In-Depth Oral Presentations, Oral Communications and Round Table

One-step techniques are a promising approach for cartilage repair. This study introduces a simple chondrocyte culturefree approach with autologous cartilage fragments loaded onto a mixed scaffold composed of high molecular weight hyaluronic acid derivative felt (Hyaff-11), injectable human fibrin glue (Tisseel) and autologous platelet-rich plasma (PRP). Nanoindentation of goat samples showed mechanical properties close to native goat-trochelarcartilage

Introduction Traumatic nerve injuries are common occurrences in developmental age, often due to blunt injury, sometimes to open lesion. In the child the small size of the nerves, the need to find appropriate nervous tissue to repair of such injuries and the aesthetic damage to the area of donor site for nerve graft have incentivated the study of alternative methods (tubulization) instead of classical nerve grafting. Moreover case series of nerve injuries in children are few in number and few are the report of nerve repair by means of synthetic tubulization. Our group applied synthetic tubulization in children since the year 2005, therefore the comparison of two homogeneous groups of nerve repair appeared to be a validation of the methods. Materials and methods We considered 20 patients, affected by brachial plexus or peripheral nerve injuries of upper and lower limb and treated in the period from January 2005 to December 2009. Ten patients of them underwent nerve repair by means of synthetic tubulization, while the others had nerve graft repair. Results Evaluation of results confirms how difficult is to compare nerve injuries, especially when nerve damage is related to large trunks, such as brachial plexus. Nerve guides in peripheral injuries repair, and particularly in brachial plexus surgery, showed slower clinical and electrophysiological signs of recovery compared to nerve grafting, but similar at a long distance in time. Failure turned out to be possible in both the methods. Discussion Regardless of the outcome in itself, the peculiarity of the paper is to specify the role of nerve repair in children by means of synthetic tubulization. Conclusions Nerve tubulization can be considered during repair of nerve lesions in developmental age as a technical advance in the presence of large nerve gaps when conventional nerve graft is insufficient, or even can represent an alternative to nerve graft. In small children, it is sometimes difficult to find veins with appropriate diameter to create biological nerve guides. In these cases, it is mandatory to use synthetic reabsorbable guides and thus spare autologous structures and avoid morbidity of donor site. The only disadvantage of this approach is the high cost of the tube and the low adaptability of synthetic guides compared to autologous nerve grafts.
Introduction Osteo-integration of non-cemented acetabular component in hip prostheses is related to several factors, like the roughness of the surface. A new type of extremely porous biomaterial for the acetabular cups, the Trabecular titanium (Delta TT, Lima), was recently developed. It has a macroscopic surface which is similar to that of the cancellous bone. It is also biocompatible and it has good mechanical properties. This material, when compared to full titanium conventional cups (Delta, Lima), has a surface hundreds times wider due to the 3-dimensional morphology. Aim of this study is to evaluate the urinary and ematic level of metal ions released from Trabecular titanium acetabular cups (D-TT) compared to conventional full titanium cups (D). Materials and methods Twenty patients entered the study: 10 subjects (average age, 70 years) were implanted with the Delta (D) cup and 10 subjects (average age, 64 years) were implanted with the Delta-TT (D-TT) cup. Aluminum (Al), Vanadium (V) and Titanium (Ti) in urine and in blood were assessed before surgery (T0) and then after one week (T1), 3 months (T2) and 6 months (T3). An ICP/MS Inductively-coupled plasma mass spectroscopy Agilent 7500 was used for the analysis of the samples (calibration solutions prepared with AccuTrace multielement certified standard, referred to a primary standard solution NIST), analytical range of 0-100 lg/l and the 5 point calibration curve. Statistical analysis between the two groups and the variance within each group were studied. Results The two groups were homogeneous for patients characteristics. No differences were detected at T0 and T1 between the patients and the values in the population. Also, no significant differences were observed on blood and urine between the two groups at different times, as well as within the same group at different times. Only the concentration of vanadium in urine at T1 was higher than in group D-TT. Discussion Although the studied metals are not reported as toxic in humans at the concentrations detected after total joint replacement, ion concentration in tissues is always a concerning topic. The starting hypothesis was that a much larger surface of the new Trabecular titanium would determine a higher release of metal ions. Conclusions These results show no differences from conventional and Trabecular cups.
Introduction Durable acetabular fixation is difficult to obtain after radiotherapy for pelvic malignancy. Acrylic cement is a short-term satisfactory solution but is associated with significant tendency to fail at a follow-up longer than 3 years. Porous tantalum has been very successfully used during the last decade in joint revision surgery and its great potential for osseointegration makes it an ideal material for use in biomechanically difficult situations such as radiotherapy sequelae. Goal of this study is the analysis of results obtained using a porous tantalum cementless acetabular component in patients undergoing total hip replacement after radiation therapy. Materials and methods This is a retrospective study of 6 patients after primary (4 cases) or revision surgery of previous failure (2 cases) after radiation therapy; 4 females and 2 males; average age, 49 years (26-76 years). Diagnosis related to radiation therapy was a primary musculoskeletal neoplasm of the pelvis in 4 cases and hematologic/secondary condition in 2 cases. At the time of surgery, none of the patients presented evidence of clinical activity of the underlying disease at a minimum follow-up of 2 years (2-12 years). The 2 revision cases consisted of an aseptic loosening and a deep infection, at 3 years and 1 year respectively from previous implant. Deep infection was treated by staged revision. In 2 cases, the porous tantalum acetabular component was associated with an ''augment'' to fill a segmental periacetabular defect and support the cup. Minimum follow-up after placement of the porous tantalum socket was 2 years. In all cases, mean follow-up was 3 years (2-5.5 years). Results In none of the cases there was local recurrence. There was 1 case of recurrent hip dislocation requiring further surgical management. There was neither clinical nor radiographic evidence of acetabular or femoral loosening at the most recent follow-up. Implant was well functioning and stable in all cases. Discussion These results are very promising to obtain durable acetabular fixation after radiotherapy and are related to the great potential for osseointegration of porous tantalum. Conclusions Porous tantalum has been very satisfactory at short term follow-up, demonstrating reliable capability to obtain biologic fixation after radiation therapy. A longer follow-up is necessary to identify later potential failures.
Human adipose stem cells can differentiate in an osteoblastic-like phenotype on trabecular titanium scaffolds without osteogenic medium Introduction Pluripotent human adipose tissue-derived stem cells (hASCs) can differentiate into multiple mesenchymal cell lineages.
Previous studies demonstrated that the material, the geometry and the porosity of scaffolds affect cell binding and migration depth of cellular ingrowth, and that hASCs can differentiate in an osteoblasticlike phenotype when seeded on trabecular titanium scaffolds with osteogenic medium. Aim of this study was to demonstrate that trabecular titanium scaffolds could induce osteogenic differentiation of hASCs also without osteogenic medium. Materials and methods hASCs were isolated from subcutaneous adipose tissue, seeded on monolayer and on trabecular titanium scaffolds (Ti6Al 4 V, LimaCorporate, Villanova di San Daniele del Friuli, Italy; average porosity, 65%, average diameter of cell pores, 640 lm) and incubated at 37°C in 5% CO (2) with osteogenic and proliferation medium in static conditions. Cells before seeding corresponded to reference group. After seeding on scaffolds, hASCs were cultured for 7 days in the presence of proliferation medium before the osteogenic medium was added (Time 0). The osteogenic differentiation was detected with real-time PCR to analyze the expression of ALP and RUNX-2 genes, at time 0 and after 3, 7 and 21 days from differentiation. Alkaline phosphatase activity on cell lysates was also measured after 7 days from differentiation. Results Monolayer: both ALP and RUNX-2 gene expression and alkaline phosphatase activity were higher in hASCs grown in presence of osteogenic medium. Trabecular titanium scaffolds: in hASCs grown in proliferation medium, ALP gene expression was higher than reference group still at time 0, and remained 2.5 fold higher at time 3 and 7. Similar results were found with osteogenic medium. RUNX-2 gene expression was higher in hASCs grown in osteogenic medium, and increased also in the presence of proliferation medium respect to reference group. At time 7, there were no difference in alkaline phosphatase activity of hASCs grown with proliferation and osteogenic medium. Conclusions hASCs on trabecular titanium expressed higher amount of ALP and RUNX-2 gene expression in proliferation medium with respect to cells on monolayer in the same condition. The expression of osteogenic genes similar in cells grown on scaffold with both medium, leads to the conclusion that trabecular titanium scaffold seems to have not only osteoconductive but also osteoinductive properties.
Introduction Failure of prosthetic implants is frequently reported in literature and is related to wear and mechanical failure of ultra high molecular weight polyethylene (UHMWPE). These phenomena are strictly connected to aging and oxidation of plastic material, because irradiation with gamma ray produces OH radicals. A blended alphatocopherol UHMWPE is a valid alternative to limit this dangerous aging effect on prosthetic plastic material. Materials and methods The present study takes into consideration a new substance to dope irradiated UHMWPE. Lipoic Acid (LA) was mixed with UHMWPE powder (GUR 1050) and solid pieces were made with 0,1%, 0,3%, 0,5%, 1%, 2% lipoic acid. Solid polyethylene was gamma ray irradiated with 30 kGy (Isomedix, Northborough, MA). An owen (80°Celsius) was used to produce an aging effect for 30 days in the doped and control samples (Conventional not doped polyethylene). This process simulates an aging effect of 10 years into the body. A Furier Transfer Infra Red (FTIR) was used to study oxidation of blended and not blended polyethylene on the surface and 1 mm under the surface. Specifically 1 mm under the surface is the most responsible layer of delamination in prosthetic material. Results Control FTIR shows in the doped lipoic acid samples a lower oxidation index versus not doped polyethylene samples. This effect was also obtained in 0.1 concentration of lipoic acid samples. Discussion This knowledge demonstrate that doped UHMWPE could be a valid alternative for the future. Lipoic acid is an antioxidant powder physiologically produced from our body and biologically known for this reason. Lipoic acid can be easily added to polyethylene because is a powder and it is simultaneously hydrosoluble and liposoluble. A low cost can be taken into consideration according to a very low concentration effect. Conclusions This paper demonstrate the possibility of lipoic acid to reduce oxidant effect on aged gamma irradiated polyethylene like alpha tocopherol.
Metal hypersensitivity in patients with total knee arthroplasties Introduction TKA failure is generally multifactorial. Chronic inflammation following the generation of wear particles has been recognized as the main biological mechanism leading to implant failure which may be induced, including a delayed-type hypersensitivity reaction (DTH). The main goals of our study were to evaluate (a) the frequency of skin sensitization in patients who had undergone TKA, and (b) the clinical impact of this event on the outcome of the implant. For this purpose we chose to use patch testing by applying a panel of haptens representative of cobaltbased alloys (CoCrMo), titanium-based alloys (TiAlV), and bone cements. Materials and methods Ninety-four Caucasian individuals were enrolled in this retrospective case control study. Three groups of patients were evaluated: the first group (no Implant) included 20 patients who were candidates for TKA; the second group consisted of 27 individuals who had already undergone TKA that was clinically and radiographically stable (stable TKA); the third group consisted of 47 patients who had already undergone total knee arthroplasty but showed clinical and radiographic evidence of failure (failed TKA). Results The frequency of positive skin reactions to at least one hapten was significantly higher in group of patients tested after TKA and no differences were observed between stable and loosened implants. In 'No Implant' group, the frequency of positive patch testing for at least one metal hapten was 15%, and differed significantly from that observed in patients with Stable TKA. Patients with stable CoCrMo/ TiAlV implants showed a higher percentage of positive patch testing to vanadium in comparison to individuals of the pre-implantation group. Discussion This study confirms that in patients with a TKA the frequency of positive patch testing is higher than in the normal population, although no predictive value is attributable to the sensitization because patch testing was not able to discriminate between stable and loose implants. On the contrary, the presence of symptoms of metal allergy before implantation should be taken into account as a potential risk factor for TKA failure. Ceramics therefore may be a solution for patients with allergies to implant materials and may have an improved resistance to wear, followed by reduced aseptic loosening rates Since the biologic effect of wear particles depends on the material and volume of wear particles, materials with less wear are of scientific interest.
Introduction Surface modification of implant devices by molecules that can stimulate bone regeneration is a hot-topic in orthopaedic materials coating. Type I collagen is a key-molecule in osteogenesis. The aim of this work is to present our in vitro and in vivo results on collagen I nanolayers coating of bone implant devices. Materials and methods In vitro tests were performed on Ti disks, both coated by porcine collagen I and uncoated control. The process involves chemical bonding to prevent attack by collagenase in the implant site. Surface characterization confirms that collagen I fibrils, a few tens of nanometers thick and a few hundreds of nanometers long, homogeneously cover the treated surface. Adhesion and growth of human mesenchymal cells (HMC) were evaluated, together with gene expression by RT-PCR. In vivo tests were performed by implanting coated and uncoated titanium screws in rabbit (both trabecular and cortical bone), followed by istomorphometry at 4 weeks. Statistical significance of differences between data was checked by Wilcoxon signed rank test. Results Adhesion and growth of HMC on titanium is affected by the collagen nanolayer. The number of adhering cells is greater on the coated samples at every experimental time (p \ 0.05, at 4, 12, 24 and 96 h). At longer time (2-3 weeks) cells grown on collagen coated surfaces display a different morphology as compared to control, and gene expression by RT-PCR shows overexpression of pro-osteogenic genes, in particular alkaline phosphatases. As to in vivo tests, both bone-to-implant contact and bone ingrowth are significantly greater on collagen coated samples. Differences are more pronounced in trabecular bone. Discussion This work is an example of the ongoing evolution of implant devices from mechanics to biology. Collagen I coating offer to HMC a competitive advantage in the race for the surface of the implanted devices, enhancing adhesion and promoting differentiation towards the osteogenic pathway. This specific bioactivity is reflected in in vivo results, that show faster and more pronounced bone regeneration at the implant surface. From a clinical point of view, main advantages of surface biomolecular stimulation are expected in marrow-rich trabecular bone, such as vertebral bodies, while we are starting evaluation on pathologic bone (osteoporotic, diabetic patients). Conclusions Nanometer thin, collagenase resistant, porcine collagen I coating on implant devices promotes HMC adhesion and differentiation in vitro and stimulates faster peri-implant bone regeneration in vivo.
A new metal part finishing method for polyethylene wear reduction in total knee prostheses Introduction Synthetic bone substitutes based on hydroxyapatite and/ or tricalcium phosphate play basically a mechanical role in regeneration of bone defects. There is presently a significant research effort aimed at endowing these products with multifunctional properties, such as molecular stimulation of bone regeneration and antibacterial effects. In this communication we present our results on in vitro characterization of a granular synthetic bone substitute, endowed with a biomolecular coating based on complexes among collagen, hyaluronan and vancomycin. The aim of the work is to confirm the effect on cell stimulation and to evaluate drug-release and antibacterial properties. Materials and methods Granules (diam., max 2 mm-min 0.3 mm) made by 75% beta-tricalciumphosphate and 25% hydroxyapatite were coated with hyaluronan-collagen-vancomycin complex. The process provides a biomolecular coating a few hundreds nanometers thick. The obtained product was analyzed by infrared spectroscopy and HPLC, and used as a substrate for inflammatory cells (J774-A2 macrophages) and human mesenchymal cells (HMC) culturing. RT-PCR measurements were performed at different time interval. The antibacterial effect was evaluated through zone of inhibition test in Agar germ, seeded with Staphylococcus epidermidis. Results HPLC measurement shows that about 100 micrograms vancomycin are loaded for every 100 milligrams of phosphate ceramic. Vancomycin release in physiological buffer occurs for a few weeks, about 70% is released in the first week. Zone of inhibition test confirms the antibacterial properties of the product, preventing the growth of S. epidermidis (zone of inhibition about 1 cm in the adopted conditions). RT-PCR measurements confirm the effect on J774-A2 cells, decreasing the pro-inflammatory response (in particular IL-1, IL-6 e MCP-1) and upregulating pro-osteogenic transcripts in HMC. Discussion Most of the present-day research effort in implant devices aims at producing multifunctional surfaces, that combine different stimulatory effects on host tissues. The material described adds to the mechanical properties of the synthetic device the biomolecular (collagen/hyaluronan) and the pharmaceutical (vancomycin release) functions, aimed at a faster bone growth in the local presence of antibacterial effect. Conclusions Present results show that biomolecular surface engineering can upgrade the properties of bone substitutes that exert mainly a mechanical function. Even if these encouraging in vitro results should be confirmed by forthcoming in vivo tests, it is clear that surface engineering applied to bone substitutes can play a fundamental role in the development of novel material of clinical interest.
Introduction Resurfacing hip arthroplasty is becoming more popular for younger or with a greater functional demand patients, with degenerative hip disease. However, taking into account the data reported in the literature regarding revision rates and adverse reactions to any individual hyper-reactivity to metal debris (joining metal to metal) [1,2], some authors question the supposed superiority of ''resurfacing'' compared to traditional total hip replacement. In this meta-analysis, we aimed to compare clinical and radiological results and complication rates of the two procedures, analyzing the most recent authoritative literature on the subject. Materials and methods We performed a systematic review of all published articles (Medline, CINAHL, Amed, EMBASE, PubMed) until January 2011. We compared the clinical and radiographic results of resurfacing series with those of traditional total hip prosthesis and evaluated carefully the incidence and the type of complication rate reported by various authors. Results 55 studies were analyzed with the results of 3957 resurfacing total hip replacement, compared with 3465 conventional total hip arthroplasties. The functional results are generally better or comparable after resurfacing, however, this type of prosthesis exhibits an higher incidence of complications such as aseptic failure of components, postoperative fractures, revision of the components, incidence of heterotopic ossification. Conclusions Based on the analysis of the recent literature regarding the comparison of traditional and resurfacing hip arthroplasties, it can be concluded that, given the increased risk of heterotopic ossification, aseptic loosening and revision surgery after hip resurfacing, traditional total hip replacement is still superior in terms of implant survival [3].  Introduction Recurrence of carpal tunnel syndrome after carpal tunnel release is a rare event, however practitioners may address again the patients to the surgeon if pain of any kind occurs in the treated hand. Electrophysiological evaluation is seek for diagnostic purposes. The electrophysiological outcome after carpal tunnel releases has been the subject of a limited number of studies. Our objective was to evaluate, during a one-year period, which changes occurred in the electrophysiological parameters and comparing them with the clinical outcome. Materials and methods Twenty patients which received open-surgery in a consecutive series (no patient was excluded) were studied by measuring electrophysiological parameters at 1-month pre-operatively and, then, at 1-, 3-, 6-, 9-and 12-month post-operatively. Sensory nerve conduction velocity of median nerve (digit1-wrist and digit3-wrist) and radial nerve (digit1-wrist), as well as distal motor latency of median nerve, were measured. Furthermore, the shift between the latency of median and radial sensory nerve actionpotentials (double peak shift), which is recorded following thumb stimulation, was investigated; this latter parameter is independent from possible inter-individual variations in nerve conduction velocity.
Results At 3 months, all patients experienced a distinctive remission in clinical signs and this was maintained afterwards; however, nerve conduction parameters did not returned to normality and this was true for most of them even after 12 months. The shift between the latency of median and radial sensory nerve action-potentials persisted in all patients at 12 months. Discussion Despite surgical treatment let the electrophysiological parameters to move towards physiological values, normality was hardly reached; this sort of ''electrophysiological scar'' was particularly evident when the ''double peak shift'' was measured.
Conclusions These results lead us to suggest that abnormal postoperative electrophysiological findings, in the long term, should not Conclusions This technique allows to reach good results also in the advanced stages of the disease and it is a good alternative procedure to the partial wrist arthrodesis, because it often preserves a good wrist range of motion and anatomy.
The F. Brunelli technique of looping the APL hemi-tendon to the first intermetacarpal ligament after trapeziectomy: one-year follow-up develop tendinosis or tendon rupture or a complex regional pain syndrome type 1. We tested the looping of a slip from the Abductor Pollicis Longus tendon around the first intermetacarpal ligament, aiming at a surgical treatment which does not require bone tunneling or looping around a tendon. Our results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis. Materials and methods Forty-two patients were followed-up for one year. Each patient had subjective assessment for: pain; function (DASH) overall satisfaction. An objective assessment was enterprised for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at 3, 6 and 12 months. X-ray films were taken to monitor thumb height.
Results A significant improvement in all the parameters was measured in all patients. X-ray films showed the maintenance of a physiological height after one year. We recorded one complication of keloid and two of temporary dysesthesia but no cases of tendinosis, delayed rupture, or CRPS 1. Introduction Because of demographic changes in industrialized countries, an increase by more than 50% of fractures of the distal radius is expected by 2030. Young patients usually show intra-articular and fragmented fractures mainly due to high energy trauma, whereas elderly patients' characteristics of these fractures is osteoporosis, which frequently leads to instability (following the criteria of Lafontaine) and secondary loss of reduction. Materials and methods At our Department 33 patients (24 women, 9 men) were treated for fractures of the distal radius with volar fixedangle plates. Introduction Due to the fact that often the femoro-acetabular impingement (FAI) occurs in combination with other pathologies related to the hip joint, the diagnosis could be difficult to achieve. To overcome these issues, different approaches have been proposed. The goal of the present study is to evaluate the dislocation of the contact areas during the physical examination commonly applied to make the femoro-acetabular diagnosis and whether they are able to effectively emphasize the presence of FAI. The following configurations were tested: 90°Flexion-Adduction-Internal Rotated, Extension-Adductio-External Rotation, Extension-Neutral-External Rotation. As a preliminary study to define the contribution of the soft tissues to hip range of motion, we tested three different conditions: intact hip, after removal of muscles and after partial capsulectomy. Materials and methods Eight fresh frozen hips from four cadavers were tested. The specimens were securely fixed to a wood base in supine and neutral alignment, the load was manually applied and each test was repeated three times. An optoelectronic system (Blu-IGS, Orthokey, DE) was used to acquire the kinematics and anatomical data. The Cardano's angles have been calculated with the goal to evaluate the reproducibility of the performed motion. In particular we evaluated the Interclass Correlation Coefficient between the three repetitions of each movement. A spherical model was developed for both the acetabulum and femoral head surface to quantify the contact areas between them. To facilitate the description of the results we got, we used the common clock-face representation for the acetabulum.

