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

O R A L P R E S E N TAT I O N S E F A C E

SESSION LU10 NEW

FRONTIERS IN VERTEBRAL SURGERY

INTERSPINOUS PROCESS TECHNOLOGY: WHY, WHEN, WHERE V. Rosso [1], C. Bignardi [2], M. Girardo [1], F. Trucchi [1], G. Collo [1], F. Castoldi [1] [1]Divisione Universitaria di Ortopedia e Traumatologia, Ospedale Mauriziano, Turin, Italy; [2]Dipartimento di Biomeccanica del Politecnico, Turin, Italy Objective: The interspinous devices are able to re-tighten the posterior joints and ligaments and the posterior fibres of annulus and to reduce the lumbar instability and intra-discal pressure. The aim of our retrospective study is to evaluate the mechanisms of action and the effectiveness of posterior dynamic stabilization device in the management of painful lumbar spinal disorders. Materials and Methods: From September 2003 to May 2006 we performed 72 implants of interspinous device in 53 patients that had 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 following selection criteria: - no surgical procedures added (herniectomy, laminectomy, fusion, etc) - more than 18 months follow-up. The diagnostic instruments used are standard lumbar spine X-rays and magnetic resonance images. In collaboration with bioengineers we carried out a finite element mathematic model of the L4-L5 spinal motion segment which is aimed at simulating the healthy and the treated L4-L5 lumbar segment with interspinous device, subjected to compressive force and flexion-extension, deformation of lumbar disc during simulation of motion. Results: At follow-up low back pain is improved in 84% of the patients; meanly improved in 12%, not improved in 4%. The computational finite element model showed that the device is able to achieve its main design purpose: to diminish the forces acting on the apophyseal joints and reduce stress on the adjacent disc. Conclusions: From our experience, the interspinous device is a safe, mini-invasive procedure with good clinical outcome, especially in young patients, diminishing surgical time and respecting anatomy.

INFLUENCE OF LOCAL FACTORS ON THE EFFICACY OF SKELETAL STEM CELLS IN EXPERIMENTAL SPINAL FUSION G. Giannicola [1], G. Cinotti [1], M. Riminucci [2], B. Sacchetti [3], A. 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 Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, Italy; [2]Dipartimento di Medicina Sperimentale, Università degli Studi dell’Aquila, Itay; [3]Dipartimento di Medicina Sperimentale e Patologia, Università degli Studi di Roma “La Sapienza”, Policlinico Umberto I; Rome, Italy; [4]Clinica Veterinaria, Rieti, Italy; [5]Dipartimento Laboratorio Modelli Animali, Istituto Regina Elena, Rome, Italy A currently used animal model for spinal fusion was adopted to investigate the new bone formation induced by skeletal stem cells loaded into an osteoconductive carrier. Materials and Methods: Skeletal stem cells (SSC) harvested from

rabbit iliac crest were cultured for 3 weeks and then loaded into coralline HA-coated granules. The graft material was then implanted on the bed graft prepared at surgery on the right side while a decortication of the transverse processes (sham) was performed on the left side of the lumbar spine (15 rabbits). Further 15 rabbits underwent spinal fusion using coralline HA-coated alone as graft material. Rabbits were sacrificed 6 months after surgery and the lumbar spine submitted to standard and high resolution (FAXITRON) radiographs and histologic analysis. Results: Radiographic results showed spinal fusion in 90% of the spine treated with SSC and in none of those submitted to sham operation. Histologic analysis showed new bone formation adjacent to the transverse processes while little or no bone formation was found between the transverse processes in the middle of the graft. In the latter zone, a tight fibrous tissue and scant blood supply was found. Conclusions: Our study shows that a graft material constituted by SSC and a coralline HA-coated carrier, which was found to promote new bone formation in previous animal studies, does not promote an adequate new bone formation to obtain a continuous bony bridge in the rabbit posterolateral spinal fusion model. This finding may possibly be due to an insufficient vascularization of the central zone of the graft.

SESSION ME04 NEW

FRONTIERS IN VERTEBRAL SURGERY

BUDGETING AND REPORTING AS INSTRUMENTS TO PREDICT HEALTH RESOURCES ALLOCATION S. D’Amico, L. Del Sasso, E. Mazza Azienda Ospedaliera S. Anna, Como, Italy Objective: Managing an organization to follow its istitutional purpose means to develop and carry out three different activities. These complementary activities are: strategic planning, management control and operative control. Budgeting is an organizing process useful to define operative goals. These goals have to be pursued allocating resources and finding decisional autonomies (departmental system) to get operative decisions evaluating economical, financial end technical actability of the chosen action programs. Thanks to communication of important information (reporting) on decisional activities of the management it is possible to foresee the chances of health policies, which has been expressed by the budget. Materials and Methods: We report the budgeting and reporting application processes that have been used for the department and operative unit contract. We analyse the Surgery Department‘s budget of the Azienda Ospedaliera S.Anna in Como. We analyse the relation between the goals of the Operative Units of the department and the goals chosen with the territorial ASL happened on January 2006 (DRG-L.E.A.control, DRG-LEA from ordinary admission to Dayhospital and ambulatory’s admission, reduction of waiting time for admission, medical DRG’s reduction). Discussion: The reporting analytical process used to find out indicators (estimated activity delta as days/DRG correlated) allows us to: - single out operative units able to allocate resources. Looking for operative units without management process political analysis. - Highlight critical relations between operative units and services. - Estimate the probability of getting budget goal. - Propose and suggest for organization’s political process. Conclusions: Budgeting and Reporting can develop programming strategies useful to reach the goals of the management policy.

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SESSION O01 KYPHOPLASTY VESSELPLASTY IN THE TREATMENT OF VCFS. PRELIMINARY REPORT V.F. Paliotta, B Magliozzi, L. Alessandro ASL Rmc, Rome, Italy Objective: Vesselplasty is a new technique in the treatment of Vertebral 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 Vertebral Body Expander and also serving as the Bone Void Material Container. It is introduced into the vertebra in a reduced configuration and once positioned it is expanded raising the endplates and creating a void along with the introduced of bone void filler material. And then, a few bone void filler material penetrates through VesselX®, interdigitating the vertebral body. This new technology, Vesselplasty, thoroughly solves the fatal problem of leakage of cement out of the vertebral body. Results: Authors discuss the first 7 patients treated with Vesselplasty at the S. Eugenio Hospital in Roma. 5 osteoporotic VFCs and 2 myeloma VCFs; 6 females and 1 male. Mean age was 71 years and mean follow-up 6 months. No major complication was observed up to now. Conclusions: According to the preliminary results Vesselplasty can be considered a procedure of choice in the treatment of VCFs. The technique is not more difficult than vertebroplasty or kyphoplasty while risks are much less. A longer follow-up is needed in order to reach a more proper evaluation.

KYPHOPLASTY FOR TREATMENT OF OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURES: CLINICAL AND RADIOLOGICAL RESULTS G. Gulino, L. Spatafora Azienda U.S.L.3, Catania, Italy Objective: The primary purpose of this study is to evaluate the clinical and radiographic outcomes, as well as the complications, of kyphoplasty in the treatment of osteoporotic vertebral compression fractures. Main goal of conventional treatment in fractures due to osteoporosis is to decrease pain and preserve bone density; nonetheless, this treatment is not able to stop evolution of the segmental deformity. Kyphoplasty is a recent surgical treatment aimed to decrease pain and restore the vertebral body height. When performed in fresh fractures, Kyphoplasty allows in most cases the vertebral body shape restoration. Materials and Methods: Twenty-eight kyphoplasty procedures were performed in 24 patients (average age 62 years, range 55-84 years) affected by symptomatic osteoporotic vertebral fractures. Mean fracture age was twenty-two days (range 6-83 days). Six thoracic (T7, T11, T12) and twenty-two lumbar vertebrae (L1, L2, L3, L4) were involved. All fractures were analyzed for improvement in reduction of pain (VAS Scale) and in sagittal alignment (kyphosis, anterior and midline vertebral body heights); procedures related complications were registered. Results: Mean VAS score improved from 8.2 points before surgery to 1.4 points after surgery. Mean local kyphosis angles improve from 17.2° (range 8°-19°) before surgery to 4.4° (range 2°-9°) after surgery. Mean anterior vertebral body height improved from 22.1 mm (range 15-25 mm) preoperatively to 27.3 mm (range 25-29 mm) postoperatively. Mean midline vertebral body height improved from

22,4 mm (range 15-24 mm) to 26 mm (range 22-28 mm). There were 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 another case a leakage occurred through the anterior vertebral wall: both patients remained asymptomatic. Conclusions: Kyphoplasty is an effective minimally invasive procedure in the treatment of osteoporotic vertebral compression fractures, leading to a reduction in local pain and an improvement of the vertebral shape, as well as a restoration of vertebral body height; moreover, Kyphoplasty allows an early recovery, above all in the elderly patients with improved quality of life.

TRANSORAL KYPHOPLASTY FOR C2 TUMORAL LOCALIZATIONS D.A. Fabris Monterumici [1], S. Narne [2], U. Nena [1], R. Sinigaglia [1] [1]Unità Operativa Complessa di Chirurgia del Rachide “Sandro Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, Padua, Italy; [2]Unità Operativa Autonoma di Chirurgia Endoscopica delle Vie Aeree, Azienda Ospedaliera, Università degli Studi di Padova, Padua, Italy Objective: Our purpose is to describe a new surgical technique, the transoral kyphoplasty, that we performed in three cases of C2 tumoral localizations. Materials and Methods: From February 2004 to January 2006 three cases of C2 tumoral localizations did not show healing after 6 months of conservative treatments. To reduce pain and avoid both C2 collapse and prolonged immobilization transoral kyphoplasties were performed. 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 unrelated causes. The second and the third are alive and, follow ups of 2 years and 3 months respectively, reveal good and pain-free cervical range of motion, with no findings regarding pathologic mobility/instability on X-ray. Discussion: The management of C2 tumoral body lesions is still controversial. The literature recommends prolonged immobilization, internal fixation (anterior or posterior) or transoral vertebroplasty [Tong 2000]. In our cases, after conservative treatment failure, we performed the transoral kyphoplasty to avoid major surgical procedures. This technique could be considered an improvement of the transoral vertebroplasty. While maintaining the normal cervical spine anatomy, and avoiding arthrodesis or fixation that reduce the cervical spine range of motion. it also reduces the leakage of PMMA cement outside the porothic vertebral body [Nussbaum 2004]. Conclusions: Transoral kyphoplasty proved to be safe, quick and effective in reducing pain and avoiding vertebral collapse in patients with C2 tumoral localizations. Transoral approach contraindications are hemorrhagic diathesis, infections, lesions with epidural extension, oropharyngeal inflammation, and patients of younger age [Gangi 2003].

PERCUTANEOUS KYPHOPLASTY IN THE TREATMENT OF VERTEBRAL ALGODYSTROPHY: A PROSPECTIVE STUDY A. Ramieri [1], M. Domenicucci [2], P. Missori [2], R. Delfini [2], G. Costanzo [1] [1]Ortopedia, Università “La Sapienza”, Polo Pontino ICOT di Latina e Fondazione Don Gnocchi; Rome, Italy; [2]Neurochirurgia, Università “La Sapienza”, Rome, Italy Introduction: Currently, percutaneous kyphoplasty is commonly used for the treatment of vertebral osteoporotic compression frac-

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tures (Phillips et al., 2003). Even without fractures, an osteoporotic vertebral body may develop some structural modifications with dystrophic aspects, defined by the literature as “intravertebral clefts” and “intravertebral vacuum” (Missori et al, 2005). Such phenomena can be painful and the MRI is the imaging technique of choice for their evaluation. Materials and Methods: A prospective consecutive series of 15 elderly patients with pain in the thoraco-lumbar or lumbar spine were evaluated. MRI findings showed modifications of the vertebral body consistent with algodystrophy. Lesions were treated by means of percutaneous kyphoplasty with unilateral transpepedicular approach. The outcomes of such procedure were evaluated with a visual analogue scale for pain (Chen et al, 2005). Results and Conclusions: Percutaneous kyphoplasty has not determined any complications either early or late. Outcomes have showed to be good or excellent, except for a case in which the quantity of injected PMMA has been considered to be insufficient. Augmentation of the vertebral body makes pain disappear, in spite of the biomechanical alterations due to algodystrophic phenomena. Inflating the balloon creates a positive pressure room inside the vertebral body, making it possible to fill it with PMMA without the risk of cement leakage.

SESSION O02 RACHIS I LUMBAR DYNAMIC STABILIZATION SYSTEMS (DYNESIS AND DIAM). FOLLOW-UP AT 2 YEARS A. Sgarbossa [1], M. Balsano [2], P. Bartolozzi [3] Ortopedica e Traumatologica, Verona, Italy; [2]ULSS 4 Alto Vicentino UO Ortopedia e Traumatologia, Thiene, Italy;[3]Clinica Ortopedica e Traumatologica, Verona, Italy

[1]Clinica

Study Design: Radiographic and clinical study at 2 year follow-up in patients treated with dynamic stabilization by means of interspinous process distraction system (DIAM) and dynamic pedicle screw system (Dynesis). Background: The surgical treatment of lumbar pain in degenerative pathology through rigid stabilization could be complicated with transition syndrome at long term follow-up. The dynamic system restricts the segmental movement and avoids progressive degeneration of lumbar spine. Methods: We selected 35 patients (19 female and 16 male, average age 44.5 years) with chronic lumbar pain, initial disc degeneration disc signal (MODIC I) and degeneration of articular joint. We treated 21 patients with DIAM and 14 patients with DYNESYS through randomized technique. All patients were evaluated with average follow-up 24.2 months through x-ray of lumbar spine and subjective evaluation with VAS and OSWESTRY scores. Results: Clinical symptoms decreased, Oswertry and VAS scores are significantly improved. The pre operative Vas score was 8.3 (average), 2.2 post operative (average). The pre operative Oswertry score was 54.3% (average), 8.6 % post operative (average), with an increase of 75%. No complications during surgery are reported. In one case, we had a superficial infection resolved with antibiotic therapy. One patient treated with Dynesis, showed increased pain symptoms. None of the patients showed any radiographic progression of articular degeneration. There were no observed complications associated with the implants. No significant difference results between the two groups are reported. Conclusions: The elastic stabilization of the lumbar spine represents a possible alternative of rigid stabilization. Both systems significantly

decreased the symptoms of treated patients. The 2 year follow-up showed good clinical and radiographic results. A long term follow-up will be necessary to validate the results and their possible limits.

THE VERTEBRO-DISCAL SUBSTITUTIVE TREATMENTS: THE MEDICO-LEGAL OPINION OF THE ORTHOPEDIC G. Martini [1], L. Perugia [1], D. Perugia [2], L. Ottaviano [2], D. Palmieri [2] [1]Commissione di Medicina Legale SIOT; Rome, Italy; [2]Gruppo di Studio della Commissione di Medicina Legale SIOT, Rome, Italy Objective: The current surgery for the locomotor apparatus is developing towards the substitutive treatments of segments or systems in which the conservative restoration does not seem suitable, due to irreversibility of the impairment or for the involvement of other structures. It is true that skill, precaution and diligence should always warn the doctor, to whom the patient’s health is remitted; however, it is also true that innovative choices often involve not well known ways in which the acquired skillness is not enough, precaution is not entirely motivated and diligence, only generic and not specific to treat problems of unknown impact. Regarding innovative choices, the Magistracy expresses more openness towards a rigorous verification rather than trusting the one who following a new way, has shown the willingness to study an itinerary in sight of notable clinical 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 biological reactions. Methods: We think that it is favourable to analyze possible causes of responsibility in the vertebro-discal substitutive treatments. Conclusions: In clinical or medico-legal field it is always difficult, when not conceited, to draw off conclusions which are demonstrated not to be from the continuous variability of the experience that only with time are transformed into scientific and normative certainties. In order to become cognitive, it is unavoidable to ask the Magistracy to complete such a path with careful methodological study, avoiding a mere judgment limited to the arrival point. The prevailing causes of faulting behaviour in connection with the risks and to the complications of such surgery get therefore marked.

PSEUDARTHROSIS IN C2 FRACTURES: SURGICAL TREATMENT F. Ennas [1], M. Ganau [2], A. Maleci [3] [1]Clinica Ortopedica, Universita’ di Cagliari, Cagliari, Italy; [2]Cattedra di Neurochirurgia - Università di Cagliari, Cagliari; [3]Cattedra di Neurochirurgia - Università di Cagliari, Cagliari, Italy C2 fractures are currently the most common among the overall traumatic lesions of the cranio-vertebral junction. Some of these fractures are undetected, therefore pseudarthrosis is a frequent evolution. Pseudarthrosis related to C2 fractures is generally responsible for intense pain, and often leads to invalidating consequences due to progressive compression of neurovascular structures.Between 2004 and 2005 a total of 32 cases of cranio-vertebral instability were admitted to our department: among these, 14 cases were a direct consequence of previous C2 fractures (class II by Anderson classification) evolved in pseudarthrosis. Every patient was studied by plain and dynamic X rays, spiral CT and MRI of cervical spine: instability was always detected, in association with various degrees of medulla compression. Those 14 cases underwent surgery, three different approaches have been performed: anterior screw fixation (5); transarticular screw fixation, according to Magerl technique (7), or posterior fixation, by the technique described by Harms (2). Immediate bone stabilization was always achieved, as radiographically verified; no complications were observed, and pain immediately resolved. Postoperative radiographic controls

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demonstrated optimal screw position in 11 cases, while in 3 cases (all treated by posterior approach) at least one screw was displaced, but without further complications nor any need for reoperation. At 6 months, bone healing has been reached in every case but one, initially treated by anterior approach, who required a second surgical treatment by posterior approach. According to our experience we advocate surgery as an effective treatment for instability due pseudarthorosis related to previous C2 fractures. Anterior approach, even if easier, and profitable in terms of preservation of cervical spine motility, should be considered less effective, and susceptible to long term complications. Posterior approach seems to be the one of choice because of the possibility to perform a C1C2 arthrodesis which allows definitive and durable results.

C1-C2 AND C1-C3 POSTERIOR FIXATION BY TRANSPEDICULAR AND LATERAL MASS SCREWS FOR TREATMENT OF ODONTOID FRACTURES M. Dobran, M. Iacoangeli, A. Di Rienzo, F. Formica, M. Scerrati Clinica di Neurochirurgia, Università Politecnica delle Marche, Ancona, Italy Background: Surgical treatment of odontoid fractures is still a matter of debate, with respect to the appropriate technique, timing and fixation system. We report our experience with the use of posterior C1-C2 and C1-C3 screwing fixation. Materials and Methods: From September 2004 to January 2006, 15 patients were operated on for odontoid fractures type II-III at our Institution. Sex distribution included 11 males and 4 females (age range 23-81 yrs). In only one patient spinal cord damage (Frankel A) was present. Surgical technique consisted of C1 lateral mass and C2 pedicle screws positioning. In case of damaged C2 pedicle, fixation was extended to C3 lateral mass. All patients underwent standard xray examination one month after surgery and CT scan/dynamic x-ray examination at 3 and 6 months. Results: There was no mortality and no major morbidity. Surgical time was always less than 2 hours, with no significant bleeding. Two patients underwent removal of the fixation system with recovery of full range of cervical motion. No case of non-union was observed so far. Discussion: The above described technique is suitable for all type of odontoid fractures, including the OBAV ones. Operative times are comparable to those required by the anterior approaches. The range of cervical motion is minimally reduced. Conclusions: In our opinion, the C1-C2/C1-C3 posterior fixation technique represents a valid alternative to the more anatomically demanding anterior approaches, and to the transarticular C1-C2 fixation, biochemanically less rigid and requiring appropriate working angles.

EFFECT OF CAPACITIVELY COUPLED ELECTRIC FIELD ON PAIN RELEASE IN PATIENTS WITH OSTEOPOROTIC VERTEBRAL FRACTURES M. Rossini [1], A. Zambito [1], G. James [1], D. Bianchini [1], S. Girardello [1], F. de Terlizzi [2], D. Gatti [1], O. Viapiana [1], S. Adami [1] [1]Reumatologia Azienda Ospedaliera, ULSS 20, Università di Verona, Verona, Italy; [2]IGEA S.R.L., Carpi, Italy The pain in patients with multiple vertebral fractures represents a frequent issue in the elderly population. In the present study we have evaluated the effects of capacitively coupled electric field (Osteospine, IGEA, Italy) on chronic pain in patients with multiple vertebral fractures. Thirty-one females older than 60 years, with multiple vertebral fractures and chronic lumbar pain, on treatment with analgesic drugs since at least 6 months have been recruited. The patients were randomised in 2 groups: group A (n°=16) the patients were treated with capacitively technique with an electric signal already used for fracture healing; it is an electrical signal based on sinusoidal waves of 60kHz frequency and automatically settled amplitude; group B (n°=15) the patients were treated with same technique

but amplitude of electric signal reduced to 0,5%. All subjects were proposed to follow a treatment of 10 hours per day for 60 days; total hours of therapy were memorized in the devices. Pain was evaluated by VAS and pain specific QUALEFFO questionnaire. Twenty-seven patients concluded the study: 13 in group A and 14 in group B. In both groups we observed pain reduction, already at first visit. By the way in group A we observed a significant negative correlation between hours of treatment and pain, evaluated by VAS (r=-0.65 p<0.05), and by specific QUALEFFO (r= -0.71 p<0.05). In group B we didn’t observe any association between hours of treatment and VAS or QUALEFFO (r = 0.12 e r = -0.34 vs VAS and QUALEFFO respectively, 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 (Osteospine) may have positive effects on chronic pain. A significant dose-response effect has only been seen in the group whit Osteospine signal and a tendency toward a reduction of use of analgesic drugs in these patients has been observed. The study is still in progress and an increase in the number of patients is foreseen in the next months.

THE DISCOGENIC LUMBAR PAIN: CLINICAL ASSESSMENT AND SURGICAL OPPORTUNITIES C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy The degenerative disc disease is the consequence of the progressive aging with dehydration of the nuclear component. The physiopathologic mechanism, that seems to be imputable to the incapability of the disk to repair the consequential injuries caused by continous solicitations, recognizes the “primum movens” in a decay of the cellular nutrition with consequent aging of the same and accumulation of degenerated molecules of matrix which achieves dehydration with relative rigidity and loss of elasticity. The surgical treatment essentially finds two kind of surgical procedures: vertebral arthrodesis and “no fusion” approaches. Vertebral arthrodesis consists of fusion two or more adjacent vertebral units to form a single unit of motion with the employment of bone graft and fixation devices. “No fusion” treatments use different systems that allow mantaining the movement of the unity of motion. The devices for intervertebral assisted motion allow a limited range of movement setting the facet joints in distraction; instead the peduncolar dynamic systems reach the same aim positioning peduncolar screws and bars that reduce the overload of the adjacent segments. At last, the discal prosthesis (nucleus /whole disc) can be used when the patient expectations depend on age, sex and grade of disc degeneration. 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 used when the facet joints are still not involved by degenerative process.

SESSION O03 RACHIS II LUMBAR SYNOVIAL CYSTS: MANAGEMENT AND FOLLOW UP OF 12 CASES F. Ennas [1], M. Ganau [2], A. Maleci [2] [1]Clinica Ortopedica, Università di Cagliari, Italy; Neurochirurgia, Università di Cagliari, Italy

[2]Cattedra

di

Synovial cysts represent a degenerative process affecting the articular facet due to progressive synovial hypertrophy and eventual herniation. The incidence in the spine is extremely low (0.02-0.8%): cysts generally arise in the lumbar metameres, especially at L4-L5, L5-S1, ed L3-

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L4. They are endowed with a synovial capsule, filled up with xantocromic liquid, rich in water and hyaluronic acid, and characterized by a diameter variable between few millimetres and 2-3 cm. Synovial cysts may protrude into the spinal canal (epidural) being anterior or posterior, or outside to the paraspinal muscles (extracanalar); moreover they can be single, bilateral or multiple; contiguous or not. Lumbar synovial cysts are occasionally detected during MRI or CT scans carried out on elderly patients affected by degenerative spondiloarthrosis, still without being responsible for their symptomatology. Only in relatively few cases synovial cysts grow up enough to compress a nerve root, causing the axial or radicular symptoms experienced by patients. From 2000 to today, 12 cases of lumbar synovial cysts (7 women, 5 men; age between 58 and 76 years), complaining about sciatica, nonresponding to analgesic or rest, have been admitted to the Chair of Neurosurgery at the University of Cagliari. At clinical examination 2 patients presented a remarkable deficit of foot dorsiflexion, and 1 complained about cauda equina syndrome. Cysts localization was L4-L5 (9), L3-L4 (2) e L5-S1 (1); during surgery we found abundant calcifications on their capsules, and in 2 cases cysts were multiple and contiguous. Every patient underwent surgery cyst excision, always performed paying particular attention to carefully spare the facet. No perioperative complications have occurred, and every patient immediately recovered, experiencing complete regression of pain. We have never noticed a relapse of symptomatology nor postoperative spine instability. Therefore we advocate surgical treatment as the management of choice for symptomatic lumbar synovial cysts.

Introduction: Purpose of this study is to evaluate retrospectively 153 cases of spinal infections, unrelated to previous spinal surgical treatment. We included patients with drug addiction. Objective of this study is to analyze the results of treatment using a diagnostic and therapeutic algorithm. This procedure may allow a systematic and comprehensive approach to the diagnosis and management of vertebral osteomyelitis. For instance, despite advances in imaging, this pathology is easily missed and treatment is often delayed. Materials and Methods: We reviewed 112 patients aged 15-83 (average 55y) treated between January 1997 and March 2005. All patients received plain radiographs, gadolinium enhanced magnetic resonance imaging, Ga-67 and Tc-99 scintigraphy. A total of 53 patients underwent CT- guided fine-needle aspiration biopsy: the coltures of spinal specimen were positive in 57% of cases. Results: Mycobacterium Tubercolosis was the main organism followed by Staphylococcus Aureus and Staphylococcus Epidermidis. All patients received intravenous antibiotics. Neurologic impairment was present in 36 patients who underwent surgery. All patients with paresis recovered completely after surgical decompression (100%). Patients with non-surgical spondylodiscitis were treated with bed rest and bracing. Conclusions: The outcome of patients with vertebral osteomyelitis in general is favourable when appropriate treatment is picked even if vertebral osteomyelitis is a rare condition and therefore often initially overlooked. Delay in diagnosis may results in spine impairment, longer hospitalisation time and higher cost. We suggest diagnostic 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. Bartolozzi [2] [1]Azienda ULSS 21, UOC Ortopedia e Traumatologia, Ospedale Mater Salutis, Legnago; [2]Clinica Ortopedica e Traumatologica, Università degli Studi di Verona, Verona, Italy Background: In patients affected by lumbar spinal stenosis surgery is indicated after conservative treatment failure. On the contrary indication for fusion is not well estabilished. Methods: From January 1992 to June 2005 174 patients (average age 68) (73 F, 101 M) with lumbar degenerative stenosis surgically treated were studied. All patients were decompressed using RoyCamille technique, whereas 57 patients underwent decompression and posterior stabilization. Average follow up was 5.1 years (range 10 months - 13.5 years). Results: The outcomes, evaluated according to Lassale evaluation scale, were satisfactory in 74.3%, with an average Oswestry Disability Index (ODI) of 15.02 in decompressed group while improved to 79.8% with an average ODI of 14.1 in the stabilized–decompressed group. Discussion: Patients treated with decompression–stabilization procedure had better results related to the decompressed group, but we have to consider the shorter follow-up of the stabilized group and potential long term complications of fusion (i.e.: adjacent segment degeneration). Moreover, this additional surgery adds significant potential morbidity and device-related problems (breakage, neurologic damage etc.). Conclusions: Choice of treatment has to be well evaluated. The instrumented stabilization should be reserved to well selected patients with degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis or evident segmental instability.

VERTEBRAL OSTEOMYELITIS: DIAGNOSTIC AND THERAPEUTIC ALGORITHM A. Gasbarrini, S. Bandiera, L. Mirabile, M. Cappuccio, S. Terzi, G. Barbanti Bròdano, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy

BRYAN CERVICAL DISC PROSTHESYS: PECULIAR FEATURES M. Brunori [1], L. Innocenzi [2], A.M. Vitale [1] di Neurochirurgia, Dipartimento di Emergenza, Aurelia Hospital,Rome, Italy; [2]Radiologia, Clinica Villa Sandra, Rome, Italy R. Greco

[1],

[1]Servizio

The Bryan cervical disc prosthesys is characterised by peculiar technical features allowing high functional integration in clinical application. The first clinical trial with Bryan prosthesis started in 2000 by Goffin, Logroscino, et al. We implanted a total of 36 devices in 35 patients throughout a 4 years period, starting on February 2002. Pre and post operative evaluation was based on Morphodynamic XRays, MRI, CT, and Dynamic Fluoroscopy. Clinical outcome was favourable in all cases. The implanted cervical column always showed a high grade of conformity with both segmental and global dynamic function. Correction of alignment and postural defects was also obtained. No structural problems or pull out were seen. The implantation kinetic function throughout time was demostrated in almost all cases. Using a suitable functional cervical disc prosthesis instaed of an interbody fusion can avoid a junctional satellite stress and a consequent secondary discopathy. The byomechanical and structural design of Bryan prosthesys has shown its suitability to define a real artificial cervical disc. The main peculiar features are: - A plyurethane nuclear structure (deformability) symmetrically organised on an equatorial line and immersed in a fluid room closed by elastic mode. - The coincidence between the prosthesys instantaneous rotation centers and the physyological ones. - The shock absorbing features. We are convinced that these three factors are the basis of the obtained results concerning the maintainence of appropriate byomecanics in the implanted cervical column.

WHAT HAPPENS TO DISCS BELOW THE ARTHRODESIS ZONE AFTER SURGERY FOR SCOLIOSIS A. Di Felice [2], M. Bergoin [1] di Chirurgia Infantile, CHU Nord, Marseille, France; [2]Casa di Cura Spatocco, Chieti, Italy J. Gennari [1]Servizio

[1],

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There are two types of degeneration below the arthrodesis area after surgery for scoliosis. First, the degeneration occurs on the frontal plane and is due to errors in strategy. Later on, the degeneration occurs on the sagittal plane because of a hyper-lordosis caused by stabilisation on L4 or L5. The KING or LENKE classifications are either incomplete or over complicated and do not take into account the position of the pelvis. We suggest a different classification of the curves. We point out the strategic defects of the instrumentation and the consequences they cause in the long term. The assessment of the stable vertebra is essential in the treatment of the thoracic curve. For thoracic-lumbar curves we have already demonstrated that the frontal approach is preferable since it respects the posterior musculature and limits the arthrodesis. In predominant thoracic double curves, in distal stabilization we have to distinguish the excluded pelvis that stops at L3 from the included pelvis that goes up to L4. In the predominant lumbars the intervention strategy is identical to that of the isolated lumbars. The same strategy used for predominant thoracic curves has to be used for double thoracic curves. In disc degenerations without initial strategic errors, the disc prosthesis could be a solution for the future, especially when there are no more than two degenerated discs below the arthrodesis. We hope to obtain agreement for a simple classification.

SESSION O04 NEW

METHODOLOGIES IN VERTEBRAL SURGERY

MINI-INVASIVE SURGERY FOR THE TREATMENT OF THE DISCOVERTEBRAL LUMBAR INSTABILITY M. Abbate, F. Lagalla, A. Bistolfi, M. Damilano, M. Dolfin, E. Raspino, E. Novarese II Clinica Ortopedica, Università di Torino, Italy Introduction: A new mini-invasive technique is described and compared to the traditional surgery of intersomatic arthrodesis (PLIF) for the treatment of the vertebral lumbar disk instability. A less invasive approach can offer advantages in blood loss, tissue damaging, pain, time of surgery, hospitalization. Economic aspects concerning the effectiveness of this technique have been analysed. Materials and Methods: 6 patients affected by lumbar partitioned instability have been treated by this mini-invasive technique. Before surgery, all patients had a six months period of conservative therapy and traditional pharmacological treatment, which did not yield adequate healing of the lumbar and sciatica symptoms. The mini-invasive surgical technique has been realized by means of Patchfinder (Abbott) instruments for the synthesis tools (piped polyaxial peduncled screws) and using Optimesh instruments and bone from a tissues bank in order to achieve inter-somatic arthrodesis. Results: In all patients the osseous fusion wasachieved. The average surgical time was similar to that of the traditional technique, while the hospital-stay was shorter. The social-working retrieval was facilitated. The surgical bleeding has been clearly reduced, thus avoiding blood transfusions. The post-operation pain has also been significantly reduced. The use of morcelized bone did not cause pain at the donor site. Discussion: This treatment allows a good recovery from the pain, with satisfaction of the patients and quick return to their working activities. The technique is quite safe and easy. Nevertheless, the analysis of the economic costs raises relevant doubts. The treatment is expensive and could be difficultly accepted in a public health framework such as the Italian one.

MINIMALLY INVASIVE PERCUTANEOUS OSTEOSYNTHESIS IN THE TREATMENT OF ADULT AND OLD PATIENT SPINE FRACTURES G. Barbanti Brodano, A. Gasbarrini, F. De Iure, L. Mirabile, L. Boriani, M. Palmisani, S. Bandiera, G.B. Scimeca, S. Boriani UO Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi, Bologna, Italy Old patients with both traumatic and osteoporotic vertebral fractures are often compelled to lie in bed for a long time. This condition is often associated with a wide range of serious complications, better known as “bed rest syndrome”. In order to face this problem and let patients walk as soon as possible after trauma, clinicians are looking for less invasive and debilitating spine osteosinthesis surgical procedures. Vertebroplasty and kiphoplasty have partially solved the problem related to Magerl A1 fractures, while the debate is still open about A2 and less serious A3 fractures treatment. Is it better to perform a classical vertebral osteosinthesis or decide for a prolonged conservative treatment, either with orthopaedic corset or a cast? A possible answer to this question is a third option, the mini-invasive technique. It consists of pedicles percuteous fixation associated with vertebral body reconstruction through verteboplasty or kiphoplasty. 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 males. Mean age was 57.2 years. Procedure has been always performed under radiological control. Patients have been assessed with self evaluating tests. They showed an improved clinical setting in the 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 Activities 44->59; 5. Sensitivities 29->51; 6. functional limitations 20->66 [p=0.0008]; 7. physical health 33->67 [p=0.0008]; 8. vitality 41->64). During a mean follow up of 5.8 months, results have remained the same and no complications happened. These preliminary data show how a mininvasive approach in A2-A3 vertebral fractures osteosinthesis could have a possible good effect in the old patient care.

COMPARISON BETWEEN VIDEO-ENDOSCOPIC AND MICROSCOPIC TREATMENT OF DISC HERNIATION A. Gasbarrini [1], A. Barbanera [2], L. Mirabile [1], F. Ascanio [2], M. Cappuccio [1], L. Boriani [1], A. Andreoli [2], M. Palmisani [1], S. Boriani [1] [1] U.O. Ortopedia e Traumatologia, Chirurgia Del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy; [2]Dipartimento di Neurochirurgia, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy Two departments at Bologna Ospedale Maggiore are involved in surgical treatment of disc herniation. They are the Orthopaedic, Traumatology and Spine Surgery Department and the Neurosurgery Department. These two groups of surgeons use two different techniques in order to treat the disease. The first group uses video-endoscopic instrumentation, the second one uses optic microscopy. Two groups of patients have been compared. Patients belonging to each group have been treated by the same surgeon (an orthopaedist for the first group and a neurosurgeon for the second one) and the same technique (respectively videodiscoscopy and microsurgical discectomy) was used. Results have been analyzed. Criteria for patients inclusion in the study were: -lumbar disc herniation localized between L2 and S1; -patient either unsuccesfully treated by drugs and different kind of physiotherapy or arrived at our institute during acute phase of the disease; -neurological deficits that needed immediate surgery. Patients with spine degenerative diseases, L1-L2 disc

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herniation, extra foraminal disc herniation, recurrencies or patients who had already been surgically treated in other hospitals for this disease were excluded from the series. Every patient was assessed through a precise neurological evaluation, CT scan and MRI. We considered type of herniation (soft, hard, foraminal, stenosis producing), type of surgery (asportation, discectomy and asportation, foraminotomy associated, hemi-laminectomy associated), intraoperative troubles (excessive bleeding, anatomic alterations such as double roots, dural tears). Recovery time and days spent in the hospital for every patient were assessed, together with a precise and adequate neurological evaluation at hospital discharge. We have followed up all patients; at 6 months the following parameters were analyzed: VAS, job and sport activity reprise, possible recurrencies.

SESSION O05 PROSTHESIS I UTILIZATION OF BIG DIAMETER PROSTHETIC HEADS N. Pace Dipartimento di Ortopedia, Jesi, Ancona, Italy Heads of big diameter (>/= 38mm) and metal-on-metal coupling are one of the last acquisitions in hip replacement. Nothing really new because the history of these implants started in the Sixties; yet, their use has been gradually abandoned in favor of smaller diameters and metal-on-poly coupling. Improvements in casting and manufacturing of metal-on-metal coupling devices dramatically improved the tribological characteristics of these articulating interfaces. Normally these implants named BDH (big diameter heads) are used as resurfacing implants or coupled with a standard femoral stem. Shared features of the sudden implants are: increase of ROM values in comparison with smaller heads – strong decreasing of instability and luxation due to the removal of impingement neck/acetabular rim – strong reduction of articulating and rim wear debris. Authors quote their clinical experience using different prosthesis, listing every values and defects they observed during their daily utilization for 4 years.

THE GREAT DIAMETER OF THE FEMORAL HEAD IN TOTAL HIP REPLACEMENT: SHORT TERM FOLLOW-UP L. Costarella, V. Pavone, M. Privitera, F.R. Evola, G. Sessa Dipartimento di Specialità Medico-Chirurgiche, Istituto di Clinica Ortopedica, Catania, Italy The evolution of total hip replacement is the result of design improvement, new biomaterial availability and surgical technique development. In order to restore the correct biomechanics of the hip and to pursue the best rotational center, the femoral head diameter plays an important role. Nowadays the most used sizes are: 22, 26, 28, 32, and 36 millimeters. The advantages of using large femoral head consist of increased range of motion, decreased incidence of dislocation and impingement of the femoral neck on acetabular component, reduction of mechanical stresses on the bone prosthesis interface. Disadvantages include increased volumetric wear of the conventional polyethylene, necessity to use polyethylene of low thickness and consequently less mechanically resistant, enlarged friction stresses. There is no still evidence of wear phenomena on the reticulated polyethylene associated with large femoral head. At the Orthopaedic Clinic, university of Catania, between October 2004 and February 2006, 34 total hip replacement were performed utilizing great femoral head (36 mm) in patients with mean age of 61

years (range 54 – 71 years) affected by degenerative disease. The follow-up achieved 18 months. Clinical assessment, using modified Harris Hip score, and radiographic evaluation showed excellent results without any sign of early aseptic loosening. In spite of excellent results, there is not enough information concerning in vivo behaviour of the implant at long term.

TOTAL HIP ARTHROPLASTY TO TREAT ACETABULAR AND PROXIMAL FEMUR FRACTURE SEQUELAE M. Girolami, G. Trisolino, C. Impallomeni F. Trentani, D. Dallari, C. Stagni Istituti Ortopedici Rizzoli, Bologna, Italy Background: Late sequelae and complications of acetabular and proximal femur fracture often pose the problem of choosing the 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 retrospectively 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 patients had malunion or traumatic arthritis of the acetabulum, and 10 patients had proximal femur nonunion. Results: All the patients underwent total hip arthroplasty. The prosthesis was uncemented in 20 cases and cemented in one case. One patient was treated bilaterally due to malunion of an acetabular fracture on the left side and nonunion of the proximal femur on the right side. The mean follow-up was 27.3 months (range, 10-45). Early loosening of the acetabular component was observed in one case (4.8%). The mean Merle-d’Aubignè score was 16 (range, 13-18) at the last follow-up. Conclusions: we believe that total hip arthroplasty can be the surgical treatment of choice disabling sequelae of acetabular and proximal femur fracture.

THE UNCEMENTED “VERSYS ET” STEM: 5 TO 10 YEARS RESULTS F. D’Angelo, M. Giudici, G. Zatti, P. Cherubino Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, Varese, Italy Objective: Aim of this retrospective study was to evaluate the medium term results of the cementless stem “Versys ET” (Zimmer, Warsaw, Indiana, USA) used in the Department of Orthopaedics and Traumatology “M. Boni”. Materials and Methods: From 1995 to 2000, 225 Versys ET stems were implanted in 206 patients (19 patients had bilateral arthroplasty at different times).This stem is made of titanium alloy (Ti-6Al-4V). All patients were evaluated clinically and radiographically by the Harris Hip Score. Results: Postoperative Harris Hip Score incremented from 54 to 97 points (p<0.05). The stem presented a varus alignment between 5° and 10° in 17 cases without any clinical relevance (HHS 96.8). We recorded 7 cases of dislocation, 2 of them were in the immediate postoperative period, thus making a stem change necessary, 1 case presented septic loosening 7 years after surgery and it was treated with a 2 times reprise. Among all the stems, only one had been revised for aseptic loosening. 8 acetabular components had been revised because of aseptic loosening or polyethylene wear. Discussion: The trapezoidal cross-section of this stem together with the longitudinal fins assure an optimal primary stability in the proximal metaphiseal region without the filling of the distal region. Therefore, we have not observed signs of “stress-shielding” and thigh pain, which are typical features of full-fit stems as the anatomical one.

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The stem stability was radiographically evaluated according to Engh’s criteria; in all cases the bone ingrowth into this titanium alloy was confirmed. Conclusion: The results of Versys ET stem at 7.5 years follow-up are similar to those obtained with other straight stem, as CLS or Zweymüller ones.

BIOSURF: A NEW TRIBOLOGICAL CONCEPT FOR BEARING SURFACES IN HIP REPLACEMENTS L. Lucente, W. Thomas, L. Tafuro Clinica Quisisana, Rome, Italy The improvement of bearing surfaces in hip replacement is considered one of the most important challenges and in Literature many studies were performed. Wear and debris depend on prosthesis design and material characteristics. Many studies have demonstrated that Me-Me couples produce a lower quantity of debris. Bearing surface debris depends on articular lubrication. To improve design and lubrification, we have studied natural models (cornea, cartilage) and we have developed a new bionic concept that is characterized by a partial texturing of the metal head (golf ball type). Biomechanical studies have demonstrated a decrease of 30% of wear with this type of metal heads of great dimension (“Biosurf”) in hip replacement surgery.

CEMENTLESS CONE STEM AND METAL-ON-METAL ARTICULATING SURFACE FOR THE TREATMENT OF ARTHRITIS FOLLOWING CONGENITAL HIP DISEASE: RESULTS AT 10 YEARS R. Binazzi, A. Bondi, E. Zamagni, A. Manca, R. Halvadzhiyan Istituto Ortopedico Rizzoli, Bologna, Italy In recent years cementless cone tapered stems have had a large success in Hip revision surgery, literally revolutioning the prognosis of many cases of dramatical bone stock loss. Nevertheless, little experience exists in the Literature about their use in primary arthroplasties. The Cone Stem was designed in the 80’s by Prof. Wagner. The stem is made of a rough blasted Titanium Alloy with a cone angle of 5° and 8 sharp longitudinal “ribs” that cut into the inner cortex, providing excellent rotational stability: The ribs depth of penetration ranges between 0.1 and 0.5 mm and is also very important to achieve osteointegration. The CCD angle is 135°. The stem is straight and can be implanted indifferently in any degree of ante- or retro-version thus being indicated in dysplastic arthritis where we need to correct anteversion. Between 1993 and 1998 the Senior Author (RB) has implanted 92 consecutive cone stems in 88 patients with dysplastic arthritis. The acetabular component was always cementless and in Titanium. The articulating surface was mostly Metal-on-Metal. The average follow-up was 10.1 years. According to the Hartofilakidis classification we had 63 patients of type A, 18 of type B and 11 of type C. Clinically we had 89% of satisfactory results with no cases of anterior thigh pain. No patient required revision of the stem, while we revised a cup in Group C. Radiographically, 17% of patients showed some resorption in femoral zone 1 and 7. In 12 cases it was a narrow fissure due to the oscillations of proximal stem under load. This lesion was never progressive. In the same zones we observed 4 cases of real osteolysis. No radiolucent line was observed in other femoral zones. In the acetabular side we had 13 cases (14%) of radiolucency. Cone stem gave excellent clinico-radiographical results in dysplastic arthritis.

SYMAX STEM: TECHNICAL NOTES AND PRELIMINARY RESULTS A. Speranza, A. Ingallina, M. Ciurluini, C. D’Arrigo, A. Ferretti Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy

Introduction: The authors reported a preliminary study of a new cementless stem (Symax, Stryker-Howmedica). It joins a proximal anatomical geometry with the characteristics of a straight stem. Materials and Methods: From October 2004 to May 2005 in our institute forty patients underwent hip replacement with a cementless stem (Symax; Stryker Howmedica). There were 24 male and 16 female with a mean age of 61 years. The diagnosis was of primary osteoarthritis in 34 cases, of R.A. in two cases and of neck femoral fracture in 4 cases. In 30 cases we performed a hip replacement using a lateral standard approach (> 12 cm), in 8 cases using a minimally invasive anterior approach and in 2 cases using a minimally invasive antero-lateral approach. In all cases we used a cementless cup (Trident; Stryker Howmedica) and a cementless stem (Symax; Stryker Howmedica). The following parameters were evaluated: intra and post operative complications, total blood loss (calculated according to Rosencher method), time of surgery, component placement, length of hospital stay and functional outcomes at three months (HHS, WOMAC). Results: No dislocations, infections and early aseptic loosening were detected in the two groups. Two proximal femoral fractures (crack) were detected in the MIS approaches. Conclusions: Total hip replacement with a Symax stem may be performed using a lateral standard approach (> 12 cm) even in patients with BMI >30. We detected greater intra operative problems with a minimally invasive anterior approach in canal preparation because of stem size.

SESSION O06 FOOT COMPLEX TALUS FRACTURES: VARIABLES INFLUENCING CLINICAL EVOLUTION W. Daghino [1], C. Errichiello [2], D. Testa [3], A. Biasibetti [1], A. Massè [4] [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, Ospedale CTO, Turin, Italy; [2]UOS Chirurgia del Piede, Ospedale CTO, Turin, Italy; [3]Università degli Studi, Bari, italy; [4]I Clinica Ortopedica dell’Università, Ospedale CTO, Turin, Italy 28 cases of complex high energy talus fractures, corresponding to class III and class IV according to Marti Weber classification, were evaluated. The following variables were considered: type of trauma, type of surgery, type of reduction and type of osteosyntesis. As complications, rupture of the tendon of the flexor longus allux, sural nerve lesion and deltoideus ligament lesion were occasionally reported. Pull or compression lesion of the posterior vasal-nerve bunldle was observed in 10% of cases. Early skin complications, like suffering of the surgical wound and infections, were frequent. Malunion prevalence seems to be relatively high and significantly correlatable with type of osteosyntesis. Malunion was observed once among 15 cases treated with osteosyntesis in compression, while 6 on 13 cases among patients operated with Kirschner wires or external fixation. No significant correlation was found between the type of osteosyntesis and osteonecrosis, which seems to be 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 beyond 12 hours. Non-correspondence between appearance of osteonecrosis and need of subsequent surgical repair has to be underlined: only 2 out of 9 cases of osteonecrosis needed a talar arthrodesis.

