J Orthopaed Traumatol (2006) 7:S1–S63 DOI 10.1007/s10195-006-0142-9 ORAL PRESENTATIONSEFACE

SESSION LU10 rabbit iliac crest were cultured for 3 weeks and then loaded into coralline HA-coated granules. The graft material was then implant- ed on the bed graft prepared at surgery on the right side while a EW FRONTIERS IN VERTEBRAL SURGERY decortication of the transverse processes (sham) was performed on N the left side of the lumbar spine (15 rabbits). Further 15 rabbits underwent spinal fusion using coralline HA-coated alone as graft INTERSPINOUS PROCESS TECHNOLOGY: WHY, WHEN, material. Rabbits were sacrificed 6 months after surgery and the WHERE lumbar spine submitted to standard and high resolution (FAX- V. Rosso [1], C. Bignardi [2], M. Girardo [1], F. Trucchi [1], G. Collo ITRON) radiographs and histologic analysis. [1], F. Castoldi [1] Results: Radiographic results showed spinal fusion in 90% of the [1]Divisione Universitaria di Ortopedia e Traumatologia, Ospedale spine treated with SSC and in none of those submitted to sham oper- Mauriziano, Turin, Italy; [2]Dipartimento di Biomeccanica del ation. Histologic analysis showed new bone formation adjacent to Politecnico, Turin, Italy the transverse processes while little or no bone formation was found between the transverse processes in the middle of the graft. In the Objective: The interspinous devices are able to re-tighten the poste- latter zone, a tight fibrous tissue and scant blood supply was found. rior joints and ligaments and the posterior fibres of annulus and to Conclusions: Our study shows that a graft material constituted by reduce the lumbar instability and intra-discal pressure. SSC and a coralline HA-coated carrier, which was found to promote The aim of our retrospective study is to evaluate the mechanisms of new bone formation in previous animal studies, does not promote an action and the effectiveness of posterior dynamic stabilization adequate new bone formation to obtain a continuous bony bridge in device in the management of painful lumbar spinal disorders. the rabbit posterolateral spinal fusion model. This finding may pos- Materials and Methods: From September 2003 to May 2006 we sibly be due to an insufficient vascularization of the central zone of performed 72 implants of interspinous device in 53 patients that had the graft. discogenic low back pain refractory to conservative treatment lasting more than 6 months; moderate degenerative disc disease (Pfirrmann ≤ 4); initial stage of facet joint osteoarthritis. Twenty five patients, 10 females and 15 males, are included in our study, with the follow- SESSION ME04 ing selection criteria: - no surgical procedures added (herniectomy, laminectomy, fusion, etc) EW FRONTIERS IN VERTEBRAL SURGERY - more than 18 months follow-up. N The diagnostic instruments used are standard lumbar spine X-rays and magnetic resonance images. In collaboration with bioengineers BUDGETING AND REPORTING AS INSTRUMENTS TO PRE- we carried out a finite element mathematic model of the L4-L5 spinal motion segment which is aimed at simulating the healthy and DICT HEALTH RESOURCES ALLOCATION the treated L4-L5 lumbar segment with interspinous device, subject- S. D’Amico, L. Del Sasso, E. Mazza ed to compressive force and flexion-extension, deformation of lum- Azienda Ospedaliera S. Anna, Como, Italy bar disc during simulation of motion. Results: At follow-up low back pain is improved in 84% of the Objective: Managing an organization to follow its istitutional pur- patients; meanly improved in 12%, not improved in 4%. The com- pose means to develop and carry out three different activities. These putational finite element model showed that the device is able to complementary activities are: strategic planning, management con- achieve its main design purpose: to diminish the forces acting on the trol and operative control. Budgeting is an organizing process useful apophyseal joints and reduce stress on the adjacent disc. to define operative goals. These goals have to be pursued allocating Conclusions: From our experience, the interspinous device is a safe, resources and finding decisional autonomies (departmental system) mini-invasive procedure with good clinical outcome, especially in to get operative decisions evaluating economical, financial end tech- young patients, diminishing surgical time and respecting anatomy. nical actability of the chosen action programs. Thanks to communi- cation of important information (reporting) on decisional activities of the management it is possible to foresee the chances of health INFLUENCE OF LOCAL FACTORS ON THE EFFICACY OF policies, which has been expressed by the budget. SKELETAL STEM CELLS IN EXPERIMENTAL SPINAL Materials and Methods: We report the budgeting and reporting FUSION application processes that have been used for the department and G. Giannicola [1], G. Cinotti [1], M. Riminucci [2], B. Sacchetti [3],A. operative unit contract. We analyse the Surgery Department‘s budget Corsi [3], E. Ferrari [1], U. Mancini [4], S. Michienzi [3], A. Funari [2], of the Azienda Ospedaliera S.Anna in Como. We analyse the relation G. Gregori [1], G. Citro [5], P. Bianco [3], F. Postacchini [1] between the goals of the Operative Units of the department and the [1]Dipartimento di Scienze dell’Apparato Locomotore, Università goals chosen with the territorial ASL happened on January 2006 degli Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, (DRG-L.E.A.control, DRG-LEA from ordinary admission to Day- Italy; [2]Dipartimento di Medicina Sperimentale, Università degli hospital and ambulatory’s admission, reduction of waiting time for Studi dell’Aquila, Itay; [3]Dipartimento di Medicina Sperimentale e admission, medical DRG’s reduction). Patologia, Università degli Studi di Roma “La Sapienza”, Policlini- Discussion: The reporting analytical process used to find out indica- co Umberto I; Rome, Italy; [4]Clinica Veterinaria, Rieti, Italy; tors (estimated activity delta as days/DRG correlated) allows us to: [5]Dipartimento Laboratorio Modelli Animali, Istituto Regina Elena, - single out operative units able to allocate resources. Looking for Rome, Italy operative units without management process political analysis. - Highlight critical relations between operative units and services. A currently used animal model for spinal fusion was adopted to - Estimate the probability of getting budget goal. investigate the new bone formation induced by skeletal stem cells - Propose and suggest for organization’s political process. loaded into an osteoconductive carrier. Conclusions: Budgeting and Reporting can develop programming Materials and Methods: Skeletal stem cells (SSC) harvested from strategies useful to reach the goals of the management policy. S2

ESSION 22,4 mm (range 15-24 mm) to 26 mm (range 22-28 mm). There were S O01 no Kyphoplasty related adverse events with clinical consequences observed in this study. Nonetheless, in one patient, a small cement leakage through the anterior venous plexus occurred, while in anoth- KYPHOPLASTY er case a leakage occurred through the anterior vertebral wall: both patients remained asymptomatic. VESSELPLASTY IN THE TREATMENT OF VCFS. PRELIMI- Conclusions: Kyphoplasty is an effective minimally invasive proce- NARY REPORT dure in the treatment of osteoporotic vertebral compression frac- V.F. Paliotta, B Magliozzi, L. Alessandro tures, leading to a reduction in local pain and an improvement of the ASL Rmc, Rome, Italy vertebral shape, as well as a restoration of vertebral body height; moreover, Kyphoplasty allows an early recovery, above all in the Objective: Vesselplasty is a new technique in the treatment of Ver- elderly patients with improved quality of life. tebral compression fractures (VCF). Materials and Methods: A PET artificial vessel, the Vessel-X®, is used to restore the height of the vertebral body, it serving as a TRANSORAL KYPHOPLASTY FOR C2 TUMORAL LOCAL- Vertebral Body Expander and also serving as the Bone Void Material IZATIONS Container. It is introduced into the vertebra in a reduced configura- D.A. Fabris Monterumici [1], S. Narne [2], U. Nena [1], R. Siniga- tion and once positioned it is expanded raising the endplates and cre- glia [1] ating a void along with the introduced of bone void filler material. [1]Unità Operativa Complessa di Chirurgia del Rachide “Sandro And then, a few bone void filler material penetrates through Vessel- Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, X®, interdigitating the vertebral body. This new technology, Padua, Italy; [2]Unità Operativa Autonoma di Chirurgia Vesselplasty, thoroughly solves the fatal problem of leakage of Endoscopica delle Vie Aeree, Azienda Ospedaliera, Università degli cement out of the vertebral body. Studi di Padova, Padua, Italy Results: Authors discuss the first 7 patients treated with Vesselplasty at the S. Eugenio Hospital in Roma. 5 osteoporotic VFCs and 2 Objective: Our purpose is to describe a new surgical technique, the myeloma VCFs; 6 females and 1 male. Mean age was 71 years and transoral kyphoplasty, that we performed in three cases of C2 mean follow-up 6 months. No major complication was observed up tumoral localizations. to now. Materials and Methods: From February 2004 to January 2006 three Conclusions: According to the preliminary results Vesselplasty can cases of C2 tumoral localizations did not show healing after 6 be considered a procedure of choice in the treatment of VCFs. The months of conservative treatments. To reduce pain and avoid both technique is not more difficult than vertebroplasty or kyphoplasty C2 collapse and prolonged immobilization transoral kyphoplasties while risks are much less. A longer follow-up is needed in order to were performed. reach a more proper evaluation. Results: There were no complications and/or complaints related to the procedure. There were no C2 related symptoms or neurological problems. The first patient died 8 months after surgery due to unre- KYPHOPLASTY FOR TREATMENT OF OSTEOPOROTIC lated causes. The second and the third are alive and, follow ups of 2 VERTEBRAL COMPRESSION FRACTURES: CLINICAL AND years and 3 months respectively, reveal good and pain-free cervical RADIOLOGICAL RESULTS range of motion, with no findings regarding pathologic G. Gulino, L. Spatafora mobility/instability on X-ray. Azienda U.S.L.3, Catania, Italy Discussion: The management of C2 tumoral body lesions is still controversial. The literature recommends prolonged immobilization, Objective: The primary purpose of this study is to evaluate the clin- internal fixation (anterior or posterior) or transoral vertebroplasty ical and radiographic outcomes, as well as the complications, of [Tong 2000]. In our cases, after conservative treatment failure, we kyphoplasty in the treatment of osteoporotic vertebral compression performed the transoral kyphoplasty to avoid major surgical proce- fractures. dures. This technique could be considered an improvement of the Main goal of conventional treatment in fractures due to osteoporosis transoral vertebroplasty. While maintaining the normal cervical is to decrease pain and preserve bone density; nonetheless, this treat- spine anatomy, and avoiding arthrodesis or fixation that reduce the ment is not able to stop evolution of the segmental deformity. cervical spine range of motion. it also reduces the leakage of PMMA Kyphoplasty is a recent surgical treatment aimed to decrease pain cement outside the porothic vertebral body [Nussbaum 2004]. and restore the vertebral body height. When performed in fresh frac- Conclusions: Transoral kyphoplasty proved to be safe, quick and tures, Kyphoplasty allows in most cases the vertebral body shape effective in reducing pain and avoiding vertebral collapse in patients restoration. with C2 tumoral localizations. Transoral approach contraindications Materials and Methods: Twenty-eight kyphoplasty procedures are hemorrhagic diathesis, infections, lesions with epidural exten- were performed in 24 patients (average age 62 years, range 55-84 sion, oropharyngeal inflammation, and patients of younger age years) affected by symptomatic osteoporotic vertebral fractures. [Gangi 2003]. Mean fracture age was twenty-two days (range 6-83 days). Six tho- racic (T7, T11, T12) and twenty-two lumbar vertebrae (L1, L2, L3, L4) were involved. All fractures were analyzed for improvement in PERCUTANEOUS KYPHOPLASTY IN THE TREATMENT OF reduction of pain (VAS Scale) and in sagittal alignment (kyphosis, VERTEBRAL ALGODYSTROPHY: A PROSPECTIVE STUDY anterior and midline vertebral body heights); procedures related A. Ramieri [1], M. Domenicucci [2], P. Missori [2], R. Delfini [2],G. complications were registered. Costanzo [1] Results: Mean VAS score improved from 8.2 points before surgery [1]Ortopedia, Università “La Sapienza”, Polo Pontino ICOT di to 1.4 points after surgery. Mean local kyphosis angles improve from Latina e Fondazione Don Gnocchi; Rome, Italy; [2]Neurochirurgia, 17.2° (range 8°-19°) before surgery to 4.4° (range 2°-9°) after Università “La Sapienza”, Rome, Italy surgery. Mean anterior vertebral body height improved from 22.1 mm (range 15-25 mm) preoperatively to 27.3 mm (range 25-29 mm) Introduction: Currently, percutaneous kyphoplasty is commonly postoperatively. Mean midline vertebral body height improved from used for the treatment of vertebral osteoporotic compression frac- S3

tures (Phillips et al., 2003). Even without fractures, an osteoporotic decreased the symptoms of treated patients. The 2 year follow-up vertebral body may develop some structural modifications with dys- showed good clinical and radiographic results. A long term follow-up trophic aspects, defined by the literature as “intravertebral clefts” will be necessary to validate the results and their possible limits. and “intravertebral vacuum” (Missori et al, 2005). Such phenomena can be painful and the MRI is the imaging technique of choice for their evaluation. THE VERTEBRO-DISCAL SUBSTITUTIVE TREATMENTS: Materials and Methods: A prospective consecutive series of 15 THE MEDICO-LEGAL OPINION OF THE ORTHOPEDIC elderly patients with pain in the thoraco-lumbar or lumbar spine G. Martini [1], L. Perugia [1], D. Perugia [2], L. Ottaviano [2],D. were evaluated. MRI findings showed modifications of the vertebral Palmieri [2] body consistent with algodystrophy. Lesions were treated by means [1]Commissione di Medicina Legale SIOT; Rome, Italy; [2]Gruppo di of percutaneous kyphoplasty with unilateral transpepedicular Studio della Commissione di Medicina Legale SIOT, Rome, Italy approach. The outcomes of such procedure were evaluated with a visual analogue scale for pain (Chen et al, 2005). Objective: The current surgery for the locomotor apparatus is devel- Results and Conclusions: Percutaneous kyphoplasty has not deter- oping towards the substitutive treatments of segments or systems in mined any complications either early or late. Outcomes have showed which the conservative restoration does not seem suitable, due to to be good or excellent, except for a case in which the quantity of irreversibility of the impairment or for the involvement of other injected PMMA has been considered to be insufficient. structures. It is true that skill, precaution and diligence should alwa- Augmentation of the vertebral body makes pain disappear, in spite ys warn the doctor, to whom the patient’s health is remitted; howev- of the biomechanical alterations due to algodystrophic phenomena. er, it is also true that innovative choices often involve not well kno- Inflating the balloon creates a positive pressure room inside the ver- wn ways in which the acquired skillness is not enough, precaution is tebral body, making it possible to fill it with PMMA without the risk not entirely motivated and diligence, only generic and not specific to of cement leakage. treat problems of unknown impact. Regarding innovative choices, the Magistracy expresses more openness towards a rigorous verifi- cation rather than trusting the one who following a new way, has shown the willingness to study an itinerary in sight of notable clini- SESSION O02 cal advantages. If the generic operation risk is known in its general characters, the specific one, in an innovative surgery, can be almost unpredictable due to the reduced experience of the individual bio- RACHIS I logical reactions. Methods: We think that it is favourable to analyze possible causes of responsibility in the vertebro-discal substitutive treatments. LUMBAR DYNAMIC STABILIZATION SYSTEMS (DYNESIS Conclusions: In clinical or medico-legal field it is always difficult, AND DIAM). FOLLOW-UP AT 2 YEARS when not conceited, to draw off conclusions which are demonstrat- A. Sgarbossa [1], M. Balsano [2], P. Bartolozzi [3] ed not to be from the continuous variability of the experience that [1]Clinica Ortopedica e Traumatologica, Verona, Italy; [2]ULSS 4 only with time are transformed into scientific and normative certain- Alto Vicentino UO Ortopedia e Traumatologia, Thiene, Italy;- ties. In order to become cognitive, it is unavoidable to ask the [3]Clinica Ortopedica e Traumatologica, Verona, Italy Magistracy to complete such a path with careful methodological study, avoiding a mere judgment limited to the arrival point. The pre- Study Design: Radiographic and clinical study at 2 year follow-up vailing causes of faulting behaviour in connection with the risks and in patients treated with dynamic stabilization by means of inter- to the complications of such surgery get therefore marked. spinous process distraction system (DIAM) and dynamic pedicle screw system (Dynesis). Background: The surgical treatment of lumbar pain in degenerative PSEUDARTHROSIS IN C2 FRACTURES: SURGICAL TREAT- pathology through rigid stabilization could be complicated with MENT transition syndrome at long term follow-up. The dynamic system F. Ennas [1], M. Ganau [2], A. Maleci [3] restricts the segmental movement and avoids progressive degenera- [1]Clinica Ortopedica, Universita’ di Cagliari, Cagliari, Italy; tion of lumbar spine. [2]Cattedra di Neurochirurgia - Università di Cagliari, Cagliari; Methods: We selected 35 patients (19 female and 16 male, average [3]Cattedra di Neurochirurgia - Università di Cagliari, Cagliari, Italy age 44.5 years) with chronic lumbar pain, initial disc degeneration disc signal (MODIC I) and degeneration of articular joint. We treat- C2 fractures are currently the most common among the overall traumat- ed 21 patients with DIAM and 14 patients with DYNESYS through ic lesions of the cranio-vertebral junction. Some of these fractures are randomized technique. All patients were evaluated with average fol- undetected, therefore pseudarthrosis is a frequent evolution. low-up 24.2 months through x-ray of lumbar spine and subjective Pseudarthrosis related to C2 fractures is generally responsible for evaluation with VAS and OSWESTRY scores. intense pain, and often leads to invalidating consequences due to pro- Results: Clinical symptoms decreased, Oswertry and VAS scores are gressive compression of neurovascular structures.Between 2004 and significantly improved. The pre operative Vas score was 8.3 (aver- 2005 a total of 32 cases of cranio-vertebral instability were admitted to age), 2.2 post operative (average). The pre operative Oswertry score our department: among these, 14 cases were a direct consequence of pre- was 54.3% (average), 8.6 % post operative (average), with an vious C2 fractures (class II by Anderson classification) evolved in increase of 75%. No complications during surgery are reported. In pseudarthrosis. Every patient was studied by plain and dynamic X rays, one case, we had a superficial infection resolved with antibiotic ther- spiral CT and MRI of cervical spine: instability was always detected, in apy. One patient treated with Dynesis, showed increased pain symp- association with various degrees of medulla compression. Those 14 toms. None of the patients showed any radiographic progression of cases underwent surgery, three different approaches have been per- articular degeneration. There were no observed complications asso- formed: anterior screw fixation (5); transarticular screw fixation, accord- ciated with the implants. No significant difference results between ing to Magerl technique (7), or posterior fixation, by the technique the two groups are reported. described by Harms (2). Immediate bone stabilization was always Conclusions: The elastic stabilization of the lumbar spine represents achieved, as radiographically verified; no complications were observed, a possible alternative of rigid stabilization. Both systems significantly and pain immediately resolved. Postoperative radiographic controls S4

demonstrated optimal screw position in 11 cases, while in 3 cases (all but amplitude of electric signal reduced to 0,5%. All subjects were treated by posterior approach) at least one screw was displaced, but proposed to follow a treatment of 10 hours per day for 60 days; total without further complications nor any need for reoperation. At 6 months, hours of therapy were memorized in the devices. Pain was evaluated bone healing has been reached in every case but one, initially treated by by VAS and pain specific QUALEFFO questionnaire. Twenty-seven anterior approach, who required a second surgical treatment by posteri- patients concluded the study: 13 in group A and 14 in group B. In both or approach. According to our experience we advocate surgery as an groups we observed pain reduction, already at first visit. By the way effective treatment for instability due pseudarthorosis related to previous in group A we observed a significant negative correlation between C2 fractures. Anterior approach, even if easier, and profitable in terms of hours of treatment and pain, evaluated by VAS (r=-0.65 p<0.05), and preservation of cervical spine motility, should be considered less effec- by specific QUALEFFO (r= -0.71 p<0.05). In group B we didn’t tive, and susceptible to long term complications. Posterior approach observe any association between hours of treatment and VAS or seems to be the one of choice because of the possibility to perform a C1- QUALEFFO (r = 0.12 e r = -0.34 vs VAS and QUALEFFO respec- C2 arthrodesis which allows definitive and durable results. tively, non significant). In group A we observed a tendency toward the reduction in the use of analgesic (chi-square test p = 0.07). These data indicate that a particular capacitively coupled electric field C1-C2 AND C1-C3 POSTERIOR FIXATION BY TRANSPE- (Osteospine) may have positive effects on chronic pain. A significant DICULAR AND LATERAL MASS SCREWS FOR TREATMENT dose-response effect has only been seen in the group whit Osteospine OF ODONTOID FRACTURES signal and a tendency toward a reduction of use of analgesic drugs in M. Dobran, M. Iacoangeli, A. Di Rienzo, F. Formica, M. Scerrati these patients has been observed. The study is still in progress and an Clinica di Neurochirurgia, Università Politecnica delle Marche, increase in the number of patients is foreseen in the next months. Ancona, Italy

Background: Surgical treatment of odontoid fractures is still a mat- THE DISCOGENIC LUMBAR PAIN: CLINICAL ASSESSMENT ter of debate, with respect to the appropriate technique, timing and AND SURGICAL OPPORTUNITIES fixation system. We report our experience with the use of posterior C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali C1-C2 and C1-C3 screwing fixation. Policlinico Universitario, Sassari, Italy Materials and Methods: From September 2004 to January 2006, 15 patients were operated on for odontoid fractures type II-III at our The degenerative disc disease is the consequence of the progressive Institution. Sex distribution included 11 males and 4 females (age aging with dehydration of the nuclear component. The physiopatholog- range 23-81 yrs). In only one patient spinal cord damage (Frankel A) ic mechanism, that seems to be imputable to the incapability of the disk was present. Surgical technique consisted of C1 lateral mass and C2 to repair the consequential injuries caused by continous solicitations, pedicle screws positioning. In case of damaged C2 pedicle, fixation recognizes the “primum movens” in a decay of the cellular nutrition was extended to C3 lateral mass. All patients underwent standard x- with consequent aging of the same and accumulation of degenerated ray examination one month after surgery and CT scan/dynamic x-ray molecules of matrix which achieves dehydration with relative rigidity examination at 3 and 6 months. and loss of elasticity. The surgical treatment essentially finds two kind Results: There was no mortality and no major morbidity. Surgical time of surgical procedures: vertebral arthrodesis and “no fusion” approach- was always less than 2 hours, with no significant bleeding. Two es. Vertebral arthrodesis consists of fusion two or more adjacent verte- patients underwent removal of the fixation system with recovery of full bral units to form a single unit of motion with the employment of bone range of cervical motion. No case of non-union was observed so far. graft and fixation devices. “No fusion” treatments use different systems Discussion: The above described technique is suitable for all type of that allow mantaining the movement of the unity of motion. The odontoid fractures, including the OBAV ones. Operative times are devices for intervertebral assisted motion allow a limited range of comparable to those required by the anterior approaches. The range movement setting the facet joints in distraction; instead the peduncolar of cervical motion is minimally reduced. dynamic systems reach the same aim positioning peduncolar screws Conclusions: In our opinion, the C1-C2/C1-C3 posterior fixation tech- and bars that reduce the overload of the adjacent segments. At last, the nique represents a valid alternative to the more anatomically demand- discal prosthesis (nucleus /whole disc) can be used when the patient ing anterior approaches, and to the transarticular C1-C2 fixation, expectations depend on age, sex and grade of disc degeneration. biochemanically less rigid and requiring appropriate working angles. Finally, our experience suggests that the vertebral arthrodesis is the best choice in case of advanced degenerative disc disease with facet joint syndrome; the dynamic devices and at last the discal prosthesis can be EFFECT OF CAPACITIVELY COUPLED ELECTRIC FIELD ON used when the facet joints are still not involved by degenerative process. PAIN RELEASE IN PATIENTS WITH OSTEOPOROTIC VER- TEBRAL FRACTURES M. Rossini [1], A. Zambito [1], G. James [1], D. Bianchini [1], S. Gi- rardello [1], F. de Terlizzi [2], D. Gatti [1], O. Viapiana [1], S. Adami [1] SESSION O03 [1]Reumatologia Azienda Ospedaliera, ULSS 20, Università di Verona, Verona, Italy; [2]IGEA S.R.L., Carpi, Italy RACHIS II The pain in patients with multiple vertebral fractures represents a fre- quent issue in the elderly population. In the present study we have evaluated the effects of capacitively coupled electric field LUMBAR SYNOVIAL CYSTS: MANAGEMENT AND FOLLOW (Osteospine, IGEA, Italy) on chronic pain in patients with multiple UP OF 12 CASES vertebral fractures. Thirty-one females older than 60 years, with mul- F. Ennas [1], M. Ganau [2], A. Maleci [2] tiple vertebral fractures and chronic lumbar pain, on treatment with [1]Clinica Ortopedica, Università di Cagliari, Italy; [2]Cattedra di analgesic drugs since at least 6 months have been recruited. The Neurochirurgia, Università di Cagliari, Italy patients were randomised in 2 groups: group A (n°=16) the patients were treated with capacitively technique with an electric signal Synovial cysts represent a degenerative process affecting the articular already used for fracture healing; it is an electrical signal based on facet due to progressive synovial hypertrophy and eventual herniation. sinusoidal waves of 60kHz frequency and automatically settled ampli- The incidence in the spine is extremely low (0.02-0.8%): cysts gener- tude; group B (n°=15) the patients were treated with same technique ally arise in the lumbar metameres, especially at L4-L5, L5-S1, ed L3- S5

L4. They are endowed with a synovial capsule, filled up with xan- Introduction: Purpose of this study is to evaluate retrospectively tocromic liquid, rich in water and hyaluronic acid, and characterized by 153 cases of spinal infections, unrelated to previous spinal surgical a diameter variable between few millimetres and 2-3 cm. Synovial treatment. We included patients with drug addiction. Objective of cysts may protrude into the spinal canal (epidural) being anterior or this study is to analyze the results of treatment using a diagnostic posterior, or outside to the paraspinal muscles (extracanalar); moreover and therapeutic algorithm. This procedure may allow a systematic they can be single, bilateral or multiple; contiguous or not. Lumbar and comprehensive approach to the diagnosis and management of synovial cysts are occasionally detected during MRI or CT scans car- vertebral osteomyelitis. For instance, despite advances in imaging, ried out on elderly patients affected by degenerative spondiloarthrosis, this pathology is easily missed and treatment is often delayed. still without being responsible for their symptomatology. Only in rela- Materials and Methods: We reviewed 112 patients aged 15-83 tively few cases synovial cysts grow up enough to compress a nerve (average 55y) treated between January 1997 and March 2005. All root, causing the axial or radicular symptoms experienced by patients. patients received plain radiographs, gadolinium enhanced magnetic From 2000 to today, 12 cases of lumbar synovial cysts (7 women, 5 resonance imaging, Ga-67 and Tc-99 scintigraphy. A total of 53 men; age between 58 and 76 years), complaining about sciatica, non- patients underwent CT- guided fine-needle aspiration biopsy: the responding to analgesic or rest, have been admitted to the Chair of coltures of spinal specimen were positive in 57% of cases. Neurosurgery at the University of Cagliari. At clinical examination 2 Results: Mycobacterium Tubercolosis was the main organism fol- patients presented a remarkable deficit of foot dorsiflexion, and 1 com- lowed by Staphylococcus Aureus and Staphylococcus Epidermidis. plained about cauda equina syndrome. Cysts localization was L4-L5 All patients received intravenous antibiotics. Neurologic impairment (9), L3-L4 (2) e L5-S1 (1); during surgery we found abundant calcifi- was present in 36 patients who underwent surgery. All patients with cations on their capsules, and in 2 cases cysts were multiple and con- paresis recovered completely after surgical decompression (100%). tiguous. Every patient underwent surgery cyst excision, always per- Patients with non-surgical spondylodiscitis were treated with bed formed paying particular attention to carefully spare the facet. No peri- rest and bracing. operative complications have occurred, and every patient immediately Conclusions: The outcome of patients with vertebral osteomyelitis recovered, experiencing complete regression of pain. We have never in general is favourable when appropriate treatment is picked even if noticed a relapse of symptomatology nor postoperative spine instabili- vertebral osteomyelitis is a rare condition and therefore often ini- ty. Therefore we advocate surgical treatment as the management of tially overlooked. Delay in diagnosis may results in spine impair- choice for symptomatic lumbar synovial cysts. ment, longer hospitalisation time and higher cost. We suggest diag- nostic and therapeutic criteria in order to simplify the treatment. LUMBAR STENOSIS: WHICH KIND OF TREATMENT? M. Cassini [1], D. Pasquetto [2], M. Marino [2], S. Giaretta [2],P. BRYAN CERVICAL DISC PROSTHESYS: PECULIAR FEATURES Bartolozzi [2] R. Greco [1], M. Brunori [1], L. Innocenzi [2], A.M. Vitale [1] [1]Azienda ULSS 21, UOC Ortopedia e Traumatologia, Ospedale [1]Servizio di Neurochirurgia, Dipartimento di Emergenza, Aurelia Mater Salutis, Legnago; [2]Clinica Ortopedica e Traumatologica, Hospital,Rome, Italy; [2]Radiologia, Clinica Villa Sandra, Rome, Università degli Studi di Verona, Verona, Italy Italy

Background: In patients affected by lumbar spinal stenosis surgery The Bryan cervical disc prosthesys is characterised by peculiar tech- is indicated after conservative treatment failure. On the contrary nical features allowing high functional integration in clinical appli- indication for fusion is not well estabilished. cation. The first clinical trial with Bryan prosthesis started in 2000 Methods: From January 1992 to June 2005 174 patients (average by Goffin, Logroscino, et al. We implanted a total of 36 devices in age 68) (73 F, 101 M) with lumbar degenerative stenosis surgically 35 patients throughout a 4 years period, starting on February 2002. treated were studied. All patients were decompressed using Roy- Pre and post operative evaluation was based on Morphodynamic X- Camille technique, whereas 57 patients underwent decompression Rays, MRI, CT, and Dynamic Fluoroscopy. Clinical outcome was and posterior stabilization. Average follow up was 5.1 years (range favourable in all cases. The implanted cervical column always 10 months - 13.5 years). showed a high grade of conformity with both segmental and global Results: The outcomes, evaluated according to Lassale evaluation dynamic function. Correction of alignment and postural defects was scale, were satisfactory in 74.3%, with an average Oswestry also obtained. No structural problems or pull out were seen. The Disability Index (ODI) of 15.02 in decompressed group while implantation kinetic function throughout time was demostrated in improved to 79.8% with an average ODI of 14.1 in the almost all cases. Using a suitable functional cervical disc prosthesis stabilized–decompressed group. instaed of an interbody fusion can avoid a junctional satellite stress Discussion: Patients treated with decompression–stabilization pro- and a consequent secondary discopathy. The byomechanical and cedure had better results related to the decompressed group, but we structural design of Bryan prosthesys has shown its suitability to have to consider the shorter follow-up of the stabilized group and define a real artificial cervical disc. The main peculiar features are: potential long term complications of fusion (i.e.: adjacent segment - A plyurethane nuclear structure (deformability) symmetrically degeneration). Moreover, this additional surgery adds significant organised on an equatorial line and immersed in a fluid room potential morbidity and device-related problems (breakage, neuro- closed by elastic mode. logic damage etc.). - The coincidence between the prosthesys instantaneous rotation Conclusions: Choice of treatment has to be well evaluated. The centers and the physyological ones. instrumented stabilization should be reserved to well selected - The shock absorbing features. patients with degenerative spondylolisthesis and spine deformities We are convinced that these three factors are the basis of the such as scoliosis or kyphosis or evident segmental instability. obtained results concerning the maintainence of appropriate byome- canics in the implanted cervical column. VERTEBRAL OSTEOMYELITIS: DIAGNOSTIC AND THERA- PEUTIC ALGORITHM WHAT HAPPENS TO DISCS BELOW THE ARTHRODESIS A. Gasbarrini, S. Bandiera, L. Mirabile, M. Cappuccio, S. Terzi, G. ZONE AFTER SURGERY FOR SCOLIOSIS Barbanti Bròdano, L. Boriani, S. Boriani J. Gennari [1], A. Di Felice [2], M. Bergoin [1] U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale [1]Servizio di Chirurgia Infantile, CHU Nord, Marseille, France; Maggiore “C.A. Pizzardi”, Bologna, Italy [2]Casa di Cura Spatocco, Chieti, Italy S6

There are two types of degeneration below the arthrodesis area MINIMALLY INVASIVE PERCUTANEOUS OSTEOSYNTHE- after surgery for scoliosis. First, the degeneration occurs on the SIS IN THE TREATMENT OF ADULT AND OLD PATIENT frontal plane and is due to errors in strategy. Later on, the degen- SPINE FRACTURES eration occurs on the sagittal plane because of a hyper-lordosis G. Barbanti Brodano, A. Gasbarrini, F. De Iure, L. Mirabile, L. caused by stabilisation on L4 or L5. The KING or LENKE classi- Boriani, M. Palmisani, S. Bandiera, G.B. Scimeca, S. Boriani fications are either incomplete or over complicated and do not take UO Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale into account the position of the pelvis. We suggest a different clas- Maggiore “C.A. Pizzardi, Bologna, Italy sification of the curves. We point out the strategic defects of the instrumentation and the consequences they cause in the long term. Old patients with both traumatic and osteoporotic vertebral fractures The assessment of the stable vertebra is essential in the treatment are often compelled to lie in bed for a long time. This condition is of the thoracic curve. For thoracic-lumbar curves we have already often associated with a wide range of serious complications, better demonstrated that the frontal approach is preferable since it known as “bed rest syndrome”. In order to face this problem and let respects the posterior musculature and limits the arthrodesis. In patients walk as soon as possible after trauma, clinicians are looking predominant thoracic double curves, in distal stabilization we have for less invasive and debilitating spine osteosinthesis surgical proce- to distinguish the excluded pelvis that stops at L3 from the includ- dures. Vertebroplasty and kiphoplasty have partially solved the prob- ed pelvis that goes up to L4. In the predominant lumbars the inter- lem related to Magerl A1 fractures, while the debate is still open vention strategy is identical to that of the isolated lumbars. The about A2 and less serious A3 fractures treatment. Is it better to per- same strategy used for predominant thoracic curves has to be used form a classical vertebral osteosinthesis or decide for a prolonged for double thoracic curves. In disc degenerations without initial conservative treatment, either with orthopaedic corset or a cast? A strategic errors, the disc prosthesis could be a solution for the possible answer to this question is a third option, the mini-invasive future, especially when there are no more than two degenerated technique. It consists of pedicles percuteous fixation associated with discs below the arthrodesis. We hope to obtain agreement for a vertebral body reconstruction through verteboplasty or kiphoplasty. simple classification. From January to December 2005 we treated 11 patients affected by Magerl A2 and A3 vertebral fractures in the thoraco-lumbar spine. Percutaneous pedicles fixations with associated vertebroplasties have been performed. Seven patients were females and 4 were SESSION O04 males. Mean age was 57.2 years. Procedure has been always per- formed under radiological control. Patients have been assessed with self evaluating tests. They showed an improved clinical setting in the NEW METHODOLOGIES IN VERTEBRAL SURGERY immediate post-operative period, statistically significant about main parameters (mean VAS 89->31; SF-36: 1. General Health 38->60; 2.Pain 19->64 [p=0.0005]; 3. Mental Health 46->74; 4. Social MINI-INVASIVE SURGERY FOR THE TREATMENT OF THE Activities 44->59; 5. Sensitivities 29->51; 6. functional limitations DISCOVERTEBRAL LUMBAR INSTABILITY 20->66 [p=0.0008]; 7. physical health 33->67 [p=0.0008]; 8. vitali- M. Abbate, F. Lagalla, A. Bistolfi, M. Damilano, M. Dolfin, E. ty 41->64). During a mean follow up of 5.8 months, results have Raspino, E. Novarese remained the same and no complications happened. These prelimi- II Clinica Ortopedica, Università di Torino, Italy nary data show how a mininvasive approach in A2-A3 vertebral frac- tures osteosinthesis could have a possible good effect in the old Introduction: A new mini-invasive technique is described and com- patient care. pared to the traditional surgery of intersomatic arthrodesis (PLIF) for the treatment of the vertebral lumbar disk instability. A less inva- sive approach can offer advantages in blood loss, tissue damaging, COMPARISON BETWEEN VIDEO-ENDOSCOPIC AND pain, time of surgery, hospitalization. Economic aspects concerning MICROSCOPIC TREATMENT OF DISC HERNIATION the effectiveness of this technique have been analysed. A. Gasbarrini [1], A. Barbanera [2], L. Mirabile [1], F. Ascanio [2],M. Materials and Methods: 6 patients affected by lumbar partitioned Cappuccio [1], L. Boriani [1], A. Andreoli [2], M. Palmisani [1],S. instability have been treated by this mini-invasive technique. Boriani [1] Before surgery, all patients had a six months period of conservative [1]U.O. Ortopedia e Traumatologia, Chirurgia Del Rachide, therapy and traditional pharmacological treatment, which did not Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy; [2]Dipartimen- yield adequate healing of the lumbar and sciatica symptoms. The to di Neurochirurgia, Ospedale Maggiore “C.A. Pizzardi”, Bologna, mini-invasive surgical technique has been realized by means of Italy Patchfinder (Abbott) instruments for the synthesis tools (piped polyaxial peduncled screws) and using Optimesh instruments and Two departments at Bologna Ospedale Maggiore are involved in sur- bone from a tissues bank in order to achieve inter-somatic gical treatment of disc herniation. They are the Orthopaedic, arthrodesis. Traumatology and Spine Surgery Department and the Neurosurgery Results: In all patients the osseous fusion wasachieved. The average Department. These two groups of surgeons use two different tech- surgical time was similar to that of the traditional technique, while niques in order to treat the disease. The first group uses video-endo- the hospital-stay was shorter. The social-working retrieval was facil- scopic instrumentation, the second one uses optic microscopy. Two itated. The surgical bleeding has been clearly reduced, thus avoiding groups of patients have been compared. Patients belonging to each blood transfusions. The post-operation pain has also been signifi- group have been treated by the same surgeon (an orthopaedist for the cantly reduced. The use of morcelized bone did not cause pain at the first group and a neurosurgeon for the second one) and the same donor site. technique (respectively videodiscoscopy and microsurgical discecto- Discussion: This treatment allows a good recovery from the pain, my) was used. Results have been analyzed. Criteria for patients with satisfaction of the patients and quick return to their working inclusion in the study were: -lumbar disc herniation localized activities. The technique is quite safe and easy. Nevertheless, the between L2 and S1; -patient either unsuccesfully treated by drugs analysis of the economic costs raises relevant doubts. The treatment and different kind of physiotherapy or arrived at our institute during is expensive and could be difficultly accepted in a public health acute phase of the disease; -neurological deficits that needed imme- framework such as the Italian one. diate surgery. Patients with spine degenerative diseases, L1-L2 disc S7

herniation, extra foraminal disc herniation, recurrencies or patients years (range 54 – 71 years) affected by degenerative disease. The who had already been surgically treated in other hospitals for this follow-up achieved 18 months. Clinical assessment, using modified disease were excluded from the series. Every patient was assessed Harris Hip score, and radiographic evaluation showed excellent through a precise neurological evaluation, CT scan and MRI. We results without any sign of early aseptic loosening. In spite of excel- considered type of herniation (soft, hard, foraminal, stenosis pro- lent results, there is not enough information concerning in vivo ducing), type of surgery (asportation, discectomy and asportation, behaviour of the implant at long term. foraminotomy associated, hemi-laminectomy associated), intraoper- ative troubles (excessive bleeding, anatomic alterations such as dou- ble roots, dural tears). Recovery time and days spent in the hospital TOTAL HIP ARTHROPLASTY TO TREAT ACETABULAR AND for every patient were assessed, together with a precise and adequate PROXIMAL FEMUR FRACTURE SEQUELAE neurological evaluation at hospital discharge. We have followed up M. Girolami, G. Trisolino, C. Impallomeni F. Trentani, D. Dallari, all patients; at 6 months the following parameters were analyzed: C. Stagni VAS, job and sport activity reprise, possible recurrencies. Istituti Ortopedici Rizzoli, Bologna, Italy

Background: Late sequelae and complications of acetabular and proximal femur fracture often pose the problem of choosing the SESSION O05 appropriate treatment strategy. Total hip arthroplasty may be the treatment of choice in selected patients. Materials and Methods: over a five-year period we assessed retro- PROSTHESIS I spectively 21 patients who presented with sequelae of acetabular or proximal femur fracture. Nine patients were men and 12 were women, and their mean age was 46.9 years (range, 16-98). Eleven UTILIZATION OF BIG DIAMETER PROSTHETIC HEADS patients had malunion or traumatic arthritis of the acetabulum, and N. Pace 10 patients had proximal femur nonunion. Dipartimento di Ortopedia, Jesi, Ancona, Italy Results: All the patients underwent total hip arthroplasty. The pros- thesis was uncemented in 20 cases and cemented in one case. One Heads of big diameter (>/= 38mm) and metal-on-metal coupling are patient was treated bilaterally due to malunion of an acetabular frac- one of the last acquisitions in hip replacement. Nothing really new ture on the left side and nonunion of the proximal femur on the right because the history of these implants started in the Sixties; yet, their side. The mean follow-up was 27.3 months (range, 10-45). Early use has been gradually abandoned in favor of smaller diameters and loosening of the acetabular component was observed in one case metal-on-poly coupling. Improvements in casting and manufactur- (4.8%). The mean Merle-d’Aubignè score was 16 (range, 13-18) at ing of metal-on-metal coupling devices dramatically improved the the last follow-up. tribological characteristics of these articulating interfaces. Normally Conclusions: we believe that total hip arthroplasty can be the surgi- these implants named BDH (big diameter heads) are used as resur- cal treatment of choice disabling sequelae of acetabular and proxi- facing implants or coupled with a standard femoral stem. Shared fea- mal femur fracture. tures of the sudden implants are: increase of ROM values in com- parison with smaller heads – strong decreasing of instability and luxation due to the removal of impingement neck/acetabular rim – THE UNCEMENTED “VERSYS ET” STEM: 5 TO 10 YEARS strong reduction of articulating and rim wear debris. Authors quote RESULTS their clinical experience using different prosthesis, listing every val- F. D’Angelo, M. Giudici, G. Zatti, P. Cherubino ues and defects they observed during their daily utilization for 4 Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, years. Varese, Italy

Objective: Aim of this retrospective study was to evaluate the medi- THE GREAT DIAMETER OF THE FEMORAL HEAD IN TOTAL um term results of the cementless stem “Versys ET” (Zimmer, HIP REPLACEMENT: SHORT TERM FOLLOW-UP Warsaw, Indiana, USA) used in the Department of Orthopaedics and L. Costarella, V. Pavone, M. Privitera, F.R. Evola, G. Sessa Traumatology “M. Boni”. Dipartimento di Specialità Medico-Chirurgiche, Istituto di Clinica Materials and Methods: From 1995 to 2000, 225 Versys ET stems Ortopedica, Catania, Italy were implanted in 206 patients (19 patients had bilateral arthroplasty at different times).This stem is made of titanium alloy (Ti-6Al-4V). The evolution of total hip replacement is the result of design All patients were evaluated clinically and radiographically by the improvement, new biomaterial availability and surgical technique Harris Hip Score. development. In order to restore the correct biomechanics of the hip Results: Postoperative Harris Hip Score incremented from 54 to 97 and to pursue the best rotational center, the femoral head diameter points (p<0.05). The stem presented a varus alignment between 5° plays an important role. Nowadays the most used sizes are: 22, 26, and 10° in 17 cases without any clinical relevance (HHS 96.8). We 28, 32, and 36 millimeters. The advantages of using large femoral recorded 7 cases of dislocation, 2 of them were in the immediate head consist of increased range of motion, decreased incidence of postoperative period, thus making a stem change necessary, 1 case dislocation and impingement of the femoral neck on acetabular com- presented septic loosening 7 years after surgery and it was treated ponent, reduction of mechanical stresses on the bone prosthesis with a 2 times reprise. Among all the stems, only one had been interface. Disadvantages include increased volumetric wear of the revised for aseptic loosening. 8 acetabular components had been conventional polyethylene, necessity to use polyethylene of low revised because of aseptic loosening or polyethylene wear. thickness and consequently less mechanically resistant, enlarged Discussion: The trapezoidal cross-section of this stem together with friction stresses. There is no still evidence of wear phenomena on the the longitudinal fins assure an optimal primary stability in the prox- reticulated polyethylene associated with large femoral head. At the imal metaphiseal region without the filling of the distal region. Orthopaedic Clinic, university of Catania, between October 2004 Therefore, we have not observed signs of “stress-shielding” and and February 2006, 34 total hip replacement were performed utiliz- thigh pain, which are typical features of full-fit stems as the anatom- ing great femoral head (36 mm) in patients with mean age of 61 ical one. S8

The stem stability was radiographically evaluated according to Introduction: The authors reported a preliminary study of a new Engh’s criteria; in all cases the bone ingrowth into this titanium alloy cementless stem (Symax, Stryker-Howmedica). It joins a proximal was confirmed. anatomical geometry with the characteristics of a straight stem. Conclusion: The results of Versys ET stem at 7.5 years follow-up Materials and Methods: From October 2004 to May 2005 in our are similar to those obtained with other straight stem, as CLS or institute forty patients underwent hip replacement with a cement- Zweymüller ones. less stem (Symax; Stryker Howmedica). There were 24 male and 16 female with a mean age of 61 years. The diagnosis was of pri- mary osteoarthritis in 34 cases, of R.A. in two cases and of neck BIOSURF: A NEW TRIBOLOGICAL CONCEPT FOR BEARING femoral fracture in 4 cases. In 30 cases we performed a hip SURFACES IN HIP REPLACEMENTS replacement using a lateral standard approach (> 12 cm), in 8 cases L. Lucente, W. Thomas, L. Tafuro using a minimally invasive anterior approach and in 2 cases using Clinica Quisisana, Rome, Italy a minimally invasive antero-lateral approach. In all cases we used a cementless cup (Trident; Stryker Howmedica) and a cementless The improvement of bearing surfaces in hip replacement is considered stem (Symax; Stryker Howmedica). The following parameters one of the most important challenges and in Literature many studies were evaluated: intra and post operative complications, total blood were performed. Wear and debris depend on prosthesis design and loss (calculated according to Rosencher method), time of surgery, material characteristics. Many studies have demonstrated that Me-Me component placement, length of hospital stay and functional out- couples produce a lower quantity of debris. Bearing surface debris comes at three months (HHS, WOMAC). depends on articular lubrication. To improve design and lubrification, Results: No dislocations, infections and early aseptic loosening we have studied natural models (cornea, cartilage) and we have devel- were detected in the two groups. Two proximal femoral fractures oped a new bionic concept that is characterized by a partial texturing (crack) were detected in the MIS approaches. of the metal head (golf ball type). Biomechanical studies have demon- Conclusions: Total hip replacement with a Symax stem may be strated a decrease of 30% of wear with this type of metal heads of performed using a lateral standard approach (> 12 cm) even in great dimension (“Biosurf”) in hip replacement surgery. patients with BMI >30. We detected greater intra operative prob- lems with a minimally invasive anterior approach in canal prepara- tion because of stem size. CEMENTLESS CONE STEM AND METAL-ON-METAL ARTIC- ULATING SURFACE FOR THE TREATMENT OF ARTHRITIS FOLLOWING CONGENITAL HIP DISEASE: RESULTS AT 10 YEARS SESSION O06 R. Binazzi, A. Bondi, E. Zamagni, A. Manca, R. Halvadzhiyan Istituto Ortopedico Rizzoli, Bologna, Italy FOOT In recent years cementless cone tapered stems have had a large suc- cess in Hip revision surgery, literally revolutioning the prognosis of many cases of dramatical bone stock loss. Nevertheless, little experi- COMPLEX TALUS FRACTURES: VARIABLES INFLUENCING ence exists in the Literature about their use in primary arthroplasties. CLINICAL EVOLUTION The Cone Stem was designed in the 80’s by Prof. Wagner. The stem is W. Daghino [1], C. Errichiello [2], D. Testa [3], A. Biasibetti [1],A. made of a rough blasted Titanium Alloy with a cone angle of 5° and 8 Massè [4] sharp longitudinal “ribs” that cut into the inner cortex, providing [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, excellent rotational stability: The ribs depth of penetration ranges Ospedale CTO, Turin, Italy; [2]UOS Chirurgia del Piede, Ospedale between 0.1 and 0.5 mm and is also very important to achieve osteo- CTO, Turin, Italy; [3]Università degli Studi, Bari, italy; [4]I Clinica integration. The CCD angle is 135°. The stem is straight and can be Ortopedica dell’Università, Ospedale CTO, Turin, Italy implanted indifferently in any degree of ante- or retro-version thus being indicated in dysplastic arthritis where we need to correct antev- 28 cases of complex high energy talus fractures, corresponding to ersion. Between 1993 and 1998 the Senior Author (RB) has implant- class III and class IV according to Marti Weber classification, were ed 92 consecutive cone stems in 88 patients with dysplastic arthritis. evaluated. The following variables were considered: type of trau- The acetabular component was always cementless and in Titanium. ma, type of surgery, type of reduction and type of osteosyntesis. As The articulating surface was mostly Metal-on-Metal. The average fol- complications, rupture of the tendon of the flexor longus allux, low-up was 10.1 years. According to the Hartofilakidis classification sural nerve lesion and deltoideus ligament lesion were occasional- we had 63 patients of type A, 18 of type B and 11 of type C. Clinically ly reported. Pull or compression lesion of the posterior vasal-nerve we had 89% of satisfactory results with no cases of anterior thigh pain. bunldle was observed in 10% of cases. Early skin complications, No patient required revision of the stem, while we revised a cup in like suffering of the surgical wound and infections, were frequent. Group C. Radiographically, 17% of patients showed some resorption Malunion prevalence seems to be relatively high and significantly in femoral zone 1 and 7. In 12 cases it was a narrow fissure due to the correlatable with type of osteosyntesis. Malunion was observed oscillations of proximal stem under load. This lesion was never pro- once among 15 cases treated with osteosyntesis in compression, gressive. In the same zones we observed 4 cases of real osteolysis. No while 6 on 13 cases among patients operated with Kirschner wires radiolucent line was observed in other femoral zones. In the acetabu- or external fixation. No significant correlation was found between lar side we had 13 cases (14%) of radiolucency. Cone stem gave excel- the type of osteosyntesis and osteonecrosis, which seems to be lent clinico-radiographical results in dysplastic arthritis. influenced not only by the lesion entity but also by time elapsing between trauma and reduction: necrosis was observed in 4 among 17 cases operated within 12 hours and in 5 among 11 cases treated SYMAX STEM: TECHNICAL NOTES AND PRELIMINARY beyond 12 hours. Non-correspondence between appearance of RESULTS osteonecrosis and need of subsequent surgical repair has to be A. Speranza, A. Ingallina, M. Ciurluini, C. D’Arrigo, A. Ferretti underlined: only 2 out of 9 cases of osteonecrosis needed a talar Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy arthrodesis. S9

