Ultra-short stems with proximal load transfer: Clinical and radiographic results at five-year follow-up.

Bone stock preservation is crucial when performing THR in young patients. Following this philosophy, an original ultra-short custom-made implant with extensive proximal load transfer was developed. It presents three very innovative features: absence of the diaphyseal portion of the stem, a well defined lateral flare with load transfer on the lateral column of the femur and a very high femoral neck cut. These innovations resulted in a very conservative implant both of the bone stock and the soft tissues. In this study we reviewed the X-rays of 111 patients with 131 primary total hip replacements performed with this implant. The average pain score using the Harris Hip Score system, at an average of five years after surgery, was 42 of 44 points; 95 per cent (124) of the patients had no or slight pain. We had no cases of thigh pain. None of the patients required a femoral stem revision. Two cases had to be re-operated for polyethylene liner exchange but the femoral implant was stable and left in place. At five years, all implants appeared radiographically stable with well maintained proximal bone stock. It was concluded that the geometry of this implant provides significant initial stability, which seems to be preserved throughout a long follow-up period. This study validates the assumption that torsional loads can be controlled even without the diaphyseal portion of the stem and that neck preservation combined with lateral flare support guarantees a more natural loading of the femur.

Shoulder prosthesis in reconstruction of the scapulohumeral girdle after wide resection to treat malignant neoformation of the proximal humerus.

Progress in preoperative chemotherapy and radiation therapy, both intra- and postoperative, has in time allowed for an increase in indications for shoulder implant surgery in malignant tumors, thus drastically reducing the number of amputations. The use of prostheses, particularly those of the more recent generation, respond to the needs to overcome the limits of loss of movement, as long as good anatomical reconstruction of the soft tissues, the premise for good functional and cosmetic recovery, is also possible. The current tendency is that of using modular shoulder prostheses that provide a wide variety of sizes. This type of prosthesis has surpassed custom made prostheses in terms of simplicity, adaptability and economy. The use of cementation in stabilization of the intramedullary stem has made them more stable even in the long term, allowing for early rehabilitation. The main problem in reconstruction with a prosthesis is the quantity of residual muscular tissue (deltoideus, extrarotators) and the stabilization system of the same to the prosthesis in order to avoid dislocation, which constitutes the main complication. It is the purpose of this study to present the clinical and functional results obtained in 23 implants carried out for primary malignant neoformation of the upper limb. The implants studied were of three types (custom made, modular in Cr-Co-Mb and Ti-Al-Va). The results reported show how a shoulder prosthesis can obtain good functional results, particularly when a part of the activator muscles of the shoulder such as the deltoideus and the extrarotators is preserved. When the contrary is true, the results obtained are modest because the prosthesis acts as a simple spacer.

Epiphyseal chondroblastoma of bone. Long-term effects on skeletal growth and articular function in 15 cases treated surgically.

The authors describe the long-term sequelae of chondroblastoma in 15 patients with open growth plates, whose age at operation ranged from 8 to 15 years. At follow-up, the youngest patient was 21 and the oldest 48 years old. Upper limb length discrepancy ranging from 2 cm to 10 cm was present in the four patients who had a proximal humeral epiphyseal location; in three of them, the range of motion of the shoulder was also limited and X-rays showed marked irregularities of the humeral head. Lower limb length discrepancy ranging from 0.5 cm to 2 cm was found in five of the eight patients in whom the tumor affected lower limb epiphyses. One patient with proximal tibial epiphyseal involvement also had mild genu valgum. Radiographic osteoarthritis was present only in the trapeziometacarpal joint of a patient in whom the first metacarpal bone affected by the tumor was replaced by a free fibular graft. The abnormalities observed did not cause important functional loss in either the everyday or the working activities of any of our patients.

The cementless PCA primary total hip system. Medium-term follow-up of 235 cases.

The Porous Coated total hip Arthroplasty (PCA), used by the authors since August 1984, represents a considerable advancement in the field of prosthetic replacement. Its original design and biological fixation give it long-lasting stability not only in young patients, but also patients with initial osteoporosis. Its use in cases of advanced osteoporosis, however, is more controversial. The 8-year results are quite satisfactory from both a clinical and radiographic standpoint, confirming, as other authors have reported, that the medium and long-term results of cementless total hip replacement tend to stabilize because there is a lack of late reactions, which are more common in cemented implants.

Conversion of the arthrodesed hip to a total hip arthroplasty. Indications and limitations.

Arthrodesis of the hip is thought to achieve satisfactory clinical and functional results in the adult despite the loss of articular mobility involved (Santori et al., 1986; Russel, 1987; Weber, 1987). Over the long term, however, most patients develop secondary degenerative arthritis in the spine, contralateral hip, and knees due to overloading. The deteriorating condition of these joints eventually causes the onset of pain, which often requires further intervention. Surgery on these joints may yield satisfactory short-term results, but these will not last if the arthrodesed hip is not converted to total hip arthroplasty either prior to or at the same time as such operations.

[The prevention and treatment of skeletal deformities in fibrous dysplasia]. / Prevenzione e trattamento delle deformità scheletriche nella displasia fibrosa.