Results
The main ICC calculated was up to 0.7 for all the tests. We found the contact areas mainly localized between 8-12 o'clock during ''Ext-Add-ExtRot'' and between 9-11 o'clock during ''Ext-Neu-Ex-tRot''. While ''90Flex-Add-IntRot'' provoked a spreader dislocation of the contact areas. The previous results remain valid even after the skin and muscles removal and partial capsulectomy. Discussion The present work does present some limitations. The use of cadaveric specimens implies the absence of muscular control. Moreover the load was manually applied without any control.
Conclusions The results confirm that the tests analyzed could be used as a method for verifying the presence of FAI. In particular, to analyze the most posterior region of the acetabulum, it is suggested to rich a configuration where the hip is both extended and external rotated. On the other hand the absence of contact areas in the most anterior portion of the acetabulum seems to challenge the effectiveness of these tests to quantify the anterior instability of the hip.
Periacetabula osteotomy: preliminary experience of the Italian group for hip conservative surgery Introduction Beside perceiving the final goal of a long lasting painfree articulation, modern total hip replacement should also fulfill the functional requirements of a increasingly demanding and younger population. The replaced hip must guarantee a primary solid mechanical stability, allow for a rapid biological integration and must represent the tool for the most accurate and biometrical correct articular reconstruction according to the pre-existing anatomical morphology. Tissue sparing surgery represents the connection ring between the theoretical advantages of a correct articular restoration and the actual outcome.
Materials and methods A radiographic study was performed on 100 patients operated with an hemispherical cup and the fitmore stem with particular regard to offset and leg length comparing the postoperative result with the contralateral non affected side. The comparative analysis was performed on 75 patients excluding cases of contralateral arthritis and cases that could not be matched because of other reasons.
Results A subtle mean difference of -0.54 mm could be achieved regarding the post-operatively offset. In one third of the cases the offset matched exactly the contralateral value, in one third of the patients it differed by a mean value of -3.03 mm, in the remaining third it was increased on average by 1.84 mm. Leg length was increased by an average of 0.44 mm compared to the contralateral side, in 60% of the cases leg length was equal, in 22% the leg resulted shorter on average by -2.6 mm, 17% of the cases longer on average by of 3.52 mm. Considering a tolerance of ± 5 mm, leg equal length was restored in 95% of the cases. Discussion The fitmore's stem design is based on different a radius of curvature according to the distinct femoral anatomy in varus or valgus hips compared to regular hips. Its considerable number of sizes in each family group allows a precise geometrical reconstruction of the new articulation provided preoperative planning is reproduced during surgery by an accurate surgical technique.
Mini-invasive treatment of necrosis of the femoral head with the use of biotechnology Materials and methods Starting from the idea of core decompression we developed a new surgical technique with a dedicated instrument that combines the removal of necrotic tissue (core decompression) with the inclusion of growth factors (rh-BMP-7) and an equine bone scaffold flexible enriched with autologous mesenchymal cells. We treated 18 patients with this method out of a total number of 20 affected patients, all patients had more than one stage IIIc according to Steinberg classification. Each patient was studied pre-operatively by clinical, radiographic, MRI and CT. Patients were then re-evaluated clinically and radiographically at 1, 3, 6, 12 and 24 months, an initial CT scan was performed at 3 months followed by a control MRI at 6 months.
Results We obtained excellent results in 17 cases of clinical and imaging (non-progression of necrosis, cortical conservation profile of the femoral head, the absence of structural collapse and good articulation) at 18-month medium follow-up; 2 cases of failure with persistence of symptoms and progression of necrosis; 1 case of subtrochanteric fracture after trauma.
Discussion The technique appears to offer good results especially given the short time required for surgery, the simplicity of the surgical technique and ability to save still healthy joint in patients young.
Conclusions With the encouraging results obtained we can conclude in favour of the application of biotechnology in polytherapy in the treatment of necrosis of the femoral head until a stage IIIc. The treatment does not preclude further surgery and prosthetic replacement and is much less invasive and well tolerated by most patients when compared with vascularized fibula autograft.
Use of bone allografts added with mesenchymal stem cells and growth factors in the treatment of necrosis of femoral head Introduction The necrosis of the femoral head is a fairly widespread problem especially in young people between 30 and 50 years. Excluding post-traumatic forms, the etiology is not yet fully understood. There is a higher incidence in certain groups of patients as in patients receiving high-dose steroid therapy for long periods, in organ transplants or patients with SLE. Several studies in the literature show that core decompression is the method of choice for the treatment of necrosis of the femoral head in the early stages, with good clinical results in the short term. Given the numerous cases of progression and collapse of the femoral head after core decompression some authors have proposed the use of allograft bone grafts. Materials and methods From May 2008 to October 2009, 12 patients (2 in stage I, 9 in stage II and 1 in stage IV according to the ARCO classification) underwent core decompression with bone graft added to mesenchymal stem cells and PrP. Mesenchymal stem cells were obtained from bone marrow aspirate from the iliac crest. Patients were evaluated in the preoperative and at 3, 6, 12, 24 months with clinical evaluation including Harris Hip Score (HHS), radiographic and MRI evaluation.
Results The patients have shown complete recovery of motion in the absence of hip pain and return to normal daily activities. Furthermore, a progressive improvement of HHS values was obtained, passing from the mean pre-operative 38.3 ± 9.9 to 79.9 ± 7.5 at 3 months (p \ 0.0001), to 85.0 ± 8.5 at 6 months (p \ 0.0001) To 84.9 ± 16.9 at 12 months (p = 0.0002) and 88.6 ± 4.1 to 24 months (p \ 0.0001). The patient with stage IV sec. ARCO underwent hip artheroplasty. In the radiographic and MRI evaluation was not observed any progression of lesions (Arlet and Steinberg classifications, respectively), except in the patient with femoral head collapse. Conclusions In conclusion, the results show that core decompression combined with bone grafting, mesenchymal stem cells and PrP may be a useful and effective method for the treatment of necrosis of the femoral head at an early stage. These data should be confirmed, however, extending the follow-up and increasing patient's number.
Intra-articular injection of autologous growth factors for degenerative pathology of the hip joint that almost all cases of hip joint arthrosis are due to some kind of development anomaly or to collagen derangement. The cellular adaptation to the articular damage determines pathological modifications of the liquid content in the collagen structure and in the proteoglycans composition, this results in cartilage degeneration and subsequent reduction of the articular space. Materials and methods We treated 11 patients with age superior to 45 years, having a diagnosis of degenerative disease of the hip joint for more than one year. Each patient had a series of intra-articular injections under ultrasound guidance of plasma rich platelets (PRP) for a total of 4 injections applied on a weekly basis. Preliminary clinical evaluation included administration NRS and WOMAC questionnaires, these tests were repeated at the end of treatment and yet another time at 6 months from the treatment end. Average patients age is 55.18 years (46-72); 7 males and 4 females were included; 8 patients presented primitive disease, and the remaining 3 had secondary disease; in 7 cases the left hip joint was affected and in 6 cases it was the right side which was affected. Two patients had X-ray examination classified as grade IV of Kellgren-Lawrence, 7 were grade III, 1 was grade II and 3 were grade I. The main complications were 4 early post-traumatic arthritis operated by hip replacement. One patient developed a gastric carcinoma and got lost at follow-up. Discussion The anatomic reduction is the first goal that surgeons must achieve in order to obtain good results. The reduction quality was adversely affected by the complexity of the fracture, associated injury of the femoral head, the patient's age, and the interval between the injury and the reduction. Most of the fractures (91%) were correctly reduced using the ilio-inguinal approach alone, through the medial window of that approach and with the help of dedicated surgical tools.
Conclusions These preliminary results indicate that it is possible to reduce both columns fractures through a single approach in order to decrease infections, operating times, skin scars and rehabilitation times. Surgeon experience and a long learning curve can help in decision making and in obtaining an anatomical reduction with a low rate of post-operative complications in this very hard orthopaedic field. Introduction Open wedge high tibial osteotomy is an established technique to treat symptomatic varus malaligned knees. The purpose of our study is to compare the clinical and radiological results of two groups of patients treated with either conventional or computer assisted open wedge high tibial osteotomy. We established the goals of correction in obtaining a postoperative mechanical axis as between 2 and 6 degrees valgus and an increase or decrease of posterior tibial slope between -2 and +2 degrees.
Materials and methods In our study we prospectively followed-up 24 patients (27 knees) affected by varus knee deformity and operated with OWHTO. They were randomly divided in two groups, A (11 patients, 13 knees) and B (13 patients, 14 knees). All patients were evaluated both clinically and radiologically, pre-operatively and postoperatively. For clinical assessment, two questionnaires were used: the Knee Society Score and the Modified Cincinnati Rating System Questionnaire. All patients were radiologically evaluated with a comparative lower limb weight-bearing digital radiograph, a standard digital antero-posterior (A-P), a latero-lateral (L-L) radiograph of the knee and a Rosemberg view.
Results At mean follow-up of 39 months we reassessed all patients. Clinical evaluation showed no statistical difference (p [ 0.05) between the two groups. Radiological results showed an 24% (3 patients) reproducibility in achieving a mechanical axis of 182°-186°i n the group A compared to a 86% (12 patients) reproducibility in achieving a mechanical axis of 182°-186°in the group B (p = 0.0392). Furthermore, only in the 24% of patients treated with the conventional technique, we obtained an increase or decrease of posterior tibial slope between -2 and +2 degrees, in patients treated with the navigation system we obtained this result in 100% of cases (p \ 0.0003).
Discussion In literature, studies concerning patients treated with HTO, agree in describing a good long-term clinical results, but there is considerable controversy regarding the ideal valgus correction angle. The use of navigation system for the tibial osteotomy has been recently introduced and studies present in literature are still discordant concerning its utility. The aim of this study is to evaluate the accuracy and reproducibility of the navigation system in the correction of varus knee deformity.
Conclusions High tibial osteotomy with navigator is more accurate and reproducible in the correction of the deformity in both coronal and sagittal plane compared with standard technique.
Use of an electronic system for balancing a total knee arthroplasty F. D'Angelo*, T. Binda, P. Cherubino Clinica Ortopedica, Università dell'Isubria (Varese, IT) Introduction The soft-tissue balancing plays a key role in the result of a total knee replacement. Currently it is a key operator dependent, linked to the surgeon's experience accumulated over the years. In order to standardize this feature a new mechanical system for intraoperative assessment of ligament tension was developed This system measures objectively the strength in the two compartments before the final cuts are made, thus balancing the ligamentous tension with a modification in femoral component rotation. Materials and methods Between April 2010 and January 2011 E-Libra (Synvasive Technology Inc.) tool was used in 50 consecutive total knee arthroplasties. The mean age was 69.55 years (range 47-85 years), 14 males and 36 females. All operations were performed by a single surgeon, using the same surgical approach, median parapatellar aggression line, and using the same model of a prosthetic posterior cruciate sacrifice. All patients were evaluated clinically using the Knee Society Score before the operation and subsequent controls.
Results In none of the 50 cases lateral release was performed, the patients included in this study reported no complications peri-or post-operative. The clinical evaluation showed an improvement in both scoring (82.7 points and 88.2 respectively for clinic and function). Discussion To sum up, the use of this device provides patient-specific rotational orientation of the femoral component. As such, the femoral component is no longer tied to conventional methods such as the epicondylar axis, the Whiteside line or 3°of external rotation with reference to the posterior condyles, which are typical anatomical landmarks often used. However, these anatomical references lead to a decrease in asymmetry of the flexion space in about 10% of cases.
Conclusions Due to the short follow-up period, only favourable impressions of the simplicity of the instrument and the reproducibility of the ligament balancing can be expressed. Discussion In our study we did not detect any advantage in using double bundle ACL reconstruction in term of clinical outcome and knee stability in the short-medium term. In our opinion, this lack of difference in our study could be related to the anatomical positioning of the AM bundle in the single bundle technique.

