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Introduction: With the advances and improvement of computer-assisted surgery devices, computer-guided pedicle screws insertion has been applied to the lumbar, thoracic and cervical spine. The purpose of the present study was to perform a systematic review of all available prospective evidence regarding pedicle screw insertion techniques in the thoracic and lumbar human spine.Materials and Methods: We considered all prospective in vivo clinical studies in the English literature that assessed the results of different pedicle screw placement techniques (free-hand technique, fluoroscopy guided, computed tomography (CT)-based navigation, fluoro-based navigation). MEDLINE, OVID, and Springer databases were used for the literature search covering the period from January 1950 until May 2010.Results: 26 prospective clinical studies were eventually included in the analysis. These studies included in total 1,105 patients in which 6,617 screws were inserted. In the studies using free-hand technique, the percentage of the screws fully contained in the pedicle ranged from 69 to 94%, with the aid of fluoroscopy from 28 to 85%, using CT navigation from 89 to 100% and using fluoroscopy-based navigation from 81 to 92%. The screws positioned with free-hand technique tended to perforate the cortex medially, whereas the screws placed with CT navigation guidance seemed to perforate more often laterally.Conclusions: In conclusion, navigation does indeed exhibit higher accuracy and increased safety in pedicle screw placement than free-hand technique and use of fluoroscopy. [ABSTRACT FROM AUTHOR]

We aimed to evaluate the possibility of hamstring tendon contamination, the correlation with clinical infection and its association with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values in 89 anterior cruciate ligament reconstructions. Two tissue samples were obtained for culture from each graft: immediately after harvesting the graft and before implantation. The ESR and the CRP were evaluated preoperatively and on the 4th and 20th postoperative days. Nine patients (10%) had positive cultures but no patient had signs of postoperative infection. All patients had ESR and CRP values elevated at the 4th postoperative day. ESR and CRP values returned to normal levels at the 20th postoperative day. Higher mean values of CRP levels at the 4th day were observed in patients with contaminated grafts compared to those with uncontaminated. Both values reached normal levels at the 20th postoperative day. [ABSTRACT FROM AUTHOR]

Background: Patellar resurfacing during total knee arthroplasty remains controversial. We aimed to evaluate the effectiveness of this technique through an evaluation of the current literature.Methods: We performed a meta-analysis of randomized controlled trials comparing total knee arthroplasties performed with and without patellar resurfacing. Outcomes of interest included the number of reoperations, the prevalence of postoperative anterior knee pain, and the improvement in various knee scores.Results: Ten trials assessing 1223 knees were eligible. The absolute risk of reoperation was reduced by 4.6% (95% confidence interval, 1.9% to 7.3%) in the patellar resurfacing arm (between-study heterogeneity, p < 0.01; I(2) = 60%), implying that one would have to resurface twenty-two patellae (95% confidence interval, fourteen to fifty-two patellae) in order to prevent one reoperation. Patellar resurfacing reduced the absolute risk of postoperative anterior knee pain by 13.8% (95% confidence interval, 6.4% to 21.2%), implying that one would have to resurface seven patellae (95% confidence interval, five to sixteen patellae) in order to prevent one case of postoperative anterior knee pain. Only four trials provided adequate data for a quantitative synthesis of the changes in the various knee scores; on the basis of those four trials, there was no difference in the mean improvement in the knee scores (standardized mean difference, 0.03; 95% confidence interval, -0.50 to 0.56).Conclusions: The available evidence indicates that patellar resurfacing reduces the risks of reoperation and anterior knee pain after total knee arthroplasty. The observed effects are clinically important despite their modest magnitude. Additional, carefully designed randomized trials are required to strengthen this claim. [ABSTRACT FROM AUTHOR]

Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication. [ABSTRACT FROM AUTHOR]

Introduction: Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term., Patients and Methods: This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period., Results: The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found ( p < 0.05). During the follow-up period no cases of radiation-induced tumours were identified., Conclusion: Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.

Background: To evaluate the associations between magnetic resonance imaging (MRI) findings and pain, disability and quality of life before surgery and up to 5 years after lumbar microdiscectomy., Materials and Methods: Sixty-one patients who underwent one-level lumbar microdiscectomy by the same surgeon participated in this analytic, observational, prospective study. Lumbar spine MRI was performed preoperatively and 5 years postoperatively. Pain, disability and quality of life were measured with VAS, ODI, Roland Morris and SF-36 pre- and up to 5 years postoperatively. Subsequently associations between radiological findings and clinical outcomes were recorded., Results: Before surgery patients with disc extrusion or sequestration, with increased thecal sac compression (d > 2/3), with Modic changes (MC) 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and both adjacent discs presented the worst preoperative clinical outcomes. MC preoperatively were not related with postoperative results, in contrast with the type of disc herniation and thecal sac compression. Preoperative Pfirrmann grade IV and V on the operated and both adjacent discs and postoperative MC 2 and 3 on the operated level were related to poor clinical outcomes 36-60 months post-discectomy., Conclusions: Extrusion or sequestration of the operated disc, increased compression of thecal sac, MC 2 and 3 on the operated level and Pfirrmann grades IV and V on the operated and adjacent discs were associated with the worst clinical outcomes. Nerve root impingement, facet joint arthritis, perineural fibrosis and disc granulation tissue had no effect on clinical scores.

