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Plate fixation with cortical allograft struts has been used at our Institute for decades to treat aseptic shaft nonunion. The aim of this study was to assess the results of this technique in humeral nonunion. We retrospectively reviewed 57 consecutive patients with humeral diaphyseal nonunion treated by internal fixation combined with cortical allograft struts in the last 7 years in our Department. The patients were followed-up for a mean of 48 months. We had union in 53 cases out of 57. There were 3 cases of infection out of 15 patients previously treated with an external fixator. In our experience the cortical allograft strut is a well standardised and reproducible technique that enables the treatment of severe atrophic non-union with a relatively low complication rate and quick functional recovery.

We reviewed our experience in the surgical treatment of 12 cases of proximal ulna nonunion. The primary injuries were 2 fracture-dislocations of the olecranon, 6 Monteggia lesions and 3 isolated fractures of the proximal ulna. According to the type of primary injury and its anatomical site, the nonunions were classified into 2 groups, considering that the nonunions nearest to the humerus-ulna joint present a more disabling clinical profile and are more difficult to treat: group A (6 patients - nonunion within 5 cm from the olecranon tip of the olecranon) and group B (6 patients - nonunion between 5 and 10 cm from the olecranon tip of the olecranon). In all cases, after fibrous callus debridement and bone surface remodelling, fixation was performed with plate and screws and homoplastic cortical bone graft (orthogonal or parallel to the plate) and an intercalary bone cylinder when the bone defect was severe. In 3 patients (group A), where the defect was smaller than 1 cm, fixation of the ulna was combined with a resection of the radial neck. Clinical-radiographic healing was achieved in all patients followed for a mean of 27 months. Complications included a case of nonunion due to failure of the intercalary graft with plate breakage. The patient healed after a new surgery performed with same technique. The score, according to the Broberg-Morrey scoring system, was 78 in group A patients and 93 in group B patients. The use of homoplastic cortical bone graft represents an effective technique to improve the mechanical properties of the fixation and supports biological union, even when the bone defect is severe.

Tissue engineering may play a major role in the treatment of rotator cuff tendon lesions through replacement of an injured tendon segment. Tendons have very poor spontaneous regenerative capabilities, and despite intensive remodelling, complete regeneration is never achieved and the strength of tendon and ligaments remains as much as 30% lower than normal even months or years following an acute injury. Tendons seem to be the least complex of the connective tissues with respect to their composition and architecture and this leads to the expectation that they would be more amenable to tissue engineered approaches than other tissues. An accurate literature revision was done in order to know the state of the art of tissue engineering therapies in the field of rotator cuff regeneration. The following techniques of tissue engineering were considered: local injection of stem cells or growth factors, gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons to be further transplanted in the lesion site. So far, few experimental or clinical studies have been done on tendon tissue engineering compared to the extensive work on other tissues of orthopaedic interest, such as bone and cartilage. The existing studies are related to the following tissue engineering methodologies: gene transfer, in situ tissue engineering and in vitro production of bioengineered tendons. In our opinion the previously described literature revision showed the necessity for future studies in this area also because of recent advances in biological and bioactive scaffolds.

Radial head displaced irreparable fracture is an indication for prosthesis; it becomes elective also when there are associated injuries of the skeletal and ligamentous stabilization systems. A retrospective study was conducted to evaluate the functional and radiographic results in 10 patients (mean age 39.6 yrs; minimum 20, maximum 80) submitted to radial head replacement. There were 4 Mason-Johnston type IV Rochwerger subtype "b" fractures, 7 type III fractures (1 associated with an Essex-Lopresti injury and 1 with fracture of the ulnar proximal metaepiphysis). Mean follow-up was 24.6 months (minimum 18, maximum 32). Postoperative functional evaluation of the elbow and ipsilateral wrist was carried out using the ESSSE/SECEC form (mean score 80.7/100; minimum 63, maximum 96) and the PRWE (mean score 11.1; minimum 0, maximum 36) respectively. Radiographically there were postoperative calcifications in 30% of cases and periprosthetic lucency in 40%. The results of this study encourage the use of a metal prosthesis, but a longer follow-up is needed for a better evaluation.

Arthroscopic repair of wide rotator cuff ruptures is burdened by a percentage of recurrences that is greater than the repair carried out when an open technique is used. One of the main reasons for this difference can be searched for in the minor hold of stitching on the tendinous aspect obtained with arthroscopic repair. In fact, when an open technique is used, good hold can be guaranteed by using reinforced stitches such as the modified Mason-Allen. Thus, arthroscopic repair technique on the tendinous aspect, particularly in wide and massive injuries, must be improved. It was the purpose of this study to compare a new reinforced stitch that can easily be obtained in arthroscopy (simple stitch that orthogonally crosses a horizontal stitch previously knotted on the tendon: SS-HL), with traditional stitches (simple stitch, mattress-stitch and modified Mason-Allen stitch). Tests were carried out on sheep infraspinatus tendons in order to evaluate the resistance of pull-out. The SS-HL stitch showed resistance to loading that was similar to that when the modified Mason-Allen was used, but it was greater than that shown by the simple stitch (+48%) and the mattress stitch (+35%).

