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Volume 93-B, Issue SUPP_III July 2011

Abdel-Rahman Lawendy David W. Sanders Aurelia Bihari Amit Badhwar

Purpose: Compartment syndrome is a limb-threatening complication of skeletal trauma. Both ischemia and inflammation may be responsible for tissue necrosis in compartment syndrome (CS). In this study, normal rodents were compared with neutropenic animals to determine the importance of inflammation as a mechanism of cellular damage using techniques of intravital videomicroscopy (IVVM) and histochemical staining.

Method: Forty Wistar rats were randomised. Twenty animals served as a control (group C). Twenty rats were rendered neutropenic using cyclophosphamide (250mg/kg) (group N). Animals were anaesthetised with 5 % isoflurane. Elevated intracompartmental pressure was induced by saline infusion into the anterior hindlimb compartment and maintained at 30–40 mmHg for 0, 15, 45 or 90 minute time intervals. Following fasciotomy, the EDL muscle was analyzed using IVVM to quantify tissue injury, capillary perfusion, and inflammatory response.

Results: The proportion of injured cells decreased in group N compared to group C at all time intervals of EICP (p< 0.05). The proportion of injured cells in group N was 8 % after 0 minutes EICP, and 12, 15, and 10 % at 15, 45, and 90 min of EICP. In group C injured cells increased from 8 % to 20, 22, and 21 % at 15, 45, and 90 minutes EICP respectively. Groups N and C both demonstrated a time-dependent reduction in capillary perfusion. In group N continuously-perfused capillaries decreased from 79±4/mm with 0 min of EICP, to 48±11/mm (15min), 36±7/mm (45min), and 24±10/mm (90min) (p < 0.05). Overall, There was no difference between groups N and C with regards to perfusion (p> 0.05).

Conclusion: This study demonstrates the importance of inflammation as a cause of injury in compartment syndrome. There was a 50% decrease in injury in neutropenic animals compared to controls after 90 minutes of elevated intracompartmental pressure. Microvascular perfusion analysis demonstrated a time-dependent decrease in capillary perfusion in both neutropenic and control animals. Blocking of the inflammatory response via neutropenia was protective against tissue injury. These results provide evidence toward a potential therapeutic benefit for anti-inflammatory treatment of elevated intra-compartmental pressure.


Frédérick-Charles Cloutier Dominique Rouleau Eric Beaumont Michael Atlan Pierre H. Beaumont

Purpose: Nerve re-generation and functional recovery are often incomplete after a peripheral nerve lesion. The aim of this study was to determine if the injection of chondrotinase ABC at the lesion site, one hour of electrical stimulation, and the combination of these treatments at the time of repair are effective in promoting nerve regeneration and muscle re-innervation.

Method: A complete right sciatic nerve section was done on 32 female Sprague-Dawley rats. End-to-end microsuture repair was performed and fibrin glue was added. Five groups were studied:

Sutures and Fibrine glue (S+F),

S+F and chondrotinase ABC,

S+F and electrical stimulation,

S+F and chondrotinase and electrical stimulation,

uninjured nerve. Video kynematic, EMG, muscle strengh and axonal count were used to asses nerve recovery at 150 days post-repair.

Results: Side video kinematics was performed and a larger excursion of the hip-ankle-toe angle during walking was showed in groups 2, 3, and 4. (p< 0.05) At 150 days, in-vivo EMg activity and maximal muscle force were similar in group 2, 3, 4, 5 and all of them were higher compared to group 1 (p< 0.05). Histological study revealed equivalent number of axone in all group and pore correlation with nerve function.

Conclusion: In conclusion, five months after nerve transection, the recovery is incomplete when using suture and fibrine glue only. Moreover, an injection of chondrotinase ABC at the lesion site and/or one hour of electrical stimulation of the proximal nerve stump is beneficial in promoting nerve regeneration and functional muscle re-innervation.


Charles Secretan Jenn Bater Keith Bagnall Nadr M. Jomha

Purpose: The introduction of supplementary cells into a region of diseased or damaged tissue is becoming a viable treatment strategy in many areas of medicine. Mesenchymal stem cells (MSCs) are attractive for this purpose because they represent an autologous, multipotent cell source. However, it has been recognized that populations of MSCs represent a heterogenous group of cells with each cell subpopulation possessing unique terminal differential capacity. The CD44 cell surface receptor has previously been identified on some of the cells within the MSC population. It is also present on chondrocytes and is thought to play a critical role in cartilage matrix generation and homeostasis. We hypothesized that a CD44+ purified subpopulation of MSCs will possess enhanced chondrogenic potential and be more suitable for articular cartilage regeneration.

Method: Bone marrow aspirates were collected from orthopaedic patients undergoing iliac crest bone grafting. Human MSCs were isolated and cultured using standard techniques. Flow cytometry was utilized to identify the cell surface antigens characteristic of the MSC population. FACS was utilized to isolate the CD44 positive cells based on antigenic recognition, generating a CD44 positive population and a CD44 negative population. To confirm the multilineage potential of the isolates, defined media and culture conditions were utilized to differentiate both groups into osteocytes, adipocytes and chondrocytes. Real time polymerase chain reaction was utilized to quantify and compare the essential markers, collagen II, collagen I and aggrecan, in the stem cell derived chondrocytes. The CD44 enriched and CD44 depleted populations were compared.

Results: The cells isolated possessed a cell morphology and surface antigen profile consistent with a MSC population. In addition, both experimental groups demonstrated multipotent ability. Real time PCR analysis of the chondrogenic cells demonstrated that the CD44 positive population expressed collagen II and aggrecan at a significantly higher level than the CD44 negative population.

Conclusion: To date no group has successfully identified a relationship between a MSC subpopulation and the multipotent progenitors responsible for generating cartilage. This work demonstrated that there are MSC sub-populations with different potential for chondrogenic expression and represents an important step towards identifying MSC subpopulations with enhanced cartilage formation potential.


Michael Monument David A. Hart A. D. Befus Paul T. Salo Kevin Hildebrand

Purpose: To determine if mast cell activity is vital to the induction of joint capsule fibrosis and contracture formation in a rabbit model of posttraumatic joint contracture.

Method: To reproducibly induce joint contractures, we used a model of surgical injury and immobilization of the knee in skeletally mature New Zealand white rabbits. Four animals groups were studied: a non-operative control group (CON), an operative contracture group (ORC) and two-operative groups treated with a mast cell stabilizer, Ketotifen fumarate at doses of 0.5mg/kg (KF0.5) and 1.0mg/kg (KF1.0) twice daily subcutaneously, respectively. Animals were sacrificed after 8 weeks of immobilization. Flexion contractures (biomechanics), cellular counts of myofibroblasts and mast cells within the joint capsule (immunohistochemistry) and the joint capsule protein expression of TGF-β1, collagen I and III were quantified (western blots). Biomechanical data was interpreted using a linear regression analysis of repeated measures and an ANOVA analysis of variance was used for molecular data. Significance was defined at p< 0.05 for all statistical tests.

Results: Flexion contractures were most severe in the ORC group and treatment with Ketotifen (both KF0.5 and KF1.0) significantly reduced contracture severity by 52% and 42%, respectively (p< 0.03). Joint capsule myofibroblast and mast cell hyperplasia was a prominent feature of the more severely contracted ORC group and myofibroblast and mast cell numbers were dramatically reduced in both Ketotifen groups (p< 0.001). The expression of TGF-β1 and collagen I was also increased in the ORC group and significantly reduced in both Ketotifen groups (p< 0.01).

Conclusion: Joint capsule fibrosis, characterized by hyperplasia of myofibroblasts and mast cells and enhanced collagen deposition, is a prominent feature of posttraumatic joint contractures in this animal model. Treatment with a mast cell stabilizer reduced the molecular markers of joint capsule fibrosis and the resultant biomechanical severity of contracture formation. These results suggest mast cell activity may be an important process in the development of posttraumatic contractures and future work is needed to determine if pharmacological inhibition of mast cell activity has a preventative or therapeutic role in humans.


Greg W. McGarr David W. Sanders Amit Badhwar

Purpose: Compartment syndrome is a severe complication of skeletal trauma. Intravital microscopy (IVVM) has demonstrated an inflammatory response to compartment syndrome (CS). The molecular mechanisms underlying this inflammatory response are unknown. The purpose of this study was threefold. First, a broad inflammatory cytokine profile was examined to determine the molecules responsible for white cell recruitment. As well, skeletal muscle expression of white cell adhesion molecules including P-Selectin, E-Selectin, Mac-1 and ICAM-1 were examined to assess the extent of white cell activation in target tissues. Finally, skeletal muscle apoptosis was measured to determine the magnitude of cell death.

Method: Normal and neutropenic rats were randomised to either compartment syndrome or control groups. CS Animals were treated with 45 minutes of elevated intra-compartmental pressure (EICP) of the hindlimb. Fasciotomy was then performed, followed by 60 minutes of reperfusion. Control animals experienced no EICP. Blood was collected from carotid arterial lines used for pressure monitoring. Skeletal muscle tissue samples were collected from the EDL following reperfusion. Blood samples were obtained from carotid arterial lines and skeletal muscle was collected following reperfusion. A Multiplex assay was used to examine serum levels of 24 proinflammatory cytokines/chemokines. Skeletal muscle mRNA levels of P-Selectin, E-Selectin, Mac-1 and ICAM-1 were evaluated using real-time PCR. Finally, skeletal muscle apoptosis was measured by DNA laddering and a caspase-3 assay.

Results: Neutropenic CS animals demonstrated a continuous increase in TNF-alpha levels, peaking at 700+/−350pg/ml by 60 minutes of reperfusion. TNF-alpha values for other groups did not increase. A 104-fold increase in ICAM-1 mRNA levels was observed in neutropenic CS rats while other groups showed no significant increase. There was no significant increase in any group for P-Selectin, E-Selectin, or Mac-1.

Conclusion: This study is the first to attempt to describe the molecular inflammatory response in CS. Neutropenic CS animals demonstrated an upregulation in TNF-alpha and ICAM-1 mRNA levels. This likely represents an attempt to generate an inflammatory response in the neutropenic animals. Additional data at incremental timepoints is necessary to further characterize the molecular mechanisms. However, both TNF-alpha and ICAM-1 appear to be important in the mechanism of inflammatory activation in compartment syndrome.


Andrei R. Manolescu David Cinats Charles Secretan Deborah O’Neill Chris Cheeseman Keith Bagnall Nadr M. Jomha

Purpose: Differentiation of BM-MSCs into adult chondrocytes represents a complex physiological mechanism and full characterization of each individual stage through which the BM-MSC differentiate into adult chondrocytes is not yet understood. The physiological micro-environment of the chondrocytes is intensely hypoxic which triggers over-expression SLC2A proteins (GLUTs) in their membranes as a compensatory mechanism for energy production within the glycolytic cycle.

Method: We cultured and differentiated BM-MSC, and adult chondrocytes in hypoxic (5% O2 tension) and normoxic (20% O2) conditions. Within this cell populations we screened for the presence of the 12 GLUT genes as well as quantification of the variation of the 12 GLUTs gene translation by simple pcr and rt-pcr. The expression profile of the GLUT proteins was investigated using western blot analysis and immunohistochemistry. Functional characterization of the GLUTs expressed in the different cell populations was carried out by the means of radio-isotope labeled hexose fluxes done accordingly to the substrate specificity and kinetic properties particular to each SLC2A isoforms.

Results: Our data showed that the functional genotype and phenotype of the adult chondrocyte and hypoxic BM-MSC comprised an extensive expression of fructose-transporting GLUTs as opposed to the glucose-only transporting isoforms expression in normoxic BM-MSC. The flux data showed clear similarities in functional GLUT profiles between BM-MSC cultured in hypoxic conditions, adult chondrocytes. Investigation of the uptake of a panel of five individual sugars (glucose, fructose, 2-deoxy-gluose, 3-orthomethyl-glucose and galactose) in these cellular populations under both hypoxic and normoxic conditions and in the presence and absence of Cytochalasin B (a GLUT1-specific inhibitor) showed that SLC2A class II transporters (GLUTs 5, 7, 9 and 11) play a more important role in the uptake of sugars by the normal hypoxic chondrocytes when compared to the ubiquitously-expressed GLUT1.

Conclusion: Use of this approach allows the correct culturing conditions to be identified that would select for those chondrocyte precursors from the total BM-MSC population that would have the best potential for producing viable articular cartilage. In addition, specific substrates for GLUTs isoforms could be used for physiologic, non-invasive and real time imaging of cartilage, BM-MSC and cartilage autograft by means of Positron Emission Tomography.


Fackson Mwale Hong Tian Wang Pierre-Luc Girard-Lauriault Michael R. Wertheimer John Antoniou Alain Petit

Purpose: Recent evidence indicates that a major drawback of current cartilage and intervertebral disc (IVD) tissue engineering is that human mesenchymal stem cells (MSCs) from osteoarthritic patients rapidly express type X collagen (COL10A1), a marker of late-stage chondrocyte hypertrophy associated with endochondral ossification. We recently discovered that a novel atmospheric-pressure plasma-polymerized thin film substrate, named “nitrogen-rich plasma-polymerized ethylene” (PPE:N), is able to inhibit COL10A1 expression in committed MSCs. However, the cellular mechanisms implicated in the inhibition of COL10A1 expression by PPE:N surfaces are unknown.

Method: Human mesenchymal stem cells (MSCs) were obtained from aspirates from the intramedullary canal of donors (60–80 years of age) undergoing total hip replacement for osteoarthritis. Bone marrow aspirates were processed and MSCs were cultured on commercial polystyrene (PS control) and on PPE:N surfaces in the presence of different kinases and cyclooxygenase inhibitors for 3 days. Total RNA was extracted with TRIzol reagent (Invitrogen, Burlington, ON) and the expression of COL10A1, cyclooxygenase-1 (COX-1), and 5-lipoxygenase (5-LOX) genes was measured by real-time quantitative RT-PCR.

Results: Results showed that a non-specific inhibitor of cyclooxygenases reduced the expression of COL10A1. In contrast, inhibitors of protein kinases stimulated the expression of COL10A1. Furthermore, potent and selective inhibitors of COX-1 and 5-LOX also reduced the expression of COL10A1. However, COX-2 and 12-LOX inhibitors had no significant effect on the expression of COL10A1. COX-1 gene expression was also decreased when MSCs were incubated on “S5” PPE:N surfaces. Interestingly, MSCs did not express 5-LOX.

Conclusion: PPE:N surfaces suppress COL10A1 expression through the inhibition of COX-1 which is directly implicated in the synthesis of prostaglandins. The decreased expression of COX-1 and COL10A1 in human MSCs cultured on PPE:N is therefore in agreement with the induction of the osteogenic capacity of rat bone marrow and bone formation by systemic or local injection of PGE2 in rats. However, PGE2 and other prostaglandins inhibited COL10A1 expression in chick growth plate chondrocytes. This suggests that the effect of prostaglandins on COL10A1 expression may be cell-specific or may be dependent on pre-existing patho-physiological conditions.


Richard C. Smith Brenton Short Paul W. Clarkson Bassam A. Masri Michael Underhill

Purpose: Chondral injuries of the knee are commonly seen at arthroscopy, yet there is no consensus on the most appropriate treatment method. However, untreated cartilage injury predisposes to osteoarthritis contributing to pain and disability. For cell-based cartilage repair strategies, an ex-vivo expansion phase is required to obtain sufficient numbers of cells needed for therapy. Although recent reports demonstrated the central role of oxygen for the function and differentiation of chondrocytes, little is known of the effect of physiological low oxygen concentrations during the expansion of the cells and whether this alters their chondrogenic capacity.

Method: Initial studies of chondrocyte expansion were performed in mature mice, with cells expanded at either atmospheric oxygen tension (21%) or 5% 02 in monolayer cultures. Chondrogenic differentiation was subsequently assessed via micromass culture. Having determined that oxygen tension influences murine chondrocyte expansion and differentiation, similar studies were conducted using adult human chondrocytes taken from knee arthroplasty off-cuts, with mRNA expression of select genes involved in the chondrogenic program analyzed by q-PCR.

Results: Cellular morphology was improved in hypoxic culture, with a markedly more fibroblastic appearance seen after greater than 2 passages in 21% O2. Micromass cultures maintained in hypoxic conditions demonstrated stronger staining with Alcian blue, indicating stronger expression of cartilaginous glycosaminoglycans. Collagen type II mRNA expression was two-fold higher in cells expanded at 5% as compared to expansion at 21% O2. Micromass cultures grown at 21% O2 showed up to a twofold increase in the tissue content of glycosaminoglycans when formed with cells expanded at 5% instead of 21% O2. However, no differences in the mRNA expression or staining for collagen type II protein were observed in these micromass cultures. Hypoxia (5% O2) applied during micromass cultures gave rise to tissues with low contents of glycosaminoglycans.

Conclusion: In-vivo, chondrocytes are adapted to a hypoxic environment. Taking this into account, applying 5% O2 in the expansion phase in the course of cell-based cartilage repair strategies, may result in a repair tissue with higher quality by increasing the content of glycosaminoglycans.


Krishna Maragh Jenn Bater Charles Secretan Keith M. Bagnall Nadr M. Jomha

Purpose: Current techniques for articular cartilage repair remain suboptimal. The best technique involves the introduction of cultured chondrocytes into the injury site. Experimental results of current chondrocyte culture and expansion techniques (passaging) have shown phenotypic alteration resulting in fibroblast-like cells. Therefore, treatment methods that propose the transplantation of cultured chondrocytes might be transplanting fibroblast-like cells instead of chondrocytes. This experiment explored the difference in genetic expression of chondrocytes left at confluence compared to chondrocytes that were passaged as performed in current culture techniques. It was hypothesized that chondrocytes left at confluence would maintain their collagen I and collagen II gene expression over time.

Method: Fresh normal human articular cartilage was collected from deceased donor patients. The matrix was digested and the chondrocytes were plated in monolayer to create two groups. The first group was cultured and passaged 2? at confluence seven times. The second group was cultured at confluence and left for seven weeks, with medium changes every 3–4 days without passaging. At weekly intervals RNA was extracted from cells in both groups and analyzed with real time PCR, probing specifically for the genes responsible for the production of collagen I, collagen II, aggrecan, and GAPDH. This was done in duplicate.

Results: Collagen II gene expression was maintained over seven weeks in cells left at confluence but was decreased in passaged cells. Collagen I gene expression decreased over seven weeks in cells left at confluence, but remained the same in passaged cells. Aggrecan gene expression remained the same in both groups.

Conclusion: Current culture and expansion techniques that employ passaging (as used in clinical scenarios) result in significant alterations in gene expression that are inconsistent with the current definition of a “chondrocyte”. Culturing chondrocytes at confluence can produce gene expression more similar to native chondrocytes but even these cells have expression of collagen type I that should not be present in chondrocytes. The results of this study suggest that further investigation is required to develop chondrocyte culture and expansion techniques that minimize the de-differentiation of chondrocytes by maintaining collagen II gene expression and eliminating/preventing collagen I gene expression.


Neil Saran Robert É. Turcotte Renwen Zhang

Purpose: Extracortical bone bridging and ingrowth have been shown to reduce stresses on the stem and cement mantle of tumor endoprostheses. The purpose of this study was to assess the effect of bone morphogenetic protein 7 (BMP-7) delivered by Peri-Apatiteâ (PA, Stryker Orthopaedics) hydroxyapatite coating on porous segmental replacement prostheses.

Method: Eighteen mature mongrel canines were implanted with unilateral segmental replacement prostheses made of a cobalt-chromium (Co-Cr) alloy and coated with two layers of sintered Co-Cr alloy beads (diameter 600 to 800mm). The control group consisted of a plain porous coated segmental prosthesis without any PA coating. Group 2 consisted of a PA-coated segmental prosthesis coated with buffer solution. Group three consisted of a PA-coated segmental prosthesis loaded with rhBMP-7 (Stryker Biotech) in a buffer solution carrier. Group 1 had the implant only. Group 2 had the buffer solution evenly applied to the porous coat and group 3 had 2.9 mg of BMP-7 in liquid buffer solution evenly applied. The canines were allowed to fully bear weight without restrictions. The femurs were retrieved at twelve weeks for radiographic and histologic analysis.

Results: Gross and radiographic data of the retrieved specimens showed that all six PA-coated implants augmented with BMP-7 had complete bone bridging; only one of the PA-coated implants and only two of the plain porous implants were completely bridged. There was a greater percentage of bone apposition for the BMP-7 augmented PA-coated group compared to both the plain (p=0.0026) and the PA-coated (p=0.0001). There was no difference in bone formation or bone apposition between the plain and PA-coated groups. Histology revealed greater depth of bone ingrowth in the BMP-7 augmented PA-coated group as compared to the plain (p< 0.0001) and the PA-coated (p< 0.0001) groups. There was also significantly greater bone apposition in the BMP-7 augmented PA coated groups as compared to the plain (p=0.0014) and PA-coated (p=0.0067) groups. There was no significant difference in depth of bone ingrowth or bone apposition between the plain and PA-coated groups.

Conclusion: BMP-7 when used to augment PA-coated prostheses in a canine segmental defect model can significantly improve extracortical bone bridging and bone ingrowth. PA-coated implants may be considered to deliver the exogenous biological growth factors.


Kivanc I. Atesok Ru Li Emil H. Schemitsch

Purpose: Endothelial Progenitor Cells (EPCs) have been proven to contribute to formation of new blood vessels. The objective of this study was to evaluate the effects of local EPC therapy on the stimulation of angiogenesis at a fracture site and the promotion of bone healing by increasing osteogenesis and callus formation.

Method: Rat bone marrow EPCs were isolated and cultured. A segmental bone defect (4mm.) was created in the rat femur diaphysis and stabilized with a mini-plate. A gelfoam piece impregnated with a solution of EPCs (1x106) was placed into the fracture gap. Control animals received only saline-gelfoam with no cells. In total, 42 rats were studied: 21 in EPC and 21 in control groups. Seven animals were sacrificed from each group at one, two, and three weeks post-operatively. Plain radiographs of the operated femur were taken before sacrifice. Operated femurs were harvested and the specimens from the osteotomy site were collected for histological evaluation. The x-rays were scored in a scale from zero to five according to the percentage and the intensity of the bone filling at the osteotomy site. Hematoxylin-eosin stained slides were evaluated for new vessel formation and the amount of bone tissue.

Results: Radiographically, at three weeks, the mean score for the EPC group was 4.5 with five out of seven animals having bridging callus; whereas for the control group, the mean score was 2.2 with no bridging callus formation. At two weeks, EPC treated animals had a mean score of 2.4, and the control group had a score of 1. Bone formation was insignificant at one week in either group, however, the scores tended to be higher in the EPC group animals than the control; 0.6 to 0.3 respectively. Histological evaluation revealed that the specimens from EPC treated animals had abundant spicules of trabecular bone containing predominantly bone cells, osteoid, and new vessels. Conversely, control animals had scarce trabecular bone with markedly less bone cells and vessels.

Conclusion: Local EPC therapy stimulates angiogenesis and increases osteogenesis and callus formation post fracture. Our report encourages further investigation of the local use of EPCs as a potential therapy to promote bone regeneration.


Paul R. T. Kuzyk Emil H. Schemitsch John E.D. Davies

Purpose: The aim of our study was to evaluate bone formation and angiogenesis produced within a biodegradable poly-D, L-lactide-co-glycolide acid/calcium phosphate (PLGA/CaP) scaffold when used to treat a diaphyseal tibia defect and compare this to an iliac crest autograft or an empty defect.

Method: An 8.0 mm diaphyseal defect was created in a canine tibia model. All tibiae were reamed to 7.0 mm and fixed with a 6.5 mm statically locked intramedullary nail. Eighteen canines were allotted into three treatment groups:

empty (N=5),

iliac crest autograft (N=6), or

PLGA/CaP biodegradable scaffold Tissue Regeneration Therapeutics Inc., ON, Canada) (N=7).

Fluorescent markers were given at different times: calcein green (six weeks), xylenol orange (nine weeks), and tetracycline (11 and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Radiography, Micro CT, and brightfield and fluorescent microscopy were used for analysis.

Results: Micro CT and brightfield images of scaffold samples displayed multiple vessels (10 to 100μm) within the scaffold. The bone volume and vasculature volume (measured with Micro CT) within the tibial defect site were reported as a percentage of the total volume of the defect site. The percent bone volume within the defect site was not different between treatment groups (p=0.112). There was greater percent vasculature volume in the scaffold group than the autograft group (p< 0.001). Bone formation at the osteotomy sites was defined as the distance from the original osteotomy site to the tip of newly formed bone. Osteotomy bone formation was significantly greater in the scaffold group than the autograft group (p=0.015). Osteotomy sites associated with greater angiogenesis displayed greater bone formation. Bone formation rates were reported as the distance between the fluorescent bone labels. Autograft samples had the greatest bone formation rates within the periosteum. Autograft and scaffold samples had the greatest rate of bone formation within the cortex.

Conclusion: Our canine tibial defect model provides a satisfactory facsimile of the traumatic tibia fracture with associated bone loss. The PLGA/CaP biodegradable scaffold we have employed promotes angiogenesis within a defect and could be used in conjunction with autografting.


Thomas Karakolis Gregory R. Wohl

Purpose: Bone fatigue damage can lead to stress fractures and may play a role in fragility fractures. The rat forelimb compression model has been used to examine biological responses and gene expression associated with woven bone repair after fatigue damage. Development a similar mouse model would enable the use of genetically modified mice to study molecular mechanisms associated with bone repair.

Method: Following approval from our Central Animal Facility, forelimbs of male retired breeder C57BL/6 mice and Sprague Dawley rats (n=31 each) were loaded in axial compression across the carpus and olecranon. First, both forelimbs (postmortem, n=6 each) were monotonically loaded to determine failure load. Next, both forelimbs of animals (postmortem, n=5 each) were loaded cyclically to sub-fracture load (67% of monotonic load for mice, 55% for rats) until fatigue failure. Following analysis of fatigue displacement histories, right forelimbs (post-mortem, n=10 each) were loaded cyclically to a set displacement short of the expected failure displacement (mice–30%; rats–55%). Non-loaded left forelimbs served as controls. Three-point bending tests were performed on the ulnae; mechanical properties were compared between fatigued and non-loaded limbs. Finally, right forelimbs (n=10 each) were cyclically loaded in anaesthetised (2.5% isofluorane) animals to 30% (mice) and 55% (rats) of failure displacement. Animals recovered for seven days; microCT imaging and three-point bend tests were performed on the ulnae.

Results: Ultimate forelimb failure loads were 5.63 ± 0.47 N (mouse) and 57.1 ± 5.8 N (rat). Measured from the 10th cycle, fatigue failure occurred at displacements of 1.68 ± 0.21 mm (mouse) and 2.96 ± 0.22 mm (rat). In three-point bending, fatigue damaged ulnae failed at significantly lower loads versus control (mouse −51.6%; rat −32.1%). After seven days healing, bone cross-sectional area was significantly greater (microCT) and mechanical properties partially recovered (−13.8% versus control).

Conclusion: Rat and mouse forelimb fatigue loading models have been developed to induce repeatable bone damage. Observed differences in fatigue behaviour necessitated different loading parameters between models. Following seven days of healing, recovery of mechanical strength accompanied woven bone formation (demonstrated by microCT). Further work will compare the biological, woven bone, response between the mouse and rat forelimb models.


Paul R. T. Kuzyk John E.D. Davies Emil H. Schemitsch

Purpose: The purpose of this study was to relate the extent of reaming to bone formation occurring around a critical sized defect in the tibia.

Method: Eleven canines were allocated into 2 groups: empty (N=5) or iliac crest autograft (N=6). All tibiae were reamed to 7.0 mm and fixed with a 6.5 mm statically locked intramedullary nail after creation of an 8.0 mm diaphyseal defect. The extent of reaming of the canal was dependent on the cross-sectional area of the tibia as all tibiae were reamed to 7.0 mm. Fluorescent markers were given at different times: calcein green (6 weeks), xylenol orange (9 weeks), and tetracycline (11 and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Radiography, Micro CT, brightfield microscopy and fluorescent microscopy were used for analysis.

Results: Bone and vasculature volume within the defect were reported as a percentage of the total volume of the defect. Linear regression analysis of percent bone volume (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.925 (p=0.025) for the empty group and 0.244 (p=0.641) for the autograft group. Linear regression analysis of percent vasculature volume (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.784 (p=0.117) for the empty group and −0.146 (p=0.783) for the autograft group. Bone formation at osteotomy sites was defined as the distance from the original osteotomy site to the tip of newly formed bone. Linear regression analysis of bone formation at the osteotomy sites (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.132 (p=0.832) for the empty group and −0.937 (p=0.006) for the autograft group. Bone formation rates were reported as the distance between the fluorescent labels. Bone formation rate was less within the endosteum, cortex and periosteum with extensive reaming in empty samples.

Conclusion: Our results suggest that the acute management of tibia fractures with bone defects should involve limited reaming. This does not apply when the defect is autografted. Limited reaming may be defined by the cross-sectional area of the tibia in ratio to that of the reamer.


John Street Brian Lenehan Charles G. Fisher Marcel Dvorak

Purpose: Apoptosis of osteoblasts and osteoclasts regulates bone homeostasis. Vertebral osteoporotic insufficiency fractures are characterised by pathological rates of osteoblast apoptosis. Skeletal injury in humans results in ‘angiogenic’ responses primarily mediated by vascular endothelial growth factor(VEGF), a protein essential for bone repair in animal models. Osteoblasts release VEGF in response to a number of stimuli and express receptors for VEGF in a differentiation dependent manner. This study investigates the putative role of VEGF in regulating the lifespan of primary human vertebral osteoblasts (PHVO) in-vitro.

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

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

Conclusion: VEGF is a potent regulator of osteoblast life-span in-vitro. This autocrine feedback regulates survival of these cells, mediated via the KDR receptor and expression of BCl2 antiapoptotic gene. This mechanism may represent a novel therapeutic model for the treatment of osteoporosis.


Claire Li Ru Li Michael D. McKee Emil H. Schemitsch

Purpose: Vascular Endothelial Growth Factor (VEGF) plays an important role in promoting angiogenesis and osteogenesis during fracture repair. Our previous studies have shown that cell-based VEGF gene therapy accelerates bone healing of a rabbit tibia segmental bone defect in-vivo, and increases osteoblast proliferation and mineralization in-vitro. The aim of this project was to examine the effect of exogenous human VEGF (hVEGF) on the endogenous rat VEGF messenger RNA (mRNA) expression in a cell-based gene transfer model.

Method: The osteoblasts were obtained from the rat periosteum. The fibroblasts were obtained from the rat dermal tissue. The cells were then cultured to reach 60% confluence and transfected with hVEGF using Superfect. Four groups were:

osteoblast-hVEGF,

fibroblast-hVEGF,

Osteoblasts alone, and

Fibroblasts only.

The cultured cells were harvested at 1, 3 and 7 days after the transfection. The total mRNA was extracted (TRIZOL); both hVEGF and rat VEGF mRNA were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and quantified by VisionWorksLS.

Results: The hVEGF mRNA was detected by RT-PCR from transfected osteoblasts after three days of gene transfection. The hVEGF mRNA expression in transfected fibroblasts increased exponentially at days 1, 3 and 7 after the transfection. We compared the endogenous rat VEGF mRNA expression level of the osteoblasts or fibroblasts that were transfected with hVEGF with the cells without the transfection. The hVEGF transfected osteoblasts had a greater rat VEGF mRNA expression than the non-transfected osteoblasts. Furthermore, when hVEGF was transfected to the rat fibroblasts, the endogenous mRNA expression level measured was also greater than that from the non-transfected fibroblasts. Rat VEGF mRNA expression increased in the first three days of the hVEGF transfection, but the expression level was reduced at Day 7.

Conclusion: These results suggest that cell-based hVEGF gene therapy enhances endogenous rat VEGF mRNA expression in both osteoblasts and fibroblasts.


Marlis Sabo Steven I. Pollmann Kevin R. Gurr Christopher Bailey David W. Holdsworth

Purpose: Bone mineral density (BMD) is an important factor in the performance of orthopaedic instrumentation both in and ex-vivo, and until now, there has not existed a reliable technique for determining BMD at the precise location of such hardware. This paper describes such a technique using cadaveric human sacra as a model.

Method: Nine fresh-frozen sacra had solid and hollow titanium screw placed into the S1 pedicles from a posterior approach. High-resolution micro-computed tomography (CT) was performed on each specimen before and after screw placement. All images were reconstructed with an isotropic spatial resolution of 0.308 mm, reoriented, and the pre-screw and post-screw scans were registered and transformed using a six-degree rigid-body transformation matrix. Once registered, two points, corresponding to the center of the screw at the cortex and at the screw tip, were determined in each scan. These points were used to generate cylindrical regions of interest (ROI) with the same trajectory and dimensions as the screw. BMD measurements were obtained within each of the ROI in the pre-screw scan. To examine the effect of artefact on BMD measurements around the titanium screws, annular ROI of 1 mm thickness were created expanding from the surface of the screws, and BMD was measured within each in both the pre-and post-screw scans.

Results: The registration process was accurate, with an error of 0.2 mm. Four specimens were scanned five times with repositioning, and error in BMD measurements was ± 2%. BMD values in the cylindrical ROI corresponding to screw trajectories were not statistically different from side to side of each specimen (p = 0.23). Artefact-related differences in BMD values followed an exponential decay curve as distance from the screws increased, approaching a low value of approximately 20 mg HA/cc, but not disappearing completely.

Conclusion: CT in the presence of metal creates artefact, making measured BMD values near implants unreliable. This technique is accurate for determination of BMD, non-destructive, and eliminates the problem of this metal artefact through the use of co-registration of a pre- and post-screw scan. This technique has applications both in-vitro and in-vivo.


Kyle A. R. Kemp Michael J. Dunbar Lori A. Livingston Allan Hennigar

Purpose: Despite their inclusion within clinical practice, standardized radiographs may not accurately project an individual’s level of function and mobility. The purpose of this study is to examine the potential relationship between established radiographic features and lurch; a functional measure of asymmetric gait, in a group of patients who will receive total hip arthroplasty (THA).

Method: Thirty-two patients (16 females, 16 males) identified as hip replacement candidates were recruited, with a mean age of 57.0 years. Lurch was obtained using the Walkabout Portable Gait Monitor (WPGM); a wireless, triaxial accelerometry device. The independent variables were comprised of the Kellgren-Lawrence Scale, and a collection of standard radiographic features, as adopted by the American Academy of Orthopaedic Surgeons (AAOS), the National Institutes of Health (NIH), and the World Health Organization (WHO). Radiographs were blinded, and the surgeon completing the rating scale was unaware of patient’s lurch values. Age-adjusted regression analyses were used to examine the potential association between each radiographic feature and lurch.

Results: Increased amounts of lurch (i.e. functional impairment) were independently associated with higher Kellgren-Lawrence Scale scores (p=.047), increased Joint Space Narrowing in the mid-portion of the joint (zone 2; p=.004), the presence of acetabular wear (p=.045), an increased severity of subchondral femoral head cysts (p=.004), and higher surgeon-rated Visual Analog Scale scores for overall severity of joint degeneration (p=.008). Lurch was not significantly associated with the remaining 10 features which were examined. Further analyses revealed that lurch was not significantly associated with certain demographic factors, including sex, Body Mass Index, and co-morbid health conditions.

Conclusion: Although the Kellgren-Lawrence scale was associated with an objective measure of gait, our results indicate that other radiographic features may provide a more accurate prediction of gait performance among this patient population. As lurch appears to be a robust objective measure of physical impairment, which is unaffected by BMI and co-morbidities, we believe that portable triaxial accelerometers can likely be used to conveniently collect objective gait data. This functional data may be used to supplement clinical efforts to screen and prioritize appropriate hip arthroplasty patients.


Louis M. Ferreira Graham J.W. King James A. Johnson

Results: Repeatability of creating motion-based JCS was less than 1 mm and 1° in all directions. The inter-specimen standard-deviations of position and orientation measurements were smaller for the motion-based than for the anatomy-based JCS in every direction and for every specimen (p< 0.006). The ulno-humeral varus angle and internal/external rotation kinematics of active flexion showed less inter-specimen variability when calculated using motion-based JCS (p< 0.05).


Petar Seslija Xunhua Yuan Douglas Naudie Terry M. Peters Robert B. Bourne Steven J.M. MacDonald David W. Holdsworth

Purpose: Accurate measurement of dynamic joint motion remains a clinical challenge. To address this problem, we have developed a low-dose clinical procedure using the Roentgen Single-plane Photogrammetric Analysis (RSPA) technique. A validation study was performed in a clinical setting, using a conventional digital flat-panel radiography system.

Method: To validate the technique, three experiments were performed: assessment of static accuracy, dynamic repeatability and measurement of effective dose. A knee joint phantom, imbedded with tantalum markers, was utilized for the experiments. Relative spatial positions of the markers were reconstructed using Radiostereometric Analysis (RSA). A digital flat-panel radiography system was used for image acquisition, and the three-dimensional pose of each segment was determined from single-plane projections by applying the RSPA technique. All images were processed using software developed in-house. To assess static accuracy, the phantom was mounted onto a three-axis translational stage and moved through a series of displacements ranging from 0 to 500 μm. Images of the phantom were acquired at each position. Accuracy was calculated by analyzing differences between reconstructed and applied displacements. To assess dynamic repeatability, the phantom was mounted on a six-axis robot, programmed to apply a flexion-extension movement to the joint. Multiple cine acquisitions of the moving phantom were acquired (30 fps, 4 ms exposure). Repeatability was calculated by analyzing the variation between motions reconstructed from repeated acquisitions. The effective dose of the procedure was measured using an ion-chamber dosimeter. The ion chamber was positioned between the phantom and x-ray source, facing the source. Entrance exposure was measured for multiple acquisitions, from which the effective dose was calculated.

Results: The accuracy determined from the static assessment was 25 μm and 450μm at the 95% confidence intervals for translations parallel and orthogonal to the image plane, respectively. Repeatability of the motion reconstructed from dynamic acquisitions was better than ± 200 μm for translations and ± 0.1 for rotations. The average effective dose for a 6 second dynamic acquisition was approximately 2μSv.

Conclusion: The proposed clinical procedure demonstrates both a high degree of accuracy and repeatability, and delivers a low effective dose.


John Antoniou Fackson Mwale David J. Zukor Olga L. Huk Alain Petit

Purpose: The presence of metal ions in the blood of patients with a metal-on-metal (MM) bearing points to the importance of understanding the long-term effects of these ions. Metal ions have the potential to induce the production of reactive oxygen species (ROS), making them prime suspects for inducing molecular damage in circulating cells. The aim of this study was to analyze the levels of oxidative stress markers in the plasma of patients with hip surface replacement.

Method: Blood was collected up to 3 years after implantation from 66 patients with articular surface replacement (ASRÔ, DePuy Orthopaedics) and 54 patients with 36 mm-head MM THA. Forty (40) pre-operative patients were also assessed as control group. Total anti-oxidant levels were measured by the Oxford Biomedical total antioxidant power assay (Oxford, MI) to obtain an overview of the defense capacity of patient’s oxidative stress. Peroxide concentrations were measured by the Biomedica OxyStat assay (Medicorp, Montreal, QC) to quantify damage to lipids in the systemic circulation. Nitrototyrosine levels were quantified using the BIOXYTECH® Nitrotyrosine-EIA assay (OxisResearch™, Portland OR) to measure damage to proteins. The concentrations of metal ions were analyzed by inductively coupled plasma-mass spectroscopy.

Results: Results showed that there were no statistical differences in the concentrations of total antioxidants, lipid peroxides, and protein nitrotyrosines between the control, the ASR, and the 36 mm-head groups. Furthermore, there was no correlation between the concentrations of these markers and the concentrations of both Co and Cr ions (r2 £ 0.006).

Conclusion: The single most significant obstacle preventing a broader application of metal-on-metal hip arthroplasties and resurfacings continues to be the concerns regarding elevated metal ion levels in the blood and urine of patients. The present results showed that there were no changes in the levels of oxidative stress markers in patients with MM bearings compared to the control group. Given the possible latency periods related to metal ion exposure, longer follow-ups are required to conclusively determine the effects of elevated circulating ions on oxidative stress in the blood of patients with MM bearings.


Inder Gill Vinod Kolimarala Richard Montgomery

Purpose: To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution.

Method: From 2001 to 2006, 23 patients with fracture non-union were treated with BMP-7 for bone healing. There were 14 male and nine females. The mean age of patients was 45 years (Range 21–76 yrs). There were 11 femoral, nine tibial and three humerus fractures. There were four open injuries. The average number of operations before BMP-7 insertion was 2.5 (Range 0–6). The mean time between the injury and BMP insertion was 52 months (Range 5–312). Nine (40%) patients had previous autologous bone graft inserted without union. 4 patients had BMP-7 insertion on its own. In another 4 patients it was mixed with allograft. In the rest of 15 patients BMP-7 was mixed with autologous bone graft. 2 patients needed BMP-7 insertion on 2 separate occasions. In all except 1 patient the original fixation of the fracture had to be revised using various appropriate methods.

Results: All the fracture went on to unite within an average of seven months (Range 4–16). There were no complications from the use of BMP-7.

Conclusion: Use of recombinant BMP-7, bone graft and stable fixation lead to fracture union in all our patients. We believe that the use of BMP-7 improved the chances of fracture healing in persistent non-unions and it is safe and easy to use.


Colin P. McDonald James A. Johnson Terry M. Peters Graham J.W. King

Purpose: While computer-assisted techniques can improve the alignment of the implant articulation with the native structure, stem abutment in the intramedullary canal may impede achievement of this alignment. In the current study, the effect of a fixed valgus (6 degree) stemmed humeral component on the alignment of navigated total elbow arthroplasty was investigated. Our hypothesis was that implantation of a humeral component with a reduced stem length would be more accurate than implantation of the humeral component with a standard length stem.

Method: Thirteen cadaveric distal humeri were imaged using a CT scanner, and a 3D surface model was reconstructed from each scan. Implantation was performed using two implant configurations. The first set was unmodified (Regular) while the second set was modified by reducing the length of the humeral stem to 25% of the original stem (Reduced). A surface model of the humeral component was aligned with the flexion-extension (FE) axis of the CT-based surface model, which was registered to the landmarks of the physical humerus using the iterative closest point algorithm. Navigated implant positioning was based on aligning a 3D computer model calibrated to the implant with a 3D model registered to the distal humerus.

Results: Implant alignment error was significantly lower for the Reduced implant, averaging 1.3±0.5 mm in translation and 1.2±0.4° in rotation, compared with 1.9±1.1 mm and 3.6±2.1° for the Regular implant. Abutment of the implant stem with the medullary canal of the humerus prevented optimal alignment of the Regular humeral component as only four of the 13 implantations were aligned to within 2.0° using navigation.

Conclusion: These results demonstrate that a humeral component with a fixed valgus angulation cannot be accurately positioned in a consistent fashion within the medullary canal of the distal humerus without sacrificing alignment of the FE axis due to stem abutment. Improved accuracy of implant placement can be achieved by introducing a family of humeral components, with three valgus angulations of 0°, 4° and 8°. Based on humeral morphology for these specimens, 12 of the 13 implants may be positioned to within 2° of the native FE axis using one of these 3 valgus angulations.


Maeghan Innes Craig E. Tschirhart David D. McErlain David W. Holdsworth Karen D. Gordon Mark Hurtig

Purpose: The mechanical function and strain behavior of the knee meniscus is not fully understood, due to multiple tissues with disparate properties, as well as complex contact patterns and intricate loading mechanisms. More comprehensive understanding of joint mechanics may contribute to improved treatment options for patients with injuries and osteoarthritis. There is very limited information available on the 3D strain of the intact meniscus. The objective of this work was to use mCT with copper microsphere markers to quantify three-dimensional strain of the meniscus under physiologic loading.

Method: Two healthy fresh frozen ovine knee specimens were harvested. Copper microspheres (0.5mm) were injected into anterior and posterior tetrahedral clusters in the medial meniscus using 20-gauge hypodermic needles. Needle cavities were sealed with ovine tendon tissue. Joints were loaded to 100% body weight in a 4 DOF CT-compatible pneumatically-driven device with flexion angles ranging from 62–98°. Images were acquired with an eXplore Locus Ultra mCT scanner and reconstructed with commercial software. A time series of images were acquired with the joint unloaded, during static loading, and at a reduced load (25% BW).

Results: The average maximum principle strains in the anterior element of the two specimens at 62o of flexion increased by 21% during loading and decreased by 13% during unloading. The maximum principle strains were 28% larger in the anterior element than the posterior. The strains in the anterior element decreased by 6.5% with time following load application, and decreased by 16% with load reduction, yielding relatively low residual strain. Strains were 2% larger in the anterior portion with larger flexion angles.

Conclusion: The objective of this work was to develop a reliable method for quantifying 3D strains in the meniscus. Results support the notion that mCT imaging with copper microspheres in the meniscus may be a viable technique for more comprehensive 3D strain analysis. The relatively low residual strains measured in this study indicate that copper microspheres are stable markers in this application. This technique may be useful in directing future studies aimed at understanding the impact of meniscal pathologies and the success of repair techniques.


Omri Lubocsky Michael R. Hardisty David Wright Hans J. Kreder Cari Whyne

Purpose: The distribution of weight bearing area within the acetabulum is of importance in addressing trauma to the acetabulum, hip joint deformities and causes of osteoarthritis. According to Wolf’s law, bone density can indicate loading patterns experienced. The objective of this study was to characterize distributions of acetabular bone density patterns by regions in the normal population.

Method: CT scans of 22 subjects, mean age 70.6 with no evidence to hip joint pathologies were analysed. Bone density distribution maps were generated within AmiraDEV4.1 image analysis software using custom written plugins (Visage Imaging, Carlsbad, USA). Acetabular cup surfaces were semi-automatically segmented from the reconstructed CT volumes with an atlas-based approach. The acetabular cups were expanded 2.5 mm into the acetabular bone, and surface bone densities were calculated as the average bone density within ±2.5mm. The distribution maps were analysed using zones to spatially classify areas of high and low bone density in a healthy population. The acetabular cups were aligned using the acetabular rim plane that was landmarked, and by rotating the cups, such that a 900 abduction angle and a 00 anteversion angle were achieved. The grid used was divided to quadrants, and subdivided into radial thirds of the average rim radius. The correspondence of left and right density maps was investigated by comparing the average bone density in corresponding zones and across the population.

Results: High bone densities were found around the roof of the acetabulum aligning with the femoral mechanical axis during standing. The highest average bone density were found to be the superior and posterior walls of the acetabulum, corresponding to regions 8, 9, and 12 compared to other regions of the acetabuli (P< 0.01). A strong correlation was found between left and right sides within subjects (R=0.91, P< 0.05); and weaker correlation was also found for overall average bone density, (R=0.77, P< 0.05).

Conclusion: The location of the zones with the highest average bone density agrees with cadaveral studies of the maximum contact stress in the acetabulum (zones 9 and 12). [1,2]. It may explain why trauma to these areas carries a higher risk for early arthritic changes.


Dan Padmos Peng Zhang Michael J. Dunbar

Purpose: Component loosening is a leading cause of joint replacement failure. Modifying titanium surfaces with chemically bound functional proteins, such as bone morphogenetic protein (BMP), can efficiently strengthen the interface between prosthesis and bone. A prototype system was developed by using gold nanoparticles (AuNPs) to bridge lysozyme (compositionally similar to BMP) and titanium.

Method: For reference, lysozyme-conjugated gold nanoparticles (Lys-AuNPs) were prepared in solution via two different pathways:

gold compound was reduced in the presence of lysozyme to form Lys-AuNPs or

citrate-stabilized AuNPs were functionalized with mercaptopropionic acid (MPA) to produce carboxylic acid terminated AuNPs which were mixed with lysozyme.

Both solutions were characterized with transmission electron microscopy, ultraviolet-visible spectroscopy, circular dichroism spectroscopy (CD), and enzymatic assays. Next, AuNPs were prepared on 99.5% titanium foil discs (n=32) through electroless deposition. Deposition parameters were modified to create two groups of discs with different average diameters of AuNPs, measured by scanning electron microscopy. Some discs from both groups also underwent treatment with MPA. All discs were treated with lysozyme and the adsorbed amounts and activities of lysozyme were examined with micro BCA and enzymatic assays.

Results: Lysozyme and AuNPs can be conjugated in solution via two different pathways. CD results showed a significant change in the secondary structure of the lysozyme and decrease in enzymatic activity when directly conjugated to AuNPs; however, little change in secondary structure and enzymatic activity was observed for the lysozyme with MPA functionalized AuNPs. For the AuNPs on the titanium discs, SEM showed that the two groups had significantly different average AuNP diameters. Bioactive lysozyme was immobilized onto the discs and the results suggested that discs with the largest AuNPs treated with MPA had higher adsorption and activity of lysozyme.

Conclusion: A wet-chemical technique may be used to bind lysozyme to titanium via gold nanoparticles. Additionally, it was possible to control the size of the AuNPs on titanium which provides a good platform for further functionalisation with thiol molecules such as MPA. This technique holds promise for binding more functional molecules to surgical implants, hence creating “smart” implants that react to their local environment.


Colin P. McDonald James A. Johnson Terry M. Peters Graham J.W. King

Purpose: This study evaluated the accuracy of humeral component alignment in total elbow arthroplasty. An image-based navigated approach was compared against a conventional non-navigated technique. We hypothesized that an image-based navigation system would improve humeral component positioning, with navigational errors less than or approaching 2.0mm and 2.0°.

Method: Eleven cadaveric distal humeri were imaged using a CT scanner, from which 3D surface models were reconstructed. Non-navigated humeral component implantation was based on a visual estimation of the flexion-extension (FE) axis on the medial and lateral aspects of the distal humerus, followed by standard instrumentation and positioning of a commercial prosthesis by an experienced surgeon. Positioning was based on the estimated FE axis and surgeon judgment. The stem length was reduced by 75% to evaluate the navigation system independent of implant design constraints. For navigated alignment, the implant was aligned with the FE axis of the CT surface model, which was registered to landmarks of the physical humerus using the iterative closest point algorithm. Navigated implant positioning was based on aligning a 3D computer model calibrated to the implant with a 3D model registered to the distal humerus. Each alignment technique was repeated for a bone loss scenario where distal landmarks were not available for FE axis identification.

Results: Implant alignment error was significantly lower using navigation (P< 0.001). Navigated implant alignment error was 1.2±0.3 mm in translation and 1.3±0.3° in rotation for the intact scenario, and 1.1±0.5 mm and 2.0±1.3° for the bone loss scenario. Non-navigated alignment error was 3.1±1.3 mm and 5.0±3.8° for the intact scenario, and 3.0±1.6 mm and 12.2±3.3° for the bone loss scenario. Without navigation, 5 implants were aligned outside 5° for intact bone while 9 were aligned outside 10° for the bone loss scenario.

Conclusion: Image-based navigation improved the accuracy of humeral component placement to less than 2.0 mm and 2.0°. Further, outliers in implant positioning were reduced using image-based navigation, particularly in the presence of bone loss. Implant malalignment may well increase the likelihood of early implant wear, instability and loosening. It is likely that improved implant positioning will lead to fewer implant related complications and greater prosthesis longevity.


Mark Hurtig Laurent Fischer Antonio Cruz Frederick David

Purpose: To determine if an adenovirus vector expressing BMP-7 can alter the progression of post-traumatic osteoarthritis.

Method: Preliminary dose-response studies were done in ovine metacarpal-phalangeal joints using 10^9, 10^10, and 10^11 virus particles (VP). In-vitro transfection efficiency studies were done using ovine synovial cells, chondrocytes and HEK293 cells. In-vivo studies were conducted in 16 sheep that underwent surgery to create bilateral contusive impact injuries to the medial femoral condyle. One week later 10^9 VP were injected into one joint of each sheep, while four sheep remained untreated bilateral controls. Three months later the sheep were sacrificed for assessments including histological scoring, cartilage glycosaminoglycan assays, and immunostaining for Col2 3/4 short collagen fragments that are generated by metalloproteinases during OA progression.

Results: Transfection with 10^9 VP produced slightly longer expression than higher concentrations of VP. HEK293 cells expressed BMP-7 quickly but synoviocytes and chondrocytes expressed this protein at 48 and 96 hours. Knee joints that received Ad5-BMP-7 produced up to 2.5 ng of BMP-7 between day seven and 21. These joints had reduced cartilage degneration at the injury sites and less centrifugal progression of OA across the femoral condyle. Histological scores were reduced as was Col2 C3/4 short immunostaining.

Conclusion: BMP-7 has a homeostatic role in cartilage and can be used therapeutically1. Ad5-BMP-7 transfection of synovial tissue produced sufficient BMP-7 to stop the progression of degenerative changes after trauma that would usually lead to OA. Adenoviral vectors can create inflammation and neutralizing antibodies but these complications were minimized by using a low (10^9) dose. Human trials using similar vectors are ongoing and the outcome of these will determine whether gene therapy will become a useful tool when patients are at risk of post-traumatic OA.


Elizabeth A. Sled Latif Khoja Kevin J. Deluzio Sandra J. Olney Elsie G. Culham

Purpose: Hip muscle weakness may result in impaired frontal plane pelvic control during gait, leading to greater medial compartment loading, as measured by the knee adduction moment, in persons with knee osteoarthritis (OA). The purpose of this study was to evaluate the influence of an 8-week home-based strengthening program for the hip abductor muscles on hip muscle strength and the external knee adduction moment during gait in individuals with medial knee OA compared to an asymptomatic control group. Secondary objectives were to determine if hip abductor strengthening exercises would improve physical function and knee symptoms in this sample of people with knee OA.

Method: Forty participants with knee OA were age and gender-matched with an asymptomatic control group. Three-dimensional gait analysis was performed to obtain peak knee adduction moments in the first 50% of stance phase. Isokinetic concentric strength of the hip abductor muscles was measured using a Biodex Isokinetic Dynamometer. Functional performance was evaluated using the Five-Times-Sit-to-Stand test. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) provided an assessment of knee pain. Following initial testing, participants with knee OA were instructed in a home program of hip abductor strengthening exercises. All participants were re-evaluated after 8 weeks.

Results: There was no significant difference in isokinetic hip abductor muscle strength between groups at baseline or at follow-up. An improvement in hip abductor strength occurred in the OA group following the intervention (p = 0.036). The OA group had higher peak knee adduction moments than the control group (p = 0.006), but there was no change in the knee adduction moment over time in either group (p > 0.05). The OA group performed the sit-to-stand test more slowly than the control group (p = 0.001). At final testing, functional performance on the sit-to-stand test had improved in the OA group compared to the control group (p = 0.021). The OA group showed a trend towards decreased knee pain (p = 0.05).

Conclusion: An 8-week home program of hip abductor muscle strengthening did not reduce knee joint loading, but improved function, in a group of participants with medial knee OA.


Emily J. McWalter David R. Wilson William F. Harvey Kelly A. Lamb Paula I. McCree David J. Hunter

Purpose: Patellar bracing is a common, mechanical-based treatment strategy for patellofemoral osteoarthritis (OA). It is thought that the brace corrects patellar tracking, however, this correction has not been quantified in the OA population. Through advances in magnetic resonance imaging (MRI), we can now assess patellar tracking in three-dimensions.

Method: We assessed three-dimensional patellar tracking in ten subjects with symptomatic radiographic patellofemoral knee OA using a validated, quasi-static, MRI-based method. Four conditions were studied:

no knee brace, no load,

no knee brace, 15% bodyweight (BW) load,

knee brace, no load,

knee brace, 15% BW load.

Patellar tracking (flexion, spin and tilt; proximal, lateral and anterior translation) was assessed. Comparisons were made at 1° increments over the coincidental range of knee flexion between the no-brace and brace conditions, at no load and 15% BW load, using a paired t-test with Bonferroni correction.

Results: All subjects (7 female, 3 male, 60.9±1.3 yrs, 89.5±19.3 kg) had radiographic lateral patellofemoral OA and seven had concomitant tibiofemoral OA (KL grade≥2). Under no load, the brace extended (mean=2.7°, CI=[2.4°, 2.9°], P< 0.001) and medially tilted (mean=−1.4°, CI=[−1.6°, −1.2°], P< 0.001) the patellae and shifted them distally (mean=0.8mm, CI=[0.6mm, 0.9mm], P< 0.001), medially (mean=0.5mm, CI=[0.5mm, 0.6mm], P< 0.001) and posteriorly (mean=0.6mm, CI=[0.5mm, 0.6mm], P< 0.001). Under 15% BW load, the brace extended the patella (mean=2.4°, CI=[2.1°, 2.8°], P< 0.001) and shifted them distally (mean=1.3mm, CI=[1.1mm, 1.4mm], P< 0.001), medially (mean=0.8mm, CI=[0.7mm, 0.9mm], P< 0.001) and posteriorly (mean 0.6mm, CI=[0.5mm, 0.7mm], P< 0.001).

Conclusion: The brace extended the patellae for both loading conditions, suggesting that patellar flexion/extension is restricted by the brace. The brace tilted the patellae medially under no load only, suggesting when the quadriceps are active (15% BW load) the brace has little effect for tilt. While the effect of bracing on patellar tracking may appear small, the differences are of similar magnitude to those observed between normals and patients with patellofemoral pain, suggesting that braces may produce clinically significant changes in patellar tracking.


Marlis Sabo Katherine Fay Louis Ferreira Colin McDonald James A. Johnson Graham J.W. King

Purpose: Osteochondritis dissecans (OCD) of the capitellum most commonly affects adolescent pitchers and gymnasts, and presents with pain and mechanical symptoms. Fragment excision is the most commonly employed surgical treatment; however, patients with larger lesions have been reported to have poorer outcomes. It’s not clear whether this is due to increased contact pressures on the surrounding articular surface, or if fragment excision causes instability of the elbow. The purpose of this study was to determine if fragment excision of simulated OCD lesions of the capitellum alters kinematics and stability of the elbow.

Method: Nine fresh-frozen cadaveric arms were mounted in an upper extremity joint motion simulator, with cables attaching the tendons of the major muscle tendons to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. Three-dimensional CT scans were used to plan lesions of 12.5% (mean 0.8cm2), 25%, 37.5%, 50%, and 100% (mean 6.2cm2) of the capitellar surface, which were marked on the capitellum using navigation. Lesions were created by burring through cartilage and subchondral bone. The arms were subjected to active and passive flexion in both the vertical and valgus-loaded positions, and passive forearm rotation in the vertical position.

Results: No significant differences in varus-valgus or rotational ulnohumeral kinematics were found between any of the simulated OCD lesions and the elbows with an intact articulation with active and passive flexion, regardless of forearm rotation and the orientation of the arm (p> 0.7). Radiocapitellar kinematics were not significantly affected during passive forearm rotation with the arm in the vertical position (p=0.07–0.6).

Conclusion: In this in-vitro biomechanical study even large simulated OCD lesions of the capitellum did not alter the kinematics or laxity of the elbow at either the radiocapitellar or ulnohumeral joints. These data suggest that excision of capitellar fragments not amenable to fixation can be considered without altering elbow kinematics or decreasing stability. Further study is required to examine other factors, such as altered contact stresses on the remaining articulation, that are thought to contribute to poorer outcomes in patients with larger lesions.


Fay Leung Clive P. Duncan Helen Burt John Jackson

Purpose: This study investigates the synergistic use of fusidic acid with vancomycin, and linezolid in poly-methylmethacrylate (PMMA) cement for the treatment of orthopedic MRSA and MRSE infections. Alone, Vancomycin is typically eluted in limited quantities from cement. The purpose of this study was to

combine FA and Vancomycin, and Linezolid alone in PMMA cement and characterize antibiotic elution, and

to improve drug release using polyethylene glycol (PEG) and NaCl in PMMA cement.

Method: Standardized 1g pellets of Palacos cement were manufactured containing Vancomycin and FA or Linezolid at increasing concentrations in three batches: without additive, with increasing concentrations of PEG, and with increasing concentrations of NaCl. The pellets were incubated in phosphate buffered saline and sampled at regular intervals. Drug analysis was performed with high pressure liquid chromatograpy.

Results: Total drug release at 2.5% loading of Vancomycin alone was 0.84% and of FA was 2.35%. Linezolid showed comparable release profiles. Vancomycin and FA combined yeilded Vancomycin release of 6.2% and FA of 8.4%. The addition of 30% PEG increased release of Vancomycin and Fusidic Acid by six-fold. The addition of 18% NaCl increased total Vancomycin release by 11-fold but had no effect on FA release.

Conclusion: Linezolid, Vancomycin and FA can be combined in PMMA and have favorable release profiles. The addition of PEG and NaCl dramatically increases the release of antibiotics, with the exception of FA and NaCl. These strategies may be useful in the management of MRSA/MRSE infections.


Paul-Edgar Beaulé David Allen Steve Doucette Othman Ramadan

Purpose: Femoroacetabular impingement (FAI) has recently been described as a cause of adult hip pain and a precursor of hip osteoarthritis. Pincer type is secondary to acetabular retroversion or coxa profunda and Cam type is secondary to lack of concavity/offset of the antero-lateral femoral head-neck junction. Purpose of this study was to determine the prevalence of bilateral deformity in patients with cam type FAI as well as the presence of associated acetabular abnormalities.

Method: One hundred and thirteen patients with symptomatic cam impingement (alpha (α) angle of Notzli > 55.5°) of at least one hip were evaluated. Eighty-two males, 31 females with an average age of 37.9 yrs (16–55). Standardized AP pelvis and bilateral Dunn views were reviewed. Alpha angle of Notzli was measured on Dunn views. Cam impingement was defined by α angle > 55.5 on the Dunn view and Pincer impingement was defined by the presence of either acetabular retroversion or coxa profunda. Statistical analysis was done using the two tailed paired t-test, chi-square test and intra-class correlation coefficient. Odds Ratios were calculated using conditional logistic regression.

Results: Eighty-eight patients (77.8%) had bilateral deformity and 27% had symptoms in both hips. Mean α angles were higher for bilateral impingement deformity than for the impingement side only when unilateral deformity was present (72.10 versus 64.50, p< 0.001). Forty-four percent of hips with an impingement deformity also had a pincer deformity, either acetabular retroversion or coxa profunda. Painful hips had a statistically significant higher mean alpha angle than asymptomatic ones (69.70 versus 63.10, p< 0.001)). Comparing hips with α angles of 61–70 with those < 60 found an odds ratio of being painful of 2.59 (95% CI: 1.32–5.08, p=0.006). Hips with α angles > 71 had an odds ratio of being painful of 2.54 (95% CI: 1.3–4.96, p=0.007).

Conclusion: The majority of patients with cam type FAI have bilateral deformities and an associated acetabular deformity less commonly. The severity of the deformity at the femoral head neck junction is a significant determining factor for the development of hip symptoms. This information is important as we better define the natural history of this deformity as well as devise effective treatment strategies.


Javad Parvizi Luis Pulido Madih Matar Nicole Marchetto Bora Og

Purpose: Femoroacetabular impingement (FAI) is recognized as an etiological risk factor for hip arthritis. The potential for joint preserving surgical techniques that may delay the progression to early arthritis and retard the possibility of arthroplasty at a young age is promising. This study presents the outcome of surgical treatment of FAI through a less invasive technique performed through a modified Smith-Peterson approach without hip dislocation, or arthroscopy.

Method: Using an institutional database, a total of 72 patients (80 hips) with radiographic and clinical diagnosis of FAI who underwent direct anterior femoroacetabular osteoplasty (FAO) were identified. Preoperative and postoperative functional evaluation was performed on these patients. The operative findings were recorded in detail and evaluated with regard to outcome.

Results: Intraoperative diagnosis of labral tear and osteochondral lesions in the anterosuperior acetabulum was confirmed in all cases. The surgical approach provided adequate access to allow labral repair and osteoplasty of the femoral neck and the acetabulum, whenever needed. There were no intraoperative complications. All patients experienced a significant improvement in function as measured by modified Harris hip and SUSHI scores. Majority (85%) of the patients were satisfied with the outcome of the surgery. In addition, Health Survey SF-36 showed most patients felt their health had improved significantly. The predictors of poor outcome were previous hip scope, lack of labrum for repair, large chondral lesions, and workman’s compensation status.

Conclusion: This study presents the early results of a less invasive surgical treatment for femoroacetabular impingement. This ongoing study shows that the described technique seems to be a viable approach for treatment of this painful condition in the young.


James D. Johnston Bassam A. Masri David R. Wilson

Purpose: Subchondral cortical and trabecular bone mineral density (BMD) may increase and/or decrease during different stages of osteoarthritis (OA) disease progression. 2D in-vivo imaging studies examining direct associations between increased proximal tibial BMD and knee OA offer conflicting results, which may be due to the inherent limitations of 2D BMD imaging tools. Our objective was to compare existing and novel 3D imaging techniques for distinguishing subchondral bone properties in OA and normal cadaveric tibiae.

Method: Eight intact cadaver knees from five donors (4M:1F; age: 77+/−10) were repositioned and scanned three times using QCT (0.5mm isotropic resolution, 0.15mSv dosage). BMD was assessed using

computed tomography absorptiometry (CT-OAM) which uses maximum intensity projections to assesses peak density values within subchondral bone, and

our novel computed tomography topographic mapping of subchondral density (CT-TOMASD) technique, which uses surface projections to assess both cortical and trabecular bone density at specific depths from the subchondral surface.

Average BMD at normalized depths of 0–2.5mm, 2.5–5.0mm, and 5.0–10mm from the surface were assessed using CT-TomasD. Regional analyses were performed consisting of:

medial/lateral (M/L) BMD ratio, and

BMD of a 10mm diameter core identified as having the maximum regional BMD.

Each bone was assessed for OA using a modified-KL scoring system: Normal (mKL=0); Early-OA (1–2); and Late-OA (3–4).

Results: OA was identified in four compartments of three tibiae (1 late OA+valgus, 1 late OA+varus, 1 early OA+neutral). Larger density differences between OA and normal knees were noted using CT-TOMASD compared with CT-OAM. CT-TomasD demonstrated that the two knees with late OA demonstrated M/L BMD ratios differing by more than 3.4 SD compared with normals, with peak cores higher than normals across all depths. The knee with early OA and neutral alignment demonstrated M/L ratios less than normals while core differences were highest proximally, with density becoming lower than normals with increasing depth.

Conclusion: CT-TomasD demonstrated larger differences between OA and normal subjects when compared with CT-OAM differences. This may be due to CT-OAM primarily assessing peak density within the thin subchondral cortical endplate; a region demonstrating fairly uniform peak densities within a limited range.


Paul-Edgar Beaulé Kalesha Hack Gina DiPrimio Kawan Rakhra

Purpose: A growing body of literature confirms that idiopathic OA is frequently caused by subtle, and often radiographically occult, abnormalities at the femoral head-neck junction or acetabulum that result in abnormal contact between the femur and acetabulum. This condition, known as femoroacetabular impingement, is a widely accepted cause of early OA of the hip. MRI is the imaging modality that is most sensitive in detecting cam morphology. There is currently little published data regarding the prevalence of abnormalities of the femoral head-neck junction in patients without hip pain or previous hip pathology. The primary aim of this project is to examine the incidence of cam morphology in a population without hip pain or pre-existing hip disease using non-contrast MRI.

Method: Two hundred asymptomatic volunteers underwent magnetic resonance imaging targeted to both hips. Subjects were examined at the time of MRI to document internal rotation of the hips at 90 degrees flexion and to assess for a positive impingement sign. The mean age was 29.4 years (range 21.4–50.6); 77.5% were Caucasian and 55.5% female. The Nötzli alpha angle was measured on oblique axial images through the middle of the femoral neck for each hip. A value greater than 50 degrees was considered consistent with cam morphology. Measurements were performed independently by two musculoskeletal radiologists.

Results: Twenty-six percent of volunteers had at least one hip with cam morphology: 20% had an elevated alpha angle on either the right or the left side, and 6% had bilateral deformity. The average alpha angle was 42.6 degrees on the right (SD=7.9) and 42.4 degrees on the left (SD=7.7). Internal rotation was negatively correlated with alpha angle (p< .05). Patients with an elevated alpha angle on at least one side tended to be male (p< .01).

Conclusion: The high prevalence of cam morphology in asymptomatic individuals is critical information in determining the natural history of FAI as well as establishing treatment strategies in patients presenting with pre-arthritic hip pain.


Deepthi Gorapalli Albert J.M. Yee Aiguo Zhang Marina Demcheva Cari Whyne J. Vournakis A. Seth

Purpose: There is interest in biologic strategies that can potentially treat degenerative disc disease (DDD). A new deacetylated derivative of a marine diatomic glycosaminoglycan (DEAC) was developed and incorporated into two sulphated hydrogel formulations; Gel 1 and 2. These materials were proposed to have a reparative effect on damaged tissue. Biochemical studies were conducted using primary human disc cell (HDC) cultures.

Method: HDCs were isolated from surgical specimens by sequential enzymatic digestion (pronase and collagenase). Time-course in-vitro studies were conducted on cell cultures treated with DEAC, Gel 1 or Gel 2 (28 day period). Proteoglycan content (alcian blue), cellular viability/proliferation (MTT assay), and type collagen II, aggrecan expression (RT-PCR, immunohistochemistry) was assessed.

Results: When compared to controls, the DEAC, Gel 1 and 2 treated HDC groups showed significant increases in proteoglycan content as early as day 12. The greatest effect was observed with Gel 1 (78.4±1.9 fold greater optical density compared to control, p < 0.05). The amount of proteoglycan quantified on DEAC treated HDCs on day 28 was 27.7±0.09 times higher than control (p< 0.05). MTT results demonstrated that Gel 1 group showed the highest viability over the study period (mean optical density 0.13+.01 versus 0.039+0.01 in controls). There were no significant differences in cell proliferation of Gel 2, DEAC and untreated control groups. RT-PCR and immunohistochemistry demonstrated expression of type II collagen and aggrecan consistent with the disc phenotype.

Conclusion: The results of this study demonstrates that formulations derived from poly-N-acetyl glucosamine (pGLcNAc) have positive effects of disc cell metabolism as quantified by proteoglycan content, cellular viability and proliferation, and the expression of key extra-cellular matrix molecules. The sulphated formulation of deacetylated pGLcNAc (Gel 1) appeared to have the greatest in-vitro effect followed by DEAC and the short fiber construct of Gel 2. It is possible that the pGlcNAc fibers in Gel 2 were not as soluble to the extent of DEAC due to their inability to form strong hydrogen bonds. This study shows promise towards ongoing evaluation of novel biomaterials for the potential DDD treatment through tissue regenerative or reparative schemes.


Javad Parvizi Orhan Bican Kevin Bozic Chris Peters

Purpose: Hip arthroscopy has been used at an increasing frequency over the last few years. Majority of patients undergoing hip arthroscopy are young and active individuals who seek definitive therapy for a painful hip condition and wish to avoid undergoing a hip replacement. Although relatively successful, complications following hip arthroscopy occur. This multi-institutional study presents a worrisome and previously unrecognized complication of hip arthroscopy, namely chondrolysis that lead to accelerated development of end-stage arthritis.

Method: Using the computerized database in each institution, patients undergoing total hip arthroplasty between 1999–2008 who had received hip arthroscopy prior to arthroplasty were identified. 39 patients were identified to have undergone at least one hip arthroscopy on the affected hip prior to arthroplasty. There were 21 female and 18 male patients. The mean age of patients at the time of hip arthroscopy was 45.9 years. Data regarding demographics, comorbidities, preoperative diagnosis, number of previous procedures, and the details of the surgical procedure were compiled. Radiographs were evaluated.

Results: The median time from arthroscopy to arthroplasty was 14.8 months (range 2.2 months to 7 years). Fourteen patients (35%) underwent THA within 12 months of a previous hip arthroscopy and in nine of these patients the indication for hip arthroscopy was labral tear debridement. These patients despite having none to minimal arthritis at the time of arthroscopy developed accelerated arthritis within a year that necessitated hip replacement.

Conclusion: Hip arthroscopy can cause accelerated degenerative arthritis of the hip in some patients. We believe the subset of our patients who developed arthritis so early after hip arthroscopy may have suffered chondrolysis and/or chondral injury during the arthroscopy that resulted in progressive and aggressive arthritis of the hip within 12 months. Hip arthroscopy should be reserved for a select group of patients. All measures to minimize the possibility of chondrolysis and/or chondral injury should be exercised.


Qingan Zhu Jie Liu Tim Bhatnagar Wolfram Tetzlaff Thomas Oxland

Purpose: Recent studies have shown differences in short term spinal cord pathology between spinal column injury mechanisms, such as contusion and fracture-dislocation. Such differences may exist at longer time points, and thus survival studies are needed in the dislocation models. A more in-depth characterization of the dislocation model is needed for development of a mild-moderate cervical spine dislocation model in a rat that is suitable for survival studies. Specifically, our objective in this study was to determine the dislocation displacement that produces initial spinal column failure in a Sprague-Dawley rat model and to validate a consistent injury at the desired dislocation in-vitro and in-vivo.

Method: For the dislocation model, the dorsal ligaments and facets at C4–C5 were removed to mimic the type of posterior element fracture and ligament injury commonly seen in a bilateral fracture-dislocation. C3 and C4 were clamped together and held stationary while the clamp holding C5 and C6 was connected to an electromagnetic actuator and displaced dorsally to produce the injury while force and displacement were recorded. Twenty-eight isolated cervical spine specimens of Sprague-Dawley rats were used to determine dislocation displacement at initial spinal column failure. The C4–C5 segment sustained dislocation (> 3mm) injury at 0.05mm/s (n=11), 100mm/s (n=4) and 1000mm/s (n=13). Initial spinal column failure was defined at with maximum force during the dislocation. A dislocation displacement of 1.4mm was applied to 7 isolated specimens and 4 anesthetized rats at 430mm/s. The spinal column failure was inspected up to 3 days after injury, as well as hemorrhage of spinal cord in-situ.

Results: The dislocation displacement at in-vitro spinal column failure was 0.95mm±0.32 and not significantly different among specimens at the three dislocation speeds. Under a dislocation displacement of 1.4mm, rupture of the C4–C5 disc occurred in all in-vitro (0.67mm±0.38) and in-vivo (0.65mm±0.17) cases. SCI hemorrhage at epicenter was observed in 3 of 4 cases.

Conclusion: The initial spinal column failure in an innovative SCI model occurs at displacement between 0.65mm and 0.95mm. Dislocation displacement of 1.4mm results in spinal column failure consistently and SCI hemorrhage, and may be suitable for survival studies.


James C. Boak Philippe Gedet Marcel Dvorak Stephen Ferguson Peter Cripton

Purpose: The average age of people suffering spinal cord injuries in many countries is shifting toward an older population, with a disproportionate number occurring in the spondylotic cervical spine. These injuries are typically due to low energy impacts, such as a fall from standing height. Since a stenotic spinal canal (a common feature of a spondylotic cervical spine) can cause myelopathy when the spine is flexed or extended, traumatic flexion or extension likely causes the injury during the low energy impact. However, this injury mechanism has not been observed experimentally.

Method: To better understand this injury mechanism an in-vitro study, using six whole cervical porcine spines, was conducted. The following techniques were combined to directly observe spinal cord compression in a stenotic spine during physiologic and super-physiologic motion:

A radio-opaque surrogate cord, with material properties matched to in-vivo specimens, replaced the real spinal cord.

Sagittal plane X-rays imaged the surrogate cord in the spine during testing.

Varying levels of canal stenosis were simulated by a M8 machine cap screw that entered the canal from the anterior by drilling through the C5 vertebral body.

Pure moment loading and a compressive follower load were used to replicate physiologic and super-physiologic motion.

Results: Initial results show that a stenotic occlusion that removes all extra space in the canal in the neutral posture, without compressing the cord, can lead to spinal cord compression within physiologic ranges of flexion and extension. The spinal cord can also be compressed during slightly super-physiologic flexion and extension with only 25% canal occlusion. Physiologic loads and motions in the same spines did not cause cord compression when canal occlusion was 0%.

Conclusion: These results support the hypothesis that cervical spinal canal stenosis increases the risk of spinal cord injury because spinal cord compression was observed during motions and loads that would be safe for a non-stenotic spine. These results are limited primarily due to the use of a porcine spine. However, this new stenosis model and experimental technique will be applied to in-vitro human spine specimens in future work.


Qingan Zhu Claire Jones Tim Schwab Chad Larson Eyal Itshayek Lawrence Lenke Washington University Peter Cripton

Purpose: A long spinal fusion across the thoracolumbar region is sometimes applied in scoliosis. Adjacent level degeneration below these constructs has been documented. Treatment with an artificial disc replacement below the fusion has been proposed to prevent degeneration there. There is currently little data detailing the expected biomechanics of this situation. The objective of this study was to evaluate range of motion (ROM) and helical axis of motion (HAM) changes due to one- and two-level Maverick total disc replacement adjacent to a long spinal fusion.

Method: A multidirectional flexibility testing protocol with compressive follower preload was used to test seven human cadaveric spine specimens (T8-S1). A continuous pure moment ±5.0 Nm was applied in flexion-extension (FE), lateral bending (LB) and axial rotation (AR), with a compressive follower preload of 400 N. The motion of each vertebra was monitored with an optoelectronic camera system. The test was completed for the intact condition and after each surgical technique:

T8-L4 fusion and facet capsulotomy at L4–L5 and L5-S1;

L4–L5 Maverick;

L5-S1 Maverick.

Maverick total disc replacement and fusion with the CD Horizon system was performed. Repeated measures ANOVA was used to analyze changes in ROM and HAM of the L4–L5 and L5-S1 segments.

Results: Following L4-L5 Maverick replacement, L4-L5 ROMs tended to decrease slightly (on average from 6.2°±2.8° to 5.1°±3.8° in FE, 1.1°±1.1° to 0.9°±0.5° in LB and 1.3°±0.9° to 1.0°±0.6° in AR). With two-level Maverick implantation, L5-S1 ROMs tended to increase slightly in FE (from 6.6°±2.6° to 7.1°±3.9°), and to decrease slightly in LB (from 1.5°±0.9° to 1.0°±0.3°) and AR (from 1.5°±1.5° to 1.1°±0.6°), compared to the fused condition. As a trend, HAM location shifted posteriorly in FE and AR, and inferiorly in LB following Maverick replacement. However, neither ROM nor HAM at these two segments showed any significant change due to the implantation of one-or two-level Maverick total disc replacement in any of the three directions.

Conclusion: The present results suggested that lower lumbar segments with Maverick disc replacement exhibited intact-like kinematics in both extent and quality of motion.


Seyed-Parsa Hojjat Michael R. Hardisty Cari Whyne

Purpose: The objective of this study is to develop and utilize a highly automated microCT based analysis tool to quantify microstructural differences in bone due to metastatic involvement in whole rat vertebrae.

Method: First and Third lumbar vertebrae from healthy (n=4) and metastatically involved (n=4) rnu/rnu rats were excised for analysis (total of 8 vertebrae). Lytic metastases were developed via intracardiac injection of MT1 human breast cancer cells. The specimens were scanned using microCT at 17.5 microns isotropic resolution. A highly automated algorithm was developed for whole vertebral segmentation based on the microCT data, including the posterior elements (AmiraDev3.1). This was accomplished using an atlas-based method incorporating demons deformable registration followed by refinement through level set curvature evolution. Volumetric concurrency was used to compare segmentations generated by the automated algorithm to manually refined segmentations. The segmentations were up-sampled by 4 and edge-enhanced and further segmented using a thresholding technique to have a clear segmentation of the individual trabeculae without advancing into the bone marrow(AmiraDev3.1). The cortical shell was removed automatically before analyzing the trabecular structure. Cortical bone volume(CBV) was calculated by subtracting the volume of the full segmentation from the segmentation with no cortical shell. The interior segmentation was then used to calculate Trabecular Bone Volume(TBV), Trabecular Thickness(TbTh), Trabecular Separation(TbSp), Trabecular Number(TbN) based on the expressions described by Parfitt, et al(1983). Finally mean intercept length(MIL) was used to calculate the anisotropy of the trabecular tissue. Analysis were carried out on both the healthy and metastatically involved vertebrae.

Results: The automated algorithm including the level set method refinement produced good tracking of the boundaries of entire rat vertebrae. Consistent results yielded significant reduction in TBV, slight reduction in TbN and TbTh, and significant increase in TbS in metastatic vertebrae compared to healthy. no significant differences were observed in CBV. The metastatic vertebrae was also found to be significantly more anisotropic than the healthy group.

Conclusion: The accuracy of the highly automated algorithm developed in this study to analyze microstructure in whole rat vertebrae make it a suitable tool for further analyzing the effects of existing and new treatments for spinal metastases at a preclinical level.


David W. Sanders Ajay Manjoo Abdel-Rahman Lawendy Amit Badhwar Michael S. Gladwell

Purpose: Indomethacin may preserve tissue viability in compartment syndrome. The mechanism of improved tissue viability is unclear, but the anti-inflammatory effects may alter the relative contribution of tissue necrosis versus apoptosis to cellular injury. Existing studies have only considered indomethacin administration prior to induction of compartment syndrome. The purpose of this study was to determine the effect of timing of indomethacin administration on muscle damage in compartment syndrome, and to assess apoptosis as a cause of tissue demise.

Method: Twenty-four Wistar rats were randomized to elevated intracompartmental pressure (EICP) for either 45 or 90 minutes (30mm Hg). In the 45 min group, indomethacin was withheld (group 1), given prior to induction of EICP (group 2) or given 15 min prior to fasciotomy (group 3). In the 90 min group, indomethacin was withheld (group 4) or provided 30 or 60 minutes prior to fasciotomy (groups 5 and 6). Intravital microscopy and histochemical staining assessed capillary perfusion, cell damage and inflammatory activation within EDL muscle. Apoptosis was assessed using ELISA staining for caspase-3. Groups were compared with one-way ANOVA (p< 0.05).

Results: Perfusion improved in indomethacin-treated groups. Nonperfused capillaries decreased from group 1 (50.1±2.5), to groups 2 (38.4±1.8) and 3 (14.13±1.73)(p< 0.0001). Similarly, groups 5 and 6 had 25% fewer non-perfused capillaries compared to group 4 (p< 0.0001). Tissue viability improved in indo-methacin-treated groups. Groups 2 and 3 showed fewer damaged cells (1±0.5% and 8.7±2%) compared to group 1 (20±14%)(p< 0.0001). Groups 5 and 6 showed decreased cell damage (13±1% and 11±1%) compared to group 4 (18±1%) (p< 0.01). Apoptotic activity was present in compartment syndrome. At 30 minutes there were elevated caspase levels in EICP groups (0.47±0.08) compared to controls (0.19±0.02). However, indomethacin treated groups did not differ from controls with regards to caspase levels (p> 0.05).

Conclusion: Indomethacin decreased cell damage and improved perfusion in compartment syndrome. The benefits of indomethacin were partially time dependent; some improvement in tissue viability occurred regardless of timing of administration. Although apoptosis was common in compartment syndrome, the protective effect of indomethacin does not appear to be related to apoptosis.


Craig Mathison Reyhan Chaudhary Lauren Beaupré Tim Joseph Samer Adeeb Martin Bouliane

Purpose: The purpose of this study is to compare two fixation methods for surgical neck proximal humeral fractures with medial calcar comminution:

locking plate fixation alone and

locking plate fixation with intramedullary allograft fibular bone peg augmentation.

Method: Eight embalmed pairs of cadaveric specimens were utilized in this study. Dual energy X-ray absorptiometry (DXA) scans were initially performed to determine the bone density of the specimens. Surgical neck proximal humerus fractures were simulated in these specimens by creating a 1-centimeter wedge-shaped osteotomy at the level of the surgical neck to simulate medial calcar fracture comminution. Each pair of specimens had one arm randomly repaired with locking plate fixation, and the other arm repaired with locking plate fixation augmented with an intramedullary fibular autograft bone peg. The constructs were tested in bending to determine the failure loads, and initial stiffness using Digital Imaging Correlation (DIC) technology. The moment created by the rotator cuff was replicated by fixating the humeral head, and applying a point load to the distal humerus. A load was applied with a displacement rate of 4 mm/min, and was stopped approximately every 5 lbs to take a picture and record the load. This process was continued until failure of the specimens was obtained.

Results: The intramedullary bone peg autograft increased the failure load of the constructs by 1.57±0.59 times (p = 0.026). Initial stiffness of the construct was also increased 3.13±2.10 times (p = 0.0079) with use of the bone peg.

Conclusion: The stronger and stiffer construct provided by the addition of an intramedullary fibular allograft bone peg to locking plate fixation may help maintain reduction, and reduce the risk of fixation failure in surgical neck proximal humerus fractures with medial comminution.


Brad Yoo Daphne M. Beingessner

Purpose: To compare locking and non-locking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fracture model. We hypothesized that posteromedial fragment fixation with medial and lateral non-locked constructs would tolerate higher loads than lateral locked constructs alone.

Method: Thirty adult-sized composite tibiae were identically fractured into an AO 41-C1.3 pattern. Six plate constructs were tested:

lateral 8-hole 3.5 mm conventional non-locking proximal tibial plate [CP];

CP + posteromedial 6 hole 3.5 mm limited contact dynamic compression plate [CP + LCDCP];

CP + postero-medial 6 hole 1/3 tubular plate [CP + 1/3 tubular];

8-hole 3.5mm Proximal Tibial Locking plate [PTLP];

8-hole 3.5 mm LCP (locking compression plate) proximal tibia plate [LCP];

9-hole Less Invasive Stabilization System [LISS] plate.

Specimens were cyclically loaded to failure or a maximum load of 4000N. Load at posteromedial fragment failure was recorded.

Results: Fragment failure occurred at the posteromedial fragment first. The CP + 1/3 tubular construct had the highest average load to failure (3040 N). In two instances, the CP + 1/3 tubular construct did not fail under the highest loads applied and was the only construct to have specimens that did not fail by 4000 N. The CP + 1/3 tubular plating construct demonstrated significantly higher load at failure compared with the PTLP (p=0.036), the LCP (p=0.004), and the LISS (p=0.012). The CP + 1/3 tubular group did not demonstrate a significant difference in load at failure when compared with the CP (p=0.093) or the CP + LCDCP (p=0.108). The LISS demonstrated a significantly higher load at failure compared to the LCP (p=0.046) but not to the PTLP (p=0.800).

Conclusion: The posteromedial fragment tolerated higher loads with the CP + 1/3 tubular plate construct. The superiority of the dual plate construct may in part be due to the unreliable penetrance of the posteromedial fragment by the laterally applied locking screws.


Mark McConkey Timothy D. Schwab Andrew Travlos Thomas Oxland Thomas J. Goetz

Purpose: Open reduction internal fixation with a volar plate is a popular surgical option for distal radius fractures. The pronator quadratus (PQ) must be stripped from the distal radius in this procedure. PQ is an important pronator of the forearm and stabilizer of the distal radioulnar joint. The purpose of this study was to investigate pronation torque in healthy volunteers before and after temporary paralysis of the PQ with lidocaine under EMG guidance.

Method: A custom-made apparatus was built to allow isometric testing of pronation torque at 5 positions of rotation: 90° of supination, 45° of supination, neutral, 45° of pronation and 80° of pronation. It was validated using a test-retest design with 10 subjects. For the study, 17 (9 male, 8 female) right hand dominant volunteers were recruited. They were tested at all 5 positions in random order and then had their PQs paralyzed with lidocaine. Repeat testing was performed in the same random order 30 minutes after injection. Three subjects underwent unblinded testing with saline injected instead of lidocaine.

Results: After paralysis of PQ with lidocaine, pronation torque decreased by 23.2% (p=0.0010) at 90° of supination, 16.7% (p=0.0001) at 45° of supination, 22.9% (p=0.0002) in the neutral position, 20.4% (p=0.0066) at 45° of pronation and 22.2% (p=0.0754) at 80° of pronation. All were statistically significant except 80° of pronation. Peak torque values before and after injection were highest in the supinated positions (8.2 Nm at 45° supination) and decreased gradually as the subjects were in more pronated positions (1.8 Nm at 80° pronation). The test-retest trial demonstrated no evidence of fatigue with repeated testing. The subjects who underwent injection of saline demonstrated no evidence of pronation torque loss secondary to pain or a pressure effect of the injectate.

Conclusion: This study demonstrated a significant decrease in pronation torque with controlled elimination of PQ function. Open reduction internal fixation of distal radius fractures damages the PQ. This may result in a pronation torque deficit. Functional significance of this loss should be shown. Pronation torque measurement may add to postoperative outcome analysis of surgical procedures about the wrist.


Steven J.M. MacDonald Robert L. Barrack Seth Rosenzweig Jeffrey F. Guerin Richard W. McCalden Eric Bohm Robert B. Bourne Cecil H. Rorabeck

Purpose: There are two broad-based categories of cementless femoral components performed during total hip arthroplasty: proximally coated versus fully porous coated. While both have enjoyed widespread clinical applications, there remains debate regarding differences in clinical outcome scores, relative incidence of thigh pain and the development of stress shielding. The purpose of this study was to investigate these variables in a multi-center prospective randomized blinded clinical trial.

Method: Between three centers 388 patients were enrolled in this clinical trial. 198 patients received a proximally coated tapered cementless femoral component (Synergy, Smith and Nephew, Memphis) and 190 patients received a fully porous coated cementless femoral component (Prodigy, Depuy, Warsaw). Patients were evaluated pre-operatively, at 3, 6, 12 months and annually thereafter, with multiple validated outcome measures including WOMAC, SF12, HSS, UCLA activity and thigh pain scores. A cohort of 72 patients underwent preoperative and postoperative DEXA scanning.

Results: 367 patients had a minimum of 2 years follow-up (average 6.4 years). There were no differences in age at surgery, BMI, or pre-operative clinical outcome scores (WOMAC, SF12, HSS, UCLA activity, thigh pain) between groups. There were no differences in any post-operative clinical outcome scores at any interval of follow-up. There were no differences in incidence of thigh pain between groups at any time. The only measurable difference between study groups was in bone mineral density evaluation. Bone density change in Gruen zone 7 was 23.7% with the Prodigy stem and 15.3% with the Synergy stem (p=0.011).

Conclusion: Both fully porous coated and proximally porous coated cementless stems performed well, with no clinical differences at a minimum of 2 years follow-up. Only bone mineral density evaluations could detect any differences between these femoral components designs.


Martin Lavigne Payam Farhadnia Pascal-André Vendittoli

Purpose: Clinical studies still show significant variability in offset and leg length reconstruction after 28mmTHA. Precise restoration of hip biomechanics is important since it reduces wear and improves stability, abductor function and patient satisfaction. There is a tendency to increase offset and leg length to ensure stability of 28mmTHA. This may not be needed with the more stable LDHTHA and hip resurfacing implants, therefore potentially improving the precision of the hip reconstruction. The aim of this study was to verify this assumption.

Method: Leg length and femoral offset were measured on standardized digital radiographs with a computer software in 254 patients (49 HR, 74 LDHTHA, 132 28mmTHA) with unilateral hip involvement and compared to the normal contralateral side.

Results: Femoral offset was increased in 72% of 28mmTHA (mean +3.3mm), 56% of LDHTHA (mean +1.0mm) and 8% of HR (mean −3.2mm) (intergroup differences p< 0.05). The mean LLI was greater after 28mmTHA (+2,29mm) vs. (−0.45mm for LDHTHA and −1.8mm for HR). The percentage of patients with increased leg length > 4mm was greater for 28mmTHA (11%) compared to LDHTHA (2.7%) and HR (2%).

Conclusion: The stability afforded by the larger head of LDHTHA reduces the surgeon’s tendency to increased leg length and femoral offset to avoid instability as during 28mmTHA. In addition, compared to HR, LDHTHA allows more precise restoration of equal leg length and femoral offset in patient with greater pre operative deformities (low femoral offset and LLI > 1cm). LDHTHA may represent the most precise method of hip joint reconstruction.


Peter Lewis Ali Al-Belooshi Michael Olsen Emil H. Schemitsch James P. Waddell

Purpose: The use of UHMW polyethylene acetabular liners is known to cause polyethylene wear related osteolysis, the major limiting factor in its use in the younger active patient. Modern alumina ceramic articulations have been developed in order to reduce wear and avoid polyethylene debris. This prospective randomized long-term study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on UHMW polyethylene articulation (CP).

Method: Fixty-six hips in 55 patients with mean age 42.2 (range 19–56) each received uncemented components (Wright Medical) and a 28mm alumina head with acetabular liner selected via sealed envelope randomization following anesthetic induction. Subsequent regular clinical and radiologic follow up measured patient outcome scores and noted any radiological changes.

Results: Twenty-six CP hips and 30 CC hips were evaluated. One failure required revision in each group. Mean St Michael’s outcome score for each group with up to 10 years follow-up (median 8 years, range 1–10) was 22.8 and 22.9 respectively (p=0.057). Radiographs with a minimum 5 years post-operative follow-up were analyzed in 42 hips (23 CC and 19 CP). The mean time of wear measurement for the CC group was 8.3 years (SD 1.3, Range 4.8–10.1 years) and for the CP group was 8.1 years (SD 0.9, Range 6.1–9.2 years)(p=0.471). Wear was identified in all but one CP hip but in only 12 of 23 CC replacements. Mean wear in the CP group was 0.11mm per year and 0.02mm per year in the CC group (p< 0.001).

Conclusion: To our knowledge this is the first long term randomized trial comparing in-vivo ceramic-on-ceramic with ceramic-on-polyethylene hip articulations. Other than significantly greater wear in the polyethylene group there was no significant difference in long-term outcome scores between the two groups with up to 10 years of follow-up. The use of a ceramic-on-ceramic bearing is a safe and durable option in the young patient avoiding the concerns of active metal ions and osteolytic polyethylene debris.


Martin Lavigne Julie Nantel Alain G. Roy Francois Prince Pascal-André Vendittoli Marc Therrien

Purpose: Better clinical outcome is generally reported after hip resurfacing when compared to conventional 28mmTHA. This may simply be the consequences of biased patient selection, patient perception or the advantageous use of larger diameter femoral heads in HR. The true clinical benefits of HR can only be assessed by comparison with LDH-THA in a blinded randomized study to eliminate/reduce those biases. This was the aim of the study.

Method: Charnley class A patients were randomized between HR or LDH-THA and kept blinded for one year. Clinical data, gait analysis, postural balance evaluations and functional tests were performed pre-operatively at 3, 6, 12 and 24 months postoperatively. Fourteen normal patients served as controls.

Results: Twenty-four patients were assigned to each group. There was no significant difference in WOMAC, SF-36, activity scores, and patient satisfaction. A slight advantage was observed for HR during the functional reach test (postural balance) and for LDH-THA during the step test (speed, strength and balance), all other tests showing no differences. Both groups quickly reached controls value for all tests by 3 months.

Conclusion: We have failed to demonstrate a clear difference in outcome between HR and LDH-THA. Both groups fully recovered quickly. The postulated clinical advantages of HR over 28mmTHA most likely result from using a larger head in highly motivated patients. The only clear advantage of HR over LDH-THA remains proximal femoral bone conservation, although with the excellent durability of currently used femoral stems, HR has to demonstrate comparable survivorship before bone conservation is considered a true benefit.


Paul-Edgar Beaulé Benoit Benoit

Purpose: The short-term results of metal-on-metal hip resurfacing (HR) have been excellent. However, extensile approaches such as the posterior and trochanteric slide have been used to ensure proper component placement. The minimally invasive (MI) anterior Hueter approach is both muscle and vascular sparing to the femoral head. The purpose of this study is to evaluate the learning curve of this approach in performing hip resurfacing.

Method: The first 50 MI HR done by a single high volume arthroplasty surgeon were compared with his previous fifty procedures performed through a trochanteric slide osteotomy, with respect to (BMI, sex, etiology and age) were comparable (p=.372,.122,.143 and .353, respectively).

Results: Overall, the traditional transtrochanteric lateral approach took significantly longer to perform compared to MI RAH (97 versus 109 minutes, p=0.014). If we exclude the first 25 MI RAH cases (mean, 106 minutes), the difference is greater (89 versus 109 minutes, p=0.002). The mean femoral component stem to femoral shaft angle (SSA) was not significantly different between the two groups (MI RAH=142.7, lateral approach=140.0, p=0.053). The cup abduction angle (CA) was slightly different between the two groups (MI RAH 42.5°, lateral approach=39.2°, p=0.03). More patients had cup abduction angles in the 45°–55° range (p=0.009) in the MI HR group but none had a cup angle over 55° of abduction in either group. On the femur side, component positioning was comparable.

Conclusion: Based on our early results, the anterior-Hueter approach is a reasonable alternative to more extensile surgical approaches. Like any MI approach to hip surgery, great care has to be taken not to put the cups too vertical. Further long-term studies as well as comparisons to other approaches such as the posterior approach will determine if the anterior approach can be recommended for hip resurfacing.


Peter Lewis Michael Olsen Emil H. Schemitsch James P. Waddell

Purpose: While the durability of most uncemented femoral stems remains unknown, it is the aim of this study to demonstrate Echelon Primary femoral stem performance with regard patient outcome and overall implant survival.

Method: Between February 1998 and March 2007, 428 patients received the Echelon Primary stem. The mean age of each patient was 58.1 (SD 11.1, Range 20–87). Body mass index averaged 30.5 kg/m2 (SD 5.8, Range 17.7–58.2). The majority of patients received a Reflection uncemented acetabular component (91%) and an ultra high molecular weight polyethylene liner (76.5%), although the highly cross linked polyethylene is now used with increased frequency, used in 31% of hips since 2005. The majority of femoral heads were cobalt chrome (79.3%).

Results: Kaplan Meier survivorship for the Echelon Femoral stem with revision for aseptic loosening as end point at 100 months is 99.3% (95% CI 97.1–99.8). Taking revision for any reason as the end point the Kaplan Meier survivorship is 98.3% at 100 months (95% CI 95.9–99.3). A pre-operative WOMAC score was available for 345 of the 392 patients with mean score of 43.5 (95% CI 41.6–45.4). At the three-month post-operative review the mean WOMAC score was significantly increased to 74.54 (95% CI 72.7–76.3)(p< 0.001) and by 1 year 84.3 (95% CI 80.5–88.1). At subsequent years, the modified WOMAC score remained at a plateau of around 80. General health assessment using the SF-36 shows an improvement in the physical component score from 33.1 (95% CI 32.3–33.9) preoperatively to 42.6 (95% CI 41.7–43.6)(p< 0.001) at three months and 48.19 (95% CI 44.2–52.2) at latest follow up. The mental component scores increased from 48.7 (95% CI 47.6–49.9) to 51.4 (95% CI 50.3–52.4)(p< 0.001) and 53.5 (95% CI 50.3–56.6) respectively.

Conclusion: This large prospective review of the Echelon Primary femoral stems reveals an excellent survivorship of the stem with a 99.3% survival at 8 years with regard aseptic loosening and 98.3% survival including revision for any reason. Patient outcome scores are significantly improved and subsequently maintained. There have been no changes with regard to manufacture or design of the stem within the period of review.


Keegan Au Kristoff Corten Robert B. Bourne Cecil H. Rorabeck Andreas Laupacis Li Ka Shing

Purpose: A randomised controlled trial comparing fixation of a Mallory-Head prosthesis for total hip arthroplasty (THA) with and without cement was performed with average 19 years (range 17–21 years) of continuous follow-up.

Method: Two hundred and fifty patients were randomised to undergo THA using either a Mallory-Head THA prosthesis designed to be inserted with cement or one designed for cementless insertion. Both patients and those involved in outcome assessment were blinded to the type of implantation. Patients were followed yearly after the first post-operative year for outcomes including mortality, revision arthroplasty, and health-related quality of life assessment scores.

Results: Primary THA was performed with cement in 124 patients and without cement in 126 patients. Mean age at the time of surgery was 64 years, and 48% were female. During the period of review, there were 78 (31%) deaths in the cohort, and 75 (30%) patients underwent revision surgery. Kaplan-Meier survivorship analysis revealed significantly increased revision rates in cemented compared with cementless THA using failure of either component (p=0.01) or femoral component (p< 0.001) as endpoints. Although acetabular failure accounted for most revisions overall, no significant difference between groups was noted (p=0.075). With the exception of cost to quality adjusted life years, all quality of life outcome measures improved post-operatively and, although reducing modestly through the period of review, demonstrated no difference between groups at final follow-up.

Conclusion: This study has demonstrated a concerning high revision rate with both cemented and cementless THA in patients with a mean age of 64 years at the time of surgery, which significantly affected cost effectiveness. With the implants studied, cementless femoral fixation was superior to cemented, with no cementless femoral component failures through the duration of this study. This study demonstrates the importance of post-market surveillance and evidence-based improvements in THA design (i.e., bearing couples and fixation).


Mitchell J. Winemaker Anthony Staibano Danielle Petruccelli Justin de Beer Carlos Lopez

Purpose: We retrospectively reviewed the pre- and postoperative radiographs of 116 patients receiving primary THA in a high volume arthroplasty centre to evaluate technical causes for limb length discrepancy. We hypothesized that limb lengthening most commonly occurs as a result of low placement of the acetabular implant.

Method: A sample of 116 primary THA’s performed between 2005 and 2007 with complete one-year postoperative clinical outcomes scores and appropriate radiographs available on PACS were identified from a prospective arthroplasty database. Pre- and one-year postoperative AP bilateral hip radiographs were reviewed, and pre- and post-operative leg length discrepancy as well as the respective acetabular and femoral contribution to any postoperative leg length discrepancy (if present) were measured.

Results: We found that 19 THA’s out of 116 (16.4%) were lengthened greater than 8 mm. Mean difference from preoperative to postoperative leg length was 13.3 mm (SD 7.6 mm). A mean of 6.3 mm (SD 6.2 mm) in lengthening was contributed by the femoral stem, and 5.3 mm (SD 6.3 mm) of lengthening was contributed by placement of the acetabular implant (p=0.738). There was a significant correlation between lengthening of the limb and femoral placement of the stem (r=0.5, p< 0.0001). Likewise, there was a strong correlation between limb lengthening and low placement of the cup (r=0.6, p< 0.0001). Of those limbs that were lengthened greater than 8 mm, Oxford Hip Score at one-year post-operative was not correlated with over-lengthening (r=0.06, p=0.551).

Conclusion: These results support our hypothesis that limb lengthening is indeed due to low placement of the acetabular implant, and equally this was attributable to error in placement of the femoral stem. We conclude that with careful preoperative planning and intraoperative identification of the tear drop, a significant reduction in clinically relevant limb lengthening can be achieved.


Andrew Warner Douglas Naudie Xunhua Yuan Robert B. Bourne Cecil H. Rorabeck David Holdsworth

Purpose: Accurate acetabular cup positioning is essential to successful total hip arthroplasty (THA). Intra-operative navigation of the acetabular component can optimize positioning, but often necessitates registration of the pelvis in the supine position. The majority of surgeons use the lateral position, however, which hides commonly employed registration landmarks. The purpose of this study was to identify novel anatomical landmarks for use in navigated THA from the lateral approach.

Method: We identified 156 patients that underwent pelvic CT scans for non-orthopaedic reasons from which 60 patients (mean age 62 years; 30 males, 30 females) were included in the study. CT scans were analyzed with sophisticated software (region grow, isosurface creation, and geometry overlay features). Saved coordinates from each scan were inputted into the program MATLAB (Mathworks, Natick, MA), v7.0, on a Macintosh-based workstation. A code was created to be able to calculate the normal vector for both planes and then calculate the angle formed between the normal vectors. The anterior plane (pubic tubercle (PT) and anterior superior iliac spine (ASIS)) was defined in addition to a series of lateral planes by retaining the ipsilateral PT and ASIS from the anterior plane, plus a variable third landmark. Angles obtained were those between the anterior and lateral planes. Angle conversions between the planes were analyzed using a paired t-test with a p-value of < 0.05 accepted as significant.

Results: The list of landmarks acquired included those used for supine registration (PT and ASIS) in addition to: posterior superior iliac spine (PSIS); posterior inferior iliac spine, (PIIS); ischial tuberosity (IT); tuber-culum of the iliac crest (TIC); and a line drawn along the outer lip of the iliac crest. The angle between the anterior plane and the novel lateral planes did not show a significant level of variance for two of the proposed lateral planes (P< 0.05).

Conclusion: An imageless navigation system in THA that can be accurately employed in the lateral position will benefit many surgeons. The invariance in angle calculations for the lateral planes calculated using the PSIS and the TIC suggest that they could be novel pelvic landmarks for lateral plane registration.


Michael Olsen Edward T. Davis James P. Waddell Emil H. Schemitsch

Purpose: Hip resurfacing is a technically demanding alternative to total hip arthroplasty. Placement of the initial femoral guidewire utilizing traditional mechanical jigs may lead to preparatory errors and a high degree of variability in final implant stem-shaft angle (SSA). Intraoperative computer navigation has the potential to decrease preparatory errors and provide a reliable method of femoral component placement. The current study evaluated the accuracy and learning curve of 140 consecutive navigated hip resurfacing arthroplasties.

Method: Between October 2005 and May 2007, 140 consecutive Birmingham Hip Resurfacings were performed on 132 patients (107 male, 25 female). The mean age of the cohort was 51.2 years (range 25–82). Indications for surgery included osteoarthritis (n=136) and avascular necrosis (n=4). Preoperative templating was performed using digital AP unilateral hip radiographs. Neck-shaft angles (NSA) were digitally measured and relative implant stem-shaft angles planned. The central guidewire was drilled and verified intra-operatively using an imageless navigation system. Implant stem-shaft angles were assessed using 3 month post-operative radiographs.

Results: Pre-operative templating determined a mean NSA of 132.2 degrees (SD 5.3 degrees, range 115–160). The planned SSA was a relative valgus alignment of 9.5 degrees (SD 2.6 degrees). The post-operative SSA differed from the planned SSA by 2.5 degrees (SD 1.9 degrees, range 0–8). The final SSA measured within ±5 degrees of the planned SSA in 89% of cases. Of the remaining 11% of cases, all measurements erred in valgus. No cases of neck notching or varus implant alignment occurred in the series. The mean navigation time for the entire series was 18 minutes (SD 6.6 minutes, range 10–50). A learning curve was observed with respect to navigation time, with a significant decrease in navigation time between the first 20 cases and the remainder of the series. There was no evidence of a learning curve for implant placement accuracy.

Conclusion: Imageless computer navigation shows promise in optimizing preparation of the femoral head and reducing the introduction of mechanical preparatory factors that predispose to femoral neck fracture. Navigation may afford the surgeon an accurate and reliable method of femoral component placement with negligible learning curve.


Gisele M. Carriere Pierre Guy

Purpose: Decubitus ulcers and post-operative infections significantly impact patients’ outcome and resource utilization. The purpose of this study is to report incidence of post-surgical infection, decubitus ulcer and associations to 30-day in-hospital mortality among elderly Canadians admitted for hip fracture.

Method: Statistics Canada’s national Health Person-Oriented Information database of linked acute care hospital discharges was queried for fiscal 2001–02, 2002–03, 2003–04 creating a cohort of 67,434 hip fracture patients aged 60+. Demographics, comorbidities (enhanced Charlson Index), fracture type and treatment were used in logistic regression models to report odds ratios for outcomes.

Results: Women were 76% of the cohort, median age was 82 yrs. Decubitus ulcer was detected in 2.3% of hip fracture patients. Increased risk was indentified for trochanteric fractures (OR 1.14, p< .05), dementia (OR 1.25, p< .05) and increasing age (OR: 1.02, p< .05). Decubitus ulcer more than doubled to 2.9% for those with 1–2 comorbidities, increasing to 6.3% for 3+ comorbidities. Between 1.2% and 1.3% of the cohort developed a post-surgical infection/inflammatory response depending on method used to calculate 30-day follow-up. Compared to internal fixation, arthroplasty showed higher infection (OR: 1.38, p< .05). Overall cohort 30-day in-patient mortality was 7%. Selected complications were significantly associated to 30-day in-hospital mortality (decubitus ulcer OR: 1.51 p< .05, post-surgical infection/inflammatory response (OR: 1.52 p< .05). Trochanteric fractures (OR: 1.19 p< .05) and hemi-arthroplasty (OR: 1.10, p< .05) were associated to 30-day mortality. No significant variation was found between total arthroplasty and internal fixation for 30-day in-patient mortality.

Conclusion: Quantification of these rates and risk factors may offer normative values to measure health system performance and possibly reflect care strategies and delays to surgery. Results may identify target groups at risk for complications and potentially highlight the impact of clinical decisions such as performing arthroplasty for all (displaced and undisplaced) femoral neck fractures.


Vishal Upadhyay Ajay Sahu Charalambos P. Charalambous N. Harshawardena Heath P. Taylor Mark Farrar

Purpose: The aim of this study was to analyze the outcome of AO cannulated screws for undisplaced fracture neck of femur and find out the correlation in outcome with respect to co-morbidities in a general trauma unit in UK.

Method: A retrospective study was conducted using data from electronic patient record, clinical coding information, clinic letters and GP’s. 315 patients who underwent AO screws for fracture neck of femur during 2000 to 2004 were included. We looked into age, place of living, classification, mechanisn of injury, comorbidities, mobility before fracture, allergy, addictions, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital, complications and treatment for complications. We assessed reasons for other admissions later on, need and type of another operation, consequently developed comorbidities, patient getting fracture of other side and its treatment, time and cause of death if happened?

Results: There were 81 males and 234 females in the study. Mean age of patients was 72 years (range 50–96 years). Non-union occurred in 19 patients (6%) and avascular necrosis occurred in 49 patients (15.5%). Reoperation with an arthroplasty was required in 69 patients (21.9 %). The incidence of avascular necrosis with internal fixation at 1 year was 31 (9.8%). Fifty-one (16%) patients died in 2 year period. The age, walking ability of the patient, and associated co-morbidities were of statistical significance in predicting fracture healing complications. We correlated our complications with comorbidities and found them more in patients with end-stage renal failure, steroid intake, osteoporosis and diabetes mellitus etc.

Conclusion: The rate of fracture healing complications and reoperations in patients with undisplaced fractures was high in our series with two year follow up. It was even higher in patients with age greater than 80 years and some specific comorbidities. We should also consider co-morbidities and age before deciding for internal fixation rather than only the fracture configuration (Treat patient not the X-rays). Outcome is multifactorial and depends on many predictive factors. Each patient should be evaluated carefully and we should treat the physiological age and not the chronological age.


Vishal Upadhyay Ajay Sahu Ravi Mahajan Heath Taylor Mark Farrar

Purpose: The aim of the study was to analyze the outcome of AO cannulated screws for fractures neck of femur in patients with Diabetes mellitus.

Method: Sixty-two patients aged 50 years or more (17 males & 45 females) who underwent AO screws for fracture neck of femur over seven years (1999–2005) and followed-up for a minimum of two years formed the study population. A retrospective review of data from electronic patient record (EPR), clinical coding, clinic & GP letters was made. Age, residential placement, Garden’s classification of fracture, mode of injury, associated other co morbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected.

Results: The mean age of patients was 67 years (range 52–96 yrs). Eleven patients died in two years time. Forty-one patients were less than 75 years of age and 21 patients were more than 75 years of age. All the patients more than 75 years of age had undisplaced intracapsular fractures. Thirteen patients were type I and 49 patients were type II diabetic. Non-union and avascular necrosis occurred in nine (17%) & 13 (26%) patients respectively. Revision surgery in the form of total hip replacement or hemiarthroplasty were performed in 21 (41%) cases. The incidence of avascular necrosis following osteosynthesis at one year was 14%. Age, control of diabetes, postoperative complications, pre-fracture mobilization status etc. Complications like wound infection were more principally in patients who had poorly-controlled diabetes.

Conclusion: Patients with diabetes mellitus have metabolic bone disease due to vasculitis. This increases the risk of complications associated with fracture fixation such as non-union, cut-through and avascular necrosis (AVN). The complications and revision surgery rate was high in patients with displaced fractures and with poorly controlled diabetes. Comorbidities like diabetes and patient’s age were also strong predictors of healing in addition to fracture configuration. Looking at very high complication and re-operation rate, our recommendation in patients with diabetes is primary hemiarthroplasty irrespective of femoral head displacement, if there age is more than 75 years.


Nicole Simunovic Sheila Sprague Mohit Bhandari

Purpose: Hip fractures are associated with a high rate of mortality and profound temporary and sometimes permanent impairment of independence and quality of life. While guidelines exist for the surgical treatment of hip fracture patients, the effect of surgical delay on mortality and other patient-important outcomes remains unclear. The objective of this systematic review and meta-analysis was to determine the effect of early surgery compared with delayed surgery on the risk of mortality, common postoperative complications, and length of hospital stay among elderly hip fracture patients.

Method: We searched MEDLINE and EMBASE for relevant prospective studies evaluating surgical delay in patients undergoing surgery for hip fractures published in all languages between 1966 and 2008. We identified additional studies through contacting experts, as well as hand searches of the bibliographies of relevant articles and the archives of orthopaedic annual meetings. Two reviewers independently assessed methodological quality and extracted relevant data. When necessary, we contacted authors for clarification of study design or to provide additional data. Data were pooled by use of a DerSimonian and Laird random-effects model based on the inverse variance method.

Results: Of 1917 citations identified, 16 observational studies, which included a total of 13,565 patients with complete mortality data, met our inclusion criteria. Irrespective of the cut-off for delay (24, 48, or 72 hours), earlier surgery (< 24, < 48, or < 72 hours) was significantly associated with a reduction in the risk of unadjusted one-year mortality (relative risk 0.55; 95% confidence interval, 0.40 to 0.75, p=0.0002) and adjusted mortality rates (relative risk 0.81; 95% confidence interval, 0.68 to 0.96, p=0.01). Earlier surgery also reduced in-hospital pneumonia (relative risk 0.59; 95% confidence interval, 0.37 to 0.93, p=0.02), pressure sores (relative risk 0.48; 95% confidence interval, 0.34 to 0.69, p< 0.0001) and hospital stay (weighted mean difference 9.95 days; 95% confidence interval, 1.52 to 18.39, p=0.02).

Conclusion: Earlier surgery reduced the risk of mortality, postoperative pneumonia, pressure sores, and length of hospital stay among elderly hip fracture patients suggesting that it may be warranted to reduce administrative delays whenever possible. However, potential residual confounding of observational studies may limit any definitive conclusions.


Joshua Gary Kelly Lefaivre Frank Gerold Michael Hay Charles M. Reinert Adam J. Starr

Purpose: Acetabular fractures in elderly patients are difficult problems with various treatment options. Our institution treats many of these patients with percutaneous acetabular fixation. We reviewed medical records and contacted patients to determine the rate of conversion to total hip arthroplasty.

Method: Our institutional trauma database was searched for all patients age 60 and older who had been treated with percutaneous screw fixation for an acetabular fracture. Seventy-nine consecutive patients (80 fractures) were identified. Medical records were examined to obtain peri-operative and follow-up information regarding the hospital course and conversion to total hip arthroplasty. A survivorship anaylsis was created with conversion to total hip arthroplasty as the censored event, and standard Kaplan-Meier curves were constructed. Five categorical variables were used to test for differences in survival of the native hip: age, sex, simple versus complex fracture pattern, closed versus limited open reduction, and occurrence of a medical complication.

Results: Seventy-five fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5 – 11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 post-operatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed versus limited open reduction, simple versus complex fracture pattern, and occurrence of a medical complication.

Conclusion: Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to other treatment methods and if conversion is required, soft tissues are preserved for future surgery.


G. Yves Laflamme Benoit Benoit Stéphane Leduc Jonah Hébert-Davies

Purpose: The age of patients presenting with acetabular fracture has increased over the last ten years. Older patients tend to have patterns involving the anterior column with comminution of the quadrilateral plate. Our goal was to investigate the appropriateness of open reduction and internal fixation using the modified Stoppa approach for geriatric acetabular fractures.

Method: A retrospective review of patients over the age of 60 having presented to an academic level I trauma center over the course of four years. Twenty patients were identified and treated using the modified Stoppa approach with plating of the quadrilateral surface. Patients were evaluated clinically using both SF-36 and Harris Hip Score. Records and radiographs (using criteria described by Matta) were reviewed retrospectively.

Results: All patients were followed for a minimum of two years with no lost at follow-up. Mean age for patients at time of intervention was 68 years. Average blood lost was 800cc and surgical time was 130 minutes (range, 55–210). There was one traumatic injury to the obturator nerve and two patients were noted to have temporary weakness of the hip adductors postoperatively. Average Harris Hip Score and the SF-36 were improved significantly (p< 0.05). Significant lost of reduction was seen in two patients and was correlated to superior dome impaction (p < 0.0001). Three patients required re-intervention with a Total Hip Arthroplasty.

Conclusion: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures of the anterior column in the elderly.


Kelly Lefaivre Wade Smith Philip Stahel Alan Elliott Adam J. Starr

Purpose: To evaluate the effect of the presence of femur fracture on mortality, pulmonary complications, and ARDS in trauma patients. In addition, we aim to compare the effects of other major musculoskeletal injuries to femur fractures on these outcomes.

Method: We retrospectively reviewed the trauma registry of two tertiary level trauma centers for a period of 12 years (1995–2007). We evaluated data points on all patients: gender, age, AIS scores, GCS, SBP, and ICD-9 codes for femur fractures and other major orthopaedic injuries. Outcome measures were death in hospital and occurrence of a pulmonary complication (Adult respiratory distress syndrome, fat embolism syndrome, pneumonia and respiratory failure) and ARDS as a sub-group. Logistic regression was used to evaluate the effect of these variables and the presence of femur fracture on the three outcomes (death, pulmonary complications, and ARDS). The effect of other major orthopaedic injuries in these models was also compared to the effect of femur fractures.

Results: There were 83, 349 patients, with 3, 433 deaths, evaluated in the initial regression models. Gender, GCS < 8, age> 60, blood pressure < 90, 4 AIS scores and femur fracture were all independent predictors of mortality. The strongest predictors of mortality were GCS < 8 (OR 16.976, 95% CI 15.176–18.990) and SBP < 90 (OR 6.835, 95% CI 6.046– 7.726). Femur fracture was an independent predictor of mortality (OR 1.480 95% CI 1.135 – 1.929). The presence of femur fracture was not a statistically significant independent predictor of pulmonary complication (OR 1.29, 95% CI 0.911–1.766) while gender, GCS, and 5 of 6 AIS scores were. Other musculoskeletal injuries were significant predictors, including pelvic ring fractures and spinal fractures. In the ARDS regression model, femur fractures were not an independent predictor (OR 1.127, 95% 0.636–1.999).

Conclusion: The risk of mortality and pulmonary complications is multifactorial; most affected by age, GCS at presentation, SBP at presentation, gender and injury severity. In this study, the presence of a femur fracture does independently increase the risk of death, but not ARDS or other pulmonary complications. There are other musculoskeletal injuries that have a greater effect on mortality and pulmonary complications.


Darren Costain Sarah L. Whitehouse Nicole L. Pratt Stephen E. Graves Ross W. Crawford

Purpose: The appropriate means of fixation for hemiarthroplasty of the hip is a matter of ongoing debate. Proponents of uncemented components cite the risk of perioperative mortality with cement implantation as justification for avoiding cement in certain patients. Because cement-related mortality is rare, we wished to compare the incidence of perioperative mortality in patients receiving cemented versus uncemented hemiarthroplasty using a large national database. Further, we wished to compare overall revision rate between fixation methods to assess their role in implant survivorship.

Method: All recorded hemiarthroplasty cases from the AOA National Joint Replacement Registry were cross-referenced to the Australian mortality data, and deaths at 1d, 7d, 28d, and one year were compared between groups. Further, subgroup analysis of monoblock, modular, and bipolar hemiarthroplasty were compared as a surrogate measure of different patient populations.

Results: Comparing all hemiarthroplasty procedures as a group, there was a a significantly increased mortality rate at day one post-operatively (p = 0.0005) when cement was used. By day 7, this trend reversed, revealing a reduced mortality risk with cement (p = 0.02). This trend reversal persisted at day 28 and one year post-operatively (p = 0.028 & p < 0.0001, respectively). With subgroup analysis, monoblock hemiarthroplasty revealed a similar trend reversal in early versus late mortality. Modular and bipolar hemiarthroplasty procedures failed to reveal a significant difference in mortality when cemented and uncemented components were compared at all time points. When fixation method was compared in different age groups, a favourable mortality rate was seen at one year when cemented monoblock components were used in patients aged 71–80, and in patients ≥81 years old (p = 0.005 & < 0.001, respectively). The opposite was true with cemented modular implants at one year in patients < 70 years old (p = 0.009). There was no significant difference in mortality between cemented and uncemented implants in any other age investigated. Revision rates were significantly higher in patients treated with uncemented hemiarthroplasty regardless of prosthesis type.

Conclusion: This study demonstrates a higher overall success rate, and comparable or reduced long-term mortality risk when cement is used in hip hemiarthroplasty.


Arvindera Ghag Pierre Guy Peter J. O’Brien Henry M. Broekhuyse Robert N. Meek Piotr A. Blachut

Purpose: Femoral and tibial shaft malunion may predispose to knee osteoarthritis but may also pose a problem for knee reconstruction; malposition of total knee prostheses being a known cause of early failure. Limb realignment may prove to be beneficial prior to proceeding with arthroplasty. The purpose of this study was to evaluate the outcome and effect of shaft osteotomy prior to total knee arthroplasty (TKA).

Method: A search of the trauma database between 1987 and 2006 was conducted. Twenty-two osteotomies were performed on 21 patients with femoral or tibial shaft malunion who had been considered for TKA. Mean age at osteotomy was 54 years and mean follow-up 86 months. Time intervals between surgical procedures and Knee Society scores were calculated. Patients were surveyed regarding pain relief and functional improvement.

Results: Femoral osteotomy improved mean Knee Society knee scores from 47 to 76 and function scores from 34 to 61. Tibial osteotomy improved knee scores from 53 to 82 and function scores from 28 to 50. Four osteotomies were complicated by nonunion and required further intervention. Osteotomy subjectively improved pain and function for a mean of 56 months. Femoral and tibial shaft osteotomy delayed TKA in 45% (10 cases) for a mean period of just over 6.5 years (89 and 73 months for femoral and tibial osteotomy respectively). Pre and post Knee society scores were: Femur: knee 56 to 88, function 41 to 72; Tibia: knee 65 to 85, function 25 to 57. One TKA was revised after 11 months due to valgus malalignment and was complicated by a wound infection. There were no other infections or wound complications. The procedure additionally relieved pain and improved function in the remaining 12 joints, not yet requiring arthroplasty.

Conclusion: Femoral and tibial shaft osteotomy may delay and possibly avoid TKA, relieve pain and improve function in patients who present with malunion and end-stage knee arthritis. The complication rate and clinical results of TKA following shaft osteotomy appear to be similar to primary TKA. This treatment strategy should be considered in younger patients with post traumatic osteoarthritis where significant femoral or tibial deformity is present.


Peter Lapner Emilio Lopez Felipe Pereira Salah Elfatori David Simon

Purpose: The upward migration index (UMI) is a useful radiographic parameter for assessment of disorders of the rotator cuff. Utility of the UMI as a prognostic indicator for outcome following cuff repair has not been previously studied. The objective of this study was to determine if an association exists between the pre-operative UMI and the improvement in clinical and quality of life outcome scores following arthroscopic rotator cuff repair.

Method: Patients with a full thickness tear of the rotator cuff who underwent an arthroscopic repair of the cuff were selected for review. Eighty-four patients were included in the series. Mean patient age was 55 (range 25–78). The UMI was measured by MRI, and patients were divided into three groups: < 1.25 (GROUP A), 1.25–1.35 (GROUP B) and > 1.35 (GROUP C). Outcome variables were the non-weighted Constant-Murley score, ASES and the WORC assessed at baseline, 6 month and 12 months post-operatively. The paired t-test was used to carry out comparisons in follow up and one-way ANOVA was used to carry out comparisons between groups.

Results: There were 9 patients in group A, 33 in group B and 42 in group C. The improvement in scores from baseline to 1 year were as follows: ASES; 21.1 (A), 32.6 (B), and 38.4 (C); Constant 21.4 (A) 19.8 (B), and 24.2 (C) and WORC 31.9 (A), 42.7 (B), and 44 (C). Statistically significant improvements were observed in all groups in all outcome measures from baseline to 6 months and from 6 months to 1 year. Although the differences were not statistically significant (p> 0.05), a trend toward greater improvement in outcomes was observed with higher upward migration indices.

Conclusion: A lower UMI was associated with less improvement in functional and quality of life outcomes following arthroscopic rotator cuff repair, although these differences were not statistically significant. Patients with a low UMI demonstrated a significant improvement in functional and quality of life scores following surgery. In isolation, a low UMI should not represent a significant contraindication to treatment by arthroscopic rotator cuff repair.


Gerard Slobogean Akin Famuyide Vanessa Noonan Peter J. O’Brien

Purpose: To quantify how well the physical examination of the shoulder predicts patient-reported functional outcome in a cohort of patients with previous proximal humerus fractures.

Method: Potential subjects were identified from a recent study cohort of proximal humerus fracture patients treated within the past six years. The cohort consisted of all fracture types and treatment modalities. Participants underwent a focused physical examination of their injured shoulder containing the components of the Constant-Murley shoulder score: range of motion for forward flexion, abduction, internal rotation, external rotation, and abduction strength measured by an IsoBex muscle strength analyzer. Participants also completed the following patient-reported functional outcome questionnaires: Disabilities of Arm, Shoulder, Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Oxford Shoulder Score (OSS). Forward- and backward-stepwise linear regression was used to assess the relationship between the functional outcomes and the physical exam measurements.

Results: Thirty-one subjects with a mean age of 70 ± 8 years participated. Sixteen patients were previously treated with ORIF and 15 were treated with sling immobilization. The mean physical examination measures were: flexion 117° ± 31°, abduction 117° ± 37°, internal rotation 7° ± 2°, external rotation 7° ± 4°, and strength 6 ± 5 Newtons. The mean functional outcome scores were: DASH 21 ± 19, ASES 82 ± 17, SST 8 ± 3, and Oxford 20 ± 8. Using linear regression, adjusted R-squared statistics suggest components of the physical exam can explain 38% of the Oxford, 50% of the DASH, 58% of the SST, and 70% of the ASES variance. Abduction strength was a significant predictor for all functional outcomes. Combinations of flexion, abduction, or internal rotation were also significant predictors depending on the outcome instrument being modeled.

Conclusion: Physical exam of the shoulder accounts for differing amounts of patient-reported functional outcome variance. Abduction strength is the most consistent predictor of functional outcome within this cohort of proximal humerus fracture patients.


Ramin Mehin Peter O’Brien Penny Brasher Henry M. Broekhuyse Piotr Blachut Robert N. Meek Pierre Guy

Purpose: Problem: Tibia plateau fractures may lead to end-stage post-traumatic arthritis that requires reconstructive surgery. The incidence of this problem is unknown but has been estimated at 20–40% by studies that were limited by small sample sizes, potential follow-up bias, and the limitations of using radiographic arthritis as a chosen outcome (not correlated to function). The use of administrative data bases to follow the care of a large number patients for robust end points such as surgery, offers an opportunity to address these limitations. Purpose: to determine the minimum ten year incidence of post-traumatic arthritis necessitating reconstructive surgery following tibia plateau fractures.

Method: We queried our prospectively collected Orthopedic Trauma Data base to identify operatively treated patients with tibia plateau fractures. These cases were cross-referenced with the data from our Province’s administrative health database and tracked over time for the performance of reconstructive knee surgery. Each individual’s exposure/follow-up period was limited by end of health plan coverage on record or date of death from vital statistics data. The minimum follow-up was ten years.

Results: Between 1987 and 1994, 378 patients with a tibia plateau fracture were treated at our institution. The average age was 46 years (sd=18, range 14–87), while 56% of patients were males. Seventeen out-of-Province residents were excluded, along with forty-six others whose “Medical Services Plan” numbers could not be identified. Of which seven were WCB patients and one who was affiliated with the military. The study cohort therefore consisted of 311 patients with 314 tibia plateau fractures. Four individuals (1.3%) we treated tibia plateau fractures have required reconstructive knee surgery for end-stage post-traumatic knee arthritis at 10 years. Of these 3 of 4 were type VI fractures and 1 of 4 was open.

Conclusion: Patients who require surgical treatment of tibia plateau fractures may be counseled on their long-term risk of requiring reconstructive knee surgery for endstage knee arthritis based on a clinical study. Based on our findings, the proportion of those who have required a total knee surgery, ten years following their injury, is lower than previously published.


Richard M. Holtby Helen Razmjou Iona MacRitchie

Purpose: There is controversial information on recovery of patients with compensable injuries. The purpose of this matched case-control study was to examine the impact of an active compensation claim following a work-related shoulder injury on reporting disability as measured by subjective and objective outcomes at 1 year post-operatively.

Method: Data of 506 consecutive patients who had undergone a decompression or rotator cuff repair were reviewed. One hundred and fourteen patients were on compensation related to their shoulder problems. Patients were matched with a historical control group (patients without a compensation claim) based on age (4 age groups: < 40, 40–49, 50–59, 60–70), sex, and pathology (full-thickness tear vs. no tear). Outcome measures used were a disease-specific outcome, the Western Ontario Rotator Cuff Index (WORC) and two shoulder specific instruments, the American Shoulder and Elbow Score (ASES) and the Constant Murley (CM) score. Paired and independent t-tests and an analysis of covariance were performed.

Results: Data of the 214 patients (72 males and 35 females in each group) was used for analysis (mean age 48, SD: 10, range 20–69). Out of 107 patients in each group, 42 patients (58%) had undergone a full-thickness repair and 65 (61%) had surgeries related to impingement syndrome. Paired and independent t-tests showed that both groups improved significantly regardless of their claim status. However, the compensation group had a significantly lower level of improvement than the non-compensation group. An analysis of covariance which adjusted for pre-operative differences in disability scores showed that an active claim was indeed a strong predictor of follow up scores.

Conclusion: This is the first study that has used a matched case-control design to control for potential confounding factors in injured worker population. Our results indicate that although patients with work-related injuries demonstrate a lower level of recovery, they still benefit from surgery.


Peter Lapner Philippe Poitras Othman Ramadan Stephen Kingwell Donald Russell

Purpose: Subacromial impingement syndrome is a painful condition which occurs during overhead activities as the rotator cuff is compressed between the greater tuberosity and the acromion. Unrecognized secondary causes of impingement syndrome may lead to treatment failure. Posterior capsular tightness, believed to alter shoulder joint kinematics, is often cited as a secondary cause but scientific evidence is lacking. The objective of this study was to evaluate the effect of posterior capsular tightness on pressure in the subacromial space.

Method: Ten fresh-frozen cadaver shoulder specimens were mounted on a custom testing apparatus. With the scapula fixed, the deltoid and cuff muscles were loaded statically with a constant ratio to elevate the humerus in the scapular plane under physiologic loading conditions. For each treatment (intact capsule, 1cm and 2cm plication), pressure in the subacromial space and glenohumeral kinematics were recorded during elevation. The treatment order was randomly assigned to each specimen. Peak pressure and translation of the humeral head center were compared using a repeated measures ANOVA.

Results: Peak subacromial pressures (mean±sd) were similar between treatment groups: 345±152 kPa, 410±213 kPa and 330±164 kPa for the intact, 1cm and 2cm plication respectively (p> 0.05). No significant differences were found for superior or antero-posterior translations of the humeral head at the peak pressure position (p> 0.05).

Conclusion: Posterior capsular tightness, as a sole variable, did not contribute significantly to increased pressure in the subacromial space or to increased anterior or superior humeral head translation during abduction. Clinically, posterior capsular tightness may occur in association with impingement syndrome but may not play a significant role in causation.


Frédéric Balg Josianne Lepine Nicolas Huppe Eve Langelier Denis Rancourt

Purpose: Comparer la technique de réparation de la coiffe des rotateurs par haubanage tendineux en simple rangée aux techniques transosseuse et double-rangée par rapport à la surface et la pression de contact à l’interface tendon-os, et la force de rupture.

Method: Pour tester la pression et la surface de contact, les techniques de réparation ont été faite sur 2 spécimens cadavériques (tête humérale et sus-épineux) chaque. Un film Prescale pressure-sensing a été interposé entre les tendons et l’os pendant 2 minutes avec une tension de 120N sur les tendons. Les films ont été numérisés pour l’analyse avec le logiciel ImageJ. La force de rupture a été testé sur un modèle Sawbones d’humérus proximal. Des tendons synthétiques en fibre de nylon et polyesther dans du silicone ont été créés pour les propriétés d’un tendon proportionnellement à la rigidité du Sawbones. La force a été appliquée à 135° jusqu’à rupture sur 2 montages par technique de réparation. La suture transosseuse utilisait 2 fils Orthocord dans 2 tunnels transosseux. La suture double rangé a été faite avec 2 ancres Spiralok médialement et 2 ancres Versalok latéralement avec des fils Orthocord. Le haubanage tendineux a été fait avec 2 ancres Panalok RC latéralement dans la zone corticale.

Results: La surface de contact du haubanage de 17mm2 était significativement plus basse que de la suture transosseuse à 48mm2 (p=0.002) et double-rangée à 86mm2 (p=0.001). La différence entre transosseux et double rangée était significative (p=0.029). La pression de contact du haubanage de 0.353MPa était significativement plus basse que de la suture transosseuse à 0.441MPa (p=0.002) et double-rangée à 0.567MPa (p=0.003). La différence entre transosseux et double rangée était significative (p-0.029). La force de rupture du haubanage de 106N était significativement plus basse que de la suture transosseuse à 249N (p=0.03) et double-rangée à 316N (p=0.04). La différence entre transosseux et double rangée n’était pas significative.

Conclusion: Le haubanage tendineux ne reproduit pas l’empreinte anatomique du sus-épineux sur la grande tubérosité ni une pression de contact adéquate en plus d’avoir une force de rupture plus faible. Malgré son coût plus élevé, la suture par double rangée est supérieure à la technique transosseuse ou simple rangée.


Peter Zarkadas Thomas Throckmorton Diane Dahm John Sperling Robert Cofield

Purpose: The indication to perform a total shoulder arthroplasty (TSA) versus a hemiarthroplasty is guided by a patient’s intended level of activity after surgery. It is unclear what activities patients actually perform following shoulder replacement, therefore, the purpose of this study was to compare the self-reported activities of patients following either a TSA or hemiarthroplasty.

Method: Two groups of 75 patients each, following TSA or hemiarthroplasty, were matched for a variety of demographic variables. A mailed activity questionnaire asked patients to report their level of pain, motion, strength, and a choice of 70 different activities. Reported activities were classified as high (i.e. tennis) or low (i.e. fishing) demand, and categorized as household (i.e. cooking), yard work (i.e. gardening), sporting (i.e. golf), or musical (i.e. piano).

Results: Ninety-six (64%) patients completed the survey, 50 in the TSA group (27F:19M, avg. 53.2 yrs), and 46 in the HA group (29F:21M, avg. 53.5 yrs). Pain was not different between groups (3.6/10 TSA: 3.9/10 HA), yet a significant difference was reported in forward flexion (145° TSA: 120° HA, P< .002) and strength (6.3/10 TSA: 5.3/10 HA, P< .01). Across all categories whether it be high or low demand, the TSA group (10.4 activities/person) reported more activities compared with the hemiarthroplasty group (8.6 activities/person).

Conclusion: The conventional understanding that a hemiarthroplasty provides the possibility for more activity following surgery is not supported by our data. Patients following a TSA reported better motion and strength and were more active than the hemiarthroplasty group.


Robert Litchfield Michael D. McKee Robert A. Balyk Scott J. Mandel Richard M. Holtby Robert Hollinshead Robert MacCormack Darren S. Drosdowech Sharon H. Griffin

Purpose: This prospective, randomized double-blinded clinical trial compared cemented fixation of the humeral component to uncemented/tissue-in-growth fixation in total shoulder arthroplasty for primary osteoarthritis of the shoulder.

Method: All patients presenting with primary osteoarthritis of the shoulder requiring replacement were screened for eligibility. Patients were randomized in the operating room after glenoid preparation to the cemented or uncemented group by a computer-generated, stratified randomization procedure. Outcome measures included disease specific QOL assessment (WOOS), SF-12, ASES, MACTAR, radiographic evaluation of component fixation, operative time, complications and revision surgery. Patients were assessed by a blinded evaluator in post-operative intervals of 2 and 6 weeks, and 3, 6, 12, 18, and 24 months. The primary endpoint was the WOOS score at 2 years.

Results: One hundred and sixty-one patients were consented and randomized for the study. There were 80 patients in the cemented and 81 patients in the uncemented group. At baseline, the groups were alike with regards to demographics and baseline evaluations. The WOOS scores at post-operative intervals of 12, 18 and 24 months showed a significant difference (p=0.009, 0.001, 0.028 respectively) in favour of the cemented group. The cemented group also had better strength (3 m p=0.038, 12 m p= 0.036, 18 m p=0.051, 24 m p=0.053) and forward flexion (6m p=0.031, 12 m p=0.04). As expected, the operative time was significantly less for the uncemented group (C = 2.26h +/−.63; U = 1.69h +/− 1.9, p= 0.03).

Conclusion: These findings provide the first evidence that cemented fixation of the humeral head provides better quality of life, strength and ROM than uncemented fixation. This was a Tier 1 Project of the JOINTs Canada group.


Patrick Denard Timothy Bahney Robert M. Orfaly

Purpose: Determine the ideal form of subacromial decompression.

Method: Six cadaveric shoulders with intact rotator cuffs (RTC) underwent “smooth & move (SM),” limited acromioplasty with coracoacromial ligament (CAL) preservation, and CAL resection. Glenohumeral translation was measured in four directions utilizing electromagnetic spatial sensors. Peak RTC pressure was measured during arm abduction utilizing pressure film sensors.

Results: Anterosuperior translation was unchanged after SM or acromioplasty, but increased from 2mm at baseline to 4mm following CAL resection with the arm at 300 abduction (p=0.03). There were no significant changes in other directions of translation following any procedure. In neutral humeral rotation RTC pressure was unchanged after SM (p=1.00). Pressure decreased 64% after a limited acromioplasty (p=0.04), and 72% after CAL resection (p=0.03). There was a trend towards increased abduction at which peak pressure occurred following CAL resection (760 compared to 620;p=0.11) In external rotation, RTC pressure decreased 26% following SM, 52% after limited acromioplasty, and 64% after CAL resection, but values were not statistically changed (p=0.52, p=0.08, and p=0.06). Similarly, abduction angle at which peak pressure was reached increased but was statistically insignificant after SM (720; p=0.75), limited acromioplasty (750; p=0.11), and CAL resection (790; p=0.08). In internal rotation, RTC pressure decreased 32% following the SM, 59% following the limited acromioplasty, and 58% following CAL resection, but none reached statistical significance (p=0.52, p=0.26, p=0.17). Abduction angle of peak pressure was unchanged after SM (670; p=0.63) and limited acromioplasty (670; p=0.63), but increased following CAL resection (620 vs. 790; p=0.04).

Conclusion: A CAL resection leads to increased anterosuperior instability. “Smooth and move” or acromioplasty can safely be performed without increasing translation. Rotator cuff pressure did not significantly decrease after SM. Rotator cuff pressure was significantly decreased to a similar degree following a limited acromioplasty or a CAL resection. A limited acromioplasty with preservation of the CAL may offer the greatest decrease in cuff pressures without the undesirable effect of increased translation. However, statistical significance was affected by high anatomic variability. Therefore, the choice between “smooth & move” and acromioplasty to decrease contact pressure is likely best to be individualized based on acromial morphology.


Ryan Bicknell Pascal Boileau Yannick Roussanne Nicolas Brassart Chris Chuinard

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA).

Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up.

Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed.

Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation.


Ryan Bicknell Frederick A. Matsen Alex Bertelsen Paul Pottinger

Purpose: The objectives of this study were to correlate the clinical course of all patients with positive intra-operative P. acnes cultures in revision shoulder surgery with the cultures and intraoperative findings to determine the clinical significance of the positive cultures.

Method: From 2005 to 2007 all revision shoulder surgeries were managed with a standard protocol in which

antibiotics were withheld until cultures obtained,

at least four fluid and tissue cultures were submitted,

frozen sections were obtained of any tissue grossly suspicious for infection, and

the surgeons’ pre-, intra-, and post-operative suspicion for infection were recorded.

Samples were observed for growth for 28 days. All cases were reviewed at a mean follow-up of 4.2 months (range, 1–12). Comparisons were made between infection cases and “clinically Insignificant” cases, with respect to: (1) risk factors, (3) symptoms/signs of infection, (2) active range-of-motion, (2) Simple Shoulder Test (SST) scores, values of (3) WBC, (4) ESR and (5) CRP, number of positive cultures for (6) P acnes and (7) other organisms and (8) subjective pre-operative, intra-operative and postoperative suspicion for occult infection.

Results: P. acnes was cultivated from 20 cases in 19 patients. Five cases (25%) were considered significant infections, while fifteen cases were considered “clinically insignificant”. The mean number of cultures positive for P. acnes was 1.7 (range, 1–4) per case. The mean active forward flexion (p=0.03) and internal rotation (p=0.03) was less for infection cases than for clinically Insignificant cases. Pre-operative ESR (p=0.04) and CRP (p=0.02) values were higher for infection cases. Infection cases had a higher number of positive intra-operative cultures for other organisms (p=0.04).

Conclusion: No combination of clinical parameters would reliably predict clinical infection in patients with positive intra-operative P. acnes cultures in revision shoulder surgery. In particular, positive P. acnes intra-operative cultures do not always represent true clinical infections. Pre-operative loss of range-of-motion, elevated ESR and CRP and positive intra-operative cultures for other organisms appear to correlate with true infections. The determination of a clinically significant infection needs to be based on the entirety of the clinical and laboratory information for each shoulder case.


Christina Goldstein Emil H. Schemitsch Mohit Bhandari George Mathew Brad Petrisor

Purpose: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the variety of different measurement tools and lack of validation of generic and foot-specific functional measures. It remains plausible that the choice of functional outcome measure may influence our ability to accurately measure treatment effects. This prospective observational study aims to correlate the scores across six functional outcome measures in patients with traumatic foot and ankle injuries and to examine agreement of scores and patients’ subjective health status.

Method: Patients with traumatic foot or ankle injuries completed two generic, the SF-12 Health Survey and the Short Musculoskeletal Functional Assessment (SMFA), and four specific health outcome measures, the Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS) Foot and Ankle Questionnaire and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, at a single follow-up visit. Raw scores were calculated and used to assign patients to a categorical functional level (excellent, very good, good, fair or poor). Agreement between the assignments was assessed and Pearson correlation co-efficients were calculated for each pair of outcome scores. Statistical significance was determined using an α of 0.05.

