9 November 2009: In-Depth Oral Presentations and Oral Communications

Preoperative planning for revision hip arthroplasty is different form and more complex than planning for primary hip replacement. The surgeon has to keep in mind a variety of issues, including existing implants, techniques of removal implant, bone quality, evidence of infection, soft tissue healing, neurovascular injuries, leg-length discrepancy. A special equipment, implants or bone graft required should be anticipated. Revision of a femoral stem and acetabular component can be a complex and technically demanding procedure due to poor bone stock, periprosthetic fracture, infection and complexities in cement or removal implant. It is mandatory to have clear management strategies with a variety of techniques available. Surgical intervention should be performed only when there is clear evidence of loosening or sepsis. Exploratory procedures without documentation of loosening or sepsis are rarely productive. In aseptic cases with no evidence of loosening, observation is prudent and not harmful.

In this analysis we retrospectively evaluated the outcome of Muller acetabular ring as a method for implant revision. This kind of device has been used in case of serious bone loss (grade III or IV); in order to classify the acetabular bone loss we referred to the guide lines proposed by the Associazione Italiana di Riprotesizzazione (Pipino 2000); this classification considers that the acetabulum must be surrounded by stable bony walls and that the center of rotation must be similar to the physiological one. There are four different degrees of bone loss, the Muller ring is used in the setting of III grade of bone loss characterized by widening and deformity of the cup associated to loss of two or more walls and fundus. The acetabulum cannot mechanically contain the cup and the whole biomechanics of the hip is altered. The advantage of this classification has the worth to typify the degree of acetabular bone loss relating it to surgical strategy. Muller's ring strengthens the load-bearing part of the hip joint, it is fixed by 3-5 screws without cement. The stability of the implant is assured through different optional techniques such as allograft bone chips, platelet gel (platelet rich plasma PRP) and growth factors (osteogenic proteins OP, bone morphogenetic proteins BMPs, transforming growth factors). The serious acetabular defects have three surgical needs: anatomical, mechanical and biological, with the purpose to restore the centre of rotation of the hip, to assure a primary stability of the implant and to reconstitute the bony patrimony through the use of bony grafts. The use of the rings of reinforcement is shown effective in restoring the geometric constants of the hip and in furnishing a suitable protection to the bony grafts up to their complete incorporation into the bone. The Muller's ring offers a good function of support, especially in the defects of the superior portion of the acetabulum and it is possible to use mini-invasive surgery techniques. The use of growth factors or bone morfogenic recombinant proteins (BMPs) together to the bony graft is able to accelerate the integration of the graft reducing the risks related to the interface bone-graft that influences for a long time in conclusive way the result term.
Intrapelvic migration of acetabular cups. Clinical experience and strategies of prosthetic revision Material and methods Starting from 2000 to 2008, 10 out of 191 patients who underwent hip prosthesis revision for acetabular component loosening presented with intrapelvic migration of the acetabular cup. The study group included 9 women and 1 man and the mean age was 64 years old (range 29-82 years). The migrated component was a primary implanted cup in 5 cases and a revision cup in 5 cases. The acetabular bone defect was grade IV in 8 cases and III in 2 cases according to the GIR classification. In 5 cases an inguinal approach has been used to identify and protect the intrapelvic neurovascular iliac axis before acetabular cup removal and implant revision. In 8 cases the acetabular reconstruction was performed with reconstructive rings (6 Burch-Schneider, 1 Ganz, 1 Mueller) and morcellised bone allograft. In 1 case we used a stemmed acetabular cup (McMinn) and morcellised bone allograft. In 1 case with massive hemipelvic bone defect the reconstruction has been performed in two stages by means of a structural acetabular bone allograft and a constrained cemented cup. Clinical results have been evaluated with the Merle d'Aubigné hip score. Results The patients underwent periodical controls and the mean time of follow-up was 4.5 years (range 1-8 years). In 9 out of 10 acetabular implants the cup was stable and the radiographs did not show signs of bone graft failure. One patient sustained successfully a revision with a constrained acetabular cup for recurrent hip dislocation. A periprosthetic infection (E. Coli) was observed in 1 patient with rheumatoid arthritis and treated with early debridement and prolonged antibiotic therapy. As for functional results, 5 patients walked with crutch and 5 without support. A light or moderate residual pain was present in 2 patients and severe pain was never reported. Discussion Before hip revision for intrapelvic dislocation of the prosthetic cup every patient should be carefully investigated in order to select the most appropriate surgical treatment. The additional inguinal approach is required when preoperative studies show the loosened cup in proximity to the neuro-vascular iliac and femoral axis. In most patients the acetabular reconstruction can be performed with reconstructive rings which by-pass the bone defect and protect bone graft allowing the insertion of cemented polyethylene cups.

HIP ARTHROPLASTY REVISION 2
Reconstruction of periprosthetic acetabular bone loss with Burch-Schneider Anti-Protrusio Cage and massive allografts A. Sandri, D. Regis, P. Bartolozzi Istituto di Clinica Ortopedica e Traumatologica, Università di Verona (Verona, IT) Objective Filling acetabular bone defects with structural allografts resulted in early failure because of the resorption of the graft. The application in combination with reinforcement devices already provided successful midterm outcomes [1,2]. Long-term results in the reconstructive treatment of acetabular osteolysis using massive allografts supported with a Burch-Schneider Anti-Protrusio Cage (APC) are reported. Material and methods From January 1992 to December 1998, 98 total hip replacements (THR) underwent acetabular revision with use of APC. Thirty-five patients (2 bilateral implants) died for unrelated causes, with a well-functioning THR in situ. The group under examination consisted of 61 hips in 60 patients, 18 males and 42 females, aged from 29 to 83 years (median, 61 years). Bone loss included types IIIA (26 cases) and IIIB (35 cases) according to Paprosky classification. Surgical procedure included filling periprosthetic bone defects with massive allografts supported with a Burch-Schneider APC. A polyethylene socket was cemented into the metal cage. Ambulation was allowed 1 week after surgery, but weight bearing was delayed 2 months. Average follow-up was 12.9 years (range 10-17.9 years). Clinical assessment was performed using Harris Hip Score (HHS). X-ray examination evaluated the signs of instability of the cage and the progression of the bone graft. Failures were considered revision of the acetabular component for any cause, migration or loosening of the acetabular construct, and severe resorption of bone graft. Results Two patients underwent resection-arthroplasty for deep infection. In 11 cases, an extensive resorption of bone graft was followed by loosening of the acetabular cage, requiring re-revision in 6. The breakage of the socket occurred in 2 hips, related to a marked wear of the polyethylene cup, and 1 of them already was operated on using the same procedure. X-ray signs of graft incorporation were observed in 46 hips. Average HHS increased from 34 points preoperatively to 77 points at the time of follow-up. The cumulative survival rate of the acetabular construct was 75.4% at an average of 12.9 years. Discussion In massive acetabular bone loss, the application of reinforcement devices combined with structural allografts has been advocated in order to prevent early bone graft resorption and cup loosening. Burch-Schneider APC proved out to protect the graft spanning the defects and promoting augmentation of periprosthetic bone stock [3]. Conclusions The use of APC and massive allografts resulted an effective procedure in the long-term reconstructive treatment of severe acetabular bone deficiencies. Outcome of isolated acetabular revisions in total hip arthroplasty Introduction The acetabular component of a total hip arthroplasty has a higher rate of early aseptic loosening than the femoral component in the survivorship curve of hip replacement registries. With a well fixed femoral stem the indication for isolated revision of the loose acetabular component is controversial: retention of femoral stem leads to a tissue sparing surgery for bone and soft tissues and may be beneficial for survival of the whole implant; on the other hand it can create problems in the correct exposure of acetabulum and in restoring correct hip offset. The purpose of this study is to report mid-term results of isolated revisions of acetabular component in total hip arthroplasty and to analyse the fate of the unrevised femoral stem.
Material and methods Thirty patients who underwent isolated revision acetabuloplasty without removal of a well-fixed femoral component between 1997 and 2002 were evaluated prospectively. Patients mean age was 70.6 years. The loosed acetabular components were in 12 cases cemented and in 18 cases cementless. Out of 30 femoral components, 13 were cemented and 17 were cementless. All femoral components had a modular femoral head with a morse taper. In 16 cases the acetabular reconstruction was made with reinforcement ring and cemented polyethylene cup. In 14 cases a cementless oblong cup was implanted. For filling bone defects morselized allograft was used in 20 cases. The average duration of follow-up from the index revision was 8.5 years (min 6, max 11 years). Results Postoperative complications were: one case of dislocation and one case of femoral nerve palsy. Clinical results with Harris Hip Score were satisfactory in 65% of patients with a improvement from a mean of 46 points before the revision to a mean of 90.4 points at 1 year follow-up. Acetabular components were judged radiographically stable in 26 cases and in 4 cases of reinforcement ring (13%) we classified as probable loosened because of the presence of progressive lines. At the last follow-up seventeen (100%) of the primary cementless femoral components were judged stable. Four of the 13 cemented femoral stems showed developing radiolucent lines at the bone-cement interface.
Conclusions The data obtained by the present study show good midterm results of isolated acetabular revision in cases with loose acetabular components and well fixed femoral component. The femoral components can be retained without adversely affecting the acetabular exposure and reconstruction surgery. Isolated revision of the acetabulum is a surgical technique particularly useful in elderly patients because of a reduced operation time and limited blood loss.

