The surgical treatment of malleolar fractures: long-term results.

The retrospective study concerns use of the AO method for the treatment of 75 ankle fractures between 1990 and 1995. After a mean follow-up of 5 years and 7 months the Cedell criteria were used for a subjective evaluation of results. Good results were obtained in 53 out of 75 patients submitted to surgery (70%), with a significant difference between uni-malleolar fractures and bi- and tri-malleolar fractures. Dorsal flexion measured an average of 24 degrees (80% of the healthy contralateral side), plantar flexion 36 degrees (90% of the healthy side). The presence of a fracture-dislocation considerably worsens prognosis because of the cartilaginous damage produced. The risk of poor results increases considerably when reduction of fracture is insufficient or absent. Post-traumatic arthrosis constitutes a common complication (25%) and it particularly affects females aged between 45 and 65 years, as a result of the presence of post-menopausal osteoporosis. Accurate reduction, fracture stabilization, sex and age constitute essential elements for satisfactory final results.

A comparison of surgical and conservative treatment in ankle ligament tears.

Good results have been reported after both primary repair and conservative management of grade III ankle sprains. This prospective study found no advantage of operative treatment compared to taping; no significant differences were found between the groups with regard to objective or subjective stability, functional scores, or the overall result.

Long-term follow-up of Perthes' disease in adolescence.

A total of 15 patients affected with Perthes' disease that occurred during adolescent were followed-up in order to study progression of the disease, and to identify the "risk factors" capable of influencing the future of the lesion. Age of onset was on the average 11 years (10-13 years), age at follow-up was 38 years (20-56 years). On diagnosis, 2 hips were classified as Catterall group II, 8 as group III, 6 as group IV. Treatment was conservative in 11 patients and surgical in 4 (valgus osteostomy). A total of 88% of the hips healed with deformity to a greater or lesser degree of the femoral epiphysis (Stulberg III-IV and V). The most significant prognostic factors that emerged from the present study were the early closing of growth plate (femoral and triradiate), disorders in growth of the proximal femur, acetabular roof insufficiency, and changes in the acetabulum.

Core decompression in the treatment of necrosis of the femoral head. Long-term results.

Long-term follow-up (5 years and 7 months) was obtained for the results of core decompression in 18 patients (20 hips) affected with ischemic necrosis of the femoral head at Ficat stages I and IIA. Two methods were used to diagnose osteonecrosis: bone scan, and MRI. Progression of the disease was monitored by annual MRI. The persistence of pain, progression of the disease in the Ficat scale, the use of total arthroplasty, were considered to be signs of failure. Core decompression was favorable in 16 hips, there was progression of the disease in 4. Good results were observed in 90% of the stage I necroses and in 70 of the stage IIA necroses. The results of the present study suggest bone reaming as the treatment of choice in initial stages of necrosis. Thus, the need for arthroplasty in young patients is delayed.

Catterall versus Herring classification in Perthes' disease.

It is the purpose of this study to compare the prognostic value of the Herring classification (lateral pillar) with that of the Catterall classification. The material is constituted by 45 patients affected with Perthes' disease and reviewed an average of 24 years after onset. At follow-up the hips were divided into three classes based on joint congruency as suggested by Stulberg. The Catterall classification demonstrated overall a better predictive value for the Herring system. Instead, the most satisfactory reproducibility seems to be that of Herring: 80% as compared to 42% for the Catterall classification.

Meyer's dysplasia epiphysealis.

Meyer's femoral cephalic dysplasia (FCD) is a rare affection that is often confused with Perthes' disease from which it differs in terms of both treatment and prognosis. A constant feature is the absence of the nucleus of ossification that does not occur until 15-18 months of age; at times there are multiple nuclei of ossification, so that the epiphysis has a "morulated" aspect. Fusion of the various centers of ossification occurs at about 5 years of age. The epiphysis does not collapse and it preserves its density and its structure. Differential diagnosis involves Perthes' disease and other pathologies such as multiple dysplasia epiphysealis, hypothyroidism, dyschondroplasia.

Radiographic variables in normal and osteoarthritic hips.

The width of the weight-bearing surface (WBS) of the acetabulum and its obliquity; height, width, opening angle and alpha angle of the gothic arch; diameter of femoral head; the angle between the center of the femoral head and the most lateral point of the acetabulum (CE angle); neck-shaft angle (CCD angle); offset; angle of aperture, surface area, and volume of the spherical sector; radius and height of the spherical bowl; and distance from teardrop were assessed to study mechanically normal and frankly osteoarthritis hips. There appears to be a direct correlation between primary alterations of the above variables and development of osteoarthritis of the hip.

Anterior cruciate ligament reconstruction. A comparison of 2 techniques.

This work compares the results of 2 different techniques of anterior cruciate reconstruction performed by 2 surgeons with the same rehabilitation program and same criteria of results evaluation. Forty-five patients were operated on using semitendinous tendon autograft, (average followup, 8 years 4 months), and 30 patients using bone patellar tendon bone autograft (average followup, 7 years 5 months). Functional results were evaluated using the Lysholm and Tegner rating systems, and clinical laxity or stability were evaluated using the Lachmann and Jerk tests. Articular stability and function were significantly better in the patients operated on using bone patellar tendon bone autograft.

Total hip replacement in the paleoacetabulum: biomechanical considerations.