MININVASIVE SURGICAL TREATMENT OF THE TALARS sidered good, but the importance of defining borders between con- FRACTURES: RESULTS AND OUTCOMES servative and surgical treatment, and between ORIF and local arth- A. Cassaro, A. Raitano, L. Licata odesis, are pointed out. Unità Operativa Complessa di Ortopedia e Traumatologia, Gela, Italy COMPLEX FRACTURES OF THE CALCANEUM: DIAGNOS- The Authors emphasize the relative increase of Talar fractures in the TIC – THERAPEUTIC ALGORITHM road traumatology, and in particular in motorcycle, and traumatol- W. Daghino [1], E. Balboni [2], M. Vigna Suria [2], R. Sisto [1],A. ogy recall their experience, matured from 2003 to the 2006, regard- Massè [4] ing one of the mininvasive treatments of decomposed fractures of [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, astragalo, by means of osteosynthesis with canulate screws oppor- Ospedale CTO, Turin, Italy; [2]Università di Torino; Turin, Italy; [4]I tunely applied. The materials introduced are: 16 fractures of talar Clinica Ortopedica dell’università, Ospedale CTO, Turin, Italy sluices, from 2003 to 2006, to the I and II group of the Hawkins’s classification. The turn out parameters were: a) the subjective result; The treatment of complex fractures of the calcaneum is a contentious b) mobility; c) the radiographic data; d) examination TC. From the argument and it often represents a real challenge, for the frequent analysis of the results, the validity of the mininvasive surgical treat- early and late complications, some of which serious, that can ment is confirmed in recent fractures of talar sluices as long as the increase healing time and compromise clinical outcomes. The limits sets up by those anatomo-pathological situations such as authors introduce a diagnostic and therapeutic protocol, created con- decomposition and excessive diastasi of fragments (some of the type sidering the most recent results in literature, aiming to orienting II and all those of type III of Hawkins’s classification) are not either the surgical indication or the type of specific surgical treat- exceeded. Moreover, according to the Authors, good results were ment. This protocol has been proved in a perspective way and is obtained thanks to the program of “progressive-gradual” premature based on a case history of 35 fractures consecutively treated from mobilization of the tibiotarsica, according to a precise outline. November 2002 to December 2005: the preliminary results of this decisional approach will be presented and some specific cases will be discussed. FRACTURE AND DISLOCATION OF LISFRANC JOINT: CASE REPORT AND LITERATURE REVIEW J.M. Taglioretti, G. Mantovani DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURE: CTO-ICP, Clinica Ortopedica, Milan, Italy RESULTS OF OPEN REDUCTION AND INTERNAL FIXATION A. Basile, M. Stopponi, A.U. Minniti de Simeonibus Dislocation and fracture – dislocation of the Lisfranc joint are not II Divisione di Ortopedia e Traumatologia, Azienda Ospedaliera common and occur at the rate of 1/55000 per year. There seems to be San Giovanni-Addolorata, Rome, Italy a direct correlation between achieving a prompt and accurate diag- nosis and an anatomic reduction and satisfactory clinical results. The Historically, displaced intra-articular calcaneal fractures (DIACFs) authors describe a case of Lisfranc fracture - dislocation type A lat- were treated non-operatively, as predictable operative reduction and eral of the Quènu and Kuss classification, and concomitant bifocal fixation were not possible. Operative treatment has become more fracture of the II metatarsus, head fracture of the II-III-IV metatar- accepted in the last ten to fifteeen years as a result of improvements sus, and cuboid fracture due to high energy trauma. The treatment in preoperative evaluations, use of intraoperative imaging to verify chosen was closed reduction, fixation by percutaneus K-wires, the quality of reduction, and advancements in surgical techniques. immobilisation in a plaster cast. RX and clinical check at 2 -4 -6 – Although more and more evidences are suggesting that operative 10 weeks and at 2 months, clinical and RX and RNM at 20 months. treatment results in better outcomes, reviews on this subject have The outcome was very satisfactory. The patient had no complaints, failed to demonstrate indisputably superior results of a single no evident degenerative changes at RX or RNM, not desultory pain approach to the treatment of DIACFs. Two meta-analysis published in the cuboid site. The authors believe that a non invasive treatment in 2000 and 2005 show that there is no level-I study evidence that can achieve a better and durable result and can avoid very serious enable the surgeon to decide upon optimal treatment for a DIACF. complaints reported after open surgery. They agree with most Both patients and social characteristics including gender, age, level authors that it is always imperative to reach an anatomic reduction. of physical activity and Workers’ Compensation seem to be very important in influencing the outcome. Buckley et al., in a large prospective, randomized, controlled multicenter trial after careful OUR EXPERIENCE IN MIDDLE FOOT TRAUMAS: CHOPART, stratification of the patient population, demonstrated that women, LISFRANC, NAVICULAR BONE patients that were not receiving Workers’ Compensation, younger P.C. Prina, M. Franceschini, F. Moioli, P. Romano, R. Franceschini males, patients with a higher Bohler angle, patients with a lighter Ospedale L. Sacco, Azienda Ospedaliera, Polo Universitario, Milan, workload, and those with a single, simple displaced intra-articular Italy fracture have better outcomes after operative treatment than after nonoperative treatment. Anatomic or near anatomic reductions Major series in literature report a low rate of middle foot traumas. enhance outcome while comminution and/or poor reductions pro- Particularly, the Lisfranc joint is involved only in 1% of all fractures duce long term outcomes that are less satisfactory. Arthrodesis rates and joint lesions of Lisfranc and Chopart are less frequent but more are significantly reduced with operative treatment. Patients who ben- serious, causing more severe consequences. Isolated or associated efit of nonoperative treatment are those who are fifty years old or navicular bone lesions are from 0.008% to 0.2% of all fractures and more, those who are receiving Workers’ Compensation and patients from 4.5% to 6% of all foot lesions. Our presentation is about ten with highly comminuted articular fractures. Up to now, evidence in complex cases of middle foot fractures, treated in most cases with the literature supports the recommendation to avoid surgery in all open reduction and internal fixation on emergency bases, percuta- patients over the age of fifty years because of the expectation of poor neous fixation, and in one case with associated external fixation. outcomes, however, recently an investigation performed by Classification of Chopart, Lisfranc, and tarsal navicular bone are Herscovici et al. challenged this statement sustaining that open then enumerated along with diagnostic means, treatment, complica- reduction and internal fixation appears to be an acceptable method tions and results at two years follow up. Global results are to be con- of treatment for DIACFs even in a careful selected population of S10

elderly patients. Our results are in line with the ones presented by LONG ARM METATARSAL OSTEOTOMY IN TREATMENT OF the study of Herscovici and Sanders. We strongly reccomend ORIF MODERATE TO SEVERE HALLUX VALGUS of DIACFs in a selected patient population in order to minimize late T.L. Giorgini [1], M. Calderaro [2] complications. [1]Casa di Cura Quisisana, Rome, Italy; [2]Ospedale San Pietro “Fatebenefratelli”, Rome, Italy

THE MITCHELL OSTEOTOMY WITH BOSH STABILIZATION A distal metatarsal oseotomy is classically used in the treatment of AND DISTAL SOFT TISSUE RECONSTRUCTION: LONG- moderate to severe hallux valgus. The long-dorsal arm osteotomy is TERM FOLLOW-UP a modification of the Austin or Chevron osteotomy, by decreasing C. Pasquali, L. Burroni, S. Moalli the osteotomy angle by 5 degrees. This modification allows greater Ospedale di Circolo e Fondazione Macchi Presidio del Verbano, osteotomy stability, increased cancellous bone-to-bone contact, and Luino, Italy the possibility for two screw osteosynthesis. This technique repre- sents a valid alternative to other osteotomies because of its ability to Between October 1999 and October 2002, 284 patients were treat- correct large degrees of deformity. By using cortical screw fixation, ed for hallux valgus with Mitchell Osteotomy and among them 81 this procedure can be used in both elder and young patients. This were available for further clinical and radiological evaluation surgical treatment does not destroy the first metatarsophalangeal (40%). The surgical procedure consisted of a modified Mitchell joint as in the Keller or Regnaud procedures. The long-dorsal arm Osteotomy in which fixation was achieved with a Kirschner wire osteotomy also allows minor metatarsal dissection as compared to followed by a distal soft tissue reconstruction. Seventy-six patients the Scarf procedure, while allowing major correction without the were included in the study, mean age at the time of surgery was 62 complication of “troughing”, as described in the literature. Stability years (range 25-80 years). Twenty-one patients were operated bilat- of this osteotomy design with increased cortical contact and 2-screw erally for a total of 97 feet examined. The first metatarsophalangeal osteosynthesis permits immediate post-operative weight-bearing and angle was measured on standing dorso plantar view radiograph decreased post-operative pain. Often, but not always utilized is dor- before surgey and the patients were divided according to their first sal transfer of the adductor hallucis tendon into the medial capsule. MTP angle: group I range 0-20° (6%), II group range 20-40° (52%), This allows better positioning of the sesamoids underneath the first III group over 40° (42%). In order to achieve a clinical assessment metatarsal head, greater cosmetic correction and stabilization of the the American Orthopaedic Foot and Ankle Score (AOFAS) was metatrsophalangeal capsular complex. The authors present a series adopted, based on a 100 points evaluation system. At an average of 80 surgeries in 63 patients utilizing this surgical technique. follow-up of 4 and a half year (range 3-6 years) the AOFAS score averaged 92 points ranging from 10 to 100; 87 patients had satis- factory results with an AOFAS score over 75/100 (90%). In group I the average AOFAS score was 83, in group II it was 95 and in group SESSION O07 III 88. At follow up every patient repeated the standing dorso plan- tar view radiograph. The radiographic evaluation was performed by calculating the difference among the first MTP angle before the PEDIATRICS operation and at follow up with the following results: in group I the average variation was 9°, in group II 23° and in group III 28°. Long term clinical results were very satisfactory in all three groups of ROLE OF VDRO IN CP IN CHILDREN hallux valgus, radiological results were better in moderate hallux A. Andreacchio, S. Désayeux, M. Chiavola, G. Ingrosso valgus, in fact, a higher percentage of loss of correction was most- Reparto di Ortopedia Pediatrica, Ospedale Infantile Regina ly shown in severe cases. Margherita, Turin, Italy

The dislocation of the hip in children with Cerebral Palsy occurs fre- OPENING ADDITIONAL BASE WEDGE OSTEOTOMY IN quently. The dislocated hip becomes painful in 50 to 70 % of TREATMENT OF HALLUX VALGUS patients, but determining the severity of pain may be difficult in the M. Calderaro [1], S. Ghera [1], T.L. Giorgini [2] non-communicating severe quadriplegic individual. The problem of [1]Ospedale “San Pietro” Fatebenefratelli, Rome, Italy; [2]Casa di the patient with dislocation of the hip includes also the gait, nursing Cura Quisisana, Rome, Italy care, sitting position and perineal care. The best treatment of spastic hip dislocation is prevention. These patients need close follow-up in Severe hallux valgus, with an intermetatarsal angle greater than 18 order to detect early any subluxation of their hips. degrees associated with ligamentous laxity and subtalar joint prona- The Authors review their 17 patients who had 19 varus, derotational tion, is a delicate pathology requiring surgical treatment with suffi- osteotomies. cient correction and low risk of complications and recurrence. It is often necessary to perform a more proximal correction of the first metatarsal base osteotomy, or in selective cases, a corrective COMBINED KIDNER-COBB PROCEDURE WITH SUBTALAR arthrodesis of the metatarsal-cuneiform joint, as described in the lit- ARTHRORESIS AND ACHILLE’S TENDON LENGTHENING erature. Osteosynthesis is indispensable in obtaining rapid healing IN TREATMENT OF JUVENILE FLAT FEET and avoiding secondary shifting of the osteotomy. The notable forces T.L. Giorgini [1], M. Calderaro [2], R.J. Giorgini [3], C. Japour [4] that occur with weight-bearing at the base of the first metarsal can [1]Casa di Cura Quisisana, Roma, Italy; [2]Ospedale “San Pietro” cause osteotomy fracture, therefore making it necessary for below- Fatebenefratelli, Rome, Italy; [3]North General Hospital, New York, the-knee casting and non-weightbearing for six weeks post-opera- USA; [4]Veteran’s Hospital, Danville (Illinois), USA tively. The authors present their experience of 10 cases treated with opening additional base wedge ostoetomy stabilized with the Bow The objective of this lecture is to report the functional and radi- plate by Daro. The technique of opening wedge osteotomy with plate ographic results of a series of patients surgically treated for sympto- application allows intra-operative correction of varying degrees, and matic flat foot. The surgery performed in 14 patients (20 feet) with earlier post-operative weight-bearing. The authors illustrate the sur- an average age of 12, and a follow-up of 7 years, consists of three gical technique and their encouraging preliminary results. contemporary procedures: percutaneous lengthening of the Achille S11

tendon, subtalar arthroresis with an absorbable screw, and Kidner- borns with risk factors. Data from the period 1992-2002 are also Cobb tenosospension. The last procedure comprises the navicular reported (clinical-ultrasound out-patient clinic dedicated to DDH). exostectomy described by Kidner, and the tenosospension of the tib- The diagnosis of DDH was made by the 8th week of age in 29% of ialis posterior tendon as described by Cobb. The combined surgical the cases in 1979, in 100% in 1989, in 72% in 1990 and in 74% dur- procedures optimize the surgical results by correcting the multiple ing the period 1992-2002. The analysis of the results has emphasized causes of this complex deformity. The modified Kidner-Cobb proce- the importance of the Ortolani Manoeuvre in the clinical screening dure is also valid in the treatment of stage 2 posterior tibial tendon of all newborns, the need of an ultrasound examination in newborns dysfunction in adults. In conclusion, this combined procedure is a with dubious or positive clinical signs and known DDH risk factors valid option in treatment of pediatric flat foot with good long-term (positive family history, breech position) and the need of a general results. ultrasound screening by the 6th week of age, even in patients with- out clinical signs and no DDH risk factor. EXPERIENCE IN THE TREATMENT OF CONGENITAL CLUB- FOOT ACCORDING TO PONSETI METHODOLOGY FRACTURES IN CHILDREN: REVIEW OF 10.070 CASES I. d’Addetta [1], D. Vittore [2], F.M. Matarazzo [3] (1995-2005) [1]U.O. Ortopedia e Traumatologia Pediatrica, Ospedale Pediatrico F. Canavese, P. Charles, A. Dimeglio Giovanni XIII, Bari, Italy; [2]Dipartimento di Metodologia Clinica e Service d’Orthopedie Pediatrique, Montpellier, France Tecnologie Medico Chirurgiche, U.O. Ortopedia e Traumatologia II, Università degli Studi di Bari; Italy; [3]U.O. Ortopedia e During a 10-year period 9.438 children were treated for fractures at Traumatologia Pediatrica, Ospedale Pediatrico Giovanni XIII, Bari, our Department. The medical records were assessed. All patients’ Italy radiographs and records were revised by a group of Pediatric Orthopaedic Surgeons before being included in the study. We Introduction: Congenital clubfoot is a serious and complex defor- reviewed 10.070 fractures, 6270 (62.2%) in boys and 3800 (37.8%) mity which occurs in approximately 100.000 children in the world in girls. Fall and summer are the seasons with the highest rate of with a rate of 1 of every 1000 babies. The exact causes of this defor- fractures (56.7%) and the peak incidence is observed during satur- mity, which develops while the baby is still forming in the uterus, days and sundays (32,1%). The mean age is 8.6 years (range: 1 day remain unknown, but it is believed heredity may be implied. Surely to 16 years). 4924 (48.9%) fractures are in the right side of the body enough, the social consequences are so heavy that they can deter- and 5146 (51.1%) the left. The mechanism of injury is frequently a mine disabling and serious psychological problems in the child and fall during sport activities. 7420 fractures are in the upper limb his/her family. In the 40’s, Dr Ignacio Ponseti was the first to under- (73.7%), 2602 (25.8%) in the lower limb and 45 (0.5%) in the spine. stand that a conservative therapy, based on precious treatments of 3811 (37.8%) fractures are in the forearm, 1362 (13.5%) in the the clubfeet by gentle manipulation and successive casts, taking humerus, 1483 (13.7%) in the hand and 806 (8%) in the clavicle. Leg advantage of the elasticity of the tissue forming the legaments joint fractures are 1161 (11.5%), foot fractures 920 (9.2%) and femoral capsulles and tendons, could give excellent results avoiding surgery. fractures 445 (4.4%). 52 cases (0.5%) are in the pelvis. In more serious cases, tenothomy of tightened Achilles tendon, may Displacement is in 4017 (39.9%) cases; articular involvement is in be adopted. 291 (2.9%) fractures; 270 are open fractures (2.7%). 4744 (47.1%) Materials and Methods: Treatment of the clubfoot should start as fractures are metaphyseal, 2804 (28.9%) are diaphyseal and 1219 soon as possible. Initially, gentle manipulations of the foot are done (12.1%) are epiphyseal and in this group 286 (23.5%) fractures are avoiding pronation, and the correction is held in a cast which is S.I, 758 (62.2%) S. II, 48 (3.9%) S.III, 32 (2.6) S.IV and 95 (7.8%) changed weekly. Six or seven castings are usually necessary to Ogden VII. 1585 (15.7%) fractures needed general anesthesia, 1707 achieve the goal and only in some cases a decision will be made (16.9%) Entonox® (N2O2) and 6768 (67.2%) did not need any anes- regarding further castings or surgery. Generally, after two months thetic at all. 2231 childrens (22.2%) were hospitalized and 7288 the foot is corrected and placed in a brace to hold the correction. (72.4%) casts were made. Fractures in children can be usually treat- Only for really serious cases subsequent surgery is necessary. ed at emergency department. Upper limb is frequently involved. Conclusions: Here the authors present 230 clubfeet Ponseti trated General anesthesia is rarely used (less than 1 fracture out of 5) and since 2001 confirming the validity of the treatment. Moreover, a vir- Entonox® (N2O2) is a good alternative. tual dynamic representation of the anathomy of the clubfoot is given to make the methodology clearer and easier to learn. COMPARTMENT SYNDROMES, VOLKMANN ISCHAEMIC CONTRACTURE AND VASCULAR INJURIES IN THE NEW- DIFFERENT APPROACHES IN SCREENING OF DEVELOP- BORN IN THE UPPER LIMB MENTAL DYSPLASIA OF THE HIP. A COMPARATIVE STUDY M. Abate, N. Della Rosa, A. Leti, A. Landi M. De Pellegrin, D. Moharamzadeh, D. Fracassetti, G. Fraschini Struttura Complessa di Chirurgia della Mano e Microchirurgia, Università Vita-Salute IRCCS San Raffaele, Unità Operativa di Modena, Italy Ortopedia e Traumatologia, Servizio di Ortopedia Infantile, Ospedale San Raffaele, Milan, Italy In 1881 R. Volkmann described a post-ischaemic palsy, due to sev- eral compressive pathologies, which is very similar to “rigor mor- Developmental dysplasia of the hip (DDH) has an incidence of tis” and leads to a strong muscolar shortening. In the adult the approximately 2% in Italy. Early diagnosis is known to have a deter- compartment pressure is 30 mmHg. Since in the newborn the com- minant influence on the treatment, duration and type and on its out- partment pressure, is not routinarely measured, it cannot be comes. The aim of this study based on our experience was to verify referred to a standard pressure gradient. However in the newborn what are the current possibilities of realising an early screening of the diastolic pressure is about 40 mmHg, so we can ipotize that any DDH and therefore to identify the most effective method and strate- raising of compartment pressure value could lead to a perfusional gy. Data obtained from 3 different periods were compared; in these defect in the muscles. Many causes, other than a sole increase of periods, 3 different types of screening were performed: 1979: clini- compartment pressure, could lead to a deficency in muscle blood cal screening in all newborns; 1989 ultrasound screening in all new- perfusion: vascular causes could cause a ischaemic injury “ab ini- borns; 1990: clinical screening and ultrasound screening in new- tio”. We observed that Compartment Syndromes and Neonatal S12

Ischaemia have many common features, so the distinction of these Results: The compliance of patients was optimal, the time of opera- pathologies in different nosological classifications seems artifi- tion was slightly longer than open reduction but the postreduction cious. We created an original classification scheme to include all care was significantly shorter. In all cases we obtained good X-ray these clinical-pathological conditions. It is fondamental to recog- and clinical results. nize as early as possible the risk factors linked to the mother or Conclusions: The arthroscopic-assisted management of intra-articu- fetus and the initial clinical features in order to be able to act med- lar knee fractures in adolescents is a valuable tool for the assessment ical and surgical approaches to limitate invalidant functional of fractures. It has the advantage of superior visualization of the injuries and take advantage of the natural plastic ability of entire joint and it is the treatment of choice for associated intra-artic- the newborn tissues. In this study, performed in the Hand and ular pathology. It allows achievement of anatomic reduction and Microsurgery Unit of Modena Policlinic, we focused on vascular rigid internal fixation with less morbidity than with open reduction. neonatal diseases and their causes and we created a practical algo- rithm to approach these pathologies from the prevention to the treatment. TREATMENT OF LOWER LIMB EPIPHYSEAL FRACTURES L. Marchesini Reggiani, M. Magnani, O. Donzelli 8° Divisione di Ortopedia e Traumatologia Pediatrica, Bologna, COMPARISON BETWEEN DIFFERENT SPLINTS IN THE Italy EARLY TREATMENT OF DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) The epiphyseal fracture represents almost 30% of fractures; they P. Ciampi, D. Moharamzadeh, M. De Pellegrin, G.F. Fraschini are more frequently caused by indirect trauma and they are more Ospedale San Raffaele, Università Vita e Salute, Milan, Italy common in males. Lesions involving phisys and epiphysis can be responsible for growth problems. The most widely used classifica- Various methods of contention and orthopaedic devices have been tion is the one made by Salter and Harris who divide epiphyseal used for the non-surgical treatment of developmental dysplasia of fractures into 5 kinds of lesions according to x-ray images. The 5th the hip (DDH). They all have in common an abducted and flexed kind is a compression lesion of the phisys, accompanied by a com- position of the hip, which permits to centre the femoral head in the promission of its vascularization; it can be dignosed only retro- dysplastic acetabulum. The diagnosis and the choice of the type of spectively and can produce a growth problems. MRI, carried out treatment to use have been based on general, non-specific criteria within 10 days after the lesion, can help classifying the fracture but (imaging and clinical) and, moreover, have been started at an it only offers a qualitative analysis. Technetium scintigraphy car- advanced age. Ultrasonography has made it possible to recognise a ried out after at least 6 months from the trauma can be useful to dysplastic hip in the first few weeks of age, to obtain detailed evaluate the qualitative and quantitative activity of the epiphyseal information on the type and stage of hip immaturity and/or dyspla- cartilage. The treatment of the epiphyseal fractures aims to sia. This precocity and specificity reflect themselves in the possi- anatomically reduce the fracture and to stabilyze it; in some cases bility to start an early, specific orthopaedic treatment, which is also it can also be necessary to treat the possible deformities caused by personalised. Due to this important variation in the approach of the fractures. Because of the difficulty to evaluate the degree of the DDH, with time, the Paci-Lorenz, Hanausek, Kramer, Fettweis phisys lesion and the compromission of the vascularization, it is methods have been abandoned. These methods were all charac- often hard to predict in an early phase the evolution of this kind of terised by scarce specificity, difficult use and compliance, and fractures using only X-ray and MRI images. were conditioned by a high incidence of avascular necrosis of the femoral head. The orthopaedic devices (pillow, splint) have been, in some cases, abandoned, in other cases, gradually modified and SIMPLIFIED METHOD OF SKELETAL AGE ASSESSMENT used in a more specific and “personalised” fashion, depending on FROM THE OLECRANON the type of dysplasia or immaturity of the hip. The Frejka pillow, F. Canavese, P. Charles, J.P. Daures, A. Dimeglio the Pavlik method, the Von Rosen, Milgram, Denis-Brown, Ilfeld, Service de Chirurgie Orthopedique, CHU Lapeyronie, Montpellier, Graig, Hoffman-Daimler, Forrester-Brown-Putti splints, and the France newest Gekeler splint have found a relevant distribution. These devices, which are apparently similar, are as a matter of fact very The Sauvegrain method of assessing skeletal age from elbow radi- different one from the other, regarding the way in which they ographs is reliable during the pubertal growth spurt from 11-13 abduct the hips. They are not interchangeable and have to be used years in girls and 13-15 years in boys. It usefully complements the in specific stages of DDH. In this study these commonly used Greulich and Pyle atlas. With a regular use of the Sauvegrain splints will be assessed, their technical characteristics, application, method, we were able to pay particular attention to the olecranon indications and contra-indications will be specified. which is characterised by a clear morphologic development during this period.Five images of the olecranon are identified: two ossifica- tion nuclei, 11 years in girls and 13 years in boys, half-moon image: ARTHROSCOPIC TREATMENT OF THE INTRA-ARTICULAR 11.5 years in girls and 13.5 years in boys, rectangular aspect: 12 KNEE FRACTURES IN THE OLDER CHILDREN years in girls and 14 years in boys, beginning of fusion: 12.5 years A. Pascarella [1], P. Guida [2] in girls and 14.5 years in boys, and complete fusion: 13 years in girls [1]Ospedale G.Fucito, Mercato San Severino; Italy; [2] Ospedale and 15 years in boys.Average intra-class correlation coefficients Santobono, Pausillipon, Naples, Italy demonstrated an excellent correlation between Sauvegrain and ole- cranon methods: r=0.9883 for boys and r=0.9721 for girls. The Objective: Authors report their experience in arthroscopic-assisted degree of correlation of both methods between the 3 observers was: management of intraarticular knee fractures in adolescents. r=0.9920 for the olecranon method and r=0.9849 for the Sauvegrain Methods: From February 2002 to February 2005, we treated by method in the boy group, r=0.9958 for the olecranon method and artrhroscopic-assisted technique 16 intraarticular knee fractures in r=0.9936 for the Sauvegrain method in the girl group.Derived from adolescents from 13 to 16 years old : 9 fractures of intercondylar the Sauvegrain method, skeletal age assessment from the olecranon eminence, 3 Salter Harris type III fractures-separations of the distal proved to be particularly simple and reliable. This method is easy to femur, 4 fractures of the proximal tibial epipysis type II Salter Harris learn and allows to obtain a rapid and relatively precise idea of and type III Salter Harris. skeletal maturity in clinical practice. S13

ESSION Methods: The X3 sequential crosslinking process gamma-irradiates S O08 compression molded GUR 1020 stock to 30 kGys followed by annealing at 130C (below the melt-temperature). This process is then repeated two more times to accumulate a total dose of 90 kGys. MISCELLANEOUS I Acetabular and tibial bearings are machined from this stock and hydrogen peroxide gas plasma sterilized. Physical, chemical and EXPERIMENTAL STUDY ON BONE QUALITY IN HIP mechanical properties were measured and hip and knee implants ARTHROPLASTY FOR OSTEOPOROTIC HIP FRACTURES were tested for wear and functional strength. AND HIP OSTEOARTHRITIS Results: Microstructure measurement (TEM and DSC) showed no G. Resmini [1], C. Redaelli [1], U. Sala [1], S. Migliaccio [2],G. change in size or amount of crystals compared to conventional Gandolini [3], S. Maggi [4], S. Lello [5], L. Dalle Carbonare [6],N. UHMWPE with crosslink density approximately doubled and free Malavolta [7], G. Iolascon [8] radicals (ESR) reduced by 99%. Yield and ultimate strength were [1]Centro per lo Studio dell’Osteoporosi e delle Malattie maintained and functional hip and knee device testing showed simi- Metaboliche dell’Osso, U.O. di Ortopedia e Traumatologia, A.O. lar or improved fatigue performance compared to conventional Ospedale Treviglio, Caravaggio, Italy; [2]Fisiopatologia Medica, UHMWPE. Hip wear testing found a statistically significant 97% Università di Roma, Rome, Italy; [3]Reumatologia, Fondazione Don reduction over conventional UHMWPE and a 70% reduction over Gnocchi, Milan, Italy; [4]Centro Invecchiamento, CNR, Padua; earlier generation highly crosslinked UHMWPE. Knee wear results [5]Ginecologia, San Carlo di Nancy – IDI, Rome, Italy; [6]Università show up to 79% reduction for CR and PS inserts under gait and stair di Padova, Padua, Italy; [7]Reumatologia, Università di Bologna; climb testing. Wear debris was similar to conventional UHMWPE. Italy; [8]Seconda Università di Napoli, Naples, Italy Contact fatigue testing showed delamination for controls but not for X3. Artificial aging showed similar oxidation performance com- Osteoporosis and osteoarthritis are the two most common diseases in pared to virgin PE with no change in physical or mechanical proper- elderly people, but remarkably they seldom coexist. Steoporosis is a ties before and after aging. chronic and progressive disorder characterized by a reduced bone Discussion and Conclusions: Sequentially crosslinked UHMWPE strength and increased susceptibility to fracture due to minor trauma. (X3) was developed to maintain the mechanical strength of conven- The bone strength depends not only on the amount of bone tissue but tional UHMWPE and improve wear resistance while providing resis- also on its quality. We have studied 18 subjects (average age 82 ± 8.0 tance to oxidation. This was accomplished by maintaining crystalline years) with hip fractures (Hip Fracture Group), 35 subjects (average age microstructure, increasing crosslink density and minimizing free rad- 70 ± 8.0 years) with arthritis of the hip (Arthritis Group) compared to icals. Material tests and hip and knee device tests confirmed this. 19 subjects (average age 70 ± 5.5 years) with normal femoral bone min- eral density (Control Group). All parameters of bone metabolism (Ca, P, Mg, Cl, Na, K, ALP, PTH 1-84, 25OH vitamin-D3 and serum CTx; Ca, ABDUCTOR-CUFF TEARS OF THE HIP: PATOGENESIS AND P, Mg, Cl, Na, K urine) were assayed within 48 hours after hip fracture CLASSIFICATION and preoperatively cement hip arthroplasty in the Hip Fracture Group, L. Tafuro, W. Thomas, L. Lucente preoperatively non-cement total hip arthroplasty in the Arthritis Group Clinica Quisisana, Rome, Italy and in the Control Group.There is a significant difference in the Ca- PTH axis with secondary hyperparathyroidism in the Hip Fracture In the literature there are many studies about anatomical and radio- Group compared to Arthritis Group and to Control Group. A marker of logical findings of the abductor cuff tears of the hip, but not as many bone resorption, C-Terminal telopeptides of type I-collagen, was signif- about histology and patogenesis. We have developed a classification icantly increased in the Hip Fracture Group by p<0.0007 and by of abductor-cuff lesions and we have elaborated a patogenetic p<0.0039 respectively in the Arthritis Group and in the Control Group. hypothesis of a trochanteric impingment of the hip. From January There were no differences on 25OH vitamin-D3 between the 3 different 2004 to March 2005, in 150 consecutive with osteoarthritis of the groups, but all subjects had vitamin D3 insufficence. In conclusion, bio- hip were performed. X-rays, Ecography and MRI studies were per- chemical markers reflecting bone turnover may improve the prediction formed pre and postoperatively. The cuff-tears were divided into of hip fracture. Bone density and bone quality changes reduce ability of three groups. The radiological and clinical (Harris Hip Score) follow osteoporotic bone to support prosthetic implants. Probably this condi- up were done at 6 weeks, 3, 6 and 12 months. The MRI showed tion might interfere with primary stabilization (immediate support to abductor-cuff tears in 32% of the cases. 10 Patients belong to group implant by close bone), and secondary stabilization (due to bone I, 27 to group II and 11 to group III, while 102 patients were not ingrowth). Therefore, before surgery, it’s important to make an accurate affected by abductor-cuff lesions. The Harris Hip Score values, dif- evaluation of bone health status (bone markers, Vitamin D,…). Our data ferent in the preoperative, are similar during the follow-up. The support the hypothesis that prudent preoperative planning is crucial to patogenetic hypotesis, the classification and the surgical protocol minimizing failures and optimizing results. The focus of orthopaedic described, permit a quickly identification of the abductor-cuff tears intervention is to inimize these sequelae through a good primary stabi- and a right surgical choice. lization, enhancement of fracture healing and aggressive rehabilitation. EFFECTIVENESS AND SAFETY OF BEMIPARIN DURING SEQUENTIALLY IRRADIATED AND ANNEALED UHMWPE: OBSERVATIONAL STUDIES FOR PREVENTION OF VENOUS THE NEXT GENERATION HIGHLY CROSSLINKED BEARING THROMBOEMBOLISM IN ORTHOPAEDIC PATIENTS MATERIAL P. Prandoni [1], L. Scalia [2], J. Martínez-González [3] A. Essner, S-S. Yau, A. Wang, J. Dumbleton, M. Manley [1]Dipartimento di Scienze Mediche e Chirurgiche, Università di Stryker Howmedica Osteonics Inc., Mahway, New Jersey, USA Padova, Padua, Italy; [2]Dipartimento Medico, Sigma-Tau, Rome, Italy; [3]Dipartimento Medico, Laboratorios Rovi, Madrid, Spain Introduction: The three issues for ultra-high-molecular-weight polyethylene (UHMWPE) are strength, wear resistance and oxida- Background: Observational studies (OS) are useful to assess the tion resistance. A novel sequential crosslinking process (X3) was incidence of adverse drug reactions (ADRs) with a new product in developed to maintain functional strength, improve wear resistance daily clinical practice and to identify rare and/or unexpected adverse and provide oxidation resistance with no compromises. drug reactions not shown in clinical trials. S14

Objective: To review the effectiveness and safety of bemiparin dur- dence from systematic research, a concept shared by doctors and ing OS for prevention of venous thromboembolism (VTE) in patients and that should replace a practice based on tradition and orthopaedic patients. dogma. However, some behaviors still outlive, despite the amount of Methods: We analysed the results of 3 bemiparin OS in orthopaedic counter evidence. As a case in point, the use of postoperative suction patients conducted during the period from 1999 to 2003. The inci- drainage in joint replacement not only causes an additional direct dence of documented symptomatic VTE, major bleeding, deaths and cost to surgery, but it is correlated with an increased rate of transfu- thrombocytopenia were extracted. sions and potential complications. To evaluate potential savings Results: A total of 9315 orthopaedic patients were exposed to bemi- resulting from the disruption of this procedure, a simplified model parin during OS for VTE prophylaxis. Most patients had leg injuries was elaborated which is based on available administrative data. Our requiring immobilisation (n = 2052), knee replacement (n = 1905), data show that the adoption of an evidence-based protocol discour- hip replacement (n = 1409), knee arthroscopy (n = 769), hip fracture aging the unsupported use of drains in primary total joint replace- (n = 437), or other leg surgery (n = 1569). Bemiparin 3500 IU/d was ment surgery on a national basis would allow money savings as well used in 87.1% of patients (high risk of VTE). Median duration of as potential prevention of complications. prophylaxis ranged from 13 to 38 days in the 3 studies. 88 patients (0.9%) developed documented symptomatic VTE, and 27 patients (0.3%) had a major bleeding event. There were 25 deaths (0.3%). Of PRELIMINARY EXPERIENCE WITH ISKD NAIL IN THE these, three were considered thromboembolic. Mild to moderate TREATMENT OF LOWER SHORTENED LIMB thrombocytopenia that did not require treatment discontinuation was F. Baldo, A. Reggiori, P. Cherubino observed in 44 patients (0.5%). No cases of spinal haematoma, type Dipartimento di Ortopedia e Traumatologia, Università degli Studi II severe thrombocytopenia, general allergic reactions, cutaneous dell’Insubria, Varese, Italy necrosis, or any other rare or unexpected ADR were reported. Conclusions: Bemiparin prophylaxis was associated with a very low Objective: Treatment evaluation in lower shortened limb with the incidence of VTE, major bleeding, and other adverse events in intramedullary skeletal kinetic distractor ISKD. orthopaedic patients in standard clinical practice. Methods: The ISKD is made up of a telescoping section able to dis- tract the proximal and distal part by a miniaturised complicated drive mechanism. This happens during physiologic daily life activity and PHARMACOLOGIC PREVENTION OF VENOUS THROM- especially physiological gate process. In our department three patients BOEMBOLISM IN ORTHOPAEDIC SURGERY: ARE WE have been treated with ISKD devices for a bone loss following lower OFFERING OUR PATIENTS THE BEST? limb trauma. The average age was 27.6 years (20-38 years), two G. Tucci [1], E. Romanini [2], M. Torre [3], V. Amorese [1] female and one male presented an average shortened of 40 mm (34-45 [1]Ospedale Specializzato Regionale “L. Spolverini”, Ariccia, Italy; mm). Two femurs and one tibia were involved in lengthening. [2]Globe, Rome, Italy; [3]ISS, Rome, Italy Results: No particular problems were observed during the surgical procedure. All patients performed themselves the rotations needed During the last years thromboembolism prophylaxis has received for lengthening since the third and fifth post-operative days. The increasing attention from the orthopaedic community. An increasing desired daily length of distraction was achieved in all patients. No volume of studies and guidelines, often based upon ACCP recom- case of non-union or malunion was ascribed to failure of device. No mendations published in the USA, made pharmacological prophy- complications related ISKD were observed during follow-up; com- laxis (particularly with low-molecular weight heparins) a common plete range of motion was reached in all patients. The patient with practice. The aim of this clinical practice is to prevent thromboem- tibial lengthening presented a light valgus deformity due to an error bolic complications, especially the dreadful pulmonary embolism. in the selected level of osteotomy. The fear of medico-legal implications related to a rare, but often Discussion: Callus taxis proposed by Ilizarov is associated with fatal, complication has created an environment in which chemopro- many complications particularly related to pins and K wires tracts phylaxis seems to be mandatory. This situation has led to an uncon- for fixation. The ISKD device, based on Ilizarov principles allows to trolled widening of the indication of chemoprophylaxis (that can reach lower limb lengthening by a simple and comfortable device. itself cause several complications) to the majority of orthopaedic This distractor system has an indication feedback monitor to control patients, even to those who are not undergoing surgery or those the effective desired lengthening of nail. affected by minimal injuries. Recently this approach has been ques- Conclusion: In our experience ISKD got the best results with tioned and an authoritative panel of orthopaedic surgeons asserted increased comfort for the patients, an early full weight bearing with the need to reassess the practice of systematic chemoprophylaxis, a complete ROM and excellent limb function. emphazising that thromboembolism, due to its complex pathogene- sis, needs a “multimodal” approach. Moreover, the possible compli- cations (i.e. major bleeding, heparin-induced thrombocytopenia) related to the use of chemoprophylaxis do not justify such a large SESSION O09 and indiscriminate use. This study is a review of current evidences about this controversial issue. SHINBONE I SUCTION DRAINS AFTER TOTAL JOINT REPLACEMENT. ECONOMIC ISSUES AND POTENTIAL RISKS OF A ROU- FRACTURES OF THE TIBIAL PLAFOND TINE PROCEDURE NOT SUPPORTED BY CLINICAL EVI- D. Lazzara, G. Caruso, A. Petrini DENCE U.O. Ortopedia, Nuovo Ospedale S. Giovanni di Dio, Florence, Italy E. Romanini [1], G. Tucci [2], M. Torre [3] [1]Globe, Rome, Iatly; [2]Ospedale Specializzato Regionale “L. Introduction: Fractures of the tibial plafond (distal tibia extending Spolverini”, Ariccia, Italy; [3]ISS, Rome, Italy into the ankle joint with different levels of comminution) represent 1% of lower limb fractures and 7-10% of all tibial fractures. These The practice of evidence-based medicine means integrating individ- fractures result from low energy injuries or, more often, from an ual clinical expertise with the best available external clinical evi- high energy injury like major falls or motor vehicle accidents. S15

Objective: To evaluate results and complications of open riduction ments was obtained with a small medial access secondary to careful and internal fixation (ORIF) of these fractures. preoperative CT evaluation. All fractures are healed; two cases of Patients and Methods: Twenty-eight patients (twenty-nine frac- delayed union have been observed, but no one showed healing suf- tures) treated between 2001 and 2003 were examinated clinically and fering of the surgical wound. The use of this mini-invasive reduction radiographically at an average of 43.4 months (30 to 59 months) after and osteosynthesis technique has been complicated and it has treatment. The average age at treatment was 44.6 years (17 to 79 required strict radioscopic intraoperative control, but it has consid- years). Twenty-seven fractures were treated operatively (using plates erably decreased surgical trauma on the soft tissues. and screws in 23 and only screws in 4 cases). Two cases were treated conservatively using cast and no weight bearing. Injuries were clas- sified according to Ruedi and Allgower (1979): we had 31% in the USE OF EXTERNAL FIXATION IN THE TREATMENT OF first, 31% in the second and 38% in the third group of increasing PILON TIBIAL FRACTURES complexity. Clinical results were evaluated using Ovadia and Beals’s F. Lavini, R. Bortolazzi, C. Dall’Oca, E. Carità, G. Gioia, L. (1986), Ruedi’s (1979) and D’Imporzano’s (2002) criteria. Bonometto, P. Bartolozzi Results: According to Ovadia and Beals we had, objectively, excel- Clinica Ortopedica e Traumatologica, Università degli Studi di lent (41.7%), good (33.3%), fair (16.7%) and poor (8.3%) results Verona, Italy and, subjectively, excellent (33.3%), good (41.7%), fair (12.5%) and poor (12.5%) results. The percentage of excellent and good results Objective: Medium-long term results in pilon fractures treated with was 70% according Ruedi’s criteria.In these series we had 2 infec- bridging or hybrid external fixation. tions, 4 cutaneous necrosis, 1 case of pseudoarthrosis and 3 cases of Materials and Methods: From 2000 to 2004 34 patients affected by vascular complications (dvt). 13 Ruedi-Allgower type I fractures, 14 type Ii, 7 type III, whose Conclusion: These kinds of fractures often represent a difficult chal- average age was 47 have ben treated using external fixation. C.T. lenge for the orthopaedic surgeon. He has to find a balance between was performed preoperatively. Ovadia-Beals evaluation form has aggressive open reduction and osteosynthesis to reproduce tibial been used at follow up performed after an average period of 27 articular surface and bone’s and soft tissue’s biology to gain early months. motion and avoid complication like cutaneous necrosis and venous Results: 32 fractures healed in av. 107 days. We do not report non thrombosis. union or skin sloughing. 13 patients showed at the latest x ray clear signs of arthritis. In two cases we observed screws osteolysis fol- lowed by fixator removal and plaster cast application. 1 case of deep DISTAL TIBIA FRACTURES: LOW PROFILE LCP VERSUS infection occurred in a Gustilo 3b fracture taht required a BKA.1 EX-FIX case of early arthritis required ankle fusion. A. Scalvi [1], M. Inguaggiato [2], G. Rocca [3] Conclusion: Post traumatic arthritis (30%) is comparable with the [1]Divisione di Otopedia e Traumatolgia OCM, Verona, Italy; percentage reported by other Authors and it seems correlated by [2]Clinica Ortopedica, Ospedale Policlinico, Verona, Italy; articular cartilage damage, the energy of trauma and soft tissues [3]Struttura Funzionale di Traumatologia OCM, Verona, Italy involvement. External fixation helps to reduce the early complica- tion such as deep infection, amputation, non union. This method The treatment of the distal tibia fractures has always been a subject does not reduce the incidence of post/traumatic arthritis, even in the of discussion. Having no muscles, this anatomic area is character- case of anatomic and stable reduction radiografically evident. ized by a critical vascularization. The soft tissues, skin and subcuta- neous tissues are often very swollen and contused because of the twisting and tractions they get with the trauma. This damage of the EVOLUTION IN TREATMENT OF PILON FRACTURES tissues has always caused important infective and necrotic compli- F. Castelli, R. Spagnolo, D. Capitani cations that can lead to a failure of the osteosynthesis. For this rea- Ospedale Niguarda Ca’ Granda Dea, Milan, Italy son the surgical approach has to be very attentive in evaluating the status of the soft tissues from which depends timing and treatment Objective: The treatment of tibial pilon fractures devolops, im- procedure. The anatomic reduction of the tibial joint surface is proves in implant’s design and in surgical approaches. mandatory in order to avoid painful arthritis with future evolution Materials and Methods: We studied new surgical approaches and into articular ankylosis. After a large case report revision we com- new implants with angolar stability. The surgical approaches were pare the results of the treatment of these fractures with two different the antero-lateral one with isolation of saphenal nerve or a lateral methods: Ex-Fix versus LCP. way plus a minimal invasive medial approach. The anterolateral way is prefered because of some specific feature of the fracture. In order to plan an osteosynthesis with plate, treated with minimal invasive MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS way, on tibial pillar fractures we need: (M.I.P.O.) FOR TIBIAL PILON FRACTURES - simple articolar fracture G. Panegrossi, M. Papalia, F. Casella, F. Falez - reducible articular fragments throug indirect tecnique Ospedale Santo Spirito in Sassia, Rome, Italy - Intregrity and reducible medial and posterior malleolus - excellent conditions of soft tissue. Fractures of the tibial pilon are notoriously difficult to treat and tra- Conclusion: In the reduction of tibial pilon fracture we can use the ditional methods of fixation are often associated with important antero-lateral approach thanks to the low rate of complications. We lesions of the surrounding soft tissues. Minimally invasive osteosyn- suppose that muscles and tendons protect the skin whithin the plate thesis techniques of the distal tibia offer several advantages com- and help the subcutaneous blood supply. Mipo tecnique in treatment pared to classic open reduction and internal fixation. A mechanical- of tibial pilon fractures allows goods results only in specific cases, ly stable fracture-bridging osteosynthesis can be obtained using a taking care of instructions and technique with the respect of the soft small approach, resulting in less surgical trauma to the bone and soft tissue. Finally, minimal invasive approach in osteosinthesis of artic- tissues. In this retrospective study we observed the results and com- ular fractures, as in other cases, is not an advantage “per se”. The plications in eight patients treated for fractures of the distal third of choice of a minimal invasive approach should be carefully consid- the tibia with locking-screws plate and less invasive technique, with ered in front of the risk of a malreduction of the articular joint that a minimum follow-up of ten months. Reduction of articular frag- is in any case unacceptable. Anatomically reconstruction of the S16

articular joint is mandatory so that during the operation we have to markedly long and thick. Therefore, with LCP technique, surgeons change the approach from a minimal invasive approach to an artro- can treat two sites of the same fracture simultaneously, making only tomy through a classical view. two small incisions.