The aim of this study is to evaluate whether computer-assisted navigated TKA reduces perioperative blood loss. Patients were randomly divided into 2 groups and underwent either a conventional TKA (n = 40) or a TKA with computer-assisted navigation (n = 40). Perioperative blood loss was evaluated by laboratory parameters, postoperative drain output and number of required transfusions. Change in hemoglobin concentration and in hematocrit levels was similar. Also, there was no statistically significant difference in drain output and in the number of transfused units. The results of this study showed that TKA with computer-assisted navigation is similar to the conventional TKA regarding perioperative hemorrhage., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: Total hip arthroplasty is one of the most successful orthopedic surgical procedures aiming to eliminate pain related to several types of hip arthritis and restore mobility. Obesity has been associated with an increased risk of complications after a total hip arthroplasty such as poor wound healing, periprosthetic joint infection, instability, and aseptic loosening., Methods: This paper presents an in-vitro study on composite femoral models to investigate the impact of different weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering normal-weight and overweight individuals from 70 to 110 kg. The micro strains on the femur during single-leg stance of gait were measured on critical stress points based on the Gruen femoral zones., Findings: The micro strains increase as the weight increases implying that the displacement in the hip joint endoprosthesis is higher for overweight subjects enhancing the risk of failure. The highest increase was measured in Gruen zone 1 by 5.60% indicating that the great trochanter is subjected to higher stress shielding with increasing the weight. Also, the statistically significant increase of the micro strain values with increasing the weight in Gruen Zones 3 (2.91%), 5 (1.56%), and 11 (1.75%) may enhance the risk for a periprosthetic fracture at the lower region of the prosthesis., Interpretation: This is the first biomechanical study which quantifies the effect of increasing weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering different positions of evaluation., (Copyright © 2019. Published by Elsevier Ltd.)

Competent fracture healing monitoring requires an extensive knowledge of the evolution of the mechanical environment of the healing bone during daily-life activities such as walking. Fractures are caused due to a traumatic incidence, while low trauma or fragility fractures can also occur due to osteoporosis. It is expected that the mechanical behavior of healing bones differs among osteoporotic and non-osteoporotic subjects. This work presents finite element simulations of gait analysis considering a fractured long bone at the hematoma stage. The aim is to investigate the evolution of the mechanical environment of the femur for an osteoporotic and a non-osteoporotic subject. This is the first computational study providing quantitative information for the impact of osteoporosis on the mechanical environment of the femur. It was shown, that higher deformation and equivalent stress values are calculated for osteoporotic bones during a gait cycle, while the highest values were observed in the femoral head.

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

Background: To evaluate the effect of lumbar microdiscectomy (LM) in pain, disability and quality of life in a 5-year period and to identify potential demographic and clinical risk factors., Methods: One hundred patients who underwent LM by the same surgeon participated in this prospective study. Clinical assessment was made with validated questionnaires preoperatively and up to 5 years postoperatively. Subsequently, associations between clinical outcomes and demographic data were recorded., Results: In every assessment questionnaire, there was a significant improvement in the first postoperative month, which lasted up to 1 year post-discectomy. After that, improvement was statistically significant (p < 0.05) but without clinical importance. Women reported more pain preoperatively and 1 month after surgery. Urban residents also presented more pain preoperatively. Older patients had more pain, disability and worse quality of life 1-5 years postoperatively. Similarly, patients with lower education presented the worst scores in every questionnaire at the same time. Smokers reported less pain 1.5-4 postoperative years. Higher alcohol consumption and obesity were associated with lower levels of preoperative pain. However, obese patients had worse SF-36 and ODI scores after the 6th postoperative month. Patients with heavy jobs presented the worst preoperative ODI scores., Conclusion: Significant clinical improvement was recorded from the first postoperative month to the first postoperative year; stabilization was noticed later on. Feminine gender, urban residency, older age, low level of education, obesity and heavy physical occupation were negative prognostic factors. Oddly smoking and alcohol were correlated with less pain.

Background: Lumbar microdiscectomy is a common procedure with satisfactory results; however, postoperative events like progressive adjacent level degeneration and perineural fibrosis can contribute to long-term pain. The purpose of the study was to evaluate MRI changes 5 years after lumbar microdiscectomy and assess their association with clinical parameters., Materials and Methods: A prospective study enrolling 61 patients who underwent microdiscectomy. Changes between preoperative and postoperative MRI findings were recorded, and these findings were tested for associations with demographic, clinical and perioperative parameters. The measured imaging parameters were degeneration of the operated and adjacent discs and endplates, morphology of the disc herniation, facet joints arthritis and the presence of postoperative perineural fibrosis., Results: Statistically significant differences were found between preoperative and postoperative morphology of the operated disc, facet joints arthritis and degeneration of the operated and caudal adjacent disc. There were no differences between preoperative and postoperative disc degeneration of the superior adjacent disc and in degeneration of the operated and adjacent endplates. Postoperatively perineural fibrosis was common; however, thecal sac compression and nerve root impingement were reduced. Age at the time of surgery was the only parameter associated with postoperative changes., Conclusion: Five years after microdiscectomy, several postoperative MRI changes including operated disc's morphology, facet joints arthritis and degeneration of the operated and caudal adjacent disc were shown. Taking into consideration that participants were on average middle-aged, these changes could be attributed not only to the impact of the surgery but also to the natural history of lumbar spine degeneration.

