Mid-term results of a custom-made short proximal loading femoral component.

Bone preservation and physiological distribution of forces on the proximal femur are key elements in introducing a successful uncemented total hip replacement. In order to achieve this, in the mid 1990s, we developed an ultra short proximal loading custom-made component with a lateral flare, a high femoral neck osteotomy and without a diaphyseal stem. We report the outcome of 129 custom-made hydroxyapatite-coated uncemented short femoral components inserted into 109 patients between June 1995 and May 2004. The mean age of the patients was 51 years (21 to 71) and the mean follow-up was eight years (4.9 to 14.1). Bone behaviour around the implant was studied on the post-operative radiographs. The mean Harris hip score improved from 44 (8 to 66) pre-operatively to 95 (76 to 100) at final follow-up. The Western Ontario MacMaster University Osteoarthritis index was 93 of 100 at final review. None of the patients reported thigh pain. A total of five hips were revised, three for polyethylene liner exchange and two for complete revision of the acetabular component. No femoral components were revised. The radiological changes in the proximal femur were generally good, as evidenced by spot welds both on the medial and lateral aspects of the femur. No component migrated. The presence of a lateral flare and use of a high osteotomy of the femoral neck provided good clinical and radiological results. The absence of a diaphyseal portion of the stem did not impair stability.

Bone preservation with a conservative metaphyseal loading implant.

Proximal load transfer and the absence of distal fixation of the stem are crucial to obtain the best behaviour of the femoral bone after total hip replacement. In this study, dual energy X-ray absorptiometry (DEXA) was employed to understand and compare the bone density changes and thus the re-distribution of mechanical forces in two different extra short stems. Two cohorts of ten patients were included in this retrospective study. Both implants are custom-made and present a well defined lateral flare. The first model is fully coated and presents a short stem (Group A), the second is an unstemmed metaphyseal implant with a polished tip (Group B). DEXA scans were obtained in all patients at the two-year follow-up. A higher BMD was detected in ROIs 1, 2, 4, 5 in Group B confirming a preservation of the proximal bone mass and thus indirectly a more proximal load transfer. The results obtained confirm the importance of the geometry of the implant on proximal bone density. Loading both medial and lateral proximal femoral flares and the complete absence of the diaphyseal portion of the stem provide the optimal bone remodelling of the femur after total hip replacement.

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

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

Acetabular labral tears: result of arthroscopic partial limbectomy.

SUMMARY: Acetabular labral tears are a rare but well recognized cause of hip symptoms in young adults. Both clinical and radiographic diagnoses are difficult. The treatment of choice in the past has been either conservative or open arthrotomy. Hip arthroscopy has proved to be an effective tool for both diagnostic and therapeutic purposes in patients with chronic hip pain refractory to conservative treatment. We reviewed a series of 76 arthroscopic limbectomies. All patients had experienced hip symptoms for more than 6 months. None responded to nonsurgical treatment. Results were evaluated with the Harris Hip Score and with a questionnaire. Fifty-eight cases had a mean 3.5 years follow-up (range, 24 to 61 months). Thirty-nine patients (67.3%) were pleased with the result of their operation. The remaining 19 (32.7%) were not satisfied. Arthroscopy is an effective noninvasive procedure for the assessment and treatment of labral lesions. Short-term follow-up shows encouraging results.

The application of shock-waves therapy in the treatment of resistant chronic painful shoulder. A clinical experience.

BACKGROUND: To evaluate the efficacy of extracorporeal shockwaves therapy (ESWT) in patients with chronic painful shoulder. EXPERIMENTAL DESIGN: a prospective design was used with a short term follow-up. SETTING: data were collected at the Service of Physioterapy in Villa Stuart Clinic-Rome. PATIENTS: 72 patients of both sexes with an average age of 38 years (range 18 to 69) affected by chronic painful shoulder, whose symptoms lasted more than 6 months. INTERVENTIONS: all patients received on average, 2,000 impulses of ESWT at level 5 energy (0.21 mJ/mm2) according to Dornier Epos equipment one session per week for 8 weeks. MEASURES: all cases underwent an instrumental examination with X-ray conventional imaging and clinical assessment of pain (visual analogue scale) and functional limitation of the shoulder, two weeks before the treatment and at one month follow-up. RESULTS: 53% of patient scored excellent results, 14% good, 13% fair and 20% poor. In the group of calcifying tendinitis we had a reduction in 37% and no changes in 63%. CONCLUSIONS: Even with a limited number of cases our early results show the efficacy and safety of ESWT in the treatment of chronic painful shoulder resistant to other conservative approaches.

Arthroscopic findings in the initial stages of hip osteoarthritis.

