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

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.

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

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

Aim: 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.

Materials and Methods: 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.

Results: 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.

Discussion: 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.

Conclusions: Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs

Foot osteomyelitis is a common problem for which management is variable and few guidelines exist.

To present our treatment protocol and the results in 36 patients (20 men, 16 women, mean age: 49.5 years) with osteomyelitis distal to the ankle, followed up for 17.6 months (range: 3–64).

Bone infection involved toes (n=4), lesser metatarsals (n=11), hallux (n=3), midfoot (n=4), calcaneus (n=9), whereas 4 cases presented as generalised osteomyelitis. Postoperative infection was the cause in 10 cases. Eleven patients were classified as host-type A, 14 as B and 11 as C. A draining sinus was present in 28 cases. The treatment protocol included surgical debridement, the bead-pouch technique for local antibiotic administration and closure primarily (n=27), or by secondary healing (n=5), skin graft (n=2), local fasciocutaneous (n=1), or free vascularised muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Generalized Charcot osteomyelitis was an indication for amputation.

Mean hospital stay was 13.8 days (range 1–34) and 2.7 (range 1–7) surgical procedures per patient were recorded. Infection control was achieved in 26 cases (72.2%), whereas amputations were performed in 10 cases (27.8%). Below-knee amputation was undertaken in 4 host-type C patients with Charcot osteomyelitis of the foot. Ray amputations were performed in 4 diabetic feet. Six amputees were classified as host-C and 3 as host-B. One host-type A patient with recurrent post-traumatic toe osteomyelitis, underwent a distal phalanx amputation as definitive solution. Amputation rates were 55% among host-C, 22% among host-B and 9% among host-A patients (p< 0.001).

Diffuse foot osteomyelitis in systemically compromised patients resulted in high amputation rates. Better results were obtained in non-compromised hosts and focal osteomyelitis.

Distal tibia and ankle sepsis can threaten the viability of the limb. We present the management protocol and results in 37 patients with chronic infection of the distal tibia and ankle, followed up for a mean of 4 years.

The mean age was 45.6 years. Host type A were 21 patients, type B were 9, and type C were 7 patients. Treatment included radical debridement, multiple cultures sampling and local antibiotic application. Twenty seven patients required bone stabilisation, whereas 3 host C patients were amputated. Soft tissue coverage included 5 free muscle flaps, 3 soleus flaps and 5 pedicle fasciocutaneous local flaps. Bone defects of a mean of 6.3 cm (3–13cm) in 20 cases were treated with distraction histogenesis (13 cases) or the free fibula vascularised graft (7 cases).

Mean hospitalisation time was 26.2 days (host-A: 19.6 vs. host B/C: 32.2, p=0.036). Host-A patients required 2.3 operative procedures whereas host-B/C 3.9 (p=0.01). Union occurred in 26/27 (96%) of cases requiring fixation (one ankle arthrodesis revision/host-B patient). External fixation frames were kept in situ for a mean of 31.7 weeks (12–85). Mean leg length discrepancy was 0.6 cm. Ankle arthrodesis was performed in 7 patients (5% among host-A patients vs. 38% among B/C). Independent ambulation was achieved in (35/37) 95%. All patients were satisfied with the result. Bacteriology revealed Staph. aureus in 71%, whereas 38% were polymicrobial (7% in host-A vs. 88% in B/C patients, p< 0.001). Infection recurrence occurred in 5.4% (none in host-A vs. 13% in B/C patients, p=0.03), whereas the overall complication rate was 43% (24% in host-A vs. 75% in B/C patients, p=0.02).

Functional limb salvage without leg length discrepancy was possible in 92% of cases. Systemically compromised patients required longer hospitalisation, more operative procedures, had frequently polymicrobial infections and more complications.

Two-staged revision TKA is a common strategy for the management of infected TKA (i-TKA) in properly selected patients. However, there is considerable variation in the parameters (e.g. the duration of intravenous administration of antibiotics and of the time interval between the stages, the intraoperative use of frozen sections, the use of knee aspiration etc.) of the treatment protocol among Orthopaedic Centres making the comparative evaluation of results difficult. The aim of this study is to present a standardised two-staged revision protocol with satisfactory mid-term clinical outcome.