Congenital disease of the hip (CDH) is a common reason for the development of secondary osteoarthritis at the hip joint and the need for total hip arthroplasty (THA). The distorted femoral anatomy in patients with CDH in combination with soft tissue considerations and leg length discrepancy complicate the procedure of THA and this sometimes precludes the implantation of classical industry designed femoral stems. In such cases a customised femoral implant must be used in order to optimise the fit of the stem to the femur, to improve strain distribution and to reconstruct hip biomechanics. The present study reviews the preoperative planning, the design and material selection of custom-made implants, the surgical techniques and the reported clinical results of the published literature on the use of custom-made femoral implants in patients with CDH.

We evaluated the outcomes of total hip arthroplasty in 67 patients (86 hips) with congenital hip disease and excessive abnormal anatomy of the proximal femur with the use of custom-made femoral stems. The design of the stem was based on CT data following the principles of CAD-CAE-CAM technique. No serious complications attributed to the femoral stem were seen. Within a median follow-up of 127.5 months the 10-year survival of any of the components was 95.4% and respective value when aseptic loosening of the stem was considered was 98.1%. Patients with high dislocations had a 10-fold risk for loosening compared to those with low dislocations. No other parameter was associated with outcomes. The clinical and radiological evaluation was in consistency with the above outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Aim: To study a modified porous tantalum technique for the treatment of osteonecrosis of the femoral head., Methods: The porous tantalum rod was combined with endoscopy, curettage, autologous bone grafting and use of bone marrow aspirates from iliac crest aspiration in 49 patients (58 hips) with a mean age of 38 years. The majority of the patients had idiopathic osteonecrosis, followed by corticosteroid-induced osteonecrosis. Thirty-eight hips were of Steinberg stage II disease and 20 hips were of stage III disease. Patients were followed for 5 years and were evaluated clinically with the Merle D'Aubigne and Postel score and radiologically. The primary outcome of the study was survival based on the conversion to total hip arthroplasty (THA). Secondary outcomes included deterioration of the osteonecrosis to a higher disease stage at 5 years compared to the preoperative period and identification of factors that were associated with survival. The Kaplan-Meier survival analysis was performed to evaluate the survivorship of the prosthesis, and the Fisher exact test was performed to test associations between various parameters with survival., Results: No patient developed any serious intraoperative or postoperative complication including implant loosening or migration and donor site morbidity. During the 5-year follow up, 1 patient died, 7 patients had disease progression and 4 hips were converted to THA. The 5-year survival based on conversion to THA was 93.1% and the respective rate based on disease progression was 87.9%. Stage II disease was associated with statistically significant better survival rates compared to stage III disease (P = 0.04). The comparison between idiopathic and non-idiopathic osteonecrosis and between steroid-induced and non-steroid-induced osteonecrosis did not showed any statistically significant difference in survival rates. The clinical evaluation revealed statistically significantly improved Merle d'Aubigne scores at 12 mo postoperatively compared to the preoperative period (P < 0.001). The mean preoperative Merle d'Aubigne score was 13.0 (SD: 1.8). The respective score at 12 mo improved to 17.0 (SD: 2.0). The 12-mo mean score was retained at 5 years., Conclusion: The modified porous tantalum rod technique presented here showed encouraging outcomes. The survival rates based on conversion to THA are the lowest reported in the published literature.

Purpose: Implant loosening represents one of the major factors of total hip arthroplasty (THA) failure. The purpose of this study was to identify specific markers indicative of septic and aseptic loosening in patients that underwent THA., Methods: Flow cytometry was performed in blood samples of 20 patients with loosening (10 septic/10 aseptic). Additional ten healthy individuals served as a control group. The expression of surface receptors and cytoplasmic molecules in patients that underwent THA was quantified. CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated and correlated with the presence of loosening. Also, a comparison between septic and aseptic THA loosening characteristics was performed., Results: The mean fluorescence intensity (MFI) for CD18 was significantly decreased on all leukocytes subsets in both septic and aseptic loosening compared to control group (p < 0.005 in all occasions). Patients with aseptic loosening showed increased MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to the control and aseptic group (p = 0.02 and p = 0.005, respectively). In patients with septic loosening, an increase in MFI for CD11c was observed in monocytes only compared to control group (p = 0.03). The comparison between aseptic and septic loosening showed significantly lower CD18 MFI value in granulocytes for aseptic loosening (p = 0.008)., Conclusions: CD11 and CD18 MFI values appear to be indicative of loosening in THAs. Flow cytometry markers can be used to identify THA loosening, as well as to differentiate between septic and aseptic cases.