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MININVASIVE SURGICAL TREATMENT OF THE TALARS FRACTURES: RESULTS AND OUTCOMES A. Cassaro, A. Raitano, L. Licata Unità Operativa Complessa di Ortopedia e Traumatologia, Gela, Italy The Authors emphasize the relative increase of Talar fractures in the road traumatology, and in particular in motorcycle, and traumatology recall their experience, matured from 2003 to the 2006, regarding one of the mininvasive treatments of decomposed fractures of astragalo, by means of osteosynthesis with canulate screws opportunely applied. The materials introduced are: 16 fractures of talar 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; b) mobility; c) the radiographic data; d) examination TC. From the analysis of the results, the validity of the mininvasive surgical treatment is confirmed in recent fractures of talar sluices as long as the limits sets up by those anatomo-pathological situations such as decomposition and excessive diastasi of fragments (some of the type II and all those of type III of Hawkins’s classification) are not exceeded. Moreover, according to the Authors, good results were obtained thanks to the program of “progressive-gradual” premature mobilization of the tibiotarsica, according to a precise outline.

FRACTURE AND DISLOCATION OF LISFRANC JOINT: CASE REPORT AND LITERATURE REVIEW J.M. Taglioretti, G. Mantovani CTO-ICP, Clinica Ortopedica, Milan, Italy Dislocation and fracture – dislocation of the Lisfranc joint are not common and occur at the rate of 1/55000 per year. There seems to be a direct correlation between achieving a prompt and accurate diagnosis and an anatomic reduction and satisfactory clinical results. The authors describe a case of Lisfranc fracture - dislocation type A lateral of the Quènu and Kuss classification, and concomitant bifocal fracture of the II metatarsus, head fracture of the II-III-IV metatarsus, and cuboid fracture due to high energy trauma. The treatment chosen was closed reduction, fixation by percutaneus K-wires, immobilisation in a plaster cast. RX and clinical check at 2 -4 -6 – 10 weeks and at 2 months, clinical and RX and RNM at 20 months. The outcome was very satisfactory. The patient had no complaints, no evident degenerative changes at RX or RNM, not desultory pain in the cuboid site. The authors believe that a non invasive treatment can achieve a better and durable result and can avoid very serious complaints reported after open surgery. They agree with most authors that it is always imperative to reach an anatomic reduction.

OUR EXPERIENCE IN MIDDLE FOOT TRAUMAS: CHOPART, LISFRANC, NAVICULAR BONE P.C. Prina, M. Franceschini, F. Moioli, P. Romano, R. Franceschini Ospedale L. Sacco, Azienda Ospedaliera, Polo Universitario, Milan, Italy Major series in literature report a low rate of middle foot traumas. Particularly, the Lisfranc joint is involved only in 1% of all fractures and joint lesions of Lisfranc and Chopart are less frequent but more serious, causing more severe consequences. Isolated or associated navicular bone lesions are from 0.008% to 0.2% of all fractures and from 4.5% to 6% of all foot lesions. Our presentation is about ten complex cases of middle foot fractures, treated in most cases with open reduction and internal fixation on emergency bases, percutaneous fixation, and in one case with associated external fixation. Classification of Chopart, Lisfranc, and tarsal navicular bone are then enumerated along with diagnostic means, treatment, complications and results at two years follow up. Global results are to be con-

sidered good, but the importance of defining borders between conservative and surgical treatment, and between ORIF and local arthodesis, are pointed out.

COMPLEX FRACTURES OF THE CALCANEUM: DIAGNOSTIC – THERAPEUTIC ALGORITHM W. Daghino [1], E. Balboni [2], M. Vigna Suria [2], R. Sisto [1], A. Massè [4] [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, Ospedale CTO, Turin, Italy; [2]Università di Torino; Turin, Italy; [4]I Clinica Ortopedica dell’università, Ospedale CTO, Turin, Italy The treatment of complex fractures of the calcaneum is a contentious argument and it often represents a real challenge, for the frequent early and late complications, some of which serious, that can increase healing time and compromise clinical outcomes. The authors introduce a diagnostic and therapeutic protocol, created considering the most recent results in literature, aiming to orienting either the surgical indication or the type of specific surgical treatment. This protocol has been proved in a perspective way and is based on a case history of 35 fractures consecutively treated from November 2002 to December 2005: the preliminary results of this decisional approach will be presented and some specific cases will be discussed.

DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURE: RESULTS OF OPEN REDUCTION AND INTERNAL FIXATION A. Basile, M. Stopponi, A.U. Minniti de Simeonibus II Divisione di Ortopedia e Traumatologia, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy Historically, displaced intra-articular calcaneal fractures (DIACFs) were treated non-operatively, as predictable operative reduction and fixation were not possible. Operative treatment has become more accepted in the last ten to fifteeen years as a result of improvements in preoperative evaluations, use of intraoperative imaging to verify the quality of reduction, and advancements in surgical techniques. Although more and more evidences are suggesting that operative treatment results in better outcomes, reviews on this subject have failed to demonstrate indisputably superior results of a single approach to the treatment of DIACFs. Two meta-analysis published in 2000 and 2005 show that there is no level-I study evidence that enable the surgeon to decide upon optimal treatment for a DIACF. Both patients and social characteristics including gender, age, level 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 stratification of the patient population, demonstrated that women, patients that were not receiving Workers’ Compensation, younger males, patients with a higher Bohler angle, patients with a lighter workload, and those with a single, simple displaced intra-articular fracture have better outcomes after operative treatment than after nonoperative treatment. Anatomic or near anatomic reductions enhance outcome while comminution and/or poor reductions produce long term outcomes that are less satisfactory. Arthrodesis rates are significantly reduced with operative treatment. Patients who benefit of nonoperative treatment are those who are fifty years old or more, those who are receiving Workers’ Compensation and patients with highly comminuted articular fractures. Up to now, evidence in the literature supports the recommendation to avoid surgery in all patients over the age of fifty years because of the expectation of poor outcomes, however, recently an investigation performed by Herscovici et al. challenged this statement sustaining that open reduction and internal fixation appears to be an acceptable method of treatment for DIACFs even in a careful selected population of

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elderly patients. Our results are in line with the ones presented by the study of Herscovici and Sanders. We strongly reccomend ORIF of DIACFs in a selected patient population in order to minimize late complications.

THE MITCHELL OSTEOTOMY WITH BOSH STABILIZATION AND DISTAL SOFT TISSUE RECONSTRUCTION: LONGTERM FOLLOW-UP C. Pasquali, L. Burroni, S. Moalli Ospedale di Circolo e Fondazione Macchi Presidio del Verbano, Luino, Italy Between October 1999 and October 2002, 284 patients were treated for hallux valgus with Mitchell Osteotomy and among them 81 were available for further clinical and radiological evaluation (40%). The surgical procedure consisted of a modified Mitchell Osteotomy in which fixation was achieved with a Kirschner wire followed by a distal soft tissue reconstruction. Seventy-six patients were included in the study, mean age at the time of surgery was 62 years (range 25-80 years). Twenty-one patients were operated bilaterally for a total of 97 feet examined. The first metatarsophalangeal angle was measured on standing dorso plantar view radiograph before surgey and the patients were divided according to their first MTP angle: group I range 0-20° (6%), II group range 20-40° (52%), III group over 40° (42%). In order to achieve a clinical assessment the American Orthopaedic Foot and Ankle Score (AOFAS) was adopted, based on a 100 points evaluation system. At an average 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 satisfactory 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 III 88. At follow up every patient repeated the standing dorso plantar view radiograph. The radiographic evaluation was performed by calculating the difference among the first MTP angle before the 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 hallux valgus, radiological results were better in moderate hallux valgus, in fact, a higher percentage of loss of correction was mostly shown in severe cases.

OPENING ADDITIONAL BASE WEDGE OSTEOTOMY IN TREATMENT OF HALLUX VALGUS M. Calderaro [1], S. Ghera [1], T.L. Giorgini [2] “San Pietro” Fatebenefratelli, Rome, Italy; Cura Quisisana, Rome, Italy

[1]Ospedale

[2]Casa

di

Severe hallux valgus, with an intermetatarsal angle greater than 18 degrees associated with ligamentous laxity and subtalar joint pronation, is a delicate pathology requiring surgical treatment with sufficient 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 arthrodesis of the metatarsal-cuneiform joint, as described in the literature. Osteosynthesis is indispensable in obtaining rapid healing and avoiding secondary shifting of the osteotomy. The notable forces that occur with weight-bearing at the base of the first metarsal can cause osteotomy fracture, therefore making it necessary for belowthe-knee casting and non-weightbearing for six weeks post-operatively. The authors present their experience of 10 cases treated with opening additional base wedge ostoetomy stabilized with the Bow plate by Daro. The technique of opening wedge osteotomy with plate application allows intra-operative correction of varying degrees, and earlier post-operative weight-bearing. The authors illustrate the surgical technique and their encouraging preliminary results.

LONG ARM METATARSAL OSTEOTOMY IN TREATMENT OF MODERATE TO SEVERE HALLUX VALGUS T.L. Giorgini [1], M. Calderaro [2] di Cura Quisisana, Rome, Italy; “Fatebenefratelli”, Rome, Italy [1]Casa

[2]Ospedale

San Pietro

A distal metatarsal oseotomy is classically used in the treatment of moderate to severe hallux valgus. The long-dorsal arm osteotomy is a modification of the Austin or Chevron osteotomy, by decreasing the osteotomy angle by 5 degrees. This modification allows greater osteotomy stability, increased cancellous bone-to-bone contact, and the possibility for two screw osteosynthesis. This technique represents a valid alternative to other osteotomies because of its ability to correct large degrees of deformity. By using cortical screw fixation, this procedure can be used in both elder and young patients. This surgical treatment does not destroy the first metatarsophalangeal joint as in the Keller or Regnaud procedures. The long-dorsal arm osteotomy also allows minor metatarsal dissection as compared to the Scarf procedure, while allowing major correction without the complication of “troughing”, as described in the literature. Stability of this osteotomy design with increased cortical contact and 2-screw osteosynthesis permits immediate post-operative weight-bearing and decreased post-operative pain. Often, but not always utilized is dorsal transfer of the adductor hallucis tendon into the medial capsule. This allows better positioning of the sesamoids underneath the first metatarsal head, greater cosmetic correction and stabilization of the metatrsophalangeal capsular complex. The authors present a series of 80 surgeries in 63 patients utilizing this surgical technique.

SESSION O07 PEDIATRICS ROLE OF VDRO IN CP IN CHILDREN A. Andreacchio, S. Désayeux, M. Chiavola, G. Ingrosso Reparto di Ortopedia Pediatrica, Ospedale Infantile Regina Margherita, Turin, Italy The dislocation of the hip in children with Cerebral Palsy occurs frequently. The dislocated hip becomes painful in 50 to 70 % of patients, but determining the severity of pain may be difficult in the non-communicating severe quadriplegic individual. The problem of the patient with dislocation of the hip includes also the gait, nursing care, sitting position and perineal care. The best treatment of spastic hip dislocation is prevention. These patients need close follow-up in order to detect early any subluxation of their hips. The Authors review their 17 patients who had 19 varus, derotational osteotomies.

COMBINED KIDNER-COBB PROCEDURE WITH SUBTALAR ARTHRORESIS AND ACHILLE’S TENDON LENGTHENING IN TREATMENT OF JUVENILE FLAT FEET T.L. Giorgini [1], M. Calderaro [2], R.J. Giorgini [3], C. Japour [4] [1]Casa di Cura Quisisana, Roma, Italy; [2]Ospedale “San Pietro” Fatebenefratelli, Rome, Italy; [3]North General Hospital, New York, USA; [4]Veteran’s Hospital, Danville (Illinois), USA The objective of this lecture is to report the functional and radiographic results of a series of patients surgically treated for symptomatic flat foot. The surgery performed in 14 patients (20 feet) with an average age of 12, and a follow-up of 7 years, consists of three contemporary procedures: percutaneous lengthening of the Achille

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tendon, subtalar arthroresis with an absorbable screw, and KidnerCobb tenosospension. The last procedure comprises the navicular exostectomy described by Kidner, and the tenosospension of the tibialis posterior tendon as described by Cobb. The combined surgical procedures optimize the surgical results by correcting the multiple causes of this complex deformity. The modified Kidner-Cobb procedure is also valid in the treatment of stage 2 posterior tibial tendon dysfunction in adults. In conclusion, this combined procedure is a valid option in treatment of pediatric flat foot with good long-term results.

EXPERIENCE IN THE TREATMENT OF CONGENITAL CLUBFOOT ACCORDING TO PONSETI METHODOLOGY I. d’Addetta [1], D. Vittore [2], F.M. Matarazzo [3] [1]U.O. Ortopedia e Traumatologia Pediatrica, Ospedale Pediatrico Giovanni XIII, Bari, Italy; [2]Dipartimento di Metodologia Clinica e Tecnologie Medico Chirurgiche, U.O. Ortopedia e Traumatologia II, Università degli Studi di Bari; Italy; [3]U.O. Ortopedia e Traumatologia Pediatrica, Ospedale Pediatrico Giovanni XIII, Bari, Italy Introduction: Congenital clubfoot is a serious and complex deformity which occurs in approximately 100.000 children in the world with a rate of 1 of every 1000 babies. The exact causes of this deformity, which develops while the baby is still forming in the uterus, remain unknown, but it is believed heredity may be implied. Surely enough, the social consequences are so heavy that they can determine disabling and serious psychological problems in the child and his/her family. In the 40’s, Dr Ignacio Ponseti was the first to understand that a conservative therapy, based on precious treatments of the clubfeet by gentle manipulation and successive casts, taking advantage of the elasticity of the tissue forming the legaments joint capsulles and tendons, could give excellent results avoiding surgery. In more serious cases, tenothomy of tightened Achilles tendon, may be adopted. Materials and Methods: Treatment of the clubfoot should start as soon as possible. Initially, gentle manipulations of the foot are done avoiding pronation, and the correction is held in a cast which is changed weekly. Six or seven castings are usually necessary to achieve the goal and only in some cases a decision will be made regarding further castings or surgery. Generally, after two months the foot is corrected and placed in a brace to hold the correction. Only for really serious cases subsequent surgery is necessary. Conclusions: Here the authors present 230 clubfeet Ponseti trated since 2001 confirming the validity of the treatment. Moreover, a virtual dynamic representation of the anathomy of the clubfoot is given to make the methodology clearer and easier to learn.

DIFFERENT APPROACHES IN SCREENING OF DEVELOPMENTAL DYSPLASIA OF THE HIP. A COMPARATIVE STUDY M. De Pellegrin, D. Moharamzadeh, D. Fracassetti, G. Fraschini Università Vita-Salute IRCCS San Raffaele, Unità Operativa di Ortopedia e Traumatologia, Servizio di Ortopedia Infantile, Ospedale San Raffaele, Milan, Italy Developmental dysplasia of the hip (DDH) has an incidence of approximately 2% in Italy. Early diagnosis is known to have a determinant influence on the treatment, duration and type and on its outcomes. The aim of this study based on our experience was to verify what are the current possibilities of realising an early screening of DDH and therefore to identify the most effective method and strategy. Data obtained from 3 different periods were compared; in these periods, 3 different types of screening were performed: 1979: clinical screening in all newborns; 1989 ultrasound screening in all newborns; 1990: clinical screening and ultrasound screening in new-

borns with risk factors. Data from the period 1992-2002 are also reported (clinical-ultrasound out-patient clinic dedicated to DDH). The diagnosis of DDH was made by the 8th week of age in 29% of the cases in 1979, in 100% in 1989, in 72% in 1990 and in 74% during the period 1992-2002. The analysis of the results has emphasized the importance of the Ortolani Manoeuvre in the clinical screening of all newborns, the need of an ultrasound examination in newborns with dubious or positive clinical signs and known DDH risk factors (positive family history, breech position) and the need of a general ultrasound screening by the 6th week of age, even in patients without clinical signs and no DDH risk factor.

FRACTURES IN CHILDREN: REVIEW OF 10.070 CASES (1995-2005) F. Canavese, P. Charles, A. Dimeglio Service d’Orthopedie Pediatrique, Montpellier, France During a 10-year period 9.438 children were treated for fractures at our Department. The medical records were assessed. All patients’ radiographs and records were revised by a group of Pediatric Orthopaedic Surgeons before being included in the study. We reviewed 10.070 fractures, 6270 (62.2%) in boys and 3800 (37.8%) in girls. Fall and summer are the seasons with the highest rate of fractures (56.7%) and the peak incidence is observed during saturdays and sundays (32,1%). The mean age is 8.6 years (range: 1 day to 16 years). 4924 (48.9%) fractures are in the right side of the body and 5146 (51.1%) the left. The mechanism of injury is frequently a fall during sport activities. 7420 fractures are in the upper limb (73.7%), 2602 (25.8%) in the lower limb and 45 (0.5%) in the spine. 3811 (37.8%) fractures are in the forearm, 1362 (13.5%) in the humerus, 1483 (13.7%) in the hand and 806 (8%) in the clavicle. Leg fractures are 1161 (11.5%), foot fractures 920 (9.2%) and femoral fractures 445 (4.4%). 52 cases (0.5%) are in the pelvis. Displacement is in 4017 (39.9%) cases; articular involvement is in 291 (2.9%) fractures; 270 are open fractures (2.7%). 4744 (47.1%) fractures are metaphyseal, 2804 (28.9%) are diaphyseal and 1219 (12.1%) are epiphyseal and in this group 286 (23.5%) fractures are S.I, 758 (62.2%) S. II, 48 (3.9%) S.III, 32 (2.6) S.IV and 95 (7.8%) Ogden VII. 1585 (15.7%) fractures needed general anesthesia, 1707 (16.9%) Entonox® (N2O2) and 6768 (67.2%) did not need any anesthetic at all. 2231 childrens (22.2%) were hospitalized and 7288 (72.4%) casts were made. Fractures in children can be usually treated at emergency department. Upper limb is frequently involved. General anesthesia is rarely used (less than 1 fracture out of 5) and Entonox® (N2O2) is a good alternative.

COMPARTMENT SYNDROMES, VOLKMANN ISCHAEMIC CONTRACTURE AND VASCULAR INJURIES IN THE NEWBORN IN THE UPPER LIMB M. Abate, N. Della Rosa, A. Leti, A. Landi Struttura Complessa di Chirurgia della Mano e Microchirurgia, Modena, Italy In 1881 R. Volkmann described a post-ischaemic palsy, due to several compressive pathologies, which is very similar to “rigor mortis” and leads to a strong muscolar shortening. In the adult the compartment pressure is 30 mmHg. Since in the newborn the compartment pressure, is not routinarely measured, it cannot be referred to a standard pressure gradient. However in the newborn the diastolic pressure is about 40 mmHg, so we can ipotize that any raising of compartment pressure value could lead to a perfusional defect in the muscles. Many causes, other than a sole increase of compartment pressure, could lead to a deficency in muscle blood perfusion: vascular causes could cause a ischaemic injury “ab initio”. We observed that Compartment Syndromes and Neonatal

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Ischaemia have many common features, so the distinction of these pathologies in different nosological classifications seems artificious. We created an original classification scheme to include all these clinical-pathological conditions. It is fondamental to recognize as early as possible the risk factors linked to the mother or fetus and the initial clinical features in order to be able to act medical and surgical approaches to limitate invalidant functional injuries and take advantage of the natural plastic ability of the newborn tissues. In this study, performed in the Hand and Microsurgery Unit of Modena Policlinic, we focused on vascular neonatal diseases and their causes and we created a practical algorithm to approach these pathologies from the prevention to the treatment.

COMPARISON BETWEEN DIFFERENT SPLINTS IN THE EARLY TREATMENT OF DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) P. Ciampi, D. Moharamzadeh, M. De Pellegrin, G.F. Fraschini Ospedale San Raffaele, Università Vita e Salute, Milan, Italy Various methods of contention and orthopaedic devices have been used for the non-surgical treatment of developmental dysplasia of the hip (DDH). They all have in common an abducted and flexed position of the hip, which permits to centre the femoral head in the dysplastic acetabulum. The diagnosis and the choice of the type of treatment to use have been based on general, non-specific criteria (imaging and clinical) and, moreover, have been started at an advanced age. Ultrasonography has made it possible to recognise a dysplastic hip in the first few weeks of age, to obtain detailed information on the type and stage of hip immaturity and/or dysplasia. This precocity and specificity reflect themselves in the possibility to start an early, specific orthopaedic treatment, which is also personalised. Due to this important variation in the approach of DDH, with time, the Paci-Lorenz, Hanausek, Kramer, Fettweis methods have been abandoned. These methods were all characterised by scarce specificity, difficult use and compliance, and 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 used in a more specific and “personalised” fashion, depending on the type of dysplasia or immaturity of the hip. The Frejka pillow, the Pavlik method, the Von Rosen, Milgram, Denis-Brown, Ilfeld, Graig, Hoffman-Daimler, Forrester-Brown-Putti splints, and the newest Gekeler splint have found a relevant distribution. These devices, which are apparently similar, are as a matter of fact very different one from the other, regarding the way in which they abduct the hips. They are not interchangeable and have to be used in specific stages of DDH. In this study these commonly used splints will be assessed, their technical characteristics, application, indications and contra-indications will be specified.

ARTHROSCOPIC TREATMENT OF THE INTRA-ARTICULAR KNEE FRACTURES IN THE OLDER CHILDREN A. Pascarella [1], P. Guida [2] [1]Ospedale G.Fucito, Mercato San Severino; Italy; Santobono, Pausillipon, Naples, Italy

[2]

Ospedale

Objective: Authors report their experience in arthroscopic-assisted management of intraarticular knee fractures in adolescents. Methods: From February 2002 to February 2005, we treated by artrhroscopic-assisted technique 16 intraarticular knee fractures in adolescents from 13 to 16 years old : 9 fractures of intercondylar eminence, 3 Salter Harris type III fractures-separations of the distal femur, 4 fractures of the proximal tibial epipysis type II Salter Harris and type III Salter Harris.

Results: The compliance of patients was optimal, the time of operation was slightly longer than open reduction but the postreduction care was significantly shorter. In all cases we obtained good X-ray and clinical results. Conclusions: The arthroscopic-assisted management of intra-articular knee fractures in adolescents is a valuable tool for the assessment of fractures. It has the advantage of superior visualization of the entire joint and it is the treatment of choice for associated intra-articular pathology. It allows achievement of anatomic reduction and rigid internal fixation with less morbidity than with open reduction.

TREATMENT OF LOWER LIMB EPIPHYSEAL FRACTURES L. Marchesini Reggiani, M. Magnani, O. Donzelli 8° Divisione di Ortopedia e Traumatologia Pediatrica, Bologna, Italy The epiphyseal fracture represents almost 30% of fractures; they are more frequently caused by indirect trauma and they are more common in males. Lesions involving phisys and epiphysis can be responsible for growth problems. The most widely used classification is the one made by Salter and Harris who divide epiphyseal fractures into 5 kinds of lesions according to x-ray images. The 5th kind is a compression lesion of the phisys, accompanied by a compromission of its vascularization; it can be dignosed only retrospectively and can produce a growth problems. MRI, carried out within 10 days after the lesion, can help classifying the fracture but it only offers a qualitative analysis. Technetium scintigraphy carried out after at least 6 months from the trauma can be useful to evaluate the qualitative and quantitative activity of the epiphyseal cartilage. The treatment of the epiphyseal fractures aims to anatomically reduce the fracture and to stabilyze it; in some cases it can also be necessary to treat the possible deformities caused by the fractures. Because of the difficulty to evaluate the degree of the phisys lesion and the compromission of the vascularization, it is often hard to predict in an early phase the evolution of this kind of fractures using only X-ray and MRI images.

SIMPLIFIED METHOD OF SKELETAL AGE ASSESSMENT FROM THE OLECRANON F. Canavese, P. Charles, J.P. Daures, A. Dimeglio Service de Chirurgie Orthopedique, CHU Lapeyronie, Montpellier, France The Sauvegrain method of assessing skeletal age from elbow radiographs is reliable during the pubertal growth spurt from 11-13 years in girls and 13-15 years in boys. It usefully complements the Greulich and Pyle atlas. With a regular use of the Sauvegrain method, we were able to pay particular attention to the olecranon which is characterised by a clear morphologic development during this period.Five images of the olecranon are identified: two ossification nuclei, 11 years in girls and 13 years in boys, half-moon image: 11.5 years in girls and 13.5 years in boys, rectangular aspect: 12 years in girls and 14 years in boys, beginning of fusion: 12.5 years in girls and 14.5 years in boys, and complete fusion: 13 years in girls and 15 years in boys.Average intra-class correlation coefficients demonstrated an excellent correlation between Sauvegrain and olecranon methods: r=0.9883 for boys and r=0.9721 for girls. The degree of correlation of both methods between the 3 observers was: r=0.9920 for the olecranon method and r=0.9849 for the Sauvegrain method in the boy group, r=0.9958 for the olecranon method and r=0.9936 for the Sauvegrain method in the girl group.Derived from the Sauvegrain method, skeletal age assessment from the olecranon proved to be particularly simple and reliable. This method is easy to learn and allows to obtain a rapid and relatively precise idea of skeletal maturity in clinical practice.

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SESSION O08 MISCELLANEOUS I EXPERIMENTAL STUDY ON BONE QUALITY IN HIP ARTHROPLASTY FOR OSTEOPOROTIC HIP FRACTURES AND HIP OSTEOARTHRITIS G. Resmini [1], C. Redaelli [1], U. Sala [1], S. Migliaccio [2], G. Gandolini [3], S. Maggi [4], S. Lello [5], L. Dalle Carbonare [6], N. Malavolta [7], G. Iolascon [8] [1] Centro per lo Studio dell’Osteoporosi e delle Malattie Metaboliche dell’Osso, U.O. di Ortopedia e Traumatologia, A.O. Ospedale Treviglio, Caravaggio, Italy; [2]Fisiopatologia Medica, Università di Roma, Rome, Italy; [3]Reumatologia, Fondazione Don Gnocchi, Milan, Italy; [4]Centro Invecchiamento, CNR, Padua; [5]Ginecologia, San Carlo di Nancy – IDI, Rome, Italy; [6]Università di Padova, Padua, Italy; [7]Reumatologia, Università di Bologna; Italy; [8]Seconda Università di Napoli, Naples, Italy Osteoporosis and osteoarthritis are the two most common diseases in elderly people, but remarkably they seldom coexist. Steoporosis is a chronic and progressive disorder characterized by a reduced bone strength and increased susceptibility to fracture due to minor trauma. The bone strength depends not only on the amount of bone tissue but also on its quality. We have studied 18 subjects (average age 82 ± 8.0 years) with hip fractures (Hip Fracture Group), 35 subjects (average age 70 ± 8.0 years) with arthritis of the hip (Arthritis Group) compared to 19 subjects (average age 70 ± 5.5 years) with normal femoral bone mineral 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, P, Mg, Cl, Na, K urine) were assayed within 48 hours after hip fracture and preoperatively cement hip arthroplasty in the Hip Fracture Group, preoperatively non-cement total hip arthroplasty in the Arthritis Group and in the Control Group.There is a significant difference in the CaPTH axis with secondary hyperparathyroidism in the Hip Fracture Group compared to Arthritis Group and to Control Group. A marker of bone resorption, C-Terminal telopeptides of type I-collagen, was significantly increased in the Hip Fracture Group by p<0.0007 and by p<0.0039 respectively in the Arthritis Group and in the Control Group. There were no differences on 25OH vitamin-D3 between the 3 different groups, but all subjects had vitamin D3 insufficence. In conclusion, biochemical markers reflecting bone turnover may improve the prediction of hip fracture. Bone density and bone quality changes reduce ability of osteoporotic bone to support prosthetic implants. Probably this condition might interfere with primary stabilization (immediate support to implant by close bone), and secondary stabilization (due to bone ingrowth). Therefore, before surgery, it’s important to make an accurate evaluation of bone health status (bone markers, Vitamin D,…). Our data support the hypothesis that prudent preoperative planning is crucial to minimizing failures and optimizing results. The focus of orthopaedic intervention is to inimize these sequelae through a good primary stabilization, enhancement of fracture healing and aggressive rehabilitation.

SEQUENTIALLY IRRADIATED AND ANNEALED UHMWPE: THE NEXT GENERATION HIGHLY CROSSLINKED BEARING MATERIAL A. Essner, S-S. Yau, A. Wang, J. Dumbleton, M. Manley Stryker Howmedica Osteonics Inc., Mahway, New Jersey, USA Introduction: The three issues for ultra-high-molecular-weight polyethylene (UHMWPE) are strength, wear resistance and oxidation resistance. A novel sequential crosslinking process (X3) was developed to maintain functional strength, improve wear resistance and provide oxidation resistance with no compromises.

Methods: The X3 sequential crosslinking process gamma-irradiates 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. Acetabular and tibial bearings are machined from this stock and hydrogen peroxide gas plasma sterilized. Physical, chemical and mechanical properties were measured and hip and knee implants were tested for wear and functional strength. Results: Microstructure measurement (TEM and DSC) showed no change in size or amount of crystals compared to conventional UHMWPE with crosslink density approximately doubled and free radicals (ESR) reduced by 99%. Yield and ultimate strength were maintained and functional hip and knee device testing showed similar or improved fatigue performance compared to conventional UHMWPE. Hip wear testing found a statistically significant 97% reduction over conventional UHMWPE and a 70% reduction over earlier generation highly crosslinked UHMWPE. Knee wear results show up to 79% reduction for CR and PS inserts under gait and stair climb testing. Wear debris was similar to conventional UHMWPE. Contact fatigue testing showed delamination for controls but not for X3. Artificial aging showed similar oxidation performance compared to virgin PE with no change in physical or mechanical properties before and after aging. Discussion and Conclusions: Sequentially crosslinked UHMWPE (X3) was developed to maintain the mechanical strength of conventional UHMWPE and improve wear resistance while providing resistance to oxidation. This was accomplished by maintaining crystalline microstructure, increasing crosslink density and minimizing free radicals. Material tests and hip and knee device tests confirmed this.

ABDUCTOR-CUFF TEARS OF THE HIP: PATOGENESIS AND CLASSIFICATION L. Tafuro, W. Thomas, L. Lucente Clinica Quisisana, Rome, Italy In the literature there are many studies about anatomical and radiological findings of the abductor cuff tears of the hip, but not as many about histology and patogenesis. We have developed a classification of abductor-cuff lesions and we have elaborated a patogenetic hypothesis of a trochanteric impingment of the hip. From January 2004 to March 2005, in 150 consecutive with osteoarthritis of the hip were performed. X-rays, Ecography and MRI studies were performed pre and postoperatively. The cuff-tears were divided into three groups. The radiological and clinical (Harris Hip Score) follow up were done at 6 weeks, 3, 6 and 12 months. The MRI showed abductor-cuff tears in 32% of the cases. 10 Patients belong to group I, 27 to group II and 11 to group III, while 102 patients were not affected by abductor-cuff lesions. The Harris Hip Score values, different in the preoperative, are similar during the follow-up. The patogenetic hypotesis, the classification and the surgical protocol described, permit a quickly identification of the abductor-cuff tears and a right surgical choice.

EFFECTIVENESS AND SAFETY OF BEMIPARIN DURING OBSERVATIONAL STUDIES FOR PREVENTION OF VENOUS THROMBOEMBOLISM IN ORTHOPAEDIC PATIENTS P. Prandoni [1], L. Scalia [2], J. Martínez-González [3] [1]Dipartimento di Scienze Mediche e Chirurgiche, Università di Padova, Padua, Italy; [2]Dipartimento Medico, Sigma-Tau, Rome, Italy; [3]Dipartimento Medico, Laboratorios Rovi, Madrid, Spain Background: Observational studies (OS) are useful to assess the incidence of adverse drug reactions (ADRs) with a new product in daily clinical practice and to identify rare and/or unexpected adverse drug reactions not shown in clinical trials.

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Objective: To review the effectiveness and safety of bemiparin during OS for prevention of venous thromboembolism (VTE) in orthopaedic patients. Methods: We analysed the results of 3 bemiparin OS in orthopaedic patients conducted during the period from 1999 to 2003. The incidence of documented symptomatic VTE, major bleeding, deaths and thrombocytopenia were extracted. Results: A total of 9315 orthopaedic patients were exposed to bemiparin during OS for VTE prophylaxis. Most patients had leg injuries requiring immobilisation (n = 2052), knee replacement (n = 1905), hip replacement (n = 1409), knee arthroscopy (n = 769), hip fracture (n = 437), or other leg surgery (n = 1569). Bemiparin 3500 IU/d was used in 87.1% of patients (high risk of VTE). Median duration of 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 these, three were considered thromboembolic. Mild to moderate thrombocytopenia that did not require treatment discontinuation was observed in 44 patients (0.5%). No cases of spinal haematoma, type II severe thrombocytopenia, general allergic reactions, cutaneous necrosis, or any other rare or unexpected ADR were reported. Conclusions: Bemiparin prophylaxis was associated with a very low incidence of VTE, major bleeding, and other adverse events in orthopaedic patients in standard clinical practice.

PHARMACOLOGIC PREVENTION OF VENOUS THROMBOEMBOLISM IN ORTHOPAEDIC SURGERY: ARE WE OFFERING OUR PATIENTS THE BEST? E. Romanini [2], M. Torre [3], V. Amorese [1] Specializzato Regionale “L. Spolverini”, Ariccia, Italy; [2]Globe, Rome, Italy; [3]ISS, Rome, Italy G. Tucci

[1],

[1]Ospedale

During the last years thromboembolism prophylaxis has received increasing attention from the orthopaedic community. An increasing volume of studies and guidelines, often based upon ACCP recommendations published in the USA, made pharmacological prophylaxis (particularly with low-molecular weight heparins) a common practice. The aim of this clinical practice is to prevent thromboembolic complications, especially the dreadful pulmonary embolism. The fear of medico-legal implications related to a rare, but often fatal, complication has created an environment in which chemoprophylaxis seems to be mandatory. This situation has led to an uncontrolled widening of the indication of chemoprophylaxis (that can itself cause several complications) to the majority of orthopaedic patients, even to those who are not undergoing surgery or those affected by minimal injuries. Recently this approach has been questioned and an authoritative panel of orthopaedic surgeons asserted the need to reassess the practice of systematic chemoprophylaxis, emphazising that thromboembolism, due to its complex pathogenesis, needs a “multimodal” approach. Moreover, the possible complications (i.e. major bleeding, heparin-induced thrombocytopenia) related to the use of chemoprophylaxis do not justify such a large and indiscriminate use. This study is a review of current evidences about this controversial issue.

dence from systematic research, a concept shared by doctors and patients and that should replace a practice based on tradition and dogma. However, some behaviors still outlive, despite the amount of counter evidence. As a case in point, the use of postoperative suction drainage in joint replacement not only causes an additional direct cost to surgery, but it is correlated with an increased rate of transfusions and potential complications. To evaluate potential savings resulting from the disruption of this procedure, a simplified model was elaborated which is based on available administrative data. Our data show that the adoption of an evidence-based protocol discouraging the unsupported use of drains in primary total joint replacement surgery on a national basis would allow money savings as well as potential prevention of complications.

PRELIMINARY EXPERIENCE WITH ISKD NAIL IN THE TREATMENT OF LOWER SHORTENED LIMB F. Baldo, A. Reggiori, P. Cherubino Dipartimento di Ortopedia e Traumatologia, Università degli Studi dell’Insubria, Varese, Italy Objective: Treatment evaluation in lower shortened limb with the intramedullary skeletal kinetic distractor ISKD. Methods: The ISKD is made up of a telescoping section able to distract the proximal and distal part by a miniaturised complicated drive mechanism. This happens during physiologic daily life activity and especially physiological gate process. In our department three patients have been treated with ISKD devices for a bone loss following lower limb trauma. The average age was 27.6 years (20-38 years), two female and one male presented an average shortened of 40 mm (34-45 mm). Two femurs and one tibia were involved in lengthening. Results: No particular problems were observed during the surgical procedure. All patients performed themselves the rotations needed for lengthening since the third and fifth post-operative days. The desired daily length of distraction was achieved in all patients. No case of non-union or malunion was ascribed to failure of device. No complications related ISKD were observed during follow-up; complete range of motion was reached in all patients. The patient with tibial lengthening presented a light valgus deformity due to an error in the selected level of osteotomy. Discussion: Callus taxis proposed by Ilizarov is associated with many complications particularly related to pins and K wires tracts for fixation. The ISKD device, based on Ilizarov principles allows to reach lower limb lengthening by a simple and comfortable device. This distractor system has an indication feedback monitor to control the effective desired lengthening of nail. Conclusion: In our experience ISKD got the best results with increased comfort for the patients, an early full weight bearing with a complete ROM and excellent limb function.

SESSION O09 SHINBONE I

SUCTION DRAINS AFTER TOTAL JOINT REPLACEMENT. ECONOMIC ISSUES AND POTENTIAL RISKS OF A ROUTINE PROCEDURE NOT SUPPORTED BY CLINICAL EVIDENCE E. Romanini [1], G. Tucci [2], M. Torre [3] [1]Globe, Rome, Iatly; [2]Ospedale Specializzato Regionale “L. Spolverini”, Ariccia, Italy; [3]ISS, Rome, Italy The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evi-

FRACTURES OF THE TIBIAL PLAFOND D. Lazzara, G. Caruso, A. Petrini U.O. Ortopedia, Nuovo Ospedale S. Giovanni di Dio, Florence, Italy Introduction: Fractures of the tibial plafond (distal tibia extending into the ankle joint with different levels of comminution) represent 1% of lower limb fractures and 7-10% of all tibial fractures. These fractures result from low energy injuries or, more often, from an high energy injury like major falls or motor vehicle accidents.

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Objective: To evaluate results and complications of open riduction and internal fixation (ORIF) of these fractures. Patients and Methods: Twenty-eight patients (twenty-nine fractures) treated between 2001 and 2003 were examinated clinically and radiographically at an average of 43.4 months (30 to 59 months) after treatment. The average age at treatment was 44.6 years (17 to 79 years). Twenty-seven fractures were treated operatively (using plates and screws in 23 and only screws in 4 cases). Two cases were treated conservatively using cast and no weight bearing. Injuries were classified according to Ruedi and Allgower (1979): we had 31% in the first, 31% in the second and 38% in the third group of increasing complexity. Clinical results were evaluated using Ovadia and Beals’s (1986), Ruedi’s (1979) and D’Imporzano’s (2002) criteria. Results: According to Ovadia and Beals we had, objectively, excellent (41.7%), good (33.3%), fair (16.7%) and poor (8.3%) results and, subjectively, excellent (33.3%), good (41.7%), fair (12.5%) and poor (12.5%) results. The percentage of excellent and good results was 70% according Ruedi’s criteria.In these series we had 2 infections, 4 cutaneous necrosis, 1 case of pseudoarthrosis and 3 cases of vascular complications (dvt). Conclusion: These kinds of fractures often represent a difficult challenge for the orthopaedic surgeon. He has to find a balance between aggressive open reduction and osteosynthesis to reproduce tibial articular surface and bone’s and soft tissue’s biology to gain early motion and avoid complication like cutaneous necrosis and venous thrombosis.

DISTAL TIBIA FRACTURES: LOW PROFILE LCP VERSUS EX-FIX M. Inguaggiato [2], G. Rocca [3] di Otopedia e Traumatolgia OCM, Verona, Italy; [2] Clinica Ortopedica, Ospedale Policlinico, Verona, Italy; [3]Struttura Funzionale di Traumatologia OCM, Verona, Italy A. Scalvi

[1],

[1]Divisione

The treatment of the distal tibia fractures has always been a subject of discussion. Having no muscles, this anatomic area is characterized by a critical vascularization. The soft tissues, skin and subcutaneous tissues are often very swollen and contused because of the twisting and tractions they get with the trauma. This damage of the tissues has always caused important infective and necrotic complications that can lead to a failure of the osteosynthesis. For this reason the surgical approach has to be very attentive in evaluating the status of the soft tissues from which depends timing and treatment procedure. The anatomic reduction of the tibial joint surface is mandatory in order to avoid painful arthritis with future evolution into articular ankylosis. After a large case report revision we compare the results of the treatment of these fractures with two different methods: Ex-Fix versus LCP.

MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS (M.I.P.O.) FOR TIBIAL PILON FRACTURES G. Panegrossi, M. Papalia, F. Casella, F. Falez Ospedale Santo Spirito in Sassia, Rome, Italy Fractures of the tibial pilon are notoriously difficult to treat and traditional methods of fixation are often associated with important lesions of the surrounding soft tissues. Minimally invasive osteosynthesis techniques of the distal tibia offer several advantages compared to classic open reduction and internal fixation. A mechanically stable fracture-bridging osteosynthesis can be obtained using a small approach, resulting in less surgical trauma to the bone and soft tissues. In this retrospective study we observed the results and complications in eight patients treated for fractures of the distal third of the tibia with locking-screws plate and less invasive technique, with a minimum follow-up of ten months. Reduction of articular frag-

ments was obtained with a small medial access secondary to careful preoperative CT evaluation. All fractures are healed; two cases of delayed union have been observed, but no one showed healing suffering of the surgical wound. The use of this mini-invasive reduction and osteosynthesis technique has been complicated and it has required strict radioscopic intraoperative control, but it has considerably decreased surgical trauma on the soft tissues.

USE OF EXTERNAL FIXATION IN THE TREATMENT OF PILON TIBIAL FRACTURES F. Lavini, R. Bortolazzi, C. Dall’Oca, E. Carità, G. Gioia, L. Bonometto, P. Bartolozzi Clinica Ortopedica e Traumatologica, Università degli Studi di Verona, Italy Objective: Medium-long term results in pilon fractures treated with bridging or hybrid external fixation. Materials and Methods: From 2000 to 2004 34 patients affected by 13 Ruedi-Allgower type I fractures, 14 type Ii, 7 type III, whose average age was 47 have ben treated using external fixation. C.T. was performed preoperatively. Ovadia-Beals evaluation form has been used at follow up performed after an average period of 27 months. Results: 32 fractures healed in av. 107 days. We do not report non union or skin sloughing. 13 patients showed at the latest x ray clear signs of arthritis. In two cases we observed screws osteolysis followed by fixator removal and plaster cast application. 1 case of deep infection occurred in a Gustilo 3b fracture taht required a BKA.1 case of early arthritis required ankle fusion. Conclusion: Post traumatic arthritis (30%) is comparable with the percentage reported by other Authors and it seems correlated by articular cartilage damage, the energy of trauma and soft tissues involvement. External fixation helps to reduce the early complication such as deep infection, amputation, non union. This method does not reduce the incidence of post/traumatic arthritis, even in the case of anatomic and stable reduction radiografically evident.

EVOLUTION IN TREATMENT OF PILON FRACTURES F. Castelli, R. Spagnolo, D. Capitani Ospedale Niguarda Ca’ Granda Dea, Milan, Italy Objective: The treatment of tibial pilon fractures devolops, improves in implant’s design and in surgical approaches. Materials and Methods: We studied new surgical approaches and new implants with angolar stability. The surgical approaches were the antero-lateral one with isolation of saphenal nerve or a lateral 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 way, on tibial pillar fractures we need: - simple articolar fracture - reducible articular fragments throug indirect tecnique - Intregrity and reducible medial and posterior malleolus - excellent conditions of soft tissue. Conclusion: In the reduction of tibial pilon fracture we can use the antero-lateral approach thanks to the low rate of complications. We suppose that muscles and tendons protect the skin whithin the plate and help the subcutaneous blood supply. Mipo tecnique in treatment of tibial pilon fractures allows goods results only in specific cases, taking care of instructions and technique with the respect of the soft tissue. Finally, minimal invasive approach in osteosinthesis of articular fractures, as in other cases, is not an advantage “per se”. The choice of a minimal invasive approach should be carefully considered in front of the risk of a malreduction of the articular joint that is in any case unacceptable. Anatomically reconstruction of the

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articular joint is mandatory so that during the operation we have to change the approach from a minimal invasive approach to an artrotomy through a classical view.

markedly long and thick. Therefore, with LCP technique, surgeons can treat two sites of the same fracture simultaneously, making only two small incisions.

RESULTS OF MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS OF FRACTURES OF THE DISTAL TIBIA

ILIZAROV’S CIRCULAR EXTERNAL FRAME IN TREATMENT OF C-TYPE TIBIAL DIAPHYSEAL FRACTURES

F. Chiodini, L. Filippi, L. Di Mento, M. Berlusconi Istituto Clinico Humanitas, Rozzano, Italy

G. Lovisetti [1], L. Del Sasso [2], V. Zottola [3], L. Bettella [1] [1] Unità Operativa di Ortopedia e Traumatologia, Presidio Ospedaliero di Menaggio, Azienda Ospedaliera Sant’Anna, Menaggio, Italy; [2] Divisione di Ortopedia e Traumatologia, Azienda Ospedaliera Sant’Anna, Como, Italy; [3]Unità Operativa di Ortopedia e Traumatologia, Presidio Ospedaliero di Cantù, Azienda Ospedaliera Sant’Anna, Cantù, Italy

Introduction: Treatment of fractures of the distal tibia is a surgical challenge: the poor soft tissue covering and the proximity to the articular surface make the surgical procedure more demanding and the results less predictable than those of tibial midshaft fractures. There is no agreement on the best treatment of these lesions: external fixation, intramedullary nailing and open reduction and internal fixation have been proposed but each option has its challenges. Minimally Invasive Plate Osteosynthesis (MIPO) with Locking Compression Plates (LCP) has shown to allow a correct fracture reduction and stabilisation without damaging the soft tissues at the fracture site. We present our results with this technique of treatment of distal tibial fractures on a consecutive series of 16 patients. Materials and Methods: From January 2005 to January 2006 at our institution 16 patients with a fracture of the distal tibia underwent MIPO with LCP. Patients have been evaluated clinically by the AOFAS Akle Score and radiografically monthly until consolidation. Time to union, quality of reduction and complications have been reported. Results: All the fractures eventually healed in a mean time of 18 months. No infections or wound complications have been seen. A valgus deviation > 10° requiring re intervention was found in one patient. With a mean follow-up of 21 weeks the mean AOFAS score was 80. Conclusions: In the treatment of fractures of the distal tibia MIPO with LCP offers the advantage of a good reduction and a stable fixation combined with minimal soft tissue damage.

SESSION O10 SHINBONE II TREATMENT OF LEG COMPLEX FRACTURES WITH PERCUTANEOUS LCP OSTEOSYNTHESIS F. Carotenuto [1], E. Favre [1], L. Curci [2], C. Di Bonito [3], N. Vendemmia [2] [1]Clinique General de Savoie, Chambery, France; [2] Policlinico Universitario “Federico II”, Naples, Italy; [3]Ospedale G. Rummo, Benevento, Italy 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 fractures involving the knee and ankle joint articulations are still difficult to treat. We describe the treatment of complex leg fracture or tibial diaphysis with percutaneous osteosynthesis using Liss LCP plate (locking compression plate), a technique that requires only two minor percutaneous incisions to insert the plates and fix the screws. The advantage of preserving the site of the fracture and the minimal invasiveness of this technique allow a safe and rapid bone consolidation, thus reducing the surgical risks of invasive incisions and facilitating post-surgical recovery. Furthermore, this percutaneous technique appears to be the ideal solution for the treatment of fractures involving joint articulations where, indeed, the incisions can be

Reduction and osteosynthesis of multifragmental high energy fractures of the tibial diaphysis with intramedullary nails can be difficult and in some instances it may expose to compartimental syndromes. Open techinques should avoid large exposures and do not permit early weight bearing. We consider Ilizarov apparatus a concrete alternative in treatment of these lesions: it consents closed careful reduction, stable osteosynthesis, soft tissue sparing, multisegmental control of the fixation and very early weight bearing. Materials and Methods: From 1993 we treated 15 tibial diaphyseal fractures 42C in 15 patients, mean age 40 years (range 19 – 64), classified as follows: 42C13 : 5 cases, 42C2: 8 cases (type 1: 2 cases, type 2: 3 cases, type 3: 3 cases), 42C33: 2 cases. 6 fractures were open: Gustilo type 1: 1 case, type 2: 4 cases, type 3A: 1 case. Results: Consolidation occurred in 15/15 cases after a mean of 27.3 weeks. We observed no case of limb lenght discrepancy, significant sepsis, malconsolidation with axial deviation. Clinical result has been judged excellent or good in all cases. Discussion: Ilizarov circular frame has been a valid approach to these lesions.The respect of the bone fragment periostal and endostal vascularization led to a complete consolidation also in presence of 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.