RESULTS OF MINIMALLY INVASIVE PLATE OSTEOSYN- ILIZAROV’S CIRCULAR EXTERNAL FRAME IN TREATMENT THESIS OF FRACTURES OF THE DISTAL TIBIA OF C-TYPE TIBIAL DIAPHYSEAL FRACTURES F. Chiodini, L. Filippi, L. Di Mento, M. Berlusconi G. Lovisetti [1], L. Del Sasso [2], V. Zottola [3], L. Bettella [1] Istituto Clinico Humanitas, Rozzano, Italy [1]Unità Operativa di Ortopedia e Traumatologia, Presidio Ospedaliero di Menaggio, Azienda Ospedaliera Sant’Anna, Menag- Introduction: Treatment of fractures of the distal tibia is a surgical gio, Italy; [2] Divisione di Ortopedia e Traumatologia, Azienda challenge: the poor soft tissue covering and the proximity to the Ospedaliera Sant’Anna, Como, Italy; [3]Unità Operativa di articular surface make the surgical procedure more demanding and Ortopedia e Traumatologia, Presidio Ospedaliero di Cantù, Azienda the results less predictable than those of tibial midshaft fractures. Ospedaliera Sant’Anna, Cantù, Italy There is no agreement on the best treatment of these lesions: exter- nal fixation, intramedullary nailing and open reduction and internal Reduction and osteosynthesis of multifragmental high energy frac- fixation have been proposed but each option has its challenges. tures of the tibial diaphysis with intramedullary nails can be difficult Minimally Invasive Plate Osteosynthesis (MIPO) with Locking and in some instances it may expose to compartimental syndromes. Compression Plates (LCP) has shown to allow a correct fracture Open techinques should avoid large exposures and do not permit reduction and stabilisation without damaging the soft tissues at the early weight bearing. We consider Ilizarov apparatus a concrete fracture site. We present our results with this technique of treatment alternative in treatment of these lesions: it consents closed careful of distal tibial fractures on a consecutive series of 16 patients. reduction, stable osteosynthesis, soft tissue sparing, multisegmental Materials and Methods: From January 2005 to January 2006 at our control of the fixation and very early weight bearing. institution 16 patients with a fracture of the distal tibia underwent Materials and Methods: From 1993 we treated 15 tibial diaphyseal MIPO with LCP. Patients have been evaluated clinically by the fractures 42C in 15 patients, mean age 40 years (range 19 – 64), AOFAS Akle Score and radiografically monthly until consolidation. classified as follows: 42C13 : 5 cases, 42C2: 8 cases (type 1: 2 cases, Time to union, quality of reduction and complications have been type 2: 3 cases, type 3: 3 cases), 42C33: 2 cases. 6 fractures were reported. open: Gustilo type 1: 1 case, type 2: 4 cases, type 3A: 1 case. Results: All the fractures eventually healed in a mean time of 18 Results: Consolidation occurred in 15/15 cases after a mean of 27.3 months. No infections or wound complications have been seen. A weeks. We observed no case of limb lenght discrepancy, significant valgus deviation > 10° requiring re intervention was found in one sepsis, malconsolidation with axial deviation. Clinical result has patient. With a mean follow-up of 21 weeks the mean AOFAS score been judged excellent or good in all cases. was 80. Discussion: Ilizarov circular frame has been a valid approach to Conclusions: In the treatment of fractures of the distal tibia MIPO these lesions.The respect of the bone fragment periostal and endostal with LCP offers the advantage of a good reduction and a stable fix- vascularization led to a complete consolidation also in presence of ation combined with minimal soft tissue damage. high energy comminuted fractures. The modular configuration of Ilizarov apparatus has proven to be useful in bifocal and trifocal lesions, expecially in the segmental control of the levels, with respect to dinamization. SESSION O10 USE OF LESS INVASIVE STABILIZATION SYSTEM (LISS) IN THE TREATMENT OF COMPLEX PROXIMAL ARTICULAR SHINBONE II FRACTURES OF THE TIBIA F.V. Sciarretta, A. Pecora, P. Zavattini TREATMENT OF LEG COMPLEX FRACTURES WITH PER- Ospedale Civile, Velletri, Italy CUTANEOUS LCP OSTEOSYNTHESIS F. Carotenuto [1], E. Favre [1], L. Curci [2], C. Di Bonito [3],N. In order to obtain a clinical functional good outcome, complex prox- Vendemmia [2] imal fractures of the tibia require operative treatment. In this paper, [1]Clinique General de Savoie, Chambery, France; [2] Policlinico the Authors present the results obtained with the new LISS system Universitario “Federico II”, Naples, Italy; [3]Ospedale G. Rummo, that enables, through the indirect fracture reduction, combination of Benevento, Italy correct fracture reduction with less soft tissue trauma, enhancing fracture consolidation. Over the last few years, remarkable changes have been made in the treatment of closed leg fractures. However, although the protocol for treating the relatively simple fractures is well defined, compound SURGICAL TREATMENT OF COMPLEX FRACTURE OF TIB- fractures involving the knee and ankle joint articulations are still dif- IAL PLATEAU ficult to treat. We describe the treatment of complex leg fracture or M. Villano, C. Carulli, M. Pietri, M. Innocenti tibial diaphysis with percutaneous osteosynthesis using Liss LCP II Clinica Ortopedica, Università degli Studi, Florence, Italy plate (locking compression plate), a technique that requires only two minor percutaneous incisions to insert the plates and fix the screws. Complex fractures of tibial plateau present an increase due to the The advantage of preserving the site of the fracture and the minimal ingrowth of high energy trauma. Because of their sequelae, treat- invasiveness of this technique allow a safe and rapid bone consoli- ment has to be aggressive in a way to obtain good stability and dation, thus reducing the surgical risks of invasive incisions and anatomical reduction: this approach is effective in young adults, but facilitating post-surgical recovery. Furthermore, this percutaneous joint replacement seems to be the only choice in elderly patients, technique appears to be the ideal solution for the treatment of frac- often afflicted by arthritis and osteoporosis. Between 1997 and tures involving joint articulations where, indeed, the incisions can be 2005, we treated 23 complex fractures of tibial plateau among 45 S17

cases (Schatzcker IV°-V°-VI°): 12 female and 11 male patients, (4) complications average age 46 years (19-71), average follow-up 4 years (2-7). We (5) functional recovery evaluated our results with Hohl score: we obtained good results with (6) a modified score to record patients outcome at each clinic visit. open reduction and plate fixation (excellent: 18.8%, good: 62.4%, Discussion: Severity of injury, age of patient, residual malalignment sufficient: 18.8%) and no cases with poor result. These results make and knee instability are conditioning for outcomes us believe that in young people a good reduction and stable fixation Conclusion: We have observed that in the same clinical conditions permit short recovery and excellent functional outcome. adults tolerate articular incongruity better than elder people and have a longer gap to develope postraumatic arthritis. RESULTS OF PROXIMAL TIBIA FRACTURES TREATED WITH THE LISS INDICATIONS FOR OPEN ARTICULAR REDUCTION IN TIB- F. Atzori [1], A. Biasibetti [1], G. Di Gregorio [1], A. Gallo [2],R. IAL PLATEAU FRACTURES Matteotti [2] M. Stopponi, A. Basile, A.U. Minniti de Simeonibus [1]Traumatologia C.T.O., Turin, Italy; [2] Dipartimento di Ortopedia II U.O.C. Ortopedia e Traumatologia, Az. Ospedaliera S. Giovanni- e Traumatologia, Turin, Italy Addolorata, Rome, Italy

Proximal tibia fractures present a difficult treatment challenge with In order to follow the trend for limited aggressive surgery, many historically high complication rates. We retrospectively observed 28 techniques for closed reduction of tibial plateau fractures have been proximal tibia fractures treated with the LISS. The fractures were developed. Indirect reduction by ligamentotaxis and closed articular classified in accord with AO metod. The follow-up was 22 months visualization by arthroscopy or radioscopy are some of the methods (range, 6 - 35 months) and included clinical examination using -Knee used. It has not been well defined which kind of fractures are best Society Scores-, functional subjective score using -Koos Knee treated by these methods, aiming to obtain a congruent joint surface, Survey- and radiologic outcome. In conclusion, the LISS provided and a stable fixation that allows an early range of motion. Open tech- stable fixation of extra-articular and intra-articular proximal tibia niques usually allow a better direct visualization of the fracture, so fractures and good functional outcomes with a low complication rate. that reduction can be more accurate. For that reason closed methods are non suitable for all kind of fractures, but surgical technique (approach, reduction technique, and method of fixation) must be TIBIAL CONDILAR FRACTURES, TREATMENT WITH LCP determined depending on the fracture characteristics. Most impor- PLATE AND “NORIAN” tant factors are stability, dislocation of the fragments, especially R. Mezzalira articular ones, comminution, fracture localization, skin condition, ASL 6 Ospedale Civile, Ciriè, Italy ligament or meniscal tears. Surgeon must obtain the best stabiliza- tion of the fracture so that cartilage can heal in an optimal, long last- The articular tibial plateau fractures, like those of other districts, ing situation. Joint functionality after fratures, depends on joint con- introduce remarkable difficulties of indication and treatment. These gruence, stability, correct articular load distribution and physiologic fractures often cause disability, like secondary osteoarthritis, inex- cartilage biology. Articular reduction must be as accurate as possi- orably leading to a prosthesis substitution. The aim of this study is bile, avoiding wide dissections and periostal stripping of fracture looking through the possibilities which recent internal fixation fragments. Contemporary fixation hardware is studied for a limited methods offer, associated with a bone substitute, in those types of invasivity and minimally interfere with bone biology. 4 yrs clinical fractures treatments. The considerable stability of LCP, which act as and radiographical results of 21 tibial plateau fractures, all treated “internal fixing device”, associated to a low damaging and more with open articular reduction, are reported. 15 fractures were stabi- conservative technique towards the periosteum and the soft tissue, lized with plate and screws, 6 with external fixation. Mean articular and to the use of synthetic bone which is more and more reliable and step was 1 mm. At late follow-up only 3 knees presented moderate avoid bone grafts transplantation, undoubtedly can facilitate the arthritic lesions. treatment of these lesions. Thirteen patients have been surgically treated. Concerning the clinical valuation we adopted the method suggested by Rasmussen, with acceptable results achieved in 100 per cent of the patients. However, the results estimated in the short SESSION O11 term, although excellent, and the small number of analyzed cases, do not allow a rigorous valuation. PROXIMAL FEMUR LONG TERM FOLLOW-UP OF TIBIAL PLATEAU FRAC- TURES MID AND LONG TERM EVALUATION OF A SERIES OF 19 L. Pisano [1], V. Sessa [2], F. Forconi [3], A. Fernicola [4] FEMORAL HEAD FRACTURE [1]Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy; N. Papapietro [1], M. Oransky [2] [2]Ospedale Fatebenefratelli, Isola Tiberina, Rome, Italy; [3]Azienda [1]Area di Ortopedia e Traumatologia, Università Campus Bio- Ospedaliera San Giovanni Addolorata, Rome, Italy; [4]Az Osp S Medico, Rome, Italy; [2]Azienda Ospedaliera San Camillo Forlanini, Giovanni, Rome, Italy Rome, Italy

Objective: To evaluate the long term clinical outcomes for patients Introduction: The femoral head fracture is an uncommon (and seri- affected by tibial plateau fractures with a minimum of 5 years from ous) injury. The majority of the Authors recommend the Smith- surgery. Petersen approach, but recently the trochanter-flip was suggested by Materials and Methods: Sixty patients have been evaluated at 1 other Authors. In our experience the Kocher-Langenbeck can be year, 2 year, and more than 5 year from trauma considering used in cases with associated acetabular fractures. This injury may (1) demographic features result in an important number of failures, if not properly treated. (2) fracture’s classification(Shatzker) and surgical technique Materials and Methods: From 1985 to 1999 we treated 19 patients, (3) associated injuries 12 males and 7 females. The clinical and radiological results were S18

classified according to Merle D’Aubignè and to Epstein radiological position, the orientation and degree of displacement of the fracture classification. determine the severity of the vascular damage at the expense of the Results: We retrospectively reviewed a series of 19 cases over a proximal epiphysis, thus influencing the type of treatment needed. period of seventeen years, and found the occurrence of femoral head Pauwels was the first to classify these fractures in 1935, dividing geodes, with joint line preservation and no correlation with clinical them into three groups according to the angle formed by the fracture results. Regarding the first group of patients treated conservatively and the horizontal surface. The most recent though most complex we had one anatomic reduction, one imperfect reduction with 2mm classification is represented by the AO system, in which the fractures of residual displacement and one unsatisfactory reduction with a dis- are also divided in three groups. In this study we used the classifica- placement of over 5 mm. In the second group of six patients, treated tion issued by Garden in 1961, which identifies 4 kinds of medial by fragment excision, the results were excellent in two cases (one femoral neck fractures, considering types I and II for patients aged Pipkin II and one Pipkin IV fracture), 2 patients had osteonecrosis under 60 or presenting pathologies which would not recommend the and one healed with ankylosis in good position because of Brooker use of arthroprosthesis. We are reporting our own experience of 10 IV ossifications, with no pain. cases treated by means of percutaneous ostheosynthesis using titani- Discussion: Most of the Pipkin type I and II fractures are adequate- um cannulated lag screws. All patients underwent continuous passive ly treated by Smith-Petersen approach. Compression fixation with mobilization from the first day after surgery with absolute restraint titanium Herbert screws is advisable to allow in future MRI. The from weight bearing for 60 days. The reductions obtained kept per- quality of reduction of an associated acetabular fracture plays a fun- fectly in the follow-up checks and the functional and clinical results damental role. Initial cartilage damage at long term favors secondary proved excellent or good. According to our experience we can assert arthrosis. It was also evident in four cases of our series the presence that this method offers various advantages: minimum surgical inva- of geodes of the femoral head, not associated to joint line reduction siveness and aesthetic damage, direct control of the anatomic reduc- or acetabular geodes (remodeling) or a clinical simptomatology. In tion obtained, low mortality risk, rapid performance and possibility future these geodes can be theoretically treated by alternative con- of applying an arthroprosthesis in case of failure due to vascular com- servative methods as grafting. plications. Summing up, this method can be regarded as a valid alter- native in the treatment of medial fractures of the femural neck, but must be performed in strictly selected cases, being aware that in case TREATMENT OF THE FEMORAL HEAD OSTEONECROSIS of failure the application of an arthroprosthesis is needed. WITH CORE DECOMPRESSION AND AUTOLOGOUS PLATELET-DERIVED GROWTH FACTORS A Gigante, C. Bevilacqua, M. Cappella, E. Cesari, F. Greco HIP REPLACEMENT IN LATERAL FRACTURES OF THE Clinica Ortopedica, Università Politecnica delle Marche, Ancona, Italy PROXIMAL FEMUR C. Carulli, M. Villano, R. Civinini, M. Innocenti The treatment of choice in the early stages of femoral head II Clinica Ortopedica, Università degli Studi, Florence, Italy osteonecrosis has not been defined yet. Core decompression of the femoral head is the most common surgical procedure, however its Although not common, hip replacement in lateral fractures of the results are controversial. Recently the use of growth factors has been proximal femur represents a well-known solution and is widely suggested to stimulate bone repair. Platelet-rich-plasma (PRP) repre- described in literature. This choice allows an early total weight-bear- sents a non-expensive source of several growth factors with osteoin- ing and a quicker functional recovery. On the other hand, surgery is ductive and angiogenetic properties. The present study evaluated the longer and more complex in comparison with internal fixation and results of surgical treatment of early femoral head osteonecrosis by hip replacement in intracapsular femoral neck fractures. In our core decompression and autologous bone graft enriched with PRP. Department, 18 patients (19 cases) with trochanteric fractures were Nine patients (6 male and 3 female, mean age 38.7 years, 3 bilateral treated with cemented hip replacement, using a Versys Cemented and 6 monolateral) affected by femoral head osteonecrosis (stage I e Revision/Calcar (CRC) prosthesis associated with cerclage or mod- II of Steinberg classification) have been treated with core decompres- ular wedges: 13 were female and 5 male patients, with an average sion associated to autologous bone graft and PRP. All patients were age of 77 years (46-89); 12 were right and 7 left hips. Pre-opera- clinically evaluated with the use of Harris hip score preoperatively and tively evaluation was performed with schedules regarding general at 1, 3, 6, 12 months after surgery. X-rays and MR were performed conditions, functional scoring (ASA, ADL, IADL) and with Harris preoperatively and at 1, 3, 6, 12 months after surgery. Clinical evalu- Hip score. Two patients were lost at follow-up. Post-operatively ation revealed a reduction of symptoms and an increased Harris hip Harris Hip score was good; no loosening or instability was revelead score (p<0.05) after surgery. X-rays at 6 and 12 months showed no at X-rays control and all stabilized trochanteric fractures were femoral heads alterations. MRI evidenced edema reduction, no signal healed. These results allows us to believe that cemented hip replace- modification neither extension increase of the necrotic areas. This ment of trochanteric fractures, with or without further stabilization study demonstrated the efficacy of core decompression associated to (cerclage or calcar substitution), is a good choice in selected cases autologous bone graft enriched with PRP in the treatment of early with adequate local and general conditions because of the quick femoral head osteonecrosis. The use of autologous growth factors recovery of weight-bearing and the low rate of complications. from PRP seems to stimulate lesions repair, with a positive clinical outcome and MR imaging improvement. EVALUATION WITH SAHFE PROTOCOL (STANDARDIZED AUDIT OF HIP FRACTURE IN EUROPE) OF 75 LATERAL OUR EXPERIENCE IN THE TREATMENT OF MEDIAL FRAC- FEMORAL NECK FRACTURES TREATED BY INTRAME- TURES OF THE FEMURAL NECK IN YOUNG PATIENTS BY DULLARY NAILING OSTHEOSYNTHESIS WITH CANNULATED LAG SCREWS G. Montemurro, F. Messore, P. Fanelli M. Candela, G. Mazzarella, M. Arena, S. Anastasio Ospedale di Anagni, Italy U.O. Ortopedia e Traumatologia, Ospedale S.Francesco di Paola, Paola, Italy The SAHFE (Standardized Audit of Hip Fracture in Europe) protocol is a European project that suggested, through the analysis of multi- The medial fractures of the femural neck affect the anatomical region centric data, standardization of the approach and treatment of the included between the femural head and the inter-trochanteric line; the femoral neck fracture in elderly people. In the present study our S19

report is relative only to lateral femoral fracture. The protocol implies tion (firmly anchored to the nail). Early evaluation (4-6 months fol- a report at patient admittance followed by postoperative and four low-up) are based on operating time, necessity of reaming, postop- month follow-up data. These data were collected through interviews erative blood transfusion, functional recovery using a modified to the patients or, in special cases, to their relatives. This study was Harris hip score, mechanical complications, mortality. conducted from December 2002 and December 2005, enrolling 75 Results: 5 patients died, in 94.9% of patients nail has been inserted patients (45 female and 30 male) with mean age 75.5 years (66-97); without diaphyseal reaming, in 38% of cases, 1.62 I.U. of blood have all these patients were affected by lateral femoral fractures. The pro- been infused postoperatively, mean application time (skin to skin) was tocol needs the registration of the following data, divided into 5 parts: 47 minutes, preoperatory modified Harris hip score was 72 (scale max- 1. Patient status before fracture; lifestyle, walking ability with or imum is 91), at discharging was 45% of the preop, at 6 weeks 87% of without aid, ASA (the American Association of Anaesthetists the preop, 3 cut-out have been reported, followed by hip prosthesys. level of anesthesiological risk) score Discussion and Conclusion: The observations based on the report- 2. Type of fracture and way of treatment ed results and the literature, allow to conclude that the system has a 3. Waiting time before surgery, time of recovery, destination at dis- low degree of invasivity, ensures a quick functional recovery and charging shows a minimal percentage (2.5%) of mechanical complications. 4. Lifestyle at 4 months follow-up 5. Possible complication related to surgery. Usually in stable lateral femoral fractures we performed a synthesis ENDOVIS BA NAIL: OUR EXPERIENCE by single cephalic screw nailing (Gamma, Stryker); in unstable and G. Bruno, F. Saponara, A.O.V. Gonnella, R. Pepe, L. Mazzucca subthrocanteric fractures we used double cephalic screw nailing Ospedale San Giovanni di Dio, Melfi, Italy (PFN, Synthes). In particular patients (2) in bad general condition we preferred an external fixator (Orthofix). Besides, we collected 10 This is to present the experience gained in our ward of Endovis B.A. patients in which surgical treatment was impossible due to severe Nail as used in lateral fractures of femural neck from May 2005 to general conditions. We reported our results concerning the analysis February 2006. We are going to discuss our indications, the advan- of the above mentioned data. tages over other kinds of fixation, the possible problems during and after the surgical procedure. The duration of the operation, the as- sembling versions, the bleeding, the staying in hospital after surgery, SIDE FRACTURES OF THE NECK OF FEMUR TREATED the function and deambulation recovery after the rehabilitative pro- WITH ENDOVIS BA: OUR EXPERIENCE gramme have been taken into account.The patients had being fol- A. Panella, D. Mongelli, U. Orsini, A. Martucci, M. Panella lowed up both during the hospitalization and one, three, six months Unità Operativa di Ortopedia e Traumatologia Universitaria, Bari, after surgery. Endovis B.A.Nail proved to be an excellent choice Italy compared with DMS plate fixation, almost the only kind of surgical treatment we have experioenced for these fractures until the begin- The increase of the population average life time involves an increase ning of 2005. incidence of the side fractures of the femur which keeps to living the interest in the search for the most adequate solutions. The synthesis means choice is made on the evaluation of several essential parame- ters, between which it is often necessary to identify the best com- SESSION O12 promise. The fundamental requirements for a synthesis means are a surgical simple, quick technique, with minimum hemal losses and minimum surgical complicanze; a good adaptability to the various FEMUR DIAPHYSIS AND DISTAL FEMUR types of fracture; a good biomechanics stability to be able to grant a precocious load. We take back our experience with the ba endovis system, an endomidollar nail in titanium under-sized with two ce- ANGLE STABLE PLATES IN DIAPHYSIAL DISTAL FRAC- phalic screws and the possibility of distal blocking. TURES OF THE FEMUR L. Guerra, E. D’Angelo, G. Di Loreto, F.P. Ciampa Ospedale G. Bernabeo, Ortona, Italy A MULTICENTRIC STUDY ON THE APPLICATION OF NEW PERTROCHANTERIC NAIL: RESULTS The Authors present their experience in the treatment of diaphysial F. Lavini [1], L. Renzi Brivio [2], P. Di Seglio [3], P. Cherubino [4],M. and metaepiphysial distal fractures of the femur, treated with angle Manca [5], L. Aluisa [6], W. Leonardi [7], N. Galante [8], P. Bartolozzi [1] stable plates. 15 cases of periprosthetic fractures and of soprainter- [1]Clinica Ortopedica e Traumatologica, Verona, Italy; [2]Ortopedia condylar fractures are presented. There is an analysis of the results e Traumatologia, Mantova, Italy; [3]Ortopedia e Traumatologia, obtained and of the complications, including the mobilization of a Novara, Italy; [4]Clinica Ortopedica e Traumatologica, Varese, Liss plate. The conclusion is that the system of angle stable plates Italy; [5]Ortopedia e Traumatologia, Massa e Carrara; [6]Clinica is effective in the treatment of this type of fracture, and in most Ortopedica e Traumatologica, Rome, Italy; [7]Ortopedia e cases it makes it possible to avoid exposure of the focal point of the Traumatologia, Catania, Italy; [8]Ortopedia e Traumatologia, fracture, and lessens post-operative hematic loss. In the presence of Castellaneta, Italy osteoporosis it is advisable to carry out adequate bicortical proxi- mal fixation. Introduction: Pertrochanteric fractures are common in elderly peo- ple; for this reason early results are based on mortality rate, func- tional recovery, biological and mechanical complications. TREATMENT OF IPSILATERAL FEMORAL SHAFT AND Materials and Methods: 118 patients (87 females, 31 males) aged TROCHANTERIC FRACTURES between 47 years and 98 years (mean age 79.4 years) sustained 58 F. Castelli, R. Spagnolo, D. Capitani fractures type A1, 48 fractures type A2, 8 fractures type A3 (AO Ospedale Niguarda Ca’ Granda Dea, Milan, Italy classification). They were treated with Veronail, an I.M. device that offers the option of applying two cephalic screws in parallel config- Objective: Treatment of ipsilateral femoral shaft and neck fractures uration (allowing controlled compression) or convergent configura- with reconstruction nails or cephalomedullary nails. S20

Introduction: An ipsilateral femoral neck fracture is rare and occurs tures; the anterograde and retrograde techniques offer an almost in approximately 6 to 9% of the all femoral shaft fractures. The diag- overlapping percentage of recovery. nosis of the neck fracture is difficult and between 19% and 50% of such fractures are missed. It increases the iatrogenic fractures caused by endomidollar nailing RETROGRADE INTRAMEDULLARY NAILING IN DISTAL procedure. We believe that in case of femoral shaft fracture due to FEMORAL FRACTURES high energy trauma the state of the femoral neck should be checked O. Moreschini, M. Anwar, M. Pagliari, M. Tardiola before operation by CT or tomogram; this is the only certain way of Rome, Italy detecting a subclinical fracture. Materials and Methods: Authors describe their experience in treat- The purpose of the present study is to report our experience with the ment of 28 ipsilateral femoral neck and shaft fractures treat from use of retrograde intramedullary nail (Distal Femoral Nail (DFN)) to 2001 to 2005. For the 28 patiens eligible for the study, the AO clas- treat distal femoral fractures. We treated 30 patients (21 M, 9 F), sification system was used to describe the proximal and the shaft between September 1999 and November 2005. The mean patient age fractures. The Proximal Femoral Nail Long – Synthes is indicated was 64 years (range 44-71 years). All 30 patients were available at for each ipsilateral lateral proximal and shaft fractures of the femur, the time of final follow up and proceeded to union at an average time pertrochanteric multifragmentary with subtrocantheric extension of 12 weeks (range 5-17 weeks). We evaluated all patients with the fractures, subtrocantheric multifragmentary fractures and in sub- use of the Neer rating system: the functional scores were excellent in trochanteric fractures with extension to the femoral shaft. In these 14 cases, good in 11 and fair in 5. ROM of the knee joint ranges from last cases, authors confirm good results and choose the PFN long 60 degrees to 130 degrees, with an average of 105 degrees. None system instead of other treatment. In author’s experience PFN long pseudoarthosis were observed. Two cases of distal locking screw system is the “gold standard” in the treatment ispilateral medial breakage were also observed. There were no iatrogenic complications poroximal and shaft fractures. The major advantages of this tech- of the vascular type, nor were there infections. The results we nique are that one device can be used in the management of both obtained suggest that DFN represents a valid alternative to the open fractures, and compression of the neck fracture can be achieved with treatment of fractures of the distal metaphysis of the femur; these the use of a partially threaded lag screw. treatement reduce invasiveness, allow early mobilization, awarded to Results: The major advantage of cephalomedullary nails is that one less blood loss and shorter amount of time require for surgery. device can be used in the management of both fractures without risk of re-fracture. The device reduces the risk of nonunion of both fractures site thanks to the chance of reaming and the chance of compressed of THE TREATMENT OF THE DISTAL FEMORAL FRACTURES the neck fracture by the use of a partially threaded duble lag screw. WITH LISS PLATES - 3 YEARS EXPERIENCE P. Savonitto [1], A. Migliorini [2], G. Rocca [1] [1]Struttura Funzionale di Traumatologia OCM, Verona, Italy; [2] THE TREATMENT OF FEMORAL SHAFT FRACTURES WITH Clinica Ortopedica, Ospedale Policlinico, Verona, Italy ANTEROGRADE AND RETROGRADE INTRAMEDULLARY NAILING The femur metaphiseal fractures are the 8% of all fractures. They are M. Candela [1], M. Arena [1], S. Anastasio [1], G. Mazzarella [1],A. normally caused by a violent trauma to the knee at flexed hip (dashboard Barletta [2] lesion). The action of the strong muscular mass inserted in the area leads [1]U.O. Ortopedia e Traumatologia, Ospedale S. Francesco di Paola, to a characteristic displacement of the fractured stumps. In particular, the Paola, Italy; [2]U.O. Anestesia e Rianimazione, Ospedale combined action of the gastrocnemious and the quadriceps flex dorsally S.Francesco di Paola, Paola, Italy the condyles and this brings often to the fracture of the anterior metaphiseal area. When the trauma divides the two condyles, these flex Objective: The femoral shaft fractures are constantly growing dorsally with a rotating effect often very different between the medial among the population, as a result of the increasing in the incidence and lateral condyle. The osteosynthesis of this anatomic area has never of high-energy injuries, which represent the most frequent cause of offered strong stability guarantee of the progressive decrease of the cor- such fractures. tical bony tissue. LCP plates, thanks to the screw heads with the same Materials and Methods: Between January 2005 and March 2006, we thickness of the plate, guarantee the grip independently by the porosity examined 14 cases (13 patients) of femoral shaft fractures, evaluated of the bone. The forced multiplanar orientation of the screw increases, according to the AO classification, all of which were treated with moreover, the pull-out strength of the whole system. We have been using intramedullary locked nailing. The case study also includes some retro- LCP system for 3 years. Results are shown here. grade nailings, an option adopted in the shaft fractures of the distal third, in the bifocal and ipsilateral fractures and in politraumatised patients. Results: The fracture consolidation, occurred in all cases, was accomplished in an average time of 16 weeks; there was no evidence SESSION O13 of clinically clear malrotation, nor of relevant shortening of the frac- tured limb. In no cases the knee ROM underwent any limitation Discussion: Thanks to the remarkable improvements in the surgical FEMUR MISCELLANEOUS treatment of femoral shaft fractures, patients’ mortality and morbidity rate have been considerably reduced; however, some of these fractures present complicated management and treatment problems, due to the PSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WITH presence of associated injuries in the same or in other skeletal seg- SEVERE PHYSICAL INJURIES ments, concomitant visceral damage and possible exposure of deep tis- C. Carducci, E. Menichetti sues. In order to allow an early recovery of movement and walking, Ospedale S. Camillo – Forlanini, Rome, Italy there is a general agreement that the intramedullary locked nailing guarantees undoubted advantages, as it is a minimally invasive tech- Extensive literature associates the exposure to traumatic events with nique which quickly stabilizes and preserves the fracture focus. the occurrence of psychological disorders: depression, anxiety, spe- Conclusion: Currently the intramedullary locked nailing is consid- cific phobias, Post Traumatic Stress Disorder (PTSD), phobic ered as the elective method for the treatment of femoral shaft frac- avoidance, substance abuse (Shalev, A. Y. and coll. 1998; Usano, R. S21

J. and coll. 1999; Koren, D. and coll. 1999; Schnyder, U. and coll. Objectives: Monitoring incidence and costs of hip fractures in Italy. 2000; Mayou, R. and coll. 2001; Schnyder, U. and coll. 2001; Methods: We examined the Italian national hospitalization database Zatzick, D. F. and coll. 2002). That being so, patients whit severe (SDO) hold by Ministry of Health concerning year 2003 (the most physical injuries were recovered and evaluated at Orthopedic divi- recent available data), considering the following ICD-9CM codes for sion of S. Camillo-Forlanini Hospital from March 2005 to January main diagnosis: 820.0, 820.1 (cervical hip fractures), 820.2 e 820.3 2006. In this period 69 patients (51 men; 18 women) were included (intertrochanteric fr.), 820.8, 820.9 and 821.1 (other hip fr.). Costs in this study. The age ranged from 16 to 65 (average = 30.7 years). were estimated by considering all the related DRG (Diagnosis From this group of patients, people with severe head injuries, sui- Related Groups). cide attempters and victims of physical assault were excluded, due Results: Overall, hip fractures occurred in 29.702 men (14,5 average to previous psychological problems. This exclusion gave a greater hospitalization days) and 76.041 women (15.5). Between 65 and 74 homogeneity to the group. Psychometric instruments included: a years old in: 4.107 (15.7) men and 10.903 (15.6) women; over 75 y.o. Biographical questionnaire, Minnesota Multiphasic Personality in: 15.613 men (15.6) and 59.173 women (15.7). Therefore, incidence Inventory (MMPI), Rathus and Zuckerman. Qualitative analysis of hip fractures is higher in the oldest age groups and particularly in showed the group was made up of subjects with pathologies that women, according to the distribution of osteoporosis in the population. were correlated and non-correlated between them. The main diag- Over 65 y.o., direct costs for hospitalization exceed 400 million Euros, nosis turned out to be the Deferred Diagnosis. With such terms we to be added to further 460 million Euros for rehabilitation. refer to a great area of comorbidity that does not allow a definition of a precise diagnosis, yet such afferent psychopathological prob- lems are all of Anxious-Depressive nature. Such data cannot be THE USE OF INTERNAL SYNTHESIS AFTER EXTERNAL underrated since the same results have been obtained from interna- FIXATION IN POLITRAUMATIZED PATIENTS tional studies on this subject. Therefore we can assert that exposure F. Lavini, E. Carità, R. Bortolazzi, C. Dall’Oca, G. Gioia, L. to traumatic events can provoke Anxious-Depressive symptoms Bonometto, P. Bartolozzi which can become pathologically stabilized in a period of time if Clinica Ortopedica e Traumatologica, Verona, Italy not adequately cured. The present study is still in course and the final results will therefore make reference to a wider group. Objective: In this study the authors evaluate the results of internal synthesis of femoral fractures in politraumatized patients initially treated by external fixation (EF). FLOATING KNEE: IPSILATERAL FRACTURES OF THE Materials and Methods: From January 2002 and December 2005, FEMUR AND TIBIA 39 femurs in 37 politraumatized patients (average age 34.2 yy 18- G. Bonanno [1], C. Villani [1], G. Manfredini [1], F. Stacca [1], R. Lo- 44) with closed fractures and ISS>20 were initially treated with EF. schi [1], C. Zapparoli [2] Group A: 13 cases after 4-7 days (average 5.6). Group B: 11 cases [1]Clinica Ortopedica, Università degli Studi di Modena e Reggio after a longer period of 4-6 months and after execution of MRI and Emilia, Policlinico, Modena, Italy; [2]U.O. Ortopedia e Traumatolo- scintigraphy with labelled leucocytes. Group C: remaining cases gia, Nuovo Ospedale S.Agostino, Estense, Modena, Italy healed with EF. Time of healing, lower limb function, time of return to previous activities and short and long-term complications were Introduction: The ipsilateral fracture of femur and tibia includes a evaluated at the follow-up. combination of diaphysal, metaphysal and intra–articular fractures. Results: Average time of follow-up was 23 months. Group A: time of It is caused by high-energy traumas as auto and motorcycle ones, and bone healing 123 days, no embolism, one case of pseudoarthrosis, one it is associated with cranial, thoracic and abdominal lesions, elevat- case of breaking of instrumentation. Group B: time of bone healing ed risk of pulmonary embolism and involvment of the soft tissue. 274 days, one case of pseudoarthrosis, one case of deep infection. The approach to the patient is initially based on the identification and Group C: average healing time 193 days, 3 cases of screws osteolysis. treatment of lesions to organs and apparatus. Later on the treatment Functional resumption was delayed by presence of other fractures. of every fracture is individually decided, in order to get the best pos- Discussion and Conclusion: External fixation is a simple, quick and sible results keeping in mind all the lesions present in the limb. safe procedure to stabilize fractures in politraumatized patients. Material and Methods: Our case history includes patients treated in According to Damage Control Orthopaedic (DCO) concepts, after an the Orthopedics Clinic from January 1995 to December 2005. The adequate period, it is possible to replace EF for internal synthesis in classification of the fractures is based on the anatomical location order to reduce general risks of this treatment in emergency and to according to the Fraser classification (1978). The type of treatment, in take advantage in post-operative management. EF can be maintained relationship to the local conditions of the limb and the emo-dynamic until the end of treatment but, when a change of synthesis is needed, condition, includes external fixation, ORIF, intramedullary nailing it is possible to do it safely after checking the absence of infectious and non operative treatment. The long term results were evaluated in bone disease. accordance with the criterions of Karlstrom and Olerud (1977). Discussion: The treatment of these complex fractures must have a character of emergency - urgency in the case of unstable patients with THE TREATMENT OF TRANSIENT BONE MARROW EDEMA a large loss of soft tissue, compartment syndrome and vascular – ner- SYNDROME OF THE PROXIMAL FEMUR WITH HYPER- vous lesions, possibly on the same occasion. In case of stable patients BARIC OXYGEN THERAPY with articular fractures the treatment is preferably deferred to allow A. Capone [1], D. Podda [1], V. Setzu [2], C. Iesu [3] an improvement of the cutaneous condition in order to get minor [1]Clinica Ortopedica e Traumatologica, Cagliari, Italy; [2] Casa di complications and best results at long term. The most frequent long Cura Lay, Cagliari, Italy; [3] Ospedale Marino, Cagliari, Italy term complications are represented by delayed union, non union, malunion, dysmetria, instability and ROM reduction of the knee. Background: Transient bone marrow edema syndrome of the femur is a recently well-documented entity that was first described as tran- sient osteoporosis of the hip. Typically the clinical presentation is INCIDENCE AND COSTS OF HIP FRACTURES IN ITALY characterized by acute, progressive pain in the hip that is exacerbat- P. Piscitelli [1], G. Iolascon [2], G. Giuseppe [2] ed by weight-bearing and by a functional disability involved the [1]Libera Università Mediterranea, Bari, Italy; [2] Seconda affected limb. The Magnetic Resonance Imaging (MRI) shows dif- Università di Napoli, Naples, Italy fuse low signal intensity in T1-images and high signal intensity in S22

T2-images extending from the femoral head to the intertrochanteric In the lapse of time between September 1996 and February 2006, region. The bone marrow edema resolves spontaneously after 426 patients with spine tumors have been surgically treated by the approximately six-eight months and the treatment of the symptoms same team of surgeons. 175 were primary tumors, 228 were metas- is therefore obtained by protected weight-bearing and drugs such as tases and 64 patients were affected by vertebral localizations of analgesics and disphosphonates. In the treatment of the disease in hematopoietic diseases such as plasmocytoma and lymphoma. patients with marked functional disability, physical therapy (electro- Eleven cases needed a revision because of instrumentation failure. In magnetic fields or hyperbaric oxigen) or pharmacological therapy more than 90% of these cases, implants broke over the cervical-tho- with diphosphonates or NSAID have been used. racic and thoraco-lumbar junctions. Thirty-nine patients (8.3%) had Materials and Methods: Two groups of 10 patients affected by surgical complications. Most of these events were related to prima- bone marrow edema syndrome of the femoral head were selected: ry lesions, whose treatment is more and more aggressive and there- the first group received pharmacological therapy alone (analgesics fore associated with high morbidity. Frequent complications have and disphosphonates), the second group pharmacological and hyper- been –a dura lesion in 2 cases; -a dehiscence or superficial infection baric oxigen therapy. The clinical outcomes were evaluated accord- of the surgical wound in 10 cases (in 8 cases radiotherapy-related); ing WOMAC evaluation form at 3, 6 and 12 months after the onset -transient neurological deficits in 7 cases; -big vessels lesions in 5 of disease. The bone marrow edema pattern was monitored with cases. Three patients deceased in the immediate post-operative peri- MRI performed after 3, 6 and 12 months. od. One of these events was due to the breaking of the cava vein, Results: The mean Womac scores at 3 months was significantly another one because of massive pulmonary embolism, the third fol- higher (p<0.05) in the hyperbaric oxigen group (71.6 points) than in lowing a laryngeal edema. We want to point out that local recurren- the first group (55.4 points). The mean WOMAC score at 6 months cy is the result of the worst failure of the surgical treatment of the was over 95 points in both groups. The MRI at 3 months showed the spine tumors, above all about primary lesions. Fifty-two patients resolution of edema in 30% of group 1 hips and in 60% of group 2 (15%) out of 344 who were submitted to excisional surgical treat- (p<0.05). For all the patients return to the normal values of the MRI ment have had a recurrency after intra- or extra-lesional excision. images was achieved after an average of eigth months. Conclusions: Patients treated with hyperbaric oxygen therapy recov- ered earlier from hip pain and limb disability than those treated with SPINAL METASTASES: TREATMENT EVALUATION ALGO- only pharmacological therapy. These results suggest that hyperbaric RITHM oxygen therapy is effective in treating transient bone marrow edema A. Gasbarrini, M. Cappuccio, S. Bandiera, L. Mirabile, G. Barbanti syndrome of the hip and reduces the time of disability. Bròdano, M. Palmisani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy SESSION O14 Spinal metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumor. These metastases develop early and are not terminal events, they have to be TUMORS I considered as severe complications because, when possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be GIANT CELL TUMOR OF THE SACRUM multidisciplinary in collaboration with oncologists and radiotherapists. P. Ruggieri [1], R. Biagini [2], G. Bosco [1], M. Rocca [1], M. Di Fiore [1], The average of survival of these patients has increased in recent years. M. Mercuri [1] The evolution of anesthaesiological techniques that permit surgical [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, treatments were once considered prohibitive. The application of new Bologna, Italy; [2]Istituto Regina Elena, Rome, Italy adjuvant therapy increases the effectiveness for surgical treatment. Controversy exists over the most appropriate treatment for patients Materials: From 1974 to 2002, 25 patients with giant cell tumor of with metastatic disease of the vertebral column. The purpose was to the sacrum were treated at the Istituto Rizzoli: 17 females and 8 determine the best sequential process to arrive at the most appropriate males, ranging in age from 14 to 68 years. Mean follow up was 7.2 treatment considering the individual general conditions and the para- years. Surgical treatment included 20 curettages plus local adjuvant meters of the metastases. We review 283 cases in 258 patients suffer- (phenol) and 1 resection. In 13 cases preoperative selective arterial ing from spinal metastases from a solid tumour treated between 1996 embolization was performed in order to reduce intraoperative bleed- and 2005. As the number of treatment options for metastatic spinal dis- ing. Fifteen of the 21 surgically treated cases received preoperative ease has grown, it has become clear that effective implementation of radiotherapy. Surgical margins were intralesional in 20 operated these treatments can only be achieved by multidisciplinary approach. cases and wide but contaminated in the resected case. Results: Neurologic deficits of variable entities were observed in 76% of patients. Oncologic outcome: 17 patients were NED, 5 patients died of CLINICAL EXPERIENCE ABOUT STACKABLE CARBON- disease, 1 patient died of ovarian carcinoma, 2 patients NED1 after treat- FIBER PROSTHETIC REPLACEMENT OF VERTEBRAL BOD- ment of local recurrence). Two patients had radioinduced malignancies. IES (90 IMPLANTS IN 89 PATIENTS) Conclusions: 80% of patients surgically treated (15 received also radio- M. Cappuccio, S. Bandiera, A. Gasbarrini, F. De Iure, L. Mirabile, therapy) remained continuously disease free. Considered that wide L. Boriani, S. Boriani resection may cause severe neurologic deficits, intralesional surgery fol- U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale lowed by radiotherapy is the treatment of choice for giant cell tumor of Maggiore “C.A. Pizzardi”, Bologna, Italy sacrum. Resection is preferable in smaller and distal lesions. Introduction: Long term survival can be expected in bone tumors of the spine when submitted to appropriate surgical and oncologic COMPLICATIONS IN ONCOLOGIC SPINE SURGERY treatment: the replacement of a vertebral body in these selected A. Gasbarrini, S. Bandiera, F. De Iure, G. Barbanti Bròdano, M. cases must be performed aiming to achieve immediate recovery of Cappuccio, L. Mirabile, L. Boriani, S. Boriani function as well as a solid fusion for long term stabilization. The U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale results presented are from a retrospective study on 102 carbonfiber Maggiore “C.A. Pizzardi”, Bologna, Italy prostheses implanted for anterior column replacement after corpec- S23

tomy or vertebrectomy performed for the treatment of bone tumors desarthrodesis were breakage of the rod in 10 cases and infection in 5 of the spine. cases. Knee megaprostheses implanted were 13 Kotz 1 type and 2 Methods: A stackable carbonfiber prosthesis has been used to HMRS. The average follow up of prosthetic reconstruction was 14 years. replace vertebral bodies after 17 corpectomies by anterior approach Methods: All patients were routinely followed in the outpatient clin- and 85 vertebrectomies by a posterior combined an anterior approa- ic and data were obtained from clinical charts. All imaging studies ch or by a posterior approach only for the treatment of 57 primary were reviewed and complications analyzed. Functional results were tumors, 37 metastases and 8 plasmacytomas. In 92 cases chips of assessed according to the MSTS functional evaluation system. autogenous bone were used to fill the prostheses for anterior fusion Results: Oncologic results showed 12 pts. continuously disease free purpose. Twenty-five cases were subsequently submitted to radia- and NED at an average follow up of 20 years. Complications tiontherapy, 3 to chemotherapy, 18 to chemo and radiation therapy. observed included 4 infections (3 had a previous infection of the Results: All the cases were evaluated by clinical, radiographic, and arthrodesis), 1 femoral stem loosening, 2 tibial component loosen- CT scan review. No intraoperative complication connected with the ing, 1 breakage of the tibial joint hinge. Four pts.had revision for we- implant occurred and no mechanical failure of the cage was ar of polyethylene components (2 pts. had 2 revisions). Functional observed. One superficial infection healed within three weeks with results were evaluated in all 15 cases according to the MSTS system antibiotic treatment. Bone ingrowth within and outside the prosthe- and were excellent in 40%, good in 33% and fair in 27% of the pts. sis was demonstrated and the arthrodesis considered “fused” in 83% Discussion: Desarthrodesis and prosthetic reconstruction of the knee of cases; in 6% of cases the fusion was not complete; in 11% of has selected indications. cases did not appear at all. This technique achieved satisfactory results in most cases although the Conclusions: This new carbon-fiber modular prosthesis filled with time elapsed from first surgery could certainly negatively affect muscle autogenous bone chips can fit the different situations occurring after function and strength. The posterior hinge of the prosthetic knee joint vertebral body resection in the treatment of bone tumors of the allows stabilization in hyperextension with minimum muscle strength. spine, allows immediate weight-bearing and promotes a solid fusion. TOTAL FEMUR PROSTHETIC RECONSTRUCTION: THE RIZ- VERTEBRECTOMY THROUGH POSTERIOR ACCESS: PRO- ZOLI INSTITUTE EXPERIENCE MID INTRODUCTION G. Bosco [1], P. Ruggieri [1], E. Botello [2], D. Antonioli [1],M. A. Gasbarrini, S. Boriani Mercuri [1] U.O. Ortopedia e Traumatologia, Ospedale Maggiore, Bologna, Italy [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, Bologna, Italy; [2]Università Cattolica, Santiago, Chile The posterior-access-tecnique vertebrectomy has been described by RoyCamille in 1983 and it was later modified by Tomita. The main Materials: From a series of 896 megaprostheses of the lower limb difference between these two tecniques is that the first foresees the after resection for bone tumors treated at the Rizzoli between 1983 vertebral body or disk osteotomy of the 2/3 of the anterior portion by and 2004, 25 cases of total femur prosthetic reconstructions per- means of a Gigli saw in anterior-posterior direction and the remain- formed between September 1987 and June 2004 were studied. There ing 1/3 is completed using chisels in posterior-anterior direction in were 15 males and 10 females, ranging in age from 7 to 62 years. order to avoid spinal cord damages. In Tomita modified tecnique a The average follow up of prosthetic reconstruction was 52 months. smaller saw is instead used through a dedicated instrument set with Total femur prostheses included 4 Kotz 1 type, 20 HMRS prostheses spatulas protecting the spinal cord. The difficulty in controlling the (1 rotating hinge and 1 expandable), 1 GMRS prosthesis. saw path, which depends on the surgeon and on the assistant keep- These were 19 primary reconstructions and 6 secondary in revisions. ing the spatula, and the lack of predictability of the surgical depart- Histological diagnosis included 15 osteosarcomas, 7 Ewing’s sarco- ment completion make this procedure unsure, so that many surgeons mas, 1 angiosarcoma, 1 chondrosarcoma and 1 Echinococcosis. prefer making the osteotomy with chisels, bistoury and scissors. The Surgical margins of the 24 tumors were wide in 23 and wide/conta- Tomita’s saw has the advantage of obtaining a perfectly smooth sur- minated in 1. For soft tissue reinsertion to the prosthesis different face for the reconstruction prosthesis positioning, reducing bleeding techniques were used. and surgery time. For this reason, we are using a system (Promid) Methods: All patients were routinely followed in the outpatient clin- which, connected to the stabilization rod, guides the saw protecting ic and data were obtained from clinical charts. All imaging studies the spinal cord during all of its path, until the complete vertebral were reviewed and complications analyzed. Functional results were body section is obtained. assessed according to the MSTS functional evaluation system. Results: Oncologic results of 24 tumors showed 11 pts. continuous- ly disease free and NED at an average follow up of 111 months (9 - DESARTHRODESIS AND PROSTHETIC RECONSTRUCTION 215 mos.), 2 pts. AWD at 20 and 32 months respectively, 11 pts. OF THE KNEE AFTER BONE TUMOR RESECTION: LONG DWD at an average of 24 months (6-66 mos.). Complications TERM RESULTS observed included 1 infection, 3 hip dislocations, 1 ETA detachment P. Ruggieri[1], G. Bosco [1], E. Botello [2], A. Galvani [1], D. Donati and 2 glutei disinsertions. Functional results were evaluated in 20 [1], M. Mercuri [1] cases, while 5 pts. with a prosthetic follow up of less than 6 months [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, were not evaluable. According to the MSTS System results were Bologna, Italy; [2]Università Cattolica, Santiago, Chile excellent or good in 85% of pts. Discussion: Total femur prosthetic reconstruction has selected indi- Materials: Fifteen patients were operated of desarthrodesis and cations. Complication rate was relatively low and functional results knee megaprosthesis at the Rizzoli between December 1983 and were satisfactory in most pts. October 1995. There were 7 males and 6 females, ranging in age from 13 to 36 years. In all cases a resection of a malignant bone tumor of the distal femur had CHONDROSARCOMA PROXIMAL HUMERUS: HISTORY OF been previously performed and reconstruction obtained with a knee CLINICAL CASE arthrodesis using Kuntscher rod and cement. Histological diagnosis was W. Leonardi, F. Nicolosi high grade osteosarcoma in 12 cases, low grade parostal osteosarcoma in U.O. Ortopedia e Traumatologia, Azienda Ospedaliera A.S.R.N., 1, malignant fibrous histiocytoma in 2. Causes of revision and Garibaldi-Santi Curro’, Ascoli Tomaselli, Italy S24

Introduction: Chondrosarcomas account for about 20% of primary catheters will be loaded to avoid the risk of scar problems. The after- malignant bone tumours; the clinical behaviour is variable. The major- loading catheters can remain in situ for several days to allow the fea- ity (80-90%) are low grade malignant tumours. Solitary(single) sibility of fractionated perioperative HDR brachytherapy. The frac- tumour is more common than multiple. A low grade, more indolent tion size depends on residual desease. After 2 weeks external beam tumor is more likely to effect an elder patient. Chondrosarcoma occurs irradiation is administered. in two forms: Primary in 75 % and Secondary in association with mul- Results and Discussion: The combination of postoperative boost tiple enchondromatosis e.g. Ollier’s disease and Maffucci’s syndrome; HDR Brachytherapy with External Beam Irradiation was used in 8 Exstosis, Condroblastoma; age is 30-60 years and male < female 2:1. cases. Authors emphasized the potential effects of this method: pos- Central axial skeleton, pelvic girdle, ribs, shoulder girdle, vertebrae & sibility of dose fractionation, better compliance with radiation safe- sternum are involved. Clinically it shows as a gradually enlarging ty policies, more sophisticated treatment planning, possibility of painfull mass(low grade type); metastasis is relatively rare. outpatient treatment delivery and low costs compared to Low Dose Materials and Methods: We observed an 82 year old patient of with Rate Brachytherapy. This approach appears feasible. However, fur- a mass by right proximal humerus of 13 cm of diameter due to a ther investigation on local control and toxicity is needed. pathological fracture which had not healed the year before. The patient was subjected to Clincal test, X-Ray, MRI, TAC, Scintigrafy Total Body, Tumor Markers. Bone biopsy was carried out with diag- SOFT TISSUE SARCOMAS ARISING IN THE POPLITEAL nosis of Dedifferentiated Chondrosarcoma. Dedifferentiated chon- FOSSA: OUR EXPERIENCE drosarcoma is the most malignant form of chondrosarcoma. This C. Scotti [1], F. Camnasio [1], G.M. Peretti [2], F. Fontana [1],G. tumor is a mix of low grade chondrosarcoma and high grade spindle Fraschini [1] cell sarcoma, where the spindle cells are no longer identifiable as [1]U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, having a cartilage origin. This biphasic quality is evident on x-ray, Università Vita-Salute, Milan, Italy; [2]U.O. di Ortopedia e where areas of endosteal scalloping and cortical thickening alternat- Traumatologia, Ospedale San Raffaele, Facoltà di Scienze Motorie, ed with areas of cortical destruction and soft tissue invasion. In Università degli Studi di Milano, Italy February 2006 the patient was operated with right forequarter ampu- tation in accordance with Berger and Littlewood for the anterior and High grade soft tissue sarcomas arising in the popliteal fossa, axilla, posterior approuch; the patient was then transferred to the intesive and antecubital fossae (flexor fossae tumors) have been classified by care department for 36 hours; the redons were removed on the3rd convention as extracompartmental tumors by the accepted staging day after surgery; no deep or superficial infection was reported. On and grading criteria of the Muscoloskeletal Tumor Society (MSTS). the fifth day the aptient was able to walk again. Extracompartmental location of the tumor makes surgery more chal- Conclusion: Dedifferentiated chondrosarcoma has a 5 year survival lenging. Advances in chemotherapy and radiation therapy have made of 10%. In our opinion, the forequarter amputation has been the gold surgical resection more feasible. In particular, neo-adjuvant standard considering both the patient’s age and the tumor progress. chemotherapy is indicated in larger tumors and high-grade tumors; At the time being the patient is in good condition and reports no adjuvant chemotherapy can be used; radiation therapy is mandatory, ghost limb pain. as adjuvant, in order to sterilize the margins of the resection. From 1994 to 2005, ten patients with soft tissue sarcomas of the popliteal fossa were treated in our department. The mean age of patients was 64 (range 45 to 82). The histologic subtypes were: liposarcoma, SESSION O15 myxoid liposarcoma, high-grade sarcomas, malignant fibrous histio- cytoma, synovial sarcoma and spindle cell sarcoma. Tumor grade varied from low to high grade, maximal diameter ranged from 6.5 to TUMORS II 18.5 cm, with a mean of 12.4 cm. All patients underwent total body CT scan and bone scan for routine pre-operative staging. The surgi- MULTIMODAL APPROACH TO THE TREATMENT OF SOFT cal approach of tumors located in the popliteal fossa is often com- TISSUE SARCOMAS: FEASIBILITY OF USING HIGH DOSE plicated by the presence of the neurovascular bundle, which can be RATE BRACHYTHERAPY incorporated in the tumor. Some authors indicate complete resection G. Maccauro [1], S. Manfrida [1], F. Muratori [2], G.C. Mattiucci [1], of vessels and substitution with prosthesis. We preferred to spare the G. Arrabito [3], M.A. Rosa [3], G. Mantini [1], N. Dinapoli [1],V. vessels even when surrounded by the tumor, relying on the adjuvant Valentini [1], N. Cellini [1], C.A. Logroscino [1] therapies, which were performed in all cases. No local recurrencies [1]Policlinico Gemelli, Rome, Italy; [2 ]Ospedale San Pietro were reported in our series. Therefore, we believe that popliteal “Fatebenefratelli”, Rome, Italy; [3]Dipartimento Ortopedia, fossa sarcomas can be treated with limb sparing surgery in associa- Messina, Italy tion to chemotherapy or radiation therapy.