Background: We aimed to report outcomes of total hip arthroplasty (THA) in very young patients under the year of 30., Methods: Thirty patients (45 hips) with various indications for THA were retrospectively reviewed radiologically and clinically and analyzed regarding survival, reasons of failure, factors associated with outcomes and postoperative complications., Results: Within a mean follow-up time of 116 months the 10-year survival rate was 90.3%. All hips were revised due to aseptic loosening. No association was found among the tested parameters with increased revision rates. Three complications associated with the THA were recorded and managed conservatively. All patients had statistically significant improved clinical scores compared to the pre-operative period, despite the underlying disorder that compromised the condition in the majority of the patients., Conclusions: Our study showed excellent long term outcomes of THA in patients younger than 30 years of age, comparable with those in older patients.

Purpose: Liposarcomas are malignant tumors that arise from primitive mesenchymal cells rather than mature adipose tissue. We aimed to evaluate the outcomes of patients with extremities and superficial trunk liposarcomas in relation to some clinicopathological factors., Methods: Sixty-three surgically treated patients with liposarcoma, with mean age 53 years, were included in this study. The 5-and 10-year survival rates were analyzed with respect to local recurrences, distant metastases and death with the Kaplan-Meier method. Cox models estimated univariate and multivariate hazard ratios for each candidate predictor of interest., Results: The 5-year overall survival was 77.8% (95% CI 65.5-87.3) and the 10-year overall survival was 63.5% (95% CI 50.4-75.3). The 5-and 10-year recurrence-free survival were 60% and 57%, respectively. The 5-and 10-year metastasis-free survival were 86% and 84%, respectively. In univariate analysis factors that were significantly associated with outcomes were grade III tumors, amputation procedures, use of chemotherapy and development of local recurrences. No significant association was observed in multivariate analysis., Conclusion: Patients with liposarcoma surviving for 5 years, have also a high probability to be alive at 10 years. The development of metastases is observed within the first 5-years from diagnosis. Metastatic disease after that period is rare. The possibility of local recurrence is not negligible after the 5th year of follow up.

Intramuscular hemangiomas (IHs) are rare benign neoplasms usually seen in children, adolescents and young adults. Although lower extremities are the commonest localization, the localization at the foot is extremely rare since only a few cases have been reported. We report a case of mixed type IH of the flexor digitorum brevis muscle in a 12-year-old boy who was treated with surgical excision, with wide surgical margins., (Copyright 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Purpose: To present a new technique for wrist arthrodesis and review its treatment outcomes in 33 patients with brachial plexus palsy., Methods: 26 men and 7 women (mean age, 26 years) with global brachial plexus palsy underwent wrist arthrodesis using an external fixator and a cannulated screw. All surgeries were performed under local anaesthesia by a single senior surgeon. An external fixator was applied to the radius and the metacarpal of the index finger. The articular surfaces of the radius, scaphoid, lunate, and capitate were debrided, and a cannulated screw inserted from the base of the radial styloid to the carpo-metacarpal joint of the ring finger. Cancellous allografts mixed with demineralised bone matrix were added to the decorticated wrist bones. The external fixator was removed at week 8 and the wrist protected with a short-arm splint until solid wrist fusion., Results: All patients achieved wrist fusion after a mean of 14 (range, 12-16) weeks. Two patients had delayed fusion and slight wrist instability, because the shorter screw was embedded in the cancellous bone and not self-tapped to the cortex. Fusion was achieved after replacement with a longer screw. No patient developed a superficial or deep wound infection; 2 developed pin track infections. All patients were satisfied with the outcome and able to perform simple daily activities after one year., Conclusion: Our new technique for wrist arthrodesis is less invasive. Blood loss, the risk of postoperative infection, and adhesions at the extensors are decreased.

Purpose: To present the results of a prospective study which aimed to evaluate the efficacy of radiation dose in a combined protocol using postoperative radiotherapy (RT) and indomethacin for the prevention of heterotopic ossification (HO) in patients undergoing total hip arthroplasty (THA) and are at high risk for HO development., Methods: Seventy-one patients with a mean age of 63 years received either a single dose of 7 Gy or a fractionated dose of 10 Gy in 5 fractions of 2 Gy within the 3 postoperative days. Concurrently all patients received 75 mg of indomethacin for 15 days. Patients were analysed for radiographical evidence of HO development and clinically with the Merle d'Aubigné score at 1 year., Results: At 12 months combined RT and indomethacin achieved excellent prophylaxis of HO. The overall radiographical incidence of HO was 7.04% (95% CI 2.33-15.67), while no patient with clinically significant HO (Brooker III-IV) was seen. There was no statistically significant difference between the two RT protocols. In a subgroup of 12 patients with bilateral THA the incidence of HO in the non-irradiated hips was statistically significantly higher compared with the irradiated hips. All patients had improved joint mobility and function during follow up compared with the preoperative period. No statistically significant differences regarding the Merle d'Aubigné score was documented between the 2 RT groups. No acute or late side effects related to RT were noted., Conclusion: This study demonstrated the efficacy of combined RT and indomethacin in preventing heterotopic ossification after total hip arthroplasty. Fractionated total dose of 10 Gy seems to offer no further benefit compared to a single dose of 7.0 Gy.

