad S. Shobaki G. Shergill S. Parekh

Abduction strength forms an important component of shoulder function assessment tools such as the Constant-Murley score. However, there is no consistency in literature with regards to the method used for its assessment. An extensive review of the literature failed to reveal any evidence to support any particular method. The purpose of this study was to compare the reliability of a single measurement with that of the maximum and average of three consecutive measurements. Sixty healthy volunteers participated in this study. Three measurements of shoulder abduction strength were taken on two occasions separated by 2 weeks. For each shoulder, two single (first) measurement values, two average values and two maximum values were obtained. For each method, 95 % limits of agreement were calculated. Both methods average and maximum have higher reliability than a single measurement. Furthermore, the reliability of the maximum is slightly higher than that of the average.


X. Crevoisier K. Aminian J. Favre H. Rouhani B.M. Jolles

Introduction: Ankle arthropathy is associated with a decreased motion of the ankle-hindfoot during ambulation. Ankle arthrodesis was shown to result in degeneration of the neighbour joints of the foot. Inversely, total ankle arthroplasty conceptually preserves the adjacent joints because of the residual mobility of the ankle but this has not been demonstrated yet in vivo. It has also been reported that degenerative ankle diseases, and even arthrodesis, do not result in alteration of the knee and hip joints. We present the preliminary results of a new approach of this problem based on ambulatory gait analysis.

Patients and Methods: Motion analysis of the lower limbs was performed using a Physilog® (BioAGM, CH) system consisting of three-dimensional (3D) accelerometer and gyroscope, coupled to a magnetic system (Liberty©, Polhemus, USA). Both systems have been validated. Three groups of two patients were included into this pilot study and compared to healthy subjects (controls) during level walking: patients with ankle osteoarthritis (group 1), patients treated by ankle arthrodesis (group 2), patients treated by total ankle prosthesis (group 3).

Results: Motion patterns of all analyzed joints over more than 20 gait cycles in each subject were highly repeatable. Motion amplitude of the ankle-hindfoot in control patients was similar to recently reported results. Ankle arthrodesis limited the motion of the ankle-hindfoot in the sagittal and horizontal planes. The prosthetic ankle allowed a more physiologic movement in the sagittal plane only. Ankle arthritis and its treatments did not influence the range of motion of the knee and hip joint during stance phase, excepted for a slight decrease of the hip flexion in groups 1 and 2.

Conclusion: The reliability of the system was shown by the repeatability of the consecutive measurements. The results of this preliminary study were similar to those obtained through laboratory gait analysis. However, our system has the advantage to allow ambulatory analysis of 3D kinematics of the lower limbs outside of a gait laboratory and in real life conditions. To our knowledge this is a new concept in the analysis of ankle arthropathy and its treatments. Therefore, there is a potential to address specific questions like the difficult comparison of the benefits of ankle arthroplasty versus arthrodesis. The encouraging results of this pilot study offer the perspective to analyze the consequences of ankle arthropathy and its treatments on the biomechanics of the lower limbs ambulatory, in vivo and in daily life conditions.


G.A. Matricali B. Bammens D. Kuypers M. Flour C. Mathieu

Background: Simultaneous pancreas-kidney transplantation is performed in type 1 diabetic patients with long standing diabetes and end stage renal disease. Morbidity and mortality rates early after transplantation are high, with lower limb amputations being an important event. However, no data are available on the exact rate of Charcot foot presentation after simultaneous pancreas-kidney transplantation. The aim of the present study was to examine the prevalence of Charcot foot in the population of simultaneous pancreas-kidney transplanted patients at our institution

Methods: We retrospectively examined the medical files and radiographic documents of 66 consecutive patients transplanted in our institution. Demographic and historical data collected included gender, date of diagnosis of DM and nephropathy, mean HbA1c and mean C-peptide, retinopathy and data on renal replacement therapy. Data on immunosuppressive therapy and transplant outcome were also collected.

Results: None of the patients was found to have Charcot foot before transplantation. 8 patients (12%) developed a Charcot foot afterwards (mean 1.8 ± 1.9 years post-transplantation) and four of them developed bilateral involvement in time (6%). No new Charcot foot attacks in the previously affected foot were recorded. Considering the pre-transplant demographic characteristics, all 66 patients were at high risk to develop Charcot foot. Comparing patients who developed Charcot foot to those who did not, a significant difference was only found for pre-transplant glycemic control (mean HbA1c 9.2 ± 1.0 vs. 8.0 ± 1.4, p = 0.01). In patients developing Charcot foot, acute rejection, graft failure and mortality show a trend to be more frequent (HR = 3.57, p = 0.164, HR = 4.56, p = 0.165 and HR = 2.46, p = 0.236, respectively).

Conclusions: Charcot foot proves to be a frequent complication early after simultaneous pancreas-kidney transplantation. Considering the important morbidity and mortality of this complication, awareness of all healthcare providers treating transplanted patients is mandatory to detect a presentation early after onset. Prompt referral to a multidisciplinary diabetic foot clinic for further diagnosis and specialised treatment must always be considered.


H. Gollwitzer P. Diehl A. von Korff J. Schauwecker L. Gerdesmeyer

Context: Published data on extracorporeal shock wave therapy (ESWT) for chronic plantar fasciitis provide controversial evidence about the clinical relevance and effectiveness. Treatment parameters have significant influence on outcome and optimal treatment protocols have to be determined.

Objective: To assess the effect size and safety of ESWT compared to placebo in the treatment of chronic painful heel syndrome with a new electromagnetic device and an optimized protocol.

Design, Setting, and Participants: Prospective, double-blind, randomized, placebo-controlled trial conducted among 40 patients. Interventions: ESWT (0.25 mJ/mm2) or placebo without anesthesia. Both groups received 3 treatments of 2000 shock wave impulses, each session 1 week apart. Main Outcome Measures: The primary outcome was the percentage change of heel pain quantified by VAS composite score 12 weeks after the last intervention compared to baseline. Secondary endpoints were defined as changes of single VAS scores (morning pain, pain at daily activities and pain with force-meter application), success rates and changes in Roles and Maudsley score.

Results: ESWT resulted in a 73.2% reduction of heel pain regarding the primary endpoint VAS composite score compared to baseline, being 32.7% superior to placebo. Effect size reached clinical relevance (Mann-Whitney effect size (MW) = 0.6737; 0.6400 being the benchmark for medium-sized, relevant superiority, p = 0.0302 single-sided). With regard to the percentage changes of the single VAS scores and the Roles and Maudsley score, the effect size denoted relevant superiority of the ESWT as well (all MWs ≥ 0.6400). No relevant adverse events occurred.

Conclusion: The results of the present study advocate ESWT for refractory painful heel syndrome demonstrating clinically relevant effect sizes. Specific treatment protocols with proven effectiveness ought to be used in the clinical setting.


A.G. Kasis M. Krishnan M.E. Griess

We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus.

Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph

The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision.

All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46).

The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear.

The functional outcome as assessed using the SF-36 health score was compatible with an age matched population.

The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores.

Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome.


Y. Tourné

Introduction: Hallux varus deformity leads to a major esthetic and shoe wearing discomfort with a severe functional disability. Surgical procedures for correction must be adapted to the degenerative changings in the first MTP joint, to the joints stiffness and the IP joint claw.

Material and Methods: 80 patients have been operated on from 1981 to 2004

An enlarged debridment of the first MTP joint was mandatory before any reconstructive procedure.

The collateral lateral ligament reconstruction has been achieved with a synthetic suture (LigaproÒ or LigasticÒ of 1.5 mm diameter) according to flexible joint with no arthritis (regimen 1 (25 cases), youngpopulation (44 years) with an average varus of −12°).

The first MTP joint arthrodesis was performed for osteoarthritis combined with stiffness. (regimen 2 (40 cases), older (64 years) with an average varus of −16°.

Results: 15 patients were lost for FU.65 patients were clinically and radiologically reviewed with a medium FU of 10 years(2 to 25 years).

In series 1 (ligament reconstruction),24/25 patients were totally painless with an artificial device well tolerated. The joint motion, the gait and the shoe-wearing were normal in 24/25 of cases. The medium post-operative valgus was of 12°.

In series 2 (MTP arthrodesis), arthrodesis healed in 39 cases with an average time of 60 days. Valgus positionning was always restaured.Degenerative changings occured in the IP joint in 4 cases without any complain. Shoe- wearing was classical in all the cases.

Conclusions: The first MTP joint arthrodesis must be the referred procedure for hallux varus deformity according to OA and stiffness in the joint site.

Among the procedures for the first MTP joint preservation, enabled to restore valgus strength, the synthetic reconstruction of the collateral lateral ligament is a reliable and reproducible technique, without any damages for the active tendons nor for the joint function.


A.V. Corotti Sasareanu J.J. Vaquero Ruiperez J.J. Beltran Bengoechea C.C. Miranda de Larra

BACKGROUND: Plantar fascitiis/heal pain is the most common condition treated by the foot and ankle specialists.The etiology of plantar fascitiis is unknown and has been attributed to manny different etiological factors.

HYPOTHESIS: We believe injecting autologus platelet concentrate into recalcitrants symptomatic plantar fascia may cause a reparative effect leading to resolution of symptoms.

METHOD: 30 patients with chronic plantar fascitiis were evaluated in this study.The patients had to drop any concomitant conservative treatment or orthotic device and stop having any cortisone injection within 90 days prior to surgery.Each patient has ultrasound mesurement of the thickness of the plantar fascia prior to the surgery and postinjection at 1 month,3months,6 months and 1 year.

RESULTS: 20 patients achieved complete resolution of symptoms after two months;four patients had a complete resolution after a second injection of autologus platelet concentrate;four patients had occasional pain when walking barefoot;two patients were dropped from the study due to an injection of cortisone.

After one year 22 patients (73,3%)had complete resolution of symptoms.

CONCLUSIONS: This successful findings indicates that injection of autologus paltelet concentrate may become a very commonly used method of treating of chronic palntat fascitiis. This technique is safe and don’t impaire the biomechanical function of the foot. We think that the results may be improved with a multifactorial treatment regimen instead a single isolated modality as we used in our study.


F. Neumayer Y. Arlettaz X. Crevoisier E. Mouhsine

Introduction: The treatment of the recently ruptured Achilles tendon is still controversial. Surgical procedures are commonly considered to restore excellent functional capacity and suffer low re-rupture rates, but are potentially associated with significant complications like wound infection and paraesthesia. Recent studies report very good results with a conservative treatment in rigid casts. Our aim was to evaluate a new method of functional and conservative treatment using immobilisation in an articulated cast.

Patients and Methods: Between March 1998 and August 2005, 12 women and 45 men with an average age of 45 (24–73), underwent a functional and conservative treatment for a recently ruptured Achilles tendon. After an immobilisation with a cast in equinus for 10 days, the patients were authorised to walk with full weight-bearing, protected by a commercial orthosis (VACO®ped, OPED). The equinus angle was set at 30° plantar flexion until the end of week 3, and at 15° until the end of week 4. At the 5th week the system was unlocked to allow ankle mobilisation of 30-15-0°, and at 30-0-0° at the seventh week. The orthosis was removed after 8 weeks. All patients had follow-up examinations up to 12 months after the trauma. The first 30 patients underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months. In June 2006 all 57 patients were contacted and received a questionnaire. Their subjective opinions of the outcome, any change in their sport activities and eventual late complications were investigated. We evaluated the questionnaire and medical records using a scoring system based on the Leppilahti Ankle Score.

Results: After one year there was not any difference in the motion of the ankle in comparison with the healthy side. There was no substantial calf amyotrophy and we found very little difference in muscular capacity. The average overall satisfaction with the outcome was 8.1 out of 10. We observed 5 complete re-ruptures (9%), 2 partial re-ruptures and 1 deep venous thrombosis complicated by pulmonary embolism. We observed few minor skin complications.

Conclusions: The present treatment resulted in good to excellent functional results in most of the cases. It requires an active participation of the patient and a systematic medical follow-up during the first 6 months. The complication rate is acceptable. We think that early ankle mobilisation in the dynamic cast promotes better functional results than a rigid immobilisation technique.

There is a place for conservative functional treatment in the acute rupture of the Achilles tendon. But prospective comparison with modern surgical techniques, like minimal invasive suture, is still required, especially in patients with high functional demand.


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

OBJECTIVE OF THE STUDY: Metatarsal osteotomies are common procedures for correction of hallux valgus. The aim of this study is to compare linear distal metatarsal osteotomy (LDMO) with SCARF osteotomy a clinical prospective randomised study.

METHODS: Forty patients affected by bilateral hallux valgus similar in both sides regarding clinical and radiographic assessment were included. X-rays, AOFAS, Maryland Foot Score (MFS) were considered before surgery up to 4 years follow-up. All patients were operated bilaterally, and received SCARF osteotomy in one side, and in the other LDMO performed through a 1 cm skin incision under the direct view control. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bondage and weight bearing with talus shoes for 4 weeks.

RESULTS: No statistical differences were observed in preoperative HVA, IMA, PASA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in LDMO (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed. At 4 year follow up, no statistical differences were observed in HVA, IMA, PASA comparing SCARF with LDMO. Average AOFAS score was 87±12 in SCARF and 89±10 in LDMO (p=0.07), and MFS was 86±7 in SCARF and 90±3 in SERI (p=0.08).

CONCLUSION: Both SCARF and LDMO techniques resulted effective in the correction of hallux valgus, however SERI, a minimally invasive technique, performed with a shorter skin incision, more rapid surgical time, fixed with a less expensive device (one kirshner wire), resulted in a better clinical outcome.


C. Kayali H. Agus L. Surer

Objectives: Nonsteroid antiinflamatory drugs have been widely used and recommended for ankle sprains despite the fact that they are also known to lead significant adverse effects especially to the gastrointestinal system. The aim of this study is to assess the efficacy of acetaminophen in comparison with diclofenac sodium.

Patients and Methods: In this prospective, double blinded, parallel group study, one hundred patients suffering from first or second degree lateral ankle sprain within 48 hours of administration were comprised. Patients with bilateral injury, ipsilateral knee injury, trird degree sprain, previous sprain within 6 months and ankle pain less than 45 according to visuel analogue score (VAS) were excluded. In addition; history including gastrointestinal, renal or hepatic disease was the reason for exclusion. Prior to enrollment cases underwent physical examination. Patients rated pain on a 100 VAS, representing 0 no pain, 100 maximal pain. After enrollment patients were randomized (1:1); diclofenac sodium 150 mg/day or acetaminophen 1500 mg/day for 5 days. Patients tretaed by diclofenac sodium were called as group I and the others were group II. In addition; cases were prescribed other intervention modalities as RICE (rest, ice, compression, elevation) and crutches. Clinical assessments were carried out at baseline; on second, tenth days and sixth weeks (end of study). In each visit, VAS and adverse effects of medication were questioned.

Results: The mean VAS of the GI and GII at the first visit were 81, 82.3 respectively. These scores decreased to 20.7, 9.9, 4.6 and 11.9, 6.3, 3 at the second, tenth days and last examination. Similar reductions in pain were observed at the last visit (p> 0.05) in both groups. However; cases treated by acetaminophen showed accelerated decrease in VAS at day 2 and 10 in comparison with GI (p< 0.05). Regarding the ankle ROM there was similar increase in both groups (38.9°, 36.9°) respectively. There was no significant difference between groups with regard to ankle ROM at the last control (p> 0.05). The incidence of gastrointestinal adverse effects of GI was much more than GII. However there was no significant difference (p> 0.05).

Conclusion: It was concluded that diclofenac sodium and acetaminophen are effective and well tolarated short term treatment alternatives for acute ankle injuries.


M. Richter S. Zech F. Hildebrand C. Schulz-Wildelau R. Gaulke K. Goering

PURPOSE: A new device for intraoperative pedography was developed. The purpose of this study was to validate the introduced method with standard dynamic pedography, and to analyze the clinical benefit.

Methods: For an intraoperative introduction of standardized forces to the footsole, a device named Kraftsimulator Intraoperative Pedographie was developed.

The validation was performed in two steps: Step 1. Comparison of standard dynamic pedography (three trials, walking, third step, three trials, mid stance force pattern), static pedography in standing position (three trials) and pedography with KIOP in healthy volunteers (three trials, total force 400 N).. Step 2. Comparison between pedography in standing position, pedography with KIOP in awake and anaesthesized patients (three trials, total force 400 N).

A randomized prospective controlled study comparing treatment with and without intraoperative pedography has started on November 1, 2005. The subjects are randomized into two groups,

a) use of intraoperative pedography, versus

b) no use of intraoperative pedography.

One-year-follow-up including standard dynamic pedography is planned. The following scores are used: American Orthopaedic Foot and Ankle Society (AOFAS), Visual-Analogue-Scale Foot and Ankle (VAS FA), Short-Form 36 (SF36, standardized to 100-point-maximum). Intraoperative consequences after the use of intraoperative pedography were recorded.

Results: Validation Step 1: 30 individuals were included (age, 26.1±8.6 years; gender, male: female = 24: 6). Step 2: 30 individuals were included (age, 55.3±30.3 years; gender, male: female = 24: 6). No significant differences between all measurements of step 1 and 2 were found for step 1 and 2 without the dynamic platform measurements of step 1.

Clinical use: 16 patients were included until January 31, 2006 (ankle correction arthrodesis, n=2; subtalar joint correction arthrodesis, n=4; arthrodesis midfoot, n=4, correction forefoot, 4; Lisfrcan-fracture-dislocation, n=2). 9 patients were randomized for the use of intraoperative pedography. The mean preoperative scores were: AOFAS: 49.6±23.7; VAS FA: 42.2±13.1; SF36: 48.1±23.2. The mean interruption of operative procedure for the intraoperative pedography was 359±34 seconds. In 4/9 cases changes were made after intraoperative pedography during the same operative procedure (correction modified, n=3; screw tightened, n=1). The follow-up has not been completed so far.

Conclusion: Since no statistical significant differences were found between the measurements of intraoperative pedography in anaesthesized individuals and the standard static pedography, the introduced method can be considered to be valid for intraoperative static pedography.

During the clinical use, in 44% of the cases a modification of the surgical correction were made after intraoperative pedography in the same surgical procedure.


S. Iqbal S. Kaleel J. Arbuthnot G. Lamont

Introduction: The problem of ingrowing toenails is worldwide, affecting all age groups. The exact incidence in children is difficult to measure.

The aim of this study was to review the different surgical modalities for ingrown toenails in the paediatric age group in a hospital setting.

Methods: We reviewed case series of 66 children aged between 9 months and 16 yrs. In total there were 89 affected toes operated upon between 1995 and 2001. The patients were followed up for up to 18 months.

All procedures were carried out under general anaesthetic. The treatment methods practised were:

Nail avulsion with or without nail matrix ablation using phenol.

Wedge excision of the nail with or without nail matrix ablation using phenol or thermal ablation.

RESULTS: We performed statistical analysis using Fischer’s exact test with the level of significance at P value 0.05. We found the recurrence rate to be 3% for those treated with wedge excision alone compared to 30% when treated with wedge excision and phenol ablation (p=0.001).

We also applied the same Fischer’s exact test for rate of infection in all the groups.

DISCUSSION: Ingrown toenails go through three stages- inflammation, infection and granulation.

During the stage of inflammation, conservative measures in the past have been noted to be successful.

In a hospital setting, most patients present in the second stage (infection). Nail avulsion is still commonly practised as a first line treatment. It provides good symptomatic relief in this stage but has been reported to have high rates of recurrence. We noted similar results (recurrence rate: 55%) in our study.

Then patients present in the next stage with symptoms of chronic ingrowths i.e. previous infection and presence granulation tissue in the nail fold. The aim of treatment here is to remove the ingrown area along with the nail fold. Wedge excision with or without removal of nail matrix is a commonly performed procedure. There are various methods for removing the nail matrix namely surgical matrixectomy, chemical matrixectomy using phenol or sodium hydroxides, diathermic/electric cauterisation, laser. There are reports that show low recurrence rates with use of phenol. In this study we found recurrence and infection to be high when phenol was used as the ablative agent. We achieved cure rate of 97% when using wedge excision alone and 70% when phenol was used for nail matrix ablation.

CONCLUSION: We advocate wedge excision as primary treatment of ingrowing toenails in children. We did not note a statistical significance in giving postoperative antibiotics but this has to correlate with the clinical presentation. We would not recommend phenol ablation of the nail matrix in the younger patient as it increases both infection and recurrence rates. The results of nail bed ablation with diathermy appear promising.


R. dega P. SINGH N. PERERA

Background: There is increasing concern regarding radiation exposure to surgeons’ using fluoroscopic guidance during orthopaedic procedures. However, there is currently a paucity of information regarding the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery.

Methods: We conducted a 12 month prospective study to measure radiation dose absorbed by the hands of a dedicated right handed foot and ankle surgeon. A thermo-luminescent dosimeter ring (TLD) was worn on little finger of each hand. Measurement of the cumulative radiation dose was recorded on a monthly basis.

Results: A total of 80 foot and ankle cases involving fluoroscopy were performed. The total screening time was 3028seconds (s) (mean screening time 37.4s). Screening time correlated positively with the number of procedures performed (r=0.92, p< 0.001), and with radiation dose in both the left TLD (r=0.85, p=0.0005) and right TLD (r=0.59, p=0.0419). There was no significant difference in radiation dose between either hand (p=0.62). The total radiation dose to the right TLD over the 12 months was 2.4 milli-sieverts.