Purpose: Conservative treatment of soft tissue sarcomas usually required a combination of surgery and External Beam Irradiation, SURGICAL TREATMENT OF THE METASTASIS OF THE TI- considered a useful adjuvant to surgery. In particular, Low Dose BIA: REVIEW OF THE LITERATURE AND OUR EXPERIENCE Rate Brachytherapy is indicated in intermediate and high grade sar- F. Liuzza [1], F. Visci [1], M. Esposito [1], M. Alesci [2], G. Maccauro comas and in recurrence to allow additional local dose in areas at [1], M.A. Rosa [2] risk for local failure. The aim of this work is to analyze feasibility, [1]Policlinico Gemelli, Rome, Italy; [2] Dipartimento di Ortopedia, methods, advantages and limits of using High Dose Rate (HDR) Messina, Italy Brachytherapy Remote After Loading associated to External Radiotherapy, an interesting perspective in the multi modal treat- Metastatic localization of the tibia is a rare event that occurs in the ment soft tissue sarcomas. late stage of the neoplastic disease. This localization constitutes a Methods: At surgical time total irradiation volume is based on pre- complex and controversial biomechanical and therapeutic problem operative imaging, and hystotype. The irradiation area is defined by because of a real risk of pathological fracture. There are several markers. After tumour resection catheters are placed parallel at 1.5 options of treatments: external radiotherapy, therapy with hor- cm of distance perpendicular to the scar. Seven days after surgery mones, diphosphonate, radioisotopes, curettage with acrylic S25

cement, plates, intramedullary nail, prosthesis and amputation. The Skeletal Repair System (Norian) represents an attempt to find a Surgical technique should be chosen according to the metastasis synthetic substitute of the bone, for the resolution of traumatic localization in the osseous segment, primitive tumour, adjuvant pathology where the bone loss was the crucial point. In the last few therapy results, life expectancy. The aim of the present study is to years the interest for the biological cement shifted to the treatment review the percentage of tibial metastases from carcinoma, the of non traumatic orthopaedic pathology where a bone substitution most common histotype causing these lesions, the possible surgi- was necessary and the treatment of hand enchondromas was includ- cal approach of this osseous segment and the results after surgery. ed in this field. From February 1998 to March 2006 in the Operative For this reason, a review of the Literature and a retrospective Unit of Hand Surgery and Microsurgery of Modena Policlinics, the analysis of all patients affected from tibial metastases and under- Aa. treated 45 patients with enchondromas of the hand by synthetic gone surgical treatment at the UCSC of Rome from 1998 to 2005 cement Norian. have been performed. In particular 10 patients, 6 males and 4 The outcome studies performed evalutation of pain, range of females, were evaluated. Each patient had a pathological fracture motion, early return to daily life activities and post-operative X- or an impending fracture. Therefore, a surgical treatment has ray control. The data analysis showed good clinical results in 37 always been necessary. From the analysis of the Literature and controlled patients. All patients had no pain and returned to daily from our experience it can be deduced that surgical treatment of life activities in a short period. Post-operative X-ray showed a the metastases of the tibia can be done in patients with a life progressive reabsorption of the synthetic cement. In the controlled expectancy longer then 3 months. The surgical treatment enables patients there was not a significant reduction of motion range. In pain relief, improvement of the quality of life, of lower limb func- two patients there was an incomplete removal of the tumour due tion, of nursing assistance and helps in keeping such a personal to a surgical error and a case presented an inflammation of the fin- independence of the oncologic patients. In conclusion authors ger tip due to infiltration of the synthetic cement in the soft tis- think that choosing a surgical treatment of these metastases, should sue. The mini-invasive procedure, an early mobilization and con- consider the systemic extension of the neoplastic disease, therefore sequently the return to daily life and working activities in a short it should be low invasive except for some histotypes as the carci- time represent the basis for the use of the synthetic cement. The noma of the kidney having a better prognosis in terms of survival. results confirm that this technique can be introduced as an alter- native to the traditional treatment techniques for enchondromas of the hand. Future researchs should consider the inflammatory- ANTEROGRADE FEMORAL NAILING (AFN) FOR THE immunologic response induced by biological cement, the osteoin- TREATMENT OF FEMORAL METASTASES: A REPORT OF ductive-conductive properties of the cement and the real evalua- 10 CASES tion of reabsorption. F. Liuzza [1], F. Pezzillo [1], B. Rossi [1], F. Muratori [2], G. Maccauro [1] [1]Policlinico Gemelli, Rome, Italy; [2]Divisione di Ortopedia, Ospedale San Pietro FBF, Rome, Italy CEMENT LEAKAGE IN PATIENTS AFFECTED BY SECON- DARY OSTEOPOROSIS DUE TO MULTIPLE MYELOMA AND Metastatic involvement of femur is a common clinical problem and CHRONIC MYELOID LEUKEMIA TREATED WITH VERTE- accounts for the third highest incidence after spine and pelvis. Surgical BROPLASTY. TWO CASE REPORTS AND REVISION OF THE approach is indicated for wide lesions, pharmacological and/or radiant LITERATURE resistant lesions and for pathological fractures. Either pain relief and G. Barbanti Bròdano, M. Cappuccio, L. Mirabile, L. Boriani, A. treatment of probable complication as pathological fractures by a solid, Gasbarrini, S. Boriani definitive and durable system are the aims of a surgical approach, Uo Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale according to clinical conditions of the patients. According to the Maggiore “C.A. Pizzardi, Bologna, Italy Literature, the intramedullary locked nailing is indicated for multiple shaft lesions and for patients with short life expectancy or severe gen- Multiple myeloma and chronic myeloid leukemia are blood diseases eral clinical conditions in order to stabilize the whole bone segment, that frequently affect elder patients. In the last 5-10 years the effica- with Recon assembling to prevent or to treat the localizations of the cy of specific chemotherapic schemes has enormously improved femur. This technique is effective to reduce the pain, to restore motion these patients’ prognosis. This situation brings more and more often of the hip with few post-surgical complications. Authors retrospective- to the surgeon’s attention patients with spine lesions and deformities ly analyzed a consecutive series of 10 pathological fractures or due to the effect of the disease itself and to the secondary osteoporo- “impending fractures” of the femur treated with a new intramedullary sis chemotherapy induced. Spine surgeons have to face empty and system (AFN), with the previous characteristics. In particular it has a painful vertebrae that cause spine failure and do not allow patient to proximal diameter of 17 mm and a distal diameter variable between 10 walk and stand. Literature has widely demonstrated how useful ver- and 12 mm with the possibility to insert 2 proximal nails and 2 distal tebroplasty and kiphoplasty are in relieving pain and in functional static hole. The histotypes were breast cancer (4 cases), colon-rectus recovery of this kind of patients. We report our experience on two (2), lung cancer (2) and mieloma (2). Curettage and/or filling with cases, each of them treated at 5 segments because of respectively the acrylic cement has not been necessary in any case. Intramedullary outcomes of a multiple myeloma and of a chronic myeloid leukemia. locked nailing has always been performed in static mode by two distal Both patients had partial improvements in pain and function, but nails. Breaking and mobilizations of the means of synthesis had never cement leakage was almost a constant. It also flew into the vertebral happened. Either pain reduction or relief, recovery of articular function canal, but fortyunately neither symptoms or neurological compres- and deambulation, perioperative bleeding, survival have been consid- sion happened. When we have to deal with highly altered vertebrae, ered. Authors believe that AFN could be particularly indicated in the as in these cases affected by neoplastic diseases and secondary osteo- treatment of secondary lesions of the femur thanks to either its biome- porosis, vertebroplasty seems to present a significant risk of cement chanical characteristics and the results obtained up to now. leakage. This complications is instead not so frequent in both senile and post-menopausal osteoporosis patients. Kiphoplasty gives better results concerning pain control and functional recovery, as Dudeney THE UTILIZATION OF SYNTHETIC CEMENT NORIAN IN et al. have recently described (J Clin Oncol.2002). Kiphoplasty is THE TREATMENT OF THE ENCHONDROMAS OF THE HAND moreover much safer than vertebroplasty as regard cement leakage A. Landi, N. Della Rosa complication. Kiphoplasty seems better than vertebroplasty in the U.O. di Chirurgia della Mano e Microchirurgia, Azienda treatment of patients affected by multiple myeloma and chronic Ospedaliera Policlinico Modena, Italy myeloid leukemia because of minor risk of cement leakage. S26

ESSION to December 2002, 65 consecutive hip revision surgeries were per- S O16 formed mostly for aseptic loosening. Femoral bone stock defects were classified according to AAOS’s criteria and consisted mainly in type II and type III. A Wagner osteotomy was performed in 25 PROSTHESIS II cases to remove primary implants that were cemented in 35 cases. Mean post-operative follow-up was 69 months (range, 36 to 91 UNCEMENTED REVISION PROSTHESIS SL WAGNER IN months). Clinical assessment at follow-up showed a significantly THE TREATMENT OF THE PERIPROSTHETIC FRACTURES improved mean Harris Hip Score from 42 points preoperatively to G. Grappiolo, G. Burastero, G. Santoro, A. Camera, G. Moraca, L. 81 points postoperatively, while the x-ray examination did show a Spotorno satisfactory distal integration of the stem in all cases and satisfac- Ospedale “Santa Corona”, Pietra Ligure, Italy tory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was under one mil- Introduction: One of the worst problems in the orthopedics limeter. According to the data leg length discrepancy exceeding 15 surgery is the periprosthetic fracture after THA. However there is millimeters caused significantly higher functional impairment and not a complete agreement about its treatment. Even if it is rela- more pain. tively rare (incidence near to 2%), the number of cases is growing because of the higher mean age of the patients and the number of the implants. TREATMENT OF PERIPROSTHETIC FRACTURES OF THE Materials and Methods: About 800 THA are performed every year FEMUR IN PATIENTS TREATED BY TOTAL HIP ARTHRO- in the Hip Surgery Unit of the “S. Corona” Hospital. The hip PLASTY periprosthetic fractures are 115 (M 24- F 91), mean age 69,86 aa. G. Pignatti, G. Trisolino, N. Rani, G. Armando Nearly the totality of the B2-B3 hip periprosthetic fractures accord- Istituti Ortopedici Rizzoli, Bologna, Italy ing to Vancouver classification are treated with the removal of the Periprosthetic fractures of the femur can be treated in different ways: prosthesis and the implantation of an uncemented SL Wagner stem conservative treatment that includes traction and immobilization with diaphyseal anchorage with brackets and made of titanium with a cast and surgical treatment that involves open reduction and porous. The patients are 67 (M 13- F 54) with mean age 71 aa ± fixation when the implant is stable, or stem replacement if it is loose. 11(min 34 max 89); the intra e post-op hemorescue system has Various techniques and surgical devices have been described in the allowed to nomalize the hematic defluxio (about 1500 ml). literature to treat these fractures. We present a retrospective study of Results: The mean follow-up is 6,5 aa with max follow-up 14 aa (11 periprosthetic fractures treated in our ward over 12 years. We treat- patients deceased and 3 lost to the follow-up); the survival rate is ed consecutively 17 patients, 3 men and 14 women, with peripros- 97%; two cases of septic mobilization, one case of pending revision. thetic fracture of the femur. Their mean age was 72 years (range 52- The clinical results are good, average HHS 87/100, and satisfactory 88). According to the Vancouver classification, 6 were type B1, 7 in all patients. type B2, and 4 type C. Twelve patients underwent fixation and 9 Discussion: Our preferred treatment allows us to obtain a higher stan- stem replacement. None of the patients were treated conservatively. dard than the treatments with osteosynthesis previously utilized; the Mean follow-up was 20 months (range 8-114). The fracture healed pre-op planning and a good intra-op routine permit a shorter and com- in all patients and weight bearing was resumed between 2 and 6 petitive surgical time on contrast to traumatologic tecniques. F.K.T is months after surgery. The clinical results were good to excellent, and very important for rapid functional resumption. The new offset of the the mean Merle-D’Aubigne Score improved from 3.47 (range 3-5) to stem, the good cablage of the great trochanter and the use of the large 16.52 (range 14-18). We believe that when possible surgical treat- heads (or cups constrained with ring) limit the risk of dislocation. ment of periprosthetic fractures of the femur should be the first choice of treatment thanks to the high success rate. RESECTION HINGE PROSTHESIS IN NON-ONCOLOGICAL DISEASES A NEW PROXIMAL FEMUR RECONSTRUCTION PROSTHE- D.S. Tigani, M. De Paolis, G. Trisolino, N. Del Piccolo, M. Mercuri, SIS: MPM-GB-COMPOSITE A. Giunti A. Gasbarrini, S. Terzi, S. Boriani Istituti Ortopedici Rizzoli, Bologna, Italy U.O.Ortopedia e Traumatologia, Bologna, Italy

Resection hinge prosthesis are currently being used for reconstruct- The proximal femur bone substance larger losses are related to: ing joints after bone resection in oncological diseases. The good resections due to oncologic problems, massive mobilization of a clinical results and the availability of new materials and designs pre-existing hip prosthetic implant or, more rarely, grave traumato- have also led to their use in secondary bone defects in non-ontolog- logic outcomes; these losses cause problems in recostruction pro- ical diseases, such as non-union and conventional joint replacement. cedures. Until today it was possible to choose between a metallic This study reports the preliminary results of a retrospective analysis reconstruction prosthesis or a combination of a revision prosthesis performed on 12 patients treated at our institute with resection hinge and a massive proximal femur homoplastic bone insert (composite prostheses in non-oncological diseases. prosthesis). The authors present a new prosthetic system, opti- mized in year 2004, which allows to perform both kind of recon- structions. The prosthesis, in titanium alloy, is composed by: a ® FEMORAL REVISION WITH THE MODULAR ZMR STEM. stem of variable diameter, available both in cemented and unce- CLINICAL AND X-RAYS RESULTS AT MEDIUM TERM FOL- mented versions which, once introduced, is the base for the further LOW-UP assemblings; a higly modular body, prepared for both anchorage to M.F. Surace, L. Murena, A. Sinigaglia, G. Zatti, P. Cherubino soft tissues or fitting within massive bone inserts; a proximal por- Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, tion characterized by two neck and three head sizes and two offset Università degli Studi dell’Insubria, Varese, Italy possibilities. The possible femural resection is within 40 and 300 mm. Since 2004 the MPM-GB-Composite prosthesis has been A retrospective review was conducted to evaluate the medium-term implanted in 13 patients: in 7 cases it has been adopted after results of the ZMR modular revision taper stem. From March 1999 tumoral resections, in 2 cases for a prosthetis re-implant, in 4 cases S27 because of post-traumatic bone losses. The main features of this SALVAGE OF FAILED OSTEOSYNTHESIS OF PROXIMAL prosthetic system are the versatility in the diameters choise, FEMURAL FRACTURER AND COMPLEX KNEE FRACTURES lengths, kind of fixation, kind of reconstruction, and the flexibility WITH MODULAR MEGAPROSTHESES in the components assembly which also allows to modify the P. De Biase, M. Mugnaini, L. Ciampalini, R. Capanna antiversion degree in any moment; moreover, it enables to success- Dipartimento di Ortopedia, SOD Ortopedia Oncologica, Florence, fully manage problems related with surgical proximal femur recon- Italy struction. Surgical revision of osteosynthesis failures in complex fractures of the proximal and distal femur is often a very complex, long lasting ACETABULAR REVISION SURGERY IN THE PRESENCE OF procedure with an unacceptable high rate of perioperative and post- SEVERE BONE LOSS: SURGICAL TECHNIQUE AND EARLY operative complications. Different techniques have been proposed: RESULTS WITH MODULAR POROUS TANTALUM AUG- revision prosthesis, strut graft augmentation, massive allografts. We MENTS AND CUPS want to present an original technique derived from authors’ experi- G. Zatti, L. Murena, M.F. Surace, G. Riva, C. Ratti, P. Cherubino ence with tumoral modular prosthesis which can represent a quick, Università dell’Insubria, Varese, Italy efficient and long term solution with a quite rapid return to activities. From 1995 to march 2006 15 patients (M/F=7/8) have been treated Subject: In the presence of minimal acetabular bone loss most revi- with a proximal femur megaprosthesis (Waldemar Link, C system) sion procedures can be done with the use of an uncemented hemi- to salvage a failed osteosynthesis. In every case the modular pros- spheric device with or without morselized allograft. thesis was implanted after two previous failed attempts of ORIF. The The use of modular porous tantalum augments and cups has been prosthesis was implanted as a bipolar head or with an acetabular cup recently introduced to address more severe bone deficiencies. The depending on patient’s age. Average operative time was 150 minutes. purpose of this study is to describe the surgical technique and early We did not observe perioperative complications, with an average age clinical results obtained with trabecular metal acetabular augments of the patients of 72 years. At 5 year follow up the functional results in cases of acetabular revision with severe bone loss. were excellent or good in 14 out of 15 cases. The fair case was due Materials and Methods: Since November 2003 seven acetabular to a dislocation of the total hip and further revision with a con- revisions have been done by means of TMT® augments and cups: strained socket. The results remained poor for the late (8 year) infec- the primary indication for acetabular revision was aseptic loosening tion of the prosthesis and subsequent removal of the prosthesis and in five patients and septic loosening in two patients. positioning of a cement spacer loaded with antibiotics. Treatment of According to Paprosky classification the acetabular bone defects this case is still in progress. We used the same modular megapros- were classified as follows: 2B in two hips, 2C in one hip, 3A in two thesis system in two cases of complex knee fractures. The patient hips and 3B in three hips. In two cases it was the first surgical hip treated with a distal femoral prosthesis had a traumatic bone loss of replacement procedure. Five cases were multiple revisions. distal femur of 12 cm, including condyles; the other patient had an Results: At an average follow-up of 24 months no implant had evi- articular fracture of proximal tibia with tibial tuberosity avulsion. dence of loosening or migration. No dislocations occurred. Both patients had a good result. In conclusion we believe that in Discussion and Conclusions: Augments provide mechanical sup- selected cases with previously failed ORIF and important residual port to hemispheric cups of various dimensions. This surgical tech- bone loss this technique offers a valid alternative to arthrodesis. nique avoids the use of structural allograft, helps to restore the cen- ter of hip rotation and increases contact area between the implant and the host bone for biological fixation. Longer follow-up is FOUR-YEAR FOLLOW-UP OF A TANTALUM, MONOBLOCK required to verify survival of these implants and potential mechani- ACETABULAR CUP: CLINICAL AND RADIOLOGICAL RE- cal and biologic complications related to use of this modular TMT® SULTS system. C. Doria, F. Milia, L. Tidu, M.A. Fadda, P. Lisai, L. Floris, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy PROSTHESIZATION IN CROWE GRADE IV HIP DYSPLASIA: INDICATIONS,TECHNIQUES AND RESULTS Objective: Osteolysis secondary to polyethylene wear is the most F.P. Ciampa, L. Guerra, M. Barbato, E. D’Angelo serious aseptic long-term complication following total hip replace- Ospedale G. Bernabeo, Ortona, Italy ment (THR). Studies have shown that fixation with screws, modu- larity and lack of extensive bone ingrowth are associated with Prosthesization in Crowe grade IV hip dysplasia is a surgical tech- increased osteolysis. This study examines our experience with tanta- nique which is technically demanding for the surgeon and requires lum cup designed to address these issues. strong motivation from the patient (because of localized pain or pain Materials: Between 2000-2001, seventy-two consecutive primary in the supra and sub-segmentary structures), as well as a careful pre- THR were performed using uncemented monoblock, elliptical, tan- operative assessment and an accurate execution of the operation. talum cup without screw holes. Average follow-up was 61 months Prosthesization can take place in single stage or two stage surgery, (range 54 to 72). Average age was 67.5 years (range 46 to 81). Pre and the site for placement can be the neocotyle or the paleocotyle. and post-operative clinical assessment used Harris hip score (HHS), The authors report their experience, in which they privileged single WOMAC and SF-36. One independent, blinded observer performed stage surgery and placement of the prosthesis in the paleocotyle. The zonal radiographic analysis with De Lee and Charnley method. use of appropriate modular prosthesic systems makes it possible to Results: Average HHS at recent follow-up was 91 (range 85 to 100). regain adequate functional dysmetria of the rotational centre, as well All cups appear fixed with bone ingrowth. Dome-gaps present in 4 as to benefit from the unquestionable advantage of performing the cups post-op; all have filled in. Radiolucencies at follow-up: 2% operation in one stage. There is a description of the surgical tech- zone 1, 6% zone 2; none greater than 1 mm. No cup migration was nique used, comprising an ample lysis of the articular and peri-artic- observed. None cup related complications. ular environment, positioning the acetabular cup in the paleocotyle, Conclusion: Tantalum cup provides secure, symptom-free fixation at 4 shortening of the femur, and the use of a modular prosthetic stem. years. No complication was reported associated with use of tantalum. The results obtained and the not uncommon complications limit this The elliptical shape of the cup creates an interference fit with the spher- type of surgery to selected cases. ically reamed acetabulum. From the pole of the dome, the interference S28

fit increases until a 2 millimeter differential is achieved at the face of the percent of the athletes evaluated were able to return to their pre- cup. Tantalum possesses a substantially higher coefficient of friction on injury activity levels, while 61% had either normal or nearly normal cancellous bone than other implant materials. This property facilitates IKDC scores. At 1 year follow-up, the STG group was noted to have direct bone apposition to increase initial stability at implantation. a weaker mean flexion strength deficit as compared to the ST group. However, these were not found to be statistically significant. Clinically, patients who underwent ACLR with STG demonstrated CEMENTLESS FEMORAL REVISION WITH TAPERED CONI- higher incidence of re-injury. CAL STEMS: THE EVOLUTION OF DESIGN FROM WAGNER Conclusion: ACL reconstruction in female athletes using ST or STG TO RESTORATION CONE-CONICAL demonstrated comparable clinical outcomes. However, a higher inci- R. Binazzi dence of re-injury was observed with the STG group which may be Istituto Ortopedico Rizzoli, Bologna, Italy related to the greater strength deficit observed following this type of reconstruction technique. Therefore, we recommend the use of ST Mid-term results obtained with the conical tapered stem designed by alone in ACL reconstructions of female athletes, especially those Wagner for cementless hip revision were on the whole very encour- involved in pivoting or cutting sports. aging. Neverthless we have identified some defects of the stem such as an excessive valgus neck, an insufficient offset for larger stems and a lack of modularity, making soft tissues tension sometimes dif- DOUBLE BUNDLE SINGLE TENDON ACLR ficult. The T3 stem was designed with the purpose of correcting A. Gobbi, R. Francisco, A. Sandoval these defects. The T3 stem is made of Titanium alloy with a textured Orthopaedic Arthroscopic Surgery International, Milan, Italy surface finish and is modular. The lateral offset has been increased to 42 mm (34 mm for Wagner’s stem) and the cervico-diaphyseal The conventional ACLR was designed to replace the AM bundle angle has been reduced from 145° to 138° degrees. Recently, the T3 with the graft located at the 11 o’clock position (R knee). The results stem has been substituted by the Restoration having a more varus obtained with this technique have been successful in restoring ante- neck (132° instead of 138°) and 3 sizes of distal stem (instead of 2). rior knee stability. Current studies have questioned its ability to pro- In this retrospective study we have analized the preliminary results vide rotatory stability. obtained with the T3 stem. We reviewed the first 30 consecutive Methods: From 2001 to 2004, 15 patients were randomly selected cases having an average FU of 6.2 years (range 4.7 - 8 years). We and underwent ACLR using only the ST tendon. Two tibial and two have always used a trans-femoral approach with “prophylactic” dis- femoral tunnels were prepared. The femoral tunnels were positioned tal cable circlage. In no case a homologous bone graft was used. at 11:00 (AM) and 9:00 (PL) with inside-out technique. Femoral fix- 90% of the cases were rated Excellent or Good. No re-revision was ation was achieved with two endobuttons CL while tibial fixation necessary. 87% of the femurs showed good bone reconstruction and was carried out with screw post. Post-operatively, patients under- 24% some subsidence (only two cases >1 cm) without clinical symp- went a standardized rehabilitation program. Results were compared toms except for the necessity of a compensatory heel pad. Distal fix- to a similar group of patients who underwent ACLR using quadru- ation stems like T3 are the implants of choice for severe bone stock pled semitendinosus grafts. loss (Paprosky 2C-3) for their immediate mechanical stability allow- Results: At two years, no significant difference in IKDC scores ing early weight bearing. Transfemoral approach allows complete (p<0.05) was observed. 91% of those operated using double bundle removal of debris and scar tissue, enhancing bone reconstruction. and 89% of those with single bundle ACLR were normal or near nor- mal. Anterior tibial translation demonstrated a similar trend with a mean of 1.9 mm for double bundle technique and 1.8 mm for single bundle. In the double bundle group, 1 patient had motion deficits SESSION O17 (10°-120°) while another patient had impingement. Conclusions: No significant differences between single bundle and anatomic double bundle ACL reconstructions were observed. The ARTHROSCOPY I better rotational stability with double bundle technique remains to be consistently demonstrated as no validated examination technique COMPARATIVE ANALYSIS OF ACLR AMONG FEMALE ATH- has yet been established. The use of two separate femoral and tibial LETES USING ST VS STG tunnels may be more anatomic but technically demanding and prob- A. Gobbi, A. Sandoval, R. Francisco, L. Busato ably prone to surgical errors. Orthopaedic Arthroscopic Surgery International, Milan, Italy

Objective: To determine the difference in the clinical outcome DIFFERENCE IN DEEP KNEE FLEXION AND INTERNAL among female athletes after ACLR when using only the ROTATION AFTER ACL RECONSTRUCTION USING SEMI- Semitendinosus (ST) tendon versus the combined use of both the ST TENDINOSUS OR SEMITENDINOSUS AND GRACILIS and gracilis (STG) autografts. AUTOGRAFTS We hypothesize that the female athletes would benefit more from a A. Gobbi, R. Francisco, A. Sandoval single ST Hamstring ACLR compared to a combined STG construct. Orthopaedic Arthroscopic Surgery International, Milan, Italy Methods: 38 cases of ST and 26 STG ACLR were evaluated pre- operatively, then at 12 and 24 months following surgery. Standard Objective: To document the changes in hamstring muscle strength technique for reconstruction and a uniform rehabilitation protocol among patients who had ACLR using hamstring autografts. We was used. Parameters analyzed included standard knee scales hypothesize that using both the STG tendons could lead to greater (IKDC, Noyes, Lysholm, Tegner), SANE score, computerized knee flexor weakness at deeper flexion angles (>90°) when compared to laxity analysis, deep flexion and Isokinetic tests. Results were sta- reconstructions using only the ST tendon. tistically analyzed using the student’s t-test. Materials and Methods: From October 2000 to November 2002, 100 Results: No significant statistical differences were noted in the final patients ACLR using either the semitendinosus (ST) or both the semi- Tegner, Lysholm, Noyes, IKDC scores, and computerized knee lax- tendinosus and the gracilis tendon (STG). Pre-operative and post-oper- ity analysis between ST and STG groups (p=0.05). Seventy-seven ative evaluation included the use of standard knee scales (IKDC, S29

Lysholm, Tegner, Noyes); computerized arthrometry to document knee In the last years the industries have developed several technologies for laxity; isokinetic tests; and measurement of deep knee flexion angles. in vitro cultivation and reconstruction of woven or organs, defining a Statistical analysis was then performed using paired t-test. new branch of biomedical sciences known like “woven engineering”. Results: IKDC, Lysholm, Tegner, and Noyes scales demonstrated no This technology allows us to expand autologous cells and to re-use significant difference between the two groups (ST vs STG) (p<0.05). them to repair and regenerate woven lesions using three-dimensional Computerized laxity test revealed slight increase in laxity among bio-polymer matrices. Nowadays it is possible to regenerate in vitro females (p=0.05) Isokinetic tests revealed comparable quadriceps different woven, modulating chemistries, mechanics and physics and hamstring strengths at flexion angles < 90°. Flexion angles > characteristic of the matrices. From October 2003 in the three divi- 90° demonstrated a significant decrease in hamstring muscle sions of Orthopaedic and Traumatology of the University of Bari we strength in both groups. STG group demonstrated weaker hamstring used this techniques to treat the chondral knee lesions, especially strength and lesser range of active movement when compared to ST using a 3-dimentional biodegradable and biocompatible hyaluronic group at deeper flexion angles (>90°). acid scaffold for autologous chondrocyte culture, the Hyalograft C Conclusions: Use of both semitendinosus and gracilis tendons for (FAB, Abano Terme, Padova, Italy), created in order to avoid the ACL reconstruction leads to decreased hamstring muscle strength drawbacks and complications related the classical autologous condro- and range of movement at deeper flexion angles. Therefore, the rou- cytes implantation. Aim of this study is to evaluate retrospectively the tine use of both tendons for reconstruction is not recommended outcomes obtained in 27 patients under 40 years old, treated with this especially in athletes engaged in activities requiring deep knee bends technique, for III-IV Outerbrige degree classification, extended over 2 and hamstring strength. cm2. The average follow-up is 25 months (min.4-max.34).

REVISION ANTERIOR CRUCIATE LIGAMENT RECON- THE ARTHROSCOPIC TREATMENT OF THE POST-TRAU- STRUCTION USING DOUBLED SEMITENDINOSUS AND MATIC SHOULDER INSTABILITY WITH BIOKNOTLESS GRACILIS TENDONS AND LATERAL EXTRA-ARTICULAR C. Colucci, V. Salini, G. Guerra, A. Natale, C.A. Orso RECONSTRUCTION Clinica Ortopedica e Traumatologica, Chieti, Italy A. Ferretti, F. Conteduca, E. Monaco, A. De Carli, C. D’Arrigo Ospedale S. Andrea, Rome, Italy Objective: This study aimed to analyze our experience on 40 patients with TUBS treated with arthroscopic capsulo-plasty using Background: The purpose of this study is to evaluate the results of anchors Bioknotless. revision ACL surgery using autogenous doubled semitendinosus and Methods: From January 2001 to June 2004 we treated in arthroscopy gracilis graft in association with an extraarticular procedure. 40 patients with TUBS. The intervention foresees the following phas- Methods: Between 1997 and 2003 thirty patients underwent a repeat es: evaluation of the capsular lesion; decortication of the anterior gle- reconstruction of a previously reconstructed torn anterior cruciate noid surface; execution of three holes; anchors introduction; ligament (ACL) using doubled semitendinosus and gracilis graft Results: We clinically appraised the patients through the Constant test combined with an extraarticular reconstruction. Primary reconstruc- with a minimum 10 months follow-up and maximum of 24 months tion had been done in 26 patients using autogenous patellar tendon (average 17 months). The middle value of the Constant score was of and in four patients with prosthetic ligament; the average time from 88 against that of 56,5 pre-operating, we only had a case of relapser. primary reconstruction to revision was five years (range one to Discussion: We believe that a careful pre-operatory and intraopera- eleven). Functional outcome, graft survival and radiological out- tory selection of the patient can sensitively reduce the risks of recidi- comes were evaluated at a mean of five years (range two to eight). A vist of the arthroscopic capsulo-plasty; excluding the patients with graft was considered a failure in case of a revision was done and if bony-Bankart> of 25% and with glenoid inverted pear. the side to side difference was greater than 5 mm and/or the pivot- Conclusions: In the light of our experience we can affirm that the shift was greater than a trace (2+). use of these anchors, that does not foresee the execution of the knot, Results: One patient underwent a re-revision reconstruction for graft allows to get not only a reduction of the surgical time, but also, and failure at three years postoperatively and was included in the failure above all, a good anchorage and capsular shift. rate. In the remaining twenty-nine patients the mean International Knee Documentation Subjective knee score was 84±12 and the mean Lysholm knee score was 90±10. The KT1000 maximum manual side ARTHROSCOPIC GRAFTING OF AUTOLOGOUS CHONDRO- to side difference was within 3 mm in twenty patients, between 3 and CYTES IN CHONDRAL LESIONS OF THE ANKLE: EARLY 5 mm in six patients and more than 5 mm in two patients. The results RESULTS of the Pivot Shift examinations were normal in fifteen patients, slight- M. Barbato, G. Di Loreto, L. Guerra, F.P. Ciampa ly positive in eleven patients and positive in two patients. 25% of Ospedale G. Bernabeo, Ortona, Italy patients showed no radiological signs of degenerative joint disease. Conclusions: Revision ACL reconstruction using autogenous dou- The production of suitable tissular supports has led to the routine graft- bled simitendinosus and gracilis graft combined with an extraarticu- ing of chondrocytes in Outerbridge grade 3 or 4 chondral lesions of the lar procedure provides satisfactory functional outcomes with a fail- knee, while in the literature, contributions regarding the use of this ure rate of 10%. technique on the ankle are still rare. Several therapeutic possibilities for chondral lesions in this small joint also exist. The type of treatment depends on the characteristics of the chondral lesions: when these are AUTOLOGOUS CHONDROCYTE TRANSPLANTATION ON 3- under one centimetre in size, bone marrow stimulation techniques are DIMENSIONAL HYALURONIC ACID SUPPORT FOR TREAT- advised, based on the principle of the recruitment of totipotent cells. MENT OF CARTILAGE KNEE LESIONS: RETROSPECTIVE The latter makes healing possible with the formation of “reparatory tis- STUDY sue”. Several studies have confirmed that the new tissue, obtained with V. Mascolo [1], S. De Giorgi [2], D. Fracchiolla [3], A. Mocci [2],A. bone marrow stimulation techniques, lacks type II collagen and pre- Piazzolla [2] sents the characteristics of fibro-cartilage and not those of hyaline car- [1]Università degli Studi di Bari, Italy; U.O. Ortopedia e tilage. When larger lesions are present, reparation techniques, such as Traumatologia III, Bari, Italy; [2]Università degli Studi di Bari, Italy; mosaic-plastic or chondrocyte grafting, are proposed. U.O. Ortopedia e Traumatologia I, Bari, Italy; [3]Università degli Studi Materials and Methods: Outerbridge grade 3 and 4 chondral di Bari, Italy; U.O. Ortopedia e Traumatologia II, Bari, Italy lesions of the head of the astragalus, measuring over one centimetre, S30

were treated by grafting autologous chondrocytes cultivated on Materials and Methods: 49 patients with unique meniscal lesion HYAFF. The technique comprises two stages: in the first, clinical underwent all-inside meniscus repair using the Meniscus Arrow fix- and instrumental data are confirmed arthroscopically, and the col- ation technique. At mean follow-up of 4 years all patients were eval- lection, necessary for the cultivation of the chondrocytes, is carried uated according to the following scales: Visual Analogue Scale, out. In the second stage, grafting of autologous chondrocytes culti- International Knee Documentation Committee Score, Lysholm II vated on HYAFF is carried out. Scale and Tegner Activity Scale. The results have been statistically evaluated according to age of patients, lesion pattern, size and chronicity, and associated ACL lesions. Results: The clinical overall success rate was 81.6%. Failure rate in SESSION O18 bucket-handle lesion group was 85.7%, while in longitudinal tear group was 7.1% (p<.0001). Patients with a lesion length greater than 2 cm had a failure rate of 75%, while patients with a lesion length ARTHROSCOPY II equal or less than 2 cm had a failure rate of 7.3% (p<.0001). The reconstructed ACL group totalled a failure rate of 12.1% and the uninjured ACL group, totalled 50% of failures (p=.012). SIMULTANEOUS ARTHROSCOPIC IMPLANTATION OF Discussion and Conclusions: Lesion pattern, size and association AUTOLOGOUS CHONDROCYTES AND HIGH TIBIAL with ACL repair influence results of meniscal repair using Meniscus OSTEOTOMY IN THE VARUS KNEE Arrows. While planning a meniscal repair, these variables should be F. Franceschi, G. Rizzello, G. Longo Umile, L. Ruzzini, R. Papalia, taken into account. A. Marinozzi, V. Denaro Università Campus Biomedico, Rome, Italy FIXATION OF UNSTABLE OSTEOCHONDRITIS DISSECANS Objective: The aim of this study was to determine the outcome of LESIONS OF THE KNEE USING MOSAICPLASTY patients with varus malalignment who underwent an arthroscopic M. Ronga [1], G. Zappalà [1], E. Ferrari [1], M.G. Angeretti [2],P. implantation of autologous chondrocytes and a high tibial osteotomy. Bulgheroni [1] Materials and Methods: Between 2002 and 2003 we performed 9 [1]Dipartimento di Ortopedia e Traumatologia, Università degli arthroscopic implantations of autologous chondrocytes in conjunc- Studi dell’insubria, Varese, Italy; [2] Dipartimento di Radiologia, tion with an opening wedge osteotomy on the medial side of the Università degli Studi dell’insubria, Varese, Italy proximal tibia in patients with chondral defects of the medial tibial plateau in varus knee. Each patient was evaluated for clinical histo- Objective: To assess the use of autogenous osteochondral graft fix- ry, clinical examination, conventional radiographs, MRI and ation (mosaicplasty) in unstable osteochondritis dissecans (OCD) arthroscopy, pre and postoperative IKCD (International Knee lesions (ICRS type 2 and 3) of the knee. Documentation Committee), pre and postoperative Lysholm, pre and Materials and Methods: Five patients with MRI confirmed OCD postoperative Tegner score and pre and postoperative VAS. lesion in their femoral condyle, that had remained symptomatic Results: The Lysholm Score, IKCD, Tegner score used for evalua- despite adequate conservative treatment, underwent arthroscopic tion showed a statistically significant improvement from preopera- mosaicplasty plug fixation of the lesion. The average size of the tive average rating to postoperative average score. lesions was 3.7 cm2 (range, 2.5 - 5.1 cm2). The OCD lesions were all Discussion: Treatment of chondral lesions involving the articular unstable at operation and were all fixed rigidly in situ using a vary- surface of the knee remains a formidable therapeutic challenge ing number of autogenous 4.5 mm osteochondral plugs harvested because articulate cartilage has limited capacity for regeneration. from the edges of the trochlea. The average age at operation was HTO alone and conventional treatments that abrade or penetrate 23.2 years (20 - 27 yrs). Clinical-functional evaluation was carried the subchondral bone (drilling or microfracture) are known to pro- out according to ICRS, modified Cincinnati knee, Lysholm II, duce fibrocartilaginous repair. On the weightbearing surfaces of Tegner and IKDC scales. MRIs (FSE FAT SAT T2, GE T2, SE T1) the knee large areas of fibrocartilage are mechanically inferior and were taken before the operation as well as at 6 and 12 months post- usually deteriorate, necessitating additional intervention. Only the operatively; at 2 years, arthro-MRI was performed. autologous chondrocyte implantation and the transplantation of Results: Follow-up averaged 31.6 months (range, 24 - 43 months). osteochondral grafts provides adequate hyaline articular cartilage, No complications occurred. At the latest follow up, knee scores which is better able to restore the durability and natural function of improved after surgery. Serial MRI scans documented healing of the the knee joint. osteochondral lesions and a continuous articular cartilage surface Conclusions: Despite the small size of the group and the need for layer in all cases but one where was evident a partial detachment of larger series, our surgical study shows that the association of an only one plug. arthroscopic implantation of autologous chondrocytes in conjunc- Discussion: The benefits of this technique are the ability to obtain tion with an opening wedge osteotomy on the medial side of the rigid stabilization of the fragment using multiple plugs, stimulation proximal tibia is a good option for the treatment of chondral of the subchondral blood supply by drilling and autogenous cancel- defects in varus knee. lous bone grafting. Conclusion: The mosaicplasty plug fixation of unstable OCD can be recommended for the treatment of these specific lesions. MEDIUM TERM RESULTS OF MENISCAL REPAIR USING THE MENISCUS ARROW: STATISTICAL ANALYSIS OF OUT- COME EFFECTING FACTORS BIOABSORBABLE POLY-D,L-LACTIC ACID (PDLLA) INTER- M. Ronga, L. Murena, L. Donnini, P. Bulgheroni FERENCE SCREWS FIXATION IN ANTERIOR CRUCIATE Dipartimento di Ortopedia e Traumatologia, Università degli Studi LIGAMENT RECONSTRUCTION: CLINICAL, ARTHROMET- dell’Insubria, Varese, Italy RIC, RADIOGRAPHIC AND IMAGING EVALUATION AT MEDIUM-TERM FOLLOW-UP Objective: Meniscus Arrows is a reliable device for meniscal repair. P. Bulgheroni [1], M. Ronga [1], G. Zappalà [1], M.G. Angeretti [2] Outcome effecting factors associated with the use of this device are [1]Dipartimento di Ortopedia e Traumatologia, Università degli not yet investigated. Aim of this study is to evaluate if several vari- Studi dell’insubria, Varese, Italy; [2]Dipartimento di Radiologia, ables can influence the success rate of meniscal repair. Università degli Studi dell’insubria, Varese, Italy S31

Objective: The standard treatment of ACL lesions has mainly relied MEDIAL RETINACULAR RETENTION FOR CHRONIC PATEL- on metal interference screws until the introduction of bioabsorbable LAR INSTABILITY materials. Fixation of autologous bone-patellar-tendon-bone with A. Schiavone Panni, M. Tartarone, A.A. Patricola, D. Sanatiti, M. bioabsorbable screws has showed results comparable with metal Gallo screws without their disadvantages at short-term follow-up. Aim of IspeO – Istituto Specialistico Ortopedico, Rome, Italy; University of this study was to analyse the medium-term clinical results and Molise, Campobasso, Italy arthrometric, radiographic and imaging findings of PDLLA screws. Materials and Methods: Twenty patients have been included in this Background: Patellar instability is a major challenge for the study. At time of ACL reconstruction, in 9 patients was performed orthopaedic surgeon and the outcomes of most interventions, con- partial meniscectomy. The average follow-up was 5.5 years (range, servative as surgical, can be discouraging. During the last decade a 4 to 7.8 yrs.). The final evaluation was performed according to the few contributions have been published regarding the combination of following clinical scores: IKDC, Tegner and Lysholm. All patients arthroscopic lateral release with plication/repair of the medial reti- were submitted to KT-2000 test, comparative radiographic plains naculum. Since a few years, given the good outcomes reported and and MRI study in order to investigate the longevity of the implant the low morbidity of the technique we perform medial retinaculum and adverse effects of this material. Statistical analyses were carried plication associated to lateral release for the treatment of patients out using Student’s t test and c2. affected patellar instability without dislocation (Fulkerson type I). Results: 85% of patients showed good or excellent clinical results. Matherials and Method: Plication of the retinaculum is performed per- In 18 cases KT-2000 test was less than 3 mm in comparison with the cutaneously with 3 resorbable #2 sutures (PDSII, Ethicon, USA) with opposite knee. Radiographic evaluation showed initial degenerative vertical antero-posterior direction. The suture, as well as the lateral changes in 7 patients, 6 of whom underwent meniscectomy release, are performed under arthroscopic assistance. Post-operatively (p<0.005). At MRI, the screws were completely reabsorbed in all the knee is immobilized with compressive elastic dressing for three cases without any foreign body reaction. An average of 2.1 mm weeks, allowing 0-60° ROM, recommending strengthening of the vastus (range, 0.6 to 5 mm) at femoral side and 2.3 (range 0.7 to 7.6 mm) medialis. From february 1999 to october 2002 40 patients (29 female, 11 at tibial side enlargement was detected. In axial plain, the tunnel was male; mean age 20.3 years) underwent this protocol in our institution. shaped like an “8” in 3 cases at femoral and in 4 at tibial level. These Results: Among this series no major complications (septic, vascular) findings were not statistically correlated to knee stability. were observed. All patients filled the Kujala questionnaire without Conclusion: The PDLLA interference screws represent a valid alter- problems. The mean follow-up was 60 months. 26 cases were clas- native to metal implants in ACL reconstructive surgery. sified as good (65%), 8 fair (20%) and 6 bad results (15%). The worst results were observed in cases presenting severe chondral lesions (Outerbrideg 2/3, Fulkerson I B/C). Other criteria that nega- MRI ANALYSIS OF THE DOUBLE BUNDLE STRUCTURE OF tively influence the outcome are Q angle measure and insufficient THE ANTERIOR CRUCIATE LIGAMENT: RUPTURE PATTERN muscular rehabilitation and ROM recovery. EVALUATION Discussion: The technique presents clear advantages, namely low G. Vadalà [1], H. Stechel [2], R. Papalia [2], V. Denaro [1],F. Fu[2] morbidity (no intervention on the extensor mechanism) and no cos- [1]Dipartimento di Ortopedia e Traumatologia, Università Campus metic damage (no visible scars). The wider indications proposed by Bio-Medico, Rome, Italy; [2]Department of Orthopaedic Surgery, some authors (including patellar dislocation) should be better inves- University of Pittsburgh, USA tigated with prospective, controlled, long term clinical trials. It should also be evaluated the effectiveness of such procedure in cases Introduction: Different authors have studied the assessment of ACL of severe cartilage damage, given the bad results reported in these tears with MRI and concluded that complete ACL tears can be diag- cases even in the short term. nosed accurately with standard orthogonal planes and paracoronal Conclusions: Major advantages of the technique are low morbidity and images. However, MRI evaluation of partial ACL tears remains dif- the possibility of completing the treatment with realignment proce- ficult and it is not always possible to establish the diagnosis dures in case of failure. However, patients must be clearly informed of Attempts have been made to improve the diagnostic accuracy of potential long term failure and strict selection of indications (excluding MRI for partial ACL tears but the diagnostic efficacy is still a key severe instability cases with chondral lesions) is key to success. area of research Methods: We used a 3T MRI imaging of the knee for description of the ACL bundle structure and partial ACL tears. This system includ- ed 2D and 3D images with an increased resolution. In order to eval- SESSION O19 uate different ACL rupture pattern we first searched for the optimal MRI planes and sequences to evaluate the AM and PL bundle struc- ture. In the next step we will cut the AM and PL bundle femoral, tib- MISCELLANEOUS II ial and midsubstance to mimic original rupture pattern with dissect- ed fresh cadaveric knees. MAINTENANCE OF CORRECTION AFTER AN OPENING Results: AM and PL were selectively identified in both oblique- WEDGE HIGH TIBIAL OSTEOTOMY USING A MONOAXIAL coronal and oblique-sagittal plans passing trough the ACL axis. AM DYNAMIC EXTERNAL FIXATOR: A 2- TO 8-YEARS FOL- and PL are oriented in parallel with the knee at full extension. LOW-UP Discussion: MRI is helpful for detection of complete ACL ruptures, N. Mondanelli, P. Aglietti, E. Russo, P. Cuomo, D. Lup, L. De Luca but at the present time has less utility for evaluation of partial ACL Prima Clinica Ortopedica, Università degli Studi di Firenze, tears. Describing partial ACL tears and their rupture pattern, optimal Florence, Italy MRI planes, and sequences still need to be found. If it is possible to describe the rupture pattern more precisely in advance, surgical Opening wedge tibial osteotomy is a treatment option for mild medi- planning could be improved, allowing reconstruction of the two bun- al knee osteoarthritis in young patients. Monoaxial dynamic external dles based on their individual status as intact or damaged. fixator (MDEF) can be employed to reach and keep correction. One Conclusion: We described the acquisition of specific MRI plans for of major concerns of this technique is correction loss. The purpose of the selective evaluation of the AM and PL bundles of the ACL, for this study was to assess clinical, subjective and radiographic results the improved diagnosis of the partial tears. at a mean follow-up of 5 (2-8) years. Between 1998 and 2004, 25 S32

patients, mean age 51(38-61) years, were operated with this tech- cally increased life expectancy of thalassemic patients. Among nique. Osteotomy was performed below the tibial tubercle, the endocrin, infective, and metabolic complications, organ failure MDEF was assembled on 2-proximal 2-distal pins. Distraction was remains the principal complication, but osteoporosis is becoming an performed 1mm/day until correction was achieved. Patients were important cause of morbidity. The authors describe a case of a 26- evaluated at MEDF removal and then yearly. Distraction started year-old female with Beta-Thalassemia Major afflicted by a fracture 6.4(4-8) days after surgery, final correction was obtained after of the proximal femur on minor trauma. Since 2-year-old she 24.7(18-30) days, MDEF was removed 74.8(60-121)days post-oper- received regular monthly blood trasfusion and took deferoxamine at atively. No patients developed pin-tract infections. One patient died the dose of 20 mg/Kg/day for 5 days a week. She had a regular of unrelated causes. Subjective KOOS results showed 80(47-100) menarche at 13 years old with regular mestrual cycle until the ageof points for pain (pre-op 57.37-92), 71(36-100) for symptoms (pre-op 20, when she developed hypogonadotropic hypogonadism. Ovarian 56.30-79), 78(57-100) for ADL (pre-op 53.30-85), 58(6-100) for function was assessed by measuring FSH, LH, Estradiol, sports activities (pre-op 18.0-35), 55(25-100) for quality of life (pre- Progesteron and other serum parameter as GH and IGF-1 were mea- op 21.0-36). IKDC subjective results showed 79(32-98) points (pre- sured too. The bone metabolism was investigated by detection of op 43.15-63). All patients but one were satisfied with surgery. serum calcium, alkaline phosphatase, Osteocalcin, beta Cross-Laps Clinical evaluation showed no patients with instability or ROM (Collagen I), 25-OH-Vitamin D. Bone Mineral Density was mea- deficit worst then pre-operatively. At MDEF removal mechanical axis sured in femoral area and lumbar spine by Dual-x-Ray absorpiome- was 4.5°(2°-7°)valgus, anatomical axis 6.8°(4°-8°)valgus, percentage try. Fracture was surgically treated with using AFN (Synthes) of mechanical axis on tibial plateau 64%(62%-66%), posterior slope intramedullary locked nailing in a static mode. In thalassemic 5°(1°-8°), metaphyseal varus 4.3°(2°-7°), Insall-Salvati ratio patients osteoporosis ethiology is still unclear but many factors can 1.02(0.95-1.18). At the latest follow-up 5 patients had a loss of cor- contribute to its development; according biochemical markers of rection of 1°-2° on mechanical axis or 1%-2% of mechanical axis on bone turn-over, low bone mass results from increasing of bone tibial plateau. Neither complications nor significant correction loss resorption. Both chelating therapy and reduction of IGF-1 levels were observed in this series. The use of a MDEF to perform an open- seem to be implicated in the unbalanced bone turn-over. Many other ing wedge tibial osteotomy seems to be a safe procedure. Advantages factors seem to be related to reduction of low bone mass as hypogo- of this technique are no need for bone graft, immediate weight-bear- nadism, vitamin D deficiency and iron overload. According to the ing, no hardware left, less residual metaphyseal deformity. Disa- literature and looking at this case we consider the importance of dvantages are less patient compliance with need for pin-tract care. therapy with biphosphonates, calcium and Vitamin D to avoid or delay osteoporosis and consequently fractures. SURGICAL TREATMENT OF HAEMOPHILIC ARTHROPATHY M. Villano, C. Carulli, R. Civinini, M. Innocenti COMPLICATIONS IN THE SURGICAL TREATMENT OF THE II Clinica Ortopedica, Università degli Studi, Florence, Italy LATERAL FEMORAL NECK FRACTURES (1200 CASES) R.M. Capelli, V. Galmarini, G.P. Molinari, A. De Amicis A great percentage (85%) of patients with low blood rate of factor A.O. Fatebenefratelli e Oftalmico, S.C. Ortopedia e Traumatologia, VIII/IX are afflicted by articular blood effusions: blood provokes Milan, Italy arthropathy by acute then chronic sinovial inflammation on one side, with release of many enzymatic substances, and, on the other side, The authors report their experience and describe the more frequent by a cartilage damage: for these reasons, both sinovial excision and complications they have had in the surgical treatment of over 1200 chondral protection could be good prophylactic treatments. Any cases of lateral femoral neck fractures. The lateral fractures of the other form of surgery has to be carefully evaluated because of the proximal end of the femur occur very frequently, especially in elder- peculiar general conditions and high rate of complications. From ly patients who have a higher risk of mortality, and are a consider- January 1999, we have collaborated with the Regional Center for able health problem for society. The result’s quality and the social Congenital Coagulopathy visiting about 6 patients for every week, recovery are in close relationship with timing of surgery, minimal with an amount of 1100 consultancies in 410 patients, most of them blood loss, minimally invasive surgery, healing fracture’s time and from Tuscany. early rehabilitation. First approach to haemophilic arthropathy was relief from symptoms Materials and Methods: From 1990 to 1998 we utilized Gamma with medical therapy and viscosupplementation. Open surgery was Nail (Howmedica) and from 1999 till today we have been using B. performed in 5% of patients: osteotomy (2 cases), arthrodesis (4 I. Nail (Bio-Implant Group).We have used 607 Gamma Nail (aver- cases), knee and hip replacement (respectively, 28 and 6 cases), age age 80,8 years), and 530 B. I. Nail (average age 81,6 arthroscopy (32 cases). Being an extremely complex pathology, years).From 1992 we treated the per-sub-trochanteric fractures and surgery is indicated only in selected cases and using well described the associated fractures of the femoral shaft with the intermediate and effective techniques. and long variant of the Gamma Nail (46 cases, average age 58,4 years), with an early functional recovery and the complete healing of the fractures, even if the reductions weren’t always “anatomical”. PATHOPHYSIOLOGY OF BONE DISORDER IN THALASSE- Conclusions: Out of 1200 treated cases of lateral neck femoral fractures MIA MAJOR we obtained: 15 iatrogenic fractures, 9 cut-out of the femoral screw, 1 F. Pezzillo [1], F. Liuzza [2], R. Di Matteo [3], A. de Matthaeis [2],G. broken intra-medullar reamer, 2 cases of non-union, 1 broken intra- Maccauro[2] medullar locking nail, 2 superficial infections, 1 deep venous thrombo- Dipartimento di Scienze Ortopediche e Traumatologia, Università sis. We are evaluating the most frequent complications (encountered in Cattolica, Rome, Italy; [2]Dipartimento di Scienze Ortopediche e our Division) and the particular cases of special interest. Traumatologia, Università Cattolica, Rome, Italy; [3]Dipartimento di Medicina Interna, Università Cattolica, Rome, Italy HIP FRACTURES: CLINICAL AND THERAPEUTIC APPROA- Beta-Thalassemia Major, firstly described by Cooley, is an inherited CH OF OSTEOPOROSIS blood disorder leading to anaemia due to an imbalanced globin chain V. Galmarini, R.M. Capelli, G.P. Molinari, F. Rotolo, A. De Amicis synthesis affecting erythroid maturation and red cell life. The com- A.O. Fatebenefratelli e Oftalmico, S.C. Ortopedia e Traumatologia, bination of both blood transfusions and chelating therapy has radi- Milan, Italy S33