Calcific tendinitis of the rotator cuff is a relatively frequent pathology and at times, in some phases, it is a disabling one: for this reason, numerous therapeutic options have been proposed. The authors propose an algorithm for the classification and treatment of calcific tendinitis and report their experience with arthroscopic treatment over a three-year period from 2001 to 2004. Based on the algorithm proposed, out of a total of 126 shoulders affected with calcific tendinitis of the rotator cuff for which debridement was indicated, 106 us-guided percutaneous surgeries (EPT), and only 20 arthroscopies were performed. Arthroscopy is indicated, on the basis of the algorithm that we followed, in patients affected by chronic and persistent calcific tendinitis who did not benefit from the execution of previous types of non-surgical treatment for a period of at least 6 to 12 months. Shoulder instability was found to be present in 8 patients out of 20 treated arthroscopically. After arthroscopy, short- and medium-term results were always positive with the exception of one case that evolved into adhesive capsulitis. Based on an analysis of this series, we were able to confirm the usefulness and clinical applicability of an algorithm to classify and treat calcific tendinitis of the rotator cuff; we also confirmed the role of arthroscopic treatment that in cases which did not respond to conservative procedures proved to be effective in resolving symptoms.

The authors report the results of percutaneous mini-invasive treatment of chronic calcific tendinitis of the rotator cuffs. A total of 39 patients have been treated by echo-guided injection under local anaesthesia since June 2000 with a follow-up of about 2 years. Considerable reduction in symptoms was obtained in 34 patients within a few days of treatment; improvement was moderate in 5 cases, there were no complications in any of the cases. Complete regression of calcification was observed in 21 patients, there was a more than 60% reduction in calcific deposits in 11 patients, there was little reduction in 5, and the calcification remained unchanged in 2. The method, based on our experience, proved to be simple to execute, low-cost and easily repeatable, offering good results from a symptomatological point of view as well. It is the purpose of this study to determine and maximize mini-invasive treatment that will allow for the elimination or reduction of calcifications by means of percutaneous and echo-guided access.

The conservative or surgical treatment of Rockwood grade III acromioclavicular dislocations continues to be a controversial subject. Thus, the authors report their experience with 52 cases; long-term follow-up was obtained for 40 of these, paying close attention to the preoperative clinical and radiographic evaluation and to the results obtained in order to ascertain whether or not surgical repair is required. The results of surgical treatment, however satisfactory (90% excellent or very good), are nearly the same as those obtained when non surgical treatment is used as reported in the international literature. The authors conclude that the use of surgical treatment must be limited to carefully selected cases, should prolonged conservative treatment fail. Of the three surgical techniques used, temporary stabilization of the acromioclavicular joint using AO wires associated with restoration of the coracoclavicular connections has proven to be more effective than Dall-Miles metal wiring and tangential resection, with a lower incidence of complication.

It was the purpose of the experimental study to use laboratory experience to verify the effectiveness of different methods used to repair the rotator cuff. The sheep was used as an animal model because its infraspinous tendon is the most similar to that in the human. Three static trials were conducted using Instron machines, comparing the repair systems used most by the same authors in their clinical work, the hold of the suturing wires with two different threading procedures in the bone tunnels and two types of knotting, and the breakage loading of the suturing wires in the two different miniplate systems. The authors conclude that tendinous anchoring must be entrusted to reinforced suturing systems (modified SCOI and Mason Allen), the threading of wires in pairs in a single bone tunnel makes surgery easier and shortens the amount of time required, with threading of wires similar to or better than threading with a single wire. There are no differences in breakage loading of the wire at the level of the holes in the two miniplates considered in this study.

The authors report a rare case of recurrence of lumbar nerve root compression caused by herniated intradiscal gas treated surgically with resolution of pain symptoms. They describe the possible causes of the formation of gaseous material reported in the literature. They believe that to avoid recurrence it is important to associated removal of the hernia with complete emptying of the disc and resection of the posterior longitudinal ligament.

The authors report their experience in a retrospective study on a sample year (1997) of cases (77 in number) of lateral epicondylitis treated non-surgically at the Rizzoli Orthopaedic Institute. The results for the 63 patients reviewed are very disappointing (healing only in 36.5% of cases). In their opinion, this may be attributed to the lack of an accurate clinical definition of the pathology, and an inadequate treatment protocol. They conclude with the proposal to classify 3 clinical forms for epicondylitis (acute, chronic recurrent, and chronic persistent) and to follow a corresponding treatment protocol, aimed at improving results.