Conclusion: Radiation dose incurred during orthopaedic foot and ankle procedures is proportional to the screening time. Our results show radiation exposure to be well below the annual dose limit set by the International Commission on Radiological Protection. This work demonstrates a simple and convenient method for evaluating a single surgeon’s radiation exposure.


A. Khurana S. Kadambande S. James H. Tanaka K. Hariharan

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil osteotomy.

Materials and Methods: A retrospective study of 75 feet (62 patients) with a mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent meta-tarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy.We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intra-operative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.


S.G. Hofstaetter G. Moser H. Vordermeier A. Schwertner E. Orthner

Introduction: The modified Lapidus-arthrodesis with standard AO screw-fixation is well known for the treatment of severe metatarsus primus varus deformity respectively a hypermobile or an arthrotic first tarso-metatarsal joint. High rates of non-union and malunion (range 3 to 12%) due to improper or poor fixation despite the postoperative course of nonweightbearing were reported in literature. The immediate postoperative weightbearing protocol varies from 2 to 6 weeks of cast immobilization. To our knowledge, this prospective investigation comprises the largest cohort of patients undergoing the Lapidus-arthrodesis, fixed with the Lapidus-Orthner locking plate.

Methods: 130 feet with an average patient’s age of 52 years (range 23 – 83 years), underwent the Lapidus fusion with the locking Orthner-plate. Indications were severe hallux valgus deformities respectively moderate hallux valgus deformities with a hypermobile first TMT 1- joint or an arthrotic first tarsometatarsal joint. The surgical technique was standardized, and the operations were performed by the inventor of the plate. All patients had a failed trial of nonoperative management (shoe-wear modification).

The 130 feet were divided into 2 groups. Group I was without TMT 1 – compression screw (n= 60) and group II with an additional compression-screw (n=70). Average age of group I was 54-years. The average age of group II was 50-years. The American-Orthopaedic-Foot and Ankle Society (AOFAS) Forefoot-Score, Visual-analog-pain-scale and foot radiographs were assessed preoperatively and after a mean of 23 months for group I and 39 months for group II. All 130 feet were treated immediately postoperative with a postoperative Darco orthowedge ® shoe.

Results: The average AOFAS score improved significantly from preoperative to follow up time-point in both groups. AOFAS pain-subscore significantly improved in both groups. The intermetatarsal-angle (IMA) of all 130 feet decreased significantly from 14° to 6° after surgery. At time of follow-up 9 % of non-unions were seen in group I whereas 0% were seen in group II with proximal compression screw, the difference is significant (p=0,024). The mean immobilisation with the Darco-Ortho® wedge shoe was 7,2 weeks (range 6 to 14 weeks) in group I and 6,3 weeks (range 5 to 12 weeks) in group II.

Conclusion: The prospective mid-term results from this study show that the locking Lapidus-Orthner plate is a very good and promising technique for the Lapidus-arthrodesis. The modified technique with compression screw has shown none non-union, despite of immediate weight-bearing in a post-op shoe after surgery. The procedure significantly reduced pain, the hallux valgus and intermetatarsal angle and increased the patient’s ambulatory capacity and patient satisfaction.


S. Green S. Lee T. Joyce A. Unsworth

The first metatarsophalangeal (MTP) joint is the key joint of the foot in terms of function during gait. Various replacement toe joint prostheses are commercially available but unlike other replacement joints such as the hip or knee, few simulator based studies have been conducted to evaluate the performance and reliability of these prostheses. Presented are results obtained using a newly developed and validated multi-station MTP joint test-rig that is able to simulate the natural biomechanics of the toe joint. The developed simulator is a multi-station computer controlled electro-pneumatic metataso-phalangeal joint simulator that applies dynamic loading and motions commensurate with the walking gait cycle. This involves the combination of plantar-dorsi flexion range of 32 degrees, 5 degrees of inversion/eversion and toe-off dynamic loading peaking at up to 820 N. Presented are the validation and in vitro test results of MTP joint simulations carried out on silastic and articulating metal and polymer designs of MTP prostheses. Despite being subjected to a reduced loading regime of 300 N peak force, the silastic prostheses were found to perform poorly in the simulator, ultimately failing due to a combination of fatigue crack growth and joint collapse. This behaviour and failure mode was consistent with that of ex vivo origin silastic MTP prostheses examined and provides confidence in the validity of the simulator.


J.D. Calder D. Farr A. Karim

Introduction: Compression staples are indicated for use in forefoot osteotomies and midfoot and forefoot fusions. The staple design can be divided into “Mechanical Compression” or “Shape Memory”. Although they are becoming increasingly popular because of their ease of use, there is little data published on the effectiveness of the true compression achieved across bony surfaces. There is no data on the optimal limb-length to staple width ratio required for compression. We aimed to compare four commercially available types of compression staple and measure the compression force achieved.

Methods and Materials: Compression in porcine tibia, cancellous bone substitute and perspex was compared using a load cell mounted within a simulated fusion site between two test blocks. The amplified output was continuously recorded using a datalogger and the data analysed. Two designs of “mechanical” compression staple and two designs of “shape memory” staple were tested. The effect of altering limb length on compression was also noted.

Results: The “mechanical” compression staples splayed open with the limbs of both designs causing either no compression or even distraction at simulated fusion site. Distractive forces of up to 23N were recorded. By contrast, the “shape memory” staples all achieved compression at the fusion site of between 5–25N. Limb length did not appear to alter the compression force achieved.

Discussion: “Mechanical” compression staples act in a similar way to basic AO principles of a 2-hole compression plate used without a lag screw technique or pre-bending. Although there is compression of the cis-cortex, the limbs of the staple splay open with a fulcrum around the bridge-limb intersection resulting in distraction of the trans-cortex. “Shape memory” staples compress both the cis- and trans-cortices along the length of the limb leading to adequate stability and compression forces across the fusion site.

Conclusion: This study demonstrates that “mechanical” compression staples cause a distractive force rather than a compressive force and manufacturers should be aware that further design modifications are required to prevent this. We recommend that “shape memory” staples, standard staples or lag screws are used instead. The limb-length to staple width ratio does not appear to be important.


B. Devos Bevernage P. Maldague T. Leemrijse

Introduction: To guide one’s surgical options if conservative treatment in metatarsalgia fails, a good understanding of the anatomy and the biomechanics of a normal forefoot is primordial. The recognition of a so-called ideal morphotype may serve as a guide, through technical or other means (clinical examination, X-rays, baropodometry,..), to obtain a calculated and subtle reconstruction of all the symptomatic elements.

Material and Methods: Between 2000 and 2005, 68 patients were operated by the same surgeon and were all, but five, reviewed retrospectively by an independent examiner.

The study of the 184 osteotomies performed (of which 177 Weil osteotomies), made use of clinical, and radiological computerised analysis.

Results: We have not been able to find a significant correlation between a harmonious curve of Maestro and postoperative recurrence or transfert metatarsalgia.

Discussion: The cause of transfert metatarsalgia is often hard to find. Known, and so evitable, are important shortening and a fault in the preoperative adjustment. Despite a precise preoperative planning and a perfectly performed surgical technique, the surgeon sometimes encounters the development of plantar callosities beneath metatarsal heads adjacent to the operated ones. Lots of variables are still unknown or not recognised: mobility at the Lisfranc, gastrocnemius retraction.

We have noted a significant relationship between the preoperative (in-)stability and the risk of developing transfert metatarsalgia (p-value = 0.03). A metatarso-phalangeal articulation, unstable in the preop setting, has 0.36 times less the risk of leading to this complication than if the operation was performed on a stable articulation preoperatively. A stable articulation would so be an indirect sign of a good tolerance by the adjacent rays.

Conclusion: One can question if the reconstruction of an architectural harmonious forefoot using the ideal curve of Maestro at any price is necessary, since we were not able do demonstrate a guaranteed postoperative pain relief. A respect of the so-called ideal morphotype of the forefoot on the dorsoplantar upright X-rays seems insufficient in the assurance of a balanced distribution of plantar pressures postoperatively. Certainly, this morphotype most probably avoids an elevated rate of complications, but may not be considered as the only criteria to be achieved.

The clinical examination stays the most essential element. Only the preoperatively symptomatic and unstable metatarsals should probably undergo this osteotomy.


J.D. Calder R. Elliot C. Seifert

Introduction: Adequate analgesia following hindfoot surgery can be difficult and conventional analgesics have significant side effects. A single bolus popliteal block of the neurovascular bundles is effective but short-lived. We have been using a retained perineural catheter with continuous local anaesthetic infusion for pain relief post-operatively.

Materials and Methods: This 2 cohort observational study compares pain relief following single bolus dose popliteal block and retained continuous infusion peri-neural catheter. With the patient supine in the anaesthetic room a nerve stimulator identified the tibial and peroneal branches of the sciatic nerve which were blocked with 20mls 0.5% marcaine. In 31 patients a perineural catheter was left in situ and connected to a Stryker “Pain Pump” infusing 0.25% bupivacaine at a rate of 4 ml/hour with 1 ml/hour patient controlled boluses. Following discharge the catheter was removed by the district nurse at 72 hours post-operatively.

Results: Patients were asked to fill in Visual Analogue Scores for 72 hours post operatively. The mean pain score for the single block group was 4.9 (range 0–9). The mean pain score for the popliteal catheter group was 1.03 (range 0–5). One patient had an air-lock in the infusion tubing leading to pain once the initial block wore-off. One patient experienced a patch of numbness in the lower leg which resolved by the 2 week follow-up. There were no other complications, such as infection, from placement of the retained popliteal catheter. All patients were satisfied with their post-operative pain control.

Conclusion: We recommend this novel technique as an effective method of pain relief after ankle and hindfoot surgery. To confirm our findings we are running a randomised, double blinded, placebo controlled trial to study this method of pain relief.


S.J. Dawson-Bowling K. Chettiar H. Cottam J. Forder R. Worth H. Apthorp

This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.

All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.

108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05).

The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.


L. Lapidus S. Rosfors S. Ponzer C. Levander A. Elvin G. Elvin E. de Bri

Background: Prophylaxis against thromboembolic complications has become routine after major trauma and major orthopaedic surgery. In contrast, it remains an issue for debate whether prophylaxis after minor surgery and immobilization is necessary, even though these treatments are well-known risk factors for deep vein thrombosis (DVT).

Objectives: The objective of this study was to evaluate the efficacy of Dalteparin (5,000 U given subcutaneously once daily for six weeks) during lower limb immobilization after surgical treatment of Achilles tendon rupture.

Methods: After surgery, 105 consecutive patients were randomized to a placebo-controlled double-blind study to evaluate the efficacy of given thromboprophylaxis. DVT screening using validated color duplex sonography was performed three weeks and six weeks after surgery, and all DVTs were confirmed with phlebography.

Results: Primary endpoint analysis was available for 91 patients. DVT was diagnosed in 16/47 patients (34%) in the Dalteparin group and in 16/44 patients (36%) in the placebo group. These figures are not significantly different (p=0.8). Proximal DVT was diagnosed in one patient (2%) in the Dalteparin group and in three patients (6%) in the placebo group (p=0.6). No pulmonary emboli or major bleeding occurred in either of the groups.

Conclusions: DVT is common after surgical treatment of Achilles tendon rupture and therefore effective thromboprophylaxis is desirable. Thromboprophylaxis with Dalteparin however, does not affect the incidence of DVT during the immobilization after Achilles tendon rupture surgery. Long-term effects of immobilization, such as the risk for post-thrombotic syndrome, need to be investigated further.


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J. Gjertsen J. Fevang T. Vinje S. Lie L. Havelin L. Ebgesaeter O. Furnes

Background: Annually about 9,000 patients in Norway are operated because of hip fractures. From January 2005 all these fractures should be reported to The Norwegian Hip Fracture Register, founded by the Norwegian Orthopaedic Association and operated by The Norwegian Arthroplasty Register from 1. January 2005.

Patients and methods: We have established contacts at every hospital in Norway that perform surgery for hip fractures. Immediately after the surgery the surgeon fills in a standardized form which is sent to the register once a month. On the form there are both patient- and procedure-related questions. Four and twelve months postoperatively we send a questionnaire to the patients, including the Norwegian translation of the EuroQol-5D. Patient information is linked to the Norwegian Death Register using the unique identification number assigned for each resident of Norway. We have so far included 5,668 primary hip fractures operations and 607 revision procedures including revisions to hemiprosthesis and total hip replacements (THR).

Results: After 1 year of registration 100 % of the hospitals are reporting to the register. Approximately 50 % of the patients have answered the questionnaire. Of the primary operated patients the mean age was 80.5 years and 73 % were females. 59 % of the fractures were intracapsular femoral neck fractures and approximately 2/3 of those were dislocated. 35 % of the fractures were intertrochanteric or subtrochanteric.

Intracapsular dislocated fractures: Screw fixation was used in 48 % of the hips while 46 % of the hips were operated with a hemiarthroplasty, and 4.1 % were operated with a THR. We could not find any difference in mortality between screw fixated patients and patients operated with a hemiarthroplasty.

Intertrochanteric/subtrochanteric fractures: The hip compression screw osteosynthesis was used in 88 % of the patients, 6.3 % of these had a lateral support plate. An intramedullary nail was used in 8.9 % of the patients.

Conclusion: After only one year, the reports from the surgeons were good. Taking the age and general status into consideration, also the response from the patients is satisfactory. With longer follow-up we will be able to give more information on the outcomes of hip fractures and of the different treatment. Updated analysis will be reported.


J. Palan A. Odutola S. White

Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include aspirin, warfarin and more recently, clopidogrel. Clopidogrel and aspirin are associated with an increased bleeding time especially if present as a combined therapy. As such, they can lead to bleeding complications in patients undergoing surgery, increasing the need to transfuse such patients and increasing the risk of cardiovascular events as a result of anaemia. Although clopidogrel is often stopped for patients undergoing elective surgery for a period of 7–10 days, to our knowledge, no such guidelines are available regarding the discontinuation of clopidogrel in patients undergoing surgery for femoral neck fractures. The aim of conducting this survey was to investigate the current practice of various orthopaedic units in the UK with regards to stopping clopidogrel in such patients.

Methods: A telephone questionnaire survey was conducted on junior doctors (House officers, Senior House Officers and Registrars) in orthopaedic departments in the UK which routinely admit and treat patients with fractured neck of femurs.

Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures?

If yes: how many days prior to surgery is the clopidogrel discontinued?

If no: are any precautions undertaken?

Clotting function checked:

Platelet cover/other blood products:

Increased X matching of packed red cells:

Other precautions?

Any complications as a result of clopidogrel?

Results: 184 NHS trusts in the UK were involved. 45% of trusts stop clopidogrel routinely prior to performing surgery on patients with femoral neck fractures. The number of days clopidogrel is stopped prior to surgery varied from 1 – 7 days. 55% of trusts did not routinely stop aspirin prior to surgery. 97% of trusts routinely stopped warfarin prior to surgery and the target INR varied from < 1.0 – < 3.2.

Conclusions: It is clear from this study that a wide range of policies exists amongst orthopaedic departments in the UK regarding the routine discontinuation of clopidogrel, aspirin and warfarin in patients with femoral neck surgery who are awaiting surgery. This highlights the need for further debate and guidelines regarding the routine discontinuation of clopidogrel.


P. Haentjens D. Vanderschueren K. Venken S. Boonen

Objectives: To determine the magnitude and duration of excess mortality after hip fracture among postmenopausal women.

Methods: We conducted a systematic review and meta-analysis of the literature to estimate the pooled relative risk of death after hip fracture by time since fracture. We selected only controlled studies that reported data on postmenaupausal women aged 50 years or older, carried out a life-table analysis, and displayed the survival curves of the hip-fracture group and an ageand sex-matched control group. Using random-effects models we calculated the pooled relative risk of death with 95% confidence intervals (95%CI) by time since fracture.

Results: Twenty-three studies contributed to this meta-analysis. The pooled relative risk of dying within three, six, twelve, and twenty-four months following hip fracture was 5.06 (95%CI: 4.31, 5.93), 3.92 (95%CI: 3.11, 4.94), 2.71 (95%CI: 2.33, 3.14), and 2.02 (95%CI: 1.83, 2.23), respectively. Thereafter, excess mortality remained relatively constant. The relative risk of mortality at five years, ten years, and fifteen years post-fracture was 1.44 (95%CI: 1.29, 1.62), 1.40 (95%CI: 1.35, 1.45), and 1.36 (95%CI, 1.31, 1.41), respectively.

Conclusions: Excess mortality among postmenopausal women having suffered a hip fracture was most apparent immediately after the event, declined steeply during the first years post-fracture, but did not return to that of age- and sex-matched controls, even at the longest duration of follow-up. The impact of a hip fracture on excess mortality among postmenopausal women continued for up to 15 years.


G. Erturan S.D. Deo

Background: The implications of clinical governance, changing epidemiology, financial restraints alongside the increasing demands of the informed consumer-patient mean we must continually adapt our practice to efficiently meet expectations.

As a busy regional Trauma and Orthopaedics Unit of a District General Hospital we are increasingly affected by economic agendas and have noted an increase in the presenting frailty of our fracture hip patients.

Our practice has already changed by the use of an Orthogeriatrics Team (OGT): optimising patient status pre-operatively and ensuring maximum post-operatively continuity. The OGT has significantly reduced time to theatre. With appropriate investigation and lower complication rates it will offset the cost of the team.

We wanted to see if the care of fractured hip patients could be further focused.

On this basis, a four-part clinical stratification system was devised for patients undergoing fractured hip repair:

Complex 0 (C0): Hip repair of a non-complex fracture pattern in an otherwise fit, healthy patient.

Complex I (CI): A fit, healthy patient with a complex hip fracture pattern.

Complex II (CII): Medically unfit patient with a non-complex hip fracture.

Complex III (CIII): Medically unfit patient with a complex hip fracture.

Patients and Methods: The first 50 patients operated on across the same three months in both 2004 and 2005 were retrospectively assessed from prospectively collected data.

Patients were grouped accordingly and age, length of stay, time to theatre and reason for delay, mental state examination score (MSE) on admission, and number of co-morbidities were also recorded.

Chi-square was performed on co-morbidity, MSE and theatre times with AVOVA used for age and length of stay data.

Results: No significant difference between groups for age.

Two fold increase in stay (2004 paired classes C0+I vs CII+III; P< 0.003).

Chance of more than 2 co-morbidities (C0+I vs CII+III): 52% vs 96% (2004) and 56% vs 92% (2005).

MSE with a positive dementia score: 26% vs 82% (2004; P0.001) and 39% vs 70% (2005; P< 0.05).

Time delays to theatre greater than 24hrs were seen 24% vs 92% (P< 0.001) in 2005. The correlating values in 2004 were 63% vs 87%.

Active treatment delaying theatre in the C0+I group 24% vs 57% (CII+III) in 2004 and 0% vs 78% 2005 (P< 0.001).

Conclusion: The benefit of the OGT can be seen clearly in most parameters and this classification system correlates and quantifies increasing hip fracture complexity with increasing post-operative burden even under their care.

Stratifying patients for pre- and postoperative planning, risk counselling, and surgeon selection can identify patient groups likely to incur greater cost during their treatment.

The classifications are easily reproducible and can be applied to larger patient groups via institutional or national joint registries.


S. Kalra M. Thiruvengada A. Khanna M. Parker

In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies was extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home.

There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduce mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery apart from one study of 399 patients, which reported an increased mortality and morbidity for those operated on within 24 hours of admission.

In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.


G.J. McLauchlan R. van Mierlo G. Perkins

A prospective audit was carried out to analyse the relationship between time to surgery, number of co-morbidities and length of stay in 357 consecutive patients operated on for a fractured neck of femur.

One hundred and thirty five patients were operated on within 48 hours (group 1), 129 between 48 and 96 hours (group 2) and 93 patients after 96 hours (group 3). The mean (std dev) age was 77.2 (12.5) years in group 1, 79.8 (9.9) years in group 2 and 79.2 (9.4) in group 3. There were 93 (69%) females in group 1, 99 (77%) in group 2 and 67 (72%) in group 3. The number (%) admitted from home was 85 (63) in group 1, 81 (63) in group 2 and 73 (79) in group 3.

In the 30 patients with no co-morbidities there was a strong relationship between wait for surgery and length of stay. In these patients the median length of stay increased from 8.5 days in group 1 to 21 days when in group 3. In the 187 patients with one or two co-morbidities the relationship was present but weaker. The median length of stay increased from 16 days in group 1 to 21 days when in group 3. In the 140 patients with 3 or more co-morbidities there was no relationship between wait for surgery and length of stay. Median length of stay was 23 days in group 1 and 21 days in group 3.

This data from a large consecutive group of patients suggests that the fit patient with a hip fracture benefits from early surgery with a shorter length of stay. Those with multiple co-morbidities have their length of stay determined by their medical condition.


A. Al-Ani B. Samuelsson A. Norling W. Ekstrom J. Tidermark T. Cederholm M. Hedstrom

Several studies have evaluated the association between timing of hip fracture surgery and mortality in elderly patients. The evaluation of functional outcome is lacking.

We studied the effect of delayed surgery on the patient’s ability to return to independent living, the incidence of pressure sore and total length of hospital stay. Days of hospital stay included the post-operative period and the rehabilitation admission in the first 4 months following the operation.

Patients older than 50 years of age, admitted to two major hospitals in Stockholm during one year were included in the study (n = 853). To eliminate the effect of time interval between injury and admission, all patients who arrived to the hospital later than 24 hours of the injury (n=75) were excluded. Patients with pathological fracture (n = 30) were also excluded. The time intervals between hospital admission and the operation were evaluated against the patient post-operative independent living at 4 months follow up.