USE OF LESS INVASIVE STABILIZATION SYSTEM (LISS) IN THE TREATMENT OF COMPLEX PROXIMAL ARTICULAR FRACTURES OF THE TIBIA F.V. Sciarretta, A. Pecora, P. Zavattini Ospedale Civile, Velletri, Italy In order to obtain a clinical functional good outcome, complex proximal fractures of the tibia require operative treatment. In this paper, the Authors present the results obtained with the new LISS system that enables, through the indirect fracture reduction, combination of correct fracture reduction with less soft tissue trauma, enhancing fracture consolidation.

SURGICAL TREATMENT OF COMPLEX FRACTURE OF TIBIAL PLATEAU M. Villano, C. Carulli, M. Pietri, M. Innocenti II Clinica Ortopedica, Università degli Studi, Florence, Italy Complex fractures of tibial plateau present an increase due to the ingrowth of high energy trauma. Because of their sequelae, treatment has to be aggressive in a way to obtain good stability and anatomical reduction: this approach is effective in young adults, but joint replacement seems to be the only choice in elderly patients, often afflicted by arthritis and osteoporosis. Between 1997 and 2005, we treated 23 complex fractures of tibial plateau among 45

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cases (Schatzcker IV°-V°-VI°): 12 female and 11 male patients, average age 46 years (19-71), average follow-up 4 years (2-7). We evaluated our results with Hohl score: we obtained good results with open reduction and plate fixation (excellent: 18.8%, good: 62.4%, sufficient: 18.8%) and no cases with poor result. These results make us believe that in young people a good reduction and stable fixation permit short recovery and excellent functional outcome.

RESULTS OF PROXIMAL TIBIA FRACTURES TREATED WITH THE LISS F. Atzori [1], A. Biasibetti [1], G. Di Gregorio [1], A. Gallo [2], R. Matteotti [2] [1]Traumatologia C.T.O., Turin, Italy; [2] Dipartimento di Ortopedia e Traumatologia, Turin, Italy Proximal tibia fractures present a difficult treatment challenge with historically high complication rates. We retrospectively observed 28 proximal tibia fractures treated with the LISS. The fractures were classified in accord with AO metod. The follow-up was 22 months (range, 6 - 35 months) and included clinical examination using -Knee Society Scores-, functional subjective score using -Koos Knee Survey- and radiologic outcome. In conclusion, the LISS provided stable fixation of extra-articular and intra-articular proximal tibia fractures and good functional outcomes with a low complication rate.

TIBIAL CONDILAR FRACTURES, TREATMENT WITH LCP PLATE AND “NORIAN” R. Mezzalira ASL 6 Ospedale Civile, Ciriè, Italy The articular tibial plateau fractures, like those of other districts, introduce remarkable difficulties of indication and treatment. These fractures often cause disability, like secondary osteoarthritis, inexorably leading to a prosthesis substitution. The aim of this study is looking through the possibilities which recent internal fixation methods offer, associated with a bone substitute, in those types of fractures treatments. The considerable stability of LCP, which act as “internal fixing device”, associated to a low damaging and more conservative technique towards the periosteum and the soft tissue, and to the use of synthetic bone which is more and more reliable and avoid bone grafts transplantation, undoubtedly can facilitate the 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 term, although excellent, and the small number of analyzed cases, do not allow a rigorous valuation.

(4) complications (5) functional recovery (6) a modified score to record patients outcome at each clinic visit. Discussion: Severity of injury, age of patient, residual malalignment and knee instability are conditioning for outcomes Conclusion: We have observed that in the same clinical conditions adults tolerate articular incongruity better than elder people and have a longer gap to develope postraumatic arthritis.

INDICATIONS FOR OPEN ARTICULAR REDUCTION IN TIBIAL PLATEAU FRACTURES M. Stopponi, A. Basile, A.U. Minniti de Simeonibus II U.O.C. Ortopedia e Traumatologia, Az. Ospedaliera S. GiovanniAddolorata, Rome, Italy In order to follow the trend for limited aggressive surgery, many techniques for closed reduction of tibial plateau fractures have been developed. Indirect reduction by ligamentotaxis and closed articular visualization by arthroscopy or radioscopy are some of the methods used. It has not been well defined which kind of fractures are best treated by these methods, aiming to obtain a congruent joint surface, and a stable fixation that allows an early range of motion. Open techniques usually allow a better direct visualization of the fracture, so 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 determined depending on the fracture characteristics. Most important factors are stability, dislocation of the fragments, especially articular ones, comminution, fracture localization, skin condition, ligament or meniscal tears. Surgeon must obtain the best stabilization of the fracture so that cartilage can heal in an optimal, long lasting situation. Joint functionality after fratures, depends on joint congruence, stability, correct articular load distribution and physiologic cartilage biology. Articular reduction must be as accurate as possibile, avoiding wide dissections and periostal stripping of fracture fragments. Contemporary fixation hardware is studied for a limited invasivity and minimally interfere with bone biology. 4 yrs clinical and radiographical results of 21 tibial plateau fractures, all treated with open articular reduction, are reported. 15 fractures were stabilized with plate and screws, 6 with external fixation. Mean articular step was 1 mm. At late follow-up only 3 knees presented moderate arthritic lesions.

SESSION O11 PROXIMAL

LONG TERM FOLLOW-UP OF TIBIAL PLATEAU FRACTURES

FEMUR

MID AND LONG TERM EVALUATION OF A SERIES OF 19 FEMORAL HEAD FRACTURE

L. Pisano [1], V. Sessa [2], F. Forconi [3], A. Fernicola [4] [1]Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy; [2]Ospedale Fatebenefratelli, Isola Tiberina, Rome, Italy; [3]Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy; [4]Az Osp S Giovanni, Rome, Italy

N. Papapietro [1], M. Oransky [2] [1]Area di Ortopedia e Traumatologia, Università Campus BioMedico, Rome, Italy; [2]Azienda Ospedaliera San Camillo Forlanini, Rome, Italy

Objective: To evaluate the long term clinical outcomes for patients affected by tibial plateau fractures with a minimum of 5 years from surgery. Materials and Methods: Sixty patients have been evaluated at 1 year, 2 year, and more than 5 year from trauma considering (1) demographic features (2) fracture’s classification(Shatzker) and surgical technique (3) associated injuries

Introduction: The femoral head fracture is an uncommon (and serious) injury. The majority of the Authors recommend the SmithPetersen approach, but recently the trochanter-flip was suggested by other Authors. In our experience the Kocher-Langenbeck can be used in cases with associated acetabular fractures. This injury may result in an important number of failures, if not properly treated. Materials and Methods: From 1985 to 1999 we treated 19 patients, 12 males and 7 females. The clinical and radiological results were

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classified according to Merle D’Aubignè and to Epstein radiological classification. Results: We retrospectively reviewed a series of 19 cases over a period of seventeen years, and found the occurrence of femoral head geodes, with joint line preservation and no correlation with clinical results. Regarding the first group of patients treated conservatively we had one anatomic reduction, one imperfect reduction with 2mm of residual displacement and one unsatisfactory reduction with a displacement of over 5 mm. In the second group of six patients, treated by fragment excision, the results were excellent in two cases (one Pipkin II and one Pipkin IV fracture), 2 patients had osteonecrosis and one healed with ankylosis in good position because of Brooker IV ossifications, with no pain. Discussion: Most of the Pipkin type I and II fractures are adequately treated by Smith-Petersen approach. Compression fixation with titanium Herbert screws is advisable to allow in future MRI. The quality of reduction of an associated acetabular fracture plays a fundamental role. Initial cartilage damage at long term favors secondary arthrosis. It was also evident in four cases of our series the presence of geodes of the femoral head, not associated to joint line reduction or acetabular geodes (remodeling) or a clinical simptomatology. In future these geodes can be theoretically treated by alternative conservative methods as grafting.

TREATMENT OF THE FEMORAL HEAD OSTEONECROSIS WITH CORE DECOMPRESSION AND AUTOLOGOUS PLATELET-DERIVED GROWTH FACTORS A Gigante, C. Bevilacqua, M. Cappella, E. Cesari, F. Greco Clinica Ortopedica, Università Politecnica delle Marche, Ancona, Italy The treatment of choice in the early stages of femoral head osteonecrosis has not been defined yet. Core decompression of the femoral head is the most common surgical procedure, however its results are controversial. Recently the use of growth factors has been suggested to stimulate bone repair. Platelet-rich-plasma (PRP) represents a non-expensive source of several growth factors with osteoinductive and angiogenetic properties. The present study evaluated the results of surgical treatment of early femoral head osteonecrosis by core decompression and autologous bone graft enriched with PRP. Nine patients (6 male and 3 female, mean age 38.7 years, 3 bilateral and 6 monolateral) affected by femoral head osteonecrosis (stage I e II of Steinberg classification) have been treated with core decompression associated to autologous bone graft and PRP. All patients were clinically evaluated with the use of Harris hip score preoperatively and at 1, 3, 6, 12 months after surgery. X-rays and MR were performed preoperatively and at 1, 3, 6, 12 months after surgery. Clinical evaluation revealed a reduction of symptoms and an increased Harris hip score (p<0.05) after surgery. X-rays at 6 and 12 months showed no femoral heads alterations. MRI evidenced edema reduction, no signal modification neither extension increase of the necrotic areas. This study demonstrated the efficacy of core decompression associated to autologous bone graft enriched with PRP in the treatment of early femoral head osteonecrosis. The use of autologous growth factors from PRP seems to stimulate lesions repair, with a positive clinical outcome and MR imaging improvement.

OUR EXPERIENCE IN THE TREATMENT OF MEDIAL FRACTURES OF THE FEMURAL NECK IN YOUNG PATIENTS BY OSTHEOSYNTHESIS WITH CANNULATED LAG SCREWS M. Candela, G. Mazzarella, M. Arena, S. Anastasio U.O. Ortopedia e Traumatologia, Ospedale S.Francesco di Paola, Paola, Italy The medial fractures of the femural neck affect the anatomical region included between the femural head and the inter-trochanteric line; the

position, the orientation and degree of displacement of the fracture determine the severity of the vascular damage at the expense of the proximal epiphysis, thus influencing the type of treatment needed. Pauwels was the first to classify these fractures in 1935, dividing them into three groups according to the angle formed by the fracture and the horizontal surface. The most recent though most complex classification is represented by the AO system, in which the fractures are also divided in three groups. In this study we used the classification issued by Garden in 1961, which identifies 4 kinds of medial femoral neck fractures, considering types I and II for patients aged under 60 or presenting pathologies which would not recommend the use of arthroprosthesis. We are reporting our own experience of 10 cases treated by means of percutaneous ostheosynthesis using titanium cannulated lag screws. All patients underwent continuous passive mobilization from the first day after surgery with absolute restraint from weight bearing for 60 days. The reductions obtained kept perfectly in the follow-up checks and the functional and clinical results proved excellent or good. According to our experience we can assert that this method offers various advantages: minimum surgical invasiveness and aesthetic damage, direct control of the anatomic reduction obtained, low mortality risk, rapid performance and possibility of applying an arthroprosthesis in case of failure due to vascular complications. Summing up, this method can be regarded as a valid alternative in the treatment of medial fractures of the femural neck, but must be performed in strictly selected cases, being aware that in case of failure the application of an arthroprosthesis is needed.

HIP REPLACEMENT IN LATERAL FRACTURES OF THE PROXIMAL FEMUR C. Carulli, M. Villano, R. Civinini, M. Innocenti II Clinica Ortopedica, Università degli Studi, Florence, Italy Although not common, hip replacement in lateral fractures of the proximal femur represents a well-known solution and is widely described in literature. This choice allows an early total weight-bearing and a quicker functional recovery. On the other hand, surgery is longer and more complex in comparison with internal fixation and hip replacement in intracapsular femoral neck fractures. In our Department, 18 patients (19 cases) with trochanteric fractures were treated with cemented hip replacement, using a Versys Cemented Revision/Calcar (CRC) prosthesis associated with cerclage or modular wedges: 13 were female and 5 male patients, with an average age of 77 years (46-89); 12 were right and 7 left hips. Pre-operatively evaluation was performed with schedules regarding general conditions, functional scoring (ASA, ADL, IADL) and with Harris Hip score. Two patients were lost at follow-up. Post-operatively Harris Hip score was good; no loosening or instability was revelead at X-rays control and all stabilized trochanteric fractures were healed. These results allows us to believe that cemented hip replacement of trochanteric fractures, with or without further stabilization (cerclage or calcar substitution), is a good choice in selected cases with adequate local and general conditions because of the quick recovery of weight-bearing and the low rate of complications.

EVALUATION WITH SAHFE PROTOCOL (STANDARDIZED AUDIT OF HIP FRACTURE IN EUROPE) OF 75 LATERAL FEMORAL NECK FRACTURES TREATED BY INTRAMEDULLARY NAILING G. Montemurro, F. Messore, P. Fanelli Ospedale di Anagni, Italy The SAHFE (Standardized Audit of Hip Fracture in Europe) protocol is a European project that suggested, through the analysis of multicentric data, standardization of the approach and treatment of the femoral neck fracture in elderly people. In the present study our

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report is relative only to lateral femoral fracture. The protocol implies a report at patient admittance followed by postoperative and four month follow-up data. These data were collected through interviews to the patients or, in special cases, to their relatives. This study was conducted from December 2002 and December 2005, enrolling 75 patients (45 female and 30 male) with mean age 75.5 years (66-97); all these patients were affected by lateral femoral fractures. The protocol needs the registration of the following data, divided into 5 parts: 1. Patient status before fracture; lifestyle, walking ability with or without aid, ASA (the American Association of Anaesthetists level of anesthesiological risk) score 2. Type of fracture and way of treatment 3. Waiting time before surgery, time of recovery, destination at discharging 4. Lifestyle at 4 months follow-up 5. Possible complication related to surgery. Usually in stable lateral femoral fractures we performed a synthesis by single cephalic screw nailing (Gamma, Stryker); in unstable and subthrocanteric fractures we used double cephalic screw nailing (PFN, Synthes). In particular patients (2) in bad general condition we preferred an external fixator (Orthofix). Besides, we collected 10 patients in which surgical treatment was impossible due to severe general conditions. We reported our results concerning the analysis of the above mentioned data.

SIDE FRACTURES OF THE NECK OF FEMUR TREATED WITH ENDOVIS BA: OUR EXPERIENCE A. Panella, D. Mongelli, U. Orsini, A. Martucci, M. Panella Unità Operativa di Ortopedia e Traumatologia Universitaria, Bari, Italy The increase of the population average life time involves an increase 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 parameters, between which it is often necessary to identify the best compromise. 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 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 cephalic screws and the possibility of distal blocking.

tion (firmly anchored to the nail). Early evaluation (4-6 months follow-up) are based on operating time, necessity of reaming, postoperative blood transfusion, functional recovery using a modified Harris hip score, mechanical complications, mortality. Results: 5 patients died, in 94.9% of patients nail has been inserted without diaphyseal reaming, in 38% of cases, 1.62 I.U. of blood have been infused postoperatively, mean application time (skin to skin) was 47 minutes, preoperatory modified Harris hip score was 72 (scale maximum is 91), at discharging was 45% of the preop, at 6 weeks 87% of the preop, 3 cut-out have been reported, followed by hip prosthesys. Discussion and Conclusion: The observations based on the reported results and the literature, allow to conclude that the system has a low degree of invasivity, ensures a quick functional recovery and shows a minimal percentage (2.5%) of mechanical complications.

ENDOVIS BA NAIL: OUR EXPERIENCE G. Bruno, F. Saponara, A.O.V. Gonnella, R. Pepe, L. Mazzucca Ospedale San Giovanni di Dio, Melfi, Italy This is to present the experience gained in our ward of Endovis B.A. Nail as used in lateral fractures of femural neck from May 2005 to February 2006. We are going to discuss our indications, the advantages over other kinds of fixation, the possible problems during and after the surgical procedure. The duration of the operation, the assembling versions, the bleeding, the staying in hospital after surgery, the function and deambulation recovery after the rehabilitative programme have been taken into account.The patients had being followed up both during the hospitalization and one, three, six months after surgery. Endovis B.A.Nail proved to be an excellent choice compared with DMS plate fixation, almost the only kind of surgical treatment we have experioenced for these fractures until the beginning of 2005.

SESSION O12 FEMUR

DIAPHYSIS AND DISTAL FEMUR

ANGLE STABLE PLATES IN DIAPHYSIAL DISTAL FRACTURES 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 F. Lavini [1], L. Renzi Brivio [2], P. Di Seglio [3], P. Cherubino [4], M. Manca [5], L. Aluisa [6], W. Leonardi [7], N. Galante [8], P. Bartolozzi [1] [1]Clinica Ortopedica e Traumatologica, Verona, Italy; [2]Ortopedia e Traumatologia, Mantova, Italy; [3]Ortopedia e Traumatologia, Novara, Italy; [4]Clinica Ortopedica e Traumatologica, Varese, Italy; [5]Ortopedia e Traumatologia, Massa e Carrara; [6]Clinica Ortopedica e Traumatologica, Rome, Italy; [7]Ortopedia e Traumatologia, Catania, Italy; [8]Ortopedia e Traumatologia, Castellaneta, Italy Introduction: Pertrochanteric fractures are common in elderly people; for this reason early results are based on mortality rate, functional recovery, biological and mechanical complications. Materials and Methods: 118 patients (87 females, 31 males) aged between 47 years and 98 years (mean age 79.4 years) sustained 58 fractures type A1, 48 fractures type A2, 8 fractures type A3 (AO classification). They were treated with Veronail, an I.M. device that offers the option of applying two cephalic screws in parallel configuration (allowing controlled compression) or convergent configura-

The Authors present their experience in the treatment of diaphysial and metaepiphysial distal fractures of the femur, treated with angle stable plates. 15 cases of periprosthetic fractures and of sopraintercondylar fractures are presented. There is an analysis of the results obtained and of the complications, including the mobilization of a Liss plate. The conclusion is that the system of angle stable plates is effective in the treatment of this type of fracture, and in most cases it makes it possible to avoid exposure of the focal point of the fracture, and lessens post-operative hematic loss. In the presence of osteoporosis it is advisable to carry out adequate bicortical proximal fixation.

TREATMENT OF IPSILATERAL FEMORAL SHAFT AND TROCHANTERIC FRACTURES F. Castelli, R. Spagnolo, D. Capitani Ospedale Niguarda Ca’ Granda Dea, Milan, Italy Objective: Treatment of ipsilateral femoral shaft and neck fractures with reconstruction nails or cephalomedullary nails.

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Introduction: An ipsilateral femoral neck fracture is rare and occurs in approximately 6 to 9% of the all femoral shaft fractures. The diagnosis 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 procedure. We believe that in case of femoral shaft fracture due to high energy trauma the state of the femoral neck should be checked before operation by CT or tomogram; this is the only certain way of detecting a subclinical fracture. Materials and Methods: Authors describe their experience in treatment of 28 ipsilateral femoral neck and shaft fractures treat from 2001 to 2005. For the 28 patiens eligible for the study, the AO classification system was used to describe the proximal and the shaft fractures. The Proximal Femoral Nail Long – Synthes is indicated for each ipsilateral lateral proximal and shaft fractures of the femur, pertrochanteric multifragmentary with subtrocantheric extension fractures, subtrocantheric multifragmentary fractures and in subtrochanteric fractures with extension to the femoral shaft. In these last cases, authors confirm good results and choose the PFN long system instead of other treatment. In author’s experience PFN long system is the “gold standard” in the treatment ispilateral medial poroximal and shaft fractures. The major advantages of this technique are that one device can be used in the management of both fractures, and compression of the neck fracture can be achieved with the use of a partially threaded lag screw. Results: The major advantage of cephalomedullary nails is that one 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 neck fracture by the use of a partially threaded duble lag screw.

tures; the anterograde and retrograde techniques offer an almost overlapping percentage of recovery.

RETROGRADE INTRAMEDULLARY NAILING IN DISTAL FEMORAL FRACTURES O. Moreschini, M. Anwar, M. Pagliari, M. Tardiola Rome, Italy The purpose of the present study is to report our experience with the use of retrograde intramedullary nail (Distal Femoral Nail (DFN)) to treat distal femoral fractures. We treated 30 patients (21 M, 9 F), between September 1999 and November 2005. The mean patient age was 64 years (range 44-71 years). All 30 patients were available at the time of final follow up and proceeded to union at an average time of 12 weeks (range 5-17 weeks). We evaluated all patients with the use of the Neer rating system: the functional scores were excellent in 14 cases, good in 11 and fair in 5. ROM of the knee joint ranges from 60 degrees to 130 degrees, with an average of 105 degrees. None pseudoarthosis were observed. Two cases of distal locking screw breakage were also observed. There were no iatrogenic complications of the vascular type, nor were there infections. The results we obtained suggest that DFN represents a valid alternative to the open treatment of fractures of the distal metaphysis of the femur; these treatement reduce invasiveness, allow early mobilization, awarded to less blood loss and shorter amount of time require for surgery.

THE TREATMENT OF THE DISTAL FEMORAL FRACTURES WITH LISS PLATES - 3 YEARS EXPERIENCE [1], A. Migliorini [2], G. Rocca [1] Funzionale di Traumatologia OCM, Verona, Italy; Clinica Ortopedica, Ospedale Policlinico, Verona, Italy

P. Savonitto [1]Struttura

THE TREATMENT OF FEMORAL SHAFT FRACTURES WITH ANTEROGRADE AND RETROGRADE INTRAMEDULLARY NAILING M. Candela [1], M. Arena [1], S. Anastasio [1], G. Mazzarella [1], A. Barletta [2] [1]U.O. Ortopedia e Traumatologia, Ospedale S. Francesco di Paola, Paola, Italy; [2]U.O. Anestesia e Rianimazione, Ospedale S.Francesco di Paola, Paola, Italy Objective: The femoral shaft fractures are constantly growing among the population, as a result of the increasing in the incidence of high-energy injuries, which represent the most frequent cause of such fractures. Materials and Methods: Between January 2005 and March 2006, we examined 14 cases (13 patients) of femoral shaft fractures, evaluated according to the AO classification, all of which were treated with intramedullary locked nailing. The case study also includes some retrograde 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 of clinically clear malrotation, nor of relevant shortening of the fractured limb. In no cases the knee ROM underwent any limitation Discussion: Thanks to the remarkable improvements in the surgical 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 presence of associated injuries in the same or in other skeletal segments, concomitant visceral damage and possible exposure of deep tissues. In order to allow an early recovery of movement and walking, there is a general agreement that the intramedullary locked nailing guarantees undoubted advantages, as it is a minimally invasive technique which quickly stabilizes and preserves the fracture focus. Conclusion: Currently the intramedullary locked nailing is considered as the elective method for the treatment of femoral shaft frac-

[2]

The femur metaphiseal fractures are the 8% of all fractures. They are normally caused by a violent trauma to the knee at flexed hip (dashboard lesion). The action of the strong muscular mass inserted in the area leads to a characteristic displacement of the fractured stumps. In particular, the combined action of the gastrocnemious and the quadriceps flex dorsally the condyles and this brings often to the fracture of the anterior metaphiseal area. When the trauma divides the two condyles, these flex dorsally with a rotating effect often very different between the medial and lateral condyle. The osteosynthesis of this anatomic area has never offered strong stability guarantee of the progressive decrease of the cortical bony tissue. LCP plates, thanks to the screw heads with the same thickness of the plate, guarantee the grip independently by the porosity of the bone. The forced multiplanar orientation of the screw increases, moreover, the pull-out strength of the whole system. We have been using LCP system for 3 years. Results are shown here.

SESSION O13 FEMUR

MISCELLANEOUS

PSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WITH SEVERE PHYSICAL INJURIES C. Carducci, E. Menichetti Ospedale S. Camillo – Forlanini, Rome, Italy Extensive literature associates the exposure to traumatic events with the occurrence of psychological disorders: depression, anxiety, specific phobias, Post Traumatic Stress Disorder (PTSD), phobic avoidance, substance abuse (Shalev, A. Y. and coll. 1998; Usano, R.

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J. and coll. 1999; Koren, D. and coll. 1999; Schnyder, U. and coll. 2000; Mayou, R. and coll. 2001; Schnyder, U. and coll. 2001; Zatzick, D. F. and coll. 2002). That being so, patients whit severe physical injuries were recovered and evaluated at Orthopedic division of S. Camillo-Forlanini Hospital from March 2005 to January 2006. In this period 69 patients (51 men; 18 women) were included in this study. The age ranged from 16 to 65 (average = 30.7 years). From this group of patients, people with severe head injuries, suicide attempters and victims of physical assault were excluded, due to previous psychological problems. This exclusion gave a greater homogeneity to the group. Psychometric instruments included: a Biographical questionnaire, Minnesota Multiphasic Personality Inventory (MMPI), Rathus and Zuckerman. Qualitative analysis showed the group was made up of subjects with pathologies that were correlated and non-correlated between them. The main diagnosis turned out to be the Deferred Diagnosis. With such terms we refer to a great area of comorbidity that does not allow a definition of a precise diagnosis, yet such afferent psychopathological problems are all of Anxious-Depressive nature. Such data cannot be underrated since the same results have been obtained from international studies on this subject. Therefore we can assert that exposure to traumatic events can provoke Anxious-Depressive symptoms which can become pathologically stabilized in a period of time if not adequately cured. The present study is still in course and the final results will therefore make reference to a wider group.

FLOATING KNEE: IPSILATERAL FRACTURES OF THE FEMUR AND TIBIA G. Bonanno [1], C. Villani [1], G. Manfredini [1], F. Stacca [1], R. Loschi [1], C. Zapparoli [2] [1]Clinica Ortopedica, Università degli Studi di Modena e Reggio Emilia, Policlinico, Modena, Italy; [2]U.O. Ortopedia e Traumatologia, Nuovo Ospedale S.Agostino, Estense, Modena, Italy Introduction: The ipsilateral fracture of femur and tibia includes a combination of diaphysal, metaphysal and intra–articular fractures. It is caused by high-energy traumas as auto and motorcycle ones, and it is associated with cranial, thoracic and abdominal lesions, elevated risk of pulmonary embolism and involvment of the soft tissue. The approach to the patient is initially based on the identification and treatment of lesions to organs and apparatus. Later on the treatment of every fracture is individually decided, in order to get the best possible results keeping in mind all the lesions present in the limb. Material and Methods: Our case history includes patients treated in the Orthopedics Clinic from January 1995 to December 2005. The classification of the fractures is based on the anatomical location according to the Fraser classification (1978). The type of treatment, in relationship to the local conditions of the limb and the emo-dynamic condition, includes external fixation, ORIF, intramedullary nailing and non operative treatment. The long term results were evaluated in 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 a large loss of soft tissue, compartment syndrome and vascular – nervous lesions, possibly on the same occasion. In case of stable patients with articular fractures the treatment is preferably deferred to allow an improvement of the cutaneous condition in order to get minor complications and best results at long term. The most frequent long term complications are represented by delayed union, non union, malunion, dysmetria, instability and ROM reduction of the knee.

INCIDENCE AND COSTS OF HIP FRACTURES IN ITALY P. Piscitelli [1], G. Iolascon [2], G. Giuseppe [2] [1] Libera Università Mediterranea, Bari, Italy; Università di Napoli, Naples, Italy

[2]

Seconda

Objectives: Monitoring incidence and costs of hip fractures in Italy. Methods: We examined the Italian national hospitalization database (SDO) hold by Ministry of Health concerning year 2003 (the most recent available data), considering the following ICD-9CM codes for main diagnosis: 820.0, 820.1 (cervical hip fractures), 820.2 e 820.3 (intertrochanteric fr.), 820.8, 820.9 and 821.1 (other hip fr.). Costs were estimated by considering all the related DRG (Diagnosis Related Groups). Results: Overall, hip fractures occurred in 29.702 men (14,5 average hospitalization days) and 76.041 women (15.5). Between 65 and 74 years old in: 4.107 (15.7) men and 10.903 (15.6) women; over 75 y.o. in: 15.613 men (15.6) and 59.173 women (15.7). Therefore, incidence of hip fractures is higher in the oldest age groups and particularly in women, according to the distribution of osteoporosis in the population. Over 65 y.o., direct costs for hospitalization exceed 400 million Euros, to be added to further 460 million Euros for rehabilitation.

THE USE OF INTERNAL SYNTHESIS AFTER EXTERNAL FIXATION IN POLITRAUMATIZED PATIENTS F. Lavini, E. Carità, R. Bortolazzi, C. Dall’Oca, G. Gioia, L. Bonometto, P. Bartolozzi Clinica Ortopedica e Traumatologica, Verona, Italy Objective: In this study the authors evaluate the results of internal synthesis of femoral fractures in politraumatized patients initially treated by external fixation (EF). Materials and Methods: From January 2002 and December 2005, 39 femurs in 37 politraumatized patients (average age 34.2 yy 1844) with closed fractures and ISS>20 were initially treated with EF. Group A: 13 cases after 4-7 days (average 5.6). Group B: 11 cases after a longer period of 4-6 months and after execution of MRI and scintigraphy with labelled leucocytes. Group C: remaining cases healed with EF. Time of healing, lower limb function, time of return to previous activities and short and long-term complications were evaluated at the follow-up. Results: Average time of follow-up was 23 months. Group A: time of bone healing 123 days, no embolism, one case of pseudoarthrosis, one case of breaking of instrumentation. Group B: time of bone healing 274 days, one case of pseudoarthrosis, one case of deep infection. Group C: average healing time 193 days, 3 cases of screws osteolysis. Functional resumption was delayed by presence of other fractures. Discussion and Conclusion: External fixation is a simple, quick and safe procedure to stabilize fractures in politraumatized patients. According to Damage Control Orthopaedic (DCO) concepts, after an adequate period, it is possible to replace EF for internal synthesis in order to reduce general risks of this treatment in emergency and to take advantage in post-operative management. EF can be maintained until the end of treatment but, when a change of synthesis is needed, it is possible to do it safely after checking the absence of infectious bone disease.

THE TREATMENT OF TRANSIENT BONE MARROW EDEMA SYNDROME OF THE PROXIMAL FEMUR WITH HYPERBARIC OXYGEN THERAPY A. Capone [1], D. Podda [1], V. Setzu [2], C. Iesu [3] [1]Clinica Ortopedica e Traumatologica, Cagliari, Italy; [2] Casa di Cura Lay, Cagliari, Italy; [3] Ospedale Marino, Cagliari, Italy Background: Transient bone marrow edema syndrome of the femur is a recently well-documented entity that was first described as transient osteoporosis of the hip. Typically the clinical presentation is characterized by acute, progressive pain in the hip that is exacerbated by weight-bearing and by a functional disability involved the affected limb. The Magnetic Resonance Imaging (MRI) shows diffuse low signal intensity in T1-images and high signal intensity in

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T2-images extending from the femoral head to the intertrochanteric region. The bone marrow edema resolves spontaneously after approximately six-eight months and the treatment of the symptoms is therefore obtained by protected weight-bearing and drugs such as analgesics and disphosphonates. In the treatment of the disease in patients with marked functional disability, physical therapy (electromagnetic fields or hyperbaric oxigen) or pharmacological therapy with diphosphonates or NSAID have been used. Materials and Methods: Two groups of 10 patients affected by bone marrow edema syndrome of the femoral head were selected: the first group received pharmacological therapy alone (analgesics and disphosphonates), the second group pharmacological and hyperbaric oxigen therapy. The clinical outcomes were evaluated according WOMAC evaluation form at 3, 6 and 12 months after the onset of disease. The bone marrow edema pattern was monitored with MRI performed after 3, 6 and 12 months. Results: The mean Womac scores at 3 months was significantly higher (p<0.05) in the hyperbaric oxigen group (71.6 points) than in the first group (55.4 points). The mean WOMAC score at 6 months was over 95 points in both groups. The MRI at 3 months showed the resolution of edema in 30% of group 1 hips and in 60% of group 2 (p<0.05). For all the patients return to the normal values of the MRI images was achieved after an average of eigth months. Conclusions: Patients treated with hyperbaric oxygen therapy recovered earlier from hip pain and limb disability than those treated with only pharmacological therapy. These results suggest that hyperbaric oxygen therapy is effective in treating transient bone marrow edema syndrome of the hip and reduces the time of disability.

In the lapse of time between September 1996 and February 2006, 426 patients with spine tumors have been surgically treated by the same team of surgeons. 175 were primary tumors, 228 were metastases and 64 patients were affected by vertebral localizations of hematopoietic diseases such as plasmocytoma and lymphoma. Eleven cases needed a revision because of instrumentation failure. In more than 90% of these cases, implants broke over the cervical-thoracic and thoraco-lumbar junctions. Thirty-nine patients (8.3%) had surgical complications. Most of these events were related to primary lesions, whose treatment is more and more aggressive and therefore associated with high morbidity. Frequent complications have been –a dura lesion in 2 cases; -a dehiscence or superficial infection of the surgical wound in 10 cases (in 8 cases radiotherapy-related); -transient neurological deficits in 7 cases; -big vessels lesions in 5 cases. Three patients deceased in the immediate post-operative period. One of these events was due to the breaking of the cava vein, another one because of massive pulmonary embolism, the third following a laryngeal edema. We want to point out that local recurrency is the result of the worst failure of the surgical treatment of the spine tumors, above all about primary lesions. Fifty-two patients (15%) out of 344 who were submitted to excisional surgical treatment have had a recurrency after intra- or extra-lesional excision.

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 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 multidisciplinary in collaboration with oncologists and radiotherapists. The average of survival of these patients has increased in recent years. The evolution of anesthaesiological techniques that permit surgical treatments were once considered prohibitive. The application of new adjuvant therapy increases the effectiveness for surgical treatment. Controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. The purpose was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. We review 283 cases in 258 patients suffering from spinal metastases from a solid tumour treated between 1996 and 2005. As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by multidisciplinary approach.

TUMORS I GIANT CELL TUMOR OF THE SACRUM P. Ruggieri [1], R. Biagini [2], G. Bosco [1], M. Rocca [1], M. Di Fiore [1], M. Mercuri [1] [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, Bologna, Italy; [2]Istituto Regina Elena, Rome, Italy Materials: From 1974 to 2002, 25 patients with giant cell tumor of the sacrum were treated at the Istituto Rizzoli: 17 females and 8 males, ranging in age from 14 to 68 years. Mean follow up was 7.2 years. Surgical treatment included 20 curettages plus local adjuvant (phenol) and 1 resection. In 13 cases preoperative selective arterial embolization was performed in order to reduce intraoperative bleeding. Fifteen of the 21 surgically treated cases received preoperative radiotherapy. Surgical margins were intralesional in 20 operated 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 disease, 1 patient died of ovarian carcinoma, 2 patients NED1 after treatment of local recurrence). Two patients had radioinduced malignancies. Conclusions: 80% of patients surgically treated (15 received also radiotherapy) remained continuously disease free. Considered that wide resection may cause severe neurologic deficits, intralesional surgery followed by radiotherapy is the treatment of choice for giant cell tumor of sacrum. Resection is preferable in smaller and distal lesions.

COMPLICATIONS IN ONCOLOGIC SPINE SURGERY A. Gasbarrini, S. Bandiera, F. De Iure, G. Barbanti Bròdano, M. Cappuccio, L. Mirabile, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy

SPINAL METASTASES: TREATMENT EVALUATION ALGORITHM A. Gasbarrini, M. Cappuccio, S. Bandiera, L. Mirabile, G. Barbanti Bròdano, M. Palmisani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy

CLINICAL EXPERIENCE ABOUT STACKABLE CARBONFIBER PROSTHETIC REPLACEMENT OF VERTEBRAL BODIES (90 IMPLANTS IN 89 PATIENTS) M. Cappuccio, S. Bandiera, A. Gasbarrini, F. De Iure, L. Mirabile, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy Introduction: Long term survival can be expected in bone tumors of the spine when submitted to appropriate surgical and oncologic treatment: the replacement of a vertebral body in these selected cases must be performed aiming to achieve immediate recovery of function as well as a solid fusion for long term stabilization. The results presented are from a retrospective study on 102 carbonfiber prostheses implanted for anterior column replacement after corpec-

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tomy or vertebrectomy performed for the treatment of bone tumors of the spine. Methods: A stackable carbonfiber prosthesis has been used to replace vertebral bodies after 17 corpectomies by anterior approach and 85 vertebrectomies by a posterior combined an anterior approach or by a posterior approach only for the treatment of 57 primary tumors, 37 metastases and 8 plasmacytomas. In 92 cases chips of autogenous bone were used to fill the prostheses for anterior fusion purpose. Twenty-five cases were subsequently submitted to radiationtherapy, 3 to chemotherapy, 18 to chemo and radiation therapy. Results: All the cases were evaluated by clinical, radiographic, and CT scan review. No intraoperative complication connected with the implant occurred and no mechanical failure of the cage was observed. One superficial infection healed within three weeks with antibiotic treatment. Bone ingrowth within and outside the prosthesis was demonstrated and the arthrodesis considered “fused” in 83% of cases; in 6% of cases the fusion was not complete; in 11% of cases did not appear at all. Conclusions: This new carbon-fiber modular prosthesis filled with autogenous bone chips can fit the different situations occurring after vertebral body resection in the treatment of bone tumors of the spine, allows immediate weight-bearing and promotes a solid fusion.

VERTEBRECTOMY THROUGH POSTERIOR ACCESS: PROMID INTRODUCTION A. Gasbarrini, S. Boriani U.O. Ortopedia e Traumatologia, Ospedale Maggiore, Bologna, Italy The posterior-access-tecnique vertebrectomy has been described by RoyCamille in 1983 and it was later modified by Tomita. The main difference between these two tecniques is that the first foresees the vertebral body or disk osteotomy of the 2/3 of the anterior portion by means of a Gigli saw in anterior-posterior direction and the remaining 1/3 is completed using chisels in posterior-anterior direction in order to avoid spinal cord damages. In Tomita modified tecnique a smaller saw is instead used through a dedicated instrument set with spatulas protecting the spinal cord. The difficulty in controlling the saw path, which depends on the surgeon and on the assistant keeping the spatula, and the lack of predictability of the surgical department completion make this procedure unsure, so that many surgeons prefer making the osteotomy with chisels, bistoury and scissors. The Tomita’s saw has the advantage of obtaining a perfectly smooth surface for the reconstruction prosthesis positioning, reducing bleeding and surgery time. For this reason, we are using a system (Promid) which, connected to the stabilization rod, guides the saw protecting the spinal cord during all of its path, until the complete vertebral body section is obtained.

DESARTHRODESIS AND PROSTHETIC RECONSTRUCTION OF THE KNEE AFTER BONE TUMOR RESECTION: LONG TERM RESULTS P. Ruggieri[1], G. Bosco [1], E. Botello [2], A. Galvani [1], D. Donati [1], M. Mercuri [1] [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, Bologna, Italy; [2]Università Cattolica, Santiago, Chile Materials: Fifteen patients were operated of desarthrodesis and knee megaprosthesis at the Rizzoli between December 1983 and 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 been previously performed and reconstruction obtained with a knee arthrodesis using Kuntscher rod and cement. Histological diagnosis was high grade osteosarcoma in 12 cases, low grade parostal osteosarcoma in 1, malignant fibrous histiocytoma in 2. Causes of revision and

desarthrodesis were breakage of the rod in 10 cases and infection in 5 cases. Knee megaprostheses implanted were 13 Kotz 1 type and 2 HMRS. The average follow up of prosthetic reconstruction was 14 years. Methods: All patients were routinely followed in the outpatient clinic and data were obtained from clinical charts. All imaging studies were reviewed and complications analyzed. Functional results were assessed according to the MSTS functional evaluation system. Results: Oncologic results showed 12 pts. continuously disease free and NED at an average follow up of 20 years. Complications observed included 4 infections (3 had a previous infection of the arthrodesis), 1 femoral stem loosening, 2 tibial component loosening, 1 breakage of the tibial joint hinge. Four pts.had revision for wear of polyethylene components (2 pts. had 2 revisions). Functional results were evaluated in all 15 cases according to the MSTS system and were excellent in 40%, good in 33% and fair in 27% of the pts. Discussion: Desarthrodesis and prosthetic reconstruction of the knee has selected indications. This technique achieved satisfactory results in most cases although the time elapsed from first surgery could certainly negatively affect muscle function and strength. The posterior hinge of the prosthetic knee joint allows stabilization in hyperextension with minimum muscle strength.

TOTAL FEMUR PROSTHETIC RECONSTRUCTION: THE RIZZOLI INSTITUTE EXPERIENCE G. Bosco [1], P. Ruggieri [1], E. Botello [2], D. Antonioli [1], M. Mercuri [1] [1]Clinica Ortopedica, Università di Bologna, Istituto Rizzoli, Bologna, Italy; [2]Università Cattolica, Santiago, Chile Materials: From a series of 896 megaprostheses of the lower limb after resection for bone tumors treated at the Rizzoli between 1983 and 2004, 25 cases of total femur prosthetic reconstructions performed between September 1987 and June 2004 were studied. There were 15 males and 10 females, ranging in age from 7 to 62 years. The average follow up of prosthetic reconstruction was 52 months. Total femur prostheses included 4 Kotz 1 type, 20 HMRS prostheses (1 rotating hinge and 1 expandable), 1 GMRS prosthesis. These were 19 primary reconstructions and 6 secondary in revisions. Histological diagnosis included 15 osteosarcomas, 7 Ewing’s sarcomas, 1 angiosarcoma, 1 chondrosarcoma and 1 Echinococcosis. Surgical margins of the 24 tumors were wide in 23 and wide/contaminated in 1. For soft tissue reinsertion to the prosthesis different techniques were used. Methods: All patients were routinely followed in the outpatient clinic and data were obtained from clinical charts. All imaging studies were reviewed and complications analyzed. Functional results were assessed according to the MSTS functional evaluation system. Results: Oncologic results of 24 tumors showed 11 pts. continuously disease free and NED at an average follow up of 111 months (9 215 mos.), 2 pts. AWD at 20 and 32 months respectively, 11 pts. DWD at an average of 24 months (6-66 mos.). Complications observed included 1 infection, 3 hip dislocations, 1 ETA detachment and 2 glutei disinsertions. Functional results were evaluated in 20 cases, while 5 pts. with a prosthetic follow up of less than 6 months were not evaluable. According to the MSTS System results were excellent or good in 85% of pts. Discussion: Total femur prosthetic reconstruction has selected indications. Complication rate was relatively low and functional results were satisfactory in most pts.

CHONDROSARCOMA PROXIMAL HUMERUS: HISTORY OF CLINICAL CASE W. Leonardi, F. Nicolosi U.O. Ortopedia e Traumatologia, Azienda Ospedaliera A.S.R.N., Garibaldi-Santi Curro’, Ascoli Tomaselli, Italy

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Introduction: Chondrosarcomas account for about 20% of primary malignant bone tumours; the clinical behaviour is variable. The majority (80-90%) are low grade malignant tumours. Solitary(single) tumour is more common than multiple. A low grade, more indolent tumor is more likely to effect an elder patient. Chondrosarcoma occurs in two forms: Primary in 75 % and Secondary in association with multiple enchondromatosis e.g. Ollier’s disease and Maffucci’s syndrome; Exstosis, Condroblastoma; age is 30-60 years and male < female 2:1. Central axial skeleton, pelvic girdle, ribs, shoulder girdle, vertebrae & sternum are involved. Clinically it shows as a gradually enlarging painfull mass(low grade type); metastasis is relatively rare. Materials and Methods: We observed an 82 year old patient of with a mass by right proximal humerus of 13 cm of diameter due to a 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 diagnosis of Dedifferentiated Chondrosarcoma. Dedifferentiated chondrosarcoma is the most malignant form of chondrosarcoma. This tumor is a mix of low grade chondrosarcoma and high grade spindle cell sarcoma, where the spindle cells are no longer identifiable as having a cartilage origin. This biphasic quality is evident on x-ray, where areas of endosteal scalloping and cortical thickening alternated with areas of cortical destruction and soft tissue invasion. In February 2006 the patient was operated with right forequarter amputation in accordance with Berger and Littlewood for the anterior and posterior approuch; the patient was then transferred to the intesive care department for 36 hours; the redons were removed on the3rd day after surgery; no deep or superficial infection was reported. On the fifth day the aptient was able to walk again. Conclusion: Dedifferentiated chondrosarcoma has a 5 year survival of 10%. In our opinion, the forequarter amputation has been the gold standard considering both the patient’s age and the tumor progress. At the time being the patient is in good condition and reports no ghost limb pain.

SESSION O15 TUMORS II MULTIMODAL APPROACH TO THE TREATMENT OF SOFT TISSUE SARCOMAS: FEASIBILITY OF USING HIGH DOSE RATE BRACHYTHERAPY G. Maccauro [1], S. Manfrida [1], F. Muratori [2], G.C. Mattiucci [1], G. Arrabito [3], M.A. Rosa [3], G. Mantini [1], N. Dinapoli [1], V. Valentini [1], N. Cellini [1], C.A. Logroscino [1] [1] Policlinico Gemelli, Rome, Italy; [2 ] Ospedale San Pietro “Fatebenefratelli”, Rome, Italy; [3]Dipartimento Ortopedia, Messina, Italy Purpose: Conservative treatment of soft tissue sarcomas usually required a combination of surgery and External Beam Irradiation, considered a useful adjuvant to surgery. In particular, Low Dose Rate Brachytherapy is indicated in intermediate and high grade sarcomas and in recurrence to allow additional local dose in areas at risk for local failure. The aim of this work is to analyze feasibility, methods, advantages and limits of using High Dose Rate (HDR) Brachytherapy Remote After Loading associated to External Radiotherapy, an interesting perspective in the multi modal treatment soft tissue sarcomas. Methods: At surgical time total irradiation volume is based on preoperative imaging, and hystotype. The irradiation area is defined by markers. After tumour resection catheters are placed parallel at 1.5 cm of distance perpendicular to the scar. Seven days after surgery

catheters will be loaded to avoid the risk of scar problems. The afterloading catheters can remain in situ for several days to allow the feasibility of fractionated perioperative HDR brachytherapy. The fraction size depends on residual desease. After 2 weeks external beam irradiation is administered. Results and Discussion: The combination of postoperative boost HDR Brachytherapy with External Beam Irradiation was used in 8 cases. Authors emphasized the potential effects of this method: possibility of dose fractionation, better compliance with radiation safety policies, more sophisticated treatment planning, possibility of outpatient treatment delivery and low costs compared to Low Dose Rate Brachytherapy. This approach appears feasible. However, further investigation on local control and toxicity is needed.

