Cementless total hip arthroplasty for osteonecrosis of the femoral head after allogenic bone marrow transplantation.

From 1998 until 2004, we performed 26 consecutive cementless total hip arthoplasties in 15 patients who had developed advanced avascular necrosis of the femoral head after allogenic bone marrow transplantation. The average age at transplantation was 31.1 years, and the mean age at implantation was 33.6 years. Follow-up period ranged from 2 to 8 years with an average of 56.4 months. The mean D'Aubigne-Postel score improved from 7.5 points preoperatively to 17 points postoperatively. The overall result was excellent in 92.3%, good in 3.8%, and fair in 3.8% of cases. There were no radiological signs of components loosening and no severe complications. Cementless total hip arthroplasty appears as a favorable alternative for the treatment of avascular necrosis of the femoral heads after allogenic bone marrow transplantation.

The Effectiveness of the Burch-Schneider antiprotrusio cage for acetabular bone deficiency: five to twenty-one years' follow-up.

From 1985 to 2001, the Burch-Schneider antiprotrusio cage (B-S APC) was implanted in 57 cases (55 patients) with massive acetabular deficiency. The B-S APC survived until the last review 5 to 21 years after operation in 89.5% of the cases, produced substantial pain relief, and increased range of hip motion and walking capacity. The 10.5% failure rate was due to aseptic loosening in 2 cases and mechanical failure in 4 cases. It appears that application of the B-S APC in extensive acetabular deficiency presents a durable solution provided that proper indications and technique are used.

Interposition arthroplasty of the first metatarsophalangeal joint with a fascia lata allograft.

A new technique for interposition arthroplasty of the first metatarsoplalangeal joint is described. It involves minimal resection of the base of the proximal phalanx and the use of a fascia lata allograft. The method is simple, safe, and easily reproducible. In selected cases it can offer restoration of pain-free motion in a nonsalvable joint.

Acute management of clavicle fractures. A long term functional outcome study.

The purpose of this study was to evaluate the long-term results after acute treatment of clavicle fractures. We reviewed 139 patients with an average age of 39.3 years (range: 18 to 74) who sustained a clavicle fracture either isolated or as part of a polytrauma. Besides demographic data, both clinical result and residual symptoms were also recorded. The average follow-up was 7.2 years (range: 4 to 13). The fracture showed a higher prevalence in young men and older women. The most frequent mechanism of injury was a fall (39.6%) and coexisting injuries were found in 12.9% of patients. Conservatively treated fractures united in 96.9% of cases and the time to union was no different with a sling or figure-of-eight bandage. Fracture location did not influence the functional outcome. One third of patients were still complaining of mild pain and discomfort during overhead activities and polytrauma patients had a lower Constant score.

Potential influence of hormones in the development of slipped capital femoral epiphysis: a preliminary study.

The potential influence of hormonal imbalance on the development of slipped capital femoral epiphysis was assessed through a prospective clinical study. The serum levels of T3, T4, thyroid-stimulating hormone, testosterone, estradiol, dehydroepiandrosterone-sulfate, follicle-stimulating hormone, luteinizing hormone, human growth hormone, adrenal cortex hormone and cortisol were evaluated in seven boys and seven girls. Forty-three out of 154 hormonal determinations (27.9%) were abnormal. The results showed increased incidence of pathological values mainly in the levels of follicle-stimulating-hormone, luteinizing-hormone and testosterone. No patient had clinical findings of endocrinopathy. A (possibly) temporary hormonal disorder may play a potentially significant role in the development of slipped capital femoral epiphysis.

Children and adolescents with idiopathic scoliosis: emotional reactions, coping mechanisms, and self-esteem.

The main aim of the present study was to investigate the relationship among emotional responses of children and adolescents with idiopathic scoliosis towards their physical state, the coping mechanisms they used, and their self-esteem and the treatment condition of their disorder, i.e., the use of a brace or not. 82 children and adolescents ages 7 to 17 years who were attending an outpatient scoliosis clinic were administered two questionnaires; one evaluated emotional and behavioral factors linked to coping with stressful situations, and the second assessed self-esteem. Analysis showed that, after adjusting for emotion-focused coping, general self-esteem, and age, the effect of the use of brace as a treatment technique on the participants' emotional reactions was not significant.