Use of transepicondilar aligner device (TAD) in 900 TKA implanted between December 2007 and December 2010
Introduction The transepicondilar aligner device (TAD) is a mechanic system that allows the right rotational positioning of knee femoral prosthesis component based on transepicondilar axis. It also helps more rapid space in flexion calculation, can be used with every prosthesis instrumentation, finally it is easy to use and uptake. Actually, we are studying a new evolution of this device that will allow to calculate both transepicondilar line and space in flexion, ensuring a superior prosthesis stability and duration. Materials and methods All 900 TKA have been implanted by the same expert surgeon through a miniparapatellar approach, using three different prosthesis models (PS mobile platform, CR mobile platform, CR fixed platform).
Results Results were evaluated using OKSS. Transepicondilar line rotational angle average, calculated by TAD with posterior reference was of 4.5°± 0.5°of external rotation in valgus knee and 3.5 ± 0.5 of external rotation in varus knee. This angle was calculated both in operation room and on pre-operative CT. Only in 8 cases of varus knee, transepicondilar line rotational angle was of 1°o f internal rotation, they were 8 varus congenital internally rotated tibias. Discussion Identification of the transepicondilar line is easy, it is enough to feel epincondyles, the more prominent markers in L-L, to trace the line and then to set TAD, or you must calculate the line on pre-operative CT and then to set TAD according with its angle. Space in flexion is more difficult to calculate although it is very important for prosthesis kinematic. An exact calculation of transepicondilar line and space in flexion generates a fulcrum with constant moment during implant work, realizing right compression and slipping forces that do not generate dissecting lines that deforms polyethylene.
Conclusions In our study of 900 TKA implanted with TAD, the common factor was almost total breakdown of patellar pain, prosthesis stability, more easy calculations and realization space in flexion with improvement of prosthesis kinematic, no patellar prosthesis, and subjective and objective feeling of almost normal joint with ROM between 0°-130°.
Preliminary results of a ceramic femoral component in total knee arthroplasty Introduction Total knee arthroplasty (TKA) is one the most successful procedures in orthopaedic surgery, with good outcomes in pain reduction and function recovery. However, the increase in life expectancy and in patients' needs have led to develop new designs and materials. The introduction of alternative materials, as ceramic, is important because allows the reduction of polyethylene wear, one of the most important causes of mobilisation, and represents a solution for the growing problem of metals hypersensitivity. The goal of this prospective study is to evaluate clinical and radiographic outcomes of a total knee prosthesis with an innovative femoral ceramic component. Materials and methods 108 patients (110 knees) underwent a total knee arthroplasty with a ceramic BIOLOX Ò delta femoral component (Multigen Plus Ceramic Knee, Limacorporate SpA, Villanova di San Daniele, Udine) in 7 European centres. The average age of the patients was 67.7 ± 5.9 years. They were female in 81 cases (73.6%) and male in 29 (26.4%) and had an average height and weight respectively of 165.9 ± 7.7 cm e 79.0 ± 11.7 kg (BMI 28.7 ± 3.5). They mainly suffered from primary osteoarthritis (93%), osteonecrosis (4%), rheumatoid arthritis (2%) and, lastly, secondary osteoarthritis (1%). Clinical evaluation was performed preoperatively, at 3, 12, 24 and 60 months using the Hospital for Special Surgery Score (HSS), WOMAC score e SF-36 questionnaire. Radiographic evaluation was planned at the same time points using the immediate postoperative as baseline. The statistical analysis was performed with the Friedman (FR) and Wilcoxon (WI) tests, with p-value \ 0.05. Results The minimum follow-up was 12 months. The average HHS value significantly improved from 55.5 ± 11.5 in the pre-operative to 77.2 ± 10.3 and 85.6 ± 8.9, respectively after 3 and 12 months (WI test p = 0.001). Significant improvements were identified in all domains, especially pain and ROM (WI test: pain p \ 0.001, function p \ 0.001, muscular strength p \ 0.001, deformity p \ 0.001).
Radiolucent lines have been identified in 3 cases, but without signs of progression. No implant-related complications, signs of mobilisation and failures occured. Conclusions Short-term clinical and radiographic outcomes in the use of the ceramic in knee femoral component arthroplasty are very promising. A long-term follow-up is necessary to confirm the results and evaluate the survivorship rate of the implants.

AT18 -KNEE 2
Medial open wedge high tibial osteotomy: hydroxyapatite-based spacers without bone graft treatment Introduction Medial Open wedge osteotomy envisages the creation of a bone defect on tibial tuberosity using a drill and osteotome technique filling the gap using autologous bone withdrawn from the iliac crest. Nevertheless, avoiding autologous bone transplantation, reduces the drawback related to associated morbidity and decreases the time of surgical procedure [1]. The aim of this clinical investigation was to demonstrate the effectiveness of a hydroxyapatite based spacers (ENGIpore) to fill the bone gap after osteotomy. An improvement of post-operative course was evaluated as well. Materials and methods In the prospective randomized study 70 patients underwent a medial open wedge high tibial osteotomy. All surgical procedures were performed by the same surgeon using standard surgical procedure and the same plate with locked screws was used for fixation in all cases. Patients were randomly divided in two groups (n = 35): Group I received no treatment and the gap was left empty (Control Group), in the Group II (Treatment group), the patients were treated with biomimetic ENGIpore bone spacers based on hydroxyapatite. All patients followed a standard post-operative rehabilitation protocol. Results At follow-up, no significant differences were observed between the two groups after X-ray evaluation, although in the EN-GIpore group the clinical evaluation exhibited a shorter recovery of normal activity with less pain in comparison to the untreated group. Both groups of patients received the same standard peri-and post-operative protocol. All patients received the same rehabilitation protocol, starting from day 1. Just patients of group A received the PEMF stimulation (I-ONE therapy, IGEA, Carpi, Italy) for 4 h/day for 60 days, starting from day 3 postsurgery. Patients were evaluated at 1, 2 and 6 months after surgery using VAS Knee Scale, Knee Score and SF-36 questionnaire. Joint swelling was also evaluated.
Results No significant differences in background factors between the two groups were observed (p [ 0.05). Homogeneity was also found in term of pre-operative SF-36, VAS, Knee Score and swelling between group A and B (p [ 0.05). After 1 month from surgery just patients of group A showed a significant improvement respect to baseline (day 3 after surgery) in term of functional recovery (p \ 0.05); however starting from 2 months these values were comparable between the two groups, and they both were significantly higher than the baseline level (p \ 0.001). The knee rating values were very similar in the two groups, with significant differences respect to baseline (p \ 0.001) already starting from 1 month after surgery. Joint swelling was significantly reduced in group A respect to group B (p \ 0.05) both at 1 and at 2 months, whereas at 6 months data between the two groups were comparable. Pain, evaluated by VAS knee scale, was significantly reduced in both groups already from 1 month after surgery; however at this time point we observed a significant difference between the two groups (p \ 0.05), with better results in group A. Discussion Even if in a small sample size, patients treated with I-ONE therapy show a better outcome in term of pain, functional recovery and joint swelling, above all in the first month after surgery. This can be due to the anti-inflammatory effect of PEMF on the whole joint tissues.
The three-in-one procedure for recurrent dislocation of the patella in skeletally immature children and adolescents M. Ronga* 1 , F. Oliva 2 , U. Longo 3 , V. Testa 4 , P. Cherubino 1 , N. Maffulli 5 1 who were suffering from recurrent unilateral patellar dislocation were included in the study and followed until skeletal maturation. The 3-in-1 procedure is an extensor mechanism realignment of the knee combining lateral release, vastus medialis obliquus muscle advancement, and transfer of the medial third of the patellar tendon to the medial collateral ligament. The patients were regularly followed-up postoperatively at 2, 4, 8, 12, and 24 weeks, and then annually. Evaluation included the modified Cincinnati and the Kujala scores, anthropometry, plain radiography, and isokinetic dynamometry.
Results The average follow-up was 3.8 years (2.5-6). The mean modified Cincinnati score increased from 51.7 to 94.3 (p \ 0.02), while the mean Kujala scores increased from 52.4 to 93.8 (p \ 0.02).
The muscle volume of the thigh of the operated limb increased with time, but remained significantly less well developed than the muscle volume of the thigh of the nonoperated limb (p = 0.03). The Insall-Salvati index remained essentially unchanged, being 1.04 preoperatively and 1.02 at latest follow-up. Significant differences were found between the operated and the contralateral limb in the various isokinetic strength variables at all angular velocities measured at the latest follow-up (0.05 \ p \ 0.0042). Only 1 patient suffered a patellar redislocation.
Discussion The minimum follow-up of 2.5 years and until skeletal maturation is long enough to consider that the results of surgery had stabilized. In a prospective randomized study, Palmu et al. observed that most of the first redislocations occurred within 2 years after surgery. Side-to-side differences in isokinetic strength and in anthropometric indices persist despite subjective success of the procedure. It is possible that heavy resistance training may have to be implemented to overcome these findings. Correct indications and a careful preoperative evaluation are of fundamental importance for successful long-term outcome. The 3-in-1 procedure does not preclude further surgical stabilization, as do the Elmslie-Trillat procedure or reconstruction of the medial patellofemoral ligament, when failure occurs after skeletal maturity.
Conclusions The 3-in-1 procedure is a safe, reliable management option for recurrent patellar dislocation in skeletally immature patients. Long-term evaluation is necessary, particularly to monitor the possible development of patellofemoral osteoarthritis.
Return to sports activity after unicompartimental knee arthroplasty Introduction There is continuing debate regarding the best treatment for young patients with unicompartimental osteoarthritis of the knee. In recent years, unicompartimental knee arthroplasty (UKA) has increased in popularity.

Materials and methods
The authors surveyed 53 patients (range 46-66 years; mean age 59.79 years at review) by questionnaires to determine their sporting and recreational activities at a mean followup of 24 ± 6 months (range 12-48) after unicompartimental knee arthroplasty (De Puy International Ltd., with a cemented all-poly tibial component). We also assessed the state of general health (SF36) and all these patients had been reviewed using the Hospital for Special Surgery (HSS) score. For SF36 and HSS, patients were divided into groups of women (38) and men (15).
Results Before surgery, 46 out of 53 patients (87%) were engaged in an average of 5.0 sports and recreational disciplines (tennis, football, cycling, swimming, jogging); 49 (92%) participated in an average of 3.1 different sports disciplines (tennis, cycling, swimming); resulting in a return to activity rate of 95%. The most common activities after surgery were cycling in 14 patients (26.4%), swimming in 12 patients (22.6%), dancing in 6 patients (11.3%), jogging in 5 patients (9.4%). Different high-impact sports, such as tennis in 5 patients (9.4%), football in 5 patients (9.4%) and mountain climbing in 3 patients (5.6%), revealed a significant decrease in participation as well as the winter disciplines of downhill in 2 patients (3.7%) and cross country skiing in 1 patient (1.8%). Five patients were able to resume recreational football player: compulsive postoperative rehabilitation with restoration of muscular control was important for optimum function and for return to this activity. Discussion The majority of patients who underwent unicompartimental knee replacement surgery were very satisfied with their quality of life, and SF36 score also improved significantly from pre-operatory after surgery (p \ 0.0001).
Conclusions A modern UKR may be considered a valid alternative to bridge the gap between a HTO (hight tibial osteotomy) and TKR (total knee replacement) for young active patients with isolated unicompartmental tibiofemoral non inflammatory disease. Most of the patients returned to sports and recreational activities after unicompartimental knee arthroplasty. The activities in which most patients participated were primarily low or mild impact such as cycling, swimming, fitness, golf. It is necessary a conclusion regarding UKR for football players.

Medial pivot prosthesis in valgus knee
Introduction Total knee arthroplasty (TKA) in valgus knee is more difficult than in well aligned or varus knee, The correction of deformities and ligament balancing are the priority. The aim of this study was to evaluate our experience on 20 knees treated with Advance TKA.

Materials and methods
The study group is based on 20 consecutive patients who underwent primary TKA using cemented prosthesis fixation and a medial pivot implant. Study participants included 14 women and 6 men with a mean age of 69.6 years (range, 60-82 years). Osteoarthritis (80%) was the most common diagnosis rheumatoid arthritis (16%), and other findings (4%). All patients received the Advance TKA (cruciate ligament sacrificing) prosthesis (Wright) using cemented fixation.
Results Twelve knees were rated excellent, 8 as good. The femorotibial mechanical axis was corrected from a valgus of 15°to 5°in post-operative. There was no varus-valgus instability in 18 knees, and 2 knees had approximately 5°varus-valgus instability in extension. There was palpable, nonpainful, patellofemoral crepitus noted in 1 knee.
Discussion The present study reports our experience on a total cohort of 20 knees using Advance medial pivot system in primary knee arthroplasty in valgus knee. This type of prosthesis imitates knee anatomy and biomechanics. Medial pivot and ''ball in a socket'' design provide great stability to the implant.
Conclusions The Advance TKA (with cruciate ligament sacrificing) prosthesis (Wright) with cemented fixation was successful in primary arthroplasty in valgus knees, also in severe deformities with incompetent medial collateral ligament. Results 29 patients were checked on follow-up (min. 12 months, max. 10 years). In all, there was a good consolidation after plaster removal without any secondary displacement. In four cases a deficit of flexion or extension (max. 15°) was observed, with no subjective functional problems reported. Any limitation of pronation and supination was observed. A constant radiographic finding was the overgrowth of the metaphyseal region proximally to the lateral condyle, independently from the type of fracture. In 8 patients the overgrowth took the appearance of a true bony prominence, clinically expressed as pseudo-varus elbow. In two cases there was axial deviation, one of which was associated with necrosis of the trochlea. In one case we found the presence of a calcification radio graphically visible in the periarticular soft tissues. Introduction It is known that the triradiate cartilage contributes significantly to enlarge the acetabular diameter proportionally to the growth of the femoral head, while the ring epiphysis enhances final acetabular depth. The function of these growth cartilages in normal and pathological hips were described but their microanatomy was not depicted in detail.