The clinical relevance of osteoporosis is the resulting fractures occur- consent received daily subcutaneous TPTD injection of 20 microg) ring in the weakened bone (fragility fractures). Recent articles suggest in association with 880 U.I. of colecalciferol and 1g of calcium car- that orthopaedic surgeons are still neglecting to identify, evaluate and bonate per os for 12 months. treat patients with osteoporosis and low-energy fractures. The lifetime Results: Haematochemical values in the 12 months demonstrated risk for an osteoporotic fracture of the hip, spine and wrist has been normal values of PTH without significant changing; low levels of 25 reported to be 40% for Caucasian women in Europe. The risk for hip OHD that increased progressively and significantly from 0 to 12th fractures is between 11% and 18% in woman, which is equal to the month (p<0.01); high levels of ALP that decreased significantly combined risk for breast, uterine and ovarian cancer. The number of (p<0.05) with inversion of percentage between hepatic and bone frac- individuals over 65 years of age is expected to almost double by the tions; normal calcemia and phosphatemia that remained unchanged. year 2040 and the number of hip fractures is predicted to rise dramat- Normal urinary levels of calcium and phosphate remained unchanged ically. In 1990, the estimated total number of hip fractures in persons from baseline to endpoint. In the first 6 months BMD is significantly over the age of 50 was 1.7 million world wide, the number of such increased of 16% in average (p<0.02) but in the second one. The fractures is estimated to reach 6.3 million worldwide. Up to a third of decreased VAS and increased QUALEFFO 41 were well correlated to patients with hip fractures will die as a result, 4% die during their ini- absence of any new fracture and to recovery of good general condi- tial hospitalisation and 10% to 24% within the first year. Such frac- tions and better compliance of elderly patients. No adverse affect was tures are also associated with substantial morbidity and function loss; observed and nobody had suspended the therapy. half of these patients do not regain their previous level of mobility. A Conclusions: Considering that PTH treatment improves the quality of patient with vertebral fractures has nearly a fivefold increased risk of life of elder osteoporotic women in term of pain relief, mobility, auton- a future similar injury and double risk on hip and other non-vertebral omy and prevention of new fracture in relative short time from base- fractures. Pharmacological intervention (calcium, vitamin D, drugs of line, it could be useful also in the first days after trauma. Further clin- AIFA 79 and 79 bis notes) has potential to reduce the risk of future ical studies will be necessary to define if this skeletal anabolic agent fracture by half in patients with existing fractures. Other measures may enhance the healing process or osteointegration of prostheses. (fall prevention, individually-tailored exercise programs) have been Suggested readings: Genant Curr Med Res Opin. 2005; Neer N En- shown to reduce fall among the elderly. Through this work we want to gl J Med 2001; Black N Engl J Med 2003; Stewart J Bone Miner analyze the problems of orthopedic surgeon facing fragility fracture. Res. 2000

PRELIMINARY RESULTS OF ADJUVANT THERAPY WITH TERIPARATIDE IN THE ORTHOPAEDIC TREATMENT OF SESSION O20 VERTEBRAL AND FEMORAL FRACTURES IN SEVERE POSTMENOPAUSAL OSTEOPOROSIS [1] [2] [1] [1] C. Corradini , F.M. Ulivieri , L. Parravicini , A. Mondini ,C. RACHIS III Verdoia [1] [1]Clinica Ortopedia e Traumatologia, Instituto G.Pini, Milan, Italy; [2]U.O. Nuclear Medicine; IRCCS Foundation, Milan, Italy SURGICAL TREATMENT OF THORACOLUMBAR OR LUM- BOSACRAL JUNCTION INSTABILITY: CLINICAL AND RADI- Introduction: Clinically, the most important aspect of orthopaedic OGRAPHIC RESULTS treatment for vertebral and femoral fractures in postmenopausal G. Gulino, L. Spatafora, V. Auteri, S. Zappalà women is the early functional recovery, the pain relief and the pre- Azienda U.S.L 3, Catania, Italy vention of new fractures. These objectives are very often difficult to obtain because of a severe osteoporosis and a late efficacy of current Objective: The primary purpose of this study is to evaluate the clin- specific drugs. The recent discovery of anabolic effects of parathy- ical and radiographic outcomes, as well as the complications, fol- roid hormone (PTH) on osteoporotic skeleton bone has opened new lowing decompression and fusion for instability of thoracolumbar or therapeutic horizon. The aim of the present study was to verify the lumbosacral spine junction. efficacy of adjuvant therapy with teriparatide [rhPTH(1-34), TPTD] Materials and Methods: Twenty-six patients affected by primary or on pain and disability in the orthopaedic treatment of vertebral secondary instability of the thoracolumbar (group A) or lumbor- and/or femoral fractures in severe postmenopausal osteoporosis. sacral spine junction (group B) were enrolled in the study. Patients Materials and Methods: We selected nine women between 64 and were evaluated by MRI and X-Ray studies (AP, lateral views and 87 years old with postmenopausal osteoporosis treated with anti- dynamic flexo-estension and lateral bending in standing position). resorptive agents and affected by persistent back and/or hip pain All the patients were subjected to decompression and instrumented with functional disability accompanied by sedentary life. Of these fusion of the junction with bone graft; long instrumentations were the youngest one was afflicted by seven vertebral fracture in two performed in 75% of Group A patients and 22% of group B patients. years for which she had received seven vertebroplasties or kypho- Patients were evaluated by clinical (VAS scale) and radiographic plasties in another hospital; five had a recent dorsal fracture with parameters (preoperative instability, postoperative fusion rate and history of 1or 2 previous vertebral fractures; three patients over symptomatic adjacent segment degeneration) and the occurrence of eighty years were undergone to hip arthroplasty for a femoral neck complications. fracture and one of them was affected by a single vertebral fracture Results: Average preoperative VAS score averaged 7.1 in group A and another one has received five years before a homolateral knee and 7.2 in group B; after surgery these values decreased to 2.3 and arthroplasty. Parathormone (PTH), alkaline phosphate (ALP), calci- 2.4 respectively. Fusion rate was 87.5% of cases in group A and 89% um (Ca), phosphorus (P) and 25-hydroxyvitamin D (25OHD) serum in group B. Neither neurological deficits nor instrumentation failure levels and calcium (Ca), phosphorus (P) on urine of 24 hours were were observed in the two groups. In patients in group B, one patient measured at the beginning and 1, 3, 6, 12 months later. Bone miner- reported adjacent level degeneration, while superficial wound infec- al density (BMD) measurements at the lumbar spine and non-injured tion occurred in another case. hip or both hips were obtained at baseline and after 6 and 12 months. Conclusion: Patients with clinical and radiological signs of spinal The pain symptoms and quality of life through respectively on a self- instability non-responding to conservative treatment are candidate to reported visual analogue scale (VAS) and QUALEFFO 41 were col- surgery. Main objective of this surgery is pain reduction. To prevent lected at 0, 6, 12 months. All the women after signature on informed adjacent segment degeneration and subsequent instability is quintes- S34

sential: A) to include T11-T12 in the fused levels for dorsolumbar with good bony mass. This technique, used from two years, has not junction instability in order to decrease local torsional forces; B) evidenced at today cases of lost correction although we have always when performing lumbosacral junction fusion surgery, to pursue lor- authorized the premature and not protected walking. dosis restoration and lumbosacral angle correction to decrease slid- ing forces that would be transferred at the adjacent level. THE TREATMENT OF SEVERE OSTEOPOROSIS WITH TERI- PARATIDE: OUR EXPERIENCE A NEW CONCEPT IN THE SURGICAL TREATMENT OF THO- A. Piazzolla, N. Capocasale, V. Mascolo, S. Saporetti, A. Luca, G. de RACIC OUTLET SYNDROME Giorgi P. Ciampi, C. Scotti, G.F. Fraschini Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. Ospedale San Raffaele, Università Vita e Salute, Milan, Italy di Ortopedia e Traumatologia I, Università degli Studi Bari, Italy

Thoracic outlet syndrome (TOS) encompasses several clinical disor- A useful aid in the treatment of the severe osteoporosis in women ders, resulting from compression of the brachial plexus and/or subcla- older than 65 years with unsatisfactory bisphosphonate treatment, vian vessels. Two different types of TOS are identified: “non-disputed T-score equal or inferior to -4, multiple vertebral osteoporotic frac- TOS” due to anatomical structures compressing the neurovascular tures and one or more age-independent risk factors (like: BMI < 19 bundle, and “disputed-TOS”, characterized by the absence of an iden- kg/m2, maternal familiarity with neck-femoral fractures before 65 tified ethiology. Usually the treatment of choice is the resection of the years old, premature menopause, conditions associated with the first rib. The aim of our study is to demonstrate the efficacy of a more extended immobility) comes from the Teriparatide, a synthetic form conservative surgical approach. We treated 50 patients, 39 women and of the natural human parathyroid hormone, that stimulates the for- 11 men. All patients were clinically evaluated. Presenting features mation of new bone by increasing the number and action of bone- included: coldness, pallor, paresthesias, dysesthesias, lack of dexteri- forming cells. Continuing in the study proposed during the 90th ty, numbness. Symptoms were usually provoked by overhead activi- SIOT reunion that evidenced the effects obtained after only six ties during work or daily living. X-ray of the neck, EMG, dynamic months of treatment, the Authors presents theirs results at the total angio-MRI were performed. Patients were divided in two groups: end of the protocol with 20 mcg per day of Forsteo, along with cal- “non-disputed TOS” group (30 patients) and “disputed TOS” group cium (1000mg) and vitamin D (400UI) supplementation, for the (20 patients), according to the clinical and radiological findings. In the previewed period of 18 months. The weekly evaluation of the first group, 21 patients were affected by abnormal first rib, 4 patients Calcium plasmatic concentration evidenced its increase for 16-24 by lipoma, 3 patients by transverse mega-apophysis, 2 patients by hours with a maximum peak in 4-6 hours. Conditions like hypocal- clavicle-pseudoarthrosis. In the second group, 16 patients were affect- caemia, se-vere renal insufficiency, renal calculosis, hyperparathy- ed by scalenus anterior anomalies, 4 by brachial plexus fibrosis (diag- roidism, Paget, alkaline hyperphosphatasaemia and previous thera- nosed during surgery). Decompression was achieved using a supra- py radiating are confirmed the main parameter of exclusion from clavicular and infraclavicular approach in order to perform: cervical the treatment. rib excision (18), combined partial cervical rib excision and partial first rib excision (3), lipoma excision (4), reduction and fixation of clavicle (2), partial scalenus resection (11), complete scalenus resec- PERCUTANEOUS VERTEBROPLASTY AND TERIPARATIDE tion (5), neurovascular release (50). No post-operative major compli- [RHPTH(1-34)] cations were noted. All patients were evaluated at 3 weeks, 3 months, P. Lisai, C. Doria, P. Tranquilli Leali, F. Milia, L. Tidu and yearly thereafter. Mean follow-up was 15 months. Complete res- Clinica Ortopedica, Università di Sassari, Italy olution of symptoms with a return to full activity was noticed in all cases. Our results demonstrate that partial resection of the first rib, Objective: Teriparatide [rhPTH(1-34)] has been shown to increase when necessary, and neurovascular release are a safe and effective BMD and reduce the risk of fracture in postmenopausal women with method to treat TOS. osteoporosis. The purpose of this study was to investigate the skele- tal effects of 9 months of treatment with teriparatide [rhPTH (1-34)] in women with osteoporotic vertebral compression fractures treated THE MINI-OPEN SURGERY IN THE TREATMENT OF COM- previously by percutaneous vertebroplasty and antiresorptive therapy. PRESSION VERTEBRAL FRACTURES Materials and Methods: Daily subcutaneous injections of 20 µg teri- A. Piazzolla, G. De Giorgi, R. Mangialardi paratide [rhPTH (1-34)] were administered for 9 months to 30 post- Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. menopausal women previously submitted to percutaneous vertebroplas- Ortopedia e Traumatologia I, Università degli Sudi di Bari, Italy ty for multilevel vertebral compression fractures. Mean age was 71.3 year (range 59-83). AlI patients had previously received alendronate In the last few years we have noticed the development of new tech- therapy administered 70 mg/once weekly far 18-36 months. Median niques for the treatment of type A, according to Magerl-Harms classi- baseline BMD T-scores was < -2.5. Median baseline bone turnover fication, vertebral compression fractures to obtain the recovery of the markers levels were osteocalcin 24µg, N-propetide of type I pro-colla- static and cinematic function in the shortest possible time and using gen 87µg, bone specific alkaline phosphatase 15 µg and N-telopeptide less invasive approaches. Nowadays, the kyphoplasty emblematically of collagen 13 nMoIBCE/L. All patients received daily calcium (1000 represents the gold-standard in the treatment of osteoporotic forms mg) and Vitamin D (500 UI) supplementation. The primary study out- and its principles can be extended also to subjects with conserved come was change in lumbar spine BMD measured by DXA. Secondary bony resistance, if suitable systems of reduction are used. According outcomes included changes in bone turnover markers and pain. to this idea, the B-Twin, initially projected like intersomatic cage Results: At 6 month follow-up, lumbar spine BMD increased 5.4% thanks to its preconfigured deformation, once positioned, with relative to baseline data. Bone turnover markers had statistically sig- transpedicular approach, and expanded, is very useful in young per- nificant increases. Median change in bone turnover markers was sons, limiting the expansion towards lower resistance zones, unlike similar at 3, 6 and 9 months. Clinical data showed significant pain kyphoplasty with its documented high deformability of the bone- relief. No adverse treatment effects were observed during teri- tamp. The Authors, also recognizing the usefulness of the kyphoplas- paratide [rhPTH (1-34)] therapy period. ty in the treatment of the osteoporotic vertebral compression fractures, Conclusion: Our data show that patients previously treated with presents their experience with B-Twin expandable system in patients alendronate respond to teriparatide [rhPTH (1-34)]. Teriparatide S35

[rhPTH (1-34)] treatment in postmenopausal women with osteo- Large soft tissue loss can be covered by microsurgery using free porotic vertebral compression fractures previously treated with alen- flaps. The most utilized flaps are: free latissimus dorsi flap, rectus dronate produces more than expected bone markers and BMD abdominis, gracilis, free anterolateral thigh flap, radial fasciocuta- responses, especially in the first period of treatment. Alendronate neous forearm flap, scapular and parascapular flap. Orthopaedic sur- pre-treatment alters the usual time course and relationships between geons who treat open fractures of the limbs must have deep knowl- teriparatide [rhPTH (1-34)] stimulation of bone formation markers edge of problems related with treatment of bone and soft tissue and changes in BMD. Can we consider teriparatide, an anabolic lesions and must follow all current protocols. Multidisciplinary drug, as support agent in percutaneous vertebroplasty? cooperation is one of the keys to obtain the best result.

LOWER-EXTREMITY AMPUTATION AND AMPUTATION- SESSION O21 LIKE INJURIES: IMMEDIATE MICROSURGICAL TREAT- MENT WITH SHORTENING AND SECONDARY LIMB LENG- THENING BY CORTICOTOMY AND CALLUS DISTRACTION OPEN FRACTURES B. Battiston [1], W. Daghino [2], A. Aprato [3], A. Gallo [4], A. Bia- sibetti [2] [1]UOS Microchirurgia Ricostruttiva, Ospedale CTO, Turin, Italy; [2]S.C. TREATMENT OF SOFT TISSUE LOSS BY ILIZAROV TECH- Traumatologia Muscolo Scheletrica e Fissazione Esterna, Ospedale NIQUE IN OPEN FRACTURES AND NON-UNIONS CTO, Turin, Italy; [3]Scuola di Specializzazione in Ortopedia e S. Reverberi Traumatologia dell’Università di Torino, Italy; [4]Università, Turin, Italy Struttura Semplice di Chirurgia Ortopedica Funzionale, Arcispedale S. Maria N., Reggio Emilia, Italy Reconstructive treatment is indicated only in few cases of amputa- tion or sub amputation of lower limb with complex injury, also Treatment of fractures and non unions with bone and soft tissue loss because, for the patient, it is longer and more difficult then regular- is a challenging work. In this topic Ilizarov method has a growing ization. When it is indicated, a good way to perform this treatment is importance. It allows fast recovery, weight bearing and tissue regen- doing a deliberate shortening to support microsurgical suture and eration without plastic surgery. If bone distraction is started seven only after some months, when injured segment’s survival is days from compactotomy and traction rating is near one millimetre obtained, restore leg-length discrepancy by callus distraction tech- a day, regenerated tissue rapidly become bone and soft tissues quick- nique. With this surgical procedure 7 patient, in the last 11 years, ly repair in the same time. So other operations such as skin flaps or were treated in CTO Hospital of Turin. Immediate shortening was vascularized bone or tissue transfer become very rare. done between 3 and 8 centimetres, later on distraction osteogenesis Among 1989 and 2005 we treated 31 patients affected by bone and was made with corticotomy and external fixator. No case requested soft tissue loss in the leg segment. Bone loss was 1,5 -20 cm. long ; secondary amputation, in two cases distraction was made with mono coetaneous loss was 7 – 60 cm2. All fractures and non unions healed axial external distraction device, while the rest with Ilizarov fixator. at final control. All patients well tolerated Ilizarov hardware. During treatment, complications were limited to few superficial pin- Minimal complies were frequent, but we have not seen major (neu- track infections, without osteomyelitis; moreover, one patient had a rological or vascular) complications. pressure ulcer in plantar site, treated with orthesis and medication and healed when posterior tibial nerve recovered. Function improving was constant and patient’s satisfaction at the TREATMENT OF SEVERE SOFT TISSUE LOSS IN HIGH end of treatment was good. ENERGY OPEN FRACTURES OF THE LOWER LIMB M. Stopponi [1], A. Basile [1], A. Loreti [2], A.U. Minniti de Simeonibus [1] THE APPLICATION OF THE ILIZAROV’S METHOD IN THE [1]II U.O.C. Ortopedia e Traumatologia, Az. Ospedaliera S. COMPLEX TIBIAL PLAFOND FRACTURES Giovanni-Addolorata, Rome, Italy; [2]Servizio di Patologia della N. Spina, R. Di Matteo, G. Dibiagi, M. Mastrangelo Mammella, Az. Ospedaliera S.Giovanni-Addolorata, Rome, Italy Unità Operativa di Ortopedia e Traumatologia, Asur Marche, Zona Territoriale 9, Macerata, Italy The treatment of high energy fractures of the lower limb often requires the cooperation of orthopaedic surgeon and plastic surgeon. Appropriate Introduction: Clinical experiences of several authors have evi- soft tissue reconstruction and stable fracture fixation are the main fac- denced the accuracy of Ilizarov external fixation in the treatment of tors to obtain a satisfactory result. Exposed bony fragments need to be tibia plafond fractures. The study regards 21 cases of complex frac- covered with well vascularized tissue as soon as possible, to preserve tures, characterized by comminution and soft tissue damage. The the viability of bone and to reduce the risk of infection and non-union. scope is to delimit the application field, to specify some sagacities It is not possible to standardize the treatment protocols for extremely of technique and to remark the advantages of the methodical one. various fracture and soft tissue loss patterns. The level and the extension Materials and Methods: 21 patients are treated with apparatus of of the soft tissue lesion dictates the choice of the flap to utilize. Ilizarov for tibial plafond complex fractures. 1) Thigh: usually treated with primary delayed closure, associated In 18 cases fracture was associated to distal fibula fracture, in 7 with split thickness skin grafts or local muscle flaps (tensor fas- dislocation of the ankle. ciae latae, gracilis, rectus femoris, vastus lateralis or biceps In the greater part of the cases, the synthesis of the fibula has been pre- femoris). Coverage of exposed bone is rarely a problem, because liminary, following by the mini-invasive synthesis of the tibial epi- of the abundance of soft tissues available. physeal segment with one or more screws. The apparatus of Ilizarov 2) Leg: non-reamed intramedullary nails are utilized also in Gustilo has been employed with a three rings pre-assembly and mixed bony III open fractures. Small-medium wounds can be covered with setting (wires and fiches). In cases of ankle instability, it has been local muscle flaps: medial or lateral head of gastrocnemius muscle, added a “pontage” to the foot (removed after 40 days approximately). medial emisoleus flap, flexor digitorum longus, local fasciocuta- Results: The fracture consolidation has been obtained in 20 neous flaps, distally based sural artery fasciocutaneous island flap. cases; vicious consolidation in 4 cases; pseudoarthrosis in 1 case; 3) Foot: adductor hallucis and abductor hallucis muscle flap, medial infection of the soft tissue in 8 cases, dealt with curettage and plantar fasciocutaneous flap, dorsalis pedis fasciocutaneous flap. medications. S36

The resumption of ankle motility and load without pain has been lesion, in order to obtain a good function without lameness, and obtained in 17 cases. recovery of plantar sensitivity. Numerous systems for the evalua- Discussion and Conclusions: Within external fixation, to our tion of these injuries are described in literature (MESS, Hannover, warning, the circular device of Ilizarov represents a valid instru- etc.) but, especially in severe cases like sub amputations and ampu- ment and a compulsory alternative in the tibial plafond fractures tations, these methods can poorly predict the time and possibility with damage of the soft tissue. The preliminary synthesis of the of an effective functional recovery. For this reason we have creat- fibula and the tibial epiphysis, also realizing a methodical hybrid, ed a simple and quick scoring system which can be easily applied make the set-up easier and offer more guarantees for reduction and in emergency. This system considers various parameters (patient’s stability. age, general condition, level and kind of injury, ischemia time, associated lesions with mainly bony or soft tissue involvement) and assigns a score to each of them. The final score gives an indi- MANAGEMENT OF COMPLEX DIAPHYSEAL FRACTURES cation to reconstruction or amputation and helps to predicting the OF THE LOWER LIMB WITH COMPRESSION-DISTRACTION final functional recovery and helping the surgeon in taking early SYSTEMS decisions. In our experience, the relatively higher importance R. Mora, L. Pedrotti, B. Bertani, G. Tuvo, I. Crivellari given to parameters such as ischemia, and soft tissue condition Clinica Ortopedica, Università di Pavia, Polo Univ. “Città di (crush injury with secondary muscle and skin necrosis, posterior Pavia”, Italy tibial nerve stretching with poor recovery of plantar sensitivity, etc.) has lead to a reduction in the incidence of complications and a Compression-distraction methods (or circular external fixation higher rate of successful results. techniques) are particularly indicated for the management of com- plex tibial fractures, thanks to their versatility and excellent imme- diate stability. FREE FLAP RECONSTRUCTION ON EXTENSIVE TISSUE They are less often employed for the management of complex LOSS AFTER TRAUMAS IN LOWER EXTREMITY, EXCLUD- femoral fractures, because of the low tolerability and the difficulty ING THE FOOT of obtaining effective reduction and stability, and because of the P. Tos, L.G. Conforti, A. Antonini, B. Battiston frequent occurrence of knee joint stiffness; they are indicated U.O.D. Microchirurgia Ricostruttiva, I^ Divisione Ortopedica, mainly when internal fixation or axial external fixation cannot pro- Ospedale CTO, Turin, Italy vide adequate stability. In these cases circular devices in non-stan- dard configurations can be employed, in order to obtain reposition Surgical treatment of complex wounds of the lower extremities has of the fragments and at the same time provide good stability and greatly evolved in the last years, leading to a higher percentage of reduce pain. These special tricks consist of the use of screws limb salvage and good functional recovery. Microsurgery surely is instead of wires, changes of the distal part of the mounting, com- a good weapon when facing extensive tissue losses and infections. bination with internal synthesis, Novikov reduction nails, double From 1994 to 2004, 25 patients have been treated in our depart- threaded screws. For the intraoperative prevention of the knee joint ment for complex traumas of the lower limb, excluding the foot. stiffness, particular kinds of fixation of the distal part of the assem- These cases include 4 acute complex injuries with extensive soft bly have been created. The postoperative prevention is based on tissue loss (Gustilo III open fractures) which were treated with 3 active and passive mobilization, use of CPM machines, use of Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals dynamic splints such as “Dynasplint”. Between 1986 and 2005, with exposed bone or bony/soft tissue loss (1 Fibula Flap for the 581 complex diaphyseal fractures of the lower limb in 549 patients distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation (with the above mentioned indications) were treated with compres- stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissi- sion-distraction systems. There were 127 femoral fractures and 454 mus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and tibial fractures. The results were satisfactory, whit a very high rate 11 late reconstructions of chronic osteomyelitis: 1 distal femur of healing and a low rate of complications: in particular only 4 infection (Double-barrel Fibula Flap), 10 infections of the middle cases of knee joint stiffness (after the management of femoral frac- or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi tures) required a surgical treatment by means of the Judet tech- Flaps, 3 Gracilis Muscle Flaps). nique. These results confirm that, with the correct indications and Over 90% of the flaps survived, leading to a good recovery of the the unavoidable limitations, the compression-distraction systems patients. The two failures were due to the necrosis of a Gracilis are a valid option for the management of these injuries. Flap in the coverage of an amputation stump and a necrosis of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated. In the last few years, the SCORING SYSTEM FOR INDICATIONS TO RECONSTRUC- approach to bony tissue losses has been changing: on one hand, TION IN LOWER LIMB AMPUTATIONS AND SUB-AMPUTA- elongation techniques for the lower extremity give good results; on TIONS the other, microsurgery may allow a single-stage reconstruction of B. Battiston, P. Tos, L.G. Conforti bone, muscle and skin defects, leading to much shorter hospital- U.O.D. Microchirurgia Ricostruttiva, I^ Divisione Ortopedica, ization time, and improvement of the patients’ quality of life Ospedale CTO, Turin, Italy because of a faster recovery.

Indications for the reconstruction of lower extremity complex wounds are more selected than for the upper limb. This is due to LOWER LIMB FRACTURE TREATMENT WITH HOFFMANN the high rate of complications that follow traumas which common- 2 EXTERNAL FIXATION SYSTEM IN MULTIPLE TRAUMA ly are high energy and often avulsion/crush injuries (necrosis, PATIENTS: OUR EXPERIENCE infections, non union, need for elongation procedures or other sec- G. Fioretta [1], L. Valenti [1], P. Gifuni [2], C.A. Roncaglio [1] ondary surgical procedures) as well as to the good results obtained [1]SIOT, Milan, Italy; [2]SIA, Milan, Italy by prosthetic replacement of the lower limb (a much more elemen- tary function compared to the upper limb, reduced hospitalization, Introduction: We choose the Hoffmann 2 external fixation system rare secondary surgical procedures). To indicate the reconstruction, for serious trauma treatments for its effectiveness, quickness and it is necessary to carefully evaluate the patient and the kind of versatility. S37

Materials and Methods: 28 patients with Gustilo II-III A or B TIBIAL NON-UNION WITH BONE AND SOFT TISSUE DE- injuries have been treated from August 2003. FECTS: TREATMENT WITH FREE VASCULARIZED FIBULAR Follow-up: x-ray monthly, examination every 7-15 days, antibiotic GRAFT therapy according to clinical and ematic results. O. Moreschini [1], M.S. Boccanera [2], F. Santanelli [3],S. Results: 28 Patients, 6 being women, 46.9 years (from 14 to 93) on Pappalardo [4] average. Femur fractures were 11 (2 refractures treated with F. E. [1]Dipartimento di Scienze dell’Apparato Locomotore, Università too), tibias 21, in two cases femur and tibia were on the same side degli Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, and in 1 case fractures interested both tibias. We had two “floating Italy; [2]Università degli Studi di Roma “La Sapienza”, Rome, Italy; knees”. All the fractures were classified according to Gustilo [3]Unita’ di Chirurgia Plastica, Ospedale Sant’Andrea, Università System II-III A, B. Union occurred in 8,6 months on average. “La Sapienza”, Rome, Italy; [4]Servizio di Ortopedia e Trauma- Complications were 3 tibial non-unions, 2 later treated with tologia, DEA Policlinico Umberto I, Rome, Italy intramedullary nailing and 2 knee stiffness. Conclusion: in our opinion external fixation is a satisfying technique Objective: The aim of this study is to evaluate the results of treat- to treat open fractures in patients with life threatening multiple injuries. ment of tibial non-union (with bone and soft tissue defects) with Infection risk and recovery time depend on soft tissue damage. free vascularized fibular graft. Experience and careful clinical controls are mandatory to obtain Materials and Methods: We retrospectively studied 7 patients: satisfactory results with this device. evaluation included clinical assessment and radiographic evidence of remodelling and hypertrophy of fibular graft. Results: All patients had type III open fracture of tibia (IIIB-5 GUNSHOT WOUNDS OF FEMORAL SHAFTS IN URBAN PO- patients, IIIC-2 patients); 2 patients had infection at exposition site PULATION: IS EMERGENT RETROGRADE INTRAMEDUL- in the first 2 months after trauma. The average bone defect was 6 LARY NAILING APPROPRIATE? cm (min-0, max-12). In all cases we performed an extensive curet- J.J. Hoegler, J. Hurbanek, R. Weir, M. Morandi tage of non-union site and vascularized graft of fibula (osteocuta- Henry Ford Hospital Trauma Center, Detroit, USA neous or osteomyocutaneous flap). The average length of bone graft was 10 cm (min-6, max-18). We obtained 100% of healing Objective: The number of fractures secondary to gunshot wounds and the average consolidation time was 5 months. The complica- (GSW) is increasing in urban populations across the United States. tions were infection on e.f. pins site (1 case) and fracture of the Antegrade intramedullary nails (IMN) have been an accepted treat- graft (3 cases). Using Mankin Classification, 5 cases were classi- ment for closed and open fractures of the femur, including those fied as “excellent” and 2 as “good” secondary to GSW. Retrograde IMN’s were originally contraindi- Conclusions: Although there are many different surgical options cated because of a potential infection spreading to the knee joint. for treatment of tibial non-union, the free vascularized fibular graft The purpose of this study was to evaluate the results of open is the only “one stage procedure” be able to treat simultaneously femoral shaft fractures secondary to GSW treated with retrograde non-union and soft tissue defect with high rate of success. IMN’s at our institution over the past ten years. Methods: A total of 2.322 GSW presented to our Emergency Depar- tment (ED) between May of 1994 and January 2005. There were 196 TREATMENT OF NON-UNIONS OF LONG BONES WITH BO- femur fractures in 195 patients. Fifty-five fractures in 54 patients were NE MARROW ALONE OR COMBINED WITH PLATELET RICH treated with retrograde IMN, 66 were treated with antegrade IMN. PLASMA OR RECOMBINANT BONE MORPHOGENETIC Results: No patient in the retrograde IMN group developed PROTEIN 7 (OP 1). AN ONGOING OBSERVATIONAL STUDY osteomyelitis or septic arthritis of the knee joint. One patient with a Grade IIIC fracture required I&D of draining thigh fasciotomies. P. De Biase, L. Ciampalini, M. Mugnaini, R. Capanna Another patient had an I&D of necrotic/draining bullet wounds. Dipartimento di Ortopedia, Sod Ortopedia Oncologica, Florence, Italy Conclusions: Our results did not show an increase in bone or joint infection with acute retrograde intramedullary nailing of open Treatment of non-unions of long bones in the last years has seen femur fractures due to GSW. Therefore, we feel this implant can be the new chance of BMP augmentation. We had already treated dif- an acceptable treatment option, thereby expanding the indications ficult and recalcitrant non unions with Concentrated Bone Marrow for retrograde intramedullary nailing. alone or associated with Platelet Derived Growth Factor (PDGF). The availability of the Bone Morphogenetic Protein 7 (BMP 7, OP 1) allowed us to compare the results of both treatments. We have now 40 cases from February 2001 to March 2006. Seven non SESSION O22 unions affected the humerus, 30 non unions affected the lower limb, 18 cases the femur, 14 cases the tibia and one an attempted subtalar arthrodesis. The average age was 30 years (16-65). In 5 cases we used the bone marrow with a percutaneous technique with PSEUDOARTHROSIS a 60% healing success. The two failures of these techniques were in the same patient. In 35 cases we used open surgery and added SURGICAL TREATMENT OF DISTAL FEMUR NON-UNION bone graft plus PDGF and Bone Marrow in 16 cases, OP 1 alone in M. Girolami, C. Impallomeni, G. Trisolino, F. Trentani 16 cases and Bone Marrow plus OP 1 in the last 3 cases. The heal- Istituti Ortopedici Rizzoli, Bologna, Italy ing rate of all groups was similar (87% vs 87% vs 100%). The higher results of the last treatment (Bone Marrow + OP 1 ± PDGF) Non-union is a rare but feared complication in the distal femur. Its was only on three patients and should be further evaluated. The repair is often hampered by thin cortex, short distal length, inadequate patients treated with OP 1 experienced a greater number of previ- bone stock and any additional general health problems that the patient ous surgeries (>3), still the BMP-7 proved to be effective in these may have (old age, osteoporosis due to lack of use, insufficient blood cases. We suggest that surgeons should take into account the use of supply, infections, etc.). Several treatments have been proposed in the BMP 7 that proved to be effective in selected, previously failed literature. We present a retrospective analysis of the results of various patients for non-unions and that adding Concentrated Bone types of surgery performed at our institute over ten years. Marrow might improve these already impressive results. S38

ESSION PHLCP have shown to achieve a strong grip even on the osteo- S O23 porotic bone while preserving bone vascularisation. We present the clinical results of 20 consecutive patients with complex proximal humeral fractures treated at our institution with open reduction and HUMERUS AND ELBOW internal fixation with PHLCP. PROXIMAL HUMERUS FRACTURES: COMPARISON OF TREATMENT M. Privitera, L. Costarella, V. Pavone, F.R. Evola, A. Rossitto, G. Sessa SESSION O24 Dipartimento delle Specialità Medico-Chirurgiche, Istituto di Clinica Ortopedica, Catania, Italy PELVIS 50-80% of the proximal humerus fractures arise composed and stable; therefore no reduction is necessary and only immobilization of the arm ACETABULAR FRACTURES: A NEW CT BASED CLASSIFI- associated to a early rehabilitation are required. Concerning the dis- CATION placed and/or comminuted fractures several treatments have been sug- G. Tamburella gested, including open or closed surgical approaches. Crrect indication Rome, Italy of treatment depends on the fracture geometry and the patient’s gen- eral and psychological conditions. These fractures are often associated The author presents his experience of acetabular fractures, as exam- to rotator cuff injury or to great tuberosity fracture producing a slow ined according to Harris’ recent (2004) CT-based classification into and incomplete recovery of range of motion. Our trend is to use K- four separate groups and relative sub-groups. Each group is here rep- wires in the comminuted fractures, closed or open reduction and screw resented as a completely documented clinical case, with pre and post- fixation in the oblique fractures and intramedullary nails in presence of operative roentgrams as well as axial and volume rendering CT stable and not displaced fractures. This study examines the different imagery. The Harris classification differs from the classic and 40 year treatments performed in the Orthopaedic Clinic of Catania in relation old Letournel classification, basically ignoring the fracture complexi- to patients’ type of fractures, sex and biological age of patient and it ty and focusing on the pattern of the fracture itself, with respect to values the clinical and radiographic results at long term. column walls and extension beyond the acetabulum. It is also possible to include some commonly seen fractures otherwise not classified by Letournel. Fracture comminution is therefore not a defining charac- GUIDELINES OF PROXIMAL HUMERAL FRACTURES teristic. This topographic approach is easier for the surgeon to com- TREATMENT IN THE ELDERLY PATIENT prehend and memorize, thus facilitating pre-operative planning and M. Bigoni, S. Guerrasio, M. Gorla, C. Pulga, E.C. Marinoni the possibility of interdepartmental assessment of the fracture types. Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina Obviously, computerized tomography is the defining technique of this e Chirurgia, Scuola di Specializzazione in Ortopedia e classification. The axial CT display of acetabular fracture patterns Traumatologia, Monza, Italy within the pelvis is furthermore confirmed by the 3D reformatted images. This classification is loosely based on that of Tile and Helfet; Proximal humeral fractures represent 5 – 7% of all fractures and they with the advantage of further simplifying the sub-groups from 27 to are often due to moderate upper limb traumas; 75% of these are occur- 16. The Harris classification is simple and unambiguous, providing ring to females over 65 years. During the last year we observed 125 clear indications for both diagnosis and surgical treatment planning of proximal humeral fractures: we treated 108 fractures in a conservative this most complex chapter of Traumatology. way, one or two fragments-like by Desault dressing and 17 complex three or more fragments–like fractures in a surgical way. Following–up these patients we concentrated our attention more on functional out- SURVIVAL MANAGEMENT IN SEVERE PELVIC TRAUMA come during daily activities than on roengtengraphic comparison. We G. Rocca, V. Danzi [2], A. Scalvi [3], P. Cosmi [2], P. Savonitto [1] believe that proximal humeral fractures current classification, based on Struttura Funzionale di Traumatologia, OCM, Verona, Italy; two–dimension radiographic evaluation, is inadequate to predict clini- [2]Anestesia e Rianimazione A, Verona, Italy; [3]Divisione di cal outcome. A correct interpretation of the fracture, through a 3D CT Ortopedia e Traumatologia, OCM, Verona, Italy elaboration, allows to change and optimize the surgical treatment. According to our own experience, we present guide–lines of proximal Pelvic fractures are about 3% of all fractures observed in emergency humeral fractures treatment in the elderly patients. rooms. They are often associated with abdominal, thoracic and head lesions. Blood loss, as the result of bone bleeding or lesion of arte- rious or venous vessels, can often cause the death (37%) of the RESULTS OF THE TREATMENT OF PROXIMAL HUMERAL patient affected by these fractures. Haemorrhagic syndrome is the FRACTURES USING THE PROXIMAL HUMERUS LOCKING most important complication that threatens the life of patients with COMPRESSION PLATE pelvic lesions. Blood loss control is the key of the treatment of com- F. Chiodini, L. Filippi, L. Di Mento, M. Berlusconi plicated pelvic fractures and must be the very first step of the Istituto Clinico Humanitas, Rozzano, Italy patient’s pre-hospitalization management. This can be achieved with adequate “filling” with different devices. The pelvis must be stabi- The ideal treatment for fractures of proximal humerus is still lized with either external fixation or C-clamp to stop or control the debated. Close reduction and fixation with K wires have not shown bleeding (venous); this has to be done as soon as possible because it better results than conservative treatment. Shoulder hemiarthro- is a life saving treatment. In some cases bleeding is mostly due to plasty provides good pain relief, but only moderate functional artery lesion (12%-80%) and thus the priority is to find the lesion recovery. When indicated, open reduction and internal fixation site by means of angiography and proceed to embolization, delaying have proved to give good results in terms of pain control and func- the open surgical treatment. tion, but the surgical procedure is demanding and the results less It is controversial the priority, in the very first stress of treatment, of predictable in the osteoporotic bone. Fixed angle plates such as external stabilization versus angiography. S39

ACETABULAR RECONSTRUCTION IN TWO COLUMN FRAC- Introduction: Femur fractures constitute a serious social and care- TURES giving problem. The dimensions of the phenomenon are imposing: G. Rocca [1], A. Scalvi [2], P. Savonitto [1], P. Ricci [1] every year in Europe over 500.000 new cases are recorded. In Italy [1]Struttura Funzionale di Traumatologia, OCM, Verona, Italy; in 2002 around 87.000 in-takes due to this pathology were reported, [2]Divisione di Ortopedia e Traumatologia, OCM, Verona, Italy with a burden for the SSN of over 1 million Euros Materials and Methods: From the Register of the hip Prostheses of The fractures of the anterior and posterior column of the pelvis are one Puglia all the interventions carried out between 2003 and 2005 with of the most difficult lesions to be handled surgically. Patients affected diagnosis “fracture of the femur” have been selected. Epi-Info6.00 by this type of damage are victims of high energy trauma and have has been used for data elaboration. often important and heavy associated injuries which delay the surgical Results: 2058 cases were examined (76% women; hospitalization approach of the orthopaedic surgeon. Large exposures are necessary middle 20 days; age median 78 years). 80% of the interventions are but they can lead the patient to higher risks of infection and thrombo- of endoprosthesis. The most effected age class for the interventions embolism. The reduction of the various fragments is more difficult due of artroprosthesis is 60-69 years, for those of endoprosthesis is > to the interposed large muscular mass, to the imperative respect of the 79 years. 3,5% of the patients died in the 6 months following the vascular, nervous and urogenital structures, and sometimes by the dif- intervention. 6,8% of the patients had post-operative general com- ficult clear and direct inspection. The fragments are often deeply stuck plications. The most frequently used surgical incision was the lat- between themselves and the above mentioned structures. For these rea- eral one (67%). All patients were given antithrombotic therapy and sons it is imperative to understand the mechanics of the fracture and the antibiotics. 70% of the prosthesis were fixed with cement. 92% of forces that have caused it in order to restore the anatomic structure of the treated cases showed a good functional recovery at 12 month the pelvis. We report our survey and the results of 5 years experience follow-up. using, in the same surgical time, the anterior ilio-inguinal and the pos- Conclusions: the use of the regional register of hip prosthesis allows terior approach using the Kocher–Langebeck approach. not only to get reliable data on the characteristics of the interven- tions, but above all on their results. Working Group: P.Agamennone, A.Ambrosone, D.Bellino, SURGICAL TREATMENT OF COMPLEX HIP ARTICULAR G.Berloco, U.Biasi, A.Bozzi, F.Buquicchio, B.C.Campa, A.Canfora, FRACTURES M.Capozzi, G. Carchia, G.Carluccio, R.Castellaneta, P.Cataldi, D. Capitani, F. Castelli, R. Spagnolo M.Centrone, G Colì, M.Colonna, F.Conserva, O.De Carolis, [1]Ospedale Niguarda Ca’ Granda Dea, Milan, Italy G.DeGiorgi, S.DeGiorgi, P.Dell’Aera, L.Dell’Aera, F.P.DiCarlo, M.DiPalo, L.Felline, Ferrari, F.Fitto, V.Galante, P.Galluccio, Objective: The articular fractures of hip comprehend femoral head P.Giannella, T.Gismondi, S.Giucastro, M.Greco, V.Innocenti, fracture and acetabular fracture. D.Laghezza, F.Larosa, A.Leo, L.Limonciello, G.Lobianco, Materials and Methods: From 1999 to 2005 DEA of Niguarda Ca’ F.Loconte, G.Loiacono, S.Lorusso, M.Mannarini, G.Mariani, Granda Hospital accepted 14730 trauma, 1443 of them were higher M.Mascolo, F.Massari, N.Mastroianni, F.Mingolla, C.Monteleone, trauma. Pelvic fractures have been 425, 286 of them went under sur- B.Moretti, L.Moretti, F.Mori, P.Nardelli, A.Ognissanti, M.Panella, gical treatment. They were 132 acetabular fractures and 154 frac- F.Pascali, G.Pasquale, V.Patella, A.Pennetta, L.Petrelli, tures of the pelvic ring. We treated 7 fractures of femoral head. N.Petruzzellis, O.Recchia, L.Romita, V.Scarano, M.Schiavone, Results: we obtained 26% excellent, 49% good, 15% sufficient, G.B.Solarino, G.Solarino, L.Spagnoletta, G. Spera, A.Spinarelli, 10% short case results. We checked 82 complex fractures on 132 A.Stomeo, G.Surace, V.Tempesta, W.Uzzi, G.Vavalle cases, i.e. 62% of the treated acetabolar fractures. The average fol- low-up is 20 months (from a maximum period of 59 months to the less one of 4). In our cases, we found 0.8% of infections, 7.2 %, THE MANAGEMENT OF UNSTABLE TROCHANTERIC FRAC- etherotopic ossifiaction, 7.2 % avascular necrosis, post-traumatic TURES OF THE FEMUR arthritis 10.4%, SPE palsy 6.4 %. A. Lispi, F. Laurenza Conclusion: ORIF in acetabular fractures is a demanding technique Ortopedia e Traumatologia, Azienda Ospedaliera S. Giovanni – with high complication rate even in expert hands. Timing is very Addolorata, Rome, Italy important, as in other surgeries: fractures must be treated in a peri- od from 4 to 10 days. If possible, only one surgical way should be Trochanteric fractures of the femur demand special consideration in used without losing reduction quality. The learning curve is neces- trauma surgery, because of their high complication rate. The combina- sary to improve diagnosis tools and methods, surgical time but above tion of medial compressive, lateral tensile and torsional stresses, and all the accuracy of the fracture reduction. In our opinion if the team the reduced vascularization in the region, has resulted in problems of consists of more expert surgeons in acetabular fractures there will be malunion, delayed union, nonunion, implant failure and iatrogenic a better control of surgical complications, more attention to the devascularisation from operative exposure. Restoration of femoral reduction perfection, and results will eventually improve. length, rotation and correction of femoral head and neck angulation in order to restore adequate abductor tension and strength are essential to regain maximal walking ability. Intramedullary devices have been shown to be biomechanically superior by different authors because of SESSION O25 the central position of the implant in relation to both medial and later- al cortices. In combined compression and bending to failure, intramedullary nails were found to support up to 400% body-weight, PROXIMAL FEMUR FRACTURES compared with up to 200% for plate systems. The cephalic screw of intramedullary devices (e.g. gamma nail, proximal femoral nail) allows controlled ìmpaction of the fracture, while its intramedullary position THE FEMUR FRACTURES IN PUGLIA: CONTRIBUTION OF provides a shorter lever arm. This means a reduction in bending stress THE REGIONAL REGISTER OF THE PROSTHESES OF HIP for the nail of up to 30% compared with extramedullary devices, and a C. Germinario [1], M. Torre [2], M.T. Balducci [1], S. Tafuri [1], lower rate of implant failure. Another important benefit of closed Regione Puglia Gruppo di Lavoro Ortopedici [3] intramedullary locking nailing is that there is no need to reconstruct the [1]Osservatorio Epidemiologico Regione Puglia, Bari, Italy; [2]CNE- medial cortex at surgery. We found that the preferred method is by min- SPS - Istituto Superiore di Sanità, Rome, Italy; [3]Regione Puglia, Italy imally invasive surgery. In the literature the use of second-generation S40