SOFT TISSUE SARCOMAS ARISING IN THE POPLITEAL FOSSA: OUR EXPERIENCE C. Scotti [1], F. Camnasio [1], G.M. Peretti [2], F. Fontana [1], G. Fraschini [1] [1]U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, Università Vita-Salute, Milan, Italy; [2]U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, Facoltà di Scienze Motorie, Università degli Studi di Milano, Italy High grade soft tissue sarcomas arising in the popliteal fossa, axilla, and antecubital fossae (flexor fossae tumors) have been classified by convention as extracompartmental tumors by the accepted staging and grading criteria of the Muscoloskeletal Tumor Society (MSTS). Extracompartmental location of the tumor makes surgery more challenging. Advances in chemotherapy and radiation therapy have made surgical resection more feasible. In particular, neo-adjuvant chemotherapy is indicated in larger tumors and high-grade tumors; adjuvant chemotherapy can be used; radiation therapy is mandatory, 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, myxoid liposarcoma, high-grade sarcomas, malignant fibrous histiocytoma, synovial sarcoma and spindle cell sarcoma. Tumor grade varied from low to high grade, maximal diameter ranged from 6.5 to 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 surgical approach of tumors located in the popliteal fossa is often complicated by the presence of the neurovascular bundle, which can be incorporated in the tumor. Some authors indicate complete resection of vessels and substitution with prosthesis. We preferred to spare the vessels even when surrounded by the tumor, relying on the adjuvant therapies, which were performed in all cases. No local recurrencies were reported in our series. Therefore, we believe that popliteal fossa sarcomas can be treated with limb sparing surgery in association to chemotherapy or radiation therapy.

SURGICAL TREATMENT OF THE METASTASIS OF THE TIBIA: REVIEW OF THE LITERATURE AND OUR EXPERIENCE F. Liuzza [1], F. Visci [1], M. Esposito [1], M. Alesci [2], G. Maccauro [1], M.A. Rosa [2] [1]Policlinico Gemelli, Rome, Italy; [2] Dipartimento di Ortopedia, Messina, Italy Metastatic localization of the tibia is a rare event that occurs in the late stage of the neoplastic disease. This localization constitutes a complex and controversial biomechanical and therapeutic problem because of a real risk of pathological fracture. There are several options of treatments: external radiotherapy, therapy with hormones, diphosphonate, radioisotopes, curettage with acrylic

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cement, plates, intramedullary nail, prosthesis and amputation. Surgical technique should be chosen according to the metastasis localization in the osseous segment, primitive tumour, adjuvant therapy results, life expectancy. The aim of the present study is to review the percentage of tibial metastases from carcinoma, the most common histotype causing these lesions, the possible surgical approach of this osseous segment and the results after surgery. For this reason, a review of the Literature and a retrospective analysis of all patients affected from tibial metastases and undergone surgical treatment at the UCSC of Rome from 1998 to 2005 have been performed. In particular 10 patients, 6 males and 4 females, were evaluated. Each patient had a pathological fracture or an impending fracture. Therefore, a surgical treatment has always been necessary. From the analysis of the Literature and from our experience it can be deduced that surgical treatment of the metastases of the tibia can be done in patients with a life expectancy longer then 3 months. The surgical treatment enables pain relief, improvement of the quality of life, of lower limb function, of nursing assistance and helps in keeping such a personal independence of the oncologic patients. In conclusion authors think that choosing a surgical treatment of these metastases, should consider the systemic extension of the neoplastic disease, therefore it should be low invasive except for some histotypes as the carcinoma of the kidney having a better prognosis in terms of survival.

ANTEROGRADE FEMORAL NAILING (AFN) FOR THE TREATMENT OF FEMORAL METASTASES: A REPORT OF 10 CASES F. Liuzza [1], F. Pezzillo [1], B. Rossi [1], F. Muratori [2], G. Maccauro [1] Gemelli, Rome, Italy; [2]Divisione di Ortopedia, Ospedale San Pietro FBF, Rome, Italy

The Skeletal Repair System (Norian) represents an attempt to find a synthetic substitute of the bone, for the resolution of traumatic pathology where the bone loss was the crucial point. In the last few years the interest for the biological cement shifted to the treatment of non traumatic orthopaedic pathology where a bone substitution was necessary and the treatment of hand enchondromas was included in this field. From February 1998 to March 2006 in the Operative Unit of Hand Surgery and Microsurgery of Modena Policlinics, the Aa. treated 45 patients with enchondromas of the hand by synthetic cement Norian. The outcome studies performed evalutation of pain, range of motion, early return to daily life activities and post-operative Xray control. The data analysis showed good clinical results in 37 controlled patients. All patients had no pain and returned to daily life activities in a short period. Post-operative X-ray showed a progressive reabsorption of the synthetic cement. In the controlled patients there was not a significant reduction of motion range. In two patients there was an incomplete removal of the tumour due to a surgical error and a case presented an inflammation of the finger tip due to infiltration of the synthetic cement in the soft tissue. The mini-invasive procedure, an early mobilization and consequently the return to daily life and working activities in a short time represent the basis for the use of the synthetic cement. The results confirm that this technique can be introduced as an alternative to the traditional treatment techniques for enchondromas of the hand. Future researchs should consider the inflammatoryimmunologic response induced by biological cement, the osteoinductive-conductive properties of the cement and the real evaluation of reabsorption.

[1]Policlinico

Metastatic involvement of femur is a common clinical problem and accounts for the third highest incidence after spine and pelvis. Surgical approach is indicated for wide lesions, pharmacological and/or radiant resistant lesions and for pathological fractures. Either pain relief and treatment of probable complication as pathological fractures by a solid, definitive and durable system are the aims of a surgical approach, according to clinical conditions of the patients. According to the Literature, the intramedullary locked nailing is indicated for multiple shaft lesions and for patients with short life expectancy or severe general clinical conditions in order to stabilize the whole bone segment, with Recon assembling to prevent or to treat the localizations of the femur. This technique is effective to reduce the pain, to restore motion of the hip with few post-surgical complications. Authors retrospectively analyzed a consecutive series of 10 pathological fractures or “impending fractures” of the femur treated with a new intramedullary system (AFN), with the previous characteristics. In particular it has a proximal diameter of 17 mm and a distal diameter variable between 10 and 12 mm with the possibility to insert 2 proximal nails and 2 distal static hole. The histotypes were breast cancer (4 cases), colon-rectus (2), lung cancer (2) and mieloma (2). Curettage and/or filling with acrylic cement has not been necessary in any case. Intramedullary locked nailing has always been performed in static mode by two distal nails. Breaking and mobilizations of the means of synthesis had never happened. Either pain reduction or relief, recovery of articular function and deambulation, perioperative bleeding, survival have been considered. Authors believe that AFN could be particularly indicated in the treatment of secondary lesions of the femur thanks to either its biomechanical characteristics and the results obtained up to now.

THE UTILIZATION OF SYNTHETIC CEMENT NORIAN IN THE TREATMENT OF THE ENCHONDROMAS OF THE HAND A. Landi, N. Della Rosa U.O. di Chirurgia della Mano e Microchirurgia, Azienda Ospedaliera Policlinico Modena, Italy

CEMENT LEAKAGE IN PATIENTS AFFECTED BY SECONDARY OSTEOPOROSIS DUE TO MULTIPLE MYELOMA AND CHRONIC MYELOID LEUKEMIA TREATED WITH VERTEBROPLASTY. TWO CASE REPORTS AND REVISION OF THE LITERATURE G. Barbanti Bròdano, M. Cappuccio, L. Mirabile, L. Boriani, A. Gasbarrini, S. Boriani Uo Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi, Bologna, Italy Multiple myeloma and chronic myeloid leukemia are blood diseases that frequently affect elder patients. In the last 5-10 years the efficacy of specific chemotherapic schemes has enormously improved these patients’ prognosis. This situation brings more and more often to the surgeon’s attention patients with spine lesions and deformities due to the effect of the disease itself and to the secondary osteoporosis chemotherapy induced. Spine surgeons have to face empty and painful vertebrae that cause spine failure and do not allow patient to walk and stand. Literature has widely demonstrated how useful vertebroplasty and kiphoplasty are in relieving pain and in functional recovery of this kind of patients. We report our experience on two cases, each of them treated at 5 segments because of respectively the outcomes of a multiple myeloma and of a chronic myeloid leukemia. Both patients had partial improvements in pain and function, but cement leakage was almost a constant. It also flew into the vertebral canal, but fortyunately neither symptoms or neurological compression happened. When we have to deal with highly altered vertebrae, as in these cases affected by neoplastic diseases and secondary osteoporosis, vertebroplasty seems to present a significant risk of cement 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 et al. have recently described (J Clin Oncol.2002). Kiphoplasty is moreover much safer than vertebroplasty as regard cement leakage complication. Kiphoplasty seems better than vertebroplasty in the treatment of patients affected by multiple myeloma and chronic myeloid leukemia because of minor risk of cement leakage.

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SESSION O16 PROSTHESIS II UNCEMENTED REVISION PROSTHESIS SL WAGNER IN THE TREATMENT OF THE PERIPROSTHETIC FRACTURES G. Grappiolo, G. Burastero, G. Santoro, A. Camera, G. Moraca, L. Spotorno Ospedale “Santa Corona”, Pietra Ligure, Italy Introduction: One of the worst problems in the orthopedics surgery is the periprosthetic fracture after THA. However there is not a complete agreement about its treatment. Even if it is relatively 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. Materials and Methods: About 800 THA are performed every year in the Hip Surgery Unit of the “S. Corona” Hospital. The hip periprosthetic fractures are 115 (M 24- F 91), mean age 69,86 aa. Nearly the totality of the B2-B3 hip periprosthetic fractures according to Vancouver classification are treated with the removal of the prosthesis and the implantation of an uncemented SL Wagner stem with diaphyseal anchorage with brackets and made of titanium porous. The patients are 67 (M 13- F 54) with mean age 71 aa ± 11(min 34 max 89); the intra e post-op hemorescue system has allowed to nomalize the hematic defluxio (about 1500 ml). Results: The mean follow-up is 6,5 aa with max follow-up 14 aa (11 patients deceased and 3 lost to the follow-up); the survival rate is 97%; two cases of septic mobilization, one case of pending revision. The clinical results are good, average HHS 87/100, and satisfactory in all patients. Discussion: Our preferred treatment allows us to obtain a higher standard than the treatments with osteosynthesis previously utilized; the pre-op planning and a good intra-op routine permit a shorter and competitive surgical time on contrast to traumatologic tecniques. F.K.T is very important for rapid functional resumption. The new offset of the stem, the good cablage of the great trochanter and the use of the large heads (or cups constrained with ring) limit the risk of dislocation.

RESECTION HINGE PROSTHESIS IN NON-ONCOLOGICAL DISEASES D.S. Tigani, M. De Paolis, G. Trisolino, N. Del Piccolo, M. Mercuri, A. Giunti Istituti Ortopedici Rizzoli, Bologna, Italy Resection hinge prosthesis are currently being used for reconstructing joints after bone resection in oncological diseases. The good clinical results and the availability of new materials and designs have also led to their use in secondary bone defects in non-ontological diseases, such as non-union and conventional joint replacement. This study reports the preliminary results of a retrospective analysis performed on 12 patients treated at our institute with resection hinge prostheses in non-oncological diseases.

FEMORAL REVISION WITH THE MODULAR ZMR® STEM. CLINICAL AND X-RAYS RESULTS AT MEDIUM TERM FOLLOW-UP M.F. Surace, L. Murena, A. Sinigaglia, G. Zatti, P. Cherubino Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, Università degli Studi dell’Insubria, Varese, Italy A retrospective review was conducted to evaluate the medium-term results of the ZMR modular revision taper stem. From March 1999

to December 2002, 65 consecutive hip revision surgeries were performed 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 cases to remove primary implants that were cemented in 35 cases. Mean post-operative follow-up was 69 months (range, 36 to 91 months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 42 points preoperatively to 81 points postoperatively, while the x-ray examination did show a satisfactory distal integration of the stem in all cases and satisfactory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was under one millimeter. According to the data leg length discrepancy exceeding 15 millimeters caused significantly higher functional impairment and more pain.

TREATMENT OF PERIPROSTHETIC FRACTURES OF THE FEMUR IN PATIENTS TREATED BY TOTAL HIP ARTHROPLASTY G. Pignatti, G. Trisolino, N. Rani, G. Armando Istituti Ortopedici Rizzoli, Bologna, Italy Periprosthetic fractures of the femur can be treated in different ways: conservative treatment that includes traction and immobilization with a cast and surgical treatment that involves open reduction and fixation when the implant is stable, or stem replacement if it is loose. Various techniques and surgical devices have been described in the literature to treat these fractures. We present a retrospective study of periprosthetic fractures treated in our ward over 12 years. We treated consecutively 17 patients, 3 men and 14 women, with periprosthetic fracture of the femur. Their mean age was 72 years (range 5288). According to the Vancouver classification, 6 were type B1, 7 type B2, and 4 type C. Twelve patients underwent fixation and 9 stem replacement. None of the patients were treated conservatively. Mean follow-up was 20 months (range 8-114). The fracture healed in all patients and weight bearing was resumed between 2 and 6 months after surgery. The clinical results were good to excellent, and the mean Merle-D’Aubigne Score improved from 3.47 (range 3-5) to 16.52 (range 14-18). We believe that when possible surgical treatment of periprosthetic fractures of the femur should be the first choice of treatment thanks to the high success rate.

A NEW PROXIMAL FEMUR RECONSTRUCTION PROSTHESIS: MPM-GB-COMPOSITE A. Gasbarrini, S. Terzi, S. Boriani U.O.Ortopedia e Traumatologia, Bologna, Italy The proximal femur bone substance larger losses are related to: resections due to oncologic problems, massive mobilization of a pre-existing hip prosthetic implant or, more rarely, grave traumatologic outcomes; these losses cause problems in recostruction procedures. Until today it was possible to choose between a metallic reconstruction prosthesis or a combination of a revision prosthesis and a massive proximal femur homoplastic bone insert (composite prosthesis). The authors present a new prosthetic system, optimized in year 2004, which allows to perform both kind of reconstructions. The prosthesis, in titanium alloy, is composed by: a stem of variable diameter, available both in cemented and uncemented versions which, once introduced, is the base for the further assemblings; a higly modular body, prepared for both anchorage to soft tissues or fitting within massive bone inserts; a proximal portion characterized by two neck and three head sizes and two offset possibilities. The possible femural resection is within 40 and 300 mm. Since 2004 the MPM-GB-Composite prosthesis has been implanted in 13 patients: in 7 cases it has been adopted after tumoral resections, in 2 cases for a prosthetis re-implant, in 4 cases

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because of post-traumatic bone losses. The main features of this prosthetic system are the versatility in the diameters choise, lengths, kind of fixation, kind of reconstruction, and the flexibility in the components assembly which also allows to modify the antiversion degree in any moment; moreover, it enables to successfully manage problems related with surgical proximal femur reconstruction.

ACETABULAR REVISION SURGERY IN THE PRESENCE OF SEVERE BONE LOSS: SURGICAL TECHNIQUE AND EARLY RESULTS WITH MODULAR POROUS TANTALUM AUGMENTS AND CUPS G. Zatti, L. Murena, M.F. Surace, G. Riva, C. Ratti, P. Cherubino Università dell’Insubria, Varese, Italy Subject: In the presence of minimal acetabular bone loss most revision procedures can be done with the use of an uncemented hemispheric device with or without morselized allograft. The use of modular porous tantalum augments and cups has been recently introduced to address more severe bone deficiencies. The purpose of this study is to describe the surgical technique and early clinical results obtained with trabecular metal acetabular augments in cases of acetabular revision with severe bone loss. Materials and Methods: Since November 2003 seven acetabular revisions have been done by means of TMT® augments and cups: the primary indication for acetabular revision was aseptic loosening in five patients and septic loosening in two patients. According to Paprosky classification the acetabular bone defects were classified as follows: 2B in two hips, 2C in one hip, 3A in two hips and 3B in three hips. In two cases it was the first surgical hip replacement procedure. Five cases were multiple revisions. Results: At an average follow-up of 24 months no implant had evidence of loosening or migration. No dislocations occurred. Discussion and Conclusions: Augments provide mechanical support to hemispheric cups of various dimensions. This surgical technique avoids the use of structural allograft, helps to restore the center of hip rotation and increases contact area between the implant and the host bone for biological fixation. Longer follow-up is required to verify survival of these implants and potential mechanical and biologic complications related to use of this modular TMT® system.

PROSTHESIZATION IN CROWE GRADE IV HIP DYSPLASIA: INDICATIONS,TECHNIQUES AND RESULTS F.P. Ciampa, L. Guerra, M. Barbato, E. D’Angelo Ospedale G. Bernabeo, Ortona, Italy Prosthesization in Crowe grade IV hip dysplasia is a surgical technique which is technically demanding for the surgeon and requires strong motivation from the patient (because of localized pain or pain in the supra and sub-segmentary structures), as well as a careful preoperative assessment and an accurate execution of the operation. Prosthesization can take place in single stage or two stage surgery, and the site for placement can be the neocotyle or the paleocotyle. The authors report their experience, in which they privileged single stage surgery and placement of the prosthesis in the paleocotyle. The use of appropriate modular prosthesic systems makes it possible to regain adequate functional dysmetria of the rotational centre, as well as to benefit from the unquestionable advantage of performing the operation in one stage. There is a description of the surgical technique used, comprising an ample lysis of the articular and peri-articular environment, positioning the acetabular cup in the paleocotyle, shortening of the femur, and the use of a modular prosthetic stem. The results obtained and the not uncommon complications limit this type of surgery to selected cases.

SALVAGE OF FAILED OSTEOSYNTHESIS OF PROXIMAL FEMURAL FRACTURER AND COMPLEX KNEE FRACTURES WITH MODULAR MEGAPROSTHESES P. De Biase, M. Mugnaini, L. Ciampalini, R. Capanna Dipartimento di Ortopedia, SOD Ortopedia Oncologica, Florence, Italy Surgical revision of osteosynthesis failures in complex fractures of the proximal and distal femur is often a very complex, long lasting procedure with an unacceptable high rate of perioperative and postoperative complications. Different techniques have been proposed: revision prosthesis, strut graft augmentation, massive allografts. We want to present an original technique derived from authors’ experience with tumoral modular prosthesis which can represent a quick, 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 with a proximal femur megaprosthesis (Waldemar Link, C system) to salvage a failed osteosynthesis. In every case the modular prosthesis was implanted after two previous failed attempts of ORIF. The prosthesis was implanted as a bipolar head or with an acetabular cup depending on patient’s age. Average operative time was 150 minutes. We did not observe perioperative complications, with an average age of the patients of 72 years. At 5 year follow up the functional results were excellent or good in 14 out of 15 cases. The fair case was due to a dislocation of the total hip and further revision with a constrained socket. The results remained poor for the late (8 year) infection of the prosthesis and subsequent removal of the prosthesis and positioning of a cement spacer loaded with antibiotics. Treatment of this case is still in progress. We used the same modular megaprosthesis system in two cases of complex knee fractures. The patient treated with a distal femoral prosthesis had a traumatic bone loss of distal femur of 12 cm, including condyles; the other patient had an articular fracture of proximal tibia with tibial tuberosity avulsion. Both patients had a good result. In conclusion we believe that in selected cases with previously failed ORIF and important residual bone loss this technique offers a valid alternative to arthrodesis.

FOUR-YEAR FOLLOW-UP OF A TANTALUM, MONOBLOCK ACETABULAR CUP: CLINICAL AND RADIOLOGICAL RESULTS C. Doria, F. Milia, L. Tidu, M.A. Fadda, P. Lisai, L. Floris, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy Objective: Osteolysis secondary to polyethylene wear is the most serious aseptic long-term complication following total hip replacement (THR). Studies have shown that fixation with screws, modularity and lack of extensive bone ingrowth are associated with increased osteolysis. This study examines our experience with tantalum cup designed to address these issues. Materials: Between 2000-2001, seventy-two consecutive primary THR were performed using uncemented monoblock, elliptical, tantalum cup without screw holes. Average follow-up was 61 months (range 54 to 72). Average age was 67.5 years (range 46 to 81). Pre and post-operative clinical assessment used Harris hip score (HHS), WOMAC and SF-36. One independent, blinded observer performed zonal radiographic analysis with De Lee and Charnley method. Results: Average HHS at recent follow-up was 91 (range 85 to 100). All cups appear fixed with bone ingrowth. Dome-gaps present in 4 cups post-op; all have filled in. Radiolucencies at follow-up: 2% zone 1, 6% zone 2; none greater than 1 mm. No cup migration was observed. None cup related complications. Conclusion: Tantalum cup provides secure, symptom-free fixation at 4 years. No complication was reported associated with use of tantalum. The elliptical shape of the cup creates an interference fit with the spherically reamed acetabulum. From the pole of the dome, the interference

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fit increases until a 2 millimeter differential is achieved at the face of the cup. Tantalum possesses a substantially higher coefficient of friction on cancellous bone than other implant materials. This property facilitates direct bone apposition to increase initial stability at implantation.

CEMENTLESS FEMORAL REVISION WITH TAPERED CONICAL STEMS: THE EVOLUTION OF DESIGN FROM WAGNER TO RESTORATION CONE-CONICAL R. Binazzi Istituto Ortopedico Rizzoli, Bologna, Italy Mid-term results obtained with the conical tapered stem designed by Wagner for cementless hip revision were on the whole very encouraging. 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 difficult. The T3 stem was designed with the purpose of correcting these defects. The T3 stem is made of Titanium alloy with a textured surface finish and is modular. The lateral offset has been increased to 42 mm (34 mm for Wagner’s stem) and the cervico-diaphyseal angle has been reduced from 145° to 138° degrees. Recently, the T3 stem has been substituted by the Restoration having a more varus neck (132° instead of 138°) and 3 sizes of distal stem (instead of 2). In this retrospective study we have analized the preliminary results obtained with the T3 stem. We reviewed the first 30 consecutive cases having an average FU of 6.2 years (range 4.7 - 8 years). We have always used a trans-femoral approach with “prophylactic” distal cable circlage. In no case a homologous bone graft was used. 90% of the cases were rated Excellent or Good. No re-revision was necessary. 87% of the femurs showed good bone reconstruction and 24% some subsidence (only two cases >1 cm) without clinical symptoms except for the necessity of a compensatory heel pad. Distal fixation stems like T3 are the implants of choice for severe bone stock loss (Paprosky 2C-3) for their immediate mechanical stability allowing early weight bearing. Transfemoral approach allows complete removal of debris and scar tissue, enhancing bone reconstruction.

SESSION O17 ARTHROSCOPY I COMPARATIVE ANALYSIS OF ACLR AMONG FEMALE ATHLETES USING ST VS STG A. Gobbi, A. Sandoval, R. Francisco, L. Busato Orthopaedic Arthroscopic Surgery International, Milan, Italy Objective: To determine the difference in the clinical outcome among female athletes after ACLR when using only the Semitendinosus (ST) tendon versus the combined use of both the ST and gracilis (STG) autografts. We hypothesize that the female athletes would benefit more from a single ST Hamstring ACLR compared to a combined STG construct. Methods: 38 cases of ST and 26 STG ACLR were evaluated preoperatively, then at 12 and 24 months following surgery. Standard technique for reconstruction and a uniform rehabilitation protocol was used. Parameters analyzed included standard knee scales (IKDC, Noyes, Lysholm, Tegner), SANE score, computerized knee laxity analysis, deep flexion and Isokinetic tests. Results were statistically analyzed using the student’s t-test. Results: No significant statistical differences were noted in the final Tegner, Lysholm, Noyes, IKDC scores, and computerized knee laxity analysis between ST and STG groups (p=0.05). Seventy-seven

percent of the athletes evaluated were able to return to their preinjury activity levels, while 61% had either normal or nearly normal IKDC scores. At 1 year follow-up, the STG group was noted to have 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 higher incidence of re-injury. Conclusion: ACL reconstruction in female athletes using ST or STG demonstrated comparable clinical outcomes. However, a higher incidence of re-injury was observed with the STG group which may be related to the greater strength deficit observed following this type of reconstruction technique. Therefore, we recommend the use of ST alone in ACL reconstructions of female athletes, especially those involved in pivoting or cutting sports.

DOUBLE BUNDLE SINGLE TENDON ACLR A. Gobbi, R. Francisco, A. Sandoval Orthopaedic Arthroscopic Surgery International, Milan, Italy The conventional ACLR was designed to replace the AM bundle with the graft located at the 11 o’clock position (R knee). The results obtained with this technique have been successful in restoring anterior knee stability. Current studies have questioned its ability to provide rotatory stability. Methods: From 2001 to 2004, 15 patients were randomly selected and underwent ACLR using only the ST tendon. Two tibial and two femoral tunnels were prepared. The femoral tunnels were positioned at 11:00 (AM) and 9:00 (PL) with inside-out technique. Femoral fixation was achieved with two endobuttons CL while tibial fixation was carried out with screw post. Post-operatively, patients underwent a standardized rehabilitation program. Results were compared to a similar group of patients who underwent ACLR using quadrupled semitendinosus grafts. Results: At two years, no significant difference in IKDC scores (p<0.05) was observed. 91% of those operated using double bundle and 89% of those with single bundle ACLR were normal or near normal. 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 (10°-120°) while another patient had impingement. Conclusions: No significant differences between single bundle and anatomic double bundle ACL reconstructions were observed. The better rotational stability with double bundle technique remains to be consistently demonstrated as no validated examination technique has yet been established. The use of two separate femoral and tibial tunnels may be more anatomic but technically demanding and probably prone to surgical errors.

DIFFERENCE IN DEEP KNEE FLEXION AND INTERNAL ROTATION AFTER ACL RECONSTRUCTION USING SEMITENDINOSUS OR SEMITENDINOSUS AND GRACILIS AUTOGRAFTS A. Gobbi, R. Francisco, A. Sandoval Orthopaedic Arthroscopic Surgery International, Milan, Italy Objective: To document the changes in hamstring muscle strength among patients who had ACLR using hamstring autografts. We hypothesize that using both the STG tendons could lead to greater flexor weakness at deeper flexion angles (>90°) when compared to reconstructions using only the ST tendon. Materials and Methods: From October 2000 to November 2002, 100 patients ACLR using either the semitendinosus (ST) or both the semitendinosus and the gracilis tendon (STG). Pre-operative and post-operative evaluation included the use of standard knee scales (IKDC,

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Lysholm, Tegner, Noyes); computerized arthrometry to document knee laxity; isokinetic tests; and measurement of deep knee flexion angles. Statistical analysis was then performed using paired t-test. Results: IKDC, Lysholm, Tegner, and Noyes scales demonstrated no significant difference between the two groups (ST vs STG) (p<0.05). Computerized laxity test revealed slight increase in laxity among females (p=0.05) Isokinetic tests revealed comparable quadriceps and hamstring strengths at flexion angles < 90°. Flexion angles > 90° demonstrated a significant decrease in hamstring muscle strength in both groups. STG group demonstrated weaker hamstring strength and lesser range of active movement when compared to ST group at deeper flexion angles (>90°). Conclusions: Use of both semitendinosus and gracilis tendons for ACL reconstruction leads to decreased hamstring muscle strength and range of movement at deeper flexion angles. Therefore, the routine use of both tendons for reconstruction is not recommended especially in athletes engaged in activities requiring deep knee bends and hamstring strength.

In the last years the industries have developed several technologies for in vitro cultivation and reconstruction of woven or organs, defining a new branch of biomedical sciences known like “woven engineering”. This technology allows us to expand autologous cells and to re-use them to repair and regenerate woven lesions using three-dimensional bio-polymer matrices. Nowadays it is possible to regenerate in vitro different woven, modulating chemistries, mechanics and physics characteristic of the matrices. From October 2003 in the three divisions of Orthopaedic and Traumatology of the University of Bari we used this techniques to treat the chondral knee lesions, especially using a 3-dimentional biodegradable and biocompatible hyaluronic acid scaffold for autologous chondrocyte culture, the Hyalograft C (FAB, Abano Terme, Padova, Italy), created in order to avoid the drawbacks and complications related the classical autologous condrocytes implantation. Aim of this study is to evaluate retrospectively the outcomes obtained in 27 patients under 40 years old, treated with this technique, for III-IV Outerbrige degree classification, extended over 2 cm2. The average follow-up is 25 months (min.4-max.34).

REVISION ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING DOUBLED SEMITENDINOSUS AND GRACILIS TENDONS AND LATERAL EXTRA-ARTICULAR RECONSTRUCTION

THE ARTHROSCOPIC TREATMENT OF THE POST-TRAUMATIC SHOULDER INSTABILITY WITH BIOKNOTLESS

A. Ferretti, F. Conteduca, E. Monaco, A. De Carli, C. D’Arrigo Ospedale S. Andrea, Rome, Italy Background: The purpose of this study is to evaluate the results of revision ACL surgery using autogenous doubled semitendinosus and gracilis graft in association with an extraarticular procedure. Methods: Between 1997 and 2003 thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament (ACL) using doubled semitendinosus and gracilis graft combined with an extraarticular reconstruction. Primary reconstruction had been done in 26 patients using autogenous patellar tendon and in four patients with prosthetic ligament; the average time from primary reconstruction to revision was five years (range one to eleven). Functional outcome, graft survival and radiological outcomes were evaluated at a mean of five years (range two to eight). A graft was considered a failure in case of a revision was done and if the side to side difference was greater than 5 mm and/or the pivotshift was greater than a trace (2+). Results: One patient underwent a re-revision reconstruction for graft failure at three years postoperatively and was included in the failure 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 to side difference was within 3 mm in twenty patients, between 3 and 5 mm in six patients and more than 5 mm in two patients. The results of the Pivot Shift examinations were normal in fifteen patients, slightly positive in eleven patients and positive in two patients. 25% of patients showed no radiological signs of degenerative joint disease. Conclusions: Revision ACL reconstruction using autogenous doubled simitendinosus and gracilis graft combined with an extraarticular procedure provides satisfactory functional outcomes with a failure rate of 10%.

AUTOLOGOUS CHONDROCYTE TRANSPLANTATION ON 3DIMENSIONAL HYALURONIC ACID SUPPORT FOR TREATMENT OF CARTILAGE KNEE LESIONS: RETROSPECTIVE STUDY V. Mascolo [1], S. De Giorgi [2], D. Fracchiolla [3], A. Mocci [2], A. Piazzolla [2] [1]Università degli Studi di Bari, Italy; U.O. Ortopedia e Traumatologia III, Bari, Italy; [2]Università degli Studi di Bari, Italy; U.O. Ortopedia e Traumatologia I, Bari, Italy; [3]Università degli Studi di Bari, Italy; U.O. Ortopedia e Traumatologia II, Bari, Italy

C. Colucci, V. Salini, G. Guerra, A. Natale, C.A. Orso Clinica Ortopedica e Traumatologica, Chieti, Italy Objective: This study aimed to analyze our experience on 40 patients with TUBS treated with arthroscopic capsulo-plasty using anchors Bioknotless. Methods: From January 2001 to June 2004 we treated in arthroscopy 40 patients with TUBS. The intervention foresees the following phases: evaluation of the capsular lesion; decortication of the anterior glenoid surface; execution of three holes; anchors introduction; Results: We clinically appraised the patients through the Constant test with a minimum 10 months follow-up and maximum of 24 months (average 17 months). The middle value of the Constant score was of 88 against that of 56,5 pre-operating, we only had a case of relapser. Discussion: We believe that a careful pre-operatory and intraoperatory selection of the patient can sensitively reduce the risks of recidivist of the arthroscopic capsulo-plasty; excluding the patients with bony-Bankart> of 25% and with glenoid inverted pear. Conclusions: In the light of our experience we can affirm that the use of these anchors, that does not foresee the execution of the knot, allows to get not only a reduction of the surgical time, but also, and above all, a good anchorage and capsular shift.

ARTHROSCOPIC GRAFTING OF AUTOLOGOUS CHONDROCYTES IN CHONDRAL LESIONS OF THE ANKLE: EARLY RESULTS M. Barbato, G. Di Loreto, L. Guerra, F.P. Ciampa Ospedale G. Bernabeo, Ortona, Italy The production of suitable tissular supports has led to the routine grafting of chondrocytes in Outerbridge grade 3 or 4 chondral lesions of the knee, while in the literature, contributions regarding the use of this 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 under one centimetre in size, bone marrow stimulation techniques are advised, based on the principle of the recruitment of totipotent cells. The latter makes healing possible with the formation of “reparatory tissue”. Several studies have confirmed that the new tissue, obtained with bone marrow stimulation techniques, lacks type II collagen and presents the characteristics of fibro-cartilage and not those of hyaline cartilage. When larger lesions are present, reparation techniques, such as mosaic-plastic or chondrocyte grafting, are proposed. Materials and Methods: Outerbridge grade 3 and 4 chondral lesions of the head of the astragalus, measuring over one centimetre,

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were treated by grafting autologous chondrocytes cultivated on HYAFF. The technique comprises two stages: in the first, clinical and instrumental data are confirmed arthroscopically, and the collection, necessary for the cultivation of the chondrocytes, is carried out. In the second stage, grafting of autologous chondrocytes cultivated on HYAFF is carried out.

SESSION O18 ARTHROSCOPY II SIMULTANEOUS ARTHROSCOPIC IMPLANTATION OF AUTOLOGOUS CHONDROCYTES AND HIGH TIBIAL OSTEOTOMY IN THE VARUS KNEE F. Franceschi, G. Rizzello, G. Longo Umile, L. Ruzzini, R. Papalia, A. Marinozzi, V. Denaro Università Campus Biomedico, Rome, Italy Objective: The aim of this study was to determine the outcome of patients with varus malalignment who underwent an arthroscopic implantation of autologous chondrocytes and a high tibial osteotomy. Materials and Methods: Between 2002 and 2003 we performed 9 arthroscopic implantations of autologous chondrocytes in conjunction with an opening wedge osteotomy on the medial side of the proximal tibia in patients with chondral defects of the medial tibial plateau in varus knee. Each patient was evaluated for clinical history, clinical examination, conventional radiographs, MRI and arthroscopy, pre and postoperative IKCD (International Knee Documentation Committee), pre and postoperative Lysholm, pre and postoperative Tegner score and pre and postoperative VAS. Results: The Lysholm Score, IKCD, Tegner score used for evaluation showed a statistically significant improvement from preoperative average rating to postoperative average score. Discussion: Treatment of chondral lesions involving the articular surface of the knee remains a formidable therapeutic challenge because articulate cartilage has limited capacity for regeneration. HTO alone and conventional treatments that abrade or penetrate the subchondral bone (drilling or microfracture) are known to produce fibrocartilaginous repair. On the weightbearing surfaces of the knee large areas of fibrocartilage are mechanically inferior and usually deteriorate, necessitating additional intervention. Only the autologous chondrocyte implantation and the transplantation of osteochondral grafts provides adequate hyaline articular cartilage, which is better able to restore the durability and natural function of the knee joint. Conclusions: Despite the small size of the group and the need for larger series, our surgical study shows that the association of arthroscopic implantation of autologous chondrocytes in conjunction with an opening wedge osteotomy on the medial side of the proximal tibia is a good option for the treatment of chondral defects in varus knee.

MEDIUM TERM RESULTS OF MENISCAL REPAIR USING THE MENISCUS ARROW: STATISTICAL ANALYSIS OF OUTCOME EFFECTING FACTORS

Materials and Methods: 49 patients with unique meniscal lesion underwent all-inside meniscus repair using the Meniscus Arrow fixation technique. At mean follow-up of 4 years all patients were evaluated according to the following scales: Visual Analogue Scale, International Knee Documentation Committee Score, Lysholm II 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 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 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). Discussion and Conclusions: Lesion pattern, size and association with ACL repair influence results of meniscal repair using Meniscus Arrows. While planning a meniscal repair, these variables should be taken into account.

FIXATION OF UNSTABLE OSTEOCHONDRITIS DISSECANS LESIONS OF THE KNEE USING MOSAICPLASTY M. Ronga [1], G. Zappalà [1], E. Ferrari [1], M.G. Angeretti [2], P. Bulgheroni [1] [1]Dipartimento di Ortopedia e Traumatologia, Università degli Studi dell’insubria, Varese, Italy; [2] Dipartimento di Radiologia, Università degli Studi dell’insubria, Varese, Italy Objective: To assess the use of autogenous osteochondral graft fixation (mosaicplasty) in unstable osteochondritis dissecans (OCD) lesions (ICRS type 2 and 3) of the knee. Materials and Methods: Five patients with MRI confirmed OCD lesion in their femoral condyle, that had remained symptomatic despite adequate conservative treatment, underwent arthroscopic mosaicplasty plug fixation of the lesion. The average size of the lesions was 3.7 cm2 (range, 2.5 - 5.1 cm2). The OCD lesions were all unstable at operation and were all fixed rigidly in situ using a varying number of autogenous 4.5 mm osteochondral plugs harvested from the edges of the trochlea. The average age at operation was 23.2 years (20 - 27 yrs). Clinical-functional evaluation was carried out according to ICRS, modified Cincinnati knee, Lysholm II, Tegner and IKDC scales. MRIs (FSE FAT SAT T2, GE T2, SE T1) were taken before the operation as well as at 6 and 12 months postoperatively; at 2 years, arthro-MRI was performed. Results: Follow-up averaged 31.6 months (range, 24 - 43 months). No complications occurred. At the latest follow up, knee scores improved after surgery. Serial MRI scans documented healing of the osteochondral lesions and a continuous articular cartilage surface layer in all cases but one where was evident a partial detachment of an only one plug. Discussion: The benefits of this technique are the ability to obtain rigid stabilization of the fragment using multiple plugs, stimulation of the subchondral blood supply by drilling and autogenous cancellous bone grafting. Conclusion: The mosaicplasty plug fixation of unstable OCD can be recommended for the treatment of these specific lesions.

M. Ronga, L. Murena, L. Donnini, P. Bulgheroni Dipartimento di Ortopedia e Traumatologia, Università degli Studi dell’Insubria, Varese, Italy

BIOABSORBABLE POLY-D,L-LACTIC ACID (PDLLA) INTERFERENCE SCREWS FIXATION IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: CLINICAL, ARTHROMETRIC, RADIOGRAPHIC AND IMAGING EVALUATION AT MEDIUM-TERM FOLLOW-UP

Objective: Meniscus Arrows is a reliable device for meniscal repair. Outcome effecting factors associated with the use of this device are not yet investigated. Aim of this study is to evaluate if several variables can influence the success rate of meniscal repair.

P. Bulgheroni [1], M. Ronga [1], G. Zappalà [1], M.G. Angeretti [2] [1]Dipartimento di Ortopedia e Traumatologia, Università degli Studi dell’insubria, Varese, Italy; [2]Dipartimento di Radiologia, Università degli Studi dell’insubria, Varese, Italy

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Objective: The standard treatment of ACL lesions has mainly relied on metal interference screws until the introduction of bioabsorbable materials. Fixation of autologous bone-patellar-tendon-bone with bioabsorbable screws has showed results comparable with metal screws without their disadvantages at short-term follow-up. Aim of this study was to analyse the medium-term clinical results and arthrometric, radiographic and imaging findings of PDLLA screws. Materials and Methods: Twenty patients have been included in this study. At time of ACL reconstruction, in 9 patients was performed partial meniscectomy. The average follow-up was 5.5 years (range, 4 to 7.8 yrs.). The final evaluation was performed according to the following clinical scores: IKDC, Tegner and Lysholm. All patients were submitted to KT-2000 test, comparative radiographic plains and MRI study in order to investigate the longevity of the implant and adverse effects of this material. Statistical analyses were carried out using Student’s t test and c2. Results: 85% of patients showed good or excellent clinical results. In 18 cases KT-2000 test was less than 3 mm in comparison with the opposite knee. Radiographic evaluation showed initial degenerative changes in 7 patients, 6 of whom underwent meniscectomy (p<0.005). At MRI, the screws were completely reabsorbed in all cases without any foreign body reaction. An average of 2.1 mm (range, 0.6 to 5 mm) at femoral side and 2.3 (range 0.7 to 7.6 mm) at tibial side enlargement was detected. In axial plain, the tunnel was shaped like an “8” in 3 cases at femoral and in 4 at tibial level. These findings were not statistically correlated to knee stability. Conclusion: The PDLLA interference screws represent a valid alternative to metal implants in ACL reconstructive surgery.

MRI ANALYSIS OF THE DOUBLE BUNDLE STRUCTURE OF THE ANTERIOR CRUCIATE LIGAMENT: RUPTURE PATTERN EVALUATION G. Vadalà [1], H. Stechel [2], R. Papalia [2], V. Denaro [1], F. Fu [2] [1]Dipartimento di Ortopedia e Traumatologia, Università Campus Bio-Medico, Rome, Italy; [2]Department of Orthopaedic Surgery, University of Pittsburgh, USA Introduction: Different authors have studied the assessment of ACL tears with MRI and concluded that complete ACL tears can be diagnosed accurately with standard orthogonal planes and paracoronal images. However, MRI evaluation of partial ACL tears remains difficult and it is not always possible to establish the diagnosis Attempts have been made to improve the diagnostic accuracy of MRI for partial ACL tears but the diagnostic efficacy is still a key 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 included 2D and 3D images with an increased resolution. In order to evaluate different ACL rupture pattern we first searched for the optimal MRI planes and sequences to evaluate the AM and PL bundle structure. In the next step we will cut the AM and PL bundle femoral, tibial and midsubstance to mimic original rupture pattern with dissected fresh cadaveric knees. Results: AM and PL were selectively identified in both obliquecoronal and oblique-sagittal plans passing trough the ACL axis. AM and PL are oriented in parallel with the knee at full extension. Discussion: MRI is helpful for detection of complete ACL ruptures, but at the present time has less utility for evaluation of partial ACL tears. Describing partial ACL tears and their rupture pattern, optimal MRI planes, and sequences still need to be found. If it is possible to describe the rupture pattern more precisely in advance, surgical planning could be improved, allowing reconstruction of the two bundles based on their individual status as intact or damaged. Conclusion: We described the acquisition of specific MRI plans for the selective evaluation of the AM and PL bundles of the ACL, for the improved diagnosis of the partial tears.

MEDIAL RETINACULAR RETENTION FOR CHRONIC PATELLAR INSTABILITY A. Schiavone Panni, M. Tartarone, A.A. Patricola, D. Sanatiti, M. Gallo IspeO – Istituto Specialistico Ortopedico, Rome, Italy; University of Molise, Campobasso, Italy Background: Patellar instability is a major challenge for the orthopaedic surgeon and the outcomes of most interventions, conservative as surgical, can be discouraging. During the last decade a few contributions have been published regarding the combination of arthroscopic lateral release with plication/repair of the medial retinaculum. Since a few years, given the good outcomes reported and the low morbidity of the technique we perform medial retinaculum plication associated to lateral release for the treatment of patients affected patellar instability without dislocation (Fulkerson type I). Matherials and Method: Plication of the retinaculum is performed percutaneously with 3 resorbable #2 sutures (PDSII, Ethicon, USA) with vertical antero-posterior direction. The suture, as well as the lateral release, are performed under arthroscopic assistance. Post-operatively the knee is immobilized with compressive elastic dressing for three weeks, allowing 0-60° ROM, recommending strengthening of the vastus medialis. From february 1999 to october 2002 40 patients (29 female, 11 male; mean age 20.3 years) underwent this protocol in our institution. Results: Among this series no major complications (septic, vascular) were observed. All patients filled the Kujala questionnaire without problems. The mean follow-up was 60 months. 26 cases were classified 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 negatively influence the outcome are Q angle measure and insufficient muscular rehabilitation and ROM recovery. Discussion: The technique presents clear advantages, namely low morbidity (no intervention on the extensor mechanism) and no cosmetic damage (no visible scars). The wider indications proposed by some authors (including patellar dislocation) should be better investigated with prospective, controlled, long term clinical trials. It should also be evaluated the effectiveness of such procedure in cases of severe cartilage damage, given the bad results reported in these cases even in the short term. Conclusions: Major advantages of the technique are low morbidity and the possibility of completing the treatment with realignment procedures in case of failure. However, patients must be clearly informed of potential long term failure and strict selection of indications (excluding severe instability cases with chondral lesions) is key to success.

SESSION O19 MISCELLANEOUS II MAINTENANCE OF CORRECTION AFTER AN OPENING WEDGE HIGH TIBIAL OSTEOTOMY USING A MONOAXIAL DYNAMIC EXTERNAL FIXATOR: A 2- TO 8-YEARS FOLLOW-UP N. Mondanelli, P. Aglietti, E. Russo, P. Cuomo, D. Lup, L. De Luca Prima Clinica Ortopedica, Università degli Studi di Firenze, Florence, Italy Opening wedge tibial osteotomy is a treatment option for mild medial knee osteoarthritis in young patients. Monoaxial dynamic external fixator (MDEF) can be employed to reach and keep correction. One of major concerns of this technique is correction loss. The purpose of this study was to assess clinical, subjective and radiographic results at a mean follow-up of 5 (2-8) years. Between 1998 and 2004, 25

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patients, mean age 51(38-61) years, were operated with this technique. Osteotomy was performed below the tibial tubercle, the MDEF was assembled on 2-proximal 2-distal pins. Distraction was performed 1mm/day until correction was achieved. Patients were evaluated at MEDF removal and then yearly. Distraction started 6.4(4-8) days after surgery, final correction was obtained after 24.7(18-30) days, MDEF was removed 74.8(60-121)days post-operatively. No patients developed pin-tract infections. One patient died of unrelated causes. Subjective KOOS results showed 80(47-100) points for pain (pre-op 57.37-92), 71(36-100) for symptoms (pre-op 56.30-79), 78(57-100) for ADL (pre-op 53.30-85), 58(6-100) for sports activities (pre-op 18.0-35), 55(25-100) for quality of life (preop 21.0-36). IKDC subjective results showed 79(32-98) points (preop 43.15-63). All patients but one were satisfied with surgery. Clinical evaluation showed no patients with instability or ROM deficit worst then pre-operatively. At MDEF removal mechanical axis was 4.5°(2°-7°)valgus, anatomical axis 6.8°(4°-8°)valgus, percentage of mechanical axis on tibial plateau 64%(62%-66%), posterior slope 5°(1°-8°), metaphyseal varus 4.3°(2°-7°), Insall-Salvati ratio 1.02(0.95-1.18). At the latest follow-up 5 patients had a loss of correction of 1°-2° on mechanical axis or 1%-2% of mechanical axis on tibial plateau. Neither complications nor significant correction loss were observed in this series. The use of a MDEF to perform an opening wedge tibial osteotomy seems to be a safe procedure. Advantages of this technique are no need for bone graft, immediate weight-bearing, no hardware left, less residual metaphyseal deformity. Disadvantages are less patient compliance with need for pin-tract care.

cally increased life expectancy of thalassemic patients. Among endocrin, infective, and metabolic complications, organ failure remains the principal complication, but osteoporosis is becoming an important cause of morbidity. The authors describe a case of a 26year-old female with Beta-Thalassemia Major afflicted by a fracture of the proximal femur on minor trauma. Since 2-year-old she received regular monthly blood trasfusion and took deferoxamine at the dose of 20 mg/Kg/day for 5 days a week. She had a regular menarche at 13 years old with regular mestrual cycle until the ageof 20, when she developed hypogonadotropic hypogonadism. Ovarian function was assessed by measuring FSH, LH, Estradiol, Progesteron and other serum parameter as GH and IGF-1 were measured too. The bone metabolism was investigated by detection of serum calcium, alkaline phosphatase, Osteocalcin, beta Cross-Laps (Collagen I), 25-OH-Vitamin D. Bone Mineral Density was measured in femoral area and lumbar spine by Dual-x-Ray absorpiometry. Fracture was surgically treated with using AFN (Synthes) intramedullary locked nailing in a static mode. In thalassemic patients osteoporosis ethiology is still unclear but many factors can contribute to its development; according biochemical markers of bone turn-over, low bone mass results from increasing of bone resorption. Both chelating therapy and reduction of IGF-1 levels seem to be implicated in the unbalanced bone turn-over. Many other factors seem to be related to reduction of low bone mass as hypogonadism, vitamin D deficiency and iron overload. According to the literature and looking at this case we consider the importance of 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 II Clinica Ortopedica, Università degli Studi, Florence, Italy A great percentage (85%) of patients with low blood rate of factor VIII/IX are afflicted by articular blood effusions: blood provokes arthropathy by acute then chronic sinovial inflammation on one side, with release of many enzymatic substances, and, on the other side, by a cartilage damage: for these reasons, both sinovial excision and chondral protection could be good prophylactic treatments. Any other form of surgery has to be carefully evaluated because of the peculiar general conditions and high rate of complications. From January 1999, we have collaborated with the Regional Center for Congenital Coagulopathy visiting about 6 patients for every week, with an amount of 1100 consultancies in 410 patients, most of them from Tuscany. First approach to haemophilic arthropathy was relief from symptoms with medical therapy and viscosupplementation. Open surgery was performed in 5% of patients: osteotomy (2 cases), arthrodesis (4 cases), knee and hip replacement (respectively, 28 and 6 cases), arthroscopy (32 cases). Being an extremely complex pathology, surgery is indicated only in selected cases and using well described and effective techniques.