Materials and methods
The pelvis of a healthy child without any orthopedic disease, died in a car accident, was investigated after ethical approval was obtained. The acetabulum was radially dissected with a microtome and each section was immediately fixed in a paraformaldeyde bath for 48 h and subsequently decalcified, dehydrated and then stained with Hematoxylin and Eosin, Giemsa and Toluidine Blue for histological and immunohistochemical analysis.
Results Our study showed the presence of multiple inclusions in the resting zone of each acetabular growth area, in the center of the acetabular cavity, in the periphery of the acetabulum and in the flanges of the tri-radiate cartilage. These inclusions varied in number and position in the three acetabular bones. Discussion Although there have been previous descriptions of histologic acetabular anatomy, the role of the inclusions described here in the resting zone of the acetabular growth centers has not been clarified in detail. We suggest that these inclusions may represent, as in other chondro-epiphysis, sites for development of secondary preossific nuclei from which subsequent ossification centres will mature. Our data do not allow to completely quantify the number and position of these nuclei as suggested by the different geographical distribution of these inclusions about the three acetabular bones.
Conclusions In DDH there is always a morphological alteration of the lateral acetabular growing cartilage. If associated with a definitive lesion of these possible precursors of the secondary ossification centres, caused at any time of growth, the definitive acetabular maturation could be geopardized. This would explain the late evidence of an altered hip joint development in even apparently normal hip after treatment for DDH.
Introduction Flexible flatfoot in children is one of the most common disorders in paediatric orthopaedic practice. In a small percentage of cases (less than 10%) symptoms will develop in middle-late childhood (from 8-9 years) as pain in the hindfoot and in the medial midfoot, and foot and lower limb fatigue, more often related to sports activities. When conservative measurements fail to relieve the pain in symptomatic children, joint-preserving deformity-correcting surgery might be considered in patients between eight and fourteen years. We propose the extra-articular subtalar arthroereisis (''calcaneo-stop'' with STJ-SAMO device) in conjunction with soft tissue procedures as spring ligament plication (medial plication, according to Pisani), posterior tibial tendon tensioning repair, and percutaneous Achilles tendon lengthening if needed. Introduction Ischial tuberosity avulsion in the young is a rare pathology that is due to ischiatic growth nucleus avulsion from the remnant ischium. This pathology has the maximum incidence in young athletes between 15 and 18 years and its pathogenesis lie in a strong thigh posterior muscles contraction during sport exercises. Differential diagnosis with Hamstring muscle-tendon damage is the first cause of misdiagnosis. Materials and methods We analysed a 15-year-old athlete case of ischiatic tuberosity avulsion following a football match trauma. The patient had an intensive oedema located on the buttock with associated pain, lameness, and ROM reduction with knee locked in extension. The ischiatic tuberosity avulsion was confirmed lately by TC and had specified fragment sizes as follow: diameter 44.4 mm, depth 10 mm, fragment diastases 14.37 mm. The conservative treatment (defined by Boyd et all. study 1997) for ischial tuberosity avulsion with fragment diastases lower than 2 cm was based on the following therapeutic planning: functional rest for 25 days with following physiotherapy focused on stretching exercises, connectival massages, Mesier airway exercises, exercises of progressive knee, pelvis e trunk stabilization, firstly out of load then static load and finally dynamic load at different degrees.

Materials and methods
Results Three months after trauma the patient had recovered biological consolidation and full articular range of motion in both sides and was pain free during all soft and strong body exercises. After 1 year the patient had a stable clinical picture and was symptoms free.
Discussion One year later the we discuss about indication and therapeutic choices.
Conclusions The conservative treatment for ischial tuberosity avulsion with fragment diastases lower than 2 cm guarantees results as better as diagnosis is earlier. Physiotherapy has not to be focused only on damaged limb but also on the other side because ischial tuberosity avulsion is only a muscular retraction clinical sign. A correct sportive education about posterior limb stretching exercises could be a valid instrument to reduce the incidence of hamstring retraction. This one is the substratum which in adding of a strong contraction produces muscular or skeletal damage. In conclusion ischial tuberosity avulsions with fragment diastases lower than 2 cm treated conservatively gives good clinical and functional results.
Arthroscopic osteoplasty for slipped capital femoral epiphysis Conclusions Arthroscopic osteoplasty at the time of hardware removal can reduce impingement after mild slipped capital femoral epiphysis. Due to short follow-up, we are unable to state that this procedure reduces subsequent articular damage. However, arthroscopic femoral osteoplasty is a minimal invasive procedure and restoration of neck-head offset and clinically normal joint motion are important achievements for the future on these young patients.
Child's bone cysts treated with courrettage and filling with bank's bone: a 15 cases report evaluating time of consolidation, risk of fracture and radiographic outcomes.

Materials and methods
The examination of 15 patients with bone cystis located respectively on homerus (5), radio (2), femur (3), tibia (2), astragalus (1) and clavicle (1), processed by courrettage and filling with bone bank, with an average follow-up of 4 years. In 2 cases the diagnosis followed a fracture in the cystic site, in the remaining cases the response was occasional. The outcome was assessed radiographically (searching pathological fractures and retention of areas of bone loss) and clinically (generalized pain or deformity). Results Our series highlights a good consolidation of the lesion in the whole sample with a complete obliteration of the cavity in 7-10 months with disappearance of the radiolucent areas.
Conclusions The results were compared with those reported in the literature confirming the validity of the technique.
Histological study of the Osgood-Schlatter lesion: etiopathogenetic considerations Introduction Phantom limb syndrome (PLS) is basically the most common and severe complication after limb amputation, occurring in more than 90% of amputees. Different medical, physical and psychological strategies have been used in this field, with overall quite unsatisfactory results. The efficacy of a prolonged perineural infusion of a high concentration of local anesthetic solution in preventing PLS has been evaluated in this study. Materials and methods A perineural catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperatively at 5 mL/h using an elastomeric pump, and continued for 4 to 83 days after surgery. PLS was evaluated on the first postoperative day and then 1, 2, 3, and 4 weeks, and 3, 6, 9, and 12 months after surgery. The severity of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 = no pain to 4 = intolerable pain, and ''phantom'' sensations were recorded as present or absent. If the VRS score was [ 1 or significant phantom sensations were present, the ropivacaine infusion was immediately restarted at 5 mL/h. If the VRS score remained at 0 to 1 and the patient had not experienced phantom sensations for 48 h, the infusion was permanently discontinued and the catheter was removed.
Results Median duration of the local anaesthetic infusion was 30 days (95% confidence interval, 25-30 days). On postoperative day 1, 73% of the patients complained of severe-to-intolerable pain (visual analog scale [ 2). However, the incidence of severe-to-intolerable phantom limb pain was only 3% at the end of the 12-month evaluation period. At the end of the 12-month period, the percentage of patients with VRS pain scores were 0 = 84%, 1 = 10%, 2 = 3%, 3 = 3%, and 4 = none. However, phantom limb sensations were present in 39% of patients at the end of the 12-month evaluation period. All patients were able to manage the elastomeric catheter infusion system at home. Discussion This technique has been associated with superior results when compared to other techniques reported in the literature and previously used.
Conclusions Use of a prolonged postoperative perineural infusion of 0.5% ropivacaine seems to be an effective therapy for the treatment of phantom limb pain and sensations after lower extremity amputation and is currently the Authors' technique of choice.
Atypical femoral fractures as a potential complication of long-term bisphosphonate therapy Introduction A subtrochanteric fracture seems to be an unusual complication of long-term treatment with bisphosphonates, however, despite numerous reports in the literature, it was not shown a significant risk increase. Clinical and radiographic features characterize this association: location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, medial spike when the fracture is complete, absence of comminution, cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Materials and methods Ee analyzed retrospectively patients treated at our Clinic for subtrochanteric fracture from 2007 to 2010 with the aim of identifying those who had the radiographic features suggestive of atypical fracture among them we investigate the use of bisphosphonates. On 72 patients of mean age 81 years, 9 women with radiographic pattern suggestive of atypical fracture were identified, all were treated with bisphosphonates (on average 9 years). Among the 63 patients with fractures without atypical characters, it was found that seven were using bisphosphonates (average 2.7 years), 39 had never used bisphosphonates, while for 17 patients no data could be obtained.
Results Statistical analysis showed that in patients undergoing longterm treatment with bisphosphonates significantly increase the risk of atypical fractures (odds ratio 1, p \ 0.02). It also showed that the average duration of bisphosphonate therapy in patients who showed an unusual pattern of fracture (9 years) was significantly higher (p 0.05) of the average duration therapy in patients treated with bisphosphonates, but with traditional X-ray pattern (2.7 years). Discussion Although limited by a small sample, our data suggest that inhibition of bone turnover induced by prolonged use of bisphosphonates may increase the risk of atypical fractures of the femur in the subtrochanteric region. It remains unclear if simultaneous conditions can help to steer bone metabolism in this direction. The subsequent radiographic revaluation of the 9 patients with atypical fractures highlighted in the subtrochanteric region of the contralateral femur some of atypical characteristics as well.
Conclusions Without questioning the anti-fracturative role of these drugs in the treatment of osteoporosis, we believe that the risk of incurring an atypical fracture should be considered in patients undergoing long-term therapy with prodromal symptoms. Results Of the 7,355 forms collected we excluded those who did not meet the inclusion criteria and therefore the final analysis was performed on 6,465 patients with a mean age of 76.9 years. The total number of patients who sustained a hip fracture was 2,902 (44.9%). Of the 6,465, 721 patients (11.15%) took sedatives, while 795 (29.12%) antidepressants. Of the 721 patients taking sedatives 439 (60.89%) had a hip fracture. Of the 795 subjects taking antidepressants, 409 (51.45%) had a hip fracture. The risk of sustaining a hip fracture was higher in both groups, with a odds ratio of 1.91 (95% CI: 1.63 to 2.23) for those using sedatives and 1.30 (95% CI: 1.12 to 1.50) for those using antidepressants. Discussion The relationship between psychotropic medication and increased risk of falls in elderly subjects may be due to the impairment of postural stability, reaction time and sensory-motor functions. It is known that balance and attention significantly worsen even with small doses of drugs. The results of our epidemiological study confirmed that the use of psychotropic drugs increases the risk of hip fracture. This risk is significantly higher in those who make use of sedative drugs for a presumed increased risk of falling. Introduction Aim of the study was to evaluate the appearance of degenerative lumbar facet joints changes due to percutaneous pedicle screw fixation for the treatment of lumbar fractures without neurological involvement. Materials and methods Thirty patients affected by fractures of the lumbar spine underwent percutaneous pedicle screw fixation. In all patients a short fixation (4 screws) without fusion was performed. Radiographic analysis was performed by a thin cut CT scan in the preoperative and post-operative time at 4 months in 10 patients, 8 months in 7 patients and 12 months in 13 patients. Facet joints degenerative alterations were classified according to Pathria criteria. In all patients the 4 facet joints adjacent the screws and these at fracture's level were evaluated. The facet joints encroachment due to screw misplaced was also evaluated.
Results Eleven patients presented an A3.1, 4 an A3.2, 15 an A.3 fracture. Patients were divided into 3 groups considering CT scan execution time: group A 4 months, group B 8 months, group C 12 months. Patients in the group A showed no statistically significant differences between pre and post-operative facet joints (p [ 0.05). Patients in the group B showed a statistically significant worsening in the 28% of the facet joints at fracture's level (p = 0.03). Patients in the group C showed a plain degeneration in the 100% of the cases (p = 0.001). Considering screws placement there was an impingement with the articular surface in 6 cases, responsible of an early degeneration of the related facet joint. Seven patients were older than 65; 3 of them showed a complete degeneration of the facet joints at fracture's level comparable to a fusion yet to 8 months.
Discussion Results' analysis showed the presence of significant facet joints degeneration yet to 8 months after a percutaneous screw fixation. Facet joints fusion was observed only in patients older than 65 with a high pre-operative degeneration grade.

Conclusions
In the authors' opinion lumbar fractures treatment with percutaneous screw fixation without fusion causes an early facet joints degeneration and has so not to be considered an harmless procedure. This study encourages to remove percutaneous pedicle screw instrumentation no later than 1 year to avoid severe facet joints degenerative changes.
Hip and knee arthroplasty in Italy: temporal trends and gender analysis Discussion In the observed period, both interventions showed a significant increase in RR. Considering that 25% of the increase in RR can be related to the increase of the arthritis prevalence, the difference on the risk for TKR might be connected to a higher spread of the indication for intervention. As show in the literature, women have a significant higher risk to be operated than men.
Conclusions Trends of hospitalization rates are continuously increasing for both THR and TKR. TKR rate is significantly higher than THR rate. Women undergo THR and TKR significantly more than men.
Open and arthroscopic arthroplasty of the STT joint In the arthroscopic group, 9 cases were females: the mean age of this group was 65 years (63-67 years). All the cases were degenerative but one. All cases were clinically evaluated preop and postoperatively with the Mayo Wrist Score and all were given the DASH questionnaire. X-rays of the wrist were taken before and after surgery and in all cases the presence of a DISI deformity of the lunate was evaluated. The Registry is a prospective observational study on a large scale, aimed to collect a few essential information on all the performed arthroplasties with the single endpoint of detecting the implant failure (revision).

Materials and methods
In 2010, to strengthen and implement the results obtained until then, Apulia Region established the Arthroplasty Regional Registry (Regional Law N.4 of 25 February 2010, Article 40) stating that all the public and accredited hospitals performing hip or knee and/or shoulder arthroplasties were required to fill in a specific paper data collection form. The same regulation established that the reimbursement of the intervention would be provided by the region to the hospital only if the data collection form has been duly filled in.
Results Apulia is one of the three regions in Italy currently running a regional registry. However, the number of reports (compliance), equal to 70% in 2003, fell to 16% in 2009. In 2010, being the surveillance system changed from voluntary to reimbursement based, participation of 100% of Apulia hospitals was registered (compliance 95%). In 2010, 7,274 arthroplasties were recorded (hip: 4,050; knee: 3,074; shoulder, 150) performed in 52 orthopaedic units of 32 public hospitals, 2 university hospitals, 2 ecclesiastical bodies, 1 IRCCS and 10 private hospitals. 37 different cups and 53 stems were identified. 28 mm femoral heads were used in 90% of implants. A higher prevalence of coxarthrosis on the right side was measured (56.3% vs. 43.7% on the left).
Discussion The dramatic increase of the compliance (+69% in 1 year) showed that, for the validity of the registry, rules that make compulsory the registration must be adopted. Therefore it is desirable that, following the Apulia example, these rules should be adopted at both national and regional levels. Conclusions The adopted model will contribute to the implementation of the National Arthroplasty Registry, tracking the implanted devices and monitoring their quality, a prerequisite for undertaking appropriate health policies.