Results: 52 patients (mean age 43.3 ± 16.8 years) were enrolled at a mean follow-up of 15.5 months. All correlations except for that between the AOFAS ankle-hindfoot scale and the mental component of the SF-12 were statistically significant. The strongest correlations were found between the SMFA, FFI, AAOS Foot and Ankle Questionnaire and the FAAM. Despite significant correlation between scores and patients’ subjective functional outcome, there was minimal agreement between assigned categorical functional levels.

Conclusion: The high correlations between scores on the generic and foot-specific functional measures suggest that it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. Generic tools also appear to function as well as specific scores in this population. However, assignment of patients to a categorical functional level based on raw outcome scores must be performed with caution as the results obtained may not accurately reflect functional outcome.


Timothy R. Daniels Ellie Pinsker Taucha Inrig Kelly Warmington Dorcas Beaton

Purpose: The objective of this study is to compare items from patient-reported questionnaires measuring musculoskeletal outcomes with items generated by pre-and post-operative ankle arthrodesis and arthroplasty patients using the Patient-Specific Index (PSI-P). The International Classification of Functioning, Disability and Health (ICF) was used as an external reference.

Method: A literature review identified six questionnaires that assess lower extremity outcomes (AAOS, patient-reported portion of AOFAS, FFI, LEFS, SMFA, WOMAC). Surgical patients (n=142) from an orthopaedic surgeon’s practice completed the patient-selected items from PSI-P. Items from questionnaires and PSI-P were coded by three reviewers and linked to the ICF. The ICF is divided into four components (Body Functions and Structures, Activities and Participation, Environmental Factors, and Personal Factors) which are then further divided into second level categories. A higher number of second level categories would indicate a questionnaire that captures a broader range of experiences.

Results: Patient’s responses from PSI-P identified 690 meaningful concepts that were linked to 45 second level ICF categories. Most PSI-P responses fell into Activities and Participation (60.6%) and Body Functions and Body Structures (35.2%) including the second level categories Walking (19.1%), Pain (16.5%), and Recreation and Leisure (15.4%). There was no statistical difference between arthrodesis and arthroplasty patients nor between pre-operative versus postoperative patients in terms of the proportion of patient responses that fell into each ICF component. A total of 237 meaningful concepts were identified in the 6 questionnaires studied and linked to 38 second level ICF categories. Overall, SMFA addressed the most number of second level categories and had the closest proportion of Body Function (23.0%) and Activities and Participation (68.9%) concepts as compared to PSI-P. The patient-reported portion of AOFAS addressed the fewest categories. LEFS only contained items from Activities and Participation. AAOS was the only questionnaire to address the issue of ‘swelling’, though it represented 4.9% of all PSI-P responses.

Conclusion: Questionnaires differ largely in their content and no single questionnaire captured all of the concerns identified by PSI-P. This analysis will guide us in the development of a new and more comprehensive instrument for evaluating ankle outcomes following fusion or replacement.


Gerard Slobogean Alastair S.E. Younger Carlo A. Marra Kevin J. Wing Murray J. Penner Mark Glazebrook

Purpose: To describe the pre- and one-year post-operative preference-based, health related quality of life (health state values) among a cohort of subjects with end-stage ankle arthritis treated with total ankle arthroplasty or ankle arthrodesis. This short-term study is not intended to compare the efficacy of arthoplasty and arthrodesis.

Method: The Short-Form 36 (SF-36) was prospectively completed by subjects enrolled in the Canadian Orthopaedic Foot and Ankle Society Multicentered Ankle Arthritis Outcome Study between 2003 and 2005. Preference-based quality of life was assessed pre-operatively and at one-year post-procedure using health state values (HSVs) derived from the SF-36 transformation described by Brazier (SF-6D). The SF-6D scores are anchored at 1.0 (full health) and at 0 (death). Basic patient demographic and treatment information was also collected. The decision to perform arthroplasty or arthrodesis was made by the attending surgeon.

Results: Two hundred four of the 214 eligible subjects had complete preoperative SF-36 data to allow transformation to SF-6D values. One-year follow-up was available for 114 of the participants. The mean age at surgery of the included subjects was 58.9 +/− 13.3 years. Of the patients with one-year follow-up, 56% were male and 59% had received total ankle arthroplasty. These demographics did not differ from the original preoperative cohort. The mean SF-6D score among all subjects with end-stage ankle arthrosis was 0.66 (95% CI 0.65 – 0.68). At one-year, the mean HSVs of the total ankle arthroplasty and ankle arthrodesis groups were 0.73 (95% CI 0.71 – 0.76) and 0.73 (95% CI 0.70 – 0.75), respectively. The reported pre-operative scores describe health states below normative data for the US population (0.76 +/− 0.01 for females, ages 55–64).

Conclusion: These are the first available HSVs for a cohort of patients with end-stage ankle arthritis treated with total ankle arthroplasty or ankle arthrodesis. These data demonstrate an improvement in preference-based quality of life following ankle arthroplasty or arthrodesis. At one-year follow-up, patient reported HSVs approach age-matched US norms.


Andrea Veljkovic Jason Fong Allan Henigar David R. Wilson Michael J. Dunbar Mark Glazebrook

Purpose: Radiostereometric Analysis (RSA) is used to measure migration and inducible displacement (ID) of orthopedic implant devices to allow early prediction of implant failure (eg. Aseptic loosening). Total Ankle Arthroplasty (TAA) is used for the treatment of end-stage ankle arthritis. First generation TAA implant have meet with widespread failures while some second generation TAA implants are showing improved results. In this study RSA is used to evaluate the biomechanical properties of a new third generation TAA implant in an attempt to set a standard for the biomechanical evaluation on TAA implants in-vivo.

Method: Patients undergoing TAA were enrolled consecutively (n=12; 7 males; mean age=59 years; mean BMI=29) and had 8 markers (0.08mm) inserted in both the tibia and talus during surgery. Standing, weight-bearing RSA exams were performed at 3 and 6 months and compared to concurrent supine exams to determine component ID.

Results: For tibial components: at six months the components had translated posteriorly (0.3mm±0.5) and proximally (0.5mm±0.2), tilted into varus (0.5°±1.3), and tilted posteriorly (0.4°±0.8). The magnitudes of ID for the tibial components were moderate (mean < 0.2mm and 0.5°, standard deviation < 0.3mm and 2.2° in each direction). For talar components: at six months the components had translated distally (0.28mm±0.35), rotated internally (0.21°±1.32) and tilted posteriorly (0.15°±0.90). There was varus/valgus tilt measured in the talar components but there was no consistent direction of migration (0.03°±1.4). At six months the magnitudes of ID for the talar components were small (mean < 0.1mm and 0.25°, standard deviation < 0.2mm and 0.6° in each direction).

Conclusion: An RSA methodology has been established to predict stability.


Peter Copithorne Timothy R. Daniels Mark Glazebrook

Purpose: For patients with moderate to severe hallux valgus with increased intermetatarsal angle, correction with a proximal first metatarsal osteotomy is indicated. The purpose of this study is to compare the opening-wedge osteotomy of the proximal first metatarsal the proximal chevron osteotomy in the treatment of moderate to severe hallux valgus with increased intermetatarsal angle.

Method: This prospective, randomized, multi-centered study is being conducted at three centers in Canada. Approximately 75 adult patients with hallux valgus are being randomized to either the proximal metatarsal opening-wedge osteotomy with plate fixation or the proximal chevron osteotomy. Patient functional scores using the SF-36, American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal inter-phalangeal score and Visual Analogue Scale (VAS) for pain, activity & patient satisfaction, are assessed prior to surgery and 3, 6, 12 and 24 months. Surgeon preference is being evaluated based on a questionnaire and actual surgical times. Radiologic measurements (inter-metatarsal angle correction, hallux valgus angle correction, sagital talus-first metatarsal (Meary’s) angle, metatarsal length and union) will also be assessed.

Results: Preliminary results demonstrate that patients who undergo the opening-wedge osteotomy have less pain at 3 months (ave. VAS pain reduction 2.9, SE±1.0) than those with the chevron (ave. VAS pain reduction 2.4, SE±1.2). VAS for activity demonstrates greater improvements with the chevron osteotomy at 3 months (0.8, SE±0.8) versus the opening-wedge (0.1, SE±1.0). AOFAS scores improve on average 18.3 (SE±8.6) with the opening wedge compared to 20.8 (SE±7.4) with the chevron at 3 months. Average hallux valgus angle correction for opening-wedge and chevron osteotomies are 11.0 degrees (SE±2.5) and 19.0 degrees (SE±3.1) respectfully. Average intermetatarsal angle correction for opening-wedge and chevron osteotomies are 6.5 (SE±1.3) and 4.3 (SE±1.7) respectfully. Both procedures are effective at maintaining metatarsal length. The opening-wedge osteotomy takes on average 60.9 minutes (SE±3.9) to complete compared to 69.1 minutes (SE±5.1) for the chevron ostetotomy. Surgeon response to the new opening-wedge osteotomy is favorable.

Conclusion: Opening-wedge and proximal chevron osteotomies have comparable pain, function and radiographic outcomes. Opening wedge osteotomy is technically less demanding and requires less surgical time.


Stéphane Leduc Michael P. Clare Scott Swanson Arthur K. Walling

Purpose: Insertional calcific Achilles tendinosis is a painful, frequently disabling, condition. The longitudinal and radial alignment of the angiosomes of the posterior region of the leg makes a straight posterior midline approach logical. The safety of the posterior midline approach and the outcome of a central tendon splitting approach associated with a Strayer procedure to treat this condition was evaluated.

Method: A retrospective review of a consecutive cohort of a single surgeon was performed. All patients had failed conservative treatment and all patients were primary cases. Forty-seven patients (48 heels) were treated over a 11-year period for chronic insertional Achilles tendinosis. All patients underwent a midline posterior splitting approach, debridment of the bursae, resection of the haglund deformity, partial Achilles detachment, debridement, reinsertion with bone anchor associated with a proximal gatrocnemius recession (strayer procedure) through a second midline incision. The average age was 59 years old (39–75), co-morbidities included four smokers and one diabetic patient. The average followup was 54 months (15–144). All patients answered pre-op and latest follow up AOFAS questionnaire, satisfaction rate and complications were reviewed.

Results: Satisfaction rate was 100%. AOFAS score improved significantly from 59 (36–80) preop to 97 (90–100) at the latest follow-up. Complications included one superficial infection and one sural nerve paresthesia. There were no major complications.

Conclusion: Achilles insertional tendinopathy treated by a posterior midline approach is a safe and reliable procedure. The procedure was associated with high patient satisfaction rate and excellent outcome.


Benoit Benoit Stéphanie Grenier G. Yves Laflamme Dominique Rouleau Stéphane Leduc

Purpose: Lors de la réduction chirurgicale des fractures de la cheville avec instabilité syndesmotique, le chirurgien se fie généralement sur les vues de mortaise et antéro-postérieure. Toutefois, une subluxation ou luxation antérieure du péroné par rapport au tibia distal peu survenir et passer inaperçu (trois exemples cliniques prouvés par CT Scan post-opératoire), spécialement lors de la pose de vis syndesmotique(s). La présente étude a pour but d’établir la relation radiologique précise sur une vue latérale fluoroscopique entre les tibia et péroné distaux qui permettra au chirurgien de confirmer en peropératoire que l’articulation tibio-péronière distale est bel et bien réduite.

Method: Les chevilles normales de trente volontaires sans antécédent de traumatisme ou de maladie de la cheville ont été imagées sous une vue latérale fluoroscopique parfaite, avec un Mini C-Arm. Les images ont été analysées et comparées entre elle afin d’établir une relation radiologique fiable et reproductible entre le tibia et le péroné distaux.

Results: Dans les trente cas, il y avait intersection du milieu de la cicatrice physaire et du cortex antérieur du péroné. Cette relation a été trouvée statistiquement significative.

Conclusion: La réduction chirurgicale parfaite de l’articulation tibio-péronière distale peut être confirmée avec une vue latérale fluoroscopique de la cheville. Le cortex antérieur du péroné doit toucher le milieu de la cicatrice physaire.


Vishal Upadhyay Ajay Sahu N. Harshavardena Charalambos P. Charalambous Richard Hartley

Purpose: The aim of this study was to compare the results and length of stay of patients of early ankle fracture fixation with conventional fixation in a busy District General Hospital in UK.

Method: A retrospective study was conducted using data from case records, electronic patient record, clinical coding information, clinic letters and Picture Archiving and Communications System (PACS). Two hundred patients who underwent ankle fracture fixation from July 2004 to June 2005 were included. We looked into age, place of living, Weber classification, mechanism of injury, comorbidities especially diabetes and peripheral vascular disease, addictions mainly smoking, whether patient was anticoagulated, delay for theatre with reasons, length of stay in hospital and complications if any. Other things to looked at were, overlying skin condition, the amount of swelling at the time of presentation to A& E, associated ankle dislocation or talar shift needing reduction, injury types-open or closed or with associated neuro-vascular injury. In-operative management – what method was used ie malleolar screws, diastasis screw, fibular plating, calcaneotalotibial nail or external fixater etc.

Results: In the 12-month retrospective review, there were 200 ankle fractures that required surgical intervention. Only twenty-two of these had surgery within 12 hours (mean length of stay, 3.3 days), and sixty-seven of these had surgery within 48 hours (mean length of stay, 4.9 days), and 111 had surgery after 48 hours (mean length of stay, 9.4 days). Finally we calculated the cost (784 bed days – £235 thousands) incurred to the trust in terms of extra bed occupancy and treating the complications as a result of wait.

Conclusion: This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. We want to emphasise on the ‘Window of Opportunity’ ie initial 12 hours to fix ankle fractures to decrease overall morbidity and cost.


Robert B. Bourne Bert Chesworth Aileen Davis Nizar N. Mahomed Kory D. Charron

Purpose: The purpose of this study was to determine why some TKR patients are satisfied and others are dissatisfied.

Method: 2,481 primary TKR patients who had completed a decision date WOMAC were randomly identified within the Ontario Joint Replacement Registry (OJRR) database. One year post-operatively, these patients were mailed a survey to determine satisfaction/expectations, willingness to undergo surgery again, Jaeschke self-reported clinical improvement, WOMAC scores and complications. The satisfied and not satisfied patient groups were identified, statistical analysis employed to determine variables that individually affect satisfaction and logistic regression used to identify significant factors which might lead to patient dissatisfaction.

Results: Only 70% of primary TKR patients felt that their expectations had been met and 15% reported that they had no expectations. Only 81% of patients reported that they were satisfied with their TKR. When asked whether they would have their surgery again, 96% of the satisfied patients reported that they would do so as compared to only 63% in the dissatisfied group (p< 0.0001). Using the Jaeschke self-reported clinical improvement scale, 87% of TKR patients reported that they were improved, but only 75% reported that they were a good, great or a very great deal improved. There was a high correlation with the WOMAC change score and the Jaeschke self-reported improvement and willingness to undergo surgery again questions. Significant differences were found between the satisfied and dissatisfied TKR patients in terms of a pre-operative WOMAC score of < 20 (p< 0.004), the WOMAC change score (p< 0.0001), expectations (p< 0.0001), complications (p< 0.0001), age (p< 0.002), referral status (p< 0.0005), living alone (p< 0.01) and comorbidities (p< 0.05). Logistic regression suggested that the most important predictive factors were a pre-operative WOMAC < 20 (p< 004), the WOMAC change score (p< 0.0001), expectations met (p< 0.0001) and complications (p< 0.0001).

Conclusion: Only one in five primary TKR patients are satisfied with their operative procedure. Significant risk factors for patient dissatisfaction after primary TKR include a pre-operative WOMAC < 20, a WOMAC change score of less than 33 points, expectations that were not met or a complication.


Pascal-André Vendittoli Melissa Collins Muthu Ganapathi Martin Lavigne

Purpose: The goal of this study is to compare patients’ perception of their hip or knee joint following joint replacement surgery.

Method: A total of 357 patients who underwent hip or knee joint surgery were included in the study. Of the patients who had knee replacement surgery, 46 had unicompartmental knee replacement (UKR) and 119 had total knee replacement (TKR). In the group of patients who had hip replacement surgery, 98 underwent hip resurfacing (SRA) and 97 had total hip replacements (THR). The perception patients had of their replaced articulation as well as functional outcome scores such as the WOMAC and SF-36 were measured at one year post-surgery and compared between the four groups.

Results: Although global satisfaction and clinical outcome scores were excellent in all four groups, WOMAC scores at 1–2 year follow-up were significantly different between hip or knee replacement surgery (p< 0.0001). Also, the perception that patients had of their reconstructed joint was significantly different between the hip and knee groups (p< 0.001). Half of patients from the hip group considered their replaced hip “as a natural joint” and 76% considered their joint as having no functional limitations compared to only 19% and 39% respectively for the knee group. Of patients with knee joint surgery, 14% (20/165) considered their joint as “artificial with important limitations” as opposed to only 1% (2/195) of those who had hip joint surgery. There were no significant differences in Womac scores or perception when comparing TKR and UKR or THR and SRA patients. Perception was strongly correlated to Womac scores for all four groups (R2=0.951).

Conclusion: Hip and knee joint replacement surgery are recognized as highly effective medical interventions in terms of cost/benefit ratio in current medical practice. It is remarkable to see that replacement of each of these articulations can yield vastly different results in terms of patient function, perception and satisfaction. From this study, it is clear that research in prosthetic development and surgical techniques should be focused on the interventions such as knee joint replacement, which are not yet capable of offering both a high level of function and satisfaction to patients.


Vishal Upadhyay Ravi H. Mahajan Ajay Sahu Usman Butt Amir Khan Rakesh B. Dalal

Purpose: To assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint.

Method: The thirty-two patients (37 feet) that had silastic implants inserted were reviewed at an average of 2 years and 4 months (ranging 7 months to 5 years and 4 months). The mean patient age was 63 years. These patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative AOFAS score was calculated for each.

Results: The follow-up assessment revealed that every patient described that their pain had decreased after surgery and 17 feet (46%) were completely pain free. There was a significant improvement in patients’ subjective pain scores after surgery (t value = < 0.0001). Pre-operatively, the mean pain score for all 37 feet was 8.14, whereas post-operative the mean pain score was 1.32. The mean AOFAS score before surgery was 39.97. This increased to a mean score of 87.40 after surgery (P = < 0.0001). This again is a significant improvement. No patient was dissatisfied with the outcome with their surgery.

Conclusion: These moderate term results are encouraging, with good subjective and objective results. However, long-term follow-up will be required to assess the longevity of this implant.


Kevin Willits Nicholas G.H. Mohtadi Crystal Kean Dianne Bryant Annunziato Amendola

Purpose: The purpose of this randomised controlled trial was to compare outcomes of operative and non-operative management of Achilles tendon ruptures.

Method: Patients with acute complete Achilles tendon ruptures were randomised to receive open suture repair followed by graduated rehabilitation or graduated rehabilitation alone. The primary outcome measure was re-rupture rate. Assessments at three and six months, and one and two years included a modified Leppelhati score (no strength data), range of motion, calf circumference, and isokinetic strength at one and two years. We report the two year findings.

Results: Two centres randomized 145 patients (118 males and 27 females), mean age 40.9±8.8 years (22.5 – 67.2) to operative (n=73) and non-operative (n=72) treatment. Fourteen were lost to follow-up. Re-rupture occurred in three patients in both groups. The mean modified Lep-pelhati score (out of 85) was 78.2±7.7 in the operative group and 79.7±7.0 in the non-operative group, which was not significant (−1.5 95%CI −6.4 to 3.5, p=0.55). Mean side-to-side difference in plantar flexion and calf-circumference in the operative group was −2.0±3.2° and −1.4±1.2cm, and in the non-operative group −0.9±3.0°and −1.6±1.8cm respectively. Mean isokinetic plantar flexion strength was 62.4±24.2 for the operative and 56.7±19.3 for the non-operative group, which was not significant (5.7, 95%CI −3.1 to 14.5, p=0.20). There were a greater number of serious adverse events in the operative group, including pulmonary embolus in one patient, deep vein thrombosis in one and deep infections requiring irrigation and debridement in three.

Conclusion: This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events.


Steven J.M. MacDonald Kory D. Charron Douglas Naudie Richard W. McCalden University Hospital Robert B. Bourne Cecil H. Rorabeck

Purpose: The growing trend of morbidly obese (BMI 40+) patients requiring a total joint replacement is becoming major concern in total knee Arthroplasty (TKA). The purpose of this study was to investigate the affects that BMI may have on implant longevity and clinical patient outcome using historical patient data.

Method: A consecutive cohort of 3083 TKA’s in 2048 patients since 1995 (minimum 2 years follow-up) were evaluated. Pre-operative scores, latest scores, and change in clinical outcome scores (KSCRS, SF12, WOMAC) were analyzed using ANOVA and Kaplan-Meier (K-M) survivorship was determined.

Results: K-M cumulative survival at 10 years by BMI group was 0.951±0.033 for Normal and Underweight (< 25, n=277), 0.944±0.024 for Overweight (25–29.9, n=915), 0.882±0.032 for Obese (30–39.9, n=1460) and 0.843±0.076 for Morbidly Obese (40+, n=352). Cumulative revision rates were 1.8% for Normal and Underweight, 1.9% for Overweight, 2.9% for Obese and 2.8% for Morbidly Obese. All pre-operative clinical scores were significantly different between the Morbidly Obese and all other BMI groups (p< 0.05), with the non-morbidly obese having higher scores in all cases. Significant difference was found in the change in WOMAC domain scores and the KSCRS knee score (p< 0.05) between the morbidly obese group and all other BMI groups, with the morbidly obese having the greatest improvement in all domains.

Conclusion: The morbidly obese patient cohort (BMI > 40) undergoing TKA demonstrated the most significant improvement in clinical outcome scores; however also had the lowest cumulative 10 year survivorship. This risk/benefit information is important in pre-operative discussions with this challenging, and increasingly prevalent, patient population.


Rajiv Gandhi Mark Takahashi Khalid Syed J Roderick Davey Nizar N. Mahomed

Purpose: Synovial fluid (SF) leptin has been shown to have an association with cartilage degeneration. Our objective was to examine the relationship between different measures of body habitus and SF leptin levels in an end stage knee osteoarthritis (OA) population.

Method: Sixty consecutive patients with knee OA were surveyed prior to surgery for demographic data. Body habitus was assessed with the body mass index (BMI), waist circumference (WC) and waist-hip ratio (WHR). SF and serum samples were analyzed for leptin and adiponectin using specific ELISA. Non-parametric correlations and linear regression modeling was used to identify the relationship between the measures of body habitus and SF leptin levels.

Results: Females had greater levels of leptin than males in both the serum and SF. Significant correlations were found between SF leptin levels and BMI and WC (R2 0.44 and 0.38 respectively, p< 0.05). Regression modeling showed that female gender and WC were independent predictors of a greater SF leptin level independent of age, BMI, and presence of diabetes.(p< 0.05)

Conclusion: WC may be a more accurate measure of body habitus than BMI in the relationship between the metabolic effects of adipose tissue and OA.


Linda J. Woodhouse Danielle Petruccelli Joanne Wright Wade Elliott Nancy Toffolo Stephen Patton Sampa Samanta Arlene Sardo Donna MacMillan Gail Johnson Christine Anderson William Evans

Purpose: Reducing wait times for total hip (THA) or knee (TKA) joint arthroplasty is a Canadian health care priority. Models that maximise the capacity of advanced practice clinicians (nurses, physical therapists, sports medicine specialists) have been established to streamline care. Hospitals across the Hamilton Niagara Haldimand Brant Local Health Integration Network in Ontario collaborated to establish a Regional Joint Assessment Centre (RJAC). This study was designed to profile patients deemed suitable for surgical review, and to examine wait times for THA or TKA in RJAC patients compared to those referred directly to an orthopaedic surgeon’s office.

Method: Patients referred to the RJAC between July 2007 and August 2008 with knee or hip OA were included. Self-reported function was evaluated using the Oxford Hip and Knee Score that is scored out of 60 (higher scores reflect greater disability). Time to surgery was measured as the number of days from initial review to surgery. Group one consisted of patients that were referred to the RJAC while group two was comprised of patients who were referred directly to a surgeon’s office. Patient characteristics were examined using univariate analyses. Independent t-tests were used to examine between group differences.

Results: One hundred thirty-six patients (mean±sd: 68±2 years, body mass index 31±6 kg/m2, 83 females) with 150 hip and/or knee joint problems were reviewed in the RJAC. Of those, only 33% (45/136 patients) were deemed suitable for surgical review. Self-reported function (Oxford Scores) in the group requiring surgical review was significantly worse (40±7, p=0.03) than in those patients deemed unsuitable for surgical review (37±9). The RJAC group waited on average 130 days for THA and 129 days for TKA (below the provincial target of 182 days) while those referred directly to the surgeons’ offices waited significantly longer (194 days for THA and 206 days for TKA, p< 0.001).

Conclusion: Patients with hip and knee OA who require surgical review have worse self-reported function than those triaged to conservative care. Wait times for THA or TKA were significantly shorter for patients referred to the RJAC under the new model of care than for those referred directly to an orthopaedic surgeon’s office.


David Backstein Christopher Peskun Ian Mayne Harsha Malempati Yona Kosashvili Vir Sennik Allan E. Gross

Purpose: Single anesthetic bilateral total knee arthroplasty (SABTKA) is a controversial procedure with a questionable safety profile. The purpose of this study was to determine if specific, individual preoperative medical co-morbidities can predict perioperative complications in patients undergoing SABTKA.

Method: The records of all SABTKA performed between 1997 and 2007 at 1 large community hospital and 1 academic, university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities (cardiovascular disease, COPD, diabetes, and hypertension), and perioperative complications for 156 patients were collected and analyzed using logistic multivariate regression analysis. Comparison was made to an age, gender, and co-morbidity matched cohort of patients treated with unilateral TKA.

Results: In the SABTKA group only 11% of patients had a preoperative history of cardiovascular disease yet 89% of all post operative myocardial infarctions (MI) occurred in this population (p< 0.001, Odds Ratio 57.8). Cardiovascular disease also predicted need for admission to ICU (p< 0.001, Odds Ratio 50.8), and number of days spent in the ICU (p< 0.001). In those patients without preoperative cardiovascular disease or COPD the rate of MI was only 0.64%. All differences were significant when compared to the matched unilateral TKA cohort. Age, gender, diabetes, and hypertension did not predict perioperative complications in the SABTKA cohort.

Conclusion: The literature indicates there are certain populations of patients at higher risk for perioperative complications after SABTKA. This study clearly identifies a subpopulation of patients that have cardiovascular disease and are at an unacceptably high risk of perioperative MI. Cardiovascular disease should likely be considered an absolute contraindication to SABTKA.


Douglas Naudie Dianne Bryant Trevor Birmingham Ian Jones J. Robert Giffin

Purpose: Medial compartment osteoarthritis (OA) is the most common primary osteoarthritis of the knee, but the treatment of this disease in young patients remains controversial. High tibial osteotomy (HTO), medial unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are all viable options. Gait analysis is one tool available to clinically assess knee kinematics, and may prove to be a good way of predicting functional outcomes of these different surgical procedures. The purpose of this study was to compare the knee kinematics, function, and quality of life of patients that underwent either a medial opening wedge HTO, UKA, or TKA for primary medial compartment OA.

Method: A matched prospective cohort study of patients between the ages of 45 and 65 who had undergone an HTO, UKA, or TKA for primary medial compartment knee OA was undertaken over a 3-year period. Primary outcome measures were gait variables, namely knee adduction moments, as measured through gait analysis. Secondary measures included quality of life (WOMAC), functional performance tests (six minute walk and timed-up-and-go), self-reported functional ability (LEFS), and general health (SF-36). Gait and functional performance tests were evaluated preoperatively and at 6, 12, and 24 months postoperatively. Self-reported quality of life, function and general health were assessed preoperatively and at 3, 6, 12, and 24 months post-operatively.

Results: Twenty HTOs, 19 medial UKAs, and 17 TKAs were matched for Kellgren-Lawrence grade of medial OA, age at surgery, and body mass index. Significant differences were observed between the three groups in step length and peak adduction moments at 24 months. Significant differences were observed in preoperative WOMAC pain and function scores, KOOS pain scores, and LEFS, but no significantly different outcome measures were observed postoperatively. Lateral Black-burne-Peel and modified Insall-Salvati ratios were the only significant radiographic differences observed between groups at 24 months.

Conclusion: To our knowledge, no gait analysis study exists comparing the medial opening wedge HTO to UKA or TKA. The results of this study suggest that most gait variables except step length and knee adduction moments are similar between groups. Moreover, except for patellar height, there were no major functional or radiographic differences between these groups.


Camilo Resterpo Javad Parvizi Peter F. Sharkey Aidin Eslam Pour Craig T. Haytmanek Nathan Roberts Richard H. Rothman

Purpose: Recently an orthopedic manufacturer has introduced a gender specific knee design implying that there is a substantial anatomical difference between the genders. If such concept is true then TKA prosthesis implanted in the female population over the last decades, by definition, must have suboptimal outcome when compared to the male patients. The purpose of this study was to examine the functional outcome, the incidence of complications, and the need for revision between the two genders receiving the same knee design.

Method: The study selected a matched group of 150 men and 250 women undergoing TKA at our instituion. The patients were matched for age, BMI, pre-op diagnosis, comorbidities, race, mode of fixation, and the type of implant. Other demographic, surgical, and medical factors between the two genders were similar. Both pre-op and post-op functional scores were compared between the two groups. Pre-op and post-op radiographic images were assessed for implant fit.

Results: There was a significant improvement in functional outcome as measured by Knee Society score, WOMAC, and SF-36 for all patients. The improvement in functional outcome was not different between the two groups. The incidence of complications, reoperations, and need for revision between the two genders was also not significantly different.

Conclusion: Total knee arthroplasty continues to be an effective surgical procedure. Both genders appear to enjoy relief of pain and improvement of function equally. Based on this retrospective study the use of non-gender specific knee prosthesis did not seem to result in suboptimal outcome in female patients. There appears to be little merit in introduction of gender specific knee designs when previous non-gender specific prosthesis appeared to function well in both genders.


Geoffrey Dervin Holly Evans Susan Madden Peter R. Thurston

Purpose: Unicompartmental replacement for medial compartment arthrosis of the knee has become popular with eligible patients because of the shortened recovery time, decreased tissue damage and easier future revision. Contemporary multimodal anesthesia has added the potential to safely perform this as outpatient surgery reducing inpatient bed burden. We describe our initial pilot experience with this approach.

Method: The first 25 patients who fulfilled the criteria developed underwent same day surgery for unicompart-mental arthroplasty for medial (19) or lateral (3) compartment replacement with either the Oxford knee (20) or the Uniglide (2). All patients were treated with an indwelling femoral nerve catheter supplied by Ropivacaine through a constant release pump (Stryker) which was discontinued at 48 hours. Home care support was made available in first 72 hours by way of RN and physiotherapy visits and mandatory use of walker or crutches for the first 48 hours.

Results: Patients in this cohort were universally very satisfied with the model of postop care as described and particularly pleased to avoid a hospital stay. Eighty percent of those who were offered this model chose it. The use of narcotic oral medication was consistently about 50% less than that observed to similar inpatients treated without catheter, and eight patients had complete opioid sparing experience. There were no complications related to the catheter, in particular serious falls or longer term neurologic sequelae. The clinical results were very good and equal to those who were in patients.

Conclusion: Outpatient unicompartmental replacement can be performed safely recognizing the decreased surgical trauma and pain stimuli associated with UKR and a relatively younger and healthier cohort screened for this alternative. These patients are amongst the most satisfied with their perioperative course and all would do the same again if given the chance. Other models of analgesia could be considered, though the catheter does seem to have a large opioid sparing effect that likely contributed to patient well being and satisfaction.


Kelly Lefaivre Adam J. Starr Brady P. Barker Stephen J. Overturf Charles M. Reinert

Purpose: To describe operative experience and reductions of pelvic ring fractures treated with a novel pelvic reduction frame.

Method: All patients with displaced pelvic ring disruptions treated with the pelvic reduction frame were included. The series includes 35 patients, with 34 acute fractures and one malunion. Pre-operative and immediate post-operative radiographs were reviewed, and maximal displacement measured using two reproducible methods. Procedure and injury data were also recorded.

Results: In our series of 35 patients, we had 19 vertical shear fractures and 16 compression injuries. Mean age was 33.5 + 2.4, and mean delay to surgery was 4.7 + 0.6 days. Mean operative time in isolated procedures was 103.4 + 6.5 minutes. All but one patient had iliosacral screws placed, 18 had anterior column screws, six had symphysis plates and 12 had anterior external fixators. Maximum horizontal or vertical displacement was improved from 30.8 + 2.7 mm to 7.1 + 0.7 mm. Diameter asymmetry as measured on the AP view was improved form 26.4 + 2.7 mm to 5.2 + 0.7 mm. Very good, good or fair reduction was obtained in all acute cases. There was no statistically significant impact of obesity, fracture type or delay to surgery on quality of reduction (p> 0.05).

Conclusion: This novel pelvic reduction frame is a powerful tool in the effective reduction and fixation of displaced acute pelvic ring disruptions.


Kelly Lefaivre Jeffrey R. Padalecki Adam J. Starr

Purpose: To provide a CT-based description of the anatomic specifics of LC-1 pelvic ring disruptionsand to describe injury severity to other body systems, and their correlation with fracture anatomy.

Method: We identified a consecutive series of 100 patients with Young and Burgess LC-1 pelvic ring disruptions. The CT scan was reviewed for each patient. Sixteen categories were reviewed for each patient. Sacral fractures were graded based on severity. The age, ISS, and six categories of AIS were recorded for each patient. A statistical analysis was performed to test the associations between fracture characteristics and injury severity.

Results: All patients but three had one or more rami fractures, and all but two had a sacral fracture. Of the 98 anterior sacral injuries, there were nine (9.2%) buckles, 39 (39.8%) simple fractures, and 50 (51.0%) comminuted fractures. Of these 98 anterior sacral injuries, 47 (48.0%) were complete, passing through the sacrum and exiting the posterior cortex. Increasing severity of anterior sacrum fracture was associated with the presence of a complete sacral fracture (p value < 0.0001). Of the 98 sacral fractures, 50 (50.0%) were Denis type I, 41 (41.8%) Denis type II, and 7 (7.1%) Denis type III. Higher Denis types had higher likelihood of complete fractures of the sacrum (p value < 0.0001). There was a significant association between the presence of a comminuted rami fracture and a complete sacrum injury (p = 0.003), and a trend to higher rates in Nakatani two superior rami fractures (p = 0.169). There was a trend to higher mean ISS scores (p = 0.2287), and significantly higher abdominal AIS scores (p = 0.0014), in those with a complete sacral fracture. Those with comminuted and complete sacral fractures were more likely to be symptomatic and require posterior ring stabilization (p-value 0.003 and 0.043 respectively).

Conclusion: LC-1 fractures of the pelvic ring represent a spectrum of injuries, with a large proportion having complete disruption of the sacrum. This complete injury of the sacrum is predicted by Denis type, severity of anterior ring disruption, Abdominal AIS, and potentially location of rami fracture and ISS. CT scanning best defines these injuries.


Robert L. Barrack R. Stephen J. Burnett C. Lowry Barnes Derk Miller John C. Clohisy William J. Maloney

Purpose: A study was undertaken to determine the current prevalence of revisions of total knee arthroplasty (TKA) following minimal incision surgery (MIS) and to compare revisions of MIS TKA procedures to revisions of TKA performed following a standard surgical approach.

Method: A consecutive series of revision TKA performed at three centers by five surgeons over a three year time period was reviewed. Revisions performed for infection and re-revisions were excluded. Review of clinical and radiographic data determined incision type, gender, age, time to revision, and primary diagnosis at time of revision.

Results: Two hundred and thirty-seven first time revision TKAs were performed of which 44 (18.6%) had been a MIS primary TKA and 193 (81.4%) had been a standard primary TKA. Patients with MIS were younger (62.1 years versus 66.2 years, p=.02). There was a trend towards a higher percentage of females in the MIS group (75% versus 63%), although this difference was not significant (p=0.12). Most striking was the difference in time to revision which was significantly shorter for the MIS group (14.8 months versus 80 months, p< .001). The MIS group was much more likely to fail at < 12 months (37% versus 5%, p< .001) and at < 24 months (81% versus 22%, p< .001).

Conclusion: MIS TKA accounted for a substantial percentage of revision TKA in recent years at these centers. The high prevalence of MIS failures occurring within 24 months is disturbing and warrants further investigation.


Rahul Vaidya Fredrick Tonnos Robert Colen Anil Sethi

Purpose: The purpose of this paper is to present a novel technique of anterior fixation of unstable pelvic fractures which is minimally invasive, biomechanically suitable, easy to apply, and uses readily available spinal implants.

Method: Eighteen consecutive patients with unstable pelvic fractures (AO type A-12 patients and type B-6 patients) underwent stabilization using the novel technique of fixation and were included in the study. Two trauma trained orthopedic surgeons performed all the procedures. All patients were evaluated clinically and with imaging studies that included antero-posterior, inlet and outlet radiographs and a CT scan. At surgery the posterior instability was addressed first with iliosacral screw fixation following reduction of the fracture in a standard fashion. A 2–3cm longitudinal incision was then made over the anterior inferior iliac spine bilaterally to obtain a starting point in the supra acetabular region. Pedicle screws of size 7mm or 8mm x 80mm (Synthes Spine Paoli, USA) were then placed in the supra-acetabular position under fluoroscopic guidance. A pre-contoured 6mm titanium rod with a bow was then tunneled subcutaneously to connect the screws. Care was taken to place the rod just below the lower abdominal crease to prevent pressure on the bowel or vascular structures. The implants were compressed using standard compressors and C-rings. Patients were followed until the pelvis fracture healed as documented on X-rays and clinical exam.

Results: Patients were followed for a minimum 6 months (range 6–12 mo). All patients healed by 3 months (similar to our prior experience using other methods). Complications included: 2 deaths in poly trauma patients unrelated to the pelvic procedure; 2 patients with transient lateral femoral cutaneous nerve palsy (one on each side), and one early implant failure due to a surgical technical error that was re-operated the next day.

Conclusion: Disruptions of the pelvic ring are complex injuries and should be managed on a case specific basis. By employing the established principles of supra-acetabular fixation, this technique allows for minimally invasive, definitive internal anterior fixation. The potential complications of pin tract infection and a cumbersome external appliance associated with external fixation are avoided with this technique and better patient acceptance is achieved.


Kajsa Duke G. Yves Laflamme Yvan Petit

Purpose: Greater trochanter reattachment is frequently accomplished using cable grip type systems. There is a relatively high failure rate for these systems, the mechanisms of which are unclear. One possible source of instability could be femoral neck cut location. Another concern is the effect of variability in cable tension. The objective is to create a femur implant model which allows for variation in cable tension, common muscle forces and the placement of the femoral neck cut in order to analyse trochanter fragment fixation.

Method: A finite element model (FEM) of a femur with simulated greater trochanter osteotomy (30°) was combined with the femoral component of a hip prosthesis and a greater trochanter reattachment system with 4 cables (Cable-Ready®, Zimmer). A total of 18 simulations were modeled in a full factorial design using three independent variables; cable tightening (178N, 356 N and 534 N), muscle forces (rest, walking and stair climbing) and femoral neck cut (10 mm and 15 mm above the lesser trochanter). Displacement of the fragment, in terms of both gap and shear components, as well, stress in the bone were investigated.

Results: The location of the femoral neck cut reduced contact surface area by 20% and had the largest influence on displacement (0.24 mm). Pivoting of the fragment was observed with a maximum gap (0.38 mm) and maximum total displacement (0.41 mm) at the bottom of the fragment. This was observed during stair climbing, while the cables were tightened to 177.9 N and with the femoral neck cut at 10 mm. Increased tightening of the cables provided no significant reduction in fragment displacement. However, higher cable tension significantly increased the stress in the bone (8 MPa and 26 MPa for cable tension of 178 N and 534 N respectively).

Conclusion: Placement of the femoral neck cut closer to the lesser trochanter significantly increased fragment displacement. Preservation of the contact surface area is recommended. Excessive cable tightening did not reduce fragment movement and only exacerbated bone stress. Caution must be used to not over tighten the cables. This model can be used to test and compare the performance of new implant designs.


David Barei Michael Gardner Sean Nork Stephen Benirschke

Purpose: Pilon fractures demonstrate complex osseous and soft tissue injury. Protocols involving immediate tibial reduction and external fixation, with or without fibular fixation, then delayed definitive fixation result in decreased complications. Our purpose was to evaluate the treatment course of pilon fractures provisionally stabilised at outside institutions and subsequently transferred, focusing on the incidence and reasons for revision procedures, and subsequent complication rates.

Method: An institutional trauma database was retrospectively reviewed, demonstrating 668 pilon fractures treated at our institution between 2000–2007. Of these, 39 patients with 42 fractures had a temporising surgical procedure prior to referral. Demographics, injury characteristics, reason for revision, and subsequent complications were determined. Clinical follow-up averaged 60 weeks (range, 1 to 281).

Results: Mean age was 41 years (range, 18–78). Twenty-two fractures (52%) were open; 38 (90%) demonstrated a fractured fibula. Referral occurred an average of 5.8 days (range, 1–20) after initial stabilization. Pre-transfer fixation was revised in 40 fractures (95%). Reasons for revision included tibial malreduction (33 fractures, 83%), fibular malreduction (4 fractures, 10%), pins in the proposed incision (5 fractures, 13%), or loose pins (3 fractures, 8%). Of the 34 fractures with distal pins, 24 (71%) required revision for pin malposition, loosening, drainage, talar placement, or extraosseous placement. Late complications occurred in 14 fractures (33%), including deep infection in 10 (24%), and non-union in 3 (7%). Twenty-three patients (55%) required additional procedures following definitive fixation, including 9 soft tissue coverage procedures and 3 amputations.

Conclusion: The majority of patients with pilon fractures treated with provisional stabilisation followed by referral to our institution required revision prior to definitive fixation. This resulted in many avoidable additional procedures, and a higher complication rate than recent contemporary controls. The authors recommend that, when possible, the initial and definitive management of these injuries be performed at the accepting institution.


Richard Jenkinson Marcella A. Maathuis Bill Ristevski Dan Omoto David J.G. Stephen Hans J. Kreder

Purpose: To determine the effect of delay to surgery on functional outcome in patients with operatively-treated acetabular fractures.

Method: Two hundred and thirty-two patients with acetabular fractures were identified from a pelvic trauma database. Functional outcome data was assessed using the validated Musculoskeletal Functional Assessment (MFA) and the Short Form 36 (SF-36) surveys in 162 patients. After 1997, functional outcome scores were collected prospectively at 6 months, 1 year and 2 years (or greater) post-operatively. Functional outcome scores, quality of reduction, and risk of complications were modeled as a function of days of delay to surgery via multivariate regression analysis adjusting for age, gender, fracture type, and associated injuries.

Results: At 6 months post-operatively, functional outcome scores were significantly worse with increasing delay to surgery. A delay of between 7 and 13 days or 14 or more days decreased the SF-36 physical component (PCS) z-scores by 0.75 (95% CI: −1.41 to −0.09) and 1.5 standard deviations (95% CI: −2.43 to −0.56) respectively. Delay of 14 or more days was associated with a worsening of the lower extremity (Move) subsection of the MFA by 18.6 points (95% CI: 3.3 to 33.8). Delay to surgery was associated with a significantly higher risk of poor reduction among those with available radiographic follow-up (n=67). Delay 14 days or more was associated with a 5 times (95% CI?.04 to 23.99) greater risk of a post operative step or gap over 2 mm. Delay to surgery was associated with an increase in thrombotic complications. In those patients who were diagnosed with a pulmonary embolism(PE) the mean delay was 11.3 days versus 7.3 days for the rest of the cohort (p=0.01). For patients with a deep vein thrombosis (DVT) average delay was 14.1 days versus 7.1 days (p=0.01).

Conclusion: Delay to surgery is associated with worsening functional outcome scores after as little as 7 days of delay. After 14 days, functional outcomes deteriorate further and radiographic outcomes are negatively influenced. Increased delay also increases risk of thrombotic events. These conclusions underscore the importance of timely treatment for displaced acetabular fractures.


Sprint Investigators Emil H. Schemitsch

Purpose: Accurate prediction of re-operation following tibial nailing may facilitate optimal patient care. We recently completed the SPRINT trial, a large, multi-centre trial of reamed versus non-reamed intramedullary nails in 1226 patients with tibial shaft fractures. Using the SPRINT data, we conducted an investigation of baseline and surgical patient characteristics to determine if they are associated with increased risk of re-operation within one year.

Method: Using multivariable logistic regression analysis, we investigated 15 characteristics for association with increased risk of re-operations. Because the primary SPRINT analysis found that reamed nailing reduced events in patients with closed but not open fractures, we considered both open and closed as well as treatment status in our model.

Results: We found an increased risk of re-operation in patients with a high energy mechanism of injury (odds ratio, OR=1.57, 95% CI 1.05 to 2.35), stainless steel versus titanium nail (OR=1.52, 95% CI 1.10 to 2.13), fracture gap (OR=2.40, 95% CI 1.47 to 3.94) and post-operative weightbearing (OR=1.63, 95% 1.003 to 2.64). Open fractures increased the risk of re-operation in patients who received a reamed nail (OR=3.26, 95% CI 2.01 to 5.28) but not in patients who received a non-reamed nail (OR=1.50, 95% CI 0.92 to 2.47). Patients with open fractures who had either wound management without any additional procedures, or delayed primary closure, had a decreased risk of re-operation when compared to patients who required subsequent reconstruction (respectively, OR=0.18, 95% CI 0.09 to 0.35; OR=0.29 95% CI 0.14 to 0.62).

Conclusion: To ensure optimal patient care surgeons should consider the characteristics identified in our analysis to reduce risk of re-operation.


Gillian Bayley Wade Gofton Allan Liew Steven Papp

Purpose: To compare the accuracy of post-operative plain radiographs versus computed tomography (CT) scans for the assessment of acetabular fracture reduction.

Method: A retrospective assessment of sixty-four fractures in sixty-two patients was performed independently by three orthopedic trauma surgeons. Pre-operative CT scans and three plain radiographs (one anteroposterior pelvis and two Judet views) were used to classify the fracture pattern and measure pre-operative articular step and gap. Post-operative reduction quality was assessed using three plain radiographs and an axial CT assessing for step, gap, intra-articular hardware or fragments and necessity to re-operate.

Results: Fracture patterns were as follows; posterior wall (n=10), posterior column (n=1), anterior wall (n=4), anterior column (n=1), transverse (n=12), posterior column posterior wall (n=4), transverse posterior wall (n=8), T-type (n=6), anterior column posterior hemi-transverse (n=5) and associated both column (n=11). Pre-operatively, the average step and gap on plain radiographs was 8.7 mm (±SD) and 15.3 mm (±SD). Post-operatively, the average step and gap was 0.6 mm (SD) and 0.9 mm (SD) based on 46 patients. The assessment was not possible in 18 patients due to overlying hardware. Using plain radiographs, one patient was found to have an inadequate reduction (> 2mm step and/or > 3mm gap). Post-operative measurement of step and gap by CT scan were 1.2 mm (SD) and 2.3 mm (SD) respectively. Using CT scans, eight patients were found to have either an inadequate reduction, intra-articular hardware or retained fragments. Computed tomography demonstrated 2 times more step and gap compared to plain radiographs.

Conclusion: Post-operative CT was found to be more sensitive than plain radiographs to assess the quality of acetabular fracture reduction. Plain radiographs detected only 1 out of 8 cases where further operative intervention may have been beneficial. Given the consequences of missing an unacceptable reduction, intra-articular hardware, or retained intra-articular fragments, it is recommended that all fractures should be assessed postoperatively with CT unless the patient is not a candidate for further surgery for reasons independent of reduction quality. The benefits of post-operative CT imaging in acetabular fractures likely outweigh the cost and radiation exposure associated with its use.


Geoffrey Wilkin Steven Papp Wade Gofton Allan Liew

Purpose: The purpose of this study was to review our results in patients with pilon fractures treated with ORIF in which surgical planning involved multiple skin incisions, ensuring that the distance incisions overlapped was less than the distance between them. We hypothesized that soft-tissue complications would be minimal despite incisions placed < 7-cm apart.

Method: A retrospective chart review identified 37 pilon fractures in 32 patients treated by three orthopedic traumatologists at The Ottawa Hospital between August 2000 and February 2007. Follow-up included measurements of incision placement and functional outcome measures.

Results: There were nine OTA type B and 28 OTA type C fractures; 28 were closed and nine were open. The mean age was 46.5 ±14.5 years, and average follow-up was 3.2 ±1.7 years. Of the patients reviewed, the average number of incisions was 3.7 ±1.1. The average overlap between incisions was 4.6-cm ±1.9 and the average skin bridge between incisions was 5.9-cm ±1.9, with 80% of the skin bridges < 7-cm. Average ROM was 4.3° ±7.1 dorsiflexion and 39.1° ±11.6 plantarflexion. The mean AMA lower extremity impairment score was 18.9% ±12.4, and mean SIP ambulation score was 9.6 ±8.8. Complications included two superficial infections, one deep infection, and three non-unions. There were no cases of wound dehiscence or necrosis, or cases requiring revision soft-tissue coverage. These outcomes were comparable to recent reports with similar injuries.

Conclusion: With careful planning and good soft-tissue management, incisions can be placed to maximize articular exposure based on fracture lines. It does not appear that the dogma of keeping incisions > 7-cm apart must be followed in most cases. Prudent surgical timing and meticulous soft-tissue handling can allow for multiple incisions to be placed as necessary for fracture reduction and optimal fixation while maintaining a low rate of complications.


Jeffrey M. Potter Lise Leveille Pierre Guy

Purpose: Lower extremity articular fracture treatment requires acccurate diagnosis and anatomic reduction and fixation. As articular injuries, posterior malleolus (PM) fractures are still poorly defined: for example the incidence of associated PM marginal impaction and of free articular fragments is unknown. The purposes of this study were:

to define the articular injuries of PM fractures into clincially relevant groups, as complex articular injuries could require specific surgical steps;

to identify clinical and radiographic parameters which would alert the surgeon to the presence of complex injuries.

Method: Our prospectively-collected orthopaedic trauma database (OTDB) query identified 796 ankle fractures treated operatively between 2003–2007. Of these 147 cases involved the posterior malleolus. Four were misclassified leaving 143 cases. We obtained demographic and injury data from the OTDB, and validated the OTDB coded mechanisms of injury by an individual chart review. We reviewed all radiographs to describe the PM injuries (fracture patterns and dimensions) and to identify the associated injuries.

Results: Of the 143 cases: Mean age was 50 years (sd=19), 68.5% were female, 51% were right sided injuries, and the median ISS=4 (in fact, 97.5% had ISS=4, most therefore being isolated trauma). The mean post malleolus AP size=11mm (sd=5). We identified recurrent patterns and classified the PM fracture as SIMPLE or COMPLEX (to include marginal impaction or free comminuted fragment, which should be anatomically reduced), 42% of cases (60/143) were COMPLEX (18 were impaction, 42 were free fragment). To help clinicians identify which cases could be COMPLEX we correlated (Chi-sq) the presence of a COMPLEX PM fracture to common clinical and radiographic variables. COMPLEX PM were statistically significantly associated with (p values)

an axial loading injury mechanism (.000),

a radiographically captured dislocation (.006),

posteromedial comminution [as defined Tor-netta] (.005)

the size of the fragment (.000).

For example, axial loading would result in a complex fracture in > 85% of cases. In contrast, there was a statistically significant association between a Weber C fracture and older age and the presence of a SIMPLE PM fracture. These factors being potentially “protective” from joint comminution.

Conclusion: We have defined and quantified the PM articular lesions which require anatomic reduction and fixation, beyond what has been published. We have defined clinical and radiographic criteria which, because higly associated with COMPLEX lesions, could

prompt surgeons to order further imaging (CT) to better delineate the lesion, and

draw his/her attention to potentially malaligned fragments at the time surgery.


Piya Kiatisevi Torsten Nielsen Malcolm Hayes Peter L. Munk Amy E. LaFrance Paul Clarkson Bassam A. Masri

Purpose: Core needle biopsy is increasingly accepted for the diagnosis of bone and soft-tissue tumours. Advantages over open biopsy include reduced morbidity, time and cost; however diagnostic accuracy remains a concern. Our objective was to assess and compare the diagnostic accuracy of core needle, open, and fine needle biopsies.

Method: We reviewed 286 cases collected in a prospective database between 2004 and 2007. Of these, 229 had core needle, 32 open, and 25 fine needle biopsies. 230 had soft-tissue lesions, 56 had bone lesions. The results of these biopsies were compared to the final resection diagnosis for accuracy and, where inaccurate, any effects on management.

Results: Ninety-two percent of the core needle, 100% of the open and 72% of the fine needle biopsies had adequate tissue to make a diagnosis. Of the adequate specimens, the accuracy of core/open/fine needle biopsy was 96%, 97% and 94% for determining malignant versus benign; of the correctly identified malignant lesions 97%, 100% and 80% were accurate for histological grade; and 79%, 84%, 59% for histological subtype.

Conclusion: Core needle biopsy yields diagnostic results comparable to open biopsy for determining malignancy and grade in bone and soft-tissue tumours. Fine needle biopsy has a high inadequate sampling rate and should not be used for diagnosing bone and soft-tissue tumours. Given the reduced cost and morbidity associated with core needle biopsies we believe they should be used routinely for diagnosis where possible, and open biopsy reserved for situations where an inadequate specimen is obtained or core biopsy is not feasible.


Nanjundappa S. Harshavardhana Brian J.C. Freeman Alan C. Perkins Ujjwal K. Debnath

Purpose: Intra-op localisation of small nidus in Osteiod osteoma and Osteoblastomas is often difficult resulting in failed excision with persistent pain. We report two year follow-up results of the efficacy and reliability of using an intra-operative gamma probe in conjunction with fluoros-copy to aid resection in primary and revision surgeries.

Method: Eight patients (6M; 2F) with a diagnosis of osteoid osteoma (7) and osteoblastoma (1) were seen at our centre. The mean age at presentation was 20.9 years (9–31y). The tumour was localised to cervical (2), thoracic(4) and lumbar (2) posterior elements. All had back or neck pain of varying duration with a mean of 20 months (6–48mo). Three patients had failed treatments including CT-guided radiofrequency ablation in one and surgical excision under fluoroscopy in two. No case had previously utilised an intra-op gamma probe for localisation. All patients had work-up with plain X-rays, CT, MRI and 99 m Technetium bone scan to identify and localise the lesion. A pre-requisite for use of intra-op gamma probe was a positive pre-op bone scan. On the day of surgery, 600 MBq Tech HMDP (hydroxy-methylene-di-phosphate) was administered IV 3 hours prior to surgery. Fluoroscopy was used to confirm anatomical level, permanent mark made on skin and area exposed surgically. A 5 mm cadmium telluride (Cd Te) probe (which converts gamma radiation into electrical signal) and rate meter were used to scan the area containing lesion and counts per second(cps) recorded. The tumour nidus was then excised and cps from tumour bed and excised specimen recorded.

Results: The mean follow-up was 5.85 years (2–12.3y). The mean cps for osteoid osteoma pre-excision was 203.8 (60–515), which fell to 72.5 (10–220) post-excision. The cps reduced from 373 to 40.5 post-operatively for Osteoblastoma. Complete excision was recorded every time and all patients reported characteristic disappearance of pre-operative pain. All had discontinued analgesic medication and returned to normal activity by three months. All patients were followed-up regularly when they filled NDI, ODI and SF-36.

Conclusion: Gamma probe guided surgical excision facilitates accurate localisation of lesion, is less invasive and most importantly confirmation of complete excision of the tumour nidus consistently every time.


Frank M. Klenke Doris E. Wenger Carrie Y. Inwards Franklin H. Sim

Purpose: Giant cell tumor (GCT) of bone is a rare, usually benign, primary skeletal lesion. The disease’s clinical course may be complicated by local recurrence subsequent to surgical treatment or the development of benign pulmonary metastases. Intra-lesional curettage is the standard treatment of primary GCT of bone. However, the value of intralesional procedures in recurrent GCT has not been well established.

Method: Forty-six patients with recurrent GCT of long bones treated between 1983 and 2005 were followed retrospectively. Minimum follow-up was three years; mean follow-up was 11.1 (±4.8) years.

Results: Wide resections were performed in 18 patients. Intralesional, joint preserving procedures were performed in 28 patients. Subsequent recurrence occurred in nine patients (20%). Wide resection was performed if joint salvage was not achievable due to expansion of the tumor. Reconstructions following wide resection included arthroplasty (n=4), osteoarticular allograft (n=3), APC (n=1) and fibular autograft reconstruction of the wrist (n=3). Amputations were performed in two patients. Patients undergoing wide resections for local recurrence had a significantly smaller risk of subsequent recurrence as compared to patients treated with intra-lesional surgery (6% versus 32%, hazard ratio: 0.28, p< 0.05). In patients treated with intralesional surgery, application of polymethylmethacrylate (PMMA) in addition to local phenol treatment significantly reduced the risk of subsequent recurrence (PMMA + phenol: 7% vs. Phenol: 25%, hazard ratio: 0.23, p< 0.05). Soft tissue expansion was not associated with an increased risk of subsequent recurrence. At follow-up, all patients with subsequent recurrence were without local disease after additional intralesional surgery (n=3) or wide resection (n=5). Metachronous benign pulmonary metastases evolved in five cases. There was no correlation between the development of pulmonary metastases and the type of treatment of recurrent disease found.

Conclusion: In recurrent disease of GCT of long bones and the possibility to salvage the adjacent joint intra-lesional surgery is the treatment of choice independent of whether soft tissue expansion is present. Intra-lesional surgery does not increase the risk of development benign pulmonary metastases. In cases with extensive tumor formation and without the possibility to preserve the adjacent joint wide resection has a high chance for long-term recurrence free disease.


Kevin B. Jones Soha Riad Anthony Griffin Benjamin Deheshi Robert S. Bell Peter Ferguson Jay S. Wunder

Purpose: The functional consequences of femoral nerve resection during soft tissue sarcoma management are not well described. Sciatic nerve resection with a sarcoma, once considered an indication for amputation, is now commonly performed during limb salvage. We compared the functional outcomes of femoral and sciatic nerve resections in patients undergoing wide resection of soft-tissue sarcomas.

Method: The prospectively collected database from a tertiary referral center for sarcomas was retrospectively reviewed to identify patients with resection of the femoral or sciatic nerve performed during wide excision of a soft tissue sarcoma. Patient demographics, treatment, complications and functional outcomes were collected.

Results: Ten patients with femoral nerve resections were identified, all women, aged 47 to 78, with large soft tissue sarcomas of varied subtypes. All patients received adjuvant radiotherapy, most pre-operatively. Six patients developed fractures with long-term follow-up, only two of which were in the prior radiation field. Musculoskeletal Tumor Society (MSTS) 1987 scores demonstrated one excellent, 4 good, and 5 fair results. MSTS 1993 scores averaged 71.4 ± 17.2 percent and Toronto Extremity Salvage Scores (TESS) averaged 61.7 ± 21.8. There were no significant differences between the functional scores for patients with femoral or sciatic nerve resections (P=1.0).

Conclusion: Femoral nerve resection appears more morbid than anticipated. The falls to which patients were prone, even years after surgery, subject them to ongoing long-term risks for fractures and other injuries. Nerve-specific functional outcomes should be considered when counseling patients prior possible resection of the femoral nerve for involvement by a soft tissue sarcoma.


Sarantis Abatzoglou Abdurahman Adoubali Cindy Wong Marc Isler Robert É. Turcotte

Purpose: Management of local recurrence (LR) remains unclear. Optimal management of primary tumour by specialised teams minimises this risk. However, previous treatments may impact on the available options when LR is encountered. We thus studied the outcome of this population with recurrent STS.

Method: Retrospective review was carried based on our prospective sarcoma databases. DFSP and ALT were excluded. Among 618 primarily managed STS we found 35 cases of local recurrences (5.7%). Median f-up after LR was 14 mos (0–98).

Results: Twenty were female. Mean age was 54 (Range 15 – 92). 22 involved lower limb, 11 upper limb and 2 the trunk. Mean delay from original surgery was 23 mos (3–75) and the mean size of LR was 4.7 cm (0.4–28.0 cm). Primary tumours were superficial in 4 and deep in 31 while recurrences were found superficial in 8 and deep in 26. Most frequent histology was MFH 8, Leiomyosarcoma 6, Liposarcoma, synovial sarcoma and MPNST had 4 each. 84% were high grade. Only 23 showed no meta-static disease at time LR was diagnosed. All 5 pts without initial RT got RT for their LR. 7 pts with therapeutic level of RT to the primary tumour got full course of RT as well for their LR. 11 did not undergo surgery. 6/18 who had initial RT underwent amputation as opposed to 0/6 who did not. Trend to amputate was for younger age, deep and large tumour and previous RT. Ultimatly, 21(60%) locally recurrent tumours showed metastatic disease; 6 prior diagnosis of LR, 6 concomitantly and 9 after with an average delay of 17 months (1–24). 6 pts developed additional local recurrences.

Conclusion: Although infrequent local recurrence correlates with impaired outcome. Albeit challenging, limb salvage and additional radiotherapy remain possible despite optimal multi modality management of the initial tumour.


Kevin B. Jones Soha Riad Anthony Griffin Benjamin Deheshi Robert S. Bell Peter Ferguson Jay S. Wunder

Purpose: Few functional outcomes of total femoral endoprosthetic replacement (TFEPR) using contemporary modular systems are available. We compared functional results between TFEPR patients receiving fixed- and rotating-hinge knee componentry following oncologic resections.

Method: Eighteen TFEPR patients were identified from a prospectively gathered sarcoma database. Six were secondary procedures and 12 primary. Four patients had metastatic carcinoma, 8 osteosarcoma, 4 non-osteogenic spindle cell sarcomas of bone, 1 Ewing’s sarcoma, and 1 femur-invading soft-tissue sarcoma. All reconstructions used modular implants from a single company. Proximally, all were bipolar hip hemiarthoplasties, 12 including abductor reattachment. Distally, 8 had fixed- and 10 had rotating-hinge knee componentry. Toronto Extremity Salvage Score (TESS), and both Musculoskeletal Tumor Society Scores (MSTS) were compared between fixed- and rotating-hinge groups using the Mann-Whitney test.

Results: Complications included 1 hip dislocation, 1 femoral malrotation, and wound problems requiring 3 debridements and 1 amputation. One metastatic carcinoma patient developed local relapse. Follow-up averaged 4 years (range 1 month to 14 years). At latest follow-up, 10 patients had died of disease. Eight remained alive, 6 disease-free, 2 with distant disease. Among patients surviving 6 months, 6 used no assistive devices, 5 used a single cane, and 4 were wheelchair bound, each at least partly due to distant disease progression. TESS averaged 74.5±17.4, MSTS1987 25.2±4.4; and MSTS1993 58.6±22.9 among the 12 patients for whom functional results were available from latest follow-up. No statistically significant differences or even trends were detected between fixed-hinge and rotating-hinge patients (lowest p = 0.755), but both instability problems were in the rotating-hinge group.

Conclusion: While both rotating- and fixed-hinge TFEPR reconstructions may function well, consideration should be given to fixed-hinge knee reconstruction when massive myectomies or poorer conditioning make hip and knee stability a primary concern in the short-term.


Paul Clarkson Kelly L. Sandford Amy E. LaFrance Anthony Griffin Jay S. Wunder Bassam A. Masri Thomas J. Goetz

Purpose: Giant cell tumour (GCT) of the distal radius is associated with high local recurrence rates unless the tumour is aggressively resected, which often leaves a significant skeletal defect. The purpose of this study is to compare the functional outcomes of two commonly used reconstructive techniques, vascularised free fibular transfer (VFF) and non-vascularised structural iliac crest transfer (NIC).

Method: Patients treated for giant cell tumour of the distal radius in either Vancouver or at Mount Sinai Hospital, Toronto were identified in the prospectively collected databases maintained in each centre. Twenty-seven patients were identified, 14 of whom underwent VFF transfer as their primary procedure. The two groups were comparable for age, sex and tumour grade. Functional outcomes were assessed with TESS, MSTS, DASH and the Ankle Osteoarthritis Scale.

Results: Fourteen patients were included in the VFF group, 13 of which were performed as the primary index procedure, one followed prior cementation. Thirteen patients underwent NIC, one followed prior cementation. Two local recurrences occurred in the VFF group and one in NIC group, all treated with local excision. In the VFF group three patients underwent further surgery for cosmesis, hardware removal and tendon release respectively. One is scheduled for future surgery for tendon release. In the NIC group two patients suffered infections requiring debridement, one of which ultimately went on to require free fibular transfer. This patient’s results were included in the NIC group as this was the index procedure. Functional scores showed no differences between the two groups on any of the parameters studied for the upper limb (Mann-Whitney test). The Ankle osteoarthritis scale had a median score of 9% for the six patients on which it was available.

Conclusion: Both VFF and NIC are effective surgical techniques that result in a well-functioning wrist arthrodesis. VFF may be more useful where there is a significant skin defect from previous interventions. We were unable to demonstrate any difference in functional scores between VFF and NIC.


David Sheps Fiona Styles-Tripp Kyle Kemp Scott Wiens Lauren Beaupré Robert A. Balyk

Purpose: Arthroscopic stabilization for post-traumatic anterior glenohumeral instability is designed to minimize soft tissue dissection while achieving similar or improved outcomes relative to open techniques. This study’s purpose was to determine the rate of post-operative recurrent instability and evaluate health related quality of life (HRQL) and shoulder range of motion (ROM) following arthroscopic Bankart repair using a bioabsorbable knotless implant.

Method: Forty-three patients were prospectively evaluated following arthroscopic anterior stabilization to assess for recurrent instability, HRQL, and shoulder ROM. Assessments were performed pre-operatively and 3, 6 and 12–24 months postoperatively. The HRQL measures included the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons Score (ASES), and the Constant Score. Repeated measures ANOVA was utilized to evaluate ROM and HRQL.

Results: The mean WOSI score improved from 45.67±17.99 pre-operatively to 83.16±18.58 at final follow-up. The mean ASES scores improved from 80.1±13.06 pre-operatively to 92.25±15.08, while the Constant score improved from 77.52±16.11 pre-operatively to 85.18±26.76. At final follow-up, 4 of 43 patients (9.3%) had experienced recurrent instability. For these 4 subjects, the WOSI score was significantly lower at final follow-up than those who did not experience recurrent instability (61.73±5.76 versus 84.38±16.94). The ASES and Constant scores at final follow-up were not significantly different between these two groups.

Conclusion: Arthroscopic anterior stabilization using a bioabsorable tack led to a recurrent instability rate similar to previous reports, and resulted in improved HRQL and shoulder ROM. The WOSI score was better able to detect problems in HRQL related to instability than either the ASES or Constant score.


Jaskarndip Chahal Tom McCarthy Jeff Leiter Daniel B. Whelan

Purpose: To determine whether generalized ligamentous laxity is a predisposing factor for primary traumatic anterior shoulder dislocation in young, active patients.

Method: Prospective case series with age and sex matched controls. The Hospital Del Mar Criteria was utilized to measure generalized ligamentous laxity. Fifty-seven (n=57) consecutive individuals (age< 30) sustaining a primary traumatic anterior shoulder dislocation between 2003 and 2006 were examined for hyperlaxity. The control group was comprised of seventy-two (n=72) undergraduate university students without a prior history of shoulder dislocation or anterior cruciate ligament injury.

Results: After adjusting for age and sex, the prevalence of hyperlaxity in the study group was 32.8% compared with 10.4% in the control group (p< 0.01). The prevalence of increased contralateral shoulder external rotation (> 85o) was 40.3% in the study group compared with 20.8% in the control group (p< 0.03). Among males, the prevalence of hyperlaxity was 28.3% in the study group and 5.3% in the controls (p< 0.01).

Conclusion: Although several studies have looked at the variables affecting shoulder instability, generalized ligamentous laxity (as measured by validated criteria) has not previously been identified as a predisposing factor for primary traumatic shoulder dislocation. This study demonstrates that generalized joint laxity and increased external rotation in the contralateral shoulder were found to be more common in patients who had sustained a primary shoulder dislocation. These observations may suggest a role for shoulder-specific proprioceptive and strength training protocols in hyperlax individuals participating in high-risk sports. Furthermore, the implications of hyperlaxity on the surgical management of traumatic primary shoulder instability are uncertain.


Arvindera Ghag Kyle Winter Erin Brown Amy E. LaFrance Paul Clarkson Bassam A. Masri

Purpose: Resection of pelvic sarcoma with limb preservation (internal hemipelvectomy) is a major undertaking. Resection requires large areas of soft-tissue to be removed. Because of wound complications, we manage these defects with immediate tissue transfer (ITT) at the time of resection when a large defect is anticipated. This study compares the outcomes of ITT with primary wound closure (PWC).

Method: Twenty patients undergoing 22 separate procedures (1995–2007) were identified in our prospectively maintained database. Demographics, tumour type, operative data and complications, and functional scores (MSTS-1993, TESS) were collected.

Results: Twelve defects were managed with ITT, nine with pedicled myocutaneous vertical rectus abdominis (VRAM) flaps (one received double VRAM flaps due to the large defect), two with tensor fascia lata (TFL) rotation flaps (one augmented by local V-Y advancement, the other with gluteus maximus rotation flap) and one received latissimus dorsi free tissue transfer. Four wound complications necessitated operative intervention in this group: two debrided VRAM flaps went on to heal and the two TFL flaps required revision: one to VRAM flap and the other to a latissimus dorsi free flap which ultimately suffered chronic infection and hindquarter amputation was performed. Ten defects were managed with PWC, and 5 wound complications occurred, all five suffered infection, one developed hematoma and one dehisced. One wound resolved with debridement, two healed after revision to pedicled gracilis and gluteus maximus myocutaneous flaps. Two patients were converted to hindquarter amputation due to chronic infection. Functional scores were collected on 8 of 12 living patients, at time of writing. The mean TESS scores were 83 and 73 in the ITT and PWC groups. Five patients in the ITT and 3 in the PWC group were deceased.

Conclusion: Soft-tissue closure following pelvic sarcoma resection remains a difficult challenge, and our experience reflects that. There were fewer wound complications (33% v 50%) and slightly better function with ITT than PWC, but this was not statistically significant due to the small size of our study. Although small, this study suggests ITT should be considered whenever a large soft tissue defect is anticipated.


Randy Mascarenhas Champ L. Baker Alex J. Kline Anikar Chhabra Mathew Pombo James P. Bradley

Purpose: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. The purpose of this study was to evaluate the results of arthroscopic methods in the treatment of athletes with symptomatic multidirectional instability of the shoulder.

Method: Forty patients (43 shoulders) with multidi-rectional instability of the shoulder were treated via arthrscopic means and were evaluated at a mean of 33.5 months post-operatively. The mean patient age was 19.1 years (range 14 to 39). There were 24 male patients and 16 female patients. Patients were evaluated with the ASES and WOSI scoring systems. Stability, strength, and range of motion were evaluated with patient-reported scales.

Results: The mean ASES score postoperatively was 91.4 out of 100. The mean WOSI post-operative percentage score was 91.1 out of 100. Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% of patients were able to return to their sport with little or no limitation.

Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.


Inder Gill Ajay Malviya Scott Muller Mike Reed

Purpose: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin.

Method: All patients undergoing Total Hip and Knee replacements over six months (October 2007 to March 2008) at three participating hospitals were prospectively followed to assess perioperative infection rates using Surgical Site Surveillance(SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg. This was compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals using 3 doses of Cefuroxime 750mg. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. The change in creatinine level postoperatively was also measured in a selected group of patients.

Results: Four hundred and eight patients underwent Total Hip Replacements (THR) and 458 patients Total Knee Replacements (TKR) during the study period. This was compared with 414 and 421 patients who underwent THRs and TKRs respectively during a previous six month period. SSI was detected in 9 THRs(2.2%) and 2 TKRs(0.44%) in the study group as compared to 13 THRs(3.1%) and 12 TKRs(2.9%) in the control group. The infection rates in THRs were not significantly different between the 2 groups(p value−0.52) but were significantly reduced in the study group for TKRs(p value−0.005). The rate of Clostridium difficile infection was reduced within the hospital with the use of gentamicin, although other measures to reduce its incidence were also introduced. The return to theatre was 1.64%(23/1402) after introduction of Gentamicin as compared with 1.05%(21/2005) [p value−0.092] before this. This was a cause for concern although not significant. The day1 postoperative creatinine level increased by more than 30 units in 6% of patients on Gentamicin.

Conclusion: This study shows that the use of single dose prophylaxis using Gentamicin is effective for Lower Limb Arthroplasty. However, be wary of increased rate of return to theatre and the rise in creatinine level following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.


Ryan Bicknell Chris Chuinard Scott Penington Frédéric Balg Pascal Boileau

Purpose: Shoulder pain in the young athlete is often a diagnostic challenge. It is our experience that this pain can be related to a so-called “unstable painful shoulder” (UPS), defined as instability presenting in a purely painful form, without any history of instability but with anatomical (soft tissue or bony) ‘roll-over’ lesions. The objectives are to describe the epidemiology and diagnostic criteria and to report the results of surgical treatment.

Method: A prospective review was performed of 20 patients (mean age 22 ± 8 years). Inclusion criteria: a painful shoulder and “roll-over lesions” on imaging or at surgery. Exclusion criteria: a dislocation/subluxation; associated pathology; previous shoulder surgery.

Results: Most patients were male (60%), athletes (85%) and involved the dominant arm (80%). All patients denied a feeling of instability and only complained of deep, anterior pain. Most had a history of trauma (80%). All patients had rehabilitation without success and 30% had subacromial injections. All had to stop sports. Most (85%) had anterior or inferior hyperlaxity. All had pain with an anterior apprehension test and relieved by relocation test. ‘Roll-over’ lesions included: labrum detachment (90%), capsular distension (75%), HAGL lesion (10%), glenoid fracture (20%) or Hill-Sachs (40%). Time from symptoms to surgery was 25 ± 23 months. All patients had arthroscopic treatment. Mean follow-up was 38 ± 14 months. Eighteen patients (90%) were very satisfied/satisfied. None had pain at rest, but one (5%) had pain with apprehension test. There was no change in elevation, external or internal rotation (p> 0.05). There were no cases of instability. Rowe and Duplay scores improved (p< 0.05).

Conclusion: Instability of the shoulder can present in a purely painful form, without any history of dislocations or subluxations. Diagnosis can be difficult, and should be suspected in young patients and athletes. Most patients have deep anterior pain and pain with apprehension test. ‘Roll-over’ lesions are necessary to confirm the diagnosis. Arthroscopic repair is effective.


Scott Kaar Stephen Fening Morgan Jones Rob Colbrunn Anthony Miniaci

Purpose: We hypothesized that glenohumeral joint stability will decrease with increasingly larger humeral head defects.

Method: Humeral head defects were created in 9 cadaveric shoulders to simulate Hill Sachs defects. Defects represented 1/8, 3/8, 5/8, and 7/8 of the radius of the humeral head. Secondary factors included abduction angles of 45 degrees and 90 degrees, and rotations of 40 degrees internal, neutral, and 40 degrees external. Specimens were tested at each defect size sequentially from smallest to largest and at each of 6 conditions for all abduction and rotation combinations. Using a 6 degree-of-freedom robot, the humeral head was translated at 0.5 mm per second until dislocation in the anteroinferior direction at 45 degrees to the horizontal glenoid axis.

Results: ANOVA demonstrated significant factors of rotation (p< 0.001) and defect size (p< 0.001). In 40 degrees external rotation, there was significant reduction of distance to dislocation compared with neutral and 40 degrees internal rotation (p< 0.001). The 5/8 and 7/8 radius osteotomies demonstrated decreased distance to dislocation compared to the intact state (p< 0.05 and p< 0.001 respectively). There was no difference found between abduction angles. Post hoc analysis determined significant differences for each arm position. There was decreased distance to dislocation at the 5/8 radius osteotomy at 40 degrees external rotation with 90 degrees of abduction (p< 0.05). For the 7/8 radius osteotomy at 90 degrees abduction, there was decrease distance to dislocation for neutral and 40 degrees external rotation (p< 0.001). For the same osteotomy at 45 degrees abduction, there was decreased distance to dislocation at 40 degrees external rotation (p< 0.001). With the humerus internally rotated, there was never a significant change in the distance to dislocation.

Conclusion: Glenohumeral stability decreases at a 5/8 radius defect and was most pronounced in 40 degrees external rotation and at 90 degrees abduction. At a 7/8 radius humeral defect, there was further decrease in stability at both neutral and external rotation. Internal rotation always maintained baseline glenohumeral stability.


R. Cole Beavis F. Alan Barber Morley A. Herbert

Purpose: New high-strength sutures demonstrate high failure loads, but may be more likely to slip compared with polyester sutures. The purpose of this study was to determine the knot security and ultimate failure load of 8 common sutures tied with 6 arthroscopic knots. The hypothesis was that knots tied using high-strength sutures would not slip and demonstrate greater tensile strengths than polyester suture.

Method: Eight different sutures (Ethibond, FiberWire, ForceFiber, Hi-Fi, MagnumWire, Maxbraid, Ortho-cord and Ultrabraid) were tied with 6 arthroscopic knots (Duncan, Revo, San Diego, SMC, Tennessee and Weston.) Knots were backed up with 4 reversed half-hitches on alternating posts. Each suture-knot combination was tied 10 times for a total of 480 knots tested. Cyclic testing was performed followed by loading to failure. Mode of failure, ultimate failure load and force during slippage was recorded.

Results: FiberWire demonstrated the highest failure load (259.70N+/−85.81) and Ethibond the lowest (143.92N+/−16.56) (p< 0.05). Knots tied with Ethibond slipped 22.4% of the time compared with 31.7%–40.0% for high-strength sutures. Frequent slippage occurred with Duncan loops (97.5%) and Weston knots (86.3%) while the SMC (1.3%) and Revo knots (3.6%) rarely slipped (p< 0.05). Mean failure loads were highest for the Revo (280.99N +/− 57.01) and SMC knots (274.89N +/−57.90) compared with all others (p< 0.05).

Conclusion: Our results demonstrate that knots tied with Ethibond were least likely to slip and yielded a more consistent (narrow standard deviation) but overall lower ultimate tensile strength than all of the high strength sutures. Early slippage of some knots tied with high-strength suture was responsible for greater variability with some failing at sub-maximal loads. The Duncan loop and Weston knots were the most likely to slip.


Alan M. Hirahara Kyle Yamashiro Russell Dunning

Purpose: To evaluate failure rates of SLAP repairs with and without a fibrin-PRP clot.

Method: 141 patients received a fibrin-PRP clot, placed arthroscopically between the labrum and bone prior to tying our sutures in repairing the SLAP lesion. Thirty-nine patients were repaired without use of a fibrin-PRP clot. Arthroscopic fixation was performed using a bio-absorbable suture anchor (Bio-SutureTak, Arthrex). The fibrin-PRP clot was made from autologous blood, using the Plasmax Plus system (Biomet). Patients were evaluated clinically with ASES scores, range of motion, time to discharge, and return to work. Repeat MRA or surgery was performed for people having persistent pain or complaints at four to six months post-operatively to evaluate healing.

Results: Four out of thirty-nine (10.3%) control patients failed to heal and required revision surgery. One out of 139 (0.7%) study patients failed to heal (p = 0.008). Pain scores decreased from pre-op to 1 to 3 to 6 months in both groups but significantly greater in the study group (7.1, 5.2, 3.0, 1.6) compared with the control group (7.1, 6.0, 4.8, 3.1) (p=NS, NS, < 0.001, < 0.05). ASES society scores increased steadily from pre-op to 1 month to 3 months to 6 months in both groups. The control group increased from 35.9 to 36.9 to 56.3 to 72.7. The study group increased from 43.1 to 45.2 to 71.0 to 81.9 and were significantly different (p = NS, < 0.05, < 0.001, 0.06). The average days to discharge in the study group was significantly improved at 119.1 days from 213.5 in the control group (p < 0.001). Time to return to work decreased from control to the study group 121.7 days to 57.1 days (p < 0.01). ROM increased in both groups non-significantly from pre-op to 3 months follow up in the study group.

Conclusion: The results of this study show that the fibrin-PRP clot enhances the healing of the labrum to the glenoid. We have significantly fewer failures, less pain, quicker time to discharge, and faster functional recovery. By suturing a fibrin-PRP clot between the labrum and glenoid, recovery and healing of the tear occurs quicker and more reliably.


Nicholas G.H. Mohtadi Jocelyn N. Fredine Heather N. Hannaford Denise S. Chan Treny M. Sasyniuk

Purpose: Shoulder instability is a common problem affecting patients in their most active years resulting in an impact on their quality of life. The WOSI is a validated, disease-specific (shoulder instability) evaluative quality of life measure. It has not been tested for its ability to discriminate between those who require surgical care and those who do not. The purpose of this study is to determine if the WOSI can discriminate between surgical and non-surgical patients and between patients with different types of shoulder instability.

Method: Sixty patients with a confirmed diagnosis of shoulder instability were included as cases. Twenty had documented multidirectional instability requiring surgery: Group 1 Surgical MDI – 20 patients had documented recurrent traumatic anterior dislocations requiring surgery: Group 2 Surgical Anterior – 20 patients were first time anterior dislocators who were followed for a minimum one year who had no further recurrences and did not require surgery: Group 3 Non-Surgical First Time Anterior – The cases were compared to 60 age and gender matched control patients with no history of shoulder problems: Group 4 Control – WOSI scores were analyzed using a one-way ANOVA.

Results: The WOSI scores were as follows: Group 1 Surgical MDI- mean 30.5 (95% CI 23.1–37.8); Group 2 Surgical Anterior- mean 39.8 (95% CI 33.1–46.5); Group 3 Non-Surgical First time Anterior- mean 76.2 (95% CI 66.4–86.0) and Group 4 Control- mean 96.6 (95% CI 95.8–97.4). Based on the 95% Confidence Intervals, there were statistically significant differences between the two surgical groups (Group 1 Surgical MDI and Group 2 Surgical Anterior) compared to the non-surgical patients (Group 3 Non Surgical First Time Anterior) and the controls (P=0.000). There is a trend to discriminate between the two surgical groups (P=0.079).

Conclusion: The WOSI Index clearly discriminates between surgical and non-surgical patients with shoulder instability, and the control population with normal shoulders. There is a trend to discriminate between MDI and recurrent anterior traumatic dislocators.


Marlis Sabo Katherine Fay Louis M. Ferreira Colin P. McDonald James A. Johnson Graham J.W. King

Purpose: Coronal shear fractures of the humerus include the Kocher-Lorenz fracture, an osteochondral fracture of the capitellar articular surface, the Hahn-Steinthal fracture, a substantial shear fragment, extension into the trochlea, and complete involvement of the capitellum and trochlea. If the fracture proves irreparable, it is not known what the impact of fragment excision would have on the biomechanics of the elbow. The purpose of this study was to examine the effect of the sequential loss of the capitellum and trochlea on the kinematics and stability of the elbow.

Method: Eight fresh-frozen cadaveric arms were mounted in an upper extremity joint testing system, with cables attaching the tendons of the major muscles to motors and pneumatic actuators. Electromagnetic receivers attached to the radius and ulna enabled quantification of the kinematics of both bones with respect to the humerus. The distal humeral articular surface was sequentially excised to replicate clinically relevant coronal shear fractures while leaving the collateral ligaments intact. Active flexion in both the vertical and valgus-loaded positions, and passive rotation in the vertical position was conducted for each excision.

Results: Excision of the capitellum had no effect on ulnohumeral stability or kinematics in both the vertical or valgus positions (p=1.0). Excision of the entire capitellum and trochlea led to significant valgus instability with the arm in the valgus position (p=0.01), while excision of the lateral trochlea led to increased valgus instability with pronated flexion in the valgus position (p=0.049). Progressive loss of the articular surface led to posterior, inferior, and medial displacement of the radial head with respect to the capitellum and increased external rotation of the ulna with respect to the humerus in the vertical position (p< 0.05).

Conclusion: Excision of the capitellum did not result in valgus or rotational instability, while excision of the trochlea resulted in multiplanar instability. The radial head displaced medially because it is constrained to the ulna by the annular ligament, and the ulna pivoted into valgus and external rotation on the residual trochlea and medial collateral ligament. In patients with coronal shear fractures, the trochlea must be reconstructed to prevent instability and the potential for secondary degenerative change.


Holman Chan Martin Bouliane Lauren Beaupré

Purpose: Due to its proximity to the glenohumeral joint, the suprascapular nerve may be at risk of iatrogenic nerve injury during arthroscopic labral repair. Our primary objective is to evaluate the risk of suprascapular nerve injury during standard drilling techniques utilized in arthroscopic superior labral repairs. Secondarily, we evaluated the correlation between this risk and scapular size.

Method: Forty-two cadaveric shoulders were dissected to isolate their scapulae. A surgical drill and guide was used to create suture anchor holes in 3 locations in the superior rim of the glenoids as typically done in arthroscopic superior labral repairs. The orientation of these drill holes correspond to common shoulder arthroscopic portals. The suprascapular nerve was then dissected from the suprascapular notch to the spinoglenoid notch. The presence of drill perforations through the medial cortex of the glenoid vault was recorded along with the corresponding hole depth and distance to the suprascapular nerve.

Results: Medial glenoid vault perforations occurred in 8/21(38%) cadavers with a total of 18/126(14%) perforations. The suprascapular nerve was in line of the drill path in 5/18(28%) perforations. Female specimens and smaller scapulae had a statistically higher risk of having a perforation (p< 0.05).

Conclusion: The results of this anatomic study suggest that there is a substantial risk of medial glenoid vault perforation. When a perforation does occur, the suprascapular nerve appears to be at high risk for injury especially with more posterior drill holes. The risk is significantly higher in females and in smaller scapulae.


Timothy H. Bell Graham J.W. King James A. Johnson Louis M. Ferreira Colin P. McDonald

Purpose: The purpose of this study was to determine the effect of serial olecranon resections on elbow stability.

Method: Eight fresh, previously frozen cadaveric arms underwent CT scanning. The specimens were mounted in an in-vitro motion simulator, and kinematic data was obtained using an electromagnetic tracking system. Simulated active and passive flexion was produced with servo-motors and pneumatic pistons attached to specific muscles. Flexion was studied in the dependent, horizontal, varus, and valgus positions. Custom computer navigation software was utilized to guide serial resection of the olecranon in 12.5% increments. A triceps advancement repair was performed following each resection.

Results: Serial olecranon resections resulted in a significant increase in valgus-varus (V-V) laxity for both passive (p< 0.001) and active (p=0.04) flexion. For passive motion this increase reached statistical significance following the 12.5% resection. This corresponded to an increase in V-V laxity of 1.4 ± 0.1o and a total laxity of 7.5 ± 1.0o. For active flexion this increase reached significance following the 62.5% resection. This corresponded to an increase in V-V laxity of 5.6 ± 1.1o and a total laxity of 11.2 ± 1.5. There was no significant effect of sequential olecranon excision on elbow kinematics or stability with the elbow in the vertical or horizontal positions. The elbows became grossly unstable after resection of greater than 75% of the olecranon.

Conclusion: A progressive increase in the varus-valgus laxity of the elbow was seen with sequential excision of the olecranon. Laxity of the elbow was increased with excision of 75% of the olecranon, likely due to the loss of the bony congruity and attachment site of the posterior band of the medial collateral ligament. Gross instability resulted when 87.5% or greater was removed, likely due to damage to the anterior band of the medial collateral ligament as it inserts on the sublime tubercle of the ulna. Rehabilitation of the elbow with the arm in the dependant position should be considered following excision of the olecranon; varus and valgus orientations should be avoided. The contribution of the olecranon to elbow stability may be even more important in patients with associated ligament injuries or fractures of the elbow.


J Whitcomb Pollock James R. Browhill Louis Ferreira Colin P. McDonald James Johson Graham J.W. King

Purpose: The role of the posterior bundle of the medial collateral ligament (PMCL) in stability of the elbow remains poorly defined. The purpose of this study was to determine the effect of sectioning the PMCL on the stability of the elbow.

Method: Varus and valgus gravity-loaded passive elbow motion and simulated active vertical elbow motion were performed on 11 cadaveric arms. An in-vitro elbow motion simulator, utilizing computer-controlled pneumatic actuators and servo-motors sutured to tendons, was used to simulate active elbow flexion. Varus/valgus angle and internal/external rotation of the ulna with respect to the humerus were recorded using an electromagnetic tracking system. Testing was performed on the intact elbow and following sectioning of the PMCL.

Results: With active flexion in the vertical position the varus/valgus kinematics were unchanged after PMCL sectioning (p=0.08). However, with the forearm in pronation, there was a significant increase in internal rotation after PMCL sectioning compared to the intact elbow (p< 0.05) which was most evident at 0° and 120° degrees of flexion (p< 0.05). This rotational difference was not statistically significant with the forearm in supination (p=0.07). During supinated passive flexion in the varus position, PMCL sectioning resulted in increased varus angulation at all flexion angles (p< 0.05). In pronation varus angulation was only increased at 120° of flexion (p< 0.05). However, internal rotation was increased at flexion angles of 30° to 120° (p< 0.05). In supination, sectioning the PMCL had no significant effect on maximum varus-valgus laxity or maximum internal rotation (p=0.1). However, in pronation, the maximum varus-valgus laxity increased by 3.5° (30%) and maximum internal rotation increased by 1.0° (29%) (p< 0.05).

Conclusion: These results indicate that isolated sectioning of the PMCL causes a small increase in varus angulation and internal rotation during both passive varus and active vertical flexion. This study suggests that isolated sectioning of the PMCL may not be completely benign and may contribute to varus and rotation instability of the elbow. In patients with insufficiency of the PMCL appropriate rehabilitation protocols (avoiding forearm pronation and shoulder abduction) should be followed when other injuries permit.


R. Cole Beavis F. Alan Barber Morley A. Herbert

Purpose: To evaluate the insertion forces required to seat osteochondral plug grafts and the accuracy of plug harvest and seating using three unique instrumentation systems. Our hypothesis was that the systems would have different insertion forces.

Method: The COR (Depuy-Mitek), Mosaicplasty (Smith & Nephew) and OATS (Arthrex.) Instrumentation systems and recommended surgical techniques were used to harvest, transfer, and implant grafts. To simulate the in-vivo surgical setting, multiple-impacts with a mallet were applied to the instruments. Ten tests each were performed for all systems in both rigid polyurethane foam blocks and porcine femur models. Plug length after harvest and final graft position were manually measured. Insertion forces were recorded using a load cell (Omega Engineering) affixed to the insertion tamp. The area under the force curve recorded by the transducer for each blow was then summed to yield the total force required to seat each graft. Means and standard deviations were then calculated and Tukey’s test was used to determine significant differences between the means.

Results: The COR system demonstrated significantly lower mean insertion forces in both polyurethane foam blocks and porcine models when compared with the OATS and Mosaicplasty systems. Graft harvest with Mosiacplasty led to greater harvest length inconsistency than with other systems tested. OATS grafts were more likely to be left proud.

Conclusion: The COR system produced significantly lower insertion forces during graft insertion. COR and OATS yielded consistent harvest lengths. The majority of OATS grafts were left proud which would require additional impaction force to fully seat the graft.


Sean Haslam Daniel P. Borschneck

Purpose: The purpose of this study was two-fold. First, we wanted to compare the cost of liquid waste disposal from the operating rooms (ORs) via a 3rd party medical waste company, with utilization of the sewer system at Kingston General Hospital. Secondly, we sought to assess national trends in liquid waste disposal, in order to make a national recommendation for liquid waste disposal from the OR.

Method: The hospital cost for OR liquid waste disposal at Kingston General Hospital was calculated by weighing the liquid waste from 871 surgical cases over a 5-week period in 2008. The materials, manpower and weight of the waste were used to calculate the costs for the two methods of liquid waste disposal. Seventy teaching hospitals across Canada were surveyed to determine their practice of liquid waste disposal in the OR.

Results: The raw cost per kg of liquid waste disposal using a medical waste company was found to be 57.126 % greater than utilizing the sewer system. Using the sewer system resulted in a total cost reduction of 40% compared with using a medical waste company. Sixty-three out of seventy teaching hospitals across the nation (90%) were found to utilize medical waste companies, while seven out of seventy hospitals (10%) utilized the sewer system to dispose of liquid waste.

Conclusion: The sewer system is an under-utilized yet safe, legal, and cost effective way to dispose of liquid waste from the OR. Using the sewer system to dispose of liquid waste would save the Canadian health care system millions of dollars compared with disposal via medical waste companies.


Michael G. Zywiel Slif D. Ulrich Arnold D. Suda James L. Duncan Mike S. McGrath Michael A. Mont

Purpose: Many strategies have been reported for decreasing the cost of orthopaedic procedures, including negotiating lower prices with manufacturers and using lower-cost generic implants, but prosthetic waste has not been investigated. The purpose of this study was to characterize the present and potential future cost of intra-operative waste of hip and knee implants.

Method: A regional prospective assessment of implant waste was performed from January 2007 to June 2008, evaluating the incidence and reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Using published data on nationwide arthroplasty volumes, the results were extrapolated to the whole of the United States. Finally, based on peer-reviewed estimates of nationwide arthroplasty volumes for the next 20 years, a projection was made about the future cost burden of implant waste.

Results: Implant waste occurred in 79 of 3443 recorded procedures (2%), with the surgeon bearing primary responsibility in 73% of occurrences. The annualized waste cost was $109,295.35, with 67% absorbed by the hospital. When extrapolated to the whole of the United States, the annual cost to hospitals of hip and knee prosthetic waste is $36,019,000, and is estimated to rise to $112,033,000 in current dollars by the year 2030.

Conclusion: This study discovered a notable incidence of intra-operative hip and knee implant waste, with the majority of cases attributed to the surgeon, and representing an important additional cost burden on hospitals. With arthroplasty rates projected to increase markedly over the next twenty years, this waste represents a potentially noteworthy target for educational programs and other cost containment measures in orthopaedic surgery.


Dominique Rouleau George Athwal Kenneth J. Faber

Purpose: Recognition of the proximal ulna dorsal angulation (PUDA) is important for anatomic reduction of proximal ulnar fractures or osteotomies, especially when using newer straight precontoured proximal ulnar plates. The purpose of this study was to characterize the PUDA in 50 patients with bilateral elbow radiographs.

Method: Bilateral elbow radiographs (100 radiographs) were magnified four times using commercial software. The PUDA was measured from the intersection of lines tangent to the subcutaneous border of the olecranon and the proximal ulnar shaft. The olecranon tip-to-apex distance of the PUDA was also measured. Three orthopaedic surgeons independently examined the radiographs and intra/inter-observer reliability was calculated using Intra-Class-Correlation (ICC).

Results: A PUDA was present in 96% of radiographs. The average PUDA was 5.7° (range, 0°to14°). The Pearson Correlation coefficient for a side-to-side comparison was 0.86(p< 0.001). The average tip-to-apex distance was 47 mm (34 mm–78mm). No correlation was identified with sex or age. Intra-observer reliability was excellent for the PUDA (ICC 0.892 and 0.863) and good for tip-to-apex distance (ICC 0.762 and 0.827). Inter-observer reliability was good for PUDA (ICC 0.784 and 0.925) and for tip-to-apex distance (ICC 0.711 and 0.769).

Conclusion: A mean proximal ulna dorsal angulation of 5.7° is present in 96% of patients at an average of 47 mm distal to the olecranon tip. Measurement of the PUDA has good/excellent inter/intra-observer reliability. Recognition of the PUDA may be helpful in anatomic plating of the ulna. Contralateral PUDA measurements are useful for surgical planning in cases with comminution or distorted anatomy.


Peter Zarkadas Ben Cass Thomas Throckmorton Robert Adams Joaquin Sanchez-Sotelo Bernard F. Morrey

Purpose: Resection elbow arthroplasty is a salvage procedure typically considered as a last resort when other reconstructive options have failed. It was the intent of this study to evaluate the long-term outcome of patients following resection elbow arthroplasty.

Method: Fifty-four elbow resections performed between 1975 and 2005 were retrospectively reviewed. Pre and post-operative elbow function was evaluated with the Mayo Elbow Performance Score (MEPS) and additional follow-up data was compiled using the Disability of Shoulder and Hand (DASH) score. All patients in this study had a resection following a failed total elbow arthroplasty (TEA). Nineteen patients had died at time of follow-up, and 5 patients were lost to follow-up, leaving 30 of the surviving 34 patients (88%) available for long-term evaluation.

Results: The main indication for resection in this study was infection (50 of 54 elbows). The average MEPS prior to resection was 36. The long-term results in 30 patients at an average of 11 yrs (range 2.7–28 yrs) demonstrated an average MEPS score of 60, and a DASH score of 71. Complications were common including persistent infection requiring re-operation (44%), intra-operative fracture (32%), transient (11%) or permanent (5.5%) nerve damage, and one case of vascular injury requiring amputation. Achieving a stable resected elbow correlated strongly with a good long-term MEPS score (r=0.75).

Conclusion: This study emphasizes the difficulty in treating patients with a failed total elbow arthroplasty. Resection arthroplasty is a salvage procedure indicated primarily for persistently infected TEA and results in satisfactory outcomes in this population.


Nyagon G. Duany Michael G. Zywiel Mike S. McGrath Junaed A. Siddiqui Lynne C. Jones Michael A. Mont

Purpose: Spontaneous osteonecrosis of the knee is a potentially greatly debilitating condition. While success has been reported with non-operative treatment of this disorder in its earliest stages, knee arthroplasty is the only viable modality if allowed to progress to condylar collapse. The purpose of this report is to review the etiologic and pathophysiologic principles of spontaneous osteonecrosis of the knee, to present our experience with joint-preserving surgical treatment of this condition, and finally to introduce a treatment algorithm developed based on this knowledge.

Method: Seventeen patients with a clinical and/or radiographic a diagnosis of spontaneous osteonecrosis of the knee, and exclusion of secondary osteonecrosis, who failed non-operative modalities were treated with joint-preserving surgery at a single center between January 2000 and December 2006. Treatment modalities included arthroscopy, and either percutaneous core decompression and/or osteochondral autograft transfer. Three knees were lost to follow-up, leaving 14 knees with a mean follow-up of 37 months (range, 11 to 84 months).

Results: Twelve of 14 knees (86%) had knee joint survival with a mean Knee Society Score of 80 points (range, 45 to 100 points) at final follow-up. One patient was treated with serial core decompression followed by osteochondral transfer, and was included in both groups. Six of 7 patients (86%) treated with core decompression alone had a successful clinical outcome, as did 7 of 8 patients (87%) treated with osteochondral autograft transfers. Two patients (14%) progressed to condylar collapse, and were treated with total knee arthroplasty with successful results.

Conclusion: Based on these results, we propose a treatment algorithm that begins with non-operative treatment, followed by joint-preserving surgery consisting of arthroscopy, core decompression, and/or osteochondral autograft transfer. Although our sample size is small, the results suggest that this proposed treatment algorithm can successfully postpone the need for knee arthroplasty in selected patients with pre-collapse spontaneous osteonecrosis of the knee.


Carol R. Hutchison Claude Martin

Purpose: Litigation continues to be a concern in orthopaedic surgery despite suggestions on how to contain liability. The purpose of this study was to characterize orthopaedic litigation in Canada from 1997–2006.

Method: This study reviewed all closed claims reported to the Canadian Medical Protective Association (CMPA) for 1997–2006 in which orthopaedic surgeons were named. There were 11,983 closed legal actions involving CMPA members (> 73,000 physicians), and 1,353 involved orthopaedic surgeons. A careful review of closed legal actions is a recognized tool for risk identification, assessment and management. The CMPA identifies any critical incidents within the closed legal files. A critical incident is defined as any omission or commission in the evaluation or management which led to the problem(s) that triggered the legal action. Each closed legal action can have more than one critical incident.

Results: Performance, diagnostic and communication issues were the most frequently identified problems. These three areas account for 55% of the critical incidents identified. Performance related issues accounted for 395 critical incidents (29%). Diagnostic issues, including deficient histories and general evaluations, were identified in 281 cases (21%). Communication-related critical incidents included those concerning informed consent. The lack of informed consent was a common allegation, proven in 71 cases. In 439 cases (32%) there was no identifiable critical incident for the orthopaedic surgeon involved. Seventy-eight per cent of patients experienced minor or no disability and 22% experienced major disability or death. Events related to tibia trauma and knee arthroscopy formed the two major categories of claims. Patient care areas of high risk include the operating room and outpatient clinic. Overall, 31% of legal actions against orthopaedic surgeons had outcomes in favour of the plaintiffs, compared with 33% of all CMPA members’ claims.

Conclusion: Although the likelihood for an orthopaedic surgeon to be sued in Canada has decreased over the last 10 years, the percentage of legal cases resolved in favour of plaintiffs has remained stable. Performance-related deficiencies, delays in diagnosis, and failures in communication represent areas of high medico-legal risk. Suggestions for risk management are provided to further decrease adverse events and the medico-legal risks for Canadian orthopaedic surgeons.


John M. Froelich Joseph C. Milbrandt D. Gordon Allan

Purpose: The current study examines the impact of the 80-hour work week on the number of surgical cases performed by PGY2 – PGY5 Orthopedic residents. We also evaluated Orthopaedic In-training Exam (OITE) scores during the same time period.

Method: Data were collected from the ACGME national database for 3 academic years prior to and 5 years after July 1, 2003. CPT surgical procedure codes logged by all residents three years prior to and five years following implementation of the 80-hour work week were compared. The average raw OITE scores for each class obtained during the same time period were also evaluated. Data were reported as the mean ± standard deviation (SD) and group means were compared using independent t-tests.

Results: No statistical difference was noted in the number of surgical procedure codes logged prior to or after institution of the 80-hour week during any single year of training. However, an increase in the number of CPT codes logged in the PGY-3 year after 2003 did approach significance (457.7 vs. 551.9, p=0.057). There was a statistically significant increase in total number of cases performed (464.4 vs. 515.5 p=0.048). No statistically significant difference was noted in the raw OITE scores before or after work hour restrictions for our residents or nationally.

Conclusion: We found no statistical difference for each residency class in the average number of cases performed or OITE scores. We also found no statistical difference in the national OITE scores. Our data suggest that the impact of the 80 hour work has not had a detrimental effect in these two resident training measurements.


Yangmin Zeng Travis Marion Pamela Leece Eugene Wai

Purpose: Persistent radiculopathy secondary to lumbar disc herniation is a common problem that greatly compromises quality of life. In North America, lumbar discectomies are among the most common elective surgical procedures performed. There is still much debate about when conservative or surgical treatments should be offered to patients. Although the related literature is comprehensive, there are limited systematic reviews on the prognostic factors predicting the outcome of lumbar discectomy. The purpose of this review is to define the preoperative factors predicting clinical outcome after lumbar discectomy.

Method: We conducted a computerized literature search using Ovid Medline and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials or prospective studies dealing with lumbar disc surgery. The preoperative predictors had to be clearly identified and correlated with outcome measures in terms of pain, disability, work capacity, analgesia consumption, or a combination of these measures. We assessed the articles as high or low quality studies using the Newcastle-Ottawa Quality Assessment Scale, and summarized the results of High Quality Studies.

Results: A total of 39 articles were included. The two most prominent negative predictors were Workers’ Compensation status and depression according to 6 studies. Poor predictors reported in 4 articles were female gender, increasing age, and prolonged duration of leg or back pain. Lower education level, smoking, and higher levels of psychological complaints were negative predictors in 3 articles. A positive Lasègue sign was a positive predictor in 7 articles. Absence of back pain, positive patient expectations, and higher income were good prognostic factors in 3 studies. Patients with contained herniations did worse than those who had uncontained disc extrusions and sequestrations according to 4 studies. The level of herniation was not a predictive factor in 7 studies.

Conclusion: Workers’ Compensation, depression, greater back versus leg pain, increasing age, female gender, contained herniations, and prolonged symptoms predict unfavourable postoperative outcomes after lumbar discectomy. Positive Lasègue sign, higher income, uncontained herniations, and positive patient expectations predict favourable postoperative outcomes. The level of herniation is not an established prognostic factor. The results of this review provide a preliminary framework for patient selection for lumbar disc surgery.


Travis E. Marion Yangmin Zeng Eugene Wai

Purpose: Perispinal core muscle strength has been theorized to be an important component in the pathogenesis of back pain. Recent research has demonstrated a strong association between preoperative perispinal musculature, adjusted for fatty infiltration and prospective outcomes and improvements in back pain in patients undergoing lumbar laminectomy without fusion. The purpose of this study is to determine if a similar relationship exists in patients undergoing elective posterior lumbar fusion and decompression (PLFD) surgery.

Method: A retrospective observational study of prospectively collected outcomes data was conducted in which pre-operative function and patient variables of those undergoing PLFD were derived from a functional status questionnaire and medical records. ImageJ Digital Imaging Software was utilized to measure the total (CSA) and percentage of fatty infiltration of the psoas, multifidus, and erector spinae muscles in pre-operative L4 axial CT images. Pre-operative and post-operative lateral images were evaluated for degree of post-operative adjacent level degeneration. Follow-up consisted of a functional status questionnaire. Outcomes measured were improvements in back pain, leg pain, and Oswestry disability scores.

Results: Twenty-three patients were analyzed with a mean follow-up of 2 years (range 1 – 5 years). Outcomes improved following surgery. There were strong to moderate correlations between percentage of fat in the pre-operative posterior spinal muscles and improvements in leg pain (r = 0.63, p = < 0.001) and improvements in back pain (r = 0.41, p = 0.05). There was a moderate trend towards greater adjacent level degeneration (r = 0.37, p = 0.1) in patients with higher percentage of fat in the pre-operative posterior spinal muscles. There was a strong relationship between greater adjacent level degeneration and pre-operative disability as measured by the Oswestry (r = 0.62, p = 0.03).

Conclusion: The results demonstrate that a potential relationship exists between pre-operative fatty infiltration of posterior perispinal muscles and post-operative outcomes, and adjacent level degeneration following lumbar fusion surgery. This suggests that perispinal muscle atrophy and conditioning may play a role in these outcomes. Results may be used for prognostication, surgical candidate selection, and interventional strategies.


Girish N. Swamy Lynn DeLoughery Rajendranath Bommireddy Zdenek Klezl Denis Calthorpe

Purpose: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial. Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience. To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs.

Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart. All patients reviewed at three months interval in a dedicated epidural follow up clinic and one-year postal and telephonic follow-up. Exhaustive epidural database maintained. VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment, at three months follow-up and one year. Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases.

Results: In the largest single series to date, we report on 928 consecutive patients, with three months follow-up and 354 patients with 12 months follow-up. Fifty-eight percent were females, 24% smoked and 4.1% had ongoing litigation due to their pain. The mean age was 56 years with BMI ranging from 17 to 50 (mean=28). Ten (0.6%) patients required subsequent surgical intervention due to disc herniation. The mean VAS, ODI and HADS improved significantly at three months and one-year results were encouraging.

Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms achieved facilitating onward referral for physical therapy. Subgroups predicting poor outcome are identified. Positive primary care feedback encourages further recruitment.


Michael Katsimihas Christopher Bailey Khalil Issa Stuart I. Bailey Jennifer Fleming Patricia Rosas-Arellano Kevin R. Gurr

Purpose: To report the clinical and radiographic prospective results of a consecutive series of patient with a minimum two year follow-up with the Charite Total Disc Arthroplasty (TDA).

Method: Between 2001 and 2005, sixty patients underwent a Charite TDA (Depuy Spine, Raynham, MA) at either L4-5 or L5-S1. The primary indication for surgery was discogenic low back pain confirmed by provocative discography. Clinical assessment was carried out preoperatively and postoperatively at 3, 6, 12 months, and once a year thereafter using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36. Radiographic analysis included: angle of sagittal rotation, translation of the rostral vertebra onto the caudal vertebra, anterior vertical motion (AVM), middle vertical motion (MVM), posterior vertical motion (PVM), pre- and post-operative lumbar lordosis, disc height and subsidence of the TDA. The radiographic measurements were performed using the GE Medical Systems Centricity PACS Software Version 1.0.

Results: There were 36 female and 24 male patients with a mean age of 39 (range 21–59). The mean duration of low back pain was 70 months. Twenty-five percent claimed work compensation status. The mean postoperative hospital stay was 4.8 days. A statistical significant improvement was demonstrated between the mean pre-operative ODI (50) and all post-operative intervals (p< 0.0001) which had declined to 27.7 by one year. Similarly, pre-operative VAS back pain (8.0), leg pain (6.1), SF-36 physical component summary score (33.5) and mental component summary score (41.8) remained improved (p< 0.0001) by three months (4.1, 3.1, 51.7, 62.0 respectively). One patient with an L5-S1 TDA has since undergone a posterolateral instrumented fusion. The mean pre- and post-operative lumbar lordosis was 34.58 and 53.48 respectively. The mean saggital rotation was 6.5 degrees at 5 year follow-up, while the mean translation was 0.83 mm. The mean AVM, MVM and PVM were 0.59 mm, −3.96 mm and 3.69 mm respectively at 5 year follow-up.

Conclusion: This study demonstrates satisfactory clinical results in carefully selected patients. The radiographic assessment confirmed preservation of movement at the replaced disc during flexion and extension of the lumbar spine.


Bernard E. Rerri Temilolu O. Opadele

Purpose: Lumbar spinal stenosis is the most common indication for spine surgery in the elderly. XStop IPD is an attractive alternative to traditional laminectomy or laminectomy with fusion as it avoids a longer procedure and anaesthesia with significantly less blood loss. The purpose of this study is to prospectively evaluate clinical outcomes, complications and functional evaluation of symptom severity, physical function and patient satisfaction following XStop IPD procedure

Method: Preoperative and postoperative clinical data as well as SF 36, visual analog scale and Roland Morris questionnaire data collected on 16 consecutive patients over 60 years undergoing XStop IPD at L3-4 and L4-5 levels or both levels. All patients had symptomatic lumbar spine stenosis with intermittent neurogenic claudication. Evaluations were made pre-operatively and post-operatively at 3, 6, 12 and 24 months. All patients had clinical radiographic data as well as data on visual analog scale SF 36 and the Roland Morris back questionnaire.

Results: Patients ages ranged from 58 to 86 years with an average age of 74.25 years. In 75 percent of patients there were two or more significant co-morbidities with 18.75 percent requiring 2 level surgery. Four of the 16 patients had lumbar degenerative scoliosis with cobb angle less than 25 degrees. 50.25% the patients had grade I spondylolisthesis. No patient had previous spine surgery. In 31.25 percent of patients there was a history of diabetes. BMI ranged from 20 to 40. Seventy five percent of patients were discharged home within 24 hours. Ninety percent of patients reported relief of their leg pain at their first follow up visit within two weeks of the surgery. There were no significant complications. One-year follow up in six patients demonstrated improvements in VAS, Roland Morris criteria and SF 36 while the remaining patients have up to nine months of follow-up clinical data.

Conclusion: We present our early results of this prospective study. There were significant improvements in functional outcomes. We therefore recommend the use of XStop IPD for elderly patients with multiple co-morbidities suffering from symptomatic lumbar spine stenosis with neurogenic claudication.


S. Samuel Bederman Nizar N. Mahomed Hans J. Kreder Warren J. McIsaac Peter C. Coyte James G. Wright

Purpose: Surgery for degenerative lumbar spinal conditions offers tremendous benefit for patients with moderate/severe symptoms failing non-operative treatment. There is little appreciation among referring family physicians (FPs) on factors that identify the ideal surgical candidate. Differences in preferences between patients and physicians leads to wide variation in referrals and impedes the shared decision-making process. Our purpose was to identify the dominant clinical factors influencing patient, FP, and surgeon preferences for lumbar spinal surgery.

Method: We used conjoint analysis, a rigorous method for eliciting preferences, in a mailed survey to all orthopaedic and neurosurgeons, a random sample of FPs, and patients in Ontario to determine the importance that respondents place on decisions for lumbar spinal surgery. We identified six clinical factors (walking tolerance, duration of pain, pain severity, neurological symptoms, typical onset, and dominant location of pain) and presented 16 hypothetical vignettes to participants who rated, on a six-point-scale, their preference for surgery. Data were analyzed using random-effects ordered probit regression models and relative importance of each clinical factor was reported.

Results: We obtained responses from 131 surgeons, 202 FPs, and 164 patients. We demonstrated that despite wide variations in overall responses, all six clinical factors were highly associated with surgical preference (p< 0.01). Surgeons placed the highest importance on the location of pain (34%), followed by pain severity (19%) and walking tolerance (19%). FPs considered neurological symptoms (23%), walking tolerance (20%), pain severity (20%), and typical onset (16%) to all be of similar importance. Pain severity (29%), walking tolerance (29%), and duration of pain (28%) were the most important factors for patients in deciding for surgery. Orthopaedic (over neurosurgical) specialty was statistically associated with a lower preference for surgery (p< 0.047). Older patient age (p< 0.03) and previous surgical consultation (p< 0.03) were both associated with a greater patient preference for considering surgery.

Conclusion: Different preferences for surgery exist between surgeons, FPs and patients. FPs may reduce over- and under-referrals by appreciating surgeons’ importance on location of pain (leg versus back). Surgeons and FPs may improve the shared decision making process by understanding that patients place high importance on duration, severity, and walking tolerance.


Michael Katsimihas Christopher Bailey Ashley Ignatiuk Patricia Rosas-Arellano Stuart I. Bailey Khalil ssa Kevin R. Gurr

Purpose: To investigate subsidence of the Charite total disc arthroplasty (TDA) and to identify if a discrepancy between vertebral endplate and the Charite footprint predispose to subsidence.

Method: Between July 2001 and May 2008, 69 patients underwent a Charite TDA (DePuy Spine, Raynham, MA). They were prospectively followed at 3, 6, 12 months, and once a year thereafter. The following measurements were performed on the replaced motion segment using a lateral radiograph:

The anterior-posterior (AP) dimension of the end plates.

Amount of subsidence.

The distance between the TDA and the posterior and anterior borders of the vertebra bodies (to represent the extent of uncoverage of the endplate by the TDA).

The AP dimension of the TDA metal end-plate.

The ratio between the actual and radiographic AP length of the metal endplate was calculated and utilized as the correction factor for the error of magnification on all other radiographic measurements.

Results: At L5-S1 the mean subsidence was 1.87 mm and occurred exclusively at the posterior part of the inferior end plate of L5. The mean posterior uncoverage was 3.5 mm (L5) and 0.27mm (S1). At L4-L5 the mean subsidence was 1.48 mm (L4) and 0.56 mm (L5). Posterior uncoverage of L4 and L5 vertebrae were 4.81 and 2.22 mm, respectively. Subsidence of more than 1 mm was present in all cases where the posterior uncoverage of the end plate with the TDA was more than 2 mm (odds ratio: 5.7). Subsidence was non – progressive in all cases. An anatomic mismatch exists between L5 and S1 endplates in the AP dimension; in more than half the patients S1 is shorter than L5.

Conclusion: The radiographic measurements suggest an increased likelihood of subsidence with more than 2 mm of posterior uncoverage of the end plate by the TDA. The endplate AP length of S1 is frequently less than that of L5. Implant selection based on the smaller S1 endplate may produce worrisome uncoverage of the L5 inferior endplate leading to an increased risk of subsidence and possible catastrophic failure. TDA design should afford modularity to compensate.


David I. Alexander William M. Oxner Alex M. Soroceanu Adrienne Kelly Donna Shakespeare

Purpose: The current gold standard for spinal arthrodesis, autologous bone graft harvested from the iliac crest, has several disadvantages including donor site morbidity, blood loss, delayed wound healing, and increased operative time. Our study explores a Demineralized Bone Matrix-Calcium Sulfate(DBM-CaSO4) composite graft with autologous bone marrow aspirate (BMA), and compares it to autologous iliac crest bone graft in lumbar and lumbosacral spinal fusions.

Method: A total of 80 patients were recruited for the study and randomised, via a computer-generated ran-domisation schedule, to autologous iliac crest bone graft (control) or DBM-CaSO4 composite graft with BMA (study) groups. Patients were evaluated at three-months, six-months, 12-months and 24-months post-operatively with questionnaires to evaluate clinical outcome (Oswestry disability questionnaire (ODI), visual analogue pain scales (VAS), and validated SF-36) and with posteroanterior and lateral x-rays of the spine to evaluate radiological outcome.

Results: At 24-months post-operatively, there were no statistical differences seen between the two groups based on the clinical outcomes measured. Average ODI values were 27.19 for the control group versus 22.68 for the study group (p > 0.05). The average back VAS pain for the control group was 3.50 versus 3.51 for the study group (p > 0.05). The SF-36 score was 89.22 for the control group versus 91.56 for the study group (p > 0.05). The average operative time was 115.7 minutes for the control group versus 104.2 minutes for the study group (p: 0.014). Average calculated blood loss was 571.9 cc for the control group versus 438.2 cc for the study group (p: 0.025). The Lenke score was 1.92 for the control group versus 2.66 for the study group (p: 0.004).

Conclusion: At two year follow-up, radiographic fusion was slightly higher in the ICBG. However, clinical outcomes were equivalent in both groups. Moreover, the DBM-CaSO4 and BMA composite graft offered the advantages of decreased blood loss and shorter operative time. Therefore, the DBM-CaSO4 and BMA composite graft represents a viable alternative to autologous iliac crest bone graft in carefully selected patients undergoing spinal arthrodesis.


Davor D. Saravanja Charles G. Fisher Marcel Dvorak Michael Boyd Paul Clarkson

Purpose: Oncologic management of primary bone tumors of the spine is inconsistent, controversial and open to individual interpretation. Tumor margin violation intraoperatively increases local recurrence and mortality. The purpose of this study is to determine whether applying Enneking’s principles to the surgical management of primary bone tumors of the spine significantly decreases local recurrence and/or mortality.

Method: A prospective and retrospective multicenter Cohort Study: Inclusion of patients undergoing en bloc or intralesional resection of primary tumors of the spine at four separate quaternary care centers, between January 1994 and January 2008. Patients were staged, using the Enneking system, prior to surgery and baseline demographic and surgical variables were recorded. Outcomes measured were disease local recurrence, or death. The results were statistically analyzed for significance.

Results: One hundred-fifty patients with primary tumors of the spine were recruited. Average age was 47.0 (range 8 to 83). Sixty-two patients were identified to have local recurrence. A statistically significant decrease in local recurrence (p=0.0001) was observed in favor of en bloc resection. In patients with local recurrence there was a significant increased risk of mortality, (p< 0.0001). There was a trend to decreased mortality in the en bloc resection group, not statistically significant (p=0.64).

Conclusion: Wide resection of primary tumors of spine with reconstruction is the standard of care. Application of Enneking’s principles to the spine when managing primary bone tumors significantly reduces local recurrence of the disease process, without an adverse outcome on mortality, and with acceptable HRQOL. Further cohort studies based on stringent data collection prospectively will provide a basis for more detailed study of individual tumor types.


John Townley Cari Whyne Michael R. Hardisty Liying Zhang Mark Clemons Albert J.M. Yee

Purpose: To identify local and systemic risk factors for the development of pathologic fractures and determine the value of the Tokuhashi Score in patients with known asymptomatic lytic spinal metastases secondary to breast cancer.

Method: A prospective cohort study was carried out on 51 patients with lytic spinal metastases secondary to breast cancer identified as having either purely lytic or mixed disease. The Tokuhashi Score, developed to estimate life expectancy for patients with symptomatic spinal metastases being considered for surgery, was calculated for each of the 51 patients. The score consists of six parameters each of which is rated from 0–2. Initial and follow up CT images and pain and function data were obtained every four months for one year. A final review of patient charts was performed two years later to determine if each patient was still alive.

Results: Tumour burden was predominantly blastic and mixed rather than lytic. There was no progression of lytic tumour burden over the 12-month period, however there was progression of blastic tumour load. Eleven compression fractures occurred in seven patients; no burst fractures occurred during the study. No correlation between tumour burden (lytic, blastic or both) and risk of fracture was found. A weak correlation between bone mineral density and length of time elapsed from diagnosis of metastatic disease and fracture risk was found. Pain and functional data results were not related to tumour load. Tokuhashi score did correlate with survival, however actual survival in our population was far longer than that found in previous studies. Negative progesterone status was found to be negatively associated with life expectancy.

Conclusion: Metastatic vertebral disease in breast cancer patients has a predominantly blastic and mixed appearance with current pharmacologic therapies. Pathologic fracture risk appears to be more related to bone mineral density than tumour burden in this population. Tokuhashi score does correlate with life expectancy in patients with relatively asymptomatic spinal metastases. Having a progesterone receptor negative tumour has a significantly negative impact on life expectancy.


Martin Lavigne Pascal-André Vendittoli

Purpose: The long term exposure to metal ions released from metal-metal articulations is worrying. Studies have shown comparable ion level between metal-metal HR and 28mmTHA. No study has analyzed the amount of ion released from LDH-THA. We compared the amount of ion released from HR and LDH-THA from the same manufacturer.

Method: Whole-blood concentrations of Cobalt was measured prospectively (pre op, 3, 6, 12, 24 months) with HR-ICPMS in 74 HR and 54 LDH-THA with the same metal bearing characteristics and acetabular component (monoblock Cobalt-Chrome with titanium plasma-spray coating). The femoral head of LDH-THA was inserted on a titanium stem with a Cobalt-Chrome adapter sleeve to adjust offset and leg length.

Results: Demographic data was similar. The pre op Cobalt level (ug/L) were 0.10 vs. 0.11, 3 months 0.90 vs. 0.84, 6 months 0.90 vs. 1.28, 12 months 0.68 vs.1.75, and 24 months 0.56 (5.6X preop level) vs. 1.82 (16.5X preop level) in the HR and LDH-THA groups, respectively. The cobalt level decreased after 6 months in HR, whereas it was still increasing at 2y with LDH-THA.

Conclusion: In order to reduce wear and ion release from metal-metal bearing, most manufacturers focus research on improvements at the bearing surfaces. This study has shown that the simple addition of a sleeve with 2 modular junctions can results in a dramatic increase in ion release, diminishing the value of improvements made at the bearing surface. The total amount of ion released from a metal-metal implant should be considered globally and as such, better modular taper designs should be developed.


Steven J.M. MacDonald C. Anderson Engh Abigial E. Thompson Supatra Sritulanondha Douglas Naudie Charles A. Engh

Purpose: Metal-on-metal articulations are an increasingly popular choice as an alternate bearing surface in total hip arthroplasty (THA) and Resurfacing implants. One advantage of a metal-on-metal bearing is the use of larger diameter femoral heads with hip simulator data demonstrating reduced wear. We performed a prospective, multicentre, randomized, blinded clinical trial comparing 28mm to 36mm metal-on-metal bearings assessing multiple validated outcome measures and serum, erythrocyte and urine metal ions.

Method: Ninety-one patients were randomized to receive a metal-on-polyethylene (34), a 28mm metal-on-metal (25) or a 36mm metal-on-metal (32) insert. All patients received the same acetabular and femoral component. Patients were evaluated pre-operatively, at 6, 12 months and annually thereafter, including an evaluation of serum, erythrocyte and urine cobalt, chromium, and titanium, outcome measures (WOMAC, SF-12, Harris Hip Score) and radiographs.

Results: At a minimum two years follow-up there were no differences in WOMAC, SF-12, Harris Hip scores or radiographs. Patients receiving metal liners had significantly (p< 0.001) elevated metal ion measurements compared with the polyethylene control group, however there were no differences between the 28mm and 36mm metal-on-metal bearings (Median serum Co (mg/L): 0.14(poly), 0.77(28mm), 0.73(36mm). Median erythrocyte Co (mg/L): 0.11(poly), 0.42(28mm), 0.42(36mm). Median urine Co(mg/day): 0.44(poly), 4.55(28mm), 5.42(36mm)). (Median serum Cr(mg/L): 0.17(poly), 1.29(28mm), 0.91(36mm). Median erythrocyte Cr(mg/ L): 1.10(poly), 1.10(28mm), 1.20(36mm). Median urine Cr(mg/day): 0.27(poly), 1.92(28mm), 2.02(36mm)).

Conclusion: Both cobalt and chromium ion measurements were significantly elevated in the blood and urine of the patients randomized to receive the metal-on-metal bearings at all time intervals. There were no differences seen between the 28mm and 36mm metal-on-metal bearings, keeping all other variables identical. The larger diameter bearing therefore provides the potential clinical advantages of improved range of motion and stability, while providing a similar metal ion profile. While reduced wear is seen with larger diameter metal-on-metal bearings in-vitro, we could not demonstrate a reduction in blood or urine metal ion levels in-vivo.


Kristoff Corten Ward Bartels Guy Molenaers Jos Vander Sloten Paul Broos Johan Bellemans Jean-Pierre Simon

Purpose: Precise biomechanical reconstruction of the hip joint by a hip arthroplasty is essential for the success of this procedure. With the increasing use of surface replacement arthroplasty (SRA), there is a need for better understanding of the key factors that influence the anatomical and the biomechanical parameters of the resurfaced hip joint. The goal of this study was to examine the influence of SRA on the vertical and horizontal offset of the hip.

Method: Twenty-one hips from 12 embalmed cadavers were resurfaced with a Birmingham Hip resurfacing. The thickness of the acetabular bone was measured pre- and post-reaming in 6 acetabular zones. Radiographs were taken before and after the procedure with a scaling marker. For statistical analysis, the paired Student’s T-test with a confidence interval of 95% and a significant p-value of p< 0.05 was used.

Results: The mean acetabular bone loss was 3.8 mm, 5.9 mm, 9.3 mm, 10.6 mm, 8.5 mm and 3.6 mm in zones 1 to 6. The “polar length loss” is the cumulative displacement of the femoral and the acetabular articulating surface in zones 2 to 5. This displacement indicates a shortening of the neck plus a medio-cranial displacement of the acetabular articulating surface and was 4.3 mm, 7.5 mm, 9.4 mm and 7.7 mm (zone 2–5). The radiographic center of rotation (COR) was significantly medialised (mean 6.2 mm) and displaced in the cranial direction (mean 6.9 mm) (p< 0.00001). The mean total (femoral plus acetabular) horizontal and vertical offset change was 6.4 mm and 9.5 mm respectively (p< 0.00001). There was a significantly higher vertical offset change in the acetabulum than in the femur (p=0.0006). This resulted in a significantly larger change in vertical than in horizontal offset (p=0,04).

Conclusion: The displacement of the acetabular COR was responsible for 60% of the total vertical and 99% of the total horizontal offset change. The femoral side did not compensate for this displacement. SRA did not restore the biomechanics of the native hip.


Rajeshkumar Kakwani Chris Wainwright Gautam Tawari Shankar Kashyap A. Roysam A. Nanu

Purpose: A single blind prospective randomised controlled trial comparing the Metal-on-polyethylene articulation with the metal-on-metal articulation in THA.

Method: The clinical and radiological findings of the consecutive patients who were enrolled in the RCT at the participating centres were recorded prospectively. The clinical evaluation was performed with the Harris scoring system as well as the Oxford Hip Scoring Sheet. The computer randomised option was revealed to the operative surgeon only after the patient was anaesthetised, during the recruitment period (June 1998 to July 2004). Of the total of 378 patients, 2 died prior to the final review and 63 were lost to follow-up. The final study group contained 315 patients, with 159 patients in the metal-on-polyethylene group and 156 patients in the metal-on-metal group.

Results: The indication for the hip arthroplasty for majority (309 patients) was primary osteoarthritis. The average age at the time of the surgery was 68.2 years and the average duration of follow-up was 85 months (42–115). There was an improvement of the Oxford hip scores from an average of 37 per-operatively to 16 postoperatively. The Harris hip scores also improved from an average of 47.0 pre-operatively to 87.3 post-operatively. The patient groups were statistically similar with respect to age, sex and duration of follow-up, and the final outcome scores revealed no statistical difference between the two groups.

Conclusion: The clinical results obtained with the use of the articulation are comparable to those obtained by the metal-on-polyethylene articulation encouraging the use of this alternative bearing surface.


Kristoff Corten Filip Van Rykel An Sermon Paul Vanderschot Stefaan Nijs Johan Bellemans Peter Reynders Jean-Pierre Simon Paul Broos

Purpose: Plate and cable alone constructs to treat periprosthetic fractures around a well-fixed femoral stem in total hip replacements, have been reported with high failure rates. The aim of this study was to evaluate the results of our surgical treatment algorithm to reliably use lateral plate and cable constructs in these fractures.

Method: One hundred and six periprosthetic fractures in 102 patients were treated between 1996 and 2006. Forty-five fractures were pre-operatively assessed as Vancouver type B1 fractures. The joint was always dislocated and stability of the implant was meticulously evaluated. This led to the identification of nine (20%) unstable stems leaving 36 fractures to be real B1-type fractures. The fracture was considered to be suitable for lateral plate and cable alone fixation if the medial cortex was not comminuted and an anatomical reduction of the medial cortex could be achieved. Twenty-nine B1- and 5 C-type fractures had been treated with a single lateral plate and cable construct. The mean length of follow-up was 43.2 months. The paired Student’s T-test with a confidence interval of 95% and a significant p-value of p< 0.05 was used to compare the pre- and postoperative UCLA hip scores.

Results: Four (12%) patients died within one month from surgery leaving 30 patients for follow-up. Twenty-nine fractures united at a mean of 6.4 months. One B1-type construct failed due to inappropriate proximal fixation. Two fractures united uneventfully with a mean of 8° of varus alignment of the proximal fragment. One patient with a C-type fracture sustained a fracture distal to the tip of the plate. There were three plate infections (8.8%). There was no significant difference between the pre- and post-operative UCLA hip scores (25 versus 23 resp.).

Conclusion: These fractures represent a difficult problem with a high complication rate of 30%. The presented treatment algorithm contributed significantly to the 97% union rate with plate and cable alone constructs that was comparable to the union rates achieved with combined plate and strut graft fixation.


Mohammad T. Ghazavi Zahra Farahani Mansour Abolghasemian

Purpose: Total hip arthroplasty in high riding congenital dislocation of the hip is a challenging procedure. In order to position the cup in the true acetabulum, femoral shortening osteotomy is often needed. The purpose of our study was to evaluate the results of two different methods of femoral shortening osteotomy.

Method: Thirty-one total hip arthroplasties were performed in 29 cases with high congenital hip dislocation. The acetabular cups were placed at true acetabulum and femoral shortening osteotomies of the femur were performed at proximal (14 hips, group 1) or distal femur (17 hips, group 2). After a mean follow up of 4.2 years, all 31 hips were evaluated with Harris Hip Scores and X-rays. Technical difficulties and complications were also reported.

Results: The mean increase in Harris Hip Score was 51 in group one and 52 in group two. There was one peroneal nerve palsy and one early dislocation in group 1, while there was no such perioperative complications in group 2. One acetabular cup and femoral stem were revised in group 1. Non-union happened in two cases of group 2. Special shape (cylindrical, non-tapered and longer than standard) femoral stems were needed for most proximal osteotomy patients.

Conclusion: Hip arthroplasty, with insertion of cup at true acetabulum and femoral shortening osteotomy in patients with high congenital dislocation, can produce good results. Either proximal or distal femoral shortening osteotomy could have advantages and disadvantages. Proximal shortening osteotomy is a more challenging procedure, may need special stem design, and could compromise stem fixation.


Stephen M. Blake Graham A. Gie Dan Williams Matthew Hubble Andrew J. Timperley

Purpose: Removal of all foreign material is the normal practice at the time of revision arthroplasty for sepsis. However, removal of well-fixed bone cement is time consuming, can result in significant bone stock loss and increases the risk of femoral shaft perforation or fracture. We have performed two-stage revision for infection in a series of cases in which we have left oseeointegrated femoral cement at the first stage and we present the results of this technique.

Method: All patients underwent two-stage revision for infection. At the first stage the prostheses and acetabu-lar cement were removed but when the femoral cement mantle demonstrated good osseo-integration it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local antibiotics delivered by cement spacers, as well as systemic antibiotics. At the second stage the existing cement mantle was reamed, washed and dried and then a femoral component was cemented into the old mantle.

Results: Sixteen patients (M:F 5:11) had at least three years follow up (mean 80 months, range 43 to 91). One patient died of an unrelated cause at 53 months. Recurrence of infection was not suspected in this case. The mean time to first stage revision was 57 months (3 to 155). The mean time between first and second stages was 9 months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureas, 4 Group B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage, five (31.2%) acetabuli were uncemented and 11 (68.8%) were cemented. There were two complications; one patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for sudden loss of fixation. No evidence of infection was found at re-revision. One patient has been revised for recurrent infection. Currently no patients are suspected of having a recurrence of infection.

Conclusion: Retention of a well-fixed femoral cement mantle during two-stage revision for infection and subsequent in-cement reconstruction is safe with a cure rate of 93%. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.


Rajiv Gandhi Fahad Razak J Roderick Davey Khalid Syed Rubini Pathy Nizar N. Mahomed

Purpose: Prophylactic use of antibiotic-laden bone cement (ALBC) has been proposed to decrease the incidence of deep infections. We asked if the use of antibiotic laden bone cement decreased the deep infection rate following primary total knee replacement (TKA) as compared to plain bone cement (PBC).

Method: We surveyed 1,625 consecutive patients undergoing cemented, primary knee replacement with either ALBC or PBC. Relevant covariates including age, body mass index (BMI), gender, education, and medical comorbidity were collected. Joint pain and functional status were assessed at baseline and at 1 year follow up with the respective Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores. The incidence of deep infection at 1 year follow up was recorded.

Results: There were 811 (49.9%) patients in the ALBC group and 814(50.1%) in the PBC group. There were no differences in age, gender, BMI, education or comorbidity between groups at baseline (p> 0.05). We found a deep infection rate of 3.1% in the ALBC group and 2.2% in the PBC group (p=0.27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (p=0.84).

Conclusion: ALBC did not reduce the incidence of deep infection following primary TKA at 1 year follow up. Further studies are needed to define any high risk groups for which ALBC might be beneficial.


Rajiv Gandhi Fahad Razak Peggy Tso J Roderick Davey Nizar N. Mahomed

Purpose: Metabolic syndrome (MS) is defined as central adiposity, elevated fasting glucose, hypertension, and dyslipidemia defined as high triglyceride and low high-density lipoprotein (HDL) cholesterol. MS is associated with a systemic proinflammatory and prothrombotic state. We asked if patients with MS undergoing total knee arthroplasty (TKA) have an increased risk for symptomatic deep vein thrombosis at 3 months follow-up (DVT).

Method: 1,460 consecutive patients were reviewed from our joint registry undergoing primary, unilateral TKA between the years of 1998–2006. Demographic variables of age, gender, comorbidity, and education were retrieved. Metabolic syndrome (MS) was defined as body mass index above 30 kg/m2, diabetes, hypertension, and hypercholesterolemia. Logistic regression was used to examine the relationship of MS on the incidence of DVT.

Results: The overall incidence of symptomatic DVT was 4.4% (65/1460). Patients with MS had an increased incidence of DVT as compared to those without MS(15.5% vs 3.4%). Adjusted analysis showed that MS increased the risk of symptomatic DVT by 3.2(95% CI [1.0,15.4], p=0.04) times compared to those without MS.

Conclusion: Hospital protocols developed for prophylactic anti-coagulation following TKR should give special consideration to patients with MS.


Elie Ghanem Ian Pawasarat Camil Restrepo Khalid Azzam Lauren May Matthew S. Austin Javad Parvizi

Purpose: The purpose of our study is to compare hips to knees in regards to the cost per increase in function, to determine the relationship of economic investment to improved quality of life.

Method: During the year 2005, a total of 23 TKA and 41 THA revisions were performed for aseptic mechanical failure. Patients were enrolled prospectively and quality of life questionnaires including the SF-36, WOMAC, Harris Hip Score (HHS), and Knee Society Score (KSS) were collected prior to and following their procedure at two year follow-up. The total cost of the procedure including the hospital, implant, and surgeon fee were implemented in a cost effectiveness model to calculate the mean cost per SF-36, WOMAC, and HHS or KSS point gained. Demographical variables and co-morbidities were collected to determine risk factors for low cost-effectiveness.

Results: The majority of patients had significant improvement in SF-36, WOMAC, HHS and KSS scales. Patients with THA revisions experience a cost per point increase for HHS of $3,000, and $500 per point SF-36 compared to knee patients who experienced a cost per point increase for KSS of $2,000, and $2,800 per point SF-36. The WOMAC exhibited similar cost effectiveness in the subscales of pain, stiffness and functioning.

Conclusion: There are few studies that have compared the cost effectiveness of total joint arthroplasty revision procedures. Given the increasing cost of health care expenditures, prioritization of funding for the different health practices will become necessary. This study demonstrates that revision THA and TKA are relatively cost effective procedures compared to other non-orthopaedic interventions.


David Backstein Dror Lakstein Oleg Safir Yona Kosashvili Allan E. Gross

Purpose: Acetabular component revision in the context of large, contained bone defects with less than 50% host-bone-contact traditionally required roof reinforcement or antiprotrusio cages. Trabecular Metal (TM) cups (Zimmer, Warsaw, Indiana) may offer a viable treatment alternative. The objective of this study was to evaluate the clinical and radiological outcome of this mode of treatment.

Method: Fifty-four hip revision acetabular arthroplasty procedures performed with TM cups for contained defects offering ≤50% contact with native bone were prospectively followed. Average follow-up was 45 months (range 24–71). All patients were clinically and radiographically evaluated for evidence of loosening or failure.

Results: Contact with bleeding host bone ranged from 0 to 50% (average 23%). At latest follow up 43 (79.6%) arthroplasties had excellent or good results, 8 (14.8%) cases had medium or fair results and 3 cases (5.6%) had poor results. Two cups failed and had to be revised. Two additional cups had radiological evidence of probable loosening. Overall preliminary survivorship of the revision acetabulae was 96%. Complications included 4 dislocations and 1 sciatic nerve palsy.

Conclusion: Treatment of cavitary defects with less than 50% host-bone contact with using TM cups, without structural support by augments or structural bone grafts, is a viable option.


David Backstein Yona Kosashvili Oleg Safir Dror Lakstein Matthew MacDonald Allan E. Gross

Purpose: Pelvic discontinuity associated with bone loss is a complex challenge in acetabular revision surgery. Reconstruction with anti protrusion cages, Trabecular Metal (Zimmer, Warsaw, Indiana) cups and morselized bone (Cup-Cage) constructs is a relatively new technique used by the authors for the past 6 years. The purpose of the study was to examine the clinical outcome of these patients.

Method: Thirty-two consecutive acetabular revision reconstructions in 30 patients with pelvic discontinuity and bone loss treated by cup cage technique between January 2003 and September 2007 were reviewed. Average clinical and radiological follow up was 38.5 ± 19 months (range 12 – 68, median 34.5). Failure was defined as component migration > 5mm.

Results: In 29 (90.6%) patients there was no clinical or radiographic evidence indicative of loosening at latest follow up. Harris Hip Scores improved significantly (p< 0.001) from 46.6 ± 10.4 to 78.7 ± 10.4 at 2 year follow up. In 3 patients the construct migrated at 1 year post surgery. One construct was revised to anti protrusion cage with a structural graft while the other was revised to a large Trabecular Metal cup. The third patient is scheduled for revision. Complications included 2 dislocations, 1 infection and 1 partial peroneal nerve palsy. Two patients died due to unrelated reasons at 1 and 3 years post surgery, respectively.

Conclusion: Treatment of pelvic discontinuity by Cup-Cage construct is a reliable option based on preliminary results which suggest restoration of the pelvic mechanical stability. However, patients should be followed closely in order to detect cup migration until satisfactory bony ingrowth into the cup takes place.


R. Stephen J. Burnett Ajay Aggarwal Stephanie A. Givens J. Thomas McClure Robert L. Barrack

Purpose: Prophylactic antibiotics are frequently withheld until cultures are obtained in revision TKA. A prospective study was undertaken to determine whether prophylactic pre-operative IV antibiotics would affect the results of cultures obtained intra-operatively.

Method: A consecutive series of 25 TKA’s with a known infecting organism were enrolled over 36 months. Inclusion criteria: clinically infected TKA, a known preoperative infecting organism, and no recent antibiotic therapy. Re-aspiration of the infected TKA was performed following anesthesia and sterile prep. IV antibiotic prophylaxis was then administered and the tourniquet was then inflated. Intra-operative culture swabs and tissue were obtained at arthrotomy. The timing of events was recorded. Pre/post antibiotic culture data were analyzed to determine the effect of IV preoperative prophylactic antibiotics on cultures obtained intra-operatively.

Results: Mean time from end of antibiotic infusion to tourniquet inflation was 15 minutes; to arthrotomy culture was 25 minutes. In all 25 knees the organism(s) cultured at arthrotomy were the same as obtained at pre-operative aspiration. In 24 knees the organism cultured was sensitive to the preoperative prophylactic antibiotics given (Ancef and Vancomycin); one patient grew Candida albicans.

Conclusion: Pre-operative prophylactic antibiotics did not affect the results of intra-operative cultures, and should not be withheld prior to infected TKA surgery when an organism has been identified on aspiration. Based on these results, holding pre-operative antibiotics prior to revision TKA is rarely justified.


William D. Fisher Michael Gent Bruce L. Davidson Michael R. Lassen Louis M. Kwong Fred D. Cushner Paul A. Lotke Frank Misselwitz Tiemo J. Bandel Alexander G.G. Turpie

Purpose: Venous thromboembolism (VTE) after major orthopaedic surgery remains an important clinical problem. Convenient, oral antithrombotic agents that are both effective and safe could improve adherence to guidelines for VTE prophylaxis. Recently, the focus has been on the development of oral agents that target a single step in the coagulation cascade and Factor Xa is a pivotal step. Rivaroxaban is an oral, direct Factor Xa inhibitor. Four international phase III trials (the RECORD programme) were undertaken to investigate the safety and efficacy of once-daily rivaroxaban for thromboprophylaxis after major orthopaedic surgery. The results of RECORD3 showed that rivaroxaban was more effective than enoxaparin 40 mg once daily after total knee replacement (TKR), with a 48% risk reduction in VTE and all cause mortality. RECORD4 was designed to determine the efficacy and safety of 10 mg rivaroxaban od compared to 30 mg bid enoxaparin after total knee replacement (TKR).

