Poster Session

Introduction We describe the use of the first generation BurchSchneider anti-protrusion cage in revision hip prosthetic surgery in a series of 30 patients, and analyze the results at 8 years follow-up. Material and methods A series of 30 patients with severe acetabular deficit at the time of revision surgery of hip prosthetic implants were treated with the implantation of a Burch-Schneider Reinforcement Cage (17 women and 13 men). The mean age at surgery was 73 years (range 54–86 years). We operated the first 12 patients screwing the disalflange of the cage in the ischiatic bone. We then moved to a different way to secure the distal flange to the ischiatic bone, by inserting it into the bone to reach a better primary mechanical stability. Patients were evaluated retrospectively with a mean follow-up of 8 years (range 5–13 years). Results In one case with a deep infection, revision of the anti-protrusion cage was required. The cages showed a survival rate of 92% at mean follow-up. Clinical evaluation of the surviving patients showed a mean Harris Hip Score of 75 points (range 30–92). Radiological evaluation revealed a major rate of loosening in the group in which the distal flange was screwed to the ischiatic bone. Conclusions Although we present a small series, and other studies are required, the Burch-Schneider cage is a good tool in case of complex acetabular deficiency in revision hip prosthetic surgery, with regard to medium-term implant survival rate. Due to better mechanical results in our series, we emphasize the positioning of the distal flange into the ischiatic bone, without screwing it on the ischiatic bone, according to the literature. Suggested readings 1. Symeonides PP, Petsatodes GE, Pournaras JD, Kapetanos GA, Christodoulou AG, Marougiannis DJ (2009) The Effectiveness of the Burch-Schneider antiprotrusio cage for acetabular bone deficiency: five to twenty-one years’ follow-up. J Arthroplasty 24(2):168–174 2. Schlegel UJ, Bitsch RG, Pritsch M, Aldinger PR, Mau H, Breusch SJ (2008) Acetabular reinforcement rings in revision total hip arthroplasty: midterm results in 298 cases Orthopade 37(9):904–913

Introduction We describe the use of the first generation Burch-Schneider anti-protrusion cage in revision hip prosthetic surgery in a series of 30 patients, and analyze the results at 8 years follow-up. Material and methods A series of 30 patients with severe acetabular deficit at the time of revision surgery of hip prosthetic implants were treated with the implantation of a Burch-Schneider Reinforcement Cage (17 women and 13 men). The mean age at surgery was 73 years (range 54-86 years). We operated the first 12 patients screwing the disalflange of the cage in the ischiatic bone. We then moved to a different way to secure the distal flange to the ischiatic bone, by inserting it into the bone to reach a better primary mechanical stability. Patients were evaluated retrospectively with a mean follow-up of 8 years (range 5-13 years). Results In one case with a deep infection, revision of the anti-protrusion cage was required. The cages showed a survival rate of 92% at mean follow-up. Clinical evaluation of the surviving patients showed a mean Harris Hip Score of 75 points (range 30-92). Radiological evaluation revealed a major rate of loosening in the group in which the distal flange was screwed to the ischiatic bone. Conclusions Although we present a small series, and other studies are required, the Burch-Schneider cage is a good tool in case of complex acetabular deficiency in revision hip prosthetic surgery, with regard to medium-term implant survival rate. Due to better mechanical results in our series, we emphasize the positioning of the distal flange into the ischiatic bone, without screwing it on the ischiatic bone, according to the literature. We then decided to perform a randomized trial to evaluate the periprosthetic bone mass content with DEXA scan (Hologic QDR 4500 with metal removal software) on CFP prosthesised subjects using one of these autologous osteoinductive factors; Cascade's Platelet Rich Plasma (PRP), a product made of growth factors derived from platelets, one of the most widely used in orthopaedic surgery and easily obtainable during the surgical act, had been chosen.
Intraoperative apposition of PRP in 10 subjects (CFP + PRP Group) in the femoral calcar region did not significally change pBMD in respect to the control group, demonstrating the inefficacy of this product in contrasting periprosthetic bone resorption in our model. We can then assume that the biological osteoinductive action of PRP is not able to antagonize the biomechanical osteoresorptive force due to stress shielding.
Paracetamol and tramadol combination for postoperative pain treatment in day-care knee arthroscopy patients: a preliminary study debris in the periprosthetic structures (bones and soft tissues), deriving from the friction among metallic prosthetic surfaces [1]. In knee arthroplasty, this event occurs as the result of tibial or metalbacked patellar polyethylene wear, which causes the direct contact between metallic components. The exact incidence of metallosis is unknown; it has been reported an incidence of 5.3% on 418 hip arthroplasties [2]. Metallosis complicates more frequently hip than knee replacements, although some authors reported a higher incidence rate in knee arthroplasty. The metal debris induce a high release of cytokines from the inflammatory cells, making a revision surgery necessary whenever osteolysis and prosthetic loosening occur [3]. We report two cases of severe metallosis that occurred respectively in a male patient who underwent unicompartimental knee prostheses 12 years before, and in a female patient with a total knee arthroplasty implanted 14 years before. In the first case, metallosis was caused by friction between femoral and tibial prosthetic metal components resulting from a full thickness polyethylene insert wear. In the second case, the consumption of the patellar plastic portion has led to friction between the metalbacked patellar component and the metallic femoral trochlea. In both patients, a single-stage revision was necessary, with rapid pain disappearance and a complete functional recovery of the knee joint. Cartilage defects represent a common problem in orthopaedic practice. The knee is frequently involved and the medial femoral condyle is the most common localization. Patello-femoral joint is involved in 11% of cases. At this level two major causes have been identified: inflammatory conditions and biomechanics alterations. These may be the consequences of traumas, malalignments, dysplasia, and instability. This issue is a key point in chondral defect treatment, since it is mandatory to address these alterations to achieve a good functional result. Recently, several surgical options have been proposed to treat patello-femoral instability, trochlear displasia and extensor mechanism malalignment. Once these problems have been solved it would be possible to focus on the chondral pathology. However, it is important a proper evaluation of the site and extension of the defect and a classification of the chondral damage. According to these information several options are the available. Streptococcal myositis is a rare and often fatal infection caused by group A beta haemolytic streptococcus. The infection onset is in the muscle without the formation of an abscess and propagation to the subcutaneous tissues is delayed. We report a case of a young healthy male who presented with a myositis of the adductor loggia of the right thigh. The delay in the diagnosis and cure lead to an extension of the infection to the soft tissues of the lover limb, trunk and upper limb in a necrotising fascitis fashion and to an aggressive surgical debridement that resulted to be ineffective. The patient underwent closely to a disarticulation of the lower limb and aggressive antibiotic therapy that controlled the infection. The onset of a cerebral abscess with a transient left haemiplegia was also treated with antibiotics alone. A retrospective analysis of the case is presented along with a reinterpretation of the exams taken in order to identify all the factors that could have leaded to an earlier diagnosis and a more effective treatment.