PATHOPHYSIOLOGY OF BONE DISORDER IN THALASSEMIA MAJOR F. Pezzillo [1], F. Liuzza [2], R. Di Matteo [3], A. de Matthaeis [2], G. Maccauro[2] Dipartimento di Scienze Ortopediche e Traumatologia, Università Cattolica, Rome, Italy; [2]Dipartimento di Scienze Ortopediche e Traumatologia, Università Cattolica, Rome, Italy; [3]Dipartimento di Medicina Interna, Università Cattolica, Rome, Italy Beta-Thalassemia Major, firstly described by Cooley, is an inherited blood disorder leading to anaemia due to an imbalanced globin chain synthesis affecting erythroid maturation and red cell life. The combination of both blood transfusions and chelating therapy has radi-

COMPLICATIONS IN THE SURGICAL TREATMENT OF THE LATERAL FEMORAL NECK FRACTURES (1200 CASES) R.M. Capelli, V. Galmarini, G.P. Molinari, A. De Amicis A.O. Fatebenefratelli e Oftalmico, S.C. Ortopedia e Traumatologia, Milan, Italy The authors report their experience and describe the more frequent complications they have had in the surgical treatment of over 1200 cases of lateral femoral neck fractures. The lateral fractures of the proximal end of the femur occur very frequently, especially in elderly patients who have a higher risk of mortality, and are a considerable health problem for society. The result’s quality and the social recovery are in close relationship with timing of surgery, minimal blood loss, minimally invasive surgery, healing fracture’s time and early rehabilitation. Materials and Methods: From 1990 to 1998 we utilized Gamma Nail (Howmedica) and from 1999 till today we have been using B. I. Nail (Bio-Implant Group).We have used 607 Gamma Nail (average age 80,8 years), and 530 B. I. Nail (average age 81,6 years).From 1992 we treated the per-sub-trochanteric fractures and the associated fractures of the femoral shaft with the intermediate 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”. Conclusions: Out of 1200 treated cases of lateral neck femoral fractures we obtained: 15 iatrogenic fractures, 9 cut-out of the femoral screw, 1 broken intra-medullar reamer, 2 cases of non-union, 1 broken intramedullar locking nail, 2 superficial infections, 1 deep venous thrombosis. We are evaluating the most frequent complications (encountered in our Division) and the particular cases of special interest.

HIP FRACTURES: CLINICAL AND THERAPEUTIC APPROACH OF OSTEOPOROSIS V. Galmarini, R.M. Capelli, G.P. Molinari, F. Rotolo, A. De Amicis A.O. Fatebenefratelli e Oftalmico, S.C. Ortopedia e Traumatologia, Milan, Italy

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The clinical relevance of osteoporosis is the resulting fractures occurring in the weakened bone (fragility fractures). Recent articles suggest that orthopaedic surgeons are still neglecting to identify, evaluate and treat patients with osteoporosis and low-energy fractures. The lifetime risk for an osteoporotic fracture of the hip, spine and wrist has been reported to be 40% for Caucasian women in Europe. The risk for hip fractures is between 11% and 18% in woman, which is equal to the combined risk for breast, uterine and ovarian cancer. The number of individuals over 65 years of age is expected to almost double by the year 2040 and the number of hip fractures is predicted to rise dramatically. In 1990, the estimated total number of hip fractures in persons over the age of 50 was 1.7 million world wide, the number of such fractures is estimated to reach 6.3 million worldwide. Up to a third of patients with hip fractures will die as a result, 4% die during their initial hospitalisation and 10% to 24% within the first year. Such fractures are also associated with substantial morbidity and function loss; half of these patients do not regain their previous level of mobility. A patient with vertebral fractures has nearly a fivefold increased risk of a future similar injury and double risk on hip and other non-vertebral fractures. Pharmacological intervention (calcium, vitamin D, drugs of AIFA 79 and 79 bis notes) has potential to reduce the risk of future fracture by half in patients with existing fractures. Other measures (fall prevention, individually-tailored exercise programs) have been shown to reduce fall among the elderly. Through this work we want to analyze the problems of orthopedic surgeon facing fragility fracture.

consent received daily subcutaneous TPTD injection of 20 microg) in association with 880 U.I. of colecalciferol and 1g of calcium carbonate per os for 12 months. Results: Haematochemical values in the 12 months demonstrated normal values of PTH without significant changing; low levels of 25 OHD that increased progressively and significantly from 0 to 12th month (p<0.01); high levels of ALP that decreased significantly (p<0.05) with inversion of percentage between hepatic and bone fractions; normal calcemia and phosphatemia that remained unchanged. Normal urinary levels of calcium and phosphate remained unchanged from baseline to endpoint. In the first 6 months BMD is significantly increased of 16% in average (p<0.02) but in the second one. The decreased VAS and increased QUALEFFO 41 were well correlated to absence of any new fracture and to recovery of good general conditions and better compliance of elderly patients. No adverse affect was observed and nobody had suspended the therapy. Conclusions: Considering that PTH treatment improves the quality of life of elder osteoporotic women in term of pain relief, mobility, autonomy and prevention of new fracture in relative short time from baseline, it could be useful also in the first days after trauma. Further clinical studies will be necessary to define if this skeletal anabolic agent may enhance the healing process or osteointegration of prostheses. Suggested readings: Genant Curr Med Res Opin. 2005; Neer N Engl J Med 2001; Black N Engl J Med 2003; Stewart J Bone Miner Res. 2000

PRELIMINARY RESULTS OF ADJUVANT THERAPY WITH TERIPARATIDE IN THE ORTHOPAEDIC TREATMENT OF VERTEBRAL AND FEMORAL FRACTURES IN SEVERE POSTMENOPAUSAL OSTEOPOROSIS

SESSION O20

C. Corradini [1], F.M. Ulivieri [2], L. Parravicini [1], A. Mondini [1], C. Verdoia [1] [1]Clinica Ortopedia e Traumatologia, Instituto G.Pini, Milan, Italy; [2]U.O. Nuclear Medicine; IRCCS Foundation, Milan, Italy Introduction: Clinically, the most important aspect of orthopaedic treatment for vertebral and femoral fractures in postmenopausal women is the early functional recovery, the pain relief and the prevention of new fractures. These objectives are very often difficult to obtain because of a severe osteoporosis and a late efficacy of current specific drugs. The recent discovery of anabolic effects of parathyroid hormone (PTH) on osteoporotic skeleton bone has opened new therapeutic horizon. The aim of the present study was to verify the efficacy of adjuvant therapy with teriparatide [rhPTH(1-34), TPTD] on pain and disability in the orthopaedic treatment of vertebral and/or femoral fractures in severe postmenopausal osteoporosis. Materials and Methods: We selected nine women between 64 and 87 years old with postmenopausal osteoporosis treated with antiresorptive agents and affected by persistent back and/or hip pain with functional disability accompanied by sedentary life. Of these the youngest one was afflicted by seven vertebral fracture in two years for which she had received seven vertebroplasties or kyphoplasties in another hospital; five had a recent dorsal fracture with history of 1or 2 previous vertebral fractures; three patients over eighty years were undergone to hip arthroplasty for a femoral neck fracture and one of them was affected by a single vertebral fracture and another one has received five years before a homolateral knee arthroplasty. Parathormone (PTH), alkaline phosphate (ALP), calcium (Ca), phosphorus (P) and 25-hydroxyvitamin D (25OHD) serum levels and calcium (Ca), phosphorus (P) on urine of 24 hours were measured at the beginning and 1, 3, 6, 12 months later. Bone mineral density (BMD) measurements at the lumbar spine and non-injured hip or both hips were obtained at baseline and after 6 and 12 months. The pain symptoms and quality of life through respectively on a selfreported visual analogue scale (VAS) and QUALEFFO 41 were collected at 0, 6, 12 months. All the women after signature on informed

RACHIS III SURGICAL TREATMENT OF THORACOLUMBAR OR LUMBOSACRAL JUNCTION INSTABILITY: CLINICAL AND RADIOGRAPHIC RESULTS G. Gulino, L. Spatafora, V. Auteri, S. Zappalà Azienda U.S.L 3, Catania, Italy Objective: The primary purpose of this study is to evaluate the clinical and radiographic outcomes, as well as the complications, following decompression and fusion for instability of thoracolumbar or lumbosacral spine junction. Materials and Methods: Twenty-six patients affected by primary or secondary instability of the thoracolumbar (group A) or lumborsacral spine junction (group B) were enrolled in the study. Patients were evaluated by MRI and X-Ray studies (AP, lateral views and dynamic flexo-estension and lateral bending in standing position). All the patients were subjected to decompression and instrumented fusion of the junction with bone graft; long instrumentations were performed in 75% of Group A patients and 22% of group B patients. Patients were evaluated by clinical (VAS scale) and radiographic parameters (preoperative instability, postoperative fusion rate and symptomatic adjacent segment degeneration) and the occurrence of complications. Results: Average preoperative VAS score averaged 7.1 in group A and 7.2 in group B; after surgery these values decreased to 2.3 and 2.4 respectively. Fusion rate was 87.5% of cases in group A and 89% in group B. Neither neurological deficits nor instrumentation failure were observed in the two groups. In patients in group B, one patient reported adjacent level degeneration, while superficial wound infection occurred in another case. Conclusion: Patients with clinical and radiological signs of spinal instability non-responding to conservative treatment are candidate to surgery. Main objective of this surgery is pain reduction. To prevent adjacent segment degeneration and subsequent instability is quintes-

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sential: A) to include T11-T12 in the fused levels for dorsolumbar junction instability in order to decrease local torsional forces; B) when performing lumbosacral junction fusion surgery, to pursue lordosis restoration and lumbosacral angle correction to decrease sliding forces that would be transferred at the adjacent level.

with good bony mass. This technique, used from two years, has not evidenced at today cases of lost correction although we have always authorized the premature and not protected walking.

THE TREATMENT OF SEVERE OSTEOPOROSIS WITH TERIPARATIDE: OUR EXPERIENCE A NEW CONCEPT IN THE SURGICAL TREATMENT OF THORACIC OUTLET SYNDROME P. Ciampi, C. Scotti, G.F. Fraschini Ospedale San Raffaele, Università Vita e Salute, Milan, Italy Thoracic outlet syndrome (TOS) encompasses several clinical disorders, resulting from compression of the brachial plexus and/or subclavian vessels. Two different types of TOS are identified: “non-disputed TOS” due to anatomical structures compressing the neurovascular bundle, and “disputed-TOS”, characterized by the absence of an identified ethiology. Usually the treatment of choice is the resection of the first rib. The aim of our study is to demonstrate the efficacy of a more conservative surgical approach. We treated 50 patients, 39 women and 11 men. All patients were clinically evaluated. Presenting features included: coldness, pallor, paresthesias, dysesthesias, lack of dexterity, numbness. Symptoms were usually provoked by overhead activities during work or daily living. X-ray of the neck, EMG, dynamic angio-MRI were performed. Patients were divided in two groups: “non-disputed TOS” group (30 patients) and “disputed TOS” group (20 patients), according to the clinical and radiological findings. In the first group, 21 patients were affected by abnormal first rib, 4 patients by lipoma, 3 patients by transverse mega-apophysis, 2 patients by clavicle-pseudoarthrosis. In the second group, 16 patients were affected by scalenus anterior anomalies, 4 by brachial plexus fibrosis (diagnosed during surgery). Decompression was achieved using a supraclavicular and infraclavicular approach in order to perform: cervical 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 resection (5), neurovascular release (50). No post-operative major complications were noted. All patients were evaluated at 3 weeks, 3 months, and yearly thereafter. Mean follow-up was 15 months. Complete resolution of symptoms with a return to full activity was noticed in all cases. Our results demonstrate that partial resection of the first rib, when necessary, and neurovascular release are a safe and effective method to treat TOS.

THE MINI-OPEN SURGERY IN THE TREATMENT OF COMPRESSION VERTEBRAL FRACTURES A. Piazzolla, G. De Giorgi, R. Mangialardi Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. Ortopedia e Traumatologia I, Università degli Sudi di Bari, Italy In the last few years we have noticed the development of new techniques for the treatment of type A, according to Magerl-Harms classification, vertebral compression fractures to obtain the recovery of the static and cinematic function in the shortest possible time and using less invasive approaches. Nowadays, the kyphoplasty emblematically represents the gold-standard in the treatment of osteoporotic forms and its principles can be extended also to subjects with conserved bony resistance, if suitable systems of reduction are used. According to this idea, the B-Twin, initially projected like intersomatic cage thanks to its preconfigured deformation, once positioned, with transpedicular approach, and expanded, is very useful in young persons, limiting the expansion towards lower resistance zones, unlike kyphoplasty with its documented high deformability of the bonetamp. The Authors, also recognizing the usefulness of the kyphoplasty in the treatment of the osteoporotic vertebral compression fractures, presents their experience with B-Twin expandable system in patients

A. Piazzolla, N. Capocasale, V. Mascolo, S. Saporetti, A. Luca, G. de Giorgi Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. di Ortopedia e Traumatologia I, Università degli Studi Bari, Italy A useful aid in the treatment of the severe osteoporosis in women older than 65 years with unsatisfactory bisphosphonate treatment, T-score equal or inferior to -4, multiple vertebral osteoporotic fractures and one or more age-independent risk factors (like: BMI < 19 kg/m2, maternal familiarity with neck-femoral fractures before 65 years old, premature menopause, conditions associated with the extended immobility) comes from the Teriparatide, a synthetic form of the natural human parathyroid hormone, that stimulates the formation of new bone by increasing the number and action of boneforming cells. Continuing in the study proposed during the 90th SIOT reunion that evidenced the effects obtained after only six months of treatment, the Authors presents theirs results at the total end of the protocol with 20 mcg per day of Forsteo, along with calcium (1000mg) and vitamin D (400UI) supplementation, for the previewed period of 18 months. The weekly evaluation of the Calcium plasmatic concentration evidenced its increase for 16-24 hours with a maximum peak in 4-6 hours. Conditions like hypocalcaemia, se-vere renal insufficiency, renal calculosis, hyperparathyroidism, Paget, alkaline hyperphosphatasaemia and previous therapy radiating are confirmed the main parameter of exclusion from the treatment.

PERCUTANEOUS VERTEBROPLASTY AND TERIPARATIDE [RHPTH(1-34)] P. Lisai, C. Doria, P. Tranquilli Leali, F. Milia, L. Tidu Clinica Ortopedica, Università di Sassari, Italy Objective: Teriparatide [rhPTH(1-34)] has been shown to increase BMD and reduce the risk of fracture in postmenopausal women with osteoporosis. The purpose of this study was to investigate the skeletal effects of 9 months of treatment with teriparatide [rhPTH (1-34)] in women with osteoporotic vertebral compression fractures treated previously by percutaneous vertebroplasty and antiresorptive therapy. Materials and Methods: Daily subcutaneous injections of 20 µg teriparatide [rhPTH (1-34)] were administered for 9 months to 30 postmenopausal women previously submitted to percutaneous vertebroplasty for multilevel vertebral compression fractures. Mean age was 71.3 year (range 59-83). AlI patients had previously received alendronate therapy administered 70 mg/once weekly far 18-36 months. Median baseline BMD T-scores was < -2.5. Median baseline bone turnover markers levels were osteocalcin 24µg, N-propetide of type I pro-collagen 87µg, bone specific alkaline phosphatase 15 µg and N-telopeptide of collagen 13 nMoIBCE/L. All patients received daily calcium (1000 mg) and Vitamin D (500 UI) supplementation. The primary study outcome was change in lumbar spine BMD measured by DXA. Secondary outcomes included changes in bone turnover markers and pain. Results: At 6 month follow-up, lumbar spine BMD increased 5.4% relative to baseline data. Bone turnover markers had statistically significant increases. Median change in bone turnover markers was similar at 3, 6 and 9 months. Clinical data showed significant pain relief. No adverse treatment effects were observed during teriparatide [rhPTH (1-34)] therapy period. Conclusion: Our data show that patients previously treated with alendronate respond to teriparatide [rhPTH (1-34)]. Teriparatide

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[rhPTH (1-34)] treatment in postmenopausal women with osteoporotic vertebral compression fractures previously treated with alendronate produces more than expected bone markers and BMD responses, especially in the first period of treatment. Alendronate pre-treatment alters the usual time course and relationships between teriparatide [rhPTH (1-34)] stimulation of bone formation markers and changes in BMD. Can we consider teriparatide, an anabolic drug, as support agent in percutaneous vertebroplasty?

SESSION O21 OPEN FRACTURES TREATMENT OF SOFT TISSUE LOSS BY ILIZAROV TECHNIQUE IN OPEN FRACTURES AND NON-UNIONS S. Reverberi Struttura Semplice di Chirurgia Ortopedica Funzionale, Arcispedale S. Maria N., Reggio Emilia, Italy Treatment of fractures and non unions with bone and soft tissue loss is a challenging work. In this topic Ilizarov method has a growing importance. It allows fast recovery, weight bearing and tissue regeneration without plastic surgery. If bone distraction is started seven days from compactotomy and traction rating is near one millimetre a day, regenerated tissue rapidly become bone and soft tissues quickly repair in the same time. So other operations such as skin flaps or vascularized bone or tissue transfer become very rare. Among 1989 and 2005 we treated 31 patients affected by bone and soft tissue loss in the leg segment. Bone loss was 1,5 -20 cm. long ; coetaneous loss was 7 – 60 cm2. All fractures and non unions healed at final control. All patients well tolerated Ilizarov hardware. Minimal complies were frequent, but we have not seen major (neurological or vascular) complications.

TREATMENT OF SEVERE SOFT TISSUE LOSS IN HIGH ENERGY OPEN FRACTURES OF THE LOWER LIMB M. Stopponi [1], A. Basile [1], A. Loreti [2], A.U. Minniti de Simeonibus [1] [1] II U.O.C. Ortopedia e Traumatologia, Az. Ospedaliera S. Giovanni-Addolorata, Rome, Italy; [2]Servizio di Patologia della Mammella, Az. Ospedaliera S.Giovanni-Addolorata, Rome, Italy The treatment of high energy fractures of the lower limb often requires the cooperation of orthopaedic surgeon and plastic surgeon. Appropriate soft tissue reconstruction and stable fracture fixation are the main factors to obtain a satisfactory result. Exposed bony fragments need to be covered with well vascularized tissue as soon as possible, to preserve the viability of bone and to reduce the risk of infection and non-union. It is not possible to standardize the treatment protocols for extremely various fracture and soft tissue loss patterns. The level and the extension of the soft tissue lesion dictates the choice of the flap to utilize. 1) Thigh: usually treated with primary delayed closure, associated with split thickness skin grafts or local muscle flaps (tensor fasciae latae, gracilis, rectus femoris, vastus lateralis or biceps femoris). Coverage of exposed bone is rarely a problem, because of the abundance of soft tissues available. 2) Leg: non-reamed intramedullary nails are utilized also in Gustilo III open fractures. Small-medium wounds can be covered with local muscle flaps: medial or lateral head of gastrocnemius muscle, medial emisoleus flap, flexor digitorum longus, local fasciocutaneous flaps, distally based sural artery fasciocutaneous island flap. 3) Foot: adductor hallucis and abductor hallucis muscle flap, medial plantar fasciocutaneous flap, dorsalis pedis fasciocutaneous flap.

Large soft tissue loss can be covered by microsurgery using free flaps. The most utilized flaps are: free latissimus dorsi flap, rectus abdominis, gracilis, free anterolateral thigh flap, radial fasciocutaneous forearm flap, scapular and parascapular flap. Orthopaedic surgeons who treat open fractures of the limbs must have deep knowledge of problems related with treatment of bone and soft tissue lesions and must follow all current protocols. Multidisciplinary cooperation is one of the keys to obtain the best result.

LOWER-EXTREMITY AMPUTATION AND AMPUTATIONLIKE INJURIES: IMMEDIATE MICROSURGICAL TREATMENT WITH SHORTENING AND SECONDARY LIMB LENGTHENING BY CORTICOTOMY AND CALLUS DISTRACTION B. Battiston [1], W. Daghino [2], A. Aprato [3], A. Gallo [4], A. Biasibetti [2] [1]UOS Microchirurgia Ricostruttiva, Ospedale CTO, Turin, Italy; [2]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, Ospedale CTO, Turin, Italy; [3]Scuola di Specializzazione in Ortopedia e Traumatologia dell’Università di Torino, Italy; [4]Università, Turin, Italy Reconstructive treatment is indicated only in few cases of amputation or sub amputation of lower limb with complex injury, also because, for the patient, it is longer and more difficult then regularization. When it is indicated, a good way to perform this treatment is doing a deliberate shortening to support microsurgical suture and only after some months, when injured segment’s survival is obtained, restore leg-length discrepancy by callus distraction technique. With this surgical procedure 7 patient, in the last 11 years, were treated in CTO Hospital of Turin. Immediate shortening was done between 3 and 8 centimetres, later on distraction osteogenesis was made with corticotomy and external fixator. No case requested secondary amputation, in two cases distraction was made with mono axial external distraction device, while the rest with Ilizarov fixator. During treatment, complications were limited to few superficial pintrack infections, without osteomyelitis; moreover, one patient had a 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 end of treatment was good.

THE APPLICATION OF THE ILIZAROV’S METHOD IN THE COMPLEX TIBIAL PLAFOND FRACTURES N. Spina, R. Di Matteo, G. Dibiagi, M. Mastrangelo Unità Operativa di Ortopedia e Traumatologia, Asur Marche, Zona Territoriale 9, Macerata, Italy Introduction: Clinical experiences of several authors have evidenced the accuracy of Ilizarov external fixation in the treatment of tibia plafond fractures. The study regards 21 cases of complex fractures, characterized by comminution and soft tissue damage. The scope is to delimit the application field, to specify some sagacities of technique and to remark the advantages of the methodical one. Materials and Methods: 21 patients are treated with apparatus of Ilizarov for tibial plafond complex fractures. In 18 cases fracture was associated to distal fibula fracture, in 7 dislocation of the ankle. In the greater part of the cases, the synthesis of the fibula has been preliminary, following by the mini-invasive synthesis of the tibial epiphyseal segment with one or more screws. The apparatus of Ilizarov has been employed with a three rings pre-assembly and mixed bony setting (wires and fiches). In cases of ankle instability, it has been added a “pontage” to the foot (removed after 40 days approximately). Results: The fracture consolidation has been obtained in 20 cases; vicious consolidation in 4 cases; pseudoarthrosis in 1 case; infection of the soft tissue in 8 cases, dealt with curettage and medications.

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The resumption of ankle motility and load without pain has been obtained in 17 cases. Discussion and Conclusions: Within external fixation, to our warning, the circular device of Ilizarov represents a valid instrument and a compulsory alternative in the tibial plafond fractures with damage of the soft tissue. The preliminary synthesis of the fibula and the tibial epiphysis, also realizing a methodical hybrid, make the set-up easier and offer more guarantees for reduction and stability.

MANAGEMENT OF COMPLEX DIAPHYSEAL FRACTURES OF THE LOWER LIMB WITH COMPRESSION-DISTRACTION SYSTEMS R. Mora, L. Pedrotti, B. Bertani, G. Tuvo, I. Crivellari Clinica Ortopedica, Università di Pavia, Polo Univ. “Città di Pavia”, Italy Compression-distraction methods (or circular external fixation techniques) are particularly indicated for the management of complex tibial fractures, thanks to their versatility and excellent immediate stability. They are less often employed for the management of complex femoral fractures, because of the low tolerability and the difficulty of obtaining effective reduction and stability, and because of the frequent occurrence of knee joint stiffness; they are indicated mainly when internal fixation or axial external fixation cannot provide adequate stability. In these cases circular devices in non-standard configurations can be employed, in order to obtain reposition of the fragments and at the same time provide good stability and reduce pain. These special tricks consist of the use of screws instead of wires, changes of the distal part of the mounting, combination with internal synthesis, Novikov reduction nails, double threaded screws. For the intraoperative prevention of the knee joint stiffness, particular kinds of fixation of the distal part of the assembly have been created. The postoperative prevention is based on active and passive mobilization, use of CPM machines, use of dynamic splints such as “Dynasplint”. Between 1986 and 2005, 581 complex diaphyseal fractures of the lower limb in 549 patients (with the above mentioned indications) were treated with compression-distraction systems. There were 127 femoral fractures and 454 tibial fractures. The results were satisfactory, whit a very high rate of healing and a low rate of complications: in particular only 4 cases of knee joint stiffness (after the management of femoral fractures) required a surgical treatment by means of the Judet technique. These results confirm that, with the correct indications and the unavoidable limitations, the compression-distraction systems are a valid option for the management of these injuries.

SCORING SYSTEM FOR INDICATIONS TO RECONSTRUCTION IN LOWER LIMB AMPUTATIONS AND SUB-AMPUTATIONS B. Battiston, P. Tos, L.G. Conforti U.O.D. Microchirurgia Ricostruttiva, I^ Divisione Ortopedica, Ospedale CTO, Turin, Italy Indications for the reconstruction of lower extremity complex wounds are more selected than for the upper limb. This is due to the high rate of complications that follow traumas which commonly are high energy and often avulsion/crush injuries (necrosis, infections, non union, need for elongation procedures or other secondary surgical procedures) as well as to the good results obtained by prosthetic replacement of the lower limb (a much more elementary function compared to the upper limb, reduced hospitalization, rare secondary surgical procedures). To indicate the reconstruction, it is necessary to carefully evaluate the patient and the kind of

lesion, in order to obtain a good function without lameness, and recovery of plantar sensitivity. Numerous systems for the evaluation of these injuries are described in literature (MESS, Hannover, etc.) but, especially in severe cases like sub amputations and amputations, these methods can poorly predict the time and possibility of an effective functional recovery. For this reason we have created a simple and quick scoring system which can be easily applied in emergency. This system considers various parameters (patient’s 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 indication to reconstruction or amputation and helps to predicting the final functional recovery and helping the surgeon in taking early decisions. In our experience, the relatively higher importance given to parameters such as ischemia, and soft tissue condition (crush injury with secondary muscle and skin necrosis, posterior tibial nerve stretching with poor recovery of plantar sensitivity, etc.) has lead to a reduction in the incidence of complications and a higher rate of successful results.

FREE FLAP RECONSTRUCTION ON EXTENSIVE TISSUE LOSS AFTER TRAUMAS IN LOWER EXTREMITY, EXCLUDING THE FOOT P. Tos, L.G. Conforti, A. Antonini, B. Battiston U.O.D. Microchirurgia Ricostruttiva, I^ Divisione Ortopedica, Ospedale CTO, Turin, Italy Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery. Microsurgery surely is a good weapon when facing extensive tissue losses and infections. From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb, excluding the foot. These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps). Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis 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 approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery.

LOWER LIMB FRACTURE TREATMENT WITH HOFFMANN 2 EXTERNAL FIXATION SYSTEM IN MULTIPLE TRAUMA PATIENTS: OUR EXPERIENCE G. Fioretta [1], L. Valenti [1], P. Gifuni [2], C.A. Roncaglio [1] [1]SIOT, Milan, Italy; [2]SIA, Milan, Italy Introduction: We choose the Hoffmann 2 external fixation system for serious trauma treatments for its effectiveness, quickness and versatility.

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Materials and Methods: 28 patients with Gustilo II-III A or B injuries have been treated from August 2003. Follow-up: x-ray monthly, examination every 7-15 days, antibiotic therapy according to clinical and ematic results. Results: 28 Patients, 6 being women, 46.9 years (from 14 to 93) on average. Femur fractures were 11 (2 refractures treated with F. E. too), tibias 21, in two cases femur and tibia were on the same side and in 1 case fractures interested both tibias. We had two “floating knees”. All the fractures were classified according to Gustilo System II-III A, B. Union occurred in 8,6 months on average. Complications were 3 tibial non-unions, 2 later treated with intramedullary nailing and 2 knee stiffness. Conclusion: in our opinion external fixation is a satisfying technique to treat open fractures in patients with life threatening multiple injuries. Infection risk and recovery time depend on soft tissue damage. Experience and careful clinical controls are mandatory to obtain satisfactory results with this device.

GUNSHOT WOUNDS OF FEMORAL SHAFTS IN URBAN POPULATION: IS EMERGENT RETROGRADE INTRAMEDULLARY NAILING APPROPRIATE? J.J. Hoegler, J. Hurbanek, R. Weir, M. Morandi Henry Ford Hospital Trauma Center, Detroit, USA Objective: The number of fractures secondary to gunshot wounds (GSW) is increasing in urban populations across the United States. Antegrade intramedullary nails (IMN) have been an accepted treatment for closed and open fractures of the femur, including those secondary to GSW. Retrograde IMN’s were originally contraindicated because of a potential infection spreading to the knee joint. The purpose of this study was to evaluate the results of open femoral shaft fractures secondary to GSW treated with retrograde IMN’s at our institution over the past ten years. Methods: A total of 2.322 GSW presented to our Emergency Department (ED) between May of 1994 and January 2005. There were 196 femur fractures in 195 patients. Fifty-five fractures in 54 patients were treated with retrograde IMN, 66 were treated with antegrade IMN. Results: No patient in the retrograde IMN group developed osteomyelitis or septic arthritis of the knee joint. One patient with a Grade IIIC fracture required I&D of draining thigh fasciotomies. Another patient had an I&D of necrotic/draining bullet wounds. Conclusions: Our results did not show an increase in bone or joint infection with acute retrograde intramedullary nailing of open femur fractures due to GSW. Therefore, we feel this implant can be an acceptable treatment option, thereby expanding the indications for retrograde intramedullary nailing.

SESSION O22 PSEUDOARTHROSIS SURGICAL TREATMENT OF DISTAL FEMUR NON-UNION M. Girolami, C. Impallomeni, G. Trisolino, F. Trentani Istituti Ortopedici Rizzoli, Bologna, Italy Non-union is a rare but feared complication in the distal femur. Its repair is often hampered by thin cortex, short distal length, inadequate bone stock and any additional general health problems that the patient may have (old age, osteoporosis due to lack of use, insufficient blood supply, infections, etc.). Several treatments have been proposed in the literature. We present a retrospective analysis of the results of various types of surgery performed at our institute over ten years.

TIBIAL NON-UNION WITH BONE AND SOFT TISSUE DEFECTS: TREATMENT WITH FREE VASCULARIZED FIBULAR GRAFT O. Moreschini [1], M.S. Boccanera [2], F. Santanelli [3], S. Pappalardo [4] [1]Dipartimento di Scienze dell’Apparato Locomotore, Università degli Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, Italy; [2]Università degli Studi di Roma “La Sapienza”, Rome, Italy; [3]Unita’ di Chirurgia Plastica, Ospedale Sant’Andrea, Università “La Sapienza”, Rome, Italy; [4]Servizio di Ortopedia e Traumatologia, DEA Policlinico Umberto I, Rome, Italy Objective: The aim of this study is to evaluate the results of treatment of tibial non-union (with bone and soft tissue defects) with free vascularized fibular graft. Materials and Methods: We retrospectively studied 7 patients: 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 patients, IIIC-2 patients); 2 patients had infection at exposition site in the first 2 months after trauma. The average bone defect was 6 cm (min-0, max-12). In all cases we performed an extensive curettage of non-union site and vascularized graft of fibula (osteocutaneous or osteomyocutaneous flap). The average length of bone graft was 10 cm (min-6, max-18). We obtained 100% of healing and the average consolidation time was 5 months. The complications were infection on e.f. pins site (1 case) and fracture of the graft (3 cases). Using Mankin Classification, 5 cases were classified as “excellent” and 2 as “good” Conclusions: Although there are many different surgical options for treatment of tibial non-union, the free vascularized fibular graft is the only “one stage procedure” be able to treat simultaneously non-union and soft tissue defect with high rate of success.

TREATMENT OF NON-UNIONS OF LONG BONES WITH BONE MARROW ALONE OR COMBINED WITH PLATELET RICH PLASMA OR RECOMBINANT BONE MORPHOGENETIC PROTEIN 7 (OP 1). AN ONGOING OBSERVATIONAL STUDY P. De Biase, L. Ciampalini, M. Mugnaini, R. Capanna Dipartimento di Ortopedia, Sod Ortopedia Oncologica, Florence, Italy Treatment of non-unions of long bones in the last years has seen the new chance of BMP augmentation. We had already treated difficult and recalcitrant non unions with Concentrated Bone Marrow 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 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 a 60% healing success. The two failures of these techniques were in the same patient. In 35 cases we used open surgery and added bone graft plus PDGF and Bone Marrow in 16 cases, OP 1 alone in 16 cases and Bone Marrow plus OP 1 in the last 3 cases. The healing rate of all groups was similar (87% vs 87% vs 100%). The higher results of the last treatment (Bone Marrow + OP 1 ± PDGF) was only on three patients and should be further evaluated. The patients treated with OP 1 experienced a greater number of previous surgeries (>3), still the BMP-7 proved to be effective in these cases. We suggest that surgeons should take into account the use of BMP 7 that proved to be effective in selected, previously failed patients for non-unions and that adding Concentrated Bone Marrow might improve these already impressive results.

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SESSION O23 HUMERUS

AND ELBOW

PROXIMAL HUMERUS FRACTURES: COMPARISON OF TREATMENT M. Privitera, L. Costarella, V. Pavone, F.R. Evola, A. Rossitto, G. Sessa Dipartimento delle Specialità Medico-Chirurgiche, Istituto di Clinica Ortopedica, Catania, Italy 50-80% of the proximal humerus fractures arise composed and stable; therefore no reduction is necessary and only immobilization of the arm associated to a early rehabilitation are required. Concerning the displaced and/or comminuted fractures several treatments have been suggested, including open or closed surgical approaches. Crrect indication of treatment depends on the fracture geometry and the patient’s general and psychological conditions. These fractures are often associated to rotator cuff injury or to great tuberosity fracture producing a slow and incomplete recovery of range of motion. Our trend is to use Kwires in the comminuted fractures, closed or open reduction and screw fixation in the oblique fractures and intramedullary nails in presence of stable and not displaced fractures. This study examines the different treatments performed in the Orthopaedic Clinic of Catania in relation to patients’ type of fractures, sex and biological age of patient and it values the clinical and radiographic results at long term.

GUIDELINES OF PROXIMAL HUMERAL FRACTURES TREATMENT IN THE ELDERLY PATIENT M. Bigoni, S. Guerrasio, M. Gorla, C. Pulga, E.C. Marinoni Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatologia, Monza, Italy Proximal humeral fractures represent 5 – 7% of all fractures and they are often due to moderate upper limb traumas; 75% of these are occurring to females over 65 years. During the last year we observed 125 proximal humeral fractures: we treated 108 fractures in a conservative 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 outcome during daily activities than on roengtengraphic comparison. We believe that proximal humeral fractures current classification, based on two–dimension radiographic evaluation, is inadequate to predict clinical outcome. A correct interpretation of the fracture, through a 3D CT elaboration, allows to change and optimize the surgical treatment. According to our own experience, we present guide–lines of proximal humeral fractures treatment in the elderly patients.

RESULTS OF THE TREATMENT OF PROXIMAL HUMERAL FRACTURES USING THE PROXIMAL HUMERUS LOCKING COMPRESSION PLATE F. Chiodini, L. Filippi, L. Di Mento, M. Berlusconi Istituto Clinico Humanitas, Rozzano, Italy The ideal treatment for fractures of proximal humerus is still debated. Close reduction and fixation with K wires have not shown better results than conservative treatment. Shoulder hemiarthroplasty provides good pain relief, but only moderate functional recovery. When indicated, open reduction and internal fixation have proved to give good results in terms of pain control and function, but the surgical procedure is demanding and the results less predictable in the osteoporotic bone. Fixed angle plates such as

PHLCP have shown to achieve a strong grip even on the osteoporotic 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 internal fixation with PHLCP.

SESSION O24 PELVIS ACETABULAR FRACTURES: A NEW CT BASED CLASSIFICATION G. Tamburella Rome, Italy The author presents his experience of acetabular fractures, as examined according to Harris’ recent (2004) CT-based classification into four separate groups and relative sub-groups. Each group is here represented as a completely documented clinical case, with pre and postoperative roentgrams as well as axial and volume rendering CT imagery. The Harris classification differs from the classic and 40 year old Letournel classification, basically ignoring the fracture complexity and focusing on the pattern of the fracture itself, with respect to 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 characteristic. This topographic approach is easier for the surgeon to comprehend and memorize, thus facilitating pre-operative planning and the possibility of interdepartmental assessment of the fracture types. Obviously, computerized tomography is the defining technique of this classification. The axial CT display of acetabular fracture patterns within the pelvis is furthermore confirmed by the 3D reformatted images. This classification is loosely based on that of Tile and Helfet; with the advantage of further simplifying the sub-groups from 27 to 16. The Harris classification is simple and unambiguous, providing clear indications for both diagnosis and surgical treatment planning of this most complex chapter of Traumatology.

SURVIVAL MANAGEMENT IN SEVERE PELVIC TRAUMA G. Rocca, V. Danzi [2], A. Scalvi [3], P. Cosmi [2], P. Savonitto [1] Struttura Funzionale di Traumatologia, OCM, Verona, Italy; [2] Anestesia e Rianimazione A, Verona, Italy; [3] Divisione di Ortopedia e Traumatologia, OCM, Verona, Italy Pelvic fractures are about 3% of all fractures observed in emergency rooms. They are often associated with abdominal, thoracic and head lesions. Blood loss, as the result of bone bleeding or lesion of arterious or venous vessels, can often cause the death (37%) of the patient affected by these fractures. Haemorrhagic syndrome is the most important complication that threatens the life of patients with pelvic lesions. Blood loss control is the key of the treatment of complicated pelvic fractures and must be the very first step of the patient’s pre-hospitalization management. This can be achieved with adequate “filling” with different devices. The pelvis must be stabilized with either external fixation or C-clamp to stop or control the bleeding (venous); this has to be done as soon as possible because it is a life saving treatment. In some cases bleeding is mostly due to artery lesion (12%-80%) and thus the priority is to find the lesion site by means of angiography and proceed to embolization, delaying the open surgical treatment. It is controversial the priority, in the very first stress of treatment, of external stabilization versus angiography.

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ACETABULAR RECONSTRUCTION IN TWO COLUMN FRACTURES A. Scalvi [2], P. Savonitto [1], P. Ricci [1] Funzionale di Traumatologia, OCM, Verona, Italy; [2]Divisione di Ortopedia e Traumatologia, OCM, Verona, Italy G. Rocca

[1],

[1]Struttura

The fractures of the anterior and posterior column of the pelvis are one of the most difficult lesions to be handled surgically. Patients affected by this type of damage are victims of high energy trauma and have often important and heavy associated injuries which delay the surgical approach of the orthopaedic surgeon. Large exposures are necessary but they can lead the patient to higher risks of infection and thromboembolism. The reduction of the various fragments is more difficult due to the interposed large muscular mass, to the imperative respect of the vascular, nervous and urogenital structures, and sometimes by the difficult clear and direct inspection. The fragments are often deeply stuck between themselves and the above mentioned structures. For these reasons it is imperative to understand the mechanics of the fracture and the forces that have caused it in order to restore the anatomic structure of the pelvis. We report our survey and the results of 5 years experience using, in the same surgical time, the anterior ilio-inguinal and the posterior approach using the Kocher–Langebeck approach.

SURGICAL TREATMENT OF COMPLEX HIP ARTICULAR FRACTURES D. Capitani, F. Castelli, R. Spagnolo [1]Ospedale Niguarda Ca’ Granda Dea, Milan, Italy Objective: The articular fractures of hip comprehend femoral head fracture and acetabular fracture. Materials and Methods: From 1999 to 2005 DEA of Niguarda Ca’ Granda Hospital accepted 14730 trauma, 1443 of them were higher trauma. Pelvic fractures have been 425, 286 of them went under surgical treatment. They were 132 acetabular fractures and 154 fractures of the pelvic ring. We treated 7 fractures of femoral head. Results: we obtained 26% excellent, 49% good, 15% sufficient, 10% short case results. We checked 82 complex fractures on 132 cases, i.e. 62% of the treated acetabolar fractures. The average follow-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 %, etherotopic ossifiaction, 7.2 % avascular necrosis, post-traumatic arthritis 10.4%, SPE palsy 6.4 %. Conclusion: ORIF in acetabular fractures is a demanding technique with high complication rate even in expert hands. Timing is very important, as in other surgeries: fractures must be treated in a period from 4 to 10 days. If possible, only one surgical way should be used without losing reduction quality. The learning curve is necessary to improve diagnosis tools and methods, surgical time but above all the accuracy of the fracture reduction. In our opinion if the team consists of more expert surgeons in acetabular fractures there will be a better control of surgical complications, more attention to the reduction perfection, and results will eventually improve.

SESSION O25 PROXIMAL

FEMUR FRACTURES

THE FEMUR FRACTURES IN PUGLIA: CONTRIBUTION OF THE REGIONAL REGISTER OF THE PROSTHESES OF HIP C. Germinario [1], M. Torre [2], M.T. Balducci [1], S. Tafuri [1], Regione Puglia Gruppo di Lavoro Ortopedici [3] [1]Osservatorio Epidemiologico Regione Puglia, Bari, Italy; [2]CNESPS - Istituto Superiore di Sanità, Rome, Italy; [3]Regione Puglia, Italy

Introduction: Femur fractures constitute a serious social and caregiving problem. The dimensions of the phenomenon are imposing: every year in Europe over 500.000 new cases are recorded. In Italy in 2002 around 87.000 in-takes due to this pathology were reported, with a burden for the SSN of over 1 million Euros Materials and Methods: From the Register of the hip Prostheses of Puglia all the interventions carried out between 2003 and 2005 with diagnosis “fracture of the femur” have been selected. Epi-Info6.00 has been used for data elaboration. Results: 2058 cases were examined (76% women; hospitalization middle 20 days; age median 78 years). 80% of the interventions are of endoprosthesis. The most effected age class for the interventions of artroprosthesis is 60-69 years, for those of endoprosthesis is > 79 years. 3,5% of the patients died in the 6 months following the intervention. 6,8% of the patients had post-operative general complications. The most frequently used surgical incision was the lateral one (67%). All patients were given antithrombotic therapy and antibiotics. 70% of the prosthesis were fixed with cement. 92% of the treated cases showed a good functional recovery at 12 month follow-up. Conclusions: the use of the regional register of hip prosthesis allows not only to get reliable data on the characteristics of the interventions, but above all on their results. Working Group: P.Agamennone, A.Ambrosone, D.Bellino, G.Berloco, U.Biasi, A.Bozzi, F.Buquicchio, B.C.Campa, A.Canfora, M.Capozzi, G. Carchia, G.Carluccio, R.Castellaneta, P.Cataldi, M.Centrone, G Colì, M.Colonna, F.Conserva, O.De Carolis, G.DeGiorgi, S.DeGiorgi, P.Dell’Aera, L.Dell’Aera, F.P.DiCarlo, M.DiPalo, L.Felline, Ferrari, F.Fitto, V.Galante, P.Galluccio, P.Giannella, T.Gismondi, S.Giucastro, M.Greco, V.Innocenti, D.Laghezza, F.Larosa, A.Leo, L.Limonciello, G.Lobianco, F.Loconte, G.Loiacono, S.Lorusso, M.Mannarini, G.Mariani, M.Mascolo, F.Massari, N.Mastroianni, F.Mingolla, C.Monteleone, B.Moretti, L.Moretti, F.Mori, P.Nardelli, A.Ognissanti, M.Panella, F.Pascali, G.Pasquale, V.Patella, A.Pennetta, L.Petrelli, N.Petruzzellis, O.Recchia, L.Romita, V.Scarano, M.Schiavone, G.B.Solarino, G.Solarino, L.Spagnoletta, G. Spera, A.Spinarelli, A.Stomeo, G.Surace, V.Tempesta, W.Uzzi, G.Vavalle

THE MANAGEMENT OF UNSTABLE TROCHANTERIC FRACTURES OF THE FEMUR A. Lispi, F. Laurenza Ortopedia e Traumatologia, Azienda Ospedaliera S. Giovanni – Addolorata, Rome, Italy Trochanteric fractures of the femur demand special consideration in trauma surgery, because of their high complication rate. The combination of medial compressive, lateral tensile and torsional stresses, and the reduced vascularization in the region, has resulted in problems of malunion, delayed union, nonunion, implant failure and iatrogenic devascularisation from operative exposure. Restoration of femoral 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 the central position of the implant in relation to both medial and lateral cortices. In combined compression and bending to failure, intramedullary nails were found to support up to 400% body-weight, 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 provides a shorter lever arm. This means a reduction in bending stress for the nail of up to 30% compared with extramedullary devices, and a lower rate of implant failure. Another important benefit of closed intramedullary locking nailing is that there is no need to reconstruct the medial cortex at surgery. We found that the preferred method is by minimally invasive surgery. In the literature the use of second-generation

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intramedullary devices (gamma nail 3, proximai femoral nail) in their long form recommended as standard, reducing the incidence of delayed union and implant failure. The advantages of the implants are that closed fracture reduction and early mobilisation with full weight-bearing are possible without reconstruction of medial support or primary autologous bone grafting.