Prevention of luxation in THA with dual mobility cups. A 18-year follow-up
Objective The aim of this study is to communicate the results in prevent luxation in THA in enderly, neuromuscular diseases, etc. with dual mobility cups. The concept of dual articolation was proposed by Prof. Gilles Bousquet in France in 1976. The rationale is to increase joint stability while reducing component wear. The implant consist of a metal shell with a mobile polyethilene acetabular liner (first articulation) and the femoral head is captive in the liner (second articolation). This implant gives high stability minimize loosening forces with high range of motion. This acetabular cup system high force for dislocation of the cup and luxation is very exceptional. Implants -hip, knee, shoulder -in our region). Therefore the data are quite serious and perfectly controlled junction with the DRG system from the regional and Italian national health system. These data are controlled and cannot be altered and we want to communicate the results of the survival of these prostheses. Thus we have data that document the survival of 228 cups inserted from 2001 to 2008. The cups removed are four on 228 implants: 1 for fracture of the bottom cup and 3 for aseptic loosening with a survival rate of 8 years equal to 98.6 percent above the regional average for other cups which equal to 97.5%. The best result is due to the fact that we have never had to remove the cups for recurrent dislocations. Only three cups were replaced for aseptic loosening and this is a good performance at 8 years and the low rate of loosening replacements in this series shows a low production of polyethylene debris, a sign that double articulation reduces debris. Discussion and conclusions We wish to communicate this positive experience that we believe is particularly good in luxation prevention in arthrosis and fracture of neck femur in elderly patients with neuromuscular disorders or lack of cooperation due to dementia or other degenerative neurological diseases. Objective Fatigue fracture of the femoral component of total hip arthroplasty is a rare complication [1]. The reported incidence of stem fractures range from 0.23 to 11% [2]. Microstructural analysis after removal of these implants are reported in a few papers. This study aims to investigate metallurgical factors that lead to two different mechanical failure of cemented revision femoral stem in hip arthroplasty.

Material and methods
Material and methods Two cemented revision femoral stems after two different mechanical failure, fatigue fracture and bending deformation, were referred to the Department of Chemistry of the Politecnico of Milan for investigation. Each component was examined macroscopically to assess for mechanical damage. Stereomicroscopy, SEM, spectrometry and microhardness tests were performed.
Results Large grain size, above 100 micron of diameter, and less microhardness tests were found in stem with the bendig deformation due to a low rate of annealing of the steel. Uniform and fine grain size was found in the stem with the fatigue fracture, but this stem had a small diameter that caused the rupture.
Discussion Several factors are involved in failure of the femoral stem in hip arthroplasty. Our results suggest that the types of failure of the stem are related to the microstructural features of the steel besides the diameter of the stem. The bending deformation in particular was due to a low rate of annealing of the steel.
Conclusions In hip revision surgery, the femoral component of the prosthesis is always subjected to high stress of load due to anatomical situation of the femur so therefore microstructural features of the implants should be warrant a greater safety margin and allow a longer survival. Main challenges of septic hip prosthesis revision are: 1. Bone loss 2. High dislocation risk 3. Infection recurrence 4. Implant long term fixation In the last years every one of these problems has been addressed and solutions proposed. In our practice, the following options have shown to improve the results: 1. Bone loss may be efficiently overcome, at the femoral level, through the use of long stem preformed antibiotic-loaded interval spacers and, at revision, through long stem, modular non cemented prosthesis, with or without bone grafts and growth factors (platelet rich plasma); bone loss in the acetabulum requires the knowledge and availability of revision prosthesis for large bone defects reconstruction. 2. Dislocation risk may be effectively reduced by the use of modular stems, that allow intra-operative choice of the offset, and by using large diameter femoral balls; 3. Overall infection recurrence may be reduced to less than 5%, through accurate two-stage revision surgery and targeted antibiotic treatment. However, compromise hosts still present a high risk of infection recurrence. All of the patient with infection recurrence, in our experience, were B-hosts. Changing B-host to A-host will be the work of the next decades. At the moment host's type represent the strongest factor for infection recurrence. 4. Implant long term fixation with uncemented prosthesis is remarkable good, in our experience, with only aseptic femoral loosening in 130 patients at a follow-up ranging from 1 to 8 years. In conclusion, septic hip revision surgery still represents a major challenge for the orthopaedic surgeon and the patients. New technological advances and better knowledge of the failure risk factors allowed to significantly improve our result in the last decade. However costs associated with this difficult surgery are elevated and higher than those calculated for aseptic revision procedures, while reimbursement of the Italian heath care system remain the same for septic and aseptic procedures. This condition may induce care providers to reduce the offer of the highest standard solutions today available to these unfortunate patients.