C49 -HIP 5
Use of two different hyaluronic acids (concentration/ molecular weight) in the hip osteoarthritis, with the support of an echographic device Discussion Pain decrease, higher in G2, could be correlated to a different HA viscosity degree. The follow-up could better be tested by OHS and LI than HHS and SF-36, with ROMs assessing, too. These scores seem to be able to assess the difference between the two groups in terms of efficacy/no efficacy of the HA therapy. No sign of collateral effects was registered.
Conclusions The use of a higher molecular weight of HA in HO seems to be related to a better pain control and functional improvement. An ultrasound device is a non invasive technique with a quite good accuracy, which is be able to better define the hip anatomy in order to follow the needle through the tissues up to the joint line, without X-ray exposure.
The volume surgeon and the frequency of endoprostesis, total hip arthroplasty and revision prosthesis dislocation Introduction Hip dislocation has long been one of the major complications after hemiarthroplasty (HA), total hip arthroplasty (THA) and revision prosthesis (RP). The purpose of this study is to report the incidence of dislocation after HA, THA and RP and analyze the factors involved, with particular emphasis to the concept of the volume surgeon. Materials and methods 561 hips received either HA(202), THA (279) and RP (80). Of the 561 prosthesis, 31 sustained early or late dislocations one or more times. The associated database was reviewed for the occurrence of subsequent procedures involving closed or open reduction of the hip joint for dislocation of the index HA, THA or RP procedure. The factors to be studied included age, sex, original diagnosis, type of prosthesis, frequency of dislocation, the surgeon and hospital volume.
Results Thirty-one hips experienced dislocation with an overall dislocation rate of 5.5%. The rate of dislocation was 3.6% in HA (7/202), 5.3% in THA (15/279) and 11.2% in RP (9/80). There were 8 men and 23 women with an average age of 78.6 (45-96), with no significant difference in the dislocation rate between them. The year hospital volume in hip surgery was 112.2, and the annual volume surgeon was 18.7. In our experience, the dislocation rate was not related to sex, age, previous revision surgery, or types of prosthesis. The rate of recurrent dislocation was not related to a history of previous surgery.
Discussion The strengths of our study include the recent time period reflecting contemporary implants. Moreover, the same surgeons made the surgical intervention of THA, HA and revision surgery. Considered as a whole, we could support the idea of a positive association between surgical volumes and improvement in most arthroplasties outcomes, including dislocations. This correlation is more clearly established for surgeon volumes than it is for hospital volumes. Introduction We analyze the experience resulting from the first three years of using the anterior access to the hip with the adoption of Maquet bed and a traction device. Materials and methods An analysis of 64 procedures performed with this technique was carried out comparing it with 60 procedures performed with anterolateral access (the traditional approach). We took into account the following parameters: (1) surgical time; (2) blood loss; (3) number of staff needed during surgery; (4) clinical and X-ray charts.
Results We observed a substantial alignment in surgical times, a slight reduction in blood loss and a net improvement in the immediate clinical results with a tendency to an alignment after two years. Discussion Given the increasingly felt need of a real miniinvasivity it was decided to take the route of direct anterior approach. This technique allows approaching the hip without any muscle detachment. However, it requires a certain adjustment period, thus the learning curve is quite long. The integration with the traction device of the Maquet surgical bed allowed us to optimize the gestures in the small surgical field available to the acetabulum at first and then to the femoral neck. The use of short stem prosthesis amplified the benefits of this access road. We believe that the good short-term results are directly linked to the greater compliance of the muscles and soft tissues.
Conclusions The Surgical approach is difficult, the surgical time is equivalent although we detected less blood loss. Good results in the short term. These considerations lead us to continue experimenting with this access. Introduction More than 20 different scores are currently available to evaluate the results of total hip replacement (THR), most of them have not been still validated in the original version or at least in Italian. In the last years, the ''objective'' assessment of the patient has been gradually substituted by scores intended to evaluate the outcome from the patient's point of view (subjective scales). In 2003, starting from KOOS questionnaire developed for knee, the HOOS score was developed to assess hip function. Materials and methods An observational prospective multicentric study including 5 orthopaedic departments and coordinated by the Italian National Institute of Health has been carried out. In the first phase the questionnaire was translated by two independent translators with a different cultural background. After reconciliation, the text was back-translated in English by an American native speaker without any specific background in the health field and blinded to the original English version. The reviewed and harmonized text together with the SF-12 standard and the EQ-5D questionnaires and the VAS scale was then administered to 96 patients undergoing THR (pre-op.) and then 6 months after surgery (follow-up). The first 10 patients recruited were also requested to fill in the questionnaires after 20 days to test its reliability.  In the first implant, the cup was applied in 146 cases of primary hip osteoarthritis, in 41 cases of DCA, in 20 cases of aseptic necrosis of the femoral head in subcapital fractures of the femorale, in 10 cases of posttraumatic arthritis, in 1 case the outcome of slipped capital femoral epiphysis and in 1 case of cut-out nail of femur nail. The cups size ranged from 44 mm to 62 mm. In 52 cases, screws were used to increase primary stability. The cups were associated with a straight stem type C2 (67), C2 lateralized (68), alloclassic (2) and with modular tapered stems modulus (93) according to the morphology of the femur. In six cases of revision surgery only the cup was replaced, and in other 6 cases a tapered revision stem was implanted. The average follow-up was 19.2 months, and the last follow-up was at 41 months.

Results
Results The Harris Hip Score (HHS) pre-operative average was 40.8. At final follow-up HHS was 95.2. One cup was replaced 9 months after surgery for aseptic loosening. Twelve cases presented radiolucent lines areas around the cup (7 in Gruen Zone 1, 2 in Gruen Zone 2, 5 in Gruen Zone 3), which not exceed 2 mm and were stable in subsequent follow-up.
Discussion Trabecular Titanium showed high capacity of osseointegration, providing excellent results in short-medium term follow-up. Further studies and long-term follow-up to compare the clinical results of TT with those obtained with other cups have already been validated.
A comparative analysis of the state of periprosthetic bone density in cementless prosthetic femoral components resurfaced with hydroxyapatite and spongy metal  Introduction The ecoguided viscosupplementation has a large application in the treatment of hip osteoarthritis: consequently various drugs are suggested for intra-articular use, and among them, the Polinucleotides recently. Therefore the object of the study was to compare the efficacy between the gel of polideossiribonucleotides (PDRN) and the Hyaluronic Acid that is esteemed the ''king drug'' in the intra-articular infiltration and certainly is very good evaluted for his clinical effects. Materials and methods We examined two homogeneous groups of 50 patients each with diagnosis of hip osteoarthritis valued group I-II in conformity with the Kellgren-Lawence's scale. Both the group advised to treatment with ecoguided viscosupplementation: in the first group (PDRN group) with a gel of Polinecleotides (Condrotide 2 ml. -20 mg/mL), in the second group (HA group) Acid Hyaluronicmolecular high weight (Hyalubrix -2 ml). All the patients of the two groups were infiltrated for 3 times, every 45-60 days.
Results The outcome measures were a 100 mm visual analogic scale (VAS) of the ankle pain, the Lequesne functional index and the drug consumption. These parameters are valued in the time of recruitment (T0), after 3 months the first intra-articular injection (Ti) and till the end of the examination (not before 6-12 months -Tf). The PN group and the HA group showed a mean symptomatic improvement from baseline (T0) with reduction of VAS (from 6.67 to 4.21 in the HA group and from 6.40 to 4.25 in the PDRN group), reduction of Laquesne index (from 11.87 to 8,98 in the HA group and from 11.57 to 9.08 in the PDRN group) and reduction of drug consumption (from 6,18 to 3,14 after 3 months and to 1,62 after 6-12 months in the HA group and from 5, 59 to 3,98 after 3 months and to 1, 77 after 6-12 months in the PDRN group). There were no differences in the incidence or nature of adverse events between groups.
Conclusions The data, clinically and statistically significant, can be considered superimposable in both groups and showed that polinucleotides and HA are important resources against the hip osteoarthritis because they reduce pain, improve function and mobility and reduce the drug consumption.

Ospedale ''Santa Corona'' (Pietra Ligure-Savona, IT)
Introduction For the last two years we have been utilizing the Just stem as a total neck preserving prosthesis. The philosophy of the prosthesis foresees the substitution of the femoral head that is replaced by a curved mini-stem which reproduces the physiological forces of the femoral neck. There are no contraindications from femoral head osteonecrosis to Just prosthesis. The Just prosthesis is inserted into the trabecular bone system and follows Wolf's law by recreating physiological bone remodelling and benefiting from that same trabecular system for integration. Materials and methods Presently 156 Just stems have been implanted, with a 2-year follow-up. The clinical and radiological results as well as the DEXA studies that have been carried out on the first 100 cases are very encouraging. Stem/bone integration has been demonstrated both clinically and via bone density meter. In no cases has the stem shown subsidence. There has been one revision with a straight, primary stem due to trauma 2 months from the implantation.
Results Less blood loss due to non opening of the canal, complete bone preservation of the neck with the exclusive substitution of the femoral head which guarantees optimal functional recuperation and physiological offset reproduction of the hip, independent of the cervical-diaphyseal angle.
Discussion The femoral neck is totally preserved, which implicates the maximum preservation of bone stock and for this reason this type of stem represents the only real alternative to the hip resurfacing prosthesis. Femoral head necrosis does not represent a contraindication to this prosthesis implant. On the contrary, the implant of the acetabular cup results more damaging and in fact use of mini invasive acetabular reamers.
Conclusions The new total neck preservation prostheses represent a true alternative to the current prostheses, which are to date less utilized. For young patients these surely represent the best choice for elevated bone stock preservation.The Just prosthesis inserts into the femoral trabecular bone system obtaining optimum primary stability and secondary osteointegration reproducing the joint physiological offset independent from the cervical-diaphyseal angle.
Gait analysis of THA with different head diameters: a prospective randomized study Introduction In recent years thanks to the development of biomaterials with lower wear, the use of prosthesis with bigger diameter head has increased. Bigger heads have advantages such has reduced risk of dislocation, an increased range of motion and perhaps a feeling of more ''physiological'' hip. The aim of this study is to evaluate the walking recovery of patients after THA with different head diameters by the means of gait analysis. Materials and methods A prospective randomized blind study was conducted on 60 patients operated by the same THA with different head diameter. Inclusion criteria were: primary hip arthritis, women, age between 55 and 70 years. Exclusion criteria were: other problems influencing walking ability. The same uncemented stem, same uncemented press-fit cup, same surgical technique and approach (posterolateral), same surgeons, same postoperative protocol and rehabilitation were employed. The only difference was the head diameter. The patients were randomized into three groups, of twenty patients each one ([ 42 mm Met-on-Met, 36 mm Cer-on-XPE, 28 mm Cer-on-XPE). The gait evaluation was performed on three temporal steps: pre-operatively, two months post-operatively and four months post-operatively. Results The first group (head [ 42 mm), 2-month after surgery was better than other groups in 3 variables (stance percentage, double support percentage and stride length) and 4-month after surgery was better in 2 variables (stride length and step length). In the second group (36 mm head), 3 variables were better than other groups at 2 months: (cadence, stride width, average speed). At 4 months the improvements were less than the other two groups. The third group (28 mm head) was better than the others in step lenght and swing speed at 2 months after surgery and has an index of improvement greater than the other groups at 4 months in 6 parameters. So the first two groups had an index of improvement better in 3 variables at 2 months after surgery, while the last group at 4 months after surgery has a higher rate of improvement in 6 variables of 8 total variables. Discussion There were no statistically significant differences for the kinematic variables between the three groups, but all the variables assessed at 4 months after surgery improved significantly in all groups. Introduction Each year, the treatment of lateral hip fractures, need high economic resources. We believe that the treatment of choice should be characterized by mininvasive surgical technique, which allows a reduction of blood loss and reduction days of hospitalization, as well as the use of fixation devices good value for money. Materials and methods We treated from 2008 to 2011, 143 patients with ''VeroNail'' (mean age, 77 years). All patients were studied by X-ray examination and all hip fractures were classificated of according to AO principles. Of the 143 nails VeroNail implanted, only 4 were long nails, in the remaining cases were implanted Ve-roNail standard. We used the cephalic parallel sliding screws in 123 patients and the cephalic converging screws in 16 patients. Was performed in all patients the distal locking nail: we preferred the distal dynamic configuration of the system to not increase the rigidity of the system and to limit the cephalic screws cut-out. Post-operative rehabilitation was always performed to functional recovery of the limb.
Results In all cases, the clinical and radiographic healing of the fracture was achieved within 3 months after surgery. The average of hospitalization days was five. We granted immediately partial load in patients with stable fractures. Walking with partial load was granted for the unstable fractures only after three weeks. The functional recovery of fractured limb was comparable to that existing before the fracture.
Discussion Our approach was to use systems that have a second antirotational screw, to ensure more stability at the synthesis. The marketing of a nail with double-screw cephalic in parallel or converging configuration, has made the system VeroNail our reference in the treatment of extracapsular proximal fractures femur. However we have not always limited to implant only a single brand nail, but we are continuing to check the validity of the twin cephalic screws systems compared to single cephalic screw. Introduction Avascular necrosis of the femoral head (AVNFH) mostly presents in young patients between the ages of twenty and forty years. The disease affects the vascularisation of the femoral head and not directly the articular surface. If untreated, AVNFH typically progresses to subchondral and articular collapse and early osteoarthritis. Conventional staging systems, based on lesion size/ location and radiographic appearance, do not provide information on the real conditions of the joint surface. Above all, imaging, often does not detect detachment of the necrotic fragment with interruption of the articular surface. Materials and methods In the last ten years, with the ambition of maximising the chances of success of non prosthetic surgical treatment in early stages AVNFH patients, we introduced arthroscopic joint evaluation for selected cases. Criteria for arthroscopy were atypical symptoms in contrast with the radiographic appearance and young age. Between 2000 and March 2010, we performed 34 arthroscopies in AVNFH.
Results In 9 hips out of 29, arthroscopy showed complete detachment of the necrotic fragment of the head. These cases were rescheduled for total hip replacement. In 25 hips, even with partial collapse of the subchondral bone, there was continuity of the femoral head articular surface. These cases, after arthroscopic assessment, were directly treated with core decompression and autologus bone grafting. Discussion Since both procedures are carried out on the traction table, the addition of hip arthroscopy took, on average, only 20 extra minutes. Rate of success of non prosthetic surgical procedures for early and intermediate AVNFH stages depends of a number of factors. Complete detachment of the necrotic fragment is a negative prognostic factor for non prosthetic treatment. In our experience, hip arthroscopy is a useful additional tool for accurate staging and for selection of the best possible treatment. Larger numbers are needed to draw definitive conclusions.
Conclusions In our experience, hip arthroscopy is a useful additional tool for accurate staging and for selection of the best possible treatment. Larger numbers are needed to draw definitive conclusions.
Gait recovery after total hip replacement: one-year longitudinal assessment of primary and compensatory gait deviations Introduction The decision of hip replacement tends to be delayed as much as possible, due to the limited time duration of the prosthesis and to minimize risk of a second replacement. The aim of this work was to perform a one-year follow-up of kinematic and kinetic gait deviations of patients that underwent hip replacement and to investigate if clinical and functional conditions just prior to surgery influenced the recovery over time. Materials and methods Patient gait was acquired before surgery, 2 weeks, 6 months and one year after hip replacement. 26 patients were enrolled, 21 of them completed the study. Results Walking speed and ten gait related variables were investigated and their variation over time was assessed by means of the Wilcoxon test. The effects of initial hip force, retractions and dynamic angular ranges on final gait speed, hip sagittal range and hip extension symmetry were assessed by the U Mann-Whitney test and the Spearman correlation coefficient respectively. Conclusions Gait speed, hip dynamic flexion-extension range and pelvic tilt range progressively improved during the follow-up year, while most of the compensatory gait deviations diminished during the year. Initial conditions minimally differentiated the degree of recovery in the sample patients after one year, who had all reached both a nearly normal hip flexion-extension range and gait speed. Due to the sample characteristics, these results pertain to patients with mild or no force reduction of hip muscles before surgery.