Method: This study randomized 3148 patients to either rivaroxaban (10 mg od started 6–8 hours after surgery) or enoxaparin (30 mg bid s.c. started 12–24 hours after surgery) for 10–14 days. The primary efficacy outcome was the composite of asymptomatic deep vein thrombosis (DVT) detected by mandatory, bilateral venography and symptomatic DVT, non-fatal pulmonary embolism (PE), and all-cause mortality up to day 13±4. Secondary outcomes included major VTE (composite of proximal DVT, non-fatal PE, and VTE-related death) and symptomatic VTE. Safety outcomes included on-treatment major and non-major bleeding.

Results: Rivaroxaban provided a 31% relative risk reduction in the incidence of the primary efficacy outcome when compared to enoxaparin (6.9% vs 10.1%, respectively; p=0.012). The corresponding rates for major VTE were 1.2% and 2.0%, respectively (p=0.124) and for symptomatic VTE were 0.7% and 1.2%, respectively (p=0.187). There were no significant differences in bleeding incidence observed between rivaroxaban and enoxaparin (major bleeding: 0.7% vs 0.3%, respectively, p=0.110; clinically relevant non-major bleeding: 2.6% vs 2.0%, respectively, p=0.279).

Conclusion: Rivaroxaban 10 mg od is the first oral thromboprophylactic agent to significantly reduce the incidence of VTE after TKR compared to enoxaparin 30 mg bid, with a similar, low rate of bleeding.


Rita Selby Bijan Borah Heather McDonald Joe Henk Mark Crowther Phil Wells

Purpose: A retrospective database analysis was conducted to

determine the extent to which the American College of Chest Physicians (ACCP) guidelines for VTE prophylaxis are followed after total hip replacement (THR) and total knee replacement (TKR) and

evaluate the incidence of VTE for patients receiving and not receiving prophylaxis according to ACCP guidelines (‘ACCP’ and ‘non-ACCP’, respectively).

Method: A claims database associated with a large US health plan was linked to the Premier database, which provides details of in-patient medication use. Patients ≥18 years undergoing TKR/THR and enrolled in the health plan 90 days before and 90 days following discharge from hospitalization (or until death) were included. Patients were considered to have received ACCP-guideline prophylaxis if they:

received LMWH, fondaparinux, or VKA following surgery

initiated prophylaxis within one day of surgery (for THR patients) and

were prescribed prophylaxis for a minimum of ten days, or until the occurrence of major bleeding, VTE, or death. In addition, the number of DVTs and PEs occurring in ACCP and non-ACCP patients was recorded.

Results: Of the 30,644 eligible patients from the health plan, 3,497 patients were linked to the in-patient database. Except for geographic indicators, there were no significant differences in demographics or baseline co-morbidities between those included and excluded from the final study sample. Of the 3,497 linked patients, 1,395 (40%) received ACCP prophylaxis. The number of DVTs occurring in the ACCP and non-ACCP groups were 28 (2.01%) and 79 (3.76%), suggesting that non-ACCP patients were almost twice as likely as ACCP patients to have a DVT (p=0.0521). The number of PEs occurring in the ACCP and non-ACCP groups were 2 (0.14%) and 25 (1.19%), respectively, suggesting that non-ACCP patients were 8.5 times more likely than ACCP patients to experience a PE (p< 0.0001).

Conclusion: This study offers a unique perspective on ‘real-world’ prophylaxis patterns and clinical outcomes in THR/TKR patients. It suggests that 40% of patients received ACCP prophylaxis and that patients not receiving ACCP prophylaxis were almost twice as likely to have a DVT and more than eight times as likely to experience a PE.


Martin Bedard Kelly G. Vince John Redfern

Purpose: Stiffness following TKA is devastating and poorly understood. This study was conducted to determine if rotational positioning of tibial and/or femoral components was related to the development of stiffness following TKA. In addition, post-revision rotational alignment was studied to determine if it contributed to improvement.

Method: Patients who presented with stiffness and either a fixed flexion contracture > 15 and/or flexion < 105 degrees were included in the study. 34 revisions were investigated preoperatively by computerized tomography (CT) for rotational evaluation of the components. Clinical and radiographic data were also recorded.

Results: All 34 revisions had some degree of combined internal rotation on the preoperative CT-scan. The net combined angle averaged fourteen point eight degrees of pathologic internal rotation (in excess of the normal eighteen degrees)[1]. The most significant source of internal rotation was the tibial component, with 33 of the 34 patients having internal rotation with a mean pathological (in excess of the normal eighteen degrees) angle of 13.3 degrees (one to 35 degrees). Postoperatively, the combined rotation angle was restored to an average of five point one degrees of external rotation for the eighteen patients with available CT-scans (p < 0.0001). The 34 revised knees were clinically followed for an average of 22 months. The mean preoperative Knee Society knee and function scores were respectively 41.6 and 47.9. The mean preoperative range of motion was 61.4 degrees. Postoperatively, the knee and function scores increased respectively to 77.3 and to 65.7 (p < 0.0045). The mean postoperative range of motion averaged 98.1 degrees (p < 0.0001).

Conclusion: Rotational positioning of the components should be investigated with CT-scan in stiff knees following TKA. Revision surgery of all the components with restoration of an adequate rotational alignment has been shown to improve range of motion, function and pain.


Fiona Ralley James J. Howard Donna Berta Valerie Binns Douglas Naudie

Purpose: Multiple studies have demonstrated the efficacy of Tranexamic Acid (TA) in reducing blood loss and red blood cell transfusion in patients undergoing primary total hip (THA) or knee (TKA) arthroplasty. However, the dosing schedules of either an initial bolus followed by a 6–12 hour infusion or multiple intravenous bolus doses are not ‘user-friendly’ for regular application. The purpose of this study was to assess the efficacy and acceptance of a single dose protocol for the use of TA in primary THA or TKA.

Method: We selected a single dosing schedule of 20mg/kg TA given either prior to skin incision for THA or approximately ten minutes prior to tourniquet release for TKA. The hospital pharmacy supplied the TA rounded off to the nearest 5kg/100mg in a 100ml mini-bag. In March 2008, we introduced the routine use of TA to all patients undergoing primary THA or TKA at our institution. Mini-bags were pre-ordered at the time of the preoperative clinic visit and delivered to the pre-surgical preparation area on day of surgery. One month after implementation of this protocol we compared blood loss, transfusion rates, and hemoglobin at discharge between the patients operated on from April 1 to June 30, 2007 (when this protocol was not in place) to those from April 1 to June 30, 2008. No other routine patient care practices were altered during this time period.

Results: We found a significant reduction in the decrease in hemoglobin from 2007 compared to 2008 for both THA and TKA (46g/L to 39g/L, and 45g/L to 36g/L, respectively), which led to both a reduction in transfusion rates (13.5% to 3.6%, and 13.1% to 2.0%, respectively) and higher hemoglobin levels at discharge. All patients received the TA as ordered.

Conclusion: Dosing and timing of TA is critical to maximize its antifibrinolytic effect. Our weight increment dose protocol led to minimal dose variability, facilitated pharmacy drug preparation, and minimized wastage. This simple ‘user-friendly’ protocol was found to reduce the decrease in hemoglobin and transfusion rates, demonstrating similar efficacy to other more complex dosing schedules. This protocol was well received and accepted by surgeons, anesthesiologists, pharmacy, and nursing staff.


Aaron Bigham James J. Howard Sugantha Ganapathy

Purpose: Spinal epimorph is commonly used as part of multimodal analgesia for patients undergoing total joint arthroplasty. Patients who receive spinal epimorph are at risk for certain post- operative complications. The purpose of this study was to determine the incidence of complications in patients undergoing total joint arthroplasty with administration of spinal epimorph compared to patients undergoing the same procedure who did not receive spinal epimorph as part of their analgesia.

Method: A retrospective chart review of 72 patients in which two age, sex and procedure matched groups were compared for differences in known spinal epimorph complications. One group received spinal epimorph as part of their analgesia while the comparative group did not receive spinal epimorph but rather continuous infusion of local analgesia. Data extraction involved foley and oxygen usage, documented nausea/vomiting and puritis, associated risk factors and complications such as prostate disease and urinary tract infections, and secondary outcome measures such as Gravol and Benadryl usage.

Results: Comparison of the two well-matched groups demonstrated that patients who received spinal epimorph had increased rates of foley insertion (p=0.0026), foley duration (p=0.015), oxygen usage (p=0.0053), documented puritis (p=0.0006) and Benadryl usage (p=0.0053). Trends towards increased nausea/vomiting (p=0.17), antiemetic use (p=0.16) and urinary tract infections (p=0.15) were seen in the spinal epimorph group, although these differences did not reach statistical significance.

Conclusion: The use of spinal epimorph as part of an analgesia protocol surrounding total joint arthroplasty is associated with increased complications and patient discomfort when compared to patients who received continuous local infiltrative analgesia. Further research is needed to determine if alternate modes of analgesia provide adequate pain relief when compared with spinal epimorph and thus provide suitable alternatives with less complications.


Martyn Snow Jay B. Adlington William D. Stanish

Purpose: To report the 2–5 year results of ACL reconstruction with doubled Tibialis anterior allograft.

Method: Seventy-three patients who underwent primary ACL reconstruction with doubled tibialis anterior allografts with minimum 2 year follow-up were included in the study. Patients were assessed via telephone interview using the Lysholm knee score, Tegner activity score, and the subjective International Knee Documentation Committee rating. In addition, they were asked if they had failure of the ACL requiring revision or any other procedures such as repeat arthroscopy for meniscal surgery/articular cartilage. Statistical analysis using levene’s test and the T-test was used to assess outcomes of patients according to age and sex.

Results: Sixty-four (88%) patients were available for follow-up. The mean age was 28.94 years (16–55). There were 33 males (51.6%) and 31 females (48.4%). The mean follow-up was 41.6 months (range 24–55 months). There were 2 (3%) complications, 1 patient suffered a DVT with subsequent PE, and 1 patient suffered a hardware problem. Four patients (6.3%) had failure of their graft and 6 patients (9%) required repeat arthroscopy. The mean Lysholm score was 91.75 (SD+/− 8.2), and the mean Tegner activity score was 5.4 (range 1–10). The mean IDKC was 88.94 (SD+/− 8.33). According to the IDKC score 58% of patients were rated as excellent, 27% as good, and 13% as fair and 2% as poor. There was no difference in outcome in patients under 30 compared to over 30 years. Males performed statistically better on the Lysholm and the IKDC scores (p 0.005 and 0.038 respectively) when compared to women.

Conclusion: ACL reconstruction with Allograft Tibialis anterior tendon provided good functional results with a low failure rate at 2–5 years. There was no statistical difference in outcome between Patients under 30 years and those above 30 years. Males performed better on the Lysholm and the IDKC questionnaires.


Randy Mascarenhas Michael Tranovich John Karpie James Irrgang Freddie H. Fu Christopher D. Harner

Purpose: This study sought to compare clinical outcomes and return to activity in high-demand patients following ACL reconstruction with either autograft or allograft patellar tendon using a matched-pairs case-control experimental design.

Method: Nineteen matched pairs were obtained based on gender (36.8 % female), age (27.9±8.1yrs autograft versus 28.1±9.1 allograft), and length of follow-up (9.1±2.7yrs autograft versus 10.3±2.6 allograft). All patients reported participating in very strenuous (soccer, basketball etc.) or strenuous (skiing, tennis etc.) sporting activity 4–7 times/ week prior to their knee injury. Patient-reported outcomes included the IKDC Subjective Knee Form, Activities of Daily Living (ADLS) and Sports Activity Scales (SAS) of the Knee Outcome Survey and SF-36. Range of motion, laxity, and functional strength were also assessed.

Results: There were no significant differences in patient-reported or clinical outcome measures. Sixteen (84.2%) subjects undergoing autograft reconstruction and 12 (63.2%) subjects reconstructed with allograft were able to participate in strenuous or very strenuous sporting activity at follow-up (p=.34). Similar percentages of subjects were able to return to their pre-injury level of sports activity [12 (63.2%) autograft vs. 11 (57.9%) allograft; p=1.0]. Fewer subjects undergoing reconstruction with autograft reported instability with very strenuous activity [5 (26.3%) autograft vs. 12 (63.2%) allograft], but this difference was not significant (p=.07).

Conclusion: While autograft and allograft patellar tendon ACL reconstruction exhibit similar clinical outcomes in high-demand individuals, autogenous patellar tendon grafts may be indicated to allow patients to return to very strenuous levels of activity.


Michael G. Zywiel Peter M. Bonutti Slif D. Ulrich Mike S. McGrath Michael A. Mont

Purpose: Minimally-invasive total knee arthroplasty has generated tremendous recent interest, but there have been reports of complications resulting from these new techniques. However, most studies have less than one year follow-up and are anecdotal in their results. The purpose of this study was to retrospectively evaluate a series of 1,000 consecutive minimally invasive total knee arthroplasties, to describe the clinical and radiographic complications of this technique, to determine whether complication rates changed with experience, and finally to compare complication rates to a match group operated by the same surgeon.

Method: Clinical and radiographic data were reviewed for the first 1,000 consecutive minimally-invasive knees (820 patients) performed by a single surgeon with a minimum 2 year post-operative period. All patients were operated using the mid-vastus approach, with a mean incision length of 10 cm (range, 8 to 13 cm). Nine patients were lost prior to 2 year follow-up, leaving 990 knees (811 patients) in this report with annual follow-up. After determining overall results, data was stratified into 100-knee groups to determine whether complication rates changed over time. Finally, complication rates were compared to a matched group of 50 knees operated by the same surgeon.

Results: There were a total of 45 clinical complications (4.5%), including 20 (2.0%) manipulations under anesthesia, 12 (1.2%) arthroscopies for painful crepitus, 4 (0.4%) component changes, and 3 (0.3%) spacer changes. There were 3 (0.3%) impending radiographic failures. Stratification of results showed a complication rate of 6% over the first 200 knees, and 1% over the subsequent 800 knees. In comparison, the matched group had a complication rate of 4% over mean follow-up of 3 years (range, 2 to 4).

Conclusion: This large series with minimum two year follow-up describes many of the long-term complications of this technique. Additionally, this large series suggests that high volume knee surgeons may require as many as 200 minimally invasive arthroplasties before achieving optimum proficiency with this technique. Nonetheless, comparison to a matched group suggests that even with this learning curve, complication rates need not increase markedly during this period if surgeons remain attentive to the potential complications associated with minimally invasive techniques.


Randy Mascarenhas Michael Tranovich Eric J. Kropf James Irrgang Freddie H. Fu Christopher D. Harner

Purpose: This study sought to examine return to sports in athletes younger than 25 following ACL reconstruction with either patellar tendon (PT) or hamstring (HS) autografts using a matched-pairs case-control experimental design.

Method: Twenty-three matched pairs were obtained based on gender (56.5% Female), age (18.3±2.5yrs PT vs.17.6±2.6 HS), and length of follow-up (4.7±2.1yrs PT vs. 4.2±1.6 HS). All patients reported participating in very strenuous (soccer, basketball etc.) or strenuous (skiing, tennis etc.) sporting activity 4–7 times/ week prior to their knee injury. Outcomes other than return to play included the IKDC, SAS, ADLS, SF-36, knee range of motion, laxity, and hop/jump testing.

Results: Most patients in both groups were able to participate in very strenuous or strenuous sporting activity at follow-up [18 (78.3%) PT vs. 19 (82.6%) HS]. However, only 13 (56.5%) of the patellar tendon subjects and 10 (43.5%) of the hamstrings patients were able to return to pre-injury activity levels in terms of frequency and type of sport (p=.63). Hamstrings patients showed higher ADLS (p< .01) and SAS (p< .01) scores and better restoration of extension (p< 0.05).

Conclusion: While autograft and allograft patellar tendon ACL reconstruction exhibit similar clinical outcomes in high-demand individuals, autogenous hamstring grafts may lead to better subjective outcomes in young patients who participate in very strenuous levels of activity. Both graft options only allowed approximately half of the injured athletes to return to their previous level of sporting activity.


Emilio Lopez-Vidriero Olufemi R. Ayeni Tracy Rupke Ahmad Bin Nasser Donnald Johnson

Purpose: To present our clinical and quality of life outcomes after one year treatment with our protocol including graft retention.

Method: Seventeen of 1, 847 patients who underwent ACL reconstruction surgery were identified as infected following retrospective chart review in our institution (University of Ottawa) from 1995 to 2005. Mean age was 37 years old (range 18–56). Gender ratio was 14 male/ three female. Laterality 13 left/ four right knees. The diagnosis was achieved by clinical suspicion and serum markers (ESR, CPR, WBC) followed with aspiration and culture of intraarticular liquid. After that, our treatment protocol included IV antibiotics (empiric and culture guided) and knee arthroscopy performing debridement and lavage with 12L of saline irrigation as well as graft retention when possible. Clinical and Radiographic data were collected at a minimum of one year follow-up (IKDC, KT-1000, Lysholm, SF-12, Tegner, Cybex Strength testing).

Results: The Incidence of septic arthritis following ACL reconstruction was 0, 92%. Bacteriology results were as follows: seven staphylococcus aureus, four Propionibac-terium acnes, one Klebsiella oxytoca, five no growth. The time from ACL reconstruction to first symptoms of infection was 37 days (range 4–63). The time from symptoms to arthroscopic debridement was 5, 5 days (range 0–33). Serology markers were as follows: ESR mean 69 (range 23–128), CPR 136 (50–387), WBC 10.3 (6–15). The average follow up was 41 months (range 12–85). Sixteen of 17 grafts were retained after 1.53 procedures per patient. Antibiotic treatment lasted 5.2 weeks on average. The average clinical outcomes were: Lysholm 77 (44–98), IKDC 74 (46–95), Quadriceps strength 71 % of non operative side, and Hamstrings strength 70 % of non operative side, KT -1000 side to side difference 1 mm (−3 to 4). Degenerative radiological changes were noted in three patients. Two later repeat reconstructions occurred due to instability (11,1%). No delayed recurrence of infection was noted.

Conclusion: ACL reconstruction is a safe procedure being the incidence of septic arthritis in our series of 0, 92%. Our protocol of treatment is clinically effective and allows for a stable knee in 88, 9% of the patients avoiding the appearance of a delayed infection.


Sheila McRae Jaskarnip Chahal Jeff Leiter Peter B. MacDonald Robert Marx

Purpose: To describe the current practices and opinions of members of the Canadian Orthopaedic Association (COA) pertaining to anterior cruciate ligament (ACL) reconstruction.

Method: All orthopaedic surgeon members of the COA residing in Canada were sent an email invitation to take part in a survey via an internet-based survey manager. Expanding on a previously published survey (Marx et al., 2003), the current survey was comprised of 30 questions regarding the natural history of ACL-injured knees, surgical and post-surgical treatment choices, and success of the surgery. Clinical agreement was defined as greater than 80% agreement in choice of response option.

Results: Two hundred and eighty-three surgeons (49.3%) responded to the survey. Responses of the 143 surgeons (50.5%) who indicated they performed ACL reconstruction in the last year are presented. Clinical agreement with respect to surgical technique was demonstrated with respect to only three practices – ipsilateral graft harvest (100%), single incision approach (86.1%), and manual graft tensioning (81.6%). In terms of natural history, the only area of agreement was that hamstring and quadriceps strength affects function in ACL deficient knees (92%). Although less than the clinical agreement threshold, a majority of surgeons indicated their preference for semitendinosis-gracilis autograft (73%), transtibial versus anteromedial portal for establishment of the femoral tunnel (65 versus 29%), notch-plasty (65% only with impingement) and promotion of full weight-bearing and range of motion immediately post-surgery (72.1 and 74.8%, respectively). The most frequent surgeon-reported complications were tunnel widening (9.8%) and graft failure (4.4%). A greater proportion of high-volume surgeons used a manual tensioning device intra-operatively and permitted earlier return to sport (p< 0.05).

Conclusion: In the rapidly evolving area of ACL reconstruction, no recent survey of practices and opinions of orthopaedic surgeons has been published. The current survey is more extensive than others conducted to date and attempts to involve all practicing orthopaedic surgeons in Canada. In addition to providing information from a Canadian perspective, such an undertaking allows surgeons to evaluate their treatment decisions based on those of their colleagues, and also presents areas of dissimilarity that can be targeted for more extensive research.


Alexandre Fuentes Neila Mezghani Nicola Hagemeister Jacques A. de Guise

Purpose: Gait analysis has become an innovative approach to assess the biomechanical adaptations due to an ACL injury. However, interpreting the large amount of data collected often requires an expert. Therefore, there is a need to develop an automatic method capable to distinguish kinetic pattern of an ACL deficient patients from an asymptomatic population.

Method: 26 ACL deficient patients and 30 asymptomatic participants took part in a treadmill gait analysis. 3D ground reaction forces (vertical, medio-lateral and anterior-posterior) were collected using the ADAL 3D treadmill. Features were extracted from the 3D ground reaction forces as a function of time and then classified by the nearest neighbour rule using a wavelet decomposition method. The classification method was tested on our data base of 56 participants.

Results: The proposed classification method obtained an accuracy of 90%. The classification accuracy per class was higher for the ACL deficient group allowing classifying correctly 25 out of 26 ACL deficient patient. 25 out of the 30 asymptomatic participants were properly classified.

Conclusion: This study shows that an automatic objective computer method could be used in a clinical setting to help diagnose an anterior cruciate ligament injury during a gait analysis evaluation. Future studies should apply this method on a larger database including data from patients with other musculoskeletal pathologies to help diagnose other injuries.


Jeff Leiter Nevin de Korompay Lindsey MacDonald Carling MacDonald Warren G. Froese Peter B MacDonald

Purpose: The increasing number of ACL reconstructions has led to the introduction of new techniques irrespective of the fact optimal tunnel angle placement has yet to be established. Improper tunnel angle placement is associated with a variety of complications including graft failure. The purpose of this retrospective study was to compare the reliability of tibial tunnel angles produced by two experienced surgeons using a free hand method or mechanical guide (HowellTM 65° Tibial Guide).

Method: Tibial tunnel angles in the coronal and sagittal planes were determined from anteroposterior and lateral radiographs, respectively, taken at 2 to 6 months postoperatively. Fifty-two sets of digital radiographs were analyzed (free hand = 28, mechanical = 24) with the knee in full extension 100 cm from the beam source. Tunnel angle measurements were calculated using NIH ImageJ software. Each angle was measured by two investigators on three separate occasions with minimum 7 days between each analysis.

Results: There was a significant difference (p< 0.05) in tibial tunnel angle placement between the mechanical guide (64.76 ± 5.88) and free hand (61.11 ± 5.04) group in the coronal plane. No significant difference in tibial tunnel placement in the sagittal plane was detected (mechanical guide =73.63 ± 7.69, free hand = 73.51 ± 6.68). Intra-rater and Inter-rater reliability for measurements in the sagittal (ICC = 0.809; 0.733) and coronal (ICC = 0.69; 0.812) plane ranged from high (> 0.75) to moderate (0.75–0.40), respectively.

Conclusion: Tibial tunnel angles in the coronal plane produced with a mechanical guide are more accurate than those drilled free hand when the intended angle of placement is 65°. The method used to measure tibial angles in this study was reliable within and between investigators. Further research will be conducted to investigate the correlation between tunnel angle placement and patient outcome measures.


Krish Maragh Lauren Beaupré Allyson Jones David Otto

Purpose: Females are at greater risk for anterior cruciate ligament (ACL) injury than males. Soccer may be a significant risk factor for ACL injury in adolescent females. ACL injury has significant consequences, including early onset of osteoarthritis. The purpose of the study was to determine

the number of ACL reconstruction surgeries performed on females between the ages of 13–18 inclusive in the Capital Health (CH) region from December 2000 to November 2005, and

those due to soccer injuries.

Secondly, we describe factors relating to the mechanism of injury.

Method: Utilizing regional administrative data, we performed a standardized chart review and telephone interviews with female adolescents who underwent ACL reconstruction in the aforementioned time period. Information gathered included:

Age at reconstruction procedure.

Indoor versus outdoor soccer playing surface.

Level of play and frequency of participation.

The Alberta Soccer Association provided the number of registrants in indoor and outdoor seasons over the same time period.

Results: 2,824 ACL reconstruction operations were performed between December 2000 and November 2005. Reconstructions in females took place at an earlier age than in males. There were 266 ACL reconstructions in 256 adolescent females, of which 253 charts were available for review. One hundred and eleven (44%) knees were injured during soccer play. Seven patients with eight ACL reconstructions who injured their ACL playing soccer could not be located. ACL injuries occurred during indoor soccer in 52 (51%) cases despite higher registration in outdoor soccer during the same time-frame. 77 (74%) subjects played competitively and 81 (79%) subjects played two or more times/week.

Conclusion: Approximately 10% of ACL reconstructions were performed on adolescent females. Nearly 50% of ACL injuries occurred during soccer play, with a similar number seen in indoor versus outdoor play. Study limitations include the use of administrative data to assess the number of ACL reconstructions rather than ACL injuries. An awareness of the propensity of knee injuries in female soccer players is important. With the increased participation of young females in soccer and the serious lifelong implications of ACL rupture, prevention and training should be improved to lower the incidence of injury.


John Choi Elton Edwards

Purpose: To document outcomes and patient satisfaction in relation to the incision used following clavicle fracture fixation. In literature, the incidence of incisional numbness following operative fixation of clavicle fractures is reported to be between 7–29%. Such wound related problems contribute significantly to the dissatisfaction of patients with operatively treated clavicle fractures. Wound related problems can be bothersome and disabling and this is poorly documented.

Method: All primary clavicle fractures treated with plating at the Alfred Hospital between 01/06/2003 and 01/06/2006 were included in the study. Patients were asked to complete paper-based questionnaires assessing satisfaction, pain, scar satisfaction, presence of numbness and the degree of disability following clavicle fixation. Their clinical notes and X-rays were reviewed for evaluation. The study sample was then divided into two groups; horizontal incision versus vertical incision then the data was analysed.

Results: The response rate was 65% (35/54). 74% of patients reported as having “good” or better outcome following their clavicle fracture fixation. There was no statistically significant difference in pain scores. However, there were statistically significant differences observed in the presence of numbness (vertical 21% versus horizontal 62%) and the disability from the numbness between the two incision types. Overall satisfaction between the two groups was also significantly different.

Conclusion: This study confirms that scar-related problems significantly affect the satisfaction following plating of clavicle fractures and numbness appears to be one of the most significant factors. Vertical incisions appear to reduce the incidence of numbness and lead to better patient satisfaction. Our results suggest that vertical incision is an attractive alternative approach in clavicle fracture fixation.


Robert G. McCormack Rafael Martinez Tom Herschmiller Kian Chung

Purpose: Treatment of knee dislocations remains challenging and controversial. Several strategies for the management of multiple ligament knee injuries have been described and there are multiple unresolved questions. These include the indications for surgery, repair versus reconstruction, surgical timing and graft selection. The aim of this survey was to identify areas of agreement and controversy, to define the current standard of care and help generate research questions.

Method: Using the standard techniques for survey development we presented six clinical scenarios of acute knee dislocations (at least three ligaments) to all orthopaedic surgeons affiliated with Canadian medical schools. The scenarios were designed to cover the common combinations of knee dislocations in both a 25 year old active individual and a 50 year old sedentary individual. The responses were divided into three groups. Group A consisted of those with fellowship training, or practices focused on, sports knee. Group B was comprised of surgeons with trauma fellowship or a sub-specialty trauma practice. Group C were the remaining surgeons without these subspecialty foci. We report on the responses of groups A and B.

Results: An average of ten different treatment algorithms were reported for each scenario but there was agreement on the need for early surgical management in the young active individual with a knee dislocation and all dislocations involving a lateral sided injury. Conversely, there was a lack of consensus regarding the need for surgical treatment of the 50 year old individual with bi-cruciate injury and medial collateral ligament. The most common combinations of reconstruction and repair are reported for each clinical scenario. Surgeons strongly favor early surgical intervention, within three weeks of injury, except for the 50 year old sedentary individual with a bi-cruciate plus medial sided injury. Allograft was the most popular choice to reconstruct the PCL and lateral ligament. For the ACL graft there was a near equal distribution between hamstrings, patellar tendon and the use allograft tissue.

Conclusion: In the absence of higher level evidence, the information from this survey helps define the standard of care in Canada and identifies areas of controversy which would be a priority for a multi-centre prospective trial.


Dominique Rouleau Stefan Parent Debbie Feldman Valérie Deslauriers

Purpose: Musculoskeletal injuries affect up to 13% of adults annually. Despite this high incidence, quality of primary care, including analgesia, may be sub-optimal. The goal of this study is to describe the quality of primary care for ambulatory patients with isolated limb injury and to identify related factors.

Method: A cross sectional study was undertaken on 166 consecutive ambulatory adult patients with isolated limb injury who presented to orthopedics service in a Level one Trauma Centre. Quality of care was assessed by evaluating analgesia, walking aids, immobilization, and quality of referral diagnosis according to actual expert recommendations. Patient satisfaction was assessed by Visit Satisfaction Questionnaire.

Results: This study revealed low quality of primary care for more than 50% of injured patients. More than half the patients had pain level over 5/10 and more than a quarter had insufficient/absent analgesia prescriptions. A third had unacceptable immobilization and 36% of patients with a lower limb injury did not receive a walking aid prescription. A total of 37% had an absent or inadequate referral diagnosis. Factors associated with lower quality depended on the specific quality indicator and included: living further away from the hospital, younger age, initially consulting at another health care center, having a fracture, and being a smoker.

Conclusion: The high frequency of low quality of care underlines the necessity for orthopedic surgeons to be involved in primary care education. Identifying factors associated with lower quality of care will orient efforts to improve medical care of patients with isolated traumatic injury.


Jaskarndip Chahal Dawn Pearce Tom McCarthy Jeff Dawson Anthea Liebenberg Daniel B. Whelan

Purpose: Traumatic knee dislocations are complex injuries. A thorough knowledge of the pattern of ligament damage is essential to plan for definitive treatment. Injuries to the structures of the posteromedial corner (posterior oblique ligament, the semi-membranosus tendon and its expansions, the meniscofemoral and meniscotibial ligaments, posterior horn of the medial meniscus and posterior reflections of the deep and superficial medial collateral ligament) can contribute to rotational laxity and have not been previously described in the setting of knee dislocations. We set out to evaluate the injury patterns of the posteromedial corner in a series of traumatic knee dislocations.

Method: A radiographic (MRI) study was conducted on 22 multi-ligament knee injuries in 22 patients, managed at a level one trauma centre by a single surgeon between July 2006 and May 2008.

Results: There were 14 male and 6 female patients with an average age of 29. The mechanism of injury was high velocity in 10 cases, and low velocity in 12 cases. One case (ACL/PCL/posterolateral corner injury) was associated with a vascular injury. While the incidence of MCL injury was 59%, injury specific to the PMC was evident on MRI in 81.8% (18/22) of cases. The deep and superficial MCL were involved in 13/18 and 12/18 PMC injuries, respectively. The posterior oblique ligament was injured in 11/18 cases and the semi-membranosus and its expansions were injured in 10/18 cases (all distal). Injuries to the posterior horn of the medial meniscus (9/18 cases) were associated with a tear of the menisco-femoral/meniscotibial ligaments in all cases.

Conclusion: Injury to the PMC was common with high-grade multi-ligament knee injuries in this series. PMC injuries were more common than MCL injuries alone. Injury to the posterior horn of the medial meniscus was predictive of more extensive PMC injury in all cases. The posteromedial corner of the knee is an under recognized area where important injuries can occur in the setting of a dislocatable knee. Future research will involve the correlation of the injury patterns described in this series to clinical measures of knee instability and laxity.


Gerard Slobogean Mohit Bhandari Peter J. O’Brien

Purpose: To compare the functional outcome and quality-of-life following a displaced extra-articular proximal humerus fracture treated with open reduction and locking plate fixation versus non-operative management. To provide preliminary data for a subsequent prospective clinical trial.

Method: Eligible subjects were identified through retrospective searches of a large emergency department admission database and the orthopaedic trauma database. All subjects ages 3 55 treated for a proximal humerus fracture between 2002 to 2005 were invited to participate. The Disabilities of Arm, Shoulder, and Hand (DASH), Health Utilities Index Mark 3 (HUI), Euroqol-5D (EQ-5D), and the SF-36 questionnaires were mailed to all eligible subjects. Initial radiographs were reviewed using the AO/OTA classification system. Only patients with A3, B1, B2, or B3 fractures were included.

Results: Thiry-four subjects were included: 15 were treated with sling immobilization and 19 with locked plate ORIF. The non-operative group was approximately seven years older (mean age 74 versus 67, p = 0.046). DASH scores were similar between the groups: ORIF 26.6 ± 24 and Sling 26.5 ± 20. The 95% CI surrounding the 0.01 point difference (−16.0 to 15.9) slightly exceeds the 13 point cutoff for the instrument’s measurement error (minimal detectable change). Using univariable analysis, no statistically significant differences in health state values were detected. The mean HUI value for the ORIF group was 0.68 versus 0.75 for the sling (p=0.48). Mean EQ-5D values were 0.77 for the ORIF group and 0.80 for the sling group (p=0.73). The SF-36 PCS scores were also similar between the two groups: ORIF 41.1 versus Sling 39.8 (p=0.77). When controlling for age and pre-injury function, a 0.09 point difference in HUI values was detected favouring the sling treatment (p=0.036). No differences in DASH, EQ-5D, or SF-36 PCS scores were detected using regression models.

Conclusion: The results of this small cohort suggest, for extra-articular fractures, the functional and quality of life outcomes may be similar between the two interventions. No trial comparing locked plate fixation and non-operative management has been reported. A total of 96 subjects will be needed for a prospective clinical trial comparing the two treatments (DASH difference 15, 80% power, 0.05 two-sided alpha).


Abdel-Rahman Lawendy Gregory McGarr Joel Phillips David W. Sanders Aurelia Bihari Amit Badhwar

Purpose: Severe compartment syndrome is associated with renal failure, end organ damage, and systemic inflammatory response syndrome (SIRS). Intravital videomicroscopy (IVVM) is a useful tool to study capillary perfusion and inflammation in end organs such as the liver and lungs. In this study, the systemic effect of hindlimb compartment syndrome was studied using hepatic IVVM. The purpose was to measure the effect of increased hindlimb intracompartmental pressure on hepatocyte viability, inflammation, and blood flow in a rodent model.

Method: Ten Wistar rats were randomised into control (C) and Compartment Syndrome (CS) groups. Animals were anaesthetized with 5 % isoflurane. Mean arterial pressure was monitored using a carotid artery catheter. Elevated intracompartmental pressure (EICP) was induced by saline infusion into the anterior compartment of the hind limb and maintained for 2 hours between 30–40mmHg in the CS group. Two hours following fasciotomy, the liver was analyzed using IVVM to quantify capillary perfusion as a measure of microvascular dysfunction. The numbers of adherent and rolling leukocytes in venules and sinusoids were quantified to measure the inflammatory response. Irreversible hepatocyte injury was measured using a fluorescent vital dye which labels the nuclei of severely injured cells.

Results: Hepatocellular injury was significantly higher in the CS group (325±103 PI labeled cells/10-1 mm2) compared to controls (30±12 PI labeled cells/10-1 mm2)(p=0.0087). The number of adherent venular white blood cells (WBC) was significantly higher for the CS group (5±2/hpf) than controls (0.2±0.2)(p=0.0099). Volumetric blood flow was not significantly different between CS and controls.

Conclusion: After only 2 hours of compartment syndrome in this animal model, the number of activated white blood cells increased 25-fold and liver cellular injury increased 10-fold compared to controls. Marked systemic inflammation and hepatocellular damage was detected in response to isolated limb compartment syndrome. Compartment syndrome is a low-flow ischemia/reperfusion injury with a profound inflammatory response. Further research into the severe end-organ damage associated with compartment syndrome is required.


Jeffrey M. Potter Peter O’Brien Piotr Blachut Emil H. Schemitsch Michael McKee

Purpose: To conduct a study to identify differences in complication rates and outcomes between previously recognized sub-groups commonly treated for limb length discrepancies (LLD).

Method: Forty-two males and 13 females were treated for LLD at two level-one trauma centres. Mean LLD was 4.4 cm (range 1.8 to 18cm). There were 44 femoral segments (in 41 patients) and 14 tibia segments lengthened. Forty were post-traumatic, and 18 congenital/ developmental. Objective data regarding complications, length achieved, and lengthening duration was collected from patient records. Two groups were compared for differences: Developmental (congenital and developmental etiology combined; LLD occurred prior to skeletal maturity and treatment involved creating new length) versus post-traumatic (restoration of previously existing length), and tibia versus femoral lengthening.

Results: A mean of 4.4 cm of length was achieved over a mean duration of 83 days, for a mean lengthening index of 18.9 days/cm. Superficial pin tract infections were the most common complication, occurring in 33 segments (56%). Deep infection occurred in six segments (10%). Three of these six had a history of open fracture, and a fourth had a history of infection during initial fracture management. All were successfully treated with irrigation and debridement, and exchange nailing. The developmental group had significantly greater incidence of flexion contracture (13% versus 78%, p< 0.001), and surgical correction for a contracture deformity (5% versus 61%, p< 0.001). The post-traumatic group had a significantly higher rate of painful hardware requiring removal following successful treatment of their LLD (45% versus 16%, p=0.04). Tibia segments had a significantly greater lengthening index (29 d/cm versus 18 d/cm, p=0.03).

Conclusion: Limb lengthening is an involved process with potential for serious complications. Patients who had limb-lengthening for congenital/ developmental discrepancies had a higher rate of adjacent joint contrac-ture and subsequent requirement for surgical release. Patients with post-traumatic lengthening had a higher rate of hardware removal, and the lengthening index was greater for tibiae than femora. Deep infection remains a significant concern. This study provides information for physicians and patients on the rate and type of complications that can be expected both overall, and within specific LLD treatment groups.


Alex Malone Peter Zarkadas Stuart Jansen Jeff Hughes

Purpose: This study reviews the early results of elbow hemiarthroplasty for distal humeral fractures.

Method: Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstruc-table fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment.

Results: At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pro-nosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and ten had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies > 1 mm; one was loose but acceptable. Five prostheses were in slight varus and two were flexed. Two elbows had early degenerative changes and 15 developed an osteophytic lip on the medial trochlea.

Conclusion: Early results of elbow hemiarthroplasty show good outcomes after complex distal humeral fractures, despite a technically demanding procedure, met-alware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy.


Darius Viskontas Daphne M. Beingessner Sean Nork Julie Agel

Purpose: To describe the pattern of injury, surgical technique and outcomes of Monteggia type IID fracture dislocations.

Method: Design: Retrospective review of prospectively collected clinical and radiographic patient data in orthopaedic trauma database with prospectively collected outcome scores. Setting: Level 1 university based trauma center. Patients / Participants: All patients with Monteggia type IID fracture dislocations admitted from January 2000 to July 2005. Intervention: Review of patient demographics, fracture pattern, method of fixation, complications, additional surgical procedures, and clinical and radiographic outcome measures. Main Outcome Measurements: Clinical outcomes: elbow range of motion, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), PREE (Patient Rated Elbow Evaluation), complications. Radiographic outcomes: quality of fracture reduction, healing time, degenerative change and heterotopic ossification.

Results: Sixteen patients were included in the study. All fractures united. There were seven complications in 6 patients including 3 contractures with associated heterotopic ossification, 1 pronator syndrome and late radial nerve palsy, 1 radial head collapse and a DVT in the same patient and 1 with prominent hardware. Outcome scores were obtained on 11 patients at an average of 49 months (range 25 – 82 months) post-operatively. The average Quickdash score was 11 (range 0–43) and the average PREE score was 13 (range 0–34).

Conclusion: Monteggia IID fracture dislocations are complex injuries with a recurring pattern. Rigid anatomic fixation, early range of motion and avoidance of complications leads to a good outcome.


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David W. Sanders Gladys Chan Amit Badhwar

Purpose: Compartment syndrome is a limb-threatening condition. Treatment is urgent decompression by fas-ciotomy. However, orthopedic surgeons are often confronted by a limb at risk for compartment syndrome, in which treatments to preserve tissue might be considered. Hypothermia has shown promise as a technique of maintaining tissue viability in transplant surgery, replant surgery and soft tissue injury. Cooling reduces microvascular dysfunction, inflammation and edema. This study was designed to determine whether tissue cooling might reduce muscle damage in the setting of elevated intracompartmental pressure. Purpose This study investigated the effect of hypothermia on tissue perfusion, viability and the inflammatory response in an animal model of elevated intracompartmental pressure. We hypothesize that hypothermia will preserve muscle tissue viability in an animal model of elevated intracom-partmental pressure.

Method: Twenty Wistar rats were randomized. Five animals had elevated intracompartmental pressure for 2 hours (CS). Five had elevated pressure and hindlimb cooling to 25oC (CS-HY). Five had hindlimb cooling to 25oC (HY) and 5 were control animals (C). All animals were anaesthesized for study. Core temperature was maintained over 30oC. Elevated ICP was maintained (30mmHg) using a saline infusion technique (groups CS and CS-HY). After 2 hours, fasciotomies were completed and intravital microscopy was used to measure tissue viability, microvascular perfusion and inflammation.

Results: The use of hypothermia reduced tissue damage by approximately 50% in the CS-HY group (8.2% injured cells) compared with the CS group (16.5% injured cells). There was no difference in capillary perfusion comparing the CS and CS-HY groups (p> 0.05). The number of adherent inflammatory cells was fewer comparing the CS-HY with the CS groups, but this did not reach statistical significance with the numbers available for study.

Conclusion: Hypothermia preserved tissue viability in an animal model of elevated intracompartmental pressure. Fasciotomy remains the gold standard treatment for established compartment syndrome. However cooling may be useful to preserve tissue viability in extremities that are at risk of developing compartment syndrome. The clinical utility of hypothermia for compartment syndrome requires further study.


George H. Thompson Douglas Dickson Connie Poe-Kochert Jochen P. Son-Hing Douglas G. Armstrong

Purpose: Determine if one or two pairs of pedicle screws were superior to multiple laminar hooks for the distal foundation segmental in spinal instrumentation (SSI) in the surgical correction of AIS.

Method: We analyzed 108 consecutive patients identi-fied from our Pediatric Orthopaedic Spine Database (1992–2005) that underwent a posterior spinal fusion (PSF) and segmental spine instrumentation (SSI). There were 3 patient groups: Group 1, one pair of pedicle screws for the distal foundation (n=12); Group 2, two or more pairs of pedicle screws (n=44) and Group 3, multiple hooks only (n=52). The mean age at surgery was 13.5 years, 14.1 years, and 13.0 years, respectively. The major curve was measured perioperatively and at one month, 6 months, 12 months, and 24 months postoperatively and the mean percentage of correction, as well as loss of correction determined. We also analyzed the length of surgery (hours), length of hospitalization and complications.

Results: The mean preoperative major curve was 52.5 degrees in Group 1, 52. degrees in Group 2, and 48.8 degrees in Group 3. The mean percent postoperative correction (POC%) at 1 month was 67.2, 65.2, and 63.4 % in the 3 groups, respectively (p=0.531). The mean percent post-operative correction (POC%) at 24 month was 55.6% for Group 1, 56.6% for Group 2 and 51.5% for Group 3 (p=0.478). The mean percent loss of correction (LOC%) at 24 months was 3.1%, 2.25%, and 2.9% respectively(p=0.648). One-way ANOVA demonstrated no significant differences in patient age, number of levels fused, length of surgery, or length of hospital stay. There were no implant related complications.

Conclusion: Hybrid constructs with one or more pairs of pedicle screws and all-hook constructs for distal foundations in SSI provided similar major curve correction, percentage postoperative correction, and are associated with a minimal loss of correction postoperatively. There was no significant difference between length of surgery, hospital stay or complications.


David Barei Craig Greene Daphne M. Beingessner

Purpose: Non-union and secondary reduction loss complicate open distal femur fractures with bone loss. We hypothesize that locking plates decrease subsequent bone grafting in these injuries, yet maintain alignment; immediate post-fixation radiographic features predict primary union.

Method: From 2001 to 2004 inclusive, 34 adults with 36 open AO/OTA C-type distal femur fractures were reviewed. All were treated with locking plates and 3-month minimum follow-up. Union required radiographic bridging callus on 2/4 cortices combined with lack of symptoms. Alignment was assessed on initial and united radiographs. Antibiotic beads within a metaphyseal defect defined clinically important bone loss.

Results: Eleven of 20 fractures with bone loss (55%) underwent staged bone grafting to achieve union, versus two of 16 fractures without bone loss (13%). The presence of antibiotic beads was significantly associated with staged bone grafting (p< 0.01). Of those with bone loss and staged grafting, three had posterior cortical bone loss, and only three had medial and posterior cortical bone loss, and five had segmental defects. Of nine fractures with bone loss not requiring grafting, all had radiographic posterior cortical contact; seven had radiographic medial cortical contact. Posterior (p< 0.001) and medial (p< 0.025) cortical continuity were associated with injuries not requiring bone graft. Thirty-four had accurate frontal plane reductions; thirty-five had accurate sagittal plane reductions. Complications included two non-unions, and one reduction loss.

Conclusion: Despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femur fractures. Those with radiographic posterior cortical contact and/or medial cortical contact are strongly correlated with primary union.


Ujjwal K. Debnath Nanjundappa S. Harshavardhana Hossein S.M. Mehdian Geoffrey R. Burwell Michael P. Grevitt John K. Webb

Purpose: To report long-term results (with a minimum follow-up of 13 years) of GR construct [Luque-trolley (LT)] in EOS, to identify factors predictive of curve progression and to establish the timing of definitive fusion.

Method: The study cohort consisted of 37 patients (22M & 15F) who had primary LT between 1983–1995 were reviewed. Group I: 7 patients had LT alone and Group II: 30 had LT with convex fusion. Cobb at initial presentation, after first surgery, before definitive fusion and at the latest follow-up was recorded. Other radiological curve parameters recorded were rib spinal angle difference (RSAD), end vertebral tilts (EVT), apical vertebral rotation (AVR) and T1-S1 length. Complications with respect to development of junctional/apical kyphosis, implant failure, pseudoarthrosis (PA), sagittal/coronal profile and instrumented spinal segment growth at maturity were evaluated.

Results: The mean age at definitive fusion for study cohort was 12.5 years. Group I: Mean age at first surgery was 7.4 years (3.3–9.5y). Mean pre-op Cobb angle of primary curve was 600 (310–710) which was corrected to 280 (200–360). They underwent definitive segmental spinal instrumentation(SSI) with fusion at 13.9 years (9.8–15.1y) when the curve had worsened to 480 (400–650). Group II: Mean age at index surgery was 3.6 years (1.6–8.8y). Mean pre-op Cobb of primary curve was 580 (300–900) which corrected to 300 (100–620). 16/30 patients underwent definitive SSI with fusion at 11.5 years (8.5–14.2y) when the curve deteriorated to 600 (530–770). Instrumented segmental spinal growth was 3.2cms (SD±1.45; range 1–5cms). 14/30 maintained their correction till skeletal maturity. JK was observed in 8 cases [proximal(3), distal(2) & apical(3)] which were corrected at the time of definitive SSI. There was a linear relationship between Cobb angle at definitive fusion with concaveRSA and upperEVT.

Conclusion: Correlation and regression statistics revealed predictive factors of curve progression to be concave RSA (®=0.91 & p=0.001) and upper EVT (®=0.81 & p=0.0004). Patients with high concave RSA and upper EVT should be closely monitored for deterioration. Spinal growth that exceeds the capacity of LT to elongate leads to apical kyphosis. Timing of definitive fusion is influenced by growth velocity, clinico-radiological factors and complications.


Victor Wu Harold Huff Mohit Bhandari

Purpose: To examine patterns of physical injury associated with intimate partner violence (IPV) among women presenting to emergency room departments.

Method: Systematic searches of Medline, EMBASE, and CINAHL electronic databases from their earliest entries up to February 2008. Reference lists from the studies included from the electronic database search were reviewed for published and unpublished studies. We contacted study authors regarding published and unpublished information. After titles and abstracts were initially screened by a single reviewer, two reviewers screened the remaining full-text articles for inclusion into the review. Studies were included if they pertained in whole or in part to women who presented to an emergency department because of IPV and reported the location or type of injuries. Studies without comparison groups of non-IPV women and case series/case reports were excluded. We performed a meta-analysis of the available data using the random effects model.

Results: We identified 262 potentially relevant titles and abstracts, of which 7 articles were included in the review. The association between head, neck, or facial injuries and IPV was higher among studies that excluded women with verifiable injuries such as witnessed falls or motor vehicle collisions (pooled odds ratio 24 (95%CI: 15 Ã-¿½ 38)). Thoracic, abdominal, or pelvic injuries were non-specific for IPV (pooled odds ratio 1.07 (95% CI: 0.89 Ã-¿½ 1.29)). Injuries in the upper extremities were suggestive of non-IPV etiology (pooled odds ratio 0.51 (95%CI: 0.41 Ã-¿½ 0.54)), as were lower extremity injuries (pooled odds ratio 0.15 (95%CI: 0.04 Ã-¿½ 0.56)).

Conclusion: Among women presenting to emergency room departments, unwitnessed head, neck, or facial injuries are significant markers for intimate partner violence. Conversely extremity injuries are less likely to have been the consequence of IPV.


Daniel Master Connie Poe-Kochert Jochen P. Son-Hing Douglas G. Armstrong George H. Thompson

Purpose: Determine the prevalence of complications in neuromuscular scoliosis surgery and to identify risk factors. We hypothesized that patients with smaller pre-operative curve magnitudes would have lower complication rates.

Method: Our Pediatric Orthopaedic Spine Database identified a cohort of 151 consecutive patients with neu-romuscular scoliosis who underwent corrective surgery between 1992 and 2005 and had a minimum of 2 years of follow-up. Twenty-two patients (15%) were excluded; 20 patients with a diagnosis of myelodysplasia and two due to death during the follow-up period. Preoperative, operative, and postoperative factors were analyzed for any association with major complications and length of stay (LOS) utilizing stepwise logistic and multiple regression. Only factors with p-values < 0.05 remained in the analysis models. Odds ratios were calculated for significant dichotomous variables and receiver operator characteristic (ROC) curves were created for significant continuous variables.

Results: There were 79 male and 50 female patients with a mean age at surgery of 13.4 years (range, 6 to 21 years). Eighty-seven patients (68%) underwent posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI). and 42 patients (32%) underwent anterior spinal fusion (ASF) and PSF with SSI. Mean follow-up was 46.4 months (range, 24 to 251 months). There were 45 major complications in 37 patients (29% prevalence). Non-ambulatory status (p < 0.05) and a high preoperative Cobb angle (p < 0.01) were associated with an increasing prevalence of major complications. Non-ambulatory patients were almost four times more likely to have a major complication (OR of 3.8, p < 0.05) in comparison to ambulatory patients. A pre-operative Cobb angle ≥ 60 degrees (p < 0.01) was the most accurate predictor for an increased risk for major complication. Patients undergoing PSF with SSI only or combined ASF and PSF with SSI on the same day who sustained one major (p < 0.05) or two minor (p < 0.01) complications had a significantly increased LOS.

Conclusion: The prevalence of complications following surgery for neuromuscular scoliosis is high. Non-ambulatory status and higher preoperative Cobb curve magnitude are directly associated with an increased risk for major complication and indirectly associated with increased LOS.


Ron El-Hawary David Russell Alex M. Soroceanu Colleen O’Connell

Purpose: Traditionally, the accepted treatments for adolescent idiopathic scoliosis (AIS) have included open anterior thoracotomy with instrumentation and posterior spinal fusion and instrumentation. Thoracoscopic instrumentation is a newer technique, whose role remains controversial. This systematic review of the literature aims to better understand thoracoscopic instrumentation as a treatment for AIS and to discuss it in the context of the alternative techniques currently used.

Method: The most commonly used medical databases (PUBMED, Medline, EMBASE, Cinahl, and the Cochrane library) were searched up to April 2008 using the search terms “VATS”, “thoracoscopic scoliosis” and “thoracoscopic scoliosis instrumentation”. Two reviewers independently performed the literature evaluation. There were no language restrictions. Because the number of randomized controlled trials was anticipared to be small, we included relevant non-randomized trials, observational studies, and uncontrolled studies.

Results: Eleven studies met the strict inclusion criteria for the systematic review, of which the majority were level III and IV evidence. Four hundred and forty-five cases have been reported, 80% of them female, with the vast majority having a diagnosis of AIS. Similar surgical techniques were used and had a mean operative time of 355 minutes, mean blood loss of 444 ml, and mean hospital stay of 5.1 days. Mean pre-operative curve magnitude was 47.9o; post-operative curve magnitude was 16.3o, with a correction of 62%. Number of levels instrumented was 6.3, pulmonary function testes returned to pre-operative values by 2-years post-operative, and complication rate was 21.6%, including a pulmonary complication rate of 9.2%. SRS questionnaires revealed that patients were satisfied.

Conclusion: The major drawbacks of the thoraco-scopic approach are the operative time and incidence of early pulmonary complications. Advantages include: minimally invasive, less blood loss, short hospital stay, excellent curve correction, few levels fused, good patient satisfaction, and no long term effect on pulmonary function. With appropriate surgeon training, careful patient selection, and precise surgical technique, this technique can offer an acceptable alternative to the more traditional procedures.


John Street Brian Lenehan Michael Boyd Marcel Dvorak Brian K. Kwon Scott Paquette Charles G. Fisher

Purpose: To evaluate the demographics, presentation, treatment and outcomes of spinal infection in a population of Intravenous Drug Users.

Method: Data on all patients with pyogenic spinal infection presenting to a quaternary referral center was obtained from a prospectively maintain database.

Results: Over the five-year study period, there were 102 patients treated for Primary Pyogenic Infection of the Spine of which 51 were Intravenous Drug Users (IVDU). Of this IVDU group there were 34 males. Mean age was 43 years (range 25 – 57). Twenty-three had HIV, 43 Hepatitis C and 13 Hepatitis B. All were using cocaine, 26 were also using Heroin and 44 more than three recreational drugs. Thirty patients presented with axial pain with a mean duration of 51 days (range 3–120). Thirty-one were ASIA D or worse with eight ASIA A. Mean Motor Score of patients with deficit was 58.6. Most common ASIA Motor Levels were C4 and C5. Mean duration of neurological symptoms was seven days (range 1–60). Blood parameters on admission were in keeping with sepsis in immunocompromised patients. None had previous surgery for spinal infection. Twenty-sex were receiving IV antibiotics for known spinal infection. 44 patients were treated surgically. 32 had infection of the cervical spine, 9 Thoracic and 3 Lumbar. 22 had a posterior approach alone, 13 had anterior only while 9 required combined. Mean operative time was 263 mins (range 62 – 742). 13 required tracheostomy. 7 required early revision for hardware failure and 2 for surgical wound infection. Mean duration of antibiotic treatment was 49 days (range 28–116). 26 patients had single agent therapy. 17 had MSSA and 17 MRSA. At discharge 28 patients had neurological improvement (mean 20 ASIA points, range 1–55), 11 had deterioration (mean 13, range 1–50) and 5 were unchanged. There were no in-hospital deaths. At 2 years after index admission 13 patients were dead and none were attending the unit for follow-up.

Conclusion: Primary pyogenic spinal infection in IVDU’s typically presents with sepsis and acute cervical quadriplegia. Surgical management must be prompt and aggressive with significant neurological improvement expected in the majority of patients.


Hossein K. Elgafy Tejaswy Potluri Ahmad Faizan Scot Foster Nikhil Kulkarni Amanesh Goyal Vijay Goel

Purpose: The current gold-standard for atlanto-axial fixation is C1-C2 Transarticular Screw (TS) fixation. In certain cases, the complicated nature of vertebral artery injury could make the application of bilateral transar-ticular screws impossible. This study biomechanically compares three atlantoaxial transarticular salvaging fixation techniques.

Method: Nine Fresh ligamentous human cervical spine specimens (C0-C4) were thawed and the tissue surrounding the spine, except the ligaments and discs, was carefully removed. Pure moments were applied to skull in increments of 0.5 Nm from 0 Nm to 2.0 Nm with the help of loading arms, nylon strings and pulleys. The specimens were tested in extension (EXT), flexion (FLEX), left lateral bending (LB), right lateral bending (RB), left axial rotation (LR) and right axial rotation (RR) for all the cases. The positions of the LEDs were recorded using an Optotrak Motion Measurement System (Northern Digital, Waterloo, Ontario, Canada) and was converted into three rotations (flexion/extension, lateral bending and axial rotation) using rigid body kinematic principles in relation to the fixed base. The specimens were tested intact and after type II odontoid fracture, were instrumented and tested with three fixation constructs:

C1-C2 TS on right side and C1LMS-C2PS on contralateral side

C1-C2 TS on right side and C1LMS-C2IL on the contralateral side and

C1-C2 TS on right side with sublaminar wire.

Results: All of the three instrumented cases significantly reduced motion across C1-C2 segment in all the modes when compared to intact (P< 0.005, two-tailed unpaired t-test at confidence interval of ninety-five percent) except in extension. TS+C1lM+C2PS is significantly stiffer than TS+ Wire only in axial rotation (P< 0.05) and equivalent in flexion/extension (P=0.75/P=0.51) and left/right bending (P=0.22/P=0.58). TS+C1LM +C2PS is equivalent to TS+C1LM+C2IL in all the loading modes (P> 0.05). TS+C1LM+C2IL is significantly stiffer than TS+Wire in axial rotation (P < 0.05) and equivalent in flexion/extension (P=0.93) and left/right bending (P=0.69/P=0.84).

Conclusion: This study showed that TS+C1LMS+C2PS fixation is equivalent to TS+C1LMS+C2ILS fixation in all the rotation modes and superior to TS+Wire fixation in axial rotation averaged over all ranges of motion. Also, TS+C1LMS+C2ILS fixation is superior to TS+Wire fixation in axial rotation averaged over all ranges of motion.


Davor D. Saravanja Charles G. Fisher Scott Paquette John Street Brian Kwon Alexander Vaccaro

Purpose: The decision of whether or not an injury to the sub-axial cervical spine needs operative management often hinges on the stability of the spine. The posterior Ligamentous Complex (PLC) is one of the primary soft tissue stabilizers of the cervical spine. Fat-saturated T2-wieghted MRI sequences are able to demonstrate soft tissue injury to the cervical spine. No studies to date have assessed the ability of MRI to accurately and reliably demonstrate PLC disruption in the sub-axial cervical spine.

Method: Forty-nine consecutive patients aged 14–85 years presenting to the two participating institutions with injury between C3 and T1 who required posterior surgery as part of their management were prospectively enrolled in the study. All patients had radiographs, CT, and MRI scans preoperatively, which were reviewed by a Neuroradiologist, and the treating surgeon separately. Their posterior intraoperative findings were then recorded by the treating surgeon and his assistant. Statistical analysis included Spearman’s rank order correlation, and Cohen’s kappa score.

Results: There was a moderate level of agreement between the radiologist’s interpretation of the preopera-tive MRI and the surgeon’s intraoperative findings for the supraspinous and intraspinous ligaments, (kappa.49 & .48 respectively). A fair level of agreement was found for the ligamentum flavum, left and right facet capsules, and the cervical fascia (kappa scores.31,.30,.30,.39 respectively).

Conclusion: MRI has a high sensitivity (78.6% to 100%) for detecting cervical PLC injury but a low specificity (53.6% to 75%). On its own MRI is not a useful tool for diagnosing cervical spine PLC injury. The clinician should be aware of the relatively high rate of false positive PLC injury diagnosis with MRI.


Brian Lenehan John Street Hongbin Zhang Vanessa Noonan Michael Boyd Charles Fisher Brian K. Kwon Scott Paquette Peter C. Wing Marcel Dvorak

Purpose: Prospective Observational Population Study to describe the incidence, demographics and pattern of spinal cord injury in British Columbia, Canada, for 10 years to 2004.

Method: Systematic analysis of prospectively collected spine registry data (Vertebase) at Vancouver General Hospital, B.C., Canada from 1995–2004.

Results: During the 10-year study period the 938 patients were admitted with a traumatic spinal cord injury. The Annual Population-Standardized Incidences ranged from 19.94 to 27.27 per million, with a median incidence of 23.34/million and with no significant change over the study period. The mean age was 39.7 years (34.73 in 1995 and 42.1 in 2004, p< 0.05) with a range of 16–92 years. 79.74 % were males. 48.2% of patients were AISA A on admission, of which 48% were quadraparetic. The most common levels of spinal cord injury were C5 (17.3%), C6 (10%), T1 (9.4%), T12 (5.8%). The Mean ASIA score was 50.22 with a range from 0–100. 19.8% of patients had a GCS£13. The mean ISS was 26.02, range of 0 – 75. Motor vehicle collisions and falls were responsible for 59% and 30% of admissions respectively. Mean length of in-hospital stay was 34 days, ranging from 1 – 275 days. In hospital mortality rate was 2.9%. ASIA Grade, Total Motor Score and anatomical level of injury all correlated directly with Length of stay (p< 0.0001).

Conclusion: Acute Traumatic Spinal Cord Injury remains a major cause of significant morbidity among young males. The incidence appears to be increasing in the elderly. Modern multidisciplinary care has greatly reduced the associated acute mortality. Despite multiple prevention strategies the Annual Population-Standardized Incidence remained unchanged over the study period.


Christopher W. Reilly James A. McEwen Lise Leveille Angeliki Perdios Kishore Mulpuri

Purpose: Tourniquet cuff pressures in paediatric patients are commonly set at standard pressures. Recent evidence on adult subjects has shown that safer and more effective cuff pressures can be achieved by measuring limb occlusion pressure (LOP) and using a wide, contour cuff. There is little evidence validating these techniques in children. The primary objective of this study was to evaluate if a difference in tourniquet cuff pressure can be achieved in a paediatric population using a wide contour cuff in conjunction with measured LOP when compared to a standard cuff and pressure.

Method: Subjects aged 10 to 17 years that underwent anterior cruciate ligament repair were included and ran-domised into either the control group or the experimental ‘LOP’ group using variable block randomisation. The tourniquet cuff was inflated to 300 mmHg in the control group or to the recommended tourniquet pressure based on LOP measurement in the LOP group. The surgeon was blinded to cuff selection, application and pressure throughout the surgical procedure. Immediately following the surgical procedure, the surgeon rated the quality of the bloodless field on a visual analogue scale (VAS). This study was powered as an effectiveness trial and intention to treat analysis was used.

Results: Following a planned interim analysis at midpoint, complete data was recorded for 11 patients (control group) and 10 patients (LOP group). The quality of the surgical field was not different between groups (p= 0.053). There was a statistically significant difference in mean cuff pressure between the control group (300 mmHg) and the LOP group (151 mmHg) (p < 0.001). We ran the same analysis comparing the LOP data to hypothetical control data of 250 mmHg and our results remained statistically significant (p < 0.001).

Conclusion: The use of an automatic LOP measurement with the use wide contour cuffs can significantly reduce average tourniquet cuff pressures in paediatric patients compared to typical practice of 300 mmHg or 250 mmHg without compromising the quality of the surgical field.


Frederick Cheng Oma Persaud Raja Y. Rampersaud

Purpose: Magnetic resonance imaging (MRI) is the diagnostic imaging modality of choice for spinal disorders. The high prevalence of “abnormal” MRI findings within asymptomatic individuals is well established, however, referrals to spine surgeons are often based on symptomatically discordant or non-surgical MRI ‘abnormalities’. The purpose of this study was to determine the prevalence of typical spine MRI abnormalities among symptomatic surgical candidates (SC) and non-surgical (NS)patients.

Method: A retrospective cohort study was conducted on 1,585 patients (with a lumbar MRI) seen by a spine surgeon. The cohorts were compared in terms of the total amount, type, severity and number of levels of abnormalities on MRI. All patients were prospectively stratified regarding surgical candidacy.

Results: There was no difference between the cohorts (n=722-SC / 863-NS) in terms of the total amount of structural abnormalities present (p=0.26). There was no difference in the prevalence of DDD, disc-herniation or previous surgery (p> 0.2). However, there was a higher prevalence of spinal stenosis (0.513 vs. 0.394) and spondylolisthesis (0.263 vs. 0.112) within the SC (p≤0.01). Logistic-regression showed that patients with disc-herniation, stenosis or spondylolisthesis were 1.49, 1.61 and 2.84 times more likely to be SC respectively (p≤0.001). Subjects with a report of severe/large herniation or stenosis were 3.30 and 2.25 times (p< 0.001) more likely to be SC respectively. Patients with one-level anomalies were 2.19 times (p< 0.0001) more likely to be SC.

Conclusion: It is hopeful that these results will better enable non-surgeons to more effectively identify and educate patients with a higher likelihood of being surgical candidates.


Ron El-Hawary Kelly A. Jeans Lori A. Karol

Purpose: To compare gait kinematics and kinetics in five-year old children treated initially with Ponseti casting versus French physical therapy. A third group, consisting of patients initially treated with these non-operative methods and then undergoing surgery consisting of more than a tendoachilles lengthening, was compared to those children treated entirely non-operatively.

Method: Ninety patients (125 clubfeet) were tested at age five years. Thirty-four feet had undergone only Ponseti treatment, 40 the French program, and 51 had initial non-operative treatment with either the Ponseti or French protocols but later had surgery at an average age of 2+3 years. Kinematics and kinetics were compared to age-matched normal subjects.

Results: Average stance-phase dorsiflexion did not differ between groups or from normal. Incidence of equinus: French 5%, Ponseti 0%; Increased stance-phase dorsiflexion: French 3%, Ponseti 24%, Surgical 18% (p < 0.05). A similar number of feet that were not operated upon at age five had in-toeing: 30% French, 32% Ponseti. Decreased ankle power generation at push-off: 53% French; 47% Ponseti; 67% Surgical. Average ankle power generation: 2.21 W/kg French, 2.36 W/kg Ponseti, 1.97 W/kg Surgical (2.83 W/kg in normal 5-year-old children). There was a difference in ankle power generation between normal feet and both the French and surgical groups (p< 0.001). Feet in the non-operative groups that had undergone Achilles tenotomy (n=28) had similar ankle power to those feet (n=42) that did not have tenotomies (p =0.223). Hip power generation was increased 33% in children who had undergone Ponseti treatment (1.38 W/kg), and 41% after French nonoperative treatment (1.47 W/kg), compared to normal (1.04 W/kg). This may be to compensate for poor ankle push-off.

Conclusion: The gait characteristics of those feet that have not had surgery reveal that the majority had normal ankle kinematics, but reduced efficiency is demonstrated by reduced ankle push-off power, regardless of whether or not an Achilles tenotomy was performed. Decreased ankle power and persistant internal rotation are more frequently seen in feet that have undergone surgery despite initial nonoperative treatment, compared to those treated only by either the Ponseti protocol or the French physical therapy program.


Stephen Kingwell Vanessa Noonan Doug Graeb Charles G. Fisher Ory Keynan Marcel Dvorak

Purpose: To determine whether neural axis level of injury (SCI, CMI, or CEI) is related to motor improvement, as defined by the International Standards for Neurological Classification of Spinal Cord Injury motor score (MS), in patients with a thoracolumbar (T11-L3) spine injury.

Method: Fifty-three patients who sustained a neurological deficit secondary to a thoracolumbar spinal injury between 1995–2003 had injury details and MS collected prospectively. An independent evaluation determined the follow-up MS and SF-36 generic health-related quality of life (HrQOL) at a mean of 6.6 (SD 2.5) years post-injury. All patients had an MRI reviewed by a spine surgeon and neuroradiologist to determine the location of their conus medullaris and precise level of neural axis injury.

Results: Nineteen patients (37%) had SCI, 20 (39%) had CMI, and 12 (24%) had CEI, while two could not be classified. Patients with SCI improved their MS by an average 7.0 motor points (SD 9.8); CMI improved 11.9 (SD 11.8); and CEI improved 16.8 (SD 16.0). This trend did not achieve statistical significance (p=0.09). Multivariate analyses demonstrated that initial MS had a significant interaction with neural axis level of injury with respect to the primary outcome. Specifically, CEI showed the greatest improvement in MS only when the initial MS was less than 75. Absence of initial anal sensation, a fracture-dislocation injury type and increasing time to surgery were all statistically associated with less improvement in MS. The mean follow-up SF-36 physical component score (PCS) was 37.3 (SD 10.1) and the mean mental component score (MCS) was 51.4 (SD 11.8). There was no significant difference in mean PCS and MCS for varying levels of neural axis injury.

Conclusion: Patients with a CEI demonstrated the most improvement in MS, while absent anal sensation, a fracture-dislocation, and long delay to surgery were poor prognostic indicators for motor recovery. The HrQOL outcomes did not vary with neural axis level of injury. The results of this study assist in determining a prognosis for patients that sustain these common injuries. Future research should focus on how specific pre- and peri-operative variables affect outcomes in patients with neurological deficits secondary to thoracolumbar injuries.


Marie-Lyne Nault Stefan Parent Marjolaine Roy-Beaudry Michele Rivard Hubert Labelle

Purpose: In pediatric orthopedics, Risser sign is used to assess skeletal maturity. Two grading system exist for the Risser sign, one US and one European. In adolescent idiopathic scoliosis (AIS) the curve acceleration phase begin at a digital skeletal age (DSA) score between 400 – 425. The objective was to asses the disagreement between both grading system and evaluate the best estimator of the curve acceleration phase.

Method: One hundred twenty-one AIS patients had a PA and lateral X-rays of the spine and a left hand and wrist X-ray. Risser sign was measured according to both grading system and bone age was calculated according to Tanner-Whitehouse III method. Kappa statistics were done to evaluate concordance between US and Euro-pean grading system and 2 multiple linear regression models were performed to find which stage best predicts the beginning of the rapid acceleration phase.

Results: Kappa statistic between the US and European system was 0.517 (moderate agreement). US Risser 1 was the best predictor of the curve acceleration phase. DSA scores predicted with Risser 1 were 425 and 445 for US and European system respectively.

Conclusion: American and European Risser grading system use different criteria to define 6 stages of a same sign. This is reflected in our study with a moderate agreement between both grading systems. US Risser 1 is the stage that best predicts the beginning of the rapid acceleration phase and a close follow up should be made at the beginning of the iliac apophysis ossification.


Amit Datta Shakir Syed Curtis Robb Chris Bradish

Purpose: The Ponseti method of clubfoot treatment has revolutionised the management of this condition. Prior to the introduction of the Ponseti regime to the UK in the late 1990’s children were frequently treated by open surgical releases. The aim of our study is to compare the patient’s perspective of outcome following Ilizarov treatment against the long-term outcome generated by the formal scoring systems.

Method: We identified nine patients and 14 feet from the theatre logbooks, treated by the senior author (CB), with recurrent deformity of idiopathic clubfeet, using an ilizarov external fixator between 1994 and 1996. A variety of objective and subjective scoring systems were used to compare the results following Ilizarov treatment.

Results: International Clubfoot Study Group (ICFSG) scores on six patients gave two excellent feet, one good foot, four fair feet and one poor foot. Giving an excellent/ good rate of only 37.5% with a mean follow up of 13.5 years. The Reinker & Carpenter scoring system resulted in five feet graded as excellent, one as good and two were rated poor. Giving an excellent/good rate of 75%. Functional questioning was also undertaken, six of seven (85%) patients deemed their treatment a success and were glad to have undergone treatment with an ilizarov frame. All but one patient is in higher education pursuing a vocational career or are in full time employment.

Conclusion: Our results show that 85% of our patients who were treated with an Ilizarov frame for correction of a relapsed clubfoot were happy with their long term outcome. Thus the patient’s perspective of the long term results of Ilizarov treatment for relapsed club foot are very encouraging. These results do not appear to correlate well with the International Clubfoot Study Group scores.


Renjit Varghese Kishore Mulpuri Benjamin Joseph

Purpose: The lateral pillar classification for Perthes disease described by Herring in 1992 has gained wide acceptance as a method of predicting outcome and planning treatment. Our purpose was to determine the reproducibility of Herring’s lateral pillar classification using visual estimation and by direct measurement and determine if the Herring’s grading alters as the child passes through the stage of fragmentation in Perthes’ disease.

Method: One hundred AP and frog lateral radiographs of children with unilateral Perthes’ disease in the stage of fragmentation were classified according to the Herrings classification by two investigators utilizing a visual and measurement technique. The change in Herring’s grading with progression of disease was evaluated in 86 patients with sequential radiographs in the stage of fragmentation.

Results: The level of intra-observer agreement by the measurement technique was excellent for both AP and lateral radiographs (Kappa = 0.92 and 0.98) as compared to the visual method for which the agreement was moderate (Kappa = 0.65 and 0.5). The inter-observer reproducibility was moderate by the visual method for both AP and lateral radiographs (Kappa = 0.51 and 0.43). The level of agreement for the measurement method was good for the AP radiographs (Kappa = 0.66) and was only moderate for the frog lateral radiographs (Kappa = 0.53). Of the total 86 cases that had sequential radiographs in the stage of fragmentation, 33 showed change in Herring’s grading. Among these 33 cases, 25 showed a change in the extent of epiphyseal collapse in the AP radiographs alone whereas 8 cases showed a change in lateral radiographs. Upgrading of Herring’s grade from A to B was seen in 11 cases and from B to C in 14 cases as observed in the AP radiographs. The clinical variables and radiological variables did not show any association with progression of Herring’s grade.

Conclusion: The measurement technique of assessing Herring’s classification is much more reliable than the originally described visual method. However, the Herring’s grade changes with the evolution of the disease even during the process of fragmentation and must be used with caution when predicting prognosis.


Brent G. Mollon W. S. McGuffin Jamie A. Seabrook K. Kellie Leitch

Purpose: The treatment algorithm for supracondylar humerus fractures in children under age seven is well-established. However, the best treatment option for these fractures in older children (8–14 year olds) is debated. The purpose of this study was to assess the efficacy of closed versus open fixation methods of this fracture type in older children. We hypothesize that closed reduction and percutaneous pinning (CRPP) is as effective as open reduction and internal fixation (ORIF).

Method: A retrospective chart review was completed of all patients 8–14 years old treated for supracondylar humerus fractures at one centre from 2000–2007. IRB approval was obtained for this study. Demographics, treatment methods, pre- and post-operative complications, functional and radiographic outcomes were reviewed. Values are reported as mean ± standard deviation.

Results: Seventy-eight eligible patients were identified: 60 (76.9%) were treated with CRPP, and 18 (23.1%) were treated with ORIF. Demographics and fracture characteristics were similar between the CRPP and ORIF groups, although patients treated with ORIF were older (p< 0.001) and weighed more (p< 0.001). The ORIF group had higher post-operative complication rates (p=0.016). Five patients treated with CRPP required additional surgery (3 underwent ORIF; 2 underwent repeat CRPP) compared with none in the ORIF group. Children treated with ORIF had greater limitations on active flexion (99.7o ± 18.2 ORIF, 140.5o ± 23.5 CRPP, p< 0.001) and active extension (34.3o ± 19.0 ORIF, 11.9o ± 21.2 CRPP, p< 0.001) at first follow-up. Limitations in active flexion persisted in the ORIF group, but not in the CRPP group, at time of last follow-up (120o ± 14.8 versus 150.4o ± 17.8, p< 0.001). There were no group differences in active extension at last follow-up (p=0.093). On radiographs, significant differences between the groups existed for Bauman’s angles (15.5o ± 5.5 ORIF, 19.3o ± 4.9 CRPP, p=0.013) and carrying angle (12.4o ± 5.7 ORIF, 16.6o ± 5.4 CRPP, p=0.008). Radiographic union was achieved in all cases.

Conclusion: Open and closed surgical fixation are both acceptable treatment options for supracondylar humerus fracture in older children. While ORIF appears to result in reduced range of motion, no further operations were required for fracture alignment in this group.


Christopher W. Reilly Darin Davidson Angeliki Perdios Simon Davidson

Purpose: In children and youth, the prevalence of psychiatric disorder associated with chronic medical illness approximates 30%. The impact of psychiatric disorder on the management of scoliosis has not been well explored in the literature. The objective of this study was to estimate the prevalence of mental health disorders in patients with adolescent idiopathic scoliosis (AIS).

Method: Adolescents being treated for AIS completed the Achenbach Youth Self-Report and one parent completed the Achenbach Child Behaviour Checklist. Both measures are validated for screening of mental health disorders. The prevalence of mental health disorder in this population was estimated on the basis of the proportion that screened positive. Univariate analysis and logistic regression analysis was conducted to estimate the association between variables. A sensitivity analysis was performed to estimate the robustness of the results.

Results: Between October 2006 and February 2008, 61 of 126 adolescents completed the study (48%). Of the 61 subjects, 18 were treated with observation, 26 with bracing, and 17 with surgical intervention. Overall, there were 41 adolescents who screened positive (67%). Sensitivity analysis demonstrated that, of those who did not return the questionnaire, the prevalence of a positive screen would have had to have been less than 0.1% in order to decrease the overall prevalence to 30%. There was a statistically significant difference in the magnitude of the scoliosis between those who screened positive (mean curve magnitude 39 degrees) compared to those who screened negative (mean curve magnitude 30.6 degrees) (p=0.03).

Conclusion: The estimated prevalence of a mental health disorder using the Achenbach questionnaires in patients with AIS is 67%. This is substantially higher than the anticipated prevalence in either the healthy population or those with a chronic illness. The results of this study provide evidence of the high burden of mental health illness amongst those with AIS. The sensitivity analysis demonstrated that the results are robust despite the relatively low response rate.


Connie Poe-Kochert Paul A. Tripi Jennifer Potzman Jochen P. Son-Hing George H. Thompson

Purpose: Postoperative pain is common following posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). It is often treated with intravenous morphine patient controlled analgesia (PCA), but no studies have examined continuous morphine infusion. The purpose of this study was to identify the safety and efficacy of continuous morphine infusion without PCA for post-operative pain management in these patients.

Method: We retrospectively reviewed 338 consecutive patients from 1992 to 2006 who received continuous morphine infusion. Following induction of general anesthesia and prior to surgical incision, patients received intrathecal morphine for preemptive analgesia. Anesthesia was maintained with 50% nitrous oxide and up to 0.6% isoflurane, with minimal or no intravenous opioids. Following surgery, pre-ordered morphine infusion (0.01 mg/kg/hr) began when patients first reported pain. The infusion rate was titrated using a strict protocol based on frequent assessment of vital signs, Wong-Baker visual analog pain scores (VAS), and clinical status. The infusion continued until patients were able to take oral analgesics at postoperative day 2–3. Factors analyzed included patient demographics, intrathecal morphine dosage, intraoperative intravenous opioid dosage, pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirement in the first 48 postoperative hours, and postoperative complications.

Results: Mean intrathecal morphine dose was 15.45 mcg/kg and mean interval to start of morphine infusion was 15:45 hours. Mean VAS pain scores were 3.05, 4.48, 4.48, and 4.60 at 12 hours, 1, 2, and 3 days postoperatively. The total mean dosage of morphine in the first 48 hours postoperatively was 0.03 mg/kg/hr. Nausea/vomiting, pruritis, respiratory depression, and PICU admissions related to the morphine drip occurred in 13.3%, 4.1%, 0%, and 0% of the patients during the same time period.

Conclusion: A low frequency of adverse events and a mean postoperative pain score of 5 or less demonstrates that continuous postoperative morphine infusion is a safe and effective method of pain management in children following PSF and SSI for IS. Continuous morphine infusion without PCA is a safe, alternative method of pain control for postoperative patients with IS.


Jochen P. Son-Hing Connie Poe-Kochert Paul A. Tripi Jennifer Potzman George H. Thompson

Purpose: Do children from different gender or racial groups receive different analgesic doses for the same acute pain condition? We previously reported on intra-thecal morphine for preemptive analgesia in children undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). We determined the optimal dose range to maximize analgesia while minimizing adverse effects. The purpose is to ensure this adopted protocol is equally effective across gender and racial groups.

Method: We studied 407 intrathecal morphine patients. Those given a moderate dose of 9–19 mcg/kg (n=293) had the most effective and safe postoperative pain relief. This group consisted of 246 female and 47 male patients. There were 224 Caucasian (CA) and 63 African-American (AA) patients. Other ethnicities were excluded. Factors analyzed included postoperative Wong-Baker visual analog pain scores (VAS), time to first opioid rescue dose, total morphine dose over the first 48 hours, and postoperative complications.

Results: For female and male gender, mean VAS pain scores in post-anesthesia care unit (PACU) were 0.48 and 0.56, mean times to first opioid rescue dose were 999.1 and 1003.3 minutes, and total morphine over the first 48 hours were 1.5mg/kg in both groups, respectively. Respiratory depression and PICU admission occurred in 2 (4.2.%) and 4 (1.6%) patients, respectively. For CA and AA patients, mean VAS pain scores in PACU were 0.48 and 0.46, mean times to first opioid rescue dose were 991.7 and 1031.9 minutes, and total morphine over the first 48 hours were 1.5mg/kg and 1.3mg/kg, respectively. Respiratory depression occurred in 5 (2.2.%) and 2 (3.2%) patients and PICU admission occurred in 4 (1.8.%) and 4 (6.3%) patients, respectively. StudentÂ’s t-test and Fisher exact test demonstrated no significant differences between genders for all variables, and no significant differences between races except less total morphine for AA patients over the first 48 hours (p=0.0024).

Conclusion: An optimal intrathecal morphine dose range of 9–19 mcg/kg provides effective and safe postoperative pain relief in children undergoing PSF and SSI for IS, regardless of gender or race. Intrathecal morphine can be given with the assurance that it does not discriminate against gender or provide less optimal analgesia to AA patients.


Denise Mackey Firoz Miyanji Renjit Varghese Davor Saravanja Christopher W. Reilly

Purpose: There is scant literature with respect to reproducibility in radiological measurements of vertebral morphology. The purpose was to determine the reliability of measurement of various parameters of vertebral morphology in idiopathic scoliosis.

Method: Ten patients with AIS were investigated with standardised low dose multi-slice helical CT. Axial reconstructions in the plane of the T8 (apical) vertebra were performed prone, as per Jamieson et al (2008). Antero-posterior (AP) canal diameter, left and right pedicle width, canal width, left and right mid-point to medial pedicle length, left and right pedicle length, and cord length, left and right transverse angles, and left and right canal area were measured by our spine surgeons and spine surgery fellow. Statistical analysis for intra-class coefficients (ICC) for intra and inter observer reliability was then performed.

Results: Intra-observer reliability was excellent, with a mean ICC score of 0.930 (range 0.608–0.996), across all fourteen variables. Inter-observer reliability was very good with a mean ICC score of 0.890 (range 0.360–0.987), across all variables. There was poor inter-observer reliability for measurement of the transverse pedicle angles (0.360 – 0.446). The intra-observer reliability for transverse pedicle angles, whilst good (0.608–0.861), was worse than any of the other intra-observer reliabilities.

Conclusion: We demonstrate excellent intra, and inter observer reliability for measurement of apical vertebrae morphology in AIS. This tool can be utilized in the further study of pedicle dysplasia. Measurement of transverse pedicle angle was less reliable than any of the other measurement variables. A standardised measurement of the morphology of vertebral canal, pedicles and vertebral body morphology is reliable both within individual observers, and across a group of observers. A standardised measure for further investigation has been validated which will enable study of the evolution of pedicle dysplasia over time. This will lead to a better understanding of the etiology of pedicle dysplasia in scoliosis.


M. David A. Datta K. Baloch

Introduction: Unicompartmental knee replacement (UKR) is a popular alternative to total knee replacement (TKR) in medial compartment disease. Early problems include bearing dislocation, persistent pain, stiffness and infection. Revision to TKR is well described as a late endpoint.

Objective: Investigate the early surgical management of persistent pain and debility following UKR, identify common themes and rate effectiveness of any re-intervention.

Methods: 381 UKRs implanted over 5 years included, and patients requiring re-operation reviewed retrospectively.

Findings: 27 re-operations performed on 17 patients at a mean 16.8 months (95% CI 9.5 to 24.1), with symptom onset post-operatively at 9 months (95% CI 4–14). There were 10 arthroscopies, 10 total knee replacements (revision), 4 manipulations under anaesthesia, 2 bearing exchanges, and 1 tibial-plateau fracture fixation. Manipulation under anaesthesia improved stiffness in 2 of 3 patients. Arthroscopy was successful in 2 patients with loose cement-bodies but did not provide a diagnosis in 8 patients, of whom 7 were revised subsequently after 17.1 months (95% CI 10.1 to 24.1) with 6 reporting symptom resolution. Overall there were 10 revisions: 9 were performed for persistent pain and 9 reported symptom improvement. Intra-operative findings included aseptic loosening (n=4), synovitis (n=2), increased posterior slope of the tibial cut (n=1), dislocated bearing (n=1), and no cause of failure in 2. Only two cases required revision implants with medial augments for bone loss. There were no deep infections.

Conclusions: The early re-intervention rate at our unit is 4.5% (95% CI 2.4 to 6.5), with a revision rate of 2.6% (95% CI 1.0 to 4.2) after a mean (±SD) follow-up of 40.1 (±16) months. Arthroscopy is a poor diagnostic and therapeutic option against persistent pain following UKR. In contrast, the decision to revise, although initially disappointing for both patient and surgeon, gave symptom improvement in 90%.


R. Nickinson T. Board A. Gambhir M. Porter P. Kay

Aim: To identify the microbiology of infected knee arthroplasty, emerging patterns of resistance over the last decade, and suggest appropriate empirical treatment.

Methods: A retrospective analysis was conducted of 121 patients with microbiologically proven infection, who underwent revision TKA between 1994–2008. The causative organism was identified from microbiological samples and the corresponding sensitivities recorded. The data was then collated to determine the most common causative organisms, changing patterns of antibiotic resistance over the time frame, and the antibiotics currently most effective at treating deep infection. A theoretical model combining gentamicin with other antibiotics was used to determine the most effective antibiotics for use as empirical treatments.

Results: Coagulase negative Staphylococcus (CNS) was the most common causative organism (49%). Staphylococcus aureus (SA) accounted for 13% of cases. The prevalence of CNS appears to be increasing, while that of SA and other organisms is decreasing. Vancomycin and teicoplanin were the most effective antibiotics with overall sensitivity rates of 100% and 96% respectively. Levels of resistance were significantly higher among the antibiotics commonly used in the community. Antimicrobial resistance was higher when the causative organism was CNS, suggesting that MRSE is becoming a problem in knee arthroplasty. Our theoretical model showed that gentamicin combined with vancomycin would be the most effective empirical treatment.

Conclusion: Understanding the microbiology of deep infection of the knee allows surgeons to treat this complication as effectively as possible. Vancomycin and tei-coplanin appear to be the most effective antimicrobials, with relative invulnerability to the development of resistance. Given the effectiveness of these antibiotics, the use of vancomycin in gentamicin bone cement, combined with IV teicoplanin potentially allows for infected knee arthoplasties to be treated with a one-stage procedure. The rational use of antibiotics may help limit the amount of antibiotic resistance which develops in the future.


D. Inman E. Lingard N. Brewster D. Deehan J. Holland A. Mccaskie M. Siddique C. Gerrand

Introduction and Aims: Morbid obesity (BMI> 40) has been shown to cause increased perioperative morbidity and poorer long-term implant survivorship following total knee arthroplasty (TKA). The aim of this study was to determine the impact of morbid obesity on patient-reported outcomes following TKA.

Methods: Patients undergoing primary TKA were invited to complete questionnaires preoperatively and one year after surgery. Questionnaires include the WOMAC and SF-36 health status measures, demographics, self-reported comorbid medical conditions, height and weight. At follow-up, satisfaction with results of TKA is included. Patients were categorised by their preoperative BMI categories as ideal weight (20–25), overweight (> 25–30), obese (> 30–40) or morbidly obese (> 40). We used multivariate analysis to adjust for known significant correlates of WOMAC and SF-36, namely age, gender and comorbid medical conditions. Adjusted mean scores for each assessment were compared by BMI category.

Results: A total of 769 patients were included in the study which included 27 morbidly obese, 280 obese, 314 overweight and 148 ideal weight patients. Morbidly obese patients when compared with non-obese patients had significantly worse preoperative WOMAC pain and function and a trend for worse SF36 scores (Vitality significantly worse, p=0.04). There was no significant difference between the BMI categories at one year for WOMAC or SF-36 scores (trend for the Physical Functioning score to be lower, p=0.052). Morbidly obese patients were all satisfied with pain relief after surgery but were less satisfied with functional results when compared to the non-obese groups.

Discussion: This study shows that morbidly obese patients report significantly worse health status prior to TKA but their post-operative improvement is greater than the non-obese population. Although morbid obesity should not be an absolute contraindication to TKA, patients should be carefully selected balancing the risk of perioperative complications and earlier failure against the demonstrated marked improvement in quality of life.


H. El-Azab P. Klabklay A. Imhoff S. Hinterwimmer

Valgus high tibial osteotomy (HTO) results in changes in the frontal as well as sagittal planes. Our hypothesis suggests that patellar height increases and posterior tibial inclination decreases after closed wedge (cw) HTO, whereas patellar height decreases and tibial slope increases after open wedge (ow) HTO.

Lateral radiographs of 100 knees were assessed for patellar height (PH) using Insall-Salvati (ISI), Caton-De Champ (CDI) and Blackburne-Peel indices (BPI) as well as posterior tibial slope. Measurements were done before HTO (50 cw and 50 ow), direct postoperatively and before hardware removal.

In the cw-group all three PH indices increased direct postoperatively and at removal of the hardware with changes in CDI and BPI being significant (P < 0.05). In the ow-group all three indices showed a significant patellar height decrease direct postoperatively and at hardware removal. There were no significant changes between the two follow-up measurements (P > 0.05). Posterior tibial slope showed a significant decrease of 3.1 ± 3.4° after closed wedge HTO and a significant increase of 2.1 ± 3.6° after ow HTO direct postoperatively. In cw-HTO the correlations between frontal plane correction and PH changes were moderate (CDI: r = 0.57; BPI: r = 0.64). In ow-HTO these correlations were weak (CDI: r = 0.44; BPI: r = 0.46). According to ISI there was no correlation (cw: r = 0.11; ow: r =0.16). There was no correlation between PH changes according to CDI and slope changes.

The incidence of patella infera increases after open wedge HTO, whereas the incidence of patella alta increases after closed wedge HTO. We recommend considering the PH and tibial slope before planning for HTO or TKR after HTO, also performing cw-HTO or ow-HTO with the tuberosity left at the proximal tibia in cases of patellofemoral complaint or patella infera.


P. Gikas T. Parratt R. Carrington J. Skinner G. Bentley T. Briggs

Introduction: Autologous Chondrocyte Implantation (ACI) is a treatment option for symptomatic, full-thickness chondral/osteochondral injuries. Goals of surgery and rehabilitation include replacement of damaged cartilage with hyaline/hyaline-like cartilage, leading eventually to improved level of function. Intermediate and long-term results are promising in terms of functional improvement.

Purpose: To explore the hypothesis that non-hyaline cartilage repair tissue is associated with worse functional outcome and to assess whether the quality of the repair tissue formed following ACI improves with time post-surgery.

Methods and Results: Two hundred and forty eight patients who underwent ACI at our institution were studied, having had post-implantation biopsies of the repair tissue. Mean timing of biopsy was 14.8 months (range 3–55). 59 biopsies showed hyaline tissue (24%), 67 mixed hyaline and fibrocartilage (27%), 113 biopsies were fibrocartilage only (46%) and 9 patients had a fibrous tissue biopsy result (9%). 126 patients (51%) had hyaline tissue in the regenerate and demonstrated a mean Modified Cincinnati Rating Score (MCRS) of 84 and a mean Lysholm Score of 88 at last follow-up (Group 1). 122 patients (49%) had no hyaline tissue in the regenerate and scored a mean MCRS of 71 and a mean Lysholm Score of 73 (Group 2). Both Groups 1 and 2 demonstrated a statistically significant improvement in functional outcome between pre and post-operative scores (p< 0.0001). There was significant difference in post-operative scores between Groups 1 and 2 suggesting that presence of hyaline tissue in the regenerate is associated with improved functional outcome (p< 0.05). Finally, our statistical analysis suggested that if time post-implantation doubles, then the likelihood of a favourable histological outcome increases significantly.

Conclusion: ACI forms a durable repair tissue that remodels and continues to improve in quality with time. Poor functional outcome may reflect the presence of a non-hyaline cartilage repair tissue.


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O.Q. Al-Dadah L. Shepstone S.T. Donell

There has been very little documented regarding the impact of meniscal injuries on knee proprioception. The aim of this study was to investigate the proprioceptive function of patients with meniscal tears and asses the influence that arthroscopic partial menisectomy has on knee proprioception.

One hundred subjects were recruited comprising an Arthroscopy group (50 patients) and a Normal Control group (50 subjects). The Biodex Balance SD System was used to assess proprioception. This equipment measures knee proprioception on an electronic platform. The balance of the subject is computed producing an Overall Stability Index (OSI). Lower scores reflect better proprioception. Knee stability was assessed clinically and with the Rolimeter knee arthrometer. The Lysholm and IKDC scoring systems were used to evaluate all the subjects.

Of the 50 subjects within the Arthroscopy group (all of whom had a normal ACL confirmed) 34 were found to have meniscal tears. Twenty-nine of the 34 patients with meniscal tears returned for their follow-up review 3 months post-operatively.

The proprioceptive function of the injured knee of the Arthroscopy group with meniscal tears (mean OSI 0.86) was significantly poorer compared to that of their uninjured knee (mean OSI 0.62, p< 0.001, 95%CI 0.14, 0.34) and to the Normal Control group (mean OSI 0.49, p< 0.001, 95%CI 0.21, 0.54). There was no significant improvement in their proprioceptive function following menisectomy (mean OSI 0.75, p=0.23, 95%CI −0.07, 0.28). There was a significant improvement of both the Lysholm (p=0.004) and IKDC (p=0.021) scores postoperatively.

Conclusion: These results indicate that there is a demonstrable proprioceptive deficit in patients with meniscal tears even in the presence of a normal ACL. This deficiency in proprioception did not improve within three months following arthroscopic partial menisectomy despite the improvement in functional outcome measures.


P.K. Jaiswal S. Macmull G. Bentley R. Carrington J. Skinner T. Briggs

Introduction: Autologous chondrocyte implantation (ACI) has been used to treat patella cartilage lesions but several studies have indicated poorer results compared to lesions on the femoral condyles. This paper investigates the effectiveness of two different methods of ACI; porcine-derived collagen membrane as a cover (ACI-C) and matrix-carried autologous chondrocyte implantation (MACI).

Methods: 124 patients (mean age 33.5) with symptomatic osteochondral lesions in the patella were selected to undergo either ACI (56 patients) or MACI (68 patients). 1 year following surgery patients underwent check arthroscopy to assess the graft. Functional assessment was performed pre-operatively, at 6 months and yearly by using the modified Cincinnati score (MCS).

Results: 37.5% of patients experienced good or excellent clinical results according to the MCS in the ACI group compared with 69.2% in the MACI group (p = 0.0011). The mean MCS improved from 43.7 pre-operatively to 49.8 2 years following surgery in the ACI group, whereas in the MACI group the improvement was from 44.6 to 60.6 (p=0.07). Arthroscopic assessment showed a good to excellent International Cartilage Repair Society score in 89.7% of ACI-C grafts and 69.6% of MACI grafts (p = 0.08). There was a higher re-operation rate (p = 0.044) in the ACI group (29%) compared with MACI (10%).

Conclusions: The results from this paper suggest that MACI is more successful in the treatment of patella cartilage lesions than ACI even though arthroscopic assessment showed the converse to be true. The higher complication and re-operation rate suggests that we should be treating such patients with MACI.


A. Rees S. Gajjar S. Tawfiq N. Barton-Hanson

Aim: The purpose of this study was to evaluate the results of transphyseal ACL reconstruction technique in skeletally immature patients.

Material & Methods: Between 2002 and 2008, twenty knees in twenty skeletally immature patients with a mean chronological age of 13.2 years (range, 7 to 16.2 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. Ten knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 2.2 years (range, 1.0 to 5.9 years) after the surgery.

Results: No patient underwent revision anterior cruciate ligament reconstruction. The mean International Knee Documentation Committee subjective knee score (SD) was 90.5 (10.0) points and the mean Lysholm knee score was 92.2 (10.0) points. The result of the Lachman examination was normal in 18 knees and nearly normal in two; it was not abnormal or severely abnormal in any knee. The mean increase in total height was 7.2 cm (range, 1.2 to 20.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included one case of knee stiffness requiring physiotherapy, one case of persistent pain leading to medial menisectomy for tear and one case of re-injury five months post ACL reconstruction requiring medial meniscus repair.

Conclusion: Excellent functional outcome was noted in skeletally immature patients after transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. There were very few complications and no growth disturbance.


R. Shariff A. Khan 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 reviewed a consecutive series of 25 children with fixed flexion deformity of the knee who underwent anterior femoral hemiepiphysiodesis using a two-hole plate (8-plate) between April 2005 and April 2008. The pre-operative and postoperative knee flexion deformity (in degrees) and complication rates were also recorded. Paired t-Test was undertaken to assess the correction in the fixed flexion deformity post-operatively

Results: Total number of patients – 25, male:female = 19:6. Total number of limbs – 46

The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001).

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.


S-N. Kang D. Coggings M. Ramachandran

Background: The treatment of congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Dobbs et al in patients with idiopathic congenital vertical talus, but applied in teratologic congenital vertical talus.

Methods: Five consecutive cases of teratologic congenital vertical talus deformity were prospectively followed at a minimum of nine months post treatment with serial casting and limited surgery consisting of percutaneous Achilles tenotomy, fractional lengthening of the anterior tibial tendon, and percutaneous pin fixation of the talonavicular joint. The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Clinical and radiographic assessments were carried out at the initial, immediate postoperative and the latest follow-up.

Results: Initial correction was obtained both clinically and radiographically in all five feet. A mean of eight casts was required for correction. At the final evaluation, the mean ankle dorsiflexion was 20° and the mean plantar flexion was 31°. Radiographically, dorsal subluxation of the navicular recurred in one patient, but was functionally insignificant as the patient was a non-ambulator and required treatment for seating purposes only. At the time of the latest follow-up, there was a significant improvement in all of the measured radiographic parameters compared with the pretreatment values.

Conclusions: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, and deformity correction, in patients with teratologic congenital vertical talus.


S. Gajjar S. Tawfiq N. Garg C. Bruce

Aim: The purpose of the study was to report the outcome of Flexible elastic nailing for femoral shaft fractures in children

Materials and Methods: Sixty-three femoral shaft fractures in 62 children treated with titanium flexible elastic nailing over a 10 year period (1998–2007). There were 44 boys and 18 girls aged 7.4 to 15.6 yrs (mean 11.2 yrs). Their body weight ranged from 22 to 64.80 kg (mean 40.99 kg). The right side was involved in 36 and the left in 27 children (including 1 bilateral fracture). The mechanism of injury varied from Road traffic accidents (RTA) in 42, Sports in 2 and Falls in 18 children. The proximal third shaft was involved in 3, middle third in 50 and distal third in 10 children. The fracture pattern varied from Transverse in 28, Oblique in 21, Spiral in 12 and Comminuted in 2 children.

Results: All fractures united with a mean union time of 15 weeks (range 6 to 30 weeks). The average follow-up was 72 weeks (range 52–104 weeks). Outcome assessment using the Titanium Elastic Nailing (TEN) Score showed 63% excellent, 32% satisfactory and 5% poor results. The minor complications varied from transient knee stiffness in 8 children, prominent nail ends in 7 children, extensor lag in 2 children, and acceptable facture angulation in 2 children. The major complications were fracture malunion, non-union, delayed union in 1 child each and re-fracture at different level in one child. The mean leg length discrepancy after union was 8mm (range 0–13 mm). There were no cases of infection. This method of treatment provided stable fixation, early mobilization and discharge.

Conclusion: We found that good surgical technique with attention to surgical details resulted in 95% excellent to satisfactory outcome.


R. Mohammed C. Bradish

We report the our experience of using the Sheffield intra-medullary telescoping nail system for managing recurrent fractures and deformity problems in the long bones of the lower limbs. 15 children with conditions like osteogenesis imperfecta, fibrous dysplasia and neurofibromatosis were operated from the years 1993 to 2001 and followed up for a mean period of five years nine months. The average age at the time of the initial nailing was six years. In all, 21 femurs and 10 tibiae were nailed.

A total of thirteen complications were noted in seven patients, including re-fractures with the nail-in-situ in seven bones, migration of the rods in four bones, fracture of the nail and one sub-clinical infection after femur nailing. Nine revision operations were necessary to address these problems including removal of the infected nail. All these revisions were successful. The estimated 5 year cumulative survival rate was 73% for femur and 75% for tibia. We have not experienced any evidence of epiphyseal damage after the procedure. All our patients can ambulate independently now.

Elongating intramedullary rods are ideal in children with any condition that can cause recurrent fractures or limb deformity as they improve walking capability and prevent further deformity.


J. Barnes S. Thomas J. Wedge

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study. Standardised, well-centered anteroposterior standing hip radiographs were obtained and using the validated method of Hefti (1995), anterior and posterior acetabular coverage and contact area were measured. From this we were able to extrapalate the acetabular version.

Ten operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks.

Twenty-six hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. 21 further age and sex matched AP pelvis radiographs were taken from the PACS system at random. All of which had been reported as normal by a consultant musculoskeletal radiologist, these formed group C.

The Kruskal Wallis test was used to compare the 4 outcomes, in the 3 groups.

A significant difference between the groups was found for contact area (p< 0.001). There was no significant difference between the other 3 outcomes. Anterior coverage (p=0.509), posterior coverage (p = 0.135) and antirversion (p= 0.845).

Conclusion: Acetabular coverage and anteversion in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. The early osteoarthritic changes seen in these hips may be related to a decreased contact area compared to the normal population. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.


P.N. Unnikrishnan H.L. George D. Shivarathre A. Bass J. Sampath

A significant proportion of children with cerebral palsy (CP) are malnourished. This is particularly the case for trace elements, vitamins and minerals. Children with CP undergoing major orthopaedic procedures lose blood intra operatively leading to post operative anaemia. The aim of our study was to estimate the prevalence of low levels of serum ferritin in children with CP awaiting major orthopaedic surgical intervention.

The ferritin levels and haemoglobin (Hb) were estimated pre-operatively in 35 children with CP (CP group) undergoing major orthopaedic surgery (Hip reconstruction or Single event multi-level surgery). During the same period, we randomly identified 1000 children (Control group) who underwent Ferritin estimation as part of routine investigations. A significant proportion of children in the study group had low levels of serum ferritin in spite of having normal haemoglobin.

It is well-recognised that commencement of iron either orally or intravenously in the post-operative period does not accelerate recovery from anaemia secondary to blood loss. It is important to note that many patients who have normal Hb levels preoperatively are iron deficient. Hb estimation alone is inadequate in this group. We therefore conclude that children with cerebral palsy undergoing major orthopaedic surgery must have their ferritin levels estimated and optimised well in advance of their surgery.


A. Atrey N. Nicoloau F. Norman-Taylor

We review all litigation brought against English Orthopaedic departments involving children under the age of 16 and attempt to highlight areas where they might be avoided. The NHSLA (the National Health Service Litigation Authority) is a special Health Authority responsible for handling negligence claims made against NHS bodies in England. In addition to dealing with claims when they arise, there is an active risk management programme to help raise standards of care in the NHS and hence reduce the number of incidents leading to claims. By analysing the claims data, we have had the opportunity to see trends for which Trusts have litigation brought against them, how much this costs the Health Service and most importantly how this information can aid in clinical practice.

Between 1995 until 2005/06 there were 408 cases involving orthopaedics in England that had reached a conclusion. Of those considered in our study (341), by far the most common broad category for litigation is missed or delayed diagnosis of a condition 179 cases (57% of all litigation cases) with 44% (80 cases) of those being upper limb traumatic injuries. Humeral supracondylar fractures and elbow injuries constitute 24% (44 cases) of all missed diagnoses with each having an average total payout of £27,998. Missed or poorly managed developmental disorders of the hip (DDH or SUFE) also have large total payouts. Other common causes for litigation are intra-operative errors with poor results/complications for fixation of humeral supracondylar fractures again being the most common. Complications of plasters also represent 7.3% of all claims, all with high total payouts.

In assessing these trends, we suggest highlighting the potential for error during training of juniors and taking extra care during clinical practice. There are also implications identified for the planned provision of Orthopaedic care of children.


H. Akrawi M. Uglow M. Marsh

Introduction: Infection with Neisseria Meningitidis remains one of the most devastating illnesses in paediatrics. Affected patients can progress from a mild viral-like illness to septicaemia and death within a matter of hours. We present our clinical experience in identifying and managing the orthopaedic complications associated with meningococcal septicaemia and highlight the long-term problems of physeal growth arrest especially after limb amputation.

Methods: Between August 1997 and June 2005, 88 consecutive children aged from 1 month to 17 years were admitted to the paediatric intensive care unit with meningococcal septicaemia. These patients were retrospectively assessed for orthopaedic manifestations.

Results: During the acute phase of the disease, there were six deaths and 22 patients suffered tissue loss from amputations. Twenty digits were allowed to demarcate and were subsequently amputated. Ten Limb amputations were performed in 6 patients, all of which developed physeal growth arrests proximal to the level of amputation. Four patients had a substantial rise in lower leg compartmental pressures but only two patients underwent fasciotomies, one of which required bilateral below knee amputations.

Conclusions: Meningococcal septicaemia is a potentially lethal paediatric disease. In the acute phase, 22 patients needed orthopaedic input to address complications related to tissue loss, vascular and ischemic problems. Limb amputations due to meningococcal septicaemia will invariably result in physeal damage and our recommendation is that patients should always be screened for this late sequela after index admission. Additionally, early compartment decompression does not appear to improve limb survival.


T. Okoro A. Qureshi B. Sell P. Sell

Purpose of study: Self reported walking distance is a clinically relevant measure of function. Our aim was to report patient accuracy and understand factors that might influence perceived walking distance.

Method: A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and Modified Zung Depression index (MZD).

Results: There are over-estimators and under-estimators. Overall the accuracy to within 10 yards was only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 121.4 yds; mean response 268yds (95% CI 192.8–344.15), Functional test 1 actual distance 32 yards; mean response 78.4 yds (95% CI 58.6–97.3), Functional test 2 actual distance 21.4yds; mean response 51.9yds (95% CI 38.3–65.5). Surprisingly patients over 60 years of age (n=43) are twice as accurate with each test performed compared to those under 60 (n=60) (average 70% overestimation compared to 140%; p=0.06). Patients in social class I (n=18) were more accurate than those in classes II–V (n= 85) (59% vs 131% p=0.13). There was a positive correlation between poor accuracy and increasing MZD (Pearson’s correlation coefficient 0.250; p=0.012). ODI, LBOS and other parameters measured showed no correlation.

Conclusions: Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate.


A. Nandakumar N. Bilolikar N. Clark M. Vadhva A. Pawulska D. Wardlaw F.W. Smith

Purpose: Correlation of clinical outcome of X stop interspinous process decompression in patients with symptomatic lumbar spinal stenosis is made with spinal canal area change on positional MRI.

Method and Results: Clinical outcome was assessed by ZCQ, ODI, SF36 and VAS scores. There is clinically significant improvement if two ZCQ domains improved > threshold or patients were satisfied. Dural sac area was measured standing erect and sitting, neutral, flexion and extension preoperatively and at 2 years. Increased dural sac area was taken as radiological improvement.

Thirty-six patients had MRI at 2 years. Using paired t test we noted statistically significant increase in mean dural sac area in all four positions mentioned above. There was clinical improvement in 26 and some or no improvement in 10 patients. Number with increase in canal cross sectional area was 28 and that with reduced area was 8. Clinical and canal area improvement was seen in 20 (56%) patients and clinical improvement with reduced canal area was seen in 5 (14%). Some or no clinical improvement with canal area improvement occurred in 8 (22%) patients and no significant clinical or canal area improvement in 3 (8%).

Conclusions:

Majority of patients (56%) showed clinical and cross sectional area improvement at 2 years.

One patient with no clinical improvement had subsequent decompression surgery (this patient had dural cross sectional area improvement).

64% patients had similar clinical and dural cross sectional area changes but there is not a clear-cut correlation between clinical outcome and change in canal cross-sectional area.

Interest statement: Commercial/industry support: Medtronics


T. Kurien R. Pearson B. Scammell

Background: Autologous bone graft remains the “gold standard”, but the associated morbidity and finite supply of tissue has resulted in surgeons seeking methods of enhancing healing with bone graft substitutes and bone morphogenic proteins (BMPs). There are 54 bone graft substitutes and 2 BMPs currently on sale in the UK. The aim of this study was to review the published clinical evidence in support of their use in spinal surgery.

Methods: The 19 manufacturers of bone graft substitutes and BMPs were contacted asking for details of their products on the market. A systematic literature review was conducted using the ISI Web of Knowledge, EMBASE (1980–2008) and OVID databases. Publications providing clinical data were classified according to the hierarchy of clinical evidence published in the Journal of Bone and Joint Surgery Am in 2003. Level I evidence is a prospective randomised control trial with definitive results to support the use of an intervention in a clinical setting. Level V evidence is isolated case reports. A Grade of recommendation A-i was accredited to each product to assist the clinical spinal surgeon in making decisions on which product to use based on the evidence in the literature.

Results: 102 clinical studies found, most of which were level IV or V evidence. Both BMPs, InductOS® and OP-1® have Level I papers and have Grade A recommendation. There is very poor evidence for the use of bone graft substitutes in spinal surgery with no products receiving Grade A recommendation and only 6 out of 54 products having Grade B recommendation.

Conclusions: There is a lack of evidenced based clinical data for the use of bone graft substitutes in spinal surgery. Regarding BMPs there is good evidence for the use of these products in spinal surgery but surgeons must be aware of the reported complications.


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J. Langdon S. Molloy J. Bernard

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones. However, the spine is the most common site of skeletal metastases. A MR-based scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body.

Methods: A retrospective analysis of 101 vertebral body metastatic lesions was carried out. The metastases were identified through the onco-radiology database. Only lesions with a MR scan and subsequent imaging within 24-months of the index scan were included. Variables potentially predictive of impending fracture were analysed for significance. The significant variables were then statistically weighted. The original MR scans were scored, and the subsequent imaging was used to identify which lesions fractured. The scores were compared between the fracture and non-fracture group. Analysis was carried out for each predictive variable to establish whether they were individually as good as the scoring system alone in predicting fracture. Intra and inter-observer variability was assessed using kappa statistics.

Results: Twenty-one of the 101 lesions fractured within 24 months. A mean score of 0.65 was identified in the non-fracture group, whilst the fracture group had a mean score of 6.52 (p< 0.0001). The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 4, so did the percentage risk of fracture (sensitivity 85.7%, specificity 97.5%). Very good intra and inter-observer agreement was present, showing the scoring system to be reliably reproducible.

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 3 or less can be left untreated. Lesions with scores of 4 or higher are at risk of fracture and should be considered for prophylactic cement augmentation.


B. Ollivere H. Chase J.M. Powell D.S. Hay D.J. Sharp

The recent NICE guidelines on management of osteoarthritis outline weight loss as first line treatment in degenerative joint disease in the obese. There is little data surrounding the effects of obesity on the outcomes in spinal surgical interventions. Intervertebral discectomy is one treatment for prolapse of a lumbar vertebral disc. We aim to investigate the effect of obesity on outcomes for discectomy.

Demographic details including age, sex, weight and BMI were recording with a pre-operative Oswestry Disability Index (ODI). The fat thickness was measured at L5/S1 using calibrated MRI scans. Outcome measures included complications, length of surgery and change in ODI at 1 year following surgery. Obesity was defined as a body mass index of over 30. The units Serial patients undergoing discectomy were recruited into the study. Patients with bony decompression, instrumentation, revision surgery or multilevel disease were excluded.

Fifty patients with a single level uncomplicated disc prolapse were entered into the study. Sixteen patients had a BMI over 30 and so were obese, whilst 34 had a BMI of less than 30. The mean pre-operative ODI was 46.5 in the obese group and 52 in the normal group this difference was not significant (p> 0.05). The mean post operative ODI was statistically improved in the high BMI group at 28 (18.5 point improvement) and 25.2 (29.1 point improvement) in the normal group. The ODI improvement was significantly better in the low BMI group (p=0.036). There was no significant difference in operative time (p=0.24). Only a single patient had a complication (dural leak), so no valid comparison could be made.

The outcomes of spinal surgery in the obese are mixed.

We found no increase in the complication rate or intra-operative time associated with an increased BMI. However, the improvement in ODI was significantly better in the normal BMI group.


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B. Balain G. Findlay D. Jaffray

How much sway is significant for a traditional Romberg test has always been open to interpretation and debate. Prospective and detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a pro-prioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.


A. Nandakumar N. Bilolikar N. Clark J. Peehal M. Vadhva F.W. Smith D. Wardlaw

Purpose: Correlation of the clinical outcome of X stop interspinous process decompression (IPD) in patients with symptomatic lumbar spinal stenosis (LSS) is made with their preoperative disc heights.

Method: 45 patients, who had clinical follow-up at 2 years, had pre-operative erect positional MRI scans. Clinical outcome was assessed by Zurich Claudication Questionnaire,ODI,SF36 and VAS scores.ZCQ is the most condition specific for LSS and was used. There is clinically significant improvement if two ZCQ domains improved > threshold (SS> 0.46, PF> 0.42, PS< 2.4) or patients were satisfied. Disc heights were measured in the standing erect posture. Osiris 4.17 software program was used for measurements. Statistics used was Chi-Square test with cross tabulation.

Results: There was clinical improvement in 33 and some or no improvement in 12 patients. Overall preoperative range of disc heights was 1.8 to 10.05 mm, median 5.93. Disc height was less than or equal to 5mm in 21 patients and it was > 5 mm in 24 patients.19 patients who had initial disc height of > 5 mm and 14 patients who had disc height of less than or equal to 5 mm had clinically significant improvement. In the group of patients who had some or no improvement the numbers were 5 and 7 respectively. We found a difference between the groups with bigger and smaller preoperative disc heights and a larger proportion of patients with bigger preoperative disc height had better clinical outcome. This difference was not statistically significant, P = 0.350.

Conclusions: The X stop device remains clinically effective at the end of 2 years in the majority of patients. Overall patients who had bigger preoperative disc heights 79% (i.e. 19/24 who had > 5mm initial disc height) had better clinical outcome compared to those with smaller preoperative disc heights.

Interest statement: Commercial/industry support: Medtronics


P. Dewan V. Batta P. Khan H. Prabhakar

Background: Traditionally, lumbar discectomy is performed under general anaesthesia because of ability to perform operations of long duration in prone position with a secure airway. Some recent reports suggest better outcomes with regional anaesthesia.

Aim: The aim of this study was to compare the intra-operative and short-term post-operative outcome variables in patients undergoing primary single-level lumbar discectomy with epidural and general anaesthesia.

Methods: This was a prospective randomized trial involving sixty patients over a two-year period in a tertiary hospital in India. Patients were allocated into two groups: Group A (n=30) patients received general anaesthesia and Group B (n=30) patients received epidural anaesthesia. Baseline and intra-operative haemodynamic parameters, surgical duration, surgical onset time, intra-operative blood loss, cost incurred by patient, nausea and vomiting and post-operative pain score were also recorded.

Results: The groups were comparable for demographic data and baseline hemodynamic observations. Patients in the epidural anaesthesia group had significantly lower blood loss (p< 0.001), lower peak pain scores (p< 0.001), lesser surgical time (p< 0.001),and significantly reduced post-operative nausea and vomiting (p< 0.01) as compared to the general anaesthesia group. The cost incurred for epidural anaesthesia was two third of that incurred in general anaesthesia (p< 0.001). Epidural group had significantly more surgical onset time (p< 0.001)

Conclusion: Lumbar discectomy can be safely performed using epidural anaesthesia. The intra-operative blood loss, surgical duration, cost incurred by the patient, postoperative nausea, vomiting and pain are significantly reduced in patients receiving epidural anaesthesia, thereby leading to a significantly higher patient satisfaction. In the present climate of NHS, where any initiative to cut down the cost of resources consumed is welcomed as long as the patient safety is not compromised, epidural anaesthetic may provide an effective alternative to general anaesthetic for lumbar discectomy.


N. Hunter R. Clayton I. Brenkel

The Depuy Sigma Total Knee Arthroplasty (TKA) was introduced in 1997 as a modification of the Pressed Fit Condylar (PFC) TKA. It is the most commonly used TKA in England and Wales, accounting for 34.9% of all primary TKAs performed in 2006. The PFC has reported 10-year survival rates of 90–95%. This study reports the first clinical and radiological outcomes at 7–9 years following TKA using the PFC Sigma prosthesis.

Three hundred and eighteen consecutive Sigma TKAs were performed in 275 patients between October 1998 and March 2000. Patients were prospectively followed up in a specialist nurse-led clinic. Final review was performed in December 2007 or January 2008, i.e. 7–9 years post surgery. Outcome measures included American Knee Society Scores, Radiographic Scores and Oxford Knee Scores. Survival analysis was performed using the life table method.

Of 318 Sigma knees, 225 (193 patients) were alive at 7–9 years. 6 knees in 5 patients were lost to follow up. 7 knees (2.2%) were revised: 6 for infection within the first two years and 1 at 59 months who underwent isolated change of polyethylene insert. The 9-year survival was 97.7% with revision for any reason as endpoint and 99.6% with revision for aseptic failure as endpoint. The mean American Knee Society Knee score was 84/100 at 7–9 years compared with 33/100 pre-operatively. 0f 140 radiographs, 48 knees had radiolucent lines but no knee showed radiological evidence of loosening.

These results suggest that the Sigma TKA gives excellent clinical results up to 9-years.


W. Chan P. Musonda A. Cooper M. Glasgow S. Donell N. Walton

We report a retrospective study of the major complications following one-stage and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally- invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage bilateral UKR and 80 patients (160 UKRs) had two-stage bilateral UKRs. The remainder were unilateral UKRs.

The bilateral UKR groups were comparable in age and ASA grade, but more females were in the two-staged group (p=0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep vein thrombosis (DVT) and adverse cardiac events within 30 days of surgery.

No statistical differences between the groups were found regarding operating surgeon, tourniquet time or minor complications (excepting distal DVT). Anaesthetic times were greater for the two-stage group (p= 0.0001). Major complications were significantly more common with one-stage bilateral UKR (13 patients, 8.2%) compared to two-stage bilateral UKR (no patients) (p=0.005). Distal DVT was more frequent in the two-stage group (p=0.036).

This series reports significantly higher risks of major complications are associated with one-stage bilateral UKR when compared to two-stage bilateral UKR. There is no evidence that the addition of chemical thrombo-prophylaxis would change this risk. We advocate caution before undertaking a one-stage bilateral UKR.


J.A. Cordell-Smith M. Izzat C. Adam R. Labrom G. Askin

Introduction: Compared with open instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS), endoscopic surgery offers clinical benefits that include reduced pulmonary morbidity and improved cosmesis. However, quantitative data on the radiological improvement of vertebral rotation using this method is limited. The aim of this study was to measure pre-operative and postoperative axial vertebral rotational deformity at the curve apex in endoscopic anterior instrumented scoliosis surgery patients using computed tomography (CT), and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction.

Methods: Between November 2002 and August 2005, twenty patients with right-sided thoracic curves underwent endoscopic single-rod anterior instrumented fusion. Pre and post surgical axial vertebral rotation was measured at the curve apex on preoperative and two-year postoperative CT using Aaro and Dahlborn’s method. Rib hump deformity correction was retrieved from a surgical database and correlated to the CT findings. Linear regression was used to investigate the correlation between apical vertebral rotation measured on CT and rib hump measured using a scoliometer.

Results: The mean angle of correction achieved in axial vertebral body derotation at the apical vertebra as measured by CT was 7.9°. This equated to a 43% improvement (range 20–90%). The preoperative and postoperative clinical measurements i.e. rib hump deformity correction, correlated significantly with CT measurements using regression analysis (p=0.03) and the mean improvement in rib hump deformity was 55%.

Conclusion: To our knowledge, this is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves the axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares favourably historically published figures for all-hook-rod constructs in posterior spinal fusion. In addition, the CT measurements obtained significantly correlated to the clinical outcome of rib hump deformity correction.


A. Agarwal A. Agarwal H. Chandra A. Chaudhry

Arthritis may cause mild to moderate pain at rest, joint stiffness and varus or valgus deformity. This may prevent a person from working or prevent them from sitting cross-legged, squatting, climbing the stairs or walking distances. The role of osteotomy have been studied. One hundred cases were performed over a 5 year period and the results were evaluated.

There were 44 men and 56 women. The majority were sedentary workers. The majority of the patients had symptoms for between 1 and 2 years. Pain was mostly located on the medial side and there was no pre-operative feeling of instability. The pre-operative range of movement was between 90–120 degrees in 68% of cases.

In 20 cases, a dome osteotomy was performed. In 80 cases a wedge osteotomy: 75 cases were valgus osteotomy and 5 cases by varus osteotomy. All patients benefited from surgery as regards the relief of pain. Very old and obese patients showed poor results after surgery due to their inability to do the required physiotherapy. The patients having a shorter duration of symptoms showed greater radiographic improvement than those with a longer duration of symptoms.

The patients with 1–10 of postoperative valgus alignment obtained the most pain relief and a good range of motion. Over correction and failure to achieve valgus showed poor results. Overall, 52 % of patients showed good results, 35 % fair and 13% poor results.


A. McGrath K. De Silva M. Parratt M. Sewell W. Ledingham

Introduction: Polymodal anaesthesia has become the core approach for the modern anaesthetist. Femoral, sciatic and obturator nerve blockade, individually or in combination, by means of either single shot or continuous infusion, are often used as adjuncts to general anaesthesia in knee arthroplasty.

Methods: We examine the outcome of 2 groups of 100 patients from 2 surgeons and their anaesthetists. All patients received a general anaesthetic. The first group receive a single shot femoral and sciatic nerve block, the second group a standard GA and local infiltration of the surgical field. Post operatively, both groups received identical analgesic regimes and rehabilitation programmes.

Results: Length of stay was prolonged in the nerve blockade group, with 21 of the 100 patients still in hospital on day 6 versus 9 patients in the local infiltration group. An initial advantage in flexion and extension in the nerve blockade group was reversed by day 2 and persisted thereafter. Motor dysfunction was seen to be more prevalent and of longer duration in the nerve blockade group. Muscle groups supplied by the sciatic nerve were 4 times more likely to be involved than those supplied by the femoral nerve. Dysaesthesia in the sciatic nerve dermatomes was 5 times more likely within the nerve blockade group, but less likely in the local infiltration group. No significant difference in rates of VTE. Pain control was superior and less analgesia was required in the nerve blockade group. Fewer patients required urethral catheterisation in the local infiltration group. One heel ulcer occurred in the nerve blockade group. Tourniquet time, significant as a possible contributor to nerve injury, was similar.

Conclusion: Nerve blockade in knee arthroplasty not recommended.


S. Nawaz Z. Khan U. Chatterji C. Esler

This study presents the intraoperative findings of a cohort of 201 cases of failed Unicompartmental knee arthroplasties (UKA) from the Trent Wales arthroplasty audit group (TWAAG) register from 1990 to 2008. The main objectives of the study were to determine the common modes of failure and trends in implant systems used using sex and age matching criteria.

Results demonstrate the varying reasons for revision, use of augmentation and surgical preference in revision system. Results include survival rates and revision rates of UKA from the Trent Wales arthroplasty audit group. The average patient age at revision surgery with the average times from primary UKA to total knee arthroplasty are demonstrated. Aseptic loosening was the commonest reason for revision in both younger and older age groups, closely followed by Polyethylene wear in the younger age group versus progression of osteoarthritis in the other compartments in the older age group. The commonest implant used was Oxford unicompartmental knee system at primary surgery with the PFC implant used in almost 50% of all cases that were revised. This study demonstrates the survival rate of UKAs to be significantly higher in female patients and in those patients with primary UKAs at a younger age. The trends in revision systems have changed over the years. In the early years, over 50% used the PFC knee systems, compared to the latter eight years where the majority used revision knee systems, (e.g. LCCK and Legion). This trend is due to increased availability and ease of use of revision systems. The commonest site of augmentation was for tibial bone defects. Approximately 50% of all augmented cases required tibial blocks or wedges.

Although current thinking suggests most UKAs can be revised to a primary total knee system without difficulty, a significant proportion required revision implant systems with associated implications.


M.T.R. Parratt S. Macmull P.D. Gikas K. Gokaraju R.W.J. Carrington J.A.M. Skinner G. Bentley T.W.R. Briggs

High Tibial Osteotomy (HTO) is a recognised method of correction for knee joint malalignment and unicom-partmental osteoarthritis. Long-term results of this technique have been reported and are favourable. Good results have also been reported with Autologous Chondrocyte Implantation (ACI-C, MACI). Malalignment, if present, should be corrected when ACI is performed. Although results have been reported for either procedure separately, the outcomes of combined HTO-ACI remain unreported. The aim of this study was to evaluate functional outcome in patients undergoing combined HTO-ACI procedures.

Twenty three patients undergoing a combined ACI-HTO procedure were identified retrospectively from a larger trial of patients undergoing ACI for symptomatic chondral defects. The mean age of the patients was 36 (28 – 49). The mean follow-up was 54 months (12 – 108) and mean defect size was 689mm2 (range 350 – 1200). Nine patients had ACI-C and HTO, the remainder having MACI and HTO. Pre and post-operative assessment was carried out using the Visual Analogue Score (VAS), the Bentley Functional Rating Score and the Modified Cincinnati Rating System.

The Mean VAS score improved from 7.4 (4 – 10) pre-operatively to 2.9 (0 – 6) post-operatively at the latest follow-up (p< 0.0001). The Bentley Functional Rating Score improved from 2.9 (2 – 4) to 1.8 (0 – 4), which was statistically significant (p< 0.0001). The Modified Cincinnati Rating System improved from 35.2 (20 – 49) pre-operatively to 68.7 (46 – 85) post-operatively (p< 0.0001). Fourteen patients underwent biopsy of the graft site at a mean of 13.7 months: 21% of biopsies were hyaline-like cartilage, 36% were mixed hyaline/fibrocartilage, 29 % were fibrocartilage and 14% were fibrous tissue.

Combining high tibial osteotomy with autologous chondrocyte implantation is an effective method of decreasing pain and increasing function in the short term. Further evaluation of this procedure is required.


T. Spalding F. Almqvist M. Brittberg B. Cole J. Farr T. Hosea A. Imhoff B. Mandelbaum S. Nehrer J. Richmond

The Cartilage Autograft Implantation System (CAIS) is being investigated as a potential alternative surgical treatment to provide chondrocyte-based repair in a single procedure for articular cartilage lesion(s) of the knee. CAIS involves preparation and delivery of mechanically morselized, autologous cartilage fragments uniformly dispersed on a 3-dimensional, bio-absorbable scaffold and fixated in the lesion with bio-absorbable staples. CAIS maintains chondrocyte viability and creates increased surface area, which facilitates the outgrowth of embedded chondrocytes onto the scaffold. A proprietary disposable arthroscopic device for harvesting precisely morselized cartilage tissue is used.

In an EU pilot clinical study involving 5 countries 25 patients were randomized and treated using a 2:1 schema of CAIS:microfracture (MFX). Subjects returned for follow-up visits at 1 and 3 weeks and then 2, 3, 6, 9, 12, 18 and 24 months and were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Outcomes at each time point were analyzed with Students t-test.

This study showed that CAIS is safe to use. During the first year, the clinical outcome data in both groups were similar. However, at 18 and 24 months we noted that selected outcome measures were different. At 18 months the Sports & Recreation values were 50.6 ± 22.70 and 21.3 ± 33.25 (p=0.016) for CAIS and MFX respectively and at 24 months 52.1 ± 27.9 and 26.7 ± 26.2 (p=0.061) for CAIS and MFX respectively. At these same time points the Quality of Life data were 43.0 ± 27.14 and 27.2 ± 29.11 (p=0.2) for CAIS and MFX respectively (18 months) and 45.1 ± 28.07 and 20.5 ± 21.47 (p=0.062) for CAIS and MFX respectively (24 months).

While some of the data are not significantly different in this pilot study, taken together they do provide evidence to support the initiation of a more robust clinical trial to investigate efficacy.


S. Jameson P. James M. Reed J. Candal-Couto

Background: Diagnostic and operative codes are routinely collected on every patient admitted to hospital in England and Wales (hospital episode statistics, HES). Linked data allows post-operative complications to be associated with the primary operative procedure, even if patients are re-admitted following a successful discharge. Morbidity and mortality data on shoulder surgery have not previously been available in large numbers.

Methods: All HES data for a 42-month was analysed and divided into three groups – elective shoulder replacement (total or hemiarthroplasty), shoulder arthroscopy (all procedures), and proximal humerus fracture surgery (internal fixation or replacement). Incidence of pulmonary embolism (PE), deep venous thrombosis (DVT) and mortality within 90 days was established.

Results: For elective shoulder replacement (10735 patients), 90-day DVT, PE and mortality rates were 0.07%, 0.11% and 0.36% respectively. Mortality in patients over 75 years was 0.9%. For arthroscopic procedures (66344 patients), 90-day DVT, PE and mortality rates were 0.01%, 0.01% and 0.03%. For proximal humerus fracture surgery (internal fixation or replacement, 4968 patients) 90-day DVT, PE and mortality rates were 0.20%, 0.38% and 2.98%. Mortality in patients over 75 years old was 6.6%.

Discussion: Venous thromboembolic (VTE) prophylaxis is rarely used for upper limb surgery. PE and mortality rates for shoulder replacement and proximal humerus fracture surgery are lower those for patients receiving chemical prophylaxis after hip replacement. Further investigation into the cause of high mortality rates following fracture surgery in patients over 75 years old is required. VTE prophylaxis may be required in this age group.


K-Y. Saw S-C. Loke Y-G. Tay

Purpose: To assess the results of chondrogenesis in the knee joint following subchondral drillings into chondral defects followed by post-operative intra-articular injections of autologous peripheral blood stem cells (PBSCs) in combination with hyaluronic acid (HA).

Methods: 10 patients with full thickness chondral defects treated with arthroscopic multiple subchondral drillings from an on-going clinical trial were included, with a minimum follow up of two years. Post-operatively, the operated knee was placed on continuous passive motion two hourly per day for a period of 4 weeks and was on partial weight bearing for the first six weeks. Autologous PBSCs were harvested by the process of apheresis after surgery. The harvested PBSCs were then divided into vials and cryo-preserved for later use. One week after surgery, a five weekly intra-articular injections of PBSCs (2.5mls) mixed with HA (2mls) were commenced.

Results: Sequential MRI scans showed healing of the subchondral bone with evidence of chondrogenesis. Second look arthroscopy with biopsy on four patients confirmed chondrogenesis and satisfactory incorporation of the newly regenerated cartilage with the surrounding articular cartilage. Chondral biopsy showed full thickness mature chondrocytes with the presence of hyaline cartilage. All patients showed improved IKDC scores post-operatively. Apart from the discomfort of PBSCs harvesting and localized pain associated with the intra-articular injections, there were no other notable adverse reactions.

Conclusion: This is a simple and effective method of regenerating articular cartilage involving only a single arthroscopic procedure followed by post-operative out-patient intra-articular injections of autologous PBSCs combined with HA.


K.F. Almqvist D. Saris J. Vanlauwe J. Victor F. Luyten

Purpose: Long-term follow-up was to determine clinical benefit of ChondroCelect (CC) in the repair of full-thickness femoral cartilage lesions as compared to microfracture (MF).

Methods: In a randomized controlled clinical trial CC (n=57) was compared to MF (n=61) in patients aged 18 to 50 years with single ICRS grade III/IV symptomatic cartilage defects of the femoral condyles. Clinical improvement was measured up to 36 months using the KOOS (Knee injury and Osteoarthritis Outcome Score). Safety was monitored throughout the study.

Results: At baseline, KOOS was comparable between treatment groups (Mean ± SD: CC, 56.30 ± 13.61 and MF, 59.53 ± 14.95). Improvement from baseline in adjusted mean ± SE for the Overall KOOS was 21.25 ± 3.60 for the CC group vs. 15.83 ± 3.48 for the MF group at 36 months. When using the mixed linear model analysis at 36 months, statistically significantly greater improvements were demonstrated in the CC group vs. the MF group in change from baseline for the overall KOOS (D 7.60%, P = 0.018), as well as in 4 of 5 KOOS domains (activities of daily living, pain, symptoms/stiffness, and quality of life). Percentages of treatment responders were 83% (n = 34/41) vs. 62% (n = 31/50) based on the KOOS for CC and MF groups, respectively. Two (3.9%) patients in the CC group and 7 (11.5%) patients in the MF group underwent a re-intervention and were therefore considered treatment failures. Both treatments were well tolerated and the proportion of patients reporting AEs diminished over time, indicating stabilization of the patients’ condition.

Conclusions: Implantation of ChondroCelect in the treatment of articular cartilage defects of the femoral condyles shows superior clinical benefit at 36 months vs. microfracture. Structural superiority in favour of the ChondroCelect group was previously demonstrated at 1 year follow up.


A. Dekker S. Evans B. Scammell

Aim: To reduce the amount of blood wastage in our unit.

Method: In 72 patients, the number of blood units cross-matched and the haemoglobin/haematocrit fall were audited for primary total shoulder replacement (n=44), primary hemiarthroplasty (n=21), and revision shoulder replacement (n=7) over twelve months (January 2008 to December 2008). The amount of crossmatched blood was compared to the amount of blood transfused, pre-operative haemoglobin and fall in haemoglobin/haematocrit.

Results: 23 of 44 primary total shoulder replacements and 5 of 21 hemiarthroplasties were crossmatched 55 units preoperatively. 4 of the 7 revision arthroplasties were crossmatched 7 units preoperatively. No units were transfused. 4 patients were later transfused 2 units each for symptomatic low haemoglobin at day 3–5 postoperatively from postoperatively crossmatched blood. No correlation existed between preoperative haemoglobin and number of units blood ordered. A haemoglobin reduction of ~2.5 g/dl was seen for both primary and revision surgery. There was significant correlation between low preoperative haemoglobin and need for transfusion (p< 0.05). Nearly all patients in whom blood was crossmatched rather than group and saved, belonged to one consultant. No patients had an adverse outcome due to a lack of immediately available cross-matched blood.

Conclusion: A large amount of blood was crossmatched and no units used in primary and revision shoulder replacement surgery. We recommend group and save only in primary shoulder arthroplasty and crossmatch of 2 units for revision shoulder surgery. Providing pre-operative haemoglobin is > 11.5 g/dl, group and save is safe even for revision shoulder arthroplasty. Wastage of blood could be reduced to zero in our unit. We recommend regular audit as a tool to ensure compliance with guidelines, and for clinical governance purposes ensuring guidelines remain best practice.


L. Crawford N. Thompson I.A. Trail J.F. Haines D. Nuttall A. Birch

The treatment of patients with arthritis of the glenohumeral joint with an associated massive irreparable cuff tear is challenging. Since these patients usually have proximal migration of the humerus, the CTA extended head allows a surface with a low coefficient of friction to articulate with the acromion.

Between 2001 and 2006 a total of 48 patients with arthritis of the shoulder joint associated with a massive cuff tear, were treated with a CTA head. The indications for use being Seebauer Type 1a and 1b appearances on x-ray and active abduction of the arm to more than 60° with appropriate analgesia. Preoperatively, a Constant score and an ASES pain and function score were completed as well as standard radiological assessment. These were repeated at follow up. Paired t tests were carried out for all the variables. A Kaplan-Meier survival analysis was performed.

Follow up varied between 2 and 8 years. Improvements in pain, function and all movement parameters were significant at p< 0.001. There was no change in the strength component. Survival analysis showed 94% survival at 8 years (95% CL 8%) there were 2 revisions and 5 deaths. Radiological assessment at follow up revealed no evidence of humeral stem loosening. In 5 (17%) cases however there was evidence of erosion in the surface of the acromion and in 13 (45%) erosion of the glenoid. Finally one component was also seen to have subluxed anteriorly.

This head design has been in use for a number of years. To date there appears to be no reported outcome of their use. This series shows that in an appropriately selected patient a satisfactory clinical outcome can be maintained in the short to medium term. The presence of erosion of the glenoid but also the under surface of the acromion does require continuing monitoring.


N. Clement K. Mathur R. Colling A. Stirrat

The metal backed glenoid component in total shoulder replacement (TSR) has been associated with high revision rates and some authors have suspended the use of this implant.

The aim of this study was to evaluate the medium to long-term outcome of the metal backed glenoid component in rheumatoid patients.

Thirty-nine patients (46 shoulders) with a mean age of 55 years (35–86 years) received a TSR with a screw fixed porous coated metal-back glenoid. Ten were lost or died before 8 years follow-up, of which none were revised. Twenty-nine patients (36 shoulders) were followed up for a mean of 132 months (96–168 months). A Constant score was measured preoperatively and annually from time of surgery, and independently at last follow-up. Radiographs were assessed for lucency, loosening and superior subluxation of the humeral head.

The Constant score improved by 12.9 points (p=< 0.001). Implant survivorship at 10 years was 89%. Five were revised: 3 for pain secondary to superior subluxation, one for infection and one for aseptic loosing. All patients with lucent zones around the glenoid (four) had superior subluxation of the humeral head two to four years prior to their development. Survival rate however at 10 years was reduced, if judged by the development of superior subluxation on radiographs (33%).

The uncemented glenoid performs well in the rheumatoid shoulder, giving pain relief and improved functional outcome. The survivorship is comparable to previously reported studies.


T. Baring P. Cashman A. Majed P. Reilly A. Amis R. Emery

Objective: There is no non-invasive gold standard for measuring gap formation following rotator cuff repair; re-tears are reported both on MRI and Ultrasound. We present a novel RSA technique using a combination of 1mm tantalum beads and metal sutures to allow monitoring of gap formation following rotator cuff repair.

Methodology: We carried out ten open rotator cuff repairs with using trans-osseous sutures on patients with moderate to massive tears. During surgery RSA markers were inserted into the shoulder to allow postoperative monitoring of the repair. These markers took the form of 1mm RSA tantalum beads in the greater tuberosity, distal to the repair site, and three metal sutures in tendon, proximal to the repair site. Direct measurements of the distance between the markers each side of the repair were taken intra-operatively (T=O). RSA images were taken of the repair immediately postoperatively (T=1–2 hours), day 3, 2 weeks, 3 months and 1 year post-operatively. Ultrasound imaging was performed at the same intervals by consultant musculo-skeletal radiologists blinded to the RSA data.

Results: At the 3 month stage post-operatively RSA data shows an increase in the average gap between the 2 sets of markers, with considerable variation between patients (5mm to 19mm).

Conclusion: The results are highly suggestive of gap formation in the repair. The greatest increase in gap formation has been seen between 2 weeks and 3 months. During this time patients come out of their abduction arm sling and commence physiotherapy. It may be that due to excessive loading on the repair before it has fully healed has causes failure in some cases.


C. Tsiouri M. Jeffery D. Mok

Aim: The aim of our study was to review the massive rotator cuff tears that were repaired arthroscopically and evaluate the clinical results in respect to repair integrity as well as the effect on the progression of osteoarthritis.

Materials and Methods: We reviewed 56 (39 male,17 female) consecutive patients who underwent arthroscopic repair of their massive rotator cuff tears using biodegradable anchors by the senior author. The technique relies on the suspension bridge principal as described by S.Burkhart (1997). The mean age was 68.2 years (30–86) with most patients between 75 and 85 years. The mean follow up was 31months (24–41). Objective evaluation was done using the Constant score and subjective with the Oxford score. Osteoarthritis was investigated with radiographs and repair integrity with ultrasound. SPSS 16 for Windows was used for the statistical analysis of out results.

Results: 93% of the patients had good (11%) or excellent results according to the Oxford score and 91% had Constant score over 75. The improvement in the scores was significant statistically in all parameters (p=0.000, p for strength=0.001). Thirteen patients had postoperative OA, but this was not correlated with the results or the improvement and 11/13 had excellent Oxford scores and Constant scores over75. Seventeen patients had a re-tear which was not correlated with the results or the improvement and 15/17 had excellent Oxford scores and Constant scores over 75. Seven patients had both osteoarthritis and retear but again improvement and results were not affected.

Conclusion: Arthroscopic repair of massive rotator cuff tears has excellent clinical results regardless of the development of osteoarthritis or the repair integrity and should be the first line of treatment.


M.A. Akhtar C.M. Robinson

Introduction: This study was performed to assess the incidence of generalized ligament laxity in patients presented with 1st time anterior shoulder dislocation.

Patients and Methods: Prospective data was collected for patients presented with 1st time anterior shoulder dislocation and clavicle fracture as a control group between Aug 2008 and Feb 2009 under the care of a specialist shoulder surgeon. Data included demographic details, mechanism of injury and generalized ligament laxity using Beighton score. Laxity is scored on a 0–9 scale. Scores of 4 or above are indicative of generalized ligament laxity. Brighton criteria was used to diagnose Benign Joint Hypermobility Syndrome (BJHS)

Results: Data was collected for 44 patients with first time anterior shoulder dislocation and 43 patients with clavicle fracture. There was no difference in the demographics of the groups. There were 40 male (91%) and 4 (9%) female patients in the dislocation group. Mean age was 25 years with a range from 15–55. Most common cause of shoulder dislocation was sports related injuries in 26 patients (60%). The average Beighton score for dislocation group was 3.6 with a range from 0–9 as compared to 2.1 with a range from 0–7 in the control group. Twenty one patients (48%) in the dislocation group had a Beighton score of 4 or more indicating generalized ligament laxity as compared to 12 patients (28%) in the control group. This difference was statistically significant with a P value of 0.009. Six patients (14%) fulfilled the Brighton criteria for BJHS in the dislocation group as compared to 3 patients (7%) in the control group.

Conclusion: We found that there is a high incidence (48%) of generalized ligament laxity in patients presented with first time anterior shoulder dislocation. Appropriate advice should be given to these patients about rehabilitation, risk of recurrent dislocations and timing of shoulder stabilization.


C. Tsiouri D.H. Mok

Aim: Retrospective evaluation of the clinical results of arthroscopic capsulolabral stabilisation using suture anchors with a mattress technique.

Materials and Methods: Sixty five consecutive procedures in sixty-two patients (50 male, 12 female) with mean age of 38 years (14–66) underwent capsulolabral stabilisation by the senior author between 2005 and 2008. There was a history of dislocation in 38 shoulders (58.4%), 16(42.6%) had recurrent and 6 bilateral instability, 27 patients (41.5% shoulders) presented with pain. Thirteen patients had gradual onset and 14 after an injury. The mean follow up was 29 months (14–54).