References
Preliminary report on the use of modular resection femoral stem in the revision of infected hip prosthesis with large femoral bone defect Introduction In case of massive bone defect, femoral stem revision may cause significant problems to the orthopaedic surgeons. The periprosthetic infection introduces a further element of complication which often leads to complex surgical strategies. The aim of this study was to assess the preliminary results of femoral revision with modular resection femoral stems in a selected group of patients with infected total hip arthroplasty and extensive bone defect (Paprosky grade III-B). Material and methods The study group included five patients (three women, two men) with an average age of 72 year-old (range 62-81 years). From 2006 to 2008 the patients underwent a prosthetic femoral revision with resection modular stems to treat a septic loosened primary hip prosthesis (one case) or revision hip prosthesis (four cases). The bacteria responsible for the infection were Meticillin Resistant Staphylococcus epidermidis (MRSE) in three cases, Meticillin Sensible Staphylococcus epidermidis (MSSE) and Streptococcus Agalactie in one case, Proteus Mirabilis in one case. Three patients were treated in election for septic loosening of hip implant and two were admitted in our Department as emergency for a periproshtetic femoral fracture (Duncan type B3). In all the patients the femoral bone defect was grade III-B according to Paprosky classification of femoral bone deficiency. One patient with periproshtetic femoral fracture underwent a one-stage prosthetic revision and four patients sustained a two-stage prosthetic revision. In one patient a local flap was performed and Vacuum Assisted Therapy was applied in order to treat an associated loss of substance. The patients underwent periodical clinical controls in which the result has been evaluated by means of Merle-d'Aubigné hip score. Results The follow-up period ranged from 10 to 28 months. We observed one case of recurrence of infection in the patient treated with a one-stage revision. At present, we did not observe signs of infection in the remaining four patients who underwent a two-stage revision. As for functional result, four patients walked with supports and one without them. No patient referred moderate or severe residual pain. One patient sustained with success a revision with application of a constrained acetabular cup because of a recurrent dislocation of the previously revised hip implant. Discussion and conclusions The preservation of bone stock is one of the most important goals in prosthetic revision procedures. In some circumstances the amount of femoral bone loss can be so wide to prevent the application of conventional or modular uncemented femoral stems. In these selected cases cemented modular resection femoral stems may represent the only available option for femoral reconstruction. In our clinical experience this solution offered altogether successful outcomes. In our opinion two-stage revision is the preferable surgical choice.
Two-stage reimplantation for knee peri-prosthetic infections. Use of articulated spacers Introduction Infection is one of the most devastating complications in total knee replacement. Treatment of a patient with periprosthetic knee infection requires often costly and prolonged hospital stays, weeks or months of antibiotic therapy, and multiple surgical procedures. Despite the use of systemic antibiotic prophylaxis, strict hygienic protocols, and special sterile enclosure with laminar flow, the infection rate in primary total knee replacement is between 1 and 3% [1]. The optimal outcome of the knee periprosthetic infection treatment, is represented by restoration of a painless and well functioning joint, and eradication of the infection. Use of spacers The first stage involves irrigation and debridement of all necrotic and infected tissues, complete synovectomy, and removal of all components and cement. Intraoperative cultures have to be performed from synovial fluid and membrane, and at polyethylene-implant, cement-implant and bone-cement interfaces. Successively, an impregnated-antibiotic cement spacer is positioned into joint. Articulated spacers The impregnated-antibiotic cement spacers allow to maintain joint space and keep the collateral ligaments from becoming contracted. Moreover, the cement spacers deliver high-dose local antibiotics to the knee in concentrations greater than could be achieved with intravenous administration. Articulated spacers allow both weight bearing and motion during the antibiotic therapy, so avoiding stiffness of the knee and osteopenia, without compromising the eradication of infection. The reimplantation procedure is facilitated by decreased quadriceps scarring, maintenance of collateral ligament integrity, and preserved bone stock [2]. Revision In general, intravenous antibiotics, appropriate to the infecting organisms, are administered for 6-12 weeks, followed by a second stage implantation of a permanent revision prosthesis fixed with antibiotic-impregnated cement. It is widely recognized that knee revisions represent more complex procedures than primary replacement, with less successful results and a higher rate of complications [3]. Conclusions This strategy of using antibiotic-impregnated cement spacers and intravenous antibiotics with delayed exchange arthroplasty, has been considered state-of-the-art in cases of infected total knee replacement and has reported success rates of 88-96% in eradicating infection [2].  Objective Many current total knee implants derive from two principal categories: anatomic and conforming design; in either the choice between cemented and press-fit is controversial. The clinical results with one design can not be readily extrapolated to a different design. Thus, we performed this prospective randomised study in order to compare in the same prosthetic design the clinical-radiographic results at a follow-up of 4 years of a cemented versus a press-fit total knee arthroplasty (GKS Prime Ò system, Permedica, Merate, Como, Italy).
Material and methods One hundred consecutive osteoarthrosis with varus knee which should be replaced using total knee arthroplasty (36 men, mean age 68.2; 64 women, mean age 70.1) and were randomised into two groups: (A) completely cemented (46 knees) and (B) completely press-fit (54 knees). They were well matched and no patient was lost during follow-up. All the operations were performed by three surgical equipe from 2000 to 2004. Clinical and radiographical evaluation was performed by Knee Society Score (KSS), TKA Scoring System, pre-operatively and at 6, 24, 48 months of follow-up. Visual Analogical Score (VAS) and patient satisfaction (expressed in 5 levels) were also considered at 12 and 48 month. Statistical analysis was performed by Student t test for unpaired data.
Results No case of infection was observed. Relief from pain, correction of deformity, stability and function were comparable in both groups: KSS was 92 (84-100) in group A and 95 (88-100) in group B; this difference was not statistically significative (p [ 0.05). The mean of knee flexion was 116°in either group. The mean of level of satisfaction was 3.8 in either group. Some radiolucencies were observed at the tibial medial site in 1, 2, 3 and 5 zones (by TKA Scoring System), 8% of cases in group A, but none was awaiting revision for loosening at 4 years follow-up.
Conclusions By clinical and radiographic results, we cannot support a clear advantage between the cemented or press-fit in our protesic model at 4 years of follow-up. The great satisfaction and knee flexion of patients lead us to prefer this model (rotating platform) of artroprotesis in varus knee with osteoarthrosis, but it is indifferent to use cemented or porotic surface with hydroxyapatite (press-fit), by results of the short follow-up. Up to date a study with a longer follow-up is performed to define wear and mobilisation of prosthetic components in the same patients.
Retained versus resected posterior cruciate ligament in total knee arthroplasty: a prospective randomised study Revision total knee arthroplasty presents several complex challenges to the adult reconstructive surgeon, including management of bone loss and ligamentous insufficiency. Bone loss patterns can be anatomically categorized and the surgical treatment can be algorithmically approached based on the bone loss pattern. Bone loss is managed usually with bone grafts and prosthetic augmentation. The options for repairing bone deficiency include cement fill with the support of screws, implants with modular augments, custom components, structural allograft, impaction grafting and metallic augments as trabecular metal. Structural allograft and impaction grafting are reproducible methods for managing the tibial bone loss. Intramedullary stems in revision cases are necessary to offload the excessive stress on the distal femur and proximal tibia to diaphyseal bone. Moreover, stems increase the surface area for implant fixation and help ensure restoration of optimal implant alignment.
Computer assisted revision of failed UKR Introduction Computer assisted surgery has been developed to help surgeon in reconstructive procedure in improving implants alignment and performances and in literature it has been different already demonstrated its efficacy in traditionally knee replacement surgery. Nevertheless very few studies have analysed its results in revision of failed TKR and none of failed UKR. The Authors reviewed their experience in using computer assisted surgery in revision of failed UKR. They hypothesized that navigation helps in preserving both bone stock and soft tissues in a real tissue sparing surgery with less invasive implants and lower costs.
Material and methods Among 603 computer assisted knee replacements performed since 1999, 42 cases were revisions of UKR for aseptic failures. The reason of failure were: uncorrect indications, implant failures, uncorrect surgical techniques and unexplainable painful implants. In all the cases intra-operatively a CT-free computer assisted navigation system was used to address the bone cuts, soft tissue balancing implants and limb alignment. The Authors matched 16 patients according to diagnosis and grade of bone loss to a similar group performed using a conventional technique to point out any significant difference in implants used, surgical time, limb alignment, restoration of the joint line and hospital costs.
Results This matched-paired study demonstrated a different implant distribution with an higher percentage of PS and CCK implants in the conventional group. Likewise the adoption of augmentations, stems and offsets was clearly more frequent in the conventional group. There were no statistical differences in the post-operative mechanical axis but with a significant lower number of outliers in the computer assisted group. Between the 2 groups there were no statistical differences in surgical time and hospital staying. There was a statistical significant difference in blood transfusion for each patient with a higher rate in the conventional group. The cost analysis demonstrated an higher cost (about 300 euros more) in the conventional UKR revision group Conclusions In this study the Authors demonstrated better aligned implants, lower use of ''invasive'' implants with no constrained implant and blood savings using navigation to assist revision of failed UKR. The costs were cheaper using a computer assisted techniques. These results underline how computer assisted surgery helps the surgeon in overcome the difficulties using traditional alignment systems in high demanding cases. Improved results can also overcome higher costs cause of systems purchasing. Total knee arthroplasty in haemophiliac arthropathy has been shown to be effective in reducing both pain and tendency to bleed, resulting in a dramatically improvement of function and quality of life in this group of patients. The use of a new-generation implant, advanced and more aggressive hematological care, combined with the decline of HIV epidemic has resulted in a lower rate of complications and better functional results.

Knee revision in haemophilia
It is undisputed nowadays that haemophiliac arthropathy could requires a modular total knee implant with stems, wedges and augmentations to address all the bony abnormalities. Revision implants are required as primary implants in case of bone loss, risk of instability, severe muscle atrophy and chronic dysfunction of the extensor mechanism. However the use of hinged knee prosthesis as primary implant is not always necessary, especially in young patients like haemophiliac patients and the use of cemented stems must be avoided whenever possible. The major complications are infection, restricted range of motion and cutaneous problems. Revision procedure in these patients is a technically demanding procedure due to bone loss, altered anatomy, soft tissue fibrosis and flexion contracture. The causes of revision are mainly severe osteolysis and septic loosening. Where severe osteolysis happens we used mesenchymal stem cells coupled with biological scaffolds which guide the cells during repair and regeneration of the tissue. To enhance bone repair and osteointegration of the implants This technique results in the filling of bone defects and secondary stability of the implants. The clinical result is good especially in young patient who probably will need further surgery. Infection of total knee replacement is considered a devastating complication especially in haemophiliac patient. In this case we recently performed the one stage revision using cancellous allograft bone impregnated with antibiotics. We addressed osseous defect in this case with allograft bone impregnated with high levels of antibiotics and it act as a carrier providing to sustained high local concentration. The high cost of the prophylactic treatment with bolus infusion of concentrates in haemophiliac patients and the good clinical result of this procedure justify our choice. Introduction Revising a total knee replacement (TKR) is a challenging surgery considering the lack of bone stock, ligamentous instability, stiffness and tissues necrosis.
Methods Clinical data on 17 revision surgeries (10 deep infections, 7 aseptic loosenings) performed at a single Centre in 15 patients with haemophilia A or B (3 with inhibitors) were reviewed. The Hospital for Special Surgery knee-rating score (HSS), data on knee flexion contracture and range of motion were collected before, after surgery and during a short-mid-term follow-up.
Results The median duration of follow-up for revision surgery is 35 months (range: 14-140). One patient died 15 months after surgery for causes unrelated to TKR. The two-stages exchange technique was used in all cases of deep infections. In 4 cases a total knee replacement had been reimplanted, in 3 cases an arthrodesis was performed. For the persistence of infection, 3 cases needed resection arthroplasty. Three deep infections and 1 aseptic loosening of the revised implant occurred after a median of 18 and 84 months, respectively. In all these cases a re-revision was performed.
Conclusions Our results show that knee revision arthroplasty is often complicated with infections. The higher risk of post-surgical infection in haemophiliacs could be correlated to the prolonged post-operative bleeding and the presence of chronic infections.

SESSION 1
The fracture-dislocations of the elbow: articular reconstruction and stabilization with external fixator Objective This work wish to demonstrate that the treatment of fracturedislocations of the elbow should achieve 2 objectives: adequate stability and early mobilization to prevent stiffness. Latest medical literature recognizes three types of instability: postero-lateral rotatory instability, postero-medial and posterior direct. In this report we study the different types of instability with its lesion models, anatomical details, diagnosis e imaging diagnosis indications and type of surgical treatment.
Material and methods From January 2006 to January 2009 we treated 14 cases of fracture-dislocation of the elbow. A combination of different techniques were used, such as the radial head prosthesis, reconstruction of coronoid process with anchors and/or screws, ligaments reconstruction or sutures, olecranum ORIF and external fixation.