The authors present their experience with a new crossed condylar and osteotomy plate, which is innovative because of the features of its design, and the instrumentation used for its application, as compared to the traditional AO blade plate. The plate is called "fork-shaped" because there are 2 prongs in place of the blade with a "U" profile, and it involves the use of more accurate and less traumatic instrumentation to implant it. The results of a study conducted on a group of 20 patients, who were homogeneous for pathology and surgery, treated by a fork-shaped osteotomy plate, compared with an equal number of patients treated by a blade plate, are reported. The results were better in the group treated with a fork plate because there was a more accurate correspondence with the preoperative planning, and because there were fewer intraoperative complications, and time required for surgery was shorter.

Snapping hip is a polymorphous pathology the genesis of which is multifactorial, characterized by a snapping sensation which may be painful, and occurring during movement of the hip or during walking. Clinical and instrumental diagnosis for an accurate etiopathogenetic classification is essential to correct surgical treatment, that must be reserved only for cases with painful symptoms and with disorders in walking. The authors provide a classification system of the syndrome, describing four different varieties of the pathology and relative surgical treatment.

The authors present an original solution for distal screw fixation in locked nail intramedullary osteosynthesis, traditionally carried out with image intensifier. The system includes the determination of an electromagnetic field produced by a microbobbin placed in the hole and, thus, coaxial with it. The study, conducted through a probe equipped with special magnet-resistant sensors capable of picking up electromagnetic variations, is based on the same principle as a compass. In addition to being effective and simple, the method avoids exposure to ionizing radiations required for the search for holes.

Authors evaluated the correlation between immune system and metal ions release in blood of 17 subjects with Cr/Co/Ni joint prostheses. For the purpose Chromium (Cr), Cobalt (Co) and Nickel (Ni) serum levels were measured and, at the same time some immunological parameters (Leukocytes, Lymphocytes and Lymphocytes T, B and Natural Killer cells sub-populations) were evaluated. The results showed a significant decrease of Leukocytes, Lymphocytes and of T Lymphocytes sub-populations. At the same time it was demonstrated a significant increase of Chromium, Cobalt and Nickel levels in patients with joint prostheses as compared to control population (23 patients). In conclusion, ions release from metallic surface of the prostheses is correlated with a depression of immune system. This correlation could depend on a toxic action on immune system caused by the products released by the implant. It could also depend on a lymphocytes compartimentalization in periprosthetic tissues as a consequence of a cell-mediated hypersensitivity reaction towards implants corrosion products.

The authors report a rare case of transverse fracture of the second sacral vertebra that was isolated, with neurologic deficit, and treated conservatively by reduction opposing the trauma mechanism, and immobilization in plaster. After 22 months there was good neurologic recovery, although some perineal sensory disorders persisted, as did sexual deficit. This method is believed to be a valid one as an alternative to surgery, which is difficult, and not without complications.

The authors report their experience in the surgical treatment of the sequelae of congenital hip dysplasia, more specifically, 125 arthroplasties performed in 116 patients, with specific reference to the technical difficulties encountered and the various surgical methods used. This review suggests that prosthetization yields a high percentage of good results (77%) and constant remission of pain. Nonetheless, joint function, particularly when motion was severely compromised before surgery, or when dislocation was very severe (Crowe grades III and IV), is not always restored.

Osteosynthesis with a humeral anchor nail may be listed along with other methods of intramedullary fixation for the treatment of diaphyseal fractures. The authors report their experience with 33 cases of humeral fractures treated between July 1987 and July 1991. Results were excellent in 61% of the cases, good in 24%, and fair in 15%; no particular complications were reported. The authors believe that the anchor nail constitutes a system of osteosynthesis involving only a small amount of trauma, and allowing for positive elastic stability for the consolidation of the fracture, as well as being a sufficiently safe system so that immobilization in plaster may be avoided. When compared with other systems of intramedullary fixation, the anchor nail is more effective than the Rush nail from a mechanical point of view, and the Kuntscher nail from a biological one.

The prevention of deep sepsis and venous thromboembolism in knee replacement surgery is of great importance for the final success of treatment. General rules of prevention must be followed when using antimicrobial drugs (environment, surgical method, patient selection). Although it does have some negative aspects (overuse, high costs, development of resistant bacteria) the administration of antibiotics is recommended, but only when it is timely, correct, and carried out for a suitable amount of time. The prevention of thromboembolism is based first on the selection of patients who risk the occurrence of angiology-related diseases, on continuous passive postoperative movement, and, finally, on intentional normovolemic hemodilution, for which the procedures used and the advantages obtained are described.

The authors studied the effectiveness of locked intramedullary nailing (Grosse-Kempf) in the treatment of proximal shaft femoral fractures. They reviewed 24 cases with an average two-year follow-up and which had obtained positive clinical radiographic results in 80% of cases as compared to 88% in a previous revision of femoral shaft fractures. The difference is due to the greater difficulty encountered in intraoperative reduction of fractures from which defects in axial (varus) and rotatory (extra) alignment arise. They discuss indications as regards locking type, weight-bearing, as well as surgical techniques, which may prevent some of the most frequent problems observed.