Results: Arthroscopic findings included three patients (5%) with glenoid bone loss more than 15%, Hill Sachs lesions greater than 20% in eighteen patients (27.6%) and six cases where the torn labrum was partially absent. Three shoulders had a panlabral tear (4.4%). A mean of 2.3 (1–4) anchors were used. The mean Rowe score was 92.3 (30–100) with 90% excellent or good and the mean Oxford Score was 41(16–48) with 89% excellent or good. All heavy manual workers returned to work in a mean of 15.4 weeks. Four professional athletes are back to preinjury level in a mean of twenty weeks. There were two (3%) failures with redislocation.

Conclusion: Reinforcement of labral repair with capsule plication is an effective means to treat shoulder instability with a 97% success rate and no exclusion criteria.


E. Mulgrew A. Sahu C.P. Charalambous M. Ravenscroft

Purpose: Tension band wiring is the most common surgical procedure for fixation of fractures of the Olecranon, but it is associated with high rate of metal work complications and implant failure leading to re-operation.

Method: We present a new fixation technique for olecranon fractures that avoids reoperation to remove hardware as compared with the standard fixation technique with Kirschner wires and tension band wiring as advocated by the AO technique. We describe fixation of displaced transverse and oblique olecranon fractures with anchor sutures, each of which has two pairs of suture strands. Prior to the insertion of the anchor sutures, the fracture is reduced through a standard open approach

Results: Twelve patients have been treated with this technique so far, with a mean follow-up of 6 months. The mean age of the patients was 46.7 years (range 14–75 yrs). We have followed all these patients till union of the fractures. No immediate complications have been noted. Radiographic results are good, with no loss of reduction.

Conclusion: This technique avoids the need for reop-eration for hardware removal without compromising the quality of reduction. It may be argued that anchor sutures may cost more than tension band wiring which is a very low cost procedure. At the same time, we should also consider the future cost involved because of reoperation rate and morbidity. Our newly described technique would be particularly useful in dealing with olecranon fractures in children where it is undesirable to cross the physeal plate by metal work. It would also be of great value in dealing with intra articular distal humeral fractures where fixation is planned initially but conversion to total elbow replacement becomes essential intra-operatively. In such cases an olecranon osteotomy can be fixed by this technique, even in presence of a total elbow replacement.


J-F. Cazeneuve

From 1993 to 2008, 44 DELTA III prostheses were implanted for 33 three-part and four-part displacements and 11 fracture-dislocations, in 3 males for 41 females, with an average age of seventy five years. The results were estimated with AP and profile X-rays.

Ten patients died and and three moved. Thirty one cases were reviewed with a mean follow-up of 6.3 years, range 1 to 15. The radiographs showed:

two 2-mm thick borders on the glenoid at four and eight years.

one aseptic loosening of the base plate at twelve years with a broken polar inferior screw.

nineteen inferior scapular notches at a mean occurrence time of 4.6 years: the longer the follow-up, the more severe the notch with two distinct patters of notches: mechanical, stable, because of an impingement between the humeral component and the pillar and biological, progressive in size, evolving over time with proximal humeral bone loss (five medial resorptions and three bone-cement interface medial borders) because of polyethylene disease.

fourteen inferior spurs, stable after emergence at a mean occurrence time of 2.5 years.

one joint ossification at 6 months and stable at 6 years.

one septic humeral loosening at 2 years.

In elderly patients with trauma, when attachment of the tubercles on the classical orthopaedics devices is impossible, the use of a RSA leads to precocious worrying and progressive images but with only one re-intervention for an aseptic loosening of the base plate at a twelve year evolution. New developments in design and bearing surfaces, new surgical techniques of implantation and a more long term results will probably provide more durable utilization of the reverse concept for this indication.


M. Anderton F. Shah M. Webb I. Harvey

Introduction: Nerve conduction study (NCS) examination of the ulnar nerve is a diagnostic tool when investigating patients presenting with cubital tunnel syndomre (CTS). However, NCS are associated with a false negative rate. Decompressive surgery of the ulnar nerve remains the primary treatment of cubital tunnel syndrome. The aim of our study was to look at:

The correlation between the results of NCS and the subsequent outcome from surgery

Compare these results with a similar group of patients that underwent decompressive surgery without NCS.

Method: A retrospective study of 75 cases of CTS was undertaken. All patients had clinical examination with documentation of features, followed by NCS if indicated. If NCS were carried out, the results of the study was graded (negative, mild, moderate or severe). All patients had decompressive surgery of the ulnar nerve at the elbow. Operative functional outcomes was evaluated pre and post operatively using standard DASH score. A successful outcome was defined as resolution of symptoms.

Results: There were 53 men and 22 women. Patient age showed a normal distribution (range 26–84, mean 49 years). Overall, 65 patients (87%) had resolution of symptoms postoperatively and 10 patients (13%) had unresolved symptoms (5 sensory, 1 pain, 2 sensory & pain, 2 sensory & motor). Outcomes of patients that did not undergo NCS showed a resolution rate of 89% (24/27). Those that had a negative NCS, showed a resolution rate of 100% (12/12), whilst those that had a positive NCS showed a resolution rate of 81% (29/36).

Discussion: Our study highlighted that patients with electro-negative CTS can be effectively and safely treated by simple decompression. Surgical outcome can be correlated to the severity of the pre-operative NCS. There would seem no reason to refer patients for NCS prior to offering operative treatment.


M. Arnander N. Cumberland M. Bott H. Chissell

Introduction: Arthroplasty infection is both devastating for the individual and expensive for the healthcare system. Many measures are taken during a patient’s pathway to try and prevent this complication. Ring fencing beds is perceived to be beneficial in this struggle, but due to complexity it is difficult to identify the effect of ringfencing on infection rates; furthermore to date there is little published data to support it’s use. We present our data of infection rates before and after the introduction of a ringfence policy. The antibiotic prophylaxis regime was the only other variable to change.

Methods: Two 24 month periods were selected before and after the introduction of a strict ringfence policy. In the first period (pre-ringfence period) patients were MRSA screened pre operatively but not placed in a ward with a ringfence policy. Cefuroxime was administered as prophylaxis. In the second period (ringfence period) screened patients were only admitted to a ward where all patients were known to be MRSA free. Tei-coplanin prophylaxis was administered. The hospital building, operating theatres, implants and surgeons were the same for both groups. Infections were identified retrospectively by analysing clinical notes and laboratory results. Statistical analysis was performed using Fisher’s exact test.

Results: Both patient groups had similar demographics. More joints were performed in the ringfence period compared to the pre-ringfence period (870 vs 590), with a shorter average length of stay (7 vs 11 days). In the ring-fencing period there was an overall significant reduction in early infections (1.26% vs 3.05%, p< 0.05). MRSA was eliminated (2.2% vs 0%, p< 0.05)

Conclusions: A combination of these two interventions led to a significant reduction in early infection rates and the elimination of MRSA in primary joint arthroplasty patients, even though the exact contribution of each intervention could not be established.


P.M. Robinson L.T. Muir

Background: Procedures performed at the incorrect anatomical site are perceived as rare events. However, they can be devastating for patients and doctors. In 2007, the Chief Medical Officer for England highlighted surgical site errors as an area of concern. Evidence from the UK and North America suggests that these events are more common than we think. We present our findings on the rates of surgical errors in England and Wales.

Methods: We obtained information from the National Patient Safety Agency (NPSA) and the NHS Litigation Authority (NHSLA) detailing reported cases of surgical error in England and Wales in the time period 1995–2007. This information was evaluated in conjunction with data detailing the total number of operations performed in England and Wales for the same time periods.

Results: Since 1995 there have been 292 cases of errors recorded on the NHSLA database. Orthopaedic surgery was the worst offending speciality with 87 cases (29.8%). There were 49 cases (16.8%) in dental surgery and 40 cases (13.7%) in general surgery. The most commonly affected sub-specialty area of orthopaedic surgery was the hand (21 cases), followed by foot and ankle (18 cases) and spine (16 cases). The total cost of the cases which have been settled was £2,252,752.58. For the year 2006–2007 the risk of an event in orthopaedic surgery was calculated to be 1 in 105,712 cases. The risk in general surgery and obstetrics and gynaecology during this period was 1 in 353,511 and 1 in 133,371 respectively.

Discussion: Orthopaedic procedures featured more commonly on the NHSLA database than any other specialty. Rates were also higher after adjustment for case load. We would like to draw attention to policies such as the WHO surgical safety checklist which aim to reduce the occurrence of such adverse incidents.


S. Isaac J. Dias A. Gaur

Introduction: Diabetes mellitus is a systemic disease affecting peripheral nerves and the use of regional anaesthesia in diabetic patients undergoing surgery could be unpredictable. We investigated the efficacy of brachial plexus block in diabetic patients undergoing upper limb surgery compared to normal individuals.

Method: Four hundred and fifty-two patients had a brachial plexus block performed under ultra-sound guidance by senior anaesthetists. There were 221 males and 231 females. Fifty-five patients were diabetic (mean age of 61 years, SD 12), 24 with type 1 and 31 with type 2 diabetes. Mean age of non-diabetic patients was 55 years (SD 15). A mixture of 0.5% Bupivacaine and 1% Prilocaine was used for the block. Post-operative proximal and distal motor and sensory functions were assessed. The assessment was conducted at a mean of 4.6 hours (SD 2.2 hours) post-operatively. MRC grading system was used to asses motor function while sensory function was assessed subjectively using a graded scale between 0, absent sensation, 1, altered sensation and 2, normal sensation.

Results: Brachial plexus block was as efficient in diabetic patients proximally for motor and sensory functions compared to non-diabetic patients. There was significant difference in the efficacy of the block distally between diabetic and non-diabetic patients in both motor (P< 001) and sensory function (P< 0001). Furthermore, in diabetic patients the response to the block between type 1 and type 2 was statistically significant (P< 001).

Conclusion: In diabetes, the efficacy of brachial plexus block is different compared to normal individuals. This study showed that brachial plexus block can be used efficiently in shoulder surgery in patients with diabetes. In more distal surgery, orthopaedic surgeons as well as anaesthetists should be prepared to either reinforce the block by using a local anaesthetic or to convert to general anaesthesia, if necessary, in diabetic patients.


J.D.D. Robinson P. Kempshall B. Sankar M. Pritchard

Introduction: Distal third fractures of the clavicle account for approximately 10–15% of clavicle fractures. Non union rates following conservative management can be as high as 30%. Many techniques have been described, including external fixation, k-wire fixation, and most recently, hook plate fixation. Non-absorbable sutures, and slings have also been utilised. All of these techniques are associated with complications. In addition, Hook plates require a second operation to remove the plate. This study reports the results of a simple technique using a PDS loop in the fixation of Neer type 2 fractures of the clavicle, performed in our institution.

Methods: Twelve patients with Neer type 2 fractures operated by a single surgeon over three years were included in the study. The mean age was 45 (14 to 63). There were 7 male and 5 female patients. Standard postoperative protocols were followed in all patients. A 1.5 PDS cord looped around the coracoid was used to hold the reduced medial clavicular shaft fragment. Patients were followed up postoperatively at two, six and twelve weeks. Final outcomes were assessed using radiographs and the Oxford and DASH scoring systems at twelve months.

Results: Ten fractures united within twelve weeks. All of these patients returned to their pre-injury activity level. There were two non unions, both in non compliant patients. One of these non unions remained asymptomatic and one patient was lost to follow up. The mean Oxford score at 12 months was 14.25 (range 12 to 16) and the mean DASH score was 5 (4–7).

Conclusion: We conclude that this technique is safe, simple and cost effective. It achieves high rates of union without the need for implant removal. As with other techniques, proper patient selection is essential. We recommend this technique as an excellent treatment option when dealing with these notoriously difficult fractures.


J. Bird J. Kitson

Background: Our Trust consists of two separate hospitals with duplicated Orthopaedic services at both sites. Sterile Services were centralised to one site in February 2006. Various problems were encountered leading to cancelled cases. What have been the financial implications of these cancellations?

It is difficult to estimate the true cost to the Trust for a cancelled case. Each cancelled case is a ‘slot’ on an operating list that has not been filled. There are regular Waiting List Initiative (WLI) Lists – the number of these have increased. Could an empty slot on a regular list have been filled by a WLI case? Would the cost of the WLI case theoretically performed in the empty slot be the cost of the cancelled case? The model is basic and has many assumptions. Patients are allocated a slot on a WLI list for a variety of reasons, however with enough numbers and across enough time, the true cost must be somewhere near these figures.

Method: Every cancelled case coded as “Surgical Equipment: checking/malfunction/unavailable” between April 2006 and Mar 2008 (2 financial years).

The total number of WLI cases in the same period and the total cost of those cases.

Results: There were 239 cancelled cases for Sterile Services reasons across Trust April 2006 – March 2008. During the same period, there were 1,566 Waiting List Initiative

Cases Cost: £3,234,000 (£2,065 per case)

Conclusions: If all of the cancelled slots had been filled by WLI cases this would have avoided a total cost to the Trust of £493,535


W.A. Wallace S. Kalogrianitis P. Manning D. Clark S. McSweeney

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated.

Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels.

Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life.

Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management.


S.S. Al-Nammari B. James M. Ramachandran

Introduction: The Foundation Programme was implemented across the United Kingdom in 2005 and aims to “bridge the gap between medical school and specialty/general practice training.” Musculoskeletal complaints are the single most common reason for patients seeking medical attention and it is imperative that all clinicians should have at least a basic competency in musculoskeletal medicine.

Aim: To determine if Foundation Programmes give junior doctors sufficient training to deal competently with musculoskeletal complaints.

Methods: We prospectively enrolled junior doctors at the completion of their Foundation Programme. They were assessed using the Freedman and Bernstein musculoskeletal examination tool- the only validated method of assessing musculoskeletal medicine knowledge currently available. Passing this test only implies a basic level of competence in musculoskeletal medicine.

Results: We recruited 112 junior doctors from across the United Kingdom. Only 8.9% of those recruited passed the assessment. Significantly higher mean scores were obtained by those with Foundation Programme exposure to Orthopaedics- 62% vs. 51.6% (p=0.005), an interest in Orthopaedics as a career- 64.8% vs. 52.8% (p=0.026) and those who felt that they had gained adequate Foundation Programme exposure to musculoskeletal medicine- 64% vs. 51.6% (p=0.0014). Those who were interested in General Practice obtained significantly lower scores than the rest of the group- 48.4% vs. 55.6% (p=0.009).

Orthopaedics, internal medicine and general practice were the future specialty interest of 6%, 29% and 36% respectively. Only 15% had any Foundation Programme exposure to Orthopaedics and only 13% felt they had been given adequate exposure to musculoskeletal medicine.

Conclusions: Foundation Programmes are currently failing to ensure junior doctors entering specialty training have a basic competence in musculoskeletal medicine. Given the high prevalence of musculoskeletal conditions encountered by most clinicians this is unacceptable and steps must be taken to improve the quality of Foundation Programme training in musculoskeletal medicine.


A. Gulihar S. Williams J. Dias W. Harper

Background: Musculo-skeletal conditions account for at least 10% of General Practice consultations yet the average time spent by UK medical students in orthopaedic and trauma surgery is only 2.7 weeks.

Aim: This study assessed whether a seven-week undergraduate musculoskeletal teaching program introduced in 2006 improved performance.

Methods: This seven week program combined Orthopaedic and Trauma Surgery with Rheumatology and allied specialities. Its main elements were weekly plenary sessions, specialist clinics, a task-based workbook, regular assessments and traditional firm based teaching. The performance of 139 students who attended the new curriculum in its first year of introduction was assessed using multiple choice questions just before their final examinations in 2008 and was compared to that of a control group of students assessed in 2005 prior to program introduction.

Results: The 2008 students showed a 6% improvement in MCQ scores (p< 0.001) over the 2005 graduates. There was no difference between the 2005 students and a second control group of 46 students from 2008, who did not attend the new teaching program.

Conclusion: The program improved performance by providing more focused musculoskeletal training using available resources and by increasing the program duration.


A. Kulkarni P. Partington M. Reed

Introduction: Following successful introduction in 2007, all training programs except two across the UK participated in the examination in 2008. The examination was run along the principles of curriculum based, online delivery with immediate results and providing supportive information for the questions. It remains free of charge as long as the trainee had contributed questions. The project is supported by an educational grant from Depuy, a Johnson and Johnson Company.

Material and Methods: In 2008 trainees from various regions were appointed to a UKITE review board, which creating good quality questions with supportive information. We took on board the feedback from 2007 examination and improved the quality of questions. Some questions from the 2008 examination were reported as ambiguous. The review board met and ambiguous questions were deleted from the exam and scores were recalculated.

Results: 648 trainees took UKITE 2008. The average scores increased up to 5th year SpR and dropped in year 6. Central organisation (86%) and local organisation (90%) were acceptable. 95% felt the examination pages were easy to use. There was difficulty in accessing the examination from NHS networks in some centers on the final day. 95% found there was educational benefit and 99% would like to sit again in 2009.

In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees wanted more questions on clinical situations. Those approaching the FRCS examination are interested in using the database towards preparation for the real examination. Some enthusiastic trainees would like the facility to submit questions early. We aim to improve on these in 2009.

In 2009 we also aim to open the examination for other surgical specialties and international trainees through elogbook.org.

Conclusion: UKITE has made progress in 2008. We aim to improve it further in 2009.


S. Gupta A. Khan S. Jameson M. Reed A. Wallace L. Sher

Introduction: In August 2007, the Department of Health initiative Modernising Medical Careers was implemented. This was a system of reform and development in postgraduate medical education and training. In preparation for the changes, the SAC for T& O outlined a new curriculum. The emphasis of early training, StR years 1 and 2, was to be trauma. We aim to identify how effectively the SAC proposals are being applied, and what difference this makes to the trainees’ operative experience? Furthermore, how do the new posts compare to the historic SHO models?

Methods: A survey carried out by BOTA allowed us to assess post compliance with the SAC recommendations. A compliant job was defined as trauma based for 50% or more of working time. Consent was obtained to evaluate the eLogbooks of trainees in compliant and non-compliant jobs, along with registrars who had previously held traditional SHO grade posts. Overall operative experience over a specified 4 month time period was examined, with focus on routine trauma procedures.

Results: The results of the BOTA and SAC survey revealed that 45% of the new orthopaedic posts were compliant with curriculum guidelines. The eLogbooks of 92 individuals were analysed; 28 historical posts, 34 compliant and 30 non-compliant. The mean total number of recorded entries by trainees in the 4 month period was 73.2 in the historic group, 90.5 in the compliant and 87.3 in the non-compliant job group. The corresponding numbers of trauma operations were 35.7, 48.4 and 41.5.

Conclusions: Operative experience has improved since the introduction of the new curriculum. The new posts are offering more operative and in particular trauma exposure than traditional SHO jobs. If jobs can be restructured such that they all comply with the SAC, educational opportunities in the early years will be maximised.


Z. Sivardeen F. Olubajo I. Khan

The use of shoulder ultrasound in clinic is a way of decreasing the time patients have to wait til definitive treatment is started. Although ultrasound is used in clinic by some surgeons, we are not aware of anyone specifically looking at the total cost implications and the impact on waiting times.

We therefore prospectively assessed the outcome of a one-stop shoulder assessment service set up by a new Consultant Orthopaedic Surgeon in a busy unit. All new patients were assessed by the Consultant, who then performed an ultrasound if indicated. Treatment or further investigation was then instituted based on the findings. The time taken and accuracy of the scans, the number of patients seen, impact on waiting times, total savings and patient satisfaction were assessed. We based cost calculations from data that included capital, structural, maintenance and staffing costs gained from the Department of Health and the hospital management.

We found that 65% of all shoulder patients required ultrasound, and these were performed in an average of 2.7 minutes, with no significant overrunning of the clinic. The sensitivity for the detection of full thickness rotator cuff tears was 88% and specificity was 89%. Four patients needed further ultrasonography by a specialist musculoskeletal radiologist. All patients reported high satisfaction rates. We calculated the cost saving over a year of two shoulder surgeons performing ultrasound in a similar setting was between £200,000 and £500,000 depending on the figures you used.

We believe ultrasound is a quick, easy, cheap imaging process for the diagnosis of soft tissue shoulder diseases. When performed at the first consultation by the surgeon it offers the advantages of high patient satisfaction rates, shorter waiting times, and significant cost savings. Should all shoulder surgeons be performing ultrasound in clinic?


M. Chowdhry V. Killampalli R. Kundra F. Chaudhry N. Fisher A. Reading

Management of hip osteoarthritis in young active patients is made more challenging by the longevity required of the prostheses used and the level of activity they must endure. The aim of this study was to compare the functional outcomes and activity levels following hip resurfacing (HR) and uncemented total hip arthroplasty (UTHA) in young active patients matched for age, gender and activity levels.

255 consecutive hip arthroplasties performed in a teaching hospital were retrospectively reviewed from which were identified 58 UTHA patients and 58 HR patients, matched for age, gender and pre-operative activity level. Mean age of patients within UTHA was 58.5 years (34 – 65) and in HR was 57.9 years (43 – 68).

No patients within the study were lost to follow-up. Mean follow-up was five years.

Within each group there was a statistically significant improvement in the mean UCLA score following surgery (p=0.00). In the HR Group, mean UCLA score improved from 4.2 (1–8) to 6.7 (3–10) while in the UTHA group the mean UCLA score improved from 3.4 (1–7) to 5.8 (3–10). Mean OHS improved from 44.4 (31–57) to 16.6 (12–31) in the HR group and from 46.1 (16–60) to 18.8 (12–45) in the UTHA group, p = 0.00 each group.

This study found no statistically significant difference in the levels of function (p= 0.82) or activity pursued (p= 0.60) after surgery between UTHA and HR in a population of patients matched for age, gender and pre-operative activity levels.

This study has shown comparable outcomes with hip resurfacing and uncemented THA in terms of both functional outcomes and activity levels in a group of young active patients. The potential complications unique to hip resurfacing may be avoided by the use of uncemented THA. In addition, uncemented THA has a longer track record.


S. Jameson A. Khan L. Andrew L. Sher W. Angus M. Reed

Background: From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

Methods: A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day [traditional on call], 24hr on call then off next working day, or shifts including nights).

Results: 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

Discussion: The eLogbook is a powerful resource that provides accurate data for the purpose of supporting orthopaedic training. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.


A. Ardolino N. Zeineh D. O‘Connor

Background: Chronic compartment syndrome is well recognised. Patients present with exercise-induced pain, relieved by rest. The condition is caused by increased intra-compartmental pressure due to inadequate muscle/fascial compartment size. Cases of forearm chronic compartment syndrome are sporadic. Previous published case series affecting the upper limb have not used compartment pressure monitoring to aid diagnosis. In our chronic compartment pressure monitoring clinic we confirmed the diagnosis of four cases. Following these diagnoses a review of the literature showed that there was no definition of normal pre or post exercise pressure for the upper limb.

Aim: Acknowledging that diagnosis of forearm chronic compartment syndrome is largely based on clinical presentation supported by an ever increasing use of hand-held compartment pressure monitors, we felt it was important to establish what represented the normal pre and post exercise pressures in asymptomatic normal individuals to give a baseline upon which perceived raised pressures can be calculated against.

Methods: Ethical approval was obtained from Dorset Research and Ethics Committee. 41 participants underwent compartment pressure measurements of the superficial flexor and extensor compartments of the forearm before and five minutes following exercise. A Stryker intracompartmental pressuremonitor was used.

Results: Normal ranges for pre-exercise extensor compartment (2–27mmHg, CI 18.8–25.2mmHg), post-exercise extensor compartment (2–24mmHg, CI16.8–22.8mmHg), pre-exercise flexor compartment (1–19mHg, CI 13.3–17.4mmHg)) and post-exercise flexor compartment (0–19mmHg, CI 16–21.4) pressures were established. No significant difference was found between pressures before and after exercise (extensor pressures; p=0.41, flexor pressures; p=0.21). There was a significant difference between sexes (extensor pressures; p=0.04, flexor pressures; p=0.008)

Discussion: This study has established a significant difference in normal forearm compartment pressures between sexes. A normal reference range of forearm compartment pressures to aid diagnosis of chronic compartment syndrome has been determined. This can also be useful in diagnosing acute compartment syndrome.


A. Malviya S. Johnson-Lynn D. Deehan H. Foster

There have been marked changes in the management of Juvenile Idiopathic Arthritis (JIA) over recent decades, mainly with earlier use of methotrexate (MTX). Our aim was to describe orthopaedic interventions in a large group of adults with JIA followed up over several decades.

This was a retrospective observational study of adult JIA patients attending a teaching hospital clinic, with information collated on JIA subtype, disease duration, orthopaedic interventions and exposure to MTX.

The study included 144 patients with median disease duration of 19 years. Survival analysis showed that joint surgery was observed in the majority (75%) of patients with disease duration over 40 years with a trend for less joint surgery in patients with oligoarticular JIA. In total 41 patients (28.5%) had received joint surgery and 17/41(41%) have required multiple procedures. Of those who have required joint surgery, 20/41(48%) had started MTX in their adult years, with only 5/41 (12%), starting MTX prior to first joint replacement and none within five years of disease onset. Of the patients who have not had joint surgery to date, most (46/103, 45%) were receiving MTX or another immunosuppressive agent, in the majority of cases MTX was started within two years of disease onset.

Many adults with JIA require joint replacement surgery and ongoing immunosuppressive treatments, emphasising that JIA is not a benign disease. Many patients who have had joint replacement surgery have had exposure to MTX albeit after many years after disease onset; it remains to be seen whether patients who have received MTX therapy early in their disease course will ultimately have less requirement for joint surgery.


M.A. Bhutta S. Arshad J. Henderson

Background: Over 70,000 hip replacements were performed in England and Wales in 2006/7 during which all litigation claims cost the National Health Service (NHS) over £600 million. Joint arthroplasty surgeons are twice as likely to be subject to litigation claims compared to other physicians. The complications associated with primary hip arthroplasty (HA) are well documented, however those instigating litigation in the UK are not known. In this study, the trends in litigation over the past 5 years were assessed to indentify the instigating factors and their associated success to highlight areas for further improvement in patient information and surgical management.

Methods: Data from the NHS Litigation Authority on claims following HA unrelated to trauma between 2002 and 2007 were obtained and analysed.

Results: 352 claims were made, 271 (77%) were settled of which 109 (40.1%) resulted in a successful claim. The total cost to the NHS was £8,558,000. The number of claims has increased from 54 in 2002 to 83 in 2007, while the rate of successful claims decreased from 46.7% to 12.9%. The three most common instigating factors were nerve injury (19.6%), Operator Error (14.2%) and ongoing pain (13.6%). The factors with greatest successful claims were Non-operative site injuries (70%), Operator Error (66%), Fracture (52.4%).

Conclusion: Litigation claims following Hip Arthroplasty are increasing, although there rate of success is decreasing. Non-operative site injuries, operator error and fractures are predictors of a successful claim. However, failure to consent adequately, adhere to policies and standard practice can result in a successful claim. Protecting patients intra-operatively and maintaining high technical expertise while implementing policies and informed consent decreases the litigation burden to the NHS


S. Glyn-Jones H. Pandit H. Doll P. McLardy-Smith R. Gundle M. Gibbons N. Athanasou S. Ostlere D. Whitwell A. Taylor R. Gill D. Murray

Metal on metal hip resurfacing (MMHR) is a popular procedure for the treatment of osteoarthritis in young patients. Several centres have observed masses, arising from around these devices, we call these inflammatory pseudotumours. They are locally invasive and may cause massive soft tissue destruction. The aim of this study was to determine the incidence and risk factors for pseudotumours that are serious enough to require revision surgery.

In out unit, 1,419 MMHRs were performed between June 1999 and November 2008. All revisions were identified, including all cases revised for pseudotumour. Pseudotumour diagnosis was made by histological examination of samples from revision. A Kaplan-Meier survival analysis was performed, Cox regression analysis was used to estimate the independent effects of different factors.

The revision rate for pseudotumour increased with time and was 4% (95% CI: 2.2% to 5.8%) at eight years. Female gender was a strong risk factor: at eight years the revision rate for pseudotumours in men was 0.5% (95% CI 0% to 1.1%), in women over 40 it was 6% (95% CI 2.3% to 10.1%) and in women under 40 it was 25% (95% CI 7.3% to 42.9%) (p< 0.001). Other factors associated with an increase in revision rate were, small components (p=0.003) and dysplasia (p=0.019), whereas implant type was not (p=0.156).

We recommend that resurfacings are undertaken with caution in women, especially those younger than 40 years of age, but they remain a good option in men. Further work is required to understand the patho-aetiology of pseudotumours so that this severe complication can be avoided.


T. Briggs B. Spiegelberg S. Hanna S. Tai K. Gokaraju R. Carrington R. Pollock S. Cannon

Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH).

Fiffty three patients have been recruited to date, 24 of whom had MoP prosthesis and 29 a MoM. 25 of these have had their one-year follow-up with blood analysis. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group.

Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in translocations present in the MoM group at 1 year.


G. Swamy A. Pace P. Howard

Introduction/Background: Uncemented total hip arthrolpasty [THA] was developed to achieve biological fixation of the prosthesis through integration of components into the prepared bone, especially in young patients with higher functional demands and longer life expectancy. The aim of this study was to update the results of a prospectiv series of primary cementless total hip arthroplasties after a minimum of 10 years follow-up

Materials and Methods: We reviewed 201 consecutive uncemented Bi-contact [Aesculap, Tuttlingen, Germany] THA in 177 patients. Harris hip score was recorded pre-operatively and at most recent follow up. Radiological measurements of the acetabulum for migration and radiolucency with Charnley-Lee zones, femur for stem subsistence, calcar resorption, prosthesis-bone radiolucency in the Gruen zones and hypertrophic calcification were carried out. Using revision as an end point, the cumulative survival of the prosthesis was noted. Survival analysis was performed using Kaplan-Meier curves and constructing life tables.

Results: 122 THR with a mean follow-up of 12.9 years were available for follow-up. 62 patients were dead and 17 patients were lost for follow-up. The mean age at surgery was 66.6 years (range 39–88).12 acetabula and 1 femur were revised in 11 patients due to any cause and 3 patients had indications for revision. The cumulative survival of the prosthesis with revision due to any cause was 95.42% at 10 years and 93.57% at 12 years. With revision due to aseptic loosening as an end-point, the cumulative survival was 97.8% at 10 years and 95.9% at 12 years. Comparison of worst-case curves using Log-rank test was statistically significant (p=0.0005).

Conclusion: Our series shows excellent stem results (without HA coating) with no revisions due to aseptic loosening. All stems were stable. Cup survivals were comparable to the other uncemented THA and cemented THA.


D. Langton S. Jameson T. Joyce N. Ramasetty S. Natu N. Antoni

In our independent centre, from 2002 to 2009, 155 BHRs (mean F/U 60 months) have been implanted as well as 420 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems (mean F/U 35)

During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 17 failures of this nature in patients with ASR implants (12 females) and 0 in the BHR group. This amounts to a failure of 3.5% in the ASR group.

Tissue specimens from revision surgery showed varying degrees of “ALVAL” as well as consistently high numbers of histiocytes. Particulate metal debris was also a common finding.

The mean femoral size and acetabular anteversion and inclination angles of the ARMeD group/all asymptomatic patients was 45/49mm (p< 0.001), 27/20°(p< 0.001) and 53/48°(p< 0.08). Median blood chromium(Cr) and cobalt(Co) was 29 and 69 μg/L respectively in the ARMeD group versus 3.9 and 2.7 μg/L in the asymptomatic patients (n=160 with ion levels). Explant analysis confirmed greater rates of wear than expected.

Lymphocyte proliferation studies involving ARMeD patients showed no hyper reactivity to Cr and Co in vitro implying that these adverse clinical developments are mediated by a toxic reaction or a localised immune response.

Our overall results suggest that the reduced arc of cover of the fourth generation ASR cup has led to an increased failure rate secondary to the increased generation of metal debris. This failure rate is 7% in ASR devices with femoral components _47mm.


S. Konan A. Soler F. Haddad

Introduction: The purpose of this study was to assess the efficacy and complications associated with revision hip arthroplasty undertaken in patients under the age group of 55 years.

Methods: A review of our institutions revision hip database showed that 430 revision hip arthroplasties undertaken over the past 9 years had a minimum follow up of 2 years. Of this 84 (56 female, 38 male) patients were under 55 years of age (range 2 to 8 years). The index procedures were preformed at an average age of 46 years (range 15 years to 54 years). The single major etiology of failure was aseptic loosening (74%), followed by infection (8%) and recurrent dislocation (7%). In majority of cases uncemented implants were used at revision surgery (91% femoral stem, 100% acetabular cups). Bone grafts were necessary in 39% of cases.

Results: There was 1% incidence of DVT requiring treatment and 1% incidence of deep infection requiring a further revision hip surgery. There were no cases of dislocation in this series. At final follow up satisfactory progress was noted in all cases with a significant improvement in Harris hip score (p < 0.05).

Discussion: In conclusion, revision of hip arthroplasty in patients below 55 years is associated with improvement in function and patient satisfaction. They perform better than older cohorts but not as good as primary THRs. The complication profile is comparable in the two groups.


B. Ollivere C. Darrah D. Howard N.P. Walton

Introduction: The BOA recommends clinical and radiological arthroplasty follow up at one year then every five years. Increasing pressures placed on NHS Trusts with the implementation of the 18 week pathway and limitation on new:follow-up ratios has increased the use of patient reported outcome scores in arthroplasty follow-up. No single score is validated for this purpose, and there is no data surrounding their effectiveness as a screening tool for aseptic loosening.

Patients & Results: Patients undergoing their 10 year follow were included in the study and scored with the Harris (HHS), Hospital for Special Surgery (HSS), Merle d’Aubigne (MDA), Visual Analogue (VAS) or Oxford Hip Score (OHS) according to the unit’s established follow-up protocol. All patients underwent clinical and radiographic review in addition to scoring. Patients subsequently listed for revision surgery were defined as failure. Statistical analysis included significance testing and ROC analysis to determine the predictive value of the individual scores.

Four hundred and twelve patients were included in the study. The mean Harris, VAS and HSS were significantly different between the failed and well fixed groups. However there was no statistically significant difference between the mean Oxford and MDA scores. ROC analysis demonstrated the Harris (0.97), VAS (0.98) and HSS (0.77) score to have good prediction of outcome.

Discussion: The scores in our study have been validated as outcome measures for joint arthroplasty, however they perform differently in the follow-up setting. There is evidence that a failing hip is reflected in a poorer VAS, Harris, Oxford and HSS scores however the VAS was more sensitive and specific than any hip score. Patient administered outcomes have a place in the follow up of joint replacement it must be remembered they are validated as outcome measures, not for follow up purposes.


J.R.B. Grundy R. O‘Sullivan A.D. Beischer

Background: The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the orthopaedic literature. We present the results of 15 operative procedures.

Method: Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring.

Results: Twelve women (13 feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean pre-operative AOFAS score was 53. Preoperative MRI showed tendinosis with longitudinal split tears in 10 tendons and tendinosis alone in two tendons. Seven of the 15 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 32 and the mean postoperative pain VAS of 1.0 out of 10, at a mean follow-up of 24 months. Three patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery.

Conclusion: Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails.


S. Dawson-Bowling A. Cohen J. Ritchie M. Fordyce

Introduction: Osteoarthritis of the first metatarsopha-langeal joint (MTPJ) is common. A range of surgical treatment options is described, including different designs of total arthroplasty. The MOJE is a ceramic-on-ceramic press fit arthroplasty. We present a maximum 8 year follow up of 32 procedures.

Methods: 32 MOJE arthroplasties were undertaken by the senior author (MF) in 30 patients (9 male, 21 female; mean age 61.9, range 37–76) over six years. Patients were followed up in special clinics where symptoms, levels of function and radiographs were subjectively and objectively scored using the SF-36, modified Kitaoka and AOFAS systems.

Results: 100% follow-up was achieved, with mean time since surgery 58 months (range 25–97). Mean scores were: Kitaoka 53.8 (15–75, maximum possible 75), AOFAS score was 61.3/100 (range 18–100, maximum 100), SF-36 physical score 48.6 (27.6–58.7) SF-36 mental score 52.2 (19.5–62.2). Eight implants had required revision; two for component fracture.

Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection.

Discussion: Although several previous studies have suggested favourable initial outcomes with this implant, all focus only on early results. The longest follow-up we found was 29 months; these authors quote excellent early outcomes but acknowledge the need for longer-term follow-up. In our series, the reoperation rate of 25% up to 8 years is worryingly high. Whilst a cohort of patients clearly have satisfactory results with the MOJE, we would suggest that surgeons contemplating its use give due consideration to these outcomes before proceeding.


C. Kerin G. Cheung N. Graham P. Cool

Background: There are no evidence based guidelines on the surveillance of cemented total hip arthroplasty. We reviewed the outcomes of those patients undergoing this procedure in 1996 & 1997.

Methods: The patients were identified from theatre log books. The follow up date was then retrieved from the electronic patient record system used at our institution. From these we recorded the age, sex, side of procedure, evidence of radiological loosening & time of revision surgery. The data with regards to radiological evidence of loosening & revision surgery were then analysed using a ® statistical software package. From this we were able to plot Kaplan-Meier survival & hazard plots.

Results: We identified 425 primary total hip arthroplasties. Using radiological evidence of loosening as the end point we found that there was an initial peak and a peak at 8 years. There was a 10 year survival rate of 85.8%. Using revision surgery as the end point we found that there was, again, an initial peak & a peak at 8 years. There was a 10 year survival rate of 91.5%.

Conclusions: Once the patient has made it through the first post operative year they do not need to be followed up again until 8 years assuming they remain asymptomatic.


B. Ollivere C. Darrah R. Evans-Gowing S.T. Donell J.A. Wimhurst I.M. Clark

Classification of osteoarthritis of the hip is fraught with difficulty Although different patterns of disease are recognised, there is no accepted classification or grading system. We aim to develop a classification system that reflects both the radiological changes, and the local disease process within the joint.

After ethical permission and consent tissue was taken from 20 patients undergoing primary hip replacement surgery. Intra-operative tissue samples were taken from each patient and the steady state gene expression of several cytokines (TNF-α, IL1-β, IFN-γ, IL-6, RANKL and OPG) measured quantitatively using Taqman RT-PCR. Relative expression was calculated for each sample using standard curves and normalised to 18S expression. The technique was consistent with high correlations for repeated measures from the same tissue type (κ=0.99) and from different tissue types in the same joint (κ=0.92). Intra-observer (κ=0.93) and inter-observer (κ=0.89) reliability for the technique were also found to be high.

Preoperative radiographs were scored by two independent observers and joint space narrowing, cysts, osteophytes and sclerosis noted in each of the DeLee-Charnley zones on the femoral and acetabular side. Based on these scores patients were then classified to either lytic or sclerotic type and subclassified into either hypertrophic or atrophic.

Subgroup analysis of cytokine expression by radiographic type was performed. There were statically significant differences in expression of macrophage stimulating cytokines (IL-1γ and OPG) in the lytic group as compared to the sclerotic group (p< 0.05). Conversely, the sclerotic group expressed significantly higher levels of IL-6. Individuals with atrophic subtype demonstrated significantly higher levels of IL-1β and IL-6, but lower levels of IFN-γ

Our results demonstrate greatly differing patterns of disease within osteoarthritic hip joints. These changes are reflected in radiographic appearances of osteoarthritis. Our proposed classification system can be used grade and classify osteoarthritis in a manner that reflects the disease process.


L. Bayam M. Karski S. Soteriadou A.A. Henderson

Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures.

Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot& ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type-2 and type-3 fractures with conservative treatment at 2 years and then, the medium term (> 5 years) outcomes of type-2 and type-3 surgical groups were assessed. Conservative group was a consecutive series of patients recruited to the study later than surgical groups, hence the smaller number in that group.

Results: 126 patients were included in our study. There were 70 in group type-2 and 38 in group type-3 with surgical management, while only 18 in the group with conservative management. The mean age for surgical type-2 = 46.2, type-3= 46.3 and conservative group = 51.7. Mean follow-ups for the groups were type-2=6y, type-3 =5.5y and conservative one =2.34y. Mean two-year scores for the surgical groups were type-2=68.13, type-3=63.78, while conservative one =51.36.

There was a statistically significant differences in their score between type-2 surgical and conservative groups (P=0.0006), and between type-3 surgical and conservative ones (P=0.04), but no significant difference between type-2 and type-3 surgical groups.

At medium-term follow-up, the scores for type-2 and type-3 surgical groups were 77.06 and 63.66 respectively, with significant increase in type-2 while type-3 remains similar comparing to two-year scores. There were 7 deep, 5 superficial infections and 32 metalwork removals in total.

Conclusion: On comparing the medium term outcome to the two-year one, surgical type-2 group of patients showed some improvement, while type-3 stayed the same.

In this series, contrary to published articles, there was a better outcome at two years with surgical treatment than conservative treatment.


R. Poulter S. Parsons

Background: Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.

Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months.

Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). Nine patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection.

Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding.


S.G. Haidar A. Hughes A. Hennessey S. Jandayala P.B. Rauh

Introduction: Muscle strength has been incorporated in the outcome assessment tools of many joints such as the shoulder and the hand. The purpose of this study was to examine the reliability and therefore the suitability of muscle strength around the ankle joint to be incorporated in foot and ankle assessment tools.

Participants: Sixty-nine healthy volunteers participated in this study (35 females and 34 males); the average age was 35 years (range: 21 to 71 years).

Methods: Three measurements of plantar flexion strength and of dorsiflexion strength of each ankle were performed using the Nottingham Mecmesin Myometer. Measurements were repeated at 2 weeks interval. The averages from first and second occasions were statistically compared.

Results: The average plantar flexion strength was 20.2 kg (range 11 to 41 kg). The average dorsiflexion strength was 14.7 kg (range 7 to 26 kg). The ninety five percent limits of agreement were −5.9 (29%) to +5.2 (26%) kg for the planter flexion and −4.9 (33%) to +5.2 (35%) kg for dorsiflexion.

Discussion/Conclusion: Both plantar flexion and dorsiflexion strengths showed repeatability. Nevertheless, the reliability of planter flexion is higher. Furthermore, this reliability is similar to those of grip strength and shoulder abduction strength. Hence, we advise to incorporate ankle planter flexion strength in foot and ankle outcome assessment tools.


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P. Saville S.C. Srinivasan P. Kothari

Hind foot arthrodesis through traditional lateral approach in patient with severe valgus deformity carries a significant risk of wound breakdowns, infection and the risk of sural nerve damage. It is also difficult to fully correct a severe valgus deformity through the lateral approach. To overcome some these problems a medial approach has been recommended. Few authors have reported good results in a small series of cases.

We present a retrospective review of 18 consecutive patients with valgus hind foot deformity who underwent hind foot arthrodesis via a medial approach. There were 10 male and 8 female with an average age of 55 years (range 28–75years). The indications included osteoarthritis in 13; post traumatic OA in 3 and rheumatoid arthritis in 2. The mean pre-op subtalar valgus angle was 32o (range 12 – 49) and mean post op valgus angle was 17 (range 10 – 25). All the wounds healed primarily and there were no incidence of wound breakdown or infection. None of the patients developed neuro-vascular complications. The average time for fusion was 5.6 months (range 3–9). Two patients needed further surgical intervention, one for FHL tethering at the fusion site and one for non-union of subtalar joint in a chronic smoker.

The medial approach not only allows a safe and fantastic access to subtalar joint making correction of valgus deformity easier but is also extendable to include talo- navicular and naviculo-cunieform fusion and FDL transfer as additional procedures through the same approach as and when indicated

In conclusion we recommend the medial approach for performing subtalar arthrodesis in valgus hind foot deformities


M. Arastu R. Partridge A. Crocombe M. Solan

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum.

Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated.

Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position.

Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position.


L. Heras A. Rafee

Ostoearthritis of the trapeziometacarpal (TMC) joint, the key joint in thumb opposition, is one of the most common diseases involving the hand, especially among middle-aged and elderly women, and can seriously impair overall hand function.

Material and Methods: The purpose of this study was to analyze our experience in the treatment of trapezio-metacarpal (TMC) osteoarthritis with a cemented surface replacement arthroplasty (SR Avantis prosthesis). We did a retrospective study of 34 patients with 43 hands operated on with this technique, with a follow-up evaluation of 36 months. We analyzed the preoperative stage, the postoperative clinical results, measured the radiographic changes found at the end of the study. For outcome, Quick-DASH (Disabilies of the Arm, Shoulder and Hand Score) scores was used.

A Jamar dynamometer was used to assess the grip and pinch strengths which showed a 63% of recovering of the grip strength. Overall survival after a mean follow up of 36 months was 93%. At final follow up mean Quick DASH score was 27.4 Radiological review of the surviving joints showed subsidence of trapezial component in 4 joints and further lucencies in 3 joints. However, these patients had good hand function and grip strength. No sign of osteolysis was seen in any of the cases. We found that the radiological findings did not correlate with clinical findings. Satisfaction rate was 26 good to excellent, with 5 fair and 3 poor.

Conclusion: The three years results of the SR joint replacement are promising with satisfactory functional outcome despite some radiological findings.


M. Hachem J. Jones G. Pathak A. Howieson

Background: PIP joint surface replacement has been shown to be effective in the treatment of arthritis. We performed a retrospective review to evaluate the clinical results and functional outcome of pyrocarbon proximal interphalangeal joint replacement, motion preserving and function in selected patients.

Method: The patients who underwent pyrocarbon PIP joint arthroplasty by the two senior authors were reviewed. Clinical assessment included range of motion, degree of pain and deformity pre and post operatively. Independent functional scores were collected. Radiographs were reviewed for evidence of loosening, fracture and dislocation. Patient overall satisfaction was assessed.

Results: 25 patients had 27 pyrocarbon PIP joint replacements between 2004 and 2008. Of these patients, there were 21 female (84%) and 4 male (16%) with average age of 62.5 (43–78). Indications for surgery were pain and loss of function. The preoperative diagnosis was post traumatic osteoarthritis in 9 (33.3%) and primary osteoarthritis in 18 (66.7%). The average arc of motion preoperatively was 42.3 (5–60), and the average postoperative one was 74.3 (45–100). Pain was relieved in majority of patients. 23 patients (92%) were satisfied completely with the procedure. Pain was relieved in the majority of cases and we had 2 dislocations requiring revision to silicone joint replacement and 2 adhesions/stiffness requiring tenolysis. There were no infections.

Conclusion: Our experience of pyrocarbon PIP joint replacement over the 4 years showed this implant is useful for relief of pain and function. A technically demanding procedure, it improves arc of motion, corrects deformity and achieves satisfactory function. We had 7 % revision rate and longer term follow-up is required.


J. Kelly D. O’Briain G. Colgan J. McCabe W. Curtin

Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio.

We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury.

One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population.

Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender


J. Fischer D. Shivarathre D. Quinton

Introduction: Trapeziectomy is a well established surgical procedure for the treatment of osteoarthritis of the carpo-metacarpal joint (CMCJ) o the thumb. The complications have been recognised in the past, but there has been limited literature describing the management and prognosis of long term complications following Trapeziectomy.

Aim: The purpose of our study was to describe our experience in management and prognosis of patients with long term complications associated with Trapeziectomy with particular references to residual pain and sensory branch of radial nerve (SBRN) paraesthesia.

Methods: 118 trapeziectomy procedures were performed in 103 patients for primary osteoarthritis of the CMCJ of thumb during the period of January 2000 – December 2005 at a single centre performed or supervised by a single surgeon (senior author). The data was obtained from the case notes retrospectively. The average follow up period was 12 months. The short term and long term complications and their management were recorded and analysed in detail.

Results: Long term complication rate was 23.7% (28 cases) which included 15 patients (12.7 %) complaining of residual pain at the base of the thumb, 6 patients (5.1%) had symptoms related to superficial branch of radial nerve and 2 patients (1.7%) had FCR rupture. Steroid injection was more successful than physiotherapy or splinting in majority of the patients with residual pain. Superficial branch of radial nerve symptoms resolved with time. However persistent symptoms were treated suceesfully by desensitization therapy.

Conclusion: Trapeziectomy is a fairly benign operation, but the complications are more than expected and the patients must be warned to expect long term complications. Most of the postoperative problems can be effectively managed non-operatively and the prognosis remains good in majority of the cases. Patients must be reassured to expect full recovery with time.


P. Johnston A. Getgood A. McKee D. Larson P. Chapman A. Chojnowski

Long-term follow up after replacement arthroplasty has become established as a “Gold Standard”, providing information that can aid optimisation in future prosthetic design and use. In less mainstream joint replacements however, the evidence for use of prostheses, and in particular long-term outcome, is scarce.

A cohort of 71 patients (93 implants) was reviewed in 1997 having had a De la Caffinière prosthesis implanted between 1980 and 1989. The conclusions of the study included the findings that the replacement was generally well regarded by recipients, pain was improved and survivorship was comparable with data from the best hip replacements.

Ethical permission was obtained to review the same cohort ten years on (16 – 26 years post-op). Similar outcome measures were employed as in the original study but in addition formal grip strength measurements were taken, along with newer outcome scores including the DASH (Disability of arm, shoulder and hand) and EQ-5D (a European quality of life measure). Radiographs allowed assessment of radiological failure using the criteria from the original study.

We found a significant mortality rate in the interim period since the original review (27 patients, 36 implants). A further 8 implants in 8 patients had been removed and were not clinically reviewed as per patients’ wishes. However, 39 implants in 26 patients were available for follow up at a mean 19 years (SD 6.3) leaving a “lost to follow up” rate of 10 patients (10 implants). Survivorship at 26 years was 73.9% (95% CI 61.2, 86.6) with the end-point as revision. Our data also demonstrated continued patient satisfaction without pain, satisfactory power and thumb mobility.

Such information may be used to counsel future patients requiring surgery that there is a functional alternative to excision arthroplasty (trapeziectomy).


S. Morgan B. Brooke N. Harris

Introduction: We present the results of the Ankle Evolution System (AES) total ankle replacements with a minimum follow up of four years.

Methods: Forty-five consecutive patients who had AES ankle replacement were included in the study. The mean age at operation was 64.6 (50–77). Pain and function were assessed using the AOFAS score. Patients had standardised AP and lateral weight bearing radiographs and were assessed for loosening and alignment. Patients’ satisfaction and complications were recorded. The survival of the implant was constructed using the Kaplan-Meier survival curve.

Results: The mean follow up for our patients who were alive and available for follow up at the final clinical review (40 patients) was 57.8 months (48–80). A total of 2 patients were revised (One patient sustained talar fracture and was converted to arthrodesis at three years postoperatively. The second patient had revision of the tibial component because of aseptic loosening at 4 years postoperatively). The mean total AOFAS score was 88.1 (53–100). For pain the mean score was 35.8 (20–40). Nine patients showed osteolysis only 2 were considered as significant. Those patients had minimal symptoms that were not progressing and further surgery was not justified. Ten patients presented with edge loading of which nine had corrective surgery. Our cohort showed high patients’ satisfaction. Our cumulative survival rate at 6 years was 94.7% with revision or decision to revise as the endpoint

Conclusion: The medium term results of the mobile AES total ankle replacement in terms of survivorship, functional outcome and patients’ satisfaction are satisfactory but we have our concerns about the high rate of osteolysis. The long-term benefit of this procedure has yet to be determined.


N.H. Shah S. Talwalkar R. Badge L. Funk

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results.

Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength.

Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique.


A. Prasthofer R. Sloan J. Old J. Coghlan S.N. Bell

Introduction: The aim of this study was to assess the outcomes of patients with recurrent antero-inferior gle-nohumeral instability with associated antero-inferior glenoid bone loss treated with a specific open stabilisation technique, using intra-substance coracoid bone grafting. It is hypothesised that this method of reconstruction produces low recurrence of instability as well potential for patients to return to high-risk sport.

Methods: 30 shoulders with recurrent anterior dislocation and glenoid bone loss were stabilised with open capsular and labral repair and intra-substance coracoid bone grafting. Motion and stability were assessed by Rowe Stability Score (RSS) with follow-up over 2 years in all cases. American Shoulder and Elbow Score (ASES) and Oxford Stability Scoring (OSS) were also recorded at follow-up. Intention to and actual return to sporting level was assessed. Union of the graft was confirmed by CT scan.

Results: For all 30 shoulders at a mean follow-up time of 2 years 11 months (range 2–5 years) the RSS improved from a mean of 32 to 78.5 post-op. 1 redislocation occurred whilst continuing high-risk sport after 2 years. ASES index at 2 years had a mean of 91.8 whilst the OSS was 18.5. Pre-operatively, 24 patients participated in high-risk sport. 20 intended to return to high-risk sport post operatively. 18 achieved this return without restriction. CT scans were available on 25 shoulders at a mean of 4.5 months after surgery. 1 showed slight resorption of the graft, union was confirmed in 23.

Conclusion: This small sample shows an overall acceptable clinical and radiological outcome at a minimum of 2-year follow-up. These results support the current literature advocating open stabilisation and bone grafting of the glenoid where loss is evident, particularly in the young contact athlete with recurrent instability and high expectations of success.


L. Hajipour A. Gulihar J. Dias

Introduction: Treatment of a partial laceration in zone 2 of a flexor tendon is controversial. Although the intact part of a partially lacerated tendon is sufficient to sustain normal physiological forces, conservative management can lead to triggering, entrapment and rupture. Surgical repair is advocated for lacerations deeper than 60%. The Silfverskiold and Halsted techniques for peripheral repair use more suture material and have been shown to be stronger than a simple running suture. Currently there are no comparison of gliding resistance between different circumferential suture techniques, which is more important than tensile strength for partial lacerations.

Aim: The purpose of this study was to compare friction coefficient and gliding resistance at the flexor tendon – A2 pulley interface using three different circumferential repair techniques.

Method: Thirty long flexor tendons from long digit of turkey foot, along with the equivalent of A2 pulley were harvested. The tendons were lacerated to 50% and ten each were subjected to a Silfverskiold, Halsted or a running suture. All experiments were carried out for intact and lacerated tendon at 30, 50 and 70 degrees of flexion and two load settings of 2 N and 4 N. Gliding resistance was measured as the difference between forces recorded at the two ends of the tendon and the friction coefficient was measured using this formula, μ = Ln[(F2/F1)]/Ø.

Results: The Halsted repair was associated with a 100% increase in gliding resistance and friction coefficient relative to the intact tendon, compared to 80% for the Sil-fverskiold repair and 60% for a running suture (p=0.05). The running suture was technically the easiest.

Conclusion: We recommend a simple running suture for peripheral repair of partial flexor tendon lacerations, where surgical repair is advocated.


C. Ingham P. Johnston M. Sommerlad D. Larson A. Chojnowski

Introduction: We present our results from a series of patients with symptomatic distal radial malunions. Between January 2005 and October 2008, 15 patients (11 female: 4 male) underwent corrective osteotomy using fixed-angle plates and either structural iliac crest or inlay hydroxyapa-tite (HA) graft. 2 patients had correction for palmar, and the remainder for dorsal, angulation. The mean age was 48 years. The mean time from injury to corrective osteotomy was 12 months (range 3–40 months).

Methods: Radiological parameters included ulna variance, radial inclination, palmar angulation and time to union following osteotomy. Clinical outcomes included wrist RoM, grip strength, VAS for pain and DASH score (Disability of the Arm, Shoulder and Hand) preoperatively and 3 months post-operatively.

Results: The mean change in radiographic parameters were 2mm increase in ulnar variance, 9° increase in radial inclination (14° – 23°) and 23° increase in palmar angulation (−26° – 3°). The only statistically significant change in RoM was an increase in supination from 55° preoperatively to 73° postoperatively. DASH scores improved from a mean 51 pre-op to 15 post-op, statistically and clinically significant. The mean improvement in grip strength was 8kg, and the VAS for pain improved from 5 preoperatively to 1 postoperatively.

We found a positive correlation between age and time to union/graft incorporation (R2 = 0.47). The mean time to graft incorporation was 16 weeks. All of the patients treated with iliac crest structural graft progressed to union. Only 2 of the 4 patients treated with HA graft achieved incorporation, while the other 2 have required revision surgery.

Conclusion: Our results therefore show a significant improvement in both radiological and clinical outcome measures following corrective surgery. We had inferior results with the HA graft, and have subsequently abandoned its use. These results support the use of corrective osteotomy following distal radial malunion.


R. Khokhar T. Colegate-Stone A. Tavakkolizadeh G. Al-Yassari C. Roslee J. Compson

Aims: To assess the usefulness of wrist arthroscopy in the assessment of symptomatic scaphoid non-unions and associated injuries and to evaluate the implications on the definitive treatment.

Methods: A prospective cohort study of patients undergoing wrist arthroscopy with established scaphoid non-union was performed between January 2006 and April 2009. This study included 17 men and 6 women with a mean age of 39 years.

Results: Majority of the study population (61%) had normal radiocarpal articular cartilage. Articular cartilage wear was mostly limited to the radial styloid and could be effectively debrided. Injuries to the TFCC (39%) followed by the LT joint (35%) and the SL joint (26%) were the most common arthroscopic findings. Other identified pathologies included: Loose bodies, protruding Herbert screw from previous fixation, Chondrocalcinosis, Distal Radio-ulnar joint (DRUJ) instability, Capitohamate (CH) instability and Ulnar styloid fracture non-union. Assessment of the state of the fracture union was best done from the mid carpal joint rather than the radiocarpal joint due to a more prominent fibrocartilage covering of the fracture site from the radiocarpal side Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (48%) and TFCC repair (4%). Post wrist arthroscopy 6 patients (26%) required a further course of conservative treatment (Physiotherapy +/− local anaesthetic and steroid injection) prior to discharge. In the remaining patients, based upon clinical and arthroscopic findings, a range of other therapeutic and salvage procedures were performed.

Conclusion: This study demonstrates an important role for the wrist arthroscopy in patients with symptomatic scaphoid non-union and in assessing the true extent of the articular cartilage wear and associated carpal injuries. Further it helped in most cases with the decision making in choosing the appropriate definitive surgical option when required.


D. Cloke S. Spencer A. Hodson D. Deehan

Objective: To ascertain the epidemiology of ankle injuries in elite youth football.

Design: Retrospective analysis of prospectively collected injury data from English Football Association Academies.

Setting: Forty-one FA Football Academies, between 1998 and 2006.

Participants: For the complete seasons studied, a total of 14776 players were registered from U9 to the U16 age category – a mean of 2463 players per year. All ankle injuries of sufficient severity to miss 48 hours or more training were studied – 2563 injuries in total.

Main outcome measurements: The incidence and burden of ankle injuries in this population, and factors associated with injury.

Results: There was a mean incidence of one ankle injury per player per year, and a mean of 20 training days and 2 matches were missed per ankle injury. Increased injury rates were seen in older players, in competition and later in each half of match time. Peaks in injury were observed early in the season and after the winter break. In competition, more injuries were associated with a contact situation than in training. Eighty-eight injuries (3.4%) required a lay-off of three months or more and in 18 (0.7%) cases, the player failed to return to training. In total, 52290 training days and 5182 match appearances were lost through ankle injury. The majority of injuries were sprains, but more severe injuries occurred accounted for 3.9% of the total.

Conclusions: Ankle injuries are common in young football players, and are often severe, with prolonged loss of training time. This has potential far reaching implications, both on and off the field. Further syudy in this area is suggested.


D. Macdonald E. Macdonald S. Perry

Introduction: The health benefits of physical exercise are well recognised. In recent years the department of health has been encouraging the UK population to exercise more. We aimed to determine if there was any change in the number and pattern of sport and exercise related injuries attending a city Emergency Department (ED) over the past two decades.

Methods: We undertook a prospective comparative study of patients attending an ED over two time periods: Aug 85 – April 86 and Aug 04 – April 05. All identified patients had a standardised proforma inserted into their notes which was prospectively completed by the attending clinician at the time of consultation.

Results: We observed a 35% increase in sporting injuries over the 19 year period (1000 injuries out of 37036 new patients vs 1351 out of 37526, p< 0.0001). The total number of new patients attending the ED remained unchanged during this time. Males remain the majority of patients with sports injuries (86%). We noted a change in age distribution with a relative increase in patients under 16 yrs (p< 0.0001), a decrease in 16–24 yrs (p=0.0002) and an increase in patients over 40yrs (p< 0.001). There was a significant reduction in patients presenting out of hours and a significant increase in the delay to presenting at ED with the majority of patients presenting over 4 hours after the injury. Football remains the commonest cause of sports injury accounting for half of all sports injuries, followed by rugby but there has been a relative decline in skiing, martial arts jogging and squash as a cause of injury and a significant increase in injuries due to snowboarding, skateboarding and basketball.

Conclusion: There has been an increase in the number of sports injuries attending hospital, which may represent a general increase in sport and exercise participation among our population.


S. Konan F. Rayan F. Haddad

Introduction: The radiographic evaluation of the antero-lateral femoral head is an essential tool for the assessment of cam type of femoroacetabular impingement. Computerised tomography (CT), magnetic resonance imaging and frog lateral plain radiograph views have all been suggested as imaging options for this type of lesion. The alpha angle is accepted as a reliable indicator of cam type of impingement and this may also be used as an assessment tool for successful operative correction of the cam lesion. The aim of our study was to analyse the reliability of The frog lateral view plain radiographs to analyse the alpha angle in cam femoroacetabular impingement.

Patients and Methods: Thirty two patients who presented with femoroacetabular impingement were studied. Interobserver reliability for assessment of alpha angles on frog lateral radiographic view was analysed using intraclass correlation coefficient. The alpha angles measured on frog lateral views using digital templating tools were compared to those measured on CT scans.

Results: A high interobserver reliability was noted for the assessment of alpha angles on frog lateral views with a correlation coefficient of 0.83. The average alpha angles measured on frog lateral views was 58.71 degrees (range 32 to 83.3). The average alpha angle measured on CT was 65.11 degrees (range 30 to 102). However, a poor correlation (Spearman r of 0.2) was noted between the measurements using the two systems.

Conclusions: Frog lateral plain radiographs are not reliable predictors of alpha angle. Various factors may be responsible for this such as the projection of the radiographs, patient positioning and quality of images. CT imaging may be necessary for accurate measurement of the alpha angle.


S. Papalexandris K. Dogiparthi L. van Niekerk

Aims: The purpose of the study was to assess the mid-term knee functional results after Medial Patellofemoral Ligament (MPFL) reconstruction with single semitendinosus autograft in patients with patellofemoral instability.

Methods and Results: Knee function was assessed in 45 patients (46 knees) who underwent MPFL reconstruction with semitendinosus autograft. The tibial insertion of the semitendinosus was preserved whereas the free end, after stripping of the tendon from the musculo-tendinus junction was rerouted through the most distal part of the medial intermuscular septum proximally to the adductor tubercle, to the superomedial border of the patella, where it was fixed. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency was documented prior to surgery. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 34 male and 11 female patients with an average age of 32.5 years, ranging from 17 to 60 years. The minimum follow up was 2 years with an average of 33.5 months (range 24–54 months). Fourteen patients (30%) presented a degree of patellofemoral dysplasia. All knee functional scores significantly improved postoperatively. Kujala score improved from 57.7 to 77.1, Tegner score improved from 3.06 to 5.26, IKDC score improved from 51.2 to 75.44 and Lysholm score improved from 58.7 to 79.3. One of the patients required revision of the MPFL reconstruction due to traumatic redislocation of the patella.

Conclusions: At a midterm follow-up, reconstruction of the MPFL with rerouting of the semitendinosus tendon is an effective method with improved function in all patients. Maximum improvement was achieved within the first six postoperative months. Heterogeneity of our population may have affected some of our results.


H.B. Colaco S. Oussedik B. Paton F.S. Haddad

Aim: To investigate the relationship between patient psychological characteristics, adherence to rehabilitation physiotherapy and outcome at one year following anterior cruciate ligament reconstruction.

Methods: 75 consecutive patients undergoing ACL reconstruction by a single experienced surgeon received a pre-operative psychological assessment comprising of five questionnaires; Athletic Identity Measurement Scale (AIMS), Recovery Locus of Control Scale (RLCS), Self-Motivation Inventory (SMI), Hospital Anxiety and Depression Scale (HADS), and Short Form Social Support Questionnaire (SSQ6). Four functional questionnaires were completed pre-operatively by the patient; Subjective Knee Evaluation Form (IKDC 2000), Tegner Activity Scale (TAS), Lysholm Score (LS), and Lower Extremity Functional Score (LEFS). LEFS is a simple, sensitive subjective assessment tool which is sensitive to change. Final outcome was assessed by repeating the functional questionnaires at 1-year post-operatively following rehabilitation. Rehabilitation adherence was measured using the Sport Injury Rehabilitation Adherence Scale (SIRAS) and physiotherapy appointment attendance.

Results: The data were analysed using regression analysis (n=57). Self motivation score (R2= 0.142), a higher athletic identity (R2= 0.067), good social support (R2=0.170) and an internal locus of control or high self efficacy (R2=0.111) were all found to be positive predictors of final outcome. Poor self motivation and an external locus of control are associated with less successful final outcome.

Discussion and Conclusion: Self motivation and self efficacy are positive predictors of final outcome after ACL reconstruction. These aspects may be reinforced during rehabilitation. Patients with an external locus of control and poor self-motivation can be identified and their pre- and post-operative management may be adapted to achieve optimal outcome.


P. Baker D. Dowen I. Mcmurtry

Introduction: The recent UK national comparative audit of the use of blood in primary, elective, unilateral THR found that 25% of patients required a peri-operative transfusion. We felt this figure was higher than should be expected, especially of surgeons with a dedicated arthroplasty subspecialty. We therefore audited our own practice with particular emphasis on the relationship between surgeon volume, implant and the need for transfusion.

Methods: A retrospective review of 508 consecutive primary, elective, unilateral hip and knee arthroplasties performed over a 12 month period. Pre- and post- operative haemoglobin levels, need for transfusion, and the timing and volume of any transfusion were recorded for each patient. Analysis determined the overall rate of transfusion, the details of any such transfusion, and the effects of surgeon volume upon the transfusion rate.

Results: The transfusion rate following THR (10%) was significantly lower than those found in the national audit. The transfusion rate following TKR was 7%. Multivariate analysis demonstrated that surgeon volume (< 50 THRs/yr Vs > 50 THRs/yr) and a preop-erative Hb < 12g/dl were the only significant determinants of a need for post operative transfusion (Both p< 0.05) following both THR and TKR. Other variables (age, gender, anaesthetic type, ASA, indication, surgeon grade and experience, implant, approach) were not significant. A preoperative haemoglobin of < 12g/dl was associated with a 6 fold and 3 fold increased risk of needing a transfusion following hip and knee replacement respectively.

Discussion: The need for allogenic blood transfusion following primary arthroplasty is influenced by both patient and surgeon related factors. Surgeons who have a dedicated arthroplasty practice and perform a high volume of procedures have significantly lower transfusion rates when compared to nationally accepted figures. This has implications for both patient care and resource management.


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R.E. Field V.K. Eswaramoorthy N.R. Rushton L.C. Biant

Aims: Minimum ten year clinical, radiological and postmortem results of the flexible Cambridge Cup. This acetabular prosthesis was designed to replace the horseshoe shaped articular cartilage and provide physiological loading with minimal resection of healthy bone.

Method: Fifty female patients aged over 70 years with a displaced intra-capsular fracture of the femoral neck were recruited to the ethically-approved prospective study. They underwent implantation of the Cambridge Cup, which has an outer polybutyleneterephthalate shell and an inner UHMWPE bearing, with a Thompson-type hemiarthroplasty. The cups were manufactured with a 60μm plasma-sprayed coating of hydroxyapatite. This was removed from half the cups to simulate the effects of long-term HA resorption. Implants were sterilised by gamma irradiation in air. Independent clinical and radiological assessments were undertaken before discharge, at 6 weeks, one year, 18 months, two -, five-, seven- and ten years. Patients were scored using the Barthel Index, the Charnley-modified Merle d’Aubigne scores and latterly the Oxford hip score. The date and cause of death were obtained from hospital records and death certificates. Fifteen Cambridge Cups were retrieved post-mortem for histological and wear analysis

Results: The mean functional scores recovered to levels before fracture. These scores decreased with advancing age at five years. The mortality rates were 16%, 28%, 46% and 92% at 1, 2, 5 and 10 years. The Oxford hip scores in patients surviving between five and ten years were maintained.

The HA coated implants remained asymptomatic. Three uncoated components required revision for migration. No evidence of accelerated UHMWPE wear was seen on retrievals or radiographs. Histological analysis of the retrieved HA coated specimens showed excellent bony fixation, uncoated cups showed predominantly fibrous tissue.

Conclusion: The uncemented Cambridge Cup was implanted in a challenging environment of osteoporotic bone. Clinical, radiographic and post-mortem results up to ten years are excellent.


O. Holubowycz D. Howie R. Middleton

Background: Our multi-centre international randomized controlled trial compared the one-year incidence of dislocation between a 36 mm and 28 mm metal on highly cross-linked polyethylene articulation in primary and revision total hip replacement (THR).

Patients: 644 patients were entered into the study. Surgical approach was posterior in primary THR and posterior, transfemoral or transtrochanteric in revision THR. Patients were stratified according to a number of factors which may influence dislocation risk and polyethylene wear. Patients were randomized intra-operatively to either a 28 or 36 mm articulation.

Results: The 12-month incidence of dislocation was statistically significantly lower in patients undergoing THR with a 36 mm articulation than in those with a 28 mm articulation (1.3% vs 5.4%, p=.004). When primary and revision THR were examined separately, the 12-month incidence of dislocation was statistically significantly lower in patients undergoing primary THR with a 36 mm articulation than in those with a 28 mm articulation (0.8% vs 4.4%, p=.007). Of the 12 primary THR patients with a 28 mm articulation who dislocated within one year, four experienced recurrent dislocation and two were revised for dislocation. Two patients with a 36 mm articulation dislocated, one of whom experienced recurrent dislocation and was revised. The incidence of dislocation after revision THR with a 36 mm articulation was 4.9%, compared to 12.2% with a 28 mm articulation. Three of the five patients who dislocated following revision THR with a 28 mm articulation experienced recurrent dislocation and were revised within one year of surgery. Two patients dislocated following revision THR with a 36 mm articulation but neither experienced recurrent dislocation or further revision.

This large randomized study unequivocally shows for the first time that, compared to a 28 mm articulation, a 36 mm articulation in THR is efficacious in reducing the incidence of dislocation in the first year following THR.


S. Konan F. Rayan G. Meermans J. Witt F. Haddad

Introduction: In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions.

Methods: In our classification system, the acetabulum is first divided into 6 zones as described by Ilizalithurri VM et al [Arthroscopy 24(5) 534–539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 – normal articular cartilage lesions; Grade 1 softening or wave sign; Grade 2 – cleavage lesion; Grade 3 – delamination and Grade 4 -exposed bone. The site of the lesion is further typed as A, B or C based on whether the lesion is 1/3 distance from acetabular rim to cotyloid fossa, 1/3 to 2/3 distance from acetabular rim to cotyloid fossa and > 2/3 distance from acetabular rim to cotyloid fossa.

For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics.

Results: We observed a high inter-observer reliability of the classification system with a kappa coefficient of 0.89 (range 0.78 to 0.91) and high intra-observer reliability with a kappa coefficient of 0.91 (range 0.89 to 0.96).

Discussion: In conclusion we have developed a simple reproducible classification system for acetabular cartilage lesions.


A. Avasthi S. Goyal L.J. Taylor

Aim and design: The Olympia prosthesis was designed to minimise the risk of cement mantle deficiency, seen with some straight stem designs. Initially six stem sizes were produced. The highly polished surface (Ra 10 nm) reduces tensile stresses and cement abrasion. The oval cross-section allows a metaphyseal rotation lock. The natural anteversion is cement mantle friendly. The absence of corners reduces the stress risers and the anatomic shape accommodates the abductor approach and MIS. A size 0 has been added to the range as have lateralised options.

Methods: The first 120 stems in 111 consecutive patients were studied prospectively and reviewed clinically and radiographically by an independent observer. All operations were carried out by the senior author (LJT) with the same team. Rigorous attention to detail was given to femoral preparation and cement technique.

Clinical Results: At a mean follow up 10 years 8 months, 92% of the patients had a Harris Hip score over 80. 97% of outcomes were classified as excellent or good on the Oxford Hip Score. At review the survival was 99.2% (one patient has been revised for non-union of a Vancouver type C peri-prosthetic fracture).

Radiographic Results: Radiographically no stems showed more than 5° varus/valgus angulation (no centraliser was used). In the lateral projection 76% were neutral and 21% posterior. All Gruen zones had an intact cement mantle and 100% of stems had Barrack A or B cement/bone interfaces. No sinkage has been identified on plain AP and lateral radiographs.

The Olympia has only been used at 3 centres until the 10 year clinical and radiographic results were available. The results at 10 years justify further evaluation. It is crucial that meticulous detail to cement technique is adhered to in the operative technique. The ease of insertion and natural anteversion has given confidence to surgeons in training.


K. Rajesparan L. Biant M. Ahmad R. Field

Background: Tranexamic acid has been shown to be effective in reducing blood loss and transfusion requirement in cardiac surgery and total knee replacement surgery. The most effective dose of tranexamic acid in hip arthroplasty surgery is not yet known. We investigated the effect of a pre-operative bolus 1g intravenous tranexamic acid on intra- and post-operative blood loss, transfusion requirement, and risk of venous thromboembolism following total hip arthroplasty.

Results: We report a cohort comparison study of 73 patients who underwent primary hip arthroplasty. Thirty-six patients received tranexamic acid (TA group), and thirty-seven received no tranexamic acid (control group). Blood loss was measured directly intra-operatively, and indirectly post-operatively by haemoglobin and haematocrit measurement. Deep vein thrombosis (DVT) was investigated by venography.

Patient demographics were similar between both groups. There was no significant difference in intra-operative blood loss between both groups. The early post-operative blood loss and total blood loss were significantly less in the tranexamic acid group. This effect of tranexamic acid was more significant in females who showed a dose-related relationship between tranexamic acid dose and blood loss. Fewer patients in the tranexamic acid group required blood transfusion. There was no increased incidence of DVT in the tranexamic acid group.

The use of a single pre-operative 1g bolus of tranexamic acid administered before surgery is a safe, cost-effective method of reducing post-operative blood loss following total hip arthroplasty. The effect is more significant in females at this dose.


P. Giannoudis R. Mallina S. Perry C. Tzioupis H-C Pape

Purpose: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing.

Methods: 22 (13 males, mean age 37.5y) consecutive patients were entered into this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group.

Results: The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups.

Conclusion: Femoral nailing and reaming induces a second hit response as supported by the post-operative increased levels of IL-6. There appears to be an inverse relationship in the concentrations of IL-6 and HMGB-1. Serum concentration of IL-6 unlike HMGB-1 strongly correlate with ISS. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immune-inflammatory process.


N.K. Kanakaris G.M. Calori N. Lasanianos R. Verdonk P. Cherubino T. Blokhuis P. De Biase P.V. Giannoudis

Purpose: Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting procedures. The purpose of this study was to investigate the efficacy of BMP-7 (biological enhancement) in the treatment of recalcitrant aseptic femoral non-unions.

Material & Methods: Since 2003 a multicenter registry (bmpusergroup.co.uk) was created to collect details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.

Results: Thirty patients, who had undergone a median of 1 (1 to 5) prior revision operations, over a median period from the injury of 24 months (9 to 65), were included in this observational study. In 76.7% (23/30) the application of BMP7 was combined with a revision of the fixation. Non-union was verified in 26/30 cases (86.7%) in a median period of 6 months (range 4–10). Over 70% of these patients returned to their preinjury level of activities, the median overall health state score was 82.5 (45 to 95). No adverse events or complications were associated with the BMP7 application over the median follow-up of 30 months (12–68).

Discussion/Conclusion: This case series has verified the safety and efficacy of the use of BMP7 in a manner comparable to the scarce existing evidence on femoral non-unions. The establishment of multicenter networks and the systematic and long-term follow-up of these patients are expected to provide further information and significantly improve our understanding on this promising osteoinductive bone substitute.


R. Leighton M. Dunbar D. Petrie K. Deluzio P. O’Brien R. Buckley J. Powell M. Mckee E. Schmitsch D. Stephen H. Kreder E.D. Harvey D. Sanders B. McCormack G. Pate A. Hawsawi A. Evans R.A. Persis

Introduction: Surgical fixation of intra-articular distal femoral fractures has been associated with nonunion & varus collapse. The soft tissuestripping associated with this fracture andthe surgical exposure have been factors associated with delayed union & infection. The limited soft tissue exposure has been lauded the as a solution to this fracture. However, it has occurred with the new fixation as well.(Locked Plate)

Aims: This study is an attempt to look at the fixation. Does the LISS system improve the results of this difficult fracture? Is there truly a difference in the outcome of this fracture utilizing the Locked plate system or is the percieved difference due to the surgical mini invasive approach.

Patients & Methods: One hunderd & forty patients were screened, only 53 were randomized and fixed in six academic centers over 5 years. All C3 fractures were excluded as they were felt not to be treatable by the DCS device, but they were treated appropiately. 35 females and 18 males were included in the study and randomized appropiatley.

Results: Fifty-three patients were randomized, 28 had the LISS implant and 25 had the DCS utilized. There were 3 nonunions in the LISS group plus two patients with early loss of reduction that required reoperation in the early post operative period. One patient developed arthrofibrosis requiring arthroscopic release and subsequently the implant failed necessitating refixation. In the DCS group, only one nonunion reported & required second surgery. This translated to a reoperation rate of 21% in the LISS group compared to 4% with DCS.

Conclusion: This prospective randomized multicentre trial showed a difference when comparing the LISS to the DCS in the supracondylar distal femur fractures.


A. Bishnoi G. Swamy H. Majeed T. Abuzakuk

Background: Aetiology of venous thromboembolism is multifactorial and thromboprophylaxis includes mechanical and chemical agents. There is no clear consensus on the choice of chemical agent in elective total hip arthroplasty (THA), although National Institute of Clinical Excellence (NICE) recommends low molecular weight heparin or fondaparinux to all patients.

Aim: The aim of our study was to define the efficacy and safety of various chemical agents currently used for venous throboprophylaxis – namely aspirin, warfarin and low molecular weight heparin in primary THA.

Methods: We retrospectively reviewed 905 consecutive patients with primary THA during an 18 month period. Medical notes were reviewed to record demographic data, inpatient and outpatient thromboprophylactic agents, total hospital stay, readmission, incidence of DVT, pulmonary embolism and death following surgery. Post-operative mobility, transfusion requirements and complications were noted. Suspected thromboembolic events were investigated with venous Doppler ultrasound scanning and CTPA.

Results: 417 (46%) patients received aspirin, 253 received enoxaparin, 190 patients had low dose warfarin and 45 patients had none or multiple agents for inpatient thromboprophylaxis. 615 patients had cemented and 290 patients received uncemented total hip arthroplasty. Patients predominantly received aspirin (61%) as outpatient prophylactic agent. 41 patients were investigated for a suspected thromboembolic event. 2 patients had DVT and 2 patients had PE. There were 3 deaths within 6 weeks, one each due to PE, sepsis and unknown cause. All 4 patients with thromboembolism were on enoxaparin for prophylaxis.

Conclusion: In our study aspirin was the preferred choice for thromboprophylaxis following total hip arthroplasty. We found that aspirin was most effective with no complications and enoxaparin was least effective. We advise the use of aspirin as the first choice drug for thromboprophylaxis as reiterated by some recent studies.


B. Rogers R. Pearce R. Walker M. Bircher

Introduction: The incidence, outcome and recovery of operatively managed pelvic ring fractures were studied from a three-year cohort of patients. No previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and natural recovery in these potentially devastating injuries.

Methods: This retrospective case series study of 489 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 42 (8.6%) patients who had sustained pelvic ring injuries with associated neural injuries. Each pelvic injury was classified using the Tile and Burgess & Young classifications, neural injuries were classified as either complete or incomplete and the degree of post-operative skeletal displacement was quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: The mean age of patients with neural injuries was 28 years, 32 (76%) were male and 37 (88%) had unstable, Tile type C, fracture patterns. The mean delay from time of injury to time of pelvic surgery was 11 days (range 3 – 42 days). Full resolution of neural symptoms was observed in 16 (38%) patients, with a mean fracture reduction of < 6mm. Incomplete improvement was observed in 11 patients and 15 patients had ongoing complete lumbosacral palsy. Patients who failed to achieve full resolution of neural function had a mean fracture or sacro-iliac joint reduction of 8.8 mm and the mean delay to surgery was 24 days.

Discussion: Pelvic ring injuries with an unstable fracture pattern are associated with a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, creates a better environment to achieve a good neural outcome. In such injuries with complete nerve palsy, delayed and suboptimal surgical reduction predicts a poor prognosis.


Z. Sivardeen A. Wafai A. Ali N. Chetty B. Holdsworth D. Stanley F. Olubajo

Background: Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome.

Methods: This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA. All procedures were performed by two Consultant elbow surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs. Both groups of patients were similar with respect to fracture configuration, age, sex, comorbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months.

Results: At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united.

Conclusion: This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications.


A.A. Odutola R. Baker J. Loveridge R. Fox T.J. Chesser A.J. Ward

Aims: To determine the incidence and pattern of pain in patients with displaced pelvic ring injuries treated surgically. To investigate the link between pain and neurological injury.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Assessment was made from validated pain scores, pain maps, a Visual Analog Scale (VAS) and correlated with outcome scores including SF36 and Euroqol. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. There were 31% Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 76% of all patients reported activity related pain; 70% of APC, 73% of LC and 86% of VS injuries (p=0.05, Chi-squared test). These results correlated directly with the pain domain of the Euroqol tool. There were however no statistically significant differences in the interference of pain with work (SF36) or the VAS between injury classes. There was a 15% prevalence of neurological injury in the cohort (9% of APC, 11% of LC and 27% of VS injuries; p=0.03 Chi-squared test). There were no statistically significant differences in the prevalence of moderate to severe pain (Euroqol) or the VAS between those with and without significant neurological injury. The presence of neurological injury significantly affected return to employment but not return to sports or social activities.

Conclusions: These results illustrate the prevalence of significant morbidity in patients with surgically treated pelvic ring fractures. Presence of pain could be linked to injury category but a link with neurological injury was not obvious. This can help give prognostic information to patients suffering displaced pelvic ring injuries requiring surgical reconstruction.


B. Rogers R. Pearce R. Walker M. Bircher

Introduction: Acetabular fractures are increasing in incidence and no previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and recovery. The incidence, outcome and recovery of operatively managed acetabular fractures with associated neural injuries were studied from a three-year cohort of patients.

Methods: This retrospective case series study of 456 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 29 (6.3%) acetabular fractures associated with neural injuries. The fractures were classified using the Letournel system, neural injuries classified as either complete or incomplete and the degree of post-operative skeletal displacement quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: Overall, the cohort had a mean age of 34 years, 17 (59%) were male and the mean delay from time of injury to time of acetabular surgery was 16 days (range 4 – 53 days). All fractures involved posterior wall and/or posterior column and 23 (79%) were of the more complex, associated type, Letournel fracture patterns. Full resolution of neural symptoms was observed in 9 (31%) patients with a mean fracture reduction of 1.6mm. Partial neurological improvement was observed in 15 patients. Ongoing complete nerve palsy was observed in 5 patients, associated with a mean fracture reduction of 2.5 mm and a significantly longer delay to surgery of 32 days (p< 0.05).

Discussion: Acetabular fractures involving the posterior wall or column have a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, affords a good neural outcome for these patients. In similiar injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predicts a poor prognosis.


P.V. Giannoudis N.K. Kanakaris V. Nikolaou D. Morell N. Prevezas

Purpose: The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.

Patients & Methods: Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the Euro-Qol-5D questionnaire were documented over a median period of follow-up of 40months (12–206).

Results: Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5years (16–80). Half of them were posterior-wall fractures, 21.6% both column, 14.7% posterior-wall and posterior-column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intraoperative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At final follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.

Discussion/Conclusion: Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome.


M.A. Akhtar K. Teoh C.M. Robinson

Background: Complex anterior fracture-dislocations of shoulder are rare injuries and little is known about the functional outcomes following operative treatment. The aim of our study was to evaluate the functional outcomes following open reduction and internal fixation for these injuries.

Methods: Over a ten and a half year period, we studied thirty-two consecutive patients who presented to shoulder injury clinic at the Royal Infirmary of Edinburgh with an acute Type-I complex anterior fracture-dislocation of the shoulder. The average age of the 19 men and 13 women was 58 years (range 21–81 years). All patients were treated with open reduction and internal fixation and were followed up for at least two years. The functional outcomes were assessed by three scoring systems (Disabilities of the Arm, Shoulder and Hand questionnaire, the Constant questionnaire, and the Short Form-36 general health questionnaire).

Results: At two years post injury, the median DASH score was 26 points and the median Constant score was 83.5 points. The range of motion of the shoulder joint showed significant improvement throughout the two year period and degree of forward flexion and abduction continued to show significant improvement at five years. At two years, the mean forward flexion was 162°, mean extension was 152°, mean internal rotation was 109° and mean external rotation was 73°. All but one patient returned to their job at two years.

Conclusions: Type I complex anterior fracture-dislocations of the shoulder are rare and occur in the middle age and elderly group of population. Following open reduction and internal fixation, the functional outcomes have been shown to be satisfactory. We recommend that open reduction and internal fixation should be the first choice of treatment in Type-I complex anterior fracture-dislocation of shoulder.


A.M.H. Jones T.S. Foong A.M. New B.J.R.F. Bolland D.G. Dunlop R.O.C. Oreffo

Introduction: One of the main factors in the success of impaction bone grafting (IBG) in revision hip surgery is its ability to resist shear and to form a stable construct. Bone marrow contains multipotent skeletal stem cells and we propose that in combination with allograft will produce a living composite with biological and mechanical potential. In this study we looked at whether coating of the allograft with type 1 collagen followed by seeding with human bone marrow stromal cells (hBMSC) would enhance the grafts mechanical and biological properties.

Methods: A control group of plain allograft and three experimental groups where used to determine the effects that collagen and hBMSC have on IBG. The samples where impacted in standardised fashion previously validated to replicate femoral IBG, and cultured in vitro for 2 weeks. The samples then underwent mechanical shear testing and biochemical analysis for DNA content and Osteogenic activity.

Results: Collagen coating of the allograft prior to seeding with hBMSC significantly enhanced the mechanical properties of the construct compared to the ‘gold standard’ of plain allograft with a 22% increase in shear strength (p=0.002). The collagen coated group also showed increased osteogenic differentiation of the stromal cells (Alkaline Phospatase specific activity: 124 +/− 18.6 vs 54.6 +/− 9.6 nM pNPP/Hr/ngDNA p= < 0.01).

Discussion: This study has shown a role in the improvement of the biomechanical properties of IBG by coating with collagen and seeding with hBMSC. Collagen coating of IBG is a simple process and translation of the technique into the theatre setting feasible. The improvement in shear strength and cohesion could lead to earlier weight bearing for the patients and allow quicker recovery. The therapeutic implications of such composites auger well for orthopaedic applications. We are currently strengthening the above findings with an in vivo study.


W. Khan A. Malik S. Tew A. Adesida J. Andrew T. Hardingham

Introduction: Bone marrow derived mesenchymal stem cells are a potential source of cells for the repair of articular cartilage defects. Hypoxia has been shown to improve chondrogenesis in adult stem cells. In this study we characterised bone marrow derived stem cells and investigated the effects of hypoxia on gene expression changes and chondrogenesis.

Material and Methods: Adherent colony forming cells were isolated and cultured from the stromal component of bone marrow. The cells at passage 2 were characterised for stem cell surface epitopes, and then cultured as cell aggregates in chondrogenic medium under normoxic (20% oxygen) or hypoxic (5% oxygen) conditions for 14 days. Gene expression analysis, glycosoaminoglycan and DNA assays, and immunohistochemical staining were determined to assess chondrogenesis.

Results: Bone marrow derived adherent colony forming cells stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic cell marker CD34 and for the neural and myogenic cell marker CD56. Interestingly, a high number of cells were also positive for the pericyte marker 3G5. Cell aggregates showed a chondrogenic response and in lowered oxygen there was increased matrix accumulation of proteoglycan, but less cell proliferation, which resulted in 3.2-fold more glycosoaminoglycan per DNA after 14 days of culture. In hypoxia there was increased expression of key transcription factor SOX6, and the expression of collagens II and XI, and aggrecan was also increased.

Discussion: Pericytes are a candidate stem cell in many tissue and our results show that bone marrow derived mesenchymal stem cells express the pericyte marker 3G5. The response to chondrogenic culture in these cells was enhanced by lowered oxygen tension, which up-regulated SOX6 and increased the synthesis and assembly of matrix during chondrogenesis. This has important implications for tissue engineering applications of bone marrow derived stem cells.


A. Getgood R. Brooks L. Fortier N. Rushton

Introduction: Platelet rich plasma (PRP) has been hypothesised to be of potential benefit to articular cartilage tissue engineering, through its release of autologous growth factors. The aim of this study was to ascertain whether the addition of thrombin is required to achieve platelet activation and sustained growth factor release in-vitro, when PRP is applied to a collagen based osteochondral scaffold.

Methods: Collagen/glycosaminoglycan scaffolds were fashioned, to which equal combined volumes of test substances were added (n=3): 500μl PRP; 375μl PRP + 125μl autologous thrombin (3:1); 455μl PRP + 45μl bovine thrombin (10:1). One ml of DMEM/F12 medium was added to each scaffold and changed completely at 12/24 hours, and 3/10 days, following which release of TGF-β1, PDGF-AB and bFGF were measured using ELISA. Secondly, equal sized collagen/glycosaminoglycan and polylactide co-glycolide scaffolds were fashioned to which 500μl of PRP were added (n=3). Similar conditions were followed as previously except that only PDGF-AB was assayed.

Results: A similar cumulative release profile of all growth factors was found over the 10 day period. An increase in growth factor release was seen in the PRP only group at all time points with PDGF-AB in particular reaching statistical significance at all time points (p< 0.006). These findings remained apparent when a correction for volume was made (p< 0.028) suggesting a particular role of the collagen in platelet activation. This was shown in the second experiment, in which a significantly increased cumulative volume of PDGF-AB was released from the collagen/glycosaminoglycan scaffold without thrombin activation (p< 0.04).

Discussion: This study shows that collagen is a potent activator of platelets, requiring no further addition to achieve satisfactory growth factor release when applied clinically. These results suggest that if PRP is combined with polymer scaffolds, it should be activated with thrombin to achieve optimum growth factor release.


I. Pountos T. Georgouli K. Henshaw D. Corscaden P. Giannoudis

Background: It has been previously shown that in elderly patients with osteoporosis the Mesenchymal Stem Cell (MSC) growth rate and osteogenic potential is decreased. The aim of this study was to elucidate the effect of BMP-2, BMP-7, PTH and PDGF on MSC’s capacity to proliferate and differentiate.

Methods: Cancellous bone samples were obtained from 10 patients (mean age 76 (70–84), (4 males)) suffering from lower extremity fractures and osteoporosis. Mes-enchymal Stem Cells (MSCs) were isolated by enzymatic digestion. Cells were cultured till passage 3 (P3). Functional assays on proliferation and osteogenic differentiation were performed under the influence of a wide range of BMP-2, BMP-7, PTH and PDGF concentrations. Proliferation was assessed using CFU-F and XTT assays. Osteogenic differentiation was assessed by alkaline phosphatase activity and total calcium production.

Results: MSC proliferation was found upregulated by medium supplementation with BMP-7 and PDGF. The highest proliferation rate increase was achieved with 100 ng/ml of BMP-7. BMP-2 and PTH did not affect MSC proliferation. All four molecules upregulated ALP activity and calcium production by growing osteoblasts. A dose dependant effect was noted. BMP-2 and BMP-7 in their highest studied concentration (100 ng/ml) produced a ~ three-fold increase on osteogenic potential of MSCs.

Conclusion: This study indicates that BMP-7 and BMP-2 have favourable effect on osteogenic differentiation of MSCs. However, BMP-7 could be more advantageous as it enhances both proliferation and osteogenic differentiation of MSCs derived from elderly osteoporotic bone.


E. Tayton S. Evans D. O’Doherty

Background: Stress shielding in the proximal femur is a widely recognized sequel of total hip replacement. It is due to a discrepancy in the stiffness between the implant and the proximal femur. The strain characteristics of implants of differing materials on the femur have previously been demonstrated in the laboratory using strain gauges and photo-elastic techniques. These are however relatively crude techniques giving limited results. Finite element analysis has also been used, but this provides only a theoretical analysis. Digital Image Correlation is an extremely accurate technique for strain analysis previously used in micro and nano engineering research.

Methods: A stainless steel, a titanium, and a carbonfibre reinforced plastic (CFRP) femoral prosthesis of the same dimensions, were implanted without cement into 5 prosthetic femora. A 1kN load was applied using a compression device. The process was repeated with 5 other prosthetic control femora. Digital Image Correlation was used to give an extremely detailed 2D strain map of inner cortex of the proximal femora during laboratory simulated static physiological loading conditions.

Results: All implants caused stress shielding in the proximal calcar area. In Gruen zones 6–4, both the stainless steel and titanium implants caused statistically significant stress shielding, whereas the femora implanted with the CFRP prosthesis did not show a statistically different strain pattern from the control group. There was a reduction in strain experienced by the medial cortex of the femora beyond the tip of all of the implants.

Conclusion: Digital Image Correlation is a novel method for strain measurement within Orthopaedic research which produces extremely accurate strain maps and data that can be reliably used for statistical analysis. Using this technique, this laboratory based investigation indicates that a carbon-fibre reinforced plastic stem is a good candidate to avoid stress shielding in total hip replacement surgery.


K-Y Saw S-C Loke P. Hussin

Purpose: A pilot study to assess whether intra-articular injections of autologous marrow-derived stem cells (MSC) and hyaluronic acid (HA) will result in a better quality of cartilage regeneration after subchondral drillings into surgically created full-thickness chondral defects.

Methods: 15 male goats were subjected to full-thickness chondral defects followed by subchondral drillings. The goats were divided into three groups: Group A, no injection (control group); Group B, a weekly intra-articular injection of HA for three consecutive weeks; Group C, a weekly intra-articular injection of autologous MSC in combination with HA for up to three consecutive weeks. The intra-articular injections were given one week after surgery. Group C goats underwent bilateral iliac crest bone marrow aspiration during surgery. The bone marrow aspirates were centrifuged and bone marrow cell suspension were then divided into vials and cryo-preserved. Prior to usage, the bone marrow cells were thawed and prepared for intra-articular injections. The repaired chondral defects were visually inspected and histologically examined at week 24.

Results: In groups A and B goats, the defects showed repair with mainly fibrous tissues. Chondral defects in Group C goats showed better repair of tissues with some specimens showing mainly hyaline cartilage as compared to the other groups.

Conclusion: Intra-articular injections of autologous MSC in combination with HA following subchondral drillings into chondral defects result in a better quality of neochondrogenesis. Preliminary results from on-going human clinical trials provide similar evidence of articular cartilage regeneration following subchondral drillings into chondral defects followed by post-operative intra-articular injections of autologous peripheral blood stem cells (PBSCs) in combination with HA.


P.K. Jaiswal N. Mangat C. Chenu I. McCarthy A. Goodship D. Marsh

Introduction: Conflicting opinions exist as to whether bone healing is affected by the administration of bisphosphonates for osteoporosis. In an animal model, we assessed the effect of bisphosphonates on osteoporotic fracture healing and whether the timing of administration made a difference.

Methods: 36 female Wistar rats underwent a mid-diaphyseal femoral osteotomy six weeks after ovariectomy. They were then divided into 3 groups:

no treatment (control);

administration of alendronate (ALN) from 14 days after osteotomy;

ALN from the time of osteotomy. Fracture repair was assessed weekly with the use of standardised radiography, DEXA scan and in vitro peripheral quantative computed tomography (pQCT). The rats were sacrificed 42 days post-osteotomy and the femora underwent mechanical testing.

Results: Of the 36 rats, 8 were unable to complete the study. Group 3 differed from control in three respects: higher bone mineral content (BMC) and density (BMD); larger callus; lower torsional stiffness. Group 2 did not differ significantly from control. There was a significant positive correlation between stiffness and change in BMC in group 1 (r=0.85, p< 0.001) but not so for group 2 (r=0.2, p> 0.05) and group 3 (r=0.04, p> 0.05). A similar trend existed for all radiographic parameters in the three groups.

Conclusion: The results suggest that, with early bisphosphonate treatment, although there is an increase in the size of the callus, that callus is biomechanically inferior. Furthermore, administration of bisphosphonates at either stage destroys the relationship between radiographic and mechanical parameters used to assess fracture healing.


J.P. Peehal F.W. Smith S.L. Barker

Aims: To investigate the clinical and radiological (MRI) effectiveness of Nuclear Magnetic Resonance Therapy (NMRT) on mild to moderate degenerative knee osteo-arthrosis (OA).

Methods: A double blind randomised control mono-centric study of 100 volunteer patients with mild to moderated knee OA. All patients underwent clinical examination, pain was recorded on visual analog scale (VAS) and Oxford knee score and WOMAC osteoarthritis index at baseline and at follow up intervals (1 week, 1 month, 3 months and 6 months). The treatment group (n=50) received five sessions of one hour NMRT on five consecutive days. Radiological assessment included baseline standing plain radiograph of the knee joint (AP and Lateral views) and positional MRI scan which was repeated at 3 months. Cartilage thickness in weight bearing areas and bone and cartilage MRI score (BAC-MS) were used to assess response of the cartilage to NMRT. Data was analysed using SPSS 16.0 software and non-parametric tests.

Results: Ninety six patients completed six months follow-up. The treatment and placebo groups were comparable except that the male: female ration was 1:1 and 1:2 respectively. No adverse effect was reported during the study. The treatment group showed mean increase of 4° in the range of movement at 6 six months, which was statistically significant (p=0.01). There was no difference in other outcome variables at any time interval between the two groups.

Radiologically, BAC-MS and cartilage thickness at three months had no significant difference between treatment and placebo groups (p-value = 0.81 and 0.88 respectively). The change in BAC-MS and cartilage thickness at 3 months was also not significant (p-value = 0.09 and 0.41 respectively).

Conclusion: Five 1 hour sessions of NMRT is a safe mode of treatment, but has no radiological (at 3 months) and clinical (6 months) beneficial effect on mild to moderate Knee Joint Osteoathrosis.


L.C. Biant R.E. Field

Aim: To assess the functional outcome and longevity of patients who are mentally competent when they sustain an intra-capsular fracture of the femoral neck.

Methods: Prospective cohort study of fifty female patients over the age of seventy years of age with a displaced intra-capsular fracture of the femoral neck. Patients with known, cognitive impairment terminal illness or active infection were excluded from the study. Patients were treated with a large head total hip replacement. Functional outcome was assessed using the the Barthel index score and the Charnley-modified Merle d’Aubigne score yearly for five years. The Oxford hip score was also recorded annually from three to ten years post op. The date and cause of death were recorded from hospital notes and death certificates.

Results: The mean age at time of femoral neck fracture was 81 years. Three patients died before discharge from hospital. The mortality rates were 18% at twelve months, 28% at two years, 44% at five years and 92% at ten years. Those patients surviving had mean Oxford scores of 24 at 3 years, 26 at 5 years, 23 at 7 years and 25 at ten years. The cause of death was ischaemic heart disease in 22%, cancer in 10%, bronchopneumonia in 12% and simply ‘old age’ in 14%.

Conclusion: Elderly female patients who are not cognitively impaired at the time of displaced intra-capsular fracture of the femoral neck have a 56% chance of living five years. Function scores in the survivors are maintained, and are better than would be expected if the patients had undergone hip hemiarthroplasty. Total hip replacement in this population may be justified.


A.A. Odutola R. Baker J. Loveridge R. Fox A.J. Ward T.J. Chesser

Aims: To determine the incidence and pattern of sexual dysfunction in patients with displaced pelvic ring injuries treated surgically. To investigate a link between sexual and urological dysfunction.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Sexual function was assessed using elements of the validated Sexual Function Questionnaire. Patients were also asked specifically about new-onset sexual and urological dysfunction. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male.

31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries.

32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients.

41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test).

There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test).

Conclusions: This large outcome study of UK patients illustrates the significant prevalence of new onset sexual dysfunction in patients with surgically treated pelvic ring fractures. The results also suggest an association between sexual and urological dysfunction. This can help give prognostic information to patients and plan service provision.


D. O’Briain J. Kelly M. Kerin S. Kearns

Introduction: Ischaemia-reperfusion-injury (IRI) is one of the most common metabolic insults in orthopaedic practice. It is often a mild insult after brief tourniquet use with minimal clinical implications; but much more severe insults may result from excessive tourniquet-times, vascular trauma or release of compartment-syndrome. It is mediated largely by oxidatively-induced endothe-lial disruption and leukocyte infiltration. Antioxidants attenuate or prevent this effect in animal models.

Hypothesis: That IRI can be attenuated using established antioxidant medications (ascorbate and n-acetyl-cysteine) in the controlled setting of elective knee arthroscopy.

Methods: A EudraCT registered, prospective, randomized-controlled trial was performed. Patients (n=24) undergoing elective knee arthroscopy were randomized to one of 3 groups (IV NAC/oral ascorbate/placebo). Full blood counts, a broad array of cytokines and adhesion molecules, physiological response, pain scores and analgesia were recorded pre-operatively and at 3 postoperative time-points (10mins, 2hours, 4hours).

Results: Physiological response, analgesia and VAS did not differ. Systemic leukocytes and neutrophils were increased (p=0.001) indicating a measurable reperfusion injury. Ascorbate tended to inhibit ICAM-1 (p=0.10) and IFN-gamma (p=0.080). NAC inhibited VCAM-1 (p=0.003) and tended to inhibit ICAM-1 (p=0.094). Selectins responded in a similar pattern but not significantly. NAC tended to increase circulating leukocytes (0.093), neutrophils (0.12) and monocytes (0.04) and also induced a transient early increase in IFN-gamma (p=0.022).

Conclusions: Elevated circulating leukocytes indicate reduced leukocyte trapping and infiltration due to reduced adhesion molecule expression. NAC attenuates IRI resulting from tourniquet use in knee arthroscopy. The study was underpowered to confirm the efficacy of ascorbate in this setting. Further studies are necessary on the effects of these substances in more extreme ischaemic insults in which they may confer significant local and systemic benefits for the patient. Ascorbate and NAC act at different points in the inflammatory cascade and their potential synergistic effects warrant investigation.


J. Alsousou T. Jenks O. Bouamra F. Lecky K. Willett

Background: It has been suggested that the transition phases of implementing daylight saving time (DST) may impact on serious or fatal injuries sustained as the result of road traffic collision (RTC). The aim of this study is to explore the effects of transitions into and out of daylight saving time on the incidence of such injuries.

Methods: This is a comparative observational study of 11-year of data submitted prospectively to the Trauma Audit Research Network (TARN) between 1996 and 2006. Data for 4 weeks before and after time transition in spring and autumn of each year was collected. The time periods selected reflect those hours with maximum light level changes due to time alterations (2-hour around sunrise and 4-hour around sunset). Travellers outside those hours are unlikely to be affected by the changes.

Results: Out of 55,826 incidents in England and Wales, TARN returned 1296 incidents meeting the above time criteria, of which 282 involved a fatality. Overall, there were more crashes in autumn (845, 65.2%) comparing to spring period (451, 34.8%), with the majority occurring around sunset (1057, 81.5%). RTC related injuries at the onset of DST in spring showed a significant increase up to 14 days post time change (P=0.029), with the majority of the increase occurring at sunset. The highest increases occurred within the fatal incidents group (P=0.0019) and affected mainly the pedestrian subgroup (P=0.013). Changes in the incidence of injuries around the change back to Greenwich Mean Time (GMT) in autumn did not reach significance.

Conclusion: The use of DST over the period studied was associated with rise in RTC related injury figures up to two weeks following the spring time transition. These findings inform the continuing clock changes debate. The introduction of 2-hour time change may result in detrimental effects on RTC related injuries.


J. Phadnis A. Trompeter K. Gallagher E. Wan D. Elliott K. Newman

Aim: To assess mid to long-term functional and symptomatic outcome after internal fixation of the distal radius.

Methods: All patients operated upon between June 2004 and October 2007 were retrospectively assessed using the ‘Disabilities of arm, shoulder and hand’ (DASH, range 0–100), and Mayo wrist (range 0–100) functional scoring systems. Fractures were classified according to the AO system. All patients were treated in one unit by the same group of surgeons using standard accepted techniques. Revision operations and patients treated at greater than four weeks after injury were excluded. Radiographic analysis of time to union was also performed.

Results: 201 patients underwent surgical fixation of which, 183 patients were contactable for follow up (9% loss). Only these patients were included in the study. Mean age was 62.5 years. Mean follow up time was 30 months. Mean time to surgery was eight days. 74% had good/excellent Mayo and 75% good/excellent DASH scores. 2% of patients had a poor outcome with both scores. 28 % reported no functional or symptomatic deficit. There was a 14% overall complication rate (6% major). Mean time to union was 8.39 weeks. Time to union increased with advancing AO grade. There was no significant difference in scores with regard to postoperative immobilisation, time to surgery, time to follow up, patient age, surgeon grade or fracture type.

Conclusion: This is one of the largest series of its type and the results compare favourably with other published operative and non-operative treatment modalities. This is a safe, reproducible technique with excellent functional outcome and is recommended as the treatment of choice when surgery is indicated for these fractures.


D. Shivarathre P. Chandran P. Ralte S. Platt

Introduction: Controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 92 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures.

Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. A standard postoperative rehabilitation programme was followed. The complications were noted and the risk factors for poor prognosis were analysed.

Results: There were 80 women and 12 men in the study. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 7% (6 cases) and the deep infection rate was 4.6% (4 cases). The 30 day postoperative mortality was 5.4 % (5 cases). 86 % (75 out of 87 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes, dementia, peripheral vascular disease and smoking were found to be statistically significant risk factors associated with wound complications. Patient with 2 or more risk factors is 5 times more likely to have wound infection.

Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with majority of patients returning to pre injury mobility status.


T. Harrison A. Hazlerigg M. Dodd D. Llewellyn Clark

Introduction: The first BOA “Standards for Trauma” detail clear management standards for hip fracture patients aged over sixty including the goal that surgery should be within 48 hours of admission. With an expanding elderly population and the number of people suffering a hip fracture increasing by 2% a year there will be an increasing burden on trauma services.

We have demonstrated that simple targeted changes can make a significant difference to wait till surgery after hip fracture.

Methods: Comprehensive data was gathered prospectively on all hip fracture admission over two 3 month periods one year apart. On the basis of the poor results in the first 3 months and after discussions with the general surgeons and anaesthetists, the following changes were implemented:

2pm to 5pm weekday trauma lists were extended from 2pm to 7pm two days a week.

Priority for one hip fracture case first thing on the CEPOD emergency list each day.

Fortnightly morning ‘day case’ trauma list for minor cases.

Results: Approximately 100 hip fracture admissions in both 3 month periods. Initially 72% of patients waited more than 48 hours, 75% of these were due to logistical reasons (mainly lack of space on trauma lists). The percentage of patients operated on within 48 hours improved from 28% to 95%.

Discussion: Auditing local practice against BOAST guidelines identified that logistical reasons (mainly lack of capacity) were the major cause for delay in our trust. Presenting and discussing these results with general surgical and anaesthetic colleagues enabled simple changes that allowed us to meet the new BOA targets.

Conclusion: We suggest that trusts audit their compliance with the new BOA standards for trauma. We have shown how this can be used to design simple improvements in service to significantly reduce waiting times for patients. Let us not write off conservative treatment of tibial shaft fractures


S. Henari L. Banks P. Ellanti D. Kane S. Morris

Objective: The deltoid ligament is an important stabilising structure in the ankle joint. We hypothesised that ultrasound can be used to allow early clinical assessment of ankle fracture stability accurately and quickly in Weber B and C ankle fractures thereby negating the need to perform arthrograms intra-operatively.

Method: A total of 20 patients were recruited prospectively. Consent was obtained prior to surgery. Patients with Weber B or C fractures requiring surgery were recruited prospectively. Following induction of anaesthesia, ultrasound examination was performed, followed by an arthrogram under fluoroscopic screening. Operating surgeons were blinded to results. Radiographs, ultrasound and arthrographic findings were compared by a panel of orthopaedic surgeons of varying grades (2 Consultants, 2 Specialist Registrars).

Results: There was 95% correlation between ultrasound and arthrogram findings. Ultrasound accurately diagnosed rupture with a sensitivity of 92% and specificity of 100%. Kappa scores for ultrasound identification of deltoid rupture was 0.8.

Conclusion: We feel ultrasound exam to be a powerful adjunct tool in the management and operative planning of ankle fractures. Its versatility means it can be used in Emergency Departments and Trauma Clinics to assess ankle stability without causing the patient excessive pain and requiring an anaesthetic.


J. Craig L. Damkat-Thomas P. Bell M. McMullan B. Fogarty

Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days.

Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes.

Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps).

Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.


B. Almazedi

Aim: The open tibial fracture is an increasingly common injury. In those with severe soft tissue damage (i.e., Gustilo type III), it is still controversial how to primarily stabilise the bony structure. This study aims to compare the use of the unreamed interlocking tibial nail (URTN) with external fixation (Ex-Fix) in the treatment of patients with grade III open tibial fractures.

Methods: A Medline literature search identified 21 studies. Only those comparing URTN with Ex-Fix for the treatment of grade III open tibial fractures, in adults, were included. Non-comparative studies were excluded. The quality of each study was assessed and relevant data extracted.

Results: Total number of patients in studies included was 53 in the URTN group and 54 in the Ex-Fix group. Non-union occurred in 10.7% of patients treated with URTN compared to 25.2% in the Ex-Fix group. Mal-union and malrotation were much lower in the URTN group than in the Ex-Fix group, 26.5% vs. 41.7% and 8.7% vs. 21.7%, respectively. Time to union was shorter with URTN (31.9 weeks) compared to Ex-Fix (37 weeks). Time to full weight bearing was significantly shorter with URTN compared to Ex-Fix, 16.6 weeks vs. 28.7 weeks, respectively. Infection rate was higher with Ex-Fix (29.1%) compared to URTN (11.5%), and nerve injury also occurred more with Ex-Fix, 16.7% vs. 9.8%. Re-operation rate was high in both groups (40% URTN, 35.9% Ex-Fix).

Conclusions: The unreamed interlocking tibial nail is superior to external fixation in the treatment of grade III open tibial fractures. It is a safe, effective technique with comparably low complication rates. Management of concomitant soft tissue injuries is consistently easier, and patients have a significantly shorter time to full weight bearing. External fixation, however, still has a role in the immediate stabilisation of these fractures, especially in the critically ill unstable patient.


K. Loganathan

Background: The main aim of this study is to compare the difference between early mobilisation versus non weight bearing in patients post ankle fracture fixation in terms of pain and functional outcome

Methods: We recruited 60 patients and were divide into two equal groups. Patients in Group A were treated with a below knee cast post ankle fracture fixation and remained non weight bearing for six weeks while groub B were patients that were treated with a backslab for two weeks post fixation. The backslab was removed and once their radiographs were deemed satisfactory, They were referred to the physiotherapy service in our unit for range of motion exercises while still remaining non-weight bearing. All patients were allowed to weight bear at six weeks time post fixation. The inclusion criteria included patients within the age of 18 to 40 years of age and all the fractures are classified using the Weber classification. Patients that were excluded from theses studies are those with unstable fractures and have high co-morbid conditions. All these patients were followed up at 2 weeks, 6 weeks, 3 months and 9 months post ankle fracture fixation. Pain and functional outcome were scored using the AOFAS scoring system.

Results: We found that patients in both these groups scored almost equally during the 2 week follow up but at 6 week, group B showed much better range of movement with less pain and a much higher satisfaction rate with their range of movement. However, at 9 months, patients in both group were able to return to their normal physical activity.

Conclusion: Our conclusion is that early mobilisation has an definite advantage over non weight bearing post ankle fracture with regards to functional outcome, pain scoring and patient satisfaction. Patient selection and compliance play a role in the outcome of the study.


A. Sharma M. Seagrave J. Fairbairn W. Jeffcoate B. Scammell

Background: The mechanisms underlying the increased prevalence of arterial calcification in diabetes are not understood. An association with distal neuropathy has been reported and a particularly high prevalence was found in patients with Charcot’s disease.

Aim: The aim of this study was to confirm this high prevalence and to determine whether it is specific to that disorder by comparing the results to patients with other types of foot disease.

Methods: A retrospective survey was conducted in three groups of patients with X-rays managed by a specialist service for the diabetic foot between 2002 and 2005. Group A (n=34) comprised patients with an acute Charcot foot, Group B (n=53) included patients with osteomyelitis and Group C (n=35) consisted of patients who had neither osteomyelitis nor Charcot’s disease. All X-rays were independently examined by three observers blinded to the underlying diagnosis, with films from each group being mixed.

Results: No differences existed (p> 0.05) in the mean age of the patients (60, 72 and 68 years, respectively), the proportion of men (68%, 64% and 51%) and the prevalence of nephropathy (41%, 30% and 14%). 100% patients in Group A, 94% in Group B and 80% of Group C had evidence of neuropathy. The overall prevalence of calcification in the three groups was 53%, 66% and 54% (p> 0.05). With all three groups combined, the only factor associated with calcification was disease duration (p=0.004). The prevalence of calcification was higher than the 40% previously reported in patients with neuropathy, but lower than that reported in patients with Charcot.

Conclusion: As there was no difference in the prevalence of calcification between the three groups, it is concluded that the increase is not specific to Charcot’s disease. It is possible that the increase in calcification in each group reflects the effect of local inflammation, possibly by activation of the RANKL/OPG signalling system.


P. Lakshmanan B. Purushothaman D. Rawlings P. Patterson M. Siddique

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding.

Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement.

Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed.

Results: The mean preoperative BMD within the medial malleolus improved from 0.58g/cm2 to mean 6 months postoperative BMD of 0.59g/cm2 and 0.60g/cm2 at 12 months. The mean preoperative BMD within the lateral malleolus decreased from 0.40g/cm2 to a mean 6 months postoperative BMD of 0.34g/cm2. However the BMD over the lateral malleolus increased to 0.36g/cm2 at 12 months. The mean alignment of the tibial component was 88.5° varus (85° varus to 94° valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865).

Conclusion: The absence of stress shielding around the medial malleolus indicates that TAR implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus.


R Trickett P Hodgson K Lyons R Thomas

Background: Acute traumatic rupture of the Tendo-Achilles is a common problem. Review of the published literature shows a conflict between surgical and non-surgical management. Primarily, surgical treatment has repeatedly been shown to have a lower re-rupture rate compared with conservative treatment. However, it is associated with a higher rate of other complications, principally infective soft tissue complications. Debate concerning the method and duration of conservative treatment regimens also remains.

Methods: We aimed to assess the effect of knee position on the gap in acute tendo-Achilles ruptures. Our null hypothesis was there is no difference in tendon gap with variation of knee position. Patients with a history and examination consistent with an acute rupture were collected prospectively. They were imaged by the same consultant musculoskeletal consultant radiologist using ultrasound. Tendon gap was measured with the foot in neutral and full tolerable equinus with the knee both flexed to 90° and fully extended. A pilot study of 10 patients was used to provide data for a power calculation and consequently a total of 25 patients were recruited.

Results: All patients had their clinical diagnosis confirmed and tendon gap measured in each of the 4 positions. A paired t-test was used to compare mean differences between each position. This confirmed there was no significant difference in the tendon gap with the knee flexed or extended providing the foot is in full equinus. This may have considerable implications on the rationale behind conservative treatment and splinting of acute tendo-Achilles ruptures.


C. Pearce J. Calder

Introduction: When conservative treatment of posterior ankle impingement syndrome (PAIS) fails, operative intervention is indicated. Traditionally this involved an open approach. More recently posterior ankle arthroscopy has been employed. We report the first series of results from an exclusively elite athlete population.

Method: We looked retrospectively at a prospectively compiled database of a consecutive series of elite professional soccer players on whom we have performed posterior ankle arthroscopy for both bony and soft tissue PAIS over the past 5 years. We reviewed our clinical and operative notes and those of the Football Association medical team. Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium).

Results: One player was lost to follow up leaving 27 out of 28 players in the study.

The mean time to return to training post operatively was 34 days (24–54) and to playing was 41 days (29–72). Significant correlations were found between the length of symptoms and the number of pre operative injections (Spearman’s rank correlation coefficient = 0.806. p< 0.001) and the length of symptoms pre-operatively and return to training (Correlation coefficient = 0.383. p=0.048) and return to play (Correlation coefficient = 0.385. p=0.048). Return to training was significantly faster after soft tissue debridement with FHL release than after bony surgery (p=0.046 Kruskal-Wallis test). There was one surgical complication in the form of a persistent portal leakage. This was successfully treated by resting the ankle in a boot for 2 weeks. One patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound guided injection. There were no infections and no neurovascular injuries.

Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player with return to training expected at an average of 5 weeks.


H-L Kerr F Grayston R Jackson P Kothari

Background: Ankle sprains are common with the majority resolving with simple measures. Some patients may have residual pain and instability caused by functional instability. Intraarticular scar formation has been implicated in these patients. Few studies have shown the effectiveness of arthroscopic procedure in treatment of this condition.

Aim: Our aim was to assess the role of arthroscopy in functional instability of the ankle.

Methods: We performed retrospective analysis of case-notes of patients who presented with functional ankle instability from 2005 – 2007 who had failed a trial of conservative therapy and who had ankle arthroscopy, provided there was no true instability as determined by EUA and stress xrays.

Results: Out of 77 patients with a mean age of 38.1, 5 patients had true mechanical instability. They underwent open repair of the lateral ligaments and were excluded from the study. 21 had steroid injections which gave temporary improvement in 11 of them but eventually all of the 72 remaining stable patients underwent ankle arthroscopy. 67 (76.7%) had significant amounts of scar tissue present which needed debridement, most commonly in the antero- lateral corner (58.3%). 52 patients improved (72.2%), 20 patients (27.8%) did not improve. 2 patients suffered a superficial wound infection. 17 patients had an osteochondral talar lesion. Of these, 14 patients improved, 2 did not and 1 patient did not attend follow up.

Outcome: Our study supports the role of arthroscopy in the treatment of functional ankle instability resistant to conservative treatment. Significant improvement in symptoms can be expected in about 70% of patients following arthroscopic debridement of scar tissue rising to approximately 90% if there is an associated talar osteo-chondral lesion. Ankle arthroscopy is associated with a low complication rate and should be offered to patients with functional instability when conservative measures have failed especially if an osteochondral lesion has been identified.


R. Owens H. Guthrie N. Gougoulias A. Sakellariou

Background: Morton’s Neuroma is most likely a mechanically induced degenerative neuropathy, presenting as forefoot pain.

Methods: The authors retrospectively reviewed clinical notes, imaging and histology from 71 consecutive patients (75 feet) treated operatively for Morton’s Neuroma between January 2006 and April 2009 and a control group of 20 patients (20 feet) undergoing MRI for other forefoot pathology. 7 feet were excluded from the surgical group due to recurrent disease or missing data.

Results: 84% of the surgical group were female. Mean age was 52. 97.4% of the surgical group presented with pain. 50% described pain in the plantar aspect of the forefoot and 85% reported that their pain was worse in shoes. Web space tenderness was positive in 95%, foot squeeze test 88%, plantar percussion 61% and toe tip sensation deficit 67%. Any two tests were positive in 92% of this group. In the control group any two tests were positive in only 39% – this difference was statistically significant (p< 0.0001 chi-squared test). MRI identified a neuroma in 97% of the surgical group (mean size 8mm) and 50% of the control group (mean size 6mm). 68% were in the 3rd web space; the remainder were in the 2nd web space. Histology confirmed neuroma in 99%.

Discussion: This cohort is larger than any other published series and is further strengthened by both the consistency of clinical testing and the independence of radiological and histological assessment.

Conclusion: We found that diagnosis of Morton’s neuroma was accurate. MRI correctly identified the neuromata in 97% and at least two clinical tests were present in 92%.


A. Howard G. McLauchlan

Background: Long term follow up data on patients following ankle fracture is scarce. As a follow on from a year long prospective audit of patients admitted to a trauma unit data was collected on a cohort of such patients at a minimum of 4 years post injury to ascertain functional outcome.

Methods: All patients with ankle fractures requiring admission to the Royal Preston Hospital in the period August 2004 to August 2005 were identified. Patients with multiple injuries were excluded. One hundred and one patients were confirmed as fulfilling the criteria that all medical notes were present and the patient had a principle injury of a malleolar fracture. Patients were then invited to a follow up clinic. Functional outcome relating to work and leisure pursuits, the American Orthopaedic Foot and Ankle Society hindfoot score (AOFAS) and a Visual Analogue Scale for residual pain were recorded.

Results: Utilising the Weber classification there were 63% B, 24% C fractures and 5% A fractures. 91 patients underwent surgical fixation. The most common post hospital discharge complication was excessive swelling and 17 patients’ required additional surgery. The only factor that predicted length of follow up before discharge was the presence of diabetes. The Weber classification had no predictive value for length of follow up. 90% of patients returned to their previous work. All ankle fractures had a significant impact on social activities, 45% with a Weber C fracture patients had not returned to their previous sporting activities. The median AOFAS score was 85/100. The median VAS pain score was 9 out of 100. Fifty-eight patients had a change to the type of footwear tolerated.

Conclusion: Patients with an ankle fracture requiring admission to hospital have significant residual symptoms at a minimum four years post injury. Weber B and C fractures have significant long term effects on ADL.


A. Kulkarni T.N. Soomro M. Siddique

Introduction: TMTJ fusion is performed for arthritis or painful deformity. First TMTJ fusion may be performed for Hallux valgus deformity. K-wire and trans-articular screws are usually used to stabilize the joints. We present our audit of experience with LP for TMTJ fusion.

Patients and Methods: 33 TMTJ in 19 patients were fused and stabilised using LP between January and September 2008. The procedure was performed for Lisfranc arthritis in 13 and Lapidus procedure in 6. Two out of 6 were revisions after failed fusion using transarticular screws. Iliac crest bone autograft was used in 26 joints in 12 patients. All patients post-operatively had below knee plaster immobilization and protected weight bearing walking for first 6 weeks. Clinical and radiological surveillance continued until bone union. AOFAS mid-foot scale was also used as an outcome measure.

Results: There were 7 male and 12 female patients with average age of 51 (14–68). AOFAS midfoot scale showed 42% improvement in pain, 30% improvement in function and 53% improvement in alignment. Average total AOFAS score improved from 30 preoperative to 67 postoperative.

All except 1 joint in one patient had clinical and radiological fusion of their joints. 1 patient needed removal of metalwork and 4 had delayed wound healing. Average satisfaction score was 7/10. 86% Patients would recommend it to a friend and 91% would have it again.

Discussion: Locking plates have been recently introduced for ankle and foot surgery. Biomechanical studies have shown plates are not as strong or stiff as trans-articular screw fixation however they are easy to use, have more flexibility for realignment and can act as a buttress for bone graft. In our review all patients except one had bone union without loss of alignment.

Conclusion: TMTJ fusion improves pain and function. Locking plates provide satisfactory stability for TMTJ fusion


A. Guha S. Mukhopadhyay M.K. Reddy R. Thomas

Background: The bunionette is a lateral prominence of the fifth metatarsal head. It is usually caused by a wide intermetatarsal angle (IMA) between the 4th and 5th metatarsals with associated varus of the metatarsophalangeal (MTP) joint. Increased pressure placed on the head of the 5th metatarsal results in pain and plantar callus formation. Failure of conservative treatment warrants bony corrective surgery. Various distal, shaft and basal osteotomies have been described in the literature.

Methods: We have used a ‘reverse’ scarf osteotomy in 12 cases (10F: 2M) with a mean follow-up of 12 months (range 5–22 months). All patients filled up a Foot Function Index (FFI) questionnaire pre-operatively and a repeat questionnaire at the latest follow-up. All angles were measured on a weight bearing AP radiograph of the foot. Post-operatively we mobilised the patients immediately using a heel bearing shoe. All osteotomies healed sufficiently at 6 weeks to allow unprotected weight bearing. Full weight bearing was allowed after clinical and radiological union was achieved.

Results: Pre-op mean IMA was 13.1 degrees (range: 10.4–18 degrees) and mean 5th MTP angle was 19.9 degrees (range 12.7–25.5 degrees). Pre-op mean FFI was 34.2 (range 14–71.3). Post operatively, mean IMA was 7.27 degrees (range: 2.0–11.5 degrees); mean 5th MTP angle was 6.36 degrees (range: 2.8–9.0 degrees) and post-operative mean FFI was 5 (range 0–16.7). All except one patient were pleased with the cosmetic correction obtained. One patient did not like the scar but her foot was asymptomatic and her FFI improved from 27 to 0. All patients would undergo the same procedure on the other foot if required and would recommend the same to a friend.

Conclusion: ‘Reverse’ Scarf osteotomy in the correction of bunionette deformity offers promising results in the short term. Further longterm follow-up would help to establish the benefits of this procedure.


O. Abouazza J. Queally D. Harmon

Study Objective: To determine the feasibility of ultrasound-guided femoral nerve blockade performed by orthopaedic trainees.

Methods: This was a prospective study involving patients presenting to Acciedent & Emergency with fractured femurs requiring analgesia. Physicians performing the nerve blocks were orthopaedic trainees who had participated in a 1-hour training session. The participants underwent ultrasonography-guided femoral nerve blocks to provide analgesia. Any additional analgesia required was recorded. Subjects rated their pain on a Numerical Pain Rating Scale (NRS) before the nerve block and 30 & 60minutes after the nerve block. The primary outcomes for feasibility were the requirement for additional analgesia following injection and the median reduction in pain on the Numerical Pain Rating Scale after the nerve block. Secondary outcomes for feasibility included the median time for completion of the entire nerve block procedure for each subject (from initiation of ultrasonography to completion of the last injection) and the percentage of participants wishing to have the same procedure for similar injuries in the future. Other secondary outcomes included the percentage of participants with complications during the procedure including nerve and vascular injection.

Results: All procedures (100%) were completed without additional anesthesia or analgesia with significant reduction in Numerical Pain Rating Scale. There were no immediate complications

Conclusion: Orthopaedic trainees can perform ultrasound-guided femoral nerve blocks in the emergency department with high patient satisfaction, after minimal training.


E. Mallick P. Radhikant A. Furlong

Background: Delay in operative fixation of neck of femur fracture is associated with increased morbidity and mortality. Apart from medical reasons, inadequate facilities or poor organization has also shown to delay neck of femur fracture patients going to theatre.

Methods: In the year 2005, the Orthopaedic Directorate of University Hospitals of Leicester formed a fractured neck of femur project group to look at achieving a mean 48 hour wait (from clinical fitness to surgery) for this group to get to theatre. The salient changes effected by the group included assigning a dedicated fractured neck of femur ward where patients can be fast tracked from A & E. A dedicated half-day theatre hip list 7 days a week was instituted staffed by senior anaesthetist and surgeons. Ortho geriatricians were designated for each day to pre- and post-operatively assess fractured neck of femur patients and optimize their medical condition. The number of Trauma Coordinators and clinical aides were increased to provide 7 days a week cover. Also various services were integrated and specialist discharge coordinator assigned for early discharge. These measures were implemented from June 2006.

Results: As a result of these measures the mean time to theatre of fit fractured neck of femur patients increased from 35% in 2005 to 75% in 2007 and 90% for the first 6 months of 2008. The mortality decreased from 18.5% in 2005 to 13.2% in 2007 and 9.3% for first 6 months of 2008. 28.7% of patients were deemed unfit for surgery in 2005. This figure dropped to 6 – 7% in the following years. Also percentage of patients staying longer in hospital decreased from 30.5% in 2005 to 13.4% in 2008.

Conclusion: Reorganisation of available resources leads to better service provision and decreased mortality rate in fractured neck of femur patients.


S. Isaac S. West

Introduction: Dr Foster data presents mortality rate for fracture neck of femur in acute trusts. We assessed the accuracy of this data in an acute trust in England for a nine-month period.

Methods: Fifty-seven patients (17.2%) died due to fracture NOF during our review period according to Dr Foster. Medical notes were retrospectively analysed in detail. There were 20 males with a mean age of 84.5yrs (64–100) and 37 females with a mean age of 85.7yrs (57–100). Data analysis included time and day of admission, admission ward, senior orthopaedic review, anaesthetic review, ASA grade, time to surgery, grade of anaesthetist and operating surgeon, type of anaesthesia, time of anaesthesia and surgery, type of surgery, post-op recovery and cause of death.

Results: Seven patients died before their planned surgery due to extensive medical co-morbidity and 50 patients (15.1%) underwent surgery as planned. Thirty-one patients (9.4%) died under the care of the orthopaedic team and were considered by the assessors to be true death due to fracture neck of femur. Eleven patients (3.3%) died in the community after discharge home some several months later. Eight patients (2.4%) died under the care of the rehabilitation team, some months later, the majority from medical causes. The mean time to surgery was 2.7 days (0–13), which was mainly affected by weekend admissions. There were no records of the cause of death in 20 patients including all those that were discharged to the community. Admission time, ward and type and duration of anaesthesia had no effect on mortality rate.

Conclusion: In our review Dr Foster overestimated true death rate due to fracture neck of femur. This trend is worrying as such indicators are linked to financial and performance targets for trusts. Accurate data presentation is therefore imperative and Dr Foster does not appear to deliver this.


A. Gulihar S. Isaac G. Taylor

Background: Dr Foster’s Good Hospital Guide 2005–2006 ranked University Hospitals of Leicester NHS Trust amongst the worst in UK for in-hospital mortality and time to theatre in hip fracture patients. The problem had been recognized in early 2005 and the Fracture Neck of Femur (FNOF) project was launched. This included an increase in trauma coordinators and clinical aides, regular orthogeriatric input, daily hip fracture operating lists, a separate hip fracture ward and a dedicated discharge nurse.

Aim: The aim of this study was to assess the outcome of the FNOF project.

Method: Data on mortality and length of stay was collected from the IM& T department and was cross referenced with the PCT database. Time to theatre data was collected from the trauma coordinators. Study period was five years from January 2003 to December 2007.

Results: 3636 patients were admitted with a hip fracture in the five year period. The length of stay reduced from 31 days in 2005 to 19 days in 2007 (p< 0.001). The in-hospital mortality reduced from 17.0 % in 2005 to 11.3% in 2007 (p< 0.01). 1 year mortality dropped from 36.9% to 27.3% (p< 0.001). The 30 day and 4 month mortality were also reduced but this was not statistically significant. 85% of patients had surgery within 48 hours in 2007 as compared to 47% in 2005–06.

Conclusions: The FNOF project was successful in reducing In-hospital and 1 year mortality, length of stay and time to theatre. However, the 30 day mortality did not show a significant reduction. In-hospital mortality is not a good comparator of hospital performance as it depends on length of stay; 30 day mortality would be more accurate. The national hip fracture database can be used to obtain accurate data for future studies.


M-S Arshad K. Bowden S. Stacey S. Hodgson

Background: Recognising the need for orthogeriatric input for fractured neck of femur patients, as evident from recent studies, has been established fact for some time now. Although, most studies suggest a healthcare model involving an orthogeriatric service of some degree, usually a visiting physician or a post-operative rehabilitation setup, we highlight an innovative strategy involving a dedicated in-house orthogeriatric team providing a high-level of care based in a stabilisation unit. Since the realisation back in 2004 that the Relative Risk for Mortality in patients with fractured neck of femurs was 164.6, CI (130.5–204.8) compared to the expected level of 100, a series of changes were introduced to combat this.

Methods: Within the orthopaedic department a trauma stabilisation unit (TSU) was setup with a dedicated orthogeriatric service and the early warning score (EWS) system was implemented. This was used to identify patients requiring higher levels of care and thus transfer to TSU.

Results: The 2007 Relative Risk for Mortality for hip fractures stands at 92.4, CI (66–125.9) suggesting a reduction of 44% in mortality. Furthermore, there has been no significant change in age, co-morbidity or delay to surgery over this period.

Discussion: The presence of an orthogeriatric service which dedicates itself to patient optimisation pre-operatively and post-operative recovery has immensely improved the outlook on this frail population. The increase level of nursing care with a ratio of 1:2 and implementation of the EWS system again adds to improved patient care and outcome. Thus we strongly advocate that the development of such a care model within trauma & orthopaedics is essential in improving the service our patients receive.


M. Ahmad A. Bajwa S. Patil R. Bhattacharya R. Nanda G. Danjoux A. Hui

Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intra-medullary or extra-medullary fixation device.

Methods: A prospective group of 31 patients with extra-capsular proximal femoral fractures were randomised to either fixation using an extra-medullary compression hip screw or an intra-medullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record pre-operative hypovolaemia and peri-operative changes in cardiac output, stroke volume and corrected flow time (FTc – a reflection of left ventricular end diastolic pressure) during placement of implants.

Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 mls of colloid replacement fluid. Application of the extra-medullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 mins post operatively.

Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve.


G. Matharu P. Najran

Aims: Secondary prevention in patients suffering neck of femur fractures is an effective but under utilised strategy in reducing subsequent fragility fractures. Published BOA guidelines recommend patients aged 75 or over with fragility fractures should receive bisphosphonates, falls risk assessment, and vitamin D supplements if there are concerns regarding deficiency. This audit aimed to determine the effectiveness of implementing secondary prevention strategies in patients admitted with neck of femur fractures.

Methods: Patients aged 75 or above admitted to a local trauma unit with neck of femur fractures were identified over a two-year period. In-hospital mortality was recorded. Discharge letters for the remaining patients were obtained. Data was collected on whether patients were commenced on bisphosphonates and vitamin D supplements in hospital, or whether advice was given for these therapies to be initiated in the community. Patients undergoing falls risk assessment prior to discharge were also noted.

Results: Overall 549 patients met the inclusion criteria. Eighty patients died during admission giving an in-hospital mortality rate of 14.6% per year. A further 238 patients were excluded due to missing data leaving 231 patients in the final study population. Mean age was 84.4 yr (range 75–97 yr) and 77.9% (n=180) were female. Bisphosphonate therapy was commenced or recommended in 22.9% (n=53), vitamin D supplements in 46.3% (n=107), and 16.5% (n=38) underwent falls risk assessment. Only 4.3% (n=10) were commenced on bisphosphonates and underwent falls risk assessment.

Conclusions: Despite evidence that secondary prevention is effective in reducing subsequent fragility fractures our findings demonstrate these strategies are poorly implemented with less than one in twenty patients receiving the recommended falls assessment and antiresorptive therapy. A standardised discharge letter for patients with neck of femur fractures would provide more effective communication between hospitals and primary care thereby assisting the implementation of secondary prevention strategies.


W. Khan A. Malik S. Anand D. Johnson J. Andrew T. Hardingham

Introduction: There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissues including the fat pad. In this study, stem cells isolated from the fat pad were characterised and their differentiation potential assessed.

Materials and Methods: The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated, expanded and stained for a number of stem cell markers. For adipogenic differentiation, cells were cultured in adipogenic inducing medium (10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine). Gene expression analyses and Oil red O staining was performed to assess adipogenesis.

Results: Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained sparsely for 3G5 (peri-cyte marker). On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining revealed triglyceride accumulation within typical adipogenic morphology, confirming the adipogenic nature of the observed vacuoles, and showed failure of staining in control cells.

Discussion: Fat pad derived stem cells expressed a cell surface epitope profile of mesenchymal stem cells, and exhibited the potential to undergo adipogenic differentiation. Our results show that the human fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.


F Daglish G Stamps P Whittaker N Holt N Unnikrishnan S Nayagam

Background: Knee stiffness from peri-articular fractures, arthroplasty or limb lengthening surgery, if intractable after an extensive programme of physiotherapy, may be resolved by quadricepsplasty. We describe the recovery of knee function in a cohort of 12 patients who underwent a Judet quadricepsplasty for loss of knee flexion.

Material and Methods: 12 adult patients underwent a Judet quadricepsplasty for recovery of knee flexion range. The causes of stiffness were trauma, arthroplasty, infection and limb lengthening surgery. A protocol of continuous passive knee movement under epidural analgesia was maintained after surgery. Continuous passive motion was continued at home for a further 4–6 weeks together with regular out-patient physiotherapy attendances. Outcome measures were range of movement, extensor lag, a modified WOMAC score for physical function, KINCOM data (with the contralateral limb as control), SF-36 and complications of surgery.

Results: There were 11 male patients and 1 female. The mean age was 30 years (20–71). The median period of follow-up was 3 years (0.8–7 years). The difference between pre-operative and final knee motion ranges was statistically significant (p=0.0048). The medians for flexion before surgery was 41 degrees (SD=18; at surgery 110 degrees (SD =15); final follow-up 105 degrees (SD=20). Extensor lag after surgery was 27.5 degrees (SD18) reducing 3.5 degrees (SD=3.5) finally. KINCOM data against a contralateral control showed a highly significant difference (p< 0.001) in quads strength. The medians for the WOMAC score was 38; PCS of the SF36 34.7 (SD13) and the MCS 53.7 (SD 13). Wound complications occurred in 7 patients and three needed further surgery.

Conclusion: Improvement in knee flexion after a Judet quadricepsplasty is maintained at one year. Extensor lag is common after the procedure but recovers. Most patients found the improvement beneficial but objective measures of knee function showed a return to normal had not been achieved.


I. Ahmed A. Gray J. Aderinto C. Howie J. Patton

Background: Chronic prosthetic joint infection is a cause of patient morbidity and can be challenging to treat. Surgeons performing revision arthroplasty of the hip and knee are confronted with a growing number of patients with extensive loss of bone stock. The use of a modular endoprosthesis is a possible method of treatment in such patients.

Aim: The purpose of this study was to assess the functional outcomes and the success of a single and two stage revision procedure in eradicating chronic prosthetic joint infection using a femoral endoprosthesis.

Methods: A prospective database was reviewed of 20 patients who underwent a proximal, total or distal femoral endoprosthetic replacement after chronic prosthetic infection. Radiographs performed at the time of latest follow up were evaluated for signs of loosening, osteomyelitis and implant failure. The functional status was assessed using the Short Form (SF)-36 health survey score, Toronto extremity salvage score (TESS) and the Enneking score.

Results: Thirteen patients underwent a single stage revision procedure and seven had been treated with a staged revision. At the latest follow up none of the 13 patients treated with a single stage procedure had evidence of ongoing infection. Of the seven patients who had a staged revision, 3 patients had evidence of ongoing infection. The mean pre operative Enneking score for the entire group was 17.1 points and this improved to 47.5 points post operatively (p< 0.0002). The mean pre operative TESS score for the entire group was 42% and this improved to 59% post operatively (p< 0.005). There was also a statistically significant improvement in all of the components of the SF-36 score.

Conclusion: We believe that the use of a modular endo-prosthesis in the treatment of chronic prosthetic joint infection is a successful and viable option in eradicating infection, preserving the limb and providing a good functional result.


A. Karantana C. Boulton K. Shan Shan Shu C. Moran

Methods: We examined prospectively collected data from 6782 consecutive hip fractures to identify 327 fractures in female patients aged 65 years and younger. We report on demographic characteristics, treatment and outcome. We compare this group with a cohort of 4810 consecutive hip fractures in older females.

Results: Not surprisingly, younger women had higher levels of mobility and independence than their older counterparts. However, over 20% mobilised with aids, needed help with activities of daily living and/or had significant co-morbidity. A significantly higher proportion of younger patients were smokers. This had a strong influence on the relative risk of “early” as opposed to “late” fracture (Hazard Ratio 4.7, p< 0.01). Mortality was 0.7% at 30 days and 4.2% at one year.

We calculated age-related incidence of hip fracture in the local population and noted the first significant increase at the interval between 40–44 and 45–49, rather than the age of 50, which is when the onset of screening of hip fracture patients for osteoporosis occurs in most health areas. Lag screw fixation was the most common method of operative fixation. General complication rates were low, as were reoperation rates for cemented prostheses. Intracapsular fractures are an interesting subgroup. When displaced, 39% (61/158) had lag screw fixation and 61% (97/158) were treated by arthroplasty. Kaplan-Meier implant survivorship of displaced intra-capsular fractures treated by reduction and lag screw fixation was 82% at two and 71% at five years.

Conclusion: Hip fractures in females to 65 years of age are sustained by a population at risk as a result of patho-physiology. Treatment in this age group, particularly of intracapsular fractures, remains a topic of debate. Understanding the characteristics of these patients, may lead to an improved opportunity, if not for prevention, at least for intervention.


J. Barnes F. Monsel R. Kirubanandan C. Aylott R. Atkins M. Jackson J. Livingstone

Methods: A Ring Fixator (Taylor Spatial Frame (TSF); Smith & Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial growth arrest following trauma.

Results: The mean corrections were 14.2° (max 28°, min 0°) in the saggital plane and 14° (max 38°, min 2°) in the coronal plane. Leg length discrepancy was also corrected (max 1cm). The average time in frame was 17.8 weeks, with an average correction time of 29.8 days. Knee Society Clinical Rating System (KSCRS) scores post operatively ranged from 95 to 100. All patients returned to full activity, and would accept the same treatment if offered again. The circular fixator is an effective, minimally invasive method for treating the complex deformities arising from this rare injury. Patients remain active during treatment, encouraging a rapid return to school/work activities.


A. James B.J.F. Dean J. Matthews A. Price D. Stubbs D. Whitwell M. Gibbons

Introduction: Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations.

Methods: Between 2003 and 2008 twenty one patients presented with complex trauma related problems and underwent EPR at a specialist tertiary referral centre. The mean age was 71 years (range 44–87) and the median number of previous surgical procedures was 3 (range 0–11). Eight patients presented following failed internal fixation of proximal femoral fractures. Nine patients had periprosthetic fractures around joint arthroplasties, seven relating to total knee replacements (TKRs) and two to total hip replacements (THRs). One case of periprosthetic fracture around THR had undergone failed internal fixation. Two patients had distal femoral fractures, of which one was infected and had undergone failed internal fixation, while the other was unrecon-structable. Two patients had proximal tibia fractures which had both undergone failed internal fixation.

Results: The mean Harris Hip Score was 89.5 (range 64–85) at a mean follow up period of 8 months (minimum 4 months). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75) at a mean follow up period of 6 months (minimum 2 months). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout.