In order to assess the efficacy of epidural steroid injections (ESI) in acute and subacute pain due to lumbar spine disk herniation, we conducted a randomized trial, comparing 2 different protocols. Fourty patients with radicular pain due to L4-L5 and L5-S1 disc herniation were assigned to receive either 3 consecutive ESI every 24 hours through a spinal catheter (group A) or 3 consecutive ESI every 10 days with an epidural needle (group B). All patients had improved Oswestry Disabilty Index (ODI) and the Visual Analog Scale (VAS) for pain scores at 1 month of follow-up compared to baseline, while no significant differences were observed between the 2 groups. The scores for group B were statistically significant lower at 2 months of follow-up compared to those of group A. The improvement in the scores of group B was continuous since the mean scores at 2 months of follow up were lower compared to the respective scores at 1 month. Protocol B (3 consecutive ESI every 10 days) was found more effective in the treatment of subacute pain compared to Protocol A (3 consecutive ESI every 24 hours) with statistically significant differences in the ODI and VAS scores at 2 months of follow-up.

Patellar instability after total knee arthroplasty (TKA) is a serious complication that impairs functional outcome and may lead to revision surgery. Its aetiology can be related to the surgical technique and component positioning, extensor mechanism imbalance, and other causes. After TKA, the presence of anterior knee pain, especially during stressful activities, is indicative of patellar instability. Diagnosis can be made by radiological evaluation of the patella position, alignment, and component fixation. Main treatment options include revision of the TKA components (in case of malposition) and lateral retinacular release with or without a proximal or distal realignment (in case of soft-tissue imbalance).

We aimed to evaluate the prognostic significance of traditional clinical predictors in osteosarcoma through an international collaboration of 10 teams of investigators (2680 patients) who participated. In multivariate models the mortality risk increased with older age, presence of metastatic disease at diagnosis, development of local recurrence when the patient was first seen, use of amputation instead of limb salvage/wide resection, employment of unusual treatments, use of chemotherapeutic regimens other than anthracycline and platinum and use of methotrexate. It was also influenced by the site of the tumour. The risk of metastasis increased when metastatic disease was present at the time the patient was first seen and also increased with use of amputation or unusual treatment combinations or chemotherapy regimens not including anthracycline and platinum. Local recurrence risk was higher in older patients, in those who had local recurrence when first seen and when no anthracycline and platinum were used in chemotherapy. Results were similar when limited to patients seen after 1990 and treated with surgery plus combination chemotherapy. This large-scale international collaboration identifies strong predictors of major clinical outcomes in osteosarcoma.

Background and Purpose: :Heterotopic ossification (HO) is a frequent complication following total hip arthroplasty. The aim of this study was to evaluate the efficacy of combined radiotherapy and indomethacin as compared to indomethacin alone for the prevention of HO after hip arthroplasty., Patients and Methods: 96 patients were prospectively enrolled to receive either a single dose of postoperative radiotherapy of 7.0 Gy and indomethacin for the first 15 postoperative days or indomethacin alone for the same period. A historical group of 50 patients that received indomethacin alone served as control. Primary endpoint was the radiographic evidence of HO at 6 months. Secondary endpoints were the evaluation of factors related to HO development, side effects from each treatment, and group differences in the clinical assessment with the Merle d'Aubigné Score., Results: Four patients in the combined-therapy group developed HO compared to 13 patients in the indomethacin group (p < 0.05) and 13 patients in the historical group (p < 0.05). One patient each in the combined group and the historical group developed Brooker III HO (nonsignificant difference). Duration of surgery and congenital hip disease were associated with HO development in the indomethacin groups, while age and congenital hip disease showed such an association in the combined-therapy group. The side effects and mean Merle d'Aubigné Score did not differ significantly between the three groups., Conclusion: Combined radiotherapy and indomethacin was more efficacious in preventing HO after total hip arthroplasty compared to indomethacin alone and should be considered for future investigation.

Introduction: The expression of E-cadherin, beta-catenin and topoisomerase II has been associated with clinical outcome of several cancers including sarcomas. We aimed to evaluate the expression of these markers in leiomyosarcomas (LMS)., Materials and Methods: Paraffin blocks of 19 primary, nonmetastatic LMS were analysed immunohistochemically for the expression of the above-mentioned markers with a cutoff level for positivity of 20% of cell staining., Results: Expression of E-cadherin was negative in all LMS. Nuclear expression of beta-catenin was also negative in all cases, while positive cytoplasmic beta-catenin expression was observed in approximately half of the patients. The majority of LMS had expression of topoisomerase IIalpha, although only in 10 patients was this expression in more than 20% of tumour cells. From the analysed factors, tumour size was statistically significantly correlated with relapse-free survival., Conclusions: Further evidence with larger series is required in order to determine the implication of these markers in LMS.