Standard radiographic projections have poor diagnostic ability in detecting early degenerative changes of the hip. Comparison of arthroscopic and radiographic findings is the best method to assess the accuracy of conventional radiography. This study reviewed the records and radiographs of 234 hip arthroscopies. One hundred eighty-six of the patients had normal preoperative radiographs; of these, 60 (32.2%) had evidence of osteoarthritis at arthroscopy. The extent and location of the chondral damage were studied, and both of these parameters were correlated to the radiographic appearance of osteoarthritis. Hips with normal radiographs but arthroscopic osteoarthritis were found to have less damage compared with the radiographically osteoarthritic hip. Hips with normal radiographs also were more likely to have only one side (60%) of the joint damaged, either the acetabulum or femoral head. Conversely, when osteoarthritis was evident radiographically, both sides of the joint were usually involved (75.7%). These patients are often young (average age: 36 years), and women are more likely to be affected than men (71% versus 29%).

Intraoperative type 1 proximal femoral fractures: influence on the stability of hydroxyapatite-coated femoral components.

We reviewed a series of 120 uncemented total hip replacements using the Omniflex stem with hydroxyapatite coating. Twenty minor intraoperative proximal fractures occurred. All fractures were treated with cerclage wiring after removal of the stem. Radiographic and clinical results of these 20 patients were compared with the remaining 100 implants in which this complication did not occur. In 20% of the cases of both groups, a migration of less than 2 mm was observed. No differences were detected in Harris Hip Scores, subsidence of the stem, and radiographic behavior. We concluded that a properly stabilized proximal femoral fracture above the lesser trochanter did not influence the clinical and radiographic results at more than 3 years follow-up.

Snowboard traumatology: an epidemiological study.

In the past 10 years, snowboarding has become a popular winter sport among young people, and the number of accidents has increased proportionately. The incidence of traumas from snowboarding is shown to be 4 to 6 for every 1000 medical examinations, which is similar to that of downhill skiing. However, other important statistical differences exist between the two sports. This study of 106 snowboarding-related injury cases analyzes the epidemiology of these injuries in Italy. Results found that 45.1% of injuries are located in the upper limbs and that significant advantages are obtained with the introduction of guards to protect the upper limbs during descent. Serious ligament injuries to the knee are more rare in snowboarding than in downhill skiing. In both sports, injuries are more common with rigid boots, which lead to a higher incidence of injury to the upper limbs. Finally, a high percentage of injury to beginners was found in this study. Training courses for those who are considering taking up the sport of snowboarding could significantly lower their risk of trauma.

Histological and structural study of the adhesive tissue in knee fibroarthrosis: a clinical-pathological correlation.

In fibroarthrosis of the knee, it is still unknown if joint range of motion is affected by anatomopathological differences in adhesive tissue, such as tissue maturity, location, and quantity. A retrospective study of 78 patients who underwent arthoscopic arthrolysis was performed to determine a correlation between location of adhesions and preoperative range of motion (ROM). In another 17 patients, a histological and structural evaluation of adhesive tissue was performed. Based on vascularization, number and shape of cells, and collagen fiber orientation, the adhesive tissue was classified into three groups: low, medium, and high maturity. Preoperative joint ROM and the time of onset of joint stiffness was correlated with the degree of adhesion tissue maturity. A strong and statistically significant correlation between the location of adhesions and joint restriction was found. However, histological and structural evaluation showed no correlation between the degree of tissue maturity, the time of onset of joint stiffness, and the amount of joint ROM.

Arthroscopic posterior cruciate ligament reconstruction with bone-tendon-bone patellar graft.

We present a retrospective study of 24 patients with chronic injury of the posterior cruciate ligament (PCL) treated by arthroscopically assisted reconstruction with bone-tendon-bone patellar autograft. At a mean follow-up of 26.5 months (range 24-53 months) the International Knee Documentation Committee (IKDC) evaluation form, Lysholm and Tegner rating systems were used to evaluate symptoms, functional limitations during sports and daily activities, and changes in activity level. At the final IKDC evaluation we found 6 patients (25%) with grade A (normal), 13 patients (54.2%) with grade B (nearly normal), 3 patients (12.5%) with grade C (abnormal) and 2 patients (8.3%) with grade D (severely abnormal). The average side-to-side difference, as measured by the KT-2000 arthrometer, was 8.38 (+/-1.95) preoperatively and 4.08 (+/-2.09) mm postoperatively at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees. The worst results significantly correlated with the time elapsed from injury to surgery (P < 0.001). The preoperative Lysholm score was 56+/-12 (range 41-79) and at follow-up 94+/-8 (range 76-100). The Tegner activity score improved for all patients after surgical treatment. Average preinjury score was 7.4 (range 4-9), decreasing to 3.40 (range 2-7) preoperatively and increasing to 5.4 (range 4-9) postoperatively. At follow-up, 12 patients (50%) regained to their preinjury scores after surgery. Our study suggests that this arthroscopic technique, which allows a more precise placement of tunnels, can improve the results of the PCL reconstruction with a bone-tendon-bone autograft.

Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation.

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Osteonecrosis after arthroscopic medial meniscectomy.

Osteonecrosis of the medial femoral condyle is an uncommon complication of meniscal surgery. Whether this disease is associated with the original medial meniscus lesion or with the arthroscopic procedure is not yet known. We present two cases in which osteonecrosis has developed shortly after arthroscopy was performed for medial meniscus pathology. Magnetic resonance imaging has been the best tool to diagnose and follow up the changes in the involved area. Concerning the etiology, the authors raise the question of whether the medial compartment overloading observed in both of these cases had any significant meaning. Osteonecrosis following meniscal surgery in relatively young patients seems to have a good prognosis when correctly treated, with avoidance of weight bearing.

Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect.

The purpose of this study was (a) to evaluate by ultrasonography the healing of the patellar tendon after its mid-third was removed for anterior cruciate ligament (ACL) reconstruction in two randomized groups of patients in whom the tendon donor site was either left open or closed; (b) to compare clinical, radiographic, and isokinetic studies of these two groups to evaluate the incidence of patellofemoral disorders. We performed 61 ACL reconstructions (22 males, 39 females) using the arthroscopically assisted in-out technique. All operations were performed by the same surgeon, and the patients were all subjected to the same postoperative protocol. The tendon defect was left open in 25 subjects (group A) and was closed in 36 subjects (group B). Postoperative patellar tendon behavior was evaluated in these two groups by ultrasonography at 3, 6, 9, and 12 months. The vertical position of the patella was measured in the follow-up lateral view at 45 degrees of flexion and compared to that of the untreated knee. A clinical evaluation was performed throughout the follow-up period, and patellofemoral problems (pain, stiffness, patello-femoral crepitus) were evaluated and recorded using a modified Larsen and Lauridsen rating scale. Isokinetic evaluation was carried out at 6 months, and a quadriceps index of the two groups was recorded. Ultrasonography showed that healing of the patellar tendon initially progressed with a compensatory hypertrophy in width and thickness. The width was greater in group B (P < 0.01). In group A we observed in the cross-sections a characteristic image of two cords separated by a low signal bridge which we defined as a "binocular pattern." Areas of high ultrasound signal intensities persisted after 1 year in the open group; such areas were filled with scar tissue. In the closed group the ultrasound tendon signal returned to normal at 1 year. At 6 months the clinical, radiographic and isokinetic findings did not significantly differ between the open and closed groups. We conclude that defect closure after patellar tendon harvesting does not significantly influence the extensor apparatus.

Lectin binding properties of bovine resting cartilage.

The aim of this study was to evaluate the differential localisation of glycoconjugates of bovine hyaline cartilage matrix by lectin histochemistry, to compare the results of lectin histochemistry with those that can be obtained in the same tissue with PAS and alcian blue. Frozen and paraffin sections were stained with HE, PAS and alcian blue (pH 1.8). Alcian blue staining was carried out also after 1 and 24 hour digestion with bovine testicular hyaluronidase. Peroxidase conjugated WGA, PNA and RS lectins were tested on all sections before and after 1 hour digestion with bovine testicular hyaluronidase. The results show that all the lectins used in this study react with sugars linked to proteoglycans of territorial matrix, the reaction being increased in territorial, and induced in interterritorial matrix by 1 hour hyaluronidase digestion. Alcian blue at pH 1.8 and PAS were complementary, the former staining territorial, and the latter interterritorial matrix. After 1 hour hyaluronidase digestion, alcian blue stained also the interterritorial matrix. These results suggest that lectins react with low molecular weight proteoglycans and that short hyaluronidase digestion causes depolymerization of high molecular weight proteoglycans without loss of their glucidic components, allowing: a) penetration of alcian blue molecules into the macromolecular proteoglycan network; b) an increase of sugar residuals available for lectin histochemistry. Lectin histochemistry can be useful for differential localisation of glycoconjugates in bovine cartilage, especially if associated with short hyaluronidase digestion and conventional histochemical techniques.

Prophylaxis against deep-vein thrombosis in total hip replacement. Comparison of heparin and foot impulse pump.

We performed a randomised controlled study to compare heparin with the A-V Impulse System in the prevention of deep-vein thrombosis (DVT) in 132 consecutive patients undergoing total hip replacement. After the operation, all patients had compression stockings, 65 were treated with calcium heparin and 67 with the intermittent plantar pump. DVT was diagnosed by Doppler ultrasound and thermography, followed by phlebography. There were 23 cases of DVT (35.4%) in the heparin group, with 16 major and seven minor thromboses. In the impulse pump group there were nine cases (13.4%) with three major and six minor thromboses. The differences for all thromboses and for major thromboses were both significant at p < 0.005. In the heparin group there was one fatal pulmonary embolism and nine patients (13.8%) had excessive bleeding or wound haematomas, as against none in the impulse pump group.