C52 -HIP 8
Early experiences with Vitae stem Introduction Titanium has been used in clinical practice for 35 years and it has proven to be extremely biocompatible. The further development of porous titanium has made it an excellent material for prosthesis implant. The aim of this paper is to present the first experiences with Vitae Adler Ortho Stem neck retaining modular stem built with Ti-Por Ò titanium. Materials and methods We will report the preliminary experiences with Vitae Stem in the 1st Orthopaedic Department of Pisa. The preoperative evaluation included X-rays of the hip, clinical evaluation, Harris Hip Score and Western Ontario and McMaster Universities Arthritis Index. The surgical approach was postero-lateral in all patients. We collected clinical and radiological data. Results The intraoperative results using this stem showed an excellent primary stability due to triplanar stability of such kind of stem and to titanium Ti-Por Ò roughness. The modularity (27 different neck combinations) allowed an easier implant technique with a restoration of original articular biomechanics. Also the post-operative clinical recovery and short term radiological results were satisfactory. Discussion Short stems represent a less invasive choice and an interesting alternative for hip prosthesis. The design and biomechanics of these implants allow the preserving of diaphyseal bone stock and a more physiological distribution of loading forces. Longterm results begin to emerge from literature and are encouraging. Porous materials allow implant integration and long term survival. Conclusions Our experience with Vitae Stem is short, but the clinical and radiological results are satisfactory. The design of this stem is indeed updated, implementing the philosophy of metaphyseal loading, modular neck and porous coated implant. Technical, bibliographic and scientific assumptions together with our preliminary results, allow supposing that this stem will have good results in the long run.
The new stemless hip implants: our experiences with the ultra short stem Introduction ''Ultra-short hip stems'' in prosthetic surgery are increasingly more widely used and allow preservation of ''bone stock''. Even if these new implants are very promising in particular in young patients, the reliability is scarcely described in Literature. The aim of this study is to assess the effectiveness of a new ''stemless'' hip implant. Materials and methods A new cementless neck preserving, stemless hip prostheses (NANOS; Smith & Nephew) was implanted between 2005 and 2010 in 136 patients with a mean age of 55.5 (M:F ratio 2.3:1) affected by osteoarthritis or avascular necrosis. All the patients were followed radiographically (Engh's criteria) and clinically (HHS, VAS pain and SF-12) before surgery and at 1, 3, 6 and 12 months postoperatively with a mean follow-up of 30 months (min. 6 and max. 66). Results The rate of implant failure (MFR) was 0%, with a percentage of osseointegrated implants of 100% and consistent improvement in recover from pain, in joint function and in the quality of life (HHS = 98, SF-12 = 96 VAS \ 3 mm.). Some complications were observed: 1 metaphyseal crack, 2 perforations of the diaphyseal cortical bone, 2 dislocations, 4 leg length discrepancies ([ 1 cm., but \ 2 cm.) and one cup aseptic loosening. Discussion Ultra short neck preserving stems showed to allow mininvasive surgery associated to primary stability and excellent preservation of the proximal femoral bone quality. Some limitations were observed in the correction of leg length. Nevertheless the clinical results were certainly better, at early follow-up., than of the traditional stems. Conclusions The new stemless implant showed to be well indicated in young patients or in case of well preserved proximal bone quality.
MiniMAX stem: preliminary results of a new anatomic stem implanted using the anterior approach Materials and methods The prosthesis was chosen because it is designed following the modern concepts of shape and anchorage, which must be performed between femur and metallic implant to optimize ''fit and fill''. It is an anatomic stem prosthesis. The contemporary acetabular shell implant was done using the cup Versafitcup Ò CC (Medacta International SA), as press-fit, with a ceramic insert. All surgeries were performed by using AMIS Ò technique (Anterior Minimally Invasive Surgery, Medacta International SA). The anterior approach is the only technique that follows a path both intermuscular and internervous and therefore considerably reduces the risk of damaged periarticular structures. To facilitate the surgical phases and to make the surgery reproducible, we add an integrative extensor device to the standard operating table: the AMIS Ò Mobile Leg Positioner which allows hip flexion, extension, abduction, adduction and internal and external rotation. The use of this device allows the reduction of: (1) theatre assistants required throughout the procedure; (2) surgical phases reproducibility. Results We found the following relevant advantages: no muscles cut, significantly shorter rehabilitation, a small skin scar, decreased postoperative pain, less blood loss, reduced hospital stay, no dislocation, faster return to daily activities. In the short-term, the stem is radiographically well integrated in the bone with a good metaphyseal grip. No loosening has been highlighted. Two revisions were performed because of suspected infection. Discussion The curved design of the stem on both surfaces, sagittal and frontal, facilitates the insertion through a small incision. Also dimensions, which are shorter respect to other prosthetic patterns, are suitable for a mininvasive approach. The clinical result of lack of thigh pain in all examined cases confirms the choice of a specific and unique tip design optimised to guide the prosthesis insertion into the femoral canal and to avoid distal interference. Conclusions Very good efforts in the short-term support a good synergy in choosing the implant of this anatomic stem with anterior approach.
Introduction In the last years, neck preserving femoral stems were more and more frequently used, due to the minimally invasive surgical technique and to less metaphyseal resorption with respect to standard stems. Aim of the study was to compare bone remodelling, regain of ROM and ambulation, and blood loss in patients treated with neck preserving stems or standard stems. Materials and methods We studied 33 neck preserving implants (Fitmore and Trialoc) and 35 standard stems (TMP). Average age of patients was 62 years (range, 24-83) in the first group, and 72.3 in the second group (range, 26-98). Both groups had similar BMI. Functional regain was evaluated by HHS and Timed Up and Go (TUG) test. Bone remodelling was measured by DXA immediately after intervention, and at 3, 6 and 12 months based on Gruen protocol. Coagulation indexes, peri-operative blood loss and quality of life by SF-36 were also evaluated. Results Results analysis evidenced faster functional regain, measured by HHS and TUG, in patients with neck preserving stems. Densitometry showed higher BMD at ROI 1 after 12 months for standard stems (+6,7%) and an increase of BMD by +4,1% and +8,3% at ROIs 3 and 7 for neck preserving stems, while, at the same ROIs, standard stems showed values of -0,5% and -2,3% respectively. In patients with conservative stems Hb loss was 2.1 mg/dl lower with respect to standard stems. Obtained data showed no significant age-related changes.
Conclusions Neck preserving stems showed good short and long time results. DXA study of peri-prosthetic bone remodelling demonstrates lower metaphyseal resorption compared to standard stems, due to reduced size at the proximal diaphysis and better load distribution in the metaphyseal areas. Functional regain was also faster, thanks to less invasive surgery and contained blood loss. They can therefore represent a good alternative to standard stems, which require more invasive techniques and higher loss of bone-stock immediately after surgery, both in younger and elderly patients. Introduction Short stems have had in the last years a remarkable development, but some surgeons are still not sure about their rotational and vertical stability and this limits their diffusion. In our opinion, porous titanium has fully changed prospects by using short stems. Materials and methods The primary stability of a short stem is linked both to the design and the surface. The topic of this paper is Stem Vitae Adler Ortho. This stem has a design that allows high primary stability and a titanium coating with a high initial grip due to porosity with interconnected titanium pores and additional 40 micron spikes at the junction of the pores (Ti-por Ò ). Vitae Stem was designed with the philosophy of minimal diaphyseal invasion, metaphyseal load, cancellous bone saving and adaptability to the major part of the proximal metaphysis.

Results
The first 100 implants gave satisfactory clinical and radiological results even though within a short follow-up (max. 10 months). Discussion As demonstrated in the literature dimension and geometry of porous, materials have a fundamental rule in promoting bone ingrowth and biological stabilization of the implants to bone. The production technique of Electron Bean Melting [EBM] Adler-Ortho makes it possible to obtain optimum porosity at the peripheral level, which is ideal for the trabecular graft and consequently to ensure secondary osteointegration. The developed technology with Ti-por Ò titanium allows to cover Vitae Stem with an extremely rugged (3D pores 700 micron) envelope. With modularity, (27 different neck combinations) this stem allows a perfect restoration of the hip geometry.
Conclusions Currently there are no short stems with this coating, which according to previous studies allow bone in-growth and consequently ensure secondary stem osteointegration. Its small size allows safety and rapidity of use, less bleeding and absence of thigh pain.

Modena, IT
Introduction Fixa Ti-Por Adler acetabular cup is a press-fit hemispherical 4th generation cup that improves the primary press-fit and promotes secondary bone-integration. Electron Bean Melting process allows coating bone contact surface with three-dimensional microstructure of titanium. This process promotes bone tissue growth in titanium's interstices, to obtain optimal size between 300 and 1000 micron, exactly 700 micron in cone penetration. Bone growth's surface was generated from a CAD model to obtain a three-dimensional surface with outer tips to improve primary fixation to bone. To obtain this surface you must use dust technology. This surface is forged with the cup from which it can't be removed or released, adding strength and endurance to the system. You can coup with polyethylene liners, metal and Delta ceramic, with possibility of using large diameter heads. The aim of our study was to evaluate the outcomes of patients treated with this technique, with a 2-year follow-up. Materials and methods From April 2009 to February 2011, we implanted 129 Fixa Ti-Por acetabular cups in primary total hip arthroplasty with uncemented anatomic Apta stem and neck preservation Parva stem. We treated patients with acetabular dysplasia, coxa profunda and also elderly patients with osteoporosis, without intraoperative and post-operative complications. Clinical evaluations were performed with HHS, WOMAC and HOOS; radiographic evaluations with X-rays in A/P and L/L cross-table view, with measuring cup inclination and anteversion and in some cases with Dexa study to evaluate the mineral distribution around the cup. Results In the first cases we had some position defects because reaming did not match to cup size and we were not able to reach the shedding of cup completely, without compromising cup's primary stability. Nowaday no cup was revised. We never needed to use stabilization acetabular screws. We coupled ceramic/ceramic in 90% of cases, never metal to metal. Conclusions In our experience the use of 4th generation-porous titanium coated cup with dust technology allowed the press-fit implant without use of acetabular screws and with excellent primary stability and rapid secondary bone-integration. We believe this type of cup to have extended indications for hip joint pathology, because of also coupling to be performed.

Innovative hydroxyapatite nanostructured coatings on titanium substrates by pulsed laser deposition (PLD)
A. Bianco* 1 , I. 4-), in order to mimic the composition of biological apatites. Several in vivo animal models studies have demonstrated that the incorporation of silicon within the apatite lattice promotes the osteoblastic activity, allowing enhanced biological performances in terms of bone apposition, bone ingrowth and cells mediated degradation [1]. The PLD (Pulsed Laser Deposition) technique presents pivotal advantages, such as good reproducibility of target composition, control of coating adhesion, crystallinity, and roughness associated to limited contamination. Sisubstituted hydroxyapatite coatings could further increase the stability and the osteointegration of bone implants in orthopedical surgery. Materials and methods Si-substituted (Si content 1.4%wt) hydroxyapatite films were deposited on the treated Ti substrates at different substrate temperatures (namely: 400, 500, 600 and 750°C) in a high vacuum PLD chamber, using as target a disc obtained by sintering wet precipitated nanopowders [2]. Depositions were performed by focusing a pulsed KrF Lambda Physik excimer laser on the rotating target. The microstructure was studied by microscopy techniques (scanning electron, SEM and atomic force, AFM), infrared spectroscopy (FT-IR) and X-Ray diffraction (XRD). Microhardness measurements were also carried out. Besides, preliminary bioactivity in vitro tests were performed. Results The optimal parameters (i.e. laser fluente and substrate temperature) for the deposition of Si-HAp coatings were identified (i.e. 2 J/cm 2 and 600°C), aimed to obtain uniform, homogeneous films with the composition close to the target one. The produced coatings resulted dense, compact and characterised by low surface roughness and a thickness of 1.5 lm. Discussion The experimental investigations demonstrated that the employed deposition technique allowed obtaining homogeneous nanostructured thin films of composition very similar to the target one. In vitro tests evidenced the formation of an apatite layer, suggesting an improved bioactive behaviour. Microhardness measurements corroborate the potential application perspectives of these coatings for osteosynthesis implants.
Conclusions In this work the PLD technique suitability to the deposition of Si-substituted hydroxyapatite coatings was demonstrated. The produced bioactive nanostructured coatings satisfied the requirements necessary for the applications in osteosynthesis devices.
Introduction The use of resorbable materials is one of the main recent applications of bioengineering in orthopaedics. We report our experience in osteosynthesis of capitellum fractures by resorbable Herbert screws. Materials and methods In the period 2005-2010, at the Shoulder and Elbow Surgery Unit of the Rizzoli Institute, 10 cases of capitellum fracture have been treated. There were 3 men and 7 women, mean age 46.4 yearrs (range, 15-65 yrs). According to McKee, fractures have been divided in: type 1, 3 cases; type 2, 1 case; type 4, (limited to capitellum) 1 case; type 4 (shear fractures), 5 cases. Type 3 fractures (highly comminuted) were excluded. ORIF was performed by Herbert resorbable screws and pins (poly-L-lactic acid, RSB Implant, Hit Medica, San Marino). Follow-up was 31.7 months (range 12-65). An MRI evaluation was performed to check the process of resorption of the biomaterial and any articular reaction at least at one-year after surgery. In every case a stable intra-operative fixation was achieved, allowing to begin the rehabilitation the day after surgery (early CPM). In two cases a screw broke during positioning, because of a non perfect congruency between the tapped hole and insertion axis. Results The fractures healed in all cases with a mean MEPS score of 98 (85-ma100). No chondrolysis or foreign body reactions have been observed at follow-up. Discussion The main advantage in the use of PMMA is to achieve an anatomical fixation passing through the articular cartilage to reach subchondral bone; the in-out technique is better in order to fix the small fractured fragments with a compression force; further surgery to remove the hardware has not to be expected. Conclusions We tested the safety and the effectiveness of capitellum fractures osteosynthesis by resorbable screws. On the other hand the surgical technique has to be extremely precise because of the fragility of the resorbable implants. Introduction A new bone acrylic cement (Porosectan) made of PMMA and ß-tricalciumphosphate is tested for evaluate its biocompatibility, osteoconduction and osseointegration. Materials and methods We implanted cylindric samples (2 9 6 mm) in 12 New Zealand White rabbits. In particular samples of Porosectan (powder + granules) in right femur proximally, Porosectan (powder) in right femur distally and PMMA in left femur as a control. Couples of rabbits were sacrificed after 1, 2, 3, 6, 9 e 12 months. Results Porosectan, with low polymerization temperature, is turned out a biocompatible cement. The increase of cement-bone interface, due to its porosity and the formation of new-borne trabeculae, not only at the interface, prove the optimal osseointegration of this cement. Porosectan shows its porosity, with 200-500 lm pore size, which create a structure open to outside. Moreover this cement is penetrated by organic fluids and cells superficially, that allow us to considerate Porosectan as a osteoconductive cement, in particular the formulation powder + granules seemed to be the right structure for the formation of a scaffold that allows bone cell neoformation inside. Conclusions Neotrabeculae growth inside the cement is histologically demonstrated, and after 12 month involve all Porosectan (powder + granules) structure. This, could be related to b-TCP reabsorption that releases osteoinductive factors like calcium and phosphate ions.
Ceramic-on-ceramic bipolar head in partial hip replacement: a mid-term experience A. Olmeda*, S. Zanarella, P. Friso Azienda Ospedaliera di Padova (Padua, IT) Introduction Femoral neck fractures represent currently one of the thoughest problems for our National Health Service. There are not comproved differences in outcome between partial arthroplasty with bipolar head and total hip arthroplasty, especially in elderly patients. The main cause of bipolar head failure is due to polyethylene wear, that leads to a grip of the inner head with the external cup. Ceramicon-ceramic bipolar head can avoid this complication, and allow extending the life of the prosthesis quite as long as a THA, with a less invasive and a cheaper surgery. Materials and methods From 2005 to 2010, we performed partial hip replacement with ceramic-on-ceramic bipolar head in 375 patients. For the implants we employed only uncemented press-fit stems. The materials were CeramTec Duo bipolar head and SL Plus or Proxy Plus (Smith & Nephew) stems. The mean age at the time of surgery was 81.5 (range 51 to 98), the timing was 36 h. Full load on the side of prosthesis was restored after three days from surgery. All of the patients were controlled with clinical and radiographical examination six weeks after surgery. The minimum follow-up was 6 months (mean 17.5%), 85% were controlled with clinical examination or phone interview. Results We saw 2 periprosthetic fractures, 1 infection, 2 dislocations (all treated for intertrochanteric fracture), 2 periprosthetic fibrosis (asymptomatic). We saw non cases of intolerance or ceramic breakage. At the follow-up, the sinking of the stem was below 1.5 mm. Pain was absent or mild in 84.9% of patients. Six months after surgery, 82% of patients returned to normal life and were able to walk individually, or using one cane or crouch. Discussion With the new ceramic-on-ceramic bipolar head we did not noticed new or unusual complications, the intra.-operative assembling is easy and does not extend the time of surgery. The follow-up was free from accidents, and the new bipolar head seems reliable. Considering problematic outcome of THA in some elderly patients, and resurfacing in younger ones, bipolar ceramic-on-ceramic cup may become an ultimate solution for partial hip arthroplasty in elderly patients and a good solution for the other categories. Conclusions On a mid-term follow-up we can demonstrate that no particular complications have been observed. In our experience, outcome of bipolar ceramic-on-ceramic cups has no difference in comparison with the other kind of implants. Introduction One of the most important factor limiting the treatment of chondral injuries is the age of the patient. In the most recent technique, the AIMC, chondral regeneration is demanded to mesenchimal cells (MSC) of sub-chondral bone. As well known, the number of MSCs in sub-chondral bone depends on many factors, between those the most known is the age of the patient. Experimentally MSCs in patients aged 55 to 65 appear as efficient as these of younger patients to become condrocities, but fewer. Materials and methods To get around this problem, from June 2009 to February 2010 we treated 24 patients from 55 to 64-year-old presenting chondral knee injuries with AMIC technique plus PRP, as we did before in younger patients, but adding bone marrow concentrate to increase cell number. 15 and 30 days after surgery patients received a PRP knee injection. Results We excluded patients with load alteration or previous surgical treatments. Patients were re-evaluated with KOOS after 1, 3, 6, 12 months of follow-up: average score increased from 53.82 (before surgery) to 81.85. Discussion 23 cases had an MRI examination 1 year after surgery, demonstrating a good reconstruction of cartilage surface. In 22 cases we carried out knee fibroarthroscopy after 4 and 8 months, demonstrating good cartilage regrowth, similar to younger patients. Conclusions No biopsy was performed. No patient needed successive surgical treatment. Clinical outcomes at short-term follow-up are now very encouraging, long-term results will give us more information to give definitive judgement.