The objectives of this study were to establish data concerning normal hand grip strength (GS) and to explore possible associations with anthropometric parameters. GS was measured in 232 individuals in a standard arm position using the Jamar dynamometer. We examined differences between right/left and dominant/nondominant hands. Possible correlations of GS with anthropometric values were evaluated. Right hand and dominant hand GS were found to be higher and statistically significant compared to left hand and nondominant hand GS, respectively. Men had higher values of GS compared to women. A negative association was observed between age and dominant hand GS. A positive association was documented between height and dominant hand GS, while the respective comparison for weight and dominant hand GS documented a statistically significant positive association only in the male group. A positive association between BMI and dominant hand GS was seen in female individuals. Additional factors associated with GS should be the goal of future investigations.

We aimed to investigate the reliability and reproducibility of a magnetic tracking technique for the assessment of overall cervical spine motion (principal and coupled movements). Ten asymptomatic male volunteers with a mean age of 29.3 years (range 20-37 years) were included in the study. Flexion, extension, left and right lateral bending and left and right axial rotation were measured using a magnetic tracking device (MTD) mounted onto a custom head-piece. For rotational movements in the frontal and sagittal planes the results were compared with the measurements of two standard inclinometers. Intra-observer, inter-observer and intra-instrument reliability was assessed with the intraclass correlation coefficient method. There were no significant differences for all motion measurements between the MTD and the inclinometer. High inter-observer reliability was found in flexion, extension, axial rotation and lateral bending indicating that the testing routine is applicable for different examiners. The intra-observer variability was high in flexion and extension, whereas in lateral bending the reliability coefficients were lower and displayed a fair to good reliability for most of the measurements with the MTD. The results of the MTD were found to be highly comparable with the inclinometer results with an inter-instrument correlation coefficient ranging from 0.88 to 0.99. The MTD is a reliable, reproducible method for three-dimensional motion analysis of the cervical spine and therefore a valuable method both for the clinical assessment of various degenerative and traumatic disorders and as a supplement of different therapeutic procedures and rehabilitation.

Introduction: We aimed to evaluate retrospectively the efficacy of combined postoperative radiotherapy and indomethacin compared to indomethacin alone for the prevention of heterotopic ossification (HO) in high-risk patients with congenital disease of hip (CDH) undergoing total hip arthroplasty (THA)., Materials and Methods: Fifty-five patients received indomethacin alone (Group A), while 44 patients received the combined protocol (Group B). Patients >or=55 years were enrolled in Group B and those younger than 55 years in Group A. Patients were evaluated radiologically for the presence of HO 6 months after the operation., Results: The incidence of HO in Group A was 34.5% (95% confidence interval 22.2-48.6%), while the respective incidence in Group B patients was 27.3% (95% CI 15.0- 42.8%). The difference was not statistically significant (p=0.5). No significant treatment-related side effects were reported., Conclusions: This is the first study evaluating the impact of HO prophylaxis in an immiscible population of patients with secondary arthritis due to CDH undergoing THA. Further future randomised evidence is required in order to ascertain the observed trend towards improved efficacy of the combined protocol for HO development.

The aim of this cadaveric study was to compare the transtibial versus the anteromedial portal with respect to the anatomic femoral positioning of the ACL attachment. Ten fresh frozen cadaveric knees were included in our study. A standard arthroscopy was performed and the normal ACL was partially cut through with arthroscopic scissors leaving a small footprint of 2 mm at the anatomical insertion area on the lateral femoral condyle. The femoral tunnel was drilled through the tibial tunnel and subsequently through the anteromedial portal. Using a probe with standard magnification, we measured the distances of the two femoral tunnels from the margin of ACL footprint arthroscopically. The femurs were then dissected and we measured the distances of the two tunnels from the posterior part of the lateral femoral condyle. The median arthroscopically measured distance of the centers of transtibial femoral tunnel and of the femoral tunnel through the anteromedial portal from the margin of the femoral ACL footprint were 6.20 mm and 2.80 mm respectively. The difference was statistically significant. After femoral dissection the median distance of the centers of the transtibial femoral tunnel and the femoral tunnel performed through the anteromedial portal from the border of the articular surface at the lateral femoral condyle was 6.10 mm and 5.25 mm respectively (p<0.001). Both measurements showed that ACL reconstruction technique through the anteromedial portal is more accurate compared to the transtibial technique.

Purpose: To perform a meta-analysis of the sensitivity and specificity of antigranulocyte scintigraphy with monoclonal antibodies (MoAbs) in the diagnosis of osteomyelitis across different patient groups and clinical settings., Materials and Methods: MEDLINE and EMBASE searches were conducted. Data on the diagnostic performance of antigranulocyte scintigraphy with MoAbs were combined. Weighted sensitivities and specificities were estimated by using a random-effects model that incorporated between-study heterogeneity and by constructing summary receiver operating characteristic (ROC) curves. The weighted positive and negative likelihood ratios (LRs) across studies were estimated. Data syntheses were performed for all patients and for various subgroups. The reference standard used in each individual study was accepted., Results: Nineteen nonoverlapping studies with a total of 714 examinations and reference standards of cell culture, histologic examination, clinical follow-up, and radiologic examination were eligible. The independent random-effects summary estimates of sensitivity and specificity were 81% (95% confidence interval [CI]: 70%, 88%) and 77% (95% CI: 66%, 86%), respectively, with statistically significant between-study heterogeneity (exact P < .001 for both metrics). In the summary ROC curve, a sensitivity of 81% corresponded to a specificity of 86%, and a specificity of 77% corresponded to a sensitivity of 87%. The weighted positive LR was 3.02 (95% CI: 2.07, 4.42), and the weighted negative LR was 0.26 (95% CI: 0.17, 0.39), with statistically significant between-study heterogeneity (exact P < .001 for both metrics). Sensitivity was better for peripheral than for axial skeleton lesions (87% vs 53%)., Conclusion: Antigranulocyte scintigraphy with MoAbs has a sensitivity of 81% and a specificity of 77% in the diagnosis of osteomyelitis., ((c) RSNA, 2007.)