Reduction of surgical site infections after decolonization of S. Aureus carriers in orthopaedic surgical team Literature and international guidelines identify antibiotic prophylaxis as a useful way to prevent surgical infection. Other recommendations to be considered are environmental treatment of the operative theatre, sterilization of surgical instruments and implants, asepsis and surgical technique. On the other hand, decolonization of S. Aureus carriers in surgical team or in patients is given no weight neither in the critical practice nor in literature. The goal of this research is to verify the usefulness of decolonization of surgical team members in order to reduce the risk of surgical site infections (SSIs).
In order to establish the real frequency of S. Aureus nasal carriers between the orthopaedic team members operating within 2 m from surgical site, we performed swab of both nares and oropharynx on 126 workers at the operating theatre who consented to cooperate to the study. 29 (23%) were found carriers of S. Aureus and treated with mupirocin ointment (Bactroban Ò ) for 5 days. The treatment was repeated 2 months later. Retrospective study on 1,000 consecutive patients operated without nasal decolonization of the surgical team showed 6% SSIs. Of the 300 cases considered after nasal decolonization, none developed a SSI. In accordance with published statistic, our work confirms the presence of 23% S. Aureus carriers in surgical teams, thus emphasizing the importance of decolonization treatment not also for patients butprobably even more strikingly-for health workers of the operating theatre. Though aware that more data need to be collected, this work might address to the development of preventive protocols and guidelines in order to introduce this kind of prophylaxis to reduce SSIs.
Introduction Also recognizing the validity of the bloodless treatment for many fracture's type, in metacarpal fractures is frequently indicated mini-invasive surgical treatment to reduce the times of immobilization and to reduce or to abolish the following rehabilitation. There are a lot of surgical approaches, techniques and materials of osteosynthesis used in literature. All the techniques fundamentally have the following problems: 1. The opening of the fracture from some osteosynthesis (as the plate) exposes to the generic risks of the open surgical treatment, essentially consisting in the risk of infection, delay of consolidation or nonunion, rigidity for iatrogenic adhesion of the extensor's tendons. 2. The articular osteosynthesis (through the MF joint) trans or iuxtaarticolar through the metacarpal head constantly involves serious problems of rigidity for capsulo-ligamentous damage or, however, for adhesion. 3. The intramedullary proximo-distal osteosynthesis, sometimes described in literature, has to our notice the defect to use nails with an extremely low diameter that do not allow a stable osteosynthesis. Over 15 years ago, we have felt the necessity to use a mini-invasive closed intramedullary proximo-distal osteosynthesis that obviated to the problems of the other methodics. Surgical technique In the surgical treatment of the metacarpal fractures, in our experience, the goals to be pursued are: the reduction of the fracture, the stability of the synthesis, an early active mobilization, the respect of the biology of the bony callus avoiding the exposure of the fracture. We set and performed a technique of closed intramedullary proximo-distal osteosynthesis in all the types of fractures, and this technique has guaranteed a stable synthesis and allowed an immediate active mobilization. The technique, previous closed reduction, consists in the use of a special surgical instrument, essentially composed by a cannulated perforator that allows the glide of Kirschner's wires with a shaped point to overcome the center of J Orthopaed Traumatol (2009) 10 (Suppl 1):S61-S77 S63 fracture. Two wires of the diameter of 1.5 mm are generally used. The choice of the diameter and of the number of wires to be used is, however, varying in relationship to the diameter of the medullary channel and to the type of fracture. Once performed the osteosynthesis, in the site of introduction the wires are refolded to straight angle and allowed to escape from the skin. No immobilization is applied and the patient is invited to move the fingers without restrictions in the immediate postoperative. Wire's removal happens around the 40°day. Results In the last 15 years we have treated more than 2000 metacarpal fractures with this technique. All the fractures healed. We have not observed therefore any case of nonunion. Complications have not been observed in the immediate postoperative, neither injury to extensor tendons, although about in the 10% of patients a superficial cutaneous infection at the point of introduction was present, anyway this occurrence did not caused the early removal of the mean of synthesis.