Results
The results were generally satisfactory, in 11 cases we obtained higher or similar ROM like Morrey functional arc, in 1 case there was a sufficient recovery ROM with just few degrees under Morrey functional arc, in 1 case there was an important stiffness, while in 1 case there was a failure with residual postero-lateral rotatory instability along with subanchilotic stiffness.
Discussion Because of the recent increase in road traumas, fracture dislocation of the elbow are observed with greater frequency. The fracture-dislocation of the elbow injuries are extremely complex; the results are often unsatisfactory and the treatment is difficult. It is important to identify the damaged structures and rebuild them in precise sequence, which varies depending on the type of instability using various surgical technics.
Conclusions Clinical and imaging investigation is fundamental in order to have a right surgical planning. The clinical examination must be improved on an accurate imaging investigation: it should be welltyped the lesion and the type of instability, to plan the adequate reconstruction of the primary stabilizing. The clinical examination should be performed even in narcosis to understand the direction of residual instability. The X-ray standard, performed before and after the reduction, must often be supplemented by CT. At the end of the treatment, range of motion of joints, although not complete, it must be at least within a defined functional arc that allows the performance of normal daily activities, and identified by Morrey in 30°-130°of flexion-extension and 50°-50°to prone-supination. We operated 16 patients, 10 with fractures of the tibial plateau and 6 with fractures of the lower tibia. All the fractures were pluri-fragmentary and in many cases there were lesions of the soft tissues. In all the cases we applied hybrid external fixation, formed by a semicircular ring with 3 or 4 Kirschner wires plus pins with single-axial fixation, sometimes associated with a synthesis with trans-cutaneous screws. In a case of lower tibia, we used a device with 2 semi-circles of which the upper one had pins. We allowed early joint mobilization and total loading was allowed after 50-60 days. The fractures healed and the fixation devices were removed on average between 5 and 10 months. Fracture reduction and the reconstruction of the joint surface were excellent in 10 cases, good in 4 and fair in 3. In 4 cases the results were unsatisfactory because of the onset of complications: in one case there was an infection; one patient with rheumatoid arthritis suffered another fracture after the fixation device was removed; in one patient there was a delay in consolidation (the device was removed after 10 months and there was a new fracture with varus deviation and so we had to resort to further corrective surgery and a synthesis with a plate; finally, in another patient in dialysis with severe kidney problems, who had an exposed fracture, there was a delay in consolidation. . For pre-operative evaluation ankle and leg anteriorposterior and lateral view X-ray was performed as well as in many cases a CT with tridimensional reconstruction. All the patients included in this study underwent a unique and definitive treatment using percutaneous distal tibial LCP plates with limited incision reduction. This treatment was in some cases combined with initial fibula fixation, which aided in re-establishing length and alignment. The time of fixation was 5-12 days from injury. Clinical outcomes were evaluated according to the AOFAS score, time to union and ROM. Ankle and leg anterior-posterior and lateral view X-ray was performed at 4 weeks, 6 months and 12 months postoperatively and at the last follow-up. Results All the fractures united without cases of primary malpositioning or secondary loss of reduction. Union was achieved completely in all patients. The union time average was 23 weeks. AOFAS average value was 91 ± 10.6 points out at final follow-up with a good range of motion (the final ankle dorsal flexion average value was 13°and the plantar flexion average value was 38°). Ankle and leg anterior-posterior and lateral view X-ray was performed at 4 weeks, 3, 6 months and 12 months postoperatively and at the last follow-up Discussion Treatment of fractures of the distal tibial is challenging. This type of plates provide greater angular stability, better biomechanical properties and the limited incision reduction and the percutaneous technique reduced the risk of soft tissue complications. Due to these advantages, early post operatively rehabilitation is possible with an improvement of functional outcome. No intraoperative or postoperative complication occurred. One patient died in 7th postoperative day. All patients were allowed full weight bearing on the affected extremity 3-10 postoperative days. Clinic and radiographic healing occurred after about 3 months (10-14 weeks). At radiographic evaluation neither loss of reduction, nor femur neck collapse, pseudoarthrosis, failure of the implant was found. All patients were able to perform activities of daily living. At 12 months follow-up functional levels were examined with the Bartel Index. The antegrade intertrochanteric nail Trigen Intertan for lateral femoral neck fractures treatment provided good results in the present series. It supplies rotational stability and maintenance of compression at the fracture site, thus reducing pseudoarthrosis and loss of reduction development. Furthermore this nail gives a clinic-radiographic fracture healing, a good functional recovery and a lower incidence of complications. This device is particularly performing in those patients whose comorbidities prevent them from more invasive surgical treatments.

SESSION 2
Treatment of subtrocanteric fracture with LISS or LCP DF ''reverse'' Percutaneous trans-ileo-sacral screws in the unstable pelvic injuries Total unstable pelvic injuries are caused by major trauma. Therefore, patients who are injured often involved in other districts or bodies. The stabilization and treatment of the sick is the result of a work team involving several specialists. Orthopedic surgeon's task is to ensure the stabilization of the skeleton. Total unstable pelvic injuries characterized by the break of the complex joint and ligament sacro-iliac back, require, like other segments, the stabilization in emergency.
There are various way available: the simple restraints, traction, the C-clamp, the external fixation, orif. The percutaneous trans-ileus-sacral-screws is a technique to stabilize mini-invasive surgery of the sacro-iliac dislocations and sacral fractures. It is not easy to carry, especially in obese subjects, anatomical variations in the sacrum (sacralization fifth lumbar vertebra) and in the hands of the not experienced surgeon. The technique in fact provides for the introduction of one or two screws directed into the body of S1, driving under x-ray in the three projections of Pennal. The main difficulty lies in finding the only corridor available for their bone smooth harm adjacent structures: the cauda equina in the sacral canal, the root L5 laterally to the sacral promontory, the root of S1 output from the first sacral foramen. Our survey includes 18 cases of percutaneous screwing together or not at the symphysis stabilization or reinforcement plate back to the sacrum.
Four were executed in association with external fixation in emergency room. The results show a consolidation 12 cases, 4 cases have still pain in the posterior sacro-iliac region, 2 cases are of recent performance and show no major problems so far. Of the 4 cases with pain, two had other associated injuries consisting of acetabular and iliac fractures and two are being studied to assess the residual stability of the complex sacro-iliac rear. We believe this is a relatively quick and non invasive method, which allows early verticalisation and particularly allow a final stabilization of those injuries that otherwise treated, would encounter a pseudoarthrosis or chronic instability Discussion The increase of the tibial plate pseudoarthrosis incidence, as shown in our casuistry, is probably also due to technical-diagnostic reasons. It was only in the last decade that the topographic studies and the 3D reconstructions enabled to describe this pathology more precisely. The essential requirements for the treatment of the tibial plate pseudoarthrosis are the same as for all the articular fractures. In the pseudoarthrosis there must be a stable and anatomical fragment synthesis, in order to grant joint motion as soon as possible, and to minimize the cartilaginous degeneration. The reduction also avoids the penetration of the sinovial fluid in the cancellous bone, that would hinder the consolidation by scattering the ossification factors. Therefore an insufficient reduction exposes the patient to a recurrence, even if it is associated to a bone graft. Conclusions In the context of an articular multifragmentary fracture, an early identification of a portion of the tibial plateau in nonunion, can be effected through a radiographic examination and CT. The interested region is the posteromedial one. The surgical intervention of revision of the synthesis allows to restore the articular morphology, the functional recovery and it avoids the rapid degeneration of the articulation. Results All fractures but one healed within 6 months. One bifocal fracture did not unite (SIRUS) and needed a second operation to heal. There were 3 iatrogenic fractures of the great trochanter (LPFN) that needed no further intervention. In 3 cases (LPFN) the longest nail available failed to control a short distal fragment leading to malalignment in one case and needing an antirotational plate in the other two.
Conclusions The use of trochanteric nails is a valid and safe option for the treatment of femoral shaft fractures. We believe that the use of nails specifically designed for the purpose can help the surgeon to minimise the complications especially when dealing with distal fractures.  We have performed seven implants, three on patients with primary arthrosis, and four cases on post-traumatic arthrosis. The mean age is 56 years (min 44, max 73). The weight bearing as been promptly allowed with a cast and crouches until the 60th day. The active articular recovery has begun after the 15th day.
Results All patient experienced an immediate relieve from pain and were able to walk freely within 2 months from surgery. The radiographic evaluation criteria for the correct positioning of the prosthesis are: AP varus 3°max; valgus 7°max; in the lateral view the tibial axis must match the talar axis. Complications can arise from the skin, the malleolus (fracture), infections, the mobilization of the prosthesis (subsidence, osteolysis). After about one year from the surgery, the AOFAS average score was 80. In two cases a modest suffering of the skin occurred, and in one case the malleolus fractured. Discussion and conclusions The need to perform limited thickness cuts on the talar dome limits the prosthesis indication only in cases of non advanced degeneration, and with an adequate bone stock. Therefore, in spite of the usual indications, the total ankle arthroplasty with a covering prosthesis and bone saving, shall be performed early. The femoral neck fracture in the elderly is considered as the most important complication of osteoporosis. With the progressive increase in the life expectancy of the population there is consequently an exponential increment of this fracture. It has been decided to formulate a metabolic study on elderly patients affected by femoral neck fracture in order to evaluate the presence of specific alterations of the mineral metabolism and the bone remodelling that characterize this population. Firstly, we studied 142 subjects recovered in our Department of Orthopaedics and Traumatology with a diagnosis of femoral neck fracture; the metabolic profile has been studied for all the patients with the evaluation of the mineral metabolism and bone remodelling. The results demonstrated that in patients affected by femoral neck fracture it is frequently observed a secondary hyperparathyroidsm complicated by vitamin D deficiency that leads to the activation of bone remodelling with a prevalent osteoclastic activity. We have defined this specific alteration as bone metabolic disease in the elderly with femoral neck fracture. Secondly, considering the absence of significant correlation between the serum levels of PTH with both vitamin D and ionized calcium-a discrepancy that could be explained by the hypothesis proposed by Fisher and Davis (Ostoporosis Int 2007) by an alteration of the ''Calcium-sensing receptor''-the PTH suppression test was performed on a selected group of 10 patients. Two subgroups of 5 patients each, according to serum levels of calcium and vitamin D, were selected; the results showed that there was an altered PTH serum levels response to the increase of calcium serum levels due to intravenous calcium infusion, in both subgroups, during the experimentation time. Hence, it was possible to conclude the increase in the PTH levels in the elderly patients affected by femoral neck fracture cannot be simply explained by the low serum level of vitamin D and ionised calcium alone, hence we recommend the consideration of an aspecific alteration of the Calcium-sensing receptor. This study could have an important application in clinical field in both the prevention and the treatment of femoral neck fractures in the elderly. We propose that the combined treatment with vitamin D and antiosteoclastic drugs should be considered as the ideal pharmacological treatment for the prevention of femoral neck fracture in the elderly. Arthroscopy is a support for the achievement of these goals and enables to view directly the reduction and stabilization of the articular surface without the need for a arthrotomy, removal of hematoma and osteochondral debris, diagnosis and treatment of meniscal and ligament injuries. Between January 2005 and November 2008 were treated with arthroscopic reduction and internal fixation (ARIF) 11 fractures of the tibial plateau. The technique we used is that described by Caspari, wich allow all operators to achieve accurately the site of fracture with a bone tunnel and introducing a special batter. By arthroscopic view is possible to check the correct reduction and treat associated injuries. For the synthesis we used one or more cannulated screws and to reach greater stability we used synthetic bone. Mobilization began in the early postoperative period, while the load bearing was granted in 2 months. All patients were clinically and radiographically evaluated according to the Rasmussen criteria. 8 patients had a type III Schatzker fracture, 2 fracture type II and 1 type I. The medium follow-up was 22 months (range 6-32 months). From a clinical point of view 7 patients achieved an excellent result and 4 good results. The clinical outcome did not show any correlation with the type of fracture, but it appears to be influenced by the presence of associated injuries: 2 lesions of the external meniscus was treated with meniscectomy, 2 lesions of the LCA (one patient is waiting for intervention of reconstruction) and 3 chondral injuries. All cases reached very good results from radiographic point of view. Arthroscopy could be an important option for treatment of tibial plateau fractures. Although in medical literature its use in every type of fracture is advocated, we reserve the ARIF technique only to type 1, 2 and 3 of Schatzker classification fracture where traditional arthrotomy requires longer time of recovery and doesn't permit the assessment of associated meniscal, ligament and condral injuries. In 1974 Biga e Thomine described a particular lesion called trans-olecranon fracture dislocation, in which failure of the ulno-humeral articulation occurs through the olecranon with the forearm dislocated anteriorly. However, none of these classifications appears complete and consistently has a therapeutic and prognostic value. Moreover, the absence of a comprehensive classification makes it difficult to compare clinical results and propose therapeutic protocols. The purpose of this study was to design a comprehensive classification for complex fracture-dislocations of the proximal ulna and radius. It can be a guide for surgeon in the operative management in order to improve the results of treatment of these complex injuries. This classification was designed by considering the recent progress either in the functional anatomy of the elbow and in the diagnostic imaging (particularly 3D CT-scan).
The new classification distinguishes specific pathoanatomic lesions able to influence the surgical treatment and prognosis. They are: (1) the site of ulnar fracture in respect of collateral ligaments insertion and possible coronoid fracture; (2) severity of damage of the joint capsule and ligaments; (3) radio-humeral or ulno-humeral dislocation; (4) proximal radio-ulnar dislocation; (5) radial fracture; (6) distal radio-ulnar joint\interosseous membrane lesion.
The classification is based on an alphanumeric code. The numbers from 1 to 6 identify the Type of ulnar fracture. The letters A-D identify joints dislocation, soft tissue lesions and radius fracture, namely: (AI-AII) radio-humeral joint lesion associated with olecranon fracture; (BI-III) radio-humeral and proximal radio-ulnar joint lesion; (CI-III) radius fracture; (D) distal radio-ulnar joint\interosseus membrane lesion. The symbol (+) identifies ulno-humeral dislocation. The aim of the management and the type of surgery stems automatically from the classification of the injury with a certain number and alphabetical letter.
In conclusion, we conceived a new validated classification which has a therapeutic and prognostic value.