TREATMENT OF SUBTROCHANTERIC FRACTURES WITH DCS DEVICE D. Lazzara, A. Petrini U.O. Ortopedia, Nuovo Ospedale S.Giovanni di Dio, Florence, Italy DCS (Dynamic Condylar Screw) system was introduced in the early 80’s by the AO/ASIF Group [1, 2] and successfully used in treating 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 proximal third of the femur or in cases of re-operation for previous, failed, osteosyntesis. Materials and Methods: Between 2003 and 2005 we implanted 20 DCS in 20 different patients. Seven were re-operation for non-union (2 patients had intramedullary nails and 5 DHS devices) and 13 were recent fractures that we classified using AO and Seinsheimer [6] radiographical criteria. The average age of patients was 72.2 (42 to 92 years). All the patients underwent pre-operative and post-operative xray (45 days and monthly until healing was achieved) and clinical examination. The average follow-up was 18 months (8 to 24). Results: We had one case of superficial infection which settled with local debridement and antibiotics and two cases of delayed union. However all the three cases healed in 9, 8 and 7 months. The other 17 cases united in an average period of 4 months. So we had a union rate of 100%. Conclusions: In conclusion DCS device is a good option in treating these difficult cases: the complication rate reflects the general condition of patients and the biomechanics of the proximal femur [7]. If 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: 1. Sanders R, Regazzoni P (1989) Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 3(3):206–213 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 3. Blatter G, Janssen M (1994) Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg 113(3):138–141 4. Pai CH (1996) Dynamic condylar screw for subtrochanteric femur fractures with greater trochanteric extension: J Orthop Trauma 10(5):317–322 5. Vaidya SV, Dholakia DB, Chatterjee A (2003) The use of a dynamic condylar screw and biological techniques for subtrochanteric femur fracture: Injury 34(2):123–128 6. Seinsheimer F (1978) Subtrochanteric fractures of the femur: J Bone Joint Surg Am 60(3):300–306 7. Warwick DJ, Crichlow TP, Langkamer VG, Jackson M (1995) The dynamic condylar screw in the management of subtrochanteric fractures of the femur: Injury 26(4):241–244

TREATMENT OF PROXIMAL FEMORAL FRACTURES WITH NEW PFN-A NAIL: PRELIMINARY RESULTS M.S. Boccanera, F. Carsillo, L. Ricchiuti, P. Verzaro, M. Papalia Divisione di Ortopedia e Traumatologia, Nuova Itor ASL Roma B, Rome, Italy

Today the surgical treatment of these fractures is based on reduction and stability of fracture obtained with “minimally invasive” technique. There are many different type of intramedullary nail: the aim of this study is to evaluate the results of first 50 patients treated with new PFN-A nail from February 2005 to March 2006. Evaluation included clinical and radiographic assessment (sex, age, fracture type, walking ability before and after operation, average healing time, intra- and post-operative complications). The clinical results confirm the excellent results of many studies. For proximal locking a spiral blade is used to produce adequate anchorage even in osteoporotic femoral head. This new device provides a better fixation in patient with poor bone quality or instable fracture, reducing the risk of femoral “cut out”. The new PFN-A nail is cannulated, don’t need anti-rotational screw and permit distal static or dynamic interlocking using only one screw.

GAMMA NAIL: 15 YEARS EVOLUTION, 15 YEARS EXPERIENCE. THE RESULTS P. Savants [1], M. Inguaggiato [2], A. Migliorini [2] Funzionale di Traumatologia, OCM, Verona, Italy; [2]Clinica Ortopedica, Ospedale Policlinico, Verona, Italy G. Rocco

[1],

[1]Struttura

The perthrocanteric fractures are the most frequent fractures in the elderly people and the increased life expectation in the population leads to a higher number of fractures. The intramedullary nailing technique represents since 15 years the first surgical choice in handling these types of fractures and the Gamma Nail has been the instrument utilized more frequently. However the Nail has been frequently modified with the aim to better fit the femoral anatomy, to increase the resistance to the mechanical stress, to increase the grip performance and therefore facilitate the surgeon in the introduction, housing, and proximal and distal locking of the Nail. In our Hospital we have used the Gamma Nail for more than 15 years as golden standard in the treatment of the perthrocanteric fractures and we have used all the updated versions. We show the results of a large review of the whole period.

SESSION O26 PROSTHESIS III THE CERAMIC COUPLING IN A SERIES OF 100 CONSECUTIVE HIP REPLACEMENT PERFORMED BY THE SAME SURGEON G. Solarino, A. Piazzolla, L. Scialpi, N. Tartaglia, G.B. Solarino [1]Università degli Studi di Bari, U.O. Ortopedia e Traumatologia I, Bari, Italy The Authors present clinical and radiological results in 100 consecutive alumina-alumina hip replacement performed by the senior author (G.B.S.). The initial diseases inducing hip replacement were: primary coxarthrosis in 55 hips, atraumatic avascular necrosis in 23, fracture of the upper femur in 10, coxarthrosis after hip dysplasia in 8, 2 coxitis, rheumatoid arthritis in 1 and post-traumatic coxarthrosis in 1. The average preoperative HHS was 35 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 anodized Ti stem in 26 cases and two cementless (one anatomical and one HA-coated straight) Ti stems in the others. To an average follow-up of 78 months (min.22- max.154), we have evaluated 82 hips (82%); 3 hips have undergone a revision (1 infection, 1 stem fracture, 1 sinking of the anatomical cementless stem). None of

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sockets have been revised for aseptic loosening and none of the implants have been revised due to mechanical failure of the ceramic components. At the last f.u. the average HHS is 95 points (min.64-max.100).

CLINICAL EVENTS DURING BEMIPARIN PROPHYLAXIS STARTED 6 HOURS AFTER HIP OR KNEE REPLACEMENT SURGERY: A REVIEW P. Prandoni [1], A. Birreci [2], A. Gómez-Outes [3] [1]Dipartimento di Scienze Mediche e Chirurgiche, Università di Padova, Padua, Italy; [2]Dipartimento Medico, Sigma-Tau, Rome, Italy; [3]Dipartimento Medico, Laboratorios Rovi, Madrid, Spain Background: Bemiparin is a second generation low-molecularweight heparin (LMWH) licensed for postoperative start of prophylaxis of venous thromboembolism (VTE), whereas recommendations for other LMWHs involve preoperative initiation. Objective: To review the available experience on the use of bemiparin started 6 hours after total hip replacement (THR) or total knee replacement (TKR) surgery. Methods: We extracted data on clinical outcomes from the 3 available clinical studies assessing postoperative bemiparin prophylaxis after THR or TKR (Planes et al., 2000; Navarro-Quilis et al., 2003; Abad et al., 2003). Pooled events were: documented symptomatic DVT or pulmonary embolism (PE), major and minor bleeding, deaths and thrombocytopenia. Results: The 3 studies included 1264 patients (421 THR and 843 TKR) who were administered bemiparin 3500 IU started 6 hours after surgery. A total of 1056 (83.6%) received extended post-hospitalisation prophylaxis with bemiparin for a median time of 38 days. Mean patients’ age was 70.6 years (range: 28-85) and 67.4% were female. Neuraxial anaesthesia was used in 1166 (92.2%) patients (31% epidural and 69% spinal). The incidence of events up to 5-6 weeks (observation period) was the following: documented symptomatic DVT, 0.4% (THR 0.2% and TKR 0.5%); documented symptomatic PE, 0%; major bleeding, 1,3% (THR 2.1% and TKR 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 major bleeding events, and, consequently, it is an effective and safe alternative to preoperative start of thromboprophylaxis and minimises the risk of spinal haematoma.

HIP ARTHROPLASTY: MINI INCISION LATERAL APPROACH VERSUS STANDARD APPROACH R. Iorio, A. Speranza, S. Giannetti, C. D’Arrigo, A. Ferretti [1]Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy Introduction: Minimally invasive surgery has become a trend over the last few years in all aspects of orthopaedic surgery, including total hip arthroplasty. The so-called “mini-incision” technique involves limiting the length of the skin incision to ≤ 10 cm with use of either anterior, lateral or posterior approach. Materials and Methods: Between March 2004 and December 2005, 120 consecutive unilateral total hip replacements were performed in our institute by the same senior surgeon. The diagnosis was of primary osteoarthritis in 101 cases, of osteonecrosis of the femoral head in 8 cases and of femoral neck fracture in 11 cases. In all cases we performed a hip replacement using a direct lateral approach (65 cases using a standard approach / 55 cases using a mini incision approach). In all cases we used a cementless cup (Trident; Stryker Howmedica) and a cementless stem (Hipstar;

Stryker Howmedica). The following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional 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 position, the length of hospital stay and Harris Hip Score (HHS) and the Womac osteoarthritis index at six months. A significant lower blood loss was found in the mini-incision group. A higher percentage of perioperative complications was recorded in mini incision group (two stupor of sciatic nerve, one fracture of the greater trochanter, one stem malposition). Conclusions: A mini incision lateral approach seems to have a lower blood loss and a shorter length of incision but a higher percentage of peri - operative complications. On the bases of our experience we could speculate that the minimally invasive surgery should be directed to the new surgical approach with muscle sparing instead of a shorter skin incision using standard approaches.

FEMUR PERIPROSTHETIC FRACTURES TREATMENT BY CABLE-READY BONE PLATE SYSTEM R. Franceschini, P. Romano, G. Salvadori del Prato, M. Franceschini, M. Grassi Dipartimento di Chirurgia Specialistica Riabilitazione, Milan, Italy Femur periprosthetic fractures have been increasing compared to primary implants. Among treatment options we have used the cable-ready bone plate system, treating 9 cases whose results are presented. This system is based on the association of plate and cerclage which run through the plate itself and are secured by a screw, giving stability to the system because plate and cerclage are secured together. The availability of molded plates, able to adapt on great trocanter, allows to fix also proximal fractures. In particular, the tensioning system is useful to adjust the strength given and to progressively retention the cerclage in order to avoid secondary loss of tension. We consider this system effective, since it allows good stability and early patient motion.

SESSION O27 KNEE I UNICOMPARTIMENTAL KNEE ARTHRITIS. UNICOMPARTIMENTAL KNEE REPLACEMENT VERSUS COMPUTER ASSISTED TOTAL KNEE REPLACEMENT: A MATCHED PAIRED STUDY N. Confalonieri, A. Manzotti, K. Motavalli [1]I U.O. Ortopedica e Traumatologica, C.T.O., Milan, Italy The Authors compared in a matched paired study at a minimum followup of 3 years, the results of 78 knees with isolated medial unicompartimental knee arthritis replaced with either UKR (group A) or Computer Assisted TKR (group B). In both groups the selection included only stable knees with range of motion of at least 110°, both without any pre-operative flexion deformity and a varus deformity bigger than 8 degrees, and a body mass index lower than 30. The matching criteria for each case were: same grade of pre-operative arthritis, age, sex and pre-operative range of motion. No implant in either group had to be revised and no intra or post-operative complication caused by the implant selection were registered. The surgical time and hospital staying was statistically longer in the CA TKR group. There were no statistical differences in the Knee Society score while the functional

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score and the GIUM score were statistically different, even if the distributions of the percentage of results were similar. In both groups there were no radiological signs of loosening. In CA TKR all the implants were positioned within 4 degrees of ideal both Hip-Knee-Ankle angle (180°) and Frontal Tibial Component angle (90°). Higher performance results were obtained using a unicompartimental knee replacement in the treatment of isolated primary unicompartimental knee replacement 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 clinical performance but increased the economical costs.

RESULTS OF COMPARISON BETWEEN TKA IMPLANTED BY ANTERO-MEDIAL ACCESS AND MID-VASTUS MEDIALIS ACCESS G. Pipino, D.C. Vaccarisi Bologna, Italy We compared 260 TKA Profix (Smith & Nephew) implanted between 2002 and 2003 by antero-medial approach and 260 TKA Profix (Smith and Nephew) implanted between 2004 and 2005 by midvastus medialis approach. TKA has been implanted by miniopen technique. In our study we analyze the following parameters: recover of quadricipital strength, range of motion, Q angle, patellofemoral pain, prosthesis component positioning, blood loss, time of postoperative recovery, patient satisfaction. We valued quadricipital strength by Isokinetic Leg-Extension-Air-Machine and ROM by digital goniometer. In patients with TKA implanted by midvastus-medialis approach we noted: 1. more easy respect of Q angle 2. reduction of patello-femoral pain 3. more easy preservation of Q angle 4. same easiness and precision of component implantation 5. riduced post-operative blood loss thanks also mini open-tecnique 6. 50 % improvement of patient satisfaction short-term and long-term.

TOTAL KNEE ARTHROPLASTY FOR VALGUS DEFORMITY 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] Clinica Ortopedica, Università degli Studi, Florence, Italy; [2]U.O. Radiologia 1, CTO, Florence, Italy

age functional score improved from 43 to 82 points. A transient postoperative peroneal nerve paralysis was observed in only one patient. The mechanical axis was corrected within 3 degrees of neutral in 72% of knees. There was one failure due to aseptic femoral loosening at 5 years. Conclusions: The Pie-crusting technique is a reliable method to correct fixed valgus deformity in patients undergoing TKA, with a low complication rate and excellent mid-to-long terms results.

EVOLUTION IN THE TREATMENT OF DEGENERATIVE KNEE 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; [3]Università di Roma La Sapienza, Polo Pontino, Latina, Italy In the last few years Unicompartimental Knee Prosthesis (UKP) has reached a new emphasis. Modern studies have started to show valid and 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 evaluate the improvement of short and mid term results using a particular UKP specifically studied to enhance the range of motion and the surgical procedure. In comparison with the Total Knee Arthroplasty (TKA) the UKP gives better ROM, faster postoperative recovery and the possibility of an easier operation in case of infection or loosening. Some features should be evaluated and the surgical technique should use modern design hardware. From January 2002 to January 2005 we implanted 57 UKP (Uni-Zimmer) in 55 patients. From April 2005 to February 2006 we used the evolution of the mentioned prosthesis, called ZUK® in 40 patients. We collected results about first 45 Uni-Zimmer in comparison with the 40 ZUK. The demographic distribution was similar in the two groups for age and gender: mean age was 64.5 (49-81); 60% female and 40% male. In both groups a minimal invasive procedure was performed. We did not have infections. We can affirm that the real qualitative difference with ZUK concerned about ROM in the early postoperative period, with 125° of flexion already in third day. Nevertheless our early data, we can conclude that in the treatment of degenerative knee, the correct selection of the patient, the surgical technique and the updated design of 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 must be sharply performed using components with updated designed.

[1]I°

SESSION O28

Introduction: Correction of fixed valgus deformity presents a major 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. Methods: Sixty-five patients with 73 knees with preoperative alignment >10 degrees of valgus were operated between January 1994 and September 2000. Fifty-five knees (75%) were reviewed with an average follow-up of 94 months (range 60-140). With the Piecrusting technique the posterolateral capsule was cut transversely at the level of the tibial osteotomy and an inside-out multiple stable incisions were made using a small knife blade, in the contracted lateral soft tissue (particularly in the ITB and the lateral capsule) until the deformity was corrected. The popliteus tendon was always preserved to limit the risk of posterolateral instability in flexion. Various types of implants were used: IB-II (20%), LPS (22%), MBK (54%) and CCK (4%). At follow-up all patients were evaluated using the Knee Society scores, a Patellar score and a radiographic study, which included also stress xrays to evaluate gaps configurations. Results: At follow-up the average Knee Society clinical score improved from 38 points preoperatively to 90 points postoperatively and the aver-

KNEE II TRENDS OF TOTAL KNEE ARTHROPLASTY IN ITALY M. Torre [1], E. Romanini [2], G. Tucci [3] [1]CNESPS - Istituto Superiore di Sanità, Rome, Italy; [2]Globe, Rome, Italy; [3]Unità Operativa di Ortopedia e Traumatologia, Ospedale “L. Spolverini”, Ariccia, Italy Objective: Knee arthroplasty has been so successful that nowadays it is the most prevalent surgical intervention in the treatment of knee arthritis. Higher confidence in surgical technique, development in biomaterials, evolution of pain control and rehabilitation protocols and, last but not least, the perception of a reliable result have contributed to the spreading of this procedure. Materials and Methods: To understand the spreading dynamics of knee arthroplasty in Italy, an analysis of data collected on the National Discharge Records Database has been performed for both Total Knee Arthroplasties (TKA; ICD9-CM 8154) and Total Knee Replacements 8155 (TKR; ICD9-CM 8155) in the period 1999-2003.

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Results: An increase of 84% for TKA and 114% for TKR has been registered. Average length of stay has shown a decrease of 26%. No change in the average age of patients undergoing TKA has been detected. However, it is interesting to analyse variations occurred in the number of procedures and in length of stay stratified per health trusts typology. The highest increase in number of procedures has been observed in Private Clinics (+146%) while the lowest has been found in Public Hospitals (+48%). All Public trusts have shown a decrease in length of stay (about -25%) while for the private ones an increase of 16% has been measured. Discussion and Conclusions: The analysis of trends in knee arthroplasties in Italy, conducted during the period 1999-2003, has highlighted the considerable increase of the number of procedures. However the high interregional variability of data suggests that the analysis must take into account the causes in order to better define reference standards to address research where it is useful and to correctly share earmarked resources as well.

Results: The study shows an overall good outcome (86,1/100), in particular the result was excellent in 45% of the cases, good in 30%, fairly-good in 17%, poor in 8%. Survival of the implants was 89,8%. The failures which caused a revision have been 9 aseptic loosening, 3 septic loosening, 2 peri-prosthetic fractures and 3 ruptures of the polyethylene. Radiolucent lines in the 42,5% of the cases, mainly in tibial area 1 have been discovered. In the 84% of the cases they did not turn out progressive. Two cases were presenting signs of initial loosening, without current indication to the revision. Discussion and Conclusion: Clinical and survivial results have been good and in agreement with the literature. TKA allows pain relief and functional recover. Aseptic loosening is the main cause of failure at long term, while septic loosening is at a shorter one. It is likely that the evolution of the materials will increase the survival of the implants. The prosecution of the study and the evaluation of other series with new implants are mandatory.

TREATMENT OF PERISPROSTHETIC FRACTURES AFTER TKA

TOTAL KNEE ARTHROPLASTY USING MODIFIED MINIMIDVASTUS TECHNIQUE

A. Camera, G. Grappiolo, M. Gramazio, G. Santoro Ospedale “Santa Corona”, Pietra Ligure, Italy

A. Toro [1], G.F. Trinchese [1], A. Russomando [1], G. Mastroroberto [2] [1]U.O. di Ortopedia e Traumatologia, Ospedale Amico “G. Fucito”, Mercato San Severino, Italy; [2]Servizio di Neurofisiopatologia Ospedale “G. Da Procida”, Salerno, Italy

Introduction: Fracture after TKA is always a delicate event, not so simple to be treated, whether it comes intra-op or in the long-period. Surgical treatment is rather necessary but standardized and often closed to personal experience of the surgeon. The incidence of this pathology is increased because of the raising number of knee prosthesis implanted and the patients’ life-expectation. Materials and Methods: In our prosthetic division of “Santa Corona” hospital are implanted 290,3 knee prostheses on the average per year. Perisprosthetic fractures treated since 2000 up to today are 26 (18 females, 8 males). In all cases except one, total prosthesis was used and only in three cases the removal of the prosthesis and the reimplant using a revision-prosthesis with taproots has been carried out, while in the other cases the treatment has been Ostesynthesis or not sanguinary treatment. Results: We have noticed that the clinic result varies a lot depending on the type and the time in which the fracture happened. On the intra-op fractures we obtained better results, while the worst are those coming from the long-period fractures where the loss of motion range and subseguently of TKS have occurred. Discussion: A periprosthetic knee fracture surgery is very hard for the surgeon; he must have traumatologic background with an adequate prosthetic instrumentation (taproots, semi-bounded or bounded prostheses), associated to a physiatric structure adapted for the post-op.

TOTAL KNEE REPLACEMENT WITH PRESS FIT CONDYLAR (PFC) PROSTHESIS: OUTCOMES AT TEN YEARS A. Bistolfi, A. Barberis, F. Lagalla, C. Olivero, E. Novarese, M. Crova II Clinica Ortopedica, Turin, Italy Introduction: The long-term follow-up of the total knee arthroplasty (TKA) is of great interest. This study evaluates the results at 10 years of 219 implants from 1993 to 1998. Materials and Methods: 15 patients died and 31 were lost at follow-up. 166 TKA (125 patients, 79% female, mean age 77,5 yy) implanted for arthritis in 83,1%, rheumatoid arthritis in 11,4%, post trauma in 1,8% and other in 3,7%. The PFC (Johnson & Johnson, USA) cemented posterior-stabilized have been used. Patella has been resurfaced in 103 cases (62%). ”Hospital for Special Surgery Knee Score” (HSS) and “Knee Society, Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System” have been used for clinical and roentgenographic evaluation, respectively.

Objective: In minimally invasive total knee arthroplasty we prefer mini-midvastus approach because it preserves extensor mechanism, also giving a good join exposure. Otherwise, the 43% of patients who had vastus splitting approach, presented electromiographic alteratus alterations after the surgery. For this reason we have modified the traditional mini-midvastus technique, including in the incision just tendon under the vastus medialis, but not the muscle. Materials and Methods: From May 2005 to January 2006 we performed 132 TKA with modified mini-midvastus technique. We studied 30 patients with electromiography performed 7 days before the surgery and 3 months after, on a standard point of vastus and on incision site. The muscle was checked for any abnormal spontaneous activity and during contraction. Results: There was no abnormal spontaneous activity in 100 % of cases before and after surgery. PUM were normal in 60 % of patients and increased in 40% before and after surgery. There were no signs of reinnervation preoperatively. The recruitment pattern indicated a little damage in 80% of cases and a big damage in 20% before the surgery. Discussion: Electromiographic alterations were already preset in preoperative exams. They were due to ipotrophy of vastus muscle 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 improved in 20% of cases is not a sign of damage. It indicates a sprouting and a regeneration of suffering fibres before surgery. Conclusion: Our results demonstrated that modified mini-midvastus technique does not only cause damage to muscle, but it also allows to obtain sign of rapid return to function.

HIGH TIBIAL OSTEOTOMY IN VARUS KNEE: VALIDITY AND RESULTS A. Schiavone Panni, M. Tartarone, A.A. Patricola, C. Mazzotta, D. Santaiti ISpeO - Istituto Specialistico Ortopedico, Rome, Italy; University of Molise, Campobasso, Italy Background: Many studies reported the value of the high tibial osteotomy (HTO) in the treatment of varus knee. In this section we would like to presents our results about HTO with Puddu-plate. Methods: From june 1999 to october 2002 we performed HTO in 20 patients; 10 patients (group 1, age min 45 max 55) were affected by

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varus knee and the others 10 patients (group 2) were young people (age: min=19, max=26) with genu-varu juvenile. We performed HTO using Puddu-plate technique; all patients were studied preoperatively with RX scan, and Lysholm and IKDC questionnaire and in the group 2 was also performed MRI study. Surgical techinique included diagnostic arthroscopic evaluation of the knee and for osteotomy greater than 10 degree we, always, used sinthetic bone block for filling the defect. In the post-op period all patients dressed a knee brace blocked in extension for 2 weeks; no- bearing was allowed for the first for 4 weeks, only partial bearing from 4 to 6 weeks and total bearing was allowed only after the 6/7 week (after X-ray evaluation). All patients were allowed for CPM since the first post-op day. Results: Among this series no major complications (septic, vascular) were observed. The mean follow-up was 52 months in group 1 and 48 months in group 2; all patients filled the IKDC and Lysholm questionnaire. In group 1 were observed satisfactory results in 70% of patients, in group 2 80%. In all cases we observed with X-Ray evaluation a good healing of the osteotomy after 8 weeks from surgery. Discussion: HTO with Puddu-plate has some advantages: it is an easy 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. 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. Conclusions: The timing and pre-op planning are necessary for the good results of surgical technique. In our opinion absolute controindication is patient with pre-op flexion ROM< than 90 degree and relatively controindication is obesity (BMI >1.32). HTO represents a valide alternative to major surgical procedure; in fact it is a very effective and low cost procedure that leaving the bone stock of the tibia allows to other eventual surgical procedures in the future.

CLINICAL EXPERIENCE OF TOTAL KNEE ARTHROPLASTY COMPUTER–ASSISTED: CLINICAL, FUNCTIONAL AND ROENTGENOGRAPHIC RESULTS AFTER 1 YEAR M. Bigoni, S. Guerrasio, A. Rossi, D. Munegato, D. Gaddi, E.C. Marinoni Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatologia, Monza, Italy Total knee arthroplasty computer–assisted surgery is getting more and more common nowadays, as testified by the increasing number of orthopaedic publications on the subject. Many Authors notice the accuracy of positioning prosthetic components is proportional to long-term good results. Navigation systems, during TKA implant, supply the surgeon with the opportunity of maximizing clinical results through his own technical surgery improvement. Authors present clinical, functional and roentgengraphic results at 1–year follow up of a consecutive group of patients undergone total knee replacement surgery computer–assisted, with a particular stress on the alignment equal or inferior to 3° which, as other Authors report, well correlate to good and excellent long-term results.

PERIPROSTHETIC DENSITOMETRIC EVALUATION OF A NON CONSECUTIVE GROUP OF PATIENTS UNDERGONE TOTAL KNEE REPLACEMENT SURGERY: A SIX–YEARS FOLLOW-UP M. Bigoni, S. Guerrasio, A. Rossi, M. Gorla, E.C. Marinoni Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatologia, Monza, Italy

The number of total knee arthroplasty is progressively increasing during the years, due to both an improvement of the surgical technique and the materials used, and for epidemiological reasons. Despite failure percentage is reducing continuously, it must be strictly considered because of the high costs charged to the patient and to the medical system. Frequently, trabecular bone failure of the tibial epiphysis is liable of prosthesis damages. The study of periprosthetic mineralization and its changing represents direct information about mechanical strength of the bone and, indirectly, information about biological competence of changing according to loading situations. Dual Energy X-ray Absorptiometry (DEXA) is the chosen method to evaluate bone mass density in a non invasive way. This technique, performed after total knee replacement surgery, is at the beginning and it doesn’t gain the experience acquired with THA. Furthermore, there aren’t studies in literature except of two-years follow-up. Authors present a retrospective study of densitometric evaluation at six-years follow-up of a non consecutive group of 40 patients undergone TKR surgery and a critical analysis of the Dexa use as a support to modern prosthetic surgery.

SESSION O29 RACHIS IV BONE GRAFT SUBSTITUTES IN POSTEROLATERAL FUSION: EFFICACY OF GRAFT MATERIAL AND ACCURACY OF RADIOGRAPHS IN THE ASSESSMENT OF BONY FUSION G. Giannicola [1], G. Cinotti [1], M. Riminucci [2], B. Sacchetti [3], A. 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 Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, Italy; [2]Dipartimento di Medicina Sperimentale, Università degli Studi dell’Aquila, Italy; [3]Dipartimento di Medicina Sperimentale e Patologia, Università degli Studi di Roma “La Sapienza”, Policlinico Umberto I, Rome, Italy; [4]Clinica Veterinaria, Rieti, Italy; [5]Dipartimento Laboratorio Modelli Animali, Istituto Regina Elena, Rome, Italy A currently used animal model of spinal fusion was adopted to investigate: 1) the osteoconductive properties of a coralline HAcoated (Proosteon 500R) as carrier for osteoinductive materials; 2) the effectiveness of autologous fresh bone marrow (AFBM) and platelet-rich plasma (PRP) associated with granules of coralline HA, in promoting spinal fusion; and 3) the accuracy of radiographic evaluation in the assessment of bony fusion. Materials and Methods: Posterolateral fusion was performed in 30 WNZ rabbits using the following graft materials: coralline HA alone and +AFBM on the left and right side, respectively (15 rabbits); coralline HA+PRP and coralline HA+AFBM+PRP on the left and right side, respectively. Six months after surgery animals were sacrificed and the lumbar spines submitted to standard and high resolution (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 AFBM, respectively, and in 71.3% of those treated with coralline HA+PRP and with coralline HA+AFBM+PRP. There was no significant difference in the radiographic results between the 4 groups. Histologic analysis showed new bone formation adjacent to the transverse processes while little or no bone formation was found between the transverse processes leading to a continuous bony bridge. Granules of coralline HA-coated were also found with scant evidence of reabsorption 6 months after surgery.

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Conclusions: Coralline HA-coated was a suitable carrier for osteoconductive material; however, a carrier with a shorter reabsorption time may be advisable, at least in some circumstances. AFBM and PRP associated with coralline HA- coated were not found to be an adequate graft material for spinal fusion. Radiographic evaluation showed a reduced accuracy in determining bony fusion, even when a high resolution technique was used.

POSTERIOR-LATERAL LUMBAR FUSION WITH OSIGRAFT®: EXPERIENCE WITH AN INTERNATIONAL MULTICENTRIC STUDY D. Prestamburgo, M.F. Surace, C. Ratti [1]Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, Università degli Studi dell’Insubria, Varese, Italy During 2005 an international, multicentric, prospectic randomized trial was conducted to evaluate the efficacy of BMPs in spine surgery. This study, in which we included ten patients, consisted in the treatment of degenerative disc disease, spondilolysis-olistesis or other single level pathologies where a surgery has never been attemped before. A PLF was performed in both groups. In the treatment group some bone chips deriving from laminectomy or spinous processes were mixed with Osigraft ® (BMP-7); the control group received an autograft from the posterior iliac crest. Concerning the surgical technique transpedicular screws were positioned and stabilized with titanium rods; also an accurate haemostasis was obtained as well as a complete exposition of the transverse processes. Both the Osigraft ®/bone complex and the autograf were positioned between the transverse processes. Five men and five women were treated with a mean age at surgery of 51 years (range, 25 to 68 years). The affected level was L4-L5 in six cases and L5-S1 in the last four. Results at most recent follow-up are presented, with particular regard to the quality and timing of the fusion healing in the two groups.

TREATMENT OF THORACIC AND LUMBAR SPINE LESIONS. BOLOGNA MAGGIORE HOSPITAL EXPERIENCE M. Palmisani, G.B. Scimeca, A. Gasbarrini, F De Iure, L. Boriani, G. Barbanti Brodano, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia Vertebrale, AUSL Città di Bologna, Ospedale Maggiore ~ Bologna In the lapse of time between October 1996 and December 2005, 419 cases of recent thoracic and lumbar spine fractures were treated in our Department. Every patient has been followed (Follow-Up (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 to 78 years); 289 patients were males, 130 females. Car crashes have been the leading cause of the traumatic events (253 cases), followed by work injuries. Mean fractures were localized at thoracic spine in 226 cases, while 193 lesions involved the lumbar spine. Every patient was treated by a posterior approach associated with laminectomy and arthrodesis of all of the instrumented areas. Eighteen patients underwent widened postero-lateral approach with intersomatic arthrodesis. Anterior approach was performed in 50 cases.Neurological damage has been assessed following Frankel criteria. Neurological setting improvement was reported only in 3 cases (2,7%) out of 134 cases with complete medullary lesions. Five deep and 3 superficial infections developed in t he postoperative period. Only one of these infected cases led to instrument removal. Three multiple-trauma patients died. Two of them because of sepsi and one because of pulmonary embolism. Two cases were characterized by cerebrospinal fluid fistula, one of

them complicated by meningitis. Both these cases eventually recovered. Two politrauma patients developed serious skin lesions that healed after conservative treatment. Thirteen cases had a mechanical failure. They recoverrd through a surgical revision (8 posterior approach, 5 double approach).

SESSION O30 DEFORMATION RESULTS OF VIDEO-ASSISTED THORACOSCOPIC SURGERY: 5 YEARS FOLLOW-UP A. Montanaro, F Turturro, E. Camerucci, M. Spoletini, A. Ferretti Cattedra e UOC di Ortopedia e Traumatologia II, Facoltà di Medicina e Chirurgia, Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy From September 2000 to October 2002, 11 consecutive patients with scoliosis underwent a video-assisted thoracoscopic anterior spinal release and fusion followed by a posterior instrumented fusion. This case series was compared to a similar group of 11 consecutive patients who were treated by open anterior spinal release and fusion followed by a posterior segmental spinal fixation and fusion. We evaluate the results on average 5 years follow-up. Methods: The VATS group included 8 female and 3 male (mean age 14.2) with the following diagnosis: 5 idiopatic scoliosis, 4 neuromuscolar spinal deformation, 1 congenital scoliosis and 1 neurofibromatosis. In the Control group were included 7 female and 4 male (mean age 15.4) with 7 cases of neuromuscular scoliosis and 4 idiopatic. The mean preoperative Cobb angle was 78° in the VATS group versus 85° in the Control group. Mean follow-up was 5.1 years. Results: There was no significant difference in the average scoliosis correction rate, which was 32° in the VATS group and 37° in the Control group respectively. No difference was observed in the average blood loss between the two groups. There were no vascular or neurological complications in both series. At final follow-up, both group no exhibited loss of percentage correction of scoliosis. Conclusion: In our series, video-assisted thoracoscopic surgery allowed to achieve anterior instrumented release and fusion as effective as standard open procedure. No difference of percentage of curve correction was observed at final follow-up. Advantage of thoracoscopic technique included lower postoperative pain, faster recovery and, cosmetically, a minor surgical scar.

THE SURGICAL TREATMENT OF SEVERE ANGULAR KYPHOSIS G. De Giorgi, A. Piazzolla, A. Luca Dipartimento di Scienze Chirurgiche Generali e Specialistiche, U.O. di Ortopedia e Traumatologia I, Università degli Studi Bari, Italy The authors present their experience in the treatment of severe angular kyphosis with anterior decompression and posterior stabilization according to an experience already consolidated in time. From 1994 they have treated 19 patients, 10 males and 9 females. In 8 cases the aetiology was congenital, in 4 infectious, 2 post-traumatic, 3 secondary to Recklinghausen, 1 secondary to Morquio, 1 neoplastic. In case of clinical evidence of medullar damage (6 patients) they have always performed previously the anterior way, with medullar decompression and application of bony graft (iliac, fibula, coast), completated, after 1-2 weeks, from the posterior instrumentation and arthrodesis. In case of absence of medullar damage they have used

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the Halo-traction preoperative in order to mobilize the spine, thus evaluating the reducibility of the kyphosis, and to notice eventual variations of the clinical conditions. Therefore, in absence of neurological deficit, they have performed first the posterior time, correcting the deformity, and subsequently the anterior one, to obtain the arthrodesis using autologous bone graft. In all cases the surgical two-time strategy produced a reduction of the deformity with regression, partial or total, of the neurological symptomatology, where present, and absence of representation in time.

POSTERIOR SPINE FUSION WITH UNIT ROD IN PATIENTS AFFECTED BY NEUROMUSCULAR SCOLIOSIS L.F. Colombo, S. Monforte, F. Motta ICP Ospedale, Milan, Italy Methods: Since 2003 we treated 32 patients for neuromuscular scoliosis with the Unit Rod instrumentation (18 males, 15 females) mean age 15th range 13 to 19. Mean preoperative curve magnitude was 78°, range 40° to 120°, and associated pelvic obliquity mean 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 mounth postoperatively. We used SRS 22 questionnaire and subjective questionnaire at 6 months. Results: The spine curvatures mean correction was of 35° range 18° to 56° (62%). The pelvic obliquity mean correction was of 11° range 0° to 24°. Mean surgery time was 5.30 h. The subjective questionnaire showed an important improvement of the quality of life. Discussion and Conclusion: With this technique we reached good results without previously using traction or cast and the patients were able 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 Rod is a good device for the treatment of neuromuscular scoliosis.

PROGRESSION RISK OF JUVENILE SCOLIOSIS DURING PUBERTY F. Canavese, P. Charles, J.P. Daures, A. Dimeglio CHU Lapeyronie, Montpellier, France We reviewed 205 scoliosis (163 girls, 42 boys) at the end of growth. There were 52 juvenile I and 153 juvenile II. At the clinics we regularly use a checklist to assess standing and sitting height, Tanner signs, menarche and bone age to map the patient on its growth curve. Topographies and Cobb angles of primary and secondary curves were measured on AP spine radiographs and refered to the pubertal growth diagram. Within 205 scoliosis 99 (48.3%) became surgical. At the begining of puberty (11 years of bone age in girls, 13 years in boys), within 109 primary curves < 20 degrees 15.6% were surgical. Within 56 curves between 21-30 degrees, the surgical rate increased to 75.0% and to 100% for curves >30 degrees. For 42.9% of the curves between 21-30 degrees and 71.4% of the curves >30 degrees that became surgical, the aggravation took essentially place during the first two years of puberty (p=0.0014). A gain of one degree per month represents a risk of 100% (p=0.0001). The surgical risk was the highest for primary thoracic curves (p=0.0001). No significant difference of evolution risk was noted for both genders. Juvenile scoliosis over 30 degrees at the begining of puberty becomes surgical. Curves between 20 and 30 degrees need a close follow-up. Our study showed that surgery was often indicated too late and allowed only partial curve reduction. An earlier intervention is preferable for a better curve correction, even if it gets necessary to sterilize the growth cartilage anteriorly to prevent a crankshaft phenomenon. Surgery at the begining of puberty represents only a minor sacrifice on sitting height.

SESSION O31 SHOULDER WOLTER’S HOOK PLATE IN 3°DEGREE ACROMION-CLAVICULAR LUXATIONS L. Lucente, W. Thomas, L. Tafuro Clinica Quisisana, Rome, Italy The treatment of the acromion-clavicular luxation is still controversial. Many orthopaedics cure this luxation in conservative way, others with surgery. In the first case they said that surgery is not sure to get a complete anatomical and functional restoration. It depends to the osteosynthesis device chosen. We prefer a temporary special plate with hook (Wolter’s plate). It enables an optimal acromio-clavicular anatomical restoration without damage of articular surfaces (cartilage, disc) and a complete and sure functional recovery.

SURGICAL TREATMENT OF ACROMION-CLAVICULAR DISLOCATION AND FRACTURE OF THIRD LATERAL OF CLAVICULA WITH A HOOK PLATE. RESULTS AT 3 YEARS S. Zoccali [1], A. Di Francesco [1], P. Cerulli Mariani [1], R. Pizzoferrato [1], C. Zoccali [2], A. Ranalletta [2] [1] U.O.Di Ortopedia e Traumatologia, Ospedale S. Salvatore L’Aquila, L’Aquila, Italy- [2]Università degli Studi L’Aquila, Clinica Ortopedica, L’Aquila, Italy Objective: The aim of this study is the evaluation of the surgical 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. Materials and Methods: We treated 25 acromion-clavicolar dislocations and 10 displaced lateral fractures of the clavicula. The therapeutic protocol was an immobilization in Gilchrist for 7 days, an early rehabilitation with passive exercises to recover R.O.M., reaching the complete R.O.M. in 8 weeks from the surgical treatment. Plate removal was performed at 12 weeks from the trauma. Clinical and radiological controls were performed at 2, 6, 12 weeks and after the removal of the plates at 12 months. Results: in all of the cases the results were satisfactory, with renewal of the normal daily activity and sport activity at 4 months from the trauma. At 12 months from the trauma a M.R was performed with observation of the entire continuance of the AC and coracoclavicular ligaments. Discussion: The hook plate of Dreithaler is a plate in titanium, in which the hook is positioned under the acromion, guaranting a stable reduction and besides, with its angulation of 15°, it is adapted to the angle of acromion-clavicola. We used plates with 3 holes for the dislocations and 4 holes for the fractures, it presents smooth border and is slightly concave on the inferior surface to adapt itself to the anatomy of the clavicula. We recommend hook plate fixation as an acceptable surgical method for the treatment of type III and V acromionclavicular dislocation and displaced lateral fractures of the clavicula fractures.

POSTOPERATIVE REHABILITATION IN SHOULDER ANATOMICAL ARTHROPLASTY: 3 YEARS FOLLOW-UP G. Merolla [1], P. Paladini [1], I. Riccio [2], V. Riccio [2], G. Porcellini [1] [1]U.O di Chirurgia della Spalla e del Gomito, Ospedale “D. Cervesi”, Cattolica, Italy; [2] Dipartimento Scienze Ortopediche, Seconda Università di Napoli, Naples, Italy

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Introduction: Degenerative arthritis of glenohumeral joint is characterized by cartilage loss and bony erosion, head flattening and bony erosion. Shoulder arthroplasty should restore anatomic congruity ensuring articular stability and proper tension on soft tissues. In this study we report 3 years follow-up on patients who underwent shoulder replacement and the rehabilitative program they followed. Patients and Methods: from January 1999 to December 2003 we performed 145 shoulder arthroplasty. Patients enrolled: 125 (86.20%); patients excluded: 20 (16%). Mean follow-up: 36 months (min: 28, max: 42). Score system: Constant scale (mean ± SD). Operations have been performed under general anesthesia and deltopectoral approach. Rehabilitative program: 0-30 days: sling, passive mobilization on scapular plane up to 40°; 30-45 days: active exercises in water pool and strenght restore, subscapular exercises at 42° day; 60 days: resistive exercises. Isometric test has been performed after 6 months and 12 months. Radiographic follow-up: post-operative, after 6 months and then yearly. Results: Constant score increased from preoperative 28.7 ± 16.2 to post-operative 68 ± 12.4. ROM increased from 10.6 ± 8.7 to 28.4 ± 6.6: Subscapular restore: no restore in 12 cases (11.42%), partial restore in 83 cases (79%), total restore in 10 cases (9.6%). We noticed 11 complications (8.8%): 8 cases (6.4%) of painful stiffness, 1 case (0.8%) of shoulder prosthesis infection, 1 case (0.8%) of periprosthetic fracture and 1 case (0.8%) of cemented glenoid component loosening. Statistical method: Chi-square test (p<0.05). Discussion: anatomic shoulder arthroplasty (Bigliani-Flatow) is a certain effective device to restore the operative ROM and an appropriate tone of active stabilizer muscles. Results can be considered good in regard to pain and function.

and double row arthroscopic technique and to correlate these results with the integrity of the cuff as determined by clinic and Arthro-MRI evaluation. Materials and Methods: 45 arthroscopic rotator cuff repairs were randomized into one of two groups: single row and double row suture anchor repair technique. All shoulders had pre and postoperative evaluation by a modified UCLA and a postoperative assessment by the use of MR Arthrography scans at 18 months from surgery. Results: We did not find a statistically significant difference in total UCLA score when comparing single row and double row. MR Arthrography examination at 18 months of follow up showed that double row suture anchor technique provides a better structural outcome (6 partial-thickness defects and 1full-thickness defect) if compared with single row suture anchor repair (9 partial-thickness defects and 2 full-thickness defect) (p<0.05) Discussion: Recent studies focused on the original insertion anatomy of the rotator cuff tendons and anatomy of the surgically reconstructed insertion, suggested that restoring of normal anatomy of rotator cuff footprint may improve the healing and mechanical strength of repaired tendons. The footprint cannot be adequately restored with a single row of suture anchors, while an anchor suture arthroscopic repair technique based on a double row of suture anchors which increases the tendonbone contact area restores the anatomic rotator cuff footprint. Conclusions: Restoring the anatomical footprint is appealing, but in our work we did not find a better clinical functional outcome in patients who underwent double row suture anchor technique versus single row suture anchor repair. However, double row repair excelled in structural outcome when compared with single row repair.

THE USE OF INVERSE PROSTHESIS OF SHOULDER IN THE ARTHROPATHY FROM RUPTURE OF ROTATOR CUFF. OUR EXPERIENCE IN 11 CASES

SURGICAL TREATMENT OF FROZEN SHOULDER

A.M. Mancini Ospedale Regionale, Aosta, Italy The arthropathy from rupture of rotator cuff determines a particular type of degeneration of the gleno-humeral articulation. The function loss of muscles of rotator cuff in determining the spin centre of the humeral head cause came up of humeral head and a sub-acromiale arthrosis with pain and loss of function. Standard prosthesis cannot solve the problem because of the irreparable rupture of rotator cuff. The use of an inverse prosthesis to fix the spin center, to ritension deltoid fibers and to increase the abductorial lever of arm would seem the best solution. The gold standard indication is represented by cases in which there is a meaningful loss of function and pain. The insufficiency of the deltoid muscle represents the main contraindication to put an inverse shoulder prosthesis. The relation places the aim to analyse the eleven cases treated near our division from 2004 to 2006, trying to establish a standard protocol for the indication to the inverse shoulder prosthesization, taking into consideration the age, the kind of activity turns, the psycho-physical conditions and the collaboration of the patient.

FUNCTIONAL AND MR ARTHROGRAPHY IMAGING EVALUATION AFTER ARTHROSCOPIC SINGLE ROW AND DOUBLE ROW SUTURE ANCHOR REPAIR F. Franceschi, G. Rizzello, A. Marinozzi, G. Longo Umile, L. Ruzzini, R. Papalia, V. Denaro Università Campus Biomedico, Rome, Italy Objective: The purpose of the present study was to evaluate the short-term results of arthroscopic repair in two focused groups of patients with large and massive rotator cuff tears treated with single

A. De Carli, L. Frate, A. Vadalà, A. Ferretti Ospedale S. Andrea, Rome, Italy Shoulder adhesive capsulitis is a pathological condition characterized by an involvement of the gleno-humeral capsula and ligaments with a progressive and severe reduction of the range of motion. Materials and Methods: Authors refer their experience on 15 patients surgically treated for frozen shoulders. These patients (6 males and 9 females with a mean age of 57 years: range 26 to 68 years) underwent arthroscopic capsular release and closed manipulation. This syndrome followed a shoulder trauma in only two patients and a rotator cuff tear with progressive loss of motion in four patients; no etiologic cause was found in nine patients. All the patients were evaluated by international functional scoring scales (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form –ASES-, Constant and Murley, Simple Shoulder Test and UCLA). Results: The pre-operative range of motion of the shoulder was measured with goniometry (side to side); the mean abduction of the involved shoulder was 60°; the mean external rotation 20°, the mean flexion 75°; during the internal rotation patients were never able to reach the lumbo-sacral vertebra. At a mean follow-up of 15 months (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 nearly 150°, a mean ER of 45° and a mean flexion of 165°; fourteen patients were able to reach the lumbo-sacral junction during the internal rotation. All the post-op functional evaluation scales also showed relevant improvements. There was any case of fracture, dislocation or other complication. Conclusion: In patients with severe adhesive capsulitis, the treatment goal is pain reduction and recovery of shoulder mobility. Patients with frozen shoulder unresponsive to traditional conservative treatment can be effectively treated with arthroscopic capsular release and closed manipulation.

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SHOULDER PAIN IN SCAPULAR DYSKINESIS: A DYNAMIC ELECTROMYOGRAPHIC STUDY G. Bonaspetti, F. Azzola, U.E. Pazzaglia Clinica Ortopedica, Spedali Civili, Brescia, Italy The aim of this study is to analyse shoulder pain in scapular dyskinesis using a sperimental dynamic electromiography. We adopted the electromiography analysis on 7 patients (4 women and 3 men) 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: 1) Shoulder chronic pain since, at least, 6 months without success after pharmacological therapy and physiotherapy; 2) Positive results on scapular “setting test”; 3) Positive result on Rochwood test; 4) Shoulder X ray in front-back position and side (axillary) and Y position negative; 5) Negative ecography exam; 6) Negative artro MRI. The following muscles have been dynamically evaluated with EMG and correlated video evaluation: pectoralis major and minor, deltoid, serratus anterior, rhomboid, superior and inferior trapezius, latissimus dorsi, sopraspinatus and infraspinatus. Through the analysis of our data we have found several differences, statistically significant, of muscle activaty during flexion movements, in front and scapular plain level (scaption) and of abduction movement. The following analyses have been done on each muscle, for every type of movement: 1st) Considering the average values of presetting at 150° of excursion; 2nd) Considering the average values of movements from the beginning (0°) to the end (150 °); 3rd) Considering the single measure points (presetting 0°,30°,90°,120°,150°). The iperactivation of pectoralis minor produces scapular anteposition and extra rotation and changes the articular relationship between omeral head and glenoid and also changes the kinetic chain on front level. These chenges produce a general iperactivation of stabilizing muscle of gleno humeral joint: infraspinatus and latissimus dorsi (according to Kronberg) and trapezius and serratus anterior. Additionally there is also an iperactivity of rhomboid that assists scapular adduction.

MUSCULAR COMPENSATION IN PATIENTS AFFECTED FROM MASSIVE ROTATOR CUFF TEAR: SUPERFICIAL ELECTROMYOGRAPHIC STUDY C. Scotti, G.F. Fraschini, P. Ciampi U. O. Ortopedia e Traumatologia, Ospedale San Raffaele, Università Vita-Salute, Milan, Italy Shoulder girdle is an extremely mobile joint, in fact it can determine 16000 different positions due to a fine coordination between bony structures and muscles. When a massive rotator cuff tear occurs, this equilibrium is altered.The aim of this study was to evaluate muscular activation of deltoid medium, superior fibers of pectoralis major, latissimus dorsi and infraspinatus with a superficial electromyographic study and the analysis of kinematics in patients with a massive rotator cuff tear. Twenty patients (mean age 65.3) with a massive tear, evaluated by clinical testing and with MRI, were enrolled in this study and compared to a control group. The study included evaluation of maximal isokinetic values and elevation on scapular plane.The study showed higher mean values of activation for the deltoid, the infraspinatus, the pectoralis major and the latissimus dorsi compared to the healthy contralateral joint. Analysis of variance showed significant differences (p=0.0001) between the activation of the 4 muscles. The Bonferroni modification, after comparing the mean EMG values of the 4 muscles, produced an highly significant difference (p<0.0001) between the

experimental group and the controls and between the pathological joint and the healthy one in the same patient.This study confirmed the compensatory activation of the deltoid and the infraspinatus, as already demonstrated in literature, and showed a compensatory activation of the latissimus dorsi and the pectoralis major in patients with massive rotator cuff tears. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear.