intramedullary devices (gamma nail 3, proximai femoral nail) in their Today the surgical treatment of these fractures is based on reduc- long form recommended as standard, reducing the incidence of delayed tion and stability of fracture obtained with “minimally invasive” union and implant failure. The advantages of the implants are that technique. There are many different type of intramedullary nail: closed fracture reduction and early mobilisation with full weight-bear- the aim of this study is to evaluate the results of first 50 patients ing are possible without reconstruction of medial support or primary treated with new PFN-A nail from February 2005 to March 2006. autologous bone grafting. Evaluation included clinical and radiographic assessment (sex, age, fracture type, walking ability before and after operation, aver- age healing time, intra- and post-operative complications). The TREATMENT OF SUBTROCHANTERIC FRACTURES WITH clinical results confirm the excellent results of many studies. For DCS DEVICE proximal locking a spiral blade is used to produce adequate D. Lazzara, A. Petrini anchorage even in osteoporotic femoral head. This new device pro- U.O. Ortopedia, Nuovo Ospedale S.Giovanni di Dio, Florence, Italy vides a better fixation in patient with poor bone quality or instable fracture, reducing the risk of femoral “cut out”. The new PFN-A DCS (Dynamic Condylar Screw) system was introduced in the early nail is cannulated, don’t need anti-rotational screw and permit dis- 80’s by the AO/ASIF Group [1, 2] and successfully used in treating tal static or dynamic interlocking using only one screw. these kind of fractures [3, 4], even in cases of comminuted fractures (if biological, indirect, reduction techniques are used) [5]. We will report our institution’s experience in using DCS for fractures of the GAMMA NAIL: 15 YEARS EVOLUTION, 15 YEARS EXPERI- proximal third of the femur or in cases of re-operation for previous, ENCE. THE RESULTS failed, osteosyntesis. G. Rocco [1], P. Savants [1], M. Inguaggiato [2], A. Migliorini [2] Materials and Methods: Between 2003 and 2005 we implanted 20 [1]Struttura Funzionale di Traumatologia, OCM, Verona, Italy; DCS in 20 different patients. Seven were re-operation for non-union [2]Clinica Ortopedica, Ospedale Policlinico, Verona, Italy (2 patients had intramedullary nails and 5 DHS devices) and 13 were recent fractures that we classified using AO and Seinsheimer [6] radi- The perthrocanteric fractures are the most frequent fractures in the ographical criteria. The average age of patients was 72.2 (42 to 92 elderly people and the increased life expectation in the population years). All the patients underwent pre-operative and post-operative x- leads to a higher number of fractures. The intramedullary nailing tech- ray (45 days and monthly until healing was achieved) and clinical nique represents since 15 years the first surgical choice in handling examination. The average follow-up was 18 months (8 to 24). these types of fractures and the Gamma Nail has been the instrument Results: We had one case of superficial infection which settled with utilized more frequently. However the Nail has been frequently modi- local debridement and antibiotics and two cases of delayed union. fied with the aim to better fit the femoral anatomy, to increase the resis- However all the three cases healed in 9, 8 and 7 months. The other tance to the mechanical stress, to increase the grip performance and 17 cases united in an average period of 4 months. So we had a union therefore facilitate the surgeon in the introduction, housing, and proxi- rate of 100%. mal and distal locking of the Nail. In our Hospital we have used the Conclusions: In conclusion DCS device is a good option in treating Gamma Nail for more than 15 years as golden standard in the treatment these difficult cases: the complication rate reflects the general con- of the perthrocanteric fractures and we have used all the updated ver- dition of patients and the biomechanics of the proximal femur [7]. If sions. We show the results of a large review of the whole period. the proximal femur is dissected only laterally and only in so far in necessary to place the DCS, cancellous bone grafting is never useful and healing can be achieved almost in all cases. References: SESSION O26 1. Sanders R, Regazzoni P (1989) Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 3(3):206–213 PROSTHESIS III 2. Schatzker J, Mahomed N, Schiffman K, Kellam J (1989) Dynamic condylar screw: a new device. A preliminary report. J Orthop Trauma 3(2):124–132 THE CERAMIC COUPLING IN A SERIES OF 100 CONSEC- 3. Blatter G, Janssen M (1994) Treatment of subtrochanteric fractures UTIVE HIP REPLACEMENT PERFORMED BY THE SAME of the femur: reduction on the traction table and fixation with dy- SURGEON namic condylar screw. Arch Orthop Trauma Surg 113(3):138–141 G. Solarino, A. Piazzolla, L. Scialpi, N. Tartaglia, G.B. Solarino 4. Pai CH (1996) Dynamic condylar screw for subtrochanteric femur [1]Università degli Studi di Bari, U.O. Ortopedia e Traumatologia I, fractures with greater trochanteric extension: J Orthop Trauma Bari, Italy 10(5):317–322 5. Vaidya SV, Dholakia DB, Chatterjee A (2003) The use of a dynam- The Authors present clinical and radiological results in 100 con- ic condylar screw and biological techniques for subtrochanteric secutive alumina-alumina hip replacement performed by the senior femur fracture: Injury 34(2):123–128 author (G.B.S.). The initial diseases inducing hip replacement 6. Seinsheimer F (1978) Subtrochanteric fractures of the femur: J were: primary coxarthrosis in 55 hips, atraumatic avascular necro- Bone Joint Surg Am 60(3):300–306 sis in 23, fracture of the upper femur in 10, coxarthrosis after hip 7. Warwick DJ, Crichlow TP, Langkamer VG, Jackson M (1995) The dysplasia in 8, 2 coxitis, rheumatoid arthritis in 1 and post-trau- dynamic condylar screw in the management of subtrochanteric matic coxarthrosis in 1. The average preoperative HHS was 35 fractures of the femur: Injury 26(4):241–244 points (min.10-max.65). In all cases we used a press fit triradius cup (Cerafit M) combined with a 32 mm alumina femoral head. Three different stems were used: a cemented collared smooth TREATMENT OF PROXIMAL FEMORAL FRACTURES WITH anodized Ti stem in 26 cases and two cementless (one anatomical NEW PFN-A NAIL: PRELIMINARY RESULTS and one HA-coated straight) Ti stems in the others. To an average M.S. Boccanera, F. Carsillo, L. Ricchiuti, P. Verzaro, M. Papalia follow-up of 78 months (min.22- max.154), we have evaluated 82 Divisione di Ortopedia e Traumatologia, Nuova Itor ASL Roma B, hips (82%); 3 hips have undergone a revision (1 infection, 1 stem Rome, Italy fracture, 1 sinking of the anatomical cementless stem). None of S41

sockets have been revised for aseptic loosening and none of the Stryker Howmedica). The following parameters were evaluated: implants have been revised due to mechanical failure of the ceram- intra and post operative complications, total blood loss, time of ic components. At the last f.u. the average HHS is 95 points surgery, component placement, length of hospital stay and func- (min.64-max.100). tional outcomes at 3 and 6 months (HHS; Womac). Results: No significant differences were found between the groups with respect to the average surgical time, the acetabular and stem posi- CLINICAL EVENTS DURING BEMIPARIN PROPHYLAXIS tion, the length of hospital stay and Harris Hip Score (HHS) and the STARTED 6 HOURS AFTER HIP OR KNEE REPLACEMENT Womac osteoarthritis index at six months. A significant lower blood SURGERY: A REVIEW loss was found in the mini-incision group. A higher percentage of peri- P. Prandoni [1], A. Birreci [2], A. Gómez-Outes [3] operative complications was recorded in mini incision group (two stu- [1]Dipartimento di Scienze Mediche e Chirurgiche, Università di por of sciatic nerve, one fracture of the greater trochanter, one stem Padova, Padua, Italy; [2]Dipartimento Medico, Sigma-Tau, Rome, malposition). Italy; [3]Dipartimento Medico, Laboratorios Rovi, Madrid, Spain Conclusions: A mini incision lateral approach seems to have a lower blood loss and a shorter length of incision but a higher percentage of Background: Bemiparin is a second generation low-molecular- peri - operative complications. On the bases of our experience we weight heparin (LMWH) licensed for postoperative start of prophy- could speculate that the minimally invasive surgery should be direct- laxis of venous thromboembolism (VTE), whereas recommenda- ed to the new surgical approach with muscle sparing instead of a tions for other LMWHs involve preoperative initiation. shorter skin incision using standard approaches. Objective: To review the available experience on the use of bemi- parin started 6 hours after total hip replacement (THR) or total knee replacement (TKR) surgery. FEMUR PERIPROSTHETIC FRACTURES TREATMENT BY Methods: We extracted data on clinical outcomes from the 3 avail- CABLE-READY BONE PLATE SYSTEM able clinical studies assessing postoperative bemiparin prophylaxis R. Franceschini, P. Romano, G. Salvadori del Prato, M. after THR or TKR (Planes et al., 2000; Navarro-Quilis et al., 2003; Franceschini, M. Grassi Abad et al., 2003). Pooled events were: documented symptomatic Dipartimento di Chirurgia Specialistica Riabilitazione, Milan, Italy DVT or pulmonary embolism (PE), major and minor bleeding, deaths and thrombocytopenia. Femur periprosthetic fractures have been increasing compared to Results: The 3 studies included 1264 patients (421 THR and 843 primary implants. Among treatment options we have used the TKR) who were administered bemiparin 3500 IU started 6 hours cable-ready bone plate system, treating 9 cases whose results are after surgery. A total of 1056 (83.6%) received extended post-hos- presented. This system is based on the association of plate and cer- pitalisation prophylaxis with bemiparin for a median time of 38 clage which run through the plate itself and are secured by a screw, days. Mean patients’ age was 70.6 years (range: 28-85) and 67.4% giving stability to the system because plate and cerclage are were female. Neuraxial anaesthesia was used in 1166 (92.2%) secured together. The availability of molded plates, able to adapt patients (31% epidural and 69% spinal). The incidence of events up on great trocanter, allows to fix also proximal fractures. In partic- to 5-6 weeks (observation period) was the following: documented ular, the tensioning system is useful to adjust the strength given symptomatic DVT, 0.4% (THR 0.2% and TKR 0.5%); documented and to progressively retention the cerclage in order to avoid sec- symptomatic PE, 0%; major bleeding, 1,3% (THR 2.1% and TKR ondary loss of tension. We consider this system effective, since it allows good stability and early patient motion. 0.95%); minor bleeding, 7.0% (THR 8.5% and TKR 6.3%); deaths, 0%; mild to moderate thrombocytopenia, 0.95%. There were no cases or spinal haematoma or severe thrombocytopenia. Conclusions: Bemiparin prophylaxis started 6 hours after surgery is associated with a low rate of documented symptomatic VTE and SESSION O27 major bleeding events, and, consequently, it is an effective and safe alternative to preoperative start of thromboprophylaxis and minimis- es the risk of spinal haematoma. KNEE I

UNICOMPARTIMENTAL KNEE ARTHRITIS. UNICOMPARTI- HIP ARTHROPLASTY: MINI INCISION LATERAL APPROA- MENTAL KNEE REPLACEMENT VERSUS COMPUTER AS- CH VERSUS STANDARD APPROACH SISTED TOTAL KNEE REPLACEMENT: A MATCHED PAIRED R. Iorio, A. Speranza, S. Giannetti, C. D’Arrigo, A. Ferretti STUDY [1]Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy N. Confalonieri, A. Manzotti, K. Motavalli [1]I U.O. Ortopedica e Traumatologica, C.T.O., Milan, Italy Introduction: Minimally invasive surgery has become a trend over the last few years in all aspects of orthopaedic surgery, including The Authors compared in a matched paired study at a minimum follow- total hip arthroplasty. The so-called “mini-incision” technique up of 3 years, the results of 78 knees with isolated medial unicompar- involves limiting the length of the skin incision to ≤ 10 cm with use timental knee arthritis replaced with either UKR (group A) or of either anterior, lateral or posterior approach. Computer Assisted TKR (group B). In both groups the selection Materials and Methods: Between March 2004 and December included only stable knees with range of motion of at least 110°, both 2005, 120 consecutive unilateral total hip replacements were per- without any pre-operative flexion deformity and a varus deformity big- formed in our institute by the same senior surgeon. The diagnosis ger than 8 degrees, and a body mass index lower than 30. The match- was of primary osteoarthritis in 101 cases, of osteonecrosis of the ing criteria for each case were: same grade of pre-operative arthritis, femoral head in 8 cases and of femoral neck fracture in 11 cases. age, sex and pre-operative range of motion. No implant in either group In all cases we performed a hip replacement using a direct lateral had to be revised and no intra or post-operative complication caused by approach (65 cases using a standard approach / 55 cases using a the implant selection were registered. The surgical time and hospital mini incision approach). In all cases we used a cementless cup staying was statistically longer in the CA TKR group. There were no (Trident; Stryker Howmedica) and a cementless stem (Hipstar; statistical differences in the Knee Society score while the functional S42

score and the GIUM score were statistically different, even if the dis- age functional score improved from 43 to 82 points. A transient postop- tributions of the percentage of results were similar. In both groups there erative peroneal nerve paralysis was observed in only one patient. The were no radiological signs of loosening. In CA TKR all the implants mechanical axis was corrected within 3 degrees of neutral in 72% of were positioned within 4 degrees of ideal both Hip-Knee-Ankle angle knees. There was one failure due to aseptic femoral loosening at 5 years. (180°) and Frontal Tibial Component angle (90°). Higher performance Conclusions: The Pie-crusting technique is a reliable method to cor- results were obtained using a unicompartimental knee replacement in rect fixed valgus deformity in patients undergoing TKA, with a low the treatment of isolated primary unicompartimental knee replacement complication rate and excellent mid-to-long terms results. in patients older than sixty compared to a computer assisted total knee replacement. In this study a computer assisted alignment system with an optimal implant positioning in TKR did not compensate its lower EVOLUTION IN THE TREATMENT OF DEGENERATIVE KNEE clinical performance but increased the economical costs. BY UNICOMPARTMENTAL PROSTHESIS G. Montemurro [1], F. Messore [1], P. Fanelli [1], P. Belli [2], G. Fanelli [3] [1]Ospedale di Anagni, Italy; [2]Ospedale di Ceccano, Italy; RESULTS OF COMPARISON BETWEEN TKA IMPLANTED [3]Università di Roma La Sapienza, Polo Pontino, Latina, Italy BY ANTERO-MEDIAL ACCESS AND MID-VASTUS MEDI- ALIS ACCESS In the last few years Unicompartimental Knee Prosthesis (UKP) has G. Pipino, D.C. Vaccarisi reached a new emphasis. Modern studies have started to show valid and Bologna, Italy encouraging results. The best candidate to a UKP is a patient over 70s, not overweight and with soft sport activity. Aim of this work is to eval- We compared 260 TKA Profix (Smith & Nephew) implanted uate the improvement of short and mid term results using a particular between 2002 and 2003 by antero-medial approach and 260 TKA UKP specifically studied to enhance the range of motion and the surgi- Profix (Smith and Nephew) implanted between 2004 and 2005 by cal procedure. In comparison with the Total Knee Arthroplasty (TKA) midvastus medialis approach. TKA has been implanted by mini- the UKP gives better ROM, faster postoperative recovery and the possi- open technique. In our study we analyze the following parameters: bility of an easier operation in case of infection or loosening. Some fea- recover of quadricipital strength, range of motion, Q angle, patello- tures should be evaluated and the surgical technique should use modern femoral pain, prosthesis component positioning, blood loss, time of design hardware. From January 2002 to January 2005 we implanted 57 postoperative recovery, patient satisfaction. We valued quadricipital UKP (Uni-Zimmer) in 55 patients. From April 2005 to February 2006 strength by Isokinetic Leg-Extension-Air-Machine and ROM by we used the evolution of the mentioned prosthesis, called ZUK® in 40 digital goniometer. patients. We collected results about first 45 Uni-Zimmer in comparison In patients with TKA implanted by midvastus-medialis approach with the 40 ZUK. The demographic distribution was similar in the two we noted: groups for age and gender: mean age was 64.5 (49-81); 60% female and 1. more easy respect of Q angle 40% male. In both groups a minimal invasive procedure was performed. 2. reduction of patello-femoral pain We did not have infections. We can affirm that the real qualitative dif- 3. more easy preservation of Q angle ference with ZUK concerned about ROM in the early postoperative peri- 4. same easiness and precision of component implantation od, with 125° of flexion already in third day. Nevertheless our early data, 5. riduced post-operative blood loss thanks also mini open-tec- we can conclude that in the treatment of degenerative knee, the correct nique selection of the patient, the surgical technique and the updated design of 6. 50 % improvement of patient satisfaction short-term and long-term. the new UKP can give satisfactory results and the UKP represents a valid alternative to TKA and HTO also regarding cost effectiveness. Some features should be carefully evaluated and the surgical technique TOTAL KNEE ARTHROPLASTY FOR VALGUS DEFORMITY must be sharply performed using components with updated designed. CORRECTED WITH THE PIE-CRUSTING TECHNIQUE: A FIVE TO TWELVE YEAR FOLLOW-UP STUDY D. Lup [1], P. Aglietti [1], A. Baldini [1], L. De Luca [1], L. Lippi [2] [1]I° Clinica Ortopedica, Università degli Studi, Florence, Italy; SESSION O28 [2]U.O. Radiologia 1, CTO, Florence, Italy

Introduction: Correction of fixed valgus deformity presents a major KNEE II challenge in primary total knee arthroplasty (TKA). The aim of our paper was to retrospectively review a cohort of primary TKA performed in patients with preoperative valgus knee using the pie-crusting technique. TRENDS OF TOTAL KNEE ARTHROPLASTY IN ITALY Methods: Sixty-five patients with 73 knees with preoperative M. Torre [1], E. Romanini [2], G. Tucci [3] alignment >10 degrees of valgus were operated between January [1]CNESPS - Istituto Superiore di Sanità, Rome, Italy; [2]Globe, 1994 and September 2000. Fifty-five knees (75%) were reviewed Rome, Italy; [3]Unità Operativa di Ortopedia e Traumatologia, with an average follow-up of 94 months (range 60-140). With the Pie- Ospedale “L. Spolverini”, Ariccia, Italy crusting technique the posterolateral capsule was cut transversely at the level of the tibial osteotomy and an inside-out multiple stable incisions Objective: Knee arthroplasty has been so successful that nowadays were made using a small knife blade, in the contracted lateral soft tis- it is the most prevalent surgical intervention in the treatment of knee sue (particularly in the ITB and the lateral capsule) until the deformity arthritis. Higher confidence in surgical technique, development in was corrected. The popliteus tendon was always preserved to limit the biomaterials, evolution of pain control and rehabilitation protocols risk of posterolateral instability in flexion. Various types of implants and, last but not least, the perception of a reliable result have con- were used: IB-II (20%), LPS (22%), MBK (54%) and CCK (4%). At tributed to the spreading of this procedure. follow-up all patients were evaluated using the Knee Society scores, a Materials and Methods: To understand the spreading dynamics of Patellar score and a radiographic study, which included also stress x- knee arthroplasty in Italy, an analysis of data collected on the National rays to evaluate gaps configurations. Discharge Records Database has been performed for both Total Knee Results: At follow-up the average Knee Society clinical score improved Arthroplasties (TKA; ICD9-CM 8154) and Total Knee Replacements from 38 points preoperatively to 90 points postoperatively and the aver- 8155 (TKR; ICD9-CM 8155) in the period 1999-2003. S43

Results: An increase of 84% for TKA and 114% for TKR has been reg- Results: The study shows an overall good outcome (86,1/100), in par- istered. Average length of stay has shown a decrease of 26%. No change ticular the result was excellent in 45% of the cases, good in 30%, fair- in the average age of patients undergoing TKA has been detected. ly-good in 17%, poor in 8%. Survival of the implants was 89,8%. The However, it is interesting to analyse variations occurred in the number of failures which caused a revision have been 9 aseptic loosening, 3 sep- procedures and in length of stay stratified per health trusts typology. The tic loosening, 2 peri-prosthetic fractures and 3 ruptures of the poly- highest increase in number of procedures has been observed in Private ethylene. Radiolucent lines in the 42,5% of the cases, mainly in tibial Clinics (+146%) while the lowest has been found in Public Hospitals area 1 have been discovered. In the 84% of the cases they did not turn (+48%). All Public trusts have shown a decrease in length of stay (about out progressive. Two cases were presenting signs of initial loosening, -25%) while for the private ones an increase of 16% has been measured. without current indication to the revision. Discussion and Conclusions: The analysis of trends in knee arthro- Discussion and Conclusion: Clinical and survivial results have plasties in Italy, conducted during the period 1999-2003, has high- been good and in agreement with the literature. TKA allows pain lighted the considerable increase of the number of procedures. relief and functional recover. Aseptic loosening is the main cause However the high interregional variability of data suggests that the of failure at long term, while septic loosening is at a shorter one. It analysis must take into account the causes in order to better define is likely that the evolution of the materials will increase the sur- reference standards to address research where it is useful and to cor- vival of the implants. The prosecution of the study and the evalua- rectly share earmarked resources as well. tion of other series with new implants are mandatory.

TREATMENT OF PERISPROSTHETIC FRACTURES AFTER TOTAL KNEE ARTHROPLASTY USING MODIFIED MINI- TKA MIDVASTUS TECHNIQUE A. Camera, G. Grappiolo, M. Gramazio, G. Santoro A. Toro [1], G.F. Trinchese [1], A. Russomando [1], G. Mastroroberto [2] Ospedale “Santa Corona”, Pietra Ligure, Italy [1]U.O. di Ortopedia e Traumatologia, Ospedale Amico “G. Fucito”, Mercato San Severino, Italy; [2]Servizio di Neurofisiopatologia Introduction: Fracture after TKA is always a delicate event, not so Ospedale “G. Da Procida”, Salerno, Italy simple to be treated, whether it comes intra-op or in the long-period. Surgical treatment is rather necessary but standardized and often Objective: In minimally invasive total knee arthroplasty we prefer closed to personal experience of the surgeon. The incidence of this mini-midvastus approach because it preserves extensor mechanism, pathology is increased because of the raising number of knee pros- also giving a good join exposure. Otherwise, the 43% of patients who thesis implanted and the patients’ life-expectation. had vastus splitting approach, presented electromiographic alteratus Materials and Methods: In our prosthetic division of “Santa alterations after the surgery. For this reason we have modified the tra- Corona” hospital are implanted 290,3 knee prostheses on the aver- ditional mini-midvastus technique, including in the incision just ten- age per year. Perisprosthetic fractures treated since 2000 up to today don under the vastus medialis, but not the muscle. are 26 (18 females, 8 males). In all cases except one, total prosthe- Materials and Methods: From May 2005 to January 2006 we per- sis was used and only in three cases the removal of the prosthesis formed 132 TKA with modified mini-midvastus technique. We and the reimplant using a revision-prosthesis with taproots has been studied 30 patients with electromiography performed 7 days before carried out, while in the other cases the treatment has been the surgery and 3 months after, on a standard point of vastus and Ostesynthesis or not sanguinary treatment. on incision site. The muscle was checked for any abnormal spon- Results: We have noticed that the clinic result varies a lot depending taneous activity and during contraction. on the type and the time in which the fracture happened. On the Results: There was no abnormal spontaneous activity in 100 % of intra-op fractures we obtained better results, while the worst are cases before and after surgery. PUM were normal in 60 % of patients those coming from the long-period fractures where the loss of and increased in 40% before and after surgery. There were no signs of motion range and subseguently of TKS have occurred. reinnervation preoperatively. The recruitment pattern indicated a little Discussion: A periprosthetic knee fracture surgery is very hard for the damage in 80% of cases and a big damage in 20% before the surgery. surgeon; he must have traumatologic background with an adequate Discussion: Electromiographic alterations were already preset in prosthetic instrumentation (taproots, semi-bounded or bounded pros- preoperative exams. They were due to ipotrophy of vastus muscle theses), associated to a physiatric structure adapted for the post-op. because patients had not been using it for a long time for pain and stiffness. Postoperatively we had signs of reinnervation in 80% of patients, that, if related to postoperative recruitment pattern TOTAL KNEE REPLACEMENT WITH PRESS FIT CONDYLAR improved in 20% of cases is not a sign of damage. It indicates a (PFC) PROSTHESIS: OUTCOMES AT TEN YEARS sprouting and a regeneration of suffering fibres before surgery. A. Bistolfi, A. Barberis, F. Lagalla, C. Olivero, E. Novarese, M. Conclusion: Our results demonstrated that modified mini-midvas- Crova tus technique does not only cause damage to muscle, but it also II Clinica Ortopedica, Turin, Italy allows to obtain sign of rapid return to function.

Introduction: The long-term follow-up of the total knee arthroplas- ty (TKA) is of great interest. This study evaluates the results at 10 HIGH TIBIAL OSTEOTOMY IN VARUS KNEE: VALIDITY AND years of 219 implants from 1993 to 1998. RESULTS Materials and Methods: 15 patients died and 31 were lost at fol- A. Schiavone Panni, M. Tartarone, A.A. Patricola, C. Mazzotta, D. low-up. 166 TKA (125 patients, 79% female, mean age 77,5 yy) Santaiti implanted for arthritis in 83,1%, rheumatoid arthritis in 11,4%, ISpeO - Istituto Specialistico Ortopedico, Rome, Italy; University of post trauma in 1,8% and other in 3,7%. The PFC (Johnson & Molise, Campobasso, Italy Johnson, USA) cemented posterior-stabilized have been used. Patella has been resurfaced in 103 cases (62%). ”Hospital for Background: Many studies reported the value of the high tibial Special Surgery Knee Score” (HSS) and “Knee Society, Total Knee osteotomy (HTO) in the treatment of varus knee. In this section we Arthroplasty Roentgenographic Evaluation and Scoring System” would like to presents our results about HTO with Puddu-plate. have been used for clinical and roentgenographic evaluation, Methods: From june 1999 to october 2002 we performed HTO in 20 respectively. patients; 10 patients (group 1, age min 45 max 55) were affected by S44

varus knee and the others 10 patients (group 2) were young people The number of total knee arthroplasty is progressively increasing (age: min=19, max=26) with genu-varu juvenile. We performed HTO during the years, due to both an improvement of the surgical tech- using Puddu-plate technique; all patients were studied preoperatively nique and the materials used, and for epidemiological reasons. with RX scan, and Lysholm and IKDC questionnaire and in the group Despite failure percentage is reducing continuously, it must be strict- 2 was also performed MRI study. Surgical techinique included diag- ly considered because of the high costs charged to the patient and to nostic arthroscopic evaluation of the knee and for osteotomy greater the medical system. Frequently, trabecular bone failure of the tibial than 10 degree we, always, used sinthetic bone block for filling the epiphysis is liable of prosthesis damages. The study of periprosthet- defect. In the post-op period all patients dressed a knee brace blocked ic mineralization and its changing represents direct information in extension for 2 weeks; no- bearing was allowed for the first for 4 about mechanical strength of the bone and, indirectly, information weeks, only partial bearing from 4 to 6 weeks and total bearing was about biological competence of changing according to loading situ- allowed only after the 6/7 week (after X-ray evaluation). All patients ations. Dual Energy X-ray Absorptiometry (DEXA) is the chosen were allowed for CPM since the first post-op day. method to evaluate bone mass density in a non invasive way. This Results: Among this series no major complications (septic, vascular) technique, performed after total knee replacement surgery, is at the were observed. The mean follow-up was 52 months in group 1 and 48 beginning and it doesn’t gain the experience acquired with THA. months in group 2; all patients filled the IKDC and Lysholm ques- Furthermore, there aren’t studies in literature except of two-years tionnaire. In group 1 were observed satisfactory results in 70% of follow-up. Authors present a retrospective study of densitometric patients, in group 2 80%. In all cases we observed with X-Ray evalu- evaluation at six-years follow-up of a non consecutive group of 40 ation a good healing of the osteotomy after 8 weeks from surgery. patients undergone TKR surgery and a critical analysis of the Dexa Discussion: HTO with Puddu-plate has some advantages: it is an easy use as a support to modern prosthetic surgery. surgical technique in skilled surgeons and allows to avoid damages to fibula and syndesmosis. Controindications are severe osteoporosis, patella baja, rheumathoid arthritis and post-traumatic knee instability; controindication is, even, a varus condition greater than 20 degree. SESSION O29 On the bases of our experience we should obtain ipercorrection in the varus-arthrosic knee and a normal alignement of the inferior limb in the young people. RACHIS IV Conclusions: The timing and pre-op planning are necessary for the good results of surgical technique. In our opinion absolute con- troindication is patient with pre-op flexion ROM< than 90 degree BONE GRAFT SUBSTITUTES IN POSTEROLATERAL FUSI- and relatively controindication is obesity (BMI >1.32). HTO repre- ON: EFFICACY OF GRAFT MATERIAL AND ACCURACY OF sents a valide alternative to major surgical procedure; in fact it is a RADIOGRAPHS IN THE ASSESSMENT OF BONY FUSION very effective and low cost procedure that leaving the bone stock of G. Giannicola [1], G. Cinotti [1], M. Riminucci [2], B. Sacchetti [3],A. the tibia allows to other eventual surgical procedures in the future. Corsi [3], E. Ferrari [1], U. Mancini [4], S. Michienzi [3], A. Funari [2], G. Gregori [1], G. Citro [5], P. Bianco [3], F. Postacchini [1] [1]Dipartimento di Scienze dell’Apparato Locomotore, Università degli CLINICAL EXPERIENCE OF TOTAL KNEE ARTHROPLASTY Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, Italy; COMPUTER–ASSISTED: CLINICAL, FUNCTIONAL AND [2]Dipartimento di Medicina Sperimentale, Università degli Studi ROENTGENOGRAPHIC RESULTS AFTER 1 YEAR dell’Aquila, Italy; [3]Dipartimento di Medicina Sperimentale e M. Bigoni, S. Guerrasio, A. Rossi, D. Munegato, D. Gaddi, E.C. Patologia, Università degli Studi di Roma “La Sapienza”, Policlinico Marinoni Umberto I, Rome, Italy; [4]Clinica Veterinaria, Rieti, Italy; [5]Diparti- Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina mento Laboratorio Modelli Animali, Istituto Regina Elena, Rome, Italy e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumato- logia, Monza, Italy A currently used animal model of spinal fusion was adopted to investigate: 1) the osteoconductive properties of a coralline HA- Total knee arthroplasty computer–assisted surgery is getting more coated (Proosteon 500R) as carrier for osteoinductive materials; 2) and more common nowadays, as testified by the increasing number the effectiveness of autologous fresh bone marrow (AFBM) and of orthopaedic publications on the subject. Many Authors notice the platelet-rich plasma (PRP) associated with granules of coralline HA, accuracy of positioning prosthetic components is proportional to in promoting spinal fusion; and 3) the accuracy of radiographic eval- long-term good results. Navigation systems, during TKA implant, uation in the assessment of bony fusion. supply the surgeon with the opportunity of maximizing clinical Materials and Methods: Posterolateral fusion was performed in 30 results through his own technical surgery improvement. Authors pre- WNZ rabbits using the following graft materials: coralline HA alone sent clinical, functional and roentgengraphic results at 1–year follow and +AFBM on the left and right side, respectively (15 rabbits); up of a consecutive group of patients undergone total knee replace- coralline HA+PRP and coralline HA+AFBM+PRP on the left and ment surgery computer–assisted, with a particular stress on the right side, respectively. Six months after surgery animals were sac- alignment equal or inferior to 3° which, as other Authors report, well rificed and the lumbar spines submitted to standard and high resolu- correlate to good and excellent long-term results. tion (FAXITRON) radiographs and histologic analysis. Results: Radiographic assessment showed a spinal fusion in 86.7 % and 93.3% of the spine treated with coralline HA alone and with PERIPROSTHETIC DENSITOMETRIC EVALUATION OF A AFBM, respectively, and in 71.3% of those treated with coralline NON CONSECUTIVE GROUP OF PATIENTS UNDERGONE HA+PRP and with coralline HA+AFBM+PRP. There was no signif- TOTAL KNEE REPLACEMENT SURGERY: A SIX–YEARS icant difference in the radiographic results between the 4 groups. FOLLOW-UP Histologic analysis showed new bone formation adjacent to the M. Bigoni, S. Guerrasio, A. Rossi, M. Gorla, E.C. Marinoni transverse processes while little or no bone formation was found Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina between the transverse processes leading to a continuous bony e Chirurgia, Scuola di Specializzazione in Ortopedia e bridge. Granules of coralline HA-coated were also found with scant Traumatologia, Monza, Italy evidence of reabsorption 6 months after surgery. S45

Conclusions: Coralline HA-coated was a suitable carrier for osteo- them complicated by meningitis. Both these cases eventually conductive material; however, a carrier with a shorter reabsorption recovered. Two politrauma patients developed serious skin lesions time may be advisable, at least in some circumstances. AFBM and that healed after conservative treatment. Thirteen cases had a PRP associated with coralline HA- coated were not found to be an mechanical failure. They recoverrd through a surgical revision (8 adequate graft material for spinal fusion. Radiographic evaluation posterior approach, 5 double approach). showed a reduced accuracy in determining bony fusion, even when a high resolution technique was used. SESSION O30 POSTERIOR-LATERAL LUMBAR FUSION WITH OSI- GRAFT®: EXPERIENCE WITH AN INTERNATIONAL MULTI- CENTRIC STUDY DEFORMATION D. Prestamburgo, M.F. Surace, C. Ratti [1]Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, Università degli Studi dell’Insubria, Varese, Italy RESULTS OF VIDEO-ASSISTED THORACOSCOPIC SURGE- RY: 5 YEARS FOLLOW-UP During 2005 an international, multicentric, prospectic randomized A. Montanaro, F Turturro, E. Camerucci, M. Spoletini, A. Ferretti trial was conducted to evaluate the efficacy of BMPs in spine Cattedra e UOC di Ortopedia e Traumatologia II, Facoltà di surgery. This study, in which we included ten patients, consisted in Medicina e Chirurgia, Policlinico “S. Andrea”, Università “La the treatment of degenerative disc disease, spondilolysis-olistesis Sapienza”, Rome, Italy or other single level pathologies where a surgery has never been attemped before. A PLF was performed in both groups. In the treat- From September 2000 to October 2002, 11 consecutive patients ment group some bone chips deriving from laminectomy or spin- with scoliosis underwent a video-assisted thoracoscopic anterior ous processes were mixed with Osigraft ® (BMP-7); the control spinal release and fusion followed by a posterior instrumented group received an autograft from the posterior iliac crest. fusion. This case series was compared to a similar group of 11 con- Concerning the surgical technique transpedicular screws were secutive patients who were treated by open anterior spinal release positioned and stabilized with titanium rods; also an accurate and fusion followed by a posterior segmental spinal fixation and haemostasis was obtained as well as a complete exposition of the fusion. We evaluate the results on average 5 years follow-up. transverse processes. Both the Osigraft ®/bone complex and the Methods: The VATS group included 8 female and 3 male (mean age autograf were positioned between the transverse processes. Five 14.2) with the following diagnosis: 5 idiopatic scoliosis, 4 neuro- men and five women were treated with a mean age at surgery of 51 muscolar spinal deformation, 1 congenital scoliosis and 1 neurofi- years (range, 25 to 68 years). The affected level was L4-L5 in six bromatosis. In the Control group were included 7 female and 4 male cases and L5-S1 in the last four. Results at most recent follow-up (mean age 15.4) with 7 cases of neuromuscular scoliosis and 4 idio- are presented, with particular regard to the quality and timing of patic. The mean preoperative Cobb angle was 78° in the VATS group the fusion healing in the two groups. versus 85° in the Control group. Mean follow-up was 5.1 years. Results: There was no significant difference in the average scolio- sis correction rate, which was 32° in the VATS group and 37° in the TREATMENT OF THORACIC AND LUMBAR SPINE LE- Control group respectively. No difference was observed in the SIONS. BOLOGNA MAGGIORE HOSPITAL EXPERIENCE average blood loss between the two groups. There were no vascu- M. Palmisani, G.B. Scimeca, A. Gasbarrini, F De Iure, L. Boriani, lar or neurological complications in both series. At final follow-up, G. Barbanti Brodano, S. Boriani both group no exhibited loss of percentage correction of scoliosis. U.O. Ortopedia e Traumatologia, Chirurgia Vertebrale, AUSL Città Conclusion: In our series, video-assisted thoracoscopic surgery di Bologna, Ospedale Maggiore ~ Bologna allowed to achieve anterior instrumented release and fusion as effective as standard open procedure. No difference of percentage In the lapse of time between October 1996 and December 2005, of curve correction was observed at final follow-up. Advantage of 419 cases of recent thoracic and lumbar spine fractures were treat- thoracoscopic technique included lower postoperative pain, faster ed in our Department. Every patient has been followed (Follow-Up recovery and, cosmetically, a minor surgical scar. (FU) has ranged from 6 to 72 months, mean FU has been 30 months) with clinical and radiographical (Xrays, CT scan/MRI) evaluation. Mean age in our series was 41 years (ranging from 10 THE SURGICAL TREATMENT OF SEVERE ANGULAR KY- to 78 years); 289 patients were males, 130 females. Car crashes PHOSIS have been the leading cause of the traumatic events (253 cases), G. De Giorgi, A. Piazzolla, A. Luca followed by work injuries. Mean fractures were localized at tho- Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. racic spine in 226 cases, while 193 lesions involved the lumbar di Ortopedia e Traumatologia I, Università degli Studi Bari, Italy spine. Every patient was treated by a posterior approach associat- ed with laminectomy and arthrodesis of all of the instrumented The authors present their experience in the treatment of severe angu- areas. Eighteen patients underwent widened postero-lateral lar kyphosis with anterior decompression and posterior stabilization approach with intersomatic arthrodesis. Anterior approach was according to an experience already consolidated in time. From 1994 performed in 50 cases.Neurological damage has been assessed fol- they have treated 19 patients, 10 males and 9 females. In 8 cases the lowing Frankel criteria. Neurological setting improvement was aetiology was congenital, in 4 infectious, 2 post-traumatic, 3 sec- reported only in 3 cases (2,7%) out of 134 cases with complete ondary to Recklinghausen, 1 secondary to Morquio, 1 neoplastic. In medullary lesions. Five deep and 3 superficial infections developed case of clinical evidence of medullar damage (6 patients) they have in t he postoperative period. Only one of these infected cases led to always performed previously the anterior way, with medullar instrument removal. Three multiple-trauma patients died. Two of decompression and application of bony graft (iliac, fibula, coast), them because of sepsi and one because of pulmonary embolism. completated, after 1-2 weeks, from the posterior instrumentation and Two cases were characterized by cerebrospinal fluid fistula, one of arthrodesis. In case of absence of medullar damage they have used S46

the Halo-traction preoperative in order to mobilize the spine, thus evaluating the reducibility of the kyphosis, and to notice eventual SESSION O31 variations of the clinical conditions. Therefore, in absence of neuro- logical deficit, they have performed first the posterior time, correct- ing the deformity, and subsequently the anterior one, to obtain the SHOULDER arthrodesis using autologous bone graft. In all cases the surgical two-time strategy produced a reduction of the deformity with regres- WOLTER’S HOOK PLATE IN 3°DEGREE ACROMION-CLA- sion, partial or total, of the neurological symptomatology, where VICULAR LUXATIONS present, and absence of representation in time. L. Lucente, W. Thomas, L. Tafuro Clinica Quisisana, Rome, Italy

POSTERIOR SPINE FUSION WITH UNIT ROD IN PATIENTS The treatment of the acromion-clavicular luxation is still contro- AFFECTED BY NEUROMUSCULAR SCOLIOSIS versial. Many orthopaedics cure this luxation in conservative way, L.F. Colombo, S. Monforte, F. Motta others with surgery. In the first case they said that surgery is not ICP Ospedale, Milan, Italy sure to get a complete anatomical and functional restoration. It depends to the osteosynthesis device chosen. We prefer a tempo- Methods: Since 2003 we treated 32 patients for neuromuscular sco- rary special plate with hook (Wolter’s plate). It enables an optimal liosis with the Unit Rod instrumentation (18 males, 15 females) acromio-clavicular anatomical restoration without damage of artic- mean age 15th range 13 to 19. Mean preoperative curve magnitude ular surfaces (cartilage, disc) and a complete and sure functional was 78°, range 40° to 120°, and associated pelvic obliquity mean recovery. value 33° range 10° to 56°. In 5 patients we perform the anterior release (2 by thoracoscopy, 3 by laparatomy). All the patients were clinical and RX evalueted preoperatively and at 6, 12, and 24 SURGICAL TREATMENT OF ACROMION-CLAVICULAR DIS- mounth postoperatively. We used SRS 22 questionnaire and subjec- LOCATION AND FRACTURE OF THIRD LATERAL OF CLAV- tive questionnaire at 6 months. ICULA WITH A HOOK PLATE. RESULTS AT 3 YEARS Results: The spine curvatures mean correction was of 35° range 18° S. Zoccali [1], A. Di Francesco [1], P. Cerulli Mariani [1],R. to 56° (62%). The pelvic obliquity mean correction was of 11° range Pizzoferrato [1], C. Zoccali [2], A. Ranalletta [2] 0° to 24°. Mean surgery time was 5.30 h. The subjective question- [1]U.O.Di Ortopedia e Traumatologia, Ospedale S. Salvatore naire showed an important improvement of the quality of life. [2] Discussion and Conclusion: With this technique we reached good re- L’Aquila, L’Aquila, Italy- Università degli Studi L’Aquila, Clinica sults without previously using traction or cast and the patients were able Ortopedica, L’Aquila, Italy to use the weel chair 7/10 days postoperative without brace. With this our first report we can confirm according to the literature that the Unit Objective: The aim of this study is the evaluation of the surgical Rod is a good device for the treatment of neuromuscular scoliosis. treatment of acromion-clavicular dislocations type III, V Rockwood and displaced lateral fractures of the clavicula with a hook plate, with a mean follow-up of 3 years. PROGRESSION RISK OF JUVENILE SCOLIOSIS DURING Materials and Methods: We treated 25 acromion-clavicolar dislo- PUBERTY cations and 10 displaced lateral fractures of the clavicula. The ther- F. Canavese, P. Charles, J.P. Daures, A. Dimeglio apeutic protocol was an immobilization in Gilchrist for 7 days, an CHU Lapeyronie, Montpellier, France early rehabilitation with passive exercises to recover R.O.M., reach- ing the complete R.O.M. in 8 weeks from the surgical treatment. We reviewed 205 scoliosis (163 girls, 42 boys) at the end of Plate removal was performed at 12 weeks from the trauma. Clinical growth. There were 52 juvenile I and 153 juvenile II. At the clinics and radiological controls were performed at 2, 6, 12 weeks and after we regularly use a checklist to assess standing and sitting height, the removal of the plates at 12 months. Tanner signs, menarche and bone age to map the patient on its Results: in all of the cases the results were satisfactory, with renew- growth curve. Topographies and Cobb angles of primary and sec- al of the normal daily activity and sport activity at 4 months from the ondary curves were measured on AP spine radiographs and refered trauma. At 12 months from the trauma a M.R was performed with to the pubertal growth diagram. observation of the entire continuance of the AC and coracoclavicu- Within 205 scoliosis 99 (48.3%) became surgical. At the begining lar ligaments. of puberty (11 years of bone age in girls, 13 years in boys), within Discussion: The hook plate of Dreithaler is a plate in titanium, in 109 primary curves < 20 degrees 15.6% were surgical. Within 56 which the hook is positioned under the acromion, guaranting a sta- curves between 21-30 degrees, the surgical rate increased to 75.0% ble reduction and besides, with its angulation of 15°, it is adapted to and to 100% for curves >30 degrees. For 42.9% of the curves the angle of acromion-clavicola. We used plates with 3 holes for the between 21-30 degrees and 71.4% of the curves >30 degrees that dislocations and 4 holes for the fractures, it presents smooth border became surgical, the aggravation took essentially place during the and is slightly concave on the inferior surface to adapt itself to the first two years of puberty (p=0.0014). A gain of one degree per anatomy of the clavicula. We recommend hook plate fixation as an month represents a risk of 100% (p=0.0001). The surgical risk was acceptable surgical method for the treatment of type III and V the highest for primary thoracic curves (p=0.0001). No significant acromionclavicular dislocation and displaced lateral fractures of the difference of evolution risk was noted for both genders. Juvenile clavicula fractures. scoliosis over 30 degrees at the begining of puberty becomes sur- gical. Curves between 20 and 30 degrees need a close follow-up. Our study showed that surgery was often indicated too late and POSTOPERATIVE REHABILITATION IN SHOULDER ANA- allowed only partial curve reduction. An earlier intervention is TOMICAL ARTHROPLASTY: 3 YEARS FOLLOW-UP preferable for a better curve correction, even if it gets necessary to G. Merolla [1], P. Paladini [1], I. Riccio [2], V. Riccio [2], G. Porcellini [1] sterilize the growth cartilage anteriorly to prevent a crankshaft [1]U.O di Chirurgia della Spalla e del Gomito, Ospedale “D. phenomenon. Surgery at the begining of puberty represents only a Cervesi”, Cattolica, Italy; [2] Dipartimento Scienze Ortopediche, minor sacrifice on sitting height. Seconda Università di Napoli, Naples, Italy S47

Introduction: Degenerative arthritis of glenohumeral joint is char- and double row arthroscopic technique and to correlate these results acterized by cartilage loss and bony erosion, head flattening and with the integrity of the cuff as determined by clinic and Arthro-MRI bony erosion. Shoulder arthroplasty should restore anatomic con- evaluation. gruity ensuring articular stability and proper tension on soft tissues. Materials and Methods: 45 arthroscopic rotator cuff repairs were ran- In this study we report 3 years follow-up on patients who underwent domized into one of two groups: single row and double row suture shoulder replacement and the rehabilitative program they followed. anchor repair technique. All shoulders had pre and postoperative eval- Patients and Methods: from January 1999 to December 2003 we uation by a modified UCLA and a postoperative assessment by the use performed 145 shoulder arthroplasty. Patients enrolled: 125 of MR Arthrography scans at 18 months from surgery. (86.20%); patients excluded: 20 (16%). Mean follow-up: 36 months Results: We did not find a statistically significant difference in total (min: 28, max: 42). Score system: Constant scale (mean ± SD). UCLA score when comparing single row and double row. MR Operations have been performed under general anesthesia and delto- Arthrography examination at 18 months of follow up showed that pectoral approach. Rehabilitative program: 0-30 days: sling, passive double row suture anchor technique provides a better structural out- mobilization on scapular plane up to 40°; 30-45 days: active exer- come (6 partial-thickness defects and 1full-thickness defect) if com- cises in water pool and strenght restore, subscapular exercises at 42° pared with single row suture anchor repair (9 partial-thickness day; 60 days: resistive exercises. Isometric test has been performed defects and 2 full-thickness defect) (p<0.05) after 6 months and 12 months. Radiographic follow-up: post-opera- Discussion: Recent studies focused on the original insertion anato- tive, after 6 months and then yearly. my of the rotator cuff tendons and anatomy of the surgically recon- Results: Constant score increased from preoperative 28.7 ± 16.2 to structed insertion, suggested that restoring of normal anatomy of post-operative 68 ± 12.4. ROM increased from 10.6 ± 8.7 to 28.4 ± rotator cuff footprint may improve the healing and mechanical 6.6: Subscapular restore: no restore in 12 cases (11.42%), partial strength of repaired tendons. restore in 83 cases (79%), total restore in 10 cases (9.6%). We The footprint cannot be adequately restored with a single row of noticed 11 complications (8.8%): 8 cases (6.4%) of painful stiffness, suture anchors, while an anchor suture arthroscopic repair technique 1 case (0.8%) of shoulder prosthesis infection, 1 case (0.8%) of based on a double row of suture anchors which increases the tendon- periprosthetic fracture and 1 case (0.8%) of cemented glenoid com- bone contact area restores the anatomic rotator cuff footprint. ponent loosening. Statistical method: Chi-square test (p<0.05). Conclusions: Restoring the anatomical footprint is appealing, but in Discussion: anatomic shoulder arthroplasty (Bigliani-Flatow) is a our work we did not find a better clinical functional outcome in certain effective device to restore the operative ROM and an appro- patients who underwent double row suture anchor technique versus priate tone of active stabilizer muscles. Results can be considered single row suture anchor repair. However, double row repair excelled good in regard to pain and function. in structural outcome when compared with single row repair.