We divided the patients into two groups depending on delay to surgery. We performed a comparison of those patients who operated within 24 hours with those who hade been operated more than 24 hours after the admission. Moreover we repeated the analysis using 36 and 48 hours cut-off points.

After adjustment for age, ASA, walking ability, living with some one, gender and reason for delay, the late operated groups had a significantly decreased OR for return to independent living at 36 and 48 hours cutoff points (OR 0.5 respectively 0.3) but not at 24 hour cut-off point. The incidence of pressure sore in the late operated groups was significantly increased at all 3 cutoff points after adjustment for age, ASA, walking ability, dementia, and duration of surgery (OR 2.2, 3.4 and 4.2 respectively).

The median length of hospital stay was significantly increased in the late operated groups (14 versus 18 days at 24 hours, 15 versus 19 days at 36 hours, and 15 versus 21 days at 48 hours cut-off point). Linear regression analysis with adjustment for age, ASA, walking ability, dementia, gender and place of residence showed that there was a significant relationship between waiting time for operation (hours) and length of hospital stay (days) (B 0.148, P 0.002). Accordingly for every 6.75 hours delay in surgery, the total hospital stays increased by one day.

Our conclusion is that early operation of patients with hip fracture is associated with a significantly improved ability to return to independent living, a reduced incidence of decubitus ulcers and reduction in the length of hospital stay before the 4-month follow up.


J. Bel L. Pidhorz F. Jacquot R. Bertin H. Pichon F. Dubrana J. Allain P. Bonnevialle J. Feron

PURPOSE: Oldest elderly trochanteric fractures treatments are common but long term follow up studies are indistinct. Previous data about all outcomes are not reported for oldest one. The purpose was to update all the results for these oldest old patients.

METHODS: A prospective, longitudinal study was undertaken of 455 “31 A1, A2, A3” (OTA) peritrochanteric femur fractures through 2002. There were 84% female patients. The age was 88 (80–105) ±5 years. Associated hip arthritis rate was 10%. 31 A1 and 31 A2 really trochanteric fractures were 90% (31 A1: 52% and 31 A2: 38%), 31 A3 subtrochanteric were 10%. Surgical treatment was achieved for 97%: [extramedullary internal fixation (dynamic hip screw): 36%, intramedullary (trochanteric nail): 56%, hip arthroplasty: 5%]. Functional treatment (not displaced or contra-indicated) was achieved for 3%. Katz, mental, Parker, walking scores, live place before and at long term after fracture, radiological healing and complications were registered.

RESULTS: The radiological healing rate after 3 months was 85% and after 6 was 97%. Complications rate: the general complications rate during 1st month was 12% and between 1st and 3rd month was 8%. The local complications rate during the 1st month was 4% (local infection: 1%) and between 1st and 3rd month was < 1%. The new surgical procedures rate during the 1st month was < 0.5%, between 1st and 3rd month was 3%, between 3rd and 6th month was 3%. Clinical results: Post-operative weight bearing was uncertain. 6th month after fracture 72% of the patients were alive (dead: 28% and non-surgically treated: twice more). All scores and live place demonstrated dependence increase. > 6th month after fracture mortality was common.

CONCLUSION AND SIGNIFICANCE: Intra/extra capsular hip fractures ratio increases after 80. These are older, more dependant and help demanding. Hip arthritis inflates hip fracture risk. Success points technical procedures had been demonstrated by randomised studies: dynamic hip screws for stable fractures and trochanteric nails for unstable; hip prosthesis for arthritis or poor bone. Practice surgery for all trochanteric fractures. Don’t separate trochanteric/subtrochanteric. The prognostic is rather poor (mortality rate, functional outcomes), depending on initial functional score and dependence. Modern internal fixation is reliable. Arthroplasty should be considered.


H. Palm N.B. Foss M. Krasheninnikoff H. Kehlet P. Gebuhr

Introduction: Rehabilitation of hip fracture patients is often lengthy with bed day consumption accounting for up to 85 % of the total hospitalization cost. Data suggests that patients who suffer surgical complications requiring re-operation have an excessive length of hospitalization, but the overall impact of surgical complications including those not requiring re-operations have not been examined in detail.

Methods: Six hundred consecutive, unselected patients with a primary hip fracture were included between 2002 and 2004. All patients received surgery and a multimodal rehabilitation program. Surgical complications were stratified into those requiring re-operation (< six months) and those not allowed mobilization postoperatively due to instability of the fracture. Surgical complications were audited and classified as being due to a patient fall, infection or due to a suboptimal surgical procedure, specified as suboptimal operation method, fracture reduction or implant position.

Results: 19.3 % (116/600) of the admitted patients were re-operated or immobilized. Assuming that the patients with complications otherwise would have had the same length of stay as the remaining patients, 27.2 % (3814/14038) of total bed day consumption was due to surgical complications. The audit of complications showed that 64 complications (55 %) were due to a suboptimal primary surgical procedure, 18 (16 %) to infections, 6 (5 %) to falls and 28 (24 %) could not be ascribed to an apparent course.

Conclusions: Surgical complications secondary to primary hip fracture surgery accounts for 27.2 % of the total bed consumption if secondary admissions due to re-operations are taken into account. Our audit suggests that as much as half the complications potentially could be spared through optimization of surgical procedures.


M.T. Kristensen N.B. Foss H. Kehlet

BACKGROUND AND PURPOSE: Previous studies using the Timed Up & Go (TUG) as a predictor of falls have primarily been based on retrospective data, while no prospective studies using the TUG to predict falls in hip fracture patients are available. The purpose of this study was to determine if the TUG could predict falls in hip fracture patients during six months follow up.

SUBJECTS: Seventy nine elderly consecutive unselected hip fracture patients being able to perform the TUG when discharged directly to their own home or assisted living facilities from a special acute orthopedic hip fracture unit, with 59 (75 %) being able to participate in the follow-up interview.

METHODS: In a prospective study all patients were contacted for a six months follow up interview about falls since discharge from the hospital and the TUG performed at discharge was compared with the New Mobility Score describing functional level before fracture, mental status on admission, gender, fracture type, residence and walking aids before and after fracture. All patients followed a well-defined care plan with multimodal fast track rehabilitation including an intensive physiotherapy program comprising two daily sessions and discharge was according to standardized criteria. Analyses and correlations of all variables were examined for prediction of falls and sensitivity, specificity, predictive values and likelihood ratios were calculated. Falls were classified as none vs. one or more.

RESULTS: Among the 59 patients in the follow up group, 19 patients (32 %) had experienced one ore more falls in the period since discharge, four of which resulted in new hip fractures. The TUG at discharge using a cutoff point of 24 seconds was the only parameter that significantly (P =.01) predicted falls within six months follow up, resulting in a sensitivity of 95%, a negative predictive value of 93%, and a negative likelihood ratio of 0.1.

DISCUSSION and CONCLUSION: The results suggest that the TUG is a sensitive measure for identifying hip fracture patients in risk of new falls, and it should be part of future outcome measures to decide in whom falls preventative measures should be instigated.


A. Moroni F. Pegreffi M. Romagnoli A. Hoang-Kim F. Tesei S. Giannini

INTRODUCTION: This prospective randomized study investigated short-term outcomes of cemented vs. HA-coated hip arthroplasty in elderly osteoporotic patients with femoral neck fractures.

METHODS: Forty consecutive patients with femoral neck fractures (AO/OTA fracture type B2 and B3) were randomized to receive either an AHS prosthesis (Group A, n = 22, cemented implant) or a Furlong prosthesis (Group B, n = 18, HA-coated implant). Inclusion criteria were: female age ≥75, fracture resulting from minor trauma, ability to communicate and bone mineral density (BMD) T-score at the contralateral hip lower than −2.5 SD. Subjective assessment was evaluated according to a rating system 0-(unsatisfactory) to 10(satisfactory). Average follow-up was 29 months for Group A and 27 months for Group B.

RESULTS: Average patient age was 75 ± 5 in both groups. There were no differences in ASA scores between the two groups. Surgical time was 77 ± 12 minutes for Group A, and 72 ± 13 minutes for Group B (ns). Harris hip score was 46 ± 36 in Group A and 62 ± 33 in Group B. (p < 0.05). SF-36 was 35 ± 32 in Group A and 54 ± 32 in Group B (ns). Subjective assessment was 5 ± 4 in Group A and 7 ± 3 in Group B (ns). The incidence of death during the follow-up period was 33% in Group A and 15% in Group B. (p < 0.05). One Group A patient underwent revision due to implant loosening. A Furlong prosthesis was successfully implanted in this patient.

DISCUSSION: Although femoral neck fractures in elderly osteoporotic patients are usually treated with cemented arthroplasty, our comparative study showed better results with the Furlong prosthesis, even if statistical significance was reached in only two parameters. The outcomes obtained with the Furlong prosthesis are due to the ability of the HA-coating to bind with osteoporotic bone, thus establishing a stable fixation. Fixation failed in only one cemented implant, but our case number was limited and the follow-up short. Post-op mortality at the time of follow-up was high. This was not unexpected, given the age level and health status of the study groups. This study shows that the HA-coated Furlong prosthesis is a viable option for the treatment of elderly osteoporotic femoral neck fracture patients.


R.S. Ahluwalia M. Mueller N. Kempraju J. Fonseca

We present the use of the Orthopaedic POSSUM Score and Surgical Risk Score (SRS) to identify optimal time for fracture neck of femur surgery. The objective of this study was to identify the physiological status of patients at admission and compare the results of operative physiological condition and differences in predictive and actual operative outcomes.

1238 consecutive hip fractures from Jan 2005 to July 2006 at 3 hospitals were assessed. Collection of demographic, admission and operative POSSUM, and SRS scores, fracture pathology, physiological status, and postoperative outcome were conducted.

In total, 1031 (83.3%) patients had surgery. The median age was 72.6 (range 55–95, mean 68). Majority had significant systemic multiple co-morbidity (78%), an average ASA score of 3.3. POSSUM predicted 18.7% (n= 194) of death at 30 days, where as the surgical risk score predicted 13.8% (n=142 deaths), the actual mortality was 11.7% (n=120).

The difference between admission and operative physiological POSSUM score increased with operative delay (see table 1). Physiological scores greater than 30 had a 67.8% risk of 30-day mortality. 361 patients had an increase in physiological score from admission to operation, resulting in higher analgesic requirements and reduced mobility scores (P< 0.005). These patients had a 12.6% increase in mortality when compared with patients operated earlier with a similar initial score (P< 0.005). Furthermore delayed surgery (> 48 hours) lead to reduced in return mobility, function, increased wound infections and other medical complications.

Possum and SRS over predict operative mortality, but are useful in prioritising their time of surgery. Declining operative physiological POSSUM scores indicate room for improvement in preoperative care, and for specific protocols if surgery has to be delayed to prevent further physiological deterioration, and induce optimal functional outcomes.


B.M. Sabnis J. Sales I. Brenkel

Background: Intracapsular neck of femur fracture (# ICNOF) is one of the most common fractures in the elderly. In octa and nonagenarians, with age associated and other co morbidities, achieving a pre injury status of mobility is the deemed result. The physiological age, rather than the chronological one is an important factor determining the type of joint used and results in these patients.

Aim: We present here, a study of 349 patients in the age group of 80 to 100, who underwent hemiarthroplasty as primary treatment for # ICNOF.

Patients and Methods: We studied the data from a prospective hip database of patients undergoing hemiarthroplasty for # ICNOF between Jan 2000 and Jan 2005. All patients admitted with # ICNOF in our centre are assessed by a Hip audit nurse. Pre and post operative data is collected in a specific format. Patients undergo hemi-arthroplasty usually within 24 hours of admission. The type of joint used in decided by the operating surgeon. Patients were reviewed at the 4 month mark after the surgery. They were assessed for pain, mobility and complications. Seven outcomes and eight possible confounding factors were considered and statistical comparison was done to find specific correlation between these factors.

Results: 613 patients underwent hemiarthroplasty during the said period. 349 of these were more than 80 years of age. The mortality and mobility in this group was studied and various factors determining the outcome were assessed and statistical correlation tested. The mortality was expectedly higher in elderly population. Post operative mobility was mainly related to the preoperative functional status. In addition, age, other co-morbidities, ASA grade and joint type also had bearing on the Results:

Discussion: We are a busy District General Hospital in Scotland and hemiarthroplasty for # ICNOF is one of the routinely performed surgeries with more than 100 patients undergoing this procedure in a year. We have a dedicated Hip audit nurse who is responsible for maintaining a database for all these patients.

With increasing age of the population, # ICNOF in over 80s has evolved into a commonly encountered problem. Early mobilisation and aiming for pre injury functional status is an achievable goal in most. ‘The better they walked before, the better they will walk after’ is the golden rule to predict outcome. We use uncemented Austin Moore prosthesis for all patients but prefer to use a bipolar uncemented HAP coated prosthesis (JRI Furlong prosthesis) for patients who are relatively active and independent, regardless their age. The early results in this second group of patients are predictably better, but it will require further detailed study to determine whether these hold true in long term as well.


M.B. Pedersen C. Emmeluth S. Overgaard

Introduction: We state that preserving the hip might be optimum in treatment of patients with dislocated femoral fractures presuming that the fractures unite. In order to be able to choose the right treatment for the patient with a dislocated femoral neck fracture, we have hypothesized that lack of blood flow and development of ischemia might have influence on outcome of the osteosynthesis. In this study we have established microdialysis and laser Doppler measurements in patients with a dislocated femoral neck fractures.

Methods and materials: 14 patients with dislocated fractures of the femoral neck were osteosynthezised by using 2 cannulated screws. During the operation blood flow was measured with laser Doppler in order to detect pulsatile flow, and microdialysis was performed to detect ischemia. Both measurements were made in the femoral head and with the greater trochanter as control. The parameters measured were lactate, pyruvate, glycerol and glucose concentrations. Lactate/pyruvate ratio was calculated in order to estimate ischemia defined as a value over 25. Measurements were done after the fracture was reduced, and during osteosynthesis. Data are presented as mean with standard deviation (SD) in brackets.

Results: In all but one patient laser Doppler showed pulsatile flow in the greater trochanter, whereas 8 patients had flow in the femoral head. In the greater trochanter the mean lactate/pyruvate ratio was 11 (7.55), in the femoral heads the mean ratio was 27.99 (21.24) although 4 heads did not show ischemia (p=0.0004). The values for glucose in the trochanter and the femoral head are 2.47 mM(1.92) and 1.53 mM(1.37) respectively, and for glycerol 0.16 mM(0.09) and 0.25 mM(0.22). During the observation period two patients were reoperated, one with hemiarthroplasty 3 months after the osteosynthesis due to failure of the osteosynthesis; the patient had flow measured by laser Doppler and ischemia with microdialysis. One had a resection arthroplasty due to infection.

Conclusion: To our knowledge it is the first time that laser Doppler and microdialysis has been established in patients with dislocated femoral neck fractures. Further studies will have to evaluate whether laser Doppler and microdialysis in combination with fracture related parameters can predict failure of the osteosynthesis. This might enable us to establish a treatment algorithm to be used in the daily clinic.


P. Haentjens P. Autier M. Barette D. Vanderschueren S. Boonen

Purpose: We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome, and to determine whether outcomes differ by fracture type.

Methods: The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures were survival and functional outcome, both at hospital discharge and one year later. Functional outcome was assessed using the Rapid Disability Rating Scale version-2.

Results: Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significant differences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities, and prefracture residence at the time of injury. At hospital discharge, intertrochanteric hip-fracture patients had a higher mortality (relative risk [RR] 9.8; 95% confidence interval [CI]: 1.3 to 74.6; p=0.006) and were functionally more impaired (0.4 units difference in ability to walk independently; p=0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (RR 2.5; 95% CI: 1.3 to 5.1; p=0.008), but functional outcome among surviving patients was similar in both groups. During the one-year period after hospital discharge, a significant functional recovery was observed regardless of fracture type (improvement by 3.9 units [p=0.003] and by 2.6 units [p=0.015] in patients with intertrochanteric and femoral neck fractures, respectively). In both groups, this recovery was reflected in a significant improvement in walking ability (p< 0.001 and p=0.006, respectively) and mobility (p=0.004 and p< 0.001, respectively).

Conclusions: We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcome differs according to fracture type at hospital discharge, but these differences do not persist over time. Our data provide evidence that these findings cannot be explained by differences in age or comorbidity. Differences in survival suggest that the two main types of hip fractures should be analyzed separately in clinical and epidemiological studies.


L. Roy Y. Laflamme M. Carrier

In the recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that innovative technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied.

This study is a prospective clinical randomized trial which primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for hemiarthroplasty in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. To date, 45 patients have been randomized between the two surgery groups has follows: 22 patients in the mini-incision surgery group (MIS) and 23 patients in the standard incision group (STD). Data were collected preoperatively as well as 4 days, 3 and 6 weeks, 3, 6, 12, and 24 months postoperatively. The following validated disease-specific outcome instruments where used: the Jaglal Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life where assessed by the components of the Harris hip Score and SF-36. Radiograghic outcomes where also evaluated as well as the rates of all reported complications and adverse events during the two years follow-up.

The demographic data where similar between the 2 groups for age, gender, weight, type of anaesthesia used, pre-operative haemoglobin and preoperative comorbidities. There was no significant difference for operative time, blood losses, 72h postoperative haemoglobin and the need for transfusion therapy between the 2 groups. Also, there was no difference between the groups for post-operative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using the LEM, TUG, Harris Hip score and SF-36 scores did not demonstrate any statistically significant difference between mini and standard incision.

This study demonstrates that the clinical and functional outcomes measured are similar between the two groups, thus limiting the potential benefits of MIS in hip fracture patients.


M.J. Parker R. Raghavan K. Gurusamy

1133 patients with an intracapsular fractures of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229(20.2%) and the incidence of avascular necrosis was 61(5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures [48 out of 565(8.5%) versus 181 out of 568(31.9%)] and in males than females [45 out of 271(16.6%) versus 184 out of 862(21.3%)]. The incidence of non-union progressively increased with age from one out of 17(5.9%) in those aged below 40 years to 84 out of 337(24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68(13.2%) in those aged less than 50 years to 10 out of 388(2.6%) in those aged over 80 years.

The information from this large series of patients treated by contemporary methods enables to surgeon to use the three factors of age, sex and present of fracture displacement to predict the risk of non-union or avascular necrosis occurring.


T. vinje J. fevang J. gjertsen S. lie L.B. engesaeter L.I. havelin K. matre O. furnes

Aims: To calculate one-year survival after dislocated intracapsular femoral neck fractures and to assess factors associated with increased risk of death.

Patients: 2045 patients treated for dislocated intracapsular femoral neck fractures during 2005 were registered in The Norwegian Hip Fracture Registry and were included in the present study.

Methods: Almost all hospitals in Norway reported proximal femoral fractures to the Registry using standard forms filled in by the operating surgeons. Survival was calculated using Kaplan Meier survival analyses, and the impact of factors possibly influencing the survival was estimated using Cox regression analysis. Mortality data for all patients were obtained from Statistics Norway.

Results: 2045 patients having dislocated intracapsular femoral neck fractures operated with 2 pins/screws (1071) and bipolar hemiprosthesis (974) were enrolled in the Registry during 2005. Among these, 333 patients died within the first year after the operation; 2 pins/screws (170) and bipolar hemiprosthesis (163). Factors adversely associated with survival included high age, male gender, dementia and with an increase in preoperative ASA classification. No statistically significant difference was found regarding preoperativ delay or for the two different treatment methods.

Conclusion: After one year there is no difference in risk of death between operation methods; 2 pins/screws and hemiprosthesis, for dislocated femoral neck fractures.


J. Fernández-Valencia L. Font I. Robert A. Domingo M. Ríos X. Gallart S. Prat J.M. Segur J. Riba

Purpose: To review the results of periprosthetic femoral fractures treated using cortical strut allograft and plate internal fixation.

Material & Methods: Between November 1996 and July 2006, 17 patients with periprosthetic fractures of the femur after hip arthroplasty were treated using deep-frozen cortical strut allografts as an adjunct support after internal fixation. The average age was 79 years (range 56 to 96 years) with 13 woman and 4 men. According to the Vancouver classification system, there were 6 type B1, 5 type B2, 1 type B3 and 5 type C fractures. All fractures were closed except for one type I of Gustilo. Twelve patients had internal fixation of the fracture using a Dall-Miles cable and plate system, 5 using a AO/ASIF 4.5 dynamic compression plate, and 2 had an associated revision arthroplasty of the stem. Cortical strut allograft was used from the femur in 6 cases and from the tibia in 11 cases. Mean follow-up was of 97.5 weeks.

Results: One patient presented a rupture of a screw and varus displacement of the fracture, but healed without symptomatic complaints. A superficial infection occurred in the patient with open fracture. All the patients, except for two, required allogenic blood transfusion. Mean inhospital stay was of 18.6 days and walk with weigh was allowed at a mean of 50.9 days. Two patients died few weeks after the treatment due to complications of their previous pathological disorders. Aseptic loosening of a hip arthroplasty occurred at two years follow-up requiring revision surgery. Three patients referred mild pain at the last follow-up visit.

Conclusions: Cortical strut allograft associated with internal fixation has provided satisfactory results in the present serie. We consider this procedure safe and effective, specially for type B1 and C periprosthetic femoral fractures.