Thirty-four consecutive cases of infected primary TKAs were treated in our department between 2000 and 2006. For 24 of them the postoperative follow-up is greater than 2 years. All patients underwent the same treatment protocol: knee aspiration prior to implant removal and surgical debridement, more than 5 specimens for frozen sections and cultures (aerobic, anaerobic and fungi) during the first stage, custom antibiodic impregnated cement spacers, intravenous administration of antibiotics for 3 weeks followed by 3 weeks of per os administration based on culture and antibiogram, a 6-week interval free from antibiotics, second aspiration and second stage with repetition of frozen sections and cultures. In the case of positive frozen section specimens during the second stage the implantation of a new prosthesis was cancelled and a different management strategy was introduced. Preoperative and postoperative data were collected in the form of Total Knee Society Score (knee score and functional score), Oxford-12 Score, laboratory parameters and radiographs at regular intervals.

At the final follow-up 22 out of 24 patients were free of infection. In four patients (2 Host C and 1 Host B) the 2nd stage was repeated (2–6 times) due to polymicrobial infection and positive intraoperative frozen sections. In one of them a knee arthrodesis was finally performed. The diagnostic accuracy of knee aspiration before the 1st stage was low. Total Knee Society Score rose from a preoperative average of 64 (50 to 95) to a postoperative average of 145 (130 to 180). The Oxford 12 score also rose from a preoperative average of 52 (44 to 58) to a postoperative average of 30 (23 to 38). At the final follow-up no radiological signs of implant loosening were observed.

The above standardised protocol of two-staged revision in i-TKA, when indicated, can provide satisfactory mid-term clinical results.

Introduction: Management strategies and results in 30 cases of foot osteomyelitis are presented.

Patients-Methods: From 1/2003 – 1/2006, 30 patients (15 men, 15 women, mean age 47.7 years, range 1.5–82) presenting with foot osteomyelitis were treated. Mean hospital stay was 12.6 days (range 1–45) and 1.3 hospital admissions were recorded (range 1–4). The follow-up period averaged 15.7 months (range 3–56). Bone infection involved the toes in 3 cases, the metatarsals in 9, the head of the hallux in 2, the midfoot in 3, the calcaneus in 9, whereas 3 cases presented as generalized charcot’s osteomyelitis. Eleven patients were classified as host-type A, 10 as B and 9 as C. Nine patients were diabetic, one rheumatoid, four had vascular insufficiency, two had insensate feet. An open calacaneal fracture was the cause in two cases, whereas ORIF of a closed calacaneal fracture in one, ORIF of metatarsal fractures in one and hallux valgus corrective surgery in two. One paediatric patient with calcaneal osteomyelitis developed subtalar arthritis. A draining sinus/wound was present in 24 cases. Each patient underwent an average of 2.3 surgical procedures (range 1–7). The treatment protocol included surgical debridement, use of the bead-pouch technique for local antibiotic administration and closure primarily (n=23), or by secondary healing (n=3), skin graft (n=2), local fasciocutaneous (n=1), or free vascularized muscle flap (n=1). Systemic antibiotics according to cultures were administered for 5–7 days. Amputation was undertaken if salvaging or reconstructive procedures could not be undertaken.

Results: Infection control (salvageable cases) was achieved in 23 cases (76.7%), whereas amputations were performed in 7 cases (23.3%). Four amputees were classified as host C (57.1%), whereas a significantly lower rate of patients successfully treated (21.7%) were host-C (p=0.0008). A below knee amputation was undertaken in two host-type C patients with generalized osteomyelitis of the foot. One 1st ray and two 1st and 2nd ray amputations were performed for not salvageable diabetic feet infections. Finally in 3 cases of posttraumatic chronic toe osteomyelitis in host-type A patients, a distal phalanx amputation was the definite solution. One patient developed a septic TKR in the contralateral leg and one diabetic patient developed osteomyelitis at a different location in the earlier affected foot.

Conclusions: The treatment strategy of radical debridement, local antibiotic delivery by the bead-pouch technique and use of flaps if needed, successfully treated salvageable feet. Amputation was the solution in neglected cases and in immunocompromised patients.

Aim: We present the surgical technique and early functional and radiological results of cementless acetabular reconstruction with Monoblock Trabecular Metal (MTM) (Zimmer Warsaw, Indiana) cups in patients with Developmental Dysplasia of the Hip (DDH).

Materials and Methods: From 1997 to 2004, 70 hips (57 patients) with DDH were received an MTM acetabular component. There where 7 men and 49 women. Average age was 50 years (range 35 to 77). According to the classification of Hartofilakidis et al there where 14 hips with high dislocation, 15 with low type I, 16 with low type II, 8 with low type III dislocation and 17 with hip dysplasia. In all patients a MTM cup was implanted in the true acetabulum through a standard posterior approach. Morselized graft was used in 6 cases and a structural graft only in one. Diameter of the cup was ranging from 42 to 56 mm with 54 out of 70 cups being smaller than 50 mm. Screws where used in 12 out of 70 cases A femoral shortening osteotomy was utilized in only two high dislocation cases.