C54 -BIOMATERIALS AND COATINGS
Why adding vitamin E to UHMWPE? Introduction Although UHMWPE has been successfully used in total joint replacement for more than 30 years now, its lifetime is often limited due to oxidative degradation induced by radiation with high energy radiation in air. Alkyl macroradicals formed upon irradiation can react with oxygen dissolved in the polymer matrix, triggering an oxidative cascade that reduces UHMWPE molecular mass with consequent worsening of mechanical properties, decrease of the abrasive wear resistance and increase of wear debris. The incorporation of the antioxidant vitamin E has been proposed recently as an alternative to postirradiation melting to avoid oxidation and simultaneously preserve the mechanical properties of crosslinked UHMWPE.
Materials and methods GUR 1020 UHMWPE plates, blended with vitamin E (0.1%wt) were irradiated at 25 to 100 kGy and tested without any further thermal treatment. The materials were characterized by FTIR, DSC, crosslink density and mechanical properties before and after accelerated aging for 14 days. Results Cross-link density increases with radiation dose. The maximum oxidation index measured before ageing was 0.05 on all samples. After ageing, the maximum OI was measured in the sample irradiated to the highest dose, but even there it did not exceed the value of 0.14. Percent crystallinity of the irradiated blends increases slightly with the radiation dose and does not vary significantly after ageing, confirming that no significant structural changes occur to the polymer. The mechanical properties of irradiated vitamin E blended UHMWPE do not differ from that of unaged, irradiated virgin UHMWPE. While the mechanical performances of irradiated UHMWPE are well known to deteriorate rapidly, the tensile tests performed on the irradiated blends before and after accelerated ageing show little differences: US decreases slightly, while YS increases and EB decreases. Discussion Vitamin E is known to be a very active antioxidant for polyolefines. We have shown that UHMWPE blended with 0.1%wt of vitamin E exhibit a high oxidation resistance, even after irradiation to 100 kGy in air without any following thermal treatment and subsequent accelerated ageing in a highly oxidizing environment. The efficiency of cross-linking is decreased in the presence of vitamin E, but an additive concentration of 0.1%wt still allows modulating the cross-link density to the desired level. Introduction The treatment of cartilage injuries is a standing problem for the orthopaedic surgeon. Reparing potential of mesenchymal pluripotent cells opened new horizons. Biologically, tissue regeneration requires several factors: cells with the ability to reproduce and differentiate, growth factors, a suitable micro-environment and a scaffold for correct tissue reconstruction. Materials and methods AMIC technique (Autologous Matrix-Induced Chondrogenesis), which we adopted in more than 200 cases, is the most recent way to treat cartilage injuries and runs in a single surgical step, combining micro-fractures that expose therefore mesenchymal ancestors, and a three-dimensional matrix. Results The purpose of this report is to describe the features of chemical, physical and biological properties of the optimal coating material in the AMIC technique. A successful scaffold should give mechanical support, must be able to be biologically active and to allow cell colonization. This balance is often a compromise between a very dense scaffold with excellent resistance and a very porous one which allows an optimal distribution of cells. About this type of bioengineering we can paraphrase the architect Robert Le Ricolais who said: ''the art of structure is where to put the holes!'' Discussion A coating material must have optimal mechanical, chemical and biological properties to ensure the best result. The mechanical properties: (1) breaking resistance; (2) handling; (3) three-dimensional; (4) visco-elasticity. Chemical properties: (1) hydrophilic; (2) optimal duration. Biological properties: (1) condroconduction; (2) biocompatibility; (3) safety; (4) condro-induction. Conclusions The report will discuss all these aspects evaluating scaffolds available and reporting clinical and experimental literature to better define what is the ''ideal'' scaffold. This work have also the goal of to stimulate research to get as close as possible to a scaffold that satisfies all the requirements for the treatment of cartilage defects.
Morphological and gene expression analysis of matrixinduced autologous chondrocyte implantation (MACI) Introduction Advances in biotechnology and the requirement of less invasive strategies for bone healing have led to the introduction of biomaterials for the treatment of bone loss. Among the materials available to the orthopaedic surgeon there is the demineralized bone matrix (DBM). The aim of this study was to evaluate the osteoinductive capacity of DBM in the short term. Materials and methods The study is ongoing and so far we used demineralized bone matrix (DBM) in 27 patients (17 males and 10 females; mean age of 44 years); 5 treated for enchondromas or bone cysts, 2 for correction of deformities, 20 for loss of substance in complex fractures or nonunion. The DBM was used in 22 cases alone and in 5 cases, in which the loss of substance was greater than 2 cm, in combination with bone substitutes. Patients underwent clinical and radiographic follow-up at 3, 6 and 12 months and were evaluated clinically for pain and joint function and radiographically for bone healing. The patients with a positive follow-up at 3 months were considered healed. Results All cases of bone cysts, deformities, and enchondromas healed. 70% of patients treated for complex fractures or nonunions achieved healing within 3 months. There were no cases of surgical site infections or osteomyelitis. Discussion The demineralized bone matrix was very useful in filling bone cysts or enchondromas, leading to healing. Its use was also very successful in the treatment of nonunions and bone gaps in comminuted fractures.
Conclusions The results obtained till now prove that DBM is very effective and valid, if used in the indications we have proposed, reducing the healing time. Furthermore none of the patients required additional surgery.

C55 -KNEE 7
Allograft versus autograft in first planting ACL reconstruction The report assesses the clinical results obtained from a prospective randomized study on a population of 30 patients treated for ACL reconstruction with hamstrings autograft (15) and cadaveric allograft for anterior or posterior tibial tendon (15). The report highlights the benefits and limitations of such techniques, comparing the clinical results obtained in the short and medium term, evaluation grids and compared with internationally accepted. Introduction The traumatic lesions of the articular cartilage of the knee are a frequent pathology of athletes. The symptoms are tumefaction, joint block, instability, pain during activities (especially when climbing stairs) and maximal flexion. The aim of this work is to develop a new surgical technique that can allow the patient to start again taking physical activity without limits and to preserve the function of the knee joint. Materials and methods From December 2006 to February 2011, five patients were treated. The average age was 30 years (range 18-46 years). The patients had a lesion at the medial condyle of the femur and were treated with a fresh osteochondral grafting. They were followed for an average of 13 months (range 1-51 months) and underwent clinical examination every 3 months for the first year, and then half-yearly checks. Results The treatment was 100% successful. Three patients had good joint function 6 months after surgery without pain during the physical activity. One patient presented articular stiffness and lameness. Discussion At present, there is not a standard treatment and there are many treatment proposed for this disease. They consist of microperforation, homologous transplantation of chondrocytes or prosthetic joint replacement. However, the prosthetic joint replacement should be considered as a last instance because of the young age of the subjects affected by this disease and the need to return to physical activity without limitation. The treatment that we propose allows patients a rapid recovery of physical activity, it is effective and safe. Conclusions The osteochondral grafting is indicated when facing a full-thickness cartilage lesion with irregularity or loss of bone substance of the basic system of the cartilage. Other factors that may determine the success of the technique are the presence of an isolated cartilage lesion, ligamental stability and the absence of axial defects. Our treatment is effective for the therapy of the osteochondral disease because it allows the rapid recovery of limb function load and a functional recovery of the joint. Moreover, the risks of this technique are minimal.
Total knee arthroplasty in rare case of type 3 Von Willebrand arthropathy Introduction This case describes a 43-year-old woman with ''type 3 Von Willebrand disease'' and severe diffuse arthropathy that in the 2007 underwent left total knee arthroplasty. At age of 14, due to recurrent hemarthrosis, the patient underwent left knee synovectomy, the following year underwent right knee synovectomy and after five years underwent left elbow synovectomy. Materials and methods The patient presented chronic left knee pain, ROM 5°-30°, double support walking, HSS Knee score 38. For the poor conditions of both bone-stock and ACL and collateral ligaments, we chose a constrained prosthesis. Factor VIII (FVIII) was administered during the operation and also in the following 4 weeks to further correct the plasmatic levels of these factors. Considering the high thromboembolic risk (related to surgery, reduction of mobility and the chronic use of estroprogestinic therapy), thrombotic prophylaxis was performed with low molecular weight heparin. Results After 26 months the clinical and radiographic control showed a substantial improvement with pain reduction, ROM 0°-95°, HSS knee score 94 and perfect prosthesis integration. Discussion Total knee arthroplasty in type 3 Von Willebrand disease patients (prevalence 1:1,000,000) is a complex surgery with high risk of hemorrhagic and infective complications. Conclusions The possibility to improve quality of life in such a satisfying manner by surgery, let the patients do not take care of potential problems and complications related to it.
Results Post-operative great hemorrhagic extravasation occurred; after drains were removed (500 cc approx.) limb was swollen, edematous with important subcutaneous ecchymosis. The patient reported pain and weakness. Blood tests showed severe anemia (hemoglobin 5.7 g/dl) and coagulation profile showed factor XI deficiency states so heparinic therapy was suspended. In the following days clinical condition improved and passive motion of the limb began. Weight bearing was permitted as tolerated from day 5; the patients had to obtain an arc of at least 0°to 90°in 20 days with Kinetec passive motion. Thrombo embolic prophylactic therapy with Clexane 4000 UI was administered in consideration of high thromboembolic risk and the temporary resolution of hemorrhagic symptoms. Conclusions Congenital deficiency of coagulation factor XI disease causes mild bleeding symptoms and it is often diagnosed after trauma or surgery. In patients with this kind of diseases is necessary to perform minimally invasive technique to reduce morbidity, swelling, soft tissue hematomas and simplify rehabilitation. Reconstruction with patellar tendon gives minor risk of blood loss than four-strand semitendinosus and gracilis tendon. Gravity drain is to prefer to vacuum type because it can reduce haemarthroses and retain into the joint cavity factors released by tunnels accelerating integration; constant monitoring is an essential tool managed in close collaboration with Blood Transfusion Centre related to clinical objectivity.
Total knee replacement and non traumatic patellar tendon rupture in a patient with recurrent patellar dislocation D. Pili*, M. Cossavella, P. Laura, A. Manunta

AOU (Sassari, IT)
Introduction More and more patients undergo TKR surgery because of the increasing average age, life expectancy and higher demand for functional capacity of the population. This has increased the cases of total knee replacement implants and therefore also the complications of this kind of surgery. Materials and methods We report the case of a 71-year-old retired lady who underwent her first right TKR at 68 years of age. This lady was examined in our Department one week after noticing functional loss of knee extension of her right knee, pain over the insertion of the patellar tendon and the presence of an extensive bruising over the same area. X-rays of the right knee showed a well positioned total knee replacement. The ultrasound carried out on the area revealed a subtotal rupture of the patellar ligament. In the patient's medical history, suffering from malignant breast cancer, it was revealed that the patient was previously treated with tamoxifen and targeted radiotherapy one year after the operation. In addition this lady underwent a proximal quadriceps tendon tenoplasty at the age of 25 years and a transposition of the patellar tendon at the age of 66 years to avoid the recurrent dislocations. We treated this lady surgically with a full reconstruction of the extensor tendon with homologous calcanear tendon graft with resolution of pain and functional recovery. Results Patients with a history of recurrent dislocation of the patella are at greater risk of tendon rupture of the patellar tendon. This risk increases in patients with TKR and in conjunction with other factors such as the use of tamoxifen. Discussion We believe it is appropriate, in patients with a history of risk factors associated with tendon rupture, the study of the patellar tendon with MRI or ultrasound scan to identify patients with high risk of rupture prior undergoing a TKR.
Conclusions In cases with high risk for tendon rupture we advocate the use of biotechnologies or primary implant of auto-graft to reduce the risk of rupture. Surgical treatment of cartilage defects is the most debated aspect of orthopaedic practice since these lesions are relatively common in young and active patients. Unfortunately they influence the function of the whole joint and the may prejudice the career of a sportsman. Moreover they are responsible for fast cartilage degeneration even on the unaffected compartments. Several surgical options have been proposed in the past decades, varying from bone marrow stimulating techniques such as perforations and microfractures, to osteochondral and autologus chondrocyte transplantation. All these techniques have their own specific inconveniences and they recreate a fibrous cartilage and not the native hyaline one. The AMIC (autologus matrix induced chondrogenesis) technique has been recently introduced. It consists in a porcine biocompatible and biodegradable collagen membrane which is called Chondrogide. This membrane has a two-layer structure with a porous deep part and a smooth superficial one. It is constituted by type 1 and 3 collagen which act as a scaffold for the penetration, growth and differentiation of chondral cells. To enhance cells flow from the bone marrow multiple perforation or microfractures are performed within the lesion. The membrane is then sealed to the margins of the lesion with fibrin glue to avoid blood dispersion. This technique is simple, it necessitate neither two-step surgery, nor donor site and recreates a hyaline like cartilage. The membrane must be protected in the first post-operative weeks, thus although mid range continuous passive motion is allowed, weight bearing is delayed for at least 4 weeks. Moreover we stress the necessity of strict patient selection. In case of knee cartilage defects we propose this procedure in patients with age varying from 18 to 50 years, with more than 2 cm 2 stage 3 or 4 defects according to the ICRS classifications, and in stable and well aligned knees. In case of kissing lesions this technique is contraindicated. Following these strict indications, from June 2007 to June 2009, 13 patients were treated with the AMIC technique in our Department. The lesion involved the medial condyle in 5 cases, the lateral in 2, the femoral trochlea in 4 and the patella in the last 2 cases. At the time of the last clinical follow-up, 9 patients were satisfied or very satisfied with their result, 3 were fairly satisfied and 1 was not satisfied. We believe the AMIC technique represent a reliable option in the treatment of chondral pathology in young and active patients. Nonetheless to achieve the expected satisfactory results strict indications must be followed. Continue surgical technique and instrumentation improvement associated with materials and design evolution have increased effectiveness and popularity of UKR in the last 10 years.