Purpose: To perform a meta-analysis of diagnostic studies regarding the accuracy of antigranulocyte scintigraphy (AGS) with monoclonal antibodies in the identification of prosthesis infection after total hip or knee arthroplasty., Materials and Methods: PubMed and EMBASE searches were conducted for the identification of relevant studies. Data on the diagnostic performance of AGS with monoclonal antibodies were combined quantitatively across eligible studies, and the overall sensitivity and specificity, along with summary receiver operating characteristic (ROC) curves and likelihood ratios (LRs), were estimated. The above parameters were evaluated for all patients and for various subgroups among the eligible studies. The reference standard used in the individual studies was accepted., Results: Thirteen eligible studies on nonoverlapping patient groups were included in the meta-analysis; there was a total sample size of 522 implants. The independent random effects summary estimates of sensitivity and specificity were 83% and 80%, respectively. The summary ROC curve estimate for weighted analysis was a sensitivity of 90% for a specificity of 80%. LR syntheses gave a weighted positive LR of 3.99 (95% confidence interval [CI]: 3.13, 5.09) and a weighted negative LR of 0.22 (95% CI: 0.15, 0.34); there was no statistically significant between-study heterogeneity for either metric. Various subgroup analyses did not reveal any statistically significant differences., Conclusion: AGS with monoclonal antibodies had a reasonably high discriminating ability to identify prosthesis infection in patients who underwent total joint arthroplasty., (Copyright (c) RSNA, 2006.)

Background: The role of adjuvant therapy in gastric cancer has been controversial., Aim: In this study, we report our experience with adjuvant chemotherapy and radiotherapy in patients with non-metastatic gastric cancer., Settings and Design: Fifty patients were reviewed and assigned to three therapeutic groups., Materials and Methods: Twenty patients received radiotherapy with concomitant administration of 5-fluorouracil and leucovorin on the first and last three days of radiotherapy; 20 patients received a five-day cycle 5-fluorouracil and leucovorin followed four to five weeks later by radiotherapy concomitant with the administration of fluorouracil on the first and the last three days of radiotherapy. Four weeks after radiotherapy two more five-day cycles of chemotherapy were administered; 10 patients received three cycles of cisplatin/docetaxel followed by radiotherapy and three additional cycles of chemotherapy after the completion of radiotherapy., Statistical Analysis: Patients were evaluated for treatment-related toxicity, local recurrences, distant metastases and deaths. We also aimed to make any possible comparisons between different chemo-radiation protocols., Results: Within a median follow-up of 21.5 months seven patients developed local recurrence and 17 patients developed distant metastases. The overall death proportion was 42% (95% CI 28.2-56.8%). Despite the limited number of patients, no statistically significant differences in local recurrences, distant metastases and deaths were observed between the three protocols. Acute and long-term treatment-related toxicity was low and no treatment-related deaths were observed., Conclusion: Despite variations of chemotherapy, our study demonstrated that combined chemo-radiotherapy for patients with resected gastric cancer can be administered safely, with acceptable toxicity.

Metastases to the tonsillar fossa due to hematogenous dissemination is an extremely rare phenomenon associated with advanced-stage disease and poor prognosis. In the present report we describe a case of cutaneous melanoma with a metastasis to the tonsil approximately 4 years after the initial diagnosis of the primary disease treated with palliative radiation therapy.

This study is a presentation of our department's experience in the treatment of localized prostate cancer with either radical or postoperative radiotherapy (RT). Fifty-five patients with clinical localized prostate cancer were reviewed. Thirty-three patients (T1-T2AN0M0 stage) were treated with radical RT and 22 (T2B-T3N0M0 stage) with postoperative RT. All patients received hormonal therapy. Primary end points of the study were the incidence of clinical and biochemical recurrences and death in the whole group and according to treatment modality. Within a median follow-up of 18 months the overall incidence of clinical relapse was 16.9%, of biochemical relapse 12.7% and of death 10.9%. Both treatment options achieved similar outcomes despite the fact that the patients in the postoperative RT group were of higher stage. Radical RT group tended to have better overall and disease-free survival compared to postoperative RT group, but there was no statistically significant evidence. Long-term toxicity was negligible.