Conclusions In our 15 year-experience, the closed intramedullary proximo-distal osteosynthesis with Kirschner's wires represents the best surgical approach to the greatest part of the metacarpal fractures, in particular, this surgical technique has shown greater advantages in the prevention of nonunion and rigidity, and in the reduction or abolition of post-surgical rehabilitation. Introduction The intramedullary osteosynthesis is very often considered a second choice, because, in the opinion of many authors, not all the types of nail guarantee the rotational stability. The intramedullary nailing of the forearm with Rush's nails uses Rx-scopia and has different advantages: it is a mini-invasive technique with microincision and missed exposure of fracture, the extremely contained costs in comparison to the others technique, and, in skilled hands, the constant consolidation of fracture or nonunion. Material and methods The nail of Rush are plunged in the radio by retrograde, in the ulna by anterograde and are nails, in biocompatible steel, of varying diameter between 2 and 5 mm, varying length, relatively flexible, with a curved extremity with a ''curl'', an important element in conferring a rotational stability to the synthesis. If possible, the diameter and the length of the nail should be established before the operation. However, in ours technique the apparently disproportionate diameter of the nail, never inferior to 3.5 mm, confers a continuity cortical-cortical and it is a fundamental element for rotational stability of the synthesis. The relative flexibility of the nail of Rush allows such mean of synthesis to suit for the physiological bendings of the forearm's bones. Although closed intramedullary nailing is the best technique, in the most of cases, for the presence of the synthesis previously affixed, obliteration of the intramedullary channels and atrophy of the stumps of nonunion, shortness of one or both forearm's bones with the necessity of a bone graft, a open (relatively closed) intramedullary nailing is needed. Because of the opening of the nonunion, it is necessary to proceed with the removal of the synthesis, the reconstitution of the medullary channels, and the restoration of the length of the two bones (where necessary, with a tricortical tubular bone graft withdrawn by the controlateral iliac crest). The patient, in any case, maintains an immobilization in BAM cast with elbow flexed to 90°and neutral prono-supination for 30 days. Among 1996 and the 2007, we treated by using the technique of the intramedullary nailing with nails of Rush 55 pseudoarthrosis (12 biossee, 12 isolated of ulna, 19 isolated of radio) in 43 patients, 30 males and 13 females, with an age ranging among 20 and 81 years (average 38 years). In 50 pseudoarthrosis in 39 patients (90.9%) the fracture had been synthesized, originally, through plate and screws; in four pseudoarthrosis in three patients (7.3%) with intramedullary nail; in a case of a fracture of radio, then hesitated in pseudoarthrosis (1.8%), the patient had been treated in bloodless way through immobilization in BAM cast. In 10 cases (18.2%) the restoration of the length of the forearm's bones was made necessary by an autologous tricortical tubular bone graft withdrawn by the controlateral iliac crest and opportunely modeled. The time intervened by the fracture varied from 6 to 84 months (average 8.7 months). The follow-up period ranged between 8 and 85 months (7 years) with a mean follow-up of 18.5 months.
Results In 54 pseudoarthrosis (98.2%) we had a complete recovery, only in one case (1.8%), a nonunion complicated by osteomyelitis, intramedullary nailing failed. The recovery time ranged between 5 and 12 months (average, 7 months). In some cases a following surgical treatment was necessary for the coexistent conditions with the nonunion or for complications. The clinical and functional results were judged excellent by 39 patients (90.7%), good by 3 patients (7%) and unsatisfactory by one patient (1.3%).
Conclusions The treatment of the nonunion mono or both of forearm's bones results particularly difficult as shown by the existing casuistry in literature that reports an elevated incidence of failures. The more used surgical procedure in literature is bone graft and synthesis with plate and screws. In our opinion, the problems inherent this technique are spongiosization of the cortical bone, risks of refracture after the removal of synthesis, as well as a loss of the intraoperative performed compression with frequent risk of not consolidation of the graft. The usual theoretical criticism to the intramedullary nailing with nail of Rush, as reported by many authors, is the scarce follow-up of the rotatory stability. In our experience, we observed an excellent rotatory stability. This probably can be explained by: (a) the use of high diameter nails involves a primary cortical-cortical taking (presplit); (b) the Rush's nail is a synthesis able to adapt the physiological scoliosis of the two bones of forearm; (c) the''curl'' of the nail of Rush has a rotational stabilizing effect associated with the necessary initial immobilization. The scaphoid nonunion develops into osteoarthritis of wrist. In Order to decreases the incidence of osteoarthritis is essential to get anatomical reduction and consolidation of the fracture. An incomplete consolidation of the isthmus of the scaphoid produces a cifotica deformation and variation in natomical proportions or carpal collapse. MTac and RMN are helpful in the evaluation of scaphoid collapse, nonunion and osteonecrosis. In our Medical Department, during the 3-year-period 2006-2008, we treated nine cases of scaphoid nonunion by micro-incision and by applying a platelet gel on the fracture focus. Follow-up at 1, 3, 6, 12 months from surgery showed a complete recovery in all cases. The use of platelet gel in mini-open, in selected cases is a good alternative to traditional method.
Mini-subvastus approach for total knee arthroplasty: 5 years of experience Division of Orthopedics and Traumatology, Center for Arthroscopy and Knee Surgery, Hospital of S. Cuore-Don Calabria (Negrar, IT) The application of minimally invasive surgery (MIS) for the total knee arthroplasty is increasingly common. From 2004 at the Hospital Sacro Cuore-Don Calabria Negrar (VR) we systematically used mini-subvastus approach for total knee arthroplasty.
The technique provides a central skin incision from the superior pole of the patella to the tibial tubercle, exposure of the medial retinaculum and mobilization of the vastus medialis muscle subcutaneously, incision of the medial retinaculum and blunt separation of the vastus medialis muscle from the intermuscolar septum, lateralization instead of eversion of the patella. In this way we get a good exposure of the articulation, without undermining the extensor apparatus and without cutting the superior-medial genicular artery. By preservation of the extensor mechanism, we obtain earlier return to active extension and flexion, less postoperative pain and reduced blood loss. Other advantages are: the conservation of superior-medial genicular artery, the maintenance of a normal patellar tracking with reduced use of the lateral release, a decreased use of analgesics, reduced hospitalization and an earlier straight leg raise (SLR). The relative contraindications are: obesity, previous standard parapatellar approach. The absolute contraindications are, in our opinion, the severe valgus osteoarthritis with medial instability and flexion contractures in more than 15 degrees. We believe that this surgical approach, as demonstrated by the literature, offers some early advantages compared to standard parapatellar approach: reduced surgical times, reduced blood loss, faster and less painful functional recovery, shorter postoperative recovery and reduced hospitalization costs. The incidence of Achilles tendon ruptures is constantly increasing, probably as a result of the increment of recreational sport activities. Percutaneous tendon repair, described for the first time in 1977 by Ma and Griffith, minimize many of complications that accompany open surgical repairs and combine the advantages of surgical and non surgical management. Currently this technique is obtaining increasing popularity and is considered safe and effective in repairing ruptured Achilles tendons. We use this procedure, modified, from 1997 and the purpose of this study is the evaluation of long term results of the first 20 cases operated between 1997 and 1999. At follow-up the control patients were evaluated subjectively with a questionnaire and clinically with a sensory assessment, measurement of calf circumference, ankle range of motion and a stress test with the patient on bilateral and unilateral tip toe. Moreover we performed bilateral ultrasonography examinations to control tendon healing and size and MRI evaluation for a more accurate study of tendon structure and thickness. The overall results were good. No re-ruptures. We confirm an increase of Achilles tendon thickness without structural impairments. At long term follow-up percutaneous repair proved tobe a simple, safe, reliable, low cost procedure with a high patient's compliance.