THE TREATMENT WITH ESWT OF CUFF ROTATOR CALCIFYING TENDONITIS VERSUS SHOULDER IMPINGEMENT SYNDROME M. Vitali [1], G. Peretti [2], L. Mangiavini [2], G. Fraschini [2] [1] Scuola di Specializzazione Ortopedia e Traumatologia I, Università degli Studi di Milano, Milan, Italy; [2] Ospedale San Raffaele, Milan, Italy The aim of our study was to assess the shock waves therapy efficacy in the treatment of patients suffering for calcification of the rotator cuff versus those with the “impingement syndrome” in the shoulder. From July 2004 to November 2005 a number of 233 patients were treated with ESWT; it was counted that 130 patients suffered from calcification of the cuff rotator and 103 patients had pain in shoulder with “impingement syndrome”. A clinical check was done right before the beginning of the ESWT and after the first and fourth months at the end of the therapy. The treatment for patients suffering from the “impingement syndrome” was positive in 55% of cases with pain reduction and jointfunction recovery. As for the treatment in the calcification of the rotator cuff it was observed that the pain was reduced or totally disappeared in 83% of patients, with also a joint-function recovery.As a matter of fact, the difference of positive results after the shock wave therapy is a 28% in favour of people suffering from the calcification of the rotator cuff compared to the patients suffering from the” impingement syndrome”. As a matter of fact, the most important cause of the “impingement syndrome” is a mechanical phenomenon that cannot be eliminated with shock waves therapy. The shoulder with calcification is the expression of a chronic inflammatory at the rotator cuff. Therefore, shock waves therapy has an analgesic and anti-inflammatory effect on the shoulder 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.

SESSION O32 WRIST

AND HAND

THE TREATMENT OF ARTICULAR FRACTURES OF THE DISTAL RADIUS USING L.C.P. PLATE L. Tarallo, R. Adani, O. Calveri Clinica Ortopedica, Università degli Studi di Modena e Reggio Emilia, Modena, Italy Objective: The aim of this work is to analyze the efficiency of L.C.P. plate for the treatment of intrarticular fractures of the distal radius type B and C according to A.O. classification. Materials and Methods: 58 distal radius articular fractures were treated, 26 were of type B and 39 of type C (35 male and 23 female).41 patients were seen at follow up on average 13 months after surgery. Mean age was 49 years, varying between 19 and 87 years old. Volar incision was used in 32 cases, dorsal incision was used in 5 cases and double access was performed in 4 subjects. Preoperative CT was used in 26 patients.

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Results: “Mayo modified wrist score” was used to evaluate patients: mean active wrist extension was 57°(range 30°-70°) while active flexion was 60° (range 25°-90°) with T.A.M. of 116.5. Type B fractures had mean ROM of 136.6 while C type fracture had a mean of 104,6. The final wrist score was: excellent in 19 cases, good in 12, fair in 6 cases and poor in 4 cases. The results were excellent/good in 76% of patients while it was fair/poor in 24%. Discussion: In our series the volar approach was mostly used in type B3 e C distal radius fractures with volar angulation of fragment. Preoperative CT investigation is recommended for type B3 e C distal wrist fractures for optimal surgical treatment. 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 wrist fractures.

chase, particularly in elderly patients with osteoporosis. This system prevents proximal migration of the screw, with reduction loss and possible compression of median nerve. In our Department 15 angular stable plates were implanted, obtaining good long term results, without major complications to tendons and nerves. In two cases we observed tingling in median nerve territory, spontaneously resolved in two and four months. In one case, we had loss of range of motion in finger flexion due to post-surgical adherences, requiring tenolisis. Angular stable volar plates are an excellent fixation means for volar distal radius, allowing effective stabilization of the fracture, and being well tolerated by nearby delicate anatomical structures.

PERCUTANEOUS SCREW FIXATION FOR UNSTABLE SCAPHOID FRACTURES

Kienbock disease is still evasive when etiopathogenesis is considered. Several theories have been proposed: a)-a direct trauma leading to a vascular alteration; b)-repeated multiple trauma leading to a vascular alteration; c)-a primary vascular impairment which leads to osteonecrosis. In Lichtman stage 2 and 3a, shortening osteotomy of the radius is quite effective. In Lichtman stage 4, proximal row carpectomy gives good clinical results. Several others surgical treatments have however been suggested and applied: in most cases (apart from the lunate joint prosthetic replacement) literature reports good results. Could it be possible to suppose a relative indipendence of these results from the technique applied? Could the surgical approach in itself start a reparative process of the lunate, by the recruitment of humoral factors yet to be identified? Kienbock disease is quite rare and the patient follow-up needs to be several years long: these are probably the two major reasons why it is difficult for any Author to set-up a comparative long-term study with an adequate number of patients. It is advisable that modern techniques of images processing and transfer (web links; digital radiography) will be applied in a multicentric multinational study, with a follow-up not shorter than 10 years, to better understand this elusive pathology.

R. Cozzolino [1], U. Passaretti [2], A. Penza [2] di Specializzazione in Ortopedia e Traumatologia, Naples, Italy; [2]Unità Operativa Complessa di Chirurgia della Mano e dei Nervi Periferici, Ospedale Pellegrini, Naples, Italy [1]Scuola

Backgrounds: The scaphoid is the most frequently fractured carpal bone and is common in young, active patients. The technique of percutaneous screw fixation, with increasing popularity, has been successfully conducted in non-displaced, stable scaphoid fractures (B1-B2 Herbert class.) resulting in shortened immobilization duration and prompt functional retrieval. The purpose of this study was to evaluate the surgical technique and to explore the potential benefits of using percutaneous screw fixation in unstable scaphoid fractures. Methods: 40 patients with scaphoid fractures surgically treated between 2000 and 2005 were enrolled in this study. There were 10 male and 30 female patients, with an average age of 30 years (range, 20–50 years). Five patients showed pseudarthrosis –D1-. Results: A 1 mm guide wire was introduced volarly. The screw length was measured directly with a second guide wire of equal length. A cannulated screw of equal length was inserted under fluoroscopic guidance. We prefer to use the Acutrak or mini-Acutrak screw system but any cannulated screw system that permits screw insertion beneath the articular surface can be used (Herbert, Kompressor). The outcome was ranked as excellent in thirty patients and good in eigth patients. Only two patients experienced occasional wrist pain or soreness after exertion Discussion: The technique is simple, permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important in order to achieve union.

ANGULAR STABLE PLATE FOR FIXATION OF DISTAL RADIUS FRACTURES E.M. Caruso, M. Franceschini, P. Prina, G. Salvadori del Prato, R. Franceschini Divisione di Ortopedia e Traumatologia, Ospedale Luigi Sacco, Milan, Italy 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 Surgery of Sacco Hospital, Milan, Synthes angular stable volar plates are used for articular fractures of the wrist with volar or dorsal dislocated fragments (Burton type), without comminution. The advantage of this device is the special threaded screw head, which stabilizes the screw to the plate, suited for the distal fragment of the fracture, where the cortical bone is thin and a standard screw would have little pur-

PRESENT DAY OUTLOOK ON KIENBOCK DISEASE A. Merolli, L. Rocchi, F. Catalano Università Cattolica, Rome, Italy

OUR EXPERIENCES ABOUT PYROLYTIC CARBON PROSTHESIS IN THE PIP JOINT A. Marcuzzi, M. Abate, N. Della Rosa, A. Landi Struttura Complessa di Chirurgia della Mano e Microchirurgia, Azienda Ospedaliera Policlinico, Modena, Italy The authors describe their experience in pyrolytic carbon prosthesis in the PIP joint of 15 patients (12 male and 3 female) (average of 47 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 a joint stiffness after Swanson prosthesis; one patien had an arthrodesis after a joint fracture. All patients were evaluated with a average follow-up of 18 months (range 3-43 months). Based on this study, the authors suggest the use of pyrolytic carbon prosthesis in the patients affected by primary and secondary osteoarthrosis of PIP joint to resolve the pain, to improve the hand grip and the range of motion of the affected finger.

MYOELECTRIC PROSTHESIS: A POSSIBLE CHOICE FOR THE METACARPAL AMPUTATION’S TREATMENT IN EMERGENCY M. Abate [1], N. Della Rosa [1], R. Sacchetti [2], C. Castagnetti [1], A. Landi [1] [1]Struttura Complessa di Chirurgia della Mano e Microchirurgia, Modena, Italy; [2]Centro Protesi INAIL, Bologna, Italy

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In this study the Authors consider the myoelettric prothesis as a possible choice of treatment in the hand amputation through the metacarpal bone, when replantation or reconstruction of a functional hand in emergency are impossible. The most diffuse attitude in the metacarpal amputation, within the thumb, is to save the residual carpal hand and the secondary reconstruction of a chela hand. This attitude often means, in emergency, to perform a free or pedicle flap or an abdominal flap due to the exposure of metacarpal bones. The second step is the reconstruction of a chela hand by several surgical and microsurgical tecniques. That is a hard care for the hand surgeon and first of all a strong sacrifice for the patient because of the results are 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 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 relation to benefit. The results enhance the validity of this choice.

AN EXPERIMENTAL STUDY OF STRESS TRANSFER BETWEEN PROSTHETIC STEM AND BONE IN A MODEL FOR THE METACARPO-PHALANGEAL JOINT A. Merolli, M.S. Spinelli, F. Catalano Chirurgia della Mano, UCSC, Rome, Italy The abnormal transfer of stresses between the prosthetic stem and bone may lead, often frequently, to the mobilization and failure of a joint replacement implant. Finite Elements Modelling (FEM) is one of the most applied methods to study the internal stresses and strains of a given material. In this work, Authors visualized the stress transfer at the interface between bone and the prosthetic stem when a torsional load is applied. They concentrate on the influence of the stem cross-section and, in so doing, a model of the metacarpal diaphysis was produced where, along the same major axis, stems of different cross-sections were inserted. Seven cross-sections were examined: 1)-trapezoidal; 2)triangular; 3)-rectangular; 4)-triangular (equilateral); 5)-squared; 6)pentagonal; 7)-circular. A FEM software ANSYS 5.7 was used. The two most important results were: a)- sharp edges in the geometry of the section are far from stabilize the stem, because they give raise to excessive loadings at the interface which will lead, in the long term, to bone rarefaction accordino to Wolff’s law; b)- circular cross-section gives the greatest homogeneity in stress transfer, which is particularly required when torsional stress are applied.

HISTORY OF METACARPO-PHALANGEAL PROSTHETIC DESIGNS A. Merolli, R. De Vitis, F. Catalano Chirurgia della Mano, UCSC, Rome, Italy Total joint replacement of metacarpo-phalangeal (MCP) joints in fingers was realized in mid-fifties in patients affected by the complete degenerative or traumatic loss of the MCP joint. The vast majority of early designs were hinged joints, allowing flexion-extension only at right angle with the palm. Biomechanics of the MCP joint is far more complex; namely, lateral deviation and axial rotation are coupled to flexion-extension in the most part of the range of motion. To solve the problem of the early mobilization of hinged prostheses, two major routes were followed: the introduction of cementing techniques and the development of flexible prostheses. The latter should not be called “joint prostheses” since form and function of the joint are far from been reproduced, but the model of this “joint spacer” proposed by Swanson is still one of the best choice for the surgeon today still.However, the lack of reproduction of the MCP function and the very limited load which can be afforded (to avoid the breakage of the prosthesis of its

mobilization) prompted the study of surface replacements which, in a quite complex shape, reproduced the physiological excursion of the MCP joint. However, these surface replacement designs lack any intrinsic stability and require the absolute integrity of the capsulo-legamentous structures of the MCP joint; this is a seldom encountered condition in rheumatoid patients, which represent the vast majority of potential users of MCP joint replacement. As a matter of fact, the optimal design for a MCP prosthesis to be used in rheumatoid patients should comply with an adequate range of motion; an effective grip strength; an intrinsic stability. Fifty years after the early designs in MCP joint prostheses these goals have not been achieved, yet.

POSTER PRESENTATIONS FEMORAL FRACTURES AND NON UNION: TREATMENT BY SHEFFIELD FRAME F. Sala, R. Spagnolo, F. Castelli, U. Valentinotti, D. Capitani Divisione di Ortopedia e Traumatologia, Ospedale Niguarda Ca’ Granda, Milan, Italy Introduction: Much has been written about the use of different treatment modalities in the management of femoral fractures. However these articles do not include the use of the Sheffield frame amongst the modalities described. We have experience in the treatment of fracture and non union by external frame. We report our experiences and conclusions. Materials and Methods: the patients who had undergone Sheffield frame management from 2003 to 2005 years. Demographic data, the type of the hardware, the complications of surgery, duration of treatment and recorded outcome were noteded. Results: We have treated 10 patients (7 male, 3 female) 7 were acute compound fractures and 3 non union / infection of the femur; the mean age at the time of frame application was 43 years (range 14 – 75). One ORIF infected non-union had removed plate and screws, infected bone resection and treated by frame with Ilizarov bifocal method. When tissue healed a new ORIF procedure was employed. The mean time from frame application to union was 8 months (range 3 – 16 months). We did not find major complication, refracture, persisting infection, chronic regional pain syndrome. The mean knee movement was of 90° (racing from 25° - 140°). Conclusions: Treatment of femur fractures and non unions/infection are notoriously difficult. In selected cases the use of Sheffield frame as the Ilizarov method provides a reliable and successful treatment option.

OLECRANON FRACTURES OSTEOSYNTHESIS: EXPERIENCE WITH THE EPINAIL-ELBOW LOCKED NAIL F.V. Sciarretta, G. Mastantuoni, P. Zavattini Ospedale Civile, Velletri, Italy Introduction: Olecranon fractures are very common lesions whose treatment strategy is determined by several clinical and biomechanical factors and always directed to obtain a stable osteosynthesis in order to achieve early elbow joint mobilization. In this work we present the results obtained with the intramedullary Epinail-Elbow locked nail recently introduced on the market. Materials and Methods: Since 2005, immediately after having known the product, at Our Institution we have started to use the Epinail-Elbow locked nail in order to reduce the complications and the need for prolonged post-op immobilization of the arm. This is a cylindrical, titanium, cannulated, locked nail whose diameter decreases from 6 to 5 mm from proximal to distal with 5 holes for the distal locking screws, disposable in 4 lengths, whose proximal compression is achieved by a washer. In this paper we present the results of our first 15 cases.

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Results: In the cases we have treated, 12 metaepiphyseal proximal ulnar fractures and 3 fractures of the proximal third of the ulnar diaphysis, we have in all cases obtained fracture’s consolidation by closed introduction of the Epinail-Elbow nail. The only intra-op complication has been the rupture of a reamer for the distal screws. We did not encounter post-op fractures or nonunions. Discussion: This new method of internal fixation of the olecranon process has some characteristics, that, in our opinion, make it unique, allowing to eliminate the usual complications encountered with previous osteosynthesis methods. This intramedullary nail, although introduced by closed technique, enables anatomic reduction of the fracture fragments and eliminates the need for a post-op immobilization. For this reason, after the first cases, we started allowing active and assisted elbow rom the first post-op day, regaining daily activities along with clinical and radiographic recovery.

ULNAR NERVE TRANSPOSITION OR SIMPLE DECOMPRESSION? CHOICE OF TREATMENT IN ULNAR NERVE COMPRESSION AT THE ELBOW G. Pilato, A. Bini, A. Vicario Dipartimento di Scienze Ortopediche e Traumatologiche “M. Boni”, Università dell’Insubria, Ospedale di Circolo, Varese, Italy The surgical treatment of ulnar nerve compression at the elbow is still controversial (Dellon,1989; Gervasio,2005; Nabhan,2005). Described methods are: neurolysis at cubital tunnel (Osborne,1957); neurolysis with anterior transposition, intramuscular (Adson,1918), subcutaneous (Platt,1928), submuscular (Learmonth,1942), microsurgical with vascular bundle (Messina,1991); neurolysis with medial epicondilectomy (King,1950). The aim of the study was to find correlations between two methods, simple decompression and anterior subcutaneous transposition, and surgical indications. From 1992 to 2005 we treated 65 patients, 60 were reviewed with a mean follow up of 71 months. 18 had undergone simple decompression (group I) and 42 anterior subcutaneous transposition (group II). We considered 28 cases as idiopathic, 34 as secondary. All the patients of group I were idiopathic. Mc Gowan classification was used to grade the compression. EMG was used to confirm the diagnosis. Independent T-test was used to analyse correlation between prognostic factors and results. Results were classified following Nouhan and Kleinert method: in group I we observed 8 eccellent results (45.5%), 9 good (50%) and 1 fair (5.5%). In group II: 20 eccellent results (47.6%), 21 good (50%) and 1 fair (2.4%). We did not observe any poor results. 94.5% (group I) and 95,2% (group II) were satisfied with the result, whereas clinical exam has shown a complete remission of symptoms respectively in 44.5% and 50%, and improvement in 50% and 40.5%. Anterior subcutaneous transposition has proved appropriate instead of simple decompression in treatment of ulnar neuropaty at the elbow, when beside compression there are additional factors of nerve damage, friction and stretching, not addressed by simple decompression.

HISTOLOGICAL STUDY ON THE PATHOGENESIS OF ROTATOR CUFF TEARS F. Franceschi, G. Rizzello, G. Longo Umile, L. Ruzzini, G. Vadalà, R. Papalia, A. Marinozzi, V. Denaro Università Campus Biomedico, Rome, Italy Objective: The aim of this study was to analyze the morphological features of the human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears and glenohumeral instability. Materials and Methods: 41 subjects were recruited for the study. 20 subjects (group 1) sustained a rotator cuff tear and proceeded arthroscopic repair of the lesion. 21 subjects (group 2) underwent

surgery due to glenohumeral instability. During surgery, under arthroscopic control, a full thickness supraspinatus tendon biopsy was harvested in the middle portion of the tendon. All slices were processed for histological analysis. Results: On surgical specimens of supraspinatus tendon from patients with rotator cuff tears, but not from patients with instability, we found increased preponderance of hyaline degeneration, fibrocartilaginous or chondroid metaplasia, calcification, lipoid degeneration, mucoid or myxoid. Degenerative changes were more evident on the articular side of the rotator cuff. Discussion: Despite the relevance of the problem, causes and mechanisms of rotator cuff disease are poorly understood and far from an exhaustive comprehension. Determining factors to the pathogenesis of rotator cuff disease are intrinsic factors (such as biomechanical faults, excessive loading, aging, poor microvascular supply) and extrinsic factors (such as compression of the tendons by bony impingement or direct pressure from surrounding soft tissue). Conclusions: The present study provides a description of the histological architecture of human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears. Preexisting degenerative change in the supraspinatus tendon seems to be the main cause of rotator cuff tears.

REPARABLE ROTATOR CUFF TEARS: SURGERY VS SHOCK WAVE THERAPY A. De Carli, M. Vulpiani, A. Russo, A. Vadalà, P. Trovato, A. Ferretti Ospedale S. Andrea, Rome, Italy Active patients with rotator cuff tear causing pain and functional disability are usually candidate to surgical treatment. An alternative choice is treatment with extracorporeal shock wave therapy (ESWT). Aim of this study is to compare the efficacy of these two options for rotator cuff tears. Materials and Methods: Thirty patients, observed from October 2001 to March 2004, with a complete rotator cuff tear, were randomly addressed to different treatment: group A underwent arthroscopically assisted surgical repair (follow-up min 12 months, max 26, mean 19), group B to shock wave therapy with electromagnetic generator (follow-up min 12 months, max 36, mean 24). All patients were clinically evaluated following Constant, UCLA, ASES and SST scoring scales; in both groups a MR imaging was performed before and after therapy at follow-up. A statistical analysis of results was carried out (T test). Results: Clinical results showed improvement after treatment in both groups: with Constant scale the mean of group A was 30 before, 77 after treatment; group B showed 33 before, 67 after treatment. The UCLA scale showed group A with 11 before, 32 after surgery; B 11 before, 27 after. With ASES scale patients of group A obtained 50 before, 87 after treatment; group B obtained 47 before, 70 after ESWT (p<0.05). Clinical evaluation showed statistically significant 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. Conclusions: Although ESWT offers a good pain relief and an appreciable resumption of shoulder function at a mean term, surgical treatment showed better overall results and in particular better resumption of strength and function in treatment of complete rotator cuff tears.

DISTAL HUMERUS NON-UNION: A HARD CASE E.C. Marinoni, M. Bigoni, S. Guerrasio, A. Rossi, D. Munegato, D. Gaddi Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatologia, Monza, Italy

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Distal humerus non-union appears in about 2 to 10% of fractures concerning this district. This kind of clinical situation represents a very difficult trial for the surgeon. There are many surgical treatments described in literature. Here we show a case report of a 66 year old woman affected by a distal humerus atrophic non union of associated with a large bone loss. In this case we decided to use an osteoconductive-osteoinductive technique after a renewal of the internal fixation. We studied the healing progression by using periodic clinical evaluations and by analyzing results obtained from Xray and DEXA analysis, and from subjective test (SF-36, VAS and GH). The results after one year from the surgery are very encouraging because of the almost complete fracture healing, the absence of pain and the quality of life the she returned to.

had only 1 deep infection, resolved with a surgical debridement and antibiotic terapy. Superficial infections of pin-track (20% of cases) resolved simply with increase of dressing care, occasionally with antibiotic therapy. We did not note important consolidation defects. Arthritis was a frequent radiological sign, not often correlated with pain and limitation of function: AOFAS median score was 69/100 and we performed tibio-tarsal arthrodesis only in 2 cases.

THE USE OF THE DYNAMIC EXTERNAL FIXATOR MINICOMPASS IN THE COMPLEX LESION AT PIPJ OF THE LONG FINGERS

Objective: Use of E.F.as main treatment of high energy tibial plateau fractures. Materials and Methods: We have studied 30 patients, affected by Schatzker 6 tibial plateau fracture,15/30 open fracture (Gustilo classification), treated by hybrid external fixation and limited internal fixation, with a 3 years followup at least. We have used a modified score to evaluate the patients at each clinic visit. Discussion: High energy tibial plateau fractures are often associated with severe soft tissue injuries like open wounds, compartment syndrome, bone devitalization and vascular injuries: E.F. stabilize bone fragments validly with free articular knee movement. Conclusions: E.F. as main treatment of Schatzer 6 tibial plateau fractures, with limited internal fixation, bone allograft, without spanning the knee is a good method to treat this type of lesions.

N. Della Rosa, M. Abate, A. Marcuzzi, A. Leti Acciaro, A. Landi Struttura Complessa Chirurgia della Mano e Microchirurgia, Modena, Italy Stiffness of the long fingers at the PIPJ secondary to articular lesions is certainly the most frequent and feared complication. Since 1998 in the Operative Unit of Hand Surgery and Microsurgery of Policlinico of Modena the Aa. uses the external dynamic fixation Minicompass in the complex lesions at the PIPJ of the long fingers. Thirty patients had treated (20 acute lesions/10 chronic lesions) with our device. The outcome studies were performed with Michigan test, the valutation of 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 groups (acute lesions/chronic lesion) the best results have been achieved in the acute lesion group with a total TAM of 220 while in chronic lesion group the TAM has been the value of 190. The mean range of motion has been 70° in acute group lesion and in chronic group lesion of 60°. In conclusion Minicompass has the ideal requirement for a external fixator: a percutaneous syntesis of the articular fractures, an early joint motion, a minimum dimension and a good clearence of the patient.

HIGH ENERGY TIBIAL PILON FRACTURES: LIMITED INTERNAL OSTEOSYNTHESIS AND EXTERNAL FIXATION TREATMENT W. Daghino [1], C. Salomone [2], G. Di Gregorio [3], D. Aloj [1], A. Biasibetti [1] [1]S.C. Traumatologia Muscolo Scheletrica e Fissazione Esterna, Ospedale CTO, Turin, Italy; [2]Scuola di Specializzaione in Ortopedia e Traumatologia, Università di Torino, Turin, Italy; [3]I Clinica di Ortopedia e Traumatologia, Università di Torino, Turin, Italy We have assessed radiological and clinical follow-up of series of high energy tibial pylon fractures, corresponding to subtypes C2 and C3 of AO classification. We studied 46 fractures, 14 of which being exposed. Median patients age is 40.3 (range 23-73), average followup 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 fixator device, placed in emergency for fracture stabilization. In 10 cases the healing was achieved with monolateral fixation, in 2 of these cases the configuration was articulated. In 28 cases we associated a limited osteosynthesis, transcutaneuos or by small skin incisions. Only in cases treated with monolateral external fixation as definitive approach we used internal osteosynthesis with plate and screws for fibula fractures. In 7 cases we applied autologous or synthetic bone graft for metaphysial losses. Average healing time was 26 weeks. We

HYBRID EXTERNAL FIXATION OF THE PROXIMAL TIBIA IN THE TREATMENT OF HIGH ENERGY PLATEAU FRACTURES L. Pisano, S. Costa, L. Promenzio, M. Tangari Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy

THE MINIMAL INVASIVE TREATMENT OF THE TIBIAL PILON FRACTURES: THE EXTERNAL FIXATION F. Loconte, M. Di Viesto, A. Ambrosone, D. De Vita A.S.L. BR/1, P.O. di Ostuni (BR) U.O.C. di Ortopedia e Traumatologia, Ostuni, Italy Tibial pilon fractures seldom occur. They are the 7-10% of the tibial fractures and less than 1% of the fractures of the lower limbs. They are serious lesions: they cause damages to the articular surface and they inevitably compromise the function of the ankle. This articular damage, with the fragmentation of the metaphysis, causes several treatment difficulties and a high percentage of poor results. Various treatments have been tested. During the last years the external fixation has been asserting its authority as an alternative treatment, isolated or associated with minimal internal fixation. A lot of new studies confirm that this method, especially in serious fractures, is associated with minor complications than the internal fixation. As a matter of fact, the external fixation allows toa void some complications of the tibial pilon fracture. This treatment gives a steady fixation, it does not involve the fracture focus and it implies a minimal surgery trauma, thus respecting the soft tissue, which is generally compromised. For almost two years we have been treating these fractures with the external fixation. The versatility of this system has allowed us to treat articular complex fractures with a minimal invasion, getting in this way a high percentage of good results and low rate of complications.

EXTERNAL FIXATION FOR TIBIAL PILON FRACTURES R. Mora [1], L. Pedrotti [1], G. Tuvo [1], B. Bertani [1], F. Quattrini [1], A. Maccabruni [2] [1]Clinica Ortopedica, Università di Pavia, Polo Univ. “Città di Pavia”, Italy; [2]Clinica Malattie Infettive, Università di Pavia, OSM Pavia, Italy Tibial pilon fractures are challenging injuries: complications are frequent and treatment results are often unsatisfactory. The treatment

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planning is based on the evaluation of concomitant diseases, kind of fracture, seriousness of bone and joint injury and soft tissue condition, that may strongly influence the prognosis. Internal fixation for complex fractures has a very high risk of complications, such as skin and soft tissue necrosis and deep infection (because a large dissection is needed), and should only be employed in simple fracture management. External fixation, and especially circular external fixation, is indicated in most cases, combined or not with minimal internal synthesis. Between 2000 and 2005 at the Department of Orthopaedics and Traumatology of the University of Pavia – “Città di Pavia” Institute, 24 cases of tibial pilon fracture were treated. According to the Ruedi and Allgower’s classification there were 6 type I fractures, 8 type II fractures and 10 type III fractures. 6 fractures were open. In 3 cases internal fixation was employed; the other cases were all treated with external fixation by means of an Ilizarov device applied to the leg (and extended to the foot in 5 cases), combined in 4 patients with minimal internal synthesis. In 3 cases of compoud fracture, soft tissue reconstruction was performed. Bone and functional results of this series were satisfactory, with a very low 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.

TWO-STAGE TREATMENT OF SEPTIC LOOSENING OF HIP PROSTHESIS G. Pignatti, N. Rani, G. Trisolino, A. Giunti Istituti Ortopedici Rizzoli, Bologna, Italy Although rare, one of the most feared complications of total hip arthroplasty is infection. Two-stage replacement has been reported as one of the most successful treatment methods for chronic infection of the prosthetic hip. It is indicated in healthy patients with a low risk of recurrent infection and to keep open the option of revision surgery. It is also indicated when debridement and antibiotic treatment has failed in early postoperative or acute hematogenous infection. The patient undergoes rigorous treatment due to the severity of the two surgical procedures, separated by a few weeks of intravenous antibiotic treatment. From 2000 to 2005, in our ward, we treated 41 consecutive patients with septic loosening of the hip prosthesis. In most cases we used a functional articulated spacer, industrially preformed (Spacer-G®), which, besides the local controlled release of antibiotics, enabled limb length and a certain degree of joint motion to be maintained, thus providing the patient with more comfort and the possibility to walk with canes and light weight bearing between the two stages. The device consists of a steel cylinder coated with acrylic cement loaded with Gentamicin (1.9%) and Vancomycin (2.5%). The evolution of the infection process was studied by clinical and laboratory tests and by radiography and scintigraphy. Revision surgery was performed when swelling had reduced and scintigraphic results were normal. At a mean follow-up of 39 (12-73) months, the 38 patients that had been treated successfully with revision surgery had no clinical or biohumoral signs of infection, or radiographic signs of loosening. Functional recovery was good to excellent and the mean Harris Hip Score was 85 (54-100).

PROPERTIES OF BIOACTIVE COATINGS IN JOINT REPLACEMENT A. Merolli, A. Militerno, G.E. Bellina Chirurgia della Mano, UCSC, Rome, Italy Several experiments have been carried out in vivo, in an experimental model in the rabbit femur, to test the properties of plasmasprayed bioactive coatings on metals. Hydroxyapatite and Bioactive Glass were used for the coatings while Titanium alloy and CoCr alloy were the metallic substrates. Bioactive coatings are

named so because they can direct bone metabolism towards an active positive response which is characterized by the physiological maturation of newly formed bone tissue on them. There are differences in commercial preparations for both Hydroxyapatite and Bioactive Glass coatings: hydroxyapatite may vary in crystallinity while Bioactive Glass in composition. About the coatings, differences may arise varying the granulometry of the starting powder, the deposition time, the temperature of the spray. Anyway, the common pattern of bone response is always the tight apposition and physiological maturation and remodelling of newly formed bone on the coating. In this way, bioactive coatings promote a bone-coating interface without the interposition of fibrous tissue, as it happens with un-coated metallic prostheses. Furthermore, the gradual and physiological process of bone maturation preserves the trabecular architercture of the surrounding bone without the “confinement rim” which is often seen with non-bioactive but biocompatible materials. In conclusions, bioactive coatings in joint replacements can provide an interface between bone and prostheses which is characterized by an apposed maturing bone.

OSTEOINDUCTIVE PROCEDURE IN NON CEMENTED HIP PROSTHESIS L. Tafuro, W. Thomas, L. Lucente Clinica Quisisana, Rome, Italy Since 1965, Urist discovered the osteoinductive properties of growth factors and body cells, many progresses in identification, characterization and clinical use of these factors have been done in orthopaedics. From June 2003 to July 2005, we performed 60 consecutive cases of hip replacements with a new procedure consisting in an osteoinductive gel, positioned on the spongiosametal surfaces of socket and stem. The gel contains three elements: Cancellous bone chips, Platelet-Rich Plasma and Bone marrow. Blood loss, operative time Hemoglobin drop values and clinical results were collected and compared with a control group of 60 hip replacements. The average operative time was similar in the two groups, while the blood loss was minor in the group treated with the gel. The Harris Hip Score moved from an average of 43 in the preoperative to 83 at 40 days, 90 at 3 months, 92 at 6 months and 94 at 12 months in the study group. For the control group values were 54 in the preoperative, 74 at 40 days, 80 at 3 months, 86 at 6 months and 94 at 12 months. We never observed complications as dislocations, DVT, infection, stem subsidence or mobilization. Our procedure shows a quickly osteointegration of the implants. The procedure is safe and easy because it includes only autologous factors without risks of disease transmission or immune response.

FIRST CLINICAL EXPERIENCES WITH PE ACETABULAR INSERT ”X3 TYPE E. Camerucci, A. Speranza, D. Topa, C. D’Arrigo, A. Ferretti Policlinico “S. Andrea”, Università “La Sapienza”, Rome, Italy 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 reticulated, was treated to assure a major resistance to wear and tear and consequentely allow the use of femural heads with larger diameter but with the same cotile implantation. Patients and Methods: In the period from September 2005 to March 2006 in S.Andrea Hospital, 22 hip arthroprothesis were implanted using PE acetabular insert X3 type. 9 males and 13 females aged from 66 to 83 (mean age 75) were included in the study. The primary diagnosis in 15 cases was primary hip arthrosis, in the other 7 cases, an intracapsular fracture of the hip. In all cases a trident (Stryker-Howmedica)) cotile was used from 46 to 58 mm.

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In 7 cases ceramic femural heads were used, while in 15 cases metal femural heads were used. In 14 cases the diameter of the femural heads used was 32 mm in the other 8 cases,36 mm. We compared the diameter of femural heads to the diameter of femural heads implanted in a serious of 22 patients operated of total hip arthroprothesis in the same period in wich the same type of cotile was used but with a PE insert Crossfire type. Results: In 18 cases out of 22 it was possible to use femural head with a larger diameter, with the same cotile than would have been possible with the PE insert used before, Crossfire type (Striker-Howmedica). Although the diameter of femural heads was larger no difficulties were observed to reduce the implants during operation. We didn’t observe any complication. No luxations of the prostheses were reported. Conclusions: The use of this new type of insert allows us, thanks to its mechanical features and the design, to implant femural heads with larger diameter and cotiles with a diameter inferior to 50 mm, with known advantages.

THE TREATMENT OF THE PSEUDOARTHROSIS OF THE LOWER LIMB THROUGH OSTEOSYNTHESIS ASSOCIATED WITH BONE GRAFT AND PLATELET GEL. 4 YEARS EXPERIENCE – THE RESULTS G. Rocca [1], P. Savonitto [1], M. Franchini [2], A. Bosinelli [2], D. Olzer [3] [1]Struttura Funzionale di Traumatologia, OCM, Veronam, Italy; [2]Servizio di Immunoematologia e Trasfusione - Banca dei Tessuti, OCM, Verona, Italy; [3]Servizio di Immunoematologia e Trasfusione, OCM, Verona, Italy In the infected pseudoarthrosis the bone tissue has lost the property to form the reparative callous. For this reason there is the need to have a biologic support and a great stability. The biological support uses the osteocondutors which, simulating in many ways the trabecular bone, improve a progressive colonization by the vessels and the bone morphogenetic factors which release a chemical stimulus suitable to implement the growth of pluripotential cells in the osteogenetic pathway. To achieve the progression of this process, a great stability is necessary and today this stability is given by the LCP plates thank to the screw heads threaded into the plates and by their different orientation that implement the pull-out strength of the whole system In collaboration with immune-haematologists we have established a treatment protocol joining the stable osteosynthesis and the bone allograft with blood platelet gel.

TREATMENT OF POST-TRAUMATIC TIBIAL NON-UNION BY RING FIXATION [1], F. Catalano [1], P. Tranquilli Leali [2] Ortopedica, Università Cattolica, Rome, Italy; Ortopedia, Università degli Studi, Sassari, Italy

A. Merolli [1]Clinica

[2]Clinica

Introduction: Authors effectively treated tibial non-union by ring fixation according to the Ilizarov method. Materials and Methods: Twenty-five patients with post-traumatic tibial non-union were treated by the Ilizarov technique with external ring fixation: seventeen had previous treatments with other techniques; twelve had infected non-union; twelve were atrophic nonunion 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 nonunion, eradicating the infection when present. Other results were functional recovery of the limb, equalization of limb-length discrepancy and correction of the axial deformity. Mean fixation time (number of days of external fixator in place) was 138 days. Conclusions: In this serie of 25 patients the Ilizarov method was effective in healing post-traumatic tibial non-union even in cases where other techniques did not succeed.

DIAPHYSIS FRACTURE WITH BONE STOCK. IN VIVO EXPERIMENTAL MODEL USING MESENCHYMAL STEM CELLS (MSC) AND GROWTH FACTORS G. Burastero [1], N. Sessarego [2], G. Grappiolo [1], G. Santoro [1], G. Panunzio [1], S. Scarfì [3], C. Fresia [3], F. Monetti [4], G. Cittadini [4], A. De Flora [3], E. Zocchi [3], L. Spotorno [1] [1]Ospedale “Santa Corona”, Pietra Ligure, Italy; [2]Ospedale “San Martino”, Genua, Italy; [3]Dipartimento di Medicina Sperimentale, Genua, Italy; [4]IST, Genua, Italy Introduction: Diaphysis fractures, characterized by severe bone loss, represent an important goal in the field of orthopaedic surgery. Cell therapy and biotechnology findings allow new therapeutic strategies. Recently it has been reported that cADPr, a potent calcium-mobilizing intracellular messenger, significantly stimulate proliferation of MSC. Considering this new findings, we developed an 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 defect was reproduced in the femoral diaphysis. Osteotomic ends were fixed with a polymethylmethacrylate plate. The osseous gap was filled with a graft composed of 6x106 MSC from patients undergoing hip artroplasty, differently associated to cADPR and BMP7 (80µg). Graft analysis was performed with high definition digital radiography and TC at 2 and 12 weeks after surgery. Bone histomorphometry was assessed at 12 weeks. Histological, radiographical studies and CT aimed to evaluate new bone formation and the trabeculae structure (osseus density, trabeculae number, thickness and interconnections between trabeculae). Results and Conclusions: Our preliminary results highlighted that the tested graft possess osteogenic properties which seem to be dose dependent. Therefore, this kind of graft could significantly improve current surgery techniques with remarkable patients benefit.

COMPLICATED FRACTURES OF THE LOWER LIMB: OUR EXPERIENCES C. Angrisani, S. Del Prete, E Taglialatela AORN Ospedale Civile S. Sebastiano, Caserta, Italy High-energy traumas determine lower limb fractures. The Authors present their clinical experiences in the surgical therapy of these important and dramatic lesions, which are important for the patient’s survival and compromise the bone segment, muscles and soft tissues involved in trauma. Because of the technique advantages and disadvantages and the difficulties of everyone lesion, handling this pathology requires specialistic surgical experience and the choice of the most useful timing and devices in order to reach the goals.Thanks to the choice protocols always used by most of the Authors and according to emergency criteria of presented 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 act. Therefore, in their experience the Authors present the possibility to use external fixation in emergency or nailing by closed surgery to treat complex fractures associated with instable steady-state in multiple injury patients and to solve difficult problems of the complicated trauma. These devices lead to a rapid resolution of survival threaten, to immediate rehabilitation and a good nursing of these patients.

REPAIR OF A PELVIS FRACTURE ASSOCIATED PSEUDOARTHROSIS WITH TERIPARATIDE TREATMENT: A CLINICAL CASE L. Ventura [1], M. Ghirardini [1], M. Taglietti [1], A. Nardi [2], A. Giustina [3], P.P. Vescovi [1] [1]Dipartimento di Medicina Az. Osp Carlo Poma, Mantova, Italy; [2]Dipartimento di Medicina Az. Osp. di Rovigo, Italy;- [3]Dipartimento di Medicina Università di Brescia, Italy

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Case: W.V. born on 07/14/1926 shows Op risk factors defined by hystero-adnexectomy due to ovaric policistosys at 29, previous smoking habit, poor calcium intake with diet. She suffers from hypertension treated with calcium-antagonist, refers Colles’ fractures at 40 and 60. On December 2000, after a fall, she underwent a pelvis trauma with secondary pain syndrome, dependence from FANS, hypakinesys syndrome. The pelvic x-ray, performed a month after the trauma, did not show any evidence of fracture. On February 2003 the pelvic tomography showed the presence of fracture of the right ischium-pubic branch, without any evidence or repair. Mineral metabolism study showed hypercalciuria (382 mg/24h), insufficient Vitamin D state (8 ng/ml), normal values of calcemia, phosphoremia, PTH, ALP. The corrective treatment of hypercalciuria, with Amiloride-Hydrochlorotiazide, and the one for hypo-Vitamin D (Ergocalciferolo + Calcium + 400 UI Vit D) did not lead to any improvement of symptoms. After occurrence of pain to the left hemi pelvis, in August 2003, scintiscan and tomography were performed, showing presence of fracture for insufficiency of the left ischium-pubic branch, absence of osseous callum in the former fracture and development of it into pseudo-arthrosis. In March 2004, a new tomography showed no changes of the right ischium-pubic branch fracture, but the left one showed the formation of osseous callum. In 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 in the right ischium-pubic branch fracture and complete repair of the left one. At the end of the 18-month therapy, a new tomography showed complete repair of right ischium-pubic branch fracture and disappear of pseudo-arthrosis. Conclusions: Teriparatide therapy (FORSTEO®), started 20 months after fractural episode, leads to a quick regression of pain symptoms, quick formation of osseous callum with complete repair of the right ischium-pubic branch fracture, pseudo-arthrosis regression, restoration of mobility.

NEW CRITERIA OF RADIOLOGICAL SEMEIOTICS IN THE EVALUATION OF OSTHEOSYNTHESIS WITH INTERNAL FIXATOR IN THE TREATMENT OF LONG-BONE FRACTURES N. Trenti [1], P. Stradiotti [1], A. Pace [2] di Radiologia Diagnostica e di Bioimmagini, Istituto Ortopedico Galeazzi, Milan, Italy; [2]Fondazione Istituto San Raffaele, G. Giglio, Cefalù, Italy A. Zerbi

[1],

[1]Servizio

Objective: To analyze the new criteria of radiological semeiotics in the evaluation of the osteosinthesys with internal fixator (IF) used today in treating long-bone fractures. Materials and Methods: From 2001 to 2003 at Trauma Unit in the Istituto Ortopedico Galeazzi, 115 long-bone fractures were treated with an IF. The postoperative and follow-up radiograms were studied in order to control the stability, instability or mobilization of the implants, as well as the evolution of the bone healing. Results: The distance of the IF from the bone surface is not necessarily a sign of loosening of the screws (as it usually happens with traditional plates), because the method by which the IF works is completely different from that of the plate. Signs of implant mobilization may be much less evident and therefore a careful comparison of the radiograms series is necessary in order to recognize them. Conclusions: The knowledge of basic principles of biomechanics of the new implants is indispensable for a correct radiological evaluation.

ROBERT-JONES BANDAGE IN TREATMENT OF LOWER LIMB TRAUMA T.L. Giorgini [2], S. Ghera [1], D. Di Martino [3] “San Pietro” Fatebenefratelli, Rome, Italy; [2]Casa di Cura Siligato, Civitavecchia, Italy; [3]Ospedale “San Paolo”, Civitavecchia, Italy C. Michele

[1]Ospedale

[1],

The Robert Jones compression dressing has been utilized for over a century, and yet is not well-known or often utilized in Italy. It has proved to be an excellent device for preventing and controlling aedema of all types, but is especially indicated for post-traumatic and postoperative swelling. This dressing is comprised of alternating layers of cotton and elastic (Ace) bandages, “pulled” at a level on compression which does not compromise cutaneous and subcutanous circulation. This allows avoidance and reduction interstitial liquid typical of aedema utilizing a controlled and diffuse compression. This dressing also offers another possibility of immobilizing the lower extremity at varying levels by application of splinting material in plaster-of-Paris or fiberglass within the dressing. Not only is the Robert Jones compressive bandage ideal in conservative treatment of foot or ankle trauma, but also as a temporary preoperative brace, especially when surgery is often delayed during the first 12 hours due to swelling and fracture blisters. Control of swelling is important not only in decreasing pain pre- and post-operatively, but also in avoiding surgical complications such as blistering and wound dehiscence post-opertively. The authors present the technique in applying the Robert Jones dressing, offering suggestions for easy and secure placement and removal, as well as describing the final results of a series of 100 traumatic cases.

COMPUTER ASSISTED KNEE ARTHROPLASTY FOLLOWING POST-TRAUMATIC KNEE DEFORMITY N. Confalonieri, A. Manzotti, K. Motavalli I-II U.O. di Ortopedia e Traumatologia, C.T.O, Milan, Italy Introduction: Computer assisted surgery has been developed to help surgeon in reconstructive procedure in improving implants alignment and performances. In literature different Authors have already demonstrated its efficacy in traditional knee replacement surgery despite different alignment systems. Nevertheless, no study has analyzed its results in high demanding replacements such as in significant post-traumatic limb and articular deformity with bone loss and multiple ligaments instability. The Authors assessed their experience in high demanding computer assisted knee replacement Materials and Methods: Among 414 computer assisted knee replacements performed since 1999, 14 cases were selected according to limb deformity and bone loss 39 arthritic knees were included in the study because following isolated fracture of the knee (26 tibial plateu fractures, 11 femoral condyle fractures and 2 patella fractures). The mean age was 66 years old with 36 males and 18 females. At a mean follow-up of 32.1 months all the patients were evaluated using both the Knee Society and the GIUM outcome score. Furthermore all the implants were assessed radiographically evaluating limb alignment and implant positioning. Results: The KKS score and the GIUM score were improved respectively to 81 and 69. No Outliners (malalignment exceding 4° of an ideal alignment) were identified. There was no complication because of the Computer Assisted technique. In one case we registered a sciatic nerve suffering following an impressive valgus deformity. The range of motion was improved in all the cases (mean: 29.5°). Conclusions: According to authors’ experience reveals different advantages of computer assisted surgery in high demanding knee replacements. Despite a longer surgical time less invasive implants, bone sparing associated to better alignments produce better results compared to traditional systems. Improved results can overcome higher costs cause of surgery time and systems purchasing.

THE HYBRID EXTERNAL FIXATION SYSTEM AO IN THE COMPLEX METAPHYSEAL FRACTURES: OUR EXPERIENCE ABOUT 14 CASES M. Roselli, D. Agosta, G. Montanari, G. Berra U.O.A. Ortopedia e Traumatologia, ASL3 TO, Ospedale Maria Vittoria, Turin, Italy

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Fourteen patients (6 women and 8 men) with complex metaphyseal fractures of lower limbs were treated in our institution with the hybrid external fixation system AO from 2002 to 2005. Fractures were classified according to AO system and Gustilo classification. Of these, 3 were fractures of distal femur, 6 of proximal tibia, 5 of distal tibia (with 1 case bilateral). All patients were operared in emergency or in 24 hours. Results were evaluated on the basis of subjective and objective rating system. Follow up periods averaged 15 months with an average time to healing of 4.5 months. There were no cases of pseudoarthrosis. Complications occurred in 5 patients and included 1 case of skin necrosis, 3 cases of loss of reduction necessitating frame revision, 1 case of malunion with axial deviation. In accordance with our experience resulting from this study, the hybrid external fixation system AO is proved useful not only for treatment in emergency, because of its easy and fast application and minimal invasive surgical modality, but also for definitive treatment, when properly employed, thanks to the relative stability of the system which allowed, in most of patients, the fractures healing respecting rotations, segmental lenght, axiality and soft tissues. A good command of surgical anatomy and knowledge of bone biology, biomechanics and principles of external fixation according to Ilizarov, are required in any case to obtained good results.