SESSION 5
Minimally invasive surgery in humeral shaft fractures. Recently the mini-invasive technique has been involved in all the fields of the orthopaedic surgery. For minimum-invasive surgery (or MIS) we mean a surgical procedure with reduced soft tissues incision than the traditional one. We analysed 95 patients treated by MIS technique during all 2008 in our Unit. The involving criteria of the study were: the area of fracture, the time passed from the trauma, the way of the traumatic event. During the post-operative and rehabilitation period, the considered parameters were: the degree of pain to the immediate assisted passive mobilisation after surgery, the income of infection, the loss of the primary reduction, the delay of consolidation (or pseudoarthrosis), the income of functional limitation after the surgical treatment. We used the Trigen nail (smith and nephew) for the intramedullary nailing and plates LCP (Synthes) for the osteosynthesis, using them both as single internal foxator, and as an hybrid-type assembly (associating the use of angular screws fixed to the plate onto that one of free screws). As concerning intramedullary nailing, new instruments gave us the possibility to remarkably reduce the size of the skin access not reducing the surgical precision.
In osteosynthesis with plates we replaced, when possible, the traditional technique AO (core fracture opening and internal reduction-Open Reduction and Internal Fixation) with new miniinvasive techniques named Minimally Invasive Plate Osteosynthesis (MIPO). In intramedullary nailing is extremely important the use of new dedicated and specific instruments while, on the other side, in the MIPO technique the point is the new osteosynthesis concept: new plates, for philosophical and biomechanical principles, are more similar to an external fixator than to traditional plates. The external fixators have the advantage to be closer to the bone surface (the screws fixed to the plate, like the fiches of a fixator, are shorter) and therefore they are able to create a stabler plate-bone system, even after surgery. Above all the older patients take benefit using mini invasive technique to fix bone fractures typical of their age: in particular we found best results in fractures treated with internal fixation plates, thanks to higher stability of the screws fixed to the osteoporotic bone. During the past 5 years, we treated 49 distal femur fractures; 17 of these fractures were stabilized by means of a condylar plate with or without mini invasive technique; in 9 cases an antegrade blocked nailing was performed, while in the remaining 23 cases the fracture was synthesized with a retrograde blocked nail. In 3 cases, the unsuccessful consolidation of the fracture, previously treated with an antegrade blocked nail, required a further retrograde blocked nailing. In all 26 cases, the retrograde nailing led to quick recovery of the fracture, in 3 cases the synthesis implied the exposure of the fracture focus. Only 2 patients had a limitation of the ROM caused by the prominence of the nail. We reckon therefore that the retrograde blocked nailing, against an absolutely strict surgery technique, should be a more largely used treatment method, due to undeniable stability and mini invasion advantages and also considering the major potentialities of the new generation nailing systems. Results Follow-up was on average 24 months and evaluation of patients satisfied the clinical and radiological criteria. The outcomes were satisfactory (62%), fair (28%), bad (10%). Healing time of the tibia was 3.6 months (range 3-7 months). To stimulate the healing of the bone a platelet gel was applied into the fracture trough the skin. In 2 cases we substituted broken synthesis, we observed 8 cases of delayed union with slow healing of bone, 5 infected pseudoarthrosis (most in the fixator). In these last cases we did local toilette, applied O 2 therapy with substitution of synthesis. In the 5 infections (3 fixators and 2 intramedullary nails), 4 cases needed a plastic surgery, 4 brachial vascular lesions, 2 amputations, 1 broken plate, 2 refractured. If necessary we used cortical or spongious bone transplantation. Another case was affected by pulmonary embolism and we took medical care. We also had 1 thrombosis. Discussion It is necessary to distinguish among the different existing possibilities in the use of external fixator and intramedullary nailing depending on the grade of exposure and the presence or absence of bone contamination. Neurovascular, abdominopelvic or thoracic complications represent important problems in these cases. It is important to choose correct timing of treating and to use modern methods knowing advantages and disadvantages of each one. Surgical solutions adopted are ratified but it is possible to change and choose the best technique for each patient. We not always reached the results expected by the surgeon and sometimes the patient needed to undertake surgery again.