Fibrous dysplasia generally leads to skeletal deformity over time, particularly when the lower extremities are affected. The authors describe their experience in this field, proposing mainly preventive treatment of progressive deformities and pathological fractures. They prefer intramedullary nailing, which by strengthening the affected bone allows free and early mobilization of the limb. Moreover, full weight-bearing prevents the onset of "ex non usu" osteoporosis, which is quite often responsible for pathological fractures.

[Osteosarcoma. A new diagnostic approach in presurgical loco-regional staging]. / Osteosarcomi. Nuovo approccio diagnostico nello staging loco-regionale pre-chirurgico.

The value of Magnetic Resonance (MR) imaging was examined in the anatomical staging of bone osteosarcomas. Eleven patients were studied--8 central and 3 parosteal osteosarcomas. The accuracy of MR imaging was compared to that of plain film, scintigraphy, CT, and angiography. MR imaging was superior to both CT and radionuclide scanning in defining intramedullary extension and in showing skip metastases. Cortical erosion in central osteosarcomas was demonstrated by MR imaging, CT, and plain film; in 1 case of parosteal osteosarcoma MR imaging was superior to CT in showing cortical penetration. In two cases MR imaging did not accurately demonstrate the relationship of the tumor to the major vessels; only angiography showed vascular involvement. MR imaging was useful in delineating extraosseous extension. The importance is stressed of a correct use of MR imaging towards an accurate diagnosis. In fact, intramedullary extension and skip metastases were better demonstrated on T1-weighted images with large fields, while T2-weighted images and small fields were needed for the best overall evaluation of extraosseous involvement. In conclusion, MR imaging should be used for preoperative staging of osteosarcomas in those cases where diagnosis was made on the basis of clinical, radiographic, and bioptic findings.

Nuclear magnetic resonance in the diagnosis of lumbar herniated disc.

The morphological study of lumbar herniated discs, aimed at ascertaining the appropriate type of surgical treatment to be used, is commonly based on the results of CT scan and/or radiculography, which are not without risks and disadvantages. An investigation of the pathological pictures of lumbar disc hernia obtained by N.M.R. and their comparison with those obtained by other methods shows that nuclear magnetic resonance is currently able to provide all the required information. In most patients, and especially young ones, it is possible to directly diagnose disc hernia with N.M.R. Radiculography is a more suitable method only in a small number of cases, namely, elderly patients with multiple discopathies which have been radiographically ascertained, and with atypical symptomatology.

[Chondrosarcoma of the bone. Differential pre- and postoperative diagnosis using magnetic resonance]. / Condrosarcomi dello scheletro. Diagnostica differenziale pre- e post-operatoria con Risonanza Magnetica.

Twelve patients were studied by means of Magnetic Resonance Imaging (MRI) in order to demonstrate either loco-regional recurrence of central chondrosarcomas or degenerative evolutions of exostoses. MRI findings were compared with plain film, scintigraphy, and Computed Tomography. MRI showed loco-regional recurrences by demonstrating their site, extent, and relationship with adjacent structures. In showing the degenerative evolution of exostoses MRI--confirmed at surgery--was superior to plain film in 3 cases out of 7, and to Computed Tomography in 2 cases. The authors discuss MRI findings: chondrosarcomas have low-intensity signal in T1-weighted sequences and high-intensity signal in T2-weighted. Thanks to its high contrast resolution MRI always allowed the detection of the chondrosarcoma. Nevertheless, MRI did not allow the tumor grading--which is due either to a difficult evaluation of the morphology of neoplastic calcifications, or to non-specific-intensity signal.

Segmental amputation with re-implantation in the treatment of malignant bone tumours of the limbs.

Stage 2 B malignant skeletal tumours are currently treated by amputation or disarticulation of the limb. The present paper describes a surgical technique for complete removal of the neoplasm and surrounding soft tissues by resection of a cylinder of the limb complete with skin. The resection of bone and adjacent soft tissues is extended sufficiently proximal and distal to the neoplasm to ensure complete removal of neoplastic tissue. The authors describe two cases; an osteosarcoma of the distal third of the femur and a malignant fibrous histiocytoma of the lower radius. After removing the affected cylinder of the limb, osteosynthesis is performed by one of a variety of methods. The main vessels and nerves are dealt with according to the findings revealed by pre-operative investigations or per-operative findings. If they have to be sacrificed, end to end suture is performed, but if main nerves can safely be spared (as in Case 1) it greatly enhances the functional prognosis. The value of this operation is that it is as radical as amputation while the aesthetic and functional results are equivalent to those of a resection-arthrodesis. The operation has therefore been designated segmental amputation.

Regional migratory osteoporosis.

The authors describe the features of regional migratory osteoporosis, a rare form of idiopathic algodystrophy, with special reference to the fact that 8 of the 13 patients in this series belonged to two families. The clinical, radiological and histological manifestations are discussed and the treatment described. The latter involves a combination of chemotherapy, orthopaedic measures and physiotherapy. The fact that so many different clinical manifestations of the same pathological entity occurred in the same family, and in particular the high incidence of a familial factor in the case material reported in the literature, appear to indicate the existence of a predisposition to local disturbances of bone turnover in the peri-articular bone tissue. A precipitating factor, which is often clearly evident, then causes the disease to become clinically manifest.