Background: Autologous bone grafts and sometimes allograft bone extenders are commonly used in spinal surgery to promoting and achieving a solid fusion mass. Materials and Methods: We report a single surgeon’s use and early results of autologous bone grafts mixed with autologous bone marrow aspirate in 25 patients undergoing lumbar spinal fusion. Of the patients included in this study, 20 (80%) patients underwent surgical intervention for lumbar spinal stenosis and 5 (20%) patients had lumbar spondylolisthesis. Twelve women and 13 men were included in the study. The average patient age was 56 years (30-74 years, SD=±12). Independent radiographic evaluation was performed. Results: Each subsequent radiographic follow-up revealed increased improvement in average Lenke score and was statistically significant between the early (1 month) and recent (24 month) follow-ups. There were statistically significant changes in Lenke score between 1 month and 6 months follow-up (p<.01), between 6 months and 12 months follow-up (p<.001), and between 12 months and 24 months follow-up (p<.01). Conclusion: The gradual and constant increment of improvement in radiographic measurements in this preliminary series may indicate a positive effect of the use of autologous bone marrow aspirate that may decrease the required amount of bone grafts.

LIGHTS AND SHADOWS ON ESWT TREATMENT OF PLANTAR FASCIITIS. MEDIUM-TERM AND LONG-TERM RESULTS

SPINAL FUSION IN POST-TRAUMATIC KYPHOSIS USING CALCIUM PHOSPHATE CERAMICS: PRELIMINARY RESULTS OF A PROSPECTIVE CLINICAL STUDY

P. Papandrea, M. Ciurluini, M. Barbarino, A. Ferretti U.O.C. Ortopedia e traumatologia, Policlinico Sant’Andrea, Rome, Italy Introduction: Biomechanical analysis of the gate underlie the primary role of the plantar fascia, which support the plantar arche in the saggittal plane and allow the transmission of the force from the Achilles tendon to the forefoot. Functional overuse and abnormal biomechanic of the foot can produce a heel pain syndrome which involves both sedentary people and athletes. Objective: Purpose of the study was to investigate medium-term and long-term clinical results of ESWT on symptomatic treatment of plantar fasciitis in athletes and in sedentary patients. Materials and Methods: 57 cases of plantar fasciitis. Group A: 27 sedentary patients; Group B: 30 athletes. In the pre-treatment phase, patients were subjected to RDX under weight bearing in order to detect any biomechanical abnormalities, and MRI. Four low-energy sessions of shockwaves without anaesthesia. Orthotic foot devices were allowed. It was used Mayo Foot and Ankle Score Scale in order to make a clinical evaluation. Results: Clinical results: at 3 months Fup 70% of patients reported satisfactory results (excellent and good results), at 17 months fup the percentage was 83%. Orthotic foot devices were removed in the 13% of cases. Results in athletes: at 3 months Fup 81% of patients reported satisfactory results and at 17 months fup the percentage was 88%. Orthotic foot devices were removed in the 11% of cases. At 48 month fup excellent and good clinical results were confirmed (the percentage was 84%). No significant radiological modification at the origin of the plantar fascia was pointed out. MRI showed decreased inflammation signs. Conclusion: ESWT represents a symptomatic treatment devoid of collateral effects, able to solve heel pain in a signify percentage of cases. Orthotic foot devices seem to be helpfull to maintain satisfactory clinic results after treatment and to correct the biomechanics of the foot during walking and running.

THE EFFECT OF AUTOLOGOUS BONE MARROW ASPIRATE TO ENHANCE THE FUSION IN INSTRUMENTED LUMBAR SPINE C. Doria [1], F. Milia [2], L. Floris [3], L. Tidu [4], P. Lisai [1], P. Tranquilli Leali [1] [1] Policlinico Universitario, Sassari, Italy; [2] Policlinico Universitario, Sassari, Italy; [3]Policlinico Universitario, Sassari, Italy; [4]Policlinico Universitario, Sassari, Italy

C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy Objective: The aim of this study is to evaluate the ability of ßtrica1cium phosphate (TCP) in granular form to achieve dorsal spondylodesis in post-traumatic kyphosis (PTK). Materials and Methods: Eight patients underwent surgical correction and were followed up for 23±14 (range 9-37) months. Posterolateral grafting was performed, using either autograft bone mixed with allograft bone (n=4; “bone group”) or autograft bone mixed with 25 g TCP (n=4; “TCP group”). Patients were followed by clinical examination, X-rays and computed tomographic (CT) scans. Fusion involved 11±1 (range 10-12) vertebrae. Results: The segments were fused after 6±1 months in both groups according to the radiographs. No pseudarthrosis was observed. Resorption of TCP and new bone apposition was complete on the radiographs after 8±2 (range 6-10) months. Conclusions: Based upon the results of this preliminary study, the use of TCP appears to be a valuable alternative to allografts for application in the spine, even when large amounts of bone are needed.

VERTEBRAL RECONSTRUCTION WITH POROUS CALCIUM PHOSPHATE CEMENT IN THE TREATMENT OF OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURES C. Doria, F. Milia, L. Floris, L. Tidu, P. Lisai, P. Tranquilli Leali Policlinico Universitario, Sassari, Italy Objective: To assess the efficacy of vertebral reconstruction with porous calcium phosphate cement (Callos) in the treatment of osteoporotic vertebral compression fracture. Background: Vertebroplasty consists of the injection of polymethylmetacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows only a short handling time. Other potential problems of using PMMA injection may include damage to surrounding tissues due to the high polymerization temperature or by the toxic unreacted monomer and the lack of long-term biocompatibility. Bone mineral cements such as calcium carbonate and Callos have a longer working time, low thermal effect, they are more suitable for injection into the vertebral bodies; they are also biodegradable while providing good mechanical strength.

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Methods: Five patients, two males and three females, affected by vertebral compression fractures responsible for severe pain unresponsive to medical terapy, were included in this open prospective study. Evaluation of patients was based on x-ray, JOA score for low back pain, and Visual Analog Scale (VAS). Results: The levels of the delayed collapsed vertebrae were T11, L1, and L2 (for one patient each) and L3 (two patients). The average operative time was 45 minutes). As for the clinical symptoms, preoperative JOA score averaged 17.8 points and was improved to 26 points postoperatively, while the preoperative VAS score of 8.6 points improved to 5 points postoperatively. Radiological evaluation showed preoperative vertebral compression ratio averaged 61% and improved to 34% immediately after the operation. Conclusions: Vertebral reconstruction with biodegradable Callos in the treatment of osteoporotic vertebral compression fracture was a safe and useful surgical treatment. Augmentation with Callos improves pain and function and enables the treated vertebral body to regain of height.

those related to thoracic trauma. The extension of this idea to spine surgery is strictly related to surgical timing despite the severity of the injury and the neurological involvement. In fact the treatment of spine injuries within 72 hours is less burdened by general complications and gives the patient more chances of neurological recovery. New minimal invasive stabilization techniques, in selected cases, can give a further contribution to polytrauma recovery, allowing an early mobilization by a minimally hemorrhagic surgical procedure. At the moment, the use of minimal invasive spine stabilization can be applied to isolated fractures without neurological involvement.

ADULT TRAUMATIC ATLANTOAXIAL ROTATORY SUBLUXATION: A CASE REPORT

Skeletal involvement in myeloma is characterized by neoplastic proliferation of highly proliferative plasmacells into the bone. Vertebral localizations are the subject of our study. They are usually revealed by a site related spine pain that is more acute during the night, with no relation to any activity. When the tumor involves roots or cauda, pain spreads along the related neurological structures. Major neurological symptoms such as para/tetraplegia may be triggered by further expansion of the lesion in the canal. Pathologic fracture (vertebral body collapse) is listed among possible first symptoms and may lead to spinal compression because of the fragments dislocation in the canal. Surgery plays two different roles in the treatment of vertebral myeloma: Functional surgery with the aim to - Decompress neurologic structures in order to either restore the lost neurologic function or prevent tumor from damaging cord and roots; - Relieve pain originated from fracture or compression; Allow weight-bearing, walking and stability. - Oncologic surgery with the aim to: - Decrease neoplastic mass; - Resect a lesion when it proved insensitive to chemio- and radiotherapy procedures; Authors report a series of 50 myelomas with vertebral lesions treated between 1997 and 2002, with a 3 years minimum follow-up.

R. Sinigaglia, D.A. Fabris Monterumici Unità Operativa Complessa di Chirurgia del Rachide “Sandro Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, Padua, Italy Objective: Report a rare case of adult traumatic atlantoaxial rotatory subluxation. Materials and Methods: In November 1996 a 21-year-old woman was referred to our Center 6 days after a car accident. On physical examination the patient presented with torticollis, neck pain and decreased cervical spine motion. Neurological and vascular evaluations were normal. Transoral X-ray showed asymmetry between the dens and the atlas, CT scan confirmed the atlantoaxial rotatory subluxation. Closed reduction was performed followed by 70 days of Halo-Vest external fixation. Results: After a 9-year follow-up the patient has no complaints related to the cervical spine, whose range of motion is completely normal. Discussion: Atlantoaxial rotatory subluxation, while not unusual in the pediatric population or those with ligamentous laxity or degeneration, is a very rare type of traumatic injury in the adult [Fielding 1977, Weisskopf 2005]. Diagnosis is often difficult, delayed, and frequently misdiagnosed [Fielding 1977, Weisskopf 2005]. For correct diagnosis standard X-ray and C0-C2 CT scan are mandatory. The reduction could be closed or open, and followed by prolonged immobilization [Fielding 1977, Weisskopf 2005], C1-C2 posterior fixation [Fielding 1977, Moore 1995, Miyamoto 2004], or transoral fixation (temporary or definitive) [Weisskopf 2005]. For some authors the integrity of the transverse ligament of the atlas determines the type of treatment [Miyamoto 2004]. Conclusion: Closed reduction followed by prolonged immobilization should be the first choice treatment for adult traumatic atlantoaxial rotatory subluxation. This conservative treatment avoids the major complaints related to the surgical procedures, allowing complete cervical spine range of motion after healing.

SPINE SURGERY AND POLYTRAUMA: DAMAGE CONTROL ORTHOPAEDIC SURGERY F. De Iure, M. Palmisani, S. Bandiera, M. Cappuccio, L. Boriani Unità Operativa di Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy In 1980 the idea of “early total care of fractures” and “damage control orthopaedic surgery” began to concern the treatment of polytrauma patients in order to prevent general complication, mainly

SURGICAL TREATMENT IN MYELOMA RELATED VERTEBRAL LESIONS S. Boriani, S. Bandiera, S. Paderni, M. Cappuccio, L. Boriani, A. Gasbarrini U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy

DIAGNOSTIC ACCURACY OF CT SCAN-DIRECTED TROCAR BIOPSY OF THE SPINE A. Gasbarrini, S. Bandiera, G. Barbanti Bròdano, L. Mirabile, M. Cappuccio, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy CT scan-directed percutaneous Trocar biopsy is a mini-invasive technique utilized in spine-surgery. This procedure is indicated when surgeons have to deal with a suspicion of unknown vertebral lesions. It provides adequate specimens for a correct and quick histo-pathological diagnosis. Aim of this paper is to describe CT scan-directed Trocar biopsy of the spine and suggest proper indications. Ct scandirected Trocar biopsy is a basic step in our diagnostic-therapeutic algorithm for the treatment of ematogenous vertebral spondilo-discitis and spine metastases. In a lapse of time comprised from 1998 and 2005, we performed this kind of biopsies on 216 vertebral lesions, on the basis of the clinical-radiological-laboratory setting. Our series was characterized by a mean age of 52 years (range from 14 to 86 years); 127 patients were male, 89 were female. We have utilized a 4th generation spiral Picker 6000 CT scanner. Procedure is percutaneously performed, under local anesthesia, and consists of

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withdrawing sufficient tissue from the lesion to have a histopathological diagnosis. The correct way to realize this biopsy is passing through pedicles, with 2.5 to 4.0 mm Trocar needles. In 100% of our cases we reached diagnosis after one shot. Fifty-three cases were diagnosed as spondilo-discitis: one patient out of these 53 received diagnosis only after cultures. One hundred sixty-three lesions were diagnosed as metastases. On the basis of our experience the described technique is easy, quick, scarcely invasive; it has proven high percentage of success (in our series the diagnostic accuracy is 100%), with a low risk of complications if correctly executed. In many cases Ct scan-directed Trocar biopsy is the only invasive procedure in the whole treatment; in other cases it addresses to a correct preoperative planning and then to an adequate treatment.

(CDF, 9 to max 151 months; average: 69 months), 69 with no evidence of disease (NED 9 to 151 months; average: 70 months), 10 alive with disease (AWD 12 to 123 months; average: 66 months); fourteen patients were died for at least 4 month (4 to 65 months; average 24). Eighteen local recurrences were observed and treated. Conclusion: En bloc resection can be performed in selected spine tumors; the indication to such major surgery must be based on the oncologic stage, and the procedure must be carefully planned. For this purpose, the Weinstein-Boriani-Biagini system could be a helpful tool.

OUR EXPERIENCE IN BALLOON KYPHOPLASTY TREATMENT 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, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy Surgical treatment of spine metastases has to reach a functional result rather than a curative one. Aim of this kind of surgery is to obtain the best local control of the disease. Surgery of vertebral metastases actually has to take into account the patient’s clinical setting and to face the risk of increasing iatrogenic morbidity percentage. Spine metastases surgery can be adequately planned following the WBB staging, specifically conceived for spine tumors. On the basis of our experience and of a precise revision of the literature we have pointed out three important steps in the treatment planning of a vertebral bone secondary lesion: - to describe the lesion with a common and appropriate terminology; - to apply the WBB staging system to plan adequate treatment; - to plan an en-bloc resection of the vertebral neoplasm in selected cases. Vertebrectomy is rarely indicated in the treatment of spine metastases. This indication depends on the age and the general clinical setting of the patient, sensitivity to adjuvant therapies, excessive risk of intraoperative bleeding, primary tumor histology and patient prognosis. In the period between January 1999 and June 2005 we have performed 32 en-bloc resection out of 226 cases of spine metastases. We have followed patients in time (follow-up ranges from 6 monthes to 60 monthes, average 19 monthes) and at present 13 cases result alive with no evidence of disease (NED), 4 patients are alive with disease (AWD) and 15 are deceased.

EN BLOC RESECTION OF PRIMARY BONE TUMORS OF THE SPINE S. Bandiera, F. De Iure, A. Gasbarrini, M. Cappuccio, L. Mirabile, G. Barbanti Bròdano, L. Boriani, S. Boriani U.O. Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy Objective: To demonstrate the possibility to apply in the spine the same principles of surgical oncology adopted for primary bone tumors of the limbs. Methods: From 1-1-1990 to 1-1-2003 ninety-three primary malignant and aggressive benign bone tumors were treated. The primary tumors were classified according to Enneking oncological system and Weinstein-Boriani-Biagini surgical system: 36 stage IA or IB, 26 stage IIA or IIB, and 31 stage 3 benign. The en bloc resection was performed in 3 cervical, 34 thoracic, in 56 lumbar. Reconstruction was performed, aiming to replace the resected elements of stability Results: No patients died during surgery or from surgical complications. At final follow-up, sixty-six patients were found disease free

Balloon Kyphoplasty has been recognised over recent years as one effective therapeutic possibility, often resolutive for the mininvasive treatment of the painful symptomatologies of the thoraco-lumbar spine. In case of painful vertebral compression fractures, resistant to conventional therapies, Balloon Kyphoplasty can represent a preferential treatment because of its low invasive character, the methodological safety of the devices and the relative semplicity of the procedure. A clear diagnostic indication and a strict selection of the cases that have to be treated are fundamental. We believe that Balloon Kyphoplasty can have further developments for the combination between the technical ease of handling and a relative safety compared to similar procedures. Some years ago our department began to treat cases of pathological vertebral compression fractures and cases of vertebral somatic collapses caused by neoplastic secondary localization. We would like to introduce some outcomes and solutions that we believe interesting for a comparison with other first users of the procedure. The standard technical procedure is not feasible in some clinical conditions and some times we must resort to a lateral approach as happened for one of our patients affected by a serious respiratory insufficiency. Our follow-up is certainly limited (2 years), but outcomes are congruous with the clinical experience of other teams, however it is a still young treatment that will be able to offer new interesting procedural developments.

CFRP CAGES FAVOUR OSTEOBLAST ADHESION AND PROLIFERATION BETTER THAN THE PEEK ONES G. Barbanti Bròdano [1], S. Boriani [1], K. Campioni [2], M. Tognon [2], C. Morelli [2] [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, Centro di Biotecnologie, Università di Ferrara, Italy Intersomatic cages built of different materials are widely used in spine surgery with the aim to obtain intersomatic arthrodesis. They have been extensively studied about mechanic features but we have no information about biologic characteristics of osteogenesis, osteo-induction and osteo-conduction. If we wanted to evaluate such features we should plan in vivo animal expensive tests, prolonged in time, with ethic problems that cage producing firms don’t usually undertake. Our group has devised a cellular system that let us quickly establish parameters above mentioned, through an in vitro test. This system is based on the line Saos-2, an osteosarcoma cell line that does not change its osteoblastic features, and a commercial line of mesenchimal stem cell (MSC) osteoblastic phenotype induced. Lines have been engineerized through trasfection of a vector containing the inactivated green fluorescent protein gene. Clones expressing this marker have been selected. With this procedure we rendered cells easily identifiable and quantifiable through fluorescent microscope observation. This method enables us to assess and compare the biological features of two intersomatic cages

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made of different materials (CFRP and PEEK). Characteristics we can evaluate are: -biocompatibility, -osteo-inductive and osteo-conductive capabilities (MSC-eGFP), -osteogenic and cell adesion capabilities (Saos-eGFP). Preliminary results point out that carbon fibre reinforced polymer (CFRP) intersomatic cages are more indicated then the polietherethereketone (PEEK) ones on the basis of many features. The CFRP cages support a more relevant osteogenesis, osteo-induction and osteo-conduction and also a bone cells surface pattern more homogeneous then the same cages made of PEEK. Our cellular model revealed a good alternative to in vivo studies. Actually it makes us able to obtain experimental data by in vitro trials, to cut down expenses, to reduce time and to avoid ethical arguments.

PAIN CONTROL AND FUNCTIONAL RECOVERY IN PATIENTS AFFECTED BY SPINE FRACTURE DUE TO OSTEOPOROSIS. A COMPARISON BETWEEN VERTEBROPLASTY AND KIPHOPLASTY G. Barbanti Bròdano, M. Cappuccio, L. Boriani, F. De Iure, A. Gasbarrini, F. De Salvo, S. Boriani Unità Operativa di Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore, AUSL Bologna, Italy During the last ten years vertebroplasty (VTP) and kiphoplasty (KIPHO) have been widely indicated in the treatment of osteoporosis related vertebral collapses. Systemic revision of the literature and few evidence based studies (RCT) on this topic did not definitely confirm the benefit given by these procedures in the cases above mentioned. Nevertheless, on the basis of their experience, all of the authors state that patients treated have had a quick and dramatic pain improvement and consequently partial functional recovery. Both vertebroplasty and kiphoplasty have the same indication that is chronic and refractory pain during conservative treatment; for this reason specific benefits related to each technique are difficult to clarify. Vertebroplasty seems to be affected by a greater cement leakage, even if this complication is almost ever only a radiographic sign with no clinical relevance, except for very rare cases. Kiphoplasty reduces fracture and consequently reduces kiphosis; it seems to relate to a better clinical outcome, with lesser risk of cement out of the vertebral body. We have retrospectively compared a homogeneous series of patients; 15 treated with kiphoplasty (B-Twin VBR Expandable Spinal System, Disc-oTech) and 18 were undergone to vertebroplasty. Self assessing tests have shown slightly better results in patients treated with kiphoplasty, but those data didn’t prove statistically significant values. (mean post-operative VAS KIFO=21 - VTP=25; SF-36. Post-operatve: 1. General Health KIFO=60 - VTP=58; 2. Pain KIFO=79 VTP=71; 3. Mental health KIFO=57 - VTP=60; 4. Social Activities KIFO=65 - VTP=57; 5. Sensitivities KIFO=40 - VTP=45; 6. Functional limitations KIFO=56 - VTP=51). No complications were found in either series. These data contribute to reflect upon the cost and benefit relationship related to these two techniques, assessing clinical, radiographic and economic variables this kind of surgery means.

MULTIDISCIPLINARY DIAGNOSTIC-THERAPEUTIC APPROACH TO THE “FAILED LOW-BACK SYNDROME” G. Barbanti Bròdano [1], L. Mirabile [1], L. Boriani [1], E. Magni [2], R. Piperno [2], S. Boriani [1] [1]Uo Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi, Bologna, Italy; [2]UO Riabilitazione e Rieducazione Funzionale, Ospedale Maggiore “C.A.Pizzardi”, Bologna, Italy Failed back syndrome (FBS) management is a controversial and difficult matter. Subjective reported symptoms are low back pain

and radiculopathies. They depend on multiple, unrelated factors, as surgical pathology, vertebral segment biomechanics, primary neurological lesion etiology, psychological and social elements. FBS causes prolonged disability, anxiety and malaise. Treating FBS patients is frustrating because of diagnostic doubts, unpredictable results, psychological problems related to the disease. Spontaneous recovery of these patients is uncertain and slow. Return to job after two years is almost 0%. The most part of these patients has no surgical indication because of specific complications such as deep peridural scar or lack of diagnosis of a precise pathogenic noxa. Only a small number of cases find a surgical solution. Our FBS series is composed of 26 patients, 14 females and 12 males, all of them with no surgical indication. They have been treated by a therapeutic protocol created in collaboration with Functional Recovery Department in our hospital. It consists in -a precise assessment of every single patient; -paying attention to explanation and comprehension of the disease through a dialogue with the patient (counseling); -a pharmacological treatment aimed to propioceptive and neuropatic pain; -a physical therapy program based on global postural re-education, propioceptive postural exercises, teaching of a sort of spine-care in order to make patients understand self-management of their disease in day-life. Results have showed a substantial improvement in every case, even if without statistical significance (mean VAS 80->63; SF-36: 1. General Health 49->58; 2. Physical Pain 20->40; 3. Mental Health 46->55; 4. Social Activities 49->60; 5. Sensitivities 36->45; 6. Functional Limitations 38->45; 7. Physical Health 45->47; 8. Vitality 45->60), attesting how useful could be a multidisciplinary approach to this peculiar clinical syndrome.

POSTERIOR LUMBAR INTERBODY FUSION (PLIF) IN DEGENERATIVE SPINE DISEASE. LONG TERM RESULTS G. Barbanti Bròdano, M. Palmisani, L. Mirabile, A. Gasbarrini, S. Bandiera, F. De Iure, G.B. Scimeca, S. Paderni, S. Boriani UO Ortopedia e Traumatologia, Chirurgia del Rachide, Ospedale Maggiore “C.A. Pizzardi”, Bologna, Italy Posterior lumbar interbody fusion is considered the best biomechanical fusion. In the lapse of time between March 1997 and December 2005 we have treated 227 patients affected by lumbar spondilo-arthrosis. They underwent PLIF associated to instrumented postero-lateral arthrodesis. Cages built of different materials (CFRP, PEEK, titan) were used. Mean age in our series was 49.4 years (range 18-77 years). Diagnosis was degenerative disc disease in 109 cases, spondilolisthesis in 76 cases, fracture outcomes or pseudoarthrosis in 25 cases (among which 5 cases of postero-lateral arthrodesis failures), degenerative scoliosis in 6 cases, lumbar stenosis in 14 cases, 1 case of osteoid osteoma localized in L4. Two patients deceased because of causes unrelated to surgery at 2 and 8 months since treatment occurred. The first one has been excluded from follow up. Clinical and radiological evaluation has been realized according to White (showing successful results in 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 VAS and SF-36 forms, showing improvement clinical settings even if not statistically significant (pre vs post: VAS 77vs54; SF-36: General Health 51vs65; Pain 24vs46; Functional Limitations 40vs51). Incidence of complications has been 4%. Eleven cases (8%) needed a second surgical procedure. At the latest follow up 31% of patients report persistent low back pain. Cages have better mechanical qualities than bone grafts; posterior fixation increases stiffness of the implant and so increases also pressure on the cages, reducing risk of mobilization. The percentage of complications and residual symptoms forces to reflect above all on the correct indications to this kind of surgery.

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PERCUTANEOUS KYPHOPLASTY: GENERAL ANESTHESIA OR LOCAL ANESTHESIA? F. Piccioni, F. Ferrari Servizio di Anestesia e Rianimazione 2, IRCCS Policlinico S.Matteo, Pavia, Italy Objective: Kyphoplasty is a minimally invasive percutaneous procedure developed to treat osteoporotic and osteolytic vertebral fractures. The aim of this retrospective study is to discuss two anesthetic approaches: general anesthesia and local anesthesia. Methods: A retrospective chart review was conducted on patients who underwent kyphoplasty at Pavia IRCCS Policlinico S. Matteo (Department of Orthopedic and Traumatology). 103 records were obtained by searching the anesthesia database from 1/1/2003 to 12/31/2005. Results: General anestesia group: 48 patients (38 female/10 male), mean age: 69.39 ASA I+II patients, 9 ASA III patients, surgical time 44’, anesthesia time 90’, 4 generic complications (bronchospasm, nausea), 1 kyphoplasty-related complication (hypotension after cement injection). Local anestesia group: 55 patients (38 female/17 male), mean age: 68. 34 ASA I+II patients, 21 ASA III patients, surgical time 26’, anesthesia time 30’, 1 generic complication (opioidrelated desaturation), 1 kyphoplasty-related complication (embolism or anaphylaxis reaction). In 2003 all patients underwent general anesthesia. We started to perform local technique in 2004. In 2005 no kyphoplasty was performed under general anesthesia. General anesthesia technique: propofol-remifentanil induction, sevofluraneor desflurane-remifentanil maintenance. Local anesthesia technique: mepivacaine 1% deep infiltration, oxygen administration by nasal cannula, midazolam and alfentanil small-bolus IV doses (mean bolus doses: 1-2mg and 0.2mg each – mean total doses: 2.7mg and 0.7mg each). Conclusions: In accord to our experience and data analysis we consider each anesthesia technique valid and safe. However, local anesthesia is the best strategy for the patient because of less emotional stress, intraoperative self-monitoring and less operating room permanence. The local anesthesia approach is easy and less expensive as regards pharmacological, equipment and operating room usage.

RADIOFREQUENCY HEAT ABLATION AND KYPHOPLASTY IN THE TREATMENT OF NEOPLASTIC VERTEBRAL BODY LOCALIZATIONS D.A. Fabris Monterumici, U. Nena, C. Stecco, R. Sinigaglia Unità Operativa Complessa di Chirurgia del Rachide “Sandro Agostini”, Azienda Ospedaliera, Università degli Studi di Padova, Padua, Italy Objective: The aim of this study is to assess the effectiveness of the treatment of thoracic and/or lumbar neoplastic vertebral localizations by radiofrequency heat ablation and kyphoplasty. Materials and Methods: From July 2002 through December 2005, we treated 25 patients with thoracic and/or lumbar neoplastic vertebral localizations using radiofrequency heat ablation associated with kyphoplasty. Six patients had primitive cancers, the other 19 had metastases. Results: This method demonstrated rapid pain relief with restoring of the weight-bearing resistance and the anatomy of the affected vertebral bodies. Patients quickly came back to their normal daily activities. Discussion: Radiofrequency heat ablation destroys the tumor tissue before kyphoplasty stabilizes the vertebra through the intrasomatic percutaneous injection of cement [Masala 2004 e 2005]. It permits decreasing of operating time, complaints, and patient’s discomfort. Kyphoplasty versus vertebroplasty allows a better anatomic restore

and a reduced risk of PMMA cement leakage outside the porothic vertebral body [Nussbaum 2004]. Conclusion: Radiofrequency heat ablation and kyphoplasty proved to be an effective, quick, and safe treatment for thoracic/lumbar neoplastic vertebral body localizations.

MAMMARY-TYPE MYOFIBROBLASTOMA OF POPLITEAL FOSSA: A CASE REPORT C. Scotti [1], F. Camnasio [1], G.M. Peretti [2], N. Rizzo [3], F. Fontana [1], G. Fraschini [1] [1]U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, Università Vita-Salute, Milan, Italy; [2]U.O. di Ortopedia e Traumatologia, Ospedale San Raffaele, Facoltà di Scienze Motorie, Università degli Studi di Milano, Milan, Italy; [3]U.O. di Anatomia e Istologia Patologica, Ospedale San Raffaele, Università Vita-Salute, Milan, Italy Mammary myofibroblastoma is a benign breast tumor, with a reported predilection for older men. We report a case of a 36-year-old man with a tumor, morphologically and immunohistochemically identical to myofibroblastoma of breast, but arising in the popliteal fossa. The patient came to our attention for a slowly growing, fixed and painless lesion located in the popliteal fossa. He underwent MRI, which showed a rounded, capsulated, 9 cm lesion, not infiltrating the neurovascular bundle. PET scan was slightly positive; for this reason the patient underwent routine staging, which did not show any secondary lesion. Due to the local characteristics of the lesion, which could potentially indicate a malignant tumor, an incisional biopsy was performed. Spindle cell lipoma was the resulting histological diagnosis. Two weeks later, a marginal excision of the lesion was performed and the histology showed a spindle cell mesenchymal neoplasia, without atipias, necrosis and mitoses. Immunohistochemical assay was positive for CD34, S100, Bcl-2, Desmin and nuclear estrogenic receptors, negative for Actin. Thus, the diagnosis of mammary-type myofibroblastoma was done. Follow-up assessment at two years is negative for local recurrence. To our knowledge, this is the first report of mammary-type myofibroblastoma with popliteal localization; moreover, this report indicates a possible different diagnosis from the functional imaging analysis and the histological assessment.

TERIPARATIDE IN SEVERE OSTEOPOROSIS: EVALUATION OF ACUTE AND CHRONIC BACK PAIN IN VERTEBRAL COMPRESSION FRACTURE (VCF) A. Nardi [1], G. Luisetto [2], L. Ventura [3], E. Ramazzina [4], L. Cozzi [1], G. Tonini [1] [1]Servizio di Patologia Osteoarticolare, Azienda ULSS 18, Rovigo, Italy; [2]Dipartimento Scienze Mediche e Chirurgiche, Divisione di Endocrinologia, Università di Padova, Padua, Italy; [3]Soc Medicina, Azienda Ospedaliera, Mantova, Italy; [4]Soc Medicina, Azienda ULSS 18, Rovigo, Italy Teriparatide (FORSTEO®) is a anabolic drug that reduce the risk of vertebral fractures (VFs) and non-vertebral fractures (nVFs). The anabolic effect on bone is also associated with considerable reduction of back pain. In this study we evaluated the course of back pain in 40 patients with Post Menopausal Osteoporosis (PMO) and at least 1 vertebral compression fracture (VCF). The mean patients age was of 74.4 years, among those, 22 patients presented a recent (less than 1 month) vertebral fracture due to compression (VCF1) and 18 patients had a compression vertebral fracture (VCF2) that occurred within few months before. The baseline mean number of VCF was 5.2. All the patients received subcutaneous injection of 20 mg/die Teriparatide (FORSTEO®) and oral supplementation of Calcium and Vitamin D. The severity of back pain was measured at baseline (T0),

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at 30 (T30), 90 (T90) and 180 (T180) days assigning the score of 3=worst pain, 2=moderate pain, 1=mild pain and 0=no pain. The motorial function and tone of mood were measured at T90 in 33 patients using a questionnaire with a score of: 2=high improvement; 1=moderate improvement; 0=no improvement. In 15 patients with VCF1 we controlled the course of the back pain from baseline to 180 days. The reduction of back pain was around 97%. In 12 patients with VCF2 we controlled the course of the back pain from baseline to 180 days. The reduction of back pain was of 90%. The improvement of the motorial function and of the tone of mood, evaluated from baseline to T90, was hight in 20 patients, moderate in 12 patients and absent in 1 patient. In conclusion Teriparatide (FORSTEO®) determines a considerable reduction of back pain due to VCF from baseline to 180 days of treatment. In patients with VCF1 the effect on pain is evident after only 30 days of treatment, similarly to what has been shown in patients with VCF2 at the baseline. 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 chronic one. The reduction in back pain was statistically significant also in patients with more than 4 vertebral fractures at baseline.

THE USE OF COMPUTER ASSISTED TECHNIQUE IN THE TREATMENT OF A FRACTURE DISLOCATION VIIC-IT IN ANKYLOSING SPONDILYTIS A. Bruno, A. Coniglio, J. Demangos, S. Aleotti U.O.C. Chirurgia Vertebrale, Turin, Italy Introduction: Ankylosing spondilytis (spondylitis ankylosans), characterised in its advanced state of rigidity and ankylosation of the spinal column, is a predisposing risk factor for spine fractures due to even minor traumatic events. The lesions usually involve the thoracolumbar region and less often the lower cervical spine. Although the posterior screws offer an osteosynthesis with a good stability, the ossification of the longitudinal ligaments, of the lateral masses and the calcification of the intervertebral discs make this vertebral stabilisation technique difficult, due to the absence of the common anatomic landmarks. Materials and Methods: Here we describe a case of a 43 year old male with a history of a fracture dislocation in C7/T1 with spinal cord injury, previously treated by C7 somatectomy, arthrodesis with a cage and titanium plate, together with a posterior focal decompression laminectomy. The patient had been transferred to our centre in the immediate post-operative period due to the development of a massive infection with generalised sepsis. Surgical debridement was performed immediately and the implants removed. Temporary immobilization was carried out by a Halo-vest for about three weeks. Posterior stabilization of C4-T4 with pedicular and lateral masses screws, was then possible with the use of the computer assisted technique. Discussion: The results, a brief outline of the surgical technique and practical comments as to the use of the navigations system will be presented.

TWO-STAGE REVISION IN INFECTED KNEE ARTHROPLASTY G. Trisolino [1], D.S. Tigani [1], D.C. Vaccarisi [1], P. Costigliola [2], N. Del Piccolo [1], F. Chiodo [2], A. Giunti [1] [1]Istituti Ortopedici Rizzoli, Bologna, Italy; [2]Policlinico S. OrsolaMalpighi, Bologna, Italy Background: Late chronic infection still represents a challenging problem after total knee replacement. Most infected knees require prosthesis removal. In these cases two-stage revision with a 6-week course of systemic antibiotics, has been advocated as the standard of treatment for infected knee replacement. Materials and Methods: Between January 2000 and December 2005, 30 patients with 31 total knee arthroplasties complicated by

infection were admitted at our department. One patient had bilateral infection. 7 of the index procedures had been done at our institution and 24 had been done elsewhere. 6 patients had an infection around a revision procedure for aseptic loosening, whereas 2 patients had been already revised for septic loosening. After removal of the component and radical debridement of the bone and soft-tissues in all the patients an antibiotic-loaded spacer was prepared at the time of surgery. For six weeks before re-implantation all the patients underwent an intravenous administration of antibiotics on the basis of sensitivity of organisms that were grown on culture. Results: The average follow-up was 34 months. Mean KSS score improved by 35.5 to 80.3. There were 4 cases of recurrent infection. Conclusion: The two-stage revision procedure was successful in eradicating the infection in 27 of 31 knees (87%). In our opinion it represents the most successful method for managing total knee arthroplasty complicated by infection.

FIBROBLAST AND BIOLOGICAL MEMBRANE FOR POTENTIAL TENDON REPAIR: AN IN VITRO PRELIMINARY STUDY 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 Milano, Milan, Italy Introduction: Tendon repair in some sites of the body, as i.e. the rotator cuff, is a current challenging clinical problem. Cell-therapy could represent a valid therapeutic solution for these lesions. The aim of this study was to create an in vitro model of fibroblasts seeded on a collagen membrane, as a potential tool for the solution of this issue. Methods: Achilles tendon biopsies were taken from young pigs. The tendons were cut in small pieces of approximately 1 mm of diameter, cultured in vitro, in order to allow the cells to leave the specimens and then to reach the confluence (approximately 1 month). The fibroblasts were then enzymatically isolated, resuspended and expanded since the new confluence was reached (5 days). The cells were seeded onto membranes of collagen type I and III of 2 mm of diameter. The membranes were cultured for two more weeks, then retrieved from cultures for macroscopic and histological analyzed. Results: Macroscopically, the seeded membranes showed a reduced biomechanical integrity compared to the unseeded membranes. The histological examination demonstrated the presence of vital cells within the membranes. Discussion: The results from this study demonstrate that the swine fibroblasts can be seeded onto a collagen scaffold. These cells remain vital during in vitro culture. Further studies will demonstrate the survival and the reparative potential of fibroblast transplantation in an orthotopic in vivo model.

IN VITRO STUDY ON A TISSUE ENGINEERED OSTEOCHONDRAL COMPOSITE: MORPHOLOGICAL AND HYSTOLOGICAL EVALUATION G.M. Peretti [1], M. Buragas [1], C. Sosio [1], L. Mangiavini [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 Milano, Milan, Italy Introduction: The purpose of this work is to create an in vitro model of engineered osteochondral composite by combining a cylinder of calcium phosphate and cartilage tissue produced by isolated swine articular chondrocytes seeded onto fibrin glue. Methods: Swine articular chondrocytes were enzimatically isolated and seeded onto fibrin glue. Immediately before gel polymerization, the fibrin glue was placed in contact with the cylinders of calcium phosphate. The osteochondral composites were left in standard cul-

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ture conditions for 5 weeks. At the end of experimental time, the samples were macroscopically analyzed and processed for histological evaluation. 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 between the fibrin glue and the cylinders, infiltrating the scaffold trabeculae. Discussion: The results of this study demostrate that isolated chondrocytes, seeded onto fibrin glue, produce a cartilage-like matrix that integrates with a cylinder of calcium phosphate. Further studies will quantify the biomechanical strength of the adhesion between the calcium phosphate scaffold and the newly formed cartilage. This tissue engineered osteochondral composite could represent a valuable model for further in vivo studies on the repair of osteochondral lesions.

PERSPECTIVE CLINICAL TRIAL TO ASSESS INTRA-ARTICULAR CONCENTRATIONS OF IL-8, IL-6, TNF-α IN PATIENTS WITH ISOLATED ANTERIOR CRUCIATE LIGAMENT LESION: PRELIMINARY RESULTS M. Bigoni [1], S. Guerrasio [1], A. Cossio [1], E.C. Marinoni [1], A. Torsello [2], I. Bulgarelli [2], L. Tamiazzo [2], P. Sacerdote [3] [1]Clinica Ortopedica, AO San Gerardo di Monza, Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Ortopedia e Traumatologia, Monza, Italy; [2]Dipartimento di Medicina Sperimentale, Ambientale e Biotecnologie Mediche, Università degli Studi Milano-Bicocca, Milan, Italy; [3]Dipartimento di Farmacologia, Chemioterapia e Tossicologia Medica, Università degli Studi di Milano, Milan, Italy In the degenerative or traumatic inflammatory diseases there is an intra-articular effusion, full of inflammatory cells, cytokines and related substances which damage the articulation itself. However few data can be derived from the analysis of the literature about the real concentration and the trend of expression of these inflammatory chemical mediators in patient with acute post-traumatic ligamentous injury of the knee. The Department of Orthopaedics and Traumatology and The Department of Pharmacology of Milan Bicocca University are carrying out an experimental trial about the identification of inflammatory chemical mediators in synovial fluid 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 of the collateral ligament and negative anamnesis for previous trauma of the knee involved. The aim of the trial is to assess the intraarticular concentrations of IL-8, IL-6, TNF-α and their trend of expression taking a sample of joint fluid from the knee injured within 48 hours, after one week during the clinical check-up, after one month as intra-operating control and after 2 and 4 week as post-operating control. The Authors present the preliminary results.

CONDYLAR MINIPROSTHESIS: A NEW METHOD FOR III AND IV GRADE CHONDRAL LESIONS W. Thomas, L. Lucente, L. Tafuro Clinica Quisisana, Rome, Italy The orthopaedic treatment of chondral lesions of III and IV grade of Outerbridge classification is still debated, especially in patients between 40 and 60 years, too young for a prosthetic replacement. Furthermore other techniques (chondroabrasion, multiple perforation, microfractures, osteotomy) cannot be performed for severe cases. Osteochondral graft, that seems to be the most biologic technique, shows poor long-term results. Authors present a therapeutic device for a perfect filling of osteochondral defects. This device is a Cr-Co pin with a ceramic bearing surface, available in some measures, so to fill

perfectly every femoral condyle osteochondral defect. The surgical technique is fast and mini-invasive. We assert that such a device represents a valid therapeutic option but long-term results must be observed.

ARTHROSCOPIC TREATMENT OF A OSTEOCHONDRITIS DISSECANS OF THE FEMORAL TROCHLEA M. Ronga [1], G. Zappalà [1], E.A. Genovese [2], P. Bulgheroni [1] [1]Dipartimento di Ortopedia e Traumatologia, Università degli Studi dell’Insubria, Varese, Italy; [2]Dipartimento di Radiologia, Università degli Studi dell’insubria, Varese, Italy Aim: Juvenile osteochondritis dissecans of the femoral trochlea is an uncommon condition observed in clinical practice. We report on 11year-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 arthroscopic approach, the fragment was reduced and fixed using three 1.5 mm diameter and 20 mm long polylactic acid (PLA) pins. Results: At 6 months, the patient did not complain of knee pain, had full range of motion, and returned to all the activities performed before the traumatic event. International Cartilage Repair Society (ICRS) score was normal. The 2000 International Knee Documentation Committee (IKDC) subjective evaluation form, Lysholm II scale, and Tegner activity scale were, respectively, 69 of 100, 90 of 100, 6 of 10. MRI and Arthro-MRI showed fragment consolidation. The three absorbable pins were still recognizable. At 24-month, ICRS score was normal, and modified Cincinnati, Lysholm II, Tegner, and IKDC scores were, respectively, 9 of 10, 95 of 100, 7 of 10, and 88.5 of 100. MRI findings confirmed healing of the lesion and the presence of the bioabsorbable pins. Discussion: Review of the literature reveals few reported cases of OCD of the medial or lateral trochlea. Surgical options of unstable JOCD include fragment removal or fixation. Several authors have demonstrated that the removal of the fragment increases risk of early osteoarthritis. Consequently, osteochondral fixation is preferred. Pins have inferior compression compared to a 2.7 mm traditional screw, but the triangular placement helped achieve good rotational stability Conclusion: It is our opinion that an arthroscopic approach, biodegradable pins and early joint motion were the keys to the successful outcome in this case.

RUPTURE OF QUADRICEPS TENDON: A TECHNIQUE FOR RECONSTRUCTION WITH HAMSTRING AUTOGRAFT USING SUTURE ANCHORS FOR FIXATION F. Franceschi, G. Rizzello, A. Marinozzi, G. Longo Umile, L. Ruzzini, M. Ippolito, R. Papalia, V. Denaro Università “Campus Biomedico”, Rome, Italy 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. Materials and Methods: In May 2003 a 45 year old male affected by complete full thickness tear of the rectus femoris of the quadriceps tendon underwent a reconstruction of the quadriceps tendon of his left knee. A transverse tunnel was drilled through the mid portion of the patella and the hamstring graft was pulled into the patellar tunnel, leaving free distal ends of tendon which were than passed through the quadriceps tendon several times to bridge the defect. Two suture anchors loaded with Fiberwire were positioned into the superior pole of the patella and the Fiberwire was then passed through the tendon. The sutures were tied leading to a complete tendon reattachment. Results: The score system (IKCD) utilized for postoperative evaluation showed a clear improvement in our patient. At the final follow up, the patient showed no symptoms in the postoperative 3 years,

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and productively returned to pain-free level of function without limitations in his competing activities. Discussion: Many authors have dealt with various techniques of reconstruction of quadriceps tendon tears. In our patient we found a full thickness lesion of the most superficial lamina of the quadriceps tendon associated with retraction, for this reason an end to end repair could not be performed and we decided to perform an autologus augmentation using tendons which are routinely harvested in reconstructing other soft tissue structures with little or not disability. Conclusions: Our simple technique allows to realize a strong fixation allowing an early range of motion that provides an ideal environment for tendon healing.

EFFECT OF BRACE-FREE REHABILITATION ON BONE TUNNEL ENLARGEMENT OF ACL RECONSTRUCTION USING HAMSTRINGS TENDONS: CT STUDY R. Iorio, A. Vadalà, V. Di Sanzo, A. De Carli, G. Argento, A. Ferretti Ospedale S. Andrea, Rome, Italy The mechanism of bone tunnel enlargement following anterior cruciate ligament (ACL) reconstruction is not yet clearly understood. Many authors hypothesized that aggressive rehabilitation protocol may be a potential factor for tunnel enlargement, especially in hamstring autograft. The purpose of our study was to evaluate the effect of brace-free rehabilitation on bone tunnel enlargement of ACL reconstruction using hamstrings tendons. Materials and Methods: In this prospective study 43 consecutive patients operated by ACL reconstruction with the hamstrings using the same technique aned fixation devices, were randomly assigned is enter the study group (A) or the control group (B). In group A an accelerated rehabilitation were performed without brace and immediate ROM and weith bearing as tolerated. In group B a two weeks brace immobilitation in full extension were apllied with partial weight bearing. A CT scan of the knee were performed in all cases the day after surgery and at a follow-up of ten months: diameters of the femoral and tibial tunnel were evaluated according to a previously described method. Results: The mean average femoral tunnel diameter increased significantly from 9.04 ± 0.05 postoperatively to 9.3 ± 0.8 in the Group

A and from 9.036 ± 0.03 postoperatively to 9.94 ± 1,12 in the group B at follow up. The mean average tibial tunnel diameter increased significantly from 9.03 ± 0.04 to 10 ± 0.8. in the group A and from 9.04 ± 0.03 to 10.6 ± 0.78 in the group B. The increase in diameter of femoral and tibial tunnel was significantly higher than that of group B. Conclusion: Our results suggest that tunnel enlargement after ACL reconstruction with hamstring autograft is significantly increased by a brace-free rehabilitation protocol.

TWO CASES OF COMPLEX KNEE PATHOLOGY IN SPORT TRAUMATOLOGY F. Carotenuto [1], L. Curci [2], C. Di Bonito [3], N. Vendemmia [2] [1]Clinique General De Savoie, Chambery, France; [2]Policlinico Universitario “Federico II”; Naples, Italy [3]Ospedale G. Rummo, Benevento, Italy We describe two cases of ski-related complex trauma of the knee ligament, without fracture. The first case regards a knee dislocation that was not reducible in narcosis. Specifically, the internal condylus of the left knee created a path between the vastus medialis and the capsular ligament apparatus. This path allowed all the remaining ligament structures to slide intact into the intercondylar fossa, thus rendering the reduction of the fracture impossible. As a result, the patient presented a tear of the posterior cruciate ligament (PCL), of the PAPI, of the medial capsule, and, only in part, of the anterior cruciate ligament (ACL). The second case regards an external malignant pentad accompanied by a tear of the entire lateral muscle-ligament complex and the external sciatic popliteus (ESP). In both cases, patients underwent surgery immediately after the trauma. In the first case, the surgery resulted crucial for the reduction of the dislocation, otherwise unfeasible with non surgical means. In the second case, it was crucial for the neurological examination and decompression of the external sciatic popliteus nerve. Actually, the immediate surgical interventions allowed us to repair such uncommon ligament injuries, and, equally important, to better understand the mechanisms underlying the complex trauma of the knee ligaments. We hope that our study will change the current therapeutic approach to the treatment of these types of complex knee injuries.