Introduction The popularity of unicompartmental knee replacement has increased over the past 10 years, due to newer designs, improved instrumentation and surgical technique. Recent studies have described 10-year survivorship of 90%, which is comparable with that of total knee arthroplasty. Recent minimally invasive techniques are increasing the appeal of unicompartmental knee replacement to patients and surgeons. As a result, the classic indications are being expanding to include younger patients with more active lifestyles. However, patients must be carefully selected: unicompartmental osteoarthritis or osteonecrosis, flexion contracture less than 10°, frontal deformity less than 10°-15°without need of ligament release, integrity of anterior cruciate ligament. Anterior pain and degenerative changes of patellofemoral joint may represent a determining factor in the decision for not proceeding to unicompartmental replacement. Introduction Knee instability after total joint arthroplasty is one of the most common cause of prosthetic failure. Knee ostheoarthritis with severe varus and valgus deformity and revision for previous prosthetic loosening are usually treated by means of constrained implants provided with modular components. In our study we comparatively evaluated functional results in two groups of patients operated on by the LCCK prosthesis in case of primary and revision knee arthroplasty in order to detect the role of preoperative status on final clinical recovery. Material and methods Starting from 2004 to 2007, 30 LCCK total knee prosthesis were implanted in our Institute. All patients were included in the study. In 17 cases the prosthesis was applied as primary implant in patients with severe varus and valgus knee deformity.

Material and methods
In 13 patients the implant was used in knee prosthesis revision for aseptic (10 cases) or septic (3 cases) loosening. The average age of patients was 73 years (range 64-85 years) and the average follow-up was 23 months (range 12-48 months). Clinical and functional results have been evaluated with WOMAC and KSS score.
Results No case of implant failure was observed during periodical controls. The WOMAC and KSS scores showed good results particularly in pain and articular function domains. We did not observe statistically significant differences among the two group of patients in which the LCCK prosthesis was used (primary vs. revision implant). Discussion and conclusions Severe knee deformities, instability and insufficient bone stock require a careful preoperative planning and, in some cases, the use of constrained prosthesis. In clinical practice the opportunity of using modular implants represents an essential element to fit the correct prosthesis in every patient. In our experience the LCCK knee prosthesis system respected preoperative expectations allowing to obtain favorable clinical results in both primary and revision knee arthroplasty.
Venous thromboembolism prophylaxis in orthopaedic surgery: impact of regional guidelines this study is to evaluate the impact of regional guidelines for VTE prophylaxis in orthopaedic surgery, with a particular focus on prescriptions for low molecular weight heparins (LMWHs) (e.g., patient eligibility, dose, duration). Secondary objective is to evaluate self reported therapy adherence at home. Material and methods Prospective pre-post intervention study. Data on VTE use in orthopaedic surgery are collected before and after the implementation of regional guidelines in 21 hospitals in the Veneto Region, Italy. Guidelines dissemination is considered the intervention. The present study describes the results of prophylaxis use before guidelines dissemination.
Results Background The tibio-talo-calcanear arthrodesis is an effective surgical treatment for the severe symptomatic degenerative pathology of the ankle and for the correction of malalignment the hind-foot.
In literature several techniques and methods of synthesis are described. The use of second and third generation retrograde nailing, compared with the first generation, adds the possibility of compacting the surfaces to be joined and allows a trans-calcaneal access, which is a more respectful vascular-nervous structures approach.
Material and methods Between January 2000 and April 2007, 22 patients (9 men and 13 women) with an average age of 54 years (range 21-81) were treated with a tibio-talo-calcanear arthrodesis using a retrograde nail. The post-operative protocol included the use of a below-knee cast and a period of non-weight bearing for 4-6 weeks. In 7 cases, where autologous bone grafting was used, the protection of the joint was delayed for further 2 weeks. All the patients was clinically evaluated using both AOFAS and Mazur Score and radiologically assessed.
Results At an average follow-up of 24.7 months (range 8-58) the rate of consolidation was 95%. Complications observed were 1 case of fracture at the apex of the nail, 1 case of perioperative infection. In 2 cases we found mild pain in the plantar region and in 2 cases sub-talar pain. The average AOFAS result was 64.2, the Mazur score was 61.83 with satisfaction in 85% of patients. The radiographic analysis showed a correct alignment in the frontal plan in all cases and only one case of non-union. Discussion The arthrodesis with retrograde nail can be considered a relatively easy surgical technique, which provides maximum stability. It also proved to be useful in case of need of early weight-bearing. The success rate is, however, related to the proper indication of this type of intervention. A key factor for a good clinical outcome is to obtain a correct position with a neutral dorsi-flexion of the foot, an external rotation of 5 1 10°and 5°of valgus deformity of the hindfoot. Contraindication are patient with a low compliance and all the cases in which there were considerable doubts about psychological acceptance of the loss of joint motion. (1) patients (n = 10) treated with a circular external fixator, mean age 42 years (min 17, max 72); (2) patients treated with a retrograde nail, mean age 61 years (min 47, max 74). The indication to the retrograde nail treatment as an alternative to the external fixation was given using the following criteria: (a) impossibility to put a prosthesis on the joint; (b) type of deformity; (c) previous arthrodesis surgery; (d) patient refusing E.F. treatment.