Discussion: Modular EPR in the lower limb is a durable reconstructive option in complex trauma problems, particularly in the elderly and those patients with significant bone loss. Preliminary functional results indicate very satisfactory results.


D. Wharton H. Shalaby K. Graham D. Nayagam

Aims: Osteomyelitis after open injuries or internal fixation of forearm fractures is uncommon. Established chronic infections do not respond fully to antibiotic suppression or limited debridement. We describe a two-stage treatment of segmental chronic osteomyelitis where wide excision of the affected area was followed by spanning external fixation and supplementary local and systemic antibiotic delivery. The bony defect was subsequently filled by vascularised fibula transfer, held by internal or external fixation.

Methods: Eleven male patients (mean age 41 years) with post-traumatic segmental chronic osteomyelitis were reviewed. There were 6 radii and 5 ulnas; the mean post-debridement defect was 7.7cm (range 5–11cm). The first stage involved wide excision and metalwork removal, followed by application of a spanning external fixator to restore distal radio-ulnar congruency. Gradual distraction was needed in some cases with long standing subluxation. ‘Dead-space’ management used gentamicin beads or gentamicin-loaded calcium sulphate, supplemented with systemic antibiotics according to tissue culture results.

A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.

Results: The mean follow-up period was 42.4 months. There was no recurrence of infection and union occurred at both graft-host junctions in all patients. The mean period to radiographic bone union was 4.4 months (range 4–6 months).

Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.

Conclusions: Staged reconstruction, as described, is a suitable treatment strategy for this challenging problem and produces a good functional outcome.


M.C. Papanna B.V. Somanchi P.M. Robinson S.A. Khan R.A. Wilkes

Introduction: Nonunion is a relatively common complication seen in orthopaedic practice. The treatment of nonunion has traditionally been revision fixation with autogenic bone grafting. Here we present our results of nonunion treatment using Osteogenic Protein -1 (OP1) and allograft paste.

Material and Methods: Forty Eight Patients with resistant nonunion including atropic, hypertrophic and infected nonunion were treated with a composite of osteogenic protein-1 and allograft paste. The series consisted of 28 males and twenty females. Average age was 54 years. The average duration of preoperative symptoms was 26 months (range 4 to 52). 28 of 48 patients had an average of three prior failed surgical attempts at union (range 1 to 6). There were thirty seven atrophic, four hypertrophic and seven infected nonunions (bone transport docking site nonunion).18 patients in the series had previous autogenic cancellous bone grafting to the fracture site for attempted union. 39 patients had revision internal fixation with application of OP-1 and allograft paste to the nonunion site. Average healing time was 6.5 months (Range 3.5–19). Three patients in this series had OP-1 insertion twice, one patient simultaneously had autogenic cancellous bone grafting with OP-1.

Results: Average follow-up was 16 months (range 4 to 38). Functional and radiological outcome was excellent in 33 patients, good in five patients and fair in three. 3 cases were ongoing. Three patients went on to non-union requiring revision surgery and are under review. One patient died during follow-up.

Conclusion: Results in our series indicate OP-1 (BMP-7) implanted with Opteform allograft paste are as effective as autogenic cancellous bone grafting in treating resistant bone nonunions.


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S. Cockshott K. Hayward R. Grimer

Introduction: Soft tissue tumours are common in the foot however few are malignant. Synovial Sarcoma of the foot is the most common soft tissue sarcoma to present in the foot (~50%). Despite this diagnosis is often delayed and treatment may be difficult. The aim of this paper is to review the presenting features, management and outcome of synovial sarcoma of the foot and to try and identify areas for improvement.

Method: The clinical presentation, radiological features and treatment of 33 patients with histologically proven synovial sarcoma of the foot were reviewed along with outcomes in terms of local control, metastases and survival.

Results: 33 patients with synovial sarcoma were treated at out unit over a 25 year period, 22 in the last 10 years. The average duration of symptoms was 125 weeks. The age range at presentation was between 11 to 80 years (mean 44). The mean size of the tumour at diagnosis was 5cm in diameter (range 1–10cm). 75% of the tumours were deep at the time of diagnosis. Treatment was by amputation in 21 patients and limb salvage in 11 with 1 patient receiving palliative chemotherapy. Only one patient had local recurrence and presented with lung metastases. Four patients had metastases at diagnosis and nine developed them subsequently. Overall survival at 10 years was 53%.

Discussion: These results have shown that late diagnosis is common for synovial sarcoma of the foot and that by the time of diagnosis 75 % have invaded extra-compartmentally leading to a high risk for amputation. 20 patients had an inadvertent excision of the tumour before referral to our unit. Local control was best achieved with amputation. Overall survival was surprisingly poor despite successful local control.

Conclusion: Earlier aggressive investigation of patients with foot swelling or pain may influence their long term prognosis.


Y. Jabbar J. Phadnis A. Khaleel

Aim: To study a staged technique for the removal of the Ilizarov fixator following bony union.

Method: A prospective case series of all fractures treated by the senior author between May 2005 and May 2007 were reviewed. When patients were able to weight bear pain free with radiological evidence of healing, the frames were dynamised initially by loosening the rods across the fracture site, then by removing all rods across the fracture site and finally the frame was removed under general anaesthetic. Patients were followed up for 6 months clinically and radiologically.

Results: Of 39 fractures (38 patients) 37 underwent staged dynamisation. No patients required further, casting, bracing or walking aids after frame removal. There were no incidences of re-fracture, non-union or late mal-union at 6 months follow up.

Conclusion: The proposed method of staged dynamisation is a safe and useful technique for confirming fracture union and guiding frame removal


S. Kapoor

Introduction: The proximal humerus is one of the common site for neoplasms requiring excision and reconstruction. Out of more than 600 cases of bone tumours operated in the last 12 years, we have managed 33 cases of proximal humerus tumours with custom made megaprosthesis.

Methods: 33 cases of neoplastic involvement of upper end humerus, aged between 18–65 years (mean age 37 years) were operated over a period of 12 years (1995–2007). 23 were males and rest females. The primary lesions were: 19 giant cell tumours; 7 osteosarcoma; 4 chondrosarcoma; 1 metastatic; 2 Round cell sarcoma. The Enneking staging was: 1b(19), IIb(13), III(1). All patients with giant cell tumour had a break of cortex and a soft tissue component necessitating wide surgical excision. Surgery was the primary mode of treatment in all patients and was always undertaken with curative intent. Surgery was supplemented with appropriate chemo- radiotherapy in patients with osteosarcoma/ewing’s sarcoma. Surgical and functional results were evaluated according to MSTS scoring system.

Outcomes: The scoring ranged from 22–27.5%. The hand and elbow function was good in all while the shoulder abduction was always lost. The minimum follow up was 24 months.

Complications included: Superficial infection (1), deep infection (1); Recurrence 2; Improper cementing (2); Neuropraxia [radial nerve] (8); Subluxation of prosthesis head (8); Post radiotherapy skin necrosis and contracture (1); 4 patients died.

Conclusion: Adequate resection of malignant tumours/benign aggressive tumours in the shoulder region gives good oncological & surgical results. For post tumour excision humeral gaps, megaprosthesis is a near ideal choice.


M. Chowdhry R. Grimer L. Jeys S. Carter R. Tillman A. Abudu

Background: Malignant tumours of the radius compose only 3% of all upper limb tumours. Owing to their rarity they are often difficult to manage satisfactorily. Of the options for fixation available, endo-prosthetic replacements have been scarcely utilized despite their success in limb preservation with malignant tumours in other parts of the body. At our centre we have used these when biological solutions (eg fibula graft) were not indicated due to extensive disease or the need for radiotherapy.

Patients: We performed four endoprosthetic replacements of the distal radius in three males and one female with ages ranging from 19–66 years (average= 42.25 years of age). Two were performed for varieties of osteosarcoma (parosteal and osteoblastic osteosarcomas), one for a large destructive giant cell tumour (GCT) and one for destructive renal metastases. Three were right sided (75%) and one left sided (25%).

Methods: Medical records were evaluated for information on local recurrence, metastases, complications and functional outcome using the Toronto Extremity Salvage Score (TESS).

Results: Follow up ranged from 22 to 205 months (average= 116.5 months). The average TESS score was 58.1% (range= 44.6–74.5%). Neither case of osteosarcoma recurred. The GCT recurred twice and the patient with renal metastases had nodules removed from his affected wrist on two further occasions. There were no cases of infection, but one of the earlier cases had problems with metacarpal stems cutting out and joint subluxation. The two earlier cases have since died at 205 (parosteal osteosarcoma) and 189 months (GCT) respectively of other disease.

Conclusions: We conclude that although this is a very small series of endoprosthetic replacement of the distal radius, the technique is a useful addition to the surgical options, with acceptable post-operative functional results and complication rates when a biological solution or preservation of the wrist joint is not indicated.


E. Marsh H. Egan R. Cave J. Long A. Abudu R.J. Grimer

Background & Methods: We reviewed the treatment of 311 patients with primary osteosarcoma treated at a specialist centre between 1995 and 2004. Of this number we identified 8 patients (2.5%) who had undergone inappropriate surgical treatment otherwise known as a ‘whoops’ procedure. These patients were studied to determine the impact of the whoops operations on their subsequent treatment and prognosis.

Results: The whoops procedure consisted of arthroscopic surgery in 3 patients, open reduction and internal fixation of pathological fractures in 2 patients, excision in 2 patients and curettage in 1 patient. The patients who had a whoops procedure were three times more likely to be male, older (median age 25 versus 16 years), had tumours in the lower extremities and were more likely to have amputation as primary local treatment (40% versus 25%). the rates of local recurrence and survival were similar in those with whoops procedures and without.

Conclusion: Whoops procedure is associated with increased risk of amputation and more extensive procedures but does not appear to affect the prognosis of the patient.


J. Long R. Cave H. Egan E. Marsh R.J. Grimer A. Abudu

Background: There is currently no standard follow up protocol for patients who have been diagnosed with and treated for high-grade osteosarcoma. We therefore investigated the possibility of creating a risk based follow-up protocol for patients with primary osteosarcomas.

Methods: 313 patients diagnosed with primary osteosar-comas were studied. The identified risk factors for local recurrence included poor necrosis, inadequate margins and high risk tumour site in the bone. The risk factors for metastases were poor necrosis, inadequate margins, extracompartmental stage and tumour size ≥5cm.

Results: The risk of local recurrence and/or metastases within three years of diagnosis increases as the number of risk factors increase. Patients were grouped according to their number of risk factors. The cumulative risk of metastases for patients with 0, 1, 2, 3 and 4 risk factors is 0%, 12%, 21%, 54% and 60% respectively (p=< 0.0001). Risk of local recurrence for patients with 0, 1, 2 and 3 risk factors is 5%, 14%, 25% and 20% respectively (p=0.0025).

Conclusion: Our investigation shows that by grouping patients together according to their number of identified risk factors, it is possible to identify groups of patients that are most at risk. This information can be used to design an evidence based follow up protocol which would have important implications for clinical practice.


P. El-Dalil T. Warrener M. De Souza A. Abudu

Introduction: Primary bones sarcomas account for 5% of childhood cancers; however the introduction of neo-adjuvant chemotherapy and the development of surgical techniques have resulted in reduced mortality and a longer length of survival. Consequently improving post operative functional outcomes has become an important focus of research. The aim of this study was to investigate and compare differences in the complications and functional outcomes of EPR and rotationplasty in skeletally immature patients.

Methods: This is a retrospective case control study of twenty-four patients, of whom twelve received rotation-plasty and twelve received EPR. Patients were selected at random and matched according to age at diagnosis, sex, site of disease and date of surgery. The Musculoskeletal Tumour Society (MSTS) score was used to evaluate functional outcome, and surgical complications were assessed qualitatively.

Results: Five patients (42%) treated with endoprosthe-ses experienced some form of post-operative surgical complication compared to three patients (25%) treated with rotationplasty. However this difference was not found to be statistically significant. The average MSTS score in the EPR cohort was 22.7 and 18.9 in rotation-plasty patients. Mann Whitney U testing confirmed this difference to be statistically significant (p=0.05).

Discussion: The study showed that patients who received EPR suffered more surgical complications than rotationplasty patients. However the results demonstrated superior functional outcomes in patients who received EPR.

The theoretical benefit historically attributed to rota-tionplasty lies in the provision of a functional and durable hinge joint, however these results suggest that this advantage has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology.

Conclusion: Our experience shows that patients with EPR are more likely to suffer more surgical complications but have similar, if not better functional outcomes compared to rotationplasty.


G. Chuter T. Barwick S. Murray C. Gerrand

Introduction: The workload of a bone and soft tissue tumour (BSTT) multidisciplinary team (MDT) is varied. Only a proportion of the workload attracts specific funding from the National Commissioning Group (NCG) but many patients who do not have primary malignant bone tumours are also seen and treated. We analysed the workload of our supra-regional BSTT MDT to determine the variety of conditions seen, the proportion that does not attract specific funding and the expertise required to run the service.

Methods: A prospective database was used to identify all new patients discussed at our weekly BSTT MDT meetings between 2004 and 2008 inclusively. Patients were divided by diagnosis into eight categories and further identified as to whether or not they attracted funding under NCG regulations.

Results: 1743 new patients were identified of which 83 were excluded. Of the remaining 1660, 65% were non-sarcoma and 50% were benign. 31% of the malignant workload was non-sarcoma. Only 9% of treated patients were eligible for NCG funding. Of those requiring surgery, the orthopaedic team managed 93% of benign and 77% of malignant cases; general, plastic, or thoracic surgical teams managed the remainder.

Discussion: NCG funds the management of all malignant primary bone tumours and the investigation and/or treatment of other selected conditions; the majority of our workload does not qualify. Despite fluctuations in the total workload, the ratio of benign to malignant cases remains relatively constant. An effective MDT requires expertise across many specialties.


T.W. Barwick G.S.J. Chuter S.A. Murray C.H. Gerrand

Introduction: The ‘Two Week Wait’ (2ww) process has been in force since the year 2000, with the subsequent implementation of 32-day diagnosis and 62-day treatment ‘rules’ in 2005. The aims of this study were to compile a definitive diagnostic profile of 2ww referrals, establish whether a histological biopsy was required for diagnosis and consider the current 2ww impact on services in our centre.

Materials and Methods: Two hundred and nine patients were referred under 2ww to the North of England Bone and Soft Tissue Tumour service and prospectively recorded on a computerised multidisciplinary tumour database from 2006–8. The data was reviewed and verified using pathology, radiology reports and patient records.

Results: Malignancy was diagnosed in 41(20%) patients. This comprised 21 soft tissue sarcomas (10%), 11 primary bone tumours (5%), and 9 metastatic bone tumours (4%). 63 (30%) benign bone or soft tissue neoplasia and 80 (38%) non-neoplastic conditions were diagnosed. No mass lesion was identifiable in 25 patients (12%). A diagnostic or therapeutic biopsy was required in 108 (52%) patients.

Discussion and Conclusion: 15% of 2ww referrals to our centre have a primary bone or soft tissue sarcoma but over half of all 2ww patients require biopsy for diagnosis creating additional strains on resources under the 32- and 62-day rule. Emphasis is placed on obtaining a rapid diagnosis, to ease pressure on time to treatment, utilising a ‘one-stop clinic’ approach for biopsies of accessible tumours where applicable. The availability of timely radiological resources, facilitated by an MDT involving a designated coordinator (‘patient-tracker’), is key to ensure treatment is not delayed for any cancer patient regardless of referral route. Our centre is 100% compliant for waiting times for sarcoma according to the Department of Health 2008 data.


A. Isidro Llorens A. Malgosa X. Jordana M. Taulé L. Gonzálvez

In Europe wide exhibition on ancient diseases in skeletal and mummified remains are scarce. In the last Congress of the EBJIS held last year in Barcelona a small sample of old infection diseases were showed. Until now, only in the specifically meetings of paleopathology it is possible to see some examples of this archaeological pieces. The knowledge of the frequency, prevalence and evolution of the most important infections that use to affect at bone across the time could be important to evaluate the health status of the population.

From February to August 2009 is been open in the Egyptian Museum of Barcelona a wide exhibition of archaeological pieces that shows a wide range of abnormalities and diseases in skeletal and mummified remains. More than 150 pieces belongings at 35 different institutions around the World are shows to the public. Among theses, 58 pieces are present in the Infection Area; they cover a wide range of time in the Mankind History, from the Neolithic Period to the end of the XIX century. We present a sample of the most important pieces of this ambit as poliomyelitis, Hanssen disease, treponematosis, tuberculosis, brucellosis, pyogenic osteomyelitis in diaphysis of long bones and in the spine, hidatidic cists. The diagnoses of some of them are evaluated by molecular evidence. We also shows the mummies of two children, one with tuberculosis and the other with triquinosis, and an adult mummy from the Tiwanaku Culture possible affected of treponematosis.


B. Costerton

Direct observations have shown that the bacteria and fungi that cause device-related and other chronic infections grow in well developed biofilms on the surfaces of biomaterials and of compromised tissues. This mode-of-growth confers on the microorganisms an inherent resistance to host defenses, and antibiotic therapy, and makes these infections very difficult to detect because biofilm bacteria do not produce colonies when plated on the agar media used in routine cultures. We have initiated two comprehensive studies of total joint prostheses, and of non-unions secondary to trauma, in which we use DNA-based (Ibis and 454) methods for the detection of bacteria and an iterative process in which we locate and visualize biofilms using FISH probes and confocal microscopy. The DNA-based detection system confirms culture results, but detects more organisms and determines their sensitivity to antibiotics, and appears to be useful in the management of both types of infection. The use of confocal microscopy and FISH probes to visualize and map biofilms, in relation to orthopedic hardware and affected tissues, confirms the Ibis data and provides useful insights into the etiology of orthopedic infections.


P. Stoodley S. Kathju

Post-operative surgical site infection following total joint arthroplasty occurs at rates between ~ 0.2–5 %, depending on the joint and the surgeon volume, as well as various patient risk factors. Given that an estimated over 700,000 knee and hip arthroplasties are performed in the US each year this translates to thousands of patients that are affected by this serious, costly and traumatic complication. In addition, it is now recognized that clinical culturing underestimates the infection rate and that a number of aseptic loosenings might actually have an infectious etiology. We have used a combination of non-culture based molecular methods to detect bacteria associated with hardware, antimicrobial impregnated cement, reactive tissue and pus collected during revision surgery in a total elbow arthroplasty (TEA) case and a total ankle revision (TAR) case. Confocal microscopy showed live cocci in biofilm cell clusters, and fluorescent in situ hybridization (FISH) demonstrated S. aureus biofilms. Reverse transcriptase (RT)-PCR, and multiplex PCR coupled with electrospray-ionization mass spectrometry (Ibis T5000) to identify S. aureus, S. epidermidis and genes for methicillin resistance. Together our complimentary techniques comprise compelling evidence that viable biofilm bacteria played an important role in the refractory infections in these cases.


G. D. Ehrlich

First generation molecular diagnostics based on PCR suggested that the routine culture of bacteria was inadequate for the detection of many pathogens, particularly after antibiotic treatment or when associated with chronic infection and biofilm growth. These techniques, however, suffered from their own problems. False negative results were caused by inhibitors of the PCR process and by the overly specific nature of most simplex assays which require an a priori assumption on the part of the investigator as to which species to test for. False positives resulted from contamination, or carryover, of amplified DNA. Recently several new technologies have been developed and have resulted in “next generation” tests that overcome the problems associated with the earlier methods. We will provide an overview of two of these technologies and present our experience in their application to the diagnosis of orthopedic infections associated with arthroplasties and external fixations. 454-based deep 16S rDNA sequencing provides for a comprehensive and quantitative analysis of all bacterial species present in clinical specimens regardless of whether the species present have been previously identified. The results of this test can be used to improve the specificity of other tests such as the Ibis Universal Biosensor. The Ibis Universal Biosensor T-5000 system uses a highly multiplex PCR front end which is coupled to a highly sensitive electron spray ionization (ESI) time-of-flight (TOF) mass spectrometer (MS) which provides for the exact base composition of the amplified DNA permitting species and even strain-specific identification of bacterial and fungal pathogens through an interface with a massive DNA sequence database. This system therefore provides both great breadth of coverage, with exquisite specificity. Moreover, this system can identify multiple species within a specimen providing a rapid analysis of polymicrobial infections.


D. Kotsougiani V. Heppert G. M. Hänsch C. Wagner

Implant-associated osteomyelitis is caused by persistent bacterial infections, predominantly by staphylococci species forming biofilms on implants or osteosynthesis – materials. In the majority of patients the systemic immune response appears to be inconspicous with only minor upregulation of activation-associated receptors on the polymorphonuclear neutrophils (PMN). We found, however, evidence the activation of T cells, apparent as the expansion of CD4+ and CD8+ T cells bearing the activation-associated receptor CD11b. These cells also lacked the co-stimulatory molecule CD28, which is a further indicator for T cell activation. Moreover, small populations of T cells expressing Toll-like receptors (TLR)1, TLR2 or TLR4 were detected in the patients, while in healthy donors less than 1 % of T cells express TLR. A preferential association of TLR1- and TLR2-expression with CD28-CD11b+ cells was seen, compatible with the fact these cells represent an activated phenotype. In addition to the peripheral blood we also analysed leukocytes recovered from the infected site during surgery for removal of the implant. Predominantly PMN were found, highly activated as judged from their surace recpetor pattern, but also CD4+ and CD8+ T cells. As expected, these T cells represented an activated phenotype, and particularly the CD8+ cells expressed CD57, a receptor identifying end-differentiated T cells. The T cells recovered from the infected site, but not the peripheral blood T cells, produced interferon gamma, a cytokine known to support the function of phagocytic cells. In conclusion our data provide evidence that in response to local, persistent bacterial infections T cells are activated to acquire – among others – receptors selective for bacterial products, which in turn might modulate the T cell function and hence the host defence.


M. Clauss A. Trampuz O. Borens T. Ilchmann

Background: Bacteria form a biofilm on the surface of orthopaedic devices, causing persistent and infection. Little is known about biofilms formation on bone grafts and bone substitutes. We analyzed various representative materials regarding their propensity for biofilm formation caused by Staphylococcus aureus.

Methods: As bone graft beta-tricalciumphosphate (b-TCP, CyclOsTM) and as bone substitute a tantalum metal mesh (trabecular metalTM) and PMMA (Pala-cosTM) were investigated. As test organism S. aureus (strain ATCC 29213) was used. Test materials were incubated with bacterial solution of 105 colony-forming units (cfu)/ml at 37°C for 24 h without shaking. After 24 h, the test materials were removed and washed 3 times in normal saline, followed by sonication in 50 ml Ringer solution at 40 kHz for 5 minutes. The resulting sonication fluid was plated in aliquots of 0.1 ml onto aerobe blood agar with 5% sheep blood and incubated at 37°C with 5% CO2 for 24 h. Then, bacterial counts were enumerated and expressed as cfu/ml. All experiments were performed in triplicate to calculate the mean ± standard deviation. The Wilcoxon test was used for statistical calculations.

Results: The three investigated materials show a differing specific surface with b-TCB> trabecular metal> PMMA per mm2. S. aureus formed biofilm on all test materials as confirmed by quantitative culture after washing and sonication. The bacterial counts in sonication fluid (in cfu/ml) were higher in b-TCP (5.1 x 106 ± 0.6 x 106) and trabecular metal (3.7 x 106 ± 0.6 x 106) than in PMMA (3.9 x 104 ± 1.8 x 104), p< 0.05.

Conclusion: Our results demonstrate that about 100-times more bacteria adhere on b-TCP and trabecular metal than on PMMA, reflecting the larger surface of b-TCP and trabecuar metal compared to the one of PMMA. This in-vitro data indicates that bone grafts are susceptible to infection. Further studies are needed to evaluate efficient approaches to prevent and treat infections associated with bone grafts and substitutes, including modification of the surface or antibacterial coating.


T. B. Beckingsale J. E. Page A. Jennings T. Fawcett

Introduction: Staphylococcus aureus is a major cause of chronic infections and causes particular problems in relation to implanted prostheses. Biofilm formation on abiotic surfaces affords bacteria innate protection from opsonophagocytosis and antibiotic agents and complicates the eradication of infection from bone and implanted prostheses. Increased concentrations of sodium, the major extracellular cation, have previously been implicated in increased biofilm formation in Staphylococcus aureus. In this study we demonstrate that increased concentrations of potassium, the major intracellular cation, also causes a significant increase in biofilm formation. Furthermore we also show that halide stress also leads to a primary increase in penicillin resistance in Staphylococcus aureus. Finally we demonstrate that pbp4, a key gene in cell wall synthesis, is down-regulated under sodium and potassium stress.

Methods: Staphylococcus aureus ATCC 9144 was cultured in broth supplemented with variable amounts of potassium chloride and sodium chloride. Biofilm formation was investigated in 96-well microtiter plates using a standard technique. Antibiotic resistance was investigated using graduated E-test strips. Gene transcription was assessed using RT-PCR.

Results: There was a positive correlation between biofilm formation and increased concentrations of sodium and potassium. Biofilm formation was noted to be even greater under potassium stress than under sodium stress. Sodium stress also lead to a five-fold increase in penicillin resistance in naïve Staphylococcus aureus cells. A key gene involved in cell wall production (pbp4) was down-regulated under sodium (p = 0.03) and potassium (p = 0.03) stress.

Discussion: Cellular injury or insult can lead to cell necrosis and lysis. The intracellular concentration of potassium is 30 times higher than that of the surrounding extracellular fluid. Hence, cell necrosis leads to markedly increased local concentrations of potassium. These experiments show that an increase in potassium concentration leads to an increase in biofilm formation. This suggests that biofilm formation and hence infection of implanted prostheses may be more likely in areas of major tissue trauma such as large resections and revisions. Furthermore, cellular stress leads to increased resistance to penicillin, a cell wall active antibiotic, in naïve cells which may nullify prophylaxis and complicate bacterial eradication in vivo. Finally we postulate a link between the experimental rise in penicillin resistance and the down-regulation of pbp4 demonstrated by RT-PCR under the same halide stresses.


G. M. Hänsch G. Brenner-Weiss U. Obst C. Wagner

P. aeruginosa produce N-3-oxododecanoyl homoserine lactone (3OC12-HSL), a so-called “quorum-sensing molecule” that provides signals for the production of virulence factors and for bacterial biofilm formation in a paracrine manner. We now found that 3OC12-HSL, but not its 3-deoxo-isomer or acyl homoserine lactones with shorter fatty acids, is also able to activate human polymorphonuclear neutrophils (PMN) in vitro: 3OC12-HSL enhanced the phagocytosis of opsonised bacteria in vitro; up-regulated the surface expression of phagocytosis-related receptors, and was chemotactic for PMN. Because induction of chemotaxis implies the polarisation of the cell by receptors expressed on the surface, we performed uptake studies with radiolabelled 3OC12-HSL. At 4° C we found saturable binding of the radiolabelled 3OC12-HSL, which could be inhibited by an excess of unlabelled 3OC12-HSL, indicating specificity of binding, and hence expression of a distinct surface receptor. By use of selective inhibitors, a signalling pathway, comprising phosphotyrosine kinases, phospholipase C, protein kinase C, mitogen activated protein kinase C was delineated, but in contrast to the well-studied chemokines C5a and interleukin 8, the chemotaxis in response to 3OC12-HSL did not depend on pertussis toxin-sensitive G proteins. Selective surface receptors for 3OC12-HSL have been identified in various bacteria species, but scrutinising a human gene bank did not reveal homologous structures. While the characterisation of the surface receptor awaits further studies, the functional consequence of the cross-kingdom signalling is obvious: by recognising and responding to 3OC12-HSL PMN are attracted to the site of a developing biofilm, and thus may prevent its progression and by that persistent infection.


C. L. Romano E. Meani M. Artini G. Scoarughi R. Papa L. Selan

Introduction: Staphylococci are a well recognized cause of orthopaedic implant infections, due to their ability to produce biofilms, that limit antibiotic and host defence capabilities. To detect serum IgM levels against staphylococcal slime polysaccharide antigens (SSPA), an original immunoenzymatic assay has been previously developed and tested in patients affected by staphylococcal vascular graft infections [The Lancet • 359:2166–2168, 2002]. This is the first report on the efficacy of this serum ELISA testing of anti-SSPA IgM in Staphylococcal Orthopaedic Implant-Related Infections (SOIRI).

Methods: SSPA is extracted and purified using a suitable original patented bacterial strain and method. The immunoenzymatic assay to detect anti-SSPA IgM was performed on sera collected from 53 patients with joint prosthesis (24 hips, 17 knees, 2 shoulders). Each serum sample was tested in triplicate in two different assays and values are expressed as means. Main exclusion criteria were: time from implant < 6 months, rheumatoid arthritis, concurrent known infections. The study was approved by the local ethical committee and all patients gave their informed consent.

28 sera were collected from controls (patients with uninfected joint prosthesis, as judged from clinical, laboratory and radiological data) and 25 sera were obtained from patients with known SOIRI, sustained by S. aureus or coagulase-negative Staphilococci (CNS) (positive joint aspiration and/or intra-operative cultural examination).

Results: 25 patients were classified as true negative, 21 true positive, 4 false negative, 3 false positive. Test efficacy calculation provided the following Results: sensitivity: 84 %, specificity: 89.3 %, positive predictive value: 87.5 %, negative predictive value: 86.2 %.

Discussion and Conclusion: Anti-SSPA IgM immunoenzymatic assay showed interesting sensitivity and specificity in this preliminary prospective study. The test appear as an innovative, user-friendly, cheap and non-invasive diagnostic tool for orthopaedic implant-related infections. Further studies should be devoted to better define the cut-off value, testing reproducibility and standardization for large scale application.


J. Holinka R. Lass M. Pfeiffer W. Graninger A. Hirschl E. Presterl

Objectives: Microbial biofilms protect planctonic bacteria growing on the implants surfaces from detection and antibiotic treatment. To investigate the efficacy of sonication cultures in our patients with prosthetic joint infections we compared our findings with the results to those of periprosthetic tissue cultures and histology.

Methods: The sonication cultures of the explanted prosthesis were cultured according to the protocol by Trampuz et al. in the New England Journal of Medicin and using the routine method incubating the aspirated pus and periprosthetic material in brain-heart-infusion broth without sonication. To assess the most frequently affected component of the prosthesis all components were “sono-cultured” separately. The diagnosis of infection was based on the presence of bacteria or leucocytes in pus or tissue plus local signs and symptoms and/or systemic markers of inflammation (fever, leucocytosis, increased C-reactive protein)

Results: We investigated 60 patients with 40 septically and 20 aseptically explanted components of total knee (n=24), hip (n=21) tumor (n=6) and shoulder (n=2) endoprosthesis, as well as osteosynthetic material (n=6) and spinal instrumentation (n=1). The most frequently affected component of the hip prosthesis was the femoral head (100%) and the inlay (88%), of the knee prosthesis was the Patella (58%) and the tibia plateau (56%), of the tumor prosthesis were the polyethylene components (100%), of the shoulder prosthesis was the sphere and stem (each 100%), of the osteosynthesis material were the plate and screws (each 33%) and of the spine instrumentation were the rod and the screws (each 100%). From all detected pathogens in sonication cultures the most frequently were Staphylococcus aureus (25%), Staphylococcus epidermidis (22%) and Streptococci (13%). The sensitivity of sonication cultures and periprosthetic tissue cultures was 85% and 78% without preoperative antibiotic therapy compared with histological analysis of 100% sensitivity. The specificity was 89% for sonication cultures, 95% for periprosthetic tissue cultures and 100% for histological analysis.

Conclusion: Our results of separating the explanted components for sonication culture proved the detection of valid pathogens for every kind of endoprosthesis or implants and supplied further information for the focus of infection.


W. Zimmerli A. Trampuz

Implants are highly susceptible to infection [1]. The infection rate is 0.5–2% after hip or knee arthroplasty [2]. Periprosthetic joint infections are hard to eradicate. Until recently, two-stage exchange or life-long antibiotic suppression therapy has been the rule. However, novel treatment concepts evolved. Whereas no controlled trials on the surgical management of prosthetic-joint associated infection are available, much is known about the optimal antimicrobial therapy. Modern treatment concepts are based on animal studies, in vitro data, observational studies and one single controlled trial comparing two different antimicrobial regimens in patients with orthopaedic device-associated infections [2]. The tissue-cage guinea pig model is especially suitable to analyse the role of antibiotics in device-related infections [3]. In this model, different aspects of implant-associated infections have been studied, namely

host-defense mechanisms around implants [1],

risk of hematogeneous infection of extravascular devices [4],

efficacy of prevention or antibiotic treatment [512],

correlation between efficacy of treatment in vivo and in vitro [11,12], and the role of biofilm formation on the activity of antibiotics [11].

Taken together, these experiments showed that an agent acting on slow-growing and adhering microorganism is needed to eradicate device-associated infection. This requirement is only fulfilled by rifamycins in staphylococcal infection and by fluoroquinolones in infections caused by gram-negative bacilli [512]. We could show that even new drugs against methicillin-resistant staphylococci (MRSA), such as linezolid and daptomycin, were not able to eradicate experimental foreign-body infections, when used as single agents. In contrast, in combination with rifampin linezolid cured 60%, and daptomycin 67% of the implant-associated MRSA-infections [9,10]. Based on these in vitro and animal data, observational studies were performed in patients with staphylococcal infections associated to orthopedic devices. We developed an algorithm allowing to choose the optimal therapeutic option for each patient [2]. This algorithm has been validated in cohort studies [13,14]. Finally, in a randomized double-blind controlled trial, the benefit of a rifampin-quinolone combination as compared to quinolone monotherapy has been proven in patients with acute orthopedic implant associated staphylococcal infection undergoing debridement with retention [15].

In conclusion, the favorable role of rifampin has been proven in vitro, in animals and in human studies. Also the newest antistaphylococcal agents must be given in combination with rifampin in order to eliminate infection without removal of the device.


A. Trampuz W. Zimmerli

Implant-associated infections do not spontaneously cure. The reason for persistence in device-associated infections is the biofilm, a specialized form of bacterial growth on surfaces. The biofilm represents a survival form of bacteria which is highly resistant against most antibiotics, and can persist over months or years as low-grade infection. Bacteria in biofilms enter a metabolically inactive state, embedded in an amorphous substance, called biofilm matrix. Together they form a complex three-dimensional structure with rudimentary communication and circulation systems.

As a rule, only a combined surgical and antimicrobial management can eradicate biofilms and cure implant-associated infection. In selected patients, implant infections can be cured without implant removal with early debridement and long-term antibiotic treatment acting against biofilms. In this presentation, common pitfalls and reasons for treatment failure will be outlined and discussed.

Adequate diagnosis. Every prosthesis with early loosening (< 2 years after implantation) or persistent/increasing pain should rise the suspicion of an implant-associated infection, which may presents without systemic signs of infection (fever), and can manifest without increased leukocyte counts or C-reactive protein). In this case, periimplant infection must be actively searched. Preoperative diagnosis includes aspiration of the synovial fluid of larger joints for Gram stain and culture; cell count and differential; and crystals (if appropriate). Swabs of the sinus tract (fistula) should not be performed, since they may not represent the causing organisms of the bone- or implant-associated infection. Intraoperative diagnosis includes multiple tissue biopsies around the prosthesis (no swabs), histopathology of the periprosthetic tissue and sonication of the removed device or its parts (if the method is available). For low-virulent organisms (such as Staphylococcus epidermidis or Propionibacterium acnes) at least two positive specimens with the same organism or an additional criterion for infection (i.e. acute inflammation in the tissue histopathology, presence of intraoperative pus or fistula) is needed. For slow-growing organisms, long incubation is needed (14 days) in order to culture these slow-growing and fastidious pathogens. Antibiotics should be discontinued at least 2 weeks prior to culture sample in order to minimize false-negative results. Novel diagnostic tests include PCR, which can also detect non-growing microorganisms and can be used for tissue specimens, joint aspirate or sonication fluid.

Adequate antibiotic therapy. The identification of the infecting pathogen is paramount for a successful treatment. Therefore, no empiric antibiotic therapy should be administered before diagnosis is microbiologically confirmed. Antibiotics administered for a secreting wound overlying an implant is a critical mistake, which makes the etiological diagnosis difficult. In addition, the risk of development of antimicrobial resistance is high, particularly for rifampin. Therefore, rifampin should not be administered as long as there is a contact between body surface and implant (e.g. open wound or wound dehiscence, fistula, VAC foam, drainage). In contrast, addition of rifampin is absolutely necessary for eradication of staphylococcal infections of implants in case of retention (see presentation from W. Zimmerli S02.KL1). Other common mistakes are short duration of antibiotic treatment (totally 3 months are needed for eradication of biofilm), low antibiotic dose (high dosing is needed to achieve sufficient concentration in bone) or switch from intravenous to oral antibiotics with insufficient bioavailability (such as oral betalactams) or inactivity against biofilms (such as cephalosporins, macrolides or clindamycin).

Adequate surgical therapy. Immediate debridement is indicated, if there is a suspicion of implant-associated infection (wound dehiscence, persisting secretion, lack of postoperative decrease of CRP). A revision is needed for diagnostic (adequate microbiological diagnosis) and therapeutic purposes (mechanical reduction of bacteria). The implant can be retained, if the symptoms of infection are lasting < 3 weeks, the prosthesis is stable and the infecting pathogen is susceptible to anti-biofilm antibiotics (i.e. staphylococci susceptible to rifampin). Importantly, a loose prosthesis can not be salvaged and always needs to be exchanged. Antimicrobial suppression therapy has a low probability of success (failure rate approximately 80% after 2 years). The drainages should be kept in place as short as possible, i.e. in general not more than 3 days. Large soft tissue defects require coverage with a flap.

In conclusion, using the proposed diagnostic and treatment algorithm (Zimmerli et al. NEJM2004; 351: 1645), the long-term success rate of periprosthetic joint infection is 80–90%. To avoid failure, it is important to select the patient for the least invasive, but still appropriate surgical and antibiotic treatment regimen and to avoid mistakes.


G. Cazander M. C. van de Veerdonk C. M. Vandenbroucke-Grauls G. N. Jukema

Biofilm formation (BF) in wounds and on biomaterials is a severe complication in trauma and orthopaedic surgery. Maggot therapy is successfully applied in wounds, that are suspected for BF. This study investigated BF by Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella oxytoca, Enterococcus faecalis and Enterobacter cloacae on polyethylene, titanium and stainless steel and tested the effect on BF by maggot excretions/secretions (ES). Comb-forming models of the biomaterials were made to fit into a 96-well microtiter plate. In the wells, a suspension of 2.5 x 105 bacteria/ml and nutrient medium was pipetted. Combs were placed in the wells and incubated for 3, 5, 7, and 9 days at 37°C. The formed biofilms were stained in crystal-violet and eluted in ethanol. The optical density (OD 595 nm) was measured to quantify BF. Then, maggots excretions/secretions (ES) were collected according to a standardized method, added in different concentrations to (non-stained) mature biofilms (7 days), incubated another 24 hours and at last stained and measured. The results showed biofilm reduction by ES on all biomaterials. Biofilms formed by S. aureus were reduced to minima of 40% on PE and SSS (p< 0.001) and 50% on TI (p=0.005). The biofilm reduction for S. epidermidis was even greater on PE, SSS and TI with respectively minima of 8% (p< 0.001), 32% (p< 0.001) and 38% BF (p< 0.001). The quantity of BF by S. aureus and S. epidermidis had a comparable strength (p=ns) and was for both bacteria the greatest on polyethylene and the lowest on titanium (p< 0.001). Klebsiella oxytoca, Enterococcus faecalis and Enterobacter cloacae formed weak biofilms on all materials. Mature BF was reached between 5 to 7 days by S. epidermidis and between 7 to 9 days by S. aureus. Our previous research showed biofilm inhibition and breakdown of Pseudomonas aeruginosa by ES. This study showed that maggot ES also reduce biofilms formed by S. aureus and S. epidermidis which are frequently isolated from biomaterial-associated infections. There may be pharmacologic agents that could be developed from maggot ES. While BF on orthopaedic materials is an increasing problem, this experimental study could indicate a new treatment for BF on infected biomaterials


A. H. Hosman H. C. van der Mei S. K. Bulstra H. J. Busscher D. Neut

Background and Purpose: The remarkably low wear of metal-on-metal (MOM) bearings involving cobalt-chromium (Co-Cr) alloys has led to a resurgence in its use. However, consequences of these wear particles and the corrosion products are for the most part unclear. Recent research efforts towards the bacteriological influences of the MOM-degradation products suggested that particulate MOM debris promotes planktonic bacterial growth. On the other hand, extremely high concentrations of metal ions, derived from salts, have shown to possess bacteriostatic effects (growth reduction) on planktonic growth and on biofilm formation. The effects of salt-derived metal ions were found to be inhibitory and not bactericidal (lethal to bacteria). However, these two findings were both found under static growth conditions and no studies have investigated these findings under more clinically resembling dynamic growth conditions. In addition, influences of Co-Cr particles on biofilm formation have not yet been studied. Therefore, the aim of this study was to evaluate how Co-Cr particles and Co-Cr ions affect biofilm formation under static and dynamic growth conditions.

Methods: A collection of clinically isolated bacterial strains were exposed to Co-Cr particles and Co-Cr ions in concentrations as found in serum and above as found in adjacent tissue. The experiments were conducted as well under static, as under dynamic growth conditions. Biofilm formation in wells, stained with live/dead viability staining and visualized by confocal laser scanning microscopy, was analyzed with COMSTAT, yielding biovolume, biofilm thickness, and live/dead ratio of the bacteria within the biofilm.

Results: Co-Cr particle concentrations of 20 g/L reduced biofilm formation significantly. Moreover, these particle concentrations were found to be bactericidal (killed the bacteria). The live/dead ratio decreased when culturing was done under dynamic growth conditions when compared to the static growth condition. Under both growth conditions, biofilm formation was inhibited at concentrations of 10/5 mg/L Co-Cr ions, as reported to occur in synovial fluids. Co-Cr ion concentrations up to 1/0,5 mg/L revealed no consistent influence on biofilm formation.

Interpretation: Long-term clinical data on infection rates for Co-Cr MOM-bearings are not yet available, but the current results suggest that Co-Cr ions may yield these prostheses less prone to biofilm formation and subsequent infection.


O. Borens R. Baalbaki F. Nussbaumer M. Clauss A. Trampuz

Background: Antibiotic-loaded spacers and cement nails are commonly used in patients undergoing a two-stage implant exchange procedure for treatment of prosthetic joint infection (PJI). During re-implantation 2–6 weeks after implant removal, tissue specimens are collected to document successful eradication of infection. However, these specimens have limited sensitivity, especially in patients receiving antimicrobial treatment. We investigated the value of sonication of removed spacers and cement nails.

Methods: We prospectively included patients in whom a spacer or cement nail was removed from January 2007 through April 2009 during a two-stage exchange procedure. The removed temporary device was sonicated in a container with Ringer’s solution in an ultrasound bath for 5 min at 40 kHz (as described in NEJM2007;357:654). The resulting sonication fluid was cultured aerobically and anaerobically for 10 days. In parallel, > 2 tissue samples were collected for conventional cultures on blood agar plates and enrichment broth. PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract or significant microbial growth in tissue or implant sonication cultures.

Results: In this ongoing study, 28 spacers and 10 cement nails from patients with confirmed PJI were included (median age 75 y; range 49–86 y). All devices were impregnated with antibiotics (gentamicin and/or vancomycin) and were placed in the hip (n=21), knee (n=9) or shoulder joint region (n=7). At the time of explantation, the following pathogens were isolated: coagulase-negative staphylococci (n=19), Staphylococcus aureus (n=7), Streptococcus agalactiae (n=3), Propionibacterium acnes (n=5) and mixed infection (n=4). All patients received systemic antibiotics for a median of 19 days (range 11–42 days) before removal of the spacer/nail. At the time of re-implantation, tissue cultures were negative in all 38 patients, whereas sonication cultures showed growth of Propionibacterium acnes in 2 of 38 patients (5%) with a hip and shoulder spacer, both in significant numbers (150 and 550 colonies/ml sonication fluid, respectively). These organisms were probably present as mixed infection already at the time of explantation, but were missed due to overgrowth due to another organism (S. aureus in one patient and coagulase-negative staphylococci in another). Both patients were not initially treated for the Propionibacterium acnes infection, but the treatment was given after re-implantation.

Conclusion: Sonication of removed spacers is a suitable approach to identify persistent infection in patients with a two-stage exchange. Sonication may replace the current standard approach consisting of multiple tissue specimens in order to document successful eradication of infection.


Full Access
F. Grill

Introduction: Bone defects in septic cases can be caused by the septic process itself or by resection of bone segments. For the budging of segmental defects, segmental bone transport is an alternative method which has been used at our department since 16 years.

For the surgical reconstruction of bone defects there are several options:

Method: Segmental consists of removing all dead bone, then stabilizing the limb by the use of an external fixator and to perform a corticotomy at the proximal or distal metaphysical area followed by bone segment transport, by gradual distraction.

Gradual distraction stimulates active bone regeneration and due to increased vascularisation also healing of the chronic infectious process. The mechanical lengthening device must insure stability.

As soon as both bone ends get into contact a docking manoever has to be performed to remove soft tissues between the bone ends and to stimulate healing by drilling of the bone ends with a k-wire and eventually adding cancellous bone grafts.

The external fixator is kept in place until full bone consolidation is accomplished.

Segmental bone transport can be performed by using monolateral fixators, by intramedullary nails (e.g. fit-bone) and by circular frame fixators like the conventional Illizarov or the new Taylor Spatial Frame.

Our preferred technique is the Weber cable technique with TSF which allows an ideal guidance of the segment to the docking site without cutting through the skin.

Results: At the paediatric orthopaedic department of the Speising hospital Vienna we have treated 32 cases of septic bone defects using different types of external fixators, segmental transport and also external fixation in combination with vascularised fibula transfer.

In all but 2 cases fusion and healing of chronic infection of bone and soft tissues could be achieved. In the 2 cases which could not be treated successfully an amputation had to be performed.

Conclusion: The treatment of segmental bone defects using external fixation and segmental bone transport has proved to be very effective. Gradual distractions of living tissues creates stresses which increase the blood supply and stimulate not only bone healing but also the healing of infection.


M. Clauss R. Baalbaki F. Nussbaumer A. Trampuz O. Borens

Background: Negative pressure wound treatment is increasingly used through a Vacuum-Assisted Closure (VAC) device in complex wound situations. For this purpose, sterile polyurethane (PU) and polyvinyl alcohol (PVA) foam dressings are fitted to the wound size and covered with an adhesive drape to create an airtight seal. Little information exists about the type and quantity of microorganisms within the foams. Therefore, we investigated VAC foams after removal from the wound using a validated method (sonication) to detect the bacterial bioburden in the foam consisting as microbial biofilms.

Methods: We prospectively included VAC foams (PU and PVA, KCI, Rümlamg, Switzerland) without antibacterial additions (e.g. silver), which were removed from wounds in patients with chronic ulcers from January 2007 through December 2008. Excluded were patients with acute wound infection, necrotizing fasciitis, underlying osteomyelitis or implant. Removed foams from regular changes of dressing were aseptically placed in a container with 100 ml sterile Ringer’s solution. Within 4 hours after removal, foams were sonicated for 5 min at 40 kHz (as described in NEJM2007;357:654). The resulting sonication fluid was cultured at 37°C on aerobic blood agar plates for 5 days. Microbes were quantified as No. of colony-forming units (CFU)/ml sonication fluid and identified to the species level.

Results: A total of 68 foams (38 PU and 30 PVA) from 55 patients were included in the study (median age 71 years; range 33–88 years, 57% were man). Foams were removed from the following anatomic sites: sacrum (n=29), ischium (n=18), heel (n=13), calves (n=6) and ankle (n=2). The median duration of being in place was 3 days (range, 1–8 days). In all 68 foams, bacteria were found in large quantities (median 105 CFU/ml, range 102–7 CFU/ml sonication fluid. No differences were found between PU and PVA foams. One type of organisms was found in 11 (16%), two in 17 (24%) and 3 or more in 40 (60%) foams. Gram-negative rods (Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa) were isolated in 70%, followed by Staphylococcus aureus (20%), koagulase-negative staphylococci, streptococci (8%), and enterococci (2%).

Conclusion: With sonication, a high density of bacteria present in VAC foams was demonstrated after a median of 3 days. Future studies are needed to investigate whether antimicrobial-impregnated foams can reduce the bacterial load in foams and potentially improve wound healing.


N. M. Mathijssen P. L. Petit P. Pilot B. W. Schreurs P. Buma R. M. Bloem

Introduction: The effect of different temperatures to antibiotics is unknown. What is the dose-response curve of bone chips impregnated with different kinds of antibiotics?

Material and Methods: Five different antibiotic pills and solutions (cefazolin, clindamycin, linezolid, oxacillin, vancomycin) were stored at −80°C, −20°C, 4°C, 20°C and 37°C. Also, bone chips were impregnated with cefazolin and vancomycin solution and were stored at −80°C and −20°C. After 1 month, 6 months and 1 year, reaction of the antibiotics to Staphylococcus epidermidis was measured using an inoculated iso-agar. Activity of the antibiotics was measured as the diameter of the Staphylococcus epidermidis-free zone.

Also, five cefazolin and vancomycin solutions were used to impregnate bone chips and to make dose-response curves. Furthermore, 1 gram bone chips was impregnated with 5ml cefazolin or 5ml vancomycin solution.

Results: A decrease of the diameter free zone Staphylococcus epidermidis was seen when oxacillin and cefazolin solutions were stored at 37°C for 1 month and when vancomycin was stored for 6 months (37°C). Also, when cefazolin and oxacillin solutions were stored at 20°C, a decrease was noticed. The storage of other antibiotic solutions, pills and bone/antibiotics composite showed no differences in reaction. Dose-response curves show that with increasing antibiotic quantity, diameter free zone increases according to a logarithmic function.

Conclusion and discussion: With the dose-response curve the optimal concentration(s) for local application can be determined. It gives the opportunity to determine the amount of antibiotics present in the patient locally. Freezing of antibiotics does not affect the activity of the investigated antibiotics.


H. K. Winkler

Infection of bone represents a major challenge in orthopaedic surgery. Chronic cases are distinguished by necrosis of parts of the osseos structures. It is generally accepted, that sequestered bone comprises bacterial colonies that show inherent resistance to both host defence mechanisms and antimicrobial chemotherapy, leaving thorough removal of all necrotic tissue a prerequisite for cure. The resulting dead space needs to be filled – defects require reconstruction. Bone grafting is a well established procedure with well documented success, however, autologous bone is available only in limited amounts and recurrence rates are still high. Availability of allograft bone is unlimited but rarely used in florid osteomyelitis since surgeons fear grafts being at risk to become a focus of ongoing infection. Fresh frozen allogeneic bone contains bone marrow consisting of fat and necrotic cells. Fat is eliciting an inflammatory response that together with immunological reactions against cell membranes may create an environment promoting bacterial growth with the necroses as a growth medium. Removing bone marrow lowers the risk of infection. When using allograft bone in sites with high risks of infection it therefore should be free of all components of bone marrow.

Highly purified allograft bone, consisting of collagen and minerals as autologous bone, is unlikely to initiate or nourish a florid infection; however, the matrix surface may represent a substratum for adherence of bacteria with formation of biofilms. To avoid bacterial adhesion the matrix may be loaded with antibiotics. It has been shown that purified bone is capable of storing huge amounts of antibiotics for prolonged periods of time. This capacity offers the possibility to use allograft bone not only as a filler but the same as a carrier for antibiotic delivery.

In chronic osteomyelitis our most obstinate opponents are not the familiar planktonic pathogens but their phenotypically different sessile forms embedded in biofilms. Those require up to 1000 fold higher concentrations of antibiotics for elimination than their planktonic forms. Debridement removes the predominant amount of bioburden but some colonies disrupted from the biofilm during manipulation may find new habitats in niches of the site and cause recurrence after an indefinite period of time. Levels reached by systemic antibiosis or local therapy with commercially available antibiotic carriers mostly are not effective in eliminating biofilm remnants. Bone impregnated with high loads of vancomycin or tobramycin may provide for high local antibiotic concentations for several weeks (> 1000x MIC) that are likely to eliminate not only planktonic bacteria but also detached biofilm clusters. Allograft bone may be impregnated both in cancellous and cortical form, morsellized or structural. Indications for their use are all forms of chronic bone infection, including osteomyelitis, infected pseudarthroses, deeply infected diabetic feet and infected total joint replacement.

Osteomyelitic lesions and pseudarthroses of long bones may successfully be treated using antibiotic loaded allograft bone, providing dead space management, antibiotic delivery and reconstruction of deficient areas at the same time. As long as local antibiotic levels are higher than the dosage required for eliminating biofilm fragments no contamination of simultaneously implanted alloplastic material needs to be feared.


R. Nanda M. Ramappa R. J. Montgomery J. Page

Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint.

Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or infected bone. This led to substantial bone defects (6–12 cm) of the debrided bone at the knee joint. The patients then underwent bone transport with a circular frame to compensate for this bone defect before achieving an Arthrodesis of the knee joint. Three patients also had a free muscle flap for soft tissue coverage before bone transport was begun.

Results: Arthrodesis of the knee was achieved in all patients at an average time of 26 months (20–32 months). None of the patients have any active infection of the limb.

Discussion and Conclusions: Knutson et al (1984) said that massive bone loss may substantially reduce the success rate of Arthrodesis of the knee. Wilde and Stearns (1989) noted decreased fusion rates with greater degrees of bone loss. In our series the bone defects were a sequelae of infective non-union, this further complicates the healing process. However, using circular frame for Bone transport to overcome the defect and to achieve compression at the Arthrodesis site is a useful technique for such challenging cases.


T. Mut S. Cervellò

Introduction: The prosthetic replacement of the infected knee is conditioned by the bone stock according with the A.O.R.I. We classified the bone defects on the infected knee following the Windsor protocol. When we find ourselves on a situation with T2-3 F2-3 and/or post-infection prosthetic replacements, we use tumoral knee prosthesis (“third prosthesis”).

The main causes of segmentary bone defects at the knee, appear after high energy injuries, tumoral resections and after infected total knee arthroplasties. Nowadays the treatment of these lesions, supposes a challenge to the orthopaedic surgeons due to the difficulty of the bone and soft tissue lesions.

Material and Methods: We present our first 35 cases involving tumoral knee prosthesis replacements after infected conminutive fractures around the knee, infected replacements and infections after tumoral resections.

Initially we used the prosthesis FINN model (BIOMET©) on 11 cases, while we have used the RHK model (BIOMET©) on the remaining 24. We followed the two-stage reimplantation using antibiotic PMMA spacers either manual or preformed depending on the defect’s size. Exposure of the stiff or ankylosed knee can be especially difficult when preoperative flexion is limited, so in these situations we use the Whitesides technique (tibial tubercle osteotomy). We used platelet derivated growth factors (inductors) associated with hydroxiapatite (conductors) with the goal to obtain the best possible osteo-integration.

Results: Our results are satisfying, considering we are confronting severe bone defects with a poor situation of soft tissues around the knee. We have not observed major complications involving the use of the inductors and conductors mentioned above.

Conclusions: We consider the use of tumoral knee prosthesis (“third prosthesis”) a useful technique which allows us to avoid the disability promoted by the knee arthrodesis, obtaining satisfactory results according to the severe lesions observed.


P. Tos S. Artiaco A. Antonini G. Burastero G. Cicero B. Battiston

For decades the treatment of chronic posttraumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopedic surgery. “Sterilization” of the osteomyelitic site, that is radical debridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the debrided area was closed with skin grafts, which were removed in a further stage, when the infection was ceased; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time requiring several-stage treatment.

We performed a retrospective study on 9 patients treated for chronic osteomyelitis of the upper limb (6 forearm – 3 arm) by means of free fibula vascularized bone graft, between 1992 and 2003 (7 male 2 female). All patients had been more than 2 previous surgical attempt with conventional treatment (sterilization and bone graft). In most of them (7 cases) a two-stage treatment was performed (resection and sterilization, eventually with muscle transfer, in the first stage and bone transfer in the second one); in other 3 cases a one-stage treatment was performed. Two cases required a composite tissue transfer with a skin pad to cover the exposure. The length of bone defect after extensive resection of necrotic bone from septic pseudoarthrosis ranged from 5 cm to 12 cm.

In all cases there was no evidence of infection recurrence in the follow-up period. The mean period to obtain radiographic bone union was 4.1 months (range 2.5–6 months). In 2 cases secondary procedures have been carried out due to an aseptic non union in one site of synthesis (cruentation and compression plate). Functional results were always satisfactory although in the forearm a complete range of motion has never been achieved (plurioperated patients with DRUJ problems).

Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius, ulna and humerus of sufficient length to reconstruct most skeletal defects. The vascularized fibular graft is indicated in patients where conventional bone grafting has failed or large bone defects, exceeding 5 cm, are observed. The application of microsurgical fibular transfers for reconstruction of the extremities allows repair of bone and soft-tissue defects when shortening is not possible with good functional results.


A. Drakou G. I. Karaliotas V. Sakellariou G. Mazis K. Starantzis S. Athanasia

Introduction: Implant materials impregnated with antibiotics have long been used to manage the dead space created by debridement surgery in patients with osteomyelitis.

Purpose: To present our preliminary results and in vivo response of patients to PerOssal used to treat bone infection in the form of long bone chronic osteomyelitis. PerOssal is a new osteoconductive bone substitution material for bone filling which consists of an entirely synthetically produced, nanocrystalline hydroxyapatite and calcium sulfate. It can be used effectively as a local antibiotic carrier for the reconstruction of infected bone defects.

Patients & Methods: During the years 2006–2009 we have treated 19 patients with long bone osteomyelitis (15 tibial, 4 femoral) with PerOssal impregnated with the appropriate antibiotic which was used following radical debridement surgery. In all cases we did not rely solely on the mechanical stability that it may provide but we supported the bone when necessary. Postoperative observations were focused on primary wound healing, inflammation markers and clinical eradication of infection (minimum FU: 12 months).

Results: We have: 15 cases with eradication of infection, 2 recurrences of disease, in terms of re-infection by different species or amputation, and 2 on-going cases. Declining wound leakage and delayed wound healing was present in 5 cases where PerOssal was used either intramedullarily but not sealed or extraosseously in relatively large amounts.

Conclusion: We have so far good results with respect to infection control. PerOssal seems to perform better when used in contained defects whereas extraosseous use seems to predispose to prolonged leakage and compromised wound healing or breakdown. The mechanical stability that it provides remains under consideration.


P. Stangenberg J. F. Wodtke

Introduction: Revision surgery in periprosthetic infection often encounters defects in bone stock caused by the loosening procedures, through continuous revisions or by explantation techniques. Since bony reconstruction in the presence of infection is critical, if no antibiotic impregnated bone grafts are available, metal implants are the last resort. Lately tantalum wedges and cones have been introduced as a stable augmentation device.

Material and Methods: Since 2007 we have used 14 tantalum implants to fill bone defects in 13 cases of severe purulent periprosthetic infection (4 cones, 10 wedges). All patients are in permanent control on an outpatient basis.

Results: Primary and continuous stability was achieved in all patients and no signs of recurrent or persistent infection were found.

Conclusion: So far this concept proves to be successful and can be recommended. The stability of the implant is recorded for numerous aseptic reconstructions. Research is needed towards the surface properties of tantalum in contact with bacteria. Positive findings like in silver coating would be desirable. Further research towards impregnation possibilities of the porous structure with antibiotics for continuous elution like from cement or fleece could – in a positive result – improve septic surgery substantially.


M. Gritsay O. Linenko D. Bilous A. Gordii G. Kolov

Our work is based on the analysis of 104 patients with suppurative posttraumatic osteoarthritis of the ankle joint.

By prolonged septic arthritis with degradation of articular surfaces of ankle and shin bones we used necrectomia with osteoarthrotomy and compression arthrodesis in the mechanism of external fixation, which allows to radically sanify the nidus of infection and eliminate the inflammatory process all together. This operation was performed for 68 patients.

Surgical treatment for 18 patients with septic arthritis of the ankle joint with considerable involvement of ankle joint metaepiphysis was performed in the following way. We performed segmental resection of the shin bone distal part, put in external fixation mechanism with the possibility of defect building, and then we performed the osteotomy of the shin bone in its upper one-third. On the 10th day we started performing building of defect by Ilizarov.

For six patients with ankle joint septic arthritis with considerable involvement of ankle bone we performed its subtotal resection and compression arthrodesis in the external fixation mechanism. For patients with total overall affection of the ankle bone we performed ankle bone excision and tibialcalcaneal fusion. For three patients we performed ankle bone excision with tibialcalcaneal fusion and external fixation. For nine patients where it was not possible to perform a single-stage fusion of shin and heel bones we used external fixation mechanism with the possibility to move the shin bone fragment. Then we performed open fusion of shin and heel bones.

The result was considered to be position (92% of patients) in case of extremity support ability recovery, suppurative process elimination and bony ankylosis achievement.

Original ankle joint injury nature and localization are very important in selecting the necessary surgical treatment variant.

Differential surgical treatment tactics selection for patients with suppurative ankle joint osteoarthritis together with adequate usage of conservative therapy allow to eliminate active purulo-necrotic process and restore the extremity support function for most patients.


P. Ochsner

Based on the analysis of Rittmann and Matter the AO advocated to leave stable implants after osteosynthesis in place and to remove them only when a sufficient bridging of the fractured would have happened. In opposition it generally became accepted to remove instable implants to be replaced by an external fixateur. Using local antiseptics such as Lavasept (Willlenegger) and intravenous antibiotics efficient against the proven bacteria one was able to cure the infection. Additional measures of osteoinduction (mainly cancellous autograft and decortication) favoured bridging of the non-union area. With the help of callus distraction after segmental resection of dead bone areas using more sophisticated external fixateurs marvellous reconstructions of big bone areas became possible.

On the other hand we have to realize, that in the upper extremities external fixation is frequently a clumsy installation inhibiting function. Because of delay of union not unfrequently secondary stabilazation of non-union or refracture areas had to be stabilized with secondary internal fixation. This was possible because the infection was already cured.

The knowledge of implant related infection did learn us, that the elimination of bacteria linked to a biofilm, which are at rest, frequently are resistant against antibiotics otherwise successful against planctonic bacteria of the same species. Be it by higher concentrations, be it by the use of antibiotics efficient against resting bacteria such as Rifampin ant once other possibilities are developed to be able to treat infections even in presence of internal osteosyntheses. When the success rate of intramedullary nails as they were used by Klemm was distinctly lower compared with external fixateurs at that time, today it becomes possible to us internal fixation in infections with bacteria with a known antibiotic treatment in presence of implants. This opens important doors for the combination of internal fixation, vascular bone grafts and antibiotic treatment accelerating the treatment of infected non-union in adequate cases.Stepwise it became possible to get to better functional results within a shorter time in adequate cases.


W. Girsch G. Petje H. Matuschk F. Grill

Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only.

Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome.

Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function.

The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.


F. Romero-Candau R. Perez-Ferri F. Najarro

Introduction: One of the more difficult questions in the management of posttraumatic osteomyelitis is the decision for removing or retaining infected hardware. We know that skeletal stabilization in posttraumatic osteomyelitis is necessary for controlling infection. However, in the presence of internal fixation, microorganisms are protected in a biofilm adherent to the implant surface. The decision to retain or remove infected implants is individualizated and depends on several factors: status of bone healing, stability provided by the hardware, fracture localization, and time since fracture fixation.

Material and Method: We used in our Hospital the algorithm proposed by Patzakis and Zalavras1 in 2005. The objective of our lecture is to define the decision to remove the implant with some case reports.

Conclusion: The management of infected hardware in patients with postraumatic osteomielitis in long bones is difficult and it is necessary to study each cases individualizated but it is necessary to have a guidelines.

We must remove the implant:

If the fracture has healed.

If the fracture has not healed and the implant does not provides stability.


R. E. Margariti M. Frank G. Hallak P. Heumann R. Böttcher J. Seifert A. Eisenschenk A. Ekkernkamp K. Bauwens

Aim: Because of the low prevalence, there is a poor evidence on the effective management of bone and joint infections of the carpus and metacarpus. We therefore studied the outcomes of patients undergoing surgical treatment at our department.

Method: We conducted a retrospective study on all patients operated on because of osteomyelitis of the carpus and metacarpus between January 1998 and June 2004. Main study endpoint were the infection controll rate at end of treatment and at time of follow-up.

Results: Of eleven subjects (nine men, two women) with a median age of 43 years (range, 19 to 79 years) serial débridement with temporary wound closure and surgical fixation proved successful in ten cases. We identified causative pathogens in ten cases (S. aureus: n=3, P. aeruginosa: n=3, mixed: n=4) by intraoperative biopsy. Eight subjects received local or free tissue flaps. A 73 year old man died in hospital.

Follow-up information was available for eight patients after a median of 19,5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection.

Conclusion: Adhering to accepted standards of treating osteomyelitis, satisfactory control rates in carpal and metacarpal infection can be achieved while salvaging the hand.


H. K. Winkler

Infection of a total joint replacement (TJR) is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. Usually at least two surgical interventions and antibiotic treatment within a period of several months are estimated being required for a favourable outcome. It is undoubted that one stage exchange, if successful, would provide the best benefit both for the patient and the society. Still the fear of re-infection dominates the surgeons’ decisions and directs them to multiple stage protocols. However, there is no scientifically based argument for that practice. Successful eradication of infection with two stage procedures is reported to average 80% to 98%, whereas there are no significant differences between revisions with or without antibiotic loaded cement, with short or long term antibiotic therapy, with or without the use of spacers and other differences. On the other hand a literature review of Jackson and Schmalzried (CORR 200) summarizing the results of 1,299 infected hip replacements treated with direct exchange (almost exclusively using antibiotic loaded cement), reports of 1,077 (83%) having been successful. For total knee replacement Jaemson et al. (Acta 2009) could show that the overall success rate in eradication of infection was 73–100% after one-stage revisions. It may be calculated, that adding a second one stage procedure for treating the failed cases the overall result with two operations may improve to > 95%, an outcome which is at least as good as the best results after two stage revisions, while requiring only one surgical intervention for the majority of cases.

Spacers have been proven to be useful for improving final functional results compared to temporary resection; however, concerning infection control no benefit could be shown. Dead space management is performed comparably effective by a new prosthesis as with a spacer. In addition a definitive prosthesis is providing increased stability, which a spacer does not. As long as protection against colonization is granted by high local antibiotic concentrations a prostheses is likely to provide better functional results than a spacer.

These results suggest, that the major factor for a successful outcome with traditional approaches may be found in the quality of the surgical debridement and dead space management. Failures in all protocols seem to be caused by small fragments of bacterial colonies remaining after debridement, whereas neither systemic antibiotics nor antibiotic loaded bone cement (PMMA) have been able to improve the situation significantly.

One stage exchange provides marked reduction of patients discomfort and costs but is performed only rarely due to a multitude of risks and disadvantages, related to the mandatory use of antibiotic loaded cement for fixation. Cemented revisions generally show inferior long term results compared to uncemented techniques; the addition of antibiotics to cement reduces its biomechanical properties. The release of antibiotics from cement is too short-lived and concentrations are too low for reliable eradication of eventually remaining pathogens, especially when they are embedded within biofilms. PMMA has been shown to be the ideal substrate for bacterial attachment and replication of sessile bacterial phenotypes. Aging cement releases antibiotics in subinhibitory amounts, leading to antibiotic resistance of adherent bacteria even years after implantation. Whenever a new prosthesis is implanted into a previously infected site the surgeon must be aware of increased risk of failure, both in single or two stage revisions. Eventual removal therefore should be easy with low risk of additional damage to the bony substance in such a case. On the other hand it should also have potential of a good long term result in case of success. Cemented systems seem to be less likely for that purpose since efficient cementing techniques will result in tight bonding with the underlying bone. Eventual removal such will be time consuming and possibly associated with further damage to the osseous structures.

Allograft bone may be impregnated with high loads of antibiotics using special incubation techniques. The storage capacities and pharmacological kinetics of the resulting antibiotic bone compound (ABC) are more advantageous than the ones of antibiotic loaded cement. ABC provides local concentrations exceeding those of cement by more than a 100 fold and efficient release is prolonged for several weeks. The same time they are likely to restore bone stock, which usually is compromised after removal of an infected endoprosthesis. ABC may be combined with uncemented implants which in case of a failure markedly facilitates their removal. There is reduced risk of creating resistances since the stored antibiotics are eluted completely and elution is terminated after several weeks.

Based on this technology new protocols for one stage exchange of infected TJR have been established, both for hips and knees. Bone voids surrounding the implants are filled with antibiotic impregnated bone graft; uncemented implants are fixed in original bone. Recent studies indicate an overall success rate of more than 90% without any adverse side effects. Incorporation of allografts appears as after grafting with unimpregnated bone grafts. The favourable results have initiated extension of the technique to simultaneous reconstruction of large septic defects using impregnated bulk allografts.

Antibiotic loaded bone graft seems to provide sufficient local antibiosis for protection against colonisation of uncemented implants, the eluted amounts of antibiotics are likely to eliminate biofilm remnants, dead space management is more complete and defects may be reconstructed efficiently. One stage revision such should be at least comparably save as multiple stage procedures, taking advantage of the obvious benefits for patients and economy.


C. L. Romano

Two-stage revision is the most widely accepted and performed intervention for chronically infected joint prosthesis. The choice of this option relies on the following considerations:

higher antibiotic concentrations may be used in the spacers, compared to the cement used for prosthetic fixation in a single-stage procedure, since high dose antibiotic-loaded cement may be too fragile for long term prosthesis fixation (Bucholz, 1986);

the frequent occurrence of bone loss and the smooth cortical bone surface, encountered at revision may prevent effective cementing;

two-stage revision allows the use of uncemented modular stems, useful for intra-operatively balancing legs’ length, offset and muscular tension;

distal fixation allows to overcome proximal frequent bone loss;

bone grafts, eventually plus growth factors, may be safely added;

a second debridment may enhance the possibility of eradicating the infection;

there is a large and growing international literature evidence in support to this option.

Two-stage reimplantation using an articulated interval spacer of antibiotic-impregnated bone-cement has been previously investigated and proved as an effective Method:

to adequately fill the void created by the implant removal,

to prevent limb shortening and soft-tissue contracture,

to allow a better function,

to provide local antibiotic therapy,

to eradicate infection,

to facilitate reimplantation.

However a considerable variation in the form and function of interval spacers exists. A spacer may in fact be commercially made, or it may be custom-made in the operating room. It may be made entirely of polymethylmethacrylate cement, or it may be a cement-coated metal composite. Favorable results have been reported with each of these types of spacers.

Preformed antibiotic-loaded spacers (InterSpace® Hip and InterSpace® Knee, Tecres SpA, Verona, Italy – Hexactech Inc. Gainesville, Florida) offer:

known mechanical resistance;

predictable antibiotic release;

reduced surgical time;

joint function preservation and partial weight bearing;

standardized technique. In particular, as to concern the hip, their most peculiar feature is their availability in short and long stem shapes, that allows to overcome frequent proximal femoral bone defects

Acceptable costs (< 5% of the total costs for a two-stage procedure).


P. Ochsner H. de Man P. Sendi

The Liestal algorithmus for the treatment of infected total joint arthroplasties proposes the abovementioned three groups for revisions with exchange.

One stage exchange is executed in the presence of a adequate soft tissue situation and in absence of bacteria difficult to treat.

Two stage revision with spacer and a interval of 2–3 weeks until re-implantation is indicated in bad soft tissue situations

Two stage revision without spacer, a curative intravenous antibiotic treatment period of 6 weeks, a break of 2 weeks followed by reimplantation is indicated in the presence of bacteria difficult to treat.

All patients of group 1 and 2 were treated with antibiotics for 3 months – the first two weeks intravenous.

The ones of group 3 only, if during reimplantation positive tissue cultures were harvested.

We analysed 72 episodes of ITHA, 22 with 1-stage exchange, 29 with 2-stage exchange with spacer, 21 with 2-stage exchange without spacer. All 16 cases but 1 with bacteria difficult to treat were included in the last group. In this presentation only cases are included following the algorithm completely as published. All patient had an overall treatment with antibioticsIn all patients the index operation was done more than two years prior to the latest control. Two patients died shortly after the operation, the result remaining unknown. Another 3 died between 1 and two years after the operation. They were regarded as probably cured. Only one case of group 2 suffered of a relapse being caused by a coagulase negative staphylococcus being resistant against Rifampin. 2-stage exchange without spacer was then successful. One case of reinfection with another bacterium happened in the group 1.

Conclusion: This analysis is indicating, that the presented algorithm allows positive results regarding elimination in around 95% of the cases. Better results may be provable when basing on a larger number of patients. It seems, that the selection of so called “easier cases” for 1-stage exchange does not lead to a higher number of relapses and helps for an overall more economic way of treatment.


E. Meani

Two-stage revision is the most widely accepted and performed intervention for chronically infected joint prosthesis. The choice of this option relies on the following considerations:

higher antibiotic concentrations may be used in the spacers, compared to the cement used for prosthetic fixation in a single-stage procedure, since high dose antibiotic-loaded cement may be too fragile for long term prosthesis fixation (Bucholz, 1986);

the frequent occurrence of bone loss and the smooth cortical bone surface, encountered at revision may prevent effective cementing;

two-stage revision allows the use of uncemented modular stems, useful for intra-operatively balancing legs’ length, offset and muscular tension;

distal fixation allows to overcome proximal frequent bone loss;

bone grafts, eventually plus growth factors, may be safely added;

a second debridment may enhance the possibility of eradicating the infection;

there is a large and growing international literature evidence in support to this option.

Two-stage reimplantation using an articulated interval spacer of antibiotic-impregnated bone-cement has been previously investigated and proved as an effective Method:

to adequately fill the void created by the implant removal,

to prevent limb shortening and soft-tissue contracture,

to allow a better function,

to provide local antibiotic therapy,

to eradicate infection,

to facilitate reimplantation.

However a considerable variation in the form and function of interval spacers exists. A spacer may in fact be commercially made, or it may be custom-made in the operating room. It may be made entirely of polymethylmethacrylate cement, or it may be a cement-coated metal composite. Favorable results have been reported with each of these types of spacers.

Preformed antibiotic-loaded spacers (InterSpace® Hip and InterSpace® Knee, Tecres SpA, Verona, Italy – Hexactech Inc. Gainesville, Florida) offer:

known mechanical resistance;

predictable antibiotic release;

reduced surgical time;

joint function preservation and partial weight bearing;

standardized technique. In particular, as to concern the hip, their most peculiar feature is their availability in short and long stem shapes, that allows to overcome frequent proximal femoral bone defects

Acceptable costs (< 5% of the total costs for a two-stage procedure).


C. E. Lautenbach

I wish to present my experience with 521 patients with infection around hip arthroplasty and 262 with infected knee arthroplasty. The management in each case depends on circumstances such as the period since surgery, the patient’s symptoms, severity of illness and general health, and the condition of the remaining bone stock.

One hundred and thirty hips and 94 knees were managed conservatively i.e. without surgery.

Nine knees and 11 hips had debridement and irrigation without removing the arthroplasty. Infection persisted in 2 knees and 3 hips.

Nine knees were exchanged in one stage. infection persisted in 5. Forty three hips were exchanged in one stage. Infection persisted in 18.

Fifty knees were exchanged in two stages. Infection persisted in 11. One hundred and ninety eight hips were exchanged in two stages. Infection persisted in 28.

Arthrodesis was performed in 77 of the more severely infected and destroyed knees. Infection persisted in 32.

One hundred and eight of the more severely destroyed hips were left as excision arthroplasties. Ten remained infected but comfortable.

Five patients required amputation above the knee and three through the hip.

Two patients sustained serious vascular complications during surgery at the hip and one at the knee.

Four patients in this series died during treatment


A. Drakou V. I. Sakellariou G. Karaliotas G. C. Babis P. J. Papagelopoulos

Introduction: Two stage revision procedures is the gold standard in management of periprosthetic infections. Cement spacers impregnated with antibiotics have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (random porosity, thermal necrosis, unspecified antibiotic delivery rate). The rationale of this study is that calcium hydroxyapatite antibiotic carrier (PerOssal) overlaps the known disadvantages of cement spacers, and leads to better outcome in terms of clinical parameters and re-infection rate.

Purpose: Our purpose was to identify specific clinical and laboratory differences between cases submitted to conventional two stage revision arthroplasty vs cases treated with PerOssal as an antibiotic carrier.

Material & Methods: During 2004 to 2008, 46 patients (38 females and 8 males, mean age 65.3 years, range 32 to 84) with infected TKR were revised using a two-stage revision protocol. In 31 patients (group A – 25 females and 6 males) a conventional articulating spacer impregnated with antibiotics was used, whereas in the remaining 15 patients (group B – 13 females, 2 males) a combination of an articulating spacer and PerOssal as antibiotic carrier was used. All patients were reviewed with laboratory exams (WBC, ESR, CRP) every 7 days and joint fluid aspiration prior to re-implantation, which was performed at mean 8 months post 1st stage (range, 6 to 12 months).

Results: At a mean follow-up of 36 months (range, 8 to 60 months) no patient was lost or died. WBC count and ESR showed no statistically significant differences at any time interval (p> 0.05). However, CRP values had a statistically significant difference between the two groups after the second week postoperatively (p3rd week= 0.042) and group B had significantly lower CRP values compared to group A at every check point thereafter (p4th week=0.038, p5th week=0.031, p6th week=0.034). Re-infection rate was 16.12% in group A and 6.6% in group B (p=0.192).

Conclusions: PerOssal can be used as an additional antibiotic carrier in cases of periprosthetic infections of TKR. It is associated with more rapid reduction of CRP levels, probably due to greater porosity and better antibiotic delivery comparing to impregnated cement. Larger series of patients could reveal potential differences in the re-infection rates as indicated by our study.


J. F. Wodtke V. Jonen P. Stangenberg

Introduction: One stage and two stage exchange procedures are acknowledged as gold standard for revision surgery in periprosthetic infection. Since the one stage concept is ethically, medically and economically superior, the last necessary argument is a fair rate of success on a large scale. The two stage procedure could then be limited to its genuine indications only.

Material and Methods: In three years (2005/06/07) 555 one stage exchanges of the hip and the knee were carried out at our clinic. A first homogenous group of 282 cases has now been analysed and followed-up. Detailed data regarding case history, clinical situation, treatment course and complications will be presented. All cases were investigated through a telephone protocol or examination on an outpatient basis by the same person. The group contained 180 hips and 102 knees. The median age was 68, (22/91). The median follow-up time was 31 months, (51/15).

Results: The primary success rate (dismissal from hospital) was 99% (1 death, 1 disarticulation). The revised rate of success in the course of the follow-up was 92,7 %.

Conclusion: With a success rate of 92,7 % this example of the one stage performance proves the standard realisation possibility of this concept. Advantages like no impairment in the interval without prosthesis, reduced complication and risk possibilities and reduced costs speak for this procedure. Nevertheless prerequisites have to be respected. But after all the one stage procedure should be made available to all patients with the appropriate indication.


M. Westberg B. Grogaard F. Snorrason

Background: Infection after total hip arthroplasty is a dreaded complication with an incidence of 0,5–1 % after primary interventions. The optimum treatment of deep infection remains controversial. Debridement, retention of the prosthesis and antimicrobial treatment is an attractive option of treatment for early deep infections, but this method has often been reported with poor outcome. If restricting this method to patients with a stable implant, short duration of symptoms and contained soft tissue, the success rate seems to be substantially improved. We report the outcome of early prosthetic joint infections treated with debridement and retention of components in a prospectively recorded 8-year cohort.

Materials and Methods: All elective hip arthroplasties between 1998 and 2005 were prospectively recorded as a part of a quality registration with demographic and clinical data. In the same period, we recorded 39 (24 women) consecutive patients with a mean age of 71 years (range, 32–89) who presented with an early prosthetic joint infection within one month after the index operation. Infection was clinically diagnosed and based on the CDC definition for deep incisional surgical site infection. Medical and surgical treatment were chosen individually by the treating surgeons on the basis of the different clinical settings. The primary outcome measures were clinical, radiographic and laboratory evidence of recurrent infection or revision with isolation of the initial microbial agent. All patients were followed from index operation to final clinical visit in 2008 or death. 11 patients were dead, and a chart review was then done.

Results: Staphylococcus aureus was isolated in 23/39 patients (59%). Coagulase negative staphylococci were isolated in 19 patients (49 %), of which 4 were methicillin-resistant. 15 of the infections were polymicrobial. 37 patients were treated with soft-tissue debridement, retention of the prosthesis and antimicrobial therapy. The mean duration of antimicrobial therapy was 70 days (range, 20–270). The mean duration of days after index operation until initial debridement, was 22 days (range, 11–63). At a mean follow-up of 48 months (range, 9–120), 35/37 patients had no signs of recurrent prosthetic infection. 26 infections (70,3%) were eradicated by debridement alone, 9 after additional surgery. When treated within 3 weeks after index operation, 17/23 infections were eradicated by debridement alone (73,9%).

Conclusions: The data suggests that debridement, retention of the prosthesis and antimicrobial treatment is a reasonable option for treating early prosthetic joint infection after primary hip arthroplasty. Efficacy seems higher with earlier diagnosis and treatment.


A. Drakou G. I. Karaliotas V. I. Sakellariou P. Pantos J. Liveris A. Papadopoulos

Introduction: Two-stage revision procedure is the gold standard in management of periprosthetic joint infections. Cement spacers have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (thermal necrosis, random porosity, unspecified antibiotic delivery rate).

Purpose: To present the concept of using PerOssal as a canal filling spacer and local antibiotic delivery system in two-stage revisions of hip and knee infected arthroplasty.

Material & Methods: 8 patients (6 females, 2 males) with infected arthroplasty (4 TKRs, 4 THRs) were managed with two-stage revision procedures during the years 2006–2008 (minimum FU: 12 months). Our protocol consisted of:

Preoperative determination of the causative organism its sensitivity to antibiotics

Radical debridement surgery and cement spacer with PerOssal implantation

Appropriate IV antibiotic therapy for 6 weeks and postoperative clinical evaluation and monitoring of inflammation markers

After a six-week antibiotic free interval and if inflammation markers had return to normal second stage surgery took place: Medullary canal reaming, intraoperative cultures, thorough wound irrigation with 10L NS and prosthesis implantation

Postoperative antibiotic therapy until culture results; IV antibiotic treatment for 6 more weeks if they were positive.

FU evaluation at 3, 6, 12, and 24 months.

Results: We had 7 cases with eradication of infection, 2 with delayed wound closure, and 1 late recurrence of disease.

Conclusion: We think that PerOssal can offer a very useful additional and genuine support in managing infected joint arthroplasties with so far good clinical results with respect to infection control.


J. Torrent A. Matamala D. Bosch D. Haro D. Mateu

Background and Purpose: Two-stage revision remains the gold standard in the treatment of infected knee arthroplasty. The purpose of this study was to evaluate the clinical results of two-stage reimplantation of an infected total knee arthroplasty using an articulating antibiotic-impregnated cement spacer.

Materials and Methods: We studied 34 patients who had undergone two-stage revision TKA for infection from 2001 to 2006. The average age of the patients was 72,7 years. The minimum followup was 25 months (mean 38 months, range, 25–94 months).

After the first stage a 10-week antibiotic course was administered according to the sensitivity of the isolated bacterial strain. The second stage procedure was carried out after 4,9 months.

Results: The overall failure rate in eradication of infection was 14,7% (5/34), being the S. Epidermidis isolated in 2 cases; and coagulase-negative staphylococcus, Corynebacterium and Enterococcus isolated in 1 case each. We had 13 complications: 2 patients suffered infection caused by a pathogen different from the original, 4 patients underwent knee arthrodesis in their second stage, 1 patellar luxation, 1 asseptical loosening, 1 patient received amputation dued vascular insuficiency, 2 patients needed skin flap transplantation, 2 patients died before the second stage was done.

Conclusion: Two-stage reimplantation with an articulating spacer for infected TKA effectively treats infection and facilitates the second stage. In our opinion the high rate of complications must be expected and justified by the complexity of the patients and the type of microorganism.


H. Clar T. Lovse J. Friesenbichler M. Hochegger M. Glehr G. Feierl R. Windhager

Introduction: Infections associated with prosthetic joints cause significant morbidity and account for substantial costs for health care systems. The management of prosthetic joint infections is less standardized, because of the variable clinical presentations and the lack of data from randomized, controlled trials.

We evaluated the results of surgical one stage versus two stage exchange of patients diagnosed positive for prosthetic infection following total hip replacement in correlation with a classification described by Mc Pherson.

Material and Methods: 94 patients were diagnosed positive for prosthetic joint infection following total hip replacement in the years 1995 to 2004: gender distribution was 45 male and 49 female patients. 37 patients were treated with a one stage exchange, 57 patients underwent a two step procedure. Patients were further divided into two groups following the mentioned classification described by Mc Pherson as infection type I+II and III. Further characterisation was performed following systemic host grade (A versus B+C) and local extremity grade 1 versus 2+3.

Results: Eradication of prosthetic infection was achieved in 94, 5% (n=52) within the group of two stage exchange and 56, 8% (n=21) of patients treated with a one stage procedure. Outcome of patients following a one stage or a two step exchange was overall significantly different with p< .001. Further deviations between the described two procedures were noted in the subgroups following the classification described by Mc Pherson. A benefit of patients who underwent a two step procedure was seen according the severity of the classification following Mc Pherson.

Conclusion: Eradication rate of prosthetic joint infections differs statistically significant overall and in the subgroups following Mc Pherson in dependence of the surgical procedure. For this reason the individual surgical procedure should be geared to an algorithm, following the classification described by Mc Pherson.


E. Meani P. Trezza

This technical choice constitutes an effective solution for all those cases where, due to the infective damage, the radical surgical debridement needed or in presence of a septic pseudoarthrosis, there is a relevant loss of bone stock in the proximal femur.

As a treatment for these specific clinical patterns oncological prosthetic implants can be used, to overcome the amount of bone loss.

Sometimes acetabular prosthetic implantation, or reimplantation, is also needed because of its septic mobilization, otherwise a bicentric endoprosthesis can be implanted.

The main issue for the surgeon is the gluteal muscular deficiency, caused often by the loss of the great trochanter, a severe condition often worsened by the damage on muscles and soft tissues given by previous surgical procedures and debridements.

The offset itself, really often not sufficient for the limited amount of sizes and lengths of the oncological designed prosthetic implants, represent a key issue of this treatment with a high luxation risk, with a higher rate in those cases when an arthroprosthesis has been performed.

In this article are described 4 cases, all four treated with a two-stage surgical approach and a definitive oncological prosthetic system to overcome the severe bone loss of the proximal femur.

The cases are examined about the surgical indication to this prosthetic choice, the postoperative period with the related complications (1 case of recurrent luxation) and with a minimum follow up of 6 months (maximum 36 months).

In all the cases at the follow up the infection is solved.

At the end the specific rehabilitation program for the range of motion and the muscular strength regain, that we developed in our Operative Unit is described; in this program we occasionally used for the immediate post surgery period a jointed hip brace.

The length of the rehabilitation could not be standard, but should be customized and variations of the program could be done during the follow up.

In the immediate post-surgical period the rehabilitative goals are maintaining the correct posture in bed and regaining the passive articular range of motion.

In the longer period the main goals are regain strength of the gluteal muscles, proprioception and gait, even if claudication (Trendelemburg), hyposthenia a recurrent dislocation can be let.

The weight bearing is allowed usually at the eight week after surgery, but only after clinical and x-ray evaluation.


C. Döttl J. Hochreiter

We want to show our results of infected THR in the years from 2006 to 2008. We use an algorithm similar to Mc Phersons’s:

In early cases with not affected surrounding tissue we prefer the one stage procedure:

When there are no radiolucent lines in X-ray und the Scan does not show any tracer enhancement we perform synovectomy and replacement of the poly liner.

If soft tissue does not have an inflammation and only the bony bed is affected, we perform a one stage procedure with use of antibiotic augmented morcelliced bone graft. We use freeze-dried cancellous bone granula from a commercial tissue bank which are bathed for 30 minutes in a combination of Tobramycin and Vancomycin which is placed into the interface of implant and bony bed.

In chronic cases with affected soft tissue we treat the patient with a two stage exchange by use of a so called intermediate spacer and the definite revision after 3 months. The intermediate spacer contains a stainless steel rod coated by Gentamicin bone cement (Tecres company) in the shape of a prosthesis. This provides the release of antibiotics into the surrounding tissue.

We treated 36 patients:

18 patients were treated by use of a single procedure and 15 could be healed in 5 cases we could heal the patients by synovectomy and change of the poly liner.

10 cases could be healed by a THR revision with antibiotic augmented morcelliced bone graft

in two cases a two stage treatment was necessary after a synovektomie and change of poly liner

one patient was treated by synovektomy first, after persistent inflammation a THR Revision with antibiotic augmented morcelliced bone graft was performed and finally she could be healed by a two stage procedure

20 patients were treated by a two stage THR with an intermediate spacer

17 patients could be healed (three cases included from failed single procedure group)

3 patients are changed to a Girdlestone Hip (one died by reason of neoplasma, one could not be healed despite 4 revision with spacer, one could not be operated as he had chronic cardiac disease and ~prostatae)

1 patient get a permanent head-spacer as the femur prosthesis (Lord) could not be revised based on cardiac and pulmonary disease

Using Mc Pherson’s algorithm we could be successful with a single stage procedure in 15 from 18 cases. The remnant three patient could be healed by a two stage procedure. Only 4 patient could not be healed by a two stage procedure which was performed for 20 times. As we were successful too in three cases by treating chronic periprosthetic hip infection with a single procedure by using antibiotic augmented bone granula, investigation are requested to prove if this procedure could be postulated for all chronic periprothetic infections too.


O. H. Cornu A. Traore K. Tribak J. Yombi

Introduction: Chronic hip arthroplasty infection is a difficult situation to solve. The use of uncemented stem is questionable, as no antibiotic loaded cement is used to fix the implant. Bone deficiencies are often enlarged by the chronic infection process and the multiple previous surgeries. We report our experience in two stage revisions with massive allograft and uncemented distal locked stem.

Material and method: We have retrospectively reviewed 15 patients operated on from chronic hip arthroplasty infection and secondary large femoral defects. Two stages revision with a temporarily antibiotic loaded cement spacer and 6-weeks second look reconstruction were performed with massive proximal femoral allograft and a long distally locked stem. The uncemented stem was cemented into the allograft and remained uncemented in the recipient distal femur. Outcome was assessed regarding infection control, allograft complication and function according to the Merle d’Aubigné score.

Results: Patients mean age was 62 years (SD 11). Patients were already operated from the same hip 5.9 +/− 2.3 times before the actual procedure. Isolated microorganisms were MRSE (7), staph Aureus (4), MRSA (1), VRE (1), enterococcus (2). Muscle flaps were performed in 2 cases and discuss for 2 more. Allograft length was 22 +/− 9 cm. Antibiotic treatment was maintained for 4.6 +/− 2.5 months (median 3 months). Mean follow-up was 29 months (SD 26; median 23). Clinical outcome based on Merle d’Aubigné score is 5.3 +/− 3 before treatment and 13.8 +/− 2.5 at the last visit. Complications were registered in 4 cases. Infection recurrence was observed in 3 cases (2,7,20 months) but the function was preserved in all cases. One of them needed a two stage procedure with a new allograft after 19 months due to acute staph Aureus infection. One allograft was broken after 80 months and need one stage revision.

Discussion: While the treatment of these cases was particularly demanding as bone deficiencies and microorganisms antibiotic resistance were high, functional result obtained was good. When infection recurrence was observed, function remains preserved. The use of uncemented distal locked stem with a cemented massive allograft did not lead to mechanical or hardware problem and allow us to restore the bone stock and the gluteus tendons insertion. The use of a modular stem was very helpful in solving these complex situations. Massive allografts can be used in case of infection as antibiotic delivery system.


B. Ongkiehong G. Ensing L. Boerboom R. Wagenmakers D. Neut P. Jutte

Introduction: Infection is a challenging problem in orthopaedic surgery. In oncologic and revision surgery large prosthesis are placed during long procedures, even in patients with immunocompromised status. Infection rates here are reported up to 10%. Infections may necessitate large segmental resections thereby creating large defects. This defect can be filled with antibiotics loaded beads that release the substances locally to sterilise the defect. In recent years solid antibiotic loaded bone cement spacers have been applied. These spacers fill the defect, stabilize the extremity, release antibiotics and keep the soft tissues on their original length. Additionally, the patients will be able to preserve mobile function as well. In small defects prefabricated bone cement spacers temporarily replace the infected hip or knee prosthesis. For larger segmental of terminal defects there are no readily available constructs.

Purpose: To report short term outcome of a newly developed customized spacer concept for treatment of large segmental resections after prosthetic infection or osteomyelitis.

Material and Methods: We have treated 13 patients with large segmental defects after infection treatment with customized antibiotic bone cement spacers reinforced with strong intra-medullar implants like the Gammanail, the DFN and the UHN.

Results: These customized spacers are easy to make, fill the defect, stabilize the extremity, release antibiotics, keep the length of the soft tissues and allow patients to practice and preserve joint function as well. In 11 of 13 patients operated with an interim construct like this, a successful reimplantation of a tumor prosthesis was performed.

Conclusion: With customized antibiotic bone cement spacers augmented with a solid implant one can fill the defect, stabilize the extremity, release antibiotics and keep the soft tissues on their original length and keep function as well in infected tumorprosthesis. Successful reimplantation could be performed in 11 of 13 cases.


P. Ruggieri E. Pala M. Montalti A. Angelini G. Ussia C. N. Abati T. Calabrò M. Mercuri

Objective of this study was to analyse results of two stage revisions in infected megaprostheses in lower limb.

Material and Methods: Between April 1983 and December 2007, 1036 modular uncemented megaprostheses were implanted in 605 males and 431 females with mean age 33.5 yrs: 160 KMFTR®, 633 HMRS® prostheses, 68 HMRS® Rotating Hinge and 175 GMRS®. Sites: distal femur 659, proximal tibia 198, proximal femur 145, total femur 25, distal femur and proximal tibia 9. Histology showed 612 osteosarcomas, 113 chondrosarcomas, 72 Ewing’s sarcoma, 31 metastatic carcinomas, 89 GCT, 36 MFH, 68 other diagnoses.

Infection occurred in 80 cases (7.7%) at mean time of 4 yrs (min 1 month, max 19 yrs) in 18 KMFTR®, 47 HMRS®, 5 HMRS® Rotating Hinge, 10 GMRS®. Sites: 51 distal femurs, 21 proximal tibias, 6 proximal femurs, 1 total femur and 1 extrarticular knee resection. Most frequent bacteria causing infection were: Staphilococcus Epidermidis (39 cases), Staphilococcus Aureus (17) and Pseudomonas Aeruginosa (5). Infection occurred postoperatively within 4 weeks in 9 cases, early (within 6 months) in 12 cases, late (after 6 months) in 59 cases.

Usual surgical treatment was “two stage” (removal of implant, one or more cement spacers with antibiotics, new implant), with antibiotics according with coltures. One stage treatment was used for immediate postoperative infections, only since 1998.

Functional results after treatment of infection were assessed using the MSTS system.

Results: A two stage revision was attempted in 73 pts (91.2%): in 58 cases a new prostheses was implanted (with negative laboratory tests for infection) at mean time of 5 months (min 2, max 16 months), but in 3 pts infection recurred and they were amputated; 4 pts died before implanting a new prosthesis; 11 pts were amputated after several spacers since infection did not heal. One stage revision was performed in 4 of the 9 immediate postoperative infections, with successful results.

In 3 cases an amputation was primarily performed, to proceed with chemotherapy.

Revisions for infection were successful in 63 pts (79%), while 17 pts were amputated (21%).

Functional results evaluated in 53 revised cases were good or excellent in 43 (81.1%).

Conclusions: Two stage treatment of infected megaprostheses is successful in most cases. One stage has selected indications, mainly in postoperative immediate infections.


G. Fuhrmann S. Hofmann C. Wenisch M. Pietsch

Purpose: 2–5 years results in the treatment of deep infection of total knee arthroplasty (TKA) after two-stage reimplantation are presented. An articulating antibiotic spacer prosthesis and a standardized antibiotic therapy were used.

Material and Methods: In a prospective study 33 consecutive patients were treated with the articulating spacer, which was made on the table by cleaning and autoclaving removed parts of the infected TKA. A parenteral double antibiotic therapy in combination with rifampin was given for 10 days, followed by oral therapy for 4 weeks.

Results: At a mean follow-up period of 47 months (31 to 67) three patients had reinfection (success rate 91 %). We could increase the average Hospital for Special Surgery knee score from 67 points (44 to 84) to 87 points (53 to 97) after reimplantation.

Based on these results, 25 knees (76 %) were rated excellent, 5 knees (15 %) were rated good, 2 knees (6 %) were rated fair and one patient (3 %) had a poor result. Complications were one temporary peroneal palsy, one luxation of the spacer due to insufficient extensor mechanism and one fracture of the tibia due to substantial primary metaphyseal bone loss.

Conclusion: Using articulating spacer prosthesis disadvantages of joint fixation between the two stages could be reduced. There is no difference in the reinfection rate compared to procedures using fixed spacer blocks. It facilitates the reimplantation and gives good functionel results.


P. Ruggieri T. Calabrò C. N. Abati E. Pala G. Ussia A. Angelini M. Montalti M. Mercuri

Objective: Aim of this study was to analyse the incidence of infections in primary prosthetic reconstructions of the humerus after resection for bone tumours and their treatment and results.

Material and Methods: Between 1974 and 2006 at Rizzoli 344 reconstructions of the humerus using prosthetic devices (alone or in association with allografts) were performed. Sites of reconstruction were: proximal humerus 311, distal humerus 19, diaphysis 5, total humerus 9. Histological diagnoses included 24 benign tumors, 253 malignant tumors and 67 metastatic carcinomas. Patients were followed periodically in the clinic. Informations were obtained from clinical charts and imaging studies with special attention to major complications requiring revision surgery. Univariate analysis through Kaplan-Meier actuarial curves was used in evaluating implant survival to major complications. Infections developing in the first 4 weeks were considered postoperative infections, those diagnosed in the first 6 months were judged early infections, while late infections those diagnosed after 6 months from surgery.

Results: In 20 patients (5.8%) a revision for deep infection was required. In 19 of these cases tumor was localized in the proximal humerus and in 1 in the distal humerus. There were 18 infections in prostheses and 2 in allograft prosthesis composites. Two infections were postoperatively diagnosed, seven were early infections and eleven late infections. Revision was required in 18 cemented prosthesis, 1 uncemented prostheses and 1 Coonrad-Morrey.

S. Epidermidis and S. Aureo were the most frequent bacteria causing infection (45%). Two stage treatment of infection was chosen: removal of the implant and temporary substitution with cement spacer with antibiotics (usually vancomycin) until infection healed. But a new prostheses was actually implanted in 3 cases only (at mean time of 5.7 mos), while in 17 the spacer was never removed by patients choice due to the acceptable result with the spacer. Systemic antibiotics were associated according to cultural results. Infection healed in all patients.

Conclusions: Infection is the most severe complication in prosthetic reconstructions for tumours of the humerus. Its incidence (5.8%) is lower than in lower limb. Treatment requires a team work: surgeon, microbiologist and infectious disease physician. One stage is indicated in postoperative infections, two stage is recommended in both early and late infections. Two stage surgery offered good results, although in most cases a new prosthesis was not implanted, since actually humeral megaprostheses act as a spacer and don’t provide a much better function.


T. Lovse P. Sadoghi M. Hochegger H. Clar S. Egner G. Feierl R. Windhager

Introduction: Prosthetic joint infections occur in 1–2 % following total knee replacement. Different options of treatment are described in literature with a lack of data from randomized, controlled trials.

We classified septic revision surgeries following total knee according to a classification published by Mc Pherson. Eradication rate of one stage versus two stage exchange was compared.

Materials and Methods: We included 74 patients who underwent septic revision surgeries following total knee replacement in the years 1998 to 2005. Gender distribution was 42 female and 32 male patients. The mean age at revision surgery was 71 years, at primary implantation mean 68,8 years.

Results: The eradication rate overall was 77 %, in one stage exchange 41.7% and in two stage procedures 86%. Multiple stage revision showed an eradication rate of 75%, necrectomy/debridement 50%, arthrodesis and amputation 100%.

Regarding Mc Pherson’s systemic grades classification the eradication rate for two stage exchanges was 85,7% in group A+B and 60%% in group C. One stage procedures achieved 0% eradication rate in group B and 60% in group C. Regarding Mc Pherson’s local extremity grade classification eradication rates within two stage revisions were 84% in group 2 and 75% in group 3. One stage revision achieved 40% and 0%.

Conclusion: Although two stage revision surgeries achieved better results regarding eradication rates then one stage revision surgery, results were statistically not significant. Reason could be a too small number of included patients for a significant statistical impact. The individual surgical procedure should orientate on the classification published by Mc Pherson.


D. Jahoda D. Pokorny V. Barták R. Hromádka I. Landor A. Sosna

The infected total shoulder arthroplasty is not a frequent finding at the present time, the necessity of treating this complication may become more urgent with the continually increasing number of arthroplasty procedures performed.

From 1992 till the beginning of 2005, eleven patients were treated for infected total shoulder arthroplasty. An acute infection occurred in one patient (9 %), subacute in three (27 %) and late in seven patients (64 %). The average period between the primary operation and infection manifestation was 19.3 months.

The group of 181 patients operated on for shoulder replacement between 1992 and 2005 was evaluated, and a deep infection of total shoulder arthroplasty was found in 11 patients (2.2 %).

An antibiotic therapy alone was sufficient to eradicate the infeciton in only 20 % of the infected patients, but these showed good Constant scores (average, 42 points). Revision surgery, debridement and irrigation drainage had a low success rate (33 %) and good Constant scores (average, 45 points) in the cured patients. A two-stage exchange was 100 % successful but had a poor outcome, with an average Constant score of 26 points. However, a two-stage exchange involving a spacer had both 100 % success rate and a good outcome with an average Constant score of 49 points. On statistical evaluation using the unpaired t-test, there was a significant difference in the Constant scores (T 4.35 p=0.005) between the patients undergoing exchange arthroplasty with (n=40) and without (n=4) the spacer.

Poor function scores after resection arthroplasty are not surprising, because a sharp residual proximal humerus is likely to irritate soft tissues and, in addition, it is not possible to reconstruct a rotator cuff to match it.

Comparing the results of one-stage with two-stage reimplantation is a complex issue. Attention should be paid to a relationship between the methods routinely used to treat an infected total shoulder arthroplasty and those preferred by the given hospital for treatment of other joints. If the therapy is well established in that hospital and gives good long-term results, it is optimal to use it also for the treatment of infected total shoulder arthroplasty.

The method of treating infected total shoulder arthroplasty is not different from other big joint therapies. The use of a spacer will allow us to remodel soft tissues satisfactorily even after extensive debridement. The functional results of treatment involving a spacer are significantly better.


P. Vavron J. Schwaighofer T. Herz A. Holzer

3462 knee prosthesis were implanted between 1.1.1998 and 31.12.2008 (11 years). There were 491 Unis in this group, but infection ocurred only in Total Knee Replacement (TKR) group. We treated 24 patients (0,69 % infection revision rate) with infected TKR in this time period. The follow-up was from 126 to 7 months. The infection agens was diagnosed by preoperative joint aspiration (Staph.aureus 40%, koagulaseneg.Streptococci 20%)

We compared 3 methods of treatment: the first group was open debridement + inlay exchange. In this group we treated 10 patients (37%). There was infection recurrence in 20 %.

The second group was one-stage exchange: 5 patients (18%) with infection recurrence 60% and two complications (spin-out and component loosening).

The third group was two-stage exchange: 12 patients (44%) without infection recurrence (0%) and no complications. Two stage-exchange was performed with custom-made cement tibialspacer and resterilized explanted femoral component which was reimplanted with [[Unsupported Character – & #8222;]]poor“ cement technique as originally described by A.Hofmann. Post-op partial to full-weight bearing with brace 0–90 degrees was allowed. For reimplantation a non- or semiconstrained revision prosthesis with mobile bearing after cca 6 weeks period was used. The prothesis‘ stems were not cemented.

Based on our experience we recommend two-stage revision in mostly cases. Use of mobile spacer keeps excellent mobility after revision and prevent excesive scarings which complicate the reimplantation and causes limitation of movement if fixed spacer was used. On the other side we could show that use of mobile spacer do not increase infection recidiv rate in septic knee surgery. A meticulous debridement is, in our opinion, the most important part of surgery, but it was possible in all cases to save the collateral ligaments and to prevent use of constrained revision prosthesis with increased revision rates because of loosening. Debridement + inlay exchange should be limited only for acute cases with short disease history.


P. T. Funovics J. Holinka R. Kotz M. Dominkus

Endoprosthetic replacement following oncological conditions has shown to be at higher risk of sceptical complications due to the use of implants of unusual size, major soft tissue loss and immunsupression.

373 patients have been treated at our institution for malignant tumours of the bone or soft tissue around the knee with a modular tumour-prostheses of the knee joint since their availability from 1978. Infection or septic complications were identified in 78 patients (20.9%).

In 15 cases of superficial wound healing disturbances with a fistula simple excision and revision of the wound was performed. In 48 cases of deep periprosthetic infections patients underwent one-stage revision with explantation of the total prosthetic material except femoral and tibial stems, extensive debridement of the wound and replantation of the disinfected prostheses throughout one operation. In 8 patients two-stage revision of the prostheses was performed, using an antibiotic impregnated cement spacer and Steinmann nails. In 5 patients amputation of the affected limb was indicated, whereas 2 patients could be treated conservatively. Out of the patients treated by one-stage revision 16 developed recurrent infection and had to undergo consecutive surgery. After two-stage surgery 4 patients showed signs of septic recurrence.

According to our results deep periprosthetic infection of tumour-prostheses primarily can be treated by one-stage revision, in recurrent infections, however, two-stage revision should be performed. We additionally suggest the use of local or pedicled muscle flaps to obtain better soft tissue coverage of the prostheses after infection.


G. Cicero F. Bellomo S. Artiaco F. Boggio E. Buttafarro

Introduction: In case of massive bone defect, femoral stem revision may cause significant problems to the orthopaedic surgeons. The periprosthetic infection introduces a further element of complication which often leads to complex surgical strategies. The aim of this study was to assess the preliminary results of femoral revision with modular resection femoral stems in a selected group of patients with infected total hip arthroplasty and extensive bone defect.

Materials and Methods: The study group included five patients (three women – two men) with an average age of 72 years (range 62–81 years). From 2006 to 2008 the patients underwent a prosthetic femoral revision with resection modular stems to treat a septic loosened primary hip prosthesis (one case) or revision hip prosthesis (four cases). The bacteria responsible for the infection were MRSE in three cases, MSSE and Str. Agalactie in one case, Proteus Mirabilis in one case. Three patients were treated in election for septic loosening of hip implant and two were admitted in our Department as emergency for a periproshtetic femoral fracture (Duncan type B3). In all the patients the femoral bone defect was grade III-B according to Paprosky classification of femoral bone deficiency. One patient with periproshtetic femoral fracture underwent a one-stage prosthetic revision and four patients sustained a two-stage prosthetic revision. In one patient a local flap was performed and Vaacum Assisted Therapy was applied in order to treat an associated loss of substance. The patients underwent periodical clinical controls in which the result has been evaluated by means of Merle-d’Aubigné hip score.

Results: The follow-up period ranged from 10 to 28 months. We observed one case of recurrence of infection in the patient treated with a one-stage revision. At present, we did not observe signs of infection in the remaining four patients who underwent a two-stage revision. As for functional result, four patients walked with supports and one without them. No patient referred moderate or severe residual pain.

Discussion: The preservation of bone stock is one of the most important goals in prosthetic revision procedures. In some circumstances the amount of femoral bone loss can be so wide to prevent the application of conventional or modular uncemented femoral stems. In these selected cases cemented modular resection femoral stems may represent the only available option for femoral reconstruction. In our clinical experience this solution offered altogether successful outcomes. In our opinion two-stage revision is the preferable surgical choice.


I. Babiak A. Gorecki

Introduction: Failed total knee replacement due to the daemage of bone stock and infection requires removal of prosthesis. Successful arthrodesis is strongly related to the quality of bone stock. Both external fixators and KAFO are not comfortable and thus poor tolerated by elderly patients. Instable knee is very disabling condition. Custom-made femoro-tibial nail combined with acrylic cement spacer offers maintenance of supportive function of extremity after removal of knee prosthesis. Avoidance of leg length discrepance is possible. Nailing can be considered only as salvage procedure for one knee.

Material and Method: Six elderly patients underwent unilateral arthrodesis of the knee after removal of knee prosthesis due to the daemage to the bone stock and periprosthetic infection. They have had conical shape of the lower leg and poor quality to the bone. Thus they were not suitable for conventional knee arthrodesis using external fixator or for pseudoarthrosis and KAFO. After removal of TKR and debridement of periprosthetic tissues an ortograde, custom-made femoro-tibial interlocking nail was inserted. The gap betveen distal femur and proximal tibia was filled with hand-made acrylic cement spacer loaded with vancomycin (2g per 40 g cement) so that the spacer finally gained tubular shape.

Results: No recurrence of infection was noted. Early postoperative full-weight bearing was possible. Implant failure occurred in one case and required replacement of nail and cement spacer. Stress fracture of femoral neck occurred in another case. Despite of this problems all patients has better ADL than with KAFO or after

Conclusion: femoro-tibial nail for failed TKR is good accepted and comfortable for patient. Disadvantage of this type of nail is stiff knee and risk for nail fracture.


D. Haro Fernández A. Matamala Pérez H. Ferrer Escobar R. Torres Romañá

Introduction: Infection is probably the most frightful complication associated with Total Hip Replacement

This infrequent complication occurs with a frequency ranging from 0,6% to 1,1% depending series, and in Revision cases it may rise up 20%.

We expose our experience in the treatment of infection associated with THR using the two-stage procedure with hand-made partial hip spacers.

Patients and Methods: Between August 1998 and March 2009, 9 patients underwent a two-stage revision procedure for infected Hip Replacement using partial hip spacers.

There were 5 men and 4 women, with an average age of 65 years, ranging from 35 to 76. 3 patients had previous surgery before presenting to our hospital.

The infecting pathogen was Gram positive in 6 out of 9 patients (66,7%), Gram negative in 2 patients (22,2%) and in the remaining patients the pathogen was not detected.

No clinical signs nor radiological findings suggested septic loosening of the femoral component, except in one patient.

The partial spacer consisted on a ball of acrylic cement with antibiotics (usually an aminoglycoside i.e. gentamicin) which is manipulated by the surgeon in order to be placed in the acetabulum. In 8 out of 9 patients femoral component was not removed.

All the patients received systemic antibiotic treatment with two or more antibiotics for more than 6 weeks after the first stage, on the basis of the antibiogram.

Results: Hip function was recorded using the method of Merle d’Aubigne, which it consists on a scoring system including pain, walking ability and range of movement. 7 patients (77,8%) had excellent or good results.

The average between the first and second-stage operations ranged from 8 to 24 weeks (mean 15,7 +− 2.1). During this period of time most patients had tolerable pain in the hip.

Success rates in terms of recurrence of infection after Revision surgery was 11,1%.

One patient presented a fistulae one year after second time surgery, and fistulectomy was carried out.

Discussion: In our experience a two-stage revision procedure with temporary implantation of a partial hip spacer allowed us to achieve a high rate of successful results in the treatment of infected Hip Arthroplasty.

The use of a hand-made device offers some advantages with respect conventional hip spacers. Easier implantation, preservation medullary canal and preservation of bone stock not requiring an extended throcanteric osteotomy for the removal of an infected long stem, especially in older patients with important associated morbidity.


O. Borens A. Trampuz M. Assal X. Crevoisier

Objectives: Total ankle replacement (TAR) is increasingly used for treatment of primary or posttraumatic arthritis of the ankle joint, if joint movement is intended to be preserved. Data on characteristics and treatment of ankle prosthetic joint infection (PJI) is limited and no validated therapeutic algorithm exist. Therefore, we analyzed all infections, which occurred in a cohort of implanted ankle prostheses during a 5-year-period.

Methods: Between 06/2004 and 12/2008, all patients with an implanted ankle prosthesis at our institution were retrospectively reviewed. All patients were operated by the same surgical team. Ankle PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract, or microbial growth in periprosthetic tissue or sonication fluid of the removed prosthesis. The surgery on the infected ankle prosthesis and the follow-up were performed by the surgical team, who implanted the prosthesis. A specialized septic team consisting of an orthopaedic surgeon and infectious diseases consultant were included in the treatment.

Results: During the study period, 92 total ankle prostheses were implanted in 90 patients (mean age 61 years, range 28–80 years). 78 patients had posttraumatic arthritis, 11 rheumatoid arthritis and 3 other degenerative disorder. Ankle PJI occurred in 3 of 92 TAR (3.3%), occurring 1, 2 and 24 months after implantation; the causative organisms were Enterobacter cloacae, Streptococcus pyogenes and Staphylococcus epidermidis, respectively. The ankle prosthesis was removed in all infected patients, including debridement of the surrounding tissue was debrided and insertion of an antibiotic loaded spacer. Provisional arthrodesis was performed by external fixation in two patients and by plaster cast in one. A definitive ankle arthrodesis with a retrograde nail was performed 6 to 8 weeks after prosthesis removal. One patient needed a flap coverage. All 3 patients received intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 4–6 weeks. At follow-up visit up to 18 months after start of treatment, all patients were without clinical or laboratory signs of infection.

Conclusions: The infection incidence after TAR was 3.3%, which is slightly higher than reported after hip (< 1%) or knee arthroplasty (< 2%). A two-step approach consisting of removal of the infected prosthesis, combined with local and systemic antibiotic treatment, followed by definitive ankle arthrodesis shows good results. Larger patient cohort and longer follow-up evaluation is needed to define the optimal treatment approach for ankle PJI.


E. Bertazzoni Minelli A. Benini

Antibiotic-loaded PMMA spacers are used with increased frequency in two-stage revision arthroplasty. The release of aminoglycosides and vancomycin, the most commonly used antibiotics, is prompt, and concentrations are inhibitory. The release kinetic from PMMA bone cement shows a biphasic profile, consisting in an initially high and rapid drug release followed by a slower but sustained phase.

However, this general profile of drug release kinetics from PMMA spacers in vitro may have great variability in terms of drug amount, modality, and duration of elution. Initial drug concentration, cement surface area and porosity are essential and well-known factors in determining the drug release. Moreover, viscosity, vacuum-preparation and the different technical characteristics of commercially available spacers are additional factors of variability. Industrial preformed spacers are considered superior to custom-made devices because of uniform mixing and standardized procedures.

Spacers produced by different manufacturers vary in their mechanical properties and antibiotic elution characteristics. Small changes in the formulation of a bone cement can also affect these properties.

Similar bone cements produced by various brands release different amount of drugs. Gentamicin diffuses from Palacos in a larger amount and for a longer period than from Simplex and CMV. Spacers produced in France (Synicem™) and in Argentina (Subiton™) elute less total amount of gentamicin than those produced in Italy (Spacer G™) and show a delayed peak drug release. The low initial release of antibiotic can contribute to unsatisfactory antimicrobial effect and to the risk of selection of resistant bacteria. Some spacers release gentamicin for longtime (months), while others release antibiotic for only two weeks.

In the last years an evolution of PMMA spacers production occurred and modifications in the polimerization process of cement can increase cement porosity and antibiotic elution from spacers.

The current commercial preformed spacers for 10 days elution (Spacer G™, prepared with Cemex HP) release more gentamicin (34.1 mg) than previous models, which were prepared with Cemex SP (16.4 mg). Furthermore, they maintain a high elution rate (1.4–1.6 mg/day after one month).

The combination of Gentamicin and Vancomycin mantains an elution pharmacokinetic profile that is superimposable to that of Gentamicin and Vancomycin alone, with synergistic effects against multiresistant bacteria in prosthetic infection site.

In conclusion, the antibiotic release from PMMA spacers of various brands is not equivalent. The old elution data are no longer valid for new preparations. Consequently, this additional factor of variability should be considered in clinical practice and literature data utilisation.


H. Ahrens G. Gosheger A. Streitbürger A. Günsel M. Balke J. Hardes R. Dieckmann

Early and late infections are the most uneventfull complications after tumor resection and implantation of a maegaendoprosthesis. Therefore, silver-coating was introduced by our department years ago with successful reduction in infection rates. After promising results in animal and Phase exclusion of side effects in our Phase I trial, we would like to share our knowledge about latest research, especially the actual results of the Phase II study. We included the results off all implanted silver-coated Megaendoprosthesis since introduction in our department. Implantation had to be more than 12 months ago to guarantee a acceptable minimum follow up for calculation of the infection rate. Actually our infection rate lies at 3,1% (N=131) in the prevention group (no previous infection in medical history) and at 19% (N=36) in our “Highest-Risk” and previous infection group. Still no side-effects could be noticed. In one case we examined retrieved samples of three silver-coated Megaendoprosthesis. Macroscopically a leopard shaped figures could be noticed on the silver-coated surface in shiny and dark areas after being implanted in an infected region. Electron microscopy pictures show still intact surface and remaining silver with dark staining. Biofilm formation coulod not be noticed, though some few dead single bacteria could be found without any signs of proliferation or matrix production after adhesion. Signs of biofilm couldn’t be seen anywhere. Despite the discoloration silver is still intact in these areas without any loss of antibacterial properties. Blisterings or even flaking off the silver coating cannot be noticed. The thickness of the silver was not thinned in a significant way leading to a breakdown after a few years.

Up to these days we have no experience in covering the whole prosthesis including the stem in human beings. Concerning osteointegration of silver-coated stems, our animal trial could not prove their effectiveness in comparison to titanium. Pull-out tests showed high significant discrepancies in osteointegration between titanium and silver coated stems in a dog model after a period of 12 months after implantation.

Summarizing we recommend silver as a safe adjuvant therapy in patients undergoing endoprosthetic reconstruction after tumor resection. Intramedullary use of silver can be done only in experimental cases and needs further changes in the technical design of the coating.


R. Sousa M. Massada M. Pereira R. Claro D. Freitas M. Vieira da Silva R. Lemos J. Costa e Castro

Introduction: Prosthetic joint infections are a growing burden. Since we felt that we were far from the optimistic results recently published, we decided to find out the reality in our department. The goals were to determine:

The rate of infections in primary and revision surgery (hip and knee)

The success rate in treating those infections

Long term survival rate of revision arthroplasties

Materials and Methods: We retrospectively reviewed clinical records of all patients that underwent surgical treatment due to infected hip or knee prosthetic joint between 1st July 2001 and 31st December 2007.

Results: Since the majority of infections (67%) presented in the first two years after surgery, we determined the rate of infections taking in to consideration a minimum two years follow-up. We calculated a 1.8% (12/678) rate of infection for primary total hip and 3.3% (20/588) for primary total knee arthroplasty. There was no statistically significant difference between the two groups. Revision hip surgery had a 5.4% (15/243) infection rate and revision knee surgery revealed an even higher rate of 10.3% (4/42). The difference between primary and revision surgery was statistically significant both for hip and knee.

Considering an infection free arthroplasty as the goal, the overall success rate of treatment was under 48% (30/69). The success of treating infections with debridement and retention of components was even lower (29%). Further analysis revealed a higher success of this approach (45%) when considering more appropriate candidates (short term infections). An interesting statistically significant difference was found favoring this approach in the knee.

Two-stage revision strategy was successful in achieving revision arthroplasty in 43% (20/46) of the cases. Most patients were never considered candidates to the second stage procedure. Knee joint and resistant microorganisms were found to be predictors of bad prognosis.

There was a 90% (18/20) survival rate of revision arthroplasties after two years average follow-up. There were only 2 cases of relapsing infection both controlled without prosthetic removal.

Conclusion: Our results compare poorly with the latest published data from different centers. They led us to implement new prophylactic measures as well as review our diagnostic and treatment options.


G. Bjerkan K. Bergh E. Witso

Aims: The symptoms of aseptic and septic prosthetic joint loosening may be similar, and identification of low-grade prosthetic infection based only on clinical history and physical examination has a reported low sensitivity. In a prospective study we explored to what extent a thorough examination of the patient’s history of sickness and a standardized preoperative clinical examination could help the surgeon to identify cases of septic loosening.

Methods: We included 54 patients undergoing revision surgery due to loosening of a total hip or knee prosthesis. Preoperatively a standardized form which included data regarding the patient’s history of sickness was obtained and a physical examination was performed.

Postoperatively a final diagnose was made based on microbiological testing, which in addition to routine culture, included sonication of the prosthesis and nucleic acid based diagnostics (PCR). Data from the preoperative examination was evaluated in relation to the final diagnose (chi-square test and Student’s t-test), and the sensitivity and specificity for diagnosing a septic loosening was calculated for each preoperative finding.

Results: According to the final diagnose, 21 patients had a septic loosening and 33 patients had an aseptic loosening. In the septic group and aseptic group the following anamnestic data was registered: Pain during rest: 16/21 vs. 7/33 (p < 0.001). Prior history of soft tissue debridement: 11/21 vs. 4/33 (p = 0.001). Prior prosthetic revision surgery: 13/21 vs. 8/33 (p = 0.006). Time from index operation to revision: 45 (5 – 144) moths vs. 159 (22–390) moths, (p = 0.02). Time from index operation to debut of prosthetic assosiated dyscomfort: 10 (0–110) moths vs. 120 (0–240) moths, (p < 0.001). The calculated sensitivity (se) and spesifisity (sp) for the pre-operative findings were: Existence of prosthetic related pain during rest: 79% se, 79% sp; history of soft tissue revision in the affected joint 52% se, 88% sp; history of prior exchange prosthetic revision in the affected joint 62% se, 76% sp, respectively.

Conclusion: We advise a carefully obtained history from every patient presenting with loosening of implanted prosthetic components for identification of a potential low grade infection. In particular, pain during rest has a notable sensitivity and specificity. A prior history of soft tissue revision also strongly indicates a septic prosthetic loosening.


T. B. Maurer W. Zimmerli P. E. Ochsner

At our institution, periprosthetic hip joint infections are treated according to a previously defined treatment algorithm. Each patient is evaluated regarding risk factors such as duration of clinical signs and symptoms, stability of the implant, condition of the soft tissue, and antimicrobial susceptibility of the microorganism. Depending on these factors, either debridement with retention, one-stage exchange, or two-stage exchange with spacer (short interval, 2–4 weeks), or without spacer (long interval, 8 weeks) is performed. Very rarely, resection arthroplasty or lifetime suppression is necessary. All surgical procedures are combined with an antimicrobial therapy for 6 or 12 weeks, depending on the surgical pathway. For infection due to staphylococci, whenever possible, rifampicin is used in combination with a fluoroquinolone. From 2002–2006, 89 patients with 95 episodes (3 patients with 2 independent episodes, 3 patients with bilateral infection) of periprosthetic hip joint infection have been treated at our hospital. Five patients died within 2 years after revision, one of them with septic shock related to the periprosthetic hip joint infection. One patient is living abroad. All other patients (n=83) had consecutive follow-up visits at least until 2 years after infection treatment without recurrence. Debridement with retention has been performed in 18 episodes, one-stage exchange in 25 episodes, two-stage exchange with temporary spacer for 2–4 weeks has been performed in 26 episodes, and two-stage exchange without spacer and an interval of 8 weeks in 19 episodes. In 4 cases, immediate resection arthroplasty was performed and 3 patients received long-term suppression therapy. After debridement with retention, 3 recurrences and one event of death occurred (4/18=22.2%), 3 of them did not fulfil the criteria of the algorithm. No failure was observed after one-stage exchange (0/25). Treatment with two-stage exchange was followed by one failure in the group with spacer and short interval (1/26=3.8%), as well as one in the group without spacer and long interval (1/19=5.3%). No recurrence occurred after resection arthroplasty or suppression therapy. All 5 patients with relapse could be cured with a one- or two-stage exchange and remained without recurrence. Comparing one-stage versus two-stage exchange, one-stage exchange is known to have better functional results. It is associated with better patient acceptance, shorter hospital stay, and therefore lower economic burden.

In conclusion, one-stage exchange implies no increasing risk of recurrence provided that the standards of our algorithm are considered.


H. De Man P. Sendi T. B. Maurer W. Zimmerli P. Graber T. Ilchmann P. Ochsner

Introduction: In treatment for prosthetic hip joint infection (PHJI), the advantages of a 1-stage exchange over the classic 2-stage approach are the lower morbidity and earlier rehabilitation. Secondly, a recently published treatment algorithm for PHJI using well-defined selection criteria for 1-stage exchange had a 85–100% rate of cure for infection. Patient satisfaction after hip surgery is highly influenced by the functional result. We hypothesized that in our used algorithm the functional and radiological outcomes after a 1-stage exchange due to an implant-associated infection would be similar to a matched control group of 1-stage exchange due to aseptic loosening.

Material and Methods: Twenty-two cases (21 patients), with PHJI according to a well-defined definition, after 1-stage exchange of the prosthesis strictly according to the algorithm, with index-surgery between april 1996 and october 2004, were included in the studygroup. Case-matching was performed with aseptic revised cases for previous surgery, type of implant, use of transfemoral osteotomy, Charnley score, duration of follow-up, age, and sex. Outcome measures were perioperatively complications, functional results (Harris hip score, limping, and use of walking support) at two years, and the occurrence of revision for any reason and radiological loosening at latest follow-up. All outcomes were compared between both groups and with the results of the two stage revisions in our cohort. Finally, the eradication of infection was scored.

Results: In 86% of the 1-stage group (n = 19) there was an event-free follow-up for ≥ 2 years. The mean Harris hip score was 84, the incidence of limping 20% and 10% required two crutches. Two stems were revised due to aseptic loosening. Both functional and radiological outcomes were not different from the matched control group.

In the 2-stage group (n = 50) results were lower but not significantly, with 80, 30% and 28% respectively, and 2 stems and 1 cup were revised due to aseptic loosening.

One case (after one stage) developed an infection with a different pathogen and one case (after two stage exchange) had a relaps of infection.

Conclusion: By using the identical surgical technique in both septic and aseptic revision hip surgery, functional results are comparable between groups. These results indicate that 1-stage exchange according to a strict algorithm leads to a successful outcome in both maintaining functional mobility and eradicating infection.


E. Luger

My X-rays and scars literally show my life-story. What they show is a destroyed right hip bone due to Osteomyelitis at the early age of 4 days and, 18 years later, a length difference between my feet of approximately 6 inch. But what they do not show is me.

The fragile infant who became a little girl, turned into a teenager, and eventually grew into a woman. A woman who, throughout this process, was forced to set her personal hopes and dreams aside in order to be (the) patient. Why is it that when you get sick you simultaneously seem to vanish as a person? It feels like your individuality becomes second to your medical status. Moreover, you are expected to stick to the rules of your role to serve the hospital system. But I am a human being after all, not a numb, genderless puppet.

Once the patient, you are trapped and challenged by the obstacles of a life that is no longer in your hands. Lying in a hospital bed, childlike and deprived of your gender, often not even capable of choosing when to act according to your personal needs, you just never know when to feel safe within yourself.

Exposure, shame, and pain become a daily routine, as your handicap is put into the spotlight of men, without any space left for privacy. This vicious circle can lead into self abandonment and depression. You break under the pressure of getting healthy and your self-imposed control. Dependency on strangers, adapting to hospital rules, waking up in a changed body after surgery and losing your self-worth are some of the consequences you have to face along the way. Pain is not the problem, your soul, adapting to the changes that are made on your body, is.

Please note, that the patients’ soul is not visible on an x-ray. Take a closer look at the bravely smiling patients, who are sitting in your offices, scheduling their next surgeries without hesitation, because they finally want to get well. The system has to be individually adapted for all parties. It is teamwork after all. As for me, I stood up for myself, got to be part of my surgical team and are now, 28 years later, living my freedom, the “normal” life, so to say. I am safe for now.


A. Donaldson B. B. Jalaludin R. C. Chan

Introduction: Aside from a technical understanding, patients’ perceptions of, and the emotional associations they make with, their illness can influence the eventual outcome. We explored this in relation to bone and joint infections as these can have major impacts on patients in terms of reduced mobility, need for surgery and long-term antibiotic use. In particular we wanted

to assess how patients viewed their infections,

to see if infection with methicillin-resistant Staphylococcus aureus (MRSA) was different to non-MRSA infections, and

to explore the emotional associations of these infections.

Methods: We adapted the Illness Perception Questionnaire of Weinman (1996) for this purpose. We focused on three domains: consequences, control/cure, and emotional responses. We asked all patients with osteomyelitis, septic arthritis or prosthetic joint infection attending the Liverpool Hospital Infectious Diseases Outpatient Clinic between May and August 2005 to complete the questionnaire.

Results: Ninety-one patients completed the questionnaire. Thirty-nine had either MRSA infection or colonisation. Overall, most patients felt that their infection had made a major impact on their life (76%) or that their infection was very serious (79%). This negative response was independently associated with younger age and having MRSA (either infection or colonisation). Patients with prosthetic joint infections felt they had reduced sense of control and likelihood of cure.

Conclusions: Bone and joint infections have a major psychological impact on patients, especially the young, those with MRSA and those with prosthetic joint infections. Health care professionals should take account of these emotional responses in order to optimise their therapeutic relationship with patients.


F. F. Rodríguez del Ama R. R. Perez-Ferri F. F. Romero-Candau

Introduction: Psychological problems and psychosocial after-effects on patients with long duration bone and joint infections do usually go unnoticed at first to doctors. Given the precedence of the traumatic injury, psychological problems are not well valued so they don’t get the needed attention that could be useful for patients. We’re submitting an initial study about psychological alterations on these patients.

Objetive: Valuing psychological alterations on patients with osteoarticular infections.

Material and Methods: Descriptive and retrospective study about psychological alterations on patients treated in the bone and Joint infections unit of a work accident mutual insurance hospital. We selected the 59 patients which required psychological assistance during the year 2008. Results have been obtained after checking their psychological medical histories. We evaluated the type and seriousness of psychological alterations, time elapsed until psychological assistance was given, previous psychological profile of the patients and social and labor characteristics of them all.

Results: Patients were mostly men, married, with a mean age of 38, with basic education and unskilled occupations. Time elapsed from accident to psychological evaluation was greater than three months in more than the 50% of the patients. 80% of them had no previous psychopatological disorders. Concerning toxic habits, smoking was the most frequent; 4 of them used drugs occasionally and 2 patients were alcoholic. Psychopatological alterations detected were 15 cases of depression, 22 cases of anxiety, 15 cases of adaptative disorder and 7 cases of other types. Patients biggest worry was uncertainty about their future, followed by possible physical limitations. 4 patients have rebuilt their work life according to their disabilities.

Conclusions: Early psychological assistance is useful in the treatment of osteoarticular infections. It’s necessary to plan a career guidance for those patients.


S. Sawalha T. Bucher S. P. Smith

Introduction: The role of prophylactic antibiotics in reducing the incidence of infection following hip and knee arthroplasty is well established. The British Orthopaedic Association (BOA) published best practice guidance on the use of prophylactic antibiotics in hip and knee arthroplasty. The guidance stated that all patients should receive prophylactic antibiotics at induction of anaesthesia and that each unit should have a locally agreed policy with advice from microbiologist. The aim of this audit was to compare the practice in our unit with the BOA guidance and implement necessary changes.

Patients and Methods: A prospective audit was conducted over a one month period in 2007 and included all patients undergoing elective primary hip and knee replacements. A similar re-audit was conducted over one month period in 2008 after the initial audit recommendations were implemented.

Results: Forty patients (40) were included in the initial audit. All patients received prophylactic antibiotics at induction but the choice, dose and duration of administration of antibiotics varied widely among surgeons in the unit. After discussion with the local microbiologist, we recommended a departmental policy for prophylactic antibiotics. The policy recommended a single dose of Cefuroxime and Gentamycin for standard cases and a single dose of Teicoplanin and Gentamycin for high-MRSA risk cases. A re-audit was conducted after the new policy was agreed. The re-audit included 33 patients. All patients received prophylactic antibiotics at induction. The choice of antibiotics was concordant with the policy in 79% of cases and duration of administration was appropriate in 85% of cases. Overall, the policy was adhered to in 22 cases (67 %).

Discussion & Conclusions: The closed audit cycle resulted in improvement of our practice but the compliance rate with the new policy was lower than expected. Although it is the primary responsibility of the operating surgeon to ensure the appropriate prophylactic antibiotics are administered, more awareness of other team members is necessary to improve the compliance rate with the new policy.


P. Frank V. Vécsei

According to the International Classification of Psychic Disturbances (ICD 10) accidents are among the traumatic incidents in a person’s experience and can lead to acute or persisting post traumatic strain reactions. During the primary medical treatment and care the patient first of all has to come to terms with the consequences of the accident. If an acute osteomyelitis occurs later on, this will be a further strain on the patient’s convalescence. At this point in time the extent of this infection is not foreseeable, neither for the team treating the patient nor for the patient him/herself. While the accident itself is to be seen as an acute trauma, the development of a chronic infection is a creeping and uncertain process. On the one hand the patient is confronted with the psychic effect of the accident and its consequences and on the other hand with the psychic effects of drawn-out treatment.

Apart from functional restrictions and cosmetically straining outcomes the patients suffer under the social effects, such as loss of work and threats to finances, changes, or loosing a partner and the social surroundings and restrictions in leisure activities. The psychological effects of chronic strain are a depressive attitude, loosing control when acute pain occurs, a decrease in sexual needs, alcohol or medication abuse and not rarely a permanent change in personality. Added to this are worries about the future, fear that the infection can “flare-up” again or the necessity of an amputation. According to the literature the existence of chronic pain is the most serious influential factor on a patient’s quality of life.

The question which personality factors contribute to the development of chronic osteomyelitis has not been answered to date. Investigations only show a connection between patients with psychiatric illnesses and a higher liability to be ill. Klemm et al. (1988) specified that for a small group of patients psychosomatic factors are involved in the “definition” (but not the cause) of chronic osteomyelitis.

The psychological treatment deals with the results of the accident and the effect of the drawn-out treatment.

Starting point is a detailed psychological and social requirement and problem orientation with an active analysis of problems and to look for resolutions. A subjective appraisal of the illness, the psychic resilience, intellectual abilities, cognitive handling strategies, personal and social resources all have a decisive effect on the progress of the therapy.


C. E. Lautenbach

I studied 1191 patients with known or suspected bone or joint infection. I divided patients with acute onset infection into three groups based on the speed of onset and the intensity of the infection. I divided the patients with known chronic infection into four groups according to the intensity of the infection. I used clinical and radiological parameters to determine the groups. There was a fifth group of patients with suspected infection who turned out to have other related or similar pathology but who were actually free of infection. The laboratory tests studied were all the parameters constituting a full blood count (CBC), tests of inflammatory activity (erythrocyte sedimentation rate, C-reactive protein, plasma viscosity and procalcitonin). I also studied the iron profile (serum iron, iron saturation, transferrin and ferritin). The same tests were used to monitor the patient’s progress as they responded to treatment – or not.

Findings: Not surprisingly those patients with the most intensive and extensive infection had disturbances across the spectrum of tests. As the intensity and extent of infection diminished more and more parameters returned to normal. It is thus possible to titrate the systemic effects of infection. Contrary to popular belief the white cell count, differential count and the activity tests can be normal in a large number of patients with recognisable infection. The most subtle evidence of infection is found in the iron profile, namely a diminished serum iron with an elevated ferritin level. Indeed the most definitive indicator of infection is the ratio of ferritin to iron.


U. Weiskirchner G. Angerler

At the Orthopedic Hospital Vienna Speising 7.857 surgeries were performed in 2008.

2.211 of these surgeries required implants. The number of performed Total Hip Arthroplasties (THA) was 836.

All of these surgeries were elective. Approximately 0,5% of the patients who underwent a surgery at our institution had a postoperative infection, 0,8% were admitted because of an already existing infection, which required treatment at our department.

In order to achieve a basis for international compatibility and to meet the legal postulations the Orthopedic Hospital Vienna Speising actively participates in ANISS (Austrian Nosocomial Infection Surveillance System)/HELICS (Hospital in Europe Link for Infection Control through Surveillance).

In 2008 a survey on incidences for Total Hip Arthroplasties was started. So the possibility of specific measures is given when interventions should be necessary.

The stuff unit for Hospital Hygiene gathers data from clinical records and conducts an evaluation by means of a standardised (equivalent surgeries) and stratified (differentiation of the patients after ASA-score- American Society of Anaesthesiologists, duration of the surgery, etc) procedure. Three times a week the stuff unit for Hospital Hygiene visits the wards and collect selected indicator-surgeries, which are entered in a specific program for registering infections. By finding noticeable problems, a detailed analysis is continued with the examination of microbiologic, histological and radiologic data as well as questions to the surgeon or attending staff and ward rounds for inspecting for instance changes of dressing.

The infectdiagnoses, based upon CDC (Center of Desease Control) definitions for nosocomial infections, are encrypted and sent to the control center quarterly. In turn our hospital receives an analysis and feedback once a year. A biannual exchange of experiences on behalf of the active members including an interpretation of the data allows to settle discrepancies and dubieties in evaluation.

This data on surveillance allows a detailed analysis of information gathered in recent years as well as a discussion with authorities.

As a result specific consequences could already been deducted like written guidelines for surgical management, recommendations for antibiotic treatment, preoperative shaving of the surgical area as well as preoperative screening for staphylococcus in Total Hip Arthroplasties.


L. Font L. Lozano M. Forga J. Ríos J. Martínez-Pastor A. Soriano L. Casanova S. García J. Mensa

Introduction: Although the influence of preoperative nutritional status on short term outcome in arthroplasty is well known, its relationship with early prosthetic joint infection (EPJI) in total knee replacement remains unclear.

Aim: Our aim was to assess the effect of preoperative nutritional status on patients who went on to present with EPJI following total knee replacement surgery. This assessment was based on preoperative blood tests and anthropometric measurements.

Methods: A total of 213 patients undergoing total knee replacement between December 2007 and May 2008 were included in the study. Patients with rheumatoid arthritis were excluded. For each patient we pre-operatively checked haemoglobin level, CRP, ESR, total lymphocyte and protein count, albumin and pre-albumin concentration and triglicerids, cholesterol and creatinine levels. Triceps skindfold and arm/muscle circumference were measured the day before surgery. The body mass index was calculated based on the information contained in the anaesthetic chart. We also collected information about co-morbidities such as Diabetes, High blood pressure, ASA grading, age and gender. Information about early infections, both superficial and deep, was collected. A descriptive statistical analysis and logistic regression models approach for independent risk factors were performed.

Results: The mean age was 71.5 years. There were 162 female and 51 male. Eleven patients (5.16%) had early wound infection: 5 deep EPJI and 6 superficial. Neither co-morbidities nor preoperatively laboratory test except CRP (OR 1.44, p=0.03) were associated with a high early infection risk. However, there was an inversely proportional relationship between EPJI and anthropometric measurements: triceps skindfold (OR 0.9 p=0.011) and fat area (FA) (OR 0.94, p=0.01).

Conclusion: A low triceps skindfold and FA were associated with an increment of risk of EPJI after a knee replacement. Although the relationship between some laboratory test as pre-albumin and lymphocyte account and wound healing and postoperatively complications is well known, we didn’t find it with EPJI in our group except for CRP levels.


H. Dale G. Hallan B. Espehaug L. I. Havelin L. B. Engesæter

Background and Purpose: The purpose of the present study was to assess the risk for revision due to deep infection for primary uncemented total hip arthroplasties (THAs) reported to the Norwegian Arthroplasty Register (NAR) over the period 1987–2007.

Methods: All primary uncemented THAs reported to NAR from the period 1987–2007 were studied. Adjusted Cox regression analyses with first revision due to deep infection as the end-point were performed. Changes in the revision rate as a function of year of operation were investigated, as was impact of risk factors (gender, age, type of diagnosis, duration of surgery, operation room ventilation and systemic antibiotic prophylaxis) on risk for revision due to deep infection.

Results: 14,348 primary uncemented THAs met the inclusion criteria. 97 THAs had been revised due to deep infection (5-year survival 99.56). Risk for revision due to deep infection increased through the period studied. Compared to the uncemented THAs implanted 1987–1992, the risk for revision due to infection was 1.2 times higher (95%CI 0.6–2.4, p=0.6) for those implanted 1993–1997, 1.4 times (95%CI 0.7–2.9, p=0.3) for 1998–2002, and 5.3 times (95%CI 2.6–10.7, p=< 0.001) for 2003–2007. The increase in risk for revision due to infection for primary uncemented THAs was most pronounced after the year 2000. No risk factor registered had any statistically significant impact on risk for revision due to infection in this study.

Interpretation: The results of this study indicate an increase in incidence of deep infection after uncemented THAs during the period 1987–2007. Concomitant changes in confounding factors, however, complicate the interpretation of these results.


D. Jahoda T. Hudec M. Hein V. Barták D. Pokorny A. Sosna

History of surgical wounds drainage is long-lasting. In our research we focused on the debated issue of safety and effectiveness of drainage.

In the period 2006–2008 we were examined 198 samples of patients after arthroplasty, or one-stage exchange for aseptic loosening and and 202 patients with infected artrhoplasty. For all patients was performed a prospective study of drain contamination using PCR methods.

Research has confirmed that the Redon drainage is a safe method that provides a clear benefit for the pacient. Based on the results of this study is recommended to keep drains 2 days after surgery.

Negative factor for the colonization of the drain are higher postoperative blood loss.

Continuous irrigation drainage can be clearly classified into standard operating procedures in the treatment of infectious diseases in the orthopedic. The use of irrigation drainage brings benefit over risk.

Prolonged irrigation drainage did not remove the contamination from the drains. Handling with irrigation drainage systems and dressing exchange did not a risk factor of contamination.

For infected knee joint is recommended to leave irrigation drainage about 100–112 hours, follow sucktional drainage and further 12 to 24 hours to remove the drains.

An important finding is the frequent presence of pathogenic fungi in the DNA material from arthroplasty area.


J. C. Schrama B. Espehaug G. Hallan L. B. Engesaeter B. T. Fevang

Objectives: The major objective of the present study was to investigate the risk of revision of infection after primary total knee replacements (TKR) in patients with rheumatoid arthritis (RA) during a 13-year period. We wished to compare RA patients with OA patients in order to detect differences in the risk of revision for infection, and to compare changes in the risk for the two patient groups over time. Furthermore we studied the time from primary implantation to revision for infection in the two groups.