Mini
Conclusions It is important to combine the expertise of many professionals in order to choose the best therapeutic protocol. The correct choice of synthesis improves the nursing and allows a quick rehabilitation of severely injured patients. On KKS score the results was Excellent in 46% of cases, 37% good, 10% sufficient and 7% poor. We think that this is a good results if we compare the complexity of pattern of fracture and the extremity of age fracture in our series. In our series the bad prognosis was related to soft tissue condition for high energy pattern of fractures, poor bone stock and highly fragmentary in elderly, perfect reconstruction of frontal axis, joint congruity, meniscal injury or grossly instability and associated ligament injury. We minimized the approach trough TARPO technique (artroscopically aided if necessary) to the joint and MIPO to the metaphysis in order to avoid additional soft tissue stripping, additional instability or source of joint stiffness.
Conclusions The locking plate offers sure advantages but does not allow the fracture healing ''per se''. The fracture often appears in different way putting in difficulty also really expert trauma surgeons. The message that I want to leave from this personal experience is that in order to avoid to get in worst prognosis of difficult fractures it's mandatory for the surgeon take care of reading of the pathoanatomy of the fracture, works with correcting timing after to have planned the reduction, choices the fixation method, choices of the implant but also the function that the system will have to carry out in this particular pattern of fracture. Surgical technique Knee flexed at 60°. We used the classic arthroscopic portals. After irrigation of the knee, morphology and displacement of fracture fragments and associated intra-articular lesions were evaluated under direct arthroscopic view. Through a cortical window on the other side of fracture, the depressed fragment was elevated using a guide-wire and then a cannulated impactor. 6.5 mm titanium cannulated screws or FTS (double threaded screws) were used to fix the fracture and bone defects could be filled using human allograft bone or by injection of adsorbable cement. Postoperative management CMP for passive mobilisation the first day, the patients were not allowed to bear weight for 10-12 weeks, a brace (range of motion of 0°-90°) was used for 1 month. . Data were gathered retrospectively. All the fractures were classified using the Schatzker classification. All patients underwent a-p and lateral plain radiography and computed tomographic CT scanning with tridimensional reconstruction of their injured knees. Clinical and radiological outcomes were evaluated according to the system of Rasmussen. The follow-up period ranged from 6 to 84 months, with an average of 50 months.
Results 24 patients had associated intra-articular soft tissue lesions which were treated both in conservative and surgical manner. Full weight bearing was allowed after 12 weeks. According to the Rasmussen grading system 42 patients scored a excellent functional result and 24 a good result.
Discussion Despite the fact that they account for just 1% of all fractures, tibial plateau fractures are associated with a diverse spectrum of injuries (to the menisci, collateral and cruciate ligaments, arteries and nerves) that can have severe consequences if not treated appropriately. Open reduction and internal fixation has a significant complication rate which has encouraged interest in percutaneous techniques. Arthroscopically assisted reduction (percutaneous osteosynthesis) provides a good view of the fractured articular surface and any other intra-articular lesion, while limiting soft tissue damage.
Conclusions Arthroscopically assisted treatment of tibial plateau fractures yields satisfactory results and can be accepted as an alternative and effective method of treatment even if not all types of tibial plateau fractures are amenable (suitable) to arthroscopic reduction. On the other side the mini-invasively percutaneous treatments with plates or screw decrease soft tissue dissection, reduce the risk of complications and promote rapid recovery. Objective The study compares the results obtained in the treatment of type B and C fracture according to AO classification with closed reduction and percutaneous wiring (associated or not to external fixator) with the results obtained with open reduction and L.C.P. plating.
Material and methods Seventy-six (76) fractures were treated: 36 were type B and 40 type C. First type (B) were treated with percutaneous wiring in 16 cases and in 20 cases (14 of subtype B3) with L.C.P. plates. Second type (C) were treated with percutaneous wiring in 18 cases (associated to external fixator in 10 cases) and in 22 cases with L.C.P. plates. 59 patients were evaluated with a mean follow-up of 11 months after surgery.
Results Patients were evaluated according to Mayo Wrist Score. In the group B the results was excellent/good in 65% of patients treated with percutaneous wiring and in 80% in those operated with L.C.P. plates. in the group C the results were excellent/good in 55% of patients treated with percutaneous wiring and were excellent/good in 68% of those operated with L.C.P. plates.
Conclusions The treatment of distal radius articular fractures evolved in the last years with the aim to obtain an anatomical reduction and to maintain a stable sintesis of all fragments. Traditional systems like closed reduction and percutaneous wiring or/and external fixator are giving up place to open reduction and sintesis with L.C.P. plates that allow a stable anatomical reduction and a faster and better functional recovery.

SESSION 7
Is anatomical reduction essential in proximal humerus fractures? A biological indirect reduction approach is a promising solution Surgical technique A closed reduction is achieved. A gentle and atraumatic dissection of the deltoid muscle is performed and stopped when the sub-muscular plane was reached (Larghi approach). The supraspinatus and subscapular tendon is pre-sutured. Both the tuberosities were usually pull distally and a quadrilateral suture technique is used to link the tuberosities together along with shaft. Therefore, and only now, due to a ligamentotaxis technique the assistant should reduced the fracture by indirect maneuvers. The ''gothic arc'' and the fracture reduction is checked fluoroscopically. Afterwards locking-compression plates is used percutaneously as internal fixator (Locking splinting) to achieve primary stability, to avoid secondary displacement, to respect the vascular blood supply of the humeral head and of the both tuberosity too. At the end of the bony fixation the rotatory cuff is sutured on the plate. Results The average follow-up was 48 months (min18-max 76). These patients were then regularly seen in the clinic with X-ray on follow-up. Constant shoulder score and the individual Constant score were assessed in every patients. We reviewed 84 patients out of 96 patients (50 female and 34 male) with an average age of 56.9 years. The average follow-up was 48 months. The overall union rate was 95.24% (80 out of 84). Sign of delayed union were noted in 3 pz and a non union in 1 pz. Clinical assessment showed an average CS of 21.77% points and an individual average CSindiv of 82.4% points. Discussion A number of studies have evaluated the functional outcome after locking plate osteosynthesis for displaced proximal humerus fractures. The delto-pectoral approach was used in all the studies, but approach and reduction technique were not addressed.
Conclusions Closed reduction and internal fixation with locking plate for proximal humeral fractures is a safe method, which produces promising functional and radiological outcomes. The suggested surgical approach provides a pain free early functional recovery.
Biological minimally invasive treatment in traumatic injury: damage control orthopaedics should be treated as group 1 or without reamed or with DCO strategy.