Results In both groups we achieved the deformity correction, the complete tibiotarsic joint fusion, and the recovery of the limb functionality (evaluated using a AOFAS chart). The residual ipometry was ranging between 1 and 2.5 cm. In all patients the tibial and talar articular surfaces were prepared (open surgery). In the group treated with an external fixator, the consolidating time was averaging 2.5 months (min 2 max 3.5). In the group of patients treated with a retrograde nail, the consolidating time was longer, 4 months (min 3 max 6), and it was related to the talus conditions, not to the deformity severity. In both groups, no patient underwent an iliac transplant.
Conclusions The external fixation allows the execution of the arthrodesis independently from the tibiotarsic bone stock. The treatment can be an immediate correction, a gradual one, or associated to a bone transport, if necessary. The external fixation is mostly indicated in complex deformities, with a severe lack of bone stock, and in reviews of previous arthrodesis. The retrograde nail allows an immediate correction of the deformity, but requires more residual bone stock of the talus. In case of an insufficient bone stock, the nail stability is precarious or risky. The arthrodesis and the deformity correction with a retrograde nail, may result into an ipometry of more than 3 cm, that will require further surgical techniques. Introduction The objective of the present study is to evaluate medium-term results of the Simons procedure for the treatment of congenital clubfoot. Material and methods Fifteen patients affected by III degree congenital talipes equinovarus (TEV) were treated surgically. TEV was bilateral in seven cases, thus the total number of operated feet were 22. The patients underwent peritalar release according to Simons, and were evaluated postoperatively with antero-posterior and lateral view X-rays. Clinical and radiological follow-up was at mean 6.7 years (range 2-13 years). Clinical and morpho-functional evaluations were performed in agreement with Manes and Laaveg/Ponseti. Also, all patients were evaluated at standard X-ray two-projection stress views, photopodogram and baropodometric exam.

Results
Of the 15 operated patients, two were not available for followup. Therefore, a total of 20 feet were evaluated. Two patients underwent another surgical intervention for deformity recurrence. At follow-up no patient presented with pain at rest. According to Manes 13 cases had good results, five cases had satisfactory results, and two cases had bad results. Results at Laaeveg and Ponseti evaluation were excellent in 16 cases, good in two cases, and unsatisfactory in two cases. Anteroposterior radiographic exam revealed an alteration of the astragalo-calcanear divergence in seven feet and a reduction of Kite angle in three patients. At lateral view, X-rays revealed a reduction of the astragalo-calcanear angle, compared to normal values, in 12 cases.
The scaphoid was dorsally subdislocated in eight cases. Photopodogram evaluation showed accentuation of the plantar vault in five cases, Static baropodometric examination showed a backward shift of the body baricenter, which determined an overload at the normal hindfoot. Discussion In the present study, we perform a complete peritalar release as described by Simons, which seems to guarantee better chances of restoring correct astragalo-calcanear anatomy. In terms of deformity correction, the clinical and morphological results were satisfactory in 90% of cases. However, a data analysis of long-term follow-up studies reported in the literature over the last years demonstrates that less invasive treatment is better than the surgical approach. In fact, the latter is more likely to determine development of pain, functional limitation, and beginning and progression of foot osteoarthritis. Despite the good results obtained with the peritalar release technique in short-term and mid-term studies, the therapeutic choice for treating TEV is unanimously shifting from extensive releases to less aggressive treatments. Introduction The calcaneus is the main tarsal bone, it is complex and represents the most important part for the supporting base of the foot. The most common treatment is open reduction and internal fixation (ORIF), but unsuccessful cases are not infrequent. We used a minimally invasive technique which also permits to treat complex fractures decreasing the complications. It is important to underline that the primary objectives to be gained are to restore the congruity of the posterior facet and of the subtalar joint, and the height of the calcaneus (Bohler's angle), to re-establish the integrity of calcaneocuboid joint, to decompress retro-peroneal space and to avoid varus or valgus deformity. Material and methods From January 2002 to December 2006 we treated 39 calcaneus fractures in 29 patients, 22 males and 7 females, in ten cases bilateral in polytraumatized patients; the mean age was 44 years (range 24-64). The time from injury to surgery ranged between 5 and 13 days. The preoperative planning foresees common X-rays with lateral and axial projections and the CT scan. The fractures were subdivided according to Sanders classification and they resulted to be type II in 19 cases, type III in 13 and type IV in 7 cases; open fractures were excluded from our study.
Results The mean follow-up was 39 months (range 24-41). Bohler and Gissane angles were restored in 90-97% of Sanders type II and III fractures and in 15% of type IV; height and thickness were restored in 87-95% of Sanders type II and III fractures, and 19% of type IV. According to Maryland foot score the mean score was 87 in type II, 83 in type III and 60 in type IV fractures; 10 fractures resulted excellent, 19 good, 7 not satisfactory and 3 bad. The reduction of the posterior facet was obtained in 29 out of 39 patients. The subtalar joint movement was restored at 75% in 12 cases, 50 % in 16 cases and 25% in 10 cases.
Conclusions To choose the right treatment of complex intra-articular calcaneal fractures it is important to consider soft tissues conditions and collateral disease of the patient. The minimal invasive technique we described, nevertheless complex to be performed, it's a valid therapeutic solution which guarantees stability principles, anatomic reduction of the fracture and soft tissues preservation. like. This treatment is followed by an immobilization in half cast for 3 weeks. Results In all cases there was healing, marked reduction or abolition of pain, correction of the anatomical deformity and recovery of a good mobility. In 12% of cases there was the appearance of a FCR's tendinitis resolved with medical and physical therapy in 10% of cases.
In the remaining 2%, rupture of the radial carpal flexor occurred between the fourth and sixth post-operative month, but did not lead to further complications.