Percutaneous Harlow Wood needle biopsy of the spine: a retrospective analysis of 238 spine lesions.

This retrospective study assessed the diagnostic accuracy and clinical usefulness of the Harlow Wood needle biopsy for spinal lesions. The medical records of 238 patients (138 men and 100 women) who underwent closed spine biopsy from 1987 through 1997 were reviewed. Patient age ranged from 21 to 83 years. Lesions involved the thoracic vertebrae in 127 patients, the lumbar vertebrae in 99 patients, and the sacrum in 12 patients. Cultures of the biopsy specimens were examined histopathologically and cytologically. One hundred twenty-four patients were diagnosed with a spinal infection, and 68 patients were diagnosed with a tumor. In the remaining 46 patients, the biopsy specimens were negative for infection or neoplasia in 20 patients and not diagnostic in 26 (10.9%) patients. There were no major complications. The Harlow Wood needle biopsy is a simple, repeatable procedure with satisfactory diagnostic accuracy (89.1%) and can be performed on an outpatient basis.

Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator.

BACKGROUND: Inferior subluxation of the proximal part of the fibula has been reported to occur with distraction osteogenesis of the tibia; however, the clinical sequelae of this subluxation are unknown. The purpose of this study was to evaluate inferior subluxation of the proximal part of the fibula and its possible clinical implications in patients who had undergone tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. METHODS: Thirty tibiae in seventeen patients with a variety of conditions underwent tibial lengthening by distraction osteogenesis with use of a unilateral external fixator and were followed clinically and radiographically for a mean of two years and ten months (range, two to four years). Ten patients were female and seven were male. Their mean age at the time of the surgery was seventeen years (range, eight to twenty-five years). The mean tibial lengthening was 8.1 cm (range, 3.5 to 13 cm). RESULTS: An inferior shift of the fibular head in relation to the tibia was evident in all cases. The shift, which ranged from 0.4 to 3.3 cm, was proportionally related to the amount of tibial lengthening. This type of subluxation is probably attributable to the tension that is exerted by the intact interosseous membrane during the distraction as well as to the tension of the regenerated bone of the fibula and the fact that the fibula itself is not fixed or directly lengthened by the external fixator. CONCLUSIONS: It appears that inferior subluxation of the fibula is a common phenomenon in patients undergoing tibial lengthening by distraction osteogenesis with use of a unilateral external fixator. However, no clinical symptoms or findings related to the inferior subluxation of the fibula were found in our series.

Wilson osteotomy stabilised by means of internal fixation for the treatment of hallux valgus.

The results achieved in 20 patients (32 feet) who underwent Wilson's osteotomy of the first metatarsal for the treatment of hallux valgus were reviewed. In all cases the osteotomy site was stabilised with one or two cortical screws. The patients' average age was 50.7 years (range: 34-74 years) and they were followed for a mean period of 33.1 months (range 12-63 months). The average AOFAS score was 85.5 (range: 62-100) at the final follow-up and in 84.4% of the cases the final outcome was very satisfactory as far as symptomatic improvement was concerned. Wilson's osteotomy stabilised with cortical screws was found to reliably give satisfactory correction of the hallux valgus and first intermetatarsal angles, while allowing safe patient mobilisation and early weight bearing. This effectively resulted in shorter rehabilitation time, early return to work or normal activities and a very satisfactory functional outcome.

Combined interbody cage and anterior plating in the surgical treatment of cervical disc disease.

The purpose of this study was to evaluate the results of treatment of symptomatic cervical disc herniation using interbody cages and anterior plate fixation. Fifteen patients were studied retrospectively. An MRI study of the cervical spine was performed preoperatively in all patients. The levels involved were C5-C6 in 9 cases, C6-C7 in 4 and C3-C4 in 1, while 1 patient had disc disease at the C5-C6, C6-C7 levels, Surgical treatment included anterior approach of the cervical spine, removal of the degenerative disc, excision of osteophytes and insertion of an interbody cage which was filled in with bovine allograft and demineralised bone matrix. The spinal unit was stabilized with an anterior plate and screws. No cervical splint was used postoperatively. The patients were followed up for 7 years on average after surgery. No failure or migration of the implants was noted, while bone fusion was achieved radiologically within 6 months postoperatively in all cases. The benefits of this surgical technique are the maintenance of cervical lordosis and disc space height, the high fusion rate, as well as avoidance of cervical orthoses.