Patients and Methods: From January 1994 to June 2008, 2482 primary TKRs in patients with RA and 25189 in OA patients were identified in the Norwegian Arthroplasty Register. Kaplan-Meier survival curves, with revision for infection as the endpoint, were constructed. Cox regression analyses were performed to calculate relative risk (RR) of revision for infection according to diagnosis, age, gender, year of surgery (from 1994 through 2000 and from 2001 to June 2008) and time of revision related to the time of primary TKR. All relative risks were adjusted for the other variables.

Results: The 5-year revision rate for infection of TKR was 1.1% in RA patients and 0.5% in OA patients. Rheumatoid arthritis patients had a 1.7 (95%CI 1.2–2.6) times higher risk of revision for infection compared to the control group (OA patients). The patients who had TKR surgery in the later period had a decreased risk of revision for infection (RR 0.72, 95%CI 0.53–0.98) compared to the time period 1994–2000. Furthermore, the risk of revision for late infection in RA patients, increased compared to OA from 4 years after the index operation.

Conclusion: Patients with RA undergoing total knee replacement surgery were at a higher risk of revision for prosthetic joint infection and had a higher risk of late infections leading to revision, than patients with OA. These findings emphasizes the importance of preoperative management and optimizing preventive strategies, especially in this patient group.


T. C. White R. Allom

Introduction: A Bradford sling is a device with which the arm can be held in an elevated position in the trauma or post-op elective setting to reduce swelling. It is marketed as a single use item but in many orthopaedic departments it is used multiple times before being discarded especially in the elective recovery setting. We asked the question ‘are there any microbiological implications to the re-use of Bradford slings?’ In our department Bradford slings were used in recovery for patients who had undergone hand surgery as a day-case. The sling would then cease to be used once it had become mechanically unusable.

Method: The Bradford slings employed in a one-month period by a single consultant working in the day surgery unit of the study hospital were examined. Prior to and following each use agar plates were inoculated by pressing the sling directly onto the plates. Two areas each of 5cm2, one in the arm and one in the forearm section of the slings were defined and labeled proximal and distal. Aseptic technique was used to avoid contamination by the investigator but otherwise the slings were treated in the same fashion as usually they would be. Patients were all screened for MRSA and were all negative

Results: In a one-month period 6 slings were used between 2 and 7 times (mean 4) resulting in 96 inoculation events. 89 (92.7%) of these events yielded significant bacterial growth. Most of these colonies were coagulase-negative Staphylococcus or Bacillus, however coliforms were cultured 5 (5.2%) times and Staphylococcus Aureus twice (2%). Also all slings demonstrated bacterial growth immediately after removal of packaging prior to first use. Indeed one sling grew coliforms prior to its first use.

There were no incidences of wound infection at 6-week follow-up.

Conclusion: The re-use of the Bradford sling poses no threat to the elective post-op patient. Most of the organisms isolated were environmental organisms unlikely to cause infection. There would only be a significant risk of infection if a patient had an open wound. Interestingly none of the Bradford slings were sterile prior to use. This study demonstrates that there appears to be minimal risk to the patient in re-using slings, but the numbers in this study are limited and a larger study would be helpful in assessing the risk further.


A. Antonini P. Tos C. Salomone M. Izzo G. Burastero

In bone infections, it is of fundamental importance to wrap any orthopaedic surgical procedure in healthy vascularised soft tissue, in order to allow good healing and to prevent infection recurrence.

Vitality of soft tissues around the knee joint can be easily jeopardized in patients undergoing multiple surgical operations as in case of infected arthroprostheses. In addition, there are very few local options in the soft tissue reconstruction of this area, due to the fact that the vascularisation of skin and subcutaneous tissue is based on the genicular arteries’ axes which prohibits the use of random skin flaps.

Preoperative planning of cutaneous incisions and reconstructive procedures is mandatory for a correct surgical treatment.

We analyze retrospectively a series of 8 patients who underwent soft tissue reconstruction of the knee area with local flaps, considering criteria and indications in the choice of each surgical option.

Main variables considered in decision-making were size and location of soft tissue defect, planned orthopaedic surgical procedure, likeliness of the need for further surgery, age, local and general condition of the patient.

Flaps employed have been medial gastrocnemius muscular flap, reverse ALT fasciocutaneous flap and the “propeller” freestyle perforator flap.

Main complications observed have been partial flap necroses and recurrence of the underlying bone infection.

In this work, the authors want to emphasize the importance of a multidisciplinary treatment of bone and prosthetic infections, where the antimicrobial therapy chosen by the Infectious Diseases Specialist must be synergic with an “orthoplastic” surgical procedure, in the effort to reduce the risk of infection persistence or recurrence and to obtain the best possible functional result and quality of life for the patient.


U. J. Spiegl R. Pätzold M. Militz P. Augat V. Bühren

Objectives: Goal of this retrospective study is to evaluate risk factors, which lead to an osteitis of the tibia depending on the fracture location.

Methods: The study was initiated 01/2002. The study population consists of 104 patients including 14 women (13%). All of them suffered from an osteitis of the tibial. All of them are complications after traumatic open or closed fractures of the tibia, treated surgical. The average age of the patients has been 48 (± 18) years. In 28 cases there has been an acute osteitis of the tibia. In the other 76 patients the infection was not noticed before the ninth week after trauma. In all patients the risk factors were analyzed depending on the fracture configuration, the soft tissue situation, and the fracture location.

Results: All infections have been localized at the fracture level. The majority of the patients suffered from open tibial fractures (77.4%). 7.9% have been first, 23.6% second, and 68.5% third degree open fractures. Almost half of the fractures (48.1%) were located at the distal third of the tibia. Equally, 25.9% of the infections were localized in the medial and proximal third of the tibia. The percentage of open fractures leading to an osteitis was significant highest (p < 0.01) at the medial third of the tibia (91.3%), whereas the percentage of open proximal fractures has been 61.1% and open distal fractures 62%. The complexity of the fractures of the proximal, medial, and distal third of the tibia was very similar. The proportion of osteosynthesis with fixateur externe, plating, or naling showed no significant differences. 37.8% of the patients were smoker. The percentage of smoker was significant highest (p < 0.05) in the subgroup osteitis after closed tibial fracture (69.9%). The number of the other risk factors (Diabetes mellitus, hypertension, alcohol consumption, adipositas, PAD) was similar in all subgroups. There have been no differences between the 28 acute versus the 76 chronic osteitis.

Conclusion: The majority of the posttraumatic tibial osteitis is localised in the distal third. The most important risk factor for the development of a posttraumatic tibial osteitis is the dimension of the soft tissue defect. This is particularly true for the medial third of the tibia where the percentage of open fractures is significant highest. Additionally nicotine consumption is a major risk factor for the development of a posttraumatic tibial osteitis, particularly in cases of closed distal tibial fractures.


U. J. Spiegl R. Pätzold T. Kern M. Militz V. Bühren

Objectives: An osteitis of the tibia remains a major problem especially in cases of open tibial fractures. A successful therapy management goes along with a radical bacterial eradication, sufficient soft tissue coverage, and a stable osseous reconstruction.

Methods: The study population consists of 112 patients (53 ± 13 years). All of them suffered from a tibial osteitis after fracture of the tibia. The study population was divided in patients with osteitis after open versus non open tibial fracture. The therapy strategy was the same in both groups. It was done according to a standardised treatment plan including radical surgical eradication of infectious and necrotic tissue, programmed lavage with vacuum sealing in combination with an effective bacterial antibiotic therapy. Surgical stabilization was done in cases of instability. Final osseous reconstruction and soft tissue coverage was performed if necessary after three negative intraoperative smears.

Results: 89 patients of the patients (79%) suffered form open tibial fractures versus 23 (21%) patients with non open fractures (NOF). The average inpatient treatment time was 13 ± 18 weeks in cases of osteitis after open tibial fractures and 8 ± 4 weeks after NOF. The average number of operative procedures after open fractures vs NOF was 10 ± 7 vs 8 ± 4. In 55 patients a muscle flap procedure was performed after open tibial fractures (53%) versus 9 (26%) after NOF. An amputation of the lower leg had to be done in 5 patients after open tibial fractures (5%) versus in 2 patients after NOF (6%). The rate of bacterial eradication with no recurrence of infection for at least one year was 53% in cases of osteitis after open tibial fracture and 65% after NOF.

Conclusion: An open fracture of the tibia is a major risk factor for developing a chronic osteitis. The eradication of bacterial infections takes a longer time and more operative procedures are necessary in cases of open tibial fractures versus closed fractures. In cases of open fractures there exists a higher need of soft tissue reconstruction by muscle flaps. After eradication there are no significant differences in the one year recurrence rate.


R. E. Margariti G. Hallak M. Frank P. Heumann A. Ekkernkamp J. Seifert

Introduction: Open fractures with severe soft tissue damage, uncovered osteosynthesis material and chronic soft tissue defect due to infection as well as its consequences represent a special challenge for the therapeutic strategy.

In these cases the soft tissue coverage has a particular importance.

Patients: Within a 24-month period (2005 to 2006) 145 open fractures of the lower leg and foot were treated. 34 of these showed a 1 °, 74 a 2 ° and 37 patients with 3 ° soft tissue damage. Furthermore, data on 16 patients with chronic soft tissue defect by infection, which had a flap coverage, have been evaluated.

Score: The average age was 43.3 years (6 to 68), the ratio of women to men 2:1. Primary definitive osteosynthesis was performed in 68 patients (47%). In 19 patients a local muscle flaps plastic (Soleus, Gastrocnemius, peroneus brevis) was carried out. Three of these were already covered in the context of the primary treatment. Fasciocutaneous flaps were performed in 17 patients.

In the most cases the defect site was closed by primary would healing, additional procedures (excision of skin necrosis, mesh grafting) were necessary in 8 cases. In one case we saw a complete loss of the muscle flap.

Conclusion: In addition to an adequate diagnosis (X-Rays, MRI) the soft tissue reconstruction of acute or chronic soft tissue defects, where the osteosynthesis material or the septic bone is uncovered, is also necessary. In the lower extremities local muscle flaps (M. soleus, M. gastrocnemius) or for smaller defects fasciocutaneous flaps (suralis) are particularly suitable.


C. L. Romano C. Bonora N. Logoluso D. Romano

Introduction: Surgical site infection is a growing and expensive complication. Surgical site surveillance is performed with the aid of laboratory tests and clinical evaluation; the latter has some limits, including reproducibility and validation of results and, as suggested by many authors, the need of a dedicated well trained staff. At present no imaging instruments are available for routine objective monitoring of “normal” or complicated surgical site healing. Recently, technological improvement made available for clinical use high resolution portable digital telethermocameras at relatively low-costs. No data are available in the literature, concerning the “physiological” thermographic pattern of surgical wounds in orthopaedics. The aim of this study is then to evaluate the physiological telethermographic pattern of surgical site healing after hip and knee prosthetic surgery, to provide a reference value for further analysis.

Methods: The surgical site of 60 consecutive patients undergoing total hip replacement and 40 patients unde-going total knee replacements were examined at fixed intervals from the day before surgery to six weeks after intervention, using a portable telethermographic camera (AVIO TVS-200EX). Results were compared with contralateral side and with laboratory data.

Results: A physiological “telethermographic pattern” of wound healing was observed and showed to be remarkably reproducible among different patients. A thermographic peak was observed at day 3, with a mean temperature elevation (hottest spot) of 2.3 +− 1.3 ^C after hip replacement and of 2.8 +− 1.5 ^C after total knee replacement. Similar results were obtained when considering the mean surface temperature in a 10 cm rectangle area identified around the surgical wound. Temperature at the surgical site slowly returned to baseline (contralateral side as reference) in a six weeks period.

Discussion and Conclusion: Telethermography through a portable camera appears a reliable, not invasive, not irradiating and easy-to-use tool to monitor surgical site following hip or knee arthroplasty at the patient’s bed. Surgical site show a highly reproducible physiological thermographic pattern, with peak values at day 3 and a constant decrease until normal values at week 6 after surgery. This findings may be used as a reference for further studies, to establish the relevance of abnormal thermographic patterns in connection with surgical site complications.


P. Ruggieri A. Angelini G. Ussia M. Montalti T. Calabrò E. Pala C. N. Abati M. Mercuri

Introduction: Tumours of sacrum are rare. Treatment depends on malignancy or local aggressiveness: resection is indicated for malignant lesions, intralesional surgery for benign. Purpose of this study was to analyse risk of infection and its treatment after surgery for the two most common primary sacral tumours.

Material and Methods: Between 1976 and 2005, 82 patients with sacral chordoma or giant cell tumour were treated in our Institution. Demographic data, surgery and adjuvant treatments were analysed in the two histotypes. All patients were periodically checked with imaging studies. Special attention was given to the assessment of deep infections, their treatment and outcome.

Patients included 44 females and 38 males, ranging in age from 14 to 74 years. Mean follow-up was 9.5 years (min. 3, max. 27). Histopathological findings included chordomas in 55 cases and giant cell tumor (GCT) in 27. Most pts. had iv antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection, surgery of GCT was intralesional excision. In 6 sacral resections a miocutaneous transabdominal flap of rectus abdominis was used for posterior closure.

Results: No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%), that required one or more additional operative procedures. In 16 pts. (70%) infection occurred within 4 weeks postoperatively, in 7 within 6 months. Most frequent bacteria causing infection were Enterococcus (23%), Escherichia Coli (20%), Pseudomonas Aeruginosa (18%). In 74% of cases a multiagent infection was detected. Surgical treatment consisted in 1 (52%) or more (48%) surgical debridements, combined with antibiotics therapy according to coltural results.

Mean surgical time was 14 hours for resections and 6 hours for excisions.

No significant difference was found comparing deep wound infections with levels of resection (15/33 resections proximal to S3-45% and 8/19 resections below or at S3-42%), previous intralesional surgery elsewhere (4/9 patients previous treated elsewhere-44% and 19/46 primarily treated patients-41%) and age at surgery.

Conclusions: Type of surgery was the prominent factor related with a major risk of infection. Operating procedure time correlated as well. Resection of sacral chordomas with wide margins improves survival although extensive soft-tissue resection in proximity to the rectum favours deep infections. Intralesional excision is the recommended surgical treatment for GCT of the sacrum and does not imply a significant risk of infection.


D. Varvarousis A. Papadopoulos A. Ploumis K. Kanellakopoulou A. Beris H. Giamarellou

Background: Perioperative Antimicrobial Prophylaxis (AP) is an established method to reduce the risk of intraoperative infection in TJR. Usual practices are not always compatible with published guidelines leading to excess morbidity, antibiotic overuse and emergence of resistance.

Methods: We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum.

Results: The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B(2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR:5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, prophylactic (group A) or therapeutic (group B), was comparable in both groups (p> 0.05).

Conclusions: Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic or therapeutic) in both groups.


M. Pons

The purpose of this study is to present the surgical and functional results of a partial and total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus.

Material: A retrospective review identified 19 calcanectomies in 16 patients: 5 partial, 11 total and 3 partial to total. The primary diagnosis was insulin-dependent diabetes mellitus (3 patients), neurophatic ulceration (2 patients), infected osteosynthesis (4 patients) and open fracture (7 patients). The average age of the patients was 42.36 years (range from 22 to 60). Prior procedures included removal of osteosynthesis, debridement, Gaenslen’s procedure and skin grafting. Operation was based in Martini’s technique. Most common bacteria were Staphylococcus aureus. Antibiotic treatment was based in cultures and has changed during this period of time.

Results: Four patients were lost (2 died) and the rest average follow-up was 9.8 years (range from 1 to 19 years). Recurrence of infection was present in 3/5 partial calcanectomies and in 1/14 of total calcanectomies. Talonavicular subluxation occurred as a late complication in the patient with recurrence after total calcanectomy and underwent a below-knee amputation. An assessment of functional ambulation was performed in all 16 patients according Volpicelli scale; the lost patients were recorded last time they were visited. All ambulatory patients needed a modified heel-containment orthosis.

Conclusions: Total calcanectomy is an alternative procedure to a bellow-knee amputation in patients with chronic osteomyelitis of the calcaneus. In our hands, partial calcanectomy has worse results in eradication of infection and we have left it.


J. H. Zwiers M. J. Bruins C. C. Verheyen M. J. Wolfhagen

Introduction: Arthrography and synovial fluid punction are two investigations easily combined as a diagnostic tool for the detection of (a)septic loosening of arthroplasties: diagnostic imaging; X-ray guided injection of iodine-containing contrast agents in (artificial)joints and synovial fluid puncture for microbiological diagnostics. The contrast agent is present in the fluid puncture for culturing. Free iodine is bactericidal, hence the assumption that the iodine causes fault negative culture results.

The older literature (1960–1982) partially supports this assumption and iodine contrast agents have been modernized considerately.

Is the effect the modern contrast agents have on the micro-organisms the cause of the fault negative culture results?

Method: The influence of modern widely used iodine containing contrast agents (Omnipaque1, Visipaque2, UltraVist3, Xenetix4) and two 30 year old agents (Hexabrix5 en Telebrix6) on the growth of the following relevant prosthesis infection causing micro-organisms were examined:

Staphylococcus aureus

Staphylococcus epidermidis

Enterococcus faecalis

Streptococcus pyogenes

Bacillus cereus

Escherichia coli (E. coli)

Pseudomonas aeruginosa

Candida albicans

Corynebacterium jeikeium

Propionibacterium acnes

Three different techniques were used: a disk diffusion test (classical resistance determination) and time-killing curves tests with a high inoculum (1,5*108 cfe/ml) and a low inoculum (10*3 cfe/ml) at 0, 2 and 24 hours.

Results: Disk diffusion tests: no contrast agent affected the growth of micro-organisms.

The high and low inoculum tests: only the combinations Telebrix with both P. aeruginosa and E. coli showed any growth inhibition but a non-significant (p = 0.07) growth inhibition of log-1. This however, did not impede the detection of these bacteria.

And with all other combinations there was no significant inhibition compared to the saline control and in every combination the percentage surviving number of bacteria was always higher than 30%.

Conclusion: Modern contrast agents do not seem to have a significant inhibitory effect on micro-organisms. They do not seem to be the cause of the fault negative synovial fluid culture results.


A. Tsezou L. Poultsides I. Papathanasiou K. N. Malizos

Septic arthritis induced by Staphylococcus aureus causes a rapid destruction of joint cartilage and periarticular bone. The mechanisms behind this phenomenon are not fully understood. Toll-like receptors (TLRs) are essential in host defense against pathogens by virtue of their capacity to detect microbes and initiate the immune response. TLR2 is seen as the most important receptor for gram-positive bacteria. TLR2 signaling can lead to the activation of NF-kB through myeloid differentiation factor 88 (MyD88) dependent pathway. The purpose of this study was to examine the catabolic role of TLR2 mediated by the NF-kB pathway in human septic arthritic chondrocytes.

Septic arthritic (SA) chondrocytes (n=7) and fibroblast-like synoviocytes (n=7) infected by gram-positive bacteria, mainly Staphylococcus aureus, as well as chondrocytes from healthy individuals (n=5) were used for this study.

The expression of TLR2 in septic articular cartilage and normal cartilage was analyzed by real time reverse transcription polymerase chain reaction as well western blot analysis. Production of matrix metalloproteinase MMP- 13 and IL-1b was evaluated by enzyme-linked immunosorbent assay. MyD88 protein expression levels and NF-kB activation were evalutated by western blot analysis. Downregulation of TLR2 expression was achieved after transfection with specific siRNA against TLR2 using liposomes.

We observed that TLR2 mRNA and protein expression was significantly up-regulated in septic arthritic cartilage. Also MMP-13 and IL-1b production were significantly increased in septic arthritic chondrocytes compared to normal. Blocking TLR2 in septic chondrocytes resulted in significant reduction of MyD88 and NF-kB protein levels as well as reduction in MMP-13 and IL-1b expression.

It could be suggested that stimulation of TLRs by microbial components may represent the initial signal promoting a pro-inflammatory environment that will enhance degeneration of articular cartilage and the surrounding synovial cells. Targeting NF-kB signalling pathway through TLR2 gene silencing may be of potential therapeutic value in treatment of joint diseases.


J. Sanchez R. Tibau J. Auleda M. Coll

Introduction: Nowadays, the use of antibiotic-impregnated cement in revision total knee arthroplasty procedures is widespread, and a substantial body of evidence demonstrates its efficacy in deep infection prevention

Nevertheless, it is not clear that it is necessary or desirable as a routine means in primary total knee arthroplasty.

Some European studies demonstrate that the use of antibiotic-impregnated cement, shows to be effective in the prevention of early to intermediate deep infection following primary total knee artrhoplasty

Material and Methods: A retrospective review of 642 primary total knee arthroplasties (Legacy-Zimmer) was made between 2003–2006

Two groups were established:

A group of 296 patients with a primary total knee arthroplasty cemented without impregnated antibiotic.

In the second group of 346 patients a primary total knee arthroplasty was performed with the use of gentamycin-impregnated antibiotic in all cases.

The mean follow up was 12 months.

We analyze the differences in the infection rate between the two groups, within the first year of follow-up

Results: No significant differences were found between groups in terms of demographic variables, surgical procedure duration, tourniquet time, postoperative blood transfusion index or medical complications.

10 postoperative deep infections were found in the antibiotic non-impregnated cement group (3.3% of infection)

3 postoperative deep infections were found in the antibiotic-impregnated cement group (0.09% of infection)

A comparative analysis was performed which showed to be statistically significant.

Conclusions: Gentamycin-impregnated cement shows statistically significant effectiveness in the prevention of early to intermediate deep infection following primary total knee artrhoplasty


A. Loro F. Fulvio O. Justin

Aims: to present a new classification of haematogenous chronic osteomyelitis based on the clinical and radiographic presentation so that a reliable post-surgery prognosis can be done.

Methods: between January 2002 and December 2008, 864 children underwent 1632 surgeries for haematogenous osteomyelitis. The clinical and surgical notes were reviewed. Three groups were identified based on clinical and radiographic findings: the first consisting of 565 patients with “ordinary” osteomyelitis requiring treatment of the infection through a sequestrectomy. The second group, classified as “difficult” osteomyelitis, included 134 patients who needed more than one surgery to cure the bone infection. The third group consisted of 165 patients with “complex” osteomyelitis in need of treatment of the infection and its complications, such as pathological fractures, bone loss, and septic arthritis. In the latter group techniques of bone transport, bone graft and radio-ulna/fibula-tibia fusion were used.

Results: all the cases of haematogenous osteomyelitis in our series could be classified in one of the following categories and the prognosis and the length of treatment needed to cure this condition appear to be closely related to these. The first group in the CoRSU classification is “Ordinary Osteomyelitis”. The sequestrum is clearly defined and there is a good involucrum on X-ray film. Surgery under tourniquet is possible. In most cases the surgical treatment achieves the healing of the bone and recurrence is uncommon.

The second group is classified as “Difficul osteomyelitis”. The bone involved presents with multiple erosions-cavities and there is no clear sequestrum on X-ray film. This category also includes those cases where surgery under tourniquet is impossible. Blood for transfusion must be available. Despite treatment, this type of osteomyelitis often recurs and further surgeries are often needed. All the cases of multiple osteomyelitis are included in this group as well. The third category covers “Complex Osteomyelitis”, whereby chronic osteomyelitis is associated with a pathological fracture or septic arthritis. There is axial deformity, bone loss and non-union. Some sort of reconstruction is always required.

Conclusions: Haematogenous chronic osteomyelitis in African children accounts for about 30% of the total number of orthopaedic surgeries performed in our Unit. The classification that is presented here facilitates the planning of the surgery, predicting the prognosis and the length of treatment needed to cure this condition.


F. V. Verhulst J. F. Meis F. H. De Man

Background: Proprionibacterium acnes (P. acnes) is a skin commensal which is often interpreted as a contaminant when found in cultures of surgical specimens. However, recent reports suggest that P. acnes can be identified as the causative micro-organism of infection. Furthermore P. acnes infections occur more often after shoulder surgery than after surgery of the lower extremities or spine. The aim of this study was to identify how frequent P. acnes was responsible for infection after orthopaedic surgery of the shoulder, lower extremity and spine in a single centre.

Patients and Methods: Inclusion criteria were the occurrence of infection after surgery of the shoulder, lower extremity (hip and knee), or spine in a 100-bed orthopaedic hospital. The inclusion period was between January 2000 and May 2008. Infection was defined when two or more cultures were positive with the same microorganism in the presence of clinical signs and symptoms. The first goal was to identify the incidence of infection due to P. acnes amongst all infections. The secondary outcome was the incidence of infection versus contamination amongst all cases with positive cultures for P. acnes. Both outcomes were compared for surgery of the shoulder, lower extremity and spine.

Results: A total of 3703 surgeries of the shoulder were performed, compared to 19906 lower extremity- and 5687 spine surgeries. The incidence of infection after surgery of the shoulder was 1.4% (52 cases; prosthesis [n=23], fractures [n=5], soft tissue surgery [n=16] and others [n=8]). After surgery of the lower extremity and spine this was 2.8% (548 cases) and 3.1% (177 cases), respectively. The incidence of infection due to P. acnes after shoulder surgery (23%) was significantly greater then after surgery of the lower extremity (1.3%; p < 0.001) or spine (0%; p < 0.001). Furthermore, in cases where P. acnes was cultured after surgery of the shoulder it was more often identified as the causative pathogen of infection than when P. acnes was cultured after surgery of the lower extremity or spine (71% vs 22%; p < 0.05 and 71% vs 0%; p < 0.01).

Conclusion: The low virulent P. acnes can cause orthopaedic surgical infections and should not be regarded a priori as a contaminant in cultures. This is especially true for shoulder surgery, where P. acnes infections occur frequently and significantly more often than in surgery of other joints.


C. L. Romano G. Giammona R. Giardino E. Meani

Introduction: Various antibiotic coatings have been proposed to prevent bacteria colonization and infection of orthopaedic implants. While most of the available technologies seem to provide an effective implant protection from infection, unknown long-term effects of antibiotic coatings raise some concerns for extensive application. Aim of the present study was to develop and test a new fast-resorbable antibacterial carrier to be used as a temporary coating to prevent early bacteria colonization of metallic implants.

Methods: The patented tested hydrogel is a co-polimer comprising hyaluronic acid (HA) and a biocompatible polyester (poly-lactic acid) with or without polyethylene glycol chains to further modulate hydrophilicity and anti-fouling characteristics of the compound. The HA derivative is then added to water and mixed, just before its use, with the chosen antibacterial agent. For the purpose of this study, different HA-PLA derivatives have been tested, with two vancomycin and tobramycin concentrations and manually spread to uniformly cover the surface of a titanium specimen. To evaluate the release of vancomycin or tobramycin, high performance chromatographic analysis (HPLC) was carried out.

Results: Antibacterial hydrogels provided vancomycin release ranging from 47 % to 80 % in two hours to 100 % (complete release) in 24 to 72 hours, with antibiotic concentrations up to 400 times the minimum inhibiting concentration. The combined release of the two antibiotics (1 % w/v) showed 26.8 % release of vancomycin and 35.8 % of tobramycin at 2 hours and complete release at 72 hours. Doubling antibiotic concentration (2 % w/v), yielded 56.6 % and 76.6 % antibiotic release, respectively for vancomycin and tobramycin at 2 hours and complete release at 48 hours.

Discussion and Conclusion: HA chemical derivatization with polyesters leads to the formation of copolymers which can be used to produce antibacterial hydrogels with promising applications in the orthopedic field. These antibacterial hydrogels are in fact easily prepared and spread over a surface, showing the ability of releasing high concentrations of antibiotics for a desired, limited, period of time. Adding antibiotics to the hydrogel just before its use, allows customized antibiotic choice and dosing, avoiding shelf-life problems.


T. Lejko-Zupanc J. Meglic-Volkar S. Lotric-Furlan

Aims: The aim of the study was to evaluate the clinical characteristics of patients with infective spondylodiscitis and concomitant endocarditis.

Methods: In the present study clinical features of patients with infective spondylodiscitis and endocarditis were compared to those without endocarditis. Case records of patients with infective spondylodiscitis treated at the Department of Infectious Diseases in Ljubljana in years 1991 to 2007 were reviewed. The following data were recorded: age, sex, underlying disease, previous or concomitant infections, previous operations, clinical features, causative agents, results of x-ray and other diagnostic examinations, complications and outcome of the disease. The Duke criteria were used for the diagnosis of endocarditis. The data were analysed using Epi Info 6 statistical programme. Patients with endocarditis were compared with others using Chi square, t-test and Mann-Whitney test.

Results: During the study period 149 patients with infective spondylodiscitis were diagnosed. There were 92 (61.7%) males and 57 (38.3%) females, aged 13 to 95 years, mean 61.0 ± 14 years. Eleven (7.0%) out of 149 patients with infective spondylodiscitis had concomitant endocarditis, two of them on prosthetic valves. The causative pathogen in patients with endocarditis was Staphylococcus aureus in seven (MRSA in two), mixed infection, Streptococcus viridans, Pseudomonas aeruginosa and coagulase negative staphylococci in one each. Staphylococcus aureus was the most common causative agent of infective spondylodiscitis. Among the three patients with MRSA spondylodiscitis, endocarditis was also present in two. Patients with concomitant endocarditis were similar to those without it but the two groups differed in mortality which was significantly higher in the group of patients with endocarditis (36% vs. 10%.; p < 0.05). In three patients (who died) spondylodiscitis presented at the same time as acute endocarditis and the clinical picture was predominantly that of severe endocarditis. In five patients (one of whom died) spondylodiscitis manifested late in the course of endocarditis and in one patient spondylodiscitis preceded endocarditis. In two patients endocarditis was diagnosed on routine echocardiography performed for staphylococcal sepsis. The urgent valve replacement was performed in two patients but was followed with relapse of endocarditis in one of them.

Conclusions: Although rarely, association of infective spondylodiscitis with endocarditis conveys a poor prognosis especially in the setting of acute staphylococcal endocarditis.


Y. Savitskaya V. Ilizaliturri A. Cicero A. Izaquirre L. Sierra C. Ibarra

Joint prosthesis infection after post-surgical intervention is an emergency. Infection development and progression are inherently dependent on the process of angiogenesis. Many immune disorders are associated with circulating natural antibodies, which bind self-protein as angiogenin (ANG). Biomarkers as anti-ANG IgA show a predisposition for infection development and must be attended by the strategies for therapeutic interventions.

To determine the relationship between the serum levels of anti-ANG IgA and risk of post-surgical joint prosthesis infection (JPI).

We have developed a ELISA, in which ANG coupled to high-molecular weight matrix (polyphenylacrylate) was coated on microtiter plates. Human serum samples were incubated in the plates, after which bound anti-ANG IgA was detected with mouse anti-human IgA-HRP. The optimal sensitivity and specificity of the assay was 91% and 84%. The specificity of ELISA was confirmed by the immunoprecipitation/immunoblotting control experiments. Serum levels of anti-ANG IgA in a cohort of healthy donors differed by more than a hundred-fold, whereas the fluctuation of anti-ANG IgA levels in individuals over time was small (coefficient of variation 6%). The study began in October 2005 and finish December 2008. For first study samples were collected from Department of Hip and Knee Articular Reconstruction. In this period we have operated 1290 patients with joint prostheses implanted. A second study examined specimens collected in Department of Bone Infections from 119 patients with JPI. In both studies, detection of anti-ANG IgA in sera by ELISA. JPI was defined as acute clinical sings of infection during the first 3 months after the placement of the prosthesis. Serum samples were obtained from 500 healthy adults.

IgA antibodies, reacting with ANG tested, were present in the sera of all patients as well as in the sera of normal individuals. Serum levels of anti-ANG IgA are significantly low in 19.1% patients with pre-surgical total joint replacement than in healthy individuals (m±SD: 385±101 versus 121±98; P< 0.001). Very low serum levels of anti-ANG IgA, as occur in primary immunodeficiency syndromes, are associated with significantly increased risk of infections (r=0.85; P< 0.005). Increases in serum anti-ANG IgA to normal/higher levels in patients before surgery associated with good response after gammaglobulin replacement therapy (m±SD: 385±101 versus 587±189; P< 0.001).Risk of JPI was dependently associated with secretory anti-ANG IgA antibody responses. Very low the expression of anti-ANG IgA in sera seem to be potentially useful as angiogenic biomarkers of risk JPI.


M. K. Wasko J. Kowalczewski W. W. Wasko

Background: Several studies have shown that uncomplicated hip or knee arthroplasties induce an abrupt rise in serum C-reactive protein (CRP) concentration for a few days, falling thereafter to preoperative level within a couple of weeks, if no infection is present.

Aim: To evaluate the computer-aided CRP levels analysis in a primary hospital care setting.

Material and Methods: 300 patients undergoing total knee and hip replacements were screened before and for 5 days after arthroplasty. The data were recorded in a database and mathematical algorithm to obtain integral and progressive field surface of the CRP curve.

Results: An elevated C-reactive protein level on the fifth postoperative day correlated positively with the development of acute periprosthetic infection in the first three months postoperatively.

Conclusions: The patient’s individual pattern not following one of the four normal patterns can be argued to necessitate introduction of any infection treatment (whether debridement with retention or antimicrobial therapy alone) within the first three months after the operation.


D. Neut H. N. Rasyid H. C. van der Mei H. W. Frijlink S. Soegijoko J. R. van Horn H. J. Busscher

Background and purpose: Commercial gentamicin-loaded bone cement beads (Septopal®) constitute an effective delivery system for local antibiotic therapy. However, these beads are not commercially available in all parts of the world, and are too expensive for common use in others. Therefore, orthopedic surgeons worldwide make antibiotic-loaded beads themselves. However, these beads are usually not as effective as the commercial beads because of inadequate release kinetics. The aim of this study was to develop a simple, cheap and effective formulation to prepare gentamicin-loaded beads with release properties and antibacterial efficacy similar to the ones of commercially available beads.

Methods: Acrylic beads were first prepared with variable monomer contents: 500 μl/g polymer (100%), 375 μl/g polymer (75%), and 250 μl/g polymer (50%) to increase gentamicin release through the creation of a less dense polymer matrix. After optimal monomer content was defined, different gel-forming polymeric fillers were added to enhance the permeation of fluids into the beads. Polyvinylpyrrolidone (PVP) 17 was selected as a suitable filler, its concentration was varied and the antibiotic release and antibacterial efficacy of the final beads were compared with the ones of Septopal® beads.

Results: Gentamicin release rate and extend of release from beads prepared with 50% monomer increased upon increasing the PVP 17 content in the beads. Beads with 15 w/w% PVP 17 released 87% of their antibiotic content within 336 h. Importantly, this is significantly more than the gentamicin-release from Septopal® beads, that appeared confined to only 59% within 336 h. In addition, acrylic beads with 15 w/w% PVP 17 reduced bacterial growth up to 93%, which is a similar reduction as achieved with Septopal®.

Interpretation: A simple, cheap and effective formulation and preparation process has been described for hand-made gentamicin-releasing acrylic beads, with release kinetics and antibacterial efficacy similar to the ones of commercially available Septopal® beads.


N. Tzanakakis G. Mouzopoulos E. Mataragas Ch. Vassos E. Antonogiannakis

To analyze the relationship between functional outcome and tissue quality after arthroscopic rotator cuff repair.

One hundred and forty-five patients who had undergone arthroscopic repair of rotator cuff tear, during the period of 2003–2008, were evaluated. All operations were performed under the same surgeons. The mean follow-up period was 2.4±1.2 years (range, 0.5 to 5 ys). The patients were devided in two groups:

patients with good tissue quality and

patients with poor tissue quality.

As good tissue quality is defined the tendon with enough mass for suturing (thickness> 3mm) and good elasticity (the footprint is covered properly under tendon traction with tissue grasper). The independent variable studied here was the tissue quality of rotator cuff tendon. Clinical outcomes preoperatively and postoperatively, were assessed with use of ASES, CONSTANT and UCLA scores. Statistical analysis was performed by using STATA 8.0.

Good tissue quality was identified in 119 patients (82%) and poor tissue quality in 26 (18%) patients respectively. At the follow up the patients with good tissue quality achieved Constant score: 86.85±12.49, ASES score: 84±3.4, UCLA score: 28.7±1.9 and the patients with poor tissue quality achieved Constant score: 62.35±13.85, ASES score: 61.49±8.9, UCLA score: 21±3.2. Significant difference between the two groups concerning the clinical outcome was observed after adjusted the data for age. Besides high correlation was noticed between old age and increased rate of poor tissue quality (r=0.88).

Better clinical outcomes are expected in patients associated with good tissue quality, adjusted for age. So the tissue quality is positively correlated with the final functional outcome.


CH. Thanassas I. Paraskeuopoulos G. Papadimitriou Ch. Charambidis A. Papanikolaou

Simple posterior elbow dislocations are often being treated with strict immobilization after reduction. We performed a study in order to investigate if a functional protocol of rehabilitation, allowing early motion, would be more effective.

We prospectively followed twenty five consecutive patients for simple posterior elbow dislocation in a non-randomized study. Patients were divided in two groups. Group A (twelve cases) was treated with immobilization using a cast in 90 degrees of flexion and neutral rotation for three weeks. Group B (thirteen cases) was treated according to a functional rehabilitation program that allowed early controlled mobilization starting on the 2nd post-traumatic day, consisting of immediate flexion from 90° and gradual extension after the 2nd week. Follow-up of the patients was recorded at six weeks and three months. The functional scores used were Mayo Clinic Performance Index, Liverpool Elbow score and Broberg and Morey.

None of the patients had an incident of redislocation. Patients of group B had statistically significant better (p< 0.05) functional scores at six weeks and better no statistically significant in three months: group B/group A: Mayo: 91.6/65.5, Liverpool: 8.8/6.1, Broberg and Morey: 89.1/73.3.

It seems that a functional rehabilitation program gives the same result in terms of stability offering at the same time patients a better range of motion and functional score at least at six weeks and three months.


G.I. Mitsionis G.N. Manoudis N.K. Paschos M.G. Lykissas A.V. Korompilias A.E. Beris

The purpose of this study is to evaluate the long-term results of the surgical treatment of cubital tunnel syndrome by comparing the in-situ decompression and release of the ulnar nerve with or without partial medial epicondylectomy and the anterior transposition and release respectively.

Material and Method: From 1991 since 2008, 119 patients, (81 men and 38 women) with an average age of 51(13–72 years) years were treated surgically for ulnar nerve compression at the elbow. The average duration of symptoms before surgery was 15 months (2–48 months). Preoperatively 2 patients were grade I, 52 patients were grade IIA, 31 patients were IIB and 34 were grade III according to the modified McGowan score. We performed in-situ decompression of the ulnar nerve in 35 patients, release with partial medial epicon-dylectomy in 44 patients and release with anterior transposition of the nerve in 40 patients.

17 patients were lost to follow-up. 108 patients were clinically assessed. Comparing the results among different surgical procedures, an improvement of at least one McGowan grade was obtained in 26 of 30 patients treated with simple decompression, in 29 of 35 patients treated with release and anterior transposition of the nerve and in 38 of 43 patients treated with release and medial epicondylectomy.

The results of this study show that the possibility for complete recovery is inversely related to the initial neuropathy grade. Partial medial epicondylectomy is a valuable surgical procedure for treating grade I to IIB ulnar neuropathy because is an anatomic method with minimal nerve manipulation preserving regional blood supply.


N. Tzanakakis G. Mouzopoulos E. Mataragas Ch. Yiannakopoulos E. Antonogiannakis

One hundred and twenty-four patients who had undergone arthroscopic repair of rotator cuff tear, during the period of 2006–2008, were evaluated. All operations were performed under the same surgeons. The mean follow-up period was 1.1±0.4 years (range, 0.5 to 2 ys). The patients were devided in three groups:

patients underwent complete repair (n=104),

patients underwent incomplete repair (n=8) and

patients underwent medialized technique repair (n=12).

Clinical outcomes preoperatively and postoperatively, were assessed with use of ASES, CONSTANT and UCLA scores. Statistical analysis was performed by using STATA 8.0.

Postoperative functional scores were better than preoperative ones, in all patients (p< 0.05).The patients underwent complete repair achieved preoperatively Constant score: 58.15±3.26, ASES score: 55±3.6, UCLA score: 22.3±1.2 and postoperatively Constant score: 92.65±4.15, ASES score: 92±2.4, UCLA score: 32.1±1.3. The patients underwent incomplete repair achieved preoperatively Constant score: 46.18±3.12, ASES score: 44.2±3.4, UCLA score: 18.1±3.3 and postoperatively Constant score: 76.35±4.22, ASES score: 72±5.4, UCLA score: 24.1±2.3. The patients underwent medialized technique repair achieved preoperatively Constant score: 52.3±1.12, ASES score: 51.9±2.4, UCLA score: 20.4±1.3. and postoperatively Constant score: 86.15±2.22, ASES score: 85.4±4.4, UCLA score: 28.24±2.3. Significant difference was observed between (a) and (b) groups (p< 0.05, CI1: 0.83–0.97, CI2: 0.86–0.95, CI3: 0.81–0.97).

Functionality improvement after arthroscopic repair of rotator cuff tear, with complete, incomplete or medialized repair either, is evidence.


N. Tzanakakis E. Mataragas G. Mouzopoulos C.K. Yiannakopoulos E. Antonogiannakis

To evaluate the incidence of early complications and operative events during shoulder arthroscopy.

A prospective study of 134 consecutive shoulder arthroscopies, performed using lateral decubitus position, by the same team, with 6 months minimum follow up. During 11 months period we performed 80 shoulder arthroscopies in male and 54 in female patients with mean age 48.6 years (15–82 years). Shoulder pathology that we treated was: 74 rotator cuff repair, 37 shoulder instability, 11 frozen shoulder, 9 calcifying tendonitis, 2 SLAP lesion and 1 debridement. We have well-placed 476 anchors and 63 side to side sutures.

We experience 4 early complications in total (2.98%): 1 anterior interosseous nerve paresis, that fully recovered 6 weeks post op, 1 motor and sensor ulnar nerve paresis that has not fully recovered 4 months post op, 1 sensor ulnar nerve paresis that has not fully recovered 5 months post op and 1 septic shoulder arthritis that was treated with arthroscopic lavage and intravenous antibiotics and has not shown recurrence 11 months post op.

Operative events: 5 (1.05%) anchor slippage, 3 (0.63%) anchor breakage, 5 (0.53%) suture slippage from anchors, 5 (3.73%) instrument breakage, 5 (0.53%) knot loosening or suture breakage.

Shoulder arthroscopy is a quite safe but technically demanding operation. Early complications occur in low rate, but due to technical difficulties operative events occur more frequently, without affecting the final outcome of the operation. Although axillary nerve is believed to be prone to injury during shoulder arthroscopy, in this series other neurological lesion occurred more frequently.


A.E. Beris M.G. Lykissas I. Kostas T. Vasilakakos M.D. Vekris A.V. Korompilias

We present a case of a 19-year-old white female patient with neurofibromatosis type I who, 10 years ago, underwent free vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius.

An external fixator was applied for gradual distraction and correction of the deformity of the pseudarthrosic site for five weeks. Wide resection of pseudarthrosis with surrounding fibrotic and thick scar tissue and bridging of the gap with a free vascularized fibular graft followed. Four months postoperatively, union was established in both graft ends. At the last follow-up, 10 years postoperatively, the patient has excellent function with full wrist flexion-extension and forearm pronation-supination.

Free vascularized fibula transfer is considered the treatment of choice for congenital radial pseudarthrosis. It allows complete excision of the pathologic tissue and covering of the gap in one operation. Due to the vascularity of the free vascularized fibular graft both sides of fibula unite easily with no additional intervention.


K. Makridis M. Georgoussis V. Mandalos N. Daniilidis S. Kourkoubellas L. Badras

Fractures of metacarpals and phalanges are common in hand injuries. The goal of treatment is the immediate mobilization of the fingers and restoration of the hand anatomy thus avoiding contractures of the metacarpo-phalangeal and phalangophalangeal joints and hand dysfunction. The aim of this study is the comparison between two methods of fixation of these fractures.

Between 2000–2007, 74 patients who suffered meta-carpophalangeal fractures were treated by K-wires and 62 patients were treated by mini external fixation. Parameters recorded were the operating time, postoperative range of motion, cost and complications. The surgical time was lesser with the use of K-wires, the operative technique much simple and the cost minimum as compared to mini external fixators. The postoperative range of motion was inferior with the external fixation. However, there was no statistical difference between the two groups. 2 patients with the external fixation and 1 patient with K-wires developed pin-track infection. There were 3 failures of fixation in the external fixator group but no failure occurred with the use of K-wires. The majority of the fractures healed within 6 weeks.

K-wires seem to be the ideal method of treatment considering the fractures of metacarpals and phalanges. The use of mini external fixation presents many disadvantages and probably is restricted to the treatment of the open and comminuted hand fractures.


F. Sayegh E. Kenanidis M. Potoupnis K. Papavasiliou St. Pellios G. Kapetanos

Aim of this prospective, randomized study is to introduce and compare a new technique of reduction of the anterior dislocation of the shoulder with the “Hippocrates” and “Kocher” methods, as far as its efficacy, safety and intensity of the pain felt by the patient during the reduction, are concerned. This is the first reported prospective, randomized comparative study of three reduction techniques of anterior dislocations of the shoulder.

154 patients suffering from acute anterior shoulder dislocation participated in the study. Patients were randomly assigned to one of the three study groups (New, “Hippocrates” and “Kocher”) and underwent reduction of their dislocation performed by residents orthopaedic surgeons.

The groups were statistically comparable (age, male/ female ratio, mechanism of dislocation, mean time interval between injury and first attempt of reduction).

Reduction was achieved with the “Fares” method in 88.6%, with the “Hippocrates” in 72.5% and with the “Kocher” in 68% of the patients. This difference was statistically significant, favoring the new method (p=0.033). The mean duration of the reduction (p=0.000) and the mean reported by the patients VAS with the new method (p=0.000) were also statistically significantly lower than those of the other methods. No complications were noted in any group.

The new method seems to be more effective, faster and less painful method of reduction of the anterior shoulder dislocation, when compared with the “Hippocrates” and the “Kocher” methods. It is easily performed by only one physician and it is not more morbid that the other two methods.


I. Ignatiadis D. Arapoglou E. Pateromihelakis P. Psyllakis N. Hatzinikolaou E. Pananis N. Gerostathopoulos

To show the role and effectiveness of semi-constrained total elbow arthroplasty in restoring elbow function in severe, irreversible post-traumatic osseous and chondral injuries.

Eighteen patients, aged 19–80, 11 male and 7 female, suffering from serious, irreversible anatomical and functional lesions of the elbow joint due to previous severe untreated or inadequately treated fractures (T-type transcondylar, trochlear-condylar, open fxs with large bony defects, severe osteochondral, heterotopic ossification in ICU fracture patients). Postop follow up was 9–57 months.

All patients were treated with modular, cemented, semi-constrained linked total elbow arthroplasty. A functional brace was used post-operatively, and motion was permitted on the 3rd post-op day. The patients were allowed a full range of motion at 1 week post-op and they were subjected to vigorous physiotherapy.

Post-op results were evaluated by using Mayo, DASH, quick-DASH scores and measuring grip strength and range of motion. Our results ranged from satisfactory to excellent in 16 patiens, with good strength and wide motion arc (with up to 15o extension-flexion deficit). One old female patient suffered a severe cerebral stroke with a bad outcome. In another young male patient the motion arc reached only 40% of the normal (spasticity, ICU patient with brain injury).

Semi-constrained linked total elbow arthroplasty proves to be an effective method of treatment in severe, irreversible, intraarticular post-traumatic elbow injuries with chondral destruction and grave functional deficit, provided the proper technique is employed and a vigorous rehabilitation program is followed.


F.N. Xypnitos E. Kolliakou D. T. Venetsanos C. G. Provatidis N. E. Efstathopoulos

The aim of the study was to investigate, firstly, the force distribution between scaphoid/radius and lunate/radius in the normal wrist and in the presence of a scaphoid fracture, secondly, how stresses and strains at the fractured area change during the healing process and thirdly, how the direction of the applied forces affects load transmission.

A 3D finite element model of the normal wrist was initially developed. Two typical scaphoid fractures B2 and B3 according to Herbert’s classification, were investigated. The fractured areas were modeled with a range of modulus of elasticity to resemble the various stages of the healing process. Furthermore, three different directions of the externally applied loads were examined.

The applied compressive vertical load in the normal joint was transmitted to the radius through the radioscaphoid and the radiolunate articular surfaces at a ratio equal to 56:46 respectively. The ratio was equal to 54:48 and 53:49 for the B2 and the B3 fracture respectively. The load direction resembling an ulnary deviated wrist caused the appearance of a significantly higher strain field at the fractured area. The maximum developed stresses at the fractured area for scaphoid fracture B2 were approximately 37%–58% higher than those of B3, for all three loading directions.

Based on our results, the onset of osteoarthritic changes in a wrist with a scaphoid fracture is due to carpal collapse and scaphoid deformity. The recorded maximum developed strains for both B2 and B3 scaphoid fractures suggested intense bone remodeling activity. Among the examined three different load directions, the one simulating an ulnary deviated wrist corresponded to the most severe effects.


G.I. Mitsionis A.V. Korompilias M.G. Lykissas D. Nousias G. Mataliotakis A.E. Beris

The objective of this study was to evaluate the functional outcome of the elbow joint in patients with heterotopic ossification of the elbow joint who underwent surgical excision of pathologic bone.

From 5/1994 to 12/2006, 24 patients (33 joints) with heterotopic ossification of the elbow joint were evaluated. All patients were attended in the Intensive Care Unit (ICU). The patient\’s age ranged from 19–48 years (mean; 32 years) The median ICU hospitalization was 3 weeks. In nine patients both elbows were affected. Unilateral involvement was equally noticed to the right (seven cases) and the left elbow (eight cases). The DASH SCORE and the range of motion were used for the evaluation of the results. All patients underwent surgical treatment in order to extract heterotopic bone and to improve the range of motion of the affected elbow joint.

Postoperatively 18 out of 33 operated elbow joints (54.54%) demonstrated improvement of the range of motion, whereas no improvement was observed in the remaining 15 elbow joints (45.45%). Higher DASH SCORE was obtained in 19 out of 24 patients (79.17%). Surgical excision of the ectopic bone around the affected elbow significantly improves the range of motion of the joint providing better use of the upper extremity and therefore a superior quality of life in these patients.


A. Fasoulas A. Baikousis N. Markantonis Ch. Petrou

To assess the outcome of Wilson’s osteotomy of the first metatarsal to correct Hallux Valgus.

Two hundred and forty feet in 172 patients who had surgery for pain were reviewed clinically and radiologically. Age ranged from 28 to 82 years (mean 55 years) and duration of follow-up ranged from 2 to 15 years (mean 6 years). A mini external fixation was used to stabilize the osteotomy.

The average AOFAS score improved from 51.6 to 89.5 points at the last follow-up. In 96% of the cases, the final outcome was satisfactory as far symptomatic improvement was concerned. A 4% only was dissatisfied with the outcome of the surgery due to metatar-salgia, restricted first metatarsophalangeal joint motion or lack of correction. There were no cases of avascular necrosis of the metatarsal head. We had five cases of delayed union but they didn’t need further surgery.

The average preoperative HVA and IMA were 34.80 (range: 180–540) and 15.10 (range: 100–290), while the average postoperative HVA and IMA were 16.10 (range: 70–280) and 7.20 (range: 30–90) respectively.

Wilson’s osteotomy as a method of treatment of Hallux Valgus is technically straightforward, effective and with a predictable outcome. We believe that the external fixation offered increased stability at the osteotomy site and could be the reason why patients had a very low incidence of postoperative metatarsalgia and returned to their normal activities faster, thus giving a higher satisfaction rate.


A. Papapanos C. Rossas V. Dalagiannis L. Tsiopos I. Alexopoulos N. Roussis

To analyze the results in proportion to the type of talar fracture.

Eighteeen talar fractures(8 of the body and 20 of the neck)in 28 patients(24 men and 4 women, between 22 and 60 years, of average age 42 years) were treated in our department in the period 1981–2007. 24 fractures were closed and 4 were open (2 B and 2 C1 grade). The Hawkins classification for the fractures of the neck is: 10 type I, 6 type II, 4 type III. The fractures of the body were: 1 type A, 4 type B, 3 type E. The most common mechanism of injury was fall from a height in 16 cases and car accidents in 12 cases. 18 patients had associated injuries. The fractures managed within 6 hours. Time of follow up ranged between 2 and 9 years.

All type I fractures of neck were treated conservatively with excellent results (Hawkins score). All type II were operated and healed with results ranging from very good ones to medium ones. From type III, one had a very good result, one medium and 2 manifested osteonecrosis. From the fractures of the body all (except three: 1 type A, 1 type B and 1 type E) manifested osteonecrosis. The time of union ranged between 2,5 and 4,5 months. There was no deep infection and 9 complications were observed.

Our results agree with those of international bibliography for these rare fractures. The fractures of the body and the type III of the neck have the worst prognosis.


I. Flieger O. Leonidou N. Pettas A. Apostolopoulos K. Antonis N. Baxevanos

Grice-Green subtalar arthrodesis was initially reported to correct valgus hindfoot deformities in patients with poliomyelitis. Nowadays, the indications of the Grice-Green arthrodesis have been significally broadened. The aim of this study is to analyse the indications of treatment and evaluate the results of the Grice-Green arthrodesis in children.

During the period 1986–2006, 17 children with valgus hindfoot deformities were treated in our department. In 12 of them the procedure was performed in both feet and in the rest (5 patients) unilaterally. The mean age at operation was 8.8 years. The most common group of patients suffered from cerebral palsy (10 patients), followed by the patients suffering from myelomeningocele (4 patients), 2 patients suffered from overcorrection following treatment of congenital equinovarus and one patient from Charcot Marie Tooth disease. In neine patients the operation was combined with Achilles tendon lengthening, capsulotomies, tendon transfers, tendonotomies, and Evans arthrodesis. In all operations bone graft from the tibia or the fibula was used. Postoperatively a balow knee non weightbearing cast was applied for 8 weeks followed by a weightbearing cast for 4 weeks. The results were avaluated according to Alman and Zimbies criteria. The mean follow up of the patients was 4.2 years. The results in 24 feet were considered excellent and in 5 cases satisfactory. In all cases subtalar arthrodesis was achieved.

Grice-Green arthrodesis is a very useful operative technique for the correction of severe valgus hindfoot deformities in children. The results of the technique are usually good and the operation does not influence the normal growth of the foot. An accurate preoperative planning and a good surgical technique is neccesary for good results.


N. Vlachos-Zounelis G. Malakasiotis E. Sarras E. Christodoulou P. Theodorakopoulos P. Baltopoulos

Pilon fractures present a unique challenge to the patient and orthopaedic surgeon. Care for the soft tissue envelope is as important as management of this articular fracture. Assessment of the degree of energy causing the fracture and careful planning of the joint reconstruction will lead to acceptable results in most cases.

Forty-five patients (AO-ASIF classification) treated between 2003 and 2008 were examined clinically and radiologically at an average of 24 months after injury. The patients were treated in three different ways: primary internal fixation with a plate following, which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least eight weeks and hybrid external fixation. Objective evaluation criteria were infection rate, pseudarthrosis, amount of posttraumatic arthritis, range of ankle movement.

In 65% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication.

The complication rate depends mainly on the type of fracture, the soft tissue damage and the type of treatment. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the hybrid external fixation. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires


M. Vlagkopoulos N. Markopoulos M. Avramidis Ch. Lyrtzis . Aleksiadis Ch. Kristallis

Is to present our clinical experience in how we evaluate ankle fractures as unstable and the use of syndesmosis screw in their treatment.

Since 2004–2008, 85 ankle fractures treated surgically. Of them 31 were evaluated as unstable according to:

preoperative x-rays findings

intraoperative tests, and syndesmosis screw was used.

We used AO-Weber classification: 14 cases type B(7 cases of B2 and 7B3), 16 cases type C(4 cases of C1 and 12 C2). Twenty-one of them were females and 10 were males. Their age rage was from 17–61 years old (Mean 42,5).The follow-up was from 6 months to 4 years(Mean 2,5 years). Syndesmosis screw was removed afters six weeks. Postoperative results were evaluated according the scoring system of Olerud and Malander. Postoperative there were 2 ankle O.A.(6,45%) due to false surgical technique. They treated by arthrodesis.

The proper evaluation of the first x-ray findings of the fracture is of great importance for the proper treatmet. The syndesmosis screw is obligatory in unstable ankle fractures, in which, in combination with proper osteosynthesis preserves the ankle’s stability and viability. Ligament and bone lesions are responsible for ankle stability


P. G. Tsailas J. D. Wiedel

There have only been a few studies in the literature which reported on the outcome of ankle arthrodesis in patients with hemophilia, furthermore the number of patients is usually low and the operative technique is not uniform. The aim of this study is to evaluate the outcome of surgery in hemophilic arthropathy of the hindfoot, using internal fixation.

From 1983 to 2006, 20 fusions were performed in 13 consecutive patients due to advanced hemophilic arthropathy of the hindfoot. There were 11 ankle fusions, 1 isolated subtalar fusion and 8 ankle and subtalar fusions, 3 of the latter on a second operation. The mean age at operation was 38.7 years and the mean followup was 9.4 years. Preoperativelly the mean modified Mazur score was 47.7. In the majority of cases the ankle fusion was achieved by two crossing screws, while, for the subtalar fusion either staples were used, or the tibiotalar screws were extended to the os calsis.

Arthrodesis of the ankle was successful in all but one patient, who was revised and progressed to fusion. The mean postoperative modified Mazur score was 94.9. There was also one painless incomplete union of the subtalar joint which did not need revision. There was no recurrent bleeding, and no deep infection.

Arthrodesis with cross screw fixation and staples is a quick, simple and effective method for fusion of the hindfoot in patients with hemophilia.


A. Badekas S. Papadakis S. Galanakos K. Panagi G. Tsakotos T. Anastasopoulos

This study concerns an epidemiological analysis of foot and ankle injuries during the Athens Olympic Games 2004.

An epidemiological survey was used to analyse injuries in all sport tournaments over the period of the Games. During the Athens Olympic Games 2004 in the period from August 1st to September 1st, 624 patients presented to the Foot and Ankle Department for treatment. The mean age of athletes was 24 years (range 21 to 32). Among the patients there were more males, 358 (58%) than females, 266 (42%).

In 525 (84.1%) patients there was only a soft tissue injury and in 99 (15.9%) patients there was bone involvement. Regarding specific diagnoses, tendinitis was the most common reason for a visit, followed by ankle sprains, nail infections/injuries, lesser toes sprains, and stress fractures. Sixty-nine (11%) required emergency transfer to the hospital.

Our experience from the Athens Olympic Games will inform the development of public health surveillance systems for future Olympic Games, as well as other similar mass events.


A. Karagiannis I. Tsolos E. Tyrpenou

The assessment of the long –term outcome (5 years) of patients treated with arthroscopic stabilization for acute traumatic patellar dislocation.

From September 2004 until April 2009 we treated 29 patients (25 male, 4 female) with a median age of 18 years (range 14–23 years), two of them had suffered from traumatic dislocation of the patella of the other knee joint in the past. The median range from injury to our surgical intervention was 20 days (7–29 days). The return in sporting activities, the possible redislocation or joint instability and the subjective assessment of the symptoms of the patients, were evaluated in a 5 years follow-up. After 5 years, 23 patients (20 males, 3 females), were re-evaluated.

After the arthroscopic medial retinacular repair all the patients return to sporting activities. All the patients presented chondral lesions at the medial facet of the patella and to the lateral femoral condyle and hemarthrosis too. The functional outcomes were evaluated with Kujala scoring scale, with Visual analog scale and Tenger scale the range of results was good.

The acute arthroscopic repair of the medial retinacular ligaments, protects the patient from redislocation or subluxation, allows the evaluation and stabilisation of the chondral lesions, the removal of free chondral bodies, as well as the evaluation of the possible damage to the menisci or ACL, PCL ligaments.

All the patients returned to normal sporting activity avoiding further injury, or the development of osteoarthritis of the knee joint


D.D. Nikolopoulos A. Apostolopoulos A. Nakos S.N. Vasilas S. Drabalos N. Barbounakis J.B. Michos

To compare the early functional and clinical results, between single (SB) and double-bundle (DB) of Anterior Cruciate Ligament (ACL) reconstruction with hamstrings (HS).

Thirty-six patients from 17 to 36 years old (average age 23), 22 ♂ and 14 ♀, from January 2006 to May 2008, were randomly allocated for ACL reconstruction with HS (SB – DB). Eighteen patients underwent a 4-stranded SB reconstruction (group A) and the remaining 18 underwent an anatomic, 2-stranded DB ACL reconstruction with 2 tibial and 2 femoral tunnel technique (group B), by using the Smith & Nephew instrumentation system. The follow-up was from 8 to 22 months (average 16 months) for both groups and included clinical evaluation (pivot-shift test, anterior laxity test with KT-1000 arthrometer and Lysholm knee score) and radiographs.

There were no statistically significant difference in the results between the 2 groups with regard to the pivot-shift test and the Lysholm score (SB: mean 91, DB: mean 89) (Mann-Whitney test, T-test). The anterior laxity was not significantly different between group A (mean, 2.2mm) and group B (mean, 0.9mm), according to KT-1000 measurements. Rotational stability, as evaluated by pivot-shift test, was better in group B than in group A, but statistical analysis showed no significant difference. The average operation time was longer in DB (110 min) compared to SB (80 min). There were no infections, though one patient of each group was found to be complicated with fixed flexion and extension lag > 5°; and underwent arthroscopic lysis.

Our study shows no statistically significant advantage of DB versus SB ACL reconstruction, concerning the clinical evaluations and the complications


G. Stamatopoulos N. Zacharakis V. Zois A. Maris A. Papailiou A. Asimakopoulos

The purpose of this retrospective study was to report the results using scarf, first metatarsal osteotomies, in correcting Hallux Valgus deformity with H-V angle > 35°.

During the period 2003–2008 we did 23 scarf, first metatarsal osteotomies in 15 patients (8 bilateral).In order to evaluate the effectiveness of this operation, patients were clinically (aofas score) and radiologically (X –ray in 4, 8, 12 weeks) assessed.

Mean follow up was 32 months. The results evaluated with the aofas score in order to study the function, the pain and the overall satisfaction of the patients. We had excellent results in 13 %, very good in 48 % good 32% and poor 7 %.There was only one complication and no one infection.

According the above results it seems that scarf osteotomy is quite reliable surgical treatment of severe Hallux – Valgus deformity with an increased IM angle.


Apostolopoulos A. Karagiannis I. Tsolos I. Staikidou G. Giannikouris I. Vrionis N. Panigirakis A. Andreakos

The assessment of graft stability in ACL reconstruction with two different techniques (endobutton vs. crosspin) and the comparative evaluation of the results of the two techniques.

From October 2005 until May 2009, 69 patients underwent ACL reconstruction with the above-mentioned techniques by two surgeons; follow-up examinations took place after a minimum of two (2) years. Postoperative radiographic and clinical assessment were carried out and Lysholm, Tenger and IKDC scores were obtained at 3, 6, 12 and 24 months; stability was checked by KT-1000 arthrometer. Clinical evaluation by Lachman and pivot shift was normal or near-normal in 65 patients. No significant differences were found both as regards the KT-1000 (1.0 mm less with the cross-pin technique) and as regards the subjective variables (the endobutton having a slight advantage). Mean postoperative IKDC evaluation was 87.4 vs. 85.3, while Lysholm was 89 vs. 86. Two patients underwent revision after a new traumatic incidence and one displayed a new meniscal lesion, which was treated accordingly. The vast majority of the patients returned to their previous occupational activities and social life (overall patient satisfaction was at 88.2 vs. 85.4).

Both the endobutton and the crosspin techniques proved to be reliable fixation methods for the treatment of ACL ruptures using the hamstrigs tendons; both methods provided safe fixation even in cases when back wall blow had occurred


V. N. Psychoyios P. Intzirtzis S. Thoma K. Dakis A. Alexandris

Forefoot involvement in rheumatoid arthritis (RA) is extremely common and the majority of the patients with RA have active foot symptoms and signs of the disease. This rertospective study was undertaken to assess the outcomes and complications in the surgery of the forefoot RA.

Seventeen patients (27 feet) with RA underwent surgical correction for the forefoot deformities. Antero-posterior and lateral weight bearing radiographs of all feet were taken preoperatively. The forefoot deformities seen with RA varied and included hallux valgus with subluxed metatarsophalangeal (MTP) joint in 23 feet, hallux valgus with dislocation of the MTP in 4, hammer or claw toes in 12 and 8 feet respectively. In addition, all 27 feet presented with variable levels of intermetatarsal deviations or widening. All the patients with hallux valgus underwent first MTP joint arthrodesis with various techniques. Deformities of the lesser toes were treated in all but 3 cases with resection arthroplasty, while the remaining 3 feet received a Weil osteotomy. Postoperatively the toes and the MTP joints were stabilised with K-wires for 6–8 weeks.

All patients have been studied for a minimum follow up of 9 months. Twenty six patients were satisfied by the outcome of the surgical treatment. Only one patient complained of persistent metatarsalgia postoperatively. The surgical complications included 2 cases of delayed union, 5 cases of delayed wound healing, 2 cases of wound infection, and 4 cases of plantar callosity. Overall, 4 patients required reoperation.

Even though complications occur in patients with RA who undergo surgical correction of the forefoot deformities, most of these complications can be treated successfully. Thus, the overall outcome of the surgical treatment is good leading to satisfactory correction of the forefoot deformities and to pain elimination


D. Alexakis A. Siderakis A. Tragkas P. Katsakou G. Dendrinos C. Skordis

We describe the treatment of traumatic anterior shoulder instability complicated with Hill-Sachs lesion, using a combined arthroscopic technique of anterior & posterior capsular fixation and infraspinatus tenodesis by means of suture-anchors, in order to fill the humeral head bone defect (i.e. “remplissage”).

We use 2 posterior portals introducing the arthro-scope through the upper one. A double-armed suture-anchor is inserted through each portal piercing the infranspinatous tendon & posterior capsule in an extra-articular mattress mode. The humeral head bone defect is filled with the aforementioned tissues.

18 patients with well established anterior instability were subject to this technique between March 2005 and December 2008. The follow-up time was 6 to 36 months (average 18 months). All were evaluated using the Rowe protocol for shoulder instability which assess stability, ROM & shoulder functionality.

In 13 patients the outcome was assessed as excellent, in 4 good & in 1 average. In one patient, post-op stiffness was developed which managed successfully with conservative means.

The arthroscopic technique of “remplissage” is an innovative choice in the armamentarium of treatment of anterior traumatic instability with concomitant Hill-Sachs lesion. The results of this technique are excellent regarding the recurrence rate of anterior instabiliy (in our series there was none episode of recurrent instability during the study period).


H.S. Vasiliadis Mats Brittberg A. Lindahl Lars Peterson

Since 1987, autologous chondrocyte implantation (ACI) has been performed in Gothenburg, Sweden in more than 1600 patients. Out of the first 442 patients operated with ACI, 153 (35%) had patella lesions and 91 (21%) had trochlea lesions. Forty two patients (9.5%) had kissing lesions of the patellofemoral joint.

The aim of the study was to evaluate the current clinical status of operated patients. Lysholm and Tegner-Wallgren self-assessment questionnaires were used. The patients were requested to compare their current status to previous states and to report whether they would do the operation again. Concomitant realignment procedures of the patellofemoral joint were also recorded and preoperative scores were also assessed from the medical files.

Patients were divided into groups according to the location of lesion. All the groups showed a significant improvement compared with the preoperative assessment. Over 90% of the treated patients were satisfied with the ACI and would have undergone the procedure again.

It seems that correcting the coexisting background factors with realignment, stabilizing or unloading procedures is improving the results over time. Despite the initial controversy about the results and indication for ACI in patellofemoral lesions, it is clear that ACI provides a satisfactory result even for the difficult cases with concomitant patellar instability. Our study reveals preservation of the good results and of high level of patients’ activities, even 10 to 20 years after the implantation.


G. Basdekis P. Christel Claude Abisafi

The purpose of this study is to determine the influence of knee flexion angle for drilling the posterolateral (PL) femoral tunnel during double-bundle anterior cruciate ligament (ACL) reconstruction via the anteromedial (AM) portal on resulting tunnel orientation and length. Methods: In nine fresh cadaveric knees, the ACL was excised and 2.4 mm guide wires were drilled through the PL bundle footprint via an AM portal. We compared knee flexion angles of 90, 110, 130 degrees. AP-, lateral- and tunnel view radiographs were measured to determine tunnel orientation, o’clock position, and direct measurement to determine intra-osseous tunnel length

On AP view, increased flexion resulted in more horizontal tunnels. The angles were 31.9 ± 7.1°, 26.4 ± 8.9° and 23.0 ± 8.1° for 90°, 110° and 130°. The pin orientation was significantly different when comparing 90° and 130°. On lateral view, increased flexion resulted in more horizontal tunnels. The angles were 68.9 ± 19.9°, 50.4 ± 11.6°, 31.3 ± 12.3° for 90°, 110° and 130°. On tunnel view, pin orientation was 22 ± 8.2°, 28.3 ± 6.7° and 35.9 ± 6.2° for 90°, 110° and 130°. Mean o’clock position was 09:00 ± 0:12. Intra-osseous length of the pins did not significantly change with knee flexion. The exit of the pins on the lateral femur with regard to femoral attachment of the LCL was proximal. The distance was 0.1 ± 6.6 mm, 6.4 ± 6.4 mm and 9.2 ± 2.4 mm for 90°, 110° and 130°. This was significant when comparing 90° and 130°. The shortest distance between the exit and the posterior femoral cortex was 4.0 ± 1.8 mm, 9.7 ± 3.5 mm, and 13.2 ± 2.8 mm for 90°, 110° and 130°. All values were significant. Conclusion: At 110°, exit of the PL pin is close to the attachment of the LCL. 90° flexion risks damage to the LCL and posterior cortex blow-out. Thus we recommend drilling the PL tunnel at 130° of knee flexion


R. Villar A. Tzaveas

Acetabular chondral delamination is a frequent finding at hip arthroscopy. The cartilage is macroscopically normal but disrupted from the subchondral bone. Excision of chondral flaps is the usual procedure for this type of lesion. However, we report 19 consecutive patients in whom the delaminated chondral flap was re-attached to the underlying subchondral bone with fibrin adhesive. We used the modified Harris hip score for assessment of pain and function.

Improvement in pain and function was found to be statistically significant six months and one year after surgery. No local or general complications were noted. Three patients underwent further surgery for unrelated reasons. In each, the area of fibrin repair appeared intact and secure.

Our results suggest that fibrin is a safe agent to use for acetabular chondral delamination.


I. Tsolos A. Karagiannis E. Tyrpenou

The assessment of the arthroscopic findings in patients suffering from impingement syndrome and partial tear of the supraspinatus tendon, staged as type 1& 2 under Ellman, Gartsman, Snyder, that were treated by acromioplasty, debridment and repair of the supraspinatus tear.

Thirty four patients,(20 male, 14 female), with a median age of 52 years, (48–64 years old), underwent shoulder joint arthroscopy. All were evaluated by two physicians and subjected to plain films (AP& Y views) as well as to MRI.

Clinically, the differencies in the evaluation of patients with type 1& 2a lesion were insignificant. Type 2b had a better outcome, but in comparison to type 1, that were subjected only to acromioplasty, variations involving range of motion, pain and scoring (Constant & Oxford scores), were observed, from the first stages of rehabilitation, with no further improvement. The comparative method in relation to the clinical trials was in favor of those patients treated with repair of the tear.

After a 29 m follow up, we suggest only acromioplasty, in stages 1& 2a, although the daily activities of each patient can change the approach. In type 2b lesions, irrespective of age, we suggest the repair of the tear


S. Alevrogiannis G.A. Skarpas A. Triantafyllopoulos A. Karavasili P. Lygdas

To present our preliminary results in fully arthroscopically performed 3-dimensional autologous cartilage transplantation (ACT-3D) for medium to large focal chondral defects at the knee.

We treated operatively in our Dept., 35 symptomatic patients between March 2007 and May 2008. The mean age was 32 years old. The mean area of cartilage defect was 6.75cm2 (2.2–10cm2) and all the cases were classified as grade III(16) and IV(18) according to Out-erbrigde scale. 18 of the cartilage lesions were located in the weight-bearing surface of the medial femoral condyle, 8 in the lateral one, 6 in the trochlea area and 2 in the lateral facet of the patella. We performed 15 applications of ACT3D as single procedure. Apart from that, we performed 11 ACL reconstructions combined with the 3D-spheres. Preop. and postoperative evaluation of patients was done using the Modified Cincinatti (MC) Rating System(0–100), the VAS (visual analogue pain score) (0–10), IKDC Knee examination score and Patient Outcome Function score.

All the cases were performed uneventfully. No major complications were seen. All cases followed a specialized rehabilitation protocol. In MC Rating System the result rose from 41.5 to 72.5 and in VAS, pain significantly reduced from 6.1 to 1.8 in 12 months time. The Patient Outcome Function score showed 81% better, 18% same and 1% worse results. The follow-up using MRI showed adequate filling of the defect without significant bone swelling.

Arthroscopically performed chondrocyte implantation (ACT) is an innovative technique with early results very promising. It’s surgeon demanding, although it’s fast performed technique and well tolerated operation. A greater number of cases and further mid and long term follow-up has to be studied in order to prove the efficacy of the method.


S. Theocharakis V. Goulidakis N. Manetakis E. Dracoulakis G. Adamopoulos

The goal of this study is to analyze the surgical management of proximal humerus fractures in medial age patients (50–65 years of age).

From 2003–2008 were treated 49 patients, 14 male and 35 female with mean age of 61 years. All patients had a proximal humerus fracture classified by the AO Universal Classification. The fractures were treated with either open reduction internal fixation (ORIF-21 patients) or with shoulder hemiarthroplasty (HSA-28 patients) under general anesthesia.

Among the patients that were treated with ORIF or HSA we did not observe statistical significant differences in the days of hospital stay, the change of pre and postoperative hemoglobin, the need of blood transfusion and the acute postoperative complications. On the contrary there were statistical significant differences in the level of acute postoperative pain, the clinical results and the range of shoulder movements after a period of 3,6 and 12 months (constant score).

ORIF seems to have better clinical results for younger medial age patients in comparison with HSA that seems to have poorer results. On the contrary HSA seems to have better clinical results for older medial age patients.


E. Mataragas C. Vassos N. Tzanakakis G. Mouzopoulos C.K. Yiannakopoulos Emm. Antonogiannakis

To evaluate humeral and glenoid bone loss in patients surgically treated for shoulder instability as factors of recurrence.

During the period 2000–2008, 114 patients (103 men and 11 women) with mean age of 28 yrs underwent arthroscopic treatment for shoulder instability by the same surgeon. Mean age of the 1st shoulder dislocation was 20,89 yo and the average number of dislocations per patient was 17,14. Glenoid bone loss was found in all patients (16 Large, 59 Medium, 29 Small), as well as Hill Sachs lesions (66 Large, 23 Medium, 8 Small) or both. Thirteen (13) patients had an “inverted pear” glenoid shape. Seventy five (75) were into sports and for 57 (76%) of them this involved Overhead/Contact activities. Also 20 patients presented joint hypermobility. Complete follow up existed for 92 patients and it ranged from 4–108 months (Mean=44). The recurrence of instability and the functional outcome were evaluated post-op using the Rowe Zarins Score.

Recurrence of instability was noted in 5 patients (4,38%). All of them presented Hill Sachs lesions and glenoid bone loss (2 Large, 2 Medium, 1 Small) but without an “inverted pear” glenoid shape or joint hypermobility. All 5 of them were into Overhead/Contact sports activities (2 Professional: Mean=15hr/w and 3 Amateur: Mean=2,5hr/w). The post op Rowe Zarins Score ranged from 80–100 (Mean=95,11).

From the evaluation of our data, it seems that humeral and glenoid bone loss do not significantly contribute to the recurrence of arthroscopically treated shoulder instability.


K. Gouvalas K. Kavvadias A. Papachristos Ch. Oikonomou D. Xanthopoylos H. Delkos Th. Mylonas A. Mpeltegris

The treatment of radius head comminuted fractures remains controversial. The radius head excision and the radius head arthroplasty have been proposed as the main treatment methods.

We present 13 cases, 6 men and 7 women aged 25–68 years old with radius head comminuted fractures Mason type III during 2005–2006. Elbow dislocation was also present in 3 patients, ulnar comminuted fracture in 1 patient and ipsilateral cubitocarpal comminuted fracture in another patient.

All patients were managed operatively with radius head removal and cementless monopolar metallic prothesis placement. The others musculoskeletal injuries were managed at the same time. The average hospitalization was 6.8 days without complication postoperatively.

12 cases were followed up and the average follow up period was 26 months.

In 6 cases the results were excellent, in 3 cases the results were moderate and in 3 cases the results were bad.

We believe that the arthroplasty is the acceptable method in radius head comminuted fractures management especially in cases were complicated elbow damages are present.


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D. Efstathopoulos El. Karadimas G. Stefanakis D. Chardaloubas D. Klapsakis G. Chatzhmarkakis

Posterior interoseous nerve (PIN) syndrome is an entrapment of the deep branch of the radial nerve just distal to the elbow joint. It may result in the paresis or paralysis of the fingers and thumb extensor muscles.

We present a review of 26 cases of PIN entrapment syndrome, diagnosed an treated over a ten years period form 1996 to 2005. Their ages ranged form 12 to 57 years, they were 18 men and 8 women. The interval between, the onset or paralysis and operation ranged from 4 months to 1 year. All the patients were diagnosed preoperatively as having PIN palsy from physical examination and electromyographic (EMG) studies of the posterior interoseous innervated muscles and all were treated by operation.

The cause of compression was, ganglia in four cases, fascia thickening at the arcad of frohse in six cases, the radial recurrent vessels in three cases, lipoma in four cases, dislocated head of the radius in two cases, infamed synovium in four cases, tumour in two cases, and Intraneural Perineurioma in one case. The periods of postoperative observation were from 1 to 10 years. The paralysis recovered completely by the six postoperative months in all cases except one girl with intraneural peri-neurioma.

Three patients developed mild reflex sympathetic dystrophy which resolved with physiotherapy and auxilary blocks. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve which recovered in a few weeks.

Having arrived at a diagnosis of PIN syndrome, it is important to select the correct level for the release of the radial nerve. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury.


I. Ignatiadis D. Arapoglou E. Pateromihelakis K. Mpeis E. Pananis P. Psyllakis N. Gerostathopoulos

We prove the importance of the complete osteoligamentary elbow reconstruction and the usefulness of the liga-mentoplasty by palmaris longus combined with other procedures in complex elbow unstable injuries.

17 patients aged between 17 and 72 suffered elbow luxation or subluxation with rupture of the medial collateral ligament, associated with:

Fracture of the radius head,

fracture of the coronoidal process(terrible triade),1) olecranon fractures.

In 3 compaound injuries we had open fractures with Brahial artery lesion, Ulnar nerve pulsy, radial nerve laceration, Brahial plexus injury.

The lesions happened between 2 hours and 2 yrs pre-operatively, caused to work accidents or to traffic accidents with a follow up between 8–62 months. 10 of the injuries were operated almost in emergency by ligamen-toplasty with palmaris longus, coronoidal process fixation with screw or ancor, radial head osteosynthesis or prosthesis. The vascular injuries urgently operated while the nerve lesions left for secondary repair. A functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint removed 2 months postoperatively, while full rang of motion obtained.

We performed both Mayo clinic, DAS scores and grasp strength force and Range of Motion measurement evaluation procedures

Satisfactory to excellent results have been obtained in 11 cases with stable joints and range of motion with 20 degrees extension-flexion deficit while in I case the instability persited, in another one arrived 50% of the normal range of motion.

The complex elbow injuries with ligamentary instability are effectively treated if except fractures we always repair The medial-anterior ligaments lesion with liga-mentoplasty and ancors.


S.I. Stavridis P. Savvidis K. Ditsios P. Givissis A. Christodoulou

The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after surgery and whether these phenomena were clinically significant and would influence the final outcome.

12 unstable, displaced metacarpal fractures in 10 patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with the Inion® OTPSTM Biodegradable Mini Plating System. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m). For patients without appearance of foreign body reaction the minimum follow-up time was 24 months

Patients were examined both radiologically to evaluate fracture healing, and clinically by completing the DASH-score and a visual analogue scale for pain assessment. Grip strength, finger strength and range of motion of metacarpo-phalangeal and interphalangeal joints were measured.

Fracture healing occurred uneventfully in all patients within six weeks. The most important complication was a foreign body reaction observed in 4 of our patients more than a year postoperatively. All were re-operated and had the materials removed. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction.

Although internal fixation of metacarpal fractures by using bioabsorbable implants is a satisfactory alternative fixation method, patients should be advised of this possible late complication and should be followed postoperatively for at least one and a half year, possibly longer.


P.V. Giannoudis P. Stavlas C. Tzioupis R. Singh C. Kontakis

To estimate the prevalence of clavicular fractures, number of cases required operative treatment, and whether removal of the implant is a frequent necessity.

Between November 2005 and Nov 2007 all patients presenting in our institution with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Retrospective review of clinical notes and radiographs. Demographic details, mode of injury, treatment protocol, operative procedures performed, time to union, complications post-surgery stabilization, and the number of cases that required implant removal were documented and analysed in a computerized database. The mean time of follow up was 24 weeks (12–48).

Out of 16,280 adult fractures that presented to our institution, 200 (1.23%), (137 males) patients met the inclusion criteria with a mean age of 43 years (19–95) and a mean ISS of 9 (4–38). There were 4 of the medial, 153 of the middle and 43 of the lateral clavicle fractures (3 were open). 178 (89%) patients were treated non-operatively and 22 (11%) operatively. Indications for surgery included open fracture, bony spike/skin threatened, grossly displaced/comminuted fracture, polytrauma and non-union. Mean time to radiological union was 14 weeks (5–38 weeks). Out of the 200 patients 12 (6%) developed non-union. Out of the 22 operated patients, 7 (32%) required plate removal and 1 had screw removal. Indications for removal of implant included, periprosthetic fracture (1), prominent metal work through skin (3), pain in shoulder (2), pressure symptoms (1). Post removal of implant, 6 (75%) patients claimed improvement in symptoms. Functional outcome was excellent/good in 90% of cases.

The incidence of clavicular fractures was 1.23%. A small number of patients (11%) required operative treatment out of which one third had metal work removal. The majority of clavicular fractures can be treated non-operative with good functional results.


K. Papanastasopoulos E. Myriokefalitakis Th. Drougas K. Savidis K. Kateros K. Sarantos

The aim of this study was to evaluate the severity of pelvic fractures, to emphasize the appearance of major complications and to record the possible permanent damage of these patients.

We studied the clinical presentation of 105 patients with solid or multiple fractures during the period 2000–2007. Thirty one patients presented with acetabular fracture (5 of which showed dislocation of the corresponding hip), 52 patients presented with pelvic ring fractures and 22 patients presented with ischio-pubic and sacral fractures. The demographic data and patient history were recorded. The patients were re-evaluated in out-patient department.

There were several major complications. Pulmonary embolism occurred in 6 patients, 15 days following the fracture. One patient had a myocardial infraction, 19 days after the fracture and 1 stroke victim, 10 days following fracture. Five patients had urinary bladder rupture. Fourteen patients presented severe injury of the sciatic nerve. Three patients had a permanent urinary tract catheter and one had penile erectile dysfunction. In 13 patients there were minor complications such as numbness of limbs, groin pain and limping during gait. We needed, on average, 3.8 units of blood.

We conclude that pelvic fractures, solid or multiple, are very severe injuries. They require high level of observation due to major complications, of which increase morbidity and mortality.


E. Zampiakis A. Mpogiopoulos E. Tsoni A. Spanomanoli M. Matala A. Mela P.A. Kinnas

The evaluation of our results from the use of transscalen block in shoulder surgery.

During September 2008 – March 2009, in our institution 25 patients underwent different types of shoulder surgery. Fifteen patients were male and ten female with mean age 56 y.o. Shoulder pathology included fractures, rotator cuff tears, subacromial decompression. Two of the patients received general anaesthesia because of anatomic variations to the neck and the rest twenty three of them underwent a transcalen block as method for anaesthesia. For the block all the patients received 20 ml Naropeine 7.5% and 10 ml NaCl 0. Two out of twenty three patients received, during the beginning of surgery, general anaesthesia because of pain. There were no other complications, regarding the anaesthesia, during the surgery. The postoperative analgesia was 8.5 hours in average. None of the patients received postoperatively any strong analgetics.

We believe that the use of transcalen block is a safe and secure method of anaesthesia for the shoulder surgery with excellent analgetics results.


E. Mataragas C. Vassos N. Tzanakakis G. Mouzopoulos C.K. Yiannakopoulos Emm. Antonogiannakis

This paper aims to evaluate the Remplissage arthroscopic technique as described by Eugene Wolf used in patients with traumatic shoulder instability that present glenoid bone loss and Hill Sachs defects.

In our study 28 patients (5 women and 23 men) with mean age of 31 yrs underwent arthroscopic stabilization of the shoulder by the same surgeon during 2007–2008 period. All patients presented Hill Sachs lesion, 11 of them had medium or large glenoid bone loss, 10 had an “inverted pear” glenoid shape, 4 had been revised for stabilization in the same shoulder and 14 presented joint hypermobility. Mean age for the age of 1st dislocation was 20,1 yrs and our follow up ranged from 5–28 months (Mean=18). The recurrence of instability and the functional outcome were evaluated pre-op and postop with the Rowe Zarins Score. The post op rehabilitation was performed by a specialist.

None of the patients presented recurrent instability. The Rowe Zarins Score raised from a mean pre op score of 23,33 (15–60) to a mean post op score of 97,11 (75–100) (p< 0.05). All the patients that were into sports activities before the presentation of shoulder instability began training again and our post op evaluation of the shoulder’s ROM showed a decrease in the external rotation from 0°–15°.

The infraspinatus tenodesis and posterior capsulodesis in patients with humeral bone loss seems to offer so far excellent post op results despite the slight decrease in the external rotation of the shoulder.


H. Vasiliadis G. Mitsionis Th. Xenakis An. Georgoulis

This study compares the endoscopic carpal tunnel release with the conventional open technique with respect to short and long-term improvements of functional and clinical outcomes.

We assessed 72 outpatients diagnosed with carpal tunnel syndrome. Thirty-seven patients underwent the endoscopic method according to Chow and 35 were assigned to the open method. Improvement in symptoms, severity and functionality were evaluated shortly preoperatively (at two days, one week and two weeks) and one year after using the Symptom Severity Scale, Symptom Severity Status and DASH questionnaire. Changes in clinical outcomes (grip strength, key pinch and two-point discrimination test) were evaluated one year postoperatively. Complications were also assessed.

Both groups showed similar improvement in all but one outcome one year after the release; increase in grip strength was significantly higher for the endoscopic group. The endoscopic method was also associated with a significantly faster short-term improvement. Separate analysis of the questionnaire components referring to pain reveals that the delay of improvement in the open group is due to the persistence of pain for a longer period. Paresthesias and numbness decrease shortly after the operation with comparable rates for both groups.


E. Apergis A. Lakoumentas X. Xaralambides S. Koukos G. Katsoulis N. Koutsoubelis

Correcting a malunited distal radial fracture usually requires osteosynthetic material applied on the dorsal side of the radius. However, contact of the material with the extensor tendons often produces irritation and rupture problems. The aim of this study is to evaluate the effectiveness of the specific osteosynthetic material (Trimed) in treating malunion of intra- or extra-articular fractures of the distal radius, after a corrective osteotomy.

We examined 11 patients (7 females, 4 males), with average age of 42 years (ranging from 21 to 69 years old), 10 of which presented with symptomatic malunited distal radial fracture of a mean duration of 2.85 months (2–7 months). In one patient the malunited fracture was 30 years old. In 7 patients the malunited fracture was extra articular whereas in 4 patients it was intra articular. A corrective osteotomy was performed in all cases, followed by application of the special osteo-synthetic material by Trimed on the dorsal side of the radius. In seven patients iliac crest bone graft was used, whereas in four allografts were applied. Furthermore, five patients had to undergo additional surgical procedures. More specifically, shortening osteotomy of the ulna in 3 patients, radio-scapho-lunate fusion in 1 and excision of scaphoid with carpal tenodesis in 1 patient.

After a mean follow-up of 15 months (6–27 months) the results were evaluated based on (Fernadez 2001), pain, range of motion, and grip strength. Excellent results (18–20 points) were observed in three patients, good results (15–17 points) in five patients and fair results (12–14 points) in two patients.

We conclude that the use of this particular material provides satisfactory stability on the corrective osteotomy and because of its low profile it can be applied on the dorsal side on the radius without interfering with the extensor tendons.


K. Papanastasopoulos K. Sarantos E. Myriokefalitakis I. Georgopoulos C. Agisilaou K. Kateros

In this study we try to evaluate the results of intramedullary nailing in the treatment of fractures of diaphysis of humerus.

During the time period of 2002 to 2006 46 patients were admitted in our clinic with fracture of the diaphysis of the humerus and 23 patients were treated surgically with intramedullary nailing. 14 patients were directly submitted to intramedullary nailing, 6 patients after unsuccessful conservative treatment and 3 patients due to nonunion after internal fixation. Average age was 51 years old. In 5 patients open reduction was applied while bone grafts were not used in any case. In all cases bone healing was obtained within 6 to 20 weeks (average 11 weeks). Final functional outcome was evaluated with Constant Score and according to it 10 patients demonstrated excellent score (> 75), 7 satisfactory (50–75) and 6 poor(< 50). Postoperative evaluation was based on clinical findings such as pain, range of motion and rehabilitation. As far as complications are concerned 2 cases with severe stiffness of the shoulder were observed and 1 case with malunion. There were no cases with non-union, sterile necrosis or neurological impairment.

Intramedullary nailing shows significant advantages such as limited damage to soft tissues, satisfactory retention of osteoporotic fractures, immobility of complex fractures and allows immediate postoperative mobilization.


V. N. Psychoyios S. Thoma P. Intzirtzis A. Alexandris E. Zampiakis

Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury.

Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement.

The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient.

Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results.


F. Nikolopoulos A. Poulilios D. Giotis I. Tsapakidis K. Tzoumakas An. Grestas

Fractures of the distal tibia metaphysis comprise a challenge for the orthopaedic trauma surgeon because of the poor blood irrigation they do not heal very easy leading sometimes to pseudarthrosis and many times arise problems with the skin.

We compare the following techniques: LC-DCP and LCP plates, MIPO, External fixators (hybrids or simple one), intramedullary nailing with multiple screws at the distal end.

94 cases of distal tibia fractures from all AO types were treated during last 3 years (2005–2008) with the following techniques:

16 ORIF with LC-DCP plates

9 ORIF with LCP plates

19 MIPO

35 External fixators

15 intramedullary nailing

The simple oblique or spiral fractures which treated with the 1st and 2nd method (ORIF), they do not seem any remarkable difference in healing but both methods demonstrate a delay in fracture healing over 5 months. The 3rd method display faster healing 2,5 months average in simple fractures with no skin wound at all. The 4th method display 3 pin track infections and dealt with removal of the material and 2 pseudarthrosis which encountered with ORIF and bone grafting from the iliac. The 5th method display 2 malunions but because of the small angle in varus we do not perform any treatment. Every technique has its own position on those type of fractures, depending of the personality of the fracture and the skill of the surgeon.


G.A. Flevarakis M. Papaioannou I. Plaitakis G. Vatikiotis J.A. Nixon T.P. Kormas

We evaluated the use of unreamed expanding nails in prophylactic stabilization of impending fractures in patients with multiple bone mets.

During 2004–2008 we treated 25 impending fractures due to metastasis (11 male, 14 female patients) with so-called expanding intramedullary nails. All they had multiple bone mets and signs of impending fracture due to extensive osteolysis. We stabilized 6 impending humeral fractures, 15 femoral and 1 tibial with antegrade nailing and 3 pertrochanteric with cephalomedullary nailing. Fluoroscopy was used to check the nail entry-point. No medullary reaming was performed. The nails were not interlocked at the mid-shaft but fixed rather firmly within the medullary cavity after introducing normal saline under pressure that expands its walls. The operation time ranged from 12min (humerus) to 25min (pertrochanteric). No blood transfusion was necessary. On follow-up (8–41 mos) all patients were reviewed. In all cases the risk of impending fracture was remarkably decreased. The patients with humeral fractures regained function quickly. The patiens with lower limb fractures were mobilized immediately post-op and were allowed to walk with TWB.

Surgery of impending fractures of long bones in patients with multiple bone mets is palliative. It aims in safer patient’s mobilization, fracture risk reduction, pain control and function restoration in order to render the patient capable to continue the treatment for the main disease. The expanding nailing is indicated in selected cases as it can be inroduced quickly and effectively with minimal blood loss and morbidity.


P. Kanellos A. Papachristos G. Lagoudakis G. Gouzias A. Mpeldekos

We present our clinical experience in treating atrophic non-union of long bones by injecting, percutaneously, autologous bone marrow aspirate concentrated as a source of progenitors stem cells

Bone marrow aspirated from the iliac crest contains progenitor cells that can be used to obtain bone-healing of non-union. However, its efficacy appears to be related to the number and concentration of progenitors in the graft. The last three-year period, 11 patients (8 men-3 women) with established atrophic non-union were treated in our department. In all cases, the gap between the fragments was smaller than 5 mm. A constant volume of 60+60 ml of marrow were aspirated from both iliac crests and centrifuged for 15 minutes aiming at the increase of concentration of progenitor-mononucleotide cells. An average volume of 20 ml (+/− 2) concentrated bone marrow was injected percutaneously, under C-arm, at the site of non-union. The graft contained an average of 272.64 x 10(6)/ ml mononucleotide cells. The evaluation of treatment was based on the clinical and radiological findings after 3, 6, 9 and 12 months. However, prior to administration of bone marrow stem cells, there was no case with evidence of ongoing deep sepsis.

Bone union was obtained in 10 out of 11 patients (full weight bearing, callus formation in 3 out of 4 cortices). In one case a second operation was needed due to impaired indications of treatment. However, in all cases, there were no signs of local or systematic complications.

Percutaneous concentrated bone marrow grafting is an efficient and safe method, for treating atrophic non-unions, with a minimal invasion technique. Contraindications for the above technique are a gap larger than 5 mm and a preexisting angular and axial deformity.


V. N. Psychoyios S. Thoma P. Intzirtzis A. Mpogiopoulos E. Zampiakis

Ankle fractures are among the most common injuries treated by orthopaedic surgeons, and surgical treatment is often required to optimise the results. This retrospective study was undertaken to assess the effectiveness of the TRIMED ankle fixation system in the treatment of malleolar fractures.

During the last ten months, fifteen patients with an average age of 63 years underwent open reduction and internal fixation of a bimalleolar ankle fracture with the TRIMED fixation system. A standart surgical approach was used for both the medial and lateral malleolus. Regarding the lateral malleolus, a TRIMED Sidewinter plate which requires no additional interfragmentary screw was applied. Based on the morphology of the fracture of the medial malleolus, either interfragmentary screws or the sled- like medial malleolus fixation system was applied. One patient underwent in addition open reduction and internal fixation of the posterior malleolus.

All fractures proceeded to uncomplicated union in an average healing time of 6 weeks. Excellent functional restoration of the ankle joint, comparable to the ipsilateral ankle, was achieved.

The TRIMED ankle fixation system represents a good alternative method in malleolar fracture fixation which simplifies the fracture reduction and obliterates the need for a lag screw, thus preserving the biology of the fracture site. Furthermore, it can be used for the reconstruction of distal fractures of the lateral malleolus. However, further long-term studies are recommended to evaluate the success of the TRIMED fixation system.


A. Boutsiadis G. Venetsanakis V. Venetsanaki G Petsatodis I. Chatzokos A. Christodoulou

Periprosthetic fractures are rare complications (0.3%–2.5%) of total knee and hip Arthroplasty. Purpose of this study is to present our experience and the mid-term clinical results of periprosthetic fracture care.

Between 2005 and 2009 nineteen femoral periprosthetic fractures were treated in our department. Seven patients with TKA had supracondylar fractures, type II according to Lewis and Rorabec classification. Twelve patients with THR had type B2 fractures according to Vacouver Classification. Seven patients were men and 12 women with average age 78.15 years. Femoral shaft fractures were treated with ORIF and DCP 4.5mm femoral plate in 8 cases, revision THR in 3 cases and 4.5mm plate with wires in one case. Supracondylar fractures were treated with ORIF abd LCP plate 4.5mm in 5 cases, Ilizarov fixator in one case and DCS plate in the last case. The average follow up was 22 months postoperatively.

Fracture healing observed in 16 patients at an average of 6 months postoperatively. No infection or non union complicated our treatment goal. Three patients died at an average of 2 months postoperatively. One should point out that mobilization and return to previous activity level is very difficult for these patients, despite fracture healing. Best clinical results observed with DCP and LCP 4.5mm plates.

Periprosthetic fractures are serious and complex complications of an arthroplasty that require stable osteosynthesis and primary patient mobilization.


J.A.F. Charity E. Tsiridis A. Sheeraz J.R. Howell A.J. Timperley G.A. Gie

Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 Developmental Dysplasia of the Hip (DDH). Prospective evaluation of the use of subtrochanteric derotational femoral shortening with a cemented Exeter stem.

15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years followed-up for a mean of 114 months (range 52 to 168). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient lost to follow up. All 18 Crowe IV hips reviewed. 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 months while radiological evidence of union at a mean of 9 months. The mean length of the excised segment was 3 cm and the mean true limb lengthening was 2 cm. 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting performed in all cases. Mean subsidence was 1 mm and no stem was found to be loose at the latest follow up. No sciatic nerve palsy was observed and there were no post-operative dislocations.

Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with when a subtrochanteric derotational shortening osteotomy (SDSO) was necessary. A transverse osteotomy is necessary to achieve derotation and reduction can be maintained with a DCP plate. Intramedullary autografting prevents cement interposition at the osteotomy site and promotes healing.


G. Rudol I. Pagkalos I. Polyzois R. Wilcox E. Tsiridis

In selected patients in-cement revision of the total hip arthroplasty components is an attractive option. Recommended roughening of the primary mantle surface remains controversial. Aim of the study was to investigate the influence of the cement surface roughening on the strength of bilaminar cement interface.

Flat, laboratory model of bilaminar cement interface was used. Prior to its creation, modeled primary mantle surface was machined to the roughness of either smooth surface observed after removal of a highly polished stem (Ra=200nm) or that following roughening (Ra=5μm). Two viscosities of interfering fluids (water and bone marrow) were also used. 6 variants (smooth or rough, both stained with water, bone marrow or with no fluid) with 7 repeats were exposed to single shear to failure.

No significant difference in resistance to shear was observed between the groups with dry smooth (16.82MPa) and rough surfaces (16.96MPa), and those stained with large volume of low viscosity fluid. In the presence of water, roughening did not significantly influence the interface (smooth – 17.04MPa and rough – 16.25MPa respectively).

In the smooth variant with large volume of viscous fluid, ultimate stress value dropped to 5.53MPa, and 9.87MPa in the roughened group with the same amount of viscous fluid (p< 0.05).

Extra roughening may offer some benefit when performing in-cement revision in the presence of large volume of viscous fluid only though in-cement revision would not be then recommended. In the presence of low viscosity fluids (blood, irrigation fluid) benefit of roughening is dubious.


G.I. Mitsionis M.G. Lykissas I. Batsilas E. Motsis H. Abuhemount T. Xenakis

The purpose of this study was to investigate the outcome after surgical therapy of patients suffering from HO of the hip after treatment in ICU.

We retrospectively examined 39 patients with heterotopic ossification of the hip (18 bilateral and 21 unilateral). All patients have had history of ICU treatment for several reasons, such as craniocerebral injury (35 patients-90%), 2 patients with Guillain-Barre syndrome (5%), 1 patient with pulmonary druse (2.5%), and 1 patient with inflammatory bowel disease (2.5%). They all underwent surgical removal of HO and postoperative irradiation therapy. On the basis of plain radiographic findings, we evaluated the recurrent ossification after an 18-month follow-up period.

The evaluation of the average 18-months follow-up period showed relief of pain and clear improvement of range of motion in most of our patients. Specifically, improvement in the range of movement was observed in 41 hip joints (71.93%) in contrast to 16 hip joints (28.07%) that did not show any alteration post-operatively. No lesion re-occurrence was observed. There was only one complication of peroneal nerve paresis following HO excision.

The majority of our patients that were treated with surgical excision of the ectopic bone around the hip joint significantly improved their range of joint movement and were relieved from pain. Surgical excision seems to provide a superior quality of life in these patients, as they have a high risk for major complications due to their poor level of mobility.


S.A. Papadakis D. Segkos V. Katsiva P. Pantoula S. Galanakos P. Katonis

To determine the gross structural alterations of the nailed bone (femur or tibia) after the removal of an intramedullary nail (IMN).

Eighteen patients (14 femoral and 4 tibia nail) underwent an IMN removal from their femur or tibia. Every patient had a spiral computed tomography scan and a plain X-ray study, immediately after the nail removal and also at their latest follow-up (24–30 months). The 4 patients with a tibia nail were additionally examined using a peripheral quantitative computed tomography study at their latest follow-up. All patients were asymptomatic.

An intramedullary shell of compact bone was demonstrated around the nail track. This new bone was apparent on plain radiographs in all of the patients. Peripheral quantitative computed tomography study revealed that the density of the bony ring was similar to that of subcortical bone. The histologic examination of the intra-medullary shell of one of our patients suggested that the bony ring was made of cortical bone.

Intramedullary nailing may enhance new cortical bone formation within the bone marrow cavity. This “cortical bone” still exists more than 2 years after implant removal. Nail insertion also causes thickening of the normal cortex at the sites of nail–cortex contact where loads are transferred from the nail to the cortex. This new finding could probably lead the research of intramedullary nailing biomechanics toward new directions as to understand the body’s reaction to IMNs.


E. Christodoulou C. Ballhorn D. Retzlaff S. Elenz

The treatment of the displaced proximal humerus-fracture with solid osteosynthesis is complicating by coexistence of osteoporosis and simultaneous degenerative changes of the rotator cuff. These specific problems, as well as the usage of primary endoprosthetic replacement should be reduced through the introduction of locking-screw-plate-systems.

From April 2006 to March 2008, 70 patients received the clinical application of a newly developed locking-screw-plate (Winsta PH) in a prospective study. 48 of 70 patients were subjected to re-examination after averagely 15 months (1–3 years), 34 women and 14 men. The average age was 68.7 years. The classification of the fractures occurred after Neer. Concerned are 12 two-fragment, 21 three-fragment and 15 four-fragment fractures. The functional result after surgery was rated according to the Constant- and Dash-Score.

The average absolute Constant-Score was 63% and the Dash-score 18.3. Patients with accurate anatomical reduction achieved a significantly better score. Secondary loss of correction occurred in 3 patients with collapse of the humeral-head and perforation of the screws. An early metal removal combined with subacromial decompression took place in 3 patients, because of post-traumatic impingement. In a Neer VI-fracture-case, an early revision to hemiarthroplasty occurred due to a postoperative dislocation. One postop-wound discharge was surgically debrided.

Modern locking-screw systems like Winsta-PH plate allow a safe treatment of complex fractures of the proximal humerus, diminishing the need for primary endoprosthetic replacement significantly. Anatomic reduction is essential for the locking screw plate system to form the pillar for a successful outcome.


R.A. Giannakos K. Bargiotas L. Papatheodorou S. Varitimidis T. Karachalios K.N. Malizos

The evaluation of the middle term behaviour of the Wagner-type stems in dysplastic femurs and the presentation of the technical and surgical differences with the implantation of a Wagner stem.

Between 1997 and 2008 we implanted 64 Wagner stems in 58 patients. Average age at the time of implantation was 64 years. 52 patients was operated because of DDH, and 12 had had previous osteotomy. All patients were prospectively evaluated radiographically and clinically at annual intervals. Functional outcome was assessed with Harris Hip Score and Oxford Score.

Mean follow-up of these series was 4 years (11-1)One stem was revised because of fracture of the lesser trochander and two more patients were re-operated for open reduction. With the re-operation as end-point and 95% Confidence Interval survivorship rate was 98, 5%. There were no progressive radiolucent lines. Stem migration was at an average 2mm (1–6) during the first two years and remained stable thereafter. There was no deep infection in these series. After the second year a dense zone is evident in all Gruen zones at the implant –bone interface with a width of 2–3 mm.

Dysplasia of the proximal femur may pose significant technical problems during THA due to the distortion of the geometry and the narrowing of the femoral canal. The sort, conical Wagner type stems can offer a very good alternative is such patients. They allow control of the anteversion and they are able get a good press-fit despite the metaphyseal/diaphyseal mismatch and the femoral bowing.

Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs.


A. Tsamatropoulos C. Vassos E. Karavas G. Epaggelis D. Chalatsis K. Sarafis

This study reports the results of hybrid stem fixation in difficult revision hip arthroplasties where proximal femoral bone stock loss was severe.

Twenty-six revision arthroplasties (21 women and 5 men, aged from 58 to 86 years), were performed between 1998 and 2008. The indication for surgery was aseptic loosening. In all cases, stabilization of the stem presented problems because of severe proximal femoral bone stock loss (due to extensive periprosthetic osteolytic defects), or because of iatrogenic defects or surgical procedures (attempts to remove the stem and cement with fenestration or extended osteotomy). The average follow-up was 48 months (range 16 to 120).

Primary stability is necessary for the successful definite fixation of a cementless implant by bone. When this was not possible (because of proximal cortical insufficiency), we used a modular distally cemented long stem, bypassing the area of bone defect for at least 6–7 cm. Proximally bone defects were grafted and osteotomy was closed with cerclage wires.

Four stems (15%) had an asymptomatic subsidence (3 stems subsided less than 3–4 mm and 1 stem about 15mm). No stem was revised to date. Major complications did not occur. The mean Harris hip score improved from 32 points preoperatively to 82.3 points (at the most recent evaluation).

Hybrid fixation offers the advantage of initial and secure stability of the cemented stem on the short term, until stabilization of the entire implant by bone occurs. Thus early subsidence and loosening is avoided and on the long term benefits of the cementless fixation are attained. Our results support the method of hybrid fixation in patients with severe femoral bone loss (and consequently problematic stabilization), when primary stability is needed.


G. Georgiades G. Babis G. Kourlaba G. Hartofilakidis

We reported on the outcome of 84 Charnley low friction arthroplasties performed by one of us (GH), the period 1973 to 1984, in 69 patients, less than fifty-five years old, with osteoarthritis mainly due to congenital hip disease.

The patients were followed prospectively; clinically using the Merle D’Aubigné and Postel scoring system, as modified by Charnley and also radiographically.

At the time of the latest follow-up, thirty-seven hips had failed (44%). In thirty-two hips, twenty-eight acetabular and thirty femoral components were revised because of aseptic loosening (six of the femoral components were broken). Three hips were infected and converted to resection arthroplasty. In two more hips a periprosthetic femur fracture occurred three and ten years postoperatively and were treated with internal fixation. After a minimum of twenty-two years from the index operation, 37 original acetabular components and 36 original femoral components were in place for an average of 29 years. The probability of survival for both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years when 35 hips were at risk.

These long term results can be used as a benchmark of endurance of current total hip arthroplasties performed in young patients, with OA mainly due to congenital hip disease.


A. Drakou G. I. Karaliotas V. Sakellariou H. Tsibidakis P. Pantos A. Papadopoulos

Two-stage revision procedure is the gold standard in management of periprosthetic infections. Cement spacers have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (thermal necrosis, random porosity, unspecified antibiotic delivery rate).

To present the concept of using PerOssal as a canal filling spacer and local antibiotic delivery system in two-stage revisions of hip and knee infected arthroplasty.

8 patients (6 females, 2 males) with infected arthroplasty (4 TKRs, 4 THRs) were managed with two-stage revision procedures during the years 2006–2008 (minimum FU: 12 months). Our protocol consisted of:

Preoperative determination of the causative organism

Radical debridement surgery and cement spacer with PerOssal implantation

Appropriate IV antibiotic therapy for 6 weeks, postoperative clinical evaluation and monitoring of inflammation markers

After a six-week antibiotic free interval and inflammation markers normalization second stage surgery took place: Medullary canal reaming, intraoperative cultures, thorough wound irrigation and prostheses implantation

Postoperative antibiotic therapy until culture results; IV antibiotic treatment for 6 more weeks if they were positive.

FU evaluation at 3, 6, 12, and 24 months.

We had 7 cases with eradication of infection, 2 with delayed wound closure, and 1 late recurrence of disease.

We think that PerOssal can offer a very useful additional and genuine support in managing infected joint arthroplasties with so far good clinical results.


I. Panastasiou M. Ioannou G. Farfalli P. Boland C. Morris J. Healey

We present the results of 15 patients revised with a Compress® prosthesis secondary to failure of other distal femur reconstruction.

One prosthesis had to be removed because of deep infection. Three patients needed a second surgery due to a vertical crack proximal to the anchor plug at the level of a cortical bone defect. At last follow-up, radiologic evaluation of the entire series showed a mean bone growth ratio higher than did preoperative radiographs. All patients had mainly good or excellent MSTS functional results.

Distal femoral prosthetic replacement with a Compress® implant in severe cases of bone loosening and instability provides a reliable reconstruction alternative that promotes bone formation. Patients with cortical defects proximal to the anchor plug should be protected with extracortical supports.


C.S. Georgiou P.D. Megas E.G. Theodorou C.G. Provatidis

Total Hip Arthroplasty (THA) is one of the most important procedures in the fields of Reconstructive Orthopaedics. This study aims to present the preliminary results of the clinical and radiological evaluation of patients who have undergone THA with metal bearings, modular necks and big femoral heads and to correlate them with the results of the Finite Element Analysis. In the period from 1/1/2006 until today 90 patients (33 men and 57 women) with mean age 62,4 years have undergone primary THA. The patients were clinically and radiographically evaluated preoperatively, as well as postoperatively, in regular time intervals (1st, 3rd, 6th, 12th month and every year afterwards). The clinical assessment was based on two scales, Harris Hip Score (HHS) and Merle d’ Aubigne (MDA) score, whereas the radiographic on Engh criteria. The mean follow up was 16 months. The mean preoperative HHS and MDA score were 45 and 10,3 respectively, whereas 89 and 16,74 at the last evaluation. The mean Engh score was 16,12. No incidence of dislocation, infection and cup or stem adverse effect occurred. We demonstrate extensively, with respect to the used combination of neck and femoral head, the radiographic findings in the zones of Grün and Charnley, in the areas of the tip of the stem and the calcar, as well as the resulting clinical manifestations. The early clinical and radiological data are in line with the increase in the stresses and strains on the upper part of the femur, which are revealed through the Finite Element Analysis.


V. N. Psychoyios I. Kormpakis P. Intzirtzis S. Thoma I. Stathakopoulos

Simultaneous compression of the median and ulnar nerve at the elbow is rather uncommon. The aim of this study was to describe 10 such cases which have been treated in our unit.

The patients presented with a combination of ulnar neuritis symptoms at the elbow with a pronator syndrome. Five patients were female and 5 male with an average age of 33 years. All patients were manual workers. Regarding the cubital tunnel syndrome, all patients complained for hypesthesia in the ulnar nerve’s distribution in the hand and 6 for additional night pain in the medial aspect of the elbow. Regarding the pronator syndrome, the patients complained for mild tenderness or pain at the proximal forearm as well as hypesthesia or paresthesias at the digits. Nerve conduction studies were positive only for the ulnar nerve compression neuropathy. Six patients were treated by decompressing both nerves at the same time through the same medial incision, creating large medial flaps. The ulnar nerve underwent a simple decompression. In one case that the symptoms were initailly attributed to ulnar nerve, a second operation for medial nerve decompression was required.

In all patients symptoms subsided following surgical decompression. Four patients developed an ugly scar and 2 a hematoma. All returned to their previous occupation. Clinical tests and nerve conduction studies were performed postoperatively to evaluate the results; all of them turned out negative for ulnar and median nerve compression neuropathy.

Simultaneous compression of the median and ulnar nerve at the elbow is rather rare. Careful evaluation of the patient’s symptoms as well as thorough clinical examination are the keystones for the correct diagnosis. Although decompression can be performed through the same medial incision, extensive dissection may be required.


E. Apergis G. Papadimitriou A. Palamidi I. Paraskeuopoulos E. Tsialogiannis T. Papagiavis

In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively.

We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC.

The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one.

We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result.


K. Papageorgiou P. tilaveridis A. Hatizioannidis I. Papageorgiou S. Christodoulou S. Gerakas

The revision of the hip surgery belongs to the major orthopaedic surgery and the purpose of our research is the presentation of our experience.

During the period 2004–2008, revision in surgery of the hip was performed in 15 patients, while most of them were women with average 73 years. 190 subcapital fractures were revisioned in 7 patients, 277 pertrochanteric fractures in 3 patients, 75 total arthroplasties in 5 patients and all of them were bipolar arthroplasties and osteosynthesis with DSH plate. The average interval between the primary operation and revision arthroplasty was 28 months, revision of the acetabular was performed in 3, revision of the femoral in 1 and regarding to the other patients both types of revision were performed. According to Paprosky classification we noted lesions of type I and type II and in 13 cases operation was made in a time. Early complications appeared in 6 patients (mostly postoperative infections). For the stabilization of the acetabular we used supporting rings with bone grafts or press fit acetabulars without cement, while for the femoral, according to the injury extend and the bone quality, the stabilization of the stem was made with cement. The average follow-up time was 20 months, we re-examined 14/15 patients and chronic complications appeared in 2 patients. The final result was satisfactory, according to Harris-Hip score with the radiological evaluation.

Conclusively, hip revisions are difficult and demanding operations, accompanied by serious complications. For their success good preoperative planning, experience and complete material-technical supporting are required with use, most of the times, of custom made prosthesis, supporting rings of the acetabular with bone graft.


E.G. Theodorou C.G. Provatidis C.S. Georgiou P.D. Megas

Total hip arthroplasty is nowadays a common treatment for a large number of pathological cases regarding the hip joint and is considered as the most successful orthopedic operation. With the mean age of patients constantly decreasing and the more intense way of life, the need for versatile implant designs has arisen. Currently modular hip implant systems are used extensively in order to compensate for difficult occasions, where offset and version correction are required. In addition to this femoral heads of bigger diameter have been introduced to deal with issues such as dislocation and impingement, although their influence on the mechanical behavior on the bone – implant assembly is not widely documented. Towards this direction a finite element model was generated. Computed tomographies of a cadaveric femur were used as raw data and processed, a Profemur-E system with variable heads was digitized, thus leading to a complete assembly consisting of the femur, the stem, the necks and the femoral heads in the commercial CAD software Solidworks. For typical loading scenarios – the stance phase of the gait cycle – the finite element analysis was performed in ANSYS Workbench. The results showed that the implementation of BFH and the neck version produced an increase in strains and stresses with respect to a normal head of 28mm and a straight neck in areas of clinical interest such as the calcar, the greater trochanter area and the stem tip region, considered responsible for thigh pain.


V. N. Psychoyios P. Intzirtzis S. Thoma V. Bavellas K. Dakis

Chronic distal biceps tendon rupture is a relatively uncommon situation with difficulties in treatment. Surgical treatment with allograft has been described in the literature with varying results. The purpose of this study was to describe 9 cases of chronic distal biceps tendon rupture which have been treated in our unit with local soft tissue as a graft.

All patients were male with an average age of 54 years. The mean interval between tendon rupture and reconstruction was 11 months. In all patients a flap from lacertus fibrosus was used in continuation with the remnants of the tendon. The flap was entubulated and advanced to the bicipital tuberocity. The biceps was released and mobilized as necessary. In addition, 3 patients underwent a fractional lengthening of the muscle. All procedures were performed through a single anterior approach. Anchors and anchor sutures were used to stabilize the tendon to the tuberocity.

The mean follow up was 3 years. No complications were encountered except for a superficial infection which resolved with oral antibiotics. All patients returned to their previous occupation. Furthermore, they all achieved 5/5 muscle strength regarding flexion and supination on manual testing. According to the Mayo Elbow performance score, the results were excellent in 8 patients, and fair in one.

We believe that the aforementioned technique is useful in treating chronic biceps ruptures. It requires no additional cost and also the risk, even if marginal, of transmitting diseases with allografts, such Achilles tendon is avoided. Furthermore, the possibility of rerupture is minimal compared to the techniques using allograft or free autografts, since a revascularisation process during which the risk for failure is high does not take place as in other types of allografts.


V. N. Psychoyios I. Kormpakis S. Thoma P. Intzirtzis E. Zampiakis

Elbow contracture is a well recognised sequel of neuromuscular disorders and can be a rather debilitating condition. Non operative treatment, such as physiotherapy and splinting, results in an improved range of motion, but since musculoskeletal pathology in neuromuscular diseases is progressive, an open surgical release of the elbow is often required. Therefore, the purpose of the present study was to assess the results of surgical treatment of elbow stiffness in patients suffering from neuromuscular disorders.

Between January 2000 and October 2008, 11 patients with neuromuscular diseases underwent surgical treatment of elbow contracture. The mean age of the patients was 21 years. Eight patients had cerebral palsy, 2 arthrogryposis and 1 brachial plexus palsy. Pre-operatively the lag of elbow flexion and extension was 45° and 38° respectively. In 6 patients releases were performed through a lateral approach, while 3 required an additional medial incision. In 2 patients the pathology was addressed through a posterior approach.

The mean follow up was 26 months. Postoperatively one patient developed skin necrosis which was treated conservatively. Furthermore, another patient developed transient ulnar neuritis, and finally one more presented with medial collateral ligament insufficiency. All patients had an improved functional arc of motion. Namely, the lag of elbow flexion and extension was reduced to 22° and 10° respectively. At the final follow up the patients maintained 90% of the range of motion that was achieved immediately postoperatively.

Open release of the elbow contracture in neuromuscular diseases yield satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion.


A. Boutsiadis K. Ditsios P. Savvides S. Stavridis P. Givisis A. Christodoulou

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.

Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.

Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.

Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.


V.N. Psychoyios P. Intzirtzis S. Thoma V. Bavellas E. Zampiakis

Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries.

Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement.

The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4.

In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management.


V. N. Psychoyios A. Alexandris S. Thoma I. Kormpakis A. Mpogiopoulos

Hinged external fixators of the elbow joint can be a valuable tool in managing complicated trauma associated with instability, instability after contracture release, and distraction interposition arthroplasty or distraction arthroplasty alone. This retrospective study focuses on the performance of the device in acute and chronic elbow instability associated with complex injuries around the elbow.

Thirteen hinged external fixators were applied in 13 patients with an average age of 46 years. All fixators were applied for various types of fractures around the elbow joint associated with elbow dislocation. In 12 patients prior to the application of the fixator, a formal open reduction and internal fixation was performed so as to neutralise the whole construct and permit early mobilisation of the joint. In one patient with a minimally displaced fracture which required no internal fixation the fixator was used to permit early mobilisation. A circular multiplanar frame was used in 4 patients and a unilateral one in the rest of them.

Eight out of 13 patients with fracture-dislocation had an uneventful outcome. Three patients required a revision surgery to correct a fracture malalignment and a subluxation of the joint. The results were evaluated according to the Mayo Elbow Performance score. Complications included 4 cases of pin tract infection and 2 of transient ulnar neuritis.

Despite the complexity of its application and the complications that may follow such device, an articulating external fixator can be a valuable tool in treating complex elbow instability.


N. Korres I. Kormpakis S. Thoma V. Bavellas E. Zampiakis P. A. Kinnas

Among the most popular techniques for the management of radial nerve palsy is the transfer of the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB), of the Flexor Carpi Radialis (FCR) to the Extensor Digitorum Communis (EDC) and of the Palmaris Longus (PL) to rerouted Extensor Pollicis Longus (EPL). This retrospective study was undertaken to assess the outcome of flexor carpi radialis transfer in the treatment of radial nerve palsy.

Twenty patients with a mean age of 36 years were included in this study. Surgical management, as described above, was decided since all patients had irreparable damage to the nerve. Parameters that were assessed included range of wrist motion, dynamic power of wrist flexion and extension, and radial and ulnar deviation and function.

The average follow-up was 4.5 years. Compared to a control group of 10 volunteers of similar characteristics, all patients achieved a functional range of motion and satisfactory power of wrist motion. All patients returned to their previous occupation.

Transfer of Flexor Carpi Radialis tendon for irreparable radial nerve palsy yields satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion as well as an adequate strength of motion.


P. Papadopoulos D. Karataglis A. Boutsiadis F. Agathaggelidis V. Alexopoulos A. Christodoulou

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.

Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.

Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.

Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.


I. Sarris M. Kyrkos N. Galanis G. Kapetanos

The aim of this study is the presentation of the midterm results of the radial head replacement with pyrocarbon head prosthesis (MoPyc).

Thirty two patients (20 males and 12 females) with a mean age of 54 y.o. (32–68 y.o.) were subjected to replacement of the radial head with a pyrocarbon head prosthesis. Twenty of them had a comminuted radial head fracture(15 Mason IV type and 5 Mason III), two had a malunion and ten had a complex elbow injury (ligamentous rupture and comminuted radial head fracture with/without coronoid process fracture). In 22 patients the fracture was on the dominant side. The mean follow up time was 27 months (21 – 46 months).

The post-operative results were:

The mean range of motion in flexion-extension was 130° (105° to 150°), while in pronation and supination was 74° (60°–80°).

The mean grip strength was 96% of the contralateral side.

There was no clinical laxity in the varus or valgus stress test.

According to the Broberg-Morrey score the good and excellent result were 77%, while according to the Mayo Clinic Elbow Performance Score (MEPS) good and excellent results were up to 97% of the total.

Pain was evaluated with a visual analogue scale. Finally there was also a radiographic evaluation of the patients (that yielded six cases of loosening or osteolysis without any clinical manifestation)

Replacement of the radial head with the specific prosthesis leads to very satisfactory results when performed under specific indications.


A.A. Narvani E. Tsiridis A. Saifuddin T. Briggs S. Cannon

The aim of this study was to compare accuracy of an image guided percutaneous core needle biopsy (PCNB), using ultrasound or computed tomography, to PCNB without image guidance in the diagnosis of palpable soft tissue tumors.

One hundred forty patients with a suspected soft tissue sarcoma underwent a percutaneous core needle biopsy with or without image guidance. One hundred eleven patients had subsequent surgical excision. The accuracy of guided PCNB and blind PCNB was calculated by comparing the histological results of the needle biopsy to the surgical specimen.

The diagnostic accuracy of blind percutaneous core needle biopsy was 78% (36 of 46 biopsies) and significantly lower (p ≤ 0.025) in comparison to image guided percutaneous core needle biopsy which was 95% (62 of 65 biopsies).

We suggest that image guidance improves the diagnostic accuracy of PCNB especially for small size deep sited suspected soft tissue tumours.


V.I. Sakellariou H. Tsibidakis G. Mazis A. F. Mavrogenis P.J. Papaggelopoulos

The purpose of this study is to compare the healing progress in cases with wound healing complications with or without VAC assistance.

From 2005 to 2008, 32 patients with a mean 56 years of age had wound healing complications necessitating for further operative intervention. 26 cases were classified as stage III and 6 cases were classified as stage IV according to the National Pressure Ulcer Advisory Panel. The mean extent of wounds was 7cm2. 17 cases (group A) were treated with repeated removal of necrotic debris. In 15 cases (group B) the VAC device was applied (75mmHg). The 2 groups were compared on the basis of total hospital stay, need for additional operation, and re-infection rates.

Mean hospital stay was 25.2 days in group A and 16.5 days in group B (p< 0.05). 7 cases needed re-operation in group A comparing to 2 in group B (p< 0.05). Re-infection appeared in 5 cases of group A comparing to 1 case of group B (p< 0.05). 1 patient of group B used VAC therapy in lower negative pressure (50mmHg) 6 days post application due to unrelenting pain.

Negative pressure wound therapy is safe and effective. It minimises the total hospital stay, it is associated with lower recurrence, re-infection and re-operations rates, and lowers total cost of therapy.


E. Yalniz M. Ciftdemir B. Tuncer

To present our experience and evaluate functional results on endoprostethic reconstruction of extremities with bone tumors after tumor resection.

47 patients (15 females, 32 males; mean age 55 years; range 13–85 years) who underwent tumor resection and cemented endoprosthetic replacement using the TMTS (Turkish Musculoskeletal Tumor Society) prosthesis for bone tumors of the extremities were analysed. Thirty patients (63.8%; mean age 63 years) had metastatic, 17 patients (36.1%; mean age 53 years) had primary tumors. The femur (70%) was the most frequent tumor location site. Functional assesments of the patients were made using the Musculoskeletal Tumor Society (MSTS) scoring system on the follow-up period. The mean follow-up period was 18 months, being 36.3 months for primary, and 7.3 months for metastatic tumors.

Postoperative complications were seen in 9 patients (19.1%). 22 patients died due to tumoral causes during follow-up period, distant metastases exists in 4 patients, and 21 patients are tumor-free. Survival rates found significantly better in patients with primary tumors. All the patients were able to walk without crutches in the postoperative period. The mean MSTS score was 58.7% in survivors, which was 71% for primary tumors, and 53.1% for metastatic tumors.

Reconstruction with cemented modular endoprostheses is an appropriate surgical alternative in the treatment of extremity tumors, with satisfactory functional results particularly in primary tumors.


H. Tsibidakis G. Mazis V.I. Sakellariou P. Patapis G. Kostopanagiotou P.J. Papaggelopoulos

Presentation of two cases of pelvic periacetabular sarcoma, which were treated with wide resection of the tumor, pelvic reconstruction and lower limb salvage.

Two patients, one male 23 y.o. with chondrosarcoma and one female 75 y.o. with chondroblastic osteosarcoma, were treated in our clinic. Both tumors were stage II according to Enneking’s classification. Both tumors were treated with Enneking type II internal hemipelvectomy due to their periacetabular localization. After wide resection of tumors, pelvic deficit was reconstructed with allograft, which was internally fixated, and total hip replacement with constrained prosthesis.

Clinical evaluation showed absence of pain and satisfactory function of the limb. Imaging evaluation with x-ray, 3D-scan kai MRI showed satisfactory position and condition of allograft and internal fixation without evidence of loosening. Non weight bearing mobilization commenced 3 weeks postoperatively.

Internal hemipelvectomy requires precise preoperative planning and surgical knowledge because it is technically demanding due to complex structure of the pelvis, the great number of muscular attachments and the presence of important vessels, nerves and pelvic viscera. Wide pelvic resection and reconstruction with allograft for periacetabular sarcomas is a challenging procedure, which offers the opportunity of limb salvage associated with functional outcome.


D. Varvarousis A. Papadopoulos A. Ploumis K. Kanellakopoulou A. Beris H. Giamarellou

To compare usual practices against published guidelines of Perioperative Antimicrobial Prophylaxis (AP), which is an established method to reduce the risk of postoperative infection in TJR.

We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum.

The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B (2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR: 5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, therapeutic (group B) or prophylactic (group A), was comparable in both groups (p> 0.05).

Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic and therapeutic) in both groups.


M. Ioannou I. Papanastassiou S. Kottakis N. Demertzis

To present the oncological outcome of eleven patients with stage-3 GCT of bone.

Thirty-nine cases of GCT who were treated the past nine years at our department were reviewed. Five tumors were classified as stage I, twenty-three tumors as stage II and eleven as stage III tumors.

In stage I or II tumors we proceeded to an intraoperative biopsy (frozen biosy).In cases where the intraoperative pathological findings confirmed our diagnosis of GCT we proceeded to operative management. In cases where the intraoperative pathologist’s findings were not clear as well as in cases of stage III tumors we performed only a traditional open biopsy proceeding surgery in a second stage. In stage III tumors we aimed wide margins. Ten of these patients underwent wide surgical excision and limb salvage, while in one patient curettage with cementation was the treatment of choice in order to obtain a fair functional outcome.

With a minimum follow up of 3 years, we had no case of local recurrence in cases treated with wide excision and limb salvage. One stage III GCT treated with curettage recurred. Two stage III tumors metastized to the lung. The average interval from initial operation to lung metastasis was six months.

Treating GCT with the above management minimizes diagnostic failures. Literature shows local recurrence rate as high as 50% in stage III GCTs. The present study shows that recurrence rate can be significantly reduced and good functional outcome can be achieved by carefully planning approach and wide excision of the tumor.


M. Iosifidis D. Neophytou I. Melas T. Liakos A. Kyriakidis

Patella recurrent dislocation and patellofemoral pain syndrome instability many young people and especially athletes. In the present study we present the results of the extension mechanism realignment through the Fulkerson oblique osteotomy of the tibial tuberosity and soft tissue balancing.

During the last two years 10 patients (7 men, 3 women, mean age 29.3/ range 20–39) were treated operatively for recurrent dislocation of the patella using the Fulkerson procedure. All patients underwent knee arthroscopy for the treatment of potential chondral damage or loose bodies and for lateral retinacular release. After that we performed oblique tibial tuberosity osteotomy, medialization and internal fixation with 2 cortical screws. This oblique osteotomy allows also the anteriorization of tibial tuberosity as we move it medially. In addition, we performed medial placation. All the patients used functional knee brace locked to 0° right after the operation and with gradual ROM increase till the 8th p.o. week.

The patients had no initial or long term complication. During their last follow up examination had a painless knee with full ROM and marked improvement of the patella tracking. The mean Lysholm score was 90.5. No patella dislocation was referred.

Our findings show that the Fulkerson osteotomy procedure, with an additional intervention on the lateral and medial patella retinacular, is an excellent option for the treatment of recurrent patella instability and relief of the patellofemoral pain.


D. Varvarousis A. Ploumis A. Beris

To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles.

In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months.

Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001).

The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection.


G.A. Flevarakis G. Vatikiotis M. Papaioannou A. Mourikis G. Kyrargyris T.P. Kormas

Complex limb-salvage surgical techniques and reconstruction with sophisticated massive endoprostheses prove to be excellent tools for effective bone tumour management.

We treated 34 bone tumours (osteosarcoma, chondrosarcoma, plasmatocytoma, Ewing’s, osseous lymphoma, histocytosis-X, MFH, mets). We excised the lesions on oncologically safe surgical margins (wide excision inclunding anatomical barriers to tumour spread) and we reconstructed the defects with 29 modular and 5 custom designed and manufactured massive endoprostheses. Intramedullary stems were all cemented and they were supplied with hydroxyapatite collars that favour callus formation and extramedullary stabilisation. We did 12 proximal femoral tumour reconstructions, 17 distal femoral and proximal tibial tumours with rotating metal or polyethylene fixed-hinge knee implants and 1 total femur. In upper limb we did 2 proximal humerous with reverse polarity shoulder endoprostheses. In 1 humeral shaft case we did subtotal excision and reconstruction with two joint-saving endoprosthesis. In 1 distal humerus tumour we used custom constrained endoprosthesis of distal humerus and elbow. If tumours did not extend too close to the cartilage we applied joint-saving techniques. Function was restored with proper implant size selection and rearrangement of muscle remnants. On follow-up (4–58 months) average TESS score was 83%. There was no local recurrence and no aseptic loosening, dislocation or implant failure. Three patients with metastatic disease DOD. One case presented with late DVT and one with late deep infection.

New surgical methods and sophisticated implants with evidence-based design contributed greatly to successful limb salvage surgery as well as in overall patient prognosis and survival who enjoy better function.


M. Ioannou I. Papanastassiou G. Farfalli M. Carol C. Morris J. Healey

The objective of this study was to compare the results of two consecutive series of patients with either intra-medullary uncemented stems (UCS) distal femoral endoprosthetic replacement or the Compress® (CMP) distal femoral implant.

Patients were divided into two groups: those who received UCS prosthesis (Group-1: 54 patients) and those who received CMP prosthesis (Group-2: 42 patients).The most frequent diagnosis was osteosarcoma. Age and gender were similar both groups.

In Group-1, at a mean follow-up of 144 months, 37 prostheses were still in place. The overall Kaplan-Meier prosthetic survival rates were 79% at five and 62 % at ten years. Most of failures were long term complications. Aseptic loosening was the primary cause of late prosthetic failure. On Cox regression analysis, prosthetic stem diameter under 13mm was a significant negative prognostic factor for prosthetic survival (p=0.016).

In Group-2, at a mean follow-up of 84 months, 36 prostheses were still in place. The overall rate of CMP prosthesis survival was 86% at 5 years. All complications were during the first postoperative year, being femoral fracture the main revision cause.

The patients who retained the prosthesis had mainly good or excellent MSTS functional results in both groups.


D.S. Evangelopoulos S. Kohl A. Krueger M. Hartel H. Kohlhof C. Roeder S. Eggli

Total knee arthroplasty (TKA) disturbs patellar blood flow, an unintended accompaniment to TKA that may be a cause for postoperative anterior knee pain. We compared patellar blood flow before and after medial parapatellar arthrotomy to pre- and postoperative anterior knee pain scores to ascertain whether disrupted patellar blood flow correlates with anterior knee pain following TKA. Blood flow measurements were performed at full extension and at 30°, 60°, 90° and 110° of flexion prior to and after medial arthrotomy in 50 patients (21 male, 29 female; mean age 73.1±8.6 years) undergoing TKA. Anterior knee pain was assessed using the pain intensity numeric rating scale. A significant decrease in blood flow was detected at 60°, 90°, and 110° of flexion (p values: 0.00314,< 0.0001,< 0.0001 respectively). The medial arthrotomy did not have a statistically significant influence on patellar blood flow in the Students’ t-test (margin of significance p& #61603;0.05) Nineteen patients exhibited an average 14% (range 1%–54%) increase in patellar blood perfusion at knee flexions of 90° and 110° after medial arthrotomy (p value: 0.32) Prior to TKA, 16 of the 50 patients (32%) complained of anterior knee pain (average NRS 7.12, range 5–10). At 6-month follow up, 4 of the 16 patients (25%) complained of moderate anterior pain (average NRS 5.7, range 5–6), while 8 of 16 (50%) patients reported discomfort (average NRS 3.5, range 2–4) around the patella. No statistically significant correlation was found between intraoperative findings on patellar blood flow and the presence of anterior knee pain


A. Mourikis K. Ioannidis G. Vatikiotis G.A. Flevarakis D. Economopoulos T.P. Kormas

Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding.

40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure.

Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery.


A. Giannakopoulos S. Kalos I. Nikolopoulos A. Verykokakis G. Krinas D. Kypriadis G. Skouteris

To analyze the treatment results of late instability and dislocation of the hip following total hip arthroplasty.

The study refers to 16 patients from 42 to 71 years old when had primary THA. The mean time of late dislocation was 9,5 years and the revision mean time was 11 years following THA. In most patients extensive polyethylene wear was documented, in 12 patients the cup or the polyethylene insert on a stable metal implant was revised and in 4 patients new polytethylene cemented insert was placed in a stable metal implant. In all cases exchange of the femoral component metal head took place.

During follow up and re-evaluation 2–7 years after the revision there were 13 patients (81.25 %) with a stable THA and good function. Instability remained in three patients, which in 2 was resolved with re-revision of the cup whereas in the third (over aged) a special abduction brace was applied.

Late hip dislocation 5 or more years after THA occurs mainly due to extensive polyethylene wear and in contrast with early dislocation requires more often surgical intervention. The main cause of late hip dislocation was the extensive polyethylene wear, which in three cases was associated with prosthesis mal-orientation at primary implantation and in lots of cases with age-related neuromuscular deficit.

The treatment of late instability with repetitive dislocations requires surgical intervention. The revision might need exchange of cup or polyethylene insert on a stable metal implant or new polytethylene cemented insert on a stable metal implant.


A. Tzaveas R. Villar

Isolated osteochondral defects (OCD) of the femoral head remain a challenging issue for the surgeons when trying to balance between a less invasive procedure and the maximum benefit for the patient. We present our experience of the Hemicap partial hip resurfacing system in 12 patients. In ten patiens the defects were identified arthroscopically. Seven of them had concurrent early degeneration of cartilage (OA, Grade I). Three patients had OCD surrounded by normal cartilage and two patients had avascular necrosis. The mean patient age was 41 years (30 to 63) and mean follow-up 27 months (range 9 to 48).

Five patients required a hip resurfacing arthroplasty or total hip replacement at a mean interval of 17 months (12 to 24) due to persistent pain. Three patients required further hip arthroscopy at a mean interval of 36 months (range, 24 to 48). Four patients did not require secondary surgery with mean follow-up 32.7 months (range, 9 to 43). In all hips with revision surgery the components were found to be stable and secure.

Partial resurfacing arthroplasty seems to have a tendency towards early failure, especially in OA patients, but more favourable results in AVN patients, and the surgeons should have a cautious approach to this type of arthroplasty.


D. Neophytou T. Liakos N. Sakorafas M. Iosifidis D. Albanos A. Kyriakidis

Failure of a TKA is caused many times from the polyethylene debris or the mechanical forces which lead to loosening mostly to tibial component. The mobile meniscal knee prosthesis could provide solution as it simulates better normal knee function.

The aim of our study is to present the midterm results of TKA using mobile bearing platform Rotaglide.

During the period 2000–2004 we performed 261 TKA with the Rotaglide mobile polyethylene prosthesis (Corin Medical, UK). They are 235 women and 26 men, mean age 76.33 years, and the 93.7% of them (N=245) with primary osteoarthritis. The tibial component was cemented for all them, and for the femur was cementless for 146 cases (hybrid) and cemented for 115. None of them had patella replacement. One hundred five patients (59 hybrid and 46 cemented) were examined clinically and radiologically and the minimum follow-up time was 5 years (mean 6,6 /range 5–8 years). We use the Knee injury and Osteoarthritis Outcome Score (KOOS- range of scale for each subscore 0–100).

There was significant improvement of knee function and the majority of our patients were satisfied from the result. Specifically, the score for general symptoms and joint stiffness was 89.1, for pain was 83.3, for daily activities was 75.6 and for the quality of life was 72.5. One patient had revision TKA for femur component aseptic loosening.

Our results indicate that the Rotaglide total knee arthroplasty is a great choice for primary knee OA with excellent functional result.


G. Babis V.I. Sakellariou G. Mazis B. Tsouparopoulos P.N. Soukakos G. Hartofilakidis

The purpose of this study is to present early results, common pitfalls and management in in cases of revision hip arthroplsty in patients with congenital disease of the hip.

From 2001 to 2006, 36 consecutive cemented THAs with a history of congenital hip disease were revised due to aseptic loosening (31 cases), stem fracture (3 cases), septic loosening (2 case). There were thirty patients, all females, with a mean age at revision 61.7 years (range, 40 to 76). The revision was performed after a mean 15.4 years post primary operation (range, 9 to 26). In 7 cases the cup only, in 5 cases the stem only, and in 24 cases both components were revised.

The mean follow-up was 43 months (range, 24 to 84). There were 3 intraoperative femoral fractures managed with long stem and circlage wires. Postoperatively, 5 hips were infected and sustained a 2 stage revision using a cement spacer. 3 hips were revised due to loosening.

28 cups and 28 stems remained intact for an average 45.2 months (range, 24 to 84). The probability of survival at 48 months was 76.3% (±9.7%) for the cups (12 components at risk) and 76.4% (±11.3%) for the stems (9 components at risk).

Revision of a CDH arthroplasty is difficult and non predictable. Lack of acetabular bone stock and anatomical abnormalities of the femur lead to increased intra and postoperative complication rate.


G. Babis V.I. Sakallariou G. Mazis M’ O’ Connor A.D. Hanssen F.H. Sim

Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases.

At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05).

Reconstruction with an allograft-implant composite is a demanding procedure. However, preservation of bone stock is a major advantage.


C. Plakogiannis B. Theruvil K. Sisak R.G. Middleton

In revision of cemented femoral components, removal of cement can be challenging. This study evaluates the use of an ultrasonic device (OSCAR, Orthosonics Ltd UK) for cement removal.

30 consecutive patients that attended our outpatients\’ clinic between May 2008 and September 2008, who underwent revision THR by the senior author or his fellows, were retrospectively reviewed. Minimum follow up was 12 months (average 34.9 months).Indications were aseptic loosening and recurrent dislocation. A posterolateral approach was used routinely. Cement was removed with osteotomes and OSCAR. An uncemented modular femoral component was used. At follow-up, radiographs were evaluated for the evidence of extended trochanteric osteotomy (ETO), fracture, cortical perforation, component loosening, migration, and adequacy of cement removal.

None of the cases required an ETO or cortical windowing. In 5 cases prophylactic cabling of the proximal femur was performed. There was one intraoperative femoral shaft fracture (3.33%). There was incomplete cement removal in 7 cases. There was no cortical perforation and no postoperative fracture. There was no case with loosening or migration of the implant.

In all cases that OSCAR was used ETO and cortical windowing were avoided. At an average 34.9 month follow up there was no evidence of thermal tissue damage. In the cases that cement was retained in the canal, this did not affect the stability of the implant. The fracture and the incomplete cement removal were in cases performed by a fellow illustrating the learning curve of the technique.


K. Papageorgiou I. Papageorgiou P. Tilaveridid D. Voutsas A. Chatzioannidis S. Gerakas

Periprosthetic fractures represent a challenging problem in joint arthroplasty the incidence of which seems to be increasing due to the big number of the arthroplasties and the increasing average life expectancy.

The purpose of this study is to present the methods of treatment, the problems that we have to solve intra-operatively and our long term results about the healing procedure and the fuctional restoration.

Between 2000–2008 we operated 15 femoral peri-prosthetic fractures(1 re-fracture). 10 of them were after hip arthroplasties.

The classification which used was Lewis-Rorabeck for the fractures after TKR and Vancouver for them after THA.

Cause of fracture was fall and the time interval from the primary operation was 1–14 years. The majority of the patients were women(14), and the mean age 65 years.

13 of the 15 fractures were treated with ORIF and the remaining two need to be revised. During the follow up 2 of them died due to other pathological problems. The post op follow up ranged from 1–8(3.5)years.

The postoperative evaluation was done according the Harris Hip Score and the Knee Society Clinical Rating System.

The fractures healed after a mean time of 6 months. Two postoperative wound infections were registered to the revised fractures and their treatment were successful with surgical debridement.

All the patients are in good health condition, moving with some kind of support and they are selfreserved.