Conclusions In light of the review of cases over a 20-year period and the experience with this specific technique, the benefits seem rather obvious if compared with the surgical alternatives, arthrodesis and prosthesis. In particular, if compared with arthrodesis, trapezectomy associated with biological arthroplasty allow a larger mobility with absence of functional overload of the trapezoid-scaphoid joint; if compared with prosthesis, in addition to the complexity of the surgical trauma, this technique presents absence of infection and especially no deterioration of the results in the years. The incidence of spinal injuries has been increasing over the last decade and the vast majority of these events are the consequence of highenergy trauma due to a road traffic accidents, falls and sports injuries. Mechanical failure of the spinal column following high-energy trauma frequently occurs at the thoracolumbar junction as a result of its transitional anatomy and biomechanical environment. In order to well analyze and consequently understand a spinal fracture, it is very important to apply a comprehensive and prognostic classification system. In our opinion the most useful classification is the one proposed by Magerl et al. in 1994. The AO classification associated with the McCormack classification points system are, in our hand, the best way to better analyze and consequently treat a spine fracture. We report our experience in the treatment of thoracolumbar spine fractures on 40 patients treated with posterior approach in our Department since January 2004. All patients underwent a posterior spinal short segment and monosegmental instrumentation for thoracolumbar injuries caused by high energy trauma. Six patients had a monosegmental stabilization. The mean age was 45 years (28-63) and the 70% of the cases had a T12 or L1 fracture. The mean spinal canal stenosis due to a retropulsed fragment was 25.6% (0-56.3) with a mean kyphotic deformity of 11.4°Cobb (0-17) measured at the end plate above and below of the fracturated level. All patients underwent a short-segment spinal instrumentation with posterior wall indirect reduction (ligamentotaxis) and kyphotic deformity correction. One patient required a direct canal decompression with a two levels laminectomy. Six patients underwent a monosegmental fixation. The mean value of kyphotic correction was 9.8°Cobb with a mean value of residual kyphotic deformity of 1.6°C obb. In 83% of the cases we performed a posterolateral fusion with autologous bone mixed with bone substitutes. All patients used a thoracolumbar othosis during the 2 months postoperatively; no complication rate was detected regarding the procedure. We report our clinical and radiological results.
Treatment of lumbar fractures with posterior shortsegment instrumentation and vertebral augmentation with X-VOID Ò reduce and stabilize thoracolumbar fractures. Hardware failure and loss of reduction are complications caused by insufficient anterior column support that can cause pain and disability in case of shortsegment instrumentation. Preliminary encouraging results are now reported with the use of the kyphoplasty in combination with posterior instrumentation. Material and methods From May 2005 to May 2007, eight patients with thoracic-lumbar burst fractures were treated with posterior shortsegment pedicle screws-and-rod XIA (Stryker, USA) and vertebral augmentation with X-VOID Ò . There were four males and four females, whose mean age at surgery was 55.5 (range 18-82 years). The affected level were L1 (n = 4), L2 (n = 1), L3 (n = 3). Preoperative anteroposterior and lateral radiographs were obtained as well as CT scan. All the fractures were type A3 according to Magerl classification. Mean post-operative follow-up was 24 months (range 19-30 months). Clinical assessment was based on the Oswestry Disability Index, the VAS score and the Beck Depression Inventory. The deformity of vertebral body was assessed on X-rays with two parameters: Angle of Deformity and Vertebral Wall Index. Results At mean follow-up of 2 years the percentage of disability (ODI) was 0% in 1 case, lower than 20% in 4 cases and between 20 and 40% in 1 patient. Four patients did not have pain (VAS = 0), three reported mild pain, one referred persistent pain. All patients had slight or absent signs of clinical depression (BDI \ 10). We obtained an average improvement of the angle of deformity of 8.87°, and an average increase of the height of anterior wall of 24%. The application of thermal energy in its two forms, removal of heat (cryotherapy) or application of heat (hyperthermia), is a common rehabilitation intervention [1,2]. Nowadays technology allows to apply energy in safety conditions and with a proven biologic efficacy [3]. The system employed is SMARTERAPIA Ò which matches both forms of thermal energy application. During session a controlled dynamic thermal shock is caused, giving benefits to tissues. The new system consistently includes 5 steps in the rehabilitation project: • Step 1: resolution of pain, swelling and inflammation • Step 2: recovery of range of motion • Step 3: recovery of muscle strength • Step 4: recovery of motor functions and coordination • Step 5: recovery of athletic movement This study aims at investigating the effect of the therapy on patient's pain, fully aware that the heat application or removal is a valid aid to the rehabilitation intervention. One hundred and nine patients in total, affected by different muscleskeleton pathologies, underwent treatment. All patients were treated in ten sessions, one session per day. At the beginning and at the end of treatment, all patients were given a VAS (visu analogic scale), in order to value the short-term effect on the pain suffered. Figure 1 shows the average results obtained by treated patients, with relevant VAS values, divided into different areas. Most patients were affected by chronic pain. As a consequence even small initial and final VAS variations have to be read with enthusiasm. The results point out the method efficacy in the orthopaedic area as a support in the rehabilitation intervention. As a result the thermal shock fits within the rehabilitation projects giving the patient all opportunities to reach the highest functional recovery. scapular-thoracic joint. We report measurement of pre and postoperative active ROM for each patient. The improvement of stability and function was the basic condition to perform palliative surgery for recovering elbow active flexion in some cases. The position of arthrodesis in 30°degrees of abduction, flexion e internal rotation did not cause any problem to the patients when upper limb was in rest position because it did not overload scapular-thoracic joint. All patients were satisfied. No complications were recorded.