The combination of radiotherapy and indomethacin for the prevention of heterotopic ossification (HO) in high-risk patients undergoing total hip arthroplasty (THA) has not been reported. The aim of the present study was to present the experience of our department with this combined therapeutic protocol. Fifty-four patients who underwent THA received a single dose of 7 Gy of postoperative radiotherapy and 75 mg of indomethacin for 15 days. Patients were analyzed for clinical and radiographical evidence of HO development at 1 year postoperatively. The overall radiographical incidence of HO was 20.4% (95% CI 10.6-33.5%), while only 1 patient with clinically significant HO was seen. Patients with secondary arthritis due to congenital hip disease had a statistically significantly higher incidence of HO compared with those with osteoarthrosis. The clinical assessment with the Merle d'Aubigné score showed that patients with radiographic documentation of HO had a lower mean score compared with those with no evidence of HO. No treatment-related side effects were seen. Combined radiotherapy and indomethacin was effective in preventing heterotopic ossification after total hip arthroplasty. The evaluation of this efficacy compared with radiotherapy or NSAIDs alone should be the future target of larger randomized designs.

Cubital tunnel syndrome is one of the most common entrapment neuropathies in adults. It is mainly caused by the depression of ulnar nerve from normal structures at the elbow area. Despite the fact that several pathgological entities can be potential mechanisms of the syndrome, the pathogenesis due to benign or malignant neoplasms is extremely rare. In the present report we describe the first case of cubital tunnel syndrome due to giant cell tumour of the tendon sheaths.

The aim of the present study was to evaluate the association of vascular endothelial growth factor (VEGF) and its receptor, KDR/Flk-1, with tumor grade, microvessel density (MVD) and clinical outcome in patients with soft tissue sarcomas (STSs). Tissue specimens of 28 patients with STSs were analyzed immunohistochemically using specific monoclonal antibodies. Tissue samples were obtained prior to any treatment. Half of the STSs exhibited strong expression of VEGF that was associated statistically significantly with high tumor grade. Strong expression of KDR/Flk-1 was detected in only 2 sarcomas. No association was demonstrated between VEGF and KDR/Flk-1 expression. MVD was significantly associated with tumor grade and was higher in sarcomas with strong VEGF expression. Limited data on clinical outcome precluded solid analyses for an association with disease progression. This study provides further evidence on the role of VEGF and MVD in tumor aggressiveness in STSs.

Gliosarcoma (GS) is an uncommon malignant brain tumor with biphasic tissue pattern consisted of both glial and sarcomatous components. It usually occurs in adult population of middle age. We report a rare case of multi-focal GS that was initially interpreted as metastases of extra-cranial tumor. The histological examination revealed the biphasic pattern of a GS. The patient was treated with postoperative external radiation therapy and had poor prognosis. To our knowledge this is the second published case of GS with multi-focal presentation. In this study we also review the literature on clinicopathological aspects of GS.

Desmoid tumours are rare neoplasms that display local aggressiveness but no propensity to metastasise. They are mainly localized in the abdominal wall, the bowel, and the mesentery or in extra-abdominal sites such as the trunk and the extremities. Surgical resection is the main treatment modality in extremities and trunk, with the optional combination of radiotherapy and/or chemotherapy. However, these tumours have a high propensity for recurrent growth.

Unlabelled: The ability of PET with (18)F-FDG to evaluate bone marrow infiltration in patients with lymphoma has been a matter of extensive investigation with controversial results. Therefore, we aimed to evaluate systematically, with a meta-analysis, the diagnostic performance of (18)F-FDG PET in this setting., Methods: Relevant studies were identified with MEDLINE and EMBASE searches (last update, August 2004). Data on the diagnostic performance of (18)F-FDG PET were combined quantitatively across eligible studies. We estimated weighted summary sensitivities and specificities, summary receiver-operating-characteristic (SROC) curves, and weighted summary likelihood ratios. We also conducted separate analyses according to various subgroups. Bone marrow biopsy (BMB) was used as the reference standard., Results: Thirteen eligible nonoverlapping studies, which enrolled a total of 587 patients, were included in the meta-analysis. The independent random-effects weighted estimates of sensitivity and specificity against BMB were 51% (95% confidence interval [CI], 38%-64%) and 91% (95% CI, 85%-95%), respectively. Results were consistent in the SROC curve: a sensitivity of 51% corresponds to a specificity of 92%, whereas a specificity of 91% corresponds to a sensitivity of 55%. The weighted positive likelihood ratio (LR+) was 5.75 (95% CI, 348-9.48) and the negative likelihood ratio (LR-) was 0.67 (95% CI, 0.55-0.82). Six of 12 patients with positive (18)F-FDG PET and negative initial biopsy were found to have bone marrow involvement when biopsy was performed at the sites with positive imaging signals. Subgroup analyses showed better sensitivity in patients with Hodgkin's disease and in aggressive histologic types of non-Hodgkin's lymphoma than in patients with less aggressive histologic types and in studies using unilateral BMB compared with those using bilateral biopsy., Conclusion: This meta-analysis showed that (18)F-FDG PET has good, but not excellent, concordance with the results of BMB for the detection of bone marrow infiltration in the staging of patients with lymphoma. (18)F-FDG PET may complement the results of BMB and its performance may vary according to the type of lymphoma.