Is obesity a contraindication for minimal invasive total knee replacement? A prospective randomized control trial.

BACKGROUND: Although total knee replacement (TKR) has been proven a very successful treatment modality for the end-stage knee osteoarthritis (OA) in obese patients, the rehabilitation period often is long and painful. Minimal invasive surgery (MIS) has gained much attention in TKR promising fast and less painful recovery. However, little is known about the effectiveness of the technique in the obese adult population. METHODS: One hundred consecutive patients with body mass index (BMI) > 30 kg/m(2) and tricompartmental knee OA were randomly assigned to undergo either standard TKR (50 patients) or MIS-TKR (50 patients). The patients were assessed clinically and radiologically before the procedure and at subsequent postoperative follow-up visits, until 2 years after the operation. RESULTS: Knee society function and pain scores were significantly higher in MIS group for 3 months following surgery. Patients after MIS had also lower levels of pain during hospitalization. Tourniquet time was on average 7 min longer during MIS-TKR (p = 0.03) but operative time was almost equal in both groups (p = 0.11). No statistical significant difference was found between groups regarding the amount of blood loss (p = 0.49) or incidence of allogeneic blood transfusion (p = 0.27). Active straight leg raising was achieved 2.2 days earlier, on average, after MIS-TKR (p < 0.001). No severe complications or residual coronal and sagittal imbalance were identified. Component alignment was in normal limits and similar in both groups. In MIS group, higher BMI did not have a negative predictive effect on knee pain and function. CONCLUSIONS: MIS is a reliable and safe option in obese patients undergoing TKR regardless the level of BMI. It is associated with improved early clinical outcome without sacrificing radiographic positioning of the implants.

Mid-term results of hydroxyapatite-coated threaded cup implanted without supplementary supporting screws.

We retrospectively reviewed the clinical, radiographic, and survivorship outcomes in a series of 180 patients that underwent 204 primary Total Hip Arthroplasties with the use of a second generation threaded hydroxyapatite-coated acetabular cup that was implanted without any supplementary supporting screws. At an average follow-up period of 10.2 (range: 8-14) years, one hundred and seventy-four patients (198 cups) were available for assessment. All patients underwent detailed physical and radiographic examination; their functional status was evaluated according to the Harris Hip Score (HHS). Following their digitization, all radiographs were further reviewed in order to determine the existence of any migration of the acetabular cup. Osteolytic lesions, radiolucent lines or zones of increased bone density were also recorded and classified according to the system of DeLee & Charnley. The modified Engh's criteria were used in order to evaluate the stability of the prosthesis. The patients' mean HHS at their latest follow-up visit (97.24 points) was statistically significantly better than the preoperative mean score of 40.31 points (p<0.001). Radiographic analysis showed "stable with bone ingrowth" fixation (modified Engh's criteria) of all implants with no significant migration of the cup (mean cranial migration: 0.597 mm, mean horizontal migration: 0.607 mm, mean observed difference of the cup's inclination angle: 0.26 degrees). No areas of significant osteolysis were found. The cumulative survival rate of the implants was 97.05%. Our results suggest that second generation hydroxyapatite-coated threaded acetabular cups can be successfully implanted (and achieve excellent results) without the use of any supplementary supporting screws.

Is tension band wiring technique the "gold standard" for the treatment of olecranon fractures? A long term functional outcome study.