T.N. Board P. Rooney P.R. Kay

Impaction grafting with morsellised allograft is becoming the treatment of choice for revision arthroplasty, especially in the younger patient. The optimum treatment of the graft prior to impaction has not been determined. Some groups wash the graft prior to impaction and others do not. Washing of graft has been shown to enhance bone ingrowth in an animal model, however the reasons for this remain unclear. The aim of this study was to identify any underlying cellular cytotoxicty of fresh frozen allograft bone before and after washing.

Paired samples of washed and unwashed morcellised FFH allograft were taken during revision hip arthroplasties. Washing was performed by 4 consecutive rinses in 300ml warmed saline, the bone being filtered between each exchange of saline. Contact cytotoxicity assays involved culture of cell lines in direct contact with bone samples. Quantitative cytotoxicity assays utilised culture media conditioned with the bone samples and subsequent assessment of cell metabolism and viability using both dimethylthiazol (MTT) and neutral red (NR) assays. Assays were performed with human osteoblastic (MG63) and fibroblastic (HSF) cell lines.

Nine pairs of samples were analysed. Contact assays demonstrated a clear zone of cellular inhibition around the unwashed bone samples. Quantitative assays were performed in triplicate for each cell type and both MTT and NR assays giving 108 paired assay results. 88.9% of pairs (92/108) showed cytotoxicity in the unwashed sample. No washed samples demonstrated cytotoxicity. When grouped by assay and cell type, analysis of means showed statistically significant differences between washed and unwashed samples in MG63-NR (p=0.0025), HSF-NR (p=0.0004) and MG63-MTT (p=0.008). The difference observed in the HSF-MTT assays did not reach statistical significance (p=0.06).

Unwashed FFH allograft can be cytotoxic to human osteoblastic and fibroblastic cell lines in vitro. This suggests that allograft should be washed prior to impaction in order to optimise the biological compatibility.


M. HASSABALLA S. Mehandale I. Learmonth

Bone stock loss is a major challenge to the revision hip surgeon. Impaction grafting is frequently the preferred option for the surgeon when faced with bone stock deficiency. This retrospective study assesses a consecutive series of patients who underwent revision hip replacement with femoral impaction grafting during the period 1994–2001. Radiographic measurement for stem subsidence was carried out by 2 independent observers on pre-operative and post-operative radiographs at 6 months, 1 year, 18 months and 2 years following surgery. Graft incorporation and trabecular remodelling were also subjectively assessed. Irradiated bone allograft was used in all cases.

Sixty-nine hips were reviewed. Radiographic analysis revealed graft incorporation in 38% of cases. However, there was no evidence of trabecular remodelling. Moderate subsidence (5–10 mm) occurred in 10 cases (14.5%), and massive subsidence (> 10 mm) occurred in 5 cases (7.2%). The survivorship with re-revision or need for further surgery as the end point was 92.8% at an average of 28 months.

The results obtained in this study are less favourable than other reported studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling reported in other series raises concerns that irradiated bone graft may be a significant factor in the post-operative progress.


D. sen H.J. gehling

Fixation of extracapsular proximal femoral fractures with intra/extramedullary device is common operation in any trauma theatre. We audited our results of fixation of 307 similar fractures over the period of Feb’03 to Jan’06. Final analysis was on 252 cases (191 female and 61 male) with mean age of 86.7 years. The fractures were classified by AO classification (A1=116, A2=84, A3=52) and the implants used were DHS (204 cases) and Gamma nail (52 cases). Fixation failure was noted in 38 cases (15.07% failure rate). Failure incidence was higher in female patients and unstable fractures (A3). There was no difference in failure rate of DHS or Gamma nail fixation. The reasons identified for failures were inappropriate implant selection, inadequate reduction (p< 0.007), poor implant placement (screw head in anterior/superior quadrant p< 0.0029, TAD> 25mm p< 0.0037, oblique placement in relation to neck axis in lateral view). Multivariate logistic regression was used to identify the effect of each individual contributing factor. More than one factor was identified in all cases of failure. Out of 38 failures 3 patients died within 6 weeks after primary surgery, conservative treatment was done in 7 cases due to co-morbid conditions, 13 cases were treated by revised fixation, and 15 cases arthroplasty was carried out. The outcome after the second surgery was no different in revision fixation or arthroplasty. We conclude that failure of fixation of these fractures are serious event with disastrous consequences, so every effort should be made to produce a stable construct with any device during primary fixation.


R. Blomfeldt H. Törnkvist K. Eriksson A. Söderqvist S. Ponzer J. Tidermark

Introduction: The treatment for the active and lucid elderly patient with a displaced femoral neck fracture is still controversial. Recent randomized controlled trials have shown that a primary total hip replacement (THR) is superior to internal fixation (IF) regarding the need for secondary surgery, hip function, and the health-related quality of life (HRQoL). Despite the good results with THR in this patient group, a vast majority of orthopaedic surgeons prefer hemiarthroplasty (HA) before THR. The aim of this study was to analyze the outcome regarding hip function and HRQoL after a displaced femoral neck fracture in a active and lucid elderly patient randomized to either a bipolar HA or THR.

Patients and Methods: 120 patients (101 females), mean age 81 (range 70 – 90), with an acute displaced femoral neck fracture (Garden III and IV) were randomized to bipolar HA or THR. Perioperative data, hip complications, general complications, hip function (Harris Hip Score, HHS) and HRQoL (EQ-5D) were assessed. The patients were summoned at 4 and 12 months.

Results: The duration of surgery was longer in the THR group, 102 versus 78 min, and the intraoperative blood loss was higher, 460 ml versus 320 ml. There were no differences between the groups regarding hip complications and general complications including mortality. There were no dislocations. Hip function (HHS score) was significantly better in the THR group at both follow-ups, p< 0.05 and < 0.001, respectively, with a trend towards an increasing difference with time. The HRQoL (EQ-5D index score) were in favor of the THR group although not statistically significant.

Discussion: The results of this study indicate that a THR gives better hip function compared to a bipolar HA already after one year without increasing the complication rate. There are good reasons to assume that this difference will increase with time. We recommend THR as the primary treatment for the active and lucid elderly patient with a displaced femoral neck fracture.


T.N. Board P.B. Young E.B. Austin P. Bobak E.J. Gray P.R. Kay

Introduction: Freezing and storage of fresh frozen femoral heads destined for use in revision hip arthroplasty is thought to result in graft cell death. Washing of the graft following the morsellisation process also removes a large proportion of the marrow content of the allograft. However, the immunological load of the impaction allografting process remains unknown. The aim of this study was to investigate the immune response by observing any changes in peripheral blood lymphocyte subsets in response to allografted bone used in revision hip replacement

Methods: 87 patients were entered into this prospective study and grouped according to whether impaction allograft was used or not. Venous blood samples were collected pre-operatively and at set time intervals up to one year post-operatively. Using flow cytometry, analysis of venous blood allowed counts of the following cells: Helper T-lymphocytes, cytotoxic T-lymphocytes, memory T-lymphocytes, naïve T-lymphocytes, Natural Killer cells and B-lymphocytes.

Results: All patients had a successful outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive allograft. Pre-operatively, a significant difference (p=0.03) was found between the groups of patients with respect to Natural Killer cells but other subsets showed no significant difference. Post-operatively the significant difference between Natural Killer cells resolved. T-helper lymphocytes, cytotoxic lymphocytes, memory T-lymphocytes and naïve T-lymphocytes in both groups showed decreases in values immediately post surgery, recovering to normal values within 6 weeks post-surgery. The allograft group showed significant increases from baseline in cytotoxic T-lymphocytes at 6 months (p< 0.01) and memory T-lymphocytes one year postoperatively (p=0.04). B-lymphocyte numbers did not alter significantly from baseline.

Conclusion: Cytotoxic T-lymphocytes recognise HLA-class I molecules which are present on all nucleated cells and have been implicated in having a role in osteoclast regulation. Memory T-lymphocytes are produced after a naïve T-lymphocyte is exposed to an antigen. The observed increases of these subsets were not observed in the non-grafting group suggesting the allografted bone had elicited an immunological response. At 12 months all grafts appeared radiologically stable and the immunological response may have been beneficial to the outcome.


T.N. Board P.B. Young E.J. Gray P. Bobak E.B. Austin P.R. Kay

Introduction: The long term success of impaction grafting depends on the remodelling process during incorporation. This project was designed to characterise any differences in the biochemical markers of bone turnover following revision hip arthroplasty performed with or without impaction grafting.

Methods: 87 patients undergoing revision hip arthroplasty were entered into this prospective study and grouped according to whether impaction allograft was used or not. Biochemical markers of bone turnover were assessed pre-operatively and post-operatively on day 2, day 9, week 6, 6 months and 1 year. Osteocalcin, pro-collagen type-I N-terminal propeptide and bone specific alkaline phosphatase were measured as bone formation markers. C-telopeptide, pyridinoline and deoxypyridinoline were measured as bone resorption markers.

Results: All patients had a successful radiological and clinical outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive allograft. Markers of bone formation tended to rise by day 9 but the rise in osteocalcin was delayed in the graft group and was significantly lower at 6 months in comparison to the non-graft group (p=0.002). Alkaline phosphatase levels remained significantly elevated at one year in the graft group (p=0.027) whilst levels in the non-graft group had normalised. Markers of bone resorption also rise in both groups but with no significant differences between the groups.

Discussion: Following impaction grafting, new bone formation may be delayed in comparison to revisions performed without graft. The pattern of markers of bone resorption did not differ significantly between the groups suggesting that there is no large scale resorption of the impacted allograft in these cases.

These results provide a biochemical insight into the bone formation and bone resorption processes during allograft incorporation.


B.J. Bolland K. Partridge S. Tilley A.M. New D.G. Dunlop R. Oreffo

Background: The use of fresh morsellised allograft in impaction bone grafting for revision hip surgery remains the gold standard. Bone marrow contains osteogenic progenitor cells that arise from multipotent mesenchymal stem cells and we propose that in combination with allograft will produce a living composite with biological and mechanical potential. This study aimed to determine if human bone marrow stromal cells (HBMSC) seeded onto highly washed morsellised allograft could survive the impaction process, differentiate and proliferate along the osteogenic lineage and confer biomechanical advantage in comparison to impacted allograft alone

Methods: HBMSC were isolated and culture expanded in vitro under osteogenic conditions. Cells were seeded onto prepared morsellised allograft and impacted with a force equivalent to a standard femoral impaction (474J/m2). Samples were incubated for either two or four week periods under osteogenic conditions and analysed for cell viability, histology, immunohistochemistry, and biochemical analysis of cell number and osteogenic enzyme activity. Mechanical shear testing, using a Cam shear tester was performed, under three physiological compressive stresses (50N, 150N, 250N) from which the shear strength, internal friction angle and particle interlocking values were derived.

Results: Cell viability of HBMSC post impaction, was confirmed with cell tracker green staining, a marker of viable cells, and observed throughout all samples. There was a significant increase in DNA content and specific alkaline phosphatase activity compared to impacted seeded allograft samples. Immunohistochemical staining for type I collagen confirmed cell differentiation along the osteogenic lineage. Mechanical shear testing demonstrated a statistical significant increase in shear strength and interparticulate cohesion in the allograft/hBMSC group over allograft alone at 2 and 4 week intervals (p< 0.001).

Conclusion: HBMSC seeded onto allograft resulted in the formation of a living composite capable of withstanding the forces equivalent to a standard femoral impaction. HBMSC under osteogenic conditions were observed to differentiate and proliferate along the osteogenic lineage. In addition, an allograft/HBMSC living composite confers a biomechanical advantage over allograft alone These changes resulting in enhancement of biological and mechanical properties of bone graft within impaction bone grafting have implications for translation and future change in orthopaedic practice in an increasing ageing population.


G. Skaliczki Á. Zahár P. Somogyi M. Makra D.I. Kovács J. Lakatos

Aim of the study: Impaction bone grafting is examined and published by numerous authors in the literature, however possible correlation between bone remodeling at the site of revision hip arthroplasty and bone turnover markers is not well known yet.

Materials and method: 22 patients undergoing revision hip arthroplasty with impaction bone grafting were enrolled in a prospective study. Bone turnover markers and bone mineral density (DXA) were measured preoperatively. WOMAC and Harris Hip Score (HHS) were evaluated pre- and postoperatively. During a one-year-period the same tests were performed after 6 weeks, 3 months, 6 months, 12 months respectively. The data were analyzed using logistic regression.

Results: Significant bone remodeling was observed at the site of revision hip arthroplasty at the 6 month follow up. WOMAC and HHS improved significantly after surgery. One deep wound infection occurred due to MRSE, removal of the prosthesis was performed.

Conclusion: Cancellous bone grafting secures primary stability for the hip implants, and after a period of 12 months proper bone remodeling is achieved.


T.N. Board P. Rooney M. Eagle P.R. Kay

Introduction: Revision arthroplasty using the impaction grafting technique is an increasingly popular technique. The lost bone stock is replaced rather than substituted with ever increasing amounts of metal. There have been many advances in the understanding of this technique in recent years. It has recently been shown that washing of the graft improves the biomechanical strength, bony ingrowth and biocompatibility of morsellised allograft bone. The aim of this study was to identify the most efficacious method of washing morsellised allograft in the operating room.

Methods: Fresh frozen femoral heads identified for research purposes were randomly divided into four groups. Group A was washed using a serial dilution technique at 37°C, group B serial dilution at 60 °C, group C pulsed lavage wash at 37°C and group D pulsed lavage wash at 60 °C. Three-gram samples of each femoral head were taken prior to washing. The heads were then washed according to the grouping. The unwashed and washed morsellised bone was then assessed for the presence of protein, haemoglobin, DNA and lipid using spectrophotometric analysis techniques. The removal of these marrow components from the femoral heads in each group was assessed as a proportion of the original content.

Results: All washing techniques removed a large proportion of the marrow load of the femoral heads. The most efficacious technique was washing by serial dilution (removal rate 67.5–87.4%). Washing by pulsed lavage removed less marrow (28.4–80.9%). Protein showed the highest removal rate (80.9–86.4%) and haemoglobin the lowest (28.4–67.5%). Removal of lipid was most affected by temperature with a larger proportion removed at 60°C as compared to 37°C.

Conclusion: We conclude that the most efficient method of washing morsellised allograft bone for impaction grafting is by serial dilution with fluid at 60°C. This information should improve the results of impaction grafting, as it is known that cleaner bone results in improved biomechanical stability, enhanced biological compatibility and accelerated bony ingrowth.


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J.K. Sunny E. Ghanem R. Malgorzata T. Freeman J. Parvizi

Introduction: Diabetes mellitus type 2 (DM II) affects 18.2 million Americans and can cause several chronic and morbid complications. Furthermore, 90% of Americans have radiographic evidence of osteoarthritis by age 40. Diabetes may be an important risk factor for symptomatic osteoarthritis later in life. The aim of our study is to determine if diabetic patients are predisposed to osteoarthritis.

Methods: We conducted a review of the all total knee arthroplasty (TKA) cases performed at our institute during the past two years for end stage osteoarthritis. We excluded TKAs performed for post-traumatic arthritis and patients with inflammatory diseases. Comorbidities and demographical information including age, gender, BMI, and family history were collected from our database. A cross sectional study was performed to analyze the prevalence of DM II in our population. This prevalence was compared to that of diabetics in the general population available from various sources including the National Center for Health Statistics.

Results: Our cohort included a total of 3421 patients (1972 females, 1449 males) who had undergone TKA for end stage osteoarthritis. The average age and BMI were 66 years (range: 39–92) and 32 (range: 21–65) respectively. The prevalence of diabetes mellitus type 2 in our cohort was 12%, while the prevalence of DM II in the general US population currently ranges from 6%–7%.

Discussion: Chronic diabetes causes multiorgan failure via microvascular and macrovascular damage and may possibly lead to degeneration of articular cartilage and eventual arthritis. Based on this study, diabetes appears to be a strong predisposing factor for arthritis. Our laboratory has launched an extensive series of experiments delinating the potential cellular mechanism for such association.


M. Buttaro A.J. Guala F. Comba F. Piccaluga

Containment of bone defects is one of the main requisites for using the bone impaction grafting technique. When the proximal femur is absent, circumferential meshes in combination with impacted bone allografts and long stems could be an alternative method. However, the initial stability of this femoral stems has not been evaluated and we were not able to find any series in the literature that includes a group of patients treated with this method.

This study has two purposes: one is to analyze the initial resistance in vitro to axial and rotational forces of a fresh frozen bovine model with a complete loss of the proximal femur reconstructed with a circumferential metal mesh containing impacted bone allografts and a long polished cemented stem. The second is to present the short-term clinical and radiographic evaluation in a group of patients with massive bone loss of the proximal femur that were reconstructed with this method.

Four femurs with an 8 cm proximal bone defect were reconstructed with a circumferential metal mesh, impacted bone grafts and a cemented long stem (group 1). Results were compared with 4 cases presenting an intact proximal femur in which the same stem was implanted (group 2).

Thirteen patients with complete massive proximal femoral bone defects (average 12 cm long) were reconstructed with a circumferential metal mesh, impacted bone allografts and a long cemented stem (average 217 cm long).

Failure mode was characterized by subsidence under axial load in group one at 617 kg and by periprosthetic fracture in control group at 1335 kg. Under rotational load, group 1 femurs failed at the cement interface at an average of 79 kg and the intact femurs presented a fracture at an average of 260 kg.

At 25 months follow-up, 6 patients had to be reoperated. We observed 2 fractures of the metal mesh at 31 and 48 months in cases reconstructed with a Charnley stem that did not by pass the mesh. Three patients presented one dislocation that needed open reduction in 2 cases. Two acute deep infections were treated with debridement, antibiotics and component retention.

This model presented a 50% resistance to axial load and 30% resistance to rotational load compared to an intact femur with the same implant. However, this resistance is by far higher than the physiologic load occurring in a normal femur during gait.

Although the incidence of complications in this patients was high, this was related to the complexity of the cases. Failures of the system were not observed except in the 2 cases presenting technical defects.

This experimental initial stability and early clinical as well as radiographic results encourage the use of circumferential meshes to contain impacted bone allografts combined with long cemented stems in complex revision hip surgery.


M. Stolz R. Raiteri R. Gottardi D. Daniels N. Friederich R. Imer U. Staufer R. Fässler U. Aebi

We have explored indentation-type scanning force microscopy (IT SFM) that allows for a direct, quantitative inspection of cartilage morphology and biomechanical properties from the millimeter to the nanometer scale ex vivo, and ultimately, in situ (Stolz et al., 2004). Here we present three examples of using IT SFM where morphological and biomechanical changes could only be spotted at the sub-micrometer scale:

We employed IT SFM for quality control of engineered cartilage cultured under various conditions. These measurements harbor the prospect to optimize and yield engineered cartilage that exhibits long-term mechanical stability, functionality and biocompatibility for joint arthroplasty.

For a more rational understanding of cartilage biology and pathology, we have recently investigated the articular cartilage of mice lacking the β1-integrin in chondrocytes. The β1-integrin gene knock-out mice differed only in stiffness when measured at the nanometer scale, i.e., exhibiting a softer extracellular matrix compared to their wild-type controls.

We inspected the changes of aging articular cartilage by employing a mouse model.

Accordingly, the stiffness of the aging cartilage increased concomitant with a decrease of its glycosaminoclycan (GAG) moiety. Frequently, aging articular cartilage takes a pathological turn called osteoarthritis (OA), which usually ends with a complete disappearance of the articular cartilage layer. Towards an early detection of OA in the human body, we inspected the morphological and biomechanical status of articular cartilage biopsies representing different grades of OA according to the ‘Outerbridge scale’. Most significantly, the early changes (grades 0 to 2) were only detectable at the nanometer scale, but not at the micrometer or millimeter scale. Based on such ex vivo indentation testing, we started to move from the bench to the patient, aiming to directly inspect the quality of human articular knee cartilage by an arthroscopic SFM (Imer et al., 2006). The arthroscopic SFM might just be the beginning of a new generation of nano tools designed for endoscopic or catheter-based interventions of other parts of the body. For such prophylactic interventions to eventually being tolerated by the patient, not only have these to be ambulant and minimally invasive, but they will require a change of paradigm vis-à-vis the patient, namely to undergo an invasive procedure without feeling sick – indeed a big challenge for nanomedicine and managed health care!