All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).

Results: Average follow up was 50 months (range 103 to 24). There were no revisions for aseptic loosening, radiologic loosening or cup migration during last evaluation. Two patients developed non-progressive radiolucencies in zone one.

There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.

Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.

Conclusion: MTM acetabular component achieved adequate initial stability in this demanding group of patients and they have excellent radiological and clinical results. Posterior approach without femoral osteotomy provided adequate exposure in almost all cases.

Purpose: Arthroscopy offers a view of intra-articular pathology, but its use in the treatment of intra-articular distal radius fractures remains controversial. This study compares functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation (EF) of distal radius fractures.

Type of study: double randomised prospective, comparison of 2 different procedures.

Methods: Between January 2000 and December 2003, 20 patients with comminuted intra-articular distal radius fractures underwent AA EF and percutaneous pinning and 20 patients underwent and FA EF reduction and pinning.

Results: Follow-up period was 9–27 months. Evaluation was clinical (grip strength, range of motion) and radiographic (palmar tilt, radial shortening, stepoff). The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the MAYO wrist score were used 3-9-12 months postoperatively. In 9/20 patients of AA group the subchodral pins were changed after artrhroscopic view because of stepoff. The following tears were found: TFCC (12 of 20 patients), SL (9/20), LT (4/20). Patients who underwent AA surgery had significantly better supination; wrist extension; and flexion compared with the FA surgery group (86 vs 75; 76 vs 65; and 76 vs 63 degrees respectively). Radial shortening and DASH scores were better for the AA group compared to the FA group (AA:12, FA:25) the 3rd and 6th postoperative month but the difference decreased after the 12th month.

Conclusions: A reduction and fixation of intra-articular distal radius fractures provides improved inspection of the ulnarsided components of the injury. Long term evaluation revealed that patients with AA procedures returned in decreased periods to their previous activities (based on DASH score) and had better of supination, flexion, and extension than patients with FA surgery.

Aim: Evaluation of intermediate clinical and radiographic results of displaced intra-articular fractures of the calcaneus treated with ORIF. Materials- Methods: From 1994 to 2002, 167 displaced intra-articular fractures of the calcaneus were treated with ORIF. There were 145 male and 12 female patients. Mean age 34 years. Standard x-rays, Broden views and CT-scan images in coronal and transverse plane were obtained pre and post operatively. Fractures were classified as type III, IV, V according to Sanders. All fractures were approached through an extended lateral L-type approach. AO calcaneal plate was used. Average follow-up was 5 years. Results: In 143 Sanders type III and IV fractures KITA-OKA score was 91. Reduction failure rate was 5.5%(8 pts). 24 patients had Sanders type V fractures and KITAOKA score was 84 and reduction failure rate was 25% (6 pts). 29/167 patients complained of peroneal tendons tenderness which subsided after hardware removal. 79/167 patients had restriction of subtalar joint movements but no complains (SF_36) There were two superficial wound infections and five patients with delayed wound closure. In a group of 45 patients with similar fracture patterns who were treated conservatively, KITA-OKA score was 71, 41 fractures were malunited, 40 patients had moderate to severe pain and early OA sings. Conclutions: Displaced intra-articular fractures of the calcaneus should be treated as any other displaced intra-articular fracture, with open reduction and stable internal fixation

Aim: Fixation implants are usually well tolerated by the patients for prolonged periods of time. However, it is not unusual for some patients to develop persistent pain with acute onset that is often combined with paresthesias. The purpose of this study was to verify if the acute onset of pain that is not combined with clinical or laboratory signs of infection could be attributed to an underlying bacterial colonization of implants. Methods: Sixty-four patients (38 male and 26 female) with mean age of 36 years (range, 10 to 73 years) were included in this study. Patients presented with acute onset of pain and/or paresthesias several years after the implantation of stainless-steel þxation materials (plate-screws: 52 and intramedullary nails: 12), in the upper (13) or lower extremity (51). All patients of the present series had negative clinical and laboratory signs of infection. All patients of the present series had their þxation materials removed in our department. The materials subsequently underwent microbiologic and corrosion evaluation. Results: Patients experienced immediate relief after removal of þxation materials. Cultures were positive in 18% of cases and Staph aureus and epidermidis were most frequently encountered. Pseudomonas and enterococcus were also cultured. Conclusions: The percentage of positive cultures (18%) in the patients of our series indicates that symptoms may be due to the bacterial colonization of implants, despite the absence of sings of infection. Although the administration of antibiotics remains controversial, removal of the implants is indicated in cases with acute delayed onset of pain at the site of the implanted þxation materials.