BACKGROUND: Tension band wiring (TBW) remains the most common operative technique for the internal fixation of olecranon fractures despite the potential occurrence of subjective complaints due to subcutaneous position of the hardware. Aim of this long term retrospective study was to evaluate the elbow function and the patient-rated outcome after TBW fixation of olecranon fractures. METHODS: We reviewed 62 patients (33 men and 29 women) with an average age of 48.6 years (range, 18-85 years) who underwent TBW osteosynthesis for isolated olecranon fractures. All patients were assessed both clinically with measurement of flexion-extension and pronation-supination arcs and radiologically with elbow X-Rays. Functional outcome was estimated using the Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS) subjective pain score and VAS patient satisfaction score. Follow up: 6-13 years (average 8.2 years). RESULTS: There was a higher prevalence of fractures among men until the 5th decade of life and among women in elderly (p = 0.032). Slip or simple fall onto the arm was the main mechanism of injury for 38 fractures (61.3%) while high energy trauma, such as fall from a height (> 2 m) or road accident, was reported in 24 fractures (38.7%). Hardware removal performed in 51 patients (82.3%) but 34 of them (66.6% of removals) were still complaining for mild pain during daily activities. The incidence of pin migration and loosening was not statistically decreased when penetration of the anterior ulnar cortex was accomplished (p = 0.304). Supination was more often affected than pronation (p = 0.027). According to MEPS, 53 patients (85.5%) had a good to excellent result, 6 (9.7%) fair and 3 (4.8%) poor result. The average satisfaction rating was 9.3 out of 10 (range, 6-10) with 31 patients (50%) to remain completely satisfied from the final result. Degenerative changes recorded in 30 elbows (48.4%). However, no correlation could be found between radiographic findings and MEPS (p = 0.073). CONCLUSION: Tension band wiring fixation remains the "gold standard" for the treatment of displaced and minimally comminuted olecranon fractures. In long term, low levels of pain may be evident regardless of whether the metalware is removed and degenerative changes have been developed.

Soft-tissue myoepithelioma of the hypothenar region: a case report.

Myoepithelial tumors only recently have been recognized as occurring primarily in soft tissue, and only a few cases have been described in the literature. The occurrence of these tumors in the hand is even more limited. In this article, we review the clinical, radiologic, and histologic features of a benign myoepithelioma of the hypothenar region of the left hand.

Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years.

The results of operative treatment of acetabular fractures as well as its role in the occurrence of post-traumatic osteoarthritis (OA) are presented. From 1990 to 2000, 50 patients (32 male and 18 female), aging from 18 to 71 years (mean: 37.8 years) underwent an open reduction and internal fixation of their displaced acetabular fracture. They were reviewed at a mean of 5.8 years (2-10 years). A typical Kocher-Langebeck approach was selected in all the patients and in 14 cases a trochanteric osteotomy was added to enhance exposure. The fractures were classified according to the Letournel-Judet classification. The aim of the operation was the anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement, which was achieved in 39 of 50 cases. Post-operative protocol included low-molecular-weight heparin (LWMH) as antithrombotic prophylaxis and 75 mg of indomethacin against heterotopic ossification (HO). At the final follow-up, the patients were evaluated clinically according to D'Aubigne-Postel scoring system and radiologically based on the criteria described by Matta. The clinical results were excellent in 20 patients, good in 18, fair in 5 and poor in 7. The radiological results were excellent in 20 patients, good in 16, fair in 5 and poor in 9. Early post-operative complications included 2 peroneal nerve palsies and 3 wound infections and late complications included 1 patient with avascular necrosis of the femoral head (ANFH), 5 patients with grade III and IV heterotopic ossification according to Brooker classification and 12 patients with post-traumatic osteoarthritis of the hip joint. Although the rates of early and late complications were relatively common, the functional outcome was satisfactory in most of the cases and comparable with other larger series. We concluded that operative treatment of most of the displaced acetabular fractures--except of isolated anterior column or/and anterior wall - could be attempted via a single posterior approach, leading to good to excellent results in the majority of the cases.

Has the management of shoulder dislocation changed over time?

Anterior shoulder dislocation is a disabling injury affecting all ages, young and old alike. Recently, the treatment of traumatic shoulder dislocation has included immobilisation for varying periods of time followed by physiotherapy. This study is the first in this country to address the demographic data and recurrence rates of shoulder dislocation. Three hundred and eight patients (170 men and 138 women) were followed up for an average of 5.9 years. The most frequent mechanism of injury was a fall (65.66% of cases), and in 92.1% of the patients, the shoulder was reduced in the Emergency Department without the need for sedation or general anaesthesia. The overall recurrence rate in all ages was 50%, but rose to 88.9% in the 14-20-year age group. The duration of immobilisation did not affect the rate of re-dislocation of the humeral head. We believe that conventional shoulder immobilisation in a sling offers no benefits, and it would be preferable not to immobilise the shoulder at all.