CHEMICAL SYNOVIORTHESIS Pages 171 - 171
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F. Fernandez Palazzi

In order to avoid recurrence of haemarthrosis in haemophilia, we must act on the syniovium membrane either resecting it (synovectomy) or fibrosing it (synoviorthesis). The intrarticular injection of Rifampicine (r) was introduce by us. Technique consists 250 mgrs. of Rifampicine injected intrarticularly in elbows and ankles and 500 mgrs. in knees with 3 to 10 cc of Lidocaine, depending on the joint size, once a week during five to seven weeks. Patients were only covered with antihaemophilic factor the day of the injection 30% above coagulation level. The evaluation was made by means of a double scale of grading. Subjective, given by the patient and objective by the examiner. Thus, objectively the grading was : EXCELLENT: “Dry joint”, recuperation of function. No haemarthrosis. No synovitis. GOOD: Clinical improvement. Synovitis. Diminution of haemarthrosis. Recuperation of function. FAIR: Synovitis. Diminution of haemarthrosis. No recuperation of function. BAD Synovitis. Recurrence of haemarthrosis. And subjectively the patient graded the results from his point of view from 1 BAD to 10 Excellent. 1,2,3 bad; 4,5,6 fair; 7 and 8 good and 9 and 10 excellent. We report on 38 patients with 39 joints with more that 3 years follow up, mean 1.8 years. on 22 knees, 9 elbows and 8 ankles with subjective excellent results in 21 joints (11 knees, 6 elbows and 4 ankles) good in 15 joints (8 knees, 3 elbows and 4 ankles), fair in 2 knees and bad in 1 knee. Objective results obtained were excellent in 20 joints (11 knees, 6 elbows and 3 ankles); good in 17 (9 knees, 3 elbows and 5 ankles); fair in 1 knee and bad in 1 knee. Since september 2000 we have been usisng OXITET-RACICLINE CLORHYDRATE named EMICINA(r) from PFIZER, comes in bottles with 20 and 100 cc of solution with a dose of 50 mg’s of active material per cc. of product. The dosage developed by us is in knees 4cc. (200mg) plus 6 cc anesthetic and for ankles 1 cc Emicina (50mg plus 1 cc anesthetic) once a week fot 3 weeks. Our experience consists in 43 joints, 21 knees 14 elbows and 8 ankles. All joints Stage I or II of our classification. Evaluation was made according to objective and subjective scale: Pain from 0 (no pain) to 10 (pain requiring medication), Range of Movement: No movement (0) to complete range of movement 10, use of limb from 0 (impossibility to weight bear) to 10 normal use in daily activities. Objective evaluation was made by measuring ROM and diameter of joint. All cases had very satisfactory results with diminution of swelling, absence of haemarthrosis and improvement of ROM and activity of daily life. Subjewctively pain diminished a mean 0.5 (Liker), movility improved 9.0 mean, and the use improved a mean of 9.3. Objectively the mean joint diameter diminished from 31.5 cmts to 30.2 cmts and ROM improved from 102.4 and 158.8 degrees pre to 112.2 and 166.7 post.


D. MAINARD P. POTTIE N. PRESLE B. TERLAIN L. GALOIS D. LOEUILLE P. NETTER

Objectives. To evaluate the contribution of leptin, an adipose-derived hormone, to the pathophysiology of osteoarthritis (OA), by determining leptin in both synovial fluid and cartilage specimens from human joints, and by investigating the effect on cartilage of intra-articular injection of leptin in rat.

Methods. Leptin levels were measured by enzyme-linked immunosorbent assay (ELISA) in synovial fluids sampled from OA patients undergoing either knee replacement surgery or knee arthroscopy. Besides, histological sections of articular cartilage and osteophytes obtained during surgery for total knee replacement, were graded using the Mankin score, and were immunostained using antibodies to leptin, TGF_ and IGF-1. For experimental studies, various doses of leptin (10, 30, 100 and 300μg) were injected into the rat knee joint. Tibial plateaus were collected and further processed for proteoglycan synthesis by radiolabeled sulfate incorporation, and for expression of leptin, its receptor (Ob-Rb), and growth factors by RT-PCR and immunohistochemistry.

Results. Leptin was found in synovial fluids from human OA-affected joints, and concentrations were correlated to Body Mass Index. A marked expression of the protein was seen in OA cartilage and in osteophytes, while few chondrocytes produced leptin in normal cartilage. Furthermore, the pattern and level of leptin expression were related to the grade of cartilage destruction, and paralleled those of growth factors (IGF-1 and TGFb-1). Animal studies showed that leptin strongly stimulated anabolic functions of chondrocytes, and induced the synthesis of IGF-1 and TGFb-1 in cartilage at both mRNA and protein levels.

Conclusion. These findings provide a new peripheral function to leptin as a key regulator of chondrocytes metabolism, and indicate that leptin may play an important role in the pathophysiology of OA.


D.P. König Ü. Güngör M. Aydinli J. Koebke

Introduction: The Donjoy OA Orthesis has been developed to treat unicompartimental osteoarthrosis of the knee joint. The idea is to reduce the load in the affected joint compartment. Sofar only clinical evaluations and gait analysis have been published. The aim of this study is to use intraarticular pressure sensors in an anatomical model to work out the existing intraarticular pressures.

Method: 5 fresh non fixated anatomical knee models were used. The models were prepared leaving the 2/3 of the femur as well as the tibia and fibula. We used a right and left-sided version of the Donjoy OA Orthesis. A defined pressure was applied via the pressure application screw.

The dorsal capsule of the knee joint was opened and the meniscus were mobilised in a way that the pressure foils (Fuji typ super low) could be placed between the undersurface of the meniscus and the tibia plateau in each joint compartment. The measurements were recorded in four different joint positions (0°, 30°, 60° flexion and 0° with removed meniscus).

Each anatomical model was well fixed in a universal testing machine” (Instron, System ID: 5565 H1703). The used axial pressure in all set ups used was 1500N.

We used 4 four different test series:

no pressure, no orthesis

no pressure, with orthesis

with pressure, no orthesis

with pressure, with orthesis

After removing the pressure foils the actual pressure could be estimated by the diameter of the coloured foil. Using the programm Mortphomet it was possible to calculate these pressure areas and give procentual figures.

Results: The Antivarus Orthesis could reduce the intraarticular joint pressure between 55–70%

Without pressure:

Knee → 64,37 %

Knee → 55,30 %

Knee → 54,43 %

Knee → 58,75 %

Knee → 44,80 %

Mean value 55%.

With pressure:

Knee → 74,59 %

Knee → 74,00 %

Knee → 67,91 %

Knee → 86,34 %

Knee → 49,69 %

mean value 70%.

The Antivalgus Orthesis could reduce the intraarticular joint pressure between 46–74%

Without pressure:

Knee → 79,78 %

Knee → 76,22 %

Knee → 75,20 %

Knee → 62,55 %

Knee → 76,49 %

Mean value 74%.

With pressure:

Knee → 42,68 %

Knee → 46,24 %

Knee → 64,61 %

Knee → 40,08 %

Knee → 37,20 %

Mean value 46%.

Conclusion: This anatomical investigation has proved for the first time via intraarticular pressure measurements that it is possible to considerable reduce the intraarticular pressure using the Donjoy antivarus and antivalgus Orthesis.


S.W. Young C. Walker R. Pitto

Introduction: Management of periprosthetic fractures following total hip arthroplasty (THA) represents a difficult clinical problem, requiring expertise in both trauma and revision surgery. Estimates of the prevalence of postoperative fracture range from 0.1% to 2.1%, and with rising numbers of patients in the population living with hip prostheses in situ there is evidence that their frequency is increasing. There remains a paucity of data on the functional outcome of these injuries, and the objective of this study was to analyse outcomes for revision THA following periprosthetic fracture, and compare these to elective revision surgery.

Methods: 233 patients (234 hips) undergoing revision THA for femoral fracture were identified from the New Zealand National Registry, and clinical outcomes were measured using Oxford Hip Scores (OHS) completed six months post operatively. A control group of 234 patients undergoing elective revision THA was selected and matched for age, sex, and time since index operation.

Results: Comparative analysis of the registry patients showed clinical outcomes were significantly worse following revision THA for fractured femur than in controls (mean OHS 28.6 vs 23.6, p=0.006), though this difference was not apparent in patients under the age of 65 years (mean OHS 26.1 vs 23.8, p =0.6). A higher mortality rate was found among fracture patients (17.1% versus 10.7 %, p=0.05), and a statistically significant higher number of periprosthetic fracture patients died within 6 months of their surgery in comparison to controls (7.3% versus 0.9%, p=0.003). A higher rate of re-revision was observed in the fracture group (7.7% versus 2.6%, p=0.02).

Conclusions: To our knowledge this study represents the largest comparative series of periprosthetic fractures in THA with functional outcome data yet reported. Management of patients with periprosthetic fractures requires recognition of the challenging nature of these injuries, their associated poor prognosis, and high complication rate.


O. Gottschalk M. Schmitt-Sody P. Metz B. Schulze H. Bohnenkamp U. Michaelis E. Guenzi M. Funk

Background: The healthy endothelium consists of quiescent endothelial cells that, under appropriate stimulation, can undergo profound changes leading to an activated phenotype. Activated endothelial cells of the synovial vasculature play a major role in the inflammatory process occurring in rheumatoid arthritis (RA) and enhanced angiogenesis contributes to the development and maintenance of RA. Thus, the endothelium can be used as an gateway for drug delivery and therapy. Cationic liposomes have been shown to target angiogenic endothelial cells in chronic inflammation in mice, also shown in tumors. They may also serve as potent vehicles for drug delivery to the synovial vasculature of rheumatoid joints.

Methods: To test whether cationic liposomes can serve as vehicles for drug delivery in RA we investigated the targeting of fluorescently labelled cationic liposomes (LipoRed) to the activated synovial vasculature of knees from arthritic mice. In a second step we used cationic liposomes carrying the compound MDG-12 (Endo-MDG-12) to study the effects of a targeted delivery of this drug to the inflamed joints in Antigen induced Arthritis (AIA). Targeting of LipoRed to the synovial vasculature was analysed by intravital microscopy (IVM) in mice with AIA. Synovial tissue was investigated at day 8 after AIA induction. Time resolved binding of liposomes was quantified at functional vessels of the microvasculature. Mice with AIA were intravenously treated with EndoMDG-12 in a therapeutic setting. Knee joints were subjected to clinical scoring and histopathology analysis.

Results: In a time dependent manner, intravenously applied LipoRed enriched more then three fold in the synovial vasculature of AIA mice when compared with healthy mice. In AIA animals maximum binding measured as relative fluorescence (Fmax=142 RFU) was already achieved 5 min after LiopoRed application (tmax) and dropped to the half maximum after 100 min (tmax/2)compared with healthy mice with a Fmax=48 RFU, tmax=15 min and tmax/2=60 min. Treatment of AiA animals with EndoMDG-12 showed a clear attenuation of the course of the disease. Analysis of the clinical score and thickness of knee joints showed a significant decrease of both parameters compared with the control group.

Conclusion: Based on our in vivo data, cationic liposomes seem to be very well suited to deliver compounds to rheumatoid joints for diagnosis and/or therapy. Furthermore, our results from animal experiments suggest that cationic liposomes like EndoMDG-12 could be a promising treatment option for RA.


B. Elmengaard J. Baas J.E. Bechtold T. Jakobsen K. Søballe

Introduction: Revision hip implants have poorer clinical outcome than primary implants. The fixation of the implants is often compromised by the formation of an endosteal sclerotic bone rim during the process of aseptic loosening. The cracking procedure is a bone sparing, low energy surgical technique which produces a controlled local perforation of the sclerotic bone rim. In previous studies, we showed that fixation of revision implants significantly improved by the cracking technique for both titanium (Ti) and hydroxyapatite (HA) coated implants (1). In this study we compared the cracking technique with the common technique of reaming, which completely removes the sclerotic bone rim.

Methods: A paired animal study (n=10), in which revision cavities was created by 20 micromotion implant systems inserted in both knees. Micromotion was 0.5mm per gait cycle. After 8 weeks revision surgery was performed.

Crack revision: The splined crack tool was introduced over the implant piston with firm axial hammer blows. This producing controlled cracking and local perforation of the sclerotic endosteal rim. The tool is a 6.0 mm cylinder fitted with axially spaced 1.1 mm pointed splines (8.2 mm outer diameter).

Reaming revision: A flat bottomed reamer was inserted over the implant piston using one rotation per second. The outer diameter was 8.2 mm in order to remove the sclerotic bone rim. Stable revision Ti implants was inserted. Observation period was 4 weeks. Mechanical push-out tests were performed. Students’ paired t-test was used. Data presented as mean and SEM.

Results: Shear strength was markedly higher with the cracking procedure 1.33± 0.3MPa vs. 0.34 ± 0.2 MPa (p< 0.05). Similar results was seen for Stiffness 6.7± 2.0 vs. 1.6 ± 0.9 (p< 0.05) in favor of the cracking procedure. A non-significant increase was seen in energy absorption 170± 47 vs. 50± 29 (p=0.07).

Discussion: The cracking procedure improves the mechanical fixation of Ti revision implants compared to a reaming procedure. Shear strength and stiffness was consistently higher for all implant pairs. We have previously shown that the sclerotic bone rim is a barrier for bone ingrowth and that implants inserted with an intact sclerotic bone rim will have a poor biomechanical fixation. Additionally, revision implants inserted with the cracking technique obtained a mechanical fixation comparable to primary implants. Reaming procedures are often used in hip revision surgery. However, as loss of bone stock is a common feature of revision cavities, the reaming procedure may not always be an optimal preparation method of the bone. Excessive removal of bone by reaming may compromise the long term implant stability or increase the risk of peri-implant fractures. The cracking technique may be an alternative or supplemental procedure to reaming.


R.G. Lusser M. Luem P. Ochsner

Introduction: The Wagner SL Stem is a well established implant to bridge proximal femoral defects in hip revision surgery. The tapered shape offers the possibility of press-fit anchorage distal to the bone defect. There are missing long term results with absolute follow-up over ten years. The goal of the study was to observe the subsidence and the restoration of the proximal bony stock within ten years.

Patients and Methods: From 1988 until 2005 198 Wagner Stems were implanted in our hospital. 50% of the indications were due to aseptic loosening, 25 % due to septic loosening and 10% due to periprosthetic fracture and 15% other indications. Clinical function was measured with an adapted Harris Hip Score; subsidence was measured in the way that was previously described by Callaghan. The bony restoration was controlled with Böhm’s technique. The length and the thickness of the area of integration were measured in mm on the ap radiographs of the femur.

Results: The over all survival of the 198 Wagner stems after 17 years was 87%, for aseptic loosening. There were 57 implanted stems with ≥10 years follow-up. 31 of the patients died before the ten year control, four stems had to be exchanged because of aseptic loosening, three patients referred the clinical control so that a total number of 19 stems could be followed for at least 10 years. In two of those 19 stems there was significant subsidence (12 and 33mm), the subsidence occurred within the first year after implantation. The area of integration showed no change of length or thickness. The bony restoration was good or excellent in 70%. The adapted Harris Hip Score declined only little from 80 postoperatively to 75 after ten years.

Conclusion: No significant subsidence after Osteointegration occurred. The principle of the tapered stem is as good that the Wagner SL Stem can be widely indicated.


F. Thorey M. Lerch H. Kiel G. von Lewinski H. Windhagen

Introduction: Revision in total hip arthroplasty (THA) continues to be a technical challenge because of difficulties in fixation of the femoral component in mostly deficient bone in the proximal femur. In the past, the use of primary stems in revision surgery has also been described by many authors. Very often, the cortical bone is not sufficient enough for torsional or axial load bearing. In this retrospective study we present our clinical results of femoral component revision surgery using the uncemented primary BiCONTACT stem (Aesculap).

Methods: In this study, seventy-nine patients were examined who underwent a revision of the femoral component in total hip arthroplasty (THA) with the uncemented primary BiCONTACT stem between December 1991 and April 2004 (mean follow-up 6.8+/−3.9 years). Only patient with a defect classification of Paprosky I–II were analysed. The average patient age was 67.1+/−10.1 years (range from 34–87 years). Forty-six female and thirty-three male patients (168+/−10 cm mean height, 75+/−12 kg mean weight, mean Body Mass Index: 26.4+/−2.5) were included in the study. All patients were clinically evaluated both preoperatively and postoperatively using the Harris Hip Score (HHS), a pain score (from 0 [no pain], to 10 [max. pain]) and a motion score (from 0 to [no flexion], to 10 [max. flexion]). Furthermore, the radiographs (anteroposterior and axial) before, after surgery and at follow-up were analysed concerning femoral defects, proximal bone loss, and to determine the quality of bony fixation. The defects were classified using the Paprosky classification. For statistical analysis, the paired Student t-test was used for preoperative and postoperative data.

Results: The postoperative Harris Hip Score (78.9+/−12.5, p < 0.001), Range of Motion Score (p < 0.05) and Pain Score (p =0.005) improved significantly. During follow-up there were only four re-revisions within two years after revision surgery: two re-infections in the first year, two aseptic loosening in the second year. There were only two cases of mild stress shielding. The survival curve (Kaplan-Meyer) showed a 10-years survival rate of 96.2 %. In two cases we found intraoperative periprosthetic fractures and in fourteen cases small fissures during removal or implantation of the stem.

Discussion: The primary uncemented BiCONTACT stem appears to be a good alternative to other revision systems in well-selected femoral revision cases with minor defects. The results of this study correspond to those published before, using a primary cementless stem in cases of revision. Therefore, in cases of minor proximal and metaphyseal bone defects (Paprosky I–II) the use of a primary stem in femoral revision should be considered. However, an exact preoperative planning, intraoperative assessment of bone stock, and experienced surgeon is necessary.


S. Tarasevicius U. Kesteris O. Robertsson H. Wingstrand

Introduction. Since the early days of total hip arthroplasty (THA) the choice of the proper diameter of the femoral head has been debated with respect to its effect on wear. The most widely accepted theory explaining aseptic loosening of THA is that of polyethylene particles induced osteolysis. In a previous study concerning 1,660 ScanHip THA’s that were followed for up to 12 years the cumulative revision rate was not found to be dependent on if a 22 mm or a 32 mm head size had been used1. We have reexamined these patients to see whether a longer follow-up time (9–21 years) would disclose an effect of head size on the revision rate.

Patients and Methods. We analyzed the CRR for 1,720 Scan Hip® Classic I THA implanted in 1,550 patients, with 22 and 32mm heads, performed at Lund University Hospital during 1983 to 1995. Patients with the 3 most common diagnoses were included in the analysis, i.e. osteoarthritis, rheumatoid arthritis and femoral neck fracture. The end-point was defined as revision of any component for aseptic loosening before the end of 2004.

Results. Using the life table method analyzed cumulative revision rate for osteoarthritis, femoral neck fracture and rheumatoid arthritis patients and found that the 32 mm head had higher cumulative revision rate (p=0.04 (Wilcoxon)). Further analysis with Cox regression adjusting for age and sex showed that the 32 mm head had 2.8 times greater risk of revision (CI 1.7–4.6), p< 0.001. For each year increase in age the risk of revision was reduced 0.96 times (CI 0.95 – 0.97), p< 0.001, males had 1.5 times (CI 1.1 – 2.1), p=0.01 greater risk of revision than females.

Discussion. The reason that we did not find any significant difference in cumulative revision rates when followed up to 12 years, depending on head size in previous study (Kesteris et al. 1998) may be the time it takes for wear particles to induce the chain of events, eventually ending up in loosening. However extended follow-up up to 21 years after THA revealed significant differences in cumulative revision rates depending on head size.


G. grappiolo L. Spotorno G. Moraca S. Tornago

Introduction: T.H.A. revisions are constantly increasing: and it’s known that bone defects – expecially if severe like in rirevision cases – are the main problem to manage during the revision surgery. Since 1988, we have chosen to bypass the bone defects by using an “elastic” non-invading tapered stem (SL Wagner); morsel bone graft is rarely necessary, we never use a massive one. According to our philosophy in revisioning, stability should be obtained by a diaphysary anchorage as proximal as possible.

Methods: Our research concerns 150 cases of SL revision stems implanted from December ’88 to December ’91. The average age is 67 years old, complete clinical evaluation and survivorship analysis for the entire study cohort was performed from 8 to 12 years follow-up, radiographic analysis in 81 cases with 101 months avg. follow-up (min. 60 – max. 143).

Results and Discussion: 4 cases required rirevision; 20 patients deceased; 12 were lost to follow-up; 96 examinated.

Clinical evaluations show an average score of 78 (acc. to HHS); 82,3 percent of patients are pain free, while slight pain still persists in a 13,7 percent pain in a 3,9 percent.

The radiographic analysis has put into evidence only 1 case of mobilization, and suffering bone in 4 percent of cases; by contrast, 79,5 percent show astonishing endosteal bone formation.


J.F. Huber G. Ruflin G. Pagenstert M. Zumstein

Introduction: Implant loosening/pseudartrhosis after THR/TKR with large femoral bone defects is associated with pain and immobilization in a wheelchair. In these cases a total femur replacement (Combined total hip and knee replacement connected with an intramedullary rod) can be a therapeutic procedure as known from tumor surgery. We describe this technique and results with in a case serie of patients.

Study Type: Monocentric prospective case serie

Patients and Methods: All patients who had a total femur replacement were followed regularly after 3, 6 months, 1, 3 and 5 years. The follow up was documented with clinical examination, x-rays and validated questionnaires. Indications were loosening after stem revisions (THR), pseudarthrosis and loosening of femoral component after TKR, pseudarthrosis and instability after THR and fracture.

For every case the implants were planned with a total leg x-ray and manufactured (Link). The implants were removed and the knee and hip joint prepared. The approach was performed with two incisions (knee, hip) to reduce the invasivity. The implantation started with the knee implants connected with the intramedullary rod and was finished with the hip implants. Postoperative weight bearing was following pain.

Results: Included were 5 cases of total femur replacement in 4 patients (three women, age from 54 to 69) with a follow up between 12 to 94 months, average 3.5 years. Three cases with stem loosening after THR and revisions before, one case with loosening and pseudarthrosis after TKR, one with pseudarthrosis and instability after THR with femur fracture. Every patient had 2–4 interventions of the affected joint before.

The pain diminuished significant in all patients in the questionnaires and the pain medication could be reduced substantially. All patients gained mobility already three months after the procedure, every patient could walk with crutches. No patients needed to be reoperated in the follow-up period. Every patient could keep the mobility over the the follow-up time. Two patients reported some pain in the knee. Radiologically the defects of the femur were partially consolidated and we could not see further bone loss.