As a conclusion we believe that this kind of fractures demand the proper surgical planning, prediction of all possible complications and the cooperation of other specialties and physiotherapisties.


V. Galanis F. Monga N. Nalmpantis E. Diamantidis D. Panagiotidis T. Mitsitskas

We present the results of a single percutaneous injection of platelet-rich-plasma (PRP) to lateral epicondyle in patients with severe chronic lateral elbow epicondylitis(ELE).

Between 2006–2008 eight patients suffered from severe chronic ELE. They had severe persistent pain (mean 85, range 70–100 on a Visual Analogue Pain scale(VAS)) despite conservative methods at least one year. Three patients were men and five were women with age from 38–63 years (mean 44). Right elbow was the involved in six patients, left elbow in one and the last patient had bilateral ELE. All patients underwent a single percutaneous injection of PRP (located to lateral epicondyle using a specific technique). PRP is derived from centrifugation of 27–30 ml autologous blood using the GPS system. After the injection of PRP all patients underwent a 2-week standardized stretching protocol and then a strengthening program for four weeks. The results estimated with a 100-mm VAS (0 no pain, 100 the worst pain) and a modified Mayo Elbow Performance Score (MEPS). The patients examinated four, eight and twenty four weeks after the injection and also at the last follow-up (mean 28, range from 16 to 38 months).

There were no regional or systemic complications. Four weeks after treatment the patients reported improvement in VAS mean score from 85 to 40 and in MEPS from 51 to 75. Eight weeks after injection the VAS mean score improved from 85 to 22 and the MEPS from 51 to 82. At six months the VAS score was 10 (mean) and the MEPS 90. Finally at the last follow-up the mean VAS score was 7 and the MEPS 92.

The percutaneous injection of PRP to lateral epicondyle in patients with severe chronic ELE seems to lead in a significant reduction of their pain and improvement of their elbow function. These good results may sustain over time.


A. Tsezou T. Orfanidou S. Varytimidis K.N. Malizos

Cartilage calcification induces the synthesis of degrading enzymes, such as matrix metalloproteinases (MMPs) and prostaglandin E2 leading to tissue degeneration. The aim of the study was to investigate the effect of vitamin D on the calcification process in osteoarthritic cartilage.

We evaluated the effect of vitamin D on klotho (KL), Fibroblast Growth Factor 23 (FGF23) and Fibroblast Growth Factor Receptor 1c (FGFR1c) mRNA and protein expression levels by real-time PCR and western blot analysis, respectively. Possible interactions between klotho and FGF23 on the receptor FGFR1c in normal chondrocytes were investigated using immunoprecipitation assay. The direct effect of 1,25 dihydroxyvitamin D3 (1,25D) on KL, FGF23 and FGFR1c promoter was also evaluated.

We found that FGF23 and FGFR1c mRNA expression levels were significantly increased in osteoarthritic chondrocytes compared to normal, while KL mRNA levels were decreased (p=0.001 for all genes). We showed that klotho-FGF23-FGFR1c form complexes in normal chondrocytes and confirmed the participation of klotho in the initiation of FGF23-FGFR1c signalling. Treatment of normal chondrocytes with 1,25D resulted in a significant dose and time dependent increase of FGF23 and FGFR1c mRNA levels and in an increase of KL mRNA levels in osteoarthritic chondrocytes compared to untreated (p=0.001). We revealed, for the fist time, the presence of conserved, canonical VDREs in the proximal promoters of KL, FGF23 and FGFR1c.

We propose a common regulatory scheme of mineral homeostasis and aging in osteoarthritic chondrocytes evidenced by the positive/negative feedback actions by KL, FGF23, FGFR1c and 1,25D, through binding of vitamin D receptor (VDR) on the promoters of the above mentioned genes.


D. Chissas P.G. Ntagiopoulos G. Stamatopoulos D. Verettas K. Kazakos A. Papalois G. Loupasis A. Papaeliou G. Anastopoulos A. Asimakopoulos

Several observational and experimental studies have investigated the potential anabolic effects of statins on undisturbed bone but only a few recent studies have examined the effect of statins on skeletal repair. The goal of the study is to investigate any potential early anabolic effect of the systemic administration of simvastatin in low doses (based on earlier safety and efficacy studies on undisturbed bone) on fracture healing.

Fifty-four skeletally mature male New Zealand White rabbits were used for the study. The rabbits were assigned to one of three experimental groups: a control group, and two groups that were orally administrated a diet with 10 and 30 mg/kg/day of simvastatin, respectively. A complete biochemical blood count was performed to exclude drug-induced complications. Half of the animals of each group were sacrificed at 15 days and the other half at 30 days after surgery at which time intervals healing quality was assessed. The bones were subjected to biomechanical testing, histomorphometric analysis and peripheral Quantitative Computed Tomography.

In animals received simvastatin of 30 mg/kg/day a significant reduction of BMD, stiffness, and energy absorbed to failure were observed. At 15 days, the amount of cartilaginous callus formation was reduced, and the void space was significantly increased, in the animals of both groups that received simvastatin when compared to the control group (p< .05).

Our results suggest that simvastatin doses of 30mg/ kg/day may have a negative anabolic effect on callus formation in rabbits, whereas doses of 10 mg/kg/day seem not to produce a significant positive or a negative effect, especially at the early stages of fracture remodeling.


E. Tsiridis I. Pagkalos I. Polyzois G. Pavlou J. Charity E. Tsiridis G. Gie R. West

Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. A review of the English-language literature identified 23 citations eligible for inclusion. A total of 2063 bilateral simultaneous THR patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.365) and dislocation (p=0.877) when comparing staged or unilateral with bilateral simultaneous THR procedures. A systematic analysis of heterogenous data demonstrated that mean length of hospital stay was shorter after bilateral simultaneous THR. Blood loss was reduced after bilateral simultaneous THR in all studies except for one, and surgical time was not different between groups. This procedure was also found to be economically and functionally efficacious when performed by experienced surgeons in specialist centres.


T.W. Briant-Evans D. Veeramootoo E. Tsiridis MJ. Hubble

Periprosthetic fractures around a cemented femoral stem present a challenge to the treating surgeon. We propose a technique whereby a well fixed cement mantle can be retained in cases with simple fractures that can be reduced anatomically. This technique is well established in femoral stem revision, but not in association with a fracture.

24 Vancouver type B periprosthetic femoral fractures were treated by reducing the fracture and cementing a revision stem into the pre-existing cement mantle, with or without supplementary fixation.

3 patients died in the first 6 months for reasons not related to surgery and one was too frail to attend follow up. The remaining 20 cases were followed up for a mean of 3.0 years. The median time to radiological and clinical union was 3.0 months (2–11). The median Modified Harris Hip Score was 76.9 (35–97) and there was no sign of loosening or subsidence of the revision stems within the old cement mantle in any case at most recent follow up. One patient had further surgery for a delayed union and there were 2 subsequent fractures distal to the original fracture site in patients with poor bone stock.

Our results support the use of the cement-in-cement stem revision technique in anatomically reducible peri-prosthetic fractures with a well preserved pre-existing cement mantle. It is particularly suitable for older patients.


C.G. Chassanidis P. Kollia S. Samara T. Koromila S. Varitimidis K.N. Malizos Z. Dailiana

Periosteum is a specialized connective tissue that surrounds bone, containing progenitor cells that develop into osteoblasts. The osteo-progenitor cells along with growth factors, such as BMPs, play critical role in development, reconstruction and bone formation. Aim: to evaluate the expression of BMPs in human periosteum and in different subrgroups, including different donor sites, gender, and smoking habits.

Gene expression of BMPs 2,4,6,7 was performed in 60 periosteal samples using quantitative RT-PCR. Samples were obtained from 32 men/28 women, 22 smokers/38 non-smokers, 29 lower/31 upper extremities.

BMP2 gene expression was significantly higher (median: 12.02, p< 0.05) than the mRNA levels of BMPs 4,6,7 (median: 1.36, 2.55, 0.04) in all samples. BMP2 mRNA levels were higher in large compared to small bones (median: 13.4 vs 9.48), while BMPs 4,6,7 gene expression was similar (1.3 vs 1.4, 2.7 vs 2.1, 0.04 vs 0.03, respectively). In lower extremities, BMPs mRNA levels were higher than in the upper; the same was detected in non-smokers versus smokers group (BMPs2,4,6,7: 13.9 vs 1.5, 3.1 vs 0.048, 8.7 vs 1.06, 1.6 vs 0.026, respectively). mRNA transcripts of BMP2 were higher in men than women (median: 13.1 vs 10.8).

In our study, BMP2 expression is characteristically higher than that of BMP4, BMP6 and BMP7, highlighting the critical role that BMP2 plays in bone homeostasis. Furthermore, the elevated expression of BMP2 in men towards women, and of all BMPs of the lower extremity samples indicate the effect of hormones and mechanical factors in periosteal BMPs gene regulation; while the effect of smoking is reflected in the reduction of BMPs expression in smokers.


A. Tsezou Th. Simopoulou F. Kostopoulou K.N. Malizos

The aim of the study was to investigate the expression of genes regulating cholesterol efflux in human chondrocytes and to study the effect of an LXR agonist on cholesterol efflux and lipid accumulation in osteoarthritic chondrocytes.

Human cartilage was obtained from 24 patients with primary osteoarthritis (OA) undergoing total knee replacement surgery. Normal cartilage was obtained from 8 individuals undergoing fracture repair surgery, with no history of joint disease. ATP-binding-cassette transporter A1(ABCA1), apolipoprotein A1 (ApoA1), and liver X receptors(LXRα and LXRβ) mRNA expression levels were evaluated using real-time PCR. The effect of the synthetic LXR agonist TO-901317 was studied after treatment of osteoarthritic chondrocytes and subsequent investigation of ABCA1 and ApoA1 mRNA expression levels. Cholesterol efflux was evaluated in osteoarthritic chondrocytes radiolabeled with [1,2(n)-3H] cholesterol after LXR treatment, while intracellular lipid accumulation was studied after Oil-red-O staining. Apoptosis was evaluated using flow cytometry.

ApoA1, ABCA1, LXRα and LXRβ mRNA expressions were significantly lower in osteoarthritic chondrocytes compared to normal. Treatment of osteoarthritic chondrocytes with the LXR agonist TO-901317 significantly increased ApoA1 and ABCA1 mRNA expression levels as well as cholesterol efflux, while it significantly reduced apoptosis. Additionally, osteoarthritic chondrocytes presented intracellular lipids deposits, while no deposits were found after treatment with TO-901317.

Our findings suggest that impaired expression of genes regulating cholesterol efflux may be a critical player in osteoarthritis, while the ability of the LXR agonist to facilitate cholesterol efflux and decrease apoptosis suggests that it may be a target for therapeutic intervention in osteoarthritis.


A. Tsezou F. Kostopoulou L. Poultsides Th. Simopoulou K.N. Malizos

Our study aimed to investigate the role of an HMG-CoA reductase inhibitor (atorvastatin) in human osteoarthritic chondrocytes and to test the in vivo effects of intra-articular injections of atorvastatin in a rabbit experimental osteoarthritis model.

Human articular osteoarthritic chondrocytes were cultured in the presence and absence of atorvastatin. mRNA and protein expression of MMP-13, COL2A1 and aggrecan were measured using real-time PCR and Western Blot analysis.

New Zealand rabbits (n=15) underwent bilateral anterior cruciate ligament transection (ACLT) to induce osteoarthritic degeneration and received intra-articular injections of atorvastatin and normal saline in the left and right knees respectively. The first injection was at the time of ACLT and injections were repeated every 3 days for 3 weeks. Data were obtained from macroscopic and histological evaluation as well as from gene expression analysis for COL2A1, aggrecan and MMP-13.

Incubation of the cultures with atorvastatin produced a decreasing effect in MMP-13 expression. Regarding aggrecan and COL2A1 expression a significant increase was observed.

Gross morphologic evaluation showed that the joints which received atorvastatin injections, showed minimal cartilage erosion, compared to the non-treated knees where the cartilage was markedly eroded, especially on the medial knee compartment. These results were supported by histological and gene expression analysis. The mRNA expression of MMP-13 was significantly reduced in the cartilage of the statin-treated knee joints, while the expression of COL2A1 and aggrecan was increased.

The clinical relevance of our results indicates a potential protective effect of atorvastatin on articular cartilage undergoing osteoarthritic degeneration.


A. Drakou G. I. Karaliotas V. Sakellariou H. Tsibidakis K. Starantzis S. Athanasia

Implant materials impregnated with antibiotics have long been used to manage the dead space created by debridement surgery in patients with osteomyelitis.

To present our preliminary results and in vivo response of patients to PerOssal used to treat bone infection in the form of long bone chronic osteomyelitis. PerOssal is a new osteoconductive bone substitution material for bone filling which consists of an entirely synthetically produced, nanocrystalline hydroxyapatite and calcium sulfate. It can be used effectively as a local antibiotic carrier for the reconstruction of infected bone defects.

We have treated 19 patients with long bone osteomyelitis (15 tibial, 4 femoral) with PerOssal impregnated with the appropriate antibiotic which was used following radical debridement surgery. In all cases we did not rely solely on the mechanical stability that it may provide but we supported the bone when necessary. Postoperative observations were focused on primary wound healing and clinical eradication of infection.

We had: 15 eradication of infection, 2 recurrences, in terms of re-infection by different species or amputation, and 2 on-going cases. Declining wound leakage and delayed wound healing was present in 5 cases where PerOssal was used either intramedullarily but not sealed or extraosseously in relatively large amounts.

We have so far good results with respect to infection control. PerOssal seems to perform better when used in contained defects whereas extraosseous use seems to predispose to prolonged leakage and compromised wound healing or breakdown. The mechanical stability that it provides remains under consideration.


N.K. Kanakaris G.M. Calori N. Lasanianos R. Verdonk P. Cherubino T.J. Blokhuis P. DeBiase P.V. Giannoudis

Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting. The efficacy of BMP-7 in the treatment of recalcitrant aseptic femoral non-unions was studied.

Since 2003 a multicenter registry (bmpusergroup.co.uk) was created collecting details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.

Seventeen patients, who had undergone a median of 1(1 to 4) prior revision operations, over a median period from the injury of 17 months(9 to 42), were included in this observational study. In 76.4%(13/17) the BMP7 was combined with revision of the fixation. Non-union healing was verified in 14/17 cases(82.3%) in a median period of 6.5 months(3–15). Over 80% of these patients returned to their pre-injury level of activities, the median overall health state score was 82.5(35 to 100). No adverse events or complications were associated with the BMP7 application over the median follow-up of 24 months(12–68).


K. Ditsios D. Kapoukranidou A. Boutsiadis A. Chatzisotiriou M Alpani A. Christodoulou

Purpose of this study is to create an experimental model on rats for EMG evaluation of the supraspinatus muscle after traumatic rupture of its tendon.

The population of this study consisted of 5 male rats of 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The electrode of a stimulator was placed under suprascapular nerve and the supraspinatus tendon was sutured on a transducer for digital record of the produced signal. Initially we found the resting length and the electric intensity for higher muscle contracture. The parameters that were evaluated after single contracture (single twitch) were strength, time to peak, half relaxation time. Furthermore, it was evaluated the strength of tetanic contractures at 10,20,40,80,100 Hz (Stimulation for 350msec each time).Finally it was evaluated the muscle fatigue with stimulation at 40Hz for 250msec and total duration of 3 minutes. Fatigue index was calculated according to the decrease of titanic muscle contracture (Initial value-Final Value/Initial Value x 100)

Our results are presented in mean ± sd. The single twitch was 8.2(5.1),the time to peak 0.034(0.02) msec, the half relaxation time 0.028(0.008)msec. The strength of titanic muscle contractures was 5.7msec at 10Hz and 17.7 at 100Hz. Finally the fatigue index was calculated at 48.4.

We believe that EMG evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair.


R.K. Mallina N.K. Kanakaris C. Tzioupis H.C. Pape P.V. Giannoudis

The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing.

22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group.

The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay > 5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03).

Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process.


E. Mataragas C. Vassos N. Tzanakakis G. Mouzopoulos C.K. Yiannakopoulos Emm. Antonogiannakis

The evaluation of the results obtained after a long term follow up (over 60 months) from patients that were treated arthroscopically for shoulder instability.

In our paper we evaluated 116 patients (108 men and 8 women) with mean age of 24 yo, that were treated surgically by the same surgeon from 1999–2004. Seventy seven (77) of them (66,4%) were into sports activities and during pre op clinical examination 15 patients (12,9%) were diagnosed with joint hypermobility syndrome taking into account the Beighton criteria. Arthroscopic findings showed that 80 of them (68,9%) had some kind of bone loss, either glenoid (7 Large, 23 Medium, 6 Small) or Hill Sachs lesion (28 Large, 30 Medium, 20 Small) and in 8 patients an “inverted pear” glenoid shape was found. Our follow up ranged from 60–117 months (Mean=84) and the recurrence of instability and functional outcome were evaluated post-op using the Rowe Zarins Score.

Recurrent instability presented in 7 patients. Five (5) of them was due to high energy accidents, one was due to non-compliance and one was involuntary. Of these patients 5 presented Hill Sachs lesion, 3 showed glenoid bone loss (2 Large, 1 Small) and in none of them an “inverted pear” glenoid shape was found. All recurrent cases were into some kind of Overhead/Contact sports activity (6 Amateur, 1 Professional). The post op Rowe Zarins Score ranged from 80–100 (Mean=95,53).

The arthroscopic treatment of glenohumeral instability is an excellent method that provides similar or better results when compared to the open surgical treatment and with clear advantages over the latter because of lower morbidity, better cosmetic effect and lower total cost.


N.E. Efstathopoulos F.N. Xypnitos V. Nikolaou J. Lazarettos E.N. Kaselouris D.T. Venetsanos C.G. Provatidis

We investigated the effect of the location and the number of distal screws in the efficiency of an intramedullary nail implementing the finite element method (FEM).

The left proximal femur of a 93-year old man was scanned and two series of full 3D models were developed. The first series, consisting of five models, concerned the use of a single distal screw inserted in five different distal locations. The second series, consisting of four models, concerned the use of four different pairs of distal screws. Each model was analyzed with the (FEM) twice, first considering that the femur is fractured and then considering that the femur is healed.

For nails with a single distal screw, stresses around the nail hole were reduced with proximal placement of the distal screw but the area around the nail hole where the lag screw is inserted is stressed more. Furthermore, for nails with a pair of distal screws, placing the pair of distal screws at a specific location is most beneficial for the mechanical behavior of the femur/nail assembly.

The distal area of the nail generally gets less stressed when a pair of distal screws is introduced, while the presence of two distal screws far away from each other results in lower proximal femoral head displacements. The stress field at the area of fracture is not influenced significantly by the presence of a single distal screw or a pair of distal screws.


G. Tsikouris A. Kyriakos Th. Papatheodorou A. Tamviskos

The expansion of arthroscopic treatment to serious and catastrophic injuries to the weightlifters of the Hellenic National Weightlifting Team. The evaluation of the results of this specific arthroscopic treatment.

45 athletes (36 male, 9 female) with shoulder injuries 2000–2009. 15 yrs – 35 yrs, average: 27 yrs. One 3-times Golden Olympic. One Bronze medalist, Two Silver Olympic, Three Olympic winners, Five World championsetc. Clinical examination and musculoskeletal ultrasound. Plain X-rays. E.M.G, M.R.I.-arthrography, 3DC/T when that was required. Strength measurement with Nottingham McMecin Myometer for ipsi-contro lateral shoulder. Full ROM was necessary for the operated shoulder before starting exercise for a competition.

All 48 underwent arthroscopic treatment (3 mini-open). Arthroscopic stabilization using absorbable or non anchors. 45 athletes, 48 shoulders operated,(3 bilat-erally).36 RC tears, 6 bony-bankart, 2 posterior and 28 anterior labrum detachment, 3 avulsion osteochondral fractures, 2 AMBRII, 4 deranged LH of biceps, 4 underwent SSN release.

All patient returned at same sport level except one with AMBRII and cervical spine pathology. Rehabilitation time for basic weightlifting exercise was 3.5 months and for competition level was 4,5 -6 months.

The shoulder demands during the snatch, clean and jerk of the weightlifters provoke often shoulder injuries. The arthroscopic surgery gives thorough and broad knowledge of their shoulder injuries. The minimal detachment, less postoperative joint stiffness and decreased shoulder pain are encouraging factors for the arthroscopic treatment. Additionally, the returning time for training and competition combining with a proper rehabilitation seems to be less than open surgery.


G. Tsikouris Th. Papatheodorou A. Kyriakos A. Tamviskos

The early diagnosis of the suprascapular nerve (SSN) entrapment in overhead athletes with simultaneous shoulder injuries and its arthroscopic release plays an important role for their appropriate treatment and recovery. SSN release at suprascapular and spinoglenoid notches, seems very helpful for increasing their performance.

21 Elite overhead athletes were treated from Jan 2005–May 2009. From 16 to 34 years old, mean 26 years, 4 Javelin throwers (Olympic and National level thrower), 4 Weightlifters (International level), 8 Volleyball Players, 3 Kick Boxer, 2 Water Polo Players.

Extreme ROM of arm creates large torques about the shoulder cycle of repetitive microtrauma to the SSN, Direct trauma: fracture, dislocation, blunt trauma traction injury, Sling effect with hyper-abduction injury at the SS Notch, Correlation ROM with SSN entrapment in volley ball players, Eccentric contraction of the ISP (spinoglenoid notch), Internal impingement, Rotator cuff tears, Biceps lesions, Instability, SLAP lesion, Bankart lesion, Mainly infraspinatus muscle atrophy. X-rays, Nerve conduction studies, EMG studies, MRI

All of them had complete pain relief, especially at the posterior shoulder, regained full ROM of the operated shoulder, 19 fully recovered at the pre-injury level, 2 at the postoperative phase, Muscle atrophy improved

Advanced SSN entrapment provoke significant muscle wasting, often irreversible. This underscores the importance of a quick and accurate diagnosis to appropriate intervention. The overhead athletes with increased ROM of their shoulder predispose in SSN entrapment and shoulder injuries and vice-versa. An arthroscopic shoulder procedure for repairing the glenohumeral pathology with a simultaneous arthroscopic SSN release seems to be the appropriate treatment regarding to our resu


D. Karataglis P. Papadopoulos A. Boutsiadis N. Fotiadou I. Papaioannou A. Christodoulou

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively.

Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy.

Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears.

On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis).

Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients.


V. Chouliaras D. Giotis C. Roussi S. Boulis A. Grestas C. Tatsis

Tunnel enlargement after AC reconstruction with a hamstring autograft has been noticed mainly the first 3–6 months postoperatively. Its etiology involves biomechanical and biological factors. The aggressive rehabilitation program is another etiological factor. The aim of this study is to investigate the tunnel enlargement after ACL reconstruction with a Hamstring autograft by the aid of CT-scan.

We investigate the tunnel diameter in a series of 25 consecutive patients who operated with a Hamstring autograft 3 months postoperatively. The mean age of the patients was 23.6 years old (18–35). The same femoral fixation system (XObutton) and the same tibial fixation system (bioabsorbable screw) were used in all the patients. All the follow the same rehabilitation program, partial weight bearing from the 1st postoperative day, brace for 3–5 weeks and return to sports activities in 6 months.

In 2 patients a meniscal suture was performed and in 3 patients a partial meniscectomy was performed. All patients had excellent clinical result which was demonstrated by the physical examination and by the KT-1000 results. Statistical analysis was performed with the SPSS system. We noticed a tunnel enlargement in the majority of the patients, but this was not statistical significant (P< 0.01).

Tunnel enlargement after ACL reconstruction with a hamstring autograft has been noticed the first postoperative months, especially with the use of suspensor fixation systems. However in our study the tunnel enlargement is not correlated with a poor clinical outcome.


K. Starantzis A. Lendi P. Kondovazainitis D. Koulalis D. Mastrokalos

Evaluation of transtibial aiming of the femoral tunnel at its anatomical position in arthroscopical ACL reconstruction.

43 ACL reconstructions with hamstrings’ graft were studied. First, the femoral tunnel was drilled through the anteromedial portal at 09.30–10.00 (14.00–14.30 resp.) and then the tibial tunnel (av. anteroposterior angle: 63,5°, sagittal: 64,2°) at the same diameter with simoultaneous radiological documentation. Then, with a femoral aiming device, we tried to put a K-wire at the center of the drilled femoral tunnel. Fotographic documentation took place. In 20 cases the diameter of the tunnels was 7mm, in 11, 7,5mm, in 7, 8mm, in 3, 8,5mm and in 1, 9mm. Evaluation of all radiological and photographic material from 2 observers followed, according to the deviation of the transtibial K-wire from the center of the femoral tunnel.

38 ACL reconstructions were evaluated. It was shown that in 11 cases the transtibial K-wire was in the femoral tunnel (28,9%) (in 7 with a diameter of 7mm., in 2 with 7,5mm. and in 2 with 8mm.). The K-wire was in 23 cases (60,5%) at the perimeter or out of the femoral tunnel (in 11, with a diameter of 7mm., in 8 with 7,5mm., in 4 with 8mm., in 3 with 8,5mm. and in 1 with 9mm.). There was no correlation with the angles of the tibial tunnel or the age of the patients.

Transtibial aiming of the femoral tunnel at its anatomical position is very difficult and there is no correlation of the transtibial deviation with the diameter of the tibial tunnel.


P. Kondovazainitis K. Starantzis A. Lendi D. Koulalis D.S. Mastrokalos

The goal of this prospective study was to evaluate the results of arthroscopic meniscal repair with the FasT-Fix repair system. Type of study: Prospective case series. Methods: 83 meniscal repairs with the FasT-Fix meniscal repair system in 80 patients with a mean age of 29 years were performed between 2004 and 2008. Concurrent anterior cruciate ligament (ACL) reconstruction was performed in 70% of the cases. All tears were longitudinal and located in the red/red or red/white zone. Criteria for clinical success included absence of joint line tenderness, locking, swelling, and a negative McMurray test. Clinical evaluation included also the Lyscholm knee score, and KT-1000 arthrometry. Results: The average follow-up was 38 months (range, 10–61 months). Six of 83 repaired menisci (7.23%) were considered failures according to our criteria. Therefore, the success rate was 92.77%. Time required for meniscal repair averaged 15 minutes. Postoperatively, the majority of the patients had no restrictions in sports activities. 92% had an excellent or good result according to the Lysholm knee score. Four patients had a restriction of knee joint motion postoperatively, and an arthroscopic arthrolysis was performed in one of them. Analysis showed that, age, length of tear, simultaneous ACL reconstruction, chronicity of injury, and location of tear did not affect the clinical outcome. Conclusions: Our results, shows that arthroscopic meniscal repair with the FasT-Fix repair system provides a high rate of meniscus healing and offers reduction of both the risk of serious neurovascular complications and operative time.


G. Tsikouris A. Kyriakos Th. Papatheodorou A. Tamviskos

Hip arthroscopy has gradually evolved over the past two decades. Recently hip arthroscopy has an increasing role in diagnosis and treatment for specific intra articular and extra articular hip injuries and especially for soft tissue injuries.

February 2002 – May 2009

18 athletes

5 football players

8 basketball players

2 weight lifters

3 gymnasts

Mean age: 32 y.o. (19–39 y.o.)

Undiagnosed hip pain, Osteoarthritis, Labral pathology, Loose bodies, Osteochondral defects, Sepsis, Liga-mentum Teres, Trauma, Synovitis

Symptoms: Deep dull ache pain during hip flexion and external or internal rotation. Decreased R.O.M.

12/18 Cam sign + (positive), 11/18 Pincher sign + (positive), 14/18 Impingement syndrome in adduction and in flexion.

Instrumentation and Equipment: 30°, 70°, 4,5mm arthroscope, High flow rate mechanical pump, 15 gauge 6" cardiac needle, Convex full radius chondroplasty blades, Special electrocautery (Philippon), Distraction apparatus, Mechanical water pump unit, Image intensifier

Surgery: Standard orthopaedic traction table, Supine position, Hip is extended and abducted 25°

Portals: Anterior, Anterolateral, Posterolateral

Intraoperative Findings – Results

Detachment of the labrum, 2/18 erosion of the articular cartilage of the acetabulum and drilling of the bare area, 12/18 Cam sign excision

The athletes with symptoms of an internal hip pain and impingement signs after a clinical exam of their hip will get a benefit from an arthroscopic procedure for treating any existing cetabulo-femoral pathology, especially for the athletes with femoraloacetabular impingement syndrome (FAI).


N.E. Efstathopoulos J. Sourlas J. Lazarettos V. Nikolaou E. Brilakis F.N. Xypnitos

To evaluate the clinical outcome of arthroscopic treatment of ACL with an Achilles tendon allograft in patient with acute rupture.

22 patients, between 2003 and 2006, with acute rupture of ACL, were treated with an Achilles tendon allograft. The mean age was 26 years. Patients were evaluated before and after surgery and at the latest follow-up with Noulis-Lahmann test and Pivot shift test. We also used IKDC score, Lysholm score and one leg stance test and functional reach test. Patients were also evaluated with Cybex II + and with plain radiographies.

The mean follow-up time was 3.5 years. 90% of the patients had a negative pivot shift test and 95% of the patients had a score at Noulis-Lahmann test +1. The mean value of IKDC score was 88 (62–100) and the mean time of Lysholm score was 91 (75–100). Until the latest follow-up there were no clinical sighs of inflammation or graft rejection. Radiologic evaluation revealed no sign of tunnel enlargement.

We believe that the use of a fresh-frozen allograft in the treatment of acute ACL ruptures is an effective procedure for the restoration of ligamentous stability of the knee.


M. Iosifidis I. Melas G. Karnatzikos N. Sakorafas A. Kyriakidis

The bead EndoPearl is bioabsorbable material which placed in the ACL graft edge, and augment the stabilization in the femoral tunnel when an interference screw is used. Our aim was to recorded the operative characteristics of this technique and the clinical results after using EndoPearl in ACL reconstruction with hamstrings graft.

In 36 of our patients who had ACL reconstruction with hamstrings we used EndoPearl bead. They were 23 men and 13 women mean age 27.8 years (17–46). The graft was fixed in the femur side with interference screw. All patients followed the same p.o. rehabilitation regime. We followed them up the 1st, 2nd, 3rd, 6th and 8th p.o. month. During the last follow-up we checked the anterior drawer test, Noulis-Lachman test and in some cases pivot shift test, and in parallel Lysholm score was recorded pre-operatively and in the last examination.

In this last F.U. check none of them had positive Noulis-Lachman test or pivot shift test. The anterior drawer test was negative to 32 patients and in 4 we found slight laxity in comparison with the health leg. Lysholm score showed significant improvement (mean 90.2 p.o.), and nobody had “giving way”.

The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased in p.o. laxity.


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N. Markeas A. Constantopoulou N. Marinos C. Patrikareas J. Glykokalamos D. Pasparakis

The aim of this retrospective study is to isolate the cases of “overuse syndromes” in young athletes in whom the initial diagnosis proved wrong.

During six-year period 2002 – 2007, 28 young athletes (16 boys and 12 girls) aged 9.6 years (ranged from 6.5 to 14 years), suffering an underlying disease that had initially attributed to “overuse syndromes”, were treated in our Department. In all of the cases the history was misleading and the clinical examination was precarious, while the x-ray examination proved to be unclear. The remaining imaging exams led finally to the correct diagnosis that was confirmed in the operating room or via the biopsy.

In 4 cases a slipped capital femoral epiphysis was ascertained. In other cases we verified an osteochondritis dissecans of femoral condyle or talus (4), an osteoid osteoma (4), Perthes disease (3), osteochondromas (3), calcaneonavicular synchondrosis (3), hemangioma (2), discoid meniscus (1), herpes zoster along the sciatic nerve (1), aneurysmal cyst of fibula (1), accessory navicular (1), and osteosarcoma of fibula (1).

Overuse syndromes in young athletes should be treated with skepticism because another more serious disease may be hidden behind the symptoms and clinical signs. The children and adolescents have a skeleton that grows constantly and develops a special pathogenesis and this fact must be always kept in mind of parents, trainers and therapists. The young subjects who expect to be integrated in the athletic family should be previously examined by Pediatrician and Pediatric Orthopedic Surgeon so that a congenital anomaly or an acquired disease will be diagnosed in time.


J. Anastasopoulos D. Petratos E. Ballas E. Morakis G. Matsinos

To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents.

Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed.

Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases.

Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones.


A. Tsarouhas M. Iosifidis D. Kotzamitelos I. Spyropoulos C. Chrysanthou I. Giakas

To evaluate in-vivo the effectiveness of the double bundle technique for Anterior Cruciate ligament (ACL) reconstruction in restoring knee rotational stability under varying dynamic loading conditions.

The study group included 10 patients who underwent double-bundle ACL reconstruction with hamstrings tendon autograft, 12 patients with single-bundle reconstruction, 10 ACL deficient subjects and 12 healthy control individuals. Kinematic and kinetic data were collected using an 8-camera optoelectronic motion analysis system and one force plate. Knee rotational stability was examined during two maneuvers: a combined 60o pivoting turn and immediate stairs ascend and a combined stairs descend and immediate 60o pivoting maneuver. The two factors evaluated were the maximum

There were no significant differences in tibial rotation between the four groups in the examined maneuvers. Tibial rotation in the single- and the double-bundle groups were even lower than the control group. Rotational moments did not differ significantly between the four groups in any of the examined maneuvers. In general, rotational moments in the affected side of the ACL reconstructed and deficient groups were found reduced compared to the unaffected side.

Double-bundle reconstruction does not reduce knee rotation further compared to the single-bundle technique during dynamic stability testing under varying conditions. The injured side of ACL reconstructed or deficient individuals is exposed to substantially lower rotational moment compared to the intact side.


V. Tsiampa A. Hitzios D. Topsis Z. Zaharopoulos I. Tsagias C. Dimitriou

During the period 2004–2009, 35 children were admitted to the emergency department,(24 males:11 females), aged 3–14 years old,(MEAN 8,45 years), with supracondylar humeral fractures (33 extension type and 2 flexion type). All fractures were closed and result of sports injuries or games and were treated with closed reduction under general anesthesia and percutaneous k-w fixation.

The postoperative follow-up lasted from 6 months to 4 years. The Bauman’s angle was evaluated postoperatively on the operated and normal elbow and was 76, 6 ±1° and 74, 7 ±0, 6°. According to Flynn’s criteria the functional outcome was excellent in 29 cases. In 6 cases where the Bauman’s angle was greater than 10–15° there has been observed varus deformity (4 cases), valgus deformity (1 case), and flexion deficit (1 case).

The percutaneous k-w fixation and preservation of Bauman’s angle with carrying angle too, on supracondylar humeral fractures on children is a safe solution to avoid future complications.


G. Christodoulou G. Tagaris P. Tsoumpos V. Syribeis B. Bitas

The aim of our study is to report on our experience with elbow dislocations in childhood, the spectrum of the associated injuries and the various treatment modalities used.

In a period of 18 years, 52 children (33 male and 12 female) with elbow dislocations were treated in our clinic. 45 patients were followed-up with an average time of 7.2 years. 13(29%) dislocations were pure while associated injuries were present in 32(71%). Three had compound injuries. 23 of the associated injuries involved medial epicondyle fractures, 6 radial head fractures, 2 coronoid fractures, 2 lateral humerus condyle fractures, 1 ulnar diaphysis fracture and 1 radial peripheral metaphysic fracture. 27 patients treated conservatively while 18 patients treated surgically.

At the final re-examination, according to Roberts PH criteria, the clinical results were excellent in 24(56%) patients, good in 11(27%) patients, fair in 4(13%) and poor in 2 (4%) patients. A transit ulnar nerve paresis was perceived in 1 patient. The x-ray findings demonstrated 6 patients with medial epicondyle pseudartrosis and 6 patients with ectopic ossification.

Most elbow dislocations are associated with elbow fractures, therefore examination for an associated fracture is necessary. Closed reduction is the treatment of choice for elbow dislocations. Surgical treatment is indicated in elbow dislocations that are not reduced closely, in open injuries and in the presence of associated injuries that demand surgical treatment. The clinical and x-ray results are usually excellent. The presence of associated fractures, especially fractures of the radial head tent to lead in poor results.


T. Oney C. Copuroglou M. Ozcan K. Saridogan

We aimed to evaluate the relationship of forearm rotation with the magnitude of radial bowing and the localization of maximal radial bowing in children. The purpose of the study was to estimate the future forearm rotation limitation related the with the radial bowing.

Forearm fractured 26 children (younger than 15 years, 20 male, 6 female) were evaluated in 2 groups. Operatively treated (n=14) and nonoperatively treated (n=12) groups included diaphysis fracture of both forearm bones. In the early postreductive X-rays, maximal radial bowing (MRB) and the localization of maximal radial bowing (LMRB) were measured. Both groups were re-evaluated after a mean follow up of 25.5 months (range 4–62) clinically by the technique of Price et al. and radiologically by the method of Schemitsch and Richards. The relation of the MRB and LMRB with the forearm rotational movements were evaluated statistically.

No meaningful difference could be observed between the MRB and LMRB values of the injured and normal sides statistically (p> 0.05). Operatively treated patient group had closer degrees of MRB when compared with the normal side but there was not any meaningful statistical analysis. The number of patients having forearm rotation was so low that limits of forearm rotation could not be determined by the statistical methods. In the forearm pronation limited cases, it was observed that, when MRB decreases, the ability of pronation decreses and when LMRB increases, the ability of pro-nation also decreases.

If radial bowing degrees close to the normal side can be obtained, forearm rotation limitations due to differences of radial bowing can be prevented. The mean values of radial bowing and localization of radial bowing must be measured after forearm fractures of both bones.


G. Christodoulou P. Tsoumpos G. Tagaris G. Sdougkos V. Syribeis

Study of olecranon fractures in childhood and evaluation of the treatment approach.

During a 20 year period, 64 children with olecranon fractures were treated in our clinic. 51 children (41 males and 10 females) aged from to 2.5 to 14 years were reviewed. The follow up period was 1 to 20 years(average 9 years). Coexisting skeletal injury appeared in 31 patients. 36 children were treated conservatively while we follow operative treatment (open reduction and stabilization with Kirschner wires with or without tension-band or screws) in 15 children.

At the very last examination 2 children complained of mild pain during weather changes. Elbow extension was reduced from 5° to 15° in 6 patients and elbow flexion was reduced up to 5° in 3 patients. Pronation shortage was observed in 3 patients from 5° to 20° and a 10° supination shortage was observed in 1 patient. One case with pronation – supination shortage (40° and 70° respectively) while persisting subluxation of radial head was in 1 patient. The greatest degree of mobility limitation was observed in patients with comminuted fractures and associated injuries. Transient paresis of the radial nerve was observed in 1 patient.

The usual therapeutic approach to olecranon fractures is conservative.

In cases of displaced fractures, especially when the intraarticular displacement is greater than 3mm, surgical approach is indicated. Complications tend to occur more frequently among those cases with associated injuries. Olecranon paramorphosis in varus needs special attention since it usually coexists with radial head dislocation.


D. Metaxiotis Th. Nikodelis D. Moscha C.A. Milonas A. Kiriakidis

The objective and dynamic documentation of the knee kinematics in ambulatory children with spastic cerebral palsy and the examination of possible causes of differences when compared to normals.

17 ambulatory patients with an average age of 10,5 years (6–17 years) with cerebral palsy, spastic diplegia where examined clinically including Duncan-Ely test. They were also examined with 3-D instrumented gait analysis. The Elite system with six cameras was used and the knee kinematics in the sagittal plane was recorded.

Almost all patients (16/17) had a positive Duncan-Ely test during clinical examination. The knee kinematics in the sagittal plane showed that in 20/34 knees the range of motion was decreased compared to normal values. In 30/34 knees there was a delayed maximum knee flexion in swing phase and in 16/34 knees the amplitude of the maximum knee flexion was decreased compared to normals. Patients with severe crouch or mild rectus spasticity had almost normal knee flexion.

Foot clearance in swing phase is one of the basic prerequisites of normal gait. Patients with spastic cerebral palsy who are able to walk have an impaired foot clearance because of the pathological action of the rectus femoris.

In our study the majority of the patients with clinically confirmed rectus spasticity had decreased timing and amplitude of max. knee flexion in swing. In patients with severe co-contraction of the knee flexors and extensors max. knee flexion within normal range. Therefore it should not be considered as the only evaluation parameter in rectus femoris spasticity.


N. Pettas I. Nikolopoulos C. Antonis D. Kypriadis A. Apostolopoulos O. Leonidou

Pes equinovarus is a multi-factorial congenital disease that involves 1/1000 births, is bilateral in half of the cases and affects usually male children.

From 1995 – 2008 we have treated in total 172 children with pes equinovarus, 116 male and 56 female with age from 1 week to 4 years-old. There was bilateral pes equinovarus in 36 children whereas unilateral disease revealed equal rate of incidence. All children were treated initially with corrective casts and sequentially 122 children had surgery consisting of Achilles tendon lengthening and posterior capsulotomy, whereas in the rest of the cases was necessary medial hind foot structures and tendons release.

Final correction with only one operation were achieved in 108 children, there were pes equinovarus recurrence in 18 children that was treated with new soft tissue operation whereas 3 children had to undergo some kind of osteotomy in a later time. The recurrence time varied from 30 months to 13 years. The treatment was successful in 70% of the cases and 30% of them needed more than one operation for achieving a satisfactory functional result.

Pes equinovarus is a severe condition that now-a-days can be early diagnosed even in fetal life, but leads to significant handicap if left without treatment. In our department there were successful rates similar to international reports. The importance of an established long-term follow up of children that were operated for pes equinovarus is the keystone of a successful outcome and the early treatment is mandatory.


Ch. Konstantoulakis S. Kandanoleon C. Krommydakis G. Grigorakis V. Petroulakis

The purpose of the present study is to evaluate the early results of the Ponseti method when used for the treatment of idiopathic clubfoot among the population of the island of Crete.

Fourteen consecutive infants (twenty-one feet) with idiopathic clubfoot deformity were managed with the Ponseti method and were retrospectively reviewed at a minimum of six months. The severity of the foot deformity was classified according to the grading system of Pirani et al. The number of casts required to achieve correction was compared with published data for the treatment of idiopathic clubfoot. Recurrent clubfoot deformities or complications during treatment were recorded. Initial correction was achieved with a mean of 5.2 casts. Tenotomy and Dennis-Browne braces followed the cast applications. One foot had a relapse which was then treated by a repeat tenotomy at the age of 8 months. Two children abandoned the protocol because the parents could not comply with bracing. No extensive surgery is needed so far and all feet are flexible and pain free. X-rays when taken showed the talo-calac-neal angle within normal limits.

We support the use of the Ponseti method for the treatment of idiopathic clubfoot, since it can deliver flexible physiological feet, in the outpatient environment, thus avoiding the consequences of extensive open surgery.


G. Anastopoulos D. Chissas J. Dourountakis P.G. Ntagiopoulos G. Stamatopoulos N. Zacharakis A. Asimakopoulos Th.A. Xenakis

Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point.

A sample population of 22 cadaveric femurs was used. Computed-tomography sections every 0.5 mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools.

In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5±1.5 mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R2=0.7310) and the projected femoral neck-shaft angle (R2=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing.

The clinical relevance of the results is that in varus hips (neck-shaft angle • 120o) the correct entry point should be positioned over the trochanter tip and the use stiff nails is advised. In cases of hips with neck-shaft angle between 120o and 130o, the optimal entry point lies just medially to the trochanter tip (at the piriformis fossa) and the use of stiff implants is safe. In hips with neck-shaft angle over 130o the anatomical axis of the canal is medially to the base of the neck, in a “restricted area”. In these cases the entry point should be located at the insertion of the piriformis muscle and the application of more malleable implants that could easily follow the medullary canal should be considered.


A. Tsezou I. Papathanasiou T. Orfanidou K.N. Malizos

The Wnt/b-catenin signaling pathway participates in normal adult bone and cartilage biology and seems to be involved in cartilage degeneration and subsequent OA progression. The aim of this study was to investigate the activation of Wnt/b-catenin pathway in osteoarthritis and the role of LRP5, a coreceptor of Wnt/b-catenin pathway, in human osteoarhritic chondrocytes.

Human cartilage was obtained from 11 patients with primary osteoarthritis (OA) undergoing total knee and hip replacement surgery. Normal cartilage was obtained from 5 healthy individuals. b-catenin and LRP5 mRNA and protein levels were investigated using real time PCR and western blot analysis, respectively. Blocking LRP5 expression was performed using small interfering (siRNA) against LRP5 and subsequent MMP-13 mRNA and protein levels were evaluated by real time RCR and western blot analysis, respectively.

We confirmed the activation of Wnt/b-catenin pathway in osteoarthritis, as we observed significant upregulation of b-catenin mRNA and protein expression in osteoarthritic chondrocytes. We also observed that LRP5 mRNA and protein expression was significantly up-regulated in osteoarthritic cartilage compared to normal. Also, blocking LRP5 expression using siRNA against LRP5 resulted in a significant decrease in MMP-13 mRNA and protein expressions.

Our findings suggest that the upregulation of LRP5 mRNA and protein expression in osteoarthritic chondrocytes results in an increased activation of Wnt/b-catenin pathway in osteoarthritis. The observed reduction of MMP-13 expression after blocking LRP5 expression in osteoarthritic chondrocytes, suggests the involvement of LRP5 in the progression and pathogenesis of osteoarthritis.


I. Flieger N. Pettas A. Leonidou N. Liarakos I. Platanitis O. Leonidou

The cause of Legg-Calve Perthes disease, 97 years after its original description remains undefined. In the present study we examined factors, which were correlated with a favourable or negative impact on the outcome of surgical treatment.

From a total of 98 children, treated during the period 1994–2006, we studied 20 cases (classified as Catterall III and IV), treated surgically. The average age was 7.4 years (4–13 years). We studied in comparison the most common procedures performed: these were the varus femoral osteotomy (12) and the lateral shelf acetabuloplasty (7). The subtrochanteric osteotomy yielded superior radiological results Stuhlberg I–II (I:6, II:6), than the lateral shelf procedure Stuhlberg II–IV (II:3, III:3, IV:1). The clinical results were similar between the two groups according to the Barrett scale, excellent or good.

Regarding the subtrochanteric osteotomy the most important factor was the precise varisation of the femoral neck and secondly the timing of surgical treatment early during the fragmentation stage of the disease, before the femoral head is significantly distorted. The most important positive factor regarding the lateral shelf procedure appears to be the accuracy of the surgical technique, in order that the graft coverage of the femoral head is accurately placed on the hip capsule. Negative factor for the lateral shelf procedure in one case was early weightbearing, which resulted in collapsing of the femoral head. It appears that with extensive necrosis (Caterall IV) the femoral head isn’t biomechanically enough resistant with this procedure to resist loads that result from early ambulation.


M. Ioannou I. Papanastassiou S. Kottakis N. Demertzis

In the treatment of osteosarcoma, many reports in the literature outline that tumor response to chemotherapy directly correlates with disease-free survival and/or mortality. The aim of this study is to evaluate if the percentage of tumor necrosis is a sole prognostic indicator of overall survival in osteosarcoma patients.

We retrospectively studied 33 osteosarcoma cases treated in our institution from 1997 to 2006. All patients were treated preoperatively with HDMTX chemotherapy. The percent necrosis of the excised specimen were compared with survival rates of the patients.

Sixteen patients were good responders (Huvos III, IV- > 90% necrosis), 16 patients were poor responders (Huvos I, II- < 90% necrosis), and one patient died during preop. chemotherapy. With a mean follow-up of 5,48 years (3–12 years) 22 patients are NOD (not evident disease), in 8 patient disease progressed, 8 patients died. Statistical analysis could not establish a significant correlation between percent necrosis and patient survival.

Outcome of osteosarcoma may be dependent on a variety of factors s.a. tumor size, location, metastasis, surgical therapy, pathologic fracture. Tumor necrosis itself may be dependent on the histological subtype of the tumor and P-glycoprotein expression. In this series we could not establish tumor necrosis as a sole prognostic factor of patient survival.


K. Kazakos D. Lyras D. Verettas A. Polychronidis S. Botaitis G. Agrogiannis

We investigated the effect of Platelet Rich Plasma (PRP) in tendon healing. The aim was to assess the effect of an application of PRP on angiogenesis and immunohistochemical expression of TGF-b1 and IGF-I during tendon healing. We used a patellar tendon defect model after resecting its central portion. 48 skeletally mature New Zealand White rabbits were divided into the respective group and each group they were randomised into controls and PRP treated cases. The rabbits were sacrificed at weekly intevals and histological and immunohistological assessments were performed. The results showed a faster healing rate, increased vascularity, and higher expression of the growth factors in the PRP group. We conclude that the mixture of growth factors present in PRP gel improved the rate and quality of tendon healing.


M. Ovrenovits E.E. Pakos G. Vartholomatos G.I. Mitsionis

The aim of the study to analyze the circulating white blood cells including the intensity expression of surface receptors and cytoplasmic molecules in patients underwent total hip replacement, with either aseptic or septic loosening of hip prostheses in order to identify cell-surface and cytoplasmic markers that could be indicative of early loosening. Flow cytometry was performed in whole peripheral blood samples of 20 patients with loosening (10 septic and 10 aseptic). Ten healthy individuals served a control group. The CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated. The mean fluorescence intensity (MFI) of CD 18 was decreased on all leukocytes subsets compared to control group. For patients with aseptic loosening we demonstrated an increase of MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to control group. In patients with septic loosening an increase of MFI for CD 11c was observed in monocytes compared to control group. The comparison between aseptic and septic loosening showed a statistically significant lower CD18 MFI value in granulocytes for aseptic loosening. A trend towards lower MFI values of CD 62L in lymphocytes and granulocytes were observed in aseptic but not in septic loosening patients compared to control group. The present study is the first study in published literature to demonstrate cell surface and cytoplasmic markers in peripheral blood indicative of loosening of THAs by means of flow cytometry.


S.I. Stavridis N.P. Hailer F. Dehghani H.W. Korf A. Christodoulou

Aim of this experimental study was to develop an in vitro model that simplifies the study of various factors regulating neuronal regeneration.

An in vitro-system that allows co-culture of slices from rat motorcortex and spinal cord (p4) was established. Two groups of cultures were investigated: In the first group, intact spinal cord slices were cultured adjacent to motorcortex slices, while in the second group the spinal cord slices were sagitally cut into halves, with the sectioned interface placed directly adjacent to the motorcortex, in order to prevent the spinal white matter from interference. Each group was further divided into two subgroups: The NT-3 group, where the culture medium contained 50 ng/ml NT-3 and the control group treated with normal culture medium. Motorcortex pyramidal neurons were anterogradely labelled with MiniRuby, a 10 kD biotinylated dextran amine.

After 4 days the co-cultures were propagated, and axonal sprouting occurred. The group of co-cultures treated with NT-3 showed an improved cortical cytoarchitecture, and sprouting axons were more frequently observed. In NT-3-treated co-cultures where spinal cord gray matter was directly opposed to cortical slices sprouting axons entered the adjacent spinal cord tissue. This phenomenon was not observed if spinal white matter was opposed to the cortical slices, or if NT-3 was absent.

Our data suggest that the absence of repellent factors such as white matter and the presence of neuro-trophic factors promote axonal sprouting. Co-cultures of motorcortex and spinal cord slices combined with anterograde axonal labelling could provide a valuable in vitro model for the simplified screening of factors influencing corticospinal tract regeneration


Y. Kang J. Pagkalos J.M. Cha M. Heliotis E. Tsiridis A. Mantalaris

Simvastatin is a 3-Hydroxy-3-methylglutaryl Co-enzyme inhibitor, widely used to reduce lipid levels. Recent studies have demonstrated pleiotropic beneficial effects the skeleton. We aim to demonstrate the effect of Simvastatin on the osteogenic differentiation and proliferation of murine embryonic stem cells.

Tg2a cells were cultured in maintenance medium until confluence and passaged twice into tissue culture flasks. They were then seeded into 6 well and 24 well plates at a density of 10.000 cells/cm2 and cultured for 3 days in maintenance medium mixed at 1:1 with HepG2 conditioned medium. The culture then continued using osteogenic medium with different concentrations of simvastatin for another 16 days. Measurements included Alizarin Red quantification for calcified matrix, ALP assay, RT-PCR for genes expressed during osteogenic differentiation (osteocalcin, Runx2, osterix, Col1a1).

Simvastatin has dose dependent effect on mineralized matrix formation. Alizarin Red quantification assays demonstrated that simvastatin (all dose groups) induced a statistically significant increase in calcified matrix formation on day 11 (P< 0.05) and 16 (P< 0.01) compared to the control group. ALP activity was significantly higher on day 8 in the groups that had a simvastatin concentration of 1nM, 10nM and 100nM (P< 0.05). RT-PCR has demonstrated that simvastatin caused increased expression of all genes measured on differentiation. Statins can induce bone formation when combined with embryonic stem cells.


G. Rudol I. Polyzois J. Pagkalos R. Wilcox E Tsiridis

During hip revision removal of old cement mantle is a major problem. In cases of satisfactory bond between cement mantle and the underlying bone, cementing the revision stem into the old mantle is regarded as a highly attractive option. The aim was the analysis of the shearing strength of the interface between two layers of poly-methylmethacrylate cement in the presence of fluid.

A laboratory, two-dimensional model of the interface was used. Effect of different viscosity fluids and volumes on its strength was checked. 6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure.

Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa. This was significantly lower compared with control monoblock (19.8MPa), dry surface variant (16.9MPa) and the stain with small amount high viscosity fluid (16.01MPa). Interestingly, presence of a large volume of low viscosity fluid did not significantly reduce resistance to shear stress (17.05MPa).

In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid could be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable


S.I. Stavridis N.P. Hailer F. Dehghani H.W. Korf A. Christodoulou

The aim of this experimental study was to provide an in vitro model suitable for the investigation of the complex interactions of neurons with non-neuronal cells that take place throughout the degenerative and regenerative processes induced by spinal cord injury.

Organotypic spinal cord slice cultures (OSCSC) were prepared from postnatal Wistar rats (p0–12), were sustained in vitro up to 12 days and characterized by immunohistochemistry by well-established markers such as NeuN, Calbindin, GFAP, IB4 and Nestin.

Calbindin+ neurons, distributed across the entire gray matter, were visible also after longer culture periods. NeuN+ neurons were best preserved in the dorsal horn, whereas large NeuN+ and ChAT+ motoneurons in the ventral horn vanished after 3 days in vitro. GFAP+ astro-cytes, initially restricted to the white matter, invaded the gray matter of OSCSC early during the culture period. Microglial cells, stained by Griffonia simplicifolia isolectin B4, were rapidly activated in the dorsal tract and in the gray matter, but declined in number with time. Nestin-immunoreactivity was found in animals of all age groups, either in cells interspersed in the ependymal lining around the central canal, or in cells resembling protoplasmic astrocytes. OSCSC derived from p0 or p3 animals showed a better preservation of the cytoarchitecture than cultures derived from older animals.

In summary, OSCSC contain defined neuronal populations, the cytoarchitecture is partially preserved, and the glial reaction is self-limited. Our model of OSCSC could prove useful in future experiments on the patho-physiology of spinal cord injury


G. Stathakos I. Koutroumpas N. Manidakis G. Hatzipavlis K. Balalis P. Katonis

The evaluation of two methods for the placement of the tibial component of total knee arthroplasties in obese patients

Between December 2004 and October 2008 we studied 38 obese patients who underwent cemented total knee arthroplasty (using the rotating platform tibial tray) due to medial compartment osteoarthritis and consequent varus deformity. All patients had a body mass index (BMI)> 40. Functional outcome was assessed using the Knee Society Score (KSS). The study was based on the comparison between extramedullary (group A) and intramedullary (group B) instrumentation systems for the placement of the tibial prosthesis. The main endpoint was the immediate post-operative knee joint alignment.

There were 10 male and 28 female patients. The average follow-up period was 13.8 months (minimum follow-up of 6 months). There were 22 patients in group A whereas 16 patients comprised group B. In 5 of the 22 patients in group A there was an average varus malalignment of 40 and a mean KSS of 71.5 at the time of the latest follow-up visit. In the rest of patients of both groups there was a valgus alignment between 0 and 70 and a mean KSS of 86.4 respectively

Our experience suggests that the intramedullary instrumentation technique for the placement of the tibial component offers a more favourable post-operative alignment as well as better functional outcome in obese patients.


G.N. Manoudis A.L. Spain P. Ousema R.R. Glisson M.E. Easley A.E. Beris

Because ankle inversion trauma can result in persistent isolated subtalar joint instability and can contribute to chronic lateral ankle instability, optimization of subtalar joint ligament injury diagnosis and treatment is essential.

12 fresh-frozen cadaver lower extremities were used. The cradle was a component of a gimbal system that allowed unrestricted inversion/eversion and anterior-posterior and medial-lateral translation of the subtalar joint. The bearing system to which the tibia/fibula were attached allowed unconstrained internal/external rotation and superior-inferior translation. 4N-m inversion/ eversion and internal/external rotational moments and translational forces of 67N were applied. All measurements were performed sequentially in neutral, 10° dorsiflexion and 20° plantarflexion, and were repeated as the cervical, calcaneofibular, and interosseous ligaments were consecutively sectioned in all possible different orders.

In neutral position, inversion increased after sectioning of the cervical (3.7°), interosseous (0.8°), and calcaneofibular (1.9°) ligaments individually. Combined sectioning of all three ligaments showed an increase in inversion of 8.3°, 8.5° and 1.4° in the neutral, plantarflexed, and dorsiflexed positions, respectively, compared to the intact ankle. External rotation also increased in neutral position after sectioning the cervical ligament (2.0°). Combined sectioning of all ligaments showed an increase in external rotation of 3.6° and 5.4° for neutral and dorsiflexion, respectively.

This is the first comprehensive biomechanical cadaver study of the contributions of the cervical, calcaneofibular, and interosseous ligaments to stabilization of the subtalar joint. The surgeon may refer to the findings in both diagnosing and planning treatment of problematic subtalar joint instability


H. Tsibidakis V. I. Sakellariou V. Tsouparopoulos G. Mazis K. Staratzis A. Kanellopoulos

To study the use of TSF system in treating trauma and bone deformities in children. To determine the difficulties of this process and the risk factors that lead to complications.

From January 2004, in 61 children (37 male and 24 female), 67 extremities, with a mean age 8.9 years children a TSF external fixator was applied for the treatment of trauma or bone deformities. 21 children were operated for angular deformity, 19 for bone lengthening, 10 for rotational deformity, 6 for combined angular deformity and lengthening and 11 for pseudoarthrosis. Intra and postoperative difficulties were classified using the Palay method in problems, obstacles and complications.

The rate of difficulties was 22.2 %. Problems were presented in 5.9% (4/67) consisting of 2 non-axial deformities, 1 pin fracture and 1 subluxation of the knee. Obstacles were presented in 10.4% (9/67) including 3 cases with delayed bone healing that needed infusion DBM, 1 peroneal nerve palsy due to hematoma formation treated with decompression of the region, 1 early bone fusion that needed re-operation and 2 cases of percutaneous achilles lengthening. Complications presented in 5.9% of (4/67) the cases including 1 fracture, 1 pseudoarthrosis, 1 peroneal nerve palsy and 1 limitation of range of motion in the knee (0–45 0).

The problems, obstacles and complications that presented during treatment influenced the final therapeutic objective. Initial deformity, preoperative planning and surgeon’s experience are associated with reducing the rate of all difficulties


P. Korovessis Th. Repantis A. Baikousis

Most studies on LBP have focused on adults although many investigations have shown that the roots of LBP lie in adolescence. Several mechanical, physical and behavioral factors have associated with non-specific LBP in adolescents. To our knowledge no previous study has investigated using advanced statistics all previously reported parameters together with psychological and psychosocial factors on LBP in adolescents aged 15–19 years.

688 students aged 16± 1 years from 5 randomly selected high schools participated in this multifactorial study and completed a questionnaire containing questions on daily activity, backpacks carrying, psychological and psychosocial behavior. Anthropometric data as well biplane spinal curvatures together with questionnaire results were included in the analysis using advanced statistics.

LBP reported 41% of the participants. Generally, statistically significant correlations were found between LBP(0.002), physical activity(P< 0.001), physician consultation(P=0.024) and depression (P< 0.001) Gender-related differences were shown regarding LBP intensity(P=0.005) and frequency(P=0.013), stress(P< 0.03), depression (P=0.005) and nervous mood(P=0.036) in favor of male students. Male adolescents had continuously energy (P=0.0258) and were calm (P=0.029) in contrast to female counterparts.

LBP was gender-related and was less common in adolescents with frequent activity. Adolescent girls with stress, depressive mood and low energy have more LBP than boys that makes physician consultation for LBP more common in female adolescents.

Systematic physical activity and control of psychological profile should decrease LBP frequency and intensity


S. Samara P. Kollia Z. Dailiana C. Chassanidis L. Papatheodorou T. Koromila K.N. Malizos

We evaluated the contribution of specific gene polymorphisms of IL-1a/IL-1R/IL-1RA/IL-4Ra/IL-1b/IL-12/γIFN/TGF-b/TNF-a/IL-2/IL-4/IL-6/IL-10 cytokines in patients with AVN.

DNA was extracted from 112 patients and 238 healthy Greek individuals. DNA analysis was performed by the PCR-SSP method and the use of the Protrans kit. Statistical analysis was performed by χ2 test.

In the patients, the TC frequency of the IL-1a (nt-889) was 52% while in normal was 40%. The C/G allele frequency of TGF-b codon 25 in patients was 9% C and 91% G vs 13% C and 87% G in normal. At position −238 of TNFa, 11% of the patients had the GA genotype in contrast to 1% of the controls. The GG/GG haplotype of TNFa gene promoter (nt. −308 and −238) was more frequent in both groups, while the GG/GA haplotype detected in 9% and 1% of the patients and controls, respectively. At the −1082 position of the IL-10 gene, the GG genotype was detected in 15% of the controls and 7% of the patients. Also, the GCC/GCC haplotype in IL-10 (positions -1082/-819/-592) was higher in the controls (15%) than the patients (7%).

The genotypes TC (nt-889) of IL-1a, GC (codon 25) of TGF-b, GC (nt-1082) of IL-10 and GA (nt −238) of TNFa, are more prevalent in the patients than the healthy individuals (p< 0.05). Based on our results, the presence of one of the above mentioned polymorphisms or the simultaneous carriage of more than one may contribute to the risk for osteonecrosis


S. Samara Z. Dailiana K.N. Malizos S. Varitimidis C. Chassanidis T. Koromila P. Kollia

Avascular necrosis (AVN) is a disorder leading to femoral head (FH) destruction, while BMPs are known for their osteogenic ability. In this study we analyzed BMP-2, BMP-4, BMP-6 and BMP-7 expression at the RNA and protein level in the normal and necrotic sites of the FHs.

Quantitative RT-PCR for BMP-2,-4,-6,-7 genes was performed in samples from the normal and necrotic sites of 52 FHs with AVN. Protein levels of BMP-2,-4,-6 were estimated by Western Blot analysis. Statistical analysis was performed using the t-test (p< 0.05).

BMP-2 and BMP-6 mRNA levels were higher in the normal than the necrotic site (BMP-2 and BMP-6, normal vs necrotic: 16.8 vs 7.5 and 2 vs 1.66, respectively). On the contrary, BMP-4 mRNA levels were higher in the necrotic (1.2) than the normal site (0.97), while BMP-7 mRNA levels were low in both sites. At the protein level, BMP-2 expressed higher in the normal (0.63) than the necrotic region (0.58), while BMP-4 and BMP-6 detected at higher levels in the necrotic site (BMP-4 and BMP-6, normal vs necrotic: 0.51 vs 0.61 and 0.52 vs 0.57, respectively).

Different mRNA levels between the normal and necrotic site, as well as discrepancies between the gene and protein BMPs expression levels suggest a different regulation mechanism between the two regions. Better understanding of the expression pattern of BMPs could lead to a more successful use of these molecules in the prevention and treatment of AVN


P.V. Giannoudis N.K. Kanakaris C. Tzioupis V.S. Nikolaou G. Kontakis

To evaluate the effectiveness of Pulsed-Lavage and of Versajet-hydrosurgery in removing two Staphylococcus aureus strains from porcine tissue and graphite powder from simulated fractures.

Overnight broth cultures (NCTC-6571) and S.aureus strains were diluted to yield inocula containing 1x103c. f.u. ml-1. Initially 8 porcine legs were used; porcine tissues were inoculated with 10ml of either of the two S.aureus strains. Control tissues were inoculated with PBS. All inoculated samples were irrigated with 300ml of saline using the pulsed-lavage system or using the Versajet. 10ml of each of the following were plated out in triplicate:

inoculum pre-incubation

inoculum post-incubation,

each left over inoculum following removal of tissue and dilutions of 10-1 and 10-2 and

Wash from all samples.

Eight additional porcine legs were used where 2 incisions were made down to bone in a cross-hatch pattern. 1g of graphite powder was infiltrated into each fracture site to simulate a contaminated open fracture. Each fracture site was irrigated with 500ml saline through pulsed-lavage or Versajet.

The average microbiological reduction using Pulsed-Lavage or Versajet was 2% and 15% respectively. The clinical S.aureus strain was more adherent than the laboratory strain. The Versajet maintained a 12–16% reduction of S.aureus, whereas pulsed-lavage did not reduce contamination. The number of graphite particles was significantly reduced with the use of the Versajet system compared with the pulsed-lavage.

Versajet system was more effective in removal of foreign particles and more effectively reduced the micro-biological load of both examined S.aureus strains in a porcine model. Further studies are indicated to evaluate the efficacy of this system in clinical practice


D. Economopoulos I. Plaitakis M. Papaioannou G. Vatikiotis D. Lekkas T.P. Kormas

Our aim was to assess the value of external fixation in pathological fractures in selected patients.

During 2003–2008 we treated 35 patients with multiple myeloma or disseminated cancer, visceral metastases and pathological fractures with external fixation under sedation and local anaesthetic, because they were not fit for general anaesthesia. We used external fixation on 1 hip fracture, 1 fracture of the second metatarsal, 2 wrist fractures, 4 radial, 5 intertrochanteric, 1 subtro-chanteric, 12 fractures of the humerus, 1 ulna fracture, 4 femoral fractures, 3 tibial fractures and 1 femoral osteolysis. Operating times were 15–35 min, all patients were comfortable, cooperated well and they did not experience any pain during the procedure. In all cases XRT was applied either pre- or post-operatively.

On follow up (2–48 months) 4 of the patients were deceased. Fracture stabilization was adequate and X-rays confirmed porosis in 4 fractures; however, two lesions expanded further, despite proper adjuvant bio-pharmaceutical therapy. 5 patients impoved so we could operate them later to treat the fractures definitively. All individuals experienced pain relief, they were adequately mobilized and most function was restored, while there was no major problem with pin tract infections.

We suggest external fixation as a palliative treatment in patients with pathological fractures and multiple metastases, who don’t qualify for major surgery because of their critical illness. The later puts under local offer an excelent chance to fix fractures quikly, manage the pain and restore function without the risks of general anaesthesia


A. Christodoulou P. Antonarakos A. Boutsiadis P. Givissis E. Christodoulou

Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis.

Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest.

All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site.

CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area.

In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects


A.F. Mavrogenis P. Liantis D. Antonopoulos S.G. Spyridonos P.J. Papagelopoulos

To evaluate the functional outcome after complete median nerve transaction and repair, and sensory reeducation.

We studied 40 patients, aged 20 to 32 years, with median nerve neurotmesis at the wrist. Primary epineural microsurgical repair using 8-0 single strand sutures was done in all patients, and a hand and wrist cast was applied for 4 weeks. After cast removal all patients went through physical therapy for 1 month to restore motion and reduce stiffness of the injured hand. After reinnervation was completed, the patients were randomly allocated into 2 equal groups: Group A patients were instructed to a sensory re-education program; Group B patients had no further treatment. Clinical evaluation was done at 18 months postoperatively including the localization test (locognosia), the static and the moving 2 point discrimination tests, the Moberg’s pick-up test (stereognosia), and the hand grip and the opposition strength tests.

All patients were included in the postoperative evaluation. Hand grip and opposition strength, static and moving two point discrimination were not statistically significant between the two groups (p= 0.622, p= 0.112 and p= 0.340, respectively). The localization test was statistically significant in group A (p= 0.007), and a trend to statistical significance was observed regarding the Moberg’s pick up test in group A (90% statistical significance, p= 0.063).

Sensory reeducation is essential for patients with median nerve neurotmesis and repair, as it significantly re-educates localization and stereognosia in the shortest time following peripheral nerve injury and repair


A.F. Mavrogenis P. Liantis K. Pavlakis A. Stamatoukou P.J. Papagelopoulos P.N. Soucacos

In the peripheral nervous system of rats, a wide-variety of toxins has been studied to selectively target neurons projecting through a particular nerve. We employed 54 adult male rats to create a neuroma-in-continuity and to evaluate the effect of the immunotoxin OX7-saporin to inhibit neuroma-in-continuity formation. Materials and Methods: The left common peroneal, tibial or sciatic nerves were crushed by one 10-second application of a microforceps. At 3 and 6 weeks after nerve crush, the respective nerve was cut distal to the site of nerve crush, and microinjection of 2 μl of natural saline or 2 μl of the OX7-saporin was done.

In all nerve specimens of the control group and the saline-injection experimental subgroups, gross observation showed a thickened area at the site of nerve crush. Histology showed features consistent with a neuroma-in-continuity. In 11 of the 14 nerve specimens of the OX7-saporin injection experimental subgroups, gross observation showed a narrowed area at the site of nerve crush. Histology showed prevention of neuroma-in-continuity formation as seen by wiping out of almost all nerve fibers, leaving an empty tube encasing by connective tissue.

This study supports the hypothesis that intraneural injection of the OX7-saporin may inhibit neuroma-in-continuity formation


C.S. Vasiliadis M. Brittberg A. Lindahl L. Peterson

We assessed 224 patients treated with Autologous Chondrocyte Implantation performed 10–20 years ago (average 12.8 years). Average age at the time of the implantation was 33.3 years. Average size of lesion was 5.3 cm2 (range 0.6–16), while 55 patients sustained multiple lesions. The participants filled out five questionnaires. Lysholm score, Tegner-Walgren, modified Cincinnati (Noyes), Brittberg score, and KOOS were assessed. In addition, the patients were asked to grade their current situation compared to their previous follow up as better, worse of unchanged. Finally, they were asked if they would do the operation again, answering with yes or no.

The patients were divided into groups according to the location and characteristics of the cartilage lesions, or concomitant surgeries during the ACI. Assessment of the outcomes reveals a significant improvement in all groups, compared with the preoperative values.

There is no other study assessing a cartilage treatment with such a long follow up. According to the results of that study, autologous chondrocyte implantation seems to be an effective and durable solution for the treatment of large full thickness cartilage and osteochondral lesions of the knee joint


A. Kalambokis C. Kokoroghiannis A. Deligeorgis E. Magnissalis I. Aktselis S. Karagiannis

Locking strategies of the sliding screw in gamma nailing (G3) were tested in an experimental biomechanical study.

Twelve Composite Femoral Bone models were used. An intertrochanteric osteotomy was performed and a gamma nail was implanted in each specimen. The specimens were divided in 3 groups:

compressed and locked,

locked at distance and

unlocked. Each specimen was subjected to 4 cycles of static vertical loading of up to 1100 Newtons (N) at a rate of 10 mm/minute.

Subsequently, the specimens were investigated for cut-out patterns using digital photography and management.

All failures occurred under supraphysiological loads. During their first loading cycles, no statistical differences for stiffness and yield load were noted. Nevertheless, there was a non–significant tendency for higher failure loads for the unlocked group. Under maximum load (1100 N) and already established deformations, all Gamma Nails behaved similarly in terms of neck-screw displacement, with no statistical differences.

Unlocked screws exhibited the most moderate failure modes followed by the compressed and locked group. The third group showed the most severe failures.

In conclusion, there is evidence that sliding is biomechanically superior in gamma nailing. Despite adverse mechanical circumstances all specimens behaved satisfactorily under physiological loading


M. Beltsios O. Savvidou E. Papavasiliou G. Giourmetakis A. Kaspiris J. Mpesiris

The frequent choice of treatment for tibial shaft fractures is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen with satisfied results.

Twenty-nine patients with complex, unstable tibial shaft fractures (13 males and 16 females) aged 18 to 76 years (mean age 49 years) were treated using Ilizarov external fixation, the last decade in our Department by the same surgeon. The indications were open Gustillo III fractures, comminuted fractures of the proximal or distal third tibia near metaphysis, concomitant plateau or pillon fractures and fractures after total knee arthroplasty (TKA). All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within2 weeks after surgery.

Union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit, 10 superficial pin tract infection treated with antibiotics and local care and 1 deep infection which needed surgical intervention.

Ilizarov external fixation gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing


M. Beltsios O. Savvidou G. Giourmetakis E. Papavasiliou J. Dimoulias

Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years).

Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed.

Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients.

Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases


G. Antypas Ath. Konstas G. Kontogiannis K. Liossis P. Gakis N. Prevezas

The treatment of high energy fractures of distal tibia by internal fixation is followed by a high rate of soft tissue complications.

The result estimation of these fractures in a two stage treatment, bridging the ankle by Ex-Fix with/without internal fixation of the fibula and internal fixation of the tibia after soft tissue recovery

In a 4 year period (2005–8), 15 patients, average of 42 years were treated. The AO fracture classification was followed. The soft tissue damage estimation (Osternn-Tscherne and Gustillo classification), the fracture pattern of the fibula and the injury mechanism consisted of the choice method criteria. The majority of the injuries was classified Tscherne II & III, and 3 open fractures Gustillo II. Fracture reduction was performed by bridging Ex-Fix of the ankle with/without plating the fibula with a 1/3 or DCP 3.5 mm plate. Definite internal fixation of the tibia by locking plate was performed from 8th –14th postoperative day after soft tissue recovery. Preoperatively CT scan was performed with grate significance, defining the soft tissue condition, the surgical approach and the osteosynthesis type.

Follow up average 14 months. None of the patients developed infection. All wounds were healed in one stage. Superficial skin necrosis was conservatively treated in two patients.

Soft tissue complications, after internal fixation of high energy fractures of the distal tibial, usually appear. Two stages treatment allows better preoperative planning, immediate patient mobilization and reduce complication rate


C. Garnavos N. Lasanianos V. Lakka M. Morakis G. Sinnis K. Papagiannakos

Although intramedullary nail fixation maybe highly indicated for comminuted and segmental humeral fractures that require operative treatment, the literature lacks reviews of this content.

The aim of the present study is to prospectively evaluate the clinical and radiographic outcomes in patients with combined head and shaft fractures of the humerus who were treated by antegrade locking intramedullary nailing.

During a period of four years 21 patients (9 men & 12 women) between 36 and 82 years old, with combined fractures of the humeral head and shaft, were operated by one surgeon. Three types of nail implants were used (Polarus long, Garnavos nail, True flex nail) and ante-grade technique was performed in all cases.

The mean operating time was 105 min (50′–140′). The period of follow-up averaged 14.25 months (range, 9 to 18 months). Two patients were lost to follow up and one died before the callus formation procedure was accomplished. The functional assessment included determination of the Constant score and documentation of shoulder function as compared with the non injured extremity. Radiographic control was obtained during the follow-up intervals and at the final follow up. No neurovascular complications, deep wound infections or non-unions were recorded and all fractures were fully healed between 4 to 8 months post-operatively. In one case the nail was extracted before callus formation was achieved, because of acromion impingement.

The results are judged as very satisfying, taking into account the comminution of the fractures. Further evaluation of the results, with comparable methods of internal fixation of such fracture patterns, is needed.


S. Plessas D. Louverdis P. Mavroeidis A. Bourlekas G. Stroboulas N. Prevezas

During the last few years, the arthroscopically assisted technique for reduction and internal fixation of tibial plateau fractures is of increasing popularity. The accumulated surgical experience allowed the possibility of treating type I, II, III according to Schatzker classification.

During the last two years 17 patients who had suffered a tibial plateau fracture were treated this way. The mean age was 44 years, while the mean FU was 16 months. According to Schatzker classification 8 fractures were type I, 6 fractures type II and 3 fractures type III. The bone reduction was achieved under arthroscopic view and flouroscopy. In all cases the fracture was fixed by the with cannulated Herbert type screws. Meniscal lesions were fixed in 9 patients, while in 5 patients ruptures of the ACL were detected, which were reconstructed at a later stage.

Full range of motion of the knee was restored in 11 patients, while lack of full knee flexion (mean 100) was found in 6 patients. All patients were assessed with a modified Lyslom Knee Scale. The Knee score was 85 points to 96 points (mean 92 points), while the anterior knee pain was the common problem especially following increased activities.

The proposed arthroscopically assisted technique for reduction and fixation of certain types of tibial plateau fractures consists a alternative minimal invasive approach. Visualization of the whole joint is possible and concomitant lesions can be detected and possibly fixed at the same time


I. Nikolopoulos S. Kalos G. Krinas D. Kypriadis A. Elias G. Skouteris

The use of external fixation in open tibia fractures with severe soft tissue injury is the most preferred and safe treatment. The primary allograft application is doubtful due to high infection risk.

The evaluation of the results of open tibia fractures type II and III according Gustillo-Anderson that were treated with simultaneous external fixation and allograft application.

From 2005–2007, twenty nine open tibia shaft fractures in 27 patients (2 bilateral) with mean age of 35 years-old were treated.

According Gustillo-Anderson classification, there were 20 GII, 6GIIIa and 3GIIIb open tibia shaft fractures without severe bone loss. All patients were treated with thorough and extensive surgical debridment, external fixation and simultaneous application of allograft and double antibiotic scheme. The patients were followed up initially weekly till stitches removal and every second week till the external fixation removal without developing any signs of infection.

Overall, there were uncomplicated union in 23 cases (18 GII, 3GIIIa and 2GIIIb) whereas in 5 cases we had to change method of treatment (3 GII and 2GIIIa) due to union delay or non acceptable fracture angulations. There were also a case that developed deep infection and septic pseudarthrosis.

The simultaneous external fixation and allograft application seems to provide a small advantage in open fracture consolidation despite the established wisdom for allograft use on a later stage. The proper initial open fracture estimation, the right surgical treatment, the surgeon’s experience and a strict patient’s follow up schedule are fundamental for a good final outcome


K. Makridis M. Georgoussis V. Mandalos N. Daniilidis S. Kourkoubellas L. Badras

Early and safe mobilization remains the mainstay of treatment for the intertrochanteric fractures. Many implants have been used but the intramedullary implants seem to provide maximum stability in unstable fractures. The aim of this study was to compare two intramedullary devices which have different philosophy and modes of action.

Between 01.07.2005 to 30.06.2007, 110 patients with trochanteric fractures treated with the intramedullary hip screw (IMHS, Smith & Nephew) nail and 105 with the ENDOVIS (Citieffe) nail. The data recorded were the fracture’s type, preoperative hemoglobin level, pre-fracture walking ability. Postoperatively were recorded the operative time, the level of hemoglobin on the first day, mobility status, complications and 12 months mortality rate. The results were comparable regarding blood loss, operative time, and mortality rate. However, the rehabilitation and functional outcome were superior in the IMHS group. This probably was attributed to the higher number of complications of the ENDOVIS nail.

IMHS is a valuable tool for the treatment of stable intertrochanteric fractures, offering also excellent results in the management of reverse obliquity, comminuted fractures and those with a subtrochanteric extension. Further investigations are necessary to prove which the ideal intramedullary implant is. However, it seems that devices combining the principles of the sliding hip screw with those of an intramedullary nail present safe and accurate fixation, fewer mechanical failures and exceptional functional outcomes


D. Katsenis A. Louris V. Triantafyllis A. Stathopoulos H. Eikonomou K. Pogiatzis

Our objective was to investigate the adequacy of the antegrade intramedullary nailing for the treatment of proximal and distal humeral fractures.

From January 2004 to April 2008, 28 proximal humerus fractures and 9 distal humerus fractures were treated with intramedullary nailing. Mean age of the patients was 69-year-old (39–82). 26 patients were males. All fractures of the first group were treated with closed static intramedullary nailing whereas in the second group closed static intramedullary nailing was achieved in 7 fractures. The clinical and radiological outcomes were evaluated.

All the proximal humerus fracture – but one – obtained bone-union at an average of 3 months (from 2 to 4 months). The mean follow up was 22 months (6–40). Functional outcome measured by Constant score showed 22 patients with an excellent and good result and 6 with a poor result. One case with osteonecrosis of the humeral head was recorded. Malunion of the greater tuberosity was recorded in 7 fractures. Only 5 distal humerus fractures united at an average of 5 months (from 4 to 7 months). Functional outcome measured by Burri – Lob score showed 3 patients with an excellent and good result and 6 with a poor result. Failure of the distal locking was noticed in 5 patients and 3 fractures united in valgus position

The antegrade closed intramedullary nailing is an effective treatment method for the proximal humerus fractures. However the role of the nailing for the distal humerus fractures is humeral nail is effective for the treatment of proximal humeral fractures remains


Th. Karachalios A.H. Zibis E. Zintzaras K. Bargiotas A.H. Karantanas K.N. Malizos

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


D. Erginoussakis A. Kostakos D. Filipiadis A. Kelekis N. Keramaris A. Gouliamos

Purpose of this study is to compare the reduction of discogenic pain associated with disk herniation in two groups. Group A (31 patients) with lumbago, with/ without sciatica, with no neurologic deficit followed consernative treatment (antiflammatory drugs, physiotherapies) and the group B (31 patients) with the same symptoms submitted in percutaneous disc decompression after six weeks consernative treatment with poor results. Follow up had a period of six months, one year and two years in two groups. All patients in both groups evaluated clinically and the symptoms registrated in special protocol that included pain distribution, sensation, muscle strength and reflections (ahilleus and patellar). All of them submitted in X-ray and MRI so that the two groups have the presuppositions for percutaneous decompression of disc (absense of a free, non-contained or sequestered fragment, remained disc height > 50%, no neurologic deficit, no arthritis in facets). An AVS scale on a questionnaire adapted to Greek population helped assessing pain relief degree, life quality and mobility improvement. The method that we used is t-test for small independent patterns.

We found a statisticasignificant decrease on terms of pain relief, mobility and life improvement during the one and two years follow-up in group B which submitted in percutaneus decompression of intervertebral disks comparetively with A


V. Tsiampa I. Tepetzis Z. Zaharopoulos T. Lakkos P. Hantzidis C. Dimitriou P. Hantzidis C. Dimitriou

To estimate the outcomes after posterior dynamic stabilization in situ with Dynesys (Zimmer Spine, Minneapolis, MN) for treatment of symptomatic spinal stenosis and degenerative spondylolisthesis in long-term follow-up.

28 patients(mean age 73 years old) with symptomatic spinal stenosis and spondylolisthesis underwent inter-laminar decompression and stabilization with Dynesys. Patients were evaluated clinically and radiologically after a follow-up from 6 months to 4 years.

Pain on VAS and walking distance improved significantly at less than 2 years and remained unchanged at 4 years follow-up. Radiographically, spondylolisthesis did not progress and the motion segments remained stable. 2 patients showed screw-loosening at 1 year follow-up and underwent revision. Overall, patient satisfaction remained high as 93% and would undergo the same procedure again.

In elderly patients with spinal stenosis and degenerative spondylolisthesis, decompression and dynamic stabilization lead to excellent clinical and radiologic results. It maintains enough stability to prevent progression of spondylolisthesis. Because no bone grafting is necessary, donor site morbidity, which is one of the main drawbacks of fusion is eliminated


P. Bobak I. Polyzois I. Pagkalos E. Tsiridis

Periprosthetic femoral fractures around total knee arthroplasty present a challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate (PMMA) cement in five patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and behaves like a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their pre-injury functional status within four months. This procedure does not disrupt the soft tissue envelope facilitating periosteal callus formation, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction in octogenarians unfit for lengthy procedures, nailed cementoplasty is proposed as a salvage procedure.


O. Kiritsi K. Tsitas G. Mikroulis F Tsivikis

The aim of the present study was to record the MRI characteristics of the thoracic spine in asymptomatic adult males and their correlation with age and thoracic level.

A cross sectional retrospective study was designed in order to record MRI thoracic spine findings in asymptomatic adult males, 35 to 65 years of age. All study participants were evaluated by MRI. The qualitative and quantitative assessed MRI parameters were as follows: disc degeneration (disk signal intensity), bulging, herniation, disc height, Modic changes, endplate irregularities, osteophytes.

Intervertebral disc signal was decreased more in the lower thoracic spine (T6-T12 level). In addition there was a strong correlation between disc degeneration (disc signal loss) and the age of the study participants. Disc bulging was most frequently observed anteriorly than posteriorly with the prevalence increased caudally. Modic changes were not so frequent and there were most commonly seen in the lower thoracic spine (T11-T12 level). In addition osteophytes were larger anteriorly than posteriorly and their prevalence increased caudally. Endplate irregularities (Schmorl nodes) were more common in the upper endplates and in the lower thoracic spine (T6-T12 level). Finally strong positive correlation was noted between osteophytes, anterior and posterior and disc bulging.

This study documents the mild to moderate grade of degenerative changes especially in the lower thoracic spine (T6-T12 level) of asymptomatic adult males, 35 to 65 years of age


N. Manidakis I. Koutroumpas G. Stathakos N. Georgiou K. Alpantaki P. Katonis

The evaluation of early results of combined percutaneous pedicle screw fixation and kyphoplasty for the management of thoraco-lumbar burst fractures

Between October 2008 and April 2009, 9 patients with thoracolumbar burst fractures underwent percutaneous short-segment pedicle screw fixation and augmentation kyphoplasty with calcium phosphate cement. All patients were selected according to the type of fracture (unstable type A3 fractures based on the Magerl classification) the absence of neurological signs and an intact posterior longitudinal ligament on the pre-operative MRI scan. Patient demographics, co-morbidities and complications were recorded. The main endpoints included Cobb angle correction, vertebral body height restoration and the length of hospital stay.

There were 3 male and 6 female patients with an average age of 43.6 years. The average follow-up was 2.4 months. The mean kyphotic angulation improved from 18.40 pre-operatively to 6, 80 post-operatively. The loss of vertebral body height improved from a mean of 38.7 % pre-operatively to 12.1 % post-operatively. The average duration of surgery was 40 minutes with insignificant blood loss. There were no post-operative complications. The average length of hospital stay was 3.2 days.

The combination of percutaneous short-segment pedicle screw fixation supplemented by balloon kypho-plasty for the management of thoracolumbar burst fractures with no neurological deficit offers correction of the normal thoracolumbar anatomy as well as augmentation of the anterior load-bearing column, using a minimally invasive technique. The early results are promising


I. Drosdov R.J. Macfarlane C.A. Ouzounis E. Tsiridis M.A. Gatzoulis

Although previous lnks have been made between congenital heart disease (CHD) and scoliosis, the molecular mechanisms involved in this association are poorly understood. During development, it appears that embryos exhibiting spine deformations resulting in scoliosis also suffer from an array of cardiac defects. Additionally, idiopathic scoliosis in patients with CHD is thought to be a response to a physiological phenomenon such as an enlarged size or abnormal thrust of the heart. Despite the fact that molecular omics data have been accumulated that are relevant to these two independent phenotypes, there appears to be a gap in the literature of over two decades on this matter and no clear correlations of the omics data have been provided. To identify genes involved in CHD and scoliosis, we have performed an analysis of genomic annotations, functional genomics data and text mining, and derived an inferred network of 123 human genes and 175 known gene interactions. Of these, 20 genes are unique to CHD, 11 to scoliosis and 5 genes are common to both abnormalities. These genes are known to be involved in molecular signaling cascades that affect the development of the musculo-skeletal system in humans and have been associated with disorders such as the Marfan or CHARGE syndromes. Our analysis sets the basis upon which investigations of this association can be performed at the molecular level, in order to both further understand the pathology and, in the future, develop suitable therapies for CHD/idiopathic scoliosis patients


A. Chatziantoniou V. Karantzoulis Ch. Matzaroglou P. Dimakopoulos P. Zouboulis

To study the preliminary clinical results of patients submitted to kyphoplasty with an expandable titanium cage (OsseoFix).

Between 09-2008 and 02-2009 16 patients (6 men, 10 women, total 36 vertebrae) with a mean age of 67 (23 to 81) were submitted to kyphoplasty using a system involving the implantation of an expandable titanium cage (OsseoFix) for the treatment of fractures in the lower thoracic and lumbar spine. Five patients were submitted to kyphoplasty at one level, 4 at two levels, 5 at three levels, and 2 at four levels. Two patients additionally needed a posterior spinal fusion. The underlying causes for the spinal fractures were: secondary osteoporosis (7), recent acute trauma (5), and malignancy (4: 1 Hodgkin lymphoma, 1 Non-Hodgkin lymhoma, 1 metastatic breast cancer, 1 metastatic prostate cancer). In 8 patients biopsy specimens were harvested at the same procedure.

Mean follow-up time was 4 months (2 to 6). No intra-operative complication occurred. No bone cement leakage or pulmonary embolism was observed. The mean pain improvement, as measured with the VAS scale, was 5,12 (7,81 preop – 2,69 postop). The mean vertebral body height restoration was 19,5%, and the kyphotic angle was corrected by a mean of 2,24°.

The main advantage of using an expandable metal cage in kyphoplasty is the improved reduction of the vertebral body compression and the minimal risk of bone cement leakage. Especially in young patients, the maintenance of the reduction could potentially be achieved even without cementation, by the mere support provided by the cage. A longer follow-up time is needed for the safe validation of these preliminary encouraging results


I. Koutroumpas N. Manidakis S. Likoudis K. Kakavelakis E. Papoutsopoulou P. Katonis

The evaluation of results following posterior decompression and fusion for the management of cervical spondylotic myelopathy

Between July 2006 and May 2008, 68 patients with cervical myelopathy underwent posterior decompression with laminectomies and pedicle screw fixation of the cervical spine. All patients were selected based on the presence of multi-level degenerative disease and the correction of cervical lordosis on the pre-operative dynamic radiographs. Patient demographics, co-morbidities and post-operative complications were recorded and analysed. Functional outcome was assessed by using the Japanese Orthopaedic Association (JOA) score.

There were 37 male and 31 female patients with an average age 67.4 years. The average follow up period was 18 months. The mean pre-operative JOA score was 8.7, whereas the mean post-operative score was 12.1 on the latest follow-up visit. 9 patients had unsatisfactory clinical results and consequently underwent anterior procedures with significant improvement. Complications included 1 epidural haematoma, 2 superficial infections and 4 cases of myofascial pain. In three cases there was mild dysfunction of the C5 nerve root which resolved spontaneously with conservative measures.

In the present series of patients posterior decompression with laminectomies is an effective method for the management of cervical spondylotic myelopathy.


P. Diaremes MC Kokkinakis A.A. Kurth K Kafchitsas

The radiological and biomechanical assessment using cement augmented cannulated pedicle screw (Biomet®, Omega 21®) and the correlation of the cement volume to the pullout strength needed for each screw

Cadaveric vertebrae of different lumbar levels were used. Through cannulated pedicle screw a definite volume of cement was applicated. The bone volume occupied by cement was assessed by means of segmentation after Computer Tomography. Biomechanical Pullout tests and statistical correlation analysis were then performed

The maximum pullout strength was 1361 N and the minimum pullout strength was 172 N (SD 331 N). The maximum cement volume was 5,29 cm3 and the minimum 1,02 cm3 (SD 1,159). The maximum cement diameter was 26,6 cm and the minimum cement diameter was 20,7 cm (SD 1,744). There is statistically significant correlation between the pullout strength and the injected cement volume (p< 0,05).

The cannulated pedicle screw was used for a better fixation in the vertebral body. The cement augmentation with this technique is easier and seems to be safer than cement augmentation of non cannulated screws. Pullout strength of the cannulated screws correlates positively with the cement volume. It is though not influenced either by the total vertebral volume or by the ratio cement volume to vertebral volume or by the maximum diameter of the cement drough


P. Diaremes M.C. Kokkinakis A.A Kurth K Kafchitsas

The influence of the intravertebral length of vertebral screws on their pull out strength.

64 Cadaveric vertebrae of different lumbar levels were used. By means of Computer Tomography the length of the screw in the bone was assessed. The ratio screw length in bone to the longest possible screw in bone was built. Biomechanical Pullout tests and statistical correlation analysis were then performed

The maximum pullout strength was 1602 N and the minimum pullout strength was 96,4 N (SD 356,9 N). The maximum ratio of the inserted screw was 95,9% and the minimum was 58,8% (SD 0,7%). There is no statistically significant correlation between the ratio of the inserted screw and the pullout strength needed. Moreover, there is a statistically significant correlation between bone mass density and pullout strength (p< 0,05).

The fixation of pedicle screws is better in a non osteoporotic vertebral body. Pullout strength and bone mass density correlate significantly whereas there is no correlation between the insertion length of the screw and the pullout strength under the condition that the insertion ratio is greater than 58,8 %. Factors such as insertion angle of the screw need to be evaluated, and new techniques for pedicle screw fixation in osteoporotic vertebrae need to be developed


K. Zachariou A. Morakis M. Tsafantakis A. Bountis P. Agourakis A. Kalabokis

To evaluate our results of treatment of kyphosis following osteoporotic fractures of the last 3 years.

28 women with a mean age of 63,2 years were treated for a painful kyphotic deformity of a mean Cobb angle 76,1°. They all had posterior fusion with pedicular screws and rods enhanced with autologous bone graft as well as allografts. Cement augmentation was used in a number of screws. A cell saver for auto transfusion and continuous neurophysiological monitoring was used intraoperatively in all cases. All patients fitted with a thoracolumbar brace for 3 months.

The postoperative mean Cobb angle was 45,2° (40,6% improvement). Pain questionnaires at a mean postoperative follow up of 16 months showed excellent results in 10 patients (35,71%), good in 8 patients (28,57%), satisfactory in 6 patients (21,42%) and poor results in 4 patients (14,28%). All patients were satisfied with the cosmetic result. 2 patients presented a postoperative infection that was treated with debridement and antibiotics.

Kyphotic deformity following osteoporotic fractures may treated satisfactory with rods and pedicular screws with cement augmentation


A. Hatzigiammakis D. Kotzamitelos E. Baburda H. Sali K. Tilkeridis C. Boyiatzis

We estimated the long term results of the different methods in chirurgical treatment of lumbar disk herniation in consideration with the presence or absence of degenerative changes and the grade in witch these factors influence the result of this kind of treatment.

Seventy eight patents with lumbar disk herniation have been submitted in partial discectomy. The men were 42 and 36 women. The patients were separated in tow groups. In the first group [48 patients, 31 of them (A1) without degenerative changes, while the 17 (A2) with degenerative changes], was applied macrodiscectomi. In the second group [30 patients, 18 of them (B1) without degenerative changes and the 12 (B2) with changes], was applied microdiscectomi with use of magnifying lenses. The mean age during operation was 44 years (18–67) and 38 years (24–62) respectively for the tow groups, and the mean time of follow-up was 7 years and 8 months (18 months-13 years). For all patients, the operation was executed from the same surgeon. The elements that were evaluated were the Visual analog scale (VAS, O-10), the Oswestry Disability Index (ODI), as well as the complications during and after the operation and the cases that required a reoperation.

In the first group VAS score was improved from 9.1 to 3.1 and the ODI score was improved from 86% to 24.2%. In the second group VAS score was improved from 9 to 2.6 and the ODI score was improved from 84.2% to 19.2%. From all patients, subgroup B1 without degenerative changes, which was submitted in microdiscectomy presented the biggest improvement. We have had to reoperate 6 patients (7.8%).

In cases of lumbar disk hernia both methods are appropriate and lead to a considerable improvement of the symptoms. Degenerative changes of the lumbar spine is a factor that leads in less satisfactory results


T.B. Grivas E.S. Vasiliadis A. Kaspiris G. Triantafyllopoulos

It was previously postulated that the IV disc wedging is a significant progressive factor for mild IS curves. The present report introduces an innovative comprehensive model of IS curves progression based on intervertebral disc (IV) diurnal variation and the subsequent patho-biomechanics of the deforming “three joint complex”, where vertebral growth occurs.

Throughout day and night, due to sustained loading and unloading, the scoliotic wedged IV disc expels fluid and imbibes it more convex-wise. The convex side of the IV sustains a greater amount of cyclic expansion than the concave side. Consequently the imposed, convex-wise, asymmetrical concentrated cyclical loads to the adjacent immature vertebral end plates and posterior elements of the spine lead to asymmetrical vertebral growth. More specifically the loading on the two facet-joins asymmetrically increases during the day, as the wedged IV space narrows due to expelled water and it asymmetrically decreases during the night, as the IV space swells due to imbibed water.

This 24 hour period cyclic asymmetric loading leads both to asymmetric growth of the end plates and wedging of the vertebral bodies, and to similarly asymmetric growth of the pedicles and arches posteriorly as an effect of Hüeter-Volkmann law. This model explains the well described anatomical findings of the more elongated pedicles and the larger facet joints in the convex side than in the concave in scoliotic spines


C. Copuroglou M. Ozcan B. Aykac B. Yilmaz Y. Gorgulu E. Yalniz

Degenerative lumbar spinal stenosis is one of the most frequent surgical indications of spinal surgery in the elderly patient group. Because of the progression of the disease and neurologic deficiencies, patients’ quality of life is affected. We aimed to evaluate the postoperative quality of life of the surgically treated spinal stenotic patients.

Between 1998 and 2009, 38 patients, who were surgically decompressed and enstrumentated in our clinic were included to the study. The patients were preoperatively and postoperatively evaluated with Visual Analogue (Scale (VAS) and Japanese Orthopaedics Association (JOA) criterias. The same patient group were re-evaluated on the postoperative 6th month with Hamilton anxiety and depression scale, on the 12th month with short form-36 and Oswestry pain scoring scales to measure the quality of life.

Mean age of 38 patients (31 female, 7 male) was 59.6 (range 44 to 82). Mean preoperative VAS was 7.97 and postoperative VAS was 2.28. The pain decreased 56.9%. According to JOA criterias, in 3 patients (7.89%) no recovery, in 13 patients (34.2%) less than 50% recovery and in 22 patients (57.8%) more than 50% recovery was obtained. On the 6th month, according to Hamilton anxiety and depression scale, in 12 patients anxiety and in 3 of these patients depression which needs treatment was observed. The pain of all the patients with anxiety recovered meaningfully (42.3%) but according to JOA, less than 50% recovery could be obtained.

Surgically treated spinal stenosis patients improved clinically and radiologically and this affected the patients’ quality of life positively


T.B. Grivas E.S. Vasiliadis A. Kaspiris G. Triantafyllopoulos R.G. Burwell

Melatonin’s concentration is high in early childhood and declines gradually thereafter. In the elderly serum melatonin levels are very low. Melatonin, the “light of night”, among other functions is involved in human sexual maturation and in osteogenesis.

Hormesis is the response of cells or organisms to an exogenous (eg drug or toxin) or intrinsic factors (eg hormone), where the factor induces stimulatory or beneficial effects at low doses and inhibitory or adverse effects at high doses [bimodal dose-response] or vice versa.

At the age around 10 years, when idiopathic scoliosis may appear, the circulating melatonin level is about 120 pg/ml – positive hormesis for menses – and menarche appears. Melatonin deficiency may result in a delay of the age at menarche and consequently the girl is susceptible to scoliosis. In these terms melatonin could be certainly involved in the scoliosis pathogenesis. Around the age of 45 years when the circulating melatonin levels are about 20 pg/ml – negative hormesis for menses, menopause starts and the woman has an increased risk for osteoporosis and fractures.

It is documented the bone-protecting effect of melatonin in ovariectomized rats which can depend in part on the free radical scavenging properties of melatonin. Additionally, melatonin may impair development of osteopenia associated with senescence by improving non-rapid eye movement sleep and restoring GH secretion. Whether modulation of melatonin blood levels can be used as a novel mode of therapy for scoliosis and augmenting bone mass in diseases deserves to be studied


P. Krallis I. Kosmidis S. Thoma Ch. Chatziantonioy A. Koutrouphinis I. Hager

Although pedicle screw instrumentation for the treatment of idiopathic scoliosis is very popular, hybrid constructs remain a safe and effective method of scoliotic curve correction. This retrospective study was undertaken to assess the outcomes of hybrid instrumentation in the treatment of idiopathic scoliosis.

Forty three children underwent surgical correction for idiopathic scoliosis. Patients were evaluated at a minimum 2-year follow-up (range 2–9 years). Clinical and radiographic assessment was performed for all patients preoperatively, immediately postoperatively, one year after surgery and at the final follow up. Radiographic parameters assessed included Cobb’s angle, coronal balance, translation of the apex vertebra, kyphosis, lordosis, angle in the T10 – L2 region and sagittal balance. Idiopathic scoliosis was classified according to the King classification system. All patients underwent posterior spinal fusion using hybrid instrumentation while 6 received, prior to the posterior fusion, anterior thoracic discectomies.

Postoperatively overall Cobb’s angle correction was 59.5%. At the final follow-up an average loss of the correction of 9.5% was recorded. Nevertheless, there was an overall correction of the translation of the apex vertebra and a satisfactory coronal balance improvement at the final follow up compared to the immediate postoperative follow-up. Although a trend toward improved sagittal balance was noted, it was not statistically significant. The surgical complications included 2 cases of deep wound infection. In addition one patient required revision and a longer fusion distally.

Operative treatment of adolescent idiopathic scoliosis with hybrid instrumentation yields satisfactory clinical and radiological results. Therefore, it can be considered as a safe and effective method of treatment of adolescent spinal deformity


K. Zachariou A. Morakis M. Tsafantakis A. Bountis P. Agourakis A. Kalabokis

The documentation of the results of combined anterior -posterior approach in the treatment of spinal tumors in our department.

A total of 28 patients (16 men – 12 women) aged 15 to 75 year old (mean age = 54 years) were treated. Of those 7 presented with a benign primary tumor and 21 with malignancies of which 15 were metastatic. 16 patients had a neurologic deficit but met the international criteria for surgical intervention. The staging of the tumors and their postoperative care was undertaken by a tumor centre. All patients underwent posterior decompression with laminectomy, resection of all posterior elements including part of the pedicle, excision of the tumor and posterior stabilization. This was followed at the same operative session by an anterior approach (transthoracic, transperitoneal or anterior cervical) corpectomy of the affected vertebrae and implantation of interbody cages secured with an anterior plate and screws in the healthy vertebrae.

7 patients improved neurologically following the operation while 9 had no change of their clinical condition. Perioperative complications were recorded in 5 patients. In 3 cases a dural tear was dealt with direct closure and 3 infections had to have surgical debridement at another stage and antimicrobial therapy.

The treatment of spinal tumors with combined anterior-posterior approach in one session for a radical excision of the tumor is a demanding procedure


T.B. Grivas E.S. Vasiliadis A. Kaspiris G. Triantafyllopoulos

The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. In addition, school screening is a unique tool for research of IS in humans, as in most published articles, all aetiopathogenetic factors are studied in animals and not in humans.

Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS


C. Matzaroglou P. Zoumboulis A. Saridis P. Spinos D. Costantinou P. Bougas A. Barba P. Dimakopoulos E. Panagiotopoulos

Aim of our study was the investigation and the cross-correlation of various neurologic scales to estimate, comparatively with the functional results of patients after damage of spinal cord injuries.

Between 1989 – 2005, 115 patients were submitted in stabilization of Lower Cervical Spine that was judged unstable.

The neurologic situation was certified with the scales: Frankel, ASIA motor score, NASCIS motor score, FIM scale, and MBI scale.

In the protocol took part the 94 patients for that existed in neurologic details and long follow-up for at least two years.

From the study of course of scores of all scales was not found statistically important difference between ASIA, NASCIS and other motor scales. However 12 patients with important improvement of mobility at ASIA motor score and NASCIS motor score they have not difference in Frankel scale, despite the make that the MRP (Motor Percentage Recovery) was improved: 21.5%

Also 8 patients with relatively big improvement in their total scores did not have corresponding functional improvement (FIM scale, and [MBI] scale)

A lot of neurologic methods – scales were used and are used today. However for the essential and modern follow-up of patients with spinal cord injuries, it needs certification with a scale of classic team of (measurement of mobility) and a scale of functional faculties of the patient


Theodoros B. Grivas R.G. Burwell C. Mihas E.S. Vasiliadis G. Triantaffylopoulos A. Kaspiris

This paper evaluates severe normal trunk asymmetry (TA) by higher and lower body mass index (BMI) values in 5953 adolescents age 11–17 years (boys 2939, girls 3014) whilst standing forward bending (FB) and sitting FB during screening for scoliosis. TA was measured as angle of trunk inclinations (ATIs) across the back (thoracic, thoracolumbar and lumbar) with abnormality defined as 2 standard deviations or more. The findings for sitting FB position are reported because the readings express TA free from any leg-length inequality. Relatively lower BMIs are associated statistically with

excess of abnormal TAs, and

later menarche.

BMI is known to be linked to puberty timing and energy balance but not to TAs in healthy students. Similar to girls with adolescent idiopathic scoliosis, we suggest that severe TA is caused by a genetically-determined selectively increased hypothalamic sensitivity to leptin with asymmetry as an adverse hormetic response, exacerbated by presumed lower circulating leptin levels associated with relatively lower BMIs. The asymmetry is expressed bilaterally via the sympathetic nervous system to produce left-right asymmetry in ribs and/or vertebrae leading to severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk


I. Flieger O. Leonidou K. Antonis M. Katsalouli A. Kiriazi A. Hatzis

Since the commencement of the Neuromuscular-Unit in the Children’s-Hospital “Agia Sofia”, from December 2002 until December 2008, 306 patients were examined suffering from different neuromuscular diseases (ND). In the present study we examined

the frequency of spine deformities,

the management in correlation with the poor general health of these patients, analyzing the most frequent presenting disease, that is Duchenne’s-muscular-dystrophy,

cases of surgical management of our Unit are presented.

From the analysis of our material we found that 152 patients were suffering from Duchenne’s-Becker muscular-dystrophy, 59 patients from spinal-muscular-atrophy I-III, 13 patients from fascioscapulohumeral muscular-dystrophy, 15 patients from hereditary motorsensory-neuropathies, 5 patients from Friedreich’s Ataxia and 62 patients from different types of dystrophinopathies–myopathies. The ages of the patients varied between 8 months and 37 years.

From the total, 89% of the patients above 10 years presented with spine deformities. Most of them were managed with wheelchairseating modifications and 33 patients were fitted with braces in an attempt to slow curve progression. Surgically were managed 24 patients with spine arthrodesis, 5 of them abroad (USA-Eng-land-France). The older patients (> 17 years wheelchair-bound) were frequently, because of impaired general health, not suitable candidates for surgery.

Pulmonary function was examined in 84 patients suffering from Duchenne’s muscular dystrophy. The crucial age, were pulmonary function has fallen dramatically (FVC< 40%), was between ages 12–15 years.

In conclusion spine deformities are very common in patients suffering from neuromuscular diseases. Because of the rapid deterioration of the general health of these patients spine arthrodesis should be performed early, in the patients severely affected, between ages 12–15 years


C. Matzaroglou P. Zoumboulis A. Saridis P. Spinos E. Panagiotopoulos D. Costantinou E. Heristanidu D. Kouzoudis A. Chatziantoniou P. Dimakopoulos

Whiplash vertigo syndrome is often seen in victims of rear-end vehicle collisions. These patients commonly complain of headache, vertigo, tinnitus, poor concentration, irritability, and sensitivity to noise and light.

Sixteen patients (medium age, 39,5 years) that they refered in orthopaedic examination because of long-lasting subjective complaints after cervical spine injury underwent clinical, laboratorial and psychometric examinations. The mean posttraumatic interval was 43 months. Ten patients were injured in road accidents, 5 during sports and one at work, all with mechanism trial of whip. Each patient was evaluated with otorhinolaryngologic examination, audiometry tests, CT: petrus – internal auditory meatus and cerebellopontine corner. Also each patient was evaluated with neurologic examination, psychological well-being scale (sf-36), and personality profile scale.

None of the patients had neurologic symptoms, and no lesions of the cervical spine were identified. All the patients had negative clinical, radiological and standard laboratorial control, but may be is a critical point that the eleven of these patients had pathologic OGTT (Oral Glucose Tolerance Test). Also did not exist differentiations from the mean values in psychological well-being scale (SF-36), and personality profile scale of healthy population. Test results were unrelated to the length of the post-traumatic interval. However, 2 distinct syndromes were identified. Ten patients had cervicoencephalic whiplash type syndrome (CES), characterized by headache, vertigo, tinnitus poor concentration, and disturbed adaptation to light intensity. Six patients had the lower cervical spine whiplash type syndrome (LCSS), characterized by vertigo, tinnitus cervical and cervicobrachial pain.

The verification of Whiplash Vertigo syndrome require more objective clinical means. This article proposes that exists an organic base for the syndrome, but does not promote that whiplash injury certainly cause it


D. Efstathopoulos El. Karadimas G. Stefanakis D. Chardaloupas Fok. Theofanopoulos G. Chatzimarkakis

Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap.

This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases.

One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months).

All nonunion fractures united within an average of 16 weeks (range 10–26 weeks).

Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory.

Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture


V. Goulidakis S. Theoharakis P. Vogiatzis I. Katsougrakis G. Adamopoulos

The presentation of results of this comparative study on the various methods of treatment for Transtrochanteric fractures.

From 2006 to 2008 we treated 272 Transtrochanteric fractures, in 75 with DHS, 116 with G3-nail (STRIKER) and 91 with F-nail (ARITI) where antjrotation screw was applied in the 37 (type F) while in the remained 54 was not applied (type G). We compared the duration of surgery, the need for transfusion, the post surgical difference of Hb, the starting day for weight bearing on the fractured limp, the days of hospitalisation and the complications between the different methods.

The patients were separated in 4 groups regarding the method of treatment (A: DHS, B: G3-nail, C: F-nail type F and D: F-nail type G). They did not differ statistically significant regarding age, sex as well as the time of the surgery from the admission. There were no difference in the duration of surgery, the need for transfusion and changes in Hb and the days of hospitalisation. Difference not statistically significant existed in the starting day for weight bearing on the fractured limp (A:3.1, B:2.5, C:2.9, D:3.0). Regarding complications D group had an incident of broken peripheral screw and C group one of broken nail after fall of the patient.

No method of treatment seams to be superior regarding incidents during hospitalisation. More data are expected to compare these methods on the issues of rehabilitation, complications and mortality


V. Goulidakis S. Theocharakis D. Gourovanidis N. Manetakis A. Diakatos G. Adamopoulos

Is to analyze the preliminary results of surgical treatment of hip fractures in regard to the time of the intervention from the admission.

In our department we treated 383 hip fractures, 272 Transtrochanteric and 111 IC-NOF fractures, from August 2006 to August 2008. The patients were split in 2 groups regarding the day of the surgery from the admission. In the group A were included patients with immediate surgical treatment (in the 1st 24 hours) and in group B patients who had there surgery after the 1st 24-hours. We evaluated the difference in Hb between the admission and the 1st post surgical day, the need for transfusion, the duration of hospitalisation and the complications.

The two groups did not differ statistically considering demographic details. Also there were no differences in regard of the change of Hb and the need for blood transfusion. There was statistically significant difference in the duration of hospitalization (A: 6.5-B: 10.3) as well as and in complications. Post surgical OPS 15 in group A and 56 in group B, urine infection 1 in A and 16 in B, respiratory infection 1 in A and 11 in B. The A group had 1 case with cardiac arrest and 1 AMI. Finally the B group had 5 cases with arrhythmia, 1 with PE and 3 with CA. Conclusions: It appears that the immediate surgical intervention of patients with hip fracture has positive effect in the duration of hospitalization, morbidity and mortality


P.D. Antonarakos L. Katranitsa L. Angelis A. Paganas E.M. Koen E.A. Christodoulou A. G. Christodoulou

The SRS-22 is a valid instrument for the assessment of the health related quality of life of patients with Idiopathic scoliosis. The purpose of this study is to evaluate the reliability and validity of the adapted Greek version of the refined Scoliosis Research Society-22 Questionnaire.

Following the steps of cross – cultural the adapted Greek version of the SRS-22 questionnaire and a validated Greek version of the SF-36 questionnaire were mailed to 68 patients treated surgically for Idiopathic Scoliosis with a mean age at the time of operation 16.2 years and a mean age at the time of evaluation 21.2 years respectively. A 2nd set of questionnaires was mailed in 30 patients within 30 days from the 1st set. Reliability assessment was determined by estimating Cronbach’s a and intraclass correlation coefficient (ICC) respectively. Concurrent validity was evaluated by comparing SRS-22 domains with relevant domains in the SF-36 questionnaire using Pearson’s Correlation Coefficient (r).

The calculated Cronbach’s a of internal consistency for three of the corresponding domains (pain 0.85; mental health 0.87; self image 0.83) were very satisfactory and for two domains (function/activity 0.72 and satisfaction 0.67) were good. The ICC of all domains of SRS-22 questionnaire was high (ICC> 0.70). Considering concurrent validity all correlations demonstrated high correlation coefficient.

The adapted Greek version of the SRS-22 questionnaire is valid and reliable and can be used for the assessment of the outcome of the treatment of the Greek speaking patients with idiopathic scoliosis


S. Kyritsis Chr. Simos S. Kleanthous A. Economou E. Giakoumakis A. Antonopoulos

We present the results of the use of a functional brace (Sarmiento) for the treatment of diaphyseal humeral fractures.

576 patients with humeral fractures (AO classification A1, 2, 3 and B1, 2) were treated in the period from 1984 to 2009. None of them had neurovascular damage.

Initially the patients were treated with a U-shape slab or a “Velpeau” bandage. After three weeks The Sarmiento brace was applied, provided that the reduction was acceptable (anterior angulation < 20°, varus deformity < 30°, shortening < 3cm)

RESULTS97.5% of the fractures examined united (562/576)

Duration of bone healing 8–11 weeks

Successfully used for treatment of compound fractures (Gustilo I)

The Sarmiento Brace is to be used only in patients who thin, ambulatory and with full range of movement of the shoulder joint.

The majority of the diaphyseal humeral fractures is successfully treated conservatively


E. Tsaridis N. Vareltzides A. Christodoulou A. Kapinas D. Evaggelidis S Sarikloglou

To present the results of femoral fracture treatment with long cephalomedullary nails.

We used long cephalomedullary nails for the treatment of certain femoral fractures. There were 30 fractures in 30 patients (12 male – 18 female), age from 32 to 87 years old, operated in our department in a 9 year period (1998 to 2007). The fractures were classified as follows: combined fractures 10 (Ia: 4, IIa:3, IIb: 3 according to Lampiris’ classification), subtrochanteric fractures 18 (IIa:2, IIb:1, IIIa:3, IIIb:7, IV:3, V:2 according to Seinsheimer’s classification), periprothetic fractures 2 (previous nailing with short g-nail). One fracture was open grade II according to Gustilo’s classification and a pathologic fracture (metastatic Ca).

We used 13 long trochanteric g-nails, 14 long gamma-3 nails and 3 long Super nails.

All nails were statically locked.

The patients were allowed partial weight bearing since 2nd post-op day. Average hospital stay: 8 days. Patient X-rays were reviewed monthly until fracture healing. In one case, the nail was dynamised in the 2nd post op month.

All fractures healed in 3–5 months (average: 17 weeks). There was no functional deficit.

The treatment of combined and subtrochanteric femoral fractures with long cephalomedullary nails is a safe and reliable choice.

It ensures early mobilization and excellent functional outcome


Ch. Konstantoulakis G. Grigorakis C. Manimanakis G. Poulios V. Petroulakis

We reviewed in retrospect the preliminary results of ilizarov type fixator for the treatment of severely comminuted calcaneal fractures.

Between February 2006 and December 2008 we dealt with six severely comminuted calcaneal fractures in six patients. Two of which were open type Gustillo IIIa. Mean age was 43 years old(28–56 years old) two of which were female and four male. Preoperatively all fractures were checked by x-ray and computed tomography and were all rated as Sanders type IV. The open fractures were treated within 6 hours and the closed ones the following day. After the positioning of the ilizarov tibial and foot frame, an indirect reduction was achieved using the Ilizarov olive wires.

Mean follow up was 20 months (9 to 36 months). Results were rated as very good in two patients (33%), good in three patients (50%) and fair in one (17%).

So far no re-operation has been required and four of the patients are back to work.

We conclude that the ilizarov system, even with indirect reduction can give very promising results in severely comminuted and complex calcaneal fractures whereas internal fixation has questionable success and many complications


P.V. Giannoudis N.K. Kanakaris P. Stavlas V.S. Nikolaou N. Prevezas

The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.

Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the EuroQol-5D questionnaire were documented over a median period of follow-up of 40 months (12–206).

Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5 years (16–80). Half of them were posterior-wall fractures, 21.6% bicolumn, 14.7 %posterior-wall and column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.

Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome


N.K. Kanakaris R.K. Mallina P. Stavlas G. Kontakis P.V. Giannoudis

Anterior wall and/or column acetabular fractures (AW/ C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre.

Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64).

15 patients (10 males) met the inclusion criteria (mean age 55.5 years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14 days(10–21 days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7 days), and 21 days(14–37 days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis.

Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favourable outcome resulting in early mobilization with limited patient morbidity


E. Athanaselis I. Gliatis P. Bougas M. Tyllianakis

The study of effectiveness of PHILOS plate in the internal osteosynthesis of humeral head fractures.

Since 2006 23 patients with 24 humeral head fractures ere treated in our clinic. 10 of them were men (43,48%) and 13 women (56,52%). The average age was 50,4 years (range 16–89 years). Fractures of the surgical neck of humerus were 8 of these (33,33%), 12 were 3 parts fractures according to Neer classification (50%) and finally in 3 cases there was a 4 part fracture (16,66%). Shoulder of dominant upper limb was injured in most of the cases (68%).

19 patients (82,6%) were examined periodically in an average follow-up period of 19 months (range 13–26 months). All the fractures were healed. In 4 cases (16,66%) insufficient reduction was detected postoperatively. Constant score was calculated 12 months post-operatively up to 82,05 by mean (range 62–100). Differentiation was observed between the patients of age less than 60 years (12 patients with average constant score 91,25 with range from 78 until 100) and these of age of 60 years or more (7 patients with average constant score 71,43 with range from 62 until 81).

Internal osteosynthesis humeral head fractures with PHILOS plate is a reliable method of treatment not only for simple head fractures but also for them of 3 or even 4 parts, without complications and with very good functional results


D.S. Evangelopoulos M. Hilty L.M. Benneker H. Zimmermann A.K. Exadaktylos

Pelvic x-ray is a routine part of the primary survey of Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard in the diagnosis of pelvic fractures. This study aims to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis, in favour of later pelvic CT scan.

A retrospective analysis of polytraumatized patients in our emergency room was conducted between 2005 and 2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and clinically stable pelvis. We excluded patients requiring immediate intervention.

We reviewed the records of 452 patients. 91 fulfilled inclusion criteria (56% male, mean age 45 years). 43% were road traffic accidents and 47% falls. In 68/91 (75%) patients, both pelvic x-ray and CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None false positive pelvic x-ray was detected. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

In hemodynamically stable patients with clinically stable pelvis, x-ray sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination. The results support the safety and utility of our modified ATLS algorithm


E. Myriokefalitakis K. Papanastasopoulos Th. Krithymos I. Giannoulias K. Kateros K. Sarantos

Tibial plateau fractures are common fractures which most of the times require surgery. Recovery can take several months. The aim of our study was to estimate the effect of tibial plateau fractures in quality of life of patients one year after the surgery.

During the time period 2004–2007 we treated 86 patients, with a mean age of 44 years (23–68). Fracture classification was according to Schatzker, hence, there were 9 patients with type I, 14 with type II, 20 with type III, 22 with type IV, 13 with type V and 8 with type VI. In 45 (52.3%) patients the articular surface was reduced with limited use of internal fixation and bone grafts, whereas the remaining patients had syndesmotaxis performed. In all patients stabilization was achieved with hybrid external fixators. Sixty four patients returned in one year postoperative for the study, at which time they completed the Short Form-36 (SF-36) general health surveys.

Compared to the standardized SF-36 categorical and aggregate scores there was no statistically significant difference between the healthy age-matched population and young patients with Schatzker I, II, III and IV fractures. But in 16 patients over 40 years old with Schatzker V and VI fracture, SF-36 score was lower in all categories, despite that 13 of them had full or partial return to pre-injury levels of functioning

We conclude that the age of patients and the complexity of tibial plateau fractures influence the quality of their life one year post-operative


K. Tilkeridis A. Khaleel D. Kotzamitelos A. Hadzigiannakis D. Elliott R. B. Simonis

We treated 60 patients with type III Pilon fractures (Ruedi and Allgower Classification) between 1996 and 2005. The fractures were distracted and then fixed with an Ilizarov circular ring fixator, without the use of open surgery. No internal fixation was used for the tibia or fibula. No bone grafting was performed.

The average time from injury to frame application was four days. The patient stayed ib frame for a mean time of 15 weeks. No second operative procedure was needed. All cases united in good alignment.

The patients were reviewed from ten years to nine months after frame removal. Four separate evaluations were performed (functional, objective, radiological and an SF-36). The function and the range of movement were better than the radiological assessment suggested.

This method of treatment gives better results with fewer complications than open surgery with internal fixation


K. Tilkeridis N. Cheema A. Khaleel

We report our experience in treating victims of the recent Earthquake Disaster in Pakistan. Our experience was based on 2 humanitarian missions to Islamabad. First in October 2005, 16 days after the earthquake and the second in January 2006, three months later. The mission consisted of a team of orthopaedic and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov External Fixators (IEF). We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad.

During the first visit we treated 12 injured limbs in 11 patients. 7 of these were children (ages 6 – 14). All the cases were complex and severe multifragmentary fractures associated with crush injuries. All of the fractures involved the tibia, which were treated with IEF.

Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening of the limb segment. After stabilization, the plastic surgeons provided soft tissue cover.

During the second, we reviewed all patients treated during our first mission. In addition we treated 13 new patients [Table 3] with complex non – unions. Eight out of 13 non-unions were deemed to be infected. All patients had previous treatment with monolateral fixators (AO type) as well as soft tissue coverage procedures, except one patient who had had a circular fixator (Ilizarov) applied by another team. All these patients had revision surgery with circular frames


Xh. Tsibidakis V.I. Sakellariou G. Karaliotas V. Tsouparopoulos G. Mazis A. Kanellopoulos

To evaluate the operative treatment of Blount disease using the TSF external fixator and to evaluate the system.

During January 2004 and August 2008, 8 males and 2 females with Blount disease (16 limbs) were treated using TSF system. For the radiological assessment we obtained standard long-leg standing radiographs and we measured the anatomic medial proximal tibial angle (aMPTA), the diaphyseal-metaphyseal tibial angle (Drennan), and the femoro-tibial angle.

The mean follow-up was 29 months (15 to 45). No patient had pain around the knee, medial or lateral instability. The range motion of the knee immediately after frame removal was 10° to 90° of flexion in two patients while in the other it was from 0° to 110°. The mean leg-length discrepancy was reduced postoperatively from mean 1,9 cm (1,7–3,2) to 0,9 cm (0− +1,5). The aMPTA angle increased from mean 73° (59°– 83°) to 94° (107°–90°), Drennan angle from 17° (14°–22°) to 3° (0°–7°), and femoro-tibial angle from 17° (10°–30°) varus to 7° (2°–10°) valgus. The frame was removed at mean 9 weeks (7–14). Two patients had delayed union, two presented with loss of correction (due to dissociation of struts and secondary to medial physeal bar), two patients had pin track infection. No neurologic complications were referred.

Accurate corrections of multiplanar deformities as varus, internal rotation and shortening of the limb that coexist in Blount disease may be accomplished using TSF system


D. Louverdis S. cPlessas P. Kontos N. Baxevanos V. Petroulias N. Prevezas

The definite treatment of closed or compound fractures of the long bones in polytrauma patients, who had been treated by bridging external fixation during the damage control phase is challenging, especially if it is performed delayed when the risk of infection is increased. In such cases the use of ring type external fixators seems to be a good choice.

During the last two years (mean FU 16 months), 22 Polytrauma patients with fractures of the long bones were treated with the use of ring type external fixators as the definite method. Multiplanar reduction at the fracture site could be achieved with this method. 14 patients had a high ISS score in the emergency department. 14 had sustained fracture of the femur while the remaining 8 patients had suffered a tibial fracture.

In all but one patient the bone union was achieved in a mean time of 19 months. In a patient with a tibial fracture where a bone defect the bone union was accomplished with bone grafting and the use of growth factors. No complications or loss of reduction were seen, while local signs of infection at the site of half pins insertion in three patients were subsided with administration of local antibiotics.

The definite treatment with ring type external fixators of long bone fractures in polytrauma patients seems to be a very good choice. Bone consolidation with no evidence of bone infection was achieved in all patients. while low rate of complications were seen


A. Saridis C. Matzaroglou A. Kallivokas M. Tyllianakis P. Dimakopoulos

Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intraarticular calcaneal fractures.

In a period of 3 years, 16 patients with 18 intraarticular fractures of calcaneus (eleven type III and seven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twelve patients were male and four female. The average age was 42 years (range 25 – 63 years). Three fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamento-taxis, and closed reduction of the subtalar joint were performed in 14 cases. In 4 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients.

The mean follow-up period was 1,5 years (range 1 – 3 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 79,8 (range 72 – 90). Six patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. One of the patients complained of heel pad pain. Nine (6.25%) grade II pin tract infections were detected from a total of 144 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done.

Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intraarticular calcaneal fractures


P. Liantis AF. Mavrogenis AD. Kanellopoulos G. Babis PN. Soucacos

The purpose of this study is to classify the pitfalls, obstacles and complications that occur during distraction histogenesis and also to evaluate the risk factors likely to lead to these problems.

In this study we have retrospectively and prospectively studied the difficulties occurring during distraction histogenesis since 2003. We studied 74 patients (mean age 19,2 years, age range 11–60 yrs) whose 97 limbs segments were lengthened. 21 patients underwent angular correction, 42 patients limb lengthening, 17 patients both angular correction and limb lengthening and 14 non-union correction. In 46 cases, we used the Ilizarov fixator, in 38 the Taylor Spatial Frame and in 10 cases the monolateral external fix-ator Orthofix LRS. Difficulties that occured during limb lengthening were subclassified into pitfalls, obstacles, and complications. For all cases we have recorded the time of appearance of all these difficulties and have associated them with the severity of the initial deformity.

The total number of difficulties in distraction histogenesis was 20%. The number of presenting problems was estimated 5.4% and involved knee subluxation, pin breakage and malalignments. Obstacles presented in 9.5% and included cases with poor bone regeneration, peroneal nerve palsy, premature consolidation and heel cord lengthening. Finally complications were noted in 5.4% of the cases. These consisted of infection, fracture, non-union and loss of range of knee motion.

The problems, obstacles and complications that occur during distraction histogenesis can all impact on the optimal therapeutic target. Extensive surgical experience, and optimal pre-operative planning in conjunction with the type of the original deformity may all contribute in minimising these difficulties


M. Ozcan C. Copuroglu N. Heybeli E. Yalniz

In this study we aimed to identify infection rates in arhroplasty patients which were operated bilaterally with single anesthesia and to discuss the reasons of infections in these patients.

We evaluated 163 knees of 82 patients (Follow up: 12 to 60 months). Mean age was 66.8. Right knees were operated first followed by left knees. 16 of the patients had diabetes mellitus, 4 of them had rheumatoid arthritis, and 1 of them had systemic lupus erithmatosus. All patients were evaluated according to operation time, wound healing, laboratory findings, clinical presentation and X rays. We had 7 infections (6 deep, 1 superficial infection). When we evaluate operation times, no statistically significant difference was obtained between the infected knees and non infected knees (p=0,275). Two of the infected knees had urinary track infection and dental abscess after the opertaion. Five of seven infected knees were left sided. Six of the infected knees were treated with debridement irrigation and antibiotics successfully. But one had two staged revision.

Bilaterally operated knee arthroplasty increases operation time significantly. This increase of operation time decreases the sterility of surgical field, and may increase infection rates. The increased infection rates in left sided knees may explain this. Postoperative dental and urinary tract infections may also increase infection rates. There is no correlation between infection and other systemic diseases like diabetes mellitus, systemic lupus erithematosus or rheumatoid arthritis


E. Kessidis K. Anagnostidis B. Makris G. Michailidis I.M. Kirkos G. Kapetanos

To determine the effectiveness of Ilizarov external fixator in the treatment of complex fractures of the tibial plateau.

From July 2006 to April 2009, we treated 10 patients with the Ilizarov fixator. Six men and four women ranging in age from 31 to 70 (mean age 56.3 years) were evaluated. All patients were preoperatively evaluated with Computed Tomography scans for better preoperative planning. Eight cases had fractures type VI according to Schatzker Classification and 2 cases type V.

In all patients fixation included pushing olive wires or simple wires and 2 to 4 frames. In 4 patients minimal invasive open reduction was performed with use of bone allograft. In 2 fractures, we combined the treatment with minimal internal fixation

There was no major complication trans- or postoperatively. The mean follow-up was 16 months (4–30). The mean hospitalization was 8 days and there were no cases of blood transfusion. Mobilization with no weight-bearing was immediately allowed, with partial weight bearing after 2 months and full weight bearing after 3 months. Three patients had minor pin tract complications. The average duration of external fixation was 120 days. All the fractures united and patients achieved full extension with more than 110 degrees of flexion.

Ilizarov circular fixation is an alternative method of treatment for these fractures when internal fixation is contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution


D. Giotikas G. Karydakis Th. Karachalios N. Roidis K. Bargiotas K.N. Malizos

Advance medial pivot total knee replacement has been designed to reflect contemporary data regarding knee kinematics. We report the clinical outcome of 284 replacements in 225 consecutive patients. All patients were prospectively followed for a mean of 7.6 years (5 to 9) using validated rating systems, both objective and subjective.

All patients showed a statistically significant improvement (p~0.01) on the Knee Society clinical rating system, WOMAC questionnaire, SF-12 questionnaire, and Oxford knee score. The majority of patients (92%) were able to perform age appropriate activities with a mean knee flexion of 117° (85 to 135). Survival analysis showed a cumulative success rate of 99.1% (95% CI, 86.6 to 100) at five years and 97.5% (95% CI, 65.6 to 100) at seven years. Two (0.7%) replacements were revised due to aseptic loosening, one (0.35%) due to infection and one (0.35%) due to a traumatic dislocation. In only two (0.7%) replacements, progressive radiological lucent lines (combined with beta angle of 85°) were observed


M. Potoupnis J. Iakovou E. Kenanidis St. Pellios N. Karatzas G. Kapetanos

Aggrecan is a major constituent of joint cartilage. A prominent feature in joint disease is loss of Aggrecan. The aim of this study was to assess the relation between the concentration of Aggrecan in the synovial fluid of knee joint and this of the peripheral blood in patients suffering from end stage knee osteoarthritis

37 postmenopausal women suffering from end-stage idiopathic knee osteoarthritis, scheduled to undergo Total Knee Arthroplasty (TKA), were enrolled in this study. Their mean age was 69.8 years (range: 49–81 years). The serum levels of Aggrecan were evaluated one day pre-operatively whether synovial fluid levels from fluid taken during the operation day.

Patients suffering from any endocrine disorder, rheumatoid or other secondary arthritis or any other disease that could interfere with the cartilage homeostasis were excluded from the study. Concentrations of aggrecan turnover were measured with appropriate assays.

Moderate correlation between serum and synovial fluid concentrations of aggrecan was revealed (r= 0, 337, p=0,197)

Serum levels of aggrecan may be related to the synovial concentration of Aggrecan in patients suffering from end stage knee osteoarthritis. The possible significant relationship between these markers may be of value in assessing cartilage degradation in patients with involvement of a single joint with a blood sample. However this correlation needs to be further investigated


I. Kouvaras S. Dagkas S. A. Psarakis A. Kaspiris G. Besiris E. Vasiliadis

The osteonecrosis of the medial femoral condyle, depending on the area occupied, causes pain and may progress into osteoarthritis. For the management of osteonecrosis numerous treatment methods have been described, as conservative, drilling, osteotomy and others.

The aim of our study is to evaluate the results of management of knee osteonecrosis with unicompartmental arthroplasty.

We studied 16 knees in 15 patients (all women) with osteonecrosis of the medial femoral condyle. The size of osteonecrosis was greater than 3.5 cm, as revealed by MRI. The mean age of patients was 72 years (range 64–80 years). The time elapsed from the onset of symptoms to surgical treatment ranged from 3 to 10 months.

All patients were followed clinically and by X-ray 1 to 6 years post-operatively and scored with Knee Society Score. The result in 14 patients was excellent and in 1 was good.

In conclusion, unicompartmental knee arthroplasty is a satisfactory method of treatment of osteonecrosis, which provides immediate relief from pain, long-term satisfactory outcome and avoids multiple operations


K. Dogiparthi L. Van Niekerk S. Papalexandris

The aim of the study was to assess the knee function after MPFL reconstruction with single hamstring autograft.

In this case series 86 patients (87 knees) were treated in total, from July 2002 till December 2008. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency were documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The tibial insertion of the graft was retained whereas its free end was rerouted through the most distal part of the medial intermuscular septum, to the supero-medial border of the patella, where it was fixed. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores.

There were 60 male and 26 female patients with an average age of 29.73 years (median age 28) and range 16–54 years. The mean follow-up was 22.4 months (range 6–78 months). All knee functional scores significantly improved postoperatively. Kujala score improved from 61.3 to 84.8, Tegner score improved from 3 to 5.3, IKDC score improved from 52.4 to 73.8 and Lysholm score improved from 58 to 76.5. The comparison was made between the preoperative and the postoperative values at two years after surgery or at the last follow up, if it was shorter than two years. All scores showed significant improvement after the third postoperative month. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella.

Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability. Significant functional improvement is achieved between the third and sixth postoperative months


G. Pavlou J. Pagkalos I. Polyzois E. Tsiridis R. West

Controversy still remains as to whether patella resurfacing in total knee arthroplasty (TKA) should be conducted as a matter of routine. Some authors recommend routine resurfacing of the patella and advocate this due to the reduction in post-operative anterior knee pain and the reduction in requirement for revision surgery.

A database search was conducted to identify prospective randomized controlled studies only. Eighteen prospective randomized trials were identified and found eligible for inclusion. A cumulative sample of 8006 knees were involved, 3418 undergoing resurfacing and 4588 undergoing no resurfacing. Primary outcome data extracted was incidence of secondary operations, incidence of anterior knee pain and functional outcome scores including subgroup analysis of the type of prosthesis used in each study. Der Simonian Laird metanalysis was conducted if studies were found to be homogenous where statistical significance was defined as an overall alpha error of < 0.05.

No statistically significant differences were found to exist between patients undergoing patella resurfacing as a primary total knee replacement and those who preserved the native patella. No differences could be found between specific prosthetic design when subgroup analysis was conducted.

The study does not offer evidence to suggest any advantage of resurfacing versus non-resurfacing. Furthermore, no significant discrepancy existed when comparing different types of total knee prosthesis. This may be due that all the knees analysed are designed to be patella friendly and allow conformity of articulation of both a native and patella button equally


S. Alevrogiannis G.A. Skarpas A. Triantafyllopoulos

To present our experince in the use of different autologous cartilage transplantation techniques with concomitant procedures.

The last 30 months we treated 42 patients with chondral defect at the knee. Their mean age was 34 y.o. and the men to women ratio was 28/14. The defect concerned the medial femoral condyle(20), the lateral femoral condyle (14), the medial facet of the patella (4) while 4 patients demonstrated chodral defects in both femoral condyles. The mean area of the defect was 6.5 cm2 while defects measuring below 2.5 cm2(10) were treated arthroscopically using microfracturing trechnique. 20 cases were treated for chondral defect alone using either MACI or ACT-3D technique for chondrocyte transplantation and in 12 cases there was a combination of cartilage transplantation with alignment correction procedures. Finally a modified rehabilitation protocol was used.

All the cases were performed uneventfully. We assesed the patients 12 months post-operatively using the LYSHOLM & GILLQUIST score, FAFA kai Visual Analogue Pain Score. The clinical outcome was excellent, the follow-up using ‘MRI showed adequate filling of the defect without significant bone swelling.

Our early results using the method are more than encouraging. The method continues to evolve and is very challenging. As far as we know this the first publication concerning 3rd generation autologous chondrocyte transplantation in both femoral condyles silmutaneously


D. Koulalis D. Kendoff C. Mustafa P. Di Benedetto C. Cranchi D. Mastrokalos A. Pearle

Measurement of precision in positioning multiple autologous osteochondral transplantation in comparison to the conventional free hand technique.

The articular surfaces of 6 cadaveric condyles (medial – lateral) were used. The knee was referenced by a navigation system (Praxim). The pins carrying the navigation detectors were positioned to the femur and to the tibia. The grafts were taken from the donor side (measurement I) with the special instrument which carried the navigation detectors. The recipient site was prepared and the donor osteochondral grafts were forwarded to the articular surface (II). The same procedure took place without navigation. The articular surface congruity was measured with the probe (measurement III)

The angle of the recipient plug removal (measurement I) with the navigation technique was 3,27° (SD 2,05°; 0°–9°). The conventional technique showed 10,73° (SD 4,96°; 2°–17°). For the recipient plug placement (measurement II) under navigated control a mean angle of 3,6° (SD 1,96°; 1°–9°) was shown, the conventional technique showed results with a mean angle of 10,6° (SD 4,41°; 3°–17°). The mean depth (measurements III) under navigated control was 0,25mm (SD 0,19mm; 0mm–0,6mm). With conventional technique the mean depth was 0,55mm (SD 0,28mm; 0,2mm –1,1mm).

The application of navigation showed that complications like diverging of the grafts leading to breakage or loosening as well as depth mismatch which can lead to grafts sitting over or under the articular surface can be avoided providing better results in comparison to the free hand procedure


N. Markopoulos M. Vlagkopoulos Ch. Lyrtzis L. Oikonomidis M. Bozoglou Gh. Krystallis

If and how closed valgus osteotomy of tibia is possible to influence intra and post operative results of total knee arthroplasty.

Since 1985 to 2002 196 high tibial osteotomies were performed. 57 of them were treated by T.K.A. In 21 of 196 cases diagnostic arthoscopy performed for evaluation of the lesion. All osteotomies were closed wedge. Stabilization of the knee was done with plaster clast and in 50% of cases staples used. The time interval from osteotomy to T.K.A was 2–17 years mean 8 years. Follow-up of T.K.A. was 3–20 years.

Scars, patella Baja, shortens of patellar tendon increased operative time and degree of difficulty. Postoperative results of T.K.A, were evaluated according the WOMAC (pain, stiffness, function) KSS (function) KSRIS (x-ray findings) were the same with those of primary T.K.A.

Postoperative complications:

11 cases decrease in range of knee movment

3 fractures of external tibial condyle

2 mechanical loosening of T.K.A

skin necrosis

rupture of extension complex.

Intaoperative difficulties in high valgus tibial osteotomy and afterrwords in T.K.A. were increased although postoperative results were the same. This is the reason that surgical experience is the target point of the result


R.A. Giannakos K. Bargiotas G. Tsougias M. Hantes S. Varitimidis K.N. Malizos

The evaluation of the outcome of CCK prostheses in primary TKA

Between 2002 and 2008 we implanted 34 CCK knees in 31 patients. Mean age was 69 (58–79) 10 patients were operated because of valgus knee and lateral compartment arthritis, 8 because of post-traumatic ligamentous laxity and/or bone loss and the remaining patients presented with advanced OA and varus deformity exceeding 30 degrees. All patients were followed regularly with radiographs annually and there were assessed clinically with KSS and Womac score. The findings were compared with a group of patients with similar characteristics and a CR prosthesis.

Mean follow-up was 3 years (6–1) There was no revision in this group neither was any radiological abnormality. Clinical outcome in terms of KSS and WOMAC score was excellent and comparable to the CR group.

The main indication for a CCK prosthesis is the ligamentous insufficiency. There is enough evidence to support its superiority as a treatment option in valgus knees but long term performance is yet unclear.

CCK prostheses are a reliable solution for unstable or imbalanced knees their long term behaviour though, is yet unclear


S. Likoudis I. Koutroumpas G. Tzoanos I. Aggelidakis K. Balalis P. Katonis

The timing of performing knee arthroplasties in bilateral osteoarthritic knees remains controversial. Our aim was to compare one-stage with two-stage bilateral knee arthroplasties (TKA).

Between November 2004 and April 2008, 128 patients (72 female and 56 male) underwent one-stage bilateral TKAs. Another group of 115 patients that underwent two-stage procedures during the same period formed the control group. All patients received the same type of anaesthesia. Study parameters included age, weight, medical co-morbidities, length of hospital stay, blood loss, post-operative complications and functional outcome.

There were no significant differences between the two groups. Co-morbidities and functional outcome based on the Knee Society Score were similar in both groups. In the one-stage group the length of hospital stay and blood losses were higher than the two-stage group; however less than double compared to the two-stage group. The early post-operative complications were higher but not statistically significant in the one-stage group.

Despite the fact that the early post-operative complications are slightly higher in the one-stage group, this particular method is an effective way of dealing with bilaterally osteoarthritic knees. It offers excellent functional outcome at a reduced cost


G. Horne P. Devane K. Adams J. Stanley

Data from the Australian Joint Register suggests that the revision rate for cruciate retaining [CR] prosthesis is less than for cruciate sacrificing prosthesis[PS]. We have analysed data from the NZOA joint register to see if this is the case in NZ.

Data for all PS and CR knee replacements in NZ between 1999 and 2004, and any subsequent revisions were analysed and the results compared with the AOA registry data [2008]. There were 3808 PS knees and 7152 CR knees on the AOA register, with a seven year revision rate of 3.3% and 2.1% respectively p=.002. On the NZOA register there were 1869 PS knees and 5749 CR knees, with a five year revision rate of 1.55% and 1.39% respectively p=.608

This aspect of prosthesis design did not influence the revision rate at five years.


M. Clatworthy

Total Knee Joint Replacement is mostly commonly performed using a measured resection technique. When the PCL is retained 9mm of bone is resected off the distal femur. If the PCL is excised 11m of bone is resected. Computer assisted total knee joint replacement will guide the surgeon to perform the optimal distal femoral resection to gain neutral alignment and full post operative extension.