Unstable patients (critical conditions with chest injury AIS [ 4)
should be treated with damage control orthopaedics for their orthopaedic injury. 4. Patients in extremis should be treated in ICU with damage control orthopaedics for their orthopaedic injuries. While patients in groups 1, 3, 4 are quite easily classified, borderline patient are more difficult to define and there is no agreement on the including criteria. Clinical data have shown no increate risk of infection when intramedullary stabilization is realized within the window of opportunities following the use of spanning external fixation. DCO strategy has proven to have encouraging results in the early surgical management of injured patients. No definitive data are found on advantages in terms of mortality and morbidity. The respect of biology in bone healing is the principle on which the current treatment of fractures is based. Sometimes, in clinical experience, more importance is given to the respect of biology than to the biomechanical validity of the osteosynthesis, leading to implant failure. Basing on a strong belief in the validity of the Perren's theory about absolute stability in simple fractures and relative stability in complex fractures, we undertook an accurate review of those patients who sustained a mini-invasive treatment, with respect of biology but insufficient mechanical resistance of the implant, with a failure of the osteosynthesis. In this study we reviewed every delayed-or non-union occurred in the last 5 years at the Department of Traumatology II at ''Istituto Clinico Humanitas'' (Milan). Our results confirm Perren's theory and show that often, mainly in the case of a simple fracture of the humeral or tibial shafts, the exposure of the fracture site (with respect of soft tissues) and the osteosynthesis with absolute stability obtained by interfragmentary compression screws and neutralisation plates, can provide better outcomes compared to a mini-invasive surgery which, according to our experience, is even contraindicated.
Retrospective study on unstable fractures of the distal radius treated with external fixation This study was designed to investigate the clinical and radiographic results of the technique of external fixation in unstable fractures of the distal radius, and to define the indications and limits of this technique. Between January 2001 and January 2006 one hundred and five patients underwent surgery for distal radius fractures using external fixation; 90 patients were analyzed retrospectively. According to the AO classification we observed 35 A type fractures (39%), 10 B type (11.1%), 45 C type (49.9%). There were 42 male (47%) and 48 female (53%) with an average age of 62 years (range 33-79). The functional and radiographic results were analysed at a mean follow-up of 53.3 months (range 24-84). The valutation considered grade of satisfaction measured by satisfaction visual analogue scale (SVAS); patients pain was measured with the visual analogue scale (VAS); strength with Jamar Hand Dynamometer; range of motion (ROM) and functional outcome was evaluated using the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH) and Gartland and Werley score. Fracture reduction was studied from radiographs taken at the post-operative and last follow-up visit; we considered intra-articular parameters (gap, step-off) in according to Knirk and Jupiter (1986) and Gliatis (2000), extra-articular parameters in according to Van der Linden (1981) and Fernandez' criteria were used for acceptability evaluation. Therefore results were statistically analyzed. The mean active wrist ROM at the final follow-up evaluation was 68 degrees extension (range 40-80), 64 degrees flexion (range 35-80), 12 degrees radial inclination (range 5-15), 15 degrees ulnar inclination (range 10-25), 70 degrees pronation (range 30-80) and 65 degrees supination (range 40-80). In 73 cases we registered a strength [60% compared to an healthy wrist. The mean DASH score was 24, mean VAS score was 2.4 and mean SVAS score was 7.6. Final radiographic measurements for radial inclination was a mean reduction of 1.5 degrees and for step-off was 0.40 mm. In 68 cases (76%) the patients were satisfied, in 19 cases (21%) the patients lament slight pain without any functional limitations and in 3 cases (3%) the results were negative and it a partial arthrodesis was necessary. This retrospective study confirms that satisfactory functional results are obtained even if the reduction is not anatomic, but it is important to respect Fernandez' criteria. Our orientation is in C2-C3 type fractures where the results are not always predictable for fracture's complexity, to use external fixation. Results 75 patients (76 fractures) returned at follow-up (37 cases group I, 39 cases group II). Mean follow-up was 12 months (range 4-26 months). Results were evaluated according to a scheme which analyzed pain, mobility, strength, radiographic measurements, return to occupation and homework (D.A.S.H. score). In group I, results were deemed optimal in 24 patients (64.9%), good in 11 (29.7%), fair in 1 (2.7%) and poor (EPL rupture) in 1 (2.7%). In group II, results were deemed optimal in 22 patients (56.4%), good in 14 (35.9%), fair in 2 (5.1%) and poor (reflex sympathetic dystrophy syndrome) in 1 (2.6%). Nevertheless, subjective patient assessment did not show poor results. Discussion and conclusions With a progressively older yet healthy population, more and more frequently patients remain physically active and engaging in sports. Post-traumatic deformities and wrist dysfunctions are not well accepted outcomes in this population. In our opinion external fixation continues to have a role in the management of distal radius fractures. Other hand free articular fragments are not reducible and pose one of the limitations of treating fractures with external fixation. ORIF with a fixed angle plate facilitate accurate reduction and earlier implementation of activity. In our as well as other Authors experience, evolution of distal radial fractures shows that these fractures can and should be treated according to the same principles that apply to other fractures involving joints.  Results In 5 hips the stem was revised because of marked complications. Two patients underwent resection-arthroplasty for deep infection. In 2 cases a significant subsidence of the stem occurred, requiring rerevision for prosthetic joint instability and for head-neck disassembly. One stem finally was replaced for old dislocation following acetabular component failure. Four hips (11.1%) dislocated, and 8 stems (19.5%) subsided. Thirty-three cases (91.6%) showed radiographically stable bone fixation of the stem. A partial restoration of the femur was detected in 95.6% of the patients, both in the proximal part and in the cortical diaphyseal bone. Average HHS improved from 36 points preoperatively to 76 points at the latest follow-up. The cumulative survival rate of the Wagner stem was 87.8% at an average of 13.9 years. Discussion The stems that required further surgery were revised for the development of severe complications. Periprosthetic new-bone formation was seen to occur regularly.
Conclusions The absence of aseptic stem loosening documents the efficacy of fluted, tapered fixation on the diaphyseal cortical bone. Wagner SL prosthesis resulted a successful implant system in femoral revision, promoting bone stock regeneration in extended defects [2,3]. Higher risk complications (dislocation, subsidence) should be reduced by the use of modular tapered stems.

SESSION 10
Early results with the Revitan modular revision stem Objective Aim of this study is to evaluate the surface of the TKA polyethylene liner, harvested after the breakage of the post nine years after the implant in a 63 years old female (BMI 39) after an hyperextension trauma.
Methods During the revision we harvested sample of the periprosthetic tissue which was prepared for the light microscopy evaluation. The samples were stained using both haematoxylineosin and Von Kossa. The PE liner was prepared for the Scanning Electron Microscopy.
Results The SEM evaluation revealed two different damage patterns considering the medial part and the lateral aspect of the sample. The medial part presented a fracture line laminated in front and smooth behind and with the tear lines with a medio-lateral and anterior posterior orientation. The lateral part presented a sharp fracture line that ends anteriorly with a laminated tear paralleled to the anterior edge of the polyethylene insert, and which implies that this area could be the terminal failure area of the fractured post. The medial part of the fracture edge appears to be smooth and with a different orientation of the fracture lines.
Conclusions These features could be explained with a ''two stage'' rupture of the polyethylene post. This could have been caused by a non-optimal ligamentous balance that weakened the post, which was finally broken by a postero-anterior stress.
Introduction Anatomic acetabular cup, studied in 1999 by Prof. M. D'Imporzano, is born to solve the problem of acetabular revision in grade I and II mobilization (GIR) [1], respectively, characterized by widening and deformation of cavity with eventual superior or posterior wall loss. The problem in these lesions is not such bone stock reconstruction, as correct positioning of new cup. Indeed superior wall loss can set wrong collocation of the cup tending to verticalization and superior migration of rotation centre, while posterior loss can lead to retroversion [2]. Material and methods The hemispheric cup owns a cranial fin for iliac support with 4 holes for stabilization with spongiosa screws. In its equatorial area features 3 holes for posterior and medial screws, according to Pauwels, and circular retention cavities in order to increase the initial stability. The external shell is covered with a porous titanium layer so as to facilitate secondary osteointegration The tapered liner is in ceramic or polyethylene eventually protruded. The originality of this cup consists in having the insertion seat of the articular liner oriented by 18°in antiversion. This choice was made in order to automatically guarantee the necessary antiversion, even if the supero-posterior iliac wall is eroded, the latter being the reason why normal symmetrical revision cups lead to undesired positioning in insufficient antiversion. Considering these features, the cup can be used, as well as in revision surgery, in treatment of Coxa Profunda, Displasic Coxo-femural Osteoarthritis and acetabular fractures outcomes [3]. In this study we present the results of 60 revisions between 2000 and 2007, with a 1-7 years follow-up.

Results and conclusions
The clinical outcome was good with an improvement from 55 to 88 considering the Harris Hip Score. As complications we observed only 1 case of sepsis, neither dislocation nor mobilization. Radiographical study of rotation centre pointed out a reduction of the superior migration from 1.2 to 0.8 cm after surgery. The shortness of follow-up period does not allow to conclude definitively about the effectiveness of this cup as the optimal solution in this surgery; however, we can state that it can be a valid solution for treatment of grade I and II contrasting the two principal problems of these revisions: superior migration of rotation centre and retroversion tendency.
Evaluation of I-ONE TM therapy in patients undergoing knee joint prosthesis Objective The employment of biophysical therapy to accelerate tissue healing is by now a well-established practice in many orthopaedic situations, and is mainly indicated for osteogenesis and chondrogenesis [1]. Material and methods We undertook a randomized prospective clinical study envisaging recruitment of 30 patients affected with knee arthrosis and undergoing replacement with prosthesis. The randomization involved subdivision into two homogeneous groups, the first with biophysical treatment with I-ONE therapy (experimental group), the second not undergoing biophysical therapy (control group). In the experimental group, the I-ONE treatment commenced at 3-7 days after surgery, was administered for 4 h daily and was continued for 60 days consecutively. Clinical evaluations were performed by compiling functional reports (Knee score, SF-36 and VAS) before operation and after operation at 1, 2, 6 and 12 months.

Results
The results provide significant data with regard to the application of the biophysical therapy as compared with the control group.
Discussion Operations for knee prosthesis are complicated by moderate-severe postoperative pain. Acute pain results from the onset of a loco-regional inflammation since the damaged tissues release interleukines, tissue necrosis factors, histamine, braykinin, prostaglandin, serotonin, P substance and acetylcholine, which stimulate the nociceptors and cause onset of the nerve impulse [2]. In this way, alteration of the sensitivity of the peripheral neurone occurs, with reduced stimulation threshold. Inadequate management of the treatment for pain relief leads to chronic pain and delay in the programme for rehabilitation and for early recovery of joint function. For this reason, it becomes necessary for the orthopaedic surgeon, in collaboration with the anesthetist and the physiatrist, to set a therapeutic, pharmacologic and instrumental protocol such as to reduce the local inflammatory reaction and limit the transmission of the nociceptive stimulus at peripheral and central level. This is the premiss underpinning the application of biophysical treatment in dealing with pain following surgery for joint prosthesis. Exposure to the physical stimulus goes hand-in-hand with transport through the membrane of the calcium ion that is recognized as proliferative signal, causing an increase in cell proliferation and thence an expansion of the pool of progenitor cells. Biophysical stimulation has been found to exert a strong anti-inflammatory action [3].
Conclusions The results of this study will make it possible to provide the basis for clinical employment of biophysical treatment with I-ONE therapy immediately following surgical intervention on joints, enabling control of inflammation and increasing anabolic activity and thence protecting the microenvironment.