Conclusion: Total femur replacement can be used also in selected patients with large bone defects after arthroplasty (THR/TKN) and loosening or pseudarthrosis. The patients profit from the reduction of pain and the gain in mobility.


M. Lerch F. Thorey H. Windhagen

Introduction: The number of revision Total Hip Arthroplasties (rTHA) continues to rise in an ageing population. High fracture rates reported point out that stem removal is associated with substantial surgical complications. Extensive Trochanteric Osteotomies (ETO) may facilitate stem removal; however, it has also been associated with hazards like increased incidence of non-union, fracture of the osteotomy fragment and stem subsidence. It is not yet clear if a permissive indication for ETO may lead to better postoperative results, than removing stem and cement from the top of the femur eventually causing fractures.

This study describes our experience, comparing peri-operative femoral fractures during stem removal with ETOs in rTHA.

Patients & Methods: Between 1992 and 2004 45 perioperative fractures during rTHA were compared to a collective of 28 ETOs. Pre-Op and after a follow-up period of 32 months (range, 21.6 – 76 months) patients were examined clinically and radiographically. Investigation parameters were Harris-Hip score, SF-36 health score, function (0 – 6) and pain (0 – 10) score, limp, postoperative complications, implant survival and radiographic parameters (stem and trochanter migration, stem alignment, bone union). Fractures were graded using the Vancouver classification.

Results: Harris hip score increase was 31 points (p = 0.004) in ETO patients and 17 points in patients with femoral fractures during stem removal. Increase for function and pain was 1.5 points and 4.4 points in ETO patients and 2 points and 3 points in patients with perioperative femoral fractures. SF-36 health score showed better increases in patients with ETOs. Joint luxation occurred in 3 (6.7%) patients with perioperative fractures and once (3.6%) in the osteotomy group. Infections were more frequently after ETO. 2 patients showed Trendelenburg gait after ETO, but were satisfied with the operation. 1 (3.6%, 12 mm) stem in the ETO group and 3 (6.7%, mean 15 mm) stems in the fracture group subsided slightly. No cable failure was detected in the ETO group, but 2 (4.4%) in the fracture group. 1 osteotomy fragment and 3 femoral fractures showed nonunion and needed re-revision. Every implanted stem had excellent alignment within standard error of ± 3°.

Discussion: Our results suggest that permissive indication for ETO in rTHA may lead to better postoperative results. Especially in patients with poor bone stock, where intraoperative fractures may likely occur, proper implant exposure and rigid fragment fixation may be crucial for success. Although the ETO might be associated with nonunion and limp, this study, as well as others, demonstrates that these observations do not necessarily compromise patient satisfaction. Conclusively, risking femoral fractures during stem removal is prejudicially, compared to proper, extensive femoral osteotomies in rTHA.


J.F. Wodtke P. Stangenberg J.F. Loehr

Introduction: Limb salvage through a total femur (TOFEM) prosthesis is a rare procedure. The infection rate is high due to the large implant surface, a long OR-time and often severely compromised soft tissues. In case of infection the one stage procedure is the way of revision to avoid impairing instability for the patient.

Material + Methods: Between 1996 and 2005 46 one stage exchanges were performed in 37 patients. 23 patients were available for review in 2006. 13 had died, 1 could not be located. The infection-free periods, subjective satisfaction with the procedure and clinical outcome were evaluated. The average follow-up time (FU) was 46 months (8/104). Male/female ratio 10/27, average age 66 yrs. (30/87). The average number of revisions before the TOFEM was 5 (1/11).

Indication for a TOFEM was fracture in 43%, bone loss in 51% and others in 6 %. Infection occurred at primary intervention in 32%, in connection with revisions in 18% or delayed in 49%.

Results: 16 Patients were cured in a one step procedure. 10 Patients underwent further revisions. Two or more exchanges were carried out in 6 cases with success. Patient’s satisfaction rate was 55%. 13 were valued unsatisfied. 8 exarticulations became necessary later and 5 Patients died in the course of the treatment. 2 of those were exarticulated before.

Conclusion: One stage exchange is a promising procedure avoiding loss of the limb. A high complication rate exists and secondary exarticulation may still become necessary.

Summary: The infectious complication in total femur prosthesesis presents a severe problem. A one stage revision offers another good chance for limb salvage, but morbidity and mortality risks are high.


O. Borens M. Hofer A. Farron C.H. Blanc

Introduction: Despite a multitude of reports detailing the management of infected hips and knees with or without arthroplasty, only little information is available on how to deal with infected shoulders. Besides primary haematogenous infection, the increasing number of surgical procedures (infiltration, arthroscopy, ORIF, total- or hemi arthroplasty) confront the orthopaedic surgeon increasingly with this devastating complication. Our goal is to present our experience with the use of a cement spacer in the treatment of infected shoulder joints.

Material and Methods: Between 1995 and 2005 9 patients were diagnosed with deep shoulder infection. The study includes 5 women and 4 men. The mean age at the time of diagnosis of the infection was 65 years (range, 51–78 years). Only 2 patient had had no prior surgery of the shoulder. 5 patients had an infection of a shoulder arthroplasty and 2 patients had been treated with ORIF for fracture.

All of the patients underwent resection the humeral head or retrieval of the arthroplasty with large debridement followed by implantation of an antibiotic impregnated polymethyl methacrylate spacer. After a mean duration of two months of antibiotics and after normalisation of the CRP a delayed reimplantation of a prosthesis was performed in 6 patients. One patient is awaiting arthroplasty, while two patients are satisfied with the functional result obtained with the spacer and do not want further surgery.

Results: None of the patients developed recurrent infection at an average follow-up time of 36 months. Shoulder function was judged objectively and subjectively to be at least satisfactory in all of the patients.

Conclusions: Staged treatment of infected shoulders using antibiotic impregnated polymethyl methacrylate spacers showed in our small group of patients, good and reproducible results. The individually moulded and fitted spacer filling the joint cavity and restoring the normal anatomy of the shoulder after joint debridement makes secondary procedures much easier. In the cases of exchange prosthetic reconstruction no recurrent infection has been experienced and all of the patients have substantial pain relief and an adequate shoulder function. Based on this experience the authors think that staged treatment and the use of a cement spacer in infected shoulder joints is a valid approach.


T. Briant-Evans M. Hubble E. Tsiridis

20 Vancouver type B periprosthetic femoral fractures were treated in our unit by cementing a revision stem into the pre-existing cement mantle following fracture reduction. The technique was used in elderly, multiply co-morbid patients with the intention of reducing operative time and peri-operative complications.

3 patients died in the first 3 months from reasons not related to surgery, with no recorded evidence of fracture healing and were excluded from the study and 1 was too frail to attend follow up. The remaining 16 cases were followed up for a mean of 3 years. The mean time to radiological union was 5 months (range: 2–11) and the mean time to clinical union was 4.9 months (range: 2–17). The mean Modified Harris Hip Score in these patients was 66.5 (range: 35.2–97). One patient had further surgery for a delayed union and there was one failure of fixation. The mean hospital stay was 10.8 days and the mean time to fully weight bear 38.1 days.

This study suggests that there is a valid role for the use of the in-cement revision technique in Vancouver type B periprosthetic femoral fractures in a highly selected group of elderly patients unsuitable for lengthy reconstructive procedure


H. Thabe

Acute periprosthetic infection, acute and chronic course of the infection with unknown spectrum of organism, hardly to treat and loss of mobility due to long lasting immobilization after implant removal are the indications for this special design of a spacer. The management of a bacterial periprosthetic infection by two-stage reimplantation using an implanted applicationspacer for antibiotics maintains mobility and soft tissue balance and ensures simultaneous local delivery of antibiotics.

After a complete synovectomy the implant components and all foreign material are removed. The implant bed is then prepared for implantation of the application-spacer for antibiotics. Silicone catheters are advanced through two separate drill holes into the intramedullary canal and then inserted into the perforated implant stems. After the applicationspacer for antibioticss has been implanted, the wound is closed.

Daily parenteral doses of antibiotics are delivered through the percutaneous silicone catheters directly into the intramedullary canal at the site of the infection. The applicationspacer for antibiotics allows daily physiotherapy and even mobilization on a CPM device. Partial weight bearing may even be allowed if there is sufficient stability. Once the CRP values have decreased to normal levels, the definitive implant is placed using antibiotic-impregnated cement according to current resistance studies. The implant beds are debrided to remove the synovial tissue that has developed in the interim. Then the revision implants can be placed in the prepared bone because the same templates are used for both the applicationspacer for antibioticss and the revision implants.

36 patients have been treated with this method since 1993. Two-stage reimplantation of a total knee was performed in 27 cases.. The longest postoperative follow-up period is now 12 years. Till now, no revision surgery has been required on a joint treated in this manner, and no periprosthetic infections have been observed. In the knee, a range of motion of 0/0/106 degrees was achieved after an average follow-up period of 7,1 years. In the hip, values of 10/0/110 degrees were achieved after an average of 7,3 years. Revision surgery for infection included cases of fungal and tubercular infection. A postoperative Hospital for Special Surgery rating of 79,5 was achieved in the knee and a rating of 81,3 in the Harris hip score.


C. Castelli R. Ferrari J. Munro R.p. Pitto

The aim of this prospective study was to assess safety and effectiveness of Spacer-K, a pre-formed articulating spacer made of gentamicin-impregnated acrylic bone cement. used in two-stage exchange technique for the infected total knee arthroplasty.

32 consecutive patients infected total knee arthroplasty were operated on in two centres. Infection was caused by Coagulase neg. Staphylococcus (21), Staphylococcus aureus (4), and others (4). In 3 case microorganisms were not identified. The mean implantation time of the spacer was 11 weeks (range, 7 to 28 weeks). The rehabilitation program between stages consisted in early range of motion exercises and partial weight-bearing. In one patient removal of the spacer and insertion of a molded cement block with vancomycin was necessary because of insurgence of methicillin-resistant Staphylococcus aureus.

The mean follow-up of 32 knees after removal of the spacer and insertion of the new prosthesis was 40 months (range, 24 to 75 months. The mean Knee Society functional score during spacer management was rated 75 points (range, 41 to 91 points) and was rated 87 points (range, 77 to 97 points) at latest follow-up. Preoperative range of motion improved markedly after removal of the infected prosthesis and insertion of the spacer. Neither breakage nor clinically relevant surface wear were detected. No implant-related complications were observed. Bone stock remained unchanged during the whole management process.

The Spacer-K is safe and effective for the management of the infected total knee arthroplasty.


P.B. McKenna K. O’Shea E. Masterson

Background: Infection remains the single most devastating complication of joint arthroplasty. In cases of established prosthetic infection, where implant retention is not feasible, there is limited consensus on an optimum management protocol.

Aim: To assess the outcome of revision for infected hip prostheses using a novel treatment regimen.

Materials and Methods: Retrospective study of a consecutive case series of 40 patients with late chronic hip joint prosthetic infection treated by a single surgeon over a 4 year period. The mean interval between index arthroplasty and revision for infection was 40 months, with patients having prior symptoms of infection for a mean of 22 months.

The treatment protocol consisted of a two stage exchange with removal of infected components via a posterior approach incorporating an extended trochanteric osteotomy, insertion of an interim antibiotic eluting cement spacer and re-implantation of an extensively coated uncemented prosthesis on the femoral side. Systemic antibiotic treatment following each stage consisted of an abridged course of 5 days post operative intravenous administration followed by complete cessation of anti-microbial therapy. The mean interval between implant removal and re-implantation was 111 days.

Results: At a mean follow up of 29.6 months (minimum 12 months), there were 2 cases of recurrent prosthetic infection. Dislocation following the second stage occurred in 7 patients. There was one mortality and one case of post operative sciatic nerve palsy. The Harris hip score increased from a pre-operative mean of 43.8 to a post operative mean of 83.9. At follow up, no patient had required revision for aseptic loosening or mechanical instability on the femoral side

Conclusion: The combination of effective staged surgical joint debridement, a shortened post operative course of systemic antibiotic treatment and an adequate latent period before re-implantation has led to encouraging early results in this series of revised chronic hip joint prosthetic infections.


Y.D. Hailer G. Olgun L. Zichner V. Schäfer

Aim of the study: Joint infection and infection of arthroplasty is a severe problem and its treatment controversial. Treatment with irrigation-suction-drain is still common. We investigated the outcome of this method.

Patients and method: In a retrospective trial, 129 patients with infection of the hip-, knee- and shoulder joint were included. 28 of these patients had an infected hip, knee or shoulder prosthesis.

The mean follow up was 5 years. Patients with rheumatic disease, tumors or patients under immunosuppressive therapy were excluded. Infectious disease consultants supervised the administration of intravenous antibiotics. No antibiotics were added to the irrigating solution.

Results: In 44, 6% of the patient group with septic arthritis the infection could not be eradicated with open surgical debridement and irrigation-suction drainage treatment. In the arthroplasty group 39, 3% were not cured. In total 55 patients underwent additional surgery once or several times to get the infection under control. In 9 of the 28 patient with arthroplasty, the prosthesis had to be removed. The predominant infectious organisms were gram-positive (Staphylococcus epidermidis, Staphylococcus aureus and Streptococcus Group B). Three percent of the knees that were infected clinically had no organisms that could be identified. In 78, 2% of the patients who had additional surgery the antibiogram showed a change in the resistance or/and a change of the pathogen microorganism. Four patients developed a MRSA. The mean duration in the hospital stay was 36 days.

Conclusion: The treatment with irrigation-suction-drain is not recommended according to these results. Other methods like debridement and local antibiotics in combination with systemic antibiotics seams to be more effective according to the literature. Even the duration of the hospital stay is shorter with other methods. The high rate of microorganism changes and changes in the resistance of the microorganism is not acceptable.


E. Ghanem C. Restrepo P.F. Sharkey M. Austin J.J. Purtill J. Parvizi

Purpose: Periprosthetic infection (PPI) is a devastating complication. Surgical intervention to treat PPI is often required. The objective of this prospective study is to determine if there is any difference in functional improvement following revision TKA in patients with infected and non-infected failures.

Methods: 123 consecutive patients undergoing revision TKA at our institution were prospectively recruited into this study. The indication for revision TKA was PPI in 37 cases and aseptic failure in 86 cases. Detailed patient demographics and functional outcome using SF-36, KSS, Womac, lower extremity functional outcome score were collected at base line and at various time points after revision TKA. The baseline and two year follow up functional scores were calculated and compared. The functional score at the time of diagnosis of PPI (prosthesis in place) were used for baseline comparisons

Results: All baseline functional scores, and their individual elements, for the infected cases were worse than the non-infected cases. The functional scores at the two-year follow-up were not different between the infected and non-infected cases. Hence, there was a more impressive improvement (Δ) in functional outcome for the infected cases following revision TKA compared to non-infected cases. However, the general health perception as determined by the patients themselves appeared to deteriorate after revision TKA in both groups.

Discussion: It appears that patients with PPI are markedly more disabled at base line than the non-infected cases. These patients, however, benefit the most from surgical intervention compared to the non-infected cases. It appears that the patients’ perception of improvement in functional scores is less optimistic than physician measured parameters.


G. Grappiolo G. Riccio G. Carrega G. Santoro A. Camera

Background. Total hip replacement (THR) has become the ideal treatment for any disorder causing joint destruction. Surgery-related infections are reported only in 1–2 % of THR, but antibiotic prophylaxis is necessary because infections are associated with significant morbidity and occasionally death. 1st and 2nd –generation cephalosporin or, in hospital with methicillin-R Staphylococcus spp (MRSA, MRSE) high prevalence, vancomycin, are the most frequently drug emplojed. The most frequent side effects of antibiotic prophylaxis are allergic reaction and pseudomembranous enterocolitis.

The objective of the present study was to assess the efficacy and tolerability of antibiotic prophylaxis for THR at S. Corona Hospital Pietra Ligure SV (Italy).

In our hospital the majority of prostethic device infections are due to MRSA, but recently we have described increment of infection due to Pseudomonas spp and other gram-. For this reason we used association of vancomycin plus pefloxacin in primary prophylaxis.

Methods. Retrospective analysis of 1118 THR performed in the period 2003–2004, receiving surgical prophylaxis with a single dose of the association vancomycin 1000 mg plus pefloxacin 400 mg. Data collection regarded patients’ age at surgery and reasons for THR. The presence of a surgery-related infection was investigated by means of a phone interview about the function of the hip device (presence of pain, deambulation impairment, fever). Patients with pain or other problems were submitted to physical exam, laboratory tests, plain radiograph and if necessary to exclude of infection, radioisotopic scans.

Results. We report the preliminary data on 218 THR in 211 patients (81 M, 122 F, median age 67.49 aa, range 29–91). THR was performed for: osteoarthrites in 168 cases, trauma in 26, osteonecrosis in 9, displasia in 4 cases, previous osteotomy in 4. 167/211 patients were submitted to a phone interview and 44 to a clinical examination.

Conclusions. In our center, the association of vancomycin-pefloxacin resulted effective and well tolerated as single dose prophylaxis for THR.


E. Ghanem J. Richman R. Barrack J. Parvizi J.J. Purtill P.F. Sharkey

Introduction: Intraoperative tissue culture remains the “gold standard” in diagnosing periprosthetic infection (PPI). However, an organism is not always cultured and this has been attributed to the fact that preoperative antibiotics were administered. This study intends to examine if preoperative antibiotics prevent isolation of intraoperative organisms.

Methods: 91 total joint arthroplasty patients diagnosed with PPI during (1999–2005) and who had positive aspiration culture were included in the study. All intravenous antibiotics that were given to the patient within seven days of surgery were documented. The total number of positive intraoperative fluid and tissue samples of patients who did and did not receive antibiotics was calculated. Susceptibility of the organism(s) to antibiotics was determined by antibiogram of the preoperative and intraoperative culture.

Results: 60 out of 91 patients received preoperative antibiotics within seven days of surgery. Antibiotics prevented isolation of an intraoperative organism in 6 out of the 60 (10%) cases. All of the 31 patients who did not receive any preoperative antibiotics had positive intraoperative cultures. Chi-square analysis revealed no significant difference between giving preoperative antibiotics within 7 days and isolating an intraoperative organism (p=0.068). Giving antibiotics that specifically targets the culprit organism did not significantly affect the fluid (p=0.585) or tissue culture yield (p=0.152) either.

Discussion: Although, giving preoperative antibiotics can prevent isolation of intraoperative organisms in 10% of cases, this is not statistically or clinically significant in patients with positive aspiration cultures because the organism is known beforehand. However, it is clinically and medicolegally relevant to withhold antibiotics in patients with negative aspiration cultures since the postoperative treatment antibiotic is tailored according to the organism cultured.


J. Parvizi V.J. Antoci T.A. Freeman I.M. Shapiro N.J. Hickok C.A. Adams

Introduction: We have previously described modification of Ti that renders the implant surface bactericidal and prevents bacterial colonization in vitro. This study evaluates the efficacy of the same surface in preventing periprosthetic infection in a small mammal model.

Methods: Control or VancTi rods were incubated with S. aureus (Ci=104CFU/mL) in TSB containing 0, 5×10-3, 4, or 100 μg/mL vancomycin at 37°C for 24h. Bacteria were detected by fluorescence (Live/Dead BacLight) and imaged by confocal microscopy. Resistance was tested by incubating control or VancTi rods with S. aureus for 0–8 weeks. Adherent bacteria were tested every 7 days on vancomycin screening agar (6μg/mL).

Results: Using a percutanous approach, the intercondylar region of the knee in rats were identified. The intrameduallry canal of the femur was retrograde reamed using an 18-gauge needle. Infection was induced by injection of 103 CFU S. aureus in 150uL of saline into the femoral canal followed by insertion of a 20 mm Ti implant. Animals were harvested at various time points. At harvest, animals were euthanized with CO2.. Detailed analysis including radiographic, micro-CT, histological, bacteriological, and clinical evaluation was performed.

Results: All animals showed signs of infection within the first few post-operative days with increased soft tissue swelling and limited mobility. At 1 week 75% of the animals showed radiographic signs of periprosthetic infection including periosteal reaction, abscess formation, widened canal, bone destruction, and formation of involucrum. PPI could be prevented in 92% of cases when modified Ti-Van was used. In one animal despite the use of antibiotic-tethered implant, PPI occurred partially due to the pin insertion penetrating the bone cortex.

Discussion: Biologically modified implants with bactericidal surface can have a promising role in management of periprosthetic infection. The modified implant described herein contains a nanoscale surface of covalently linked antibiotics that can potentially confer bactericidal properties throughout the life of the implant


W. Mayer S. Wagner R. Linke S. Maegerlein V. Jansson P.E. Müller

Introduction: Arthroplasty plays a growing role in our society today. Due to scientific and medical progress there are an increasing number of viable candidates and the improvement of quality of life thereafter speaks for itself.

Even though the operations are largely successful, complications after joint replacement surgery occur frequently. Approximately 10% of lower limb arthroplasties need surgical revision, of which 70% are due to loosening. The purpose of this study was to assess the feasibility of 18-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) in detecting septic and aseptic endoprosthetic loosening of hip and knee endoprostheses.

Materials and Methods: Thirty-three patients (age range: 45 – 90y) with lower limb arthroplasty complaints (74 prostheses) were studied preoperatively with 18F-FDG-PET. All patients underwent surgery at a later stage with microbiological culturing to differentiate aseptic and septic loosening and to confirm the final diagnosis. Prostheses were tested intraoperatively for stability and microbiology.