Conclusions Results obtained from revision of our cases reflect literature's results. In patients with sequelae of the brachial plexus injury the shoulder arthrodesis improves upper limb function. It is the basic condition to perform tendon transfers on distal segments. Shoulder arthrodesis in 30°degrees of abduction, flexion and internal rotation keeping body as reference point is the best position because it allows the development of potential muscles' strength (trapetius, serratus anterior, elevator scapulae, rhomboids) and ensures to the patient the best upper limb position as regards scapular-thoracic joint. Purpose Patients with adhesive capsulitis were clinically evaluated for establishing whether pain elicited by pressure on the coracoid area, which is just above the anatomical structures involved in the disease, may be considered a pathognomonic sign of this condition. Material and methods The study group included 85 patients with primary adhesive capsulitis, 465 with rotator cuff tear, 48 with calcifying tendonitis, 16 with glenohumeral arthritis, 66 with acromioclavicular arthropathy and 150 asymptomatic subjects. We aimed at evaluating whether digital pressure on the coracoid area evocated pain. Digital pressure was also carried out on the acromioclavicular joint and the anterolateral subacromial area. The test was considered positive when pain on the coracoid region was more severe by three points or more (VAS scale) with respect to other areas.
Results The test was positive in 96.4% of patients with adhesive capsulitis. In rotator cuff tear, calcifying tendonitis, glenohumeral and acromioclavicular arthritis a positive test was found in 11.1, 14.5, 6.2 and 10.6% of patients, respectively. A positive result was obtained in 3/150 normal subjects (2%). If adhesive capsulitis was compared to the other four conditions, the test had a sensitivity of 0.96 and a specificity from 0.87 to 0.89. Respect to controls, the sensitivity and specificity was 0.99 and 0.98. Conclusions Because this test is very specific and sensitive, it may be used to confirm or exclude diagnosis of adhesive capsulitis. The coracoid pain test could be considered as a pathognomonic sign in physical examination of patients with stiff and painful shoulder.
The anatomic features of proximal radius and their implication for osteosynthesis with plate comminution. ORIF often gives unsatisfactory results because of the difficulty in restoring the head-neck off-set and the radial head inclination relative to its neck. In these cases radial head replacement may be indicated; however, there are no long-term studies on complications and survival of the implant. Recently precontoured plates for the proximal radius has been introduced but no trials have determined whether they are able to restore the normal anatomy of the radius. The latter is still partially unknown because no studies have analyzed the morphology of posterolateral aspect of radial head and neck (''safe zone''). Our study was aimed at: (1) determining the possible presence of anatomical variations of the safe-zone and (2) analyzing the anatomical congruence of precontoured plates to this zone. Measurements, performed on 44 cadaver dry radii of adults, included: length of the radius, diameters and height of the radial head, and height and diameter of the neck of the radius. The radius of bending of the safe zone was also calculated. The morphological evaluation of the ''safe zone'' of the radius revealed three different morphological types of this zone: A (flat) (25%), B (slightly concave) (63.6%) and C (markedly concave) (11.4%). Adherence of a precoundered plate (Acumed) to the bone surface of the safe zone was performed independently by three of us, and the gap between plate and bone was measured. Plate adaptability was good in Type B, scarce in Type C and absent in Type A.
In conclusion, we identified three different morphologies of the safe zone, not previously described, and we found that the precountered plates now available can ensure a good restoration of anatomy only in one half of the human radii. Background Traumatic dislocation of the hip is an extremely severe injury. Although previously considered an uncommon lesion, it is now seen more often as a result of MVA. In most cases this injury can result in a high incidence of complications. Early diagnosis, in politrauma patient too, and a early closed reduction constitute the gold standard of a proper treatment of this injury. The reduction should always be as close to the anatomical as possible.

Material and methods
The fibular reconstruction is best made with an antigliding posterior plating. In the osteoporotic bone we suggest LCP reconstruction plate.
Objective The proximal humeral fractures represent the 4-5% of the totality of the fractures; of these about 15% are displaced and may produce a healing with a bad consolidation, with a negative impact on the functionality of the shoulder [1]; the aim of the treatment of this kind of lesions is an acceptable and painless recovery of shoulder's function.
Material and methods From September 2005 to November 2008 in the Orthopaedics Department of Legnago (VR), 48 nails (T2 Stryker Ò ) were implanted in as many patients, affected by a displaced humeral fracture (36 females, 12 males, average age 64 years, range 28-83).
The fractures according to Neer classification [2] were type II in 20 cases (42%), in type III in 24 cases (50%) and type IV in four cases (8%). A preoperative CT was always performed in the III and IV types. The patients maintained a brace for 3 weeks after surgery. Clinical evaluation (pain, ROM and strength) and radiographic examinations were performed at 3, 6 weeks; 3, 6 months and at 1 year after surgery.
Results We observed fracture healing in 43 patiens (89%) with disappearance of pain and satisfying restore of shoulder's function. In 36 cases (75%) we observed a complete strenght recovery. In six cases (12.5%) removing the nail was necessary; in four patients (8%) an arthroplasty was performed after the nail removal. In two young patients (4%) the nail was removed because poorly tolerate. Discussion and conclusions In our opinion, the four cases of failure with removal of the nail and conversion in arthroplasty, enhance the necessity to obtain a good reduction of the fracture before the insertion of the nail. Reduction is often difficult in Neer's type III fractures and becomes extremely difficult in type IV. In our experience, the T2 intramedullary locked nail is a valuable tool for the treatment of displaced proximal humeral fractures of type II and III.
In major degree fractures, the great fragmentation and the poor quality of bone's tissue, makes it less effective and imprudent. In such cases we prefer to use other treatments such as locked plates in younger patients, or prosthesis in elderly. We strongly suggest the preoperative CT scan in Neer's type III and IV fractures [3], since the conventional X-ray views frequently under-estimate the lesion .