S158
J Orthopaed Traumatol (2011) 12 (Suppl 1):S125-S164 Unicompartmental knee arthroplasty provides some advantages as less peri-operative morbidity and post-operative pain, less peri-operative bleeding, shorter hospital stay and inferior social costs. Polyethylene wear, loosening and deterioration of the unreplaced compartments remain the most important causes of failure in UKR. Careful patient selection and newer instrumentation has reduced the progression of arthrosis and tibial loosening leaving polyethylene wear as the predominant failure mechanism in contemporary UKR. Revision for polyethylene wear usually occurs after a minimum of 8 years, but some early catastrophic failures from wear have been reported. Excessive wear affects joint alignment and stability leading to an increased load at the bone-implant interface and accelerate loosening. Wear increases the debris volume at the bone-implant interface producing osteolysis which plays a role in component loosening (and unreplaced compartment degeneration). Factors associated with accelerated wear of the tibial polyethylene are polyethylene thickness, manufacturing processes, sterilization method, shelf aging, reduced conformity in the design. Polyethylene is now thicker than 6 mm for fixed bearings and the shelf age of polyethylene inserts sterilized with gamma irradiation in air is well documented. Congruous mobilebearing implants could play a substantial role in reducing wear if they are not associated with dislocation and non-reproducible surgical technique. Recent improvements in manufacturing processes like cross-linking may be valuable in some fixed and mobile designs. Important technical factors include accurate and modern instrumentation avoiding component-to-component malposition and edge loading, allowing slight under-correction of the pre-operative deformity even with a minimally invasive incision. Conversion of the UKR to TKR may result technically demanding, especially in septic revisions. Challenges of UKR revisions may be joint exposure, component removal, bone defects and instability. Conversion of the failed UKR can be a technically demanding procedure that depends on how conservative the initial procedure was and the mode of failure. As the amount and success of UKR procedure increase we will continue encounter failures that require conversion to TKR.
Unicompartmental knee replacement with ZUK prosthesis: mid-term results Differently from the historic clinical reports, all recent series in literature show excellent or good results at long-term follow-up after unicompartmental knee replacement. This difference is mainly the consequence of improved surgical technique and materials, and the new prosthetic designs and ancillary. Aim of our study was to report the mid-term results with ZUK prosthesis. Thus we performed a retrospective study on 80 patients treated for unicompartmental arthritis or necrosis. Maximum follow-up was 5 years. From February 2005 to December 2007, 80 ZUK prosthesis were implanted in 80 patients affected by primary unicompartmental arthritis (68 patients) or necrosis (12 patients). Right and left knees were affected in 43 and 37 cases respectively. Medial and lateral compartments were involved in 71 and 9 patients respectively. The status of the ACL was not a strict indication criteria as well as patellofemoral cartilage aspect except for bone to bone damage. Mean age at the time of surgery was 69 years. In all cases a ZUK prosthesis, consisting in fixed bearing metal back tibial tray was implanted. All patients were evaluated with IKS scoring system and with complete X-ray study to check pre-operative and post-operative limb alignment and components positioning.
Survivorship rate at the last follow-up was 100%. Knee and function scores improved from 46 and 54 preoperatively to 80 and 94 at the lat follow-up. As expected, since this implant replace the loosened amount of cartilage and do not correct bony deformities, no variations in the lower limb alignment (hyper or hypo correction) was detected on postoperative X-ray controls. Unicompartmental knee replacement joins the concepts of tissue sparing and minimally invasive surgery. This allows for lower perioperative morbidity and faster recovery with shorter hospitalization and lower costs for health system if compared to total joint replacement.
Technical notes on the implant of a total knee arthroplasty after tibial valgus osteotomy High tibial osteotomies represent an historic chapter of orthopaedic practice. In the past decades they have been proposed in the treatment of constitutional varus deformity in young adult and arthritic varus knee. Recently they have been associated with ligament reconstruction and chondral defects treatment to change the lower limb axis and thus to protect them. The advantages of maintaining the propioception and the native knee make them the ideal choice in young and high demanding patients. Unfortunately several series in literature report deterioration of the initial good functional and X-rays results along with time. In such cases the only option relies on the implant of a total knee arthroplasty. This is a more technically demanding option if compared to a primary prosthesis. Thus an accurate preoperative planning as well as precise surgical techniques are mandatory. However some aspects must be considered in preoperative planning to adopt proper surgical solution at the time of surgery. Some problems are related to previous surgeries: surgical approach, joint exposure and hardware removal. These aspects may require a two-stage procedure and can be extremely challenging especially in case of patella baja. Soft tissue balancing can be demanding in case of concavity retraction and convexity slackness. Finally proximal tibia malunions could lead to loss of anatomical references and increased tibial slope thus making tibial cut difficult. Even in case of a precise surgical technique, several studies report lower functional and clinical results compared to primary implants. According to these considerations we do believe patient information to be crucial both at the time of osteotomy (explaining the possible deterioration of functional results) and at the time of further prosthesis (explaining the possible intraoperative complications and unpredictable post-operative functional results).

C56 -BASIC RESEARCH
Effect of local injection of platelet concetrate and microfrature on the treatment of focal chondral defects of the knee: an experimental study Introduction Arthroscopic microfractures represent the mostly used surgical technique for the treatment of full-thickness chondral defects of the knee. It is well known that platelet-derived growth factors (GFs) can stimulate chondrogenic differentiation of BMSCs and enhance chondrocyte proliferation and metabolism. Autologous Conditioned plasma (ACP) is a blood-derived product with no leukocytes and a two-fold platelet concentration compared to whole blood. The purpose of the present study was to assess efficacy of repeated local injections of platelet concentrate on cartilage repair after microfractures for the treatment of full-thickness focal chondral defects of the knee. Materials and methods A full-thickness chondral lesion on the weight-bearing area of the medial femoral condyle was performed in 30 sheep. Animals were randomly divided into 2 groups (15 animals each), according to treatment: in Group 1: Microfractures; Group 2: Microfracture + five weekly injections of ACP. Animals were sacrificed at 3, 6 and 12 months after treatment. Contralateral knees were used as controls. Histological evaluation was performed on each sample. Slices were stained with haematoxylin eosin (H-E) and Safranin-O/fast green, and examined under the light microscope.
Histological appearance was scored according to a modified O'Driscoll score. Comparison between groups was performed with Mann-Whitney test. Significance was set at p \ 0.05. Results In group 1, repair tissue consisted of a thin layer of noncartilaginous tissue. A great amount of small rounded cells covered the surface of the defect. Tidemark formation was almost absent. Healthy cartilage surrounding the defect showed clusters of chondrocytes along the border of the defect. In group 2 repair tissue showed a regular surface, flushing with that of healthy surrounding cartilage and covered almost completely the defect. However, it was thinner than surrounding cartilage. A great amount of small rounded cells showed a columnar arrangement similar to that of hyaline cartilage. Tidemark was present in the defect area. Group 1 showed a significantly worse histological score than group 2 at each time interval.
Discussion Local injections of ACP combined with a microfracture produce hyaline-like cartilage at 6 and 12 months after treatment.
Conclusions ACP showed a positive effect on the healing process of chondral lesions of the knee after microfractures.
Perineurium and Endoneurium contribute two distinct patterns in the production of the ''bands of Fontana'' in the rat sciatic nerve Introduction In 1781 the anatomist Felice Fontana identified the appearance of transversal and oblique bands (or ''striae'') along peripheral nerves. The gentle stretching the nerve produces an increase in the spacing of the spiral bands but, withdrawing the distracting force, a ''recoiling'' occurs similar to that occuring in a metallic spring. Since this early observation, several Authors reported on the possible structural basis of this morphological characteristic; the conclusions described the ''bands of Fontana'' as an optical illusion produced by the scattering of incident light on the assembly of wavy nerve components. Several papers identified staggered endoneural components as the cause, while others pointed at the contribution of perineural components.

Materials and methods
We documented the recoiling phenomenon, in the rat sciatic nerve, by a 30 frames per second digital video recording, while performing in vivo microdissection of the nerve trying to single-out the causative components. With the aid of a Computer Assisted Design (CAD) software, we thus made a model of the nerve structural assembly trying to reproduce the visual appearance of the ''bands of Fontana''.
Results Well defined ''spiral bands'' were visible, in vivo, around the main fascicles of the nerve; however, they became extremely faint (and more ''staggered'' than ''spiral'') as tiny endoneurial streaks were dissected. Digital video recording showed that the spiral bands recoil back and forth, always with the same morphology, in fascicles with an intact Perineurium. In vivo microdissection showed distinctive black & white (greater amplitude), highly packed (shorter wave-length) bands in the Perineurium which are distinguishable from widely spaced (longer wave-length), translucent dark grey -pale grey (smaller amplitude), staggered bands in the Endoneurium. Images of ''interference figures'' produced by CAD, merging these two patterns of waving features, provided pictures resembling the appearance of the bands in vivo. Discussion Our observations may provide a possible explanation which is able to incorporate some of the apparently conflicting evidences of the past.
Conclusions Two different repetitive structures, one with a shorter wave-length and a bigger amplitude, in the Perineurium, the other with longer wave-length and smaller amplitude, in the Endoneurium, can merge under incident highlight and give rise to the appearance of the ''bands of Fontana''. Introduction Patients undergoing major orthopaedic surgery have a high risk for thromboembolic events. The low molecular weight heparins (EPBM) are commonly used in post-operative prophylaxis, but there are other molecules that act by directly inhibiting factor Xa, and are administered orally, such as rivaroxaban.

Materials and Methods
We studied sixty patients undergoing hip and knee prosthetic surgery, thirty-three received LMWH (Clexane 1FL 4000 IU sc daily with the first dose 12 h after surgery), twentyseven 1CP Rivaroxaban 10 mg daily (with first dose 8/12 h after surgery), post-operative prophylaxis lasted 8 weeks for patients receiving EPBM and 6 weeks for patients receiving Rivaroxaban. Patients were evaluated clinically for deep vein thrombosis and pulmonary embolism post-operatively and 8 and 12 weeks after treatment.
Results There were no cases of pulmonary embolism and deep vein thrombosis from a total of sixty patients concerned.
In the Rivaroxaban group 11% (3 patients) had blood loss from the wound (more than 500 ml) and infarcitura of the surgical site that required discontinuation of therapy.
Conclusions The oral administration of the drug offers benefits on the tolerability and patient compliance, but in our experience there were episodes of bleeding that must be taken into account in assessing the effectiveness and the handling of the drug.
Introduction A significant proportion of clinical orthopaedic research involves attempts to stimulate bone healing thanks to substances with osteoinductive properties. A considerable amount of data indicates that vitamin D and vitamin K are essential to maintain proper homeostasis of bone metabolism. The aim of the present study is to assess the effects on differentiation and proliferation of vitamin MK-7 alone and in combination with vitamin D on human mesenchymal stem cells (hMSC).
Introduction Some authors have recently demonstrated the prevalence of angiogenesis in the shoulder affected by rotator cuff tendinosis as compared to the contralateral unaffected shoulder. In view of this finding, Alfredson and Ohberg suggested treating tendinosis by sclerosing procedures, reporting a significant regression of the clinical and anatomopathological picture after such treatment. Aim of this study was to assess the effect of extracorporeal shock wave therapy (ESWT) on tissue perfusion in the treatment of tendinopathy.
Materials and methods An observational clinical study was made on 30 patients undergoing ESWT for tendinopathy of the rotator cuff.
ESWT was administered with a Minilith SL1 (Storz, Swiss) electromagnetic generator equipped with in-line US-guidance, during 3 sessions, at 3-4 day intervals, emitting 2000 impulses with an energy flux density (EFD) ranging from 0.04 to 0.07 mJ/mm 2 . Before each session, and at each follow up (FU), we recorded the tissue oxymetry values of the symptomatic and contralateral shoulders, using the cerebral and somatic/peripheral oxymeter INVOS 5100C (Somanetics Corporation, USA). Results A clinical improvement was obtained in 65.6% of patients at 2 and 6 months. This was associated with a statistically significant reduction in the oxygen tissue saturation, measured by oxymetry, that was apparent already during treatment, as well as at subsequent follow-up visits. Discussion It has been hypothesized, on the basis of results in experimental studies, that shock waves applied to the tendon tissue increase VEGF synthesis, inducing new vessel formation, increased transforming growth factor-beta1 and insuline-like growth factor-I expression and fibroblasts, stimulating the tenocyte metabolism and extracellular matrix deposits, as well as inhibiting the synthesis of interleukin-1 and metalloproteinases, thus limiting the inflammatory process. In view of our results, we can hypothesize that in an inflamed tendon (even in a degenerative process) where the angiogenic process is active, ESWT induces an integrated anti-inflammatory and regenerative action on the different tissue components. The progressive resolution of the inflammation process then limits and reduces the primary local angiogenic response and thus modulates the disease process and restores the metabolic and functional balance of the various tendon structures.
Conclusions The reduced perfusion achieved with ESWT supports the hypothesis that this treatment can regulate the inflammatory process and offset increased vascularization, restoring physiological Introduction Scoliosis is a disorder characterized by derlla spine tilt of the spine and rotation of the vertebrae. Epidemiologically in recent times has increased the spread of school age. Materials and methods Our work is based on clinical and functional evaluations simple and complex in 5 schools in the province of Cosenza. The survey provides, in addition to the medical testing posture, the creation of working groups based on global postural reeducation techniques or other types of posture.
Results The study is still in progress. The preliminary data are certainly insufficient to allow a statistical treatment. Anyway there is a clear correlation between scoliosis and some parameters of life (sex, sport, date of first menstruation). In some cases, scoliosis is part of a broader global postural dysfunction configuring a tonic postural system dysfunction. Discussion Scoliosis is a condition extremely common in school age. Scoliosis is often in close connection with TMJ dysfunction or disruption of the visual system or the vestibular system. Conclusions In this area a close collaboration between physiotherapists, physical therapists, orthopaedists, who graduated in physical education is fundamental. Is the individual rehabilitation project in patient over 70 surgically treated with prosthetic hip or knee replacement always necessary? In recent months, the ASP of Lazio has given indications of postacute rehabilitation of patients surgically treated with prosthetic hip or knee replacement, supporting the indication of rehabilitation at home and/or possible admission to extensive rehabilitation. We believe the need for comprehensive care of this type of patient, with a recovery program schema motor and step performed in a specialized environment, to prevent early and late complications (DVT, wound infection, dislocation, generalized pain, gait deficit, etc.), and to give the clinical stabilization of vital parameters (oxygenation, metabolic and hemodynamic balance) in relation to the complexity of care related to multiple comorbidities. Therefore we believe a short stay in intensive rehabilitation (2 weeks) to be the most proper and safe procedure which was also directed to the proper recovery of the autonomy of the person and probably to a reduction of health costs.