Results: The sensitivity/specificity of 18F-FDG-PET towards implant loosening in the hip was 80%/87%, in the knee 56%/82%.

The sensitivity/specificity for infectious loosening in hip replacement arthroplasties was 67%/83%, in the knee 14%/89%.

Discussion: 18F-FDG-PET seems an excellent method for detecting hip endoprosthetic loosening and a moderate tool to diagnose hip implant infection. It should not be seen as the method of choice to diagnose knee endoprosthetic loosening and infection.


E. Ghanem J. Parvizi P.F. Sharkey N.R. Keshavarzi J.C. Clohisy

Introduction: Although there is no absolute diagnostic test for PPI, synovial leukocyte counts and neutrophil percentages have been reported to have high sensitivity and specificity making them valuable tests for diagnosis. However, no cut off value for the latter is agreed upon. This study intends to evaluate to define definite cut-off values for preoperative synovial fluid leukocyte count and PMN percentage that allow physicians to diagnose infection in a prosthetic joint.

Methods: We analyzed synovial fluid aspirated preoperatively from 593 total knee arthroplasties (161 infected; 432 aseptic) from three different institutions. Using ROC curves, we determined cut-off values with optimal accuracy in diagnosis of infection for fluid leukocyte count and PMN percentage. The sensitivity, specificity, and predictive values were calculated for the above cutoff values.

Results: The synovial fluid leukocyte count was higher in patients with PPI (median, 31 × 103 cell/μl) compared to aseptic joint arthroplasties (median, 0.219 × 103 cells/μl)(p< 0.0001). Similarly, the neutrophil percentage was higher in patients with PPI (median, 90%) than in those with noninfected joints (median, 26%)(p< 0.0001). The cut-off values for optimal accuracy in diagnosis of infection were 1760 cells/μl for fluid leukocyte count and 73% for PMN percentage. A fluid cell count > 1760 cells/μl had a PPV of 99% and NPV of 88%, while a neutrophil percentage > 73% yielded a PPV of 96% and NPV of 91%. Chi-square analysis revealed the fluid WBC count and the neutrophil percentage to be significantly associated with the diagnosis of infection (p< 0.0001).

Discussion: Synovial fluid leukocyte count and differential are useful adjuncts to ESR and CRP in the preoperative diagnosis for infection in TKA. This study has identified a cut-off value for leukocyte count and neutrophil percentage that can be used to diagnose infection in a prosthetic joint.


T. Kern M. Militz V. Bühren

Objectives: This study evaluates the number of recurrence of acute infection following total knee arthroplasty treated with a concept of implant salvage using programmed revision surgery and specific long-term antibiotic therapy with and without additional application of antibiotics penetrating bacterial biofilms like rifampicin.

Methods: In a retrospective study, 24 patients with early infection of unconstrained total knee arthroplasty were treated according to our protocol and were followed up for a period of 4 years [range 1,2–6,2]

using a questionnaire to investigate course of disease and health-related quality of life (VAS). 7 patients were treated with and 17 patients without additional application of antibiotics penetrating bacterial biofilms.

Results: In the group of patients treated without additional application of antibiotics penetrating bacterial biofilms 11 of 17 (65%) implants were salvaged. In 5 cases revision arthroplasty and 1 arthrodesis were necessary to eradicate infection. Health-related quality of life and function of the arthroplasy were superior in the group of salvaged implants.

In the group of patients treated with additional application of antibiotics penetrating bacterial biofilms 6 of 7 (86%) implants were salvaged and reduced number of revison surgery was needed.

Conclusion: Treatment of infection with implant salvage may be one therapeutic option if the implant is not loose. Therapy with retention of the prosthesis may be indicated: in the case of early infection (< 3 weeks of ongoing symptoms), with unconstrained implants, in the case of infection by a single organism that is susceptible to antibiotic therapy, if soft tissue envelope is not affected, and if the immune system is not compromised. Early and consequent therapy with operative debridements and specific long-term antibiotic therapy are necessary to achieve implant salvage. Additional application of antibiotics penetrating bacterial biofilms such as rifampicin contribute to improve prognosis.

Due to the fact that revision arthroplasty is often associated with limited function after infection of total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.


V. Alt A. Bitschnau A. Sewing S.A. Meissner S. Wenisch E. Domann R. Schnettler

Introduction: Similar local infection prophylaxis as in cemented total joint by antibiotic-loaded bone cement has not been possible yet for cementless prostheses. In this study, a gentamicin-coating which can be brought additionally onto standard hydroxyapatite (HA) coatings of cementless prostheses is presented. It was tested whether this gentamicin-coating can reduce infection rates in a rabbit infection model with Staphylococcus aureus compared to compared to standard-HA coating. Furthermore, the biocompatibility of this gentamicin coating was investigated.

Materials and Methods: Staphylococcus aureus with a dose of 10(7) CFUs was inoculated into the intramedullary canal of the tibia of 30 rabbits followed by the implantation of standard hydroxyapatite (HA) K-wires, K-wires coated with a HA--gentamicin combination, and K-wires coated with a HA-RGD-gentamicin combination, respectively. The animals were sacrificed after 28 days and clinical, histological and microbiological assessment on the bone and on the removed K-wire itself by agar plating and DNA-pulse field gel electrophoresis were carried out to detect infection. Infection was defined as positive culture growth from the bone and/or cement samples. In another study with 40 rabbits biocompatibility of the two gentamicin-coating types was assessed after an implantation time of 12 weeks and compared to pure HA-coating and uncoated implants.

Results: Infection rates were 88% (7 of 8 animals) for the standard HA, 0% (0 of 9 animals) for the HA-gentamicin and 0% (0 of 10 animals) for the HA-RGD-gentamicin group. There was a statistically highly significant reduction of infection rates by both gentamicin-coating types compared to standard HA-coating (p < 0.001). The animals that were identified to have positive culture growth corresponded to the animals that showed clinical signs of infection. An excellent correlation between agar plating testing results of the K-wires and of the bone samples was found. Detailed histology showed cortical lysis, abcess and sequester formation in the infected animals. There were no major differences in the biocompatibility between the different groups. There were only a few giant cells and regions of bone marrow necrosis in the gentamicin-groups which was comparable to the control implants. There was a very similar histologic appearance of the gentamicin coatings and the standard HA coating.

Conclusion: Both gentamicin-coating types showed significant improvement of infection prophylaxis compared to standard HA coating. Furthermore, both gentamicin coating types revealed good biocompatibility after 12 weeks. Therefore, HA-gentamicin and HA-RGD-gentamicin coatings could help to reduce infection rates in cementless arthroplasty in all day clinical use


R. Tate M.R. Broadbent C.A. Carnegie E.M. Christie A.J. Johnstone

Aims: In recent years, volar locking plates have increased in popularity for the treatment of displaced distal radial fractures. The angular stability of the screws help maintain reduction permitting early mobilisation. The aim of this study was to assess functional outcome using both subjective and objective methods.

Methods: The study was a prospective cohort study. Over a 2 year period 110 patients with closed, displaced distal radial fractures were considered suitable for treatment with the distal radius volar locking plate. Of these, 51 patients were followed up for a full 12 months. One year post-operatively all patients were reviewed and both subjective and objective measurements made:

Subjective:

Pain – visual analogue scale (VAS) (0 = no pain, 10 = worst pain ever).

Overall function – patients’ perception – VAS (0 = no function, 100 = full function).

Objective: Strength – grip and pinch – measured objectively as a percentage of the uninjured side.

Range of Motion – Flexion, extension, pronation and supination – measured objectively as percentages of the uninjured side.

For the purpose of this analysis, the fractures were divided into intra- and extra-articular fracture patterns based on the initial pre-operative X-rays.

Results: The mean age was 55 years (28 – 83), 36 were female and 15 male. Of the fractures, 26 were extra-articular and 25 intra-articular. 28 of the 51 patients had a period of physiotherapy post-operatively. 23 patients were either not referred to physiotherapy or failed to attend.

Subjectively 75% of patients had an excellent result with a pain VAS score of 0–1/10 (mean 0.9 for extra-articular and 1.2 for intra-articular) and an overall function VAS score of 9–10/10 (mean 92% for extra-articular and 86% for intra-articular).

Objective outcome measures were also very good. The results for the extra-articular group showed a mean grip strength of 85%, a mean pinch grip of 91%, a mean flexion of 82%, a mean extension of 88%, a mean pronation of 98% and a mean supination of 98%. The results for intra-articular fractures showed a mean grip strength of 80%, a mean pinch grip of 88%, a mean flexion of 78%, a mean extension of 83%, a mean pronation of 94% and a mean supination of 93%.

Conclusions: Overall patients made an excellent recovery. The majority of patients had little or no pain and almost complete return to function at 12 months post-operatively. Interestingly, individual patient demographics (age, sex, fracture type, physiotherapy) did not make a statistically significant difference to the outcome measures.

This study confirmed excellent functional results comparable with other methods of fixation for extra-articular fractures, but it also showed good results with the more complex intra-articular fractures.


V.J. Antoci C.A. Adams H.M. Hoffsommer J. Binoy S. King T.A. Freeman J. Parvizi I.M. Shapiro

INTRODUCTION: We have previously demonstrated the efficacy of a modified Ti-surface tethered with antibiotics in preventing bacterial colonization. It is not known if coverage of this surface with serum or other physiological material may hinder the bactericidal properties of such a surface.. The in vitro activity and efficacy of such a surface against S. aureus and S. epidermidis was tested following coverage of the surface with serum.

METHODS: Vancomycin was coupled to Ti6Al4V pins by aminopropylation, linker addition, and vancomycin coupling (VancTi). Bactericidal activity was tested in solutions of bacteria (Ci=1×104cfu/ml) incubated with pins±pre-incubation with fetal bovine serum (FBS). Anti fibronectin and anti-vancomycin antibodies were used to detect surface coating or modification. Bacteria were detected by fluorescent labeling (Syto9) or by direct counting after solubilization.

RESULTS: By immunofluorescence, pins were extensively covered with serum fibronectin which did not interfere with the diffuse, intense vancomycin staining. When incubated with S. epidermidis or S. aureus, VancTi showed little colonization compared to control pins (> 95% reduction in cfu).

DISCUSSION: In a physiological environment, implants will be coated with serum proteins. Activity of the VancTi was unaffected by this coating and maintained potent inhibition of bacterial colonization. We have described a surface modification that allows Ti implants to resist colonization and subsequent periprosthetic infection. Such surfaces hold great promise for the prevention and treatment of periprosthetic infections.


O. Franz M. Wolfgang

Question: We doveloped a locking plate for palmar fixation of comminuted fractures of the distal radius.

Method: Implant: stability of the angle between screws and plate, achieved by a different hardeness of the locking plate and the screws (pure titanium an titanium alloy), screw holes allow angulation between 70 and 110 degrees, anatomically contoured, low profile plate. The plate can be postioned on the palmar aspect of the radius without expecting a loss of correction. Surgery one week after trauma, palmar approach, open reduction, bone substitute if necessary, dorsal splint for two weeks, physiotherapy.

Follow-up: Retrospective study, period of follow up examinationes: 1–5 years, radiological and clinical examination.

Results: From 2000 until 2004 241 patients with fracturs of the distal radius underwent open reduction an internal fixation with ITS locking plate. Age between 25–81 yeas, 2/3 of the patients were women, 1/3 men. We did the score according to Cooney an the DASH-Score. We could find approximately 80 percent excellent and good results in both scores. Radiological findings: we compared the intraoperative reduction with the healthy other side: an anatomical reduction was achieved in more then 90 percent. At follow up time we mashured length and radial angulation. Shortening was between 0–3 mm, radial tilt maximum 3 degrees.

Conclusion: The anatomical results of reduction could be stabilized until bony union. In mid term follow up examinations most patients reached functional range of motion and normal health related quality of life.


I.M. stevenson C. Carnegie E. Christie K. Kumar A. Johnstone

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures.

Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery.

Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side.

Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures.


C.J. Chambers T.M. Barton G.C. Bannister

Introduction: Radial shortening has been associated with a poor functional outcome following a fractured distal radius. Traditionally, outcome has been measured using doctor-based scores such as the Gartland and Werley Scoring System or modifications thereof.

Aims: The aim of this study is to compare patient based outcome scores with the Frykman class of the fracture and radial shortening both at injury and fracture union.

Methods: We followed up 60 patients over 55 who underwent closed reduction and k-wire fixation of distal radial fractures. Outcome was recorded by the Patient Rated Wrist Evaluation (PRWE) score, a validated subjective outcome measure.

Results: No association was found between radial shortening either at injury or fracture union with subjective outcome score but there was a significant association between Frykman Classification and outcome (p< 0.05).

Discussion: Our results showed that for distal radius fractures that united with a moderate degree of radial shortening, increasing Frykman Class was associated with a worse functional score.


H.V. Kurup V. Mandalia K.A. Shaju A.R. Beaumont

The aim of this study was to find out whether distal radius fractures treated by K wire fixation loose reduction after wire removal and analyze the variables may influence this. Patients who underwent K wire fixation for unstable fractures of distal radius over a period of 3 years were included in this retrospective study. Fractures were classified according to AO classification. Radiographs taken just prior to removal of K wires and radiographs taken at least 1 month after wire removal were analyzed to study three radiological parameters; Palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analyzed statistically against variables like age, sex, AO classification, type of K wires used, delay in fixation and duration of fixation. 59 fractures were analyzed with mean age of 56 years and male to female ratio of 1:2. Average loss of radial tilt was 2.6 deg, loss of palmar tilt was 2.6 deg and loss of ulnar variance was 1.3 mm. We found that distal radius fractures treated by percutaneous K wire fixation, do not suffer significant loss of reduction of fracture position after removal of wires. This remains true regardless of age, sex, fracture type according to AO type, type of wires used, delay in fixation or duration of wire fixation.


L. Obert D. Lepage S. Rochet S. Klingelschmitt O. Blagonoskonov Y. Tropet P. Garbuio

Introduction: Occult fractures of carpal bones are underestimed. To be treated succesfully fractures of the scaphoid must be identified at an early stage. A delay in detection may result in non union. We validated with 3 prospective studies a new tool using scintigraphy : The quantitative Xray bone scan (QRS)

Material and Methods: A previous preliminary prospective study with 60 patients was performed and published to valid the QRS as a step in diagnosis of wrist occult bones fractures equal to RMI. This exam is a bone scan with 2 improvments.

1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure.

2) If you combine plain Xrays of the the wrist with scintigraphy the fracture is automatically located. This previous report pointed that repeat set of scaphoid views, dynamic and static, Ct scan, proved unsuitable for screening occult fractures of the wrist.

Result: Between november 97 and march 04, 667 patients were enrolled in a prospective continue study. 40% (260/667) of patients with an injury of the wrist with normal X ray sustained an occult fracture. QRS was performed at an average of 17,7 days after the injury and after clinical exam and repeat set of scaphoid view. Scaphoid fractures were most frequent. Fixation was most important if scintigraphy was performed between 11 and 20 days after the injury. Fixation did not depend on age, sex, volume of the bone, and delay (after 15 days).

Discussion: As Dikson, Dias, Thompson, and Kuckla, repeat set of scaphoid view are unable to improve significativally the number of occult fractures of the wrist. RMI as reported by Kuckla can reduce the need for further imaging procedure. RMI and scintigraphy are both the best exam to diagnose surely an occult fracture of the wrist. But QRS does not over diagnose, as RMI, bones fracture’s.

Conclusion: “Plaster cast and wait” is not the treatment for occult carpal bones fracture’s. The quantitative Xray bone scan is able to diagnose such fractures with short delay.


L. Obert D. Lepage S. Rochet D. Gallinet P. Garbuio Y. Tropet

Objective: 6 cases of postraumatic arthritis of the distal radius treated by chondro costal graft are reported with a minimum follow up of 2 years

Material and methods: 6 patients (One 22 years old patient with a dislocated radiocarpal joint 6 months after an injury, 3 patients (48, 52 and 53 years old) respectively 1, 1,5 and 2 years after a intraarticular fracture of distal radius and a patient (74 years old) with radio lunate arthritis reported two mains complaints : pain and stiffness. The last patient was a female with a destruction of radio scaphoid joint after septic complication of scaphoid surgery. Location of the cartilage defect was central in two cases and palmar in the others. A dorsal approach in one case, a palmar approach in the five others allowed reduction and reconstruction of the destroyed radial part of joint. An osteochondro costal graft harvested on the eight’s rib was inserted and fixed by plate in place of the articular impaction. Plaster cast of 3 months in the first case and 1 month in the others cases followed the articular reconstruction

Results : No complication have been pointed. Union was achieved in all 6 cases. Integration and viability of the graft were evaluated with RMI. At the highest follow up functionnal result are excellent in the youngest first case (male, 22 years old) where motion and grasp are similar than the controlateral side. In the 4 others cases of mal union patients were pain free in daily activity with a functionnal wrist score of 72/100 (54–82) and a DASH of 38,3 (22,5–51,7). Only the case with the septic problem failed with pain at follow up.

Conclusion: Reconstruction of a partially destroyed articular surface by a costal graft is reliable and allows filling and resurfacing an articular cartilage void. If chondro costal graft is currently used in maxillo facial surgery it is the first report in post traumatic arthritis secondary to intra articular mal union.


L. Obert D. lepage S. rochet P. garbuio

Objective: The purpose of the present study was to report on the author’s experience using injectable cement as a bony substitute in distal radius corrective osteotomies. The interest of such a bone substitute is the real capacity to adapt itself to the bone defect. Harvesting a trapezoidal cortico spongious graft which can fill very precisely the void and not more remains a challenging objective in treating extra articular mal union.

Material and Methods: 5 patients with an average age of 57 yo (42–74) had a corrective osteotomy for a malunited distal radius fracture using Injectable bone substitute (Eurobone, Jectos, Kasios Inc) as an alternative to an autogenous bone graft. Internal fixation of the osteotomy was achieved by using one plate without post operative immobilisation. Two patients were stiff at preoperative time.

Results: At an average follow-up evaluation of 26 months (14–37 mo) all the osteotomies united. Wrist flexion-extension motion improved from 56° to 110°, forearm rotation increased from 112° to 142°, and grip strength had an average increase of 120% at the time of the final follow-up evaluation. All patients were satisfied but there one report of persistent pain. Radiographic evaluation showed an average volar tilt improvement from a preoperative dorsal angulation shifting into a neutral position in the sagittal plane; Radiographically the injectable cement showed evidence of progressive re-absorption over time but with no complete disappearance.

Conclusions: On the basis of this preliminary experience it is reasonable to consider injectable cement as a viable alternative to bone grafting in conjunction with surgical correction and internal fixation of extra articular distal radius malunion.


E. Apergis G. Papadimitriou G. Arealis A. Lakoumentas C. Thanasas X. Xaralabidis

Wrist malalignment, in cases of malunited fractures of the distal radius, is not always a consequence of adaptation of the wrist to new conditions, but an expression of non-diagnosed ligamentous injuries. The aim of our study is to examine if the wrist malalignment is correctable with radius osteotomy.

Twenty nine patients (17 female, 12 male) of mean age 51 years, with symptomatic malunited fracture of the distal radius with dorsal angulation, of duration 3 months -47 years, were examined. Twenty seven patients underwent corrective radius osteotomy (open dorsally in 26 cases and closed palmarly in 1 case). Fixation material (plate and screws) was placed on the dorsal side in 23 cases and on the volar side in 4 cases. In all patients measurements on the lateral X-ray view, concerning the reversal of the normal palmar tilt of the radius, the radiolunate and lunocapitate angles, were performed before and after surgery. Based on those measurements patients were divided in two groups:

a) In group A (23 patients) the malalignment concerned the midcarpal joint, and

b) In group B (6 patients) the malalignment concerned the radiocarpal joint.

The radiographic element of evaluation was the radiolunate angle. Radiolunate angle greater than 25° indicated malalignment at the radiocarpal level while radiolunate angle less than 25° indicated malalignment at the mid-carpal level. In 5 patients post-operative measurements were not performed because in addition to the radial osteotomy they were subjected to operative correction of wrist malalignment.

Results estimated immediately postoperative and at the final follow-up, 6 months later. In patients with midcarpal malalignment, correction was possible, under the condition of a sufficient radius osteotomy and a non fixed midcarpal deformity. In patients with radiocarpal malalignment the deformity persisted despite the correction of the radial osteotomy.

We conclude that correction of wrist malalignment is not always achieved with corrective osteotomy of the radius and that preoperative radiological control may be indicative of the possibility of correcting the deformity.


I.M. Stevenson A. Johnstone

Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.

Aims: To investigate if an easily identifiable and predictable relationship exists in the normal wrist between the distal radius and lunate; and if so, to compare fractured wrists (pre and postoperatively)using conventional and new assessment methods.

Methods: 22 patients with displaced distal radial fractures treated by ORIF, were included. Patients had pre and postoperative radiographs taken of the injured and uninjured wrists. From true lateral radiographs, measurements were performed using the PACS system. A line was superimposed upon the dorsal radial cortex at least 2cm proximal to the wrist and extending distally. The following measurements were performed: lunate height, distance from the ‘line’ to the superior and inferior poles of the lunate, and conventional measurements of dorsal tilt and angulation.

Results: Uninjured wrist: Most noticeably the dorsal radial line always passed superior to the lunate, mean distance of 3.27mm (1.75–6.6mm). As a ratio, the distance from the line to the superior pole of the lunate divided by the distance to the inferior pole (‘lunate ratio’) had a mean of 0.16 (0.11–0.19).

Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm).

Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement.

Discussion: Our study suggests that there is a strong relationship between the distal radius and the lunate that could be used to assess fracture displacement and quality of reduction. Its main advantages are simplicity and ease of use despite the presence of metalwork.


P. Fenton A. Ali F. Qureshi D. Potter

Distal biceps tendon ruptures are uncommon with a reported incidence of 1.24 per 100,000 per year.

They typically occur in males in the fourth decade.

Operative treatment has been shown to improve functional outcomes in the treatment of distal biceps tendon ruptures. A variety of surgical techniques have been described, usually using the dual incision Boyd-Anderson approach.

We report a series of 10 patients with 10 tendon ruptures treated using a single incision volar approach and using the Arthrex Biotenodesis screw to reattach the tendon to the radial tuberosity.

This method has been previously described in only one case report.

All ten patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS) and functional assessment using the DASH scoring system. The power was assessed isokinetically using the Nottingham Myometer.

Based on the MEPS and DASH grading system all patients achieved a good or excellent result.

In our experience reattachment of the distal biceps tendon using a single incision approach and Arthrex Biotenodesis screw is a new technique which gives a good functional outcome.


K. Hirpara P. Sullivan J. Kelly M. O’Sullivan

Aim: To compare strength the to failure of Silversjold type B repair (SJBR) using bites two, four and six millimetres from the repair site of an ex-vivo porcine flexor tendon model.

Methods: Seventy freshly harvested procine flexor tendons were transected and randomised to repair using either SJBR or simple running epitendinous repair with and without a two strand Modified Kessler repair (MKR), repairs also performed spanning four and six millimetres from the repair site.

Biomechanical testing was performed with a Zwig tensinometer using a one neuton preload and a distraction rate of 20mm/min. Bulking was measured with a digital micrometer and each repair group was tested for mean load to repair failure and mean load to 2mm gap formation. In each case the mechanism of failure was recorded.

Results: The addition of an epitendonous suture statistically increases strength to failure over a core suture alone. The SJB with MKR at all distances was stronger than the the standard epitendonous suture with MK. Optimal strength was obtained at a distance of 6mm from the repair site. Data was assesed using an ANOVA analysis. Repairs failed in all repairs by suture breakage.

Conclusion: The use of an epitendonous suture adds valuable strength to a flexor tendonn repair. The SJBR is somewhat more complicated that a standard running suture however the augmentation in strength makes this worthwhile. The placement of IHM is optimal at 6mm from the repair site and did not statistically increase the tendon bulk.


P.K. Inaparthy J.E. Nicholl

Background: Fracture of the scaphoid bone is the most common fracture of the carpus and frequently diagnosis is delayed. The unique anatomy & blood supply of the scaphoid itself predisposes to delayed union or non-union.

The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid non-unions.

Aim: To conduct a retrospective study looking at union rate, time to union and complications and correlating the outcome of treatment against the delay between injury and surgery and location of the fracture within the bone.

Methods: 36 patients with scaphoid non-union (30 waist & 6 proximal pole) treated by a single surgeon with the cannulated Synthes screw & corticocancellous bone graft were reviewed retrospectively.

Results: We achieved 78% overall union rate. Those patients operated within 6 months of injury achieved 100% union rate. Of the patients with persistent non-union after surgery, half reported no pain and increased movement in the wrist. The failure rate was high in patients whose injury was more than 5 years old, and in proximal pole non-unions.

Conclusion: Our study demonstrates that cannulated screw fixation with bone grafting has high success rate for delayed union of scaphoid waist fractures and scaphoid waist nonunions present for less than 5 years. Patients who present more than 5 years after injury or with proximal pole nonunions have a high chance of persistent nonunion, but can symptomatically improve.


D. Pavlopoulos D. Kafidas L.S. Badras

Introduction: Metacarpal and phalangeal fractures are frequent (13% of the total number of fractures). It seems that the best treatment for the displaced fractures is fixation. Various methods have been used, such as plates and screws, wires, IM-nailing, external fixation. The main problems are adhesions of extensor tendons, scarring and stiffness of the joints.

The purpose of this study is to examine the efficacy of internal fixation using Kirschner wires, applied open or closed, treating metacarpal and phalangeal fractures.

MATERIALS AND Methods: Between 1998 and 2005 145 out of a total of 2848 (5.2%) metacarpal and phalangeal fractures underwent operative treatment. Fixation was achieved by placing extrarticularly two or more Kirschner wires.

The wires were removed after 4 weeks and patients underwent physiotherapy for 2 to 4 weeks. The follow-up period was 3 – 15 mos (average 12 mos) and total range of movement and function of the injured hand was evaluated.

Results: Bone union was evident in 3 to 5 weeks. Range of movement was approximately 90% of normal, except for cases of comminuted intraarticular fractures and also in 6 cases of elderly non-cooperative patients.

One case of infection, complicating a metacarpal fracture and well responding to antibiotic treatment, was recorded. Three further infections resulted after neglected intraarticular fractures, all of which underwent arthrodesis. No rotational deformities were observed. There was no mechanical failure of the fixation in any case.

Conclusion: The fixation of metacarpal and phalangeal fractures using K-wires seems to be a useful method minimally invasive, stable and well tolerated by the patient, not interfering with the mobility of the joints. K-wires are easily removed and of low cost. The functional outcome of this method seems to be quite satisfactory.


J. Chandrasenan M. Espag R. Dias D.I. Clark

The aim of this study was to assess the outcome of a pre-contoured anatomic plate in the treatment of midshaft clavicle fractures.

We treated thirty patients consecutively for middle third clavicle fractures between March 2001 to March 2006. Surgery was performed for acute fractures, non-unions and malunions by a senior surgeon.

Fifteen patients were treated by open reduction and internal fixation with a precontoured small fragment clavicle plate (mean age of thirty-eight years).

Our control group consisted of a consecutive series of fifteen patients treated by internal fixation with conventional plates (mean age of forty-one years). Ten patients had fixation of their clavicles with a reconstruction plate whilst five patients had fixation with a dynamic compression plate (DCP).

Outcomes assessed for both groups were; complications, need for removal of plate, post-operative outcome, and time to union.

All patients were followed up for an average of eighteen months (range eight to thirty months). In the pre-contoured plate group none required removal of hardware. Five patients had complications. Three of these patients complained of numbness around the caudal aspect of the wound which subsequently resolved within six to eight weeks of the operation. The remaining two patients suffered from adhesive capsulitis postoperatively. Their symptoms resolved completely after four months. All patients regained full range of motion. All patients went on to clinical and radiological union with average time to union being 4.7 months (range three to ten months).

In the conventional plate group, nine patients required removal of their plate. Average time to removal of plate from index operation was 7.7 months (range four to thirteen months). Of the nine plate removals there were two plate breakages, five removals for local soft tissue irritation and two persistent painful non-unions. Three patients required subsequent re-plating for non-unions. All fractures united in this group with mean time to union of 5.4 months (range 2 to 14 months).

A pre-contoured clavicle plate provides rigid fixation without compromising plate stiffness and fatigue strength. We have successfully treated patients with acute fractures, nonunions and malunions of midshaft clavicle fractures, where there was gross distortion of normal anatomy. None of our patients required the removal of their plates (minimum follow-up of 8 months). We have also found these plates to be a valuable anatomical template when reconstructing a malunion, nonunion or highly comminuted fracture.

In conclusion, this is the first reported series demonstrating the use of anatomical pre-contoured plates for clavicle fractures. They can reduce time spent on intra-operative contouring, are low-profile and thus far, plate removal has not been necessary.


S. BATRA S. Kale M. Wadhwa

The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25.

The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options.


D.J. Bell M. Pelletier T. Gothelf H.P. Boegl T. Kossman W.R. Walsh

Introduction: The majority of midshaft humeral fractures will achieve a satisfactory outcome with non-operative management. However, internal fixation is occasionally required to assist with rehabilitation, particularly in multiply-injured patients. Although the clinical risks and benefits of the locking plate and humeral nail are well known, there is a paucity of data comparing their mechanical properties.

The aim of this study was to determine the torsional and 4-point bending properties of a midshaft humeral osteotomy reconstructed with either an intramedullary nail or locking plate.

Methods: 19 fresh cadaveric humeri were DEXA scanned to ensure similar BMD. Non-destructive 4-point bending was performed on the intact bone to determine stiffness in the sagittal and coronal planes. Load was applied using an MTS MiniBionix 858 (Mechanical Testing Systems, MN) at a rate of 1 mm/min to a maximum of 450 N.

A transverse midshaft osteotomy was created and a spacer ensured a constant 3-mm gap between the bone ends. Reconstruction was performed with either

Trigen humeral nail (Smith & Nephew, TN) – 10 specimens

Humeral locking plate (Synthes, PA) – 9 specimens

Non-destructive 4-point bending was repeated, and then each humerus was embedded in a low-melting point alloy proximally and distally for torsional testing. Torque was applied at 5 deg/min until failure. Maximum torque, maximum angle and stiffness were calculated.

All data were analysed with SPSS for Windows (SPSS Inc., Il) using ANOVA.

Results: One specimen in the locking plate group fractured during plate application and was excluded from the study. Non-destructive bending tests showed no significant difference in stiffness of the intact bones between the two groups.

4-point bending: the bones reconstructed with the intramedullary nail were ~50% as stiff as the intact state in both planes. There was no statistically significant difference in stiffness between the intact bones and those reconstructed with the locking plate.

Torsional testing: the locking plate specimens were 3 times as stiff as the intramedullary nail specimens (P< 0.05) and failed at twice the torque (P< 0.05).

Discussion: Humeral intramedullary nails are reported to have an advantage over plates under axial loading (Chen et al, 2002). However, this study demonstrates that locking plates are superior to intramedullary nails in torsion and four-point bending. Although the clinical situation often dictates the most appropriate management, locking plates should be considered in patients when torsional or four-point bending loads are expected to predominate in the post-operative period.


A.G. Baltov N.N. Tzachev N.P. Tivchev A.M. Iotov

Objectives: To evaluate and compare the results of interlocking nailing (ILN) and plating (PL) in fresh humeral shaft fractures (HSF)

Material and Methods: During 7 years period 145 patients with HSF (84 males and 61 females) were operated and followed up for 8 – 60 months (mean 18 months). According to AO there were 64 Type A, 53 Type B and 28 Type C fractures. Of 18 open injuries there were 10 grades I, 5 grades II and 3 grades IIIA. There were 33 patients with polytrauma, 11 cases with associated limb injuries, 9 cases with floating elbow and 22 patients with primary neurological deficit. In 75 fractures ILN was performed and PL in rest 70.

Results: The mean operative time was 85 min for ILN vs./117 min for PL and the mean blood loss 100ml vs./250 ml. Healing occurred in 139(95.6%) fractures with mean healing time 75 days vs./85 days. Functional results according to Rommens score were as follows. Shoulder: excellent 62(82.6%) vs./55(78.5%), good 11(14.6%) vs./11(15.7%), poor 2(2.8%) vs./4(5.8%).

Elbow: excellent 69(92%) vs./52(74.3%), good 6(8%) vs./16(22.8%), poor 0 vs./2(2.9%). Complications noted were iatrogenic nerve palsy 1(1.3%) vs./12(17%), delayed union 5(7%) vs./2(3%), non union 1(1.3%) vs./5(7%), infection 0 vs./1(1.4%), fixation failure 1(1.3%) vs./5(7%) and reosteosynthesis 1(1.3%) vs./1(1.4%), shoulder impingement 8(11%) vs./2(3%).

Conclusions: Interlockimg nailing reduces risk of nerve injury and infection, provides more stability in segmental, complex and osteoporotic HSF. No significant differences in the term of healing in the both methods. Plating should be preferred in open Fx with incidental nerve palsy or vascular injury and juxtaarticular Fx, especially distally located. The method provides anatomical reduction, but requires extended approach and increases risk of iatrogenic nerve palsy.


O. Alborov G.M. Chochiev I.A. Odincova S.M. Vorobjev G.M. Karaulov S.L. Tikhomirov N.V. Panteleev

Early percutaneous pin fixation after closed reduction is the treatment of choice for displaced distal humerus fractures.

Our purpose was to study the outcome of closed reduction and external fixation more than 1 week after injury.

Material and methods: Ninety-one children with fractures of the distal humerus were treated more than 7 days after injury (range 7 – 65 days, average 10,5 days). The average age at the time of surgery was 6,7 years (range 3,3 – 16,1years). 63 were male. All had 1–3 previous unsuccessful closed or\and open reductions in another clinic. Twelve had iatrogenic nerve injury. Our method consists of applying the Ilizarov’ apparatus in the proximal humerus for primary transolecranon traction and close reduction using image intensifier. After reduction two crossed K-wires were passed through the condyles and final fixator was constructed. The K-wire from olecranon was removed. Postoperative fixation was done for 3 – 6 weeks. Elbow motion was started 2–3 days after surgery.

Results: The results depended on the severity of the fracture and time after injury. All fractures went on to union. Good and excellent results (no deformity or contracture) occurred in 95 % of 59 patients with transcondylar fractures (AO classification type A2 and A3) and 7–16 days after injury. Of twenty patients with transcondylar fractures (AO classification A2 and A3) and more than 17 days 85% had similar result. Three children required eventual supracondylar osteotomy because of progressive rotational-varus deformity. Of twelve children with T- of Y- fractures (AO C1, C2, or C3) three (25%) had poor Results: Conclusion: Late reduction with external fixation was accomplished with anatomic reduction and good functional outcome and allowed early motion of the elbow.


R. Ekholm J. Adami J. Tidermark K. Hansson H. Törnkvist S. Ponzer

Introduction: Humeral shaft fractures account for 1–3% of all fractures. Little is known about additional epidemiological data on this specific fracture type. The aim of this study was to investigate the epidemiology of humeral shaft fractures in patients 16 years or older in Stockholm during the years 1998–99.

Patients and Methods: All patients 16 years or older with a humeral shaft fracture admitted to any of six major hospitals in the County of Stockholm during the two years 1998–99 were included in the study. A total of 401 fractures in 397 patients were found. Three hundred and sixty-one of the fractures were traumatic and were classified according to the Orthopaedic Trauma Association (OTA) classification system. The remaining 40 fractures were pathological (n=34) or peri-implant fractures (n=6). Open fractures were classified using the Gustilo classification system. Data regarding the injury mechanism, age, gender, side of the injury and occurrence of possible radial nerve injury were collected from the medical charts. The overall incidence and the age-specific incidence were calculated on the basis of data from Statistics Sweden.

Results: The incidence was 14.5 per 100 000 persons per year with a gradually increasing age-specific incidence from the fifth decade in both genders and reaching an incidence of almost 60 per 100 000 persons and year in the ninth decade. The majority of fractures were closed ones sustained after simple falls among elderly patients. The age distribution among females was characterised by a peak in the eighth decade while the age distribution among males was more even. Type A (simple) fractures were by far the most common and the majority of the fractures were located in the middle and proximal parts of the humeral shaft. The incidence of radial palsy was 8%. Fracture localisation in the middle and distal part of the shaft was associated with an increased risk for having radial nerve palsy. Only 2% of the fractures were open and 8% were pathological.

Discussion: These recent epidemiological data on humeral shaft fractures are representative of a society with a limited amount of high-energy trauma, including penetrating trauma, which probably reflects the situation in the majority of European countries. Our results can be used to facilitate the future treatment of patients with this particular fracture.


R. Bryant S. Kapoor S. Royston M. Dennison

Background: The Ilizarov Method is well established for lower limb trauma and reconstruction. However, although the same principles apply, its use in the upper limb is less well described.

Aims of Study: To review indications and outcomes of all Ilizarov arm fixators applied by the two limb reconstruction surgeons in our unit.

Methods and Results: All patients treated using an upper limb Ilizarov frame were identified and reviewed. Demographic data, indications and durations of frames collected. Fifty-one cases identified. Average age 43 (17–81). Tertiary referrals in 63%. Previous surgery in 78%. Mechanism of injury included: 37% RTA, 40% simple falls. Reasons for frame usually multifactorial including 22 for non-unions. 43% of fixators applied acutely (< 6 weeks). Average frame time was 152 days (34–343). Over 80% achieved expected outcome –obtaining good function or fracture union. 14 needed further frame surgery including 5 for frame removal, 3 adjustments and 2 corticotomies. Most frames removed in clinic.

Complications: 30% superficial pin site infection. No deep wire infections. 1 wrist malunion requiring delayed correction. 2 patients had neurological complications from frame surgery. One radial palsy possibly from humeral plate removal. One median palsy due to pressure from wire. One patient had an above-elbow amputation for persistent infection.

Conclusions: The Ilizarov technique appears well tolerated and successful despite often infected or deformed tissues. Indication and intended purpose of arm frames very varied. This technique allows stabilization (with/without bone loss), treatment of non-unions and lengthening/bone transport. The Ilizarov Method is valuable for limb salvage/reconstruction.


M. Contreras Joya F. Santos Yubero S. Navarro Martinez M. Fernandez Centeno

We have achieved a retrospective study in 37 cases of complex radial heads fractures (By Morrey classification). We used the Judet bipolar prosthesis (1996) because it has an integrated articulation that allows an arc of motion of 35°. We revised clinical indication and surgical technique. We analyse clinical and radiographics findings with Bro-berg-Morrey scoring system (1986) for clinical outcome and radiographic Morrey evaluation (1981).

Material: We report our experience over 5 years (since April of 2000 till June 2005) with floating radial head prosthesis over 36 patients. A bilateral case; and a 38 months of medial follow-up (range, 12 to 74 months).

We made a clinical and radiographic control at 1, 3, 6 and every 12 months. We used the Broberg and Morrey scale to value the clinical results; and the radiographic value scale of the same author.

The diagnosis distribution was the following:

16 luxation fracture (Masson type-IV fracture)

Monteggia variety

posttraumatic stiffness after primary treatment

Hotchkiss “terrible triad”

associated MCL tears

Results: There were two complications: 2 infections, only in one of them we needed to take away the implant. Its represented a 5,3%. We took away one prosthesis for a infection and another for a insufficient osteothomia (“overstuffing”). We had 2 cases of neuropatya (posterior interosseous and cubital) but it resolved without surgery. Six stiffness, four of them were posttraumatic stiffness, then there were stiffness before surgery. 1 case of osteolysis and prosthesis instability after 5 years.

The clinical results were:

Excellent 21, 6% (8 cases)

Good 56, 7% (22 cases)

Fair 13, 5% (5 cases)

Bad 8% (3 cases)

Conclusion: The excellent-good result were 78,3% but there were much better in acute surgery (86,1%) than in secondary or delayed surgery (50%) Bypolar design allows a continuous contact against the convex humeral condyle during elbow movement. This clinical results confirm that floating prostheses is well tolerated and it can prevent proximal migration and provide stability while bone and soft tissue heal. From biomechanical point of view, this anatomic design may lead to longer functional lifetime compared with the standard metal prosthesis.

In summary the floating head prostheses is a useful option in Masson III fracture associated with elbow dislocation with or without associated destabilizing fractures but is not free of complications.


G. ZARATTINI S. Galli M. Marchese U.E. Pazzaglia

The purpose of this study was to evaluate the long-term results of isolated closed Mason type-II and III fractures treated by internal fixation or by radial head resection.

METHODS: A long-term retrospective study was undertaken of eighty-seven patients with a Mason type-II and type-III isolated closed fracture of the radial head. Fifty of them were treated by radial head resection, two by excision of the fracture’s fragment and thirty-five of them by internal fixation. The average length of follow-up was 92.25 months. The patients were divided into two homogeneous groups, of which group 1 was made up of fifty-two patients treated by capitellectomy and by excision of the fracture’s fragment, and group 2 was made up of thirty-five patients treated by osteosynthesis.

The patients were submitted to clinical and radiographic evaluation. The subjective outcome was assessed with the DASH questionnaire (Disabilities of Arm-Shoulder-Hand); elbow pain on loading and at rest (VAS scale); and tenderness, loss of strength, and range of motion of the affected elbow. The uninjured arm served as the control. Flexion and extension of the elbow and the wrist, pronation and supination of the forearm, and the angle of the extended/flexed elbow were measured with a goniometer. Grip strength of the hand was evaluated with the Jamar vigorimeter. The radiographic evaluation included antero-posterior and lateral projections of the elbow and antero-posterior of the wrist.

RESULTS: The previously injured elbows in group 1 had an average loss of flexion of 14.61° and an average loss of extension of 8.65° compared with the uninjured, and there was less pronation of the forearm on the injured side (4.81°) and less supination (9.04°). Instead the injured elbows in group 2 had an average loss of flexion of 3.71° compared with the uninjured and an average loss of extension of 2°, which is minimal, and there was a further minimal loss of pronation of 1° and loss of supination of 0.86°.

In group 1, the definate average DASH value was 21.26, much higher than the value of 2.81 found in group 2. The VAS average value was also superior in the group 1 (3.87) compared with group 2 (1.2).

We also evaluated, in direct manner, the instability of the injured elbow using the valgus-stress test, which revealed a slight instability (48%) and a moderate instability (35%) of group 1. No instability however was found in group 2.

With regard to radiographic analysis, radiographic signs of arthrosis were present in 90% of patients who had undergone capitellectomy, and in 16% of those who had undergone osteosynthesis.

CONCLUSION: The patients in whom the radial head fracture was treated with open reduction and internal fixation had satisfactory joint motion, with greater strength and better function than the patients who had undergone radial head resection.