The authors analyze the biomechanics of the dislocated hip in preparation to total hip replacement. Using the Pauwels criteria as a starting point, the authors observe the pathologic modification of this equilibrium when the hip is congenitally dislocated. Finally, applying these criteria to the acetabular component positioned in both the neoacetabulum and the true or paleoacetabulum, the authors show that the latter is biomechanically more advantageous.

Acute lesions of the lateral ligaments of the ankle. Clinical and radiographic review.

We reviewed 36 patients who had undergone reconstructive surgery of the ligaments of the lateral compartment of the ankle between 1981 and 1986. The follow-up period averaged 6 years (range, 3-9 years). Ligamentous lesion was diagnosed by clinical examination and contact thermography. Eighty-six percent of the subjects reviewed achieved a good result, resuming sports activity and regaining full joint stability. Reports in the literature are conflicting: good results have been achieved by both conservative treatment and reconstructive surgery. We are convinced that surgery offers young athletes a better chance of regaining joint stability because it is the only treatment that promotes anatomical healing of the ligaments without lengthening or loss of strength. Contact thermography is an important means of diagnosis because of its few limitations and low cost.

Tibial osteotomy in the treatment of varus osteoarthritic knee.

Fifty-three patients treated between 1979 and 1986 with high tibial osteotomy for varus osteoarthritic knee are evaluated. The average follow-up was 6 years and 8 months (range 3-10 years). All of the osteotomies were stabilized using Weber's method. The purpose of the operation was to realign the mechanical axes with overcorrection of 3 degrees. Results were good in 71% of the patients, and 85% claimed to be satisfied with the operation. The preoperative varus, 9.5 degrees on average, was corrected to 2-degree valgus; the deformity was exactly corrected in 59% of the cases, undercorrected in 9%, and overcorrected in 32%. The corrections slowly deteriorated over time. The correlation between the results and the stage of the arthritis, the degree of deformity, and the alignment of the mechanical axes showed that the best results were obtained in monocompartmental lesions with a varus deformity of less than 10 degrees and in osteotomies resulting in an average postoperative mechanical axis of 184.5 degrees. Weber's method has undeniable advantages over other methods, such as stable internal fixation, rapid healing, early restoration of articular function and resumption of weight-bearing.

Dorsal dislocation of the fifth carpometacarpal joint.

A case of isolated dorsal dislocation of the fifth carpometacarpal joint treated conservatively is reported. The mechanism is thought to be a force hitting the head of the fifth metacarpal in a dorso-palmar direction, along the longitudinal axis of the metacarpal. Both clinical and radiological results 1 year after injury are satisfactory.

Models of hip prosthesis mobilisation.

The mechanisms of prosthetic hip mobilisation are analysed, both in regard to the acetabular component and the femoral component. These are correlated with the clinical and radiographic manifestations with the aim of facilitating the comprehension and memorisation of different types of mobilisation. These are summarised in a chart illustrating the eight different mechanisms which provide both the orthopaedist and the radiologist with a rapid "aide memoire" when faced with a radiograph in a case of aseptic prosthetic hip mobilisation.

The early diagnosis of idiopathic femoral osteonecrosis.

Idiopathic osteonecrosis of the femoral head presents many problems of diagnosis and treatment during the early stages of the disease due to the paucity of clinical manifestations and the absence of radiographic evidence. By the time that the radiographic and clinical evidence are sufficient for a reliable diagnosis, the disease is so advanced that treatment is a problem. Early diagnosis is therefore the key issue and, in this context, instrumental tests, CT scanning and the measurement of blood flow velocity play an ever-increasing role. In the early stages of the disease CT scanning shows characteristic changes in the socalled "asterisk sign" of Dihlmann, and this has proved useful not only in terms of diagnosis, but also in order to initiate early treatment of the disease. Although radioisotope methods with double tracer do not allow for direct visualisation of the circulation in the femoral head, they have proved to be extremely reliable in evaluating the perfusion index of the femoral heads by providing activity/time curves which are a reliable estimate of regional blood flow.

[Radiological criteria of the evaluation of prosthetic hip implants]. / Criteri radiologici di valutazione degli impianti protesici dell'anca.

The radiographic criteria are described for the evaluation of total hip replacement. The authors' purpose is to uniform all different parameters for a correct long-term radiographic follow-up. The basic radiographic parameters are pointed out for the assessment of eventual loosening/wearing out of prosthetic material: 1) correct positioning of the acetabular and femoral components; 2) initial wearing of the plastic; 3) state of the bone-cement, bone-implant attachments. These criteria represent the base for a prognostic evaluation of the implant, for they allow the quantification of the radiographic changes (sinking, demarcations, fractures of cement, loosening etc.) during time.

The surgical treatment of idiopathic osteonecrosis of the femoral head.

The results of surgery in the treatment of osteonecrosis of the femoral head are analysed and discussed. Medullary decompression by the forage biopsy technique in the early stage facilitates normalisation of the intramedullary pressure and breaks the vicious circle constituted by ischaemia-oedema-increased medullary pressure-ischaemia which eventually produces bone death. Flexion osteotomy is indicated in the advanced stage (Ficat stage 3) provided certain parameters are respected such as the age of the patient, the stage of the lesion, the extent of the necrosis and the absence of secondary arthritis. For cases classified as Ficat stage 4, the only solution is total arthroprosthesis.