THE USE OF INVERSE PROSTHESIS OF SHOULDER IN THE SURGICAL TREATMENT OF FROZEN SHOULDER ARTHROPATHY FROM RUPTURE OF ROTATOR CUFF. OUR A. De Carli, L. Frate, A. Vadalà, A. Ferretti EXPERIENCE IN 11 CASES Ospedale S. Andrea, Rome, Italy A.M. Mancini Ospedale Regionale, Aosta, Italy Shoulder adhesive capsulitis is a pathological condition character- ized by an involvement of the gleno-humeral capsula and ligaments The arthropathy from rupture of rotator cuff determines a particular with a progressive and severe reduction of the range of motion. type of degeneration of the gleno-humeral articulation. The function Materials and Methods: Authors refer their experience on 15 patients loss of muscles of rotator cuff in determining the spin centre of the surgically treated for frozen shoulders. These patients (6 males and 9 humeral head cause came up of humeral head and a sub-acromiale females with a mean age of 57 years: range 26 to 68 years) underwent arthrosis with pain and loss of function. Standard prosthesis cannot arthroscopic capsular release and closed manipulation. This syndrome solve the problem because of the irreparable rupture of rotator cuff. followed a shoulder trauma in only two patients and a rotator cuff tear The use of an inverse prosthesis to fix the spin center, to ritension with progressive loss of motion in four patients; no etiologic cause was deltoid fibers and to increase the abductorial lever of arm would found in nine patients. All the patients were evaluated by international seem the best solution. The gold standard indication is represented functional scoring scales (American Shoulder and Elbow Surgeons by cases in which there is a meaningful loss of function and pain. Standardized Shoulder Assessment Form –ASES-, Constant and The insufficiency of the deltoid muscle represents the main con- Murley, Simple Shoulder Test and UCLA). traindication to put an inverse shoulder prosthesis. The relation Results: The pre-operative range of motion of the shoulder was mea- places the aim to analyse the eleven cases treated near our division sured with goniometry (side to side); the mean abduction of the from 2004 to 2006, trying to establish a standard protocol for the involved shoulder was 60°; the mean external rotation 20°, the mean indication to the inverse shoulder prosthesization, taking into con- flexion 75°; during the internal rotation patients were never able to sideration the age, the kind of activity turns, the psycho-physical reach the lumbo-sacral vertebra. At a mean follow-up of 15 months conditions and the collaboration of the patient. (range 6 to 45 months) all the patients were reviewed. They all referred an improvement in range of motion and a decrease of pain. Post-operative physical examination showed a mean abduction of FUNCTIONAL AND MR ARTHROGRAPHY IMAGING EVALU- nearly 150°, a mean ER of 45° and a mean flexion of 165°; fourteen ATION AFTER ARTHROSCOPIC SINGLE ROW AND DOUBLE patients were able to reach the lumbo-sacral junction during the ROW SUTURE ANCHOR REPAIR internal rotation. All the post-op functional evaluation scales also F. Franceschi, G. Rizzello, A. Marinozzi, G. Longo Umile, L. showed relevant improvements. There was any case of fracture, dis- Ruzzini, R. Papalia, V. Denaro location or other complication. Università Campus Biomedico, Rome, Italy Conclusion: In patients with severe adhesive capsulitis, the treat- ment goal is pain reduction and recovery of shoulder mobility. Objective: The purpose of the present study was to evaluate the Patients with frozen shoulder unresponsive to traditional conserva- short-term results of arthroscopic repair in two focused groups of tive treatment can be effectively treated with arthroscopic capsular patients with large and massive rotator cuff tears treated with single release and closed manipulation. S48

SHOULDER PAIN IN SCAPULAR DYSKINESIS: A DYNAMIC experimental group and the controls and between the pathological ELECTROMYOGRAPHIC STUDY joint and the healthy one in the same patient.This study confirmed G. Bonaspetti, F. Azzola, U.E. Pazzaglia the compensatory activation of the deltoid and the infraspinatus, as Clinica Ortopedica, Spedali Civili, Brescia, Italy already demonstrated in literature, and showed a compensatory activation of the latissimus dorsi and the pectoralis major in patients The aim of this study is to analyse shoulder pain in scapular dyski- with massive rotator cuff tears. We believe that these data are valu- nesis using a sperimental dynamic electromiography. We adopted able in the surgical and rehabilitation planning in patients with a the electromiography analysis on 7 patients (4 women and 3 men) massive rotator cuff tear. between 19 and 42 years old and 7 shoulders of 7 healthy persons (6 man and 1 woman) between 25 and 30 years old. The criteria to select the patients were: THE TREATMENT WITH ESWT OF CUFF ROTATOR CALCI- 1) Shoulder chronic pain since, at least, 6 months without success FYING TENDONITIS VERSUS SHOULDER IMPINGEMENT after pharmacological therapy and physiotherapy; SYNDROME 2) Positive results on scapular “setting test”; M. Vitali [1], G. Peretti [2], L. Mangiavini [2], G. Fraschini [2] 3) Positive result on Rochwood test; [1]Scuola di Specializzazione Ortopedia e Traumatologia I, 4) Shoulder X ray in front-back position and side (axillary) and Y Università degli Studi di Milano, Milan, Italy; [2] Ospedale San position negative; Raffaele, Milan, Italy 5) Negative ecography exam; 6) Negative artro MRI. The aim of our study was to assess the shock waves therapy efficacy in The following muscles have been dynamically evaluated with EMG the treatment of patients suffering for calcification of the rotator cuff and correlated video evaluation: pectoralis major and minor, deltoid, versus those with the “impingement syndrome” in the shoulder. From serratus anterior, rhomboid, superior and inferior trapezius, latissimus July 2004 to November 2005 a number of 233 patients were treated dorsi, sopraspinatus and infraspinatus. Through the analysis of our data with ESWT; it was counted that 130 patients suffered from calcification we have found several differences, statistically significant, of muscle of the cuff rotator and 103 patients had pain in shoulder with “impinge- activaty during flexion movements, in front and scapular plain level ment syndrome”. A clinical check was done right before the beginning (scaption) and of abduction movement. The following analyses have of the ESWT and after the first and fourth months at the end of the ther- been done on each muscle, for every type of movement: apy. The treatment for patients suffering from the “impingement syn- 1st) Considering the average values of presetting at 150° of excur- drome” was positive in 55% of cases with pain reduction and joint- sion; function recovery. As for the treatment in the calcification of the rotator 2nd) Considering the average values of movements from the begin- cuff it was observed that the pain was reduced or totally disappeared in ning (0°) to the end (150 °); 83% of patients, with also a joint-function recovery.As a matter of fact, 3rd) Considering the single measure points (presetting the difference of positive results after the shock wave therapy is a 28% 0°,30°,90°,120°,150°). in favour of people suffering from the calcification of the rotator cuff The iperactivation of pectoralis minor produces scapular anteposition compared to the patients suffering from the” impingement syndrome”. and extra rotation and changes the articular relationship between omer- As a matter of fact, the most important cause of the “impingement syn- al head and glenoid and also changes the kinetic chain on front level. drome” is a mechanical phenomenon that cannot be eliminated with These chenges produce a general iperactivation of stabilizing muscle of shock waves therapy. The shoulder with calcification is the expression gleno humeral joint: infraspinatus and latissimus dorsi (according to of a chronic inflammatory at the rotator cuff. Therefore, shock waves Kronberg) and trapezius and serratus anterior. Additionally there is also therapy has an analgesic and anti-inflammatory effect on the shoulder an iperactivity of rhomboid that assists scapular adduction. and it reduces the calcification with the reduction/removal of the painful symptoms. However, in both painful pathologies, it is necessary to note that ESWT cannot and must not be replaced by surgery. MUSCULAR COMPENSATION IN PATIENTS AFFECTED FROM MASSIVE ROTATOR CUFF TEAR: SUPERFICIAL ELECTROMYOGRAPHIC STUDY C. Scotti, G.F. Fraschini, P. Ciampi SESSION O32 U. O. Ortopedia e Traumatologia, Ospedale San Raffaele, Università Vita-Salute, Milan, Italy WRIST AND HAND Shoulder girdle is an extremely mobile joint, in fact it can deter- mine 16000 different positions due to a fine coordination between bony structures and muscles. When a massive rotator cuff tear THE TREATMENT OF ARTICULAR FRACTURES OF THE occurs, this equilibrium is altered.The aim of this study was to eval- DISTAL RADIUS USING L.C.P. PLATE uate muscular activation of deltoid medium, superior fibers of pec- L. Tarallo, R. Adani, O. Calveri toralis major, latissimus dorsi and infraspinatus with a superficial Clinica Ortopedica, Università degli Studi di Modena e Reggio electromyographic study and the analysis of kinematics in patients Emilia, Modena, Italy with a massive rotator cuff tear. Twenty patients (mean age 65.3) with a massive tear, evaluated by clinical testing and with MRI, Objective: The aim of this work is to analyze the efficiency of were enrolled in this study and compared to a control group. The L.C.P. plate for the treatment of intrarticular fractures of the distal study included evaluation of maximal isokinetic values and eleva- radius type B and C according to A.O. classification. tion on scapular plane.The study showed higher mean values of Materials and Methods: 58 distal radius articular fractures were activation for the deltoid, the infraspinatus, the pectoralis major and treated, 26 were of type B and 39 of type C (35 male and 23 the latissimus dorsi compared to the healthy contralateral joint. female).41 patients were seen at follow up on average 13 months Analysis of variance showed significant differences (p=0.0001) after surgery. Mean age was 49 years, varying between 19 and 87 between the activation of the 4 muscles. The Bonferroni modifica- years old. Volar incision was used in 32 cases, dorsal incision was tion, after comparing the mean EMG values of the 4 muscles, pro- used in 5 cases and double access was performed in 4 subjects. Pre- duced an highly significant difference (p<0.0001) between the operative CT was used in 26 patients. S49

Results: “Mayo modified wrist score” was used to evaluate patients: chase, particularly in elderly patients with osteoporosis. This system mean active wrist extension was 57°(range 30°-70°) while active prevents proximal migration of the screw, with reduction loss and pos- flexion was 60° (range 25°-90°) with T.A.M. of 116.5. Type B frac- sible compression of median nerve. In our Department 15 angular sta- tures had mean ROM of 136.6 while C type fracture had a mean of ble plates were implanted, obtaining good long term results, without 104,6. The final wrist score was: excellent in 19 cases, good in 12, major complications to tendons and nerves. In two cases we observed fair in 6 cases and poor in 4 cases. The results were excellent/good tingling in median nerve territory, spontaneously resolved in two and in 76% of patients while it was fair/poor in 24%. four months. In one case, we had loss of range of motion in finger flex- Discussion: In our series the volar approach was mostly used in type ion due to post-surgical adherences, requiring tenolisis. Angular stable B3 e C distal radius fractures with volar angulation of fragment. Pre- volar plates are an excellent fixation means for volar distal radius, operative CT investigation is recommended for type B3 e C distal allowing effective stabilization of the fracture, and being well tolerated wrist fractures for optimal surgical treatment. by nearby delicate anatomical structures. Conclusions: The type B fractures had a better outcome in term of wrist range motion and pain. Early surgical treatment and correct use of CT investigation also allow to obtain good results in type C PRESENT DAY OUTLOOK ON KIENBOCK DISEASE wrist fractures. A. Merolli, L. Rocchi, F. Catalano Università Cattolica, Rome, Italy

PERCUTANEOUS SCREW FIXATION FOR UNSTABLE Kienbock disease is still evasive when etiopathogenesis is consid- SCAPHOID FRACTURES ered. Several theories have been proposed: a)-a direct trauma lead- R. Cozzolino [1], U. Passaretti [2], A. Penza [2] ing to a vascular alteration; b)-repeated multiple trauma leading to [1]Scuola di Specializzazione in Ortopedia e Traumatologia, Naples, a vascular alteration; c)-a primary vascular impairment which Italy; [2]Unità Operativa Complessa di Chirurgia della Mano e dei leads to osteonecrosis. In Lichtman stage 2 and 3a, shortening Nervi Periferici, Ospedale Pellegrini, Naples, Italy osteotomy of the radius is quite effective. In Lichtman stage 4, proximal row carpectomy gives good clinical results. Several oth- Backgrounds: The scaphoid is the most frequently fractured carpal ers surgical treatments have however been suggested and applied: bone and is common in young, active patients. The technique of per- in most cases (apart from the lunate joint prosthetic replacement) cutaneous screw fixation, with increasing popularity, has been success- literature reports good results. Could it be possible to suppose a fully conducted in non-displaced, stable scaphoid fractures (B1-B2 relative indipendence of these results from the technique applied? Herbert class.) resulting in shortened immobilization duration and Could the surgical approach in itself start a reparative process of prompt functional retrieval. The purpose of this study was to evaluate the lunate, by the recruitment of humoral factors yet to be identi- the surgical technique and to explore the potential benefits of using fied? Kienbock disease is quite rare and the patient follow-up percutaneous screw fixation in unstable scaphoid fractures. needs to be several years long: these are probably the two major Methods: 40 patients with scaphoid fractures surgically treated reasons why it is difficult for any Author to set-up a comparative between 2000 and 2005 were enrolled in this study. There were 10 long-term study with an adequate number of patients. It is advis- male and 30 female patients, with an average age of 30 years (range, able that modern techniques of images processing and transfer 20–50 years). Five patients showed pseudarthrosis –D1-. (web links; digital radiography) will be applied in a multicentric Results: A 1 mm guide wire was introduced volarly. The screw multinational study, with a follow-up not shorter than 10 years, to length was measured directly with a second guide wire of equal better understand this elusive pathology. length. A cannulated screw of equal length was inserted under fluo- roscopic guidance. We prefer to use the Acutrak or mini-Acutrak OUR EXPERIENCES ABOUT PYROLYTIC CARBON PROS- screw system but any cannulated screw system that permits screw THESIS IN THE PIP JOINT insertion beneath the articular surface can be used (Herbert, A. Marcuzzi, M. Abate, N. Della Rosa, A. Landi Kompressor). The outcome was ranked as excellent in thirty patients Struttura Complessa di Chirurgia della Mano e Microchirurgia, and good in eigth patients. Only two patients experienced occasion- Azienda Ospedaliera Policlinico, Modena, Italy al wrist pain or soreness after exertion Discussion: The technique is simple, permitting accurate screw The authors describe their experience in pyrolytic carbon prosthesis placement in the central axis of the scaphoid, which is biomechani- in the PIP joint of 15 patients (12 male and 3 female) (average of 47 cally advantageous and important in order to achieve union. years, range 18-73 years) treated between November 2001 and March 2005. Ten patients had a pain and stiffness of PIP joint by old fracture; three patients had a primary osteoarthrosis; one patient had ANGULAR STABLE PLATE FOR FIXATION OF DISTAL a joint stiffness after Swanson prosthesis; one patien had an RADIUS FRACTURES arthrodesis after a joint fracture. All patients were evaluated with a E.M. Caruso, M. Franceschini, P. Prina, G. Salvadori del Prato, R. average follow-up of 18 months (range 3-43 months). Based on this Franceschini study, the authors suggest the use of pyrolytic carbon prosthesis in Divisione di Ortopedia e Traumatologia, Ospedale Luigi Sacco, the patients affected by primary and secondary osteoarthrosis of PIP Milan, Italy joint to resolve the pain, to improve the hand grip and the range of motion of the affected finger. Surgical treatment of distal radius fractures has widened its indications, since long distance results due to poor conservative treatment are badly tolerated by high demand patients. In our Department of Orthopaedic MYOELECTRIC PROSTHESIS: A POSSIBLE CHOICE FOR Surgery of Sacco Hospital, Milan, Synthes angular stable volar plates THE METACARPAL AMPUTATION’S TREATMENT IN EMER- are used for articular fractures of the wrist with volar or dorsal dislo- GENCY cated fragments (Burton type), without comminution. The advantage M. Abate [1], N. Della Rosa [1], R. Sacchetti [2], C. Castagnetti [1],A. of this device is the special threaded screw head, which stabilizes the Landi [1] screw to the plate, suited for the distal fragment of the fracture, where [1]Struttura Complessa di Chirurgia della Mano e Microchirurgia, the cortical bone is thin and a standard screw would have little pur- Modena, Italy; [2]Centro Protesi INAIL, Bologna, Italy S50

In this study the Authors consider the myoelettric prothesis as a pos- mobilization) prompted the study of surface replacements which, in a sible choice of treatment in the hand amputation through the quite complex shape, reproduced the physiological excursion of the metacarpal bone, when replantation or reconstruction of a functional MCP joint. However, these surface replacement designs lack any hand in emergency are impossible. The most diffuse attitude in the intrinsic stability and require the absolute integrity of the capsulo-lega- metacarpal amputation, within the thumb, is to save the residual carpal mentous structures of the MCP joint; this is a seldom encountered con- hand and the secondary reconstruction of a chela hand. This attitude dition in rheumatoid patients, which represent the vast majority of often means, in emergency, to perform a free or pedicle flap or an potential users of MCP joint replacement. As a matter of fact, the opti- abdominal flap due to the exposure of metacarpal bones. The second mal design for a MCP prosthesis to be used in rheumatoid patients step is the reconstruction of a chela hand by several surgical and should comply with an adequate range of motion; an effective grip microsurgical tecniques. That is a hard care for the hand surgeon and strength; an intrinsic stability. Fifty years after the early designs in first of all a strong sacrifice for the patient because of the results are MCP joint prostheses these goals have not been achieved, yet. not always satissfactory. The possible alternative choice suggested by the Authors is the disjointing, at the wrist elvel, of the residual hand and, after a couple of months, the myoelettric prothesis. In the Centre of Hand Surgery and Microsurgery of Modena in co-operation with POSTER PRESENTATIONS Prothesis Centre of Vigorso di Budrio, the Authors have compared the clinical otucomes of chela hand and the myoelettric prothesis through the evaluation of function, aesthetics, psychologic aspects, cost in FEMORAL FRACTURES AND NON UNION: TREATMENT BY relation to benefit. The results enhance the validity of this choice. SHEFFIELD FRAME F. Sala, R. Spagnolo, F. Castelli, U. Valentinotti, D. Capitani Divisione di Ortopedia e Traumatologia, Ospedale Niguarda Ca’ AN EXPERIMENTAL STUDY OF STRESS TRANSFER Granda, Milan, Italy BETWEEN PROSTHETIC STEM AND BONE IN A MODEL FOR THE METACARPO-PHALANGEAL JOINT Introduction: Much has been written about the use of different A. Merolli, M.S. Spinelli, F. Catalano treatment modalities in the management of femoral fractures. Chirurgia della Mano, UCSC, Rome, Italy However these articles do not include the use of the Sheffield frame amongst the modalities described. We have experience in the treat- The abnormal transfer of stresses between the prosthetic stem and bone ment of fracture and non union by external frame. We report our may lead, often frequently, to the mobilization and failure of a joint experiences and conclusions. replacement implant. Finite Elements Modelling (FEM) is one of the Materials and Methods: the patients who had undergone Sheffield most applied methods to study the internal stresses and strains of a frame management from 2003 to 2005 years. Demographic data, the given material. In this work, Authors visualized the stress transfer at the type of the hardware, the complications of surgery, duration of treat- interface between bone and the prosthetic stem when a torsional load ment and recorded outcome were noteded. is applied. They concentrate on the influence of the stem cross-section Results: We have treated 10 patients (7 male, 3 female) 7 were acute and, in so doing, a model of the metacarpal diaphysis was produced compound fractures and 3 non union / infection of the femur; the where, along the same major axis, stems of different cross-sections mean age at the time of frame application was 43 years (range 14 – were inserted. Seven cross-sections were examined: 1)-trapezoidal; 2)- 75). One ORIF infected non-union had removed plate and screws, triangular; 3)-rectangular; 4)-triangular (equilateral); 5)-squared; 6)- infected bone resection and treated by frame with Ilizarov bifocal pentagonal; 7)-circular. A FEM software ANSYS 5.7 was used. The method. When tissue healed a new ORIF procedure was employed. two most important results were: a)- sharp edges in the geometry of the The mean time from frame application to union was 8 months (range section are far from stabilize the stem, because they give raise to exces- 3 – 16 months). We did not find major complication, refracture, per- sive loadings at the interface which will lead, in the long term, to bone sisting infection, chronic regional pain syndrome. The mean knee rarefaction accordino to Wolff’s law; b)- circular cross-section gives movement was of 90° (racing from 25° - 140°). the greatest homogeneity in stress transfer, which is particularly Conclusions: Treatment of femur fractures and non unions/infection required when torsional stress are applied. are notoriously difficult. In selected cases the use of Sheffield frame as the Ilizarov method provides a reliable and successful treatment option. HISTORY OF METACARPO-PHALANGEAL PROSTHETIC DESIGNS OLECRANON FRACTURES OSTEOSYNTHESIS: EXPERI- A. Merolli, R. De Vitis, F. Catalano ENCE WITH THE EPINAIL-ELBOW LOCKED NAIL Chirurgia della Mano, UCSC, Rome, Italy F.V. Sciarretta, G. Mastantuoni, P. Zavattini Ospedale Civile, Velletri, Italy Total joint replacement of metacarpo-phalangeal (MCP) joints in fin- gers was realized in mid-fifties in patients affected by the complete Introduction: Olecranon fractures are very common lesions whose degenerative or traumatic loss of the MCP joint. The vast majority of treatment strategy is determined by several clinical and biomechan- early designs were hinged joints, allowing flexion-extension only at ical factors and always directed to obtain a stable osteosynthesis in right angle with the palm. Biomechanics of the MCP joint is far more order to achieve early elbow joint mobilization. In this work we pre- complex; namely, lateral deviation and axial rotation are coupled to sent the results obtained with the intramedullary Epinail-Elbow flexion-extension in the most part of the range of motion. To solve the locked nail recently introduced on the market. problem of the early mobilization of hinged prostheses, two major Materials and Methods: Since 2005, immediately after having known routes were followed: the introduction of cementing techniques and the the product, at Our Institution we have started to use the Epinail-Elbow development of flexible prostheses. The latter should not be called locked nail in order to reduce the complications and the need for pro- “joint prostheses” since form and function of the joint are far from been longed post-op immobilization of the arm. This is a cylindrical, titani- reproduced, but the model of this “joint spacer” proposed by Swanson um, cannulated, locked nail whose diameter decreases from 6 to 5 mm is still one of the best choice for the surgeon today still.However, the from proximal to distal with 5 holes for the distal locking screws, dis- lack of reproduction of the MCP function and the very limited load posable in 4 lengths, whose proximal compression is achieved by a which can be afforded (to avoid the breakage of the prosthesis of its washer. In this paper we present the results of our first 15 cases. S51

Results: In the cases we have treated, 12 metaepiphyseal proximal surgery due to glenohumeral instability. During surgery, under ulnar fractures and 3 fractures of the proximal third of the ulnar dia- arthroscopic control, a full thickness supraspinatus tendon biopsy physis, we have in all cases obtained fracture’s consolidation by was harvested in the middle portion of the tendon. All slices were closed introduction of the Epinail-Elbow nail. The only intra-op processed for histological analysis. complication has been the rupture of a reamer for the distal screws. Results: On surgical specimens of supraspinatus tendon from We did not encounter post-op fractures or nonunions. patients with rotator cuff tears, but not from patients with instabili- Discussion: This new method of internal fixation of the olecranon ty, we found increased preponderance of hyaline degeneration, fibro- process has some characteristics, that, in our opinion, make it cartilaginous or chondroid metaplasia, calcification, lipoid degener- unique, allowing to eliminate the usual complications encountered ation, mucoid or myxoid. Degenerative changes were more evident with previous osteosynthesis methods. This intramedullary nail, on the articular side of the rotator cuff. although introduced by closed technique, enables anatomic reduc- Discussion: Despite the relevance of the problem, causes and mech- tion of the fracture fragments and eliminates the need for a post-op anisms of rotator cuff disease are poorly understood and far from an immobilization. For this reason, after the first cases, we started exhaustive comprehension. allowing active and assisted elbow rom the first post-op day, Determining factors to the pathogenesis of rotator cuff disease are regaining daily activities along with clinical and radiographic intrinsic factors (such as biomechanical faults, excessive loading, recovery. aging, poor microvascular supply) and extrinsic factors (such as compression of the tendons by bony impingement or direct pressure from surrounding soft tissue). ULNAR NERVE TRANSPOSITION OR SIMPLE DECOM- Conclusions: The present study provides a description of the histo- PRESSION? CHOICE OF TREATMENT IN ULNAR NERVE logical architecture of human surgical specimens of normal COMPRESSION AT THE ELBOW supraspinatus tendon from patients with rotator cuff tears. G. Pilato, A. Bini, A. Vicario Preexisting degenerative change in the supraspinatus tendon seems Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, to be the main cause of rotator cuff tears. Università dell’Insubria, Ospedale di Circolo, Varese, Italy

The surgical treatment of ulnar nerve compression at the elbow is REPARABLE ROTATOR CUFF TEARS: SURGERY VS SHOCK still controversial (Dellon,1989; Gervasio,2005; Nabhan,2005). WAVE THERAPY Described methods are: neurolysis at cubital tunnel (Osborne,1957); A. De Carli, M. Vulpiani, A. Russo, A. Vadalà, P. Trovato, A. Ferretti neurolysis with anterior transposition, intramuscular (Adson,1918), Ospedale S. Andrea, Rome, Italy subcutaneous (Platt,1928), submuscular (Learmonth,1942), micro- surgical with vascular bundle (Messina,1991); neurolysis with medi- Active patients with rotator cuff tear causing pain and functional dis- al epicondilectomy (King,1950). The aim of the study was to find ability are usually candidate to surgical treatment. An alternative correlations between two methods, simple decompression and ante- choice is treatment with extracorporeal shock wave therapy rior subcutaneous transposition, and surgical indications. From 1992 (ESWT). Aim of this study is to compare the efficacy of these two to 2005 we treated 65 patients, 60 were reviewed with a mean follow options for rotator cuff tears. up of 71 months. 18 had undergone simple decompression (group I) Materials and Methods: Thirty patients, observed from October and 42 anterior subcutaneous transposition (group II). We consid- 2001 to March 2004, with a complete rotator cuff tear, were ran- ered 28 cases as idiopathic, 34 as secondary. All the patients of domly addressed to different treatment: group A underwent arthro- group I were idiopathic. Mc Gowan classification was used to grade scopically assisted surgical repair (follow-up min 12 months, max the compression. EMG was used to confirm the diagnosis. 26, mean 19), group B to shock wave therapy with electromagnet- Independent T-test was used to analyse correlation between prog- ic generator (follow-up min 12 months, max 36, mean 24). All nostic factors and results. Results were classified following Nouhan patients were clinically evaluated following Constant, UCLA, and Kleinert method: in group I we observed 8 eccellent results ASES and SST scoring scales; in both groups a MR imaging was (45.5%), 9 good (50%) and 1 fair (5.5%). In group II: 20 eccellent performed before and after therapy at follow-up. A statistical results (47.6%), 21 good (50%) and 1 fair (2.4%). We did not analysis of results was carried out (T test). observe any poor results. 94.5% (group I) and 95,2% (group II) were Results: Clinical results showed improvement after treatment in satisfied with the result, whereas clinical exam has shown a com- both groups: with Constant scale the mean of group A was 30 before, plete remission of symptoms respectively in 44.5% and 50%, and 77 after treatment; group B showed 33 before, 67 after treatment. improvement in 50% and 40.5%. Anterior subcutaneous transposi- The UCLA scale showed group A with 11 before, 32 after surgery; tion has proved appropriate instead of simple decompression in B 11 before, 27 after. With ASES scale patients of group A obtained treatment of ulnar neuropaty at the elbow, when beside compression 50 before, 87 after treatment; group B obtained 47 before, 70 after there are additional factors of nerve damage, friction and stretching, ESWT (p<0.05). Clinical evaluation showed statistically significant not addressed by simple decompression. difference between two groups in UCLA and ASES scoring scales (p<0.05). MR revealed in group A good coverage of the humeral head; in group B all cases showed no improvement. HISTOLOGICAL STUDY ON THE PATHOGENESIS OF ROTA- Conclusions: Although ESWT offers a good pain relief and an appre- TOR CUFF TEARS ciable resumption of shoulder function at a mean term, surgical treat- F. Franceschi, G. Rizzello, G. Longo Umile, L. Ruzzini, G. Vadalà, R. ment showed better overall results and in particular better resumption Papalia, A. Marinozzi, V. Denaro of strength and function in treatment of complete rotator cuff tears. Università Campus Biomedico, Rome, Italy

Objective: The aim of this study was to analyze the morphological fea- DISTAL HUMERUS NON-UNION: A HARD CASE tures of the human surgical specimens of normal supraspinatus tendon E.C. Marinoni, M. Bigoni, S. Guerrasio, A. Rossi, D. Munegato, D. from patients with rotator cuff tears and glenohumeral instability. Gaddi Materials and Methods: 41 subjects were recruited for the study. Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina 20 subjects (group 1) sustained a rotator cuff tear and proceeded e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatolo- arthroscopic repair of the lesion. 21 subjects (group 2) underwent gia, Monza, Italy S52

Distal humerus non-union appears in about 2 to 10% of fractures had only 1 deep infection, resolved with a surgical debridement and concerning this district. This kind of clinical situation represents a antibiotic terapy. Superficial infections of pin-track (20% of cases) very difficult trial for the surgeon. There are many surgical treat- resolved simply with increase of dressing care, occasionally with ments described in literature. Here we show a case report of a 66 antibiotic therapy. We did not note important consolidation defects. year old woman affected by a distal humerus atrophic non union of Arthritis was a frequent radiological sign, not often correlated with associated with a large bone loss. In this case we decided to use an pain and limitation of function: AOFAS median score was 69/100 and osteoconductive-osteoinductive technique after a renewal of the we performed tibio-tarsal arthrodesis only in 2 cases. internal fixation. We studied the healing progression by using peri- odic clinical evaluations and by analyzing results obtained from X- ray and DEXA analysis, and from subjective test (SF-36, VAS and HYBRID EXTERNAL FIXATION OF THE PROXIMAL TIBIA GH). The results after one year from the surgery are very encour- IN THE TREATMENT OF HIGH ENERGY PLATEAU FRAC- aging because of the almost complete fracture healing, the absence TURES of pain and the quality of life the she returned to. L. Pisano, S. Costa, L. Promenzio, M. Tangari Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy

THE USE OF THE DYNAMIC EXTERNAL FIXATOR MINI- Objective: Use of E.F.as main treatment of high energy tibial pla- COMPASS IN THE COMPLEX LESION AT PIPJ OF THE teau fractures. LONG FINGERS Materials and Methods: We have studied 30 patients, affected by N. Della Rosa, M. Abate, A. Marcuzzi, A. Leti Acciaro, A. Landi Schatzker 6 tibial plateau fracture,15/30 open fracture (Gustilo clas- Struttura Complessa Chirurgia della Mano e Microchirurgia, sification), treated by hybrid external fixation and limited internal Modena, Italy fixation, with a 3 years followup at least. We have used a modified score to evaluate the patients at each clinic visit. Stiffness of the long fingers at the PIPJ secondary to articular lesions Discussion: High energy tibial plateau fractures are often associated is certainly the most frequent and feared complication. Since 1998 in with severe soft tissue injuries like open wounds, compartment syn- the Operative Unit of Hand Surgery and Microsurgery of Policlinico drome, bone devitalization and vascular injuries: E.F. stabilize bone of Modena the Aa. uses the external dynamic fixation Minicompass in fragments validly with free articular knee movement. the complex lesions at the PIPJ of the long fingers. Thirty patients had Conclusions: E.F. as main treatment of Schatzer 6 tibial plateau treated (20 acute lesions/10 chronic lesions) with our device. The out- fractures, with limited internal fixation, bone allograft, without come studies were performed with Michigan test, the valutation of spanning the knee is a good method to treat this type of lesions. range of motion, Jamar test and aspecific pinch tests. The total results in the two groups are satisfactory both for final results of theMichigan test and for the motion and strenght range. Distinguishing the two THE MINIMAL INVASIVE TREATMENT OF THE TIBIAL groups (acute lesions/chronic lesion) the best results have been PILON FRACTURES: THE EXTERNAL FIXATION achieved in the acute lesion group with a total TAM of 220 while in F. Loconte, M. Di Viesto, A. Ambrosone, D. De Vita chronic lesion group the TAM has been the value of 190. The mean A.S.L. BR/1, P.O. di Ostuni (BR) U.O.C. di Ortopedia e Trauma- range of motion has been 70° in acute group lesion and in chronic tologia, Ostuni, Italy group lesion of 60°. In conclusion Minicompass has the ideal require- ment for a external fixator: a percutaneous syntesis of the articular Tibial pilon fractures seldom occur. They are the 7-10% of the tibial fractures, an early joint motion, a minimum dimension and a good fractures and less than 1% of the fractures of the lower limbs. They are clearence of the patient. serious lesions: they cause damages to the articular surface and they inevitably compromise the function of the ankle. This articular dam- age, with the fragmentation of the metaphysis, causes several treat- HIGH ENERGY TIBIAL PILON FRACTURES: LIMITED IN- ment difficulties and a high percentage of poor results. Various treat- TERNAL OSTEOSYNTHESIS AND EXTERNAL FIXATION ments have been tested. During the last years the external fixation has TREATMENT been asserting its authority as an alternative treatment, isolated or W. Daghino [1], C. Salomone [2], G. Di Gregorio [3], D. Aloj [1],A. associated with minimal internal fixation. A lot of new studies confirm Biasibetti [1] that this method, especially in serious fractures, is associated with [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, minor complications than the internal fixation. As a matter of fact, the Ospedale CTO, Turin, Italy; [2]Scuola di Specializzaione in Ortope- external fixation allows toa void some complications of the tibial pilon dia e Traumatologia, Università di Torino, Turin, Italy; [3]I Clinica fracture. This treatment gives a steady fixation, it does not involve the di Ortopedia e Traumatologia, Università di Torino, Turin, Italy fracture focus and it implies a minimal surgery trauma, thus respect- ing the soft tissue, which is generally compromised. For almost two We have assessed radiological and clinical follow-up of series of high years we have been treating these fractures with the external fixation. energy tibial pylon fractures, corresponding to subtypes C2 and C3 of The versatility of this system has allowed us to treat articular complex AO classification. We studied 46 fractures, 14 of which being fractures with a minimal invasion, getting in this way a high percent- exposed. Median patients age is 40.3 (range 23-73), average follow- age of good results and low rate of complications. up is at 34 months (range 6-50). In all cases we used external fixation with ligamentotaxis. We used mainly circular external fixator Ilizarov as immediate solution or as substitute of a monolateral external fixa- EXTERNAL FIXATION FOR TIBIAL PILON FRACTURES tor device, placed in emergency for fracture stabilization. In 10 cases R. Mora [1], L. Pedrotti [1], G. Tuvo [1], B. Bertani [1], F. Quattrini [1], the healing was achieved with monolateral fixation, in 2 of these A. Maccabruni [2] cases the configuration was articulated. In 28 cases we associated a [1]Clinica Ortopedica, Università di Pavia, Polo Univ. “Città di limited osteosynthesis, transcutaneuos or by small skin incisions. Pavia”, Italy; [2]Clinica Malattie Infettive, Università di Pavia, OSM Only in cases treated with monolateral external fixation as definitive Pavia, Italy approach we used internal osteosynthesis with plate and screws for fibula fractures. In 7 cases we applied autologous or synthetic bone Tibial pilon fractures are challenging injuries: complications are fre- graft for metaphysial losses. Average healing time was 26 weeks. We quent and treatment results are often unsatisfactory. The treatment S53

planning is based on the evaluation of concomitant diseases, kind of named so because they can direct bone metabolism towards an fracture, seriousness of bone and joint injury and soft tissue condi- active positive response which is characterized by the physiologi- tion, that may strongly influence the prognosis. Internal fixation for cal maturation of newly formed bone tissue on them. There are dif- complex fractures has a very high risk of complications, such as skin ferences in commercial preparations for both Hydroxyapatite and and soft tissue necrosis and deep infection (because a large dissec- Bioactive Glass coatings: hydroxyapatite may vary in crystallinity tion is needed), and should only be employed in simple fracture while Bioactive Glass in composition. About the coatings, differ- management. External fixation, and especially circular external fix- ences may arise varying the granulometry of the starting powder, ation, is indicated in most cases, combined or not with minimal the deposition time, the temperature of the spray. Anyway, the internal synthesis. Between 2000 and 2005 at the Department of common pattern of bone response is always the tight apposition Orthopaedics and Traumatology of the University of Pavia – “Città and physiological maturation and remodelling of newly formed di Pavia” Institute, 24 cases of tibial pilon fracture were treated. bone on the coating. In this way, bioactive coatings promote a According to the Ruedi and Allgower’s classification there were 6 bone-coating interface without the interposition of fibrous tissue, type I fractures, 8 type II fractures and 10 type III fractures. 6 frac- as it happens with un-coated metallic prostheses. Furthermore, the tures were open. In 3 cases internal fixation was employed; the other gradual and physiological process of bone maturation preserves the cases were all treated with external fixation by means of an Ilizarov trabecular architercture of the surrounding bone without the “con- device applied to the leg (and extended to the foot in 5 cases), com- finement rim” which is often seen with non-bioactive but biocom- bined in 4 patients with minimal internal synthesis. In 3 cases of patible materials. In conclusions, bioactive coatings in joint compoud fracture, soft tissue reconstruction was performed. Bone replacements can provide an interface between bone and prosthe- and functional results of this series were satisfactory, with a very low ses which is characterized by an apposed maturing bone. rate of major complications (such as soft tissue necrosis and deep infection), and confirm that circular external fixation methods are a valid option in the management of these difficult injuries. OSTEOINDUCTIVE PROCEDURE IN NON CEMENTED HIP PROSTHESIS L. Tafuro, W. Thomas, L. Lucente TWO-STAGE TREATMENT OF SEPTIC LOOSENING OF HIP Clinica Quisisana, Rome, Italy PROSTHESIS G. Pignatti, N. Rani, G. Trisolino, A. Giunti Since 1965, Urist discovered the osteoinductive properties of growth Istituti Ortopedici Rizzoli, Bologna, Italy factors and body cells, many progresses in identification, character- ization and clinical use of these factors have been done in Although rare, one of the most feared complications of total hip orthopaedics. From June 2003 to July 2005, we performed 60 con- arthroplasty is infection. Two-stage replacement has been reported as secutive cases of hip replacements with a new procedure consisting one of the most successful treatment methods for chronic infection of in an osteoinductive gel, positioned on the spongiosametal surfaces the prosthetic hip. It is indicated in healthy patients with a low risk of of socket and stem. The gel contains three elements: Cancellous recurrent infection and to keep open the option of revision surgery. It bone chips, Platelet-Rich Plasma and Bone marrow. Blood loss, is also indicated when debridement and antibiotic treatment has operative time Hemoglobin drop values and clinical results were col- failed in early postoperative or acute hematogenous infection. The lected and compared with a control group of 60 hip replacements. patient undergoes rigorous treatment due to the severity of the two The average operative time was similar in the two groups, while the surgical procedures, separated by a few weeks of intravenous antibi- blood loss was minor in the group treated with the gel. The Harris otic treatment. From 2000 to 2005, in our ward, we treated 41 con- Hip Score moved from an average of 43 in the preoperative to 83 at secutive patients with septic loosening of the hip prosthesis. In most 40 days, 90 at 3 months, 92 at 6 months and 94 at 12 months in the cases we used a functional articulated spacer, industrially preformed study group. For the control group values were 54 in the preopera- (Spacer-G®), which, besides the local controlled release of antibi- tive, 74 at 40 days, 80 at 3 months, 86 at 6 months and 94 at 12 otics, enabled limb length and a certain degree of joint motion to be months. We never observed complications as dislocations, DVT, maintained, thus providing the patient with more comfort and the infection, stem subsidence or mobilization. Our procedure shows a possibility to walk with canes and light weight bearing between the quickly osteointegration of the implants. The procedure is safe and two stages. The device consists of a steel cylinder coated with acrylic easy because it includes only autologous factors without risks of dis- cement loaded with Gentamicin (1.9%) and Vancomycin (2.5%). The ease transmission or immune response. evolution of the infection process was studied by clinical and labora- tory tests and by radiography and scintigraphy. Revision surgery was performed when swelling had reduced and scintigraphic results were FIRST CLINICAL EXPERIENCES WITH PE ACETABULAR normal. At a mean follow-up of 39 (12-73) months, the 38 patients INSERT ”X3 TYPE that had been treated successfully with revision surgery had no clini- E. Camerucci, A. Speranza, D. Topa, C. D’Arrigo, A. Ferretti cal or biohumoral signs of infection, or radiographic signs of loosen- Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy ing. Functional recovery was good to excellent and the mean Harris Hip Score was 85 (54-100). Background: The Authors report a preliminary study about the use of a new type of polyethylene acetabular insert, X3 type, for total hip replacement. This new type of polyethilene insert, highly reticulat- PROPERTIES OF BIOACTIVE COATINGS IN JOINT REPLA- ed, was treated to assure a major resistance to wear and tear and con- CEMENT sequentely allow the use of femural heads with larger diameter but A. Merolli, A. Militerno, G.E. Bellina with the same cotile implantation. Chirurgia della Mano, UCSC, Rome, Italy Patients and Methods: In the period from September 2005 to March 2006 in S.Andrea Hospital, 22 hip arthroprothesis were Several experiments have been carried out in vivo, in an experi- implanted using PE acetabular insert X3 type. 9 males and 13 mental model in the rabbit femur, to test the properties of plasma- females aged from 66 to 83 (mean age 75) were included in the sprayed bioactive coatings on metals. Hydroxyapatite and study. The primary diagnosis in 15 cases was primary hip arthrosis, Bioactive Glass were used for the coatings while Titanium alloy in the other 7 cases, an intracapsular fracture of the hip. In all cases and CoCr alloy were the metallic substrates. Bioactive coatings are a trident (Stryker-Howmedica)) cotile was used from 46 to 58 mm. S54

In 7 cases ceramic femural heads were used, while in 15 cases metal DIAPHYSIS FRACTURE WITH BONE STOCK. IN VIVO EX- femural heads were used. In 14 cases the diameter of the femural PERIMENTAL MODEL USING MESENCHYMAL STEM heads used was 32 mm in the other 8 cases,36 mm. We compared the CELLS (MSC) AND GROWTH FACTORS diameter of femural heads to the diameter of femural heads implant- G. Burastero [1], N. Sessarego [2], G. Grappiolo [1], G. Santoro [1],G. ed in a serious of 22 patients operated of total hip arthroprothesis in Panunzio [1], S. Scarfì [3], C. Fresia [3], F. Monetti [4], G. Cittadini [4], the same period in wich the same type of cotile was used but with a A. De Flora [3], E. Zocchi [3], L. Spotorno [1] PE insert Crossfire type. [1]Ospedale “Santa Corona”, Pietra Ligure, Italy; [2]Ospedale “San Results: In 18 cases out of 22 it was possible to use femural head with Martino”, Genua, Italy; [3]Dipartimento di Medicina Sperimentale, a larger diameter, with the same cotile than would have been possible Genua, Italy; [4]IST, Genua, Italy with the PE insert used before, Crossfire type (Striker-Howmedica). Although the diameter of femural heads was larger no difficulties were Introduction: Diaphysis fractures, characterized by severe bone observed to reduce the implants during operation. We didn’t observe loss, represent an important goal in the field of orthopaedic surgery. any complication. No luxations of the prostheses were reported. Cell therapy and biotechnology findings allow new therapeutic Conclusions: The use of this new type of insert allows us, thanks to strategies. Recently it has been reported that cADPr, a potent calci- its mechanical features and the design, to implant femural heads um-mobilizing intracellular messenger, significantly stimulate pro- with larger diameter and cotiles with a diameter inferior to 50 mm, liferation of MSC. Considering this new findings, we developed an with known advantages. experimental model of critical femoral defect treated with expanded MSC, growth factors as BMP7 and cADPr. Materials and Methods: In 24 athymic rats a 6 mm segmental THE TREATMENT OF THE PSEUDOARTHROSIS OF THE defect was reproduced in the femoral diaphysis. Osteotomic ends LOWER LIMB THROUGH OSTEOSYNTHESIS ASSOCIATED were fixed with a polymethylmethacrylate plate. The osseous gap WITH BONE GRAFT AND PLATELET GEL. 4 YEARS EXPE- was filled with a graft composed of 6x106 MSC from patients under- RIENCE – THE RESULTS going hip artroplasty, differently associated to cADPR and BMP7 G. Rocca [1], P. Savonitto [1], M. Franchini [2], A. Bosinelli [2], D. Olzer [3] (80µg). Graft analysis was performed with high definition digital [1]Struttura Funzionale di Traumatologia, OCM, Veronam, Italy; radiography and TC at 2 and 12 weeks after surgery. Bone histo- [2]Servizio di Immunoematologia e Trasfusione - Banca dei Tessuti, morphometry was assessed at 12 weeks. Histological, radiographical OCM, Verona, Italy; [3]Servizio di Immunoematologia e Trasfusione, studies and CT aimed to evaluate new bone formation and the tra- OCM, Verona, Italy beculae structure (osseus density, trabeculae number, thickness and interconnections between trabeculae). In the infected pseudoarthrosis the bone tissue has lost the property Results and Conclusions: Our preliminary results highlighted that to form the reparative callous. For this reason there is the need to the tested graft possess osteogenic properties which seem to be dose have a biologic support and a great stability. The biological support dependent. Therefore, this kind of graft could significantly improve uses the osteocondutors which, simulating in many ways the trabec- current surgery techniques with remarkable patients benefit. ular bone, improve a progressive colonization by the vessels and the bone morphogenetic factors which release a chemical stimulus suit- able to implement the growth of pluripotential cells in the osteoge- COMPLICATED FRACTURES OF THE LOWER LIMB: OUR netic pathway. To achieve the progression of this process, a great sta- EXPERIENCES bility is necessary and today this stability is given by the LCP plates C. Angrisani, S. Del Prete, E Taglialatela thank to the screw heads threaded into the plates and by their differ- AORN Ospedale Civile S. Sebastiano, Caserta, Italy ent orientation that implement the pull-out strength of the whole sys- tem In collaboration with immune-haematologists we have estab- High-energy traumas determine lower limb fractures. The Authors pre- lished a treatment protocol joining the stable osteosynthesis and the sent their clinical experiences in the surgical therapy of these important bone allograft with blood platelet gel. and dramatic lesions, which are important for the patient’s survival and compromise the bone segment, muscles and soft tissues involved in trau- ma. Because of the technique advantages and disadvantages and the TREATMENT OF POST-TRAUMATIC TIBIAL NON-UNION BY difficulties of everyone lesion, handling this pathology requires special- RING FIXATION istic surgical experience and the choice of the most useful timing and A. Merolli [1], F. Catalano [1], P. Tranquilli Leali [2] devices in order to reach the goals.Thanks to the choice protocols always [1]Clinica Ortopedica, Università Cattolica, Rome, Italy; [2]Clinica used by most of the Authors and according to emergency criteria of pre- Ortopedia, Università degli Studi, Sassari, Italy sented in every situation it is possible to show the limits of a device and to analyze the necessity of a new surgery to complete the first surgical Introduction: Authors effectively treated tibial non-union by ring act. Therefore, in their experience the Authors present the possibility to fixation according to the Ilizarov method. use external fixation in emergency or nailing by closed surgery to treat Materials and Methods: Twenty-five patients with post-traumatic complex fractures associated with instable steady-state in multiple tibial non-union were treated by the Ilizarov technique with external injury patients and to solve difficult problems of the complicated trau- ring fixation: seventeen had previous treatments with other tech- ma. These devices lead to a rapid resolution of survival threaten, to niques; twelve had infected non-union; twelve were atrophic non- immediate rehabilitation and a good nursing of these patients. union and thirteen were hypertrophic non-union. Twenty-three patients had a significative axial deviation. Results: Treatment by ring fixation always led to the healing of non- REPAIR OF A PELVIS FRACTURE ASSOCIATED PSEUDO- union, eradicating the infection when present. Other results were ARTHROSIS WITH TERIPARATIDE TREATMENT: A CLINI- functional recovery of the limb, equalization of limb-length discrep- CAL CASE ancy and correction of the axial deformity. Mean fixation time (num- L. Ventura [1], M. Ghirardini [1], M. Taglietti [1],A. Nardi[2],A. ber of days of external fixator in place) was 138 days. Giustina [3], P.P. Vescovi [1] Conclusions: In this serie of 25 patients the Ilizarov method was [1]Dipartimento di Medicina Az. Osp Carlo Poma, Mantova, Italy; effective in healing post-traumatic tibial non-union even in cases [2]Dipartimento di Medicina Az. Osp. di Rovigo, Italy;- [3]Diparti- where other techniques did not succeed. mento di Medicina Università di Brescia, Italy S55

Case: W.V. born on 07/14/1926 shows Op risk factors defined by hys- The Robert Jones compression dressing has been utilized for over a tero-adnexectomy due to ovaric policistosys at 29, previous smoking century, and yet is not well-known or often utilized in Italy. It has habit, poor calcium intake with diet. She suffers from hypertension proved to be an excellent device for preventing and controlling aedema treated with calcium-antagonist, refers Colles’ fractures at 40 and 60. of all types, but is especially indicated for post-traumatic and post- On December 2000, after a fall, she underwent a pelvis trauma with operative swelling. This dressing is comprised of alternating layers of secondary pain syndrome, dependence from FANS, hypakinesys syn- cotton and elastic (Ace) bandages, “pulled” at a level on compression drome. The pelvic x-ray, performed a month after the trauma, did not which does not compromise cutaneous and subcutanous circulation. show any evidence of fracture. On February 2003 the pelvic tomogra- This allows avoidance and reduction interstitial liquid typical of aede- phy showed the presence of fracture of the right ischium-pubic branch, ma utilizing a controlled and diffuse compression. This dressing also without any evidence or repair. Mineral metabolism study showed offers another possibility of immobilizing the lower extremity at vary- hypercalciuria (382 mg/24h), insufficient Vitamin D state (8 ng/ml), ing levels by application of splinting material in plaster-of-Paris or normal values of calcemia, phosphoremia, PTH, ALP. The corrective fiberglass within the dressing. Not only is the Robert Jones compres- treatment of hypercalciuria, with Amiloride-Hydrochlorotiazide, and sive bandage ideal in conservative treatment of foot or ankle trauma, the one for hypo-Vitamin D (Ergocalciferolo + Calcium + 400 UI Vit but also as a temporary preoperative brace, especially when surgery is D) did not lead to any improvement of symptoms. After occurrence of often delayed during the first 12 hours due to swelling and fracture pain to the left hemi pelvis, in August 2003, scintiscan and tomography blisters. Control of swelling is important not only in decreasing pain were performed, showing presence of fracture for insufficiency of the pre- and post-operatively, but also in avoiding surgical complications left ischium-pubic branch, absence of osseous callum in the former such as blistering and wound dehiscence post-opertively. The authors fracture and development of it into pseudo-arthrosis. In March 2004, a present the technique in applying the Robert Jones dressing, offering new tomography showed no changes of the right ischium-pubic branch suggestions for easy and secure placement and removal, as well as fracture, but the left one showed the formation of osseous callum. In describing the final results of a series of 100 traumatic cases. July 2004 the subject started treatment with Teriparatide (FORSTEO®). After 2 months, W.V. did not referr any pain and could restart walking; after 6 months a tomography showed osseous callum COMPUTER ASSISTED KNEE ARTHROPLASTY FOLLO- in the right ischium-pubic branch fracture and complete repair of the WING POST-TRAUMATIC KNEE DEFORMITY left one. At the end of the 18-month therapy, a new tomography showed N. Confalonieri, A. Manzotti, K. Motavalli complete repair of right ischium-pubic branch fracture and disappear I-II U.O. di Ortopedia e Traumatologia, C.T.O, Milan, Italy of pseudo-arthrosis. Conclusions: Teriparatide therapy (FORSTEO®), started 20 months Introduction: Computer assisted surgery has been developed to help after fractural episode, leads to a quick regression of pain symptoms, surgeon in reconstructive procedure in improving implants align- quick formation of osseous callum with complete repair of the right ment and performances. In literature different Authors have already ischium-pubic branch fracture, pseudo-arthrosis regression, restoration demonstrated its efficacy in traditional knee replacement surgery of mobility. despite different alignment systems. Nevertheless, no study has ana- lyzed its results in high demanding replacements such as in signifi- cant post-traumatic limb and articular deformity with bone loss and NEW CRITERIA OF RADIOLOGICAL SEMEIOTICS IN THE multiple ligaments instability. The Authors assessed their experience EVALUATION OF OSTHEOSYNTHESIS WITH INTERNAL FI- in high demanding computer assisted knee replacement XATOR IN THE TREATMENT OF LONG-BONE FRACTURES Materials and Methods: Among 414 computer assisted knee A. Zerbi [1], N. Trenti [1], P. Stradiotti [1], A. Pace [2] replacements performed since 1999, 14 cases were selected accord- [1]Servizio di Radiologia Diagnostica e di Bioimmagini, Istituto ing to limb deformity and bone loss 39 arthritic knees were includ- Ortopedico Galeazzi, Milan, Italy; [2]Fondazione Istituto San ed in the study because following isolated fracture of the knee (26 Raffaele, G. Giglio, Cefalù, Italy tibial plateu fractures, 11 femoral condyle fractures and 2 patella fractures). The mean age was 66 years old with 36 males and 18 Objective: To analyze the new criteria of radiological semeiotics in females. At a mean follow-up of 32.1 months all the patients were the evaluation of the osteosinthesys with internal fixator (IF) used evaluated using both the Knee Society and the GIUM outcome today in treating long-bone fractures. score. Furthermore all the implants were assessed radiographically Materials and Methods: From 2001 to 2003 at Trauma Unit in the evaluating limb alignment and implant positioning. Istituto Ortopedico Galeazzi, 115 long-bone fractures were treated Results: The KKS score and the GIUM score were improved respec- with an IF. The postoperative and follow-up radiograms were stud- tively to 81 and 69. No Outliners (malalignment exceding 4° of an ied in order to control the stability, instability or mobilization of the ideal alignment) were identified. There was no complication because implants, as well as the evolution of the bone healing. of the Computer Assisted technique. In one case we registered a sci- Results: The distance of the IF from the bone surface is not necessari- atic nerve suffering following an impressive valgus deformity. The ly a sign of loosening of the screws (as it usually happens with tradi- range of motion was improved in all the cases (mean: 29.5°). tional plates), because the method by which the IF works is complete- Conclusions: According to authors’ experience reveals different ly different from that of the plate. Signs of implant mobilization may advantages of computer assisted surgery in high demanding knee be much less evident and therefore a careful comparison of the radi- replacements. Despite a longer surgical time less invasive implants, ograms series is necessary in order to recognize them. bone sparing associated to better alignments produce better results Conclusions: The knowledge of basic principles of biomechanics of compared to traditional systems. Improved results can overcome the new implants is indispensable for a correct radiological evaluation. higher costs cause of surgery time and systems purchasing.