Purpose: We present the results of subacromial decompression and repair of the rotator cuff through a minimal deltoid-on approach.

Material and Method: Eighty-seven patients with longstanding shoulder pain were evaluated in two years (1999–2000) in our department. In sixty -eight of them symptoms were due to impigment syndrome. Eight patients with follow up time less than six months were excluded from this study, twenty were treated conservatively and the remaining forty (22 female, 18 male, mean age 50.3) underwent surgery. Three x-ray views were obtained in all patients, i.e. standard AP, true AP, and subacromial space projection. MRI was also obtained in all patients. MRI revealed calcific tendinitis in fifteen patients, osteophytes of the acromioclavicular joint in thirteen, a hooked (type III) acromion in ten and partial tear of the supraspinatus tendon in nineteen. In five of them there was also a partial tear of the infraspinatus. Finally, seven patients were suffering of a full thickness tear of the supraspinatus tendon. All patients were operated through a minimal deltoid-on approach. Acromioplasty and coracoacromial ligament dissection was performed in all. In patients with osteoarthritis of the acromioclavicular joint, osteophytes were carefully removed. Calcific deposits were also removed in all patients. In eighteen patients tears of the rotator cuff were detected and repaired using bone anchors.

Results: All patients were examined six months postoperatively. Results were evaluated with CONSTANT SCORE and with a questionnaire for patient’s satisfaction. Thirty-seven patients were very satisfied with the result and three were satisfied. As for Constant score, pain improved at an average of 7.8 points, daily activities by 5.4, and range of movement by 4.2 points. Results were evaluated by the examiner as excellent in thirty-six patients (90%) and very good in four patients.

Conclusion: Deltoid-on approach, in patients with impingement syndrome of the shoulder provides adequate exposure for the surgical repair with minimal trauma and a very low rate of complications.

We evaluated the clinical outcome of IM nailing for the treatment of femoral shaft pseudarthrosis in patients who had multiple failed plate osteosyntheses. From January 2000 untill April 2001, 20 (19 male-1 female, mean age 28) patients were treated because of femoral shaft non-union in our institution. All patients had two or more failed plate osteosyntheses. There were no septic non-unions in this group. Eight patients had an established non-union on an average of nine months post-op and the remaining eleven had radiological and clinical evidence of implant failure. There was no segmental bone loss, hi all patients the implants were removed and nailing was performed. Extensive periosteal stripping, bone necrosis and soft-tissue scaring were constant findings in all patients. Twelve patients received interlocking nails. Eight femurs were grafted with iliac crest bone graft. All patients were followed by serial x-rays until union.

There were no postoperative complications. All pseudarthroses were healed within an average of 9.7 months (8–12). Non-unions which received bone graft (eight out of twenty) in day one, were healed faster than those which didn’t. There were no re-operations among these patients. Among the remaining ten patients five were grafted five to six months postoperatively and three had had nail dynamization.

IM nailing for femoral shaft non-unions after multiple failed plate osteosyntheses is a safe and effective method of treatment. Autologous bone graft reduces healing time and re-operation rate.

Purpose: The efficacy of nasal salmon calcitonin (CT) in preventing bone loss after a hip fracture and in reducing the incidence of further contralateral hip fractures was evaluated.

Material and Methods: Fifty women aged 70–80 years who sustained a pertrochanteric fracture were randomly allocated to Group A (200 IU of nasal salmon calcitonin daily for three months) and Group B (placebo). Biochemical bone markers (1st, 7th, 15th, 45th and 90th day post injury) and bone mineral density of the lumbar spine and the intact contralateral hip (4th and 90th postoperative day, and one year after the fracture) were measured.

Results: Patients in the calcitonin group showed statistically significantly higher total (p< 0,005) and bone alkaline phosphatase (p< 0,002) and osteocalcin (p< 0, 05) levels on the 15th day, while statistically significantly lower uCTX values on the 15th (p< 0,045), 45th (p< 0,002) and 90th (p< 0,002) day and uHpr/Cr values on the 15th (p< 0,015) and on the 45th (p< 0.05) day post injury. In the placebo group patients showed a statistically significant reduction (all p values < 0.05) of bone density values at 3 months and one-year post surgery while in the calcitonin group no significant changes from baseline. When the two groups were compared, patients in the calcitonin group showed statistically significantly higher bone mineral density values (all p values < 0.05), in all recorded sites, at 3 months and one-year post operatively. After a four years clinical follow-up, five patients (5/25, 20%) sustained a new fracture of the contralateral hip in the placebo group.

Conclusion: Nasal salmon calcitonin prevented early bone loss in these patients and may have a protective role on the occurrence of a new fracture of the contralateral hip in the same patient.