Three hundred TKJR’s were performed by one surgeon using the De Puy Ci navigation system. A ligament balancing technique is used whereby a neutral tibial resection is performed. A ligament tensor is inserted in extension and flexion. The navigation system then performs an optimization process whereby the distal femoral cut is calculated to give a neutral mechanical axis and 0° of knee extension. Data was collected measuring the distal femoral resection in the PCL retained and resected knees.

The distal femoral cut required to achieve full extension for the PCL retaining TKJR ranged from 5 – 15mm. The mean was 11.2mm. The distal femoral cut required to achieve full extension for the PCL sacrificing TKJR ranged from 5 – 15mm. The mean was 10.8mm. There was no difference between the two groups (p=0.07). Both the PCL retaining and sacrificing TKJR distal resections correlated with the preoperative flexion deformity, i.e. patients with a greater fixed flexion deformity required a greater distal femoral resection to achieve full extension

There is a wide variation in the distal femoral cut to achieve full extension in TKJR. It is accepted that a smaller distal resection is required for a PCL retaining than a PCL sacrificing TKJR. Our study refutes this premise. A greater femoral resection is required if there is a greater fixed flexion deformity. A measured resection technique will result in a large percentage of patients with a fixed flexion deformity following TKJR


G. Hooper A. Pearse A. Rothwell C Frampton

The purpose of this study was to investigate the surgical options for unicompartmental osteoarthritis (OA) in younger patients by comparing the survivorship and functional results of Total Knee Replacement (TKR) following osteotomy with the results for both primary TKR and revision of Unicompartmental Knee Replacement (UKR) to a TKR, and thereby recommend the most appropriate index procedure for this group of patients.

We reviewed the revision rate and functional outcome of all patients who had a total knee replacement (TKR) following an osteotomy or Unicompartmental Knee Replacement (UKR) on the New Zealand Joint Registry. We used this data to compare the results to primary TKR scores, including comparison of age-matched subgroups.

There were 711 patients who had undergone TKR as salvage for a failed osteotomy with a revision rate of 1.33 revisions per 100 component years and a mean Oxford knee score (OKS) of 36.9. 205 patients had failed UKR converted to TKR with a revision rate of 1.97 revisions per 100 component years and a mean OKS of 29.1. The revision scores of TKR for both failed osteotomy and failed UKR were significantly poorer than following primary TKR (p← 0.05). The mean OKS following revision of a UKR was significantly poorer than both primary TKR (p←0.001) and TKR for a failed osteotomy (p←0.001). There was no significant difference in mean OKS between primary TKR and TKR for a failed osteotomy, even amongst patients younger than 65 years (p=0.8).

This study has shown that if a surgeon is choosing between an osteotomy and a UKR in the younger patient than the better for any subsequent revision procedure will be achieved with an osteotomy. Revision of a failed osteotomy to a TKR has improved functional results compared to revision of a failed UKR. However, both yield poor survivorship rate compared to primary TKR.


M. Clatworthy

MACI Cartilage Transplantation has been performed in New Zealand for the last five years for patients with isolated articular cartilage defects who have failed a microfracture technique.

Thirteen patients have undergone this procedure. Patients were evaluated by an independent research assistant preoperatively and at 6 months, 1, 2, 3 and 5 years Visual analogue pain score, ICRS score, WOMAC score, KOOS score, IKDC score and SF 36 were collected at all time points. An MRI scan was performed in all patients at all time periods. Biopsies are taken at three years.

There is an improvement in visual analogue pain score, ICRS score, WOMAC score, KOOS score, IKDC score and SF 36 at all time points. Results improve with time. No procedures have failed. All MRI scans showed restoration of articular cartilage. Histology shows hyaline like cartilage

Medium term results are encouraging. The rehabilitation is long thus 12 month data does not give an accurate outcome measure. Ongoing evaluation is occurring.


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W. Leigh H. Crawford M. Street S. Manners M. Huang

Osteomyelitis continues to be a common problem amongst the paediatric population. Osteomyelitis of the calcaneus is an uncommon problem that still poses a problem to the treating physician. The purpose of this paper is to retrospectively review a large series of paediatric patients with calcaneal osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid earlier diagnosis and or improve treatment outcomes.

A 10-year retrospective review was performed of clinical records of all cases of Paediatric calcaneal osteomyelitis managed at the two children’s orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children’s Hospital, and 1998 and 2008 at Middlemore’s Kids First Hospital.

Sixty patients fulfilled the inclusion criteria. The average duration of symptoms was 6.8 days. 40% of patients had a recent episode of trauma. 82% of patients could not weight bear on admission. Only 22% of patients had a temperature above 38 C. 27% of patients had positive blood cultures with Staph aureus being the most commonly cultured organism. X Rays, bone scans and MRI were all used to aid the diagnosis. ESR was elevated in 81% and the CRP was elevated in 77% of patients. 20% of patients had surgery with an average of 1.3 surgeries for those who progressed to surgery. Treatment length was an average of 2 weeks 6 days of oral antibiotics and 3 weeks 2 days of oral treatment. There was no post surgical complications and 10 readmissions, 3 for relapse, 3 for PICC line problems and 4 for antibiotic associated complications.

Although a sometimes more difficult diagnosis to make, calcaneal osteomyelitis can be diagnosed with an appropriate history, clinical examination and investigations. Treatment with intravenous and oral antibiotics and surgical debridement if indicated can lead to a good clinical outcome with minimal complications


M. Siu T. Bidwell

Child abuse is often called a New Zealand Epidemic in the popular media. It encompasses sexual, physical, emotional, and neglect. As Orthopaedic surgeons, our primary involvement is with the physical side. The diagnosis of a femoral fracture in very young children has been reported as highly suggestive of NAI, with rates ranging from 11% to 60%. The purpose of this study was to determine the characteristics of children presenting to the Starship Hospital who had sustained a femoral fracture as a result of Non-Accidental Injury (NAI).

All confirmed cases with concurrent diagnoses of NAI and femoral fracture presenting to the Starship over a ten year period from Jan 1999 to 2009 were reviewed. These patients were then compared with all patients with femoral fracture who were referred to the child protection team and with all patients presenting with traumatic femoral fracture during this period. Cases were examined with regards to demographics, circumstances of injury, comorbidities and fracture characteristics.

Compared to all femoral fractures, those as a result of NAI were significantly younger. All were aged 3 years or less, with the majority aged 12 months or less. In this age group, approximately a third of those with femoral fracture had a confirmed diagnosis of NAI. In the NAI group, multiple fractures including bilateral femoral fractures were more common. Prematurity was a common co-morbidity. Approximately half of the patients had been seen in hospital for any reason prior to the index admission.

More than half of the cases of confirmed NAI presented primarily to the Orthopaedic service. It is important for Orthopaedic surgeons to be able to identify those children with fractures who may be at risk of NAI. In particular, this includes children under the age of 1 who present with femoral fractures.


T. Lamberton V. Poutawera

Knee flexion is often decreased in severe arthritis causing pain, and functional limitations in lifestyles and occupations. Newer knee replacement designs offer the possibility of greater knee motion. The objective of our study was to compare the clinical outcomes, in particular the range of motion, in patients treated with a total knee arthroplasty using either a standard posterior stabilized knee prosthesis or a high flexion posterior stabilized knee prosthesis, with regard to return to function within 1 year of surgery.

This was a prospective randomized single blinded study. Forty patients were randomly assigned to receive either a standard fixed bearing posterior stabilized or a modified high flexion fixed bearing posterior stabilized Smith & Nephew Genesis II total knee joint replacement. Clinical outcomes were determined from data collected on all patients who were evaluated pre-operatively, at twelve weeks post-operatively, and at one year post-operatively. Data collected included SF-12, WOMAC, and Oxford knee scores, and knee range of motion measurements.

37 of 40 patients enrolled completed the study. 22 patients were randomized to receive a standard posterior stabilized fixed bearing Genesis II knee replacement and 22 were randomized to receive a Hi-Flex posterior stabilized fixed bearing knee replacement. ROM, quality of life, and clinical scores at 12 months will be presented.


R. Puna M. Huang H. Crawford K. Karpik

Acute haematogenous osteomyelitis in children is relatively uncommon but delay in diagnosis and inadequate treatment can result in significant morbidity. Most recently evidence has suggested conservative treatment with adequate antibiotic therapy should be the mainstay, with provision for surgical intervention in those who fail to respond to conservative management. The outcome of primary management has been evaluated in this review.

Retrospective analysis of an osteomyelitis database was conducted on individuals presenting to Auckland’s Starship and Middlemore Hospital with an ICD-10 diagnosis of Osteomyelitis between January the 1st 1999 and December the 31st 2008.

813 children fulfilled the criteria for inclusion into this review. The annual incidence of acute haematogenous osteomyelitis in the paediatric population in Auckland over this period was approximately 1:4,000. 64% were male and 36% were female. The majority were New Zealand European (35%), with the other significant ethnic groups represented being New Zealand Maori (22%), and Pacific Island (30%). 23% of patients were aged less than three. 51% of patients were between three and ten, and 26% older than ten. Only 32% had an elevated white cell count on admission. A responsible pathogen was isolated in 50% with the most common being Staphylococcus aureus, which was isolated in 77% of this group. Diagnosis was made radiologically in 66%, clinically in 27%, and surgically after exploration in 7%. The most common site of osteomyelitis was the femur in 254 individuals, followed by the tibia in 198 individuals. 49 had multi-focal involvement. Flucloxacillin was the most common antibiotic used, with 510 individuals being administered flucloxacillin at one point in time during their management. The average length of treatment was 43.7 days, which included intravenous therapy of 22.3 days, and oral therapy of 21.4 days. 60% had a range of duration of therapy from greater than three weeks through to six weeks. 44% required surgical intervention. The relapse rate was 6.8%. The average duration till relapse was 5.8 months. Only 1.7% of the total population went on to develop chronic osteomyelitis.

The incidence of paediatric acute haematogenous osteomyelitis in this population appears to be relatively high. The average length of treatment was longer than that now reported to be successful for eradication. This could possibly be a factor in the relatively low rate of relapse and low subsequent rate of chronic osteomyelitis.


G. Hooper A. Rothwell P. Martin C. Frampton

This study reviewed the revision rate of fully cemented, hybrid and cementless primary total knee replacements (TKR) registered in the New Zealand Joint Registry from 1999 to May 2008 to determine whether there was any significant difference in the survival and reason for revision with these different types of fixation.

The percentage rate of revision was calculated per 100 person years (HPY) and compared to the reason for revision, type of fixation and the patient’s age.

Of the 28707 primary TKR registered, 522 underwent revision procedures requiring change of at least one component with a survival rate of 0.44 HPY (1.8%). The majority of revisions were for pain (153) followed by deep infection (133) followed by loosening of the tibial component (98). Overall the rate of tibial loosening was 0.07 HPY (0.3 %) in the cemented group vs 0.25 HPY (1%) in the cementless group (p < 0.001). There was no significant difference in the type of fixation used for the femoral component, but there was a significant difference in the different types of fixation when revised for pain, with the uncemented tibia performing the poorest. There was no significantly difference in the younger patient (< 55 years) with respect to tibial loosening (p=0.92).

Failure of the uncemented total knee replacement was due to pain and tibial loosening although the results in patients under 55 years were similar in all fixation groups. There was no difference in the fixation method of the femoral component.


M. Rosenfeldt M. Van Niekirk W. Bevan

The ideal treatment of the unstable slipped upper femoral epiphysis (SUFE) is not clearly defined in the literature. Unstable SUFE occurs with less frequency than the stable SUFE. The incidence of unstable SUFE is between 14–25% of all SUFE’s. The literature reports a variety of accepted methods of treatment of the unstable SUFE, consequently, in Auckland there are various methods of treatment.

The unstable SUFE is at risk of development of avascular necrosis (AVN) of the femoral head. The reported incidence of AVN in unstable SUFE is between 15–50%. We expect that different treatment will influence the rate of AVN.

Our aim was to determine current practice and outcomes in Auckland. We reviewed the records and radiographs of all SUFE’s treated in Auckland from 2000–2007. In this time period there were 463 patients across the Auckland region, 109 of which had bilateral SUFE’s which allowed 572 treated hips to be followed. Over this time period there were 34 unstable SUFE representing 6% of treated hips. There was a difference in average weight, with unstable SUFE on average 10kgs lighter (60.5 vs 70.3kgs). Average time to surgery was 43 hours (range: 4–360hrs). Cases operated within 24 hours have a reduced rate of AVN (20%) compared to those operated after 24 hours (AVN 50%). Of the 34 cases, 13 cases had radiological evidence of AVN (35%). Of these there were 11 cases of pin penetration requiring further surgery. There was no difference in rate of AVN when comparing single screw to double screw fixation (SS 44% v DS 38%). There were 11 cases of pin penetration, 8 with single screw and 3 with double screw fixation.

Our review of unstable SUFE in Auckland has shown a difference in the weight of patients when compared to stable SUFE’s presenting from the same population. We have also found that cases operated on within 24 hours have a lower rate of AVN. Single screw fixation is more common than double screw fixation. There was no statistical difference in the rate of AVN but there was a higher rate of screw penetration when using a single screw fixation.


Full Access
R. Maxwell

A cementless version of the Phase 3 Oxford UKR has been used in our unit since mid 2005. We report on our early experience with this implant, reviewing the National Joint Register (NJR) data on UKR in general and Oxford specifically, with respect to six month Oxford Knee Scores (OKS) and revision rates.

A single surgeon review of 170 cementless and 132 cemented cases revealed a mean 6 month OKS of 41.5 and revision rate per 100 component years of 0 for the cementless group, and mean 6 month OKS of 40.0 and revision rate of 1.05 for the cemented group. The equivalent results from the NJR for UKR are 38.75 and 1.44. Radiological review of the 170 cementless cases showed no concerns regarding subsidence and encouraging features with respect to ingrowth. There were no radiolucent lines at one year. The cementless components appear to be strongly osteophilic. The NZ experience with the Cementless Oxford is single centre, comprising a small number of high volume surgeons, and the OKS and revision rates are presented. To date, there have been 346 cases with a revision rate per 100 component years of 0.30.

In summary, single surgeon and national early experience of the Cementless Oxford UKR from clinical and radiological evidence is encouraging.


A. Johnston M. Hanlon P. Blyth R. Kejriwal

Correct sizing of knee arthroplasty implants avoids problems such as stiffness from too large an implant, or periprosthetic fractures from undersizing. Currently most implants are based on a generic unisex population. Femoral component sizing is therefore based solely on the AP measurement after the distal femoral cut. In order to investigate the differences between the New Zealand population and other populations with reported anthropometrics we studied the anthropometrics of the male and female distal femur.

The distal femur of 26 cadaveric knees was resected using standard cutting guides. Using a sizing guide the AP dimension was measured from the posterior condyle to the anterior cortex just proximal to the trochlea (posterior referencing). The ML dimension was measured at the cut surface in the coronal plane of the epicondylar axis.

Overall AP measurement had a mean(standard deviation) of 62(±6.7) mm, the ML measurements had a mean (sd.) of 72(±6.6)mm yielding an ML/AP(100) ratio of 117(±11). The male AP mean was 67(±4.5) mm and female AP 57 (±4.4)mm. The male ML was 77 (±4.7)mm and female ML 68 (±4.5)mm. The ML/AP ratio for male was 111(±12) and female was 120 (±10).

This pilot study has shown differences between genders in the NZ population even with this small sample size. As this data is important for designers of total knee implants, planning is currently underway to perform measurements intraoperatively from approximately 400 patients undergoing total knee replacement.


Dr. S. Senthi Mr. H. Crawford Dr. T. Maxwell

The non-operative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. Non-compliance with abduction bracing has been proven to be a major risk factor for recurrence of clubfoot. The purpose of this retrospective study was to identify those patients who were non-compliant with the abduction bracing post casting and to then assess the rate and severity of recurrence.

One-hundred and fifty children (184 feet) with unilateral or bilateral clubfoot who were treated with the Ponseti method by the senior author from 1999 to 2008 were reviewed. We identified those patients who were non-compliant with the abduction bracing. Compliance was defined as three months full time wear followed by twelve months night-time/nap-time wear. Recurrence was classified as minor, defined as those requiring an extra-articular surgical procedure and major, requiring an intra-articular procedure.

We identified fifty children with seventy clubfeet who were followed up for a minimum of 12 months. None of these patients were compliant with brace wearing. Of the 70 feet, 40 (57%) required surgical intervention. There were 30 (43%) feet with no clinical recurrence. In 5 of the bilateral cases only one of the feet had required corrective surgery. In the 29 patients who required surgical intervention we identified 52 procedures (37 extra-articular and 15 intra-articular).

Compliance with the post correction abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. Despite non-compliance however there is a significant proportion of patients who do not require any surgical intervention. We recommend initiating the Ponseti technique on all patients with clubfeet rather than being selective due to anticipated compliance issues with the family.


D Whitehead G Hooper Bell

We prospectively reviewed patients who had undergone a Revision Total Knee Replacement (TKR) to a mobile-bearing arthroplasty. We wanted to assess functional outcome and survival, and to determine whether the perceived advantages of a mobile-bearing arthroplasty could be expanded to the revision situation.

We divided the patients into two groups. Group 1 consisted of 40 patients who were revised to a rotating platform, with or without stems and augments, and group 2 consisted of 41 patients revised to a varus-valgus constrained mobile-bearing device that still allowed rotation of the bearing. All were assessed with Knee Society Knee Scores, WOMAC, and New Jersey Knee Scores and standard radiographs by an independent examiner.

Group 1 had an average age of 71 years at revision and a follow-up of 5–9 years. Seventy-six percent had excellent or good results with 89% survival at 9 years. Group 2 had an average age of 71 years at revision and a follow-up of 2–5 years. The patient satisfaction score was 8/10 and the normality score was 6.8/10. There was only one case of instability in both groups in a patient with a patellar fracture.

A mobile-bearing TKR can be used in the revision situation with acceptable clinical results and patient outcome without compromising the stability or survivorship in the short-term. It has proved to be a “patellar-friendly” procedure with reduced re-operation for patellar complications; however longer-term studies are required to determine whether the rates of polyethylene wear are reduced by the use of a more congruent articulation.


R. Schouten A. Vincent

The aim of this study was to evaluate the results of a consecutive series of distal tibial fractures treated by percutaneous plating.

85 patients with distal tibial fractures were treated using minimally invasive medial plate fixation. 18 patients had open fractures. Eight had displaced intra-articular fractures (AO type 43C). The majority had extra-articular fractures (AO type 42 or 43A). Patients ranged in age from 16–89 years. All were followed to union with a minimum follow-up period of 6 months (average 47 months). Outcome measures assessed retrospectively were alignment, time to full weight bearing and complications including infection, delayed or non-union and secondary surgery.

The mean time to surgery after injury was 5 days (range 0–22). 51 patients had unlocked pre-contoured plates and the remaining 34 had locking plates. The fibula was plated in 41 cases. Post-operative mal-alignment greater than 5 degrees varus or valgus occurred in 3 cases (3.5%). The average time to full weight bearing was 11 weeks. Superficial infection occurred in 6 patients (7%) and deep infections in 4 cases (4.7%). There was one case of plate fracture. 4 patients, including this case, required further surgery to achieve union. There was a high rate of metalware symptoms that prompted plate removal.

Percutaneous plate fixation of distal tibial fractures is a reliable method of treatment with complication rates lower than reported for open techniques.


S. Senthi S. Stott P. Blyth R. Metcalfe

Unrecognized pin penetrance in the treatment of SCFE by percutaneous pinning has been shown to be under-reported with serious long-term sequelae. The purpose of this study was to use post-operative CT to determine the true position of the screw tip when compared to intra-operative x-rays.

Twenty-four patients were offered post operative CT scans in the acute and clinic setting. Intra-operative plain films (AP and lateral) were compared to post operative CT scans (coronal and axial) to determine

the distance of the screw tip from the particular surface of the hip joint,

the number of screw threads across the physis and

the three dimensional placement of the screw tip in the femoral head relative to the physis.

The positions of a total of 38 screws were measured. Plain x-rays where shown to consistently underestimate the distance to the articular surface. There were significant differences in the distance to the articular surface in the AP (5.5 mm) vs. coronal (3.4 mm) and lateral (4.7 mm) and vs. axial CT (4.1 mm) planes (p < 0.01). The average number of screw threads across the articular surface on the lateral x-ray was 6.7 vs. 8.1 in the coronal CT (p< 0.05). Four of the screws were shown to penetrate the joint surface in CT not shown on plain film.

This study has found that CT scans show screws are closer to the joint surface in the axial and coronal plane on CT when compared to plain x-ray in the AP and lateral plane. CT scans also show that there are more screw threads across the epiphysis than shown on plain x-ray. Placement of the screw within specific quadrants of the femoral head was found to be similar on CT and x-ray. CT scans identified pin penetrance not seen on intra-operative images.


M. Schollum K. Wade P Robertson N Broom

Most researchers have employed conventional histological and related methods to investigate the complex architecture of the IVD. Recognizing the inherent limitations of these methods we have pioneered new microstructural and micromechanical techniques that have greatly enhanced our understanding of the 3-D architecture of the IVD. Using sectioning planes that take full account of the oblique fibre angles in the annular wall, combined with specialized optical imaging techniques that provide high resolution structural images of fully hydrated thick sections we have described new levels of structural complexity that are clearly implicated in the biomechanical function of this highly complex connective tissue organ.

The primary regions of structural interest are the annulus, the annular-endplate junction and the nucleus-end-plate junction. Within the complex multilayered annular wall we have identified a system of collagen-rich bridging structures that both integrate proximate oblique and counter-oblique layers as well as providing long-range radial continuity across many layers. We argue that this system has an important biomechanical role of lashing alternate ‘like’ layers together whilst providing for some freedom of fibre angle change between immediately adjacent layers coursing in counter oblique directions. Thus, under the deformations generated by direct compressive, bulging, flexion and minor rotational forces, the structural integrity of the annulus is maintained.

We have also clarified important features of both annular/endplate and nucleus/endplate structural integration. Our very recent structural studies of the lumbar motion segment suggest that the current models of disc/endplate integration require substantial revision. This presentation will describe new experimental evidence in support of a more appropriate model of structural integration.


C. Aylott R. Puna P. Robertson

The Lumbar Spinous Processes (LSP) have an important anatomical and biomechanical function protecting the neural structures in the spinal canal, and as an anchor for the inter and supraspinous ligaments, and the inter-segmental paraspinal muscles. They also influence access to the spinal canal for neural decompressive surgical procedures. More recently the LSPs have attracted increased interest as a site for surgical device attachment in an attempt to both decrease the symptoms of spinal stenosis, and as a site for intersegmental stabilization without formal fusion. There is evidence that various anatomical structures have altered morphology with ageing, and there is anecdotal evidence of changing LSP morphology with age. This study aims to clarify the influence of age on LSP morphology, and on lumbar spine alignment.

200 CT scans of the abdomen were reformatted with bone windows in sagittal and coronal planes allowing precise measurement of LSP dimensions, and Lumbar Lordosis. Observers were blinded to patient demographics. Inter-observer reliability was examined. Data was analysed by an independent statistician.

The smallest LSP is at L5. The male LSP is on average 2–3mm higher and 1mm wider than the female LSP. LSP height increases significantly with age at every level in the lumbar spine (p< 10-5 at L2). The LSPs increase in height by 2–5mm between 20–85 years of age (p< 10-6), which was as much as 31% at L5 (p< 10-8). Width increases proportionally more, by 3–4mm or greater than 50% at each lumbar level (p< 10–11). Lumbar lordosis decreases in relation to increasing LSP height (p< 10-4) but is independent of increasing LSP width (p=0.2).

This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology.

The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disc space narrowing, but also as a consequence of increased LSP dimensions.


E. Yee C. Chan

Spinal infections can result in devastating consequences for the patient. Surgery is indicated in certain circumstances. Our institution’s surgical intervention for the treatment of spinal infection was studied. The aim was to identify characteristics helpful for future management. Areas of particular interest were the causative agent, organism identification methods, indications for surgery, materials used for anterior column reconstruction and the ultimate outcome.

A retrospective investigation of all patients receiving surgery for spinal infections between the years of 2004 to 2009 was conducted. All surgical postoperative infections were excluded. Twenty patients were identified in the nominated study period. Twelve males and eight females aged in between 15 to 83 with an average age of 59.4 years. The offending organism was a gram positive in half (50%) of the study group. Staphylococcus aureus was overwhelmingly the representative bacterium (90%). Five cases (25%) were attributed to gram negative organisms while tuberculosis was present in four (20%). No organism was identified in one. Blood cultures identified the causative agent in just over half (55%) of the cases while seven (35%) relied on surgically obtained tissue. Computer tomography guided biopsy was positive in only one case. The most common reason for surgical intervention was a combination of neurological deficit and failing medical management. The second most common reason was in cases with an unidentified organism along with neurological issues. Anterior column reconstruction using cortical strut allograft was performed in four patients while another four received a synthetic spacer device. Two patients had both allograft bone and a spacer device. Only single case of autograft anterior column reconstruction was identified. Two deaths occurred following surgery while all surviving patients with preoperative neurological deficits improved. All surviving patients are currently infection free.

The surgical management of spinal infections can result in advantageous outcomes for the patient, especially in the setting of neurological deterioration or failing medical management. The use of allograft bone and synthetic spacer devices in the midst of infection does not appear to prevent successful organism eradication. The possibility of tuberculosis being the offending bacterium cannot be overlooked.


R. Schouten G. Hooper

The aim of this study was to examine the results of medial opening wedge high tibial osteotomies in which TRISOITE (hydroxyapatite tricalcium phosphate composite) wedges have been used as bone graft substitute and to compare the histological results with the clinical outcome.

There were 36 medial opening wedge high tibial osteotomy performed in 33 patients with a mean age of 45 years. Medial compartment osteoarthritis with varus alignment was the indication in 32 patients. All were followed to union with a minimum follow up of 6 months (average 50 months).

The surgical technique involved creating an oblique upper tibial osteotomy at an angle of 60 degrees from distal-medial to proximal lateral, passing distal to the insertion of the patellar ligament and preserving the lateral cortex. The osteotomy was opened to the desired angle of correction and preformed Triosite wedges were inserted. Stabilisation was obtained with a contoured titanium T-plate (ENZTEC). Re-operation was required for metal removal or conversion to total knee replacement in 10 cases. All of these patients had a biopsy of the osteotomy site.

The clinical notes and x-rays were retrospectively reviewed. One patient developed a superficial infection post-operatively which was successfully treated with intravenous antibiotics. Bone grafting was required to achieve union in 1 case (2.8%). There were no cases of varus deformity recurrence as a result of graft collapse. Biopsies provided microscopic evidence of bony incorporation around the tricalcium phosphate with bone healing. Three patients were converted to total knee replacement with no problems at the osteotomy site.

Triosite wedges appear to be a reliable synthetic bone graft substitute to act as a scaffold for bone healing in opening wedge osteotomies. They reduce the morbidity associated with iliac crest bone graft.


S. Veres P. Robertson N. Broom

Intervertebral disc herniation and internal disc disruption are both thought to be primarily mechanically based pathologies. Although several studies have previously disrupted discs in vitro, none have examined the resulting disruptions microscopically.

The technique of nuclear pressurization was used to mechanically disrupt ovine lumbar motion segments. A hollow injection screw was inserted longitudinally through the inferior vertebra of each motion segment, so that the injection screw’s tip was located in the centre of the nucleus. Through this screw, a radio-opaque gel was gradually injected into each segment’s nucleus until failure occurred, marked by a large drop in nuclear pressure, or focal change to the disc’s periphery. Following mechanical testing, the internal failure characteristics of each motion segment were assessed using micro-CT and microscopy. During nuclear pressurization, motion segments were held in one of four postures:

0° flexion,

7° flexion,

10° flexion, or

7° flexion plus 2° axial rotation.

Group I (0° flexion; n=12): Discs failed at a mean nuclear pressure of 13.2±2.1MPa. In most cases failure occurred in a diffuse manner via sequential circumferential tears within the posterior annulus. Group II (7° flexion; n=17): Discs failed at a mean nuclear pressure of 11.2±2.5MPa. Compared to the Group I discs, 7° flexion led to the creation of radial tears extending through the central posterior disc wall. Two types of radial tear occurred: mid-axial and annular-endplate. Mid-axial radial tears were confined to the annulus. Annular-endplate radial tears incorporated both annular and endplate failure; endplate failure in these tears always occurred adjacent to the mid-annulus at the cartilaginous/vertebral endplate junction. Group III (10° flexion; n=17): Discs failed at a mean nuclear pressure of 9.8±2.6MPa. Compared to the Group II discs, 3° of additional flexion increased the proportion of annular-endplate radial tears. Group IV (7° flexion + 2° axial rotation; n=25): Discs failed at a mean nuclear pressure of 7.9±2.4MPa. Compared to the Group II discs, the addition of 2° axial rotation significantly decreased the nuclear pressure at which discs failed, and reduced the occurrence of mid-axial radial tears.

Postures that reduced the disc wall’s ability to withstand high nuclear pressures were associated with an increase in the proportion of disc failures that incorporated tears of the cartilaginous endplates, specifically at the cartilaginous/vertebral endplate junction adjacent to the mid-annulus. The robustness of this junction appears to be intimately linked to the robustness of the disc wall.


A. Don E. Carragee E. Hurwitz J. Cuellar J. Carrino

Prospective match cohort study of disc degeneration progression over ten years with and without baseline discography

To compare progression of common degenerative findings between lumbar discs injected ten years earlier with those same disc levels in matched subjects not exposed to discography

Seventy-five subjects without serious low back pain illness underwent a protocol MRI and a L3/4, L4/5 and L5 S1 discography in 1997. A match group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for ten years. At 7 to 10 years after baseline assessment, eligible discography in controlled subjects underwent another protocol MRI. MRI graders, blind to group designation, scored both groups for qualitative findings.

Well matched cohorts, including 50 discography subjects and 52 control subjects met eligibility criteria for follow up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (non-injected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (p=0.03); 55 new disc herniations in the discography group compared to 22 in the control group (p=0.0003). New disc herniations were disproportionately found on the side of the annular puncture (p=0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (p=0.05) and signal intensity (p=0.001) in the discography disc compared to the control disc.

This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology. The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disk space narrowing, but also as a consequence of increased LSP dimensions.


R. Tomlinson

Modern microsurgery has allowed severed digits to be salvaged by replantation. A retrospective case review was undertaken of all patients undergoing digital replantation at Middlemore Hospital between February 2004 and February 2009. 48 digits from 28 patients underwent digital replantation during this period. The aim of the analysis was to determine what factors were predictive for survival of the replants. Secondary outcomes of interest included subjective functional recovery, pain and further procedures.

Digital replantation over the review period was subject to a 75% survival rate. Smoking and male gender were identified as significant negative prognostic factors (p=0.02). 69% of patients reported post operative stiffness, chronic pain or cold intolerance. The majority of replanted digits underwent secondary procedures.

Patients should be counseled prior to digital replantation that while the procedure is subject to a high rate of digit survival, they should expect stiffness and discomfort and are likely to undergo secondary procedures.


S. Young C. Walker P. Poon

Cuff tear arthropathy represents a challenge to the shoulder arthoplasty surgeon. The poor results of conventional total shoulder arthroplasty in cuff deficient shoulders secondary to glenoid component loosening have meant hemiarthroplasty has traditionally been the preferred surgical option. Recently reverse total shoulder arthroplasty (RSA) has gained increasing popularity due to a clinical perception of an improved functional outcome, despite the absence of comparative data. The aim of this study was to compare the early functional results of Hemiarthroplasty versus RSA in the management of cuff-tear arthropathy.

102 primary hemiarthroplasties performed for cuff tear arthropathy were compared against 102 RSAs performed for the same diagnosis. Patients were identified from the New Zealand National Joint Registry and matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford shoulder scores (OSS) were collected at 6 months and 5 years post operatively and were compared between the two groups, together with mortality and re-revision rates.

There were 51 males and 51 females in each group, with a mean age of 71.6 in the Hemiarthroplasty group and 72.6 in the RSA group. The mean ASA score was 2.2 in both groups. The mean OSS was 31.1 in the hemiar-throplasty group and 38.1 in the RSA group. At follow up, there were 7 revisions in the hemiarthroplasty group and 5 in the RSA group. No difference in mortality was seen between the two groups.

This study provides the first direct evidence of a improved functional outcome of RSA compared to Hemiarthroplasty in the treatment of patients with cuff tear arthropathy. Longer term follow up is needed to confirm that the improved function is maintained, and that late complications such as component loosening remain comparable between the two groups.


M. Melloh T. Zweig E. Aghayev C. Röder J.C. Theis

Posterior lumbar fusion is a frequently performed procedure in spinal surgery. High percentages of good and excellent results are indicated by physicians. On the other hand patient-based outcomes are reported. Little is known about the correlations of these two assessment types. We aimed at their comparison.

The analysis included 1013 patients with degenerative spinal disease or spondylolisthesis from an international spine registry, treated with posterior lumbar fusion. All patients were pre/postop assessed by physician-based McNab criteria (‘excellent’, ‘good’, ‘fair’, ‘poor’). Of these patients, 210 (mean age 61 years; 57% females) were in addition assessed by patient-based Oswestry Disability Index (ODI). The remaining 803 patients (mean age 59 years; 56% females) were assessed by patient-based Core Outcome Measure Index (COMI), including

Visual Analogue Scale (VAS) for back and leg pain as well as verbal self-rating (‘helped a lot’, ‘helped’, ‘helped only little’, ‘didn’t help’, ‘made things worse’). McNab criteria were compared to the Minimal Clinically Important Difference (MCID) in ODI (12.8), in VAS back (1.2) and leg pain (1.6). We investigated the correlations between McNab criteria and these patient-based outcomes.

In the ‘excellent’ group as rated by physicians, the proposed MCID was reached in 83% of patients for ODI, in 69% for VAS back and in 83% for VAS leg pain. All patients said the treatment had ‘helped’ or ‘helped a lot’. In the ‘good’ group 56% (ODI), 66% (back pain) and 86% (leg pain) reached the MCID. 96% of patients perceived the treatment as positive. In the ‘fair’ group 37% (ODI), 55% (back pain) and 63% (leg pain) reached the MCID. 49% had positive treatment considerations. The ‘poor’ group revealed 30% (ODI), 35% (back pain) and 44% (leg pain) of patients with reached MCID. Only 15% rated the treatment as positive.

The Spearman correlation coefficients between McNab criteria on the one hand and ODI, back and leg pain as well as patients’ verbal self-rating on the other hand were 0.57, 0.37, 0.36 and 0.46 respectively.

The comparison of physician and patient-based outcomes showed the highest correlations between McNab criteria and ODI, somewhat weaker correlations with patients’ self-rating and the weakest correlations with back and leg pain. Based on these findings, physicians’ evaluation of patient outcomes can be considered a valuable part of patient assessment, corresponding very well with patients’ perceptions of success or failure of spinal surgery.


P. Robertson D. Aponso

There is controversy whether or not the midline structures (spinous processes, inter and supraspinous ligaments) should be preserved or sacrificed (MLP vs MLS) during decompression in the treatment of lumbar spinal stenosis(LSS). MLP operations are popular as they preserve the posterior tension resisting structures. Equally it is increasingly recognized that the facet joints(FJ), partially resected during decompressive procedures for LSS, have importance resisting postoperative spondylolisthesis and instability. This study was performed to examine the effects of MLP or MLS upon FJ morphology.

MRI scans from 7 patients with LSS (L2/3 to L5/ S1), and 4 patients without LSS (L3/4 to L5/S1) were examined and subjected to theoretical decompression with operative plans that performed decompression via a 10mm corridor that either preserved the midline structures via a parasagittal/laminomy (MLP), or sacrificed the midline structures providing an angled corridor for decompression from the opposite side of the table (MLS). The lateral margin of the decompression was the medial border of the pedicle. Cross sectional area (CSA) was determined for the FJ before and after decompression with both MLP and MLS using Image J cross sectional area analysis.

The cross sectional area of the facet joints prior to surgery was 287 mm2 at L3/4, 275 at L4/5, and 284 at L5/S1 in non-LSS pts. In LSS patients the values were 257, 267, 328, and 319mm2 at the levels L2/3 to L5/S1 respectively. MLS reduced the FJ CSA by 6, 4, and 0 % respectively in the non LSS pts (L3/4 to L5/S1), and 14, 9, 11, and 6% in the LSS pts (L2/3 to L5/S1). MLP reduced the FJ CSA by 34, 25 and 17% in non LSS pts (L3/4 to L5/S1), and 57, 43, 39 and 29% in the LSS pts (L2/3 to L5/S1). The differences between the MLP and MLS reductions of FJ CSA were highly significant. Greater relative reductions were seen with MLP when the CSA of the inferior articular process was examined.

This study demonstrates that preservation of the midline significantly reduces the CSA of the facet joint and in particular the IAP. Biomechanical and clinical evidence suggests that the FJs have a greater role in stability of the motion segment in the lumbar spine, and this study suggests that well-intentioned determination to preserve the midline structures may have a deleterious effect upon the anatomical structures responsible for stability of the lumbar spine.


C. Chow H. Cheng P. Ho L. Hung W. Ip

Functional deficient of the little finger flexor digitorum superficialis (FDS-V) is known to be present in our population. The aim of this study is to evaluate the prevalence of the absence of FDS-V function in the Hong Kong Chinese population. The association between FDS-V absence and various variables (age, gender, hand dominance, occupation, smoking status, plamaris longus absence) were evaluated. The effects on the grip power due to FDS-V absence were analyzed. The anatomical variations were studied by cadaveric study. The clinical and anatomical variations were correlated by MRI study.

152 adult Chinese men and women from age 18 to 65 were recruited randomly. Subjects with congenital abnormalities, history of hand injury, history of upper limb surgery or underlying neuromuscular diseases were excluded. This study has 3 different parts. The first part is a clinical survey to determine the prevalence of the absence of FDS-V function by both the standard test and the modified test. The second part is a cadaveric study to determine the anatomical variations of FDS-V tendon by cadaveric dissection. The third part of this study is to correlate the clinical findings with MRI study.

Total 152 subjects were recruited with 51 male and 101 female, average age 37.6. The prevalence of the absence of FDS-V function by the standard test was 40.1% for right hand and 37.5% for left hand (38.8%). The prevalence of the absence of FDS-V function by the modified test was 9.2% on the right hand and 9.9% on the left hand (9.54%). The absence of FDS-V function was found more common to be bilateral than unilateral. This was found that 68.6% were bilateral by the standard test and 61% were bilateral by the modified test. The associations of functional FDS-V absence with various variables were insignificant. The effects of various variables on the grip power were analyzed using the multiple linear regression. Gender was1he only variable that had significant effects on the grip power for both the right and left hand. On either hand, the absence of Palmaris longus tendon and the absence of the FDS-V function had no significant effects on the grip power. Cadaveric study showed that the little finger FDS tendon was present in all 10 cadaveric hands. Abnormal muscle or tendon interconnection was not found. MRI study showed that there was hypoplastic tendon in subjects with absent FDS-V function.

The prevalence of the absence of FDS-V function in the Hong Kong Chinese population was 38.8% by the standard test and 9.54% by the modified test. The absence of little finger FDS function has no significant effects on the functional status as quantified by the grip power. We can postulate that patients with little finger FDS tendon injury can have normal range of motion and hand function if the FDP tendon is intact.


M. Brick M. Caughey S. Haszard

The New Zealand Nationwide Rotator Cuff Registry is a first worldwide. An initiative of The NZ Shoulder and Elbow Society, work commenced on the project in July, 2005, and the Pilot Study involving four surgeons and 200 patients commenced in September 2007 and finished in February, 2009. The Nationwide Registry commenced in March, 2009, and by 30th June 520 patients had been recruited. This presentation will focus on the data for the first six months of the study.

Analysis of data for the first four months showed that 71% of patients were male and 29% female. 62% involved the right shoulder. 88% of patients considered their shoulder problem accident-related. The rotator cuff repair was undertaken all-arthroscopic in 71 (13.8%), mini-open in 256 (49.6%), and open in 189 (36.6%). 95% were primary operations and acromioplasty was undertaken in 90%.

Using Cofield’s classification, tear size was small (< 1cm in AP length) in 10%, 1–3cm in 62% and large in 28%. Average pain score did not correlate with AP tear size but the Flex-SF activity score deteriorated with tear size. The supraspinatus was normal in 6% and had a full thickness tear of all of the tendon in 39%, part of the tendon in 38% and had a partial thickness tear in 17%. The subscapularis was involved in 33% and infraspinatus in 28%. A labral tear was present in 8.4% and was repaired in 2.1%. Distal clavicle excision was undertaken in 9% of which 62% were open and 38% arthroscopic. The long head of biceps was normally located in 82%, subluxed in 11% and dislocated in 7%. In 47% of cases it was normal, in 42% damaged and in 11% ruptured. Tenodesis was undertaken in 24%, tenotomy in 19% and in 57% the tendon was left in situ. Double row repair was utilised in 60% and single row in 40%. Suture anchors were used in 78% of repairs, bone tunnels in 7% and a combination in 15%. The tendon quality was rated very well in 26%, good in 54% thin in 13% and poor in 7%.

Postoperatively 42% were immobilised for 6 weeks, 24% for 4 weeks and 11% were not immobilised. A polysling was used in 56% and abduction pillow in 21%, and an ultrasling in 10%. Smoking and NSAID use will be compared in patient-derived outcome data at 6 months, one year and two years from surgery.


M. Boland J. Bader R. Royalty T. Uhl

The objectives of this study were to elucidate the function of Brachioradialis during forearm rotation to determine whether it is a neutralizing muscle and a protector of hyper-rotation by eccentric contraction.

The distance from the brachioradialis (BRAR) origin to insertion was measured on 10 left fresh frozen cadaveric arms using an electromagnetic tracking system. This was done in 10¢aincrements over the full range of forearm rotation. In addition, fine-wire electrodes were placed in the BRAR of twelve living subjects. EMG data was collected as the subject rotated the forearm in both a pronating and a supinating direction.

The muscle length data shows that length is shortest at neutral and greatest closer to full rotation in either direction. When rotating from full pronation to neutral the EMG data show a steady increase while the muscle length decreases indicating a concentric contraction. When rotating from neutral to full pronation the muscle length increased and with load the EMG level increased indicating an eccentric contraction. During rotation from full supination to neutral, the EMG activity increased slightly with the muscle length, indicating a concentric contraction. When rotating from neutral to full supination, the EMG level remained variable while the muscle length increased indicating an eccentric contraction or a passive stretch.

EMG activity can occur during isometric, eccentric, or concentric contractions, the accompanying muscle length data is useful for establishing the direction of the activity. We conclude BRAR is a neutralizing muscle as it has a linear relationship with EMG activity when returning the forearm to neutral. It also acts eccentrically slowing extreme pronation and thus it has a dynamic effect on DRUJ stability.

This knowledge will assist surgeons in Tendon Transfer surgery and injury to the Brachioradialis muscle.


M. Boland J. Bader R. Royalty T. Uhl

Change in forearm muscle length can be used to predict muscle function during pronosupination. In ten fresh cadaveric specimens, markers were placed at fifteen muscle origins and insertions. The forearm was positioned at 10° increments from 80° of pronation to 90° of supination with the elbow flexed at 90°. An electromagnetic tracking system was used to digitally collect 3D origin and insertion coordinates. These coordinates were used to create a vector representing muscle length as a straight line from the muscle origin to the muscle insertion. To normalize the data, all lengths were normalized as a percentage of the maximum muscle length for each specimen. Differences in the data were determined through paired t-test analysis.

The muscles which exhibited a significant decrease in length from pronation to supination throughout the entire range were the biceps brachii and the palmaris longus. Muscles exhibiting a significant increase over the range were the pronator teres at both the humeral and ulnar origins as well as the pronator quadratus. The brachialis also exhibited an increase, though not as pronounced. The supinator, extensor indicis and the extensor carpi ulnaris all exhibited maximum length at the neutral position while length decreased in both pronation and supination directions. The only muscle to exhibit minimal length at neutral with increasing length in each direction was the brachioradialis. The extensor carpi radialis longus kept a consistent length during pronation and increased during supination. Muscles that remained consistent during pronation but decreased their length during supination included the extensor policis longus, the flexor carpi ulnaris, and the radial and ulnar origins of the abductor policis longus. The extensor carpi radialis brevis and the flexor carpi radialis exhibited no significant change in muscle length during forearm rotation.

Forearm Rotation involves a complex interaction between the Radius and Ulna. Multiple muscles traverse the forearm en route to the hand. Many muscles change significantly in length during pronosupination. These muscles

Must adapt to this change in length to allow coordinated Upper Extremity function.

Produce a force vector stressing the Distal and Proximal Radioulnar joints.

Assist with Forearm Motion.

Clinical Relevance- Rehabilitation following Injury needs to take into account the effect of forearm rotation, Splint position may vary depending on which Muscle or Tendon is injured, Surgical Procedures and Implants need to be designed to take into account transverse and longitudinal forces on the forearm.


S. Foliaki P. Poon

Total elbow arthroplasty is usually performed through a posterior approach. The management of the triceps tendon insertion include; Triceps division (V-Y Triceps turn down), Detachment of the Triceps insertion either by triceps splitting (Gschwind approach) or triceps reflecting (Bryan-Morrey approach), or by leaving the Triceps insertion intact (Triceps On approach). The ideal approach needs to meet three broad criteria; firstly it should be quick and easy, secondly it should offer excellent exposure and thirdly it should have low morbidity to the Triceps tendon. An approach that is also versatile provides an additional advantage.

The purpose of this study was to present and discuss the surgical technique of a “new” posterior approach to the elbow. To biomechanically evaluate and compare the strength of the Triceps tendon repair with the Bryan-Morrey approach (recently demonstrated in a cadaveric study to be the strongest of three methods of management of the Triceps tendon).

The Bryan-Morrey and Oxford approach were each performed on fourteen pairs of cadaveric elbows with the two Triceps tendon repairs carried out. The contra-lateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied.

This new approach demonstrated a significant reduction in operative time as well as providing excellent exposure suitable for multiple indications. Final analysis of the data using % ultimate strength loss (%USL) compared to the control specimens as the ultimate end point showed this new approach is as strong as the Bryan-Morrey approach with %USL of −40% for both approaches.


A Johnston C Senior R Sharp B Farrington

Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland.

A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored.

33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy.

Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate.


S. Deo G. Horne E. Howick P. Devane

Acoustic emission is an uncommon but well-recognised phenomenon following total-hip arthroplasty using hard-on-hard bearing surfaces. The incidence of squeak has been reported between 1% – 10%. The squeak can be problematic enough to warrant revision surgery. Several theories have been proposed, but the cause of squeak remains unknown. Acoustic analysis shows squeak results from forced vibrations that may come from movement between the liner and shell. A potential cause for this movement is deformation of the shell during insertion.

6 cadaver hemipelvises were prepared to accept ace-tabular components. A shell was selected and pre-insertion the inner shape was measured using a profilometer. The shell was implanted and re-measured. 2x screws were then placed and the shells re-measured. The results were assessed for deformation.

Deformation of the shells occurred in 5 of the 6 hemi-pelvises following insertion. The hemipelvis of the non-deformed shell fractured during insertion. Following screw insertion no further shell deformation occurred.

The deformation was beyond the acceptable standards of a morse taper which may allow movement between components, and this may produce an acoustic emission. Further in-vitro testing is being conducted to see whether shell deformation allows movement producing an acoustic emission.


R. Gordon R. Kejriwal

Digital radiographs have taken over from conventional radiographs in most of the hospitals in New Zealand. This has created a challenge with respect to templating and pre-operative planning of total hip replacement surgeries. Digital templating has not, until recently, been available in our hospitals. Recently, a digital templating system (Cedara) has become available and has been installed and used at Middlemore Hospital and at Manukau Surgical Centre. This system allows computerised templating of digital radiographs. The aim of this study was to assess the accuracy of digital templating and to compare this method to the “compromised” conventional templating that has been performed at Middlemore hospital for the last 10 years.

In order to correct for magnification a fiducial stand has been created. This is a plastic stand and a pole with a movable 36mm metal ball. The ball is placed at the level of the greater trochanter and the stand is then placed between the patients legs. A standard templating “AP pelvis for hips” radiograph is then taken with the limbs internally rotated, such that the patellae are facing anteriorly. A traditional hard film was then created from this image for traditional acetate templating. Digital templating, with the Cedara system, was performed on the digital images after calibrating the image size using the fiducial image of known size. The results of the two methods were tabulated. The operation record was read and the component size and type was tabulated. The postoperative radiographs were assessed and the component positioning was evaluated and compared with the conventional and digital templates. A critical assessment of component size, with respect to under sizing and over sizing, was also performed on the postoperative radiographs and this was correlated with the digital and conventional templates.

This templating, and the evaluation of the postoperative radiographs, was performed by the authors of this paper (a consultant surgeon and a registrar). The accuracy of the two templating methods was assessed by comparison with the post operative radiographs and also with the aid of the knowledge of the actual components which were used at the time of surgery.

The templating images and radiographs of 100 patients were evaluated in the above stated manner and the results were analysed. The results from this analysis will be presented.


D. Kieser M. Krishnan H. Blackley

Revision arthroplasty for infected hip arthroplasty creates a challenging scenario to surgeons. Either a single stage or more traditionally a two-stage revision is performed. Most surgeons utilise an antibiotic loaded cement spacer, but the implant is often rotationally unstable predisposing to dislocation, acetabular bone loss and fracture of the spacer. Pain and discomfort on mobilisation also often occur. We would like to introduce an alternative approach to this challenging scenario with the use of a two-stage revision with an extended trochanteric osteotomy and loosely cemented hip arthroplasty as the first stage spacer.

Surgical Technique: The first stage involves removal of metal ware with all infected tissue and cement performed through an extended trochanteric osteotomy. Circlage wires reduce the osteotomy and a long stem femoral component is inserted with antibiotic infused cement limited to the calcar region. The acetabulum is similarly removed and replaced with a loosely cemented polyethylene liner. The second stage is delayed until the infection is settled and the osteotomy is healed. Removal of the metalware is performed with relative ease, without need for an osteotomy. Reinsertion of an uncemented femoral and acetabular component is then performed. However a second stage is not always required in some patients.

We report a single surgeon series comprising 10 patients from December 2003 to June 2007. The most common organism isolated was Staphylococci species. All operations were performed via a posterior approach. 9 patients were clinically assessed and the Harris hip score calculated. All patients were radiologically assessed. Osteotomies healed in all patients. Only 6 patients underwent a second stage and radiographs show good osseous integration of both components. Two patients are awaiting a second stage revision, while the other two are asymptomatic and not interested in undertaking the second stage.

No dislocations, bony erosions or reinfection was noted in our series.

We recommend this alternative approach to the conventional one or two staged revision arthroplasty. The extended trochanteric ostoetomy ensures rapid and complete removal of all foreign and infected material. The loosely cemented spacer effectively delivers local antibiotic and provides a stable, asymptomatic hip whilst awaiting the second stage, which may not be required.


M. Krishnan R. Tai H. Blackley

Moderate to severe acetabular bone loss in revision hip arthroplasty is challenging. Various treatment options are available but the medium to long term results have not been encouraging. The porus tantalum uncemented cup may be used successfully to address moderate to severe bone loss in acetabulum revision surgery.

We report a single surgeon series. Between December 2003 and June 2007, 39 patients (43 hips) underwent hip revision surgery. There were 17 men and 23 women with a mean age at surgery of 71.9 years (range 36–96). The mean follow up was 40 months (range 24–66). A porus tantulum modular multi hole uncemented cup was used in all cases. At time of assessment 6 patients had died, 2 patients developed dementia and another 2 patients were not contactable. All 10 patients had no significant clinical or radiological concerns at their last orthopaedic review. The remaining 29 alive patients (33 hips) were available for clinical evaluation. Harris hip score of these 33 hips showed, 24 excellent or good, 7 fair and 2 poor. Radiological results: All 39 patient’s (43 hips) radiographs were reviewed. The acetabular defect was quantified according to Paprosky.

Classification taking into account the intra operative findings and pre operative imaging. The horizontal (x-axis), vertical (y-axis) distance from the ipsilateral tear drop and abduction angle were measured in both the pre-operative and post-operative radiographs. According to Paprosky’s classification there were two 2A, ten 2B, six 2C, fourteen 3A and eleven 3B defects. All 43 hips showed good osseous integration. No loosening was noticed in our series. No significant improvement was noticed in the abduction angle and x-axis but significant improvement was noticed in the y-axis indicating more anatomical positioning of the cup within the acetabulum.

One deep infection. 2 of the 5 dislocations were recurrent and successfully managed with a constrained liner. We recommend the Porus tantulum uncemented cup as a very useful implant in often very difficult situation. The mechanical properties of the trabecular metal certainly helps to positively encourages osseous integration providing a sound biological fixation and the high co-efficient of friction helps to implant these cup with as little as 30% host bone contact.


E. Selvarajah G. Hooper P. Devane T. Woodfield

The aim was to assess the wear rate of highly Cross Linked (X3) polyethylene with the use of 36mm femoral heads in total hip arthroplasty (THA). We have previously reported our early results and raised some concern regarding the potential excessive femoral head penetration rates. These results give the 2 year wear rates following this initial bedding-in phase.

There were 100 consecutive patients who had a THA with the same femoral and acetabular components using a 36mm femoral head and X3 polyethylene that were assessed prospectively. Validated computer software (Polyware) was used to assess linear and 3 dimensional wear using standardised x-rays. Examinations were performed at 2,12,18 and 24 months.

There were 40 hips that had completed the 2 year x-ray examination (average 2.4 years). The mean 2-dimensional linear wear rate was 0.17 mm/yr and the mean volumetric wear rate was 113.73 mm3/yr. Steady state wear was achieved after the 2 month and before the 1 year examination. The steady state wear rate was 0.001mm/yr. There was no difference in wear rate with the different sized cups used and wear rate was independent of liner thickness.

The early high wear rates reported have now settled into a more expected pattern of steady state wear similar to other results presented in literature with the use of smaller femoral heads. Using a 36 mm femoral head has not adversely increased the wear rates compared to smaller head sizes when used in conjunction with X3 polyethylene in the short term for THA. These results suggest that the wear rate of X3 is not compromised even with thinner liners and raise the possibility of safely using even larger head sizes with this polyethylene.


A. Segar S. Malak I Anderson R. Pitto

Correct positioning of the femoral component in resurfacing hip arthroplasty (RHA) is an important factor in successful long-term patient outcomes. Computer-assisted navigation (CAS) shows potential to improve implant positioning and possibly prolong survivorship in total hip and knee arthroplasty. The purposes of CAS systems in resurfacing the femoral head are to insert the femoral head and neck guide wire with greater accuracy and to help in sizing the femoral component, thus reducing the risk of notching of the head and neck junction. Several recent studies reported satisfactory precision and accuracy of CAS in RHA. However, there is little evidence that computer navigation is useful in the presence of anatomical deformities of the proximal femur, which is frequently observed in young patients with secondary degenerative joint disease.

The purpose of this in-vitro study was to determine the accuracy of an image-free resurfacing hip arthroplasty navigation system in the presence of two femoral deformities: pistol grip deformity of the head and femoral neck junction and slipped upper femoral epiphysis deformity. An artificial phantom leg with a simulated hip and knee joint was constructed from machined aluminum. Implant-shaft angles for the guide wire of the femoral component reamer were calculated, in frontal and lateral planes, with both a computer navigation system and an electronic caliper combined with micro-CT.

With normal anatomy we found close agreement between the CAS system and our measurement system. However, there was a consistent disagreement in both the frontal and lateral planes for the pistol grip deformity. Close agreement was found only on the frontal plane angle calculation in the presence of the slipped upper femoral epiphysis deformity, but calculation of the femoral head size was inaccurate.

This is the first study designed to assess the accuracy of a femoral navigation system for resurfacing hip arthroplasty in the presence of severe anatomical deformity of the proximal femur. Our data suggests CAS technology should not be used to expand the range of utilisation of resurfacing surgery, but rather to improve the surgical outcome in those with suitable anatomy.


A. Thambyah N. Broom

In this microanatomical and biomechanical study we investigated OA lesion sites and the adjacent intact tissue in an attempt to uncover clues of a pre-OA tissue state and its progression to OA.

Bovine patellae (n=30) showing various degrees of degeneration, where lesions were located in the distal-lateral quarter, were used for the microanatomical study. Cartilage-on-bone samples were cut to include one with the lesion site and the other with the adjacent intact site. These blocks were formalin fixed. For the mechanical testing tissue samples (n=20) ranging from intact to mildly through to severely degenerate were statically compressed (7MPa) to near-equilibrium using a cylindrical indenter, and then formalin-fixed to capture this deformed state. Following mild decalcification of both sets of tissues, full-depth cartilage-bone cryo-sections incorporating the intact-lesion transition and the deformation profile were obtained and studied in their fully hydrated state using differential interference contrast optical microscopy (DIC).

There were three mechanically-significant microstructural features of the cartilage-bone system that varied with tissue degeneration:

the integrity of the strain limiting surface layer,

the degree of transverse interfibrillar connectivity, and

the degree of calcification at the osteochondral junction (zone of calcified cartilage).

Importantly, our mechanical analysis showed how disruption of the cartilage continuum by surface disruption and matrix fibrillar de-structuring, had wider mechanical consequences at the biologically-active osteochondral junction of the adjacent healthy cartilage. The structural changes in the osteochondral junction beneath the still-intact articular cartilage adjacent to the lesion site included the ‘sprouting’ of bone spicules or cones that were morphologically similar to those associated with primary bone formation.

The microanatomical and micromechanical data suggests that there is a mechanobiological link between the altered microstructural response of degenerate cartilage to load and the way in which structural changes develop in the normal adjacent tissue. We propose that while the progression of OA involves first the processes of new bone formation in tissue adjacent to lesion sites, its initiation is due to a disrupted cartilage matrix that alters a regional mechanical environment that includes adjacent healthy tissue.


S. Young F. Claros J. Blacutt J. Cruz

Developmental Hip Dysplasia (DDH) presents considerable technical challenges to the primary arthroplasty surgeon. Autogenous bulk grafting using the femoral head has been utilised to achieve anatomic cup placement and superolateral bone coverage in these patients, but reported outcomes on this technique have been mixed with lack of graft integration and subsequent collapse seen as an early cause of failures. Achieving union and incorporation of the autogenous graft have been identified as key determinants of a successful outcome with this technique. The main factors affecting incorporation are stability of the construct and host-graft bone contact. We describe a novel technique combining the use of bulk autograft with an iliac osteotomy, which provides primary stability and optimises direct cancellous-cancellous bone contact.

21 hips in 21 patients with DDH underwent this technique and were followed for a mean 8.1 years. The pre-operative radiographic classification was Crowe type I in 12 hips (57%), type II in 4 hips, and type III in 5 hips, and the mean Sharp angle was 49.6° (range 42–60°). All grafts united by year. At time of follow up, there was no radiographic evidence of graft collapse or loosening. There were no reoperations.

Our study has shown that this technique variation combining an iliac osteotomy with bulk autograft in cases of developmental hip dysplasia provides early stability and reliable graft incorporation, together with satisfactory clinical and radiological outcomes in the medium term. Longer term study is necessary to confirm the clinical success of this procedure.


J. Munro V. Shim I. Anderson R. Pitto

Aseptic loosening is the leading cause for revision in total hip arthroplasty. Retro-acetabular lysis is often a silent process until severe bone loss causes catastrophic failure. This presents a technically difficult problem for the surgeon and a poorer result for the patient compared to primary arthroplasty. While the major cause of osteolysis is reaction to polyethylene particles, there is little data on the initiation and progression of such lesions. Further, alterations in the mechanical environment caused by such pathology is unclear. We present our use of 3D, finite element (FE) models of retro-acetabular pathology to investigate the biomechanical effects of osteolysis in total hip arthroplasty. Axial CT scan slices from a patient with cystic osteolysis were selected. Areas of cortical bone, cancellous bone, the cup and the cyst are accurately identified. The axial images are matched to a predetermined grid and used to build a complex finte element model. In this way complex anatomy can be built into the FE model and used to map cystic lesions. Force is then applied to the acetabulum.

Initial analysis shows similar stress transmission in cystic disease compared to the post operative pelvis. Pelvic bone still behaves as a sandwich construct with transmission from the acetabulum to the SI joints, pubic symphysis and medial wall. In the setting of pelvic medial wall deficiency, stress transmission is altered with areas of low stress around the defect.

The FE models containing pathology can be compared to models with generic bone density values immediately after total hip arthroplasty. The presence of a cyst in cancellous bone with intact cortical bone, demonstrates strain patterns similar to the post operative pelvis. Once cortical bone loss occurs strain patterns begin to change. This may mark a critical point in osteolytic progression. We present a developing new tool to be used in the assessment of a patient population with retroacetabular cystic disease.


C. Wainwright J.C. Theis S Williams

Statistics New Zealand states “Over the next five decades the 65+ dependency ratio is projected to more than double, from 18 (people aged 65+ years) per 100 (people aged 15 – 64 years) in 2006 to 45 per 100 in 2061. This means that for every person aged 65+ years, there will be 2.2 people in the working-age group in 2061, compared with 5.4 people in 2006 “. This will have a profound impact on health care, specifically in those fractures sustained by the elderly e.g. fractured neck of femur (#NOF).

Also at present little is proven regarding outcome following #NOF in the New Zealand population. These two factors (population change and patient outcome) led to disagreement and healthy debate at the 2008 NZOA ASM. After a pilot study in Dunedin we have examined national electronic records of 52,456 patients presenting with a first admission due to #NOF over the last 20 years.

The mean age at which a patient sustained their first #NOF was around 80 and 71% of these patients have since died. Approximately 10% of patients had a subsequent readmission for #NOF. There was a trend for increasing age over the last twenty years proportional to the increased average age of the general population. One year survival was 75% and mean survival was 3½ years with a third of patients living longer than six years. We found differences in outcome for gender and fracture type (intracapsular vs. extracapsular). Our patients also showed a trend to higher survival risk ratios (i.e. they are clinically “sicker” than they used to be). The incidence of #NOF has increased over the last 20 years with a projected doubling in the number of cases (to 5600 per year) at around 25yrs from now based on the most conservative estimates.


S. Walsh

Drug Free Sport New Zealand (DFSNZ) aims to maintain New Zealand Sport as a drug free environment and thereby enhance our proud and successful sporting culture. New Zealand is bound into the World Anti-Doping Code and must therefore adhere to World Anti-Doping rules.

Detection of doping violations is one of the functions of DFSNZ. An aim of DFSNZ is to eliminate the risk of athletes failing a sports anti-doping test as a result of using legitimately prescribed medication as treatment without a Therapeutic Use Exemption (TUE). This can create major problems for the athlete who may then have to appear before the Sports Tribunal.

Some substances on the prohibited list are used by Orthopaedic Surgeons as part of regular management. “National level” athletes require a TUE to be completed prior to use of these medications or immediately following use in emergency situations. Examples are:

Narcotics and Intravenous Corticosteroids perioperatively.

Probenecid to enhance antibiotic concentrations in treating infections

Other athletes who are not in this category but may be tested do not require a TUE immediately but still have to be able to provide evidence that the medication was used for therapeutic use if they were subsequently to fail a test. It is the athlete’s responsibility to notify the surgeon and obtain the appropriate documentation. Athletes in the Testing Pools will carry a card with reference to MIMS Resources, the DFSNZ website and Hot-line. From time to time athletes stressed by the situation of their injury may forget to notify the surgeon, prior to surgery, of anti-doping requirements. Surgeon (and anaesthetist) awareness and support for the programme will enhance the overall care of the patient and limit subsequent demands on both the patient and medical staff. The aim of this presentation is to enlighten NZOA members regarding the correct procedures to follow should a prohibited substance be required when treating an athlete who is subject to drug testing in sport.


T. Woodfield G. Hooper G. Dias M. Staiger

Replacement of damaged or diseased tissues with permanent metal implants based on stainless steel, cobalt chrome and titanium alloys has been at the forefront of classical biomaterials research and the orthopaedic medical device industry for decades. Biodegradable polymers have also reached the market but often have limited capacity in load bearing orthopaedic applications due to their low stiffness and poor mechanical properties. The development of biodegradable metals based on magnesium (Mg) could be heralded as a major breakthrough in the field of orthopaedic surgery. Degradable implants eliminate the time and cost associated with a secondary surgery to remove hardware, and reduces the period the implant is exposed to instability, fibrous encapsulation, stress shielding and inflammation. The metabolism of Mg and its excretion via the kidneys is a natural physiological process that is well understood, however, controlling the rapid degradation of Mg biomaterials in vivo is a major challenge yet to be resolved for the safe and effective use of Mg in orthopaedic implants.

In this study, we describe a novel manufacturing method for fabricating Mg/Mg alloy implants, as well as the development of an in vitro method for screening Mg/Mg alloy degradation rate by considering both their electrochemical corrosion behaviour and biological characteristics.

A range of Mg alloys with varying amounts of calcium (0.8–28%) and zinc (3–10%) were cast and then machined into Ø4mm and 15mm discs for biocompatibility (HETCAM) and parallel in vitro testing. Alloys were placed in various simulated body fluid (SBF) solutions in vitro (7–28 days) to determine effect of alloy composition on degradation rate. These potentiostatic and potentiodynamic tests were designed to simulate, to varying degrees, the in vivo environment, with the crucial factors (e.g. temperature, pH, serum proteins, CO2 level) controlled to ensure consistency across the test methods. The mechanisms of corrosion on the Mg/Mg alloy microstructure and the effect of protein adsorption all played key roles in dictating the corrosion of alloys in vitro. Specifically the inclusion of physiological levels of serum proteins decreased the corrosion rate up to 600% over more standard SBF solutions described in literature.

This work provides an improved understanding of the effects of corrosion variables on Mg alloys, while making major steps towards deciding the most appropriate screening tests for new alloys for their use as a biomedical material prior to moving to in vivo animal studies.


R. Elliot M. Flint G. French

Objective: Appendicular soft tissue tumours are rare. They represent less than 1% of all malignancy. Failure to appropriately investigate a malignant mass can result in unnecessary loss of limb or life. New Zealand is a sparsely populated country and has four orthopaedic tumour surgeons which is in keeping with the recommended ratio of 1/1,000,000. Consequently some patients find themselves long distances from Tertiary tumour centres. We looked at the investigation and referrals of patients to the Bone and Soft tissue tumour service at our institution.

We reviewed the charts of all patients (126) with a soft tissue tumour referred to the senior authors in 2006 and 2007. The information was stored in a prospective Tumour Registry Database. Where information was not available in records kept at our institution, the referring institution was contacted.

There were 92 tertiary referrals and 34 GP referrals. The majority of the tertiary referrals came from orthopaedic surgeons (55), and general surgeons (28). The mean duration between referral and review was 16 days (0–215 days). There was a of 13 days wait for tertiary referral review. Tissue samples and histology reports accompanied 33 patients which had resulted from 35 invasive Pre Referral Procedures (PRP). This group suffered 21 complications affecting 18 patients. The remainder (91) were Pre Biopsy Referrals (PBR). Biospy was deemed necessary in 47 cases. The PBR group suffered 4 complications. Only one complication occurred to a patient with benign histology in each group. There was an extremely significant relationship between Pre Referral Procedures and suffering a complication (P< 0.0001). The relative risk of complication was 6.2 (C.I. 2.0–18.4) if an invasive procedure was performed prior to referral. There were 3 amputations (plus one recommended but refused by patient) in the PRP group and 1 amputation in the PBR group. This was not statistically significant. The median interval between referral and senior author review was 8 days for the PRP group and 10 days for the PBR group (P=0.2574). Sixty six percent of tertiary referrals were PBR (74% when including GP referrals).

Biopsy of suspected appendicular Soft Tissue Sarcoma should be done by a tumour specialist or in prior consultation with one. There is virtually no delay to see an orthopaedic tumour specialist in New Zealand and achieving a tissue diagnosis does not expedite this.


D. Kieser S. Paul

Osteoporosis affects over 350,000 New Zealanders including 30% of women aged over 60 years and more than half aged over 80. Osteoporotic fractures are a significant cause of morbidity and mortality. From July 1999 to 30 June 2000, 3131 people aged over 65 sustained a fractured neck of femur. 27% died in the subsequent 12 months, equating to 17% of all cause mortality. Fractures are also a significant economic burden. In the period, July 2005 to June 2006, over $18 million was spent on hip fractures in those aged over 65 years. Bisphosphonates improve Bone Mineral Density and consequently reduce the incidence of fracture; however oral bisphosphonates are contraindicated in some patients. Zoledronate is an intravenous bisphosphonate that has recently been licensed for osteoporosis treatment.

We undertook a retrospective chart review and General Practitioner consultation of CMDHB patients who received zoledronate from June 2006 to June 2008. Assessment of clinician compliance with current safety protocols, patient outcomes and side effects were assessed. 78 patients received 101 doses of zoledronate, approximately double the preceding 2 year period (37 patients and 60 administrations). The most commonly indication was osteoporosis. 19% (19/101) administrations were organised through the geriatric clinic and 81% (82/101) were inpatients

Bone Mineral Densities within 2 years were available for 59% (48/82) of administrations. 80% (51/64) had previous osteoporotic fractures. 84% (54/64) of osteoporotic patients were utilising additional calcium and vitamin D therapy. Oral bisphosphonates were contraindicated in 94% (60/64) because of gastrointestinal upset, 3% (2/64) for headaches and 3% (2/64) for worsened BMD despite oral bisphosphonates. Following treatment 13% (8/64) of patients sustained further fractures. In inpatient administration 83% (21/82) pre-creatinine and 80% (66/82) post-creatinine measurements were appropriately assessed in comparison to 58% (11/19) and 79% (15/19) respectively for clinic patients. In inpatients administration 59% (48/82) pre-calcium and 63% (52/82) post-calcium measurements were appropriately assessed in comparison to 37% (7/19) and 68% (13/19) respectively for clinic patients. For GP follow-up of creatinine and calcium measurements, 90% had creatinine and 80% had calcium correctly assessed. Zoledronate was well tolerated with no jaw osteonecrosis in this cohort.

Zoledronate is a well tolerated treatment for osteoporosis in those patients intolerant of oral bisphosphonates. The use of zoledronate has more than doubled in the last 2 years. Stricter adherence to current guidelines is needed to prevent incipient adverse effects.


T. Lamberton A. Vane

After 2 fatalities from this condition at our institution in 2005, a retrospective review of elective surgical records from the previous five years was undertaken and we established 16 further non-fatal cases of Ogilvie’s Syndrome. (This work was presented as a poster at the Christchurch NZOA 2005). We have since prospectively recorded any occurrence of Ogilvie’s Syndrome after elective orthopaedic surgery.

Over the last 2 years since the previous report, we have identified a further 8 cases of Ogilvie’s Syndrome, with one further fatality. This little-known condition is far more prevalent than thought, and is often not diagnosed despite severe consequences. All surgeons should be aware of this condition. Early recognition and intervention is critical to patient survival. Hallmarks of the clinical presentation will be discussed, along with acute management guidelines.


T. Lamberton

A unit of 12 orthopaedic surgeons serving a population catchment of 180,000 have collaborated to collect prospective data on a wide range of orthopaedic conditions, using well proven internationally validated scoring systems. All patients, rural and urban, public and private, in the region are being enrolled. This project is distinct from but complementary to National Joint Registry data. A benchmarking period of 2 years has been completed, and now prospective trials are being commenced. 4000 patient datasets have been obtained to date.

We report on the logistics of establishing a regional research program in a medium-sized New Zealand centre, and results achieved to date. We present our experience with a view to encouraging other centres to consider similar ventures.


P.S. Cullis A. Gregori

Non-image based navigation has catalysed an ongoing revolution in total knee arthroplasty technique. Few systems, however, have been designed and subsequently analysed in UKA. A new system designed for use with the Oxford UKA prosthesis offers two ways to determine the ideal tibial resection depth for insertion of the tibial component of the prosthesis. Tibial resection may be calculated using femoral or tibial referencing. Clinical experience suggests that femoral referencing calculates tibial resection depth incorrectly. We set out to confirm whether femoral referencing is, in fact, less accurate than tibial referencing in calculating tibial resection depth in this new navigation system, and to determine factors responsible.

The navigated procedure for UKA was carried out on an artificial limb to the point of tibial resection using the latest Vector Vision-Biomet-BrainLAB navigation system. The depth of resection achieved was measured and the procedure repeated in multiple series using femoral and tibial referencing. Intraoperative flexion angle and joint space were altered to assess their effect on accuracy. Analysis of variance revealed that femoral referencing is less accurate than tibial referencing (p = 0.001). Though intraoperative hyperflexion and increased joint space width exacerbated the inaccuracy, their contribution did not achieve significance (p = 0.078 and p = 0.02, respectively).

We propose that femoral referencing be omitted as an option in the determination of tibial resection depth in this system. This study has revealed an inaccuracy in a commercially available navigation system that can result in a prolonged and more complicated procedure, suggesting that more stringent pilot assessment of orthopaedic products is needed.


O. Berber P. Sanjay SB. Manjure Y. Kalairajah

Navigation in total knee replacement is now used more frequently. The proven benefits in comparison to a conventional knee replacement include reduced hospital stay, reduced blood loss, and improved component alignment. A retrospective study was carried out to evaluate the difference in post-operative pain outcomes between conventional and computer-assisted navigation knee arthroplasty in a high volume setting. Computer-assisted surgery may be more painful because of the extra pin holes required for the navigation. The amount of anti-emetic use between the two groups was also looked at as evidence exists that greater anti-emetic is used if pain levels are greater.

All the navigated arthroplasty operations were performed by one of two surgeons in a single hospital using a uniform surgical approach and navigation system. A single type of prosthesis was used in the conventional group. In the first part of the study, the navigated group consisted of 87 patients and the conventional group of 40 patients (total = 127 cases). In the second ‘antiemetic use’ study, the navigated group consisted of 71 patients and the conventional group of 39 (total = 110). The analgesic and anti-emetic use was collated for the 72-hour post-operative period. This was chosen so that any analgesic influence of the anesthetic would have been negated over this period.

Pain scores were measured over the 72 hour period at regular intervals using a visual analogue scale. Patients in the navigated group seemed to report less pain in the first 24 hours but this was later reversed. Interestingly, their pain scores were more constant during this period, whilst the conventional group exhibited greater variability. The actual difference in pain scores between the two groups was however not significant (p=0.33).

The amount of opioid used by patients in each group was the primary factor used to see if a difference exists between the two procedures. The assumption was made that a correlation exists between opioid usage and pain. The total opioid usage was calculated by using referenced opioid conversion calculations for intravenous and oral forms of morphine including weaker opioids such as codeine and tramadol.

The average opioid used in the conventional group was 164.8 mg whilst in the navigated it was 173.7mg. However using the Student’s t-test this difference was not significant with a p value = 0.69. The percentage of patients requiring opioid greater than 300mg in 72 hours was actually greater in the conventional group (15% vs 12.6%).

The average antiemetic use looking initially at cyclizine was 57.7mg in conventional and 50.4mg in the navigated. This difference was also not significant (p=0.59).

On analysis of the tourniquet times between the groups it was noted that the average time for a conventional operation was 89.6 minutes whilst it was 88.6 minutes in the other. This is in contrast to previous findings and it seems that the learning curve is improving at least in this high volume setting.

This paper suggests that there is no difference between the two groups with respect to pain experienced in the post-operative period.


K.W. Cheung K.H. Chiu

Malalignment of more than three degrees in coronal plane was associated with poor outcome. Most of the alignment occurred in the tibial coronal plane alignment. Computer assisted surgery (CAS) in total knee arthroplasty (TKA) aimed to minimize malalignment. Most of the CAS-TKA results were using infrared tracking system. Electromagnetic navigation in total knee arthroplasty was developed in recent years. It aimed at high accuracy and easy signal detection. However, there was limited result being published.

From August, 2006 to March, 2008, 50 patients had TKA performed with Medtronic electromagnetic navigation (EM CAS-TKA). The results were compared with 50 matched patients who had TKA performed with conventional technique. The post-operative limb alignments were compared. More than three degrees deviation from neutral alignment was defined as outliers.

There was no significant difference in the age, sex distribution, pre-operative range of motion and pre-operative deformity between the two groups. EM-CAS TKA group had significantly less deviation from neutral in the tibial coronal plane (p < 0.001) and femoral sagittal plane (p = 0.006) plane than conventional group. There was no significant difference in femoral coronal plane and tibial sagittal plane alignment between the two groups (p = 0.069 and 0.185 respectively). There were significantly more outliers (> 3 malalignment) in tibial coronal plane (p = 0.004) and femoral sagittal plane (p = 0.049) in conventional group than EM-CAS TKA group. There was no significant difference in the outliers in femoral coronal plane, and tibial sagittal plane (p = 1 and 0.1 respectively). The mean tourniquet time of the EM-CAS TKA group, 95.7 minutes (range, 65 to 126 minutes), was significantly higher than the conventional group, mean 72.1 minutes (range, 45 to 120 minutes), p value < 0.001. There was no pin tract complication and infection in the electromagnetic navigation group.

Electromagnetic navigation had improved the tibial coronal plane and femoral sagittal plane alignment in total knee arthroplasty with less outlier. Better alignment may improve the survival of the prosthesis. The learning curve is short and it is easy to handle. Electromagnetic navigation has the potential application in minimally invasive total knee arthroplasty.


S.A.C. Sampath S.H. Voon H. Davies

Uncemented total knee arthroplasty (TKA) implants were designed as an alternative to cemented implants. However, critical studies revealed a unique set of complications. At the same time, cemented prostheses continue to yield excellent results. To address some of the issues with uncemented implants, porous coatings were introduced. This follow-up study reports the early results of Plasmapore® coating in Navigated uncemented rotating platform TKA.

277 patients who had consecutively undergone a Navigated TKA procedure with the e.motion knee endoprostheses were followed up at the Bluespot Knee Clinic in Blackpool, UK. Of these 277 patients, 91 received an uncemented TKA between May 2005 and September 2007. The prosthesis is coated with a 350μm plasma-sprayed titanium layer. All procedures were carried out by the senior author (SACS). The Orthopilot navigation system was used to accurately restore the axial alignment of the implants.

Men comprised 51% and women 49%. The mean age was 69 years and the mean BMI was 30. There were 50 right and 41 left knees. The mean operating time was 59 minutes. Of the 91 patients who received an uncemented e.motion TKA, 84 patients had at least 1 follow-up assessment. The average follow-up period for these 84 cases was 7 months. The integrated Knee Society Score (KSS) defined as the sum of functional and clinical KSS, was recorded for all 91 patients preoperatively and had a mean of 78. The KSS had increased to 182 after 4 months, 193 after 1 year and 198 after 2 years. Oxford score was recorded for 87 of the 91 patients preoperatively. The average preoperative score was 44. It had decreased to 18 after 4 months, and 16 after 1 year and 13 after 2 years.

Radiological examination showed no evidence of periprosthetic lucency and no subsidence.

There were 5 DVTs with 2 pulmonary embolisms, 2 cases of reflex sympathetic dystrophy, 2 stitch abscesses, 2 haematomas, and 9 cases of wound erythema. These preliminary findings compare favourably with published series of cemented TKAs. They have prompted a more detailed review which is in progress.


Neal L Millar Angela H Deakin Lauren L Millar Frederic Picard

Recent studies suggest the use of computer navigation during TKA can reduce intraoperative blood loss. The purpose of this study was to assess if navigation affected blood loss after TKA in the morbidly obese patient (BMI> 40).

Total body blood loss was calculated from body weight, height and haemotocrit change, using a model which accurately assess true blood loss.

The computer navigated group comprised of 60 patients, 30 with BMI > 40 and 30 with BMI< 30. The matched conventional knee arthroplasty group consisted of 62 consecutive patients, 31 with BMI> 40 and 31 with BMI< 30 The groups were matched for age, gender, diagnosis and operative technique.

Following TKA, the mean total loss was 1014mls (521-1942, SD 312) in the computer assisted group and 1287mls (687-2356, SD 330) in the conventional group. This difference was statistically different (p< 0.001). The mean calculated loss of haemoglobin was 19 g/dl in the navigated group versus 25 g/dl in the conventional group; this was also significant at p< 0.01. The mean total loss was 1105mls in patients with a BMI> 40 in the navigated group compared to 1300mls in the conventional group (p< 0.01). A significant correlation was found between total blood loss and BMI (r=0.2, p< 0.05).

This study confirms a highly significant reduction in total body blood loss and calculated Hb loss between computer assisted and conventional TKA in obese patients. Therefore navigation-assisted TKA could present an effective and safe method for reducing blood loss and preventing blood transfusion in obese patients undergoing TKA.


M. Sarungi P. Basanagoudar P. Nunag A.H. Deakin

Many studies have already been published to prove the improved accuracy in achieving the ideal post-operative long leg alignment when using computer navigation in total knee arthroplasty (TKA). Surgeons who use traditional instrumentation with a fixed distal femoral resection angle (most commonly 6°) assume little or no variation in the angle between the anatomical and mechanical axis of the femur (FMA angle) in different patients.

The aims of this study were to investigate the distribution of the FMA angle in pathological knees of patients about to undergo TKA and to analyse if there was any correlation between the FMA angle and the pre-operative lower limb alignment in the coronal plane (varus or valgus).

The study consisted of 158 consecutive patients undergoing 174 primary TKA between January and October 2007. All patients had pre-operative digital Hip-Knee-Ankle radiographs. The FMA angle and the mechanical femorotibial angle (MFT angle) were measured in all cases. Intra- and inter-observer variation was measured by second observer readings and repeated measurements.

The mean age of the study cohort was 69.9 years (SD 8.7 years). There were 75 male and 99 female knees. The repeatability for measurement of the FMA angle was good (intra-observer Intra Correlation Coefficient (ICC) = 0.91, inter-observer ICC = 0.85) and for the measurement of MFT angle was very good (intra-observer ICC = 0.99, inter-observer ICC = 0.99). There were 135 knees with a varus or neutral alignment and 39 knees with valgus alignment. The median alignment was 6.5° varus ranging from 23° varus to 16° valgus. The FMA angle was between 2° and 9°, with a median of 6°. The FMA angle was 6° in 35.4% of cases, 5° in 22.9% and 7° in 18.3%. There was a statistical significant correlation between the FMA angle and the pre-operative lower limb alignment (Pearson correlation coefficient = −0.5, p < 0.001), with valgus knees having on average a lower FMA angle. The group of females and males had statistically different FMA angles (Mann-Whitney, p < 0.001) with females having on average a lower FMA angle. Cluster analysis based on the original clinical definitions of severe varus, varus and valgus gave three groups of FMA angle for MFT angle < 8° varus, MFT angle of 8° varus to 1° valgus and MFT angle > 1° valgus. There was a statistically significant difference in median FMA angle between these three groups (Kruskal-Wallis, p < 0.001).

This study indicates that one of the main reasons why optimal post-operative coronal alignment cannot be achieved with a fixed distal femoral resection angle is the fact that the FMA angle has a wide, natural distribution. It is possible that better results may be achieved with traditional instrumentation by individual measurement of FMA angle for each patient pre-operatively and adjusting the distal femoral resection to account for this. However, with computer navigation the distal femoral cut is adjusted for each patient.


S.A.C Sampath S.H. Voon H. Davies

Previous studies of osteoarthritic knees have examined the relationship between the variables body mass index (BMI) and weight on the one hand and coronal plane deformity on the other. There is a consensus that weight and BMI are positively correlated to the degree and progression of a varus deformity. However, there does not appear to be a consensus on the effect of these variables on knees with a valgus deformity. Indeed, the view has been expressed that in knees with a severe deformity a relationship might not exist. A review of these studies reveals that in all cases, the alignment of the lower limb was obtained from a standing antero-posterior long leg radiograph. In no cases was the deformity in the sagittal plane measured. This study analyses the relationship between BMI, weight, deformity in the sagittal plane and valgus deformity.

The study group consisted of 73 patients with osteoarthritis and valgus knees. All of them had failed conservative treatment for their symptoms and were listed for navigated TKA. Their weight and height were measured two weeks preoperatively and the BMI calculated. At operation the coronal and sagittal deformities were measured using the Orthopilot® navigation system (BBraun Aesculap, Tuttlingen). The results were analysed using SPSS 15.

Regression analysis showed a significant relationship (p< 0.05) with a negative correlation between valgus deformity and weight. the correlation coefficient for flexed knees (−0.59) showed a moderately strong relationship whereas that for extended knees (−0.38) showed a relatively weak relationship.

It is acknowledged that there is an increased force on the lateral compartment with increased valgus deformity. a larger deformity causes a larger moment arm about the centre of the knee. this study has shown that at the time of surgery, individuals with lower weights have larger valgus deformities. we postulate, therefore, that when the moment due to the weight of the individual and the length of the moment arm exceeds a certain value, a symptomatic threshold is crossed. in the presence of a fixed flexion deformity, the force on the patella-femoral joint is increased, contributing further to the onset of discomfort.

Further investigation into the subsets of valgus knees appears to be warranted.


J.J. George Malal S. Deshpande

Oxford medial uni compartmental knee replacement is a common and widely accepted procedure that relies on accurate positioning and alignment of the implants for optimal outcome and longevity. Posterior slope of the tibial base plate has been shown to be an important factor affecting long term survivorship.

The aim of the study was to evaluate whether navigation increased the accuracy of Oxford knee replacements using the posterior slope of the tibial component as an index measure.

The posterior slope of tibial trays from 58 sequential Oxford medial unicondylar knee replacements over a two year period was checked on standard lateral x-rays against the recommended range.

There were 12 cases in the navigated and 46 in the conventional group across six Orthopaedic firms. The mean posterior slope for navigated and conventional implantations was 4.75 and 3.3 degrees respectively with the difference not being statistically significant. However, when considering the data for low volume surgeons, the mean posterior slope with and without navigation was 4.75 and 1.83 degrees respectively which was significant with a p value of 0.017. Navigation was also found to significantly decrease the chance of implanting the knee with the posterior slope outside the acceptable range (p=0.024). In both analyses the navigated cohort had a narrower data spread and fewer outliers compared to the conventional group. No other factors were found to significantly correlate with the posterior slope.

The study suggests that navigation might help low volume surgeons in increasing the accuracy and decreasing the incidence of extreme variations from the desirable range of implant positioning for unicompartmental knee replacements.


J. Sandhu A.H. Deakin N.A. Munro

The orthopaedic unit at the Golden Jubilee National Hospital consists of eight consultant orthopaedic surgeons who have a varied practice with regard to navigated TKA with some surgeons using navigation for all cases, some for what are deemed difficult cases and others using it rarely or not at all. One mechanical jig-based system and two different navigation systems are in routine use. The results from the two navigated (nav 1 and nav 2) and non-navigated (non-nav) systems were audited and compared with published studies to determine whether the reported results from randomised controlled trials were reproduced in our routine practice. The primary outcome measure was the mechanical femorotibial (MFT) angle as measured by Hip-Knee-Ankle (HKA) radiographs. This is a standard outcome measure that allowed ready comparison with other studies.

Demographic data and post-operative MFT angles were collected retrospectively for each patient. The HKA digital radiographs (stored on a Picture Archive and Communication system) were taken six to twelve weeks post-operatively. The MFT angle was measured using a standardised protocol, which used the method of Mose to find the centre of the femoral head, the highest point in the femoral notch as the centre of the knee and the middle of the talus for the centre of the ankle. Repeated measurements were taken to identify intra- and inter-observer error.

There were 86 patients in the nav 1 series, 95 in nav 2 and 95 in non-nav. Mean age was nav 1 = 70, nav 2 = 69 and non-nav = 71. Mean BMI was nav 1 = 34, nav 2 = 31.5 and non-nav = 30. Male to female ratio was nav 1 = 51:35, nav 2 = 44:51 and non-nav = 30:65. Intra- and inter- observer comparison showed a maximum difference of 1° for the measurement of MFT angle. For series nav 1 74% of TKAs had a MFT angle in the range ±3°, for series nav 2 this was 85% and for the non-nav series it was 68%.

Much of the literature on RCTs for navigation vs. non navigation outcomes in TKA indicates that over 93 % of patients undergoing navigated TKA have a mechanical axis alignment within the ±3° range, with non-navigated techniques having 73–87% within this range [1,2]. Our audit shows lower percentages for both navigated and non-navigated techniques. Our results are however similar to those obtained by Chauhan et al. [3] with 85% and 66% respectively. The lower numbers of patients falling into the ±3° range may be due to our audit covering a number of surgeons and trainees. The nav 1 series had five consultants and six trainees, nav 2 had two consultants and the non-nav series had four consultant and six trainees. It may also relate to the extent of pre-operative deformities, which were not quantified. In conclusion the high levels of TKA coronal alignment within ±3° seen in many RCTs may not be readily reproducible in a general setting.


A. Karim A.M.J. Bull O. Kessler N.P. Thomas A.A. Amis

Our aim was to determine the effects of tibial component malrotation and posterior slope on knee kinematics following Scorpio cruciate retaining total knee replacement in cadaver specimens.

The movements of the hip, thigh and lower leg were monitored in 3D using a validated infra-red Computer Navigation System via bone implanted trackers. Ten normal comparable cadaver specimens were mounted in a custom rig allowing 3D assessment of kinematics under various loading conditions. The specimens then underwent Navigated TKR as per normal operating surgical protocols however an augmented tibial component was implanted. This allowed the researchers to precisely modify the rotation of the tibial component around its predetermined central axis, as well as to alter the posterior slope of the component. A pneumatic cylinder was used to provide a simulated quadriceps extension force while the knee was tested with a variety of applied loads including anterior and posterior draw, abduction and adduction, internal and external rotation.

TKR kinematics are significantly different from those of the native knee (p< 0.05). Increasing tibial posterior slope resulted in an incremental posterior position of the femur (p< 0.05), deviation of the neutral path of motion (p< 0.05) and alteration of the normal AP envelope of laxity (p< 0.05). Tibial component malrotations over 10 degrees resulted in increasing deviations of the neutral movement path of motion (p< 0.05) without significantly affecting the envelope of laxity. Tibial component malrotations of more than 10 degrees, when combined with a posterior slope of six degrees or more, resulted in prosthetic subluxation under certain loading conditions.

This study has demonstrated significant differences in knee kinematics before and after total knee implantation. Increasing values of internal and external rotation, as well as posterior slope of the tibial tray resulted in further deviations of total knee kinematics from normal by altering the neutral path of motion and the soft tissue envelope, with combined misalignments resulting in the greatest deviations from normal with prosthetic subluxation in some cases. Deviations from normal kinematics may result in increased ligament tension and incongruence or dysfunction of the component articulations, with the generation of sheer forces in the gait cycle. These may contribute to premature wear and loosening. Surgeons should be aware of this when considering the addition of posterior slope or assessing tibial component positioning in TKR.


A. Saithna AP. Dekker

Individuals learn to master new motor skills (such as learning a new surgical technique) by evaluating available feedback to alter future performance. Continuous concurrent augmented feedback is supplementary information presented to the learner throughout the performance of a task. An example of this type of feedback is the visual information provided by computer navigation during arthroplasty surgery. This type of feedback is a potentially powerful tool for learning because it theoretically guides the learner to the correct response, reduces errors, and reinforces correct actions. However, motor learning theory suggests that this type of feedback may impair learning because of development of dependence on the additional feedback or distraction from intrinsic feedback. In the current era of reduced number of training hours it is essential to assess the role of computer navigation on trainees.

Our objective was to determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty. We conducted a systematic review and critical appraisal of the literature. There is some evidence from randomised controlled trials that navigation use by trainees facilitates accurate placement of arthroplasty components compared to conventional instrumentation. There is no evidence that training with computer navigation impairs performance in retention tests (re-testing on same task after an interval of time) or transfer tests (re-testing in different conditions i.e. without concurrent feedback).

We conclude that although there are significant limitations of the published literature on this topic there is no available evidence that supports concerns regarding the theoretical detrimental effects of computer navigation on the learning curve of arthroplasty trainees.


S.A.C. Sampath S.H. Voon H. Davies

There have been mixed reports of the contribution of the anterior cruciate ligament (ACL) to the overall envelope of tibial rotational stability. The effect of single bundle ACL reconstruction on the separate components of internal and external rotational stability respectively is also unclear.

We determined the internal and external rotation, and antero-posterior movement of the knee before and after single bundle computer assisted reconstruction of the anterior cruciate ligament (ACL) in 57 patients. The Orthopilot® ACL (v2) software (BBraun, Aesculap) was used.

The mean overall range of tibial rotation was also significantly reduced from 30.5 degrees to 16 degrees (p< 0.0001). The mean internal rotation was significantly reduced from 16 degrees to 8 degrees (p< 0.0001). Mean external rotation was also significantly reduced from 15 degrees to 8 degrees (p< 0.0001). Unlike previous studies we did not find a greater reduction of internal rotation compared with external rotation. The mean antero-posterior movement of the tibia was significantly reduced from 12mm to 4mm (p< 0.0001).

The results of this study seem to indicate that computer assisted single bundle ACL reconstruction results in a significant intraoperative improvement in both internal and external rotatory stability as well as a significant improvement in antero-posterior stability.


K.W. Cheung K.H. Chiu

Unicompartment knee arthroplasty (UKA) was proven to be one of the standard treatments of medial compartment osteoarthritis. The key to success was restoration of pre-operative alignment. Overcorrection of coronal (AP) alignment may predispose to early osteoarthritis in the contralateral compartment, change in post-operative tibial slope may predispose to proximal tibial bone collapse and loosening of tibial prosthesis. Minimally invasive surgery (MIS) in UKA was developed quickly in the last ten years. However, MIS has limited access to visualize the surgical field and limb alignment. Computer navigation may help the surgeon to place the component in more accurate position. We aim to study the radiological alignment of computer assisted MIS UKA.

Eighteen patients with UKA (PreservationTM, all poly tibia, DePuy Orthopaedics Inc, Warsaw, IN) implanted using MIS technique were studied prospectively. The CiTM system (DePuy International Ltd, Warsaw IN) were used for computer navigation. Five male and 13 female patients were studied. The mean age of the patients was 58.2 (range, 45 to 70). All patients had medial compartment osteoarthritis with varus deformity. The postoperative coronal (AP) alignment and tibial slope of the operated limb were compared with the pre-operative alignment for any significant difference.

The mean pre-operative and post-operative radiographic coronal (AP) alignment of the operated limb were 8.4° varus (range, 2° to 12°) and 7.2° varus (range, 1° to 15°) respectively, the difference was not significant (p = 0.537). The mean pre-operative and post-operative tibial slope were 6.8° (range, 3° to 11°) and 5.8° (range, 3° to 10°) respectively, the difference was not significant (p = 0.066). The post-operative tibial slope correlated well with the intra-operative tibial slope recorded by computer after bone cut was made (Cronbach’s Alpha = 0.771). The mean tourniquet time was 124 minutes (range, 94 to 140 minutes).

There was no significant difference in pre-operative and post-operative coronal alignment of the operated limb. Computer assisted MIS UKA could reproduce the pre-operative coronal alignment and tibial slope. Restoration of the pre-operative limb alignment in coronal plane and tibial slope was crucial to the survival of UKA. Computer navigation could help the surgeon to position the component during minimally invasive surgery. However, the learning curve of computer assisted MIS UKA was steep.


K. Karthik A. P. Shetty J. Dheenadhayalan S. Rajasekaran

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous methods.

We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. During the entire procedure, the tool navigator was used frequently to reconfirm the location and the depth of burring. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.

The age of the patients varied from 10 years to 27 years. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it was attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.

Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.


A. Pillai V. Soon M. Foxworthy

Background: The role of digital radiography has evolved consistently over the last decade. In many European hospitals, radiographs have been completely digitised and have moved to Picture Archiving and Communications System (PACS). Pre-operative templating for arthroplasty has been a major problem with using the system.

Aims: We investigate the accuracy of the OrthoviewTM software in templating for hip and knee arthroplasty.

Methods: A retrospective review of 20 Stryker-Exter hip and 20 Biomet- Vanguard knee arthroplasties were carried out. Anonymised preoperative radiographs were reviewed by experienced orthopaedic surgeons blinded to the purpose of the study. Templated component sizes were compared with actual implant sizes used at surgery. All radiographs were digitised on Kodak Car-estream PACS. Five surgeons were asked to separately review the radiographs to avoid intra-observer error.

Results: In templating for hip arthroplasty, Orthoview TM was 80% accurate in predicting the femoral stem size within one size of the actual component used. It also predicted the offset with 100% accuracy. In 90% of the patients, the actual head implant was within one size of the templated head. The system was able to predict the acetabular component size in only 30%. In knee arthroplasty, OrthoviewTM was 80% accurate within one size of the actual component used for the femur and 90% for the tibia.

Discussion: Digital radiographs have several well documented advantages over traditional radiographs. Orthoview TM enables the flexibility of digitised films to be used for pre-operative templating. It is reasonably accurate in prediction of femoral component size in both hip and knee arthroplasty and tibial size in knee arthroplasty. It is considerably less useful for acetabular sizing. Surgeons have to keep this variability in mind until more accurate systems are available.


D.J. Macdonald J.V. Clarke A.W.G. Kinninmonth

Computer-assisted surgical techniques in knee replacement procedures have been shown to increase the accuracy of implant positioning and reduce the incidence of alignment and soft-tissue balancing “outliers”. The use of this technology as a training tool is less widely reported. However, the recent implementation of the EWTD 48-hour working week for junior doctors has focussed attention on the issues of surgical training and experience. Recent evidence from trainee logbooks has shown a significant downward trend in operative exposure and this is forcing changes in the principles of how training should be delivered. Trainees are actively required to demonstrate operative competence in order to progress but are increasingly faced with limited opportunities to acquire these skills. On the other hand, trainers also face difficulties with the prospect of supervising less accomplished trainees which raises ethical issues of patient protection. We present a trainee’s perspective of experience gained in a unit routinely using computer-assisted technology and highlight the potential to enhance the learning process.

Navigation systems provide constant visual and numerical feedback via a computer simulated interpretation. Initially this displays relevant functional anatomy, helps in the identification of anatomical landmarks and demonstrates sagittal and coronal plane deformities which can be difficult to accurately assess “by eye”. Computer-assisted systems have the benefit of displaying only bony anatomy which improves visualisation. This can then be compared to the palpable, clinical deformity on the table. The geometry of the native knee is also made clear with the navigation system leading to a better understand of the objectives of TKR. There are some aspects of the biomechanics of the knee which are difficult to appreciate, such as the changes in varus-valgus alignment during flexion and extension. This may be very subtle and difficult to pick up manually but can look quite dramatic on the computer.

The position of cutting jigs which are held to the bone by pins can be altered by inadvertently lifting or hanging on them with the saw, when making the bone cuts. Additionally the cut can be altered by advancing the cutting block closer to the bone, for example if cutting the tibia with a posterior slope. Both these effects can be quantified by using the navigation tools to confirm the cut that has been made. Trainers can have the benefit of seeing the alignment and confirming the cuts made by a trainee without having to get closely involved with the operation. Cementation technique is also open to scrutiny with the ability to compare pre and post cementation alignment.

The positive feedback obtained from computer assisted surgery is educational to the trainee, by giving an undisputable computer generated graphic of what they are doing during the different stages of total knee arthroplasty. It also shows what has been achieved at the end of the procedure. This can give both the trainer and trainee more confidence in the procedure and ensures patient safety.


A. Ferguson A. Deakin S. Wearing F. Picard

As further improvements in surgical accuracy are made possible by computer-aided surgery, there is a demand for new pre- and post- surgical assessment and more accurate intra-operative registration techniques. Ultrasonic palpation is being used in navigated hip surgery but as yet little work had been published on the identification of anatomical landmarks used in knee surgery with this technique. The aim of this study was to investigate the accuracy of the identification of the femoral condyles with ultrasound in both saline and in tissue mimicking material (TMM).

The system comprised of an image free navigation system (OrthoPilot, B Braun Aesculap) synchronized with a standard B-mode ultrasound system (Echoblaster 128, TELEMED) used with passive trackers. Bony anatomy was represented by two sawbone phantoms; one involving an isolated femur and one simulated knee joint. Both phantoms had fiducial markers in the form of steel pins inserted into the condylar eminences of the femur, providing sharply defined structural interfaces for determination of inter-condylar distance (ICD). Initial testing was completed in a waterbath filled with saline (NaCl 4500ppm) maintained at 22°C. Further testing used both sawbone phantoms encased in TMM. To gain accurate dimensions of the ICD, 3D models of both sawbone phantoms were created using a high-resolution non-contact 3D digitiser (Konica Minolta Sensing Inc.) and measurements taken using Geomagic software. Measurements for all test set-ups were repeated and mean (SD) values calculated.

The mean ICD measurement (SD) of the isolated femur from the high resolution 3D model was 53.6mm (1.2mm) (n=4). The ICD for the isolated femur in the saline water bath was 48.8mm (0.7mm) (n=5). For the isolated femur encased in TMM the mean ICD was 54.6mm (0.7mm) (n=4) with the probe positioned parallel to the shaft of the femur and 52.2mm (0.4mm) (n=5) with the probe held perpendicular to the femur. For the second phantom, which consisted of an articulated knee joint, the mean ICD measured from the high-resolution 3D model was 43.5mm (1.0mm) (n=5). When encased in TMM, the mean ICD derived from the navigation system was 42.6mm (1.4mm) (n=5).

Average ICD measurements for phantoms encased in TMM were within 1mm of that determined by high resolution, non-contact 3D digitization. However, results in the saline waterbath were less accurate, with an average difference of 4.8mm in ICD measurement. We believe these differences largely reflect the digitisation error associated with manual registration of the fiducial markers and highlights the difficulty in using this method and taking measurements within one scanned plane. Hence we are now developing a new method of automatic registration that uses multiple scans and will hopefully provide a more accurate outcome.


JV Clarke AH Deakin AC Nicol F Picard

Computer-assisted technology has provided surgeons with intra-operative quantitative measurement tools that have led to the development of soft-tissue balancing algorithms based on surgeon-applied varus-valgus stress. Unfortunately these forces tend not to be standardised and the resultant algorithms may at best be surgeon-specific. Furthermore, these techniques are only available intra-operatively and rely on the rigid fixation of trackers to bone. The aim of this study was to develop a non-invasive computer-assisted measurement technique and assess the variation in collateral knee laxity measurements between different clinicians.

An image-free navigation system was adapted for non-invasive use by developing external mountings for active infrared trackers. A leg model with rigid tracker mountings was designed and manufactured for comparison. Multiple kinematic registrations of alignment were made for both the model and the right leg of a volunteer to quantify the soft tissue artefacts. Repeatability of the system was assessed by performing two registration processes on eight volunteers. Collateral knee laxity was assessed on a single volunteer by 16 participants of varying experience each applying a maximum varus and valgus knee stress. Two surgeons performed repeated examinations to assess intra-observer variation.

For repeated registrations of alignment, the SD of the non-invasive mounting (0.8°) was only a third higher than the leg model (0.6°) and the actual range was only 1° larger. The repeated alignment measurements on the volunteers showed a high level of agreement with an intraclass correlation coefficient of 0.93. Varus-valgus stress values showed poor inter-observer variation with a wide range of angles for both varus (1° to 7°) and valgus stress (0.5° to 5°). A Mann-Whitney test between the two sets of repeated tests showed that both varus stress and overall laxity were significantly different (p< 0.0001) but that valgus stress was marginal (p=0.052). Intra-observer measurements overall appeared more consistent.

Soft tissue artefacts did not significantly reduce the repeatability of the assessment of coronal knee alignment using a navigation system and this provided a non-invasive technique for assessing coronal knee laxity. The perception of an ‘end-point’ varied significantly between different clinicians and although there may be a role for surgeon-specific algorithms, to use this quantitative data more widely there is a need to standardise the forces and moments applied.


K. Davda F. Iranpour A.J. Hart J.P. Cobb

A 10° deviation from the ideal cup orientation in Metal on Metal (MoM) bearing couples leads to increased wear and the subsequent risk of early revision surgery. We assessed the accuracy of orthopaedic trainees and consultants in achieving optimal acetabular cup orientation.

49 trainees and 18 consultants were asked to orientate an acetabular component to 40° inclination and 20° anteversion in 3 consecutive pelvic models:

osteoarthritic (OA),

OA with anterior pelvic tilt,

OA with soft tissue cladding, the task most realistic of a surgical scenario.

The trainee group experience in performing hip arthroplasty procedures ranged from novice to expert (> 100 procedures performed). Performance was measured using an image based navigation system.

Average angular error in all tasks was less than 10°, but the range in anteversion or inclination was up to 65°. Eighteen percent of trainees were +/− 10° of the target orientation in Station A, 29% in B and 2% in C. Forty four percent of consultants achieved the safe zone in A, 16% in B and 0% in C. There was no significant difference in accuracy between the two groups in any of the tasks (p> 0.01). There was no correlation between experience and angular accuracy.

We have been unable to demonstrate trainees have the ability to achieve the optimal cup orientation in a clinically relevant safe zone. A similar range of error is found in experienced surgeons. Focused training or intra-operative computer assistance may provide the solution to improving accuracy in this core orthopaedic skill.


K. Davda P. Konala F. Iranpour M.T. Hirschmann J.P. Cobb

A robust frame of reference is required to accurately characterize pathoanatomy in the proximal femur and quantify the femoral head-neck relationship. A three dimensional (3D) femoral neck axis (FNA) could serve such a purpose, but has not yet been established in the current literature.

The primary aim of this study was to develop and evaluate a reliable method of determining the 3D femoral neck axis. Secondly, we wanted to quantify the translational relationship between the femoral head and neck in normal and cam type hips.

Pelvic computed tomographic scans (CT) and radiographs were retrieved from our database of patients who had undergone navigated hip surgery or CT colonography. All patients had given informed consent for their medical files and imaging to be used for research purposes, as approved by the institutional review board.

Pre-operative scans were performed using the Siemens Sensation 64 slice scanner (Siemens Medical Solutions, Erlangen, Germany). The Imperial Protocol developed at the authors’ orthopaedic unit was applied, allowing acquisition of Digital Imaging and Communications in Medicine (DICOM) files of 0.75mm thickness.

Normal and cam type hips (n=30) were identified for analysis. ‘Normal’ hips (n=15) were defined in asymptomatic patients with no previous history of hip disease, and, no obvious abnormality on radiographs or CT. The ‘cam’ hip type (n=15) was defined by the presence of an anterior osseous bump at the head-neck junction, and an alpha angle greater than 50° on hip radiographs.

DICOMs were converted to 3D stereolith (STL) images using validated commercial image processing and analysis software (3-Matics, Materialise Group, Leuven, Belgium).

In order to determine the 3D-FNA, a best fit sphere was applied to the femoral head with a root mean square error of less than 0.5mm. The border between sphere and femoral neck defined the head -neck junction. The bone surface was marked here (including the anterior bump in cam hips) and at the neck base, providing two anatomical rings that defined the superior and inferior limits of the femoral neck. The centre point of each ring was calculated. A line connecting these points defined the femoral neck axis, and was verified on a DICOM viewer in sagittal, axial and coronal planes. The offset between the femoral head centre and neck axis was measured.

The 3D image and axis were further analysed to examine the femoral head-neck relationship, using customized software developed at our institution and previously validated in previous research projects.

To standardize rotational alignment, the femoral neck was aligned vertically in two planes by creating an axis between the tip of the greater trochanter and the center of the lesser trochanter. The aligned proximal femur was viewed end on, and the version of the head relative to the neck determined by calculating the angle between the head centre and a vertical marker placed at the 12 o’clock position. Angles below 180° demonstrated anteversion, while those above 180° demonstrated retroversion.


I. H. Khan S. Nicol M. Jackson F. Monsell J. A. Livingstone R. M. Atkins

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and limb dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between the anatomic and mechanical axes. We have found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We have devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (𝛉) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.

We have examined the utility and reproducibility of the new method using one hundred normal femurs. Θ=81+/− sd 2.5°. As expected, 𝛉 correlated with femoral length (r=0.74). P (expressed as the percentage of the distal from the medial edge of the joint block to the intersection) = 61% +/− sd 8%. P was not correlated with 𝛉.

Intra-and inter-observer errors for these measurements are within acceptable limits and observations of twenty paired normal femora demonstrate similar values for 𝛉 and p on the two sides.

We have employed this technique in a variety of distal femoral deformities, including vitamin D resistant rickets, growth arrest, fibula hemimelia, post-traumatic deformity and Ellis-van Creveld syndrome. We find the system universally applicable and reliable.


F. Iranpour A.M. Merican M.T. Hirschmann J.P. Cobb A.A. Amis

Differing descriptions of patellar motion relative to the femur have resulted from many in-vitro and in-vivo studies. The aim of this study was to examine the tracking behaviour of the patella. We hypothesized that patellar kinematics would correlate to the trochlear geometry and that differing previous descriptions could be reconciled by accounting for differing alignments of measurement axes.

Seven normal fresh-frozen knees were CT scanned and their kinematics with quadriceps loading was measured by an optical tracker system and calculated in relation to the previously-established femoral axes. CT scans were used to reliably define frames of reference for the femur, tibia and the patella. A novel trochlear axis was defined, between the centres of best-fit medial and lateral trochlear articular surfaces spheres.

The path of the centre of the patella was circular and uniplanar (RMS error 0.3mm) above 16°±3° knee flexion. The distal end of the median ridge of the patella entered the groove at 6° knee flexion, and the midpoint at 22°. This circle was aligned 6.4° ± 1.6° (mean± SD) from the femoral anatomical axis, 91.2°±3.4° from the epicondylar axis, and 88.3°±3° from the trochlear axis, in the coronal plane. In the transverse plane it was 91.2°±3.4° and 88.3°±3° from the epicondylar and trochlear axes. Manipulation of the data to different axis alignments showed that differing previously-published data could be reconciled. When the anatomic axis of the femur was used to align the coordinates, there was an initial medial and then a lateral translation. Comparing this with the uniplanar and circular path of the center of the patella, it shows that the orientation of the femoral coordinate system affects the description of the patellar medial-lateral translation.

This study has shown the effect of using different coordinate systems on reporting the patellar translation. Choosing a femoral reference that is more in line with the plane of the circular path of motion and the trochlear groove in the coronal plane diminishes the reported subsequent lateral translation of the patella. Once the frame of reference had been aligned to the trochlear axis, there was minimum medial-lateral translation of the patella.


F. Iranpour J. Sayani M.T. Hirschmann J.P. Cobb

A profound understanding of the pathoanatomy of the patellofemoral joint is considered to be fundamental for navigated knee arthroplasty. Previous studies used less sophisticated imaging modalities such as photography and plain radiographs or direct measurement tools like probes and micrometers to define the morphology of the trochlear groove, with differing results. This may be due to the complexity of the biomechanics and the geometry of this joint. Our primary goal was to compare normal, osteoarthritic and dysplastic PFJs in terms of angles and distances. To do this we first had to establish a reliable frame of reference.

Computed tomography scans of 40 normal knees (> 55 years old), 9 knees with patellofemoral osteoarthritis (group A) and 12 knees with trochlear dysplasia (group B) were analyzed using 3D software. The femurs were orientated using a robust frame of reference. A circle was fitted to the trochlear groove. The novel trochlear axis was defined as a line joining the centres of two spheres fitted to the trochlear surfaces, lateral and medial to the trochlear groove. The relationship between the femoral trochlea and the tibiofemoral joint was measured in term of angles and distances (offsets). T-test for paired samples was used (p< 0.05). The study was approved by the institutional review conforming to the state laws and regulations.

The normal trochlear groove closely matched a circle (RMS 0.3mm). It was positioned laterally in relation to the mechanical, anatomical, and trans-condylar axes of the femur. It was not co-planar with any of the three axes. After aligning to the new trochlear axis, the trochlear groove appeared more linear than when other axes were used. In comparison to the normal knees; the medial trochlear was smaller in group A (p=0.0003)- see figure 2. The lateral trochlear was smaller in group B (p=0.04). The trochlear groove was smaller in groups B (p=0.0003). Both trochlear centers in groups A+B were more centralized (p=0.00002–0.03). The medial trochlear center was more distal in group A (p=0.03) and the lateral trochlear center was more distal in group B (p=0.00009). The trochlear groove started more distal in group B (p=0.0007).

A better understanding of the 3-dimensional geometry can help better treat or even prevent the progression of disease to the stage of patellofemoral osteoarthritis. In osteoarthritic and dysplastic patellofemoral joints, the trochlea is both smaller and more distally located along the femur. These two factors may contribute to excessive loads that lead to early joint wear. These differences could have biomechanical implications and give us an insight into why joints fail. The data collected may also help in improving current designs and current navigational and surgical techniques used for the treatment of patellofemoral osteoarthritis.


P. Nunag N. Willcox A.H. Deakin K. Deep

The recognition of the correct pattern and severity of deformity in knee osteoarthritis has important implications in its surgical management. Our unit routinely uses standing long leg films and computer navigation. However, these modalities are not widely available and most surgeons rely on clinical assessment and short films. Our experience is that clinical assessment can give the opposite impression of the true deformity pattern particularly among obese patients and there is evidence that short knee films are not reliable. Our study aims to compare clinical, radiographic and computer measurements of knee deformity, assess the influence of Body Mass Index and asses the relationship between coronal and flexion deformity.

We measured 52 consecutive knees prior to arthroplasty using clinical, long leg radiographs and computer navigation methods. Systematic clinical measurement was done with patient standing. Standing radiographs stored in a Picture Archiving System were measured by two independent observers. The senior surgeon performed computer measurement while applying axial load to the foot to simulate weight bearing.

Using long leg films as baseline, clinical and X-ray measurement had a mean error of 0.8° (−12 to +12). Seven clinically valgus knees turned out varus on X-ray. Mean BMI for this group was the same as the rest. Using navigation as baseline, clinical and navigation coronal measurements had a mean error of 0.3° (+9 to −10.5). Four clinically valgus knees turned out varus with navigation. Mean BMI for this group was the same as the rest. Flexion deformity was similar between clinical and computer measurement. Three clinically normal knees showed significant varus in both X-ray and navigation. Compared directly, radiographic and navigation coronal deformity showed significant difference in the degree of deformity but not in the pattern of deformity. There was no correlation between BMI and both the error in clinical assessment of coronal deformity and navigation coronal alignment. If flexion deformity was > 5°, higher BMI indicates higher flexion deformity. There was a weak correlation between navigation coronal and flexion deformity.

Although error in clinical measurement did not reach statistical significance, based on our result, clinical assessment can give an incorrect pattern of deformity in up to 13% and hence should not be the sole basis of assessing deformity. Contrary to expectation, BMI did not influence error of clinical assessment or severity of coronal deformity. It however appeared to influence larger flexion deformities. The discrepancy between radiographic and navigation measurements reflects the absence of true weight bearing with navigation even though we tried to simulate this by applying axial load to the foot.


F. Iranpour M.Y.B. Salmasi M. Murphy M.T. Hirschmann J.P. Cobb

When navigating patellofemoral/unicompartmental knee surgery, the surgeon makes assumptions based upon algorithms developed for total knee arthroplasty. In this study we set out to show how variable the normal knee is. Minor anatomical variations in the shape of our knee may make a big difference in terms of orientation and joint wear patterns. Tibial patho-morphology has been described as a factor that predisposes to medial compartment osteoarthritis of the knee (anteromedial-OA), yet this is limited to 2D analysis. We aimed to describe the 3D morphology of both the tibial and femoral components of the medial compartment of the knee. We hypothesized that morphological differences do exist between normal knees and those predisposed to osteoarthritis.

A total of 20 normal (group A) and 20 pre-OA knees (group B) were included. Group A consisted of contra lateral knees of young patients (< 55 years) awaiting hip surgery and group B of asymptomatic contra lateral knees of patients awaiting unicompartmental knee arthroplasty (UKA). Using 3D reconstructions from CT scans, we analyzed the tibiofemoral joint, which consists of the femoral condyles and the tibial plateau. The femur was aligned to the transcondylar and anatomical axes. The medial femoral extension facet (MFEF) was modeled as a segment of a sphere. The offsets between the MFEF centre and the medial femoral flexion facet centre were measured. The MFEF radius and the MFEF 2D arc angle in the sagittal plane were also measured. The tibias were aligned for flexion-extension and varus-valgus to a flat portion of the flexion facet (flexion facet plane), which lie’s roughly perpendicular to the tibial mechanical axis. To control for axial rotation, the anatomical tibial axis was used. A model of analysis was developed by rotating several increments towards and away from the midline to obtain several sagittal section images. For each sagittal section the medial tibial extension facet (MTEF) slope angle, its length, and the medial tibial submeniscal plane (MTSP) angle and length were analyzed. The relative length proportions of the MTEF, medial tibial flexion facet and MTSP were also measured.

The MFEF was larger and more offset in pre-OA knees. Pre-OA knees also had a significantly larger MFEF arc angle than normals (p< 0.05). The MTEF appeared similar between normal and pre-OA knees. The submeniscal plane was highly variable between subjects but on average horizontally inclined (median 0o, range −15–14o) and formed a crescent shape anteriorly. There was no significant difference in tibial measured parameters between normal and pre-OA tibias (p> 0.05). The method showed good reproducibility using intraclass correlation coefficient (ICC value> 0.9) and Bland-Altman plot analysis.

This study gives the CAOS surgeon some interesting insights into the anatomical variation of the normal knee. We have found evidence of a predisposing patho-morphology to medial-OA in the femoral condyle, but not the tibia. There is evidence of an enlarged flatter extension facet on the medial femoral condyle in the pre-OA knees, with no significant difference in the geometry of the medial tibial plateau, which is now reliably defined based upon a flexion plateau frame of reference.


J.P. Cobb K. Logishetty K. Davda A. J. Murphy F. Iranpour

Cam femoroacetabular impingement (FAI) is currently treated by resecting the femoral cam lesion. Some surgeons advocate additional anterosuperior acetabular rim resection. However, the exact acetabular contribution to cam-FAI has yet to be described. Using 3D-CT analysis, we set out to quantify the acetabular rim shape and orientation in this condition, and to determine the roles of these factors in cam-FAI.

The acetabula of twenty consecutive cam hips (defined by α-angle of Notzli greater than 55° on plain radiographs) undergoing image based navigated surgery. These were compared with twenty normal hips (defined as disease free sockets with a normal femoral head-neck junction) obtained from a CT colonoscopy database.

Using 3D reconstruction software, the pelvis was aligned to the anterior pelvic plane (APP). Starting at the most anterior rim point, successive markers were placed along the rim. A best-fit acetabular rim plane (ARP) was derived, and the subtended angle (SA) between each rim marker and a normal vector from the acetabular centre was calculated. Values above 90° indicated a peak, with less than 90° representing a trough. Inclination and version were measured from the APP.

Our results showed that the rim profile of both cam-type and normal acetabular is an asymmetric succession of three peaks and three troughs. However, the cam-type acetabulum is significantly shallower overall than normal (Mean SA: 84±5° versus 87±4°, p< 0.0001). In particular, at anatomical points in the impingement zone between 12 and 3 o’clock, the subtended angle of cam hips were never higher than normal, and, in fact, at certain points were lower (iliac eminence: 90±5° vs. 93±4° p=0.0094, iliopubic trough: 79±5° vs. 83±4° p=0.0169, pubic eminence 83±7° vs. 84±4° p=0.4445). The orientation of cam and normal hips were almost identical (Inclination: 53±4°vs. 51±3° p=0.2609 and Anteversion: 23±7° vs. 24±6° p=0.3917).

We concluded that cam-type acetabula are significantly shallower than normal. The subtended angles at all points around the hip were lower, and in particular, in the impingement zone between 12 and 3 o’clock not one cam had a subtended angle over 90°. We have therefore been unable to support the hypothesis of mixed-type FAI in cam-type hips.

Bony rim resection in cam hips therefore runs the risk of rendering the acetabulum more morphologically abnormal and even functionally dysplastic. We do not recommend acetabular rim resection in patients with pure cam-type impingement, and await the longer-term results of this practice with apprehension.


J.P. Cobb K. Logishetty K. Davda A. J. Murphy F. Iranpour

Pincer femoroacetabular impingement (FAI) is cited as being the result of a socket that is either too deep or retroverted, or both. Using 3D-CT analysis, we set out to quantify the acetabular rim shape and orientation to determine the roles of these two factors in FAI.

Twenty pincer acetabulae were selected from patients undergoing image based navigated surgery, where the lateral centre edge angle was greater than 40° on plain radiographs. The normal group of disease free sockets were obtained from a CT colonography database.

Using 3D reconstruction of their CT scans, a novel method of mapping the acetabular rim profile was created. The pelvis was aligned to the anterior pelvic plane. Starting at the most anterior rim point, successive markers were placed along the rim. A best fit plane (ARP) through the acetabulum was derived, and the subtended angle (SA) between each rim marker and a normal vector from the acetabular centre was calculated. Values above 90° indicated a peak, with less than 90° representing a trough. Inclination and version were measured from a horizontal plane and the ARP, in the coronal and axial view respectively.

The results showed that asymmetric acetabular rim profiles in normal and pincer hips were very similar. However, pincer hips are significantly deeper overall (Mean SA 96±5° vs. 87±4° p< 0.00001) and at each anatomical point of the three eminences (pubic [SA: Normal 84±4° vs. Pincer 94±7° p< 0.00001], iliac [SA: 93±4° vs. 100±6° p=0.00021] and ischial [SA: 92±3° vs. 102±8° p=0.00005]) and two troughs (ilio-pubic [SA: Normal 83±4° vs. Pincer 94±8° p=0.00001] and ilio-ischial [SA: 92±3° vs. 102±8° p=0.00002]).

The orientation of normal and pincer were almost identical (Inclination: 51±3° vs. 51±6° p=0.54 and Version: 24±6° vs. 25°±7° p=0.67).

We conclude that the rim shape of pincer hips follows the same contour as normal hips. In agreement with current radiographic diagnosis, pincer-type hips are characterised by a deeper acetabulum. This ‘overcoverage’ of the femoral head confirms the biomechanical model of pincer-type impingement.

Both inclination and version in these two groups were almost identical, with no truly retroverted acetabulum seen. Pincer impingement resulting from ‘acetabular retroversion’ is a concept currently based upon radiographic signs that we have been unable to confirm in this small 3D study using the subtended angle as the key descriptor of acetabular morphology.


T. Springer Z. Al-Janabi A.H. Deakin M. Sarungi

In Total Knee Arthroplasty (TKA) restoring the mechanical alignment of the knee joint is essential. This can be improved by considering the individual variability in the angle between the mechanical and anatomical axes of the femur (FMA angle). However with the traditional instrumentation and the use of the most common fixed distal femoral resection angle of 6° we assume little or no variation in the FMA angles in different patients. In a previous study we showed that the FMA angle had a wide distribution and that there was a good correlation between the FMA angle and the pre-operative lower limb alignment in the coronal plane. Our hypothesis was that improved post operative limb alignment would be achieved with traditional instrumentation by individual measurement of the FMA angles pre-operatively and adjusting the distal femoral resections accordingly. In the study we compared the post-operative coronal limb alignment for a cohort of patients with a variable distal femoral resection angle to the previous cohort of fixed distal femoral resection angle.

The study consisted of 103 patients undergoing 103 consecutive primary TKAs between October 2008 and March 2009. All patients had pre- and post-operative Hip-Knee-Ankle digital radiographs and had TKAs performed using a variable distal femoral cut angle. The FMA angle and the mechanical femoro-tibial (MFT) angles were measured in all cases. Inter-observer variation was measured by second observer readings. We compared our results with the group of 158 consecutive patients undergoing 174 primary TKAs operated between January and October 2007 using fixed distal femoral resection angle.

Patient demographics of the two cohorts (age, gender, BMI) were similar.

The pre-operative coronal deformity for the variable cohort was less than the fixed, mean 3.7° varus (SD 5.8°) compared to 4.7° varus (SD 7.9°). The FMA angles for the variable cohort ranged from 4° to 8°, (the fixed cohort from 2° to 9°). The variable valgus resection angles cohort showed a correlation between FMA and pre-operative MFT angles as had previously been shown in the fixed cohort (r = −0.499 and r = −0.346 respectively). Post op alignment showed that accuracy within ±5° increased from 86% (fixed resection angle group) to 96% (variable resection group). When using the more commonly quoted accuracy of within ±3°, this changed from 67% (fixed resection angle group) to 85% (variable resection group). These improvements were statistically significant (chi-squared 0.025 and 0.002, respectively). To further evaluate the effect of using variable angles we analysed the improvement of each of the different groups of deformity identified in the previous study (> 8° varus, 8° varus to 1° valgus, > 2° valgus). The range was reduced in both the extreme varus and valgus groups with the variable angles. The most significant improvement was found in the valgus group with the median reducing from 3° to 2° and range from 14° to 8°.

It seems logical to use a variable distal femoral resection angle based on the patient’s individual anatomy. By doing so, our results show significant improvement of postoperative limb alignment compared to traditional method of using fixed distal femoral resection angle. In units where preoperative long leg film radiographs are available, measuring the FMA angle and setting the distal femoral resection angle guide accordingly improves the postoperative limb alignment. However, where long leg radiographs are not available, changing the distal femoral resection angle according to the pre-operative varus-valgus deformity is likely to improve the post operative limb alignment. (e.g. 4°–5° distal femoral resection angle for preoperative valgus, 6° for preoperative mild/moderate varus, and 7°–8° for preoperative severe varus).Computer navigation, however, enables us not only to use customised distal femoral cut for each patients, but it also provides many other useful information such as dynamical limb alignment through motion, component rotation, soft tissue balancing.


S. Ball J. Windley P. Harnett D. Nathwani

Computer navigation has the potential to revolutionise orthopaedic surgery. It is widely accepted that component malalignment and malrotation leads to early failure in knee arthroplasty. We aimed to assess the use and reliability of computer navigation in both total (TKR) and unicompartmental (UKR) knee replacement surgery.

We analysed 40 consecutive UKRs and 40 consecutive TKRs. All procedures were carried out with the Brain-LAB navigation system and all were carried out by one consultant orthopaedic surgeon. Preoperative aim was neutral tibial cuts with 3 degrees posterior slope. Coronal and sagittal alignment of tibial components were measured on postoperative radiographs. Patients were also scored clinically with regards to function and pain.

In the TKR group, mean tibial coronal alignment was 0° (range 1 to −2.) Mean sagittal alignment was 2° posterior slope (range 0 to 4.) In the UKR group, mean tibial coronal alignment was 0.55° (range 0 to −3.) Mean sagittal alignment was 2.1° posterior slope (range 0 to 4°.) Clinical outcome scores were very satisfactory for the majority of patients, with far superior functional scores in the UKR group.

Our results demonstrate very accurate placement of the prosthesis in both the TKR and UKR group with computer navigation. There is a very narrow range with no outliers, (all within +/−3 degrees of desired alignment.) Functional outcome scores are good. We advocate the use of computer navigation in unicompartmental as well as total knee replacment surgery, in order to minimise early failures.


W. Wilson A.H. Deakin S. Wearing A. Payne F. Picard

As well as improved component alignment, recent publications have shown that navigation systems can assess knee kinematics and provide a quantitative measurement of soft tissue characteristics. In particular, navigation-based measures of varus and valgus stress angles have been used to define of the extent of soft-tissue release required at the time of the placement of the prosthesis. However, the extent to which such navigation-derived stress angles reflect the restraining properties of the collateral ligaments of the knee remain unknown. The aim of this cadaveric study was to investigate correlations between the structural properties of the collateral ligaments of the knee and stress angles measured with an optically-based navigation system.

Nine fresh-frozen cadaveric knees (age 81 ± 11 years) were resected 10-cm proximal and distal to the knee joint and dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femoral and tibial were rigidly secured within a test system which replicated the lower limb and permitted kinematic registration of the knee using the standard workflow of a commercially available image free navigation system. Frontal plane knee alignment and varus-valgus stress angles in extension were acquired. The manual force required to produce varus-valgus stress angles during clinical testing was quantified with a dynamometer attached to the distal tibial segment. Following assessment of knee laxity, bone–ligament–bone specimens were prepared and mounted within a uniaxial materials testing machine. Following 10 preconditioning cycles specimens were extended to failure. Force and crosshead displacement were used to calculate principal structural properties of the ligaments including ultimate tensile strength and stiffness as well as the instantaneous stiffness at loads corresponding to those applied during varus-valgus stress testing. Differences in the structural properties of the collateral ligaments and the varus and valgus laxity of the knee were evaluated using paired t tests, while potential relationships were investigated with scatter plots and Pearson’s product moment correlations.

There was no significant difference in the mean varus (4.3 ± 0.6°) and valgus laxity measured (4.3 ± 2.1°) for the nine knees or the corresponding distal force application required during stress testing (9.9 ± 2.5N and 11.1 ± 4.2N, respectively). Six of the nine knees had a larger varus stress angle compared to the valgus angle. There was no significant difference in the stiffness of the medial (63 ± 15 N/mm) and lateral (57 ± 13 N/mm) collateral ligaments during failure testing. The medial ligament, however, was approximately two fold stronger than its lateral counterpart (780 ± 214N verse 376 ± 104N, p< 0.001). While the laxity measures of the knee were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments.

The findings of the current study suggest that computer-assisted measures of passive knee laxity are largely independent of the ultimate strength and stiffness of the collateral ligaments. The force applied during manual stress testing of the knee, however, was strongly correlated with the instantaneous stiffness of the collateral ligaments suggesting users may attend to the low-stress behaviour of the ligaments. Nonetheless the force applied during stress testing varied between knees, as did the resultant angular deviation. Therefore to make use of the quantified data given by navigation systems, further work to understand the relationships between applied force, resultant stress angles and clinical outcomes for knee arthroplasty is required.


K. Deep C Menna

Total knee arthroplasty (TKA) is one of the commonest orthopaedic procedures. Traditionally the surgeon, based on experience, releases the medial structures in knees with varus deformity and lateral structures in knees with valgus deformity until subjectively they feel that they have achieved the intended alignment. The aim of this prospective study was to record the frequency of medial and lateral releases for computer navigated TKAs.

Seven four consecutive patients operated on by a single surgeon were included in this study. All patients had TKA using either Stryker or Orthopilot computer navigation systems. The implants used were Scorpio NRG or Columbus. The biomechanical axis was taken as the reference for distal femoral and proximal tibial cut. The trans-epicondylar axis was taken as the reference for frontal femoral and posterior condylar cuts. A soft tissue release was undertaken after the bony cuts had been made if the biomechanical axis did not come to within 2° of neutral as shown by computer readings in extension. The post-operative alignment was recorded on the navigation system and also analysed with long leg hip knee ankle radiographs.

There were 43 female and 31 males in the study, 34 left and 40 right knees with an age range of 43 to 87 years. The range of pre-operative deformities on long leg radiographs was 15° varus to 27° valgus with a mean of −5.0° and SD 7.4°. Only two patients needed a medial release. None of the patients needed a lateral release. The fixed flexion deformities needed posterior release. None of the patients needed lateral release for patellar tracking. Post-operative alignment was available for 71 patients. The post implant navigation value was within 2° of neutral in all cases. The mean biomechanical axis on radiographs was 0.1° valgus with a SD 2.1° and range from 6° varus to 7° valgus. From the radiographs six patients were outside the ±3° range.

If one sticks to biomechanical axis and transepicondylar axis as the reference for bony cuts, there will be minimal requirement for medial or lateral soft tissue release. According to our results the use of computer navigation gives a low frequency of medial and lateral release in total knee replacement. Other authors have also found that navigation data can help to give a lower rate of soft tissue release, such as Picard et al. who had decreased their soft tissue release to 25%.


K. Deep F. Picard J. Baines A. Deakin A. Kinninmonth M. Sarungi

Arthritic knees, for the purpose of surgical correction during arthroplasty, are generally thought to be either varus knees or valgus knees and soft tissue releases are done in accordance with the same concept. This view is dependent on the clinical deformity in extended knee and the plain AP radiograph of the extended knee. This concept is now challenged by the observations from our study of the arthritic knee kinematics using computer aided navigation when performing total knee replacement arthroplasty. We performed 283 total knee replacements with computer aided navigation. Imageless navigation was used with Stryker and Orthopilot systems. Bone trackers were fixed to the bones and through real time infrared communication the data was collected. The knee kinematics were recorded before and at the end of surgery. This included measurement of biomechanical axis with the knee extended and then gradually flexed. The effect of flexion on the coronal alignment was recorded real time on the computer. The results were then analysed and compared with plain radiographic deformity on long leg films.

Majority of the knees did not behave in a true varus or valgus fashion. We classified the deformity into different groups depending on the behavior of the knee in coronal plane as it moves from extension to flexion. 2 degree was taken as minimum deviation to signify change, as the knee bends from full extension to flexion. The classification system is as follows

Neutral

Deformity - Varus/Valgus to start with in extension

Gp1

Deformity remains the same as the knee flexes

Increasing deformity as the knee flexes

Gp2

Decreasing deformity but does not reach neutral in flexion

Decreasing deformity reaches neutral in flexion

Gp3

Decreasing deformity and crosses to opposite (Varus to valgus or valgus to varus) deformity in flexion

Gp4

Deformity first increases and then decreases but does not reach neutral

Deformity first increases and then decreases to neutral

Deformity first increases and then decreases to cross over to opposite deformity in flexion

Traditional releases of medial or lateral structures without realising the true picture of what happens when the knee is flexed, may not be correct. From our study it is clear that not all arthritic varus or valgus knees behave in the same way. Some of the releases we perform conventionally may not be required or need to be modified depending on the knee kinematics.


A. Molajo P. Konala S. Ball F Iranpour D. Nathwani

Reconstructive knee arthroplasty in patients with limb deformity can be a daunting and complex task. These patients are often younger and so post traumatic osteoarthritis poses a real challenge. In view of their relative youth, bone preservation would be favourable; however accurate implantation of components is essential. Formulation of a well calculated plan and accurate execution is essential for successful surgery.

We report on a novel method which combines 3D CT joint analysis and computer navigation to define the deformity present pre-operatively and determine whether the proposed reconstruction is feasible. If the reconstructive surgery is feasible, an accurate calculation the correction required is performed. The planned surgery is executed using computer aided navigation surgery.

Eight patients have benefited from the technique. Four patients presented with isolated medial compartment osteoarthritis and intact anterior cruciate ligament. These patients underwent 3D CT joint analysis and computer assisted navigation surgery to accurately implant unicondylar knee replacements.

Four Patients presented with two or three compartment disease. These patients underwent similar 3D CT analysis and navigated Total Knee Replacement.

The series demonstrates the merits of 3D CT joint analysis to accurately define deformity and therefore determine pre-operatively feasibility of corrective surgery proposed. The technique is then complimented by computer assisted navigation surgery to ensure the proposed surgical plan is accurately executed.


K. Deep N. Willcox B. Smith A Deakin

It is generally accepted that Hip-Knee-Ankle (long-leg) radiographs are a good measurement tool for biomechanical axis of the knee and they have been used as the outcome measure for many studies. Most of the surgeons recommend having pre operative and post operative long leg radiographs for total knee replacement surgery, although practice is not as common. We studied the biomechanical axis on long-leg films and compared it with computer navigation.

The objectives were to find out repeatability of measurements of biomechanical axis with inter observer readings on long leg radiographs and to compare biomechanical axis measurements with Navigation values obtained during total knee replacement surgery.

Our institution routinely uses long-leg radiographs for total knee replacement (TKR) surgery both pre- and post-operatively. A series of 209 patients who had navigated TKR between Jan 2007 and 2008 were selected. Stryker and Orthopilot systems for navigation were used. The intra-operative biomechanical axis measurements from the computer navigation files both pre-and post- implant were recorded. The long leg films were measured with a defined protocol from the digital images on PACS system. Centre of the head of femur was taken as the upper point. For the knee centre the midpoint of a line joining the distal femoral notch centre and upper tibia was used. For the ankle centre midpoint of the upper talar margin was used. An angle between the three points represented the radiological biomechanical axis. To investigate inter-observer error, two observers measured the pre- and post-operative biomechanical axis on long leg radiographs independently on 57 patients.

For the inter-observer measurements on 57 patients, the intraclass correlation coefficient was 0.99 for pre-operative radiographs and 0.98 for post-operative radiographs. Maximum difference between the two observers was 2° in four cases. All other cases showed the same readings or 1° difference.

There was a strong correlation, which was statistically significant, between the pre-operative radiographic and navigated measurements with Pearson correlation coefficient of 0.810 (p< 0.001). The maximum difference between the radiographic and navigated measurement was 24 degrees. The relationship between the postoperative measurements was weaker but statistically significant with Pearson correlation coefficient of 0.323 (p< 0.001). The maximum difference between the two methods of measurement was larger 15.5.

It can be concluded from this study that biomechanical axis on a long leg radiograph is a repeatable measure with good inter-observer correlation.

Although it is statistically significantly correlated with navigated readings, the absolute values may be different with both the methods. This raises the question on the reliability of long leg radiographs for the prediction of true biomechanical axis. Most of the larger value differences had a fixed flexion deformities (9 – 45 degrees). This can affect the readings on the long leg radiographs and make the deformity look either smaller or bigger. Also as our knee kinematic study has proven that the deformity does not remain the same in flexion as it was in extended knee that could also account for the difference in the readings. Other reasons for difference in the pre operative readings could be weight bearing status and surgical opening of the joint before taking the pre operative biomechanical axis measurements. Difference in the post operative readings could be attributed to weight bearing status, time length between navigation and radiographic measurements (6–12 wks), scarring of the soft tissues in the time and flexed posture of knee in the early post operative period.


Y. Tenzer C. Schwingshackl A. Gondhalekar B. Davies F. Rodriguez y Baena

Surgical long shape tools, such as the arthroscopic hooked probe, are used during knee-arthroscopy procedures by surgeons to manipulate tissues and diagnose problems. These procedures allows surgeons to assess the physical properties of tissues (such as wear, tear, inflammation, stiffness, etc), which are impossible to evaluate using real-time video observation or MRI and CT mapping. This study focuses on the dynamic properties of the hooked probe and its ability to deliver tactile information, created at the tip of the hook as the tissue is being manipulated, to the handle where the surgeon is grasping the instrument.

From previous studies, it is known that when a probe comes into contact with hard tissues, such as bones, vibrations can occur that enhance the tactile feedback. To better understand the importance of the dynamic influence on the tactile feedback, initially a vibration analysis of the probe (Model 8399.95 by Richard Wolf UK Ltd) was performed; a stepped sine sweep was carried out to evaluate the dynamic behaviour of the probe, including its resonance response frequencies and the damping behaviour. Several vibration modes were identified in a range up to 2000Hz parallel and perpendicular to the probe. The measurement values were correlated to a finite element model of the probe and an error of less than 5% was found for all relevant resonance response frequencies, thereby validating the accuracy of the model.

Measurement and simulation results show that tapping on different materials excites different modes of the probe at different levels, leading to a tactile feedback that harder materials “shift” the probe resonances to higher levels. To verify this, a tapping experiment was performed and the resulting vibrations, while tapping on different materials, were recorded. The study shows that the dynamic behaviour of the probe are somewhat influenced by the fact that the probe is being held in hand leading to a slight reduction in its natural frequencies.

A study on an individual’s ability to discriminate between the stiffness of different materials while tapping on them using an arthroscopy hooked probe is currently underway. Ten subjects are being asked to sort five materials (silicon, latex, rubber, plastic, steel) from the softest to the hardest by simple tapping. During the test, each subject is exposed to two materials each time, iteratively until the sort is complete. The subjects are blindfolded and white noise is played through headphones, to blur the sounds of tapping. The resulting dynamic response of the probe is recorded, using an accelerometer, along with the impact forces on the material, measured by a force sensor. Results to date show that subjects can distinguish quite accurately between the soft materials (silicon and latex), but find it difficult to distinguish between stiffer materials (plastic and steel), but comprehensive statistics are not yet available.


S. Hakki

Proximal load fixation in THA is paramount for maximum bone preservation and thus longevity of the implant. Conventional femoral stems may not achieve satisfactory proximal fixation in proximal/ distal femoral canal mismatch as in champagne type of femur, mal-united fractures, excessively bowed femur and some young large patients. Such mismatch can lead to uneven loading and a higher incidence of loosening or periprosthetic fracture. This risk is becoming higher with the recent trend to mini-invasive surgery. As an alternative to standard stem, the short stem femoral prosthesis was originally developed in the 1950’s and has recently been making a resurgence as a design conducive to the minimal invasive techniques, and allows for greater preservation of the natural anatomy. Our objective is to measure the clinical and radiological outcomes of the Metha® hip short stem (a cementless, metaphyseal fix conserving diaphysis implant) with computer assisted technique and minimal invasive surgical approach.

This study is a single center, open label, data collection study of 35 consecutive subjects undergoing OrthoPilot® navigation, Metha® stem plasmapore cup system with minimal invasive muscle sparing surgical approach. (B. Braun Aesculap; Tuttlingen, Germany). Pre-Operatively an IRB Informed Consent, no exclusion specific to the implant, Harris Hip Evaluation and routine hip/pelvis plain xray was performed. Post-Operatively, a CT Scan within 6 months, repeat Harris Hip Score (HHS) Evaluation. The implant is made of titanium alloy with plasmapore coating in @ 2/3 of the implant (< 8 cm engages in proximal femur with a total length average of 10.75 cm)(range 9.75–11.75). The bearing surface is metal/ highly cross linked polyethylene. Size 32 head of modular neck with plasmapore shell. All cases were done thru muscle sparing anterolateral mini invasive approach.

At 6 months ± 1 month with an average age = 67, BMI= 37 (one was 360 pounds), Harris score was 46 preop and 96 post op.No thigh pain, No dislocation, Trendelenberg negative. Patient satisfaction was high. One fell had a non displaced fx of the neck that did not require revision but slowed full weight bearing for 6 weeks. One subsided in a 360 pound patient after he went full wt bearing while getting out of the shower a week after surgery. This was revised with a standard stem. The tip of two implants was discovered to have penetrated the proximal femur with no symptoms at 3 months period and no restriction to weight bearing during that period. This happened in the first 5 cases in which we modified technique with no other penetrations. Xray/CT scan showed no subsidence good bony ingrowth no radiolucency or loosening. The two penetrated corteses showed intense bony overgrowth on the two protruded tips of stem.

We conclude that cementless metaphyseal short stem with proximal plasmapore coating is associated with excellent clinical and radiological results. The technical errors we faced in the early two cases were identified and avoided by using awl canal finder with suction tube palpation of canal and direct visualization of the metaphyses before hammering the broach. The combination of the short stem prosthesis, modularity of the neck, computer assisted technique and minimal invasive arthroplasty is expected to reduce recovery time, increase the potential for successful restoration of function and add to the longevity of the prosthetic joint.