ROBERT-JONES BANDAGE IN TREATMENT OF LOWER THE HYBRID EXTERNAL FIXATION SYSTEM AO IN THE LIMB TRAUMA COMPLEX METAPHYSEAL FRACTURES: OUR EXPERIENCE C. Michele [1], T.L. Giorgini [2], S. Ghera [1], D. Di Martino [3] ABOUT 14 CASES [1]Ospedale “San Pietro” Fatebenefratelli, Rome, Italy; [2]Casa di M. Roselli, D. Agosta, G. Montanari, G. Berra Cura Siligato, Civitavecchia, Italy; [3]Ospedale “San Paolo”, Civi- U.O.A. Ortopedia e Traumatologia, ASL3 TO, Ospedale Maria tavecchia, Italy Vittoria, Turin, Italy S56

Fourteen patients (6 women and 8 men) with complex metaphyseal Background: Autologous bone grafts and sometimes allograft bone fractures of lower limbs were treated in our institution with the hybrid extenders are commonly used in spinal surgery to promoting and external fixation system AO from 2002 to 2005. Fractures were classi- achieving a solid fusion mass. fied according to AO system and Gustilo classification. Of these, 3 Materials and Methods: We report a single surgeon’s use and early were fractures of distal femur, 6 of proximal tibia, 5 of distal tibia (with results of autologous bone grafts mixed with autologous bone mar- 1 case bilateral). All patients were operared in emergency or in 24 row aspirate in 25 patients undergoing lumbar spinal fusion. Of the hours. Results were evaluated on the basis of subjective and objective patients included in this study, 20 (80%) patients underwent surgical rating system. Follow up periods averaged 15 months with an average intervention for lumbar spinal stenosis and 5 (20%) patients had time to healing of 4.5 months. There were no cases of pseudoarthrosis. lumbar spondylolisthesis. Twelve women and 13 men were included Complications occurred in 5 patients and included 1 case of skin necro- in the study. The average patient age was 56 years (30-74 years, sis, 3 cases of loss of reduction necessitating frame revision, 1 case of SD=±12). Independent radiographic evaluation was performed. malunion with axial deviation. In accordance with our experience Results: Each subsequent radiographic follow-up revealed increased resulting from this study, the hybrid external fixation system AO is improvement in average Lenke score and was statistically significant proved useful not only for treatment in emergency, because of its easy between the early (1 month) and recent (24 month) follow-ups. There and fast application and minimal invasive surgical modality, but also were statistically significant changes in Lenke score between 1 month and for definitive treatment, when properly employed, thanks to the relative 6 months follow-up (p<.01), between 6 months and 12 months follow-up stability of the system which allowed, in most of patients, the fractures (p<.001), and between 12 months and 24 months follow-up (p<.01). healing respecting rotations, segmental lenght, axiality and soft tissues. Conclusion: The gradual and constant increment of improvement in A good command of surgical anatomy and knowledge of bone biology, radiographic measurements in this preliminary series may indicate a biomechanics and principles of external fixation according to Ilizarov, positive effect of the use of autologous bone marrow aspirate that are required in any case to obtained good results. may decrease the required amount of bone grafts.

LIGHTS AND SHADOWS ON ESWT TREATMENT OF PLAN- SPINAL FUSION IN POST-TRAUMATIC KYPHOSIS USING TAR FASCIITIS. MEDIUM-TERM AND LONG-TERM RESULTS CALCIUM PHOSPHATE CERAMICS: PRELIMINARY RE- P. Papandrea, M. Ciurluini, M. Barbarino, A. Ferretti SULTS OF A PROSPECTIVE CLINICAL STUDY U.O.C. Ortopedia e traumatologia, Policlinico Sant’Andrea, Rome, Italy C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy Introduction: Biomechanical analysis of the gate underlie the pri- mary role of the plantar fascia, which support the plantar arche in the Objective: The aim of this study is to evaluate the ability of ß- saggittal plane and allow the transmission of the force from the trica1cium phosphate (TCP) in granular form to achieve dorsal Achilles tendon to the forefoot. Functional overuse and abnormal spondylodesis in post-traumatic kyphosis (PTK). biomechanic of the foot can produce a heel pain syndrome which Materials and Methods: Eight patients underwent surgical correc- involves both sedentary people and athletes. tion and were followed up for 23±14 (range 9-37) months. Objective: Purpose of the study was to investigate medium-term and Posterolateral grafting was performed, using either autograft bone long-term clinical results of ESWT on symptomatic treatment of mixed with allograft bone (n=4; “bone group”) or autograft bone plantar fasciitis in athletes and in sedentary patients. mixed with 25 g TCP (n=4; “TCP group”). Patients were followed Materials and Methods: 57 cases of plantar fasciitis. Group A: 27 by clinical examination, X-rays and computed tomographic (CT) sedentary patients; Group B: 30 athletes. In the pre-treatment phase, scans. Fusion involved 11±1 (range 10-12) vertebrae. patients were subjected to RDX under weight bearing in order to Results: The segments were fused after 6±1 months in both groups detect any biomechanical abnormalities, and MRI. Four low-energy according to the radiographs. No pseudarthrosis was observed. sessions of shockwaves without anaesthesia. Orthotic foot devices Resorption of TCP and new bone apposition was complete on the were allowed. It was used Mayo Foot and Ankle Score Scale in order radiographs after 8±2 (range 6-10) months. to make a clinical evaluation. Conclusions: Based upon the results of this preliminary study, the Results: Clinical results: at 3 months Fup 70% of patients reported sat- use of TCP appears to be a valuable alternative to allografts for appli- isfactory results (excellent and good results), at 17 months fup the per- cation in the spine, even when large amounts of bone are needed. centage was 83%. Orthotic foot devices were removed in the 13% of cases. Results in athletes: at 3 months Fup 81% of patients reported sat- isfactory results and at 17 months fup the percentage was 88%. Orthotic VERTEBRAL RECONSTRUCTION WITH POROUS CALCIUM foot devices were removed in the 11% of cases. At 48 month fup excel- PHOSPHATE CEMENT IN THE TREATMENT OF OSTEO- lent and good clinical results were confirmed (the percentage was POROTIC VERTEBRAL COMPRESSION FRACTURES 84%). No significant radiological modification at the origin of the plan- C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali tar fascia was pointed out. MRI showed decreased inflammation signs. Policlinico Universitario, Sassari, Italy Conclusion: ESWT represents a symptomatic treatment devoid of collateral effects, able to solve heel pain in a signify percentage of Objective: To assess the efficacy of vertebral reconstruction with cases. Orthotic foot devices seem to be helpfull to maintain satisfac- porous calcium phosphate cement (Callos) in the treatment of osteo- tory clinic results after treatment and to correct the biomechanics of porotic vertebral compression fracture. the foot during walking and running. Background: Vertebroplasty consists of the injection of poly- methylmetacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows THE EFFECT OF AUTOLOGOUS BONE MARROW ASPIRATE only a short handling time. Other potential problems of using TO ENHANCE THE FUSION IN INSTRUMENTED LUMBAR PMMA injection may include damage to surrounding tissues due to SPINE the high polymerization temperature or by the toxic unreacted C. Doria [1], F. Milia [2], L. Floris [3], L. Tidu [4], P. Lisai [1], P. Tran- monomer and the lack of long-term biocompatibility. Bone mineral quilli Leali [1] cements such as calcium carbonate and Callos have a longer work- [1]Policlinico Universitario, Sassari, Italy; [2]Policlinico Uni- ing time, low thermal effect, they are more suitable for injection into versitario, Sassari, Italy; [3]Policlinico Universitario, Sassari, Italy; the vertebral bodies; they are also biodegradable while providing [4]Policlinico Universitario, Sassari, Italy good mechanical strength. S57

Methods: Five patients, two males and three females, affected by those related to thoracic trauma. The extension of this idea to spine vertebral compression fractures responsible for severe pain unre- surgery is strictly related to surgical timing despite the severity of sponsive to medical terapy, were included in this open prospective the injury and the neurological involvement. In fact the treatment study. Evaluation of patients was based on x-ray, JOA score for low of spine injuries within 72 hours is less burdened by general com- back pain, and Visual Analog Scale (VAS). plications and gives the patient more chances of neurological Results: The levels of the delayed collapsed vertebrae were T11, L1, recovery. New minimal invasive stabilization techniques, in select- and L2 (for one patient each) and L3 (two patients). The average ed cases, can give a further contribution to polytrauma recovery, operative time was 45 minutes). As for the clinical symptoms, pre- allowing an early mobilization by a minimally hemorrhagic surgi- operative JOA score averaged 17.8 points and was improved to 26 cal procedure. At the moment, the use of minimal invasive spine points postoperatively, while the preoperative VAS score of 8.6 stabilization can be applied to isolated fractures without neurolog- points improved to 5 points postoperatively. Radiological evaluation ical involvement. showed preoperative vertebral compression ratio averaged 61% and improved to 34% immediately after the operation. Conclusions: Vertebral reconstruction with biodegradable Callos in SURGICAL TREATMENT IN MYELOMA RELATED VERTE- the treatment of osteoporotic vertebral compression fracture was a BRAL LESIONS safe and useful surgical treatment. Augmentation with Callos S. Boriani, S. Bandiera, S. Paderni, M. Cappuccio, L. Boriani, A. improves pain and function and enables the treated vertebral body to Gasbarrini regain of height. U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy

ADULT TRAUMATIC ATLANTOAXIAL ROTATORY SUBLUXA- Skeletal involvement in myeloma is characterized by neoplastic prolif- TION: A CASE REPORT eration of highly proliferative plasmacells into the bone. Vertebral R. Sinigaglia, D.A. Fabris Monterumici localizations are the subject of our study. They are usually revealed by Unità Operativa Complessa di Chirurgia del Rachide “Sandro a site related spine pain that is more acute during the night, with no Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, relation to any activity. When the tumor involves roots or cauda, pain Padua, Italy spreads along the related neurological structures. Major neurological symptoms such as para/tetraplegia may be triggered by further expan- Objective: Report a rare case of adult traumatic atlantoaxial rotato- sion of the lesion in the canal. Pathologic fracture (vertebral body col- ry subluxation. lapse) is listed among possible first symptoms and may lead to spinal Materials and Methods: In November 1996 a 21-year-old woman compression because of the fragments dislocation in the canal. was referred to our Center 6 days after a car accident. On physical Surgery plays two different roles in the treatment of vertebral examination the patient presented with torticollis, neck pain and myeloma: decreased cervical spine motion. Neurological and vascular evalua- Functional surgery with the aim to tions were normal. Transoral X-ray showed asymmetry between the - Decompress neurologic structures in order to either restore the dens and the atlas, CT scan confirmed the atlantoaxial rotatory sub- lost neurologic function or prevent tumor from damaging cord luxation. Closed reduction was performed followed by 70 days of and roots; Halo-Vest external fixation. - Relieve pain originated from fracture or compression; Results: After a 9-year follow-up the patient has no complaints Allow weight-bearing, walking and stability. related to the cervical spine, whose range of motion is completely - Oncologic surgery with the aim to: normal. - Decrease neoplastic mass; Discussion: Atlantoaxial rotatory subluxation, while not unusual in - Resect a lesion when it proved insensitive to chemio- and radio- the pediatric population or those with ligamentous laxity or degen- therapy procedures; eration, is a very rare type of traumatic injury in the adult [Fielding Authors report a series of 50 myelomas with vertebral lesions treat- 1977, Weisskopf 2005]. Diagnosis is often difficult, delayed, and ed between 1997 and 2002, with a 3 years minimum follow-up. frequently misdiagnosed [Fielding 1977, Weisskopf 2005]. For cor- rect diagnosis standard X-ray and C0-C2 CT scan are mandatory. The reduction could be closed or open, and followed by prolonged DIAGNOSTIC ACCURACY OF CT SCAN-DIRECTED TROCAR immobilization [Fielding 1977, Weisskopf 2005], C1-C2 posterior BIOPSY OF THE SPINE fixation [Fielding 1977, Moore 1995, Miyamoto 2004], or transoral A. Gasbarrini, S. Bandiera, G. Barbanti Bròdano, L. Mirabile, M. fixation (temporary or definitive) [Weisskopf 2005]. For some Cappuccio, L. Boriani, S. Boriani authors the integrity of the transverse ligament of the atlas deter- U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale mines the type of treatment [Miyamoto 2004]. Maggiore “C.A. Pizzardi”, Bologna, Italy Conclusion: Closed reduction followed by prolonged immobiliza- tion should be the first choice treatment for adult traumatic CT scan-directed percutaneous Trocar biopsy is a mini-invasive atlantoaxial rotatory subluxation. This conservative treatment avoids technique utilized in spine-surgery. This procedure is indicated when the major complaints related to the surgical procedures, allowing surgeons have to deal with a suspicion of unknown vertebral lesions. complete cervical spine range of motion after healing. It provides adequate specimens for a correct and quick histo-patho- logical diagnosis. Aim of this paper is to describe CT scan-directed Trocar biopsy of the spine and suggest proper indications. Ct scan- SPINE SURGERY AND POLYTRAUMA: DAMAGE CONTROL directed Trocar biopsy is a basic step in our diagnostic-therapeutic ORTHOPAEDIC SURGERY algorithm for the treatment of ematogenous vertebral spondilo-disci- F. De Iure, M. Palmisani, S. Bandiera, M. Cappuccio, L. Boriani tis and spine metastases. In a lapse of time comprised from 1998 and Unità Operativa di Ortopedia e Traumatologia, Chirurgia del 2005, we performed this kind of biopsies on 216 vertebral lesions, Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy on the basis of the clinical-radiological-laboratory setting. Our series was characterized by a mean age of 52 years (range from 14 In 1980 the idea of “early total care of fractures” and “damage con- to 86 years); 127 patients were male, 89 were female. We have uti- trol orthopaedic surgery” began to concern the treatment of poly- lized a 4th generation spiral Picker 6000 CT scanner. Procedure is trauma patients in order to prevent general complication, mainly percutaneously performed, under local anesthesia, and consists of S58

withdrawing sufficient tissue from the lesion to have a histopatho- (CDF, 9 to max 151 months; average: 69 months), 69 with no evi- logical diagnosis. The correct way to realize this biopsy is passing dence of disease (NED 9 to 151 months; average: 70 months), 10 through pedicles, with 2.5 to 4.0 mm Trocar needles. In 100% of our alive with disease (AWD 12 to 123 months; average: 66 months); cases we reached diagnosis after one shot. Fifty-three cases were fourteen patients were died for at least 4 month (4 to 65 months; diagnosed as spondilo-discitis: one patient out of these 53 received average 24). Eighteen local recurrences were observed and treated. diagnosis only after cultures. One hundred sixty-three lesions were Conclusion: En bloc resection can be performed in selected spine diagnosed as metastases. On the basis of our experience the tumors; the indication to such major surgery must be based on the described technique is easy, quick, scarcely invasive; it has proven oncologic stage, and the procedure must be carefully planned. For this high percentage of success (in our series the diagnostic accuracy is purpose, the Weinstein-Boriani-Biagini system could be a helpful tool. 100%), with a low risk of complications if correctly executed. In many cases Ct scan-directed Trocar biopsy is the only invasive pro- cedure in the whole treatment; in other cases it addresses to a correct OUR EXPERIENCE IN BALLOON KYPHOPLASTY TREAT- preoperative planning and then to an adequate treatment. MENT R. Magri, G. De Pace, R. Magri Naples, Italy EN BLOC RESECTION OF VERTEBRAL METASTASES S. Bandiera, F. De Iure, A. Gasbarrini, M. Cappuccio, L. Mirabile, Balloon Kyphoplasty has been recognised over recent years as one L. Boriani, S. Boriani effective therapeutic possibility, often resolutive for the mininvasive U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale treatment of the painful symptomatologies of the thoraco-lumbar Maggiore “C.A. Pizzardi”, Bologna, Italy spine. In case of painful vertebral compression fractures, resistant to conventional therapies, Balloon Kyphoplasty can represent a prefer- Surgical treatment of spine metastases has to reach a functional ential treatment because of its low invasive character, the method- result rather than a curative one. Aim of this kind of surgery is to ological safety of the devices and the relative semplicity of the pro- obtain the best local control of the disease. Surgery of vertebral cedure. A clear diagnostic indication and a strict selection of the metastases actually has to take into account the patient’s clinical set- cases that have to be treated are fundamental. We believe that ting and to face the risk of increasing iatrogenic morbidity percent- Balloon Kyphoplasty can have further developments for the combi- age. Spine metastases surgery can be adequately planned following nation between the technical ease of handling and a relative safety the WBB staging, specifically conceived for spine tumors. On the compared to similar procedures. Some years ago our department basis of our experience and of a precise revision of the literature we began to treat cases of pathological vertebral compression fractures have pointed out three important steps in the treatment planning of a and cases of vertebral somatic collapses caused by neoplastic sec- vertebral bone secondary lesion: ondary localization. We would like to introduce some outcomes and - to describe the lesion with a common and appropriate terminol- solutions that we believe interesting for a comparison with other first ogy; users of the procedure. The standard technical procedure is not fea- - to apply the WBB staging system to plan adequate treatment; sible in some clinical conditions and some times we must resort to a - to plan an en-bloc resection of the vertebral neoplasm in select- lateral approach as happened for one of our patients affected by a ed cases. serious respiratory insufficiency. Our follow-up is certainly limited Vertebrectomy is rarely indicated in the treatment of spine metas- (2 years), but outcomes are congruous with the clinical experience of tases. This indication depends on the age and the general clinical set- other teams, however it is a still young treatment that will be able to ting of the patient, sensitivity to adjuvant therapies, excessive risk of offer new interesting procedural developments. intraoperative bleeding, primary tumor histology and patient prog- nosis. In the period between January 1999 and June 2005 we have performed 32 en-bloc resection out of 226 cases of spine metastases. CFRP CAGES FAVOUR OSTEOBLAST ADHESION AND PRO- We have followed patients in time (follow-up ranges from 6 monthes LIFERATION BETTER THAN THE PEEK ONES to 60 monthes, average 19 monthes) and at present 13 cases result G. Barbanti Bròdano [1], S. Boriani [1], K. Campioni [2], M. Tognon alive with no evidence of disease (NED), 4 patients are alive with [2], C. Morelli [2] disease (AWD) and 15 are deceased. [1]Uo Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi, Bologna, Italy; [2]Dipartimento di Morfologia ed Embriologia, Sezione di Istologia ed Embriologia, EN BLOC RESECTION OF PRIMARY BONE TUMORS OF Centro di Biotecnologie, Università di Ferrara, Italy THE SPINE S. Bandiera, F. De Iure, A. Gasbarrini, M. Cappuccio, L. Mirabile, Intersomatic cages built of different materials are widely used in spine G. Barbanti Bròdano, L. Boriani, S. Boriani surgery with the aim to obtain intersomatic arthrodesis. They have been U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale extensively studied about mechanic features but we have no informa- Maggiore “C.A. Pizzardi”, Bologna, Italy tion about biologic characteristics of osteogenesis, osteo-induction and osteo-conduction. If we wanted to evaluate such features we should Objective: To demonstrate the possibility to apply in the spine the plan in vivo animal expensive tests, prolonged in time, with ethic prob- same principles of surgical oncology adopted for primary bone lems that cage producing firms don’t usually undertake. Our group has tumors of the limbs. devised a cellular system that let us quickly establish parameters above Methods: From 1-1-1990 to 1-1-2003 ninety-three primary malig- mentioned, through an in vitro test. This system is based on the line nant and aggressive benign bone tumors were treated. The primary Saos-2, an osteosarcoma cell line that does not change its osteoblastic tumors were classified according to Enneking oncological system features, and a commercial line of mesenchimal stem cell (MSC) and Weinstein-Boriani-Biagini surgical system: 36 stage IA or IB, osteoblastic phenotype induced. Lines have been engineerized through 26 stage IIA or IIB, and 31 stage 3 benign. The en bloc resection was trasfection of a vector containing the inactivated green fluorescent pro- performed in 3 cervical, 34 thoracic, in 56 lumbar. Reconstruction tein gene. Clones expressing this marker have been selected. With this was performed, aiming to replace the resected elements of stability procedure we rendered cells easily identifiable and quantifiable Results: No patients died during surgery or from surgical complica- through fluorescent microscope observation. This method enables us to tions. At final follow-up, sixty-six patients were found disease free assess and compare the biological features of two intersomatic cages S59

made of different materials (CFRP and PEEK). Characteristics we can and radiculopathies. They depend on multiple, unrelated factors, as evaluate are: -biocompatibility, -osteo-inductive and osteo-conductive surgical pathology, vertebral segment biomechanics, primary neu- capabilities (MSC-eGFP), -osteogenic and cell adesion capabilities rological lesion etiology, psychological and social elements. FBS (Saos-eGFP). Preliminary results point out that carbon fibre reinforced causes prolonged disability, anxiety and malaise. Treating FBS polymer (CFRP) intersomatic cages are more indicated then the poli- patients is frustrating because of diagnostic doubts, unpredictable etherethereketone (PEEK) ones on the basis of many features. The results, psychological problems related to the disease. Spontaneous CFRP cages support a more relevant osteogenesis, osteo-induction and recovery of these patients is uncertain and slow. Return to job after osteo-conduction and also a bone cells surface pattern more homoge- two years is almost 0%. The most part of these patients has no sur- neous then the same cages made of PEEK. Our cellular model revealed gical indication because of specific complications such as deep a good alternative to in vivo studies. Actually it makes us able to obtain peridural scar or lack of diagnosis of a precise pathogenic noxa. experimental data by in vitro trials, to cut down expenses, to reduce Only a small number of cases find a surgical solution. Our FBS time and to avoid ethical arguments. series is composed of 26 patients, 14 females and 12 males, all of them with no surgical indication. They have been treated by a ther- apeutic protocol created in collaboration with Functional Recovery PAIN CONTROL AND FUNCTIONAL RECOVERY IN PA- Department in our hospital. It consists in -a precise assessment of TIENTS AFFECTED BY SPINE FRACTURE DUE TO OSTEO- every single patient; -paying attention to explanation and compre- POROSIS. A COMPARISON BETWEEN VERTEBROPLASTY hension of the disease through a dialogue with the patient (coun- AND KIPHOPLASTY seling); -a pharmacological treatment aimed to propioceptive and G. Barbanti Bròdano, M. Cappuccio, L. Boriani, F. De Iure, A. neuropatic pain; -a physical therapy program based on global pos- Gasbarrini, F. De Salvo, S. Boriani tural re-education, propioceptive postural exercises, teaching of a Unità Operativa di Ortopedia e Traumatologia, Chirurgia del sort of spine-care in order to make patients understand self-man- Rachide, Ospedale Maggiore, AUSL Bologna, Italy agement of their disease in day-life. Results have showed a sub- stantial improvement in every case, even if without statistical sig- During the last ten years vertebroplasty (VTP) and kiphoplasty nificance (mean VAS 80->63; SF-36: 1. General Health 49->58; 2. (KIPHO) have been widely indicated in the treatment of osteo- Physical Pain 20->40; 3. Mental Health 46->55; 4. Social porosis related vertebral collapses. Systemic revision of the litera- Activities 49->60; 5. Sensitivities 36->45; 6. Functional Limi- ture and few evidence based studies (RCT) on this topic did not tations 38->45; 7. Physical Health 45->47; 8. Vitality 45->60), definitely confirm the benefit given by these procedures in the attesting how useful could be a multidisciplinary approach to this cases above mentioned. Nevertheless, on the basis of their experi- peculiar clinical syndrome. ence, all of the authors state that patients treated have had a quick and dramatic pain improvement and consequently partial function- al recovery. Both vertebroplasty and kiphoplasty have the same POSTERIOR LUMBAR INTERBODY FUSION (PLIF) IN indication that is chronic and refractory pain during conservative DEGENERATIVE SPINE DISEASE. LONG TERM RESULTS treatment; for this reason specific benefits related to each tech- G. Barbanti Bròdano, M. Palmisani, L. Mirabile, A. Gasbarrini, S. nique are difficult to clarify. Vertebroplasty seems to be affected by Bandiera, F. De Iure, G.B. Scimeca, S. Paderni, S. Boriani a greater cement leakage, even if this complication is almost ever UO Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale only a radiographic sign with no clinical relevance, except for very Maggiore “C.A. Pizzardi”, Bologna, Italy rare cases. Kiphoplasty reduces fracture and consequently reduces kiphosis; it seems to relate to a better clinical outcome, with less- Posterior lumbar interbody fusion is considered the best biome- er risk of cement out of the vertebral body. We have retrospective- chanical fusion. In the lapse of time between March 1997 and ly compared a homogeneous series of patients; 15 treated with December 2005 we have treated 227 patients affected by lumbar kiphoplasty (B-Twin VBR Expandable Spinal System, Disc-o- spondilo-arthrosis. They underwent PLIF associated to instrument- Tech) and 18 were undergone to vertebroplasty. Self assessing tests ed postero-lateral arthrodesis. Cages built of different materials have shown slightly better results in patients treated with kipho- (CFRP, PEEK, titan) were used. Mean age in our series was 49.4 plasty, but those data didn’t prove statistically significant values. years (range 18-77 years). Diagnosis was degenerative disc disease (mean post-operative VAS KIFO=21 - VTP=25; SF-36. Post-oper- in 109 cases, spondilolisthesis in 76 cases, fracture outcomes or atve: 1. General Health KIFO=60 - VTP=58; 2. Pain KIFO=79 - pseudoarthrosis in 25 cases (among which 5 cases of postero-later- VTP=71; 3. Mental health KIFO=57 - VTP=60; 4. Social Activities al arthrodesis failures), degenerative scoliosis in 6 cases, lumbar KIFO=65 - VTP=57; 5. Sensitivities KIFO=40 - VTP=45; 6. stenosis in 14 cases, 1 case of osteoid osteoma localized in L4. Functional limitations KIFO=56 - VTP=51). No complications Two patients deceased because of causes unrelated to surgery at 2 were found in either series. These data contribute to reflect upon and 8 months since treatment occurred. The first one has been the cost and benefit relationship related to these two techniques, excluded from follow up. Clinical and radiological evaluation has assessing clinical, radiographic and economic variables this kind been realized according to White (showing successful results in of surgery means. 84% of cases) and to Brantigan & Steffee (resulting in complete radiographic arthrodesis in 91.4% of cases) classifications. During the last years clinical results of 57 patients were evaluated through MULTIDISCIPLINARY DIAGNOSTIC-THERAPEUTIC AP- VAS and SF-36 forms, showing improvement clinical settings even PROACH TO THE “FAILED LOW-BACK SYNDROME” if not statistically significant (pre vs post: VAS 77vs54; SF-36: G. Barbanti Bròdano [1], L. Mirabile [1], L. Boriani [1], E. Magni [2], General Health 51vs65; Pain 24vs46; Functional Limitations R. Piperno [2], S. Boriani [1] 40vs51). Incidence of complications has been 4%. Eleven cases [1]Uo Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale (8%) needed a second surgical procedure. At the latest follow up Maggiore “C.A. Pizzardi, Bologna, Italy; [2]UO Riabilitazione e 31% of patients report persistent low back pain. Cages have better Rieducazione Funzionale, Ospedale Maggiore “C.A.Pizzardi”, mechanical qualities than bone grafts; posterior fixation increases Bologna, Italy stiffness of the implant and so increases also pressure on the cages, reducing risk of mobilization. The percentage of complications and Failed back syndrome (FBS) management is a controversial and residual symptoms forces to reflect above all on the correct indica- difficult matter. Subjective reported symptoms are low back pain tions to this kind of surgery. S60

PERCUTANEOUS KYPHOPLASTY: GENERAL ANESTHESIA and a reduced risk of PMMA cement leakage outside the porothic OR LOCAL ANESTHESIA? vertebral body [Nussbaum 2004]. F. Piccioni, F. Ferrari Conclusion: Radiofrequency heat ablation and kyphoplasty proved Servizio di Anestesia e Rianimazione 2, IRCCS Policlinico S.Matteo, to be an effective, quick, and safe treatment for thoracic/lumbar neo- Pavia, Italy plastic vertebral body localizations.

Objective: Kyphoplasty is a minimally invasive percutaneous pro- cedure developed to treat osteoporotic and osteolytic vertebral frac- MAMMARY-TYPE MYOFIBROBLASTOMA OF POPLITEAL tures. The aim of this retrospective study is to discuss two anesthet- FOSSA: A CASE REPORT [1] [1] [2] [3] ic approaches: general anesthesia and local anesthesia. C. Scotti , F. Camnasio , G.M. Peretti , N. Rizzo , F. Fontana [1] [1] Methods: A retrospective chart review was conducted on patients , G. Fraschini [1] who underwent kyphoplasty at Pavia IRCCS Policlinico S. Matteo U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, Uni- [2] (Department of Orthopedic and Traumatology). 103 records were versità Vita-Salute, Milan, Italy; U.O. di Ortopedia e Traumato- obtained by searching the anesthesia database from 1/1/2003 to logia, Ospedale San Raffaele, Facoltà di Scienze Motorie, Univer- [3] 12/31/2005. sità degli Studi di Milano, Milan, Italy; U.O. di Anatomia e Results: General anestesia group: 48 patients (38 female/10 male), Istologia Patologica, Ospedale San Raffaele, Università Vita-Salute, mean age: 69.39 ASA I+II patients, 9 ASA III patients, surgical time Milan, Italy 44’, anesthesia time 90’, 4 generic complications (bronchospasm, nausea), 1 kyphoplasty-related complication (hypotension after Mammary myofibroblastoma is a benign breast tumor, with a report- cement injection). Local anestesia group: 55 patients (38 female/17 ed predilection for older men. We report a case of a 36-year-old man male), mean age: 68. 34 ASA I+II patients, 21 ASA III patients, sur- with a tumor, morphologically and immunohistochemically identical gical time 26’, anesthesia time 30’, 1 generic complication (opioid- to myofibroblastoma of breast, but arising in the popliteal fossa. The related desaturation), 1 kyphoplasty-related complication (embolism patient came to our attention for a slowly growing, fixed and pain- or anaphylaxis reaction). In 2003 all patients underwent general less lesion located in the popliteal fossa. He underwent MRI, which showed a rounded, capsulated, 9 cm lesion, not infiltrating the neu- anesthesia. We started to perform local technique in 2004. In 2005 rovascular bundle. PET scan was slightly positive; for this reason the no kyphoplasty was performed under general anesthesia. General patient underwent routine staging, which did not show any sec- anesthesia technique: propofol-remifentanil induction, sevoflurane- ondary lesion. Due to the local characteristics of the lesion, which or desflurane-remifentanil maintenance. Local anesthesia technique: could potentially indicate a malignant tumor, an incisional biopsy mepivacaine 1% deep infiltration, oxygen administration by nasal was performed. Spindle cell lipoma was the resulting histological cannula, midazolam and alfentanil small-bolus IV doses (mean diagnosis. Two weeks later, a marginal excision of the lesion was bolus doses: 1-2mg and 0.2mg each – mean total doses: 2.7mg and performed and the histology showed a spindle cell mesenchymal 0.7mg each). neoplasia, without atipias, necrosis and mitoses. Immunohistoche- Conclusions : In accord to our experience and data analysis we mical assay was positive for CD34, S100, Bcl-2, Desmin and nuclear consider each anesthesia technique valid and safe. However, local estrogenic receptors, negative for Actin. Thus, the diagnosis of anesthesia is the best strategy for the patient because of less emo- mammary-type myofibroblastoma was done. Follow-up assessment tional stress, intraoperative self-monitoring and less operating at two years is negative for local recurrence. To our knowledge, this room permanence. The local anesthesia approach is easy and less is the first report of mammary-type myofibroblastoma with popliteal expensive as regards pharmacological, equipment and operating localization; moreover, this report indicates a possible different room usage. diagnosis from the functional imaging analysis and the histological assessment. RADIOFREQUENCY HEAT ABLATION AND KYPHOPLASTY IN THE TREATMENT OF NEOPLASTIC VERTEBRAL BODY TERIPARATIDE IN SEVERE OSTEOPOROSIS: EVALUATION LOCALIZATIONS OF ACUTE AND CHRONIC BACK PAIN IN VERTEBRAL D.A. Fabris Monterumici, U. Nena, C. Stecco, R. Sinigaglia COMPRESSION FRACTURE (VCF) Unità Operativa Complessa di Chirurgia del Rachide “Sandro A. Nardi [1], G. Luisetto [2], L. Ventura [3], E. Ramazzina [4], L. Cozzi Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, [1], G. Tonini [1] Padua, Italy [1]Servizio di Patologia Osteoarticolare, Azienda ULSS 18, Rovigo, Italy; [2]Dipartimento Scienze Mediche e Chirurgiche, Divisione di Objective: The aim of this study is to assess the effectiveness of the Endocrinologia, Università di Padova, Padua, Italy; [3]Soc treatment of thoracic and/or lumbar neoplastic vertebral localiza- Medicina, Azienda Ospedaliera, Mantova, Italy; [4]Soc Medicina, tions by radiofrequency heat ablation and kyphoplasty. Azienda ULSS 18, Rovigo, Italy Materials and Methods: From July 2002 through December 2005, we treated 25 patients with thoracic and/or lumbar neoplastic verte- Teriparatide (FORSTEO®) is a anabolic drug that reduce the risk of bral localizations using radiofrequency heat ablation associated with vertebral fractures (VFs) and non-vertebral fractures (nVFs). The kyphoplasty. Six patients had primitive cancers, the other 19 had anabolic effect on bone is also associated with considerable reduction metastases. of back pain. In this study we evaluated the course of back pain in 40 Results: This method demonstrated rapid pain relief with restoring patients with Post Menopausal Osteoporosis (PMO) and at least 1 of the weight-bearing resistance and the anatomy of the affected vertebral compression fracture (VCF). The mean patients age was of vertebral bodies. Patients quickly came back to their normal daily 74.4 years, among those, 22 patients presented a recent (less than 1 activities. month) vertebral fracture due to compression (VCF1) and 18 patients Discussion: Radiofrequency heat ablation destroys the tumor tissue had a compression vertebral fracture (VCF2) that occurred within before kyphoplasty stabilizes the vertebra through the intrasomatic few months before. The baseline mean number of VCF was 5.2. All percutaneous injection of cement [Masala 2004 e 2005]. It permits the patients received subcutaneous injection of 20 mg/die decreasing of operating time, complaints, and patient’s discomfort. Teriparatide (FORSTEO®) and oral supplementation of Calcium and Kyphoplasty versus vertebroplasty allows a better anatomic restore Vitamin D. The severity of back pain was measured at baseline (T0), S61

at 30 (T30), 90 (T90) and 180 (T180) days assigning the score of infection were admitted at our department. One patient had bilateral 3=worst pain, 2=moderate pain, 1=mild pain and 0=no pain. The infection. 7 of the index procedures had been done at our institution motorial function and tone of mood were measured at T90 in 33 and 24 had been done elsewhere. 6 patients had an infection around patients using a questionnaire with a score of: 2=high improvement; a revision procedure for aseptic loosening, whereas 2 patients had 1=moderate improvement; 0=no improvement. In 15 patients with been already revised for septic loosening. After removal of the com- VCF1 we controlled the course of the back pain from baseline to 180 ponent and radical debridement of the bone and soft-tissues in all the days. The reduction of back pain was around 97%. In 12 patients patients an antibiotic-loaded spacer was prepared at the time of with VCF2 we controlled the course of the back pain from baseline surgery. For six weeks before re-implantation all the patients under- to 180 days. The reduction of back pain was of 90%. The improve- went an intravenous administration of antibiotics on the basis of sen- ment of the motorial function and of the tone of mood, evaluated sitivity of organisms that were grown on culture. from baseline to T90, was hight in 20 patients, moderate in 12 Results: The average follow-up was 34 months. Mean KSS score patients and absent in 1 patient. In conclusion Teriparatide (FOR- improved by 35.5 to 80.3. There were 4 cases of recurrent infection. STEO®) determines a considerable reduction of back pain due to Conclusion: The two-stage revision procedure was successful in VCF from baseline to 180 days of treatment. In patients with VCF1 eradicating the infection in 27 of 31 knees (87%). In our opinion it the effect on pain is evident after only 30 days of treatment, similar- represents the most successful method for managing total knee ly to what has been shown in patients with VCF2 at the baseline. arthroplasty complicated by infection. After 180 days of Teriparatide (FORSTEO®) the reduction of back pain was statistically significantly both in VCF1 patients, in which the pain was acute, and in VCF2 patients in which the pain was of FIBROBLAST AND BIOLOGICAL MEMBRANE FOR POTEN- chronic one. The reduction in back pain was statistically significant TIAL TENDON REPAIR: AN IN VITRO PRELIMINARY STUDY also in patients with more than 4 vertebral fractures at baseline. G.M. Peretti [1], L. Mangiavini [1], C. Sosio [1], M. Buragas [1], C. Scotti [1], A. Di Giancamillo [2], C. Domeneghini [2], G.F. Fraschini [1] [1]Ospedale San Raffaele, Milan, Italy; [2]Università degli Studi di THE USE OF COMPUTER ASSISTED TECHNIQUE IN THE Milano, Milan, Italy TREATMENT OF A FRACTURE DISLOCATION VIIC-IT IN ANKYLOSING SPONDILYTIS Introduction: Tendon repair in some sites of the body, as i.e. the A. Bruno, A. Coniglio, J. Demangos, S. Aleotti rotator cuff, is a current challenging clinical problem. Cell-therapy U.O.C. Chirurgia Vertebrale, Turin, Italy could represent a valid therapeutic solution for these lesions. The aim of this study was to create an in vitro model of fibroblasts seed- Introduction: Ankylosing spondilytis (spondylitis ankylosans), char- ed on a collagen membrane, as a potential tool for the solution of acterised in its advanced state of rigidity and ankylosation of the spinal this issue. column, is a predisposing risk factor for spine fractures due to even Methods: Achilles tendon biopsies were taken from young pigs. The minor traumatic events. The lesions usually involve the thoracolumbar tendons were cut in small pieces of approximately 1 mm of diame- region and less often the lower cervical spine. Although the posterior ter, cultured in vitro, in order to allow the cells to leave the speci- screws offer an osteosynthesis with a good stability, the ossification of mens and then to reach the confluence (approximately 1 month). The the longitudinal ligaments, of the lateral masses and the calcification of fibroblasts were then enzymatically isolated, resuspended and the intervertebral discs make this vertebral stabilisation technique dif- expanded since the new confluence was reached (5 days). The cells ficult, due to the absence of the common anatomic landmarks. were seeded onto membranes of collagen type I and III of 2 mm of Materials and Methods: Here we describe a case of a 43 year old diameter. The membranes were cultured for two more weeks, then male with a history of a fracture dislocation in C7/T1 with spinal cord retrieved from cultures for macroscopic and histological analyzed. injury, previously treated by C7 somatectomy, arthrodesis with a cage Results: Macroscopically, the seeded membranes showed a reduced and titanium plate, together with a posterior focal decompression biomechanical integrity compared to the unseeded membranes. The laminectomy. The patient had been transferred to our centre in the histological examination demonstrated the presence of vital cells immediate post-operative period due to the development of a massive within the membranes. infection with generalised sepsis. Surgical debridement was performed Discussion: The results from this study demonstrate that the swine immediately and the implants removed. Temporary immobilization fibroblasts can be seeded onto a collagen scaffold. These cells was carried out by a Halo-vest for about three weeks. Posterior stabi- remain vital during in vitro culture. Further studies will demonstrate lization of C4-T4 with pedicular and lateral masses screws, was then the survival and the reparative potential of fibroblast transplantation possible with the use of the computer assisted technique. in an orthotopic in vivo model. Discussion: The results, a brief outline of the surgical technique and practical comments as to the use of the navigations system will be presented. IN VITRO STUDY ON A TISSUE ENGINEERED OSTEO- CHONDRAL COMPOSITE: MORPHOLOGICAL AND HYSTO- LOGICAL EVALUATION TWO-STAGE REVISION IN INFECTED KNEE ARTHROPLASTY G.M. Peretti [1], M. Buragas [1], C. Sosio [1], L. Mangiavini [1],C. G. Trisolino [1], D.S. Tigani [1], D.C. Vaccarisi [1], P. Costigliola [2], Scotti [1], A. Di Giancamillo [2], C. Domeneghini [2], G.F. Fraschini [1] N. Del Piccolo [1], F. Chiodo [2], A. Giunti [1] [1]Ospedale San Raffaele, Milan, Italy; [2]Università degli Studi di [1]Istituti Ortopedici Rizzoli, Bologna, Italy; [2]Policlinico S. Orsola- Milano, Milan, Italy Malpighi, Bologna, Italy Introduction: The purpose of this work is to create an in vitro model Background: Late chronic infection still represents a challenging of engineered osteochondral composite by combining a cylinder of problem after total knee replacement. Most infected knees require calcium phosphate and cartilage tissue produced by isolated swine prosthesis removal. In these cases two-stage revision with a 6-week articular chondrocytes seeded onto fibrin glue. course of systemic antibiotics, has been advocated as the standard of Methods: Swine articular chondrocytes were enzimatically isolated treatment for infected knee replacement. and seeded onto fibrin glue. Immediately before gel polymerization, Materials and Methods: Between January 2000 and December the fibrin glue was placed in contact with the cylinders of calcium 2005, 30 patients with 31 total knee arthroplasties complicated by phosphate. The osteochondral composites were left in standard cul- S62

ture conditions for 5 weeks. At the end of experimental time, the perfectly every femoral condyle osteochondral defect. The surgical samples were macroscopically analyzed and processed for histolog- technique is fast and mini-invasive. We assert that such a device repre- ical evaluation. sents a valid therapeutic option but long-term results must be observed. Results: Preliminary data showed a macroscopically integrity of the osteochondral samples. Histology showed cartilage-like tissue maturing within the fibrin glue scaffold and the presence of GAG ARTHROSCOPIC TREATMENT OF A OSTEOCHONDRITIS between the fibrin glue and the cylinders, infiltrating the scaffold DISSECANS OF THE FEMORAL TROCHLEA trabeculae. M. Ronga [1], G. Zappalà [1], E.A. Genovese [2], P. Bulgheroni [1] Discussion: The results of this study demostrate that isolated chon- [1]Dipartimento di Ortopedia e Traumatologia, Università degli drocytes, seeded onto fibrin glue, produce a cartilage-like matrix that Studi dell’Insubria, Varese, Italy; [2]Dipartimento di Radiologia, integrates with a cylinder of calcium phosphate. Further studies will Università degli Studi dell’insubria, Varese, Italy quantify the biomechanical strength of the adhesion between the cal- cium phosphate scaffold and the newly formed cartilage. This tissue Aim: Juvenile osteochondritis dissecans of the femoral trochlea is an engineered osteochondral composite could represent a valuable model uncommon condition observed in clinical practice. We report on 11- for further in vivo studies on the repair of osteochondral lesions. year-old child with a complete separate trochlea fragment. Materials and Methods: MRI have shown a 2,5 x 2,2 cm grade IV osteochondral lesion, according to the ICRS classification. Using PERSPECTIVE CLINICAL TRIAL TO ASSESS INTRA-ARTIC- arthroscopic approach, the fragment was reduced and fixed using ULAR CONCENTRATIONS OF IL-8, IL-6, TNF-α IN PA- three 1.5 mm diameter and 20 mm long polylactic acid (PLA) pins. TIENTS WITH ISOLATED ANTERIOR CRUCIATE LIGAMENT Results: At 6 months, the patient did not complain of knee pain, had LESION: PRELIMINARY RESULTS full range of motion, and returned to all the activities performed M. Bigoni [1], S. Guerrasio [1], A. Cossio [1], E.C. Marinoni [1],A. before the traumatic event. International Cartilage Repair Society Torsello [2], I. Bulgarelli [2], L. Tamiazzo [2], P. Sacerdote [3] (ICRS) score was normal. The 2000 International Knee Documen- [1]Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di tation Committee (IKDC) subjective evaluation form, Lysholm II Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e scale, and Tegner activity scale were, respectively, 69 of 100, 90 of Traumatologia, Monza, Italy; [2]Dipartimento di Medicina 100, 6 of 10. MRI and Arthro-MRI showed fragment consolidation. Sperimentale, Ambientale e Biotecnologie Mediche, Università degli The three absorbable pins were still recognizable. At 24-month, Studi Milano-Bicocca, Milan, Italy; [3]Dipartimento di Farmaco- ICRS score was normal, and modified Cincinnati, Lysholm II, logia, Chemioterapia e Tossicologia Medica, Università degli Studi Tegner, and IKDC scores were, respectively, 9 of 10, 95 of 100, 7 of di Milano, Milan, Italy 10, and 88.5 of 100. MRI findings confirmed healing of the lesion and the presence of the bioabsorbable pins. In the degenerative or traumatic inflammatory diseases there is an Discussion: Review of the literature reveals few reported cases of OCD intra-articular effusion, full of inflammatory cells, cytokines and of the medial or lateral trochlea. Surgical options of unstable JOCD related substances which damage the articulation itself. However include fragment removal or fixation. Several authors have demon- few data can be derived from the analysis of the literature about the strated that the removal of the fragment increases risk of early real concentration and the trend of expression of these inflammato- osteoarthritis. Consequently, osteochondral fixation is preferred. Pins ry chemical mediators in patient with acute post-traumatic ligamen- have inferior compression compared to a 2.7 mm traditional screw, but tous injury of the knee. The Department of Orthopaedics and the triangular placement helped achieve good rotational stability Traumatology and The Department of Pharmacology of Milan Conclusion: It is our opinion that an arthroscopic approach, Bicocca University are carrying out an experimental trial about the biodegradable pins and early joint motion were the keys to the suc- identification of inflammatory chemical mediators in synovial fluid cessful outcome in this case. of patients with post-traumatic ACL injury. The following are the inclusion criteria: only male patients of age between 14 and 30 years with acute ACL injury and without lesion or with first degree lesion RUPTURE OF QUADRICEPS TENDON: A TECHNIQUE FOR of the collateral ligament and negative anamnesis for previous trau- RECONSTRUCTION WITH HAMSTRING AUTOGRAFT ma of the knee involved. The aim of the trial is to assess the intra- USING SUTURE ANCHORS FOR FIXATION articular concentrations of IL-8, IL-6, TNF-α and their trend of F. Franceschi, G. Rizzello, A. Marinozzi, G. Longo Umile, L. expression taking a sample of joint fluid from the knee injured with- Ruzzini, M. Ippolito, R. Papalia, V. Denaro in 48 hours, after one week during the clinical check-up, after one Università “Campus Biomedico”, Rome, Italy month as intra-operating control and after 2 and 4 week as post-oper- ating control. The Authors present the preliminary results. Objective: The purpose of this paper is to describe a new technique of augmentation of quadriceps tendon with hamstring tendon autograft associated with an end to end type repair using suture anchors. CONDYLAR MINIPROSTHESIS: A NEW METHOD FOR III Materials and Methods: In May 2003 a 45 year old male affected AND IV GRADE CHONDRAL LESIONS by complete full thickness tear of the rectus femoris of the quadri- W. Thomas, L. Lucente, L. Tafuro ceps tendon underwent a reconstruction of the quadriceps tendon of Clinica Quisisana, Rome, Italy his left knee. A transverse tunnel was drilled through the mid portion of the patel- The orthopaedic treatment of chondral lesions of III and IV grade of la and the hamstring graft was pulled into the patellar tunnel, leav- Outerbridge classification is still debated, especially in patients ing free distal ends of tendon which were than passed through the between 40 and 60 years, too young for a prosthetic replacement. quadriceps tendon several times to bridge the defect. Two suture Furthermore other techniques (chondroabrasion, multiple perforation, anchors loaded with Fiberwire were positioned into the superior pole microfractures, osteotomy) cannot be performed for severe cases. of the patella and the Fiberwire was then passed through the tendon. Osteochondral graft, that seems to be the most biologic technique, The sutures were tied leading to a complete tendon reattachment. shows poor long-term results. Authors present a therapeutic device for Results: The score system (IKCD) utilized for postoperative evalu- a perfect filling of osteochondral defects. This device is a Cr-Co pin ation showed a clear improvement in our patient. At the final follow with a ceramic bearing surface, available in some measures, so to fill up, the patient showed no symptoms in the postoperative 3 years, S63

and productively returned to pain-free level of function without lim- A and from 9.036 ± 0.03 postoperatively to 9.94 ± 1,12 in the group itations in his competing activities. B at follow up. The mean average tibial tunnel diameter increased Discussion: Many authors have dealt with various techniques of significantly from 9.03 ± 0.04 to 10 ± 0.8. in the group A and from reconstruction of quadriceps tendon tears. 9.04 ± 0.03 to 10.6 ± 0.78 in the group B. The increase in diameter In our patient we found a full thickness lesion of the most superfi- of femoral and tibial tunnel was significantly higher than that of cial lamina of the quadriceps tendon associated with retraction, for group B. this reason an end to end repair could not be performed and we Conclusion: Our results suggest that tunnel enlargement after ACL decided to perform an autologus augmentation using tendons which reconstruction with hamstring autograft is significantly increased by are routinely harvested in reconstructing other soft tissue structures a brace-free rehabilitation protocol. with little or not disability. Conclusions: Our simple technique allows to realize a strong fixa- tion allowing an early range of motion that provides an ideal envi- TWO CASES OF COMPLEX KNEE PATHOLOGY IN SPORT ronment for tendon healing. TRAUMATOLOGY F. Carotenuto [1], L. Curci [2], C. Di Bonito [3], N. Vendemmia [2] [1]Clinique General De Savoie, Chambery, France; [2]Policlinico EFFECT OF BRACE-FREE REHABILITATION ON BONE TUN- Universitario “Federico II”; Naples, Italy [3]Ospedale G. Rummo, NEL ENLARGEMENT OF ACL RECONSTRUCTION USING Benevento, Italy HAMSTRINGS TENDONS: CT STUDY R. Iorio, A. Vadalà, V. Di Sanzo, A. De Carli, G. Argento, A. Ferretti We describe two cases of ski-related complex trauma of the knee Ospedale S. Andrea, Rome, Italy ligament, without fracture. The first case regards a knee dislocation that was not reducible in narcosis. Specifically, the internal condy- The mechanism of bone tunnel enlargement following anterior cru- lus of the left knee created a path between the vastus medialis and ciate ligament (ACL) reconstruction is not yet clearly understood. the capsular ligament apparatus. This path allowed all the remain- Many authors hypothesized that aggressive rehabilitation protocol ing ligament structures to slide intact into the intercondylar fossa, may be a potential factor for tunnel enlargement, especially in ham- thus rendering the reduction of the fracture impossible. As a result, string autograft. The purpose of our study was to evaluate the effect the patient presented a tear of the posterior cruciate ligament of brace-free rehabilitation on bone tunnel enlargement of ACL (PCL), of the PAPI, of the medial capsule, and, only in part, of the reconstruction using hamstrings tendons. anterior cruciate ligament (ACL). The second case regards an Materials and Methods: In this prospective study 43 consecutive external malignant pentad accompanied by a tear of the entire lat- patients operated by ACL reconstruction with the hamstrings using eral muscle-ligament complex and the external sciatic popliteus the same technique aned fixation devices, were randomly assigned is (ESP). In both cases, patients underwent surgery immediately after enter the study group (A) or the control group (B). In group A an the trauma. In the first case, the surgery resulted crucial for the accelerated rehabilitation were performed without brace and imme- reduction of the dislocation, otherwise unfeasible with non surgi- diate ROM and weith bearing as tolerated. In group B a two weeks cal means. In the second case, it was crucial for the neurological brace immobilitation in full extension were apllied with partial examination and decompression of the external sciatic popliteus weight bearing. A CT scan of the knee were performed in all cases nerve. Actually, the immediate surgical interventions allowed us to the day after surgery and at a follow-up of ten months: diameters of repair such uncommon ligament injuries, and, equally important, the femoral and tibial tunnel were evaluated according to a previ- to better understand the mechanisms underlying the complex trau- ously described method. ma of the knee ligaments. We hope that our study will change the Results: The mean average femoral tunnel diameter increased sig- current therapeutic approach to the treatment of these types of nificantly from 9.04 ± 0.05 postoperatively to 9.3 ± 0.8 in the Group complex knee injuries.