SESSION 11
Biological and mechanical pitfalls in modular prostheses used for bone oncology Primary and metastatic bone tumours are currently treated with limb salvage procedures avoiding in the majority of cases limb amputation. Different modalities of reconstruction after bone resection are recommended: modular prostheses, custom made prostheses, composite modular prostheses and rotationplasty. Among these different modalities of reconstruction modular tumour prostheses is considered a well established option for the reconstruction of osseous defects after resection of malignant bone tumours. This system allows today to replace almost every joint and even total bones (e.g., total femur or humerus), and good functional results can be achieved in the different series taking into account the different prosthetic models. We report our experience using modular endoprostheses of different design in the management of 143 cases of malignant primary and metastatic tumours from 1995 to 2008 summarizing the indications, limits, and complications as well as the functional results. Except the major problem consisting in the infection rate, we focus on the biological complication consisting in PE wear in the knee prosthesis, implant loosening in all the joint replaced, implant fracture, especially in the implant system with screws; coxitis in some cases of proximal femur treated with bone resection and reconstruction with modular endoprostheses. On the basis of our experience we conclude that although the complication rate with the use of modern modular endoprostheses is constantly decreasing, the need for revision surgery is still significantly higher than in primary joint arthroplasty. Objective The Author presents a new system (OMNIA) introducing innovative concepts in the field of acetabular prosthetic revisions: the aim is to provide the surgeon with various options for fixation of the acetabulum so that these can be implemented together as required depending on the seat and the severity of the bone defects actually encountered during surgery, as well as according to the operator's personal preferences. Modularity features are introduced to simplify the surgical technique allowing changes in the inclination and the acetabular rotation subsequent to cup implantation. The method makes it possible to easily handle unexpected intraoperative situations such as bone defects more serious than those encountered during preoperative investigations, and is therefore a suitable solution for all cases of acetabular revision. Material and methods The system can employ various types of fixation that can be implemented together in different ways, with one common feature, i.e. mechanical principles of angular stability. The cup is hemispherical; it is available in all the most common diameters thereby ensuring maximum saving of the bone tissue, and making it suitable for implantation also locking it by means of the ''press fit'' method. There are eight holes having the same diameter (9 mm) distributed at various distances from the pole and can be used to receive the three different auxiliary fixation devices. Three different fixation methods are possible, to be used singly or in association with one another; the selection of the type and implementation of the fixation is done during the surgery on the basis of the complexity of the acetabular defects. 1. Screws: characterized by their large diameter (8.5 mm) and the device for angular locking in relation to the cup, obtained by means of a special screw cap. Both these features contribute to increasing the mechanical resistance considerably as compared to systems which use standard screws. 2. Pegs: these are nails with six fins and tapered tip; they are available in various lengths, with 9 mm diameter at the base, and are inserted directly inside like the screws, after positioning the acetabular cup. The iliac fixation they provide is less invasive; they can also be positioned to obtain complementary fixations in the pubic and/or ischial region. The pegs are implanted simply by ''abutting'' after the housing is prepared by perforation. In this case too, angular stabilization of the ''peg'' follows by means of a screw for locking to the cup. The acetabular implant completed with screws and/or pegs provides the system with radiographic aspects comparable to those of a primary implant in terms of space occupied. Results and discussion The preliminary results refer to the first 130 implant cases in the last 2 years. The possibility of transformation of the implant from a simple ''press-fit'' hemispherical cup to a system with multiple fixation aids has made it possible to handle all types of acetabular prosthesis with a single system. The possibility of sequential adjustment of the cup implant parameters has actually helped simplify the technique and prevent acetabular orientation defects. Thanks to the numerous options available, application of the OMNIA system may also be extended to cover various ''difficult'' cases of primary prosthetization (dysplastic outcomes, traumatic outcomes, severe bone stock deficiency. The loosening of prosthetic joints in the absence of infection (aseptic loosening) is the most common reason for revision surgery. A significant part in this process is undoubtedly played by the generation of wear debris, mainly from the bearing surfaces of the joint, and the cellular reaction to this in the implant bed (the so called ''effective joint space'' [1]). Phagocytic cells (macrophages and multinucleated giant cells) are the ones that remove foreign material from the tissues, and these cells function in the interface between implant and bone lead up to the local production of many mediators including numerous cytokines (TGF-a, M-CSF, GM-CSF, IL-1, IL-6, TNF-a), enzymes and integrins. There is also evidence for interactions between macrophages and locally recruited lymphocytes, which may or may not give rise to an immunologically mediated process and a consequent bone loss and progressive prosthetic loosening. All the process is so started by the presence of wear particles [2]. Numerous studies suggest that the cellular reactions detected in the tissues in cases of aseptic loosening are indeed those of contact sensitization. There is good evidence to show that a type IV cellmediated immune reaction is taking place, with TH1 cell involvement (T helper lymphocyte) and active antigen presentation [3]. The extent to which sensitization is present in individual cases of aseptic loosening remains a subject for further work and this needs all the sophisticated molecular methods now available to modern biology to be applied in appropriate prospective clinical studies coupled with experimental models in vitro and in vivo. Immunological processes play a very important part in joint loosening than previously considered. alignment; (3) unchanging consolidation process: (4) avoiding the risk of complications; (5) restoring the function quickly. Through the positioning of two or three pins for clamp, with least incisions of 1 cm approximately we succeed in treating different types of fractures, without opening the focus. To understand the philosophy of dynamic external fixators, understanding the physiology of the biological process of fracture consolidation is required firstly. Phases of bone reparation 1. Reparation with granulation tissue 2. Formation of the primary callus 3. Formation of the definitive callus Dynamic axial fixators respect the biological process of fracture consolidations. In the initial stage of the process, rigidity and axial movement graduality is respected, while in the advanced ones, controlled and progressive movements in the area of the fracture is achieved. Objective The experience acquired in the treatment of non-unions of the long bones, with external fixators is presented. Orthofix dynamic axial fixator proved to be, with respect to rigid fixators causing bone healing problems and still pseudoarthrosis, an excellent method for pseudoarthrosis treatment. First evaluation must include: (1) physical and mental condition of the patient;

Material and methods
(2) quality of the soft tissues; (3) range of movements in joints.
Aims of the treatment are: (1) improvement of bone and soft tissue quality; (2) correction of length and angulations; (3) mobility of adjacent joints We classified them accordingly to their treatment in: hypertrophic non-unions, atrophic and infected.
Material and methods From 360 external fixators placed in order to treat different kind of orthopedic and traumatic pathologies, 74 corresponded to the treatment of upper and lower limbs non-unions. Evolution before surgery was, from 7 months to 20 years. Types: 18 hypertrophic; 22 atrophic and 34 infected. Patients consisted in 23 females and 51 males, ranging from 12 to 82-year-old. We used in all cases different models of Orthofix external fixator created and developed by Prof. G. De Bastiani and col. (University of Verona). The treatment should follow three principles: (1) realignment; (2) stabilization; (3) stimulation. In hypertrophic non-unions, the method included two steps: first 4-6 week compression, then dinamization progressively. In atrophic non-unions, bone graft from iliac crest was routinely employed, followed by dinamization after the appearance of the early radiological evidences of bone callus formation. In infected non-unions, primary toilettes were achieved, followed by external fixator placement in order to give strong and sustained compression Discussion The evaluation of the results was carried out using the following parameters: (1) bone healing; (2)  (2) no implants in the focus; (3) easy placement; (4) initial rigid fixation; (5) free access to repair soft coverings. The bone healing was obtained in 94.6% of the cases, with satisfactory results in 81.5% considering the dynamic external fixation an excellent choice for the treatment of non-union.

SESSION 14
Mechanical problems in femoral rear-nailing after periprosthetic fractures of the knee Retrograde intramedullary (IM) stabilization of unstable supracondylar femur fractures has become the treatment of choice for many fractures based on biologic and mechanical considerations. This resulted in early recovery, lesser hospital stay, and early rehabilitation of patient with good results. The presence of the intramedullary nail, however, introduces the potential for high concentration of stress at its proximal end. Moreover, finite element analysis showed an increased stress concentration around the proximal locking screws with an higher risk for fatigue fracture when an unused screw hole of the diaphyseal region occurs. To prevent undesired stress concentration at the proximal end of the nail, the careful selection of the proper nail length is recommended. Use of the longest possible intramedullary nail for supracondylar femur fractures improves fracture stability and reduces the risk of hardware fatigue failure. Anatomical positioning of the nail in the middle of the medullary canal avoids impingement of the tip of the nail with the cortices of the femur preventing further risks of a fatigue fracture after cyclic physiological loading. The ''fibula for tibia'' constitutes an historical intervention of orthopaedic surgery, that was employed for solving connected important problems in the infectious and in some neoplastic lesions of the tibia. The reconstitution of the skeletal continuity, when it is not possible to use osteosynthetic metallic tools and/or homoplastic transplants, can be obtained with this technique that, in our opinion is able, still today, to give, the correct indication when the basic pathology occurs in conjunction with other systemic diseases. We present our experience obtained on a series of 10 observations, of which 7 related to chronic osteomyelitis of tibia and 3 on adamantinomas, one of which had a recurrence. Diabetes was the systemic disease found most frequently in our experience and was also the cause of failures in interventions performed before the technique in examination. In one case the ''fibula for tibia'' was performed in conjunction with a following intervention of plastic coverage through a sural flap. The follow-up of this technique goes from a minimum of 4 years to a maximum of 16 years.