Introduction
The external fixation has showed to be a very useful technique in the emergency treatment of several post-traumatic conditions as severe limb injuries, complicated fractures and polytraumatized patients. The global incidence of fractures of the proximal femur is constantly increasing in parallel with the average age of the population. Therefore, this disease represents a significant cause of morbidity and mortality in all age groups, particularly among the oldest; it is estimated that approximately 15-20% of patients with the far end of the proximal fracture of the femur dies within 1 year after the trauma. These fractures usually occur after an accidental fall and are more common among the elderly, with a prevalence for the female sex (male/female 1:4). The incidence of such fractures in the elderly is related to a number of factors, including: osteoporosis, malnutrition, reduced physical activity, decrease in visual acuity, neurological deficits, altered reflexes, weakness and imbalance. There are several classifications: some place emphasis on the problem of stability that is provided mainly by the whole of medial cortical, but also on the postero-medial part of the great trochanter. The treatment of lateral fractures of the femur neck is firstly rappresented by the search for stability that enables immediate rapid mobilization and, where possible, a early load. The solutions for the orthopaedic surgeon are many but the indications are very specific and must be accurately respected. We can choose an osteosynthesis with screw-plate or alternatively a central osteosynthesis with Ender nails, disused, or intramedullary nails (gamma, pfn, etc). In particular, since November 2007, we have been using a new cephalic screw (U-blade) in order to avoid the cut-out and a cylinder of hydroxyapathite, Lag-fix, as a filler spongy bone of the head of the femur. The results seem to be very encouraging. Finally we consider a very good choice the hip replacement with a prosthesis especially in A2.2 and A2.3 fractures type according to the AO classification. These fractures are very unstable. For this reason the osteosynthesis, central or peripheral, could be very difficult and complicated. In conclusion we tried, based on the AO classification, to create an algorithm of the various treatment options for lateral femur neck fractures.

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Introduction Calcaneal fractures are the most frequent tarsal fractures, and are caused by high energy injuries. They are usually highly comminuted, with involvement of the posterior joint surface. The outcome of conservative treatment is poor, and often leads to a chronic disability. On the other hand, surgical treatment not always leads to good results, and exposes the patient to high risk of severe complications. In this study we summarize the results of surgical treatment of joint calcaneal fractures, with open reduction and internal fixation with locking compression plates (LCP), with a lateral approach.
Material and methods Between 2005 and 2008 at our Institution 37 patients (40 calcaneus) underwent surgery with open reduction and internal fixation with LCP. All fractures belonged to group III-IV according to Sanders' classification. Timing of surgical treatment has been settled according to soft tissues conditions, with an average waiting time of 5 days. A lateral approach has always been performed, in order to restore a satisfactory Bohler's angle and a good reduction of posterior joint surface. The bone defect was treated with synthetic bone. Follow-up included monthly clinical examination and X-rays until consolidation, recording all the occurred complications. AOFAS score and Bohler angle was monthly determined.
Results Mean increase of Bohler angle was 32 degrees. Mean AOFAS score was 76. Most of the patients were satisfied with the outcome of surgical treatment. In eight patients some complications occurred: one deep infection (after 2 years) treated with implant removal and antibiotic therapy, and seven wound problems (all in heavy smokers).
Conclusions We believe that in joint calcaneal fractures open reduction and osteosynthesis with LCP is an efficacious procedure to restore the normal calcaneal anatomy with a good clinical outcome in selected patients. Wound problems are highly related to heavy smoking behaviour, and this element has to be considered when proposing such a surgical treatment. Treatment of proximal humerus fractures, epiphyisary and metaepiphisary, is still a much debated argument nowadays.
If the conservative treatment is generally reserved to compound or moderately split fractures, LCP plate osteosynthesis represents a largely used and shared treatment method, unless out-of-date and approximate cures are performed. Nevertheless, the introduction of a new generation of nailing systems, given major potentialities due to multi planar blocking, has allowed to synthesize under closed sky many proximal humerus epiphysary metaphysary fractures. During the past 4 years we have surgically treated 71 proximal humerus fractures. In 31 cases the fracture was reduced under open sky by means of a deltoid pectoral way of access and then stabilized with a LCP plate. In other 40 patients, we performed a reduction and a synthesis with a Proximal T2 nail, according to the mini invasive technique. In many cases the treatment choice was not conditioned by the splitting degree. Therefore, we compared the results of the two methods in terms of recovery times, functional recovery and patient approval. In most cases the blocked nailing allowed a major reduction of time in clinical and radiographic recovery, a better recovery of the joint motion of the shoulder and a minor effort in the re-educational phase, which led to a major satisfaction on behalf of the patient. We reckon therefore that the osteosynthesis of the proximal humerus fractures with the Proximal T2 nail is a reliable method which, given the large possibilities and an easily learnable mini-invasive technique, is advisable in the treatment of many proximal humerus fractures.
Surgical treatment of the disruption of the pelvic ring: our experience L. Rizzi, C. Castelli Orthopaedic and Trauma Department, Ospedali Riuniti di Bergamo (Bergamo, IT) Objective Disruption of the pelvic ring is a rare lesion, 1-3% of the traumatic skeletal lesion, that involves the three bones of the pelvis, nerves, vessels and its viscera. Surgical treatment of these lesions is aimed to fix instable lesions and to restore pelvic anatomy in order to avoid deformities and pain due to chronic instability and non-union [1,2]. We report our experience during the last 4 years. Material and methods Forty-seven patients were treated with anterior and/or posterior internal fixation for the injured pelvic ring between 2005 and 2008. The modified Tile classification was applied for evaluation of the pelvic ring injury. An average follow-up of 29 months included both radiological and clinical examination.
Results Patients treated for a B-type lesion had 80% of excellent and good results and healed anatomically. C-type fractures had a less percentage of anatomical reduction and only 33% of excellent and good results. Discussion Pelvic ring fractures have a high incidence of poor results due to the residual pain. In our experience we found a poor correlation between clinical and radiological results in C-type fractures because of associated traumatic lesions and due to high energy injuries.
Conclusions Our data suggest that the better clinical results are related to the greater stability of the fixation of the posterior pelvic ring. Anatomical reduction of the pelvic ring and internal fixation of the disruption of the pelvis is the goal standard in the treatment of these lesions.